Every finding on record at Yellowstone River Nursing and Rehabilitation

Based on interview and record review, the facility failed to ensure staff provided services for dependent residents requiring assistance with activities of daily living for 2 (#s 59 and 98) of 38 sampled and supplemental residents. The deficient practice placed residents #59 and #98 at risk for skin integrity issues and adverse psychosocial outcomes. Findings include:Review of a facility reported incident, submitted to the State Survey Agency on 8/13/26, showed nursing management had been informed of staff member G's lack of timely care for two residents, residents #59 and #98. Residents #59 and #98 had severe cognitive impairments, with resident #59's Brief Interview for Mental Status (BIMS) score of 7, and resident #98's BIMS score of 0. Staff member G did not reposition, check, or change the residents in a timely manner. Staff member G was suspended from work pending investigation of the incident.Review of the facility reported incident's investigative findings, submitted to the State Survey Agency on 8/20/26, showed residents #59 and #98 were assessed for skin and pain concerns, and monitored by staff for psychosocial changes. Staff assessments showed residents #59 and #98 had no signs of pain, no evidence of skin impairments, and no outcome of psychosocial harm. Staff member G had unintentionally not checked on residents #59 and #98 from the beginning of the morning shift until closer to 11 a.m., per her statement. The facility determined staff member G did not provide the required care to the residents in a timely manner. The facility notified the two residents' (#s 59 and 98) providers and family members of the incident.During an interview on 8/27/26 at 9:47 a.m., staff member D stated she had worked with staff member G when the facility reported incident involving residents #59 and #98 occurred. Staff member D stated she had expressed an issue with staff member G's lack of care provided to residents #59 and #98. Staff member D stated staff member C had noted the last time the two residents had been checked was before the day shift began. Staff member D found that the two residents had not been repositioned or checked and changed by staff member G several hours into the shift. Staff member D stated resident #59 did not usually request help but still needed to be checked on regularly. Staff member D stated resident #98 had cognitive impairments and was not able to communicate his needs to staff.Review of resident #59's comprehensive Minimum Data Set (MDS) with an assessment reference date (ARD) of 6/5/26 showed resident #59 used a wheelchair. Section GG - Functional Abilities showed that GG0130. Self-Care had toileting hygiene coded as 1, which showed resident #59 was dependent on staff for completion of the activity. The section for lower body dressing and personal hygiene was coded as 2, which showed resident #59 required substantial or maximal assistance from staff to complete those activities. GG0170. Mobility showed resident #59 required substantial or maximal assistance from staff to perform changing positions in rolling left and right, sitting to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair, and toilet transfers. Section H - Bladder and Bowel showed resident #59 was always incontinent of urine and bowel movements. Review of resident #98's comprehensive care plan, showed:- A focus area initiated 10/16/24, of Transfers/Bed Mobility/Ambulation: I need assistance with my transfers, bed mobility and ambulation, I use wheelchair for my mobility needs. [sic]- Interventions revised on 6/29/26 showed, I need extensive assistance of 1 with bed mobility and am dependent with transfers. I do not ambulate at this time. I use an EZ stand for transfers with assist of 2. [sic]- A focus area initiated 10/16/24, of, Toileting: I need assistance with my toileting, I am continent of bowel and bladder. [sic]- The associated goal was, I want to be clean and odor free.- Interventions revised on 10/28/25 showed, apply barrier cream after each incontinent episode for protection. I need extensive assistance of 1 in toileting, I am incontinent of bowel and bladder, I need assistance with cleansing. [sic]Review of a facility document, untitled and undated, included in the facility's investigation report, showed: [Staff member G] is a PRN staff member. Attached is her schedule for the months of August and September. She is not scheduled to again until 09/07/2026 and will be educated regarding time management, ADL's and abuse and neglect. [sic]Review of a facility policy titled, Activities of Daily Living (ADLs), revised 6/10/25, showed: Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate.Care and services will be provided for the following activities of daily living:1. Bathing, dressing, grooming.;2. Transfer and ambulation;3. Toileting.Policy Explanation and Compliance Guidelines:. 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good . personal and oral hygiene.Review of a facility policy titled, Turning and Repositioning, revised 6/6/25, showed: . Policy Explanation and Compliance Guidelines:1. All residents at risk of, or with existing pressure injuries, will be turned and repositioned.2. Turning and repositioning is a primary responsibility of nursing assistants. However, all nursing staff are expected to assist with turning and repositioning.

Based on interviews and record review, the facility failed to notify the resident's representative, in writing, of the reason for the transfer and the required bed-hold information for 1 (#9), of 10 sampled residents. Findings include:Review of resident #9's nursing progress note, dated 5/9/26 at 4:46 p.m., showed resident #9 was found on the floor after falling. Resident #9 was sent to the local hospital and was admitted . Review of resident #9's Psychosocial assessment dated [DATE] showed resident #9 had a diagnosis of unspecified dementia, moderate with agitation. The assessment showed resident #9 had a BIMS (brief interview for mental status) of 12. A BIMS score of 12 indicates mild to moderate dementia.Review of resident #9's electronic health record showed a Notice of Transfer/Discharge form dated 5/9/26. Resident #9 was given a verbal notice of transfer.During an interview on 7/30/25 at 2:35 p.m., staff member K said the discharge notices were given to the resident verbally, and the power of attorney gets Notice of Transfer/Discharge sent to them by mail. Staff member K said during the time when resident #9 was sent to the hospital, she was off work. Staff member K said in her absence, the discharge transfer form was probably not sent to the power of attorney. Staff member K said there probably wasn't anyone at the facility that would send the form to the representatives. During an interview on 7/30/26 at 8:15 a.m., NF5 said she was aware resident #9 had been to the hospital several times in the past. NF5 said the facility had called to inform her of the discharge, but she said she did not receive any written documentation for those times.

Based on interview and record review, the facility failed to ensure a staff member provided safe transportation of a resident being transferred to the facility for admission for 1 (#10) of 10 sampled residents. The deficient practice caused resident #10 injury, resulting in a left ankle fracture, requiring hospitalization and surgery, which prolonged the resident's stay at the facility. The facility identified that the resident was not transported safely and immediately addressed and corrected the deficient practice before the survey, resulting in the findings of past non-compliance. Findings include:Review of a facility-reported incident, submitted to the State Survey Agency on 3/5/26, showed resident #10 was being transported from a local hospital to the facility for admission. Resident #10 was in a wheelchair in the facility van and was injured when the transportation staff member had to brake abruptly. The transportation staff member immediately called for emergency services assessment, and resident #10 was transported by emergency services to the hospital for evaluation of her left ankle pain and injury.Review of the facility reported incident's investigative findings, submitted to the State Survey Agency on 3/12/26, showed resident #10 was not properly secured in her wheelchair in the transport van. The transportation staff member involved was terminated for failure to follow safety protocols and standards of care. Resident #10 was admitted to the facility on [DATE] for rehabilitation, with psychosocial monitoring. The findings showed transportation staff were educated on safety protocols through competencies and return demonstration. Transportation staff received training on defensive driving and securing residents in wheelchairs for transport.Review of a facility document, dated 3/12/26, showed that a former transportation staff member was terminated from the position due to failure to follow established safety protocols and failure to meet expected standards of care and job performance related to the resident's transfer accident. The document showed the former staff member failed to properly secure a newly admitted resident in the facility van during transport to the facility. The failure resulted in the resident sustaining an ankle fracture from a fall, which was caused by the driver abruptly pushing the brakes while the vehicle was moving. The resident fell from her wheelchair because she was not secured in the chair. During an interview on 4/30/26 at 11:20 a.m., resident #10 stated she was injured when she was transported from a hospital on the way to the facility for admission in March 2026. Resident #10 stated she fell from her wheelchair because the facility driver did not secure her in with all the seat belts, and her chair had been moving around. Resident #10 stated she was very upset about the situation when it happened. Resident #10 stated she had been in pain, was hospitalized , and had surgery to repair her left ankle fracture. Resident #10 stated she was supposed to be admitted to the facility for rehabilitation following hip surgery. Resident #10 stated she had physical therapy for strengthening of her right leg scheduled, and services were added for her left ankle injury when she was finally admitted . Resident #10 stated that staff checked on her to see how she was feeling and doing often when she was admitted to the facility. Resident #10 stated she felt safe with the current facility driver.During an interview on 5/5/26 at 2:10 p.m., staff member A stated he had been in his role since 2025. Staff member A stated he was shown by a former staff member in the role of different duties and responsibilities. Staff member A stated he had not reviewed transportation staff competencies or education coming into the role. Staff member A stated the former transport employee who was terminated following the incident in March (2026) had been in his role since 2024. Staff member A stated that things had been going well with the former transport employee, and there were no complaints or concerns about his driving from residents. Staff member A stated that, looking back in hindsight, he should have verified transportation staff competencies and education.Review of a facility document, titled 3/5/26, showed that a former transportation staff member was trained by staff member A on the transportation staff's role in securing residents in wheelchairs in the facility van.Review of facility documents titled Inservice Education Summary showed transportation staff were educated on resident seat belt safety on:- 3/24/26, - 4/14/26, - 4/17/26, and- 4/21/26.Review of facility documents showed transportation audit logs were reviewed and completed by staff member A weekly for residents being transported by drivers from 3/11/26 through 4/30/26.Review of a facility document titled Action Plan: Accident, dated 3/5/26, showed that a Quality Assurance and Performance Improvement meeting was held on 3/6/26 for the incident review for resident #10. The document identified the resident involved and corrective actions, the identification of others involved, systemic changes to prevent recurrence, and ongoing monitoring through auditing, for a compliance date of 3/7/26.Review of a facility policy titled Transporting a Resident (Facility Van or Vehicle), dated 6/10/25, showed: . 6. The van will be well-maintained and equipped with safety features. Each resident will be secured in a seat with a seatbelt or in their wheelchair secured with wheelchair tie-downs. 8. Staff authorized to drive the van will have the necessary training and licensure to operate the vehicle as well as knowledge on van safety features. Copies of any necessary documentation will be kept in each employee's personnel file.

Based on interview and record review, the facility failed to ensure medications were transcribed into a resident's electronic medical record accurately, and failed to identify a high-risk medication ordered for a resident with end-stage renal disease for 1 (#6) of 4 residents sampled for dialysis. This deficient practice resulted in resident #6's altered mental status, requiring hospitalization and treatment. Findings include:During an interview on 5/6/26 at 3:20 p.m., staff member B stated residents were reviewed by the interdisciplinary team as new admissions, and nursing management would enter admission orders. Staff member B stated there were two staff members to check the admission orders that were entered, so they would not miss something with an order. Staff member B stated that if a resident was transferred from a hospital as a new admit, discharge orders were entered by nurse management. Staff member B stated it must have been a mistake that a couple of orders were entered differently from discharge orders for resident #6. Staff member B stated that providers entered orders after they saw a resident. Staff member B stated if there was a medication that was high-risk, the system sometimes had an alert of an interaction. Staff member B stated that when providers entered physician orders, the orders would be pending confirmation until a nurse reviewed the order. Staff member B stated that the staff trusted the providers with what they ordered for the residents. Staff member B stated she did not know that nurses would question an order for Baclofen given to a resident on dialysis. Staff member B stated she did not know if there was a warning of a medication interaction alert that appeared for providers when they entered orders in the system.Review of resident #6's hospital discharge orders, dated 10/24/25, showed: Carvedilol 6.25 mg oral tablet. Take 1 tab(s) (6.25 mg) by mouth 2 times a day .Clonidine 0.1 mg oral tablet. Take 2 tab(s) (0.2 mg) by mouth 2 times a day .Review of resident #6's medication administration record, dated October 2025, showed: . Carvedilol Oral Tablet 6.25 MG. Give 1 tablet by mouth one time a day for Hypertension -Start Date- 10/25/2025. cloNIDine . Oral Tablet 0.2 MG. Give 1 tablet by mouth one time a day for Hypertension -Start Date- 10/25/2025Review of resident #6's nursing progress notes, dated 10/24/25 at 2:03 p.m., written by staff member B, showed: . This order is outside of the recommended dose or frequency.Carvedilol Oral Tablet 6.25 MG Give 1 tab by mouth one time a day for Hypertension- The frequency of daily is below the usual frequency of 2 times per day.The facility nursing staff did not transcribe admission orders for resident #6 correctly, by entering a lesser dose than was ordered for antihypertensive medications.Review of resident #6's provider progress note, dated 10/31/25, showed: . Assessment/Plan:. #Resistant hypertension. following with nephrology#Hyperkalemia, resolved. -Dialyzes Tuesday/Thursday/Saturdays-I do wonder if hyperkalemia is exacerbated by telmisartan double max daily dose, review of past notes show that this is consistent.#Chronic back pain. -Schedule Dilaudid . Trial baclofen 5 mg bid . Patient verbalizes understanding and has no further questions. - Previously ineffective treatment/adverse effects with Tylenol #3, oxycodone, tramadol, gabapentin, fentanyl patch, Flexeril. [sic]The facility staff failed to take into context the high-risk associated with the use of a muscle relaxant (Baclofen). Resident #6's end-stage renal disease and her pattern of refusal of dialysis treatments, placed her at high-risk for medication toxicity. The provider documented that risks, benefits, and alternatives were reviewed with resident #6. Review of resident #6's nursing progress note, written by staff member H, dated 11/3/25 at 5:54 p.m., showed: Note Text: Resident lethargic this shift, Received critical potassium notification. Provider notified in house at bedside and orders received. Resident refusing medications . [sic]Review of resident #6's physician progress note, dated 11/3/25, showed: . #Hyperkalemia . potassium of 6.2 this morning. Patient is to get dialysis tomorrow. Hyperkalemia is thought to be secondary to missing dialysis last week. At this point I wish to avoid extended release opiates. The family was very concerned today about her slow breathing in the room. I expressed to them that with potent opiates that she is on. as well as her decreased renal function on hemodialysis, missing dialysis (as happened last week), will cause narcotics to build up in her system and increase her sedation. Nursing staff was very concerned today as patient was initially not arousable and sternal rub had to be used to wake patient in the morning. Because of this we decreased her Dilaudid. We also stopped her baclofen. Of note, at this time patient is full code. [sic]Review of resident #6's transfer form, dated 11/3/25 at 7:52 p.m., showed that a transfer to a hospital emergency room by a staff nurse was completed. The document showed the reason for transfer was for Other family/patient request. Vital signs recorded at 7:48 p.m. showed resident #6's blood pressure was 201/101, and pulse oximetry reading was 92%.Review of resident #6's hospital physician progress note, dated 11/5/25, showed: . Patient presenting to the hospital with encephalopathy initially thought to be hypertensive emergency but with improvement following dialysis rather than blood pressure reduction, highest suspicion is for . baclofen toxicity . Would recommend discontinuing and never restarting this medication. It has been adder to her adverse reaction/allergy list. [sic]Review of a facility policy titled Provision of Quality Care, dated 6/10/25, showed: . 1. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 4. Qualified persons will provide the care and treatment in accordance with professional standards of practice, the resident's care plan, and the resident's choices.

Based on interview and record review, facility staff failed to complete an assessment of a resident's health status prior to and after returning from the dialysis center for 2 (#s 2 and 6) of 4 sampled residents receiving dialysis treatments. This deficient practice increased the risk of residents #2 and #6 to experience adverse outcomes related to complications from end-stage renal disease. Findings include:1. Review of resident #2's electronic medical record, dated February 2026, showed an admission date of 2/10/26, with pertinent diagnoses including end-stage renal disease, Type 2 diabetes mellitus, anemia in chronic kidney disease, and dependence on renal dialysis.Review of resident #2's medication administration record, dated February 2026, showed orders initiated on 2/11/26 for weights and pre and post dialysis assessments to be completed every day shift on Mondays, Wednesdays, and Fridays.Review of resident #2's electronic medical record showed facility staff failed to obtain resident #2's weight on 2/23/26 and 2/27/26. Facility staff failed to complete a post-dialysis assessment on 2/23/25.2. Review of resident #6's electronic medical record showed she was admitted on [DATE] with a primary diagnosis of end-stage renal disease, and pertinent diagnoses including: dependence on renal dialysis, heart failure, Type 2 diabetes mellitus, and hyperkalemia. Review of resident #6's medication administration record, dated October 2025, showed dialysis assessments were to be completed before and after dialysis every Tuesday, Thursday, and Saturday.Review of resident #6's electronic medical record, dated October 2025, showed facility staff failed to complete dialysis pre and post assessments on 10/25/25 and failed to complete a pre assessment on 11/1/25. Resident #6 refused dialysis on 10/28/25 and 10/30/25, but facility staff failed to document the refusal of dialysis on 10/28/25 or 10/30/25 on a pre and post assessment form. Facility staff failed to document on 10/28/25 any staff communication to explain the risks or provide education of refusal of dialysis to resident #6, or to notify the provider of refusal.During an interview on 5/6/26 at 3:11 p.m., staff member B stated nursing staff were to obtain vital signs and complete a pre and post assessment of a resident receiving dialysis. Staff member B stated it was important to see how much fluid was taken off, and if any medications were given. Staff member B stated if something significant happened to a resident the provider should be notified, and if there was a refusal of dialysis, the provider should be notified. Staff member B stated there should be a monitoring for change in condition if a resident refused dialysis, with a documented nursing note stating risks.Review of a nursing protocol, titled, Dialysis patients, not dated, showed: 1 Obtain vitals pre and post treatment as well as a weight pre and post on respective dialysis days2 Complete. Dialysis Pre & Post Assessment EACH and every day they have dialysis. [sic]Review of a facility policy titled, Hemodialysis, revised 5/1/25, showed: . The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include:- The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. 3. The facility will coordinate and collaborate with the dialysis facility to assure that:a. The resident's needs related to dialysis treatments are met;. c. Documentation requirements are met to assure that treatments are provided as ordered. 4. The facility will monitor for and identify changes in the resident's behavior that may impact the safe administration of dialysis before and after treatment and will inform the attending practitioner. 10. The facility will communicate with the attending physician . of any canceled or postponed dialysis treatments and document any responses to the changes in treatment in the medical record.Review of a facility policy titled, Residents' Rights Regarding Treatment and Advance Directives, revised 6/10/25, showed: . 11. Should the resident refuse treatment of any kind, the facility will document the following in the resident's chart as applicable.a. What the resident refused.b. The reason for the refusal.c. How the resident was educated regarding the consequences of refusal f. That the physician was notified of refusal and the resident's response to education/offering of alternatives.

Based on observation, interview, and record review, the facility failed to complete a Significant Change MDS (Minimum Data Set) assessment for a resident's change in condition, for 1 (#9) of 10 sampled residents. This deficient practice increased the risk of resident #9 not receiving services for his care to prevent further decline. Findings include:During an observation on 4/28/26 at 1:33 p.m., resident #9 was walking in a hallway on the secure care unit, following a housekeeper pushing her cart to his room. Staff member I stated resident #9 wanted to help the housekeeper with work, and he was usually interactive with staff. During an observation on 4/30/26 at 7:05 a.m., resident #9 walked in a hallway on the secure care unit outside of the activities room and stopped to talk with staff member J. Resident #9 asked her about what he could do now. Resident #9 gave staff member J a hug and a kiss on the side of her cheek and continued to talk with staff member J while walking down the hallway. During an interview on 5/6/26 at 2:53 p.m., staff member G stated he worked on MDS assessments for two days a week. Staff member G stated he would receive emails from staff member B about changes in a resident's condition that required a significant change assessment. Staff member G stated he also reviewed the resident's quarterly assessments to determine if a significant change assessment was needed. Staff member G stated that a Significant Change assessment should be completed when two or three resident care areas are changed. Staff member G stated he was not sure why resident #9 had not had a Significant Change assessment done after changes in condition were found in resident #9's quarterly assessments.Review of resident #9's diagnoses report showed he was admitted to the facility on [DATE] with pertinent diagnoses of Type 2 Diabetes Mellitus, Alzheimer's disease, and unspecified dementia. Review of resident #9's Quarterly MDS assessment, with an Assessment Reference Date of 12/12/25, showed:- Section E Behavior: no hallucinations or delusions, no behavioral symptoms exhibited, no rejection of care exhibited, and no wandering behaviors exhibited;- Section H Bladder and Bowel: no episodes of urinary or bowel incontinence;- Section K Swallowing/Nutritional Status: no changes in weight loss or weight gain, and therapeutic diet given while a resident.Review of resident #9's Quarterly MDS assessment, with an Assessment Reference Date of 3/13/26, showed:- Section E Behavior: delusions, verbal behavioral symptoms directed towards others occurred one to three days, other behavioral symptoms not directed towards others occurred daily, rejection of care occurred one to three days, and daily wandering behavior exhibited;- Section H Bladder and Bowel: occasionally incontinent of bowel;- Section K Swallowing/Nutritional Status: gain in weight of 5% or more in the last month or gain of 10% or more in the last six months and not on physician-prescribed weight gain regimen, and therapeutic diet given while a resident.Resident #9 had changes from quarterly assessments in care areas for behaviors, bladder and bowel, and nutritional status which had not been identified as a significant change in condition.Review of a facility policy titled, MDS 3.0 Completion, revised 5/5/25 showed: . 1. According to federal regulations, the facility conducts. periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State. d. Significant Change in Status Assessment . - a comprehensive assessment completed within 14 days of the identification of a status change. i. A significant change is a major decline or improvement in a resident's status that: (1) will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. (2) impacts more than one area of the resident's health status, and (3) requires interdisciplinary review and/or revision of the care plan.

Based on observation, interview, and record review, the facility failed to complete and maintain resident documentation for PASARR (Preadmission Screening and Resident Review) assessment prior to admission for 1 (#9) of 3 residents sampled for PASARRs. The deficient practice increased the risk of resident #9 not receiving services for mental disorder or intellectual disability. Findings include:During an observation on 5/4/26 at 8:03 a.m., resident #9 was standing near the nursing station on the secure care unit. Resident #9 walked over to the surveyor standing by the medication cart. Resident #9 smiled and asked what he could do. Resident #9 patted the surveyor's shoulder after talking to the surveyor and walked over to staff member D near the medication cart. Resident #9 lifted his shirt and pointed to the right side of his abdomen, and stated to staff member D, Ouch, this hurts. Resident #9 walked away from the medication cart and followed staff member D as she left the medication cart to administer medications.During an interview on 5/4/26 at 4:03 p.m., staff member F stated she could only find resident #9's PASARR Level I screening. Staff member F stated she looked for a Level II screening for resident #9 and did not find any. Staff member F stated she did not know why a Level II screening would not have been done, but she had not been trained in her position to work on PASARRs.During an interview on 5/6/26 at 10:31 a.m., staff member E stated she worked in the admissions role in 2024 and would have worked on resident #9's PASARR screening in September 2024. Staff member E stated she would work on Level I screenings as needed when a resident was admitted to the facility. Staff member E stated she would complete them when they physically arrived at the facility. Staff member E stated she would update or redo a resident's Level I screening when more information was requested by the business office manager. Staff member E stated she worked on Level I screenings, and the business office manager handled anything after Level I screenings and Level II screenings.Review of resident #9's diagnosis report showed he was admitted to the facility on [DATE] with pertinent diagnoses of Alzheimer's disease and unspecified dementia. A diagnosis of cognitive communication deficit was added on 3/18/25.Review of resident #9's electronic medical record showed he was transferred to a local hospital for evaluation related to behaviors directed towards residents or staff members on:- 1/5/26,- 2/23/26,- 2/26/26,- 2/28/26,- 3/2/26.Review of a document for resident #9 titled PASRR Assessment - Level I, dated 9/6/24, showed: . Describe mental illness diagnosisUnspecified dementia, unspecified severity, with agitation. Describe indications of mental illnessresident is a&o to self .B. Mental Retardation or Related Conditions1. Does the individual have a diagnosis of mental retardation? * No. 3. Has the individual ever been referred to or served by an agency/institution serving persons with mental retardation or related conditions? * No . Approved: NoReferral for Level IIMental Retardation. [sic]Review of a facility document, sent by the facility on 5/7/26 at 10:46 a.m., showed a Level II request for resident #9 dated 9/18/24: A request for a Level II Preadmission Screening and Resident Review. evaluation to be completed for [Resident #9] was received on 9/16/24. [Resident #9] is not known to the Developmental Disabilities Program. An evaluator . will be contacted to evaluate if [Resident #9] meets the. definition of Developmental Disability, and to determine the need for any Specialized Services. Review of a facility policy titled, Resident Assessment - Coordination with PASRR Program, revised 5/5/25, showed: . a. PASRR Level I - initial pre-screening that is completed prior to admissioni. Negative Level I screen - permits admission to proceed and ends the PASRR process unless a possible serious mental disorder or intellectual disability arises later.ii. Positive Level I screen - necessitates a PASRR Level II evaluation before admission 2. The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission.3. A record of the pre-screening shall be maintained in the resident's medical record. 6. The facility designee shall be responsible for keeping track of each resident's PASRR screening status . 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review.

Based on interview and record review, facility staff failed to ensure a resident at risk for nutritional deficits was provided a therapeutic diet and had fluids limited as ordered by a provider for 1 (#6) of 4 residents sampled for dialysis. This deficient practice increased resident #6's risk of experiencing hyperkalemia and fluid imbalance as related to end-stage renal (kidney) disease, when she required treatment for hyperkalemia (high level of potassium) and altered mental status resulting in hospitalization. Findings include:Review of resident #6's electronic medical record showed she was admitted on [DATE] with a primary diagnosis of end-stage renal disease, and pertinent diagnoses including: dependence on renal dialysis, heart failure, Type 2 diabetes mellitus, and hyperkalemia. During an interview on 5/6/26 at 12:53 p.m., staff member C stated she would review resident records and complete nutritional assessments each week at the facility, spending about eight to ten hours on the work. Staff member C stated she received communications from providers about nutritional needs and therapeutic diets for the residents. Staff member C stated she completed a nutritional assessment on resident #6 on 10/31/25. Staff member C stated she reviewed resident #6's hospital discharge documents and decided to keep her on a regular diet. Staff member C stated she did not always order a therapeutic diet if a resident had a condition like diabetes, renal failure, or heart disease. Staff member C stated it would depend on the resident's situation and review of labs, medications, and the resident's overall condition.During an interview on 5/6/26 at 3:18 p.m., staff member B stated that newly admitted residents were reviewed by the interdisciplinary team. Staff member B stated residents on dialysis would usually have diet orders reflecting a renal diet or taking supplements. Staff member B stated that nursing management would enter admission orders for the resident. Staff member B stated there were two staff members checking the admission orders that were entered for a resident. Staff member B stated the providers would enter physician orders into the electronic medical record system after they saw a resident.Review of resident #6's provider progress note, dated 10/29/25, showed: . Assessment/Plan:#Resistant hypertension. following with nephrology#Hyperkalemia, resolved.#Hyperlipidemia. - Cardiac diet.Review of resident #6's electronic medical record did not show any dietary order changes were documented after 10/29/25 to reflect the provider's plan for resident #6 to start on a cardiac diet with less than two grams of sodium daily, and less than two liters of fluids daily.Review of resident #6's nutritional assessment, completed by staff member C on 10/31/25, showed: . Initial assessment: End stage renal disease; dialysis; . hypertensive heart disease with heart failure. Medications: reviewedLabs: reviewedAlert/oriented, able to make needs knownDiet order: Reg/reg, consuming 50-100% of meals, independent w/eating, fluids offered.Monitoring: . intake . labs.Review of resident #6's care plan, dated October 2025, showed: . Focus: Alteration in Blood Glucose due to hyper/hypoglycemia.Interventions:- Observe for high blood sugar symptoms - increased thirst, increased hunger, increased urinary output- Observe for low blood sugar symptoms - flushed face, sweating, change in usual mental status. Focus of: Diet/Eating: . I am on a regular diet/regular texture/thin liquidsInterventions: I receive a regular diet. Focus: Potential for complications . for Malnutrition Nutrition Score:8.Interventions:- Diet as ordered by physician- Nourishment/supplements as ordered .- RD to evaluate for recommendations for nutritional/calorie needs .The care plan failed to show a therapeutic diet order and fluid restrictions as ordered by a provider on 10/29/25 to meet the needs of resident #6's multiple clinical conditions.Review of resident #6's nursing progress note, dated 11/3/25 at 9:06 p.m., showed: . daughter located this writer on 300 halls stating, my [resident] is not acting right. I am about to call 911. This writer went to residents' room to assess resident. She was alert but would not answer any questions. Explained to [family member] that resident labs showed K+ to be elevated and provider had ordered new medications to decrease her K+ which she declined until . 6pm. I did aske resident if she would like to go to ER for eval and she stated yes. [sic]Review of resident #6's electronic medical record showed resident #6 had not received the provider's ordered diet and fluid restrictions for five days, from 10/29/25 to 11/3/25. Resident #6 was transferred to a local hospital on [DATE] and did not return to the facility.Review of a facility policy titled Therapeutic Diets, dated 1/2026, showed: The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals. Therapeutic Diet is a diet ordered by a physician, or delegated registered or licensed dietitian, as part of the treatment for a disease or clinical condition. It also may be ordered to eliminate, decrease. specific nutrients. Examples include low salt, diabetic, or low cholesterol diets. 2. Therapeutic diets. will be based on the resident's individual needs. may be considered in certain situations.a. Inadequate nutritionb. Nutritional deficits .d. Medical conditions such as diabetes, renal disease, or heart disease. 5. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed.

Based on the interview and record review, the facility failed to ensure staff responded to resident needs timely for a resident requiring assistance with activities of daily living for 1 (#4) of 7 sampled residents. The deficient practice increased the risk for adverse psychosocial outcomes and skin integrity issues. The facility identified the failure of staff to respond timely, addressed and corrected the deficient practice before the survey, resulting in the findings of past non-compliance. Findings include:Review of a facility-reported incident, submitted to the State Survey Agency on 11/5/25, showed resident #4 contacted a family member over a concern about having to wait for staff to assist with personal care. Resident #4's family member attempted to call the facility. The facility did not respond. The family member contacted the local police, who arrived at the facility to do a welfare check on resident #4, due to the facility's lack of response.Review of the facility reported incident's investigative findings, submitted to the State Survey Agency on 11/12/25, showed resident #4 waited for personal care after being checked on by staff members, and had no psychosocial harm or skin breakdown based on assessments by staff. The findings showed the staff involved received discipline, with re-education provided to all nursing staff about the facility call light policy, nursing rounds at shift change, and abuse and neglect identification and prevention.During an interview on 12/30/25 at 9:00 a.m., staff member M stated she did not check on resident #4 when she started her shift at 6:00 p.m. on 11/4/25. Staff member M stated staff member I and staff member O went into resident #4's room at separate times after 6:00 p.m. to check on resident #4 due to her call light being turned on. Staff member M stated, she and staff member I, were assisting residents after dinner, and several residents required extensive assistance with care. Staff member M stated resident call lights were answered, in order of when the call light was turned on, along with their priority level of care needs due to some residents being at risk for falls. Staff member M stated that staff member O was passing medications to residents when her shift began at 6:00 p.m.During an interview on 12/30/25 at 12:15 p.m., staff member H stated she did not see resident #4's call light turned on after 5:30 p.m. on 11/4/25. Staff member H stated she checked on resident #4 during the day and changed resident #4's brief three times due to urinary and bowel incontinence. Staff member H stated the last time she saw resident #4, resident #4 did not request assistance with changing her brief. Staff member H stated she was catching up on charting around 5:30 p.m. and was at a nursing station during that time, while staff member L was in the dining room assisting residents with dinner. Staff member H stated there was a meeting held earlier in the year for all staff members, and staff were instructed to leave call lights on until a resident's request for assistance was completed.During an interview on 12/30/25 at 3:10 p.m., resident #4 stated she had her call light on for over four hours on 11/4/25 in the evening. Resident #4 stated she needed assistance from staff with having her brief changed due to urinary and bowel incontinence. Resident #4 stated staff members entered her room, did not turn off her call light, and did not return to assist her with personal care. Resident #4 stated she had a cow bell to use when she requested immediate assistance from staff, or when her call light was not working. Resident #4 stated she did not use the cow bell or call out loud for staff assistance on 11/4/25, although her call light remained on.During an interview on 12/31/25 at 7:38 a.m., staff member I stated she started her shift on 11/4/25 at 6:00 p.m. and did not receive information from staff member H that resident #4 needed assistance with changing her brief due to incontinence issues. Staff member I stated she entered resident #4's room to check on her due to her call light being on around 7:30 p.m. Staff member I stated she told resident #4 she would return with another staff member to assist with her personal care. Staff member I stated she and staff member M were responding to other residents who had call lights on, since they needed staff supervision and assistance. Staff member I stated she did not turn off resident #4's call light when she went into her room to check on her, because of information given during an all staff meeting to keep a resident's call light on until they were able to finish everything needed for the resident. Staff member I stated staff member O had also entered resident #4's room at a different time to assist her. Staff member I stated a police officer arrived in the facility and went to resident #4's room. Staff member I stated due to the police officer's arrival, she and staff member M were unable to assist resident #4 with personal care until he left resident #4's room.Review of a facility document titled, Past Calls, dated 11/4/25, showed resident #4's call light total response time was 4 hours and 41 minutes, with a starting time of 5:33 p.m.Review of resident #4's Minimum Data Set (MDS) with a Quarterly assessment reference date (ARD) of 9/13/25, Section GG - Functional Abilities, showed that GG0130. Self-Care was coded as, 1, for lower body dressing and toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). The 1 code indicated resident #4 was dependent on staff and/or required the assistance of two or more staff to help with all effort in completing the personal care activities. Section H - Bladder and Bowel, showed that resident #4 had a code of 3, as always having urinary and bowel incontinence.Review of resident #4's comprehensive care plan, showed a problem initiated on 5/15/23 of, I am at risk for alteration of bowel and bladder functioning related to .urinary and bowel incontinence. The associated goal was to remain free from skin breakdown, with the following interventions: .apply moisture barrier to the peri-area after incontinent episode, Keep call light within reach, Remind, offer and assist with toileting as needed. Toileting- assistance of 1 staff person . check and change and toilet me frequently per my needs.Review of a facility document titled, CNA EXPECTATIONS, showed staff members H, I, and M each signed individual documents with the included information: . All CNAs are expected to check on every patient every 2 hours this includes changing/toileting patients. When checking on patients ask about. their continence (do they need changed? Do they need to be toileted?) Always ask before leaving the room if they need anything else, this ensures all the patient's needs are met at that time. All CNAs are expected to answer call lights in a timely manner. All CNAs are expected to provide our patients with safety, dignity, communication, independence, and privacy. [sic]Review of a facility document dated 11/14/25, showed staff members H, I, M, and O signed individual disciplinary actions for: . Failure to answer call lights in a timely manner.Corrective Action: The expecation is that call lights will be answered in a timely manner and resident's needs will be addressed immediately. [sic]Review of a facility document titled, Walking Touch Rounds Shift Report, revised 11/6/25, showed staff members H, I, and M each signed individual documents on 11/11/25 for included information: It is the policy of this facility to use walking touch round shift reporting to promote successful transfer of information between all c.n.a.'s at shift change in an effort to prevent adverse events, falls, and improve timeliness of care. [sic]Review of a facility document titled, Call Lights: Accessibility and Timely Response, revised 11/10/25, showed staff members H, I, and M each signed on 11/11/25 for included information: . 10. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.11. Process for responding to call lights:a. Turn off the signal light in the resident's room. c. Listen to the resident's request and respond accordingly. Inform the resident if you cannot meet the need and assure him/her that you will notify the appropriate personnel. f. If assistance is needed with a procedure, summon help by using the call light. Stay with the resident until help arrives.12. All call lights will be answered in a timely manner.Review of a facility document titled, Inservice Education Summary, dated 11/10/25, showed an ad hoc QAPI meeting was held with management staff for discussion of call lights. A facility document titled, Action Plan, dated 11/10/25, showed a problem was identified regarding call lights not being answered in a timely manner. The facility outlined a corrective action, with identification of others, plans for systemic changes, ongoing monitoring, and a target date of when education would be completed for facility staff of the action plan by 11/14/25. Review of a facility document titled, Inservice Education Summary, dated 12/9/25, showed an educational meeting was held for facility staff regarding a follow up to call light audits and current call light times.

Based on interview and record review, the facility failed to hire and employ a full-time social worker who met the regulatory requirements and to meet the mood, behavioral, emotional, and psychosocial needs of residents. The facility was licensed for 160 beds. Findings include:During an interview on 11/18/25 at 2:35 p.m., staff member A stated that staff member F had been in the social services director position for about three months and held a degree in psychology. Staff member A stated the social services staff member prior to staff member F did not have a degree. Staff member A stated the other staff member who worked in a social services role (staff member E) did not have a degree.During an interview on 11/19/25 at 11:46 a.m., staff member A stated the facility's census had never reached 120 residents. Staff member A stated that since the census had never reached or went over 120, the facility met the social worker regulation with the two staff members in their social services roles. Staff member A stated the facility's census was currently 115, so they were getting a little nervous about that number. Staff member A stated the facility's corporate company had a licensed social worker who could oversee staff member F and act as a consultant as needed.Review of the facility's health care facility service license, dated 5/2/24, showed for the license specifications of Title 18/19 SNF (Skilled Nursing Facility), the facility was licensed for 160 beds.Review of a facility document titled, Job Title: Social Worker, which described staff member F's job description, showed: .QUALIFICATIONS. The requirements listed are representative of the knowledge, skill and or ability required.Education and Experience. - Bachelor's degree in Social Work from an accredited institution is required (Master's degree and/or experience in long-term care is preferred) .Certificates, Licenses, Registrations- Social Work license in the state employed is required.- Become familiar with and comply to all local, state, and federal regulations relating to the job.The document showed staff member F signed the job description on 8/18/25.Review of staff member F's academic transcripts and resume showed staff member F attained a bachelor's degree in psychology. The resume did not show a year of supervised social work experience in a health care setting working directly with individuals.A review of S483.70(o), the long term care regulatory requirements for a social worker showed, any facility with more than 120 beds must employ a qualified social worker on a full-time basis, which included one year of supervised experience in a healthcare setting. The regulatory requirement did not reflect that a facility was allowed to forgo employing a qualified social worker if the census was 120 or less. Refer to F656 - Comprehensive Care Plan, and F740 - Behavioral Services, related to concerns with a resident not receiving the necessary care and services for mood, behavior, and psychosocial concerns.

Based on interview and record review, the facility failed to ensure a provider reviewed a resident's total program of care during a single visit with the resident, when the resident fired the physician who left not finalizing the visit, but then no other physicians attempted to finish the assessment, for 1 (#4) of 8 sampled residents. This deficient practice caused resident #4 to be at risk of not receiving medications, treatments, and services for maintaining physical, mental, and psychosocial well-being. Findings include:During an interview on 11/17/25 at 1:32 p.m., NF1 stated resident #4 fired the male provider who saw her for her initial visit, due to his bedside manner. NF1 stated resident #4 was concerned the provider did not listen to her, and things should have been straightforward to treat her GI issues. NF1 stated resident #4 was concerned that staff member D was dismissive towards her and did not fully hear her out. During an interview on 11/18/25 at 10:16 a.m., staff member D stated he visited residents in the facility who received services through [Hospital Name], and worked with [Staff Name] as the attending physician. Staff member D stated he had a visit with resident #4, which ended quickly due to the resident's emotional state. Staff member D stated, I was only in the room for five to ten minutes and was kicked out of the room; there was no physical exam done. Staff member D stated he was aware resident #4 fired him as her provider and stated she was allowed to do that. Staff member D stated he asked for resident #4 to have cares in pairs when staff went into the room to assist her, for her safety, and that of the staff. Staff member D stated the facility assists the resident with services of another provider, if the resident fired one, since the facility had physicians and non-physician practitioners who saw residents.During an interview on 11/18/25 at 12:58 p.m., resident #4 stated she went to the facility for rehab services after a hospital stay, due to different medical conditions. Resident #4 stated she had concerns with how staff treated her from the time she got to the facility. Resident #4 stated she tried to ask questions about her care and medications, and staff would get upset when discussing things with her. Resident #4 stated she requested a different provider due to concerns with how her assigned provider treated her, but she never got to see a provider after that first short visit.During an interview on 11/18/25 at 2:35 p.m., staff member F stated resident #4 had expressed concerns to her about treatment by staff members, including nursing staff and a provider. Staff member F stated resident #4 had fired her initial provider, and staff had attempted different ways and times to have her seen by a provider. Staff member F stated she tried to arrange for resident #4 to be seen by a different male non-physician practitioner, and the physician who oversaw staff member D. Staff member F stated resident #4 was offered to attempt a visit with staff member D, along with another staff member in the room, but resident #4 refused.Review of resident #4's provider notes, written by staff member D, dated 9/9/25, showed: . Today patient seated in wheelchair. She is quite tangential with mild pressured speech when describing a multitude of symptoms and comorbid conditions. Complains that left lower extremity remains weak since stroke like symptoms reported 9/3, unable to stand or ambulate where previously she was fully ambulatory. Describes hands and feet numbness, tingling and sharp pains. In my attempt to narrow her review of systems and history based upon complaints she was offering patient became upset and asked me to leave before I was able to complete my assessment or perform physical exam. Nurses consulted. Therapy team consulted. Vitals and MAR reviewed. Disposition: Based upon condition and comorbidities patient is appropriate for SNF stay, no anticipated discharge at this time. Reengage patient next visit to determine how best to serve her needs while at SNF. [sic]The provider failed to review resident #4's total program of care, when seeing the resident for one visit, while the resident resided in the facility for services. The provider was not able to assess resident #4's cardiopulmonary, GI/GU, musculoskeletal, neurologic, and psychiatric systems on 9/9/25. This did not allow resident 4's complete assessment for ongoing care and treatment. Resident #4 did not receive any other visits from providers, to include a full examination, history and physical, and recommendations while in the facility.Review of a facility policy titled, Comprehensive Care Plans, implemented 7/1/25, showed: . 7. The physician, other practitioner, or professional will inform the resident. of the risks and benefits of proposed care, of treatment, and treatment alternatives/options. The facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident.

Based on interview and record review, the facility failed to provide individualized medically related social services, and accurately and thoroughly assess a resident, for her mood, behavior, and psychosocial status, and the resident displayed mood symptoms and took an antidepressant, displayed anxiety, paranoia, would often refused care, and act out toward others; and the facility failed to ensure her care plan included individualized interventions for care staff to use when the resident did display symptoms or concerns of the mood, behavior, or psychosocial concerns; and she was not referred for mental health services, although this was identified as necessary, for 1 (#4) of 8 sampled residents. Findings include: During an interview on 11/18/25 at 2:35 p.m., staff member F stated she tried to build rapport with resident #4, but resident #4 had a lot of emotional behaviors, and each day could be different. Staff member F stated her past work experience helped her recognize resident #4's mental health behaviors and cycling of emotions. Staff member F stated she notified a staff nurse to inform resident #4's provider of a request for mental health services. Staff member F stated staff attempted different ways and times to have resident #4 seen by a provider, but stated she had no record of any referrals made for resident #4 to receive counseling, therapy, or mental health services.During an interview on 11/19/25 at 2:29 p.m., with staff members B and C, staff member C stated the interdisciplinary team reviewed care plans when there were mental health, behavioral, or safety concerns with a resident newly admitted to the facility. Staff member B stated the interdisciplinary team, which included social services, added information to a resident's care plan when they were a new admission to the facility. Staff member B stated she thought the facility used to provide telehealth counseling services through [Company Name]. Staff member B stated that the social workers functioned in facilitating counseling services. Review of resident #4's psychosocial assessment, dated 9/9/2025 at 12:19 p.m., showed she had a BIMS of 17, but the highest score possible is 15. The resident was emotional and excitable, easily distracted, and had difficulty regulating her emotions. For her behavioral patterns, she was excitable and animated, easily distracted, and was emotional and crying off and on. Under the assessment for her mood and psychosocial well-being, the notes showed the resident was having difficulty settling in, and the facility was working through issues in regards to staff.Review of resident #4's social service note by staff member F, dated 9/19/25 at 10:17 a.m., showed, Resident is refusing to take prescription medication. resident is combative. Doctor attending to resident has been notified of her refusal to take medication. [Provider Name] PA has noted that resident has a long history of mental health concerns. No documentation was included to show how staff attempted to alter or provide interventions for the resident and for the refusals of care. A review of resident#4's Comprehensive MDS, signed as completed on 9/15/25, showed:-Resident #4 had a BIMS of 14; cognitively intact. She displayed disorganized thinking and inattention continuously. -Under section D -Mood, the resident score showed a 00 with no mood concerns identified. -Under Section E - Behavior, the resident showed she displayed no behaviors towards self/others. -Under section E900 - the resident was not coded as rejecting care. -Under section N, it showed the resident was taking an antidepressant but not taking a psychotropic medication. -For section V, for the CAAs, nothing triggered for mood or behavior. A request was made on 11/19/25 at 10:35 a.m., for referrals for behavioral health services for resident #4. No documentation was provided prior to the end of the survey.A review of resident #4's Progress Notes, from 9/17/25 to 9/22/25, failed to show consistent and individualized interventions staff attempted to utilize to assist with the resident when displaying symptoms of anxiety, depression, paranoia, manipulation, or rejection of care, although concerns were noted related to her mood, psychosocial status, and behavior. Several of the entries appeared to be carried over from prior entries added to the Progress Notes. A review of resident #4's care plan showed she had several issues related to mood/behavior, including:-The resident was taking a psychotropic medication for depression, initiated 9/8/25. There were no interventions for staff to utilize to assist the resident with the depression, other than monitoring the medications and side effects, and observing for changes.-The resident had paranoid tendencies, thinking others were taking her things, initiated on 9/19/25. The only intervention for this problem was a lock box, but there was nothing identified for staff to utilize in the event the resident displayed paranoia.-The resident would manipulate, make up stories, and was anxious, but again, there were no individualized and measurable interventions staff could use to alter or intervene in these behaviors when exhibited by the resident, other than to monitor or observe. Although the resident displayed a multitude of mood, behavior, and psychosocial concerns, these issues were not effectively addressed by the facility. Individualized interventions were not identified for staff to use for altering the resident's mood/behavior. Refer to F850 - Social Service Director; F740 Behavioral Health Services; and F656 - Comprehensive Care Plan

Based on interview and record review, the facility failed to assist a resident who requested mental health counseling to receive behavioral health services; when the resident had consistent documentation of emotional behaviors and concerns with her care staff that occurred since the date of admission, for 1 (#4) of 8 sampled residents. Findings include:Review of resident #4's electronic medical record showed resident #4 was admitted on [DATE] with diagnoses which included alcohol abuse (in remission). There were no other behavioral health diagnoses listed.During an interview on 11/18/25 at 12:58 p.m., resident #4 stated she went to the facility for rehab services after a hospital stay, due to different medical conditions. Resident #4 stated she saved notes and papers with information she kept from her time in the facility. Resident #4 stated she did not review them since her discharge because it would be retraumatizing. Resident #4 stated she had concerns with how staff treated her from the time she got to the facility. Resident #4 stated she tried to ask questions about her care and medications, and staff would get upset when discussing things with her. Resident #4 stated she felt staff at the facility covered for each other, so things were not resolved when she expressed concerns. Resident #4 stated she had submitted a grievance about the nursing staff and how they treated her. Resident #4 stated she requested a different provider due to concerns with how her assigned provider treated her, but she never got to see a provider after that first short visit. Resident #4 stated she tried to ask for help from staff member F, but things were not fixed during her time in the facility.During an interview on 11/18/25 at 2:35 p.m., staff member F stated resident #4 had expressed concerns to her about treatment by staff including nursing staff and a provider. Staff member F stated she tried to build rapport with resident #4 while working with her, but resident #4 had a lot of emotional behaviors, and each day could be different. Staff member F stated her past work experience helped her recognize resident #4's mental health behaviors and cycling of emotions. Staff member F stated she informed a staff nurse to inform resident #4's provider of a request for mental health services. Staff member F stated it was difficult because resident #4 had fired her provider, and staff attempted different ways and times to have her seen by a provider. Staff member F stated she had no record of any referrals made for resident #4 to receive counseling, therapy, or mental health services.During an interview on 11/19/25 at 2:29 p.m. with staff members B and C, staff member C stated the interdisciplinary team reviewed care plans when there were mental health, behavioral, or safety concerns with a newly admitted resident. Staff member C stated she met with resident #4 to review a grievance she filed, to discuss options for her care team staff. Staff member C stated some options discussed with resident #4 included having another staff member in the room for her assigned provider appointments, or firing of her assigned provider, with reassignment with another provider. Staff member B stated the interdisciplinary team, which included social services, would add information to a resident's care plan when they were a new admission to the facility. Staff member B stated she thought the facility used to provide telehealth counseling services through [Company Name]. Staff member B stated the social workers functioned in facilitating counseling services. Staff member B stated social workers had previously set up residents to have appointments with a telehealth provider in their rooms.Review of resident #4's grievance, dated 9/8/25, showed a concern related to her treatment, such as the staff would Grab my plate out of my hand and a CNA told the resident, We only have one CNA on this hall, and he can't be sitting here helping you. The resident denied abuse and wanted to be treated better. Review of resident #4's psychosocial assessment, dated 9/9/2025 at 12:19 p.m., showed: she was emotional and excitable, she was easily distracted, and had difficulty regulating her emotions. She has requested copies of all paperwork completed while in the facility. For her behavioral patterns, she was excitable and animated, easily distracted, and was emotional and crying off and on. Under the assessment for her mood and psychosocial well-being, the notes showed the resident was having difficulty settling in, and the facility was working through issues in regards to staff.Under section 9, the grievance reflected Yes was marked, showing the care plan was updated to reflect psychosocial well-being and mood components. Review of a section of resident #4's CAA (Care Area Assessment) worksheet completed by staff member F on 9/15/25, showed there was a referral to another discipline warranted, for the assessment by mental health and to address mental health concerns. Review of resident #4's nursing progress note, dated 9/9/25 at 2:54 a.m., showed: . she was very paranoid about medications. she was saying repeatedly things [NAME] right, this isnt right, i just dont get it tried to explain medications to her and reason for taking and she was concerned with vitamins and why i was not giving them to her. we went over med list and she still was concerned pulling out numerous papers of med lists from different facilities. tried to show her how the medications were the same but different names. she continued to be paranoid saying she didnt trust this place she was very concerned with what hospital did and why things changed and they were different. she admits she cant remember stuff and will have to talk with her daughter about her medications. [sic]Review of resident #4's nursing progress note, dated 9/9/25 at 7:05 a.m., showed: Resident is alert and oriented x3 (self, situation, place). Resident has pressured, rapid speech. Resident appears confused at times about [Facility Name] policies, dietary menu, and medications. Resident refuses all COPD medication. Resident has denied cares from this nurse during day.Review of resident #4's social service note by staff member F, dated 9/9/2025 at 5:23 p.m., showed: Note Text : I held the Initial Care Conference (ICC) with [Resident's name] . Psychosocial evaluation: No past suicide attempts or ideation, no current active ideation. Feels like she would like to get a mental health assessment, resident is struggling settling in. Additional Notes: [Resident's name] was very emotional at the time of the conference. She has concerns about staff and being treated respectfully.Review of resident #4's nursing progress note, dated 9/15/25 at 8:50 p.m., showed, . [Resident #4] Shook her walker when this RN asked about her heart monitor, stated I just want to be left alone. I had a bad day. A lot of things happened. I had to call the State in [NAME]. Advised resident to call for assistance as needed. Will continue to monitor.Review of resident #4's social service note by staff member F, dated 9/19/25 at 10:17 a.m., showed, Resident is refusing to take prescription medication during med pass. Resident is combative and is saying that she is allergic to the medication. Doctor attending to resident has been notified of her refusal to take medication. [Provider Name] PA has noted that resident has a long history of mental health concerns.Review of resident #4's nursing medication administration note, dated 9/20/25 at 3:55 a.m., showed, Resident ambulating with walker in hallway. Spent 1.5 hours in the shower tonight. Refused Duoneb as she stated she had just completed a treatment. Refused Nortriptyline as she said it was only prescribed for her in the hospital when her mood was up and down as she described through hand gestures.Review of resident #4's nursing medication administration note, dated 9/20/25 at 6:54 a.m., showed, Resident came up to this nurse asked if I was an RN, I let her know I was an LPN, and Charge Nurse on duty she stated she did not want current nurse giving her medications . The nurse explained medications could be provided with two nurses, and the resident stated, . no I don't want her in there, I stated you can fire a nurse from being the main nurse; however she will be present as we will go in and give all medications together. Resident not agreeable to this and currently does not want myself to be her nurse either. The manager on duty was notified of the concerns. Review of resident #4's nursing medication administration note, dated 9/20/25 at 8:23 a.m., showed, Resident came out of her room in the early am and went to the Charge nurse stating, I do not want her (me) giving me my meds after the way I was treated yesterday. The resident stated to the charge nurse that she called a female Dr. at a hospital and the Dr. told her she was malnourished and needed Boost maximum protein, which the facility did not have, so the nurse attempted to provide Boost glucose control. The resident requested to speak to the Administrator who was not at the facility at the time, and the nurse documented, Resident will not listen to reason and she will fire you. Review of a facility document, titled Behavioral Health Services, implemented 6/15/25, showed:.It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning .4. The facility will ensure that a resident who, upon admission was not assessed or diagnosed with a mental or psychosocial adjustment difficulty or a documented history of trauma and/or PTSD does not develop patterns of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors while residing in the facility. The policy showed staff were to monitor the resident, evaluate for distress or changes, share concerns with the IDT to determine causes for behaviors or changes, accurately document concerns and triggers, and ensure appropriate follow-up assessments are completed as needed. Section 12 of the policy showed the Social Services Director shall serve as the facility's contact person for questions regarding behavioral services provided by the facility and outside sources such as physicians, psychiatrists, or neurologists.Review of staff member F's job description showed duties were to include the ongoing assessment of the social service needs of participants and/or their family caregiver and development of the social service portion of the participant care plan within five days of admission and evaluation of same with progress notes no later than 14 days after the date of enrollment, to provide individual or group counseling to participants as needed, to assess participants for signs of mental illness and/or dementia and make appropriate referrals, to arrange and coordinate support services which were not available at the facility, to assist program staff in adapting to changes in a resident's behavior and provide or arrange for individual, group or family psychotherapy for participants with significant psychological needs. The document showed staff member F signed the job description on 8/18/25. A request was made on 11/19/25 at 10:35 a.m., for referrals for behavioral health services for resident #4. No documentation was provided prior to the end of the survey.

Based on interview and record review, the facility failed to include person-centered information in the resident comprehensive care plan to include measurable objectives and timeframes to meet medical, nursing, and psychosocial needs for 2 (#s 1 and 4) of 8 sampled residents. This deficient practice increased the risk of resident #4 not having psychosocial needs met, and for staff assisting with resident #1's care to not follow enhanced barrier precautions to prevent infection. Findings include:During an interview on 11/19/25 at 9:50 a.m., staff member I stated nurses who admitted residents would begin a care plan for them. Staff member I stated charge nurses would add information and nursing supervisors as part of the IDT team would add information into resident care plans. Staff member I stated residents admitted to the facility with a foley catheter would have been started on enhanced barrier precautions. Staff member I stated that information would be added to a resident's care plan, to go along with TAR orders.During an interview on 11/19/25 at 2:29 p.m., with staff members B and C, staff member B stated nursing staff admitting a new resident would begin a resident's care plan. Staff member C stated the interdisciplinary team reviewed care plans when there was mental health, behavioral, or safety concerns with a resident newly admitted to the facility. Staff member B stated the interdisciplinary team, which included social services, added information to a resident's care plan when they were a new admission to the facility. Staff member B stated nursing supervisors added information to a resident's care plan following a interdisciplinary team meeting discussion to include changes in a resident's clinical status or treatment needs.1. Review of resident #1's MDS (Minimum Data Set) with an assessment reference date of 9/29/25, showed resident #1 was dependent on staff for toileting hygiene and required substantial/maximal assistance from staff for personal hygiene. It showed resident #1 had an indwelling urinary catheter and frequent episodes of bowel incontinence. Resident #1's primary medical condition was non-traumatic spinal cord dysfunction, and he had a diagnosis of obstructive uropathy.Review of resident #1's comprehensive care plan showed an admission date of 9/26/25. The care plan showed the following problems and interventions, initiated 10/14/25: .Focus. Potential for infection related complications r/t UTI .Goal. Infection will resolve with interventions through next review date.Interventions.- . ALERT CHARTING--Assess status of infection r/t UTI DOCUMENT SYMPTOMS, INTERVENTIONS and notify provider with any concerns. Monitor every shift for entire course of infection including 3 days post completion of antibiotics.- . Monitor for side effects of antibiotic treatment.- . Medications as ordered- . Treatment to affected area as needed- . Use good standard infection control precautions before and after providing care. [sic]Resident #1's care plan did not include specific information regarding resident #1's indwelling catheter related to enhanced barrier precautions, although the resident required frequent catheter changes and was at risk for potential UTIs.Review of resident #1's nursing progress note, dated 10/14/25 at 9:33 a.m., showed: LATE ENTRYNote Text: Infection - pt complained of increased difficulty with urination and increased amount of sediment noted in catheter. Catheter changed with sample obtained. pt culture results revealed e-coli and pt was placed on antibiotics for 7 days. will monitor for adverse reactions related to antibiotics. pt and family aware of treatment. [sic]2. During an interview on 11/18/25 at 2:35 p.m., staff member F stated resident #4 had expressed concerns to her about treatment by staff members including nursing staff and a provider. Staff member F stated she tried to build rapport with resident #4 in working with her, but resident #4 had a lot of emotional behaviors, and each day could be different. Staff member F stated her past work experience helped her recognize resident #4's mental health behaviors and cycling of emotions. Staff member F stated she notified a staff nurse to inform resident #4's provider of a request for mental health services. Staff member F did not state she added information to resident #4's care plan following these events.Review of resident #4's electronic medical record showed resident #4 was admitted on [DATE] with a diagnosis which included alcohol abuse (in remission). There were no other behavioral health diagnoses listed.Review of resident #4's care plan showed the following problems and interventions related to psychosocial wellbeing: .Focus . I have behaviors of manipulation and making up stories, I am very anxious Date Initiated: 09/09/2025. Goal. Minimal behaviors and mood disruptions. Interventions. Cares in pairs. Monitor for manipulative behaviors and attempt to redirect.Focus. Resident has paranoid tendencies with thoughts of people taking her personal belongings. Date Initiated: 09/19/2025. Goal. Resident will feel secure with belongings through the next review. Interventions. I have a lock box to store my personal belongings.Focus. I am taking Psychotropic Medications for depressiin Date Initiated: 09/08/2025. Goal. I want to be free of side effects and stable in my illness. Interventions.- .Anti-Depressant Medication- Monitor for sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, Headache ,skin rash, photosensitivity, excess weight gain.- . Monitor for episodes of crying/tearful and isolation r/t psychotropic medication use.- . Staff will observe for changes in my condition- . Staff will observe me for side effects of these drugs. [sic]Resident #4's care plan did not include a comprehensive person-centered focus of any emotional and behavioral needs, with interventions to assist the resident when instances occurred besides monitoring the resident and providing a psychotropic medication for depression. Review of resident #4's psychosocial assessment, dated 9/9/2025 at 12:19 p.m., showed: . 2. Cognitive Status/Communication. 8. Summary of Cognitive Status Questions 1-7: Assessment of cognitive presentations, communication skills, and related diagnosis:Resident was emotional and excitable, she was easily distracted and has difficulty regulating her emotions. She has requested copies of all paperwork completed while in the facility. 2. Summary of behavioral patterns/presentations:Resident was excitable and animated. Easily distracted but aware of those around her, she was emotional and crying off and on through out the meeting. 8. Summary of Sections above (Assessment of mood, affect, and psychosocial well-being):Resident is having some difficulty settling in, we are working through issues in regards to staff.9. Care plan has been updated to reflect psychosocial well-being and mood components:a. Yes.Review of resident #4's social service note by staff member F, dated 9/9/2025 at 5:23 p.m., showed: Note Text : I held the Initial Care Conference (ICC) with [resident's name]. Psychosocial evaluation: No past suicide attempts or ideation, no current active ideation. Feels like she would like to get a mental health assessment, resident is struggling settling in. Additional Notes: [Resident's name] was very emotional at the time of the conference. She has concerns about staff and being treated respectfully.Review of a facility policy titled, Comprehensive Care Plans, implemented 7/1/25, showed: . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident. that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs.1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. 3. The comprehensive care plan will describe, at a minimum, the following:a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.b. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment. 4. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to:a. The attending physician or non-physician practitioner.b. A registered nurse with responsibility for the resident.f. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.

Based on observation, interview, and record review, the facility failed to prevent the development of a pressure ulcer to the coccyx for 1 (#5) of 26 sampled residents. The resident's medical record failed to include consistent and accurate documentation to reflect if the wound was avoidable, although the resident was at risk for malnutrition and had a severe weight loss over recent months; and the facility implemented some interventions for prevention, but failed to thoroughly and consistently assess the wound and document the status of the pressure ulcer, such as the size, measurements, severity, characteristics and detail, and at one point, the wound was documented as a Stage IV with no defining characteristics as to why this was determined. Findings include: During an interview on 8/27/25 at 3:41 p.m., staff member P stated resident #5 has had consistent weight loss starting after his stroke (on 7/1/25).During an interview on 8/28/25 at 8:01 a.m., staff member U stated there could be a concern with resident pressure ulcers at the facility, as staff member U felt residents were not getting turned (repositioned) enough. Staff member U felt this may have been due to not enough staffing at times.During an interview with staff members B and V, on 8/28/25 at 10:43 a.m., staff member B stated that some floor staff found it difficult to reposition resident #5 as he could be combative. Staff member V stated they were able to complete all cares for resident #5, including repositioning and wound dressing changes. Staff members V and B both stated that other staff may have to work on their approach with resident #5, and this could be the root cause as to why resident #5 would refuse repositioning. Staff member V stated a pressure ulcer could worsen if a resident was not repositioned frequently enough and if a resident had inadequate nutrition. Staff member V stated this could be why resident #5's pressure ulcer was worsening. Staff member V stated they were made aware of resident #5's pressure ulcer on 8/6/25, and it was Unstageable at this time due to the wound's slough. Staff member V stated the wound was not open at that time. Staff member V stated they felt they should have been notified sooner by the floor staff, as they felt the wound looked pretty bad. Staff members V and B both stated education had been recently given, and will be given in the future, to staff regarding dementia training, approach for when a resident refuses care, and pressure ulcer recognition and reporting. Staff member V voiced being an LPN, not a certified wound nurse. Staff member V stated they did not always agree with the physician's assessment of the wounds when the physician determined the stage of the wound. During an interview and observation on 8/28/25 at 11:42 p.m., staff member V showed resident #5's wound progression pictures, located in the resident's EHR. Staff member V stated resident #5's wound was first photographed on 8/12/25. Staff member V described the wound as having granulation, epithelial, and necrotic tissue. Staff member V stated they were unsure what stage or how deep the wound was on 8/12/25, as they were unable to see past the necrotic tissue and slough. Staff member V stated the wound was not debrided until 8/21/25, as the physician had been on vacation, and the wound was labeled as a Stage IV pressure ulcer by the physician, but there was no documentation or measurements showing how this was determined. Staff member V stated the physician staged the wound too high as there had only been partial thickness loss. During the observation of resident #5's EHR, the pressure ulcer was still staged at a Stage III pressure ulcer as of 8/28/25. The observation of the pictured wound on 8/21/25, after it had been debrided, looked bright pink, with a moderate amount of depth (appeared to be three to four millimeters) and circumference. No bone was observed.Review of resident #5's physician orders showed wound care(s) was started 8/12/25.Review of resident #5's assessment, titled Weekly Head to Toe Skin Check, showed the following information between 8/3/25 to 8/20/25: -8/3/25, showed . Coccyx Excoriation of the skin still present .,-8/4/25, showed . Left buttock pressure breakdown,-8/11/25, showed . Left buttock pressure breakdown,-8/20/25, showed . Left buttock pressure ulcer wound. No wound measurements or wound stage were included in this assessment.Review of resident #5's EHR showed a Weekly Skin/Weight Note, dated, 8/20/25, which showed . Stage IV to coccyx - followed by wound Dr. Review of resident #5's first Skin and Wound Evaluation, dated 8/21/25, showed . Pressure, Stage 3 ., Coccyx, In-House Acquired, Exact Date: 8/5/25 . No wound measurements were documented in this assessment.Review of resident #5's EHR showed a Skin/Wound Note, dated 8/25/25: Resident seen by wound nurse on rounds on 8/21. Pressure injury to left buttock continues. Shows improvements. Measures 3cm x 4.4cm x 0.4cm. Wound bed 50% granulation and 50% slough. [sic]Resident #5's weight decline: Review of resident #5's physician order showed: At risk for malnutrition, with a start date of 4/1/25.Review of resident #5's EHR weight documentation showed a 10.49 percent weight loss which showed severe weight loss, and the resident went from 195.5 pounds on 6/7/25 to a weight of 175.0 pounds on 8/19/25.Review of resident #5's EHR showed a document, titled the Braden Scale for Predicting Pressure Injury Risk - With Interventions, dated 7/30/25, which showed a score of 11, reflecting the resident was at high risk of developing a pressure injury.Review of resident #5's EHR showed the following nursing notes from 7/11/25 to 8/20/25:-7/11/25 - Weekly Skin/Weight Note: . Significant weight loss noted . struggling to feed self .-7/25/25 - Weekly Skin/Weight Note: Significant weight loss noted . struggling to feed self - receiving 1:1 meal assistance in dining room .-8/6/25 - Weekly Skin/Weight Note: . Breakdown on coccyx .-8/6/25 - Skin/Wound Note: Was notified y floor nurse that area on left buttock has deteriorated. Wound has the appearance of pressure injury. wound bed shows granulation tissue and slough. [sic]-8/13/25 - Skin/Wound Note - . Breakdown on coccyx .,-8/20/25 - Skin/Wound Note - . Breakdown on coccyx . In review of resident #5's medical record documentation for pressure ulcers and prevention, the documentation showed the staging (determination of wound severity) of resident #5's wound was never documented in an assessment. The only two times the wound size measurements were documented in a wound note were on 8/12/25 and 8/25/25. On 8/12/25 and 8/25/25, the documentation failed to show the staging of the pressure ulcer. Overall, the documentation failed to show why or how the staging was determined based on the characteristics of the wound. There were inconsistencies in the documentation when the wound was first found, which was either 8/5/25 or 8/6/25. The assessments and the nursing notes were found to be conflicting concerning the staging of the wound versus a breakdown of the coccyx wound. Resident #5 showed signs of malnutrition months prior to the wound development progression.

Based on observation, interview, and record review, the facility failed to follow interventions related to resident assistance, evaluate current abilities, and implement additional interventions and monitoring for a severe weight loss of 7.65% in one month, and the resident had a new diagnosis of Severe Protein Calorie Malnutrition, for 1 (#94) of 26 sampled residents. Findings include:During an observation on 8/27/25 at 9:13 a.m., resident #94 was asleep in bed with his breakfast tray dropped off on his bedside table, untouched.During an observation on 8/27/25 at 9:35 a.m., resident #94's full breakfast tray was dumped into the cart for dirty dishes. Staff member S stated the resident was drowsy and did not want any of the breakfast.Review of resident #94's documented weights showed:-7/22/25 132 lbs.,-8/17/25 121.9 lbs. This represented a 7.65% weight loss over one month.Review of resident #94's medication administration record, on 8/27/25, showed the resident was to be weighed weekly, but there was no documented weight for 8/26/25. Review of resident #94's care plan, with an initiation date of 7/22/25, showed under interventions for Diet/Eating, I require extensive assistance with eating.Review of resident #94's admission MDS, with an ARD of 7/28/25, showed the resident needed supervision or touching assistance for eating. Review of resident #94's physician visit note, dated 8/11/25, showed SPCM [Severe Protein Calorie Malnutrition] was added to his list of diagnoses as the physician identified an eight-pound weight loss since the resident's admission. The physician notes advised an RD [Registered Dietitian] consult and Might Shakes twice daily.Review of resident #94's progress notes, dated 8/11/25 - 8/26/25, did not show a dietary note regarding the resident's weight loss. During an observation on 8/27/25 at 12:39 p.m., resident #94 was eating lunch in the dining room. He was bringing his fork to his mouth, and food would fall off the fork before reaching his mouth. He was shaking his head and visibly frustrated. He was not receiving any staff assistance.During an interview on 8/27/25 at 3:51 p.m., staff member P stated that weight reports were pulled weekly for weight loss monitoring, and dietary interventions against weight loss were individualized and resident-specific, looking at what factors could be contributing to a weight change. Staff member P stated she did not think she saw resident #94 on the weight loss report that had been pulled that morning. Staff member P stated #94 would now be added to weekly monitoring, and new dietary interventions were then added to the resident's diet orders. During an interview on 8/28/25 at 9:13 a.m., staff member R stated resident #94 had been admitted after a stroke and was recovering to improve functioning. Resident #94 was receiving therapy on admission, but later declined participation.

Based on observation and interview, the facility failed to provide a wheelchair-accessible grievance box, so residents could submit a grievance independently or anonymously, and the box was not within reach for all the facility residents who used wheelchairs for mobility; and this failure affected 1 (#112) of 26 sampled residents. Findings include: During an observation and interview on 8/26/25 at 4:19 p.m., a grievance box was observed on top of a counter, next to the receptionist's desk, in the main lobby. There was a trash can on the floor in front of the counter, creating a barrier for someone wishing to reach the grievance box. The grievance box had a lid that needed to be pulled down for a resident or person to deposit a grievance form. Staff member G stated she sometimes had to help residents put their grievance forms into the grievance box when they were unable to reach the box themselves, especially if they were in a wheelchair.During an interview on 8/27/25 at 7:52 a.m., staff member A stated he felt any resident in a wheelchair could access the grievance box easily. During an interview on 8/27/25 at 8:33 a.m., resident #112 stated her only means of independent mobility was in a wheelchair. Resident #112 stated she could not reach the grievance box, so she would give a grievance to staff member G, therefore, it was not anonymous if she wished it to be. Resident #112 stated, I can't even make it (a grievance) anonymous. I wish it (grievance box) was accessible and somewhere not everyone could see so easily.

Based on observation, interview, and record review, the facility failed to ensure resident meal trays were served to the residents' rooms in a timely manner and according to the posted mealtimes for 3 (#s 19, 42, and 97) of 26 sampled residents, and it was reported the meals could be lukewarm and residents felt hungry due to having to wait so long for the room trays to be served. Findings include:Review of a facility document, titled Meal Times, not dated, showed: Breakfast 7:30 a.m. through 8:30 a.m.; Lunch 12:00 p.m. through 1:00 p.m.1.During an interview on 8/25/25 at 1:59 p.m., resident #97 stated the food was consistently served thirty minutes late in the resident's rooms. Resident #97 stated he always ate in his room, and his food was often late and was usually lukewarm, which he did not like.During an observation and interview on 8/27/25 at 12:27 p.m., there was no lunch served in resident #97's room, and resident #97 stated, Apparently they're running late. Resident #97 stated he thought lunch was served in the dining room at 12:00 p.m., with the room trays being delivered shortly following that time.During an observation and interview on 8/27/25 at 12:45 p.m., there was no lunch served in resident #97's room, and resident #97 stated he was a ten out of ten hungry (using the scale of one to ten).During an observation and interview on 8/27/25 at 12:59 p.m., resident #42 had been served a drink by the nursing staff but had not been served any food. Resident #42 stated he was eight out of ten hungry (using the scale of one to ten).During an observation on 8/27/25 at 1:06 p.m., resident #97 was served his lunch. The lunch meal was delivered after the designated end time for the meal deliveries. During an observation on 8/27/25 at 1:15 p.m., resident #42 stated he was served his lunch a few minutes ago and stated the food was lukewarm. Per the resident's comment, the lunch was served late. During an interview 8/27/25 at 1:20 p.m., resident #19 stated she had just gotten her meal and stated she was worried about time constraints due to an appointment that she had at 2:30 p.m.During an interview on 8/27/25 at 2:18 p.m., staff member C stated the facility could be better about getting the room trays to the residents faster. Staff member C stated the trays were often late getting to the residents' rooms. During an interview on 8/27/25 at 2:28 p.m., staff member D stated one of the facility's biggest goals was to get the food trays out to the resident rooms on time. Staff member D stated the room trays also affected the CNAs' time management.2. During an observation on 8/28/25 at 8:14 a.m., resident #97 was lying forward on his bedside table and had not been served breakfast. During an interview on 8/28/25 at 8:21 a.m., staff member E stated the meal trays were usually served late due to the food not coming out of the kitchen fast enough. Staff member E stated this issue did seem to be improving, and it was a large issue in the past.During an interview on 8/28/25 at 8:45 a.m., resident #97 stated he got his food about five minutes before the surveyor met with him; therefore, the meal would have been served late. During an interview on 8/28/25 at 9:48 a.m., staff member F stated the food trays were served on the Sapphire hall, then the Crossroads Hall, and lastly the Summit hall. Staff member F discussed hearing the residents complaining of cold food being served to their rooms and stated a kitchen staff member took the food carts to the halls where the residents were residing, and then the CNAs would serve the food from there. Staff member F stated the food could have been cold due to the CNAs playing on their phones and being lazy.During an interview on 8/28/25 at 10:09 a.m., staff member D stated they were not aware of concerns about the food being delivered to the resident rooms late. Staff member D stated the facility was changing the meal times and was in the process of getting feedback from the staff. Staff member D stated breakfast should be served to the resident rooms at 8:25 a.m. on the Sapphire hallway, but this information was not posted anywhere for the residents to see. The employee stated it could be possible that some residents had expectations that the food would be served at 8:00 a.m. Staff member D stated that this information was never posted or communicated to the residents, and stated they may change the times in the future to better serve the residents.

Based on observation, interview, and record review, the facility failed to follow the doctor's orders for edema treatment for 2 (#s 12 and 80) of 26 sampled residents. This deficient practice increased the risk for serious complications related to the edema, especially due to their mobility issues. Findings include:1.Resident #12 During an observation on 8/25/25 at 1:22 p.m., resident #12 was sitting in her wheelchair with noticeable swelling in both of her lower legs and feet. Resident #12 was not wearing elastic bandages or compression stockings. Resident #12 stated the swelling in her legs and feet started months ago, and said, The staff do nothing about it since I got here. During an observation on 8/26/25 at 8:48 a.m., resident #12 was in bed, her legs were not elevated, and there were no pillows at the foot of her bed. There were no items available to be used to assist with the resident elevating her leg(s). During an observation on 8/26/25 at 4:36 p.m., resident #12 was sitting in the dining room, and the resident was not wearing elastic bandages or compression stockings. During an observation on 8/27/25 at 8:49 a.m., resident #12 was sitting in the dining room. The resident was not wearing elastic bandages or compression stockings. During an interview on 8/27/25 at 10:08 a.m., staff member L stated, We try and elevate her [Resident #12's] legs sometimes. During an interview on 8/27/25 at 10:09 a.m., staff member K stated they do not use ace wraps anymore for resident #12. A review of a Weekly Head to Toe Skin Check documentation note for resident #12, located in the resident's electronic health record, dated 8/23/25, with a unknown author, showed: . Does resident have any skin issues? Answer: No . A review of resident #12's Care Plan Report, dated 7/28/25, with an unknown author, showed, . Potential for complications r/t Edema .Apply compression stockings, sleeves, gloves, or [NAME] hose to keep pressure on affected area to minimize fluid retention in the tissue and monitor pressure constriction of the skin . Monitor lower extremities for dependent edema. Elevate lower extremities above the heart to reducing swelling . [sic] Although the care plan had the interventions to prevent worsening edema, the interventions were not observed to be utilized on multiple occasions during this surveyor's observations. A review of resident #12's Treatment Administration Record, dated 8/1/25 - 8/31/25, showed: . Compression ACE wraps on daily off at bedtime, elevate legs when in bed higher than level of heart every morning and at bedtime for Edema - Start Date - 6/9/25 1800 [6:00 p.m.] . [sic]. This treatment was documented as having been applied by staff on 8/25/25, 8/26/25, and 8/27/25, even though the wraps and interventions for the edema were not observed to be in place, and the order wasn't carried out by staff. 2. Resident #80 During an observation on 8/25/25 at 2:35 p.m., resident #80 was lying in bed, and noticeable swelling was observed in both of her lower legs and feet. Resident #80 was not wearing elastic bandages or compression stockings on the lower legs or feet. During an observation on 8/26/25 at 3:52 p.m., resident #80 was lying in bed and was not wearing elastic bandages or compression stockings. During an interview on 8/27/25 at 9:35 a.m., staff member J stated only the nurses were allowed to apply ace wraps, especially when the resident's edema was bad, like hers (resident #80). During an interview on 8/27/25 at 9:44 a.m., staff member M stated the nurses should be applying ace wraps if they were ordered by the physician. During an interview on 8/27/25 at 11:28 a.m., resident #80 stated staff member M was one of the only nurses who put her ace wraps on the residents, and then took them off the resident, before she (staff member M) went home. During an interview on 8/27/25 at 2:16 p.m., staff member K stated if a resident had edema she would chart it in the resident's medical record on the weekly skin check assessment. During an interview on 8/27/25 at 2:23 p.m., staff member B stated nurses typically chart edema on the weekly skin check assessments. During an interview on 8/28/25 at 9:06 a.m., staff member B stated she expected nurses to apply ace wraps if they were ordered (by the provider). A review of a Weekly Head to Toe Skin Check progress note for resident #80, located in the resident's electronic health record, dated 8/26/25, and authored by staff member T, showed: . Does resident have any skin issues? Answer: No . A review of resident #80's Treatment Administration Record, dated 8/1/25 - 8/31/25, showed: . ACE Wrap for compression on qAM/off qHS to BLE's in the evening Off at HS - Start Date - 7/11/23 1600 [4:00 p.m.] . ACE Wrap for compression on qAM/off qHS to BLE's one time a day On in the AM - Start Date - 7/12/23 0600 [6:00 a.m.] . [sic] The physician's order was documented as having been applied by staff on 8/25/25 and 8/26/25, even though this surveyor did not observe the wraps to be in place at the time they were ordered for.

Based on observation, interview, and record review, the facility failed to respect a resident's personal items. The staff cleaned the resident's room, disposing of personal resident items without the resident being present or aware of what was disposed. The lack of respect for the resident's belongings and environment caused the resident frustration, for 1 (#53) of 26 sampled residents. Findings include:During an observation and interview on 8/26/25 at 10:01 a.m., resident #53 was proudly showing off personal items he had collected. There were rocks, some painted and arranged along the windowsill, and a small plant [NAME] he had made from tree branches. Various papers were scattered around the room. The sink was full of apples. There was no smell, and the walkways were clear, therefore, the items in the room did not appear to create a safety hazard at the time.Review of resident #53's care plan, with an initiation date of 7/31/25, showed, Focus: I enjoy spending time in nature-based activities such as picking flowers, rocks, and vegetation.During an observation and interview on 8/26/25 at 1:39 p.m., staff member B and two additional staff members were holding a large black garbage bag and cleaning resident #53's room. Resident #53 was not present at the time the room was being cleaned. The windowsill, which was observed earlier, was now empty, and rocks were being tossed into a crate under the resident's bed. Staff member B stated it was okay for them to clean resident #53's room without him being present, and that he was aware it was something that needed to be done from time to time.During an interview on 8/27/25 at 9:19 a.m., staff member N stated they had to throw away stored food from resident #53's room when doing their scheduled housekeeping because he would hoard food in the sink and drawers.During an interview on 8/27/25 at 4:18 p.m., resident #53 stated, I guess they cleaned cause the state guys (surveyors) are here. Resident #53 stated he would have to go collect more rocks since the ones he had painted were gone. He stated, Those papers are all over the [expletive] place I don't know where they put them. He showed his frustration and did not want to discuss his room being cleaned while he was not present.Review of resident #53's care plan, with an initiation date of 8/8/25, showed: Focus: . personal hx [history] of homelessness and hoarding. Please help me remain in a living environment that meets and supports my need to be safe and continue to meet my need to obtain items I feel are important to me.Interventions, with a revision date of 8/26/25, showed, [Resident name] has previously consented to staff going in and cleaning out his room, even if he is not in there. He enjoys going outside and bringing in rocks, leaves, and other items he finds as ‘treasures.' Staff will remove some of these items to help prevent it from becoming hazardous for him. The plan did not show how staff were to ensure the resident was comfortable with the room cleaning and that he was aware of or ok with items being disposed of by staff. During an interview on 8/28/25 at 10:32 a.m., staff member B stated the intervention related to the resident's room cleaning had not been added previously to the care plan, which was why it was added after the surveyor's observation and identification of the concern. She stated the resident had given permission previously, and she would check if they had a contract or other documentation showing the resident's agreement to the room cleaning and disposing of his personal items. Staff member B stated the facility had given resident #53 a tote to put things away that were very important to him so they wouldn't get tossed, and staff would've allowed resident #53 to look through everything before it was thrown away if he had asked, but he could also be tough to track down during the day. Staff member B stated there was no reason the rocks had to be moved from the windowsill, just like they wouldn't move someone's trinkets. Staff member B stated they were going to reach out to the nurse from that day to determine where and why the resident's rocks on display were moved. During an interview on 8/28/25 at 11:34 a.m., staff member Q stated a conversation had taken place between resident #53 and the previous social service person, that it was okay to go into his room, and it was okay if staff picked up food and certain items. Staff member Q stated this conversation and or signed permission was not documented anywhere.During an interview on 8/28/25 at 11:45 a.m., staff member A stated they did not have a policy related to hoarding or room cleaning (for safety concerns). Review of the facility's Information and Policies, dated June 2023, included in the admission packet, which showed, The facility encourages the creation of a home-like-environment, and we therefore attempt to accommodate all reasonable requests to individualize rooms.

Based on observation, interview, and record review, the facility failed to prevent Immediate Jeopardy level accidents and hazards resulting in a resident with a traumatic brain injury eloping from the facility through unsecured doors, accessing a public road and leaving the facility property, without staff supervision, for 1 (#1) of 9 sampled residents. This failure placed other residents at risk for elopement if they successfully exited out the unsecured doors not equipped with a wander guard alarm system, for 5 (#s 10, 11, 12, 13, and 14) of 9 sampled residents. The facility's failure increased the risk of serious bodily harm, injury, impairment, or death, due to the facility's failure to sufficiently address the doors the resident eloped from. On 6/3/25 at 1:18 p.m., the facility Administrator, previous Interim Administrator, Administrator in-training, Director of Nursing, and Clinical Nurse Unit Manager were notified of an Immediate Jeopardy (IJ) situation, which involved resident #1. The IJ pertained to F689 - Free of Accident Hazards/Supervision/Devices. On 6/5/25 at 4:40 p.m., the facility provided an acceptable plan to remove the immediacy for the residents residing in the facility who are at continued risk for elopement. The surveyor was onsite and did verify the removal of immediacy by observations, interviews, and record reviews. The Severity and Scope of the Immediate Jeopardy was identified to be at the level of K, and upon removal of immediacy, lowered to H. Findings include: 1. Review of a facility reported incident submitted to the State Survey Agency, dated 3/28/25 at 9:50 p.m., showed resident #1 was last observed in his room on 3/28/25 at 7:15 p.m. He was seated in a lounge chair. At approximately 7:30 p.m., staff heard a door alarm and discovered a delayed egress door had been opened. The facility's elopement protocol was immediately activated. Facility staff confirmed resident #1 was no longer in the facility. This prompted a thorough search of both the interior and exterior of the facility. Police were contacted, and upon the officer's arrival, an individual who was outside reported seeing a man near a school, but the person was unable to provide an exact location. Resident #1 was located by law enforcement and returned to the facility on 3/28/25 at 7:57 p.m. The resident was alone and unattended for about 45 minutes, he left the facility property, and walked a good distance on his own. During an observation and interview, on 6/2/25 at 2:30 p.m., staff member E was present when a set of double doors were observed at the end of the crossroads unit. The windows on the double doors had white faux wood window blinds. The blinds were closed blocking the view of any person exiting to the outside. The double doors did not have a wander guard alarm system in place to alert staff of a potential elopement. The double doors opened to a vestibule that led to double egress exit doors which alarmed once the push bar on the door was pressed upon exiting. Staff member E stated resident #1 eloped from the facility on 3/28/25 at 7:30 p.m., and he exited out the emergency exit doors at the end of the hall on the crossroads unit. The unit was not occupied by residents or staff at the time of resident #1's elopement. Staff member E stated the exit doors at the end of the hall on the crossroads unit had not been secured with a wander guard alarm system in the last four years that she was aware of. Staff member E stated prior to resident #1's elopement, on 3/28/25, the resident would spend time on the memory care secure unit and would then be brought back to his room on the summit unit after dinner. Staff member E stated the facility's plan was to move resident #1 to the secure unit permanently, after the secure doors on the unit were moved, allowing a room to become available for resident #1. Staff member E stated resident #1 was moved to the secure unit on 4/7/25. During an interview on 6/2/25 at 4:21 p.m., staff member C stated the wander guard alarm system was not installed on the exit doors on the crossroads and sapphire unit. Staff member C stated the wander guard alarm system was not needed on these units because the emergency exit doors had an alarm. The alarm sounded if a resident exited the facility. Staff member C stated the IDT reviewed resident #1 prior to discontinuing the 1:1 staff monitoring on 3/28/25. Staff member C stated she did not recall when the IDT met regarding resident #1, but a progress note or assessment should have been entered into the resident's EHR. Staff member C stated she was not sure if any measures were used in evaluating resident #1 during the IDT meeting, but the resident had been sleeping at night, and the IDT decided to trial the resident without a 1:1 monitor, on 3/28/25. Staff member C stated, Obviously it didn't work. Staff member C stated she would be most concerned about a resident who was an elopement risk exiting the facility and getting hit by a car. During an interview on 6/4/25 at 5:20 p.m., staff member D stated on 3/28/25 he returned to the facility at 7:30 p.m. to pick up his phone. Staff member D stated he arrived and entered the facility's back parking lot. Staff member D stated he noticed the facility's emergency exit door was opened, and an alarm was sounding. Staff member D stated when he walked into the facility, the nurse told him an elopement occurred and resident #1 was missing. Staff member D stated he went back outside to look for resident #1. Staff member D stated two people were outside and stated they had seen an older gentleman at the school near the facility. Staff member D stated he returned to his vehicle and drove over to the school. Staff member D stated he did not see resident #1 at the school, but he did see a police car down the street in a residential area. Staff member D stated he arrived at the location of the police vehicle and observed resident #1 speaking to a police officer. Staff member D stated he approached resident #1 and encouraged him to come back to the facility. Staff member D stated the resident eventually got into the police vehicle and returned to the facility. Review of resident #1's EHR showed resident #1 was admitted to the facility on [DATE] for skilled nursing services with a diagnosis of traumatic brain injury and agitation. Review of resident #1's nursing progress notes showed the following: On 3/6/25 at 5:17 p.m., resident #1 eloped from the facility as staff accompanied him. No injuries were identified by nursing staff. Resident #1 became agitated and combative with staff, and the local police department was called to assist with transferring the resident back to the hospital. Resident #1's care plan was updated to include the resident was to be in direct line of site of staff at all times. On 3/12/25 at 9:21 p.m. resident #1 eloped from the facility as staff accompanied him. No injuries were identified by nursing staff. Resident #1 became impulsiveness and was unable to be redirected. Resident #1 was transferred to the hospital for a psychiatric evaluation on 3/13/25. Resident #1 returned to the facility. Resident #1's care plan was updated, and a wander guard alarm was placed on the resident's left ankle with staff checking the device every shift to ensure it was functioning. On 3/28/25 at 7:30 p.m., resident #1 eloped from the facility, going out double egress doors on a unit not occupied by residents or staff, and the doors were not secured with a wander guard alarm. The double doors opened to a vestibule and led to double egress doors, which alarmed once the push bar on the door was pressed, as exiting. Resident #1 left on foot, crossing the street and making his way down the block, unattended. The resident was found by the local police department at a residential location, 0.2 miles from the facility. Resident #1 was brought back to the facility by the police, and the nurse completed an assessment of resident #1. No injuries were identified. The resident's care plan was updated to resume 1:1 staff monitoring. 2. Review of resident #10's elopement risk assessments showed the resident was a risk for elopement on the following assessment dates: 9/6/24, 12/6/24, 3/6/25, and 6/3/25. Review of resident #10's care plan, dated 6/3/25, showed the resident had a wander guard on his right wrist instructing staff to check the device every shift to ensure it was functioning properly. 3. Review of resident #11's elopement risk assessments showed the resident was a risk for elopement on the following assessment dates: 10/24/24, 11/8/24, 2/6/25, 5/8/25, and 6/3/25. Review of resident #11's care plan, dated 4/2/25, showed the resident had a wander guard on her right ankle instructing staff to check the device every shift to ensure it was functioning properly. 4. Review of resident #12's elopement risk assessments showed the resident was a risk for elopement on 5/30/25 and 6/3/25. Review of resident #12's care plan, dated 6/2/25, showed the resident had a wander guard on his left ankle instructing staff to check the device every shift to ensure it was functioning properly. 5. Review of resident #13's elopement risk assessments showed the resident was a risk for elopement on the following assessment dates: 12/16/24, 3/15/25, 4/14/25, and 6/3/25. Review of resident #13's care plan, dated 4/15/25, showed the resident had a wander guard on his left wrist instructing staff to check the device every shift to ensure it was functioning properly. 6. Review of resident #14's elopement risk assessments showed the resident was a risk for elopement on the following assessment dates: 6/14/24, 7/24/24, 10/24/24, 11/26/24, 2/26/25, 5/26/25, and 6/3/25. Review of resident #14's care plan, dated 6/3/25, showed the resident had a wander guard alarm on his left wrist instructing staff to check the device every shift to ensure it was functioning properly. It was identified during the interviews and record reviews the wanderguard checks were not being completed as required. During an interview on 6/2/25 at 5:00 p.m., staff member I stated she worked on the sapphire unit. Staff member I stated she did not know who checked the wander guard alarm system, but she believed it worked, because when a resident with a wander guard alarm device would get close to an exit door the alarm would start to beep. During an interview on 6/3/25 at 9:00 a.m., staff member L stated she had one resident who was an elopement risk and the resident wore a wander guard alarm device. Staff member L stated the facility doors exiting outside to a public area have a wander guard alarm system installed on the door. Staff member L stated it was a facility regulation the system was installed on all doors exiting the facility. Staff member L stated if a resident who had a wander guard alarm device on moved to close to an exit door it would cause a beeping sound. Staff member L stated the beeping noise alerts staff to look in the area where exit doors are located, and staff can then redirect the resident prior to the resident exiting the door. During an interview on 6/3/25 at 9:22 a.m., staff member J stated if she had a resident with a wander guard, she would take the resident close to an exit door to see if the device was working. Staff member J stated if the door started making a beeping noise, she would know the device was working. Staff member J stated she assumed all exit doors in the facility had a wander guard alarm system installed. Staff member J stated the wander guard door alarm system had a different sound than the doors which alarmed when the emergency exit doors were opened. Staff member J stated she responded to a wander guard alarm immediately; whereas if an emergency exit alarm sounded her response would not be immediate, because at times it would be a staff member using the door. Staff member J stated the emergency exit door was propped open, and the alarm was disarmed by staff. Review of the facility document titled, (Facility Name) Elopement Policy and Procedure, undated, showed: Policy Statement It is the policy of the facility that all residents are afforded adequate supervision to provide the safest environment possible . Procedure 1. Residents who have been assessed at risk for elopement/wandering shall be provided with a least one of the following safety precautions by the facility: a. An adult electronic monitoring device will be used to notify/alert staff by sounding an alarm when the resident enters the perimeter around an alarmed door. 2. As part of the facility's Preventative Maintenance Program, all door keypads will be checked for proper function daily by the Maintenance department/designee. These checks will be documented with date and time completed. 3. Residents with an adult electronic monitoring safety device will be checked every shift to ensure the device is in place. 4. Adult electronic monitoring safety devices will be checked nightly to ensure the device is functioning properly. 5. At no time shall a door alarm be turned off, without the continual supervision of the exit. *If the alarm must be turned off, it is the responsibility of the person disarming it to make sure it is functioning properly once the alarm is turned back on. Routine Procedure for Wandering Residents and Prevention of Missing Residents/Elopement: . 3. All residents at risk for possible elopement/wandering shall be accompanied by staff or a responsible party when leaving the residents unit and/or facility grounds. . 5. When a door alarm sounds, staff members shall immediately respond to determine the cause of the alarm. Routine Procedure for wandering Residents and Prevention of Missing Residents/Elopement: . 5. When a door alarm sounds, staff members shall immediately respond to determine the cause of the alarm. a. The staff responding to the alarm will check the outside of the area's building/vicinity to see if a resident has exited the building. [sic] Review of a facility document titled (Facility Name) Facility Assessment dated, May 2025 showed: . Staff Plan . Licensed Nurses (LN): RN, LPN, LVN providing direct care .The ratio of registered and licensed practical nurses to nursing aides shall be sufficient to assure professional guidance and supervision in the nursing care of the resident. Each nurse is limited to one hall or designated number of rooms within the facility and has all patient room entrances and exits within sight from the nurse's station or medication/treatment cart. The exception is when coverage may be limited to one-night nurse. When this occurs, a medication aide will be used in the place of the 2nd nurse. .

Based on interview and record review, the facility failed to implement appropriate measures to prevent skin breakdown and identify pressure ulcers timely, for 1 (#108) of 2 sampled residents, resulting in the development of five Stage II pressure ulcers, and four Deep Tissue Injuries after admission to the facility, resulting in infections and increased pain. Findings include: Review of a complaint filed with the State Survey Agency, reflected, Resident was admitted not very long ago and has since developed a serious wound. Review of resident #108's EMR progress note, dated 3/31/23 at 5:50 p.m., reflected resident #108 admitted to the facility alert and oriented, transferred with moderate assist of one with a walker, required extensive assist with activities of daily living, and the resident's skin was frail but intact. Resident #108 did not have any pressure ulcers or skin breakdown at the time of admission. Review of resident #108's baseline care plan, date initiated 3/31/23, reflected resident #108 had a potential for pressure ulcer development related to his Braden score (score # was blank) and dehydration. Interventions included, .Follow facility policies/protocol for the prevention/treatment of skin breakdown and .Notify nurse immediately of any new areas of skin breakdown, such as redness, blisters, bruises, discoloration noted during bath or daily care. Review of resident #108's EMR alert note, dated 4/10/23 at 8:46 p.m., reflected the resident complained of tailbone pain, and a skin assessment revealed a pressure wound with black eschar measuring 3.5 cm x 3 cm, redness from tailbone to rectum measuring 13 cm x 4.5 cm, and an open yellow area below the black eschar measuring 1.5 cm x 1 cm. There was no staging (classification of wound) identified at that time. Review of resident #108's care plan, updated on 4/13/23, reflected resident #108 was .at risk for pressure ulcers related to limited mobility, sacral unstageable ulcer, R buttock stage 2, L buttock stage 2. [sic] 1. Care plan interventions initiated included: - .Apply gel cushion to wheelchair. - .HIGH RISK: skin check every shift. Report abnormalities to the nurse. - .Keep skin clean and dry. Use lotion on dry skin. - .pressure relieving cushions to w/c and recliner. - .Position side to side. - .RD referral. - .Zinc, Proheal, and dressing changes 3x weekly. and - .Air distribution wheelchair cushion to recliner and wheelchair. The resident's care plan was updated on 4/13/23 to include a bruise to the left hand. 1. Interventions initiated included: .Activities to supervise 1:1 (one on one) with colored pencils. - .Evaluate for UTI. Review of resident #108's physician progress note, dated 4/14/23, reflected resident #108 developed a fever, and the presumed source of the fever was his sacrum pressure ulcers. The resident was evaluated for hospice care. Resident #108's daughter and son-in-law were in agreement to pursue hospice care, and to provide the resident with comfort measures. Review of resident #108's progress note, dated 4/16/23 at 9:43 p.m., reflected a finding of .what appeared to have been a fluid filled blister on the right heel that had obviously drained . Review of resident #108's care plan, revised on 4/17/23, reflected .right heel stage 2, blister from ill-fitting slippers, left skin tear left hand. [sic] 1. Interventions initiated included: - .Float heels when in bed to avoid pressure to heels. - .Encourage resident to sit in his recliner some during the day with feet elevated to decrease swelling in his feet and legs. - .Geri sleeves. Review of resident #108's physician note, dated 4/17/23, reflected resident #108 improved after antibiotic and IV therapy. Resident #108 no longer wished to pursue hospice and would remain on skilled services. Resident #108's goal was to return to an assisted living facility. Review of resident #108's EMR, from 4/16/23 to 4/24/23, failed to show any Skin Alteration Evaluations (skin assessments) had been completed for resident #108. Review of resident #108's physician note, dated 4/21/23, reflected resident #108 wanted to pursue wound clinic treatments for his sacral pressure ulcers. Review of resident #108's physician note, dated 4/27/23, reflected resident #108 had developed a fever, antibiotics and fluids were ordered, and family stated they would not want resident #108 to go to the emergency department if the sacral ulcer became overly complicated. A wound clinic appointment was scheduled for 5/1/23. Review of resident #108's physician note, dated 5/3/23, reflected resident #108's sacral pressure ulcers were debrided with a recommendation for continued antibiotic treatment, and a wound vac placement. Review of resident #108's physician note, dated 5/8/23, reflected staff member S found a pressure ulcer on resident #108's left ear during a routine visit. Review of resident #108's care plan, revised on 5/8/23, reflected, left ear stage 2, right ear, right and left hip DTI, left knee stage 2. [sic] 1. Interventions initiated included: .Encourage pt to sleep on right side and ensure tubing is appropriately placed to avoid pressure. Review of resident #108's physician note, dated 5/12/23, reflected resident #108 had developed delirium with an underlying infection source as probable etiology. Review of resident #108's nursing progress notes and physician progress notes, from 4/10/23 to 5/8/23, reflected resident #108 had developed five Stage II pressure ulcers, and four Deep Tissue Injuries, since his admission on 3/31/23. Review of resident #108's physician note, dated 5/15/23, reflected resident #108 continued to decline, and resident #108's family requested to defer further wound clinic visits and opted for hospice care. Review of resident #108's care plan, revised on 5/15/23, reflected the following interventions: - .Wound Vac @ 125mm/hg and change every M, W, and F. - .Air mattress, setting should be close to pt weight, and - .Hospice to evaluate. Review of resident #108's physician note, dated 5/17/23, reflected .He still has been displaying some increased pain and grimaces, staff are unable to find positions where he is comfortable. Review of resident #108's EMR progress note, dated 5/18/23 at 6:21 a.m., reflected resident #108 passed away on 5/18/23. During an interview on 6/21/23 at 4:30 p.m., staff member A stated staff member H had been suspended and removed from the position held at the time of the survey. Staff member A stated the facility had. made attempts to address staff member H's wound competency with training, and completed a performance improvement plan with her, but these incidents were the final straw. Staff member A was not able to discuss resident 108's facility acquired pressure ulcers and his decline.

Based on observation, interview, and record review, facility staff failed to ensure residents received adequate supervision and assistive devices to prevent accidents for 2 (#s 21 and 32) of 10 sampled residents, resulting in falls with fractures, and the potential for a fall related to the safe and appropriate use, by a staff member, for the sit-to-stand mechanical lift. Findings include: 1. During an observation on 6/20/23 at 8:14 a.m., resident #21 was sitting on the side of her bed. Staff member W placed the sit-to-stand mechanical lift against the bed, and placed the mid back strap on the resident, attaching the lift to resident #21. The lift's legs did not fit under the bed, and staff member W was not able to get the lift close enough to get resident #21 to a standing position. Staff member W began moving the sit-to-stand lift in various directions, in attempts to get the lift's legs to move under the bed. Resident #21 was sliding side to side and was attempting to stay on the bed. Resident #21 was lifted into a standing position. Staff member W failed to use the knee straps for safety, which are attached to the sit-to-stand lift. Resident #21 was then moved across the room to the bathroom. During resident #21's time on the toilet, staff member W left the room and resident #21 removed her arm from the sling. During an observation on 6/20/23 at 8:33 a.m., staff member W returned to the resident's room, and reminded resident #21 to keep the sling on (the resident's arm). Staff member W used the sit-to-stand lift to transfer resident #21 from the bathroom. Resident #21 was left standing in the sit-to-stand lift while staff member W cleaned the resident's peri area. Resident #21 began to move her left arm out of the underarm sling to show staff member W a picture on her phone. Staff member W reminded her to keep her arm in the sling to prevent a fall. The sit-to-stand lift's safety knee straps were not used during the transfers, and resident #21 was inconsistent in safe use of the arm/back strap. The unsafe practices increased the risk of #21 falling from the sit-to-stand lift. Record review of resident #21's care plan, initiated 7/12/22, reflected resident #21 had an altered thought process; was resistive to cares; had poor safety awareness, and required the use of assistive devices. The failure to ensure safe and appropriate use of the sit-to-stand lift increased the resident's fall risk. 2. A record review of a facility reported incident, dated 1/21/23, showed resident #32 had fallen on 1/21/23, resulting in a left hip fracture requiring hospitalization . The report showed resident #32 attempted to transfer himself from his recliner to his wheelchair. Review of resident #32's care plan, initiated on 9/15/22, reflected: .I am a high fall risk related to history of falls with fractures, incontinence, limited mobility. Interventions included: .Ensure that I will be able to use the call light. If the call light is difficult to press, consider giving me a foam pad call light or other adaptive call lights . - I need skilled therapy intervention to improve my strength and endurance . There were no new fall interventions documented after the fall on 1/21/23. A record review of a facility reported incident, dated 2/5/23, showed resident #32 fell on [DATE], resulting in a fractured nose, fractured ribs, and a possible torn ligament in the right leg. A review of resident#32's care plan showed new interventions were added after resident # 32's second fall with multiple fractures. The report showed resident #32 was in bed, dropped his television remote, attempted to retrieve it, and fell out of bed. Review of resident #32's fall care plan, revised on 2/17/23, reflected: fall mat, a call don't fall signs at bedside, a reacher at bedside, and a new bed in the low position at all times. During an observation on 6/21/23 at 3:08 p.m., resident #32 did not have a fall mat next to his bed. A recliner was in place at end of the resident's bed, with no room for a fall mat to be used next to it. During an observation on 6/22/23 at 10:08 a.m., resident #32 did not have a fall mat next to his bed. A recliner was in place at end of bed, with no room for a fall mat to be placed. During an interview on 6/22/23 at 10:09 a.m., staff member U stated resident #32 did not have or use a fall mat. A review of the facility's policy, Assessing Falls and Their Outcomes, revised March 2018, reflected, .When a resident falls, the following information should be recorded in the resident's medical record . 6. Appropriate interventions taken to prevent future falls.

Based on interview and record review, the facility failed to protect 1 (#62) of 27 sampled residents from physical abuse and neglect by a staff member. Findings include: Abuse: 1. Review of a Facility Reported Incident, dated 5/4/22, showed an incident involving NF5 and resident #62 on 4/30/22, where NF5 pushed the resident back into a chair and had placed the medication cart in front of the resident, preventing her from rising from the chair. The incident report also showed NF5 holding the resident's hands down while speaking to her. Review of new hire documentation showed background checks were completed for NF5 on 4/9/21 and 4/19/21. A background check was completed on 5/6/22 following the incident. Review of the facility sign in sheets showed, NF5 attended abuse and neglect training on 4/23/22. Review of NF5's orientation documents showed abuse training was completed on 5/19/21. Review of NF5's Corrective Action form, dated 5/13/22, showed, On 5/4/22 through conducting the investigation on the reported fall [resident #62's fall], footage was witnessed on 4/30/22 of you pushing a resident [#62] back into a chair with your arms and hands, getting into the resident's face and using the medication cart to keep the resident from getting up. Under Level of Corrective Action showed Termination. During an interview on 7/21/22 at 10:46 a.m., staff member L stated abuse training is completed online and was done monthly. Staff member L stated if abuse was witnessed, it would be reported to the nurse and nurse manager. During an interview on 7/21/22 at 11:37 a.m., staff member A stated the camera footage is reviewed once or twice a week, and we just happened to see the incident in question involving NF5. After seeing this we went back a couple of months and reviewed the footage and could not find any other incidents. Neglect: 2. Resident #62 fell and sustained a bruise to her right upper leg on 4/30/22. Neither NF5, staff member P, or staff member Q immediately reported the fall or the resident's bruising to appropriate management and/or administration until 5/4/22. Review of resident #62's care plan showed she had cortical blindness and needed staff assistance to move around the unit. Review of the Verification of Investigation for resident #62's fall, dated 5/4/22, showed the following: - Resident #62 had a fall on 4/30/22. The fall was witnessed by staff. The nurse did not assess the resident, did not assist the resident up off the floor, did not notify the provider or POA, and did not document the fall. - Staff review of camera footage from the common area on 5/4/22 of the unit showed resident #62 bumped into a chair trying to get around the medication cart. - Through the investigation, the facility determined the resident then walked into a garbage can located in the hallway and fell . - A full body skin assessment was performed on 5/4/22 with bruises noted to the resident's right upper leg. Review of two statements submitted on 5/4/22, showed the fall was witnessed by staff member P, and staff member Q. The statements showed NF5 told the two staff members to shush about the fall. The Statements showed NF5 stood and watched the resident get herself up off the floor. Review of the investigation submitted to the State Survey Agency showed the facility did determine the fall occurred on 4/30/22, and the staff on the unit did not report the incident until 5/4/22. During an interview on 7/21/22 at 11:37 a.m., staff member A stated the camera footage was reviewed and it was verified the fall did occur, and the resident got up on her own without staff assistance from staff members P, Q, and NF5.

Based on observation, interview, and record review, the facility licensed nursing staff failed to meet professional standards of practice by not accurately assessing and reporting a worsening surgical wound to a physician for 1 (#250) of 1 sampled resident; failed to report a worsening yeast infection as ordered by the physician for 1 (#15) of 1 sampled resident; failed to follow physician orders regarding resident weights for 2 (#s 237 and 245) of 2 sampled residents; failed to meet professional standards of documentation related to physician communications and nursing assessment for 1 (# 237) of 1 sampled residents. Findings include: 1. Resident #250 was admitted to the facility following a below the knee amputation on 1/11/22. A record review of a facility reported incident to the State Survey Agency, dated 2/23/22, showed: .On 2/23/22, floor nurse received a call from [provider] staff informing her that [resident #250] will need a right BKA revision . .they [provider] had received a call from dialysis in regard to the appearance of the incision to [resident #250's] BKA.staff reviewed previous documentation in PCC Wound Rounds that was performed by wound nurse (staff member F) on 2/22/22. Wound Round documentation did not note discoloration, discharge, dehisced, or steri-strips removed or notification to provider.Provider ordered resident to be evaluated at the ER. During an interview and record review on 7/20/22 at 3:19 p.m., staff member G reviewed wound documentation and explained the timeline that led to resident #250 having to return to surgery for a revision of her below the knee amputation. Resident #250's wound documentation showed: - 1/11/22- Resident #250 returned to the facility following a below the knee amputation. - 2/10/22- Surgical staples were removed by resident #250's orthopedic surgeon, leaving one staple still in the wound. Steri-strips were placed over the wound, and a dressing was applied by the physician. - 2/21/22- The remaining surgical staples were removed by the unit nurse. - 2/22/22- Facility document, Wound Assessment Details, dated 2/2/22 at 5:02 p.m., documented by staff member F showed: . Tissue Types: Epithelial (Pale Pink or Red): 75%, Necrotic Soft, Adherent: 25% Measurements: Length 1.8 cm, Width 19.50 cm, Depth 0.00 cm . .Exudate: Amount- None, Type- None Periwound Criteria: Normal Wound Edge: Distinct &Attached . .Signs of Infection Present: No . . Wound bed fragile, adherent slough at wound edges. Steri-strips intact. - 2/23/22- Resident #250 was sent for dialysis treatment. The dialysis clinic contacted resident #250's orthopedic provider. The provider ordered resident #250 to be sent to the ER for further evaluation. Resident #250 then returned to the facility on Doxycycline antibiotic and was scheduled for a follow-up with her orthopedic provider on 3/1/22. - 2/25/22- Resident #250's dressing was changed by staff member D; no photo or documentation present in wound round system. - 2/27/22- Resident #250's dressing was changed by staff member N; no photo was documented in the wound round system. The progress notes showed the wound was red, non-tender, not warm, and no drainage. The resident was on an antibiotic. - 3/1/22- Resident #250 was seen and evaluated in the orthopedic clinic by the orthopedic provider. The orthopedic provider applied a dressing and scheduled resident #250 for a revision of her below the knee amputation on 3/4/22. The resident returned to the facility with a dressing with Do Not Remove written in bold letters. - Licensed nursing staff providing services for the surgical wound failed to accurately assess and document the status of the surgical wound, and the physician was not notified the wound was deteriorating. 2. During an observation on 7/20/22 at 10:58 a.m., resident #15 was observed multiple times with her hand down the front of her brief and appeared to be scratching her peri area. During an observation on 7/20/22 at 11:03 a.m., resident #15 was observed with her hand down the back of her brief and appeared to be vigorously scratching her buttock area. During an interview on 7/20/22 at 11:10 a.m., staff member J said, resident #15's yeast infection was improving but now it had gotten worse. Staff member J stated resident #15 was not always cooperative with cares and cream application to treat the yeast infection. A record review of resident #15's physician order, dated 5/26/22, showed, apply to affected groin area, two times a day, for yeast infection, notify provider if no improvement and/or worsening. A review of facility document, LGHC Skin Evaluation for resident #15 by staff member M, effective date 7/16/22, showed, resident #15 had an alteration in skin integrity. Non-Pressure Ulcer area of the assessment was blank, no site was identified, no description was documented. Additional skin/treatment note showed, yeast infection in groin area, treated with Clotrimazole and Nystatin powder. No documentation of an increase in size of resident #15's yeast infection or physician notification was documented. A record review of resident #15's progress note, created date 7/17/22, by staff member M showed, Yeast infection increasing in size despite the treatment with Clotrimazole, resident scratching and area is mostly moist. Physician notification, the size, description of the skin area affected by the yeast, were documented. During an interview on 7/21/22 at 8:17 a.m., staff member F stated, staff member M was not available for interview. During an interview on 7/20/22 at 10:07 a.m., staff member E stated, physicians are notified of resident abnormal findings by phone, by the nurse, and notification should be documented in the progress note. Staff member E said that skin documentation should include the size of affected area, detailed description of the area, and if a physician was notified. The note should also include any follow-up. A record review of resident #15's progress note, dated 7/20/22, which was during the survey, by staff member F showed, Provider was notified of yeast type infection not resolving. Provider was going to review chart to see previous treatments that were tried in past to see what treatment could be started. Awaiting response from provider. 46400 3. Review of resident #237's care plan, initiated 7/15/22, showed, .Obtain weight as ordered. Review of resident #237's physician orders, dated 7/12/22, showed, Weigh upon admission/readmission every day shift for 3 days and every day shift every 7 day(s) for 28 days weekly x4 . Review of resident #237's medical record showed a weight of 137.4 lbs on her 7/12/22 admission. No further weights were documented when the survey ended on 7/21/22. 4. Review of resident #245's physician orders, dated 7/12/22, showed, Weigh upon admission/readmission every day shift for 3 days and every day shift every 7 day(s) for 28 days weekly x4 . Review of resident #245's medical record showed a weight of 132.8 lbs on his 7/12/22 admission No further weights were documented when the survey ended on 7/21/22. During an interview, on 7/21/22 at 8:19 a.m., staff member D stated residents are weighed on admission and then for three consecutive days to be sure they get an accurate weight. After that it is once a week times four, then monthly if they are here that long. 5. Review of resident #237's nursing progress notes, dated 7/16/22, showed, Resident showing signs of UTI, contacted practitioner she stated to order an urine sample on her. attempted to perform In and out cath residents diaper was wet, no urine collected. will attempt in another hr [sic]. During an interview on 7/20/22 at 2:40 p.m., staff member G stated for a UTI they would call the provider for a urine dip order. There would be an SBAR note with symptoms: fevers, foley, vitals, ect She stated, We could work on being better on follow up notes. During an interview on 7/21/222 at 10:10 a.m., staff member D stated she would also wonder what UTI symptoms the writer of resident #237's 7/16/22 progress note was referring to. Review of resident #237's medical record reflected a lack of documented follow up on the residents suspected UTI from 7/16/22 to 7/19/22. A late entry note, dated 7/19/22, was put in after the UA results were requested by the surveyor on 7/19/22. Review of a late entry nursing progress note for resident #237, dated 7/19/22 at 5:06 p.m., showed, Per conversation with provider yesterday, 7/18/22, straight cath would not be indicated due to cognitive function and physical limitations of resident. Provider said she would follow up and let writer know the plan, but writer is still waiting to hear back. All VS are stable [sic]. During an interview on 7/21/22 at 10:15 a.m., staff member D stated the provider hadn't gotten back to the staff [regarding the UTI concerns for resident #237 on the 16th]. She stated the nurse had talked to him the next day but forgot to put the note in (the medical record). The doctor discontinued the UA order on 7/20/22 due to believing the resident's symptoms were related to dementia instead of a UTI.

Based on observation, interview, and record review, the facility failed to prevent and identify the development of 2 Stage III pressure injuries for 1 (#20), and failed to prevent a catheter-related pressure injury on the penis; and failed to accurately assess and identify a pressure injury on the coccyx for 1 (#19) of 5 sampled residents. Findings include: Ankle wound 1. During an interview on 7/18/22 at 3:30 p.m., resident #20 stated she had a long-standing sacral wound, goes to the wound clinic, and uses a wound vacuum for healing. She also stated she had a pressure sore on her ankle that had recently gotten bigger. Resident #20 stated the wound was on her right ankle, towards the wall, when she was in her bed, and the staff had not caught it. She stated it had gotten infected in April 2022, and she was hospitalized and was on several antibiotics. Review of resident #20's Skin Evaluation report, dated 4/1/22, showed the identification of the right ankle pressure injury. It did not include measurements, description, or Staging (severity) of the wound. A written note showed Resident has a new pressure injury to right ankle, new orders obtained and will have wound nurse evaluate. Review of the facility wound nurse's wound assessment, dated 4/6/22, showed the ankle wound was a Stage III, with 25 percent slough, and measured 1.10 x 0.30 x 0.01 cms. Review of resident #20's care plan, dated 4/1/22, showed the resident had a right ankle and right heel wound, described as arterial. Review of resident #20's nursing progress note, dated 5/11/22, showed the resident's wound would now be classified as a vascular wound, instead of pressure. During an observation on 7/19/22 at 10:50 a.m., resident #20's ankle wound was about the size of a [NAME]. During an interview on 7/20/22 at 4:30 p.m., staff member G stated the facility determined resident #20's wound was not related to pressure, because it had not developed over a bony prominence, and had deteriorated so quickly. During a phone interview on 7/21/22 at 8:20 a.m., NF3 stated it was the wound clinic's opinion that resident #20's ankle and heel ulcers were related to pressure. A vascular study had been completed by the wound clinic for resident #20, and the report showed no impairment. She also stated the ankle wound had been infected, and resident #20 was hospitalized for sepsis in April, 2022. She stated the current treatment for resident #20's ankle may not have been applied correctly, because it was full of slough again on 7/18/22, and it should not have worsened if the treatments were done correctly. Heel wound Review of resident #20's nursing progress note, dated 5/23/22 showed New wound noted to resident's right Achilles heel. Area measures 1cm x1.2 cm x unknown depth. 50 % slough. The provider was notified. Review of resident #20's wound clinic note, dated 7/5/22, showed the wound was a Stage III pressure injury. Review of resident #20's current wound clinic note, dated 7/18/22, showed the heel wound measured 1 cm x 0.7 cm x 0.1 cm. During a phone interview on 7/21/22 at 8:20 a.m., NF3 stated resident #20's heel wound was better, but still contained some slough. During an interview on 7/20/22 at 3:29 p.m., staff member C stated she did not have the answer to how a weekly skin check could miss new pressure injuries until they were Stage IIIs. 2. Penis wound Review of resident #19's nursing progress note, dated 7/14/22, showed the resident was complaining about pain from his catheter. The staff member noticed blood around the head of the penis, and pulled back the foreskin to find a sore on the right side of the penis head. The area was cleansed and anitbacterial ointment was applied. The catheter was placed on 6/7/22 for urinary retention. Review of resident #19's physician order, dated 7/14/22, showed the wound should be monitored each shift by nursing staff. It also included an order for a leg strap to avoid exacerbation to the penile wound. Review of resident #19's Skin Evaluation, dated 7/15/22, showed the catheter was rubbing on the resident's penis, which caused the pressure injury. It measured 3 cm with 75% slough. Review of resident #19's MAR, dated 7/20/22, showed a physician order change to assess the wound each shift. During an interview on 7/20/22 at 1:55 p.m., staff member I, the nurse for resident #19, stated she did not know anything about the sore on resident #19's penis. Cocyyx wound Reivew of resident 19's skin evaluation form, dated 5/18/22, showed the resident complained his bottom hurt. Upon assessment, he does not have any pressure injuries on his bottom at this time. Review of resident #19's nursing progress note, dated 5/20/22, showed the resident had returned from the hospital after an evaluation for falls. The note showed the resident had a pressure ulcer on his coccyx that measued approimately 1cm and was open to air. No drainage was noted. Review of resident 19's general progress note, dated 5/20/22, showed the plan was to put an air cushion in his chair for the sore on his bottom. The note showed We would have the wound nurse look at it and put in orders for maximum healing. Review of a picture of the area provided by the facility, dated 5/24/22, did show an open area, measured at 1 cm, and labeled as a small scratch. Review of resident 19's nursing progress note, dated 6/4/22, 6/14/22 and 6/18/22 showed wound care was provided and the coccyx area was healing well. Review of the facility skin program policy and procedure, dated 4/2021, showed the facility would provide care and services to prevent pressure injury development and promote healing of pressure injuires that are present.

Based on observation, interview, and record review, the facility failed to: - properly implement infection prevention strategies (transmission-based precautions, face masks, room restriction, and social distancing) in order to prevent the transmission of COVID-19 in the memory care unit for 10 (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) of 10 residents sampled. Five residents (#s 2, 3, 4, 5, and 6) were diagnosed with [REDACTED].#1). Of the six total residents who were positive, one resident (#1) died in the facility, one resident (#2) was hospitalized and subsequently died , and two (#s 4 and 6) demonstrated fatigue and a poor appetite. The four remaining residents (#s 7, 8, 9, and 10) demonstrated a variety of symptoms from a general feeling of being unwell, vomiting, poor appetite, fatigue and fever. - ensure COVID-19 positive residents wore appropriately fitted PPE when leaving the isolation unit and the facility for care for 1 (#21) - perform appropriate hand hygiene between glove changes, between residents when providing care, and after touching contaminated PPE for (#s 13, 21, 23, 24, and 25) - ensure staff always wore the necessary PPE when in the facility, for 1 (#26) of 26 sampled residents. IMMEDIATE JEOPARDY On [DATE], an Immediate Jeopardy situation was announced to the facility administrator at 2:28 p.m. Deficient practices were identified for F880 - Infection Control, of the State Operations Manual, Appendix PP. The Severity and Scope of the deficient practice was identified to be at the level of K, and upon removal of the immediacy, lowered to an H. PLAN TO REMOVE IMMEDIACY An acceptable plan to remove the immediacy for F600 - Neglect, and F880 - Infection Control, was accepted by the State Survey Agency at 2:58 p.m. on [DATE]. An onsite revisit was completed on [DATE] for verification of the removal of immediacy, which was confirmed to have occurred on [DATE] at 5:00 p.m. Refer to Fed-F-000 of the FORM CMS-2567 for details of the plan. Findings Include: During an observation on [DATE] at 11:00 a.m., resident #1 was seen sitting on a couch in the common area of the memory care unit. Resident #1 was not wearing a facemask and was sitting within six feet of one unknown resident. Resident #9 and another resident were observed sitting side by side, neither wearing face masks. Resident #5 and another resident were observed sitting side by side in recliners, neither was wearing a facemask. Resident #1's room, 213, did not have signage related to transmission-based precautions or a stock of PPE near the resident's room for ready use. During an interview on [DATE] at 11:05 a.m., staff member F stated resident #1 was the only resident on the memory care unit who had tested positive for COVID-19, and she had been isolated for a few days. Staff member F stated resident #1 was asymptomatic except for fatigue. Staff member F stated they could not keep her in her room and did not have anyone to do a one-on-one. Resident #1's roommate, resident #10 had not been moved to a different room, in an effort to minimize resident #10's exposure to a COVID-19 positive resident (#1). During an interview on [DATE] at 1:13 p.m., staff member C stated resident #1 remained on the memory care unit, and not on the COVID-19 unit, because she was so mobile, and was a high elopement risk. Staff member C stated resident #1 was on enhanced precautions, which meant the staff were supposed to do group activities in the resident's room in order to minimize the number of times staff needed to enter resident #1's room. Staff member C was not able to describe how the other residents in the memory care unit were being protected from the transmission of COVID-19, if a COVID-19 positive resident was not in transmission-based precautions, not restricted to her room, not wearing a face mask, and not maintaining social distance from the other residents. During the phone interview, staff member C added staff members A and B to the discussion. Staff member B stated, based on experiences at a sister facility, these types of residents (memory care) do poorly when taken out of their usual setting. Staff member B stated, It completely upsets the apple cart. Staff member B also stated cognitively impaired residents did not keep a face mask on, and the facility was doing the best they could for the resident by encouraging hand hygiene and trying to keep resident #1 away from other residents. Staff member B was not able to explain how the other residents on the unit were being protected from exposure and transmission of COVID-19. During an observation and interview on [DATE] at 11:20 a.m., the memory care unit was accessed by the door in the courtyard, and opened by staff member G. Staff member G stated an isolation area had been set up sometime prior to her arrival at work on the morning of [DATE]. Staff member G was not sure exactly when the isolation area had been set up. The isolation area was located at the end of the unit adjacent to the Unit 1 entrance, separated from the rest of the memory care unit by plastic sheeting across the hallway. The isolation area contained four rooms, 201 through 204. Staff member G stated there were currently three residents in the isolation area, resident #s 1, 4, and 6. Staff member G stated resident #3 refused to be moved and remained in her regular room. Observation of room [ROOM NUMBER] showed a red stop sign velcroed across the doorway. When asked about the location of PPE for use with cares for resident #3, staff member G stated staff were already wearing face masks and eye protection, gowns were stored in the locked medication room, and each staff member had their own bottle of alcohol-based hand sanitizer in a pocket. No signage for transmission-based precautions was observed on or near the door to room [ROOM NUMBER]. Staff member G stated no isolation carts were in the hallway due to the risk of cognitively impaired residents on the unit getting into them. However, observation of the isolation area within the memory care unit showed isolation carts had been placed outside the three occupied rooms in this area. Staff member G stated the staff caring for the residents in transmission-based precautions in the isolation area were also caring for residents not in transmission-based precautions outside the isolation area. During an interview on [DATE] at 11:22 a.m., NF1 stated she was attending a care conference on [DATE], and overheard a conversation regarding a COVID-19 positive resident, later determined to be resident #5, not being separated from the other residents on the memory care unit who were negative for COVID-19. NF1 stated she contacted the administrator at approximately 11:00 a.m. with her concern, and an isolation area in the memory care unit was established sometime after her contact with the administrator. Review of the resident COVID-19 test results showed the following: -Resident #1's specimen was collected on [DATE], and a positive result was received on [DATE]. -Resident #2's specimens were collected on [DATE] and [DATE], and positive results were received on [DATE] and [DATE]. -Resident #3's specimens were collected on [DATE] and [DATE], and positive results were received on [DATE] and [DATE]. -Resident #4's specimens were collected on [DATE] and [DATE], and positive results were received on [DATE] and [DATE]. -Resident #5's specimen was collected on [DATE], and a negative result was received on [DATE], and the specimen collected on [DATE], had a positive result on [DATE]. -Resident #6's specimens were collected on [DATE] and [DATE], showed positive results were received on [DATE] and [DATE]. Based on record review, the information in the resident records showed resident #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 were potentially exposed to COVID-19 after [DATE], without the necessary interventions implemented to prevent the spread of the infection to others. Review of resident #1's room location, dated [DATE], showed resident #1 remained in room ,[DATE] with a roommate, resident #7, until [DATE] when resident #1 was moved to room ,[DATE]. The two residents were housed together for 10 days while resident #1 was COVID-19 positive and #10 was not. The isolation unit within the memory care unit was established on [DATE] and included room [ROOM NUMBER]. Resident #1 remained in room ,[DATE] until her death on [DATE]. Review of resident #2's room location, dated [DATE], showed resident #2 remained in room ,[DATE] with a roommate, resident #9, until [DATE] when resident #2 was admitted to the hospital. Resident #2 did not return to the facility and died in the hospital on [DATE]. The two residents were housed together for five days while resident #2 was COVID-19 positive and resident #9 was not. Review of resident #3's room location, as of [DATE], showed resident #3 remained in room ,[DATE], with a roommate, resident #10, until the roommate was moved to another room on [DATE]. The two residents were housed together for 14 days while resident #3 was COVID-19 positive and resident #10 was not. Review of resident #4's room location, as of [DATE], showed resident #4 remained in room ,[DATE], without a roommate, until [DATE] when she was moved to room ,[DATE]. The isolation unit within the memory care unit was established on [DATE] and included room [ROOM NUMBER]. Review of resident #5's room location, dated [DATE], showed resident #5 remained in room ,[DATE], without a roommate, until [DATE] when she was moved to room ,[DATE] in the isolation unit within the memory care unit. Resident #5 was moved back to room ,[DATE] on [DATE]. Review of resident #6's room location, dated [DATE], showed resident #6 remained in room ,[DATE], without a roommate, until [DATE] when she was moved to room ,[DATE]. The isolation unit within the memory care unit was established on [DATE] and included room [ROOM NUMBER]. Review of resident #7's progress note, dated [DATE] at 2:46 p.m., showed resident was extremely fatigued, sleeping all day Sunday, afebrile, not eating due to sleepiness, no other symptoms. Review of resident #8's progress note, dated [DATE] at 4:30 a.m., showed the resident complained of not feeling well, and appearing weak. Review of resident #9's room location, dated [DATE], showed the resident was in room ,[DATE], with resident #2, until [DATE], when resident #2 was transferred to the hospital. Review of resident #9's progress notes showed the following: - [DATE] at 11:23 a.m., one episode of vomiting after breakfast - [DATE] at 1:20 a.m., one small episode of vomiting and skin cool to touch - [DATE] at 2:38 a.m., temperature 100.7 degrees F - [DATE] at 4:34 a.m., temperature 99.6 degrees F, refusing offer of fluids - [DATE] at 10:14 a.m., decreased appetite, one episode of vomiting, pale appearance, sleeping more Review of resident #10's room location, dated [DATE], showed resident #10 remained in room [ROOM NUMBER], with a roommate, resident #3, until [DATE] when resident #10 was moved to room ,[DATE]. The two residents were housed together for 14 days while resident #3 was COVID-19 positive and resident #10 was not. Infection Control Practices During an observation and interview on [DATE] at 10:17 a.m., resident #21 was seen sitting in her wheelchair in the hallway. Resident #21 stated she was waiting for her ride to take her to [MEDICAL TREATMENT]. Resident #21 was wearing a disposable plastic gown over her regular clothes. The gown did not adequately cover her and was too small to be tied in the back. Resident #21 stated the gown and face mask were what she usually wore to [MEDICAL TREATMENT]. During an observation on [DATE] at 11:15 a.m., staff members R and W were assisting resident #13 with changing her incontinence brief, get dressed, and transfer to her wheelchair. After removing her urine-soaked brief, staff member R cleaned her peri area with a disposable wipe. Staff member R did not perform hand hygiene or change her gloves before touching resident #13's oxygen tubing. Staff member R left the resident's room, wearing the same gloves used to wash resident #13. Staff member W changed gloves but did not perform hand hygiene before putting on clean gloves. During an interview on [DATE] at 11:25 a.m., staff member Y stated she cleaned resident rooms the same regardless of the signage. She stated she always wore a mask and face shield but decided whether to wear a gown depending on how direct care staff were treating the resident. Staff member Y stated this meant if the resident appeared sick, or the direct care staff were treating the resident differently, she would wear a gown. If the resident appeared well, she did not wear a gown. During an observation on the COVID-19 isolation unit on [DATE] at 12:45 p.m., staff member R was delivering meal trays to two residents who were negative for COVID-19, but had been roommates with a resident who tested positive, and were, therefore, exposed to COVID-19. These two residents were in transmission-based precautions and had signage instructing staff not to enter the room with extended use PPE (gowns, N95 masks, and eye protection). Staff member R had removed her isolation gown and placed it on top of the cart containing supplies outside room [ROOM NUMBER]. After donning a clean isolation gown, but wearing the same mask and eye protection, staff member R delivered a meal tray to resident #24 in room [ROOM NUMBER]. While wearing the same PPE, staff member R delivered a meal tray to resident #25 in room [ROOM NUMBER]. No hand hygiene was performed between rooms [ROOM NUMBERS]. Staff member R then placed the dirty gown, left on the supply cart, into a small garbage bag and disposed of the bag and gown in a larger garbage bin down the hallway. Staff member R then entered rooms [ROOM NUMBERS] to turn off call lights. After assisting the resident in room [ROOM NUMBER] to the bathroom, staff member R entered the staff bathroom. No hand hygiene was observed during the activities performed between rooms [ROOM NUMBERS]. During an observation on the COVID-19 isolation unit on [DATE] at 12:55 p.m., staff member R adjusted her face shield with her bare hands and did not perform hand hygiene prior to providing care to resident #23. Staff member R, with the assistance of another staff member, transferred resident #23 from her bed to a chair. Staff member R was not wearing gloves during the transfer. Staff member R left the room, bare handed, carrying the gait belt used during the transfer. The contaminated gait belt was place on top a garbage bin while staff member R entered another occupied room to retrieve gloves. After donning the clean gloves and disinfecting the gait belt, staff member R adjusted her mask and face shield. The gloves were then removed, and hand hygiene was performed. During an interview on [DATE] a 4:36 p.m., NF3 stated while having a window visit with resident #26, she saw staff not wearing masks or wearing masks over their mouth only and not covering their nose. On [DATE], during a window visit, she observed a CNA enter resident #26's room wearing a mask which was not covering her nose or mouth. When NF3 motioned to the CNA to pull her mask up to cover her nose and mouth, the CNA, who was within one inch of resident #26's face, just giggled and did not pull up her mask. During an interview on [DATE] at 7:55 a.m., staff member A stated she believed the COVID-19 outbreak was caused in part by the lax use of PPE and hand hygiene by direct care staff. Staff member A stated she knew staff were not always wearing the necessary PPE after administrative staff left for the day and had received complaints from family members who had observed this while doing window visits with a resident.

Based on interview and record review, the facility failed to ensure staff identified, assessed, intervened, and documented changes in a resident's vital signs, medical condition, and repeated falls, which occurred over a 24-hour period, resulting in neglect for 1 (#11); and the facility failed to identify neglect based on written complaints from residents, family, and staff for 4 (#s 13, 14, 19, and 22) of 26 residents sampled. Resident #11 did pass away, and the physician was not notified of the resident's change in status until after his death. Findings include: 1. IMMEDIATE JEOPARDY On [DATE], an Immediate Jeopardy situation was announced to the facility administrator at 2:28 p.m. Deficient practices were identified for F600 - Neglect, of the State Operations Manual, Appendix PP. The Severity and Scope of the deficient practice was identified to be at the level of J, and upon removal of the immediacy, lowered to a G. PLAN TO REMOVE IMMEDIACY An acceptable plan to remove the immediacy for F600 - Neglect, and F880 - Infection Control, was accepted by the State Survey Agency at 2:58 p.m. on [DATE]. An onsite revisit was completed on [DATE] for verification of the removal of immediacy, which was confirmed to have occurred on [DATE] at 5:00 p.m. Refer to Fed-F-000 of the FORM CMS-2567 for details of the plan. Findings include: During an interview on [DATE] at 9:25 a.m., staff member D stated she did not remember notifying a nursing supervisor, or a physician, about the elevated temperature for resident #11 on [DATE] at 1:32 a.m. Staff member D stated the only thing she remembered about resident #11, during her shift on [DATE], was that he was restless and after being dressed at approximately 1:00 a.m., the resident rested quietly for the remainder of the shift. During an interview on [DATE] at 9:30 a.m., staff member C stated she was on the Covid-19 unit assisting the travel nurse working the day shift. She stated she was not present for the nursing change of shift report, and therefore did not hear anything regarding resident #11's elevated temperature or pulse during the night shift on [DATE]. Staff member C stated she was in the room adjacent to resident #11's room, assisting with a transfer for another resident, when staff member E called out for help from resident 11's room. Staff member C stated she saw staff member E struggling to get resident #11 into the bed. Staff member C stated she assisted staff member E to get resident #11 back into bed from a standing position near the bed. Staff member C stated she looked at resident #11 and believed he had died immediately upon getting into bed. Staff member C assessed resident #11's condition and confirmed he was deceased . Staff member C stated she had been focusing on the needs of the resident requiring transfer to the emergency department and was unaware of resident #11's condition, or recent history of elevated temperature and pulse, when she entered the room to assist staff member E. During an interview on [DATE] at 9:47 a.m., staff member E stated she received report from the off going CNA, and started her shift on [DATE] at approximately 6:30 a.m. Staff member E stated she was immediately told, by a nurse, resident #11 had fallen, and she needed to get his vital signs. Staff member E was unable to remember which nurse asked her to get resident #11's vital signs. Staff member E stated, upon entering resident #11's room, she found the resident lying face down on his bed, shaking and struggling to breathe. Staff member E was unable to explain who had found resident #11 on the floor, or who had placed him in his bed in the face down position. Staff member E stated she repositioned him on his back, took his vital signs, wrote them on a piece of paper, and gave them to staff member D. Staff member E stated she did not remember the exact vital sign values, but thought the temperature was greater than 102, and the O2 saturation was 93%. When asked about the circumstances surrounding the resident's condition just prior to his death, staff member E stated she and another CNA entered resident #11's room just before 11:00 a.m. and found him squatting at the foot of his bed. Staff member E and another CNA attempted to assist him back to bed. Staff member E stated they were unable to get resident #11 back into bed, and he collapsed onto the floor. Staff member E then called for help and stated staff member C, who was in an adjacent room, came into the room. Staff member E stated staff member C, upon seeing resident #11 on the floor, left the room to retrieve a Hoyer lift. Staff member E stated staff member C returned with the lift and the staff present transferred resident #11 from the floor to his bed. Staff member E thought resident #11 had already passed away while on the floor. She stated she placed a pillow under his head and stayed with him until staff member C returned with the lift. Staff member E stated staff member C then assessed the resident for signs of life and determined the resident had passed away. Staff member E stated resident #11 had fallen at least three times between the beginning of her shift (6:30 a.m.) and the final fall when the resident passed away at 11:00 a.m., on [DATE]. During an interview on [DATE] at 1:05 p.m., the travel nurse working her first shift on [DATE], stated she was working her last shift and would be leaving for her home in another state after completing the shift. Due to this, the travel nurse was not available for interview on [DATE]. Review of resident #11's MAR indicated [REDACTED] - at 8:00 a.m., T 97.6 degrees F, P 80 bpm, RR 16 per minute, O2 saturation 95%, BP ,[DATE] - at 12:00 p.m., T 97.6 degrees F, P 80 bpm, RR 16 per minute, O2 saturation 95%, BP ,[DATE] - at 4:00 p.m., T 97.6 degrees F, P 80 bpm, RR 16 per minute, O2 saturation 95%, BP ,[DATE] - at 8:00 p.m., T 97.6 degrees F, P 80 bpm, RR 16 per minute, O2 saturation 95%, BP ,[DATE] -note, all vital signs are exactly the same Review of resident #11's MAR indicated [REDACTED] - at 1:32 a.m., T 102.4 degrees F, P 114 bpm, irregular, RR 24 per minute, O2 saturation 90% - at 4:18 a.m., T 99.1 degrees F, P 114 bpm, RR 24 per minute, O2 saturation 90% - at 7:04 a.m., O2 saturation 90% No other vital signs or screening documentation was found for [DATE] until 11:00 a.m. Review of resident #11's physician orders, dated [DATE], showed, Monitor every 4 hours: V/S (temp, resp. rate, pulse, O2 sat., B/P), cough, SOB, Lung Sounds, while on quarantine for COVID-19 symptoms. Call On-Call immediately with any elevated temperatures or new or worsening respiratory symptoms. Review of resident #11's nursing progress note, dated [DATE] at 10:30 a.m., showed the resident was found on the bathroom floor by a CNA at approximately 8:00 a.m. Resident #11 communicated via gestures he had hit the left side of his face on the toilet and the wall. Nursing assessment showed no new injuries, but the resident had a distressed demeanor. The progress note showed notifications to the ADON, a provider, and a family member. The progress noted showed the resident was, Sent to ER for head scan. Review of resident #11's nursing progress note, dated [DATE] at 8:14 p.m., showed an ambulance was called at 9:25 a.m. to take resident to (facility name). The progress note showed report was received from the ER at 4:15 p.m., and, Scan done on resident head with negative results. A c-5 fracture found that could not be determined to be old or new. Nurse stated that resident is refusing to wear a nack (sic) collar/brace. CHest (sic) x-ray came back negative. VS:BP: ,[DATE], P:92, O2: 94% on 5L. Review of resident #11's nursing progress note, dated [DATE] at 8:30 a.m., showed an IV catheter had been left in the resident's left arm from the ER visit on [DATE]. The progress note showed the IV catheter was removed, and resident #11 kept taking his oxygen off and needed encouragement to keep his oxygen on. No other progress notes were found in resident #11's medical record between 8:30 a.m. on [DATE] and the note on [DATE] at 11:00 a.m. showing the resident had died . Review of resident #11's progress notes, dated [DATE], failed to show any notifications to the on call nurse or on call provider related to elevated temperature, elevated pulse, or decreased O2 saturation, or the three reported falls, to include assessments for injury, vitals, notifications to physician, etc. The facility did not identify the neglect of resident #11 until notification of the Immediate Jeopardy situation on [DATE] at 2:28 p.m. 2. Grievances Identified as Neglect During an interview on [DATE] at 1:36 p.m., staff members J and V stated they had submitted multiple written complaints on [DATE] after several care conferences were completed. Staff member J stated the complaints were submitted on behalf of residents and families who had complaints about the care being received. Staff member J stated she had heard nothing after giving the written complaints to staff member A. During an interview on [DATE] at 7:55 a.m., staff member A stated she found eight grievances from [DATE] which had not been reviewed for possible abuse or neglect, assigned for investigation, or investigated. Staff member A stated she believed the grievances had been missed due to the COVID-19 outbreak which started the same week. Staff member A stated some of the grievances missed contained allegations of neglect which should have been immediately investigated and reported to the State Survey Agency as allegations of neglect. During an interview on [DATE] at 10:24 a.m., NF5, resident #19's family member, stated they felt the resident had been receiving terrible care by the facility, and they were very unhappy, and felt the resident's lack of hygiene was pure neglect by the facility. The family member stated they have been asking the facility to take care of the resident's mustache under his nose, it has become way too bushy, and it goes into his mouth when he eats, and that was not very hygienic at all. They stated the resident's fingers nails always had dirt and poop under them, and they never wash his hands. They stated the facility did not clean him as clean as he needed to be cleaned after having a BM, and he has dried BM left on him. His hair is never combed, they never have tried to do his teeth, and they were afraid he would lose all his teeth. The eight grievances found were documented as received by the administrator on [DATE], and as of [DATE], only one had documentation of a resolution. Resident #13's grievance had documentation a shower had been given on [DATE], but the form failed to show any documentation of an investigation. The other seven grievances showed no documentation of being assigned for investigation, no resolution had been documented, and there was no documentation related to a neglect determination related to the lack of cares being provided. Review of a sample of the written grievances, dated [DATE], showed the following: - resident #13, the resident and her family were concerned about the frequency of showers being given, her last shower was on [DATE] (10 days earlier), resident #11 had requested morning showers and was told she could only have evening showers, and resident #11 was observed to have had a, foul odor and dirty hair noticed by IDT team. - resident #14, her roommate (resident #22) was concerned about resident #14 being, left in her bed and never checked on at times, not offered her Boost, left for whole shifts in her bed or chair left unattended, one time was completely soiled and left. - resident #19, family and staff were concerned he is often dirty and unkept (sic), his face was unshaven, nails were dirty, clothing was covered in food, staff were leaving him in his chair too long, and the resident was not being cleaned up before Facetime visits because staff was too busy. - resident #22, reported her concerns about not enough staff and working with one CNA at times, not getting showers, being told by staff member Q she already had 13 residents on the shower schedule and could not put her on the schedule, and because evening showers were not getting done, she wanted to be put back on the morning shower schedule. Review of the facility's policy titled, Abuse and Neglect, last reviewed [DATE], showed if neglect was suspected, the facility would: - take immediate steps to assure the protection of the resident - notify the appropriate agency of the initiation of an investigation immediately after ensuring resident safety - perform a careful and deliberate investigation, based on facts, observations, and statements from the alleged victim and witnesses - report the findings to the appropriate authorities, as required by law

Based on observation, interview, and record review, the facility administration failed to provide oversight to ensure appropriate infection prevention and control practices were in place during a COVID-19 outbreak for 14 (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 21, 24, 25, and 26); adequate numbers of staff were available to provide resident care, including the on time administration of medication, personal hygiene, and showers for 8 (#s 13, 14, 15, 17, 19, 20, 21, and 22) of 26 residents sample. The facility administration also failed to ensure an adequate system was in place for the provision of resident care supply availability to direct care staff for use on a daily basis. This deficient practice had the potential to affect all residents in the facility. Findings include: 1. Infection Prevention and Control Practices During an interview on 9/16/20 at 1:13 p.m., staff members A and B stated they were aware of a COVID-19 positive resident in the memory care unit who was not in transmission-based precautions, not wearing a mask, not restricted to her room, and not socially distanced from the other residents in the unit. This situation resulted in an Immediate Jeopardy situation for 10 residents (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) in the memory care unit. During an interview on 9/23/20 at 7:55 a.m., staff member A stated she believed the COVID-19 outbreak was caused in part by the lax use of PPE and hand hygiene by direct care staff. Staff member A stated she knew staff were not always wearing the PPE necessary to prevent the transmission of COVID-19 from person to person. She stated this was occurring after administrative staff left the building for the day. During observations on the COVID-19 unit, the following deficient infection control practices were observed: - resident #21 was wearing a disposable gown which was too small to cover her or be tied correctly - resident #s 24 and 25 were being housed on the COVID-19 unit because they had been exposed to roommates who tested positive for [MEDICAL CONDITION], staff were observed to be entering the resident's rooms wearing PPE which was potentially contaminated, despite signage indicating no extended PPE was to be worn in these rooms - resident #26 was cared for by a CNA who was not wearing her mask correctly, and despite prompting from a family member to wear her mask correctly, the CNA did not don her mask correctly in order to cover her nose and mouth 2. Staffing During an observation and interview on 9/15/20 at 9:57 a.m., the posted staffing for Unit 1 during the day showed one nurse, one medication aide, and one CNA. The night shift staffing showed one nurse and no CNA. Staff member Q stated there had been two CNA's, but one was sent home an hour earlier due to illness. During the interview, two CNA's from the Crossroads unit arrived to assist with resident care. Staff member Q stated there were usually three to four CNA's during the day. During an interview on 9/16/20 at 2:10 p.m., resident #20 stated there was not enough staff to give showers or get her out of bed. She stated she had missed physical therapy earlier in the week because the staff did not get her up and out of bed on time. Resident #20 stated there had been a day during the previous week when there was no nurse on the unit to give her noon medication. She stated she did not get the medication until 4:00 p.m. During an interview on 9/17/20 at 10:15 a.m., resident #21 stated, We have had a skeleton crew for the past three to four weeks, and she had not had a shower in a month. During an interview on 9/23/20 at 7:55 a.m., staff member A stated staff had expressed concerns with staffing, particularly the past three to four weeks. Staff member A stated the number of staff calling off due to illness had been the issue. Staff member A stated it was difficult to get agency staff at the last minute, and the facility was doing the best they could. During an interview on 9/23/20 at 11:22 a.m., NF1 stated she has had many calls from family members of residents complaining about the lack of resident care and neglect. NF1 stated she had tried multiple times, without success, to speak with staff member A regarding these concerns. During an interview on 9/24/20 at 9:47 a.m., staff member E stated she worked by herself for more than five hours on 9/10/20. Staff member E stated she was assigned to the COVID-19 unit during the day shift on 9/10/20. She stated there were 11 residents and no other CNA's. Staff member E stated the nurse left at 10:00 a.m., and another nurse did not arrive on the unit until after 3:00 p.m. Between 10:00 a.m. and 3:00 p.m., staff member E stated she made multiple phone calls and texts to nursing leadership responsible for staffing, asking when there would be a nurse. She stated the only answer she got was, soon. Staff member E stated during the time she was alone on the unit, lunch was served, no blood sugars were checked, no insulin or other medications were given. Staff member E stated she tried to get help, and no one came. Review of resident #20's medical record, her [MEDICATION NAME] was scheduled to be given at 12:00 p.m. and 8:00 p.m. On 9/10/20, resident #20 received her 12:00 p.m. dose of [MEDICATION NAME] at 3:41 p.m. Review of resident #s 13, 14, 15, 17, 19, 20, 21, and 22 bathing documentation for the past 30 days showed none of the residents received twice weekly showers as scheduled. Nor was there documentation explaining why the showers were not completed as scheduled. Refer to F677 for additional information related to neglect of care for resident #s 13, 14, 15, 17, 19, 20, 21, and 22. Refer to F658 for additional information related to late medication for resident #20. 3. Supplies During an observation on 9/15/20 at 10:17 a.m., the supply room on Unit 1 was noted to be out of disposable wipes, facial tissue, and medium, large, and extra-large pull-ups. During an interview on 9/17/20 at 10:52 a.m., staff member R stated there was no regular, supply guy. She stated if they needed supplies, they had to ask the nurse, and the nurse would write it up and, send it up the chain. During an interview on 9/22/20 at 11:10 a.m., staff member CC stated sometimes they have to, scramble for gloves sometimes. When asked the process for obtaining supplies, staff member CC stated she just called staff member X and had never gone through the nurse to get supplies. During an interview on 9/22/20 at 7:55 a.m., staff member A stated supply acquisition went through staff member X. She stated when supplies were needed, the nurse requested them from staff member X. During an interview on 9/25/20 at 10:30 a.m., staff member X stated he was responsible for ordering supplies, and ensuring they were delivered to the resident care area storage rooms. Staff member X stated he was also responsible for maintenance at both Avantara and (facility name), along with ordering supplies. Staff member X stated he did not have a specified order date. He stated ordering supplies was a lower priority than his maintenance responsibilities, and he did it when he had time.

Based on observation, interview, and record review, the facility failed to perform and document skin assessments as ordered, failed to prevent the development of new pressure ulcers, failed to complete and document wound care as ordered for 3 (#s 13, 14, and 15) of 26 sampled residents. Findings include: 1. During an observation and interview on 9/17/20 at 11:15 a.m., resident #13 was being assisted to get dressed and up into her wheelchair by staff members R and W. Resident #13 was observed to be on an air mattress which was not plugged in and was deflated. There was only one electrical outlet near the bed and resident #13's oxygen concentrator and bed were plugged into the outlet. Staff member R stated they (the facility) would need to get a power strip so all of her necessary equipment could be used. Wound dressing noted to left buttocks when resident was turned onto her left side while having her incontinence brief changed. During an interview on 9/23/20 at 11:20 a.m., resident #13's family member stated they were contacted about ten days ago by the facility informing them the resident had developed a new pressure ulcer at the base of her spine. They were told by a staff member that the facility did not have exact measurements of the new pressure ulcer, but it was about the size of your palm. He stated they were concerned if the facility did not keep the resident clean, she could develop a new pressure ulcer. The family member stated the staff member who told them about the resident's pressure ulcer said if the resident soiled herself, and they did not clean her up right away, the BM could get into the wound. The family member said this was very upsetting for them because they have had concerns with the resident's cleanliness for some time now. During an interview on 9/30/20 at 12:02 p.m., staff member L stated resident #13 had an open sore on buttocks for some time, and the documentation about it was poor. Review of resident #13's physician orders, dated 7/2/20, showed an order for [REDACTED]. Review of resident #13's TAR, dated 9/2020, showed a skin assessment being done on 9/4/20. The skin assessment for 9/11/20 was not documented. Review of resident #13's skin/wound progress note, dated 9/15/20, show the presence of a 9 cm by 6.5 cm open area on her buttocks, with sloughing skin, a small amount of clear drainage, and pain. Review of resident #13's physician orders, dated 9/15/20, showed an order for [REDACTED]. Review of resident #13's September TAR, printed on 9/23/20 at 2:52 p.m., showed a dressing change order started on 9/16/20 at 8:00 a.m. The TAR showed dressing change due dates to be 9/16/20, 9/18/20, 9/21/20, and 9/23/20. None of the dates contained any documentation indicating the dressing change had been completed. Review of resident #13's skin/wound progress note, dated 9/24/20, showed a change in the wound size to, 9cm by 4cm and 2cm tunneling at 7 c'clock, with moderate clear to bloody drainage, and a slight odor. 2. During an interview on 9/21/20 at 1:36 p.m., staff member J stated she and staff member V had submitted two separate complaints regarding care for resident #14. Staff member J stated one of the complaints came from her roommate who had concerns about resident #14 being left in bed or her chair, unattended, for extended periods of time, and being left soiled. The other complaint showed on 9/1/20, resident #14 has a wound dressing with a date of 8/23/20 (9 days old). During an interview on 9/30/20 at 11:28 a.m., staff member Z stated the CNA's are responsible for notifying their nurse if they see anything different on a resident's skin. Review of resident #14's most recent comprehensive skin assessment, dated 7/25/20, shows resident #14 had an alteration in skin integrity, but failed to identify the location, size, or appearance of any areas of altered skin integrity. Review of resident #14's physician orders, dated 9/2020, showed the following skin assessment and wound care orders: - 7/13/18, skin assessment weekly - 12/6/19, cleanse right and left gluteal (buttocks) with normal saline, pat dry, cover around wound with no sting skin prep, cover with collagen powder and border foam dressing every three days and as needed, discontinue when resolved - 6/6/20, cleanse left upper back abrasion with normal saline, cover with hydrogel and border foam dressing three times a week and as needed - 8/28/20, cleanse right heel with normal saline, pat dry, cover with no sting skin prep, and border foam dressing on Monday, Wednesday, Friday, and as needed Review of resident #14's TAR, dated 9/2020, showed the following treatments: - a skin assessment was completed on 9/26/20, the remaining three weeks showed no documentation indicating a skin assessment had been done - wound care to right and left gluteal wound care was completed on 9/13/20, the remaining 10 days showed no documemtation indicating the wound care had been done - wound care to left upper back was completed on 9/17/20, 9/24/20, and 9/26/20, the remaining nine days showed no documentation indicating the wound care had been done - wound care to right heel was completed on 9/2/20, the remaining 10 days showed no documentation indicating the wound care had been done 3a. During an interview on 9/15/20 at 10:17 a.m., staff member I stated she was aware of a complaint related to care and hygiene of resident #15's perineum and penis. During an interview on 9/30/20 at 11:38 a.m., staff member AA stated skin assessments come up on the MAR weekly or the CNA's let us know if they see anything different. Review of a facility reported incident on 7/16/20 showed an allegation of neglect for resident #15 related to the condition of resident #15's perineum and penis observed while at a urology appointment on 7/10/20. Review of resident #15's skin assessment, dated 7/28/20, showed only redness on his penis, and no other areas of skin impairment. Review of resident #15's TAR, dated 8/2020, showed wound care to penis was to be done every shift (twice a day), was documented as completed for 44 of 62 opportunities, and missed 31 percent of the time Review of resident #15's skin assessment, dated 9/16/20, showed a worsening of his perineum and penis, with groin redness, excoriation, and incontinence [MEDICAL CONDITION]. Review of resident #15's skin/wound progress note, dated 9/16/20, showed extensive redness and excoriation to his scrotum and inner thighs, and a torn urethra resulting in leakage of urine around the catheter. Review of resident #15's care plan, dated 5/20/20, showed he was a high risk for pressure sore development with intact skin except for a surgical incision on his right hip. 3b. During an interview on 9/30/20 at 11:38 a.m., staff member AA stated she did not know how resident #15 got the sore on his heel. Staff member AA stated skin assessments come up on the MAR weekly or the CNA notified the nurse of any skin changes observed. During an interview on 9/30/20 at 12:54 p.m., staff member H stated dressing changes are the responsibility of the wound care nurse and the floor nurse. Staff member H stated the wound care nurse had been away from work more the past few months, and floor nurses were expected to complete the dressing changes if the wound nurse was gone. Staff member H stated if a resident went to the wound clinic for wound care, there would have been an order for [REDACTED]. Review of resident #15's skin assessment, dated 7/28/20, showed no impaired skin integrity on his heels. Review of resident #15's skin assessment, dated 8/1/20, showed a 3.6 by 2.5 wound on his right heel. The documentation did not identify the unit of measure for the size of the wound. Review of resident #15's physician orders, dated 9/2020, showed the following skin and wound care orders: - 8/11/20, wound care to right heel on Monday, Wednesday, Friday, and as needed, note wound first identified on 8/1/20 on skin assessment - 8/20/20, wound care to right heel changed to Tuesday, Thursday, Saturday, and as needed - 9/14/20, wound care to right heel changed to Tuesday, Friday, and as needed Review of resident #15's TAR, dated 8/2020, showed wound care to right heel was completed on 8/14/20, 8/19/20, 8/24/20, 8/28/20, leaving 8/7, 8/12, 8/17 with no documentation indicating if the wound care had been done. Review of resident #15's nursing progress note, dated 9/3/20 at 10:49 a.m., showed the resident continued to by seen by the wound clinic for care of his right heel. Review of resident #15's medical record failed to show a referral for wound clinic services, an order for [REDACTED]. A request for documentation of all MAR and TAR documentation of wound care provided for resident #15 was made on 9/30/20. No TAR for September 2020 was received prior to the end of the survey.

Based on interview and record review, the facility failed to adequately respond to a change in condition, ultimately ending in death, for 1 (#11); and failed to administer scheduled medications on time, resulting in pain and distress, for 1 (#20) of 26 sampled residents. Findings include: 1. Change in Condition During an interview on 9/23/20 at 9:25 a.m., staff member D stated she was aware of resident #11's elevated temperature on 9/13/20 at 1:32 a.m. but did not remember notifying anyone. During an interview on 9/23/20 at 9:47 a.m., staff member E stated she received change of shift report and started her shift in the COVID-19 unit at 6:30 a.m. on 9/13/20. Staff member E stated as soon as she was finished with report, the nurse told her to get resident #11's vital signs as he had just been found on the floor. Staff member E took resident #11's vital signs, wrote them on a piece of paper, and gave them to a nurse. Staff member E stated resident #11 had a temperature over 102 degrees F. Between 6:30 a.m. and 11:00 a.m., staff member E stated resident #11 had fallen at least three times. The last fall, at approximately 11:00 a.m., ended with resident #11 passing away. Staff member BB was not available for interview on 9/23/20. Review of resident #11's physician's orders [REDACTED]. The order also required a provider to be notified immediately with any elevated temperature. Record review for resident #11 showed vital signs were documented twice on 9/23/20, and on one occasion the resident had a temperature of 102.4 degrees F. No other vital signs were found for 9/13/20 until 11:00 a.m. when resident #11 had passed away. Review of resident #11's nursing progress note, dated 9/13/20 at 11:00 a.m., showed resident #11's absence of vital signs and determination of death. No progress notes were found for resident #11 between 9/12/20 at 8:30 a.m. and 9/13/20 at 11:00 a.m. The medical record failed to show any documentation of notifications to the provider regarding an elevated temperature, an elevated pulse, a decreased O2 saturation, or anything related to the falls sustained on the morning of 9/13/20. 2. Late Medications During an interview on 9/15/20 at 10:17 a.m., staff member I stated she had been told by a resident #20 there had been no nurse on the COVID-19 unit for eight hours during the previous week. The resident told staff member I this had caused her medications to be given late. During an interview on 9/16/20 at 2:10 p.m., resident #20 stated due to staffing the previous week, she had received her noon medication at 4:00 p.m. During an interview on 9/24/20 at 9:47 a.m., staff member E stated she had been working on the day there was no nurse on the unit. Staff member E stated resident #20 got her pain medications way late. Staff member E stated resident #20 was, crying and in so much pain. Review of resident #20's administration record, provided by the facility, showed [MEDICATION NAME] was due to be given at 12:00 p.m. and 8:00 p.m. On 9/10/20 the [MEDICATION NAME] 10 mg was documented as given at 3:41 p.m. and 8:25 p.m. Review of resident #20's medical record failed to show an explanation for the late 12:00 p.m. dose.

Based on interview and record review, the facility failed to perform investigations of possible neglect; after receipt of the allegations, failed to prevent further neglect while an investigation was conducted; and failed to report the results of the investigations to the State Survey Agency within five working days of the incident, for 5 (#s 11, 13, 14, 19, and 22) of 26 sampled residents. Findings include: 1. During an interview on 9/23/20 at 7:55 a.m., staff member A stated if an incident was identified as neglect, the unit manager where the incident occurred, was assigned to investigate the allegation. Staff member A stated the investigation was expected to be completed within 72 hours. The results of the investigation were to be given to staff member A. Staff member A stated the unit managers investigating allegations of abuse and neglect have had no specialized training, but did receive informal training from the interim DON on how to handle abuse and neglect allegations. Review of the State Survey Agency incident reporting system on 9/28/20 showed a report for an incident with resident #11 had occurred on 9/13/20, and was unknown to the facility until notification of an Immediate Jeopardy situation on 9/24/20 at 2:12 p.m. The results of the investigation into this incident were entered on 9/29/20, 16 days after the incident. Refer to F600 for additional information regarding resident #11 and neglect of care. 2. Investigation of Grievances During an interview on 9/21/20 at 1:36 p.m., staff members J and V stated they had submitted multiple written complaints on 9/1/20 from residents and family members about resident neglect of care. During an interview on 9/23/20 at 7:55 a.m., staff member A stated she found eight grievances from September 1-2, 2020, which were overlooked. Staff member A stated some of the grievances were allegations of neglect and should have been investigated when she received them. Refer to F600 for additional information regarding the grievances submitted for resident #s 13, 14, 19, and 22. As of 9/23/20, none of the written grievances given to staff member A on 9/1/20 had been investigated or had interventions implemented for resident protection.

Based on interview and record review, the facility failed to notify a resident's physician about a significant change of condition over a 24-hour period, including abnormal vital signs, and multiple falls, for 1 (#11) of 26 sampled residents. Findings include: Review of resident #11's nursing progress note, dated 9/11/20 at 8:14 p.m., showed he had returned from the hospital after sustaining a fall. Resident #11's blood pressure was 120/76, pulse was 92, respiratory rate was 26, and his oxygen saturation was 95% on 5 liters of oxygen per minute. The note showed the head scan results to be negative, except for a C-5 fracture, indeterminate age. Review of resident #11's vital signs on 9/13/20, showed the following: - at 1:32 a.m., T 102.4 degrees F, P 114 bpm, irregular, RR 24 per minute, O2 saturation 90% - at 4:18 a.m., T 99.1 degrees F, P 114 bpm, RR 24 per minute, O2 saturation 90% - at 7:04 a.m., O2 saturation 90% No other vital sign documentation was found for 9/13/20 until 11:00 a.m. Review of resident #11's medical record failed to show any provider or resident representative notification regarding the abnormal vital signs, or the multiple falls sustained by resident #11 between 6:30 and 11:00 a.m. on 9/13/20. See F600 for additional information related to resident #11 and neglect of care. During an interview on 9/23/20 at 9:25 a.m., staff member D stated she was aware of resident #11's elevated temperature and pulse at 1:32 a.m. but did not remember notifying anyone. During an interview on 9/23/20 at 9:30 a.m., staff member C stated she had not been aware of the abnormal vital signs or the falls sustained by resident #11 on the morning of 9/13/20. During an interview on 9/23/20 at 9:47 a.m., staff member E stated she was instructed, by the nurse, to get resident #11's vital signs because he had just been found on the floor. After taking resident #11's vital signs at approximately 6:30 a.m., staff member E gave the nurse a piece of paper with the vital signs written on it. Staff member E remembered resident #11 had a temperature over 102 degrees F, and labored respirations. Staff member E stated resident #11 had fallen at least three times between the beginning of her shift (6:30 a.m.) and the final fall when the resident passed away at 11:00 a.m., on 9/13/20. Review of the facility's policy titled, Notification of Change of Condition, dated 12/19, showed the expectation was the facility must immediately consult with the resident's physician, and notify the resident's representative when a significant change in the resident's physical, mental, or psychosocial status, meaning a deterioration, occurs.

Based on interview and record review, the facility failed to set up an alternate method of communication for a deaf resident, thereby failing to provide a reasonable accommodation based on the resident's needs and preferences, for 1 (#11) of 26 sampled residents. The deficient practice caused frustration and anxiety, and potentially resulted in the use of unnecessary [MEDICAL CONDITION] medications as treatment. Findings include: Review of the State Survey Agency incident reporting system, dated 9/17/20 at 2:14 p.m., showed the following submission: Resident #11, .was deaf and the facility never connected his only source of communication due to covid. He was on medication that seemed to be used to put him in a chemical hold. Review of resident #11's social service note, dated 4/14/20 at 4:42 p.m., showed the facility was aware of the web camera needing to be set up so the resident could use it to communicate. Review of resident #11's nursing progress note, dated 4/23/20 at 1:15 p.m., showed communication was hard and the resident became upset when he had to write on the white board or paper. The note also showed staff attempted to assist resident #11 to call his daughter, but he became upset and motioned staff to stop and get out of his room. Review of resident #11's social service note, dated 4/28/20 at 12:14 p.m., showed increased agitation and frustration when staff were attempting to communicate with him. The note also showed the resident showed signs of frustration, closing his eyes between interactions and waving to stop, when staff member V wrote questions on paper during a care conference. Review of resident #11's general progress note, dated 4/29/20 3:16 p.m., showed he was having a great deal of difficulty communicating his needs to the staff, became easily frustrated and was acting out daily. Review of resident #11's nursing progress note, dated 5/3/20 at 2:42 a.m., showed he wanted to leave if the interpretation tv was not made to work. Staff were unable to get the television to work, resident #11 became angry and flipped off the nurse. The note showed an antopsychotic was given after the incident. Review of resident #11's Pharmacy Consultation Report, dated 4/28/20, showed he had an as needed [MEDICATION NAME] 10 mg order which was given 15 times in April of 2020 for anxiety and agitation. The reported showed when [MEDICATION NAME] is administered on an as needed basis, the medication has more of a sedative effect, rather than a mood stabilizer. The pharmacist recommended discontinuing the as needed [MEDICATION NAME], and only continuing the scheduled doses of [MEDICATION NAME] at bedtime. The medical provider documented to discontinue the as needed [MEDICATION NAME] and signed the form on 5/6/20. Review of resident #11's care plan, dated 4/17/20, showed communication impairment related to congenital [DIAGNOSES REDACTED]. Interventions shown included the use of sign language, lip reading, and appropriate augmentative devices. The care plan failed to identify the web camera used by resident #11 prior to his admission to the facility or the difficulty with lip reading when staff were wearing masks. The care plan also showed resident #11 became easily frustrated when he was unable to communicate his needs. During a telephone interview on 9/22/20 at 4:00 p.m., NF2 stated resident #11 was deaf and had used a web camera before being admitted , which was connected to his television and allowed him to communicate with others more easily. NF2 stated she had requested, multiple times, for it to be set up on his television, and it never was. She stated the resident was isolated without being able to communicate and the web camera allowed him the opportunity to remain connected and communicate with his family and friends. She also stated when the resident became frustrated when trying to communicate and could not get his needs met, he could become agitated and act out in frustration. NF2 stated after resident #11 passed away, the facility gave them the resident's belongings. In those belongings was a notebook which he used to communicate with the staff. The notebook was full of written statements by the resident of, I am in pain, I want my family, I hurt, help me, call my daughter please. NF2 stated she was upset to find this notebook because she knew he needed to communicate with someone, and the facility never set up his one link to the outside world and his family. During an interview on 9/24/20 at 11:35 a.m., staff member U stated she worked with resident #11 for a short time before she was transferred to another unit in the facility. Staff member U stated she believed the web camera was set up and working. The only issue related to the web camera was when resident #11 was transferred to the COVID-19 unit on 9/10/20. Staff member U stated the web camera could not be set up in the COVID-19 unit due to wiring issues. Staff member U stated she remembered having discussions with staff regarding agitation and confusion occurring until the web camera was set up. During an interview on 9/25/20 at 10:27 a.m., staff member V stated she did not think the web camera ever worked. She had used a pen and paper to communicate with resident #11, and because one of the activity aides knew sign language, staff member V had sometimes asked her to translate. During an interview on 9/25/20 at 10:30 a.m., staff member X stated the web camera was initially set up after resident #11 was admitted in April of 2020. Staff member X remembered receiving a message regarding the web camera not working over a weekend. However, by the time staff member X returned to work, the direct care staff had already fixed it. Staff member X stated he had not received any other work orders and assumed the web camera was working.

Based on observation, interview, and record review, the facility failed to ensure adequate numbers of staff were available to provide resident care, including the on time administration of medication, personal hygiene, and showers for 9 (#s 11, 13, 14, 15, 17, 19, 20, 21 and 22) of 26 residents sample, and had the potential to affect all residents in the facility. During an observation and interview on 9/15/20 at 9:57 a.m., the posted staffing for Unit 1 during the day showed one nurse, one medication aide, and one CNA. Staff member Q stated there were usually three to four CNA's during the day. The night shift staffing showed one nurse and no CNA. Staff member Q stated there had been two CNA's initially, but one was sent home an hour earlier due to illness. During the interview, two CNA's from the Crossroads unit arrived to assist with resident care. During an interview on 9/16/20 at 2:10 p.m., resident #20 stated there was not enough staff to give showers or get her out of bed. She stated she had missed physical therapy earlier in the week because the staff did not get her up and out of bed on time. Resident #20 stated there had been a day during the previous week when there was no nurse on the unit to give her noon medication. She stated she did not get the medication until 4:00 p.m. During an interview on 9/17/20 at 10:15 a.m., resident #21 stated, We have had a skeleton crew for the past three to four weeks, and she had not had a shower in a month. During an interview on 9/23/20 at 11:22 a.m., NF1 stated she has had many calls from family members of residents complaining about the lack of resident care and neglect. NF1 stated she had tried multiple times, without success, to speak with staff member A regarding these concerns. During an interview on 9/24/20 at 9:47 a.m., staff member E stated she worked by herself for more than five hours on 9/10/20. Staff member E stated she was assigned to the COVID-19 unit during the day shift on 9/10/20. She stated there were 11 residents and no other CNA's. Staff member E stated the nurse left at 10:00 a.m., and another nurse did not arrive on the unit until after 3:00 p.m. Between 10:00 a.m. and 3:00 p.m., staff member E stated she made multiple phone calls and texts to staff member H asking when there would be a nurse. She stated the only answer she got was, soon. Staff member E stated during the time she was alone on the unit, lunch was served, no blood sugars were checked, no insulin or other medications were given, and resident #11 returned from the hospital for readmission to the facility. Staff member E stated there was no one to set up resident #11's oxygen, or to receive report from the ambulance crew who performed the transfer. Staff member E stated she tried to get help, and no one came. Review of resident #20's medical record, showed her [MEDICATION NAME] was scheduled to be given at 12:00 p.m. and 8:00 p.m. On 9/10/20, resident #20 received her 12:00 p.m. dose of [MEDICATION NAME] at 3:41 p.m. During the review of grievances submitted on 9/1/20, multiple complaints regarding the neglect of resident care were identified. The following interviews pertain to these grievances. During an interview on 9/23/20 at 10:24 a.m., NF5, resident #19's family member, stated they felt the resident had been receiving terrible care by the facility, and they were very unhappy. NF5 stated before the quarantine, they were there to visit resident #19 every day, and they really did much of his care for him. The staff did not have to worry much about his daily hygiene. But now since they can no longer visit resident #19 his care has become nonexistent. They stated it was hard to see him like that knowing they cannot do anything for him. During an interview on 9/23/20 at 11:20 a.m., NF4 stated concern about resident #13 receiving regular showers and being kept clean because of a bed sore. NF4 stated when they asked about showers, the facility would say no because of an appointment, or a scheduling conflict. NF4 stated they told the facility it did not matter what days the showers were done, but they wanted them done twice a week. Review of resident #s 13, 14, 15, 17, 19, 20, 21, and 22 bathing documentation for the past 30 days showed none of the residents received twice weekly showers as scheduled. Nor was there documentation explaining why the showers were not completed as scheduled.

Based on interview and record review, the facility failed to provide adequate supervision for a resident at high risk for falls, failed to document falls which had occurred, failed to complete the post-fall evaluation, and implement modified interventions in response to repeated falls for 1 (#11), and failed to adequately assess a resident for injury after a fall for 1 (#16) of 26 sampled residents. Resident #11 sustained at three undocumented falls within six hours, and the resident passed away at the time of the second undocumented fall. Resident #16 sustained a femur fracture during a fall which was not identified until two days later, and a delay in surgical intervention occurring an additional four days later. Findings include: 1. During an interview on 9/24/20 at 9:47 a.m., staff member E stated she was told by nursing, on the morning of 9/13/20, resident #11 was found on the floor and she needed to get his vital signs. Staff member E later found resident #11 out of bed, and when she attempted to get him back into bed, he collapsed to the floor. Staff member E stated she, staff member C, and another CNA used a lift to transfer resident #11 from the floor to his bed. Review of resident #11's nursing progress note, dated 9/11/20 at 10:30 a.m., showed the resident was found on the floor of the bathroom by a CNA at approximately 8:00 a.m. Using gestures, resident #11 expressed that he had hit the left side of his head on the toilet and the wall. The note also showed resident #11 had no observable injuries but did have a distressed demeanor. Resident #11 was sent to the emergency room for a head scan. Review of resident #11's Fall Risk Evaluation, dated 9/11/20 at 8:00 a.m., showed he had no alteration in cognition, inadequate vision, an unsteady gait, but was able to walk. The evaluation showed resident #11 was a high fall risk. Review of resident #11's fall care plan, dated 4/15/20, showed he was a high fall risk at the time of his admission to the facility. No revisions of the care plan were documented after resident #11 fell on [DATE]. Review of resident #11's medical record, dated 9/11/20 through 9/13/20, failed to show any documentation of any post-fall management related to the fall sustained on 9/11/20 other than the emergency room visit. The record also failed to show the occurrence of, or any post-fall management, for the three falls sustained by the resident on the morning of 9/13/20. The medical record did show resident #11 passed away at 11:00 a.m., the same time the third fall was reported by staff member E. 2. During an interview on 9/22/20 at 12:30 p.m., staff member BB stated resident #16 had fallen and sustained a femur fracture and was hospitalized for [REDACTED]. Review of resident #16's progress note, dated 9/16/20 at 11:43 p.m., showed she was found on the floor of her room after tripping over her shoes while attempting to transfer by herself. Resident #16's assessment immediately after the fall showed right knee and hip pain at a nine or 10 out of 10. Review of resident #16's Fall Risk Evaluation, dated 9/19/20 at 11:20 p.m., showed she was a low fall risk. Review of resident #16's Physical Therapy encounter note, dated 9/17/20, showed she was having pain to her left hip and knee and unable to roll comfortably side to side. The note showed nursing had cleared resident #16 to participate in therapy including transfers, standing, and ambulation. Resident #16 declined to get out of bed and was assisted by physical therapy to a position of comfort. The note showed resident #16's status and pain were discussed with the IDT. Review of resident #16's Occupational Therapy encounter note, dated 9/17/20, showed resident #16 needed to use the bathroom, but refused to get out of bed due to her pain, and required total assistance to turn side to side during toileting. Review of resident #16's Occupational Therapy encounter note, dated 9/18/20, showed since resident #16's fall she had complained of pain at a nine to 10 out of 10, and waiting to see if resident is to receive orders for x-rays to determine the level of injury. Review of resident #16's History and Physical from (acute hospital name), dated 9/21/20, showed she had a CT scan done on 9/18/20 which revealed a left [MEDICAL CONDITION]. The note also showed, It is unclear what transpired to precipitate a delay in presentation to the ER for orthopedic evaluation/admission today. A request was made on 9/30/20 for all progress notes related to falls during the past three months. No notes for 9/19/20 through 9/22/20 were received. No documentation explaining the delay in [DIAGNOSES REDACTED]. Review of the facility's policy titled, Falls Management, dated 11/2019, showed resident management after a fall involves the following steps: - complete a head-to-toe assessment of the resident - ask the resident to explain what happened and what they were trying to do when they fell - obtain vital signs - obtain neurological checks, even if resident denied hitting their head - contact the provider and the resident representative and document in the medical record, include the time and who was notified Post fall injury prevention involves the following steps: - investigate the circumstances in order to determine the reason for the fall - determine and implement new interventions for fall prevention and record on the care plan - complete a fall risk evaluation - complete a pain assessment - discuss the findings with the resident and resident representative for inclusion in care planning - update and communication interventions - provide appropriate training for caregivers, noting any changes implemented - educate the resident and resident representative, as appropriate

Based on observation, interview and record review, the facility failed to prevent the development and worsening of pressure ulcers for 4 (#s 1, 2, 17, 18); failed to complete timely assessments, accurately stage pressure ulcers, consistently identify anatomical location of a pressure ulcer, accurately identify eschar in a wound bed, analyze the root cause of pressure ulcers, and implement appropriate interventions for 1 (#18); and failed to identify, monitor care for, develop care plans for, and document the resolution of unstageable deep tissue ulcers for 1 (#2) of 23 sampled residents. Findings include: 1. Review of resident #17's Bath Sheet, dated 10/14/17, showed the resident had a sore to the heel, and the wound nurse was informed. Review of the resident #17's Weekly Wound Log, dated 10/16/17, showed a deep tissue injury, and an order for [REDACTED]. Review of the resident #17's Weekly Wound Log, dated 10/30/17, showed a new intervention of an ankle roll. Review of a PT note, dated 11/22/17, showed the resident did not like the foam boot, because she said it kept her up all night. During an interview and observation on 11/21/17 at 8:20 a.m., NF1 stated the resident's heel looked better, but the skin area was covered with eschar, so the wound was not stagable. Review of resident #17's Significant Change MDS, with the ARD of 10/16/17, showed the resident had a Stage II pressure ulcer, with no pressure ulcer care in place. During an observation on 11/20/17 at 1:00 p.m., resident #17 was lying in bed with her shoes on. She stated she was waiting for therapy. She was not aware of any foot-wear restrictions, and she said she had a bed sore on her heel. Review of a physician order, dated 10/20/17, showed In sandals with no strap or covering on right heel due to pressure to the heel, and Heel floating right heel and foam boot to both feet when in bed. During an observation on 11/21/17 at 1:40 p.m., resident #17 was asleep in her bed and without the ankle roll. Review of resident #17's Physician Visit, dated 10/3/17, showed Due to patient's severe diabetic [MEDICAL CONDITION], she is unable to feel foot (sic) pain. Review of resident #17's Braden Scale for pressure ulcer risk factors, dated 10/15/17, showed no risk for pressure ulcers. During an interview on 11/21/17 1:05 p.m., staff member U stated she did not know anything about resident #17's heel or treatment for [REDACTED]. During an interview on 11/21/17 at 1:30 p.m., staff member K stated she knew resident #17 had a sore on her heel, and stated the nurses take care of the treatment. She did not know about pressure reduction for the heel. Review of resident #17's Physician Orders, dated 10/20/17, showed a dietary consult was requested for wound healing. Review of the Physician order [REDACTED]. During an interview on 11/20/17 at 8:40 a.m., staff member O stated she would have reviewed resident #17 during the skin and wound meeting. She said resident #17 had a poor appetite after admission to the facility, but had recently experienced a severe weight gain. During an interview on 11/21/17 at 10:45 a.m., staff member J stated staff would learn about the care and treatment for [REDACTED]. She also stated resident #17 had the right to wear any type of shoe. Staff member J stated the facility was unable to provide documented education for resident #17's risk and benefits regarding pressure reducing interventions. Record review of skin care and treatments provided by the facility showed no pressure ulcer care or interventions until 10/20/17, one week after it was discovered, and the wound had deteriorated from a blister to an unstageable pressure ulcer. 2. Resident #1 was admitted to the facility in April 2017 with [DIAGNOSES REDACTED]. He was discharged from the facility on 8/21/17. Review of resident #1's Admission MDS, with an ARD of 4/24/17, showed resident #1 required extensive assistance with activities of daily living, and he had a BIMS of 15; cognitively intact. He was admitted to the facility with one Stage IV pressure ulcer to his coccyx. The dimensions of the pressure ulcer were 06.2 cm x 02.1 cm x 05.8 cm. The most severe tissue type for this ulcer was coded as 3; Slough - yellow or white tissue that adhered to the ulcer bed in strings or thick clumps, or is mucinous. Review of resident #1's Quarterly MDS, with an ARD of 7/17/17, showed resident #1 required extensive assistance with activities of daily living, and he had a BIMS of 15; cognitively intact. He was coded as having four Stage III pressure ulcer and 1 Stage III pressure ulcer upon admission. The dimensions of the pressure ulcer were 08.7 cm x 06.1 cm x 0.1 cm. The most severe tissue type for this ulcer was coded as 3; Slough- yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous. Review of resident #1's Discharge MDS, with an ARD of 8/21/17, showed resident #1 required extensive assistance with activities of daily living, and he had a BIMS of 15; cognitively intact. He was coded as having four Stage III pressure ulcers. The dimensions of the pressure ulcer were 08.7 cm x 06.1 cm x 00.1 cm. The most severe tissue type for this ulcer was not coded. A review of resident #1's TAR (treatment administration record) reflected the following: - 4/19/17 to 4/27/17, staff provided wound care twice weekly. Orders read, Remove dressing. Rinse with NS (normal saline) and pat dry. Apply 4x4 soaked in Vasche x 15 minutes. Apply Santyl. Apply NPWT with bridge technique to hip. Use Adapt to gluteal cleft to seal. 125 mmHg continuous. Will be changed at wound care appointment on Mondays. - 4/24/17 to 7/2/17, orders read, offload sacral / sacrum at all times. - 4/27/17 to 5/9/17, staff provided wound care three times weekly. Starting 4/28/17. Orders read, Remove dressing. Rinse with NS and pat dry. Apply 4x4 soaked in Vasche x 15 minutes. Apply Santyl. Apply NPWT with bridge technique to hip. Use Adapt to gluteal cleft to seal. 125 mmHg continuous. Will be changed at wound care appointment on Mondays. PLEASE SEND DRESSING CHANGE. - 5/9/17 TO 5/28/17, Orders read, Wound Care every eight hours .PU stage (sic) II right ischial tuberosity. Apply [MEDICATION NAME] TID. - 5/9/17 to 7/2/17, staff provided wound care three times weekly. Orders read, Remove dressing. Rinse with NS and pat dry. Apply 4x4 soaked in Vasche x 15 minutes. Apply Santyl. Apply NPWT with bridge technique to hip. Use Adapt to gluteal cleft to seal. 125 mmHg continuous. Will be changed at wound care appointment on Mondays . - 5/16/17 to 5/28/17, staff provided wound care every seven days, starting 5/15/17. Orders read, DTI bulla left proximal posterior heel. 0.5 x 0.7 x 0.0 cm. Serosanguinous filled bulla to posterior heel. Tx: offload and cover with foam border every 7 days and as needed if soiled. - 5/22/17 to 7/2/17, staff provided wound care three times weekly. Orders read, [MEDICATION NAME] 1 over bone. Skin prep and Duoderm to periwound (sic). - 6/5/17 to 7/2/17, orders read, offload feet ulcers at all times. - 7/7/17 to 7/9/17, orders read, heels/ ankle: offload on feet, [MEDICATION NAME] with alginate, Kerlix. - 7/10/17 to 7/25/17, orders read, Pressure ulcer of sacral region, stage (sic) 4. Remove old dressing. Rinse with NS and pat dry. Apply 4x4 soaked in Vasche x 10 minutes. Apply Santyl. Apply NPWT with bridge technique to hip. Use Adapt to gluteal cleft to seal. 125 mmHg continuous. Change Monday, Wednesday, Friday, and as needed if unable to maintain pressure. - 7/10/17 to 7/25/17, orders read, Pressure ulcer of right heel, unspecified stage, pressure ulcer of left heel, unstageable. Remove old dressing. Rinse with NS and pat dry. Soaked wound in Vasche on 4x4 x 10 minutes. Apply felt to off load wounds to bilateral heels, bilateral lateral foot, and right toe cluster. Apply [MEDICATION NAME] and Alginate to wounds. Cover with Curlex (sic) and tape to secure. - 7/25/17 to 8/4/17, orders read, Pressure ulcer of sacral region, stage (sic) 4. Remove old dressing from coccyx. Rinse with NS and pat dry. Apply Vasche to 4x4 x 10 minutes. Apply skin prep to Periwound are and (sic) allow to dry. NPWT using black foam with bridge technique to hip. Apply negative pressure at 125 mmHg continuous. Change Monday, Wednesday, Friday, and as needed if unable to maintain pressure. - 7/25/17 to 8/4/17, orders read, Pressure ulcer of right heel, unspecified stage, pressure ulcer of left heel, unstageable. Remove old dressing. Rinse with NS and pat dry. Soaked wound in Vasche on 4x4 x 10 minutes. Apply felt to off load wounds to bilateral heels clusters, bilateral lateral feet, and right 3rd toe. Apply [MEDICATION NAME] and Alginate to wounds. Cover with Curlex (sic) and tape to secure. Change Monday, Wednesday, Friday, and as needed if unable to maintain pressure. - 8/7/17 to 8/21/17, orders read, Document resident position every 2 hours. Staff did not document twenty-two instances of positioning. - 8/7/17 to 8/21/17, orders read, Wound care three times weekly. Remove old dressing from injuries to feet. Rinse with NS and pat dry. Apply skin prep and allow to dry. Apply felt to off load wounds to bilateral heels clusters, bilateral lateral feet, and right 3rd toe. Apply [MEDICATION NAME] and Silver Alginate to left heel wounds. Apply silver alginate to right heel wound. Cover both feet with Kerlix and tape to secure. Change Monday, Wednesday, Friday, and as needed if soiled. Float feet at all times. A review of resident #1's BRADEN skin assessments reflected the following: - 4/17/17 at 4:13 p.m., staff documented a score of 19; not at risk- no interventions necessary at this time. - 4/24/17 at 2:02 p.m., staff documented a score of 15; at risk- if other risk factors are present e.g. advanced age, fever, poor dietary intake of protein, hemodynamic instability advance to next level of risk. - 5/1/17 at 3:44 p.m., staff documented a score of 14; moderate risk- if other major risk factors are present advance to next level of risk. - 5/12/17 at 9:10 a.m., staff documented a score of 14; moderate risk. - 7/7/17 at 6:27 p.m., staff documented a score of 15; at risk. - 7/22/17 at 12:26 a.m., staff documented a score of 16; at risk. - 7/28/17 at 11:06 a.m., staff documented a score of 16; at risk. A review of resident #1's ADL Verification Worksheet reflected the following: - 4/18/17 to 4/30/17, staff provided extensive assistance to the resident eighteen times with repositioning in bed, and provided extensive assistance twelve times with transfers. - 5/1/17 to 5/31/17, staff provided extensive assistance to the resident thirty-five times with repositioning in bed, and provided extensive assistance to the resident with transfers twenty-three times. - 6/1/17 to 6/30/17, staff provided extensive assistance to the resident twenty-eight times with repositioning in bed, and provided extensive assistance to the resident with transfers sixteen times. - 7/1/17 to 7/31/17, staff provided extensive assistance to the resident twenty-one times with repositioning in bed, and provided extensive assistance to the resident with transfers twenty times. - 8/1/17 to 8/21/17, staff provided extensive assistance to the resident thirteen times with repositioning in bed, and provided extensive assistance to the resident with transfers nine times. Review of resident #1's Clinical Nurse's Notes read: - On 4/18/17 at 2:03 a.m., PU (sic) Stage IV coccyx. 6.2 x 2.1 x 5.8 cm. Tunneling at 1100-0100. Wound bed is 75% granulation and 25% slough .Wound edges are slightly macerated but intact . Change dressing at (hospital name's) wound clinic Monday, and at the facility on Wednesday and Friday. - On 4/27/17 at 6:50 a.m., PU (sic) Stage IV coccyx. 7.3 x 3.0 x 7.0 cm. Tunneling at 1000-0300 to depth of 5.0 cm. Wound bed is 75% necrotic eschar and slough .Wound edges are slightly macerated but intact . Change dressing at (hospital name's) wound clinic Monday, and at the facility on Wednesday and Friday. - On 4/28/17 at 10:49 a.m., .Left heel has black spot that measures 1.7 cm x 1 cm. On his right heel, black spot measures 0.8 x 0.5 (cm). [MEDICATION NAME] applied to the site. Will inform provider and wound care nurse about this. - On 5/2/17 at 12:05 a.m., .PU (sic) Stage IV coccyx .PU (sic) Stage III left buttock 0.6 x 1.4 x 0.1 cm. 75% eschar/slough, 25% granulation. - On 5/9/17 at 3:08 a.m., PU (sic) Stage IV coccyx. Assessment per (Dr.'s name) 7.5 x 5.5 x 4.5 cm . Change dressing at (hospital name's) wound clinic Monday, and at the facility on Wednesday and Friday .PU (sic) Stage III left ischial tuberosity 0.6 x 1.4 x 0.1 cm. 75% eschar/slough, 25% granulation. PU stage II right ischial tuberosity 0.6 x 0.9 x 0 cm. OTA (open to air) DTI (deep tissue injury) Bulla Achilles tendon 1.0 x 1.5 x 0 cm. OTA DTI posterior heel 2.5 x 2.5 x 0 cm .TA open lesion anterior tibial boarder 0.5 x 0.9 x 0 cm .OTA DTI right lateral #5 metatarsal head 2.0 x 1.5 x 0 cm. PU stage 1 right posterior heel 2.0 x 3.0 x 0 cm. DTI right lateral heel 1.4 x 1.0 x 0 cm. - On 5/16/17 at 2:16 a.m., PU (sic) Stage IV coccyx. Assessment per (Dr.'s name) 14.9 x 11.2 x 5.0 cm. S/p revision. Wound bed 25% granulation, 50% adherent slough, 25% eschar. Bone and fat layer exposed .Tunneling at 0300 4.8 cm .Change dressing at (hospital name's) wound clinic Monday, and at the facility on Wednesday and Friday .PU (sic) Stage III left ischial tuberosity 0.5 x 0.5 x 0.1 cm. 75% eschar/slough, 25% granulation .OTA DTI Bulla left Achilles tendon 1.0 x 1.0 x 0 cm .OTA DTI Bulla left proximal posterior heel 0.5 x 0.7 x 0 cm .DTI posterior heel 2.0 x 2.5 x 0 cm .OTA open lesion left anterior tibial boarder 0.5 x 0.4 x 0 cm .OTA DTI right lateral #5 metatarsal head 1.6 x 1.0 x 0 cm .OTA DTI right lateral heel 1.0 x 1.1 x 0 cm .DTI left hallux plantar 0.5 x 1.1 x 0 cm .Wound care to continue monitoring pt. (sic) weekly. - On 5/28/17 at 12:27 a.m., PU (sic) Stage IV coccyx. 12.7 x 12.0 x 5.4 cm. S/p revision. Wound bed 25% granulation, 50% adherent slough, 25% eschar. Bone and fat layer exposed .Tunneling at 0300 - 1200 4.0 cm .Change dressing at (hospital name's) wound clinic Monday, and at the facility on Wednesday and Friday .OTA Unstageable left Achilles tendon 2.0 x 2.0 x 0 cm. Wound bed crusted .OTA unstageable left proximal posterior heel 0.5 x 0.5 x 0 cm .DTI left posterior heel 2.0 x 2.3 x 0 cm .OTA open lesion left tibial boarder 0.5 x 0.5 x 0 cm .OTA DTI right lateral #5 metatarsal head 2.0 x 1.5 x 0 cm .OTA DTI right Achilles tendon 1.9 x 1.0 x 0 cm .OTA DTI right lateral heel 2.0 x 1.7 x 0 cm .DTI left hallux plantar 0.5 x 0.9 x 0 cm .OTA Shear injury left ischial crest 5.0 x 10.0 x 0 cm .Wound care to continue monitoring pt. (sic) weekly. - On 6/6/17 at 1:25 a.m., PU (sic) Stage IV coccyx. 11.0 x 9.5 x 4.3 cm. Wound bed 50% granulation, 50% adherent slough. Fat layer exposed .Undermining at 0900 - 1200 4.0 cm . Change dressing at (hospital name's) wound clinic Monday, and at the facility on Wednesday and Friday .OTA Unstageable left Achilles tendon BCWC, 100 % black eschar .PI Unstageable left proximal posterior heel. BCWC. 100% black eschar .DTI left posterior heel. BCWC. 100% black eschar .OTA DTI right Achilles tendon. BCWC. 100% eschar .OTA DTI right lateral heel. BCWC. 100% eschar .DTI left hallux plantar 0.4 x 0.9 x 0 cm . - On 6/12/17 at 10:52 p.m., PU (sic) Stage IV coccyx. 11.4 x 9.0 x 4.0 cm. Wound bed 50% granulation, 50% adherent slough. Fat layer exposed .Change dressing at (hospital name's) wound clinic Monday, and at the facility on Wednesday and Friday .DTI left lateral #5 metatarsal head. BCWC. 100% black eschar .PI Unstageable left Achilles tendon. BCWC, 100 % black eschar .DTI left posterior heel. BCWC. 100% black eschar .DTI right lateral #5 metatarsal head 2.0 x 1.0 x 0 cm . black eschar .DTI right Achilles tendon. BCWC. 100% eschar .DTI right lateral heel. BCWC. 100% eschar . DTI left hallux plantar 0.4 x 0.9 x 0 cm . - On 6/20/17 at 4:37 a.m., PU (sic) Stage IV coccyx. 10.9 x 8.5 x 3.0 cm. Wound bed 75% granulation, >25% adherent slough. Undermining from 1000 to 0300, 3.0 cm . Fat layer exposed .Change dressing at (hospital name's) wound clinic Monday, and at the facility on Wednesday and Friday .DTI left lateral #5 metatarsal head. 1.5 x 1.0 x 0 cm .100% black eschar .Chg at facility Friday and (hospital name) WC on Monday DTI right Achilles tendon. Dimensions changed to right heel cluster. DTI right lateral heel .DTI left hallux plantar 0.4 x 0.9 x 0 cm .50% black eschar and 50% granulation .Chg at facility Friday and (hospital name) WC on Monday PI left heel cluster. 8.0 x 10.5 x 0 cm. 100% black eschar .Chg at facility Friday and (hospital name) WC on Monday right #2 LRE digit 1.0 x 0.5 x 0 cm. Dorsum of toe braided after foot fell of W/C foot pegs Secure with contour gauze Abrasion right #3 LRE digit 1.2 x 0.7 x 0 cm . During an interview on 11/20/17 at 4:30 p.m., staff member Y stated resident #1 developed pressure ulcers to both heels, which worsened at the facility. She stated the resident was dragging his feet while propelling in the hallways in his wheelchair. During an interview on 11/20/17 at 4:45 p.m., staff member H stated the resident was admitted from the hospital to the facility with a pressure ulcer to his coccyx. The staff member stated within a month, that ulcer became worse, and within a few months, the resident had developed ulcers to both of his heels. Staff member H stated the facility should have done a better job in assistance with bed mobility, turning and repositioning, and ensuring resident #1 did not develop or have worsening pressure ulcers. During an interview on 11/20/17 at 5:05 p.m., staff member Z stated she had reported to the facility nursing staff resident #1's coccyx and heels looked worse. Staff member Z stated she was not sure what interventions were in place to prevent the development and worsening of pressure ulcers for resident #1. During an interview on 11/20/17 at 5:30 p.m., staff member AA stated resident #1 was admitted to the facility with a pressure ulcer to his coccyx area. He stated the resident required limited assistance with activities of daily living, and only provided minimum skin assessments, and treatments for the resident. During an interview on 11/20/17 at 8:22 p.m., staff member BB stated resident #1 developed new pressure ulcers to his heels while residing at the facility. She stated the facility could have done a better job at ensuring worsening, or the development of pressure ulcers, was avoided. During an interview on 11/20/17 at 9:00 p.m., staff member CC stated the resident developed heel ulcers while at the facility. The staff member stated she reported skin changes to the charge nurse, but did not know if new interventions were implemented. 3. Review of resident #2's Admission MDS, with a ARD of 4/19/16, the Quarterly MDS, with and ARD of 7/11/17, and a Significant Change MDS, with an ARD of 9/14/17, showed that resident #2 did not have any stagable or unstageable ulcers, but was at risk for developing ulcers. Review of resident #2's Clinical Notes, dated 4/25/17, showed resident #2 had a Stage 1 ulcer on her left upper gluteus, and a deep tissue injury (unstageable ulcer) on her right medial posterior heel. Documentation on the assessment and treatment of [REDACTED]. Upper Left Gluteus: 4/25/17-described as a Stage one ulcer 5/1/17-described as a DTI (deep tissue injury), non blanchable, no open area 5/8/17-described as resolved 5/9/17-described as a DTI, dark purple area under intact hyperkeratinized dermis, soft. No open area . 5/15/17-gluteus not addressed 5/26/17-the Clinical Notes lacked evidence of the DTI status, or resolution of the DTI Right medial posterior heel: 4/25/17- heel described as DTI (deep tissue injury); 5/1/17-heel described as DTI ulcer, dark purple area under intact hyperkeratinized dermis, soft .; 5/9/17-heel was described as resolved; 5/16/17- heel was described as a right medial posterior heel .Dark purple area under intact hyperkeratinized dermis, soft. No open area, No drng (sic), no odor, no pain .; 5/26/17-heel was described as having black eschar over area. No open area .; 6/6/17-heel was described as having hard black eschar over area. No open area .; 6/12/17-heel was described as having black eschar over area. No open area.; 6/20/17-heel was described as having black eschar over area. No open area .; 6/23/17-follow up to white areas on resident's heels. Resident with hx s/p . Areas to be observed daily by nursing staff with tx as ordered and followed weekly by wound care nurse. Float heels and apply foam boots. Resident is aware of importance of offloading.; and, 6/22/17-heel was described as, Suspected deep tissue injury of heals (sic) resolved. Review of resident #2's Clinical Note for 6/27/17, showed there were two new ulcers on the left and right plantar surfaces of resident #2's feet, and a reopening or possible continuation of a previous ulcer on the medical posterior heel: 6/27/17-heels were described as, PI DTI R (Plantar Deep Tissue Injury Right) medial posterior heel. 1.0 x 1.1 x 0.0 cm. Black eschar over area. No open area. No drng, no odor, no pain. Periwound intact with intact wound edges. TX: Foam boot at all times not in shoes and pillow under calves while in bed. PI DTI R (Plantar Deep Tissue Injury Right) heel plantar. 3.0 x 2.0 x 0.0 cm. Intact dermis. Light purple coloration. No drng, odor, No edges but well demarked border. Periwound Pink and cool. TX: Offload heels. Float heels while in bed. Wear shoes or foam boots during wake hours. PI DTI L (Plantar Deep Tissue Injury Left) heel plantar 2.0 x 2.2 x 0.0. Intact dermis. Light purple coloration. No drng, odor, No edges but well demarked border. Periwound Pink and cool. TX: offload heels. Float heels while in bed. Wear shoes or foam boots during wake hours. Wound care to continue monitoring pt. Review of resident #2's Clinical Notes lacked evidence that the three new foot wounds (ulcer or DTI) and the left gluteus ulcer had been resolved at the time of the Quarterly MDS assessment, with an ARD of 7/11/17. Review of the Quarterly MDS assessment, with an ARD of 7/11/17, did not reflect any skin issues for resident #2. Review of resident #2's, Skin Risk Assessment / Braden, dated for the 7/11/17 MDS, showed, Resident has a stage (sic) 1 or greater, a scar over bony prominence, or a non-removable dressing/device. The assessment lacked evidence the three newly developed foot wounds were addressed as DTIs (deep tissue injuries). Review of resident #2's care plan showed interventions were put in place for, Risk for alteration in skin integrity r/t decreased mobility and bowel incontinence, on 4/12/17, and updated on 4/19/17. The care plan did not address resident #2's having developed four separate skin issues in the facility. Review of resident #2's Clinical Notes, dating back to 4/12/17, showed resident #2 she had orders to Turn q 2 hours. The care plan showed an intervention of wearing Podus type boots while the resident was in bed, and to check for incontinence, monitor skin, supplements, weekly skin audits, education on offloading and pressure reduction, cushion in wheelchair, and assist with turning and positioning every two hours. Interventions put into place by the house nurses, the house wound care nurse, or either the on-site or off-site Certified Wound Care nurses were not added to the care plan. After the discovery of the of the open heel wound on 4/24/17, an additional intervention was initiated by the nurse in elevating the heels on pillows and moisturizing the feet. The patient was referred to the wound nurse. Dressing changes were ordered to be administered, along with orders for TED Hose, wearing shoes or foam boots during wake hours, weekly skin audits, Wound Care to monitor, and, Ace wraps utilized for [MEDICAL CONDITION]. The care plan was not updated to include any of these interventions. Review of resident #2's Clinical Notes, dated 8/5/17, 9/8/17, 9/26/17, and 10/24/17 showed no further ulcers, or unstageable DTI's. Review of resident #2's Physician order [REDACTED]. With TX to include offload heels, float heels while in bed, wear shoes or foam boots during wake hours, and to conduct a skin audit weekly on bath days. During an observation and interview of resident #2 in her room on 11/19/17 at 4:00 p.m., she was up in her w/c and did not have on shoes or Podus boots. She said she had some skin issues in the past, but thought the wounds were better. She said she sometimes wears the boots. During an observation of resident #2 in her room on 11/20/17 at 8:15 a.m. she was lying in bed, her heels were not floated, and she was not wearing the Podus boots. During an observation and interview regarding resident #2's heels and gluteal fold on 11/21/17 at 10:30 a.m., with staff members U and V, the heels and gluteal fold areas appeared to be CDI and healed. Staff member's U and V said they had not seen any skin wounds on resident #2 for a while. On 11/21/17 at 8:59 a.m., a request was made to staff member's G, J, and K, for any documentation that showed the continuation of care, or the resolution of the ulcers and DTI's experienced by resident #2 in the facility. During an interview on 11/21/17 at 12:04 p.m. staff member B said, We do not have any more documentation of the heel wounds for (resident #2) past the date of 6/27/17. We have looked, and this was all that we could find. During an interview on 11/21/17 at 12:55 p.m., staff member K said the Certified Wound Nurse who had worked for the company left his position on 8/7/17. She said that when he did work for the company, he sometimes worked in conjunction with the (local clinic). He was considered to be the house wound nurse and was certified as a wound nurse. During an interview on 11/21/17 at 1:04 p.m., staff member U, who was charged with caring for resident #2 at that time, said she did not know if resident #2 had any skin issues, and would not know where to locate this information unless there was an actual wound care order. She said she was not sure where the CNA's would document the implementation of interventions, such as turning and positioning but that sometimes a note would pop up as a reminder for the nurse to turn and position a resident. Staff member U said each time a nurse changed a dressing they would be assessing and monitoring a wound. She said she thought a nurse could update a care plan if needed, but was unsure of this process. Staff member U said she was not sure if a change in wound status was reported by the floor nurse, the charge nurse, or the wound nurse. She said she was relatively new and unsure of the facilities policies. During an interview on 11/21/17 at 1:30 p.m., staff member V said the CNAs report skin problems to the nurse when they see them. She said she gets her information about the residents in report when she comes on shift and did not look at care plans. 4. Review of resident #18's Annual MDS, with an ARD of 2/15/17, showed resident #18 had a risk for the development of pressure ulcers but had no pressure ulcers during the assessment reference period. Review of resident #18's Quarterly MDS, with an ARD of 8/18/17, showed the presence of two Stage II pressure ulcers. a. Review of resident #18's clinical notes showed the following: -7/18/17, A large blister had popped on the right heel. -7/20/17, The right heel had a blister draining serous fluid. -8/6/17, An area on the heel was open. Drainage on the removed dressing was yellowish green with foul odor. -9/5/17, A nurse reported the right heel had healed. -9/11/17, Treatment was done to heel wound, which was a pea size scab. -9/17/17, No dressing was applied to heel. Wound not open with a small scab area. -9/16/17, . had (a) Stage 2 area to right heel which has now resolved only small scab area that will soon be off (sic). -9/19/17, Right heel had reopened and was draining serosanguinous fluid. No dressing was in place, and ace wraps had not been applied to legs when assessed. -9/20/17, Scabbing was present to right heel. -9/22/17, Heel wound was open and a small amount of blood noted. -9/23/17, Right heel wound is healing nicely .not completely scabbed over. 9/25/17, Right heel wound was deeper. Loose slough was removed, and discolored drainage was noted. 10/5/17, Legs wrapped and right heel left OTA. Very small dry scab on her right heel. 11/10/17, Right heel had a pea sized scab area. Review of resident #18's assessments titled, Other Ulcers/Injuries, Wounds, & Skin Problems Weekly Assessment, showed four assessments completed from 8/4/17-8/22/17 for a Stage II pressure ulcer to the right heel. Two of the assessment were dated as signed on 8/4/17, and the next assessment was dated as signed on 8/17/17. Each of these assessments showed the presence of slough, necrotic tissue, or both. The next assessment following 8/22/17 was dated 9/4/17. Four assessments were completed in September 2017, with the fourth one dated 9/25/17. The pressure ulcer was documented as a Stage III on each September 2017 assessment. The next assessment was completed on 10/10/17, followed by assessments on 10/23/17, an undated assessment, and on 11/16/17, per sequential order of the records in the EHR. There were no assessments provided for July 2017. On multiple occasions, there were gaps of greater than one week between assessments, with gaps of 13-14 days at least three times. b. Review of resident #18's clinical notes showed the following excerpts: -7/10/17, sore on her buttocks still red and (sic) with black spot on the center, non-draining. -7/12/17, Resident buttocks sore still red, non-draining and no pain reported. Encourage resident to off-load her buttocks. -7/17/17, Resident seen by wound care today for dressing to right buttock. -7/23/17, Her buttocks re-opened with a size 1 cm x 1.3 cm and wound nurse was notified. -7/24/17, Resident has open sore on buttocks and barrier cream applied . -7/29/17, No open area on buttocks. -8/4/17, resident has redness on buttocks and barrier cream applied, [MEDICATION NAME] (sic) applied to pannus, buttocks and groin. -8/11/17, Resident has redness and wound on buttocks and barrier cream applied. -8/16/17, Resident buttocks improving but still has redness and wound, barrier cream applied during toileting. Review of resident #18's Weekly Wound Log showed an entry, dated 8/16/17, for an in-house acquired, un-staged wound to buttocks. The word healed was written under the column for the wound measurement. Review of resident #18's clinical notes from 8/16/17-9/16/17 showed the buttocks continued to have redness and or open areas. A clinical note, dated 9/16/17 at 1:24 p.m., showed there was an open area to the buttock. A clinical note dated 9/19/17 showed resident #18's buttock wound was healed. Review of resident #18's Weekly Wound Log showed measurements, and the presence of slough for an unstaged buttocks wound on 9/4/17 and 9/12/17. The entry dated 9/19/17 showed measurements of 0 x 0 x 0, and the word closed was written. The last entry for the buttocks wound, dated 10/10/17, with a single line through the date only, showed measurements and a change of treatment. The word recurrent was written under the Treatments/Comments column. Review of resid

Based on observation, record review, and interview, the facility failed implement meaningful interventions, complete adequate root cause analysis, or monitor the effectiveness of fall interventions, to prevent three falls, one with injury, for 1 (#10) of 23 residents. Findings include: Resident #10 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of resident #10's admission fall risk assessment, dated 10/27/17 showed a score of 15, and a high risk for falls, related to diminished safety awareness, balance problems while standing and walking, use of an antidepressant, and jerkiness and instability when making turns. Review of resident #10's hospital discharge report, dated 10/26/17, showed 2 security guards at the bedside all night. Haldol 5mg with minimal benefit. Benzodiazepines perhaps made worse. The fall risk assessment did not include the use of these medications. Review of resident #10's Nursing Note, dated 10/26/17, showed CNA informed me that the resident fell . She tried to get up from the chair, where she was sitting, lost balance and fell . No injuries were sustained. It was the resident's first day in the facility. Review of resident #10's Follow up Report, dated 10/28/17, showed the Root Cause was dementia, agitation, unsteady gait, and attempting to transfer self. It did not include why she was attempting to get up from the chair. Resident often requires one on one attention throughout the day and night due to cognitive deficit and unsteadiness, and inability to respond to cues of safety or direction. No interventions were implemented. Review of resident #10's Follow up Report, dated 11/6/17 showed the resident had another fall on 11/5/17. The root cause was she tripped. The fall was witnessed by staff. Resident has a history of poor safety awareness and unsteady gait. No root cause or interventions were provided. Review of resident #10's clinical Nursing note, dated 11/13/17, showed CNA came to get this nurse and stated that (resident) had fallen and hit her head and was bleeding. When this nurse got to (resident) she was on the floor sitting up by the med room and had a large welt, was bleeding from a cut by her left eye about one inch long. (Resident) was unable to follow commands for neuro's. She was not able to answer any questions appropriately. When asked her name, she replied with '15.' Husband decided to have her sent to the ER. She was diagnosed with [REDACTED]. Review of resident #10's Follow up report, dated 11/20/17, showed the resident fell on [DATE]. The documentation showed the resident was in the day area by the nursing station and staff observed her standing next to the wall. As staff passed her she was noted to have fallen to the floor. There were no other staff members or residents within the vicinity of the resident. The Root Cause identified was poor safety awareness. The facility did not attempt to identify why she fell after standing next to the wall. Review of resident #10's Care Plan, dated 10/27/17, showed the interventions to reduce falls with injury were: 1. Assist for transfers, as needed. 2. (Resident) has been seen to sit self-down on the floor to sit and watch happenings, she is able to get self-up. 3. Encourage use of call light and keep call light, remotes, and personal items, in reach. 4. Keep pathways free of clutter in room. 5. Observe for side effect of psychotropic drug use. 6. Encourage use of walker with assistance and to rise slowly and get balance before ambulating. 7. Encourage rest periods and frequent rests when ambulating to decrease fall risk. The care plan had not been updated after the falls identified above, and no new interventions directly relating to the root causes of the falls were implemented to prevent the third fall, in which the resident sustained [REDACTED]. During an observation and interview on 11/20/17 at 11:15 a.m., resident #10 was unable to understand what the call light was for, had a fading yellow bruise over her right eye, and was ambulating without a walker throughout the unit and other resident rooms. During an interview on 11/21/17 at 9:45 a.m., staff member K stated the facility discussed falls daily and trended them. During an interview on 11/21/17 at 1:30 p.m., staff member J stated the facility had nothing more specific for resident #10's falls interventions.

Based on interview and record review, the facility failed to adequately control a resident's pain, which interfered with the residents daily activities and made it hard for him to sleep, and provide adequate pain intervention to maintain the resident's highest practicable well-being, 1 (#1) of 23 sampled residents. Findings include: 1. Resident #1 was admitted to the facility in April 2017 with [DIAGNOSES REDACTED]. The resident was discharged from the facility on 8/21/17. Review of resident #1's Admission MDS, with an ARD of 4/24/17, section C, showed the resident had a BIMS of 15; cognitively intact. Review of this MDS, section J, showed the resident had frequent episodes of pain, which measured 7 of 10 on the pain scale. The pain interfered with resident #1's day-to-day activities. Review of resident #1's Quarterly MDS, with an ARD of 7/17/17, showed the resident was in pain almost constantly. The pain measured 9 of 10 on the pain scale. The pain interfered with day-to-day activities and made it hard for the resident to sleep at night. Review of resident #1's July 2017 recapitulation Physician Orders, showed the following had been ordered for pain management: - [MEDICATION NAME], 15 mg extended release, three tablets every 12 hours. - [MEDICATION NAME], 2 mg tablet, one tablet if pain was 5 of 10 on the pain scale, and two tablets when the pain was 6 of 10 on the pain scale, every 4 hours as needed for pain. Review of resident #1 MARs (Medication Administration Record) showed the following for the resident's inadequate pain management program, and lack of documentation showing the physician was notified of the resident's ongoing pain even after medication was provided: - April 2017; Orders reflected [MEDICATION NAME] 2 mgs, and 4 mgs, as needed every four hours (for pain). a. On 4/18/17 at 6:01 a.m., staff documented in resident #1's EMR that his pain level was an 8 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 8:01 a.m., staff documented the resident's pain level was still an 8 of 10. The physician was not notified that the [MEDICATION NAME] was ineffectual. At 10:07 a.m., the resident's pain was documented as being a 7 of 10 on the pain scale. He was administered [MEDICATION NAME] 4 mgs. At 12:07 p.m., staff documented the efficacy as 5 of 10. The physician was not notified of the ineffectual doses of [MEDICATION NAME] 4 mgs. b. On 4/20/17 at 5:58 p.m., staff documented in resident #1's EMR that his pain level was an 8 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 7:58 p.m., staff documented an efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. c. On 4/21/17 at 12:10 p.m., staff documented in resident #1's EMR that his pain level was a 9 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 2:10 p.m., staff documented an efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. d. On 4/21/17 at 5:23 p.m., staff documented in resident #1's EMR that his pain level was a 9 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 7:23 p.m., staff documented an efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. e. On 4/22/17 at 8:06 a.m., staff documented in resident #1's EMR that his pain level was a 10 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 10:06 a.m., staff documented an efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. f. On 4/22/17 at 12:19 p.m., staff documented in resident #1's EMR that his pain level was an 8 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 2:19 p.m., staff documented an efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. - May 2017; Orders reflected [MEDICATION NAME] 2 mgs, 1-2 tablets, as needed every four hours (for pain). a. On 5/5/17 at 5:29 p.m., staff documented in resident #1's EMR that his pain level was a 7 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 7:29 p.m., staff documented an efficacy of 7 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. b. On 5/15/17 at 5:40 p.m., staff documented in resident #1's EMR that his pain level was a 6 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 7:40 p.m., staff documented efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. - June 2017; Orders reflected [MEDICATION NAME] 2 mgs, 1-2 tablets, as needed every four hours. Noted- One tablet for pain 0-5, two tablets 6-10 (on the pain scale). a. On 6/7/17 at 5:15 p.m., staff documented in resident #1's EMR that his pain level was a 6 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 7:15 p.m., staff documented an efficacy of 7 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. b. On 6/12/17 at 4:59 p.m., staff documented in resident #1's EMR that his pain level was a 6 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 6:59 p.m., staff documented an efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. c. On 6/30/17 at 5:54 p.m., staff documented in resident #1's EMR that his pain level was a 6 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 7:54 p.m., staff documented an efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. - July 2017; Order reflected [MEDICATION NAME] 2 mgs, 1-2 tablets, as needed every four hours. Noted- One tablet for pain 0-5, two tablets 6-10 (on the pain scale). [MEDICATION NAME] 4 mgs, 1 tablet as needed every four hours. Noted- for severe pain. a. On 7/1/17 at 5:47 p.m., staff documented in resident #1's EMR that his pain level was a 6 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 7:47 p.m., staff documented an efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. b. On 7/9/17 at 5:28 p.m., staff documented in resident #1's EMR that his pain level was a 5 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 7:28 p.m., staff documented an efficacy of 5 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. c. On 7/13/17 at 4:48 p.m., staff documented in resident #1's EMR that his pain level was a 5 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 6:48 p.m., staff documented an efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. d. On 7/18/17 at 5:28 p.m., staff documented in resident #1's EMR that his pain level was a 5 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 7:28 p.m., staff documented an efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. e. On 7/19/17 at 4:23 p.m., staff documented in resident #1's EMR that his pain level was a 6 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 6:23 p.m., staff documented an efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. f. On 7/22/17 at 5:23 p.m., staff documented in resident #1's EMR that his pain level was a 5 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 7:23 p.m., staff documented an efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. During an interview on 11/21/17 at 8:00 a.m., staff member DD stated the physician should have been notified when ineffectual doses of narcotics for pain management were discovered by the nursing staff. During an interview on 11/21/17 at 10:18 a.m., staff member EE stated resident #1's physician should have been notified when the ineffectual doses for pain management was documented by the staff member. She stated the physician might have decided to increase, or change, the dose of narcotics being administered to resident #1. During an interview on 11/21/17 at 10:25 a.m., staff member Y stated when ineffectual doses of narcotics for pain management were observed for resident #1, the staff member(s) should have contacted the resident's physician. During an interview on 11/21/17 at 11:42 a.m., resident #1 stated he was frequently in a lot of pain and couldn't get out of it someday's. The resident stated he had increased episodes of pain which prevented him from leaving his room much. Resident #1 stated he started having problems with sleeping at night because of pain. An unsuccessful interview on 11/21/17 at 11:57 a.m., was attempted with resident's #1's physician. Review of the facility's policy, Pain Management and Assessment, page 2, read, 3. Pain Management . If the resident's pain is not controlled by the current treatment regime the physician should be notified.

Based on observation, record review and interview, the facility failed to adequately assess, care plan and monitor 1 (#1) of 12 sampled residents for risk of elopement, which resulted in resident #1's elopement from the facility, without activation of the alarm system. The resident required transfer to the emergency room and admission to the hospital for a UTI, pelvic fracture, caused from fall, and exacerbation of atrial fibrillation. The facility failed to follow manufacturer's instructions and warnings for placement of wander guards for 2 (#s 8 and 12) of 12 sampled residents. An Immediate Jeopardy was announced to the facility's administrator (staff member A) on [DATE], at 2:55 p.m., for failure to adequately assess, care plan and monitor residents at risk for elopement. Resident #1 had a wander guard and left the facility via the front entrance without sounding the alarm system. Facility staff did not know the resident was missing, and were alerted by a visitor that there was a resident lying in the snow calling for help. The facility failed to follow the manufacturer's instructions and warnings for placement of the wander guards, which increased the risk for elopement and injury, without sounding the alarm system. Observations of resident's with wander guards showed placement under or on wheel chairs and wrapped around the legs of walkers. An acceptable plan to remove the immediacy for the Immediate Jeopardy was received on [DATE] at 5:18 p.m. The severity and scope was decreased from a J to a G. Findings include: 1. Resident #1 was admitted to the facility's secure unit on [DATE] for elopement risk. [DIAGNOSES REDACTED]. Review of the resident's Clinical Notes Report, from ,[DATE] through ,[DATE], showed the following: -[DATE]; The resident remained on the secure unit for safety. Propels self via wheel chair with some help from staff for direction, cueing, and at times, movement. -[DATE]; The resident was moved from the secure unit to a regular unit. -[DATE]; the resident used a wheel chair as primary mode of transportation. She had made statements about going home, but was easily redirected. -[DATE]; The resident was able to mobilize the unit using her wheel chair and slowly propelled herself short distances. -[DATE]; Late entry: the resident was found on [DATE], seated in her wheel chair between two sets of doors by staff member E. She took the resident to the nurses station. Staff member E informed the nurse and CNA about the situation. -[DATE]; The resident was able to mobilize on the unit via wheel chair, but needed redirection in her room. -[DATE], at 7:45 p.m.; The resident was found lying on her right side outside the front entrance, at the edge of the side walk. The resident's wheel chair was behind her. The resident was crying out. As the resident was taken through the main entrance doors, her alarm did not sound. The resident reported severe pain to her right hip and right lower extremity with movement. The resident's right lower extremity appeared externally rotated. The resident was transferred to the hospital emergency room for evaluation at 8:50 p.m. -[DATE]; The resident returned to the facility with hospice services. -[DATE]; The resident expired at the facility. Review of the Occurrence Report, dated [DATE] at 7:45 p.m., showed the resident was found outside the facility, lying on her right side by staff member B. During an interview on [DATE] at 10:40 a.m., staff member B stated she had completed her shift and was outside brushing snow off of her car and was alerted to someone crying out for help by an individual she did not recognize as staff. Staff member B stated she was the first staff member to visualize the resident lying on the ground. She stated the main entrance doors could not be entered or exited after the doors were locked in the evening. Staff member B stated she could not remember the time she left shift on [DATE]. Review of the resident #1's clinical record, and interviews with staff, failed to identify a consistent time line regarding what time the resident was found outside, and failed to identify the individual/individuals who found the resident. During an interview on [DATE] at 10:15 a.m., a family member of resident #1 stated the resident had been moved to the facility because she had a history of [REDACTED]. The family member stated she was supposed to have an alarm on. The family member stated the facility moved the resident to the regular unit because she was not an elopement risk. The resident's family member stated the facility reported the pharmacist is the one who found the resident outside. The family member stated the resident was always wanting to go home whenever family visited. During an interview on [DATE] at 12:05 p.m., staff member A stated the front sliding doors were locked daily, around 7:00 p.m. He stated there were no logs regarding the times the doors were locked. Staff member A stated the receptionist left the building at approximately 7:00 p.m., five nights per week and would usually lock the door, however on [DATE], she had left early. Staff member A stated the night floor maintenance worker would lock the door between 6:00 p.m. and 7:00 p.m. Staff member A stated wander guards were checked one time daily and logged, but there was no documentation prior to ,[DATE]. During an interview on [DATE] at 1:35 p.m., staff member D stated he arrived, at the facility, at 6:45 p.m. on [DATE]. He stated he did not see anybody outside lying on the ground, however had not entered the facility through the main entrance. Staff member D stated the weather on [DATE] was cold with temperatures in the single digits. He stated he left the facility between 7:00 and 7:05 p.m. Staff member D stated staff member B was leaving the facility at the same time and was told by someone outside that someone was calling for help. During an interview on [DATE] at 8:00 a.m., staff member E stated she had found resident #1 stuck in the doors at the end of the 100 wing hallway on [DATE]. Staff member E stated she wheeled resident #1 back to the 100 wing sitting area. Staff member L stated she told a CNA and the unit nurse where she had found resident #1. Staff member E stated the CNA and the unit nurse did not appear concerned, and they told staff member E if resident #1 had gotten out the second set of doors, the fire alarm would have sounded, and they would have brought resident #1 back inside the building. Staff member E stated she had known resident #1 when the resident was at another facility. Staff member E stated the resident was specifically transferred to this facility due to the resident's need to be on a secured unit because of her wandering and exit seeking. Review of resident #1's Care Plan did not show problems, goals or interventions related to elopement risk or wander guard use. Review of Clinician Progress Notes from [DATE] through [DATE], showed resident #1 was moved to the dementia unit, from another facility, due to risk of elopement. Review of a Clinician Progress Note, dated [DATE], showed the resident had sustained acute pelvic fractures due to a fall at the facility. Review of the hospital clinical record showed the following: -[DATE] at 9:44 p.m.; blood pressure; ,[DATE]; heart rate 151; respiratory rate 21; oxygen saturation 80% on room air. -[DATE]; X-Ray showed deformity of the right superior and inferior pubic rami, which was new compared to prior exam, suggesting non-acute fracture -[DATE]; X-Ray showed two, mildly displaced pelvic fractures. Age indeterminate, but may be acute. -[DATE]; CT scan showed two acute pelvic fractures and moderate sized right pelvic sidewall hematoma. -[DATE]; Hospital course: resident received treatment for [REDACTED]. -[DATE]; discharged to the facility with hospice services. Review of resident #1's Elopement Risk Assessment, dated [DATE], showed the resident was low risk for elopement due to placement on the secure unit. The facility did not provide elopement assessments completed when the resident was moved to the regular unit. Review of resident #1's TAR, dated [DATE] through [DATE], did not show behavior monitoring related to wandering or exit seeking. The TAR did not show monitoring of a wander guard. 2. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's MDS, with an ARD of [DATE], showed the resident was cognitively intact with a BIMS score of 15. Review of the resident's Elopement Risk Assessment, dated [DATE], showed the resident had a wander guard applied for preventative action due to recent move to the facility. During observation and interview on [DATE] at 2:00 p.m., resident #8 had a wander guard hooked under her wheel chair. The resident stated she did not know why it was there. 3. Resident #12 was admitted to the facility for dementia. Review of the resident's MDS, with an ARD of [DATE], showed the resident had severely impaired cognitive skills. Review of the facility's list of residents with wanders guards showed resident #12 had a wander guard in place. Review of resident #12's Elopement Risk Assessment, dated [DATE], showed the resident had a history of [REDACTED]. Review of the resident's care plan for behaviors, with a goal date of [DATE], showed the resident's wander guard was placed on her w/c (wheel chair) and staff was to check the wander guard placement every shift and check function daily. Review of the resident's TAR for [DATE] through [DATE], showed the resident's wander guard was to be checked daily for function by the night shift CNA. The TAR did not show monitoring for exit seeking behavior or elopement attempts. Review of the facility's Policy for Elopement Risk Evaluation showed the following: -Assess the resident for risk of elopement upon admission and throughout their stay by the IDT care plan team. -Observe resident determined to be at risk for elopement by staff for elopement signs and/or attempts, and interventions will be included in their comprehensive plan of care to address the potential for elopement. Review of the facility's Policy for Wander Guard use showed the following: -The elopement evaluation, which indicates the need for a wander guard, is kept in the assessment section of the medical record. -The wander guard alarm is listed on the care plan. -The wander guards are checked daily by the nursing staff to assure that they are in place and working properly. Wander guard checks are documented. -All wander guards are to be used according to the manufacturer's instructions. -Door alarm system checks are conducted twice a month. Review of the manufacturer's instructions for wander guard placement, under the warning section, showed do not place the signaling device on or next to metal, such as wheel chair frames, jewelry, watches, etc. or allow it to come in contact with a door or associated hardware such as crash-bars, push-up bars, etc. Metal could interfere with the signal sent to the door modules.

During observation, interview, and record review, the facility failed to operationalize and maintain the abuse policy and procedures at the facility, to include the following failures: - Failed to adequately train staff in the identification, prevention, and reporting of abuse, as to protect the residents at the facility; - Failed to implement procedures to identify residents with repeated patterns of manipulation and aggression, and who were verbally abusive to others, as well as to monitor those behaviors to prevent abuse for other residents for 2 (#s 1 and 2) of 2 sampled residents; - Failed to prevent abuse by not responding to all allegations of reported or observed abuse, and failed to intervene in a situation of misappropriation of resident property for 5 (#s 1, 2, 3, 4 and 5) of 5 sampled and supplemental residents; - Failed to develop, implement, assess, and monitor meaningful care plan interventions for residents with a history of manipulative, verbal, and aggressive behaviors which resulted in abuse toward other residents for 2 (#s 1 and 2) of 2 sampled residents; - Failed to report allegations of abuse for 2 (#s 1 and 2) of 2 sampled residents. These failures had the potential cause psychosocial harm for resident #1 and #2, manifested in the resident's behavioral outbursts with anger, physical aggression and verbal aggression, and threatening behavior toward others. This included hitting and shoving of other residents. The deficient findings had the potential to affect all residents at the facility due to the overall lack of of awareness relating to the operationalize of the abuse policy, and lack of action taken by staff involved in abuse situations. Findings include: An Immediate Jeopardy was announced to the facility's administrator (Staff member A) on 1/5/17 at 3:33 p.m., for failure to report an alleged allegation of resident to resident abuse during a group activity. During the group activity, four separate department personnel witnessed the altercation between the resident #1 and resident #2. None of whom reported the incident. A second occurrence of verbal abuse between the same two residents occurred in the dining room which was also not reported. An acceptable plan to remove the immediacy for the Immediate Jeopardy was received on 1/5/17 at 9:05 p.m. The severity and scope was decreased from a K to a H. Findings Include: 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #1's Quarterly MDS, with an ARD of 11/17/16, showed the resident was cognitively intact with a BIMS score of 15. During an interview on 1/4/17 at 5:45 p.m., resident #1 stated he was independent and able to move freely in his wheelchair throughout the facility. He stated he was able to leave the facility by himself to go shopping and enjoy other activities. He stated the bus would take him where he needed to go. He stated he did not recall a disagreement between himself and other residents. He stated he did recall having an argument with another resident, but they were now friends, and he had no further concerns with that resident. A review of resident #1's Resident Care Summary, showed: - Toileting: Assist PRN x 1, continent of bladder and bowel. - Behavior: Agitation, anger, disruptive has pain, negative statements physically threatens, poor long term memory, refuses cares. Requires redirection when resists cares. Verbally inappropriate and impulsive. - Mobility: Assist PRN W/C, independent. - Communication: Able to express needs understands, usually. - Comments: Two staff member in room at all times. Redirection, re-approach, request assistance, report behaviors. A review of resident #1's Care Plan, with a goal date of 2/24/17, showed: - Problems: Inappropriate behavior (status active). - Goal: (resident #1's) behavior to be manageable and undisrupted to others thru ARD. -Interventions: Involve (resident #1) in diversional activities. Monitor behavior and document on BMF record. Provide a structured daily routine for resident so that behaviors can be anticipated. Keep (resident #1) positioned close to the nursing station when not in activities or meals. Social services to interact 1:1. Administer psych meds as per Dr.'s orders. Report any escalations in behaviors to Dr. or ARNP. Utilize 2 staff members in the room with him as able related to behaviors. (sic) A review of resident #1's Care Plan, with a goal date of 2/24/17, showed: -Problems: Cognition/Behaviors/Psychosocial, hx of psychiatric or behavior problems, hx of depression, first admission to skilled nursing facility. The care plan interventions for these identified problems were discontinued and not part of the residents active plan of care. A review of resident #1's TAR's, dated December 2016 through January 2017, showed the resident had, behavior monitoring three times daily. Notes: Resident takes [MEDICATION NAME] for [MEDICAL CONDITION] nurse to document # of hours slept on shift. The resident's behavior monitoring in the TAR indicated behavior monitoring for hours slept on shift, not for the residents, inappropriate behaviors, as noted in the resident's care plan. A facility request list was provided to the facility on [DATE] at 4:00 p.m. requesting the behavior monitoring sheets for resident #1. Resident #1's TAR was provided, which showed the behavior monitoring for the hours of sleep. The facility failed to provide behavior monitoring forms for resident #1. During an interview on 1/4/17 at 7:17 p.m., staff member B stated the behavior monitoring for resident #1 was in his TAR. The expectation was for the staff to document on the resident's behaviors daily. The nurses were expected to make a daily progress note every shift and mention the resident's behavior/mood. The staff member stated the expectation of the staff was to update the care plan if there was a change in the resident's condition, such as an increase in negative behavior. A. A review of resident #1's Clinical Note, dated 8/19/16 at 10:08 a.m., showed, Resident alert and oriented x 3, he continues to be a behavioral problem. Some of the other residents are complaining of him making rude comments to them and he is also very rude and belligerent to the nursing staff. The DON has been notified of his behavior as has the social worker who has been asked to speak with him about his behavior .He continues to complain about almost everything that we try to do with him. He is not participating in his cares and is very belligerent every time nursing has to interact with him. He is not pleasant, he is rude and obnoxious to the nursing staff. Will continue to monitor behaviors and notify administration about his behaviors. (sic) B. A review of resident #1's Social Service Note, dated 8/22/16, showed, Resident told an employee this a.m. that he is afraid of one of the CNA's named (staff name). He stated that the CNA offered him narcotics, and that he saw him walking through the hallway with a beer. The employee who relayed this info to SS, stated she was unsure at this time if the events actually occurred or if the resident had possibly overheard talk about this particular employee, and has imagined these events. The CNA who the resident was referring to is not currently on shift at BHRC, and mostly likely will not be returning to his employment at BHRC. A request for documentation for the incident report relating to the event on 8/22/16 was made on 1/5/17 at 8:18 p.m. The information was not received prior to the end of the survey. During an interview on 1/5/17 at 8:40 p.m., staff member B stated the incident from 8/22/16 was not reported to the state. Staff member B stated resident #1 was in the hallway when an off shift CNA came into the facility intoxicated. Staff member B stated the staff member was no longer employed at the facility due to the event, and the police were notified. Staff member B stated the incident was a reportable event, and should have been reported and investigated. She stated the resident should have been assessed for safety. C. A review of resident #1's Clinical Notes, dated 11/11/16 at 10:28 a.m., showed, Res was found to be in an argument with another resident. Just loud talking is all it amounted to but both res were hopped up and ready for possible fist fight. (sic) A review of resident #1's Clinical Notes, that included behavior monitoring, failed to show any updated behavior monitoring interventions or modification plans or goals. The documentation failed to address the prevention of the resident's behavioral disruptions related to the potential abuse regarding the 11/11/16 incident. D. A review of resident #1's Clinical Notes, dated 11/17/16 at 7:30 p.m., showed, Incident happened at the crossroads hallway at around 1830 pm. Resident propelled himself together with resident (#3). While resident (#3) was yelling the hallway, resident punched (resident #3's) left arm and slapped his left leg. CNA moved each resident from each other. Provider notified via faxed at 1924 pm. Called POA however, phone was disconnected. Will continue to monitor the resident. Addendum note: Incident happened at the crossroad hallway at around 1830 pm. Resident propelled himself together with resident (#3). While resident (#3) was yelling the hallway, resident (#1) punched (resident #3) left arm and slapped his left leg. CNA moved each resident from each other .State notified at 1843 pm. Will continue to monitor. (sic) A request for the incident report was made on 1/5/17 at 8:18 p.m., relating to the 11/17/16 abuse event. No further documentation was received prior to the end of survey. E. A review of resident #1's Clinical Notes, dated 11/27/16 at 3:45 a.m., showed, around 3:15 a.m., today, a CNA told this nurse that she saw the resident having an inappropriate behavior. She went to the main dining hall to get coffee and saw the resident standing and peeing in a mug. This nurse went to the main dining hall, calmly ask the resident if he peed on any mugs but he denied it. I asked him what happened and he told me that 'he went to the sink, threw what was inside his mug, put the mug on the tray, then scratch his right buttocks with his right hand.' and that was the time when the CNA saw him. This nurse tried to look for the mug with urine but did not find any. It is possible that he rinsed the mug or put it somewhere else. advised other units to not take any mugs/pitchers/unsealed drinks from the main dining hall. The resident has been having inappropriate behaviors in the past week. Addendum note: Around 0445, 3 CNAs brought a green mug from the main dining hall. they said that it had been rinsed, kept upside down on the sink but still smells like urine. kept the cup (as proof) inside a clean plastic bag and kept in the med room. It'll probably still smell like urine in the next few days. Will inform kitchen staff, DON and ED. Residents behavior might cause harm to our residents. he has also been showing aggressive behaviors towards the staff. Will also inform social services by Monday. (sic) A request for the incident report was made on 1/5/17 at 8:18 p.m., for documentation relating to the abuse events that occurred on: 8/19/16, 11/11/16, 11/17/16 and 11/27/16. The information was not received prior to the end of survey. A review of the state agency reportable events for the facility showed the 8/19/16, 11/11/16, 11/17/16 and 11/27/16 events had not been reported as required. A review of resident #1's Care Plan, with a goal date of 2/24/17, failed to show updated interventions, assessment, and monitoring of the resident's increased verbal aggression toward others from 8/19/16, 11/11/16, 11/17/16 and 11/27/16. A review of resident #1's Clinical Notes, which included behavior monitoring, failed to show updated behavior monitoring, interventions, or modification plans for the behaviors, or new goals. The documentation failed to address the prevention of the resident's behavioral disruptions related to the abuse toward other residents on 8/19/16, 11/11/16, 11/17/16 and 11/27/16. During an interview on 1/4/17 at 3:18 p.m., staff member I stated resident #1 had urinated in a cup in the dining room, because he couldn't get back to his room. Staff member I stated resident #1 could become easily angered, and would yell and curse at staff. Staff member I stated she saw resident #1 throw a napkin at another resident, but she did not report that incident. Staff member I stated she did not feel it needed to be reported since the napkin did not make contact with another resident. Staff member I stated her last abuse training provided by the facility was the second week in March. During an interview on 1/4/17 at 3:30 p.m., staff member J stated resident #1 made her feel uncomfortable. She stated resident #1 was verbally abusive to a nurse, and the nurse yelled and cussed back at the resident. The nurse's employment ended due to the interaction with the resident. The staff member stated she understood why the nurse's employment ended, but was worried resident #1 would say something to administration about her, and then her employment would end also. She stated the resident would become easily angered, and would start yelling and cussing at staff. Staff member J stated she was only aware of one intervention for 2 CNA's to go into his room, due to his behavior. Staff member J stated she was not aware of the need to report any other specific behaviors to the charge nurse. Staff member J was able to explain the different types of abuse, as well as the facility's process to report allegations. Staff member J stated her last abuse training provided by the facility was in October 2016. During an interview on 1/4/17 at 6:00 p.m., Staff member N stated resident #1 had been verbally aggressive toward her. The staff member stated resident #1 would complain about other residents to get a rise out of them. This showed the resident had purposeful behavior. The staff member stated it was the facility protocol to generate a documentation note in the resident's electronic health record of any behaviors. She stated she did not recall any specific incidents between any other residents and resident #1. Staff member N stated any resident behavior was documented in the daily charting. She stated the nurses could update the care plan for a resident if something had changed. During an interview on 1/4/17 at 6:55 p.m., staff member B stated the facility was working on possibly discharging the resident to a safe location. Staff member B stated resident #1 has had many conversations with administration regarding his behaviors. Staff member B stated resident #1's physician had ordered a psychological evaluation, but the resident refused the order. The facility was still trying to arrange another psychological evaluation for the resident. The staff member stated resident #1 was to have behavior monitoring in place, and the nurse was expected to chart in the resident's TAR every shift on the behaviors. Staff member B stated if a resident had a negative behavior, it would be documented in the nurses notes. She stated the care plan should be updated with any changes in the resident's condition or behavior. During an interview on 1/5/17 at 8:40 p.m., staff member B stated the incidents involving resident #1, on 8/19/16, 8/22/16, 11/11/16, 11/17/16 and 11/27/16, were not reported. An investigation was not conducted to follow up with the residents' involved. F. During an interview on 1/4/17 at 2:20 p.m., staff member F stated she recalled an incident which occurred on 12/9/16, during an ice cream social. The interaction was between resident #1 and #2. Staff member F stated she was dishing up ice cream, and heard screaming and yelling. The staff member stated she did not see the altercation, but went to intervene between the two resident's. She stated when she got to the resident's, the resident said, If he is going to try to choke me, I will choke him. Staff member F stated there were several other staff members present at the time who witnessed the altercation. This included: activities aide's, nursing, dietary and physical therapy staff. The staff member stated she did not report the incident, but knew the event was reportable. Since the nursing staff had removed both the resident's she felt the nurse's would report the altercation. She stated she had not completed documentation in the resident's record for the incident. Staff member F stated she was aware of a second incident between resident #1 and #2, which occurred the week prior, and this was in the dining room. Staff member F stated resident #1 was sitting at his dining table, and was yelling at resident #2. He called him a masturbator, and was telling resident #2 that it was nasty, and he needed to leave the diningroom. She stated staff member A came and asked the two resident's to respect each other, and stop yelling. Staff member A had to come back out to the dining room two more times after this before either resident stopped. She stated there was no physical contact between the two resident's, but they were yelling obscenities at each other. The staff member stated there were other residents present in dining room at the time of the verbal altercation. Staff member F stated she knew the event was reportable, but she had not reported as required, due to staff A's involvement and awareness of the situation. She thought he would complete the report. Staff member F stated her last training on abuse prohibition was in November. During an interview on 1/4/17 at 4:00 p.m., staff member L stated she had heard about the incident during the ice cream social between resident #1 and 2. Staff member L stated she was not asked to assess the resident's for new behavior interventions after the altercation. Staff member L stated she was also aware of an incident which occurred in the dining room last week. Staff member L stated resident #1 and resident #2 were screaming at each other over a salt shaker. Staff member L stated she intervened and separated the two resident's. She stated she told the staff member A about the incident. Staff member L stated she had not reported the incident per the facility's procedure to call the state hot-line and report the event to the state agency because she had verbally notified staff member A. Staff member L stated she did not document the incident in the resident's medical record. She stated she relied on nursing staff to manage resident #1 and #2's behavior's, and also to update the resident care plan's for the intervention's and monitoring of the resident behavior's. Staff member L stated she was not sure what type of intervention's would be appropriate for the two resident's. The staff member stated her last abuse training provided by the facility was two months ago. The staff member failed to follow the facility procedures, and report the abuse as required. During an interview on 1/4/17 at 4:28 p.m., staff member M stated she was sitting at the reception desk by the main dining room. The staff member stated she heard resident #1 call resident #2 a masturbator. Staff member M stated she remembered there were four other residents sitting at the dining room table with resident #1. Staff member M stated staff member A came out of his office and intervened between resident #1 and 2. Staff member M stated she observed Staff member A come to the dining room two more times, and he had asked the resident's to separate themselves. The staff member stated staff member A has had a lot of conversations with resident #1 regarding his behavior toward staff and other residents. Staff member M stated she would consider yelling and name calling a form of abuse, but did not consider reporting the incident in the dining room since staff member A was involved. Staff member M stated the last abuse training provided to her by the facility was a couple months ago. During an interview on 1/4/17 at 7:17 p.m., staff member A stated the incident on 12/9/16 in the ice cream parlor, between resident #'s 1 and #2, was not reported to the state. He stated no investigation was conducted, and there was not a five day follow up summary report submitted to the state. Staff member A stated he felt the incident was isolated, and the facility did a good job on reporting abuse to the state. Staff member A stated it was the expectation of staff to make the initial report to the state, then they were to notify him of the incident by putting an alert watch in the resident's electronic health record. The staff member stated any staff member could call the state to make a report. Staff member A stated he did not report the incident between resident #1 and resident #2, which occurred in the dining room last week, because he did not feel it was a reportable event. Staff member A stated resident #1 and resident #2 were yelling at each other in the dining room about a salt shaker. He stated resident #2 grabbed the salt shaker off resident #1's dining table, and resident #1 was yelling at resident #2 to give it back. He stated he was going to kick his (resident #2's) ass. Staff member A stated the residents were three tables apart with voice's raised. Staff member A stated he intervened three separate times. He asked resident #1 to take a walk around the facility to cool down. Staff member A was able to explain the different types of abuse. Staff A did the abuse training at the facility. Staff member A stated the abuse reporting was the responsibility of the social worker, but he had been doing all the incident reporting. Staff member A had not followed the facility policies and procedures for abuse. During an interview on 1/5/17 at 10:26 a.m., staff member R stated she was present during the altercation on 12/9/16 between resident #1 and #2, during the ice cream social. Staff member R stated she was seated in the parlor when she heard the resident's yelling at each other from the doorway of the parlor. The staff member stated resident #1 was rocking back and forth in his wheelchair and rolled back on resident #2's foot. Resident #2 responded by pushing resident #1's wheelchair away, and pushed him by his shoulder. Staff member R stated resident #1 thought resident #2 was trying to choke him, so resident #1 yelled at resident #2. He said, If you're going to choke me, I'll choke you. The staff member stated the resident's were separated by the nursing staff and removed from the parlor. Staff member R stated she could not actually see how the altercation started, and it was a reportable event. She did not report the incident. The staff member was able to explain the different types of abuse, and what the facility's policy was on reporting abuse. During an interview on 1/5/17 at 11:00 a.m., staff member S stated he witnessed the altercation between resident #1 and #2 on 12/9/16, in the parlor. Staff member S stated the resident's were waiting in line for ice cream. Resident #1 was in front of resident #2, and began rocking back and forth in his wheelchair. Resident #1's wheelchair rocked back onto resident #2's left foot. Resident #2 put his right hand on resident #1's right shoulder, and pushed him to get him off of his foot. Resident #1 thought resident #2 was trying to choke him, and he started yelling verbal threats at resident #2, stating, If you are going to choke me, I am going to choke you back. Staff member S stated the two residents was separated by nursing staff and brought back to their units. The staff member stated there was a lot of staff and residents at the ice cream social. The staff member stated he was unsure if either resident was assessed for injuries. Staff member S stated it was his responsibility, as well as all staff, to report suspected abuse. He stated he reports to management any suspected abuse. The staff member stated he did not report this incident since there were so many nursing staff present. He thought the nursing staff would report the incident. 2. Resident #2 was admitted to the facility with a [DIAGNOSES REDACTED]. A review of the residents Annual MDS, with an ARD of 11/3/16, showed the resident was cognitively intact with a BIMS of 13. A review of resident #2's Resident Care Summary showed, Position: Independent. Mobility: Assist PRN W/C, independent. Communication: Able to express needs, understands, usually. Comments: Straight cath every 4 hours, redirection, re-approach, report behaviors. A review of resident #2's Care Plan, with a goal date of 2/3/17, showed: -Problems: Inappropriate behavior: verbal behavior symptoms directed at others. Openly expresses anger with others. (Resident #2) has stated he will take care of the issue by any means necessary. (Resident #2) has h/o grabbing/striking out at others. Status: (Active) -Goals: (Resident #2) will be able to verbalize reasons for conflict/anger. (Resident #2's) behavior to be manageable and undisrupted to others thru ARD. -Interventions: Involve resident in diversional activities. Monitor behavior and document on the BMF record. Provide a structured daily routine for resident so that behaviors can be anticipated. Co-habitat (resident #2) with other residents that would not be at risk for being disrupted by resident's inappropriate behavior. Keep (Resident #2) positioned close to nursing station when not in activities or meals. If needed psych services to follow up PRN. Conduct 1:1 sessions with (resident #2). Encourage resident to verbalize feelings in an appropriate manner and provide realistic feedback. Report any escalations in behavior to Dr. or ARNP. Talk with family and friends to identify potential sources/reasons. (sic) A review of resident #2's Resident Care Summary showed: - Position: Independent. Transfer Ax1, Ax1, walker, pivot and wheelchair. - Mobility: Assist PRN W/C, independent. - Comments: Straight cath every 4 hours, redirection, re-approach, report behaviors. A review of resident #2's TAR, dated December 2016 and January 2016, failed to show evidence for behavior monitoring. A review of resident #2's Clinical Notes, dated 6/21/16 at 3:11 p.m., showed, at 2:57 p.m., I was in my office on the phone and heard a resident say 'watch where your going,' as I looked up (resident #2) had backed into another resident. He began to use profanity towards the resident so the resident pushed (Resident #2) away with his feet. (Resident #2) turned around to the resident trying to back up and swing at him. The beautician was getting the other resident out of the way of harm from resident #2. As the beautician was going by (resident #2) swung his arm again saying 'I'll knock him into next Tuesday. The other resident replied, 'no you won't, don't touch him.' Once I got off the phone I caught the CNA, coming out of the oxygen room because no one was answering the phone on the unit and let her know what happened. She went and found a nurse on the unit to let them know what happened. The nurse (name) came down and talked to the beautician. (sic) A review of resident #2's Clinical Notes, dated 6/21/16 at 6:38 p.m., showed, CNA told the nurse about the aggressive behavior of the resident near the oxygen area. Nurse investigated the situation, and the beautician said she heard the increased voice and saw (resident #2) swing his arm to (resident #5). The beautician said she interfered right away and removed (resident #5) from the situation. Beautician said to ask resident (initials), because she knew what happened. Resident (initials) said (resident #2) blocked the hallway and when he was told to move he stared to get mad and said foul words. (Resident #2) moved backward and (resident #5) kicked the wheelchair of (resident #2). (Resident #2) tried to swung (sic) his arm but the situation was stopped. Nurse talked to (resident #2) however, his voice raised and would not listen. Nurse will continue to monitor. A request was made on 1/5/17 at 8:18 p.m. for the incident report relating the altercation on 6/21/16. No further documentation was received prior to the end of survey. A review of resident #2's Care Plan, with a goal date of 2/3/17, failed to show updated interventions regarding the resident's negative behavior for the incident on 6/21/16. A review of resident #1's Clinical Notes, which included behavior monitoring, failed to show updated behavior monitoring, new interventions, or modifications to the plan, or goals. The documentation failed to address the prevention of the resident's behavioral disruptions related to the potential abuse regarding the 6/21/16 incident. During an interview on 1/5/17 at 8:40 p.m., staff member B stated the incident on 6/21/16, between resident #2 and resident #5, was not reported. No investigation was completed to follow up with the resident's. She stated the residents should have been assessed for safety. Staff member B stated an incident report was created, and a late report was submitted to the state on 1/5/17, although the event occurred at least six months prior. Staff member B stated the expectation of the staff was to update the care plan if there was a change in the resident's condition. This would include an increase in negative behavior. During an interview on 1/5/17 at 9:00 a.m., resident #2 stated the staff, and other residents, told lies about him. The resident stated he didn't mind other people as long as they told the truth about him. He would get mad when lies were told. The resident felt safe at the facility, mainly because of all the other people which have tried to hurt him. He stated he had always been able to protect himself, and would call the authorities if he felt the need to, or if no one was able to help. Resident #2 stated he didn't feel he had enough activities to keep him occupied, and said They don't give me much of anything to do. When resident #5 became his roommate, he didn't like his light on at night, his snoring, or his talking in his sleep. It was difficult for resident #2 to sleep. Eventually, he moved out of the room. Resident #2 stated his next roommate, resident #3, poured water on his bed, and he felt the facility ignored his concerns. This made him angry. He stated he felt that if the facility was not going to help him, then he would take matters into his own hands. During an interview on 1/5/17 at 9:37 a.m., resident #3 stated when resident #2 was his roommate, he would sleep with the light on, and it created a problem between the two of them. Resident #3 stated he caught resident #2 masturbating in the room when they were roommates, and he reported it to the administration. He stated they didn't do anything about his concern. The resident stated a little over two weeks ago, the administration moved him out of the room with resident #2. Resident #5 stated he and resident #2 had a verbal altercation in the dining room. He stated the administration separated everyone, and moved the dining room seating as well. Resident #5 stated he felt better after moving into his own room. During an interview on 1/5/16 at 11:34 a.m., resident #4 stated she had overheard resident #2 and #3 arguing. She stated she could hear them arguing from her room. She stated she thought they were being obnoxious. 3. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED].#4's Quarterly MDS, dated [DATE], showed the resident was cognitively intact with a BIMS of 15. During an observation on 1/4/17 at 5:09 p.m., resident #1 was propelling in his wheelchair. He stopped in front of resident #2. Resident #2 was also propelling in his wheelchair, trying to go to his dining table for dinner. Resident #1 held up a green water bottle to show resident #2. He told him he had purchased the water bottle at JC Penny's for one dollar, and he would pick one up for resident #2, the next time he went to the mall. Resident #2 thanked resident #1, and propelled away in his wheelchair. Resident #2 propelled himself to another table in the dining room with female residents. During an observation on 1/4/17 at 5:09 p.m., resident #1 was sitting at a dining room table with four fe

Based on record review and interview, the facility failed to ensure 1 (#1) of 2 sampled residents was free from physical abuse by an agency CNA. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/22/16 at 5:00 p.m., an incident was received by the State Agency regarding an allegation of physical abuse to resident #1. The date the incident occurred was 3/19/16. During an interview on 3/23/16 at 10:20 a.m., staff member A stated the incident should have been submitted to the State Agency within 24 hours. Staff member A stated the facility was investigating the incident and had requested the abuse training information from the contracted staffing agency. Review of the investigation witness report written on 3/19/16 by contracted agency staff H showed: Resident was getting combative when we were trying to help him get ready for bed. He was holding on to (staff name's) arm. (Staff name) wasn't handling it well and hit him back as he was swinging his arm up at us. Her face was tomato red and and she was yelling at him to stop and was being very aggressive. I told her that she can't hit the resident as she can get into trouble and she replied 'well he can't be hitting me either.' So we proceed with getting him cleaned up, we get him into bed, and he started to lift up his arm and she hit his arm with fist (sic) and said knock it off. Then I said again do not hit him. To this there was no response, and we moved him up in bed and left the room. He was not (sic) hard enough to leave a bruise, but still was on purpose and aggressively and happened twice. Attached to the Witness Report was a statement written by staff member E on 3/21/16 that stated: On Saturday evening (staff name) told this nurse that (agency name) aid (sic) had just hit (resident name) (staff name) stated 'I told her you can't do that and you will get fired.' (staff name) stated 'well he can't hit me. (staff name) stated that (staff name) was hitting him with her forearm and that she hit him maybe three times. Nurse (initials) spoke to (staff name) and (staff name) stated 'I did not hit him' and she stated he was hitting her and she 'blocked' him with her forearm. Nurse (initial) then called the unit manager. Review of the statement written by staff member K stated .we finally got his shirt off and and his feet on the front of the lift when he grabbed my right arm and wrist (sic) started to twist and grab roughly I grabbed (h)is hand away prying his finger release (sic) his grip. He started hitting me I (sic) grab (sic) his wrist and arm and told him to stop hitting me. A review of the staffing schedules for 3/19/16, showed staff member K was sent home. Further review of the schedule showed on 3/20/16 the schedule had documentation next to agency staff K as follows: alleged issue, can't be in (facility name). During an interview on 3/23/16 at 7:15 a.m., staff member A stated the incident had happened on 3/19/16 at approximately 7:00 p.m, when an agency staff member K, had allegedly slapped and hit a resident. Staff member A stated the incident had been observed by another CNA and reported to the nurse immediately and staff member K was sent home. Staff member A stated he was notified of the incident on 3/19/16 at approximately 7:30 p.m. and advised the nurse to immediately send staff member K home. During an interview on 3/23/16 at 2:00 p.m., staff member J stated she worked the 2 p.m. - 10 p.m. shift on 3/20/16 and was told by the charge nurse that resident #1 had gotten aggressive and he hit staff member K and staff member K hit him back. She further stated staff member K would get upset if she had to go to a different wing to work than she was assigned. Staff member J was not aware of any previous aggression by staff member K. Staff member J stated staff member K did not come back to work in the facility after the incident of alleged abuse. During an interview on 3/23/16 at 2:00 p.m., staff member I stated resident #1 becomes agitated easily and does sometimes hit staff. Staff member I stated she has worked with resident #1 approximately 2 years. She stated resident #1 told her a crazy lady was trying to tell him it was time for bed. Staff member I stated resident #1 had told his wife that he was hit by a CNA. Staff member I stated that she asked the nurse if resident #1 had been injured and was told by the nurse that management was taking care of the incident and not to discuss it. During an interview on 3/23/16 at 3:00 p.m., staff member D stated she got a phone call from staff member E stating a CNA had hit a resident. Staff member D stated she notified the staffing agency and contacted the administrator. During an interview on 3/23/16 at 3:28 p.m., agency staff member H stated staff member K asked for help with resident #1. Staff member K went into resident #1 room and the resident had a firm grip on staff member K's hand. Staff member K pulled her hand out and hit him on his right forearm. Staff member H said you can't hit him and staff member K said he can't hit me either. During incontinent care, staff member K was wiping resident #1 very aggressively. They put resident #1 in bed and he lifted his arm while lying down and staff member K hit him again. Staff member H stated she had not previously worked with staff member K before, but staff member K was complaining about having to work with the residents and she was upset about a phone call she had received from her staffing agency. The nurse evaluated the resident and did not find any bruises or redness. The nurse told staff member H not to tell anyone about the incident except for supervisors or nurses. Staff member H did not report the incident to the next shift of CNAs. Staff member H stated she had worked at the facility approximately 6 months and took her CNA training elsewhere in 2013. She further stated she had not had abuse training since she started working for the staffing agency. During an interview on 3/23/16 at 4:00 p.m., BB stated she had received a call on 3/23/16 at 3:39 p.m. from a family member of resident #1. She stated the family member had been notified by a staff member that (resident name) had been slapped and hit by a temporary employee. She stated the incident happened at 7:00 p.m. on Saturday and was reported to her on 3/22/16 at 5:00 p.m. During a phone interview on 3/23/16 at 4:15 p.m., a family member stated she was told by a CNA that resident #1 had been hit by another CNA. She stated resident #1 did not sleep all night because he was afraid. During an observation of resident #1 in his room on 3/23/16 at 4:40 p.m., the resident yelled get out. During an interview on 3/24/16 at 8:05 a.m., contracted staff DD, stated she does CNA training for new hires and the training includes 1 1/2 hours of abuse. DD also stated she does not do abuse training for other staff. During an interview on 3/24/16 at 9:50 a.m., staff member E stated a CNA told her another CNA had hit a resident. Staff member E asked What do you mean hit (resident name). Staff member E stated the CNA told her she hit the resident's forearm with her forearm. Staff member E asked the CNA who allegedly hit the resident if she hit him and the CNA responded I never hit him, I was using my arms to protect myself. Staff member E stated she called staff member D to report the incident and staff member D told her to have the CNA fill out a witness report and staff member D notified the staffing agency. Staff member E stated she thought staff member D was going to notify the family and MD and thought there would be an investigation on Sunday. Staff member E stated she was not told not to talk about the incident, but told the CNAs not to gossip about the incident because it was a big deal. Staff member E stated she sent the CNA home at approximately 7:30 p.m. and reported the incident to the next shift. She also stated she had been in communication with the charge nurse during the incident. During an interview on 3/24/16 at 10:20 a.m., a professional from a contracting company AA,stated his company provided training for CNAs going through CNA training held at the facility. He stated they did not provide annual training for the CNAs that are hired by his company that were trained elsewhere. During an interview on 3/24/16 at 10:40 a.m., resident #1's family members stated they were not notified of the incident of alleged abuse until they were told by a CNA that resident #1 had been hit. They said the facility notified them on 3/23/15. They also stated there was an answering machine that a message can be left on if the family member was unavailable and the facility had previously left messages when resident #1 had fallen. During an interview on 3/24/16 at 7:00 a.m., staff member A stated he had received a phone call regarding the alleged abuse at approximately 7:30 on 3/19/16. He stated he told the caller to send the CNA home and ensure the resident was safe. He also stated the facility was reviewing and updating the contracts they have with agency staff to ensure all training was up to date and the facility will keep files of all agency staff on site. Staff member A stated he did not tell anyone not to talk about the incident of alleged abuse with resident #1. Staff member A did say they had recently had a HIPPA training and staff was told not to talk about incidents with anyone who was not involved with direct care. Staff member A stated the CNA who allegedly hit resident #1 would not be allowed to work with residents in the future.

Based on record review, interview, and observation, the facility failed to document a weekly and daily skin check, provide pressure reduction to prevent the development of pressure ulcers, and accurately assess the stage of an existing pressure ulcer for 2 (#s 10, and 13) of 24 sampled residents. Findings include: 1. Review of the Treatment Records for resident #10's skin checks for October 2015, showed a skin check was completed on 10/8/15 and 10/14/15, by an initial of the nurse. The initials of the nurse were the only documentation to show the skin check had been completed. The facility had no written skin check to show what the skin check included or what was found during the skin check. Review of resident #10's care plan reflected Monitor/Observe skin daily with care being provided for signs and symptoms of skin breakdown; nursing to do weekly full body skin assessment. The facility did not provide evidence of monitoring skin daily, or of the nursing weekly full body check. Review of a nursing progress note dated 10/17/15 showed, sores found on coccyx and inner coccyx. One area was dark purple red, 3.5 cm x 3.376 cm with dark scabbed area; another area was a 4 cm circular dark purple red area with dark scabbed center. Review of the OTHER ULCERS WOUNDS & SKIN PROBLEMS Weekly assessment dated [DATE] reflected 2 unstageable areas and 2 stage I pressure areas. During an observation of the pressure areas on 10/21/15 at 4:30 p.m., staff member F stated the pressure areas looked like stage II pressure ulcers. One area was beefy red with full-thickness skin loss. Staff member C stated she was not comfortable with the staging of pressure ulcers. During an interview on 10/22/15 at 9:05 a.m., staff member L stated the resident had been on a foam cushion, and she had changed it to a pressure-relieving cushion that morning. The resident had a custom chair so the facility had not wanted to alter the chair. The cushion was replaced during the survey process, 5 days after the resident's pressure ulcer was identified. During an observation on 10/21/15 at 11:20 a.m., the resident was up in his chair. During an observation on 10/22/15 at 10:00 a.m., the resident was up in his chair, saying help. During an interview on 10/22/15 at 1:30 p.m., staff member C stated she thought the resident got the pressure area from being up in his chair. Review of the physician visit dated 8/14/15, showed the resident had severe protein-calorie malnutrition. Review of the physician order, dated 10/17/15, showed, monitor unstageable decubitus sore on inner coccyx creases. Needs repositioning frequently replace form (sic) dressing prn. A new order written on 10/19/15 showed Apply skin prep, stoma powder and [MEDICATION NAME] to buttocks q shift. 2. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #13's Hospital Discharge Instructions and Skilled Nursing Facility admission orders [REDACTED]. Review of the undated Report Sheet for Admits, under type of wound, showed, stage 2 wound to the right buttock - calzime (sic) cream and no dressing. Review of the TAR dated September 2015 showed the pressure ulcer was not addressed. Review of the skin risk assessment sheet dated 9/30/15 showed resident #13 was at risk for developing pressure ulcers, and had one or more unhealed pressure ulcers at stage 1 or higher. Under skin and ulcer treatments resident #13 was not assessed for the use of pressure reducing devices for his chair or bed. Resident was assessed as no for skin/ulcer treatment/care, ointments, and resident was assessed as being occasionally incontinent. Review of the TAR for October 2015 showed an order dated 10/1/15 Monitor, Measure and document in nurse notes and wound tab on right upper buttock. Review of the care plan dated 9/30/15 under Problems: (resident name) has a stage 2 pressure ulcer on right ischium/ r/t weakness, recent infection, incontinence, ADL impairment, poor nutrition. Under interventions; monitor skin integrity, notify m.d. of any open or non-blancheable areas asap. Follow m.d. orders for dressing changes, care of ulcer. Document ulcer measurements weekly. The care plan did not address the need for pressure relieving devices to bed or chair. Review of the Nutritional assessment dated [DATE] showed skin intact. Review of the Clinical Notes Report showed: - 10/3/15 Open sore on right ischium 1.5 cm X 1.5 cm. Wound with light pink wound bed and no drainage. Site cleanses with saline; wound covered with [MEDICATION NAME] gentle. - 10/5/15 Dressing changed on sacrum. - 10/6/15 wound on the sacral healing, dressing changed with [MEDICATION NAME]. - 10/15/15 Res. skin intact. Wound issues are healed. - 10/19/15 stage lll pressure ulcer noted. - 10/20/15 Area on right ischium has small scab covering wound. No increased redness or warmth. Area blanches well. Barrier cream applied to area every AM and HS as well as with toileting/pull up change. Review of the Other Ulcer, Wounds and Skin Problems Weekly Assessment: -On 10/3/15 showed resident #13 had a stage lll pressure ulcer that was present on admission on the right ischium and measure length: 1.5. width: 1.5 and Depth: 0.2. Characteristics of wound bed documented light pink granulation with scant amount of serous drainage. Wound edges were very dark with pink wound bed. -On 10/7/15 the Weekly Assessment showed stage ll pressure ulcer on the right ischium measuring length: 0.6 X Width: 0.5 X Depth 0.1. Characteristics of wound bed show granulation and no drainage. No further documentation on the assessment of the pressure ulcer was available. Review of the MDS with an ARD of 10/4/15, under section M300, showed one stage 2 pressure ulcer. Review of the TAR dated September 2015 did not address the pressure ulcer. On 10/13/15 it was documented that the wound was healed on TAR, and the order was discontinued. During an interview on 10/20/15 at 10:00 a.m., staff member U stated the pressure ulcer was healed. On 10/20/15 at 10:10 a.m., a one inch round circle with a pencil eraser size open area in the middle of the area on resident #13's right buttock was observed with staff members S and T. During an interview on 10/20/15 at 10:10 a.m., staff member S stated he was unsure of resident #13's pressure ulcer, as he had not worked with him before. During an interview on 10/20/15 at 4:05 p.m. staff members C and F stated they felt the area was a stage ll pressure ulcer. Resident #13 was currently on a pressure relieving mattress and an air mattress was being added. The physician was contacted for orders regarding the pressure ulcer.

Based on observation, interview and record review, the facility failed to ensure safe management of a gastrostomy tube for 1 (#10) of 24 sampled residents. Specifically, the facility failed to provide the following technical aspects of a tube feeding: A. The facility failed to maintain a clean technique and utilize proper hand hygiene while providing a tube feeding. B. The facility failed to assess the gastrostomy tube placement prior to giving a tube feeding and medication administration. C. The facility failed to define the volume of water used for flushing the gastrostomy tube for the medication administration. D. The facility failed to ensure the resident received correct caloric intake resulting in a significant weight loss. E. The delayed treatment for [REDACTED]. Findings include: Resident # 10 was admitted to the facility on [DATE] with [MEDICAL CONDITION]. A. During an observation on 10/21/15 at 9:33 a.m., staff member A washed her hands and put on a pair of gloves, then went to close the door to the resident room. Staff member A moved a yellow housekeeping caution sign out of the door way with her gloved hands. She grabbed the caution sign by the handle and moved it out of the door way, then shut the door. Staff member returned to resident #10 and began the tube feeding. During an interview on 10/21/15 at 10:51 a.m., staff member A stated she should have changed gloves and washed hands after moving the caution sign. B. During an observation on 10/21/15 at 9:40 a.m., staff member A did not check the gastrostomy tube placement for resident #10 prior to starting the tube feeding and medication administration. During an interview on 10/21/15 at 10:51 a.m., staff member A stated she did not check the tube placement prior to the tube feeding for resident #10. Staff member A stated she was new to long term care and was not aware she needed to check the tube placement. Staff member A stated she should have listened for bowel sounds prior to the administration of the tube feeding to check for the proper placement of the gastrostomy tube. C. A review of resident #10's MAR from 10/1/15 showed a change in resident #10's tube feeding order on 10/16/15, to administer 150 ml of water flushes four times daily. During an observation on 10/21/15 at 9:33 a.m., staff member A filled a graduated calibrated basin with 280 ml of water from the bathroom sink. Staff member A flushed resident #10's gastrostomy tube with 30 ml of water prior to administering one 237 ml can of [MEDICATION NAME] 1.2 Cal. Staff member A then administered a second can of [MEDICATION NAME], giving 138 ml of the [MEDICATION NAME] 1.2 Cal for a total of 375 ml of [MEDICATION NAME]. Staff member A then flushed the gastrostomy tube with 30 ml of water. Staff member A mixed resident #10's medication of [MEDICATION NAME] with 30 ml of water, administered the medication via the gastrostomy tube and then flushed the tube with 30 ml water. Staff member A continued to administer the [MEDICATION NAME], and Tylenol separately with 30 ml's of water with each administration. Staff member A flushed the gastrostomy tube with 10 ml of water after the medication administration. Staff member A then administered the liquid [MEDICATION NAME] and flushed the gastrostomy tube with 30 ml of water. For a total of 280 ml of water administered during the tube feeding and medication administration. Resident #10 received an excess of 130 ml of water at the time of the tube feeding. During an interview on 10/21/15 at 10:45 a.m., staff member A stated resident #10's order stated resident should have 150 ml of water for the tube flushes, but sometimes she would give more to make sure resident #10 gets enough water. A review of resident #10's after visit summary from St. Vincent Healthcare, dated 8/12/15, recommended providing tube feedings with the following schedule: Give 2 cans of tube feedings at 0600 and 1700 (flush 60 cc H20 with each feeding) Give 1 can of tube feeding at 1200 and 200 cc of H20. Give 120 cc H20 at bedtime (includes H20 used for flush) recommended a total of 600 ml of free water per day. This includes water provided with medications and the 60 ml flush following the tube feeds. Provide free water between tube feed administration; not with feedings (when giving 2 cans). A review of resident #10's MAR/TAR did not provide directions for how much and when to administer free water for the resident. The MAR/TAR did not show the recommendation to avoid administration of additional free water during tube feedings. During an observation on 10/21/15 at 10:48 a.m., after completion of the tube feeding resident #10 started to cough up a thick white, yellow foamy exudate. Resident had audible gurgling sound in chest and throat after the tube feeding. During an observation on 10/21/15 at 10:49 a.m., suctioning machine available by residents bedside for suctioning. Resident #10 was not suctioned of the excess secretions after receiving the bolused tube feeding. During an observation on 10/21/15 at 9:35 a.m., prior to the tube feeding, resident #10 did not have a cough present and did not have an audible gurgling sound in chest and throat. During an interview on 10/21/15 at 10:49 a.m., staff member A stated resident #10 did not need to be suctioned very often for his excess secretions. A review of the facility's policy titled Tube feeding-Enteral, dated 10/26/14, reflected the following: 6. Check for placement with 10 cc or more air bolus. If sounds are absent notify physician and do not start tube feeding. 12. Check gastric residual before intermittent (bolus). 13. Verify placement of tube before feeding, medication administration and or flushing the tube by one of the following. (Flush tube before and after checking residual) A. Aspirate stomach contents before each feeding, check the amount and re-insert the Residual into the stomach. (This method is not used for jejunostomy tube) Or you may insert 10-30 cc of air into the tube and listen for auscultation of air in the upper left quadrant. B. Continue feeding if amount is less than 60 ml. D. Review of resident #10's admission nutritional assessment showed the resident's current weight was 98 pounds, and his caloric requirements were 1550 kcals per day. The tube feeding provided 1425 kcals per day. A reason for not providing the required calories was not included on the nutritional assessment. The assessment did not identify a problem with tolerance of the tube feeding. A review of the admission orders [REDACTED]. During an interview on 10/20/15 at 2:10 p.m., staff member J, stated the resident was not receiving the calories his body required because of tolerance problems. It's well documented. Review of resident #10's care plan did not indicate tolerance problems with the tube feeding. Review of the physician visit note dated 8/14/15 showed After initial difficulty with tube feed initiation (primarily due to a higher than actually needed caloric requirement calculation based on an erroneous [DIAGNOSES REDACTED]. Review of a progress note dated 8/19/15 by staff member J, showed Severe diarrhea per nursing. Suggest: Reevaluate med: MG, K+ [MEDICATION NAME] which have side effect of Diarrhea. Consider change to a formula such as Glucerna 1.0 with lower osmolality. Provider noted via SBAR form.(sic) Review of the August and September nursing progress notes revealed one note regarding intolerance of the tube feeding dated 8/19/15: Tube feeding infused over 1 hour via pump as per order, immediately afterward res had large loose incontinent stool. All other relevant nursing notes reflected tolerating tube feedings well. Review of the nursing progress notes dated 9/9/15 by staff member J, reflected weight 90# which is down from admission weight of 95#. Resident with Hx of severe diarrhea now doing better since mg and potassium were discontinue with now only an occasional loose stool noted. TF's increased to [MEDICATION NAME] 1.2, 350 cc with 150 cc H20 flushes QID. This will provided 1400 cc [MEDICATION NAME] 1.2, 1700 calories, 75 grams protein. Review of the medical record reflected resident #10 was not provided adequate calories from 8/12/15 to 9/9/15. Review of a progress note dated 10/01/15 by staff member J, showed weight 92#. Weight fluctuated b/w 89-95# in September. Tolerating TF's per nursing. Will continue to monitor. E. Review of the Speech Therapy Evaluation dated 8/13/15, for the resident's ability to swallow reflected, Overall Abilities = Profound/Absent. Review of resident #10's nursing progress notes dated 10/10/15, reflected During tube feeding, res disconnected device and put in mouth while [MEDICATION NAME] was being admin 350 ml/hour. Patient teaching done, and not effective. Res again disconnected device and put the [MEDICATION NAME] in his mouth. MD notified via fax and SBAR. Review of a nursing progress note dated 10/11/15 showed Productive cough, coughing up copious amt's of sputum. Review of a nursing progress note dated 10/15/15 showed, Resident once again connected his feeding tube and was drinking the [MEDICATION NAME] from the tubing. Lungs with ronchi (sic) bilat. O2 sat 83 on room air Placed on O2 at 2L per NC. Review of a nursing progress note dated 10/16/15 showed, resident ran low grade fever at 0030. Was 100.1 encouraged to DBC resident cooperative with DBC. Suctioned for large amount thick yellow phlegm. Review of a nursing progress note dated 10/16/15 showed, Lungs have crackles in all lobes . Review of the a nursing progress note dated 10/16/15 at 7:40 a.m. showed, resident started on [MEDICATION NAME] per feeding tube Treatment was provided six days after symptoms were identified from drinking the formula. Review of the medical record lacked evidence the facility did a chest X-ray to determine if the resident had a negative outcome from the oral consumption of food.

Based on record review and interview, the facility failed to ensure a resident with a PEG tube received the required calories which resulted in an eight pound weight loss 38 days; and failed to ensure a resident received adequate calories which resulted in a 24 pound weight loss in 4 months for 2 (#s 10, and 19) of 24 sampled residents. Findings include: 1. Resident #10 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of resident #10's admission nutritional assessment showed the resident's current weight was 98 #s, and his caloric requirements were 1550 kcals per day. The tube feeding provided 1425 kcals per day. A reason for not providing the required calories was not included on the nutritional assessment. The assessment did not identify a problem with intolerance of the tube feeding. Review of the admission orders [REDACTED]. During an interview on 10/20/15 at 2:10 p.m., staff member J stated the resident was not receiving the calories his body required because of tolerance problems, It's well documented. Review of resident #10's care plan did not show intolerance problems with the tube feeding. Review of the physician visit note dated 8/14/15 showed, After initial difficulty with tube feed initiation (primarily due to a higher than actually needed caloric requirement calculation based on an erroneous [DIAGNOSES REDACTED]. Review of a progress note dated 8/19/15 by staff member J showed Severe diarrhea per nursing. Suggest: Reevaluate med: MG, K+ [MEDICATION NAME] which have side effect of Diarrhea. Consider change to a formula such as Glucerna 1.0 with lower osmolality. Provider noted via SBAR form. Review of the physician orders [REDACTED]. Review of the August and September nursing progress notes revealed one note regarding intolerance of the tube feeding dated 8/19/15: Tube feeding infused over 1 hour via pump as per order, immediately afterward res had large loose incontinent stool. All other related nursing notes reflected tolerating tube feedings well. Review of the nursing progress notes dated 9/9/15 by staff member J reflected, weight 90# which is down from admission weight of 95#. Resident with Hx of severe diarrhea now doing better since mg and potassium were discontinued with now only an occasional loose stool noted. TF's increased to [MEDICATION NAME] 1.2, 350 cc with 150 cc H20 flushes QID. This will provided 1400 cc [MEDICATION NAME] 1.2, 1700 calories, 75 grams protein. Review of the medical record reflected resident #10 was not provided adequate calories from 8/12/15 to 9/9/15. Review of resident #10's lab values showed a range in [MEDICATION NAME] level from 3.1 (8/20/15) to 2.7, (8/24/15) indicating protein-calorie malnutrition. Review of a progress note dated 10/01/15 by staff member J, showed weight 92#. Weight fluctuated b/w 89-95# in September. Tolerating TF's per nursing. Will continue to monitor. Review of a physician note date 10/05/15 showed feeding adjustment to keep weights up. Resident #10's weight recorded 10/05/15 on the physician note was 87 pounds. 2. Resident #19 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of resident #19's annual MDS with the ARD of 4/26/15, showed the resident had a weight of 130 pounds. Review of the quarterly MDS with the ARD of 7/21/15 showed the resident had a weight of 113 pounds, a severe weight loss in three months. Review of the current MDS with the ARD of 10/15/15 showed the resident had a weight of 106 pounds, a severe weight loss of 18% in six months. Review of the dietary progress notes, dated 8/5/15 reflected, weight loss. Review of the second dietary progress notes dated 8/5/1 reflected, No update on weight. Behaviors and poor intake continue. Evaluation by medical provider is pending per nursing. Review of the dietary notes dated 8/14/15 reflected, Med changes noted. Intakes remain poor. Staff continues to offer and encourage meals, snacks supplement. Review of the current dietary note dated 10/1/15 reflected, Weight 107 pounds. Intakes improved somewhat with much encouragement. Review of the physician's orders [REDACTED]. Review of the diet ticket for resident #19 showed no food preferences or dislikes, and no enhanced foods or supplements. Review of the dietary care plan with the goal date of 10/16/15 reflected, Provide snacks hs and prn and provide cereal with half and half added at breakfast. Review of the ADL Verification Worksheet showed no snacks were offered for the month of August. The diet card lacked the half and half for breakfast. During an interview on 10/21/15 at 1:40 p.m. staff member J stated the unit would know more about her weight loss, and to talk to them. During an interview on 10/21/15 at 3:30 p.m., staff member K stated the resident is one of the most active people on her unit. She stated they tried fortified foods, snacks, and the supplement. The resident was often angry and would refuse her meals, and sometimes her medication. She said the son and sister are aware of the weight loss. Review of the nursing progress notes dated 7/17/15 showed gets confused very easily, and covers with anger or angry outbursts. Can usually be redirected with good results. Resident often refuses meals, but does like to eat cheerios. Has scheduled supplements that she also frequently refuses. The care plan and clinical notes lacked evidence the facility tried other interventions to prevent the severe weight loss, except for the [MEDICATION NAME] and supplements in July.