Every finding on record at Wellspring Health & Rehabilitation of Cascadia

Based on observations, interviews, and policy review, the facility failed to ensure medications were labeled with open and discard dates, individual insulin syringes were labeled with the resident's name, expired medications were disposed of and not made available, and unknown pill left in pill cup on the medication cart for two of two medication carts (200 hall and 300/500 hall) reviewed. This had the potential to cause medication errors, adverse medication reactions, and residents to receive suboptimal therapeutic actions of medications. Findings: Review of facility's policy titled, Medication Management revised 10/15/24 revealed, Cascadia, in collaboration with a contract pharmacy, develops policies, procedures and clinical practice guidelines to manage medications so they are safely provided and administered to residents. Cascadia facilities follow the contract pharmacy's policies and procedures. Policies and procedures are not limited to: LTC policies and procedures . Medication labels and packaging . Storage and expiration of medications, biological, syringes, and needles. Licensed nurses follow appropriate procedures for destruction and disposal of controlled, cytotoxic, and noncontrolled medications. Medications and biologics are not used beyond their expiration dates. Medications are discarded by the expiration date unless indicated by the pharmacy and/or manufacturer's instructions to discard sooner. Medications that may require special packaging other than unit dose include: . injectable medications. Upon delivery of medications from the provide pharmacy, the Licensed Nurses are responsible for validating the medications received are labeled correctly: resident's name, name of medication, dosage, and frequency. 1. During a review of the medication cart on the 200-hall cart on 09/17/25 at 3:32 PM with Licensed Practical Nurse (LPN) 19, the following were observed:a. Insulin Aspart 100 units per milliliter (ml) pen with open date of 08/01/25 and a discard date of 09/10/25 with no name label was in a bag with R35's last name written on it. LPN19 confirmed the open date, discard date was beyond 28 days, and the pen did not have the resident's name. During an interview on 09/17/25 at 3:45PM, LPN19 stated the pen should have been discarded since it expired and had no name. b. A pill cup was in the top drawer with a loose pill. The cup had no name. LPN19 confirmed the loose pill in the cup with no resident name. During an interview on 09/17/25 at 3:45PM, LPN19 stated she left the cup and pill in the drawer and believed it was Lasix (a diuretic medication). LPN19 stated she placed the cup in the drawer because the resident did not want to come out of the dining room to take his medication and then she got pulled away to do something else. 2. The following observations were made in the 300-500 hall medication cart with LPN20 on 09/17/25 at 3:50 PM: a. Lantus Pen with no resident label, opened date 09/15/25 found in resident's bag labeled with last name. LPN20 confirmed the insulin pen had no resident label. During an interview on 09/17/25 at 4:00 PM, LPN20 stated the insulin pen needed to be disposed since it did not have a resident name and insulin pens cannot be used for more than one resident.During an interview on 09/17/25 at 4:02 PM, the Director of Nursing (DON) stated insulin pens are to be discarded within 28 days of the open date. The pharmacy sends the pens with resident labels and staff should date the cap of the pen with the open and discard dates. Since the pens did not have a pharmacy label, the pens may have been pulled from the emergency kit. If an insulin pen is pulled from the emergency kit, the expectation is that the nurse writes the resident's name and open date on the pen. The DON stated the expectation is that nurses administer medications at the time the medication is removed from the cart. If the medication is not administered, the medication is to be discarded and new medication was to be obtained later if the resident decides to take it.

Based on observation, resident interview, staff interview, and record review, it was determined the facility failed to: 1. a. protect residents who had tested negative for COVID-19 and had a roommate who tested positive for COVID-19 from continuing to be exposed by their cohort and, b. ensure infection control measures were implemented and executed in accordance with professional standards of practice for hand hygiene and use of personal protective equipment (PPE) to prevent the spread of COVID-19. These failures placed the 84 residents currently residing in the facility in immediate jeopardy of serious illness, harm, impairment, or death due to the increased risk of contracting COVID-19. 2. provide COVID-19 vaccinations to every resident who requested vaccination. This was true for 1 of 5 residents whose vaccination records were reviewed. This failure placed Resident #73 at risk of serious illness when she contracted COVID-19 after her legal guardian consented for her to receive the COVID-19 vaccine. 3. complete hand hygiene after providing incontinence care. This failure placed Resident #53 at risk for illness when staff failed to complete hand hygiene when appropriate. Findings include: 1. On 7/22/24 at 8:15 AM, signs documenting the facility was experiencing an increased number of cases of COVID-19 and masks were encouraged. On 7/22/24 at 8:30 AM, some staff were observed wearing surgical masks and some staff were observed wearing N95 respirator masks. Overdoor hanging pocket organizers were observed on multiple doors in 200-hall. The overdoor hanging pocket organizers contained disposable gowns, N95 respirator masks, boxes of gloves, and disposable face shields. Some rooms had touchless alcohol-based hand rub (ABHR, commonly known as hand sanitizer) dispensers affixed to the wall next the doorway and sets of plastic drawer units containing the same PPE and garbage cans were sitting in the hallway. The doors with the overdoor hanging pocket organizers and plastic drawer units had red signs indicating the resident(s) in those rooms had tested positive for COVID-19 and staff were to follow the following directions before entering and exiting the room: - Use standard precautions and enhanced droplet precautions. - Wear a gown over clothing, N95 respirator mask, eye protection (such as a face shield or goggles), and gloves, before entering the room. - Remove gowns, remove gloves, and perform hand hygiene before exiting the room. On 7/22/24 at 8:38 AM, the CEO stated a resident tested positive for COVID-19 on 7/19/24. The CEO stated that resident lived in 500-hall and now residents who lived in 200-hall and 500-hall were testing positive for COVID-19. The CEO stated there were 22 residents who were positive for COVID-19 at that time. On 7/22/24 at 11:50 AM, the CEO stated on Friday 7/19/24 at 7:00 AM, they were made aware that a resident who had been transported to the emergency room the night of Thursday 7/18/24 had tested positive for COVID-19. The CEO added they were holding an all-staff meeting at that time and they took the opportunity to re-educate the staff in attendance of their hand hygiene and infection prevention policies and procedures. He stated himself, the IP, and the CNO had been present on-site on 7/20/24 providing 1 on 1 training for staff on the use of PPE. On 7/22/24 at 3:55 PM, the CEO and Clinical Resource Nurses (CRN) #1 & #2 presented a document delineating a timeline of events of the COVID-19 outbreak beginning Thursday 7/18/24 until the present time on 7/22/24 that documented the following: -On 7/19/24 at 7:30 AM, the CEO stated they tested all residents for COVID-19 who lived in the vent unit in the 500-hall as they were the most vulnerable and that is where the resident that was hospitalized lived. The CEO stated at that time, 5 residents tested positive for COVID-19, and management initiated the direction for all staff to wear source control (surgical) masks. -On 7/19/24 at 8:30 AM, the Infection Preventionist (IP) contacted the county health department and was given the direction to test the remaining residents living in the vent unit, the staff working in the vent unit, and any other staff showing symptoms. At that time 2 staff were identified to have tested positive for COVID-19. -The facility began contact tracing any symptomatic residents and staff. A resident that lived in the 200-hall presented with symptoms and tested negative. -After testing the remaining residents and staff living and working on the 200-hall and 500-hall, the total numbers of positive COVID-19 tests were 8 residents and 7 staff. -On 7/20/24 the IP sent out training messages to staff on their secure messenger system and provided 1 on 1 training with staff as the opportunity arose. - On 7/20/24, 3 additional residents and 4 additional staff tested positive for COVID-19. -On 7/21/24, 11 additional residents and 4 additional staff tested positive for COVID-19. Of the staff that tested positive on this date, included the IP and CNO. -On 7/22/24, the IP spoke with the county health department a second time and received guidance to begin testing all staff before they come in for their shift. -On 7/22/24 at 5:34 PM, 33 of 84 residents, and 16 staff had tested positive for COVID-19 a. The CDC web page titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 3/18/24, accessed on 8/1/24, documents the following: - The recommendations in the guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency. - Place a patient (resident) with confirmed COVID-19 in a single-person room. The door should be kept closed if safe to do so. - Only residents with the same respiratory pathogen should cohort (share a room). The facility policy titled, Management of Coronavirus COVID-19, revised 7/3/24, documents residents who test positive for COVID-19 should be placed in a single-person room on transmission-based precautions. The policy documents if cohorting, only residents with the same respiratory pathogen should be housed in the same room. On 7/22/24 at 8:15 AM, the facility had a census of 84 residents. This facility was licensed to house a maximum of 120 residents in either private or double occupancy rooms. On 7/22/24 at 11:00 AM, Resident #34 stated she was concerned she would get COVID-19 because her roommate had it. On 7/22/24 at 3:55 PM, the CEO stated residents who had not tested positive but had a roommate test positive should be moved if there were available beds. He stated they did not want to expose anyone who had not been exposed, he added, moving [the residents] did not make sense at the time. On 7/22/24 at 5:07 PM, the facility provided a copy of their census sheet which showed which resident resided in which room and showed which rooms were empty. The facility indicated which residents had tested positive for COVID-19 by writing the date in which they tested positive next to their name. Based on the census sheet, 11 residents were identified to have a roommate who had tested positive for COVID-19 while they had not tested positive, 5 residents were identified to have tested positive for COVID-19 and resided as a singular resident in a double occupancy room. Also, based on the census sheet, the facility was noted to have 6 empty private rooms and 4 empty double occupancy rooms. b. The facility policy titled, Transmission-Based Precautions Conventional Plan, revised 4/2/24, standard precautions include the directions to complete hand hygiene using an ABHR or wash hands with soap and water before and after wearing PPE. The policy documented positive cases of COVID-19 will have droplet transmission-based precautions implemented and directed the use of a N95 mask when managing a COVID-19 outbreak. The facility policy titled, Management of Coronavirus COVID-19, revised 7/3/24, documented the facility would provide education to staff on what infection control practices should be used and would provide competency-based education to staff on the use of PPE. On 7/22/24 at 9:02 AM, two staff were observed entering a resident room with the red sign on the door stating the resident(s) in the room had tested positive for COVID-19, both staff were not wearing a face shield or goggles. On 7/22/24 at 12:11 PM, a staff was observed lifting the lid of a garbage can with her left hand then donning (putting on) gloves without completing hand hygiene. On 7/22/24 at 12:18 PM, ACNO #1 was observed donning PPE without completing hand hygiene. When ACNO #1 was observed doffing (taking off) her PPE, she removed her N95 mask and disposed of it inside the COVID-19 positive room. On 7/22/24 at 12:28 PM, CNA #5 was observed donning and doffing her PPE when she went into a COVID-19 positive room, during this observation she did not complete hand hygiene as required before donning and after doffing the PPE. CNA #5 stated she forgot to complete hand hygiene before and after entering the room. On 7/22/24 at 12:40 PM, a staff wearing PPE was observed doffing their PPE after leaving a COVID-19 positive room, the staff removed the soiled N95 mask, then put on a clean surgical mask without completing hand hygiene. On 7/22/24 at 12:45 PM, LPN #3 stated they did not know how to don and doff PPE, and it was over [their] head. On 7/22/24 at 3:56 PM, the CEO stated the facility could not provide documentation the staff providing hands-on care to people diagnosed with COVID-19 had been provided competency-based training and the staff were not evaluated to demonstrate the skills of appropriately completing hand hygiene and safely donning and doffing PPE. 2. The CDC web page titled, COVID-19 Vaccination for Long-Term Care Residents, updated 7/2/24, accessed on 8/1/24, documents the following: - The CDC recommends everyone aged 5 years or older, including people who live and work in long-term care settings get 1 updated COVID-19 vaccine. - COVID-19 vaccines can help keep you from getting seriously ill if you do get COVID-19. Resident #73 was admitted to the facility on [DATE], with multiple diagnoses including spastic diplegic cerebral palsy (a neurological condition that permanently affects muscle control and coordination), hemiplegia of her right/dominant side (paralysis that affects one side of the body), and fibromyalgia (a chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness, and insomnia). Resident #73 depended on a legal guardian to make her healthcare decisions. On 4/4/24, Resident #73's record documented her legal guardian consented for her to receive the COVID-19 vaccination. On 7/26/24 at 4:15 PM, the CNO stated Resident #73 should have received the vaccination if her legal guardian had requested the vaccine, unless it was later refused or documented as medically contraindicated by a physician. The CNO stated she was unable to provide documentation Resident #73 had received the vaccination as requested. On 7/24/24 at 10:00 AM, the immediacy was removed following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at a F scope and severity following the removal of the immediate jeopardy. 07246 3. The facility's Hand Hygiene policy revised 2/11/22 documented hand hygiene is the single most important procedure for preventing the spread of infection . Under Opportunities for hand hygiene . item 4. Before moving to a clean body site after caring for a soiled body site. Resident #53 was admitted to the facility on [DATE], with multiple diagnosis including neuromuscular dysfunction of bladder. An annual MDS assessment, dated 11/7/24 documented Resident #53 was cognitively impaired. A care plan revised 10/22/23 documented Resident #53 was totally dependent on two staff for toileting. During observation on 7/22/24 at 3:11 PM, CNA #2 and CNA #4 were observed providing incontinence care to Resident #53. After providing incontinence care CNA #2 and CNA #4 did not remove or change their gloves and were observed to reposition Resident #53 to his left side and pulled the bedsheet up to his chest with the same soiled gloves they used during his incontinence care. CNA #4 was then observed to reached near Resident #53's tracheostomy site and adjusted the ventilator circuit tubing attached to the tracheostomy tube. During an interview with CNA #2 and CNA #4, they stated they should have washed their hands and changed their gloves after they provided the incontinence care to Resident #53. CNA #4 stated they should have washed her hands and put on a clean pair of gloves prior to pulling the sheet and adjusting Resident #53's ventilator circuit tubing.

Based on record review and staff interview, it was determined the facility failed to ensure a person who received nutrition through an enteral tube received the appropriate treatment to prevent complications. This was true for 1 of 2 residents (Resident #85) whose records were reviewed for the use of enteral feeding tubes. This failure harmed Resident #85 and placed other residents who used enteral feeding tubes at risk for feeding tube complications. Findings include: Resident #85 was admitted to the facility on [DATE] with multiple diagnoses including acute respiratory failure with hypoxia (low blood oxygen levels), a tracheostomy (a surgically created opening through the neck into the windpipe to allow air to fill the lungs), she was dependent on the use of a ventilator to breathe (a ventilator is a machine that recreates the process of breathing by pumping air into the lungs), and was dependent on the use of a nasogastric tube (a NG tube is a thin tube inserted through a nostril, down the throat, and into the stomach) as the sole route for her to receive nutrition, hydration, and medications. The facility policy titled, Tube Placement Verification, dated 11/28/2017, included documentation the accurate placement of a nasogastric tube needed to be verified before administering any fluids though the tubing. The policy describes three methods of visually evaluating the position of the tubing: 1. Assess the distance of the mark on the tube in relation to the nostril, the mark is made by the clinician at the time of insertion. 2. Measure the length of the visible portion of the inserted tube and compare this measurement with the measurement taken immediately after insertion. 3. Verify the tube is anchored in place using tape or a tube fixation device. The policy directed staff to notify the physician of suspected misplaced tube and documented an x-ray is used to verify tube placement anytime placement is question. Resident #85's physician orders, dated 5/16/23, documented, Enteral Feed Order- every shift for enteral nutrition precautions check feeding tube placement by observing change in the external length marked at entry point before administering formula, medication administration, or flushing of tube. On 5/31/23 at 10:46 PM, in a nursing note, LPN #5 documented she noticed the tube seemed longer than previously observed and the marking on the tube was completely off and when she flushed the NG tube with water, the water came out of the residents' nostrils. LPN #5 documented the resident immediately began crying and was in a significant amount of pain and thought her tube had been dislodged. LPN #5 documented the physician on-call was contacted and they directed staff to send Resident #85 to the emergency department to verify placement of the NG tube and assess for aspiration pneumonia (a lung infection from inhaling food or liquid). Resident #85's hospital record from her emergency department encounter on 5/31/23 at 11:57 PM, documented she had been assessed and diagnosed with a right-sided pneumothorax (right lung collapse), aspiration pneumonia, and sepsis (a life-threatening condition in which the body takes an extreme immune response to an infection). On 7/25/24 at 3:00 PM, Clinical Resource Nurse #3 stated it appears LPN #5 recognized the NG tube was displaced and did not follow the standards of practice by continuing to attempt to flush the NG tube. On 7/26/24 at 4:24 PM, the CNO stated, when a nurse suspects a NG tube is displaced, they should stop any administration of fluids through the NG tube, call the physician for an order for an x-ray to verify placement, and ensure nothing is administered through the NG tube until placement is verified in an x-ray.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure the kitchen equipment and environment was maintained in a sanitary manner. These deficiencies had the potential to affect 69 of 80 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: The FDA Food Code Section 6-501.12 Cleaning, Frequency and Restrictions. Cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when foods are in protected storage and when food is not being served or prepared. On 7/25/24, during the follow-up kitchen inspection and tray line observation, the following was observed: - A build-up of dirt above the second fan in the walk-in refrigerator. - A white, powder residue on the shelf below the steam table where the steam table pans were stored. A review of Shift #1 AM [NAME] Weekly Cleaning List documented the steamtable and the stainless shelves were wiped down. On 7/25/24 at 10:57 AM, the CDM confirmed that the fan was cleaned by maintenance at the beginning of July 2024, and maintenance had removed the fans to clean the area. She could not explain why the dirt was on the fan. On 7/25/24 at 12:10 PM, the RD could not explain what the white substance was. She stated the CDM had cleaning schedules to ensure that all areas of the kitchen were cleaned. The RD reported the kitchen's cleaning schedule is completed daily, weekly, and recorded. She stated the CDM is very good about making sure the areas are cleaned and, I do sample audits to ensure they are on top of things.

Based on review of the glucometer calibration documentation, policy review and staff interview, it was determined facility failed to ensure glucometers were calibrated to maintain accuracy, ensure reliability, and ensure correct results for 2 of 4 halls (100 Hall and 200 Hall) whose glucometer were reviewed. This deficient practice had the potential for a higher risk for improper blood sugar monitoring of residents who required blood glucose monitoring. Findings include: The facility's Blood Glucose -EvenCare Glucose Monitoring, revised 3/4/24 documented directed staff to calibrate the glucometer nightly or per manufacturer's guidelines. Review of the facility's 100 Hall and 200 Hall's Blood Glucose Control Record logbook for glucometer calibration, revealed glucometer calibration were inconsistently performed for the months of January 2024 through April 2024. There were no glucometer calibrations conducted for the month of May, June, and July 2024. During an interview with RN #1 on 7/26/24 at 10:30 AM, he stated that the night shift nurses conducted the glucometer calibration checks. During an interview with LPN #4 on 7/26/24 at 10:45 AM, she stated that the night shift nurses did the glucometers calibration. During an interview with the CNO on 7/26/24 at 3:54 PM, the CNO stated the glucometer calibration should be done once a week every Tuesday. The CNO reviewed the calibration records of the 100 hall and 200 hall's Blood Glucose Control Record and stated they were not being calibrated as directed. She stated, yes it should be done weekly and documented. The CNO stated the night shift nurses should be the ones to calibrate the glucometer. The CNO further stated that the importance of doing the glucometer calibration is to make sure the reading is correct and accurate.

Based on observation, record review, and staff interview, it was determined the facility failed to develop and implement comprehensive resident-centered care plans. This was true for 2 of 22 residents (#26 and #74) whose care plans were reviewed. These failures placed residents at risk of negative outcomes if services were not provided, or provided incorrectly, due to a lack of information in their care plan. Findings include: The facility's Comprehensive Resident Centered Care Plans policy, revised 10/15/22 documented a comprehensive care plan is developed consistent with the resident's specific conditions, risks, needs, behaviors, cultural expectations, preferences and with standards of practice including measurable objectives, interventions/services, and timetables to meet the resident's needs as identified in the resident's comprehensive assessment or as identified in relation to the resident's response to the interventions or changes in the resident's condition. Resident #26 was admitted to the facility on [DATE], with multiple diagnoses including infection and inflammatory reaction due to indwelling urethral catheter, acute kidney failure, chronic kidney disease, neuromuscular dysfunction of bladder, and retention of urine. A physician order, dated 6/1/24, documented EBP (enhanced barrier precaution) was necessary to care for an indwelling urinary (Foley) catheter, and to measure and record output. The MAR, dated 6/20/24, included a physician's order to change bag on tubing on admission and every 30 days at every day shift for 30 days for urinary catheter maintenance, to provide EBP for catheter care every shift for infection prevention for high contact patient care, and to cleanse and monitor hydration at every shift for indwelling catheter and hydration management. A review of Resident #26's care plan did not include catheter care, maintenance, or monitoring. On 7/26/24 at 8:38 AM, after reviewing Resident #26's records, the CNO stated she could not explain why catheter care was not included on the care plan. 35690 The facility's Comprehensive Resident Centered Care Plans policy, revised 10/15/22 documented a comprehensive care plan is developed consistent with the resident's specific conditions, risks, needs, behaviors, cultural expectations, preferences and with standards of practice including measurable objectives, interventions/services, and timetables to meet the resident's needs as identified in the resident's comprehensive assessment or as identified in relation to the resident's response to the interventions or changes in the resident's condition. Resident #74 was admitted to the facility on [DATE], with multiple diagnosis including long-term (current) use of anticoagulants (blood thinner). A physician's order, documented Resident #74 was to receive Apixaban (anticoagulant) 5 mg via her G (gastric)-tube two times day as prophylaxis for DVT (deep vein thrombosis), ordered 6/24/24. Resident #74's care plan, did not document she was on anticoagulant. On 7/26/24 at 10:24 AM, the CNO stated Resident #74 was receiving Apixaban. The CNO stated Resident #74's should have a care plan for the anticoagulant and staff should look for bruising, bleeding, and any other adverse effects. The CNO stated the care plan was created and updated by all nursing staff and should be done timely.

Based on interview, record review, and policy review, the facility failed to ensure grievances were promptly resolved and ensure all written grievance decisions included the date of the grievance, a summary of the resident's grievance, a summary of the findings, a statement as to whether the grievance was confirmed or not confirmed, corrective action taken as a result of the grievance, and the date the decision was issued. Specifically, the facility failed to ensure grievances about call lights, voiced by residents during resident council were documented, investigated, resolved, and followed up on by the facility. This failure had the potential to placed residents at risk of ongoing frustration and decreased self-worth, as well as, unmet care needs, when issues of concern to them were not promptly addressed by the facility. Finding include: The facility's Resident Council policy, dated 5/24/19, documented that actions need to be taken to address needs or concerns expressed by the Resident Council members with the minutes and/or grievance tool. The Resident Council minutes from January 2024 through June 2024 documented residents' concerns. Examples include: a. Resident Council Meeting minutes, dated 1/25/24, documented one staff attended and 29 residents attended. The Hot Topics section of the Resident Council Meeting Minutes documented residents still have the same concern as last month with the call lights not being answered to their liking. b. Resident Council Meeting minutes, dated 2/13/24, documented two staff and 15 residents attended. The Hot Topics section of the Resident Council Minutes documented residents still have the same concern as last month with the call lights not being answered to their liking. They have a concern about CNAs leaving dirty linen in their room when they leave. c. Resident Council Meeting minutes, dated 3/26/24, documented one staff and 15 residents attended. The Hot Topics section of the Resident Council Minutes documented residents mention that they would like more communication when receiving care and call lights are still not being answered to their liking, Director of Nursing (DON) notified. d. Resident Council Meeting minutes, dated 5/30/24, documented one staff and 18 residents attended. The Hot Topics section of the Resident Council Meeting Minutes documented The CNAs have gotten better with answer[sic] lights to their liking, still struggling on Hall 5 . The residents on Halls 1 and 2 would like the CNAs to pay more attention to the lights when sitting at the nursing station. e. Resident Council Meeting minutes, dated 6/25/24, documented one staff attended and 19 residents attended. The Hot Topics section of the Resident Council Meeting Minutes documented residents discussed call lights not being answered in a timely manner. Residents are concerned that the CNAs are turning lights off and not coming back in sufficient time. During an interview on 7/22/24 at 9:25 AM, Resident #74 stated there was often a delay with call lights being answered. She said sometimes she waited up to one hour. During an interview on 7/25/24 at 11:57 AM, the Licensed Master Social Worker (LMSW) said she was responsible for grievances. She said if the concern was related to resident care she would bring the grievance to the morning stand-up meeting. The concern would then go to the CNO for education. The LMSW said she had only been invited to Resident Council twice and was not involved in grievances brought up in Resident Council. During an interview on 7/25/24 at 4:06 PM, the Activities Director (AD) said she attends all Resident Council meetings to take notes and facilitate the meeting. She said everyone has trouble with call lights. She said she would talk to department managers and assume they would resolve it. She said if the residents brought it up again in Resident Council, she would speak to department managers again. The AD said there was not any kind of tracking system and said there was no way to see if the issue had been resolved. During an interview on 7/25/24 at 4:15 PM, the CNO stated she was unable to find any documented education or follow-up regarding Resident call lights. The CNO said a plan would be implemented to ensure concerns in Resident Council were followed up on and staff education would be documented.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents who were offered and consented to the pneumococcal and influenza vaccine, received the vaccines. This was true for 3 of 5 residents (Resident's #52, #64, and #73) whose records were reviewed for pneumococcal and influenza vaccinations. This failure created the potential for residents to have an increased risk of contracting pneumococcal (bacterial) pneumonia and influenza. Findings include: The facility policy titled, Pneumococcal Program-Residents, revised 10/2022, documented each resident was offered the pneumococcal immunization based on current CDC guidelines, unless the immunization was medically contraindicated, or the resident had already been immunized. In the case the resident had already been immunized, the policy directed staff to offer the next vaccination in the series as indicated. The policy documented there were two types of pneumococcal vaccines available for adults: Pneumococcal Conjugate Vaccines (PCV15 and PCV20) and Pneumococcal Polysaccharide Vaccine (PPSV23). The use of PCV13 has been discontinued. The Centers for Disease Control and Prevention (CDC) website, dated 6/26/23, accessed on 7/29/24, included recommendations for administration of pneumococcal vaccinations for adults younger than [AGE] years of age with increased risk of illness, and adults [AGE] years or older as follows: - If a person has never received any pneumococcal vaccine, the CDC recommends receiving one dose of PCV20 or PCV15. -If a person has previously received PCV15, the CDC recommends receiving one dose of PPSV23 one year later. - If a person has previously received PPSV23, the CDC recommends receiving one dose of PCV20 or PCV15 at least one year after administration of PPSV23. - If a person has previously received PCV13 at any age, the CDC recommends receiving one dose of PCV20 or PPSV 23 at least one year after administration of PCV13. - If a person has previously received PCV13 at any age and PPSV23 while younger than [AGE] years of age, the CDC recommends receiving PCV20 at least five years after administration of PCV13 or PPSV23. The facility policy titled, Influenza Program-Residents, revised 3/2022, documented each new resident and upon request was offered the influenza immunization based on current CDC guidelines, unless the immunization was medically contraindicated, or the resident had already been immunized. The CDC website, dated 12/16/22, accessed on 7/29/24, included recommendations for annual influenza vaccinations for all people 6 months and older. 1. Resident #52 was admitted to the facility on [DATE], with multiple diagnoses including autism, epilepsy, and congenital malformation syndromes (conditions present at birth that cause physical and intellectual disabilities). Resident #52 relied on a legal guardian to make his healthcare decisions. Resident #52's record documented he received the pneumococcal vaccine PCV15 on 3/3/23. Based on CDC recommendations, Resident #52's immunization history indicated he was due to receive the PPSV23 booster on 3/3/24. On 7/26/24 at 4:15 PM, the CNO stated Resident #52 should have received the booster. She stated she was unable to provide documentation the PPSV23 booster was administered to Resident #52. 2. Resident #64 was admitted to the facility on [DATE], for care following an operation. Resident #64 also had multiple diagnoses including sepsis (a life-threatening condition in which the body takes an extreme immune response to an infection), chronic respiratory failure with hypoxia (low blood oxygen levels), quadriplegia (paralysis affecting the body and limbs from the neck down). Resident #64 had a tracheostomy (a surgically created opening through the neck into the windpipe to allow air to fill the lungs), and he was dependent on the use of a ventilator to breathe (a ventilator is a machine that recreates the process of breathing by pumping air into the lungs). Resident #64 was able to make his health care decisions independently. On 10/27/23, Resident #64's record documented he consented to receive pneumococcal vaccines as they became appropriate. Based on CDC recommendation, Resident #64's immunization history indicated he was due to receive PCV20 on 1/24/24. On 7/26/24 at 4:15 PM, the CNO stated Resident #64 should have received the immunization. She stated she was unable to provide documentation PCV20 was administered to Resident #64. 3. Resident #73 was admitted to the facility on [DATE], with multiple diagnoses including spastic diplegic cerebral palsy (a neurological condition that permanently affects muscle control and coordination), hemiplegia of her right/dominant side (paralysis that affects one side of the body), and fibromyalgia (a chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness, and insomnia). Resident #73 depended on a legal guardian to make her healthcare decisions. On 4/4/24, Resident #73's record documented her legal guardian consented for her to receive the pneumococcal vaccine and the influenza vaccine. Based on CDC recommendation, Resident #73's immunization history indicated she was due to receive PCV20 and the influenza vaccine. On 7/26/24 at 4:15 PM, the CNO stated Resident #73 should have received the immunizations. She stated she was unable to provide documentation PCV20 or the influenza vaccines were administered to Resident #73.

Based on policy review, observation, record review, and staff interview, it was determined the facility failed to ensure physician orders for the maintenance of supplemental oxygen, ensuring respiratory equipment was changed, and documenting treatment outcomes were followed. This was true for 2 of 6 residents (#48 and #231) reviewed for supplemental oxygen use and respiratory care. This placed residents at risk for respiratory infections when the supplemental oxygen and nebulizer tubing and humidifier bottle were not dated when changed, and treatment outcomes were not documented. Findings include: The Wellspring of Cascadia Respiratory Care Policy states that based on the type of respiratory care and services provided, which may include oxygen services (to include the safe handling, humidification, cleaning, storage, and dispensing of oxygen), the resident's record should reflect ongoing assessment of respiratory status, the response to oxygen therapy, and for mechanical ventilation/tracheostomy care, to monitor the resident for specific risks of possible complications. Routine machine maintenance and care for ventilator equipment to include water/tubing changes, safety checks on alarms, machine function checks, and clean equipment per manufacturer's recommendations. 1. Resident #48 was admitted to the facility on [DATE], with multiple diagnoses including acute respiratory failure with hypoxia (a condition of low oxygen levels in body tissues), and chronic respiratory failure with hypercapnia (excessive carbon dioxide in the bloodstream, caused by inadequate respiration.) A physician's order, dated 11/30/2023, documented, oxygen RA - 3 LPM via trach mas/Airvo at NOC and PRN for R/T diagnosis of chronic respiratory failure/respiratory compromise should be monitored every shift. A Trach care plan, initiated on 3/18/22, directed staff to monitor and document respiratory rate, breath sounds, work of breathing, and to check and document every shift as ordered. The PAR (pulmonary administration) record for May 2024 through July 2024, documented that treatment had not been recorded on the following dates: 5/3/24 - 5/5/24, 5/13/24, 6/1/24, 6/10/24 - 6/11/24, 6/15/24-6/16/24, 6/20/24-6/23/24, 6/29/24, 7/2/24-7/4/24, 7/7/24, and 7/10/24. On 7/24/24 at 1:45 PM, after reviewing the PAR with the surveyor, RT 2 verified that on the dates listed above, there was no data on recorded on the PAR. She stated she did not know why the areas of care, treatment, and monitoring were not documented on the PAR as she had documented earlier in the day. 36193 2. Resident #231 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including acute respiratory failure with hypoxia (low levels of oxygen in the body tissues) and hypercapnia (buildup of carbon dioxide in the bloodstream), and diabetes. Resident #231's TAR, documented change his oxygen/nebulizer tubing, humidification bottle and clean filter every week . Date and provide bag as indicated. As needed and replace with soiling. started 6/14/24. On 7/23/24 at 10:00 AM, Resident #231 was observed in bed receiving oxygen via nasal cannula at 6 liters per minute. The humidifier (container of water attached to the oxygen concentrator) was empty. ON 7/23/24 at 10:05 AM, LPN #2 removed the humidifier from the oxygen concentrator. LPN #2 stated it was empty and there was crystallization on the bottom of the container. LPN #2 then filled the humidifier with distilled water. LPN #2 stated he believed the night shift staff should be the ones to be checking the humidifier, On 7/24/24 at 12:38 PM, ACNO #1 stated the humidifier should be filled with distilled water as needed and not be kept empty. ACNO #1 stated the CNAs should be checking it and inform the nurse when it is empty.

Based on record review, policy review and staff interview, it was determined the facility failed to ensure investigation of allegation of verbal abuse and medication errors were thoroughly investigated. This was true for 2 of 2 residents (#44 and #81) reviewed for abuse and neglect. This failure created the potential for harm due to lack of an investigation. Findings include: The facility's Identification and Investigation of Abuse, Neglect and Misappropriation and Injuries or Unknown Origin policy, revised 8/1/23 documented the facility has processes in place to assist early detection and investigation for allegations of abuse, neglect, misappropriation, exploitation, and injuries of unknown origin. Evidence of investigation should be documented in accordance with Quality Assurance Performance Improvement protocols. Resident #81 was admitted to the facility on [DATE], with diagnosis of low back pain. A physician's order, documented Fentanyl (an opioid pain medication) patch 72-hour 25 mcg (micrograms)/hour apply one patch transdermal one time a day every three days for pain. Remove old patch before applying new every 72 hours with a start date of 6/14/21 and discontinue date of 1/15/23. A nurse's progress notes, dated 1/7/23, documented Resident #81 had been lethargic and confused during shift. Oxygen saturation was 80% with 2 liters of oxygen. Oxygen increased to 4 liters to maintain oxygen saturation at 94%. Resident #81 decreased in response to voice or pain. Checked resident for fentanyl patch, one was noted on the left shoulder dated 1/5/23 and a second patch was noted on his right mid back dated 1/2/23. The physician was notified after both patches were removed. At 1:51 PM an intramuscular Narcan (a drug to reverse opioid overdose) was given due to a drop in blood pressure at 57/38. The resident was noted to be diaphoretic and trying to move and open his eyes. Requested to send Resident #81 to the hospital. An attempt was made to interview the nurse who wrote the above note was unsuccessful. Review of the Narcotic Record Book provided by the facility documented that on 1/2/23 and on 1/5/23 a new Fentanyl patch was applied on each day and the old one was destroyed. The documentation on the Narcotic Book also documented that the old Fentanyl patches were destroyed and witnessed by to staff members. Review of the hospital Emergency Medicine provider addendum notes dated 1/7/23 revealed that that Resident #81 was found with decreased responsiveness hypoxia and severe hypotension.arrives profoundly hypotensive and altered presumed opiate overdose, . he did receive 0.4mg of IM Narcan and then 2mg of IV Narcan prehospital in addition to IV fluids with modest improvement in blood pressure and respiratory effort but patient remains unresponsive and not conversant .Narcan drip is ordered, 4 hours into the ED stay he still is nonverbal. Multiple metabolic abnormalities are found with acute renal failure, hypomagnesemia, these are corrected, he will require admission . During an interview with ACNO #2 on 7/25/24 at 2:40 PM, she stated that they were unable to find any documentation or incident report investigation regarding Resident #81 and the alleged fentanyl patch incident. During an interview with LPN #3 on 7/26/24 at 12:15 PM, who was the nurse providing care to Resident #81 on 1/7/23, he stated he always applies the transdermal patch in a different body area and ensures the old patch is removed. LPN #3 also stated that the previous administration had investigated the fentanyl incident and they had cleared him of any wrongdoing. He further stated that all the fentanyl patches were accounted for, and it was concluded that there was no wrong doing. He additionally stated that he was discarding the patches in the sharps' container (500 Hall Med Cart) and that the prior administrative staff opened the sharps container and fished out the used Fentanyl patches with long needle nose pliers and that all the used discarded Fentanyl patches were found in the container. During an interview with the CNO on 7/26/24 at 3:20 PM, she stated that the current administration was new, and the incident with Resident #81 and the alleged fentanyl error occurred during the previous administration. The CNO further stated that there was no investigation found regarding Resident #81 nor was there any documentation found regarding the alleged improperly administered opiate medication. During an interview with the facility Attending Physician #1 on 7/26/23 at 3:26 PM, he stated that he was aware of Resident #81 and the alleged fentanyl incident. He stated that Resident #81 did not sustain a fentanyl overdose but was diagnosed with a urinary tract infection (UTI), chronic kidney disease, dehydration, and other co-morbidities when admitted to the hospital. 36193 2. The facility's Complaints and Grievances policy, revised 10/15/22, documented complaints were acknowledged, investigated, and the complainant apprised of progress toward a resolution and takes appropriate corrective action if the alleged violation is confirmed by the facility. Resident #44 was admitted to the facility on [DATE], with multiple diagnoses including osteomyelitis, paraplegia (paralysis of the lower body) and pressure ulcer of the sacral region (bottom of the spine). A Grievance report, dated 6/22/24, documented on 6/21/24 at approximately 11:00 PM, Resident #44 asked for pain medication. Resident #44 was told the nurse was on break and would come back in when he returned. The grievance report documented Resident #44 turned on his call light two more times and a CNA responded to him saying the nurse was helping others and would be in shortly. The report documented when the nurse did respond, the nurse yelled at him and stated don't disrespect me like that. Resident #44 stated the the nurse got in my face when he said it. He feels like the nurse hates him as this happens every time he has that nurse. The Grievance report documented the CNO spoke to LPN #2 the nurse identified on Resident #44's grievance. LPN #2 stated as soon as Resident #44 call light was on, staff were at his room and his medication was administered as ordered. LPN #2 stated Resident #44 became agitated and became aggressive, and was yelling out. LPN #2 stated he did not yell at Resident #44 but told him not to yell and disrespect him, the CNAs and his roommate with his yelling and curse words. There was no documentation other residents under the care of LPN #2 or other staff who worked on that day was interviewed. On 7/25/24 at 3:27 PM, the CNO stated she interviewed Resident #44's roommate and he stated it was Resident #44 who was yelling and cursing. The CNO stated Resident #44's roommate apologized to the nurse for Resident #44's behavior that night. The CNO stated she did not document the conversation It was all verbal. The CNO also stated she did not feel like the incident had to be investigated because when she asked Resident #44 if it was more a customer service issue, Resident #44 stated yes, and it was settled that night.

Based on record review and staff interview, it was determined the facility failed to notify the physician of a significant change in weight loss. This deficiency had the potential to affect 1 of 1 resident (Resident #50) whose record was reviewed for timely physician notification. This placed the resident at risk of experiencing complications related to unexpected weight changes. Findings include: The Wellspring of Cascadia Resident Change of Condition policy states that, Upon recognition of a potentially life-threatening condition or significant change in status, the nurse should communicate with other health care providers to meet the needs of the resident. A change of condition may include . weight gain or loss no more than 5% body weight. Immediate notification to the physician should be [provided] at the time the event occurs, [or] as soon as possible. Resident #50 was admitted to the facility on [DATE], with multiple diagnoses including dementia and aphasia (an impairment of language due to brain injury, affecting the production or comprehension of speech and the ability to read or write). Resident #50's care plan documented that she was at risk for weight loss. On 7/1/24, Resident #50's weight was recorded at 126 pounds. This weight was documented as a 9.2% weight loss in one month. A review of records did not show any notification of the weight loss to Resident #50's doctor on 7/1/24. On 7/26/24 at 9:54 AM, the CNO reported she was unable to find a record of notification to the physician regarding Resident #50's weight loss on 7/1/24.

Based on observation, record review, policy review and staff interviews, it was determined the facility failed to ensure residents' incontinence care were met. This was true for 1 of 2 residents (Resident #4) reviewed for incontinence care. This deficient practice placed Resident #4 at risk for experienced embarrassment, isolation, decreased sense of self-worth, skin impairment, and compromised physical and psychosocial well-being. Findings include: The facility's Quality of Life policy, revised 10/15/22, documented the facility provides the necessary services to maintain good nutrition, grooming, oral and personal hygiene for residents unable to carry out their activities of daily living. A request was made for a policy specific to providing incontinence care and none was provided by the time of the exit of the survey. 1. Resident #4 was admitted to the facility on [DATE], with a diagnosis of neuromuscular dysfunction of bladder. An annual MDS assessment, dated 5/11/24 documented Resident #4 was cognitively impaired. A care plan, revised 5/20/24, documented Resident #4 was totally dependent on two staff for toileting. During an observation on 7/25/24 at 12:15 PM, Resident #4 was nonverbal and unable to respond to question. LPN #1 and CNA #3 turned Resident #4 to his left side for incontinence check. Resident #4 was noted to be incontinent of bowel. Resident #4 was then repositioned on his back by CNA #3 and LPN #1. CNA #3 then turned towards the exit door when the surveyor asked CNA #3 if incontinence care was going to be provided to Resident #4. CNA #3 stated she was the shower aide. LPN #1 stated he was going to find a CNA assigned to provided incontinence care to Resident #4 During observation on 7/25/24 at 12:40 PM, CNA #1 and LPN #1 provided incontinence care to Resident #4. Resident #4 was observed to have a large amount of dark brown fecal material on his right and left buttock. The fecal material on the right buttock was dry indicating Resident #4 had been incontinent of bowel for some time. Resident #4 was noted to be incontinent of bowel at 12:15 PM and was not provided incontinence care until 12:40 PM (25 minutes later). During a interview on 7/25/24 at 12:40 PM, CNA #1 stated incontinent rounds were conducted at 6:00 AM, 11:30 AM and 1:30 PM.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure informed consent was obtained and documented prior to use of a [CONDITION(S)] medication and behavior monitoring was initiated and implemented. This was true for 2 of 6 residents (#1 and #2) reviewed for [CONDITION(S)] medications. This created the potential for harm if the resident experienced adverse effects due to lack of informed consent and behavior monitoring while taking the [CONDITION(S)] medication. Findings include: A facility policy on Psychoactive Drug Use, revised on 4/4/19, documented the facility obtained a responsible party acknowledgement form and implemented a behavior monitoring log to document the need for and response to a drug. It further stated the facility would determine the responsible party's wishes and attitudes about psychoactive drugs through record review, observation, and discussion. This policy was not followed. 1. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including weakness, repeated falls, and need for assistance with personal care. Resident #2's admission MDS assessment, dated 9/10/20, documented she was cognitively intact and she received antianxiety medication. Resident #2's physician orders documented she was to receive a new antianxiety medication, [MEDICATION(S)] 5 mg by mouth two times per day and the order started on 9/14/20. A nursing progress note, dated 9/14/20 at 9:38 PM, documented Resident #2 was started on [MEDICATION(S)] that night, and she tolerated the initial dose without any adverse effects. Resident #2's care plan documented she used antianxiety medications related to her anxiety disorder, and the focus area was initiated on 9/16/20. Resident #2's MAR documented [MEDICATION(S)] was administered on September 14 through September 23, 2020. There was no documentation in Resident #2's record a consent was signed by Resident #2 when the [MEDICATION(S)] was started on 9/14/20. There was no documentation of behavior monitoring when Resident #2 was receiving medication for anxiety. On 2/24/21 at 2:32 PM, the DON said when a psychoactive medication was started, there should be communication with the resident's family, a consent should be signed by the resident, the care plan should be updated, and the resident should be monitored for side effects. On 2/24/21 at 4:00 PM, the DON said she did not see documentation in Resident #2's record of behavior monitoring or a signed consent related to [MEDICATION(S)]. The DON said the care plan should reflect the behavior monitoring to be done, and behavior monitoring should be documented on the TAR. The DON said she did not know why behavior monitoring did not occur for Resident #2. 2. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, dementia, hearing loss, and diabetes. Resident #1's record included documentation he had an appointed Power of Attorney (POA) for healthcare. An Acknowledgement of Psychoactive Medication Use, dated 9/25/20, documented it was recommended by the Interdisciplinary Team Resident #1 should take [MEDICATION(S)] (an antipsychotic medication) 12.5 mg for his diagnosis of dementia with behavioral disturbance and was signed by Resident #1. The document was not signed by his POA. A history and physical, dated 9/28/20 and signed by a Physician Assistant, documented Resident #1 had a history of Alzheimer's with no behavioral changes and he was to continue taking [MEDICATION(S)] 12.5 mg once a day at bedtime. A behavior meeting note, dated 12/15/20, documented, per the [CONDITION(S)] Committee's recommendation, Resident #1 had a trial discontinuation of the [MEDICATION(S)]. There was no documentation Resident #1 or his POA were included as part of this decision or notified of the decision. A nursing progress note, dated 12/17/20 at 10:21 AM, documented Resident #1's [MEDICATION(S)] was to be stopped starting that evening. A nursing progress note, dated 12/23/20 at 11:17 AM, documented Resident #1 had no adverse effects from the discontinuation of [MEDICATION(S)]. A nursing progress note, dated 12/30/20 at 1:17 AM, documented Resident #1 was agitated and walking around the facility halls at the beginning of the night shift. The note documented when staff attempted to redirect Resident #1 to use his walker and to help him back to his room he became combative. The nursing note documented staff called his family to help calm him and after the phone call he went and laid down on his bed. The note documented Resident #1's POA stated she did not know his [MEDICATION(S)] was discontinued and she requested a call from administration to discuss these issues. During an interview, on 2/25/21 at 10:09 AM, the DON stated if a resident had a diagnosis of dementia they do keep the resident involved and talked to them let the resident sign the form. The DON stated, after reviewing Resident #1's record, it included documentation he was taking [MEDICATION(S)] prior to admission but there was no documentation this was discussed with his family or POA about this medication.

Based on record interview, policy review, and staff interview, it was determined the facility failed to ensure residents' representatives were notified of changes in the residents' condition. This was true for 1 of 2 residents (Resident #2) whose records were reviewed for changes in condition. This failed practice had the potential to cause psychosocial harm and distress when a resident's family and close relations were not made aware of their significant change in condition. Findings include: The facility's policy for Resident Change of Condition, released on 11/28/17, documented the facility immediately informed the resident, consulted with the resident's physician, and notified the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status and when there was a need to alter treatment significantly. This policy was not followed. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's admission MDS assessment, dated 9/10/20, documented she was cognitively intact and she received antianxiety medication. A nursing progress note, dated 9/18/20 at 8:52 PM, documented Resident #2 was using the toilet when she suddenly became unresponsive and parlor [sic], and her skin was cold and clammy. After she recovered, she was placed back in bed, the medical provider was notified, and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation Resident #2's representative was notified of her change in condition. On 2/25/21 at 12:45 PM, the DON said the nurse should have notified Resident #2's family regarding her change of condition related to the incident in her bathroom. The facility did not notify Resident #2's representative when she experienced a significant change in condition which required treatment.

Based on record review and staff interview, it was determined the facility failed to ensure the resident and/or their representative were included and informed of a change in treatment modality for an infection. This was true for 1 of 6 residents (Resident #3) who were reviewed for medications. This deficient practice placed residents at risk of receiving medications without knowledge of the risks and benefits associated with the mediations and the right to refuse the medications. Findings include: Resident #3 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's quarterly MDS assessment, dated 1/29/21, documented she was moderately cognitively impaired, and she received an antibiotic. Resident #3's MARs from January 2021 and February 2021 documented she received [MEDICATION(S)] (antibiotic) from 1/26/21 through 1/29/21, and she received [MEDICATION(S)] (antibiotic) from 1/30/21 through 2/13/21. A nursing progress note, dated 1/30/21 at 2:10 PM, documented Resident #3's final blood culture results were received from the laboratory and a new order was received from her physician to discontinue [MEDICATION(S)] (which she was receiving for a urinary tract infection with [CONDITION(S)]- a potentially life-threatening condition that occurs in response to an infection) and to start [MEDICATION(S)] intravenously for 14 days. On 2/25/21 at 2:00 PM, the DON said she did not see documentation in the progress notes Resident #3's daughter was notified when her antibiotic was changed. Resident #3's family/representative was not notified when an order was received to change her antibiotic.

Based on policy review, record review, and staff interview, it was determined the facility failed to provide adequate supervision to meet resident needs. This was true for 1 of 6 residents (Resident #1) reviewed for supervision and accidents. Resident #1 was at risk for harm when staff failed to provide adequate supervision, resulting in his elopement from the facility. Findings include: A facility policy Elopement, dated 11/28/17, stated upon identification a resident is missing staff immediately search the facility to confirm, including searching the grounds of the facility. The immediate response included notifying the family and to discuss possible locations the resident may try to go to. The policy also stated once the resident was located to assess the resident for injury and to document when the resident was discovered as missing, the steps taken in searching for the resident, who was notified, the date and time the resident was found, and the resident assessment. This policy was not followed. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, dementia, hearing loss, and diabetes. Resident #1's admission MDS assessment, dated 10/2/20, documented Resident #1 was severely cognitively impaired, he did not have behavioral symptoms, and he did not have wandering behavior. A nursing note, dated 12/29/20 at 9:52 PM, documented Resident #1 was missing and staff were attempting to locate him. Resident #1 was found in the parking lot of the facility and told staff he was going home. The nursing note documented Resident #1 was assisted back to his room and into his bed. A nursing note, dated 12/30/20 at 1:17 AM, documented Resident #1 was agitated and walking around the facility halls at the beginning of the night shift. The note documented when staff attempted to redirect Resident #1 to use his walker and to help him back to his room he became combative. The nursing note documented staff called his family to help calm him and after the phone call he went and laid down on his bed. The note documented Resident #1's family member was upset because she did not know he had eloped earlier in the evening and one of his medications was discontinued. An undated document related to the investigation of Resident #1's elopement stated on 12/29/20 at 8:50 PM he exited the building without being witnessed and was found 30 feet from the front door in the parking lot at 9:18 PM, 28 minutes after it was identified he was missing. The investigation document stated Resident #1 was dressed and wearing a coat with the hood up. The investigation document stated Resident #1 was assessed for injuries and he was then placed on 15-minute checks and a wander guard was attached to his walker. According to Timeanddate.com, website accessed on 3/11/21, on December 29, 2020 the temperatures for that evening ranged from a high of 27 degrees Fahrenheit to a low of 23 degrees Fahrenheit. On 2/24/21 at 3:53 PM, LPN #1 stated he was the nurse on duty when Resident #1 eloped. He stated Resident #1 was pacing all night and at one point he went through the double doors and did not come back through the unit. He stated he thought the POA was notified, but he did not call them. On 2/24/21 at 3:55, RN #2 stated she was the person who made the phone calls regarding the elopement of Resident #1, but she did not call Resident #1's family. On 2/25/21 at 11:51 PM, the DON stated it was the nurse's job to immediately notify the Administrator, herself, and the family if a resident was missing. The DON stated staff were educated upon hire, and annually, about what to do if a resident eloped.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure the record of each discharged resident included a written notice of discharge, physician documentation, and documentation of communication with the receiving provider. This was true for 1 of 3 residents (Resident #2) reviewed for transfers or discharges. This resulted in the potential for a resident to be discharged without cause and for the receiving facility to be unable to meet the resident's needs. Findings include: Resident #2 was admitted to the facility on [DATE] from a local hospital, and then discharged back to the same hospital on the same day. Resident #2 had [DIAGNOSES REDACTED]. The facility's Transfer and Discharge policy, dated 11/28/17, stated a resident could be discharged on ly when It is necessary for the resident's welfare and the resident's needs cannot be met in the facility. The facility failed to implement their Transfer and Discharge policy, as follows: a. The facility's Transfer and Discharge policy, dated 11/28/17, stated a written notice of transfer/discharge included a reason for transfer/discharge, the effective date of transfer/discharge, the location to which the resident is transferred/discharged , a statement the resident has the right to appeal the action to the state, the name, address, and telephone number of the state long term care ombudsman, and as applicable, the mailing address and telephone number of the agency responsible for protection and advocacy of developmentally disabled or mentally ill individuals. The policy stated a copy of the notice was to be sent to a representative of the Office of the State Long-Term Care Ombudsman, and appropriate steps were to be taken to inform the resident where they were going and to assure safe transportation. Resident #2's Transfer Order from the hospital, dated 10/21/20 and signed by a physician, documented Resident #2 was being transferred to the facility because she required 24-hour skilled nursing care. Resident #2's record documented she arrived at the facility on 10/22/20 at 2:10 PM and was assigned to room [ROOM NUMBER]. A progress note for Resident #2, dated 10/22/20 at 3:57 PM, stated non-emergent transport called to transport back to ER (emergency room ). A progress note, dated 10/22/20 at 6:44 PM, stated Resident #2 had arrived at the facility at 2:10 PM and received 1:1 care from the time she arrived until the time transport took her back to the hospital ER. The progress note stated Res (Resident #2) fixating and impulsive. Res (Resident) was transported back to (hospital). Resident #2's record did not include a written notice of discharge. On 10/28/20 at 10:43 AM, the Administrator stated the facility received three PASRRs (a federal screening requirement to help ensure individuals with developmental disabilities and/or mental illness) from a hospital social worker and the third PASRR documented Resident #2 was receiving [MEDICATION NAME] for sleep which was not allowed in the facility. The Administrator stated the admission paperwork was emailed to Resident #2's family member on 10/22/20 at 1:09 PM and the family member did not open the email until 7:07 PM. The Administrator stated the expectation was that admission documents be signed and returned the same day as admission, and without a signed consent to treat, medication could not be administered to the resident. On 10/28/20 at 10:00 AM, the DON stated the hospital did not identify all of Resident #2's medications and the facility found out Resident #2 received [MEDICATION NAME] and [MEDICATION NAME] for sleep. The DON stated not all of the admission paperwork was completed and there was no written notice of discharge or physician discharge order because the facility did not actually admit Resident #2. Resident #2's Physician order [REDACTED]. Her record also included screening, assessments, and an evaluation were completed while she was in the facility on 10/22/20, as follows: - A Coronavirus Screening was completed at 2:39 PM. - A Fall Risk assessment was completed at 2:39 PM. - A Braden Scale for Predicting Pressure Sore Risk was completed at 2:39 PM. - A Skin Inspection Evaluation was completed at 2:39 PM. - A Pain assessment was completed at 2:45 PM. Resident #2's record also included a progress note, dated 10/23/20 at 9:19 AM, which stated (Resident #2) admitted 1410 (2:10 PM) .Admission did get me an order changed back to puree diet due to our concerns of no ST (speech therapy) with dysphagia DX. (diagnosis) for her safety. A discharge note from the hospital, dated 10/21/20 and signed by a Nurse Practitioner, documented Resident #2's routine medications included [MEDICATION NAME] 10 mg twice a day (an antianxiety medication), [MEDICATION NAME] 50 mg at bedtime for sleep (an antidepressant and sedative), and [MEDICATION NAME] 100 mg at bedtime for depression (an antipsychotic). She was to continue [MEDICATION NAME] (an antibiotic) 300 mg orally twice a day until gone (quantity prescribed was 10 caplets) for a urinary tract infection. The Physician order [REDACTED].#2's routine medications included [MEDICATION NAME] 10 mg each morning and at bedtime for anxiety, [MEDICATION NAME] 100 mg each evening for depression, and [MEDICATION NAME] 50 mg at bedtime for sleep. Both the facility physician and the hospital physician documented [MEDICATION NAME] was prescribed for depression not for sleep. [MEDICATION NAME] was not included in the hospital's documentation or on the facility's Physician Orders. b. On 10/28/20 at 10:00 AM, the DON stated the referral information the facility received was misleading. The DON stated while Resident #2 was in transport to the facility, a nurse to nurse report (between the hospital and the facility) was conducted and the hospital nurse stated that on the evening of 10/21/20, Resident #2 pulled out her IV line and had a ground level fall. The DON stated the hospital nurse reported Resident #2 required almost 1:1 supervision. The DON stated that after Resident #2 presented to the facility, Resident #2 had behavioral and supervision needs the facility was not able to accommodate. A progress note, dated 10/22/20 at 5:55 PM, stated Res (Resident #2) was received from (hospital) this afternoon for what was described to us in her referral as needing therapy for weakness following UTI (urinary tract infection). Once she arrived to this facility, it was immediately identified that she would require an extensive amount of observation. Nursing staff was present in her room on arrival and were unable to safely leave her on her own due to her weakness/fall risk, impulsive transfers and poor safety awareness, as it had been expressed in nurse-to-nurse report after (Resident #2) had left the hospital that she would require nearly 1: 1 supervision for safety. This level of care had not been communicated in her referral, but was quickly identified and appreciated on her arrival. At the time of my observation, the nurse had been in the room with (Resident #2) from the time of her arrival. She expressed sincere concern for the level of care that (Resident #2) was requiring, due to her fall risk and behaviors identified. (Primary physician) was contacted regarding this admit and nursing expressed their concerns for safety and her level of care required, as this is not a behavioral unit. It was discussed with (primary physician) at this time that it was not an appropriate fit for (Resident #2) to be admitted to this facility and nursing's request to transfer her back to (the hospital) for more appropriate discharge plan. (Primary physician) agreed with this plan. The facility's Transfer and Discharge policy, included a section titled Required Documentation, which stated In the event the discharge or transfer is necessary for the resident's welfare and the facility cannot meet the resident's needs .the physician should document in the medical record: a. Specific need that could not be met; b. Facility efforts to meet those needs through care planning interventions, accommodation of individual needs and attention to the resident's customary routines; and c. Specific services the receiving facility will provide to meet the needs of the resident which cannot be met at the current facility. Resident #2's record did not include documentation from the physician regarding what specific needs Resident #2 had the facility could not meet, what efforts the facility had made to meet Resident #2's specific needs, or what specific services the receiving facility would provide to meet Resident #2's need that could not be met by the facility. c. A progress note, dated 10/22/20 at 5:55 PM, stated Later in the evening, nursing received a call from (emergency room physician) wanting to know why (Resident #2) had been transferred back to the hospital. I returned (emergency room physician's) call and discussed with him that in her referral, (Resident #2) was described to us as a high functioning, dow[DIAGNOSES REDACTED] individual who would be coming to us for skilled nursing and therapies after experiencing GLF's (ground level falls) at home likely related to UTI (urinary tract infection). I expressed to (emergency room physician) that it is common to receive an admit that doesn't always reflect the referral and we always do our best to support the variances. However, in this situation this facility is not staffed to support the level of direct care/supervision that (Resident #2) requires. (emergency room physician) stated that he was unaware that (Resident #2) had a reported fall in the hospital the night before, had pulled her IV (intravenous) line out or required primarily 1: 1 supervision for safety. He agreed with me that the communication should have been better on events that precipitated her discharge, that he would be following up with hospital staff regarding these incidents that were not passed on to him. (Primary physician) was then informed of my conversation with (emergency room physician) that evening. The facility's Transfer and Discharge policy, included a section titled Information Conveyed to Receiving Provider, the policy stated Information provided to the receiving provider should include .Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer . The facility did not provide communication with the receiving hospital regarding Resident #2 to ensure continuity of care. The policy also stated Facilities may choose their own method of communicating transfer or discharge information, such as a universal transfer form or an electronic health record summary, as long as the method contains the required elements .The transferring or discharging facility may transmit the information electronically in a secure manner which protects the resident's privacy, as long as the receiving facility has the capacity to receive and use the information .Communication of this required information should occur as close as possible to the time of transfer or discharge. Resident #2's record did not include documentation required information had been provided to the hospital. Resident #2's record did not include a written notice of discharge, physician documentation regarding the reasons for her transfer, and communication requirements were sent to the receiving provider.

Based on policy review, record review, and staff interview, it was determined the facility failed to keep a complete and accurate medical record for 1 of 3 residents (Resident #1) reviewed for discharge. This deficient practice resulted in incomplete documentation of the course of stay for Resident #1 and was a practice that could diminish the accuracy and completeness of other resident records. Findings include: The facility's Resident Medical Record policy, revised 2/28/19, stated, Medical records are maintained on each resident in accordance with accepted professional standards and practice .are: Complete; Accurately documented; Clear, concise, and complete reflecting resident responses and outcomes related to care received; Readily accessible; and Systematically organized. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Progress notes, from the date of admission on 9/7/20 through 9/11/20, did not include documentation when or why Resident #1 was discharged from the facility. Emails between facility staff, dated 9/11/20 through 9/15/20, were provided by the facility. An e-mail dated 9/11/20 stated, (Resident #1) is going to the hospital for a procedure after [MEDICAL TREATMENT] (8pm) he will be returning the following evening at (5pm). There was no documentation in Resident #1's record about an outpatient procedure scheduled for 9/11/20. On 10/28/20 at 9:07 AM, Clinical Resource Staff #1 said, I could not find a physician summary of the resident's stay and there would not be a discharge order because he was sent to the hospital from [MEDICAL TREATMENT]. On 10/28/20 at 9:07 AM, the Admissions Coordinator said, He was supposed to be at (a community hospital) for an outpatient procedure and he never came back. On 10/28/20 at 9:45 AM, the DON said, He went to [MEDICAL TREATMENT] and went to have a procedure at (a community hospital) and was supposed to be returning on Sunday. A nurse had attempted to contact the family on the 13th to see when he was coming back. They left a message on the phone. Resident #1's record lacked evidence this information was documented. The DON said, I would have liked to see a physician summary of the discharge, that's an appropriate thing to have in the record. Resident #1's record did not include documentation detailing of an outpatient procedure, transfer to an acute hospital, or Resident #1's discharge from the facility. A phone interview with Resident #1's daughter was conducted on 10/28/20 at 10:10 AM. She indicated Resident #1 had declined after his outpatient procedure, was transferred to an acute long-term care facility, and then to the town in which she lived, and ultimately passed away. Resident #1's record was not complete and accurate.

Based on observation, interview, and record review the facility failed to implement and maintain standard infection control measures and practices to contain or prevent facility transmission of COVID-19 infection. The facility reported an active COVID-19 outbreak with 33 of 50 current residents and 24 staff positive for COVID-19. The facility designated an area of the facility as a COVID unit but failed to ensure physical separation and dedicated staff for the COVID unit in accordance with Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services. (CMS) guidelines. The COVID unit shared a nursing station and common areas with the non-COVID unit with ongoing co-mingling of COVID and non-COVID unit staff and co-mingling of COVID staff and non-COVID staff's PPE (personal protective equipment) for re-use. Staff failed to perform hand hygiene when indicated and staff traveled between the COVID and non-COVID units without changing PPE. The facility failed to ensure staff donned, doffed, and used PPE in accordance with accepted standards of practice to prevent contamination of PPE intended for reuse and to prevent transmission of COVID-19 or other infectious organisms from one person, object, or surface to another. These failures placed all COVID negative residents and staff in the facility in immediate jeopardy and at risk for facility-transmission of serious and potentially life threatening COVID-19 infection. Findings include: Upon arrival at the facility on 8/10/20 at 10:15 AM, the facility main entrance opened to the foyer. The foyer had two wire shelf units filled with lunch-size brown paper bags. The bags were dated and labeled with staff names. A large plastic tub in the lobby held washable/reusable gowns. Facility administrative staff performed screening and directed surveyor to don a gown and keep the facemask and eye protection on while in the facility. The administrator explained all staff except for staff assigned to the ventilator unit entered and exited through the main entrance for screening and to don a gown, facemask and eye protection. The administrator stated the brown paper bags held facemasks for staff reuse for up to 5 days. During an interview on 8/10/20 at 10:30 AM the facility Administrator and the Director of Nursing (DON) reported the facility experienced an outbreak of COVID-19 with a total of 34 residents and 24 staff tested positive. The administrator reported the facility implemented physical barriers and dedicated staff to ensure separation of a COVID-19 positive unit (200 and 300 halls), a quarantine unit for new admissions (400 hall), a COVID negative unit (100 hall), and specialized Ventilator unit (500 hall). The DON provided a copy of the LTC Respiratory Surveillance Line List for the period 7/15/20 to 8/8/20 which showed positive COVID-19 test results for residents residing on the 200 and 300 halls. Most recently, positive results were reported for R2 and R5 on 8/3/20. In the prior two weeks, 7/26/20 -8/8/20, positive COVID-19 test results were reported for fourteen staff who worked on the listed departments or units; 100 hall, 200 hall. 100/200, ventilator unit, wound care, dietary, and maintenance. The DON said COVID positive residents were moved to the 200/300 COVID unit. The DON confirmed a census of 50 with 33 of 50 (66%) current residents COVID positive. On 8/17/20/20, review of the Centers for Disease Control and Prevention (CDC) cases and deaths by county report at htttps://www.cdc.gov/coronavirus/2019-ncov/cases-updates/county-map.html, updated 8/17/20, showed Canyon County, the location of the facility, had 2,768 cases per 100,000 indicating a high level of community COVID-19 activity. The door from the foyer led to a large open corridor with an open sitting area and a nurse station. The nurse station was directly ahead and was open to the corridor. A corridor to the right had a temporary plastic barrier that hung from ceiling to floor and wall to wall across the entrance to the 100 hall. The plastic barrier had an opening in the center to allow staff to pass through. The corridor to the left housed a conference room, dining room, kitchen and other services. The corridor straight ahead was the 200/300 halls (COVID unit). The COVID unit was open to the corridor and nurse station. Resident rooms [ROOM NUMBERS] were directly across from the open nurse station. On 8/10/20 at 11:50 AM the 201 and 203 doors were open. Resident (R1) sat in the doorway to room [ROOM NUMBER] and called out for assistance. Licensed nurse LN1 wore two gowns, LN1 entered the room and repositioned R1's wheeled chair to next to the bed. LN1 removed disposable eating utensils and disposable food containers from the room. LN1 changed gloves and performed hand hygiene then still wearing the two gowns, LN1 went directly to room [ROOM NUMBER] and removed eating utensils and food containers. Still wearing two gowns with mask and face shield, LN1 went from room [ROOM NUMBER] to the nurse station. LN1's top gown was tied loosely at the neck. LN1 pulled the gown up over her head and then hung the gown on a hook in the nurse station. LN1 performed hand hygiene with ABHR (alcohol-based hand rub) after doffing the gown. Five gowns hung on hooks at various locations throughout the nurse station and one hung in the corridor. Three of the gowns were hung with the outside of the gown out and two were hung with the inside out. When asked about the gowns, LN1 pointed out a plastic tub on the floor that held clean gowns. LN1 said you need to put on a gown to go in the 200 and 300 halls. LN1 said you put it on over the gown you put on at screening. LN1 said, Then you just find an empty hook somewhere in the nurse station so you can use it again during the shift. LN1 said the facility issued a new facemask and face shield or goggles every five days and added This is my Monday so I have new PPE. On 8/10/20 at 12:40 PM central supply staff (CS1) exited from the Ventilator unit and went to 100 hall. CS1 pushed a cart with supplies and went from room to room on the 100 hall. CS1 wore a gown, facemask, and eye protection. CS1 did not wash hands or perform hand hygiene after exiting each resident room. CS1 said she did not touch anything, just dropped off supplies When interviewed, CS1 explained that her duties in central supply included stocking resident rooms, nurse stations, and other areas of the building such as supply closets. CS1 said she was in the process of delivering supplies. CS1 described her typical day and duties. CS1 said she was screened at the front entrance then put on her facemask, eye protection and gown then went outside to central supply. CS1 said she always started her day in the clean area, the ventilator unit. Then went to the other units and lastly the COVID unit. CS1 said she wore the same gown all day and mask for five days for all units. CS1 said after she went on the COVID unit she did not go anywhere else in the building until the next morning. CS1 stated at the end of the day she returned her mask to her brown bag in the front lobby area for reuse the following day. On 8/10/20 at 1:18 PM nursing assistant (NAC1) was observed in room [ROOM NUMBER]. The door was wide open. NAC1 made the bed nearest the door. NAC1 wore a facemask, eye shield, and two gowns. NAC1 did not wear gloves. NAC1 leaned against the bed and [MEDICATION NAME] the bed linens with her forearms and hands. When asked if she should wear gloves to make the bed, NAC1 responded Yes, I need gloves. NAC1 stated PPE supplies were available but she must have forgot the gloves. Observation on 8/10/20 at 1:18 PM; NAC1 and NAC2 were observed in the nurse station wearing two gowns. Two randomly observed staff each wearing one gown exited the nurse station and entered the COVID-negative 100 hall. RCM1 exited through the plastic barrier and entered the nurse station. RCM1 wore one gown and sat at a computer in the nurse station. 100 hall staff and COVID unit staff comingled at the nurse station and both COVID unit staff and 100 hall staff went down the hall toward the dining room. In an interview on 8/10/20 at 3:00 PM the DNS stated the breakroom and time clock were located at the end of the corridor (dining room). On 8/10/20 at 1:22 PM NAC1 and NAC2 prepared to perform incontinent care for R3. NAC1 and NAC2 wore facemasks, eye protection, gloves, and two gowns. NAC2 unfastened the incontinence brief and cleansed R3's perineum (area between legs) and noted bowel movement on the wipe. R3 moved onto her side and NAC1 cleansed the BM and changed gloves. NAC1 did not wash her hands or perform hand hygiene with ABHR before donning clean gloves. NAC1 and NAC2 placed a clean brief on R3. NAC1 again changed gloves with no hand hygiene. When asked about the second glove change, NAC1 said she changed them because she touched the new brief. NAC1 confirmed she did not perform hand hygiene with glove change. NAC1 and NAC2 were interviewed immediately following incontinent care.at 1:40 PM. When asked what the facility instructed staff about hand hygiene and glove changes. NAC1 said she used ABHR at other places but Not so much here because there was no alcohol in the rooms. NAC2 said she agreed it made it difficult to perform hand hygiene when indicated because the facility did not make ABHR available in the resident rooms. NAC2 said she did not like to leave the resident uncovered or near the edge of the bed and added So I don't leave the resident's side to go way over there (pointed to the bathroom in the far corner of the room) to wash my hands. NAC2 said the facility taught/instructed staff to perform hand hygiene each time gloves were changed. On 8/10/20 observation of the nurse station between 2:02 PM and 2:30 PM revealed LN2 entered the nurse station wearing two gowns, facemask and eye protection (goggles), but no gloves at 2:06 PM. With bare hands, LN2 removed her goggles and laid them face down on the chart rack, then removed her isolation gown and hung it on a hook. LN2 then re-donned the goggles touching the front of the goggles with bare hands. LN2 sat at the desk in the nurse station without disinfecting/sanitizing the chart rack where she laid the contaminated goggles and without performing hand hygiene after doffing her contaminated gown and handling contaminated goggles. RCM1 traveled back and forth between the 100 hall and the COVID unit. RCM1 brought ice and handed it off to COVID staff. RCM1 entered rooms at the back of the nurse station, handled the staffing clipboard and sat briefly at the nurse station desk conversing with COVID unit staff LN1 and LN2. RCM1 wore one gown, facemask, and eye protection and returned to the 100 hall in the same gown, facemask, and eye protection. In an interview at 2:23 PM when asked where the nurse station was for the 100 hall, LN2 said It is right here. LN2 confirmed the nurse station also served the COVID unit but added; RCM1 is the nurse for the 100 hall but RCM1 does not come out here much (referring to the nurse station). When informed of observations of co-mingling of staff from the COVID unit and the 100 hall, LN1 and LN2 agreed staff comingled, including close contact such as tying gowns for each other and sharing of the nurse station space and equipment including computer keyboards, documents and supplies. CDC website: Responding to Coronavirus (COVID-19) in Nursing Homes; Considerations for the Public Health Response to COVID-19 in Nursing Homes Updated Apr. 30, 2020 Considerations for establishing a designated COVID-19 care unit for residents with confirmed COVID-19 Ideally the unit should be physically separated from other rooms or units housing residents without confirmed COVID-19 o Depending on facility capacity (e.g., staffing, supplies) to care for affected residents, the COVID-19 care unit could be a separate floor, wing, or cluster of rooms. Assign dedicated HCP (health care professionals) to work only on the COVID-19 care unit. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. HCP working on the COVID-19 care unit should ideally have a restroom, break room, and work area that are separate from HCP working in other areas of the facility. o To the extent possible, restrict access of ancillary personnel (e.g., dietary) to the unit. o Assign environmental services (EVS) staff to work only on the unit. If there are not a sufficient number of EVS staff to dedicate to this unit despite efforts to mitigate staffing shortages, restrict their access to the unit. Also, assign HCP dedicated to the COVID-19 care unit (e.g., NAs) to perform cleaning and disinfection of high-touch surfaces and shared equipment when in the room for resident care activities. Observation: 8/10/20 at 2:28 PM LN2 got up from the desk in the nurse station and went to a small table with the assignment book, LN2 pulled her mask down and her goggles up then lifted her gown and wiped sweat from her face with the front of the gown. LN2 replaced her goggles and facemask and sat back at the computer with no hand hygiene after handling her facemask and eye protection and no gown change after wiping her face including her mouth and nose with the gown In an interview on 8/10/20 at 3:00 PM DON said the facility had adequate PPE supplies and utilized a PPE conservation plan. DON explained the current facility expectation regarding PPE. DON said it was company policy for staff to don either facility provided scrubs or a cover gown when entering the facility and wear facemask and eye protection for continual use for all care in the facility. DON said washable gowns for extended use on the COVID unit (200 and 300 hall) should be donned when entering the unit and doffed when exiting the unit. DON said the COVID unit should use one gown per one staff per shift. DON said the COVID-negative unit (100 hall) was on a two-gown system in which the staff donned an isolation gown over the top of the cover gown to enter a resident room that required transmission-based precautions. Gowns hung on the outside of the 100 hall rooms and staff donned the gown and gloves at the threshold. When asked why gowns hung on the outside of the door instead of inside the room, DON said it was originally due to wall space in long term resident rooms that had many decorations and no space to hang gowns. When informed of observations of COVID unit staff donning and doffing PPE in the nurse station, DON said the practice was unacceptable. DON stated all staff were trained on PPE use including proper sequence and technique for donning and doffing. The facility policy titled Personal Protective Equipment (PPE) Conservation Plan read in part: *Extended use refers to the practice of wearing the same PPE for repeated encounters with several residents, without removing PPE between the encounters. Extended use may be implemented when multiple residents are infected and placed together in dedicated area, room, or unit(s). *Reuse refers to the practice of using the same piece of PPE for multiple encounters with residents under precautions but removing it ('doffing') between encounters with other residents. The PPE is stored between encounters and reused. *Continual use refers to the practice of wearing the same PPE for all resident care as the PPE is dedicated for use by individual healthcare personnel for a single shift. Decontamination is required between continual use shifts. Procedure: IA. Gloves are single patient use. Hand hygiene occurs prior to putting on (donning) and with taking off (doffing). New gloves are utilized for each new patient. D. Extended use is preferred over re-use on the premise that it is safer for the health care professional (HCP) to leave their mask and eye protection in place, to reduce the risk of self-contamination through frequent donning and doffing of the same equipment. G. Donning and doffing PPE is an essential process to prevent contamination of the item and protect the employee. When conservation of PPE is implemented it is even more important to maintain the integrity of the PPE as the exterior/front (outside) of the gown of reused PPE is now soiled during the next donning process. Education is provided to HCP, posters are placed as reminders for good practice, and surveillance is in progress to validate technique. II. Hand hygiene continues to be extremely important. If a staff member touches the front of the mask or face shield, hand hygiene is essential at that time. G. Isolation Gowns Extended Use - Washable/Disposable: 3. Storage - Gowns are only removed during breaks. Remove your gloves, complete hand hygiene and don a clean pair of gloves. Untie gown belt tie, then neck pulling the front of the gown off the shoulders. Ensure that sleeves do not touch your personal clothing. Lean slightly forward. Place one hand down the neck and inside one sleeve without touching the outside of the gown, slide the sleeve cuff over the hand in a straight forward motion keeping hands inside the sleeve, using care that the outside of the gown or sleeve does not contact your clothing. With your hand inside the sleeve, use the sleeve as a barrier to pull the cuff over the other hand. Hands are now both inside the sleeves. Be sure that you are only touching the inside of the gown as the outside contains potential contaminates. While still holding the inside of the gown hang on the hook. The arm openings and the inside of the gown face out for easy donning. Use caution so the outside of the gown does not make contact with the clean side of the gown. Validate that your gown is not touching other gowns. 4. Disinfecting-At the end of the shift. HCP will be asked to doff their gown as they exit the building. Receptacles are placed so that gowns may be collected for laundering, decontamination, and redistribution. On 8/10/20 at 4:00 PM NAC3 and NAC4 provided incontinent care to R3. NAC4 removed the incontinent brief and cleansed the perineum and surrounding skin. NAC4 prepared to open a clean brief when NAC3 reminded NAC4 to wash her hands and change her gloves. The edges of a dressing on the coccyx (tailbone) appeared wet, had a brown tinge and was separating from the skin. When asked if the dressing was OK, NAC3 directed NAC4 to call the nurse. NAC3 said R3 had a large sore. LN1 entered the room, opened a new duoderm (brand of wound dressing) and laid the new dressing on the bed. LN1 removed the soiled dressing, which consisted of duoderm with a foam dressing over the top, and placed it in the trash. LN1 did not change the soiled gloves. While wearing the gloves soiled by the old wound dressing, LN1 opened the door and called out to staff to bring her wound cleanser. LN1 pulled back the privacy curtain and answered a knock on the door. LN1 took the wound cleanser, a spray bottle, and moistened gauze pads. LN1 touched the spray bottle to the bed linens. LN1 cleansed the wound then removed her gloves but did not perform hand hygiene. LN1 donned new gloves and proceeded to dry the area around the wound. LN1 applied a skin preparation and the dressing. LN1 placed the bottle of wound cleanser on the table near the door, removed her gloves, and used ABHR for hand hygiene in the corridor. LN1 removed the top gown in the nurse station using bare hands. The Centers for Disease prevention and Control website provided guidelines for glove use: When and How to use gloves. Wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. *Gloves are not a substitute for hand hygiene. *If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. *Perform hand hygiene immediately after removing gloves. *Change gloves and perform hand hygiene during patient care if; gloves become damaged *gloves become visibly soiled with blood or body fluids following a task *when moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs. *Never wear the same pair of gloves in the care of more than one patient. *Carefully remove gloves to prevent hand contamination. On 8/10/20 at 4:30 PM facility administrator and DON were informed deficient infection control practice was identified regarding no physical separation of COVID-positive unit with comingling of COVID-positive unit and COVID-negative unit staff in a shared nurse station and common areas. COVID positive unit staff donned and doffed contaminated PPE in the shared nurse station. PPE was not donned and doffed correctly for safe reuse and staff failed to perform hand hygiene when indicated/required. Staff CS1 worked on all units during the course of the day including ventilator unit, COVID positive unit, and COVID negative unit while wearing the same PPE. At 4:40 PM, the administration was informed that these findings represented systemic failure in infection control and prevention and constituted immediate jeopardy. On 8/11/20 at 11:30 AM the facility administrator presented an immediate jeopardy removal plan that included re-education of staff regarding separation of COVID unit and dedicated COVID unit staff, PPE use, and handwashing. The facility relocated barriers to define and segregate the COVID unit, and revised central supply procedures. On 8/11/20 observation at 10:00 AM revealed the barrier was relocated to include nurse station in the COVID unit and separate the COVID unit from the remainder of the building. The COVID-negative unit was now open to the common area and foyer entrance. Observation on the COVID-negative unit (100 hall) revealed signage on room [ROOM NUMBER] that read simply Stop. Speak to nurse before entering. The signage did not indicate required PPE. Two gowns hung on wall hooks in the corridor outside resident room [ROOM NUMBER]. One gown hung inside out and one gown hung incorrectly with the outside out. Outside of room [ROOM NUMBER], two gowns hung, stacked on one hook both gowns were outside out. Two gowns hung on separate hooks outside rooms 114 one inside out and one outside out. The DON observed the 100 hall gowns and agreed they were hung incorrectly. The DON said the gowns must be doffed in a manner to prevent contamination and the gown should consequently be inside out when hung to prevent contamination of staff when re-donned. DON said staff were educated and re-educated on donning and doffing PPE for reuse. DON spoke to RCM1 regarding reuse of gowns and directed the gowns be discarded and new gowns hung properly. Observation on the COVID unit at 1:48 PM revealed a gown hanging outside out on a hook in an office designated as COVID unit breakroom. LN3 worked at a desk and acknowledged it was her gown. When asked if the gown was properly hung, LN3 said she did not know about the gown right or wrong because she was off 2 ½ weeks and just came in to help. LN3 said she was a wound nurse. NAC4 spoke up and said the gown was not properly hung for reuse. On 8/11/20 at 2:15 PM NAC5 measured resident vital signs (temperature, pulse, oxygen saturation). NAC5 took the wheeled vital sign equipment caddy into room [ROOM NUMBER] and placed the blood pressure cuff on R11's arm then placed the oxygen saturation monitor device on a finger. NAC placed the blood pressure cuff and finger probe into a basket attached to the wheeled caddy. NAC5 recorded the vital signs on a clipboard then placed it in the basket. NAC5 sanitized his hands but did not sanitize the blood pressure cuff or finger probe which had direct contact with the resident's hand. NAC5 repeated the process in room [ROOM NUMBER], 214, and 217. When asked if vital sign equipment should be sanitized between residents, NAC5 said he was not sure. In an interview on 8/11/20 at 2:28 PM when asked what the facility taught and expected regarding equipment that was shared from room to room and resident to resident, NAC 4 stated things like Hoyers (mechanical lifts) did not get wiped down because they were not shared with other units. Regarding vital sign equipment, NAC4 said it should be wiped down with alcohol between residents. The facility infection control policy for transmission-based precautions was consistent with CDC guidelines. The facility policy stated: Contact surfaces: 1. Resident Care Equipment: a. dedicated use of noncritical resident care equipment for the residents in enhanced precautions. B. If this is not possible, then the equipment should be cleaned and disinfected before use on another resident using an EPA registered disinfectant. C. Items are to be cleaned in the resident's room, then brought out and left to air dry. At 2:17 PM CS1 entered the COVID unit already wearing a facemask, eye protection and a gown pushing a wheeled cart stacked high with supplies such as packages of incontinent briefs, boxes of gloves, and other supplies. CS1 went into room [ROOM NUMBER] and donned gloves, CS1 proceeded down the hall and entered each room sometimes leaving supplies in the room. When asked if anyone spoke with her about being on the COVID unit, CS1 said Yes when it all started. CS1 said she knew she had to start on the cleanest unit so she started her day on the ventilator unit and lastly the COVID unit. CS1 said she knew about the wall move because she saw them moving it yesterday but was not aware of any other changes. CS1 said she was not informed of change to central supply processes. At 2:45 PM CS1 moved the cart down the hall to a room labeled temporary storage. CS1 held packages of briefs and other supplies against her gown as she moved them from the cart into the storage room. CS1 approached surveyor and asked Should I change my gown when I come on this unit? When asked what the facility told her to do CS1 responded Well no one else changes gowns on this unit. CS1 confirmed that the supplies may be used in other units in the building and asked Why? When informed of observation of supplies held against her contaminated gown, CS1 again asked Do you want me to change my gown? CS1 added she showered when she got home. CS1 was again advised to seek direction from the facility. The above findings were shared with the DON. The DON said NAC4 correctly described the facility process that required vital sign equipment be sanitized between residents. DON said; Ideally CS1 should not go on the COVID unit. CS1 should pass supply cart through to COVID staff and then the cart must be wiped down. DON said she spoke with CS1 but perhaps was not clear enough regarding facility expectations with regard to essential dedicated staff on the COVID unit. In a meeting on 8/11/20 at 4:00 PM the facility administrator was informed of ongoing practice concerns regarding PPE use, dedicated staff for COVID unit and failure to sanitize resident care equipment between uses for different residents. The facility IJ removal plan was not fully implemented. The immediacy was not removed and the immediate jeopardy was ongoing at the conclusion of the onsite survey.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the transmission of COVID-19 when they 1. Failed to implement and follow the CDC's guidance to use all COVID-19 Personal Protective Equipment (PPE) for newly admitted residents during a fourteen day observation period and 2. Failed to implement and follow mitigation strategies for limited PPE. These failures had the potential to transmit and spread the coronavirus that causes COVID-19 to other residents at higher risk for severe illness which included residents who have serious underlying medical conditions, and staff. Findings: Observed Licensed Practical Nurse (LPN) 3 prepare and administer medications for Resident 22 on [DATE] at 09:30 AM. While preparing medications, LPN3 stated she had been working at the facility for about one year. She stated that Resident 22 went to [MEDICAL TREATMENT] 3 days a week, used oxygen and had a [MEDICAL CONDITION] (a surgically created hole (stoma) in the windpipe (trachea) that provides an alternative airway for breathing). LPN3 entered Resident 22's room at 09:45 AM with the medications wearing a mask and hands the prepared medication to the resident. LPN3 exited the room at 09:51 AM and performed hand hygiene. LPN3 confirmed she was assigned to work on the hallway with residents who had tracheostomies, and ventilators (the 500 hallway) as well as the hallway where the new admissions were co-horted together (hallway 400) during the COVID-19 observation period. Resident 22's Admission Record was reviewed on [DATE]. It revealed Resident 22 was admitted on [DATE] and [DIAGNOSES REDACTED]. On [DATE] at 10:10 AM observed LPN3 prepare to apply topical medication for a resident on the 400 hallway. LPN3 who was already wearing a mask, gathered Resident 24's medication and gloves and entered the room. Following application of medication, LPN3 removed gloves in the room and discarded them. She then exited the room and proceeded to a sink and washed hands. LPN3 did not don an isolation gown, or eye protection prior to entering the room. During an interview immediately following this observation, LPN3 stated that new admissions were quarantined for 14 days. LPN3 described the required precautions needed for new admissions were the standard precautions, a mask, and extra handwashing. When asked if Resident 24's COVID-19 status was known or unknown, she stated Right now they don't have any symptoms. When asked to clarify if any of the newly admitted residents were negative for COVID-19, she stated We don't know for sure. When asked if she was aware of the CDC's recommended PPE for new admissions with unknown COVID-19 status, she was unable to relay what the recommendation was, asking Just a mask and hand washing? Resident 24's Admission Record was reviewed on [DATE]. It revealed Resident 24 was admitted on [DATE] from an acute care hospital. The acute care hospital Emergency/Urgent Care exam read the resident's [DIAGNOSES REDACTED]. Registered Nurse (RN) 2 stated during an interview on [DATE] at 10:40 AM she had worked at the facility for at least a year. She confirmed she does work on the New Admission hallway sometimes, though she usually works on a different hallway. When asked to describe the process for new admissions in light of the public health emergency, she stated they are quarantined for 14 days. When asked to explain what that meant, she stated they are separated from everyone else. She further described that the facility does not accept COVID-19 positive residents due to the ventilator dependent residents in the facility. When asked what transmission precautions were utilized on the new admission hallway, she stated well, standard (precautions). RN2 was able to relay the CDC's recommendation of droplet precautions for residents with confirmed or suspected COVID-19. When asked if the current standard precautions would protect other residents and staff if an asymptomatic COVID-19 positive resident was admitted to the facility she stated probably not. During an interview with the Rehab Director on [DATE] at 11:38 AM she listed the required PPE for providing care to a resident on quarantine as a mask, and gloves. She also described that they tried to see the new admissions at the end of the day, and if they used any equipment they would leave it in the room as dedicated to that resident. Interviewed the Infection Preventionist (IP) on [DATE] at 11:15 AM on the facility's plan to prevent the spread of COVID-19 in the facility. The IP described the current level of PPE was limited and that contingency capacity mitigation actions were being used. When asked to describe how new admissions were handled, she stated the facility did not take residents known to be COVID-19 positive, due to the ventilator patients. Ventilator residents were vulnerable she explained. Newly admitted residents were quarantined on the 400 hallway for 14 days. She clarified that Quarantined meant separated from the rest of the population. She described that residents were observed and monitored for sign or symptoms twice a day. When asked what transmission based precautions the facility used to prevent the spread of possible coronavirus infection, she stated Contact precautions. The IP also stated that during the initial assessment, staff wear gown, mask, and gloves. When asked if they also wore eye protection, she confirmed Yes. When asked if the facility knew if newly admitted residents had COVID-19 or not, she stated their status was unknown. The IP confirmed she was aware the CDC recommended droplet precautions. When asked if the current level of transmission based precautions would prevent the spread of COVID-19 if an asymptomatic resident was admitted , the IP stated No it wouldn't. The IP stated, We wouldn't have enough (PPE) if we were using enhanced droplet precautions. During a phone interview on [DATE] at 04:30 PM with the Administrator and Director of Nursing (DON), they both confirmed that the facility was operating under contingency capacity as described on the CDC's website for Strategies to Optimize the Supply of PPE and Equipment. They confirmed they were reviewing the website during the interview. The DON also confirmed that the licensed nurse assignment to cover both the vent unit and the new admissions hallway was an established practiced. When asked if they had considered the risk of cross-contamination from the new admissions to the high-risk ventilated residents, the DON stated Yes and there was not a risk because they (nursing staff) would practice all the precautions. During this same interview with the Administrator and DON, when asked if they followed the CDC's guidance for transmission based precautions for newly admitted residents with an unknown COVID-19 status, they replied We discussed it with our medical director. If we would have had anyone with signs or symptoms (of COVID-19), we would have done droplet precautions. When asked how they mitigated the PPE shortage, they said We don't accept anyone with signs and symptoms of COVID. And that during the initial admission assessment all PPE was utilized. When asked to clarify what they had done other than opt not to use gowns and eye protection, they replied they understood that because they were having trouble getting PPE from suppliers, that it would be understandable to not use it. Reviewed the facility's undated COVID-19 PREPAREDNESS PLAN on [DATE]. The first bullet point under Local Threat (Community Spread) read in part Infection Preventionist/CNO to research specific . CDC recommendations. The 11th bullet read Screen new admits prior to facility entry and upon admission. A sub-bullet read Use droplet precautions to complete initial assessment. The document did not further detail what precautions were to be implemented after the initial assessment. The 15th bullet read Infection Preventionist/CNO review CDC Guidelines . for COVID-19 regularly for changes/updates and community exposure. Idaho's Southwest District Health reported COVID-19 stats were reviewed on [DATE]. They revealed that Canyon County (the county where the facility was located) had the highest count of confirmed cases and deaths for this district. Confirmed cases read 316, with 6 deaths. Other counties in the district read between 3 and 42 cases, and ,[DATE] deaths. Reviewed CDC guidance titled Preparing for COVID-19 in Nursing Homes accessed on [DATE] at web site, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html . It read in part, Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. HCP (health care provider) should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. CDC Guidance titled Strategies to Optimize the Supply of PPE and Equipment accessed on [DATE] at web site, https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html read Contingency and then crisis capacity measures augment conventional capacity measures and are meant to be considered and implemented sequentially. As PPE availability returns to normal, healthcare facilities should promptly resume standard practices. CDC Guidance titled Strategies for Optimizing the Supply of Isolation Gowns listed Contingency Capacity Strategies as Shift gown use towards cloth isolation gowns . Consider the use of coveralls .Use of expired gowns beyond the manufacturer-designated shelf life for training .and Use gowns or coveralls conforming to international standards. Crisis Capacity Strategies listed Extended use of isolation gowns . Re-use of cloth isolation gowns . Prioritize gowns during high-contact care activities . such as Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care. Under the heading When No Gowns Are Available guidance read, Consider using gown alternatives that have not been evaluated as effective. Nowhere did the guidance read to omit the use of gowns. The [DATE] CMS letter titled COVID-19 Long-Term Care Facility Guidance bullet point 1. read, Nursing Homes should immediately ensure that they are complying with all CMS and CDC guidance related to infection control. A sub-bullet read, facilities should refer to and use guidance on conservation of personal protective equipment (PPE) when unable to follow the long-term care facility guidance.

Based on staff interview and record review, it was determined the facility failed to ensure residents were given at least 30 days notice before discharge. This was true for 1 of 2 residents (#100) reviewed for discharge from the facility. The failure to provide adequate notice resulted in harm when Resident #100 required transfer from an acute care setting to a Skilled Nursing Facility (SNF) in another state where she did not have family. Findings include: Resident #100 was originally admitted to the facility on [DATE]. She was readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. She also had a history of [REDACTED]. A 3/1/18 quarterly MDS assessment documented Resident #100: * had adequate hearing * could see large print * did not speak but usually understood others and was usually understood by others * was totally dependent on staff for all activities of daily living * had limited range of motion in both upper and lower extremities * indicators of pain, such as bracing, guarding, rubbing or massaging a body part or area, clutching or holding a body part during movement, were observed daily in the last 5 days * she received 51% or more of total calories and 501 cc (cubic centimeters) per day or more of fluid intake by IV (intravenous) or tube feeding during the last 7 days * Was administered antianxiety medication 3 of the last 7 days * Insulin injections and opioid medications were administered 7 of the last 7 days * Received suctioning, [MEDICAL CONDITION] care, and was on a ventilator during the last 14 days * Participated in the assessment. A 3/7/18 MDS assessment, coded 99 as the type of assessment (which meant it was not a federally required assessment), documented Resident #100 was discharged to an acute hospital setting on 3/7/18. The MDS assessment was documented as complete on 3/15/18. Resident #100's care plans, goals, and interventions, included: * Diabetes with a goal of no complications through 3/14/18, interventions included medications as ordered and BG (blood glucose) as ordered. * Cognitive deficit with memory, judgment, decision making and thought process, with a goal of Resident #100 displaying understanding by appropriately moving eyes/head in response to questions through 3/14/18. Interventions included, break activities into manageable subtasks, one instruction at a time, encourage resident to make choices within abilities, explain each activity/care prior to beginning it, gently redirect when resident makes inappropriate actions, give two choices when presenting decisions, and observe and report changes in cognitive status. * Impaired communication with a goal of Resident #100's communication needs being met as evidenced by written or non-verbal interactions by 3/14/18. Interventions included providing reassurance, patience, and pen and paper when communicating with Resident #100. * Risk for dehydration with a goal no signs or symptoms of dehydration through 3/14/18. Interventions included a Registered Dietician (RD) to monitor for hydration monthly and as needed and monitor for signs and symptoms of dehydration (sunken eyes, dry mucous membranes, lethargy, mental changes, decreased urinary output, dark concentrated urine, tenting skin). The interventions were initiated or revised on 10/23/17. Free water as ordered, was added 2/19/18. * Feeding tube required related to swallowing impairment with a goal of Resident #100 tolerating enteral feeding without complications and no significant weight loss by 3/14/18. Interventions included NPO (nothing by mouth) and NAR (nutrition at risk) review, initiated 10/3/17. Flush tube with water before and after medication administration, and lung sounds every shift and prn, both initiated 10/23/17. * At risk for pain related to chronic abdominal pain from advanced [MEDICAL CONDITION], revised 10/23/17, with a goal of no complaints of pain, facial grimacing or other signs and symptoms of pain by 3/14/18. Interventions included offer nonpharmacological interventions (repositioning, relaxation, backrub, or diversion), administer ordered pain medications and monitor for effectiveness, notify the physician if satisfactory relief not achieved with medication and other pain management techniques, assess pain every shift and as needed and rule out other causes of discomfort such as the need for repositioning and fever. * Inadequate/compromised respiratory function, [MEDICAL CONDITION], and ventilator dependence with a goal of no s/sx of respiratory distress through 3/14/18. Interventions included Respiratory Therapy (RT), ventilator settings, oxygen use, suctioning, and [MEDICAL CONDITION] care per physician orders; head of bed elevated for comfort and to promote adequate air exchange; monitor for complications (sputum, elevated temperature, SOB (shortness of breath), increased respiratory distress), monitor, observe for, and report respiratory distress to physician. * Discharge Status, long-term care due to my care needs being grater (sic) than can be manage (sic) by my family in the community was initiated 3/6/18, with a goal that Resident #100 remain comfortable with her medical status and placement through 3/20/18. Interventions initiated 3/6/18 included the activities program to provide 1 to 1 visits, encourage visits from family and friends, social services to build rapport through 1 to 1 supportive visits. Resident #100's facility and hospital records included the following information from 2/19/18 to 3/21/18: * 2/19/18 at 11:25 AM Nurse's Note - Re-admission Note: Resident arrived alone, alert and cooperative. * 2/19/18 at 10:30 PM Nurse's Notes - Resident nodding head yes & no. Incontinent of loose stool 1 time. * 2/20/18 at 2:30 AM Nurse's Notes - At midnight, attempted to check BG, resident pulled hand away and placed it under blanket. * A 2/22/18 Nutrition Assessment documented Resident #100 returned to the facility after possible ventilator associated pneumonia, she was on antibiotics and [MEDICATION NAME], and had diarrhea. The RD documented the resident's tube feeding was changed from Glucerna to [MEDICATION NAME] 1.2 to help with the diarrhea then changed back to Glucerna 1.5 at 75 ml/hr for 20 hours per day with 200 ml of free water every 6 hours. * 2/22/18 at 6:00 PM Nurse's Notes - Dietician order to (decrease) TF (tube feeding) to 60 ml/hr. POA (power of attorney) refusing, wants it to remain at 75 ml/hr . * 2/23/18 at 7:30 AM Nurse's Notes - Resident voiding quite regular after urinary catheter taken out. Refused BG this AM. * 2/25/18 at 5:30 AM Nurse's Notes - Refused BG at 6:00 AM, cooperates when she decides. * 2/26/18 at 6:00 AM Nurse's Notes - 5 BMs (bowel movements) in 24 hours and 4 on 2/24/18. New order to check stool for [MEDICAL CONDITION] ([MEDICAL CONDITION], a bacterium that causes diarrhea and more serious intestinal conditions such as [MEDICAL CONDITION]). * 2/26/18 at 6:00 PM Nurse's Notes - Negative [MEDICAL CONDITION], Physician Assistant notified and made medication changes, increased [MEDICATION NAME] to 3 times a day. RD (Registered Dietician) to evaluate TF formula. * 2/27/18 at 10:00 AM Nurse's Notes - Loose stools continue. Resident alert, nodded no when asked if she was in pain. No s/sx of SOB. * 2/27/18 at 2:00 PM Nurse's Notes - New order for [MEDICATION NAME] 1.5 at 70 ml/hr for 20 hours, 250 cc water bolus 4 times a day, and [MEDICATION NAME] for loose stools. * 3/1/18 at 10:00 PM Nurse's Notes - Before 4:00 PM, resident's daughter interrupted nurse, who was on phone with pharmacy, and said the resident's pain was 7 out of 10 and she needed an [MEDICATION NAME]. The nurse explained that [MEDICATION NAME] was not ordered but [MEDICATION NAME] was and would be given as soon as possible. At 4:00 PM, the daughter approached the nurse, who was with another resident, and demanded the [MEDICATION NAME] now. [MEDICATION NAME] was administered at 4:40 PM. * 3/2/18 Nurse's Notes - Late entry for 3/1/18 - Lengthy conversation (with) resident's son & daughter regarding [MEDICATION NAME]. New order obtained to resume [MEDICATION NAME]. Son requested a decrease in [MEDICATION NAME] to 2.5 mg every 6 hours prn. .discussed (with) both the facility's policy of not FaceTiming facility staff on social media platforms & to be respectful of staff's time & when asking them to stop cares by asking multiple repeated questions. Finally, I have requested family to keep clinical questions directed towards licensed nurses or RT. The entry was signed by UM #2. * 3/2/18 - PAR (Patient At Risk) Note: Persistent diarrhea/New RD recommendations/Family issues continue. Diarrhea continues. On 2/22 RD attempted to (decrease) Glucerna rate in attempt to (decrease) episodes of watery stools. However, POA would not agree .Res(ident) seen again on 2/28/18 by RD .order for [MEDICATION NAME] 1.5 at 70 ml x 20 (hours) + 250 ml QID (4 times/day) .accepted by POA .implemented (with) good results. [MEDICAL CONDITION] x 2 have been negative. Will cont(inue) to follow. The entry was signed by UM #2. * 3/2/18 at 1:20 PM - Daughter approached nurse for pain med for resident's pain at 7 out of 10. The nurse reported he asked res ((with) daughter present) if she was in pain. Res reported, 'No' by shake of head. When asked if she wants a pain pill again res responded (with) 'no.' Daughter recognizes (and) acknowledged resident's wishes. No meds given. The entry was signed the UM #2. * 3/2/18 PM Nurse's Notes - Resident's daughter asked [MEDICATION NAME] to be given more often. Resident's son called many times asking for CBC (complete blood count, a lab blood test) to be run, question will be addressed to the Dr / on Dr's journal if it is necessary. * 3/3/18 AM Nurse's Notes - Resident in bed resting throughout day. Alert, respirations even, unlabored, no SOB. No complaints of pain or discomfort. Daughter visited and requested resident get [MEDICATION NAME] at 3:00 PM. * 3/5/18 at 7:00 AM Nurse's Notes - Resident in bed with eyes closed for a while, then stripping, pulling at trach, refuses to wear Prevalon boots or have drsg ings (dressings) to .feet. Res given prn anxiety med (with) good results. * 3/6/18 at 2:10 PM Nurse's Notes - (Physician's name) called to order indefinite hold on [MEDICATION NAME] which he reports (POA's name) is insisting on. * 3/6/18 at 4:15 PM Nurse's Notes - VSS (vital signs stable) (POA's name) repeatedly calling .insisting res be sent to hospital d/t (due to) failure. RT & RN assessed res who had already been assess by RN as easily aroused & no TF issues. Res opens eyes .skin warm & dry, resp(irations) on vent (illegible), some crackles (illegible). BS x 4 (Bowel sounds in all 4 quadrants). No s/s pain. Report to manager who (illegible) to (POA's name). Res waved goodbye to nurse. * 3/7/18 at 1:04 PM Nurse's Notes - Daughter came and said the resident was in pain. The resident was assessed and clearly nodded her head no' when asked if she was in pain. The daughter said she saw the resident say no. * Resident #100's Vital Signs (VS) Flow Sheet documented her blood pressure, pulse, respirations, temperature, and oxygen saturation levels were stable on 3/6/18 and 3/17/18. * Daily Respiratory Therapy notes for 3/1/18 to 3/7/18 documented Resident #100's respiratory status was stable and unchanged, she was suctioned 4 times on 3/1/18 and 3/2/18, twice on 3/3/18, and once daily on 3/4/18 through 3/7/18. * 3/7/18 at 7:45 PM Nurse's Notes - UM #2 received a courtesy call from the Police Department at approximately 7:15 PM and was informed the resident's POA reported the facility was not properly caring for the resident and had requested paramedics transport the resident to a hospital ED (emergency department). The UM advised dispatch that the Ombudsman's office has been notified by facility management team today of the family's escalation of refusing us to provide cares to the resident, causing significantly elevated BGs (329) as well as insisting we give the resident pain medications when the resident is refusing same. Two ambulance services arrived, one at approximately 7:25 PM and another 5 minutes later. The resident's status and family history was provided to both ambulance services. The floor nurse gave clinical report to the first ambulance service, which included VS within normal limits, no tremors, and no s/sx of pain or discomfort. The ambulance service was informed the transfer was at the request of the family, not because of any clinical abnormalities. The resident was transferred at 7:45 PM to the ED. The DNS, Administrator, and Medical Director were informed. * A 3/7/18 hospital H & P documented, Allegedly son is not happy with the care at (name of SNF) and was told that the easiest way to deal with this was to discharge her directly to the hospital, which apparently was done. No other details of the events of the day are present. We have care (sic) for this patient previously, and she is obviously altered . Physical Examination documented, .She does open her eyes to mild tactile stimulus and loud voice. She does track from side-to-side .able to squeeze my hands, but globally weak .able to wiggle her toes, cannot bend her knees or elevate her legs .has [MEDICAL CONDITION], midline, well healed. Assessment and Plan was, 1. Altered mental status, likely multifactorial, no clear source of infection. Chest x-rays did not show consolidation, urine showed no source of infection, no obvious skin infection, and it was unclear if she had been having diarrhea or not. A liter of IV fluids and neurological checks every 4 hours were ordered, and [MEDICATION NAME] (an opioid pain medication) and [MEDICATION NAME] ([MEDICATION NAME] medication) were held. 2. Volume depletion with [MEDICAL CONDITIONS] (elevated potassium and sodium levels) .chronic in nature .suspect this is secondary to lack of access to free water. She has been getting 250 cc (4 times a day) per the MAR . 3. Chronic [MEDICAL CONDITION] . 4. Diabetes, blood sugars look high .may also be contributing to free water loss with osmotic diuresis . 5. Chronic [MEDICAL CONDITION] . 6. Allegedly son does not want his mother to go back to (name of facility). He had her discharged from there today, but did decline to come into the Emergency Department .get Social Work and Case Management involved tomorrow . * A 3/8/18 hospital Consultation note documented, Impression and Plan: .calcium and sodium are elevated because of profound dehydration .our strategy is just to be able to give her fluid and to control her electrolytes .Overall, the patient is at moderate risk for complications during her hospital stay, which includes worsening altered mental status, further electrolyte abnormalities and worsening [MEDICAL CONDITION]. * On 8/10/18 at 11:00 AM, a Notice of Discharge addressed to Resident #100 son, dated 3/13/18, was provided by the facility. It was formal notification of the facility's intention to discharge Resident #100 due to nonpayment of rendered charges after reasonable and appropriate notice was given. It documented the account was past due as of 2/10/18 and the outstanding balance would need to be paid by 4/12/18 to prevent discharge. Information regarding the right to appeal was included in the notice. * A hospital Case Management (CM) Progress Note, dated 3/19/18 at 9:58 AM, documented transfer back to the facility was scheduled for 11:00 AM that morning and Resident #100's son agreed with the plan. At 2:08 PM, the CM documented the facility canceled the transfer due to concerns raised by son and the facility was working with the State Ombudsman and son to develop acceptable boundaries for readmission to facility. The CM documented a physician contacted her after son contacted him with financial questions and other concerns., The CM contacted the facility and was told the financial questions were related to monies owed to the facility. The CM documented, will hold off contacting son until situation with facility has resolved. A 3/19/18 physician progress notes [REDACTED].Disposition: Awaiting for placement since it appears that the family no longer wants her to go back to (facility's name). * On 8/10/18 at 4:30 PM, the SSD provided an untitled typed document, dated 3/19/18, which listed the Administrator, RTS, previous DNS, UM #2, and the SSD in attendance on a phone call with Resident #100's son, the facility's Ombudsman, and the State Ombudsman, to discuss the parameters the facility would like to put into place before we accept the resident back. The parameters were: one phone call at 2:45 PM daily with the UM or RTS, no FaceTime when anyone else was in the room, room move near the nurse's station, must pay share of cost prior to admit, cannot drive her care - will abide by doctor's orders, and POA paperwork by close of business on 3/19/18. The 3/19/18 untitled document documented the son argued on all counts, he was not willing to listen, he would say he would abide by the parameters then argue as to why he could not, and it was decided the Ombudsman would come to the facility for a second meeting. It documented there was a second meeting (date not provided) with the same people present except Resident #100's son who participated by phone. It documented the son became very aggressive and argumentative, he was not willing to agree with the parameters and had a tendency to go in circles and rehash the same information over and over. It also documented quotes from Resident #100's son included, Bad review with facilities in two other towns (including one in another state), We are wonderful. We have extended his mom's life and More than happy to get us paid and they will get us POA paperwork. * A hospital CM Progress Note, dated 3/20/18 at 1:12 PM, documented the CM was notified the that facility will not be accepting pt (patient) back. The CM talked to son .discussed need to locate another SNF that accepts Trach/Vent patients. (Son's name) verbalized understanding. The son was informed the CM was looking at facilities in (name of another state) . At 1:49 PM, the CM documented the resident's son requested she slow down her search for another facility so that he could continue to work with (facility's name). The CM documented she informed the son she would continue to search per protocol and notify him when a facility was located and she would keep him informed of any progress. At 1:59 PM, the CM documented she left a message and sent an email to a SNF in another state. * A 3/21/18 physician progress notes [REDACTED]. * A hospital Discharge Summary with a print date/time of 3/21/18 at 6:28 PM. Resident #100 was discharged to a facility out of state. On 8/10/18 at 12:48 PM, UM #2 said she was present the night Resident #100's son called 911. The UM said none of the resident's family were in facility at the time and that the resident was fine. UM #2 said the resident's vital signs were stable, she did not have fever, and she was not having respiratory or gastrointestinal issues. UM #2 said two ambulance teams responded to the 911 call and both ambulance teams were reluctant to take the resident to the hospital. UM #2 said after a supervisor for one of the ambulance services arrived, they decided to take the resident to the hospital. UM #2 said she gave a verbal report to the paramedics and sent the resident's face sheet, medication list, code status, and the H & P with the paramedics for the hospital. UM #2 said the previous DNS, and the Administrator, were the ones who determined if Resident #100 would be readmitted or not. UM #2 said Resident #100 did not return to the facility. On 8/10/18 at 2:15 PM, the Respiratory Therapy Supervisor (RTS) and the Social Services Designee (SSD) said Resident #100's family's discharge plan was Resident #100 would go home with the son and nephew as the caregivers. The RTS said she had extensive conversations with the son and nephew by phone and with the daughter in person about the need for education and training to care for Resident #100 at home. The RTS and SSD said they tried to get the son and nephew to come in for training on [MEDICAL CONDITION] care, respiratory care, tube feeding and care, and her care in general, but they never came in, and there was no plan for the daughter to be a caregiver. The RTS said the daughter was observed feeding Resident #100 at least twice when the resident was NPO, after which Resident #100 was hospitalized for [REDACTED]. The SSD said the son wanted to drive the care Resident #100 received in the facility and he would make decisions based on FaceTime calls with his sister when she was visiting Resident #100. The SSD said during Resident #100's (MONTH) (YEAR) hospitalization , that she, the previous DNS, and the Administrator had phone conversations with the son and the Ombudsman about the parameters needed for Resident #100 to return to facility. The Administrator and SSD said the facility determined Resident #100 was discharged and return to the facility was not anticipated when they were notified Resident #100's son did not want her to return to the facility. The RTS and Administrator said the hospital case manager reported the son did not want Resident #100 to return to the facility initially but later changed his mind after he checked out other SNF, including one in another state. The SSD said the facility would not allow Resident #100 to return to the facility because her son would not agree to the parameters as outlined. The RTS, SSD, and Administrator said the son initiated Resident #100's discharge from the facility when he called 911 on 3/7/18 and transferred her to the hospital. The SSD said the facility was unable to meet Resident #100's needs as defined by Resident #100's son and because the son was unwilling to agree to any parameters. The RTS said the facility could have met the resident's needs if the son and daughter had not been driving her care contrary to physician orders. Resident #100, who required specialized care including mechanical ventilation, was harmed when the facility did not provide at least 30 days notice, as they wrote in their Notice of Discharge letter to her representative on 3/13/18, and she was transferred to a facility in another state where her family and support system were not available.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents were provided assistance with oral care and bathing. This was true for 4 of 11 residents (#s 2, 4, 5 and 6) reviewed for activities of daily living (ADLs) and resulted in harm to Resident #5 when 12 new areas of dental decay/cavities developed and she experienced oral/dental pain. The failure also created the potential for Resident #4 to experience oral care/dental problems, Resident #2 and #6 to experience alterations in skin integrity, and for all four residents to experience embarrassment and/or rejection by others from unclean appearance and/or odor. Findings include: 1. Resident #5 was admitted to the facility in 2015 with multiple diagnoses, including right side [MEDICAL CONDITION] and [MEDICAL CONDITION] related to a [MEDICAL CONDITION] ([MEDICAL CONDITION] - stroke). A 10/6/17 quarterly Minimum Data Set (MDS) assessment documented Resident #5 had severe cognitive impairment; was usually understood by others and usually understood others; required total staff assistance with personal hygiene; had limited functional range of motion in one upper extremity; and had frequent pain at 5 (on a 0-10 scale). An 8/16/17 care plan documented Resident #5 required staff assistance with all ADLs, including oral care. Staff were to monitor for any oral/dental concerns and notify a nurse and/or Social Services for a dental appointment if necessary. The care plan did not address the potential for oral and/or dental pain. A 9/6/17 physician's orders [REDACTED].#5, schedule a dental appointment, and change the texture of Resident #6's food to mechanical soft until she had been examined by a dentist. A 9/18/17 physician's orders [REDACTED].#5's food back to regular texture per the resident's request. The resident's October 2017 physician orders [REDACTED]. Resident #5's Nurse's Notes, from 9/10/17 to 10/15/17, documented: * 9/10/17 at 4:30 am - first notation of the resident's complaint of tooth pain. * 9/10/17 at 2:00 pm - .tearful .(R) (right) front tooth on the back is painful. Dental appointment scheduled and [MEDICATION NAME] was effective. * 9/11/17 4:00 am - .continues (with) filling that has fell (sic) out . has pain . [MEDICATION NAME] (and) Ibprofen (sic) helps . * 9/11/17 untimed - .continues to complain of pain in her tooth . using anbasal (sic) and [MEDICATION NAME] PRN and had an [MEDICATION NAME] . * 9/12/17 10:00 pm - (Dentist) here .Res(ident) continued to c/o (complain of) pain . * 9/13/17 at 1:00 pm - . has had tooth pain . * 9/14/17 at 11:50 pm - . lost her dental crown according to (interested party). I spoke with (dentist) today . will make time to visit her tomorrow . She cont(inues) to c/o tooth pain. * 9/15/17 at 2 pm - . Dentist in today and assessed tooth . [MEDICATION NAME] out an area . * 9/27/17 at 10:30 am - . c/o pain oral (R) (lower) teeth .Denist (sic) is in facility (and) will exam her today . * 9/27/17 at 1:00 pm - Dentis (sic) into see pt (patient) . filling placed # 25-26-27-24 both sides. Oral hygiene started. Education completed, gause (sic) in place . * 9/28/17 at 1:10 pm - . crying . in pain. [MEDICATION NAME] 50 mg given . for 8/10 dental/oral pain . quietly resting at this time. * 10/2/17 at 11:30 pm - . continues (with) oral pain d/t several cavities . * 10/3/17 at 10:40 am - Resident alerted staff that crown had fallen off front tooth. Able to save crown. No c/o pain . Message left for (dentist) . Awaiting return call. * There were no other entries regarding the dentist or the resident's dental/oral status. Documentation by the dentist included: * 4/10/17 at 12:52 am - . in your facility on [DATE], to see (Resident #5) . having issues (with) her upper front teeth . determined at that time that we could splint those teeth to help them survive . Getting the material needed to do this was the issue . received word thru (sic) you, about her concern to have this done. I came by the facility on April 7th, to verify what I needed. There is a complication in the the whole corner of a tooth . it will have to be rebuilt w/pin retention. The other issue is her loose front right incisor which has a crown . I talked to her (relative) . to confirm . and he was OK . best to plan for Tues(day), the 11th about 1 pm . (On 10/27/17 at 9:30 am, the Clinical Resources Nurse (CRN) said that the dentist's visit notes for 1/31/17 and 4/11/17 were not found). * 9/7/17 - Cleaning . Patient did well - gums should start to feel better after cleaning. * 9/12/17 - . had lost filling or crown. Could not find, but severe traumatic occlusion to upper . teeth . Note: Had to clean pt's teeth before I could see what I was trying to diagnose . Has broken/decayed tooth/teeth needing restoration. Oral hygiene status deficient, will require monitored oral hygiene efforts. I was appalled at the debris (and) plaque on her teeth - hard to even see! Pt has limited use of left hand (and) none of right - how can she clean her teeth(?) Discussed w/ (Resident Services staff) (and) new Facility Director. She has to have help. After cleaning teeth, which were clean 5 days ago, I found 12 new areas of decay!! Cavities since my last exam - [DATE] . So sad!!! Plan: Rec(ommend) Xylitol mints or (gum) .high dose preventive [MEDICATION NAME] toothpaste . * 9/27/17 - It was tough on her today . Fillings placed in # 25, 26, #27 (illegible) both sides . (and) #24 both sides under crn (crown) .Oral hygiene status deficient, will require monitored oral hygiene efforts. Lots of food debris & plaque still, specially (sic) in between teeth. * 10/17/17 - Lost her crn (crown) off tooth #8 which messed up the spint (sic) to stabilize her upper front teeth . Re-cement crn #8 (and) Repair splint . Findings/Assessment: Has broken/decayed tooth/teeth needing restoration. An undated Nurse Aide's Information Sheet included a section titled Mouth Care with Assist marked and own teeth in handwriting. There were no other notations or entries on the form regarding oral care. ADL Records for August, September and October 2017 included spaces to document Resident #5's level of self-performance and highest level of support provided for grooming during each shift (nights, days and evenings) for each day of the month. The ADL Records for this period, however, did not include specific documentation related to oral care. On 10/26/17 at 10:10 am, the Clinical Resource Nurse (CRN) and Unit Manager #1 reviewed Resident #5's grooming ADL documentation. The CRN said the documentation was not specific for oral care and there was no other documentation in the clinical record regarding oral care. The facility's meals were provided at 8:00 am, 12:00 pm and 6:00 pm. On 10/24/17 at 8:55 am, Resident #5 was observed leaving the dining room after breakfast with a Certified Nursing Assistant (CNA), who accompanied the resident to the therapy department. At 10:00 am, the resident was observed in her room with food debris on her front teeth. The resident said staff sometimes helped her with oral care, but had not assisted with oral care that morning. On 10/24/17 at 1:40 pm, Resident #5 was observed in bed with food debris on- and between her top and bottom teeth. At 4:30 pm, the same food debris was still on and between the resident's teeth. The resident said, No, when asked if staff had assisted with oral care. On 10/25/17 at 11:20 am, Resident #5 was observed in her wheelchair with food debris on the top right front tooth and debris between her left front teeth. The resident said she could do her own oral care and answered, No, when asked if staff had offered to help brush her teeth. On 10/25/17 at 4:00 pm, CNA #5 said she makes sure her residents are clean and she helps them get ready for bed. CNA #5 said Resident #5 needed set-up help to brush her teeth with an electric toothbrush and could use the electric toothbrush without problems. On 10/26/17 at 9:05 am, an interested party said s/he had visited Resident #5 several times and found the resident with food particles on- and between her teeth hours after meal times. The interested party said s/he complained to two nurses that Resident #5 was not provided oral care, to which a weekend nurse said she would get after the CNAs about oral care. The interested party said that during later visits the resident still had food in her teeth. The interested party said an electric toothbrush was purchased about 2 months ago to make it easier for Resident #5 to brush her own teeth, but the resident still needed help into the bathroom and with putting toothpaste on the toothbrush. On 10/26/17 at 1:40 pm, Resident #5 was observed in the hallway near her room with a large piece of food debris on her right front teeth and red debris between her teeth. At 2:10 pm, Licensed Practical Nurse (LPN) #3 was observed greeting the resident, who had food debris on- and between her teeth. The LPN noted the food debris and said she would have a CNA help the resident to brush her teeth. Resident #5 developed and experienced pain from 12 cavities when the facility failed to assist her with oral care/hygiene. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly MDS assessment, dated 10/2/17, documented Resident #4 was cognitively intact; was usually understood by others and understood others; required total assistance from staff with all ADLs, including personal hygiene; and experienced functional limitations in range of motion in both upper and lower extremities. Resident #4's ADL care plan, initiated 2/23/17, included an intervention for daily oral care and oral care as needed (PRN), initiated 9/13/17. The September and October ADL Records included spaces to document the resident's level of self-performance and highest level of support provided for grooming (mouth care, hair, nails, shaving) during each shift (nights, days and evenings) for each day of the month. However, there was no specific documentation for oral care. On 10/24/17 at 9:05 am, Resident #4 said she had to ask staff to clean her mouth and teeth. Resident #4, who was observed with a small amount of food debris on her teeth, stated staff did not routinely offer to help her with oral hygiene. On 10/25/17 at 3:45 pm, Resident #4 said only one CNA will offer to provide oral care for her and that she has to ask the other CNAs to help her with oral hygiene. 3. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS assessment, dated 8/31/17, documented Resident #2 experienced both short- and long-term memory impairment, severely impaired daily decision-making skills, and required extensive assistance from- or was totally dependent upon staff to complete all ADLs, including bathing. The ADL Care Plan, dated 8/14/17, documented Resident #2 required staff assistance for all ADLs, was cognitively impaired, exhibited impaired decision making skills, and mobility deficits. Staff was directed to encourage- and provide assistance to the resident with all ADLs. The facility's bath schedule documented Resident #2 was to shower each Wednesday and Friday. Resident ADL Records for September and October 2017 documented Resident #2 was not showered as scheduled on 9/13, 9/15, 9/20, 9/27, 9/29, 10/4, 10/13, or 10/20/17. The ADL Records did not document those showers were rescheduled during this time. 4. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #6's quarterly MDS assessment, dated 8/4/17, documented minimally impaired cognition and extensive staff assistance required, or total dependence on staff for all ADLs, including bathing. The ADL Care Plan, dated 10/6/17, documented staff were to provide Resident #6 with assistance with all ADLs, including oral care, bathing, grooming, washing her hair with medicated shampoo, and personal hygiene. The facility's bath schedule documented Resident #6 was to shower each Tuesday and Thursday. Resident ADL Records for September and October 2017 documented Resident #2 was not showered as scheduled on 9/5, 9/7, 9/14, 9/19, 9/21, 9/28, 10/3, 10/5, 10/10, 10/17, 10/19, and 10/24/17. The ADL Records did not document those showers were rescheduled during this time. On 10/25/17 at 8:50 am, CNA #1 stated she was the only shower aide on the ventilator unit where Resident #2's and Resident #6's rooms were located. CNA #1 stated she had not been able to complete the two residents' showers as scheduled because she had been repeatedly reassigned to another nursing unit. CNA #1 stated she had been trying to provide at least one bath weekly to each resident on the ventilator unit, including Resident #2 and Resident #6, but had not always been able to do so. On 10/25/17 at 9:20; am, the Director of Nursing (DON) stated she was not aware residents on the ventilator unit had not received showers as scheduled.

Based on observation; resident, staff, resident group, and resident family interviews; and review of facility policies and procedures, staffing records, resident records, the facility's grievances, facility in-service records, Resident Council minutes, and the facility's menus and food service; it was determined the facility was not administered in a manner to effectively use its resources to attain or maintain the highest practicable well being of each resident. The administration failed to ensure the facility was in compliance with the following regulatory requirements which affected or potenitally affected all residents in the facility. The failed practice placed the health and safety of 8 of 27 sampled residents (#2, #6, #8, #10, #11, #13, #15, and #25) in Immediate Jeopardy of serious harm, impairment, or death, and had the potential to negatively impact the remaining residents receiving services and treatment at the facility. The facility's administration failed to ensure there were sufficient numbers of qualified staff to provide care and that services were adequate to protect residents from neglect and/or abuse. Specifically, it was determined the facility failed to ensure adequate numbers of trained RN, LPN, and CNA staff were on duty throughout the facility to provide care as planned, and to ensure residents' needs were met, including those with special needs. Facility Administration was informed of the Immediate Jeopardy, and the need to develop and implement an acceptable plan to remove the Immediacy, at 4:20 pm on 7/15/16. Findings include: Widespread Immediate Jeopardy for all resident in the facility was identified in the following areas: * F224 for the facility's failure to ensure residents were free from abuse and neglect. * F353, for the facility's failure to ensure there were sufficient numbers of nursing staff to enable residents to reach their highest practicable physical, emotional, and psychosocial well-being. On 7/13/16 at 4:15 pm, the Administrator stated the facility had been through a number of leadership changes in the preceding months, starting with a long-time administrator and a number of staff in leadership positions leaving the facility en masse. The Administrator stated he had been working in the facility a little over four months, and when he started there was a DNS in place who was not effective. The Administrator stated he had to go through the process to remove the DNS, which took some time, before bringing on the current DNS. The Administrator stated the current DNS had been in place for 2 weeks prior to survey. The Administrator stated he knew the facility had some serious problems, but had not had a chance to address them due to the short time he had been in the facility. The Administrator stated the facility had identified a staffing shortage, and had been utilizing agency nurses from four different agencies, but through their recruiting efforts anticipated they would be able to rely solely on facility staff by 8/1/16. On 7/15/16 at 9:00 am, the RVP stated he had been aware of the facility staffing shortages and the use of agency staff. The RVP stated he was aware the use of agency staff could be problematic in terms of consistency of care, but did not think there had been significant care outcomes for facility residents. The RVP stated the facility's former parent organization had eliminated most nursing policies and procedures approximately a year prior.

Based on observation; resident, staff, resident group, and resident family interviews; facility policy and procedure review; resident record review; review of the facility's grievances; and review of the facility's Resident Council minutes; it was determined the facility failed to ensure there was adequate staffing to provide for the needs and well-being of residents. The failed practice placed the health and safety of The failed practice placed the health and safety of 21 of 27 sampled residents #s 1-10, 14-21, and 23-27)in Immediate Jeopardy of serious harm, impairment, or death, and had the potential to adversely affect the remaining residents receiving services and treatment at the facility when the facility failed to provide an adequate number of trained RN, LPN, and CNA staff on duty throughout the facility to provide care as planned and to ensure residents needs were met due to the high acuity level. The deficient practice also resulted in serious harm, injury, or death for 4 of 4 sampled residents (#s 11, 13, 21, and 22) no longer residing in the facility. Facility Administration was informed of the Immediate Jeopardy, and need to develop and implement an acceptable plan to remove the Immediacy, at 4:20 pm on 7/15/16. Findings Included: 1. Licensed Nurse and CNA staffing: The facility had a specialty unit for residents with ventilators and tracheostomies. At the time of entrance on July 18, 2016 the facility provided care to 7 residents with tracheostomies and 19 residents who were ventilator dependant. According to interviews with CNA #1 on 7/15/16 at 9:55 am and CNA #13 7/13/16 4:55 pm, all residents on ventilators required two person assist for repositioning and transfers, and many of the residents with tracheostomies required two person assist for transfers. Per the CNAs, assisting the residents with ventilators required approximately 20 minutes, even if the minimal amount of care was provided, and required them to exercise extreme caution so as to protect the residents' airways as cares were provided. 2. Resident Group Interview: On 7/13/16 at 11:00 am, the resident group stated, Please help us. We are suffering. The group reported many ongoing problems with the lack of care in the facility. There were 8 residents in group, all of whom expressed issues with the inadequate nursing staff. The Group report included: *They had to wait too long for call lights to be answered. The residents reported call light response times were either slow, or the call lights would be turned off without needs being addressed and staff would leave the room. They reported the staff would tell them Just a minute and that minute would turn into an hour later. * Residents reported they would be in the bathroom, sitting on the toilet, but when they called for assistance nobody would come. One resident stated that within the past week s/he had to wait an hour to be helped off the toilet. * Two residents reported they had to press the call light multiple times to get what they needed. The CNA's entered their rooms and did not have the time to wait and see all the things a resident might need before leaving. When the residents pressed the call light again, the staff got annoyed with them and yelled at them for pressing the call light too much. One resident stated, It hurt my feelings. * The residents reported the ratio of residents to aides was not good. One resident reported s/he had waited up to 2 1/2 hours for assistance to get out of bed. The group stated the night shift or evening shift was the most understaffed. The residents reported the 300 and 500 halls have 1 CNA each to assist all the residents. If both aides were in one room assisting a resident, that left no one to help the others and it felt awful. One resident reported nursing staff did not have time for us or time to do their job, The residents reported the staff rushed them (the residents) out of bed but made the residents wait for nursing staff when the residents needed things. a. Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #24's Quarterly MDS assessment, dated 6/17/16, documented he had a mild cognitive impairment, required extensive assistance of two people for all transfers and extensive assistance of one person for toilet use. On 7/14/16 at 5:05 am, Resident #24's room was on. At 5:08 am, CNA #21 entered Resident #24's room, turned off the call light, then left the room. On 7/14/16 at 5:12 am Resident #24 activated his call light. At 5:23 AM, CNA #21 entered the room, turned off the call light, and left. On 7/14/16 at 5:35 am, Resident #24 activated his call light. At 5:43 am, CNA #21 entered the room, turned off the call light, and left. On 7/14/16 at 5:43 am, CNA #21 stated Resident #24 had put his call light on several times asking for assistance to get up. CNA #21 stated she was the only CNA currently assigned to that hall. She stated she knew she should get Resident #24 up like he asked, but she could not because she had to give change of shift report to the oncoming CNA, and other residents were also activating their call lights. CNA #21 stated Resident #24 required two people to transfer him, and there was no one else to help with the transfer. CNA #21 said with only one CNA, it is hard getting to all the call lights on time and doing what the residents request. On 7/14/16 at 5:44 am, Resident #24 again activated his call light. CNA #21 responded and told him, You are going to have to wait a bit longer. I will get you up in bit. CNA #21 turned the call light off and left the room. On 7/14/16 at 5:58 am, Resident #24 activated his call light again. CNA #21 and a nurse entered the room to assist Resident #24 out of bed. b. Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #8's 4/25/14 ADL Care Plan documented she was dependent on 1-2 staff members for extensive assistance with all cares. On 2/24/16 at 7:50 pm, an I&A report documented Resident #8 was found on the floor after attempting to reach her cheesy bread. The report documented this incident could have been prevented if Resident #8 had bed rails up, and that the facility was low staffed and needed more people. The Witness Accounts documented the following: * Resident #8's O2 monitor was alarming, and she was calling out for help. * CNA #13 stated there were only 2 aides on duty for 28 high acquity residents, and they were in another room assisting a resident off of the commode when the event occurred. The witness statement documented there were untrained ventilator aides called to assist on the ventilator unit when it was short staffed. * RN #10 stated Resident #8 was calling out help, help and stated she fell out of bed trying to reach her cheesy bread. The witness statement documented Resident #8 stated she pushed her call light and no one came to help. In addition, the statement documented a response to Resident #8's call light request had taken too long. The reason RN #10 gave was short staffed. 4. Staff Interviews a. On 7/15/16 at 10:19 am CNA #1 stated the CNA's are instructed to leave residents who cannot talk and take care of the ones who can talk, if you are busy, due to the ones who can talk can report it. She stated residents are lucky to get turned and changed once per shift. CNA #1 stated it sucks going home like this and leaving people like this. She reported over the last few months there had been shift cuts and staff were often sent home due to low census. CNA #1 reported this happened mostly on evening and night shifts, and stated the 200 hall usually had two CNA's on staff, but it had recently been cut to one. b. Observation on 7/14/16 from 5:00 am to 5:45 am (a total of 45 minutes) a call light was on in room [ROOM NUMBER]. No staff was observed on the 200 hall or to answer the call light during this time. On 7/14/16 at 5:00 am., LPN #7 stated that she was an agency nurse, and was the only nurse working the graveyard shift covering hall 100 and 200 halls. LPN #7 further stated, I'm only one nurse to 46 people and it's hard for me to know everyone. It can be very stressful at times. On 7/14/16 at 5:10 am., CNA #22 stated, I'm the only CNA working the 100 unit now for 23 residents. The CNA then stated, There was a time they pulled the 300/500 (identified as the ventilator unit) CNA to float and work the 200 hall because the agency CNA who was assigned to the 200 hall didn't show up. So no one was able to come in. They had no choice to pull the aide off the 300/500 hall to come help the 200 hall. This happened on the graveyard shift about a month ago. c. During tour of the 500 hall on 7/14/16 at 5:10 am, one charge nurse was noted handling multiple tasks. The charge nurse was observed providing guidance to the CNA, LPN, and consulting with the Respiratory Therapist. On 7/14/16 at 5:30 am, the charge nurse, who wished to remain anonymous for fear of retaliation, stated It is very busy back here. Up until last week I had an additional License Practical Nurse but I reported him for sleeping on the job and he was fired. I asked administration when a new nurse would be hired and I was informed if I was able to work on this 500 hall with one nurse sleeping then there is no need to replace the nurse who was terminated. The charge nurse further stated, A disaster is going to happen. There are residents on ventilators back here on the 500 hall. Two nurses can't manage this hall at night. 5. Also, refer to the following deficiencies as they relate to the facility's failure to ensure sufficient numbers of nursing staff: Refer to F224 as it relates to the facility's failure to ensure residents were free from neglect. This failure resulted in all residents in the facility being placed in immediate jeopardy of serious injury, impairment, or death. Refer to F246 as it relates to the facility's failure to ensure call lights were accessible to residents, and the facility's practice of removing call lights from residents for excessive use during periods of low staffing. Refer to F309 as it relates to the facility's failure to ensure changes in residents' medical conditions were monitored, or anticipated, and residents were assessed for pain. Residents were harmed as a result of this deficient practice. Refer to F312 as it relates to the facility's failure to provide assistance with oral care and grooming. Residents were harmed as a result of this deficient practice. Refer to F314 as it relates to the facility's failure to prevent pressure ulcers from developing or worsening. Residents were harmed as a result of this deficient practice. Refer to F315 as it relates to the facility's failure to ensure care and services to maintain or restore urinary continence, or to maintain urinary catheters. Residents were harmed as a result of this deficient practice. Refer to F322 as it relates to the facility's failure to ensure care and services for feeding tube management. Refer to F323 as it relates to the facility's failure to supervise residents sufficiently to prevent accidents. Refer to F325 as it relates to the facility's failure to prevent unplanned weight loss. Residents were harmed as a result of this deficient practice. Refer to F327 as it relates to the facility's failure to ensure residents were adequately hydrated. Residents were harmed as a result of this deficient practice. 6. Leadership Interviews: On 7/13/16 at 3:50 pm, the DNS and Administrator stated they were aware of issues, but could not change it overnight. The Administrator stated the facility had identified a staffing shortage, and had been utilizing agency nurses from four different agencies. The Administrator stated the RTs working would help the residents and he counted them towards staffing needs. The DNS stated the facility had posted positions on multiple Internet employment sites. The DNS stated the facility had offered sign on bonuses for CNA, LPN and RN positions. On 7/14/15, the Administrator provided the RT job description. RT responsibilities included assisting residents with maintaining their respiratory function. The job description did not include: * RT staff was able to assist residents to the toilet, or assist residents change soiled attends and then perform pericare. * RT staff was able to assist residents with eating needs. * RT staff was able to transfer and reposition residents. On 7/15/16 at 9:00 am, the RVP stated he had been aware of the facility staffing shortages and the use of agency staff. The RVP stated he was aware the use of agency staff could be problematic in terms of consistency of care, but did not think there had been significant care outcomes for facility residents.

Based on observation; resident, staff, resident group, and resident family interviews; and review of residents' records and the facility's policies and procedures, staffing records, in-service records, and menus and food service; it was determined the facility failed to ensure residents were free from abuse and neglect. The failed practice placed the health and safety of 17 of 27 sampled residents (#1-#10, #15, #20, #24, and #25) ,8 of 8 residents in the resident group in Immediate Jeopardy of serious harm, impairment, or death, and had the potential to adversely affect the remaining residents receiving services and treatment at the facility. The deficient practice also resulted in serious harm, injury, or death for 3 of 4 sampled residents (#s 11, 13, and 22) no longer residing in the facility. The facility failed to ensure there were sufficient numbers of trained and qualified RNs, LPNs, and CNAs to protect residents from neglect and/or abuse, meet residents' needs, including those with special needs, and provide care as planned. Facility Administration was informed of the Immediate Jeopardy and the need to develop and implement an acceptable plan to remove the Immediacy at 4:20 pm on [DATE]. Findings include: 1. Resident Group Interview: On [DATE] at 11:00 am, a resident group interview was held with 8 residents. One resident stated, Please help us. We are suffering. The other seven residents agreed with that statement. The group reported a consensus on the lack of care and services in the facility. The group consensus included: * It was customary for call lights to be unanswered for anywhere from an hour to two and a half hours, especially in the evenings and at night, starting between 5:00 and 6:00 pm. * Staff responding to call lights enter the room in a hurry, address the primary need identified by the resident, then bolt out without finding out if residents have additional needs, and did not follow up later. * The group reported, They (staff) don't have time for you or time to do their job. They rush us at bedtime, yet you have to wait an hour and a half to use the toilet. * One resident in the group stated if they re-activated their call light too much it was taken away from them. * One resident stated s/he was yelled at for putting his/her call light on, which hurts my feelings. * Other residents in the group reported their call lights were often placed out of reach, prompting them to call out when they needed assistance. * The group stated they suspected this happened to other residents as well, as they could often hear residents hollering out for assistance at night. Residents who resided on the 500 hall stated they could hear residents calling out from other units in the facility and that this was so loud and so frequent their sleep was often disrupted. * Staff would vent their frustrations regarding facility practices to one another while providing cares. One resident stated, We have our own issues. I know they are venting to each other, but it feels like they are venting to me. * The resident group reported staff frequently addressed them like two year olds. One resident in the group stated s/he had been scolded when trying to retrieve personal beverages from the community refrigerator. Another resident stated when s/he took his/her last soda from the refrigerator, s/he was repeatedly reminded in a condescending tone that was their last soda, and s/he had better not be seen near the refrigerator again until s/he had purchased more. * Cares were per staff convenience, not per resident need or preference, and when providing these cares at night staff enter the room abruptly, turn on all the lights, and do not lower their voices. * The resident group reported the facility suffered from a lack of sufficient staff for quite some time, but it is getting worse instead of better. This included a lack of both nurses and CNAs. * The residents reported many of them required 2 staff assistance for ADLs, transfers, and mobility. The residents reported there was rarely enough staff on duty for evening and night shift to meet their needs. The residents reported there were many times when the facility had only ,[DATE] CNAs on the specialty care (ventilator and [MEDICAL CONDITION])unit, but they needed at least 5. The residents stated, With only two or three staff, they can all be in the room helping one person, and there is nobody else to answer call lights for the rest of us. * The residents reported they frequently had to stay in bed too long. sit up in their chairs too long, could not get assistance to come out of their rooms for meals. and could not get assistance for ADLs. * The residents reported the facility frequently served small portions of food. One resident stated, A two-year old eats more than they give us sometimes. * Residents stated whether they ate in their rooms by choice or because there was no one to get them up, they could not get substitutions if they did not like their meal or second helpings if their portion was not sufficient. 2. Individual Resident Reviews: a. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #11 had a urinary catheter, was on a ventilator and had a [MEDICAL CONDITION], when admitted to the facility. Resident #11 remained in the facility until he was transferred to the hospital on [DATE] where he died two days later. The [DATE] hospital discharge summary documented Resident #11's cause of death included intracranial mass of the brain, urinary tract infection, bacteremia, severe [MEDICAL CONDITION] with dehydration, and acute kidney injury. Resident #11's [DATE] H&P documented erosion of the tip of his penis from long term catheter use and the number of times the catheter had become dislodged. On [DATE] and [DATE], the NP documented Resident #11 was at risk for sustaining further injury or interruption should the catheter become dislodged again, and ordered the facility to ensure the catheter was secured. Resident #11's record contained no evidence his catheter was consistently secured to his leg by staff. Resident #11 experienced a change in condition prior to his hospitalization on [DATE]. In the 3 weeks leading up to his hospitalization , Resident #11's Tube Feeding Record did not document the facility was following the physician's orders [REDACTED]. The facility had no documentation of Resident #11's condition for the 52 hours leading up to his hospitalization . When Resident #11 was admitted to the hospital on [DATE], the ED Physician Note, documented at 2:50 pm, stated, He has quite poor hygiene, primarily oral hygiene . Oral mucosa is significantly dry with brownish crusting over tongue and oral mucosa. He is edentulous. Tongue is significantly dry with a layer of brownish crusting. Resident #11 received all nutrition via a feeding tube.The facility's weight record did not have documentation that Resident #11's weights were measured each week as ordered by the physician and directed in his care plan. Resident #11 experienced a severe unplanned weight loss from 176.8 pounds to 159.6 pounds (17 lbs/9.6%)between [DATE] and [DATE], less than 3 months. His tube feeding regimen, however, was not adjusted to stop further weight loss and promote weight gain, and to provide physical and psychosocial comfort. Resident #11's POA was interviewed on [DATE] at 9:40 am. The POA stated he had cared for Resident #11 for [AGE] years prior to admission to the facility. He stated Resident #11 was not provided adequate fluids and he was severely dehydrated when he went to the hospital on [DATE]. The POA also stated Resident #11 had a large growth at his right eye that the facility had not identified or addressed. The POA stated Resident #11's cognition had already begun to deteriorate on [DATE], when the facility scheduled a care conference. The POA stated Resident #11 was alert and oriented at baseline, but became increasingly incoherent over the last month of his life. The POA stated Resident #11 was very thirsty and often asked for ice chips, which he had been allowed to have until he was moved off of the ventilator unit on [DATE]. The POA stated he observed Resident #11 with a dry mouth and with cracked dry lips in the week preceding his hospitalization . The POA stated once Resident #11 moved to a different room after [MEDICAL CONDITION] out and the use of the ventilator was discontinued, he was no longer allowed ice chips, as the facility expressed concern that Resident #11 would aspirate. During a [DATE] care plan meeting the POA stated he expressed his desire that Resident #11 be allowed to have ice chips and that he be allowed to eat and drink. The POA further stated Resident #11's mouth was dry and he was not provided with adequate oral care. Concerns regarding Resident #11's oral hygiene were raised at the care plan meeting held on [DATE]. The POA stated Resident #11 was denied fluids, ice chips and food. The POA stated, He died at the hospital. The doctor said he didn't know how Resident #11 could get so dehydrated. His electrolytes were through the roof. It was like he had been in the desert for weeks. Nobody bothered giving him fluids. On [DATE] at 3:15 pm, CNA #13 stated she remembered Resident #11 requested ice chips, and said, His urine had a lot of sediment; he had low urine output. He wanted ice chips, but he was NPO. We were not able to give (ice chips) due to the (physician's) order. On [DATE] at 5:40 am, LN #8 stated output was recorded per shift for all residents who had catheters. When asked who totaled and monitored the daily output records, he stated, I don't know who reviews it. The nurse practitioner looks at the MAR. I don't know who in nursing is responsible. On [DATE] at 2:20 pm, LN #5 stated she remembered being able to give Resident #11 ice chips and then not being able to. She stated, He got ice chips for a while. At the end I could not let him have them. I felt bad. LN #5 stated Resident #11 asked repeatedly for ice chips. On [DATE] at 2:40 pm, the NP stated nursing was responsible for monitoring urine output and it was nurses' responsibility to let him know of abnormal output. The NP did not remember if he was notified of decreased urine output for Resident #11. However, there was no evidence in the medical record of physician notification of low urine output. On [DATE] at 10:10 am, CNA #1 stated Resident #11 was not provided with adequate oral care. The CNA stated there was not enough staff to take care of the residents. She stated there were a number of instances when she came on her shift and found Resident #11 had not been provided oral hygiene. She stated, He never got oral care done. CNA #1 stated, He asked for ice chips constantly. CNA #1 stated she was told by the nurses not to give Resident #11 ice chips. b. Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #8's most recent Quarterly MDS assessment, dated [DATE], documented moderate cognitive impairment with mild depression, and ,[DATE] staff assistance required with all cares, except eating. The MDS documented Resident #8 rejected cares ,[DATE] days per week and was totally dependent on 2 staff with toileting needs. The MDS documented a bladder retraining trial had not been attempted. On [DATE] at 8:45 am, Resident #8 stated that during the night of [DATE] and early morning hours of [DATE], I had to yell and yell and that got old fast. I was left alone in here and they took away all my communication. Resident #8 was asked to show what was removed from her reach and she touched her call light and stated, They took this away. On [DATE] at 4:25 pm, when the surveyor asked to observe peri-care on Resident #8, CNA #19 and CNA #20 stated Resident #8 received peri care three times a day on a scheduled basis and that it was scheduled to be completed before breakfast, at about 2:45 or 3:00 pm, and after dinner. On [DATE] at 2:45 pm, CNA #19 stated Resident #8 would not receive peri-care that shift because she was in an activity, but that Resident #8 would be offered peri-care at her next scheduled time after dinner. On [DATE] at 5:56 pm, CNA #19 stated Resident #8 did not receive peri-care in the afternoon after the activity because she was up in her chair and it was almost time to eat dinner. c. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #6's Quarterly MDS assessment, dated [DATE], documented no cognitive impairment with minimal signs of depression, total dependence on staff for nutrition via a feeding tube. The MDS documented Resident #6 was able to perform transfers, dressing and ambulation with staff supervision. On [DATE] at 8:36 am, Resident #6 had a meal tray delivered to her room, where she was lying flat on her back with the tube feeding pump still connected to her . Resident #6 was wearing a hospital gown and used a blanket to cover herself because she was not dressed and was embarrassed. She stated she wanted to get out of bed and dressed, but could not because she was still hooked up to the tube feeding pump. Resident #6 reported the pump stopped pumping at 8:00 am, but should have been finished at 7:00 am. Resident #6 stated the tube feeding would often get started late. Resident #6's call light was hooked onto the tube feeding pump stand, out of her reach, and she stated it was placed there by staff. Resident #6 stated she was instructed to remain in bed until a nurse came and unhooked her from the tube pump. On [DATE] from 9:00 am to 10:00 am, Resident #6 remained in her bed and hooked up to the tube feeding pump. The call light remained secured to the tube feeding pump stand and out of her reach. Resident #6 asked the surveyor to get her a nurse because she really wanted to get up and get dressed and could not reach the call light. On [DATE] at 10:01 am, the surveyor informed LPN #4 that Resident #6 requested to get out of bed. On [DATE] at 10:19 am, LPN #4 unhooked Resident #6 from the tube feeding pump. On [DATE] at 8:39 am, Resident #6 was lying flat on her back hooked up to the tube feeding pump, and wearing the same clothes as the day before. Resident #6 again used a blanket to cover herself and the call light was hooked onto the tube feeding pump stand, out of her reach. She remained hooked up to the tube feeding pump until 10:49 am, when LPN #4 administered medications. On [DATE] at 11:00 am, LPN #4 stated she was late getting to Resident #6, as the LPN had to be in the dining room as a licensed nurse was required to be present during residents' meals. On [DATE] at 10:19 am, CNA #1 stated Resident #6 was ignored often by staff and waited for extended periods of time for assistance. On [DATE] at 5:45 pm, the ADON stated it was not acceptable for the tube feeding pump to be left on for extended periods of time after her feeding was finished, or to place Resident #6's call out of her reach. d. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Initial MDS assessment, dated [DATE], documented cognitive impairment, mild depression, and that he required extensive assistance of 2 staff members required for all transfers, and extensive assistance of 1 staff member for hygiene, dressing, and eating. Resident #2's ADL Care Plan, dated [DATE], documented he required extensive assistance or was totally dependent on staff for ADL assistance. On [DATE] from 2:37 pm to 3:50 pm, Resident #2 was observed laying in his bed with his call light on his pillow behind his head and was out of his reach; his water cup was on a table about 3 feet from the bed. Resident #2 remained without access to his call light or his water throughout this seventy-three minute observation. On [DATE] from 8:35 am to 12:30 pm, Resident #2 was observed lying in his bed without being moved or repositioned. Resident #2's water cup was on the bedside table about 3 feet from him from 8:35 am until his lunch arrived at 12:30 pm. Resident #2 was observed in his bed with his call light out of reach, on his pillow behind his head; the call light was moved to within his reach at 10:35 am. On [DATE] at 10:15 am, CNA #1 stated Resident #2 often did not have his call light within reach because the staff was too busy to help him. e. Resident #9 was admitted to the facility on [DATE] with current [DIAGNOSES REDACTED]. His breathing muscles were affected and he subsequently had a [MEDICAL CONDITION]. He required a ventilator to assist with breathing. Resident #9 was quadriplegic and had total loss of the use of all four limbs and torso. Resident #9 was totally dependent upon staff for all activities of daily living. Resident #9's annual MDS assessment, dated [DATE], documented his cognitive skills for daily decision making were not impaired and he was alert and oriented. Resident #9 required the assistance of 2 staff for toileting and personal hygiene. He was able to use his 'blow by' call light to alert staff when he needed to toilet. Resident #9 was dependent upon staff to place the urinal and to assist him onto the bedpan. On [DATE] at 2:20 pm, Resident #9 stated, There is a lack of staff and they are stressed out. They are almost always shorthanded. On [DATE] at 9:05 am, Resident #9 stated, One night they were shorthanded. I was left on the bed pan for 4 hours. Sometimes I have to wait an hour to go pee. What if I had an emergency? I am just scared for the others (residents). Something is going to happen. f. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #13 used a ventilator, had a [MEDICAL CONDITION], and was fed via PEG tube. Resident #13 was discharged to the hospital on [DATE] due to blood in [MEDICAL CONDITION] decreased oxygen saturations. Resident #13 was readmitted to the facility on [DATE]. Resident #13 was again discharged to the hospital on [DATE] for a [DIAGNOSES REDACTED]. Nurse's notes documented: * [DATE], 4:40 am: Resident was (sic) explained implications that can arise from him refusing his feeding and (water). Resident stated 'You guys don't listen!' Resident did allow pm (night) meds to be given and allowed PEG tube to be flushed. Resident stated he will not take his feedings and (water) because he is not toileted quickly enough and does not like to have accidents. * [DATE], 1:00 pm: Resident is alert and oriented, able to make his needs known . He is able to be continent of B & B but tends to need someone right as he is pushing the call light . He says he doesn't like being incontinent and afraid if he eats he will be. * [DATE], no time documented: Resident has refused all meds, food, (and) fluids stating that he will not be eating or anything else until CNAs (and) other staff answer his light with no longer than (illegible number) min (minutes) from time it goes on, because he does not want to have an accident. I proceeded to inform him I'd be there to help & he said no not till everyone does this. I educated him on the issues this would cause like dehydration (and) he said that he was willing to risk this. This stance did not change throughout the shift. * [DATE], 11:00 pm: Pt c/o constantly being incont (incontinent) of urine due to slow response of CNA .Mother reported pt sat in urine for over 45 minutes w/o anyone answering call light. When talking with mother I informed her it had only been 25 minutes since I had been in and there was no mention of needing to be changed when asked. On [DATE] at 9:15 am, LN #5 stated she cared for Resident #13 a total of 3 times. She stated the first 2 times she did not have any issues with Resident #13; he allowed all care and did not refuse anything. She stated she answered his call light and Resident #13 told her it was not that way when other nurses were working. LN #5 stated the last time she cared for Resident #13 he refused his tube feeding, medications and respiratory care because he stated his call light was not answered quickly enough. LN #5 stated Resident #13 could remain continent if staff toileted him quickly. On [DATE] at 9:45 am, Resident #13's guardian stated Resident #13 was medically complex and acted younger than his [AGE] years. She stated, He does not have much control but he can say 'No.' She verified Resident #13 got very irritated and upset and as a result refused cares. Resident #13's guardian stated Resident #13 refused tube feeding and water flushes because staff did not toilet him quickly enough. She verified Resident #13 knew when he needed to use the toilet and was incontinent if staff did not toilet him in a timely manner. She stated she visited Resident #13 twice when he waited 25 minutes for staff to respond to the call light and stated, We timed it. On [DATE] at 10:10 am, CNA #1 stated Resident #13 was not toileted due to short staffing. CNA #1 stated Resident #13 knew when he needed to use the urinal and put on his call light, but that he could be continent if he was toileted in a timely manner. CNA #1 stated It is a lot of work to toilet him and it takes 2 people. He could use the urinal. He was not toileted; it was easier to change him than toilet him. On [DATE] at 1:30 pm, Resident #13's family member stated she had been Resident #13's care giver previously and had removed him from the facility a couple of years prior due to poor care. She stated the care had deteriorated since then and was worse now. Resident #13's family member stated Resident #13 refused to allow his tube feeding and water flushes to be administered because staff would not toilet him, which resulted in him soiling himself. The family member stated He told me, 'If I have to piss and[***]on myself, I would rather be dead.' He does pretty well with his bladder (remaining continent)if he is toileted. I timed it; he waited 51 minutes for someone to respond(to his call light)while I was there and not just once. (Resident #13)is stubborn. He(Resident #13)never liked to be messy since he was a small child. I have been in tears a lot of times to see him that way(soiled with urine and feces). Resident #13 was not provided with adequate assistance for toileting and as a result was incontinent. He was aware of the need to void and could be continent most of the time if staff answered his call light in a timely manner. Resident #13 required the assistance of 2 staff for toileting. He was extremely distressed by soiling himself; he refused food/fluids (tube feeding and flushes) because he did not want to soil himself. g. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5's [DATE] Admission MDS assessment documented he required extensive assistance from staff for bed mobility, transfers and toileting; had impaired range of motion with contractures of both lower extremities; had 2 stage IV pressure ulcers; and was cognitively intact. On [DATE] at 2:36 pm, Resident #5 stated, I am paralyzed from the waist down and need a Hoyer lift and 2 people (for transfers). Resident #5 stated he voluntarily admitted himself to the facility to receive treatment and services to heal his 6 pressure ulcers. He stated he allowed himself 2 hours per day to be up in his wheelchair and remained in bed the remainder of the time to promote healing of the pressure ulcers. Resident #5 reported, Staffing on days is good. Evenings are a problem. We had a barbecue on Friday. There was one CNA for the whole floor. I can only stay up for 1 hour. I wanted to go to bed at 7:00 pm. They did not get back to me until 8:30 pm. I was up an hour and a half longer than I should have been. Resident #5 also reported having problems when staff transferred him with the Hoyer lift. He stated there were staff that came to transfer him that did not know how to use the Hoyer. Resident #5 stated there was one instance when he was not transferred properly and was leaning over to the side. Resident #5 stated he no longer allowed certain CNAs to transfer him. A Nurse's Note, dated [DATE], documented Resident #5 complained of shoulder pain relating to a Hoyer lift transfer. Upon investigation, it was determined the CNAs reported the sling was too small. On [DATE], CNA #12 stated Resident #5's transfer approach had been changed a couple weeks prior by Physical Therapy and that a Hoyer was to be used with the assistance of 2 staff, using the sling with 2 straps under his legs. h. Resident #25 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #25's [DATE] Quarterly MDS assessment documented she was cognitively intact, had minimal depression, displayed physical behavioral symptoms ,[DATE] days of the previous 7 days, and was dependent on two staff for bed mobility and personal hygiene. On [DATE] at 10:10 am, CNA #1 stated there was not enough staff to take care of the residents. She said there were several female residents whose hair did not get brushed and that resulted in severe tangling and matting. CNA #1 stated Resident 25's hair was so matted her head had to be shaved. On [DATE] at 11:15 am, Resident #25 was observed lying in bed in a hospital gown. Her hair was approximately,[DATE] inch long. She was on a ventilator with [MEDICAL CONDITION] place. The respiratory therapist came into the room and provided treatment that enabled Resident #25 the ability to talk and then left the room. Resident #25's mouth was dry with a white substance around her lips and a foul odor emanated when she spoke. She had difficulty speaking. When asked if she was provided oral care and baths, she said, No. When asked if staff brushed her hair, she said they did not and stated her hair was tangled and matted prior to it being cut. i. Resident # 20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 20's [DATE] Annual MDS assessment documented he had moderately impaired cognition; difficulty communicating but was able to make himself understood; and required staff assistance for all activities of daily living. A Corrective Action Plan, dated [DATE], and written by LN #10 for CNA #23, documented, I had gone in to give (Resident 20) his meds. He was still in w/c and CNA #23 came in behind me. She goes to (Resident #20) and starts patting him on his left shoulder somewhat forcefully. I told her not to hit his shoulder that it was the one injured. She came back with 'Oh, he's ok. He's not hurt.' Since I had given him something for pain a couple of hours before I was not able to give him anything else at the time. Due to her attitude I stayed in room and helped get him to bed before leaving . You were corrected by the nurse, yet you continued with rough treatment. The nurse felt she could not leave you alone with the resident. On [DATE] at 3:15 pm, the ADON stated she did not know if CNA #23 was an employee of the facility. Later that day she stated CNA #23 was an employee and scheduled to work. Upon arrival to the unit where CNA #23 was scheduled to work, the surveyor was informed CNA #23 had left the unit to go home and was not scheduled to work the rest of the week. On [DATE] at 3:30 pm Resident #20 responded to some yes/no questions regarding activities of daily living but did not respond to questions regarding the incident. The facility failed to ensure allegations of abuse/neglect were investigated. 3. Staff Interviews: a. On [DATE] at 4:55 pm, CNA # 13 reported: * CNAs were directed to assist less cognitively impaired residents before those residents with greater impairment, as the more cognitive residents were more likely to complain about the lack of care. * If CNAs were in a room caring for a lesser cognitive resident, and a more cognitively aware resident put their call light on, the CNAs had been instructed by the charge nurses to leave the lesser cognitive resident to take care of the more cognitively aware resident, then return to the lesser cognitively aware residents as time allowed. * It was uncommon for either facility LNs or agency LNs to assist with responding to resident requests for assistance. * One of the CNAs from the 300 hall was assigned to set tables in the dining room prior to a meal, and clear the tables after the meal. This meant that in the time leading up to and following the evening meal, there was only one CNA to answer call lights on that hall. Many of the residents on that hall required 2 person assistance. * In the evenings, the specialized unit typically had 3 CNAs, although most of the residents required 2 person assistance for ADLs, mobility, and transfers. The CNAs responded to this by having one CNA take vital signs and turn the trachs(reposition residents with tracheostomies), and the other two CNAs assisting residents with ventilators. CNA #13 stated all residents on ventilators required 2 staff assistance, and the only way to successfully provide assistance to all of the residents on ventilators was to go from room to room, rather than retrace their steps to answer call lights. * CNAs did not always have time to provide water, or the necessary assistance for residents to drink water. CNA #13 reported it was not uncommon for residents with catheters to have low urine output, with dark colored urine with sediment. * The facility did not stock up-to-date mechanisms to secure catheters, but instead used a rubber band type thing to hook the catheters to the sheet or bed. CNA #13 stated residents frequently complained of a pulling sensation, and she had known of catheters to become dislodged or pulled out from this practice. b. On [DATE] at 10:10 am, CNA #1 reported: * There were not enough CNAs to reposition residents. Examples of this included shearing type skin issues for residents who did not have adequate assistance for repositioning, including Resident #s 10 and 12. CNA #1 stated Resident #10 was lucky to get repositioned once a shift. * Residents are not assisted with toileting needs. CNA #1 cited examples including Resident #13, who had been incontinent at least in part because it was easier to change him than toilet him; Resident #36, who would sit for hours in his/her own urine and feces because s/he was too heavy to change and there was no time for a shower; and Resident #23 and #34 who had been left sitting on the toilet up to 90 minutes. She said Resident #11 would be left sitting in feces for hours at a time and pleading for ice. CNA #1 stated staff often had to choose between passing meal trays and changing incontinent residents. CNA #1 stated the result was that residents pee on themselves and cry. * Cares are provided to verbal residents before non-verbal residents. CNA #1 stated she had been in a room in the midst of caring for a non-verbal resident on more than one occasion, and was interrupted to leave and provide care for a verbal resident who was capable of complaining. CNA #1 stated during one recent shift, non-verbal residents did not have their adult briefs changed or be repositioned from 4:00 pm until 1:00 am the next day. * Call lights were placed out of reach for res

Based on observation, staff interview, and review clinical records and Incident and Accident Reports, it was determined the facility failed to ensure an injury of unknown origin on a resident's breast was thoroughly investigated to rule out whether abuse or neglect had occurred. This was true for 1 of 11 residents (#41) reviewed for possible abuse or neglect. The facility's failure to recognize a skin tear of unknown origin on Resident #41's breast as a possible instance of abuse or neglect, and investigate the cause of the injury, placed Resident #41, and all residents in the facility who sustained an injury of unknown origin, in immediate jeopardy of serious harm, injury, or death. Findings include: Resident #41 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #41's Quarterly MDS assessment documented her hearing was highly impaired, she did not speak, her cognition was severely impaired, she was dependent on 2 or more staff for all ADL's, transfers, and mobility, and she had contractures in all extremities. Resident #41's 1/16/15 care plan documented a problem area of impaired cognition from a TBI limiting her ability to answer simple yes or no questions, impaired communication related to aphonia (the inability to speak) and a [MEDICAL CONDITION], and ADL deficits requiring dependence on two staff members to anticipate her needs and provide cares accordingly. An Incident/Accident Report for Resident #41, dated 8/30/16 at 4:00 pm, documented, Skin tear noted by CNA .in shower, pointed out to me (LN) in resident's room. The skin tear was documented to be in Resident #41's left lateral breast/chest area, and measured 1.0 cm X 0.5 cm. The form documented the injury appeared: Recent - Dry appearance - Edges don't approximate easily, as opposed to: New, Fresh, Bleeding, or: Old - Scab present - Dry. The Intervention/Corrective Action/ Supervisor Follow Up area of the form documented the injury was not witnessed, and that abuse or neglect was not suspected or alleged. The cause of the injury was documented as: Assessment done, noted a 1 cm X 0.5 cm skin tear to (left) lateral breast, no bleeding noted. The form documented the injury could not have been prevented as Resident #41 had fragile skin. The corrective action was documented as: Assessed, (treatment) done . A NN in Resident #41's record, dated 8/30/16 at 4:00 pm, documented, Skin tear noted by CNA, (left) lateral breast, possibly from gown arrangement with ADL's .Resident alert, non-verbal .needs anticipated by staff (with frequent) rounding. 2 staff ADL and hoyer transfer . There was no further documentation in Resident #41's NN regarding an investigation as to when or how the injury occurred. There were no care plan updates to reflect what should be done differently with Resident #41's gown arrangement to prevent further injuries to her. An OT note in Resident #41's record, dated 8/30/16 at an unknown time, documented, (Patient) noted with skin brake (sic) down on (left) chest which could be due to elbow orthotic. Plan to allow time to heal and trial orthotic on (left) elbow again with cushion spacer between arm and chest. There was no documentation that nursing staff was notified of the injury, or whether the injury was noted before or after 4:00 pm, when Resident #41's NN documented its discovery. On 8/30/16, Resident # 41's skin care plan was updated to include a skin tear to her left breast, with a goal that the area would heal. Approaches included treatment as ordered, monitor for infection, and weekly skin checks. There was no documentation on the care plan related to actual or possible causes of the skin tear, or how staff should prevent further injury. On 10/3/16 at 8:53 am, Resident #41 was observed laying on her back in bed with splints on both hands. Resident #41 did not move or otherwise interact when addressed. At 10:00 am, Resident #41 was observed in the same position and tracking various objects in her room with her eyes. She did not move any part of her body, including her head or neck, while looking around. She did not speak when addressed. On 10/5/16 at 2:45 pm, the Administrator stated he was designated as the person in the facility responsible for the coordination of investigations into cases of potential abuse or neglect. After reviewing Resident #41's 8/30/16 Incident/Accident Report, the Administrator stated the facility did not identify the skin tear as a potential instance of abuse, and therefore, did not conduct an investigation into its origin. The Administrator stated since Resident #41 was in the shower chair when the injury to her left breast was discovered, it was reasonable to assume it had occurred during the transfer into the chair. When asked specifically how the facility had determined through investigation that abuse or neglect had not occurred, the Administrator stated, I don't know. I don't have anything to do with that. It's a clinical issue. The Administrator stated it was the responsibility of the clinical team to determine the cause of an injury, and if an injury needed to be investigated as potential abuse or neglect. The Administrator stated his signature was on the Incident/Accident Report form, so the clinical team must have decided no further investigation was warranted. The Administrator stated the interim DON would have further information. On 10/5/16 at 3:20 pm, the interim DON reviewed the Incident/Accident Report and stated, I don't know. Maybe this happened in the shower chair, or with a transfer. The interim DON stated when the injury was discovered, the LN should have assessed Resident #41 and talked to staff to see how it occurred. The interim DON stated the results of the staff interviews would be documented as attachments to the Incident/Accident Report. The DON stated she would look for the statements, but stated if they were not with the Incident/Accident Report she was not sure where they would be. The DON did not recall the IDT investigating the injury to Resident #41's left breast. The DON stated the clinical team would make the determination as to when a skin tear to the breast of a woman who was quadriplegic and non-communicative, should be investigated as potential abuse or neglect based on an assessment of the size (of the skin tear.) The DON stated she would need to check the Idaho regs to see what size a skin tear had to be in order to warrant investigation. On 10/5/16 at 4:40 PM, the Administrator and Regional Consultant referred to the 8/30/16 NN and OT progress notes as evidence that the cause of the skin tear to Resident #11's left breast had been determined, and that there was no need to investigate the injury as an instance of potential abuse. The Administrator and Regional Consultant could not explain how the two conflicting statements, one of them documented at an undetermined time, were evidence to rule out abuse. On 10/7/16 at 3:30 pm, the Corporate Nurse Consultant stated the facility's initial investigation did not include documentation of when Resident #41's skin was most recently intact prior to the 8/30/16 injury, but referred to the 8/30/16 NN's and OT notes as evidence of the facility's investigation. The Corporate Nurse Consultant was unable to state, based on those notes, whether Resident #41 had OT before or after her shower, or whether the skin tear was present at the beginning of the therapy session. The Corporate Nurse Consultant stated the facility did not talk to the CNA who initially reported the injury, the OT, or the LN who assessed Resident #41 after the skin tear was discovered, as part of the facility's investigation commencing 8/30/16. The Corporate Nurse Consultant stated, The skin tear was small and healed quickly. She (Resident #41) was never in any danger from that injury. The facility placed Resident #41, and all residents in the facility sustaining an injury of unknown origin, in immediate jeopardy when it failed to identify a skin tear to the left breast of a woman who was non-communicative, quadriplegic, cognitively impaired, and dependent on staff for all mobility and cares, as an instance of potential abuse, and failed to investigate the cause of the injury. Removal of Immediate Jeopardy: The facility was notified in writing of the immediate jeopardy, and the need to formulate and implement a plan of removal, on 10/6/16 at 2:10 pm. On 10/7/16 at 4:40 pm, the facility provided evidence that an acceptable plan to remove the immediacy had been developed and implemented. The plan included an investigation into Resident #41's injury; the addition of a QA/Risk Management RN; the implementation of a standardized investigation process and checklist to be reviewed by the facility's IDT each weekday for all incidents and grievances, including injuries of unknown origin; updating the facility's Abuse Prevention Policy and Procedure to include processes for responding to injuries of unknown origin; implementing a system for corporate Risk Management personnel to review the facility's incidents and grievances daily for allegations of potential abuse and neglect; and educating all staff, including IDT members, to the changes above.

Based on observations, record review, resident, staff, medical provider, and POA interview, it was determined the facility failed ensure 4 of 27 sampled residents (#2, #8, #11, #15) were provided with sufficient fluids to maintain hydration. Residents were observed with dry mouths; they complained of being thirsty and asked for water. a) Resident #11 was harmed when he was not provided feeding tube formula and free water per MD order, and became severely dehydrated. b) Residents #2, #8, and #15 had potential for harm when they were not provided with fluids and/or assistance to consume them, complained of thirst, and were observed with dry mouths. Findings include: 1. Resident #11 was admitted to the facility on [DATE]: [DIAGNOSES REDACTED]. He had a catheter, was on a ventilator and had a [MEDICAL CONDITION]. A Social Service Progress Note, dated [DATE], indicated Resident #11 was alert and able to communicate needs and preferences with a goal of weaning from the ventilator and returning to the group home where he previously resided. Resident #11 was transferred to the hospital on [DATE]; he died two days later. Resident #11's closed record was reviewed. a. Record Review Resident #11 was at risk for dehydration due to history of urinary tract infections, constipation with prescription of 2 daily medications ([MEDICATION NAME] 17 grams and Senna 8.6 grams) and issues with the feeding tube becoming clogged/resident not receiving full feeding and flushes. The course of the resident's 3-month stay was as follows: The admission MDS, dated [DATE], documented Resident #11 usually made himself understood and usually understood others. He was totally dependent on staff for eating. The assessment documented Resident #11 had a swallowing disorder and received nutrition via a feeding tube. The ADL Care Area Assessment (CAA) indicated Resident #11 was dependent for all ADLs due to limited mobility of his arms and legs. The communication CAA indicated Resident #11 spoke both Spanish and English; however, his ability to was hampered by [MEDICAL CONDITION] ventilator. The nutrition care area assessment in full read, Resident is at nutritional risk due to [MEDICAL CONDITION], [MEDICAL CONDITIONS] sacral wound. He is on a tube fed diet and is being followed by the RD. The feeding tube care area assessment documented use of a gastric tube ([DEVICE]) for all calories, nutrition and fluids. The dehydration care area assessment documented in full, Care plan addressing potential for dehydration or fluid imbalance will be addressed in Tube Feeding care plan [DATE]. Resident #11's causal risk factors for dehydration were not identified or thoroughly assessed. According to the initial physician's orders [REDACTED]. There was a lack of documentation in nursing, dietary or meal intake records to demonstrate he was provided ice cream (one entry only on [DATE]) during his stay. On [DATE], the Medical Nutrition Assessment was completed. Resident #11's weight was 176.8 lbs. He was prescribed Promote with Fiber at a rate of 55 cc per hour for a period of 20 hours per day continuously via a pump. The tube feeding formula provided 914 cc of water and Resident #11 had an order for [REDACTED]. Resident #11's fluid needs were calculated as being between ,[DATE] cc day (using an adjusted body weight of 60 kg and factor of ,[DATE]). Due to the tube feeding regimen not meeting Resident #11's needs, the tube feeding rate was increased to 75 cc an hour based on the dietitian's recommendation. The revised tube feeding regimen provided 1247 cc of water and the free water of 600 cc daily remained the same for a daily total of 1847 cc daily. Resident #11's tube feeding orders remained unchanged through date of his transfer to the hospital on [DATE]. On [DATE] Resident #11 was diagnosed with [REDACTED]. Resident #11 was admitted to the hospital on [DATE] after [MEDICAL CONDITION] found no longer in place. The [DATE] hospital H&P documented, The patient felt sleepy and thirsty and asking for ice water with chips even though the patient has a history of dysphagia, has a PEG tube for tube feed. On [DATE], Resident #11 transitioned from his room on the ventilator unit to a room on the rehabilitation hall due to successful de-cannulation. [MEDICAL CONDITION] been pulled out and the decision was made not to replace it. Resident #11 was breathing adequately without the ventilator. A [DATE] Speech Therapy Plan of Care indicated Resident #11 was to start working with speech therapy with a goal of pureed foods and thin liquids being safely consumed. Documentation indicated he had been wanting to eat/drink for several weeks. Swallowing difficulties were noted due to [MEDICAL CONDITIONS] recently de-cannulated. A [DATE] Speech Therapist Progress note indicated Resident #11's pureed diet had not been initiated. His positioning in bed was documented as being a challenge with an increased risk aspiration and lethargy being present. Caregiver education on proper positioning was given. A [DATE] nurse practitioner Progress Note indicated Resident #11's feeding tube was clogged. A [DATE] nurse practitioner Progress Note indicated Resident #11's family inquired whether he would be able to begin to eat and drink. Documentation indicated the speech therapist was spoken to and a [MEDICATION NAME] swallow was scheduled. On [DATE] a diet requisition form from speech therapy indicated a diet trial would be completed at lunch on [DATE], [DATE], and [DATE]. A [DATE] Nutrition at Risk (NAR) note indicated Resident #11 experienced a significant weight loss with a weight of 159.6 lbs being recorded on [DATE]. This constituted a 5.67% weight loss in the past month and 9.62% weight loss since admission on [DATE]. The issue of the feeding tube clogging was documented. There was no evidence Resident #11's fluid balance was evaluated in light of the weight loss. On [DATE], the Resident Care Conference notes indicated nursing, dietary, activities, and family were present for the meeting. The family was documented as expressing concerns with Resident #11's fluid restriction. A [DATE] Nurse's Note, documented Resident #11's feeding tube being clogged with nursing being unable to get it unclogged. The NP was notified and an order obtained to send Resident #11 to the emergency department to have it changed. A [DATE] NAR note documented Resident #11 was receiving 100% of nutrition via the feeding tube, he was being seen by speech therapy for possible initiation of oral feeding and for the potential discontinuance of the feeding tube. On [DATE] a new speech therapy goal to complete oral care to reduce the risk of decline of oral debris was initiated. Resident #11 was determined to be unsafe for oral intake based on the [MEDICATION NAME] swallow results. A recommendation for small ice chips via ½ teaspoon was written; the trial of pureed foods was discontinued. Resident #11 was to be allowed small amount of ice chips. There were no nurse's notes for a 2-day period preceding Resident #11's hospitalization ([DATE] at 12:30 p.m. until a note [DATE] at 4:35 p. m). A [DATE] Nurse's Note at 4:25 p.m., documented Resident #11 was sent to the emergency department to be evaluated for a stroke. A note later that day at 10:00 p.m. documented, No ice chips or water should be left in pt (patient's) room. There was no evidence Resident #11's hydration status was evaluated. On [DATE] in the nurse practitioner Progress Note, Resident #11 was documented with altered mental status, decreased oxygen saturation in the 80s and somnolence. He was hospitalized on this date. Resident #11 was hospitalized on [DATE] due to a change in mental status. Review of the ED Physician Note, documented at 2:50 p.m. on that date, indicated, He has quite poor hygiene, primarily oral hygiene . Oral mucosa is significantly dry with brownish crusting over tongue and oral mucosa. He is edentulous. Tongue is significantly dry with a layer of brownish crusting. The note further documented an elevated sodium lab of 190 (,[DATE] normal range), BUN 140 (,[DATE] normal range), and creatinine 2.5 (XXX,[DATE].25 normal range). Clinical impressions were, 1. Altered level of consciousness, 2. Intracranial mass, 3. Dehydration, 4. [MEDICAL CONDITION] (high sodium). The note stated, Severe dehydration and rehydration high risk for cerebral [MEDICAL CONDITION]. Resident #11 passed away on [DATE] in the hospital. According to the [DATE] hospital Discharge Summary, admitting [DIAGNOSES REDACTED]. Resident #11's cause of death was documented in full, 1. Intracranial mass, possible olfactory neuro[DIAGNOSES REDACTED] or other malignancy of the brain. 2. Urinary tract infection, possibly secondary to suprapubic catheter with gram negative rods. 3. Gram positive cocci bacteremia, unclear source. 4. Severe [MEDICAL CONDITION] with dehydration 5. Acute [MEDICAL CONDITION], possibly secondary to dyselectrolytemia (electrolyte disorder) and infection. 6. Acute kidney injury. Review of the Tube Feeding Record for [DATE] indicated Resident #11 was not provided with tube feeding and water flushes per physician's orders [REDACTED]. There were 2 shifts on the 14th and 17th in which the flush of 200 cc was not documented as having been administered. The order for flushing the [DEVICE] with ,[DATE] cc of fluid was not documented as having been completed on the night shift for the 8 days prior to Resident #11's hospitalization (from [DATE]- [DATE]). Review of the MARs demonstrated Resident #11's output was not adequately monitored in the facility prior to his hospitalization . For the month of [DATE], catheter output was not documented for 11 out of 62 shifts (through am shift on [DATE]). Resident #11's total output per day was not totaled for any of the days in [DATE]. Of the days in which output was documented for all 3 shifts (12 days out of 21 days total), Resident #11's output averaged 1104 cc per day (per the surveyor's calculations). Review of Resident #11's output records for the month of [DATE] showed an average output of 1670 cc per day, demonstrating decreased urinary output, not identified by the facility, prior to Resident #11's hospitalization . b. Interview with POA Resident #11's POA was interviewed on [DATE] at 9:40 a.m. and stated he had cared for Resident #11 for [AGE] years prior to his admission to the facility. He stated Resident #11 was not provided adequate fluids and he was severely dehydrated when he went to the hospital on [DATE]. The POA relayed the series of events. The POA stated Resident #11's cognition had already begun to deteriorate at the time the care plan meeting was held [DATE]. The POA stated Resident #11 became increasingly incoherent over the last month of his life and indicated he had been basically alert and oriented previously. The POA stated Resident #11 was very thirsty and often asked for ice chips, which he had been allowed to have previously when he was on the ventilator. The POA stated he observed Resident #11 with a dry mouth and with cracked dry lips in the week preceding his hospitalization . The POA stated once Resident #11 moved to a different room following [MEDICAL CONDITION] out and the discontinuance from the ventilator, he was no longer allowed ice chips. The POA stated the facility was afraid he would aspirate. During the care plan meeting ([DATE]) the POA stated he expressed his desire that Resident #11 be allowed to have ice chips and that he be allowed to eat and drink. The POA stated Resident #11 was denied fluids, ice chips and food. The POA stated, He died at the hospital. The doctor said he didn't know how he (the resident) could get so dehydrated. His electrolytes were through the roof. It was like he had been in the desert for weeks. Nobody bothered giving him fluids. c. Staff Interview Staff interviews showed Resident #11 was thirsty, he was denied ice chips and fluids, and no one knew who was responsible for monitoring urinary output: -CNA #13 was interviewed on [DATE] at 3:15 p.m., and stated she remembered Resident #11 requested ice chips. CNA #13 stated, His urine had a lot of sediment; he had low urine output. He wanted ice chips, but he was NPO. We were not able to give them (ice chips) due to the (physician's) order. - Nurse #8, was interviewed on [DATE] at 5:40 a.m., and was asked about monitoring output for residents who had catheters. He stated output was recorded per shift for all residents who had catheters. When asked who totaled and monitored the daily output records, he stated, I don't know who reviews it. The nurse practitioner looks at the MAR. I don't know who in nursing is responsible. When asked about documenting tube feeding administration and free water administration, he stated it was all recorded in the MAR. -The Speech Language Pathologist (SLP) was interviewed on [DATE] at 10:10 a.m., and stated Resident #11 had a lot of gunk in his mouth and he had dry lips. -Nurse #5 was interviewed on [DATE] at 2:20 p.m. and stated she remembered being able to give Resident #11 ice chips and then not being able to. She stated, He got ice chips for a while. At the end I could not let him have them (ice chips). I felt bad. Nurse #5 verified Resident #11 asked repeatedly for ice chips. -The NP was interviewed on [DATE] at 2:40 p.m. and stated nursing was responsible for monitoring urine output and it was their responsibility to let him know of anything abnormal. He stated he did not remember any specific hydration concerns related to Resident #11. -CNA #1 was interviewed on [DATE] at 10:10 a.m., and stated, He (Resident #11) asked for ice chips constantly. CNA #1 stated she was told by the nurses not to give Resident #11 ice chips. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Initial MDS assessment, dated [DATE], documented Resident #2 had no cognitive impairment. Resident #2's Dehydration Care Plan, dated [DATE], documented he was at potential risk for dehydration related to [MEDICAL CONDITION] and the inability to obtain water independently. Interventions included: *Staff was to assess his hydration status daily. *Staff was to encourage and offer him fluids with meals, upon rounds, with med pass, and PRN. Resident #2's medical record did not contain documentation of how or when the staff assessed his hydration status. On [DATE] at 2:37 pm through 3:50 pm, Resident #2 was observed laying in his bed with his call light out of reach. The call light was on his pillow behind his head. Resident #2's water cup was on a table about 3 feet from the bed. Staff were not observed to encourage him to drink. On [DATE] from 8:35 am through 12:30 pm, Resident #2 was observed laying in his bed. Resident #2's water cup was on the bedside table about 3 feet from him from 8:35 am until his lunch arrived. Staff were not observed to encourage him to drink. On [DATE] at 9:50 am, the ADON stated residents should have call lights so they can ask for help. The ADON agreed that residents should have fluids available and get help if they need it. 3. Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #8's UTI Care Plan, dated [DATE] and [DATE], documented she had a UTI. Interventions included stated staff were to encourage adequate fluid intake and they were to offer fluids at frequent intervals. On [DATE] at 5:05 am, Resident #8 was observed in her bed and asleep. Her call light was on her pillow above her head on the left side of her body, out of her reach. On [DATE] at 5:46 am Resident #8 was calling out hello, hello, hello, Rocky. No call light was used to get staff assistance. On [DATE] at 5:51 am, a staff entered the room to assist Resident #8. Resident #8 stated she was thirsty and needed water. The staff member filled up her water mug and left the room. On [DATE] at 5:59 am, Resident #8 was observed to laying in bed. She had a water mug in front of her with a straw in it. She had white around her mouth, dry lips, and was licking her lips. Resident #8 kept picking up her cup and was attempting to get the straw to her mouth. She stated she was calling out for staff this morning because she could not reach her call light and she was thirsty. The call light was now on her chest by her right side. She stated I need help I don't want to dribble on myself .Help me, why are you not helping me. She grabbed her mug and attempted to get it to her mouth again. She could not get it to her mouth and put it down. Resident #8 stated Are you going to help or not. The surveyor asked her what she usually did to get help. She stated she used this and pointed to her light. She stated You are not helping me .They never help me. Resident #8 was reminded to use her call light for help if she needed it. On [DATE] at 9:50 am, the ADON was notified of the above observations. The ADON stated Resident #8's call light should have been where she could reach it to call for help with drinking her water. 4. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #15 quarterly MDS assessment, dated [DATE], documented he had a mild cognitive impairment and was usually understood usually he communicated, but he had difficulty with some words or finishing thoughts. Resident #15's Elimination Care Plan, dated [DATE], documented he was at risk for alterations of bladder function related to him requiring a suprapubic catheter for his [MEDICAL CONDITION] bladder. Interventions included that staff was to encourage fluids intake. Resident #15's Hydration Care Plan, dated [DATE], he was at risk for dehydration related to alterations in cognition and dementia. Interventions Included: *Staff was to offer him fluids within diet parameters, with med passes as ordered, and PRN. *Staff was to assess Resident #15 for signs and symptoms of dehydration. Resident #15's July Physician order [REDACTED]. Resident #15's Bladder Evaluation, dated [DATE], documented his average fluid intake was 1000 mL for 24 hours. In addition, it documented his average fluid output was ,[DATE] mL per 24 hours. Resident #15's July MAR up to [DATE] failed to document the administration of the 120 mL water offered on two occasions. The MAR indicated [REDACTED]. On [DATE] at 4:30 pm Resident #15 was in his room sitting in his wheelchair about 2 and ,[DATE] feet from the bed. He had his head bent over and he was tearful. The call light was on his bed out of his reach. The water cup was on a dresser at the foot of his bed out of his reach. As Resident #15 was talking it was observed his mouth had a white crusty looking film around it and he kept licking his lips and his mouth had a thick looking mucus in it. Resident #15 stated I am so needing fluids can you help? As his call light was not in his reach the surveyor noticed a CNA in the hall and CNA #16 came in the room. He started to talk to her but she interrupted him and asked are you thirsty. He stated yes I am so needing fluids. She gave him a drink of water but returned the water cup back to the dresser at the foot of the bed, out of his reach. On [DATE] at 9:48 am, the ADON was informed of the observation and agreed residents should have fluids available where they can reach them and have call lights where they can call for help. On [DATE] at 10:19 am CNA #1 stated Resident #15 did not get his light to call for help often. She agreed if the call light was out of reach he could not ask for water if he needed it.

Based on observations, record review, resident, staff, and family/decision maker interview, it was determined the facility failed to ensure 3 of 27 sampled residents (#3, #8, and #11) received nutritional interventions to prevent unplanned weight loss. As a result: a) Resident #11 was harmed when his tube feeding regimen was not adjusted and he experienced a severe unplanned weight loss. b) Resident #3 was harmed when she experienced a severe unplanned weight loss without implementation or revision of nutritional interventions. c) Resident #8 had the potential for harm when assistance was not provided at meals per her care plan. Findings include: 1. Resident #11 was admitted to the facility on [DATE]: [DIAGNOSES REDACTED]. The resident had a catheter, was on a ventilator and had a [MEDICAL CONDITION]. A Social Service Progress Note, dated [DATE], indicated Resident #11 was alert and able to communicate needs and preferences with a goal of weaning from the ventilator and returning to the group home where he previously resided. The resident was transferred to the hospital on [DATE]; he died two days later. Resident #11's closed record was reviewed. a. Record Review The admission MDS assessment, dated [DATE], indicated Resident #11 usually made himself understood and usually understood others. He was totally dependent on staff for eating. It was documented Resident #11 had a swallowing disorder and received nutrition via a gastrostomy feeding tube. A Nutrition at Risk (NAR) note, dated [DATE], documented his weight of 210 pounds (lbs) in the hospital prior to admission. The assessment indicated Resident #11 had 2 stage 2 pressure ulcers and 1 stage 4 pressure ulcer, all present at time of admission. The stage 4 pressure ulcer was 4.0 cm by 2.6 cm in length and 0.3 cm in depth. The nutrition care area assessment in full read, Resident is at nutritional risk due to [MEDICAL CONDITION], [MEDICAL CONDITIONS] sacral wound. He is on a tube fed diet and is being followed by the RD. The feeding tube care area assessment documented use of a gastrostomy ([DEVICE]) tube for all calories, nutrition and fluids. According to the initial physician's orders [REDACTED]. Although he was allowed to have ice cream, there was a lack of documentation in nursing, dietary or meal intake records to demonstrate the resident was provided ice cream (except one entry on [DATE] in nurse's notes) during his stay. Resident #11's care plan with an onset date of [DATE], read in its entirety: Dietary: Resident is at nutritional risk due to [MEDICAL CONDITION], trach, [MEDICAL CONDITION] and sacral wound. The goal was Resident will not have a weight change greater than 5% in 30 days or 7.5% in 90 days. Interventions were, Provide a tube fed diet, Weekly weights, RD (Registered Dietitian) to follow PRN. The care plan was developed prior to Resident #11's nutritional assessment being completed by the dietitian. The care plan was not revised at any time during the resident's 3 month stay even though he did not achieve the goals and, in fact, experienced a 5% weight loss within a month and greater than a 7.5% weight loss in 90 days. Resident #11's significant weight loss was not identified on the care plan. On [DATE], a physician's orders [REDACTED].#11. There was a delay of 6 days from the order and his admission until the initial nutritional assessment was completed by the RD on [DATE]. On [DATE], the Medical Nutrition Assessment was completed. Resident #11 was not weighed upon admission; his initial weight was taken on [DATE] (5 days after admission); he weighed 176.8 pounds and his height was documented as 62 inches (equivalent to 5'2 tall). There was a lack of evaluation of Resident #11's weight of 176.8 lbs compared to the documented hospital weight of 210 lbs. Resident #11 was initially prescribed Promote with Fiber at a rate of 55 cc per hour for a period of 20 hours per day continuously via a pump. According to the [DATE] Medical Nutrition Assessment, the tube feeding regimen provided a total of 1100 kcal (meeting 73% of the resident's needs), 69 grams (gm) protein, and a total of 1514 cc (cubic centimeters) of fluid (formula and water flushes combined). The RD determined Resident #11's tube feeding regimen was insufficient to meet his nutritional needs by 400 calories per day. Resident #11's daily nutritional needs were calculated by the RD as: ,[DATE] calories, ,[DATE] gm protein, and ,[DATE] cc fluids. The RD recommended an increase in the rate of Promote with Fiber from 55 cc to 75 cc an hour and the addition of [MEDICATION NAME] twice daily and Juven twice daily for his wounds. According to the [DATE] Medical Nutrition Assessment, the revised tube feeding regimen provided 1500 calories, 93 gm protein, and 1847 cc fluids which met the resident's nutritional needs according to the RD's calculations. The RD calculated Resident #11's nutritional needs based on an adjusted body weight of 132 lbs (60 kg) when he actually weighed 176.8 lbs. According to the Academy of Nutrition and Dietetics, Evidence Analysis Library, Adult Weight Management, dated [DATE], current nutrition protocol does not include use of an adjusted body weight for calculating nutritional needs except in limited and specific situations (critically ill overweight and obese patients when a hypocaloric and/or high-protein feeding has been prescribed or with people having amputations). According to the Academy of Nutrition and Dietetics, Evidence Analysis Library, Adult Weight Management, There is no evidence that substituting adjusted or ideal weight results in improved accuracy. Many of the resting metabolic rate, or RMR, equations were developed using actual body weight. The use of adjusted body weight, or ABW, may underestimate or overestimate RMR in patients depending on their weight status . Actual body weight is advocated when assessing energy, protein and fluid needs. Resident #11's nutritional needs were likely underestimated by using adjusted body weight rather than actual body weight as evidenced by Resident #11 experiencing a significant weight loss while his calculated nutritional needs indicated intake (tube feeding providing 1500 calories) was sufficient for weight maintenance. Resident #11's tube feeding orders remained unchanged through date of transfer to the hospital on [DATE]. A [DATE] Nutrition at Risk (NAR) note indicated Resident #11 experienced a significant weight loss with a weight of 159.6 lbs being recorded on [DATE]. This constituted a 5.67% weight loss in the past month and 9.62% weight loss since admission on [DATE]. The weight loss occurred during a 1 month period of time in which Resident #11 was not weighed. He was noted with a Weight Change Notification form signed by the physician on [DATE]. The form included Resident #11's weights that demonstrated significant weight loss occurred. Interventions or actions to be taken were not identified. There was no information on the form regarding what would be done based on the weight loss even though there was a section on the form for documenting this information. Resident #11 and his POA expressed their joint interest in Resident #11's transition to oral intake of food and fluids after [MEDICAL CONDITION] out on [DATE]. The initiation of pureed diet trial was delayed and was not implemented according to the speech therapy plan: -A [DATE] Speech Therapy Plan of Care, indicated Resident #11 was to start working with speech therapy (ST) with a goal of pureed foods and thin liquids being safely consumed. Documentation indicated he had been wanting to eat/drink for several weeks. Swallowing difficulties were noted due to [MEDICAL CONDITIONS] recently de-cannulated. -A [DATE] Speech Therapist Progress note indicated Resident #11's pureed diet had not been initiated. His positioning in bed was documented as being a challenge with an increased risk aspiration and lethargy being present. Caregiver education on proper positioning was given. -A [DATE] nurse practitioner Progress Note indicated Resident #11's family inquired whether he would be able to begin to eat and drink. Documentation indicated the speech therapist was spoken to and a [MEDICATION NAME] swallow was scheduled. On [DATE], a diet requisition form from speech therapy indicated a diet trial would be completed at lunch on ,[DATE], ,[DATE], and [DATE]. -A [DATE], a NAR note documented Resident #11 was receiving 100% of nutrition via the feeding tube, he was being seen by speech therapy for possible initiation of oral feeding and for the potential discontinuance of the feeding tube. -On [DATE], a new speech therapy goal to complete oral care to reduce the risk of decline of oral debris was initiated. Resident #11 was determined to be unsafe for oral intake based on the [MEDICATION NAME] swallow results. A recommendation for small ice chips via ½ teaspoon was written; the trial of pureed foods was discontinued. Resident #11 was to be allowed small amount of ice chips. On [DATE], in the nurse practitioner Progress Note Resident #11 was documented with altered mental status, decreased oxygen saturation in the 80s and somnolence. He was hospitalized on this date and passed away in the hospital 2 days later. Review of the tube feeding records showed the tube feeding was not consistently signed off during the week prior to Resident 11's hospitalization . Review of the Tube Feeding Record for [DATE] showed the tube feeding administration was not signed off by nursing as being completed for 5 shifts between [DATE] and [DATE]. On [DATE] at 10:50 a.m., the RD was asked for weight records for Resident #11 outside of what was documented in the medical record; none were provided. The care plan directed staff to obtain weekly weights. Resident #11 resided in the facility a total of 13 weeks; he was weighed 7 times. Review of Resident #11's weights documented in Nutrition Services Progress Notes showed the following progression: -210 lbs hospital (no specific date documented) -176.8 lbs [DATE] -174.4 lbs [DATE] -170 lbs [DATE] -171 lbs [DATE] -169.4 lbs [DATE] -166.8 lb [DATE] -161.8 lbs [DATE] -159.8 lbs [DATE] -160 lbs [DATE] b. Staff Interviews- -CNA #13 was interviewed on [DATE] and stated residents were to be weighed upon admission and on shower days. Weights were entered into a weight book kept at the nurse's station. -The RD was interviewed on [DATE] at 10:50 a.m. and stated she assessed new residents within 3 to 7 days after admission. If a resident was on tube feeding, she assessed them sooner, within 3 days if she was aware of their admission. The dietitian stated she used adjusted body weight if a resident was obese. She stated Resident #11 had wounds, issues with a clogged feeding tube, and was in and out of the hospital several times during his stay. The RD verified significant weight loss occurred and that Resident #11's family was interested in Resident #11 progressing to oral intake. The RD stated that speech therapy had the final say on diet textures. If a resident was interested in a diet upgrade, the typical procedure was to do a 3-day diet trial. 2. Resident #3 was admitted to the facility on [DATE] and was readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #3's Admission MDS assessment, dated [DATE], documented moderate cognitive impairment with BIMS of 10, and she required set-up only for eating with no difficulty in swallowing. Her admit weight was 129 lbs. Resident #3's care plan documented a problem, dated [DATE], Resident is at nutritional risk due to [MEDICAL CONDITION], pneumonia, trachea/ventilator, [MEDICAL CONDITIONS], anxiety . Approaches to this problem included Provide regular diet, resident is independent with eating and making food choices, RD to follow PRN, monthly weights, resident eats in her room per choice. Resident #3's care plan was revised on [DATE] for staff to give 2 oz of 2 cal QID with medication pass and one can of Ensure TID with meals, and on [DATE] it was noted Resident #11 preferred to have ice cream with her Ensure. Resident #3's Care Plan did not address what staff were to do when she refused her meals or when she consumed less than 25% of her meal. Resident #3's [DATE] physician's orders [REDACTED].>*Regular diet, yogurt with meds *Ensure with meals Resident #3's Nutrition at Risk Progress Notes documented: *[DATE] at 12:00 pm, weight 123.2 decrease of 6.6 lbs since admission. See RD note. Excoriation state 1 buttocks .Continue Plan Of Care (POC), NAR in 1 week. *[DATE] at 1:45 pm, Review of resident's current status since last NAR. See RD notes. wt on ,[DATE] 124.4 lbs, (increase) 1.2 lbs since last NAR. O ,[DATE] skin: admitted (with) buttocks wound. Now healed. Cont POC, D/C from NAR/PAR. *[DATE] at 12:00 pm, weight 120.2, intake ,[DATE]% of meals. Nursing reports pt (picking at meals. Daily weights x 3, 2 Cal 2 oz (with) med pass recommended by dietary . *[DATE] at 12:30 pm, weight 116.4 no changes, PO intake varies. See RD note. No new meds, labs reviewed by RD. Cont POC. Next NAR 1 week. Meal intake records documented: *February 2016, 34% of the time, the resident ate 25% or less of her meals *[DATE]% of the time the resident ate 25% or less of her meals *[DATE]% of the time the resident ate 25% or less of her meals *[DATE]% of the time the resident ate 25% or less of her meals The Meal Intake record showed Resident #3's intake was decreasing from February to May and did not document that she was offered a substitution for meals when less than 25% was consumed. Nutrition Services Progress Notes included: *[DATE], Resident #3's PO [DATE] with 783 cc fluid and to continue POC, regular diet, Ensure 1 can TID with meals and NAR in one week. *[DATE], wt ,[DATE] - 124.4 lbs increase 1.2 lbs since NAR. PO [DATE] with 2 refusals. Skin ,[DATE]- skin buttocks/healed .Cont POC, D/C NAR. *[DATE], .Rec daily wts x 3 days to verify any changes. Cont regular diet, Ensure TID, MVI. 1+ [MEDICAL CONDITION] .Begin two Cal 2 oz BID with med pass. Cont POC . Resident #3's daily weights documented: *[DATE]- 121.2 *[DATE]- 118.2 *[DATE]- 123.4 *[DATE], .(-) 13.1 lbs since admission. Cont regular diet, Ensure with meals, yogurt, cont MVI .wt loss probably (secondary) to (decrease) [MEDICAL CONDITION]. Cont two cal 2 oz BID (with) med pass. Pt (with) mental decline, PO and supplement intake is variable. *[DATE], .since admission shows significant wt (decrease) at 1 month and (at) 75 days .Cont regular diet with yogurt (at) meals, Ensure 1 can TID with meals. [MEDICATION NAME] started [DATE] .Folic Acid, Cont 2 Cal 2 oz BID (with) med pass, MVI . Resident #3's Functional Maintenance Program-Caregiver Instructions from the ST documented the following: * Resident #3 to received one can of Ensure during breakfast, lunch and dinner and staff were to open the can of Ensure and pour it into a glass with ice and a straw, and to instruct the resident to finish it during the meal. * Staff were to give Resident #3 one can of Ensure either chocolate or strawberry flavor in a glass with ice and a straw at 10:00 am, 2:00 pm and 7:00 pm and to instruct her to consume the Ensure within 15 minutes. Staff should check back in 15 minutes to insure it is gone. ST also commented Resident #3 often complained of feeling full, and for staff to encourage her to finish all presented Ensures. On [DATE] at 8:30 am, Resident #3 was observed inside her room and on her overbed table were 1 unopened can of Ensure vanilla flavor, a chocolate drink with ice (resident said it was Ensure), and an opened yogurt container which was still full. Resident #3 said she was full and preferred to eat inside her room. On [DATE] at 6:50 pm, Resident #3 was observed in her room and said she just eaten her dinner. On her overbed table were a glass full of chocolate Ensure with ice, yogurt container still full, and 2 cans of unopened Ensure one vanilla and one chocolate flavor. Resident #3 said the staff gave her 6 Ensure a day and she couldn't drink them all. On [DATE] at 9:10 am, the RD with the CDM said part of the problem with Resident #3 was she did not like to eat that much and she just wanted to have Ensure. When asked how sure they were Resident #3 was consuming her Ensure, the RD said she believed the ST gave Resident #3 a journal to record what she was taking in. When the RD showed the journal to the surveyor she said I will be honest with you. There's nothing in here. When asked why other interventions were not considered for Resident #3 when her intake was 25% or less, the RD said Resident #3's wounds were healing, and it didn't mean she was not getting enough nutrition. When asked how they monitored Resident's #3's supplement intake, the RD did not answer. CDM looked at Resident #3's Meal Intake and said Resident only ate 25% of her breakfast and refuses her lunch a lot. I got your point this is not good. It looks like they only give Ensure because that is what the resident wants. Resident #3 experienced a significant weight loss of 12.6 pounds (10.07 percent) in two months, with no documentation additional interventions were implemented or considered. Her POC was not revised or reviewed when the desired result was not achieved. Her care plan was not updated or individualized when she was consuming only 25% or less of her meal. 3. Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #8's Quarterly MDS assessment, dated [DATE], documented moderate cognitive impairment with mild depression, and required assistance of ,[DATE] staff with all cares, except eating. The care plan did not address Resident #8 changes in her ability to self-feed. On [DATE] Resident #8's Therapy Referral and Screening Form documented: * From nursing, the Change in ability to feed self was checked and * Difficulty transferring hand to mouth was written out. * In addition, from the Therapist, decreased intake, increased refusals at meals, difficulty with self-feeding regarding increased assist/cues was written. On [DATE] in Resident #8's July Physician order [REDACTED]. In addition, it documented Resident #8 needed work on her positioning and needed adaptive equipment for eating. On [DATE] in Resident #8's Nurses' Notes, documented she had new orders for OT to see her for positioning and adaptive equipment for eating. Resident #8's OT note, dated [DATE], documented the OT was following Resident #8 in regards to a decline in ADL's of self-feeding. The note indicated she had increased refusals for self-feeding. The Initial Assessment portion of the notes documented Resident #8's current level of ADL Self Care, Self-Feeding was at moderate assistance which the note defined as Resident #8 required ,[DATE]% assist with meals. This section documented Resident #8 required cues and redirection for safety on multiple occasions during the evaluation; she completed up to 50% of normal active and passive range of motion; and she had a severe impairment in her motor control. In addition, the OT's goal for improvement, in regards to Resident #8's self-feeding deficit, was documented as: (Resident #8) would require minimal assistance, defined as ,[DATE]% assist, to help her self-feed at least 25% of her meal utilizing adaptive equipment as needed. The date the goal was to be met and evaluated on was [DATE]. Resident #8's ADL Meal Intake Record documented: *In [DATE]% of the time, Resident #8 consumed between ,[DATE]% of her meals. Resident #8 refused 1 meal. *In [DATE].2% of the time, Resident #8 consumed 25 - 50% of her meals. Resident #8 refused zero meals. (The May ADL copy was of very poor quality.) *In [DATE].3% of the time, Resident #8 either refused or consumed 25 - 50% of her meals. Resident #8 refused 6 meals. *[DATE]st - [DATE]th 2016, 51.5% of the time, Resident #8 either refused or consumed 25 - 50% of her meals. Resident #8 refused 4 meals. On Resident #8's morning breakfast ticket, dated [DATE], documented she was impulsive and required supervision for all PO intake. On [DATE] at 8:19 am through 8:26 am, Resident #8 was sitting in her bed with her meal tray in front of her. She appeared asleep and had not touched her meal. Resident #8 was holding onto a Sippy cup and it was tipped over onto her lap. There was no aide to help her eat or supervise Resident #8. On [DATE] at 8:26 am, Resident #8 was woken up and her tray was taken away. The ADON stated she would look into why the meal ticket stated she required supervision and what the supervision should look like. She believed it just meant they had to look in on her as they passed by the room. The ADON made me a copy of the breakfast ticket. On [DATE] at 8:16 am, Resident #8 was calling out Hello, Hello, Hello continuously until 8:20 am. It was observed her call light was above her left shoulder on the outside of the pillow and out of her reach. She had her meal tray in front of her and the food was whole and not cut up. She was observed trying to get the food to her mouth and the food kept falling off of her fork. On [DATE] at 8:20 am, CNA #2 walked into Resident #8's room and asked her what she needed. Resident #8 pointed to her tray and CNA#2 asked if she needed help with it and she stated yes. On [DATE] at 9:50 am, the ADON stated respiratory therapists told her Resident #8 was safe to eat from a respiratory perspective. The ADON was shown the nursing Therapy Referral and Screening Form requesting OT services and the OT note. The OT note documented Resident #8 required moderate assistance with self-feeding issues at the present time. She stated she would look into it. On [DATE] at 10:19 am, CNA #1 stated Resident #8's cares got neglected often because the staff did not like going into her room.

Based on observation; staff, resident, and family interview; and record review, it was determined the facility failed to ensure cares were provided for residents to be able to retain their highest practicable physical and psychosocial wellbeing in regards to their different toileting needs. This was true for 7 of 10 residents (#2, #4, #7, #8, #10, #13, and #15) sampled for decreased bladder control, UTI's, and indwelling urinary catheters. As a result: a) Resident #13 experienced psychosocial harm when the facility failed to offer him timely opportunities to use a urinal and he started to refuse medication, respiratory treatments, TF feedings and he stated If I have to piss and[***]on myself, I would rather be dead. b) Resident #10 was harmed when the facility failed to ensure that the resident received the appropriate care and services to maintain an indwelling catheter in proper working order; and provide sufficient medical information to the transferred treating facility and to prevent infections. c) Resident #8 was harmed when the facility failed to provide pericare on an as needed basis and provided it 3 times a day and she experienced frequent UTI's. d) Resident #2 and #15 had the potential to be harmed when the facility failed to ensure residents with indwelling urinary catheters were provided appropriate care, and had the potential to cause harm, to include development of urinary tract infections. e) Resident #4 had the potential for harm when the facility failed to complete a bladder assessment evaluation form to assess her toileting needs and creating the potential psychosocially embarrassing incidents of incontinence. f) Resident #7 had the potential to be harmed when the facility failed to complete a bladder retraining program after his Foley Catheter was discontinued by the physician. This created the potential for harm if the residents' continence status declined, skin was compromised from prolonged exposure to urine, or the resident experienced psychosocially embarrassing incidents of incontinence. Findings include: 1. Resident #13, [AGE] years old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #13 used a ventilator, had a [MEDICAL CONDITION] (trach), and was fed via gastrostomy feeding tube. The resident was discharged to the hospital on [DATE] due to blood in [MEDICAL CONDITION] decreased oxygen saturations. Resident #13 was readmitted to the facility on [DATE]. The resident was again discharged to the hospital on [DATE] for a [DIAGNOSES REDACTED].#13's needs (per physician's order on 7/8/16). The resident's closed record was reviewed. a. Record Review A 9/24/15 Psychiatric Consultation conducted prior to Resident #13's admission to the facility, demonstrated his desire to be admitted to the facility. His chief complaint was, I want to live at (name of facility). Resident #13 was documented with a history of [MEDICAL CONDITION] and ventilator dependence secondary to a motor vehicle accident several years earlier. Resident #13 had been living with his mother who could no longer care for him and he had been admitted to the hospital. The resident stated the facility was one of the only places that could take him due to his medical status and needs. Resident #13's mother was his guardian since he was 18 and he now wanted to make his own decisions. The resident was documented as having a good understanding of his medical illness. His mental status was documented as not having suicidal or homicidal thoughts, no hallucinations or delusions, reporting his mood as good and his affect being full and appropriate. Short and long term memory appeared to be intact with insight and judgment being good. The admission Bladder Evaluation, dated 5/18/16, indicated Resident #13 had a [DIAGNOSES REDACTED]. The resident used a urinal and was alert and oriented. Resident #13 had urge incontinence and had 1 incontinent episode per week. Some sections of the form were incomplete/blank: recent surgery, onset of incontinence, duration of incontinence, catheter, pattern of fluid intake, skin status, types of programs, and ability to participate in program. The box for Unable to participate in program was checked with the reason of [MEDICAL CONDITION] with [MEDICAL CONDITION] bladder documented. Resident #13 was documented as having a voiding pattern of every 2 hours; however, there was no evidence the resident's voiding patterns had been assessed. Voiding records were not found in his closed record. The care plan, dated 6/13/16, indicated Resident #13 required staff assistance with all activities of daily living (ADLs) related to incomplete [MEDICAL CONDITION] and impaired mobility. Although, the Bladder Evaluation, dated 5/18/16 indicated the resident had the perception of the need to void and had only 1 incontinent episode per week, the care plan read, elimination: I am incontinent of bowel and bladder d/t (due to) [MEDICAL CONDITION] bowel and bladder. The care plan goal did not address keeping the resident continent to the extent possible and instead read in full, Will remain free of urinary tract infection through next review 8/31/16. Care plan approaches did not include providing the urinal, toileting the resident, or indicating how much assistance was needed. What was to be provided (toileting or wearing an incontinent brief with checking and changing) in regards to incontinence was not identified. Care plan approaches read in full, Bowel care protocol per facility policy, -Monitor and report to charge nurse any change in color of urine, increased odor, or c/o (complaints of) pain, -Administer bowel care meds (medications) as ordered by my physician, -Administer medication for bladder spasms as ordered by physician, -Notify physician of the presence of fever, urine with dark color, odor, change in volume, or if no voiding within 8 hour period. Review of Nurse's Notes demonstrated Resident #13 was initially compliant with cares following his 5/18/16 admission to the facility. However, Resident #13's behavior deteriorated during his stay. He refused his tube feeding and water flushes, stating this was because he was not provided with toileting assistance in order to remain continent. Eventually, he refused most care including respiratory therapy. The progression was as follows: -5/18/16, 8:00 p.m., Pt (patient) able to use restroom for bowel and bladder with times of incontinence. Pt declines a need for Attends (incontinent brief) at this time. -5/19/16, 2:10 p.m., Very Pleasant and excited to be back. -5/20/16, 6:35 p.m., Res (resident) has [MEDICAL CONDITION] bladder and is able to use toilet for urine and bowel. Res has periods of urinary incontinence. -5/22/16, 5:00 a.m., Cont (continent) of B & B (bowel and bladder), all fluids and nutrition and meds (medications) given through(NAME)tube button. Res (resident) tolerates well. Has 2 Cal (tube feeding formula) for bolus with water tolerates well. Pleasant and cooperative with cares. -5/23/16, 7:38 p.m., Res pleasant . No issues noted. -5/24/16, no time documented, NPO (nothing by mouth) nutrition via tube feeding. Tolerating well. -5/26/16, 10:15 p.m., Feeding and water given as ordered. Res had no c/o (complaints of) pain or SOB (shortness of breath). RT (Respiratory therapist) at bedside for all resp (respiratory)/vent/trach needs. No issues noted. -5/28/16, 3:20 p.m., Resident alert oriented, challenging with staff and cares. Resident angry about bolus feeding this am and noon attempting to pull(NAME)tube appliance from body. -5/29/16, 4:40 a.m., Resident was explained implications that can arise from him refusing his feeding and H20 (water). Resident stated 'You guys don't listen!' Resident did allow pm meds to be given and allowed PEG tube to be flushed. Resident stated he will not take his feedings and H20 because he is not toileted quickly enough and does not like to have accidents. -5/30/16, 6:00 p.m., Pt refusing 2 Cal nutrition. -5/30/16, 8:00 p.m., Res is frustrated. He is unable to control his bladder. Res stated that is why he has been refusing water and 2 Cal -6/1/16, 1:00 p.m., Resident is alert and oriented, able to make his needs known .He is able to be continent of B & B but tends to need someone right as he is pushing the call light .He says he doesn't like being incontinent and afraid if he eats he will be. -6/3/16, 10:00 p.m., Negative mood and affect. Pt refused nursing cares, meds, tx (treatment), 2 Cal and H20. -6/5/16, 3:00 p.m., Res cont (continues) to refuse bolus feedings, H20, medications per RT has [MEDICAL CONDITION]. -6/8/16, 2:25 a.m., Resident has been compliant with cares this evening. Resident continues to be upset. He feels as though the CNAs on evening shift are not taking care of him properly .Resident continent of b/b (bowel and bladder). -6/10/16, 11:00 p.m., Pt is continent of bladder and asks to use urinal. Resident #13 was sent to the hospital on [DATE] due to the ventilator alarming due to blood in his trach. Resident #13 was readmitted to the facility on [DATE] following a hospital stay of 6 days. Following his readmission, no refusals were noted for 6 days. After 6 days the following was documented: -6/23/16, 4:00 p.m., Res declined bolus. Upset with CNA when she cleaned him in bathroom. -6/29/16, 4:00 p.m., Refused 1600 (4:00 p.m.) meds and bolus. -6/30/16, 6:30 p.m., Resident has refused all medications and feedings today. -6/30/16, no time documented, Resident has refused all meds, food, & fluids stating that he will not be eating or anything else until CNAs & other staff answer his light with not longer than (illegible number) min (minutes) from time it goes on, because he does not want to have an accident. I proceeded to inform him I'd be there to help & he said no not till everyone does this. I educated him on the issues this would cause like dehydration & he said that he was willing to risk this. This stance did not change throughout the shift. -7/1/16, 2:30 a.m., Res has refused all cares and PEG flush of 315 cc. -7/1/16, 11:00 p.m., Pt c/o constantly being incont (incontinent) of urine due to slow response of CNA .Mother reported pt sat in urine for over 45 minutes w/o (without) anyone answering call light. When talking with mother I informed her it had only been 25 minutes since I had been in and there was no mention of needing to be changed when asked. -7/2/16, 1:00 p.m., Pt refused Two Cal today et (and) meds. -7/3/16, 2:00 p.m., Pt continuing to R (refuse) all meds & nutrition. -7/3/16, 7:10 p.m., (Guardian) states pt is intentionally making himself sick so he can go to the hospital. Pt is upset he has not been discharged to group home yet. -7/4/16, 12:30 a.m., Called to room by RT (respiratory therapist) who expressed concern that res was becoming dehydrated. -7/4/16, 3:00 p.m., He refused all meds and fluids including feeding. -7/6/16, 1:00 a.m., Contd (continues) to refuse most nrs (nursing) cares. -7/6/16, 10:10 a.m., New order per NP (nurse practitioner) - send to ER non emergent dx (diagnosis) dehydration. Pt sent non emergent at approximately 1030 (10:30 a.m.). Resident #13 was transferred to the hospital on [DATE] at 11:00 a.m. The Interact, Review of Acute Care Transfer form stated the hospital's [DIAGNOSES REDACTED]. b. Family Interview Resident #13's family member was interviewed on 7/15/16 at 1:30 p.m. She stated she had been Resident #13's caregiver previously and had removed him from the facility a couple of years ago due to poor care. She stated the care had deteriorated since then and was worse now. The family member stated the current plan was for the resident to transition into a group home where he could live more independently since he was a young adult and wanted to exercise his independence as much as possible and live with people closer to his own age. His recent admission to the facility was intended to be of short duration while everything was put into place for his new living situation. Resident #13's family member stated, The care is substandard. They are terribly understaffed. The family member stated the resident refused to allow his tube feeding and water flushes to be administered because staff would not toilet him resulting in him soiling himself. The family member stated He told me, 'If I have to piss and[***]on myself, I would rather be dead.' He does pretty well with his bladder (remaining continent) if he is toileted. I timed it; he waited 51 minutes for someone to respond (to his call light) while I was there and not just once. (Resident #13) is stubborn. He never liked to be messy since he was a small child. I have been in tears a lot of times to see him that way (soiled with urine and feces). Wheelchair cushions cost a lot of money. Someone has to pay for it (a new cushion) if it becomes ruined (due to incontinence). c. Resident #13's guardian was interviewed on 7/15/16 at 9:45 a.m. She stated the resident was medically complex and acted younger than his [AGE] years. She stated, He does not have much control (over things in his life) but he can say 'No.' She verified Resident #13 got very irritated and upset and as a result refused cares. Resident 13's guardian stated, They were short staffed and slower than ideal. Resident #13's guardian stated the resident refused tube feeding and water flushes because staff did not toilet him quickly enough. She verified Resident #13 knew when he needed to use the toilet and was incontinent if staff did not toilet him timely. She stated there were 2 incidents when she visited Resident #13 when he waited 25 minutes for the call light and stated, We timed it. d. Staff Interview CNA #1 was interviewed on 7/15/16 at 10:10 a.m. She stated Resident #13 was not toileted, in part due to short staffing. CNA #1 stated the resident knew when he needed to use the urinal and put his call light on. She stated he could be continent if he was toileted timely. CNA #1 stated It is a lot of work to toilet him and it takes 2 people. He could use the urinal. He was not toileted; it was easier to change him (after he had been incontinent) than toilet him. Nurse #5 was interviewed on 7/15/16 at 9:15 a.m. and stated she cared for Resident #13 a total of 3 times. She stated the first 2 times she did not have any issues with him; he allowed all care and did not refuse anything. She stated she answered his light and he told her it was not that way when other nurses were working. Nurse #5 stated the last time she cared for Resident #13 he refused his tube feeding, medications and respiratory care because he stated his call light was not answered quickly enough. Nurse #5 stated Resident #13 could remain continent if staff could toilet him quickly. 2. Resident #10's was re-admitted to the facility on [DATE]. He had a history of [REDACTED]. His annual MDS dated [DATE], documented he was severely cognitively impaired, nonverbal and unable to make himself understood. He was unable to move all 4 extremities and was totally dependent upon staff for activities of daily living. He had a PEG (feeding tube) and a [MEDICAL CONDITION] to facilitate mechanical ventilation. Resident #10 had a suprapubic catheter. Review of the ARNP Progress Note, dated 2/17/16, documented, Day staff told me the night shift changed his suprapubic catheter and when they came on duty they found suprapubic catheter out and blood on his thighs.His suprapubic catheter is out and a Foley catheter has been placed thru (through) his urethra. I tried to reinsert the suprapubic catheter but the stoma has closed and I was unsuccessful. The ARNP [DIAGNOSES REDACTED]. I doubt seriously that he pulled it out. The stoma had closed and I was unable to replace a suprapubic catheter. We have been able to replace a Foley catheter thorough his urethra and I will leave that in place. I will not send him out to urology to have the suprapubic catheter replaced unless we have trouble with his Foley catheter. Resident #10's clinical record lacked nurse's notes, and intake/output notes, from March 2016 to July 2016. A care plan for any period of time was lacking. A request was made of the medical records director to provide the clinical records for the missing months on 7/12/16 at 10:00 a.m, 7/13/16 at 8:35 a.m. and 3:30 p.m., 7/14/16 at 7:05 p.m., and 7/15/16 at 11:15 a.m. The records were never provided. An H&P documented by the emergency room physician, dated 3/28/16, stated Resident #10 was admitted to a hospital with chronic indwelling Foley catheter in place .The Foley catheter allegedly was changed out on the 17th of this month. The patient apparently has not been having any urinary output unclear for what period of time .The staff at the facility could not get an IV (intravenous) fluid and due to concern of dehydration, he was sent to the Emergency Department. The Foley catheter was removed with purulent drainage and then replaced, draining 1000 mL out . The patient's white cell count was 26,000 (4,500-10,000 white blood cells per microliter (mcL)) . The emergency physician's Assessment and Plan included [MEDICAL CONDITION], meeting criteria with fever of 38.4 Celsius (101.12 Fahrenheit), heart rate 128, respiratory rate 20 .With urinary tract infection and possible pneumonia in a patient who has [MEDICAL CONDITION] and indwelling Foley catheter which was obstructed . In addition, the emergency room physician documented, Medical record. (The facility) at this point is refusing to send over complete medical record which would include the last dosing and timing of the medications because it is their new policy. I requested to speak to the supervisor as this puts the patient at high medical risk for medical error .Anticipate patient will be in the hospital greater than 2 midnights due to the severity of his illness, wait for culture results .The patient is in the step-down unit as he has high potential of becoming hemodynamically unstable. 3. Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #8's Quarterly MDS assessment, dated 6/14/16, documented moderate cognitive impairment with mild depression, and that Resident #8 required 1-2 staff assistance with all cares, except eating. The MDS documented Resident #8 rejected cares 1-3 days a week and was totally dependent on assistance from 2 staff for toileting. The MDS documented a bladder retraining trial had not been completed. Resident #8's Elimination Care Plan, dated 11/17/14, documented she was incontinent of bowel and bladder. Interventions included: *Staff was to observe skin daily for irritation and redness. *Staff was to provide pericare with each incontinence episode. *Staff was to check and change Resident #8 on rounds and PRN. Resident #8's UTI Care Plan, dated 5/11/16 and 7/11/16, documented she had a UTI. Interventions included: *Staff was to administer antibiotics as ordered. * Staff was to observe urine for odor, color, and sediment. * Staff was to report if Resident #8 had changes in her voiding patterns. A June UTI Care Plan was not provided for review. Resident #8's May 2016 MAR indicated [REDACTED] *Cipro 500 mg PO BID for 10 days to treat a UTI, beginning on 5/9/16 and discontinuing on 5/11/16. * [MEDICATION NAME] 100 mg PO BID for 1 week to treat a UTI, beginning on 5/11/16 and discontinuing on 5/18/16. Resident #8's June 2016 MAR indicated [REDACTED] * [MEDICATION NAME] 300 mg by mouth twice a day for 10 days to treat a UTI, beginning on 6/13/16 and discontinuing 6/22/16. The MAR indicated [REDACTED]. The documentation on the MAR indicated [REDACTED]. The NN documentation did not provide a reason the medication was not provided. Resident #8's July 2016 MAR indicated [REDACTED]. Resident #8's Urinalysis results from 6/6/16 and 6/10/16 document she had trace [MEDICATION NAME], blood and protein in her urine, was positive for [MEDICATION NAME] in her urine, and had bacteria in her urine. Resident #8's Urinalysis result from 7/6/16 documented she had blood in her urine and was positive for [MEDICATION NAME], and had bacteria in her urine. Resident #8's Bladder Evaluation, dated 4/18/16, documented no bladder retraining program was trialed as she was unable to follow a program. Resident #8's Bowel Retraining Evaluation, dated 4/18/16, documented she was unable to participate due to confusion. On 7/11/16 at 3:27 pm, Resident #8 was scheduled to get her incontinence briefs changed and staff existed her room at 3:30 pm and told an RN in the hall that Resident #8 had hit one of them and they would not be doing pericare at this time they would try and come back later. On 7/11/16 at 3:40 pm Resident #8 stated to CNA #8 her incontinence briefs had been soiled and she wanted them off. CNA #8 loosened the briefs and told Resident #8 that she took care of it and left the incontinence briefs on. On 7/12/16 at 4:25 pm, CNA #19 and CNA #20 stated the facility completed peri care three times a day for Resident #8. It was scheduled to be completed in the early mornings, at about 2:45 or 3:00 pm, and after dinner. On 7/13/16 at 2:45 pm CNA #19 stated Resident #8 was not going to get pericare at this time because she was in an activity. On 7/13/16 at 5:56 pm CNA #19 stated Resident #8 did not receive peri care in the afternoon after the activity because she was up in her chair and it was about time to eat dinner. On 7/13/16 at 4:34 pm the ADON stated residents should be checked on whenever you have contact with them or at a minimum of every two hours. The staff should provide pericare whenever there is an episode of incontinence. She stated the staff should not rely on change of shifts to check the residents which was three times a day. The ADON agreed that if a resident was not changed and pericare not completed, it may increase their risk of UTI's. On 7/15/16 at 10:19 am CNA #1 stated Resident #8's cares get neglected often because the staff do not like going into her room. She stated Resident #8 did not reject cares if people treated her like a person and talked to her first. If staff went into her room and started whipping her around then she would get upset. 4. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Initial MDS assessment, dated 6/21/16, Resident #2 had a [MEDICAL CONDITION] and a suprapubic catheter. Resident #2's Suprapubic Catheter Care Plan documented he was at risk for alterated elimination, interventions included: * Staff were to encourage good fluid intake each shift. *Staff were to provide pericare as needed. * Staff were to provide suprapubic care as ordered. Resident #2's July Physician Orders Review documented: * Foley Catheter to be changed every month and PRN for [MEDICAL CONDITION] bladder, beginning 6/14/16. Resident #2's MAR from 6/18/16 to 6/30/16, documentation included: * Staff was to assure patency to the gravity bag drain every shift. The MAR indicated [REDACTED]. * Staff was to check catheter output every shift. The MAR indicated [REDACTED]. *Staff was to assure catheter care and catheter strap was in place every shift. The MAR indicated [REDACTED]. Resident #2's MAR from 7/1/16 to 7/12/16, documentation included: * Staff was to assure patency to the gravity bag drain every shift. * Staff was to check catheter output every shift. The MAR indicated [REDACTED]. *Staff was to assure catheter care and catheter strap was in place every shift. On 7/13/16 at 12:00 pm, the DON stated she would look for the documentaion of catheter care and if it was somewhere in the clinicial record. On 7/14/15 at 3:45 pm, the DON was unable to find if the documentation for the catheter care. 5. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #15 quarterly MDS assessment, dated 7/8/16, documented he had a mild cognitive impairment and no behaviors. The MDS documented he had a Suprapubic Catheter. Resident #15's Elimination Care Plan, dated 4/2/15, documented he was at risk for alterations of bladder function related to him requiring a suprapubic catheter for his [MEDICAL CONDITION] bladder. (Resident #15 did not have a separate catheter care plan.) Interventions included: * Staff members were to encourage fluid intake. * Staff members were to flush his catheter with NS PRN for occlusion. * Staff was to change his catheter and drainage bag per policy or as ordered by the MD. There was no physician order for [REDACTED]. * Staff was to empty his urinary bag every shift, upon rounds, and PRN and record the urine output per facility protocol. Resident #15's July Physician Orders included: * Foley Catheter to be changed every month and PRN for [MEDICAL CONDITION] bladder, beginning 4/20/15. * Staff may flush his foley with NS PRN if occluded, beginning 11/16/15. Resident #15's Bladder Evaluation, dated 2/28/16, documented his average fluid intake was 1000 mL for 24 hours. In addition, it documented his average fluid output was 4-5000 mL per 24 hours. Resident #15's May 2016 MAR indicated [REDACTED] * Staff was to assure patency to the gravity bag drain every shift. The MAR indicated [REDACTED]. * Staff was to check catheter output every shift. The MAR indicated [REDACTED]. *Staff was to assure catheter care and catheter strap was in place every shift. The MAR indicated [REDACTED]. Resident #15's June 2016 MAR indicated [REDACTED] * Staff was to assure patency to the gravity bag drain every shift. The MAR indicated [REDACTED]. * Staff was to check catheter output every shift. The MAR indicated [REDACTED]. *Staff was to assure catheter care and catheter strap was in place every shift. The MAR indicated [REDACTED]. Resident #15's July 2016 MAR indicated [REDACTED] * Staff was to assure patency to the gravity bag drain every shift. The MAR indicated [REDACTED]. * Staff was to check catheter output every shift. The MAR indicated [REDACTED]. *Staff was to assure catheter care and catheter strap was in place every shift. The MAR indicated [REDACTED]. 7/14/16 at 9:48 am the ADON stated she would have to look for the missing documentation but to check in the nurses notes. The nurses' notes did not contain documentation of the missing information. 6. Resident #4's admitting [DIAGNOSES REDACTED]. The 1/5/16 admission Bladder Evaluation indicated, Hx (history) of incontinence per H&P. The Bladder Evaluation included a section on the form which indicated, Evaluation for Bladder Program Potential. Able to participate in program. Evaluation period: 1/5/16 to 1/8/16. The 1/12/16 admission MDS Care Area Assessment (CAA) for ADL/ Functional/ Rehabilitation indicated Resident #4, Requires assistance with ADLs related to impaired mobility .she is able to make needs known. She is incontinent of B&B (bowel and bladder) and is unaware of urge. Review of an undated Care Plan indicated Resident #4 Is always incontinent of urine. On 7/12/16 at 3:45 p.m. during interview, the DON stated, I'm not sure what system is in place for bowel and bladder assessments yet. I haven't looked at it yet and haven't gone through this form (referring to the Bladder Evaluation form). Usually the admitting nurse would be the one doing the bowel and bladder assessment at the time if admission. In the first three hours of admission, they may not know things (related to incontinence of the resident) right away, but I would expect they (staff) still need to get the information on the form. On 7/12/16 at 4:00 p.m. during interview, the Regional Nurse Consultant stated, The admitting nurse does the initial bowel and bladder assessment upon admission to see if the resident is a candidate for a bowel and bladder program. I would have to find out what took place from 1/5/16 to 1/8/16 as was indicated on the bladder evaluation. On 7/15/16 at 2:50 p.m. during a second interview regarding a bowel and bladder training program for Resident #4, the Regional Nurse Consultant stated, I spoke with to the nurse regarding the bowel and bladder evaluation form and she indicated she did fill out the information for those three days (1/5/16 to 1/8/16). When I spoke to the nurse, she said she could not find it anywhere in the chart. So we could not find any documentation of a bowel and bladder training program that was done for those three days. 7. Resident #7's clinical record indicated he was admitted to the facility with a Foley Catheter on 5/24/16. Physician's Orders, dated 5/26/16, stated staff were to initiate bladder training for removal of the Foley Catheter. On 6/1/16, Resident #7's physician wrote the following order, What happened to the Bladder Training I ordered- Did it get done-if not see 5/26/16 order. A Nurse's Note, dated 6/9/16, included, D/C Foley Catheter to begin bladder training. During an interview with the Regional Nurse Consultant on 7/13/16 at 10:00 a.m. she stated the Nurse's Note dated 6/9/16 was incorrect since bladder training should occur prior to removal of the catheter by clamping and releasing of the catheter. She further stated she was unable to locate a facility policy or procedure for staff to follow related to how to perform bladder training.

Based on observation, staff interviews, and record review, the facility failed to provide services to prevent the development of pressure ulcers, promote healing of pressure ulcers and adhere to infection control measures designed to prevent cross contamination resulting in the development and worsening of avoidable pressure sores for 5 of 5 residents (#s 1, #2, #8, #10, and #22) with pressure ulcers. As a result: a) Resident #1 was harmed when he developed a Stage III pressure ulcer on his left heel and a Stage II pressure ulcer on his right heel. b) Resident #2 was harmed when a blister on his right heel worsened to an unstageable pressure ucler. c) Resident #22 was harmed when she developed multiple Stage II pressure ulcers on her coccyx and a blood blister on her left great toe. d) Residents #8 and #10 experienced the potential for harm when they were not turned or their skin was not monitored, placing them at risk for developing pressure ulcers. Findings include: 1. Resident #22 was admitted to the facility on [DATE] in a comatose state, with a trach, and required a ventilator. She was morbidly obese and had history hemorrhagic stroke and underwent a craniotomy on 9/21/15 where part of her brain was resected. Resident #22's skullcap was not replaced and the bone flap from her skull was implanted into her abdomen. Resident #22's 11/14/15 MDS Assessment documented the following regarding her status: * Totally dependent on staff and required extensive assistance of two persons for all her ADLs * Had an indwelling catheter * At risk of developing pressure ulcers * Did not pressure ulcer(s) at Stage 1 or higher * Had surgical wounds on her abdomen * Her skin and and ulcer treatment was, pressure reducing device for bed. * On turning reposition program Resident #22's care plan documented: * Resident #22 was at risk for impaired skin integrity related to persistent vegetative state and lack of purposeful movement. * Skin Integrity Risk: High * Use lotion to ensure skin is well moisturized * Watch for skin tears or reddening of the skin * Ensure that direct care staff are aware of skin risk * Place resident on a pressure reducing cushion in wheelchair, if used. * Keep heels and other areas covered to reduce friction. * Monitor skin condition on a weekly basis and PRN with bath. * Do ROM with daily dressing to increase circulation. * Air mattress to bed to decrease risk of impaired skin integrity. Check function frequently. Resident #22's care plan did not document the need to float her heels or wear a protective boots. Resident #22's Weekly Non-Pressure Skin Report for her right buttock documented on 10/29/15, excoriated R (right) buttock and on 4/6/16, healed Resident #22's Weekly Non-Pressure Skin Report for her left buttock documented: *4/6/16, buttock was excoriated, measuring 0.3 cm x 0.7 cm x 0.1 cm *4/13/16, buttock was excoriated, measuring 1.2 cm x 0.8 cm x 0.1 cm *4/21/16, resolved There was no skin report on Resident #22's blood blister on her L great toe. Resident #22's Nurse's Notes documented the following: * 11/4/15 at 7:00 pm, .Pt buttocks appears to be peeling possibly due to increased loose stool. [MEDICATION NAME] applied with a non adherent dressing. Pt to be placed on side and buttock up off relieving pressure . *11/6/15 at 11:15 am, Checked area on coccyx. Applied Z Guard for protection. Order for Z Guard TID until healed . *11/10/15 at 6:00 am, .Resident has wound on coccyx area, wound nurse contacted to observe . *1/8/16 at 2:00 pm, Clean sacrum w/ NS. Apply there honey and sacral dressing (change) M-W-F. *1/10/16 at 3:30 am, Resident shearing to coccyx covered with dressing . *2/2/16 at 4:00 am, .[MEDICATION NAME] to open area on coccyx use optifreeze to cover .Get Res. off bottom every 2 hours. Do not pull her up in bed without lifting her bottom off bed because of shearing. LPN to evaluate each time she is turned. *2/7/16 at 1:05 am, .Wound to coccyx has 2 open areas to upper (cheeks) . *2/8/16 at 3:00 pm, Ok for Prevalon boots. When you turn her I want her completely off the open areas . *2/21/16 at 10:00 pm, .Res has new blood blister on L toe which is being monitored by wound nurse. Family stated they were not happy about this. *2/23/16 at 9:00 am, .(family) concerned re; new blood blister on her L big toe and dsg to coccyx off since (after)shower . *2/26/16 at 11:00 am, .NP on rounds today and viewed resident's bottom and requested we place a wedge pillow . An NP Progress Note dated 2/8/16 documented, the Resident #22's family had called him and had some concerns about skin damage to Resident #22's heels and skin breakdown on her buttocks. The NP assessed Resident #22 to have Buttocks stage I and 2 wounds- the skin on her buttocks is moist and a bit [DIAGNOSES REDACTED]tous- she has 2 small circular stage II wounds on her buttocks cheeks. The wound nurse is following her routinely. The NP told the staff he wanted the resident off her buttocks routinely and to be repositioned from side to side every 2 hours. A physician's orders [REDACTED]. *11/6/15, Z Guard to coccyx TID til healed *1/8/16, Clean sacrum with NS. Apply thera honey and sacral dressing change M-W-F. *2/4/16, Get off her bottom every Q hrs. Do not pull her up in bed without lifting her bottom off bed-shearing. Use Z Guard each time she is turned. *2/5/16, Apply [MEDICATION NAME] AG and cover with . *2/8/16, Ok for Prevalon boots *2/26/16, Place wedge pillow under her bottom *2/29/16, May (discontinue) [MEDICATION NAME] to buttocks. Continue [MEDICATION NAME] gel to open areas on buttocks apply Q day and PRN . On 7/14/16 at 9:50 am, the Wound Nurse said, Resident #22 required total care. She said the wound on Resident #22's buttocks were more moisture related. She also said Resident #22 was being repositioned every 2 hours and said she remembered a wedge pillow was ordered for her but because of her size, air could not easily circulate on her bottom area. On 7/15/16 at 9:55 am, CNA #1 said Resident #22 needed an extensive assistance of two persons and staff were unable to repositioned her every 2 hours as ordered, especially during the night. She also said there were not enough staff to meet the residents' needs, especially where Resident #22 was, where most residents required 2 persons assistance. Resident #22 developed blood blister on her L great toe and wounds on her buttocks while in the facility which included multiple Stage II and Stage I ulcers, as noted by the NP. Resident #22 was high risk for pressure ulcers upon admission due to her persistent vegetative state and [MEDICAL CONDITION]. The facility failed to ensure interventions sufficient to prevent Resident #22's pressure ulcers were implemented as stated in her care plan and initiated in a timely manner. 2. Resident #1, was admitted to the facility on [DATE]. An Admission Body Audit showed he had no skin breakdown on either heel. The Norton Plus Pressure Ulcer Scale, completed on admission 6/10/16, documented a score of 10, indicating Resident #1 was at risk for the development of pressure ulcers. Resident #1's Weekly Body Audit sheets dated 6/10/16, 6/17/16 and 6/24/16, documented he remained free of skin breakdown on his heels. On 6/26/16, nurses' notes indicated the resident was sitting in his wheel chair for an extended period of time waiting for van transport to the wound clinic for treatment of [REDACTED]. Upon return from his appointment, during the evening hours, a stage 3 pressure ulcer was noted on his left outer heel and a stage 2 pressure ulcer was noted on his right outer heel. During an interview with the treatment nurse on 7/14/16 at 10:00 a.m., she reported Resident #1 was admitted with a wound on his coccyx. The treatment nurse further stated the pressure of his feet on his wheel chair foot rests was the only rationale she knew of that could have contributed to the development of the two pressure ulcers on his heels. Observation of both heels on 7/14/16 at 12:00 p.m., noted he had bilateral heel booties and a bed cradle on the bottom of the bed. The treatment nurse removed the heel booties, painted each wound with [MEDICATION NAME] and placed the booties back on each foot/heel. Infection control practices of keeping the wound clean after painting with [MEDICATION NAME] was omitted. The bed covers were replaced over the bed cradle and the treatment nurse exited the room. Resident #1's record showed the facility failed to consistently measure the wound for signs of and evidence of improvement. 2. According to Resident #10's MDS assessment, dated 02/12/16, he was [AGE] years old. Resident #10 had a history of [REDACTED]. He was nonverbal and was able to nod his head to yes/no question inconsistently. He was rarely understood and sometimes was able to understand others. He remained dependent upon staff to anticipate and meet all of his needs. The ARNP's [DIAGNOSES REDACTED]. an order for [REDACTED]. [REDACTED]. Resident #10's clinical record documented that he had a history of [REDACTED]. His skin was observed in the presence of the wound care nurse on 7/12/16 at 10:25 a.m. Resident #10 had excoriation from his coccyx to the scrotum. There were 2 round opened areas approximately 0.5 centimeters on both sides of the inner buttocks. In addition, there was yeast-like substance from the coccyx to the scrotum. The wound care nurse indicated she was unaware of Resident #10's skin condition. She instructed CNAs #1 and #2 to put Dimethacone Skin Protectant on the area. Resident #10's clinical record lacked a care plan. Nurse's notes, CNA notes, turning schedules, weekly skin checks were also lacking in the clinical record from March 1 to July 1, 2016. 3. Resident #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Initial MDS assessment, dated 6/21/16, documented Resident #2 had no cognitive impairment, mild depression, and required extensive assistance of 2 staff members for all transfers, extensive assistance of 1 staff member for hygiene, dressing and eating. The MDS documented Resident #2 was totally dependent on 1 staff member for locomotion on the unit and in his room and he was totally dependent on 2 staff members for bathing. The MDS documented Resident #2 had a [MEDICAL CONDITION] and a suprapubic catheter. The MDS documented Resident #2 was admitted with an unstageable pressure ulcer no location was specified. Resident #2's July Physician order [REDACTED].>*Staff was to turn Resident #2 every 2 hours to offload the coccyx, beginning 6/16/16. *Staff were to perform weekly skin checks on Tuesday's, beginning 6/16/16. *Post-operative flap sitting regimen staff was to monitor for skin breakdown or redness. If Resident #2's skin showed signs of redness or breakdown, staff was instructed to put him on bed rest for a few days, beginning 4/26/16. * Staff was to cleanse Resident #2's right malleolus (ankle bone area) with a wound DE cleanser. Nursing was to use a felt donut, beginning 5/6/16. *Staff was to use an Prevalon boot to the right ankle and nursing were to remove the boot every shift and assess for signs and symptoms of skin breakdown, beginning 6/14/16. Resident #2's discontinued orders documented: *Staff was to use AFO suspension boot to the right foot and remove every shift and assess for signs and symptoms of skin breakdown, beginning 4/29/16 and discontinued 7/10/16. Resident #2's admit Weekly Body Audit, dated 6/14/16, documentation included: * 3.5 by 2.5 unstageable pressure sore to right malleolus; * 3.5 by 2.8 intact fluid filled blister to the right heel; * Scar from a reconstructed sacral coccyx flap; * Suprapubic catheter; * [MEDICAL CONDITION]. Resident #2's Weekly Body Audit, dated 6/21/16, documented no new or worsening skin issues. Resident #2's Weekly Body Audit, dated 6/30/16, documented no worsening skin issues with a new abrasion to the calf which measured 5 cm by 1cm. Resident #2's Weekly Body Audit, dated 7/5/16, documented no new or worsening skin issues. The Weekly Body Audit's did not document new skin issues to the coccyx or worsening skin issues to the right heel. Resident #2's June 2016 MAR documentation for the skin to be assessed under the boot was incomplete for 7 shifts. The facility could not provide documentation that the skin was assessed during those shifts. The June MAR documentation for Resident #2's coccyx to be offloaded and for him to be turned every 2 hours was documented once per shift. The facility could not provide documentation that the 2 hour offloading of Resident #2's coccyx was completed. In addition, there were 7 shifts where the documentation was missing. Resident #2's July 2016 MAR documentation for his skin to assessed under the boot was completed 7/1/16 through 7/11/16 and the documentation was missing during 1 shift. The July 2016 MAR documentation for Resident #2's coccyx to be offloaded and and for him to be turned every 2 hours was not documented on the MAR. The facility could not provide documentation that the 2 hour offloading of Resident #2's coccyx was being completed. On 6/17/16, Resident #2's MD progress note documented he had a history of [REDACTED]. The note documented the wound was a stage 4 with complications of [DIAGNOSES REDACTED] (flesh eating bacteria). On 6/18/16, Resident #2's Nurses' Notes documented he was using an orthotic boot. On 6/19/16, Resident #2's Nurses' Notes documented he was wearing a boot. On 6/20/16, Resident #2's Nurses' Notes documented it was reported to the treatment nurse that a preexisting blister on the right foot heel opened. 6/21/16, Resident #2's Nurses' Notes documented he had two unstageable wounds one to his right ankle and the other on his right heel. On 6/25/16, Resident #2's Nurses' Notes documented he was wearing a Prevalon boot on his right foot. On 6/26/16, Resident #2's Nurses' Notes documented he was wearing a Prevalon boot on his right foot. On 6/27/16, Resident #2's Nurses' Notes documented sacral flap reconstruction without open areas. On 6/27/16, Resident #2's Nurses' Notes documented he was wearing a Prevalon boot on his right foot. On 7/11/16 at 2:37 pm through 3:50 pm, Resident #2 was observed lying in his bed. He was not moved or turned during the observation. On 7/11/16 CNA #24 stated Resident #2 had skin issues on his coccyx, and right leg. On 7/12/15 from 8:35 am through 12:30 pm, Resident #2 was observed lying in his bed without being moved or repositioned. On 7/12/16 at 3:30 pm, the Wound RN stated Resident #2 had pressure sores to his heel and ankle and that he did not have any skin issues on his coccyx. She stated she changed the dressing twice a week on his shower days which were Tuesdays and Thursdays. On 7/12/16 at 3:30 pm, Resident #2's pericare was observed and he was found to have a wound on his coccyx. There was no bandage on the coccyx. The wound bed was covered with a yellow cheesy yeast like substance. This substance indicated a sign of infection to the wound bed. On 7/12/16 at 3:50 pm, the Wound RN and Regional RN #2 entered the room to determine the nature of the wound. The wound was measured to be 4 cm and the Wound RN described it, like a slit. On 7/15/16 at 10:15 am, CNA #1 stated residents were lucky to get repositioned or turned once per shift and if the residents could not talk they were left from 4:00 pm - 1:00 am without being changed or repositioned. On 7/13/16 at 12:00 pm, the DON stated CNA's are responsible for a giving a report to the wound nurse after residents are showered. The wound nurse audits the reports and that is how new or worsening skin issues are brought to light. She stated in Resident #2's, case of the coccyx wound, no report or I&A was developed until 6/12/16. The facility could not provide documentation of the wound to the coccyx prior to 6/12/16. The DON stated the Wound RN would be able to tell when the wound started. The DON stated she thought moisture contributed to the development of the coccyx wound. She was not aware of residents not being turned. 4. Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #8's Quarterly MDS assessment, dated 6/14/16, documented she had moderate cognitive impairment with mild depression, and required assistance of 1 to 2 staff members with all cares, except eating. The MDS documented Resident #8 would reject cares 1-3 days week and was totally dependent on 2 staff for toileting needs. Resident #8's July Physicians' Orders included: * [MEDICATION NAME]/bagbalm to buttocks twice daily PRN for irritation, beginning on 12/23/14. * [MEDICATION NAME] powder to excoriated area twice daily PRN, beginning on 10/8/15. * Air Mattress to bed to decrease risk of impaired skin integrity, check function frequently, beginning on 12/23/14. Resident #8's Elimination Care Plan, dated 11/17/14, documented she was incontinent of bowel and bladder. Interventions included: * Staff was to observe skin daily for irritation and redness. * Staff was to provide pericare with each incontinence episode. * Staff was to check and change Resident #8 on rounds and PRN. Resident #8's Skin Care Plan, dated 4/25/14, documented she was at high risk of skin breakdown related to impaired mobility and history of [MEDICAL CONDITION]. Interventions included: *Staff was to provide turning and repositioning on rounds and PRN and check and change incontinent briefs. * Staff was to assess skin weekly and document. Resident #8's ADL Care Plan, dated 4/25/14, documented she required staff assistance for all ADL's related to left [MEDICAL CONDITION] and a history of [MEDICAL CONDITION]. Interventions stated Resident #8 was dependent on 1-2 staff members for extensive assistance with all cares. On 7/2/16 Resident #8's Weekly Body Audit documentation included 1 small red area on her buttock. The Nurses' Notes did not include documentation of follow up related to the red area on her buttocks until 7/11/16 at 9:45 pm. A copy of the 7/11/16 weekly body audit documentation was not provided. Resident #8's July 2016 MAR documentation included: *Weekly Body Audits to be done on Monday evenings. The MAR documentation on 7/11/16 was blank. * [MEDICATION NAME]/Bagbalm to buttocks twice daily PRN for irritation, was ordered 12/23/14. The MAR documentation did not include administration of the cream 7/1/16-7/12/16. *[MEDICATION NAME] Powder to excoriated areas twice daily PRN, was ordered 10/8/15. The MAR documentation did not include administration of the powder 7/1/16-7/12/16. * Staff were to check the function of the air mattress frequently. Resident #8's records did not contain documentation of when the air mattress function was checked. The documentation did not include a specific frequency of the air mattress checks and what the checks entailed. On 7/11/16 at 9:45 pm, Resident #8's Nurses' Note documented Resident #8 received a treatment to her left buttocks and she tolerated the procedure well. This was the first documentation after the 7/2/16 weekly body audit documented the irritation on Resident #8's left buttock. Resident #8's Skin Care Plan was not updated to reflect the changed skin condition of Resident #8's buttocks. On 7/11/16 at 3:27 pm, Resident #8 was scheduled to get her incontinence briefs changed and staff exited her room at 3:30 pm and told an RN in the hall that Resident #8 had hit one of them and they would not be doing pericare at this time; they would try and come back later. On 7/11/16 at 3:40 pm, Resident #8 told CNA #8 her incontinence briefs had been soiled and she wanted them off. CNA #8 loosened the briefs and told Resident #8 that she took care of it and left the incontinence briefs on. On 7/12/16 from 8:25 am through 10:46 am, Resident #8 was observed in her bed watching TV and was not repositioned or turned. On 7/12/16 at 4:25 pm, CNA #19 and CNA #20 stated the facility completed pericare three times a day for Resident #8. It was scheduled to be completed in the early mornings, at about 2:45 or 3:00 pm, and after dinner. On 7/13/16 at 2:45 pm CNA #19 stated Resident #8 was not going to get pericare at this time because she was in an activity. On 7/13/16 at 5:56 pm CNA #19 stated Resident #8 did not receive pericare in the afternoon after the activity because she was up in her chair and it was about time to eat dinner. Resident #8 had not received pericare since early that morning. Resident #8 did not receive pericare or have her incontinent briefs changed, for approximately 8 hours. On 7/13/16 at 4:34 pm, the ADON stated residents should be checked on whenever staff had contact with them or at a minimum of every two hours. The staff should provide pericare whenever there is an episode of incontinence. She agreed that pericare and changing of incontinent briefs is important especially when residents are at increased risk of skin breakdown and if residents had limited mobility. On 7/15/16 at 10:19 am, CNA #1 stated Resident #8's cares got neglected often because the staff do not like going into her room. CNA #1 stated Resident #8 did not reject cares if people treated her like a person and talked to her first. If staff went into her room and started whipping her around then she would get upset.

Based on observations, record review, and resident, staff, and resident family interview, the facility failed to provide assistance with ADLs for 6 of 27 sampled residents (#6, #7, #8, #11, #25, and #26) who required staff assistance for all or some of their ADLs. Resident #11 was harmed when he did not receive oral care and his mouth contained a brownish crust when he was admitted to the hospital. Resident #25 was harmed when her hair became so matted and tangled from the lack of assistance with grooming that she had to have her head shaved. Residents #6 and #8 had the potential for psychosocial harm when they were not provided with grooming or hygiene to meet their needs and were observed unkempt, odorous and soiled which could lead to feeling a loss of self-worth. Residents #26 and #7 were at risk of harm when they did not receive bathing or oral hygiene care consistent with their needs. Findings include: 1. Resident #11 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. Resident #11 had a urinary catheter, was on a ventilator, and had a [MEDICAL CONDITION]. He was transferred to the hospital on [DATE]. The 10/22/15 admission MDS assessment indicated Resident #11 usually made himself understood and usually understood others. The assessment documented he was totally dependent on staff for eating and required the assistance of one staff. He was documented as having a swallowing disorder and receiving nutrition via a feeding tube. The ADL care area assessment (CAA) indicated Resident #11 was dependent for all ADLs due to limited mobility of his arms and legs. Resident #11's care plan, dated 12/30/15, identified the problem of requiring staff assistance to maintain personal hygiene due to [MEDICAL CONDITION] and contractures. The goal was, Will be clean, dry, odor free and dressed appropriately for season, place and time of day through review date. Pertinent care plan approaches were, I am dependent on one person for oral care .Provide oral care at least 2x (twice) shift (added 1/18/16). Record review demonstrated concerns with Resident #11's oral hygiene, as follows: * A 1/11/16 Speech Therapist Progress note indicated a concern with oral care, Patient/care giver training - Education re: risks of aspiration and PNA (pneumonia) with poor oral care. * The 1/13/16 Resident Care Conference form included, Family Input: Oral care concerns . * A 1/19/16 Speech Therapist Progress note included, Oral care continues to be a challenge. Initiation of staff education re: necessity of completing oral care up to 4x (4 times) a day, along with, how oral care should be completed. Resident #11 was hosptalized on [DATE] due to a change in mental status. The ED Physician Note, documented at 2:50 p.m., stated He has quite poor hygiene, primarily oral hygiene .Oral mucosa is significantly dry with brownish crusting over tongue and oral mucosa. He is edentulous. Tongue is significantly dry with a layer of brownish crusting. Resident #11's POA was interviewed on 7/12/16 at 9:40 a.m. The POA stated Resident #11's mouth was dry and he was not provided with adequate oral care. Concerns regarding his oral hygiene were raised at the care plan meeting held on 1/13/16. The SLP was interviewed on 7/14/16 at 10:10 a.m. and stated Resident #11 had increased salivary secretions which resulted in him having a lot of, gunk in his mouth. She stated he had dry lips and had increased needs for oral care. She stated she instructed staff how to provide oral care as he was at risk for aspiration due to the contents in his mouth. CNA #13 was interviewed on 7/13/16 at 3:15 p.m., and stated the respiratory therapist did oral care once per shift and the CNAs did it in between. CNA #1 was interviewed on 7/15/16 at 10:10 a.m. and stated there was not enough staff to take care of the residents. She stated there were a number of instances when she came on her shift and found Resident #11 without oral hygiene having been provided. She stated, He never got oral care done. 2. Resident #25 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #25's 5/5/16 Quarterly MDS assessment documented she was cognitively intact, had minimal depression, displayed physical behavioral symptoms 1-3 days of the previous 7 days, and was dependent on two staff for bed mobility and personal hygiene. On 7/15/16 at 10:10 a.m., CNA #1 was interviewed and stated there was not enough staff to take care of the residents. She said there were several female residents whose hair did not get brushed that resulted in severe tangling and matting. CNA #1 stated Resident 25's hair was so matted, her head had to be shaved. Resident #25 was interviewed on 7/15/16 at 11:15 a.m. She was lying in bed in a hospital gown. Her hair was short, approximately 1/2 inch long. Resident #25 was on a ventilator with [MEDICAL CONDITION] place. The respiratory therapist came into the room and provided treatment that would enable her to talk and then left the room. Resident #25's mouth was dry with a white substance around her lips and a foul odor emanated when she spoke. She had difficulty speaking. When asked if she was provided oral care and baths, she said, No. When asked if staff brushed her hair, she said they did not and stated her hair was tangled and matted prior to it being cut. 3. Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #6's quarterly MDS assessment, dated 6/22/16, documented she had no cognitive impairment with minimal signs of depression. The MDS documented she was totally dependent on staff for eating due to a feeding tube. The MDS documented Resident #6 was able perform the task of transfers, dressing and ambulation with staff supervision. Resident #6's ADL Care Plan, dated 5/1/14, documented she required supervision while performing ADL's but may require some staff assistance with grooming, hygiene, oral care, dressing, toileting, and bathing related to weakness and RA. Interventions included: Resident #6's Care Plan did not address how often she would like to receive a bath or shower; address her grooming preferences; and her clothing preferences. Resident #6's June 2016 ADL Records documented Resident #6 refused a shower on 6/26/16. The facility could not provide documentation regarding the refusal or of attempts to reapproach and encourage her to take a shower. On 7/13/16 at 5:45 pm, the ADON stated they did not document reapproaches when showers were refused, however, staff were to reapproach and to look in the nursing notes. The nursing notes did not include documentation of reapproach or shower refusal. On 7/15/16 at 10:19 am, CNA #1 stated Resident #6 got ignored often by staff and had to wait for extended periods of time before getting help. She stated Resident #6 used to have really long hair and it had to be cut because Resident #6 could not brush it out by herself, and it kept getting tangled. CNA #1 stated if staff did not have time to do cares like grooming or showers they would document the resident refused. On 7/15/16 at 12:35 pm, Resident #6 stated she previously had long hair and it got tangled often and had to be cut. She stated she liked her haircut now because it was not heavy on her head or as much maintenance. The facility failed to ensure Resident #6 was appropriately assisted with bathing, grooming and personal hygeine. 4. Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #8's Quarterly MDS assessment, dated 6/14/16, documented she had moderate cognitive impairment with mild depression, and required the assistance of 1 to 2 staff for all cares, except eating. The MDS documented Resident #8 rejected cares 1-3 days per week and was totally dependent on the assistance of two staff for toileting. Resident #8's ADL Care Plan, dated 4/25/14, documented she required staff assistance for all ADL's due to left [MEDICAL CONDITION]. Interventions included: *Resident #8 was dependent on 1-2 staff members for extensive assistance with all cares. Resident #8's Care Plan did not address how often she would like to receive a bath or shower, her grooming preferences, and her clothing preferences. On 7/11/16 at 2:30 pm, Resident #8 was in her bed wearing a hospital gown. The gown was off of her left shoulder and her breast was exposed. On 7/11/16 at 3:40 pm, Resident #8 remained in her bed wearing a hospital gown. The gown was off of her left shoulder and her arm was almost out of the gown. CNA #8 entered the room and helped her put her arm back in the gown. On 7/12/16 at 8:45 am, Resident #8 was wearing a hospital gown. The gown was coming off the shoulder and her breast was exposed. She attempted to lift up her gown and place it back on her shoulder. She was unable to complete this task herself and the gown remained off of her shoulder. On 7/12/16 at 4:25 pm, CNA #19 and CNA #20 stated the facility completed pericare three times a day for Resident #8. It was scheduled to be completed early in the morning, at about 2:45 or 3:00 pm, and after dinner. On 7/13/16 at 2:45 pm, CNA #19 stated Resident #8 was not going to get pericare at that time because she was in an activity. On 7/13/16 at 4:34 pm, the ADON stated residents should be checked on whenever staff had contact with them, or at a minimum of every two hours. This was to include all cares. The ADON stated staff should provide pericare whenever there was an episode of incontinence. On 7/13/16 at 5:56 pm, CNA #19 stated Resident #8 did not receive pericare in the afternoon after the activity because she was up in her chair and it was about time to eat dinner. Resident #8 last pericare was early in the morning at change of shift. On 7/15/16 at 10:19 am, CNA #1 stated Resident #8's cares got neglected often because the staff did not like going into her room. She stated Resident #8 did not reject cares if people treated her like a person and talked to her first. If staff went into her room and started whipping her around then she would get upset. CNA #1 stated if staff did not have time to do cares, like grooming or showers, they would document the resident refused. 5. Resident #26 was admitted to the facility on [DATE] for rehabilitation after a surgical repair of a [MEDICAL CONDITION]. Resident #26's admission MDS assessment, dated 8/31/16, documented she was cognitively intact with BIMS of 15, and required two person assistance for transfers and one person assistance for hygiene and bathing. The MDS documented she had impairment on one side of her lower extremity and had used wheelchair for mobility. The MDS also documented she did not reject of cares and it was very important for her to choose between tub bath, shower, bed bath, or sponge bath. Resident #26's Care Plan did not addressed how often she would receive a bath or shower. Resident #26's ADL Record for August 2015, documented she had refused her bath three times on 8/25/15 and the nurse was notified. Between 8/26/15 and 8/31/15, Resident #26 did not received a bath. There was no documentation in her ADL record that she refused her bath on those days. On 7/15/16 at 9:55 am, CNA #1 said Resident #26 had not refused her bath or shower but would like her bath or shower to be done in her own way and not be rushed, and staff would not accommodate it. 6. Resident #7's clinical record documented [DIAGNOSES REDACTED]. His admission Minimum Data Set, dated dated [DATE], stated he required total assistance from staff for performance of personal hygiene. Resident #7's care plan, dated 5/24/16, documented he required assistance with oral care related to [MEDICAL CONDITION]. During an observation of Resident #7 on 7/12/16 at 8:30 a.m., his lips and oral cavity were cracked and dry. During an interview on 7/12/16 at 9:15 a.m., with the manager of the respiratory therapy team, she stated her staff were responsible for oral care, as well as, the nurses.

Based on observation; staff, resident, and family interview; review of I&As, and record review, it was determined the facility failed to ensure care and services necessary for residents to achieve their highest practicable physical, emotional, and psychosocial wellbeing. This was true for 5 of 27 sampled residents (#1, #2, #11, #15, and #22). As a result: a) Resident #11 was harmed when the facility failed to identify, treat, and monitor significant changes in his condition, which culminated in his hospitalization and subsequent death 2 days later. Resident #11 was also harmed when facility failed to secure his urinary catheter resulting in it being pulled out frequently, causing damage to penis and urinary tract. b) Resident #15 was harmed when he experienced pain for which he was not assessed and treated, and became tearful, expressing concern that facility staff did not listen to him. c) Resident #2 had the potential for harm when his pain was not assessed for needing pre-medication prior to wound care and needing a scheduled pain medication, given his high PRN usage and could have experienced uncontrolled pain. d) Resident #22 had the potential for harm when the facility failed to provide a helmet replacement due to the resident's craniotomy and she could have experienced further head injury. e) Resident #1 had the potential for harm when the facility failed to follow physician orders [REDACTED]. Findings include: 1. Resident #11 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. Resident #11 had a catheter, was on a ventilator, and had a [MEDICAL CONDITION]. He resided in the facility until he was transferred to the hospital on [DATE], where he died two days later. a. Resident #11 had a long history of catheter use with the condition of his penis being compromised. His catheter was not adequately secured and was pulled out during his stay. The NP initiated orders on 2 different occasions to ensure Resident #11's catheter was secured; however, there was evidence his catheter was not consistently secured. The progression was as follows: Resident #11's [DATE] MDS assessment documented, Long history of indwelling catheter use. Per the H&P .he has erosion from the tip of his penis which necessitated an alternate insertion site for the catheter. It is now placed in an opening under his penis, through his scrotum and requires replacement q (every) ,[DATE] weeks using a guide wire. It is done by a urologist at off-site appointments. The Urologic Institute History and Physical, dated [DATE], indicated Resident #11 had a complex history as follows: Pt (patient) apparently has developed ventral urethral meatal erosion secondary to a long-term indwelling Foley catheter. Foley catheter changes have been done on a q (every) ,[DATE]-week basis and have required either surgery or have been done with a catheter over wire technique. Had a suprapubic catheter at one time and this was discontinued because it kept getting pulled out. The plan was for suprapubic catheter if possible so catheter changes could be completed at the care facility. The [DATE] NP's Progress Note indicated Resident #11's Foley catheter had to be inserted at the base of his penis because of flaying of his penis from the Foley use. Resident #11 was scheduled for placement of the suprapubic catheter by urology. An [DATE] Nurse's Note documented the CNAs finding Resident #11's catheter out on rounds. The balloon was ruptured and Resident #11 denied pulling it out. An [DATE] NP's Progress Note indicated Resident #11's Foley catheter came out and he was sent to the emergency department; however, the emergency department was unable to reinsert the Foley. Urology was called and recommended the catheter be left out which was done. Resident #11 was voiding some urine. An [DATE] NP's Progress Note indicated the urologist had to replace the catheter using a guide wire. The note documented, We sent him to the ER over the weekend and they were unable to replace it. They contacted urology and were told to leave the catheter out as long as he was voiding yesterday when I saw him his abdomen is quite distended and painful with palpation and I was concerned that he was retaining urine. I sent him to the emergency department for further evaluation .Resident #11's Foley was replaced at the surgical center. It was not secured to his thigh so I told the staff that I wanted it secured to his thigh to try to prevent any further episodes of it coming out. A telephone order was written on this date as follows: Make sure Foley is secured to his thigh. A [DATE] NP's Progress Note documented S/P (status [REDACTED]. It was replaced and is now sutured in place. I told the staff that I wanted that catheter secured to his abdomen as all times. He continues to have a Foley catheter inserted that is plugged and he does have a follow up with urology scheduled. A second telephone order was written on this date as follows: Please make sure suprapubic cath (catheter) is secured to his abd (abdomen) at all times. A [DATE] Physician's Progress Note documented Resident #11 was present for a suprapubic exchange. His catheter was changed on this date. A [DATE] NP's Progress Note documented Resident #11 was complaining of pain around the suprapubic catheter site. Documentation indicated cream that was indicated was in use and the catheter was not secured as follows: There was some type of whitish cream around the catheter that I removed. I asked the staff not to place any cream around that area. The catheter was not appropriately secured. I asked the staff to be sure and have his gastrostomy tube and his suprapubic catheter secured with a device called a stat lock. I also demonstrated how to properly use it to the nurse. The NP was interviewed on [DATE] at 2:40 p.m. and stated he did not remember the specifics regarding Resident #11's catheter; however, if he documented the catheter was not secured, then it was not. The NP further stated, It (catheter) might not come out if it was secured. Nurse #8, the charge nurse, was interviewed on [DATE] at 5:40 a.m. and stated it was standard nursing practice to ensure catheters were secured and it was unusual to see a physician's orders [REDACTED]. b. Resident #11 experienced a change in condition prior to his hospitalization on [DATE]. There was a lack of following physician's orders [REDACTED]. In the timeframe immediately preceding Resident #11's hospitalization , there was evidence he experienced a change in condition that was not identified or monitored by facility staff. The progression was as follows: On [DATE] the Medical Nutrition Assessment was completed. Resident #11's admission weight was 176.8 lbs. The tube feeding rate was increased from 55 to 75 cc an hour based on the dietitian's recommendation on this date. The revised tube feeding regimen provided a daily total of 1847 cc fluid daily. Resident #11 was allowed ice chips and ice cream orally and no other food or beverages. Resident #11's tube feeding orders remained unchanged through date of transfer to the hospital on [DATE]. A [DATE] Social Service Progress Note indicated Resident #11 was alert and able to communicate needs and preferences with a goal of weaning from the ventilator and returning to the group home where he had resided. During the course of his stay he had a number of medical issues such as his catheter coming out, Gastrostomy tube ([DEVICE]) becoming clogged, [MEDICAL CONDITION] coming out, having a urinary tract infection, and sustaining significant weight loss. Cross refer to F327 and F325 for details. Nurse's notes for the week preceding hospitalization documented: * On [DATE] at 12:00 noon Resident #11 was documented as being alert, in bed, with the tube feeding being administered, and antibiotic being applied to his right eye. * On [DATE] at 9:50 p.m., Resident #11's [DEVICE] was documented as being clogged with nursing being unable to get it unclogged. He was sent to the hospital and returned with the issue resolved and the tube feeding running. * On [DATE] at 6:20 p.m., Resident #11's right eye was documented as being swollen with medications being given as ordered. * There were no notes on [DATE]. * On [DATE] at 8:00 a.m., Resident #11 was documented as being alert and confused. Tube feeding was administered per orders, Foley intact, and continuation of antibiotic for his eye. A note at 10:30 p.m. documented tube feeding running without problems, the Foley catheter was leaking, respirations were even and unlabored. Resident #11 was documented with clear speech and his needs being anticipated. * On [DATE] the only Nurse's Note was a Nutrition at Risk (NAR) note, written at 12:30 p.m., that documented a weight of 160 lbs with no new medications or labs being available. * There were no Nurse's Notes for a 2-day period preceding Resident #11's hospitalization , [DATE] at 12:30 p.m. until a note on [DATE] at 4:35 p.m. * A [DATE] Nurse's Note at 4:25 p.m., documented Resident #11 being sent to the emergency department to be evaluated for a stroke. Vital signs were oxygen saturation at 84% with an increase to 98%, heart rate ,[DATE], blood sugar 181, blood pressure ,[DATE] with Resident #11 having slurred speech. A note later that day at 10:00 p.m. documented, No ice chips or water should be left in pt (patient's) room. * On [DATE] in the NP's Progress Note Resident #11 was documented with altered mental status, decreased oxygen saturation in the 80s and somnolence. He was hospitalized on this date. Resident #11 was hospitalized on [DATE] due to a change in mental status. The ED Physician Note at 2:50 p.m. documented, He has quite poor hygiene, primarily oral hygiene .Oral mucosa is significantly dry with brownish crusting over tongue and oral mucosa. He is edentulous. Tongue is significantly dry with a layer of brownish crusting. The note further documented an elevated sodium lab of 190 (,[DATE] normal range), BUN 140 (,[DATE] normal range), and creatinine 2.5 (XXX,[DATE].25 normal range). Clinical impressions were, 1. Altered level of consciousness, 2. Intracranial mass, 3. Dehydration, 4. [MEDICAL CONDITION] (high sodium). The note stated, Severe dehydration and rehydration high risk for cerebral [MEDICAL CONDITION]. Resident #11 passed away on [DATE] in the hospital. According to the [DATE] hospital Discharge Summary admitting [DIAGNOSES REDACTED]. The cause of Resident #11's death was documented in full, 1. Intracranial mass, possible olfactory neuro[DIAGNOSES REDACTED] or other malignancy of the brain. 2. Urinary tract infection, possibly secondary to suprapubic catheter with gram negative rods. 3. Gram positive cocci bacteremia, unclear source. 4. Severe [MEDICAL CONDITION] with dehydration 5. Acute [MEDICAL CONDITION], possibly secondary to dyselectrolytemia (an electolyte disorder) and infection. 6. Acute kidney injury. Review of Resident #11's Tube Feeding Record for [DATE], indicated he was not provided with tube feeding and water flushes per physician's orders [REDACTED]. There were 2 shifts on [DATE] and [DATE] in which the flush of 200 ccs was not documented as having been administered. The order for flushing the [DEVICE] with ,[DATE] ccs of fluid was not documented as having been completed on night shift for the 8 days prior to Resident #11's hospitalization (from [DATE]- [DATE]). Review of the MARs demonstrated Resident #11's output was not adequately monitored in the facility prior to his hospitalization . For the month of [DATE] (through am shift on [DATE]), catheter output was not documented for 11 out of 62 shifts. Resident #11's total output per day was not totaled for any of the days in [DATE]. Of the days in which output was documented for all 3 shifts (12 days out of 21 days total), Resident #11's output averaged 1104 cc per day (per the surveyor ' s calculations). Review of Resident #11's output records for the month of [DATE], showed an average output of 1670 cc per day, demonstrating decreased urinary output, not identified by the facility, prior to Resident #11's hospitalization . Resident #11's POA was interviewed on [DATE] at 9:40 a.m. and stated he had cared for Resident #11 for [AGE] years prior to Resident #11's admission to the facility. He stated Resident #11 was not provided adequate fluids and he was severely dehydrated when he went to the hospital on [DATE]. The POA also stated Resident #11 had a large growth at his right eye that the facility did not address adequately or timely. The POA stated Resident #11's cognition had already begun to deteriorate at the time the care plan meeting was held [DATE]. The POA stated Resident #11 became increasingly incoherent over the last month of his life and indicated Resident #11 had been basically alert and oriented previously. The POA stated Resident #11 was very thirsty and often asked for ice chips, which he had been allowed to have previously when he was on the ventilator. The POA stated he observed Resident #11 with a dry mouth and with cracked dry lips in the week preceding his hospitalization . The POA stated, He died at the hospital. The doctor said he didn't know how he (the resident) could get so dehydrated. His electrolytes were through the roof. It was like he had been in the desert for weeks. Nobody bothered giving him fluids. 2. Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #15's quarterly MDS assessment, dated [DATE], documented he had a mild cognitive impairment with signs of moderate depression and no behaviors. The MDS documented he received scheduled pain medications and no PRN pain medications. The MDS documented that Resident #15 was usually understood when he communicated, but had difficulty with some words or finishing thoughts. Resident #15's Pain Care Plan, dated [DATE], documented he was at risk for pain related to muscle weakness, history of UTI's and bladder spasms. Interventions included: *Staff was to offer him non-pharmacological relief to include massage, repositioning, music, relaxation, and diversion. *Staff was to assess for pain each shift. *Staff was to observe him for non-verbal signs and symptoms of chronic pain. Resident #15's Hydration Care Plan, dated [DATE], documented he was at risk for dehydration related to alterations in cognition and dementia. Interventions Included: *Staff were to offer him fluids within his diet parameters, with med passes as ordered, and PRN. *Staff was to assess Resident #15 for signs and symptoms of dehydration. Resdient #15's last Pain Evaluation, dated [DATE], documented his non-verbal signs of pain included: * grimacing * frowning * tearing * crying/whimpering * rocking, * rubbing body parts, * increased hand/finger movement. Resident #15's July Physician order [REDACTED].>* 37XXX,[DATE] mg [MEDICATION NAME] twice daily for pain. * 650 mg Tylenol every 4 hours as needed for pain. * 37XXX,[DATE] to,[DATE] mg [MEDICATION NAME] every 6 hours as needed for pain. Resident #15's May MAR indicated he was not given the scheduled pain medications 5 times. Four of the 5 times the medications were not given, the reason was not documented. The May MAR showed Resident #15's pain was not assessed during 1 shift. Resident #15's June MAR he was not given the scheduled pain medications as ordered 1 time and the reason the medications were not administered, was not documented. The June MAR showed Resident #15's pain was not assessed during 4 shifts. Resident #15's July MAR up to [DATE], showed that on 1 occasion his pain medications were not given and the reason was not documented. The July MAR showed Resident #15's pain was not assessed for 2 shifts and no PRN pain medications were administered. On [DATE] at 4:30 pm, Resident #15 was in his room sitting in his wheelchair about 2 and half feet from the bed. He had his head bent over and he was tearful. He was holding on to his right wrist and was rubbing it. He started to rock back slightly in his chair. The call light was on his bed out of his reach. Resident #15's water cup was on a dresser at the foot of his bed out of his reach and he smelled of urine. He was asked how he was doing and Resident #15 stated not good. When asked why not, Resident #15 stated he did not know what he did to deserve this, he had lived a good life, raised his kids, made good money, and now he was here. As Resident #15 was talking it was observed his mouth had a white crusty looking film around it and he kept licking his lips and his mouth had a thick looking mucus in it. During the interview Resident #15 stated I am so needing fluids can you help? Resident #15 expressed pain all over his body, as well, and stated that he smelled bad. Since his call light was not in his reach, the surveyor noticed a CNA in the hall and CNA #16 came in the room. Resident #15 started to talk to CNA #16, however, she interrupted him and asked if he was thirsty. He stated yes I am so needing fluids. She gave him a drink of water, then returned the water cup back to the dresser at the foot of the bed, out of Resident #15's reach. Resident #15 thanked her for the water and continued to talk. CNA #16 interrupted him and stated Do you want to call your son in a bit that always cheers you up. He stated yes he would like that but he smelled bad. CNA #16 stated she would be back in a bit to get him to dinner. Resident #15 was still tearful and stated he did not want to go to dinner. She left the room before he could finish talking and he could tell her he hurt. The surveyor asked Resident #15, who can you tell about your pain? and he stated he tried to tell her (CNA #16). The surveyor told Resident #15 he should try again to talk with CNA #16 about his pain when she came back. Toward the end of the interview, CNA #16 returned to Resident #15's room and and started talking to him again and told him she was going to put him to bed since he did not want to go to dinner and she would get him a dinner tray. CNA#16 did not notice Resident #15's non-verbal signs of pain and did not wait for him to communicate his needs. [DATE] at 9:48 am, the ADON stated the facility documented pain assessments once per shift. She stated if a resident had pain at other times it would be on the PRN pain medication administration sheet. Issues were discussed with ADON related Resident #15's difficulty communicating and that is was observed that staff did not assess him for pain during the above observation/interview, when Resident #15 was tearful, held onto and rubbed his wrist, had his head bent over, and was rocking in his chair. She stated there was not a place on the MAR for random pain checks for residents who had dementia or could not communicate their pain needs well. The staff was to watch for non-verbal signs of pain and tell an RN who could then administer PRN pain medications. 3. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Initial MDS assessment, dated [DATE], documented Resident #2 had no cognitive impairment and mild depression. The MDS documented he received PRN and scheduled pain medications. It documented Resident #2 was admitted with a un-stage pressure ulcer no location was specified. Resident #2's July Physician order [REDACTED].>* 650 mg of Tylenol every 4 hours as needed for pain, beginning [DATE]. * ,[DATE]mg of [MEDICATION NAME] every 4 hours as needed for pain, beginning [DATE]. Resident #2's orders did not include a routinely scheduled pain medication. Resident #2's hospital H&P, dated [DATE], documented he had received PRN Tylenol and [MEDICATION NAME] as ordered above, for pain and also had a scheduled pain medication of 25 mcg [MEDICATION NAME] which was changed every three days. The H&P documented Resident #2 had a reaction to the [MEDICATION NAME] and it was discontinued. Resident #2's MAR from [DATE] to [DATE], documented PRN [MEDICATION NAME] was administered 15 times and Tylenol PRN was administered one time for pain. Resident #2's Pain Management Flowsheet from [DATE] documented an additional 4 doses of [MEDICATION NAME] administered [DATE] at 4:00 am, [DATE] at 3:00 pm, [DATE] at 8:00 pm, and [DATE] at 2:45 pm. The administrations were not documented on the MAR. Resident #2 was administered [MEDICATION NAME] PRN 19 times in 28 days ([DATE] to [DATE]). Resident #2's average pain rating from the [DATE] Flowsheet was 7.78 on a scale of ,[DATE], with 10 being the worst. On [DATE], Resident #2 Nurses' Notes documented he complained of neck pain. On [DATE], Resident #2's Nurses' Notes documented he complained of pain. On [DATE], Resident #2's MD progress note documented he had chronic pain and used Tylenol and [MEDICATION NAME] when necessary. On [DATE], Resident #2's Nurses' Notes documented he complained of pain after a shower. On [DATE], Resident #2's Nurses' Notes documented he complained of pain in his back. On [DATE] at 10:38 am, Resident #2 was observed during a dressing change to his heal wound. Resident #2 was sitting up slightly in bed and the dressing change started. There was no observation of pre-medication offered to Resident #2. While positioning Resident #2 to work on his multiple skin issues, the wound nurse started to move the bed position and move Resident #2. Resident #2 closed his eyes, started grimacing and made a hissing sound. The dressing change and skin assessment continued. On [DATE] at 9:50 am, the ADON stated that residents get assessed once a shift for pain. The facility could not provide documentation that pre-medication was offered prior to wound care. In addition, the facility could not provide documentation that Resident #2's chronic pain had been addressed in regards to his frequent use of PRN pain medication as a sign he needed a scheduled pain medication. 4. Resident #1's clinical record documented a [DIAGNOSES REDACTED].#1 had a past medical history of [REDACTED]. Resident #1's physician's orders [REDACTED]. Documentation on the [DIAGNOSES REDACTED].#1's Physician that stated, I had ordered an iron and Ferritin level that I do not see. On [DATE] at 11:15 a.m., the Regional Nurse Consultant confirmed the laboratory had not been made aware of the physician's orders [REDACTED]. During a phone interview on [DATE] at 11:30 a.m., with the facility's Nurse Practitioner, he stated that staff often failed to ensure labs were drawn. He stated he does not know why this had been occurring. 7. Resident #22 was admitted to the facility on [DATE] in comatose state with a history of hemorrhagic stroke and craniotomy on [DATE], where part of her brain was removed. Resident #22's skullcap was not replaced. Resident #22's MDS Assessment, dated [DATE], documented, she was totally dependent on staff for all of her ADLS. Review of Resident #22's Nurse's Notes documented: *[DATE] , .resident skull bone flap out. Order for helmet for OOB (out of bed) . *[DATE] at 6:00 am, .hoyer transfer (with) helmet on . Resident #22's Social Services Progress Note, dated [DATE], documented the resident was to wear a helmet when she was out of bed. Resident #22's October and [DATE] MAR had no documentation of her using a helmet when she was OOB. A Resident Care Conference, dated [DATE], documented Nursing will get, ask for an order for [REDACTED]. Resident #22's Physician Order, dated [DATE], documented Ok for Helmet when OOB. Resident #22's February 2016 MAR documented an order, dated [DATE], she was to use a helmet when she was OOB. Resident #22's NP's Progress Note, dated [DATE], documented Resident #22's family member had called that morning and had some concerns about Resident 22's rashes on her arms, skin damage to her heels, and skin breakdown on her buttocks. The family member also inquired about a helmet to be used when Resident #22 was out of bed because she was missing part of her skull. The NP's Progress Notes also documented he had already ordered a helmet to be used by Resident #22 when she was up and out of bed. On [DATE] at 9:50 am, the Wound Nurse said Resident #22 had a helmet but she cannot remember when it was ordered or when Resident #22 started using it. She said it was used whenever Resident #22 was out of bed for her shower. There was no documentation found on the Resident #22's clinical record that she was provided with a helmet when she was out of bed, until [DATE] when it was ordered by the NP. 7. Resident #1's clinical record documented a [DIAGNOSES REDACTED].#1 had a past medical history of [REDACTED]. Resident #1's physician's orders [REDACTED]. Documentation on the [DIAGNOSES REDACTED].#1's Physician that stated, I had ordered an iron and Ferritin level that I do not see. On [DATE] at 11:15 a.m., the Regional Nurse Consultant confirmed the laboratory had not been made aware of the physician's orders [REDACTED]. During a phone interview on [DATE] at 11:30 a.m., with the facility's Nurse Practitioner, he stated that staff often failed to ensure labs were drawn. He stated he does not know why this had been occurring.

Based on observation, record review and interview, the facility failed to ensure the dignity of residents was maintained. This was true for 4 of 27 sampled residents (#4, #6, #8, and #15). The deficient practice caused psychosocial harm for Resident #4 when her self-worth declined. The deficient practice created the potential for psychosocial harm when residents were not provided the care and assistance necessary to ensure a) they did not smell of urine, b) their clothes were changed when they were incontinent, c) they received timely assistance to dress and were appropriately dressed, and d) they received showers to prevent body odors. Findings include: The facility's undated Resident Rights Policy included, This is to assure that (Name of Resident) a resident at (Name of Facility) is treated with consideration, respect, and full recognition of his dignity and individuality, including privacy in treatment and in care for his personal needs. This policy was not followed. Examples include: 1. During the initial tour of the facility on 7/11/16 at 10 a.m., LPN #9 stated Resident #4 was incontinent of urine, needed total assistance from staff with toileting, and used a bed pan. On 7/11/16 at 4:00 p.m., CNA #5 stated, She (Resident #4) can't get out of bed on her own. It takes two people to get her up. We always put her on the bed pan to toilet her and lay her down after each meal. She is always, usually wet, and she will let us know if she needs to go. She is always incontinent and will ask for the bed pan. She can't walk to get to the toilet and can't stand, so this is why we use a bed pan for her. Review of the 12/31/15 History and Physical indicated Resident #4 had a past medical history of [REDACTED]. Review of the undated Face Sheet indicated Resident #4's admitting [DIAGNOSES REDACTED]. The 1/5/16 Bladder Evaluation indicated Resident #4 had, hx (history) of incontinence per H&P. Review of the 1/12/16 admission MDS assessment and the 6/30/16 quarterly MDS assessment documented Resident #4 had no signs of [MEDICAL CONDITION], disorganized thinking, or altered level of consciousness and the BIMS score was 12 out of 15 on 1/12/16, and 15 out of 15 on 6/30/16. The 1/12/16 Admission MDS Assessment noted Resident #4, Requires assistance with ADLs related to impaired mobility .she is able to make needs known. She is incontinent of B&B and is unaware of urge. An undated Care Plan documented Resident #4 Is always incontinent of urine, and requires staff assistance for all ADL's related to impaired mobility, cognitive deficit. Interventions for staff were, Toilet the resident with AM and PM care before and after meals and PRN. The undated Nurse Aide's Information Sheet stated Resident #4 was incontinent of bladder. However, there was no indication of the use of a bed pan. A 7/11/16 In-service Training document stated, Resident is able to tell you when she needs to toilet. Please offer bed pan .She needs to be as continent as possible. On 7/13/16 from 8:15 a.m. to 11:32 a.m. (a total of 3 hours and 15 minutes) Resident #4 was observed sitting on a blue Hoyer sling in her wheelchair in the main dining room, eating breakfast, then again in her room still seated on the blue Hoyer sling in her wheelchair. During this time, Resident #4 had a strong smell of urine and no staff were observed asking her if she needed to use the restroom, or offering to assist her with using the bed pan. On 7/13/16 at 9:30 a.m., CNA #9 was interviewed and stated, We are supposed to be offering her a bed pan, but I was not aware of a bed pan prior to this morning. There was some in-service book I was told to read today when I came in, and it just said to offer a bed pan to her. I didn't know this. I worked with her last week on Tuesday and Wednesday and I was not made aware of her using a bed pan. She is a 'heavy wetter.' When I've worked with her before, I usually lay her down after meals because she would already be wet. The other CNA working today didn't mention anything to me about a bed pan. The nurse didn't mention anything either about a bed pan. When I came in this morning, she was already wet in bed so no bed pan was offered. On 7/13/16 at 10:05 a.m., CNA #10 was interviewed and stated, I have never given her a bed pan. I've never known her to ask for one. I'm not sure if she has ever had a bed pan or not. She is very incontinent and is usually, always wet. When I came in this morning, she was wet. The nurse never informed me of a bed pan or to even encourage her to use a bed pan. I guess we could offer her a bed side commode but I've never seen her use one. When the CNA was asked how she was made aware of each of the residents assigned to her, the CNA stated, There is a sheet in the CNA ADL book, at the nurse's station that tells us about each resident. When the CNA was asked if she was made aware of an in-service book at the nurses' station regarding Resident #4 and the need to use a bed pan, the CNA stated, I have never seen this (referring to the in-service book) before. All I know is she (Resident #4) likes to be laid down after breakfast, but we haven't done that yet. On 7/13/16 at 10:30 a.m. LPN #4 stated, She (Resident #4) is continent. Most of the time she lets us know when she needs to go to the bathroom and she uses a bed pan. When the LPN was asked, how staff knew Resident #4 used a bed pan, the LPN stated, the CNAs have an ADL book that they are supposed to review and it tells them about each resident and those get updated whenever anything changes. When the CNA ADL booklet was reviewed with LPN #4 specifically for Resident #4, the LPN was asked how staff knew about a bed pan. The LPN stated, It's not checked here. It also says the resident is incontinent and a bed pan is not checked here, so I could see how the CNAs wouldn't know. On 7/13/16 at 10:50 a.m., Resident #4 was observed sitting in her wheelchair on a blue Hoyer sling with a strong urine odor. Resident #4 was interviewed at that time and stated, They don't let me use the bathroom because I can't walk, so I have to use the restroom in my clothes. When Resident #4 was asked how this made her feel, she stated, Like an idiot. Resident #4 then stated, I can't say how often they change me here. Sometimes they leave me wet for a very long time and I can't feel it coming when I have to go, so I just go, and by then it's just too late when they come around. I have really sensitive skin and I feel like I'm not worth much here. When Resident #4 was asked if any staff had offered the bed pan to her or offered to toilet her after breakfast this morning, she stated, No, I've been sitting here in my chair this whole time and I would really like to lay down. During a second interview with CNA #9 on 7/13/16 at 11:25 a.m. she was asked why Resident #4 had not been assisted to her bed or offered the bed pan after breakfast, the CNA stated, Yeah, I know. The other CNA went to lunch and she (CNA #10) said she asked her (Resident #4) if she wanted to be laid down and said she didn't want to, so I went to lunch, and I just came back a few minutes ago. Especially with our residents who are Hoyer lifts (as she is) we need two people to transfer and since there is only one person on the unit, we can't do it by ourselves. We were planning on changing her before she goes to lunch though. During a second interview with CNA #10 on 7/13/16 at 11:30 a.m., she was asked why Resident #4 was not in bed or offered the bed pan after breakfast, the CNA stated, Part of the reason was, I was helping other people. On 7/13/16 at 11:32 a.m., Resident #4 was observed still sitting on the blue Hoyer sling in her wheelchair and there was still a strong smell of urine coming from the resident. During an interview with CNA #22 on 7/14/16 at 5:00 a.m. she stated, She (Resident #4) uses a bed pan and she doesn't know when she has to go so we have to change her a lot because she is incontinent. During an interview with the OT on 7/14/16 at 9:10 a.m. she stated, She (Resident #4) could never advance to using a bedside commode because she was non-weight bearing, had a leg brace and could never make it to her feet, so it would be up to the nurses to utilize a bed pan if she couldn't get up. Nursing knows she needs to use a bed pan and I would assume that if the staff can't get her on a commode, then the way to toilet her would be with a bed pan. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/12/16 at 8:36 am, Resident #6's bed was flat and she was lying on her back hooked up to the tube feeding pump. She was wearing a hospital gown and used a blanket to cover herself up because she was not dressed yet. She was embarrassed to have someone see her like this. Her hair was disheveled and she kept trying to push it out of her face and she kept covering her mouth because her teeth were not brushed. Resident #6 stated she wanted to get up and get dressed but could not because she was still hooked up to the tube feeding pump. She stated she was to remain in bed until nursing came and unhooked her. Resident #6 stated she liked her door open when she was not hooked up to the pump but since she would be hooked up to the tube feeding pump for extended periods of time it was closed often. On 7/12/16 at 9:00 am through 10:00 am, Resident #6 remained in her bed and hooked up to the tube feeding pump. Resident #6 asked the surveyor to get her a nurse because she really wanted to get up and get dressed. On 7/12/16 at 10:01 am, LPN #4 was informed of Resident #6's request to get up. On 7/12/16 at 10:19 am, LPN #4 unhooked Resident #6 from the tube feeding pump. Resident #6 got up shortly after being unhooked from the TF pump. She could not get up to complete her morning grooming activities because she had been hooked up to the TF pump. She stated she would have to wait long periods of time before she could. On 7/13/16 at 8:39 am, Resident #6's bed was flat and she was lying on her back hooked up to the tube feeding pump. She was wearing the same clothes as the day before and used a blanket to cover herself up because she was not dressed yet. She was embarrassed to have someone see her like this. Her hair was disheveled and she kept trying to push it out of her face and she kept covering her mouth because her teeth were not brushed. She stated that she had RA and her hands could not grab things well and staff would have to help her with something's but she could manage most things. The pump had stopped pumping at 8:30 am per Resident #6. She remained hooked up to the tube feeding pump until 10:49 am when LPN #4 gave her morning medications to her. Resident #6 had a comode sitting next to her bed. The room smelled of urine and she stated she had used it in the night. It was emptied and changed at 10:39 am. On 7/13/16 at 5:45 pm, the ADON stated the tube feeding pump being left on Resident #6 was not ok. She agreed being left on the pump interfered with her ability to get up and get dressed. On 7/15/16 at 10:19 am, CNA #1 stated Resident #6 gets ignored often by staff and will have to wait for extended periods of time before getting help. Resident #6 had complained that staff members would talk about her and they did not want to give her a reason to think they were talking about her. She stated Resident #6 used to have really long hair and it had to be cut because Resident #6 could not brush it out by herself, and it kept getting tangled. CNA #1 stated if staff did not have time to do cares like grooming or showers they would document the residents' refused. On 7/15/16 at 12:35 pm, Resident #6 stated she used to have long hair and it used to get tangled and it had to be cut. 3. Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #8's ADL Care Plan, dated 4/25/14, documented she required staff assistance for all ADL's related to left [MEDICAL CONDITION] and history of [MEDICAL CONDITION]. The care plan included the intervention that Resident #8 was dependent on 1-2 staff members for extensive assistance with all cares. On 7/11/16 at 2:30 pm, Resident #8 was in her bed wearing a hospital gown and it was off of her left shoulder and her breast was exposed. On 7/11/16 at 3:27 pm, Resident #8 was scheduled to get her incontinence briefs changed and staff exited her room at 3:30 pm and told an RN in the hall that Resident #8 had hit one of them and they would not be doing pericare at this time, they would try and come back later. On 7/11/16 from 3:28 pm through 3:40 pm Resident #8 could be heard calling out I need a knife to cut this; give me something to cut this. Do something right for a change you ignorant [***] . On 7/11/16 at 3:40 pm, Resident #8 remained in her bed wearing a hospital gown, it was off of her left shoulder and her arm was almost out of the gown. CNA #8 entered the room and helped her put her arm back in the gown. Resident #8 stated to CNA #8 she needed a knife to cut this. CNA #8 stated what do you need a knife for? Resident #8 stated come here and I will show you. Resident #8 lifted up her hospital gown and tugged on her incontience briefs. CNA #8 told Resident #8 that it could not be cut because it was there to keep her incontience briefs on. CNA #8 loosened the incontience briefs and left them on the resident. Resident #8 was heard telling the CNA that she had loosened the incontience briefs and had not remove them. Resident #8 stated she needed them off because there was poop on them. CNA #8 told Resident #8 that she took care of the problem and threw the briefs in the trash. Resident #8 stated no you did not you just loosened them. On 7/12/16 at 8:45 am, Resident #8 was wearing a hospital gown. The gown was coming off the shoulder and her breast was exposed. She attempted to lift up her gown and place it back on her shoulder. She was unable to complete this task herself and the gown remained off of her shoulder. Resident #8 could be seen in the hall as people walked by her room. On 7/12/16 at 4:25 pm, CNA #19 and CNA #20 stated the facility completed peri care three times a day for Resident #8. It was scheduled to be completed in the early mornings, at about 2:45 or 3:00 pm, and after dinner. CNA #19 stated they had just completed pericare and the surveyor would have to wait until tomorrow afternoon to watch. They would come get the surveyor in the afternnon before they stated pericare. On 7/13/16 at 2:45 pm CNA #19 stated Resident #8 was not going to get pericare at this time because she was in an activity. On 7/13/16 at 5:56 pm CNA #19 stated Resident #8 did not receive peri care in the afternoon after the activity because she was up in her chair and it was about time to eat dinner. Resident #8 last pericare was early in the morning at change of shift. On 7/15/16 at 10:19 am, CNA #1 stated Resident #8's cares got neglected often because the staff did not like going into her room. Resident #8 was reported to have a history of refusing cares and the staff did not like to deal with her. CNA #1 stated Resident #8 did not reject cares if people treated her like a person and talked to her first. If staff went into her room and started whipping her around then she would get upset. In addition, CNA #1 stated if staff did not have time to do cares like grooming or showers they would document the resident refused. 4. Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 7/13/16 at 4:30 pm, Resident #15 was in his room sitting in his wheelchair about 2 and 1/2 feet from the bed. He had his head bent over and he was tearful. Resident #15 smelled of urine. When asked how he was doing, Resident #15 stated not good. When asked why not, Resident #15 stated he did not know what he did to deserve this, he had lived a good life, raised his kids, made good money, and now he was here. Resident #15 stated he smelled bad. Since his call light was not in his reach, the surveyor saw a CNA in the hall and CNA #16 came in the room. He started to talk to her but she interrupted him and asked if he was thirsty. He stated yes I am so needing fluids. She gave him a drink of water. Resident #15 thanked her for the water and continued to talk. CNA #16 interrupted him and stated Do you want to call your son in a bit that always cheers you up. He stated yes he would like that, but he smelled bad. CNA #16 did not respond to Resident #15 when he stated he smelled bad.

Based on record review, staff interview and POA interview, it was determined the facility failed to ensure 1 of 27 sampled residents (#11) had the right to refuse medical treatment. Resident #11 was harmed when the facility repeatedly declined to honor his expressed wishes to have water and ice chips. Findings include: Resident #11 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. Resident #11 received nutrition via a feeding tube, had a urinary catheter, was on a ventilator and had a [MEDICAL CONDITION]. A [DATE] Social Service Progress Note indicated Resident #11 was alert and able to communicate needs and preferences with a goal of weaning from the ventilator and returning to the group home where he previously resided. Resident #11 remained in the facility until he was transferred to the hospital on [DATE]; he died two days later in the hospital. The [DATE] admission MDS assessment indicated Resident #11 usually made himself understood and usually understood others. The MDS documented Resident #11 was totally dependent on staff for eating and required the assistance of one staff. He was documented as having a swallowing disorder and receiving nutrition via a feeding tube. The ADL CAA stated Resident #11 was dependent for all ADLs due to limited mobility of his arms and legs. The feeding tube care area assessment documented use of a gastrostomy tube ([DEVICE]) for all calories, nutrition and fluids. According to the initial physician's orders [REDACTED]. Nurses' notes documented Resident #11 received ice cream one time only, on [DATE]. Resident #11 and his POA expressed their joint interest in the resident's transition to oral intake of food and fluids that was documented as follows: -A [DATE] Speech Therapy Plan of Care indicated Resident #11 was to start working with ST with a goal of pureed foods and thin liquids being safely consumed. Documentation indicated Resident #11 had been wanting to eat/drink for several weeks. Swallowing difficulties were noted due to [MEDICAL CONDITIONS] recently de-cannulated. -A [DATE] Speech Therapist Progress note documented Resident #11's pureed diet had not been initiated. The resident's positioning in bed was documented as being a challenge with an increased risk for aspiration and lethargy being present. Caregiver education on proper positioning was given. -A [DATE] nurse practitioner Progress Note indicated Resident #11's family inquired whether he would be able to begin to eat and drink. Documentation indicated the speech therapist was spoken to and a [MEDICATION NAME] swallow evaluation was scheduled. On [DATE], a diet requisition form from speech therapy indicated a diet trial would be completed at lunch on ,[DATE], ,[DATE], and [DATE]. -On [DATE], the Resident Care Conference notes showed nursing, dietary, activities, and family were present for the meeting. The family was documented as expressing concerns with Resident #11's fluid restriction. -A [DATE] NAR note documented Resident #11 was receiving 100 percent of nutrition via the feeding tube, he was being seen by speech therapy for possible initiation of oral feeding and for the potential discontinuance of the feeding tube. -On [DATE], a new speech therapy goal to complete oral care to reduce the risk of decline of oral debris was initiated. Resident #11 was determined to be unsafe for oral intake based on the [MEDICATION NAME] swallow evaluation results. A recommendation for small ice chips via one-half teaspoon was written; the trial of pureed foods was discontinued. Resident #11 was to be allowed a small amount of ice chips. -A [DATE] Nurse's Note at 4:25 pm documented Resident #11 being sent to the emergency department to be evaluated for a stroke. A note later that day at 10:00 p.m. documented, No ice chips or water should be left in pt (patient's) room. -On [DATE], in the nurse practitioner Progress Note Resident #11 was documented with altered mental status, decreased oxygen saturation in the 80's, and somnolence. He was hospitalized on this date. Resident #11 was hospitalized on [DATE] due to a change in mental status. The ED Physician Note documented at 2:50 p.m., stated, He has quite poor hygiene, primarily oral hygiene .Oral mucosa is significantly dry with brownish crusting over tongue and oral mucosa. He is edentulous. Tongue is significantly dry with a layer of brownish crusting .Severe dehydration and rehydration high risk for cerebral [MEDICAL CONDITION]. Resident #11 passed away on [DATE] in the hospital. According to the [DATE] hospital Discharge Summary, admitting [DIAGNOSES REDACTED]. Resident #11's POA was interviewed on [DATE] at 9:40 a.m. and stated he had cared for Resident #11 for [AGE] years prior to Resident #11's admission to the facility. He stated Resident #11 was not provided adequate fluids and he was severely dehydrated when he went to the hospital on [DATE]. The POA stated the resident was very thirsty and often asked for ice chips, which he had been allowed to have previously when he was on the ventilator. The POA stated he observed Resident #11 with a dry mouth and with cracked dry lips in the week preceding his hospitalization . The POA stated once Resident #11 moved to a different room after [MEDICAL CONDITION] out and use of the ventilator was dicontinued, he was no longer allowed ice chips. The POA stated the plan was for the facility to start with oral feeding after the ventilator came out; however, this was not done. The POA stated the facility was afraid Resident #11 would aspirate. During the care plan meeting ([DATE]) the POA stated he expressed his desire that Resident #11 be allowed to have ice chips and he be allowed to eat and drink, but this was not allowed. The POA stated Resident #11 was denied fluids, ice chips and food. CNA #13 was interviewed on [DATE] at 3:15 p.m. and stated she remembered Resident #11 requested ice chips. CNA #13 stated, He wanted ice chips, but he was NPO (nothing by mouth). We were not able to give them (ice chips) due to the (physician's) order. CNA #1 was interviewed on [DATE] at 10:10 a.m. and stated, He (Resident #11) asked for ice chips constantly. CNA #1 stated she was told by the nurses not to give the resident ice chips. Nurse #5 was interviewed on [DATE] at 2:20 p.m. and stated she remembered being able to give Resident #11 ice chips and then not being able to. She stated, He got ice chips for a while. At the end I could not let him have them (ice chips). I felt bad. Nurse #5 verified Resident #11 asked repeatedly for ice chips. The NP was interviewed on [DATE] at 2:40 p.m. and when asked about Resident #11's desire to eat and drink in light of his swallowing impairment, the NP stated, He doesn't get it (food or fluids orally) if it is not safe, except if he is able to make an informed decision. We tell him the consequences; he can sign a waiver. The NP further stated if the resident was not competent; his medical decision maker could make the decision for him. The licensed social worker was interviewed on [DATE] at 9:50 a.m. and was asked if there was a process for a resident who wanted foods and fluids outside their physician prescribed diet order. The social worker stated, if a resident refused treatment this would be directed to the physician first. She stated the family and resident would then be approached to discuss the risks and benefits. The social worker stated a resident or the power of attorney had the right to make healthcare decisions as long as they understood the ramifications. When asked if this had been offered to Resident #11, she stated she was newly employed when the events concerning Resident #11 occurred, but it would be documented under the pertinent discipline if the conversation was held. The following sections of the medical record were reviewed: physician, nursing, social service, dietary, and speech therapy. There was no documented evidence of a conversation being held concerning Resident #11 and his POA being explained the risks, the waiver process, or the possibility of being allowed food or fluid contrary to physician's orders [REDACTED]. The SLP was interviewed on [DATE] at 10:10 a.m. and stated she completed an evaluation on [DATE] due to Resident #11's desire to eat and drink. She stated the goal was to begin a pureed diet trial with thin liquids. The SLP stated Resident #11's positioning in bed was poor and this delayed the initiation of the feeding trial. She stated she first fed him 4 ounces of applesauce with 100 percent accuracy, on [DATE]. A 3-day feeding trial for lunch was then ordered to take place on ,[DATE]- [DATE]. The SLP stated, when she reviewed therapy records, the feeding trial occurred on [DATE] only and was provided by the other SLP. She stated it was not provided on [DATE] or [DATE] by the other SLP; she stated she was not sure why. It was discontinued after this date. The SLP stated ice chips were discontinued due to the results of the [MEDICATION NAME] swallow that showed the resident was a silent aspirator. When asked if there was a protocol if a competent resident or family/decision maker requested food or fluids outside of the diet order, she stated a waiver could be signed if a resident/decision maker was informed of the risks of not adhering to the diet order. When asked if this was pursued or explored as a possible option for Resident #11, she stated it was not.

Based on observations, staff interviews, record review, and review of Incident/Accident Reports, it was determined the facility failed to ensure a hoyer sling was properly attached to the mechanical lift prior to transferring a resident and the facility failed to ensure adequate safety and supervision were provided to a resident with severely impaired cognition who fell multiple times, sustained a hip fracture and dislocation to his fractured hip. This was true for 2 of 4 (#s 2 & 5) residents sampled for falls. Resident #2 was injured when he fell out of the hoyer sling and sustained a laceration to the back of his head and Resident #5 was harmed when he fractured his hip requiring surgical intervention. Findings include: Resident # 5 was admitted to the facility on [DATE], and most recently re-admitted on [DATE], with the multiple diagnoses, including left femur fracture, dislocation of the left hip, subarachnoid hemorrhage, left facial bone fracture, and dementia. The Quarterly MDS assessment, dated 1/27/15, coded the resident was sometimes understood and sometimes had the ability to understand others; his cognitive skills for decision making were not assessed; he required supervision for bed mobility, transfers, walking, dressing, toileting, and personal hygiene; he had no impairment to the upper/lower bilateral extremities; and his fall history was not assessed. The Significant Change MDS, dated [DATE], coded the resident was severely cognitively impaired; inattentive and experienced psychomotor retardation (slow movements); he was extensive assist of one person for bed mobility, transfers, dressing, toileting, and personal hygiene. The resident did not walk during the assessment period. On 2/11/15, the resident fell at the facility, and was transported and admitted to the hospital, where he was diagnosed with [REDACTED]. Nurse's Notes, dated 2/15/15, documented the resident was to receive Physical Therapy interventions, including gait training, a bedside sitter, and bed and chair alarms, related to the 2/11/15 fall. Nurse's Notes, dated 2/23/15 through 3/2/15, documented the resident was to receive 15-minute checks by staff related to the fall. NOTE: The facility did not provide requested documentation that the PT interventions, including gait training, were provided; nor were these interventions included in a revised care plan. Note: The resident was re-admitted on [DATE], discharged to a local hospital on [DATE] with [DIAGNOSES REDACTED]. The Care Plan, dated 2/19/2015, documented the resident was at risk for falls due to muscle weakness, cognitive deficit, decreased mobility, and history of falls. Additionally, the resident "did not remember to use (his) call light or alert staff when (he) needed to go to the (bathroom)." Interventions included an alarm to the resident's bed and wheelchair. Nurses notes documented the following: 3/15/15 - 9 PM: Alert with confusion, fall risk, pressure alarm on wheelchair and bed 3/16/15 - 2 PM: Confused to person, place, time 3/16/15 - 9 PM: Fall risk, pressure alarm on bed and wheelchair, incontinent, and 1 person assist 3/17/15 - 4 AM: Alert with confusion, fall risk, alarm in bed related to poor safety awareness, 1 person assist for transfers and mobility An Incident/Accident Report, dated 3/17/15 at 8:15 PM, documented, "Resident not steady on his legs, weakness noted. Resident trying to get up, got up and fell on the floor. Res(ident) has dementia, poor safety awareness." Interventions added after fall included a concave mattress and anti-rollbacks on the wheelchair, however it could not be determined how anti-rollback breaks were an appropriate intervention when the resident was not in his wheelchair when he fell . A physician visit report, dated, 3/18/15, documented the physician was notified the resident fell on his right hip. The physician's evaluation documented the resident was able to bear some weight on his right hip, some pain at the left hip, some tenderness of the left knee, and pain with hip flexion. The resident was transferred to the hospital, where he was admitted on [DATE] and discharged back to the facility on [DATE] after a "left hemiarthroplasty" for his left hip fracture. A Nurse's Note, dated 3/19/15, when the resident was still in the hospital, documented, "Res(ident) cont(inues)to be in a room at nurses station for (increased) observation. Alarms in place. Res(ident had been (with) sitters, but had weaned off r/t (related to no) evidence of need." NOTE: On 4/20/15, from 1:55 PM to 2:20 PM, six staff at the nurses station and ten staff members walking past the resident's room were observed not to perform any type of check on the resident. The following interventions were added to the resident's Fall care plan: 3/24/15 - 24-hour sitter, discontinued 3/27/15 3/24/15 - Concave mattress, discontinued 3/30/15 3/27/15 - Change sitter to 8 PM -8 AM, discontinued 3/26/15 (date discrepency not explained) 3/29/15 - 15 minute checks between 8 AM-8 PM, discontinued 3/31/15 3/30/15 - Mat next to bed 3/31/15 - "Change 15 minute checks to 24 hours day..." (No specific description or times provided by the facility) Nurses Notes, dated 3/24/15, documented, "Resident is at baseline mentation, which is confused ... Concave mattress in place. Will do (sic) 1:1 sitter (for) 72 hours but review daily regarding safety. A physician's note, dated 4/15/15, documented, "The patient was seen today acutely in follow up of left hip pain. The patient has been working with therapy and seemed to be doing fairly well. He was noted yesterday, but particularly this morning, to have some increased pain in the left hip. He is guarding the area. There is some increase in swelling and abduction. The patient does not allow for any movement of the leg due to the discomfort." On 4/15/15 at 5:50 PM, the resident was transported to the hospital and diagnosed with [REDACTED]. A Hospital Consultation note documented the 4/15/15 hospital admission was related to a fall, which resulted in a dislocated left hip verified by X-ray in the emergency room . The physician documented, "The patient was sent in from (the facility) after (he) had a fall ... the patient was taken to the OR (operating room) for a closed reduction (surgical repair)." Facility Incident and Accident Reports from 11/20/14 to 4/20/15 did not include a report for the hospital-identified fall on 4/15/15. On 4/23/15 at 11:05 AM, the DNS was interviewed about the identified concern and asked to provide a timeline for the resident's falls that included interventions implemented after each fall. On 4/24/15 the timeline was received, which did not resolve the identified concern. On 4/24/15 at 11:15 AM, the Administrator was notified of the concern. Additional information received from the facility on 4/27/15 did not resolve the concern. The facility failed to ensure a resident with a subarachnoid hemorrhage who developed significant medical and cognitive decline received adequate care and supervision to prevent multiple falls which resulted in fractures of the resident's left facial bone and left hip fracture, and a subsequent dislocation of the left hip. 2. Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. The resident's most recent annual MDS Assessment, dated 1/28/15, documented the resident was moderately cognitively impaired and needed total assistance of at least 2 staff for transfers and toilet use, and had experienced a fall with injury. An undated Fall Risk Assessment documented the resident was at high risk for falls. The fall care plan, initiated on 12/22/08, documented interventions that the resident required a Hoyer (mechanical) lift with the assistance of 2 staff for transfers. An Incident Report (IR), dated 1/11/15 at 1:45 PM, documented Resident #2 fell when the front left loop of the Hoyer came off as staff were lifting the resident. The IR documented the safety latch that held the loop was missing from the Hoyer and the resident was lowered to the floor by two CNA's. The resident experienced a 1 cm laceration to the back of his head as a result of the fall. The IR documented the incident could have been prevented and the Hoyer was taken out of commission until the safety clip could be replaced. An Incident Witness Account by CNA #6, dated 1/11/15, documented the use of the Hoyer lift when transferring the resident to his bed, and that the sling strap slipped off the hook due to missing safety clip on the Hoyer. The facility provided an undated Safe Lifting and Movement of Residents policy which documented guidelines for appropriate techniques and devices to lift and move residents. The policy documented: * "9. Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order.; and, * 11. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: A. Involves employees in identifying problem areas and implementing workplace safety and injury-prevention strategies...D. Continually evaluates the effectiveness of workplace safety and injury-prevention strategies." On 4/22/15 at 3:00 PM, the DNS stated the Hoyer had six hooks and the latch was to prevent the Hoyer sling from coming out of the hook. She stated the safety loop should have been in place. The DNS stated, "I think they (staff) use the Hoyer so much they don't necessarily look at the whole thing from top to bottom. This incident was brought through the QA Process, maintenance did a 100% audit check and there was 1:1 training with the CNA's involved." On 4/24/15 at 11:30 AM, the Administrator and DNS were made aware of the concern regarding falls. On 4/27/15 at 4:32 PM, the facility provided additional information, which included a 1/12/15 Root Cause Analysis that documented, "The hoyer sling hooks were all hooked up to hoyer hooks. The resident was in his chair, which leaves some slack in the sling for the top hooks. The CNA's that were doing the transfer didn't notice that when they began to raise the resident up that one of the sling hooks was coming off the hoyer hook. The hook came all the way off during the transfer. The CNA's reacted as quickly as they could and attempted to guide his shoulders down. If (sic) was only his upper body that was falling back. They slowed his fall but could not prevent his head from touching the ground and the resident sustained [REDACTED]." The information provided by the facility on 4/27/15 did not resolve the fall concern for Resident #2.

Based on record review, and resident and staff interviews, it was determined the facility failed to identify weight loss trends and failed to implement interventions in a timely manner after the resident's weight loss became significant. This failed practice harmed 1 of 6 (#1) sampled residents. The resident was harmed when she experienced severe weight loss of 15% in 14 days. Additionally, this failed practice had the potential to harm any resident who experienced a compromised nutritional status. Findings included: Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The admission MDS assessment, dated 6/11/14, documented Resident #1 was cognitively intact with a BIMS of 14, had a depression severity score of 14, did not display behaviors, required supervision after setup for eating, weighed 189 pounds with no weight loss or gain of 5% or more in the preceding month or a loss of 10% or more in the preceding 6 months and did not receive diuretic medications. The quarterly MDS assessment, dated 11/10/14, documented Resident #1 did not display behaviors, required limited assistance of 1 person for eating, weighed 163 pounds with no weight loss or gain, and did not receive diuretic medications. The June 2014 Resident ADL Record documented Resident #1 ate 25% of meals 18 times, 50% of meals 27 times, 75% of meals 8 times, 100% of meals 9 times, and refused meals 5 times. There were 8 meals not documented. The July 2014 Resident ADL Record documented Resident #1 ate 25% of meals 48 times, 50% of meals 10 times, 75% of meals 1 time, 100% of meals 5 times, and refused meals 25 times. There were 3 meals not documented and one meal involved a family party. The following information was gathered from the Dietary Care Plan (CP), Yearly Weight Record (YWR), Comprehensive Nutritional Assessment (CNA), Nutrition Services Progress Note (NSPN), physician progress notes [REDACTED]. 6/4/14 (YWR) - 185.8 lbs (pounds); 6/4/14 (CP) - Provide regular diet per MD order, honor likes and dislikes, weekly weights, Registered Dietitian (RD) to follow PRN (as needed), resident eats in room per her choice, resident is making independent food choices, and resident is independent with eating; 6/9/14 (PPN) - Visit for [DIAGNOSES REDACTED], anxiety and [MEDICAL CONDITION] with no mention of weight loss concerns; 6/11/14 (YWR) - 189.2 lbs (3.4 lb gain); 6/12/14 (PPN) - Visit for iron [MEDICAL CONDITIONS] and Vitamin D deficiency with no mention of weight loss concerns; 6/13/14 (Admission Evaluation CNA) - Admit weight 185.8 (Weight taken on 6/5/14). Evaluation & Summary: Resident independent with eating and making food choices. Feeds self in room due to isolation. Increased BMI (Body Mass Index) 33. Slow gradual weight loss would be desirable. Last labs with decreased iron, hemoglobin and hematocrit. Resident on supplements to help improve. Skin intact. Recommendations & Plan: Continue with plan of care. Monitor weight and notify RD with significant change. Review PRN; 6/18/14 (YWR) - 179.2 lbs (10 lb loss); 6/18/14 (PPN) - Visit for [MEDICAL CONDITION] disorder, [MEDICAL CONDITION], diabetes, iron [MEDICAL CONDITION] and Vitamin D deficiency with no mention of weight loss concerns; 6/20/14 (CNA) - Weight 189.2, taken on 6/11/14. Evaluation & Summary: Resident feeds self and is independent with making food choices. Increased BMI. Slow gradual weight loss would be desirable. Intakes fair between 25-50% most meals and inadequate for fluids. Offer increased fluids with and between meals. Last labs 6/12 with decreased hemoglobin and hematocrit, on supplement. Meds with nutrition interactions. Skin intact. Recommendations & Plan: Start NCS (No Concentrated Sweets) diet related to diabetes mellitus. Monitor weight. Notify RD with significant change. Review PRN; 6/20/14 (PPN) - Visit for [MEDICAL CONDITION] with no mention of weight loss concerns; 6/25/14 (YWR) - 160 lbs (19.2 lb loss, with a total of 29.2 lbs since admit); 6/26/14 (NSPN) - Weight 179.2, taken on 6/18. Resident weight down 10 pounds from previous weight. Resident still with increased BMI. Family also brings in food. New labs 6/17. Resident is on iron supplement and [MEDICATION NAME] for cholesterol. Continue with plan of care at this time. If weight decreases significantly again will implement interventions to slow. Gradual weight loss desirable; 6/26/14 (CP) - NCS diet; 6/29/14 (YWR) - 156.8 lbs (3.2 lb loss, with a total of 32.4 lbs since admit); 7/1/14 (NSPN) - Weight 160, taken on 6/25/14. Resident weight down 9 pounds (Weight down 19.2 pounds, not 9 pounds) this week. Intakes not adequate. No new labs. No new meds. Recommend to start nutritionally enhanced meals until intakes improve. RD attempted to meet with resident but was sleeping, will attempt again. RD to continue to monitor weight loss; 7/1/14 (CP) - Nutritionally Enhanced Meals; 7/2/14 (PPN) - Visit for dysphagia, anxiety [MEDICAL CONDITION] and diabetes with no mention of weight loss concerns; 7/7/14 (PPN) - Visit for weight loss. "(Resident's name) tells me she doesn't 'like' the food here. Family does bring in some food. Will have nutrition see her to see if they can meet her preferences. She has lost ~29lbs since her admission here." 7/9/14 (YWR) - 147.4 lbs (9.4 lb loss, with a total of 41.8 lbs since admit); 7/10/14 (NSPN) - Weight 156.8, taken on 6/29. Resident weight down 3 pounds this week. Resident with multiple refusals. RD was notified that husband is eating food. Family still providing some foods from home. No new labs. 7/9 [MEDICATION NAME] decreased. Recommend to start increased kcal with poor appetite at meals. Send FFL (Full Fortified Liquids) three times per day with all meals to help improve kcals and fluids. Weight stabilization desirable. Will continue to monitor. Continue to encourage. Resident with some confusion, may need increased assistance at meals; 7/10/14 (CP) - FFL three times per day with all meals and increase kcal snacks three times per day; 7/18/14 (NSPN) - Weight 147.4, taken on 7/9. Resident weight down 9 pounds this week. All previous recommendations started. Resident now with UTI and increased confusion, started on antibiotics. New labs 7/10. MD aware of weight loss. Discussed interventions in place. RD will be coming in 6/20 to meet with family about weight loss, interventions and possibly artificial nutrition. Intakes could continue to improve as UTI clears. Send sherbet all meals. Will implement further interventions after discussion with family. Add to NRR in next week; 7/18/14 (CP) - Sherbet all meals; 7/19/14 (YWR) - 147.2 lbs 7/20/14 (NSPN) - RD met with family to discuss weight loss and any further interventions that may be effective to slow. Family aware of weight loss. Resident was alert but confused. Family had also brought in some food. Family states she might need increased encouragement with meals. Will notify nursing. Resident and family state at this time she is doing better with things she can drink. Send whole milk all meals. Resident states she continues to have a poor appetite. Will discuss with MD possibility of an appetite stimulant. Family is filling out menu states she is a picky eater. Dietary Manager to reobtain preferences. Resident BGs (blood sugars) fairly low and recommend to discontinue NCS portion to liberalize to help improve intakes. family providing nondiabetic foods. Send increased kcal desserts in place of fruit. RD also discussed artificial nutrition with family if weight loss continues. Family and resident state they would like that to happen if weight loss continues so rapidly; 7/20/14 (CP) - Send whole milk all meals and increase kcal desserts in place of fruit; 7/21/14 (NSPN) - IDT reviewing resident related to weight loss. Weight on 7/19 was 147.2 lbs. Resident weight stabilized this week. RD discussed newest recommendations. Will receive order. Also to request clarification order for interventions in place. Nursing to assess isolation now that antibiotics ending today. Resident might do well in assist dining room. Resident on multiple meds with increased appetite and increased weight side effects. Will wait on appetite stimulant at this time. Weight stabilization desirable. IDT will follow resident weekly. Will continue with by mouth interventions at this time. If significant weight loss continues to occur will readdress artificial nutrition. Review in 1 week; 7/22/14 (NSPN) - Nursing requesting to change supplement with med pass to 2 cal. With recent weight loss this is appropriate. Discontinue FFL or equivalent four times per day with med pass. Change order to 2 cal 120 cc with med pass. Continue to follow. Review prn; 7/24/14 (CP) - Start 4 ounces (oz) 2cal with med pass, now on regular diet; 7/30/13 (NSPN) - Weight 145.8, taken on 7/30. Resident weight down 1 pound this week. Weight loss slowed. Resident received order for discontinuing NCS diet. Resident was also started on [MEDICATION NAME] 7/22 for depression. side effects of increased weight and increased appetite. Intakes have improved. Dietary manager reinterviewed for preferences. New labs 7/23. Resident could benefit from 1-2 oz of extra protein with meal to help with depleted protein stores. Multiple interventions in place for weight loss. Weight stabilization desirable; 7/30/14 (CP) - Will increase protein intake with meals, extra protein (1-2 oz) with each meal. On 2/4/15 at 9:03 AM, Resident #1 was interviewed and said when she was admitted she did not have an appetite and was not eating. On 2/4/15 at 12:40 PM, the DON was asked which interventions were added when Resident #1 lost 10 lbs in 1 week. She said on 7/1 - 7/10/14 nutritionally enhanced meals, FFL three times per day, sherbet at all meals, and higher kcal snacks three times per day were the first interventions she could see in the resident's record. The DON said the resident was refusing meals because she was very depressed when she was first admitted , was unable to get out of bed due to the ventilator and her husband was not visiting enough. The only physician notification the DON could find regarding weight loss was in October 2014, four months after Resident #1's admission to the facility, but she would look into it further. The DON said the desired gradual weight loss was part of the resident's personal plan, but the physician would not be involved unless the resident triggered for 5% or 10% weight change. On 2/4/15 at 2:50 PM, the RD was interviewed via phone and said, "We hadn't added any interventions" after Resident #1 lost 10 lbs. The resident initially gained 3.4 lbs and the 10 lb loss was not compared to the admission weight; and staff were trying to get a baseline. She explained when the resident lost 10 lbs, the percentage of loss did not change much from the 3.4%, which was under 5%. The following week, when the resident had a significant drop in weight, the RD was notified and requested a reweigh, which was accurate in regards to the 19.2 lb weight loss. A fortified meal program was started on 7/1/14, after the weight fluctuations. When asked about the process for RD notification of significant weight changes, the RD said usually the nurses would be notified and would then report the information to the RD, who would then address the concerns on her next working day (worked on Tuesdays and Fridays). The RD said she was not sure what caused the initial weight gain as the resident was not on any diuretics and did not have [MEDICAL CONDITION]. Weights tended to fluctuate while the resident was on the ventilator unit, the resident was not eating much in general, and the husband was eating the resident's left over food. When asked about physician involvement with the gradual weight loss desired, as documented in the Comprehensive Nutrition Assessment, the RD said if the BMI was high, they work towards the personal goal of the resident, and gradual weight loss could be beneficial. The RD was asked if there was an order for [REDACTED]." On 2/5/15 at 1:00 PM, the RD was asked about the time gap between weights and her notes/assessments (8-9 day difference). She explained the staff usually weighed residents on shower days. The Nurse Manager on Fridays would put the weights together from the shower book and give the report to the DON. The DON would put together her reports and notify the physician and RD. The RD and DON would review the reports together to determine a plan. The RD and DON also did some education with the Dietary Manager (DM) to start interventions and notify the RD of those interventions. If the shower day was on Monday, the weights would not be reviewed until Friday. The RD said she did not know if the DM was notified of the weight changes for Resident #1. The resident initially gained 3.4% and was started on a diabetic diet in which the resident was not compliant. The RD stated she was looking at the "full picture" with weight fluctuations. The RD explained the NEM and FFL provided an extra 200-300 calories. When asked about the DM's credentials, the RD said the DM took an online course and the DM was not sure of that course's educational parameters; better for her to be cautious than overstep. On 2/5/15 at 1:20 PM, the policy and procedure related to weights was requested. At 2:23 PM, the DON she said the facility did not have a formal policy related to weighing, but an internal process was writtenand provided to surveyors. The Internal Process, no date provided, documented, "There is no Policy for weighing resident's (sic) or reporting just our internal procedure. Weights are done weekly (unless res(ident) requests otherwise or they are CMO (term unknown)). Shower aides do all weights with their shower and record in weight book(.) Unit manager gathers weights on Fridays and makes the weight lists(.) Unit managers record weights in chart and DNS records weight in computer. Weight list is given to RD/DM weekly(.) RD/DNS print weight loss comparison report weekly to identify weight changes. NAR (Nutrition At Risk) is held weekly. RD is in building twice weekly." Resident #1 was admitted on [DATE] with a weight of 185.8 lbs and gained 3.4 lbs in the first week. The second week, the resident lost 10 lbs (9.4% of body weight) and no interventions were put into place at that time to prevent further weight loss. The third week, the resident lost another 19.2 lbs (15.4% of body weight) and nutritionally enhanced meals were implemented. The resident lost more than 15% of her body weight in 14 days. The physician or NP did not order a gradual weight loss plan, nor were they notified of the severe weight loss until 7/7/14 (two weeks after 29.2 lbs were lost). Additionally, there were time gaps between weights and the RD assessments of 8 to 9 days, and the DM did not intervene with timely planning and interventions. On 2/5/15 the Administrator provided a QA (Quality Assurance) document, dated September 2014, which documented, "It has been discovered that the RD assessments in the dietary sections of the charts have not been done timely and are out of compliance. The DM had not been trained in completing these, and the RD that rounds weekly was not able to do all admits, quarterly's and annuals. Not all of the high risk charts have been followed closely, also not all new admits or wound pts (patients) have been seen timely. NAR/PAR (Nutrition At Risk/unknown) was not at a set time or date and no lists were being made of resident's (sic) being reviewed..." On 2/5/15 at 3:30 PM, the Administrator and DON were informed of the significant weight loss issues. No further information was provided. On 2/6/15 additional information was provided by the facility, however, it did not resolve the issue.