Every finding on record at Windsor Grove Health and Rehabilitation

Based on observations, interviews, and record reviews, the facility failed to ensure sufficient staffing to meet the needs of the 106 of 106 residents in the facility. The facility failed to ensure there was one nurse on each the Blue Unit and the Pink Unit during the night shift on 04/29/25 and failed to ensure enough staff to implement the care plan intervention of one-to-one supervision for five residents who required one-to-one-supervision. Findings include: 1. Review of a document provided by the Administrator on 04/30/25 revealed there were five residents (R35, R54, R55, R87, and R98) on the secure unit that required one-to-one supervision. a. Review of R35's Admission Record, located in the resident's electronic medical records (EMR) section titled Profile, revealed the resident was admitted to the facility on [DATE] with diagnoses that include cerebral infarction with left sided hemiplegia and hemiparesis, severe vascular dementia with agitation, and memory deficit. A review of R35's Care Plan, with a revision date of 01/05/25 and located in the resident's EMR section titled Care Plans, revealed the resident failed to cooperate with activities of daily living (ADL) care related to dementia and had potential for verbal and physical aggression. One of the interventions for these behaviors included one-to-one supervision as needed. b. Review of R54's Admission Record, located in the resident's EMR section titled Profile, revealed the resident was admitted to the facility on [DATE] with diagnoses that included vascular dementia with behavioral disturbances, moderate intellectual disabilities, and reoccurring major depressant disorder. A review of R54's Care Plan, with a revision date of 03/15/25 and located in the resident's EMR section titled Care Plans, revealed the resident had attempted to leave the facility, inappropriate sexual behaviors, and physical aggression towards when redirected. One of the interventions for these behaviors include one-to-one supervision. c. Review of R55's Admission Record, located in the resident's EMR section titled Profile, revealed the resident was admitted to the facility on [DATE] with diagnoses that included major depressive disorder and dementia with behavioral disturbance. A review of R55's Care Plan, with a revision date of 01/20/25 and located in the resident's EMR section titled Care Plans, documented the resident had poor impulse control and an allegation of physical contact to another resident. One of the interventions for these behaviors included behavior monitoring. d. Review of R87's Admission Record, located in the resident's EMR section titled Profile, revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia, schizophrenia, and psychotic disorder with delusion. A review of R87's Care Plan, with a revision date of 04/08/25 and located in the resident's EMR section titled Care Plans, documented the resident was involved in a resident-to-resident physical contact altercation. One of the interventions for this behavior included one-to-one monitoring to prevent striking others and/or impulsive acts. e. Review of R98's Admission Record, located in the resident's EMR section titled Profile, revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with mood disturbances, major depressive disorders, and anxiety disorder. A review R98's Care Plan, with a revision date of 02/12/25 and located in the resident's EMR section titled Care Plans, revealed the resident was assessed for wandering, inappropriate behavior such as allegations sexual contact with a female resident and exposing his genitals. One of the interventions for these behaviors included one-to-one supervision by staff as needed. Review of staff assignment sheets on the following revealed the following: 03/15/25 (Saturday) - only two Certified Nursing Assistants (CNAs) were scheduled to work each shift. None of the five residents received one-to-one supervision. 03/16/25 (Sunday) - only two CNAs scheduled to work the evening and night shifts; two residents (R54and R98) on the evening shift received supervision; and none of the five residents received supervision on the night shift. 03/23/25 (Sunday) - only two CNAs were scheduled for the night shift; none of the five residents received one-to-one supervision. 04/18/25 (Friday) - on the day shift only R54 and R98 received the one-to-one supervision; the other three residents (R35, R55 and R87) did not receive the supervision. 04/25/25 (Friday) - only two CNAs were scheduled to work the night shift; none of the five residents received the one-to-one supervision. 04/29/25 (Tuesday) - on the night shift only two CNAs were scheduled to work; none of the five residents received one-to-one supervision. Observation during the initial tour on 04/29/25 at 2:00 PM revealed that R54 and R98 shared the same room, and one staff member provided one-to-one supervision for both residents. R35, R55, and R87 each had an individual staff member for supervision. Observation on 04/3025 at 5:33 AM revealed R35, R54, R55, R87 and R98 were asleep in their rooms. None of the residents had staff members assigned them to provide one-to-one supervision. There were only two Certified Nursing Assistants scheduled to work that night. An interview on 04/30/25 at 5:40 AM with CNA9 revealed the evening nurse worked overtime until about three or four that morning and the nurse on the blue unit was covering unit until the day shift staff arrived. CNA9 stated that she and another CNA were the only CNAs scheduled to work that. CNA9 stated it was impossible to provide one-to-one supervision with only two staff members. CNA9 also stated that this was not the first time that only two CNAs were scheduled on the unit. An interview on 04/30/25 at 5:55 AM with CNA18 revealed there were only two CNAs scheduled to work that night. She stated if you look at the resident's behavior monitoring notebook you will notice the night shift section is left blank since they were unable to provide monitoring for those residents. CNA18 stated that to her knowledge none of those residents exhibited any behaviors during the night. An interview with CNA15 on 04/30/25 at 6:20AM revealed that she also functioned as the staffing coordinator. CNA15 stated that she tries hard to ensure there is sufficient staffing throughout the facility, especially on the secure unit. CNA15 states there have been times that she herself has provided one-to-one supervision for those five residents. CNA15 stated It is like robbing [NAME] to [NAME] to ensure there's coverage for the residents on the secure unit that require one-to-one supervision. An interview on 04/30/25 at 4:20 PM with LPN7 revealed that she was aware there were only two CNAs scheduled on Tuesday 4/29/25 night shift. LPN7 stated that the facility was staffing challenged, meaning it was difficult to get sufficient coverage especially for the residents that require one-to-one supervision. LPN7 reviewed the residents' behavior monitoring sheets and stated it was an expectation that staff assigned to supervision will document each hour of supervision and the documents the resident behavior during that time. LPN7 also stated since there was no documentation on the behavior monitoring sheet, it would seem the residents did not receive 1:1 supervision. An interview on 04/30/25 at 6:00PM with the Director of Nursing (DON) revealed the facility did not have a policy for staffing or a policy for one-to-one supervision. The DON stated that when residents are placed on one-to-one supervision it is a nursing judgement and currently, they do not require physicians to write orders for that supervision. The DON stated that probably the physician or the nurse practitioner could write orders for a timeframe for supervision and look at tapering the residents off one-to-one supervision. 35690 2. During the survey on 04/30/25 at 2:00 PM, a Resident Council meeting was held. R2 stated she had to wait for help and was told by the CNAs if you get up you can't go back to bed because there was not enough staff. R2 stated she needed the mechanical lift for transfers and sometimes there would only be one CNA who would assist with the transfer. She stated it depends on who is working (if there are one or two CNAs). 3. During an interview on 05/01/25 at 12:50 PM, the Social Services Director (SSD) stated that due to staffing shortages, not all departments were able to attend care conferences. The facility failed to ensure all required Interdisciplinary Team (IDT) Members attended care conferences. Cross Reference F657: Comprehensive care plan prepared by an IDT and the resident and/or resident's representative. 4. During an interview on 05/01/25 at 4:34 PM, LPN 1 stated the scheduler would frequently ask her to be responsible for both the Peach Unit and Blue Unit. She stated she would never do that because it would put her license at risk. LPN 1 stated I can't be on one hall because I couldn't see the other hall. 5. The facility failed to ensure residents received adequate supervision. Cross Reference F689: Supervision. During an interview on 05/01/25 at 5:24 PM, the Administrator stated they had six open CNA positions, seven open LPN positions, and seven open Registered Nurse (RN) positions. The Administrator stated they did not have a Staffing Policy.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free from significant medication errors for 2 Residents (#87 & #94) in a survey sample of 55 Residents. The findings included: 1. For Resident #87 the facility staff failed to ensure she received Risperdal Consta injections every 2 weeks as ordered by physician for Schizophrenia. Resident # 87 was admitted to the facility on [DATE] with diagnoses that included, but we're not limited to dementia, schizophrenia, anemia, hypertension, psychotic disorder with delusions due to unknown physiological condition, and cognitive communication deficit. Resident number 87's most recent minimum data set with an ARD (Assessment Reference Date) of 4/16/25 coded Resident # 87 as having a BIMS (Brief Interview of Mental Status) score of 6 out of 15 indicating severe cognitive impairment. Resident number 87 could follow simple conversation. On 4/29/25 a review of the clinical record revealed that Resident #87 had the following orders: Risperdal Consta Intramuscular Suspension Reconstituted ER 25 MG Inject 25 mg intramuscularly one time a day every 14 day(s) for schizophrenia due to noncompliance with oral tablets/worsening behaviors. A review of the MAR revealed that Resident #87 was started on Risperdal Consta due to refusal of oral medications. She received her first dose on 1/3/25 however did not get another dose until 2/3/25 and then a third dose on 2/17/25 followed by a missed dose on 3/3/25, and given a dose on 3/19, followed by 2 missed doses in April finally getting a dose on 4/30/25. A review of the clinical record revealed the following notes about the injections not being available: 3/3/25 5:09 p.m. - Risperdal Consta Intramuscular Suspension Reconstituted ER 25 MG Inject 25 mg intramuscularly one time a day every 14 day(s) for schizophrenia due to noncompliance with oral tablets/worsening behaviors Medication will be delivered tonight **There was no follow up indicating the Resident received this dose. ** 4/2/25 5:55 p.m. - Risperdal Consta Intramuscular Suspension Reconstituted ER 25 MG Inject 25 mg intramuscularly one time a day every 14 day(s) for schizophrenia due to noncompliance with oral tablets/worsening behaviors Not Available, Pharmacy Made aware Note from psychiatric provider on 4/10/25 read: Date of Service: 04/10/2025 - Schizophrenia: No reported delusions or hallucination, the patient is on Risperdal Consta [NAME] 25 mg every 14 days for schizophrenia because of noncompliance with oral medication. Recommend continuing the current medications. 4/16/25 4:46 p.m. - Risperdal Consta Intramuscular Suspension Reconstituted ER 25 MG - Inject 25 mg intramuscularly one time a day every 14 day(s) for schizophrenia due to noncompliance with oral tablets/worsening behaviors not available [sic] pharmacy made aware On 4/28/25 at 11:00 a.m. an interview was conducted with LPN #6 who was asked what the procedure is if you do not have a medication for your Resident, she stated that they look in Omnicell (stat meds), and if it is not there, we notify the pharmacy, and they usually get it on the next run. When asked about documenting she stated that they should document what they have done to try and obtain the medication and who they have notified. When asked who they should notify she stated the physician, pharmacy, resident or representative, and the DON or Unit Manager. When asked if Resident #87 was receiving any oral antipsychotics she stated that she was not. When asked if her psychiatric provider was made aware of the lack of consistent administration of this medication, she stated that the NP is notified. When asked if the NP is managing Schizophrenia and medications like Risperdal Consta or is the psychiatrist, she stated that she was not sure. 4/30/25 at 10:20 a.m. spoke with LPN #7 the unit manager and we went to the medication refrigerator on the unit and discovered that Resident #87's Risperdal Consta was unopened, and it was dated as sent from the pharmacy on 4/16/25. On 5/1/25 a review of the clinical record revealed the following note: 4/30/25 at 7:22 p.m. - Resident was given injection in left upper arm per her request. According to Johnson & Johnson the manufacturer of Risperdal Consta: Managing missed doses The appropriate strategy for patients who have missed a dose or doses of RISPERDAL CONSTA will depend on whether a steady-state plasma concentration of RISPERDAL CONSTA has been reached. Generally, steady-state plasma concentrations are achieved after 4 consecutive injections. Steady-state plasma concentration achieved The next dose of RISPERDAL CONSTA should be given as soon as possible if steady-state concentrations of RISPERDAL CONSTA have been achieved and only 3-6 weeks have passed since the last injection. Clinicians should monitor symptom recurrence. If more than 6 weeks have elapsed since the last injection, risperidone long-acting should be initiated as soon as possible and 3 weeks of coverage with an oral antipsychotic should be given. Steady-state plasma concentration not achieved (<4 consecutive injections) RISPERDAL CONSTA should be reinitiated as soon as possible, and oral antipsychotic coverage for 3 weeks should be given. A review of the MAR revealed no oral coverage was being administered. On 5/1/25 during the end of day meeting the Administrator was made aware of the findings and no further information was provided. 2. For Resident #94 the facility staff failed to ensure Midodrine was given as prescribed by the physician according to the parameters in the order. Resident number 94 was admitted to the facility on one/22/24 with diagnoses that included but we're not limited to alcohol abuse anemia, hypertension, muscle weakness was Wernicke's encephalopathy, cognitive communication deficit, insomnia, and signs and symptoms involving cognitive functions and awareness. On 4/28/25 a review of the clinical record revealed the following orders: Midodrine HCl oral tablet 2.5 mg give one tablet by mouth three times a day for low blood pressure hold for systolic >110 A review of the MAR (Medication Administration Record) for April 2025, revealed that in the following days and times the proper assessment, and parameters were not followed with regard to the Midodrine administration order: Blood pressure not assessed, and medication not given: 2 p.m. - 4/5, 4/12, 4/16, 4/20 9 p.m. - 4/ 2/, 4/9, 4/11, 4/18, 4/21, 4/22, 4/25, 4/28 The following dates blood pressure was not assessed, and medications were given: 9 p.m. - 4/3, 4/8, 4/16, 4/22, 4/23, 4/26, 4/27 The following dates blood pressures were assessed out of parameters and meds given anyway. 8 a.m. - 4/14/25 - 140/77 9 pm - 4/4/24 - 122/62, 4/14/25 - 116/74 2p.m. - 4/28/25 - 114/78 A review of the previous MAR's for February and March revealed the same errors. On 4/30/25 at approximately 3:00 pm an interview was conducted with the Unit Manager about the administration of Midodrine and parameters. When asked what Midodrine was used for she stated keeping your blood pressure up, when asked why the use of parameters with Midodrine, and she stated so that you don't use it and make the blood pressure too high. When asked if the order has parameters should a nurse ever give it without first checking the blood pressure, she stated they should not. When asked if the nurse should hold the medication if the blood pressure was not taken, she stated that there would be no reason to hold it if you don't know the blood pressure. When asked if a nurse checks the blood pressure and it is above the parameters, she should give the medication she stated that she should not. When asked if the blood pressure assessment, and parameters ordered in Resident #94's chart were followed and she stated that they were not. On 5/1/25 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on interviews and record reviews, the facility failed to ensure Certified Nurse Aides (CNA) received performance reviews at least once every 12 months and regular in-service education based on the outcome of the reviews for four of five CNAs (CNA6, CNA9, CNA10, and CNA12) whose personnel files were reviewed. This had the potential to have a negative impact on resident care. Findings include: Review of CNA 6's personnel file revealed a start date of 02/02/23. There was no documented evidence in the personnel file that CNA6 had a performance evaluation or in-service education based on the outcome of the review. Review of CNA 9's personnel file revealed a start date of 08/01/22. There was no documented evidence in the personnel file that CNA9 had a performance evaluation or in-service education based on the outcome of the review. Review of CNA 10's personnel file revealed a start date of 09/20/23 There was no documented evidence in the personnel file that CNA10 had a performance evaluation or in-service education based on the outcome of the review. Review of CNA 12's personnel file revealed a start date of 12/13/23. There was no documented evidence in the personnel file that CNA12 had a performance evaluation or in-service education based on the outcome of the review. During an interview on 05/01/25 at 4:30 PM, CNA 1 stated she had not received a performance evaluation in many years. She stated she would like to have one because it is nice to be recognized and get feedback on how she is doing. During an interview on 05/01/25 at 5:02 PM with CNA3 and CNA4, CNA 3 stated she had worked in the facility for one year. She stated she had not had a performance review and had not received any competency training since she started. CNA 4 stated he had worked at the facility for three years. He stated he had had one performance review since he started and had never received competency training. During an interview on 05/01/25 at 5:24 PM, the Administrator stated as a result of multiple changes in nurse management, competencies and performance evaluations had not been completed.

Based on interview, record review, and review of facility policy, the facility failed to thoroughly investigate an injury of unknown origin for one of one residents (Resident (R)71) reviewed for abuse out of a total sample of 55 residents. This had the potential for further abuse to the resident. Findings include: Review of the facility's policy titled, Abuse, Neglect, Exploitation, & Misappropriation initiated 11/16/22 stated, .An incident report shall be filed by the individual in charge who received the report .The Abuse Coordinator and/or Director of Nursing shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. He/she shall also secure all physical evidence. Upon completion of the investigation, a detailed report shall be reported .injuries of unknown source .is obligated to report such information immediately, but no later than 2 hours after the allegation is made . Review of R71's undated Admission Record located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of dementia. Review of R71's Care Plan located in the EMR under the Care Plan tab initiated 11/25/22 revealed R71 was dependent on staff for her physical needs due to cognitive deficits. Review of R71's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/08/25 located in the EMR under the MDS tab included a Brief Interview for Mental Status (BIMS) score of 99 indicating that the resident was not capable of participating in the assessment and had severe cognitive impairment. R71 was also noted to be dependent on staff for all activities of daily living (ADL). Review of R71's Progress note dated 05/30/23 at 9:47 AM located in the EMR under the Progress Notes tab revealed that R71 was noted with a bruise to the right forehead, right eye, bridge of nose, and slight bruising under the left eye. The resident was evaluated by the nurse practitioner and sent to the Emergency Department (ED) for evaluation and treatment on 05/30/23 at 9:35 AM. A computed tomography scan (CT) (medical imaging technique using x-rays to create images of the body) was performed with no abnormal findings. The responsible party (RP) was notified and the resident returned from the facility at 5:14 PM on 05/30/23. Review of the Facility Reported Incident (FRI) revealed the facility filed an initial report with the Virginia (VA) Department of Health (DOH) on 05/30/23 at 12:22 PM for an injury of unknown origin. A follow-up investigation dated 07/06/23 was sent to the VA DOH concluding at R71 had a Brief Interview for Mental Status (BIMS) score of 99 as of 04/27/23 with a primary diagnosis of vascular dementia without behavioral disturbances. A complete investigation was conducted and Adult Protective Services (APS) was notified on an unknown date/time. The Director of Nursing (DON) (RN1) and Unit Manager visited with R71 and her roommate to discuss concerns on an unknown date/time along with staff interviews on an unknown date/time. The follow-up investigation sent to VA DOH concluded that abuse was unsubstantiated. During an interview on 04/29/25 at 5:30 PM with the current Administrator stated that Certified Nursing Assistants (CNAs)9 and CNA17, Licensed Practical Nurse (LPN)9, and Registered Nurse (RN)1 were on duty on 05/30/23 at the time R71 was noted with an injury. The Administrator stated that she was not employed at the facility at the time of the reported incident, and that CNA17 and LPN9 no longer work at the facility. The Administrator confirmed that she had no completed investigation on file, witness statements, or investigation notes but should have. During an interview on 04/30/25 at 7:39 PM with CNA9 stated that she recalled R71 having bruising to her face on 05/30/23 and did not recall R71 and her roommate (R100) being involved in any disputes, however the roommate was very volatile and was known to strike out with very little provocation. The incurred injury received by R71 was unwitnessed. On 04/30/25 at 8:32 PM a voicemail was left for RN1 and no return phone call was received.

Based on observation, interview, and facility policy review, the facility failed to ensure medications were stored and labeled for three of four medication carts observed and one of two medication rooms observed. This had the potential for misappropriation of medications and possible unsafe medication administration. Findings include: Review of the facility policy titled Storage and Expiration Dating of Medications and Biologicals revised [DATE] revealed, .Facility should ensure medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding .Facility should ensure external use medications and biologicals are stored separately from internal use medications and biologicals .Facility should ensure all controlled substances are stored in a manner that maintains their integrity and security .Facility should ensure medications and biologicals for expired or discharged or hospitalized residents are stored separately, away from use, until destroyed or returned to the provider .Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with pharmacy return/destruction guidelines and other applicable law .Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis . 1. During an observation and interview on [DATE] at 6:20 AM of the Blue Unit medication cart, revealed in the second drawer there were eight solid tablets laying loose, six partial/broken tablets, and one capsule loose in the drawer; the third drawer had one loose capsule. The Administrator was present and confirmed the loose medications and stated that it was the expectation of the facility for loose medications to immediately be removed from the cart. Licensed Practical Nurse (LPN) 10 was also present and stated that she normally would discard the loose medications in the sharps container. Staff confirmed that they did not know what the medications were or to whom they belonged. 2. During an observation and interview on [DATE] at 6:50 AM with LPN5 of the medication cart on the [NAME] Unit revealed in the fourth drawer was a resident's cipro (antibiotic) 250 milligram (mg) with a pharmacy dispense date of [DATE], there were five tablets remaining. One tablet of pyridium (pain reliever for urinary tract infections)100mg was in the fourth drawer with a dispense date of [DATE]. LPN5 stated that the cipro had been discontinued and no longer in use. LPN5 was unable to locate the start and stop date of the medication in the EMR. LPN5 stated that the medication should not have been in the drawer and should have been placed in the medication storage room until the pharmacy could pick up the medications and dispose of them. Additionally, there was a narcotic blister pack with two tablets taped closed. LPN5 confirmed that the tablets should not be taped in the blister pack and should have been disposed of. The sixth drawer contained two and a half tablets and one capsule that were loose. LPN5 was unable to determine what the loose medications were or to whom they belonged. There was a card of cephalexin (antibiotic) 500 mg capsules with one capsule remaining. LPN5 stated that the medication had been completed. The third drawer had eight tablets and three half tablets loose in the third drawer, and the second drawer had 44 solid tablets, one capsule, and 13 partial tablets loose in the drawer. LPN5 stated that all nurses should maintain the medication carts. 3. During an observation and interview on [DATE] at 7:25 AM with LPN5 of the [NAME] Unit medication storage room included a blister pack for a resident dated [DATE] for cipro HCL 250 mg tablets with three tablets remaining in the pack. LPN5 stated that normally the Unit Manager disposes of any discontinued medications, and she was not sure why this pack was propped up against the wall behind intravenous supplies. 4. During an observation and interview on [DATE] at 8:45 AM with LPN11 of the Peach Unit revealed the second drawer had 22 tablets, two capsules, and eight half tablets that were loose in the drawer. The third drawer had five partial pills loose; fourth drawer had one tablet loose; and the eighth drawer had a bottle of alcohol and wound cleanser spray stored with a resident's permethrin 5% cream dispensed by the pharmacy on [DATE]. Additionally, a resident's ammonium lactate 12% cream was with other resident's oral medications. The narcotic drawer had one loose solid tablet and eight partial/broken tablets. LPN11 stated that when they find loose pills the protocol was for them to put them in the sharps container. LPN11 confirmed that the resident's permethrin cream had been discontinued and should have been put in the medication storage room for return to the pharmacy and that all topical medications should be kept separate from oral medications. LPN11 was not able to identify the loose tablets.

Based on clinical record review and staff interviews, the facility staff failed to maintain an effective pest control program for 1 of 55 residents (Resident #65), in the survey sample. Resident #65 was admitted to the facility on [DATE] with diagnoses of but not limited to hemiplegia and hemiparesis of right-side cerebral infarct, dysphagia, chronic congestive heart failure, and dementia. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 04/24/25. Resident # 65's BIMS (Brief Interview for Mental Status) Score was a 15 out of 15, indicating no cognitive impairment. Resident #65 required assistance with all ADL's (Activities of Daily Living). On 4/29/2025 during the initial tour, Resident # 65's room was observed with a bag sitting in a folding chair beside the bed with a large number of ants crawling in around and on the bag, chair and wall. Resident # 65 stated she did not know what exactly was in the bag or that it had ants. The CNA (Certified Nursing Assistant) #3, came in to clean the bag out and added Resident #65's room to the focus pest control log for 04/30/2025. A review of the facility pest control log revealed that Resident #65's room was treated on 04/30/2025. On 04/30/2025 during the end of day meeting, the Administrator and Director of Nursing were informed of the findings. No additional documentation provided.

Based on observation, interview, clinical record review, and facility documentation the facility staff failed to ensure Residents received adequate nutrition to prevent weight loss for 1 Resident (#55) in a survey sample of 55 Residents. The findings included: For Resident #55 the facility staff failed to ensure adequate nutrition to prevent a weight loss of over 17% in five months since admission. Resident # 55 was admitted to the facility on [DATE] with diagnoses that included, but we're not limited to hypertension, high cholesterol, dementia, depression, major depressive disorder, muscle, weakness, cognitive, communication, deficit, insomnia, and presence of a pacemaker. Resident # 55's most recent MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 3/3 25, scored the resident as having a BIMS (Brief Interview of Mental Status) score of 4 out of 15 indicating severe cognitive impairment. During the survey Resident #55 was observed to be unable to follow simple instructions by staff, feed herself or engage in meaningful conversations. Resident #55 was admitted to the facility on ,d+[DATE], her admission weight was 184.4 pounds. On 4/21/25 Resident # 55 weighed 151 pounds which is a 17.68% weight loss in five months' time. A review of the clinical record revealed Resident #55 had orders for a regular diet, dysphagia advanced texture with regular/thin liquid consistency. She started receiving liquid protein on 2/6/25, large protein portions were supposed to start on 2/12/25, however, this was not reflected on the meal ticket or the diet orders in her clinical record. Med-Pass 120 ml. 3 times per day was not added until 4/2/25. Attempts x 2 by telephone were made to contact the Dietician, however, with no results. The following excerpts are from the dietician's notes: 1/29/25 at 2:03 PM Significant weight loss trigger 1/16/25, 164.4 pounds. Note documented edema in November with Lasix ordered. Discussed with teen and MD referral entered notify dietary to update preferences for optimal meal intake remove lactose restriction and provide large portions per unit feedback will continue to trend and adjust accordingly 2/12/25 nutrition: significant weight trigger, noting diuretic use some fluid related weight changes anticipated. 1/29/25 lactose restriction removed, and large portions added to optimize meal intake. 2/6/25 liquid protein Q Day added. Will continue to follow and trend above MNT accordingly no current healthy weight within normal limits. 2/19/25 8:18 am nutrition: significant weight change trigger 2/3/25 154.2 pounds. February weekly weights indicate desired weight gain trend with nutrition intervention in place will continue to follow, noting potential for additional fluid related changes related to diuretic use. 3/26/25 4:35 p.m. - Nutrition: significant weight change trigger: 3/24/25: 156.4 lb. Resident remains stable in mid-150 lb. range with current nutrition interventions. Appropriate weight for age and height. Will continue to monitor as reported well-nourished status, 4/2/25 4:59 p.m.: Nutrition: Significant weight change trigger: 3/31/25: 156.0 lbs. -10% - Resident is maintaining 155 lbs. +/- 3 lbs., noting Lasix use with some anticipated weight related changes. 4/1/25: Med Pass 120 ml TID added to orders. Remeron remains in orders. Will continue to follow and discuss with team prn. 4/24/25 6:05 p.m. Nutrition Follow Up: significant weight changes -7.5%, -10% 4/21/25: 151.8 lbs. Noted on 4/2/25 that resident was maintaining weight in the 150's range. Assess at this time that this represents new baseline weight, with some fluid related changes anticipated with diuretic use. Will plan to keep Med Pass and Remeron in POC at this time to maintain current status. On 4/29/25 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on interview, record review, and facility policy review, the facility failed to ensure that three residents (Resident (R) 66, R71 and R55) had valid advanced directive documents on file. Specifically, R66 and R71 had orders on file for Do Not Resuscitate (DNR) but did not have valid documentation to carry out the orders. This failure had the potential for the resident's wishes to be unmet in the event of cardiac arrest. Findings include: Review of the facility policy titled, Advanced Directives revised [DATE] revealed, .Social Services and/or Business Development Coordinator/designee will assist the resident/ resident representative to complete the Advance Directives Discussion Document. If an advance directive exists the Social Services and/or Business Development Coordinator/designee will obtain a copy and place it in the resident's medical record .Upon completion of Advanced Directives Discussion Document, Social Services or nurse will notify the Physician of the resident's wishes and procure a state approved Do Not Resuscitate Order, if necessary .Advanced Directives will be reviewed: quarterly, hospice admission .Any changes to advanced Directives will require a new Advanced Directives Discussion Document to be completed and place in the medical record 1. Review of R66's undated Admission Record located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of hypertensive heart disease with heart failure. Review of R66's quarterly Minimum Data Set (MDS) Assessment located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of [DATE] included a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that the resident was cognitively intact. Review of R66's Care Plan Report initiated [DATE] located in the EMR under the Care Plan tab included an advance directive status of DNR. Review of the facility document titled DNR Chart Audit dated [DATE] included R66 having an order for DNR and state specific DNR form. Review of R66's Durable Do Not Resuscitate Order Virginia Department of Health dated [DATE], revealed no physician's signature but indicated that the resident was incapable of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment because he/she is unable to understand the nature, extent or probably consequences of the proposed medical decision, or to make a rational evaluation of the risks and benefits of alternatives to that decision . During an interview on [DATE] at 2:10 PM with R66 stated that she was on hospice and that her advanced directive status was DNR. 2. Review of R71's undated Admission Record located in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of dementia. Review of R71's quarterly MDS Assessment located in the EMR under the MDS tab with an ARD of [DATE] included a BIMS score of 99 indicating that the resident was not capable of participating in the assessment and had severe cognitive impairment. Family Member (FM)1 was R71's responsible party (RP). Review of R71's Care Plan Report revised [DATE] located in the EMR under the Care Plan tab indicated that R71 had no advanced directive on file and was to be a full code. Review of R71's Order Summary Report included an order for Do Not Resuscitate dated [DATE]. Review of R71's Virginia Advance Directive dated [DATE] located in the EMR under the miscellaneous tab included her deceased spouse's name on the document. No documentation was located with R71's name. Review of the facility document titled DNR Chart Audit dated [DATE] included R7 not having an order for DNR or state specific DNR form. During an interview on [DATE] at 11:28 AM with FM1 confirmed that R71's advance directive status was DNR. FM1 confirmed that the name on R71's Virginia Advance Directive document was her deceased father's name/her mother's deceased spouse. During an interview on [DATE] at 12:43 PM with Social Services Assistant (SSA)2 stated that advanced directives are reviewed during care conferences and confirmed that the orders on file for R66 and R71 were for DNR. During an interview on [DATE] at 12:50 PM the Social Services Director (SSD) stated that both R66 and R71 had orders for DNR status. The procedure for a resident coding who didn't have complete or accurate documentation for DNR status was for the nurse on duty to contact the Emergency Contact/RP, if not able to contact them, then they would need to contact the resident's physician for authorization and ensure a second nurse was witness to the conversation. SSD confirmed that the Durable Do Not Resuscitate Order Virginia Department of Health on file for R66 did not have a physician's signature and was not sure if the document was in effect with no physician signature. SSD confirmed that R71's Virginia Advance Directive on file was for R71's deceased spouse and not for R71. SSD confirmed that she did not have proper documents for R66 or R71 but that SSA2 had just called R71's FM1 and they would make arrangements to obtain the correct documents. SSD confirmed that advance directive status was reviewed during care conferences, and she was not sure why/how these issues were overlooked. During an interview on [DATE] at 4:55 PM with Emergency Medical Technician (EMT) on site at the facility stated that R66's Durable Do Not Resuscitate Order Virginia Department of Health and R71's Virginia Advance Directive would not be in effect if EMS would be called for either resident because R66's did not include a physician's signature and because R71's did not have her name on it. In either case, EMS would have to perform cardiopulmonary resuscitation (CPR) in the case of an emergency. 40026 3. For Resident #55 the facility staff failed to have a signed copy of the DNR available in the clinical record. Resident # 55 was admitted to the facility on [DATE] with diagnoses that included, but we're not limited to hypertension, high cholesterol, dementia, depression, major depressive disorder, muscle, weakness, cognitive, communication, deficit, insomnia, and presence of a pacemaker. Resident # 55's most recent MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of ,d+[DATE] 25, scored the resident as having a BIMS (Brief Interview of Mental Status) score of 4 out of 15 indicating severe cognitive impairment. During the survey Resident #55 was observed to be unable to follow simple instructions by staff, feed herself or engage in meaningful conversations. On [DATE] during clinical record review it was found that Resident #55 had a DNR dated [DATE], this document was filled out to read as follows: 2. (box checked) The patient is INCAPABLE of making informed decision about providing, withholding or withdrawing specific medical treatment . (If you check box 2 above check A, B, or C below) C. The patient has not executed a written advance directive (living will or durable power of attorney for health care). (Signature of Person Authorized to Consent on the Patient Behalf is REQUIRED) This document was unsigned. On [DATE] an interview was conducted with the Administrative Staff #6 who were asked who is responsible for the DNR forms being entered into the system. She stated that Social Services Dept was responsible. When asked to pull up Resident #55's DNR form she did so in the electronic health record. She was asked if there is any problem with the DNR form and she stated that there was no signature on it. When asked what the problem is if there is no signature, she stated that it is not legal if it has not been signed. When asked what the implications of that are and she stated the Resident would receive CPR because the form is not valid without a signature. On [DATE] a review of the clinical record revealed the progress following note: [DATE] at 7:08 p.m. NP [Nurse Practitioner name redacted] DON, and UM spoke to POA [name redacted] to confirm code status. [Name Redacted], daughter POA acknowledged and confirmed resident is a DNR and she has faxed a sign copy to the Facility. DON repeated code status and POA [Name redacted]. NP [name redated] signed DNR Code Status form. A review of the policy, entitled advanced directives, revealed the following excerpts: Policy: the center will abide by state and federal laws regarding advanced directives. The center will honor all properly executed advanced directives that have been provided by the resident and/or resident representative. Process: 1. Upon admission, social service Director or business development coordinator/designee will: a) Communicate to resident and/or resident representative his or her right to make choices concerning healthcare and treatments, including life-sustaining treatments. b) Determine whether a resident has an advanced directive, and if not, determine whether the resident wishes to establish an advanced directive. c) Document in the resident record via the advanced discussion form that a resident and or represent resident representative has been apprised of his or her right to formulate in advanced directive. 2. Social services and or Business development coordinator/designated will assist the resident/representative to complete the advanced directives discussion document. If an advanced directive exists, the social services and/or business development coordinator/design will obtain a copy and place it in the residence medical record. 3. If the resident has not executed in advanced directive, but wishes to establish an advanced directive, the social services will assist the resident/resident representative with obtaining the state approved, advanced directive documents. Formulating and advanced directed is the choice of the resident and is not required. No center employee shall act as witness or notary for advanced directive forms, but staff can assist in ensuring documentation is properly executed 4. upon completion of the advanced directive discussion, document social services, or nurse will notify the physician of the residence. Wishes and procure state approved. Do not resuscitate order if necessary. Notification will be documented in the clinical record. On [DATE] during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure a resident visually impaired resident received training and assistance on infection prevention measures were followed while providing urinary catheter care self care for 1 of 55 residents (Resident #43), in the survey sample. The findings included: Resident #43 was originally admitted to the facility 11/05/22 and readmitted [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Neuromuscular Dysfunction of the Bladder. The quarterly revision, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/22/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #43 cognitive abilities for daily decision making were intact. In section B (Hearing, Speech and Vision) the resident was coded moderately impaired with vision and coded Yes, for corrective lenses. In sectionGG(Functional Abilities Goals) the resident was coded as requiring set-up help with eating and oral hygiene. Resident coded as dependent with toileting hygiene. Requiring substantial/maximal assistance with shower/bathe self. Requiring partial/moderate assistance with personal hygiene. (Functional Limitations in Range of Motion) Resident coded as no impairment for upper extremity. Resident coded as impairment on both sides for lower extremities. (Mobility Devices) Resident coded as requiring a wheelchair. (Mobility) Resident coded as independent with rolling left and right. Requires supervision or touching assistance with sit to lying and lying to sitting. Resident coded as a dependent chair to bed. In Section H (Bladder and Bowel) the resident was coded as having an indwelling, external catheter. The April 2025 Physicians Order Summary (POS) read: Catheter care every shift and as needed every shift for Foley catheter -Start Date- 11/08/2024 7:00 pm. The person-centered care plan dated 3/08/23 read that Resident #43 has impaired visual function r/t Diabetes, Glaucoma R eye severe impairment, L eye adequate. (Revised on 3/08/23). The Goals for Resident #43 are the resident will maintain optimal quality of life within limitation imposed by visual function through the review date and the resident will have no indications of acute eye problems through the target date of 4/22/25. The interventions for Resident #43 are Arrange consultation with eye care practitioner as required (3/08/23). Monitor/document/report PRN any s/sx of acute eye problems (3/08/23). The person-centered care plan dated 10/30/23 read that Resident #43 has an indwelling foley catheter as well as a colostomy r/t diabetes, BPH, and dx of other obstructive and reflux uropathy. The Goals for Resident #43 are the resident will The resident will show no s/sx of Urinary infection through review date and the resident will be/remain free from catheter-related trauma through review date (4/22/25). The interventions for Resident #43 are to monitor/document for pain/discomfort due to catheter and Monitor/record/report to MD for s/sx UTI (Urinary Tract Infection). On 04/30/25 at approximately 10:17 am, a brief interview was conducted with Resident #43. Resident #43 said that he had an enlarged prostate a few years ago that's why I have a foley. I have had infections (Urinary Tract Infections/UTI's), I see the Urologist one a month to get my foley changed. Resident #43 was asked if the staff performs daily catheter care. Resident #43 stated, I do my own (foley) catheter care. Permission was granted from resident to be observed performing his foley catheter care. A review of the resident's medical records read that he's had several Urinary Tract Infections last year (2025). On 4/30/25 at approximately 11:00 am., foley catheter self care was observed. Certified Nursing Assistant (CNA) #14. CNA #14 was observed setting up one basin, placing 2 wash cloths inside with a bar of soap. The steps were as follows: CNA #14 washed Resident's back, used wash cloth placed back into the basin with clean wash cloth, resident reached for clean wash cloth in the basin, rung it out, washed his left and right groin and perineal area, placed wash cloth in basin and rung out cloth again, took wash cloth out of the basin, wipe his foley catheter moving downward and placed wash cloth inside basin. On 4/30/25 at approximately 11:15 AM., a brief interview was conducted with CNA #14 concerning Resident #43s catheter care. CNA #4 said that she realized that she should have provided 2 basins, 1 basin with soap water and the other with rinse water. On 05/01/25 at approximately 1:45 pm., a brief interview was conducted with Certified Nursing Assistant (CNA) #14. CNA #14 said that she was never informed to assist the resident with catheter care other than emptying his foley. On 05/01/25 at approximately 12:13 pm., an interview was conducted with Licensed Practical Nurse (LPN) #10. LPN #10 said that the CNAs do the catheter care as part of the (Activity of Daily Living) ADLs. On 05/01/25 at approximately 11:08 am., a brief interview was conducted with the Assistant Director of Nursing (ADON). The ADON said that the CNAs should help with foley catheter care. We will educate the resident on proper foley care. Policy: Effective Date: 11/30/2014. Revised Date: 9/05/17. Catheter Care, Urinary Assemble the following: Towel and wash cloth, soap, basin of warm water, disposable gloves, hand hygiene, remove catheter securement device, wash perineal area with soap and water from front to back, rinse and dry, clean catheter tubing with soap and water, reattach securement device, perform hand hygiene. On 5/01/25 at approximately 7:00 p.m., during the pre-exit the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant and [NAME] President of Operations. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to develop and implement a comprehensive person-centered care plan for 1 Resident (# 38) in a survey sample of 55 Residents. The findings included: For Resident # 38 the facility failed to develop a comprehensive care plan that addressed measures to reduce the possibility of any injures during falls and to protect the recently replaced hip. Resident # 38 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Hypertensive Heart Disease with Heart Failure, presence of artificial hip joint following cerebrovascular disease, and depression. Resident # 38's most recent MDS (Minimum Data Set) was coded as an Admission Assessment with an ARD (Assessment Reference Date) of 4/11/2025. The MDS coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 15 out of 15 indicating no cognitive impairment. Resident # 38 required assistance with Activities of Daily Living. On 4/29/2025 at 2:28 p.m., Resident # 38 was observed sitting up in a wheelchair next to his bed. His wife was visiting and told the surveyor that she had some concerns. She stated the resident had fallen at home and fractured his hip which had to be replaced. Resident # 38's wife stated he was in the facility to get therapy before returning home. On 04/29/0225 at 2:31 p.m.- Resident # 38's wife stated resident has fallen twice since admission. She stated she heard about fall mats and wants one for Resident # 38. She stated she was afraid he was going to re-injure that hip. She stated she noticed that some other residents in the facility had fall mats. No fall mats were noted on either side of the bed. On 4/30/2025 at 9:45 a.m Resident # 38 was observed lying in bed. He stated he was just resting. No fall mats were noted on either side of the bed. On 05/01/25 at 12:22 p.m., an interview was conducted with Licensed Practical Nurse # 1 who stated nursing measures were discussed in the IDT (Interdisciplinary Team) meeting. Licensed Practical Nurse # 1 stated it was important for interventions to be implemented to help the residents maintain optimal health and safety. On 05/01/25 at 12:24 p.m., an interview was conducted with the Physical Therapy Director who was asked if Resident # 38 had been assessed for the use of floor mats to reduce the possiblity of any injures and to protect the recently replaced hip. The Physical Therapy Director stated he would have been present at the Risk Meeting regarding Resident # 38 where the administrative team discussed new admissions and plans of care. The Physical Therapy Director stated he would check any notes to see why mats were not listed as an intervention. Review of the care plan revealed that Resident # 38's care plan did not address the use of fall mats to to reduce the risk of injuries if any falls occurred. On 5/1/2025 during the end of day meeting, the Administrator and Director of Nursing were made aware of the findings that interventions did not include fall mats to reduce the risk of injuries during falls. No further information was provided.

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to review and revise the care plan for 1 resident (#43) and invite the interdisciplinary team to the care plan meeting for 2 residents (Resident #59 and 71), of 55 residents in the survey sample. The findings included: 1. The facility's staff failed to review and revise Resident #43's care plan to include self catheter care. Resident #43 was originally admitted to the facility 11/05/22 and readmitted [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Neuromuscular Dysfunction of the Bladder. The quarterly revision, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/22/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #43 cognitive abilities for daily decision making were intact. In sectionGG(Functional Abilities Goals) the resident was coded as requiring set-up help with eating and oral hygiene. Resident coded as dependent with toileting hygiene. Requiring substantial/maximal assistance with shower/bathe self. Requiring partial/moderate assistance with personal hygiene. (Functional Limitations in Range of Motion) Resident coded as no impairment for upper extremity. Resident coded as impairment on both sides for lower extremities. (Mobility Devices) Resident coded as requiring a wheelchair. (Mobility) Resident coded as independent with rolling left and right. Requires supervision or touching assistance with sit to lying and lying to sitting. Resident coded as a dependent chair to bed. In Section H (Bladder and Bowel) the resident was coded as having an indwelling, external catheter. The April 2025 Physicians Order Summary (POS) read: Catheter care every shift and as needed every shift for Foley catheter -Start Date- 11/08/2024 7:00 pm. The person-centered care plan dated 10/30/23 read that Resident #43 has an indwelling foley catheter as well as a colostomy r/t diabetes, BPH, and dx of other obstructive and reflux uropathy. The Goals for Resident #43 are the resident will The resident will show no s/sx of Urinary infection through review date and the resident will be/remain free from catheter-related trauma through review date (4/22/25). The interventions for Resident #43 are to monitor/document for pain/discomfort due to catheter and Monitor/record/report to MD for s/sx UTI (Urinary Tract Infection). On 04/30/25 at approximately 10:17 am, a brief interview was conducted with Resident #43. Resident #43 said that he had an enlarged prostate a few years ago that's why I have a foley. I have had infections (Urinary Tract Infections/UTI's), I see the Urologist one a month to get my foley changed. Resident #43 was asked if the staff performs daily catheter care. Resident #43 stated, I do my own (foley) catheter care. Permission was granted from resident to be observed performing his foley catheter care. A review of the resident's medical records read that he's had several Urinary Tract Infections last year (2025). On 4/30/25 at approximately 11:00 am., foley catheter self care was observed. Certified Nursing Assistant (CNA) #14. CNA #14 was observed setting up one basin, placing 2 wash cloths inside with a bar of soap. The steps were as follows: CNA #14 washed Resident's back, wash cloth placed back inside the basin with clean wash cloth, resident reached for clean wash cloth in the basin, rung it out, washed his left and right groin area, placed wash cloth in basin and rung out cloth again, took wash cloth out of the basin, wipe his foley catheter moving downward and placed wash cloth inside basin. On 4/30/25 at approximately 11:15 AM., a brief interview was conducted with CNA #14 concerning Resident #43s catheter care. CNA #4 said that she realized that she should have provided 2 basins, 1 basin with soap water and the other with rinse water. On 05/01/25 at approximately 1:45 pm., a brief interview was conducted with Certified Nursing Assistant (CNA) #14. CNA #14 said that she was never informed to assist the resident with catheter care other than emptying his foley. On 05/01/25 at approximately 12:13 pm., an interview was conducted with Licensed Practical Nurse (LPN) #10. LPN #10 said that the CNAs do the catheter care as part of the (Activity of Daily Living) ADLs. On 05/01/25 at approximately 11:08 am., a brief interview was conducted with the Assistant Director of Nursing (ADON). The ADON said that the CNAs should help with foley catheter care. We will educate the resident on proper foley care. On 5/01/25 at approximately 7:00 p.m., during the pre-exit the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant and [NAME] President of Operations. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided. 40824 Review of the facility's policy titled, Plans of Care revised 09/25/17 revealed, .An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) .Develop and implement an individualized person-centered comprehensive plan of care by the Interdisciplinary Team that includes but is not limited to - the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident . 2. Review of R59's undated Admission Record located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with a Wernicke's encephalopathy (mental status changes and gait ataxia). Review of R59's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 02/17/25 included a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that the resident was cognitively intact. Review of R59's Care Planning Invitation scheduled for 05/29/24 indicated that the Social Services Director (SSD), Social Services Assistant (SSA), responsible party and R59 attended the care conference. No other departments attended the care conference. Review of R59's Care Planning Invitation scheduled for 08/21/24 indicated that the Social Services Director (SSD), Social Services Assistant (SSA) and R59 attended the care conference. No other departments attended the care conference. Review of R59's Care Planning Invitation scheduled for 12/04/24 indicated that the Social Services Director (SSD) and R59 attended the care conference. No other departments attended the care conference. Review of R59's Care Planning Invitation scheduled for 03/06/25 indicated that the Social Services Director (SSD), Social Services Assistant (SSA), and R59 attended the care conference. No other departments attended the care conference. During an interview on 04/29/25 at 1:30 PM with R59 stated that he had concerns with his social security checks, returning to the community and his clothing. He did not recall attending any care conferences. 3. Review of R71's undated Admission Record located in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of dementia. Review of R71's quarterly MDS located in the EMR under the MDS tab with an ARD of 04/08/25 included a BIMS score of 99 indicating that the resident was not capable of participating in the assessment and had severe cognitive impairment. Review of R71's Care Planning Invitation scheduled for 07/11/24 indicated that the Social Services Director (SSD), Social Services Assistant (SSA), and Family Member (FM)1 attended the care conference. No other departments attended the care conference. Review of R71's Care Planning Invitation scheduled for 10/15/24 indicated that the SSD and FM1 attended the care conference. No other departments attended the care conference. Review of R71's Care Planning Invitation scheduled for 01/14/25 indicated that the SSD and FM1 attended the care conference. No other departments attended the care conference. During an interview on 04/30/25 at 11:06 AM with R71's Family Member (FM)1 stated that the facility called her with updated information at times, but other times she doesn't find out information until later. When she was not able to attend care conferences she did not receive notification of information discussed or changes that were taking place. FM1 had concerns with pressure ulcers, activity participation, and hydration status. During an interview on 05/01/25 at 10:38 AM with the Director of Nursing (DON) confirmed that care conferences were to be held quarterly and as needed for each resident. The DON confirmed that a staff member from the nursing department should always attend and did not elaborate on why no one from the nursing department had attended the care conferences for these residents. During an interview on 05/01/25 at 12:57 PM with Licensed Practical Nurse (LPN)10 stated that she had not been invited to attend any care conferences and she was not sure who was supposed to attend the meetings. During an interview on 05/01/25 at 1:28 PM with SSD confirmed that all departments involved in the residents' care should attend the care conferences but due to staffing shortages, they frequently are unable to attend. Her protocol was to send an email to notify each department at the beginning of the month with the care conference schedule. All attendees were to sign the attendance sheet if they attended. The SSD was unable to locate any sign in sheets and did not recall speaking with R59 regarding concerns with transferring to the community, his clothing, or his social security checks. The SSD did not bring it to the attention of Administration regarding all departments not attending the care conferences, no reason was given. Additionally, SSD said she was not clinical, so when dietary, therapy, nursing, etc. were not available she would just have to review their notes in EMR (if they were available) to determine if there were any concerns that needed to be shared with the resident/RP. SSD stated that in the past (unknown dates/timeframes) she had used a sign in sheet, but couldn't recall when she last used one. During an interview on 05/01/25 at 4:11 PM with the Dietary Manager (DM) confirmed that she either received email invitations or a paper copy of care conference meeting dates. DM confirmed that all departments were required to attend and in the past, most departments attended and if they had done so they would sign to confirm their attendance. During an interview on 05/01/25 at 5:00 PM with the Director of Rehabilitation (DOR) stated that he received invitations for care conferences at the beginning of each month but only attended meetings if the family or the resident requested him to do so. He did not confirm/deny if he was required to attend if the resident was currently receiving services.

Based on interview, clinical record review and facility documentation, the facility staff failed to ensure services were provided to meet professional standards of quality for 1 Resident (55) in a survey sample of 55 Residents. The findings included: For Resident #55 the facility staff failed to schedule follow up with cardiology as ordered by physician. Resident # 55 was admitted to the facility on [DATE] with diagnoses that included, but we're not limited to hypertension, high cholesterol, dementia, depression, major depressive disorder, muscle, weakness, cognitive, communication, deficit, insomnia, and presence of a pacemaker. Resident # 55's most recent MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 3/3 25, scored the resident as having a BIMS (Brief Interview of Mental Status) score of 4 out of 15 indicating severe cognitive impairment. During the survey Resident #55 was observed to be unable to follow simple instructions by staff, feed herself or engage in meaningful conversations. On 4/30/25 during clinical record review it was found that Resident #55 had a recent emergency room visit. Excerpts from the discharge summary read as follows: 4/10/25 instructions your work up show evidence of thyroid nodules. I would recommend that you follow up for outpatient ultrasound of your thyroid. The battery life on your pacemaker is towards the end. Please follow up with your cardiologist as soon as possible you will likely require battery replacement within the next three months. On the afternoon of 4/30/25 an interview was conducted with administrative staff #14 who stated that she scheduled the transportation to appointments. She looked in the transportation book and stated that she did not have Resident #55 scheduled for cardiology through the end of 2025. On the afternoon of 4/30/25 an interview was conducted with LPN #7, the unit manager, who stated that she schedules follow up appointments for the Residents on her unit. LPN #7 stated that she was not aware of any cardiology appointments for Resident #55. LPN #7 checked her appointment book and stated that she did not have any appointments scheduled for cardiology through the end of 2025. When asked to read the discharge summary from the ER she stated that the follow up must have gotten missed when she returned to the facility. She stated that they did follow up on the thyroid nodules but must have missed the cardiology appt. When asked what could happen if a pacemaker battery is not replaced timely, she stated the Resident would become symptomatic and may have skipped heartbeats, dizziness, fainting and slow heartrate. On 5/1/25 a review of the clinical record revealed the following progress note: 4/30/35 at 7:33 p.m. - Pacemaker battery replacement-Cardiology [address and phone number redacted]. Awaiting call back for the appointment time and date, RP [name redacted] and MD notified. The National Institutes of Health (NIH) and its affiliated institutions, including the National Library of Medicine (NLM), heavily rely on following physician orders as the foundation of patient care. Physician orders are the initial communication that enables healthcare providers to implement treatment plans, and they are essential for ensuring coordinated care, patient safety, and quality measures according to the National Institutes of Health (NIH.gov) On 5/1/25 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on observation, interview, record review, and facility policy review the facility failed to ensure that activities of daily living (ADL) care related to toenail care was provided to one resident (Resident (R)80) out of a total sample of 55 residents. This failure had the potential to cause the resident foot problems. Findings include: Review of the facility policy titled Foot Care revised 08/23/17 included .Examine feet and report any unusual condition to nurse and/or physician . The policy did not indicate which department was responsible for toenail care. Review of R80's undated Admission Record located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of dementia. Review of R80's quarterly Minimum Data Set (MDS) Assessment located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 03/23/25 included a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating that the resident was severely cognitively impaired. Review of R80's Care Plan Report initiated 08/30/23 located in the EMR under the Care Plan tab included ADL care self-care performance deficit related to dementia and required staff to check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Review of R80's Order Summary Report located in the EMR under the Orders tab included an order for podiatry referral to clip toenails as of 11/18/24. Review of R80's Consulate Weekly Skin Integrity Review dated 04/27/25 and located in the EMR under the Assessment tab did not indicate R80 had any concerns with her toenails. Review of R80's undated Visual/Bedside Kardex Report located in the EMR under the Tasks tab included checking nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. During an observation and interview on 04/29/25 at 2:17 PM R80 was in bed and reported to this surveyor that she had been waiting to see the podiatrist for four years. R80 proceeded to take off her left shoe and it was noted that she had long, thick, discolored toenails. During an interview on 04/30/25 at 5:16 PM with Social Services Director (SSD) stated that she spoke with Licensed Practical Nurse (LPN)10 and confirmed that R80 needed her toenails trimmed. SSD confirmed that R80 had not been seen by a Podiatrist since she was admitted to the facility. During an interview on 05/01/25 at 10:25 AM with Certified Nursing Assistant (CNA)8 confirmed that she had assisted the resident to dress prior to this surveyor entering the room. She was not aware of R80 having long, thick, discolored toenails. CNA8 stated that it was the facility policy for CNA's to trim the resident's finger nails, but if toenails needed trimming or had concerns the CNAs were to notify the nurse who would make a referral to podiatry. Once the nurse is aware the resident needs toenail care, the SSD would be notified who would then schedule an appointment. During an interview on 05/01/25 at 10:38 AM with the Director of Nurses (DON) stated that it was her expectation for the CNAs to let the nurse know if the resident needed toenail care. The nurse would then notify the SSD who would schedule a podiatry visit. During an interview on 05/01/25 at 10:45 AM with LPN10 stated that she was not aware that R80 had long, thick, discolored toenails. LPN10 stated that it was her understanding that CNAs trimmed the toenails unless the resident was diabetic and she confirmed R80 was not diabetic. The facility policy was for the CNA to notify the nurse if a resident needed to be seen by podiatry, then the SSD puts the resident on the podiatry list.

Based on interviews, record reviews, and facility policy reviews, the facility failed to notify the Responsible Party (RP) of a change in condition for one resident (Resident (R)71) investigated for changes in condition out of a total sample of 55 residents. Findings include: Review of the facility policy titled, Notification of Change in Condition, revised 12/16/20 revealed The Center to promptly notify the Patient/Resident , the attending physician and the Resident Representative when there is a change in the status or condition .Need to alter treatment significantly- new treatment . Review of R71's undated Admission Record located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of dementia. Review of R71's quarterly Minimum Data Set (MDS) Assessment located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 04/08/25 included a Brief Interview for Mental Status (BIMS) score of 99 indicating that the resident was not capable of participating in the assessment and had severe cognitive impairment. The resident was dependent on staff for all activities of daily living (ADL). Review of R71's Care Plan Report, initiated 03/09/23, located in the EMR under the Care Plan tab included having the potential for pressure injury development related to impaired cognitive function, incontinence, and limited mobility. Interventions included following facility policies/protocols for the prevention/treatment of skin breakdown and informing the resident/resident representative of any new area of skin breakdown. Review of R71's Consulate Weekly Skin Integrity Review, dated 03/12/25, located in the EMR under the Assessments tab, indicated she had an unstageable deep tissue injury to the right hip, stage two pressure ulcer to the left hip, and moisture associated dermatitis to the sacrum. Treatment initiated as ordered and wound physician in the facility per documentation. Review of R71's Initial Wound Evaluation & Management Summary by VOHRA Wound Physicians dated 03/12/25 and located in the EMR under the miscellaneous tab included R71 presenting with wounds to the left lip, right hip, and sacrum. Diagnoses included unstageable deep tissue injury (DTI) to the right hip, stage two pressure ulcer (PU) to left hip, and MASD to sacrum. Review of R71's Change in Condition (SBAR) located in the EMR under the Assessments tab dated 03/18/25 indicated that R71's Responsible Party (RP) was notified of deep tissue injury to the right hip, and open areas to the sacrum and left hip. During an interview on 05/01/25 at 6:22 PM with the RP/Family Member (FM)1 stated she was not notified of the resident's stage 3 pressure ulcer until the physician called her with a follow up. The physician acted like she already knew, which she did not. She was only aware of her Mother requiring an air mattress and wedge pillow to help prevent pressure ulcers. During an interview on 05/01/25 at 6:49 PM with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that R71's wound was discovered on 03/12/25. The wound care specialist was onsite (VOHRA) started and initiated treatment. On 03/18/25 the VOHRA physician and LPN notified daughter of wounds. The wound should have been reported to FM1 on 03/12/25.

Based on record review, interview and policy review, the facility failed to ensure that physician's orders were followed for one of 55 residents (Resident (R) 116) whose records were reviewed. This failure has the potential to negatively impact R116 and others that have similar orders that currently reside at the facility. Findings include: Review of facility policy titled, Administering Medications, revised 04/2019, indicated, Medications are administered in a safe and timely manner and as prescribed. Policy Interpretation and Implementation . 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Review of R116's Admission Record, located under the Profile in the Electronic Medical record (EMR), indicated that R116 was admitted to the facility on [DATE] with diagnoses that included hypertension, chronic kidney disease (CKD), major depressive disorder (MDD), atrial fibrillation (a-fib), and vitamin b-12 deficiency. Review of R116's Order Summary Report, dated 03/15/24 and located under the Orders in the EMR, indicated the resident was to receive: amiodarone 200 milligrams (mg), give one tablet by mouth (PO) one time a day for a-fib; amlodipine 2.5 mg, give one tablet PO one time a day for hypertension ascorbic acid 1000 mg, give one tablet PO one time a day for supplement bumetanide 1 mg, give one tablet PO one time a day every other day for hypertension calcitriol .25 micrograms (mcg), give one capsule PO one time a day every Monday, Wednesday, Friday for low calcium citalopram hydrobromide 20 mg, give one tablet PO one time a day for depression cyanocobalamin 1000 mcg, give one tablet PO one time a day for supplement Eliquis 5 mg PO one time a day for anticoagulant lidocaine external patch 5%, apply to lower back topically every 12 hours for pain metoprolol succinate extended release (ER) 25 mg, give one tablet PO a day for hypertension and hold for systolic blood pressure (sys) less than 110 potassium chloride ER 20 milliequivalent (meq), give one tablet PO twice a day (BID) for low potassium multivitamin with minerals, give one tablet PO one time a day for supplement; house supplement twice a day (BID) with breakfast and lunch vital signs every shift. Review of Medication Administration Record (MAR), dated 03/15/24 through 03/24/24, revealed no documented evidence that R116 received the morning medications as ordered. There was no documented evidence that R116's evening dose of metoprolol tartrate ER and potassium chloride were given on 03/21/24 and/or 03/24/24. There was no documented evidence that vital signs were taken as ordered on the day shift on the following days: 03/16/24, 03/18/24, 03/20/24, 03/21/24, and/or 03/24/24. Also, there was no documented evidence that vital signs were taken as ordered on the night shift on the following days: 03/21/24 and/or 03/21/24. Interview on 05/01/25 at 8:50 PM, the Director of Nursing (DON) confirmed that R116's medications should have been given as the physician ordered and they were not.

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure residents received vision services for 2 of 55 residents (Resident #43 and 87), in the survey sample. The findings included: 1. The facility's staff failed to ensure Resident #43 received services to maintain vision. Resident #43 was originally admitted to the facility 11/05/22 and readmitted [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Primary open angled Glaucoma, Left Eye, Severe Stage, Acquired Absence of Left Leg Below the Knee. The quarterly revision, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/22/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #43 cognitive abilities for daily decision making were intact. In section B (Hearing, Speech and Vision) the resident was coded moderately impaired with vision and coded Yes, for corrective lenses. In sectionGG(Functional Abilities Goals) the resident was coded as requiring set-up help with eating and oral hygiene. Resident coded as dependent with toileting hygiene. Requiring substantial/maximal assistance with shower/bathe self. Requiring partial/moderate assistance with personal hygiene. (Functional Limitations in Range of Motion) Resident coded as no impairment for upper extremity. Resident coded as impairment on both sides for lower extremities. (Mobility Devices) Resident coded as requiring a wheelchair. (Mobility) Resident coded as independent with rolling left and right. Requires supervision or touching assistance with sit to lying and lying to sitting. Resident coded as a dependent chair to bed. The person-centered care plan dated 3/08/23 read that Resident #43 has impaired visual function r/t Diabetes, Glaucoma R eye severe impairment, L eye adequate. (Revised on 3/08/23). The Goals for Resident #43 are the resident will maintain optimal quality of life within limitation imposed by visual function through the review date and the resident will have no indications of acute eye problems through the target date of 4/22/25. The interventions for Resident #43 are Arrange consultation with eye care practitioner as required (3/08/23). Monitor/document/report PRN any s/sx of acute eye problems (3/08/23). The Physician's Order Summary (POS) for April 2025 read: Please refer to eye doctor to evaluate and treat one time only for eye exam for 1 Day -Start Date- 04/09/2025 5:45 pm., A review of the Medication Administartion Record (MAR) showed that the above order was not checked off by staff as being completed. Please refer to eye MD, for eyeglasses one time only for Needs eye exam and eye glasses for 3 Days -Start Date- 04/25/2025 3:30 pm. Signed off on 4/25/25. A review of the April 2025 MAR show that a staff signed off on the MAR but no call but no appointment was made. On 04/30/25 at approximately 10:14 am., during the initial tour Resident #43 said that he was blind, needed glasses and could only see people as gray shadows. Resident #43 also said that he had mentioned needing glasses to the activities staff (Others Staff #4) a while back and was given a pair of reading glasses. On 04/30/25 at approximately 4:29 pm., a brief interview was conducted with the met with the Social Services Assistant (SSA#1). The SSA #1 said that Resident #43 was not on the list to receive services when the vision van came two weeks ago. I knew he had vision problems. The list is taken to each unit by me for the nurses to list residents needing to be seen. The nurses will inform us. On 5/01/25 at approximately 9:50 am., an interview was conducted with Activities Staff (Other Staff #4) The activities staff said while working 1:1 with Resident #4, he was asked to help him get a pair of glasses about a month ago. He initially said the glasses help. Then he mentioned to me to talk with the Social Worker about making him an appointment to see the eye doctor and I did. On 05/01/25 at approximately 10:50 am., a brief interview was conducted with the SSA #1. The SSA #1 said that the Assistant Director of Nursing (ADON) had mentioned to her last Friday that Resident #43 needed an eye appointment but it hadn't been made. On 5/01/25 at approximately 7:00 p.m., during the pre-exit the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant and [NAME] President of Operations. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided. 40026 2. For Resident #87 the facility staff failed to schedule vision services for a resident with visual impairment. Resident # 87 was admitted to the facility on [DATE] with diagnoses that included, but we're not limited to dementia, schizophrenia, anemia, hypertension, psychotic disorder with delusions due to unknown physiological condition, and cognitive communication deficit. Resident number 87's most recent minimum data set with an ARD (Assessment Reference Date) of 4/16/25 coded Resident # 87 as having a BIMS (Brief Interview of Mental Status) score of 6 out of 15 indicating severe cognitive impairment. Resident number 87 could follow simple conversation. On 4/29/25 Resident #87 stated I need glasses, I can't see. When asked if she had an eye examination, she stated that she could not remember when the last time she had an eye examination. A review of the clinical record revealed that since admission she had not been seen by an optometrist for a routine vision examination. On 4/30/25 an interview with Administration #6 was conducted and she was asked if the facility provides routine screening for eye exams, she stated that there is a company that came to the facility to provide those services. She stated that she is the person who arranges the vision services to come to the facility and schedules the appointments for Residents to be seen. She stated that the unit managers usually are the ones who notify her of Residents needing vision services. She looked in the electronic health record for Resident #87 and stated that she had not been seen by the eye doctor since admission to the facility in 2023. When asked how often most Residents are seen for screening she stated, they should be seen yearly. On 4/30/25 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on observation, clinical record review and staff interviews, the facility staff failed to provide foot care for two (2) Residents (#65 and #90) of 55 residents, in the sample survey. The findings included: 1. Resident #65 was admitted to the facility on [DATE] with diagnoses of but not limited to hemiplegia and hemiparesis of right-side cerebral infarct, dysphagia, chronic congestive heart failure, and dementia. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 04/24/25. Resident # 65's BIMS (Brief Interview for Mental Status) Score was a 15 out of 15, indicating no cognitive impairment. Resident #65 required assistance with all ADL's (Activities of Daily Living). On 4/30/2025 during an afternoon tour, Resident # 65's was observed in bed on her back, sitting up. Resident # 65's toenails were thick, long with uneven edges. They were brown in color with some lighter brown to yellow areas. Resident #65 stated that she would see the podiatrist but that she does not remember seeing a podiatrist in the past. A review of Resident #65's progress notes did not reveal any foot or podiatry care. On 04/30/2025, at 5:40 p.m., an interview was conducted with the LPN #2 who stated she would put Resident #65 on the schedule to see Podiatry when they come to the facility next month. 2. Resident #90 was admitted to the facility on [DATE] with diagnoses of but not limited to visual loss, dementia, vitamin D deficiency, pulmonary disease, cognitive communication deficit. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 03/05/25. Resident # 90's BIMS (Brief Interview for Mental Status) Score was a 15 out of 15, indicating no cognitive impairment. Resident #90 required assistance with Activities of Daily Living. On 4/29/25 and 4/30/2025 during an afternoon tour, Resident #90's was observed in bed. Resident #90 stated that she needed to see the Podiatrist because her toe nails are long and are had begun to get snagged in her bed covers. Resident #90's toenails were observed long, thick and curved. They had little discoloration. Resident #90 said she had seen the podiatrist before, but that it was early like 7:00 am on a Saturday and that it had been a long time ago. She stated that she would let the Podiatrist trim and treat her toenails because they get caught in the bedcovers now and cause her pain. A review of Resident #90's progress notes did not reveal any foot or podiatry care. On 04/30/2025, at 5:40 p.m., an interview was conducted with LPN 2 who stated that Resident #90 had refused to have Podiatry in the evaluate her feet and toenails in the past but that she would put her on the schedule to see Podiatry when they come to the facility next month. On 04/29/2025, an interview was conducted with the DON who stated that the facility does not have an independent Foot Care Policy, but she provided the Health Care Agreement for Podiatry. She went on to say that Resident #65 and Resident #90 had been added to the Podiatry list for evaluation and treatment. On 4/29/2025, during the end of day meeting the Administrator, DON (Director of Nursing) and the Regional Consultant were informed of the concerns. No additional information was provided.

Based on observation, interviews, and record review, the facility failed to 1.) provide supervision for one of five residents (Resident (R) 35) identified as requiring one-to-one supervision for aggressive behaviors, 2) ensure potential hazardous items were not left unattended in the room of one (R) 2 and provide supervision for a resident (R) 114 with a known balance/gait issues, of 55 sampled residents. These failures had the potential for injury to other residents from R35's aggressive behavior and for injury related to exposure to unknown substances. Findings include: 1. Review of R35's Admission Record located in the resident's electronic medical records section titled Profile revealed the resident was admitted to the facility on [DATE] with diagnoses that include cerebral infarction with left sided hemiplegia and hemiparesis, severe vascular dementia with agitation, and memory deficit. Review of the facility's Accident and Incident Log, dated 12/24/24 and provided by the facility, revealed R35 had an incident of verbal aggression with other residents. A review of the facility's investigation, dated 12/27/24, revealed R35 threatened to smother his roommate R21at the time with a pillow. The physician, resident's responsible party, and the police department were notified. R35 was placed on one-to-one supervision. The resident was evaluated by psychiatric services and his medications were reviewed with no changes. R21 was moved to another room on the unit, and 1:1 supervision continued for R35. The resident's care plan was revised to reflect the supervision. The investigation was completed and submitted to the office in a timely manner. Review of R35's Care Plan, with a revision date of 01/05/25, revealed the resident failed to cooperate with activities of daily living (ADL) care related to dementia and had potential for verbal and physical aggression. The intervention for these behaviors included one-to-one supervision as needed. Review of R35's Quarterly Minimum Data Set (MDS), with an Assessment Reference date (ARD) of 02/05/25 and located in the resident's EMR section titled MDS revealed the resident had a Brief Interview for Mental Status score of 14 out 15 which indicated the resident's cognition was intact. The resident did not exhibit any behaviors during the assessment period. The resident required substantial with all activities of daily living. The resident was assessed to have limited range of motion of the left upper and lower extremities. The resident was coded to receive anticonvulsant medication. Review of the facility's Accident and Incident Log, dated 03/10/25 and provided by the facility, revealed R35 had an incident of verbal aggression with other residents. A review of R35's Psychiatric Consultant Progress Notes, dated 04/11/25 and located in the resident's EMR section titled Miscellaneous, revealed the resident was a poor historian due to cognitive and psychiatric impairment. It was documented the resident denied hallucinating, insomnia, or poor appetite. It was documented that the resident was refusing medications. The consultant's recommendation was for nursing to continue supportive care, and training the staff on 1:1 supervision and how to address residents with aggressive behaviors. A review of R35's Physicians Orders, dated 05/01/25 and located in the resident's EMR section titled Orders, failed to reveal an order for the resident to have one-to-one supervision. A review of the facility's investigation dated 03/11/25 for an incident that occurred 03/07/25, revealed R35 and R72 had a heated verbal exchange in which R72 threatened to shoot R35 and R35 threatened to cut off R72's head. The responsible parties for both residents were notified of the incident, and the police department and the physician were notified. It was decided since R35 was the aggressor, he was placed on one-to-one supervision. Both residents' care plans were revised. As soon as a male room opened on the unit, R72 was to be moved to another room. The facility investigation (day one and five day) was completed and submitted to the office within the allotted timeframe Observation on 04/29/25 at 1:30 PM revealed R35 in a wheelchair propelling himself in room with his left hand resting on a pillow. The resident had a staff member providing one-to-one supervision. An observation on 04/30/25 at 5:21 AM revealed R35 in bed asleep. The resident did not have staff member present providing one-to-one supervision. An interview on 04/30/25 at 9:40 AM with a Certified Nursing Assistant (CNA)15 revealed that she was also responsible for staffing the facility. CNA15 stated that R35 was placed on one-to-one supervision a couple of months ago after the resident threatened to cut off his roommate's head. CNA15 stated the supervision included making sure the resident did not have access to any objects that he could harm himself or others. An interview on 04/30/25 at 11:47 AM with Licensed Practical Nurse (LPN)7 revealed the resident initially resided in the Blue Unit until the resident went out the back exit door. The incident was discussed with the resident's responsible party, and it was decided to place the resident on the secure unit. LPN7 stated there was an incident that occurred on 12/24/24 in which R35 threatened physical harm to his roommate (R21). R35 was placed on one-to-one supervision until R21 could be moved to a different unit. LPN7 stated R35 seemed to calm down after having the room to himself and the supervision was discontinued. LPN7 added that R72 was placed in the room with R35 since there were no other male rooms available. Both R35 and R72 made verbal threats to each other (threatening to shoot one and the other threatened to cut the other's head off). Since R35 was the more aggressive threat, he was placed again on one-to-one supervision. The only time both residents are in the room together is at night when they go to bed. Neither resident had made any more threats. LPN7 stated the facility does not have a policy for one-to-one supervision or for the physician to write orders for one-to-one supervision. An interview with the Administrator on 05/01/25 at 2:00 PM revealed that whenever a resident makes that kind of threat she immediately starts an investigation, separates the residents when possible; notifies the appropriate parties; obtains witness statements; have residents examined for possible injuries; and notify the police department. The Administrator stated that with the first incident involving R21, she was able to move that resident to another unit; however, with R35 and R72, neither of them can be relocated to non-secure unit and currently there are no male bed beds available on the secure unit. The Administrator stated the resident is being followed closely by psychiatric services. At this time neither resident has not exhibited or verbalized any aggressive behaviors. 25232 2. Review of Admission Record, located under tab Profile tab in the EMR, indicated R2 was readmitted to the facility on [DATE] with diagnoses that included bipolar disorder and post-traumatic stress disorder (PTSD). During the initial observational tour on 04/29/25 at 2:02 PM, a 10 milliliter (ml) syringe containing an unknown clear liquid was observed lying on top of R2's dresser. There was no needle attached to the syringe. At 2:05 PM, confirmed with Licensed Practical Nurse (LPN) 2, that the syringe was there and confirmed that it should not have been. Interview on 05/01/25 at 7:51 PM, the Director of Nursing (DON) indicated that she expected staff to ensure syringes were not left in resident rooms. 40711 3. The facility staff failed to maintain adequate supervision/safety for a resident known to have balance and gait issues when ambulating for 1 resident during a fall on 5/31/23, sustaining a fracture of his right hip, on the memory care unit. Resident #114 was no longer a resident of the facility; therefore, a closed record review was conducted. Resident #114 was admitted to the facility on [DATE] and discharged on [DATE]. Resident #114's diagnoses included Vascular Dementia, Unspecified Severity, with Agitation. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/11/23 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired for daily decision making. In section G (Functional Status) the resident was coded as an activity occurring once or twice with the assistance of one person with transfers, Locomotion on and off unit, walking in the room. Requires total dependence of two people with toilet use and personal hygiene. The personal centered care plan dated 1/16/24 read that resident is at risk for falls r/t Confusion, Deconditioning, Gait/balance problems, Psychoactive drug use, new admission. A Goal for Resident #114 was Minimize the risk of sustaining a serious injury through the review date. The interventions for the resident were to ensure that the resident is wearing appropriate footwear and or nonskid socks when ambulating or mobilizing in wheelchair (w/c), Anticipate and meet the resident's needs, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. On 04/30/25 at approximately 4:14 pm., an interview was conducted with the Director of Rehab., (DOR) Services concerning the above. The DOR said from 5/08/23-5/31/23 Resident #114 received therapy services for ambulation and balance. It was brought to my attention that he had a few loss of balances, poor cognition. He was a resident on memory care. I came to get him for therapy and found him on the floor. The DOR also said that the resident walked independently, We tried to stand him and he couldn't bare weight. On 4/30/25 a telephone interview was conducted with the complainant at 7:05 PM., The complainant said that her father had fallen, fracturing his right hip at the facility for rehabilitation. A review of a nursing progress note dated 5/31/2023 at 1:30 PM., read that patient (pt) was found lying in his room bathroom by staff, assessment completed with noted pain to right hip, 911 was called and transported to ER for evaluation, pt was unable to explained what he was trying to do prior to fall. pts daughter Responsible Party (RP) was called, Nurse Practitioner (NP) aware. A review of an Interdisciplinary Team note on 6/01/23 at 10:05 AM., read (IDT) 5/31/23 Resident tripped over shoes and fell , Sent to ER. According to the hospital discharge summary Resident #114 was admitted on [DATE] and discharged on [DATE] for a closed fracture of neck of the right femur. The hospital note read: Resident came from the nursing home to the hospital with a fall in the facility bathroom, unwitnessed fall complaining of pain in the right hip. Patient underwent right hemiarthroplasty on 6/01/23, tolerating the procedure. Patient ready to discharge back to the nursing facility for rehab. On 05/01/25 at approximately 12:45 PM., an interview was conducted with Certified Nursing Assistant (CNA) 16. CNA #16 said that Resident #114 was very combative and stayed in his room a lot. He didn't want to be bothered with. CNA #16 also said that she doesn't remember him falling but does remember seeing Physical Therapy (PT) working with him a couple of times. On 05/01/25 at approximately 12:25 PM., an interview was conducted with CNA #19. CNA #19 said that the Physical Therapy wasn't successful working with the resident because he never liked leaving his room. On 5/01/25 at approximately 7:00 p.m., during the pre-exit the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant and [NAME] President of Operations. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on observation, Resident interview, staff interview and clinical record review, the facility staff failed to provide services in the facility with reasonable accommodation of resident needs and preferences, for 1 Residents (# 362) in a survey sample of 55 Residents. 1. For Resident # 362, the facility staff failed to ensure the bed was an appropriate size for a resident with morbid obesity (Body mass index greater than 40). The findings included: 1. For Resident # 362, the facility staff failed to ensure the bed was an appropriate size for a resident with morbid obesity (Body mass index greater than 40). Resident # 362 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Acute and Chronic Respiratory Failure, Hypertensive Heart and Chronic Kidney Disease-Stage 5 with Heart Failure, Diabetes- Insulin Dependent, Chronic Pulmonary edema, Chronic Sleep Apnea and Persistent Mood Affective Disorder . There was no Minimum Data Set (MDS) Assessment because it was too soon to complete the assessment. indicating no cognitive impairment. Review of the clinical record was conducted on 4/29/2025-5/1/2025. During rounds on 4/29/2025 at 1:45 p.m., Resident # 362 was observed sitting up in bed, eating lunch and talking with a visitor. Resident # 362 was able to converse with the surveyor. When the surveyor asked if there were any concerns, Resident # 362 stated he needed rails to help move himself up in the bed. He complained that his bed was too small. He stated he needed a larger bed. Resident # 362 stated he did not have enough room to move in the bed. He stated that he felt like he was going to fall out of the bed whenever he tried to move. He stated rails would at least give some support. He showed the surveyor that it was difficult to move in the bed. It was observed that there were less than three inches of space on either side of of the mattress when Resident # 362 was lying in bed. Resident # 362 was struggling to adjust his position in the bed. On 4/30/2025 at 12:30 p.m., Resident # 362 was observed lying in bed tilted toward his right side. There was very limited space on the mattress. On 4/30/2025 at 3:10 p.m., an interview was conducted with the Director of Nursing who stated residents had to be assessed for the use of rails before any rails could be used. She also stated that it was important for residents to be safe from entrapment. Review of the clinical record revealed Resident # 362's weight was 334 pounds and height was 70 inches. His body mass index was listed as 47.8. Staff persons were observed in the room talking with Resident # 362 during the survey, picking up food trays, and delivering ice and water. No staff person addressed the issue of the bed being to small for Resident # 362. On 04/30/2025 at 3:22 p.m., an interview was conducted with Licensed Practical Nurse # 1 who stated a resident's size should be utilized to determine the appropriate sized bed. She stated the bed size should be tailored to the size of the Resident if possible. On 5/1/2025 at 9:30 a.m., observed Resident # 362 lying in a bariatric bed. Resident # 362 stated the bed was much more comfortable and that he felt much better being able to move more freely. He stated he slept better also. On 5/1/2025 at 11 a.m., an interview was conducted with the Maintenance Director who stated he had replaced the bed with a bariatric bed. During the end of day debriefing on 5/1/2025, the Facility Administrator, the Regional [NAME] President of Operations, Regional Nurse Consultant and Director of Nursing were informed of the findings. They all stated it was important for residents to have beds that fit the residents properly. No further information was provided.

Based on interviews and record reviews, the facility failed to timely report an injury of unknown origin for one of one residents (Resident) (R71) reviewed for reporting of alleged violations out of a total sample of 55 residents. This had the potential for further abuse. Findings include: Review of the facility's policy titled, Abuse, Neglect, Exploitation, & Misappropriation initiated 11/16/22 stated, .An incident report shall be filed by the individual in charge who received the report .The Abuse Coordinator and/or Director of Nursing shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. He/she shall also secure all physical evidence. Upon completion of the investigation, a detailed report shall be reported .injuries of unknown source .is obligated to report such information immediately, but no later than 2 hours after the allegation is made . Review of R71's undated Admission Record located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of dementia. Review of R71's Care Plan located in the EMR under the Care Plan tab initiated 11/25/22 stated R71 was dependent on staff for her physical needs due to cognitive deficits. Review of R71's quarterly Minimum Data Set (MDS) Assessment located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 04/08/25 included a Brief Interview for Mental Status (BIMS) score of 99 indicating that the resident was not capable of participating in the assessment and had severe cognitive impairment. R71 was also noted to be dependent on staff for all activities of daily living (ADL). Review of R71's Progress note dated 05/30/23 at 9:47 AM located in the EMR dated under the Progress Notes tab were reviewed and confirmed that R71 was noted with a bruise to the right forehead, right eye, bridge of nose, and slight bruising under the left eye. The resident was evaluated by the nurse practitioner and sent to the Emergency Department (ED) for evaluation and treatment 05/30/23 at 9:35 AM. A computed tomography scan (CT) (medical imaging technique using x-rays to create images of the body) was performed with no abnormal findings. The responsible party (RP) was notified and the resident returned from the facility at 5:14 PM on 05/30/23. Review of the Facility Reported Incident (FRI) provided by the facility revealed the facility filed an initial report with the Virginia (VA) Department of Health (DOH) on 05/30/23 at 12:22 PM for an injury of unknown origin, over three hours after being aware of R71's bruising. The FRI included a timeline indicating that on 05/30/23 at 9:40 AM bruising was noted to R71's face, at 9:47 AM, 911 was called and at 9:58 AM the resident was transported to the ED. R71 returned to the facility on [DATE] at 5:14 PM with no abnormal findings. During an interview on 04/29/25 at 5:30 PM with the current Administrator stated that Certified Nursing Assistants (CNA9 and CNA17), Licensed Practical Nurse (LPN9), and Registered Nurse (RN1) were on duty on 05/30/23 at the time R71 was noted with an injury. The Administrator stated that she was not employed at the facility at the time of the reported incident, and that CNA17 and LPN9 no longer work at the facility. Her expectation was that an injury of unknown origin be reported immediately (within two hours) to the DOH and the completed investigation be submitted to the DOH on the fifth day. The Administrator confirmed that she had no completed investigation on file, witness statements, or investigation notes but should have.

Based on observation, staff interviews, clinical record review and facility document review the facility staff failed to provide the necessary care and services to prevent the development and promote healing of a facility acquired pressure injury for 1 of 2 residents in the survey sample, Resident #2. The facility staff failed to correctly identify a pressure injury, failed to apply treatment as ordered, and failed to identify and notify the physician of a decline in the wound to obtain appropriate and timely treatment prior to the wound physician identifying it as an unstageable pressure injury on Resident #2's left calf. The findings include: Resident #2 was originally admitted to the facility on [DATE] and re-admitted on [DATE] following a hospitalization for a fractured right hip as a result of a fall at the facility on 7/30/19; other [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) a significant change with an assessment reference date of 8/13/19 coded the resident as scoring a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident had severely impaired cognition. The resident was dependent on two staff for bed mobility and transfers. The resident had limited range of motion to the right lower extremity and was wheelchair bound. Section M. Skin Conditions coded the resident as having a stage II pressure injury (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough, may also present as an intact or open/ruptured blister. The area was a blister was to the left heel. The comprehensive person-centered plan of care dated 6/25/19 identified the resident was at risk for development of pressure injury related to bowel and bladder incontinence and dementia. The resident developed two fluid filled blisters to the right inner and outer heel that merged on 8/22/19 and opened on 8/23/19. The care plan was revised on 9/17/19 and identified the resident with an open area to the left calf. The goal was for the pressure injuries to show signs of healing and have minimal risk of infection by the next review date 11/14/19. Interventions listed included to administer treatments as ordered and monitor for effectiveness, Heels up boots when in bed. Pressure reducing mattress to bed and w/c (date initiated is 8/19/19), monitor/document/report PRN (as needed) any changes in skin status. The nurses notes dated 9/6/19 written by Licensed Practical Nurse (LPN#1) read: Called to residents room by therapist, resident has old skin tear to posterior left leg, received order from PA (physician assistant) to cleanse area with NS (normal saline), apply [MEDICATION NAME] and cover with dry dressing daily. RP (representative party) notified. There was no additional description of the skin tear in the clinical record. There was no skin tear investigation of how or what caused the skin impairment per the Corporate Nurse. The [MEDICATION NAME] was scheduled to be applied every day at 9:00 a.m. On 9/17/19 at 3:45 p.m., the therapist (licensed physical therapy assistant #1) who initially identified the left calf wound and notified the nurse on 9/6/19 was interviewed. She stated that during a therapy session in the resident's room she was assisting the occupational therapist to remove the resident's pants. After the pants were removed they observed a open area to the residents left calf. She then notified the nurse (LPN#1). The therapist stated the resident propels himself in the wheelchair with the left leg, the fractured right leg is elevated on the wheelchair leg rest and when he rests he puts the left leg over on top of the wheelchair leg rest pedal or over his right leg, demonstrating the exact area where the wound is located. The therapist described the open area as measuring approximately 4 centimeters (cm) in length and 1 cm in diameter. On 9/17/19 at 6:31 p.m., LPN #1 was interviewed. She stated the left calf open area Looked like it was an old skin tear, dried up looking like it was there a couple of days .maybe an injury from the wheelchair? She stated she did not measure it but stated it was about an inch in length. The Treatment Administration Record for (MONTH) evidenced the staff failed to cleanse the wound or apply the [MEDICATION NAME] treatment as ordered to the left calf on the following days; 9/8/19, 9/11/19, and 9/16/19. On 9/17/19 at 2:55 p.m., RN #2 was interviewed. She stated the resident liked to cross his legs (left over right). She further stated, He had a red area from crossing his legs (pointing to the left calf area where the wound was located), I called the physician and got an order for [REDACTED]. Record review revealed on 9/10/19 the wound care physician evaluated the left calf wound. The notes read, in part: . a thorough wound care assessment and evaluation was performed today. He has an unstageable (due to necrosis) of the left calf for at least 1 days duration. There is moderate serous exudate. The patient appears to have associated pain evidenced by grimacing, restless. Appetite-fair. Etiology-Pressure, wound size (Length x width x depth) 7.0 (cm-centimeters) x 3.0 (cm) depth-not measurable, 60% thick adherent black necrotic tissue (eschar), 30% thick adherent devitalized necrotic tissue, 10% granulation tissue. Reason For No Debridement: Debridement refused. Patient/surrogate made aware of risks of not removing necrosis including infection;[MEDICAL CONDITION]; limb loss or death. Dressing Treatment Plan-Santyl (an enzymatic topical [MEDICATION NAME] agent) apply once daily for 30 days on normal saline moistened gauze. Secondary dressing(s)-gauze island (w/border) apply once daily for 30 days. Plan of Care Reviewed and Addressed. Recommendations-Off-load wound; reposition per facility protocol. This patients care was discussed with another health care provider Nursing Staff Member during this visit. Review of the Medication Administration Record [REDACTED]. The order for the Santyl was entered on 9/16/19 with a start date of 9/17/19. The treatment cart was checked and a tube of Santyl for Resident #2 was found, with the dispense date of 9/16/19. The treatment in place was the [MEDICATION NAME] which the staff was not applying consistently as noted by blank entries on the TAR for 9/8/19, 9/11/19 and 9/16/19, the [MEDICATION NAME] discontinue date was 9/16/19. The facility staff failed to recognize the wound was a pressure injury and [MEDICATION NAME] (an antibiotic ointment) was not an appropriate treatment. The wound care physician was interviewed via the telephone on 9/17/19 at 4:57 p.m. The wound care physician stated the wound was not a result of a skin tear as described by the staff. She stated the Director of Nursing and the unit manager were not available for the initial consult, however she did have a staff member with her during the consult, RN#1. She stated she gave a verbal order to RN#1 for the Santyl treatment for [REDACTED]. She further stated her consult notes were transcribed after midnight and would have been available for review no later than Thursday 9/12/19, after she had given access to the staff. She further stated she would have expected no more than a two day delay for the facility to initiate the treatment if she did not give a verbal order. RN #1 was interviewed on 9/17/19 at 4:07 p.m. She stated she did accompany the physician during the consult. When asked if the wound care physician had given her verbal orders for the treatment of [REDACTED]. The Blue unit manager was interviewed on 9/17/19 at 4:10 p.m. She stated that was the first week that the wound physician had rounded in the building. She stated she did not have access to the wound consult notes on 9/11/19 but did see it on Friday 9/13/19 in the system. While working from home on 9/13/19 she placed the order for the Santyl in the system but had some computer issues at home and was not sure if the order had transferred. When she returned to work on Monday 9/16/19 she noted the order was not in the computer system. She then placed it in and called the pharmacy to ensure the Santyl order was there and that it would be delivered that day. When asked if she had followed up on Saturday 9/14/19 or Sunday 9/15/19 with the nursing staff to find out if the order was in the system, she stated she had not. Following the interview with the Blue unit manager this surveyor went with her to the resident's room to examine the pressure injury. The resident was observed sitting up in the wheelchair, the border dressing was peeled back, the pressure injury wound bed was black with redness surrounding the pressure injury. The size appeared to be what was documented by the wound physician based on her examination on 9/10/19. During the pre-exit meeting on 9/17/19 the above findings was shared with the Administrator, the Director of Nursing (DON) and the Corporate Nurse. The DON stated, I think we missed it and should have been better and questioned why we were placing [MEDICATION NAME] on a pressure injury. The Corporate Nurse stated, We self identified that wound education is needed. No additional information was provided prior to exit. The facility's Policies and Procedures Clinical Guideline Skin & Wound date 4/1/17 read, in part: Overview: To provide a system for identifying skin at risk, implementing interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of / prevention of pressure injury. Process: *Licensed Nurse to report changes in skin integrity to the physician / practitioner and resident/ responsible party an document in the medical record *Monitor residents' response to treatment and modify as indicated Pressure Ulcer - A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). National Pressure Ulcer Advisory Panel (NPUAP) Unstageable/Unclassified: Full thickness skin or tissue loss-depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED]tous or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/) Debridement-Debridement is the removal of devitalized/necrotic tissue and foreign matter from a wound to improve or facilitate the healing process.

Based on a complaint investigation, clinical record review, staff and family interview and facility documentation, the facility staff failed to ensure the necessary care and services were provided to prevent pressure ulcer development for 2 of 27 residents in the survey sample, Resident #24, which constitutes harm. 1. The facility staff failed to identify Resident #24 had developed a left lateral leg (stump area) pressure ulcer until it had advanced to unstageable and presented with 80% eschar (dead and black) tissue. 2. The facility staff failed to provide appropriate care and services to prevent pressure ulcer development and promote healing of pressure ulcers for Resident #2, to include failure to conduct weekly skin checks, failure to consistently conduct weekly pressure ulcer assessments, and failure to identify a change in skin integrity. The findings included: 1. Resident #24 was originally admitted to the facility 5/8/17 and was discharged to a local acute care hospital on [DATE] for altered mental status, acute kidney injury, acute kidney failure, dehydration and high potassium levels in the blood. The [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/12/17 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #24's cognitive abilities for daily decision making was intact. In sectionG(Physical functioning) the resident was coded as requiring supervision after set-up with eating, limited assistance of 1 with locomotion on the unit, extensive assistance of 1 person with bed mobility, transfers, walking, locomotion off unit, personal hygiene, dressing, and toileting, and total care of 1 person with full body baths. On 6/19/17 an unstageable pressure ulcer to the left lateral leg (stump area) was initially identified by the Power of Attorney (POA) of Resident #24 who informed the facility staff to assess the site. The left lateral leg (stump area) pressure ulcer was without drainage, measured 1.3 centimeters by 1.1 centimeters. The pressure ulcer bed presented with 80% eschar (dead and black) tissue that required treatment with a chemical [MEDICATION NAME] agent. Review of the clinical record revealed skin assessments as follows; 5/29/17 skin intact, 6/5/17 skin intact, 6/12/17 skin tact, 6/19/17 a rash to the groin, right buttock, left knee and right leg with treatment in progress to all sites. No skin assessments were offered for 5/12/19 and 5/19/17 but the admission MDS assessment with an ARD of 5/12/17 coded the resident as at risk for pressure ulcer developments but without one or more unhealed pressure ulcer. The current care plan dated 5/25/17 had a problem which read; (name of resident) has the potential for impaired skin integrity related to immobility and occasional urinary incontinence. The goal read; (name of resident) will be free from impaired skin integrity through next review 8/7/17. The interventions were; Assist resident with turning and repositioning frequently. Avoid scratching and keep hands and body parts from excessive moisture. Maintain trim short nails. Braden scale on admission and time 4 weeks. Encourage adequate nutrition and hydration in order to promote healthier skin. Encourage appropriate fluid intake. Float heels. Incontinence care post episodes. Keep skin clean and dry. Monitor for and report any new skin impairment noted during care. Nutritional evaluation quarterly and as needed. Nutritional evaluation quarterly and as needed. Weekly skin checks. The above care plan had not been updated to reflect Resident #24's newly identified pressure ulcers. Review of the local hospital history and physical exam notes dated 6/21/17 read; the resident was admitted from (name of facility). Since that time he was not eating well and now has multiple decubitus ulcers along with altered mental status. He was brought to the emergency department and found to have acute [MEDICAL CONDITION] and [MEDICAL CONDITION] and now referred for admission and treatment. On 10/26/17 at approximately 11:15 a.m., an interview was conducted with the Registered Nurse, Assistant Director of Clinical Services (RNADCS). The RNADCS was asked about the unstageable pressure ulcer to the left lateral leg. She stated all of the pressure ulcers were identified on 6/19/17, after she was asked by a staff member to assess the wounds to 3 body sites identified by Resident #24's POA. The RNADCS identified the sites as a blood blister to his partially amputated right great toe, a stage II pressure ulcer of the left buttock and an unstageable pressure ulcer of the left lateral leg. The RNADCS stated there were no prior reports of Resident #24 having any type of skin impairment prior to 6/19/17. The Braden Scale for Predicting Pressure Ulcer Risk assessment dated [DATE] evidenced the resident scored 17. This indicated the resident was at low risk for pressure ulcer development. Another Braden Scale for Predicting Pressure Ulcer Risk assessment dated [DATE] evidenced a score of 19 indicating no risk. The Director of Clinical Services (DCS) was asked if a root cause was identified relating to the unstageable left lateral leg pressure ulcer development and she answered no official documentation was used but the team felt use of the prosthesis was identified as the causative factor. The DCS stated Resident #24 donned and doffed the prosthesis to the left leg and didn't allow the staff to manipulate it yet she confirmed the resident required staff assistance with incontinence care, bathing and dressing and the first line of detecting skin impairment would have been from direct care observations during care and weekly skin checks and assessments. The DCS also stated the resident complied with weekly skin assessments. An interview was conducted with the Director of Rehabilitation Services on 10/26/17 at approximately 1:30 p.m. The Director of Rehabilitation stated the resident had utilized the prosthesis since 1999 or 2000 therefore they didn't work with him on use of the prosthesis. The Director of Rehabilitation Services further stated often Resident #24 did not don the prosthesis because he didn't want to participate in rehabilitative services and as a result of him frequently missing rehab services he was discharged from Part B rehabilitation therapy. A telephone interview was conducted with Resident #24's POA on 10/26/17 at approximately 1:50 p.m. The POA stated Resident #24 passed away 7/5/17 because he was unable to recover from the condition he was in when admitted to a local hospital on [DATE]. She stated Resident #24 had been a resident of the nursing facility for almost 6 weeks when she discovered something on his left stump and right big toe. She further stated the resident had a urine infection, was dehydrated from not receiving sufficient food and fluid intake and his rear end was in a terrible condition. The POA stated she didn't think the resident would have received any care if she had not insisted the facility staff send him to the emergency room . The above information was shared with the Administrator, Director of Nursing and Corporate Consultant on 10/26/17 at 3:45 p.m. The Director of Nursing stated the facility staff had identified the above information also and a Quality Assurance Performance Improvement (QAPI) plan was developed and on 6/27/17 and the allegation of compliance date was 6/28/17. The facility policy titled Clinical Guideline - Skin and Wound dated 4/1/17 read; To provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. On admission/readmission the resident's skin will be evaluated for baseline condition and documented in the medical record. Braden Risk evaluation to be completed on admission/re-admission, weekly for 4 weeks from admission, quarterly and with a significant change in condition. Licensed Nurse to complete skin evaluation weekly and prior to transfer/discharge and document in the medical record. CNA to complete skin observations and report changes to Licensed Nurse. Licensed Nurse to document presence of skin impairment/new skin impairment when observed and weekly until resolved. The QAPI plan read as follows; 1. Facility failed to notify physician and POA of in-house acquired pressure ulcers for Resident #24. 2. Current residents in the facility to have skin assessments performed by a licensed nurse to identify current skin conditions completed 7/3/17. Physician and Responsible Party to be notified of any new areas of concern. 3. DCS or designee to have the following areas reviewed; Current residents re-evaluated using the Braden Scale for risk for skin breakdown. New Braden scales to be completed by licensed nurse 7/27/17. Review and Update care plans for interventions by the MDS staff for residents with a Braden score below 10 by 7/28/17. Kardex updated as indicated. Treatment regime for residents with existing skin conditions to be reviewed by the interdisciplinary team (IDT) on 7/28/17 for necessary changes. Weekly At Risk meeting to be conducted 7/28/17 to review residents with wounds and or skin integrity issues. Skin Grids to be completed 6/28/18 on current residents with Wound and Skin Integrity issues. Residents with new Skin and Wound Issues to be placed on 24 Hour Report and reviewed in Daily Clinical Meeting. Nursing staff re-educated on the use of the Stop and Watch to report changes in skin integrity. Education for Certified Nursing Assistants (CNA) related to prevention and reporting to be completed 6/28/17. Licensed Nurses to be educated related to identification of wounds, prevention, reporting and monitoring residents at risk for skin breakdown by 6/28/17. 4. DCS and or ADCS to Quality monitoring completion of weekly skin checks, and skin grids in Daily Morning meeting. Unit Managers to Quality monitor completion of Stop and Watch forms, Shower/bathing sheets, and use of barrier cream/incontinence care to be completed 5 times per week by DCS or designee. DCS and or ADCS to Quality monitor completion of Braden Scales schedule to be completed weekly by MDS staff on new admissions times 4 weeks. Quality monitoring for turning/positioning and use of off-loading devices to be conducted7 times per week by charge nurses, supervisor, mock survey and Corporate Support. Care plans of residents with new or worsening skin conditions to be reviewed at the weekly wound meeting to ensure appropriate interventions are in place. Findings of quality monitoring to be reviewed for recommendation by the QARI committee, Quality monitoring schedule to be modified based on findings. 5. Compliance date 6/28/17. The facility presented a plan of correction however another resident was identified with a pressure ulcer after their compliance date. COMPLAINT DEFICIENCY Pressure Ulcer - A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). National Pressure Ulcer Advisory Panel (NPUAP) Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/) Debridement - Debridement is the removal of devitalized/necrotic tissue and foreign matter from a wound to improve or facilitate the healing process. 2. The facility staff failed to provide appropriate care and services to prevent pressure ulcer development and promote healing of pressure ulcers for Resident #2, to include failure to conduct weekly skin checks, failure to consistently conduct weekly pressure ulcer assessments, and failure to identify a change in skin integrity. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current MDS (Minimum Data Set) a significant change with an assessment reference date of 8/26/17 coded the resident as scoring a 3 out of a 15 on the Brief Interview for Mental Status (BIMS), indicating the resident had severely impaired daily decision making skills. The resident required extensive assistance for all Activities of Daily Living (ADL's) to include one staff for bed mobility and transfers. The resident was assessed as being incontinent of bladder and bowel. The resident was coded as having one stage III pressure ulcer (1). The Comprehensive Person Centered Care Plan dated 10/20/15 identified the resident had the potential for impaired skin integrity related to incontinence and decreased mobility. Goal was the resident would continue to have interventions in place to prevent impaired skin integrity. Interventions included-Braden scale quarterly, notify nurse of any new areas of skin breakdown: redness, blisters, bruises, discoloration during bath or daily care, weekly skin checks. The most current Braden Scale (a risk assessment tool used as an indicator for pressure ulcer development) found in the clinical record was dated 6/27/17. The staff scored the resident as a 15, indicating the resident was at low risk for pressure ulcer development. There was no quarterly Braden Scale found prior to this date or after this date. According to the Weekly Pressure Ulcer Records a pressure ulcer to the sacrum was initially identified on 8/17/17 as a stage III. The pressure ulcer measured 1.8 cm x 2.3 cm x 0.2 cm (centimeters). The facility staff failed to assess this pressure ulcer the week of 8/24/17. The next assessment was on 8/31/17. The pressure ulcer measured 0.5 cm x 0.3 cm x 0.1 cm. The sacral stage III pressure ulcer was healed on 9/6/17 per the ADON, the treatment was discontinued on 9/12/17 per the TAR (Treatment Administration Record). Review of the weekly skin sheets scheduled to be done every Tuesday by the night shift licensed nurse evidenced that on 8/15/17 the resident's skin was intact, this was later found to be inaccurate, according to the ADON the resident was identified with a stage III pressure ulcer on 8/15/17. The 8/22/17 weekly skin sheet was also inaccurate, it indicated the resident's skin was intact, instead of identifying the stage III sacral pressure ulcer. Per the interview with the ADON on 10/25/17 at 4:05 p.m., she and the then unit manager were responsible for measuring pressure ulcer wounds on the Green unit every Tuesday. The ADON was asked what was the root cause of the stage III sacral pressure ulcer, she stated It was first identified on 8/15/17, it was caused from the fold in her upper buttock, the brief would roll up under it causing pressure .the resident sat up in a chair most of the time. When asked why the pressure ulcer was not measured on Tuesday 8/24/17, she stated Sometimes the unit manager got pulled to work the floor .I don't have any measurements for any wounds for the week of 8/24 . When asked why the wound was initially identified at an advanced stage and not sooner, she stated, It should have been found before it was a stage II .she had three sets of eyes on her skin every day at a minimum. The facility staff failed to perform weekly skin assessments for Resident #2 from 8/23/17 through current 10/25/17. During this time frame on 9/28/17 the Pressure Ulcer Record identified the resident had again developed an advanced stage III pressure ulcer and multiple stage II pressure ulcers as described below: 1. A stage II to the sacrum-measuring 1.5 cm x 2.0 cm x 0.2 cm. The wound bed had red granulation tissue and small amount of sero-sanguineous drainage. The peri-wound was intact. 2. A stage II to the left thigh measuring 1.2 cm x 6.3 cm x 0.2 cm. The wound bed had granulation tissue, the wound edges were firm and without redness, with moderate amount of sero-sanguineous drainage. The peri-wound was intact. 3. A stage III to the right thigh measuring 13.0 cm x 1.3 cm x 0.2 cm. The wound bed had red granulation tissue, the wound edges were firm and without redness, with moderate amount of sero-sanguineous drainage. The peri-wound was intact. The Comprehensive Person Centered Care Plan was revised on 9/29/17. The care plan included the impaired skin integrity related to cognitive deficit and impaired mobility as evidenced by pressure areas to the left and right thigh and sacrum. The goal was the resident would not develop additional skin integrity problems or wounds through next review. Interventions included- Administer treatments as ordered and monitor for effectiveness, Braden scale quarterly, identify/document potential causative factors and eliminate/resolve where possible and monitor changes in skin status. The facility staff failed to conduct a weekly pressure ulcer assessment on all three pressure ulcers the week of 10/8/17 through 10/14/17. The Pressure Ulcer Record dated 10/16/17 documented the pressure ulcers as: 1. Sacrum- 7.5 cm x 7.0 x 0.2 cm. The wound bed had red granulation tissue and small amount of sero-sanguineous drainage. The peri-wound was intact. 2. Left thigh-1.0 cm x 0.3 cm x 0.1 cm. The wound bed had granulation tissue, the wound edges were firm and without redness. The peri-wound was intact. 3. Right thigh- 3.5 cm x 0.8 cm x 0.1 cm. The wound bed had red granulation tissue, the wound edges were firm and without redness. The peri-wound was intact. On 10/24/17 at 11:45 a.m., a dressing change observation of the three pressure ulcer sites was observed. The dressing change was conducted by Licensed Practical Nurse #3 and the ADON. The sacral pressure ulcer had two separate small open areas, the peri-wound was pink. The right and left thigh pressure areas involved both the anterior and posterior (front and back) of the upper thighs. The front pressure sore areas of both upper thighs were pink and wrapped around to the backside. The right back thigh pressure ulcer wound bed was pink, there was no dressing on this site as ordered. LPN #3 stated she was not informed by the CNA (certified nurse aide) that the dressing had come off. On 10/25/17 at 4:05 p.m., the ADON was interviewed in her office. Resident #2's pressure ulcer development was reviewed. The ADON stated the nurses note on 9/26/17 identified open areas to both thighs. A Foley catheter was inserted on 9/27/17 to aide in healing (a tube placed into the bladder to drain urine into a bag). The ADON stated the second sacral pressure ulcer was not in the same area as the previous healed sacral ulcer that healed on 9/6/17. She was asked what the root cause of the second sacral pressure ulcer was, she stated, I probably can't tell you. When asked what was the root cause of the pressure ulcers to both thighs, she stated, The resident's briefs would bunch up .the resident was resistant to opening her legs so the CNAs were not able to properly place the briefs on her .it took three of us to open up her legs to assess (the thigh pressure ulcers). The ADON stated she staged the right thigh pressure ulcer as a stage III due to visualization of subcutaneous fat. The ADON stated a no brief order was obtained and currently active (this order was not found on the Active Order Summary Report dated 10/24/17 or found on the care plan). The Treatment Administration Record indicated the resident was being treated for [REDACTED]. When asked if this was the same area as the pressure ulcers of the thighs she stated, No, different areas. She stated I was horrified the first time I saw them (thigh pressure ulcers). The staff failed to identify a change in skin condition resulting in the resident acquiring an advanced stage III pressure ulcer to the right thigh and two stage II pressure ulcers, one to the left thigh and one to the sacrum. The TAR for October 2017 evidenced physician treatment orders as follows: 1. 9/27/16-Clean left and right inner thigh with normal saline, apply hydrogel and cologen and cover with dry dressing every day shift. 2. 9/28/17-Clean sacrum with normal saline, apply hydrogel, and collagen, cover with dry dressing daily every shift. The October 2017 TAR's entries for the above treatments evidenced no nursing initials to indicated the treatments were provided on the following days: 10/13, 10/14, 10/15, 10/17, 10/18, and 10/19. The above findings of the blank entries was shared with the ADON on 10/25/17. She stated the electronic record system goes down at times. The ADON stated there is a back up if this happens, the TAR's can be printed and used during this time. The ADON was asked to provide evidence of printed TAR's for this time frame. Prior to exit no additional information was provided to support that the treatments were provided on 10/13, 10/14, 10/15, 10/17, 10/18, and 10/19. The above findings was shared with the Administrator, the Director of Clinical Services and the Regional Director of Clinical Services during the pre-exit meeting conducted on 10/26/17. The facility's Clinical Guideline-Skin & Wound dated 4/1/17 read, in part: Overview-To provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. Process: 1. Braden Risk Evaluation to be completed on admission/re-admission, weekly for 4 weeks from admission, quarterly and with a significant change in condition. 2. Licensed Nurse to complete skin evaluation weekly and prior to transfer/discharge and document in the medical record. 3. CNA to complete skin observations and report changes to Licensed Nurse. 4. Licensed Nurse to document presence of skin impairment/ new skin impairment when observed and weekly until resolved. 5. Develop individualized goals and interventions and document on the care plan and the CNA kardex. 6. Monitor resident's response to treatment and modify treatment as indicated. Definitions: 1. Stage III pressure ulcer- Full thickness skin loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. (MDS-Section M.) 2. Stage II pressure ulcer- Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact fluid filled blister.(MDS-Section M.) 3. Pendulous abdomen-Swinging freely like a pendulum; hanging. (Referenced from Taber's Cyclopedic Medical Dictionary) 3. The facility staff failed to ensure interventions were implemented according to the resident's identified needs and Person Centered Care Plan to promote healing of a right heel suspected deep tissue injury for Resident # 12. Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 8/4/17 coded the resident as scoring a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident had severely impaired cognition. The resident was dependent on 1 staff for bed mobility and 2 staff for transfers. The resident was coded as having a suspected deep tissue injury-SDTI (1). The Comprehensive Person Centered Care Plan with a review date of 10/3/17 identified the resident had impaired skin integrity to the right heel related to mobility as evidenced by a pressure ulcer to the right heel. The goal was that the resident would not develop additional skin integrity or wounds and the pressure ulcer to the right heel would resolve without complications. Interventions to achieve and maintain the goals was to float the heels as indicated. The resident was readmitted to the facility on [DATE] after a hospitalization for a fractured right femur following a fall. Four days after returning from the hospital the resident was identified with a suspected deep tissue injury to the right heel. The Pressure Ulcer Record dated 6/28/17 documented the right heel pressure ulcer measured 3.0 cm x 4.5 cm (centimeters) and presented as a suspected deep tissue injury. The physician orders [REDACTED]. The physician orders [REDACTED]. The current Pressure Ulcer Record dated 10/16/17 assessed the right heel pressure ulcer as measuring 1.2 cm x 2.0 cm presented as a deep tissue injury. On 10/24/17 at 7:20 a.m., 9:15 a.m., 10:30 a.m., and 11:30 a.m. the resident was observed in bed laying on her back. The resident's heels were directly on the mattress surface and not floated. The heels up cushion was observed on the floor next to the bed. On 10/25/17 at 10:45 a.m., the resident was observed in bed awake on her back. The resident's heels were directly on the mattress surface and not floated. The heels up cushion was observed on the floor next to the bed. On 10/25/17 at 5:20 p.m., the above observations was shared with the Assistant Director of Nursing (ADON). When asked what caused the right heel pressure ulcer she stated when the resident returned from the hospital for the fractured right leg an abductor pillow was used and as a result the resident developed the SDTI. When asked if the resident required her heels to be floated, she stated Yes. The ADON was asked to define what float the heels as indicated meant per the care plan, she stated, Per the doctor's orders, when in bed. On 10/26/17 at 10:40 a.m., the ADON was asked to escort the inspector into Resident #12's room to inspect the right heel ulcer. The resident was observed sitting up in a wheelchair. The resident's right tennis shoe and sock was removed. The pressure ulcer to the right lateral heel was observed to be the size of a quarter, the wound bed was black and hard. The above findings was shared with the Administrator, the Director of Clinical Services and the Regional Director of Clinical Services during the pre-exit meeting conducted on 10/26/17. Definitions: 1. Suspected Deep Tissue Injury- a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. (MDS-Section M.) COMPLAINT DEFICIENCY

Based on observations, clinical record review, staff interviews and facility documentation, the facility staff failed to ensure the necessary treatment, care and services were provided to promote healing and prevent pressure ulcer deterioration for 1 of 27 residents (Residents #8) in the survey sample. The facility staff failed to assess and revise treatment, implement, evaluate and provide appropriate care for the 9/15/15 facility acquired pressure ulcer which resulted in deterioration of the pressure ulcer and harm to Resident #8. The facility staff were not clear of the anatomical location of the pressure ulcer, did not have wound care educated staff assessing the pressure ulcer and failed to notify the physician and/or designee of the pressure ulcer. The facility staff allowed the pressure ulcer to deteriorate and did not seek additional assistance or notify the physician and/or designee until the surveyor intervened. A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. (www.NPUAP.org) The findings included: Resident #8 was originally admitted to the facility 3/13/14 and readmitted [DATE] after an acute illness. The current [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/23/15 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicates Resident #8's cognitive abilities for daily decision making are moderately impaired. In section G (Physical functioning) the resident was coded as requiring extensive assistance of 1 person with eating, total care of 1 person with personal hygiene and dressing and total care of 2 person with transfers and bathing. In section M (Skin Conditions) Resident #8 was coded as at risk for developing pressure ulcers, having a stage 2 pressure ulcer acquired on 9/15/15 and the worse tissue type was coded as [MEDICATION NAME]. The most recent care plan initiated on 10/20/15 read; CAA (Care Area Assessments) 16 The resident has impaired skin integrity r/t (related to) a history of pressure ulcers, incontinence, decreased mobility, wound, requires total assistance with transfers, mobility, pressure ulcer, diabetes and [MEDICAL CONDITION]. The goals are the resident's wound will show signs of healing and remain free from infection through the next review. The resident will not develop additional skin integrity problems or wounds through the next review. Some of the interventions were; administer medications as ordered. Administer supplements as ordered. Administer treatments as ordered and monitor for effectiveness. Apply barrier cream after incontinence care. Assist with turning and positioning frequently. Apply stock moisturizer to resident's skin. Encourage adequate nutrition and hydration. Float heels in bed as tolerated. Keep skin clean and dry. Handle and position to reduce friction. Category/Stage II: Partial thicknessPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation.*Bruising indicates deep tissue injury. Category/Stage III: Full thickness skin lossFull thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. (www.NPUAP.org) The most recent Braden Scale for predicting pressure sore risk dated 8/20/15 scored Resident #8 with a total score of 10 (10-12 = high risk). The Braden Scale assessed the resident as slightly limited in sensory perception, constantly moist, chairfast in the activity category and does not make even slight changes in extremity positioning without assistance, completely immobile in the mobility section probably inadequate nutritional intake, and requires moderate to maximum assistance in moving which may result in friction/shearing. The medical record revealed Resident #8 acquired a stage 2 pressure ulcer to the left buttock which was first identified on 9/15/15. The measurements on 9/15/15 were length 1.4 centimeters by width 1.5 centimeters by depth 0 centimeters. [MEDICATION NAME] tissue was noted in the wound bed. The initial treatment was for Santyl (enzymatic debridng agent) to the wound bed, skin prep to the periwound followed by Duoderm dressing, change the Duoderm dressing every 3 days. The following day 9/16/15 there was a clarification order written for the left buttock pressure ulcer. The new order was for Hydrogel to the wound bed, apply Duoderm to cover and change every 3 days. The medical record also revealed on 9/22/15 the same stage 2 pressure ulcer was now of the right buttock instead of the left buttock. It measured length 4.2 centimeters by width 2.4 centimeters by depth 0.1 centimeters. [MEDICATION NAME] tissue was noted in the wound bed and it remained staged as a stage 2 pressure ulcer. Zinc sulfate 220 mg every day was ordered. The medical record revealed the interdisciplinary team met to discuss the wound to the sacral area. The pressure ulcer record does not contain documentation of a sacral ulcer. The interdisciplinary team note states the sacral pressure ulcer was without drainage or odor. The wound bed was pink and the edges were intact. It stated the resident was turned and repositioned every 2 hours while in bed, a low air mattress was in place, cushion was in the wheelchair. Resident is consuming 75 - 100% of meals. Additional hydration provided at 10 a.m. and 2 p.m. Incontinence care provided every 2 hours at a minimum. Supplements and nutritional support in place per physician order. On 9/29/15 the right buttock was assessed and the measurements were length 3.4 centimeters by width 1.3 centimeters by depth 0.1 centimeters, showing an improvement. [MEDICATION NAME] tissue was noted in the wound bed. The Interdisciplinary team met to discuss Resident #8 sacral area (the wound care record states the resident has a right buttock pressure ulcer only ) in the weekly meeting. No changes were made to the treatment plan. On 10/6/15 the medical record revealed Resident #8 right buttock pressure ulcer measurements were length 3.8 centimeters by width 1.0 centimeters by depth 0.1 centimeters. [MEDICATION NAME] tissue was noted in the wound bed but the wound edges are red and the periwound is now mushy/boggy and it remained staged as a stage 2 pressure ulcer. On 10/7/15 the medical record revealed the interdisciplinary team met to again discuss the wound to the sacral area. The treatment was changed to Hydrogel to wound bed, cover with border gauze every day. The change is the border gauze and daily wound care instead of duoderm and change every 3 days. On 10/14/15 the right buttock was assessed and the measurements were length 4.8 centimeters by width 1.8 centimeters by depth 0.1 centimeters. [MEDICATION NAME] tissue was noted in the wound bed and it remained staged as a stage 2 pressure ulcer. There was no interdisciplinary team note which discussed the wound's status. No new interventions were implement and the treament was not revised. On 10/22/15 at approximately 5:15 p.m. an interview was conducted with Unit Manager (UM) #7. UM #7 stated a nurse from a sister facility came in and assessed Resident #8's pressure ulcer on approximately 10/20/15. The nurse from the sister facility did not document the assessment of the pressure ulcer and did not recommend any changes in the treatment of [REDACTED]. On 10/21/15 at approximately 1:05 p.m. Resident #8 was observed in bed lying on the right side. A wedge cushion was behind the back and the eyes were closed. The surveyor asked the resident if the wound care observation could be viewed on 10/22/15. Resident #8 stated yes and offered no further conversation. On 10/22/15 at approximately 11:00 a.m. Resident #8 was again observed in bed lying on the right side with a wedge behind the back. The surveyor reminded the resident I was there to observe the wound care. Resident #8 nodded indicating yes. Unit Manager # 7 and Licensed Practical Nurse #50 explained to Resident #8 they were present to provide the wound care. Resident #8 was reclined on a low air loss bed. The bed linens were pulled down to expose her bottom. There were navy blue socks on bilateral feet and a heelz-up positioning device was in place but it was not providing pressure relief. Resident #8's feet were resting on the device. Unit Manager #7 stated the staff would be educated on how to place the heelz-up device and the purpose of the device. The 2 nurses positioned Resident #8 to observe the pressure ulcer but noted there was a large amount of pasty brown stool between the buttocks. They proceeded to provide incontinence care prior to providing the pressure ulcer care. After incontinence care was provided the dressing was removed to expose the pressure ulcer. The pressure ulcer was between the buttocks. The pressure ulcer was cleaned with normal saline solution. Inside the pressure ulcer bed to the left was a small hole, inside the wound bed to the right was an area with yellow tissue and inside the yellow tissue was a small area with dark brown tissue. The wound edges from 1 o'clock to 5 o'clock consisted of white tissue. The surveyor asked Unit Manager #7 after the wound care was completed; what was the current anatomical position of the pressure ulcer and what was the current stage of the pressure ulcer? Unit Manager #7 stated she was unable to stage pressure ulcers but she would have someone qualified to stage to assess and stage the pressure ulcer. The Assistant Director of Clinical Services (ADCS) came is and assessed the pressure ulcer as a stage 3 with the following measurements length 5.0 centimeters by width 2.1 centimeters by depth 0.4 centimeters with undermining 0.4 centimeters. The pressure ulcer contained [MEDICATION NAME] and slough tissue, yellow serous drainage and the periwound was with maceration and hardness. The site of the wound was not defined by the Assistant Director of Clinical Services. An interview was conducted with the ADCS on 10/23/15 at approximately 4:35 p.m. the ADCS stated she had been working in the facility approximately 4 weeks and when she began working at the facility she was told only Registered Nurses could assess and stage pressure ulcers but there was no policy with this stipulation. The ADCS stated she had not assessed Resident #8 pressure ulcer until today because the Director of Clinical Services was overseeing the pressure ulcer. The ADCS further stated another nurse from a sister facility last came in within the last 5 days and assessed Resident #8 pressure ulcer but the documentation of this assessment was not available. Resident #8 was also observed on 10/23/15 at approximately 6:10 p.m. in bed lying on the right side with a wedge behind the back. The lower extremities were in the same position as previously observed, the heels and feet were not floating. The surveyor asked Resident #8 if he/she was comfortable and free of pain. The resident responded yes and closed the eyes. Review of the medical record revealed the physician and/or designee had no progress notes referencing the pressure ulcer to the buttock or sacrum. The most recent progress note was dated 8/28/15 and the pressure ulcer acquire date was 9/15/15. On 10/24/15 at approximately 1:45 p.m., an interview was conducted with the physician assistant who usually coordinates Resident #8's care. The physician assistant stated she could not say she had been informed or assessed Resident #8 for a pressure ulcer which was acquired on 9/15/15. The physician assistant further stated when she assesses a resident a progress note is written. The surveyor asked the physician assistant how would she be notified by the facility staff of a need to see a resident? The physician assistant stated there is a book called 'physician notification' which she reviews when she is in the facility and she follows up on listed concerns. The surveyor viewed the physician notification book from 9/5/15 through 10/24/15 and there was only 1 entry for the physician and/or designee to assess Resident #8; the entry was on 10/22/15 and read: Resident #8 has open area on sacral that's worsening. The physician assistant stated her order after observation and assessment of the pressure ulcer was to begin the current recommended treatment. The recommended treatment was: Cleanse the right side of the coccyx with normal saline, pat dry, skin prep to the periwound, apply Santyl to the wound bed, cover with tented saline moistened gauze, cover with border gauze every day. An interview was conducted with the acting Director of Clinical Services (DCS) on 10/24/15 at approximately 5:00 p.m. The acting DCS stated she was asked to further assess Resident #8's pressure ulcer on 10/23/15 and she determined the anatomical site is right of the coccyx. She further stated she assessed the wound to make recommendations for the most appropriate treatment based on the facility's wound care protocol. The assessment revealed Resident #8's pressure ulcer also had right side induration (hardening area), 60% maceration (white tissue indicating too much moisture exposure) to the wound edges and the same wound measurements as previously recorded on 10/22/15. The acting DCS's recommendations were: Cleanse the right side of the coccyx with normal saline, pat dry, skin prep to the periwound, apply Santyl to the wound bed, cover with tented saline moistened gauze, cover with border gauze every day. The corporate Nurse stated on 10/24/15 at appoximately 7:10 p.m. the procedure is for any licensed nurse to assess and stage identified open area, using the Pressure Ulcer - Appropriate Treatment - At - A - Glance interventions as recommendations. Notify the physician for orders and put the Resident's name in the physician notification book for the Resident to be seen within 24 hours on regular business days or the next business day if it is a weekend or holiday. The corporate representative was asked if anyone in the facility has been educated to assess, stage and recognize tissues types and changes in wounds. The corporate representative stated no because the nurse educator is the ADCS and this individual was recently hired and has not began to educate the staff yet. An interview was conducted with the Corporate Registered Dietitian on 10/24/15 at approximately 7:10 p.m. The Corporate Registered Dietitian stated the Registered Dietitian would be notified by the Dietary Manager of the need to see a resident for an acute concern. The Dietary Manager may gain the information in various ways such as during the morning meeting, from the Unit Manager/other nurse. The Corporate Registered Dietitian stated once the Registered Dietitian learns of the new concern a based upon the information received recommendations would be made. A nutritional assessment and interventions will instituted after the Registered Dietitian makes the regular visit to the facility. The medical record revealed in Resident #8's case the Registered Dietitian assessment was completed on 9/25/15 secondary to an unidentified significant change. The Prostat AWC was already prescribed in 7/2015, as well as Thera-M, Vitamin C and the Medpass supplement. The Zinc Sulfate was added 9/16/15 and the Prostat AWC 30 milliliter was increased from 2 times per day to 3 times per day on 9/29/15. The Registered Dietitian note dated 9/25/15 stated Mighty shakes 2 times per day were in place but they were not noted on the physician order [REDACTED]. The Corporate Nurse on 10/24/15 at approximately 7:10 p.m.stated there is no facility's policy and procedure for pressure ulcers but various other policies were submitted. They included the Skin Evaluation - Weekly with a revision date of 1/30/15. It stated the licensed nurse will complete a total body evaluation on each resident weekly, paying particular attention to any skin tears, bruises, stasis ulcers, rashes, pressure ulcers, [MEDICAL CONDITION], abrasions, redden areas and skin problems. At Procedure 3 it reads: If a resident is assessed as having a skin problem, the evaluating nurse will initiate the appropriate form. For pressure areas complete the pressure ulcer record. For all other skin conditions, complete the non-pressure skin condition record. The surveyor informed the Executive Director, acting Director of Clinical Service, the Corporate Registered Dietitian and Corporate Nurse of the above finding on 10/24/15 at 7:10 p.m. No further information was provided prior to the survey team's exit on 10/24/15.

Based on a complaint investigation, observations, clinical record review, staff interviews and facility documentation, the facility staff failed to ensure each resident received supervision and assistance to prevent accidents for 3 out of 27 residents (Resident #21, #20 and #13) in the survey sample. 1. The facility staff failed to transfer Resident #21 per her assessed assistance needs which resulted in a fall with multiple fractures and constituted harm for this resident. 2. The facility staff failed to investigate a fall with injuries and a Resident to Resident altercation with an injury on 5/19/15 for Resident #20. 3. The facility staff failed to address Resident #13's falls and provide ongoing fall prevention interventions. The findings include: 1. Resident #21 was originally admitted to the nursing facility on 10/22/10 and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to the hospital on [DATE] with a [DIAGNOSES REDACTED]. The resident did not return to the nursing facility, thus a closed record review was completed. The Minimum Data Set (MDS) assessment dated [DATE] was a quarterly and coded the resident with a total score of 00 on the Brief Interview for Mental Status (BIMS) out of a possible score of 15, which indicated the resident was severely impaired in the skills needed for daily decision making. The resident was coded without speech, was unable to make herself understood, but had the ability to understand others. The resident was assessed with [REDACTED].#21 was not coded for any behavioral or mood problems on this assessment. The resident was assessed totally dependent with the support assistance of two staff for all transfers. She was totally dependent on one staff for all other Activities of Daily Living (ADL) needs. She was coded unsteady without staff assistance for surface-to surface transfers. She was unable to move from a seated to standing position, unable to walk, unable to turn around and face the opposite direction and was unable to move on and off the toilet. She used the wheelchair only as her primary mobility device. The resident was coded always incontinent of bowel and bladder. The assessment recorded the resident had 2 or more falls with no major injury. She was coded unimpaired in upper and lower extremity. The Significant Change in Status MDS assessment dated [DATE] coded Resident #21 with a physical restraint marked as other used in bed and in chair. The Care Assessment Areas (CAA) dated 8/10/14 indicated the considered restraint was bed bolsters while in bed. There was no notation as to what the restraint was while out of bed and the presented care plan did not specifically address restraints. The CAA indicated the resident had impaired balance during transitions and difficulty maintaining a sitting balance. The care plan presented to this surveyor as the care plan they stated they were using prior to the resident's discharge was dated, last revised, on 3/6/14. The facility stated the resident was discharged on [DATE] and there was no 2015 care plan. The facility did no transition to electronic records until July 2015 after the resident's discharge, therefore the 2014 care plan was the one used to identify resident problems. The 3/6/14 care plan identified Resident #21 at risk for falls due to unsteady gait and cognitive status and history of falls. The goal set for the resident by the staff was that the resident would have no falls. The interventions and approaches the staff would implement to accomplish this goal included the following: -Complete falls risk on admission and quarterly -PT/OT screen as needed -Low bed -Mechanical lift (sit-to-stand) -Bed bolsters (3/26/14) -Wheelchair -Hipsters -Concave mattress -Floor mats -Personal Alarm -Bed and personal alarm, to be answered by staff on activation -Medication review -Call bell within reach Resident #21's CNA care card that was used by the CNAs to provide care indicated the resident required the assistance of two for transfers with a full body mechanical lift. The card was written in with pencil and changed as necessary, so the card was considered always updated and current. The Activities of Daily Living (ADL) Tracking Form indicated the resident was transferred on 2/25/15 and 2/26/15 for the 7/3 and 3/11 shift as a 4/2 meaning total dependence on one staff for transfers. It was recorded that no transfer occurred on the 11/7 shift. The Transfer/Mobility Status Criteria sheet dated 6/4/14 and the most recent one dated 11/18/14 both indicated Resident #21 was totally dependent with full performance of Activities of Daily Living (ADL) for the resident, totally non-weight bearing and required a total lift with full body sling. It was noted on the Criteria sheet that the resident was unable to assist with transfers. Two Fall Risk Assessments were presented from the facility on 10/22/15 at 4:00 p.m. as the only fall risk assessments for Resident #21. The first fall risk assessment dated [DATE] scored the resident with an 18 (greater than 10 represented the resident was at risk) and that the resident had 1 fall. This assessment indicated the resident was chair bound, unable to stand and required assistive devices. The second Fall Risk assessment dated [DATE] assessed the resident with the same score of 18. The Director of Rehabilitation presented information to the survey team on 10/22/15 at 12:30 p.m. regarding the resident's therapy evaluations. The Occupational Therapy (OT) Evaluation dated 11/13/13 indicated the resident required maximal assistance for feeding, was totally dependent on staff for all ADLs, was dependent of staff for bed mobility and transfers. She was noted to be wheelchair bound had impaired left and right lower extremity strength, requiring HOYER (Brand name for a total/full lift) lift for transfers. She stated the resident could not, Under no circumstances use a sit-to-stand lift because she had a left foot deformity and could not straighten her leg properly. She said the sit-to-stand required the resident to be an active participant, to come to a secure standing position, with the support of the sling around the waist area and hold on to the bars. She stated, with the sit-to-stand there was always the chance the resident would just slide through the sling onto the floor especially without the stability of her legs. In addition she said the resident could not safely bear weight or stand and pivot, which would have been necessary for transfers without the full mechanical lift. The OT evaluation also indicated both hands had mild impairment in fine motor coordination which may have disabled the resident to be able to use a call bell, plus she had to be totally fed her meals by staff. Her gross motor coordination was intact and she was able to propel herself in a wheelchair. Her hearing and vision was assessed intact and it was determined she was oriented to others, but unable to verbalize. She was able to follow commands and attend to tasks and sequences. The OT evaluation noted the resident had scoliosis (curvature of the spine) and her trunk was shifted to the left in a fixed position. The summary indicated Due to the documented physical impairments and associated functional deficits, the patient is at risk for falls, further decline in function, inability to express basic wants/needs effectively and muscle atrophy. No other OT evaluation was presented to this surveyor prior to survey exit. The physician's recertification orders dated 2/1/15 indicated the resident had 1/2 siderails times (x) 2 and a wanderguard to alert the staff of attempts to elope from the facility. According to nurses notes dated as written on 2/26/15 at 2:00 p.m. the nurse was called to the room by the Certified Nursing Assistant (CNA) because she had noticed swelling and bruising to the resident's right lower extremity. Range of Motion was tender and the physician was notified. Orders were obtained for a right lower extremity venous Doppler study of the extremity. Tylenol was given for discomfort. Signed by Licensed Practical Nurse (LPN) #12, who was not available to interview, but her written statement was reviewed and is in the body of this report. The facility's SBAR report dated 2/26/15 supported the information in the above nurses notes and indicated the resident had swelling and bruising of the right lower extremity to knee with decreased range of motion upon assessment. The SBAR indicated the following information was reported to the physician on 2/26/15 at 10:00 a.m.: Observed swelling/bruising to right lower extremity and right knee, purple in color, warm to touch and tender to touch, limited range of motion. Tylenol 650 milligrams (mg) given for discomfort. MD (Medical Doctor) was notified. Order received for venous Doppler. The SBAR is an acronym for Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication to medical personnel (physicians and nurses). There was no Doppler study on 2/26/15, with no explanation in the nurse's notes as to why this study was not performed. The next nurse's notes were written on 2/27/15 at 12:00 p.m. which indicated the physician was notified of blisters, swelling and bruising of the right lower extremity with orders for the mobile x-ray STAT. The facility's SBAR report dated 2/27/15 supported the information in the above nurses notes and indicated the x-ray was completed and fractures were identified of the right lower extremity. The mobile x-ray report indicated an x-ray of the right lower extremity was obtained 2/27/15 and read by the radiologist at 2:52 p.m. The report identified multiple fractures if the proximal *tibia and fibula with slight displacement. The remainder of the leg was within normal limits. The mobile ultrasound results of the right extremity obtained on 2/27/15 and read by the radiologist at 9:28 p.m. identified a right leg *deep venous thrombosis at the distal femoral vein. The SBAR report indicated the following information was reported to the physician on 2/27/15 at 4:20 p.m. and at that time orders were received from the physician to send the resident to the local Emergency Department (ED) to evaluate and treat. *The tibia is a large bone located in the lower front portion of the leg. The tibia is also known as the shinbone, and is the second largest bone in the body. There are two bones in the shin area: the tibia and fibula, or calf bone. *The fibula is smaller and thinner than the tibia. These two bones connect the ankle to the knee and work together to stabilize the ankle and provide support to the muscles of the lower leg; however, the tibia carries a significant portion of the body weight (http://www.healthline.com/human-body-maps/tibia-bone). *Deep vein thrombosis (throm-BO-sis), or DVT, is a blood clot that forms in a vein deep in the body. Blood clots occur when blood thickens and clumps together. Most deep vein blood clots occur in the lower leg or thigh. They also can occur in other parts of the body (Deep vein thrombosis (throm-BO-sis), or DVT, is a blood clot that forms in a vein deep in the body. Blood clots occur when blood thickens and clumps together. Most deep vein blood clots occur in the lower leg or thigh. They also can occur in other parts of the body (http://www.nhlbi.nih.gov/health/health-topics/topics/dvt/). The local hospital ED indicated the resident arrived at the ED on 2/27/15 at 5:16 p.m. and was admitted to the hospital at 8:31 p.m. X-rays at the hospital indicated acute displaced fractures of the right distal femoral metaphysis with *impaction component with angulation and acute displaced fractures of the right proximal tibia and fibula. The PVL study to determine if the resident had a DVT in the right extremity was performed and concluded no evidence of DVT in the right lower extremity, but exam limited by swelling and the patient was placed on heparin (blood thinner). The ED notes dated 2/27/15 and the Admission History and Physical dated 2/28/15 indicated they needed to assess how these injuries occurred and determine where patient to be discharged given possible elder abuse (or fracture related to patient transfer). Adult Protective Services attempted while in the ED without success and would contact again on 3/2/15. *A buckled fracture, also known as an impacted fracture, is one whose ends are driven into each other (http://www.webmd.com/a-to-z-guides/understanding-fractures-basic-information). *In a displaced fracture, the bone snaps into two or more parts and moves so that the two ends are not lined up straight (http://www.webmd.com/a-to-z-guides/understanding-fractures-basic-information). *An angulated fracture is a fracture in which the fragments of bone are at angles to one another (http://medical-dictionary.thefreedictionary.com/angulated+fracture). The orthopedic consultation report dated 2/27/15 recommended conservative treatment for [REDACTED].*fracture blisters and inflammatory nature of the *fracture hematoma. The patient was placed in a well padded splint, to return to be seen in the orthopedic office in 2 1/2 weeks at which time hopefully we can either convert her to a long leg cast or a fracture brace. The note indicated the injury/event was under investigation, there was no report of a fall and the patient was unable to communicate to provide any history. The report indicated the resident winces in pain. The pulses in the right foot were assessed as normal. *Fracture blisters are a relatively uncommon complication of fractures in locations of the body, such as the ankle, wrist elbow and foot, where skin adheres tightly to bone with little subcutaneous fat cushioning. The blister that results resembles that of a second degree burn. These blisters significantly alter treatment, making it difficult to splint or cast and often overlying ideal surgical incision sites. Review of the literature reveals no consensus on management; however, most authors agree on early treatment prior to blister formation or delay until blister resolution before attempting surgical correction or stabilization. The blister formation is proposed to result from the increased interstitial pressure of post-traumatic edema. Venous stasis due to thrombosis of injured vessels and fragile lymphatics also contribute to local tissue hypoxia leading to epidermal necrosis and blister formation. These forces combine to cause an injury which resembles a second-degree burn rather than a friction blister. Blisters can form as early as six hours post fracture and the majority within 24-48 hours(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC 93/). *Fracture hematoma is a hematoma formation (mass of clotted blood) at fracture site. Tissue in fracture site swells, very painful, obvious inflammation, and bone cells are dying (http://www.cwu.edu/~acquisto/fractures.htm). The hospital discharge summary dated 3/3/15 indicated the patient was discharged to a different skilled facility per the Responsible Party's request that the patient not return to previous nursing facility. The facility's documented investigation of the injury was conducted by the Director of Nursing (DON) who was on leave, in conjunction with the Administrator, indicated interviews were conducted with staff that were assigned to provide care for Resident #21 on 2/25-27/15. The Administrator was a part of the investigation as evidenced in the Facility Reported Incident (FRI) sent to the State survey and certification agency stamp dated 3/4/15. The transmission verification facsimile report indicated the initial report of an injury of unknown origin was repeatedly faxed using the wrong fax number on 2/27, 2/28 and 3/2/15. The initial report received by the State on 3/4/15 indicated Resident had a change of condition in her leg which revealed fracture of tibia and fibula. Investigation pending. The final outcome of the investigation dated 3/5/15 indicated interviews were conducted of the nursing personnel on all units which did not reveal any information to assist them in determining the origin of the injury. This surveyor began interviewing and reviewing written statements and investigative documentation from the following available staff that worked with Resident #21: The CNA (#9) who cared for the resident on 2/25-27/15 was interviewed on 10/22/15 at 11:10 a.m. She was accompanied by another CNA (#14)during the interview. CNA #9 stated she was regularly assigned to the resident. She stated Resident #21 could not walk, but could propel herself in the wheelchair and was not a behavioral problem for her. She stated she had the resident on the 7/3 shift 2/25/15 and left her up in the wheelchair around 3:15 p.m. at the beauty salon for a hair appointment. CNA #9 also wrote the same information in her statement inherent in the facility's investigation documentation. She stated the next morning on 2/26/15 at around 10:00 a.m., the resident was in bed when she began ADL (activites of daily living) care. She stated it was at that time she discovered blisters on the resident's right lower leg and the area was swollen, purple and red. She stated she immediately reported her observations to the 7/3 LPN #12, which was reported to the unit manager and the DON. She said no one from the previous shift (11/7) had told her anything was wrong with the resident. She stated the resident did not speak, but was shaking and crying. CNA #9 stated she worked her entire shift and was surprised the resident did not have any test or go out to the hospital with the condition of her leg, and was told by the DON, Don't expect anyone to come out here to do anything with all this snow. CNA #9 said the resident stayed in the bed for her shift. She stated whenever she transferred the resident, she used a sit-to-stand lift and CNA #14 stated she transferred the resident with the full mechanical lift. CNA #14 answered yes to the DON's questioning in the investigation documentation to the question, Have you been made aware of or do you know if the resident was being transferred other than by the sit-to-stand. CNA#9's documented answer was No to the question. Both answered No to whether they were aware of any falls or had assisted the resident from the floor. Both CNA #9 and #14 stated the resident had a low bed with short upper 1/2 side rails, no bottom side rails. LPN #12, who CNA #9 first reported her observations to, was not available for interview, but her written statement dated 2/27/15 as a part of the facility's investigation revealed she was called to the room by CNA #9. Bruising and swelling to the resident's right knee and right lower extremities was observed. She paged the unit manager. The facility's investigation documentation indicated LPN #12 worked the previous day and did not observe any deformities of the right leg and when she left her shift (7/3), the resident was sitting near the unit manager's office waiting to be taken to get her hair done. It was noted by this LPN, the resident remained in her wheelchair to get her hair done, no transfer to another seat was required. The unit manager (LPN #13), who no longer worked at the nursing facility, did not have a written statement in the investigation documentation for review by this surveyor. There was a note from the DON with a question that asked if she was aware of any falls, if she was asked to assist resident from floor or if the resident had been transferred other than the sit-to-stand. The answer to all of those questions was No. On 10/22/15 at 3:15 p.m., an interview was conducted with CNA (#5) who relieved CNA #9 on 2/25/15 for the 3/11 shift. When asked if she transferred the resident on 2/25/15 for the 3/11 shift; she answered, When I came on she was already in bed and I am certain of it. I did not transfer her to bed that evening. This statement was contrary to the DON's questioning during investigation of the injury, where it was asked and recorded on the back of CNA #5's written statement; Who put resident resident to bed? I (referring to herself, CNA #5) put her back to bed after dinner. There were no other questions on the back of the CNA's written statement, to include who assisted her to place the resident in bed. When asked how she transferred the resident when she had to, she stated using the full mechanical lift with two people. She said, once the resident was placed in bed, the floor mats are placed on each side of the bed, so if she rolled out, the resident would roll out safely onto the mats. She stated, I told the (3/11 LPN #14's name) that the resident was jittery and was throwing her legs over the side rail, but you need to check into the 11/7 CNA that was on that night after I left. It was suspicious that the 11/7 LPN (#8) charge nurse could not get in the room that night because the door was blocked and everyone knows that CNA (#8) probably did something. Make sure you check with (LPN #8's name), she will tell you. When I went off my shift at 11:00 p.m. that night (2/25/15) I pulled back the covers on all my residents during report to (CNA #8's name) and saw nothing on (Resident #21's name). The 3/11 LPN #14 no longer worked for the facility and could not be reached for telephone interview. LPN #8 was called with a message that the phone number was not a valid one, thus unable to be interviewed by this surveyor. The CNA (#8) referenced in the above interview that worked the 11/7 shift on 2/25/15 leading into 2/26/15 was interviewed on 10/23/15 at 12:01 a.m. She stated she and CNA #5 never went to each resident and pulled back the covers. She stated she routinely provided care for the resident and she never got up on her shift and the resident did not get up on the 11/7 shift 2/25/15 leading into 2/26/15. She stated the most she did that night was to roll her over and change her brief and at the time she did not see anything obvious below the knee on the right leg, but wasn't performing a bath to the lower extremities and if it was a fresh injury, it may not have been visible at the time. She stated she was informed by the 3/11 CNA (#5), she had put her to bed. She stated she found out the resident was given something on the 3/11 shift for constipation. A physician's orders [REDACTED]. She also stated the resident's bed only had short upper 1/2 rails and she could have never thrown her legs over siderails because they were not there. She stated the resident was quiet, no yelling or screaming. She stated her bed was maintained in its lowest position, which was near the floor with floor mats. The CNA said she gave report to an available CNA when she went off the next morning because she was not sure who had Resident #21 on 2/26/15 for the 7/3 shift. During the above interview, CNA #8 stated she saw the extent of the resident's injury on the next day 11/7 shift, 2/26/15 leading into 2/27/15. She said, When I came to work, it was evident at this time because the leg was swollen, badly bruised with blisters all over. The leg would not go over. It was like it was in two separate pieces below the right knee. I told the charge nurse (LPN #8) and another CNA (#15) saw it with me and we both went into the Administrator's office to tell him. I understand she finally went to the hospital the evening of 2/27/15. CNA #15 was not available for interview. When asked if she had barricaded the resident's door and not allowed the 11/7 LPN #8 charge nurse to enter on the 2/25-26/15 11/7 shift; she stated, I heard she and (CNA #5) was saying something like that, but I have been here [AGE] years and would have thought if I did that, someone would have reported me, tried to get in the room by force for the resident's sake, called the Administrator or the police at time and suspended or fired me if I supposedly did that; and for what reason. I was never asked about that by the DON or the Administrator. LPN #8 was unavailable for interview, but her written statement dated 2/28/15 indicated the following: On Wednesday night 11/7 shift 2/25/15, this nurse was told in report via the 3/11 nurse that the resident was agitated on her shift and to monitor her. Resident noted to attempt to throw her legs over the bedrails at times. Approximately 3:00 a.m., this nurse heard the resident yell out, I went down the hall and asked the CNA (#9) what was wrong with the resident and the CNA replied, I don't know. The resident yelled out again, so I went in to give the resident some meds (Tylenol) for signs and symptoms of pain/discomfort. Knocked on the door and heard someone reply, I'm in here. I went back down the hall to the nurse's station for about 15 minutes, then went back into the resident's room around 4:00 a.m. and medicated the resident. There were no nurse's notes written by this LPN regarding the aforementioned information, no pain assessments or general assessment of the resident in light of what the LPN wrote in her statement about the resident's agitation, yelling and throwing her legs over the siderails. All other interviewed staff said the resident only had short upper 1/2 bedrails, which would negate the resident throwing her legs over the siderails and having to give her pain medication. The questions asked of her by the DON were written on the reverse side of this written statement and they were the following with answers: 1. DON: What and what day were you made aware of the issue with the resident's leg? LPN#8: On the 11/7 shift (2/26/15), the 3/11 charge nurse informed me of the issue. 2. DON: Was the sound of the resident typical? LPN#8:The First yell, but the second yell sounded as if she was in pain. 3. DON: When you attempted to go in the room, who was assisting the resident? LPN: I believe it was (CNA #9's name) 4. DON: What did you witness? LPN: Nothing, because I couldn't open the door. 5. DON: When you went in to give the medication did you see anything abnormal? LPN: No, I just gave her the pain medication. 6. DON: What position was the bed in? LPN: Lowest position. We did walking rounds, noted 314A restless in bed with right leg over the side of the rail. No swelling or discoloration noted, had range of motion in leg, 0300 leg was not swollen, 0400 resident appeared to be trembling in bed. There was no evidence that this information about not being able to get in the room was immediately reported to anyone (Supervisor, DON, Administrator) at the time LPN #8 said it occurred on the 11/7 shift 2/25/15. In addition, the resident's low bed only had short upper 1/2 rails. There were no lower siderails for the resident to throw her legs over. This information was not documented in the nurse's notes, nor did it appear in the 24 hour report for 2/25/15. The DON, in her questioning of this LPN, did not ask about why the barricading of the room and not allowing her in the room was not reported to the supervisor, the DON or the Administrator. The DON in her questioning did not ask a pertinent question about the LPN's failure to assess the resident when she said she heard the resident yelling, even the first time. The DON did not question the siderail observation made by LPN #8, when the low bed did not have lower siderails. There was documentation where the DON asked all remaining nursing staff if they had to assist Resident #21 with transfer from the floor and if they were aware Resident #21 had experienced any falls, all answered No. There were no questions to ascertain if anyone heard yelling 2/25/15 on the 11/7 shift. On 10/22/15 at 1:50 p.m., a telephone interview was conducted with the Director of Nursing (DON). She stated she was on leave until 11/12/15 and would no longer be officially working for the nursing facility after that date. She said she was never able to determine how Resident #21 sustained multiple fractures of the right leg, but thought she narrowed it down to the 11/7 shift on 2/25/15 leading into 2/26/15. When asked how she came to that conclusion, she stated because the 11/7 LPN #8 could not get in the door on the 11/7 shift 2/25/15, so she was suspicious of the 11/7 CNA #8 doing something to Resident #21. The DON was not able to explain why she did not immediately suspend CNA#8 if she was suspicious of her doing something to the resident. The DON did not provide an explanation as to why she documented that she asked CNA #8 only one question, Who put the resident to bed? with an answer from the CNA, I put her to bed after dinner. The DON could not explain why she did not further explore how CNA #5 placed the resident in bed on 3/11 shift and who may have helped her. She stated to her knowledge the resident was a sit-to-stand with one person, but could not explain why when all of the resident's assessments indicated she was a full total body lift with the mechanical lift and the assistance of 2 staff. She said, It sounds like there was a reason how she broke the leg. She was transferred with the wrong lift and without 2 people on the 3/11 shift. During the above interview, the DON was asked if she said there was no reason to call mobile x-ray from coming to the facility to perform the Doppler study when it was ordered on [DATE] because of the snowy weather, she said, I can't remember. She stated she remembered the bad snow the area had during that time, but did not see that it would have stopped any emergency services needed by any resident otherwise they would send out via 911. She said the staff had the ability to call 911 anytime they thought it was necessary without a doctor's order. Based on the emergent condition of the resident's right leg as observed on 2/26/15 at 10:00 a.m., the resident was not sent out and evaluated in the ED until 31.25 hours later, and furthermore sent to the ED via non-emergent transportation. She stated she did not start her interviews and investigation of the injury on the 2/26/15 when all the unknown bruising, swelling and blisters were observed, but after she found out the right leg was broken. She said she gave everything to the Administrator, to include an incident report. On 10/22/15 at 5:30 p.m., an interview was conducted with the Administrator. He stated he did not have an incident report of injury of unknown origin from when the bruising, swelling and blisters were first observed on the morning of 2/26/15, nor did he have evidence of the beginnings of an investigation on that day. The Administrator said they, referring to the facility staff, really felt the resident hit her leg on the side rail and broke it. He was reminded that information was not in the final report sent the State agency for licensing and recertification and responded, I guess that wasn't the reason then. He stated, whatever was missing the DON had it, even though he said he was the Abuse and Neglect Coordinator. On 10/22/15 at 7:20 p.m., a second interview was conducted with CNA #5. The Administrator, Interim DON, Assistant Director of Nursing (ADON) and three Corporate Registered Nurses (RN) were present during this interview. When asked by the group if she transferred Resident #21 to bed on the 3/11 shift 2/25/15, she stated, she did not remember. CNA #5 was shown the DON's question on the back of her written statement and her response that she placed the resident to bed after dinner, she stated, I did not write that and I did not say that. I said I may have put her to bed, but really I don't remember and I think I didn't put her back to bed that evening. She went on to talk about how the staff talked about CNA #8 barricading Resident #21's door and LPN #8 could not get in, which did not involve her or her shift, but she could not remember what her physical body did on her assigned shift. She stated whenever she transferred the resident she used the full lift with the assist of another staff, but could not remember what she did that

Based on observation, clinical record review, facility documentation and staff interviews the facility staff failed to ensure that 3 of 27 residents in the survey sample received and were provided the necessary care and services to maintain their highest practicable physical well-being in accordance with the comprehensive assessment and plan of care to include Resident's #10, #4, and #15. 1. The facility staff failed to assess and provide services in a timely manner for Resident #10 after a significant change of condition related to a fall with an injury exhibited by increased resident indicators of pain which constitutes harm. 2. The facility staff failed to address Resident #4's lack of bowel movements for 9 days. 3. Facility staff failed to follow physician orders [REDACTED].#15. The findings included: 1. The facility staff failed to assess and provide services in a timely manner for Resident #10 after a significant change of condition related to a fall with an injury exhibited by increased resident indicators of pain which constitutes harm. Resident #10 was a [AGE] year old admitted to the facility initially on 9/13/2011 and then re-admitted to the facility on [DATE]. Resident #10's [DIAGNOSES REDACTED].*Closed [MEDICAL CONDITION] hip status [REDACTED].*Dementia, and *[MEDICAL CONDITION]. *[MEDICAL CONDITION]: an abnormal condition of the brain characterized by occlusion by an [MEDICAL CONDITION], thrombus, or [MEDICAL CONDITION] hemorrhage or vasospasm, resulting in ischemia of the brain tissues normally perfused by the damaged vessels. *[MEDICAL CONDITION]: an abnormal neurologic condition in which language function is disordered or absent because of injury to certain areas of the cerebral cortex. The deficiency may be sensory in which language is not understood, or motor which words cannot be formed or expressed. *Dementia: a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses. *[MEDICAL CONDITION]: an acute organic mental disorder characterized by confusion, disorientation, restlessness, clouding of the consciousness, incoherence, fear, anxiety, excitement, and often hallucinations. The above definitions were derived from Mosby's Dictionary of Medicine, Nursing, and Health Professions 8th Edition. The most recent Minimum Data Set (MDS) assessment was a Significant Change 5 day with an Assessment Reference Date (ARD) of 9/7/15 with a Brief Interview for Mental Status (BIMS) coded as 0 under C0100 indicating that Resident #10 is rarely/never understood. Based on the MDS Resident #10 has long and short term memory problems and cognitive skills for daily decision making are severely impaired. The Comprehensive Careplan last revised 8/25/15 that was in place for Resident #10 prior to his discharge to the hospital on [DATE] with a right [MEDICAL CONDITION] documented in part, read as follows: Focus Category: Pain/Comfort Approaches and Interventions: Monitor and report to Facility nurse, Any s/sx (signs or symptoms) of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut/glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Resident #10's clinical record review revealed a Situation Background, Assessment Recommendation (SBAR) tool dated 8/26/15 at 16:17 p.m. (4:17 p.m.) after a fall, documented in part, read as follows: Nurses Notes: While getting ready for med pass, resident heard yelling and slid to dining room floor on his bottom while from shoulder noticed upward and from middle back downward noted flat to the floor. Did not hit his head to the floor. On assessment, no injury, bleeding, bruise and hematoma observed. Resident assisted both nurse and CNAs (certified nurse assistant) in the process of getting him off the floor. Resident nodded head to denies pain. No facial grimacing noticed. Will continue to monitor. This entry was submitted by Licensed Practical Nurse (LPN) #1. LPN #1 also entered a nurse's note on 8/26/15 at 21:26 p.m. (9:26 p.m.) documented in part, read as follows: No changes observed at this time from post fall. Resident is in bed with eyes close and easily arouse. Will continue to monitor. A phone interview was conducted with CNA #4 on 10/22/15 at 9:30 a.m. CNA #4 was the nurses assistant assigned to Resident #10 the first shift following his most recent fall. CNA #4 was asked to tell the surveyor about Resident #10's condition during her 11-7 shift the morning of 8/27/15. CNA #4 stated, I came in on 11-7, as normal he (Resident #10) was in bed. I didn't get report because the 3-11 CNA had left early. At about 12:30 a.m. I went in to check on him on my first rounds. I first noticed his arm had a little scratch with blood and a bruise on it, so I went to tell the charge nurse about the scratch and she told me he had fallen on 3-11. I said ok, I didn't know. He was sleeping so I didn't bother him. I went back in his room at 3:30 a.m. to check on him. He was still sleeping and not soiled so I didn't bother him. At 5:30 a.m. I went in to check on him and he was awake. So I went to change him and when I went to turn him over he was in pain, moaning outloud. Surveyor asked CNA #4, Does he normally do that? CNA #4 stated, No, he is always quiet. I went to get the nurse (LPN #9), but she was not on the unit. But then I saw the DON ( previous Director Of Nursing) was on the unit (name), so I asked her to come and check him. I told (name previous DON) that he fell on ,[DATE]. DON (name previous DON) came in and looked at him and said she was going to get an x-ray done. I gave report to (name CNA #1) about how he was, told her something was not right he was not his self he was in pain. I work with him every night this was not normal for him. Surveyor asked CNA #4, When did the resident first show signs of pain? CNA #4 stated, At 5:30 a.m. he started showing signs of pain. On 10/21/15 at 1:20 p.m. an interview was conducted with CNA #1 regarding Resident #10. CNA #1 was asked about Resident #10 prior to and after the fall on 8/26/15. CNA #1 stated, He would walk around all day, walked pretty much all day. On 8/26/15 on 3-11 I stayed here until 9:00 p.m. We were moving people from the dining area to the chair area, he (Resident #10) was sitting in the chair next to the nurse's station. We heard him fall. We got to him, his chair was tipped over toward his right side. We went to him, the nurse was on break so I went to get another nurse to check him. Then me and another CNA helped him up and walked him to his room. Surveyor indicated to CNA #1 that the staffing sheets showed her as the CNA for Resident #10 on the 7-3 and 3-11 shifts on 8/27/15. CNA #1 acknowledged agreement and was asked to recall her care of Resident #10 for those shifts. CNA #1 stated, That morning I came in and the 11-7 CNA (CNA #4) said he was grimacing, she said (resident's name) ain't right, he was grabbing his hip, moaning out and grimacing when he was turned. So because she told me this for his morning care I got help, CNA (name) (CNA #2) helped me. He was moaning loud, loud enough you would know something was wrong. We had to turn him because he was not continent. We reported how he was acting to the nurse. Surveyor asked, What nurse? CNA #1 stated, We told (name of LPN #4) she went in to check him. I kept him in bed all day because of the condition he was in, I knew something was wrong. Surveyor asked, You worked a double on 8/27/15 correct? CNA #1 stated, Yes. Surveyor asked if anything else happened that day with the resident. CNA #1 stated, The LPN (LPN #1) on 3-11 came on and assessed him then sent him to the hospital on 3-11. On 10/21/15 at 1:30 p.m. an interview was conducted with CNA #2. CNA #2 was asked to explain what she remembered about Resident #10 on 8/27/15. CNA #2 stated, I helped (name) (CNA #1) do his morning care and when we turned him he was moaning and groaning out loud. I could tell something was wrong, he wasn't feeling good. He is normally not like that. LPN #4's nurse's note dated 8/27/15 at 9:17 a.m. documented in part, read as follows: resident in bed sitting upright with breakfast tray at bedside. cna assisting with feeding. s/p (status [REDACTED]. An interview was conducted on 10/21/15 at 2:00 p.m. with LPN #1 regarding Resident #10. LPN #1 was asked to tell the surveyor what she remembered about Resident #10 from the time he fell on [DATE] to the point he was sent to the hospital. LPN #1 stated, I did the assessment on him when he fell . I checked him he could move everything, no pain. We got him up and walked him to his room. I did the SBAR. The next day on 3-11 before I made rounds I got a call from his daughter and she said, My dad is not well today, he complained of pain. I told her ok I would do an assessment. The 7-3 nurse (LPN #4) told me in report that he didn't look good today and had been in bed all day. So I went to check on him, the CNA (CNA #1) and myself. We went to turn him and he complained of pain, he was moaning out. He had his hand on his right hip and was guarding it. The 7-3 CNA (CNA#1) said he had guarded the hip and had pain this morning when she turned him. He couldn't get up. I gave him his prn (as needed ) pain medication and called the doctor to let him know the changes. Surveyor asked, Tell me about your assessment of the resident. LPN #1 stated, He had no range of motion, I tried to hold his leg up and he started yelling out. He couldn't lift the leg and his right hip was red. LPN #1's nurse's note dated 8/27/15 at 17:00 p.m. ( 5:00 p.m.) documented in part, read as follows: Resident observed with facial grimacing while providing care and kept holding onto his right hip area when turning. PRN Tylenol 325mg (milligrams) two tabs given. Awaiting results from pain med (medication) given. Will continue to monitor. Resident #10's August Medication Administration Record [REDACTED]. Resident #10's clinical record review revealed a Situation Background, Assessment Recommendation (SBAR) tool dated 8/27/15 at 18:46 p.m. (6:46 p.m.) regarding right hip pain. The SBAR documented in part, read as follows: Post fall day one. Blood Pressure: 138/66 Date: 8/27/15 18:51 (6:51 p.m.) Pulse: 76 Date: 8/27/15 18:52 (6:52 p.m.) Functional Status Changes (compared to baseline) was not addressed. Nursing Notes: Resident noted with facial grimacing and holding onto right hip while providing care. Tylenol prn given with some effects. MD (doctor) on call made aware with new order received to sent resident out to ER (emergency room ) for further EVAL (evaluation). Son also made aware about resident changed of condition. Consented to order given by MD on call. will continue to monitor. LPN #1's nurse's note dated 8/27/15 at 21:53 p.m. (9:53 p.m.) documented in part, read as follows: SENT OUT TO ER for further eval. (evaluation) due to right hip pain per MD's ordered. Physician order [REDACTED].#1 on 8/27/15 documented in part, read as follows: To sent resident to ER (emergency room ) for further Eval. due to post fall c/o (complaints of) right hip pain. (name MD on call). A Clinical Record for Resident #10 also revealed a Nursing Home to Hospital Transfer Form dated 8/27/15 completed by LPN #1. The transfer Form under KEY Clinical Information documented in part, read as follows: Reason's for transfer: C/O Right hip pain. Order given to send over to ER to rule out fracture. Most recent pain level: Facial grimacing Pain location: Right Hip The Interim Director of Nursing submitted a time line for Resident #10 for 8/27/15 document in part, read as follows: 17:00 (5:00 p.m.) text note- facial grimacing. 18:46 (6:46 p.m.) SBAR started. 18:52 (6:52 p.m.) vital signs recorded. 20:43 (8:43 p.m.) text medication effective. 21:53 (9:53 p.m.) sent to ER. A phone interview was conducted on 8/23/15 at 3:00 p.m. with the previous Director of Nursing. The surveyor asked, Did you assess Resident #10 on 8/27/15 at approximately 5:30 a.m. after being asked by CNA #4? The previous Director of Nursing stated, I may have, if I remember correctly. (Name of Resident #10) was lying in bed Surveyor asked, Do you remember telling CNA #4 that you were going to get an x-ray done on him? The previous Director of Nursing stated, I don't remember making that statement, I'm pretty good about stuff like that, I don't remember. Minutes later the phone conversation got disconnected and after multiple attempts to reach the previous Director of Nursing back it was not answered. On 10/23/15 at 6:15 p.m. a phone interview was conducted with LPN #9. LPN #9 was asked to recall her interactions with Resident #10 on the night of 8/26/15 thru the morning of 8/27/15. LPN #9 stated, I got in report that he had fallen and I remember telling the CNA that he had a fall because we had to get vitals. I also remember (name previous Director of Nursing) asking me about the fall, but I don't remember her saying anything about an x-ray. I remember he had a skin tear. On 10/22/15 at 2:00 p.m. an interview was conducted with Resident #10's daughter-in-law. Resident #10's daughter-in-law was asked if she was the one who came to visit him on 8/27/15. The daughter-in-law stated, No, it was my (name of sister-in-law). She did tell me about coming over here that day she said he was in a lot of pain and she had called back to ask them to get an x-ray. He is non-verbal he could not communicate and tell you he was hurting all he could do was moan. I will get my sister-in-law to call you. A phone interview was conducted with Resident #10's daughter-in-law on 10/22/15 at 6:00 p.m. Resident #10's daughter-in-law was asked if she went to visit her father-in-law on 8/27/15. The daughter-in-law stated, Yes, I went around lunch time. He was in bed being fed his lunch. The aide (CNA) told me he had been complaining of his leg hurting. He had been in bed all day, he is not usually in bed all day. It was was unusual for him to be in bed and not dressed. I went back to work but started thinking about things so I called the nursing home back between 4:30-5:00 p.m. and asked the nurse if they could check him and get an x-ray of his leg. We got a call that he was leaving the nursing home and going to the hospital. He went to surgery after midnight. Resident #10 started complaining of pain and had a change of condition at 5:30 a.m. on 8/27/15 and was assessed by the previous Director of Nursing with no evidence to support any action was taken on the resident's behalf. On the 7-3 shift on 8/27/15 CNA #1 reported the resident had a change of condition and being in discomfort to LPN #4 with no evidence to support any action was taken on the resident's behalf. Resident #10's daughter-in-law called the facility and requested the resident to be assessed and the physician to be contacted around 4:30 p.m. LPN #1 assessed Resident #10 at 5:00 p.m. noticing facial grimacing, right hip guarding and redness and administered tylenol. At 6:46 p.m. LPN #1 started the SBAR, recorded vital signs at 6:52 p.m., and charted medication effectiveness at 8:43 p.m. and received order from on call physician to send the resident to the emergency room to rule out a right [MEDICAL CONDITION]. Resident #10 left the facility via 911 enroute to the hospital at 9:53 p.m. From the time Resident #10 was first noted to be in pain and experiencing a change of condition until he left the facility via 911 to the hospital a total of 16 hours had passed. On 10/25/15 at 11:00 a.m. a phone interview was conducted with Resident #10's Attending Physician. The Physician was made aware of the above information regarding Resident #10. The Attending Physician was asked by the Surveyor what would he have expected the staff to do when they were aware at 5:30 a.m. on 8/27/15 that the resident was experiencing a change of condition. The Attending Physician stated, I would expect them to call me. I would have taken the information from the nurse's assessment and either ordered further testing like an x-ray, or if I was pretty sure based on the assessment that there may be a fracture I would have sent him out to the hospital. The Surveyor asked, Should they have waited until they were prompted by the family at 4:30 p.m. to call you? The Attending Physician stated, No they should have called that morning. I'm not sure why they didn't, they call us for everything else. But they should also call right away if a resident has a change of condition. I feel there was an unnecessary delay with treatment because they failed to follow the facilities established policies. He (Resident #10) fell through the crack. Sounds like they waited too long, it was an unnecessary delay in care for this resident and that is unfortunate. A clinical record review for Resident #10 revealed a hospital discharge summary dated 8/31/15 which is current readmitted for Resident #10 back to the facility. On the hospital discharge summary under Discharge Diagnosis, Fall and Closed fracture of right hip status [REDACTED]. Facility document review revealed a Mandatory Inservice Training Attendance Roster dated 8/3/15 document in part, read as follows: Inservice Training Topic: 1. Facility Transfer Resident to Hospital Policy. 2. Assessing Resident with a reported or observed change in condition. Each Employee In Attendance Must Personally Sign Below: Name: LPN #4 LPN #9 LPN #1 The facility policy titled, Change in Resident Condition dated 11/30/14 documented in part, read as follows: Policy: The Clinical Nurse will recognize and appropriately intervene in the event of a change in resident condition. The Physician/Family/Responsible Party will be notified as soon as possible. Procedure: The primary Clinical Nurse will communicate to the nurse manager/supervisor any change in resident condition as it occurs. This will also be communicated in the 24 hour report as well. The Physician/Family/Responsible Party will be notified as soon as possible but not limited to significant change, accident/incident, change in treatment, transfer/Discharge. All physician-ordered interventions will be immediately carried out by the Clinical Nurse overseen by nurse manager/supervisor. With change of resident status, the Clinical Nurse will gather all subjective and objective assessment information. The Nurse is responsible to complete an assessment of the resident's condition to include vital signs, level of consciousness and any other symptoms related to the condition and make any judgement calls regarding the course of action to be taken, the need to contact the agent/surrogate/contact person and or physician and must document date, time, party's notified, findings and details of the notification in the Nurses Notes. Notification of the physician and agent/surrogate/contact person of a significant change in status shall routinely occur during the shift which it occurs. A pre-exit interview was conducted with the Administrator, Interim Director of Nursing, and the Cooperate Director of Clinical Operations on 10/23/15 at approximately 4:15 p.m. where the above findings were shared. The Surveyor asked, What should have happened for this resident? The Interim Director of Nursing stated, We should have called the doctor. The Surveyor asked, When should the doctor have been called? The Interim Director of Nursing stated, When he first had pain. The Surveyor asked, When did the resident first show signs of pain? Interim Director of Nursing stated, At 5:30 a.m. that morning. Prior to exit no further information was provided. 2. The facility staff failed to address Resident #4's lack of bowel movements for 9 days by not offering an as needed laxative. The findings include: Resident #4 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. sugars are uncontrolled), Bilateral [MEDICAL CONDITION] (both eye [MEDICAL CONDITION]), Chronic constipation, and Hypertension (high blood pressure). Resident #4's MDS annual (Minimum Data Set - an assessment protocol) with an ARD (Assessment Reference Date) of 08/26/15 assessed the resident as having a BIMS (Brief Interview for Mental Status) of 10 out of 15 indicating a moderate impairment of cognition. The MDS further coded Resident #4 as requiring extensive assistance with one staff person assistance for Transfers, Dressing, and Hygiene. The resident was coded as occasionally incontinent of bowel and bladder. Review of Resident #4's bowel function flow sheet revealed that he had no bowel movement at a minimum from 09/23/15 until 10/01/15. An interview with Resident on 10/21/15 he reports feeling fine. Observations of Resident #4 on 10/20/15 at approximately 4:45 p.m., 10/21/15 at approximately 2:30 p.m., and 10/23/15 at approximately 4:00 p.m. all revealed the resident lying in bed without complaint. The resident states he can get up to the bathroom alone. Review of the Resident's Medication Administration Record [REDACTED]. This order was initiated on 07/29/15. Resident #4's care plan was reviewed. The problem: At risk for bowel elimination related to decreased mobility and medication side effects was initiated on 09/16/15. The interventions included but are not limited to: Check resident frequently and assist with toileting as needed, encourage mobility as tolerated, encourage fluids as tolerated, notify the physician of abdominal distention, dullness on percussion or abnormal bowel sounds. An interview was conducted on 10/22/15 at approximately with MDS coordinator #6. When asked what she felt should be done after 9 days without a bowel movement, she stated that she felt an assessment would be needed for laxative use or other interventions. The facility administration was informed of the findings during a briefing on 10/23/15 at approximately 5:15 p.m. No further information about the findings were presented. 3. Staff failed to complete skin care treatments for Resident #15 to change the dressing to the skin tag on his back every three days and apply a daily dry dressing to his sacral excoriation. Resident #15 was [AGE] years old and newly admitted from the hospital to the facility on [DATE]. A Minimum Data Set (MDS) had not yet been completed. Observation of the resident evidenced he ambulated with a walker. The nursing notes evidenced he was oriented to self and place. Resident #15's [DIAGNOSES REDACTED]. On the evening of 10/20/2015 at 5:45 pm, the surveyor was passing Resident #15's room. The door was open and the resident was observed without a shirt and with someone behind him applying lotion to his back. The surveyor knocked, introduced herself and was invited into the room. The family member applying the lotion stated she was concerned that the dressing on the resident's back was dated 10/14/15. The surveyor also confirmed the date as 10/14/15 on the 11 to 7 shift. The family member also stated the resident had an area on his sacrum and the dressing on that was half off. The family member asked the resident to stand and was able to slide the elastic waistband down so that the dressing was exposed. Half of the dressing was missing and the family member was requested to hold up the other half so the wound could be observed. An area of denuded skin, the size of a quarter was noted. Review of the clinical record evidenced a physician's orders [REDACTED]. The admission nursing skin assessment evidenced the open sacrum area was due to excoriation. The area on the resident's back was, open area with skin tag noted, no s/s (signs/symptoms) of infection, skin is discolored. Both areas were present on admission. On 10/21/15 at 2:30 pm the two areas were again observed. Certified Nursing Assistant #10 pulled the back up of Resident #15's shirt and observed that the dressing was dated 10/14/15. CNA #10 also slipped the elastic waist of his pants down to reveal the half dressing was still in place on his sacrum. Following these observations the ADON was made aware of the situation and stated she would have to check Resident #15's orders. The ADON reported to the surveyor that he had an order for [REDACTED]. The TAR was initialed 10/14/15 through 10/17/15 for daily application of both dressings. On 10/18/15 the code (5) was used to indicate both dressings held, and on 10/19/15 the code (2) was used to indicate the resident had refused. On 10/20/15 The TAR evidenced both treatments were done. On 10/20/15 was the first observation that the back dressing was dated 10/14/15 and the sacrum dressing was half off. The ADON directed LPN #1 to provide the dressing changes. About an hour later the surveyor returned and requested to see the dressings. Both the back and sacrum dressings were a foam type dressing. The order for the back was a foam dressing but the order for sacrum was a dry dressing. When LPN #1 was questioned about the sacrum she stated, I did not put any moisture on it so it was dry. Oh, I guess it could have been a dry gauze dressing. I didn't look at the order first. LPN #1 continued; the foam dressing was in the drawer available for use on Resident #15. During the administrative meeting on 10/13/15 at 6:30 pm with the Administrator, Regional Nurse Consultant and the acting Director of Nurses they were requested to provide any additional information. None was received. A policy on following physician's orders [REDACTED].

Based on staff interviews, clinical record review and during the course of a complaint investigation the facility staff failed to identify an existing [DIAGNOSES REDACTED].#1. 1 A. The facility staff failed to identify Resident #1 had a medical history of [REDACTED]. 1 B. The facility staff failed to identify and acknowledge that Resident #1 had a Responsible Party (RP), the daughter. The daughter identified the resident had a change in condition for three days. The daughter requested Resident #1 be transferred to the emergency room for evaluation each of those three days. The resident was subsequently sent out 911 on 6/28/15 and admitted to the ICU (intensive care unit) [MEDICAL CONDITION] and in a diabetic coma with a blood sugar greater than 1500 mg/dl (milligrams/deciliter-the hospital laboratory reference range for blood sugar was between 65-99 mg/dL). Sepsis is a life-threatening complication of infection. It often occurs in people who are elderly or have weak immune systems. www.nih.gov The findings included: 1 A. Resident #1 was admitted from the hospital to the facility on [DATE] with [DIAGNOSES REDACTED]. A gastrostomy feeding tube ([DEVICE]) is a tube that is surgically placed into the stomach through the abdominal wall. The [DEVICE] is used to administer medications and feedings. www.nih.gov The admission MDS (Minimum Data Set) with an assessment reference date of 6/17/15 Section C. Cognitive Patterns assessment was incorrectly conducted, and the score was invalid. The social services staff responsible for completing this section stated the resident was not able to answer any of the questions asked. She stated the resident would just stare at her and not respond. Review of the admission nursing telephone report received by the facility staff from the hospital staff on 6/10/15 indicated the resident was receiving Glucerna via the tube feeding. The Nutrition Evaluation Initial and Annual form dated 6/19/15 filled out by the registered dietician noted the resident's tube feeding previous to admission was Glucerna 1.2 at 50 ml (milliliters) an hour. Glucerna products are specifically and scientifically designed to meet the needs of people with abnormal glucose metabolism. These products are formulated with reduced carbohydrate, modified fat, and fiber to help manage blood glucose response and lipid levels. Glucerna products have been clinically demonstrated to be efficacious (having the power to produce a desired result or effect) for people with diabetes. www.abbott.co The admission tube feeding order written by the physician assistant was for [MEDICATION NAME] 1.5 at 50 ml an hour. The laboratory complete metabolic profile (CMP) reported blood glucose (sugar) levels obtained on 6/12/15 and 6/19/15 were high. 1. On 6/12/15 the blood glucose level was 216 mg/dL. 2. On 6/19/15 the blood glucose level was 239 mg/dL. The facility's laboratory reference range for blood glucose was between 65-100 mg/dL. Both of these lab reports were initialed as reviewed by the physician assistant. There were no additional orders from the physician assistant or the physician addressing the high blood sugar levels noted in the clinical record. On 7/9/15 at 2:30 pm, the attending physician was interviewed. The resident's previous use of Glucerna via the [DEVICE] prior to admission and elevated blood sugars were discussed. When asked if he was aware of Resident #1's history of diabetes he reviewed his notes and then stated, I don't see it on my notes. He then looked at the 6/10/15 hospital discharge medications and stated, No diabetic medications were listed, why did (gender) come here without any treatment? He stated he always obtains blood work for new admissions. After reviewing the blood work (CMP blood glucose levels), he was asked if the physician assistant should have initiated a treatment plan for the resident. He stated, Yes, we should have at least collected a hemoglobin A1C level and monitored the resident's blood sugar every 6 hours and probably change the [MEDICATION NAME] to Glucerna. The physician stated the report from the hospital to the nursing staff of the resident receiving Glucerna should have been a red flag for the staff. He further stated, This issue needs to be addressed, definitely. Hemoglobin A1C provides an average of your blood sugar control over the past 2 to 3 months and is used along with blood sugar monitoring to make adjustments in medicines. www.nih.gov The resident was sent to the emergency room via 911 on 6/28/15 with [DIAGNOSES REDACTED]. A diabetic coma could happen when your blood sugar gets too high -- 600 milligrams per deciliter (mg/dL) or more -- causing you to become very dehydrated. It usually affects people with type 2 diabetes that isn't well-controlled. It's common among those who are elderly, chronically ill, and disabled. This is a serious condition, and if it isn't spotted soon and treated quickly, it could be fatal. www.nih.gov Further review of hospital records evidenced a consult that read, in part: .resident is known to me from prior evaluation in 2014.past medical history: diabetes. 1 B. On 7/9/15 at 4:00 pm, an interview was conducted with the daughter. She alleged she was the RP for the resident for the past [AGE] years that the resident had resided with her. The daughter stated she was the contact person who was called when there was a procedure/consent for treatment or any change when the resident was at a previous long term facility and while the resident was in the hospital. The daughter indicated she did not know why the facility did not have her listed as the RP. The daughter stated she had noted there was a change in the resident first identified on Thursday 6/24/15. She stated the resident appeared to be drugged, sleepy, lethargic/ disoriented. The daughter indicated the resident had been receiving pain medications for complaints of tooth pain due to infected gums and this could have attributed to the resident's change. The RP indicated she had visited with the Resident on 6/25/15, 6/27/15 and 6/28/15. Each of those days the RP noted the resident was not responding to her as he/she normally would and grew more concerned. The RP stated she had asked staff each of those days to send the resident out to the emergency room for evaluation. On 6/28/15 the RP stated she was very upset at the nursing staff's lack of acknowledging that the resident had a change in condition (not responding to her). The RP stated the staff had told her that the resident was acting that way (unresponsive) because she was there. The RP indicated she threatened to get a court order to have the resident sent to the emergency room and then left to do so. Several hours later, the facility had called her to tell her that the resident was being sent out 911 for a change in condition. Interviews were conducted with the nursing staff involved with Resident #1's care on 6/25/15, 6/27/15 and 6/28/15. The licensed practical nurse (LPN) #1 was interviewed on 7/9/15 at 10:15 am. She indicated she was assigned to care for the resident on 6/25/15 during the day shift. LPN #1 stated the resident's daughter was in an Uproar about the tooth infection. LPN #1 stated an oral surgeon was to have followed up with the resident's tooth concern but the facility had not received any information for a follow up oral surgeon appt. The daughter wanted to take the resident to the emergency room to be evaluated. The nurse stated she told the daughter that she was unsure if she could take the resident to the emergency room and referred her to the nurse at the front desk. Several minutes later the daughter came back down the hall and stated to the nurse, Everything was taken care of. Review of the clinical record evidenced a physician order [REDACTED].{sic} to gums bid (twice a day) PRN (as needed) sore gums, work (with) family to get oral surgeon appt. (appointment) scheduled. On 7/8/15 at approximately 5:30 pm, LPN #2 was interviewed. She was assigned to care for Resident #1 on 6/27/15 during the day shift. The nurse stated, The daughter told me she was the RP for the resident.she was belligerent, she said that we were doping the resident and making (him/her) sick with narcotics and we didn't care.she was yelling she wanted the resident to be sent out to a hospital in (name of town approximately 47 miles from facility).I told her if you feel he/she is in that bad of shape you can call EMS.I went back to the desk and started getting the paperwork ready, I called the on call physician.I called (non-emergent) transport, they came and stated they could not transport the resident to the specific hospital the daughter had requested the resident be sent to (name of town approximately 47 miles from facility) .then I realized the daughter was not the RP (after reviewing the face sheet).so I went to the resident's room and asked the resident if he/she was their own responsible party and he/she nodded yes, I then asked the resident if he/she wanted to go the hospital and he/she nodded, no. So then I went down and spoke with transport and they left. The nurse indicated the resident's daughter had already left the building. LPN #2 stated she called the daughter's phone number and left a message informing her that the resident was still in the building. LPN #2 stated, The doctor never called back.I had my hands full. LPN #2 indicated she had never taken care of the resident before. She was not aware of the resident's baseline. She stated the resident had received a pain medication at 8 am for tooth pain that morning. She stated the resident was responsive, non-verbal, awake and oriented to self and place. The resident's vital signs were documented on the nurses notes as 96 temp, 20 respirations, blood pressure 120/74, the resident was on oxygen at 2 liters per minute with a pulse oxygen saturation of 98%. LPN #3 assigned to care for the resident on 6/28/15 for the first part of the evening shift was interviewed on 7/9/15 at 3:00 pm. She stated the day shift nurse had reported to her that the resident's family member (daughter/RP) had requested the resident be sent out to the hospital that morning. The day shift reported the daughter was loud, belligerent and threatening stating she wanted the resident sent out to the emergency room . The day shift nurse reported to the daughter that the resident was stable and there was no medical justification to send the resident out. The day shift nurse documented at 10:00 am, the resident's vital signs as: blood pressure 136/60, pulse 62, respirations 18 and temperature 97.5 At 1:00 pm, the nurse documented, Family member verbalizing (resident) has changed. LPN #3 stated at approximately 8:00 pm, the oncoming nurse made rounds and noted the resident was unresponsive except to sternal stimuli and had approximately 60 cc of bright red blood return when the resident's PEG tube residual was checked. 911 was called and the resident was transported to the local hospital emergency room . LPN #3 stated she called and notified the daughter of this change. The daughters response was, I am glad you sent (resident) out. The daughter stated she knew there was something going on with the resident. The resident was sent to the emergency room via 911 on 6/28/15 and diagnosed with [REDACTED]. The resident's blood sugar was elevated at greater than 1500 mg/dl. The resident was placed on a IV (intravenous) fluids, insulin drip and antibiotics and placed in the ICU for further care. The emergency physician documented, .Patient had reportedly been increasingly lethargic over the last few days--daughter had been trying to get him/her sent to hospital reportedly since that lethargy began. Patient has had a steady decline then was found unresponsive by staff on day of admission--upon arrival WBC (white blood count) >22 (normal lab reference is 4.0-11), glucose 1500, lactic acidosis present, along with [MEDICAL CONDITION] (low blood pressure). Lactic acidosis is a physiological condition characterized by low pH in body tissues and blood accompanied by the buildup of [MEDICATION NAME]. Lactic acidosis is commonly found in people who are unwell for one of various reasons, such as severe heart and/or lung disease, a severe infection with Sepsis, or severe Hypovolemia depletion of body fluid. www.nih.gov The above findings was shared with the director of clinical services on 7/9/15 during a pre-exit meeting. She indicated resident's should be sent out to the hospital whenever an RP requests. She stated, If the daughter requested the resident go to the emergency room then we should have called and notified the doctor and moved forward. COMPLAINT DEFICIENCY

Based on observation, staff interview, clinical record review, and review of the facility's policy the facility staff failed to ensure the necessary treatment, care and services were provided to promote healing and prevent new pressure ulcers from developing for 1 of 37 residents (Resident #4), in the survey sample. Resident #4 had a facility acquired pressure ulcer to the sacrum that was first assessed at an advanced stage (stage 3). Licensed practical nurse (LPN) #4 initially identified the open area on 8/18/14 but was unable to classify it because of lack of education; therefore, the Assistant Director of Nursing (ADON) and Director of Nursing (DON) were notified to further evaluate the open area. The ADON did not assess and document on the sacral pressure ulcer until 2 days later, 8/20/14. The 8/20/14 pressure ulcer record documentation measurements were: (length) 7.5 centimeters by (width) 7.0 centimeters by (depth) 0.1 centimeters. The wound bed contained red granulation tissue, the edges were firm, and a small amount of no color sero-sanguineous drainage was present. The facility staff failed to demonstrate the development of the sacral pressure ulcers was un-avoidable. The facility staff failed to assess the sacral pressure ulcers for 2 days after identifying it. The facility staff failed to accurately assess, stage and institute treatments to promote healing of the sacral pressure ulcer. The findings included: Resident #4 was originally admitted to the facility 8/2/04 and has never been discharged from the facility. The current [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/18/14 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired decision making abilities. In section "G" (Physical functioning) of the 11/18/14 MDS assessment Resident #4 was coded as requiring total care of 2 person with bed mobility and transfers and total care of 1 person with locomotion on the unit, dressing, eating, toileting, personal hygiene and bathing. In section "M" (Skin conditions) of the 11/18/14 MDS assessment Resident #4 was coded as at risk of developing a pressure ulcer at "M0150" and coded as not having any unhealed pressure ulcers at "M0210." At " M1200" Resident #4 was coded as receiving nutrition or hydration interventions to manage skin problems, applications of ointments/medications other than to feet and application of dressings to feet. Category/Stage III: Full thickness skin lossFull thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/. Pressure ulcer prevention requires assessment of the resident's risk factors and development of a plan to reduce or eliminate the risk factors. These include constant monitoring as care is rendered for redden areas especially over bony prominences, protecting the skin from incontinence episodes, lifting the resident off surfaces use of a draw sheet, limiting elevation of the head to 30 degrees, establishing and implementing an individualized turn schedule, notifying appropriate staff of changes identified in the skin. (Pottery & Perry 7th edition, chapter 48 page 1303) Resident #4's care plan implemented 8/18/14 reads: Care Area Assessment (CAA) 16; the resident has impaired skin integrity. The resident has a potential for impaired skin integrity. The identified risk factors included: history of pressure ulcers, immobility, nutritional deficiency, fragile skin, and incontinence. The goals read: the resident's wound will show signs of healing and remain free from infection through next review and the resident will not develop additional skin integrity problems or wounds through next review. The care plan did not identify the location of the impaired skin; therefore, an interview was conducted with MDS coordinator #2 on 12/2/14 at approximately 3:15 p.m. MDS coordinator #2 stated she did not think Resident #4 had any open wounds and that is the reason it's not on the care plan. The surveyor handed the pressure ulcer flow sheets to MDS coordinator #2 and License practical nurse (LPN) #9 nodded her head to MDS coordinator #2. MDS coordinator #2 stated the care plan in the book was not Resident #4's current care plan and the current care plan was on the desk in the MDS office. MDS coordinator #2 left to retrieve the current care plan from the MDS office but had not returned at 5:30 p.m. MDS coordinator #2 handed the surveyor an updated care plan on 12/3/14 at approximately 11:00 a.m. A handwritten entry on the care plan dated 8/20 read: Stage III to sacrum. Another handwritten entry read 11/25/14 stage II to sacrum. The goal read: will show signs of healing. The interventions were: - Serve diet as ordered, assist as needed, monitor intake, offer snacks as needed. - Administer medications as ordered. (observe for and report any side effects. - Assist resident with turning and repositioning frequently. - Inform the physician of any new area of skin breakdown - Inform the resident/family/caregivers of any new area of skin breakdown. - Supplements as ordered to promote wound healing- Administer treatments as ordered and monitor for effectiveness. - Resident requires specialty mattress (low air loss). - Resident requires adaptive device (foot cradle to bed). - Notify nurse of any new areas of skin breakdown; redness, blisters, bruises, and discoloration noted during bath or daily care. - If resident refuses treatment, attempt to determine why and try alternative methods to gain compliance. - Monitor for pain during treatment. Treat pain as per orders prior to treatment to ensure the residents comfort. - Float heels. - Apply barrier cream after peri care. - Weekly skin checks. - Notify physician for change in condition. There was no entry on the care plan for treatment of [REDACTED]. Also, there was no entry on the care plan for the 8/22/14 new order for [MEDICATION NAME] Ag. The sacral pressure ulcer treatment orders history is as follows: 8/22/14- Cleanse with normal saline. Pat dry. Apply [MEDICATION NAME] Ag and cover with border gauze. (This order was discontinued on 10/22/14). 10/22/14- Cleanse with normal saline, pat dry, apply santyl to wound bed, cover with dry dressing every day and as needed. (The order was discontinued 11/11/14). 11/11/14- Clean with normal saline. Pat dry. Apply skin prep to peri-wound, Apply Hydrogel to the wound bed. Cover with [MEDICATION NAME] everyday. (This order was discontinued on 11/21/14). 11/21/14- Clean with soap and water. Pat dry. Apply [MEDICATION NAME] every shift. (This order was discontinued on 12/3/14). An interview was conducted with Unit manager (UM) #3 on 12/3/14 at approximately 1:30 p.m. UM #3 stated she does wound rounds on the Green unit once a week. During the rounds the wounds are assessed, monitored for change, measured and staged. UM #3 stated if changes are noted in the wound the physician is notified for new orders. UM #3 stated the physician neither the DCS nor ADCS completes the wound rounds with her. UM #3 also stated she has never had training in wound management. UM #3 down staged the sacral pressure ulcer from a stage 3 pressure ulcer to a stage 2 pressure ulcer on 9/3/14. UM #3 recorded the measurements on the pressure ulcer record. The measurements were: (length) 1.5 centimeters by (width) 2.2 centimeters by (depth) 0.2 centimeters. The wound bed contained pink and red granulation tissue, the edges were red and a small amount of pink and red serous drainage was present. Serous wound drainage is clear, watery plasma. (Pottery & Perry 7th edition, chapter 48 page 1287). UM #3's most recent and current sacral pressure ulcer record documentation on Resident #4 sacral pressure ulcer was dated 11/25/14. The measurements were: (length) 3.8 centimeters by (width) 1.5 centimeters by (depth) 0 centimeters. The wound bed contained pink and red [MEDICATION NAME] and granulation tissue, the edges were red and no drainage was present. The sacral pressure ulcer was still down staged to a stage 2. Stage 2 pressure ulcers by definition have partial-thickness loss of the dermis. Granulation tissue, slough and eschar are not present in stage 2 pressure ulcers. Therefore stage 2 pressure ulcers should not be coded has having granulation, slough or eschar tissue ... (RAI manual, MDS 3.0 chapter 3 page M-24) The National Pressure Ulcer Advisory Panel (NPUAP) (2007a) has advanced a four-stage classification system... Thus once you have staged the pressure ulcer this stage endures even as the pressure ulcer heals. Pressure ulcers do not progress from a stage 3 to a stage 1, rather a stage 3 pressure ulcer demonstrating signs of healing is described as a healing stage 3 pressure ulcer (NIX, 2007). (Pottery & Perry 7th edition, chapter 48 page 1282) An interview was conducted with LPN #9 on 12/03/14 at 1:40 p.m. LPN #9 stated she completed the intial skin assessment form on 8/18/14 and notified the DCS and the ADCS that Resident #4 had an opened area to the sacrum. LPN #9 stated it was not policy for her to stage the pressure ulcer or obtain orders for treatment unless the DCS, ADCS or UM) are not in the facility. The medical record contained the weekly skin integrity review dated 8/18/14 in which LPN #9 completed. There was no additional documentation stating whom LPN #9 notified. LPN #9 stated "I need education if I am expected to take responsibility for the wounds." The ADCS was also interviewed on 12/3/14 at 1:45 p.m. The ADCS stated she did not assess and stage the pressure ulcer to Resident #4 sacrum until 8/20/14. This was 2 days after the pressure ulcer was identified. The sacral pressure ulcer documentation record dated 8/20/14 measurements were: (length) 7.5 centimeters by (width) 7.0 centimeters by (depth) 0.1 centimeters. The wound bed contained red granulation tissue, the edges were firm, and a small amount of no color sero-sanguineous drainage was present. Sero-sanguineous wound drainage is a pale, red watery mixture: of clear and red fluid. (Pottery & Perry 7th edition, chapter 48 page 1287) The DCS was interviewed on 12/3/14 at approximately at 1:55 p.m. The DCS stated the expectation was for the nurse who completes the skin assessment for a new pressure ulcer is to assess and stage the pressure ulcer, notify the physician, obtain orders, implement the orders and notify the Responsible party. The DCS stated the licensed nurses had not been educated to assess wounds. The DCS also stated the facility has a Pressure Ulcer - Appropriate Treatment At- A- Glance policy. The policy was revised 9/12. This policy guides the staff in determining which product to use for a pressure ulcer at various stages and which products are not to be used. [MEDICATION NAME] was on the "do not use list" for every stage. [MEDICATION NAME] Ointment is a multipurpose, moisture barrier ointment. [MEDICATION NAME] Ointment was formulated for use on intact or mildly damaged skin. (http://www.[MEDICATION NAME].com/). On 12/3/14 at approximately 2:10 p.m. Resident #4 was observed in bed prior to receiving wound care. Resident #4 was lying in bed on her back. She was dressed in a hospital gown and wearing blue prevalon boots, also a foot cradle was being utilized. As the staff positioned Resident #4 onto her right side using the cloth incontinence pad beneath her the fitted sheet was observed with multiple dried yellow stains and the incontinence pad was completely saturated. The cloth incontinence pad was also with yellow and light brown stains. The CNAs at bedside stated it was urine and feces. A small amount of soft brown feces was observed at the rectal orifice. LPN #9 stated the CNA staff would clean Resident #4 after the wound care was completed. No dressing was noted to the wound but there was no order for a dressing. On 12/3/14 at approximately 2:10 p.m with LPN # 9, UM #3, CNA #100, CNA #101, the writer and another surveyor observed wound care for Resident #4. LPN # 9 cleaned Resident #4's sacral pressure ulcer with soap and water, followed by clear water. Afterwards LPN #9 stated the white color to the wound was [MEDICATION NAME] ointment that could not be removed but UM #3 stated this white area was skin maceration. The sacral pressure ulcer was with some maceration the wound bed contained pink and red tissue, but there was no exudate or foul odor. LPN #9 stated all wound care is provided by the direct licensed nurse not the licensed nurse management staff which includes the UM, ACDS, and DCS. LPN #9 further stated the UM, ACDS, and DCS would be notified if there was a change observed in the wound. After LPN #9 cleaned Resident #4 sacral pressure ulcer the surveyor asked UM #3 to assess and identify tissue types in the sacral pressure ulcer. UM #3 stated this was not the day Resident #4's pressure ulcer was to be assessed but she observed the sacral pressure ulcer and identified [MEDICATION NAME] and granulation tissue as well as maceration in the wound. LPN # 9 then patted the sacral pressure ulcer dry and applied [MEDICATION NAME] ointment and proceeded to tidy the work area as the CNAs repositioned Resident #4. The pressure ulcer was left open to air. UM #3 exited the room and returned with the NP. The NP requested the [MEDICATION NAME] be removed to allow her to assess the sacral pressure ulcer further. Excessive wound exudate or other bodily fluids, such as urine or sweat, can cause skin maceration to occur around a wound. Maceration may delay pressure ulcer healing and lead to other complications. (<http://www.ncbi.nlm.nih.gov/pubmed/ 719>). On 12/3/14 at approximately 2:30 p.m. an interview was conducted with the Nurse practitioner (NP) directing Resident #4 care. The NP stated Resident #4 care had been directed by her for 3 years but she could not say she had ever seen Resident #4's sacral pressure ulcer. The NP stated if I have there will be a note in the physician's progress note. The NP assessed the sacral pressure ulcer after the interview with the surveyor. The NP stated 3 times "I am not a certified wound care nurse" as she continued assessing Resident #4 wound. The NP then stated several times to use the [MEDICATION NAME] because she believes in it and it worked well for her son. The NP was observed measuring the sacral pressure ulcer from side to side first, then from head to toe. While the NP was at bedside assessing Resident #4 sacral pressure ulcer, she stated the 0.25 deep area in the middle of the wound was the site of the stage 3 pressure area. Length x Width: Measure the greatest length (head to toe) and the greatest width (side to side) using a centimeter ruler. Multiply these two measurements (length x width) to obtain an estimate of surface area in square centimeters (cm2). www.npuap.org The NP documented in the physician/NP progress note on 12/3/14 there was a 1-2 millimeter area with 0.25 centimeter depth. The sacral pressure ulcer measurements were: (length) 6.5 centimeters by (width) 2.0 centimeters by (depth) 0.25 centimeters. A new treatment was ordered by the NP to clean the sacral pressure ulcer with 0.9 % normal saline daily, pat dry, apply [MEDICATION NAME] Ag dressing and cover with border gauze. Switch dressing once duoderm arrives. Check pre-[MEDICATION NAME] and complete blood count on 12/4/14. There were no physician/NP progress notes dated 8/22/14 through 11/26/14 which identified Resident #4 as having a sacral pressure ulcer. The Interdisciplinary team (IDT) met weekly to discuss Resident #4's pressure ulcers. The IDT concentration was nutritional. On 8/19/14 speech completed an evaluation secondary to decreased nutritional intake with holding/pocketing of foods and liquids. On 8/22/14 Zinc, Prostat AWC, vitamin c and med pass were identified as the current ordered supplements. Ensure was ordered on [DATE], if the family provided them. [MEDICATION NAME] was added 9/12/14. The med pass was changed on 9/30/14 to 120 millimeters 2 times per day. An appetite stimulant ([MEDICATION NAME]) was ordered, discontinued and reordered. [MEDICATION NAME] was not on the physician order [REDACTED]. Resident #4 had a pre-[MEDICATION NAME] test completed on 8/1/14. It revealed a low level of 10.90 mg/dl with the normal range 16.0 - 40.0 mg/dl. There were no follow-up labs to ascertain if the Pro-stat was effective. Prostat AWC is a complete liquid protein with [MEDICATION NAME], citrulline, cysine, vitamin c and zinc. Prostat Advanced Wound Care (AWC) is a supplement used to promote pressure ulcer and wound healing. It contains 17 grams of protein and 100 calories per serving. (Information obtained from the Prostat AWC label) The [MEDICATION NAME] test was believed to be a useful marker of nutritional status and was used to help detect and diagnose protein-calorie malnutrition as well as to monitor people receiving total [MEDICATION NAME] nutrition.... A low level of [MEDICATION NAME] may be seen with malnutrition, severe or chronic illness, inflammation, and trauma such as burns, [MEDICAL CONDITION], serious infections, and certain digestive disorders. (http://labtestsonline.org/understanding/analytes/[MEDICATION NAME]/tab/test). Other factors such as type of surface to the bed, minimizing moisture, turning frequency, shearing, and friction and avoiding direct pressure to the wound were not addressed in the IDT meetings documentation. Ongoing assessment of the skin is necessary to detect early signs of pressure damage. Pressure ulcers are under-detected in individuals with darkly pigmented skin because of areas of redness are not easily seen, frequency of inspection may need to be increased in response to any deterioration in overall condition. The facility's undated policy titled Skin Risk assessment stated Residents will be evaluated at the time of admission, quarterly, annually and a significant change by a licensed nurse. Resident's #4's Braden and skin risk assessments were not provided after multiple requests. The undated Skin assessment weekly policy states the licensed nurse will complete a total body assessment on each resident weekly, paying particular attention to any skin tears, bruises, stasis ulcers, rashes, pressure ulcers, [MEDICAL CONDITION], abrasions, reddened areas and skin turgor problems... This process not only provides a means for licensed nurses to regularly assess each resident's skin condition, but also provides a means of evaluating the nursing assistant's reporting of and responses to residents with skin problems. The procedure read: if a resident is assessed as having a skin problem, the evaluating nurse will initiate the appropriate form. For pressure areas complete the "Pressure Ulcer Record" For all other skin conditions, complete the "Non-Pressure Skin Condition Record." The above findings were shared with the Executive Director, Director of Clinical Services and corporate representative on 12/4/14 at approximately 6:45 p.m. No additional information was provided.

Based on observations, clinical record review, staff and resident interviews, and facility documentation review, the facility staff failed to monitor the bowel movements and address specific pain related to a fecal impaction for 1 of 15 residents in the survey sample, Resident #102. The findings include: Resident #102 was admitted to the nursing facility on 3/4/13 with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #102 with a score of 15 on the Brief Interview for Mental Status which indicated he was cognitively intact in the skills needed for daily decision making. He was not assessed to reject care. He was coded to use a walker and wheelchair for mobility with the assistance of one staff. He utilized continuous oxygen therapy. He was assessed always continent of bowel and had an indwelling urinary urinary catheter. The care plan dated 3/31/13 indicated the resident had the potential for complications due to a history of constipation. The goal the staff set for the resident was the resident would have no episodes of constipation through next review. Some of the approaches the staff would take to accomplish this goal included record bowel movements every shift. Notify charge nurse if no bowel movement times 3 days, if complaints of pain when passing stool, if resident had to strain to have a bowel movement, or if resident is having hard dry stools. Administer medication for prevention and/or treatment of [REDACTED]. An interview was conducted with Resident #102 on 4/10/13 at 3:30 PM who resided on the Blue Unit. The resident stated he had been uncomfortable for at least 4 to 5 days. When asked to specifically explain he stated, "I feel like there is a brick at my rectum. It is the kind of pain I can't predict, but it has kept me up at night and I don't eat or drink much because I don't want to make it worse. I'm not sure if I need a new bed; maybe the bed is pushing up in that area with waves of pain." During the 30 minute conversation, the resident stopped talking to raise his buttocks off the surface of the bed to blow, pant and at one time banged his fist into the bed. With each of these three episodes he said, "See this is what I'm talking about. I just want it to stop. When these spells hit me, it also hurts my penis and stops the urine from flowing through the tube. Last night I thought I had soiled my whole bed because of this feeling and I called for help. Two nurse's turned me over and there was nothing there. I just knew I had messed everywhere. This kind of pain and pressure is horrible." The resident stated he had been telling the nurse's and aids about waves of pain in his rectum, but thought no one took him seriously. On 4/10/13 at 4:10 PM, an interview was conducted with the Nurse Practitioner (NP), who was at the nurse's station when this writer exited the resident's room. She stated she was aware of the resident having generalized "all over" pain and she ordered [MEDICATION NAME] 50 milligrams (mg) every 6 hours as well as a stool softener 100 mg 2 times a day on 4/3/13. She said, "I was not aware or made aware of this type of pain, described specifically as 'waves of pain'. I plan on seeing him before I leave today." She also stated she ordered a psychiatric evaluation on 4/8/13 because the resident was not eating or sleeping well and the staff felt he may be a little depressed. She stated she knew the psychological exam was performed, but she had not reviewed the report; she was in the building Monday/Wednesday and Friday. Licensed Practical Nurse (LPN) #1 was standing at the nurse's station, stated he was full time and had the resident when he worked, but knew nothing about his rectal pain and wasn't told of this complaint by anyone. [MEDICATION NAME] is a man-made (synthetic) [MEDICATION NAME] (pain reliever). The recommended dose of [MEDICATION NAME] is 50-100 mg (immediate release tablets) every 4-6 hours as needed for pain. The maximum dose is 400 mg/day. Commonly reported side effects include constipation (medicinenet.com). The nurse's notes did not reveal pain until 3/31/13, which was assessed/described as generalized pain and complaints of constipation. The resident was medicated with Milk of Magnesia (MOM) at 4:00 PM on 3/31/13 for the constipation and Tylenol 650 mg for generalized "all over" pain. On 4/1/13 and 4/3/13, Resident #102 complained of generalized pain and was medicated with Tylenol 650 mg. The NP ordered scheduled [MEDICATION NAME] 50 mg for generalized pain to start on 4/3/13 at 6:00 PM and every 6 hours thereafter. Review of the nurse's notes through 4/10/13 did not describe Resident #102's specific rectal pain. The Psychological Evaluation dated 4/8/13 indicated the resident was grossly cognitively intact and he complained of pain in his peri-rectal area and shifted uncomfortably. He also explained to the examiner when he saw food he thought of the "pain of peeing and pooping" and he could not sleep because spent half the time trying to get comfortable. He also stated to the examiner he attributed his limited therapy efforts to the pain in his penis when the catheter tubing moves. He indicated in the report the resident stated he was not listened to by some staff, knew he is declining and was growing fearful that he would never leave the facility. The Social worker was interviewed on 4/12/13 at 1:30 PM. She stated the Psychologist that conducted the aforementioned psychological evaluation placed the report in her box on the 4/8/13 and she would have normally placed it on the NP's desk, but she was off that day which was one of the days the NP was in the building. She stated she left the report on the NP's desk 4/9/13 and she would see it the next time she came in the building on 4/10/13. Further review of the clinical record to include the Bowel Movement Worksheet indicated a "O" entered in the blocks for each shift for 7 days from 4/4-10/13. On 4/11/13 at 5:30 PM, the Director of Nursing stated the licensed nurse on the 3/11 shift was responsible to review the Bowel Movement Worksheets every evening and call the physician for an order for [REDACTED]. The NP was interviewed again on 4/11/13 at 5:45 PM. She stated when she examined the resident on 4/10/13 at 4:45 PM, he reported to her waves of pain and that it worsened with anus movement and stated he thought he had a BM and when the nurses checked there was nothing in his brief. The NP said she checked with the attending physician and was told to check the last time the resident had a BM, at which time she discovered according to CNA documentation on the BM Worksheet, no BM in 7 days. She stated based on her rectal exam, the resident was constipated with fecal impaction; a moderately firm ball of stool noted in the brief and another in the rectal vault. She stated she offered a fleets enema, but the resident wanted to try the MOM first. The NP further stated she added MOM PRN, [MEDICATION NAME] (osmotic-type laxative) every day, [MEDICATION NAME] (topical anesthetic) jelly to penis 4-5 time a day for penile discomfort and for the [MEDICAL CONDITION] an increase in [MEDICATION NAME] (improves urination in men with [MEDICAL CONDITION]) to 0.8 mg daily. She said the generalized pain was well controlled on the [MEDICATION NAME] and would be maintained on the medication. The NP stated she told the Assistant Director of Nursing (ADON) to inform her of no BM in 3 days. She said she was called by the ADON earlier on 4/11/13 for a fleets enema order because of very little results from the the MOM administered the evening of 4/10/13. According to the nurse's notes, the resident was administered a Fleets enema by the ADON on 4/11/13 around 3:15 PM with good results and verbalized relief in rectal pressure. The Interim Director of Nursing (IDON) and Corporate Nurse joined the interview at 6:00 PM. The NP reiterated to them she was not made aware of the type of pain described by the resident until inquiry of this writer on 4/10/13 at 4:10 PM. Resident #102 was re-interviewed on 4/11/13 at 5:15 PM. He stated he was completely relieved after the enema, passed a lot of stool he felt like "a new man". The nurse's notes dated 4/11/13 5:10 PM indicated the resident had large amounts of stool following the enema and additional documentation of large stool at 2:00 AM on 4/12/13. On 4/12/13 at 10:50 AM, the resident stated he had one of the best night's sleep than he had in several days and all he wants to do is rest after what he had gone through in the past few days. According to the resident his appetite had improved, as well as his meal consumption and his ability to sleep without rectal pain. On 4/12/13 at 11:00 AM, the Blue Unit LPN (#2) charge nurse stated she had the resident on the 7/3 shift since she started a month ago and was not made aware of rectal pressure type pain experienced by Resident #102. She stated it was the responsibility of the Certified Nursing Assistants (CNA) to report to the nurse any pain experienced by the residents, as well as alerting the nurse the resident had no bowel movements for successive days. She also stated the 3/11 licensed nurse was responsible to check the Bowel Movement Worksheet daily and call the physician for laxative orders if not BM in three days. The policy and procedures entitled Bowel Movement assessment dated [DATE] indicated the 3/11 shift clinical nurse checks the Bowel Movement Worksheet at the beginning of every shift for the date of the resident's last bowel movement. If the resident has not had a bowel movement by the third day, he/she is given a laxative or suppository depending upon the circumstances and the physician orders. Each AM, the 7/3 clinical nurse checks the Bowel Movement Worksheet as follow-up for effectiveness of the laxative or suppository. The facility's policy and procedure entitled Pain assessment dated [DATE] indicated residents would be assessed for pain when there is a new onset of pain or experiencing uncontrolled pain. A pain flow record would be maintained with the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record the following: Date and time, site/location, type of pain, intensity, precipitating/aggravating, interventions (non-medication/medication), intensity of pain after intervention, side effects and initials.

Based on staff interview, clinical record review and during the course of a complaint investigation the facility staff failed to provide the necessary care and services to maintain the highest practicable mental and psychosocial well-being for 1 of 3 residents in the survey sample, Resident #2. The facility staff failed to address the mental and psychosocial needs of Resident #2. The findings include: Resident #2 is a [AGE] year old admitted to the facility from another long term facility on 11/12/12 with [DIAGNOSES REDACTED]. Resident #2 resided on the secured / locked unit. The admission MDS (Minimum Data Set) with an assessment reference date of 11/19/12 evidenced the resident scored a 2 out of 15 on the BIMS (Brief Interview for Mental Status), indicating the resident has severely impaired cognition. The resident was assessed as exhibiting signs and symptoms of [MEDICAL CONDITION] such as inattention, disorganized thinking and altered level of consciousness which was an acute change in mental status from the resident's baseline. Under section E. Behaviors potential indicators for [MEDICAL CONDITION] such as hallucinations and delusions was checked for "none of the above". Resident #2 did not exhibit any overall presence of behavioral symptoms such as physical behaviors, verbal behaviors or other behavioral symptoms not directed towards others. Resident #2 did not exhibit any rejection of care necessary to achieve the resident's goals for health and well-being. Section E 0900 indicated the resident did exhibit wandering behaviors. The impact of the wandering placed the resident at risk for getting into a dangerous place (e.g. outside the facility), and significantly intruded on the privacy and or activities of others. Resident #2 required limited assistance of 1 staff for bed mobility and transfers, and required extensive assistance of 1 staff for walking in room and corridor, dressing, toileting, personal hygiene and bathing. Resident #2 was steady with ambulation and did not require a mobility device such as a cane, walker or wheelchair. The resident was frequently incontinent of both bladder and bowel. Review of the medication regime evidenced the resident was receiving [MEDICATION NAME] 10 mg (milligrams) every night for the treatment of [REDACTED]. Review of the clinical record evidenced the following identified behaviors for Resident #2: 1. Nursing notes 11/13/12 & 11/14/12- wanders into other resident rooms 2. Nursing notes 11/25/12-attempting to steal roommates clothing, grouchy, yelling 3. Nursing notes 11/28/12-agitated with redirection 4. Nursing notes 11/29/12-yelling at roommate 5. Nursing notes 12/2/12- exit seeking, entering other resident rooms 6. Nursing notes 12/2/12-went to other resident room and urinated on the floor and dresser 7. Nursing notes 12/24/12-refused accu check (blood sugar monitoring), grabbed nurses finger & bent it 8. Nursing notes 1/9/13-argumentative with staff & roommate 9. Behavioral flow sheet 1/24/13- physical aggression 10. ADL flowsheet 1/24/13-while trying to assist resident out of another residents room became combative 11. Nursing notes 2/14/13-argumentative with staff & roommate 12. Weekly Nursing progress notes: 11/26/12-some agitation 12/7/12-bed seeks, voiding in other resident room dresser drawers 12/21/12-has BM's (bowel movements) voids (urinates) in other resident dressers, takes others clothes 12/28/12-takes things out of other resident rooms, voids in other things 2/1/13-delusional 2/15/13-at times get's verbally aggressive 13. The Behavior /Intervention Monthly Flow Record evidenced the resident exhibited 2 episodes of physical aggression requiring redirection and 1:1 interventions during the evening shift on 12/24/12. Interviews were conducted with staff and certified nurse aides (CNA's) during the survey; the following statements were obtained: 1. On 2/20/13 at 1:26 P.M., the licensed practical nurse MDS coordinator stated,"When I did his MDS he did not have any behaviors on admission...I was not aware of any behaviors...just the wandering". 2. On 2/21/13 at 10:47 A.M., CNA#1,"He (Resident #2) was real nice, easy to do, only time he gave me a problem was in the afternoon to change him...he would get agitated with his roommate...he doesn't get that agitated to the point of getting physical..." 3. On 2/22/13 at 11:21 A.M., CNA #2 stated, "One day (1/24/13) he wandered into another residents room, I went to direct him out of the room, he was like"No", he was fiddling with the sheets on the bed, a resident was in the bed at this time...I said it looks like your wet let's go change you...we were walking out of the room and suddenly he turned around and grabbed my wrist tight...he put a tight lock on it...he wouldn't let go...I had to pull and tug to get his hand off my wrist...I notified the charge nurse". When asked if this was a change in his behavior she said,"For the most part he was calm, at times he would get agitated...that was the first time he got aggressive towards me...he would come out of his room sometimes and open the closet drawer in the hall and urinate in the drawers. I heard he had a BM in his laundry hamper". Review of the clinical record did not evidence the physician was notified of this incident. 4. On 2/22/13 at 11:37 A.M., licensed practical nurse (LPN#1) stated," He didn't like to get his finger stuck (for the blood sugars), one day he was grabbing and fighting, he was trying to slap my hand away...he did slap my hand...somebody in his room peed in both water pitchers...we couldn't figure out who..." 5. On 2/20/13 at 2:15 P.M., CNA #3 was asked if Resident #2 had aggressive behaviors and she stated, "Yea, I heard he got really loud and swung at a CNA (the CNA was not identified)... he is not really aggressive with me he just gets agitated...it get's worse in the evenings". The plan of care failed to evidence development of intervention strategies to prevent occurrences and monitoring for changes that would trigger abusive behaviors such as verbal and physical aggression. The plan of care was not revised to address the resident's inappropriate behavior of voiding or defecating in drawers or other areas. The comprehensive plan of care was not revised to include individualized diversional activities. The impaired cognition plan of care related to dementia was not revised to include behavioral strategies to prevent occurrences of agitation. On 2/21/13 at 4:00 P.M., the licensed practical nurse (LPN#2) was interviewed. When asked if Resident #2 was on a behavioral management plan of care or any other behavioral program she stated, "No...not that I am aware of". She stated Resident #2 becomes "frustrated" when redirected. LPN#2 was asked if a resident exhibited aggressive behaviors what is the course of action? She stated, "I would step in, redirect and make sure both were okay...for him (Resident #2) I would note it in the chart, put it in the nurse practitioners communication book and request for a psych consult." Review of the clinical record evidenced the aggressive behavior exhibited by Resident #2 on 1/24/13 was not noted in the nurses progress notes or in the nurse practitioners communication book. The plan of care was not revised to include intervention strategies to prevent occurrences. On 2/16/13 at approximately 7:45 PM to 8:00 P.M., Resident #2 wandered into Resident #3's room unnoticed and began physically assaulting her. As a result of the assault, Resident #3 was hospitalized and sustained extensive bruising to her face, swelling and bruising to both eyes, and a 2.5 to 3 inch skin tear to the left lower cheek area. Review of the clinical record evidenced resident #2 was receiving rehab services at another long term facility, from there he was admitted to the hospital from 11/6/12 -11/8/12 and discharged back to that long term facility (LTC#1). The hospital transfer summary discharge plan was for a psych consult for Resident #2 related to his [DIAGNOSES REDACTED]. On 11/12/12 Resident #2 was transferred to this long term care facility (LTC#2) before the psych consult could be obtained. [MEDICAL CONDITION] is a loss of contact with reality, usually including false beliefs about what is taking place or who one is (delusions) and seeing or hearing things that aren't there (hallucinations). On 2/21/13 at 1:44 P.M., the medical director ( Resident #2's attending physician) was interviewed. When asked to describe Resident #2 behaviors he stated,"They are pretty unremarkable...he was on the closed unit due to wandering...that's my understanding". The above facility identified behaviors prior to the assault on 2/16/13 were shared with the physician at this time. When asked if he was made aware of these behaviors he stated, "No". When asked if he would have expected the staff to have informed him of them he stated, "Yes". When asked if he would have implemented any changes to the current orders based on these behaviors he stated,"Behavior modification program, perhaps a 1:1, focus on changing behaviors". When asked if he participated in the development of the interdisciplinary plan of care for Resident #2 he stated, "No". The hospital discharge summary for a psych consult was discussed. The physician stated he was not aware of the request for a psych consult. The physician was asked if a psych consult would have been warranted based on the resident's behaviors prior to 2/16/13 he stated, "I agree...now with 20/20 hindsight, absolutely". Review of the social services progress notes dated 11/15/12 indicated Resident #2 was admitted to the facility due to dementia and need for the locked unit for safety awareness. She documented the resident has dementia with delusions, anxiety and agitation. "Gets agitated if he is told not to do something, at time mimic scenes from TV shows and will present with delusions and hallucinations at moments. The Social Service assessment dated [DATE] indicated the resident transfers and ambulated independently. The resident was alert & orientated with cognitive impairment and confusion. Under Mood State/Behavior Problems/ Psychosocial Adjustment the social worker documented, "Like {sic} to be to himself, likes to walk at night, if you try to tell him he can't go he will get agitate {sic} and say I can do what I want to do I am grown. Mimics TV shows, has times when he will present delusions and hallucinations". On 2/20/12 at 12:49 P.M., the social worker (SW) was interviewed. The facility identified behaviors in the clinical record were shared. She stated she had not been made aware of these behaviors. She stated she took over the responsibility of development of behavioral care plans at the beginning of February 2013, prior to this it was the responsibility of the unit managers. When asked if a behavioral plan of care should have been developed for Resident #2, she stated, "Absolutely". She also stated, "If the nurses felt he needed a psych consult they would tell me and I would put it on the list...the psychologist nurse practitioner comes here every Tuesday and Wednesday, and the psychiatrist comes here every Monday." The SW was asked if a psych consult would have been warranted based on the aforementioned behaviors prior to the abuse on 2/16/13, she stated, "Yes". The SW was not able to describe what type of hallucinations the resident was exhibiting. On 2/21/13 at 3:17 P.M., the director of nurses (DON) was interviewed, in attendance was the vice president of operations (VPO), the assistant director of nurses and the corporate nurse. The above behaviors for Resident #2 was discussed. The DON stated it is the responsibility of the SW to conduct behavior assessments, documentation and development of the behavior plan of care. When asked if the resident was on any behavioral programs based on his needs she stated, "No, not that I can see". While looking through the clinical record, the DON was asked if a behavioral plan of care was needed for Resident #2, she stated, "That's what I am looking for". The DON was asked if the resident had any aggressive behaviors, she stated, "No". The VPO asked the DON if the resident was aggressive with redirection, she replied, "No". When asked if the above behaviors were a change in behavior for Resident #2 she stated, "No, it is part of the dementia...I don't believe he had a change in behavior...he had agitation..." She stated behavioral interventions for Resident #2 included diversional activities, redirection and removing him from the situation. Review of the comprehensive plan of care did not include individualized diversional activities. The DON stated the nurse practitioner and the physician assessed the resident. Review of the nurse practitioner progress notes and the physician progress notes [REDACTED]. 1. Admission history and physical dated 11/13/12 by the physician: Emotional: delusional at times. Diagnoses: [REDACTED]. There is no mention of behaviors. 2. Nurse practitioner regular visit note dated 12/19/12: ...nursing notes and notes from previous facility document wandering, delusions and confusion at times. Psych: Awake, A&O x 2 today. There is no mention of behaviors. 3. Physician regular visit note dated 1/20/13: A&O x 1 (alert and orientated) Impression: Alzheimer's, NIDDM, all orders reviewed. There is no mention of behaviors. According to the Alzheimer's Association anyone experiencing behavioral symptoms should receive a thorough medical checkup, especially when symptoms appear suddenly. Treatment depends on a careful diagnosis, determine possible causes and the types of behavior the person is experiencing. Aggression can be caused by many factors including physical discomfort, environmental factors and poor communication. Medication interactions could also worsen agitation. If a person with Alzheimer's begins hallucinating, it's important to have a medical evaluation to rule out other possible causes and to determine if medication is needed. Prior to exiting the survey the facility did not provide the surveyor with any additional information on additional services provided to the resident to maintain his highest practicable mental and psychosocial well being.

Based on staff interview, clinical record review and during the course of a complaint investigation the facility staff failed to provide adequate supervision to prevent injury for 2 of 3 residents in the survey sample, Resident #3 and #2. The findings include: 1. Resident #3 was an [AGE] year old admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Resident #3 resided on the peach unit (secured/ locked unit). The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 1/21/13 assessed the resident as scoring a 1 out of 15 on the BIMS. Resident #3 exhibited physical behavioral symptoms directed towards others. Resident #3 required extensive assistance from 2 staff for bed mobility, and was dependent on staff for transfers, dressing, toileting, personal hygiene and bathing. The State Agency (SA) received a Facility Reported Incident (FRI) indicating there was an incident of resident to resident physical abuse between Resident #3 and Resident #2 that occurred on 2/16/13. Further investigation by the SA evidenced the following: At approximately 7:45 PM to 8:00 P.M., on 2/16/13 Resident #2 wandered into Resident #3's room unnoticed and physically assaulted her. Both residents were sent to the emergency room for evaluation. Review of the emergency room hospital records documented the following assessment of the injuries sustained by Resident #3, "Extensive bruising to face, bilateral periorbital bruising (around the eyes) and swelling, 2 1/2 to 3 inch skin tear to left lower cheek, bleeding controlled at this time, multiple hematoma's to head (a collection of blood, usually clotted, in a tissue or organ, caused by a break in a blood vessel), multiple scattered bruising to both arms, skin tear to left arm that was steri stripped and wrapped in Kerlix by nursing home prior to arrival." The emergency department [DIAGNOSES REDACTED]. 1. Facial contusion 2. Soft tissue injury 3. Dementia 4. Closed head injury The emergency physician documented the following: "[AGE] year old female admitted for evaluation for assault, obviously the patient is a nursing home resident for Alzheimer's who was in her room and she was assaulted by another demented resident, she came in here with contusion all over her face as well as bruises, she was seen by the ER physician and will be admitted for pain that is progressively getting worse into her face, with multiple bruises." Resident #2 received the following pain medication during her hospitalization : 1. IV Morphine 4 mg (milligram) at 10:54 P.M., on 2/16/13. 2. IV Morphine 2 mg at 3:24 P.M., on 2/17/13 3. Tramadol 50 mg one tablet at 9:32 A.M.,on 2/18/13 4. Tramadol 50 mg one tablet at 9: 04 P.M.,on 2/19/13 5. Tramadol 50 mg one tablet at 3:51 P.M.,on 2/20/13 6. Tramadol 50 mg one tablet at 5:00 A.M.,on 2/21/13 On hospital day #2 the physician documented the following: "She had a drop in her H&H (hemoglobin and hematocrit), presumably from some minor bleeding from the contusions and because she is already so iron deficient. " As a result, Resident #2 was transfused 2 units of packed red blood cells. The laboratory results were: Hemoglobin 7.6 and Hematocrit 11.6. Normal lab reference range is Hemoglobin 12.6-17.1, and Hematocrit 35.1-48.3. Resident #3 was discharged on [DATE] to another long term facility. Interviews with staff on duty at the time of the incident was conducted as follows: On 2/20/13 at 3:00 P.M., certified nurse aide (CNA#4) was interviewed. She stated,"I was coming out of another residents room when I heard a scream, I went to the room and noticed the door was closed, I opened the door and he (Resident #2) was sitting on her (Resident #3's) bed...he had his fist up...I immediately yelled for help, the nurse was at the cart, I asked him to get up... I tried to get him up (Resident #2)... it took me and two other staff to get him out of the room, he had blood on his hands, she (Resident #3) was bleeding...we got her vital signs, the nurse cleaned her up, we got another aide to do 1 to 1 (for Resident #2)...the other aide heard him say she "deserved it"...he was calm after this..." On 2/20/13 at 2:15 P.M., CNA #3 was interviewed about the incident. She stated, "There were four of us (CNA's) working that evening, two of them were at lunch, so it left me and (CNA#4), it was after dinner and I needed to do some ADL care. I asked a resident if she needed to go to the bathroom, I took her to her room and didn't notice another resident had followed me into the room. I asked CNA#4 to come in and help take this resident out of the room because the resident in the first bed was getting upset, she was saying,"Get her out of my room before I punch her". CNA #4 escorted the resident out of the room. I began to take the resident to the bathroom, at that time I heard my name being called. The way my name was called I knew I had to leave right away. I sat the resident back on her bed and I power walked to (Resident #3's) room. I poked my head in and I said "Oh my god". I saw Resident #2 sitting on (Resident #3's) bed...his hand was raised...I saw so much blood...I thought I was going to puke. I immediately called for the nurse. It literally took all 3 of us to get him off her...off the bed...he shook his arms and got agitated and said," We'll she deserved it" We stood him up and he looked back at her (Resident #3) and said, "She deserved it". I had a nightmare that night about it". 2. Resident #2 is a [AGE] year old admitted to the facility from another long term facility on 11/12/12 with [DIAGNOSES REDACTED]. Resident #2 resided on the secured / locked unit. The admission MDS (Minimum Data Set) with an assessment reference date of 11/19/12 evidenced the resident scored a 2 out of 15 on the BIMS (Brief Interview for Mental Status), indicating the resident has severely impaired cognition. The resident was assessed as exhibiting signs and symptoms of delirium such as inattention, disorganized thinking and altered level of consciousness which was an acute change in mental status from the resident's baseline. Under section E. Behaviors potential indicators for psychosis such as hallucinations and delusions was checked for "none of the above". Resident #2 did not exhibit any overall presence of behavioral symptoms such as physical behaviors, verbal behaviors or other behavioral symptoms not directed towards others. Resident #2 did not exhibit any rejection of care necessary to achieve the resident's goals for health and well-being. Section E 0900 indicated the resident did exhibit wandering behaviors. The impact of the wandering placed the resident at risk for getting into a dangerous place (e.g. outside the facility), and significantly intruded on the privacy and or activities of others. Resident #2 required limited assistance of 1 staff for bed mobility and transfers, and required extensive assistance of 1 staff for walking in room and corridor, dressing, toileting, personal hygiene and bathing. Resident #2 was steady with ambulation and did not require a mobility device such as a cane, walker or wheelchair. The resident was frequently incontinent of both bladder and bowel. Review of the clinical record evidenced the following identified behaviors for Resident #2: 1. Nursing notes 11/13/12 & 11/14/12- wanders into other resident rooms 2. Nursing notes 11/28/12-agitated with redirection 3. Nursing notes 11/29/12-yelling at roommate 4. Nursing notes 12/24/12-refused accu check (blood sugar monitoring), grabbed nurses finger & bent it 5. Nursing notes 1/9/13-argumentative with staff & roommate 6. Behavioral flow sheet 1/24/13- physical aggression 7. ADL flowsheet 1/24/13-while trying to assist resident out of another residents room became combative 8. Nursing notes 2/14/13-argumentative with staff & roommate 9. Weekly Nursing progress notes: 11/26/12-some agitation 12/7/12-bed seeks, voiding in other resident room dresser drawers 12/28/12-takes things out of other resident rooms, voids in other things 2/1/13-delusional 2/15/13-at times get's verbally aggressive 10. The Behavior /Intervention Monthly Flow Record evidenced the resident exhibited 2 episodes of physical aggression requiring redirection and 1:1 interventions during the evening shift on 12/24/12. Review of the resident's comprehensive plan of care did not include a behavioral plan of care or development of intervention strategies to prevent occurrences and monitoring for changes that would trigger abusive behaviors such as verbal and physical aggression. An elopement risk care plan was developed based on the resident's history of wandering and /or elopement due to acute or chronic confusion or disorientation. Two of the approaches listed was to redirect the resident from doors and exit as needed, and assess for wandering/ elopement patterns. There were no specific interventions listed addressing the resident's behavior of wandering into other resident rooms. On 2/20/13 at 2:15 P.M., CNA #3 stated on 2/16/13 during dinner Resident #2 had "gotten aggressive with 2 residents", stating, "I didn't witness the first one, I was giving a shower to a resident." The 2nd incident she stated (Resident #2) was being directed to sit at another dinner table, another resident was in his way she stated, "He got upset (Resident #2), acting like he was going to go after him". CNA #3 stated there were 4 CNA's working that evening due to CNA#4 coming in extra due to the anticipated inclement weather that was expected that evening (snow). On 2/2/20/13 at 3:00 P.M., CNA#4 was interviewed and asked to describe the dinner incident on 2/16/13 between Resident #2 and another resident on 2/16/13. She stated,"He (Resident #2) became agitated when we were passing out dinner trays, I guess it was over a racial slur, he (Resident #2) grabbed hold of this other residents arms and held them down, we separated them and he was saying (Resident #2) "He better watch himself, he better get his MF (explicit word) out of the way". On 2/20/13 at 3:56 P.M., CNA#5 was interviewed, and asked to describe the dinner incident on 2/16/13 between Resident #2 and another resident. She stated, " We were prepping for dinner and (Resident #2) and another resident were sitting at the same table, it was brought to my attention by the nurse who yelled, and I saw the other resident swinging towards Resident #2. Resident #2 was holding his arms (other resident) to prevent him from hitting him. The two residents were separated. Resident #2 stated, "If the MF (explicit word) hits me again I am gonna beat the (explicit word) out of him". We were escorting him (Resident #2) to another table, and another resident was in his way. Resident #2 yelled at this resident...I had not heard him (Resident #2) say this before...I was shocked and appalled". The CNA stated after dinner Resident #2 was observed calm and watching TV in the activity area of the unit. She stated," It's a very active unit...we try to make it safe for everyone...at all times we have a CNA who is monitoring...this evening we didn't have an activities assistant to help monitor residents...they usually leave at 5:30 P.M., but we haven't had on one the weekends for a while now...the charge nurse helps us monitor...we have a lot of wanderers...you have to constantly monitor those residents..." At the time of the incident CNA #5 stated she and another CNA were off the unit for a dinner break...stating," we rotate out for dinner...if we have 4 CNA's that shift then 2 of us will go to dinner at the same time". Between 7:45 PM to 8:00 P.M., Resident #2 wandered into Resident #3's room unnoticed and physically assaulted her. According to the charge nurse on duty that evening (LPN#2) she was monitoring the residents while the 2 CNA's on the floor were attending to other residents in their room. She stated, "At 7:45 P.M., I was sitting at the nurses station, looking at the residents who were watching TV, I said to myself I need to get up I had meds to give and treatments to do...I walked to the treatment cart and got out supplies...then one of the CNA's called me and said "come quick"...I went in there (Resident #3's room). I saw (Resident #2) sitting on the bed...we assisted him out of the room immediately...I assessed (Resident #2) for injuries...I cleaned her arm, there was a skin tear on her arm...I applied a saline compress to her cheek...I knew she would have to go the hospital...I called 911..." Resident #3's right hand was bleeding and swollen especially the 3rd and 4th knuckles..." The nurse was asked to describe what she was doing while she was sitting at the nurses station ,she stated, "charting...I kept looking up...there were 2 CNA's somewhere in the area in residents rooms...there were some (residents) wandering...one CNA was at lunch and the other (CNA) I am not sure where she was...Resident #2 was watching TV". The area where Resident #2 was watching TV was directly across from Resident #3's room. The charge nurse (LPN#2) stated that while she was at the treatment cart her back was turned away from the residents. She stated, "I usually work 11-7 shift, this was my first 3-11 shift by myself. I know (Resident #2) wanders, he would go into other resident rooms, if they wander into other resident rooms we get them out immediately". At the time of the assault, there were 3 staff on the unit. Two CNA's were in a resident room, one was attempting to toilet a resident, one was assisting with redirecting a wandering resident, and the charge nurse was at the treatment cart prepping for the administration of treatments. In the few minutes that the charge nurse was not supervising the residents the assault occurred. At the time of the assault the census on the secured unit was 29.

Based on staff interview, clinical record review and during the course of a complaint investigation the facility staff neglected to develop intervention strategies to prevent physical abuse for 2 of 3 residents in the survey sample, Resident #3 and #2. 1. Resident #3 was physically abused by Resident #2, resulting in hospitalization . 2. Resident #2 exhibited behaviors that were not addressed by the facility. The findings include: 1. Resident #3 was an [AGE] year old admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Resident #3 resided on the secured/ locked unit. The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 1/21/13 assessed the resident as scoring a 1 out of 15 on the BIMS. Resident #3 exhibited physical behavioral symptoms directed towards others. Resident #3 required extensive assistance from 2 staff for bed mobility, and was dependent on staff for transfers, dressing, toileting, personal hygiene and bathing. The State Agency (SA) received a Facility Reported Incident (FRI) indicating there was an incident of resident to resident physical abuse between Resident #3 and Resident #2 that occurred on 2/16/13. Further investigation by the SA evidenced the following: On 2/20/13 at 3:00 P.M., certified nurse aide (CNA#4) was interviewed. She stated,"I was coming out of another residents room when I heard a scream, I went to the room and noticed the door was closed, I opened the door and he (Resident #2) was sitting on her (Resident #3's) bed...he had his fist up...I immediately yelled for help, the nurse was at the cart, I asked him to get up... I tried to get him up (Resident #2)... it took me and two other staff to get him out of the room, he had blood on his hands, she (Resident #3) was bleeding...we got her vital signs, the nurse cleaned her up, we got another aide to do 1 to 1 (for Resident #2)...the other aide heard him say she "deserved it"...he was calm after this..." On 2/20/13 at 2:15 P.M., CNA #3 was interviewed about the incident. She stated, "There were four of us (CNA's) working that evening, two of them were at lunch, so it left me and (CNA#4), it was after dinner and I needed to do some ADL care. I asked a resident if she needed to go to the bathroom, I took her to her room and didn't notice another resident had followed me into the room. I asked CNA#4 to come in and help take this resident out of the room because the resident in the first bed was getting upset, she was saying,"Get her out of my room before I punch her". CNA #4 escorted the resident out of the room. I began to take the resident to the bathroom, at that time I heard my name being called. The way my name was called I knew I had to leave right away. I sat the resident back on her bed and I power walked to (Resident #3's) room. I poked my head in and I said "Oh my god". I saw Resident #2 sitting on (Resident #3's) bed...his hand was raised...I saw so much blood...I thought I was going to puke. I immediately called for the nurse. It literally took all 3 of us to get him off her...off the bed...he shook his arms and got agitated and said," We'll she deserved it" We stood him up and he looked back at her (Resident #3) and said, "She deserved it". I had a nightmare that night about it". CNA #3 stated there were 4 CNA's working that evening due to CNA#4 coming in extra due to the anticipated inclement weather that was expected that evening (snow). Review of the emergency room hospital records documented the following assessment of the injuries sustained by Resident #3, "Extensive bruising to face, bilateral periorbital bruising (around the eyes) and swelling, 2 1/2 to 3 inch skin tear to left lower cheek, bleeding controlled at this time, multiple hematoma's to head (a collection of blood, usually clotted, in a tissue or organ, caused by a break in a blood vessel), multiple scattered bruising to both arms, skin tear to left arm that was steri stripped and wrapped in Kerlix by nursing home prior to arrival." The emergency department [DIAGNOSES REDACTED]. 1. Facial contusion 2. Soft tissue injury 3. Dementia 4. Closed head injury The emergency physician documented the following: "[AGE] year old female admitted for evaluation for assault, obviously the patient is a nursing home resident for Alzheimer's who was in her room and she was assaulted by another demented resident, she came in here with contusion all over her face as well as bruises, she was seen by the ER physician and will be admitted for pain that is progressively getting worse into her face, with multiple bruises." Resident #2 received the following pain medication during her hospitalization : 1. IV [MEDICATION NAME] 4 mg (milligram) at 10:54 P.M., on 2/16/13. 2. IV [MEDICATION NAME] 2 mg at 3:24 P.M., on 2/17/13 3. [MEDICATION NAME] 50 mg one tablet at 9:32 A.M.,on 2/18/13 4. [MEDICATION NAME] 50 mg one tablet at 9: 04 P.M.,on 2/19/13 5. [MEDICATION NAME] 50 mg one tablet at 3:51 P.M.,on 2/20/13 6. [MEDICATION NAME] 50 mg one tablet at 5:00 A.M.,on 2/21/13 On hospital day #2 the physician documented the following: "She had a drop in her H&H (hemoglobin and hematocrit), presumably from some minor bleeding from the contusions and because she is already so iron deficient. " As a result, Resident #2 was transfused 2 units of packed red blood cells. The laboratory results were: Hemoglobin 7.6 and Hematocrit 11.6. Normal lab reference range is Hemoglobin 12.6-17.1, and Hematocrit 35.1-48.3. 2. Resident #2 is a [AGE] year old admitted to the facility from another long term facility on 11/12/12 with [DIAGNOSES REDACTED]. Resident #2 resided on the secured / locked unit. The admission MDS (Minimum Data Set) with an assessment reference date of 11/19/12 evidenced the resident scored a 2 out of 15 on the BIMS (Brief Interview for Mental Status), indicating the resident has severely impaired cognition. The resident was assessed as exhibiting signs and symptoms of [MEDICAL CONDITION] such as inattention, disorganized thinking and altered level of consciousness which was an acute change in mental status from the resident's baseline. Under section E. Behaviors potential indicators for [MEDICAL CONDITION] such as hallucinations and [MEDICAL CONDITION] was checked for "none of the above". Resident #2 did not exhibit any overall presence of behavioral symptoms such as physical behaviors, verbal behaviors or other behavioral symptoms not directed towards others. Resident #2 did not exhibit any rejection of care necessary to achieve the resident's goals for health and well-being. Section E 0900 indicated the resident did exhibit wandering behaviors. The impact of the wandering placed the resident at risk for getting into a dangerous place (e.g. outside the facility), and significantly intruded on the privacy and or activities of others. Resident #2 required limited assistance of 1 staff for bed mobility and transfers, and required extensive assistance of 1 staff for walking in room and corridor, dressing, toileting, personal hygiene and bathing. Resident #2 was steady with ambulation and did not require a mobility device such as a cane, walker or wheelchair. The resident was frequently incontinent of both bladder and bowel. Review of the medication regime evidenced the resident was receiving [MEDICATION NAME] 10 mg (milligrams) every night for the treatment of [REDACTED]. Review of the clinical record evidenced the following identified behaviors for Resident #2: 1. Nursing notes 11/13/12 & 11/14/12- wanders into other resident rooms 2. Nursing notes 11/17/12-anxious, exit seeking 3. Nursing notes 11/25/12-attempting to steal roommates clothing, grouchy, yelling 4. Nursing notes 11/28/12-agitated with redirection 5. Nursing notes 11/29/12-yelling at roommate 6. Nursing notes 12/2/12- exit seeking, entering other resident rooms 7. Nursing notes 12/2/12-went to other resident room and urinated on the floor and dresser 8. Nursing notes 12/24/12-refused accu check (blood sugar monitoring), grabbed nurses finger & bent it 9. Nursing notes 1/9/13-argumentative with staff & roommate 10. Behavioral flow sheet 1/24/13- physical aggression 11. Nursing notes 1/20/13-refused accu check 12. ADL flowsheet 1/24/13-while trying to assist resident out of another residents room became combative 13. Nursing notes 2/14/13-argumentative with staff & roommate 14. Weekly Nursing progress notes: 11/26/12-some agitation 12/7/12-bed seeks, voiding in other resident room dresser drawers 12/21/12-has BM's (bowel movements) voids (urinates) in other resident dressers, takes others clothes 12/28/12-takes things out of other resident rooms, voids in other things 2/1/13-delusional 2/15/13-at times get's verbally aggressive 15. The Behavior /Intervention Monthly Flow Record evidenced the resident exhibited 2 episodes of physical aggression requiring redirection and 1:1 interventions during the evening shift on 12/24/12. Interviews were conducted with staff and certified nurse aides (CNA's) during the survey; the following statements were obtained: 1. On 2/20/13 at 1:26 P.M., the licensed practical nurse MDS coordinator stated,"When I did his MDS he did not have any behaviors on admission...I was not aware of any behaviors...just the wandering". 2. On 2/21/13 at 10:47 A.M., CNA#1,"He (Resident #2) was real nice, easy to do, only time he gave me a problem was in the afternoon to change him...he would get agitated with his roommate...he doesn't get that agitated to the point of getting physical..." 3. On 2/22/13 at 11:21 A.M., CNA #2 stated, "One day (1/24/13) he wandered into another residents room, I went to direct him out of the room, he was like"No", he was fiddling with the sheets on the bed, a resident was in the bed at this time...I said it looks like your wet let's go change you...we were walking out of the room and suddenly he turned around and grabbed my wrist tight...he put a tight lock on it...he wouldn't let go...I had to pull and tug to get his hand off my wrist...I notified the charge nurse". When asked if this was a change in his behavior she said,"For the most part he was calm, at times he would get agitated...that was the first time he got aggressive towards me...he would come out of his room sometimes and open the closet drawer in the hall and urinate in the drawers. I heard he had a BM in his laundry hamper". Review of the clinical record did not evidence the physician was notified of this incident. 4. On 2/22/13 at 11:37 A.M., licensed practical nurse (LPN#1) stated," He didn't like to get his finger stuck (for the blood sugars), one day he was grabbing and fighting, he was trying to slap my hand away...he did slap my hand...somebody in his room peed in both water pitchers...we couldn't figure out who..." Review of the resident's comprehensive plan of care did not include a behavioral plan of care or development of intervention strategies to prevent occurrences and monitoring for changes that would trigger abusive behaviors such as verbal and physical aggression. On 2/21/13 at 4:00 P.M., the licensed practical nurse (LPN#2) was interviewed. When asked if Resident #2 was on a behavioral management plan of care or any other behavioral program she stated, "No...not that I am aware of". She stated Resident #2 becomes "frustrated" when redirected. LPN#2 was asked if a resident exhibited any physically aggressive behaviors what is the course of action? She stated, "I would step in, redirect and make sure both were okay...for him (Resident #2) I would note it in the chart, put it in the nurse practitioners communication book and request for a psych consult." Review of the clinical record evidenced the physically aggressive behavior exhibited by Resident #2 on 1/24/13 was not noted in the nurses progress notes or in the nurse practitioners communication book. The plan of care was not revised to include intervention strategies to prevent occurrences. On 2/20/13 at 2:15 P.M., CNA #3 was asked if Resident #2 had aggressive behaviors and she stated, "Yea, I heard he got really loud and swung at a CNA (the CNA was not identified)... he is not really aggressive with me he just gets agitated...it get's worse in the evenings". CNA#3 stated on 2/16/13 during dinner Resident #2 had "gotten aggressive with 2 residents", stating, "I didn't witness the first one, I was giving a shower to a resident." The 2nd incident she stated (Resident #2) was being directed to sit at another dinner table, another resident was in his way she stated, "He got upset (Resident #2), acting like he was going to go after him". On 2/2/20/13 at 3:00 P.M., CNA#4 was interviewed and asked to describe the dinner incident on 2/16/13 between Resident #2 and another resident. She stated,"He (Resident #2) became agitated when we were passing out dinner trays, I guess it was over a racial slur, he (Resident #2) grabbed hold of this other residents arms and held them down, we separated them and he was saying (Resident #2) "He better watch himself, he better get his MF (explicit word) out of the way". On 2/20/13 at 3:56 P.M., CNA#5 was interviewed, and asked to describe the dinner incident on 2/16/13 between Resident #2 and another resident. She stated, " We were prepping for dinner and (Resident #2) and another resident were sitting at the same table, it was brought to my attention by the nurse who yelled, and I saw the other resident swinging towards Resident #2. Resident #2 was holding his arms (other resident) to prevent him from hitting him. The two residents were separated. Resident #2 stated, "If the MF (explicit word) hits me again I am gonna beat the (explicit word) out of him". We were escorting him to another table, and another resident was in his way. Resident #2 yelled at this resident...I had not heard him (Resident #2) say this before...I was shocked and appalled". The CNA stated after dinner Resident #2 was observed calm and watching TV in the activity area of the unit. Following the aforementioned altercations during dinner, Resident #2 was not placed on a specialty watch to ensure the safety of other residents. The charge nurse on duty stated she was monitoring the residents while the 2 CNA's on the floor were attending to other residents in their room. At approximately 7:45 PM to 8:00 P.M., Resident #2 wandered into Resident #3's room unnoticed and physically assaulted her. Resulting in Resident #3 being hospitalized , as mentioned above. Review of the clinical record evidenced resident #2 was receiving rehab services at another long term facility, from there he was admitted to the hospital from 11/6/12 -11/8/12 and discharged back to that long term facility (LTC#1). The hospital transfer summary discharge plan was for a psych consult for Resident #2 related to his [DIAGNOSES REDACTED].#2) before the psych consult could be obtained. [MEDICAL CONDITION] is a loss of contact with reality, usually including false beliefs about what is taking place or who one is ([MEDICAL CONDITION]) and seeing or hearing things that aren't there (hallucinations). On 2/21/13 at 1:44 P.M., the medical director ( Resident #2's attending physician) was interviewed. When asked to describe Resident #2 behaviors he stated,"They are pretty unremarkable...he was on the closed unit due to wandering...that's my understanding". The above facility identified behaviors prior to the assault on 2/16/13 were shared with the physician at this time. When asked if he was made aware of these behaviors he stated, "No". When asked if he would have expected the staff to have informed him of them he stated, "Yes". When asked if he would have implemented any changes to the current orders based on these behaviors he stated,"Behavior modification program, perhaps a 1:1, focus on changing behaviors". When asked if he participated in the development of the interdisciplinary plan of care for Resident #2 he stated, "No". The hospital discharge summary for a psych consult was discussed. The physician stated he was not aware of the request for a psych consult. The physician was asked if a psych consult would have been warranted based on the resident's behaviors prior to 2/16/13 he stated, "I agree...now with 20/20 hindsight, absolutely". Review of the social services progress notes dated 11/15/12 indicated Resident #2 was admitted to the facility due to dementia and need for the locked unit for safety awareness. She documented the resident "Gets agitated if he is told not to do something, at time mimic scenes from TV shows and will present with [MEDICAL CONDITION] and hallucinations at moments." The Social Service assessment dated [DATE] indicated the resident transfers and ambulated independently. The resident was alert & orientated with cognitive impairment and confusion. Under Mood State/Behavior Problems/ Psychosocial Adjustment the social worker documented, "Like {sic} to be to himself, likes to walk at night, if you try to tell him he can't go he will get agitate {sic} and say I can do what I want to do I am grown. Mimics TV shows, has times when he will present [MEDICAL CONDITION] and hallucinations". The SW was not able to describe what type of hallucinations the resident was exhibiting. On 2/20/13 at 12:49 P.M., the social worker (SW) was interviewed. The facility identified behaviors in the clinical record was shared. She stated she was not aware of these behaviors. She stated she took over the responsibility of development of behavioral care plans at the beginning of February 2013, prior to this it was the responsibility of the unit managers. When asked if a behavioral plan of care should have been developed for Resident #2, she stated, "Absolutely". She also stated, "If the nurses felt he needed a psych consult they would tell me and I would put it on the list...the psychologist nurse practitioner comes here every Tuesday and Wednesday, and the psychiatrist comes here every Monday." The SW was asked if a psych consult would have been warranted based on the aforementioned behaviors prior to the abuse on 2/16/13, she stated, "Yes". On 2/21/13 at 3:17 P.M., the director of nurses (DON) was interviewed, in attendance was the Vice President of Operations (VPO), the assistant director of nurses and the Regional Director of Clinical Services. The above behaviors for Resident #2 was discussed. The DON stated it is the responsibility of the SW to conduct behavior assessments, documentation and development of the behavior plan of care. When asked if the resident was on any behavioral programs based on his needs she stated, "No, not that I can see". While looking through the clinical record, the DON was asked if a behavioral plan of care was needed for Resident #2, she stated, "That's what I am looking for". The DON was asked if the resident had any aggressive behaviors, she stated, "No". The VPO asked the DON if the resident was aggressive with redirection, she replied, "No". When asked if the above behaviors were a change in behavior for Resident #2 she stated, "No, it is part of the dementia...I don't believe he had a change in behavior...he had agitation..." She stated behavioral interventions for Resident #2 included diversional activities, redirection and removing him from the situation. Review of the comprehensive plan of care did not include individualized diversional activities. The DON stated the nurse practitioner and the physician assessed the resident. Review of the nurse practitioner progress notes and the physician progress notes [REDACTED]. 1. Admission history and physical dated 11/13/12 by the physician: Emotional: delusional at times. Diagnoses: [REDACTED]. There is no mention of behaviors. 2. Nurse practitioner regular visit note dated 12/19/12: ...nursing notes and notes from previous facility document wandering, [MEDICAL CONDITION] and confusion at times. Psych: Awake, A&O x 2 today. There is no mention of behaviors. 3. Physician regular visit note dated 1/20/13: A&O x 1 (alert and orientated) Impression: Alzheimer's, NIDDM, all orders reviewed. There is no mention of behaviors. Prior to exiting the survey the facility did not provide the surveyor with any additional information on additional services provided to the resident to prevent abuse.

Based on staff interview, clinical record review and during the course of a complaint investigation the facility staff failed to provide sufficient quantity of staff to provide needed care to prevent injury for 2 of 3 residents in the survey sample, Resident #3 and #2. The findings include: 1. Resident #3 was an [AGE] year old admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Resident #3 resided on the peach unit (secured/ locked unit). The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 1/21/13 assessed the resident as scoring a 1 out of 15 on the BIMS. Resident #3 exhibited physical behavioral symptoms directed towards others. Resident #3 required extensive assistance from 2 staff for bed mobility, and was dependent on staff for transfers, dressing, toileting, personal hygiene and bathing. The State Agency (SA) received a Facility Reported Incident (FRI) indicating there was an incident of resident to resident physical abuse between Resident #3 and Resident #2 that occurred on 2/16/13. Further investigation by the SA evidenced the following: At approximately 7:45 PM to 8:00 P.M., on 2/16/13 Resident #2 wandered into Resident #3's room unnoticed and physically assaulted her. Both residents were sent to the emergency for evaluation. Review of the emergency room hospital records documented the following assessment of the injuries sustained by Resident #3, "Extensive bruising to face, bilateral periorbital bruising (around the eyes) and swelling, 2 1/2 to 3 inch skin tear to left lower cheek, bleeding controlled at this time, multiple hematoma's to head (a collection of blood, usually clotted, in a tissue or organ, caused by a break in a blood vessel), multiple scattered bruising to both arms, skin tear to left arm that was steri stripped and wrapped in Kerlix by nursing home prior to arrival." The emergency department [DIAGNOSES REDACTED]. 1. Facial contusion 2. Soft tissue injury 3. Dementia 4. Closed head injury The emergency physician documented the following: "[AGE] year old female admitted for evaluation for assault, obviously the patient is a nursing home resident for Alzheimer's who was in her room and she was assaulted by another demented resident, she came in here with contusion all over her face as well as bruises, she was seen by the ER physician and will be admitted for pain that is progressively getting worse into her face, with multiple bruises." Resident #2 received the following pain medication during her hospitalization : 1. IV [MEDICATION NAME] 4 mg (milligram) at 10:54 P.M., on 2/16/13. 2. IV [MEDICATION NAME] 2 mg at 3:24 P.M., on 2/17/13 3. [MEDICATION NAME] 50 mg one tablet at 9:32 A.M.,on 2/18/13 4. [MEDICATION NAME] 50 mg one tablet at 9: 04 P.M.,on 2/19/13 5. [MEDICATION NAME] 50 mg one tablet at 3:51 P.M.,on 2/20/13 6. [MEDICATION NAME] 50 mg one tablet at 5:00 A.M.,on 2/21/13 On hospital day #2 the physician documented the following: "She had a drop in her H&H (hemoglobin and hematocrit), presumably from some minor bleeding from the contusions and because she is already so iron deficient. " As a result, Resident #2 was transfused 2 units of packed red blood cells. The laboratory results were: Hemoglobin 7.6 and Hematocrit 11.6. Normal lab reference range is Hemoglobin 12.6-17.1, and Hematocrit 35.1-48.3. Resident #3 was discharged on [DATE] to another long term facility. Interviews with staff on duty at the time of the incident was conducted as follows: On 2/20/13 at 3:00 P.M., certified nurse aide (CNA#4) was interviewed. She stated,"I was coming out of another residents room when I heard a scream, I went to the room and noticed the door was closed, I opened the door and he (Resident #2) was sitting on her (Resident #3's) bed...he had his fist up...I immediately yelled for help, the nurse was at the cart, I asked him to get up... I tried to get him up (Resident #2)... it took me and two other staff to get him out of the room, he had blood on his hands, she (Resident #3) was bleeding...we got her vital signs, the nurse cleaned her up, we got another aide to do 1 to 1 (for Resident #2)...the other aide heard him say she "deserved it"...he was calm after this..." On 2/20/13 at 2:15 P.M., CNA #3 was interviewed about the incident. She stated, "There were four of us (CNA's) working that evening, two of them were at lunch, so it left me and (CNA#4), it was after dinner and I needed to do some ADL care. I asked a resident if she needed to go to the bathroom, I took her to her room and didn't notice another resident had followed me into the room. I asked CNA#4 to come in and help take this resident out of the room because the resident in the first bed was getting upset, she was saying,"Get her out of my room before I punch her". CNA #4 escorted the resident out of the room. I began to take the resident to the bathroom, at that time I heard my name being called. The way my name was called I knew I had to leave right away. I sat the resident back on her bed and I power walked to (Resident #3's) room. I poked my head in and I said "Oh my god". I saw Resident #2 sitting on (Resident #3's) bed...his hand was raised...I saw so much blood...I thought I was going to puke. I immediately called for the nurse. It literally took all 3 of us to get him off her...off the bed...he shook his arms and got agitated and said," We'll she deserved it" We stood him up and he looked back at her (Resident #3) and said, "She deserved it". I had a nightmare that night about it". 2. Resident #2 is a [AGE] year old admitted to the facility from another long term facility on 11/12/12 with [DIAGNOSES REDACTED]. Resident #2 resided on the secured / locked unit. The admission MDS (Minimum Data Set) with an assessment reference date of 11/19/12 evidenced the resident scored a 2 out of 15 on the BIMS (Brief Interview for Mental Status), indicating the resident has severely impaired cognition. The resident was assessed as exhibiting signs and symptoms of [MEDICAL CONDITION] such as inattention, disorganized thinking and altered level of consciousness which was an acute change in mental status from the resident's baseline. Under section E. Behaviors potential indicators for [MEDICAL CONDITION] such as hallucinations and [MEDICAL CONDITION] was checked for "none of the above". Resident #2 did not exhibit any overall presence of behavioral symptoms such as physical behaviors, verbal behaviors or other behavioral symptoms not directed towards others. Resident #2 did not exhibit any rejection of care necessary to achieve the resident's goals for health and well-being. Section E 0900 indicated the resident did exhibit wandering behaviors. The impact of the wandering placed the resident at risk for getting into a dangerous place (e.g. outside the facility), and significantly intruded on the privacy and or activities of others. Resident #2 required limited assistance of 1 staff for bed mobility and transfers, and required extensive assistance of 1 staff for walking in room and corridor, dressing, toileting, personal hygiene and bathing. Resident #2 was steady with ambulation and did not require a mobility device such as a cane, walker or wheelchair. The resident was frequently incontinent of both bladder and bowel. Review of the clinical record evidenced the following identified behaviors for Resident #2: 1. Nursing notes 11/13/12 & 11/14/12- wanders into other resident rooms 2. Nursing notes 11/28/12-agitated with redirection 3. Nursing notes 11/29/12-yelling at roommate 4. Nursing notes 12/24/12-refused accu check (blood sugar monitoring), grabbed nurses finger & bent it 5. Nursing notes 1/9/13-argumentative with staff & roommate 6. Behavioral flow sheet 1/24/13- physical aggression 7. ADL flowsheet 1/24/13-while trying to assist resident out of another residents room became combative 8. Nursing notes 2/14/13-argumentative with staff & roommate 9. Weekly Nursing progress notes: 11/26/12-some agitation 12/7/12-bed seeks, voiding in other resident room dresser drawers 12/28/12-takes things out of other resident rooms, voids in other things 2/1/13-delusional 2/15/13-at times get's verbally aggressive 10. The Behavior /Intervention Monthly Flow Record evidenced the resident exhibited 2 episodes of physical aggression requiring redirection and 1:1 interventions during the evening shift on 12/24/12. Review of the resident's comprehensive plan of care did not include a behavioral plan of care or development of intervention strategies to prevent occurrences and monitoring for changes that would trigger abusive behaviors such as verbal and physical aggression. An elopement risk care plan was developed based on the resident's history of wandering and /or elopement due to acute or chronic confusion or disorientation. Two of the approaches listed was to redirect the resident from doors and exit as needed, and assess for wandering/ elopement patterns. There were no specific interventions listed addressing the resident's behavior of wandering into other resident rooms. On 2/20/13 at 2:15 P.M., CNA #3 stated on 2/16/13 during dinner Resident #2 had "gotten aggressive with 2 residents", stating, "I didn't witness the first one, I was giving a shower to a resident." The 2nd incident she stated (Resident #2) was being directed to sit at another dinner table, another resident was in his way she stated, "He got upset (Resident #2), acting like he was going to go after him". On 2/20/13 at 3:00 P.M., CNA#4 was interviewed and asked to describe the dinner incident on 2/16/13 between Resident #2 and another resident on 2/16/13. She stated,"He (Resident #2) became agitated when we were passing out dinner trays, I guess it was over a racial slur, he (Resident #2) grabbed hold of this other residents arms and held them down, we separated them and he was saying (Resident #2) "He better watch himself, he better get his MF (explicit word) out of the way". On 2/20/13 at 3:56 P.M., CNA#5 was interviewed, and asked to describe the dinner incident on 2/16/13 between Resident #2 and another resident. She stated, " We were prepping for dinner and (Resident #2) and another resident were sitting at the same table, it was brought to my attention by the nurse who yelled, and I saw the other resident swinging towards Resident #2. Resident #2 was holding his arms (other resident) to prevent him from hitting him. The two residents were separated. Resident #2 stated, "If the MF (explicit word) hits me again I am gonna beat the (explicit word) out of him". We were escorting him (Resident #2) to another table, and another resident was in his way. Resident #2 yelled at this resident...I had not heard him (Resident #2) say this before...I was shocked and appalled". The CNA stated after dinner Resident #2 was observed calm and watching TV in the activity area of the unit. Between 7:45 PM to 8:00 P.M., Resident #2 wandered into Resident #3's room unnoticed and physically assaulted her. According to the charge nurse on duty that evening (LPN#2) she was monitoring the residents while the 2 CNA's on the floor were attending to other residents in their room. She stated, "At 7:45 P.M., I was sitting at the nurses station, looking at the residents who were watching TV, I said to myself I need to get up, I had meds to give and treatments to do...I walked to the treatment cart and got out supplies...then one of the CNA's called me and said "come quick"...I went in there (Resident #3's room). I saw (Resident #2) sitting on the bed...we assisted him out of the room immediately...I assessed (Resident #2) for injuries...I cleaned her arm, there was a skin tear on her arm...I applied a saline compress to her cheek...I knew she would have to go the hospital...I called 911..." Resident #3's right hand was bleeding and swollen especially the 3rd and 4th knuckles..." The nurse was asked to describe what she was doing while she was sitting at the nurses station ,she stated, "charting...I kept looking up...there were 2 CNA's somewhere in the area in residents rooms...there were some (residents) wandering...one CNA was at lunch and the other (CNA) I am not sure where she was...Resident #2 was watching TV". The area where Resident #2 was watching TV was directly across from Resident #3's room. The charge nurse (LPN#2) stated while she was at the treatment cart her back was turned away from the residents in the TV area. She stated, "I usually work 11-7 shift, this was my first 3-11 shift by myself. I know (Resident #2) wanders, he would go into other resident rooms, if they wander into other resident rooms we get them out immediately". At the time of the assault, there were 3 staff on the unit. Two CNA's were in a resident room, one was attempting to toilet a resident, one was assisting with redirecting a wandering resident, and the charge nurse was at the treatment cart prepping for the administration of treatments. At the time of the assault the census on the 30 bed secured unit was 30. On 2/20/13 at 3:56 CNA#5 was interviewed. She stated," It's a very active unit...we try to make it safe for everyone...at all times we have a CNA who is monitoring...this evening we didn't have an activities assistant to help monitor residents...they usually leave at 5:30 P.M., but we haven't had on one the weekends for a while now...the charge nurse helps us monitor...we have a lot of wanderers...you have to constantly monitor those residents..." At the time of the incident CNA #5 stated she and another CNA were off the unit for a dinner break...stating,"we rotate out for dinner...if we have 4 CNA's that shift then 2 of us will go to dinner at the same time". CNA#5 stated staffing for the 3-11 shift is usually 1 charge nurse and 3 CNA's. CNA#5 stated, "when we come on shift we get report and then provide hygiene, we try to keep the residents involved in activities, we try to keep them active, we set up for dinner at 5:30 P.M., dinner gets here around 6 PM, we pass trays, and after dinner we provide toileting, some residents we put to bed others we put back into the activities area to watch TV, we always keep an aide down there (activities/ TV area) to monitor the residents". On 2/20/13 at 3:00 P.M., CNA#4 was interviewed about staffing and stated,"For 3-11 shift it would take 3-4 CNA's, with at least 2 CNA's on the floor at all times watching the residents and at least 3 CNA's to provide care....on 2/16/13 that evening we couldn't do much as far as ADL's, because we only had 2 CNA's on the floor, we had to wait for another CNA to come back (from dinner)...some of these resident's are so combative with care it takes at least 2-3 to provide care to them..." On 2/20/13 at 2:15 P.M., CNA #3 was asked about staffing and stated,"day shift usually has 3-4 CNA's, 3-11 has 3 CNA's and 11-7 shift have 2 CNA's, each shift has 1 charge nurse". When asked if the quantity of staffing was sufficient to provide care she stated, " Not with the type of people (residents) who have been coming in here...they are very aggressive...a lot of them need 2 staff to provide ADL care". She stated when she began working on the secured unit she did not receive any training for handling aggressive residents. She stated, "They don't train you on what to do if a resident attacks you...they sent me back there without any training...I learned quick back there..." CNA #3 stated there were 4 CNA's working that evening due to CNA#4 coming in extra due to the anticipated inclement weather that was expected that evening (snow). On 2/21/13 the director of nurses and the assistant director of nurses (ADON)stated the staff are provided training for handling residents with behaviors during orientation, and annually through a computer based training program. The DON stated,"During general orientation I spend about an hour talking about what is dementia, communication, approaches, avoiding catastrophic events, understanding behaviors..." On 2/20/13 at 10:30 A.M., a family member/ RP of one of the residents on the secured unit was visiting her loved one the closed unit and was interviewed. She stated she was not informed by the facility about the incident of the assault of another resident on the secured unit. She stated, "A family member of mine called me and asked me if (name of resident) was okay, she told me about the assault that made the local news". She stated, "The staff back here do a good job, but they don't have enough help...it is not the girls (staff) fault this happened, I blame the corporate people for not giving them enough help. She states that she visits every other day and provides ADL care for her loved one so the staff can attend to the other residents. On 2/21/13 from 4:00 P.M.-6:30 P.M., the following observations were made on the secured unit by the surveyor: There were 8 staff members on the secured unit, 2 activities staff, 3 CNA's, 1 charge nurse, the ADON and 1 MDS coordinator. Two different activities were occurring at the same time. One group of approximately 7 resident's were participating in a card game with an activities staff. One group of 5 resident's were engaged in an activity with the other activities assistant #2 and a volunteer who brought in a dog for the resident's to pet After pet therapy, the activities assistant #2 engaged these same residents in a ring toss game. Two of the CNA's were monitoring and redirecting 2 resident's who were observed constantly wandering in and out of other residents rooms. One resident was exit seeking and needed to be redirected from the exit doors several times during this observation. One CNA was observed blocking a resident door entrance with her body to prevent another resident from entering...the resident was observed pushing against the CNA to try to enter the room...this CNA did not offer the resident an alternative/ diversional activity. The ADON was going around and attempting to engage residents in conversation. One CNA was holding the hand of a resident while walking him around the unit in his wheelchair. During dinner the 3 CNA's, MDS coordinator and one of the activities staff were observed attempting to sit the residents at various dinner tables to prepare for dinner, activities assistant #2 was charting. During this time several of the residents would sit for a matter of minutes, would then get back up, wander and needed redirection to sit back down for dinner. There were several residents who ate in their rooms. The charge nurse was observed providing 1:1 with a resident to assist him with dinner at the nurses station. There was a lot of activity going on the unit with residents wandering, needing constant redirection and supervision. At 6:15 P.M., the primary activities assistant for the secured unit was interviewed. She stated she did not have any specialized training for working with this type of population, other then having a grandmother who had Alzheimer's. When asked about resident to resident altercations and handling aggressive residents, she stated, "I've been trained to divert situations". The activity assistant was asked if any of the residents are on an individualized activity program, she stated,"No...there is nothing specifically geared towards any one individual". She stated she works Monday through Friday. On the weekends there is an activity personal who comes to the facility. She states she generally leaves at 5:30 P.M., and before she leaves she puts in a movie for the residents to watch after dinner. She states about 25% of the residents can actually sit through the whole movie. She stated, "I usually put in the Sound Of Music", we wind up watching a lot of the same stuff over and over again...a lot of the movies are scratched." During an interview with the DON on 2/21/13 she stated, "The full time 3-11 charge nurse has trained her staff to take turns for providing ADL's and rotate for monitoring, so that not everyone is in a room providing care at the same time...the charge nurse helps with baths...if all CNA's are providing ADL care then she is monitoring the residents". She stated, "Part of education is need for supervision it is not one to one, we encourage group activities...we added a FT activities person in November of last year (for the locked unit) to work 8 hours a day 7 days a week...the CNA's take over activities after supper. They (the residents) enjoy a calm movie after supper, it's peaceful for the most part...less calmer activities are done in the evening". The DON was asked about staffing on the peach unit, she stated," We staff with 3 CNA's on the day and evening shifts, and 2 CNA's on the night shift, 1 charge nurse on each shift...a restorative aide is probably there on the unit an hour or two daily...an activities assistant Monday through Friday from 9 am -5 :30 pm, on the weekends the CNA's provide activities...The DON was asked how does she ensure there is sufficient number of staff on the secured unit to ensure neglect/ abuse doesn't occur, she stated, "I monitor the patterns of behaviors, I talk to them (staff) daily, at times we can provide 1:1 if required...the night this happened (2/16/13) we had an extra CNA that night". I will be putting another full time CNA 3-11 on the secured unit starting with the next schedule (March), she used to monitor residents for falls during dinner on the green unit, but that population has changed and now I am going to filter those hours on the peach unit (secured unit)...it's just a question of putting manpower where you need it...and I know it will change from time to time..." At the time of the assault, there were 3 staff on the unit. Two CNA's were in a resident room, one was attempting to toilet a resident, one was assisting with redirecting a wandering resident, and the charge nurse was at the treatment cart prepping for the administration of treatments. In the few minutes that the charge nurse was not supervising the residents the assault occurred. At the time of the assault the census on the secured unit was 29.