Every finding on record at Avir at Arlington

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of 5 residents (Residents #1) reviewed for infection control. The facility failed to ensure CNA A performed hand hygiene after glove changes during incontinence care for Resident #1. This failure could place residents at risk of infection. Findings include:1. Record review of Resident #1's Face Sheet, dated 07/28/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The face sheet did not list the resident's diagnoses. Record review of Resident #1's Comprehensive Care Plans, dated 07/24/26, reflected:There were no care plans for incontinence care[TF1.1]. In an observation on 07/28/26 at 11:55 AM, CNA A prepared to perform incontinence care for Resident #1. Resident #1 was incontinent of urine[TF2.1]. CNA put on gloves and pulled down the resident's brief. CNA A cleaned the peri-area and changed gloves without performing hand hygiene. CNA A cleaned the resident's buttocks and changed gloves without performing hand hygiene. CNA A put a clean brief on the resident. In an interview on 07/28/26 at 12:05 PM, CNA A said he changed gloves during incontinence care but did not perform hand hygiene. He said he just did not perform hand hygiene this time. CNA A said hand hygiene was important to prevent cross contamination and the spread of germs and he was trained to perform hand hygiene[TF3.1]. In an interview on 07/28/26 at 2:30 PM, the DON said staff were supposed to perform hand hygiene after changing gloves. She said the staff were in-serviced on 07/28/26 and she did not know if staff were trained prior to her arrival to the facility. The DON said failure to perform hand hygiene between glove changes could cause contamination. Record review of the facility's policy and procedure, Handwashing/Hand Hygiene, dated 2001, reflected: Policy StatementThis facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. 1.Hand hygiene is indicated.g.immediately after glove removal.

Based on interview and record review, the facility failed to ensure a Registered Nurse was on duty in the facility for a minimum of eight consecutive hours a day, seven days a week, for 1 of 5 quarters (Quarter 2 of 2025) reviewed for RN coverage. 1.The facility failed to have 8 consecutive hours of RN coverage for 15 of 31 days in January 2025.2.The facility failed to have 8 consecutive hours of RN coverage for 25 of 28 days in February 2025.3.The facility failed to have 8 consecutive hours of RN coverage for 5 of 31 days in March 2025. This failure could affect the residents by placing them at risk for not having their nursing and medical needs met and receiving improper care.Findings included:Record review of the CMS PBJ Staffing Data Report revealed no RN hours for the following dates:01/01/25, 01/05/25, 01/11/25, 01/12/25, 01/18/25, 01/19/25, 01/25/25, 01/26/25, 01/29/25, 01/31/25, 02/02/25, 02/04/25, 02/05/25, 02/06/25, 02/07/25, 02/08/25, 02/09/25, 02/11/25, 02/12/25, 02/13/25, 02/14/25, 02/15/25, 02/16/25, 02/17/25, 02/18/25, 02/19/25, 02/20/25, 02/21/25, 02/22/25, 02/23/25, 02/24/25, 02/25/25, 03/18/25, 03/19/25, 03/20/25, and 03/21/25. Record review of an excel file, undated, for RN time stamp hours from 01/01/25 through 03/31/25 revealed no RN coverage on the following dates:01/01/25, 01/05/25, 01/11/25, 01/12/25, 01/18/25, 01/19/25, 01/25/25, 01/26/25, 01/29/25, 01/31/25, 02/02/25, 02/04/25, 02/05/25, 02/06/25, 02/07/25, 02/08/25, 02/09/25, 02/11/25, 02/12/25, 02/13/25, 02/14/25, 02/15/25, 02/16/25, 02/17/25, 02/18/25, 02/19/25, 02/20/25, 02/21/25, 02/22/25, 02/23/25, 02/24/25, and 02/25/25. Further review of the excel file revealed there was less than 8 hours of RN coverage on the following dates:- 6.83 hours on 01/04/25- 7.43 hours on 01/08/25- 2.50 hours on 01/22/25- 7.67 hours on 01/27/25- 3.57 hours on 01/30/25- 2.35 hours on 02/01/25- 7.74 hours on 02/03/25- 4.00 hours on 02/10/25- 7.37 hours on 03/24/25Interview on 02/26/26 12:31 PM, the HR Director stated the staffing coordinator was responsible for scheduling. She stated she verified the 8 hour RN requirement was met during payroll. She stated she submits payroll to a company the facility outsources with and if there were questions the company would send it back so she could verify the PBJ data. Interview on 02/26/26 at 12:37 PM, the Staffing Coordinator stated she was responsible for the schedule and was aware of the 8 consecutive hour RN requirement. She stated they had a nurse consultant who was an RN, but she was not always on site. She said they had a lot of change of DONs and did not know why there was not an RN scheduled during that time. She said the Administrator that was working at the time worked closely with her to meet the RN hours but the Administrator was not available due to being on leave. The Staffing Coordinator stated there was no risk to residents not having an RN scheduled because they had other licensed nurses. Interview on 02/26/26 at 12:52 PM, the DON stated she had worked at the facility since January of 2026. She said the staffer was responsible for scheduling RN coverage. She said if there were any gaps like requested time off or call-ins, she would fill in that space herself or reach out to a prn RN on staff. She said the 8 hours was calculated through HR and the contracted company reviews the RN hours and makes sure they were submitted appropriate to CMS. She stated she did not know why there was no RN coverage during those times. She said the risk of not having an RN would be no oversight. Interview on 02/26/26 at 5:07 PM, the Interim Administrator stated there should be an RN scheduled for 8 consecutive hours. He stated the staffing coordinator was responsible for scheduling and HR reviewed the hours. He said the risk to residents would be no oversight from an RN in the facility. Record review of the facility policy titled, Staffing, Sufficient and Competent Nursing revised August 2022, revealed .3. A registered nurse provides services at least eight (8) hours every 24 hours, seven (7) days a week.

Based on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 3 of 3 residents (Resident #26, Resident #62, and Resident #63) reviewed for Medicare/Medicaid coverage. 1. The facility failed to ensure Resident #26, Resident #62 and Resident #63 were given a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) form when discharged from skilled services at the facility. 2. The facility failed to ensure Resident #26, Resident #62 and Resident #63 were given a Notice of Medicare Non-Coverage (NOMNC) form with information on how to appeal the decision when residents were discharged form skilled services prior to covered days being exhausted.This failure could place residents at risk of not being informed of changes to provided services. Findings included:Record review of the document titled Beneficiary Notice - Residents discharged Within the Last Six Months, dated 09/2024 through 02/2025, completed by the facility, revealed who discharged from a Medicare Part A stay with benefit days remaining. Residents #26, #62 and #63 were listed.Resident #26Record review of Resident #26's admission record dated, 03/02/26, revealed an [AGE] year-old female who admitted to the facility on [DATE] with a principal diagnosis of cerebral infarction due to embolism of right middle cerebral artery (stroke caused by a blood clot traveling from elsewhere in the body and blocking the middle cerebral artery). The date of discharge was 02/13/26, length of stay 42 days, and discharge home with home health. Record review of email, dated 03/02/26, sent to Surveyor by the DON revealed she was not able to provide Resident #26's MDS assessment by email.Record review of Resident #26's physician orders, dated 01/02/26, revealed admit to [facility name] under the care of Dr. [name].Record review of the SNF Beneficiary Protection Notification Review, completed by the facility, revealed Resident #26's Medicare Part A skilled service episode start date was 01/02/26 and the last covered day of Part A service was 02/13/26. The SNF ABN and NOMNC were marked as not provided to the resident with no explanation why the form was not provided. Record review of Resident #26's progress note, dated 02/13/26, revealed Resident discharged from facility accompanied by [family member] to home residence. Resident in stable condition denies pain or discomfort at time of discharge. Resident's [family member] given discharge instructions, medications, and educated [family member] about medication administration. NP made aware.Resident #62Record review of Resident #62's admission record, dated 03/02/26, revealed an [AGE] year-old female with an original admission date of 11/05/25 and readmission date of 11/13/25 to the facility. Resident #62's principle diagnosis was metabolic encephalopathy. The date of discharge was 11/30/25, length of stay 17 days, and discharge home with no home health.Record review of email, dated 03/02/26, sent to Surveyor by the DON revealed she was not able to provide Resident #62's MDS assessment by email.Record review of Resident #62's physician orders, dated 01/21/26, revealed admit to [facility name] under the care of Dr. [name].Record review of the SNF Beneficiary Protection Notification Review, completed by the facility, revealed Resident #62's Medicare Part A skilled service episode start date was 11/05/25 and the last covered day of Part A service was 11/21/25. The SNF ABN and NOMNC were marked as not provided to the resident with no explanation why the form was not provided.Record review of Resident #62's progress note dated 11/30/25 revealed Resident alert and awake, ate breakfast with assistance of CNA, AM care given. Clean and dressed. Resident in stable condition. Resident discharged home with Hospice via stretcher and ambulance with 2 attendants. Hospice representative present at discharge. Resident discharged to [Address] the [family member's] home. Medications given to Hospice representative. IDT made aware. MD notified.Resident #63Record review of Resident #63's admission record, dated 03/02/26, revealed a [AGE] year-old female who admitted on [DATE] with diagnosis that included cerebral infarction (stroke). The date of discharge was 12/27/25, length of stay 25 days, and discharge home with home health.Record review of email, dated 03/02/26, sent to Surveyor by the DON revealed she was not able to provide Resident #63's MDS assessment by email.Record review of Resident #63's physician orders, dated 01/2/26, revealed I Certify that the resident Requires/Continues to require Long Term Nursing care at this facility for the next 180 days.Record review of the SNF Beneficiary Protection Notification Review, completed by the facility, revealed Resident #63's Medicare Part A skilled service episode start date was not included and the last covered day of Part A service was 12/22/25. The SNF ABN and NOMNC were marked as not provided to the resident with no explanation why the form was not provided.Interview on 02/26/26 at 4:22 PM, the Director of Social Services stated she was responsible for issuing SNF ABN and NOMNC forms to residents. She stated she issued ones for managed care and did not realize they were needed for traditional Medicare. She said that if a resident was on managed care the insurance would send her the NOMNC and she would give it to the resident or POA the same day so they would have at least 48 hours notice and a chance to appeal by 12 the next day. She said she had just been educated on the facility policy and when to issue the forms. She said if the forms were not given to residents it could cause the facility not to be paid, the resident would not be able to appeal on time and the resident would not be informed of changes. Interview on 02/26/26 at 5:07 PM, the Interim Administrator stated the Director of Social Services was responsible for issuing the forms. He stated residents could be at risk of not being informed of changes to services. Record review of the facility's policy titled Medicare Advance Beneficiary and Medicare Non-coverage Notices revised September 2022, revealed the following: .Skilled Nursing Facility Advance Beneficiary Notice (CMS form 10055) 1. If the director of admissions or benefits coordinator believes (upon admission or during the resident's stay) that Medicare.will not pay for an otherwise covered skilled service(s), the resident (or representative) is notified in writing why the service(s) may not be covered and of the resident's potential liability for payment of the non-covered service(s).Notice of Medicare Non-Coverage (CMS form 10123)1. If the resident's Medicare covered Part A stay or when all of Part B therapies are ending, a Notice of Medicare Non-coverage (CMS from 10123) is issued to the resident at least two calendar days before benefits end. 2. The Notice of Medicare Non-Coverage informs the resident of the pending terminate of coverage and of his/her right to an expedited review by a Quality Improvement Organization.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on one of two medication carts (station one) reviewed for pharmacy services.The facility failed to ensure the station one nurses' medication cart contained accurate narcotic logs for Resident #21 on 02/25/26.This failure could place residents at risk for medication error, and drug diversion. Findings included: Review of Resident# 21's Quarterly MDS Assessment, dated 01/29/26, reflected the resident was [AGE] year-old female admitted to the facility on [DATE] and readmission on [DATE], with diagnoses that included pain. The resident had moderately impaired cognition with a BIMS score of 11.Review of Resident #21's physician's orders dated 2/27/25 reflected an order for Resident #21 to receive one tablet of Acetaminophen-Codeine Tablet 300-30 milligrams (pain medication) by mouth as needed every six hours.Review of Resident #21's medication administration record for February 2026 on 02/25/26 reflected an order for Resident #21 to receive one tablet of Acetaminophen-Codeine Tablet 300-30 milligrams (pain medication) by mouth as needed every six hours and last administration was on 2/22/26 at 02:59.Observation and record review on 02/25/26 at 8:54 AM of station one nurses' medication cart and the Narcotic Administration Record, with LVN C, revealed the following:Resident #21's Narcotic Administration Record for Acetaminophen-Codeine Tablet 300-30 milligrams reflected a total of 4 pills remaining, while the blister pack count was 5 pills. It was last administered on 02/24/26 at 8:00 PM.Interview with LVN C on 02/25/26 at 12:47 PM revealed she did not realize the narcotic count and narcotic log was not matching. She stated she had counted with outgoing staff that morning and she did not know she was having more on count than what was documented on the narcotic log. She said nobody had noticed it during shift change. LVN C stated the Narcotic log should always match with the count. She stated signing off when no medication was administered it could lead to medication error. She stated she had done an in-service on medication administration, but she could not recall when. Interview on 02/26/26 at 12:05 PM with Resident #21 revealed she got pain pills as needed. She could not recall when she received one last. Interview on 02/26/26 at 01:35 PM, the DON revealed her expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the medication administration record and to sign on the narcotic log to prevent discrepancies. She stated the oncoming should count with outgoing staff each shift and report any discrepancies. She stated the Narcotic administration record should match the count. She stated on 02/24/26 she had checked all the carts, and the Narcotic logs were balancing with count. The DON stated the nurses are responsible for checking on each other ensuring the counts are correct before shift change. She stated it was her responsibility to audit the carts monthly and because she has been to this facility for two weeks, she had managed to audit only one cart and one Medication administration record. She stated Failure to sign off could lead to risk based on resident assessment like pain not being controlled. She stated she had not done training on medication administration since she was newly hired.Interview on 02/26/26 at 05:20 PM, the Interim Administrator revealed he expected the nursing staff to be attentive when performing the narcotic shift change count. He also expected for the nursing staff to document on the narcotic log when a narcotic was administered. He stated the risks of not doing so was that a resident could miss a dose; it could create room for medication error; and drug diversion.Record review of the facility training reflected no previous in-services training was provided; the facility started training on narcotic count after the issue was noticed.Record review of the facility's current Administering Medication policy, dated April 2019, reflected the following: .g. The individual administering medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next dose.

Based on observation, interview, and record review the facility failed to ensure each resident's environment remained free of accident hazards for 1 of 8 residents (Resident #11) reviewed for accident hazards.The facility failed to assess Resident #11 for the ability to self-administer a dietary supplement, Gelatide Dietary Supplement, which was kept in her room at her bedside.This failure could affect residents by placing residents at risk of consuming unsafe medications.Findings included: Record review of Resident #11's face-sheet revealed a [AGE] year-old female admitted to facility on 01/04/2026. Her diagnosis included: Unspecified Fracture of Right Femur, Subsequent Encounter for Closed fracture with Routine Healing (healing or recovery phase , receiving routine follow-up care); Essential (Primary) Hypertension (high blood pressure that is multi-factorial with no distinct cause); Trigeminal Neuralgia (a chronic, often debilitating nerve disorder causing sudden, severe electric shock-like facial pain, usually on one side). Record review of Resident #11's admission MDS dated [DATE] revealed BIMS score to be 15 with memory intact. Resident #11 able to make decisions r/t her care but needs max to substantial assistance with ADL care. Record review of Resident #11's care plan revealed that there was no documentation r/t self-administration of medication. Record review of Resident #11's physician orders revealed no orders for self-administration of medication. Observation on 02/24/26 at 10:30 AM revealed a bottle of Gelatide Dietary Supplement (a plant-based weight management supplement) Warning label revealed in part, Keep out of the reach of children. Bottle located on Resident #11's bedside table. Interview and observation on 02/24/26 at 10:35 AM revealed when LVN C was asked about the Gelatide Dietary Supplement found on Resident #11's bedside table, she immediately went to the room and removed the supplement. Resident #11 currently was not in the room at the time. Interview on 02/24/2026 at 2:00 PM with LVN C revealed that Resident #11 stated she bought the supplement over the weekend. Resident #11 stated to LVN C if it was a problem she would send it back home with her family member. LVN C stated the policy of the facility was there are to be no medications of any kind at a resident's bedside. If staff find medications in room, they are to notify the physician and get an order for resident to have the medication. No orders are ever written to self-medicate. LVN C stated the risk of having medication at the bedside was that a resident could overdose, poly pharmacy, which was a concurrent use of multiple medications for same diagnosis, and drug interactions with current medications. Interview on 02/24/2026 at 11:33 AM, Resident #11 revealed that she did not realize she could not have supplement with her. Resident stated she was not told by the facility. Resident #11 stated the nurse came in and explained that another resident with dementia could come in and take the medication not know what it was. Resident #11 did not indicate how he got the supplement. Interview on 02/24/2026 at 1:29 PM, the DON revealed that Resident #11 had the supplement on her bedside table. The DON stated the risk could be Resident #11 could have an adverse reaction to current medications and the facility would not be aware of the cause. The resident rooms are usually checked during daily rounds for medications and other items residents should not have. The DON reported that the physician wrote an order for resident to take the supplement every day. Resident #11 was upset that she had to give it to the nurse to place in the cart. Physician stated there would be no adverse effects to resident if she continues to take supplement. Interview on 02/26/2026 at 5:06 PM with Administrator revealed r/t medications at bedside. Residents should have an assessment to determine if they can self-administer meds at the bedside. Provide a lockbox if they pass the assessment for the self-administration. May cause an adverse effect. The risk was having an adverse effect. Administrator's his expectation was to make sure the med self-administration was correct and make sure they have a lockbox in their room to lock up the medication. Staff are to make sure no meds are brought in from the outside unless checked off. Review of facility's policy Medication Labeling and Storage, revised February 2023 revealed in part, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Policy does not address medications found at the bedside or medications brought in by the resident and/or the resident representative found at the bedside. Record review of facility's policy General guidelines - Medication Administration Procedures revealed in part .Administration: 2. Medications are to be poured, administered, and charted by the same licensed person. 5. After the resident has been identified, administer the medication and immediately chart doses administered on the medication administration record.

Based on observations, interviews, and record reviews, the facility failed to ensure residents had the right to a safe, clean, comfortable and homelike environment to include maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 3 of 17 residents (Resident #14, Resident #2 and Resident #60) reviewed for environmental conditions.1. The facility failed to ensure flooring was replaced in Resident #14's room. 2. The facility failed to ensure the faucet knob was replaced in Resident #2 and #60's bathroom.These failures could place residents at risk of living in an unsanitary, unsafe environment and a diminished quality of life.Findings included: Record review of Resident #14's Quarterly MDS, dated [DATE], revealed a [AGE] year-old male who admitted to the facility on [DATE], with diagnoses that included unspecified dementia (memory loss and cognitive decline without a specific cause) and cerebral infarction (stroke). Resident #14's BIMS score was 5 indicating sever cognitive impairment. Observation on 02/24/26 at 10:24 AM in Resident #14's room, revealed the flooring was missing underneath one of the legs of A bed and two legs of B bed. The flooring was peeled back and started to roll up on the edge of the entrance to the bathroom. It appeared like black nonskid tape had been used to cover the missing and peeled areas of flooring. Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a [AGE] year-old male who admitted to the facility on [DATE], with a primary diagnosis of Cerebral Infarction (stroke). Resident #2' s BIMS score was 14, indicating intact cognition. Record review of Resident #60's Face Sheet, dated 02/26/26, revealed a [AGE] year-old male who admitted to the facility on [DATE], with a diagnosis of hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting left non-dominant side. Observation and interview on 02/26/26 at 10:45 AM in Resident #2 and #60's bathroom revealed the right knob on the sink was missing. Resident #60 stated he had been at the facility since Friday (02/20/26) and the knob had been broken since he had been there. He said it bothered him that it was broken.Interview on 02/26/26 at 1:48 PM, LVN D stated she Resident #14's floor looked bad before and she had called Maintenance and remembered putting it in the book. She could not recall how long ago or how long the floor had been like that. She stated when they did patient care the beds kept messing up the floors. She said staff were supposed to put maintenance requests in the computer. She said if repairs were not done it would not be homelike for the patient, and it would possibly be a tripping hazard. She stated she was not aware of Resident #2 and #60's faucet knob missing. She said residents could not be able to wash their hands and could spread infection.Interview on 02/26/26 at 3:49 PM, the Maintenance Director stated his expectation was for staff to report repairs to the nurse or place them in the work order system. He stated he was aware of the flooring in Resident #14's room and said the black tape was a layer of flooring. He said the risk was the resident could trip and it was not homelike. He said he already replaced the knob on the sink in Resident #2 and #60's room. He stated he looked in the work order system and nothing was found for the sink. He said the risks included Residents #2 and #60 could cut their hand and they do not have proper access to water. Interview on 02/26/26 at 4:45 PM the DON stated she expected staff to communicate any repairs needed in the app that Maintenance used. She said it would not be homelike if repairs were needed and not done. Interview on 02/26/26 at 5:07 PM the Interim Administrator stated Maintenance was responsible for repairs and his expectation for staff was to place work orders in the computer system or paper log. He stated the risk would be quality of life, tripping hazards and sanitization. Record review of facility's policy tilted Maintenance Service revised December 2009, revealed the following: .2. Functions of maintenance personnel include, but are not limited to: .b. maintaining the building in good repair and free from hazards.

Based on interview and record review, the facility failed to ensure care plans were developed in consultation with the resident's and representative for 2 of 8 residents (Resident #10 and Resident #11) reviewed for comprehensive care plans.The facility failed to invite Resident #10 and Resident #11's resident representative to participate in the residents' care plan meetings.The failure could place residents at risk of their care plans not including resident-specific needs.Findings include: Resident #10Record review of Resident #10's face-sheet revealed an [AGE] year-old male initially admitted to facility on 05/12/20 and readmitted on [DATE]. His diagnosis included: Type 2 Diabetes Mellitus with Ketoacidosis without Coma (a serious, acute metabolic complication where the body produces high levels of ketones acid due to insulin deficiency or resistance, without causing loss of consciousness ); Parkinsonism, Unspecified (neurological disorder causing motor symptoms like tremors, stiffness, slow movement, bradykinesia, balance issues, without a specific, determined cause ); Dementia in other Diseases Classified elsewhere, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety (dementia is a symptom or manifestation of an underlying physical condition). Record review of Resident #10's MDS dated [DATE] noted BIMS score to be 15 with memory intact. Resident #10. Resident #10 able to make decisions r/t care and requires set-up to supervision with ADL care. Record review of Resident #10's clinical record revealed no documentation of quarterly care plan meetings with the resident or resident representative in the clinical records noted since admission. Interview on 02/26/2026 at 11:25 AM, Resident #10 revealed he has not been involved in care plan meetings with the team members. Resident #10 stated he had not been given any information about his medications. Resident #10 stated his family member was his RP. 02/26/2026 4:00 PM attempted to contact Resident #10's family member. Left message for family member to return call. Interview on 02/27/2026 at 4:00 PM, Resident #10's family member stated she had not been involved in the resident's care plan meetings since the resident had been at the facility. Family Member revealed that a care plan meeting was held with SW on 02/26/2026 by phone. Family member did not reveal time meeting was held. Resident #11Record review of Resident #11's face-sheet revealed a [AGE] year-old female admitted to facility on 01/04/2026. Her diagnosis included: Unspecified Fracture of Right Femur, Subsequent Encounter for Closed fracture with Routine Healing (healing or recovery phase, receiving routine follow-up care); Essential (Primary) Hypertension (high blood pressure that is multi-factorial with no distinct cause); Trigeminal Neuralgia (a chronic, often debilitating nerve disorder causing sudden, severe electric shock-like facial pain, usually on one side). Record review of Resident #10's MDS revealed BIMS score to be 15 with memory intact. Resident #10 was able to make independent decisions r/t to his care and required set-up to supervision to supervision with ADL care. Record review of Resident #11's clinical record revealed no documentation of initial care plan meeting with resident or resident representative. Interview on 02/24/2026 at 11:33 AM with Resident #11 revealed that she has not met with the SW or team members to discuss her plan of care. Resident #11 stated she has spoken with the SW concerning her discharge home and has appealed her discharge because she must be able to safely walk at home. Interview on 02/26/2026 at 4:30 PM with SW revealed the process for care plan meetings are to set up meeting with resident and family members or RP. Initial base line care plan meeting at admission. Discharge planning discussed. Quarterly care plan conference. Team will hold meetings in resident's room or the conference rooms. SW revealed she would make a call the RPs and invite them to the meeting. SW uses the MDS Schedule as a guide to schedule care plan meetings. PASARR coordinator is involved with care plan with residents on specialized service. No documentation noted r/t to care plan meeting calls or invitations in SW progress notes for Resident #10 or Resident #11. No documentation of care plan meetings in SW progress notes for Resident #10 or Resident #11. SW did not indicate how far in advance notification was provided to resident or RPs r/t care plan meetings. Interview on 02/26/2026 at 4:46 PM with DON revealed the policy for care plan meetings with residents and the RPs are to follow CMS policy related to initial and quarterly care plan meeting schedules. DON's expectations are to follow the guidelines and be in compliance going forward DON stated the benefits of the care plan meeting are understanding the expectations of resident's diagnosis, changes of conditions, and knowledge of the resident's care. Interview on 02/26/2026 at 5:06 PM with Administrator revealed the care plan meetings are to be completed as required. Review of facility's Care Plans, Comprehensive Person-Center, revised March 2022 revealed in part, A comprehensive, person-centered care that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The resident is informed of his or her right to participate in his or treatment and provided advance notice of care planning conferences. If the participation of the resident and his/her resident representative in developing the resident's care plan in determined to not be practicable, an explanation is documented in the resident's medical record.

Based on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for two (Residents #1 and #2) of four residents reviewed for pressure ulcers. The facility failed to ensure Resident #1 received the physician ordered treatment for her pressure ulcer. Staff did not consult with the facility physician or wound care nurse practitioner when the wound started deteriorating. The ulcer worsened and the resident required hospitalization on 12/25/25. On 01/08/26 at 5:10PM, an Immediate Jeopardy (IJ) was identified, and the Administrator was notified. While the Administrator was notified that the IJ was removed on 01/10/26 at 12:15PM, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. 2. The facility to ensure the WCN treated Resident #2's pressure ulcer according to facility policy. This failure could place residents at risk of deterioration of their wound if they were not treated according to physician orders and facility policy.Findings included: Record review of Resident #1's Quarterly MDS Assessment, dated 11/26/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her BIMs score was 9. Her cognitive skills for daily decision-making was moderately impaired. Her diagnoses included cancer, heart failure, and sepsis. The resident was at risk for pressure ulcers. The resident did not have a pressure ulcer. Record review of Resident #1's Care Plans, not dated, reflected:12/09/25 Resident was at risk for skin alterations. Unstageable to the buttock.Facility interventions included:Monitor site for signs/symptoms of infection, monitor for effectiveness of treatment, notify the physician as needed, and perform weekly skin assessments. Record review of Resident #1 Physician Order Summary Report for December 2025 reflected:12/18/25: Cleanse coccyx with wound cleanser or normal saline, pat dry, apply collagen, cover with dry dressing one time a day for wound care. Record review of Resident #1 Treatment Administration Record for December 2025 reflected that the wound treatment was not completed on 12/19/25. LVN C treated the wound on 12/20/25-12/21/25. The WCN initials were listed for 12/22/25 - 12/25/25. Record review of Resident #1's progress notes and skin checks reflected:Effective Date: 12/18/25 1:30 PM Skin Check .Skin Issues Note: reopen wound to sacrum, open areas to left and right buttocks. Skin issue education: Treatment of skin issue. Skin issue education: Turn every 2 hours. - LVN A Effective Date: 12/22/25 3:24 PM Type: [Weekly] Skin/Wound Note: Note Text: Sacral pressure injury assessed and treated per order. Wound cleansed and dressing changed. Peri wound skin protected. Patient repositioned and tolerated well. - WCN Date of Service: 12/24/2025 Visit Type: [Weekly] Skin and Wound Note: .Information necessary for today's visit was obtained from the patient, nursing staff, per patient's medical record. Reason for visit: first evaluation of existing wound patient by new wound care team. 12/24/2025: Received new consult to assess resident for sacrum pressure ulcer. WOUND ASSESSMENT:Wound: 1Location: CoccyxPrimary Etiology: Pressure Ulcer/InjuryStage/Severity: Unstageable (Pressure ulcer that cannot be staged due to the large amount of dead tissue on the ulcer)Wound Status: First Evaluation of existing wound by new ProviderOdor Post Cleansing: Malodorous (bad smell)Size: 4.5 cm x 4.5 cm x 3.5 cm. Calculated area is 20.25 sq cm.Wound Base: . 40% granulation (indicates percentage of wound that is healing), 40% slough (the percentage of dead tissue in the wound), 20% eschar (percentage of dead tissue in the wound that is black in color)Exposed Tissues: Dermis, SubcutaneousWound Edges: AttachedPeri-wound (area around the wound): Ecchymosis (type of bruise), Fragile, Non-blanchable (indicates structural problems in the tissue), maroon discolorationExudate (drainage): Moderate amount of Serosanguineous (watery, pink, drainage). PROCEDURES:A sharp debridement (procedure to cut away dead tissue) was not performed today due to this is the first evaluation of the patient and further plan for debridement will be reviewed as part of the care plan. An autolytic (assists in healing of wound) dressing is in place. WOUND TREATMENT:Wound # 1 Coccyx Pressure Ulcer/InjuryTreatment Recommendations:1. Cleanse with 0.125% Dakins solution (antiseptic solution for wounds).2. apply Iodoform packing strip (antiseptic dressing strips) to base of the wound.3. secure with superabsorbent (dressing).4. change Every other day, and PRN. - Wound Care Nurse Practitioner Effective Date: 12/25/25 9:12 AM Type: Nurse's Note Note Text: Resident stable RP here pick up the resident and left for Christmas cerebrations, left with portable Oxygen machine and the charge. - LVN A Review of Resident #1's Hospital Records reflected:12/25/25 6:24 PM Emergency Department Physician Note: .Skin: Wound check: unstageable decubitus noted to coccyx with foul odor and necrotic tissue. - Emergency Department Physician An observation of Resident #1's wound picture, provided by Resident #1's Responsible Party and dated 12/25/25, on 01/08/25 at 11:10 AM revealed the resident had a large, open, dark, unstageable pressure ulcer to her coccyx. The wound had necrotic tissue and was packed loosely with a dressing, possibly iodoform. The wound was a dark brown color. Unable to determine depth and size. The ulcer looked to be about the size of an orange. The tissue around the wound was a deep red color. The resident also had a Stage II pressure ulcer on her right, lower buttock that was open, red, and approximately the size of a quarter. An interview was conducted with the Responsible Party for Resident #1 on 01/08/26 at 11:15 AM. The Responsible Party said they took Resident #1 home for a holiday dinner on 12/25/25. The Responsible Party said the facility told her the resident had a hot spot on her bottom and were treating it. The facility did not tell her the severity of the wound. The Responsible Party said on the night of 12/25/25 they saw the wound and immediately took the resident to the hospital. The Responsible Party said the resident had sepsis possibly due to the wound and ultimately passed away. An interview on 01/08/26 at 10:45 AM with the WCN for Resident #1 revealed she started employment at the facility on 12/15/25. She said she was notified on 12/18/25 that Resident #1 had a wound. The WCN said the Wound Care Nurse Practitioner saw the wound on 12/24/25. She said she notified the Responsible Party for Resident #1 about the wound on 12/24/25. An interview on 01/08/26 at 1:00 PM with the DON regarding Resident #1 revealed she never looked at the wound for Resident #1. An interview on 01/08/26 at 1:05 PM with LVN A and CNA B for Resident #1 revealed CNA B saw Resident #1's open wound on 12/18/25. He said he notified LVN A about the wound. LVN A said she did not measure the wound, but it was about the size of a dime. LVN A said she notified the WCN about the wound. LVN A said an order was obtained from the WCN and LVN A said she did not treat the wound because the WCN was at the facility. CNA B said following 12/18/25, the wound always had a dressing on it and he never visualized the wound after 12/18/25. LVN A said she never visualized the wound after 12/18/25. LVN A and CNA B said on 12/25/25 the wound had a dressing on it and they both assisted Resident #1 into the car of the Responsible Party. An interview on 01/08/26 at 1:35 PM with the Wound Care Nurse Practitioner for Resident #1 1 revealed she saw the wound on 12/24/25 but did not take a picture of it. She said she ordered Dakin's solution to clean the wound and iodoform to pack the wound. She said she requested a wound culture but was told the facility did not have wound culture supplies. She said she did not find out about the wound until she arrived to the facility on [DATE]. She said she was given a list of residents to see, and Resident #1 was on the list. The Wound Care Nurse Practitioner said the resident had an unstageable pressure ulcer on her coccyx. She said the facility should have notified her or the facility physician before the wound worsened. She said when she saw the resident she was not septic and did not need to go to the hospital. An interview on 01/08/26 at 2:05 PM with the Facility Physician revealed he did not assess Resident #1's wound from 12/18/25 - 12/25/25. He said he did not know what the wound looked like. He said he was only notified about the wound on 12/18/25. He said staff should have notified him when the wound had a change in condition or they suspected an infection. He said he did not know if the facility should have sent her to the hospital for the wound. An interview on 01/08/26 at 2:20 PM with CNA C revealed he was the CNA that would bathe Resident #1. He said he noticed a change in the resident's wound on 12/21/25. He said it looked a little more open and he notified the nurse. He said he did not know how to describe the size of it. He said every time he saw the wound; it had cream on it. An interview on 01/08/26 at 3:09 PM with the WCN and DON revealed they both looked at the Treatment Administration Record for Resident #1. The WCN said her initials were not on the Treatment Administration Record and she did not know who completed the treatments for the resident on 12/23/25 and 12/25/25. The WCN said she only saw the resident's wound on 12/22/25 and on 12/24/25. She said on 12/22/25 the wound on the coccyx was about the size of a tangerine and was curved in, but she did not actually measure the wound or document the size of it. She said it did not have drainage or odor. The WCN said she contacted the Wound Care Nurse Practitioner by phone on 12/22/25 but did not document it. She said she did not notify the Facility Physician about the wound. The WCN said when she saw the wound on 12/24/25, it looked the same as it did on 12/22/25. The DON said she did not recognize the initials on Resident #1 Treatment Administration Record for 12/22/25-12/25/25 even though it was the same initials each day. The DON said she was over the Wound Care Program and that the Facility Physician was notified on 12/18/25 about the wound. An interview on 01/08/26 at 4:05 PM revealed LVN D performed wound care for Resident #1 on 12/20/25-12/21/25. He said the treatment was to apply calcium alginate (treatment that keeps the wound bed moist for healing) and a dry dressing. He said the wound was about the size of a quarter and was not very deep. He said the wound did not have drainage. An interview on 01/08/26 at 5:10 PM with the Corporate Nurse revealed the initials on the Treatment Administration Record for Resident #1 (12/22/25-12/25/25) belonged to the WCN. Record review of Resident #2's Quarterly MDS Assessment, dated 10/29/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her BIMs score was 7. Her cognitive skills for daily decision-making were severely impaired. Her diagnosis included diabetes. The resident had a Stage III pressure ulcer on her sacrum. Record review of Resident #2's Care Plans reflected:10/15/25 Resident had a pressure ulcer wound due to prolonged pressure and limited mobility, which requires wound care and repositioning to support healing and prevent infection. Facility interventions included:Assess and document wound appearance (size, depth, exudate, tissue type, odor) during dressing changes. Record review if Resident #2's Order Summary Report, January 2026, reflected: 12/25/25 Cleanse with wound cleanser, pat dry, apply medical grade honey, apply bordered dressing until healed one time a day for wound care. day for wound care An observation on 01/09/26 at 10:25 am of wound care for Resident #2 revealed the WCN and the DON were in the room together. The resident was positioned on her right side. The DON raised the left buttock to keep it from touching the pressure ulcer. The open ulcer was red, shallow, and had slough in it. The WCN sprayed wound cleanser, picked up gauze sponges and cleaned the wound cleanser off the skin around the wound. She did not clean the wound cleanser off the ulcer. The WCN measured the wound to be 1.5 cm long. The WCN stepped away from the bed to change her gloves. The DON let go of the resident's left buttock and it fell on the ulcer. The WCN put on new gloves and the DON picked up the left buttock. The WCN nurse measured the width of the wound to be 1.0 cm. The WCN performed hand hygiene but did not re-clean the wound. The WCN put the treatment for the wound on a long Q-tip and started to apply it to the wound bed. The WCN was asked if she was going to clean the wound. The WCN stopped and put the treatment on the table. The WCN sprayed the wound with wound cleanser but did not clean the wound cleanser out of the ulcer itself, just the intact skin around the wound. The WCN was asked if she was going to clean the wound cleanser off the wound. The WCN picked up a gauze and cleaned the wound cleanser of the wound and then cleaned the wound cleanser off the skin around the wound. The WCN applied the treatment to the wound after cleaning it and applied a bandage. An interview on 01/09/26 at 11:00 AM with the DON revealed she said it was important to clean the ulcer and the skin around the wound and to reclean the wound if the resident's buttock touched the wound. An interview on 01/09/26 at 11:10 AM with the WCN said it was important to cleanse the wound cleaner off the ulcer and the skin around the ulcer. She said it was important to reclean the ulcer if the resident's buttocks re-touched the wound because she did not want to transfer bacteria into the ulcer itself. Record review of the facility policy, Wound Care, revised October 2025, reflected: .PurposeThe purpose of this procedure is to provide guidelines for the care of wounds to promote healing.Preparation1. Verify that there is a physician's order for this procedure.2. Review the resident's care plan to assess for any special needs of the resident.8. Pour liquid solutions directly on gauze sponges on their papers.9. Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound.10. Wear gloves when physically touching the wound or holding a moist surface over the wound.11. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with antiseptic or normal saline solution.12. Apply treatments as indicated.13. Dress wound. This was determined to be an IJ on 01/08/26 at 4:50 PM. The Administrator and the DON were notified. The Administrator was provided the IJ template on 01/08/26 at 4:55 PM. The following Plan of Removal was submitted by the facility and was accepted on 01/09/26 at 11:36 AM and reflected the following:The facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #1) of 4 residents reviewed for pressure ulcers.Action: All residents with wounds assessed on 01/08/26, current condition of the wound communicated with the residents' physician and the wound care nurse practitioner to ensure proper treatments to treat and heal residents' wounds are in place. Person(s) Responsible: Director of Nursing, Treatment Nurse, Assistant Director of Nursing, and/or DesigneeDate: 01/08/26Action: Regional Nurse Consultant will provide education to the Director of Nursing, Treatment Nurse, Assistant Director of Nursing over the Change in Condition policy as it relates to physician notification, following orders that promote healing and prevention of pressure ulcers, and documenting all characteristics of wounds, including the measurements.Person(s) Responsible: Regional Nurse ConsultantDate: 01/08/26Action: Education provided to all nurses on the Change in Condition policy as it relates to physician notification. All nurses will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing, Treatment Nurse, Assistant Director of Nursing, and/or DesigneeDate: 01/08/26Action: Education provided to all nurses, including the treatment nurse, as it relates to documenting all characteristics of wounds, including the measurements, and following physician orders as it relates to healing and preventing pressure ulcers. All nurses will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing and/or DesigneeDate: 01/08/26Action: A test to ensure competency completed with nurses as it relates to physician notification, following orders that promote healing and prevention of pressure ulcers, and changes in skin.All nurses will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing, Treatment Nurse, Assistant Director of Nursing, and/or DesigneeDate: 01/08/26Action: The Treatment Nurse is designated to complete wound care Monday-Friday, Assistant Director of Nursing, Director of Nursing, or a Designated Nurse will complete wound care in the event that the Treatment Nurse is unable to complete/on leave. Saturday and Sunday wound care will be completed by weekend supervisor or assigned charge nurse. Person(s) Responsible: Director of Nursing for scheduling/designating wound care. Treatment Nurse. Weekend Supervisor. And/or DesigneeDate: 01/08/26Action: Director of Nursing and/or designee will observe 3 wounds a week, x4 weeks, to ensure documentation and proper notification is charted. Any discrepancies or concerns noted will be immediately discussed with the resident's physician and wound care practitioner and will result in reeducation for the nurse. Director of Nursing and/or designee will review the wound care nurse practitioner's notes weekly, x4 weeks to ensure no additional concerns are noted by the NP. Person(s) Responsible: Director of Nursing and/or DesigneeDate: 01/08/26Action: Ad hoc QAPI performed with the Medical Director to review the IJ template, root cause the deficient practice and discuss the facility's plan to remove the immediacy. Person(s) Responsible: Director of NursingDate: 01/08/26 Monitoring the facility's Plan of Removal included the following: Monitoring the facility's Plan of Removal included the following: Observations of Resident #2 and #3's wound care was not completed. The residents wound care had been completed prior to plan of removal acceptance. Record review of Resident #2 and #3's wound care on 01/09/26 did not reflect worsening of their wounds. Record review of Staff In-services was completed on 01/09/26. Interviews were conducted on 01/09/26 from 1:45 PM to 01/10/26 at 12:25 PM with staff from various shifts. The staff included LVN A, ADON, LVN E, LVN F, LVN G, LVN H, LVN D, LVN I, and RN J.All staff were able to identify:The required documentation for pressure ulcers included type of wound, color of wound, odor, wound size, drainage, and wound location. They understood the WCN/designee was required to treat the wounds Monday - Friday, and the charge nurse/house supervisor/designee would provide wound treatments on the weekend. The staff were able to verbalize the necessity to provide wound care as ordered. An interview on 01/09/26 at 2:15 PM with the WCN revealed she understood the process to treat wounds and the requirements for documentation. She said she knew the importance of completing wound care per physician orders. An interview on 01/10/26 at 12:00 PM with the DON revealed her role in the facility plan of removal included: to ensure the wounds were treated per policy and physician orders. She said she would also be monitoring a sample of wounds herself. An interview on 01/10/26 at 12:25 PM with the Administrator revealed her role in the facility plan of removal was to ensure the Plan of Removal was overseen and completed. On 01/08/26 at 5:10PM, an Immediate Jeopardy (IJ) was identified, and the Administrator was notified. While the Administrator was notified that the IJ was removed on 01/10/26 at 12:15PM, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two (Residents #1 and #3) of four residents reviewed for care plans. The facility failed to follow Resident #1's care plan. The resident's wound site was not monitored for signs/symptoms of infection, the effectiveness of treatment, and the physician was not notified for wound changes. The resident was sent out on pass with her family on 12/25/25. The RP took her to the hospital the same night and was told the resident had sepsis due to an infection of the wound. The resident did not recover and passed away on 01/03/26. On 01/09/26 at 3:00PM, an Immediate Jeopardy (IJ) was identified, and the Administrator was notified. While the Administrator was notified that the IJ was removed on 01/10/26 at 12:15PM, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. 2. The facility failed to ensure Resident #3 had a care plan in place for his pressure ulcer on the coccyx and chronic ulcer of the left leg. This failure could place residents at risk of deterioration of their wound if the care plan was not initiated and followed.Findings included: Record review of Resident #1's Quarterly MDS Assessment, dated 11/26/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her BIMs score was 9. Her cognitive skills for daily decision-making was moderately impaired. Her diagnoses included cancer, heart failure, and sepsis. The resident was at risk for pressure ulcers. The resident did not have pressure ulcers. Record review of Resident #1's Care Plans, not dated, reflected:12/09/25 Resident was at risk for skin alterations. Unstageable to the buttock.Facility interventions included:Monitor site for signs/symptoms of infection, monitor for effectiveness of treatment, notify the physician as needed, and perform weekly skin assessments. Record review of Resident #1 Physician Order Summary Report for December 2025 reflected:12/18/25: Cleanse coccyx with wound cleanser or normal saline, pat dry, apply collagen, cover with dry dressing one time a day for wound care. Record review of Resident #1 Treatment Administration Record for December 2025 reflected that the wound treatment was not completed on 12/19/25. LVN C treated the wound on 12/20/25-12/21/25. The WCN treated the wound 12/22/25 - 12/25/25. Record review of Resident #1's progress notes reflected:Effective Date: 12/18/25 1:30 PM Skin Check .Skin Issues Note: reopen wound to sacrum, open areas to left and right buttocks. Skin issue education: Treatment of skin issue. Skin issue education: Turn every 2 hours. - LVN A Effective Date: 12/22/25 3:24 PM Type: [Weekly] Skin/Wound Note: Note Text: Sacral pressure injury assessed and treated per order. Wound cleansed and dressing changed. Peri wound skin protected. Patient repositioned and tolerated well. - WCN Date of Service: 12/24/2025 Visit Type: [Weekly] Skin and Wound Note: .Information necessary for today's visit was obtained from the patient, nursing staff, per patient's medical record. Reason for visit: first evaluation of existing wound patient by new wound care team. 12/24/2025: Received new consult to assess resident for sacrum pressure ulcer. WOUND ASSESSMENT:Wound: 1Location: CoccyxPrimary Etiology: Pressure Ulcer/InjuryStage/Severity: Unstageable (Pressure ulcer that cannot be staged due to the large amount of dead tissue on the ulcer)Wound Status: First Evaluation of existing wound by new ProviderOdor Post Cleansing: Malodorous (bad smell)Size: 4.5 cm x 4.5 cm x 3.5 cm. Calculated area is 20.25 sq cm.Wound Base: . 40% granulation (indicates percentage of wound that is healing), 40% slough (the percentage of dead tissue in the wound), 20% eschar (percentage of dead tissue in the wound that is black in color)Exposed Tissues: Dermis, SubcutaneousWound Edges: AttachedPeri-wound (area around the wound): Ecchymosis (type of bruise), Fragile, Non-blanchable (indicates structural problems in the tissue), maroon discolorationExudate (drainage): Moderate amount of Serosanguineous (watery, pink, drainage). PROCEDURES:A sharp debridement (procedure to cut away dead tissue) was not performed today due to this is the first evaluation of the patient and further plan for debridement will be reviewed as part of the care plan. An autolytic (assists in healing of wound) dressing is in place. WOUND TREATMENT:Wound # 1 Coccyx Pressure Ulcer/InjuryTreatment Recommendations:1. Cleanse with 0.125% Dakins solution (antiseptic solution for wounds).2. apply Iodoform packing strip (antiseptic dressing strips) to base of the wound.3. secure with superabsorbent (dressing).4. change Every other day, and PRN. - Wound Care Nurse Practitioner Effective Date: 12/25/25 9:12 AM Type: Nurse's Note Note Text: Resident stable RP here pick up the resident and left for Christmas cerebrations, left with portable Oxygen machine and the charge. - LVN A Review of Resident #1's Hospital Records reflected:12/25/25 6:24 PM Emergency Department Physician Note: .Skin: Wound check: unstageable decubitus noted to coccyx with foul odor and necrotic tissue. - Emergency Department Physician An observation of Resident #1's wound picture, provided by Resident #1's Responsible Party and dated 12/25/25, on 01/08/25 at 11:10 AM revealed the resident had a large, open, dark, unstageable pressure ulcer to her coccyx. The wound had necrotic tissue and was packed loosely with a dressing, possibly iodoform. The wound was a dark brown color. Unable to determine depth and size. The ulcer looked to be about the size of an orange. The tissue around the wound was a deep red color. The resident also had a Stage II pressure ulcer on her right, lower buttock that was open, red, and approximately the size of a quarter. An interview was conducted with the Responsible Party for Resident #1 on 01/08/26 at 11:15 AM. The Responsible Party said they took Resident #1 home for a holiday dinner on 12/25/25. The Responsible Party said the facility told her the resident had a hot spot on her bottom and were treating it. The facility did not tell her the severity of the wound. The Responsible Party said on the night of 12/25/25 they saw the wound and immediately took the resident to the hospital. The Responsible Party said the resident had sepsis possibly due to the wound and ultimately passed away. An interview on 01/08/26 at 10:45 AM with the WCN for Resident #1 revealed she started employment at the facility on 12/15/25. She said she was notified on 12/18/25 that Resident #1 had a wound. The WCN said the Wound Care Nurse Practitioner saw the wound on 12/24/25. She said she notified the Responsible Party for Resident #1 about the wound on 12/24/25. An interview on 01/08/26 at 1:00 PM with the DON regarding Resident #1 revealed she never looked at the wound for Resident #1. An interview on 01/08/26 at 1:05 PM with LVN A and CNA B for Resident #1 revealed CNA B saw Resident #1's open wound on 12/18/25. He said he notified LVN A about the wound. LVN A said she did not measure the wound, but it was about the size of a dime. LVN A said she notified the WCN about the wound. LVN A said an order was obtained from the WCN and LVN A said she did not treat the wound because the WCN was at the facility. CNA B said following 12/18/25, the wound always had a dressing on it and he never visualized the wound after 12/18/25. LVN A said she never visualized the wound after 12/18/25. LVN A and CNA B said on 12/25/25 the wound had a dressing on it and they both assisted Resident #1 into the car of the Responsible Party. An interview on 01/08/26 at 1:35 PM with the Wound Care Nurse Practitioner for Resident #1 1 revealed she saw the wound on 12/24/25 but did not take a picture of it. She said she ordered Dakin's solution to clean the wound and iodoform to pack the wound. She said she requested a wound culture but was told the facility did not have wound culture supplies. She said she did not find out about the wound until she arrived to the facility on [DATE]. She said she was given a list of residents to see, and Resident #1 was on the list. The Wound Care Nurse Practitioner said the resident had an unstageable pressure ulcer on her coccyx. She said the facility should have notified her or the facility physician before the wound worsened. She said when she saw the resident she was not septic and did not need to go to the hospital. An interview on 01/08/26 at 2:05 PM with the Facility Physician revealed he did not assess Resident #1's wound from 12/18/25 - 12/25/25. He said he did not know what the wound looked like. He said he was only notified about the wound on 12/18/25. He said staff should have notified him when the wound had a change in condition or they suspected an infection. He said he did not know if the facility should have sent her to the hospital for the wound. An interview on 01/08/26 at 2:20 PM with CNA C revealed he was the CNA that would bathe Resident #1. He said he noticed a change in the resident's wound on 12/21/25. He said it looked a little more open and he notified the nurse. He said he did not know how to describe the size of it. He said every time he saw the wound; it had cream on it. Record review of Resident #3's admission MDS Assessment, dated 12/23/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 15. Her cognitive skills for daily decision-making were intact. His diagnoses included heart failure, wound infection, paraplegia, malnutrition, and chronic bone infection. The resident had a Stage III pressure ulcer. The MDS did not show that Resident #3 had any other wounds. Record review of Resident #3's Care Plans, not dated, reflected:Resident had an actual impairment to skin integrity related to a non-pressure chronic ulcer to right leg. Facility interventions included:Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. to the Physician. Treat per physician orders.There was not a care plan for the chronic ulcer on the left leg and the pressure ulcer on the sacrum. Record Review of Resident #3's January 2026, Order Summary Report reflected: 12/17/25 Clean left lower leg area with NS (normal saline), pat dry cover with Xerofoam (dressing), Iodoplex (dressing) in hypergrandulated (area of wound) area and apply abdominal pad dressing, wrap with kerlix and ACE wrap, dry gauze dressing in between toes every Monday, Wednesday, and Friday for wound treatment. 12/17/25 Clean right lower leg with NS, pat dry cover with Xerofoam, iodoplex hypergrandulated area and abdominal pad dressing, pad, wrap with kerlix and ACE wrap, dry gauze dressing in between toes every Monday, Wednesday, and Friday. 12/25/25 Cleanse [coccyx] wound with wound cleanser; pat dry. Apply Collagen (treatment) and Triad paste (treatment) cover with bordered dressing for daily wound care. Review of the Facility's Wound Report, dated 01/07/26 reflected Resident #3 was not listed on it. An interview on 01/09/26 at 8:00 AM with the WCN revealed she said she had already provided wound care for Resident #3. She said Resident #3 had wounds and that included a pressure ulcer. An interview on 01/09/26 at 8:30 AM with the DON revealed she did not know why Resident #3 was not listed on the Wound Care Report. She said Resident #3 had a pressure ulcer and two leg wounds. The State Surveyor requested an accurate copy of the facility Wound Care Report. An interview on 01/09/26 at 11:10 AM with the WCN revealed she did not know why the care plan for Resident #1 was not followed. She said she did not know why Resident #3 did not have a care plan for the wound on his sacrum and left leg. She said she was responsible for ensuring wound care plans were written and she used the care plans to educate staff about the resident's wounds. An interview on 01/09/26 at 11:10 AM with the DON revealed an in-service on completing care plans was given on 12/30/25. She said if treatments were not administered and care plans were not implemented and followed then the resident was at risk of infection and deterioration of the wound. She said the WCN was responsible for wound care plans for residents with wounds. Record review of the facility policy, Care Plans, Comprehensive Person-Centered, dated 2001, reflected: Policy StatementA comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.7. The comprehensive, person-centered care plan:a. includes measurable objectives and time frames;b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including:(1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;(2) any specialized services to be provided as a result of PASARR recommendations; and(3) which professional services are responsible for each element of care;c. includes the resident's stated goals upon admission and desired outcomes;d. builds on the resident's strengths; ande. reflects currently recognized standards of practice for problem areas and conditions.8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are:a. provided by qualified persons;b. culturally competent; andc. trauma-informed. This was determined to be an IJ on 01/09/26 at 2:55 PM. The Administrator and the DON were notified. The Administrator was provided the IJ template on 01/09/26 at 2:59 PM. The following Plan of Removal was submitted by the facility and was accepted on 01/09/26 at 5:06 PM and reflected the following:The facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 2 of 4 residents reviewed for care plans.Action: Resident #1 no longer resides at the facility. Resident #3's care plan was updated to reflect the current state of their wound and interventions per the interdisciplinary team's discussion. Person(s) Responsible: MDS CoordinatorDate: 01/09/26Action: All residents with wounds were reviewed to ensure the care plans are reflecting the residents' current wound status. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, MDSC, and/or Designee Date: 01/09/26Action: Regional Nurse Consultant will educate Director of Nursing, Assistant Director of Nursing, Treatment Nurse, and MDSC Nurse over the care plan policy with emphasis on care planning wounds to include- Wound, location of the wound, type of wound, stage of wound and to follow physician orders and to ensure the care plans are developed and implemented as comprehensive person-centered, consistent with the resident rights, and include measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs.Person(s) Responsible: Regional Nurse Consultant Date: 01/09/26Action: All licensed nurses will be educated over the care plan policy with emphasis on care planning wounds to include- Wound, location of the wound, type of wound, stage of wound and to follow physician orders, and to ensure the care plans are developed and implemented as comprehensive person-centered, consistent with the resident rights, and include measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs.All nurses will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing and/or Designee Date: 01/09/26Action: The Treatment Nurse and/or Designee will complete and update the care plans with any changes for wounds. The Director of Nursing or Designee will review the wound care plans as needed and at minimum weekly to ensure they are present, accurate, and being followed. Person(s) Responsible: Treatment Nurse, Director of Nursing, and/or Designee Date: 01/09/26Action: Once weekly, in Quality of Care meeting, the Director of Nursing, Assistant Director of Nursing, Treatment Nurse, and/or Designee will review residents with wounds, weekly wound report from wound care nurse practitioner, facility wound report, wound care orders, and wound care plans to ensure accurate information is present and documented. Person(s) Responsible: Director of Nursing, Treatment Nurse, and/or Designee Action: Ad hoc QAPI performed with Medical Director to inform them of the Immediate Jeopardy and the facility's plan to remove the immediacy. Person(s) Responsible: AdministratorDate: 01/09/26 Monitoring the facility's Plan of Removal included the following:Observations of Resident #2 and #3's wound care was not completed. The residents wound care had been completed prior to plan of removal acceptance. Record review of Resident #2 and #3's wound care on 01/09/26 did not reflect worsening of their wounds. Record review of Staff In-services was completed on 01/09/26. Interviews were conducted on 01/09/26 from 1:45 PM to 01/10/26 at 12:25 PM with staff from various shifts. The staff included LVN H, LVN D, LVN I, and RN J.All staff were able to identify that the RN was responsible for initiating care plans. Any nurse could update a care plan. The care plan was important because it showed staff how to care for the resident. An interview on 01/10/26 at 11:50 AM with the WCN revealed a care plan had to be created by an RN. She said she was responsible for updating the care plans for residents with wounds. She said the care plan was important because it shoed updates on the wound and interventions to care for the wound. She said she and the DON were responsible for ensuring the Wound Care Report was accurate. An interview on 01/10/26 at 12:00 PM with the DON revealed her role in the facility plan of removal was to ensure each care plan was initiated and that the WCN would update care plans for residents with wounds. The DON said she would be monitoring the care plans and that the interventions were put in place. An interview on 01/10/26 at 12:25 PM with the Administrator revealed her role in the facility plan of removal included: ensuring the Plan of Removal was overseen and completed. She said the facility would have weekly clinical meetings and she would review documentation and speak to the physician regarding changes in condition. On 01/09/26 at 3:00PM, an Immediate Jeopardy (IJ) was identified, and the Administrator was notified. While the Administrator was notified that the IJ was removed on 01/10/26 at 12:15PM, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for one (Resident #1) of four residents reviewed for physician notification. The facility failed to notify Resident #1's physician when there was a significant change in her wound status on 12/22/25. The resident was sent out on pass with her family on 12/25/25. The RP took her to the hospital the same night and was told the resident had sepsis due to an infection of the wound. The resident did not recover and passed away on 01/03/26. On 01/08/26 at 5:10PM, an Immediate Jeopardy (IJ) was identified, and the Administrator was notified. While the Administrator was notified that the IJ was removed on 01/10/26 at 12:15PM, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of deterioration of their wound if the physician is not notified of changes in wound status.Findings included: Record review of Resident #1's Quarterly MDS Assessment, dated 11/26/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her BIMs score was 9. Her cognitive skills for daily decision-making was moderately impaired. Her diagnoses included cancer, heart failure, and sepsis. The resident was at risk for pressure ulcers. The resident did not have a pressure ulcer. Record review of Resident #1's Care Plans reflected:12/09/25 Resident was at risk for skin alterations. Unstageable to the buttock.Facility interventions included:Monitor site for signs/symptoms of infection, monitor for effectiveness of treatment, notify the physician as needed, and perform weekly skin assessments. Record review of Resident #1 Physician Order Summary Report for December 2025 reflected:12/18/25: Cleanse coccyx with wound cleanser or normal saline, pat dry, apply collagen, cover with dry dressing one time a day for wound care. Record review of Resident #1 Treatment Administration Record for December 2025 reflected that the wound treatment was not completed on 12/19/25. LVN C treated the wound on 12/20/25-12/21/25. The WCN treated the wound 12/22/25 - 12/25/25. Record review of Resident #1's progress notes reflected:Effective Date: 12/18/25 1:30 PM Skin Check .Skin Issues Note: reopen wound to sacrum, open areas to left and right buttocks. Skin issue education: Treatment of skin issue. Skin issue education: Turn every 2 hours. - LVN A Effective Date: 12/22/25 3:24 PM Type: Skin/Wound Note: Note Text: Sacral pressure injury assessed and treated per order. Wound cleansed and dressing changed. Peri wound skin protected. Patient repositioned and tolerated well. - WCN Date of Service: 12/24/2025 Visit Type: Skin and Wound Note: .Information necessary for today's visit was obtained from the patient, nursing staff, per patient's medical record. Reason for visit: first evaluation of existing wound patient by new wound care team. 12/24/2025: Received new consult to assess resident for sacrum pressure ulcer. WOUND ASSESSMENT:Wound: 1Location: CoccyxPrimary Etiology: Pressure Ulcer/InjuryStage/Severity: Unstageable (Pressure ulcer that cannot be staged due to the large amount of dead tissue on the ulcer)Wound Status: First Evaluation of existing wound by new ProviderOdor Post Cleansing: Malodorous (bad smell)Size: 4.5 cm x 4.5 cm x 3.5 cm. Calculated area is 20.25 sq cm.Wound Base: . 40% granulation (indicates percentage of wound that is healing), 40% slough (the percentage of dead tissue in the wound), 20% eschar (percentage of dead tissue in the wound that is black in color)Exposed Tissues: Dermis, SubcutaneousWound Edges: AttachedPeri-wound (area around the wound): Ecchymosis (type of bruise), Fragile, Non-blanchable (indicates structural problems in the tissue), maroon discolorationExudate (drainage): Moderate amount of Serosanguineous (watery, pink, drainage). PROCEDURES:A sharp debridement (procedure to cut away dead tissue) was not performed today due to this is the first evaluation of the patient and further plan for debridement will be reviewed as part of the care plan. An autolytic (assists in healing of wound) dressing is in place. WOUND TREATMENT:Wound # 1 Coccyx Pressure Ulcer/InjuryTreatment Recommendations:1. Cleanse with 0.125% Dakins solution (antiseptic solution for wounds).2. apply Iodoform packing strip (antiseptic dressing strips) to base of the wound.3. secure with superabsorbent (dressing).4. change Every other day, and PRN. - Wound Care Nurse Practitioner Effective Date: 12/25/25 9:12 AM Type: Nurse's Note Note Text: Resident stable RP here pick up the resident and left for Christmas cerebrations, left with portable Oxygen machine and the charge. - LVN A Review of Resident #1's Hospital Records reflected:12/25/25 6:24 PM Emergency Department Physician Note: .Skin: Wound check: unstageable decubitus noted to coccyx with foul odor and necrotic tissue. - Emergency Department PhysicianThe remaining hospital records were requested by the State Surveyor and were not received. An observation of Resident #1's wound picture, dated 12/25/25, on 01/08/26 at 11:10 AM revealed the resident had a large, open, dark, unstageable pressure ulcer to her coccyx. The wound had necrotic tissue and was packed loosely with a dressing, possibly iodoform. The wound was a dark brown color. Unable to determine depth and size. The ulcer looked to be about the size of an orange. The tissue around the wound was a deep red color. The resident also had a Stage II pressure ulcer on her right, lower buttock that was open, red, and approximately the size of a quarter. An interview was conducted with the Responsible Party for Resident #1 on 01/08/26 at 11:15 AM. The Responsible Party said they took Resident #1 home for a holiday dinner on 12/25/25. The Responsible Party said the facility told her the resident had a hot spot on her bottom and were treating it. The facility did not tell her the severity of the wound. The Responsible Party said on the night of 12/25/25 they saw the wound and immediately took the resident to the hospital. The Responsible Party said the resident had sepsis possibly due to the wound and ultimately passed away. An interview on 01/08/26 at 10:45 AM with the WCN for Resident #1 revealed she started employment at the facility on 12/15/25. She said she was notified on 12/18/25 that Resident #1 had a wound, unknown location. The WCN said the Wound Care Nurse Practitioner saw the wound on 12/24/25. She said she notified the Responsible Party for Resident #1 about the wound on 12/24/25. An interview on 01/08/26 at 1:00 PM with the DON regarding Resident #1 revealed she never looked at the wound for Resident #1. An interview on 01/08/26 at 1:05 PM with LVN A and CNA B for Resident #1 revealed CNA B saw Resident #1's open wound on 12/18/25. He said he notified LVN A about the wound. LVN A said she did not measure the wound, but it was about the size of a dime. LVN A said she notified the WCN about the wound. LVN A said an order was obtained from the WCN and LVN A said she did not treat the wound because the WCN was at the facility. CNA B said following 12/18/25, the wound always had a dressing on it and he never visualized the wound after 12/18/25. LVN A said she never visualized the wound after 12/18/25. LVN A and CNA B said on 12/25/25 the wound had a dressing on it and they both assisted Resident #1 into the car of the Responsible Party. An interview on 01/08/26 at 1:35 PM with the Wound Care Nurse Practitioner for Resident #1 revealed she said she ordered Dakin's solution to clean the wound and iodoform to pack the wound. She said she requested a wound culture but was told the facility did not have wound culture supplies, by unknown staff. She said she did not find out about the wound until she arrived to the facility on [DATE]. She said she was given a list of residents to see, and Resident #1 was on the list. The Wound Care Nurse Practitioner said the resident had an unstageable pressure ulcer on her coccyx. She said the facility should have notified her or the facility physician before the wound worsened. She said when she saw the resident she was not septic and did not need to go to the hospital. An interview on 01/08/26 at 2:05 PM with the Facility Physician revealed he did not assess Resident #1's wound from 12/18/25 - 12/25/25. He said he did not know what the wound looked like. He said he was only notified about the wound on 12/18/25. He said staff should have notified him when the wound had a change in condition or they suspected an infection. He said he did not know if the facility should have sent her to the hospital for the wound. An interview on 01/08/26 at 2:20 PM with CNA C revealed he was the CNA that would bathe Resident #1. He said he noticed a change in the resident's wound on 12/21/25. He said it looked a little more open and he notified the nurse, unknown name. He said he did not know how to describe the size of it. He said every time he saw the wound; it had cream on it. An interview on 01/08/26 at 3:09 PM with the WCN and DON revealed they both looked at the Treatment Administration Record for Resident #1. The WCN said her initials were not on the Treatment Administration Record and she did not know who completed the treatments for the resident on 12/23/25 and 12/25/25. The WCN said she only saw the resident's wound on 12/22/25 and on 12/24/25. She said on 12/22/25 the wound on the coccyx was about the size of a tangerine and was curved in. She said she did not measure it, and it did not have drainage or odor. The WCN said she contacted the Wound Care Nurse Practitioner by phone on 12/22/25 but did not document it. She said she did not notify the Facility Physician about the wound because the resident was going to be seen by the Wound Care Nurse Practitioner. The WCN said when she saw the wound on 12/24/25, it looked the same as it did on 12/22/25. The DON said she did not recognize the initials on Resident #1 Treatment Administration Record for 12/22/25-12/25/25 even though it was the same initials each day. The DON said she was over the Wound Care Program and that the Facility Physician was notified on 12/18/25 about the wound. An interview on 01/08/26 at 4:05 PM revealed LVN D performed wound care for Resident #1 on 12/20/25-12/21/25. He said the treatment was to apply calcium alginate (treatment that keeps the wound bed moist for healing) and a dry dressing. He said when he saw the wound it was about the size of a quarter and was not very deep. He said the wound did not have drainage. An interview on 01/08/26 at 5:10 PM with the Corporate Nurse revealed the initials on the Treatment Administration Record for Resident #1 (12/22/25-12/25/25) belonged to the WCN. Record review of the facility policy, Change in a Resident's Condition or Status, revised April 2025, reflected:. Policy Interpretation and Implementation1. The nurse will notify the resident's attending physician or physician on call when there has been a(an):a. accident or incident involving the resident;b. discovery of injuries of an unknown source;c. adverse reaction to medication;d. significant change in the resident's physical/emotional/mental condition;e. need to alter the resident's medical treatment significantly;f. refusal of treatment or medications three (3) or more consecutive times);g. need to transfer the resident to a hospital/treatment center;h. discharge without proper medical authority; and/[NAME]. specific instruction to notify the physician of changes in the resident's condition.2. A significant change of condition is a major decline or improvement in the resident's status that:a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting). This was determined to be an IJ on 01/08/26 at 4:50 PM. The Administrator and the DON were notified. The Administrator was provided the IJ template on 01/08/26 at 4:55 PM. The following Plan of Removal was submitted by the facility and was accepted on 01/09/26 at 11:36 AM and reflected the following:The facility failed to consult with the resident's physician a significant change in the resident's physical, mental, or psychosocial status for Resident #1.Action: All residents with wounds assessed on 01/08/26, current condition of the wound communicated with the residents' physician and the wound care nurse practitioner. Person(s) Responsible: Director of Nursing, Treatment Nurse, Assistant Director of Nursing, and/or DesigneeDate: 01/08/26Action: Regional Nurse Consultant will provide education to the Director of Nursing, Treatment Nurse, Assistant Director of Nursing over the Change in Condition policy as it relates to physician notification and documenting all characteristics of wounds, including the measurements.Change in condition to include:a. accident or incident involving the resident; b. discovery of injuries of an unknown source; c. adverse reaction to medication; d. significant change in the resident's physical/emotional/mental condition (to include changes in skin) e. need to alter the resident's medical treatment significantly; f. refusal of treatment or medications three (3) or more consecutive times); g. need to transfer the resident to a hospital/treatment center; h. discharge without proper medical authority; and/or i. specific instruction to notify the physician of changes in the resident's condition.Person(s) Responsible: Regional Nurse ConsultantDate: 01/08/26Action: Education provided to all nurses on the Change in Condition policy as it relates to physician notification. Change in condition to include:a. accident or incident involving the resident; b. discovery of injuries of an unknown source; c. adverse reaction to medication; d. significant change in the resident's physical/emotional/mental condition (to include changes in skin) e. need to alter the resident's medical treatment significantly; f. refusal of treatment or medications three (3) or more consecutive times); g. need to transfer the resident to a hospital/treatment center; h. discharge without proper medical authority; and/or i. specific instruction to notify the physician of changes in the resident's condition.All nurses will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing, Treatment Nurse, Assistant Director of Nursing, and/or DesigneeDate: 01/08/26Action: Education provided to all nurses, including the treatment nurse, as it relates to documenting all characteristics of wounds, including the measurements. All nurses will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing and/or DesigneeDate: 01/08/26Action: A test to ensure competency completed with nurses as it relates to physician notification and changes in skin. All nurses will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing, Treatment Nurse, Assistant Director of Nursing, and/or DesigneeDate: 01/08/26Action: The Treatment Nurse is designated to complete wound care Monday-Friday, Assistant Director of Nursing, Director of Nursing, or a Designated Nurse will complete wound care in the event that the Treatment Nurse is unable to complete/on leave. Saturday and Sunday wound care will be completed by weekend supervisor or assigned charge nurse. Person(s) Responsible: Director of Nursing for scheduling/designating wound care. Treatment Nurse. Weekend Supervisor. And/or DesigneeDate: 01/08/26Action: Director of Nursing and/or designee will observe 3 wounds a week, x4 weeks, to ensure documentation and proper notification is charted. Any discrepancies or concerns noted will be immediately discussed with the resident's physician and wound care practitioner and will result in reeducation for the nurse. Director of Nursing and/or designee will review the wound care nurse practitioner's notes weekly, x4 weeks to ensure no additional concerns are noted by the Nurse Practitioner. Person(s) Responsible: Director of Nursing and/or DesigneeDate: 01/08/26Action: A QAPI meeting was performed with the Medical Director to review the IJ template, root cause the deficient practice, and discuss the facility's plan to remove the immediacy. Person(s) Responsible: Director of NursingDate: 01/08/26 Monitoring the facility's Plan of Removal included the following: Observations of Resident #2 and #3's wound care was not completed. The residents wound care had been completed prior to plan of removal acceptance. Record review of Resident #2 and #3's wound care on 01/09/26 did not reflect worsening of their wounds. Record review of Staff In-services was completed on 01/09/26. Interviews were conducted on 01/09/26 from 1:45 PM to 01/10/26 at 12:25 PM with staff from various shifts. The staff included LVN A, ADON, LVN E, LVN F, LVN G, LVN H, LVN D, LVN I, and RN J.All staff were able to identify:Changes in conditions including wound changes had to be reported to the Physician. The staff were able to identify what wound changes could look like as well as the signs/symptoms of a wound infection. An interview on 01/09/26 at 2:15 PM with the WCN revealed she understood that changes in wound conditions and signs and symptoms of an infection had to be reported to the physician immediately. An interview on 01/10/26 at 12:00 PM with the DON revealed her role in the facility plan of removal included: Make sure the staff were notifying the physician for changes in resident condition. An interview on 01/10/26 at 12:25 PM with the Administrator revealed her role in the facility plan of removal included: ensuring the Plan of Removal was overseen and completed. She said the facility would have weekly clinical meetings and she would review documentation and speak to the physician regarding changes in condition. On 01/08/26 at 5:10PM, an Immediate Jeopardy (IJ) was identified, and the Administrator was notified. While the Administrator was notified that the IJ was removed on 01/10/26 at 12:15PM, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on interview and record review, the facility failed to ensure the MDS Assessment accurately reflected the resident's status for (Residents #3) of four residents reviewed for MDS Assessments. The facility failed to ensure Resident #3's MDS Assessment was correct. This failure could place residents at risk of not receiving care for issues not addressed in the MDS assessment.Findings included: Record review of Resident #3's admission MDS Assessment, dated 12/23/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 15. His cognitive skills for daily decision-making were intact. His diagnoses included heart failure, wound infection, paraplegia, malnutrition, and chronic bone infection. The resident had a Stage III pressure ulcer. The MDS did not show that Resident #3 had any other wounds. Record review of Resident #3's Care Plans, not dated, reflected:Resident had an actual impairment to skin integrity related to a non-pressure chronic ulcer to right leg. Facility interventions included:Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. to the Physician. Treat per physician orders. Record Review of the Facility Wound Care Report dated 12/31/25 reflected:Resident #3 had an atypical lesion on his right leg and one on his left leg. The resident had a Stage III pressure ulcer on his coccyx. He admitted with the wounds on 12/16/25. An interview was attempted with the MDS Coordinator on 01/09/26 at 4:00 PM and 01/10/26 at 10:35 AM. The MDS Coordinator did not return the phone calls. An interview on 01/09/26 at 4:25 PM with the DON revealed she did not sign the MDS Assessment for Resident #3. The Corporate Nurse signed the MDS. The DON said she did not know who was responsible for ensuring MDS Assessments were correct but did say they were important to ensure the resident received the right interventions for care. An interview on 01/10/26 at 10:36 AM with the Corporate Nurse revealed she signed the MDS Assessment for Resident #3 on 12/29/25. She said she signed the MDS Assessment to show it was completed. She said the MDS Coordinator filled out the MDS. Record review of the facility policy, Resident Assessments, dated 2001, reflected: 3. A comprehensive assessment includes:completion of the Minimum Data Set.5. The interdisciplinary team uses the MDS form currently mandated by federal and state regulations to conduct the resident assessment.

Based on interviews and record reviews, the facility failed to ensure 1 (Resident#1) out of 4 residents received adequate supervision and assistance devices to prevent incidents. The facility failed to provide Resident#1 with adequate supervision when transferring her on 10/09/25. This failure could result in falls, injuries and a decline in quality of life. Findings included:Record review of Resident#1's face sheet, dated 10/16/25 reflected, she was a [AGE] year-old female who was originally admitted on [DATE] and readmitted on [DATE], diagnosed with but not limited to: Alzheimer's disease (progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior) and is the with late onset, adult failure to thrive (a condition characterized by significant decline in physical and emotional well-being) , chronic embolism and thrombosis of left popliteal vein (Presence of blood clots located behind the knee) , generalized muscle weakness(Decreased muscle strength across multiple muscle groups), unsteadiness on feet, other abnormalities of gait and mobility, and unspecified lack of coordination. Record review of Resident#1's MDS, dated [DATE] reflected her BIMS score was blank which indicated Resident#1 could not recall. Resident#1 had a manual wheelchair. Resident#1 had an actively diagnosed with Hemiplegia (one-sided paralysis or weakness of the face, arm or leg) or Hemiparesis (Muscle weakness on one side of the body). Resident#1 functional status reflected: *Bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) required Extensive assistance (resident involved in activity, staff provide weight-bearing support) with One-person physical assist.* Transfer ( how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position. ) required Total dependence (full staff performance every time during entire 7-day period) with Two- person physical assist. Record review of Resident#1 care plan, revised 07/15/25 reflected, Resident#1 had ADL self-care performance deficit r/t Limited Mobility and hemiplegia. Resident#1 goal was to maintain current level of function. Resident#1 intervention included bed mobility extensive with one person assist and transfer extensive with two-persons assist. Record review of Resident#1's hospice report reflected, Resident#1 started hospice on 07/29/25.Record review of Resident#1's SW general visit note, dated 10/09/25 reflected: [Resident#1] requires assistance with all ADL's and naps throughout the day. Record review of Resident#1's Hospice aide notes dated 09/29/25 reflected Resident#1 was a complete assist/total dependence for all ADL's including ambulation and transfers. During an interview on 10/16/25 at 9:10 pm CNA C stated he transferred Resident#1 from her wheelchair to the bed by himself. CNA C stated Resident#1 was transferred comfortably without an injury. CNA C stated Resident#1 was tiny and she would bear hug him, while he transferred her. He stated bear hug meant Resident #1 would either put her hands around his neck or stomach area for support. CNA C stated Reszident#1 was a one- person transfer now. CNA C stated Resident#1 could move very little side to side. During an interview on 10/21/25 at 9:30 am, Family member stated they were told by staff that Resident#1 was transferred by two staff with a mat. Family member stated while she was in the facility on 10/09/25 she observed Resident#1 being picked up by CNA C from her wheelchair and transferred to the bed by himself. During a phone interview on 10/21/25 at 5:12 pm, CNA J stated Resident#1 was a one-person transfer. CNA J stated Resident#1 would put her arms around her and she would lift her from the wheelchair to the bed. CNA J stated on 10/09/25 she transferred Resident#1 to her bed by herself with no injuries or concerns. CNA J stated Resident#1 was a one person transfer now. During an interview and observation on 10/21/25 starting at 6:50 pm., with the Admin and the Regional Nurse, the Admin stated Resident#1 used to be a mechanical lift when she first was admitted because she was combative and a heavier lady. The Admin stated Resident#1 use to be a two person assist but was now a one person assist. The Admin was asked why the care plan did not reflect Resident#1 being a one person assist, the Regional Nurse left the room and returned with a paper care plan, which now stated the resident was a one person assist. The Admin did not provide an explanation on why the MDS reflected the resident was a two person assist. The Admin stated a gait belt should have been used on Resident#1 for transfers. The Regional Nurse stated that was incorrect and the gait belt was not necessary for Resident #1. The Regional Nurse stated Resident#1 could have gotten bruises from the gait belt and that Resident #1 was a one person assist. Record review of facility policy titled Safe Lifting and Movement of Residents, last revised July 2017, reflected the following Policy Statement . In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include the following: a. Resident's preferences for assistance; b. Resident's mobility (degree of dependency); c. Resident's size; d. Weight-bearing ability; e. Cognitive status; f. Whether the resident is usually cooperative with staff; and g. The resident's goals for rehabilitation, including restoring or maintaining functional abilities.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. 1. [NAME] G failed to wear a beard guard while prepping food. 2. The facility failed to ensure foods in the refrigerator were properly stored, labeled with the item's contents, and dated with the date in which the food was to be used or discarded. These failures could place residents at risk for food borne illness. Findings included: Observation of the facility's only kitchen on 11/18/24 at 8:33AM, revealed the following: -Cook G was prepping food, with a beard guard pulled down to his neck (Cook G's beard appeared to be approximately 1/4 in. in length) -a block of Swiss cheese in the refrigerator that had been partially wrapped but was still exposed to air/elements, and which was not dated with the date in which the food was to be used or discarded -a plastic container of green beans in the refrigerator that was covered in plastic wrap, was not labeled with the item's contents, and was not dated with the date in which the food was to be used or discarded During an interview with [NAME] G on 11/18/24 8:36AM, he stated he had pulled his beard guard down to his neck a few minutes prior, as he had briefly left the kitchen. He did not pull his beard guard back up to his face upon re-entering the kitchen, which left his beard exposed while he was prepping food. [NAME] G stated the risk of not wearing a beard guard while prepping food included the potential for bacteria to contaminate the food. [NAME] G confirmed that in the refrigerator, there was an undated block of Swiss cheese that had been previously opened and partially re-wrapped, but was still exposed to air/elements. He also confirmed there was an undated and unlabeled plastic container in the refrigerator that held green beans; he did not know when the green beans were prepared or the date in which they needed to be used or discarded. [NAME] G stated all foods in the refrigerator should be labeled, dated, and completely sealed. He stated the risk of improper food storage and/or improper labeling included contamination of said food items. Review of the facility's Food Storage policy, dated 2018, reflected, .Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage . The Food and Drug Administration Food Code dated 2017 reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety .

Based on observations, interviews, and record review, the facility failed to be adequately equipped to allow for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area for 1 of 7 residents (Resident #28) reviewed for physical environment. The facility failed to ensure the call system in Resident #28's room was functioning properly. This could place the residents at risk of not receiving the care and services to maintain their highest level of well-being. Findings included: Record review of Resident #28's Face Sheet, dated 11/20/24, reflected an [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #28's Quarterly MDS Assessment, dated 9/10/24, reflected she had moderately impaired cognition and required supervision with dressing and partial assistance with transfers. Her diagnoses included unspecified dementia and need for assistance with personal care. An observation on 11/18/24 at 1:14 PM revealed Resident #28 was in her room, sitting on the side of the lower end of her bed facing her wheelchair. She stated she was going to get dressed and pointed at clothing laying on her wheelchair. When asked if she called for assistance, she pointed toward the call light button clipped to her pillow and stated, you can push that. When the call light button was pressed, the light above her door was not functioning, no sound was heard at the nurses' station, and the panel near the nurses' station was not lit to indicate the call was placed. Resident #28's call light was plugged into the wall in her room using a cord that was split with another cord and the call light for the other half of her room [unoccupied]. The second call light was checked and found to be functioning appropriately. Further interview with Resident #28 revealed she could not recall whether she had previous problems with her call light and she stated her memory was not very good. In an observation on 11/18/24 at 1:37 PM revealed LVN A entered Resident #28's room and asked her if she needed assistance. LVN A stated she was not Resident #28's Charge Nurse but was responding to her call light. CNA B arrived in the room and stated she was unaware her call light was not working. She checked the second call light, found it was functioning and replaced Resident #28's button with the functional one located on the other side of her room. CNA B stated she would report the malfunction to maintenance and request a replacement cord. In an interview on 11/19/24 at 2:51 PM with the Maintenance Supervisor revealed he tested the call light function daily and rotated through a different set of rooms every day. The Maintenance Supervisor stated he was unaware the call light in Resident #28's room was not functioning and would ensure the cord was replaced. He stated call light malfunctions placed residents at risk of being unable to call for assistance when needed. An observation on 11/20/24 at 7:45 AM revealed the call light in Resident #28's room had been replaced and was functioning properly. In an interview on 11/20/24 at 11:23 AM, LVN C stated she was Resident #28's Charge Nurse that week and was unaware her call light was not working. She stated call lights should be checked periodically and reported to maintenance if they were not working properly. She stated she would have called the Maintenance Supervisor and also entered the information into the maintenance logbook at the nurses' station if she knew a call light wasn't working. LVN C stated Resident #28 had confusion and she had never known her to use her call light much as she liked to try and do things for herself. She stated they checked on her frequently. LVN C stated the risk of nonfunctioning call lights included residents not getting the care they needed and injuries. In an interview on 11/20/24 at 4:00 PM, the Administrator stated she was unable to locate a policy for call light testing. She stated the Maintenance Supervisor was responsible for ensuring the call lights functioned and had a variety of things he tested daily. The Administrator stated Resident #28 was very verbal and was able to communicate with the nursing staff. She stated the risk of call lights not functioning included resident's possibly being unable to call for assistance. Record review of the Maintenance Log Book entries dated between 8/11/24 and 10/5/24 revealed there were no entries related to call light malfunctions. There were no entries dated after 10/5/24. Record review of the facility's policy titled, Call Light-Use of, dated 12/2018 reflected: Policy: It is the policy of this home to ensure residents have a call light within reach that they are physically able to access and that they have been instructed on its use. Equipment 1/ Bedside call light in functioning order .Procedure 1. All nursing personnel must be aware of call lights at all times .10. Report any defective call lights to the charge nurse immediately. 11. Log defective call lights, with exact location, in maintenance log .

Based on observations, interviews, and record review, the facility failed to accommodate residents' food intolerances and preferences for 1 of 5 residents (Residents #43) reviewed for food preferences. The facility failed to provide daily oatmeal as requested for Resident #43. This failure could place residents at risk for not having their choices and food preferences accommodated, possible weight loss and a diminished quality of life. Findings included: Record review of Resident #43's Face Sheet dated 11/19/24 reflected a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #43's Admission MDS assessment dated [DATE] reflected she had moderately impaired cognition and her diagnoses included gastroesophageal reflux disease (a disease where stomach acid flows into and irritates the esophagus); diabetes (disease that results in too much sugar in the blood); and end stage renal disease (condition in which the kidneys stop functioning. She was receiving dialysis (treatment to remove toxins from the blood of patients with kidney failure). During an interview on 11/18/24 at 11:06 AM, Resident #43 stated she did not like the breakfast served at the facility and preferred they just bring her oatmeal every day. She stated she did not like the bacon or eggs she was given. She stated the bacon was too salty for her. She stated she had asked the nurse and the lady that brings me medicine about it more than once but they still brought her the other breakfast and sometimes a small bowl of oatmeal. Resident #43 stated she just wanted a large bowl of oatmeal every day. During an interview on 11/19/24 at 7:25 AM, LVN C stated resident meal preferences were communicated with the dietary staff. She stated, if a resident did not eat their meal, they offered them an alternate meal. She stated, if a resident made a request such as oatmeal, that would be a one-time request and would not replace their regular meal. She stated residents sometimes made requests then forgot they made the request and would be upset the next day when they received the same thing. When asked how a resident would know ahead of time what was planned to be served for lunch or dinner that day, LVN C replied, If they ask us, we can let them know . An observation and interview on 11/19/24 at 8:01 AM revealed the DON was standing near the entrance of the dining room near the menu postings. The DON stated residents were not receiving daily menus in their rooms, but nursing staff could inform any resident what was planned for the day. She stated she did not believe the deadlines of 9 AM and 2 PM were completely accurate. She stated, if a CNA noticed a resident was not eating or did not like the food, they could request an alternate meal for the residents at any time during the meal service and it would be provided . In an observation and interview on 11/19/24 at 8:25 AM revealed Resident #43 was sitting up in bed eating breakfast. Her tray consisted of eggs, toast, grits, and sausage. She stated she was eating the grits and sausage but still preferred oatmeal. She stated she would like to talk to the DON about her concerns. The DON was observed in the hallway nearby and was asked to speak to Resident #43. Resident #43 informed the DON she had previously requested she only wanted oatmeal for breakfast and continued to receive eggs on her plate. She pointed to the grits and eggs. The DON asked the resident if it was possible staff believed it was a request for that particular day only and Resident #43 told her it was not. In an interview on 11/19/24 at 12:20 PM, CNA D stated she had not taken any meal orders from any of the residents. She stated she normally worked on the weekends and was working an extra shift that day. CNA D stated, if a resident complained about the food, they could offer an alternate meal during mealtime. She stated she had not received any special requests from residents. She stated, if a resident wanted a diet change, she should tell the Charge Nurse. In an interview on 11/20/24 at 7:27 AM, LVN C stated Resident #43 had previously told her she liked hot cereal, but she had no idea she meant for every breakfast meal. She stated she thought the request was for that particular meal only. LVN C stated they monitored residents meal intake to ensure they were getting what they wanted, and she had misunderstood the resident's request. She stated the risk of not honoring resident's food preferences included residents not eating, malnutrition, and weight loss. In an interview on 11/20/24 at 12:32 PM, the Dietary Manager stated what had occurred was the menus were posted on the wall outside the dining room and the dietary staff were following whatever diet order was on the ticket. She stated she just started the position the previous week. She stated, What I started today was printing the 'always available' menu and daily menu and I took them to the charge nurses. She stated the nurse should request the menu item or other item and let the dietary staff know. The Dietary Manager stated she preferred to get the lunch requests by 9:00 AM or 10:00 AM so the resident's trays were not delayed, but the residents could order an alternate any time during the meal service. She stated the nurses could enter special request orders at any time to be included on the resident's tickets. The Dietary Manager stated, since she started, she had been walking around the dining room and visiting resident rooms during meals to ask residents how their meals were. She stated she had not received any complaints. She stated the risk of not honoring resident preferences included the residents would be unhappy, not eating, and have potential weight loss . During an interview on 11/20/24 at 1:04 PM, MA E stated Resident #43 had told her about 2 weeks prior that she only wanted oatmeal for breakfast and that she had already told other people, including the previous Dietary Manager, the same thing. MA E stated she recalled telling the previous Dietary Manager herself about the request. She stated she thought she recalled telling the Charge Nurse the same but was unable to recall who she spoke with. MA E stated she did not know her diet order had not been switched. She stated residents sometimes ask her for food items while she was passing medications and she typically told the charge nurse. She stated the risk for residents not receiving their meal preferences were they may stop eating. In an interview on 11/20/24 at 4:00 PM, the Administrator stated she had not received any complaints related to food preferences or meal service. She stated she tested the trays three times a week herself for quality. The Administrator stated, since she started, food service had been their strongest area and they had never had any complaints. She stated there had been staff turnover within dietary services over the past two weeks and there may have been a drop in communications. She stated the risk to residents was they had the right to check the menu and make requests . An email from the Administrator received on 11/20/24 at 3:03 PM revealed the facility did not have a policy related to dietary services and resident preferences.

Based on observations, interviews, and record review the facility failed to properly secure medications in locked compartments for 1 (Station 3) of 4 medication carts reviewed for drug storage. MA E failed to lock and secure the medication cart on Station 3. This failure placed 48 residents at risk for their identifiable information accessed by anyone who had unauthorized access to the medication cart and consumption of harmful medications. Findings included: An observation on 11/20/24 at 3:11 PM revealed a medication cart parked on the hallway of Station 3 that was not locked and secured. There were not any staff in the hall and a resident was observed walking in the hallway past the medication cart on Station 3. MA E was observed inside a resident ' s room. HHSC surveyor observed the cart to be open and accessible. In an interview on 11/20/24 at 3:19 PM, MA E said she was the only Medication Aide for the facility. She stated that she was responsible for ensuring that the medication cart was locked and always secured. She said that she thought that she locked the medication cart prior to entering the resident ' s room. She stated that the medication cart should remain locked and always secured to ensure the medications were not ingested by anyone. MA E stated that the risk of the medication cart being unlocked and not properly secured was that anyone could have access to the medication cart and take anything from the cart. She stated that if someone had access to the medication, they could ingest the medication and it could cause harm if they had an allergic reaction to the medication. She stated that if someone had blood pressure issues and they ingest a medication, the unauthorized use of the medication could make it worse, and possibly send them to the hospital. MA E stated that she has been employed at the facility for a couple of months and received In-Service Trainings related to medication administration and storage since being employed at the facility. In an interview on 11/20/24 at 3:35 PM, LVN F stated that she was unaware that MA E did not properly lock and secure her medication cart that was parked on Station 3. LVN F stated that if she observed a medication cart that was unlocked, she would lock the medication cart. She stated that she had been trained via In-Service Trainings that the medication carts were to remain locked and always secured when they were unattended. She stated that she has been employed at the facility for 6 years and she and other staff were regularly retrained and reeducated on medication storage and securing the medication carts. She stated that the risk of a resident or anyone else having access to an unlocked medication cart could cause the potential for someone who was not prescribed the medication, access to the medication, and ingest the medication. LVN F stated that if someone ingests medication that was not prescribed to him/her it could cause harm and lead to an overdose, illness, and a possibly hospitalization . In an interview on 11/20/24 at 3:42 PM, the DON stated that she was unaware that MA E left her medication cart unlocked in the hallway of Station 3. She stated that her expectation was that the medication cart was to be always locked when it was not in use. She stated that if a medication cart was not properly locked and secured anyone including a resident could walk up to the medication cart and take anything from the medication cart. She stated that someone could only ingest the medication if they could pop the pills from the package. She stated that harm could be caused to anyone who ingested a medication that was not prescribed to them. She stated that she would hope that staff would be able to hear the door or drawer being opened from the medication cart and they would be able to stop anyone from taking anything from the medication cart. The DON stated that she will retrain and educate MA E and staff on medication administration and storage because they all have access to the medication carts. In an interview on 11/20/24 at 4:18 PM, the Administrator stated that she was not aware that MA E left her medication cart unlocked on the hallway of Station 3. She stated that all staff have been trained via In-Service Training relating to how to properly secure the medication carts. She stated that if a medication cart was unlocked, there was a risk or potential for someone to get access to the medication stored in the medication cart. The Administrator stated that she was not clinical, therefore she did not want to give any information regarding any potential harm if someone had access to an unlocked medication cart. She stated that there was a possibility of no harm or there was a possibility that there could be some adverse effects. Record review of the facility's policy titled, Medication Storage - in the Home, dated 12/2018 reflected: Policy: It is the policy of this home that medications will be stored appropriately as to be secure from tampering, exposure, or misuse. Procedure 2. Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications (i.e., medication aides, etc.) are allowed access to medications. Medication rooms, carts, and medications supplies are locked or attended by persons with authorized access .9. Schedule III and IV controlled medications are stored .in a locked drawer or compartment .

Based on observations, interviews, and record review, the facility failed to ensure that each resident had a right to personal privacy and confidentiality of residents' personal and medical information for 1 of 4 medication carts reviewed for clinical records on Station 3. MA E failed to lock and secure the laptop on medication cart on Station 3. This failure could affect 48 residents by placing them at risk of resident-identifiable information being accessed by the public. Findings included: An observation on 11/20/24 at 3:11 PM revealed a laptop medication cart on the hallway of Station 3 that was unattended, unlocked, and unsecured. HHSC surveyor observed resident information (name, date of birth, photo etc.) on the screen from the laptop on the medication cart that was unlocked, unattended and unsecured. There were not any staff in the hall and a resident was observed walking in the hallway past the medication cart on Station 3. MA E was observed inside a resident ' s room. In an interview on 11/20/24 at 3:19 PM, MA E said she was the only Medication Aide for the facility. She stated that she was responsible for ensuring that the laptop on the medication cart was locked and always secured. She said that she thought that she locked the laptop on the medication cart prior to entering the resident ' s room. She stated that the laptop on the medication cart should remain locked and always secured to ensure that no one could look at the screen on the laptop and have access to resident ' s confidential medical records. MA E stated that the risk of the laptop on the medication cart being unlocked and not properly secured was that anyone could have access to the resident ' s information. She stated that if someone gained access to any resident ' s private information, they could use it against them and could cause harm to a resident. MA E stated that she has been employed at the facility for a couple of months and received In-Service Trainings relating to medication administration, storage, and HIPPA since being employed at the facility. In an interview on 11/20/24 at 3:35 PM, LVN F stated that she was unaware that MA E did not properly lock and secure the laptop on her medication cart on Station 3. LVN F stated that if she observed a medication cart that was unlocked, she would lock the medication cart. She stated that she has been trained via In-Service Trainings that the medication carts were to remain locked and always secured when they were unattended. She stated that she has been employed at the facility for 6 years and she and other staff were regularly retrained and reeducated on medication storage and securing the medication carts. She stated that the risk of a resident or anyone else having access to an unlocked laptop medication cart could cause the potential for someone to obtain residents confidential information and medical records. She stated that harm could be caused to a resident if someone gained unauthorized access to their medical records and could use the information against them. In an interview on 11/20/24 at 3:42 PM, the DON stated that she was unaware the MA E left the laptop on her medication cart unlocked in the hallway of Station 3. She stated that her expectation was that her staff were to lock and secure any computer or laptop they used when they were not in use. She stated that the laptop on each medication cart was to be always locked and secured. She stated residents, visitors, and guests could look at and obtain confidential and private information from the open laptop. She stated that harm could be caused to residents if anyone looked at their information on the laptop, which should be accessed only by staff. She stated that a resident or someone in a wheelchair would not be able to look at the information on the laptop on the medication cart due to the medication cart being too high for a person in a wheelchair to have eye level access to the information on the laptop. The DON stated that she will retrain and educate MA E and staff on medication administration and storage because they all have access to the medication carts. In an interview on 11/20/24 at 4:18 PM, the Administrator stated that she was not aware that MA E left the laptop on her medication cart unlocked on the hallway of Station 3. She stated that all staff have been trained via In-Service Training relating to how to properly secure the laptops on the medication carts. She stated that harm could be caused to a resident if a laptop on a medication cart was unlocked, which was a HIPPA violation, which meant that access to personal and confidential records and information should not be available for anyone to access. She stated that staff at the facility are In-Serviced on HIPPA at least on a quarterly basis. She reported that MA E was a new hire and received HIPPA training as part of her New Hire Orientation. Record review of MA E ' s CEU Certificate revealed that she completed 1 hour of development and/or training for HIPPA and You on 11-04-24. Record review of the facility's policy titled, Medication Storage - in the Home, dated 12/2018 reflected no information regarding securing clinical records. An email from the Administrator received on 11/22/24 at 1:42 PM revealed the facility did not have a policy related to HIPPA policies, procedures, and guidelines. She stated that the facility follows the HIPPA Guidelines in relation to the Health Insurance Portability and Accountability Act of 1966.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. Cook Z and Cook X failed to properly wear a beard restraint while in the food preparation area. This failure could place residents at risk for food contamination and foodborne illness. Findings included: Observation on 09/26/23 at 8:45 AM of Cook Z and Cook X revealed they both had facial hair. Cook Z was observed near the dishwashing machine loading dishes into the machine. Cook X was observed near the steamtable wiping surfaces down to clean them. In an interview on 09/26/23 at 10:31 AM with Cook Z and Cook X, they revealed they had run out of beard restraints yesterday (09/25/23) and did not have access to them since they were locked up in the Dietary Manager's office. Cook Z and Cook X said they knew they were supposed to wear beard restraints since they both had facial hair but since the Dietary Manager had not arrived to open her office before breakfast service they had to go without. Cook Z and Cook X said that once the Dietary Manager arrived at the facility, she was able to provide them with beard restraints. In an interview on 09/26/23 at 10:35 AM with the Dietary Manager, she revealed she arrived after the breakfast service and did have the beard restraints locked up in her office. The Dietary Manager said both Cook Z and Cook X had facial hair and should have been wearing beard restraints but did not have access to them until she arrived. The Dietary Manager said she did not realize the staff had run out of the ones available to them outside her office, so she did not replenish them until she arrived after breakfast. The Dietary Manager said the purpose of wearing a beard restraint was to keep hair from getting into the resident's food. Record review of the facility's Employee Sanitation policy, dated 10/01/18, reflected: .3. Employee Cleanliness Requirements .b. Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces Record review of the Federal Food Code 2022 reflected: .2-402.11 Effectiveness. (Hair Restraints) 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel (b) (1) Wearing outer garments suitable to the operation (4) Removing all unsecured jewelry (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints (8) Confining .eating food, chewing gum, drinking beverages or using tobacco and (9) Taking other necessary precautions .

Based on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for three (Residents #34, #9, and #11) of four residents reviewed for resident rights. The facility did not ensure CNA Y treated residents with dignity and respect by referring to them as feeders. This failure could place residents at an increased risk of embarrassment, isolation, and diminished quality of life. Findings included: During a dining observation on 09/26/23 at 12:14 PM, CNA Y stated to multiple unknown staff that those residents over at that table were feeders. CNA Y was in the middle of the dining room where 21 residents were currently seated at different tables. In an interview on 09/26/23 at 12:34 PM with PTA V, she revealed she was not sure who said the word feeder but did hear someone refer to a table in the dining room as the feeders' table. PTA V said she had been trained not to say that word because it could be offensive to residents. In an interview on 09/26/23 at 12:36 PM with CNA Y, she revealed she did say the word feeders and did not see anything wrong with it because that was what the residents were since the residents needed help with feeding or being fed. CNA Y said she was trying to communicate to the other staff in the dining room that there was another table that would be considered feeders and would need that help. CNA Y said she had never been told to say something different or use a different phrase. CNA Y said she did not see anything wrong with what she said or how she said it in front of the residents in the dining room. In an interview on 09/26/23 at 1:11 PM with ST U, she revealed she was in the dining room and did hear that CNA Y had referred to residents as feeders. ST U said she tried to correct CNA Y in the moment by saying assisted diners, but she was not sure if CNA Y heard or not. ST U said the term feeders was not ensuring residents were dignified and using the term assisted diners sounded more appropriate and professional for staff to say. In an interview on 09/26/23 at 1:14 PM with Medical Records, she revealed she was in the dining room and did hear CNA Y calling residents feeders when discussing how to arrange the residents at the tables. Medical Records said she did not normally use that terminology or call residents that, instead she called them residents who needed assistance. Medical Records said all staff had been educated on what terms to use regarding residents. In an interview on 09/26/23 at 2:02 PM with the DON, she revealed she was not in the dining room during meal service earlier; however, she had heard from staff that CNA Y referred to residents as feeders in front of everyone. The DON said staff should not use that term anymore and instead should use a phrase such as residents who need assistance with dining or eating because it was derogatory and not dignified. The DON said she had never heard staff using that word, so she never addressed it with them before today. In an interview on 09/26/23 at 2:50 PM with the Administrator, she revealed she was not in the dining room during meal service earlier, however she had heard from staff that CNA Y referred to residents as feeders in the dining room. The Administrator said CNA Y should have used a different term because they needed to keep resident's dignity in mind and be respectful of their needs. The Administrator said instead CNA Y could have used phrases such as residents who need assistance with eating. The Administrator said staff do not want residents to feel bad about being labeled as something such as feeders. Review of the facility's Protecting Resident Rights policy, dated 12/01/18, reflected: Rights of Residents .These include the right to .privacy

Based on observation, interview, and record review, the facility failed to provide an MDS assessment that accurately reflected the resident's status for one resident (Resident #23) of five residents reviewed for accurate assessments in that: Resident #23's depression was not listed as an active diagnosis on his MDS assessment. This deficient practice could affect residents who receive MDS assessments and could result in missed care. Findings included: Review of Resident #23's face sheet, dated 09/27/23, reflected the resident was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included paranoid schizophrenia (altered perception of reality), schizoaffective disorder (a mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), bipolar type, and major depressive disorder (clinical depression). Review of Resident #23's continuity of care document, dated 09/27/23, reflected he was diagnosed with paranoid schizophrenia, schizoaffective disorder, bipolar type, and major depressive disorder, recurrent with psychotic symptoms on 04/17/23; which were all being medically managed. Review of Resident #23's quarterly MDS Assessment, dated 08/16/23, revealed he had active diagnoses of schizophrenia and anxiety. The MDS did not reflect the resident had a diagnosis of depression. Review of Resident #23's care plan, dated 03/09/23, reflected he was currently taking psychotropic drugs for the treatment of: anxiety, depression, and bipolar. In an interview on 09/28/23 at 10:28 AM with the MDS Coordinator, she revealed she was responsible for ensuring any diagnoses a resident had were documented on the MDS if they were receiving treatment for it. The MDS Coordinator said she reviewed Resident #23's most recent MDS on 08/16/23 and saw that depression was not triggered under active diagnoses even though he had an active diagnosis. The MDS Coordinator said the purpose of ensuring the active diagnoses on the MDS were correct was to ensure the facility was care planning and providing the maximum care that benefits the resident for the diagnoses. The MDS Coordinator said there was not a concern with a diagnosis not being triggered on the MDS assessment for a resident. In an interview on 09/28/23 at 10:44 AM with the DON, she revealed the MDS Coordinator was responsible for ensuring all accurate diagnoses for a resident were included on the MDS. The DON said the purpose of this was to develop a comprehensive care plan for the resident. The DON said the concern with a diagnosis being left off the MDS was that staff needed to make sure they were monitoring the resident's mood and behavior and to see if they were adjusting well to any medications prescribed. In an interview on 09/28/23 at 11:00 AM with the Administrator, she revealed the MDS Coordinator was responsible for verifying if a resident had a diagnosis and reflecting it on the MDS. In an email from the Administrator, dated 09/28/23, revealed the facility did not have policy addressing MDS Assessments but followed the RAI guidelines.

Based on observation, interview and record review the facility failed to ensure residents received adequate supervision for 1 of 1 resident (Resident #1) reviewed for safety and supervision. The facility failed to ensure Resident #1 who had cognitive impairment had supervision at a physician's appointment outside of the facility. Resident #1 left the faciity on [DATE] at 6:55 AM to attend his appointment and left the appointment on his own. He was gone from the facility for 35 hours. The resident returned to the facility at on 8/27/22 at 6:00 PM. The facility staff failed to follow the facility's protocol related to missing residents. The facility did not have a policy related to transportation of residents to include supervision. An Immediate Jeopardy (IJ) was identified on 8/28/22 at 2:00 PM and the IJ template was provided to the facility CNO on 8/28/22 at 3:00 PM. While the immediate jeopardy was removed on 8/31/22 at 5:00 PM the facility remained out of compliance at a severity no actual harm with potential for more than minimal harm and a scope of isolated, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. These failures could place residents requiring supervision during transportation to outside appointments at risk of elopement leading to injuries, hospitalization , or death. Findings include: Review of Resident #1's face sheet dated 8/28/22 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of Nodular [CONDITION(S)] [CONDITION(S)] (a type of lymphatic cancer); Type 2 Diabetes Mellitus (insulin dependent); Cerebral Infarction (stroke); [CONDITION(S)] (disease of the heart); Chronic Obstructive Pulmonary Disease ([CONDITION(S)]) (an obstruction in the lungs); Bilateral above knee [CONDITION(S)]. Review of Resident #1's MDS dated [DATE], reflected resident had a BIMS score of 4 indicative of severe cognitive impairment. The MDS did not indicate any observed behaviors of wandering; MDS also did not indicate need for assistance with ambulation. Review of Resident #1's care plan dated 6/14/22 revealed Focus: Resident will require supervision at Dr. Appointments; Goal: Resident will be provided supervision at outside appointments; Interventions: Family or staff to accompany resident on outside doctor appointments; if family or staff cannot accompany resident to appointments then appointment is to be rescheduled. Review of Resident #1's progress notes documented by LVN C dated 8/26/22 at 7:31 AM revealed that Resident left for a GI doctor appointment left well hydrated and nourished. Review of Resident #1's progress note documented by LVN C dated 8/26/22 at 2:50 PM revealed Resident remains in his appointment oncoming nurse notified. Preview of Resident #1's progress note documented by LVN A dated 8/27/22 at 10:45 AM revealed Res not back from Dr. Appt since yesterday 8/26/22. This writer called the [doctor's office address and phone number] to inquire on the res. An employee [name of employee of doctor's office] stated to this writer by phone that the Res was seen last at 11:55 AM 8/26/22. Family and DON aware of the situation. This writer called 911 to report of the missing res. Police on arrival [officer's name] to a statement from this writer [police report number]. Review of Resident #1's progress notes revealed that on 8/27/22 at 11:00 AM CNO entered note Resident left for an appointment at 7:30 AM 8/26/22. Resident did not return to the facility. Nurse [LVN B] notified this writer at about 12:40 AM 8/27/22 that resident had not returned. Spoke with sister [RP] who had started calling hospitals and notified police. This writer contacted nurse on duty (unknown) at about 6:30 AM 8/27/22 and was informed resident still had not returned. This writer called and spoke with the sister who reported she had no updates. She stated to this writer that she was informed by staff at the GI Dr. Office that he had refused help with toileting and then never returned to the office. GI Dr. office never notified facility of resident being ready for pick up or that he was missing. Facility contacted police and filed a separate report. Review of Resident #1's progress note documented by CNO on 8/27/22 at 3:31 PM revealed Resident left for an appointment at 7:30 AM 8/26/22. Resident did not return to the facility. Nurse [LVN B] notified this writer at about 12:40 AM 8/27/22 that resident had not returned. Spoke with sister [resident #1's sister] who had started calling hospitals and notified police. This writer contacted nurse on duty at about 6:30 am 8/27/22 and was informed resident still had not returned. This writer called and spoke with sister who reported she had no updates. She stated to this writer that she was informed by staff at the Dr. office that he had refused help with toileting and then never returned to the office. Dr office never notified facility of resident being ready for pick up or that he was missing. Facility contacted police and filed a separate report. Phone interview with CNO on 8/28/22 at 9:10 AM revealed she was on her way to the facility but was about an hour and half away, the Administrator was about 4.5 hours away. She stated that the resident in question (Resident #1) was taken by transport to his doctor appointment on Friday 8/26/22 for an 8:30 AM doctor appointment. She said the family would usually meet him at his doctor's appointments, but she guessed they didn't this time. Supposedly the doctor's office said they last laid eyes on him on Friday about noon. He was located by [local police department] walking on the sidewalk on 8/27/22 about 1/2 mile from the doctor's office in which he was left at. She stated that she was made aware that he was not in the facility at approximately on 8/27/22 at 12:40 AM. She said they (the facility) did not provide their own transportation that they used outside companies for transport. Interview on 8/28/22 at 9:52 AM with Resident #1's responsible party who stated she tried to go to all of his appointments but this time she could not go with him. She said she was contacted by the social worker at the facility earlier in the week and asked if she would be able to go to his appointment with him in which RP stated she would not be able to go as she would be out of town. The SW told her that she would find someone to go with him and that if she couldn't find someone then she would go herself. RP received a call Friday night (8/26/22) at 9:59 PM from a nurse at the facility who asked about her brother and to let her know that he had never returned to the facility from his appointment the previous day (8/26/22). The RP then called the SW and asked if someone had gone with her brother to his appointment, in which she was told by the SW that she did not know if someone went with him or not. RP said that she was very upset that she was not made aware of someone not going with him that also that no one had called her and told her about him not returning. She stated that she began calling the local hospitals and she even filed a police report. She said she was so worried about him because he was diabetic and insulin dependent and had heart failure and had cancer. She was very worried because she was certain he hadn't had anything to eat or drink or had not taken any of his medications mainly his insulin. She stated she received a call from the local police department on 8/27/22 at about 2:00 PM that he had been located on a street (sidewalk) within 1/2 mile from his appointment location. Interview with the CNO on 8/28/22 at 10:21 AM revealed she did not think Resident #1 was an elopement risk. She said she was notified of his nonreturn on 8/27/22 at 12:40 AM by a facility nurse. She said typically if the SW learned that the RP could not go with a resident to an appointment then the SW would let Medical Records know and she (medical records) would typically go with the resident. The CNO stated, When [Resident #1] returned to the facility a full head to toe assessment was completed. The nurse checked his blood sugar and said it as too high to be read so the nurse called the doctor and got an order to give him insulin. She also said she would expect the nurse to do a complete set of vital signs upon return. Interview on 8/28/22 at 10:29 AM Medical Records stated, she was responsible for arranging transportation for residents to go to outside appointments. She stated that they (the facility) use two different transport companies for transporting residents to outside appointments. Medical Records stated that the SW schedules the outside doctor's appointments and then she will schedule the transportation. The SW scheduled Resident #1's appointment for Friday 8/26/22. The SW called the family and lets them know about the Appt. The facility staff all know the residents that need someone to go to the appointments with them. The SW called the family first to find out if they could attend the appointment with the resident. Medical Records stated, that it was not in her job description to go with residents to the appts. SW told her (medical records) that the family (Resident #1's) would not go to the appointment on 8/26/22 due to family being out of town. Medical Records stated she had planned to go with him but had some family problems that morning (8/26/22); so, did not go. She said she didn't notify anyone the morning of 8/26/22 and let them know that she would not be going to the appt with Resident #1. She (medical Records) said that she felt that he (resident #1) was not capable of going to appointments by himself. She said she should have called the nurse and let her know that she would not be going with him but didn't. She said that when a resident is done at the appointment that the doctor's office typically calls [transport company] to pick the resident up from the appointment. When she arrived at work, she was made aware (unknown who made her aware) that he went by himself to the appointment. She overheard (unknown who she overheard) on 8/26/22 at 5:30 PM that he (Resident #1) wasn't in the building. She said when she came into work on Saturday (8/27/22) the nurse [LVN A] told her that resident #1's sister had been calling and that he had been missing since that Friday (8/26/22). She said she thought the nurses knew which residents need supervision for outside appointments. She stated she did not notify anyone of her inability to go with him to his appointment because she was busy with her personal issues at home. Medical Records also stated He (Resident #1) was not capable of going to appointments by himself. She should have called the nurse and let her know that she was unable to go to his appointment with him; however, she thought the nurse should have made sure that someone went to the appointment with him. Review of timeline and content (handwritten) from [transportation company] on transportation of Resident #1 from [Transport Company] revealed 8/26/22 Driver arrived at 6:47 AM to pick up [Resident #1] from facility. Driver dropped off [Resident #1] at 7:28 AM at address of GI Doctor appointment. [Office person at GI doctor] called [transportation company] at 10 am to notify [Resident #1] was ready to be picked up [Office person at GI doctor] called [transportation company] at 11:40 AM-11:45 AM to get updated ETA on [Resident #1] because he had not been picked up. [Transport driver] arrived at 12 pm to pick up [Resident #1] from GI Doctor address. [Transport company staff] called facility at 12:10 PM to advise them that the driver was there to pick up [Resident #1] and the driver couldn't locate him. Approximately 30-40 minutes later someone from [Facility] called to ask if transport had picked up [Resident #1]; transport company advised facility that she had called earlier to let someone know and was told everyone was at lunch. Interview on 8/28/22 at 12:03 PM with SW who stated she became aware of Resident #1 not being in the facility at 12:40 AM when Resident #1's RP text her cell phone and asked about her Resident #1. The RP had asked the SW and who had gone to his appointment with him. SW said she had text the CNO and advised her of the missing resident. SW said that she also contacted Medical Records and asked if she had gone to the appointment with him on 8/26/22 in which Medical Records stated, no she came in late on Friday 8/26/22. SW said she is responsible for setting up physician appt. and that she had set up the appt for [Resident #1]. She said the appointment was up in July. She said she had confirmed the appt on Monday (8/22). She called his RP on Tuesday 8/23/22 and asked if she would be going with him and the sister said no. SW said he had told medical records that the RP would not be able to attend the appointment. She said that if a RP is unable to attend the appointments, then Medical Records would be responsible for going with the resident or possibly [Activity Director]. SW said she had called the RP earlier in the week a day or two prior to his appointment date (8/26/22) to remind her of the appointment and find out if the RP would be attending the appointment with Resident #1. SW said she was told by the RP that she (RP) would not be able to attend the appointment. She said that she told Medical Records that the RP of Resident #1 could not attend his appointment on 8/26/22 and she thought at that point Medical Records would attend the appointment with him (Resident #1). SW said she was made aware that he had not returned from his appointment when his RP text SW's personal phone on 8/27/22 at 12:40 AM. The text read my brother isn't at the facility! The RP told the SW that the nurse had called hours before and said her brother had not returned back from the appointment. SW told RP that she would call the facility and find out what was going on. SW said she called and spoke with a male nurse and SW asked the nurse to walk to his room and make sure he wasn't there. SW said that the nurse told her that after checking Resident #1's room he was not located in his room. SW said she immediately called [medical records] and received no answer; so, she called [activities director] who was at the facility. Activities Director told her what was going on, she said he wasn't at the facility and SW said she hadn't been notified until the RP had told her. SW said that on Friday morning 8/26/22 at 9:30 AM had Resident #1 left for his appointment in which she was told yes he had already left for the appointment. She said she then asked [medical records] who went with Resident #1 to his appointment. [medical records] said she didn't because she came in late. SW said that she never found out who had gone with him. SW said she had never returned the call to Resident #1's RP due to her phone was on 5% battery life left. SW said text CNO to let her know that the RP had called her about her brother (Resident #1) not at the facility. Interview with CNO on 8/28/22 at 12:50 PM who stated that the entire facility staff are responsible for missing residents; but mainly the nurse that is in charge of the resident. CNO stated that If a resident is missing, it is reported to the administrator or DON they give direction on what to do next. She said that the administrator was notified directly from her (CNO) as soon as she became aware of the resident missing. She stated that she had just found out that the text messages were not from the nurse on the early morning of 8/27/22 but were instead from the SW. She just started sitting the building as the DON a few weeks ago she is Chief Nursing Officer she doesn't have everyone's number in her phone. She was under the impression that it was the nurse that text her. CNO said that she had given the SW the direction to call the hospitals and call the police. She stated that LVN A had informed her via text message that she (LVN A) had called the police CNO stated that she had tried to file the report to [Regulating Agency] twice and kept getting disconnected, then she emailed it in to [regulating agency]. CNO stated that she didn't call in the report if Resident #1 missing when she first learned about it; stating that, we were still trying to determine what was going on. At some point I was like ok I need to call it into the state. She was trying to determine if it was a true elopement since he didn't leave from the facility he left from a doctor's appt. The administrator was unsure also what to do and so they talked it out and said, ok yes we are going to report it. She said they (facility) general does not admit residents who are an elopement risk. CNO said that the facility had never had an elopement drill because they don't admit elopement risk residents. If an elopement assessment was done it would be under assessments in PCC. He doesn't have a diagnosis of dementia or anything like that. She stated that in order to ensure he does not elope again the facility staff were aware what happened, so they are keeping a close eye on him. Interview on 8/28/22 at 1:26 PM with LVN A who stated she LVN stated that she did not think she had any residents that were an elopement risk. She stated that if an elopement assessment was completed then it would be completed by the RN and documented in the medical records. She said that she didn't work Friday (8/26/22), she worked Saturday, 6A-6P. She became aware that he (Resident #1) wasn't in the facility, when she came in on 8/27/22 by LVN B who told her that the resident had not come back from the hospital. LVN A said that she knew he had gone for an appointment at the doctor on 8/26/22 at 8:30 AM appointment. She said she had followed up herself on his appointment; she went to the communications tab in PCC and that was where she saw the Hospital he had went to [hospital in local city]. LVN A said she did call the hospital (number on appointment reminder) she inquired about Resident #1. She received a call back from [employee at doctor's office] he was an employee that had all the information, he said the last time the resident was seen was on Friday 8//26/22 at 11:55 AM. She said [employee at doctor's office] had told her that It concerned a bathroom issue and the way he stated the resident was resisting help going to the bathroom. She said that as she was finished with the call; Resident #1's RP was calling, and she was also inquiring about the whereabouts of Resident #1; she gave her the info she had received from [doctor's office staff]. LVN A said the CNO was texting her (LVN A) on the phone asking if the resident had come back. LVN A said she text the CNO back and gave her the same information that she had been given from the doctor's office. She said that the CNO told her to call the police about a missing person. The RP was upset, she also told her that she had called the police. LVN A said that the CNO did not come to the facility but kept calling to her on the phone. She said that after the resident returned to the facility, she did a head-to-toe assessment and that Resident #1's blood sugar was so high it would not record on the glucometer. LVN A said she called [on call physician] and told her that his BS was high, she received an order to give insulin and hold the next dose (8:00 PM dose). LVN A said that his high blood sugar would be a change of condition and she would let the doctor and family know about the change of condition. Interview with Activity Director on 8/29/22 at 10:16 AM she stated that she had told medical records that if there was no one to go to an appointment with a resident then she would go with them. She was not aware that Resident #1 did not have a staff member accompany him to his doctor appointment. She said that she felt that Resident #1 did need someone to accompany him to all his doctor's appointments. Activity Director said that Resident #1 was confused; she thinks he would elope if no one was with him. Phone interview with [ Transportation Company office manager] on 8/29/22 at 12:48 PM who stated that the facility's [medical records] called them (transport company) on 8/22/22 to advise them of Resident #1 needed to be picked up the morning of 8/26/22 for an 8:00 AM appointment time and to be picked up at 7:15 AM; he would have an additional passenger with him. The driver had arrived on time to the facility at 6:47 AM. Transportation driver picked Resident #1 up from the facility at 8/26/22 at 6:55 AM. He was dropped off at the appointment at 7:28 AM. She said that the Doctor's office had called and said that he was ready for pickup (approximately 10:00 AM on 8/26/22) she said he is ready for pickup, on a will call they have up to 60 minutes to get the driver there. Transportation Company Office Manager said she had called the doctor's office told them it would be anywhere from 30-60 minutes before a driver would be able to pick Resident #1 up from his appointment; she was told that the resident was asleep in his wheelchair in the lobby of the Doctor's office. She said she was told by the doctor's office that the first 30 minutes Resident #1 was sleeping. She said that when the transport driver arrived at 12:00 PM the driver went to the doctor's office and asked for Resident #1 who was told he was outside. The driver could not locate the resident outside of the doctor's office nor inside the doctor's office building. The driver went back inside the doctor's office and told them (doctor's office staff) that she could not find Resident #1. The driver was questioning if another transport company had picked him up. The transport driver said that 'she was told that when he awoke (in the lobby) that he was trying to get out of the double doors of the doctor's office. Resident #1 told the doctor's office staff that he had to go to the bathroom, and he propelled his wheelchair toward the elevator. [Transport Company] called the facility, before the driver had left to see if another transportation company had picked him up from the appointment. Transport Company was told that Resident #1's location was unknown; and that everyone at the facility was at lunch. Transport Company Office Manager said that approximately an hour later (8/26/22 at 1:00 PM) she received a call from the facility (unknown name) the caller had asked her if the Transport Company had picked Resident #1 up from his appointment and that he was not at the facility. Interview with [office manager at transport company] on 8/30/22 at 12:10 PM who stated she had a handwritten timeline put together of the events leading the disappearance of Resident #1. She read her notes aloud which stated at 1:37 PM on 8/26/22 a call was placed to Dr office where resident had his appointment on Friday (8/26/22). Spoke to [Doctor's front office supervisor] the patient he was down for 8:30 appt. he checked in at 8:23 AM taken back to office area, he checked out at 9:52 AM on 8/26/22. [Doctor's front office supervisor] assisted him outside the door where he wheeled himself out, she handed his packet over to receptionist who called the transport company to pick him up. Doctor's office closed at noon for lunch; another call was placed call to transport, prob an hour and ten or so minutes after the first call for pick up. She said that she advised the Doctor's office that Resident #1 would be picked up within another 30 minutes (approximately 11:30 AM). Interview with LVN F on 8/31/22 at 4:22 PM who stated that when she came in on Friday (8//26/22) the morning nurse (unknown name) had told her that Resident #1 had went to the hospital. She said that he had a scheduled appt with GI according to the communications tab on the Electronic Medical record. LVN F said that after dinner, the aide asked what to do with his (resident #1's) dinner. LVN F said that she thought maybe he had gotten admitted to the hospital, and so she tried to call the RP to see if the RP had any information about his appointment and his whereabouts. LVN F said that she left a message for the RP stating, this is [LVN F] at [facility] please give us a call when you get a chance. She (RP) called back 8/26/22 close to 11:00 PM at night, she said she was returning the phone call, LVN asked RP why her brother was admitted to the hospital; he went to an appointment that morning, but he didn't come back to the facility. The RP said no, she knows he wasn't admitted to the hospital she was going to call the police. [LVN B] was the oncoming nurse for the 10:00 PM to 6:00 AM shift and LVN F documented on the 24-hour report that Resident #1 was in the hospital. LVN F said that he called the number listed (for doctor's office) but no one answered her call. LVN F said she gave report to [LVN B] that Resident #1 had went out to his appointment and that he must have been admitted to the hospital. She told him (LVN B) to follow up. LVN F said that LVN B had had called her (LVN F) on 8/27/22 around 1:00 AM and asked her what number she (LVN F) had called to look for him (resident #1). Review of facility's Elopement Protocol, no date, revealed The facility will identify residents who are at risk of elopement and will strive to prevent harm while maintaining the least restrictive environment for residents. Protocol: 3. If a resident is missing, initiate the elopement/missing resident emergency procedure. a. Determine if the resident is out on an authorized leave or pass c. if the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative, the attending Physician, law enforcement officials, 4. When the resident returns to the facility, the Charge Nurse shall: a. Examine the resident for injuries; b. Contact the Attending Physician and report findings and conditions of the resident; c. Notify the resident's legal representative; e. Complete and file an incident report; and f. Document relevant information in the resident's medical record. Review of dates 8/26/22 at 10:00 AM through 8/27/22 at 6:00 PM Accuweather link: https://www.accuweather.com/en/us/fort-worth/ /august-weather/ 6 accessed on 8/28/22 revealed temperatures during the time of resident missing reached temperatures of 96 degrees Fahrenheit. On 8/28/22 at 3:00 PM, The CNO was notified that an Immediate Jeopardy had been determined. The CNO was given the IJ template at 3:00 PM on 8/28/22 and a Plan of Removal was requested at that time. The Facility's Plan of Removal was accepted 8/31/22 at 5:00 PM. 8/29/2022 Plan of Removal- Safety HHSC Findings Accidents Hazards and Supervision The facility failed to ensure that a resident with cognition issues had supervision at a physician appointment outside of the facility. The facility failed to ensure resident safety for a resident with a BIMS score of 4 (severe cognitive deficit)- the resident left the faciity on [DATE] at 7:30 a.m. and returned to the facility on [DATE] at 6:00 p.m. The facility failed to provide medical evaluation upon return to the facility after being gone from the facility for 34.5 hours. The facility failed to respond to locate a missing resident in a timely manner. The facility failed to follow the protocol related to missing residents. The facility does not have a policy related transportation of residents. Resident was unaccounted for 34.5 hours from the time he left the facility with transportation until the time he returned with a family member. Immediate Action Taken Resident #1 returned to the facility 8/27/2022 about 6:00 p.m. and the RP was notified of the resident's return. Resident #1 was assessed for any apparent injury, and none were noted 8/27/2022 6:00 p.m. Resident #1 had vital signs checked and blood sugar checked due to missed medications. Vital signs were stable; blood sugar was high, and MD was notified, and orders received and followed out. The RP was notified of the change. Resident was provided food and water. Orders are obtained for further medical workup to include lab work, increased vital sign monitoring and neurological evaluations. RP notified of additional orders 8/28/2022 1:30 p.m. Maintenance to conduct elopement drills on all 3 shifts. System Changes Elopement Protocol was revised 8/29/2022 by CNO to include post incident follow up. Transportation policy was developed by CNO on 8/29/2022. All upcoming appointments are audited by the Social Worker to verify appropriate supervision is in place, appointments without appropriate supervision available are rescheduled. Implemented 8/29/2022. Residents will have an Elopement Risk Evaluation completed quarterly and on change of condition. Nurses will perform bedside report to visualize all residents by outgoing/incoming nurse at change of shift. Any resident not in the facility at change of shift will be reported to DON/Admin for further investigation. Education Administrator and CNO are educated by the Regional Nurse Consultant regarding timely response to a missing resident to include RP notification 8/30/2022. Administrator and CNO educated by Regional Nurse Consultant regarding Abuse and Neglect, Elopement protocol and Notification for changes in condition 8/30/2022 Administrator and CNO are educated by Regional Nurse Consultant regarding protocol for residents going on appointments with supervision. 8/30/2022 Administrator and CNO are educated by Regional Nurse Consultant regarding updated Elopement Protocol for missing residents. 8/30/2022 Administrator and CNO are educated by Regional Nurse Consultant regarding transportation policy 8/30/2022. Social Worker educated by RN regarding scheduling appointments, ensuring supervision and communication to charge nurses 8/28/2022 and 8/30/2022. Nursing Staff are educated by RN regarding verifying through PCC communications appropriate supervision is in place for outside appointments on 8/28-8/30/2022. Nursing Staff are educated by RN to notify families of resident departure from facility to appointments 8/30/2022. Nursing Staff are educated by RN on new transportation policy 8/30/2022 Nursing Staff are educated by RN on the Elopement protocol and timely response to a missing person 8/28-8/30/2022. Any nurse not present on 8/29/2022 or 8/30/2022 will receive education in person/ via phone prior to providing care for any resident. Nurses will not be allowed to assume care of residents until education is completed and competency verified by Regional Nurse or designee. Employees will demonstrate competency by answering questions related to education material at the end of the training session. This will be done in post education test form. New hires and agency staff will be expected to complete training as well prior to taking assignment of care of any resident. Any nurse not present on 8/29/2022 or 8/30/2022 will receive education in person/ via phone prior to providing care for any resident. Nurses will not be allowed to assume care of residents until education is completed and competency verified by Regional Nurse or designee. Employees will demonstrate competency by answering questions related to education material at the end of the training session. This will be done in post education test form. Monitoring DON/designee will conduct daily recap with social worker during morning meeting for all appointments in the next 24 hours to ensure appropriate supervision is in place or appointments are rescheduled. Maintenance will be responsible for quarterly elopement drills to ensure compliance with Elopement Protocols Regional Nurse Consultant and RN and Regional Support staff LNFA D and LNFA E will be on-site to deliver education and ensure processes remain in place. [MD] notified of IJ 8/28/2022 at 3:42pm and agrees with plan of removal and systemic changes. Interview on 8/31/22 at 10:15AM Director of Maintenance revealed that on 8/29/22 and 8/30/22 he had hosted code purple elopement drill, he had completed them on all three shifts, he did 2nd shift and 3rd on 8/29 and first shift was 8/30. He will be completing them quarterly; he was doing them only once a year since they do not have a memory care unit at the facility. He stated that he would be responsible for in se [TRUNCATED]

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse of residents for two (Resident #10 and Resident #12) of 12 residents reviewed for abuse. 1. The SW failed to notify the Administrator on 02/02/17 when Resident #10 reported a male aide (CNA H) was rough with his care. CNA H had continued to provide direct resident care with no preventative measures to reduce the risk of further incidents of abuse. Resident #10 was nervous because the aide still continued to work in the facility. 2. The SW failed to notify the Administrator on 01/12/17 when Resident #12's family reported CNAs treated the resident disrespectfully and laughed at him when he had incidents of falling. Resident #12 had no known negative outcome. The Administrator was not informed of the above allegations until 02/09/17, when notified by a state surveyor. No investigations of the above incidents were initiated until 2/09/17. 3. The facility failed to immediately report the incidents involving Resident #10 and Resident #12 to the state survey agency. An Immediate Jeopardy was identified on 02/10/17. While the IJ was removed on 02/11/17, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm, and a scope of widespread because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. These failures had the potential to place all 53 residents at risk for further abuse. Findings included: 1. The facility's current policy and Procedure Manual for Abuse - Reportable Events (Texas Homes), effective 01/2008, revised 08/2016, and provided by the Administrator on 02/07/17 reflected: 4. Identification: .b. Incident/Accident Reports will be reviewed by the administrator and Director of Nurses or designee to identify possible incidents of abuse .d. Employees are required to report all incidents of possible abuse, mistreatment, or neglect of any resident .to a Senior Staff Member. The Senior Staff Member is defined as the highest ranking person in the building at the time of the incident: Administrator, Director of Nurses, Assistant Director of Nurses, Charge Nurse e. The supervisor or Senior Staff Member shall immediately report to the Administrator or the person on call. 5. Investigation: When an employee becomes aware of an allegation or suspicion of abuse the employee should: Immediately report the allegation or suspicion to the charge nurse on the unit on which the resident resides immediately (sic). Take appropriate action if an employee is involved in the allegation or suspicion of abuse. This will include removing the employee from duty and will be placed on investigative suspension . 7. Reporting: All alleged allegations (sic) of abuse will be reported to the appropriate state agency and to all other agencies as required by regulation. The facility's current Guidelines for Abuse, Neglect, or Mistreatment, effective 01/2005 and provided by the Administrator on 02/10/17, reflected .Suspected or substantiated cases of resident abuse, neglect, misappropriation of property or mistreatment shall be thoroughly investigated and documented by the Administrator/designee and be reported to the appropriate state agencies . 1. Any alleged violation involving mistreatment, misappropriation of property, abuse, exploitation or neglect of a resident shall be reported to the administrator (abuse coordinator) or alternate immediately .4. The administrator will take steps to to ensure and prevent further potential abuse while investigation is in progress: a. If a direct care giver is observed, suspected. Or alleged to have engaged in abuse .the care giver will be relieved of duty and placed under investigative suspension .until the investigation is completed 2. Review of Face Sheet for Resident #10, dated 02/10/17, reflected she was a 61year old female readmitted on [DATE] whose [DIAGNOSES REDACTED]. Review of the MDS assessment for Resident #10, dated 12/06/16, reflected she had unclear speech but was usually understood by others. Her BIMS was 14, indicating the resident was cognitively intact; her mood severity score was three; and she displayed no signs of [MEDICAL CONDITION] or behavior symptoms. Review of the grievance book reflected a Grievance/Complaint Report was filed by resident #10 and signed and dated by the SW on 02/02/17. The documentation of the specific nature of the grievance/complaint was Male aide (10-6) is rough with care and does not make bed the way she wants it. Review of Resident #10's nursing notes for the months of December of 2016, and January and February of 2017 reflected no documentation of the allegation. Interview with Resident #10 on 02/09/17 at 1:30 PM revealed she stated she identified the nurse aide as CNA H, who she described was a black man with short hair and a Nigerian accent, was very rough with everyone. The resident stated the aide grabbed her forearm very rough to get her out of bed. Resident #10 stated she told the night nurse that the aide had been rough with her and she did not want the aide getting her up in the future. The resident said that while CNA H had not worked directly with her since complaining about the rough treatment, she was nervous because the aide was still working in the facility. Interview with the SW on 02/09/17 at 12:20 PM revealed she referred the grievance involving Resident #10 to nursing because she could not identify the aide. She said she distributed copies of the grievance form to all department heads' mailboxes and had not received a response from nursing regarding the grievance. The SW could not recall whether she verbally notified the Administrator about the grievance. When asked to review the grievance for Resident #10, the SW stated, It's definitely abuse. The aide was physically rough with her. Review of time card detail for CNA H reflected he worked the 10:00 PM to 6:00 AM shift on the following days in February: 2, 3, 4, 5, and 6. 3. Review of Face Sheet for Resident #12, dated 02/10/17, reflected he was a [AGE] year old male admitted to the facility on [DATE] whose [DIAGNOSES REDACTED]. Review of MDS assessment for Resident #12, dated 12/08/16, reflected his BIMS was six, indicating the resident was severely impaired; his mood severity score was zero; he was able to understand others without a hearing aid; was able to be understood by others; and displayed no signs of [MEDICAL CONDITION] or behavior symptoms. Resident #12 used a wheelchair for mobility and required extensive, one person assistance for bed mobility, transfers, locomotion on and off unit, dressing, and toilet use. Review of the grievance book reflected a Grievance/Complaint Report was filed by Resident #12 and his family on 01/12/17. The documentation of the specific nature of the grievance/complaint was CNAs don't treat him with respect. Laugh at him when he falls. Review of Resident #12's nursing notes for the months of December of 2016 and January and February of 2017 reflected no documentation of the allegation. Observation and interview of Resident #12 on 02/09/17 at 9:30 AM revealed the resident was in his room, dressed, groomed, and seated in his wheelchair. The resident was facing the back corner of the room and displayed a flat, detached affect. He was leaning forward in his wheelchair, facing down, and his helmet was on his bedside table. During the interview, the resident provided yes, no, or other one word responses to the surveyor's questions. Resident #12 denied having been hurt by staff but answered yes when asked if staff was ugly with him. When asked if the staff had ever laughed at him in the shower, the resident answered yes followed by yesterday in response to the question of when Interview with Resident #12's responsible party on 02/09/17 at 2:40 PM revealed she was aware of the grievance, but another family member had reported the grievance. Attempts were made to contact Resident #12's family member, but without success. Interview with the SW on 02/09/17 at 12:20 PM revealed she referred the grievance involving Resident #12 to the DON, who then told her he would in-service staff. The SW stated she had not received any subsequent information regarding the grievance from the DON. When shown the Grievance/Complaint Report filed by Resident #12's family on 01/12/17, the SW said it was an issue of verbal abuse because staff was were talking to and treating residents disrespectfully. The SW could not recall whether she verbally notified the Administrator about the grievance. 4. Interview with the SW on 02/09/17 at 12:20 PM revealed she managed the grievance process and maintained the grievance book. The SW stated she worked with appropriate department heads to investigate and resolve grievances. Grievances were to be documented on the Grievance/Complaint Report forms, and the SW stated she notified residents, appropriate family members and the Administrator when grievances were resolved. The SW said she usually gave the Administrator immediate verbal notifications when she received grievances that were potential allegations of abuse. The Administrator usually notified her when grievances were actually identified as allegations of abuse that were subsequently reported to DADS. The SW stated she did not know why the grievances involving Resident #10 and Resident #12 were not properly addressed and resolved. When asked why she did not follow up with the Administrator regarding both grievances, the SW said, .my fault; didn't follow up on that. 5. Interview with the Administrator on 02/09/17 at 11:55 AM revealed she did not believe she had received verbal or written notifications from the SW about the grievances involving Resident #10 and Resident #12. She said she would check the facility's recent reportable incidents to refresh her memory. When shown the Grievance/Complaint Reports filed by Resident #10 and Resident #12, the Administrator stated she they were allegations of abuse and should have been investigated and reported to DADS. Interview with the Administrator on 02/09/17 at 1:06 PM revealed she was the facility's Abuse Prevention Coordinator. She confirmed she had not been made aware of the grievances involving Resident #10 and Resident #12. She confirmed the two grievances had neither been investigated nor reported to DADS. The Administrator stated the SW was responsible for ensuring grievances were documented on the Grievance/Complaint Report form, copying and distributing Grievance/Complaint Reports to department heads' mailboxes, and verbally notifying the Administrator when grievances containing potential allegations of abuse were received. The SW was also responsible for documenting outcomes on the Grievance/Complaint Report form and notifying residents and families when grievances had been resolved. The Administrator stated neither she nor any of the department heads received copies of the Grievance/Complaint Report forms filed by Resident #10 on 02/02/17 or by Resident #12 and his family on 01/12/17 and stated she would report the grievance to DADS. 6. Interview with the DON on 02/10/17 at 10:18 AM revealed he was not aware of the grievances involving Resident #10 and Resident #12. He said the SW had never verbally notified him of the two grievances and had never received copies of the grievances in his inbox. 7. An Immediate Jeopardy was identified on 02/10/17 at 12:10 PM. The Administrator and Regional Nurse Consultant were notified, and a Plan of Removal was requested at that time. 8. The Plan of Removal was accepted on 02/11/17 at 9:00 AM and reflected the following steps taken to remove the immediacy: - In-service training with return demonstration for all staff on resident rights and the process of identifying, investigating, and reporting allegations of abuse or neglect. - Facility Abuse and Neglect protocols were initiated for previously unreported allegations. - Thorough head to toe assessments of Residents #10 and Resident #12. - Interviews with Resident #10, Resident #12, and their respective families. - Administrator disciplined employees determined to have been involved in alleged abuse. - CNA H suspended pending investigation on 2/9/17 and terminated on 2/9/17. - SW in-serviced on abuse/grievances and disciplinary action was taken. - Medical Director notified of the abuse allegations on 2/9/17 and the IJ on 2/10/17. - ADM, DON, and ADON to review the Twenty-Four Hour Report, Incident/Accident Reports, and grievances daily for compliance. 9. Review of statement of Abuse allegation by Resident (#10) against employee (CNA H) dated 02/09/17 and signed by the Administrator reflected during a telephone conversation between CNA H, the Administrator, the DON, and the Regional RN Consultant, CNA H became .upset in his voice tone and started to verbally ramble and carry on a bizarre conversation. Then he stated, 'Don't call me at home, I am not on the floor. I am on a boat cruising.' The DON tried to explain why he had called and left messages for (CNA H) to return (the DON's) call at the facility. (CNA H) again started bizarre conversation and then said, I called you and you don't call me (in a hostile voice tone). Administrator asked again about the allegation and (CNA H) again started bizarre conversation (something about the residents). {CNA H) continued not to respond to questions and continue to ramble. The Administrator informed him he was being terminated for his refusal to answer questions regarding an abuse allegation and not to return to the facility 10. Review of Employee Termination/Separation form signed and dated by the Administrator on 02/09/17 reflected CNA H was terminated per abuse policy. The Explanation for Termination reflected Refused to answer investigation regarding allegations of abuse against him. 11. Review of Notice of Disciplinary Action dated and signed by the Administrator and the SW on 02/09/17 reflected the SW was disciplined for Abuse Policy and Compliance Violations. The SW commented, I did discuss these issues in morning meeting but I did not follow protocol and report to administrator as abuse. 12. Interview with the Medical Director on 02/10/17 at 3:55 PM revealed he was surprised that an IJ had been called in the facility. He stated he had been working very closely with the facility's Quality Assurance Program in recent months and knew the facility had reported several incidents to DADS. The Medical Director said the facility notified him soon after the IJ was called and understood the importance of investigating and reporting abuse allegations to DADS. 13. Interview with the DON on 02/11/17 at 9:45 AM revealed he supervised staff by frequent in-services, random questioning to validate understanding, and visual monitoring. The DON stated he was encouraging staff members to follow up with him or the Administrator about any incidents they reported. The DON believed the SW's failure to follow policies and procedures caused the breakdown in the grievance reporting system. He stated that while the SW often brought grievances to daily staff meetings, he did not recall ever receiving a photocopy of a grievance in his mailbox. 14. Interview with the Administrator on 02/11/17 at 10:00AM revealed she believed the IJ was caused by the SW's failure to follow the facility's policies and procedures for documenting, investigating, and reporting allegations of abuse. The Administrator stated she would assume full control of the grievance reporting process and will encourage all staff to follow up with her whenever they report potential allegations of abuse. She said that the facility would continue with frequent in-servicing and one-on-one staff interviews to determine how well employees understood identification and investigation of abuse. 15. Interview with the Regional Nurse Consultant on 02/11/17 at 10:35 AM revealed she did not understand why grievances had not been resolved. She stated that she will be actively involved with the facility's efforts to ensure grievances and allegations of abuse are properly investigated and reported. The Regional Nurse Consultant stated the Administrator would assume control of the grievance system and would personally conduct regular in-servicing and random staff audits. 16. Review of the State database confirmed the allegation made by Resident #10 and the allegation made by Resident #12 were both reported to DADS on 02/09/17. 17. On 02/11/17, the Regional Nurse Consultant provided sign-in sheets and post tests for in-services conducted from the evening of 02/10/17 through the morning of 02/11/17 on identifying, investigating, and reporting abuse and neglect. The staff were informed to report to the Administrator, the DON if the Administrator was not available, and then to the next person in the chain of command (which was clarified). The staff were instructed to call and leave voice messages with the Administrator if she could not be reached directly. Facility employees were also encouraged to follow up with the Administrator after they reported potential allegations of abuse. The facility reiterated to staff that as the Abuse Prevention Coordinator, the Administrator or her designee, was responsible for investigating all potential allegations of abuse, and all employees alleged to have committed abuse were to be suspended immediately for the duration of the investigation. 18. On 02/11/17 at 9:00 AM, the Administrator stated all employees who had worked the 2:00 PM - 10:00 PM shift on 02/10/17, the 10:00PM - 6:00AM on 02/10/17 - 02/11/17 and the 6:00AM - 2:00 PM shift on 02/11/17 were in-serviced and had taken and passed the post test. The Administrator stated the facility was in the process of calling in PRN staff to be in-serviced. 19. On 02/11/17, 26 individual staff interviews were conducted. Staff were asked to describe the Abuse and Neglect training they had just received. Staff were asked about abuse and neglect policies and protocols, how they would respond to seeing staff abusing residents, to whom they would report potential abuse allegations, to whom to report potential abuse allegations in the Abuse Prevention Coordinator's absence, when they should report suspected abuse, and what they would do if allegations reported to the Abuse Prevention Coordinator (or her designee) were not acted upon. All employees interviewed were able to correctly answer questions. The employees were as follows: --Day Shift (6:00 AM to 2:00 PM): ADON, AAD, AIT, BOM/AD, DM, POD, Wound Nurse, CNAs D and K, LVNs J, L, N and X, and HSKP I and M. --Evening Shift (2:00 PM to 10:00 PM): CNAs R and S; HSKP P; Laundry Q; LVNs O and U; MA T; and RN Supervisor. --Night Shift (10:00 PM to 6:00 AM): CNA W, and LVNs V and X. 20. On 02/10/17, ten individual resident interviews were conducted. The residents represented residents from all units/halls were residents resided (Residents #1, #4,#16, #17, #18, #19, #20, #21, #22, and #23). All residents interviewed stated they felt safe living in the facility and were aware of no incidents of abuse/mistreatment. They were all able to identify staff that they would notify if any incident of abuse/mistreatment occurred. 21. On 02/11/17 at 2:00 PM the Administrator, DON, and Regional Nurse Consultant were informed the IJ was lifted removed. While the IJ was removed on 02/11/17, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm and at a scope of widespread because the facility was continuing to in-service staff and monitor the effectiveness of the Plan of Removal. Form CMS 672, Resident Census and Conditions of Residents, completed by the MDS Coordinator on 02/07/17, reflected 53 residents currently resided at the facility.

Based on observation, interview and record review, the facility failed to make prompt efforts to resolve grievances; failed to ensure immediate action was taken to prevent further potential violations of resident right to be free from abuse; and failed to ensure grievances related to abuse were immediately reported to the administrative and state survey agency for two (Resident #10 and Resident #12) of 12 residents reviewed for grievances. 1. The SW failed to notify the Administrator on 02/02/17 when the SW received and wrote a grievance report for Resident #10 regarding a male aide (CNA H) was rough with his care. CNA H had continued to provide direct resident care with no preventative measures to reduce the risk of further incidents. Resident #10 was nervous because the aide still worked in the facility. 2. The SW failed to notify the Administrator on 01/12/17 when the SW received and wrote a grievance report for Resident #12's family who reported CNAs treated the resident disrespectfully and laughed at him when he had incidents of falling. 3. The facility failed to make prompt efforts to resolve the grievance received from Resident #10 and the grievance received from Resident #12's family. The Administrator was not informed of the above allegations until 2/09/17, when notified by a state surveyor. No effort to resolve the grievances occurred until 2/09/17 when the Administrator became aware and initiated an investigation of each allegation of abuse. 4. The facility failed to immediately report to the state survey agency the alleged incidents of abuse involving Resident #10 and Resident #12. 5. The facility failed to take immediate action to prevent further potential violations of resident rights to be free form abuse while the allegations related to Resident #10 and Resident #12 were investigated. An Immediate Jeopardy was identified on 02/10/17. While the IJ was removed on 02/11/17, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm and at a scope of widespread because the facility was continuing to in-service staff and monitor the effectiveness of the Plan of Removal. These failures had the potential to place all 53 residents at risk of abuse. Findings included: 1. Review of Face Sheet for Resident #10, dated 02/10/17, reflected she was a 61year old female readmitted on [DATE] whose [DIAGNOSES REDACTED]. Review of the MDS assessment for Resident #10, dated 12/06/16, reflected she had unclear speech but was usually understood by others. Her BIMS was 14, indicating the resident was cognitively intact; her mood severity score was three; and she displayed no signs of [MEDICAL CONDITION] or behavior symptoms. Resident #10 used a walker for mobility and required limited, one person assistance with bed mobility, transfers, and toileting. Review of the grievance book reflected a Grievance/Complaint Report was filed by resident #10 and signed and dated by the SW on 02/02/17. The documentation of the specific nature of the grievance/complaint was Male aide (10-6) is rough with care and does not make bed the way she wants it. Review of Resident #10's nursing notes for the months of December of 2016, and January and February of 2017 reflected no documentation of the allegation. Interview with Resident #10 on 02/09/17 at 1:30 PM revealed she stated she identified the nurse aide as CNA H, who she described was a black man with short hair and a Nigerian accent, was very rough with everyone. The resident stated the aide grabbed her forearm very rough to get her out of bed. Resident #10 stated she told the night nurse that the aide had been rough with her and she did not want the aide getting her up in the future. The resident said that while CNA H had not worked directly with her since complaining about the rough treatment, she was nervous because the aide was still working in the facility. Interview with the SW on 02/09/17 at 12:20 PM revealed she referred the grievance involving Resident #10 to nursing because she could not identify the aide. She said she distributed copies of the grievance form to all department heads' mailboxes and had not received a response from nursing regarding the grievance. The SW could not recall whether she verbally notified the Administrator about the grievance. When asked to review the grievance for Resident #10, the SW stated, It's definitely abuse. The aide was physically rough with her. Review of time card detail for CNA H reflected he worked the 10:00 PM to 6:00 AM shift on the following days in February: 2, 3, 4, 5, and 6. 2. Review of Face Sheet for Resident #12, dated 02/10/17, reflected he was a [AGE] year old male admitted to the facility on [DATE] whose [DIAGNOSES REDACTED]. Review of MDS assessment for Resident #12, dated 12/08/16, reflected his BIMS was six, indicating the resident was severely impaired; his mood severity score was zero; he was able to understand others without a hearing aid; was able to be understood by others, and displayed no signs of [MEDICAL CONDITION] or behavior symptoms. Resident #12 used a wheelchair for mobility and required extensive, one person assistance for bed mobility, transfers, locomotion on and off unit, dressing, and toilet use. Review of the grievance book reflected a Grievance/Complaint Report was filed by Resident #12 and his family on 01/12/17. The documentation of the specific nature of the grievance/complaint was CNAs don't treat him with respect. Laugh at him when he falls. Review of Resident #12's nursing notes for the months of December of 2016 and January and February of 2017 reflected no documentation of the allegation. Observation and interview of Resident #12 on 02/09/17 at 9:30 AM revealed the resident was in his room, dressed, groomed, and seated in his wheelchair. The resident was facing the back corner of the room and displayed a flat, detached affect. He was leaning forward in his wheelchair, facing down, and his helmet was on his bedside table. During the interview, the resident provided yes, no, or other one word responses to the surveyor's questions. Resident #12 denied having been hurt by staff but answered yes when asked if staff was ugly with him. When asked if the staff had ever laughed at him in the shower, the resident answered yes followed by yesterday in response to the question of when the staff laughed at him. The resident did not answer when asked if the staff had been rough with him. Interview with Resident #12's responsible party on 02/09/17 at 2:40 PM revealed she was aware of the grievance, but another family member had reported the grievance. Attempts were made to contact Resident #12's family member, but without success. Interview with the SW on 02/09/17 at 12:20 PM revealed she referred the grievance involving Resident #12 to the DON, who then told her he would in-service staff. The SW stated she had not received any subsequent information regarding the grievance from the DON. When shown the Grievance/Complaint Report filed by Resident #12's family on 01/12/17, the SW said it was an issue of verbal abuse because staff was were talking to and treating residents disrespectfully. The SW could not recall whether she verbally notified the Administrator about the grievance. Review of Resident #12's nursing notes for the months of December of 2016 and January and February of 2017 reflected no documentation of the allegation. 3. Interview with the SW on 02/09/17 at 12:20 PM revealed she managed the grievance process and maintained the grievance book. The SW stated she worked with appropriate department heads to investigate and resolve grievances. Grievances were to be documented on the Grievance/Complaint Report forms, and the SW stated she notified residents, appropriate family members and the Administrator when grievances were resolved. The SW said she usually gave the Administrator immediate verbal notifications when she received grievances that were potential allegations of abuse. The Administrator usually notified her when grievances were actually identified as allegations of abuse that were subsequently reported to DADS. The SW stated she did not know why the grievances involving Resident #10 and Resident #12 were not properly addressed and resolved. When asked why she did not follow up with the Administrator regarding both grievances, the SW said, .my fault; didn't follow up on that. 4. Interview with the Administrator on 02/09/17 at 11:55 AM revealed she did not believe she had received verbal or written notifications from the SW about the grievances involving Resident #10 and Resident #12. She said she would check the facility's recent reportable incidents to refresh her memory. When shown the Grievance/Complaint Reports filed by Resident #10 and Resident #12, the Administrator stated she they were allegations of abuse and should have been investigated and reported to DADS. 5. Interview with the Administrator on 02/11/17 at 10:00AM revealed she believed the SW failed to follow the facility's policies and procedures for documenting, investigating, and reporting allegations of abuse. The Administrator stated she would assume full control of the grievance reporting process. 6. Review of Incident Reports from November 2016 through February 2017 revealed no entries regarding Resident #10 or Resident #12's grievances. 7. Review of the Grievance-Voicing and Resolution Policy and Procedure effective 01/2008 and revised 03/2012, reflected .2. Grievance will be written on the home's Grievance/Complaint Report form. 3. The home will address each grievance in a reasonable time frame. 4. The home will accept grievances in written and verbal form. 5. The home will keep a Grievance/Complaint Report Log outlining each grievance/complaint and the disposition of the complaint. 6. The home will provide acknowledgement of grievance to person who filed complaint. 7. Home will upon resolution of a grievance, follow-up in a timely manner to assure that resolution has been successful. 8. Review of undated Statement of Resident Rights provided by the Regional Nurse Consultant on 2/09/17 reflected .The resident may voice grievances or recommend changes or recommend changes in policy or services without restraint, interference, coercion, discrimination or reprisal . 9. An Immediate Jeopardy was identified on 02/10/17 at 12:10 PM. The Administrator and Regional Nurse Consultant were notified, and a Plan of Removal was requested at that time. 10. The Plan of Removal was accepted on 02/11/17 at 9:00 AM and reflected the following steps taken to remove the immediacy: - In-service training with return demonstration for all staff on resident rights and the process of identifying, investigating, and reporting allegations of abuse or neglect. - Facility Abuse and Neglect protocols were initiated for previously unreported allegations. - Thorough head to toe assessments of Residents #10 and Resident #12. - Interviews with Resident #10, Resident #12, and their respective families. - Administrator disciplined employees determined to have been involved in alleged abuse. - CNA H suspended pending investigation on 2/9/17 and terminated on 2/9/17. - SW in-serviced on abuse/grievances and disciplinary action was taken. - Medical Director notified of the abuse allegations on 2/9/17 and the IJ on 2/10/17. - ADM, DON, and ADON to review the Twenty-Four Hour Report, Incident/Accident Reports, and grievances daily for compliance. 11. Review of statement of Abuse allegation by Resident (#10) against employee (CNA H) dated 02/09/17 and signed by the Administrator reflected during a telephone conversation between CNA H, the Administrator, the DON, and the Regional RN Consultant, CNA H became .upset in his voice tone and started to verbally ramble and carry on a bizarre conversation. Then he stated, 'Don't call me at home, I am not on the floor. I am on a boat cruising.' The DON tried to explain why he had called and left messages for (CNA H) to return (the DON's) call at the facility. (CNA H) again started bizarre conversation and then said, I called you and you don't call me (in a hostile voice tone). Administrator asked again about the allegation and (CNA H) again started bizarre conversation (something about the residents). (CNA H) continued not to respond to questions and continue to ramble. The Administrator informed him he was being terminated for his refusal to answer questions regarding an abuse allegation and not to return to the facility. 12. Review of Employee Termination/Separation form signed and dated by the Administrator on 02/09/17 reflected CNA H was terminated per abuse policy. The Explanation for Termination reflected Refused to answer investigation regarding allegations of abuse against him. 13. Review of Notice of Disciplinary Action dated and signed by the Administrator and the SW on 02/09/17 reflected the SW was disciplined for Abuse Policy and Compliance Violations. The SW commented, I did discuss these issues in morning meeting but I did not follow protocol and report to administrator as abuse. 14. Review of Notice of Disciplinary Action dated and signed by the Administrator and the SW on 02/09/17 reflected the SW was disciplined for Abuse Policy and Compliance Violations. The SW commented, I did discuss these issues in morning meeting but I did not follow protocol and report to administrator as abuse. 15. Interview with the Medical Director on 02/10/17 at 3:55 PM revealed he was surprised that an IJ had been called in the facility. He stated he had been working very closely with the facility's Quality Assurance Program in recent months and knew the facility had reported several incidents to DADS. The Medical Director said the facility notified him soon after the IJ was called and understood the importance of investigating and reporting abuse allegations to DADS. 16. Interview with the DON on 02/11/17 at 9:45 AM revealed he supervised staff by frequent in-services, random questioning to validate understanding, and visual monitoring. The DON stated he was encouraging staff members to follow up with him or the Administrator about any incidents they reported. The DON believed the SW's failure to follow policies and procedures caused the breakdown in the grievance reporting system. He stated that while the SW often brought grievances to daily staff meetings, he did not recall ever receiving a photocopy of a grievance in his mailbox. 17. Interview with the Administrator on 02/11/17 at 10:00AM revealed she believed the IJ was caused by the SW's failure to follow the facility's policies and procedures for documenting, investigating, and reporting allegations of abuse. The Administrator stated she would assume full control of the grievance reporting process and will encourage all staff to follow up with her whenever they report potential allegations of abuse. She said that the facility would continue with frequent in-servicing and one-on-one staff interviews to determine how well employees understood identification and investigation of abuse. 18. Interview with the Regional Nurse Consultant on 02/11/17 at 10:35 AM revealed she did not understand why grievances had not been resolved. She stated that she will be actively involved with the facility's efforts to ensure grievances and allegations of abuse are properly investigated and reported. The Regional Nurse Consultant stated the Administrator would assume control of the grievance system and would personally conduct regular in-servicing and random staff audits. 19. Review of the State database confirmed the allegation made by Resident #10 and the allegation made by Resident #12 were both reported to DADS on 02/09/17. 20. On 02/11/17, the Regional Nurse Consultant provided sign-in sheets and post tests for in-services conducted from the evening of 02/10/17 through the morning of 02/11/17 on identifying, investigating, and reporting abuse and neglect. The staff were informed to report to the Administrator, the DON if the Administrator was not available, and then to the next person in the chain of command (which was clarified). The staff were instructed to call and leave voice messages with the Administrator if she could not be reached directly. Facility employees were also encouraged to follow up with the Administrator after they reported potential allegations of abuse. The facility reiterated to staff that as the Abuse Prevention Coordinator, the Administrator or her designee, was responsible for investigating all potential allegations of abuse, and all employees alleged to have committed abuse were to be suspended immediately for the duration of the investigation. 21. On 02/11/17 at 9:00 AM, the Administrator stated all employees who had worked the 2:00 PM - 10:00 PM shift on 02/10/17, the 10:00PM - 6:00AM on 02/10/17 - 02/11/17 and the 6:00AM - 2:00 PM shift on 02/11/17 were in-serviced and had taken and passed the post test. The Administrator stated the facility was in the process of calling in PRN staff to be in-serviced. 22. On 02/11/17, 26 individual staff interviews were conducted. Staff were asked to describe the Abuse and Neglect training they had just received. Staff were asked about abuse and neglect policies and protocols, how they would respond to seeing staff abusing residents, to whom they would report potential abuse allegations, to whom to report potential abuse allegations in the Abuse Prevention Coordinator's absence, when they should report suspected abuse, and what they would do if allegations reported to the Abuse Prevention Coordinator (or her designee) were not acted upon. All employees interviewed were able to correctly answer questions. The employees were as follows: --Day Shift (6:00 AM to 2:00 PM): ADON, AAD, AIT, BOM/AD, DM, POD, Wound Nurse, CNAs D and K, LVNs J, L, N and X, and HSKP I and M. --Evening Shift (2:00 PM to 10:00 PM): CNAs R and S; HSKP P; Laundry Q; LVNs O and U; MA T; and RN Supervisor. --Night Shift (10:00 PM to 6:00 AM): CNA W, and LVNs V and X. 23. On 02/10/17, ten individual resident interviews were conducted. The residents represented residents from all units/halls were residents resided (Residents #1, #4, #16, #17, #18, #19, #20, #21, #22, and #23). All residents interviewed stated they felt safe living in the facility and were aware of no incidents of abuse/mistreatment. They were all able to identify staff that they would notify if any incident of abuse/mistreatment occurred. 24. On 02/11/17 at 2:00 PM the Administrator, DON, and Regional Nurse Consultant were informed the IJ was lifted removed. While the IJ was removed on 02/11/17, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm and at a scope of widespread because the facility was continuing to in-service staff and monitor the effectiveness of the Plan of Removal. Form CMS 672, Resident Census and Conditions of Residents, completed by the MDS Coordinator on 02/07/17, reflected 53 residents resided in the facility.

Based on observation, interview and record review, the facility failed to thoroughly investigate and report to DADS incidents involving two (Resident #10 and Resident #12) of 12 residents reviewed for abuse. The facility failed to protect residents from further potential abuse by allowing alleged perpetrator CNA H to continue to work directly with residents after an allegation of abuse had been made against him. 1. The SW failed to notify the Administrator on 02/02/17 when Resident #10 reported a male aide (CNA H) was rough with his care. CNA H had continued to provide direct resident care with no preventative measures to reduce the risk of further incidents of abuse. Resident #10 was nervous because the aide still continued to work in the facility. 2. The SW failed to notify the Administrator on 01/12/17 when Resident #12's family reported CNAs treated the resident disrespectfully and laughed at him when he had incidents of falling. Resident #12 had no known negative outcome. The Administrator was not informed of the above allegations until 02/09/17, when notified by a state surveyor. No investigations of the above incidents were initiated until 2/09/17. 3. The facility failed to immediately report the incidents involving Resident #10 and Resident #12 to the state survey agency. An Immediate Jeopardy was identified on 02/10/17. While the IJ was removed on 02/11/17, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm and at a scope of widespread because the facility was continuing to in-service staff and monitor the effectiveness of the Plan of Removal. These failures had the potential to place all 53 residents who resided at the facility at risk for abuse. Findings included: 1. Review of Face Sheet for Resident #10, dated 02/10/17, reflected she was a 61year old female readmitted on [DATE] whose [DIAGNOSES REDACTED]. Review of the MDS assessment for Resident #10, dated 12/06/16, reflected she had unclear speech but was usually understood by others. Her BIMS was 14, indicating the resident was cognitively intact; her mood severity score was three; and she displayed no signs of [MEDICAL CONDITION] or behavior symptoms. Review of the grievance book reflected a Grievance/Complaint Report was filed by resident #10 and signed and dated by the SW on 02/02/17. The documentation of the specific nature of the grievance/complaint was Male aide (10-6) is rough with care and does not make bed the way she wants it. Review of Resident #10's nursing notes for the months of December of 2016, and January and February of 2017 reflected no documentation of the allegation. Interview with Resident #10 on 02/09/17 at 1:30 PM revealed she stated she identified the nurse aide as CNA H, who she described was a black man with short hair and a Nigerian accent, was very rough with everyone. The resident stated the aide grabbed her forearm very rough to get her out of bed. Resident #10 stated she told the night nurse that the aide had been rough with her and she did not want the aide getting her up in the future. The resident said that while CNA H had not worked directly with her since complaining about the rough treatment, she was nervous because the aide was still working in the facility. Interview with the SW on 02/09/17 at 12:20 PM revealed she referred the grievance involving Resident #10 to nursing because she could not identify the aide. She said she distributed copies of the grievance form to all department heads' mailboxes and had not received a response from nursing regarding the grievance. The SW could not recall whether she verbally notified the Administrator about the grievance. When asked to review the grievance for Resident #10, the SW stated, It's definitely abuse. The aide was physically rough with her. Review of time card detail for CNA H reflected he worked the 10:00 PM to 6:00 AM shift on the following days in February: 2, 3, 4, 5, and 6. 2. Review of Face Sheet for Resident #12, dated 02/10/17, reflected he was a [AGE] year old male admitted to the facility on [DATE] whose [DIAGNOSES REDACTED]. Review of MDS assessment for Resident #12, dated 12/08/16, reflected his BIMS was six, indicating the resident was severely impaired; his mood severity score was zero; he was able to understand others without a hearing aid; was able to be understood by others; and displayed no signs of [MEDICAL CONDITION] or behavior symptoms. Resident #12 used a wheelchair for mobility and required extensive, one person assistance for bed mobility, transfers, locomotion on and off unit, dressing, and toilet use. Review of the grievance book reflected a Grievance/Complaint Report was filed by Resident #12 and his family on 01/12/17. The documentation of the specific nature of the grievance/complaint was CNAs don't treat him with respect. Laugh at him when he falls. Review of Resident #12's nursing notes for the months of December of 2016 and January and February of 2017 reflected no documentation of the allegation. Observation and interview of Resident #12 on 02/09/17 at 9:30 AM revealed the resident was in his room, dressed, groomed, and seated in his wheelchair. The resident was facing the back corner of the room and displayed a flat, detached affect. He was leaning forward in his wheelchair, facing down, and his helmet was on his bedside table. During the interview, the resident provided yes, no, or other one word responses to the surveyor's questions. Resident #12 denied having been hurt by staff but answered yes when asked if staff was ugly with him. When asked if the staff had ever laughed at him in the shower, the resident answered yes followed by yesterday in response to the question of when Interview with Resident #12's responsible party on 02/09/17 at 2:40 PM revealed she was aware of the grievance, but another family member had reported the grievance. Attempts were made to contact Resident #12's family member, but without success. Interview with the SW on 02/09/17 at 12:20 PM revealed she referred the grievance involving Resident #12 to the DON, who then told her he would in-service staff. The SW stated she had not received any subsequent information regarding the grievance from the DON. When shown the Grievance/Complaint Report filed by Resident #12's family on 01/12/17, the SW said it was an issue of verbal abuse because staff was were talking to and treating residents disrespectfully. The SW could not recall whether she verbally notified the Administrator about the grievance. 3. Interview with the SW on 02/09/17 at 12:20 PM revealed she managed the grievance process and maintained the grievance book. The SW stated she worked with appropriate department heads to investigate and resolve grievances. Grievances were to be documented on the Grievance/Complaint Report forms, and the SW stated she notified residents, appropriate family members and the Administrator when grievances were resolved. The SW said she usually gave the Administrator immediate verbal notifications when she received grievances that were potential allegations of abuse. The Administrator usually notified her when grievances were actually identified as allegations of abuse that were subsequently reported to DADS. The SW stated she did not know why the grievances involving Resident #10 and Resident #12 were not properly addressed and resolved. When asked why she did not follow up with the Administrator regarding both grievances, the SW said, .my fault; didn't follow up on that. 4. Interview with the Administrator on 02/09/17 at 11:55 AM revealed she did not believe she had received verbal or written notifications from the SW about the grievances involving Resident #10 and Resident #12. She said she would check the facility's recent reportable incidents to refresh her memory. When shown the Grievance/Complaint Reports filed by Resident #10 and Resident #12, the Administrator stated she they were allegations of abuse and should have been investigated and reported to DADS. Interview with the Administrator on 02/09/17 at 1:06 PM revealed she was the facility's Abuse Prevention Coordinator. She confirmed she had not been made aware of the grievances involving Resident #10 and Resident #12. She confirmed the two grievances had neither been investigated nor reported to DADS. The Administrator stated the SW was responsible for ensuring grievances were documented on the Grievance/Complaint Report form, copying and distributing Grievance/Complaint Reports to department heads' mailboxes, and verbally notifying the Administrator when grievances containing potential allegations of abuse were received. The SW was also responsible for documenting outcomes on the Grievance/Complaint Report form and notifying residents and families when grievances had been resolved. The Administrator confirmed stated neither she nor any of the department heads received copies of the Grievance/Complaint Report forms filed by Resident #10 on 02/02/17 or by Resident #12 and his family on 01/12/17 and stated she would report the grievance to DADS. 5. Interview with the DON on 02/10/17 at 10:18 AM revealed he was not aware of the grievances involving Resident #10 and Resident #12. He said the SW had never verbally notified him of the two grievances and had never received copies of the grievances in his inbox. 6. The facility's current policy and Procedure Manual for Abuse - Reportable Events (Texas Homes), effective 01/2008, revised 08/2016, and provided by the Administrator on 02/07/17 reflected: 4. 4. Identification: .b. Incident/Accident Reports will be reviewed by the administrator and Director of Nurses or designee to identify possible incidents of abuse .d. Employees are required to report all incidents of possible abuse, mistreatment, or neglect of any resident .to a Senior Staff Member. The Senior Staff Member is defined as the highest ranking person in the building at the time of the incident: Administrator, Director of Nurses, Assistant Director of Nurses, Charge Nurse e. The supervisor or Senior Staff Member shall immediately report to the Administrator or the person on call. 5. Investigation: When an employee becomes aware of an allegation or suspicion of abuse the employee should: Immediately report the allegation or suspicion to the charge nurse on the unit on which the resident resides immediately (sic). Take appropriate action if an employee is involved in the allegation or suspicion of abuse. This will include removing the employee from duty and will be placed on investigative suspension . 7. Reporting: All alleged allegations (sic) of abuse will be reported to the appropriate state agency and to all other agencies as required by regulation. 7. An Immediate Jeopardy was identified on 02/10/17 at 12:10 PM. The Administrator and Regional Nurse Consultant were notified, and a Plan of Removal was requested at that time. 8. The Plan of Removal was accepted on 02/11/17 at 9:00 AM and reflected the following steps taken to remove the immediacy: - In-service training with return demonstration for all staff on resident rights and the process of identifying, investigating, and reporting allegations of abuse or neglect. - Facility Abuse and Neglect protocols were initiated for previously unreported allegations. - Thorough head to toe assessments of Residents #10 and Resident #12. - Interviews with Resident #10, Resident #12, and their respective families. - Administrator disciplined employees determined to have been involved in alleged abuse. - CNA H suspended pending investigation on 2/9/17 and terminated on 2/9/17. - SW in-serviced on abuse/grievances and disciplinary action was taken. - Medical Director notified of the abuse allegations on 2/9/17 and the IJ on 2/10/17. - ADM, DON, and ADON to review the Twenty-Four Hour Report, Incident/Accident Reports, and grievances daily for compliance. 9. Review of statement of Abuse allegation by Resident (#10) against employee (CNA H) dated 02/09/17 and signed by the Administrator reflected during a telephone conversation between CNA H, the Administrator, the DON, and the Regional RN Consultant, CNA H became .upset in his voice tone and started to verbally ramble and carry on a bizarre conversation. Then he stated, 'Don't call me at home, I am not on the floor. I am on a boat cruising.' The DON tried to explain why he had called and left messages for (CNA H) to return (the DON's) call at the facility. (CNA H) again started bizarre conversation and then said, I called you and you don't call me (in a hostile voice tone). Administrator asked again about the allegation and (CNA H) again started bizarre conversation (something about the residents). {CNA H) continued not to respond to questions and continue to ramble. The Administrator informed him he was being terminated for his refusal to answer questions regarding an abuse allegation and not to return to the facility 10. Review of Employee Termination/Separation form signed and dated by the Administrator on 02/09/17 reflected CNA H was terminated per abuse policy. The Explanation for Termination reflected Refused to answer investigation regarding allegations of abuse against him. 11. Review of Notice of Disciplinary Action dated and signed by the Administrator and the SW on 02/09/17 reflected the SW was disciplined for Abuse Policy and Compliance Violations. The SW commented, I did discuss these issues in morning meeting but I did not follow protocol and report to administrator as abuse. 12. Interview with the Medical Director on 02/10/17 at 3:55 PM revealed he was surprised that an IJ had been called in the facility. He stated he had been working very closely with the facility's Quality Assurance Program in recent months and knew the facility had reported several incidents to DADS. The Medical Director said the facility notified him soon after the IJ was called and understood the importance of investigating and reporting abuse allegations to DADS. 13. Interview with the DON on 02/11/17 at 9:45 AM revealed he supervised staff by frequent in-services, random questioning to validate understanding, and visual monitoring. The DON stated he was encouraging staff members to follow up with him or the Administrator about any incidents they reported. The DON believed the SW's failure to follow policies and procedures caused the breakdown in the grievance reporting system. He stated that while the SW often brought grievances to daily staff meetings, he did not recall ever receiving a photocopy of a grievance in his mailbox. 14. Interview with the Administrator on 02/11/17 at 10:00AM revealed she believed the IJ was caused by the SW's failure to follow the facility's policies and procedures for documenting, investigating, and reporting allegations of abuse. The Administrator stated she would assume full control of the grievance reporting process and will encourage all staff to follow up with her whenever they report potential allegations of abuse. She said that the facility would continue with frequent in-servicing and one-on-one staff interviews to determine how well employees understood identification and investigation of abuse. 15. Interview with the Regional Nurse Consultant on 02/11/17 at 10:35 AM revealed she did not understand why grievances had not been resolved. She stated that she will be actively involved with the facility's efforts to ensure grievances and allegations of abuse are properly investigated and reported. The Regional Nurse Consultant stated the Administrator would assume control of the grievance system and would personally conduct regular in-servicing and random staff audits. 16. Review of the State database confirmed the allegation made by Resident #10 and the allegation made by Resident #12 were both reported to DADS on 02/09/17. 17. On 02/11/17, the Regional Nurse Consultant provided sign-in sheets and post tests for in-services conducted from the evening of 02/10/17 through the morning of 02/11/17 on identifying, investigating, and reporting abuse and neglect. The staff were informed to report to the Administrator, the DON if the Administrator was not available, and then to the next person in the chain of command (which was clarified). The staff were instructed to call and leave voice messages with the Administrator if she could not be reached directly. Facility employees were also encouraged to follow up with the Administrator after they reported potential allegations of abuse. The facility reiterated to staff that as the Abuse Prevention Coordinator, the Administrator or her designee, was responsible for investigating all potential allegations of abuse, and all employees alleged to have committed abuse were to be suspended immediately for the duration of the investigation. 18. On 02/11/17 at 9:00 AM, the Administrator stated all employees who had worked the 2:00 PM - 10:00 PM shift on 02/10/17, the 10:00PM - 6:00AM on 02/10/17 - 02/11/17 and the 6:00AM - 2:00 PM shift on 02/11/17 were in-serviced and had taken and passed the post test. The Administrator stated the facility was in the process of calling in PRN staff to be in-serviced. 19. On 02/11/17, 26 individual staff interviews were conducted. Staff were asked to describe the Abuse and Neglect training they had just received. Staff were asked about abuse and neglect policies and protocols, how they would respond to seeing staff abusing residents, to whom they would report potential abuse allegations, to whom to report potential abuse allegations in the Abuse Prevention Coordinator's absence, when they should report suspected abuse, and what they would do if allegations reported to the Abuse Prevention Coordinator (or her designee) were not acted upon. All employees interviewed were able to correctly answer questions. The employees were as follows: --Day Shift (6:00 AM to 2:00 PM): ADON, AAD, AIT, BOM/AD, DM, POD, Wound Nurse, CNAs D and K, LVNs J, L, N and X, and HSKP I and M. --Evening Shift (2:00 PM to 10:00 PM): CNAs R and S; HSKP P; Laundry Q; LVNs O and U; MA T; and RN Supervisor. --Night Shift (10:00 PM to 6:00 AM): CNA W, and LVNs V and X. 20. On 02/10/17, ten individual resident interviews were conducted. The residents represented residents from all units/halls were residents resided (Residents #1, #4, #16, #17, #18, #19, #20, #21, #22, and #23). All residents interviewed stated they felt safe living in the facility and were aware of no incidents of abuse/mistreatment. They were all able to identify staff that they would notify if any incident of abuse/mistreatment occurred. 21. On 02/11/17 at 2:00 PM the Administrator, DON, and Regional Nurse Consultant were informed the IJ was lifted removed. While the IJ was removed on 02/11/17, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm and at a scope of widespread because the facility was continuing to in-service staff and monitor the effectiveness of the Plan of Removal. Form CMS 672, Resident Census and Conditions of Residents, completed by the MDS Coordinator on 02/07/17, reflected 53 residents currently resided at the facility.

Based on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as body weight and protein levels when there were was a nutritional problem and failed to ensure residents were provided a therapeutic diet when there was a nutritional problem for three (Residents #1, #2, and #3) of 10 residents reviewed for nutrition. The facility failed to ensure: 1. Resident #1 received her nutritional supplements as ordered and her nutritional supplement as recommended by the Registered Dietitian, and the resident had a one month weight loss of 1.6%, and a three month weight loss of 6.3%. 2. Resident #2 received her snack of choice as ordered and her nutritional supplement as recommended by the Registered Dietitian, and the resident had a one month weight loss of 1.4%, a three month weight loss of 3.2%. 3. Resident #3 received medication to improve his appetite as recommended by the Registered Dietitian, and the resident had a one month weight loss of 3.1%, a three month weight loss of 5.6%, and a six month weight loss of 11.4%. These failures could affect the 21 residents, who had physician orders [REDACTED]. Findings included: 1. Resident #1's MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was able to usually understand and be understood by others. Her cognition was moderately impaired. The MDS did not reflect any issues with weight loss. The resident required extensive assistance with eating. The resident was 62 inches in height and weighed 81 pounds. The resident required a therapeutic diet. The Care Plan for Resident #1 dated 11/30/14 reflected the goal was for the resident to eat 75-100% of all meals. Facility interventions included monitor/record weight, notify the health care provider and family of significant weight change of 5% in 30 days or 10% in 120 days, assess for dehydration, administer a mechanically altered diet with bolus feedings (the resident did not have a feeding tube), monitor for signs of malnutrition and decreased appetite, and to report labs indicative of malnutrition. On 12/03/15, 03/17/16, and 04/21/16 there was documentation by unknown staff members to continue the plan of care. The DON signed the care plan, date unknown. The care plan did not address the trending down of the resident's weight, it did not reflect the correct diet, and it did not include the supplements ordered for the resident. The physician's orders [REDACTED].#1 reflected a mechanical soft diet with honey thick liquids by staff, and served a frozen treat with lunch and dinner meals. A Physician order [REDACTED].#1 was to receive Ensure pudding at 10:00 a.m., 2:00 p.m., and 7:00 p.m. A Physician order [REDACTED]. The Recommendations by the Registered Dietitian dated 06/08/16 revealed Resident #1 had significant weight loss of 4.8% for one month with a Body Mass Index =14 (severely underweight for height.) The Registered Dietitian recommended to discontinue Ensure pudding three times daily and add Med Pass 2.0 (fortified nutritional supplement) 120 ml, honey consistency, orally three times daily to support desirable weight gain. Resident #1's Physician order [REDACTED]. An interview on 07/06/16 at 1:55 p.m. with MA E revealed Resident #1 did not receive Med Pass 2.0. She stated the resident received honey-thickened liquids with her medications. June 2016 MARs for Resident #1 reflected the resident did not receive the Ensure pudding as ordered at 7:00 p.m. on 06/11/16, at 7:00 p.m. on 06/18/16, and at 11:00 a.m. on 06/30/16. An interview on 07/06/16 at 2:00 p.m. with the ADON revealed she had received the email for the recommendations for Resident #1 from the Registered Dietitian on 06/08/16, but she forgot to contact the doctor for orders. The Monthly Weight Record for Resident #1 revealed weights: January 2016 =76 pounds, February 2016 =77 pounds, March 2016 =78.4 pounds, April 2016 =80.8 pounds, May 2016 =78.8 pounds, June 2016 =75 pounds, July 2016 =73.8 pounds. The Resident Weight Record Comments for Resident #1 reflected the DON documented each weight recorded and whether the weight reflected a gain or loss. On 04/19/16 the DON documented to follow all dietary recommendations. An interview on 07/06/16 at 10:03 a.m. with CNA H revealed she weighed each resident every month, documented the weight in the weight record, and the information was reviewed by the ADON and DON every month. An observation on 07/06/16 at 10:35 a.m. revealed Resident #1 was thin with her rib bones and hip bones protruding. She was sitting in a geri-chair next to the nurses' station preparing to eat a snack. CNA A was assisting the resident to eat. CNA A had eight-ounces of water that was thickened to honey consistency and a container of Yoplait yogurt instead of Ensure pudding to give to the resident. The resident ate the yogurt and drank the thickened water. Abbot Nutrition at abbottnutrition.com and retrieved on 07/18/16 reflected Ensure Pudding, vanilla, 4 ounces contained 170 calories with 5 grams of fat. Yoplait Yogurt at yoplait.com retrieved on 07/18/16 reflected yogurt, vanilla, 6 ounces contained 150 calories with 2 grams of fat. Hormel Health Labs at hormelhealthlabs.com retrieved on 07/18/16 reflected Med Pass 2.0, vanilla, contained 180 calories and 7 grams of fat per 120 ml's. An interview on 07/06/16 at 10:45 a.m. with Resident #1 revealed she was supposed to get Ensure pudding at least one time a day which she preferred, and she did not know why she received yogurt instead. The resident reported she had always been thin and used to have a feeding tube, but it was removed and she did not want another one. An interview on 07/06/16 at 11:07 a.m. with LVN D, charge nurse for Resident #1, stated any resident could receive Ensure pudding if there was an order for [REDACTED]. An observation on 07/06/16 at 12:32 p.m. revealed Resident #1 had a mechanical soft lunch tray with thickened water, thickened milk, spinach, cornbread, ground riblets, and ranch style beans. There was not a frozen treat on the lunch tray. The resident was assisted to eat by staff and the resident ate 75% of the meal. An observation on 07/06/16 at 1:38 p.m. of Resident #1 weighed by CNA H reflected her weight was 74.2 pounds. An interview on 07/06/16 at 1:50 p.m. with the Dietary Manager revealed Resident #1 was supposed to have gotten a frozen treat at lunch, but she forgot to put it on the tray. An interview on 07/06/16 at 1:30 p.m. with the Registered Dietitian revealed she had made recommendations for Resident #1 on 06/08/16 and emailed her recommendations to the DON and ADON. An interview on 07/07/16 at 1:05 p.m. with the DON revealed she did not remember seeing the recommendations for Resident #1 from the Registered Dietitian. The DON reported it was her responsibility to review weights for the residents, to review all recommendations from the Registered Dietitian, and to contact the physician within 48 hours for orders regarding the recommendations from the Registered Dietitian. She reported she reviewed the weights each month for Resident #1 and the facility had offered the resident supplements, hospice, and another feeding tube. The DON reported the resident refused to have another feeding tube placed. 2. Resident #2's MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Her cognition was intact. The resident was able to usually understand and be understood by others. The resident required set-up assistance with eating. The resident was 67 inches in height and weighed 145 pounds. The MDS did not reflect issues with weight loss. The Care Plan for Resident #2 dated 06/21/14 reflected the goal was the resident would receive adequate nutrition and stable weight. Facility interventions included serve diet as ordered and weigh resident monthly. The care plan did not reflect administration of supplements or the resident's weight loss. The lab results dated 05/26/16 for Resident #2 revealed an [MEDICATION NAME] level (indicator of the amount of protein in the blood) of 2.7 (normal range reference 3.4-4.8) No new orders were written. The Monthly Weight Record for Resident #2 revealed weights: May 2016 =143.4 pounds, June 2016 =140.8 pounds, July 2016 =138.8 pounds. Review of the Recommendations by the Registered Dietitian dated 06/08/16 revealed Resident #2 had weight loss of 7.1% for the previous 6 months and an [MEDICATION NAME] level of 2.7. She recommended the resident receive Prostat 30 ml with 4 ounces fluid orally three times daily instead of the current order for Prostat 30 ml with 4 ounces fluid orally twice daily for [MEDICATION NAME] level 2.7 and a snack of choice three times daily between meals at 10:00 a.m., 2:00 p.m., and at bedtime due to weight trending down. The physician's orders [REDACTED].#2 reflected Prostat (liquid protein supplement) 30 ml with four-ounces of fluid orally twice a day. The physician's orders [REDACTED].#2 reflected the Prostat order was changed to 30 ml with 4 ounces fluid orally three times daily, snack of choice three times daily, Med Pass 2.0 supplement 90 ml orally three times daily, [MEDICATION NAME] 7.5 mg orally every day at bedtime. Nutricia Advanced Medical Nutrition at specializedadultnutrition.com retrieved on 07/18/16 reflected Prostat provides 11 grams of protein and 80 calories per 30 ml's. BID dose =22 grams of protein and 160 calories. TID dose = 33 grams of protein and 240 calories. The June 2016 MARs for Resident #2 reflected she was receiving Prostat 30 ml oral twice a day. The July 2016 MARs for Resident #2 reflected a new order with a start date of 07/06/16 to receive a snack of choice three times a day at 10:00 a.m., 2:00 p.m., and 8:00 p.m., Prostat 30 ml with 4 ounces fluid orally three times a day, Med Pass 2.0 supplement 90 ml orally three times a day, and [MEDICATION NAME] 7.5 mg orally every day at bedtime. An observation and interview on 07/07/16 at 10:55 a.m. revealed Resident #2 was thin and lying in bed. She reported she did not receive her ordered snack at 10:00 a.m. An interview on 07/07/16 at 11:10 a.m. with CNA F revealed Resident #2 did not receive her morning snack, and the resident should have received it at 10:00 a.m. An interview on 07/07/16 at 11:32 a.m. with LVN G revealed she was responsible for giving Resident #2 her snack at 10:00 a.m., but the resident refused the snack offered to her. LVN G stated the resident was going to eat a Nutrigrain bar she kept in her room instead. An interview on 07/07/16 at 11:36 a.m. with Resident #2 revealed she did not eat a Nutrigrain bar at 10:00 a.m., and she did not have any Nutrigrain bars in her room. She reported she was offered her snack at 10:00 a.m., but she did not like the snack the facility offered. An interview on 07/06/16 at 1:30 p.m. with the Registered Dietitian revealed she had made recommendations for Resident #2 on 06/08/16 and emailed her recommendations to the DON and ADON. An interview on 07/07/16 at 1:05 p.m. with the DON revealed she did not remember seeing the recommendations for Resident #2 from the Registered Dietitian. She reported the weight loss for Resident #2 would not have flagged on her report until it reached 10% loss for 6 months. 3. Resident #3's MDS assessment dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was able to sometimes understand and be understood by others. The resident's cognition was moderately impaired. The resident required set-up assistance with eating. The resident was 72 inches in height and weighed 200 pounds. The MDS did not address weight loss issues. The Care Plan for Resident #3 dated 11/02/14 reflected a problem for potential weight loss. The goal was the resident would maintain current body weight. Facility interventions included administer medications as ordered, monitor/record weight monthly and if weight loss of 5% in 30 days or 10% in 180 days occurs start weekly weights for four weeks then re-evaluate the need to continue, provide supplements as needed, and offer resident a substitute of sandwich, soup, ice cream, jello, or cookies if the resident eats 25% or less of a meal. Review of the Monthly Weight Record for Resident #3 revealed weights: February 2016 =210 pounds, March 2016 =207 pounds, April 2016 =200 pounds, May 2016 =197 pounds, June 2016 =192 pounds, July 2016 =186 pounds. Lab results dated 04/13/16 for Resident #3 reflected Total Protein (measures total protein level amount in the blood) 5.9 with a reference range of 6.3-8.4 and [MEDICATION NAME] level of 3.4 with a reference range of 3.4-4.8. No new orders written. Review of the Recommendations by the Registered Dietitian dated 06/08/16 revealed Resident #3 had weight loss of 7.2% for 3 months with meal intake fluctuations. She recommended the physician be contacted for an order for [REDACTED]. The Physicians Orders for Resident #3 dated 01/26/16 reflected regular diet with large meat portions in place of vegetables. The Physician order [REDACTED]. The June 2016 MARs for Resident #3 reflected he did not receive the House Shake supplement at 12:00 p.m. on 06/29/16. The July 2016 MARs for Resident #3 reflected he did not receive the House Shake supplement at 12:00 p.m. on 07/01/16 and 12:00 p.m. on 07/06/16. The Physician order [REDACTED].#3 reflected no orders for an appetite stimulant. A Physician order [REDACTED].#3 reflected [MEDICATION NAME] (appetite stimulant) 7.5 mg orally everyday at bedtime. An interview on 07/06/16 at 1:30 p.m. with the Registered Dietitian revealed she had made recommendations for Resident #3 on 06/08/16 and emailed her recommendations to the DON and ADON. An interview on 07/07/16 at 1:05 p.m. with the DON revealed she did not remember seeing the recommendations for Resident #3 from the Registered Dietitian. She reported the weight loss for Resident #3 would not have flagged on her report until it reached 7.5% loss for 3 months. An observation on 07/07/16 at 9:55 a.m. of Resident #3 revealed he was awake, alert, non-interviewable, and propelling himself in his wheelchair down the hallway. 4. The facility's policy for Nutritional Recommendations dated 03/2012 reflected the DON would address recommendations made by the Dietitian within three working days and would contact the physician for orders or denial of the recommendations. 5. An interview on 07/6/16 at 3:20 p.m. with the Administrator and Regional Nurse revealed there were two days of dietary recommendations written on 06/08/16 not addressed by the facility. The Regional Nurse reported she would complete a monthly audit to ensure dietary recommendations were followed up on. Orders were obtained from the physician on 07/06/16 for Resident's #1, #2, and #3 based on the Dietitian's recommendations. The Dietary Supplements Report dated 06/07/16-07/07/16 reflected 21 residents with physician orders [REDACTED].

Based on interview, record review, and observation, it was determined the facility failed to implement policies and procedures that prohibited mistreatment, neglect, and the abuse of five (Residents #6, #16, #19, #20, and #21) of 39 residents, who were reviewed for abuse and neglect. 1. The facility failed to provide adequate supervision of Resident #14, who was known to run into other residents with her walker. On 05/05/15, Resident #14 ran into Resident #6's leg with her walker causing a large hematoma, which required the resident to be transferred to the hospital for evaluation and treatment. This incident was not reported to DADS. 2. The facility failed to provide adequate supervision to prevent Resident #24 from physically abusing other residents. On 04/18/15, Resident #20 was punched in the chest by Resident #24, and this was reported to the local police department. Prior to this incident, Resident #24 hit Resident #21 on the top of the head. These incidents were not immediately reported to the Administrator and not reported to DADS. 3. The facility failed to prevent the elopements of two confused residents and failed to ensure there was a system in place to check the WanderGuard bracelets of those residents identified as being elopement risks. The facility also failed to ensure the gate leading away from the smoking area was locked to prevent residents from leaving the facility unsupervised. On 05/03/15, Resident #19 eloped from the facility and was found at a business establishment across from the facility. On 04/06/15, Resident #16 eloped from the facility and was found by police officers at a fast food restaurant located 0.2 miles from the facility. Both residents were found on the other side of a busy, four-lane road with a speed limit of 40 miles per hour. Resident #19's elopement was not reported to the Administrator, and he did not learn about the elopement until survey inquiry. The facility failed to ensure WanderGuard bracelets were in place and/or functioning for the following six residents, who were identified as being at risk for eloping, Residents #14, #22, #28, #29, and #30, and #33. An Immediate Jeopardy (IJ) was identified on 05/07/15. While the IJ was removed on 05/11/15, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" due to the facility still monitoring the effectiveness of the Plan of Removal. The failure could result in all 86 residents being placed at risk for abuse and neglect. Findings included: 1. The facility's current Abuse-Reportable Events policy and procedure, revised November 2013, reflected: "Policy: It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law of any incident/event in which there is a cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. Definitions: Abuse: Any act, failure to act, or incitemnet to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. This includes financial, verbal, sexual, mental/psychological, or physical abuse... Physical abuse: Physical action within the definition of 'abuse', including but no limited to, hitting, slapping, pinching, and kicking... Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Suspicion of a crime against a resident: if the events that cause the reasonable suspicion result in serious bodily injury, the report must be made immediately after forming the suspicion (but no later than two hours after forming the suspicion). Otherwise, the report must be made not later than 24 hours after forming suspicion. The home's administration will prohibit neglect, verbal, mental or physical abuse, including involuntary suclusion...of residents caused by another person. The home's administration will prohibit all crimes against a resident. The home's administration will conduct and conduct and investigate allegations of crimes, suspected abuse, neglect, or misappropriation of property, and will provide notification and release of information to the proper authorities, in accordance with federal and state regulations. The home's administration will designate a qualified staff member as the Abuse Coordinator. Procedure: ...Training:...Identification of potential victims of abuse or neglect. Appropriate interventions to deal with aggressive, stubborn resident, etc... ...Prevention:...Identification, correction and intervention in situations in which abuse, crimes against residents, neglect and/or misappropriation is likely to occur ...Identification: Administrative and licensed staff will be aware of potential situations of abuse during rounds and contact with staff, residents and resident family members. Incident/Accident Reports will be reviewed by the Administratior and Director of Nurses or designee to identify possible incidents of abuse...Employees are required to report all incidents of possible abuse, mistreatment, or neglect of any resident, crimes against a resident...immediately to their supervisor or Senior Staff Member. The Senior Staff Member is defined as the 'highest ranking person in the building at the time of the incident...Investigation: When an employee becomes aware of an allegation or suspicion of abuse the employee should: Immediately report the allegation or suspicion to the charge nurse on the unit on which the resident resides immediately ...Protection: All residents will be immediately protected from harm...If another resident is the alleged perpetrator, they shall immediately be assissed for treatment options. The safety and protection of other residents is the home's primary concern ...Reporting: All alleged allegations of abuse will be reported to the appropriate state agency and to all other agencies as required by regulation... Resident to Resident Abuse: Procedure: The charge nurse will: If a resident-to-resident incident occurs, staff should immediately intervene. Separate residents and take them to areas away from each other until the situation has subsided. If the resident(s) has been injured, give immediate medical care as indicated. If necessary, obtain an order from the physician and send the resident(s) to the hospital. If hospilalization occurs related to a resident to resident altercation then it is then reportable as a crime against a resident and notification to the local law enforcement along with the state is required...Immediately notify the Administrator and/or the Director of Nursing. If the alleged perpetrator is placed on location monitoring, staff will be instructed on reason for monitoring and targeted behaviors being monitored. Complete an incident/accident report for the alleged perpetrator and the victim.. Notify the responsible party/guardian and physician of each resident. Document in each resident's medical record in conjunction with frequent monitoring and documentation to continue for at least 24 hours. The Administrator will: Notify state agency as required. Will seek proper placement at another home if the physician, responsible party, and/or interdisciplinary care plan team feel that a resident will be a danger to other residents and/or self." 2. Resident #6's MDS assessment, dated 02/27/15, reflected Resident #6 was a [AGE] year-old female, who was admitted to the facility on [DATE] with a re-admission on 02/20/15. Resident #6 had [DIAGNOSES REDACTED]. The resident had moderately impaired cognitive skills and required extensive assistance with her ADLs. An observation on 05/05/15 at 9:00 a.m. revealed Resident #6 was in her room in bed receiving incontinent care. A hematoma or large tissue swelling was observed on her right shin. The swelling was approximately four-inches wide, eight-inches long, and appeared to be full of fluid. Resident #6 stated she got the injury when she was hit by another resident's (Resident #14) walker. An interview on 05/05/15 at 9:10 a.m. with LVN K revealed Resident #6's cognition was fair, and the resident could make her needs known. She stated the resident had Diabetes, and she was able to propel herself in the wheelchair. An observation on 05/05/15 at 11:00 a.m. revealed Resident #6 sitting by the front nurses' station in her wheelchair. The resident's right leg was hanging down, and a large raised area was on her right leg below the knee approximately six to eight-inches by four-inches wide and very swollen. The foot and ankle did not appear to be swollen. Resident #6 stated Resident #14 "bashed into it with her cart." She stated she thought Resident #14 "did it on purpose." Resident #14 passed by Resident #6, and Resident #6 pointed to her identifying Resident #14 as the person who hurt her leg. An observation on 05/05/15 at 12:30 p.m. of Resident #6 revealed the resident in her room in bed. A large raised swollen area was on the resident's right shin, and an ice bag was on the area. The resident removed the ice bag because she stated it was too painful. Resident #6 called out for pain medication. The resident's family was in the room and expressed distress at what happened to Resident #6. An observation on 05/05/15 at 2:00 p.m. revealed Resident #6 was not in her room. LVN KK stated the resident had been transferred to the hospital for evaluation of her swollen leg. An observation on 05/08/15 at 8:00 a.m. revealed Resident #6 was in the hospital. The resident was awake, alert, and sitting on the side of the bed. Her legs were visible, and the skin on her left leg had a grayish color. The right leg has a large black area on the shin measuring approximately six-inches wide and ten-inches long. The skin on the foot and upper leg appeared pink in color. The resident stated prior to the incident with Resident #14 her right leg was her good leg, and she had not had any problems with it. She stated it "really hurt me" when it happened. She revealed she now takes the narcotic pain reliever [MEDICATION NAME] every six hours now. A phone interview on 05/08/15 at 12:00 p.m. with family member of Resident #6 revealed Resident #6 had circulation problems in only her left leg and ankle from a previous fracture on that side. Prior to the incident, she used her right leg to propel herself in her wheelchair. A hospital radiology report, dated 05/06/15, reflected Resident #6 had marked soft tissue swelling anterior to the proximal and mid tibia (shin area) of the right leg. A hospital History & Physical report, dated 05/06/15, reflected Resident #6 developed a large right lower extremity hematoma at a local nursing home. An interview on 05/07/15 at 4:15 p.m. with the DON and Medical Director revealed they wanted to clarify that Resident #6 was not sent to the hospital because she was hit by Resident's #14 walker. They stated Resident #6 had a history of [REDACTED]. Both the DON and Medical Director maintained the hematoma was a result of her circulation problems. The DON incorrectly identified the leg with the hematoma as her left leg. The DON was told the hematoma was on the right leg. She was asked if the hematoma suddenly appeared at the same time she was hit by the walker, but was not the cause of the hematoma. She replied, "Yes, that is what we are saying." The DON stated there was documentation of a history of skin and wound problems for the injured right leg in the resident's clinical record. She was asked to provide these if they showed skin issues or open wounds of the right leg. No documentation was ever provided prior to exit on 05/11/15. Resident #6's Skin Assessment Flowsheet - Non-Pressure Ulcer Conditions forms dated 03/18/15, 03/26/15, 04/01/15, 04/8/15, 04/20/15, 04/22/15, and 04/29/15 reflected the only area being treated by the Wound Care Nurse and Wound Care Physician was on the resident's left outer ankle. Pictures and documentation showed no areas on the resident's right leg. Resident #6's Skin Assessment Flow Sheet - Non-Pressure Ulcer Conditions form dated 05/06/15, following the incident, reflected "shin with (symbol used) huge Black raised hematoma...seen by (Wound Care Physician) to Hosp. (hospital)." Resident #6's Wound Care physician progress notes [REDACTED]. The area was noted to have heavy serosanguinous drainage. The Wound Care Physician documented the following additional information: "was injured by another patient and the patient's walker. See at (hospital) and inadequately drained and sent back with orders for tid (three times a day) [MEDICATION NAME]. Will transfer to (wound care hospital) for treatment..." A Comprehensive Plan of Care, dated 05/05/15, for Resident #6 reflected the resident was care planned for a large hematoma to the right shin that measured 20.0 cm x 12.0 cm. The care plan reflected: "(5-5-15) Injury to (R) shin hit with (symbol used) walker developed excessive hematoma. Sent to hosp for eval (evaluation). 5-5-15 Returned from hosp. (5-6-15) eval. (R) leg (Wound Care Physician) sent to (hospital) direct admit..." An interview on 05/08/15 at 1:30 p.m. with the facility's Wound Care Nurse/LVN F revealed all of Resident #6's previous wound treatments were for an area on the outer aspect of the resident's left ankle. She stated she did not observe any open areas or blisters on the resident's right leg prior to the incident. She described the area on the right shin as a hematoma which measured 20 cm x 12 cm. She stated the hematoma was the size of a tennis ball when Resident #6 was initially injured. LVN F stated she did not think the hematoma was from Resident #6's chronic leg injury. She thought it was the result of the incident involving Resident #14. An Incident Report signed and dated by the Administrator on 05/11/15 reflected on 05/05/15 at 6:15 a.m. Resident #20 was sitting in her wheelchair when another resident (Resident #14) walked by her and hit her in the lower leg with a walker. The report reflected the aggressor (Resident #14) was placed on one-to-one monitoring, and her walker was removed on 05/11/15. The report further reflected Resident #20 was sent to the hospital emergency room twice. A Witness Statement was with the report and reflected Housekeeper FF witnessed Resident #14 hit Resident #20's leg. A Comprehensive Pain Assessment Form, dated 05/05/15, reflected Resident #20 reported experiencing terrible pain to her lower leg after the incident and scored it as a 10 out 10. An observation on on 05/06/15 at 10:00 a.m. revealed Resident #14 ambulating with a rolling walker down the hall. Resident #14's MDS assessment, dated 04/27/15, reflected she was a [AGE] year-old female, who was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The resident had severe cognitive impairment and wandered daily. The assessment did not identify Resident #14 as having any behavioral symptoms. The resident required only supervision for walking and used a walker for mobility. Resident #14's Care Plan, initiated on 01/19/15 reflected a care plan to address behavioral symptoms which were identified as the resident hitting another resident on the arm on 01/18/15. This care plan was continued on 03/13/15. The care planned approaches developed to address the behavior included: 1. Keep residents away from other resident at least arm length when ambulating with rolling walker. 2. Remove (Resident #14) away from other residents when she is displaying agitation. 3. Approach (Resident #14) in calm voice when she is displaying anxious or agitation towards others. 4. Notify nurse when (Resident #14) is acting out. 5. Provide redirection when (Resident #14) is agitated while ambulating throughout the facility. ...7. Document all behaviors as they occur. 8. Psych consults as needed. 9. Assess reason of...agitation. 10. Notify family of behaviors as they occur." Resident #14's Nurses Notes, dated 01/18/15 at 8:15 a.m., reflected: "Resident up (symbol used) & ambulating with (symbol used) her walker; walked by a resident sitting in her w/c (wheelchair) by nurse's station...and struck her (R) arm without (symbol used) provocation. Resident redirected...Resident had been wandering earlier in and out of rooms and striking out @ (at) CNAs as they attempted to redirect her...Administrator notified." Resident #14's Nurses Notes, dated 01/31/15, reflected: "Resident up (symbol used) and ambulating with (symbol used) her walker - wandering in and out of rooms, exit seeking (front door 4x) and combative with (symbol used) staff during redirection attempts..." Resident #14's Nurses Notes, dated 02/08/15 at 4:00 a.m., reflected: "Resident has been awake for about 45 minutes, she has been ambulating up and down the hallway and getting into other resident room, Resident is hard to be redirected, she has been verbally aggressive..." Resident #14's Nurses Notes, dated 03/05/15 reflected the following entries: 7:00 a.m. - "...Up & down halls with (symbol used) walker. Pacing constantly. Running into other residents w/c if they don't move out of her way quick enough. Constantly taking things off the med carts...Going in other residents rooms & taking their belongings. Attempted to retrieve bottle of male resident's lotion. Resident threw bottle @ this nurse." 11:00 a.m. - "...When agitated, throws glasses of water @ staff members." The next note at 11:10 a.m. reflected: "Amb quickly down hall & ran into female resident standing in hallway. When attempted to redirect, resident punched this nurse in the (R) side of mid back close(d) fisted." 12:10 p.m. - "...Walked up behind CNA, punched her in the back & then rammed walker into CNA's (R) knee, CNA cried out in pain...." 2:00 p.m. - "...Resident pushed roommate out of door way not allowing her to enter room...." Resident #14's Nurses Notes, dated 03/13/15 at 6:30 p.m., reflected: "(Psychiatrist) in facility...Res behaviors cont to escalate and her anxiety levels continue upward..." The notes reflected the resident's family member did not want the resident's psychoactive medications adjusted. Resident #14's psychiatric follow-up notes written by the Psychiatrist on 03/13/15 reflected: "Pt was seen in dayarea she was walking with (symbol used). Staff related she is easily agitated...pushes staff & residents with (symbol used) her walker & difficult to manage..." An interview on 05/07/15 at 4:34 p.m. with Resident #26 revealed Resident #14 would "bang" her walker into a person if she was going down the hallway. He stated she did this to him a month and half ago, and he witnessed her do the same to other residents. He stated he tried to avoid her. Resident #26 stated he told staff what she did, but nothing changed. An interview on 05/08/15 at 10:00 a.m. with CNA CC revealed Resident #14 ran into people with her walker. She stated she observed Resident #14 run into two residents, who were in wheelchairs. On the day of the incident involving Resident #6, she stated she heard Resident #6 screaming that Resident #14 ran into her leg with her walker. An interview on 05/08/15 at 11:12 a.m. with the DON revealed the facility addressed Resident #14's behaviors by using redirection, psychiatric treatment, and a new order for [MEDICATION NAME] twice daily. She also revealed administration had been talking to the family about discharging the resident to another facility, but the family was resistant to the idea. An interview 05/08/15 at 11:24 a.m. with the Administrator revealed he talked to Resident #14's family numerous times. He stated the resident's family was against medication changes, but he hoped the family would let the Psychiatrist treat Resident #14. He stated there was a conference scheduled with the family and Psychiatrist in a few days. At this time, he stated Resident #14's walker was taken away with approval from physical therapy. The Administrator stated staff was providing Resident #14 with one-to-one monitoring. He stated there was still a possibility that alternate placement would be sought for the resident. An observation on 05/08/15 at 12:30 p.m. revealed Resident #14 was capable of walking without the use a rolling walker. The resident was followed by a staff member for one-to-one monitoring. An interview on 05/11/15 at 1:00 p.m. with the Psychiatrist revealed the facility staff and doctors had tried very hard to work with Resident #14 and her family. She stated the resident's dementia prevented her from knowing what she was doing. The Psychiatrist explained that Resident #14's family was uncomfortable with many medications, and the resident was very difficult to manage. She stated the family was also resistant moving her to another facility. Currently, she stated the resident was receiving the anti-anxiety medication [MEDICATION NAME] twice daily, and she was on one-on-one supervision. 3. A resident group interview on 05/06/15 at 3:30 p.m. with seven alert and oriented residents as identified by the facility revealed several residents did not think the facility acted upon their concerns when the concerns were brought to the attention of facility administration. One resident stated that he/she invited both the DON and the Administrator to their Resident Council Meeting, and the residents explained their concerns about the facility to them. In that meeting, the residents stated they discussed other residents' behaviors, which was an on-going concern. The residents explained their concerns regarded the aggressive residents, who were being brought into the facility. They stated the number of these types of residents being admitted to the facility had been increasing since the DON came to the facility, and "turned things upside down." The residents stated they heard the DON worked at a "psych" facility before and was trying to bring those residents to their facility to live. The residents stated facility administration listened to their concerns; however, nothing was done to the address their concerns, and the problems continued. One resident stated he/she felt that the facility administration "make excuses" for the residents with behaviors. The residents stated they felt "fearful" and "scared of some residents." One resident stated he/she "doesn't look anyone the eye anymore because you don't know how they will react to you." Another resident stated it affected him/her personally as he/she had to increase his/her [MEDICATION NAME] due to increased anxiety recently. One resident stated he/she felt the need to watch people closely as there was not enough staff around to redirect and felt he/she had to "for their own protection." One resident stated a roommate was staring at him/her making him/her so uncomfortable he/she felt they needed to sleep on the couch in the lobby. The resident stated he/she switched rooms and now has a different roommate. Multiple residents at the group meeting spoke about being a victim of aggression or affected by the behaviors of other residents. One resident stated he/she witnessed a resident (Resident #14) use her walker to "purposely" run into residents, and further explained, if you don't or cannot get out of her way fast enough, she will hurt you. One resident stated (Resident #6) was just hurt by the walker and had to be sent to the hospital because of being hit in the leg by the walker belonging to Resident #14. Residents also reported Resident #14 wandered into resident rooms and slept in other residents' beds. At least two residents stated they were recently hit with Resident #14's walker. Also during the resident group interview, residents stated an unknown male resident (Resident #19) eloped from the facility over the past weekend, and the staff were looking for the resident. They stated he was found across the street, and staff "fought him back to the facility." The residents stated Resident #19 was also the resident who pulled the fire alarm earlier on this day (05/06/15). Another resident stated he/she had seen Resident #19 trying to leave the facility before. The resident explained Resident #19, who was not a smoker, would go outside with the smokers to the smoking area. The Resident Council Minutes, dated 02/12/15, reflected nine residents were in attendance. The notes reflected residents discussed the following: "Concerned about violent resident's (sic) new/old alike." The Resident Council Minutes, dated 04/16/15, reflected 18 residents were in attendance. The minutes reflected the Administrator and DON attended the meeting by council request. The items discussed were documented as: "New residents seem to be an issue ...Worried about safety ...Chaotic after hours ...Complaint about residents we are bringing into the facility. Those residents are taking too much of the CNA's (sic) time...." An interview on 05/07/15 at 12:45 p.m. with MA M revealed many of the residents, who resided at the facility had behaviors. She stated the staff had to watch those residents closely, as well as, place them on one-to-one monitoring at times. MA M stated, "If given a chance, some residents will fight each other." A confidential interview on 05/07/15 at 12:50 p.m. with a facility nursing employee revealed the residents, who were being admitted to the facility, were not appropriate for the facility due to their behaviors affecting others. He/She stated those residents fought others, and they needed to be watched closely by staff; however, the staff could not be everywhere they needed to be so the other residents "paid for it." He/She stated the facility was more concerned with filling the beds and not taking into consideration the behaviors or histories of these residents. The nursing employee stated there were problems with resident behaviors at the facility, and the facility administration was aware of the problem, but it was not addressed. He/She stated the facility was not able meet the residents' needs, and it was not safe at the facility. An interview on 05/07/15 at 2:15 p.m. with CNA ll revealed he spent a lot of time during his shift redirecting residents. He stated he tried to manage the residents as best as he could, but some of the residents were combative and aggressive. CNA ll explained there was a resident (Resident #14), who ran into other residents with her walker. An interview on 05/07/15 at 4:10 p.m. with CNA R revealed some residents wandered into other residents' rooms. She stated Resident #14 often got into other residents' beds. A interview on 05/08/15 at 11:00 a.m. with Resident #23 revealed there was a female resident (Resident #14), who often wandered into her room and crawled into her roommate's empty bed. Resident #23 was asked what she did when that occurred, and she stated, "I sit still and don't say anything. I don't know what they want and don't know what they will do." She stated she was hopeful the staff was monitoring the resident, and she hoped the staff would respond if needed. An interview on 05/08/15 at 11:15 a.m. with Resident #20 revealed she had been a resident at the facility for one month. Resident #20 stated she did not feel safe at the facility. She stated Resident #14 was always walking into her room and all over the facility. She stated she felt Resident #14 did not like her, and Resident #14 would hit her with her walker on purpose. Resident #20 explained that she was hit by Resident #14 and Resident #24. Resident #20 was asked if facility staff were aware of the incidents. She stated they were aware, and she talked to the Administrator about the incidents. When asked how the facility handled her concerns, she pointed to her head and stated, "They just say that she's just not all there." Resident #20 stated the facility staff continued to make excuses for the residents' behaviors. Resident #20 stated these problems affected her so much she began smoking again. Resident #20's MDS assessment, dated 04/17/15, reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #20's Nurses Notes reflected: "04/18/15 at 2:40 p.m.:...Reported by res (resident) that res had hit her in the chest, assessment of chest area performed, no bruises or skin breaks noted. Res does complain of pain, x-ray called in, res stated 'I called the police,' present at this time at the facility. Police report filed, res filed charges. DON and Administrator informed of changes." " 04/18/15 at 4:30 p.m.: Asked res if she wanted to move to another room on station one, res taken to room [ROOM NUMBER] and res states 'I am fine where I am.' Will continue to monitor." 04/19/15 Chest x-ray return, no definite evidence of acute fracture or dislocation. In bed one person assist...Denies pain or discomfort. Able to make needs known." Resident #20's x-ray results, dated 04/18/15 reflected: "Clinical information: PAIN...Findings: Left shoulder, two views. There is no radiographic evidence of acute fracture or dislocation..." An interview on 05/08/15 at 11:55 a.m. with Resident #21 revealed she experienced and observed many incidents with residents being aggressive. She stated this made her feel unsafe at the facility. Resident #21 stated Resident #24 hit her on top of her head with a closed fist approximately a month ago. She stated Resident #24 also entered her room a couple weeks ago, while she was in bed and her roommate (Resident #20) was sitting on the edge of the bed near the door. She stated Resident #24 walked into their room, and they told him to leave. Resident #24 did not leave, so they used their call lights to get help and began yelling for help. Resident #21 stated Resident #24 then approached Resident #20, and he punched Resident #20 in the chest. The residents called 911 because they were scared and staff was taking too long. Two staff members came in and had to "fight" Resident #24 to get him out of the room pulling him by the arms. Resident #21 stated the police came in and talked to them. She stated Resident #20 had to get an x-ray and was bruised from the incident. Resident #21 explained it bothered her that when this incident occurred, the nurse told them, "He (Resident #24) can't help it." Resident #21 stated she told administration that Resident #24 did not belong at the facility because he was very violent. She stated she talked to the Administrator, and her brother also talked to the Administrator regarding the incident. Resident #21 stated, "They don't say anything. They know what happens, and they let it happen." Resident #21 stated Resident #24 was placed on one-to-one monitoring so they could watch him. Resident #21 then described a third incident regarding Resident #25, whom she described as "always looks at me like he's fixing' to knock me out." She stated Resident #25 yelled out, "Hey!", then grabbed his crotch. She stated his behavior made her feel uncomfortable. Resident #21 stated she reported this to the nurse, and she told the nurse the next time Resident #25 did that to her she would "grab it and break it off." The nurse told her, "No, don't do that. He will hurt you!" Resident #21 stated all of these incidents made her feel like she "needs to be out of here." She stated it made it her feel unimportant because the administration did not take her concerns seriously. Resident #21 stated there were many people living at the facility that should not be at the facility because of their behaviors. She stated this caused her fear. A review of the facility's incident/accident reports for the past four months revealed there were no incident report regarding the incidents described by Resident #20 or Resident

Based on interview, record review, and observation, it was determined the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse, which affected five (Residents #6, #16, #19, #20, and #21) of 39 residents, were reported immediately to the Administrator of the facility and to other officials in accordance with State law through established procedures including to the State survey and certification agency (DADS). 1. The facility failed to provide adequate supervision of Resident #14, who was known to run into other residents with her walker. On 05/05/15, Resident #14 ran into Resident #6's leg with her walker causing a large hematoma, which required the resident to be transferred to the hospital for evaluation and treatment. This incident was not reported to DADS. 2. The facility failed to provide adequate supervision to prevent Resident #24 from physically abusing other residents. On 04/18/15, Resident #20 was punched in the chest by Resident #24, and this was reported to the local police department. Prior to this incident, Resident #24 hit Resident #21 on the top of the head. These incidents were not immediately reported to the Administrator and not reported to DADS. 3. The facility failed to prevent the elopements of two confused residents and failed to ensure there was a system in place to check the WanderGuard bracelets of those residents identified as being elopement risks. The facility also failed to ensure the gate leading away from the smoking area was locked to prevent residents from leaving the facility unsupervised. On 05/03/15, Resident #19 eloped from the facility and was found at a business establishment across from the facility. On 04/06/15, Resident #16 eloped from the facility and was found by police officers at a fast food restaurant located 0.2 miles from the facility. Both residents were found on the other side of a busy, four-lane road with a speed limit of 40 miles per hour. Resident #19's elopement was not reported to the Administrator, and he did not learn about the elopement until survey inquiry. An Immediate Jeopardy (IJ) was identified on 05/07/15. While the IJ was removed on 05/11/15, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" due to the facility still monitoring the effectiveness of the Plan of Removal. The failure could result in all 86 residents being placed at risk for abuse and neglect. Findings included: 1. Resident #6's MDS assessment, dated 02/27/15, reflected Resident #6 was a [AGE] year-old female, who was admitted to the facility on [DATE] with a re-admission on 02/20/15. Resident #6 had [DIAGNOSES REDACTED]. The resident had moderately impaired cognitive skills and required extensive assistance with her ADLs. An observation on 05/05/15 at 9:00 a.m. revealed Resident #6 was in her room in bed receiving incontinent care. A hematoma or large tissue swelling was observed on her right shin. The swelling was approximately four-inches wide, eight-inches long, and appeared to be full of fluid. Resident #6 stated she got the injury when she was hit by another resident's (Resident #14) walker. An interview on 05/05/15 at 9:10 a.m. with LVN K revealed Resident #6's cognition was fair, and the resident could make her needs known. She stated the resident had Diabetes, and she was able to propel herself in the wheelchair. An observation on 05/05/15 at 11:00 a.m. revealed Resident #6 sitting by the front nurses' station in her wheelchair. The resident's right leg was hanging down, and a large raised area was on her right leg below the knee approximately six to eight-inches by four-inches wide and very swollen. The foot and ankle did not appear to be swollen. Resident #6 stated Resident #14 "bashed into it with her cart." She stated she thought Resident #14 "did it on purpose." Resident #14 passed by Resident #6, and Resident #6 pointed to her identifying Resident #14 as the person who hurt her leg. An observation on 05/05/15 at 12:30 p.m. of Resident #6 revealed the resident in her room in bed. A large raised swollen area was on the resident's right shin, and an ice bag was on the area. The resident removed the ice bag because she stated it was too painful. Resident #6 called out for pain medication. The resident's family was in the room and expressed distress at what happened to Resident #6. An observation on 05/05/15 at 2:00 p.m. revealed Resident #6 was not in her room. LVN KK stated the resident had been transferred to the hospital for evaluation of her swollen leg. An observation on 05/08/15 at 8:00 a.m. revealed Resident #6 was in the hospital. The resident was awake, alert, and sitting on the side of the bed. Her legs were visible, and the skin on her left leg had a grayish color. The right leg has a large black area on the shin measuring approximately six-inches wide and ten-inches long. The skin on the foot and upper leg appeared pink in color. The resident stated prior to the incident with Resident #14 her right leg was her good leg, and she had not had any problems with it. She stated it "really hurt me" when it happened. She revealed she now takes the narcotic pain reliever [MEDICATION NAME] every six hours now. A phone interview on 05/08/15 at 12:00 p.m. with family member of Resident #6 revealed Resident #6 had circulation problems in only her left leg and ankle from a previous fracture on that side. Prior to the incident, she used her right leg to propel herself in her wheelchair. A hospital radiology report, dated 05/06/15, reflected Resident #6 had marked soft tissue swelling anterior to the proximal and mid tibia (shin area) of the right leg. A hospital History & Physical report, dated 05/06/15, reflected Resident #6 developed a large right lower extremity hematoma at a local nursing home. An interview on 05/07/15 at 4:15 p.m. with the DON and Medical Director revealed they wanted to clarify that Resident #6 was not sent to the hospital because she was hit by Resident's #14 walker. They stated Resident #6 had a history of [REDACTED]. Both the DON and Medical Director maintained the hematoma was a result of her circulation problems. The DON incorrectly identified the leg with the hematoma as her left leg. The DON was told the hematoma was on the right leg. She was asked if the hematoma suddenly appeared at the same time she was hit by the walker, but was not the cause of the hematoma. She replied, "Yes, that is what we are saying." The DON stated there was documentation of a history of skin and wound problems for the injured right leg in the resident's clinical record. She was asked to provide these if they showed skin issues or open wounds of the right leg. No documentation was ever provided prior to exit on 05/11/15. Resident #6's Skin Assessment Flowsheet - Non-Pressure Ulcer Conditions forms dated 03/18/15, 03/26/15, 04/01/15, 04/8/15, 04/20/15, 04/22/15, and 04/29/15 reflected the only area being treated by the Wound Care Nurse and Wound Care Physician was on the resident's left outer ankle. Pictures and documentation showed no areas on the resident's right leg. Resident #6's Skin Assessment Flow Sheet - Non-Pressure Ulcer Conditions form dated 05/06/15, following the incident, reflected "shin with (symbol used) huge Black raised hematoma...seen by (Wound Care Physician) to Hosp. (hospital)." Resident #6's Wound Care physician progress notes [REDACTED]. The area was noted to have heavy serosanguinous drainage. The Wound Care Physician documented the following additional information: "was injured by another patient and the patient's walker. See at (hospital) and inadequately drained and sent back with orders for tid (three times a day) [MEDICATION NAME]. Will transfer to (wound care hospital) for treatment..." A Comprehensive Plan of Care, dated 05/05/15, for Resident #6 reflected the resident was care planned for a large hematoma to the right shin that measured 20.0 cm x 12.0 cm. The care plan reflected: "(5-5-15) Injury to (R) shin hit with (symbol used) walker developed excessive hematoma. Sent to hosp for eval (evaluation). 5-5-15 Returned from hosp. (5-6-15) eval. (R) leg (Wound Care Physician) sent to (hospital) direct admit..." An interview on 05/08/15 at 1:30 p.m. with the facility's Wound Care Nurse/LVN F revealed all of Resident #6's previous wound treatments were for an area on the outer aspect of the resident's left ankle. She stated she did not observe any open areas or blisters on the resident's right leg prior to the incident. She described the area on the right shin as a hematoma which measured 20 cm x 12 cm. She stated the hematoma was the size of a tennis ball when Resident #6 was initially injured. LVN F stated she did not think the hematoma was from Resident #6's chronic leg injury. She thought it was the result of the incident involving Resident #14. An Incident Report signed and dated by the Administrator on 05/11/15 reflected on 05/05/15 at 6:15 a.m. Resident #20 was sitting in her wheelchair when another resident (Resident #14) walked by her and hit her in the lower leg with a walker. The report reflected the aggressor (Resident #14) was placed on one-to-one monitoring, and her walker was removed on 05/11/15. The report further reflected Resident #20 was sent to the hospital emergency room twice. A Witness Statement was with the report and reflected Housekeeper FF witnessed Resident #14 hit Resident #20's leg. A Comprehensive Pain Assessment Form, dated 05/05/15, reflected Resident #20 reported experiencing terrible pain to her lower leg after the incident and scored it as a 10 out 10. An observation on on 05/06/15 at 10:00 a.m. revealed Resident #14 ambulating with a rolling walker down the hall. Resident #14's MDS assessment, dated 04/27/15, reflected she was a [AGE] year-old female, who was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The resident had severe cognitive impairment and wandered daily. The assessment did not identify Resident #14 as having any behavioral symptoms. The resident required only supervision for walking and used a walker for mobility. Resident #14's Care Plan, initiated on 01/19/15 reflected a care plan to address behavioral symptoms which were identified as the resident hitting another resident on the arm on 01/18/15. This care plan was continued on 03/13/15. The care planned approaches developed to address the behavior included: 1. Keep residents away from other resident at least arm length when ambulating with rolling walker. 2. Remove (Resident #14) away from other residents when she is displaying agitation. 3. Approach (Resident #14) in calm voice when she is displaying anxious or agitation towards others. 4. Notify nurse when (Resident #14) is acting out. 5. Provide redirection when (Resident #14) is agitated while ambulating throughout the facility. ...7. Document all behaviors as they occur. 8. Psych consults as needed. 9. Assess reason of...agitation. 10. Notify family of behaviors as they occur." Resident #14's Nurses Notes, dated 01/18/15 at 8:15 a.m., reflected: "Resident up (symbol used) & ambulating with (symbol used) her walker; walked by a resident sitting in her w/c (wheelchair) by nurse's station...and struck her (R) arm without (symbol used) provocation. Resident redirected...Resident had been wandering earlier in and out of rooms and striking out @ (at) CNAs as they attempted to redirect her...Administrator notified." Resident #14's Nurses Notes, dated 01/31/15, reflected: "Resident up (symbol used) and ambulating with (symbol used) her walker - wandering in and out of rooms, exit seeking (front door 4x) and combative with (symbol used) staff during redirection attempts..." Resident #14's Nurses Notes, dated 02/08/15 at 4:00 a.m., reflected: "Resident has been awake for about 45 minutes, she has been ambulating up and down the hallway and getting into other resident room, Resident is hard to be redirected, she has been verbally aggressive..." Resident #14's Nurses Notes, dated 03/05/15 reflected the following entries: 7:00 a.m. - "...Up & down halls with (symbol used) walker. Pacing constantly. Running into other residents w/c if they don't move out of her way quick enough. Constantly taking things off the med carts...Going in other residents rooms & taking their belongings. Attempted to retrieve bottle of male resident's lotion. Resident threw bottle @ this nurse." 11:00 a.m. - "...When agitated, throws glasses of water @ staff members." The next note at 11:10 a.m. reflected: "Amb quickly down hall & ran into female resident standing in hallway. When attempted to redirect, resident punched this nurse in the (R) side of mid back close(d) fisted." 12:10 p.m. - "...Walked up behind CNA, punched her in the back & then rammed walker into CNA's (R) knee, CNA cried out in pain...." 2:00 p.m. - "...Resident pushed roommate out of door way not allowing her to enter room...." Resident #14's Nurses Notes, dated 03/13/15 at 6:30 p.m., reflected: "(Psychiatrist) in facility...Res behaviors cont to escalate and her anxiety levels continue upward..." The notes reflected the resident's family member did not want the resident's psychoactive medications adjusted. Resident #14's psychiatric follow-up notes written by the Psychiatrist on 03/13/15 reflected: "Pt was seen in dayarea she was walking with (symbol used). Staff related she is easily agitated...pushes staff & residents with (symbol used) her walker & difficult to manage..." An interview on 05/07/15 at 4:34 p.m. with Resident #26 revealed Resident #14 would "bang" her walker into a person if she was going down the hallway. He stated she did this to him a month and half ago, and he witnessed her do the same to other residents. He stated he tried to avoid her. Resident #26 stated he told staff what she did, but nothing changed. An interview on 05/08/15 at 10:00 a.m. with CNA CC revealed Resident #14 ran into people with her walker. She stated she observed Resident #14 run into two residents, who were in wheelchairs. On the day of the incident involving Resident #6, she stated she heard Resident #6 screaming that Resident #14 ran into her leg with her walker. An interview on 05/08/15 at 11:12 a.m. with the DON revealed the facility addressed Resident #14's behaviors by using redirection, psychiatric treatment, and a new order for [MEDICATION NAME] twice daily. She also revealed administration had been talking to the family about discharging the resident to another facility, but the family was resistant to the idea. An interview 05/08/15 at 11:24 a.m. with the Administrator revealed he talked to Resident #14's family numerous times. He stated the resident's family was against medication changes, but he hoped the family would let the Psychiatrist treat Resident #14. He stated there was a conference scheduled with the family and Psychiatrist in a few days. At this time, he stated Resident #14's walker was taken away with approval from physical therapy. The Administrator stated staff was providing Resident #14 with one-to-one monitoring. He stated there was still a possibility that alternate placement would be sought for the resident. An observation on 05/08/15 at 12:30 p.m. revealed Resident #14 was capable of walking without the use a rolling walker. The resident was followed by a staff member for one-to-one monitoring. An interview on 05/11/15 at 1:00 p.m. with the Psychiatrist revealed the facility staff and doctors had tried very hard to work with Resident #14 and her family. She stated the resident's dementia prevented her from knowing what she was doing. The Psychiatrist explained that Resident #14's family was uncomfortable with many medications, and the resident was very difficult to manage. She stated the family was also resistant moving her to another facility. Currently, she stated the resident was receiving the anti-anxiety medication [MEDICATION NAME] twice daily, and she was on one-on-one supervision. 2. A resident group interview on 05/06/15 at 3:30 p.m. with seven alert and oriented residents as identified by the facility revealed several residents did not think the facility acted upon their concerns when the concerns were brought to the attention of facility administration. One resident stated that he/she invited both the DON and the Administrator to their Resident Council Meeting, and the residents explained their concerns about the facility to them. In that meeting, the residents stated they discussed other residents' behaviors, which was an on-going concern. The residents explained their concerns regarded the aggressive residents, who were being brought into the facility. They stated the number of these types of residents being admitted to the facility had been increasing since the DON came to the facility, and "turned things upside down." The residents stated they heard the DON worked at a "psych" facility before and was trying to bring those residents to their facility to live. The residents stated facility administration listened to their concerns; however, nothing was done to the address their concerns, and the problems continued. One resident stated he/she felt that the facility administration "make excuses" for the residents with behaviors. The residents stated they felt "fearful" and "scared of some residents." One resident stated he/she "doesn't look anyone the eye anymore because you don't know how they will react to you." Another resident stated it affected him/her personally as he/she had to increase his/her [MEDICATION NAME] due to increased anxiety recently. One resident stated he/she felt the need to watch people closely as there was not enough staff around to redirect and felt he/she had to "for their own protection." One resident stated a roommate was staring at him/her making him/her so uncomfortable he/she felt they needed to sleep on the couch in the lobby. The resident stated he/she switched rooms and now has a different roommate. Multiple residents at the group meeting spoke about being a victim of aggression or affected by the behaviors of other residents. One resident stated he/she witnessed a resident (Resident #14) use her walker to "purposely" run into residents, and further explained, if you don't or cannot get out of her way fast enough, she will hurt you. One resident stated (Resident #6) was just hurt by the walker and had to be sent to the hospital because of being hit in the leg by the walker belonging to Resident #14. Residents also reported Resident #14 wandered into resident rooms and slept in other residents' beds. At least two residents stated they were recently hit with Resident #14's walker. Also during the resident group interview, residents stated an unknown male resident (Resident #19) eloped from the facility over the past weekend, and the staff were looking for the resident. They stated he was found across the street, and staff "fought him back to the facility." The residents stated Resident #19 was also the resident who pulled the fire alarm earlier on this day (05/06/15). Another resident stated he/she had seen Resident #19 trying to leave the facility before. The resident explained Resident #19, who was not a smoker, would go outside with the smokers to the smoking area. The Resident Council Minutes, dated 02/12/15, reflected nine residents were in attendance. The notes reflected residents discussed the following: "Concerned about violent resident's (sic) new/old alike." The Resident Council Minutes, dated 04/16/15, reflected 18 residents were in attendance. The minutes reflected the Administrator and DON attended the meeting by council request. The items discussed were documented as: "New residents seem to be an issue ...Worried about safety ...Chaotic after hours ...Complaint about residents we are bringing into the facility. Those residents are taking too much of the CNA's (sic) time...." An interview on 05/07/15 at 12:45 p.m. with MA M revealed many of the residents, who resided at the facility had behaviors. She stated the staff had to watch those residents closely, as well as, place them on one-to-one monitoring at times. MA M stated, "If given a chance, some residents will fight each other." A confidential interview on 05/07/15 at 12:50 p.m. with a facility nursing employee revealed the residents, who were being admitted to the facility, were not appropriate for the facility due to their behaviors affecting others. He/She stated those residents fought others, and they needed to be watched closely by staff; however, the staff could not be everywhere they needed to be so the other residents "paid for it." He/She stated the facility was more concerned with filling the beds and not taking into consideration the behaviors or histories of these residents. The nursing employee stated there were problems with resident behaviors at the facility, and the facility administration was aware of the problem, but it was not addressed. He/She stated the facility was not able meet the residents' needs, and it was not safe at the facility. An interview on 05/07/15 at 2:15 p.m. with CNA ll revealed he spent a lot of time during his shift redirecting residents. He stated he tried to manage the residents as best as he could, but some of the residents were combative and aggressive. CNA ll explained there was a resident (Resident #14), who ran into other residents with her walker. An interview on 05/07/15 at 4:10 p.m. with CNA R revealed some residents wandered into other residents' rooms. She stated Resident #14 often got into other residents' beds. A interview on 05/08/15 at 11:00 a.m. with Resident #23 revealed there was a female resident (Resident #14), who often wandered into her room and crawled into her roommate's empty bed. Resident #23 was asked what she did when that occurred, and she stated, "I sit still and don't say anything. I don't know what they want and don't know what they will do." She stated she was hopeful the staff was monitoring the resident, and she hoped the staff would respond if needed. An interview on 05/08/15 at 11:15 a.m. with Resident #20 revealed she had been a resident at the facility for one month. Resident #20 stated she did not feel safe at the facility. She stated Resident #14 was always walking into her room and all over the facility. She stated she felt Resident #14 did not like her, and Resident #14 would hit her with her walker on purpose. Resident #20 explained that she was hit by Resident #14 and Resident #24. Resident #20 was asked if facility staff were aware of the incidents. She stated they were aware, and she talked to the Administrator about the incidents. When asked how the facility handled her concerns, she pointed to her head and stated, "They just say that she's just not all there." Resident #20 stated the facility staff continued to make excuses for the residents' behaviors. Resident #20 stated these problems affected her so much she began smoking again. Resident #20's MDS assessment, dated 04/17/15, reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #20's Nurses Notes reflected: "04/18/15 at 2:40 p.m.:...Reported by res (resident) that res had hit her in the chest, assessment of chest area performed, no bruises or skin breaks noted. Res does complain of pain, x-ray called in, res stated 'I called the police,' present at this time at the facility. Police report filed, res filed charges. DON and Administrator informed of changes." " 04/18/15 at 4:30 p.m.: Asked res if she wanted to move to another room on station one, res taken to room [ROOM NUMBER] and res states 'I am fine where I am.' Will continue to monitor." 04/19/15 Chest x-ray return, no definite evidence of acute fracture or dislocation. In bed one person assist...Denies pain or discomfort. Able to make needs known." Resident #20's x-ray results, dated 04/18/15 reflected: "Clinical information: PAIN...Findings: Left shoulder, two views. There is no radiographic evidence of acute fracture or dislocation..." An interview on 05/08/15 at 11:55 a.m. with Resident #21 revealed she experienced and observed many incidents with residents being aggressive. She stated this made her feel unsafe at the facility. Resident #21 stated Resident #24 hit her on top of her head with a closed fist approximately a month ago. She stated Resident #24 also entered her room a couple weeks ago, while she was in bed and her roommate (Resident #20) was sitting on the edge of the bed near the door. She stated Resident #24 walked into their room, and they told him to leave. Resident #24 did not leave, so they used their call lights to get help and began yelling for help. Resident #21 stated Resident #24 then approached Resident #20, and he punched Resident #20 in the chest. The residents called 911 because they were scared and staff was taking too long. Two staff members came in and had to "fight" Resident #24 to get him out of the room pulling him by the arms. Resident #21 stated the police came in and talked to them. She stated Resident #20 had to get an x-ray and was bruised from the incident. Resident #21 explained it bothered her that when this incident occurred, the nurse told them, "He (Resident #24) can't help it." Resident #21 stated she told administration that Resident #24 did not belong at the facility because he was very violent. She stated she talked to the Administrator, and her brother also talked to the Administrator regarding the incident. Resident #21 stated, "They don't say anything. They know what happens, and they let it happen." Resident #21 stated Resident #24 was placed on one-to-one monitoring so they could watch him. Resident #21 then described a third incident regarding Resident #25, whom she described as "always looks at me like he's fixing' to knock me out." She stated Resident #25 yelled out, "Hey!", then grabbed his crotch. She stated his behavior made her feel uncomfortable. Resident #21 stated she reported this to the nurse, and she told the nurse the next time Resident #25 did that to her she would "grab it and break it off." The nurse told her, "No, don't do that. He will hurt you!" Resident #21 stated all of these incidents made her feel like she "needs to be out of here." She stated it made it her feel unimportant because the administration did not take her concerns seriously. Resident #21 stated there were many people living at the facility that should not be at the facility because of their behaviors. She stated this caused her fear. A review of the facility's incident/accident reports for the past four months revealed there were no incident report regarding the incidents described by Resident #20 or Resident #21. A review of the facility's 24-hour report book revealed no written note of an elopement for the past week. An interview on 05/08/15 at 1:32 p.m. with the Administrator revealed he was unaware of any resident behaviors. He stated he was unaware there were 22 incident/accident reports involving resident-to-resident altercations within the past three months. He stated this was not brought to his attention. The Administrator stated any time there was a resident-to-resident incident he was supposed to be informed because he was responsible for determining whether to investigate and report to DADS. The Administrator stated they "don't have the right people here" to report what was occurring and as a result he was unaware of what was happening. The Administrator was asked who determined whether a resident was admitted to the facility. He stated it was an interdisciplinary team decision, and the interdisciplinary team consisted of the DON, MDS Nurse, and the Business Office Manager. The Administrator explained the residents consisted of "a mix" of residents with varying needs, and they "need to care for all our residents." He explained that when resident-to-resident incidents occurred, they immediately separated the residents and put interventions in place including alternate placement. During the same interview, concerns were discussed with the Administrator regarding Resident #14 and the complaints voiced by other residents of her running into the residents with her walker. The Administrator explained that Resident #14 has "no mental concept" of what she was doing. He stated he did not think she was doing it intentionally, but acknowledged that residents were tired of her behavior. He stated her behavior was affecting the other residents. He stated they were working with the family currently to come up with a plan. The Administrator denied knowing of the incident regarding Resident #20 being punched in the chest on 04/18/15. He stated he was unaware the police were called to the facility at the time of the incident. He stated the incident should have been called into the State, but first of all, should have been reported to him. The Administrator stated he did not understand, and shook his head. The Administrator stated he was the Abuse Prevention Coordinator for the facility. An interview on 05/08/15 at 2:05 p.m. with the DON revealed she was invited to attend the Resident Council Meeting, and the residents expressed concerns about some the residents that were being admitted to the facility. She stated the residents felt as though care was being taken away from them, and the residents were concerned about some of the residents acting out with behaviors. The DON stated she explained to the Resident Council that the interdisciplinary team decided as a team who lived at the facility. The DON acknowledged she was aware that some residents were concerned for their safety. She added, "Everyone needs somewhere to live." The DON was asked about the incident which occurred on 04/18/15 involving Resident #20 and #21, in which the police were called. The DON stated she recalled that the police were called and thought it was in regards to Resident #21 complaining that a resident hit her on the head. The DON stated that Resident #21's story changed because the resident reported that she was hit on the head, and then later stated she was hit in the chest. The DON was not able to identify that these were separate incidents which occurred. The DON denied knowledge regarding Resident #20 being punched in the chest on 04/18/15. In addition, she was she unaware an x-ray was obtained for the resident. The DON stated there was not an incident report for the incident in which Resident #24 hit Resident #20 in the chest because they were unaware of the incident. The facility's current Behavior Assessment-Management Interventions policy and procedure, revised November 2013, reflected: "Policy: It is the policy of this home to have a behavior intervention and management program to prevent, reduce, or eliminate inappropriate behaviors, which may be detrimental to the individual or other as well as to establish and maintain an ongoing assessment program that enables staff to be effective in our goal to provide a better quality of life for our residents. ...The home should consider resident behavior inappropriate if it: · Presents a risk of danger or harm to the resident. · Presents a risk of danger or harm to others. · Interferes with resident or other residents' optimal functioning and or · Significantly interferes with the staff's ability to provide care." An Immediate Jeopardy (IJ) was identified on 05/08/15 related to supervision to prevent accidents. The Administrator and DON were notified of the IJ in the area of Quality of Care on 05/08/15 at 2:25 p.m. The facility was requested to submit a Plan of Removal. The facility's Plan of Removal as accepted on 05/09/15 at 2:11 p.m., and the Plan of Removal was as f

Based on interview, record review, and observation, it was determined the facility failed to implement written policies and procedures that prohibited mistreatment, neglect, and the abuse of five (Residents #6, #16, #19, #20, and #21) of 39 residents, who were reviewed for abuse and neglect. 1. The facility failed to provide adequate supervision of Resident #14, who was known to run into other residents with her walker. On 05/05 /15, Resident #14 ran into Resident #6's leg with her walker causing a large hematoma, which required the resident to be transferred to the hospital for evaluation and treatment. This incident was not reported to DADS. 2. The facility failed to provide adequate supervision to prevent Resident #24 from physically abusing other residents. On 04/18/15, Resident #20 was punched in the chest by Resident #24, and this was reported to the local police department. Prior to this incident, Resident #24 hit Resident #21 on the top of the head. These incidents were not immediately reported to the Administrator and not reported to DADS. 3. The facility failed to prevent the elopements of two confused residents and failed to ensure there was a system in place to check the WanderGuard bracelets of those residents identified as being elopement risks. The facility also failed to ensure the gate leading away from the smoking area was locked to prevent residents from leaving the facility unsupervised. On 05/03/15, Resident #19 eloped from the facility and was found at a business establishment across from the facility. On 04/06/15, Resident #16 eloped from the facility and was found by police officers at a fast food restaurant located 0.2 miles from the facility. Both residents were found on the other side of a busy, four-lane road with a speed limit of 40 miles per hour. Resident #19's elopement was not reported to the Administrator, and he did not learn about the elopement until survey inquiry. An Immediate Jeopardy (IJ) was identified on 05/07/15. While the IJ was removed on 05/11/15, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" due to the facility still monitoring the effectiveness of the Plan of Removal. The failure could result in all 86 residents being placed at risk for abuse and neglect. Findings included: 1. The facility's current Abuse-Reportable Events policy and procedure, revised November 2013, reflected: "Policy: It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law of any incident/event in which there is a cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. Definitions: Abuse: Any act, failure to act, or incitemnet to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. This includes financial, verbal, sexual, mental/psychological, or physical abuse... Physical abuse: Physical action within the definition of 'abuse', including but no limited to, hitting, slapping, pinching, and kicking... Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Suspicion of a crime against a resident: if the events that cause the reasonable suspicion result in serious bodily injury, the report must be made immediately after forming the suspicion (but no later than two hours after forming the suspicion). Otherwise, the report must be made not later than 24 hours after forming suspicion. The home's administration will prohibit neglect, verbal, mental or physical abuse, including involuntary suclusion...of residents caused by another person. The home's administration will prohibit all crimes against a resident. The home's administration will conduct and conduct and investigate allegations of crimes, suspected abuse, neglect, or misappropriation of property, and will provide notification and release of information to the proper authorities, in accordance with federal and state regulations. The home's administration will designate a qualified staff member as the Abuse Coordinator. Procedure: ...Training:...Identification of potential victims of abuse or neglect. Appropriate interventions to deal with aggressive, stubborn resident, etc... ...Prevention:...Identification, correction and intervention in situations in which abuse, crimes against residents, neglect and/or misappropriation is likely to occur ...Identification: Administrative and licensed staff will be aware of potential situations of abuse during rounds and contact with staff, residents and resident family members. Incident/Accident Reports will be reviewed by the Administratior and Director of Nurses or designee to identify possible incidents of abuse...Employees are required to report all incidents of possible abuse, mistreatment, or neglect of any resident, crimes against a resident...immediately to their supervisor or Senior Staff Member. The Senior Staff Member is defined as the 'highest ranking person in the building at the time of the incident...Investigation: When an employee becomes aware of an allegation or suspicion of abuse the employee should: Immediately report the allegation or suspicion to the charge nurse on the unit on which the resident resides immediately ...Protection: All residents will be immediately protected from harm...If another resident is the alleged perpetrator, they shall immediately be assissed for treatment options. The safety and protection of other residents is the home's primary concern ...Reporting: All alleged allegations of abuse will be reported to the appropriate state agency and to all other agencies as required by regulation... Resident to Resident Abuse: Procedure: The charge nurse will: If a resident-to-resident incident occurs, staff should immediately intervene. Separate residents and take them to areas away from each other until the situation has subsided. If the resident(s) has been injured, give immediate medical care as indicated. If necessary, obtain an order from the physician and send the resident(s) to the hospital. If hospilalization occurs related to a resident to resident altercation then it is then reportable as a crime against a resident and notification to the local law enforcement along with the state is required...Immediately notify the Administrator and/or the Director of Nursing. If the alleged perpetrator is placed on location monitoring, staff will be instructed on reason for monitoring and targeted behaviors being monitored. Complete an incident/accident report for the alleged perpetrator and the victim.. Notify the responsible party/guardian and physician of each resident. Document in each resident's medical record in conjunction with frequent monitoring and documentation to continue for at least 24 hours. The Administrator will: Notify state agency as required. Will seek proper placement at another home if the physician, responsible party, and/or interdisciplinary care plan team feel that a resident will be a danger to other residents and/or self." 2. Resident #6's MDS assessment, dated 02/27/15, reflected Resident #6 was a [AGE] year-old female, who was admitted to the facility on [DATE] with a re-admission on 02/20/15. Resident #6 had [DIAGNOSES REDACTED]. The resident had moderately impaired cognitive skills and required extensive assistance with her ADLs. An observation on 05/05/15 at 9:00 a.m. revealed Resident #6 was in her room in bed receiving incontinent care. A hematoma or large tissue swelling was observed on her right shin. The swelling was approximately four-inches wide, eight-inches long, and appeared to be full of fluid. Resident #6 stated she got the injury when she was hit by another resident's (Resident #14) walker. An interview on 05/05/15 at 9:10 a.m. with LVN K revealed Resident #6's cognition was fair, and the resident could make her needs known. She stated the resident had Diabetes, and she was able to propel herself in the wheelchair. An observation on 05/05/15 at 11:00 a.m. revealed Resident #6 sitting by the front nurses' station in her wheelchair. The resident's right leg was hanging down, and a large raised area was on her right leg below the knee approximately six to eight-inches by four-inches wide and very swollen. The foot and ankle did not appear to be swollen. Resident #6 stated Resident #14 "bashed into it with her cart." She stated she thought Resident #14 "did it on purpose." Resident #14 passed by Resident #6, and Resident #6 pointed to her identifying Resident #14 as the person who hurt her leg. An observation on 05/05/15 at 12:30 p.m. of Resident #6 revealed the resident in her room in bed. A large raised swollen area was on the resident's right shin, and an ice bag was on the area. The resident removed the ice bag because she stated it was too painful. Resident #6 called out for pain medication. The resident's family was in the room and expressed distress at what happened to Resident #6. An observation on 05/05/15 at 2:00 p.m. revealed Resident #6 was not in her room. LVN KK stated the resident had been transferred to the hospital for evaluation of her swollen leg. An observation on 05/08/15 at 8:00 a.m. revealed Resident #6 was in the hospital. The resident was awake, alert, and sitting on the side of the bed. Her legs were visible, and the skin on her left leg had a grayish color. The right leg has a large black area on the shin measuring approximately six-inches wide and ten-inches long. The skin on the foot and upper leg appeared pink in color. The resident stated prior to the incident with Resident #14 her right leg was her good leg, and she had not had any problems with it. She stated it "really hurt me" when it happened. She revealed she now takes the narcotic pain reliever [MEDICATION NAME] every six hours now. A phone interview on 05/08/15 at 12:00 p.m. with family member of Resident #6 revealed Resident #6 had circulation problems in only her left leg and ankle from a previous fracture on that side. Prior to the incident, she used her right leg to propel herself in her wheelchair. A hospital radiology report, dated 05/06/15, reflected Resident #6 had marked soft tissue swelling anterior to the proximal and mid tibia (shin area) of the right leg. A hospital History & Physical report, dated 05/06/15, reflected Resident #6 developed a large right lower extremity hematoma at a local nursing home. An interview on 05/07/15 at 4:15 p.m. with the DON and Medical Director revealed they wanted to clarify that Resident #6 was not sent to the hospital because she was hit by Resident's #14 walker. They stated Resident #6 had a history of [REDACTED]. Both the DON and Medical Director maintained the hematoma was a result of her circulation problems. The DON incorrectly identified the leg with the hematoma as her left leg. The DON was told the hematoma was on the right leg. She was asked if the hematoma suddenly appeared at the same time she was hit by the walker, but was not the cause of the hematoma. She replied, "Yes, that is what we are saying." The DON stated there was documentation of a history of skin and wound problems for the injured right leg in the resident's clinical record. She was asked to provide these if they showed skin issues or open wounds of the right leg. No documentation was ever provided prior to exit on 05/11/15. Resident #6's Skin Assessment Flowsheet - Non-Pressure Ulcer Conditions forms dated 03/18/15, 03/26/15, 04/01/15, 04/8/15, 04/20/15, 04/22/15, and 04/29/15 reflected the only area being treated by the Wound Care Nurse and Wound Care Physician was on the resident's left outer ankle. Pictures and documentation showed no areas on the resident's right leg. Resident #6's Skin Assessment Flow Sheet - Non-Pressure Ulcer Conditions form dated 05/06/15, following the incident, reflected "shin with (symbol used) huge Black raised hematoma...seen by (Wound Care Physician) to Hosp. (hospital)." Resident #6's Wound Care physician progress notes [REDACTED]. The area was noted to have heavy serosanguinous drainage. The Wound Care Physician documented the following additional information: "was injured by another patient and the patient's walker. See at (hospital) and inadequately drained and sent back with orders for tid (three times a day) [MEDICATION NAME]. Will transfer to (wound care hospital) for treatment..." A Comprehensive Plan of Care, dated 05/05/15, for Resident #6 reflected the resident was care planned for a large hematoma to the right shin that measured 20.0 cm x 12.0 cm. The care plan reflected: "(5-5-15) Injury to (R) shin hit with (symbol used) walker developed excessive hematoma. Sent to hosp for eval (evaluation). 5-5-15 Returned from hosp. (5-6-15) eval. (R) leg (Wound Care Physician) sent to (hospital) direct admit..." An interview on 05/08/15 at 1:30 p.m. with the facility's Wound Care Nurse/LVN F revealed all of Resident #6's previous wound treatments were for an area on the outer aspect of the resident's left ankle. She stated she did not observe any open areas or blisters on the resident's right leg prior to the incident. She described the area on the right shin as a hematoma which measured 20 cm x 12 cm. She stated the hematoma was the size of a tennis ball when Resident #6 was initially injured. LVN F stated she did not think the hematoma was from Resident #6's chronic leg injury. She thought it was the result of the incident involving Resident #14. An Incident Report signed and dated by the Administrator on 05/11/15 reflected on 05/05/15 at 6:15 a.m. Resident #20 was sitting in her wheelchair when another resident (Resident #14) walked by her and hit her in the lower leg with a walker. The report reflected the aggressor (Resident #14) was placed on one-to-one monitoring, and her walker was removed on 05/11/15. The report further reflected Resident #20 was sent to the hospital emergency room twice. A Witness Statement was with the report and reflected Housekeeper FF witnessed Resident #14 hit Resident #20's leg. A Comprehensive Pain Assessment Form, dated 05/05/15, reflected Resident #20 reported experiencing terrible pain to her lower leg after the incident and scored it as a 10 out 10. An observation on on 05/06/15 at 10:00 a.m. revealed Resident #14 ambulating with a rolling walker down the hall. Resident #14's MDS assessment, dated 04/27/15, reflected she was a [AGE] year-old female, who was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The resident had severe cognitive impairment and wandered daily. The assessment did not identify Resident #14 as having any behavioral symptoms. The resident required only supervision for walking and used a walker for mobility. Resident #14's Care Plan, initiated on 01/19/15 reflected a care plan to address behavioral symptoms which were identified as the resident hitting another resident on the arm on 01/18/15. This care plan was continued on 03/13/15. The care planned approaches developed to address the behavior included: 1. Keep residents away from other resident at least arm length when ambulating with rolling walker. 2. Remove (Resident #14) away from other residents when she is displaying agitation. 3. Approach (Resident #14) in calm voice when she is displaying anxious or agitation towards others. 4. Notify nurse when (Resident #14) is acting out. 5. Provide redirection when (Resident #14) is agitated while ambulating throughout the facility. ...7. Document all behaviors as they occur. 8. Psych consults as needed. 9. Assess reason of...agitation. 10. Notify family of behaviors as they occur." Resident #14's Nurses Notes, dated 01/18/15 at 8:15 a.m., reflected: "Resident up (symbol used) & ambulating with (symbol used) her walker; walked by a resident sitting in her w/c (wheelchair) by nurse's station...and struck her (R) arm without (symbol used) provocation. Resident redirected...Resident had been wandering earlier in and out of rooms and striking out @ (at) CNAs as they attempted to redirect her...Administrator notified." Resident #14's Nurses Notes, dated 01/31/15, reflected: "Resident up (symbol used) and ambulating with (symbol used) her walker - wandering in and out of rooms, exit seeking (front door 4x) and combative with (symbol used) staff during redirection attempts..." Resident #14's Nurses Notes, dated 02/08/15 at 4:00 a.m., reflected: "Resident has been awake for about 45 minutes, she has been ambulating up and down the hallway and getting into other resident room, Resident is hard to be redirected, she has been verbally aggressive..." Resident #14's Nurses Notes, dated 03/05/15 reflected the following entries: 7:00 a.m. - "...Up & down halls with (symbol used) walker. Pacing constantly. Running into other residents w/c if they don't move out of her way quick enough. Constantly taking things off the med carts...Going in other residents rooms & taking their belongings. Attempted to retrieve bottle of male resident's lotion. Resident threw bottle @ this nurse." 11:00 a.m. - "...When agitated, throws glasses of water @ staff members." The next note at 11:10 a.m. reflected: "Amb quickly down hall & ran into female resident standing in hallway. When attempted to redirect, resident punched this nurse in the (R) side of mid back close(d) fisted." 12:10 p.m. - "...Walked up behind CNA, punched her in the back & then rammed walker into CNA's (R) knee, CNA cried out in pain...." 2:00 p.m. - "...Resident pushed roommate out of door way not allowing her to enter room...." Resident #14's Nurses Notes, dated 03/13/15 at 6:30 p.m., reflected: "(Psychiatrist) in facility...Res behaviors cont to escalate and her anxiety levels continue upward..." The notes reflected the resident's family member did not want the resident's psychoactive medications adjusted. Resident #14's psychiatric follow-up notes written by the Psychiatrist on 03/13/15 reflected: "Pt was seen in dayarea she was walking with (symbol used). Staff related she is easily agitated...pushes staff & residents with (symbol used) her walker & difficult to manage..." An interview on 05/07/15 at 4:34 p.m. with Resident #26 revealed Resident #14 would "bang" her walker into a person if she was going down the hallway. He stated she did this to him a month and half ago, and he witnessed her do the same to other residents. He stated he tried to avoid her. Resident #26 stated he told staff what she did, but nothing changed. An interview on 05/08/15 at 10:00 a.m. with CNA CC revealed Resident #14 ran into people with her walker. She stated she observed Resident #14 run into two residents, who were in wheelchairs. On the day of the incident involving Resident #6, she stated she heard Resident #6 screaming that Resident #14 ran into her leg with her walker. An interview on 05/08/15 at 11:12 a.m. with the DON revealed the facility addressed Resident #14's behaviors by using redirection, psychiatric treatment, and a new order for [MEDICATION NAME] twice daily. She also revealed administration had been talking to the family about discharging the resident to another facility, but the family was resistant to the idea. An interview 05/08/15 at 11:24 a.m. with the Administrator revealed he talked to Resident #14's family numerous times. He stated the resident's family was against medication changes, but he hoped the family would let the Psychiatrist treat Resident #14. He stated there was a conference scheduled with the family and Psychiatrist in a few days. At this time, he stated Resident #14's walker was taken away with approval from physical therapy. The Administrator stated staff was providing Resident #14 with one-to-one monitoring. He stated there was still a possibility that alternate placement would be sought for the resident. An observation on 05/08/15 at 12:30 p.m. revealed Resident #14 was capable of walking without the use a rolling walker. The resident was followed by a staff member for one-to-one monitoring. An interview on 05/11/15 at 1:00 p.m. with the Psychiatrist revealed the facility staff and doctors had tried very hard to work with Resident #14 and her family. She stated the resident's dementia prevented her from knowing what she was doing. The Psychiatrist explained that Resident #14's family was uncomfortable with many medications, and the resident was very difficult to manage. She stated the family was also resistant moving her to another facility. Currently, she stated the resident was receiving the anti-anxiety medication [MEDICATION NAME] twice daily, and she was on one-on-one supervision. 3. A resident group interview on 05/06/15 at 3:30 p.m. with seven alert and oriented residents as identified by the facility revealed several residents did not think the facility acted upon their concerns when the concerns were brought to the attention of facility administration. One resident stated that he/she invited both the DON and the Administrator to their Resident Council Meeting, and the residents explained their concerns about the facility to them. In that meeting, the residents stated they discussed other residents' behaviors, which was an on-going concern. The residents explained their concerns regarded the aggressive residents, who were being brought into the facility. They stated the number of these types of residents being admitted to the facility had been increasing since the DON came to the facility, and "turned things upside down." The residents stated they heard the DON worked at a "psych" facility before and was trying to bring those residents to their facility to live. The residents stated facility administration listened to their concerns; however, nothing was done to the address their concerns, and the problems continued. One resident stated he/she felt that the facility administration "make excuses" for the residents with behaviors. The residents stated they felt "fearful" and "scared of some residents." One resident stated he/she "doesn't look anyone the eye anymore because you don't know how they will react to you." Another resident stated it affected him/her personally as he/she had to increase his/her [MEDICATION NAME] due to increased anxiety recently. One resident stated he/she felt the need to watch people closely as there was not enough staff around to redirect and felt he/she had to "for their own protection." One resident stated a roommate was staring at him/her making him/her so uncomfortable he/she felt they needed to sleep on the couch in the lobby. The resident stated he/she switched rooms and now has a different roommate. Multiple residents at the group meeting spoke about being a victim of aggression or affected by the behaviors of other residents. One resident stated he/she witnessed a resident (Resident #14) use her walker to "purposely" run into residents, and further explained, if you don't or cannot get out of her way fast enough, she will hurt you. One resident stated (Resident #6) was just hurt by the walker and had to be sent to the hospital because of being hit in the leg by the walker belonging to Resident #14. Residents also reported Resident #14 wandered into resident rooms and slept in other residents' beds. At least two residents stated they were recently hit with Resident #14's walker. Also during the resident group interview, residents stated an unknown male resident (Resident #19) eloped from the facility over the past weekend, and the staff were looking for the resident. They stated he was found across the street, and staff "fought him back to the facility." The residents stated Resident #19 was also the resident who pulled the fire alarm earlier on this day (05/06/15). Another resident stated he/she had seen Resident #19 trying to leave the facility before. The resident explained Resident #19, who was not a smoker, would go outside with the smokers to the smoking area. The Resident Council Minutes, dated 02/12/15, reflected nine residents were in attendance. The notes reflected residents discussed the following: "Concerned about violent resident's (sic) new/old alike." The Resident Council Minutes, dated 04/16/15, reflected 18 residents were in attendance. The minutes reflected the Administrator and DON attended the meeting by council request. The items discussed were documented as: "New residents seem to be an issue ...Worried about safety ...Chaotic after hours ...Complaint about residents we are bringing into the facility. Those residents are taking too much of the CNA's (sic) time...." An interview on 05/07/15 at 12:45 p.m. with MA M revealed many of the residents, who resided at the facility had behaviors. She stated the staff had to watch those residents closely, as well as, place them on one-to-one monitoring at times. MA M stated, "If given a chance, some residents will fight each other." A confidential interview on 05/07/15 at 12:50 p.m. with a facility nursing employee revealed the residents, who were being admitted to the facility, were not appropriate for the facility due to their behaviors affecting others. He/She stated those residents fought others, and they needed to be watched closely by staff; however, the staff could not be everywhere they needed to be so the other residents "paid for it." He/She stated the facility was more concerned with filling the beds and not taking into consideration the behaviors or histories of these residents. The nursing employee stated there were problems with resident behaviors at the facility, and the facility administration was aware of the problem, but it was not addressed. He/She stated the facility was not able meet the residents' needs, and it was not safe at the facility. An interview on 05/07/15 at 2:15 p.m. with CNA ll revealed he spent a lot of time during his shift redirecting residents. He stated he tried to manage the residents as best as he could, but some of the residents were combative and aggressive. CNA ll explained there was a resident (Resident #14), who ran into other residents with her walker. An interview on 05/07/15 at 4:10 p.m. with CNA R revealed some residents wandered into other residents' rooms. She stated Resident #14 often got into other residents' beds. A interview on 05/08/15 at 11:00 a.m. with Resident #23 revealed there was a female resident (Resident #14), who often wandered into her room and crawled into her roommate's empty bed. Resident #23 was asked what she did when that occurred, and she stated, "I sit still and don't say anything. I don't know what they want and don't know what they will do." She stated she was hopeful the staff was monitoring the resident, and she hoped the staff would respond if needed. An interview on 05/08/15 at 11:15 a.m. with Resident #20 revealed she had been a resident at the facility for one month. Resident #20 stated she did not feel safe at the facility. She stated Resident #14 was always walking into her room and all over the facility. She stated she felt Resident #14 did not like her, and Resident #14 would hit her with her walker on purpose. Resident #20 explained that she was hit by Resident #14 and Resident #24. Resident #20 was asked if facility staff were aware of the incidents. She stated they were aware, and she talked to the Administrator about the incidents. When asked how the facility handled her concerns, she pointed to her head and stated, "They just say that she's just not all there." Resident #20 stated the facility staff continued to make excuses for the residents' behaviors. Resident #20 stated these problems affected her so much she began smoking again. Resident #20's MDS assessment, dated 04/17/15, reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #20's Nurses Notes reflected: "04/18/15 at 2:40 p.m.:...Reported by res (resident) that res had hit her in the chest, assessment of chest area performed, no bruises or skin breaks noted. Res does complain of pain, x-ray called in, res stated 'I called the police,' present at this time at the facility. Police report filed, res filed charges. DON and Administrator informed of changes." " 04/18/15 at 4:30 p.m.: Asked res if she wanted to move to another room on station one, res taken to room [ROOM NUMBER] and res states 'I am fine where I am.' Will continue to monitor." 04/19/15 Chest x-ray return, no definite evidence of acute fracture or dislocation. In bed one person assist...Denies pain or discomfort. Able to make needs known." Resident #20's x-ray results, dated 04/18/15 reflected: "Clinical information: PAIN...Findings: Left shoulder, two views. There is no radiographic evidence of acute fracture or dislocation..." An interview on 05/08/15 at 11:55 a.m. with Resident #21 revealed she experienced and observed many incidents with residents being aggressive. She stated this made her feel unsafe at the facility. Resident #21 stated Resident #24 hit her on top of her head with a closed fist approximately a month ago. She stated Resident #24 also entered her room a couple weeks ago, while she was in bed and her roommate (Resident #20) was sitting on the edge of the bed near the door. She stated Resident #24 walked into their room, and they told him to leave. Resident #24 did not leave, so they used their call lights to get help and began yelling for help. Resident #21 stated Resident #24 then approached Resident #20, and he punched Resident #20 in the chest. The residents called 911 because they were scared and staff was taking too long. Two staff members came in and had to "fight" Resident #24 to get him out of the room pulling him by the arms. Resident #21 stated the police came in and talked to them. She stated Resident #20 had to get an x-ray and was bruised from the incident. Resident #21 explained it bothered her that when this incident occurred, the nurse told them, "He (Resident #24) can't help it." Resident #21 stated she told administration that Resident #24 did not belong at the facility because he was very violent. She stated she talked to the Administrator, and her brother also talked to the Administrator regarding the incident. Resident #21 stated, "They don't say anything. They know what happens, and they let it happen." Resident #21 stated Resident #24 was placed on one-to-one monitoring so they could watch him. Resident #21 then described a third incident regarding Resident #25, whom she described as "always looks at me like he's fixing' to knock me out." She stated Resident #25 yelled out, "Hey!", then grabbed his crotch. She stated his behavior made her feel uncomfortable. Resident #21 stated she reported this to the nurse, and she told the nurse the next time Resident #25 did that to her she would "grab it and break it off." The nurse told her, "No, don't do that. He will hurt you!" Resident #21 stated all of these incidents made her feel like she "needs to be out of here." She stated it made it her feel unimportant because the administration did not take her concerns seriously. Resident #21 stated there were many people living at the facility that should not be at the facility because of their behaviors. She stated this caused her fear. A review of the facility's incident/accident reports for the past four months revealed there were no incident report regarding the incidents described by Resident #20 or Resident #21. A review of the facility's 24-hour report book revealed no written note of an elopement for the past week. An interview on 05/08/15 at 1:32 p.m. with the Administrator revealed he was unaware of any

Based on interview, record review, and observation, it was determined the facility failed to ensure the resident environment remained as free of accident hazards as possible for eleven (Residents #6, #14, #16, #19, #20, #21, #22, #28, #29, #30, and #33) of 39 residents, who were reviewed for supervision to prevent accidents. 1. The facility failed to provide adequate supervision of Resident #14, who was known to display aggressive behaviors and to run into other residents with her walker. On 05/05/15, Resident #14 ran into Resident #6's leg with her walker causing a large hematoma, which required the resident to be transferred to the hospital for evaluation and treatment. The failure resulted in Resident #14 sustaining a large hematoma to her right lower leg which required hospitalization . 2. The facility failed to provide adequate supervision to prevent Resident #24 from physically abusing other residents. On 04/18/15, Resident #20 was punched in the chest by Resident #24. Resident #20 did not sustain injury as a result of being hit. The resident reported the incident to the local police department. Prior to this incident, Resident #24 hit Resident #21 on the top of the head. The failure to provide adequate supervision to prevent resident-to-resident abuse could result in injury, fear, withdraw, and isolation. 3. The facility failed to prevent the elopements of two confused residents and failed to ensure there was a system in place to check the WanderGuard bracelets of those residents identified as being elopement risks. The facility also failed to ensure the gate leading away from the smoking area was locked to prevent residents from leaving the facility unsupervised. On 05/03/15, Resident #19 eloped from the facility and was found at a business establishment across from the facility. On 04/06/15, Resident #16 eloped from the facility and was found by police officers at a fast food restaurant located 0.2 miles from the facility. Both residents were found on the other side of a busy, four-lane road with a speed limit of 40 miles per hour, and neither resident sustained [REDACTED]. The facility failed to ensure WanderGuard bracelets were in place and/or functioning for the following six residents, who were identified as being at risk for eloping, Residents #14, #22, #28, #29, and #30, and #33. The failure had the potential to result in residents, with cognitive deficits, eloping from the facility and potentially being injured or seriously harmed. An Immediate Jeopardy (IJ) was identified on 05/07/15. While the IJ was removed on 05/11/15, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" due to the facility still monitoring the effectiveness of the Plan of Removal. These failures could affect all 86 residents in the facility. Findings included: 1. Resident #6's MDS assessment, dated 02/27/15, reflected Resident #6 was a [AGE] year-old female, who was admitted to the facility on [DATE] with a re-admission on 02/20/15. Resident #6 had [DIAGNOSES REDACTED]. The resident had moderately impaired cognitive skills and required extensive assistance with her ADLs. An observation on 05/05/15 at 9:00 a.m. revealed Resident #6 was in her room in bed receiving incontinent care. A hematoma or large tissue swelling was observed on her right shin. The swelling was approximately four-inches wide, eight-inches long, and appeared to be full of fluid. Resident #6 stated she got the injury when she was hit by another resident's (Resident #14) walker. An interview on 05/05/15 at 9:10 a.m. with LVN K revealed Resident #6's cognition was fair, and the resident could make her needs known. She stated the resident had Diabetes, and she was able to propel herself in the wheelchair. An observation on 05/05/15 at 11:00 a.m. revealed Resident #6 sitting by the front nurses' station in her wheelchair. The resident's right leg was hanging down, and a large raised area was on her right leg below the knee approximately six to eight-inches by four-inches wide and very swollen. The foot and ankle did not appear to be swollen. Resident #6 stated Resident #14 "bashed into it with her cart." She stated she thought Resident #14 "did it on purpose." Resident #14 passed by Resident #6, and Resident #6 pointed to her identifying Resident #14 as the person who hurt her leg. An observation on 05/05/15 at 12:30 p.m. of Resident #6 revealed the resident in her room in bed. A large raised swollen area was on the resident's right shin, and an ice bag was on the area. The resident removed the ice bag because she stated it was too painful. Resident #6 called out for pain medication. The resident's family was in the room and expressed distress at what happened to Resident #6. An observation on 05/05/15 at 2:00 p.m. revealed Resident #6 was not in her room. LVN KK stated the resident had been transferred to the hospital for evaluation of her swollen leg. An observation on 05/08/15 at 8:00 a.m. revealed Resident #6 was in the hospital. The resident was awake, alert, and sitting on the side of the bed. Her legs were visible, and the skin on her left leg had a grayish color. The right leg has a large black area on the shin measuring approximately six-inches wide and ten-inches long. The skin on the foot and upper leg appeared pink in color. The resident stated prior to the incident with Resident #14 her right leg was her good leg, and she had not had any problems with it. She stated it "really hurt me" when it happened. She revealed she now takes the narcotic pain reliever Morphine every six hours now. A phone interview on 05/08/15 at 12:00 p.m. with family member of Resident #6 revealed Resident #6 had circulation problems in only her left leg and ankle from a previous fracture on that side. Prior to the incident, she used her right leg to propel herself in her wheelchair. A hospital radiology report, dated 05/06/15, reflected Resident #6 had marked soft tissue swelling anterior to the proximal and mid tibia (shin area) of the right leg. A hospital History & Physical report, dated 05/06/15, reflected Resident #6 developed a large right lower extremity hematoma at a local nursing home. An interview on 05/07/15 at 4:15 p.m. with the DON and Medical Director revealed they wanted to clarify that Resident #6 was not sent to the hospital because she was hit by Resident's #14 walker. They stated Resident #6 had a history of [REDACTED]. Both the DON and Medical Director maintained the hematoma was a result of her circulation problems. The DON incorrectly identified the leg with the hematoma as her left leg. The DON was told the hematoma was on the right leg. She was asked if the hematoma suddenly appeared at the same time she was hit by the walker, but was not the cause of the hematoma. She replied, "Yes, that is what we are saying." The DON stated there was documentation of a history of skin and wound problems for the injured right leg in the resident's clinical record. She was asked to provide these if they showed skin issues or open wounds of the right leg. No documentation was ever provided prior to exit on 05/11/15. Resident #6's Skin Assessment Flowsheet - Non-Pressure Ulcer Conditions forms dated 03/18/15, 03/26/15, 04/01/15, 04/8/15, 04/20/15, 04/22/15, and 04/29/15 reflected the only area being treated by the Wound Care Nurse and Wound Care Physician was on the resident's left outer ankle. Pictures and documentation showed no areas on the resident's right leg. Resident #6's Skin Assessment Flow Sheet - Non-Pressure Ulcer Conditions form dated 05/06/15, following the incident, reflected "shin with (symbol used) huge Black raised hematoma...seen by (Wound Care Physician) to Hosp. (hospital)." Resident #6's Wound Care physician progress notes [REDACTED]. The area was noted to have heavy serosanguinous drainage. The Wound Care Physician documented the following additional information: "was injured by another patient and the patient's walker. See at (hospital) and inadequately drained and sent back with orders for tid (three times a day) silvadene. Will transfer to (wound care hospital) for treatment..." A Comprehensive Plan of Care, dated 05/05/15, for Resident #6 reflected the resident was care planned for a large hematoma to the right shin that measured 20.0 cm x 12.0 cm. The care plan reflected: "(5-5-15) Injury to (R) shin hit with (symbol used) walker developed excessive hematoma. Sent to hosp for eval (evaluation). 5-5-15 Returned from hosp. (5-6-15) eval. (R) leg (Wound Care Physician) sent to (hospital) direct admit..." An interview on 05/08/15 at 1:30 p.m. with the facility's Wound Care Nurse/LVN F revealed all of Resident #6's previous wound treatments were for an area on the outer aspect of the resident's left ankle. She stated she did not observe any open areas or blisters on the resident's right leg prior to the incident. She described the area on the right shin as a hematoma which measured 20 cm x 12 cm. She stated the hematoma was the size of a tennis ball when Resident #6 was initially injured. LVN F stated she did not think the hematoma was from Resident #6's chronic leg injury. She thought it was the result of the incident involving Resident #14. An Incident Report signed and dated by the Administrator on 05/11/15 reflected on 05/05/15 at 6:15 a.m. Resident #20 was sitting in her wheelchair when another resident (Resident #14) walked by her and hit her in the lower leg with a walker. The report reflected the aggressor (Resident #14) was placed on one-to-one monitoring, and her walker was removed on 05/11/15. The report further reflected Resident #20 was sent to the hospital emergency room twice. A Witness Statement was with the report and reflected Housekeeper FF witnessed Resident #14 hit Resident #20's leg. A Comprehensive Pain Assessment Form, dated 05/05/15, reflected Resident #20 reported experiencing terrible pain to her lower leg after the incident and scored it as a 10 out 10. An observation on on 05/06/15 at 10:00 a.m. revealed Resident #14 ambulating with a rolling walker down the hall. Resident #14's MDS assessment, dated 04/27/15, reflected she was a [AGE] year-old female, who was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The resident had severe cognitive impairment and wandered daily. The assessment did not identify Resident #14 as having any behavioral symptoms. The resident required only supervision for walking and used a walker for mobility. Resident #14's Care Plan, initiated on 01/19/15 reflected a care plan to address behavioral symptoms which were identified as the resident hitting another resident on the arm on 01/18/15. This care plan was continued on 03/13/15. The care planned approaches developed to address the behavior included: 1. Keep residents away from other resident at least arm length when ambulating with rolling walker. 2. Remove (Resident #14) away from other residents when she is displaying agitation. 3. Approach (Resident #14) in calm voice when she is displaying anxious or agitation towards others. 4. Notify nurse when (Resident #14) is acting out. 5. Provide redirection when (Resident #14) is agitated while ambulating throughout the facility. ...7. Document all behaviors as they occur. 8. Psych consults as needed. 9. Assess reason of...agitation. 10. Notify family of behaviors as they occur." Resident #14's Nurses Notes, dated 01/18/15 at 8:15 a.m., reflected: "Resident up (symbol used) & ambulating with (symbol used) her walker; walked by a resident sitting in her w/c (wheelchair) by nurse's station...and struck her (R) arm without (symbol used) provocation. Resident redirected...Resident had been wandering earlier in and out of rooms and striking out @ (at) CNAs as they attempted to redirect her...Administrator notified." Resident #14's Nurses Notes, dated 01/31/15, reflected: "Resident up (symbol used) and ambulating with (symbol used) her walker - wandering in and out of rooms, exit seeking (front door 4x) and combative with (symbol used) staff during redirection attempts..." Resident #14's Nurses Notes, dated 02/08/15 at 4:00 a.m., reflected: "Resident has been awake for about 45 minutes, she has been ambulating up and down the hallway and getting into other resident room, Resident is hard to be redirected, she has been verbally aggressive..." Resident #14's Nurses Notes, dated 03/05/15 reflected the following entries: 7:00 a.m. - "...Up & down halls with (symbol used) walker. Pacing constantly. Running into other residents w/c if they don't move out of her way quick enough. Constantly taking things off the med carts...Going in other residents rooms & taking their belongings. Attempted to retrieve bottle of male resident's lotion. Resident threw bottle @ this nurse." 11:00 a.m. - "...When agitated, throws glasses of water @ staff members." The next note at 11:10 a.m. reflected: "Amb quickly down hall & ran into female resident standing in hallway. When attempted to redirect, resident punched this nurse in the (R) side of mid back close(d) fisted." 12:10 p.m. - "...Walked up behind CNA, punched her in the back & then rammed walker into CNA's (R) knee, CNA cried out in pain...." 2:00 p.m. - "...Resident pushed roommate out of door way not allowing her to enter room...." Resident #14's Nurses Notes, dated 03/13/15 at 6:30 p.m., reflected: "(Psychiatrist) in facility...Res behaviors cont to escalate and her anxiety levels continue upward..." The notes reflected the resident's family member did not want the resident's psychoactive medications adjusted. Resident #14's psychiatric follow-up notes written by the Psychiatrist on 03/13/15 reflected: "Pt was seen in dayarea she was walking with (symbol used). Staff related she is easily agitated...pushes staff & residents with (symbol used) her walker & difficult to manage..." An interview on 05/07/15 at 4:34 p.m. with Resident #26 revealed Resident #14 would "bang" her walker into a person if she was going down the hallway. He stated she did this to him a month and half ago, and he witnessed her do the same to other residents. He stated he tried to avoid her. Resident #26 stated he told staff what she did, but nothing changed. An interview on 05/08/15 at 10:00 a.m. with CNA CC revealed Resident #14 ran into people with her walker. She stated she observed Resident #14 run into two residents, who were in wheelchairs. On the day of the incident involving Resident #6, she stated she heard Resident #6 screaming that Resident #14 ran into her leg with her walker. An interview on 05/08/15 at 11:12 a.m. with the DON revealed the facility addressed Resident #14's behaviors by using redirection, psychiatric treatment, and a new order for Ativan twice daily. She also revealed administration had been talking to the family about discharging the resident to another facility, but the family was resistant to the idea. An interview 05/08/15 at 11:24 a.m. with the Administrator revealed he talked to Resident #14's family numerous times. He stated the resident's family was against medication changes, but he hoped the family would let the Psychiatrist treat Resident #14. He stated there was a conference scheduled with the family and Psychiatrist in a few days. At this time, he stated Resident #14's walker was taken away with approval from physical therapy. The Administrator stated staff was providing Resident #14 with one-to-one monitoring. He stated there was still a possibility that alternate placement would be sought for the resident. An observation on 05/08/15 at 12:30 p.m. revealed Resident #14 was capable of walking without the use a rolling walker. The resident was followed by a staff member for one-to-one monitoring. An interview on 05/11/15 at 1:00 p.m. with the Psychiatrist revealed the facility staff and doctors had tried very hard to work with Resident #14 and her family. She stated the resident's dementia prevented her from knowing what she was doing. The Psychiatrist explained that Resident #14's family was uncomfortable with many medications, and the resident was very difficult to manage. She stated the family was also resistant moving her to another facility. Currently, she stated the resident was receiving the anti-anxiety medication Ativan twice daily, and she was on one-on-one supervision. 2. A resident group interview on 05/06/15 at 3:30 p.m. with seven alert and oriented residents as identified by the facility revealed several residents did not think the facility acted upon their concerns when the concerns were brought to the attention of facility administration. One resident stated that he/she invited both the DON and the Administrator to their Resident Council Meeting, and the residents explained their concerns about the facility to them. In that meeting, the residents stated they discussed other residents' behaviors, which was an on-going concern. The residents explained their concerns regarded the aggressive residents, who were being brought into the facility. They stated the number of these types of residents being admitted to the facility had been increasing since the DON came to the facility, and "turned things upside down." The residents stated they heard the DON worked at a "psych" facility before and was trying to bring those residents to their facility to live. The residents stated facility administration listened to their concerns; however, nothing was done to the address their concerns, and the problems continued. One resident stated he/she felt that the facility administration "make excuses" for the residents with behaviors. The residents stated they felt "fearful" and "scared of some residents." One resident stated he/she "doesn't look anyone the eye anymore because you don't know how they will react to you." Another resident stated it affected him/her personally as he/she had to increase his/her Ativan due to increased anxiety recently. One resident stated he/she felt the need to watch people closely as there was not enough staff around to redirect and felt he/she had to "for their own protection." One resident stated a roommate was staring at him/her making him/her so uncomfortable he/she felt they needed to sleep on the couch in the lobby. The resident stated he/she switched rooms and now has a different roommate. Multiple residents at the group meeting spoke about being a victim of aggression or affected by the behaviors of other residents. One resident stated he/she witnessed a resident (Resident #14) use her walker to "purposely" run into residents, and further explained, if you don't or cannot get out of her way fast enough, she will hurt you. One resident stated (Resident #6) was just hurt by the walker and had to be sent to the hospital because of being hit in the leg by the walker belonging to Resident #14. Residents also reported Resident #14 wandered into resident rooms and slept in other residents' beds. At least two residents stated they were recently hit with Resident #14's walker. Also during the resident group interview, residents stated an unknown male resident (Resident #19) eloped from the facility over the past weekend, and the staff were looking for the resident. They stated he was found across the street, and staff "fought him back to the facility." The residents stated Resident #19 was also the resident who pulled the fire alarm earlier on this day (05/06/15). Another resident stated he/she had seen Resident #19 trying to leave the facility before. The resident explained Resident #19, who was not a smoker, would go outside with the smokers to the smoking area. The Resident Council Minutes, dated 02/12/15, reflected nine residents were in attendance. The notes reflected residents discussed the following: "Concerned about violent resident's (sic) new/old alike." The Resident Council Minutes, dated 04/16/15, reflected 18 residents were in attendance. The minutes reflected the Administrator and DON attended the meeting by council request. The items discussed were documented as: "New residents seem to be an issue ...Worried about safety ...Chaotic after hours ...Complaint about residents we are bringing into the facility. Those residents are taking too much of the CNA's (sic) time...." An interview on 05/07/15 at 12:45 p.m. with MA M revealed many of the residents, who resided at the facility had behaviors. She stated the staff had to watch those residents closely, as well as, place them on one-to-one monitoring at times. MA M stated, "If given a chance, some residents will fight each other." A confidential interview on 05/07/15 at 12:50 p.m. with a facility nursing employee revealed the residents, who were being admitted to the facility, were not appropriate for the facility due to their behaviors affecting others. He/She stated those residents fought others, and they needed to be watched closely by staff; however, the staff could not be everywhere they needed to be so the other residents "paid for it." He/She stated the facility was more concerned with filling the beds and not taking into consideration the behaviors or histories of these residents. The nursing employee stated there were problems with resident behaviors at the facility, and the facility administration was aware of the problem, but it was not addressed. He/She stated the facility was not able meet the residents' needs, and it was not safe at the facility. An interview on 05/07/15 at 2:15 p.m. with CNA ll revealed he spent a lot of time during his shift redirecting residents. He stated he tried to manage the residents as best as he could, but some of the residents were combative and aggressive. CNA ll explained there was a resident (Resident #14), who ran into other residents with her walker. An interview on 05/07/15 at 4:10 p.m. with CNA R revealed some residents wandered into other residents' rooms. She stated Resident #14 often got into other residents' beds. A interview on 05/08/15 at 11:00 a.m. with Resident #23 revealed there was a female resident (Resident #14), who often wandered into her room and crawled into her roommate's empty bed. Resident #23 was asked what she did when that occurred, and she stated, "I sit still and don't say anything. I don't know what they want and don't know what they will do." She stated she was hopeful the staff was monitoring the resident, and she hoped the staff would respond if needed. An interview on 05/08/15 at 11:15 a.m. with Resident #20 revealed she had been a resident at the facility for one month. Resident #20 stated she did not feel safe at the facility. She stated Resident #14 was always walking into her room and all over the facility. She stated she felt Resident #14 did not like her, and Resident #14 would hit her with her walker on purpose. Resident #20 explained that she was hit by Resident #14 and Resident #24. Resident #20 was asked if facility staff were aware of the incidents. She stated they were aware, and she talked to the Administrator about the incidents. When asked how the facility handled her concerns, she pointed to her head and stated, "They just say that she's just not all there." Resident #20 stated the facility staff continued to make excuses for the residents' behaviors. Resident #20 stated these problems affected her so much she began smoking again. Resident #20's MDS assessment, dated 04/17/15, reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #20's Nurses Notes reflected: "04/18/15 at 2:40 p.m.:...Reported by res (resident) that res had hit her in the chest, assessment of chest area performed, no bruises or skin breaks noted. Res does complain of pain, x-ray called in, res stated 'I called the police,' present at this time at the facility. Police report filed, res filed charges. DON and Administrator informed of changes." " 04/18/15 at 4:30 p.m.: Asked res if she wanted to move to another room on station one, res taken to room 15 and res states 'I am fine where I am.' Will continue to monitor." 04/19/15 Chest x-ray return, no definite evidence of acute fracture or dislocation. In bed one person assist...Denies pain or discomfort. Able to make needs known." Resident #20's x-ray results, dated 04/18/15 reflected: "Clinical information: PAIN...Findings: Left shoulder, two views. There is no radiographic evidence of acute fracture or dislocation..." An interview on 05/08/15 at 11:55 a.m. with Resident #21 revealed she experienced and observed many incidents with residents being aggressive. She stated this made her feel unsafe at the facility. Resident #21 stated Resident #24 hit her on top of her head with a closed fist approximately a month ago. She stated Resident #24 also entered her room a couple weeks ago, while she was in bed and her roommate (Resident #20) was sitting on the edge of the bed near the door. She stated Resident #24 walked into their room, and they told him to leave. Resident #24 did not leave, so they used their call lights to get help and began yelling for help. Resident #21 stated Resident #24 then approached Resident #20, and he punched Resident #20 in the chest. The residents called 911 because they were scared and staff was taking too long. Two staff members came in and had to "fight" Resident #24 to get him out of the room pulling him by the arms. Resident #21 stated the police came in and talked to them. She stated Resident #20 had to get an x-ray and was bruised from the incident. Resident #21 explained it bothered her that when this incident occurred, the nurse told them, "He (Resident #24) can't help it." Resident #21 stated she told administration that Resident #24 did not belong at the facility because he was very violent. She stated she talked to the Administrator, and her brother also talked to the Administrator regarding the incident. Resident #21 stated, "They don't say anything. They know what happens, and they let it happen." Resident #21 stated Resident #24 was placed on one-to-one monitoring so they could watch him. Resident #21 then described a third incident regarding Resident #25, whom she described as "always looks at me like he's fixing' to knock me out." She stated Resident #25 yelled out, "Hey!", then grabbed his crotch. She stated his behavior made her feel uncomfortable. Resident #21 stated she reported this to the nurse, and she told the nurse the next time Resident #25 did that to her she would "grab it and break it off." The nurse told her, "No, don't do that. He will hurt you!" Resident #21 stated all of these incidents made her feel like she "needs to be out of here." She stated it made it her feel unimportant because the administration did not take her concerns seriously. Resident #21 stated there were many people living at the facility that should not be at the facility because of their behaviors. She stated this caused her fear. A review of the facility's incident/accident reports for the past four months revealed there were no incident report regarding the incidents described by Resident #20 or Resident #21. A review of the facility's 24-hour report book revealed no written note of an elopement for the past week. An interview on 05/08/15 at 1:32 p.m. with the Administrator revealed he was unaware of any resident behaviors. He stated he was unaware there were 22 incident/accident reports involving resident-to-resident altercations within the past three months. He stated this was not brought to his attention. The Administrator stated any time there was a resident-to-resident incident he was supposed to be informed because he was responsible for determining whether to investigate and report to DADS. The Administrator stated they "don't have the right people here" to report what was occurring and as a result he was unaware of what was happening. The Administrator was asked who determined whether a resident was admitted to the facility. He stated it was an interdisciplinary team decision, and the interdisciplinary team consisted of the DON, MDS Nurse, and the Business Office Manager. The Administrator explained the residents consisted of "a mix" of residents with varying needs, and they "need to care for all our residents." He explained that when resident-to-resident incidents occurred, they immediately separated the residents and put interventions in place including alternate placement. During the same interview, concerns were discussed with the Administrator regarding Resident #14 and the complaints voiced by other residents of her running into the residents with her walker. The Administrator explained that Resident #14 has "no mental concept" of what she was doing. He stated he did not think she was doing it intentionally, but acknowledged that residents were tired of her behavior. He stated her behavior was affecting the other residents. He stated they were working with the family currently to come up with a plan. The Administrator denied knowing of the incident regarding Resident #20 being punched in the chest on 04/18/15. He stated he was unaware the police were called to the facility at the time of the incident. He stated the incident should have been called into the State, but first of all, should have been reported to him. The Administrator stated he did not understand, and shook his head. The Administrator stated he was the Abuse Prevention Coordinator for the facility. An interview on 05/08/15 at 2:05 p.m. with the DON revealed she was invited to attend the Resident Council Meeting, and the residents expressed concerns about some the residents that were being admitted to the facility. She stated the residents felt as though care was being taken away from them, and the residents were concerned about some of the residents acting out with behaviors. The DON stated she explained to the Resident Council that the interdisciplinary team decided as a team who lived at the facility. The DON acknowledged she was aware that some residents were concerned for their safety. She added, "Everyone needs somewhere to live." The DON was asked about the incident which occurred on 04/18/15 involving Resident #20 and #21, in which the police were called. The DON stated she recalled that the police were called and thought it was in regards to Resident #21 complaining that a resident hit her on the head. The DON stated that Resident #21's story changed because the resident reported that she was hit on the head, and then later stated she was hit in the chest. The DON was not able to identify that these were separate incidents which occurred. The DON denied knowledge regarding Resident #20 being punched in the chest on 04/18/15. In addition, she was she unaware an x-ray was obtained for the resident. The DON stated there was not an incident report for the incident in which Resident #24 hit Resident #20 in the chest because they were unaware of the incident. The facility's current Behavior Assessment-Management Interventions policy and procedure, revised November 2013, reflected: "Policy: It is the policy of this home to have a behavior intervention and management program to prevent, reduce, or eliminate inappropriate behaviors, which may be detrimental to the individual or other as well as to establish and maintain an ongoing assessment program that enables staff to be effective in our goal to provide a better quality of life for our residents. ...The home should consider resident behavior inappropriate if it: · Presents a risk of danger or harm to the resident. · Presents a risk of danger or harm to others. · Interferes with resident or other residents' optimal functioning and or · Significantly

Based on observation, interview and record review, the facility failed to ensure adequate supervision and assistance devices were in place to prevent accidents for three (Residents #1, #12 and #13) of eight residents reviewed for accidents. The facility failed to implement interventions, consistent with their needs, goals, plan of care, and standards of practice. 1) Resident #13, who required two people to transfer, using a Hoyer lift, sustained a left shoulder neck fracture. The facility failed to ensure nurse aides were informed of the correct transfer procedure for Resident #13. Resident #13 was transferred to an assisted dining room area and was left unsupervised in the room. Resident #13 fell on her face and sustained diagnoses of Closed Head Injury, Neck Pain, and Shoulder Contusion. The facility failed to ensure staff were aware and knowledgeable Resident #13 and the other 40 residents who were in a wheelchair all or most of the time, were not to be left unsupervised when in their wheelchairs. 2) Resident #1 was not provided adequate supervision, assistive devices and/or re-evaluations to prevent falls and multiple bruises on her right forehead and eye. 3) Resident #12 was not provided with a personal safety alarm to the bed as ordered by the physician. These failures placed Resident #13 and the other 40 residents in the facility, who required assistance for transfer and supervision, at risk for injury including bruising, abrasions, skin tears, closed head injury, subdural hematoma, dislocation of limbs, and fractures. Findings included: 1) Observation of Resident #13 was made during the initial rounds on 05/29/13 at 10:04 AM. During rounds CNA N stated Resident #13 was alert to self only, was incontinent of bowel and bladder, and required assistance with feeding and all her activity of daily living needs. Resident #13 also required the use of the Hoyer lift for transfers. CNA N stated 2 to 3 weeks prior, Resident #13 had a fall and also a fracture of the shoulder. Resident #13 did not speak English. CNA N further stated Resident #13 had a history of [REDACTED]. The surveyor also observed Resident #13 to have a stuffed pad/pillow under her clothes on the left side of her shoulder. Review of the face sheet record, dated 05/01/12, reflected Resident #13 was a [AGE] year old female who did not speak English. The most current annual Minimum Data Set (MDS) assessment, dated 05/02/13, reflected diagnoses that included Depression, [DIAGNOSES REDACTED] and Left Heart Failure. Further review of the MDS revealed Resident #13 had no fall history from since admission. In an interview with the facility Corporate Nurse (CN) on 05/30/13 at 4:10 PM, she stated to the surveyor, "I just figured out how she fractured her shoulder." The surveyor asked the CN how Resident #13 fractured her shoulder. The CN stated Resident #13 was always seen by staff hitting her left shoulder with her right hand and because she had Osteoporosis and Osteopenia, she fractured herself on the left shoulder bone. The surveyor inquired from the CN if the problem was care-planned. The CN stated she would check. On 05/31/13, the facility RNC presented the surveyor a care plan sheet, dated 07/03/12, for "behavior problem: Hits self in the chest and on the thigh. The "on the thigh" had a line drawn through it and a hand written note reflected: "at risk for bruising related to behavior." The care plan reflected this was reviewed 02/21/13. The approaches identified by the facility for this behavior were: 1) Approach resident in a calm manner; 2) Speak to resident in a calm voice; 3) Explain all procedures; 4) Listen attentively; 5) Attempt to redirect; 6) Attempt to get resident involved in problem solving; 7) Update family about resident behavior and involve them in problem solving; 8) Contact physician as needed; and 9) Place a small pillow over chest. Approach #9 was added, per the care plan on 02/21/13. Interviews with the ADM, DON, ADON, CN, and RNC revealed they do not know whose writing it was that modified the care plan on that date. Observation of Resident #13's skin was made on 06/03/13 at 2:00 PM, with CNAs F and W. The left shoulder was observed with a small pinkish bruise and the area was slightly bigger than the right side. Review of Resident #13's most current Annual MDS assessment dated [DATE], revealed Resident #13 was a [AGE] year-old female with diagnoses which included Depression, Left Heart Failure, [DIAGNOSES REDACTED], Muscle Weakness, and Lack of Coordination. The MDS assessment also reflected Resident #13 required extensive assistance with transfers and needed two people to assist. The Quarterly MDS dated [DATE], also reflected Resident #13 was totally dependent for transfers and required two people to assist. The 08/07/12 MDS assessment, also reflected Resident #13 had a fall with injury. The Annual MDS assessment, an dated 05/02/13, reflected Resident #13 required extensive assistance with transfers and assistance of two persons. The MDS assessment reflected Resident #13 had not had any falls since admission/entry and/or re-entry. The number of falls area reflected a blank space; however, the clinical records reflected Resident #13 fell on [DATE]. Review of Resident #13's Annual MDS assessment, dated 05/02/13, reflected the resident scored 3 for the cognitive skills for daily decision-making. Resident #13 had problems with long-term and short-term memory. Review of the fall risk assessment, dated 02/07/13, revealed the assessment was for a post-fall and a quarterly assessment. Resident #13 scored 13 on the assessment which indicated a score of 10 which indicated a high risk for falls. Review of Resident #13's current comprehensive care plan, dated 05/07/13, revealed no care plans for fall risk. The care plan reflected Resident #13 had an inappropriate behavior of hitting self with right hand fist on left chest and left shoulder area. The potential for self injury reflected Osteoporosis. The approaches identified for this problem were: Assist with a gentle and calm manner; Provide and place a small pillow on left upper chest; When resident becomes physically aggressive, redirect when inappropriate; Administer medications as ordered; Discuss concern of behavior with Medical Director (MD), Responsible Party (RP), Social Services (SS) and the potential consequences; Psychological services and when indicated; The comprehensive care plan reflected Resident #13 had a recent fracture and was at risk for increased pain. Some of the approaches identified for this problem were; Assist with activities of daily living/repositioning on routine rounds use positioning devices for proper body alignment; and ensure arm sling is on left arm. The care plan reflected Resident #13 required total assistance with her activity of daily living needs (ADLs) and required the assistance of two for transfers. Interview with the facility CN on 05/31/13 at 2:00 PM, revealed the care plan was updated after the fall and identification a fracture to the resident's left shoulder area. The CN was informed there were no care plans in the clinical records that addressed the resident's history of falls and transfers. On 06/03/13, the surveyor observed a care plan in the clinical record which revealed: Resident has a history of falls and is at risk for increased falls and/or fracture as evidenced by: Cognitive impairment, Non-Weight Bearing and Physical impairment. Some of the approaches identified for this problem were: Resident will not be left alone in the dining room after meals; Ensure call light is within reach, answer promptly; Reposition resident in chair for correct positioning frequently; Use high back wheelchair with a pommel cushion to assist with maintaining body position; and Use scoop mattress on bed to assist resident when in bed. There were no directions for the staff as to how Resident #13 would get from bed to wheelchair, wheelchair to bed, and what method and how many should be involved. Review of the Incident/Accident report faxed to the State Office on 05/09/13 at 16:49 p.m. (4:49 p.m.) revealed Resident #13 had an injury, broken bone related to fall. The date of the incident was 04/15/13 at 5:00 p.m., in the dining room. The description of the allegation reflected the resident was found on the floor in the dining room. The injury/adverse effect was a fracture to the left shoulder. Description of injury: Acute comminuted fracture of Humeral neck with minimal displacement and angulation. The report reflected that resident had complained of pain to the left shoulder . The provider response reflected the resident was immediately sent out after the fall to an area hospital. The report reflected that the hospital report revealed that due to the severe Osteopenia, the shoulder was suboptimally seen. However, the resident continued to complain of pain. An X-ray taken on 04/29/13, revealed a fracture. The resident was sent back to the hospital. The summary of the investigation on this report, reflected Resident #13 was left alone in the dining room in preparation of getting all the feeders to the feeding room. The staff when she returned to the dining room found the resident on the floor. Another Incident/Accident Report, dated 04/15/13 at 5:00 PM, revealed Resident #13 was found on the dining room floor, lying prone, landing on her forehead, legs hanging on the wheelchair. The report reflected Resident #13 sustained a hematoma to her left forehead and swelling to the right upper lips. The resident was sent to the hospital. The report revealed staff were interviewed and stated resident was last observed sitting in the wheelchair in the dining room. The report also reflected Resident #13 did not have supervision oversight while in the dining room. The final disposition was that pommel cushion was placed on her wheelchair to reduce occurrence of sliding down in chair. Review of an Incident/Accident report, dated 04/29/13 at 1:00 PM, revealed an X-ray was done to Resident #13's left shoulder, and it revealed Resident #13 had an acute comminuted fracture of the Humeral neck and head with minimal displacement and angulation. The report reflected the injury was of unknown origin. Review of the telephone order for 04/16/13, revealed an order to readmit Resident #13 to the facility. The telephone order reflected Resident #13 had diagnoses of "closed head injury, neck pain, and shoulder contusion." The X-ray report from the hospital, dated 04/15/13, reflected on the left shoulder that there was no definite acute fracture or dislocation of the left shoulder. Due to severe Osteopenia, the shoulder was suboptimally seen. The impression reflected: "No definite evidence of acute fracture or dislocation of the left shoulder." The telephone order, dated 04/29/13, reflected an order for [REDACTED]. The Radiology Report, dated 04/29/13, reflected that there was an acute comminuted fracture of the humeral neck and head with minimal displacement and angulation. Review of the nurse's notes, dated 04/15/13 at 4:45 PM, revealed an entry from the facility Corporate Nurse (CN) at that time. The nurse's note reflected Resident #13 slid out of her wheelchair during dinner. The nurse's note on 04/15/13 at 5:20 PM, reflected Resident #13's left frontal side was swollen with a dent on the right side of her upper lip. Facility staff applied ice packs to the left frontal side of her face. Review of the nurse's notes, dated 04/15/13 at 8:48 PM., revealed an order was received from the physician to send the resident to the hospital. The nurses' note reflected Resident #13 was sent to the hospital at 9:10 PM. The Provider Investigation Report, sent to the State Office by the facility, dated 05/09/13 at 4:49 PM reflected: "patient injury broken bone r/t (related to) fall on 04/15/13." Continued review of the nurse's notes revealed Resident #13 returned to the facility on [DATE] at 3:00 AM, with the swelling on her face decreased, and she had a sling to the left hand. The nurses' notes reflected that a fall mattress was placed on the floor and the call light placed within reach. Review of the nurses' note, dated 04/16/13 at 10:00 AM, reflected the sling was in place on the left arm, and the resident had no signs and symptoms of pain or discomfort. At 7:00 PM, during the same date, the nurses' note reflected there were no injuries noted from the fall, and the sling remained in place. On 04/17/13 at 1:00 AM, the nurses' note reflected Resident #13 had no late injuries observed at that time. No signs and symptoms of pain or discomfort was noted and no swelling and complaint of the forehead. On 04/17/13 at 9:00 AM, the nurses' note reflected there were no delayed injuries from the fall. At 7:00 PM, the nurses' note reflected: "No pain/discomfort noted. No further injuries noted from the fall." The nurses' notes on 04/18/13 at 1:00 AM, 10:00 AM, 7:00 PM, and on 04/20/13 at 2:00 AM and 4:30 PM, and on 04/21/13 at 2:00 AM, all reflected Resident #13 had not shown signs and symptoms of pain, discomfort or swelling from the fall. On 04/21/13 at 11:00 a.m., the nurses reflected that Resident #13's family member notified the nurse at that time that Resident #13 complained of pain to her left shoulder area and was requesting pain medication. Tylenol was administered to the resident at that time. There was no documented assessment of the left shoulder area by the nurse. The nurses' notes dated 04/22/13 at 2:00 AM and 11:30 AM, reflected Resident #13 had denied complaints of pain, and there were no signs and symptoms of pain and/or discomfort. The nurses' notes dated 04/29/13 at 3:00 AM, reflected the nurse was notified by the CNA from the 2:00 p.m. to 10:00 p.m. shift, that Resident #13 had swelling and pain on the left shoulder. The note reflected assessment was completed and the resident showed signs of pain when the left shoulder was touched. An X-ray was ordered at that time. The nurses' notes, dated 04/29/13 at 1:00 PM, reflected: "Positive x-ray report received. Acute comminuted fracture of the Humeral Neck and Head with minimal displacement and angulation noted." The nurses' notes reflected an order was received from the physician at 1:30 PM to send the resident to the hospital. However, Resident #13 was not transferred to the hospital for treatment until 3:30 PM. (Note: It had been 14 days since Resident #13 was found face down in the dining room area with no diagnoses of fracture.) An interview with CNA N on 05/31/13 at 11:00 AM, revealed she had observed Resident #13 several times wiggling out of her low bed to the floor mattress, and that she had a history of [REDACTED]. CNA N stated she usually called in CNA R or the RA to speak to the resident in her language. CNA N stated most times she hits herself was when she needed something or was in pain. The interview revealed that she had not been interviewed about the resident's behavior and/or incident. CNA N stated after the fall, Resident #13 did not complain of pain as much. Now when you touch the arm she would cry and pull away. CNA R was interviewed on 05/31/13 at 11:54 AM. CNA R stated Resident #13 would hit her chest or thigh when in pain. She would ask her when she observed her doing that timeand the resident would tell her she was in pain. The RA was interviewed on 05/31/13 at 11:59 AM. The interview revealed Resident #13 would hit her chest when she was in pain, wanted to talk, or wanted water. The RA stated the resident also used to pat her thigh, but now mostly her chest. The RA stated she came to the resident's room about 9:00 AM on 04/29/13, and she told her to go get the nurse. The RA the stated resident did not have to tell her she was in pain because it was all over her face that something was wrong. Staff stated the nurse no longer worked in the facility; however, when the nurse came she reported to the nurse that her shoulder hurts. The nurse asked through her what happened to it. The resident stated she could not remember why the shoulder hurts more. The RA stated Resident #13 was confused and could not remember. However, she heard the resident tell her family she fell , but could not remember the details of the fall. An interview conducted with CNA P on 05/31/13 at 12:45 PM, revealed Resident #13 would hit her chest or thigh area when she was in pain. CNA P stated she was caring for Resident #13 when she removed her shirt and noticed the shoulder was swollen, and the resident grimaced and cried out during care. She reported it to the charge nurse on her shift and the nurse went to the resident's room. CNA P stated she also reported to the aide on the 10:00 PM to 6:00 AM shift. CNA P stated her nurse also told her Resident #13 had fallen, did not know when, but was concerned that the resident was yelling and crying when she was removing her shirt. The interview also revealed Resident #13 was a two person transfer and staff did not use the Hoyer lift until after the fall. Staff used the Hoyer pad to transfer the resident. LVN J was interviewed on 05/31/13 at 1:05 PM. LVN J stated Resident #13 required total care with all her activity of daily living needs. Staff were using the sling pad of the Hoyer lift to transfer the resident, but now used the Hoyer lift. LVN J stated Resident #13 was now on constant pain from the fracture which he believed did not occur during the fall. LVN J stated the CNA reported to him that the resident had swelling, was agitated, and in pain. He called the physician and received an order for [REDACTED]. He stated the first fall was negative for a fracture. The interview also revealed that the resident's family member had told staff that when his/her mother hits her chest or thigh, that it meant she was in pain or needed something done for her. CNA V was interviewed on 06/02/13 at 7:53 PM. CNA V stated she had cleaned and wheeled Resident #13 to the dining room and left her there with other residents. She left the room to get four more residents and the other staff members were doing the same. The interview revealed that one staff was supposed to be in the room, but was not as she was also bringing residents to the dining room. CNA V stated when she returned to the dining room, she observed Resident #13 with her head in front of a wheelchair in front of her. Resident #13's legs were on the top of her foot rest. She observed a hematoma on the left side of her forehead, she had bit her lip, and she had a bruise on it. CNA V stated the fracture was identified the next day after the fall. She also stated that it was only the resident's forehead that was swollen since the fall on 04/15/13. Review of the facility's fall prevention policy and procedure, dated 03/20/12, provided by the facility RNC on 06/03/13, revealed that it was the facility policy to evaluate residents for their fall risk and develop interventions for prevention. Risk factors associated with fall. The following were examples of common intrinsic risk factors: Gait and balance disorder; Muscular weakness (particularly of the lower extremities); Dizziness or vertigo; Confusion; Incontinence; Previous falls, etc. FOLLOWING A FALL, THE FOLLOWING STEPS SHOULD BE UNDERTAKEN: Evaluate the resident promptly in order to identify and treat injuries...Following the resident's evaluation, transfer the resident to the appropriate surface and evaluate further if indicated. Monitor closely for indications of pain or discomfort in any area, reddened or discolored areas, or other signs of any injury. ...Ask the resident what happened prior to the fall or what may have caused the fall. ...If the fall was unwitnessed, initiate the investigation including statements from staff and residents. Try to determine who was the last person to see the resident prior to the fall and the resident's condition at that time. EDUCATION OF STAFF RELATED TO FALL PREVENTION: To include; Safe transferring techniques; and Use of assistive device. 2) During initial tour on 05/29/2013 at 10:10 AM, Resident #1 was observed sitting in her wheelchair in the activities room. CNA N stated Resident #1 was alert, oriented sometimes, required one person assistance with ADLs (activities of daily living), was continent of bowel and bladder, and was on a toileting program. On 05/29/2013 at 11:30 AM, Resident #1 was observed sitting in a wheelchair in the hallway outside of the nurses' station and an alarm and seat cushion were in use. The resident was dressed, appeared clean and was odor-free. Resident #1 was noted to have a large and slightly swollen dark purple bruise on the upper right forehead area and a dark purple bruise around her right eye. She was wearing geri-gloves covering both arms from hand to elbow. Numerous small bruises were noted above the gloves on her upper arms. In addition, her legs were covered with TED stockings from toes to mid-calf bilaterally. She was not wearing shoes. Her legs were slightly swollen, feet resting in the wheelchair footrests. In response to a question about her bruises, CNA N stated Resident #1, "is black and blue because I think she fell last weekend when I was off." Review of an interviewable resident list provided by the facility on 05/29/13 revealed Resident #1 was not interviewable. On 05/29/13 at 12:10 PM, Resident #1's room was observed with a floor mat folded up by the bedside, and a helmet on a shelf above the sink. When asked about how often the resident wore the helmet, CNA N stated, "She always takes it off," and "we've tried but can't get her to wear it." Review of the Physician order [REDACTED].#1's physician, was originally dated 07/25/12. (Note: During observation on the initial tour of 05/29/13, no helmet was observed on Resident #1.) Resident #1 was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses including: Hypertension, End-Stage Renal Disease, [DIAGNOSES REDACTED], Transient Ischemia, Non-Alzheimer's Dementia, [DIAGNOSES REDACTED], and [DIAGNOSES REDACTED] small intestine, per the annual MDS assessment, dated 03/27/13. Further review of this assessment revealed the resident required extensive assistance with transfers, toileting, was always incontinent of bowel and bladder, and one fall since admission/entry or re-entry or prior assessment, whichever was more recent, and sustained no injuries. Also, upon admission to the facility on [DATE], the Admission/Readmission Data Summary, completed by RN K, revealed Resident #1 was confused, with unstable gait, weakness, history of syncope or seizures, with a fall in the past 3 months. In addition, the summary contained a drawing showing three stitches on the right side of the head with an abrasion on the right hip, and abrasions on the right and left forearms. RN K noted Resident #1 was continent of bowel, and continent of bladder with physical/verbal assist (can't be left alone). In a note on page 6 of the summary, RN K noted Resident #1 was "...a high fall risk, mat placed at bedside." Review of a Fall Risk Assessment Form for Resident #1, dated 02/23/13, reflected a total score of 29. The assessment notes that a score of 10 or more indicates high risk for falls. On 05/06/13, a Comprehensive Care Plan was written for abnormal bleeding and bruising from anticoagulant therapy for a possible DVT (deep vein thrombosis). In addition, a Comprehensive Care Plan of Care, dated 05/09/13, identified the resident as being at high risk for increased bleeding due to Coumadin therapy, with twelve accompanying approaches. Per Mosby's 2013 Nursing Drug Reference, 26th edition, p.1227, Coumadin is classed as an anticoagulant that interferes with blood clotting, is used in the treatment of [REDACTED]. Review of the Care Plan dated 03/28/13 for Resident #1 revealed: - Problem: History of Falls; Risk for Fractures - Goal: Dignity will be maintained incidence of falls will be reduced and no occurrence of injury will occur over the next 90 days. - Approach: 1) Encourage resident to ask for assistance of staff; 2) Ensure call light is within reach, answer promptly; 3) Therapy to eval (evaluation) and treat per orders; 4) Anticipate needs, provide prompt assistance; 5) Assure lighting is adequate and areas are free of clutter; and 6) Encourage socialization and activity attendance - as tolerated There were no additions/revisions added to the 'Falls' Care Plan of 03/28/13, found of record. Two additional care plans for falls were established on 05/26/13 (established after Resident #1's second fall of 05/26/13), with additional information about assessing need, and maintain adaptive and safety devices (without naming the safety devices), encouraging restorative/exercise program, arranging suitable seating, and if resident falls follow procedure Falls Critical Pathway. Another care plan relating to falls was established on 05/28/13, with additional information about encouraging resident to wear a helmet for head protection. Review of Incident/Accident Reports in the last three months, March - May 2013, for Resident #1 revealed a fall on 05/06/13 at 1445 hours (2:45 PM) when she sustained a slight bruise injury to the bridge of the nose and left foot, and a fall on 05/26/13 at 3:45 PM, when she sustained bruise injuries to the forehead, right shoulder, and right forearm. Review of Incident/Accident Report by RN K, dated 05/06/13 revealed: - Location of Incident: "Another resident's room - Rm #1." - Witness Statement/Brief Summary of Incident by CNA L - "At 2:45 PM patient was found in another resident room #11 coming from bathroom. Patient had complained on her knee for pain on left foot. She has redness on her nose." - Outcome of Interview with staff: "Resident found on her knees - upper body supported by wheelchair. Assessment did not reveal any acute injury. Res A&O (alert & oriented) X (times) 2." - Was reasonable root cause of occurrence established? "Yes." - State Cause: "CNA not making rounds to ensure all residents were safe. Resident required toileting." - Final Disposition: "CNA L verbally counseled regarding not ensuring residents are safe at change of shift and chair alarm operating - Resident maintains functional status." (Note: Rooms #1 and #11 were used as the location on the Incident/Accident Report of 05/06/13. Room #1 contained two residents. Room #11 was vacant, had no resident plaque on the wall, was not listed in the Resident Bed List Report of 05/29/13, and appeared to be used for a staff training room. In an interview on 06/03/13 at 9:05 AM with Resident #16 revealed she did not remember any resident falling in her room on Monday, 05/06/13. Per initial tour of 05/29/13, CNA N stated that Resident #16 was alert and oriented X3, bedfast and paraplegic, and did not leave her room. The MDS assessment, dated 01/30/13, for Resident #16, revealed a BIMS (Brief Interview for Mental Status) total score of 15, recall of 2 (no cue required). Review of an interviewable resident list provided by the facility on 05/29/13, revealed Resident #16 was interviewable. Review of Nurse Progress Notes, dated 05/06/13 at 2:45 PM, revealed the resident was observed "in another resident's room on knees, upper body supported by wheelchair. Resident toileted self and was unable to return to wheelchair, which was positioned at door of rest room. c/o (complaint of) mild pain both knees and left dorsal foot. Has bruise bridge of nose - bruise left dorsal foot. Observed resident to have TED hose on removed - noted 4+ (plus) edema bilateral lower extremities." In an Interview on 05/31/13 at 2:00 PM, CNA L was asked what happened on 05/06/13 with Resident #1. CNA L stated as she was walking down the hall around 2:45 PM on 05/06/13, she heard shouts for help coming from Room #11. She found Resident #1 on the floor in between the bathroom door and room. Resident #1 had a wheelchair alarm, but it was off. CNA L put Resident #1 back into her wheelchair, turned the alarm back on, and checked that the alarm was working. CNA L noted Resident #1 had a slight red area on her nose, but denied any pain. When asked how she helped to prevent falls for the resident, CNA L stated Resident #1 was on a Toileting Program, and every 2 hours she took Resident #1 to the bathroom. CNA L corroborated that she was counseled about checking the wheelchair alarms, and proper supervision of residents. Review of the Contracture Primary Risk Factors Screening Form, dated 02/07/13 revealed: "Weakness - occasionally falls down if tries to walk or stand. General pain - chronic back pain. Painful joints - right hip pain when applying pressure." Review of Physical Therapy (PT) reports indicate the last report of record was dated 03/14/13, with a notation that "patient has reached maximum rehab potential at this time and will discontinue from therapy." During an Interview on 06/03/13, the PT Supervisor indicated she was notified through interoffice communications from the nursing staff whenever a resident had a fall. She was notified on 05/07/13, by the nursing staff about Resident #1's fall on 05/06/13. She stated PT recommended a helmet which she did not like to wear. She corroborated that the last PT report, dated 03/14/13, noted that "patient has reached maximum rehab potential at this time and will discontinue from therapy." When queried about any PT interventions after 03/14/13, she stated, "We all keep an eye on her, PT and nursing. She's supervised, and when she's discontinued from PT, she's placed on Restorative." Review of the Restorative Program Flow Sheet for March and April 2013 revealed: - March: Twenty-six 15 minute sessions during the day shift to provide dressing or grooming; twenty-six 15 minute sessions during the day shift to provide lower extremity dressing; twenty-six 15 minute sessions during the day shift to provide upper extremity dressing; twenty 15 minute sessions during the day shift, and two 15 minute sessions during the evening shift to perform active range of motion to bilateral upper extremities - April: Eight 15 minute sessions and one 8 minute session during the day shift to provide dressing or grooming; seven 15 minute sessions and two 10 minute sessions during the day shift to provide lower extremity dressing; six 15 minute sessions, one 16 minute session, and two ten minute sessions during the day shift to provide upper extremity dressing; and five 15 minute sessions during the day shift, and one 15 minute session during the evening shift for active range of motion to bilateral upper extremities. During an interview on 05/30/13 at 3:10 PM, when the DON was asked what, if any, 'Fall' care plan revisions were made for Resident #1 and/or specific interventions were enacted by the facility to prevent falls since 05/09/13 for Resident #1, the DON indicated she was new, had been in the facility since 04/09/13, and would need to consult the chart. She stated, "A chair alarm was implemented after 05/06/13, a care plan was implemented stating nursing goals of communicating with staff members, and there was an emphasis to keep the resident in open areas and supervised. In addition, she had made telephone calls to the physician and PT Supv for implementation of a 'lap buddy,' and other interventions will be considered by PT tomorrow. Regarding the discrepancy in the Fall Risk Assessment forms of 02/23/13 (score of 29) and 05/26/13 (score of 17), the DON indicated, "two different people assessed the resident and the scores are subjective." During an interview on 06/03/13 at 10:20 AM, the DON was asked to produce a copy of the 'Critical Pathways Procedure' (per Fall care plan of 05/26/13). She provided a copy of 'Falls - Evaluation and Prevention' effective 01/2008, and said she believed this was 'Critical Pathways,' but was unsure if it was current. The RNC also pulled a copy of the 'Falls - Evaluation and Prevention' effective 01/2008, revised 03/2012, that appeared nearly identical to the policy pulled by the DON. Review of both policies indicated: "Residents should be evaluated for their fall risk on admission/re-admissio

Based on observation, interview, and record review, it was determined the facility failed to provide the necessary care and services to help each resident attain or maintain their highest practicable physical, mental, and psychosocial well-being. The facility's failures included: When Resident #13 complained of pain and swelling in her left shoulder on 04/29/13, CNA R told LVN Q, who questioned the resident, but did not assess her or arrange for any care and/or treatment. LVN Q stated this new pain and swelling was from her fall on 04/14/13, more than two weeks previously. On 04/29/13, CNA P told LVN T on the night shift about Resident #13's complaints and the LVN immediately assessed her. However, x-rays were not called for until 3:00 a.m. and the LVN did not call for a stat x-ray. The resident's x-ray was not done until almost noon, more than 12 hours since the pain and swelling of Resident #13's left shoulder was first identified. The results were not received until 1:00 p.m. on 04/29/13 and identified a [MEDICAL CONDITION] shoulder. These failures to provide a timely assessment, to respond immediately and ensure Resident #13 had pain medication, which would ease her pain left the resident with unrelieved pain and a delay in treatment. These failures could affect the facility's 70 residents and placed them at risk for not receiving timely interventions with a change in condition. Findings included: Observation of Resident #13 was made during the initial rounds on 05/29/13 at 10:04 a.m. During rounds CNA N stated Resident #13 was alert to self only, was incontinent of bowel and bladder, and required assistance with feeding and all her activity of daily living needs. Resident #13 also required the use of the Hoyer lift for transfer. CNA N stated 2 to 3 weeks prior, Resident #13 had a fall and also a [MEDICAL CONDITION]. Resident #13 did not speak English. CNA N stated the facility utilized two female staff to interpret and speak to the resident. CNA N further stated Resident #13 had a fall history and was a fall risk. The surveyor also observed Resident #13 had a stuffed pad/pillow under her clothes on the left side of her shoulder. Review of the face sheet record, dated 05/01/12, reflected Resident #13 was a [AGE] year old female, who did not speak English. The most current annual Minimum Data Set (MDS) assessment, dated 05/02/13, reflected [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #13 had no fall history since 05/01/12. Review of the care plans, dated 05/07/13, revealed Resident #13's care plan had not been updated to reflect she had a history of [REDACTED]. Review of the new care plan, dated 06/03/13, revealed, "1) Resident will not be left alone in the dining room after meals." The care plan, dated 05/07/13, revealed Resident #13 "hits self in the chest" and was at risk for bruising due to this behavior. However, the care plan did not address the fact that the resident could be in pain and the hitting her chest could have been a sign of distress. The facility's incident/accident report, dated 04/15/13 at 5:00 p.m., reflected Resident #13 was found on the floor in the dining room in a prone position, having landed on her forehead with legs hanging on the wheelchair. The incident/accident report also reflected Resident #13 "did not have supervision oversight while in dining room." Review of the nurses note, dated 04/15/13 at 4:45 p.m., revealed a note from the facility Corporate Nurse (CN) revealing Resident #13 slid out of the chair during dinner. Review of the nurses note, dated 04/15/13 at 5:20 p.m., reflected the physician was notified of the fall. Resident #13's face was described as "swollen with a dent on the right side of her upper lip area." The nurse's note at this time revealed Tylenol 325 mg (milligrams) was administered for pain. The nurse's note at 5:45 p.m. reflected medication was effective at that time. On 04/15/13, the nurse's notes at 8:48 p.m. revealed an order was received from the physician to transfer to the hospital for evaluation. The nurse's note at 9:10 p.m. revealed the ambulance came and transported the resident to the hospital. The nurse's note at 3:00 a.m. on 04/16/13 reflected Resident #13 returned from the hospital. The nurse's note reflected Resident #13 had no signs and symptoms of distress, swelling to left side of forehead had lesssened, sling to left arm in place. Review of the telephone order dated 04/16/13 revealed an order to readmit Resident #13 to the facility. [DIAGNOSES REDACTED]. Review of the X-ray report dated 04/15/13 at 10:34 p.m., revealed there was no evidence of an acute fracture or dislocation of the left shoulder and due to the severe Osteopenia as the shoulder was sub optimally seem. The facility received information of Resident #13's injury post fall after several hours the incident occurred. The nurse's note, dated 04/21/13 at 11:00 a.m., reflected Resident #13's family member, who was visiting the resident reported to the charge nurse LVN T Resident #13 was in pain. Resident #13 complained of left shoulder pain and was requesting pain medication. The nurse's note reflected "needed Tylenol pain medication was provided." The nurse's note did not reflect how much pain medication was given. In addition, the nurse's note did not reflect an assessment to the left shoulder or Resident #13's pain had been performed at that time. LVN T was interviewed on 06/03/13 at 10:40 a.m. LVN T stated she did not assess the left shoulder and did not ask the resident to use a pain scale on 04/21/13 as she did not speak English and she did not ask the family member, who was visiting to question the resident further. The nurse's note, dated 04/29/13 at 3:00 a.m., reflected the nurse was notified by CNA P from the 04/28/13 2:00 p.m. to 10:00 p.m. shift Resident #13 had swelling and pain to her left shoulder. The shoulder area was immediately checked according to the nurses notes. Resident #13 exhibited signs of pain when the left shoulder was touched. At 1:20 a.m., the nurse's note reflected the resident was medicated with pain medication. The X-ray company was notified at 3:00 a.m. of the need for an X-ray. However, facility staff did not send the order as urgent. On 04/29/13 at 10:30 a.m., the nurse's note reflected Resident #13 complained of pain when the left shoulder was touched. The note also reflected an X-ray report was pending. However, interview with the employee from the X-ray company stated the X-ray was ordered at 3:00 a.m. and the X-ray staff arrived at the facility at 11:52 a.m. to obtain the X-ray. The result was sent to the hospital at 1:00 p.m., which was more than 24 hours since Resident #13 had initially complained of the left shoulder pain. Review of the X-ray report dated 04/29/13 revealed Resident #13 had sustained an acute comminuted [MEDICAL CONDITION] neck and head with minimal displacement and angulation. The surveyor interviewed CNA R on 05/31/13 at 11:54 a.m. During the interview, CNA R stated when she went into the resident room on 04/29/13 around 9:00 a.m., she knew something was wrong as the resident had a frown and looked like she was in pain. As the CNA kept asking her what was wrong, the resident told her to get the nurse. She then reported this to LVN Q, who was on duty that day. They both questioned the resident and Resident #13 told them she did not know why her shoulder was hurting more. However, CNA R stated Resident #13 told her family she fell but could not give much detail as to when she fell . CNA P was interviewed on 05/31/13 at 12:45 p.m. CNA P stated while caring for the resident, she was taking off her shirt when she noticed Resident #13 crying, grimacing and pulling away from her. CNA P stated she noticed the resident's left shoulder was swollen. CNA P told the surveyor when she reported Resident #13's pain to LVN T, LVN T told CNA P Resident #13 had a recent fall and was experiencing pain from the fall. CNA P stated she had taken care of Resident #13 since the fall on 04/15/13, and the swelling was not present until the day she told LVN T about it. LVN J was interviewed on 05/31/13 at 1:05 p.m. LVN J stated Resident #13 did not sustain the fracture from the fall of 04/15/13. He stated something must have happened again to her the facility staff were not aware of. LVN J stated he had an admission on 04/15/13 and another nurse assisted him with the fall assessment. He notified the physician around 5:20 p.m. but the physician did not return the call till 8:48 p.m. or so. During that time, Resident #13 remained in pain. Tylenol and repositioning was provided to make her a little comfortable. LVN O was interviewed on 06/02/13 at 8:38 p.m. LVN O stated he was told by the night-shift CNA the "off going" CNA reported to her Resident #13 had swelling to her left shoulder area. LVN O stated he was not happy the day-shift nurse did not do anything about it, and that he heard about it from the night shift CNA, who was told about the problem from the evening shift CNA. He called for X-ray before midnight but did not request for a stat X-ray. He stated when he went to assess Resident #13, her hand was warm and she complained of a lot of pain. The surveyor asked LVN O when he became aware of the problem? He stated it was at approximately 10:00 p.m. During the interview, LVN O stated when he told LVN T about ordering the X-ray, she told him if he had known, she would have told him not to order another one as the first X-ray was negative for fractures, and the resident was just experiencing the after effects of that fall. The CMS form 672, dated 05/30/13 and signed by the MDS coordinator, reflected a facility census of 70 residents.

Based on observation, interview, and record review, it was determined the facility failed to implement it's policy and procedures to prohibit neglect for three (Residents #1, #2 and #3) of seven residents reviewed for pressure ulcers. 1. The facility failed to monitor, notify the physician, and/or possibly treat an "area" on Resident #1's skin around his scrotum, which LVN X knew about on [DATE]. Resident #1's family member showed the ADON and the DON the "golf ball," sized pressure ulcer on [DATE]. Resident #1 was sent to the hospital on [DATE], was admitted to the hospital for treatment of [REDACTED]. 2. The ADON failed to write and initiate the physician's orders [REDACTED]. Resident #2 was provided the wrong dressing for four days, until surveyor inquiry. This failure resulted in Resident #2's pressure ulcer worsening as evidenced by the ulcer getting larger. 3. Staff failed to toilet Resident #3, who had a stage II pressure ulcer on her coccyx, the night of [DATE] for at least 11 hours. CNA D, whose shift started at 6:00 AM, failed to provide care to Resident #3 on [DATE] until 9:45 AM. These failures resulted in Resident #3 being upset and tearful. She and her bed were saturated in urine and there were brown rings on her sheets and a puddle of urine on her mattress, when the linens were removed. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. These failures could affect the eight residents in the facility identified as having pressure ulcers by placing them at risk for worsening of existing pressure ulcers, infections, and pain/discomfort. Findings included: After Administrative Review, it was determined an IJ existed, and the surveyors re-entered the facility on [DATE] to inform the facility an IJ existed and to request a Plan of Removal. 1) Resident #1 was a [AGE] year-old male, who was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1's MDS assessment, dated [DATE], reflected he was cognitively intact, did not exhibit behaviors or reject care, utilized a wheelchair and required extensive assistance from staff for transfers, personal hygiene, toileting, and dressing. The MDS assessment also reflected he was at risk for developing pressure ulcers, but at the time of the assessment he did not have a pressure ulcer. Resident #1's MDS assessment reflected he had a pressure reducing device for his chair, pressure reducing device for his bed, and was on a turning/repositioning program to prevent the development of a pressure ulcer. Taber's Cyclopedia Medical Dictionary 21st Edition reflected on page on 1708, "...Skin care is of great importance, as persons with [MEDICAL CONDITION] are at risk for pressure sore development because of their motor, sensory, and vasomotor deficits...." Resident #1's Care Plan, dated [DATE], reflected he was at risk for impaired skin integrity, and one of the interventions to maintain intact skin was to complete skin assessments weekly and PRN. Resident #1's Weekly Skin Assessment, dated [DATE], reflected "No areas of skin impairment." Resident #1's Skin Assessment Flowsheet-Non-Pressure Sore Conditions, dated [DATE], reflected, "No Skin problems." Resident #1's Release of Responsibility for Leave of Absence form, dated [DATE], reflected he signed himself out of the facility on that day. An interview on [DATE] at 11:30 AM with Resident #1's family member revealed the resident signed himself out of the facility on [DATE] for a weekend visit with his family, and when the family member assisted the resident with perineal care later that day, the family member noticed a pressure ulcer the size of a golf ball between the resident's scrotum and anus. The family member stated she measured the depth of the wound, wearing sterile gloves, to be approximately 1 ? inches deep and 2 inches across. Resident #1's family member revealed the resident asked the family to take care of the wound over the weekend because he did not feel he would get adequate care at the facility on the weekend. The family member stated he/she cleaned the wound with sterile water, packed it with sterile calcium alginate and dressed it with sterile gauze. The family member said the wound appeared to have necrotic (dead) tissue, had yellow pus running from the inside, and smelled of stool. The family member stated when he/she looked deep into the wound, he/she thought bone was seen because the wound was so deep. According to the family Resident #1 was asked, "How could no one have noticed this pressure sore?" The resident's response was, "It is because they do not care and they do not pay attention." Continued interview with Resident #1's family member on [DATE] at 11:30 AM revealed he/she continued to apply sterile dressings to the wound three times a day as requested by the resident. He/she stated, on [DATE], he/she took the resident back to the facility and told the ADON he/she was very unhappy because of the pressure ulcer found on the resident during his weekend pass. The family member stated he/she showed the ADON the pressure ulcer and the ADON's "mouth fell open in disbelief." He/she revealed he/she asked the ADON, "...how trained, certified nursing personnel could overlook so obvious a pressure sore when changing and showering," and the ADON replied, "There is no excuse for this, and this should not have been overlooked." Resident #1's family member stated the ADON summoned the DON, who also showed disbelief and concurred with the ADON there was no reason for a pressure ulcer to be allowed to become this big and go unnoticed. The family member revealed he/she requested the facility have the wound physician assess the resident immediately, and at about 1:30 PM that day, Resident #1 called and reported the wound care physician would not be able to see him until Wednesday, [DATE]. The family member said he/she stated that was not acceptable and called the facility and spoke to the Administrator. The family member revealed he/she asked the Administrator if she was aware of the situation and the Administrator said yes. The family member stated he/she told the Administrator a delay in treatment was unacceptable and the resident needed to be admitted to the hospital immediately. He/she revealed the Administrator told him/her "...it was not that simple. The facility contracts the doctor and he comes by the facility when he has time in his schedule." The family member stated he/she told the Administrator again that it was not acceptable at which time the Administrator turned the telephone over to the ADON, who said Resident #1's Primary Care Physician ordered the resident to be admitted to the hospital. An interview with the ADON on [DATE] at 12:10 PM revealed when any resident had a wound, she was made aware of it, so she could get the resident on the schedule to see the wound care physician, who made rounds every Friday. She stated she was aware of all the wounds because she made rounds with the physician. The ADON could not recall the last time she assessed Resident #1 as having impaired skin integrity, until the resident's family member brought him back from pass on [DATE]. She revealed Resident #1's family member showed her the pressure ulcer. She stated she removed the gauze, the family member had placed in the wound, and the wound looked like an old surgical site, which had opened or dehisced (burst open). The ADON revealed the wound was under his scrotum/testicles, and she could see how someone could wash the resident and not see the wound, unless they lifted his scrotum. She stated the resident did not like staff to pull on him down there. The ADON said the wound did not have any drainage or odor, and the wound was flat, but if the scrotum was pulled back, the wound opened up to the size of a golf ball and measured 4.0 cm x 4.0 cm x 4.0 cm. The ADON revealed the family member wanted the resident to be seen by the wound care physician immediately, but the physician could not come before Wednesday, so the resident's attending physician ordered him to be sent to the hospital for evaluation instead. An interview with the DON on [DATE] at 12:25 PM revealed she recalled the day, [DATE], when Resident #1's family member brought him back from pass and reported he/she found a pressure ulcer on the resident. The DON stated she interviewed staff, none of whom said the resident was observed with a pressure ulcer in the past year. She revealed she observed the wound on [DATE], and it did not have any drainage or odor. The DON stated Resident #1's family member wanted him seen by the wound care physician, but the physician could not come until Wednesday. She revealed the resident was subsequently sent to the hospital for further evaluation. The DON further stated an Incident Report was completed, and she later ensured all nursing staff was re-in-serviced. The facility's In-Service Training Report, dated [DATE], reflected nursing staff were in-serviced on Pressure Ulcer prevention and treatment. An interview with the Administrator on [DATE] at 12:45 PM revealed after she found out Resident #1's family member alleged the resident went home on pass with a pressure ulcer on [DATE], the facility completed an Incident Report. While investigating, nursing staff and CNAs were interviewed and no one observed the resident with any type of impaired skin integrity before he left on pass. She stated the resident was transferred to the hospital on [DATE]. The facility's Incident Report, dated [DATE] at 11:00 AM, reflected a statement from Resident #1's Charge Nurse, LVN X, which was dated [DATE] with no time. The statement reflected LVN X had assessed Resident #1's skin two to three times a week and had never observed an opened area to the buttocks or scrotum. Further review of the statement revealed LVN X assessed Resident #1's skin on [DATE] and found he was bleeding from his scrotum from rubbing against the edge of the shower chair. The statement reflected LVN X assessed his scrotum to see where the blood was coming from, and she observed a small abrasion to his scrotum. The statement further reflected she cleaned and covered the area with 4 x 4 gauze, and instructed the staff to be careful and not rub his scrotum on the edge of the shower chair. (Note: Resident #1's Weekly Skin Assessment, dated [DATE] and his Skin Assessment Flowsheet-Non-Pressure Sore Conditions, dated [DATE], did not reflect this area.) Resident #1's clinical record did not reflect any information about the area LVN X described in the above statement. Resident #1's hospital Face Sheet, with a print date of [DATE], reflected he was admitted to the hospital on [DATE]. Resident #1's Emergency Department Clinical Report, dated [DATE], reflected the resident was seen in the ER at 3:57 PM, and the ER physician initially assessed the resident as having a "Scrotal Lesion. This started about 1 month ago and is still present." Further review of the Clinical Report revealed, "...6 X 4 cm ulcer inferior to the scrotum draining purulent pus, about 3 cm deep...." The Clinical Impression was a Stage III pressure ulcer that was infected in the perineal area. Resident #1's hospital Nurses Clinical Report, dated [DATE] reflected, "PHYSICAL ASSESSMENT...Skin breakdown noted; located on sacral area. Present on arrival ...skin to sacral region is 5x4 cm with 3 cm of tunneling...." Resident #1's hospital History and Physical dated [DATE] reflected he presented in the ER with a "large and deep perineal open wound." The Assessment section of the History and Physical reflected, "Perineal Large Decubitus Ulcer." Resident #1's hospital Infectious Disease Consultation Report, dated [DATE], reflected he had a "huge wound, which he states has been ongoing for the last month. However, on examination, it looks horrible. It looks certainly like it has been going on for longer than that." The Consult further reflected, "the perineal wound is approximately 7 cm in diameter and significant undermining. It tracks all the way down the bony prominence of the lower pelvic rim, which can be palpated, and is jagged to palpation, indicating that the patient probably has ongoing osteo[DIAGNOSES REDACTED] (inflammation of the bone and marrow, usually caused by infection. Organisms may invade bone from an adjacent site such as a decubitus ulcer) of the infection already beyond the cortex (outer layer) of the bone." The Infectious Disease physician's impression was a stage IV perineal wound with pelvic bone Osteo[DIAGNOSES REDACTED]. The Plan was to continue the Resident #1 on [MEDICATION NAME] (antibiotic) and start [MEDICATION NAME] (antibiotic) 2 grams IV every 12 hours, and a [DEVICE] over the wound. Resident #1's hospital Cardiology Consult, dated [DATE], reflected he had experienced Sinus [MEDICAL CONDITION](rapid heart over 100 beats per minute) secondary to his wound. The Cardiologist recommended moving the resident to "intensive care unit for close observation." The Consult reflected the physician was going to start the resident on IV hydration, and his heart rate should improve once the resident was hydrated and his infection was under control. Resident #1's hospital Physician's Progress Note, dated [DATE], reflected, "...having problems maintaining his blood pressure, receiving large quantities of IV fluids to maintain his blood pressure...MRSA surveillance screen is positive. Urine is growing yeast...1. [MEDICAL CONDITION] secondary to [MEDICAL CONDITION]...4. Large [MEDICATION NAME] (sic) decubitus ulcer...Continue same medication and care. Infectious disease consultant is already on the case, along with the cardiologist...." Resident #1's hospital Physician's Progress Note, dated [DATE], reflected, "...very short of breath, went into respiratory distress and then had [MEDICAL CONDITION]. The patient received resuscitation and ended up intubating (sic). Now, patient is sedated on ventilator. Patient's status is discussed with (family members) at length...Blood culture is positive for budding yeast. Wound is growing light growth of Staphylococcus aureus. The patient is already on [MEDICATION NAME] and antifungal...3. [MEDICAL CONDITION]...4. Staphylococcus infected perineal large decubitus ulcer...." Resident #1's hospital Physician's Progress Note, dated [DATE], reflected, "...is seen intubated again, on ventilator. Patient had code blue. Family aware of his declining status ...1. Recurrent [MEDICAL CONDITION] and code blue. The patient is reintubated on ventilator...." Resident #1's hospital Physician's Progress Note, dated [DATE], reflected, "...remains on ventilator spiking high fever since last night, not looking good...Spiked fever all the way up to 104.5 ...1. Septic shock. 2. Yeast urosepsis...." Resident #1's Discharge Summary, dated [DATE], reflected, "... on the 21st, patient started spiking fever, which ran all the way up to 104.5 without any breakthrough. Patient eventually had [MEDICAL CONDITION] on the ventilator. Patient was pronounced dead...." Interview with RN K on [DATE] at 11:10 AM revealed Resident #1 went home during the weekends with his family. RN K stated staff was providing treatments to either Resident #1's buttocks or coccyx, but she could not be more specific about the description of the wound. She revealed she was not the direct care nurse, but she knew staff were providing treatments to him. An interview with the Administrator on [DATE] at 11:57 AM revealed Resident #1 went out that weekend, and he had not had a catheter change because his family member would not let anyone else change it. She stated Resident #1's family member changed his catheter that weekend. The Administrator revealed the nurse, who took care of Resident #1 at the facility, died . An interview with LVN U on [DATE] at 6:15 PM revealed he remembered Resident #1. He stated the last pressure ulcer he saw on the resident was the day the resident's family member showed the ADON and him (LVN U) the pressure ulcer the family member discovered. An interview with CNA G on [DATE] at 4:35 PM revealed she checked Resident #1 whenever he called for assistance. CNA G also revealed she did not see any opened areas on his skin. She stated he was up on her shift and the night shift put him in bed. An interview with CNA N on [DATE] at 11:48 AM revealed she did not recall Resident #1 having any skin problems. 2) Resident #2 was an [AGE] year-old female, who was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Physician's Telephone Order, dated [DATE], reflected to apply [MEDICATION NAME] to the coccyx every three days as a preventive measure. http://emedicine.medscape.com/article/ 5-treatment reflected, "...Stage II ulcers confined to the epidermis or dermis may be treated with a [MEDICATION NAME] occlusive dressing ([MEDICATION NAME]), which maintains a moist environment to facilitate [MEDICATION NAME] (growth of skin over a wound)...." (retrieved on [DATE]). Resident #2's MDS assessment dated , [DATE] reflected her short and long-term memory was impaired, her cognitive skills were severely impaired, she was not ambulatory, she was incontinent of bowel and bladder, and she required extensive assistance from staff for toileting and personal hygiene. The assessment also reflected she was dependent on staff for transfers, locomotion, dressing, and eating, and she was at risk for developing pressure ulcers, but at the time of the assessment she did not have any pressure ulcers. Resident #2's Skin Evaluation Flow Sheet - Pressure Sore form reflected on [DATE] she had a stage II pressure ulcer, which measured 2.2 X 0.9 X 0.4 cm. The Flow Sheet did not reflect the location of the ulcer. The Flow Sheet reflected to wash the pressure ulcer with normal saline, pat dry, and apply [MEDICATION NAME]. Resident #2's Care Plan, updated on [DATE], reflected she had a history of [REDACTED]. One of the Care Plan's Approaches was to provide wound care as ordered by the physician. Resident #2's [DATE] Treatment Flowsheet reflected an order to apply [MEDICATION NAME] to coccyx every three days as a preventative once a day on Wednesday and Saturday. However putting the [MEDICATION NAME] on the resident's coccyx only on Wednesdays and Saturdays was not following the physician's orders [REDACTED]. Resident #2's Treatment Flowsheets for January and February 2013 reflected the same, which was not according to the physician's orders [REDACTED]. Resident #2's Wound Care Specialist Evaluation dated [DATE] reflected she had a stage III pressure ulcer on her coccyx of at least one day duration, which measured 1.7 cm x 0.8 cm x 0.1 cm. The Evaluation also reflected the pressure ulcer had 10% necrotic (dead) tissue and 90% granulation (healing) tissue, and he debrided the wound via a curette during the examination. The Evaluation further reflected the physician ordered a Collagen dressing applied to the wound once a day. http://www.woundresearch.com/article/use-collagen-dressings-long-term-care-retrospect-case-series reflected a collagen dressing, recommended for wet, draining wounds such as Stage III and IV pressure ulcers, allows for stimulation of wound repair and an increase in collagen produced by the wound. (retrieved on [DATE].) An interview on [DATE] at 10:50 AM with LVN A, Resident #2's nurse, revealed the resident had a stage II pressure ulcer on her coccyx. She stated the wound was pink, not beefy red or " angry." She revealed the wound opened on [DATE]. When asked about the current treatment, LVN A replied she was putting [MEDICATION NAME] over the pressure ulcer every three days. An observation on [DATE] at 11:00 AM of Resident #2's wound care revealed the resident was incontinent of bowel and bladder. CNA C removed the resident's clothing and the resident had a pressure ulcer on her right coccyx area, which was not covered with [MEDICATION NAME] or any type of dressing. The wound was covered in stool, and the CNA cleaned the resident and wiped off the wound. CNA C stated she had worked with Resident #2 off and on over the past two months, and the area on her coccyx had always been opened. She further stated she had never seen any type of dressing or bandage covering the wound, when she provided incontinent care for Resident #2. Following the incontinent care, LVN B came in to provide wound care because LVN A was on break. LVN B stated the pressure ulcer care order was just changed. She stated instead of [MEDICATION NAME], the resident was supposed to have a collagen dressing applied once a day. LVN B provided the wound care with the new dressing. Prior to applying the new dressing, LVN B measured Resident #2's pressure ulcer, which had increased in size to 2.2 cm x 1.8 cm x 0.2 cm. At that time, the surveyor returned to the Nurse's Station and observed the ADON writing a new Physician's Telephone Order for Resident #2. The Physician's Telephone Order, dated [DATE], reflected to discontinue the [MEDICATION NAME] to Resident #2's coccyx every three days and to now clean the stage III pressure ulcer, apply collagen dressing, and cover with a dry dressing every day. The wound care physician's new treatment order for Resident #2's stage III pressure ulcer was not initiated until four days later, after surveyor questioning. An interview on [DATE] at 12:05 PM with the ADON revealed the nurses assessed their residents' skin. She stated she made rounds with the wound care physician on [DATE] and knew he wanted the resident's [MEDICATION NAME] treatment order changed to a daily Collagen dressing, however she forgot to write the order until the surveyor started asking questions about Resident #2's pressure ulcer treatment. The surveyor attempted to interview Resident #2 on [DATE] at approximately 10:45 AM, but the resident would not respond. An observation of Resident #2's coccyx at that time revealed the pressure ulcer was healing. An interview with the Administrator on [DATE] at 11:57 AM revealed Resident #2 had a history of [REDACTED]. The Administrator revealed since the ADON made rounds with the wound care physician, she would be in charge of transcribing the orders, so there would be no "gaps" (Note: The ADON was the nurse who forgot to write the order to change Resident #2's pressure ulcer treatment from [MEDICATION NAME] to Collagen, until surveyor inquiry. She made rounds with the wound care physician and was aware he wanted the change.) 3) Resident #3's MDS assessment, dated [DATE], reflected she was a [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment also reflected she needed extensive assistance of two staff for bed mobility, transfers, and toileting, and needed assistance of one staff for locomotion, dressing, eating, and personal hygiene. The MDS assessment further reflected she was not on a bladder training program, and she was incontinent of bladder and frequently incontinent of bowel. Resident #3's Care Plan, last updated on [DATE], reflected she had impaired Activities of Daily living, was incontinent of bowel and bladder, and required two person assistance with her care. To meet the resident's needs, staff was to monitor the resident for incontinence every two hours and PRN, apply skin protectant barrier cream, and monitor for skin breakdown. Resident #3's Braden Scale (pressure ulcer risk assessment) dated [DATE] reflected a score of 17, which indicated she was at low risk for pressure ulcers. However, she exhibited the following clinical conditions, which placed her at high risk for developing pressure ulcers: "Resident refusal of some aspects of care and treatment...Cognitive impairment...Continuous Urinary Incontinence or Chronic Voiding Dysfunction...." Resident #3's Care Plan, dated [DATE], reflected she had a stage II pressure ulcer to her left buttock, and the Approaches including providing wound care as ordered and assisting with turning and repositioning. The Approaches did not include providing incontinent care when needed and keeping the resident clean and dry. Resident #3's Skin Assessment Flow Sheet - Pressure Ulcer form dated [DATE] reflected a stage II pressure ulcer (location not documented on this form), which measured 2.0 cm X 0.5 cm with no depth. The wound bed was described as pink with no signs of infection. Resident #3's Skin Assessment Flowsheet - Non-Pressure Sore Conditions, dated [DATE], reflected stage II pressure ulcer on her left buttocks, which measured 2.0 X 0.5 cm and the wound bed was described as pink with no drainage. Resident #3's Physician's Telephone Order, dated [DATE], reflected to apply skin protectant to the affected area on her left buttock after each incontinent episode every shift. On [DATE] at 9:45 AM, CNA D told the ADON she was about to get Resident #3 up for the day. When CNA D, the ADON, and surveyor entered Resident #3's room, an observation at that time revealed the resident was visibly upset and in tears. The resident stated, "They left me wet all night long!" CNA D revealed, "This is an everyday thing." CNA D provided incontinent care to the resident, and the resident's clothing, incontinent brief, bed pad, and bed linens were urine soaked. There were two dark brown urine stain rings covering ? of the width of the bed on her fitted sheet, which indicated the resident had urinated a large amount at least twice with the linens not being changed. The outside urine ring appeared to be dry. CNA D removed the linens, and Resident #3 was lying in a small puddle of urine on the mattress. The room smelled of urine as the CNA continued to care for the resident. Resident #3 had a pressure ulcer on her left buttock with no obvious skin protectant on the wound, which was covered in urine for an extended period of time. The resident continued to cry off and on as CNA D provided incontinent care. The resident stated, "I wanted to go to the pot but they wouldn't take me." She also stated, "Last night they left me and never came back." An interview with CNA D at that time revealed the resident was able to be toileted on the commode without difficulty with staff assistance (Note: Resident #3's MDS assessment dated [DATE] indicated the resident could toilet with staff assistance.) An interview with the ADON on [DATE] at 11:30 AM revealed she was not sure who the resident's CNA was during the night shift because they rotated, but she would follow-up with the concern. On [DATE] at 11:35 AM, the DON was also informed Resident #3 was urine soaked, which was not promoting the healing of her pressure ulcer. The DON stated she did not know who the night shift CNA was, but she would find out and follow-up on the concern. An interview with CNA D, with the Administrator present, on [DATE] at 11:35 AM revealed she made rounds with the on [DATE]. CNA D stated she was not assigned to care for Resident # 3 that day, but the resident did not want males providing care to her. She stated Resident # 3 was "real wet." CNA D revealed there was a brown ring, and the night shift did not change the resident. CNA D stated the night shift said Resident #3 would not let them. CNA D revealed, "I didn't say anything because ADON was in there." When CNA D was asked if she reported this to the Administrator, she replied, no. An interview with Resident #3 on [DATE] at 7:02 AM revealed some staff would not take her to the bathroom. She stated some staff told her to "pee in bed." An interview with CNA S on [DATE] at 8:22 AM revealed she knew pressure ulcers normally appeared in stages, and they were caused from lying in one spot for a long time or being wet for a long time. She stated if a resident had a pressure ulcer, they were supposed to turn them every two hours and as needed. CNA S also stated there were times when a resident had a brown ring, which was starting to dry, when she came on shift at 6:00 AM. CNA S also revealed one of the residents with a brown ring was Resident #3. She stated sometimes Resident #3 would not let staff touch her, but it should be documented. She said when she found brown rings, she immediately reported it to her nurse. CNA S also stated they checked the residents ' skin during showers when they could see more. An observation of Resident #3's coccyx on [DATE] at 10:25 AM revealed the pressure ulcer was healed. 4) An interview with LVN B on [DATE] at 10:05 AM revealed to prevent pressure ulcers from developing staff turned residents every two hours, provided good skin care, showered the residents every other day, monitored pressure points, changed the residents every two hours and the CNAs made rounds every two to three hours. 5) An interview with CNA W on [DATE] at 10:53 AM revealed when she saw a pressure ulcer she put cream on it, and she turned the resident every two hours. She stated she told the nurse, who did an assessment. CNA W also revealed they checked the residents' skin during showers or skin checks, they reported to the nurses who assessed the residents, and then they put cream on the pressure ulcer. She stated there were different creams. 6) An interview with CNA C on [DATE] at 11:25 AM revealed there were times when she observed that a resident did not get proper care and she reported it. She stated it was not consistent, and she had not seen it lately. 7) An interview with Resident #8 on [DATE] at 10:00 AM revealed the staff on the night shift gripe at her and gave her an attitude when she asked for assistance. She stated the evening shift would not empty her bedside commode right before 10:00 PM, so she had to wait for the night shift to come and empty her commode before she could use it again. Resident #8 also stated if her dressing came off after the nurse treated her wound, the nurses would not redress her wound until the next day when the nurse would do her dressing again. 8) An interview on [DATE] at 10:00 AM with Resident #6 revealed she wore a brief, but usually urinated in the brief and then called for assistance. She stated the time it took to get assistance depended on if staff was nearby. She revealed it could take minutes or hours to get help. Resident #6 stated if it took a long time, she would call again for assistance. 9) An interview with Resident #7 on [DATE] at 11:14 AM revealed it took a long time for his call light to be answered during the day shift. He stated it took over an hour for his light to be answered. Resident #7 revealed he knew they were short staffed. 10) An interview with Resident #7 on [DATE] at 11:14 AM revealed it took a long time for his call light to be answered during the day shift. He stated it took over an hour for his light to be answered. Resident #7 revealed he knew they were short staffed. An observation at this time revealed he had two urinals on his over bed table, one was completely full and the other one was ,[DATE] full. Resident #7 stated LVN B came in his room saw the urinals and left. 11) A review of the Nursing Facility's Abuse Policy and Procedure dated [DATE] revealed the following: "...It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/even in which there

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident having pressure ulcers received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for three (Residents #1, #2 and #3) of seven residents reviewed for pressure ulcers. 1. The facility failed to monitor, notify the physician, and/or possibly treat an "area" on Resident #1's skin around his scrotum, which LVN X knew about on [DATE]. Resident #1's family member showed the ADON and the DON the "golf ball," sized pressure ulcer on [DATE]. Resident #1 was sent to the hospital on [DATE], was admitted to the hospital for treatment of [REDACTED]. 2. The ADON failed to write and initiate the physician's orders [REDACTED]. Resident #2 was provided the wrong dressing for four days, until surveyor inquiry. This failure resulted in Resident #2's pressure ulcer worsening as evidenced by the ulcer getting larger. 3. Staff failed to toilet Resident #3, who had a stage II pressure ulcer on her coccyx, the night of [DATE] for at least 11 hours. CNA D, whose shift started at 6:00 AM, failed to provide care to Resident #3 on [DATE] until 9:45 AM. These failures resulted in Resident #3 being upset and tearful. She and her bed were saturated in urine and there were brown rings on her sheets and a puddle of urine on her mattress, when the linens were removed. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. These failures could affect the eight residents in the facility identified as having pressure ulcers by placing them at risk for worsening of existing pressure ulcers, infections, and pain/discomfort. Findings included: After Administrative Review, it was determined an IJ existed, and the surveyors re-entered the facility on [DATE] to inform the facility an IJ existed and to request a Plan of Removal. 1) Resident #1 was a [AGE] year-old male, who was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1's MDS assessment, dated [DATE], reflected he was cognitively intact, did not exhibit behaviors or reject care, utilized a wheelchair and required extensive assistance from staff for transfers, personal hygiene, toileting, and dressing. The MDS assessment also reflected he was at risk for developing pressure ulcers, but at the time of the assessment he did not have a pressure ulcer. Resident #1's MDS assessment reflected he had a pressure reducing device for his chair, pressure reducing device for his bed, and was on a turning/repositioning program to prevent the development of a pressure ulcer. Taber's Cyclopedia Medical Dictionary 21st Edition reflected on page on 1708, "...Skin care is of great importance, as persons with [MEDICAL CONDITION] are at risk for pressure sore development because of their motor, sensory, and vasomotor deficits...." Resident #1's Care Plan, dated [DATE], reflected he was at risk for impaired skin integrity, and one of the interventions to maintain intact skin was to complete skin assessments weekly and PRN. Resident #1's Weekly Skin Assessment, dated [DATE], reflected "No areas of skin impairment." Resident #1's Skin Assessment Flowsheet-Non-Pressure Sore Conditions, dated [DATE], reflected, "No Skin problems." Resident #1's Release of Responsibility for Leave of Absence form, dated [DATE], reflected he signed himself out of the facility on that day. An interview on [DATE] at 11:30 AM with Resident #1's family member revealed the resident signed himself out of the facility on [DATE] for a weekend visit with his family, and when the family member assisted the resident with perineal care later that day, the family member noticed a pressure ulcer the size of a golf ball between the resident's scrotum and anus. The family member stated she measured the depth of the wound, wearing sterile gloves, to be approximately 1 ? inches deep and 2 inches across. Resident #1's family member revealed the resident asked the family to take care of the wound over the weekend because he did not feel he would get adequate care at the facility on the weekend. The family member stated he/she cleaned the wound with sterile water, packed it with sterile calcium alginate and dressed it with sterile gauze. The family member said the wound appeared to have necrotic (dead) tissue, had yellow pus running from the inside, and smelled of stool. The family member stated when he/she looked deep into the wound, he/she thought bone was seen because the wound was so deep. According to the family Resident #1 was asked, "How could no one have noticed this pressure sore?" The resident's response was, "It is because they do not care and they do not pay attention." Continued interview with Resident #1's family member on [DATE] at 11:30 AM revealed he/she continued to apply sterile dressings to the wound three times a day as requested by the resident. He/she stated, on [DATE], he/she took the resident back to the facility and told the ADON he/she was very unhappy because of the pressure ulcer found on the resident during his weekend pass. The family member stated he/she showed the ADON the pressure ulcer and the ADON's "mouth fell open in disbelief." He/she revealed he/she asked the ADON, "...how trained, certified nursing personnel could overlook so obvious a pressure sore when changing and showering," and the ADON replied, "There is no excuse for this, and this should not have been overlooked." Resident #1's family member stated the ADON summoned the DON, who also showed disbelief and concurred with the ADON there was no reason for a pressure ulcer to be allowed to become this big and go unnoticed. The family member revealed he/she requested the facility have the wound physician assess the resident immediately, and at about 1:30 PM that day, Resident #1 called and reported the wound care physician would not be able to see him until Wednesday, [DATE]. The family member said he/she stated that was not acceptable and called the facility and spoke to the Administrator. The family member revealed he/she asked the Administrator if she was aware of the situation and the Administrator said yes. The family member stated he/she told the Administrator a delay in treatment was unacceptable and the resident needed to be admitted to the hospital immediately. He/she revealed the Administrator told him/her "...it was not that simple. The facility contracts the doctor and he comes by the facility when he has time in his schedule." The family member stated he/she told the Administrator again that it was not acceptable at which time the Administrator turned the telephone over to the ADON, who said Resident #1's Primary Care Physician ordered the resident to be admitted to the hospital. An interview with the ADON on [DATE] at 12:10 PM revealed when any resident had a wound, she was made aware of it, so she could get the resident on the schedule to see the wound care physician, who made rounds every Friday. She stated she was aware of all the wounds because she made rounds with the physician. The ADON could not recall the last time she assessed Resident #1 as having impaired skin integrity, until the resident's family member brought him back from pass on [DATE]. She revealed Resident #1's family member showed her the pressure ulcer. She stated she removed the gauze, the family member had placed in the wound, and the wound looked like an old surgical site, which had opened or dehisced (burst open). The ADON revealed the wound was under his scrotum/testicles, and she could see how someone could wash the resident and not see the wound, unless they lifted his scrotum. She stated the resident did not like staff to pull on him down there. The ADON said the wound did not have any drainage or odor, and the wound was flat, but if the scrotum was pulled back, the wound opened up to the size of a golf ball and measured 4.0 cm x 4.0 cm x 4.0 cm. The ADON revealed the family member wanted the resident to be seen by the wound care physician immediately, but the physician could not come before Wednesday, so the resident's attending physician ordered him to be sent to the hospital for evaluation instead. An interview with the DON on [DATE] at 12:25 PM revealed she recalled the day, [DATE], when Resident #1's family member brought him back from pass and reported he/she found a pressure ulcer on the resident. The DON stated she interviewed staff, none of whom said the resident was observed with a pressure ulcer in the past year. She revealed she observed the wound on [DATE], and it did not have any drainage or odor. The DON stated Resident #1's family member wanted him seen by the wound care physician, but the physician could not come until Wednesday. She revealed the resident was subsequently sent to the hospital for further evaluation. The DON further stated an Incident Report was completed, and she later ensured all nursing staff was re-in-serviced. The facility's In-Service Training Report, dated [DATE], reflected nursing staff were in-serviced on Pressure Ulcer prevention and treatment. An interview with the Administrator on [DATE] at 12:45 PM revealed after she found out Resident #1's family member alleged the resident went home on pass with a pressure ulcer on [DATE], the facility completed an Incident Report. While investigating, nursing staff and CNAs were interviewed and no one observed the resident with any type of impaired skin integrity before he left on pass. She stated the resident was transferred to the hospital on [DATE]. The facility's Incident Report, dated [DATE] at 11:00 AM, reflected a statement from Resident #1's Charge Nurse, LVN X, which was dated [DATE] with no time. The statement reflected LVN X had assessed Resident #1's skin two to three times a week and had never observed an opened area to the buttocks or scrotum. Further review of the statement revealed LVN X assessed Resident #1's skin on [DATE] and found he was bleeding from his scrotum from rubbing against the edge of the shower chair. The statement reflected LVN X assessed his scrotum to see where the blood was coming from, and she observed a small abrasion to his scrotum. The statement further reflected she cleaned and covered the area with 4 x 4 gauze, and instructed the staff to be careful and not rub his scrotum on the edge of the shower chair. (Note: Resident #1's Weekly Skin Assessment, dated [DATE] and his Skin Assessment Flowsheet-Non-Pressure Sore Conditions, dated [DATE], did not reflect this area.) Resident #1's clinical record did not reflect any information about the area LVN X described in the above statement. Resident #1's hospital Face Sheet, with a print date of [DATE], reflected he was admitted to the hospital on [DATE]. Resident #1's Emergency Department Clinical Report, dated [DATE], reflected the resident was seen in the ER at 3:57 PM, and the ER physician initially assessed the resident as having a "Scrotal Lesion. This started about 1 month ago and is still present." Further review of the Clinical Report revealed, "...6 X 4 cm ulcer inferior to the scrotum draining purulent pus, about 3 cm deep...." The Clinical Impression was a Stage III pressure ulcer that was infected in the perineal area. Resident #1's hospital Nurses Clinical Report, dated [DATE] reflected, "PHYSICAL ASSESSMENT...Skin breakdown noted; located on sacral area. Present on arrival ...skin to sacral region is 5x4 cm with 3 cm of tunneling...." Resident #1's hospital History and Physical dated [DATE] reflected he presented in the ER with a "large and deep perineal open wound." The Assessment section of the History and Physical reflected, "Perineal Large Decubitus Ulcer." Resident #1's hospital Infectious Disease Consultation Report, dated [DATE], reflected he had a "huge wound, which he states has been ongoing for the last month. However, on examination, it looks horrible. It looks certainly like it has been going on for longer than that." The Consult further reflected, "the perineal wound is approximately 7 cm in diameter and significant undermining. It tracks all the way down the bony prominence of the lower pelvic rim, which can be palpated, and is jagged to palpation, indicating that the patient probably has ongoing osteo[DIAGNOSES REDACTED] (inflammation of the bone and marrow, usually caused by infection. Organisms may invade bone from an adjacent site such as a decubitus ulcer) of the infection already beyond the cortex (outer layer) of the bone." The Infectious Disease physician's impression was a stage IV perineal wound with pelvic bone Osteo[DIAGNOSES REDACTED]. The Plan was to continue the Resident #1 on [MEDICATION NAME] (antibiotic) and start [MEDICATION NAME] (antibiotic) 2 grams IV every 12 hours, and a [DEVICE] over the wound. Resident #1's hospital Cardiology Consult, dated [DATE], reflected he had experienced Sinus [MEDICAL CONDITION](rapid heart over 100 beats per minute) secondary to his wound. The Cardiologist recommended moving the resident to "intensive care unit for close observation." The Consult reflected the physician was going to start the resident on IV hydration, and his heart rate should improve once the resident was hydrated and his infection was under control. Resident #1's hospital Physician's Progress Note, dated [DATE], reflected, "...having problems maintaining his blood pressure, receiving large quantities of IV fluids to maintain his blood pressure...MRSA surveillance screen is positive. Urine is growing yeast...1. [MEDICAL CONDITION] secondary to [MEDICAL CONDITION]...4. Large [MEDICATION NAME] (sic) decubitus ulcer...Continue same medication and care. Infectious disease consultant is already on the case, along with the cardiologist...." Resident #1's hospital Physician's Progress Note, dated [DATE], reflected, "...very short of breath, went into respiratory distress and then had [MEDICAL CONDITION]. The patient received resuscitation and ended up intubating (sic). Now, patient is sedated on ventilator. Patient's status is discussed with (family members) at length...Blood culture is positive for budding yeast. Wound is growing light growth of Staphylococcus aureus. The patient is already on [MEDICATION NAME] and antifungal...3. [MEDICAL CONDITION]...4. Staphylococcus infected perineal large decubitus ulcer...." Resident #1's hospital Physician's Progress Note, dated [DATE], reflected, "...is seen intubated again, on ventilator. Patient had code blue. Family aware of his declining status ...1. Recurrent [MEDICAL CONDITION] and code blue. The patient is reintubated on ventilator...." Resident #1's hospital Physician's Progress Note, dated [DATE], reflected, "...remains on ventilator spiking high fever since last night, not looking good...Spiked fever all the way up to 104.5 ...1. Septic shock. 2. Yeast urosepsis...." Resident #1's Discharge Summary, dated [DATE], reflected, "... on the 21st, patient started spiking fever, which ran all the way up to 104.5 without any breakthrough. Patient eventually had [MEDICAL CONDITION] on the ventilator. Patient was pronounced dead...." Interview with RN K on [DATE] at 11:10 AM revealed Resident #1 went home during the weekends with his family. RN K stated staff was providing treatments to either Resident #1's buttocks or coccyx, but she could not be more specific about the description of the wound. She revealed she was not the direct care nurse, but she knew staff were providing treatments to him. An interview with the Administrator on [DATE] at 11:57 AM revealed Resident #1 went out that weekend, and he had not had a catheter change because his family member would not let anyone else change it. She stated Resident #1's family member changed his catheter that weekend. The Administrator revealed the nurse, who took care of Resident #1 at the facility, died . An interview with LVN U on [DATE] at 6:15 PM revealed he remembered Resident #1. He stated the last pressure ulcer he saw on the resident was the day the resident's family member showed the ADON and him (LVN U) the pressure ulcer the family member discovered. An interview with CNA G on [DATE] at 4:35 PM revealed she checked Resident #1 whenever he called for assistance. CNA G also revealed she did not see any opened areas on his skin. She stated he was up on her shift and the night shift put him in bed. An interview with CNA N on [DATE] at 11:48 AM revealed she did not recall Resident #1 having any skin problems. 2) Resident #2 was an [AGE] year-old female, who was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Physician's Telephone Order, dated [DATE], reflected to apply [MEDICATION NAME] to the coccyx every three days as a preventive measure. http://emedicine.medscape.com/article/ 5-treatment reflected, "...Stage II ulcers confined to the epidermis or dermis may be treated with a [MEDICATION NAME] occlusive dressing ([MEDICATION NAME]), which maintains a moist environment to facilitate [MEDICATION NAME] (growth of skin over a wound)...." (retrieved on [DATE]). Resident #2's MDS assessment dated , [DATE] reflected her short and long-term memory was impaired, her cognitive skills were severely impaired, she was not ambulatory, she was incontinent of bowel and bladder, and she required extensive assistance from staff for toileting and personal hygiene. The assessment also reflected she was dependent on staff for transfers, locomotion, dressing, and eating, and she was at risk for developing pressure ulcers, but at the time of the assessment she did not have any pressure ulcers. Resident #2's Skin Evaluation Flow Sheet - Pressure Sore form reflected on [DATE] she had a stage II pressure ulcer, which measured 2.2 X 0.9 X 0.4 cm. The Flow Sheet did not reflect the location of the ulcer. The Flow Sheet reflected to wash the pressure ulcer with normal saline, pat dry, and apply [MEDICATION NAME]. Resident #2's Care Plan, updated on [DATE], reflected she had a history of [REDACTED]. One of the Care Plan's Approaches was to provide wound care as ordered by the physician. Resident #2's [DATE] Treatment Flowsheet reflected an order to apply [MEDICATION NAME] to coccyx every three days as a preventative once a day on Wednesday and Saturday. However putting the [MEDICATION NAME] on the resident's coccyx only on Wednesdays and Saturdays was not following the physician's orders [REDACTED]. Resident #2's Treatment Flowsheets for January and February 2013 reflected the same, which was not according to the physician's orders [REDACTED]. Resident #2's Wound Care Specialist Evaluation dated [DATE] reflected she had a stage III pressure ulcer on her coccyx of at least one day duration, which measured 1.7 cm x 0.8 cm x 0.1 cm. The Evaluation also reflected the pressure ulcer had 10% necrotic (dead) tissue and 90% granulation (healing) tissue, and he debrided the wound via a curette during the examination. The Evaluation further reflected the physician ordered a Collagen dressing applied to the wound once a day. http://www.woundresearch.com/article/use-collagen-dressings-long-term-care-retrospect-case-series reflected a collagen dressing, recommended for wet, draining wounds such as Stage III and IV pressure ulcers, allows for stimulation of wound repair and an increase in collagen produced by the wound. (retrieved on [DATE].) An interview on [DATE] at 10:50 AM with LVN A, Resident #2's nurse, revealed the resident had a stage II pressure ulcer on her coccyx. She stated the wound was pink, not beefy red or " angry." She revealed the wound opened on [DATE]. When asked about the current treatment, LVN A replied she was putting [MEDICATION NAME] over the pressure ulcer every three days. An observation on [DATE] at 11:00 AM of Resident #2's wound care revealed the resident was incontinent of bowel and bladder. CNA C removed the resident's clothing and the resident had a pressure ulcer on her right coccyx area, which was not covered with [MEDICATION NAME] or any type of dressing. The wound was covered in stool, and the CNA cleaned the resident and wiped off the wound. CNA C stated she had worked with Resident #2 off and on over the past two months, and the area on her coccyx had always been opened. She further stated she had never seen any type of dressing or bandage covering the wound, when she provided incontinent care for Resident #2. Following the incontinent care, LVN B came in to provide wound care because LVN A was on break. LVN B stated the pressure ulcer care order was just changed. She stated instead of [MEDICATION NAME], the resident was supposed to have a collagen dressing applied once a day. LVN B provided the wound care with the new dressing. Prior to applying the new dressing, LVN B measured Resident #2's pressure ulcer, which had increased in size to 2.2 cm x 1.8 cm x 0.2 cm. At that time, the surveyor returned to the Nurse's Station and observed the ADON writing a new Physician's Telephone Order for Resident #2. The Physician's Telephone Order, dated [DATE], reflected to discontinue the [MEDICATION NAME] to Resident #2's coccyx every three days and to now clean the stage III pressure ulcer, apply collagen dressing, and cover with a dry dressing every day. The wound care physician's new treatment order for Resident #2's stage III pressure ulcer was not initiated until four days later, after surveyor questioning. An interview on [DATE] at 12:05 PM with the ADON revealed the nurses assessed their residents' skin. She stated she made rounds with the wound care physician on [DATE] and knew he wanted the resident's [MEDICATION NAME] treatment order changed to a daily Collagen dressing, however she forgot to write the order until the surveyor started asking questions about Resident #2's pressure ulcer treatment. The surveyor attempted to interview Resident #2 on [DATE] at approximately 10:45 AM, but the resident would not respond. An observation of Resident #2's coccyx at that time revealed the pressure ulcer was healing. An interview with the Administrator on [DATE] at 11:57 AM revealed Resident #2 had a history of [REDACTED]. The Administrator revealed since the ADON made rounds with the wound care physician, she would be in charge of transcribing the orders, so there would be no "gaps" (Note: The ADON was the nurse who forgot to write the order to change Resident #2's pressure ulcer treatment from [MEDICATION NAME] to Collagen, until surveyor inquiry. She made rounds with the wound care physician and was aware he wanted the change.) 3) Resident #3's MDS assessment, dated [DATE], reflected she was a [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment also reflected she needed extensive assistance of two staff for bed mobility, transfers, and toileting, and needed assistance of one staff for locomotion, dressing, eating, and personal hygiene. The MDS assessment further reflected she was not on a bladder training program, and she was incontinent of bladder and frequently incontinent of bowel. Resident #3's Care Plan, last updated on [DATE], reflected she had impaired Activities of Daily living, was incontinent of bowel and bladder, and required two person assistance with her care. To meet the resident's needs, staff was to monitor the resident for incontinence every two hours and PRN, apply skin protectant barrier cream, and monitor for skin breakdown. Resident #3's Braden Scale (pressure ulcer risk assessment) dated [DATE] reflected a score of 17, which indicated she was at low risk for pressure ulcers. However, she exhibited the following clinical conditions, which placed her at high risk for developing pressure ulcers: "Resident refusal of some aspects of care and treatment...Cognitive impairment...Continuous Urinary Incontinence or Chronic Voiding Dysfunction...." Resident #3's Care Plan, dated [DATE], reflected she had a stage II pressure ulcer to her left buttock, and the Approaches including providing wound care as ordered and assisting with turning and repositioning. The Approaches did not include providing incontinent care when needed and keeping the resident clean and dry. Resident #3's Skin Assessment Flow Sheet - Pressure Ulcer form dated [DATE] reflected a stage II pressure ulcer (location not documented on this form), which measured 2.0 cm X 0.5 cm with no depth. The wound bed was described as pink with no signs of infection. Resident #3's Skin Assessment Flowsheet - Non-Pressure Sore Conditions, dated [DATE], reflected stage II pressure ulcer on her left buttocks, which measured 2.0 X 0.5 cm and the wound bed was described as pink with no drainage. Resident #3's Physician's Telephone Order, dated [DATE], reflected to apply skin protectant to the affected area on her left buttock after each incontinent episode every shift. On [DATE] at 9:45 AM, CNA D told the ADON she was about to get Resident #3 up for the day. When CNA D, the ADON, and surveyor entered Resident #3's room, an observation at that time revealed the resident was visibly upset and in tears. The resident stated, "They left me wet all night long!" CNA D revealed, "This is an everyday thing." CNA D provided incontinent care to the resident, and the resident's clothing, incontinent brief, bed pad, and bed linens were urine soaked. There were two dark brown urine stain rings covering ? of the width of the bed on her fitted sheet, which indicated the resident had urinated a large amount at least twice with the linens not being changed. The outside urine ring appeared to be dry. CNA D removed the linens, and Resident #3 was lying in a small puddle of urine on the mattress. The room smelled of urine as the CNA continued to care for the resident. Resident #3 had a pressure ulcer on her left buttock with no obvious skin protectant on the wound, which was covered in urine for an extended period of time. The resident continued to cry off and on as CNA D provided incontinent care. The resident stated, "I wanted to go to the pot but they wouldn't take me." She also stated, "Last night they left me and never came back." An interview with CNA D at that time revealed the resident was able to be toileted on the commode without difficulty with staff assistance (Note: Resident #3's MDS assessment dated [DATE] indicated the resident could toilet with staff assistance.) An interview with the ADON on [DATE] at 11:30 AM revealed she was not sure who the resident's CNA was during the night shift because they rotated, but she would follow-up with the concern. On [DATE] at 11:35 AM, the DON was also informed Resident #3 was urine soaked, which was not promoting the healing of her pressure ulcer. The DON stated she did not know who the night shift CNA was, but she would find out and follow-up on the concern. An interview with CNA D, with the Administrator present, on [DATE] at 11:35 AM revealed she made rounds with the on [DATE]. CNA D stated she was not assigned to care for Resident # 3 that day, but the resident did not want males providing care to her. She stated Resident # 3 was "real wet." CNA D revealed there was a brown ring, and the night shift did not change the resident. CNA D stated the night shift said Resident #3 would not let them. CNA D revealed, "I didn't say anything because ADON was in there." When CNA D was asked if she reported this to the Administrator, she replied, no. An interview with Resident #3 on [DATE] at 7:02 AM revealed some staff would not take her to the bathroom. She stated some staff told her to "pee in bed." An interview with CNA S on [DATE] at 8:22 AM revealed she knew pressure ulcers normally appeared in stages, and they were caused from lying in one spot for a long time or being wet for a long time. She stated if a resident had a pressure ulcer, they were supposed to turn them every two hours and as needed. CNA S also stated there were times when a resident had a brown ring, which was starting to dry, when she came on shift at 6:00 AM. CNA S also revealed one of the residents with a brown ring was Resident #3. She stated sometimes Resident #3 would not let staff touch her, but it should be documented. She said when she found brown rings, she immediately reported it to her nurse. CNA S also stated they checked the residents ' skin during showers when they could see more. An observation of Resident #3's coccyx on [DATE] at 10:25 AM revealed the pressure ulcer was healed. 4) An interview with LVN B on [DATE] at 10:05 AM revealed to prevent pressure ulcers from developing staff turned residents every two hours, provided good skin care, showered the residents every other day, monitored pressure points, changed the residents every two hours and the CNAs made rounds every two to three hours. 5) An interview with CNA W on [DATE] at 10:53 AM revealed when she saw a pressure ulcer she put cream on it, and she turned the resident every two hours. She stated she told the nurse, who did an assessment. CNA W also revealed they checked the residents' skin during showers or skin checks, they reported to the nurses who assessed the residents, and then they put cream on the pressure ulcer. She stated there were different creams. 6) An interview with CNA C on [DATE] at 11:25 AM revealed there were times when she observed that a resident did not get proper care and she reported it. She stated it was not consistent, and she had not seen it lately. 7) An interview with Resident #8 on [DATE] at 10:00 AM revealed the staff on the night shift gripe at her and gave her an attitude when she asked for assistance. She stated the evening shift would not empty her bedside commode right before 10:00 PM, so she had to wait for the night shift to come and empty her commode before she could use it again. Resident #8 also stated if her dressing came off after the nurse treated her wound, the nurses would not redress her wound until the next day when the nurse would do her dressing again. 8) An interview on [DATE] at 10:00 AM with Resident #6 revealed she wore a brief, but usually urinated in the brief and then called for assistance. She stated the time it took to get assistance depended on if staff was nearby. She revealed it could take minutes or hours to get help. Resident #6 stated if it took a long time, she would call again for assistance. 9) An interview with Resident #7 on [DATE] at 11:14 AM revealed it took a long time for his call light to be answered during the day shift. He stated it took over an hour for his light to be answered. Resident #7 revealed he knew they were short staffed. 10) An interview with Resident #7 on [DATE] at 11:14 AM revealed it took a long time for his call light to be answered during the day shift. He stated it took over an hour for his light to be answered. Resident #7 revealed he knew they were short staffed. An observation at this time revealed he had two urinals on his over bed table, one was completely full and the other one was ,[DATE] full. Resident #7 stated LVN B came in his room saw the urinals and left. 11) The facility's Nursing Facility's Skin Integrity Monitoring System Policy and Procedures dated [DATE] reflected: "...1. A system will be in place to assure t