Every finding on record at Windsor Health and Rehabilitation

Based on observation, interview and record review it was determined the facility failed to provide necessary behavioral health services for 1 of 1 sampled resident (#32) reviewed for behavior. This failured resulted in Resident 32 continuing to experience untreated mental health symptoms, including expressing statements of wanting to die and socially isolating her/himself. Findings include:Resident 32 admitted to the facility in 4/2026 with diagnoses including anxiety disorder, obsessive-compulsive disorder, attention deficit hyperactivity disorder, post-traumatic stress disorder, major depressive disorder, and bipolar disorder.A 4/30/26 admission MDS revealed Resident 32 had a score of 19 on the Patient Health Questionaire-9 (an assessment of depression symptoms), which indicated she/he had moderately severe depression symptoms. Resident 32 indicated she/he had thoughts of being better off dead or hurting her/himself 12 to 14 days out of 14 days; felt down, depressed or hopeless 12 to 14 days out of 14 days; and stated she/he often felt lonely or isolated from those around her/him. A 5/1/26 Care Conference evaluation revealed Resident 32 requested to be seen by a mental health provider.A 5/5/26 Progress Note revealed a mental health provider attempted to see Resident 32, but she/he was at an appointment.A review of the medical record revealed no other communication, visit, or referral to a mental health provider.A 5/8/26 Social [NAME] admission and History evaluation indicated Resident 32 was very emotional and could benefit from additional mental health support.On 7/7/26 at 3:55 PM Staff 39 (CMA) stated when Resident 32 first admitted to the facility she/he made statements about wanting to die. On 7/8/28 at 10:11 AM Resident 32 was observed in her/his room, was tearful and yelling out.On 7/8/26 at 10:21 AM Resident 32 was in her/his wheelchair, was tearful and crying. Resident 32 stated when she/he admitted to the facility her/his mood was very poor and the facility did not do anything to help.On 7/8/26 at 1:37 PM Staff 6 (SSD) stated she did not recall if a referral for mental health was requested for Resident 32 but thought maybe she/he declined mental health treatment. Staff 6 stated Resident 32 had behaviors related to smoking, became agitated, and changed her/his emotions quickly. Staff 6 stated Resident 32 elected to temporarily go on hospice as a response to a depressive episode.On 7/8/26 at 2:02 PM Staff 28 (LPN Resident Care Manager) stated Resident 32 was generally unhappy but stated that was normal for Resident 32's diagnoses. Staff 28 stated Resident 32 briefly went on hospice as a response to not being able to smoke and a family conflict. Staff 28 stated she thought mental health support was offered and denied by Resident 32. On 7/13/26 at 1:09 PM Staff 1 (Administrator) stated if Resident 32 requested mental health support a mental health professional should have been contacted.

Based on interview and record review it was determined the facility failed to staff a registered nurse for eight consecutive hours per day, seven days per week, for 18 out of 34 days reviewed for staffing. This placed residents at risk for unmet assessment needs. Findings include:A review of the Direct Care Staff Daily Reports dated 6/3/26 through 7/6/26 revealed there were 18 days without 8 consecutive hours of registered nurse coverage on any shift in a 24 hour period on the following dates: 6/3/26, 6/4/26, 6/8/26, 6/9/26, 6/10/26, 6/15/26, 6/16/26, 6/17/26, 6/18/26, 6/22/26, 6/23/26, 6/24/26, 6/25/26, 6/29/26, 6/30/26, 7/1/26, 7/2/26, and 7/6/26. On 7/7/26 at 5:19 PM, Staff 18 (LPN) stated Staff 2 (DNS) did not work the floor. On 7/8/26 at 10:43 AM, Staff 2 confirmed she was not scheduled to work the floor on days when there were no RNs scheduled. Staff 2 stated she was only available three hours daily to complete resident assessments as an RN due to DNS obligations. Staff 2 acknowledged the requirements for RN coverage in the facility were not met. On 7/8/26 at 12:33 PM, Staff 36 (Regional Director of Clinical Operations) acknowledged the facility did not meet the staffing requirement for RNs.

Based on observation, interview, and record review it was determined the facility failed to provide personalized individual and independent activities for 3 of 3 sampled residents (#s 7, 9, and 33) reviewed for activities. This placed residents at risk for unmet physical, mental, and psychosocial needs. Findings include: 1. Resident 7 was admitted to the facility in 2021 with diagnoses including seizures and history of TIA (mini stroke). An 8/5/25 Activity Evaluation indicated Resident 7 preferred independent and one-to-one activities. The 2/6/26 Quarterly MDS revealed Resident 7 indicated it was very important to do her/his favorite activities. Resident 7's 6/1/26 Revised Care Plan identified she/he enjoyed listening to music and watching TV or movies, had impaired psychosocial well-being, and was visually impaired. The 7/2026 Activity Calendar revealed planned sessions of one-to-one visits every Wednesday at 4 PM. No documentation was found in Resident 7's electronic health record that indicated the resident was offered or participated in independent or one-to-one activity opportunities. Observations of Resident 7 were made at various times of day from 7/6/26 through 7/9/26. Resident 7 spent all her/his time in bed and alone, except when receiving care. Occasionally Resident 7 had her/his TV on but was most often observed sleeping or lying in bed with the light off. On 7/6/26 at 1:32 PM Resident 7 stated she/he was bedbound and visually impaired. Resident 7 indicated no one in the facility offered her/him any activities to do in her/his room. On 7/8/26 at 4:04 PM Resident 7 indicated activity staff never offered the opportunity to participate in the planned one-to-one visits. On 7/9/26 at 9:49 AM Staff 15 (Activities Director) acknowledged the facility did not have a meaningful activity program for residents unable to attend group activities. Staff 15 was unable to identify a personalized independent or one-to-one activity program for Resident 7. On 7/9/26 at 10:33 AM Staff 1 (Administrator) acknowledged residents unable to attend group activities needed individualized and meaningful activity opportunities. 2. Resident 9 was admitted to the facility in 4/2026 with diagnoses including generalized anxiety disorder and adult failure to thrive. A 4/23/26 Care Conference note indicated Resident 9 was unable to get up from bed, and preferred independent activities and one-to-one visits. A 5/23/26 Revised Care Plan revealed Resident 9 preferred self-directed or independent activities in her/his room. The care plan indicated Resident 9 identified an interest in arts and crafts, reading, religious studies, watching TV and sports, and electronic use. The 7/2026 Activity Calendar revealed planned sessions of one-to-one visits every Wednesday at 4 PM. No documentation was found in Resident 9's electronic health record that indicated the resident was offered or participated in independent or one-to-one activity opportunities. On 7/6/26 at 10:53 AM Resident 9 stated she/he was frequently bored, and the only thing to do in her/his room was watch TV. Resident 9 stated she/he was interested in being offered independent activities, if the activity was something she/he was interested in. On 7/8/26 at 9:35 AM Resident 9 indicated activity staff never offered the opportunity to participate in the planned one-to-one visits. On 7/9/26 at 9:49 AM Staff 15 (Activities Director) acknowledged the facility did not have a meaningful activity program for residents unable to attend group activities. Staff 15 was unable to identify a personalized independent or one-to-one activity program that aligned with Resident 9's interests. On 7/9/26 at 10:33 AM Staff 1 (Administrator) acknowledged residents unable to attend group activities needed individualized and meaningful activity opportunities. 3. Resident 33 was admitted to the facility in 4/2026 with diagnoses including Chronic Obstructive Pulmonary Disease and hearing loss. A 4/30/26 Activities Evaluation indicated Resident 33 did not like to color, preferred independent activities, and liked bingo. The 5/1/26 admission MDS and related CAAs revealed Resident 33 had a BIMS score of 13 which indicated the resident was cognitively intact, the resident was at risk for impaired communication, and it was very important for the resident to be outside when the weather was good. Review of Resident 33's Activity Progress Notes revealed the resident was offered group activities but declined and participated in independent activities on multiple days during the following months:-5/2026: 12 days -6/2026: 20 days-7/2026: 2 days No additional activities were identified from 5/1/26 through 7/6/26. A 5/23/26 revised Care Plan indicated Resident 33 preferred self-directed activities which included arts and crafts, watching television, and listening to music. On 7/6/26 at 9:27 AM, Resident 33 stated no meaningful activities were offered. Resident 33 stated she/he was more active at home and did not spend much time watching television. A television displayed a cartoon program and Resident 33 intermittently dozed during the interview. No radio or activity supplies were observed in the resident's room. Resident 33 stated she/he did not like cartoons and fell asleep often because of the lack of activities. On 7/8/26 at 8:29 AM, Resident 33 stated her/his roommate was new to the facility and activities staff came to visit the roommate. Resident 33 stated they walk past my bed and don't even ask her/him about activities. Resident 33 had the television on and no activities supplies were in her/his room. On 7/8/26 11:31 AM, Staff 15 (Activities Director) stated she never thought to encourage staff to get Resident 33 up for activities. She was aware residents complained about the lack of weekend activities, and residents who often remained in bed were limited to coloring and one-on-one conversations. Staff 15 stated she lacked documentation of conversations with Resident 33 and needed to improve personalized activities options. Staff 33 stated she was unsure what meaningful activities were for Resident 33 and Staff 15 was behind in her responsibilities including revision of care plans. On 7/8/26 at 2:08 PM, Staff 20 (CNA) stated she worked with Resident 33 routinely and never saw activity staff visit the resident or provide one-on-one interaction. Staff 20 indicated Resident 33 often remained in bed. Family occasionally visited but less often recently. On 7/8/26 at 5:34 PM, Witness 4 (Family Member) indicated she was concerned about the lack of activities for Resident 33. Witness 4 stated Resident 33 liked to play bingo and go outside at home and would benefit with more interactions since the resident continued to remain in her/his room with little to do. On 7/9/26 at 10:33 AM, Staff 1 (Administrator) stated she expected an individualized and meaningful activity program for each resident, care plans should be updated to reflect the interests of each resident, and progress notes should be accurate and reflect conversations that were conducted.

Based on observation, interview, and record review it was determined the facility failed to have adequate staff available to meet the needs of residents in a timely manner for 1 of 2 halls (South Hall) reviewed for sufficient staffing. This placed residents at risk for unmet needs. Findings include: 1. Resident 2 admitted to the facility in 6/2026 with diagnoses including diabetes, dysphasia (difficulty swallowing) and pressure ulcer. Resident 2 resided on the South Hall. An undated Meal Delivery Times document indicated breakfast was delivered to the South Hall at 7:30 AM and at 7:45 AM to the dining room. An undated Residents that Smoke document indicated the approximate supervised smoking schedule was from 6:30 AM to 7:00 AM, 10:00 AM to 10:30 AM and 1:00 PM to 1:30 PM on day shifts. The 6/18/26 admission MDS revealed Resident 2 had a BIMS score of 5 which indicated the resident was severely cognitively impaired. A 6/25/26 revised Care Plan revealed Resident 2 required two staff to assist with transfers, one staff to assist with dressing, and the resident was to dine in the dining room with close supervision due to risk of aspiration (the accidental breathing in of foreign objects, such as food, into the lungs). On 7/7/26 at 5:19 PM, Staff 18 (LPN) stated nursing staff routinely followed up on nursing tasks not completed by the previous shift. Staff 18 stated resident admissions often required unplanned time to complete required nursing tasks. Staff 18 stated Staff 2 (DNS) was often not present on the nursing unit, and competing nursing responsibilities delayed nurses from providing timely assistance to CNAs with resident care requests. On 7/8/26 at 8:21 AM, Staff 20 (CNA) stated she returned from the supervision of smoke breaks after being away from resident care for 40 minutes and was assigned to assist Resident 2. Staff 20 stated she was not able to timely attend to the needs of Resident 2 to ensure his/her brief was changed and she/he was up for breakfast. On 7/8/26 at 8:22 AM, Resident 2 was observed in bed with her/his call light on and the resident was in her/his gown. On 7/8/26 at 8:36 AM, Staff 20 answered the call light for Resident 2 and stated the resident's morning routine required a lot of time with staff and included: two staff to assist her/him into her/his wheelchair, one staff to supervise her/his eating, and both a nurse and CNA to change her/his wound dressing and brief change. Staff 20 stated it took additional time and staff coordination to address Resident 2's morning care which was difficult. On 7/8/26 at 8:41 AM, Staff 18 provided wound care for Resident 2. On 7/8/26 at 10:43 AM, Staff 2 (DNS) stated the nursing management team and many nurses were new to the facility. Staff 2 stated nursing staff often had more than two admissions which impacted their workload and residents were waiting for 30 minutes for care. On 7/8/26 at 4:55 PM, Staff 25 (CNA) stated care was often delayed for Resident 2 who required the assistance of two staff. Staff 25 stated the staff assigned to monitor smoke breaks often had to extend the allotted time due to residents' behaviors. Staff 25 stated Resident 2 complained of leg pain when she/he was left in bed for extended periods of time. Staff 25 stated extended smoke breaks at 1:00 PM frequently interfered with the timely care of residents before change of shift at 2:00 PM. On 7/10/26 at 11:37 AM, Staff 7 (Resident Care Manager-LPN) stated she was new to the facility, and the facility needed a culture change to ensure staff were available to assist with resident care. Staff 7 stated she needed to be on the floor to know how the building operated. On 7/10/26 at 12:20 PM, Resident 2 confirmed she/he experienced increase pain when she/he was in bed for extended periods of time. On 7/13/26 at 9:34 AM, Staff 1 (Administrator) stated the facility budget for staffing was limited and not based on resident acuity, CNAs were scheduled to maintain minimum staffing ratios with some additional shifts for resident showers, and management was expected to assist with call lights. Staff 1 acknowledged care lights were not addressed timely. 2. Resident 40 was admitted to the facility in 12/2025 with diagnoses including left and right below the knee amputation. Resident 40 resided in the South Hall. A 3/17/26 revised Care Plan revealed Resident 40 required set-up assistance for toileting and dressing and the resident used prosthetic legs for safety. A 4/21/26 BIMS assessment revealed Resident 40 had a score of 15 which indicated the resident was cognitively intact. On 7/6/26 at 12:58 PM and 7/10/26 at 1:56 PM, Staff 19 (CNA) stated staff breaks, meetings and resident smoke breaks often occurred at the same time which impacted timely resident care. Staff 19 stated there was not sufficient staff to address resident care needs, and the expectation was to answer call lights within seven to ten minutes. On 7/7/26 at 4:47 PM, Staff 4 (LPN) stated the current staffing levels did not meet the behavioral issues of current residents. Staff 4 stated staff were in a hurry and did not address all the resident needs when they entered resident rooms. Staff 4 stated some residents suffered because of the lack of thorough care. On 7/8/26 at 10:43 AM, Staff 2 (DNS) stated the nursing management team was new to the facility. Staff 2 acknowledged residents waited 30 minutes for care. On 7/12/26 at 6:15 PM, Staff 10 (CNA) stated call lights were difficult to answer timely without a consistent shower aide, and the wait times exceeded 30 minutes. On 7/13/26 at 9:00 AM, Resident 40 stated she/he turned on her/his call light at 5:20 AM which was not answered until 6:10 AM. Resident 40 stated she/he did not receive the required assistance with dressing and toileting which prevented the resident from being ready for the day. Resident 40 stated Staff 14 (CNA) was unavailable due to the care of other residents and her morning meeting. On 7/13/26 at 9:12 AM, Staff 14 stated she started her shift after the morning meeting and addressed the needs of another resident who was yelling before answering Resident 40's call light. Staff 14 stated she was unaware Resident 40's call light was on for more than 45 minutes and care often took 30 minutes for some residents. Staff 14 stated nurses were not always available to assist. On 7/13/26 at 9:34 AM, Staff 1 (Administrator) stated she attempted to have consistent and additional staff above the CNA minimums but had to work within a budget. Staff 1 stated she expected call lights to be answered as soon as possible and acknowledged call lights were not answered timely. 3. Resident 4 was admitted to the facility in 1/2026 with diagnoses including chronic pain and muscle weakness. Resident 4's Care Plan revealed she/he needed the assistance of two staff to transfer via a mechanical lift (a device used to transfer a person with limited mobility). The Care Plan also indicated the resident had right shoulder pain and muscle weakness, and pain was a trigger for impaired psychosocial well-being. On 7/13/26 at 9:15 AM Staff 14 (CNA) was observed trying to find a second CNA to assist with transferring Resident 4 out of bed. Staff 14 stated the other two CNAs for the hall were busy assisting a different resident who also needed two people for transfers. Staff 14 notified Resident 4 that she was unable to transfer her/him out of bed and would return. When Staff 14 left, Resident 4 yelled, Don't leave me laying like this, and said she/he was uncomfortable in bed. From 9:17 AM to 9:43 AM Staff 14 answered call lights on her own, and no other CNAs were available to assist her with Resident 4. During that time Resident 4 continued to express displeasure at being left in bed and indicated pain and discomfort.At 9:46 AM Staff 14 and a second CNA entered Resident 4's room to transfer her/him out of bed. On 7/13/26 at 11:05 AM Resident 4 stated there was a long wait time to get out of bed that morning, and her/his shoulder bothered her/him while waiting. On 7/13/26 at 2:53 PM Staff 1 (Administrator) stated the facility staffed CNAs based on the required minimum, not based on resident acuity. On 7/13/26 at 2:57 PM the posted Direct Care Staff Daily Report revealed seven total CNAs for day shift, which was consistent with the state required minimum number of CNAs for the shift.

Based on interview and record review it was determined the facility failed to assist residents in obtaining dental services for 3 of 3 sampled residents (#s 7, 10, and 43) reviewed for dental services. This placed residents at risk for unmet dental needs. Findings include: 1. Resident 7 was admitted to the facility in 2021 with diagnoses including seizures and history of TIA (mini stroke). On 7/6/26 at 1:43 PM Resident 7 stated her/his teeth were disintegrating. Resident 7 pulled back her/his lips to show her/his teeth, and the resident was observed to have several teeth missing on the top and bottom. Resident 7 stated she/he was supposed to have a dental appointment earlier in the year, but the visit did not occur and was not rescheduled. No documentation related to dental services was found in Resident 7's electronic health record. On 7/9/26 at 10:58 AM Staff 6 (Social Services Director) acknowledged Resident 7 had a dental appointment scheduled for 2/17/26, but it was cancelled for an unknown reason. Staff 6 further acknowledged the cancelled dental appointment was not rescheduled and follow up with the resident was not completed. 2. Resident 10 was admitted to the facility in 10/2024 with diagnoses including dysphagia (difficulty swallowing) and trigeminal neuralgia (a rare chronic nerve condition that causes sudden, severe, electric-shock-like facial pain). On 7/6/26 at 10:56 AM, Resident 10 stated her/his upper dentures were broken and she/he needed to see the dentist. On 7/9/26, at 10:30 AM, Staff 6 (SSD) stated Resident 10 saw the dentist on 1/21/26 but she was unable to locate the progress notes for the 1/21/26 dental appointment. Staff 6 stated it was her responsibility to make dental appointments for residents when requested, but she had no process to assess the need for dental appointments. On 7/10/26 at 10:10 AM, Staff 27 (CMA) stated about a month ago Resident 10 reported to her that her/his dentures were broken. Staff 27 stated she informed the charge nurse but could not remember which charge nurse. On 7/13/26 at 3:43 PM, Staff 2 (DNS) stated Staff 6 was responsible for making dental appointments for residents when requested. Staff 6 stated it was the expectation was for residents to be assessed for the need for dental visit quarterly, during the care conference. 3. Resident 43 was admitted to the facility in 1/2025 with diagnoses including hemiplegia (partial paralysis) of right dominant side following a stroke. On 7/6/26 at 11:13 AM, Resident 43 was observed to have missing teeth and tooth decay. Resident 43 stated she/he needed to go to the dentist, but she could not transfer to a chair alone, so she/he was unable to be seen by a dentist. A 9/29/25 progress note indicated Resident 43 requested to see a dentist. A 10/21/25 progress note indicated Resident 43 had a dental appointment on 10/9/25, but Resident 23 was unable to be seen due to inability to transfer to the dental chair. On 7/9/26 at 10:30 AM, Staff 6 (SSD) stated 43 had a telehealth dental appointment on 2/6/26 but she was unable to locate any notes from that visit. Staff 6 stated it was her responsibility to make dental appointments for residents when requested, but she stated she had no process to assess the need for dental appointments. On 7/13/26 at 3:43 PM, Staff 2 (DNS) stated Staff 6 was responsible for making dental appointments for residents when requested. Staff 6 stated it was the expectation was for residents to be assessed for the need for dental visit quarterly, during the care conference.

Based on interview and record review the facility failed to ensure residents were fully informed and understood the binding arbitration agreement for 3 of 3 sampled residents (#s 2, 33, and 53) reviewed for arbitration. This placed residents at risk for being uninformed regarding their legal rights. Findings include:1. Resident 2 was admitted to the facility in 6/2026 with diagnoses including adjustment disorder and paranoid schizophrenia (mental illness). A 6/15/26 BIMS assessment revealed Resident 2 had a score of 5 which indicated the resident was severely cognitively impaired. A State Arbitration Agreement dated 6/15/26 revealed Resident 2 signed the document.Review of Resident 2's clinical record revealed the resident had a durable Power of Attorney (person appointed to make financial decisions) who was not family.During interviews on 7/8/26 at 1:35 PM and 7/13/26 at 12:50 PM, Staff 30 (Admissions) stated she had family present when Resident 2 signed the Arbitration Agreement and was unaware on 6/15/26 the resident had a POA when the resident signed the document. Staff 30 stated she was unaware residents had 30 days to rescind the agreement and no follow-up conversation occurred. Staff 30 stated the electronic admission documents forced the acceptance or declination of the Arbitration Agreement in order to complete Resident 2's admission to the facility.On 7/13/26 at 3:41 PM, Staff 1 (Administrator) acknowledged the facility needed a different process to ensure the resident or representative understood the Arbitration Agreement. Staff 1 stated staff were expected to have a follow up conversation with residents about the Arbitration Agreement within 30 days of the resident signing the form. 2. Resident 33 was admitted to the facility in 4/2026 with diagnoses including Chronic Obstructive Pulmonary Disease and symptoms and signs involving cognitive function and awareness. The 5/1/26 admission MDS revealed Resident 33 had a BIMS score of 13 which indicated the resident was cognitively intact. A State Arbitration Agreement dated 4/26/26 revealed Resident 33 signed the document.Review of Resident 33's clinical record revealed Witness 4 (Family Member) was the resident's medical and financial Power of Attorney.On 7/8/26 at 8:29 AM, Resident 33 stated she/he was not at her/his best during the admission process and was alone because Witness 4 was traveling. Resident 33 stated she/he did not recall information or education regarding an Arbitration Agreement.During interviews on 7/8/26 at 1:35 PM and 7/13/26 at 12:50 PM, Staff 30 (Admissions) stated it was difficult to ascertain the cognition of a resident during admission. Staff 30 stated she believed Resident 33 was able to understand and sign the Arbitration Agreement. Staff 30 stated she was unaware residents had 30 days to rescind the agreement and no follow-up conversation occurred. Staff 30 stated the electronic admission documents forced the acceptance or declination of the Arbitration Agreement in order to complete Resident 33's admission to the facility.On 7/8/26 at 5:34 PM, Witness 4 stated she arrived a few days after Resident 33 admitted to the facility and would not have allowed Resident 33 to sign the Arbitration Agreement. Witness 4 stated she was unaware the Arbitration Agreement was signed by Resident 33 until today.On 7/13/26 at 3:41 PM, Staff 1 (Administrator) acknowledged the facility needed a different process to ensure the resident or representative understood the Arbitration Agreement. Staff 1 stated staff were expected to have a follow up conversation with residents about the Arbitration Agreement within 30 days of the resident signing the form. 3. Resident 53 was admitted to the facility in 5/2026 with diagnoses including anxiety and depression.A 5/5/26 BIMS assessment revealed Resident 53 had a score of 13 which indicated the resident was cognitively intact. A State Arbitration Agreement dated 5/6/26 revealed Resident 53 signed the document. During interviews on 7/8/26 at 1:35 PM and 7/13/26 at 12:50 PM, Staff 30 (Admissions) stated it was difficult to ascertain the cognition of a resident during admission. Staff 30 stated she believed Resident 53 was able to understand and sign the Arbitration Agreement. Staff 30 stated she was unaware residents had 30 days to rescind the agreement and no follow-up conversation occurred. Staff 30 stated the electronic admission documents forced the acceptance or declination of the Arbitration Agreement in order to complete Resident 53's admission to the facility.On 7/8/26 at 5:12 PM, Resident 53 stated she/he did not recall signing the Arbitration Agreement and would not have signed it based on the current education provided. Resident 53 stated she/he hoped the facility would ensure a resident was at their best when signing important documents during admission, and she/he was not at her/his best at that time. On 7/13/26 at 3:41 PM, Staff 1 (Administrator) acknowledged the facility needed a different process to ensure the resident or representative understood the Arbitration Agreement. Staff 1 stated staff were expected to have a follow up conversation with residents about the Arbitration Agreement within 30 days of the resident signing the form.

Based on observation, interview, and record review it was determined the facility failed to follow Enhanced Barrier Precautions, failed to disinfect reusable resident equipment between residents, and failed to ensure staff implemented proper hand hygiene while assisting residents for 1 of 1 facility reviewed for infection control. This placed residents at risk for exposure to infections and illness from cross contamination. Findings include: The facility's 8/2025 Handwashing/Hand Hygiene policy indicated hand hygiene is performed as soon as feasible after hands become contaminated, such as after contact with mucous membranes and/or body fluids or excretions, and after handling/transporting soiled linen. The facility's 3/2025 Standard Precautions policy indicated reusable resident-care equipment is not used for the care of another resident until it has been appropriately cleaned. 1. On 7/7/26 at 1:51 PM Staff 16 (CNA) and Staff 18 (CNA) were observed to exit room [ROOM NUMBER] with a mechanical lift (a device used to transfer a person with limited mobility) and place it in the hallway. Staff did not clean the lift before leaving the areas. On 7/7/26 at 1:56 PM Staff 12 (CNA) was observed near the lift. Staff 12 stated if a lift was in the hallway, she assumed it was clean and ready to use. On 7/7/26 at 2:06 PM Staff 16 stated she did not clean the lift after it was used in room [ROOM NUMBER] and did not know if Staff 18 cleaned it. On 7/7/26 at 2:09 PM Staff 18 stated she did not clean the lift after it was used with the resident in room [ROOM NUMBER]. On 7/13/26 at 12:05 PM Staff 3 (Infection Preventionist) stated lifts were to be cleaned after each use. 2. On 7/9/26 at 10:40 AM Staff 9 (CNA) was observed exiting room [ROOM NUMBER] holding a bag of soiled linens in each hand. Staff 9 walked down the hall, placed the bags in the soiled utility closet, then proceeded to walk through the facility, stopping at the nurses station and therapy room. On 7/9/26 at 10:47 AM Staff 9 acknowledged hand hygiene was not completed after she dropped off the bags to the soiled linen closet. On 7/9/26 at 2:14 PM Staff 3 (Infection Preventionist) stated hand hygiene was to be completed immediately after disposing of dirty linens. 3. On 7/10/26 at 3:32 PM Staff 13 (CNA) was observed coughing into his hands and blowing his nose as he approached Resident 8 near the nurses station. Staff 13 put his hands on the resident's wheelchair handles, transported the resident into her/his room, and closed the door. On 7/10/26 at 3:42 PM Staff 13 acknowledged hand hygiene was not performed between coughing into his hands and blowing his nose and touching Resident 8's wheelchair. On 7/13/26 at 12:05 PM Staff 3 (Infection Preventionist) stated staff were to perform hand hygiene immediately after contact with bodily fluids. 4. On 7/10/26 at 3:48 PM Staff 7 (Resident Care Manager LPN) and Staff 17 (CNA) were observed to take a mechanical lift (a device used to transfer a person with limited mobility) into room [ROOM NUMBER] to transfer the resident to bed. At 3:54 PM Staff 7 exited the room. At 4:02 PM Staff 17 exited the room and moved on to other tasks down the hall; the lift was observed inside room [ROOM NUMBER] near the door. On 7/10/26 at 4:11 PM Staff 17 stated the lift is used for any resident in the facility and acknowledged it was not cleaned after it was used with the resident in room [ROOM NUMBER]. On 7/13/26 at 12:05 PM Staff 3 (Infection Preventionist) stated lifts were to be cleaned after each use. 5. On 7/7/26 at 3:51 PM Staff 33 (CNA) and Staff 34 (CNA) entered Resident 32's room; an Enhanced Barrier Precautions (EBP) sign was observed on her/his door. Staff 33 and Staff 34 used a mechanical lift to assist Resident 32 into bed; neither staff donned a gown prior to providing care to Resident 32. On 7/7/26 at 3:59 PM Staff 34 acknowledged Resident 32 was on EBP, but since the staff only assisted her/him to bed they did not need to follow EBP for that task. On 7/7/26 at 4:07 PM Staff 33 stated Resident 32 was not on EBP, but if the resident was on EBP he would have followed the precautions for any activities where the resident was touched. Staff 33 stated he did not follow EBP when he assisted Resident 32 into bed. On 7/10/26 at 12:04 PM Staff 3 (LPN/IP) stated when staff assisted any resident on EBP into bed the staff were to wear gloves and a gown.

Based on interview and record review it was determined the facility failed to assess for self-administration of medications for 1 of 4 sampled residents (#31) reviewed for choices. This placed residents at risk for delayed treatment for chest pain and shortness of breath. Findings include:Resident 31 was admitted to the facility in 6/2026 with diagnoses including asthma and angina pectoris (temporary chest pain, pressure, or discomfort that happens when your heart muscle isn't getting enough oxygen-rich blood).A review of physician orders revealed a 6/12/26 order for nitroglycerin (a medication used to treat chest pain) as needed for chest pain and a 6/12/26 order for albuterol inhaler (a fast-acting rescue medication that quickly relaxes tight muscles around the airways in your lungs) as needed for difficulty breathing or shortness of breath.On 7/6/26 at 2:11 PM, Resident 31 stated she/he requested to self-administer her/his nitroglycerin and albuterol but was informed that she/he could not self-administer while in the facility. Resident 31 expressed concern related to extended wait times for medications and stated she/he wanted to self-administer the nitro and albuterol because those were the two medications she/he needed immediately when having symptoms.A review of Resident 31's medical record revealed no evidence of a self-administration evaluation or self-administration orders.On 7/10/26 at 2:00 PM, Staff 28 (LPN Resident Care Manager) stated Resident 31 asked if she/he could self-administer her/his mediations and Staff 28 informed Resident 31 she/he could not self-administer mediations while in the facility.On 7/13/26 at 3:45 PM, Staff 2 (DNS) stated residents had the right to self-administer their medications if they were able do it safely. Staff 2 stated if a resident requested self-administering their medications, staff were expected to assess the resident's ability to self-administer medication and if residents were assessed to be safe, staff were expected to request orders for self-administering medications.

Based on observation and interview the facility failed to ensure residents could meet in private for 1 of 1 resident council meeting reviewed for resident rights. This placed residents at risk for diminished quality of life. Findings include: On 7/8/26 at 11:00 AM, Resident Council took place in the dining room with this surveyor and four residents, including Resident 43 and Resident 15. During the Resident Council meeting, which lasted approximately 30 minutes, staff entered the dining room without knocking four different times.On 7/9/26 at 9:33 AM, Resident 15 stated during their monthly Resident Council staff interrupted often.On 7/9/26 at 10:07 AM, Resident 43 stated during their monthly Resident Council Meeting, staff interrupted the meeting multiple times. Resident 43 stated when staff interrupted the meeting, she/he lost her/his train of thought.On 7/9/26 at 10:13 AM, Staff 15 (Activity Director) stated staff were expected to allow the residents to have a private Resident Council meeting. Staff 15 state she was aware staff interrupted the staff have interrupted the Resident Council Meeting, but it was improving and during the June 2026 Resident Council Meeting, staff only interrupted once.On 7/13/26 at 4:20 PM, Staff 1 (Administrator) stated residents had the right to meet privately and staff were expected to not interrupt during Resident Council meetings.

Based on interview and record review it was determined the facility failed to ensure non-psychotropic PRN medication was administered prior to psychotropic medication as ordered for 1 of 5 sampled residents (#8) reviewed for medications. This placed residents at risk for adverse side effects of psychotropic medication. Findings include:Resident 8 was admitted to the facility in 1/2024 with diagnoses including anxiety disorder and heart failure. The 10/16/25 Significant Change MDS and related CAAs revealed Resident 8 elected hospice services on 10/12/25 due to a decline in health and heart failure. Resident 8 received psychotropic medications to address her/his hallucinations and anxiety.A 3/16/26 signed hospice physician order indicated Resident 8 was to receive lorazepam (antianxiety medication) every four hours as needed and to use albuterol (fast acting medication for shortness of breath) first.The 6/2026 and 7/2026 TARs revealed Resident 8's albuterol was not administered prior to the resident's lorazepam on 6/4/26, 6/16/26, 6/20/26, and 7/1/26. On 7/8/26 at 1:56 PM, Staff 25 (CNA) stated it was not unusual for Resident 8 to have hallucinations which triggered her/his anxiety. On 7/10/26 at 11:12 AM, Staff 27 (CMA) stated she relied on nurses to conduct assessments prior to PRN medication administration. Staff 27 confirmed she gave Resident 8 lorazepam on 6/20/26 and stated she was not instructed by Staff 18 to provide the resident's albuterol first. On 7/10/26 at 9:00 AM, Staff 2 (DNS) stated the 3/16/26 order for lorazepam was unclear. Staff 2 stated nursing staff were to follow physician orders as written and to contact the physician for clarification. On 7/10/26 at 9:45 AM, Witness 1 (Hospice Director of Nursing) stated hospice preferred the least restrictive interventions for Resident 8. Witness 1 stated albuterol was intended to address the main symptom of the resident's anxiety which was shortness of breath.

Based on observation, interview, and record review it was determined the facility failed to allow resident self-determination related to smoking for 2 of 4 sampled residents (#s 31 and 32) reviewed for choices. This placed residents at risk for diminished quality of life. Findings Include:A review of the Resident Smoking Safety Policy revealed no evidence relating to the number of cigarettes residents were allowed to smoke during their 20-minute smoking break.1. Resident 31 was admitted to the facility in 6/2026 with diagnoses of cervical spondylosis with myelopathy (age related arthritis of the neck/spine).On 7/6/26 at 1:57 PM, Resident 31 stated she/he was allowed to smoke during the 20-minute smoke breaks, but she/he felt like the facility treated the residents who required supervision while smoking, like children by allowing them two cigarettes only during each smoking break. Resident 31 stated she/he wanted to be allowed to smoke as many cigarettes as she/he wanted during the 20-minute smoke break.On 7/9/26 at 10:09 AM, Staff 29 (CNA) was observed with the residents who required supervised smoking. Staff 29 stated she was trained that residents were only allowed to smoke two cigarettes during their 20-minute smoking break.On 7/9/26 at 10:49 AM, Staff 1 (Administrator) stated supervised smokers were allowed five smoking breaks daily, and during those breaks the supervised smokers were allowed two cigarettes each break per the smoking policy which the residents sign.On 7/13/26 at 4:19 PM, Staff 1 (Administrator) acknowledged the smoking policy, and the smoking schedule did not state the number of cigarettes a resident was allowed to smoke during their 20-minute smoking break. Staff 1 acknowledged residents who required supervised smoking were allowed to have as many cigarettes as they wanted during their 20-minute smoke break.2. Resident 32 was admitted to the facility in 4/2026 with diagnoses including end stage renal disease and chronic pain.On 7/9/26 at 10:09 AM, Staff 29 (CNA) was observed with the residents who required supervised smoking. Staff 29 stated she was trained that residents were only allowed to smoke two cigarettes during their 20-minute smoking break.On 7/10/26 at 10:11 AM, Resident 32 was observed at the smoking break. Resident 32 stated the facility treats us like kids by only allowing two cigarettes during their 20-minute smoke break.On 7/9/26 at 10:49 AM, Staff 1 (Administrator) stated supervised smokers were allowed five smoking breaks daily, and during those breaks the supervised smokers were allowed two cigarettes each break per the smoking policy which residents sign.On 7/13/26 at 4:19 PM, Staff 1 (Administrator) acknowledged the smoking policy, and the smoking schedule did not state the number of cigarettes a resident was allowed to smoke during their 20-minute smoking break. Staff 1 acknowledged residents who required supervised smoking were allowed to have as many cigarettes as they wanted during their 20-minute smoke break.

Based on interview and record review it was determined the facility failed to safely store narcotics for 1 of 1 sampled resident (#70) reviewed for safe medication storage. This placed residents at risk for misappropriation of their narcotic. Findings include:Resident 70 was admitted to the facility in 3/2026 with diagnoses including a fractured left femur (thigh bone) and a fractured left humerus (upper arm bone)On 7/10/26 at 10:15 AM Witness 5 (Complainant) stated two months ago Resident 70 was moved from the North Hall to the South Hall and there was a card of oxycodone (narcotic pain medication) missing. Witness 5 stated the card was located a few days later behind a picture frame in the North Hall.On 7/10/26 at 3:34 PM, Staff 4 (LPN) stated a couple of months ago she was counting medications with the night shift nurse and discovered Resident 70 was a card of oxycodone. Staff 4 stated the nurse manager was immediately notified.A 4/27/26 investigation indicated a card of Resident 70's oxycodone was missing on 4/25/26 and was found a few days later behind the back of a picture frame. The investigation indicated a diversion audit was to be completed by the pharmacy on 5/5/26 and education was to be provided to nurses and CMAs after completion of audit of the narcotic book. The 4/27/26 investigation stated misappropriation of Resident 10's oxycodone was identified.On 7/13/26 at 11:44 AM, Staff 2 (DNS) stated staff discovered Resident 70 was missing card of oxycodone during count on 4/27/26 and during the investigation it was discovered the card was missing since 4/25/26. Staff 2 stated the missing oxycodone card was found on 4/30/26 behind the picture frame. Staff 2 stated no further investigation was completed to determine how Resident 70's card of oxycodone ended up behind a picture frame in the facility's hallway and police were not notified of the misappropriation of Resident 10's oxycodone.

Based on interview and record review it was determined the facility failed to conduct a Significant Change MDS assessment within the required timeframe for 1 of 4 sampled residents (#51) reviewed for choices. This placed residents at risk for unassessed needs. Findings include: Resident 51 admitted to the facility in 2025 with diagnoses including dementia.A 6/19/26 Election of Hospice Benefit form revealed Resident 51 admitted to hospice services on 6/19/26.On 7/10/26 a Significant Change MDS assessment dated [DATE] was not yet completed, 22 days after Resident 51 admitted to hospice.On 7/10/26 at 2:08 PM Staff 38 (MDS Coordinator) confirmed Resident 51's Significant Change MDS was not yet completed. On 7/13/26 at 10:55 AM Staff 2 (DNS) stated a Significant Change MDS assessment was to be completed within 14 days of Resident 51's start on hospice services.

Based on interview and record review it was determined the facility failed to accurately complete a diabetic baseline care plan for 1 of 5 sampled residents (#2) reviewed for medications. This placed residents at risk for lack of diabetic care and monitoring. Findings include: Resident 2 admitted to the facility in 6/2026 with diagnoses including diabetes. The 6/18/26 admission MDS revealed Resident 8 received insulin. The 6/2026 and 7/2026 TAR revealed no monitoring for adverse reactions to insulin administration were in place. A 6/25/26 revised care plan revealed no diabetic focus or interventions for Resident 2. On 7/8/26 at 2:43 PM, Staff 18 (LPN) stated a Resident Care Manager was to verify orders for new residents and ensure all treatments, orders, and monitors were in place. Staff 18 stated she believed no treatments were missing for Resident 2. On 7/8/26 at 4:55 PM, Staff 25 (CNA) observed Resident 2's care plan and confirmed she was not able to identify Resident 2 was a diabetic which was important for the monitoring of hypoglycemia (low blood sugar levels). On 7/13/26 at 4:19 PM, Staff 2 (DNS) stated she expected the baseline care plan to include diabetic care within 48 hours especially because Resident 2 received insulin.

Based on interview and record review it was determined the facility failed to provide ROM for 1 of 1 sampled resident (#16) reviewed for decreased ROM. This placed residents at risk for contractures. Findings include:Resident 16 was admitted to the facility in 2017 with diagnoses including flaccid hemiplegia (complete lack of movement) of the right side following a cardiovascular accident (stroke).On 7/6/26 at 10:00 AM Resident 16 stated she/he was unable to move her/his right side and Resident 16 stated staff did not assist her/him with ROM exercises.A 5/12/25 revised Care Plan indicated Resident 16 was to receive ROM in the morning and evening.A review of Resident 16's chart revealed no documentation of ROM exercises being completed.On 7/10/26 at 10:04 AM Staff 27 (CMA) stated she never saw ROM exercises being completed with Resident 16.On 7/10/26 at 10:21 AM, Staff 29 (CNA) stated there was no time to complete ROM exercises with residents.On 7/10/26 at 11:19 AM, Staff 21 (CNA) stated Resident 16's extremities were moved when they got her/him dressed but ROM exercises were not completed.On 7/10/26 at 11:57 AM, Staff 22 (LPN) stated she never saw ROM exercises being completed with Resident 16.On 7/13/26 at 8:46 AM, Staff 31 (CNA) stated Resident 16 did not receive ROM exercises.On 7/13/26 at 8:47 AM, Staff 7 (LPN Resident Care Manager) stated Resident 16 was not on the RA program and she was unaware if ROM exercises were completed with Resident 16.On 7/13/26 at 12:03 PM, Staff 2 (DNS) stated staff were expected to complete ROM exercises with Rresident 16 while providing care and dressing alone was not sufficient replacement for ROM exercises.

Based on interview and record review it was determined the facility failed to ensure residents received appropriate supervision during meals for 1 of 3 sampled residents (#58) reviewed for accidents. This placed residents at risk for choking and aspiration. Findings include:Resident 58 was admitted to the facility in 5/2024 with diagnoses including lung cancer and dysphagia (difficulty swallowing). A 1/17/26 SLP progress note indicated Resident 58 needed distant supervision while eating. A review of Resident 58's current care plan indicated no information related to the provision of distant supervision while eating. A 5/4/26 facility investigation indicated Resident 58 was eating without supervision and the 1/17/26 recommendation for distant supervision while eating was never put in place for Resident 58. On 7/10/26 at 11:13 AM, Staff 37 (RN) stated Resident 58 had difficulty swallowing. Staff 58 stated distant supervision meant staff needed to keep the residents within line of sight while the residents were eating. On 7/10/26 at 11:16 AM, Staff 21 (CNA) stated Resident 58 had difficulty chewing and swallowing. Staff 21 stated distant supervision would be staff remaining in the doorway while the resident eats. On 7/10/26 at 1:36 PM, Staff 18 (LPN) stated Resident 58 had difficulty swallowing and was supervised eating at some point. Staff 18 stated distant supervision meant staff needed to keep the resident within line of sight while the resident was eating. On 7/10/26 at 1:53 PM, Staff 28 (LPN Resident Care Manager) stated distant supervision meant staff needed to keep residents within sight while the resident was eating, if the resident was eating in their room, staff remained by the door so they could see the resident. On 7/13/26 at 3:45 PM, Staff 2 (DNS) stated when a resident was care planned for distant supervision, staff were expected to stay in the room until the resident was done eating. Staff 2 stated Resident 58 received the correct diet but was not supervised. Staff 2 stated SLP failed to inform staff of the recommendation made for Resident 58 in 1/2026 to have distance supervision while eating. The deficient practice was identified as Past Noncompliance based on the following:On 4/27/26 the deficient practice was identified by the facility and was corrected when the facility completed a root cause analysis of the incident and determined Resident 58's care plan was not updated for distant supervision based on a 1/17/26 SLP recommendation. The Plan of Correction included: 1. An audit was completed which reviewed all SLP notes since 1/2026 to ensure all recommendations and orders were correct, 2. Meal supervision care plan were assigned to the Kardex (CNAs care plan) for CNA viewing of supervision requirements for meals, 3. All nursing staff were educated regarding various level of supervision during meals, what the various levels of supervision mean, where to find the information, and timely entering of new SLP or provider orders related to diet, 4. Education provided to therapy staff to ensure they are consistently utilizing their communication forms with nursing for all care plan updates, 5. Education provided to dietary staff regarding residents who require supervision for meals.

Based on observation, interview and record review it was determined the facility failed to ensure physician orders for respiratory care, an individualized respiratory care plan, and ongoing respiratory monitoring and assessment were in place for 1 of 2 sampled residents (#4) reviewed for respiratory care. This placed residents at risk for breathing difficulty. Findings include:Resident 4 was admitted to the facility in 1/2026 with diagnoses including COPD (chronic obstructive pulmonary disease- a lung disease that restricts airflow and makes breathing difficult) and respiratory failure. Physician Orders dated 1/30/26 indicated Resident 4 used a CPAP (Continuous Positive Airway Pressure- a device that blows a steady stream of pressurized air into your airway through a mask) machine while sleeping, but if she/he removed the CPAP, or refused to wear it, then the facility was to implement supplemental oxygen. The order further indicated the resident was to be on room air (natural breathing with no supplemental oxygen) when awake. The 2/11/26 Care Plan reiterated the same information as the 1/30/26 Physician Orders. The Oxygen Monitoring Task revealed staff intermittently monitored Resident 4's oxygen saturation levels, but not daily. For example, monitoring was not completed 6/25/26 through 6/28/2026 or 7/6/26 through 7/9/26. Resident 4's electronic health record did not have orders and indications for use of supplemental oxygen when she/he was not wearing a CPAP device. There was no information on the Care Plan or Treatment Activity Record of the supplemental oxygen delivery system or equipment, parameters for when to administer supplemental oxygen, how or when to monitor oxygen saturation levels, or documentation of ongoing assessment of the resident's respiratory status or response to supplemental oxygen use. From 7/6/26 through 7/9/26 many observations were made of Resident 4, and she/he consistently received supplemental oxygen via nasal cannula (tubing that delivers oxygen into the nostrils), either from an oxygen tank affixed to the back of her/his wheelchair or an oxygen concentrator when in bed. On 7/9/26 at 4:24 PM Staff 10 (CNA) stated Resident 4 received supplemental oxygen at all times. On 7/10/26 at 10:19 AM Staff 7 (Resident Care Manager LPN) stated Resident 4 required the use of supplemental oxygen at all times. Staff 7 acknowledged the facility did not have orders or a care plan in place to administer supplemental oxygen, and the electronic health record lacked sufficient assessment and monitoring for use of the supplemental oxygen. On 7/10/26 at 10:51 AM Staff 2 (DNS) acknowledged appropriate orders, care planning, assessment, and monitoring were not in place for Resident 4's use of supplemental oxygen.

Based on interview and record review it was determined the facility failed to ensure dialysis (a procedure which removes waste products and excess fluid from the blood when the kidneys are no longer functioning properly) services were in place including communication with the dialysis provider for 1 of 1 sampled resident (#46) reviewed for dialysis. This placed residents at risk for dialysis complications and delayed treatment. Findings include: Resident 46 admitted to the facility in 6/2026 with diagnoses including end stage renal disease.A 6/26/26 Care Plan revealed resident 46 had dialysis on Mondays, Wednesdays, and Fridays.A review of Resident 46's Pre Dialysis Evaluation and Post Dialysis Evaluations from 6/24/26 and 7/8/26 revealed the following days when the facility did not have a Pre Dialysis or Post Dialysis Evaluation:-6/26: no Pre Dialysis Evaluation was completed;-7/1: no Pre Dialysis Evaluation was completed;-7/6: no Pre Dialysis Evaluation or Post Dialysis Evaluation was completed;-7/8: no Pre Dialysis Evaluation was completed.A 7/3/26 Progress Note indicated the dialysis center communication included directions to increase potassium in Resident 46's diet.A review of Resident 46's health record revealed no evidence the 7/3/26 Progress Note was implemented or of additional communication with the dialysis center.On 7/9/26 at 1:34 PM Staff 32 (Registered Dietitian) stated she was unaware of the 7/3/26 Progress Note to increase Resident 46's potassium and it was not implemented.On 7/9/26 at 4:14 PM Staff 2 (DNS) confirmed the facility was to communicate with the dialysis center and complete the pre and post dialysis evaluations. Staff 2 confirmed no Pre Dialysis Evaluations were competed on 6/26/26, 7/1/26, 7/6/26, and 7/8/26; and no Post Dialysis Evaluations were completed on 7/6/26 and 7/8/26. Staff 2 also stated she was unaware of the 7/3/26 Progress Note to increase potassium in Resident 46's diet and was unaware of any communications to the dialysis center to confirm the order.

Based on interview and record review it was determined the facility failed to ensure a safe discharge for 1 of 2 sample residents (#60) reviewed for discharge planning. This placed residents at risk for unmet discharge needs and failed discharge. Findings include: Resident 60 admitted to the facility in 2/2026 with diagnoses including femur fracture.A 2/14/26 admission Skin/Wound Evaluation revealed Resident 60 had a stage 2 pressure wound to her/his right buttock.A 3/12/26 Face to Face/Discharge Orders revealed the facility requested orders for Resident 60 to have home health physical therapy and occupational therapy. Home health nursing services were not included in the orders.A review of the 3/2026 TAR revealed a 3/15/26 order to clean sacrum wound with wound cleanser, pat dry and apply medihoney to wound bed and cover with a bordered dressing daily and prn.A 3/16/26 Progress Note revealed Resident 60 discharged from the facility on 3/16/26.A 3/16/26 Discharge Summary/Plan of Care/Recapitulation of Stay evaluation revealed Resident 60 had a pressure injury to her/his buttock and the skin treatment was to apply barrier cream twice a day.A 3/17/26 Progress Note revealed Staff 3 (LPN/IP) was contacted by Resident 60's assisted living facility and they were not aware Resident 60 had a Stage 2 pressure injury. The progress note also indicated the new facility was not provided with updated wound care orders for Resident 60. On 7/9/26 at 10:06 AM Witness 7 (Home Health Director) stated she reviewed Resident 60's home health orders sent to the company for her/his discharge and nursing care was not requested.On 7/10/26 at 3:13 PM Staff 3 (LPN/IP) stated on discharge from the facility Resident 60 had a worsening wound on her/his coccyx. Staff 3 stated Resident 60's assisted living facility was not informed of the wound care on discharge and was not able to provide the needed care for Resident 60. Staff 3 stated Resident 60's wound care orders were changed right before discharge. Staff 3 stated Resident 60 did not have a safe discharge.On 7/13/26 at 12:51 PM Witness 9 (Assisted Living Facility Nurse) stated when Resident 60 discharged to the assisted living facility updated wound status and care was not provided to the assisted living facility. Witness 9 stated home health nursing was required for Resident 60's wound care.On 7/13/26 at 1:05 PM Staff 1 (Administrator) stated the facility should have known to request home health nursing orders for Resident 60 and Staff 1 expected all current wound care orders to be sent to the assisting living for discharge.

Based on interview and record review it was determined the facility failed to ensure the call light was accessible for 1 of 3 sampled residents (#10) reviewed for accommodation of needs. This placed residents at risk for the inability to call for assistance. Findings include:Resident 10 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (chronic condition where the heart is unable to pump blood effectively, leading to fluid buildup in the lungs and other body parts) and weakness.A review of Resident 10's 2/27/26 admission MDS revealed she/he was cognitively intact.A 2/26/26 Facility Reported Incident (FRI) reported Resident 10 received a bed bathe on 2/23/26 on the evening and the call light was not accessible to the resident until the next morning. Resident 10 reported no one checked in on her/him throughout the night and the resident needed to use the toilet.On 3/17/26 at 10:08 AM Staff 6 (CNA) stated she checked on Resident 10 on 2/24/26 at approximately 7:40 AM and her/his call light button was clipped to the top corner of the mattress and untucked under the pillow. Staff 6 stated Resident 10 was very upset because the call light was not accessible and had an episode of fecal incontinence in bed because she/he was unable to call for assistance throughout the night.On 3/17/26 at 10:13 AM Staff 7 (LPN) stated Staff 6 had informed Resident 10 was very upset after having an episode of fecal incontinence during the night because the resident's call light was not accessible. On 3/17/26 at 12:40 PM Staff 1 (Administrator) acknowledged Resident 10 did not have the call light accessible and experienced an episode of fecal incontinence. Staff 1 stated she expected staff to check on residents at least every two hours during the shift.

1. Based on observation, interview, and record review it was determined the facility failed to ensure a resident was assessed and interventions were implemented to prevent aspiration for 1 of 3 sampled residents (#13) reviewed for accidents. This failure resulted in an immediate jeopardy situation. This placed residents at risk for aspiration and death. Findings include: Resident 13 admitted to the facility on [DATE] with diagnoses including pneumonitis (inflammation of lung tissue) due to inhalation of food and vomit, dysphagia (difficulty swallowing), stroke and hemiparesis (weakness to one side of the body). The 1/25/22 Speech Therapy Evaluation indicated Resident 13 had the following history: -2/13/19 diagnoses included pneumonitis due to inhalation of food and vomit. -1/25/22 diagnoses included dysphagia. The 12/13/21 Care Plan indicated Resident 13 had chewing problems, swallowing problems and required limited to extensive assistance of one staff or family at meals. The 9/20/22 Quarterly MDS indicated Resident 13 was cognitively intact and required extensive assistance for eating. The 10/6/22 progress note indicated Resident 13 was assisted during meals and had a possible swallowing disorder. On 11/30/22 at 9:17 AM and 12/1/22 at 2:57 PM Resident 13 stated she/he sometimes coughed after drinking coffee and after eating food. Resident 13 stated this happened throughout the day during meals or between meals. Resident 13 further stated it had been a while since speech therapy evaluated her/him. On both occasions Resident 13 was observed to be alone in her/his room with candy and multiple drinks with straws on the bedside table within reach. A review of Swallowing Tasks Sheets indicated staff were to monitor coughing or choking during meals or when swallowing and staff were to document yes or no. Documentation was completed three times daily by CNA staff. Resident 13 had a progression of choking or coughing incidents as follows: *August 2022: 13 occasions *September 2022: 10 occasions *October 2022: 13 occasions *November 2022: 26 occasions No evidence was found to indicate a speech therapy evaluation was completed for Resident 13 since 2/24/22. The Therapy Quarterly Screen had a section for swallowing concerns (yes/no). The form dated 6/21/22 and 9/21/22 indicated no under swallowing concerns. There was no documented evidence a full speech therapy evaluation was completed for Resident 13 on 6/21/22 or 9/21/22. Interviews on 11/30/22 revealed the following: -9:43 AM Staff 31 (CNA) stated Resident 13 needed assistance with meals and eats candy and drinks fluids independently. Staff 31 further stated she observed the resident coughing during meals and believed the resident had a signed a risks versus benefits form for the current diet texture. -9:47 AM Staff 5 (LPN) stated Resident 13 received assistance with meals and the resident had candy at the bedside. Staff 5 stated she was not aware of Resident 13 choking or coughing at meals as no staff reported incidents to her. -9:55 AM Staff 6 (CNA) stated Resident 13 coughed after drinking fluids and she documented it on the task sheets. Staff 6 stated she did not report coughing incidents to nursing staff. -3:47 PM Staff 7 (CNA) stated he assisted Resident 13 with meals, and he observed her/him choking and coughing after taking bites of food. Staff 13 stated the resident was able to drink fluids independently and had snacks at the bedside. -4:05 PM Staff 8 (CNA) stated he observed Resident 13 to both cough and choke when eating and drinking. He stated he documented the incidents but did not report them to nursing staff unless it looks like [she/he] aspirated or it's not cleared up. He stated there was nothing rising to the level of reporting to the nurse. Staff 8 stated he saw empty candy wrappers in the resident's room but did not observed the resident to eat the candy on her/his bedside table. -4:31 PM Staff 9 (CNA) stated she observed Resident 13 cough during meals maybe a minute at most and the incidents happened while eating. Staff 9 stated Resident 13 had a hard time swallowing sometimes. Staff 9 further stated she did not see the resident eat candy, but she/he was able to consume candy independently if she/he wanted to. -4:45 PM Staff 10 (CNA) stated he observed Resident 13 cough and choke with every meal. He stated the resident coughed and aspirat[ed] kind of, more when drinking fluids. Staff 10 further stated he documented the incidents and I would think nursing staff is aware of it. On 12/1/22 at 10:40 AM Witness 2 (Family Member) stated Resident 13 liked having chocolates on her/his bedside table. Witness 2 stated Resident 13 had pneumonia from aspirating on 11/22/21 and he often observed the resident eating and drinking and she/he mainly had problems when swallowing drinks and coughed like she/he swallows it wrong and aspirating. Witness 2 stated that is how Resident 13 ended up in the hospital last time, she/he swallowed and went into lungs. On 12/1/22 at 9:59 AM Staff 2 (Regional RN) stated no Risks Versus Benefits form was completed for Resident 13's diet as the resident was on the diet that speech therapy recommended. On 12/1/22 at 11:19 AM Staff 12 (Therapy Director) stated she was unaware of the 26 documented choking/coughing episodes from 11/1/22 through 11/29/22 for Resident 13. Staff 12 stated the expectation was for staff to report incidents of choking/coughing to therapy after a resident had 1-2 coughing/choking episodes so speech therapy could evaluate the resident and possibly alter their diet as soon as possible for safety. On 12/1/22 at 1:12 PM Staff 11 (SLP) stated he was unaware of Resident 13's 26 choking/coughing episodes from 11/1/22 through 11/29/22, which placed Resident 13 at risk for aspirating on food or fluids. The facility identified two additional residents at risk for aspiration risk not including Resident 13. On 12/1/22 at 3:10 PM Staff 1 (Administrator), Staff 2 (Regional RN), and Staff 30 (Regional RN) was notified of an immediate jeopardy (IJ) situation and were provided a copy of the IJ template related to the facility's failure to ensure residents were adequately assessed regarding meals. An immediate plan of correction (POC) was requested. On 12/1/22 at 6:43 PM the facility submitted a final POC. The IJ Removal Plan included: -Provider contacted for speech therapy orders for Resident 13 to evaluate and treat as indicated; -Facility staff spoke with Resident 13 regarding downgrading diet for safety pending speech therapy evaluation and treatment. Resident refused to accept a modified texture diet even on a temporary basis and a risk vs. benefit was completed with resident and provider was informed; -Resident 13 assessed for signs/symptoms of aspiration; none noted; -Candy and drinks were removed from bedside 12/1/22; Resident 13 was not agreeable to this and demanded the return of [her/his] items so [she/he] could have them as [she/he] chooses. Risk vs. benefit done with resident including the risk vs. benefits of consuming candy or drinks on [her/his] own in [her/his] room; -Call was placed to Resident 13's spouse and discussed the risk vs. benefit completed; -Resident 13's care plan reviewed and updated regarding episodes of coughing/choking that have a noted increase in frequency per documentation; -Resident 13 was placed on alert monitoring x 72 hours for signs/symptoms of aspiration; -Staff education was started regarding the need to communicate noted changes in coughing/choking episodes observed during meals. Staff would sign in-service attendance sheet acknowledging they understand the information provided and have had the opportunity to ask questions. Staff list would be cross-referenced to validate that all staff receive education. This would include current agency staff; -New hires and agency staff new to the center would be educated on the need to communicate noted changes in coughing/choking episodes observed during meals. Staff would sign in-service sheet acknowledging they received and understood the education provided; -Residents in center were reviewed for any changes/increases in coughing/choking episodes during meals by reviewing POC documentation for the past 90 days; -Residents in center would be reviewed to identify those with an active diagnosis of dysphagia and/or aspiration pneumonia as an active problem upon admission to ensure care plan accurately identifies the risk factors and interventions for noted residents; -Speech therapy to evaluate residents in center to determine aspiration risk; -Residents in center at risk for aspiration reviewed to ensure care plan is current and accurately identifies the resident's risk factors and interventions. On 12/5/22 at 11:48 AM Staff 2 (Regional RN) was notified the immediacy was removed based on onsite verification the IJ removal plan was implemented. 2. Based on interview and record review it was determined the facility failed to ensure residents were free from accident hazards for 1 of 3 sampled residents (#13) reviewed for accidents. This failure resulted in Resident 13 spilling coffee on her/himself and receiving a second-degree burn. This placed residents at risk for accidents. Findings include: o First-degree burns involve the top layer of skin (e.g., minor sunburn). These may present as red and painful to touch, and the skin will show mild swelling. o Second-degree burns involve the first two layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin. Resident 13 admitted to the facility on [DATE] with diagnoses including stroke and hemiparesis (weakness to one side of the body). The 9/20/22 Quarterly MDS indicated Resident 13 was cognitively intact. The 12/13/21 Care Plan indicated Resident 13 required limited to extensive assistance of one staff or family at meals. An 8/4/22 Progress Note Late Entry [for 8/3/22] indicated Resident was drinking coffee last night at around 8:00 PM and spilled coffee on [her/his] chest. CNA reported to LN [licensed nurse]. The coffee caused a first-degree burn on resident's chest. Slight separation of skin. The 8/4/22 11:46 PM Nursing Progress Note indicated Resident 13 had a large burn on her/his chest and right groin. Chest burn is approximately 12 [cm] x 6 [cm] and starts at her/his chest and down to her/his right breast. Resident's chest is open, red around the edges and the area that goes down to her/his right breast is blistered. The area on her/his right groin is approximately 4 [cm] x 2 [cm] and is blistered. Resident had no bandage on and no treatment orders. Dressing applied and placed call to on-call physician, awaiting call back for treatment orders. The 8/3/22 at 8:00 PM Non-Pressure Skin Investigation completed by Staff 19 (LPN) indicated the following: -Resident was drinking coffee last night at around 8:00 PM and spilled coffee on her/his chest. CNA reported to licensed nurse. The coffee caused a first-degree burn on the resident's chest. Slight separation of skin. Resident unable to give a description. Assessment was done on wound. Slight separation of skin. No complaints of pain at the time of accident. Licensed nurse was able to get triple antibiotic ointment on skin and cover with bandage. CNAs were able to get an ice pack to relieve some discomfort. -Family member notified on 8/4/22 at 6:30 PM. (Noted by Staff 19). -The assessment did not include pain level, mental status, predisposing environmental factors, predisposing physiological factors, predisposing situation factors and witness list or witness statements. -The 8/10/22 Summary completed by Staff 4 (Former DNS) indicated Resident 13 had a history hemiplegia, dysphagia, and strokes. The resident had a diagnosis of pneumonia related to MRSA. Resident 13 was drinking hot coffee and spilled it on her/himself and had burn noted to right chest and on right groin. This seemed to be related to the cups the resident prefers to re-use from her/his favorite coffee place in the community her/his husband gets coffee from. Family notified this cup is not appropriate for re-use and to ensure that coffee is under 150 F when serving to resident to avoid burns. Hot beverage evaluation completed with resident and family and physician notified. Treatment put in place to open area. Resident is not voicing complaints of pain at this time. Abuse and neglect ruled out and resident and family educated on a new coffee mug for her/him to drink hot beverages from to avoid future issue with hot beverages. Temperature protocol utilized to ensure residents do not burn themselves [Noted by Staff 4 (DNS)]. -In an 8/16/22 interview with Staff 18 (Nursing Assistant) completed by Staff 4 (Former DNS), Staff 18 stated: I measured the temperature and it was not more than it should have been. I checked the temperature before and it was within range. I got the coffee from the break room. It went into the cups that Resident 13 always had, it's like a paper cup and at that time it felt like I could hold it in my hand easily like it wasn't too hot. I told her/him that if it feels too hot to wait a minute. I don't remember off the top of my head the temperature because it was several days ago, I just referenced the paper that was right there hanging in the break room. There was no indication a Hot Beverage Safety Evaluation was completed for the resident until 8/10/22. The safety evaluation indicated the following: -Resident demonstrated impaired orientation in one or more of the following areas: person, place or time; -The resident had a diagnosis of neuropathy or other neurological impairment; -The resident had a history of injury related to independent consumption of hot beverages. The 8/17/22 provider note indicated staff reported resident has chest burn from spilling coffee on [her/his] chest while eating. On examination, medial blister on chest .Active medical problems second degree burn. Assessment and plan second degree burn apply Silvadene cream cover with dressing, leave open to air .Diagnoses: Burn of second degree of chest wall, initial encounter. There was no indication the physician was notified the day the burn occurred on 8/3/22 and no indication treatments were implemented except for triple antibiotic ointment on 8/2/33. On 11/28/22 at 10:31 AM Witness 2 (Family Member) stated approximately three months prior staff used the single-cup coffee maker in the staff break room, the coffee was boiling hot and Resident 13 spilled it all over [her/himself]. Witness 2 further stated Resident 13 did not go to the hospital afterward and felt the facility down-played it. Witness 2 stated the resident had a blister on her/his chest and on the crevice of her/his leg. Witness 2 and Resident 13 showed the surveyor the area on the upper right chest just below the collar bone that was healed, but a red area remained and was approximately the size of the palm of a hand. On 11/29/22 at 1:34 PM Staff 19 (LPN) stated he worked on 8/3/22 and Resident 13 was drinking a lot of coffee that day. Staff 18 (Nursing Assistant) made the coffee too hot and Resident 13 spilled it on her/himself because she/he was not able to hold the cup. Staff 19 stated Staff 20 (CNA) reported it to him and the resident was kind of painful and had discomfort on [her/his] chest and right thigh from the burn. Staff 19 stated the area was red and she/he was given a cold pack and medication. Staff 19 stated Resident 13 had a history of spilling stuff. Staff 19 stated he was unsure if he notified the physician of the burn and acknowledged he did not put treatments in place on 8/3/22. Staff 19 stated he did not get witness statements the evening the burn occurred (8/3/22). On 11/30/22 at 12:08 PM Staff 29 (LPN) stated when she came to work on 8/4/22 a CMA or CNA asked her to look at the burn on Resident 13 and she/he had an open area at the top of her/his chest, maybe where a blister was that opened, and it blistered as it went down to her/his right breast and also had a burn on her/his groin area, she stated the areas were not covered, it looked awful and it made me sick. Staff 29 stated Resident 13 complained that she/he was hurting. Staff 29 stated the burn was not a first degree burn because it was open and blistered and was more than red, at least a second degree burn. Staff 29 stated there were no treatment orders in place on 8/4/22 and she called the physician to get orders. She further stated the physician ordered to clean the area and apply Silvadene (burn cream). Staff 29 stated the burn happened the evening shift on 8/3/22 and she worked night shift on 8/4/22, and the resident went over a day without treatment. Staff 29 stated she made the DNS, the physician and the family aware of Resident 13's burn. She confirmed the progress note that indicated the measurements of 12 x 6 on the chest and 4 x 2 on the groin were measured in centimeters. Staff 29 stated the area was slow to heal and staff stopped giving Resident 13 coffee that was too hot and the facility got rid of the single-cup coffee machine. On 11/30/22 at 12:26 PM and 12:42 PM Staff 4 (Former DNS) stated Resident 13 received a burn on her/his chest and leg from hot coffee spilling on her/him on 8/3/22 and he was made aware of it the next day. Staff 4 acknowledged the physician was not notified of the burn until the evening of 8/4/22, there was no indication the care plan was updated, no indication the area was treated or measured until 8/4/22, and he did not start the investigation until 8/10/22, seven days after the burn occurred. Staff 4 further acknowledged he did not interview Staff 18 (Nursing Assistant) until 8/16/22, 13 days after the burn occurred. Staff 4 acknowledged there were no witness statements for the investigation. Staff 4 further acknowledged the hot beverage assessment was not completed until 8/10/22, seven days after the burn occurred, and there was no prior hot beverage assessment. Staff 4 further acknowledged there was no ongoing monitoring or measuring of Resident 13's burn after it occurred. On 12/5/22 at 7:59 AM Staff 20 (CNA) stated she worked on 8/3/22 when the resident was burned and Staff 18 (Nursing Assistant) got a cup of coffee from the single-cup coffee maker and placed it in a disposable cup once she arrived to the resident's room. She further stated there was a thermometer in the break room but not everyone used it. Staff 20 stated Resident 13 required a cup with a lid and a straw due to both of her/his arms being shaky. Staff 20 further stated Resident 13 pushed her/his call light and when Staff 20 responded the resident told her the lid was not all the way closed on the coffee cup and the resident spilled it on her/himself. Staff 20 stated Resident 13 reported being burned on her/his right side of the chest and groin and when she checked the burn, it was really bad, the skin was peeling off, it didn't blister it just peeled off. Staff 20 stated she reported the burn to Staff 19 (LPN). On 12/5/22 at 1:29 PM Staff 2 (Regional RN) acknowledged Resident 13 received a burn and notes indicated there was separation of skin indicating at least a second- degree burn. Staff 2 further acknowledged the physician was not notified of the burn on 8/3/22 when it occurred, and treatments were not put in place on 8/3/22 by Staff 19 (LPN). Staff 2 further acknowledged the physician and Witness 2 were not notified until 8/4/22 and there was no indication besides the progress note on 8/4/22 that the area was measured and assessed and there was no ongoing monitoring for the burn. Staff 2 acknowledged the Non-Pressure Skin Investigation was not thorough and did not include the resident's level of pain, mental status, injuries reported post incident, predisposing environmental factors, predisposing physiological factors, predisposing situation factors or witness statements. Staff 2 further acknowledged Staff 4 (DNS) indicated he knew about the burn on 8/4/22 and did not start the investigation until 8/10/22, 7 days after the burn occurred and did not interview Staff 18 (Nursing Assistant) until 8/16/22, 13 days after the burn occurred . Staff 2 further acknowledged the care plan was not updated to reflect the need for Resident 13 to have non-disposable cups, the history of the burn or the appropriate temperature for hot liquids. Staff 2 acknowledged the TARs indicated Resident 13 did not receive treatments on 8/9/22, 8/19/22 or 8/22/22. Staff 2 stated the policy was for an investigation to be completed within 72 hours. 3. Based on observation, interview and record review it was determined the facility failed to ensure pain patches were properly disposed of for 1 of 1 observation during medication administration. This placed residents at risk for accidents. Findings include: The 8/2018 Disposal of Medications and Medication-Related Supplies indicated the following: C. Options to dispose of non-flushable prescription drugs include: 2d. Use a commercially available pharmaceutical disposal system that meets Federal and State disposal requirement (e.g. Rx Destroyer or Drug Buster) for proper disposal. On 12/2/22 at 8:19 AM Staff 23 (CMA) was observed to remove buprenorphine 15 mcg patch (opioid pain patch) from Resident 19 using gloves. Staff 23 then turned the gloves inside out, folding the patch inside of the gloves, and disposed of it in the trash located on the side of the medication cart in the hallway. On 12/2/22 at 8:20 AM Staff 23 stated the used pain patch should probably go in the sharps container, but since it's cloth I don't put it in there. On 12/5/22 at 1:41 PM Staff 2 (Regional RN) stated the expectation was for staff to use the Drug Buster for disposal of pain patches and a witness was needed to destroy the patch. Staff 2 stated opioid pain patches were not to be discarded into the trash. 40767 4. Based on interview and record review it was determined the facility failed to complete a thorough fall investigations for 2 of 3 sampled residents (#s 15 and 23) reviewed for accidents. This placed residents at risk for injury. Findings include: a. Resident 23 admitted to the facility in 2021 with diagnoses including a stroke and seizures. The 4/29/22 Quarterly MDS indicated the resident was cognitively intact and had no history of falls since admission. A 5/26/22 Nursing Progress Note completed by Staff 19 (LPN) indicated the resident fell and there was no injury noted or complaints of pain voiced. There was no further information provided in the note. A 5/26/22 Fall Investigation completed by Staff 19, indicated that evening, Resident 23 had a witnessed fall by an unidentified CNA. The note indicated the resident fell off the edge of the bed and sustained a skin tear to the right knee and prn pain medication was administered. The resident was assessed with no major pain. The resident stated, my mattress is slippery and moves when I roll to the side, that is probably what caused it. A summary completed by Staff 4 (Former DNS) indicated Resident 23 had a witnessed fall from bed with a CNA present and sustained no serious injuries. Fall precautions were noted to be in place. Abuse and neglect were ruled out. The investigation did not include witness statements, a mental status or pain level assessment, predisposing factors, the root cause of the fall, interventions to prevent further falls, and if the care plan was updated. The investigation was dated as completed on 6/2/22 (seven days after the incident). The Fall Care Plan, last updated 6/23/22, indicated the resident was at moderate risk for falls due to gait/balance issues, incontinence, deconditioning, and chronic fatigue. There was no indication the resident experienced a fall. The care plan indicated Resident 23 required one staff member to turn and reposition in bed. On 11/28/22 at 11:18 AM Resident 23 stated she/he believed in April 2022, the resident's mattress was not on the bed properly and the resident fell off. Resident 23 was unable to provide more details. On 11/29/22 at 1:30 PM Staff 19 (LPN) stated a former CNA (Staff 26) informed him Resident 23 fell off the bed during a brief change. Staff 19 did not believe the resident sustained any injuries. Staff 19 was unable to recall further information but stated he did not believe a witness statement was completed by Staff 26. On 11/29/22 at 2:05 PM Staff 2 (Regional RN) confirmed there were no witness statements for Resident 23's 5/26/22 fall and Staff 26 no longer worked at the facility. Attempts were made to contact Staff 26 on 11/29/22 at 2:13 PM and 11/30/22 at 11:50 AM but the phone number was out of service. On 11/30/22 at 10:26 AM Staff 4 (Former DNS) was unable to state the root cause of Resident 23's fall. Staff 4 confirmed the investigation did not include a witness statement, mental status and pain assessments, what the predisposing factors were prior to the fall, and a discussion of care plan interventions. Staff 4 confirmed there were no new care plan interventions put in place to prevent further falls and stated the expectation was to complete investigations within five days, but the 5/26/22 investigation was not completed until the seventh day. 34324 b. Resident 15 admitted to the facility in 2021 with diagnoses including dementia and muscle weakness. The facility's 2016 Charting for Event Investigation Report Policy indicated investigations should include observable factors and what was reported by the person involved. The 1/26/22 Care Plan indicated Resident 15 had impaired cognitive function related to dementia with behaviors. The Care Plan indicated the resident was a high risk for falls due to confusion. A 11/19/22 Fall Investigation indicated Resident 15 was found in between the bed and the bathroom. It appeared the resident self-transferred and attempted to walk. Resident 15 was noted to have dementia and was unable to explain the fall. The investigation did not include information related to potential factors contributing to the fall such as environmental, physiological, situational or when the resident was last visualized and received cares. The investigation did not include the name of the witness or a witness statement. On 12/2/22 at 12:18 PM Staff 2 (Regional RN) stated a book with witness statements was kept but was unable to be located. Staff 2 confirmed the 11/19/22 fall investigation for Resident 15 was not thorough.

Based on interview and record review it was determined the facility failed to develop a baseline care plan based on identified health conditions and initial goals for 2 of 7 sampled residents (#s 5 and 11) reviewed for pressure ulcers and abuse. This resulted in Resident 5's development of facility acquired pressure ulcers and placed residents at risk for unmet care needs. Findings include: 1. Resident 5 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/4/20 Admission Nursing Evaluation revealed Resident 5 had a sacrum rash. The Baseline Care Plan documented Bathing 1 specify type. The Baseline Care Plan did not identify Resident 5's impaired skin condition or any other conditions and risks affecting the resident's health and safety to meet Resident 5's immediate needs. The 1/11/20 Hospital Records revealed Resident 5 returned to the hospital with a Stage IV (full thickness skin loss) sacral pressure ulcer and an unstaged open and draining pressure ulcer to the right heel. On 2/21/20 at 6:50 AM Staff 14 (LPN) stated Resident 5 had a Stage one pressure ulcer (non-blanchable, intact skin) to her/his heel but was unaware it progressed any further. On 2/25/20 at 9:49 AM Staff 5 (Divisional Director of Clinical Operations) acknowledged Resident 5 admitted to the facility on [DATE] with a rash to the sacrum and discharged from the facility with a Stage IV sacral pressure ulcer and a right heel pressure ulcer. Staff 5 acknowledged Resident 5's Baseline Care Plan did not meet her/his initial needs for prevention of potential skin impairment. Refer to F656 for related information. 2. Resident 11 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/18/20 Baseline Care Plan listed bathing as the resident need. The Comprehensive Care Plan had a 1/9/20 Potential for Impaired Nutrition Status initiated. No other care plan was in place within 48 hours of Resident 11's admission. There was no evidence in the medical record the Baseline Care Plan was offered to Resident 11. On 2/21/20 at 10:17 AM Staff 5 (Divisional Director of Clinical Operations) verified the Baseline Care Plan was not completed for Resident 11 and there was no evidence in the medical record the Baseline Care Plan was offered to Resident 11.

Based on interview and record review it was determined the facility failed to prevent pressure ulcer development and assess pressure ulcers for 2 of 3 sampled residents (#s 5 and 8) reviewed for skin conditions. This resulted in multiple facility acquired pressure ulcers for Resident 5 and placed residents at risk for facility acquired pressure ulcers. Findings include: 1. Resident 5 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 5 discharged to the hospital on [DATE]. The 1/3/20 Hospital Records indicated Resident 5's perineal area was red and excoriated. The 1/4/20 Admission Nursing Evaluation revealed Resident 5 had a sacrum rash. The evaluation did not identify any skin impairment to Resident 5's bilateral heels. The 1/4/20 Admit Skin Worksheet revealed Resident 5 had a red buttocks. The 1/9/20 Care Conference identified Resident 5's concerns with her/his bed and listed a goal of wanted to get out of bed more often. The notes indicated Staff 21 (Social Service Director) addressed Resident 5's concerns. Additionally, there was no documentation of any resident care refusals. Resident 5's Baseline Care Plan did not identify any current skin conditions, the risk for potential skin impairment or had skin at risk interventions in place. The Comprehensive Care Plan included the following: * 1/5/20 ADL Care Plan indicated Resident 5 had an ADL self-care performance deficit related to fatigue and impaired balance. No interventions were in place. * 1/9/20 Limited Physical Mobility related to weakness. Interventions included to provide supportive care and assistance with mobility as needed. Review of Resident 5's progress notes revealed on 1/10/20 Resident 5 did not have any identified non-surgical skin conditions. A second note on 1/10/20 indicated Resident 5 had a red and black appearing rash/abrasion, with peeling skin . The progress notes did not have further documentation of the sacrum rash Resident 5 admitted with or the right heel pressure ulcer Resident 5 developed. There was no documentation of care refusals from Resident 5. The 1/10/20 Facility Investigation indicated Resident 5 was confused, drowsy, had impaired memory and was incontinent of bowel and bladder. The investigation indicated Resident 5 was non-compliant with being turned and repositioned (no evidence of refusals of care was found in medical record). The January 2020 TARs revealed a 1/11/20 physician order [REDACTED]. A review of Resident 5's medical record revealed no evidence of care refusals. The 1/17/20 Hospital Records revealed Resident 5 presented to the hospital on [DATE] with a 12 cm x 15 cm Stage IV (full thickness skin loss) sacral pressure ulcer with blood and malodorous exudate (drainage) and a right heel open ulcer with exudate. Resident 5 was on anticoagulant medication and admitted with an upper GI (gastrointestinal) bleed. Resident 5 passed away on 1/17/20 with the principal [DIAGNOSES REDACTED]. On 2/25/20 at 9:49 AM Staff 5 (Divisional Director of Clinical Operations) stated no skin assessments were completed to Resident 5's sacrum or right heel. Staff 5 stated she knew Resident 5 had a Stage 1 (non-blanchable intact skin) pressure ulcer to the right heel but was unaware it had opened. Staff 5 stated she believed Resident 5 had an air mattress and remembered Resident 5 did not want to get out of bed, she/he had a recliner at home and was more comfortable sitting in a recliner so the facility tried but was unable to locate a recliner Resident 5 was comfortable in while at the facility. Staff 5 further stated she knew staff turned and repositioned Resident 5 and had personally assisted a few times in the turning and repositioning. Staff 5 verified the baseline care plan did not meet Resident 5's needs for prevention of potential skin impairment. On 3/3/20 at 12:44 PM Staff 23 (CNA) stated she did not see Resident 5's buttocks during her/his stay at the facility and did not recall any care refusals. On 3/3/20 at 12:48 PM Staff 24 (LPN) only vaguely remembered Resident 5 and was unable to recall the condition of Resident 5's buttocks. On 3/3/20 at 12:50 PM Staff 25 (RN) acknowledged she completed the 1/10/20 Facility investigation and did not know what the red and black appearing buttocks wound was. Staff 25 further acknowledged the medical record did not have any evidence of Resident 5 care refusals and stated she obtained this information from what the CNA staff told her. Staff 25 was unable to recall which CNAs reported this information to her. On 3/3/20 at 12:57 PM Staff 29 (CNA) verified Resident 5's buttocks were red upon admission and staff applied barrier cream to protect her/his skin. Staff 29 was unable to recall the skin condition to Resident 5's right heel. Staff 29 stated she assisted Resident 5 with reposition and further stated Resident 5 did not refuse to turn and reposition and was compliant with care. 2. Resident 8 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 12/20/19 Admission MDS indicated Resident 8 had no pressure ulcers. a. A 12/29/19 progress note identified a facility acquired open sore to the mid-back which measured 1 cm x 1 cm and a facility acquired open Stage II (partial thickness wound which may involve tissue loss at the epidermis and dermis levels) to the [MEDICATION NAME] spine measuring 1.2 cm x .7 cm x 0.1 cm. Review of the medical record revealed no further skin assessments were completed until 2/2/20. The January TARs revealed a 1/20/20 physician order [REDACTED]. The TARs revealed no wound treatments were in place from 12/29/19 through 1/20/20. On 2/21/20 at 10:24 AM Staff 5 (Divisional Director of Clinical Operations) verified the upper-mid vertebrae pressure ulcer was facility acquired and no skin assessments were completed from the initial 12/29/19 assessment until 2/20/20. Staff 5 verified no assessments were completed for the lower back open wound. Staff 5 acknowledged no treatments were in place until 1/20/20. b. A 1/8/20 Physician Visit note revealed areas of scabs to the left scapula. The 1/16/20 Nutrition/Dietary Note revealed Resident 8 developed a new pressure ulcer to the scapula area despite improved intake at meals and significantly increased supplement intake. A 1/17/20 progress note revealed Resident 8 had a scapula wound. The January TARs revealed a 1/20/20 physician order [REDACTED]. The TARs revealed no wound treatments were in place from 1/8/20 through 1/20/20. The 1/23/20 Nutrition/Dietary Note revealed the left scapula wound was a Stage II pressure ulcer. The 1/23/20 Weekly Skin Evaluation revealed the left scapula pressure ulcer measured 0.8 cm x 0.3 cm. On 2/21/20 at 10:24 AM Staff 5 (Divisional Director of Clinical Operations) verified the left scapula pressure ulcer was facility acquired and no skin assessments were completed until 1/23/20. Staff 5 acknowledged no treatments were in place until 1/20/20. c. The January 2020 TARs revealed a 1/18/20 physician order [REDACTED]. There were additional heel treatment orders in place. The 1/30/20 Skin Evaluation identified a Stage II right heel facility acquired pressure ulcer. The assessment did not identify the date the wound was identified. Review of the medical record revealed no evidence the physician was notified of the Stage II right heel pressure ulcer or when the wound was first identified. On 2/21/20 at 10:24 AM Staff 5 (Divisional Director of Clinical Operations) verified right heel pressure ulcer was facility acquired. Staff 5 stated she was informed the facility identified the wound as a Stage 1 (superficial reddening of intact skin which does not blanch when pressed) on 1/23/20. Staff 5 did not know when the wound declined to a Stage II and verified there was no evidence the physician was notified of the Stage II wound and did not know if the facility requested treatment orders for the wound. d. The January 2020 TARs revealed a 12/22/19 physician order [REDACTED]. The dressing was to be changed every two days and as needed. The 1/14/20 Comprehensive Skin Impairment Care Plan indicated the wound to the bridge of the nose was related to the weight of Resident 8's glasses. Review of the medical record revealed no weekly skin assessments of the facility acquired pressure ulcer. On 2/21/20 at 10:24 AM Staff 5 (Divisional Director of Clinical Operations) acknowledged the nose pressure ulcer was facility acquired and no skin assessments were completed.

Based on interview and record review it was determined the facility failed to ensure a resident with a diagnosed mental disorder and a documented history of trauma received needed care and services to prevent psychosocial decline for 1 of 8 sampled residents (#196) reviewed for allegations of abuse and neglect. This failure, determined to be an immediate jeopardy situation, resulted in Resident 196 experiencing ongoing emotional distress, repeated refusals of care, a lack of dignity, worsening skin conditions, development of pressure ulcers, prolonged periods without incontinent care, repeated falls and neglect. Findings include: On [DATE] a complaint was received by the state agency which alleged Resident 196 did not receive necessary care and services including incontinence care, wound treatment, falls and dignity. Resident 196 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The resident died in the facility on [DATE]. The resident's admission assessments from (YEAR) were requested from facility staff, who were unable to provide them at the time of this investigation. A [DATE] PASRR II (Pre-Admission Screening and Resident Review - mental health evaluation) consisted of resident and staff interviews, the resident's clinical record and a prior PASRR II from (YEAR). The PASRR II indicated the following: - The resident had a [DIAGNOSES REDACTED]. The resident also had a history of [REDACTED]. - The resident was dependent on staff for ADLs including mobility, personal hygiene and incontinence care. - The resident refused care including medication, personal hygiene and incontinence care. - The resident displayed behaviors including agitation, screaming, delusions about going to Hell and perseverating about a previous suicide attempt. - The resident developed a rash related to the resident's refusals of hygiene and incontinence care and was noncompliant with diabetic management. - The resident was more cooperative with care from two particular staff members. - Recommendations included behavior monitoring to identify changes in behavior and distress. Recommendations also included to educate staff on the resident's routines and the use of appointed point persons to assist the resident. - The PASRR II also repeated a past recommendation for ongoing psychiatric services for ongoing medication management and mental health services. No evidence was found to indicate the (YEAR) PASRR II's recommendations for education of employees was implemented. No evidence was found to indicate the facility identified point persons or preferred staff members in order to assign them to Resident 196's care. No evidence was found to indicate the resident received ongoing psychiatric medication management or mental health services. Behavior Monitoring records were requested and the only documents provided were dated ,[DATE], ,[DATE] and ,[DATE]. No other evidence was found to indicate Resident 196's behaviors were monitored. The only noted behaviors were related to refusal of care and medication. The provided logs did not include specific targeted behaviors such as delusions, screaming, agitation or any other noted behaviors. The logs also did not include resident-specific interventions to address the behaviors. A review of Resident 196's [DATE] care plan for decline in psychosocial condition, which included no new interventions since [DATE] included the following: - Two staff were to provide care for the resident (specific preferred staff or point persons were not identified). - Resident 196 was to be reminded that her/his gestures and comments are inappropriate and not acceptable. - The resident was to be reviewed at quarterly psych meetings. - Document resident's behaviors. - Staff were to compliment the resident on how nice she/he looked when she/he was compliant and nice and clean in order to promote compliance next time. A [DATE] Quarterly Social Service Evaluation completed by Staff 45 (Former Social Services Director) indicated Resident 196 was: - unable to converse sensibly and was unable to write. - delusional and did not remember things as they were. - unable to make decisions in her/his own best interest. - without any real relationships in the facility. - noted to have varying moods, but was mostly stable though the resident refused cares, had delusional thoughts and was sexually inappropriate with male caregivers. - functionally limited due to mental impairment. - The evaluation also indicated the resident enjoyed visits with friends and had family members to handle personal and financial affairs. A review of the resident's clinical record revealed no evidence Resident 196 or her/his responsible party signed a risk and benefit statement regarding the consequences of refusing medications. The only signed risk and benefit statement found regarding the resident's refusals of care was completed in (YEAR). The [DATE] MDS indicated the resident was unavailable or refused to have a cognitive assessment. The staff assessment indicated the resident was moderately impaired in her/his decisions and required cues and supervision. The following were also indicated during the assessment lookback period: -The resident was noted to be always incontinent of bowel and bladder. -The resident required extensive assistance with the aid of two staff people for toileting and personal hygiene. -The resident was noted to be short tempered or easily annoyed seven to 11 days. -The resident was noted to reject cares. -The resident displayed continuous disorganized thinking, had delusions, had verbal and other behaviors symptoms. -The resident received antipsychotic medication 3 of 7 days. An [DATE] Quarterly Social Service Evaluation indicated the following about Resident 196: -The resident had poor decision making skills accompanied by behaviors. -The resident did not adjust to changes easily -The resident disliked most staff, and rejected care, medication and food at times. -The resident had frequent missed medication. -Usually remains in room. On occasion can be convinced to come from (her/his) room and has a good time. -noted to have no pressure ulcers, wounds or skin problems. The [DATE] Quarterly MDS indicated the resident was cognitively intact. The MDS also included the following for Resident 196's 14-day lookback period: -felt down, depressed or hopeless ,[DATE] days. -had trouble falling or staying asleep, or sleeping too much ,[DATE] days. -felt tired or had little energy ,[DATE] days. -felt bad about her/himself and that he/she was a failure or let her/his family down ,[DATE] days. -had trouble concentrating on things, such as reading the newspaper or watching television. -displayed delusions indicative of [MEDICAL CONDITION]. -rejected cares daily. -had moisture associated skin damage. -received antipsychotic medication 7 out of 7 days and opioid medication 4 out of 7 days. A [DATE] pharmacy recommendation indicated the patient refused cares and vitals, constantly cried and stated she/he was going to Hell or was already in Hell. A request to increase the resident's [MEDICATION NAME] (antipsychotic medication) was sent to the physician. The response from Staff 21 (House Physician/Medical Doctor) stated, (She/he) does not take (her/his) meds consistently so why (increase) it? A [DATE] [MEDICAL CONDITION] Drug and Behavior Medication Review Form, located in Resident 196's clinical record was noted to be blank. The [DATE] Quarterly MDS indicated the following information during the 14-day look-back period: -had a fluctuating behavior of inattention and disorganized thinking. -had little interested or pleasure in doing things ,[DATE] days. -felt or appeared down, depressed or hopeless ,[DATE] days. -felt tired or had little energy ,[DATE] days. -had trouble concentrating on things ,[DATE] days. -indicated she/he felt bad about her/himself, felt like a failure or felt she/he had let her/his family down ,[DATE] days. -stated like isn't worth living, wishes for death, or attempts to harm self ,[DATE] days. -was short tempered or easily annoyed ,[DATE] days. -rejected cares daily. -displayed physical behavioral symptoms toward other one to three days. -displayed verbal behaviors symptoms toward others daily. -displayed other behavioral symptoms daily. -required extensive assistance from two or more staff to turn her/himself in bed and for personal hygiene. -received antipsychotic medication 5 of 7 days during the look-back period. An Investigation Report dated [DATE] indicated Resident 196 had a finger infection and the resident stated it was painful and wanted staff to fix it. The investigation further indicated the cause of the infection was related to Resident 196's history of refusing cares (including bathing and nail care) due to psychiatric conditions. The reporting indicated Resident 196 used her/his fingers to pull stool from the resident's rectum, which exposed her/his nails to feces. The [DATE] Significant Change in Status MDS indicated the resident was cognitively intact. The MDS included the following information for Resident 196's 14-day lookback period: -felt down, depressed or hopeless ,[DATE] days. -had trouble falling or staying asleep, or sleeping too much ,[DATE] days. -felt tired or had little energy ,[DATE] days. -displayed hallucinations and delusions indicative of [MEDICAL CONDITION]. -had verbal or other behaviors directed towards her/himself or others ,[DATE] days that significantly impacted the resident's care and significantly disrupted or impacted the living environment for others. -noted to have no wounds, but to have had moisture associated skin damage and to be treated with applications of ointment/medications. -received an antipsychotic for five of seven days. An undated and unsigned document provided to survey staff on [DATE] by Staff 29 (LPN MDS Coordinator) indicated Resident 196's [DATE] MDS was triggered based on a change in incontinence and nutrition status. The note indicated Resident 196 experienced a 14.43% weight loss since ,[DATE] and the resident had increased incontinence. However, a review of the resident's record did not indicate a clear decline in the resident's incontinence status. A [DATE] Physician Facsimile Order Form composed by Staff 2 (DNS) requested if the resident's medications could be discontinued, as (she/he) only wants treatments PRN. An undated physician reply stated No because I think we should offer (her/his) meds - little is better than nothing. Review of the ,[DATE] through ,[DATE] monthly pharmacist reviews revealed the following: ,[DATE] - indicated the resident requested all her/his PO medications discontinued. ,[DATE] - indicated the resident refused medications three times during AM medication pass and refused her/his medications 13 items for evening medication pass. ,[DATE] - indicated the resident was still refusing meds (mainly PM). No evidence was found to indicate the facility reassessed the resident's refusals of [MEDICAL CONDITION] medications and why the resident more frequently accepted medication in the AM than PM. A review of the resident's record revealed no evidence the resident's medication and treatment orders were reviewed by Staff 21 in ,[DATE] or ,[DATE]. The only review of the resident's use of [MEDICAL CONDITION] medication found in the resident's record since (YEAR) was dated [DATE]. The [DATE] [MEDICAL CONDITION] Drug and Behavior document indicated the following: -Target behaviors summary: outbursts and refusal of care/meds daily and sometimes multiple times daily. Staff honor resident wishes when (she/he) refuses. MD doesn't want any more notification about refusals; she is aware and still does not want to change or DC (discontinue) medication. -The document was not completed by an inter-disciplinary team, but consisted of only nursing staff, including Staff 2 (DNS), Staff 5 (Regional RN) and Staff 3 (LPN Resident Care Manager). No evidence was found to indicate a physician or qualified social services director participated in the [MEDICAL CONDITION] drug review. -Non-drug interventions were to assess and address pain/care needs, re-approach and redirect with conversation. -Behavior monitoring flowsheets were documented to be in place. -Team recommendations included, Continue to monitor behaviors/mood and follow up with MD as indicated. Generally stable overall at this point; resident does refuse, but mood is managed. Review of the resident's clinical record related to physician progress notes [REDACTED]. Review of Resident 196's clinical record from ,[DATE] through ,[DATE] revealed signed physician progress notes [REDACTED]. The physician progress notes [REDACTED]. needs. The physician's notes from ,[DATE] through ,[DATE] included: -The ,[DATE] Assessment and plan read: 1. Psych: stable on [MEDICATION NAME] (mood stabilizer) 2. Pain: stable on [MEDICATION NAME] (narcotic pain medication) 3. DM (diabetes) on [MEDICATION NAME] (anti-diabetic medication) refuses labs. -The ,[DATE] notes revealed the resident refused the physical examinations and continued to refuse insulin (diabetic medication). The note further read, 1) DM (diabetes) - keep trying to offer (treatment). 2) .(psych) - takes meds sporadically. -The ,[DATE] note revealed no indication of the resident's recent significant change of condition, as per the [DATE] Significant Change MDS. The Assessment and plan portion of the note indicated the resident refused medications, examinations, treatments and care. The note indicated to continue to offer. -The [DATE] note revealed the resident refused most of the exam. The Assessment and Plan read, .stable but refuses most meds and (treatments) for (diabetes, [MEDICAL CONDITION] disorder, [MEDICAL CONDITION]). None of the identified physician progress notes [REDACTED]. medical or psychiatric regimen. Resident 196's clinical record indicated she/he was placed on hospice status on [DATE] and died on [DATE]. On [DATE] at 1:16 PM Witness 1 (Complainant) stated Resident 196 was mistreated while at the facility. At the time of Resident 196's death, her/his entire body was a sore which was painful. Witness 1 did not feel the facility was an appropriate placement for Resident 196. The resident was covered in feces and urine, was laying in urine-soaked sheets and was neglected while in the facility, and fell through the cracks which hastened the resident's death. Witness 1 stated the facility's indication that Resident 196's refused care was not true as the resident only refused care based on the staff being too busy as the facility was understaffed. Resident 196's level of care needs were increasing and the resident's health crashed. When the resident transitioned to hospice status the resident's skin began to improve because she/he received better care from hospice staff including baths. Witness 1 stated Resident 196 needed to be referred to a psychiatric doctor or for a psychiatric evaluation. Witness 1 stated Staff 1 (Administrator) was in over his head. Witness 1 stated an unknown staff member told him that facility staff were afraid to work with Resident 196 due to the resident's history of making a false allegation against staff. Witness 1 stated the unknown staff member made him promise not to tell what was reported to him. Witness 1 stated he should have removed Resident 196 from the facility at that time. Witness 1 stated the last six months were the worst with regard to the resident's rash and mental illness. On [DATE] at 5:08 PM Witness 6 (Hospice RN) stated she worked with Resident 196 after the resident transitioned to hospice care on [DATE]. Witness 6 and other hospice staff were able to provide baths and cares to Resident 196 due to their gentle approach and additional time. Witness 6 stated when she visited the resident was laying on a disgusting urine soaked mattress and the resident's room had the most foul smell. Witness 6 described Resident 196's skin condition as, The most atrocious thing I've ever seen, a hot bright red rash with pocks and scales. Witness 6 stated she removed two cups of skin that scaled off the resident during the bath. Witness 6 described the rash as from head to toes including through the perineal area, that appeared painful and systemic. Witness 6 stated she was traumatized by observing Resident 196's condition. Facility nursing staff told Witness 6 that Resident 196 refused all cares including having linens changed. Witness 6 stated she was successful with bathing the resident and she changed the bedding during their first visit and ordered a new mattress. Witness 6 stated when the resident was lifted out of bed, the bedding smelled foul and was covered in white crystals which indicated urine crystallization. Witness 6 stated facility staff informed her the resident refused to be changed all day long and wore the same urine soaked brief for quite some time. Witness 6 stated Resident 196 was generally cooperative with care. The following interviews with facility nursing staff were completed from [DATE] through [DATE]: - On [DATE] at 11:08 AM Staff 9 (CMA) stated Resident 196 had mental health issues, disruptively yelled out, refused to change her/his clothes but sometimes allowed certain people to assist. The resident shared past information about physical and sexual abuse. The resident attempted suicide in the past and believed she/he was in Hell. There were no consistent social services in the facility and the resident was not a good fit for the facility. - On [DATE] at 11:04 AM Staff 26 (LPN) stated Resident 196 refused care and medication numerous times per day and yelled and cried about going to Hell. The resident told staff to get out (of her/his room) and went days without being bathed and refused to wear clothes. Staff 26 did not know of a therapist ever seeing Resident 196. The resident was verbally aggressive, talked about killing her/himself and going to Hell. The resident refused to be changed and her/his bed was soiled. At one point the resident had an infection in her/his finger due to touching her/his own feces and refusing hygiene assistance. Staff 26 stated Resident 196 had an incontinence [MEDICAL CONDITION] rash. - On [DATE] at 11:55 AM Staff 32 (CNA) stated Resident 196 declined significantly in the last six months of her/his life. Resident 196 had a painful rash due to refusals of incontinence and hygiene assistance. Staff 32 stated Resident 196 and her/his bedding were sometimes covered in feces in her/his last six months of life. Staff 32 did not believe the facility was an appropriate placement for the resident. Resident 196 previously went outside the facility for activities but no longer left her/his room to engage in activities outside of her/his room. Staff 32 stated when concerns regarding Resident 196's refusals and incontinence rash were discussed with administrative staff, Staff 32 was told it was a resident rights issue. Staff 32 expressed belief the resident's refusals of care resulted in multiple infections. The resident often talked about a suicide incident and prayed for forgiveness in front of staff. Staff 32 stated the resident usually calmed down if staff discussed religion with the resident. The resident frequently yelled out and was heard all day, during any shift, from the nurses station. Staff 32 stated Resident 196 could go an entire shift without a brief change. Staff 32 stated during Resident 32's decline she began sleeping through the day and night and refused care more often and did not want her/his lights on. - On [DATE] at 2:56 PM Staff 37 (LPN) stated Resident 196 was very difficult to work with, was constantly wet, with visibly soiled bedding and linens. The resident's skin was cold and breaking down. The resident just lied in bed and cried, saying ow or Please God let me die. Staff 37 stated Resident 196 sometimes went an entire shift in that state due to her/his refusals. Staff 37 stated there was feces everywhere and the resident had her/his hands in it. Resident 196 preferred gentle staff, was often naked, and did not want the privacy curtain open. Resident 196 was afraid of the light in her/his room and wanted it off. Resident 196's perineal/buttocks rash was described as looking like ground beef. The rash was on her/his back and arms and the resident scratched and picked at the rash. Staff 37 stated the house physician only wanted to be notified of urgent matters related to Resident 196. Resident 196 previously came out for smoke breaks and visited with other residents, and at that time did not have a lot of behaviors. Resident 196 over time refused more and became less compliant with care. - On [DATE] at 9:46 AM Staff 38 (CNA) stated Resident 196 had red, painful sores all over her/his body which caused the resident to scream out in pain. The resident had dry skin that peeled off during care. The resident frequently cried out, Help me! Staff 38 stated the resident refused care frequently but was actually refusing the person or the approach of certain staff. Staff 38 stated clothes were painful for the resident and the resident did not want the door or privacy curtain closed. Staff 38 stated the resident sometimes went two full shifts without care due to her/his refusals. The following interviews were completed with facility administrative staff from [DATE] through [DATE]: - On [DATE] at 4:26 PM Staff 1 (Administrator) stated Resident 196 was noncompliant with care, did not let staff clean her/his mattress or body and had a lot of mental health issues. Staff 1 stated Resident 196 was abusive to family members and the family did not want to be made aware of falls. Staff 1 stated Resident 196 cooperated with cares when staff provided black licorice and 7up (soda). Resident 196 had a rash but only let Staff 2 (DNS) examine the rash if he was also in the room. Resident 196 had a pressure ulcer and did not let staff provide repositioning. The resident refused medication and refused to sign a risk versus benefit statement unless money was given to the resident. Staff 1 stated he recommended hospice to the resident's family and the family agreed. Resident 196 yelled out a lot, would not talk to certain people and went weeks without being bathed. Staff 1 was not aware of when Resident 196's mental status was last assessed. Staff 1 stated the facility was on its fourth social services staff since ,[DATE]. - On [DATE] at 11:24 AM Staff 5 (Regional RN) stated Resident 196 declined in the last six months of her/his life. Resident 196 drove her/his own care and refused almost everything including medication. Staff 5 stated Resident 196 was aware of the risk of her/his choices and did not have dementia or any memory issues. Staff 5 sometimes dug into her/his own feces, which got into her/his fingernails and the resident refused to be cleaned. Staff 5 stated the resident allowed simple cares but always dictated the care. Staff 5 did not remember the resident's preference to be naked, but stated, It wouldn't surprise me. Staff 5 stated Resident 196 refused meals and had potential to be left in a soiled brief for an extended period of time. Staff 5 expressed she was unaware of the resident's history of trauma, abuse or [MEDICAL CONDITION] disorder. - During interviews on [DATE] at 11:11 AM and [DATE] at 6:42 PM Staff 3 (LPN Resident Care Manager) stated she was not aware of Resident 196 receiving mental health services in the past year prior to the resident's death. Staff 3 stated it was difficult to meet Resident 196's needs due to her/his refusals. Staff 3 indicated the facility was not the most appropriate care setting for the resident. Staff 3 stated she believed the resident's increase in refusals contributed to the resident's decline. - On [DATE] at 11:17 AM Staff 21 (Medical Director) referred to Resident 196 as a psych patient with psych issues but was unsure what her/his specific mental health [DIAGNOSES REDACTED]. When asked about the resident's status during the physician visits, Staff 21 stated the information was in the physician progress notes [REDACTED]. On [DATE] at 6:30 PM during an interview with Staff 2 (DNS), Staff 3 (LPN Resident Care Manager) and Staff 5 (Regional RN) and three survey staff, Staff 2, Staff 3 and Staff 5 all acknowledged there was no evidence to indicate an updated evaluation of Resident 196's mental health was obtained or attempted since the (YEAR) PASRR II was completed. The staff acknowledged Resident 196 needed to to be seen by a qualified mental health professional as the resident declined significantly in the last few months prior to resident's death. Staff 2 acknowledged any assessments completed by facility staff were not related to the resident's mental health and stated, We are not psych professionals. When asked if they considered calling 911 at any point to obtain services for Resident 196, the staff members indicated they were not sure. - In a follow-up interview with Staff 21 on [DATE] beginning at 9:49 AM and ending at 10:14 AM, present with three survey staff, Staff 21 made the following statements with regard to Resident 196's treatment and care: -When asked to describe Resident 196's decline, Staff 21 stated, It's been gradual, the thing is (she/he) wouldn't take meds, couldn't take labs . how would I know? I'd say ok, we can't get labs, try in a month . after the order would get so old, I'd say forget the labs and we'd try a year later . Staff 21 further indicated, occasionally (she/he) would allow me to look at (her/him). -When Staff 21 was asked when the last time she was able to complete a full assessment on Resident 196 was, she stated .It's been years since a full assessment was completed. -Staff 21 stated Resident 196 was neglecting (her/himself) due to refusals of care. -Staff 21 stated Resident 196 had a rash due to refusing diaper changes. -Staff 21 indicated she believed the resident was cognitively aware enough to say no but she did not believe the resident was cognitively intact enough to understand the consequences of her/his medication and treatment refusals. -Staff 21 stated Resident frequently screamed when she entered the room and told staff to go away when they woke the resident up. -Staff 21 indicated the facility and resident's local region had poor resources for psych cases. When asked if she referred Resident 196 for a mental health evaluation since (YEAR) she acknowledged she did not and stated she did not believe there was anyone to whom she could refer the resident. -Staff 21 indicated she was never involved in interdisciplinary team discussions regarding the resident's use of [MEDICAL CONDITION] medications. She further stated the only review of [MEDICAL CONDITION] medications she did for any resident was in response to pharmacist reviews. - In a follow up interview on [DATE] at 12:36 PM Staff 1 (Administrator) stated the facility was on its fourth Social Services director since [DATE]. Staff 1 acknowledged there were times when the facility did not have a functioning Social Services director. Staff 1 stated staff who were unfamiliar with Social Services tried to cover the responsibilities including himself, Staff 5 (Regional RN) and Staff 41 (Admissions). Staff 1 stated he did not consider bringing in a qualified Social Services director from another facility to cover on a temporary basis. On [DATE] at 12:44 PM the survey team reviewed findings related to Resident 196 and determined the following: - Resident 196 had severe [MEDICAL CONDITION] disorder with psychotic features and a history of trauma. Resident 196 refused medication, refused treatment for [REDACTED]. No evidence was found to indicate the facility attempted to provide behavioral health services as Resident 196 continued to experience physician and psychosocial declines. The resident was placed on hospice care on [DATE] and died eight days later on [DATE]. - Resident 196 experienced extensive incontinence [MEDICAL CONDITION] with pain covering the majority of the resident's body, ongoing delusions and emotional distress, continued refusals of needed [MEDICAL CONDITION] medication and treatments. - No evidence was found to indicate the facility utilized a functional social services department or interdisciplinary team to assess, reassess and provide services to meet Resident 196's behavioral health needs. Based on the identified findings, deficient practice related to the failure to provide behavioral health services to Resident 196 was determined to be an immediate jeopardy situation in consultation with state agency staff. On [DATE] at 12:57 PM the facility administrative staff including Staff 1 (Administrator), Staff 2 (DNS), Staff 5 (Regional RN) and Staff 30 (Regional Vice President) were informed of the immediate jeopardy situation and an immediate plan of correction was requested. On [DATE] at 6:06 PM the facility submitted a plan of correction was accepted by the survey team. The IJ removal plan included: - Current residents were reviewed to ensure no residents were currently putting themselves at risk due to refusals of care or suffering from emotional distress. None were identified. - Regional Nurse in-serviced staff on the facility's policy and procedure regarding [MEDICAL CONDITION] drugs and behavior management. The pharmacist and/or MD would be notified of any noted changes in behaviors, side effects, recommendations or needed follow up. - The facility currently utilized the services of a qualified Social Services Director and consulted with other social services providers as needed. - Direct care staff were educated on the reporting of noted behaviors including refusals. Trends would be monitored by the interdisciplinary team beginning [DATE]. - New admits and current residents would be audited to ensure psychosocial needs were addressed. On [DATE] at 6:07 PM the facility was informed that the immediate jeopardy situation was removed as no other residents in the facility were noted to refuse medication, treatments and be experiencing psychosocial decline. From [DATE] through [DATE] the IJ removal was verified by the survey team. No further concerns related to the immediate jeopardy situation were noted.

Based on observation, interview and record review it was determined the facility failed to ensure staff followed professional standards related to the provision of behavioral health services, pain management, physician services, admission, transfer and discharge requirements and resident assessments for five administrative staff: Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (LPN Resident Care Manager), Staff 5 (Regional RN) and Staff 21 (House Physician/Medical Director) and six licensed nurses: Staff 4 (LPN), Staff 6 (LPN), Staff 17 (LPN), Staff 18 (LPN), Staff 37 (LPN) and Staff 43 (LPN) reviewed for behavioral health services, pain, physician services, hospitalization , dementia and medication. These failures resulted in Resident 196 experiencing psychosocial decline, Resident 20 experiencing uncontrolled pain and hospitalization , Resident 243 experiencing uncontrolled pain, Resident 193 experiencing psychosocial harm, and residents being placed at risk for drug diversion and unmet dementia needs. Findings include: 1. Resident 196 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 196 refused medication, refused treatment for [REDACTED]. No evidence was found to indicate the facility provided ongoing behavioral health services as Resident 196 continued to experience psychosocial and medical declines. The resident was placed on hospice care on [DATE] and died eight days later. a. On [DATE] at 6:30 PM during an interview with Staff 2 (DNS), Staff 3 (LPN Resident Care Manager) and Staff 5 (Regional RN) and three survey staff, Staff 2, Staff 3 and Staff 5 all acknowledged there was no evidence to indicate an updated evaluation of Resident 196's mental health was obtained or attempted since a (YEAR) PASRR II (mental health evaluation) was completed. The staff acknowledged Resident 196 needed to be seen by a qualified mental health professional as the resident declined significantly in the last few months prior to resident's death. Staff 2 stated, We are not psych professionals and acknowledged no outside mental health services were provided during the resident's decline. When asked if they considered calling 911 at any point to obtain services for Resident 196, the staff members indicated they were not sure. Refer to F600, F677, F684, F686 and F742. b. On [DATE] at 9:49 AM Staff 21 (House Physician/Medical Director) stated it was years since Resident 196 received a full assessment, indicated the resident neglected her/himself by refusing cares and was not cognitively intact enough to understand the consequences of her/his refusals. Staff 21 stated she did not consider sending Resident 196 to the emergency room for an evaluation because she believed the resident would just be sent back to the facility. Staff 21 stated she did not refer Resident 196 for a psychiatric assessment because the local region had poor resources for psych cases. Staff 21 stated she was not part of the interdisciplinary team and did not participate in reviews related to Resident 196's use of [MEDICAL CONDITION] medication unless triggered by a pharmacist's review. Refer to F600, F711, F742 c. On [DATE] at 12:36 PM Staff 1 (Administrator) indicated the facility was using its fourth Social Services director since [DATE]. Staff 1 acknowledged there were times when the facility did not have a functioning Social Services director. Staff 1 stated staff who were unfamiliar with Social Services tried to cover Social Services duties including himself, Staff 5 (Regional RN) and Staff 41 (Admissions). Staff 1 stated he did not consider bringing in a qualified Social Services director from another facility to cover on a temporary basis. Refer to F600, F636 and F742. 2. Resident 20 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Interview and record review revealed Resident 20 did not receive ordered [MEDICATION NAME] (narcotic pain medication) on [DATE] and [DATE] despite the resident's complaints and visible signs of pain. Resident 20 was sent to the emergency room and treated for [REDACTED]. Staff 4 (LPN) and Staff 36 (LPN) were responsible for providing Resident 20's medication on [DATE] and [DATE] and indicated the medication was not available. However, interview and record review revealed the medication was available in the facility on both [DATE] and [DATE]. Refer to F600 and F697. 3. Resident 243 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview and record review revealed Resident 243 did not receive ordered PRN pain medication in a timely manner on [DATE] and [DATE], despite the resident's requests for pain medication. Resident 20 experienced unrelieved and exacerbated pain as a result of not receiving pain medication in a timely manner. Staff 18 (LPN) indicated she was responsible for providing medication to Resident 243 on [DATE], but did not respond to the resident's request because another staff member had an attitude when the request was made. Staff 37 (LPN) indicated she was responsible for providing medication to Resident 243 on [DATE], but did not provide the pain medication in a timely manner. On [DATE] at 9:07 PM Staff 2 (DNS) indicated Staff 37 messed up and forgot about the requested pain medication on [DATE]. Refer to F600 and F697. 4. Resident 193 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Interview and record review revealed Resident 193 was hospitalized on [DATE] and was informed on [DATE] that she/he was not permitted to return to the facility due to her/his noncompliance with the smoking policy. The resident was tearful and anxious about being transferred to another facility outside of the local area. On [DATE] at 2:51 PM Staff 1 (Administrator) stated he personally informed Resident 193 that she/he was not permitted to return to the facility based on her/his noncompliance with the smoking policy and told the resident he would think about taking her/him back if she/he was compliant with smoking. Refer to F600 and F626. 5. A review of the facility's narcotic drug book and various residents' MARs revealed numerous inconsistencies including the following: - Correction doses, documented by Staff 2 (DNS), without further information about the disposition of the medication. - Pages without authorized signatures indicating drugs were disposed of or administered. - Pages indicating medication was present and then was gone, with no explanation, signed by Staff 4 (LPN). - Numerous doses indicated on the narcotic log but not on medication administration records, or other inconsistencies documented by various staff including Staff 4 (LPN), Staff 6 (LPN), Staff 17 (LPN), Staff 18 (LPN) and Staff 37 (LPN). - No signature sheet was found to identify staff signatures. On [DATE] at 9:12 AM and [DATE] at 12:16 PM and 12:36 PM Staff 2 (DNS) and Staff 5 (Regional RN) acknowledged the numerous inconsistencies above findings and stated the facility was aware of the inconsistencies related to medication and previously terminated Staff 18 (LPN) and Staff 43 (LPN). Staff 2 stated she was unfamiliar with the facility's policy regarding the management of narcotic medication to prevent drug diversion. On [DATE] at 7:31 AM Staff 5 (Regional RN) stated the was no process in place to audit the narcotic logs. Refer to F607 and F755. 6. Deficient practice was identified related to a failure to comprehensively assess residents' cognitive loss and dementia. Staff 1 (Administrator) indicated he completed assessments of residents' cognitive loss/dementia even though he was not a qualified social services staff member. Staff 1 acknowledged the assessments were not comprehensive. During interviews with administrative staff from [DATE] through [DATE] the survey team was informed that Staff 2 (DNS) and Staff 5 (Regional RN) were responsible for signing off on finished assessments requiring a RN signature. Refer to F636 and F744.

Based on observation, interview and record review it was determined the facility failed to prevent neglect of care related to uncontrolled pain, behavioral health needs, skin conditions, right to return to the facility after hospitalization and accident prevention for 6 of 8 sampled residents (#s 10, 11, 20, 193, 196 and 243) reviewed for allegations of abuse and neglect. This failure resulted in Resident 196 experiencing physician and psychosocial decline, Resident 243 experiencing unrelieved pain, Resident 20 experiencing unrelieved pain and hospitalization , Resident 11 experiencing a worsening skin condition, Resident 193 experiencing emotional distress and placed other residents at risk for accidents. Findings include: 1. Resident 196 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. During the last six months of the resident's life, the resident increasingly refused medication, refused treatment for [REDACTED]. No evidence was found to indicate the facility attempted to provide behavioral health services as Resident 196 continued to experience physical and psychosocial declines. The resident was placed on hospice care on [DATE] and died eight days later on [DATE]. Resident 196 experienced extensive incontinence [MEDICAL CONDITION] with pain covering the majority of the resident's body, ongoing delusions and emotional distress and continued refusals of [MEDICAL CONDITION] medication and treatments. No evidence was found to indicate the facility utilized a functional social services department or interdisciplinary team to assess, reassess and provide services to meet Resident 196's behavioral health needs. On [DATE] at 9:49 AM Staff 21 (Medical Director) acknowledged Resident 196's significant mental health impairment and decline. Staff 21 also acknowledged the lack of mental health treatment for [REDACTED]. Refer to F658, F677, F684, F686, F711, F742, F745, F835 and F841. 2. Resident 243 admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The [DATE] Admission Nursing Assessment indicated the resident rated her/his pain as an eight out of ten with ten indicating the worst possible pain. The assessment further indicated the resident was cognitively intact. Review of the [DATE] through [DATE] MAR indicated [REDACTED]. Interview and record review indicated Resident 243 asked for pain medication on [DATE] at 2:34 PM and reported an eight out of ten rating for her/his pain. The pain medication was not provided to the resident until 11:45 PM. Interview and record review indicated on [DATE] at 6:00 PM Resident 243 asked for pain medication to be administered at 9:00 PM, but it was not administered until 10:00 PM. The resident indicated by 10:00 PM the pain was unable to be controlled by the medication. A documented statement by Staff 18 (LPN) indicated Resident 243 asked for pain medication repeatedly but Staff 18 did not respond to the resident's requests due to another staff member's attitude. Interview and record review indicated Resident 243 asked nursing staff for pain medication on [DATE] at 10:00 PM but did not receive it until [DATE] at 4:30 AM due to staff forgetting about the resident's request for pain medication. On [DATE] at 9:07 AM Staff 2 (DNS) acknowledged the medication was available for Resident 243's requested administrations at the time the requests were made and acknowledged the medication was not provided to the resident in a timely manner. Refer to F697. 3. Resident 20 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The [DATE] Annual MDS Pain CAA indicated Resident 20 experienced frequent pain and had an increase in pain recently. It further indicated the resident took pain medications which eased the pain but her/his pain never ceased completely. The [DATE] care plan indicated the resident's pain was alleviated by [MEDICATION NAME] and rest and to monitor complaints of pain. Interview and record review indicated Resident 20 did not receive ordered pain medication on [DATE] and was sent to the emergency room due to excessive pain on that date. Resident 20 returned to the facility on [DATE] and missed two additional doses of pain medication on [DATE]. The staff who worked with Resident 20 on [DATE] and [DATE] indicated the pain medication was not provided because it was not available. However, during an interview on [DATE] at 9:26 AM Staff 2 (DNS) stated the medication was available for Resident 20 at the facility on both [DATE] and [DATE]. Refer to F697. 4. Resident 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The ,[DATE] Skin Integrity Policy and Procedure indicated the nurse was to document skin impairment including measurements of size and presence of pain associated with the skin impairment in the nurse's notes and on the Weekly Wound Evaluation and implement interventions. Interview and record review indicated Resident 11 did not receive ordered treatment for [REDACTED]. On [DATE] the resident's wound was described as pink and beefy, was identified as a skin tear or laceration measuring 3 cm in length, 2 cm in width and 0 cm in depth. On [DATE] the wound measured 4.5 cm in length by 3 cm in width and 0.1 cm in depth, had dead tissue and drainage and the resident reported pain when the wound was cleaned. On [DATE] at 3:03 PM and [DATE] at 1:25 PM Staff 5 (Regional RN) acknowledged the facility was aware of Resident 11's leg wound and was unable to provide a rationale for why treatment and services for the wound were not provided. She acknowledged there was no system in place to assess and track skin conditions or to ensure skin care was completed as ordered. On [DATE] at 8:55 AM Staff 2 was observed to measure the resident's leg wound and stated the wound started as a skin tear. Refer to F684. 5. Resident 193 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. A [DATE] smoking evaluation indicated the resident was independent with decision making, was able to safely operate smoking materials and had no history of smoking related incidents. According to interview and record review Resident 193 was hospitalized on [DATE] due to an acute medical issue. On [DATE] Staff 1 (Administrator) went to the hospital and informed the resident that she/he was not permitted to return to the facility, which caused psychosocial harm to the resident as the resident was tearful and anxious about transferring to another facility outside of the family's local area. On [DATE] at 2:51 PM Staff 1 confirmed he did inform Resident 193 that she/he was not permitted to return to the facility, despite the resident's right to return to the facility. Refer to F626. 6. Resident 10 was admitted to the facility in 2019 with [DIAGNOSES REDACTED]. The [DATE] Nursing Admission Evaluation indicated the resident was at risk for falls and used a slide board for transfers. Interview and record review indicated on [DATE] Resident 10 was transferred to bed without using the slide board by two staff. Facility documentation indicated the resident kept staff in the room for an hour and 45 minutes and argued with the staff while expressing the need for the slide board but eventually allowed the staff to transfer her/him without the slide board. Resident 10 stated she/he needed the slide board due to a broken back and stated she/he began to fall and had to catch her/himself during the transfer because the slide board was not used. The resident stayed in bed for the remainder of [DATE] and [DATE] due to not having access to a slide board for transfers to and from bed. Staff indicated the slide board was not utilized because it was not available. However, other staff indicated the slide board was available. On [DATE] at 1:57 PM Staff 1 (Administrator) acknowledged the facility had a slide board available for use at all times including on [DATE]. Refer to F689.

Based on the lack of effective systems for ensuring the provision of behavioral health services, pain management, compliance with admission, transfer and discharge requirements, adequate staffing levels, accurate, complete and reconciled narcotic records to prevent diversion and notification the long term care ombudsman office of resident hospitalization s the facility administration failed to utilize its resources effectively and efficiently to ensure all residents attained or maintained their highest practicable physical, mental and psychosocial well-being. These failures resulted in residents experiencing psychosocial harm and unrelieved pain. These failures also placed residents at risk for delayed care, drug diversion and lack of awareness of resident rights. Findings include: 1. Deficient practice was identified regarding the facility's failure to provide behavioral health services. This failure resulted in Resident 196 experiencing psychosocial harm. On 3/20/19 at 12:36 PM Staff 1 (Administrator) stated the facility was on its fourth Social Services director since 1/1/18 and acknowledged there were lapses in Social Services coverage. Staff 1 stated he did not attempt to use the services of a qualified Social Services director in the interim periods. Refer to F658, F742 and F745. 2. Deficient practice was identified regarding the facility's failure to provide effective pain management. This failure resulted in Resident #s 20 and 243 experiencing unrelieved pain. During interviews with Staff 2 (DNS) on 3/8/19 at 9:07 AM and 3/21/19 at 12:16 PM Staff 2 confirmed she was aware of multiple failures to provide effective pain management for Resident #s 20 and 243 which continued to occur after the failures were identified. Refer to F697. 3. Deficient practice was identified regarding the facility's failure to ensure residents were permitted to return to the facility. As a result of this deficient practice Resident 193 experienced psychosocial harm. On 3/13/19 at 2:52 PM Staff 1 (Administrator) stated he informed Resident 193 that she/he was not permitted to return to the facility but he would think about allowing her/him to return if the resident was compliant. Refer to F626. 4. Deficient practice was identified regarding the facility's failure to ensure adequate RN and CNA staffing. On 3/13/19 at 11:00 AM Staff 1 (Administrator) stated he was aware the facility was not in compliance with staffing requirements. Refer to F727, F732. 5. Deficient practice was identified regarding the facility's failure to implement policies to prevent misappropriation of resident property. This failure resulted in a failure to maintain accurate, complete and reconciled narcotic medication records. On 3/21/19 at 12:16 PM Staff 2 (DNS) and Staff 3 (Regional RN) acknowledged the discrepancies and missing information in the narcotic drug books and acknowledged the facility's policy for oversight of the narcotic drug books was not followed. Refer to F755. 6. Deficient practice was identified regarding the facility's failure to ensure the Long Term Care Ombudsman's (LTCO) office was notified of resident hospitalization s. On 3/13/19 at 2:52 PM Staff 1 (Administrator) stated he was aware of the requirement to notify the LTCO of hospitalization s but there was no process in place. Refer to F623.

Based on observation, interview and record review it was determined the facility's quality assessment and assurance committee (QAA) failed to systematically identify and correct deficiencies in the areas of resident rights, freedom from abuse, neglect and exploitation, resident assessments, comprehensive resident centered care plans, quality of life, quality of care, nursing services and infection control. This resulted in substandard quality of care and multiple outcomes to residents including unaddressed pain, psychosocial decline, and worsening skin conditions. Findings include: 1. The facility failed to ensure residents' responsible parties were notified of changes in condition and reasonable needs were accommodated. These deficient practices were also noted on the 10/2017 survey. Refer to F580. 2. The facility failed to ensure allegations of abuse and neglect were thoroughly investigated. This deficient practice was also identified on the 10/2017 survey. Refer to F610. 3. The facility failed to ensure residents' needs were comprehensively assessed. This deficient practice was also identified on the 10/2017, 8/2016 and 6/2015 surveys. Refer to F636. 4. The facility failed to ensure residents' needs were comprehensively care planned. This deficient practice was also identified on the 10/2017, 8/2016 and 6/2015 surveys. Refer to F656. 5. The facility failed to ensure physician's orders were followed and quality care was provided. This deficient practice was also identified on the 10/2017, 8/2016 and 6/2015 surveys. Refer to F684. 6. The facility failed to ensure residents received ADL assistance. This deficient practice was also identified on the 10/2017 survey. Refer to F677. 7. The facility failed to ensure residents received treatment and services related to pressure ulcers, pain and accidents. These deficient practices were also identified on the 10/2017 survey. Refer to F686, F689 and F697. 8. The facility failed to ensure adequate RN staffing and appropriate posting of staffing information was in place. These deficient practices were also identified on the 10/2017 and 8/2016 surveys. Refer to F727 and F732. 9. The facility failed to ensure pharmacist recommendations were addressed. This deficient practice was also identified on the 10/2017 and 8/2016 surveys. Refer to F756. 10. The facility failed to ensure medication was properly stored. This deficient practice was also identified on the 10/2017 survey. Refer to F761. 11. The facility failed to ensure staff practice appropriate infection control techniques. This deficient practice was also identified on the 10/2017 survey. Refer to F880. On 3/7/19 at 12:36 PM Staff 1 (Administrator) acknowledged the repeated deficient practices. Staff 1 stated the facility's QAA team met monthly to identify and implement measures to correct deficiencies. Staff 1 stated a new Resident Care Manager was hired two months ago to assist with the identified areas. Staff 1 stated the lack of effective processes to address physician's orders for medication reductions, treatments and pain medication was attributed to the lack of a consistent and effective medical records director.

Based on observation, interview and record review it was determined the facility failed to provide ADL assistance related to bathing, toileting and hygiene for 3 of 4 sampled residents (#s 23, 42 and 196) reviewed for ADLs. This failure resulted in Resident 196 remaining in soiled briefs and bed linens for extended periods and developing skin deterioration that worsened over time. Findings include: 1. Resident 196 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 196's undated facility face sheet indicated she/he was her/his own responsible party, and further indicated Witness 1 (Family) was the resident's number one emergency contact. The [DATE] Significant Change MDS indicated the resident was cognitively intact. The [DATE] CAAs indicated Resident 196 had behaviors related to her/his [DIAGNOSES REDACTED]. A [DATE] Risk Versus Benefit document related to the resident's refusals of care, was unsigned the Resident 196. No evidence was found to indicate the resident's family was informed of the resident's care refusals. The [DATE] Quarterly MDS indicated the resident was not cognitively intact. On [DATE] at 1:16 PM Witness 1 (Family) stated Resident 196 was often covered in feces and urine from her/his sheets. The witness further stated he observed the soiled sheets were not changed from one day to the next. He believed Staff 1 (Administrator) should have referred the resident out to a doctor or possibly the psych ward for an evaluation. He stated the facility noted the resident refused all cares, yet upon admission to hospice on [DATE], the hospice staff were often able to provide cares without the resident refusing. On [DATE] at 4:26 PM Staff 1 stated Resident 196 was non-compliant with all cares in general and further stated the resident had a rash up her/his backside that was pretty red. Staff 1 stated the resident wouldn't let us clean the mattress or clean (her/him) and further stated the resident went weeks without being bathed. On [DATE] at 11:24 AM Staff 5 (Regional RN) stated she did not remember the resident being super dirty but stated she did remember the resident would dig in (her/his) own feces and refused to allow staff to clean her/him up. She further stated the resident had potential to sit in her/his own feces for a long period of time due to refusals of care. On [DATE] at 9:12 AM Staff 21 (House Physician/Medical Director) stated Resident 196 had an incontinence [MEDICAL CONDITION] rash due to the resident's refusals to have her/his brief changed. On [DATE] at 11:04 AM Staff 26 (LPN) stated the resident refused cares numerous times a day. She stated the resident sometimes screamed at staff when they reattempted to provide cares, but sometimes just going in and spending time with the resident helped. She further stated the resident's bedding was soiled and the resident had an incontinence [MEDICAL CONDITION] rash due to refusing personal cares. On [DATE] at 11:55 AM Staff 32 (CNA) stated the resident had a rash that was painful, and her/his bedding and body was often covered in feces. He further stated the resident went an entire shift without having her/his brief changed. On [DATE] at 5:08 PM Witness 6 (Hospice RN) stated the resident was laying on a urine soaked mattress when she first visited the resident and had a fire engine red colored rash on her/his backside and into her/his perineal and groin region. She stated the skin rash on Resident 196 was atrocious, awful, scaling and peeling. She described having no issue with the resident being compliant with bathing, and further stated over the short period of time the resident was on hospice before she/he died , they did not have a lot of refusals of care as she took a gentle approach. On [DATE] at 9:46 AM Staff 38 (CNA) stated (Resident 196) would refuse care, but refused the person or their approach, maybe more the approach. Staff 31 further stated the resident went up to two shifts in a row without ADL assistance. On [DATE] at 9:49 AM Staff 21 stated Resident 196 was neglecting (herself/himself) due to refusing care. At 9:55 AM Staff 21 further stated she did not believe the resident was cognitively intact enough to understand the consequences of her/his refusals, and did not believe the resident was cognitively intact enough to understand the unsigned [DATE] Risk Versus Benefit form completed by Staff 5. 2. Resident 42 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. The [DATE] Admission MDS indicated Resident 42 was cognitively intact and required two-person extensive assistance for toileting. The Care Plan initiated [DATE] indicated Resident 42 was occasionally incontinent of bladder and bowel and was able to make toileting/incontinence needs known. A Facility Reported Incident report dated [DATE] revealed Resident 42 was placed on a bedpan on [DATE] at approximately 10:00 PM by Staff 23 (CNA). Staff 23 then went to the break room to chart and after charting went home. Staff 23 did not inform other staff that the resident was placed on a bedpan. Staff 38 (CNA) stated she got to Resident 42's call light around 10:30 PM after answering other lights. She reported Staff 23 did not let her know that Resident 42 was on her/his bed pan. On [DATE] at 8:58 AM Staff 23 stated the alleged incident was between 9 PM and 10 PM. Staff 23 stated he helped Resident 42 on the bed pan per the resident's request on [DATE] at 10:00 PM and left the room. Staff 23 further stated he went to the break room to do some charting and forgot to go back to assist Resident 42 off the bed pan. 3. Resident 23 admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. A [DATE] Significant Change MDS indicated Resident 23 required extensive assistance with hygiene. Resident 23's care plan for ADL assistance indicated the resident sometimes refused care. Staff were to give extra time, reapproached and notify the nurse if they were unable to provide care due to refusals. On [DATE] at 11:32 AM Resident 23's hair appeared unclean, greasy and matted. Resident 23 did not know when she/he was last bathed and stated she/he was bathed less than one time per week. On [DATE] at 9:00 AM Staff 8 (CNA) stated Resident 23 refused showers at times. Staff 8 stated nurses were notified when residents refused showers. On [DATE] at 9:11 AM Staff 6 (LPN) stated Resident 23 did refuse showers at times and staff were supposed to try three times and then inform the nurse if the resident still refused and they were unable to bathe the resident. Staff 6 stated the information was documented on shower sheets and progress notes. A review of Resident 23's bathing records revealed the resident was bathed three times from [DATE] through [DATE]. Refusals were documented on [DATE], [DATE], [DATE] and [DATE]. No evidence was found to indicate staff reapproached Resident 23 or notified the nurse of the resident's refusals. On [DATE] at 11:29 AM Staff 2 (DNS) stated aides were to offer residents a shower three times and then inform the nurse if they were unable to provide a shower due to refusals. Staff 2 acknowledged the lack of evidence to indicate staff reapproached Resident 23 to offer a shower or contacted the nurse regarding the resident's refusals on the documented dates.

Based on interview and record review it was determined the facility failed to allow a resident to return to the facility after the resident was hospitalized . This resulted in the resident being sent to another facility which was not easily accessible by the resident's family and the resident experienced emotional distress for 1 of 3 sampled residents (#193) reviewed for discharge. Findings include: Resident 193 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. The 10/9/18 Admission MDS indicated Resident 193 was cognitively intact. A 10/3/18 smoking evaluation indicated the resident was independent with decision making, was able to safely operate smoking materials and had no history of smoking related incidents. Review of the resident's progress notes indicated the following: -10/5/18 the resident was spoken to regarding smoking cessation options and education was provided. The resident stated she/he was not ready to quit smoking. -10/6/18 the resident followed the smoking policy and left smoking materials at the nurses station. -10/7/18 the resident was noncompliant with the smoking rules and Staff 40 (Maintenance Director) obtained the resident's cigarettes and informed her/him of the rules. -10/9/18 the resident was spoken to regarding the smoking policy the day prior and agreed to follow the protocol. The resident smoked with a supervised group and frequently walked to the store. -10/16/18 the resident was sent to the hospital due to drainage for the chest incision site. No other documentation was noted in Resident 193's medical record to indicate further noncompliance with smoking. Review of hospital Care Management Progress notes indicated the following: -10/16/19 the resident was admitted to the hospital for a wound infection in her/his chest surgical site. -10/17/18 Staff 1 (Administrator) came to the hospital to inquire about Resident 193. Staff 1 stated he would not accept the resident back to the facility due to her/his noncompliant behavior such as refusing to quit smoking. Staff 1 stated he took actions to remove the resident's cigarettes. - 10/22/18 it was noted Resident 193's case manager contacted 12 skilled nursing facilities (SNF) in an attempt to secure placement for the resident. -10/24/18 placement was secured at a SNF in another city. The resident was informed of being discharged to the SNF and became tearful as the challenge of securing a placement was gently explained. -10/25/18 the resident was tearful and stated she/he was anxious about going to a SNF in another city. The resident stated her/his family was not familiar with the new city and she/he would miss her/his daughter's baby shower. Case Manager provided support and reassurance. The resident stated she/he still had belongings at the facility. Staff 1 came to the hospital and delivered the resident's belongings. On 3/6/19 at 3:25 PM Staff 18 (LPN) stated the resident went outside to smoke on her/his own and stated there was a store a block away from the facility where she/he got cigarettes. Staff 18 stated she could not recall any issues with the resident smoking. On 3/7/19 at 7:00 AM Staff 4 (LPN) stated the resident was able to get out the back door to smoke and was not signing out at the nurses station. She stated the resident propped the door open with a rock while she/he smoked. She stated she informed the resident about turning in smoking materials at the nurses station and the resident agreed. Staff 4 stated she only saw the resident at the back door one time. She stated after she spoke with the resident about smoking she had no further issues. On 3/8/19 at 8:54 AM Witness 4 (Hospital Care Manager) stated when she spoke with Staff 1 she was told Resident 193 was not able to return back to the facility due to her/his noncompliance and her/his smoking was a safety hazard. She stated Staff 1 also mentioned it was a survey window with the fire marshal. On 3/13/19 at 12:40 PM Staff 3 (LPN Resident Care Manager) and Staff 2 (DNS) stated the resident went across the street to smoke and the staff did not recall any issues related to noncompliance with smoking. They stated they were not aware the resident was not able to return back to the facility after her/his hospital stay and the resident could have returned if she/he wanted to. On 3/13/18 at 1:00 PM Staff 40 (Maintenance Manager) stated he found cigarettes in Resident 193's room and she/he smoked on the facility property. Staff 40 stated he provided the resident with the smoking policy and had no further issues. He stated the incident with the resident's smoking took place in (MONTH) (YEAR) which was a survey window and they wanted to make sure they were in compliance with the fire marshal. On 3/13/19 at 2:51 PM Staff 1 stated he went to the hospital and met with the care manager regarding Resident 193. He stated he spoke with the care manager about the resident's noncompliance with the smoking policy. He stated he informed the resident she/he could not return to the facility and told the resident he would think about taking her/him back if she/he was compliant with smoking.

Based on observation, interview and record review it was determined the facility failed to identify, accurately assess, treat and monitor incontinence [MEDICAL CONDITION], skin infections, bruises and worsening skin conditions and failed to follow physician's orders for medication for 6 of 8 sampled residents (#s 11, 19, 37, 42, 193 and 196) reviewed for non-pressure skin conditions and pain. This failure resulted in Residents 11, 37 and 196 experiencing worsening skin conditions. Findings include: 1. Resident 196 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. a. The Pressure Ulcer/Injury CAA dated 1/30/18 indicated Resident 196 was frequently incontinent of bowel and bladder and depended on staff for all cares. It further indicated skin evaluations were competed weekly by a nurse as Resident 196 was at risk for skin breakdown. An 8/10/18 Investigation Report signed on 8/15/18 indicated Resident 196 was found to have a finger infection and the resident stated it was painful and wanted staff to fix it. The investigation further indicated the cause of the infection was related to Resident 196's history of refusing cares (including bathing and nail care) due to psychiatric conditions and pulling stool from her/his rectum, exposing her/his nails to feces. It noted Resident 196's physician was notified of the skin condition. An 8/10/18 Weekly Skin Evaluation for Resident 196's right finger was not signed as complete by Staff 5 (Regional RN) until 9/23/18. The wound was noted to not be resolved. The 8/2018 TAR indicated staff were to to soak the fifth finger of the resident's right hand in salt water for 20 minutes or as requested. It further indicated to apply triple antibiotic ointment to the cuticle and apply a dressing as tolerated every evening shift beginning 8/13/18. There were no other weekly skin assessments found in Resident 196's medical record. A 10/3/18 physician order indicated Resident 196's finger infection had resolved and treatment would be discontinued. The 8/2018 through 12/2018 TARs revealed despite staff notification to the physician the finger infection was resolved, the treatment continued on the TAR through 12/19/18. On 3/20/19 at 2:56 PM Staff 5 (Regional RN) confirmed there was only one skin evaluation for the right finger wound. She further acknowledged the treatment for [REDACTED]. b. The facility's (MONTH) (YEAR) updated Skin Integrity policy indicated skin impairments including a rash, would be evaluated weekly by the nurse and documented in the medical record. The 6/25/18 Care Plan indicated Resident 196 had a rash on her/his arms, legs and back related to refusal of care, showers and scratching. Interventions included the application of coconut oil to the resident's back and legs, the use of [MEDICATION NAME] cream and to monitor the rash for increased spread. A 7/11/18 fax to the physician noted the resident had incontinence [MEDICAL CONDITION] that was painful. The resident was noted to refuse care from staff and laid in urine. The 9/21/18 Significant Change MDS indicated the resident had no skin conditions. Review of hospice notes indicated the following: -12/23/18 - the resident had wide spread, raw, dry and flaky skin with a rash all over her/his extremities and trunk. -12/24/18 - resident had a full body rash. 12/26/18 - resident was noted to be incontinent and laid in her/his own urine and feces often. The resident's skin was identified to have fiery red sores which covered her/his whole body. Review of Resident 196's medical record revealed no indication weekly skin monitoring was completed for the rash. On 3/7/19 at 4:26 PM Staff 1 (Administrator) stated Resident 196 had a rash up her/his backside that was pretty red. On 3/14/19 at 11:17 AM Staff 21 (House Physician/Medical Director) acknowledged the resident had a rash that was likely due to incontinence [MEDICAL CONDITION]. On 3/18/19 at 2:56 PM Staff 37 (LPN) stated staff used coconut oil and [MEDICATION NAME] cream for the resident's rash. She stated the rash was on the resident's back, arms, all over her/his body and appeared like a heat rash. Staff 37 stated the rash never changed. On 3/18/19 at 5:08 PM Witness 6 (Hospice RN) stated resident's skin rash for awful, scaling and peeled. She stated the first bed bath that was given to the resident, she removed about two cups of skin from the resident. She stated the rash was from head to toe and went up the resident's hairline. She stated every inch of the resident was covered in a rash. On 3/19/19 at 9:46 AM Staff 31 (CNA) stated the resident was red all over which was painful. On 3/21/19 at 3:25 PM Staff 5 (Regional RN) and Staff 2 (DNS) acknowledged the resident's rash, and confirmed weekly skin monitoring was not completed for Resident 196's rash. They stated they did not track rashes, yet acknowledged the facility's policy indicated skin issues such as rashes were to be monitored weekly. c. The 5/30/18 Care Plan indicated Resident 196 was to receive [MEDICATION NAME] ([MEDICATION NAME], narcotic pain medication) every six hours for pain. The 11/2018 MAR indicated [REDACTED]. review of the resident's medical record revealed [REDACTED]. On 3/21/19 at 1:49 PM Staff 5 and Staff 3 (LPN Resident Care Manager) acknowledged the [MEDICATION NAME] was discontinued without an indication or physician's order. 2. Resident 37 admitted to the facility 1/31/19 from the hospital with [DIAGNOSES REDACTED]. a. A 2/1/19 signed Weekly Skin Evaluation indicated Resident 37 admitted to the facility with a genital region bruise measured at 20 cm x 10 cm. The bruise was noted to be dark re-purple in color and indicated the bruise did not present with any pain for the resident. A 2/1/19 signed physician order indicated staff were to monitor bruising to Resident 37's genital region every shift for healing or worsening. The undated Visual/Bedside Service Plan Report (CNA Care Plan) did not indicate CNA staff were to notify nursing staff of any changes or worsening in current skin conditions. The 2/3/19 care plan did not indicate the resident had genital region bruising. A 2/9/19 Weekly Skin Evaluation indicated Resident 37's perineal area bruise had not changed in size, with color changing to red-purple-yellow. The evaluation indicated the resident did not experience pain from the bruising, and the bruising was unresolved. Review of the resident's clinical record revealed no further Weekly Skin Assessments for the genital region bruising. The 2/13/19 Admission MDS indicated Resident 37 was not cognitively intact and had a [DIAGNOSES REDACTED]. On 3/12/19 at 3:13 PM Staff 1 (Administrator) indicated nursing staff who completed admission paperwork for newly admitted residents may need more education for asking more questions when a resident has an order to monitor perineal bruising. On 3/12/19 at 3:30 PM with Staff 1, Staff 2 (DNS), Staff 5 (Regional RN) and Staff 3 (LPN Resident Care Manager) present, Staff 2 stated she was made aware upon Resident 37's admission of her/his physician order to monitor the perineal bruising for healing or worsening. She further stated she was contacted by APS (Adult Protective Services) for any skin assessments the facility had completed since her/his admission for an abuse investigation. On 3/13/19 at 10:13 AM Staff 15 (CNA) stated when Resident 37 was first admitted , she/he would cry out in pain, was tearful and it was difficult to get the resident to open her/his legs for brief changes. She further stated two CNAs would provide cares, and they would need to be very gentle with the resident in order to get her/him to cooperate. She stated the resident's bruising over her/his inner legs and groin region was extensive. She further stated when the resident displayed signs of pain during brief changes she would notify nursing staff. On 3/13/19 at 12:07 PM Staff 5 (Regional RN) acknowledged the only weekly skin assessments completed for the resident's current genital region bruising were 1/31/19 and 2/9/19. On 3/15/19 at 8:30 AM Staff 27 (CNA) stated the resident was very swollen, bruised and painful. Staff 27 stated the resident's genital area had dark purple bruising. She stated she was never made aware of any special instruction on the resident's genital bruising in terms of providing cares, but had assumed the bruising was from the resident's fall at her/his previous facility. Staff 27 stated it was difficult at times to get the resident to open her/his legs for brief changes, it would take a long time to complete brief changes and CNA staff often had to stop and let the resident catch her/his breath. b. Signed physician orders indicated staff were to administer Xarelto (blood thinning medication) to Resident 37 once per day starting 1/31/19. A 2/1/19 progress note composed by Staff 37 (LPN) indicated Xarelto was on order, and not available in the Cubex (facility emergency kit). A 2/4/19 progress note composed by Staff 37 indicated Resident 37's physician was notified of two missed doses of Xarelto on 1/31/19 and 2/1/19. Review of the resident's clinical record revealed no outcome to the related to the missed doses of Xarelto. On 3/13/10 at 12:03 PM Staff 5 (Regional RN) acknowledged Resident 37 was not administered her/his daily doses of Xarelto on 1/31/19 and 2/1/19. 3. Resident 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 3/2018 Skin Integrity Policy and Procedure indicated the nurse was to document skin impairment including measurements of size and presence of pain associated with the skin impairment in the nursing notes and on the Weekly Wound Evaluation. It further indicated to implement interventions. The 10/18/18 physician orders indicated the resident had a wound to the right lower leg and it was to be treated every three days. A 10/23/18 Weekly Skin Evaluation indicated Resident 11 right lower leg wound was pink and beefy and identified it as a skin tear or laceration measuring 3 cm in length, 2 cm in width and 0 cm depth. The TARs indicated no treatments to the leg wound were documented on 11/28/18, 12/19/18 and 12/31/18. The 1/2018 TAR indicated treatments were discontinued on 1/5/19. No order or documentation was located in Resident 11's clinical record to indicate the rationale for the discontinued treatment. A 1/20/19 progress note by Staff 42 (LPN) indicated Resident 11's wound to the right lower extremity measured 4.5 cm x 3 cm x 0.1 cm and had 50% slough (dead tissue) to the wound with drainage and the resident reported pain when cleaning the wound. A 1/20/19 fax to the physician by Staff 42 indicated Resident 11's wound to the right lower leg was 50% slough, measured 4.5 cm x 3 cm had drainage and she/he reported pain. It further indicated the wound was cleansed with wound cleanser and ABD dressing was applied and wrapped with Kerlix and asked for any new orders. A 1/20/19 physician order indicated to cleanse the right lower extremity wound with wound cleanser, pat dry, apply ABD pad and wrap with Kerlix in the morning every other day. The 1/21/19 physician response to the fax asked if the resident was working with wound care and if a referral was appropriate or if the wound was adequately managed by the facility. A 1/23/19 fax to the physician indicated the facility would complete wound care to the right lower extremity and would follow up with the physician PRN for a referral. It indicated there was decreased slough and the wound bed was 90% beefy pink with specks of slough remaining. The 1/2019 TAR had no documentation to indicate a dressing change was completed on 1/22/19, 1/24/19 and 1/26/19. The 1/2019 TAR also revealed a dressing change was not completed for seven days. On 3/13/19 at 10:41 AM Staff 17 (LPN) was observed to complete a dressing change for Resident 11. The resident had a red area on her/his right lower leg that was red and not open. Staff 17 stated weekly skin evaluations should be completed for the wound. A 3/14/19 Weekly Skin Evaluation completed by Staff 26 (LPN) indicated the wound to the right lower leg was 2 cm x 1 cm. On 3/15/19 at 8:55 AM Staff 2 (DNS) was observed to measure the resident's wound at 4.3 cm x 2 cm and stated it started out as a skin tear. On 3/13/19 at 3:03 PM and 3/15/19 at 1:25 PM Staff 5 (Regional RN) stated the resident admitted with the right lower leg wound and it was documented on the weekly skin evaluation on 10/23/18. She stated no weekly skin measurements were completed from 10/23/18 until 3/14/19 and her expectation would be the skin evaluations to be completed weekly. She acknowledged the TARs indicated no treatment to the leg wound was documented on 11/28/18, 12/19/18 and 12/31/18. She stated she could not find anything to explain why the treatments to Resident 11's leg wound were discontinued on 1/5/19. She further acknowledged Resident 11 had lack of treatment to the wound and the wound worsened. She acknowledged there were discrepancies with wound measurements on 3/14/19 and 3/15/19 and stated the nurses were expected to complete skin sheets on their shift weekly. She acknowledged there was no system in place to assess and track skin conditions or to ensure skin care was being completed for residents. 4. Resident 193 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's updated (MONTH) (YEAR) Skin Integrity Policy indicated skin impairments identified on admission such as surgical wounds would have implemented interventions and be documented in resident care plans. The policy indicated wounds such as a significant surgical wound were to be evaluated weekly by facility staff. A 10/3/18 Weekly Skin Evaluation indicated Resident 193 had a chest surgical incision. The incision measured 19.7 cm x 0.1 cm. linear in shape and was not resolved. The 10/2019 TAR indicated to leave sternal incision open to air and to monitor for wound healing BID with a start date of 10/3/18. The 10/9/18 Pressure Ulcer CAA indicated the resident admitted with a surgical incision site open to air. Weekly skin evaluations were to be completed by the nurse with daily care PRN. It further indicated this was to be included in the care plan. The 10/9/18 Pain CAA indicated the resident experienced frequent pain to her/his sternal incision site, was on pain medication and used a cardiac pillow. The CAA indicated pain would be addressed in the care plan. The 10/3/18 care plan did not include the Resident 193's risk for skin integrity related to the chest incision site with goals or interventions such as the use of a cardiac pillow. The care plan failed to address the resident's pain related to her/his chest incision site with goals or interventions and did not include any issues related to noncompliance of treatments. Review of Resident 193's medical record revealed no indication of any Weekly Skin Evaluations completed after 10/3/18 or any evidence the resident refused treatment. A progress note dated 10/16/18 indicated the resident was sent to the hospital due to a large amount of drainage coming from the chest incision. The resident stated the incision was open and painful. A 10/20/18 hospital note indicated Resident 193 admitted to the hospital with [REDACTED]. On 3/8/19 at 8:54 AM Witness 4 (Hospital Care Manager) stated Resident 193 had open heart surgery and went to the facility for rehabilitation. She stated there was concern with how the resident's infection presented on admission to the hospital. She stated the resident was known to be noncompliant with treatments at times, but was at the facility to receive care. On 3/13/18 at 12:40 PM Staff 3 (LPN Resident Care Manager) and Staff 2 (DNS) stated Resident 193 had cardiac surgery, was not always compliant with treatments and also did not always use the cardiac pillow. Staff 3 confirmed the resident's care plan did not address the skin integrity related to the surgical chest incision, pain associated with the incision site or behaviors related to any noncompliance of treatment. Staff 3 confirmed no weekly skin evaluations were completed after 10/3/18. 5. Resident 19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 3/2018 Skin Integrity Policy and Procedure indicated the nurse was to document skin impairment including measurements of size and presence of pain associated with the skin impairment in the nursing notes and on the Weekly Wound Evaluation. Interventions were to be implemented and documented on the resident's care plan. The 1/23/19 physician order indicated Resident 19 had a wound vac which would be discontinued at the follow up appointment with the podiatrist. The 1/28/19 physician order indicated to remove the wound vac and apply xeroform, 4 x 4 gauze and wrap with Kerlix and secure with tape. Leave dressing in place for one week or until podiatry follow up appointment. Change if soiled or if dressing comes off. The order was received at 9:17 AM and was not added to the 1/2019 TAR until the following day. The 1/2019 TAR indicated the wound vac was not removed until 1/30/19. The 2/2019 TAR indicated the following: -Cover the right foot incision with xeroform and gauze 4 x 4 wrap with Kerlix and leave in place for one week, may change if soiled or if it comes off. -The dressing changes were documented to be completed from 2/1/19 through 2/4/19. Podiatry physician orders indicated the following: -2/4/19 order indicated to begin iodosorb every other day with xeroform, 4 x 4 gauze, Kerlix and ace wrap. -2/14/19 order indicated to begin Santyl (medicated ointment) daily to the amputation site and was discontinued on 2/27/19. -2/27/19 order indicated to apply [MEDICATION NAME] to the right foot daily. The 2/2019 and 3/2019 TARs indicated the following: -There was no documentation to indicate a dressing change was completed on 2/5/19, 2/14/19, 2/25/19 and 2/26/19. -The Santyl treatments continued until 3/5/19, six days after the treatment was discontinued. -The [MEDICATION NAME] order did not start until 3/1/19, two days after the order was received. The 3/10/19 Weekly Skin Evaluation indicated Resident 19 had a 12 cm x 6 cm x 0.2 cm oblong surgical wound on the right foot. No other Weekly Skin Evaluations could be located in Resident 19's clinical record. On 3/20/19 at 10:40 AM Staff 3 (LPN Resident Care Manager) acknowledged the discrepancies with the physician orders and treatments administered for Resident 19's right foot wound. She further stated Resident 19's wound was not measured weekly. She stated the facility did not have all of the podiatry visit notes and physician orders from the visits, and the facility did not have a process in place to ensure physician visit notes and orders were implemented. On 3/20/19 at 11:25 AM Witness 8 (Podiatrist) stated the wound was progressing as expected and the wound did not get worse. 6. Resident 42 admitted to the facility 2/2019 with [DIAGNOSES REDACTED]. a. The 2/2019 MAR indicated [REDACTED]. The 2/2019 Facility Narcotic Book documented Staff 18 (Former LPN) administered one tablet of [MEDICATION NAME] on 2/23/19 at 5:18 PM and 8:30 PM. On 3/15/19 at 7:31 AM Staff 5 (Regional RN) acknowledged the resident received more than her/his ordered amount of [MEDICATION NAME] within a six hour period. b. The 3/2019 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On 3/14/19 at 4:47 PM Staff 41 (stated he/she ran out [MEDICATION NAME] the facility had not yet received anymore. The resident further stated she/he had informed staff of this but there had been no follow up. On 3/14/19 at 5:09 PM Staff 47 (LPN) stated an hour prior she had been informed by Resident 42 they had not [MEDICATION NAME] 3/10/19. Staff 41 stated she faxed a request for a [MEDICATION NAME] to the resident's physician. A nursing progress note completed on 3/14/19 at 10:07 PM indicated Resident 42's physician was notified and a new orders were received to [MEDICATION NAME]. On 3/15/19 at 9:48 PM Resident 42 stated she/he finally received her/[MEDICATION NAME]/14/19 and stated she/he finally was able to have a good nights sleep. On 3/15/19 at 10:08 AM Staff 5 (Regional RN) acknowledged the facility did not follow up on the request for an additional PRN order [MEDICATION NAME] the resident in a timely manner.

Based on interview and record review it was determined the facility failed to accurately assess, provide treatment and monitor pressure ulcers for 2 of 2 sampled residents (#s 8 and 196) reviewed for pressure ulcers. This failure resulted in Resident 196 developing multiple pressure ulcers. Findings include: 1. Resident 196 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The facility's (MONTH) (YEAR) updated Skin Integrity policy indicated skin impairments including pressure sores would be evaluated weekly by the nurse and documented in the medical record. The 2/13/18 CAAs for Resident 196 indicated she/he needed extensive physical assistance for bed mobility and toileting, and was incontinent of bowel and bladder. The assessment further indicated the resident frequently refused cares. She/he was noted to currently have a pressure reducing mattress on her/his bed and a pressure reducing mattress on her/his wheelchair. The assessment indicated weekly skin evaluations were completed by nursing staff. The 10/5/18 CAAs indicated Resident 196 continued to need extensive assistance for bed mobility and toileting and was incontinent of bowel and bladder. Resident 196 was noted to be alert and able to make her/his needs known, and spent much of her/his time in bed putting her/him at increased risk for skin impairment. Redness to her/his groin and buttocks was reported by CNAs, [MEDICATION NAME] cream was applied to her/his perineal and back area and barrier cream was applied to her/his sacrum. Coconut oil was applied once daily to her/his back for skin care maintenance and preventative skin care. The resident was noted to not have any current pressure ulcers, and to be utilizing a pressure reducing mattress and wheelchair pad. a. The 6/20/18 updated Care Plan for skin indicated Resident 196 was at risk for pressure ulcer development. The care plan indicated the resident had a pressure area to the sacrum (tailbone region). Interventions in place prior to 6/20/18 included the following: -Administer medication as ordered -Pressure reducing mattress on her/his bed -RD to review PRN -Ensure her/his skin was clean and dry after each incontinent episode -Follow facility protocol for the prevention/treatment of [REDACTED]. A 6/20/18 Skin Issue investigation initiated by Staff 2 (DNS) indicated the resident had a deep tissue injury (DTI, pressure related injury) to the sacrum (tailbone region) that measured 4 cm x 3.5 cm. The investigation included the following information: -the area was dark purple and non blanchable (indicating lack of blood flow, consistent with a pressure sore) -the are was clean with NS ([MEDICATION NAME], antifungal cream) and covered with barrier cream. The physician and Staff 1 (Administrator) were notified. -the resident was placed on alert charting -the resident was repositioned to laying on (her/his) right side -the resident was provided education on repositioning -the resident noted the area was painful and indicated an eight out of 10 on the pain scale. -the resident was noted to be alert and oriented to person and place -other info stated noncompliance with repositioning and does not always allow staff members to change (her/his) brief. -the investigation was signed as complete on 6/28/19, eight days after the identification of the DTI. Weekly Skin Evaluations were located in the resident's record and included: -6/20/18 evaluation noted the wound was a deep tissue injury. The assessment was completed by Staff 2 (DNS) on 6/23/18. -6/28/18 evaluation noted the wound became smaller in size. -7/5/18 evaluation indicated the resident refused to allow an assessment of the wound. The physician was notified. The area was visualized and noted to be intact with no concerns related to the surrounding area. The area was noted to have not yet resolved. The assessment was completed by Staff 5 (Regional RN) on 7/11/18. -7/11/18 assessment completed by Staff 2 on 7/18/18 indicated the deep tissue issue injury to the sacrum was resolved. A 6/21/19 physician fax to Staff 21 (Medical Director), indicated the newly identified sacrum deep tissue injury. The note indicated staff repositioned the resident, placed an order for [REDACTED].? The response dated 6/22/18 indicated no change to be made to treatments. The 6/2018 through 12/2018 TARs indicated staff were to apply barrier cream to the resident's sacrum every shift for pressure area. The treatment was initiated on 6/22/18 and was discontinued on 10/2/18. A new order for barrier cream to the resident's sacrum for skin breakdown began on 10/3/18 and was not canceled until 12/19/18. Review of the 6/2018 TAR indicated there were no documented administrations of the treatment on the night shifts of 6/27/18 and 6/28/18. The treatment was continued through 12/19/18. b. The 7/11/18 physician order [REDACTED]. Began as incontinence [MEDICAL CONDITION]. Pain, (resident) refuses care from staff. Lays in urine (not) allowing staff to change (her/his) brief. Applied [MEDICATION NAME] to area will attempt to (change every 3) days. Any further orders? A response by Staff 21 dated 7/16/18 indicated ok. A 7/11/18 Skin Issue investigation document indicated Resident 196 had a new stage 2 pressure ulcer on the right gluteal fold with an open area. The physician was notified. The documented was not signed as complete until 7/23/18, twelve days after the identification of the pressure ulcer. A 7/11/18 Weekly Skin Evaluation indicated the resident refused the skin assessment. This document was not signed as complete until 7/21/18, eleven days after the resident refused the assessment. The 7/2018 TAR indicated dressing changes to the Stage 2 pressure ulcer were to be completed every three days. On 7/24/18 there was no documentation to indicate a dressing change was completed. A 7/26/18 progress note indicated the physician was informed that the right gluteal wound resolved. The 8/2018 and 9/2018 TARs indicated Resident 196 continued to receive wound treatment for [REDACTED]. A 9/7/18 progress note indicated Resident 196's skin was clear on the right gluteal fold. c. The 12/19/18 Skin Ulcer investigation document indicated Resident 196 had a Stage 2 pressure ulcer to the right hip measuring 3.0 cm x 2.8 cm. The physician and family were notified. This document was not signed as completed until 12/31/18. The 12/19/18 Weekly Skin Evaluation indicated the resident had a Stage 2 pressure ulcer on the right hip measuring 3.0 cm x 2.8 cm x 0.1 cm. The 12/21/18 Weekly Skin Evaluation indicated the Stage 2 pressure ulcer measured 2.9 cm x 2.8 cm x 0.1 cm. The 12/27/18 Weekly Skin Evaluation indicated the family refused assessment of the pressure ulcer. During a group interview with Staff 2 (DNS), Staff 5 (Regional RN) and two survey staff on 3/20/18 at 2:45 PM, the resident's pressure wounds and treatment were reviewed. No additional information was provided regarding a failure to complete timely assessments of Resident 196's pressure wounds and to provide consistent treatment and monitor the resident's wounds. 2. Resident 8 readmitted to the facility in 8/2018 with [DIAGNOSES REDACTED]. The 12/21/18 Significant Change MDS indicated Resident 8 had a terminal prognosis and was on hospice status. The MDS indicated Resident 8 was at risk for pressure ulcers, but did not currently have any pressure ulcers. Resident 8's care plan for pressure ulcers risk indicated the resident refused interventions related to pressure ulcer treatment and prevention. Staff were to apply pressure reducing interventions and pressure ulcer treatment as the resident allowed. A 2/23/19 progress note indicated a new pressure ulcer was found on Resident 8's buttock/coccyx area. The wound was treated and the physician was notified. No evidence was found to indicate physician orders [REDACTED]. A 2/27/19 hospice progress note indicated treatment was provided to the buttock/coccyx wound. The 3/2019 TAR included a 3/12/19 order for treatment of [REDACTED]. No evidence was found to indicate treatment for [REDACTED]. On 3/13/19 at 11:56 am Staff 2 (DNS) stated Resident 8 had a previous buttocks/coccyx wound that resolved. Staff 2 stated the facility notified the physician and hospice of the new pressure ulcer but no treatment orders were received. Staff 2 stated it was facility protocol to put treatment in place pending confirmation from a physician. Staff 2 acknowledged no treatment was put in place for the pressure ulcer until 3/12/19, 17 days after the pressure ulcer was identified. Observations of Resident 8 during the survey from 3/5/18 through 3/18/18 revealed the resident was not compliant with pressure ulcer treatment. Resident 8 refused to allow surveyors to observe the wound.

Based on interview and record review it was determined the facility failed to provide catheter care for 1 of 3 sampled residents (#202) reviewed for catheter care. This failure resulted in Resident 202 experiencing significant pain and hospitalization for urine retention. Findings include: Resident 202 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 2/22/19 physician's orders [REDACTED]. A 3/1/19 Admission MDS indicated Resident 202 was severely cognitively impaired. A 3/1/19 Urinary Incontinence CAA indicated the resident needed physical assistance with toileting and was incontinent of urine. The CAA did not include information on the resident's risk for [MEDICAL CONDITION] or the need for PRN bladder scans or catheterization. The resident's care plan for incontinence, initiated 3/4/19, indicated the resident used a brief. The care plan did not indicate the resident's risk for [MEDICAL CONDITION]. Progress notes from 3/6/19 through 3/10/19 indicated Resident 202 complained of pain, yelled out, woke up from pain and screamed out in pain. There was no indication Resident 202's bladder was assessed. A 3/11/19 at 4:46 AM progress note indicated Resident 202 consistently complained and cried out in pain. Pain medication was ineffective. There was no indication Resident 202's bladder was assessed. A 3/11/19 at 4:03 PM progress note indicated Resident 202 had extreme swelling to the peri area which obstructed the urethra and the resident had not voided urine in the past six hours. The resident's pain level was a nine out of ten even after receiving PRN pain medication. The physician was contacted and the resident was ordered to go to the emergency room . No evidence was found to indicate the resident was assessed for post void residual urine or to indicate the output volume was measured to determine if the resident was fully voiding while she/he resided at the facility. Hospital records dated 3/11/19 indicated Resident 202 was diagnosed with [REDACTED]. On 3/15/19 at 1:24 PM Staff 9 (CMA) stated Resident 202 sometimes yelled out in pain. During interviews with Staff 17 (LPN) on 3/15/19 at 1:31 PM and 3/18/19 at 10:19 AM Staff 17 stated Resident 202 was painful and confused. Staff 17 stated she thought the resident was voiding appropriately based on how saturated the resident's brief was. Staff 17 stated she had no way to tell if the resident was fully emptying her/his bladder because the facility did not have a bladder scanner. During interviews with Staff 2 (DNS) and Staff 3 (LPN Resident Care Manager) on 3/15/19 at 5:20 PM and 3/18/19 at 10:51 Staff 2 stated the order for PRN catheterizing and bladder scans did not necessarily indicate [MEDICAL CONDITION] was an area of focus for Resident 202. Staff 2 stated the facility did not have a bladder scanner, so they were not able to fulfill the physician's orders [REDACTED]. Staff 2 acknowledged the order to bladder scan and straight catheterize Resident 202 was not clarified.

Based on interview and record review it was determined the facility failed to ensure residents received needed pain medication for 2 of 3 sampled residents (#s 20 and 243) reviewed for pain. This failure resulted in Residents 20 and 243 experiencing severe unrelieved pain and Resident 20 being hospitalized . Findings include: 1. Resident 20 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 1/25/19 Annual MDS Pain CAA indicated Resident 20 experienced frequent pain and had an increase in pain recently. It further indicated the resident took pain medications which eased the pain but her/his pain never ceased completely. The resident's pain was reported in her/his back and lower extremities. The 8/23/18 care plan indicated the resident's pain was alleviated by medication and rest and to monitor complaints of pain. A 1/30/19 physician order [REDACTED]. The 2/2019 MAR indicated [REDACTED]. A 2/12/19 progress note by Staff 4 (LPN) indicated the pharmacy was contacted regarding Resident 20's [MEDICATION NAME] and that it was unable to be pulled from the Cubex (Facility emergency kit) and the pharmacy stated it would arrive on the night delivery. A 2/13/19 progress note by Staff 4 indicated at 1:00 AM the CNA notified the nurse Resident 20 complained of uncontrolled pain, had facial grimacing and kept twitching in the wheelchair. The resident stated she/he hurt all over and wanted to go to the hospital. The nurse called 911 at 1:15 AM and paramedics arrived at 1:30 AM. The resident left the facility at 1:55 AM and was transferred to the hospital. A 2/13/19 hospital note indicated Resident 20 presented to the emergency department for pain control and had a history of [REDACTED]. [MEDICATION NAME] (pain medication) was administered and the resident had a current pain level of 8 out of 10. The resident stated the facility did not order the medication and per the RN the [MEDICATION NAME] was supposed to come tomorrow. At 4:59 AM the resident was sleeping and had reached adequate pain control and was appropriate for discharge. On 3/5/19 at 10:43 AM and 3/8/19 at 12:15 PM Resident 20 and Witness 9 (Family) stated [MEDICATION NAME] (narcotic pain medication) was not provided as ordered on [DATE] and 2/13/19 and the resident was hospitalized for [REDACTED]. Witness 9 further stated Resident 20 still did not receive [MEDICATION NAME] on 2/13/19 after returning to the facility. On 3/7/19 at 6:45 AM Staff 4 stated she worked the night of 2/12/19 and day shift 2/13/19. She stated the [MEDICATION NAME] was not administered because the resident's supply had run out. When she was made aware of the lack of [MEDICATION NAME] she contacted the pharmacy. Staff 4 stated the [MEDICATION NAME] was not available in the Cubex. She further stated between 11:30 PM on 2/12/19 and 12:00 AM on 2/13/19 the CNA reported to her that Resident 20 was having twitching and jerking motions, rated her/his pain at ten out of ten and wanted to be sent out to the emergency room so she called 911. On 3/8/19 at 12:02 PM Staff 2 (DNS) stated Resident 20 did not receive [MEDICATION NAME] on three occasions on 2/12/19 and was sent to the hospital due to having pain and twitching. She stated the hospital gave the resident pain medications and she/he returned to the facility at 8:15 AM on 2/13/19. She acknowledged the resident did not receive the 8:00 AM dose or the 2:00 PM dose of [MEDICATION NAME] on 2/13/19 after arriving back from the hospital. She stated the medication was not received from pharmacy until around evening shift on 2/13/19. On 3/14/19 at 4:32 PM Witness 10 (Pharmacist) stated [MEDICATION NAME] was delivered to the facility on [DATE] at 1:41 PM. On 3/20/19 at 9:26 AM Staff 2 provided further information from the pharmacy regarding the Cubex inventory and stated the [MEDICATION NAME] was available in the Cubex on 2/12/19 and 2/13/19. Staff 2 was unable to provide a rationale for why the [MEDICATION NAME] was not administered as ordered on [DATE] and 2/13/19. On 3/21/19 at 12:16 PM Staff 5 (Regional RN) stated the facility was able to have the pharmacy send a medication within two hours when requested. Staff 5 stated the medication was available in the Cubex on 2/12/19 and 2/13/19. 2. Resident 243 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 3/5/19 Admission Nursing Assessment indicated the resident rated her/his pain as an eight out of ten at 2:34 PM. The assessment further indicated the resident was cognitively intact. The 3/5/19 Visual/Bedside Individual Service Plan Report (CNA Care Plan) indicated Resident 243 was able to verbalize and indicate where her/his pain was located. The document further indicated staff were to report to nursing staff any resident complaints of pain or requests for pain treatment. Hospital discharge records dated 3/5/19 indicated Resident 243 had orders to receive [MEDICATION NAME] (narcotic pain medication) every four hours PRN for severe pain rated between 7-10. The orders also indicated Resident 243 was to receive Tylenol (pain medication) every four hours for fever or mild pain rated 1-3. a. A facility Grievance Form dated 3/6/19 indicated Resident 243 arrived at 3:00 (PM) or so, got pain pill (Tylenol) at 3:30 (PM) or so. Was still in pain got insulin shot before dinner. Got ice pack after dinner. Got more medication a(t) 11:58 (PM). The steps taken to investigate read, passed onto a formal investigation. On 3/6/19 at 11:57 AM Resident 243 stated she/he admitted to the facility on the afternoon of 3/5/19. The resident stated she/he asked for [MEDICATION NAME] (narcotic pain medication) at 7:30 PM and then again at 9:00 PM. The resident further stated staff informed her/him that the facility had not yet received the medication. Resident 243 stated she/he indicated to staff that her/his pain level was so high that she/he would call 911 if she/he did not receive the [MEDICATION NAME] soon. The resident stated she/he did not receive the [MEDICATION NAME] pain until two minutes to midnight. A 3/5/19 packing slip from the facility's delivering pharmacy indicated Resident 243's [MEDICATION NAME] was received by the facility at 11:30 PM. Review of the Facility Narcotic Book indicated Resident 242 received her/his first dose of [MEDICATION NAME] on 3/5/19 at 11:45 PM b. On 3/7/19 at 12:37 PM Resident 243 stated she/he asked for Tylenol at 6:00 PM on 3/6/19 and indicated to nursing staff she/he wanted [MEDICATION NAME] administered at 9:00 PM. The resident stated at 9:00 PM a different nurse was on duty and the new nurse expressed she was unaware of the resident's prior request for [MEDICATION NAME]. Resident 243 stated the [MEDICATION NAME] was not administered until 10:00 PM but by that time she/he was already in such intense pain that she/he struggled with continued pain through the overnight hours. Resident 243 stated at midnight her/his pain was a nine or ten out of ten. c. On 3/8/19 at 8:25 AM Resident 243 stated at 10:00 PM on 3/7/19 she/he requested [MEDICATION NAME], and indicated to staff that her/his pain level was an eight out of ten. Resident 243 went on to say she/he did not get her/his pain medication until 4:25 AM the morning of 3/8/19. The resident further stated she/he informed staff multiple times throughout the night of her/his need for pain medication. A facility Grievance Form dated 3/8/19 indicated Resident 243 reported during night shift of 3/7/19 she/he asked for pain medication at the beginning of the shift (night shift starts at 10:00 PM). The resident stated she/he did not receive her/his pain medication until 4:30 AM. The form indicated the nursing staff in question was suspended pending the facility investigation. An undated and in-progress Abuse Investigation Steps/documentation form was submitted to the survey team. The document was the facility investigation in progress following the first resident grievance received by the facility for Resident 243 on 3/6/19 and additionally included information related to the resident's grievance on 3/8/19. The document indicated the following: -On 3/6/19 resident reported concern about a delay in receiving her/his PRN pain medication. -On 3/8/19 the resident reported a concern about not receiving requested PRN pain medication during N[NAME] shift. - Staff 18 (LPN) was identified, suspended and terminated on 3/8/19. - Staff 37 (LPN) indicated to facility staff Resident 243 requested pain medication at the beginning of night shift and stated she did not administer the resident her/his requested pain medication until 4:30 AM. A 3/6/19 documented witness statement by Staff 11 (CMA) indicated Staff 18 was asked by Staff 26 (LPN) to give pain medications at shift change (day shift into night shift, typically 2:00 PM). She stated Staff 26 asked multiple times to follow up with pain medication and to administer Tylenol to assist with pain while calling the pharmacy to request the [MEDICATION NAME] order. A 3/6/19 documented witness statement by Staff 18 read as follows: I wasn't doing any of the meds. (Staff 26) didn't give me report. (Staff 26) did report (Resident 243) needed pain medications. I didn't have the medication list to confirm them. (Staff 26) gave me (the) packet at 2:30 PM and that's when I start(ed) confirming them. I gave Tylenol 650 mg. I didn't respond to the resident's request for it because (Staff 26) had an attitude when she asked me to do it. Patient had asked for pain medications twice, once on my shift and then again asked (Staff 4/LPN/night nurse). 4:45 PM was the time I gave it (Tylenol) Pt (patient) told me she/he was here for pain, pain to left leg/hip and knee 8/10 pain. Ice pack was also provided . I didn't have the [MEDICATION NAME] to administer, it (wasn't) received from pharmacy yet. I did not call pharmacy. I don't know why I didn't call. [MEDICATION NAME] was not administered on my shift. Pt was not in excessive pain. A 3/7/19 Witness Report with Staff 26 indicated the following: -Staff 26 admitted Resident 243 to the facility on [DATE]. - On admission, the resident reported and eight out of ten on the pain scale. -Staff 26 stated she faxed the resident's orders over to the pharmacy, and additionally called the pharmacy at around 2:00 PM requesting an access code for the Cubex (locked and encoded machine housing facility emergency sources of medication). Staff 26 indicated the pharmacist stated she would return a call to the facility with an access code shortly. -Staff 26 notified the resident the facility was waiting for a call back from the pharmacy, and the resident stated at least the Tylenol. -Staff 26 stated she informed the two nurses on shift at this time, Staff 18 (LPN) and Staff 37 (LPN) as well as Staff 11 (CMA). Staff 26 stated she indicated the pharmacist would be calling back with an access code for the Cubex and indicated the resident currently needed to be medicated with Tylenol. Staff 26 further indicated resident orders needed to be confirmed by two nursing staff, and she had already confirmed them. She indicated she notified Staff 18 multiple times she needed to confirm the orders, and to medicate Resident 243. She stated at no point in time did Staff 18 lack access to Resident 243's orders that needed a second confirmation by nursing staff. Review of the 3/5/19 through 3/8/19 MAR indicated [REDACTED]. The Tylenol order on the MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED] - 3/5/19 - 4:45 PM Staff 18 administered Tylenol and documented a pain level of 8. - 3/5/19 - 11:37 PM Staff 4 (LPN) administered Tylenol and documented a pain level of 5. Review of the 3/5/18 through 3/8/19 MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED] - 3/5/19 - 11:37 PM Staff 4 (LPN) administered the medication and documented a pain level of 5. - 3/6/19 - 9:51 PM Staff 37 administered the medication and documented a pain level of 6. - 3/7/19 - 7:16 AM Staff 17 (LPN) administered the medication and documented a pain level of 8. - 3/7/19 - 5:32 PM Staff 41 (LPN) administered the medication and documented a pain level of 7. - 3/8/19 - 4:29 AM Staff 37 administered the medication and documented a pain level of 7. Review of the 3/5/19 through 3/8/19 Facility Narcotic Log did not indicate a 3/8/19 administration of [MEDICATION NAME] by Staff 37 at 4:29 AM. On 3/8/19 at 9:07 PM Staff 2 (DNS) acknowledged the 3/2019 MAR indicated [REDACTED]. Staff 2 stated if the facility was unable or did not have a resident's ordered medication, they could call the pharmacy to receive a code. The code was required for them to access pain medication in the Cubex, and typically took about five minutes to get. Staff 2 stated Staff 18 did not attempt to call the pharmacy in order to get into the Cubex, but rather waited until the resident's medication arrived from the pharmacy. She stated Staff 18 was suspended pending an investigation and would ultimately be terminated, following the resident's grievance. When asked about the evening of 3/7/19 and the resident's grievance related to going the entire night shift without receiving her/his requested pain medication, Staff 2 indicated the nurse working that evening was Staff 37. She stated Staff 37 reported she messed up to Staff 29 (LPN MDS Coordinator) who then communicated the information to her. Staff 2 indicated she believed Staff 37 forgot about the resident's request. On 3/8/19 at 9:35 AM Staff 5 (Regional RN) stated Staff 37 was suspended following investigation of the resident grievance. On 3/8/19 at 9:07 AM Staff 5 stated Staff 37 was back to work at the facility, and on an action plan. She further acknowledged the Facility Narcotic Book for 3/8/19 did not indicate the 4:29 AM dose Staff 37 documented as administered on the 3/8/19 MAR. A 3/8/19 attempt by survey staff to reach Staff 18 for interview was unsuccessful. On 3/14/19 at 11:23 AM Staff 26 stated she was the admitting nurse for Resident 243. She stated the resident was having pain at the end of the assessment. Staff 26 stated both Staff 18 and Staff 37 were sitting together when she informed them the resident was requesting pain medication. She stated she had already called the pharmacy to have the orders verified, and indicated to them the orders needed a second confirmation in the system. She stated Staff 37 was the day shift nurse and Staff 18 was the evening shift nurse. She stated she informed both Staff 37 and Staff 18 multiple times the orders needed a second confirmation. She further indicated the pharmacy never called back that evening, and even if the orders did have a second confirmation from nursing staff, the medication could not be administered without a pharmacy verification. She stated nursing staff working the evening and night shifts could have called the pharmacy, but they did not. Staff 26 stated instead of calling the pharmacy the nurses waited for the medication to come in that night. On 3/15/19 at 1:54 PM Staff 4 (LPN) confirmed she worked the night shift of 3/5/19 into 3/6/19. She stated she received report from Staff 18. She stated it was close to 11:00 PM when she was informed the resident needed pain medication, and she did not recall who informed her of the resident's request for pain medication. Staff 4 stated pharmacy orders typically arrived at the facility between 11:00 PM and 12:00 AM. Staff 4 stated if a medication was not available for a resident, her process was to pull from the Cubex, and further stated when the resident's medication arrived that evening, she administered it. She stated when she went to give the resident her/his pain medication, the resident indicated she/he had been waiting a long time. On 3/18/19 at 2:53 PM Staff 37 acknowledged Resident 243 requested pain medication at 10:30 PM on 3/7/19. She acknowledged she did not administer the pain medication to the resident until 4:30 AM on 3/8/19.

Based on interview and record review it was determined the facility failed to ensure medically related social services were provided related to discharge, mental health, dementia care and cognitive assessments for 1 of 1 facility reviewed for social services. Findings include: 1. Deficient practice was identified related to a failure to provide care and services for resident discharges. These failures resulted in residents not receiving information about the discharge process and bed-hold policies, not being allowed to return to the facility after hospitalization and not informing the Long Term Care Ombudsman of hospitalization s. This failure resulted in Resident 193 experiencing psychosocial harm.Refer to F623, F625 and F626. 2. Deficient practice was identified related to a failure to provide care and services to residents with behavioral health needs. This failure resulted in Resident 196 experiencing psychosocial decline. Refer to F742. 3. Deficient practice was identified related to a failure provide resident assessments. This failure resulted in residents' cognitive needs not being comprehensively assessed. Refer to F636.4. Deficient practice was identified related to a failure to provide care and services to residents with dementia. This failure resulted in a lack of comprehensive care plans and appropriate treatment for [REDACTED]. On 3/20/19 at 12:36 PM Staff 1 (Administrator) stated the facility was on its fourth Social Services director since 1/1/18. Staff 1 acknowledged there were times when the facility did not have a functioning Social Services director. Staff 1 stated staff who were unfamiliar with Social Services tried to cover the responsibilities including himself, Staff 5 (Regional RN) and Staff 41 (Admissions). Staff 1 stated he did not consider bringing in a qualified Social Services director from another facility to cover on a temporary basis.

Based on interview and record review it was determined the facility failed to ensure a resident's total program of care was reviewed, and sign and date all orders by a physician for 1 of 7 sampled residents (#196) reviewed for abuse. This placed residents at risk for not unassessed medical needs and adverse side effects of medication. Resident 196 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A Significant Change of Condition MDS was completed for Resident 196 on 9/21/18. The MDS indicated the resident was cognitively intact. A 12/19/18 Quarterly MDS indicated Resident 196 was not cognitively intact. The undated face sheet for Resident 196 indicated Staff 21 (Medical Director) was her/his primary care physician. Review of Resident 196's Medication Review Reports from 5/2018 through 12/2018 revealed there were no Medication Review Reports in the clinical record for the months of 6/2018, 8/2018, 9/2018 and 12/2018. The review further indicated the 11/2018 Medication Review Report was not signed by Staff 21 (Medical Director). Review of Resident 196's clinical record from 6/2018 through 12/2018 revealed signed physician progress notes [REDACTED]. -The 6/2018 Assessment and plan read: 1. Psych: stable on [MEDICATION NAME] (mood stabilizer) 2. Pain: stable on [MEDICATION NAME] (narcotic pain medication) 3. DM (diabetes) on [MEDICATION NAME] (anti-diabetic medication) refuses labs. -The 8/2018 notes revealed the resident refused the physical examinations and continued to refuse insulin (diabetic medication). The note further read, 1) DM (diabetes) - keep trying to offer (treatment). 2) .(psych) - takes meds sporadically. -The 10/2018 note revealed no indication of the resident's recent significant change of condition, per the 9/21/18 Significant Change MDS. The Assessment and plan portion of the note indicated the resident refused medications, examinations, treatments and care. The note indicated to continue to offer. -The 12/4/2018 note revealed the resident refused most of the exam. The Assessment and Plan read, .stable but refuses most meds and (treatments) for (diabetes, [MEDICAL CONDITION] disorder, [MEDICAL CONDITION]). None of the identified physician progress notes [REDACTED]. medical regimen. None of the above noted progress notes reflected an overall review of the resident's total program of care or current condition. On 3/14/19 at 11:17 AM Staff 21 (Medical Director) referred to Resident 196 as a psych patient with psych issues but was unsure what her/his mental health [DIAGNOSES REDACTED]. When asked about the resident's status during the physician visits, Staff 21 stated the information was in the physician progress notes [REDACTED]. In an interview with Staff 21 on 3/20/19 beginning at 9:49 AM, present with three survey staff, she made the following statements and indications with regard to Resident 196 and her/his treatment and care: -When asked to describe Resident 196's decline, Staff 21 stated, it's been gradual, the thing is (she/he) wouldn't take meds, couldn't take labs . how would I know? I'd say ok, we can't get labs, try in a month . after the order would get so old, I'd say forget the labs and we'd try a year later . Staff 21 further indicated, occasionally (she/he) would allow me to look at (her/him). -When Staff 21 was asked when the last time she was able to complete a full assessment on Resident 169 was, she stated .it's been years since a full assessment was completed. -Staff 21 stated Resident 196 was neglecting (her/himself) due to refusals of care. -Staff 21 indicated she believed the resident was cognitively aware enough to decline care but she did not believe the resident was cognitively intact enough to understand the consequences of her/his medication refusals. -Staff 21 indicated the facility and resident's local area had poor (mental health) resources for psych cases. When asked if she had ever referred Resident 196 for a mental health evaluation she acknowledged she did not refer Resident 196 for mental health services because she did not believe there was anyone to refer to. -Staff 21 indicated she not involved in interdisciplinary team discussions regarding the resident's use of [MEDICAL CONDITION] medications. She further stated the only review of [MEDICAL CONDITION] medications she did for residents was to review pharmacist reviews. Refer to F600, F658, F711, F742 and F868.

Based on interview and record review it was determined the facility failed to develop a care plan, notify the physician of a change in wound status and monitor pressure ulcers for 3 of 3 sampled residents (#s 10, 11 and 12) reviewed for pressure ulcers. Resident 10's wound worsened and the resident was hospitalized . Findings include: The facility Skin Integrity policy updated (MONTH) (YEAR) indicated when a resident was admitted to the facility with a skin impairment staff were to measure the wound, identify drainage, describe color and document the findings on the weekly wound evaluation form. The policy indicated treatment orders were to be on the TAR and documented when implemented. Interventions were to be identified and placed on the resident's care plan. 1. Resident 10 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The hospital 2/13/18 Certified Wound Ostomy Nurse note indicated the resident had a deep tissue injury (localized purple or maroon discolored area to the skin due to damage under the skin-the wound may rapidly reveal the actual extent of tissue injury, or may resolve without tissue loss) with non-blanchable redness surrounding the wound. The wound was located to the left and right buttock. The wound bed was beginning to demarcate (separate) to reveal a pink, moist wound bed. The wound had a small amount of serosanguinous drainage (straw colored drainage). The recommendation was to continue with a foam dressing. The note indicated a wheelchair cushion was ordered. The 2/15/18 Nursing Admission Evaluation indicated the resident did not have a history of a pressure ulcer and had right and left buttock wounds. There were no measurements or description of the buttock wounds. The 2/15/18 Progress Note by Staff 3 (LPN) indicated the resident had a Stage 2 pressure ulcer (partial thick skin loss with a pink wound bed and no slough/dead tissue) to the buttocks. On 4/30/18 at 11:47 am Staff 3 indicated she admitted the resident to the facility. The resident had a dressing over the ulcer and she did not remove the dressing to evaluate the stage and size of the ulcer. The 2/22/18 CAAs indicated the resident had short term memory problems, required extensive assistance with bed mobility and had a pressure ulcer. The current interventions included resident repositioning, wound care, a pressure reducing mattress and wheel chair pad. The record did not have a comprehensive care plan related to ADL care or pressure ulcers. There were no interventions to direct staff to keep the resident off the coccyx or to minimize time in a chair. On 5/1/18 Staff 4 (DNS) acknowledged there was no comprehensive care plan developed for ADLs or pressure ulcers. There were no interventions to ensure the wound did not worsen. The 2/15/18 admission orders [REDACTED]. There were no directions for how often the dressing was to be changed. The (MONTH) TAR did not include wound care for Resident 10's pressure ulcer. The Progress Notes indicated the dressing was changed to the pressure ulcer on 2/16/18, 2/17/18, 2/19/18, 2/21/18 and 2/22/18. The notes did not indicate a skin protectant was applied to the skin. The 2/22/18 note indicated there was an open area to the buttocks, the drainage was malodorous, the physician was notified and a change in wound care was requested. The 2/23/18 Physician order [REDACTED]. The 2/24/18 Progress Note indicated the ulcer was 90-100 percent covered with slough. The borders were red, had copious amounts of serous drainage with a strong odor. There were no signs of infection. On 2/28/18 the note indicated the dietary consult recommended additional calories and supplements for healing and a pressure relieving cushion for the wheel chair was implemented. The director of nursing ordered a wheel chair cushion and air bed. The Rental Contract indicated the resident's air bed was provided on 2/28/18. The invoice provided by Staff 4 (DNS) for Resident 10's wheelchair cushion indicated the cushion was shipped on 3/8/18. This was 21 days after the resident was admitted to the facility with a deep tissue injury. On 5/3/18 Staff 7 (LPN) indicated Resident 10 did not have a wheel chair cushion for a few weeks. If a wheel chair cushion was provided the therapy department ordered the cushions. On 5/4/18 at 9:26 am Staff 8 (Occupational Therapist) indicated if a wheelchair cushion was provided the therapy department worked with the nurses to order an appropriate cushion. Staff 8 indicated Resident 10's family brought in a cushion purchased at a local store. The cushion was foam and was covered with plastic. The resident's record did not have weekly skin evaluations of the pressure ulcer to describe the size, drainage and healing progress until 2/28/18, 13 days after the resident was identified to have an ulcer. The 2/28/18 weekly skin evaluation indicated the ulcer was covered with 100 percent of slough had moderate amount of serosanguinous drainage and was unstageable (depth unable to be determined due to slough). The 3/2/18 Progress by Staff 7 (LPN) indicated the resident's wound had copious amounts of purulent drainage. The resident's vital signs were stable. There was no note to indicate the physician was notified. On 5/3/18 at 12:02 pm Staff 7 indicated if a physician was notified of a change in wound status it was documented in the Progress Notes. The 3/7/18 Nutrition/Dietary Note indicate the resident coccyx pressure injury was 6.8 cm long by 8.0 cm long and .1 cm deep and was covered with 100 percent slough. The resident had pressure relieving cushion in the wheelchair and alternating air flow mattress. The 3/8/18 Weekly skin evaluation indicated the ulcer was identified to be 3.5 cm long by 5.2 cm wide and .2 cm deep and was unstageable. The ulcer was oval/heart shaped, the wound bed was beefy red with 50 percent slough. There was heavy serosanguinous drainage with moderate odor. The 3/10/18 Progress Note indicated the resident ulcer had copious amounts of drainage with a strong odor. The wound been was covered with slough. The note did not indicate the physician was notified of the copious amounts of drainage. There were no notes in the record to indicate the facility requested a change in wound care to address the drainage and continued slough. The 3/12/18 Progress note indicated the resident had increased purulent drainage with odor. A request for a wound clinic visit was made to the physician. The 3/13/18 Weekly Skin evaluation indicated the unstageable ulcer had copious amounts of foul drainage. The resident was transported to the wound clinic on 3/14/18. The 3/14/18 hospital History and Physical and 3/20/18 Discharge summary indicated the resident had worsening pain to the pressure ulcer. The resident was assessed at the wound clinic and the ulcer was probed and found to be the bone. The resident was sent to the hospital emergency department. At the hospital an exam of the resident's wound was performed. Upon spreading of the resident's buttocks a large amount of purulent drainage leaked out of the wound. The resident did not have a bone infection and was started on antibiotics. A vacuum dressing was applied. 2. Resident 12 was readmitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 1/14/18 Skin Issue Occurrence Report indicated on 1/19/18 the resident's right foot slid off the foot rest as a family member assisted the resident in the wheelchair. The resident's toe was observed to have a blister on the bottom of the right great toe. The area opened and the wound bed was deep red and the size of the quarter. The (MONTH) (YEAR) TARs indicated treatment to the toe was provided daily. The wound was cleaned, an antiseptic was applied and the wound was covered with a clean dressing. The 1/29/18 Progress Note indicated the right great toe was black and looked like eschar (dead tissue). The physician was notified. The 2/12/18 Physician's Progress Notes indicated the resident had a black area to the bottom of the right great toe. The staff were to debride the black area with an ointment and an X-ray of the toe was ordered. The x-ray obtained on 2/12/18 indicated there were no concerns related to the right great toe. There were no weekly skin assessments of the right great toe from 1/19/18 until 3/1/18. On 3/1/18 the right great assessment indicated the resident had a pressure ulcer . The ulcer was brown/black and 100 percent eschar (black/brown dead tissue). The ulcer was 3.3 cm long by 2.5 cm wide. The surrounding skin was without signs of infection. The ulcer was identified to be a Stage Two Ulcer (superficial opening of the skin with no slough/dead tissue). On 4/30/18 at 1:42 pm Staff 5 (LPN Resident Care Manager) indicated if an ulcer was covered with eschar the ulcer was not a Stage Two pressure ulcer. The ulcer would be unstageable (depth of the ulcer is not able to be determined due to being covered with slough/eschar). The 3/9/18 Weekly Skin Evaluation indicated the toe was without significant change. The resident was transferred to the hospital for an unrelated issue on 3/15/18 and returned on 3/20/18. The 3/20/18 hospital Discharge Summary indicated the resident had a necrotic toe, was recently evaluated at the podiatrist and a cream to the toe to debride the eschar was ongoing. The 3/22/18 Weekly Skin Evaluation indicated the right great toe did not change significantly from the 3/9/18 assessment. There were no assessments of the toe from 3/22/18 until 4/6/18. The ulcer continued to be assessed as a Stage Two pressure ulcer. The size of the ulcer on 4/13/18 was 3.2 cm long by 2.9 cm wide and covered with eschar. On 4/30/18 at 3:00 pm Staff 4 (DNS) indicated she would expect weekly assessments to be completed on the right great toe and acknowledged the right great toe ulcer was identified in (MONTH) (YEAR) and the skin sheets located in the resident's record were started on 3/1/18. 3. Resident 11 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 11/2/18 CAAs and Care Plan initiated 10/2017 indicated the resident was admitted to Hospice services and had a pressure ulcer to the coccyx. The CAA indicated the resident had an air mattress, staff were to provide treatments and perform weekly measurements. The resident's health was expected to decline. The Weekly Skin Evaluation sheets indicated the resident's ulcer was monitored seven out of nine opportunities from 11/8/17 through 1/9/18. On 1/9/18 the assessment indicated the resident had a 3 cm long by 2.5 cm wide by .5 cm deep Stage Three ulcer (full thickness skin loss in which muscle of fat may be visible. Slough/dead tissue may or may not be present). The record did not have documentation to indicate the pressure ulcer was assessed from 1/16/18 to 2/23/18. From 3/1/18 to 4/6/18 the ulcer was assessed two out of five opportunities. On 4/30/18 at 12:50 pm Staff 5 (LPN Resident Care Manager) indicated the Hospice staff, with facility staff present, assessed the resident's ulcer weekly. The 1/24/18 to 4/23/18 Hospice care summary indicated the resident's coccyx wound was healing well. On 4/30/18 at 12:50 pm Staff 5 (LPN Resident Care Manager) indicated the pressure ulcer was to be monitored weekly. Staff 5 acknowledged the skin assessments were not documented weekly. Staff 5 reviewed the Hospice notes and did not see wound measurements but the notes indicated the ulcer improved.

Based on observation, interview and record review it was determined the facility failed to ensure a resident's environment remained free of accident hazards for 5 of 5 sampled resident (#s 20, 38, 49, 96 and 125) reviewed for accidents. Resident 96 experienced increased, ongoing pain. Findings include: 1. Resident 96 was admitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] indicated Resident 96's BIMS score was 14 (little to no cognitive impairment). A Progress Note in Resident 96's medical record dated 9/19/17 indicated Resident 96 was in the hallway in her/his wheelchair at approximately 2:00 pm when another resident bumped into her/his wheelchair with a power scooter. Review of the 9/2016 and 10/2016 MARs revealed the following: * From 9/1/17 through 9/19/17 oxycodone 5 mg one tablet every six hours PRN for pain. Resident 96 was administered one tab of the oxycodone on 26 occasions. * From 9/19/17 through 10/6/17 oxycodone 5 mg one to two tablets every six hours PRN for pain. Resident 96 was administered one tab on four occasions and two tabs on 27 occasions. On 10/5/17 at 8:47 pm and 10/9/17 at 12:04 pm Resident 96 stated Resident 38 was driving her/his electric scooter too fast in the hallway and ran into the back of her/his wheelchair while she/he was sitting in it. Resident 96 stated part of her/his wheelchair lifted off the ground and she/he was pinned between a doorframe and Resident 38's scooter. Resident 96 stated she/he was in pain after the accident, was given pain medications and was sent to the hospital where x-rays were obtained. Resident 96 did not know the result of the x-rays. Resident 96 stated she/he was still in pain from the accident, her/his chronic pain was more severe and was mostly in her/his lower back. Resident 96 stated before the accident she/he was able to sit up in her/his wheelchair for up to eight hours a day but could no longer stay up in the chair for that long. Resident 96 stated before the accident staff were aware resident 38 drove too fast in her/his scooter, Resident 96 did it daily and almost hit other people. On 10/6/17 at 9:53 am Staff 11 (LPN) stated Resident 38 currently used a wheelchair for ambulation and a few weeks ago used an electric scooter. Staff 11 stated when Resident 38 used the electric scooter she/he ran into walls and doorways, would drive quite fast and she would tell her/him to slow down or she/he would hurt someone. Staff 11 stated Resident sped in the scooter all day long ever since she/he admitted to the facility (7/2017). On 10/06/17 at 10:00 am Staff 12 (CNA) stated Resident 38 would at times drive too fast in her/his electric scooter and bumped into walls in hallways. Staff 12 stated she would tell her/him to slow down so she/he wouldn't hurt anyone. On 10/6/17 at 10:10 am Staff 13 (Housekeeping Director) stated she saw Resident 38 drive fast in her/his electric scooter several times. When Resident 38 was speeding she would tell the resident to slow down. On 10/6/17 at 4:12 pm Resident 38 stated she/he was no longer able to ride in her/his electric scooter because of poor vision and had an accident about two weeks earlier. Resident 38 stated staff told her/him to slow down when she/he drove the scooter and she/he ran into things like doors and walls. Resident 38 stated she/he had neuropathy in her/his hand and it affected her/his ability to drive the scooter. On 10/9/17 at 10:10 am Staff 5 (Administrator) stated Resident 38's electric scooter was taken away after she/he ran into another resident in the hallway. Staff 5 stated he did not know if Resident 38 was unsafe to drive the scooter prior to the accident and did not witness Resident 38 to drive the scooter unsafely. Staff 5 stated if staff had knowledge Resident 38 was driving unsafely prior to the accident it should have been reported. Resident 38 would then have been assessed to determine if she/he was safe to drive the scooter. On 10/9/17 at 10:50 am and 11:04 am Staff 4 (LPN Resident Care Manager) stated Resident 96 originally said she/he was fine after the accident but after a couple of hours complained of back pain and was sent to the hospital. Staff 4 stated Resident 96 was diagnosed at the hospital with a muscle strain. Staff 4 acknowledged Resident 96 was taking more pain medication after the accident. 2. Resident 38 was admitted to the facility in 7/2017 with [DIAGNOSES REDACTED]. The Admission MDS dated [DATE] indicated Resident 38's BIMS score was 15 (little to no cognitive impairment). A Progress Note in Resident 38's medical record dated 9/19/17 indicated Resident 38 ran into the wheelchair of another resident. Resident 38 complained of blurry vision and was transferred to the hospital. In interviews on 10/6/17 at 9:53 am, 10:00 am, and 10:10 am, Staff 11 (LPN), Staff 12 (CNA) and Staff 13 (Housekeeping Director) stated prior to the accident when Resident 38 ran into Resident 96's wheelchair, Resident 38 rode the scooter too fast, was told to slow down and ran into walls and doorways. On 10/6/17 at 12:29 pm Staff 2 (DNS) stated when Resident 38 first admitted to the facility there were no issues with her/him driving the electric scooter. Staff 2 stated Resident 38 was unsafe in her/his electric scooter, was given a wheelchair for ambulation and was seen by PT/OT after the accident. Staff 2 was unable to locate a safety evaluation for Resident 38's ability to use the electric scooter prior to the accident. On 10/6/17 at 4:12 pm Resident 38 stated she/he no longer was able to ride in her/his electric scooter because of poor vision and had an accident about two weeks earlier. Resident 38 stated staff told him to slow down when she/he drove the scooter and she/he ran into things like doors and walls. Resident 38 stated she/he had neuropathy in her/his hand and it affected her/his ability to drive the scooter. On 10/9/17 at 10:10 am Staff 5 (Administrator) stated Resident 38's electric scooter was taken away after she/he ran into another resident in the hallway. Staff 5 stated he did not know if Resident 38 was unsafe to drive the scooter prior to the accident and did not witness Resident 38 to drive the scooter unsafely. Staff 5 stated if staff had knowledge Resident 38 was driving unsafely prior to the accident it should have been reported. Resident 38 would then have been assessed to determine if she/he was safe to drive the scooter. 3. Resident 125 admitted to the facility in 9/2017 with [DIAGNOSES REDACTED]. The (undated) bedside care plan under Devices indicated transfer/mobility bar. The Device Informed Consent form dated 9/8/17 indicated mobility bars for increase in bed mobility. The Device Evaluation form dated 9/13/17 indicated mobility bar to enhance resident function, contributes to self-performance, enhances transfer status and potentially prevents resident from rolling out of bed. An Occurrence Report dated 9/16/17 indicated resident sustained [REDACTED]. Resident 125 reported to staff she/he obtained the bruise after leaning against her/his bed rail. It was further noted Resident 125 desired no change to the plan of care or mobility bars as they were helpful to her/him. There was no documentation in Resident 125's record to indicate the risks verses the benefits of Resident 125's mobility bars were re-evaluated with the resident or her/his representative to determine if they remained appropriate for Resident 125. On 10/05/17 at 8:22 am Staff 2 (DNS) stated Resident 125 had transfer bars on her/his bed and were on the bed when Resident 125 admitted to the facility. Staff 125 acknowledged the mobility bars were not evaluated prior to placing them on Resident 125's bed. On 10/5/17 at 9:41 am Staff 4 (LPN Resident Care Manager) stated Resident 125's mobility bars were on the bed at admission. Staff 4 stated she just learned about the incident on 9/16/17 indicating Resident 125 was injured from a mobility bar. Staff 4 acknowledged the risks versus the benefits of the devices should have been re-evaluated to determine if they remained appropriate for Resident 125. Refer to F225, example 2. 4. Resident 49 was admitted to facility in 6/2016 with [DIAGNOSES REDACTED]. Observation of Resident 49's bed revealed mobility bars on both sides of the bed. The mobility bar on the right side of the bed was loose. On 10/4/17 at 1:24 pm Staff 9 (CNA) stated she was unaware of Resident 49's loose mobility bar. Staff 9 stated if mobility bars were loose or were not functioning properly maintenance would be made aware in the maintenance log at the nurses station. On 10/5/17 at 8:07 am Staff 16 (Maintenance Director) looked at Resident 49 mobility bar and acknowledged it was loose and in need of tightening. Staff 16 stated he was unaware Resident 49's mobility bar was loose. 5. Resident 20 admitted to the facility in 2011 with [DIAGNOSES REDACTED]. On 10/2/17 at 12:33 pm Resident 20 was observed to have bruising on the back of her/his left hand. The resident was observed to have a grab bar adjacent to her/his bed and an overbed table within reach of the resident. No evidence of an assessment or treatment for [REDACTED]. On 10/4/17 at 3:20 pm Staff 19 (RN) stated documentation of skin issues was located in the alert charting book. Staff 19 reviewed the book and stated there was no information about the resident's bruises in the alert charting book. On 10/5/17 at 3:25 pm Staff 4 (LPN Resident Care Manager) was asked about an injury to Resident 20's left hand and stated she would look into it. On 10/6/17 at 9:57 am Staff 4 confirmed the resident had bruising to the back of her/his left hand. Staff 4 acknowledged no assessment or treatment for [REDACTED]. Staff 4 stated she believed the injury was caused by the resident hitting her/his hand on the overbed table on 9/24/17 (12 days prior). Staff 4 acknowledged the investigation was not complete and no new interventions were put in place yet regarding the resident's risk for injury.

Based on observation, interview and record review it was determined the facility failed to ensure residents maintained acceptable parameters of nutritional status for 2 of 4 sampled residents (#s 107 and 112) reviewed for nutrition. This resulted in a severe weight loss from declining food intake due to the facility's failure to assess and address the residents ongoing decline in nutritional status. Findings include: Resident 107 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 107 discharged to the hospital on [DATE] and re-admitted to the facility on [DATE]. The medical record revealed the following weights: July 2017 31st 259 lbs (pounds) August 1st 254 lbs 2nd - 253 lbs 3rd 253 lbs 4th 250 lbs 5th 249 lbs 6th 249 lbs 7th 250 lbs 8th 253 lbs 9th 247 lbs 10th 240 lbs 11th 250 lbs 16th 237 lbs 17th 233 lbs 18th 233 lbs 19th 233 lbs 20th 234 lbs 21st 235 lbs 22nd 234 lbs 23rd 231 lbs 24th 230 lbs 27th 224 lbs 28th 223 lbs 29th 229 lbs 30th 218 lbs 31th 217 lbs September 2017 1st 220 lbs 2nd 215 lbs 3rd 214 lbs 4th 212 lbs 5th 209 lbs 6th 210 lbs 7th 209 lbs 8th 207 lbs 9th 206 lbs 11th 204 lbs 12th 205 lbs 13th 204 lbs 14th 203 lbs 15th 202 lbs 16th 199 lbs 18th 198 lbs 19th 199 lbs 20th 196 lbs 21st 196 lbs 22st 196 lbs 23rd 195 lbs 26th 193 lbs 27th 194 lbs 28th 193 lbs 29th 193 lbs 30th 194 lbs October 2017 1st 192 lbs The 8/1/17 Care Plan indicated inadequate protein and calorie intake related to taste alterations, [MEDICAL CONDITION] and diuretic use. The 8/7/17 Admission MDS Nutritional CAA indicated Resident 107 was at risk for impaired nutrition, weights and meal intake were monitored by staff and the RD. If there were any health concerns or recommendations the physician would be notified and orders requested as appropriate. The 8/29/17 Nutrition Hydration Skin (NHS) committee review indicated the resident had a significant weight loss of 14% since admission. The weight loss was attributed to diuretic medication use and decreased food intake. The plan was to notify the physician of the significant weight change. The care plan was updated on 9/15/17 to reflect a decreased appetite and staff were to monitor and evaluate any weight loss. The 9/15/17 NHS committee review indicated Resident 107 was on [MEDICATION NAME] and [MEDICATION NAME] (fluid removed off of the body through medication), usually ate 25-50% of meals, and her/his appetite was likely affected by medication. The plan was to add cal dense (nutritional supplement) 60 cc twice daily. A 9/30/17 Care Plan indicated the resident had a potential nutritional problem due to dietary restrictions and a decreased appetite. Staff were to provide and serve nutritional supplements as ordered. The Nutrition Monitor for August 2017 and September 2017 revealed variable food intake from 0 to 100%. The 8/2017, 9/2017 and 10/2017 MARs revealed Resident 107 was to be weighed daily and to notify the physician of a weight change equal to or greater than three pounds in two days or greater than five pounds in a week. Review of the medical record indicated no nutritional supplements were ordered or given since admission. No evidence was found to indicate the physician was notified of the weight loss or the RD recommendations. On 10/4/17 at 8:34 am Resident 107 was asleep in bed with the breakfast tray on the bedside table. The food was uncovered and untouched. On 10/4/17 at 11:56 am Resident 107 stated she/he did not eat breakfast that morning because she/he did not like it. Resident 107 acknowledged she/he lost 68 pounds since admission to the facility, due to purposely limiting her/his food intake because the food was bad. Resident 107 further stated when fruit was placed on a hot plate it became hot and unpalatable. Resident 107 stated no staff questioned her/him about the decreased food intake or her/his weight and stated the weight loss was not due to medications or altered taste. On 10/5/17 at 8:24 am Staff 4 (LPN Resident Care Manager) acknowledged the severe, unplanned weight loss of 68 pounds or 25.8%. She stated she would provide information if the weight loss was unavoidable. Staff 4 verified Resident 107 had a real nutritional problem and the plan of care needed to be revised. Staff 4 acknowledged the facility had received RD recommendations for a nutritional supplement which were not followed. Staff 4 stated the facility expected some weight loss with the diuretic use but not 60 pounds. Staff 4 acknowledged the physician was not notified of the weight loss and the facility did not follow-up on the RD recommendations. Staff 4 acknowledged the facility identified the weight loss and impaired nutritional risk in 8/2017. Staff 4 stated she would need to research how the facility addressed the risk factors for the impaired nutritional status, how the facility implemented, monitored or modified the interventions to maintain acceptable parameters of the nutritional status. On 10/5/17 at 9:36 am Staff 8 (RD) stated she recommended adding calorie dense (nutritional supplement) and NEM (nutritionally enhanced meal) interventions on 8/1/17 but the recommendations were not followed. Staff 8 stated Resident 107 was seen by multiple RD's in August and September. The nutritional supplement was again recommended on 9/5/17 and not implemented. Staff 8 stated after the nutrition meetings she would write up the recommendations and give them to the facility. She reviewed her recommendations monthly to see if the facility followed up on them. Staff 8 acknowledged Resident 107 sustained an unplanned severe weight loss. Staff 8 acknowledged the facility did not implement or modify interventions as appropriate to maintain acceptable parameters for the nutritional status. Staff 8 verified Resident 107 lost over 25% of her/his weight since admission and although she/he was on a diuretic medication it would not cause a 68 pounds weight loss in approximately two months. Staff 4 did not provide any additional information to indicate Resident 107's severe weight loss was unavoidable or how the facility addressed the risk factors for the impaired nutritional status, how the facility implemented, monitored or modified the interventions to maintain acceptable parameters of Resident 107's nutritional status. 2. Resident 112 admitted to the facility in 8/2017 with [DIAGNOSES REDACTED]. Resident 112's medical record revealed the following weights which represented a 20 pound or 8.9% loss. 8/17/17: 245 pounds 9/1/17: 243 9/5/17: 240 9/12/17: 225 9/13/17: 225 The 8/29/17 Nutritional Evaluation indicated no significant weight changes. Resident 112 indicated she/he felt she/he was losing weight related to stress and her/his appetite was so-so. Resident 112's food intake did not meet the estimated caloric needs and was at nutritional risk. The document also revealed social services would be alerted to the resident statement of weight loss related to stress. The 9/15/17 nutritional note indicated the resident's weight had declined due to an improvement in the [MEDICAL CONDITION], the resident had junk food by the bed at all times although she/he was diabetic, and her/his CBGs varied from 52-269. The 9/22/17 nutritional note indicated Resident 112's intake did not meet estimated caloric needs and the physician would be notified of the significant weight loss. The medical record did not reveal any notes regarding stress and/or weight loss or social service evaluations regarding stress and weight loss. On 10/4/17 at 8:38 am Resident 112 was asleep in bed. The breakfast tray was on the bedside table next to the bed with less than 10% eaten. On 10/5/17 at 8:12 am Resident 112 was awake in bed. The breakfast tray was on the bedside table with the food untouched. On 10/5/17 at 12:42 PM a CNA removed the lunch tray from Resident 112's room. 10% of the food was eaten. On 10/5/17 at 12:45 pm a test tray revealed a lunch consisting of meat, potato, salad, biscuit and desert. The food appeared unappetizing, the food was bland to taste, the texture was appropriate. On 10/4/17 at 12:34 pm Resident 112 stated she/he was aware of the 20 pounds weight loss in one month. Resident 112 stated the weight loss was a combination of feeling stressed and the food tasting bad. The resident stated she/he limited her/his food intake because of the taste of the food. On 10/4/17 Staff 6 (Social Service Director) stated she was not alerted to Resident 112's statement regarding stress and weight loss and had not addressed this with the resident because she was unaware of the concern. On 10/4/17 Staff 4 stated the RD recommended NEM (nutritionally enhanced meal) on 8/29/17 and the recommendation was not followed-up on with the physician and not implemented. Staff 4 acknowledged Resident 112 lost 20 pounds in less than one month.

Based on findings establishing Substandard Quality of Care and multiple citations in the areas of Resident Assessment, Quality of Care which included Immediate Jeopardy for Resident 108, and Nursing Services, it was determined the management team failed to administer facility resources in an effective and efficient manner. As a result residents did not receive the necessary care and services to attain or maintain their highest practicable physical, mental and psychosocial welling. Findings include: The facility's management team failed to: 1. Provide adequate supervision for cognitively impaired Resident 108 who exhibited exit seeking and elopement behavior. Refer to F-323. 2. Have a functioning system for initiation and timely investigation of a cognitively impaired resident with exit seeking and elopement behavior. Refer to F-226. 3. Ensure behavior monitoring occurred for residents exhibiting behavioral symptoms and receiving psychoactive medications. Refer to F-329. 4. Review and revise the care plan of a cognitively impaired resident who exhibited a pattern of exit seeking and elopement behavior when existing interventions proved ineffective. F-280. 5. To complete admission MDSs within 14 days of admission. Refer to F-273 6. Ensure resident assessments were comprehensive. Refer to F-272. 7. Follow physician orders [REDACTED]. Refer to F-309. 8. Ensure medications administered to residents had indications for use, were monitored for effectiveness, were at the lowest effective dose, were reviewed monthly by a pharmacist and were evaluated for risk versus benefit. Refer to F-154, F-329 and F-428. 9. Provide appropriate care and services for residents with incontinence and indwelling catheters. Refer to F-315. 10. Provide RN services as required. Refer to F-354. 11. Accurately post the numbers of nursing staff working each shift. Refer to F-356.

Based on observation, interview and record review it was determined the facility failed to ensure a resident received adequate supervision for 1 of 2 sampled residents (#108) reviewed for elopement and exit seeking behavior. These failures of staff to implement adequate supervision solutions resulted in Immediate Jeopardy situation and was determined to be Substandard Quality of Care. Findings include: Resident 108 was admitted to the facility in March 2016 with [DIAGNOSES REDACTED]. A review of the resident's Clinical Notes revealed the following events took place: - 4/11/16 1:30 pm: Resident demonstrated intermittent wandering behavior related to disorientation and increased confusion. - 4/16/16 11:48 pm: Resident was alert and confused, very difficult to redirect. Resident had impression that she/he would be going home to live with her/his son and could not grasp the concept that she/he needed to reach specific goals with therapy and be determined safe to live independently. Resident was volatile, had a bad temper, was easily set off by little things and became aggressive. - 4/21/16 2:11 pm: Saint Louis University Mental Status (SLUMS) assessment completed 4/11/16. The SLUMS score of 06 indicated dementia. Cognitive deficits were noted in orientation, short and long term memory, safety awareness, insight, judgement, attention, time and counting. - 4/26/16 11:44 pm: Resident was alert to self and place with short term memory loss noted. Resident had poor impulse and judgement skills. - 5/31/16 at 9:35 am: CNA reported she could not find Resident 108 and had looked for her/him the last 15 minutes. The Executive Director was notified and a message was left for the DNS. Staff started to look in all the rooms, bathrooms, closets and checked around the facility. An LPN went out to drive around the area. At 8:20 am 911 was called. At 8:33 am the LPN called the facility and reported she found the resident approximately three city blocks from the facility. Resident 108 appeared agitated and stated What are you doing here? I am going to see my son. - 6/12/16 at 8:52 pm: Resident 108 was found seated outside the facility. - 6/24/16 at 9:35 am: The facility received a phone call from the local transit authority. Resident 108 rode a bus to the neighboring town. DNS was notified. - 7/4/16 at 2:30 pm: Resident 108 was outside when an LPN came to work. The resident stated she/he would not come in and planned to stay outside. Once inside the resident stated she/he would not escape now but tomorrow was another adventure. - 7/5/16 at 12:43 am: Resident 108 was found outside the facility at the corner of the street pushing her/his wheelchair. Two staff members responded. Resident 108 was physically abusive toward a staff member. Resident 108 attempted to push her/his wheelchair into a car that stopped to assist. - 7/12/16 at 12:04 am: Resident 108 was noted to be at the front door of the facility with pen and paper, copying the exit code to the door. On 7/28/16 at 12:25 pm, Staff 12 (CNA) was observed working on Resident 108's hall. Staff 12 stated she was aware the resident eloped from the building on several occasions. Staff 12 stated she did not receive any direction from facility administration on changes to the resident's care after the elopements. On 7/28/16 12:27 pm, Staff 35 (CNA) was observed working on Resident 108's hall. Staff 35 stated she was aware the resident eloped from the building on several occasions. Staff 35 stated she did not receive any direction from facility administration on changes to the resident's care after the elopements. On 7/28/16 at 12:35 pm, Staff 21 (DNS) stated the resident never eloped from the facility. On 7/28/16 at 12:39 pm, Staff 2 (Executive Director) stated when Resident 108 was first admitted to the facility the resident left the faciity on her/his own. Staff 2 stated the resident started going further from the facility and leaving more often. Resident 108 told staff she/he was going to walk home. Staff 2 stated the resident's cognition was declining. Staff 2 stated the facility changed the code on the front door on approximately 7/12/16 and since then there were no issues with the resident getting out without staff assistance. Staff 2 stated there were no incident reports or investigations completed because the resident was deemed ok to leave independently. Staff 2 could not provide any documentation Resident 108 was assessed to leave the facility independently. Observations made of the facility and its immediate surroundings revealed high traffic roads within blocks of the facility, train tracks and a steep terrain that led to a flowing body of water. On 7/28/16 at 1:55 pm, Witness 11 (Guardian) stated to his knowledge the resident was never safe to leave the facility unsupervised. Witness 11 stated the resident was very crafty and waited until visitors opened the door or asked others for the code to the door. Witness 11 stated the resident's cognition changed from day to day and declined since admission to the facility. Witness 11 stated the resident was not safe to be on her/his own and that was the purpose for placement at the facility. Witness 11 believed he was aware of the times the resident eloped from the facility. The witness stated he was contacted by the police when the resident rode the bus to the neighboring town, and he then informed the facility. Review of Resident 108's care plan effective 3/25/16 revealed the resident demonstrated wandering behaviors related to disorientation and confusion. No information was listed regarding the resident's multiple elopements from the facility. Review of Resident 108's in room care plan dated 6/20/16 revealed no information the resident was at risk for wandering, disorientation, confusion, exit-seeking behavior or elopements from the facility. On 7/28/16 at 11:52 am, Staff 3 (RN Consultant) acknowledged the resident's care plans did not reflect her/his wandering, disorientation, confusion, exit-seeking behavior or elopements from the facility. On 7/28/16 at 3:25 pm after consultation with State survey supervisors, the survey team informed Staff 2, Staff 3 and Staff 21 the failure to ensure Resident 180 received adequate supervision constituted a situation of Immediate Jeopardy to the resident and resulted in Substandard Quality of Care. Staff 2 acknowledged the substandard practices and stated I agree that was wrong. The survey team requested a plan of correction to be developed and implemented by the facility to immediately protect the resident from accidents and elopement. On 7/28/16 at 4:14 pm the plan of correction submitted by the facility was not accepted and corrections were requested. On 7/28/16 at 4:30 pm, a plan of correction was submitted by the facility that ensured the resident's safety from accidents and elopement from the facility. The plan of correction stated: A short term plan has been developed to provide the immediate safety to Resident 180. Resident 180 has been placed on a one on one effective immediately. As a one on one, (she/he) will be kept within line of sight for 24 hours a day by an assigned staff member. A long term safety plan will be developed based on clinical assessment and resident needs. The plan will be reviewed and implemented once approved through the CQI (Continuous Quality Improvement) process with the Executive Director responsible for final implementation. Periodic observations between 3:50 pm and 4:35 pm on indicated Resident 108 received one on one staff supervision. Following review, the plan of correction was accepted by the survey team and the Immediate Jeopardy was abated at 4:35 pm. Periodic observations between 8:00 am and 5:00 pm on 7/29/16 revealed the plan of correction was implemented and Resident 108 had one on one supervision.

Based on interview and record review it was determined the facility failed to provide necessary care and services for 1 of 3 sampled residents (#1) reviewed for falls with injury. The resident fell , sustained a subdural hematoma and died in the local hospital secondary to head injuries. Findings include: Resident 1 was admitted to the facility in [DATE] with [DIAGNOSES REDACTED]. Nursing 2011 Drug Handbook indicated [MEDICATION NAME] was to be used cautiously in residents at risk from increased bleeding from trauma. On [DATE], Staff 1 (Administrator) provided type-written documentation the facility did not have a policy on when to contact Emergency Medical Services. Staff 1 wrote "Each nurse must use their professional clinical judgment to determine there is an emergent situation and need for calling emergency medical services and or the attending physician." The [DATE] Interdisciplinary Progress Notes written at 11:00 pm indicated "Resident returned from [MEDICAL TREATMENT] at approx 4:30 pm. This nurse assisted resident to bed. Resident attempted to climb out of bed and asked to use the phone. Resident told phone was in use but would let her/him use it when it was free. This nurse left room. Resident was found standing next to bed, tab alarm was sounding. CNA and nurse put resident back to bed, approximately 5 minutes later, resident found laying (sic) on floor on the floor at the foot of her/his bed-unresponsive. PCP (primary care physician) called and gave orders to monitor. Upon family request resident was sent to (local hospital)...." On [DATE], Witness 5 (former LPN) completed an event investigation questionnaire to indicate after the fall she was not able to arouse the resident. Witness 5 documented she was saying the resident's name and was trying to get resident to respond and the resident was non-responsive. Witness 5 indicated the resident had a 2 by 1.5 cm bump on the posterior of her/his head. Witness 5 documented neuro checks were started (neuro checks are an assessment made by a medical professional on someone with a head injury. Neuro checks could consist of level of consciousness, alert and oriented and compare with the resident's baseline, speech clarity, facial symmetry tongue midline, grasp strength, pupil check- PERRLA-equal, round, react to light and accommodation. Immediate medical attention if the resident had poor mental alertness, abnormal walking, abnormal balance, abnormal behavior, abnormal pupils, abnormal speech, abnormal thinking, decreased strength in the arms and legs) and the resident's vital signs were within normal limits. The [DATE] Event Investigation Report completed by Witness 5 (former LPN) indicated Resident 1 fell in her/his room at 5:00 pm. Witness 7 (on-call physician) was notified at 5:30 pm and requested the facility continue to monitor the resident and conduct neuro checks. Witness 3 (family member) was called at 5:45 pm and requested the resident be transported to the local hospital emergency department. Witness 7 was informed of the family's request and ordered emergency transport. There was no documentation of neuro checks conducted for Resident 1 on [DATE] until the facility provided a neuro check flow sheet on [DATE]. There was no documentation the resident's neuro checks were done at the time of the fall and before the resident was transferred into bed. The neuro check flow sheet was started at 5:20 pm on [DATE] by Staff 2 (DNS). Staff 2 documented "the resident was in bed, eyes open, alert answers yes-no, simple statement. Accepting of water with intake with assistance. Denies...feeling dizzy. Appears comfortable...PERRL normal-right and left grasp equal. Left sided weakness with [MEDICAL CONDITION]." The [DATE] Investigator's Interview/Statement of event written by Staff 2 (DNS) indicated Staff 2 knew Resident 1 fell and the resident was lying in bed on her/his back. Staff 2 "felt a 2 by 1.5 cm (high) bump to posterior head. Res. (Resident) was alert and words were not clear. Did accept H2O and took two sips without trouble ...." Staff 2 wrote the resident was not her/his usual self and went to report to the charge nurse. Staff 2 indicated Witness 5 (former LPN) was on the phone with the resident's family and they requested the resident be evaluated at the local hospital emergency department. The [DATE] local ambulance report indicated the facility called for emergency transportation at 6:03 pm and the ambulance was at the facility at 6:10 pm. The ambulance report indicated the resident squeezed her/his eyes shut with painful stimulus. The resident resisted manual efforts to open her/his eyelids though when her/his eyes were opened the resident's eyes were moving and looking around. In response to an ammonia inhalant the resident groaned and attempted to turn her/his head away. The resident's pupils were equal, round and reactive though somewhat sluggish. The resident was assessed to have a large egg-sized hematoma over her/his occipital region. Resident 1 was placed in the trauma system based on ground level fall, use of blood thinners and altered level of consciousness. The report indicated when the resident was being unloaded at the local hospital the resident opened her/his eyes spontaneously but was unable to answer questions. The local hospital [DATE] trauma note indicated "6:50 pm-resident arrived via local ambulance service, on stretcher with full spine precautions ...Pt (Patient) not responsive. Initial observation of spontaneous extremity movement are none ..." The [DATE] local hospital trauma admission history and physical indicated the resident was transported to the local hospital emergency department for evaluation and management. "On arrival, she/he was reportedly able to answer questions though not completely oriented. Denied pain, abdomen was soft, chest x-ray unremarkable. However she/he had difficulty cooperating with the plan of care and the decision was made to intubate her/him to facilitate workup and treatment ....Patient was evaluated in the emergency department ...and found to have multiple bilateral subdural and subarachnoid hemorrhages ...she/he was admitted to the ICU ...." The local hospital Discharge/Death Summary indicated the resident died at the local hospital on [DATE] and the cause of death was from a fall with subsequent bilateral subdural hematoma and subarachnoid hemorrhage with severe [MEDICAL CONDITION]. The Facility's [DATE] Event Investigation Final Summary for the [DATE] incident signed by Staff 1 (Administrator) Staff 2 (DNS) and Witness 6 (Former RNCM) indicated the resident appeared "alert with no expression and then confused during assessment. The resident did not respond to or answer any questions. Completing range of motion there was noted stiffness to the resident's lower extremity joints though no verbal or non-verbal indicators of pain, vital signs were taken and the resident was assessed for physical injury. A raised bump approximately 2 by 1.5 cm to her/his posterior right head was noted. The resident was assisted back to bed...." On [DATE] at 4:30 pm Witness 5 (former LPN) stated she was informed by Staff 3 (CNA) Resident 1 was on the floor. Witness 5 stated the resident hit her/his head so she started neuro checks and at first the resident was unresponsive. Witness 5 stated the facility staff conducted neuro checks every ,[DATE] minutes. Witness 5 stated the documentation of the neuro checks would be in the nurses notes. Witness 5 stated the on-call physician was called and directed Witness 5 to monitor the resident. Witness 5 stated the resident was assisted into bed. Witness 5 stated the resident had a "knot on her/his head." The resident was not bleeding and had no other injury. Witness 5 stated the resident was able to drink a few sips of water. Witness 5 stated she called Witness 3 (family member) at 5:45 pm and Witness 3 wanted the resident to be evaluated by the local hospital emergency department. Witness 5 called the local ambulance at 6:00 pm. Witness 5 stated it was an hour from the time the resident fell until the ambulance was called. On [DATE] at 4:45 pm Staff 3 (CNA) stated on the evening of [DATE] she heard the resident's alarm sounding and found Resident 1 on the floor. Staff 3 stated the resident did not respond to her and Staff 3 was concerned because the resident had a "knot" on the back of her/his head. Staff 3 indicated Witness 5 (former LPN) was the charge nurse and Witness 6 (former RNCM) was in the resident's room. Staff 3 stated Witness 6 checked Resident 1's pupils and the resident was not communicating with the staff. Staff 3 stated she was very concerned why the resident wasn't sent to the local hospital immediately because of the resident's head injury. Staff 3 stated she asked Witness 6 (former RNCM) about the situation. Staff 3 stated Witness 6 stated she conducted neuro checks and determined the resident had no visible signs of a concussion. Staff 3 stated the nurses continued to conduct neuro checks. Staff 3 stated she stayed with the resident after the fall and Resident 1 continued not to respond to her when lying in bed. Staff 3 stated the resident's eyelids were closed though her/his eyes were "fluttering" under the eye lids. Staff 3 stated the resident fell around 5:00 pm and the resident was transported to the local hospital around 6:00 pm. Staff 3 stated she did not offer the resident any fluids and could not remember the resident drinking any fluids. Staff 3 stated Staff 4 and 5 (CNAs) assisted with the resident's transfer from the floor to the bed. On [DATE] at 4:50 pm Staff 4 (CNA) stated on [DATE] she assisted with Resident 1's transfer from the floor to the bed. Staff 4 stated the resident did not respond to her though the nurses stated her/his pupils were responding and she/he was communicating. Staff 4 stated she did not observe the resident communicating with the nurses. Staff 4 stated she remembered the resident had a bump on the back of her/his head. On [DATE] at 5:10 pm Staff 5 (CNA) stated on [DATE] she had just finished her lunch break and saw Resident 1 on the floor. Staff 5 stated she assisted with the resident's transfer from the floor to the bed the resident's eyes were closed and she/he did not respond when the staff tried to talk with her/him. Staff 5 stated Staff 6 (LPN/admissions coordinator) talked with the resident in Spanish to attempt to elicit a response. On [DATE] at 7:30 pm Witness 2 (family member) stated the family wanted to know what happened when the resident fell . Witness 2 stated Witness 3 (family member) was called by the facility on the evening of [DATE] and was informed of the resident's fall. The facility stated the physician recommended the resident be monitored at the facility. Witness 3 asked the facility to send the resident to the local hospital emergency department for an evaluation. Witness 2 questioned why the resident wasn't sent to the local hospital emergency department after the fall with head injury because the resident received [MEDICATION NAME]. Witness 3 (family member) reported the facility staff stated the resident was awake and drinking fluids. Witness 2 (family member) stated the physicians at the local hospital told the family the resident was not able to drink fluids when the resident was admitted to the local hospital. On [DATE] at 10:04 am and 4:18 pm Staff 6 (LPN/Admissions coordinator) stated on [DATE] a CNA came out of Resident 1's room and asked for her assistance. Staff 6 stated she tried to talk with the resident in English and Spanish and she/he was not responding to her Staff 6 stated Witness 5 (former LPN) and Witness 6 (former RNCM) were in the room and the resident was not responding to the staff. On [DATE] at 10:27 am Witness 3 (family member) stated the facility called on [DATE] and reported Resident 1 fell at the facility. Witness 3 stated the nurse said the resident was "OK" and the physician told the facility staff to monitor him. Witness 3 stated she told the nurse "No, I want her/him seen at the Emergency Department." Witness 3 stated she did not live far from the local hospital and by the time Witness 3 saw Resident 1 she/he was in a coma. Witness 3 questioned why the resident was not sent immediately to the local hospital emergency department after the fall. On [DATE] at 11:47 am Witness 6 (former RNCM) stated Witness 5 (former LPN) contacted her about Resident 1's fall. Witness 6 stated both Witness 5 and 6 conducted a head to toe assessment of the resident. Witness 6 stated the resident's room-mate at the time indicated the resident fell on the floor and hit her/his head. Witness 6 stated they noticed a lump on the back of the resident's head and the resident was not responding. Witness 6 stated three minutes later the resident appeared to be responding better. Witness 6 stated the resident was not bleeding and her/his neuro checks were within normal limits. Witness 6 was asked where the documentation for the neuro checks would be located. Witness 6 stated the neuro checks were documented in the nursing notes or on the neuro check worksheet. Witness 6 stated the resident did not appear to be knocked out and her/his eyes were responding. Witness 6 stated when the resident's eyes were closed her/his eyes were blinking under the eye lids. Witness 6 stated the staff assisted the resident into bed and put a perimeter mattress in place. Witness 6 stated Staff 2 (DNS) was at the facility when the incident occurred and also assessed the resident. Witness 6 stated she made sure Witness 5 (former LPN) informed the physician of the incident and the physician indicated the staff was to monitor the resident in the facility. Witness 6 stated when Witness 5 called the resident's family and they requested the resident be evaluated at the local hospital emergency department. Witness 6 stated the resident was responding to her questions. Witness 6 was asked what questions she asked the resident and the resident's responses. Witness 6 stated the resident was able to answer yes or no answers to questions regarding pain and discomfort. Witness 6 was asked if there would be any different approaches regarding the resident's head injury and the use of [MEDICATION NAME]. Witness 6 stated "no" the resident was not bleeding and was answering appropriately. Witness 6 stated she had not documented her involvement and assessment of the resident on [DATE]. On [DATE] at 1:16 pm Staff 2 (DNS) stated on [DATE] she had been out of the facility and when she returned to the facility she learned the resident fell . Staff 2 stated she did not conduct an assessment of the resident at the time of the incident though she knew the resident fell and looked at different fall interventions. Staff 2 stated when she was in the resident's room she observed the resident to be lying in bed and was alert. Staff 2 stated she asked the resident if she/he wanted water and the resident said "yes." Staff 2 stated the resident was able to drink the water. Staff 2 was not aware Witness 6 (former RNCM) was in the resident's room after the incident. Staff 2 was asked about the resident's neuro checks and she stated Witness 5 (former LPN) documented the neuro checks were started. Staff 2 was not able to locate documentation of neuro checks conducted. Staff 2 (DNS) stated Witness 3 (family member) indicated the resident had episodes of unresponsiveness with a "glass-like" face. Staff 2 was asked if Witness 7 (on-call physician) was aware the resident was on [MEDICATION NAME] when Witness 5 (former LPN) called about the fall with injury. Staff 2 stated Witness 7 knew the medications the resident was on when informed of the fall. On [DATE] at 3:00 pm Witness 7 (on-call physician) stated he remembered the facility calling him regarding Resident 1's fall. Witness 7 was not aware of the documentation the resident was unresponsive. Witness 7 stated the facility informed him the resident's neuro checks were within normal limits and the facility was going to continue with the neuro checks. Witness 7 stated he would expect the facility staff to document the results of the neuro checks. Witness 7 was asked what would need to be included in the neuro check documentation and he stated he would expect documentation of level of consciousness, if the resident was rousable and pupil check (equal, round, react to light and accommodation). Witness 7 stated he had not been informed by the facility the resident received [MEDICATION NAME]. Witness 7 stated he would have ordered emergency transport immediately if he would have known the resident was on [MEDICATION NAME] and was unresponsive. There was no documentation of neuro checks conducted for Resident 1 on [DATE] until the facility provided a neuro check flow sheet on [DATE]. There was no documentation the resident's neuro checks were done at the time of the fall and before the resident was transferred from the floor into bed. The first entry on the neuro check flow sheet was at 5:20 pm on [DATE] by Staff 2 (DNS). Staff 2 documented "the resident was in bed, eyes open, alert answers yes-no, simple statement. Accepting of water with intake with assistance. Denies...feeling dizzy. Appears comfortable...PERRL normal-right and left grasp equal. Left sided weakness with [MEDICAL CONDITION]." The neuro check flow sheet contained evidence of neuro checks conducted at 5:30 pm and 5:45 pm by Staff 2 (DNS). The documentation indicated the resident was alert, pupils were equal and reactive to light, hand grasps were equal and appropriate pain response. The facility provided a type-written statement, dated [DATE] and signed by Witness 5 (Former LPN), to indicate on "[DATE]" at 5:10 pm Witness 5 was informed Resident 1 was on floor and unresponsive. Witness 5 documented she found the resident on the floor at the foot of the bed, flat on her/his back. Witness 5 called out the resident's name and asked the resident if she/he was OK and proceeded to start neuro checks on the resident. Witness 5 documented the resident became responsive and was trying to talk. Witness 6 (Former RNCM) was also in the room and guiding Witness 5 through the neuro checks. Witness 5 documented the resident's pupils were round and equal and reactive to light. Resident 1 showed no signs of pain when her/his limbs and neck were moved, her/his grips were equal and her/his vitals were stable. Witness 5 documented she called the on-call physician and informed the physician the resident fell , hit her/his head, provided verbal list of medications, including [MEDICATION NAME]. Witness 5 explained the resident's current condition, that she/he was responsive, her/his vitals were stable and neuro checks were started and would be done every 15 minutes for the first hour. Witness 5 documented the resident was responsive, taking sips of water and appeared to be OK, with no complaints of pain, while being moved around when the scoop mattress was being changed by Staff 2 (DNS). Staff 2 transcribed the neuro checks to the neuro check flow sheet for Witness 5 (Former LPN). The facility provided a type-written statement, dated [DATE] and signed by Staff 2 (DNS), to indicate Staff 2 (DNS) returned to the facility at 5:20 pm and was informed of Resident 1's fall. Staff 2 indicated she went to the resident's room and Staff 3 (CNA) was present. Staff 2 documented she went to the resident's bedside, completed a neurological check. After assessing the resident for the fall occurrence Staff 2 evaluated her/his fall interventions and decided to place a perimeter mattress to provide boundary identification for Resident 1. Staff 3 (CNA) stayed with the resident and Staff 2 went to the storage shed to obtain a perimeter mattress for the resident's bed. Staff 2 documented Resident 1 "stood up with two person assist and I switched out the perimeter mattress ...At approximately 5:50 pm at the nurse's station, I looked for the neuro-sheet to document and as I did not see the sheet, I initiated the sheet, documented on the back my initial assessment at 5:20 pm ...." On [DATE] at 11:46 am Witness 5 (Former LPN) was asked why the documentation on [DATE] in the Interdisciplinary Progress Notes and the Incident Investigation indicated the resident was non-responsive and the documentation dated [DATE] indicated the resident was responsive. Witness 5 stated the documentation at the time of the incident pertained to when the resident was found on the floor and Witness 5 stated the resident "came to" and responded to Witness 5. Witness 5 stated Witness 6 (Former RNCM) was in the room also and assessed the resident. Witness 5 stated she could not remember if neuro checks were done when the resident was moved from the floor to the bed. On [DATE] at 1:28 pm Staff 1 (Administrator) called to state Witness 5 (Former LPN) called him about the interview on 11:46 am. Staff 1 stated there was additional documentation of Witness 5's investigation interview regarding Resident 1's responsiveness and Staff 1 requested to submit the information. On [DATE] an [DATE] Event Investigation Charge Nurse Interview signed by Witness 5 (Former LPN) had a question "What did the resident tell you? (Ask the resident what occurred)." There was a statement written by Witness 5 to indicate the resident was "unresponsive." On the document the word "unresponsive" had a line written through it and the documentation indicated "Res (Resident) was alert with blank kind of look, no SOB (shortness of breath), did not answer questions ...." On [DATE] at 1:10 pm Staff 2 (DNS) was asked about the change in the Event Investigation Charge Nurse Interview documentation. Staff 2 stated she drew a line through the statement of "unresponsive" and added the documentation after she interviewed Witness 5 (Former LPN) on the evening of [DATE]. Staff 2 verified she did not sign or date the form. Staff 2 was asked why she did not indicate she conducted neuro checks of the resident during previous interviews. Staff 2 stated she did not consider herself involved in the assessment of the resident. Staff 2 stated she documented on the neuro check flowsheet at 5:20 pm and transcribed Witness 5's (Former LPN) documentation onto the neuro check flowsheet. Staff 2 stated she considered the neuro checks as part of Witness 5 (Former LPN) documentation. Resident 1 was admitted to the facility in [DATE] and received [MEDICATION NAME]. On [DATE] at 5:00 pm, Resident 1 fell on the floor and hit her/his head. There was no documentation of neuro checks conducted at the time of the fall and before the resident was transferred into bed. On [DATE] at 5:30 pm Witness 7 (on-call physician) was contacted by the facility. There was no documentation the facility accurately conveyed the resident's condition to Witness 7 and resulted in a delay of transport to the local hospital emergency department.

Based on interview and record review it was determined the facility staff failed to document an assessment, document a late entry in a timely manner and changed documentation without proper identification for 1 of 3 sampled residents (#1) who were reviewed for falls with injury. The resident fell , sustained a subdural hematoma and died in the local hospital secondary to head injuries. Findings include: The State Board of Nursing-Scope of Practice Standards for Registered Nurses: [DATE] (1) The Board recognizes that the scope of practice for the registered nurse encompasses a variety of roles, including but not limited to: (a) Provision of client care; (b) Supervision of others in the provision of care; (2) Standards related to the Registered Nurse's responsibility for nursing practice implementation...the Registered Nurse shall: (a) Conduct and document initial and ongoing comprehensive and focused nursing assessments of the health status of clients by: (A) Collecting objective and subjective data from observations, examinations, interviews, and written records in an accurate and timely manner as appropriate to the client's health care needs and context of care; (B) Distinguishing abnormal from normal data, sorting, selecting, recording, analyzing, synthesizing and reporting the data; (C) Detecting potentially inaccurate, incomplete or missing client information and reporting as needed; (D) Anticipating and recognizing changes or potential changes in client status;identifying signs and symptoms of deviation from current health status; and (E) Validating data by utilizing available resources, including interactions with the client and health team members. (b) Establish and document nursing diagnostic statements and/or reasoned conclusions which serve as the basis for the plan or program of care. (c) Develop and coordinate a comprehensive and/or focused plan of nursing care. The State Board of Nursing-Conduct Derogatory to the Standards of Nursing Defined [DATE] Nurses, regardless of role, whose behavior fails to conform to the legal standard and accepted standards of the nursing profession, or who may adversely affect the health, safety, and welfare of the public, may be found guilty of conduct derogatory to the standards of nursing. Such conduct shall include, but is not limited to, the following: (3) Conduct related to communication:(a) Inaccurate recordkeeping in client or agency records.(b) Incomplete recordkeeping regarding client care; including, but not limited, to failure to document care given or other information important to the client's care or documentation which is inconsistent with the care given ... (g) Failing to maintain client records in a timely manner which accurately reflects management of client care, including failure to make a late entry within a reasonable time period. (h) Failing to communicate information regarding the client's status to members of the health care team (physician, nurse practitioner, nursing supervisor, nurse coworker) in an ongoing and timely manner.... Resident 1 was admitted to the facility in [DATE] with [DIAGNOSES REDACTED]. The [DATE] Interdisciplinary Progress Notes written at 11:00 pm by Witness 5 (Former LPN) indicated "Resident returned from [MEDICAL TREATMENT] at approx 4:30 pm. This nurse assisted resident to bed. Resident attempted to climb out of bed and asked to use the phone. Resident told phone was in use but would let her/him use it when it was free. This nurse left room. Resident was found standing next to bed, tab alarm was sounding. CNA and nurse put resident back to bed, approximately 5 minutes later, resident found laying (sic) on the floor at the foot of her/his bed-unresponsive. PCP (personal care physician) called and gave orders to monitor. Upon family request resident was sent to (local hospital)...." On [DATE], Witness 5 (former LPN) completed an event investigation questionnaire to indicate after the fall she was not able to arouse the resident. Witness 5 documented she was saying the resident's name and was trying to get the resident to respond and the resident was non-responsive. Witness 5 indicated the resident had a 2 by 1.5 cm bump on the posterior of her/his head. Witness 5 documented neuro checks were started (neuro checks are an assessment made by a medical professional on someone with a head injury. Neuro checks could consist of level of consciousness, alert and oriented and compare with the resident's baseline, speech clarity, facial symmetry tongue midline, grasp strength, pupil check- PERRLA-equal, round, react to light and accommodation. Immediate medical attention if the resident had poor mental alertness, abnormal walking, abnormal balance, abnormal behavior, abnormal pupils, abnormal speech, abnormal thinking, decreased strength in the arms and legs) and the resident's vital signs were within normal limits. The [DATE] Event Investigation Report completed by Witness 5 (former LPN) indicated Resident 1 fell in her/his room at 5:00 pm. Witness 7 (on-call physician) was notified at 5:30 pm and requested the facility continue to monitor the resident and conduct neuro checks. Witness 3 (family member) was called at 5:45 pm and requested the resident be transported to the local hospital emergency department. Witness 7 was informed of the family's request and ordered emergency transport The local hospital [DATE] trauma note indicated "6:50 pm-resident arrived via local ambulance service, on stretcher with full spine precautions ...Pt (Patient) not responsive. Initial observation of spontaneous extremity movement are none ...." The [DATE] local hospital trauma admission history and physical indicated the resident was transported to the local hospital emergency department for evaluation and management. "On arrival, she/he was reportedly able to answer questions though not completely oriented. Denied pain, abdomen was soft, chest x-ray unremarkable. However she/he had difficulty cooperating with the plan of care and the decision was made to intubate her/him to facilitate workup and treatment ....Patient was evaluated in the emergency department ...and found to have multiple bilateral subdural and subarachnoid hemorrhages ...she/he was admitted to the ICU ...." The local hospital Discharge/Death Summary indicated the resident died at the local hospital on [DATE] and the cause of death was from a fall with subsequent bilateral subdural hematoma and subarachnoid hemorrhage with severe [MEDICAL CONDITION]. On [DATE] at 4:30 pm Witness 5 (former LPN) stated she was informed by Staff 3 (CNA) Resident 1 was on the floor. Witness 5 stated the resident hit her/his head so she started neuro checks and at first the resident was unresponsive. Witness 5 stated the facility staff conducted neuro checks every ,[DATE] minutes. On [DATE] at 4:45 pm Staff 3 (CNA) stated on the evening of [DATE] she heard the resident's alarm sounding and found Resident 1 on the floor. Staff 3 stated the resident was not responding to her and Staff 3 was concerned because the resident had a "knot" on the back of her/his head. Staff 3 indicated Witness 5 (former LPN) was the charge nurse and Witness 6 (former RNCM) was in the resident's room. Staff 3 stated Witness 6 checked Resident 1's pupils and the resident was not communicating with the staff. Staff 3 stated she was very concerned why the resident wasn't sent to the local hospital immediately because of the resident's head injury. Staff 3 stated she asked Witness 6 (former RNCM) about the situation. Staff 3 stated Witness 6 stated she conducted neuro checks and determined the resident had no visible signs of a concussion. There was no documentation in the resident's record of Witness 6's (former RNCM) assessment of the resident on [DATE]. On [DATE] at 11:47 am Witness 6 (former RNCM) stated Witness 5 (former LPN) contacted her about Resident 1's fall. Witness 6 stated both Witness 5 and 6 conducted a head to toe assessment of the resident. Witness 6 stated the resident's room-mate at the time indicated the resident fell on the floor and hit her/his head. Witness 6 stated they noticed a lump on the back of the resident's head and the resident was not responding. Witness 6 stated three minutes later the resident appeared to be responding better. Witness 6 stated the resident was not bleeding and her/his neuro checks were within normal limits. Witness 6 was asked where the documentation for the neuro checks would be located. Witness 6 stated the neuro checks were documented in the nursing notes or on the neuro check worksheet. Witness 6 stated the resident did not appear to be knocked out and her/his eyes were responding. Witness 6 stated when the resident's eyes were closed her/his eyes were blinking under the eye lids. Witness 6 stated the staff assisted the resident into bed and put a perimeter mattress in place. Witness 6 stated Staff 2 (DNS) was at the facility when the incident occurred and also assessed the resident. Witness 6 stated she made sure Witness 5 (former LPN) informed the physician of the incident and the physician indicated the staff was to monitor the resident in the facility. Witness 6 stated when Witness 5 called the resident's family and they requested the resident be evaluated at the local hospital emergency department. Witness 6 stated the resident was responding to her questions. Witness 6 was asked what questions she asked the resident and the resident's responses. Witness 6 stated the resident was able to answer yes or no answers to questions regarding pain and discomfort. Witness 6 was asked if there would be any different approaches regarding the resident's head injury and the use of [MEDICATION NAME]. Witness 6 stated "no" the resident was not bleeding and was answering appropriately. Witness 6 stated she had not documented her involvement and assessment of the resident on [DATE]. There was no documentation of neuro checks conducted for Resident 1 on [DATE] until the facility provided a neuro check flow sheet on [DATE]. There was no documentation the resident's neuro checks were done at the time of the fall and before the resident was transferred from the floor into bed. The first entry on the neuro check flow sheet was at 5:20 pm on [DATE] by Staff 2 (DNS). The facility provided a type-written statement dated [DATE] and signed by Witness 5 (Former LPN) to indicate on "[DATE]" at 5:10 pm Witness 5 was informed Resident 1 was on floor and unresponsive. Witness 5 documented she found the resident on the floor at the foot of the bed, flat on her/his back. Witness 5 called out the resident's name and asked the resident if she/he was OK and proceeded to start neuro checks on the resident. Witness 5 documented the resident became responsive and was trying to talk. Witness 6 (Former RNCM) was also in the room and guiding Witness 5 through the neuro checks. Witness 5 documented the resident's pupils were round and equal and reactive to light. Resident 1 showed no signs of pain when her/his limbs and neck were moved, her/his grips were equal and her/his vitals were stable. Witness 5 documented the resident was responsive, taking sips of water and appeared to be OK, with no complaints of pain, while being moved around when the scoop mattress was being changed by Staff 2 (DNS). Staff 2 transcribed the neuro checks to the neuro check flow sheet for Witness 5 (Former LPN). On [DATE] at 11:46 am Witness 5 (Former LPN) was asked why the documentation on [DATE] in the Interdisciplinary Progress Notes and the Incident Investigation indicated the resident was non-responsive and the documentation dated [DATE] indicated the resident was responsive. Witness 5 stated the documentation at the time of the incident pertained to when the resident was found on the floor and Witness 5 stated the resident "came to" and responded to Witness 5. Witness 5 stated Witness 6 (RNCM) was in the room also and assessed the resident. Witness 5 stated she could not remember if neuro checks were done when the resident was moved from the floor to the bed. On [DATE] at 1:28 pm Staff 1 (Administrator) called to state Witness 5 (Former LPN) called him about the interview on 11:46 am. Staff 1 stated there was additional documentation of Witness 5's investigation interview regarding Resident 1's responsiveness. On [DATE] an [DATE] Event Investigation Charge Nurse Interview signed by Witness 5 (Former LPN) had a question "What did the resident tell you? (Ask the resident what occurred)." There was a statement written by Witness 5 to indicate the resident was "unresponsive." On the document the word "unresponsive" had a line written through it and there was hand-written documentation to indicate "Res (Resident) was alert with blank kind of look, no SOB (shortness of breath), did not answer questions ...." On [DATE] at 1:10 pm Staff 2 (DNS) was asked about the change in documentation on the Event Investigation Charge Nurse Interview form. Staff 2 stated she drew a line through the statement of "unresponsive" and added the documentation after she interviewed Witness 5 (Former LPN) on the evening of [DATE]. Staff 2 verified she did not sign or date the form. Refer to F-309.

Based on interviews and record review it was determined the facility failed to ensure that unclear admission orders [REDACTED]. Resident 1 was repeatedly moved and experienced prolonged unrelieved pain. Findings include: Review of the Scope of Practice Standards for Registered Nurses [PHONE NUMBER] "(1)...(a) Advocates for the client's right to receive appropriate care, including person centered care and end-of-life care, considerate of the client's needs, choices and dignity...(6)(f) Has the authority and responsibility to question any order or recommendation which is not clear, perceived as unsafe or contraindicated for the client..." Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital Nursing Facility Transfer Form dated 4/25/11 indicated the resident had a pelvic fracture and "weight bearing status/limitations and ambulate w/assistance." No other information was documented on the hospital transfer form related to the resident's ambulation and weight bearing. The form noted the resident was to follow up with the primary care physician in 3 days. Emergency Department notes dated 4/25/11 at 6:15 pm indicated a one person transfer was attempted with the resident but the resident became too painful and was unable to bear weight on her/his legs. The resident became weak and needed to be basket lifted back into bed. A fax dated 4/25/11 was sent to the resident's physician with the hospital admission orders [REDACTED]. The physician could select that the resident does not need to be seen, to see the resident and a time frame or to have the house doctor follow the resident. Resident 1's physician selected "have house physician follow." There were no additional information documented on the fax nor were any additional faxes located in the resident's record. A NN dated 4/25/11 at 10:00 pm indicated the resident was admitted by Staff 9 (RN) to the nursing facility from the emergency room . The resident was noted to be alert and oriented. The resident was assisted with two staff to the commode with increased pain with movement, "seems to be afraid of taking steps." NN Physical Therapy (PT) entry dated 4/26/11 indicated the resident required maximum assist of two for transferring from the wheelchair to the bedside commode. Staff 3 (PT) indicated while working with the resident she heard a loud cracking, popping (crepitus). The RNCM was notified and ambulation held until a physician order [REDACTED]. Additional NNs dated 4/26/11 indicated Witness 3 (Physician) was contacted regarding the admission orders [REDACTED]. NN at 11:58 am indicated the resident rated her/his pain as a 9 out of 10, "significant...awaiting return call." A NN dated 4/27/11 indicated the resident would be seen by the orthopedist on May 2nd. No other information was noted in the NN to show a response had been received to clarify the resident's weight bearing and ambulation status. Interviews on 6/1/11 between 2:30 & 4:30 pm with Staff 5, 6 and 7 (CNAs) indicated the resident was alert and oriented with periods of confusion. The Staff indicated the resident showed a lot of pain whenever moved but seemed to do better once she/he was still. The Staff further indicated the resident rarely would ask for pain medication and most of the time would not verbalize the pain. Staff 6 & 7 stated the resident would get up in the wheelchair for meals and on many occasions would be transferred for toileting needs as well. Staff 5 stated the staff would remind the resident they needed to reposition her/him to keep her/him from getting bedsores. The Staff further indicated the resident would usually agree but it was obvious from her/his facial expressions that she/he was in pain while being positioned. In an interview on 6/1/11 Staff 2 (DNS) indicated she was not sure why the resident's orders had not been clarified sooner. In an interview on 6/2/11 at 8:33 am Staff 9 (RN) indicated she could not remember admitting the resident. Staff 9 indicated if the admission orders [REDACTED]. Staff 9 was not sure why she did not clarify the orders Refer to F-309

Based on observations, interviews and record review it was determined the facility failed to ensure a resident's care plan reflected pain management needs, accurate weight bearing and transfer status and assess and administer pain medications to maintain the resident's comfort for 1 of 3 sampled residents (#1). Resident 1 experienced prolonged unrelieved pain. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital Nursing Facility Transfer Form dated 4/25/11 indicated the resident had a pelvic fracture and "weight bearing status/limitations and ambulate w/assistance." No other information was documented on the hospital transfer form related to the resident's ambulation and weight bearing. The form noted the resident was to follow up with the primary care physician in 3 days. Emergency Department notes dated 4/25/11 at 6:15 pm indicated a one person transfer was attempted with the resident but the resident became too painful and was unable to bear weight on her/his legs. The resident became weak and needed to be basket lifted back into bed. A NN dated 4/25/11 at 10:00 pm indicated the resident was admitted by Staff 9 (RN) to the nursing facility from the emergency room . The resident was noted to be alert and oriented. The resident was assisted with two staff to the commode with increased pain with movement, "seems to be afraid of taking steps." Additional NNs dated 4/26/11 indicated Witness 3 (Physician) was contacted regarding the admission orders [REDACTED]. NN at 11:58 am indicated the resident rated her/his pain as a 9 out of 10, "significant...awaiting return call." The resident's in room care plan dated 4/25/11 indicated the resident had a pelvic fracture, was a fall risk, occasionally confused and used a walker and a wheelchair. The care plan further indicated the resident had full weight bearing status, required one or two person assistance for transfers and bed mobility and required one person assistance for toileting. No information regarding the resident's pain management and interventions were documented on the care plan. The resident's initial chart care plan indicated the resident had a pelvic fracture. Interventions included pain monitor prn, assess for effectiveness quarterly and prn, notify physician prn, follow bedside care plan and offer diversional activity. There was no additional information documented about the resident's specific pain needs. In an interview on 5/16/11 at 10:45 am and on 6/1/11 at 10:10 am Witness 2 (Complainant) indicated the resident had been repeatedly moved while at the facility without sufficient pain control. Witness 2 further indicated the resident was not persistently in pain; when the resident was still the pain seemed to subside. However, whenever the resident was moved to be toileted, transferred or bed linens changed she/he would cry out in pain. Witness 2 indicated the resident would cry out, yell and scream when moved. The resident was sent to the facility with an order for [REDACTED]. Witness 2 had declined to have the resident be seen by the physician and orthopedist on 4/26/11 as the resident had just been seen the day before in the emergency room and travel was painful for the resident. According to Witness 2 until Hospice began to see the resident the pain was not well controlled with movement. The resident was lucid with moments of confusion. NNs from 4/25/11 through the morning of 4/30/11 showed the resident was up for meals, bathing and some therapy. The resident was also noted to have some pain on three occasions. NNs beginning in the evening of 4/30/11 indicated the resident was resting in bed and pain medications were given every 4 hours as well as pre-medicating before any movement with the additional medication of [MEDICATION NAME]. The resident passed away on 5/1/11. The resident's April 2011 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The resident was treated with 2 tablets of Tylenol w/[MEDICATION NAME] once on 4/27/11 & once on 4/28/11. The resident's MAR indicated [REDACTED]. The Tylenol w/[MEDICATION NAME] order was changed on 4/30/11 to 2 tablets every 4 hours. There were no refusals documented on the April 2011 MAR. As of 5/1/11 Hospice added the additional orders for [MEDICATION NAME] as needed for pain and for pre medication 1 hour prior to moving the resident. The May 2011 MAR indicated [REDACTED]. Interviews conducted on 6/1/11 between 2:30 pm and 4:35 pm showed: Staff 3 (PT) and Staff 4 (PT Assistant) indicated the resident was seen by PT a few times while at the facility. Staff 3 indicated the resident was alert but "very painful." Staff 3 indicated she worked on only a few things with the resident related to transfers from the bed and the commode. Staff 3 and Staff 4 stated they did not have the resident work on ambulation, but did more of a stand pivot transfer with some weight bearing primarily on the strong side. Both Staff indicated they resident always seemed willing to participate, did not ask to stop nor did she/he verbalize the pain. The Staff indicated the resident's pain indicators were non verbal and very clear she/he was in pain especially with weight bearing. Staff 4 further indicated the resident participated in a small number of group exercise classes, no weights were used but lower extremities were exercised. Staff 5, 6 and 7 (CNAs) indicated the resident was alert and oriented with periods of confusion. The Staff indicated the resident showed a lot of pain whenever moved but seemed to do better once she/he was still. Staff 5 & 6 stated the resident's pain was evident in her/his facial expressions as she/he would grimace, gasp, etc. Staff 6 indicated she had worked with the resident later in her/his stay and the staff could not even dress the resident without making sure she/he had been given medication for the pain. The Staff further indicated the resident rarely would ask for pain medication and most of the time would not verbalize the pain. The Staff stated the resident was always a 2 person assist for transfers and they would be as careful as they could. She/he did not refuse pain medications when offered as far as the staff knew. Staff 6 & 7 stated the resident would get up in the wheelchair for meals and on many occasions would be transferred for toileting needs as well. Staff 5 stated the staff would remind the resident they needed to reposition her/him to keep her/him from getting bedsores. The Staff further indicated the resident would usually agree but it was obvious she was in pain while being positioned and the charge nurse would be informed of the signs of pain. In an interview on 6/2/11 at 8:20 am Witness 1 (Hospice Patient Care Manager) indicated the resident was on Hospice for 2 days before she/he passed away. Witness 1 stated the Hospice notes indicated the resident had pain with movement, any change in position and sitting/standing. The resident was noted to "scream and cries" when moved but when still resident pain level was down. Witness 1 further indicated Hospice put orders in place to pre-medicate the resident before moving her/him to help with comfort and pain control. In an interview on 6/2/11 at 9:29 am Staff 8 (RNCM) indicated she was unaware the resident was experiencing pain with movement. She had not been told by any of the staff about the resident's pain. Staff 8 further indicated physical therapy had informed her of a loud cracking (crepitus) when working with the resident. When Staff 8 observed Staff 3 (PT) working with the resident she had asked the resident if she/he was in pain and the resident indicated the pain wasn't too bad. Staff 8 wanted the resident to be seen at the emergency room but the family declined. After much discussion the family agreed to take the resident to see her/his primary physician on 5/2/11 but the resident passed away before she/he could go to the appointment. Staff 8 stated she had not really observed the resident during movement other than the one occasion with PT. Staff 8 contacted the physician for clarification on the resident's weight bearing status but no return contact had been received from the physician. Staff 8 could not say why the resident's initial chart and in room care plans did not accurately document the appropriate weight bearing and staff assistance status nor why the care plans were not reflective of the resident's individual needs for pain. In an interview on 6/3/11 9:02 am Witness 4 (Witness 3's (Resident's Physician) Medical Assistant) stated on behalf of Witness 3 that it was reasonable for the resident to have some therapy services. The resident "continued to decline and the pain was too much, Hospice services were initiated" as requested by the family. Witness 4 further indicated the resident passed away soon after Hospice services were started likely due to the combination of the resident's failure to thrive and her/his underlying [MEDICAL CONDITION]. Multiple daily observations on 6/1/11 of 2 additional sampled residents (#s 2 & 3) showed the residents to be comfortable and without verbal/non-verbal signs and symptoms of pain. Interviews conducted on 6/1/11 between 12:00 pm and 1:00 pm both Resident 2 and 3 indicated they felt their pain was well controlled both with medication and non medication related interventions. Resident 2 and 3 indicated they both had as needed medications and scheduled medications if they were having pain problems. Both residents stated they received therapy services and when/if they felt uncomfortable or had pain the staff did not push them to physically continue but assisted them to achieve relief.