Every finding on record at Avir at Bandera

Based on observations, interviews, and record review the facility failed to ensure Comprehensive Care Plans - The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements for 3 of 16 (Residents #3, #51, #41) residents reviewed for care plans. 1. The facility failed to ensure Resident #3 had a care plan to educate and re-direct the resident from wearing his indwelling urinary catheter collection bag above his bladder. 2. The facility failed to ensure Resident #51's care plan had discharge plans. 3. the facility failed to ensure Resident #41's care plan had discharge plans. This could affect resident and could result in residents not being educated on indwelling catheter positioning and residents not having a discharge plan or goal to set. The Findings: 1. A record review of resident #3's admission record dated 5/20/2026, revealed Resident #3 was admitted on [DATE] with diagnoses which included sepsis due to pseudomonas (Sepsis is a life-threatening medical emergency that happens when your body has an extreme, overactive response to an infection / pseudomonas are bacteria widely distributed across the globe in soil, water, and vegetation) and obstructive and reflux uropathy (bladder disease when the drainage of urine is blocked and begins to flow backwards and cause infections). A record review of Resident #3's admission MDS assessment dated [DATE] revealed Resident #3 was a [AGE] year-old male admitted for LTC support with his ADLs complicated by his history of pneumonias (infections of the lungs) and Parkinson's disease (a brain disorder that causes problems with movement, balance, and coordination). Resident #3 was assessed with a BIMS score of 13 out of a possible 15 which indicated intact cognition. Resident #3 was assessed with the ability to be understood and could understand others. A record review of Resident #3's physicians orders dated 5/19/2026 with start date of 3/5/2026 revealed the physician prescribed care for Resident #3's indwelling urinary catheter, every shift (name brand) catheter care with soap and water. A record review of Resident #3's care plan dated 5/19/2026 at 1:29 PM revealed Resident #3 had an indwelling urinary catheter without nursing interventions to educate and re-direct Resident #3 with his habit of wearing his urinary collection bag above his bladder. A record review of Resident #3's nursing medical record reviewed for the period 3/42026 through 5/19/2026 revealed no documentation for educating and directing Resident #3 to wear his urinary catheter collection bag and tubing below his bladder to reduce the potential risk for urinary tract infections. During an observation on 5/19/2026 at 11:05 AM revealed Resident #3 ambulating with his rollator (a mobility aid with three or four wheels that you push while walking) throughout the facility while wearing his indwelling urinary catheter collection bag and tubing secured to his short pants belt at his waist above his bladder. Resident #3 was observed to have walked by CNA K and RN G while wearing his urine collection bag and tubing above his bladder. During an interview on 5/19/2026 at 11:06 AM, CNA K stated she was the CNA caring for Resident #3. CNA K stated Resident #3 had a need for an indwelling urinary catheter. CNA K stated Resident #3 dressed and toileted himself as well as drained his own urine collection bag. CNA K stated she had not dressed him that morning, and she would provide catheter-care for Resident #3 every day by cleaning the catheter with soap and water. CNA K stated Resident #3 had a routine to dress himself and wear his indwelling urinary catheter collection bag and tubing secured to his short pants belt at his waist above his bladder. CNA K stated she had not received training from the nurse to redirect Resident #3 to wear his urinary collection bag below his waist. During an observation on 5/20/2026 at 12:03 PM revealed Resident #3 ambulating with his rollator (a mobility aid with three or four wheels that you push while walking) throughout the facility while wearing his indwelling urinary catheter collection bag and tubing secured to his short pants belt at his waist above his bladder. Resident #3 was observed to have walked by RN G while wearing his urine collection bag and tubing above his bladder. During an interview on 5/20/2026 at 12:16 PM RN G stated she was the charge nurse for Resident #3. RN G stated Resident #3 had a need for an indwelling urinary catheter and was independent with his ADL care, dressed himself and cared for his urinary catheter collection bag. RN G stated Resident #3 had a routine to dress himself and wear his indwelling urinary catheter collection bag and tubing secured to his short pants belt at his waist above his bladder as he was doing today. RN G stated she was concerned Resident #3's habit would put him at risk for an infection. RN G stated, in the past, she had recommended Resident #3 to wear his urinary catheter bag below his waist but could not recall a date and time. RN G stated she could not recall if she had documented her education or re-direction for Resident #3 to wear his urinary collection bag below his bladder. RN G stated she had not redirected Resident #3 to wear his urinary catheter bag below his bladder yesterday nor today. RN G stated she could not refer to Resident #3's care plan and suggested MDS nurse could refer to Resident #3's care plan. During an interview on 5/20/2026 at 12:55 PM, Resident #3 stated he had a history of difficulty emptying his bladder and had a history of recurring urinary infections. Resident #3 stated he had a need or an indwelling urinary catheter and urine collection bag. Resident #3 stated he would take care of his indwelling urinary catheter and urine collection bag himself and would hang the urine collection bag from his belt. Resident #3 stated he had not received any education for keeping his urinary collection bag and tubing below his waist and bladder. Resident #3 stated he would consider any measures to reduce the frequencies of urinary infections. During an interview on 5/21/2026 at 2:10 PM, the MDS nurse stated her review of Resident #3's care plan had no interventions to address Resident #3's habit of wearing his indwelling urinary catheter collection bag above his waist. MDS Nurse stated she had seen Resident #3 with his urinary collection bag above his bladder and had not assessed Resident #3 with a need to update his care plan to include education and redirection to wear his urine collection bag below his bladder. MDS Nurse stated that the practice of wearing the urine collection bag above the bladder could potentially contribute to an infection of the bladder. MDS Nurse stated that any nurse could have assessed Resident #3 with a need for an update to his care plan. During an Interview on 5/21/2026 at 2:05 PM, Resident #3's Representative stated due to Resident #3's dementia, Resident #3 had a poor recent memory and could not recall recent memories for the past weeks. Resident #3's Representative stated Resident #3 prior to being admitted to the nursing home, lived alone and had a need for an indwelling urinary catheter and had a practice of securing his urine collection bag at his beltline onto his pants and or shorts. Resident #3's Representative stated Resident #3 also had a reoccurring history of UTI's. Resident #3's Representative stated no one had contacted her to provide education that it would be recommended to have Resident #3 wear his urinary collection bag below his waist to reduce the possibility of infections. Resident #3's Representative stated that if she had received the education and report, she would have attempted to re-direct Resident #3 to change his habit and wear his urine collection bag below his bladder. During an interview on 5/22/2026 at 4:00 PM the DON stated Resident #3 had received education and redirection from nursing staff to not wear his urinary collection above his waist and it was Resident #3's choice to wear the bag above his bladder. The DON stated that the documentation was in the updated care plan dated 5/19/2026. A record review of the Facility's Catheter Care, Urinary policy updated July 2024, revealed, The purpose of this procedure is to prevent catheter associated urinary tract infections. general guidelines: . The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder . 2. A Record review of Resident #51's admission Record dated 5/21/2026 was documented as she was admitted on [DATE] with diagnoses of Alzheimer's disease, and lack of coordination. A Record review of Resident #51's Quarterly MDS dated [DATE] was documented her BIMs score was 1/15 (severely cognitively impaired), and ADLs were for eating, toileting, upper/lower extremity and putting on footwear required set-up assistance. A Record review of Resident #51's Care Plan dated 2/12/2026 did not have discharge plans. 3. A Record review of Resident #41's admission Record dated 5/22/2026 was documented as she was admitted on [DATE] with diagnosis of low back pain, lack of coordination and cognitive communication deficit. A Record review of Resident #41's Quarterly MDS dated [DATE] was documented that her BIMs score was 15/15 (cognitively intact), she required a wheelchair for mobility and ADLs were for eating, toileting, upper/lower extremity and putting on footwear required set-up assistance. A Record review of Resident #41's Care Plan dated 5/3/2026 did not have discharge plans. During an interview on 5/21/2026 at 4:49 PM, the MDS nurse stated she did not have discharge planning for Resident #51 and #41. The MDS Nurse stated that she had missed it in the coding for discharge planning. The MDS nurse stated she was responsible for care plans. During an interview on 05/22/2026 at 12:09 PM with the ADM stated residents that did not have discharge plans in the care plans would be residents not knowing what the next step would be. Record review of Policy, Care Plan, comprehensive Person-Centered dated March 2022 was documented a 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.

Based on observations, interviews, and record reviews the facility failed to ensure Other Environmental Conditions - The facility must ensure that the resident environment is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes: a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 of 2 (100/200 hall and 300/400 hall) main shower rooms in that and 1 of 1 facility common area for accidents and hazards. The facility failed to ensure the 100/200 and the 300/400 shower rooms did not have several razors and 2 chemical sprays used for cleaning in an unlocked area in the shower rooms. This failure could lead to resident accident or injury.The facility failed to ensure on 400 hall in the dining/activity area that 4-5 acrylic paints in various colors were not in a drawer unsecured. This could lead to potential ingestion, skin contact or reactions.The facility failed to ensure that residents could not access and utilize the cookie oven and bread machine in the main dining room area. This failure could lead to injury or burns. These failures could affect all residents that shower in the main shower rooms and could cause water damage or flooding. The Findings:1.Observation on 5/19/2026 at 12:18 PM in the 100/200 hall shower room revealed the door was unlocked. An unlocked cabinet had 4 razors and a disinfecting cleaner bottle stated, caution keep out of reach of children. Observations on 5/19/2026 at 12:19 PM in the 300/400 hall shower room with CNA C revealed the doors were unlocked and had 11 used razors in an open sharp's container. Interview on 5/19/2026 at 12:08 PM in the 100/200 shower rooms, CNA C confirmed it was unlocked. CNA C stated the 100/200 shower rooms and cabinets in the shower rooms should be locked and any harmful chemical sprayer should be locked in cabinets CNA C stated the 4 razors in cabinet should be locked and residents could cut themselves with them and harm themselves with the chemical sprayer. Interview on 5/19/2026 12:27 PM with CNA C in the 300/400 hall shower room confirmed the door was unlocked, and there were 11 used razors in an open sharp's container. CNA C did not respond to additional questions. 23.Observation on 5/19/2026 at 2:52 PM on 400 halls in the dining/activity area, in a drawer there were 4-5 acrylic paints in various colors. Interview on 5/19/2026 at 1:07 PM with CNA L stated she had worked at facility for year. CNA L stated the Residents in the 300/400 halls wander residents in halls, in different rooms, it used to be the memory care unit. CNA L stated there were residents in the 100/200 halls that wander in the facility, and staff re-direct them. CNA L confirmed the acrylic paints in the drawer. Interview on 5/22/2026 at 11:57 AM with ADM stated the showers rooms should be locked, and the razors/disinfect bottle should be locked. The ADM stated residents should be kept away from hazards. The ADM stated the shower leaking water or had puddles of water could affect residents and they could get hurt from a misstep or trip. The ADM stated the acrylic paint; staff want to make sure residents don't have access to any hazards that could cause harm. The ADM stated staff should try to keep residents away from toxins. ADM stated the showers rooms should be locked, and it was important to make sure residents did not go in the shower room, when other residents were in the shower, and residents should be kept away from hazards/harm by staff. The ADM stated the beauticians brought in products and supplies and was responsible for own items. The ADM stated they did not have a policy on acrylic paint. During an observation on 05/19/2026 at 12:03 pm, the surveyor observed a cookie oven and a bread machine in the main dining room on a dresser set under the TV in the room. It was observed that both the cookie oven and the bread machine were plugged in operable. The cookie oven did not have a secured oven door and began heating immediately upon turning on. The bread machine did not have a secure lid and had a mechanism that spun rapidly at the bottom of it that had protruding notches. During an observation on 05/19/2026 at 12:07 pm, the surveyor observed Resident #20 sitting no more than five feet from the dresser with the cookie oven and bread machine. 4. Record review of Resident #20's Face Sheet, dated 05/21/2026, revealed a [AGE] year-old female that admitted to the facility on [DATE] with diagnoses including Dementia (syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities); Cognitive Communication Deficit (condition where a person's ability to communicate effectively is impaired by underlying problems in mental processes, rather than by a language or speech disorder); Insomnia (disorder characterized by difficulty falling asleep, staying awake, or waking up too early and not being able to return to sleep); and Metabolic Disorders (condition disrupting body's normal biochemical processes, affecting how it breaks down, stores, or uses nutrients).Record review of Resident #20's Quarterly MDS, dated [DATE], revealed a BIMS score of 0.0 indicating severe cognitive impairment, suggesting significant difficulties with memory, orientation, and thinking skills. Resident #20's MDS also revealed ambulation with a walker.Record review of Resident #20's Care Plan, revised 05/06/2026, revealed a communication problem, risk for falls, self-care deficit, impaired cognitive function, and impaired thought process.Record review of Resident #20's Order Summary report, dated 05/21/2026, revealed Tylenol for pain, levothyroxine 25mcg, and multi-vitamins.During an interview on 05/19/2026 at 12:37 pm, the AD stated she was unaware that the items were plugged in and that she has only been the AD for about two months. The AD stated that she had been slightly nervous about utilizing the cookie oven herself so she may have only used it once in her time as the AD. The AD stated that she is not sure if the items are normally plugged in. The AD stated that the negative impact could be that a resident gets burned or injured. During an observation on 05/19/2026 at 12:45 pm, the DON and AD observed removing the cookie oven and bread machine from the main dining area. Record review of policy, Hazardous Areas, Devices and Equipment, dated 2001, was documented, all hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure residents' safety and mitigate accident hazards to extend possible. Identification of hazards: 1. A hazard is defined as anything in the environment that has the potential to cause injury or illness examples of environment hazards included but not limited to the following; a. equipment and devices that are left unattended or are malfunctioning. C. Sharp objects that are accessible to vulnerable residents d. Open areas or items that should be locked when not in use. e. irregular floor surfaces. g. Access to toxic chemicals.

Based on observation, interview and record review the facility failed to ensure each resident received, and the facility provided, food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 6 residents, and 1 of 1 meal reviewed for palatability, attractiveness, and appetizing foods.The facility failed to provide food that was palatable and at an appetizing temperature for residents. This failure could place residents at risk of a decrease in food intake, hunger, and unwanted weight loss. Findings: Record review of Resident Council Minutes dated 3/23/2026 had concerns with cold food. Record review of Resident Council Minutes dated April 2026 had concerns with cold food. Record review of the Dining Manager, Philly Steak Sandwich, dated 2026 was documented roll, New England Style hot dog/Frank Bun. Record review of Resident #9's Face Sheet, dated 05/20/2026, revealed a [AGE] year-old female that admitted on [DATE] with diagnoses which included Gastro-Esophageal Reflux Disease (chronic condition where stomach acid flows back into the esophagus); Neurogenic Bowel Disorder (condition where nerve damage disrupts normal bowel function, leading to constipation, fecal incontinence, or both); Age-related Physical Debility (progressive decline in strength, endurance, and physiological function that occurs as people age); and Diabetes Mellitus (chronic condition that occurs when the body cannot properly use blood sugar, leading to high blood sugar levels). Record review of Resident #9's Quarterly MDS, dated [DATE], revealed a BIMS score of 14 indicating normal cognitive function with minimal or no memory impairment. Record review of Resident #9's Care Plan, revised 03/09/2026, revealed a risk for falls, self-care deficit, incontinence, and diabetes mellitus. Record review of Resident #9's Order Summary report, dated 05/20/2026, revealed orders for a fortified diet, Humulin 70/30 Pen-Injector inject 11 units in the evening and 13 units in the morning, and Miralax 1 packet mixed into 4-6 ounces of water. Record review of Resident #48's Face Sheet, dated 05/20/206, revealed a [AGE] year-old male that admitted to the facility on [DATE] with diagnoses which included Gastro-Esophageal Reflux Disease (chronic condition where stomach acid flows back into the esophagus); Neurogenic Bowel Disorder (condition where nerve damage disrupts normal bowel function, leading to constipation, fecal incontinence, or both);Adult Failure to Thrive (syndrome of progressive decline in weight, nutrition, physical function, and mental health, often seen in older adults); and Post-Traumatic Stress Disorder (mental health disorder that is caused by an extremely stressful or terrifying event- either being part of it or witnessing it). Record review of Resident #48's Quarterly MDS, dated [DATE]-026, revealed a BIMS score of 14 indicating normal cognitive function with minimal or no memory impairment. Record review of Resident #48's Care Plan, revised 05/11/2026, revealed risk of self-care deficits, falls, hospice services, and nutritional problems related to terminal prognosis. Record review of Resident #48's Order Summary, dated 05/20/2026, revealed orders for a fortified diet, Depakote 250mg twice daily, Baclofen 20mg once daily and every six hours as needed. During an interview on 05/19/2026 at 10:42 am, Resident #9 stated that the food in facility sucks. Resident #9 stated that the food is cold when received and that there were never any fresh vegetables or fruit given. Resident #9 stated they have told the kitchen multiple times but nothing changes. During an interview on 05/19/2026 at 11:25am, Resident #48 stated that the food was horrible, it never tastes good and was always cold. During an observation on 05/19/2025 at 12:11 pm, meal tray cart was observed on the hallway. The cart that the meal trays rested on was observed not enclosed and that the trays had plates covered with lids. During an observation on 05/21/2026 at 10:57 am, during lunch preparation and serving. [NAME] A checked temperatures on serving line and all temperatures were within guidelines at 12:05pm. The surveyor requested a test tray to go out as last tray on the last cart that was sent to hallways. [NAME] A stated that they usually send 200 hall out last at lunch. DA began plating 200 hall cart at 12:37pm. A total of 13 trays were placed on the cart for 200 hall and the test tray was added at 12:44pm. Cart rolled to dining room for nurse to check trays for accuracy at 12:45pm. RN G completed accuracy check and cart was pushed to 200 hall at 12:50pm. Trays were passed residents on 200 hall and the test tray came off of cart at 12:57pm. At 12:58pm the surveyor checked food temperatures for items on tray. Coleslaw temped at 80.4 degrees and was in a bowl set on the warm plate under the food cover, Philly cheesesteak sandwich with a hot dog bum, tempted at 123.6 degrees, potato wedges tempted at 108 degrees, and the cheesecake for dessert temped at 63.3 degrees and was set to the side of the covered warm plate. During an interview on 05/21/2026 at 3:45pm, DM stated that the temperatures for the food items on the tray were not within the guidelines and were in the danger zone for foodborne illnesses. The DM stated that the danger zone was between the 41-degree and 135-degree range. The DM stated that their goal is to get food out at the cooked temperature, as close as possible. DM stated that the coleslaw was too warm and would probably not be appetizing, as well as the cheesecake. The DM stated that she would prefer her sandwich hotter than the temperature the food was when it arrived to the resident. The DM stated she would look into how to get the food to the residents faster. During an interview on 05/22/2026 at 10:10am, [NAME] A stated that the kitchen used to have metal plates that sat in the food warmers that were warmed in their own mechanism, but they broke a while back and everything was removed from the kitchen. Surveyor confirmed that the metal plate sat below the served plates that the food sat on to assist in keeping the heat. During an interview on 5/22/2026 at 12:17 PM with ADM stated the resident food not having the correct temperature and not palatable could cause residents not to eat. During an interview on 05/22/2026 at 2:00 pm, Resident Council was held with 4 residents. Four residents stated that the food at the facility was cold, bland, and did not look good. The 4 residents stated that the Philly cheesecake sandwich was on a hot dog bun and did not look like a Philly cheesesteak. The food was visually unappealing. Record review of facility grievances, dated 03/13/2026 and 02/15/2026, revealed several complaints of cold food. Record review of facility Food Receiving and Storage Policy, revised November 2022, revealed that the danger zone means temperatures above 41-degrees Fahrenheit and below 135-degrees Fahrenheit allow the rapid growth of pathogenic microorganisms that can cause food borne illness.

Based on observation, interview and record review, the facility failed to 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 disease and infection for 1 of 16 residents (Residents #76) and 1 CNA (CNA E) reviewed for infection prevention and control. The facility failed to ensure the SLP and MA P donned the appropriate PPE when on 5/20/2026 they entered Resident #76's isolation room.The facility failed to ensure while passing out trays on the facility's 300-hall, CNA B sanitized her hands between delivering residents' lunch meal trays. This failure could place residents at risk of cross-contamination and the spread of infection. The findings included: 1. A record review of Resident #76's admission record dated 5/19/2026 revealed an admission date of 5/18/2026, diagnosis included Respiratory Syncytial Virus (RSV, a highly contagious, common respiratory virus that infects the lungs and breathing passages). A record review of Resident #76's admission MDS dated [DATE] revealed Resident #76 was a [AGE] year-old female admitted for LTC ADL supports complicated by her diagnosis of RSV. A record review of Resident #76's care plan dated 5/18/2026 revealed, I have infection related to compromised medical condition: . pneumonia with RSV . strict droplet precautions / isolation . A record review of Resident #76's physicians orders dated 5/18/2026 revealed Resident #76 was to be cared for under isolation with droplet precautions, Strict isolation precautions. Full PPE sic[personal protection equipment] when in room. During an observation and interview on 5/20/2026 at 5:34 PM revealed Resident #76's room had signage on the door which stated stop droplet precautions: everyone must: clean their hands, including before entering and when leaving the room. Make sure their eyes, nose, mouth are fully covered before room entry or remove face protection before room exit. Further observation revealed that SLP prepared to enter Resident #76's room. SLP stated she was entering Resident 76's room to assess her for speech language therapy. SLP was observed to practice hand hygiene, donned (donned; a practice of putting on PPE) a surgical face mask, face shield and gloves without a gown and entered Resident #76's room. During an observation on 5/20/2026 at 5:40 PM, MA P prepared to enter Resident #76's room and practiced hand hygiene, donned gloves, a surgical mask, and goggles and entered Resident #76's room. Observation on 5/20/2026 at 5:44 PM revealed MA P exited Resident #76's room. During an interview on 5/20/2026 at 5:45 PM, MA P stated she entered Resident #76's to administer Resident #76's medications. MA P stated Resident #76 was diagnosed with RSV and was cared for by staff who wore PPE. MA P was asked what PPE she wore and MA P replied, gloves, surgical mask and eye protection. MA P stated she did not wear a gown because she was not trained to do so, and the door poster did not mention the need for a gown. During an interview on 5/20/2026 5:47 PM RN G stated she was the RN for Resident #76 who was diagnosed with RSV and was under droplet precautions isolation. RN G stated her expectation was for staff to wear PPE when entering Resident #76's room which included a gown as well as the gloves, surgical mask, and face shield. RN G stated that when she entered Resident #76's room she would wear a gown with all the other PPE. RN G stated she did not know why the signage did not call for the use of a gown and stated she would refer to the DON for guidance. During an interview on 5/20/2026 6:02 PM the DON and the ADON stated Resident #76 was admitted from the hospital diagnosed with RSV and was cared for under isolation droplet precautions in a private room. The DON and ADON stated they had referred to the CDC online resources and developed and implemented signage for droplet precautions which do not call for the use of gown and stated droplet precautions were for airborne droplets and RSV was not transmitted by contact. A policy to support the DON's statements was requested and as of 5/31/1016 no policy was presented. 2. During an interview on 05/19/2026 at 9:05am, DON stated that facility had two residents on precaution. One resident was on 200 hall and the other resident was on 300 hall. During an observation on 05/19/2026 at 12:15pm, CNA E was observed passing meal trays out on 300 hall. CNA E was not observed sanitizing or washing hands before beginning meal tray pass. CNA E was observed not sanitizing hands before or between passing out meal trays for the first 5 rooms that CNA E passed out trays to on 300 hall. CNA E washed hands and then passed out 3 more trays, sanitizing between each of the 3 trays. During an interview on 05/20/2026 at 10:15am, CNA E stated that staff should sanitize before and after entering a resident room. During an interview on 05/20/2026 at 11:40am, LVN D stated that staff should be sanitizing before and after entering a resident room. During an interview on 05/22/2026 at 2:35pm, DON stated that all staff should be sanitizing or washing their hands per guidelines and when called for, especially between tasks and resident rooms. A record review of the United Stated of America's Centers for Disease Prevention and Control's website titled 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings Last update: September 2024; accessed 5/21/2026; https://www.cdc.gov/infection-control/media/pdfs/Guideline-Isolation-H.pdf revealed, Droplet transmission: Droplet transmission is, technically, a form of contact transmission, and some infectious agents transmitted by the droplet route also may be transmitted by the direct and indirect contact routes. The categories of Transmission-Based Precautions are unchanged from those in the 1996 guideline: Contact, Droplet, and Airborne. One important change is the recommendation to don the indicated personal protective equipment (gowns, gloves, mask) upon entry into the patient's room for patients who are on Contact and/or Droplet Precautions since the nature of the interaction with the patient cannot be predicted with certainty and contaminated environmental surfaces are important sources for transmission of pathogens. Modes of transmission: Several classes of pathogens can cause infection, including bacteria, viruses, fungi, parasites, and prions. The modes of transmission vary by type of organism and some infectious agents may be transmitted by more than one route: some are transmitted primarily by direct or indirect contact, (e.g., Herpes simplex virus [HSV], respiratory syncytial virus, Staphylococcus aureus), others by the droplet, (e.g., influenza virus, B. pertussis) or airborne routes (e.g., M. tuberculosis). When applying Standard Precautions, an isolation gown is worn only if contact with blood or body fluid is anticipated. However, when Contact Precautions are used (i.e., to prevent transmission of an infectious agent that is not interrupted by Standard Precautions alone and that is associated with environmental contamination), donning of both gown and gloves upon room entry is indicated to address unintentional contact with contaminated environmental surfaces. Isolation gowns are always worn in combination with gloves, and with other PPE when indicated. Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment.

Based on observations, interviews the facility failed to ensure Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 1(1 salon) in that: 1. The salon had 2 brushes in a drawer and in the cabinet 4-15 rollers in a tray, with some hair on them. This could affect all residents that use the salon and could cause unsanitary germs to residents. 2. The facility failed to ensure the 300/400 hall shower room did not have bedding sheets on the floor to keep the water from going out in the hall while residents were taking a bath. The findings: 1. Observation on 5/22/2026 at 10:58 AM, with the AD, in the hair salon revealed 2 brushes in a drawer and in the cabinet 4-15 rollers in a tray, with some hair on them.Interview on 5/22/2026 at 10:59 AM with AD confirmed the hair salon 2 brushes in a drawer and 4-15 rollers in a tray, with some hair on them in the cabinet. The AD stated that the Beautician came on Tuesday, 5/19/2026 in the afternoon.Interview on 5/22/2026 at 11:57 AM, the ADM stated that the hair salon room hairbrushes and rollers should be cleaned and disinfected, with daily use. The ADM stated the beautician brought in products and supplies and was responsible for own items. ADM stated no one wanted to have someone else's hair and not be sanitized. ADM stated they did not have a policy on the hair salon. 2. Observation on 5/19/2026 at 12:20 PM in the 300/400 hall shower room had a bed sheet at the entrance that was stained and soaked with water from the shower area. Observations in the 300/400 hall shower rooms revealed 3 shower stalls, these shower stalls were not big enough to fit a shower bed. No other other shower could accommodate the shower beds. Observations of the shower water not going into the shower drain and going towards the hall. There was no metal diversion on the shower floor to divert water from the hall, like the 100/200 hall shower room. Interview on 5/19/2026 at 12:28 PM with CNA C stated she used the bed sheets on the floor to stop the water from going out in the hall, it's been like that for a while (did not recall date). CNA C stated she showered residents on the shower bed, and the water sprayed out onto the floor near the hall. CNA C did not say if she reported this to MD. Interview on 5/19/2026, interview at 3:25 pm, the Maintenance Director and Regional MD, in the 200/400 shower room, stated the floor in the shower room did slope, however the ratio of the slope was not significant enough to drain appropriately. MD stated the water came out of the shower stall when aides use the shower with a resident that required a shower bed. Interview on 5/19/2026 at 3:39 PM, the LSC surveyor stated in the 300/400 hall shower, the floors were not sloped, which allows the water to drain in the drainage. CNA's having to place bed sheets to stop the water from going into the hallway. Interview on 5/21/2026 at 11:10 AM with MD in the 300/400 hall shower room, stated the tile floor was not decreased around the drain, so the water drain does not catch the water from the showers. Record review of policy, Hazardous Areas, Devices and Equipment, dated 2001, was documented, all hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure residents' safety and mitigate accident hazards to extend possible. Identification of hazards: 1. A hazard is defined as anything in the environment that has the potential to cause injury or illness examples of environment hazards included but not limited to the following; a. equipment and devices that are left unattended or are malfunctioning. C. Sharp objects that are accessible to vulnerable residents d. Open areas or items that should be locked when not in use. e. irregular floor surfaces. g. Access to toxic chemicals.

Based on observations, interviews, and record reviews, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible, for 1 of 8 residents (Resident #3) reviewed for catheter care.On 5/19/2026 the facility failed to ensure RN G and CNA J educated and redirected Resident #3 when he applied his urinary drainage collection bag above his bladder and secured the urine collection bag to his waist. The failure could place residents at risk for urinary tract infections.The findings included:A record review of resident #3's admission record dated 5/20/2026, revealed Resident #3 was admitted on [DATE] with diagnoses which included sepsis due to pseudomonas (Sepsis is a life-threatening medical emergency that happens when your body has an extreme, overactive response to an infection / pseudomonas are bacteria widely distributed across the globe in soil, water, and vegetation) and obstructive and reflux uropathy (bladder disease when the drainage of urine is blocked and begins to flow backwards and cause infections).A record review of Resident #3's admission MDs assessment dated [DATE] revealed Resident #3 was a [AGE] year-old male admitted for LTC support with his ADLs complicated by his history of pneumonias (infections of the lungs) and Parkinson's disease (a brain disorder that causes problems with movement, balance, and coordination). Resident #3 was assessed with a BIMS score of 13 out of a possible 15 which indicated intact cognition. Resident #3 was assessed with the ability to be understood and could understand others. A record review of Resident #3's physicians orders dated 5/19/2026 revealed on 3/5/2026 the physician prescribed care for Resident #3's indwelling urinary catheter, every shift (name brand) catheter care with soap and water. A record review of Resident #3's care plan dated 5/19/2026 at 1:29 PM revealed Resident #3 had an indwelling urinary catheter with nursing interventions which included, . position catheter bag and tubing below the level of the bladder . A record review of Resident #3's nursing medical record reviewed for the period 3/42026 through 5/19/2026 revealed no documentation for educating and directing Resident #3 to wear his urinary catheter collection bag and tubing below his bladder to reduce the potential risk for urinary tract infections.During an observation on 5/19/2026 at 11:05 AM revealed Resident #3 ambulating with his rollator (a mobility aid with three or four wheels that you push while walking) throughout the facility while wearing his indwelling urinary catheter collection bag and tubing secured to his short pants belt at his waist above his bladder. Resident #3 was observed to have walked by CNA K and RN G while wearing his urine collection bag and tubing above his bladder. During an interview on 5/19/2026 at 11:06 CNA K stated she was the CNA caring for Resident #3. CNA K stated Resident #3 had a need for an indwelling urinary catheter. CNA K stated Resident #3 dressed and toileted himself as well as drained his own urine collection bag. CNA K stated she had not dressed him that morning and she would provide catheter-care for Resident #3 every day by cleaning the catheter with soap and water. CNA K stated Resident #3 had a routine to dress himself and wear his indwelling urinary catheter collection bag and tubing secured to his short pants belt at his waist above his bladder. CNA K stated she had not recommended Resident #3 to wear his urinary collection bag below his waist. During an observation on 5/20/2026 at 12:03 PM revealed Resident #3 ambulating with his rollator (a mobility aid with three or four wheels that you push while walking) throughout the facility while wearing his indwelling urinary catheter collection bag and tubing secured to his short pants belt at his waist above his bladder. Resident #3 was observed to have walked by RN G while wearing his urine collection bag and tubing above his bladder. During an interview on 5/20/2026 at 12:16 PM, RN G stated she was the charge nurse for Resident #3. RN G stated Resident #3 had a need for an indwelling urinary catheter and was independent with his ADL care, dressed himself and cared for his urinary catheter collection bag. RN G stated Resident #3 had a routine to dress himself and wear his indwelling urinary catheter collection bag and tubing secured to his short pants belt at his waist above his bladder as he was doing today. RN G stated she was concerned Resident #3's habit would put him at risk for an infection. RN G stated, in the past, she had recommended Resident #3 to wear his urinary catheter bag below his waist but could not recall a date and time. RN G stated she could not recall if she had documented her education or re-direction for Resident #3 to wear his urinary collection bag below his bladder. RN G stated she had not re-directed Resident #3 to wear his urinary catheter bag below his bladder yesterday nor today. During an interview on 5/20/2026 at 12:55 PM, Resident #3 stated he had a history of difficulty emptying his bladder and had a history of recurring urinary infections. Resident #3 stated he had a need or an indwelling urinary catheter and urine collection bag. Resident #3 stated he would take care of his indwelling urinary catheter and urine collection bag himself and would hang the urine collection bag from his belt. Resident #3 stated he had not received any education for keeping his urinary collection bag and tubing below his waist and bladder. Resident #3 stated he would consider any measures to reduce the frequencies of urinary infections. During an Interview on 5/21/2026 at 2:05 PM, Resident #3's Representative stated due to Resident #3's dementia, Resident #3 had a poor recent memory and could not recall recent memories for the past weeks. Resident #3's Representative stated Resident #3 prior to being admitted to the nursing home, lived alone and had a need for an indwelling urinary catheter and had a practice of securing his urine collection bag at his beltline onto his pants and or shorts. Resident #3's Representative stated Resident #3 also had a reoccurring history of UTI's. Resident #3's Representative stated no one had contacted her to provide education that it would be recommended to have Resident #3 wear his urinary collection bag below his waist to reduce the possibility of infections. Resident #3's Representative stated if she had received the education and report she would have attempted to re-direct Resident #3 to change his habit and wear his urine collection bag below his bladder. During an interview on 5/22/2026 at 4:00 PM, the DON stated Resident #3 had received education and redirection from nursing staff to not wear his urinary collection above his waist and it was Resident #3's choice to wear the bag above his bladder. The DON stated the documentation was in the updated care plan dated 5/19/2026. A record review of the Facility's Catheter Care, Urinary policy updated July 2024, revealed, The purpose of this procedure is to prevent catheter associated urinary tract infections. general guidelines: . The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder . ER .

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 kitchens reviewed for food safety requirements. The facility failed to store food in accordance with professional standards for food service safety. This failure could place residents who eat meals from the kitchen at risk for the spread food borne illness. The findings include: Based on observation on 05/19/2026 at 9:20am, two sandwiches within walk-in cooler that were not dated. Quaker Grits packages were observed in the dry food storage that were not dated. Pureed brownies, cottage cheese and the heresy's chocolate syrup that were in the small refrigerator near the ice machine were observed not to have dates on them. During interview on 05/19/2026 at 9:30am, the DM stated that the foods needed to be labeled and she was not sure why they were not labeled. The DM stated that the brownies were just made, as well as the sandwiches. The DM stated that the negative outcome for residents with undated food items is that there is a potential for the resident to receive bad food. The DM stated that staff had been trained on labeling food items in kitchen. During an interview on 05/19/2026 at 9:40am, [NAME] B stated that all items should have a date on them, this could be the date received, the date opened or the date prepared. [NAME] B did confirm verbally that they had been trained on dating items in the kitchen. Record review of facility Food Receiving and Storage Policy, revised November 2022, revealed that all foods stored and received should be covered, labeled and dated with use by date. Food and Drug Administration food code Section3-501.17 requires date marking on certain items to prevent foodborne illness.

Based on observation, interview, and record review, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for food safety. The facility failed to ensure staff with facial hair was covered by a hair restraint or worn properly. This failure could place residents at risk of foodborne illness. Findings included:Observation on 04/21/2026 at 10:25 a.m. Dietary Aide A was observed in the kitchen with his beard restraint over his beard but not over the mustache top of his top lip. Observation on 4/21/2026 at 10:30 a.m. Dietary Aide B was observed walking in from the back door of the kitchen through the kitchen to the dining room door and got a hair restraint placing it on his head, however, did not put on beard restraint to cover his mustache and beard growth to his chin and jaw line. Dietary Aide B proceeded to the dish room and was putting dishes up from the dish washing trays where they had air dried and then continued to the silverware where he was separating the silverware after it had been washed. Dietary Aide A adjusted his beard restraint to cover his mustache, however in doing so he pulled it up off his chin and left his beard exposed while he prepped meal trays for the meal. Observation on 04/21/2026 at 11:59 a.m. Dietary Aide B was assisting a staff member at the kitchen door by providing with a craft of juice while not wearing a beard restraint with his mustache and beard growth to side of the face and chin exposed. Dietary Aide A was also observed wearing a beard restraint; however, his mustache was not covered as he assisted with lunch service and tray preparation. During an interview on 04/21/2026 at 1:15 p.m. [NAME] C stated hair nets should always be worn when in the kitchen. [NAME] C stated she told Dietary Aide B he needed to wear a beard guard. [NAME] C stated not wearing hair nets could allow hair to get in the food and could cause cross contamination. During an interview on 04/21/2026 at 1:26 p.m. Dietary Aide A stated any time someone was in the kitchen they were to wear hair restraints. Dietary Aide A stated his beard restraint had fallen from his mustache. Dietary Aide A stated it should have been worn completely and made a motion with his hands covering his beard and his mustache. He stated the beard restraint was so that hair did not fall in the food. Dietary Aide A stated the hair if it fell in a resident's food could choke them and it could cross contaminate the food. Dietary Aide A stated residents could possibly get sick from hair if it fell in the food. During an interview on 04/21/2026 at 1:37 p.m. Dietary Aide B stated it was a mistake to walk through the kitchen without having placed a hair net on when he entered the kitchen. Dietary Aide B stated hair nets and beard guards were to be worn anytime they entered the kitchen. Dietary Aide B stated hair restraints kept the hair from falling in the food or else they would be tasting someone's DNA (a molecule that stores genetic instruction for an organism's development, growth and reproduction) if hair fell into the food. Dietary Aide B further stated it could cause cross contamination and could probably cause them to get sick. During an interview on 04/22/2026 at 10:00 a.m. the Dietary Manager stated hair nets/restraints were supposed to be put on before anyone entered the kitchen. The Dietary Manager stated beard restraints were to be worn even if you have one or two hairs on the chin/face. The Dietary Manager stated they were to wear restraint because hair could fall in the food, especially if staff scratched their chin. The Dietary Manager further stated by not wearing proper hair restraints hair could get on the residents' food. The Dietary Manager stated by not wearing hair nets or beard restraints could cause contamination and this could make the resident sick. The Dietary Manager stated beard restraints should cover all face hair. During an interview on 04/23/2026 at 2:41 p.m. the DON stated a hair net should be always worn when working in the kitchen as part of cleanliness and infection control. The DON stated hair nets/beard restraints were worn so the hair would not get in the food. The DON further stated if hair got in the food, it could spread germs and could cause food borne illness. During an interview on 04/23/2026 at 2:54 p.m. the Administrator stated hair restraints should be always worn when in the kitchen. The Administrator stated hair nets/beard restraints needed to be worn to not cause some food illnesses and cross contamination. Review of facility's policy, Food Safety and Sanitation, no date, read Policy: All local, state, and federal standards and regulations will be followed to assure a safe and sanitary food and nutrition services department.Procedure: 2. C. Employees are required to.Hair restraints are required and should cover all hair on the head. [NAME] nets are required when facial hair is visible. Review of facility's policy, Employee Hygiene for Food Safety, no date, read Policy: All food and nutrition services employees will practice good personal hygiene and safe food handling procedures.Procedure: All Employees will: 1. Wear hair restraints (hair net, hat, and/or beard restraint) to prevent hair from contacting exposed food. Review of facility's policy, Personal Hygiene and Health Reporting, no date, read Policy: All food and nutrition services employees will be trained in appropriate personal hygiene and health reporting.Procedure: 2. Personal hygiene criteria to follow include the following: b. Hair should be neat and clean. Hair restraints must be worn around exposed food, in the kitchen or food service areas and dining areas. c. Beards and mustaches should be closely cropped and neatly trimmed. When near exposed foods, beards must be restrained using beard covers. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-402 Hair Restraints, 2-402.11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involved abuse, to the Administrator and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 4 residents (Resident #1) reviewed for freedom from abuse, neglect, and exploitation.The facility failed to report to HHSC that Resident #1 had made an allegation of sexual misconduct against CNA A.This failure could place residents at risk of abuse, neglect, and exploitation.The findings were:Record review of Resident #1's face sheet dated 2/7/26 revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included pneumonia (infection of one or both of the lungs caused by bacteria, viruses, or fungi), urinary tract infection (when bacteria enter the urinary tract through the urethra and begins to spread in the bladder), and dementia in other diseases classified elsewhere unspecified severity without behavioral, psychotic, or mood disturbance and anxiety (general term for loss of memory, language, problem-solving and other thinking abilities caused by another, underlying disease, classified elsewhere, with no behavioral, psychotic, or mood disturbances, or anxiety).Record review of Resident #1's admission MDS dated [DATE] revealed the resident had minimal difficulty hearing, had impaired vision but did not wear eyeglasses, had clear speech, and a BIMS score of 12 out of 15 indicating the resident was moderately cognitively impaired. The resident needed partial assistance with bathing, dressing, and toileting but was independent in ambulation and used a walker and a manual wheelchair and the resident was always incontinent of bowel and bladder.Record review of Resident #1's care plan, undated, had a focus initiated on 2/4/26 and revised on 2/5/26 for behavior problems related to delusions and stating to staff that someone had been in her room and touching her inappropriately, requests female caregivers only. Interventions included 2 caregivers, female caregivers only, anticipate and meet the resident's needs, and if reasonable, discuss the resident's behavior and explain/reinforce why behavior is inappropriate and/or unacceptable to the resident.Record review of Resident #1's nursing notes revealed a nursing note by the DON dated 2/5/26 at 12:42 p.m. It was reported to me by staff from therapy that resident stated she had been touched. I interviewed resident. I asked her when she was touched? she stated, oh you know here and there. Then I asked when this happened? She stated again here and there. Then I asked Who did this? She said, I am not telling you that.Review of CNA A's employee file revealed background check completed on 12/19/25. The EMR, and NAR checks were completed on 12/11/25 with no concerns. ANE statement and senate bill statement on ANE was signed by CNA A on 12/20/25. CNA A completed ANE training on 12/23/25, 12/26/25, and 2/5/26. And had no disciplinary actions. In an observation and interview on 2/7/26 at 12:05 p.m. Resident #1 was lying on top of her bed, well-groomed and dressed appropriately. The resident was alert and oriented to person and place. The resident stated staff treated her good. The resident denied any inappropriate touching by any staff member and denied any ANE at the facility. The resident stated she had some sweaters go missing but that was the only issue and showed me she was wearing 2 sweaters and had more in her closet.In an interview on 2/7/25 at 1:02 p.m. the Administrator stated the allegation was reported on the 4th (2/4/26) to the DON who had interviewed the resident but the Administrator was not notified until 2/5/26 and immediately suspended the accused CNA and started an investigation. The Administrator stated they had a meeting with their corporate staff, and it was determined that it was not reportable. The Administrator stated she understood that it should have been reported to her immediately and to HHSC. In an interview on 2/7/26 at 1:40 p.m. the DON stated therapy had come to her on Wednesday 2/4/26 and informed her Resident #1 had stated she had been touched in a sexual manner. The DON stated she interviewed the resident and the resident stated she was not going to tell her that. The DON stated she did not report it to the Administrator on Wednesday. The DON did report it to the Administrator on Thursday 2/5/26 during the morning meeting. The DON stated she should have reported it to the Administrator immediately.In an interview on 2/7/26 at 3:00 p.m. the Administrator stated the possible consequences of allegations not being reported to her immediately and the state agency was that it could continue to happen but in this case it was untrue, and she consulted with corporate and due to it not being true, did not report to HHSC. In multiple interviews on 2/7/26 1:00 p.m. to 2:30 p.m. 6 residents denied any ANE including any inappropriate touching by staff. In a telephone interview on 2/7/26 at 3:51 p.m. CNA A denied the allegation and stated he had never touched any residents inappropriately.Review of the facility policy on ANE reporting and investigating revised September 2022 indicated all reports of abuse. are reported to local, state, and federal agencies as required by current regulations. 1. If resident abuse, neglect, exploitation. is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying and licensing the facility. 3. Immediately is defined as a. within 2 hours of an allegation involving abuse.

Based on observation, interview, and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #1) of three residents reviewed for indwelling urinary catheters. The facility failed to identify a change in condition or recognize symptoms of a UTI when Resident #1, who required a catheter and had a history of UTIs, began experiencing increased bladder spasms and dysuria (painful urination) from 03/13/25 - 03/21/25. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 04/04/25 at 1:07 PM and an IJ template was given. While the IJ was removed on 04/05/25 at 1:35 PM, the facility remained out of compliance at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents with indwelling urinary catheters at risk of pain, renal failure, urinary tract infections, and sepsis. Findings Included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, obesity, overactive bladder, and personal history of urinary tract infections (an infection in any part of a urinary system, including kidneys, bladder, ureters, and urethra). Review of Resident #1's quarterly MDS assessment, dated 01/01/25, reflected a BIMS score of 14, indicating she had no cognitive impairment. Section H (Bladder and Bowel) reflected she had an indwelling catheter. Review of Resident #1's quarterly care plan, dated 03/10/25, reflected she required an indwelling catheter related to obstructive and reflux uropathy (blockage in urinary tract) with an intervention of monitoring for signs and symptoms of infection. Review of Resident #1's physician order, dated 01/06/25, reflected oxybutynin chloride oral tablet 2.5 MG - Give 1 tablet by mouth every 4 hours as needed for bladder spasms. Review of Resident #1's MAR, February 2025, reflected she was administered oxybutynin chloride on 02/01/25, 02/03/25, twice on 02/05/25, 02/10/25, and 02/11/25. Review of Resident #1's physician order, dated 02/10/25, reflected an order for a urinalysis. Review of Resident #1's UA results, reported 02/12/25, reflected she was positive for a UTI. Review of Resident #1's physician order, dated 02/13/25, reflected Amoxicillin Oral Tablet 500 MG - Give 1 tablet by mouth three times a day for UTI for five days. Review of Resident #1's MAR, March 2025, reflected she was administered oxybutynin chloride (for bladder spasms) on 03/02/25, 03/06/25, 03/08/25, 03/10/25, 03/13/25, twice on 03/14/25, once from 03/15/25 - 03/17/25, twice from 03/18/25 - 03/21/25, and once on 03/22/25. Review of Resident #1's physician order, dated 01/06/25, reflected phenazopyridine HCl oral tablet 200 MG - Give 1 tablet by mouth every 4 hours as needed for dysuria/pain. Review of Resident #1's MAR, March 2025, reflected she was administered phenazopyridine HCl twice on 03/14/25, once from 03/15/25 - 03/18/25, once on 03/20/25, and twice on 03/21/25. Review of Resident #1's progress note, dated 03/22/25 at 3:41 PM and documented by LVN A, reflected the following: Called to room per [FM D]. [Resident #1] very lethargic she will open eyes when name is called. O2 nasal cannula was not on [Resident #1] checked o2 sats 78. Placed nasal cannula on [Resident #1] and rechecked o2 sat fluxuating [sic] between 88 and 90 at this time. She is mouth breathing and encouraged to use her nose to breath [sic] . Review of Resident #1's progress note, dated 03/22/25 at 3:58 PM and documented by LVN A, reflected the following: [Resident #1] is not responding to verbal stimuli. She remains lethargic. O2 sats are 88 to 90. Family members her [sic] requests to go to hospital . Called for ambulance. Review of Resident #1's EMS records, dated 03/22/25, reflected yellow puss was noted to be present in her foley catheter bag. Review of Resident #1's hospital records, dated 03/22/25, reflected the following: Reason for visit: Septic Shock . Assessment/Plan: Septic shock: [Resident #1] reportedly has been off for the past 3 days and became obtunded late this afternoon at her nursing home. Was found to be tachycardic to 120, febrile to 103, tachypneic, WBC of 16, lactate of 3.66. With history of recurrent UTIs and positive urinalysis positive. [Resident #1] given total of 2 L IV fluid bolus . Given initial dose of ceftriaxone (antibiotic) in ED . UTI (Urinary Tract Infection): [Resident #1] presents with acute encephalopathy without focal deficits, able to answer her name. [Resident #1]'s urinalysis positive for leukocyte esterase . Plan: ICU . HPI [FM B] said UTI and put [sic] coming out of catheter. This is an ongoing issue, has happened numerous times. Severe abdominal pain and bladder spasms, three days. Review of Resident #1's hospital discharge paperwork, dated 03/29/25, reflected her diagnosis was septic shock due to UTI and a suprapubic catheter (a tube that drains urine from the bladder through a small incision in the abdomen) had been surgically placed. During a telephone interview on 03/27/25 at 11:15 AM, Resident #1's FM C stated FM D visited Resident #1 every day. She stated FM C told her Resident #1 had been complaining of increased bladder pain and had been drowsy at least three days before hospitalization (03/22/25). She stated FM D was at the facility on 03/22/25 and FM C told her it looked like Resident #1 had a stroke and asked the nurse to check on her. She stated the nurse found her to be non-responsive and she was sent to the hospital and diagnosed with septic shock and a UTI. During a telephone interview on 03/27/25 at 11:40 AM, Resident #1's NP stated if Resident #1 had been having increased bladder pain, she would have expected to be notified and for a UA to be conducted. She stated when she saw her the previous month (February 2025), she was having similar symptoms (increased pain/burning), so she ordered a UA, and she was diagnosed with a UTI. During an interview on 03/27/25 at 12:38 PM, LVN E stated she worked with Resident #1 sometimes but was not sure if she had the week before she went to the hospital. She stated Resident #1 had been having a lot more bladder spasms over the last few months. This Surveyor showed her the MAR from March (2025) and she stated it definitely did like she had been in more pain before her hospitalization . She stated her needing an increase in pain medication could indicate an obstruction, sediment build-up, which could lead to bladder retention, which could lead to a UTI or sepsis. She stated she believed at that point, the nurses should have requested a UA from the NP. During an interview on 03/27/25 at 12:48 PM, LVN A stated she only worked one time a week, but she worked on Resident #1's hall and she was the one that had sent her to the hospital on 03/22/25. She stated she did seem to be in a little more pain than usual, but when she had a change in condition, and she called 911. She did not observe any puss in her drainage bag. This Surveyor showed her Resident #1's March (2025) MAR and LVN A stated the doctor should have been made aware of her increased pain. She stated especially with the bladder problems Resident #1 had a history of, if she had increased pain, there could be a complication. She stated the catheter could have been plugged or she could have a UTI. During a telephone interview on 03/27/25 at 1:03 PM, LVN F stated she worked with Resident #1 regularly (her initials were on the MAR regularly for the pain medications during the time Resident #1 was having increased pain). She stated she had been requesting more pain medication during that time, but she believed they were effective in managing her pain. She stated she did not think that would be a reason to request a UA because of her history of bladder spasms. During an interview on 03/27/25 at 1:42 PM, the DON stated Resident #1 had chronic pain. She stated her expectations were that she be notified if she had been experiencing higher pain than normal or requesting in increase in pain medications. She stated she had not heard anything about an increase in pain. A negative outcome could be a missed infection or not having her pain controlled. She stated Resident #1's increase of requesting more pain medication could be an indication of a UTI. During a telephone interview on 03/27/25 at 4:45 PM, Resident #1's FM D stated he visited her every day. He stated for about four or five days or so before her hospitalization , her spasms and pain had been much worse. He stated he had mentioned to the nurses (could not give names) several times that it must be a UTI if she was having spasms as much as she was. He stated on 03/22/25 around 5:00 PM he could not get her to respond so he asked for her to be sent to the ER. He stated she was in the ICU for several days but now was back in a regular room. Observation on 04/04/25 at 11:20 AM revealed two CNAs performing catheter care on Resident #1's suprapubic catheter that had a dressing dated 04/04/25. Resident #1 expressed no pain, and the care was provided appropriately with no infection control issues. During an interview on 04/04/25 at 12:34 PM, Resident #1 was sitting up in her bed with her lunch tray in front of her. She stated she had recently returned from the hospital. She stated for a few days before she went to the hospital on 03/22/25, she was in excruciating pain. She stated she had to ask the nurses for pain medications all the time. She stated pain and bladder spasms were typical in the past when she had a UTI, but she had never felt that kind of pain before. She stated she would just lay in her bed and sob. She stated she was happy when she was sent to the hospital because she did not think she was going to make it. She stated if she had not made it, it would have been okay because at least she would not have been in pain anymore. Review of the facility's Quality of Care Policy, revised January 2023, reflected the following: Quality of care is a fundamental principle that applies to all treatment and care provided to community residents. Based on the comprehensive assessment of a resident, the community will ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, the resident's choices. . A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections . Review of the facility's Incontinence and Catheterization Assessment and Evaluation Policy, revised January 2023, reflected the following: The community's protocols include policies and procedures that monitor the risk, prevention, and detection of urinary tract infections. The community notifies the physician of the resident's condition or changes in the resident's continence status or development of symptoms that may represent a symptomatic UTI. Review of an online article from Web MD entitled Bladder Spasms, dated 08/13/24, reflected the following: A bladder spasm, or detrusor contraction, occurs when the bladder muscle squeezes suddenly without warning, causing an urgent need to release urine . People who have had such spasms describe them as a cramping pain and sometimes as a burning sensation. Some women with severe bladder spasms compared the muscle contractions to severe menstrual cramps and even labor pains experienced during childbirth. However, you are more likely to have bladder spasms with urine leakage if you: Are elderly or have a urinary tract infection. Some common causes of bladder spasms are: Urinary tract infection (UTI): Bladder pain and burning are a common symptom of a UTI. The ADM and DON were notified on 04/04/25 at 1:07 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 04/05/25 at 11:30 AM: F690 - The facility must ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. Date: 4-4-25 Corrective Action: Resident was being treated for a pain/discomfort with PRN medications prescribed to treat chronic pain/bladder spasms. Was being monitored by licensed nurse. Resident was sent to hospital for evaluation & treatment. Regional Nurse provided in-service to DNS/Admin/Admin in- training /ADNS regarding the following areas: 1. The process for ensuring that changes in conditions have been identified, and reported to the medical provider, notify PCP of abnormal labs, also orders provided bb PCP nurse should be implemented as ordered and nursing should document in the electronic health record the notification of the change in condition to the MD/NP/PA as well as any prescribed orders and notification to Resident's family or representative. 2. Nurse conducting a proper assessment and documenting in the Electronic Health Record (E.H.R.) 3. Notifying medical provider of the change in condition (increased pain). 4. Adhering to physician's orders and recommendations. 5. Communicating pertinent information regarding the status of resident's condition to ensure the well-being of our residents during the nurse / shift change report. 6. Documentation of the resident's status and delivery of care provided according to the plan of care. 7. If the nurse is unable to reach the medical provider, they will place a call to Medical Director to ensure timely notification to the Medical Doctor, Nurse Practitioner, or Physician's assistant (MD/NP/PA.) 8. Nurses should conduct on-going monitoring of resident r/t the change in condition and to ensure that the nurse is communicating the resident's status during change of shift and to ensure proper follow up and necessary interventions are in place and properly documenting findings, interventions and response to care provided within the Electronic Health Record (E.H.R). 9. Nurses will conduct on-going monitoring of residents and specifically monitor residents with bowel/bladder issues, and indwelling catheters to identify and recognize sign/symptoms of UTI: such as flank discomfort, urinary frequency, discomfort upon urination, increased confusion, changes in mental status, changes in urine odor, color, amount of urine and hematuria. 10. Nurse/Interdisciplinary team (IDT) to review the plan of care and/or updating the plan of care accordingly. 11. Abuse and Neglect (ANE_- Identifying Prevention and Reporting). Comprehension of the training was verified through return demonstration and/or follow up questioning. Questions to include: What is a change in condition and examples, Who do you report change in condition to, What do you do when a resident is experiencing more and bladder and bowel pain. Administrator and Director of Nursing conducted an AdHoc Quality Assurance Performance Improvement (QAPI) meeting with the Medical Director on _4/4/2025____ to review plan of removal / immediate corrective action plan implemented. Date Completed: 4/4/2025 Risk Identification: All residents who have experienced a significant change in condition may be at risk. Director of Nursing/Assistant Director of Nursing conducted 100% audit/assessment/evaluation of all current/active residents; to include but not limited to residents with bladder and bowel issues, incontinence and indwelling catheters, to identify any signs or symptoms (s/s) of a change in condition and validated that the medical provider has reported to the PCP for physician's review and to ensure appropriate plan of care is in place. This includes residents with bladder and bowel issues. Outcome: Change in condition on 4/4/25 on 2 residents :outcome: MD and family notified. We were provided with new orders that were implemented. Date Completed: 4/4/2025 Director of Nursing/Assistant Director of Nursing conducted an audit of all residents to identify any changes in conditions to ensure proper notification of the Medical Doctor (MD) and family representatives and to ensure appropriate interventions were in place. Outcome: There were no negative outcomes identified. Date Completed: Systematic Changes: Director of Nursing/Assistant Director of Nursing conducted in-service training to all licensed nurses prior to the nurse working his/her next scheduled shift: Comprehension verified through follow up questions. Questions to include: What is a change in condition and examples, Who do you report change in condition to, What do you do when a resident is experiencing more and bladder and bowel pain. 1. The process for ensuring that changes in conditions have been identified, and reported to the medical provider, also orders provided bb PCP nurse should be implemented as ordered and nursing should document in the electronic health record the notification of the significant change in condition to the MD/NP/PA as well as any prescribed orders and notification to Resident's family or representative. 2. Nurse conducting a proper assessment and documenting in the E.H.R. 3. Adhering to physician's orders and recommendations. 4. Communicating pertinent information regarding the status of resident's condition to ensure the well-being of our residents during the nursing shift change report process. 5. Documentation of the resident's status and delivery of care provided according to the plan of care. 6. If the nurse is unable to reach the medical provider, they will place a call to Medical Director to ensure timely notification to the Medical Doctor, Nurse Practitioner, or Physician's assistant (MD/NP/PA.) 7. Nurses will conduct on-going monitoring of the resident r/t the change in condition and to ensure that the nurse is communicating the resident's status during change of shift and to ensure proper follow up and necessary interventions are in place and properly documenting findings, interventions and response to care provided within the Electronic Health Record (E.H.R). 8. Nurse/Interdisciplinary team (IDT) to review the plan of care and/or updating the plan of care accordingly. 9. Nurses will conduct on-going monitoring of residents and specifically monitor residents with bowel/bladder issues, and indwelling catheters to identify and recognize sign/symptoms of UTI: such as flank discomfort, urinary frequency, discomfort upon urination, increased confusion, changes in mental status, changes in urine odor, color, amount of urine and hematuria. 10. Abuse & Neglect (ANE)- Identifying Prevention and Reporting 11. Director of Nursing / Assist. Director of Nursing will conduct at least daily rounds (5-7 days per week) to identify any resident with a change in condition and will ensure appropriate documentation, notifications and appropriate interventions are in place and documented with in the electronic health record. 12. Director of Nursing / Assist. Director of Nursing will conduct at least daily rounds (5-7 days per week) to identify any resident with a change in condition and will ensure appropriate documentation, notifications and appropriate interventions are in place and documented with in the electronic health record. 13. Director of Nursing / Assist. Director of Nursing will conduct at least daily rounds (5-7 days per week) to identify any resident with a change in condition and will ensure appropriate documentation, notifications and appropriate interventions are in place and documented with in the electronic health record. Director of Nursing / Designee will ensure all licensed nursing staff will be educated to include nurses on leave/agency/Part time staff (PRN staff) -Nurses will be in serviced prior to working their next shift. DNS/ Designee will ensure administrative nursing staff in the community will provide in-service/education prior to team members working their assigned shift. The trainings will also be conducted with new hires. Monitoring: Director of Nursing / Assist. Director of Nursing will review nursing 24hr reports, progress notes and SBARS/change in condition and abnormal labs during the morning clinical review meeting (5-7 days per week) and to ensure that appropriate interventions are in place, proper follow up and notifications to MD/NP/PA has been made in order to ensure patient care needs are met, and documentation is noted within the medical record. The Director of Nursing / Assist. Director of Nursing will maintain a monitoring log of the interviews in order to identify compliance or need for additional training is necessary. The monitoring logs will be retained in the Administrator's survey binder. Director of Nursing / Assist. Director of Nursing will conduct at least daily rounds (5-7 days per week) to identify any resident with a change in condition and will ensure appropriate documentation, notifications and appropriate interventions are in place and documented with in the electronic health record (EHR). Director of Nursing / Assist. Director of Nursing will conduct at least 3 times per week random audits of documentation of progress notes, Medication Administration Record (MARS) (pain meds) as well as staff interviews to identify any Signs and symptoms (s/s) of a resident with a change in condition and will ensure appropriate documentation, notifications and appropriate interventions are in place and documented with in the electronic health record (EHR). The Director of Nursing / Assist. Director of Nursing will maintain a monitoring log of the interviews in order to identify compliance or need for additional training is necessary. The monitoring logs will be retained in the Administrator's survey binder. Director of Nursing / Assist. Director of Nursing will conduct at least 3 times per week random interviews with the nursing team members to identify competency/comprehension of the following: Identifying signs and symptoms (s/s) of a urinary tract infection, increased pain, and other signs of a change in condition as well as the process for reporting the identified change in condition to the license nurse, the process for the nurse to conduct an assessment, will ensure appropriate documentation, MD and family notifications as well as ensuring appropriate interventions are in place and documented with in the electronic health record (EHR). The Director of Nursing / Assist. Director of Nursing will maintain a monitoring log of the interviews in order to identify compliance or need for additional training is necessary. The monitoring logs will be retained in the Administrator's survey binder. The facility will conduct a monthly Quality Assurance Performance Improvement (QAPI) meeting to review the status and compliance notification to Medical Doctor, Nurse practitioner, or physician's assistant (MD/NP/PA) ensuring appropriate intervention and orders are implemented as ordered and appropriate documentation is in noted within the Electronic Health Record (E.H.R.) Findings of audits and status of compliance will be reviewed to the Administrator and the Quality Assurance Performance Improvement (QAPI) committee during the monthly meetings for the next 2 months. The Director of Nursing / Assist. Director of Nursing will maintain a monitoring log of the interviews in order to identify compliance or need for additional training is necessary. The monitoring logs will be retained in the Administrator's survey binder. The Surveyor monitored the POR on 04/05/25 as followed: Observations were made on 04/05/25 from 1:04 PM - 1:10 PM of three residents' catheter tubing and bags. All three had clear drainage with no sediment noted. During interviews on 04/05/25 from 11:32 AM - 1:28 PM, three RNs, three LVNs, one MA, and five CNAs from different shifts all stated they were in-serviced before working their shift on catheter care, communication during shifts, change in conditions, and signs and symptoms of a UTI. All stated a change in condition could be increased pain, altered mental status, or anything that is out of the resident's baseline. All staff stated that any change in condition should be relayed to the NP because it could indicate a bigger issue that could be occurring that needed to be addressed. They all gave signs and symptoms of a UTI such as altered mental status, burning during urination, dark urine, or increased pain. The aides and MA stated if they noticed any of those signs and symptoms, they would notify a nurse immediately. All stated a negative outcome of not getting orders for a suspected UTI could be sepsis or hospitalization . The nurses stated during shift changes, instances of new skin integrity issues, new orders, or any change in condition with residents should be communicated to the oncoming nurse. During an interview on 04/05/25 at 12:20 PM, the ADM stated he was in-serviced by the RNC and was aware of the process for ensuring changes in conditions were identified and relayed to the MD/NP. He stated all staff were being in-serviced before working their shifts. Review of the facility's Ad Hoc Meeting agenda, dated 04/04/25, reflected the ADM, MD, DON, and AIT were in attendance. Review of an in-service conducted by the RNC, dated 04/04/25 reflected the ADM, DON, and ADON were in-serviced on the following: 1. The process for ensuring that changes in conditions have been identified, and reported to the medical provider, notify PCP of abnormal labs, also orders provided bb PCP nurse should be implemented as ordered and nursing should document in the electronic health record the notification of the change in condition to the MD/NP/PA as well as any prescribed orders and notification to Resident's family or representative. 2. Nurse conducting a proper assessment and documenting in the Electronic Health Record (E.H.R.) 3. Notifying medical provider of the change in condition (increased pain). 4. Adhering to physician's orders and recommendations. 5. Communicating pertinent information regarding the status of resident's condition to ensure the well-being of our residents during the nurse / shift change report. 6. Documentation of the resident's status and delivery of care provided according to the plan of care. 7. If the nurse is unable to reach the medical provider, they will place a call to Medical Director to ensure timely notification to the Medical Doctor, Nurse Practitioner, or Physician's assistant (MD/NP/PA.) 8. Nurses should conduct on-going monitoring of resident r/t the change in condition and to ensure that the nurse is communicating the resident's status during change of shift and to ensure proper follow up and necessary interventions are in place and properly documenting findings, interventions and response to care provided within the Electronic Health Record (E.H.R). 9. Nurses will conduct on-going monitoring of residents and specifically monitor residents with bowel/bladder issues, and indwelling catheters to identify and recognize sign/symptoms of UTI: such as flank discomfort, urinary frequency, discomfort upon urination, increased confusion, changes in mental status, changes in urine odor, color, amount of urine and hematuria. 10. Nurse/Interdisciplinary team (IDT) to review the plan of care and/or updating the plan of care accordingly. 11. Abuse and Neglect (ANE_- Identifying Prevention and Reporting). Review of and in-service entitled Bowel and Bladder, dated 04/04/25 - 04/05/25 and conducted by the ADM and DON, reflected all nursing staff were in-serviced on identifying bowel and bladder issues and recognizing changes in residents - increased use of PRN pain medications or increased pain with urination, and notifying the NP of those changes. Review of and in-service entitled Peri Care/Catheter Care dated 04/04/25 - 04/05/25 and conducted by the DON, reflected all nursing staff were in-serviced on the peri care audit tool and peri care steps to decrease the risk of infection. Review of assessments, dated 04/04/25, reflected all residents were assessed for pain, discomfort, or a change in condition by the DON and ADON. Two residents were determined to have a change in condition, the MD was notified, and new orders were put in place. Review of the facility's Monitoring Tool to review the 24-hour report, progress notes, SBAR/CIC, and labs daily, on 04/05/25, reflected it had been signed off as completed and they were in compliance on 04/04/25 and 04/05/25. The ADM and DON were notified on 04/05/25 1:35 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to immediately notify the resident's physician when there was a significant change in the resident's physical status for one (Resident #1) of three residents reviewed for resident rights. The facility failed to ensure Resident #1's NP was notified when she, who required a catheter and had a history of UTIs, began experiencing signs and symptoms such as increased bladder spasms and dysuria (painful urination) from 03/13/25 - 03/21/25. This failure placed residents at risk of medical diagnoses not getting treated and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, obesity, overactive bladder, and personal history of urinary tract infections (an infection in any part of a urinary system, including kidneys, bladder, ureters, and urethra). Review of Resident #1's quarterly MDS assessment, dated 01/01/25, reflected a BIMS score of 14, indicating she had no cognitive impairment. Section H (Bladder and Bowel) reflected she had an indwelling catheter. Review of Resident #1's quarterly care plan, dated 03/10/25, reflected she required an indwelling catheter related to obstructive and reflux uropathy (blockage in urinary tract) with an intervention of monitoring for signs and symptoms of infection. Review of Resident #1's physician order, dated 01/06/25, reflected oxybutynin chloride oral tablet 2.5 MG - Give 1 tablet by mouth every 4 hours as needed for bladder spasms. Review of Resident #1's MAR for, March 2025, reflected she was administered oxybutynin chloride (for bladder spasms) on 03/02/25, 03/06/25, 03/08/25, 03/10/25, 03/13/25, twice on 03/14/25, once from 03/15/25 - 03/17/25, twice from 03/18/25 - 03/32/25, and once on 03/22/25. Review of Resident #1's physician order, dated 01/06/25, reflected phenazopyridine HCl oral tablet 200 MG - Give 1 tablet by mouth every 4 hours as needed for dysuria/pain. Review of Resident #1's MAR for, March 2025, reflected she was administered phenazopyridine HCl twice on 03/14/25, once from 03/15/25 - 03/18/25, once on 03/20/25, and twice on 03/21/25. During a telephone interview on 03/27/25 at 11:40 AM, Resident #1's NP stated if Resident #1 had been having increased bladder pain, she would have expected to be notified and for a UA to be conducted. She stated when she saw her the previous month (February 2025), she was having similar symptoms (increased pain/burning), so she ordered a UA, and she was diagnosed with a UTI. She stated she had not been notified recently of an increase in pain for Resident #1. During an interview on 03/27/25 at 12:38 PM, LVN E stated she worked with Resident #1 sometimes but not during the week before she went to the hospital. She stated Resident #1 had been having a lot more bladder spasms over the last few months. This Surveyor showed her the MAR from March (2025) and she stated it definitely did look like she had been in more pain before her hospitalization . She stated her needing an increase in pain medication could indicate an obstruction, sediment build-up, which could lead to bladder retention, which could lead to a UTI or sepsis. She stated she believed at that point, she would have requested a UA from the NP. She stated the NP should have been notified as she should be notified any time there was a change in condition. During an interview on 03/27/25 at 12:48 PM, LVN A stated she only worked one time a week, but she worked on Resident #1's hall and she was the one that had sent her to the hospital on 03/22/25. She stated she did not seem to be in more pain than usual until she had a change in condition, and she called 911. This Surveyor showed her Resident #1's March (2025) MAR and she stated the doctor should have been made aware of her increased pain. She stated especially with the bladder problems Resident #1 had a history of, if she had increased pain, there could be a complication. She stated the catheter could have been plugged or she could have a UTI. She stated the NP should have been notified because if there was a complication they could order labs or be sent to the ER. She stated the NP should be notified anytime there was a change in condition. During an interview on 03/27/25 at 1:42 PM, the DON stated Resident #1 had chronic pain. She stated her expectations were that she be notified if she had been experiencing higher pain than normal or requesting in increase in pain medications. She stated she had not heard anything about an increase in pain. A negative outcome could be a missed infection or not having her pain controlled. She stated Resident #1's increase of requesting more pain medication could be an indication of a UTI. She stated she would have expected for the nursing staff to have notified the NP of the increase in pain and bladder spasms as she should be notified any time there was a difference from their baseline or a significant change. She stated a negative outcome could be a missed infection or not having their pain controlled. During an interview on 04/04/25 at 12:34 PM, Resident #1 was sitting up in her bed with her lunch tray in front of her. She stated she had recently returned from the hospital. She stated for a few days before she went to the hospital on 03/22/25, she was in excruciating pain. She stated she had to ask the nurses for pain medications all the time. She stated pain and bladder spasms were typical in the past when she had a UTI, but she had never felt that kind of pain before. She stated she would just lay in her bed and sob. She stated she was happy when she was sent to the hospital because she did not think she was going to make it. She stated if she had not made it, it would have been okay because at least she would not have been in pain anymore. Review of the facility's Changes in Resident Condition Policy, revised January 2023, reflected the following: The resident, attending physician, and resident representative or designated family member should be notified when changes in condition or certain events occur. Review of the facility's Incontinence and Catheterization Assessment and Evaluation Policy, revised January 2023, reflected the following: The community notifies the physician of the resident's condition or changes in the resident's continence status or development of symptoms that may represent a symptomatic UTI.

Based on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan which described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, to include the resident's preference and potential for future discharge; for 2 of 8 residents (Residents #43 and #84) reviewed for care plan development. 1. The facility failed to care plan Resident #43's wishes to discharge from the facility. 2. The facility failed to develop care plan interventions for Resident #84's implanted defibrillator / pacemaker and accompanying cellular monitor. These failures could place residents at risk for psychosocial and physical harm. The findings included: A record review of Resident #43' admission record dated 3/20/2025, revealed an admitted [DATE] with diagnoses which included dementia, generalized anxiety disorder, and depressive episodes. A record review of Resident #43's quarterly MDS assessment dated [DATE] revealed Resident #43 was an [AGE] year-old widowed female admitted for long term care related to a history of stroke. Resident #43 was assessed with a BIMS score of 14 out of a possible 15 which indicated intact cognition. Resident #43 was assessed as literate with adequate vision, hearing, with the ability to understand others and could make herself understood. Resident #43 was assessed with nearly every day feeling down, depressed, or hopeless and Little interest or pleasure in doing things. Resident #43 was assessed with partial moderate assistance - helper does less than half the effort for oral hygiene, toileting hygiene, bathing, and dressing. Resident #43 was assessed with setup or clean up assistance - helper sets up or cleans up; Resident completes activity . for sitting to lying, sit to stand, chair bed transfer, toilet transfer shower transfer, and walking up to 150 feet. In reference to the question Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? the facility documented Resident #43 had requested only to be asked during comprehensive assessments. Further review revealed a referral to the local contact agency was not made related to Resident #43 refusal. A record review of Resident #43's nursing admission assessment dated [DATE] revealed no documentation for Resident #43's Discharge Planning without any goals and interventions for discharge planning. A record review of Resident #43's care plan meeting documents dated 9/2/2024 and 3/6/2025 revealed Resident #43 attended along with the MDS nurse, and the Social Worker Assistant (SSA). Further review revealed the MDS nurse documented Resident #43's discharge election was for Resident #43 to transition to Medicaid pending LTC (long term care). Record reviews of Resident #43's care plan dated 8/31/2024 and 12/19/2024 revealed, interview Resident regarding . discharge plans. Communicate with IDT as indicated. During an interview on 3/18/2025 at 4:10 PM, Resident #43 stated she was frustrated with the lack of information regarding her discharge home. Resident #43 stated she was admitted to the facility in August 2024 for care after a hospitalization for a stroke. Resident #43 stated she has had therapy since and has improved with her ability to care for herself and wished to return home. Resident #43 stated she did have difficulty thinking and ability to recall since her stroke. Resident #43 stated no one had gotten Back to her with information for her discharge. Resident #43 stated she had a place to stay and just needed a little assistance. During an interview on 3/20/2025 at 3:20 PM, APS stated she was Resident #43's adult protective services case worker in the past. APS stated Resident #43 had a closed adult protective service case and stated Resident #43 had family who wished not to participate in Resident #43's life. APS stated Resident #43 had been living in the community and had a history of strokes with hospitalization s and was living in nursing homes due to not being able to afford safe independent living with private home health care, She has nowhere to go and no family that wants to assist her, she is not safe by herself. During an interview on 3/19/2025 at 1:45 PM, the MDS nurse stated Resident #43 had little financial means and was in the facility for long term care. During an interview on 3/20/2025 at 5:20 PM, the Administrator stated Resident #43 had no financial means, no home, and or family to assist Resident #43 to transition to the community. The administrator stated the facility had assisted Resident #43 and applied to the state Medicaid program for financial assistance which was pending approval. During a joint interview on 3/21/2024 at 5:00 PM, the Administrator and the DON stated discharge planning began upon admission and should be in the resident's care plan which would have had direct input from residents' wishes. The DON stated the risk was for inaccurate care plans and residents not receiving care and or being supported with their needs. 2. A record review of Resident #84's admission record dated 3/21/2025 revealed an admitted [DATE] with diagnoses which included presence of automatic cardiac defibrillator (a small battery-powered device placed in the chest. It detects and stops irregular heartbeats. It constantly checks the heartbeat. It delivers electric shocks, when needed, to restore a regular heartbeat) and chronic atrial fibrillation (AFib - an irregular and often very rapid heart rhythm, can lead to blood clots in the heart. Also increases the risk of stroke, heart failure and other heart-related complications.) A record review of Resident #84's quarterly MDS assessment dated [DATE] revealed he was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 15, which indicated intact cognition. A record review of Resident #84's physicians orders dated 3/21/2025 revealed resident had an implanted pacemaker defibrillator, ICD/Defibrillator: Left ant sic(anterior) chest: Manufacture Type: (name brand implanted) Serial# (number) Model#DTMA1D1 Procedure Date: 02/08/2023 Cardiologist & Contact Information: (name of cardiologist). A record review of Resident #84's care plan dated 3/20/2025 revealed Resident #84 had a focus for his ICD pacemaker without details for use, care, or monitoring, I have an implanted device r/t: Defibrillator Date Initiated: 08/19/2024 . I will not experience complications associated with my implanted device through my next review date. During an observation and interview on 3/19/2025 at 11:10 AM, Resident #84 was observed in his room seated in his wheelchair. Resident #84 stated he had a history of irregular heartbeats which had made him weak and limited in his lifestyle. Resident #84 stated he could no longer have endurance for simple everyday tasks like walking due to shortness of breaths. Resident #84 stated he had an implanted pacemaker in his chest which could deliver shocks to his heart if it needed it. Resident #84 stated he was aware of the devices inability to work if he encountered any strong magnates, microwaves, and or radio signals. Resident #84 stated he had a box which sent messages to the doctor and demonstrated an electronic device kept by his bedside. An observation of the device revealed a manufactures label which identified the device as a cardiac monitor for Resident #84's implanted pacemaker. Further observation revealed Resident #84 had a cellular phone. Resident #84 stated he had a cellular phone and used it seldomly. Resident #84 stated he had no information regarding his cell phone and his pacemaker. During an interview on 3/19/2025 at 11:50 AM, CNA B stated she was unaware of Resident #84's pacemaker and or monitoring for his pacemaker and suggested for information to ask the Director of Clinical Education. During an interview on 3/19/2025 at 11:54 AM, the Director of Clinical Education stated she was aware Resident #84 had a pacemaker and a monitoring device and stated her expectation was for CNAs to ensure the monitoring device was to be plugged into the electrical receptacle and kept by Resident #84's bedside. The Director of Clinical Education stated she was unaware if the care plan reflected her expectations for Resident #84's pacemaker's care. During an interview on 3/19/2025 at 11:56 AM, the MDS nurse stated she was the MDS nurse who assessed Resident #84 with an implanted pacemaker and assisted the IDT to develop a care plan for Resident #84 pacemaker. The MDS nurse stated Resident #84 care plan did not have any interventions for specific care and or directions for Resident #84 pacemaker and or monitor. During a joint interview on 3/21/2024 at 5:05 PM, the Administrator and the DON stated residents who had implanted pacemakers and monitoring devices should have specific nursing interventions for care and monitoring in the care plan. The DON stated the risk was for lack of care and monitoring for residents' pacemakers. A record review of Resident #84's pacemakers' manufactures website: https://www.medtronic.com/content/dam/emanuals/crdm/CONTRIB_228434.pdf titled MRI Heart Failure Pacemaker with Defibrillation patient manual accessed 3/20/2025, revealed instructions for patients not to handle cellular phones close to the implanted device, To avoid any possible interference between mobile phones and your heart device, keep all mobile phones at least 6 inches (15 centimeters) away from your heart device. When using a mobile phone, hold it to the ear that is farthest away from your heart device. Also, do not carry a mobile phone close to your heart device, such as in a shirt pocket. A record review of Resident #84's cardiac bedside monitor's manufactures website: https://www.medtronic.com/en-us/l/patients/treatments-therapies/remote-monitoring/mycarelink-monitor/setup-instructions.html accessed 3/20/2025 titled set up guide revealed instructions for the first time set up for the device to cellularly communicate with the cardiologists' office, Monitor setup guide Wireless devices: Information is sent automatically, usually while you sleep, after you send information manually the first time. Your monitor should be set up within 6-10 feet (2-3 meters) of where you sleep, preferably on a nightstand. The monitor should receive adequate cellular signal. Make sure your monitor is always on and plugged into a power outlet. Sending information the first time: Follow the steps above to send your first (manual) transmission. Ongoing use: Your device will automatically wake up and send your data on your scheduled transmission dates. Sometimes your clinic may ask you to send a manual transmission. If this happens, follow the steps above to send a manual transmission. A record review of the facility's Care Plan policy dated January 2023 revealed, The care plan in conjunction with the plan of care throughout the medical record is developed and or recommended to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Whenever there is a conflict between a resident's right and the resident's health or safety, the community has an obligation to accommodate the resident's rights and the resident's health by exploring alternatives.

Based on observations, interviews, and record reviews, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities for 3 (Residents #34, #40, and #48) of 8 residents reviewed for activities. 1. The facility failed to provide residents in the memory care unit, including Resident #40, with activities designed to meet their interests and promote physical, mental, and psychosocial well-being. 2. The facility failed to provide in-room activities for Resident #34, Resident #48 reviewed for activity interventions. This failure could place residents at risk for decline in mental acuity and increase in negative behaviors due to a lack of stimulation, boredom, and depression. The findings included: 1. Record review of Resident #40's Admission Record, dated 03/21/2025, reflected a [AGE] year-old female resident initially admitted to the facility on [DATE], with diagnosis of dementia, anxiety, and mood disorder. Record review of Resident #40's Quarterly MDS Assessment, signed and completed on 01/28/2025, reflected a BIMS score of 0, indicating the resident was severely cognitively impaired. Record review of Resident #40's Comprehensive Person-Centered Care Plan, dated as last review completed 03/20/2025, reflected that Resident #40 was able to participate in activities of her choice, with interventions such as, Provide me with an activity calendar, and Remind & Assist me to the planned activities as scheduled. Observation and interview on 03/18/2025 at 11:08 AM, CNA G stated that many times CNA's are left in the memory care alone and while they attempt to occupy the residents, there are too many to adequately host activities. CNA G stated that they have a new activities director and he will sometimes come and do a little thing with a ball for the residents. CNA G stated that is the only activity she has ever seen done and that it is not daily. Observation did not reveal an activities calendar available in the memory care unit. CNA G stated that activities, or even going outside, would be beneficial for residents especially in the memory care to assist with mitigating anxious behaviors. No nurse was observed in the memory care. 2. Record review of Resident #34's face sheet revealed a [AGE] year-old female admitted [DATE] and readmitted [DATE]. Record review of Resident #34's most recent physician's progress noted dated 3/5/25 revealed diagnosis CHF (Congestive Heart Failure, a chronic condition in which the heart does not pump blood as well as it should), HTN (Hypertension, a condition in which the force of the blood against the artery walls is too high), Afib (Atrial fibrillation, an irregular, often rapid heart rate that commonly causes poor blood flow), COPD (Chronic Obstructive Pulmonary Disease, a group of lung diseases that block airflow and make it difficult to breathe), emphysema (a chronic lung disease that permanently damages the lungs' air sacs, making it difficult to breath). Record review of Resident #34 activity participation log on 3/20/25 revealed no data regarding in-room activity participation program. Record review of Resident #48's face sheet revealed an [AGE] year-old female admitted [DATE] and readmitted [DATE]. Record review of Resident #48's most recent physician's progress noted dated 2/24/25 revealed diagnosis CHF (Congestive Heart Failure, a chronic condition in which the heart does not pump blood as well as it should), encephalopathy (a broad term for any brain disease that alters brain function or structure), PVD (Peripheral Vascular Disease, a condition that affects the blood vessels outside the heart and brain, typically in the legs), respiratory failure, anemia (a condition in which the blood doesn't have enough health red blood cells and hemoglobin to carry oxygen all through the body), Afib (Atrial fibrillation, an irregular, often rapid heart rate that commonly causes poor blood flow), CVA (Cerebrovascular Accident (stroke), a medical condition where blood flow to the brain is disrupted), hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone). Record review of Resident #48 activity assessments and participation log revealed no data regarding in-room activity participation program. Record review of Resident #48 Care Plan dated 3/10/25 revealed no data for activity interventions addressed. In an interview on 3/20/25 at 1:15 PM, ACT stated he has not started in-room activities at this time. Stated he was recently hired two weeks ago and Administrator advises him on what to do. In an interview on 3/20/25 at 2:10 PM, ACT 2 stated that documentation for activity interventions for each resident could be found under activity assessments. In an interview on 3/21/25 at 3:00 PM, ADM stated that he is working with the new activity director to focus on community resources that will increase activity events for the facility by offering a variant of activities. Administrator stated he is ultimately responsible for ensuring the health and well-being of all residents. Observation and record review of March 2025 Activities Calendar revealed that there were no activities scheduled for residents between 03/01/2025 and 03/07/2025, with one activity scheduled on 03/08/2025. Record review of Facility Policy, dated revised 01/2023, titled, Activities Program, reflected, The community provides an ongoing, organized program of activities designed, in accordance with the comprehensive assessment, to meet the interests and to maintain the physical, mental, and psychosocial well-being of each resident. 50531

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 4 (Residents #1, #34, #37, and #79) of 16 residents reviewed for quality of care. 1. The facility failed to take blood pressure on Resident #37 prior to providing a blood pressure medication, amlodipine, as ordered by the resident's physician. 2. Facility failed to monitor for signs and symptoms of heart failure for Residents #1, #34, and #79 while being treated with diuretic medications furosemide (Resident #1) and spironolactone (Resident #34 and #79). This failure could place residents at risk for not receiving appropriate care and treatment and/or a decline in their health. The findings included: 1. Record review of Resident #37's Admission Record, dated 03/21/2025, reflected a [AGE] year-old female resident with an initial admitted [DATE]. MD J was identified as Resident #37's Primary Physician. Resident #37 had diagnosis that included acute chronic diastolic (congestive) heart failure (a condition in which your heart's main pumping chamber becomes stiff and unable to fill properly), cardiac arrhythmia (an abnormal heartbeat), and essential (primary) hypertension (high blood pressure). Record review of Resident #37's Quarterly MDS Assessment, signed and completed on 12/30/2024, reflected Resident #37 had a BIMS score of 11, indicating the resident was moderately cognitively impaired. Resident #37 is documented as having an active diagnosis of hypertension. Record review of Resident #37's Comprehensive Person-Centered Care Plan, dated as last review completed 02/14/2025, reflected that the resident had a diagnosis of heart disease with an intervention, dated 09/30/2022, to monitor vital signs as indicated. Record review of Resident #37's Order Audit Report, dated 03/21/2025, reflected an order for AmLODIPine Besylate Oral Tablet 5 MG (Amlodipine Besylate) Give 1 tablet by mouth in the evening for HTN hold if Systolic B/P<100 with an order date of 02/03/2025, ordered by MD J. Record review of Resident #37's Blood Pressure Summary Report, dated 03/20/2025, reflected the following blood pressures obtained for March of 2025: 3/9/2025 16:34 149/72 mmHg 3/12/2025 05:00 101/45 mmHg 3/12/2025 05:15 110/52 mmHg 3/12/2025 05:30 116/50 mmHg 3/12/2025 06:00 126/67 mmHg 3/12/2025 06:24 123/58 mmHg Record review of Resident #37's Progress Notes, dated 03/20/2025, reflected EMAR progress notes that detail Resident #37's blood pressure taken on the following dates: 03/01/2025: 134/72 mmHg 03/04/2025: 135/60 mmHg 03/06/2025: 134/71 mmHg 03/11/2025: 131/59 mmHg 03/16/2025: 120/71 mmHg Record review of Resident #37's March 2025 Medication Administration Report reflected that amlodipine Besylate Oral Tablet 5 MG was provided every day from 03/01/2025 to 03/19/2025, apart from 03/10/2025 in which Resident #37's blood pressure was too high. There are no blood pressure vitals documented on Resident #37's Medication Administration Report. Based on the combination of these record review's, it was determined that on the following dates, Resident #37 was provided amlodipine besylate without blood pressure vital signs being checked or documented in accordance with parameters set by MD J. The dates are as follows: 03/02/2025, 03/03/2025, 03/05/2025, 03/07/2025, 03/08/2025, 03/13/2025, 03/14/2025, 03/15/2025, 03/17/2025, 03/18/2025, and 03/19/2025. Therefore, between March 1, 2025, and March 19, 2025, Resident #37 was provided Amlodipine Besylate without following orders on physician parameters 10 of 19 instances in which the resident received the medication. During an interview on 03/20/2025 at 4:50 PM, the DON stated that most residents have parameters related to blood pressure medication, so their blood pressure is generally at least taken once daily, or as ordered on the medication. During an interview on 03/21/2025 at 10:21 AM, the DON stated that their Medical Director, MD F, had changed the order the evening of 03/20/2025 after the surveyor brought the discrepancies to their attention, as he did not prefer residents to have parameters on blood pressure medication. The DON stated that the blood pressure vitals on the resident were likely taken as they were held one day. 2. Record review of Resident #1's face sheet revealed a [AGE] year-oldRR reveals a [AGE] year-old female admitted to this facility on 4/29/22 and readmitted on [DATE]. Record review of Resident #1's most recent physician's progress note dated 2/17/25 revealed diagnosis of chronic right sided chest pain, Afib (an irregular, often rapid heart rate that commonly causes poor blood flow), chronic lower extremity edema (excess fluid buildup in the body's tissues), fibromyalgia, left lower extremity cellulitis (bacterial skin infection), left lower extremity hemiplegia, and heart failure. Record review of Resident #1's Quarterly MDS dated [DATE] revealed resident required set up assistance with self-feeding, moderate assistance in oral care and wheelchair mobility; maximum assistance in upper body dressing and was totally dependent in peri-care, bathing, lower body dressing, and transfers. Record review of Resident #1's physician's orders revealed an order dated 9/21/24 for Furosemide tablet 20mg (a medication used to treat fluid retention (edema) and swelling that is caused by congestive heart failure and belongs to the group of loop diuretics (water pills); Give 1 tablet by mouth one time a day related to Heart Failure. Record review of Resident #1's Care Plan problem dated 6/7/22 identifies risk for complications such as chest pain, SOB, fatigue, dizziness, poor endurance/activity intolerance and edema due to CHF/Heart Failure. Record review of Resident #1's weight record revealed current weight March 2025 of 182.2lbs, with the following weight fluctuations: 1/6/25 175.5lbs, 2/3/25 181.7 lbs = weight loss of 6.2lbs in 1 month (3.4%) and, 10/10/24 162.9lbs, 11/4/24 173.6 lbs = weight gain of 10.7lbs in 1 month (7.2%). Record review of Resident #34's face sheet revealed a [AGE] year-old female admitted [DATE] and readmitted [DATE]. Record review of Resident #34's most recent physician's progress noted dated 3/5/25 revealed diagnosis CHF (Congestive Heart Failure, a chronic condition in which the heart does not pump blood as well as it should), HTN (Hypertension, a condition in which the force of the blood against the artery walls is too high), Afib (Atrial fibrillation, an irregular, often rapid heart rate that commonly causes poor blood flow), COPD (Chronic Obstructive Pulmonary Disease, a group of lung diseases that block airflow and make it difficult to breathe), emphysema (a chronic lung disease that permanently damages the lungs' air sacs, making it difficult to breath). Record review of Resident #34's Quarterly MDS dated [DATE] revealed resident required set-up assistance in self-feeding; moderate assistance in bathing, upper body dressing and wheelchair mobility; maximum assistance in peri-care, lower body dressing, and bed mobility. toilet hygiene and lower body dressing. No gait. Record review of Resident #34's physician's orders revealed an order dated 9/24/24 for spironolactone tablet 100mg (a medication used to treat build-up of fluid in your body caused by heart failure); Give 1 tablet by mouth one time a day related to congestive and diastolic heart failure and an order dated 9/24/24 for torsemide 20mg (a medication used to treat fluid retention and swelling that is caused by congestive heart failure and belongs to the group of loop diuretics (water pills); Give 4 tablet by mouth one time a day related to congestive and diastolic heart failure. Record review of Resident #34's care plan problem revised 5/4/24 identifies focus problem that resident has heart disease and is at risk for associated cardiac complications such as chest pain, SOB, fatigue, dizziness, poor endurance/activity intolerance and edema. Record review of Resident #34's weight record revealed current weight March 2025 131lbs. with the following weight fluctuations: 8/1/24-12/11/24 a loss of 31.5 lbs. Record review of Resident #79's face sheet revealed a [AGE] year-old female admitted [DATE]. Record review of Resident #79's most recent physician's progress note dated 3/19/25 revealed diagnoses include CVA (stands for cardiovascular accident, commonly known as a stroke. It refers to a medical condition where blood flow to the brain is interrupted, causing brain tissue damage), dysphagia (difficulty swallowing), Afib (Atrial fibrillation, an irregular, often rapid heart rate that commonly causes poor blood flow), DMII (Diabetes Type II (a long term condition in which the body has trouble controlling blood sugar), depression, history of breast cancer with mastectomy (surgical procedure to remove all or part of a breast), ASHD (Arteriosclerotic Heart Disease, a condition where the arteries that supply blood to the heart become narrowed or blocked due to buildup of plaque), heart failure. Record review of Resident #79's physician's orders revealed an order for spironolactone 25mg (a medication used to treat build-up of fluid in your body caused by heart failure); Give 1 tablet by mouth in the morning related to HTN (Hypertension, a condition in which the force of the blood against the artery walls is too high). Record review of Resident #79's care plan revealed dated 3/19/25 identifies focus problem that resident has heart disease and is at risk for associated cardiac complications such as chest pain, SOB, fatigue, dizziness, poor endurance/activity intolerance and edema. Record review of Resident #79's weight record revealed current weight March 2025 143lbs with noted increased of 17lbs over 6 months and triggered 9.7% loss x 90 days and insidious weight loss x 30 days. During observation attempt of Resident #1 on 3/17/25 at 2:07 PM, resident was lying in bed with blanket. Declined further surveyor observation. During observation of Resident #34 on 3/17/24 at 1:59 PM, revealed no signs of exacerbation of congestive heart failure. During observation of Resident #79 on 3/17/25 at 2:45 PM, revealed no signs of exacerbation of heart failure. During interview on 3/20/25 at 2:15 PM, LVN D stated that she does monitor residents with heart failure or diuretic use for pitting edema, SOB, respiratory distress. Stated indications to monitor are not noted on the MAR or in the progress notes. During an interview on 3/20/25 at 2:40 PM, MDS Nurse stated residents on diuretics usually have weekly weights in the TAR. During an interview on 3/20/25 at 5:55 PM, RN E stated that it is standard nursing measures to assess residents on diuretics. Stated that they do not document effectiveness of medications and chart by exception. During interview on 3/20/25 at 12:07 PM, ADON stated protocol for residents on diuretics with weight fluctuations will be re-weighed to verify weight, and verification that resident is taking the medication will be completed. Stated that residents with cardiac medical conditions and residents at risk for fluid loss due to diuretic use would be monitored. Stated that all new admission residents will be weight x 3 weeks to obtain a baseline weight and IDT members would determine additional monitoring for diuretic use. During an interview on 3/20/25 at 12:30 PM, the DON stated that Resident #1 is non-compliant with her dietary restrictions, and she believes identified weight gain is related to food intake. DON stated she would do more research on this concern. During an interview on 3/21/25 at 12:29 PM, NP C stated she believes the facility does monitor the blood pressure, weights, and edema every shift. Stated she believes the nursing assessments are done every shift and she feels good about the facility actions and assessments on the residents who receive diuretics and does not feel it is necessary to add additional criteria or orders as the nursing measures are being done. During interview on 3/21/25 at 3:15 PM, DON stated that adverse effects of not monitoring residents for the effects of diuretic use could result in delay in treatment for residents, physical and functional decline, and possible hospitalization or death. DON stated she is responsible for ensuring the nursing staff are appropriately monitoring the effects of medications to include use of diuretics according to professional standards. During an interview on 3/21/25 at 3:20 PM, Administrator stated that the nursing department is ultimately responsible for monitoring the medical status of all the residents and assessing the effects of medications. Record review of facility policy, titled, Medication Administration with a revision date of January 2024 reflected, If applicable and/or prescribed, take vital signs or tests prior to administration of the dose. Review of Quality of Care policy (revised January 2023) revealed, Based on the comprehensive assessment of a resident, the community will ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person centered care plan . 50531

Based on interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident #37) reviewed for personal hygiene. The facility failed to provide Resident #37, 4 of 20 scheduled showers between 02/03/2025 and 03/20/2025. This failure could place residents who require assistance from staff for personal hygiene at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections. The findings included: Record review of Resident #37's Admission Record, dated 03/21/2025, reflected a [AGE] year-old female resident with an initial admitted [DATE]. MD J was identified as Resident #37's Primary Physician. Resident #37 had diagnosis that included acute chronic diastolic (congestive) heart failure (a condition in which your heart's main pumping chamber becomes stiff and unable to fill properly), cardiac arrhythmia (an abnormal heartbeat), and essential (primary) hypertension (high blood pressure). Record review of Resident #37's Quarterly MDS Assessment, signed and completed on 12/30/2024, reflected Resident #37 had a BIMS score of 11, indicating the resident was moderately cognitively impaired. Resident #37's MDS assessment indicated that Resident #37 needed substantial/maximal assistance (helper does more than half the effort) for showering/bathing. Record review of Resident #37's Comprehensive Person-Centered Care Plan, dated as last review completed 02/14/2025, reflected interventions stating the resident had an ADL self-care performance deficit related to impaired mobility, spinal stenosis, polyarthritis, and generalized weakness with interventions such as x2 person assist on hygiene, dressing, and grooming. Record review of Resident #37's Hospice Physician Order, dated 02/04/2025, reflected, HHA will help PT bathe on Tuesdays and Thursdays, with facility nurse bathing PT on Saturday. Record review of Resident #37's Hospice Client Calendar Report, dated 03/20/2025, reflected that the hospice aide visited Resident #37 every Tuesday and Thursday since beginning on hospice on 02/02/2025, and had provided her a shower each day. Record review of Resident #37's tasks in her electronic health record reflected that the resident's shower days were Tuesday, Thursday, and Saturday. Further review revealed Resident #28 did not receive 4 of the 6 showers scheduled on Saturdays since beginning hospice care on 02/02/2025. The Saturdays in which showers were missed are as follows: 02/08/2025, 02/15/2025, 02/22/2025, and 03/15/2025. Interview on 10/21/2025 at 10:21 AM, the DON stated she was not aware Resident #37 was not receiving showers and that while it was likely she did receive a shower, they did not have documentation apart from what was provided to show that Resident #37 was provided a shower on 02/08/2025, 02/15/2025, 02/22/2025, or 03/15/2025. Record review of facility policy, dated revised January 2023, titled, Routine Resident Care reflected Showers, tub baths, and/or shampoos should be scheduled at least twice weekly and more often as needed or per residents' preference. Shower schedule should be geared to resident preference and scheduled as such.

Based on interviews and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for accuracy of records, in that: The facility failed to ensure the medication administration record (MAR) for Resident #1 accurately reflected urine sample was not collected on the January 2024 MAR on the 3rd, 4th, and 5th. The facility failed to document or provide a rationale from a medical provider in January of 2024 when the order for collection of a urine sample for a urinalysis for Resident #1 was canceled on January 11th of 2024 by the DON. This failure could put residents at risk of an untreated urinary tract infection due to inaccurate documentation and lead to missed or delayed diagnosis and treatment. The findings were: Record review of Resident #1's Admission Record (face sheet), dated 02/20/2025, revealed an [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses which included nontraumatic subarachnoid hemorrhage (condition where blood leaks into the subarachnoid space, which is the area between the brain and the membranes that cover it), aphasia following cerebral infarction (Language disorder that affects your ability to communicate. It's most often caused by strokes in the left side of the brain that control speech and language.), contracture of right hand (condition that causes one or more fingers to bend toward the palm of the hand), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), cognitive communication deficit, and hemiplegia and hemiparesis (weakness or loss of strength of one side of the body) of right side. A diagnosis of urinary tract infection was not documented on the admission record. Record review of Resident #1's MDS, a Quarterly assessment dated [DATE], revealed her cognition was severely impaired; and she was always incontinent of bowel and bladder. Record review of Resident #1's care plan, dated 02/20/2025, for infection or recurrent/chronic infection related to compromised medical condition: UTI, revealed under interventions was to 1. Report changes in condition to MD as clinically indicated. 2. Administer medication and/or antibiotic as clinically indicated. 3. Monitor vital signs as indicated. with a start date of 11/11/23. Educated RP that frequent bladder catheterization for UA as requested potentially allows bacteria to enter your body. This can cause an infection in the urethra, bladder, or the kidneys, initiated on 11/11/2023, and revised 03/19/2024. Record review of Resident #1's care plan, dated 02/20/2025, revealed to obtain urinalysis via in and out catheter every 3 months due to history of chronic UTIs created on 03/19/2024 and revised on 08/29/2024. Record review of Resident #1's new order form, dated 09/29/2022, revealed the urologist ordered a urinalysis reflex to culture (a process where the laboratory performs a chemical urinalysis (UA) to detect abnormalities such as blood, protein, glucose, and indicators of bacterial infection) if positive on the 1st of each month for UTI. Record review of Resident #1's urology clinical notes, dated 10/26/2023, revealed the resident was seen for multiple UTIs, a diagnosis for urinary tract infection debilitated, in a facility. Monthly UAs due to hx decomp events. Record review of Resident #1's Physician's Order Listing Report, dated 02/20/2025, revealed the following orders: -May obtain urinalysis via in and out cath every 3 months for urinalysis and culture if indicated with a start date of 03/19/2024, reflected as active, and a no end date. -Urinalysis with culture on 1st of each month Dx: UTI reoccurrence with a start date of 09/30/2022 and discontinued 11/11/2023. -Urinalysis with culture on 1st of each month Dx: UTI reoccurrence every night shift starting on the 1st and ending on the 5th every month collect per in and cath for lab pick with a start date of 06/15/2023 and a discontinue date of 01/11/2024. Record review of a document titled Discontinued Order for Resident #1, dated 01/11/2024 revealed an order summary for Urinalysis with culture on 1st of each month Dx: UTI reoccurrence every night shift starting on the 1st and ending on the 5th every month COLLECT PER IN AND CATH FOR LAB PICK was created on 01/11/2024 by the DON at 9:34 a.m. and discontinued at 9:43 a.m., and was signed by NP D on 02/06/2024 at 10:52 a.m. The reason for the order being discontinued was blank. The order was not reflected in Resident #1's physician orders listing report dated 02/20/2025. Record review of Resident #1's January 2024 MAR revealed a urinalysis with culture on the 1st of each month starting on the 1st and ending on the 5th was documented as refused on 01/01/2024 by LVN A; documented as refused on 01/02/2024 by LVN A; documented as administered on 01/03/2024 by LVN B; documented as administered on 01/04/2024 by LVN B; and blank on 01/05/2024. Record review of document titled 1/11/2024 Report, revealed .HAS MONTHLY UA BEEN COLLECTED??? Reinstated order for p/u on Friday morning (1-12-24) Was cancelled on 1-3/24 per lab receipts .MONTHLY ORDER DISCONTINUED DO NOT COLLECT . Record review of Resident #1's lab results report dated 02/20/2025 revealed there were no lab results collected in January of 2024 for a urinalysis. Record review of Resident #1's progress notes dated 02/20/25, revealed: -12/05/2023 at 7:47 p.m. by NP D reflected follow-up urine from 12/01/2023 ua is negative .plan: . Will fax monthly urine culture to nephrologist whom ordered lab for management. Will follow up with recommendations. Exam stable . -01/02/2024 at 5:29 a.m. LVN A reflected attempted to perform I/O cath, resident refused. Will try again tomorrow night. At 5:30 a.m. Urinalysis with culture on 1st of each month Dx: UTI reoccurrence every night shift starting on the 1st and ending on the 5th every month COLLECT PER IN AND CATH FOR LAB PICK will attempt again on night shift 1/2/2024 -01/03/2024 at 4:51 a.m. by LVN A reflected Urinalysis with culture on 1st of each month Dx: UTI reoccurrence every night shift starting on the 1st and ending on the 5th every month COLLECT PER IN AND CATH FOR LAB PICK resident refused, became very combative. will try again on Thursday evening. -01/11/2024 at 3:51 p.m. by LVN C reflected Received in bed responsive to verbal stimuli. Family visits often and are very supportive of her care.UA to be collected tonight. -01/22/2024 at 6:18 p.m. by NP D reflected follow-up monthly regulatory assessment. no acute issues noted. medications and labs reviewed . -02/29/2024 at 8:43 a.m. by NP D reflected follow-up, continues with aphasia (a disorder that results from damage to the parts of the brain responsible for language, typically affecting the left hemisphere. It can impact a person's ability to communicate, including difficulties in speaking, understanding speech, reading, and writing.), no new issues, called and spoke with [family member] in regards to no medical reason for continued ua's, will monitor q 3 months and prn . -03/14/2024 at 3:00 p.m. by the DON reflected This nurse called [Urologist] office to verify if [Urologist] will be managing the urinalysis reflux to culture and sensitivity when positive every monthly for 12 months per prescription dated 3/5/24. Staff stated will return call after verifying with [Urologist]. -03/14/2024 at 3:16 p.m. by LVN E reflected [Staff] from [Urologist] office called regarding resident's recent UA C&S and requested the results be sent to his office (once sensitivity is available) wherein which [Staff] informed this nurse that she would be calling resident's RP thereafter to inform her that [Urologist] office will not be recommending a monthly UA. In an interview on 02/20/25 at 5:30 p.m. LVN C stated the resident was known to be uncooperative with UA collections and she would chart the resident refused in the MAR and add a progress note. LVN C stated on 1/11/24 she notated they planned to collect a UA from Resident #1 on the night shift because there was an order. LVN C stated she would have noted if there was an order to cancel the UA. In an interview on 02/20/25 at 4:25 p.m. the DON stated most resident orders were in the EMR. The DON stated if an order was not in the EMR it was because it was a brand-new order, or the resident had just returned from a medical appointment, and it had not been entered yet. The DON stated if there was an order to discontinue an order, she would DC in the EMR. The DON stated sometimes the nurses would add a note as to why and the provider would sign the order. The DON stated in January of 2024 she recalled having a phone conversation with NP D to discontinue to monthly UA order because the family member of Resident #1 wanted it done monthly but the facility doctor wanted it done every 3 months. The DON stated the rationale was not documented in January 2024 in the EMR however she provided an order to discontinue the monthly UA, signed by NP D on 02/06/2024. The DON stated she was unsure which the medical provider originally ordered a monthly UA or if the order came from the urologist. The DON stated the urologist stopped practicing in 2024 and was not treating Resident #1 any longer. The DON stated she needed a doctor's order to DC an order. The DON stated she was not a doctor and did not know why they ordered a monthly UA on Resident #1. The DON stated the UA was ordered monthly at the time of the January 2024 MAR and they gave staff opportunities on the 1st-5th to collect the urine sample because the resident would refuse often. The DON stated staff should document if the resident refused, let the provider know, and use the code in the EMR for refused. The DON stated the check marks on the MAR meant the UA order was done which was improper documentation. The DON stated if staff had collected the urine sample for the UA they should have discontinued the order for the rest of that month or document it was already collected. When asked if there was a risk to the resident when staff incorrectly documented a sample was collected, the DON stated staff would document in the 24-hour report they had already collected the sample so other staff would not try to collect the sample again. Record review of the facility's policy Medical Records, dated 02/2017, revised January 2023, stated Compliance Guidelines: A medical record is maintained for every person admitted to a community in accordance with accepted professional standards and practices. The administrator has ultimate responsibility for the maintenance of medical records but may delegate this responsibility to another team member. The medical record consists of but not limited to the following: o information to identify the resident o a record of the resident's assessments o the plan of care and services provided o the results of any preadmission screening conducted by the state and progress notes .

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for 1 (Resident #1) of 3 residents reviewed for elopement risk. Resident #1 was found lying in the grass beside his wheelchair on the opposite side of a two-lane road after he had eloped from an exit door of the facility, resulting in a laceration to his right eye and facial bruising. The noncompliance was identified as PNC. The IJ began on 06/4/2024 and ended on 06/05/2024. The facility had corrected the noncompliance before the survey began. This failure could place all 3 residents who used a wander guard at risk for serious injuries. The findings were: Record review of Resident #1's face sheet, undated, revealed Resident #1 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (a disease that affects the central nervous system and makes it difficult for the brain to send signals to the rest of the body) and dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Resident #1's significant change MDS assessment, dated 05/20/2024, revealed a BIMS score of 04, indicating severe cognitive impairment. Record review of Resident #1's significant change MDS assessment, dated 05/20/2024, revealed Resident #1 had exhibited wandering behavior four to six days over a seven day look back time period. The MDS revealed, Resident #1 was at significant risk of getting into a potentially dangerous place (e.g., stairs, outside of the facility). Record review of Resident #1's June 2024 physician orders revealed an order check functionality and visualization of wander guard bracelet on LLE every shift with a start date 02/14/2023 and end date 06/05/2024. In addition, there was an order check functionality and visualization of wander guard every shift with a start date 06/05/2024. All dates and shifts in June 2024 were initialed as completed. Record review of Resident #1's care plan revealed a care plan, initiated 03/06/2023 and revised on 06/11/2024, I am exit seeking. I am at risk for elopement and/or wandering with unsafe boundaries r/t: History of attempts to leave community or home setting unattended, poor safety awareness r/t cognitive impairment. The care plan goal, initiated on 03/06/2023 with a target date 06/11/2024, stated my safety will be maintained, and I will demonstrate a well adjusted and content demeanor with my daily routine through my next review date. The care plan inventions included: Care plan with family regarding exit seeking behaviors, dated initiated 06/05/2024; Close monitoring in place for exit seeking behaviors, date initiated 06/05/2024; Distract me from exit seeking by offering pleasant diversions, structured activities, food, conversation, television, book. I prefer the following: sitting in recliner in room, dated initiated 03/06/2023; I wear a wander guard device; confirm functioning of device and change device as indicated, date initiated 03/06/2023; Identify a pattern of exit seeking: intervene as appropriate in efforts to minimize behavior, date initiated 03/06/2023; Med review per NP and psych NP, and labs ordered, date initiated 06/06/2024; Room change closer to nurses' station, date initiated 05/06/2024. Record review of Resident #1's progress notes, 03/06/2024 at 7:26pm, revealed this resident attempted to elope from this facility. Resident had pushed open the emergency door exit on the 100-hall unit and set off the alarms. This nurse along with another nurse found this resident being assisted back to the building by the facility administrator. Resident did have eyes on him during the attempted elopement. Record review of Resident #1's progress notes, 04/13/2024 at 3:29pm, revealed resident wandering to door, causing alarm to sound. Pulled resident back and encouraged him to go to another area of the building. Resident wandered down hall 100 and caused the alarm to sound. Before intervention could take place, resident was halfway out the door. Resident was holding onto door frame and his hand had to be pride (s/p) off the door frame to bring him back into the building. Record review of Resident #1's progress notes, 05/05/2024 at 3:55pm, revealed resident was noted to be sitting in wheelchair on sidewalk by med nurse. Redirected resident inside without difficulty. Record review of document titled Nrsg: Exit Seeking Risk Tool TSC-v3, dated 05/06/2024 and signed by the DON, revealed Resident #1 had on one or more occasions attempted to exit or has exited the facility in effort to wander away and Resident #1 was physically able to exit on foot or by wheelchair. Record review of an in-service, dated 05/05/2024, stated the subject was checking door alarms and listed the steps to check door alarms as check which hall the alarm(s) is/are going off on, make sure that hall does not have any residents at its exit door, ensure there are no residents outside the door of the hall the alarm(s) are sounding from, visually see and count every resident that belongs on that hall and once all steps above are completed the staff may turn off the alarm. The in-service was signed by 33 employees including RN A. Record review of the facility's PIR, dated 06/12/2024, revealed on 06/04/2024 at approximately 6:45pm during change of shift report, RN A was alerted by a family member that Resident #1 was outside lying in the grass in supine (lying on back) position next to his wheelchair. RN A assessed the resident and provided first aide and out of abundance of caution, Resident #1 was sent to the emergency room for evaluation. The investigation stated Resident #1 had previously been identified as exit seeking at times and the IDT determined that a wander guard device should be used, and Resident #1 was wearing the wander guard at the time of the incident. The investigation revealed, at approximately 6:35pm, RN A indicated she heard the door alarm sounding, she proceeded to the alarm area, did not identify anything unusual and silenced the alarm. At approximately 6:40pm-6:45pm CNA D identified Resident #1 was no longer in his room and staff immediately initiated a room search and notified RN A at approximately 6:45pm. Around 6:45pm to 6:50pm, staff was notified that Resident #1 was located outside b a visitor. Resident #1 was sent to the hospital and returned to the facility around 10:22pm with a minor laceration/skin tear to forehead and no other significant injuries identified by the ER staff. The conclusion of the PIR stated it was determined, after a thorough investigation, RN A re-set the sounding alarm prior to staff confirming that all residents were accounted for. The PIR stated RN A acknowledged prematurely resetting the sounding alarm before confirming all residents were accounted for and RN A failed to adhere to the facility's elopement response policy. As a result, RN A was terminated effective 06/12/2024. Record review of Resident #1's incident report, dated 06/04/2024, revealed nurses were alerted that a resident was outside and observed lying supine in the grass next to his wheelchair. 911 was called, he was assessed for injury and tried to make resident as comfortable as possible without lifting him, to wait for EMS. The incident reported stated EMS arrived at 7:00pm to transport Resident #1 to the ER and revealed Resident #1's family member, physician, DON, ADON and Administrator were notified of the incident. Injuries observed at the time of the incident were listed as skin tear on the face. Mental status revealed Resident #1 was oriented to person and listed his mobility as wheelchair bound. Predisposing physiological factors included impaired memory, lower extremity weakness and confusion. Predisposing situation factors included active exit seeker. Record review of facility document SNF/NF to Hospital Transfer Form dated 06/04/2024, revealed Resident #1 was sent to the hospital and listed fall as the reason for the transfer. Review of the document revealed Resident #1's family member and physician were notified of the hospital transfer. Record review of weatherspark.com revealed the temperature in the city in which the facility was located on 06/04/2024 at 5:54pm was 102 degrees Fahrenheit and 100 degrees Fahrenheit at 6:54pm with mostly clear skies. Record review of Resident #1's hospital records revealed Resident #1 had a CT scan on 06/04/2024 and the findings revealed no acute intracranial abnormality. Record review of Resident #1's document titled PCC Skin & Wound-Total Body Skin Assessment, dated 06/04/2024 at 10:45pm, revealed Resident #1 had normal skin temperature and one new wound. Observation of the facility grounds, 06/19/2024 at 8:30am, revealed the facility was located along side and facing a two-lane farm to market road. Observation upon approaching the facility revealed the front door to be locked and a keypad present without an access code posted. Surveyor rang the doorbell and was let inside by the Receptionist. The front door was observed and had a delayed egress bar, keypad and a wander guard system. Observations of the facility, 06/19/2024 at 8:47am, revealed exit doors at the end of each of the 4 hallways had a delayed egress bar, STOP alarm box in the armed position and a code alert box. Exit door alarms sounded when the surveyor pressed on the delayed egress bars at all exit doors. A framed sign by the code alert alarm box, located on the wall by the nurse's station, read When door alarm sounds and ready to clear: 1. Push 1234 on keypad 1. Push green button at nurses' station. 3. Push 1234 on the keypad again. 4. Check if red light is back on all keypads. When memory alarm sounds: 1. Push 1234. 2. Push red button on wall twice. 3. Push green button once. 4. Check if red light is back on all keypads. 5. Check outside gate and doors in memory unit. Observation of the facility grounds and route Resident #1 traveled to exit the facility to the location he was found, 06/19/2024 at 9:15a.m., revealed Resident #1 propelled himself approximately 100 yards from the 300 hall exit door, through the parking lot and across the road where he was found lying in the grass. Observation of Resident #1, 06/19/2024 at 9:20am, revealed Resident #1 sitting up in a recliner in his room with a blanket covering his legs and torso. Resident #1 was watching television and was not exhibiting any signs of pain or distress. Observation revealed an approximate one-inch laceration/skin tear above Resident #1's right eye and faded brown bruising to the right side of his right eye. A wander guard was observed on Resident #1's left ankle. Resident #1 had a walker and a transport wheelchair in his room. During an interview with Resident #1, 06/19/2024 at 9:20am, Resident #1 was pleasant and was able to answer simple yes or no questions. Resident #1 denied being in pain, falling or being outside at any time. When asked how he got the laceration above his eye he said I fell and hurt my eyeball but was unable to find the correct words to give a description of how he fell . Resident #1 said he used a wheelchair to move around the room and facility. Resident #1 denied any additional injuries. During an interview with CNA A, 06/19/2024 at 9:50am, CNA A stated she was assigned to 300 hall and had provided care to Resident #1 for over a month. CNA A revealed Resident #1 was an elopement risk, was exit seeking and wandering in the facility daily and had multiple elopement attempts prior to 06/04/2024. During an interview with Resident #1's family member, 06/19/2024 at 10:52am, Resident #1's family member said she received a call from RN A around 7pm on 06/04/2024. Resident #1's family member said RN A informed her that Resident #1 got out of the facility, went across the road, fell out of his wheelchair, hit his head on the ground and was sent to the ER with a cut above his eye. Resident #1's family member stated she went up to the facility the next day, found the Administrator and told him they needed to have a meeting. Resident #1's family member said during the meeting, the Administrator told her two people driving by the facility saw Resident #1 lying by the road and one of the people went in the facility and notified the staff that Resident #1 was across the road. Resident #1's family member said the Administrator told her the facility was investigating the incident and RN A had been placed on suspension. Resident #1's family member said Resident #1 had tried to exit the facility in the past and proceeded to say when she was in the meeting with the facility staff, the Administrator told her Resident #1 was trying to get out of the facility three or four times a day and that his wander guard only works for the front door. Resident #1's family member said she was aware he was exit seeking but had no idea it was three or four times a day, that seems excessive. Resident #1's family member said she was aware Resident #1 exited the facility through a hallway exit door last month but a staff member saw him go out the door and brought him back in. Resident #1's family member said the facility had recently moved him last month to a different hall prior to the elopement on 6/4/2024 but stated she did not feel like the facility was doing enough to keep Resident #1 safe. Resident #1's family member stated the facility had not issued Resident #1 a discharge notice but had discussed Resident #1 moving to a male secured unit for safety. Resident #1's family member stated she had been touring other facilities and had found a facility she was interested in moving Resident #1 which is in a nearby town. Resident #1's family member stated, in her opinion the incident should have never happened and stated she did not think the staff were watching him appropriately. Resident #1's family member said when she went to visit Resident #1 on 06/05/2024 she observed large red and purple bruising to his cheek and right side of his eye along with a laceration above his right eye. During an interview with LVN A, 06/19/2024, LVN A stated Resident #1 had a history of exit seeking behavior. LVN A stated Resident #1 eloped out of the door on 100 hall on 05/05/2024 while she was passing medications. LVN A stated she heard the door alarm going off at the end of 400 hall and stated she finished giving a medication and then went to the 100-hall door and observed Resident #1 in the parking lot about 15 feet away from the facility. LVN A said she did not see him exit the 100 hall door. LVN A said she went outside and redirected him back into the facility through the front door and stated Resident #1 said he was looking for his family member. LVN A stated Resident #1 was moved to 300 halls after that incident. LVN A explained that the 300 halls exit door is not visible at the end of the hall like it is on 100 and 200 halls. The 300-hall door is around a corner by the therapy gym so the staff thought if Resident #1 could not see the door, it might prevent him from trying to exit. LVN A stated before the 06/04/2024 elopement, people's normal reaction was not to really react to the alarms. Record review of an undated statement, provided by the Administrator and signed by LVN A, stated On 5/5/24 [name redacted] was noted exiting the 100-hall door. This nurse was out the door in 45 seconds saw the resident at all times. Redirected back into building via front door within 5 mins. During an interview with the Administrator, 06/19/2024 at 3:59 p.m., The Administrator said was notified on the evening of 06/04/2024 before 8p.m., Resident #1 was found outside of the facility lying across the road in the grass and was being sent to the hospital. The Administrator said he immediately began an investigation into the incident and identified RN A silenced the sounding alarm at the nurse's station. The Administrator said RN A said she heard the alarm sounding, identified the alarm code to be Zone 6 which was labeled 300 hall exit door, looked down the hall and did not see anything unusual and silenced the alarm. The Administrator stated the expectation when a door alarm goes off is for staff to look at the alarm keypad and identify which exit door has been opened, go to that door and complete a search inside and outside of the facility and complete a resident head count before the alarm is deactivated. The Administrator stated a head count of all residents was conducted when the facility became aware of the incident. All staff received education on responding to door alarms, elopement and exit seeking prevention and abuse/neglect training. The Administrator stated Resident #1's family member and physician were notified of the incident, Resident #1 was placed on 15-minute checks when he returned to the facility, self-report was completed to HHSC, Resident #1's plan of care was updated, a care plan meeting was held on 06/05/2024 with Resident #1's family member, and an Ad Hoc QAPI meeting was held on 06/05/2024 with the Medical Director. The administrator also stated the facility completed 100% audit of all residents by completing a new exit seeking tool on each resident and updated plans of care based on the outcome of the assessments. The Administrator stated the facility began random elopement drills on each shift to validate staff competency. The Administrator revealed there were 3 residents (Resident #1, #3 and #4) who were at risk for elopement and wore wander guard bracelets. During an interview with RN A, 06/19/2024 at 7:12 p.m., RN A stated on the evening of 06/04/2024 she was giving report to an oncoming nurse when she heard the alarm go off. RN A said no one else knew how to respond to the alarm because they were all with the staffing agency. RN A said she looked down the hallway and did hear the door alarm from the end of the hall, so she went over to the alarm keypad and silenced the alarm. RN A said, I was going to finish my medication count and then I was going to go down to the door and check it. RN A said, about that time a family member came in from outside and said Resident #1 was outside. I called 911 and ran outside and observed him lying in the grass in a supine position on the opposite side of the road. RN A said once Resident #1 left with EMS, RN A returned to the facility and completed a head count of all the other residents. RN A stated she had received training on exit seeking residents and responding to door alarms prior to the 06/04/2024 elopement and confirmed she was terminated from her position at the facility. During an interview with CNA D, 06/19/2024 at 7:34 p.m., CNA D stated she was assigned to Resident #1 on the evening of 06/04/2024. CNA D said around 6:30 p.m., after dinner, CNA D placed Resident #1 in his room between his bed and the recliner, locked his wheelchair brakes, turned on the television and placed his call light within reach. CNA D said she worked for a staffing agency but was familiar with Resident #1 and had worked with him many times over the past month. CNA D said she was in another room talking to a family member for about five minutes and when she walked back by Resident #1's room, he was not there. CNA D said she went to the 300 hall exit door and did not see anyone outside and said she touched the delayed egress bar and the alarm sounded. CNA D then went to the nurse's station to tell RN A she could not find Resident #1 and at that time, a family member came in and said Resident #1 was outside. CNA D stated this all occurred in approximately 11 minutes. During an interview with the facility Maintenance Director, 06/20/2024 at 10:56a.m., the Maintenance Director said the door alarms were checked weekly to validate they were functioning properly. The Maintenance Director stated the last time 300 hall door was tested for functionality was 05/30/2024 and no issues were identified. The Maintenance Director stated the door alarm was triggered when a person presses on the delayed egress bar. The alarm at the door would sound for 15 seconds and then the door would open and the alarm would stop sounding. This alarm also triggers an alarm at the nurse's station that is coded by zones to identify which exit door has been opened. In addition, there is a red stop alarm on the door that is triggered when the door opens. This alarm will sound for 15 seconds. The Maintenance Director said the alarm at the nurse's station will continue to sound until the alarm is silenced or reset. The Maintenance Director stated he provided door alarm training during orientation and the training included identifying the exit door on the keypad when the alarm sounds, going to the exit door and conducting a search inside and outside of the door and completing a head count prior to deactivating the alarm. Record review of a facility document titled Work History Report listed a task doors, locks & alarms: Corridor -Doors. The task completion was marked down on time by Maintenance Director on 05/30/2024. During an interview with a facility family member, 06/20/2024 at 1:20p.m., the family member stated she was leaving the facility around 6:45p.m. on the night of 06/04/2024. When the family member was pulling out of the parking lot, she saw a man lying on the grass on the opposite side of the road tangled up in his wheelchair. The family member said she stopped her car and ran to Resident #1 and got his wheelchair off him. The family member said another person passing by stopped to help so the family member ran across the street and notified the facility staff that Resident #1 was lying out by the road. The family member said approximately five people ran out to help and said, It was like 103 degrees outside that day, who know what would of happened to him if I didn't see him. The family member also said she went to the store and bought bottled water for the staff because it was so hot outside at the time of the incident. Record Review of a facility policy titled Elopement Response & Exit Seeking Management, date implemented 2019 and date reviewed/revised January 2023, revealed if a resident is unable to be located or the alarms have sounded, immediately initiate a search of the entire community both inside and outside the premises. The facility course of action prior to surveyor entrance included: Record review of the Administrator's PIR, dated 06/12/2024, revealed an investigation was initiated on 06/04/2024 and all required notifications were made which included the Medical Director, responsible party, and physician. Record review of a facility document titled [Facility] Elopement Response, initiated date 06/04/2024, revealed the following actions: Director of Nursing/Designee will educate current team members and new hires and agency personnel prior to working the floor regarding: missing person response and elopement/exit seeking risk and proper response to missing resident/resident elopement protocol and preventing, identifying, and reporting abuse and neglect. Administrator/DNS/Designee conducted an elopement drill to ensure that team members understand and carry out an appropriate elopement response. Resident # 1 placed on close monitoring and to ensure maintain safety. Nursing notified MD and family representative of incident and resident status. The following was initiated on 06/05/2024: VP of Clinical Operations and VP of Operations conducted in-service training to the identified, Director of Nursing and Administrator regarding: missing person and elopement/exit seeking response. Addition education provided reviewed the process for reviewing the TXHHSC PL for reporting criteria of missing resident/elopement in order to ensure compliance with state and federal regulations: preventing, identifying and reporting abuse and neglect, facility process for identifying potential risks for elopement; implementing appropriate interventions and updating the plan of care as indicated. Director of Nursing/Designee will conduct an audit of all recent new admissions and readmission, reviewing the exit seeking assessment in order to identify any concerns with exit seeking or elopement risks and the IDT will review and/or will update the plan of care as indicated. Administrator/Social Worker/Director of Nursing/Designee will conduct staff and resident interviews to identify any concerns of exit seeking/elopement behaviors. If identified the IDT will review the plan of care and/or will update the plan of care as indicated in order to ensure it appropriately reflects potential exit seeking/elopement risk noted. Director of Nursing/Designee to conduct retraining for all team members as well as agency staffers (nurses/CNAs) prior to assuming next shift. DNS/Designee will ensure that all newly hired team members receive the training as part of the onboarding. Ad Hoc QAPI held with Administrator, Director of Nursing and Medical Director to review the concerns and plan of removal implemented. Admin/DNS/SW/Designee will conduct random weekly audits of 1-3 new admission and/or readmission initial care plans and comprehensive care plans in order to validate the accuracy of the care plan by ensuring identified elopement risk are noted in the plan of care and appropriate interventions are in place. Director of Nursing/Designee will audit and review progress notes, changes in conditions, risk management reports and the nursing 24 hr. report daily 5-7 days per week during the morning clinical meeting in order to validate appropriate follow up and necessary interventions are in place. Administrator/Director Nursing/Designee will conduct elopement/missing person response drill on random shifts to identify competency of TMs or to identify additional education needs. Drills will be conducted 2-4 times per month for the next 1-2 months. This plan will remain in place for the next 2 months and findings will be reported to the QAPI committee during monthly meeting for the next 2 months. The QAPI committee will then determine compliance or identify a need for additional training. Record review of facility document titled Conduct and Workplace Expectation Notice revealed RN A was suspended on 06/05/2024 during the investigation and was terminated by phone from employment on 06/12/2024. The document was signed by the Administrator and DON. Record review of Resident #1's chart revealed an exit seeking risk tool assessment, completed 06/02/2024 at 10:30p.m., and skin assessment, completed 06/04/2024 at 10:45p.m., when Resident #1 returned from the hospital. Record review revealed Resident #1's care plan had been updated on 06/05/2024 to include a care plan meeting with Resident #1's family regarding exit seeking behaviors, close monitoring in place for exit seeking behaviors, medication review per NP and psych NP and labs as ordered. Record review of a facility staff roster, undated, revealed 57 employee signatures. Record review of an in-service titled Abuse and Neglect, dated 06/05/2024, with the facility abuse and neglect policy attached, revealed 62 employee names. Record Review of an in-service titled Door Alarms, dated 06/05/2024, revealed the following guidance with bullet points: Check which hall the alarm(s) is/are going off on the panel, make sure that hall does not have any residents at its exit door, ensure there are no residents outside the door of the hall the alarm(s) are sounding, visually verify and count each resident that resides on that hall and once all steps above are completed the staff may turn off the alarm. The in-service has 63 employee signatures. Record review of an in-service titled Elopement Response and Exit Seeking Management, dated 06/05/2024, revealed 61 employee signatures. Record review of an in-service titled Missing Person and Elopement/Exit Seeking Response, dated 06/05/2024 and conducted by VP of Clinical Operations and VP of Operations, was signed by the Administrator and DON. The in-service read Missing person and elopement/exit seeking response. Additional education provided reviewed the process for reviewing the TXHHSC PL for reporting criteria of missing resident/elopement in order to ensure compliance with state and federal regulations: Preventing, identifying and reporting abuse and neglect, Facility's process for identifying potential risk of elopement; implementing appropriate interventions and updating the plan of care as indicated. Record review of an Ad Hoc QAPI Meeting, dated 06/05/2024 at 10:15a.m., revealed 6 signatures, including the Administrator, DON and Medical Director. Record review of a facility document titled IDT: Care Plan Conference & Advanced Care Planning Review-V4, dated 06/05/2024 at 12:45p.m., revealed a care plan meeting with Resident #1's resident representative, Administrator, DON and ADON. The care plan meeting was held to discuss Resident #1's exit seeking behavior and a potential discharge to a male memory care unit. Record review of 5 resident charts revealed new elopement risk assessments completed on 06/05/2024. Record review revealed elopement drills were conducted on 06/05/2024 at 6:15p.m., 06/06/2024 at 10:10a.m., 06/07/2024 at 5:00a.m., 06/07/2024 at 5:15p.m., 06/07/2024 at 6:15p.m., 06/08/2024 at 6p.m. - 6a.m., 06/08/2024 at 8:00 a.m., 06/09/2024 at 10:15a.m., 06/09/2024 at 6p.m. - 6a.m., 06/10/2024 at 6:10p.m., 06/10/2024 at 11:35a.m. Record review of maintenance work history report revealed door locks and alarms were marked as completed on 06/04/2024, 06/13/2024 and 06/20/2024. Record review of Resident #3's face sheet revealed Resident #3 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included Dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Resident #3's quarterly MDS assessment, dated 04/15/2024, revealed Resident #3 had a BIMS of 04, indicating severe cognitive impairment. In addition, the MDS revealed Resident #3 had no exhibited wandering behavior during the 7 day look back period. Record review of Resident #3 June 2024 physician orders revealed Resident #3 had an order to check functionality and visualization of wander guard/exit management system through wand or alarmed door, start date 09/26/2023. Record review of Resident #3's exit seeking tool, dated 06/05/2024 revealed Resident #3 was wandering and exit seeking, had verbalized the need or desire to go home or to another location, had sundown syndrome (resident experiences increased confusion, occurring specifically at dusk) and was physically able to exit on foot or by wheelchair. Record review of Resident #3's care plan revealed Resident #3 had an exit seeking care plan, initiated 06/20/2022 and revised 09/26/2023. Observation of Resident #3, 06/20/2024 at 11:00a.m., revealed Resident #3 sitting in a stationary chair in her room reading a magazine. A wander guard bracelet was observed on Resident #3's left arm. Observation of Resident #1, 06/20/2024 at 11:08a.m., revealed Resident #1 lying in his bed watching television. Resident #1 had his call light in reach and wander guard on his left leg. Resident #1 was pleasant and did not appear to be in any pain or distress. Record review of Resident #4's face sheet revealed Resident #4 is an [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included Dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Resident #4's quarterly MDS assessment, dated 05/13/2024, revealed a BIMS score of 01, indicating severe cognitive impairment. In addition, the MDS revealed Resident #4 had exhibited wandering behavior 1 to 3 days in the 7 day look back period. Record review of Resident #4's June 2024 physician orders revealed Resident #4 had an order to check functionality and visualization of wander guard/exit management system through wand or alarmed door, start date 05/02/2024. Record review of Resident #4's exit seeking tool, completed 06/05/2024 revealed Resident #4 was exit seeking, had a diagnosis associated with confusion which may indicate future likelihood for wandering, had confusion, had sun [TRUNCATED]

Based on interview and record review, the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission for 22 (Residents #53, #901, #88, #7, #50, #27, #39,, #41, #47, #141, #902, #903, #17, #63, #34, #1, #62, #904, #905, #84, #20, and #906,) of 43 residents reviewed for physician services. The facility failed to ensure PCP A made physician visits since he started on or about 10/01/2023. The facility failed to ensure 22 of 43 residents (Residents #53, #901, #88, #7, #50, #27, #39, #41, #47, #141, #902, #903, #17, #63, #34, #1, #62, #904, #905, #84, #20, and #906) were seen by a Physician within 30 days of admission to the facility. This failure could place residents at an increased risk of not receiving appropriate, adequate medical care in a timely manner resulting in a decline in health status or diminished quality of life. The findings included: Record review of the EHR revealed a lack of physician documentation for newly admitted residents, after 10/1/2023, wherein PCP A documented a review of the resident's total program of care, including the resident's current condition, progress and problems in maintaining or improving their physical, mental and psychosocial well-being and decisions about the continued appropriateness of the resident's current regimen. There were no physician progress notes written, signed and dated by PCP A for newly admitted residents after 10/1/2023. Record review of Admission/Discharge Report dated 1/27/2024, indicated there were 43 residents admitted [DATE] to 1/23/2024. Of those 43 residents, there was no documentation of required physician visits available in the EHR for 22 residents. Record review of admission record revealed Resident #53 was a resident admitted on [DATE] with dementia [general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities] as a diagnosis. Record review of admission record revealed Resident #901 was a resident admitted on [DATE] with osteomyelitis [infection of the bone] as a diagnosis. Record review of admission record revealed Resident #88 was a resident admitted on [DATE] with Parkinson's disease [progressive disorder that affects the nervous system and the parts of the body controlled by the nerves] as a diagnosis. Record review of admission record revealed Resident #7 was a resident admitted on [DATE] with chronic obstructive pulmonary disease [chronic inflammatory lung disease that causes obstructed airflow from the lungs] as a diagnosis. Record review of admission record revealed Resident #50 was a resident admitted on [DATE] with severe chronic kidney disease, stage IV [severe loss of kidney function for 3 months or more] as a diagnosis. Record review of admission record revealed Resident #27 was a resident admitted on [DATE] with acute respiratory failure as a diagnosis. Record review of admission record revealed Resident #39 was a resident admitted on [DATE] with weakness as a diagnosis. Record review of admission record revealed Resident #41 was a resident admitted on [DATE] with hypertensive heart and chronic kidney disease state V [also known as end-stage kidney disease] as a diagnosis. Record review of admission record revealed Resident #47 was a resident admitted on [DATE] with respiratory syncytial virus [common respiratory virus that usually causes mile, cold-like symptoms, but can be severe symptoms in older adults and infants] as a diagnosis. Record review of admission record revealed Resident #141 was a resident admitted on [DATE] with repeated falls as a diagnosis. Record review of admission record revealed Resident #902 was a resident admitted on [DATE] with acute respiratory failure as a diagnosis. Record review of admission record revealed Resident #903 was a resident admitted on [DATE] with orthopedic surgery aftercare as a diagnosis. Record review of admission record revealed Resident #17 was a resident admitted on [DATE] with ataxic cerebral palsy [developmental disorder that affects motor function such as balance and coordination] as a diagnosis. Record review of admission record revealed Resident #63 was a resident admitted on [DATE] with disorientation as a diagnosis. Record review of admission record revealed Resident #34 was a resident admitted on [DATE] with urinary tract infection as a diagnosis. Record review of admission record revealed Resident #1 was a resident admitted on [DATE] with chronic obstructive pulmonary disease as a diagnosis. Record review of admission record revealed Resident #62 was a resident admitted on [DATE] with syncope [fainting] and collapse as a diagnosis. Record review of admission record revealed Resident #904 was a resident admitted on [DATE] with systemic inflammatory response syndrome [exaggerated defense response from the body to a harmful stressor] as a diagnosis. Record review of admission record revealed Resident #905 was a resident admitted on ,d+[DATE] with dehydration [occurs as a result of abnormal water loss from the body, or not taking in enough fluids] as a diagnosis. Record review of admission record revealed Resident #84 was a resident admitted on [DATE] with encephalopathy [any diffuse disease of the brain that alters brain function or structures, results in altered mental state] as a diagnosis. Record review of admission record revealed Resident #20 was a resident admitted on [DATE] with falls as a diagnosis. Record review of admission record revealed Resident #906 was a resident admitted on [DATE] with alcohol dependence as a diagnosis. Record review of the EHR, between 1/24/2024 and 1/25/2024, produced no electronic documentation of physician visits for Residents #53, #901, #88, #7, #50, #27, #39,, #41, #47, #141, #902, #903, #17, #63, #34, #1, #62, #904, #905, #84, #20, or #906. In a confidential interview on 1/24/2024 at 2:45 PM, 2 of 5 residents stated they had not seen their doctor in a while and wanted to see him/her more often. These residents could not recall the name of their new doctor or the last time they saw him. In an interview on 1/25/2024 at 4:13 PM, the ADM stated the MD stepped down as providing PCP services, and PCP A took over the PCP role about 10/01/2023. The ADM stated PCP A was at the facility multiple times per week and saw many residents each time he was in the building. The ADM stated most of his communication with PCP A was via messages or over the telephone. The ADM stated PCP A usually conducted his visits to the facility outside of normal business hours of Monday to Friday 8:00 AM to 5:00 PM, so it was not often that the ADM saw PCP A. The ADM stated he did not have a list of residents the PCP A or NP B had seen as a required physician visit once every 30 days during the first 90 days, and every 60 days thereafter. The ADM stated the facility did not keep track of which residents were seen and when. In a joint interview on 1/25/2024 at 5:00 PM, the DON and the ADM stated the MD would be adding a quality assurance check for the monitoring of physician visits for PCP A and NP B. The ADM stated when PCP A started, he knew there was a learning curve for using the facility's EHR. The ADM stated he had only just learned today [1/25/2024] that PCP A had not entered any physician notes. The ADM stated, it was his understanding that PCP A would be working on immediately transcribing and uploading his notes into the EHR system. The ADM stated it was his sincere belief that all residents' medical concerns had been attended to promptly. The DON stated she did not believe any resident health care concerns had been missed, and all necessary treatments had received valid orders in a timely manner and that facility staff had executed those orders appropriately. The ADM stated he would run an audit report [Admission/Discharge Report] and indicate which residents were missing documentation of required physician visits. In an interview on 1/26/2024 at 12:44 PM, the DON stated that there was some risk that documentation was not done, but she was confident the care was being provided. The DON stated she felt the level of communication between the facility, NP B and PCP A was intact and therefore adequate for provision of care to the residents. The DON stated she felt that all the residents' medical needs were being attended to and appropriate care was provided. In an interview on 1/26/2024 at 3:30 PM, the MD stated he had been medical director at this facility since it opened, approximately 15 or [AGE] years now. The MD stated it had never come up on a facility meeting agenda for the medical director to track timely physician visits. The MD stated that he was the medical director for over 50 nursing facilities in the area. The MD stated he assumed each nursing home was tracking when each resident needed to be seen for a physician visit versus a medically necessary visit. The MD stated he did not know if residents were seen by a physician every 60 days or if newly admitted residents were seen by a physician once every 30 days for their first 90 days after admission. The MD stated, the residents at the facility could elect to see him in his clinic, but he would not be considered the primary care physician because he did not see patients at the nursing home. In an interview on 1/26/2024 at 4:10 PM, NP B stated he had covered this facility since October 2023. NP B stated he visited the facility 2 or 3 times per week depending on acuity. NP B stated at each facility visit he saw between 10 and 15 residents. NP B stated that he believed the rules for nurse practitioner visits were that new residents needed to be seen within the first 7 to 10 days after arrival at the facility, and every 60 days thereafter for long term residents as a follow up, and of course PRN for medically necessary occurrences, along with annual visits. NP B stated he prioritized which residents would be seen based on the after hours on-call notifications, a review of new laboratory and imaging results, consults with on-site nursing staff regarding any issues for residents. NP B stated there was a communication binder in which the on-site nurses would document any concerns they wanted him to address via orders. NP B stated these were typically non-acute or routine issues that needed orders to be filled. NP B stated he did not feel that any medical or nursing concern had been missed. NP B stated there is a lot of communication occurring between facility staff and the medical team to address any issues. NP B stated he did not have a list of which residents were seen on particular dates he visited the facility. NP B stated he did not have a list of which residents were seen for a medically necessary visit versus a required physician visit delegated to the NP role. In an interview on 1/27/2024 at 10:45 AM, the ADM stated, the MD saw all the residents on or about 9/25/2023, when the MD was stepping down from dual role of PCP and MD and would be assuming the role of MD only. The ADM stated that the residents would have next had a required visit on or about 11/25/2023 that could be an alternate visit conducted by NP B. The ADM stated that with the 10-day slippage, or grace period, there was still enough time for the required physician visits scheduled for 1/25/2024 to occur. The ADM stated that prior to that 10-day slippage, or grace period being up, all residents would be seen by either PCP A or the MD for the required physician visit every 30 days in the first 90 days and every 60 days thereafter visit. The ADM stated this would include a review of each resident's total program of care, current condition, progress or problems with health and well being maintenance. The ADM stated going forward, it would be a specific visit to meet the regulatory requirements. A telephone interviews with PCP A were attempt and unsuccessful on the following days: *1/25/2024 at 3:30 PM, * 1/26/2024 at 3:15 PM, and *1/27/2024 at 11:15 AM. Record review of Physician Services and Medical Director policy, implemented 2/2017, revealed, under the subheading Physician responsibilities, .physician is responsible for reviewing and approving the resident's total program of care. Under the subheading of Frequency of physician visits, residents are seen at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. Record review of Medical Records policy, revised 1/2023, did not address accuracy or timely updates to the medical records.

Based on interviews and record reviews, the facility failed to maintain medical records on each resident that are accurately documented for 24 (Residents #53, #901, #88, #7, #50, #27, #39,, #41, #47, #141, #902, #903, #17, #63, #34, #1, #62, #904, #905, #84, #20, and #906,) of 24 residents reviewed for accurate medical records in that: The facility failed to ensure PCP A documented physician notes in the EHR since he started on or about 10/01/2023. This deficient practice could place all residents at an increased risk of not having their total program of care and condition reviewed, decisions about the continued appropriateness of the resident's current medical regimen documented, which could result in a decline in health and well-being. The findings included: Record review of the EHR revealed a lack of physician documentation for newly admitted residents, after 10/1/2023, wherein PCP A documented a review of the resident's total program of care, including the resident's current condition, progress and problems in maintaining or improving their physical, mental and psychosocial well-being and decisions about the continued appropriateness of the resident's current regimen. There were no physician progress notes written, signed and dated by PCP A for newly admitted residents after 10/1/2023. Record review of Admission/Discharge Report dated 1/27/2024, indicated there were 43 residents admitted [DATE] to 1/23/2024. Of those 43 residents, there was no documentation of required physician visits available in the EHR for 22 residents. Record review of admission record revealed Resident #53 was a resident admitted on [DATE] with dementia [general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities] as a diagnosis. Record review of admission record revealed Resident #901 was a resident admitted on [DATE] with osteomyelitis [infection of the bone] as a diagnosis. Record review of admission record revealed Resident #88 was a resident admitted on [DATE] with Parkinson's disease [progressive disorder that affects the nervous system and the parts of the body controlled by the nerves] as a diagnosis. Record review of admission record revealed Resident #7 was a resident admitted on [DATE] with chronic obstructive pulmonary disease [chronic inflammatory lung disease that causes obstructed airflow from the lungs] as a diagnosis. Record review of admission record revealed Resident #50 was a resident admitted on [DATE] with severe chronic kidney disease, stage IV [severe loss of kidney function for 3 months or more] as a diagnosis. Record review of admission record revealed Resident #27 was a resident admitted on [DATE] with acute respiratory failure as a diagnosis. Record review of admission record revealed Resident #39 was a resident admitted on [DATE] with weakness as a diagnosis. Record review of admission record revealed Resident #41 was a resident admitted on [DATE] with hypertensive heart and chronic kidney disease state V [also known as end-stage kidney disease] as a diagnosis. Record review of admission record revealed Resident #47 was a resident admitted on [DATE] with respiratory syncytial virus [common respiratory virus that usually causes mile, cold-like symptoms, but can be severe symptoms in older adults and infants] as a diagnosis. Record review of admission record revealed Resident #141 was a resident admitted on [DATE] with repeated falls as a diagnosis. Record review of admission record revealed Resident #902 was a resident admitted on [DATE] with acute respiratory failure as a diagnosis. Record review of admission record revealed Resident #903 was a resident admitted on [DATE] with orthopedic surgery aftercare as a diagnosis. Record review of admission record revealed Resident #17 was a resident admitted on [DATE] with ataxic cerebral palsy [developmental disorder that affects motor function such as balance and coordination] as a diagnosis. Record review of admission record revealed Resident #63 was a resident admitted on [DATE] with disorientation as a diagnosis. Record review of admission record revealed Resident #34 was a resident admitted on [DATE] with urinary tract infection as a diagnosis. Record review of admission record revealed Resident #1 was a resident admitted on [DATE] with chronic obstructive pulmonary disease as a diagnosis. Record review of admission record revealed Resident #62 was a resident admitted on [DATE] with syncope [fainting] and collapse as a diagnosis. Record review of admission record revealed Resident #904 was a resident admitted on [DATE] with systemic inflammatory response syndrome [exaggerated defense response from the body to a harmful stressor] as a diagnosis. Record review of admission record revealed Resident #905 was a resident admitted on ,d+[DATE] with dehydration [occurs as a result of abnormal water loss from the body, or not taking in enough fluids] as a diagnosis. Record review of admission record revealed Resident #84 was a resident admitted on [DATE] with encephalopathy [any diffuse disease of the brain that alters brain function or structures, results in altered mental state] as a diagnosis. Record review of admission record revealed Resident #20 was a resident admitted on [DATE] with falls as a diagnosis. Record review of admission record revealed Resident #906 was a resident admitted on [DATE] with alcohol dependence as a diagnosis. Record review of the EHR, between 1/24/2024 and 1/25/2024, produced no electronic documentation of physician visits for Residents #53, #901, #88, #7, #50, #27, #39,, #41, #47, #141, #902, #903, #17, #63, #34, #1, #62, #904, #905, #84, #20, or #906. In a confidential interview on 1/24/2024 at 2:45 PM, 4 of 5 residents stated they had not seen their doctor in a while and wanted to see him/her more often. These residents stated that they could not recall the name of their new doctor or the last time they saw him. In an interview on 1/25/2024 at 4:13 PM, the ADM stated the MD stepped down as providing PCP services, and PCP A took over the PCP role about 10/01/2023. The ADM stated PCP A was at the facility multiple times per week and saw many residents each time he was in the building. The ADM stated most of his communication with PCP A was via messages or over the telephone. The ADM stated PCP A usually conducted his visits to the facility outside of normal business hours of Monday to Friday 8:00 AM to 5:00 PM, so it was not often that the ADM saw PCP A. The ADM stated he did not have a list of residents the PCP A or NP B had seen as a required physician visit once every 30 days during the first 90 days, and every 60 days thereafter. The ADM stated the facility did not keep track of which residents were seen and when. In a joint interview on 1/25/2024 at 5:00 PM, the DON and the ADM stated the MD would be adding a quality assurance check for the monitoring of physician visits for PCP A and NP B. The ADM stated when PCP A started, he knew there was a learning curve for using the facility's EHR. The ADM stated he had only just learned today [1/25/2024] that PCP A had not entered any physician notes. The ADM stated, it was his understanding that PCP A would be working on immediately transcribing and uploading his notes into the EHR system. The ADM stated it was his sincere belief that all residents' medical concerns had been attended to promptly. The DON stated she did not believe any resident health care concerns had been missed, and all necessary treatments had received valid orders in a timely manner and that facility staff had executed those orders appropriately. The ADM stated he would run an audit report [Admission/Discharge Report] and indicate which residents were missing documentation of required physician visits. In an interview on 1/26/2024 at 12:44 PM, the DON stated that there was some risk that documentation was not done, but she was confident the care was being provided. The DON stated she felt the level of communication between the facility, NP B and PCP A was intact and therefore adequate for provision of care to the residents. The DON stated she felt that all the residents' medical needs were being attended to and appropriate care was provided. In an interview on 1/26/2024 at 3:30 PM, the MD stated he had been medical director at this facility since it opened, approximately 15 or [AGE] years now. The MD stated it had never come up on a facility meeting agenda for the medical director to track timely physician visits. The MD stated that he was the medical director for over 50 nursing facilities in the area. The MD stated he assumed each nursing home was tracking when each resident needed to be seen for a physician visit versus a medically necessary visit. The MD stated he did not know if residents were seen by a physician every 60 days or if newly admitted residents were seen by a physician once every 30 days for their first 90 days after admission. The MD stated, the residents at the facility could elect to see him in his clinic, but he would not be considered the primary care physician because he did not see patients at the nursing home. In an interview on 1/26/2024 at 4:10 PM, NP B stated he had covered this facility since October 2023. NP B stated he visited the facility 2 or 3 times per week depending on acuity. NP B stated at each facility visit he saw between 10 and 15 residents. NP B stated that he believed the rules for nurse practitioner visits were that new residents needed to be seen within the first 7 to 10 days after arrival at the facility, and every 60 days thereafter for long term residents as a follow up, and of course PRN for medically necessary occurrences, along with annual visits. NP B stated he prioritized which residents would be seen based on the after hours on-call notifications, a review of new laboratory and imaging results, consults with on-site nursing staff regarding any issues for residents. NP B stated there was a communication binder in which the on-site nurses would document any concerns they wanted him to address via orders. NP B stated these were typically non-acute or routine issues that needed orders to be filled. NP B stated he did not feel that any medical or nursing concern had been missed. NP B stated there is a lot of communication occurring between facility staff and the medical team to address any issues. NP B stated he did not have a list of which residents were seen on particular dates he visited the facility. NP B stated he did not have a list of which residents were seen for a medically necessary visit versus a required physician visit delegated to the NP role. In an interview on 1/27/2024 at 10:45 AM, the ADM stated, the MD saw all the residents on or about 9/25/2023, when the MD was stepping down from dual role of PCP and MD and would be assuming the role of MD only. The ADM stated that the residents would have next had a required visit on or about 11/25/2023 that could be an alternate visit conducted by NP B. The ADM stated that with the 10-day slippage, or grace period, there was still enough time for the required physician visits scheduled for 1/25/2024 to occur. The ADM stated that prior to that 10-day slippage, or grace period being up, all residents would be seen by either PCP A or the MD for the required physician visit every 30 days in the first 90 days and every 60 days thereafter visit. The ADM stated this would include a review of each resident's total program of care, current condition, progress or problems with health and well being maintenance. The ADM stated going forward, it would be a specific visit to meet the regulatory requirements. A telephone interviews with PCP A were attempt and unsuccessful on the following days: *1/25/2024 at 3:30 PM, * 1/26/2024 at 3:15 PM, and *1/27/2024 at 11:15 AM. Record review of Physician Services and Medical Director policy, implemented 2/2017, revealed, under the subheading Physician responsibilities, .physician is responsible for reviewing and approving the resident's total program of care. Under the subheading of Frequency of physician visits, residents are seen at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. Record review of Medical Records policy, revised 1/2023, did not address accuracy or timely updates to the medical records.

Based on record review and interview, the facility failed to ensure residents who were unable to carry out activities of daily living were provided with the necessary services to maintain good personal hygiene for 8 of 8 (Resident #4, #5, #45, #51, #57, #64, #78) in that: 1. The facility failed to prevent Resident #5 from missing 6 of 10 scheduled showers between 1/1/2024 and 1/25/2024. 2. The facility failed to prevent Resident #45 from missing 9 of 11 scheduled showers between 1/1/2024 and 1/25/2024. 3. The facility failed to prevent Resident #51 from missing 10 of 11 scheduled showers between 1/1/2024 and 1/25/2024. 4. The facility failed to prevent Resident #57 from missing 5 of 11 scheduled showers between 1/1/2024 and 1/25/2024. 5. The facility failed to prevent Resident #64 from missing 7 of 11 scheduled showers between 1/1/2024 and 1/25/2024. 6. The facility failed to prevent Resident #78 from missing 10 of 11 scheduled showers between 1/1/2024 and 1/25/2024. These failures could place residents who require assistance from staff for personal hygiene at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections. The findings were: Record review of Resident #5's face sheet, dated 1/26/2024, reflected a [AGE] year-old resident initially admitted on [DATE] with diagnosis including acute pancreatitis without necrosis or infection, unspecified (a condition where the pancreas becomes inflamed over a short period of time), dysphagia (difficulty or discomfort in swallowing), and fibromyalgia (a chronic disorder characterized by widespread pain). Record review of Resident #5's MDS, dated [DATE] reflected the resident was noted as Dependent under Section GG, in the evaluation of resident's ability to shower or bathe themselves. Record review of Resident #5's Care Plan, dated 12/28/2023, reflected interventions stating the resident required assistance of staff while bathing/showering. Record review of the facility shower schedule, dated 1/26/2024, revealed that Resident #5 was scheduled to shower every week on Tuesday, Thursday, and Saturday during the 2:00 PM to 10:00 PM shift. Record review of Resident #5's Shower Documentation Report, dated 1/26/2024, reflected Resident #5 received 4 of 10 scheduled showers between 1/1/2024 and 1/25/2024. Resident #5's Shower Documentation Report reflected Yes for resident bathing on dates 1/4/2024, 1/9/2024, 1/16/2024, and 1/23/2024. There is no documentation to indicate that the resident was showered or bathed on the scheduled shower dates: 1/2/2024, 1/6/2024, 1/11/2024, 1/13/2024, 1/18/2024, and 1/20/2024. This is 19 of 25 days in January 2024 without a shower. Record review of Resident #45's face sheet, dated 1/26/2024, reflected an [AGE] year-old resident initially admitted on [DATE] with diagnosis including dementia (A group of thinking and social symptoms that interferes with daily functioning), and Chronic Systolic (Congestive) Heart Failure (occurs when your left ventricle can't pump blood efficiently). Record review of Resident #45's MDS, dated [DATE], reflected the resident was noted as requiring Substantial/maximal assistance under Section GG in the evaluation of the resident's ability to shower or bathe themselves. Record review of the facility shower schedule, dated 1/26/2024, revealed that Resident #45 was scheduled to shower every week on Monday, Wednesday, and Friday during the 2:00 PM to 10:00 PM shift. Record review of Resident #45's Shower Documentation Report, dated 1/26/2024, reflected Resident #45 received 2 of 11 scheduled showers between 1/1/2024 and 1/25/2024. Resident #45's Shower Documentation Report reflected Yes for resident bathing on scheduled shower dates 1/5/2024 and 1/12/2024. There was no documentation to indicate that the resident was showered or bathed on the scheduled shower dates: 1/1/2024, 1/3/2024, 1/8/2024, 1/10/2024, 1/15/2024, 1/17/2024, 1/19/2024, 1/22/2024, and 1/24/2024. Record review of Resident #51's face sheet, dated 1/26/2024, reflected a [AGE] year-old resident initially admitted on [DATE] with diagnosis including non-Hodgkin lymphoma (cancer that starts in the lymphatic system), and type 2 diabetes (a condition that affects the body's ability to process blood sugar). Record review of Resident #51's MDS, dated [DATE], reflected the resident was noted as requiring Setup or clean-up assistance under Section GG in the evaluation of the resident's ability to shower or bathe themselves. Record review of Resident #51's care plan, dated 12/28/2023, reflected interventions that the resident preferred to be showered 2-3 times weekly and required supervision assistance with showering. Record review of the facility shower schedule, dated 1/26/2024, revealed that Resident #51 was scheduled to shower every week on Monday, Wednesday, and Friday during the 6:00 AM to 2:00 PM shift. Record review of Resident #51's Shower Documentation Report, dated 1/26/2024, reflected resident #51 received 2 of 12 scheduled showers between 1/1/2024 and 1/26/2024. Resident #51's Shower Documentation Report reflected Yes for resident bathing on scheduled shower dates 1/10/2024 and 1/26/2024. There is no documentation to indicate that the resident was showered or bathed on the scheduled shower dates: 1/1/2024, 1/3/2024, 1/5/2024, 1/8/2024, 1/12/2024, 1/15/2024, 1/17/2024, 1/19/2024, 1/22/2024, and indication the resident refused a shower on 1/24/2024. Record review of Resident #57's face sheet, dated 1/26/2024, reflected a [AGE] year-old resident initially admitted on [DATE] with diagnosis including chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), and dementia (group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #57's MDS, dated [DATE], reflected the resident was noted as requiring Setup or clean-up assistance under Section GG in the evaluation of the resident's ability to shower or bathe themselves. Record review of the facility shower schedule, dated 1/26/2024, reflected that Resident #57 was scheduled to shower every week on Monday, Wednesday, and Friday during the 2:00 PM to 10:00 PM shift. Record review of Resident #57's Shower Documentation Report, dated 1/26/2024, reflected resident #57 received 6 of 11 scheduled showers between 1/1/2024 and 1/26/2024. Resident #57's Shower Documentation Report reflected Yes for resident bathing on scheduled shower dates 1/1/2024, 1/8/2024, 1/15/2024, 1/17/2024, 1/19/2024, and 1/24/2024. There was no documentation to indicate that the resident was showered or bathed on the scheduled shower dates: 1/3/2024, 1/5/2024, 1/10/2024, 1/12/2024, 1/22/2024. Record review of Resident #64's face sheet, dated 1/26/2024, reflected a [AGE] year-old resident with diagnosis including severe protein-calorie malnutrition and hypoxemia (an abnormally low concentration of oxygen in the blood). Record review of Resident #64's MDS, dated [DATE], reflected the resident was noted as requiring Supervision or touching assistance under Section GG in the evaluation of the resident's ability to shower or bathe themselves. Record review of Resident #64's care plan, dated 1/2/2024, reflected interventions that the resident had a self-care deficit and preferred to be showered 2-3 times weekly. Record review of the facility shower schedule, dated 1/26/2024, reflected that Resident #64 was scheduled to shower every week on Tuesday, Thursday, and Saturday during the 6:00 AM to 2:00 PM shift. Record review of Resident #64's Shower Documentation Report, dated 1/26/2024, reflected resident #64 received 4 of 11 scheduled showers between 1/1/2024 and 1/26/2024. Resident #64's Shower Documentation Report reflected Yes for resident bathing on scheduled shower dates 1/4/2024, 1/11/2024, 1/13/2024, and 1/23/2024. There was no documentation to indicate that the resident was showered or bathed on the scheduled shower dates: 1/2/2024, 1/6/2024, 1/9/2024, 1/16/2024, 1/18/2024, 1/20/2024, and indication that the resident refused a shower on 1/25/2024. Record review of Resident #78's face sheet, dated 1/26/2024, reflected a [AGE] year-old resident with diagnosis including type 2 diabetes (a condition that affects the body's ability to process blood sugar). Record review of Resident #78's MDS, dated [DATE], reflected the resident was noted as requiring Substantial/maximal assistance under Section GG in the evaluation of the resident's ability to shower or bathe themselves. Record review of Resident #78's care plan, dated 1/5/2024, reflected the resident required staff assistance while showering and preferred to be showered 2-3 times weekly. Record review of the facility shower schedule, dated 1/26/2024, reflected that Resident #78 was scheduled to shower every week on Tuesday, Thursday, and Saturday during the 2:00 PM to 10:00 PM shift. Record review of Resident #78's Shower Documentation Report, dated 1/26/2024, reflected resident #78 received 1 of 11 scheduled showers between 1/1/2024 and 1/26/2024. Resident #78's Shower Documentation Report reflected Yes for resident bathing on scheduled shower dates 1/9/2024. There was no documentation to indicate that the resident was showered or bathed on the scheduled shower dates: 1/2/2024, 1/4/2024, 1/6/2024, 1/11/2024, 1/13/2024, 1/16/2024, 1/18/2024, 1/20/2024, 1/23/2024, and 1/25/2024. On 1/24/2024 at 2:45 PM, during confidential interviews, 3 of 4 residents interviewed stated they are not showered on their scheduled days and if a shower was requested on a Sunday, they are told that showers are not performed on Sundays. Interview on 1/26/2024 at 11:45 AM, the Administrator stated that they are confident residents are showered but were not aware why it was not documented. Interview on 1/26/2024 at 12:15 PM, the DON stated that she was confident that residents are showered, but that CNA's do not have time to document residents' showers at times. In an interview on 1/26/2024 at 12:40 PM, CNA C stated that she was frequently tasked with providing showers to residents. CNA C stated she provided the showers to residents on their schedule day when she was working. CNA C stated she does not always have time to document that she provided a shower to a resident. CNA C stated she did not know if she had missed providing a shower to a resident. In an interview on 1/26/2024 at 12:44 PM, the DON stated that there was some risk that documentation was not done, but she was confident the care was being provided. The DON stated the nurse managers should be spot checking showers are given and documented. The DON stated nurse managers include the ADONs and her as the DON. The DON stated she does not think anyone has been checking for bathing documentation. The DON stated that the nurse managers can tell by looking at the residents, that they are being bathed as needed. Record review of Facility Policy titled Activities of Daily Living, dated February 2017, reflected each resident's ability to perform activities of daily living will not diminish unless the individuals clinical condition demonstrates that diminution was unavoidable, including personal hygiene. Record review of Facility Policy titled Routine Resident Care, revised January 2023, reflected, showers, tub baths and/or shampoos should be scheduled at least twice weekly and more often as needed or per residents' preference. Shower schedules should be geared to resident preference and scheduled as such.

Based on interview and record review the facility failed to ensure the resident's right to be free from abuse for 12 of 15 residents (Resident #1-7, 12-16) reviewed for abuse: a. CNA B was alleged to get in the resident's face, yell and then aggressively remove the resident's hand from the wheelchair and CNA B was alleged to have pulled Resident #1 hair. b. CNA D was alleged to have turned off the Resident #2's call light without assisting the resident resulting in emotional distress for Resident #2. c. CNA B was alleged to have told Resident #3 to cut off her leg if it was causing her so much pain which resulted in emotional distress and depression to the resident. d. CNA A and CNA B were alleged to have been rough with Resident #4 when providing care. e. NA C was alleged to have been rough with care to Resident #5 and her roommate, Resident #16 which caused the resident to feel bad. f. NA C was alleged to have been rough with care to Resident #6 and shook her roommate, Resident #7 causing emotional distress. g. CNA A and CNA B were verbally and physically aggressive with Resident #13 in the shower room. An Immediate Jeopardy (IJ) was identified on 5/14/2021. While the IJ was removed on 5/20/2021, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility still monitoring the effectiveness of the Plan of Removal. These failures resulted in resident abuse, a fear of reporting abuse and a delay in identifying abuse within the facility which caused emotional and psychosocial harm to the residents. The findings were: Record review of a staffing schedule, dated 5/10/2021-5/16/2021 revealed: -CNA A and CNA B worked together on the 300-hallway from 6 am-2 p.m. on 5/10/2021, 5/11/2021 and 5/12/2021 and were scheduled to work together on the 300-hallway on 5/14/2021, 5/15/2021 and 5/16/2021. -CNA C and CNA D worked together on the 300-hallway from 2 p.m.-10 p.m. on 5/10/2021, 5/11/2021 and 5/12/201 and were scheduled to work together on the 300-hallway on 5/14/2021, 5/15/2021 and 5/16/2021. a. Record review of a face sheet for Resident #1, dated 5/13/2021 revealed the resident was a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's quarterly MDS, dated [DATE], revealed that the resident had a BIMS' score of 5 (maximum score 15) which indicated the resident was severely cognitively impaired and was unable to recall words and phrases after minutes, had no documented behaviors and required the assistance of 1-2 staff members for care. Record review of Resident #1's Care Plan created on 5/22/2018 and last revised on 4/01/2020 revealed the resident had an impaired cognitive function or impaired thought process with impaired decision making and required staff to present just one thought, idea, question or command at a time. During an interview on 5/12/2021 at 5:25 p.m., with Resident #1 revealed the resident had childlike mannerisms and speech in which he repeated what was spoken to him. Resident #1 was unable to be interviewed due to his intellectual disability and cognitive status. During an interview on 5/12/2021 at 1:19 p.m. LVN G stated she learned during change of report (unknown source) that Resident #1 complained that a staff member pulled his hair over the weekend (5/8/2021-5/9/2021). LVN G stated she reported it to the DON on 5/10/2021. The DON responded with That's hard to prove, it could have been a joke. During an interview on 5/13/2021 at 2:27 p.m., the Speech Pathologist stated she was standing in the 300-hallway on 12/20/2020 near the therapy area when she heard a someone talking aggressively to Resident #1. The Speech Pathologist looked in the direction of the commotion and witnessed CNA B tell Resident #1 in an aggressive manner to go to his room. The resident stated to CNA B that he did not want to go to his room, so CNA B got in Resident #1's face, yelled at the resident and began moving the resident's wheelchair. She also witnessed CNA B aggressively remove Resident #1's hand from his wheelchair. CNA A was observing from 3 feet away and a MA (unknown) was also in the hallway. CNA B stopped what she was doing when she saw she was being observed. Approximately 10 minutes later CNA A was sitting at the nurse's station and said something to Resident #1. The resident responded with no. CNA A then responded with yes and kept going back and forth with the resident and wouldn't let it go. The Speech Pathologist stated she informed the Administrator when the incident occurred either 12/20/2020 or 12/21/2020 via text. The Administrator called her back within 30 minutes of the notification and stated, Yeah, we have been getting some complaints about CNA B. Thank you for letting me know. The Speech Pathologist stated this incident really shook her. She stated, I have seen and heard harsh voice before, but this was to the point of abuse. The Speech Pathologist stated she had not been interviewed, had not been asked to give a witness statement and had not been asked to give any other details to the witnessed event. Record review of a text message dated Sunday, 12/20/2020 between the Speech Pathologist to the Administrator revealed a message that read: Hi, Administrator! Sorry to bother you today, but if you have a moment, I'd like to talk to you about something I saw today at the facility. There was no response from the Administrator via text . During an interview on 5/14/2021 at 1:15 p.m., the Administrator stated she was not aware of any grievance from the Speech Pathologist in December or since that time period or anyone else regarding CNA A and CNA B abusing or mistreating Resident #1 prior to surveyor intervention. The Administrator stated she had no concerns about the way staff talk to Resident #1. During an interview on 5/14/2021 at 5:44 p.m. the DON stated she did not have any knowledge of complaints of abuse or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/10/2021, LVN G informed her Resident #1 stated CNA B pulled his hair . The DON stated she talked to Resident #1 and he said someone touched his hair. The DON stated you just have to know Resident # 1 . The DON confirmed she did not suspend CNA B or remove her from resident care during the investigation and did not interview other residents or additional staff. The DON stated other people would have reported it if they had a concern. The DON stated several residents had expressed concerns about CNA A and CNA B talking to them loud and the Administrator had spoken to the two CNA's in her office to talk to them about it. The DON indicated Resident #1 had behaviors and repeated things he heard. The DON stated she does not remember if she notified the Administrator. The DON stated she was trained to report abuse to the Administrator immediately. b. Record review of a face sheet for Resident #2, dated 5/13/2021, revealed a [AGE] year-old-female admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's quarterly MDS, dated [DATE], revealed that the resident had a BIMS' score of 12 (maximum score 15) which indicated a moderate cognitive impairment without signs and symptoms of [CONDITION(S)], [CONDITION(S)] or other behaviors. Resident #2 required the assistance of 1-2 staff members for care. Record review of Resident #2's Care Plan created on 9/01/2020 revealed staff should discuss with the resident/family any concerns, fears, issues regarding health or other subjects. Record review of a facility grievance dated 5/4/2021 revealed a family member of Resident #2 called and said Resident #2 needed to be changed since beginning of shift and stated CNA D just turns off light and (unknown staff) promised to change but did not. The Administrator signed the document and dated it as received on 5/04/2021. The document indicated Resident #2 was unhappy when NA C and CNA D care for her and yells at them to get out of her room. The plan to resolve the grievance was to move Resident #2 to a different hallway. During an interview on 5/12/2021 at 1:41 p.m., Resident #2 stated she moved from the 300 to the 200-hallway because she wanted to get away from CNA C and CNA D. She stated, They are real mean[OBSCENITY] s to me. Resident #2 stated NA C and CNA D also didn't do what they were supposed to do for her. Resident #2 also stated that CNA B was bossy. She stated, she would rather not give any further details because she was afraid of what would happen. Resident #2 stated she had talked to the DON who stated she would take care of it but nothing improved. Resident #2 stated she had the Administrators cell phone number and tried to reach her without success, so she called her family member and informed them of what had occurred. During an interview on 5/12/2021 at 5:31 p.m. RN N stated Resident #2 complained about not being changed in a 4-hour window and also complained that CNA D was rude (date unknown). RN N stated he had a hard time believing it was true because he had been up and down the hallway and into the resident room and Resident #2 had never said anything to him about it prior. The Resident's family member was upset when he called and spoke to RN N about the concern. RN N stated he notified the Administrator via telephone that Resident #2 had said staff was rude. He stated he didn't know how the Administrator responded. During an interview on 5/12/2021 at 6:34 p.m., the DON stated Resident #2 first had issues with the brother of NA C, who no longer worked at the facility. The DON stated she honored Resident #2's request to not work with the brother of NA C. Then Resident #2 complained NA C was too rough (unknown date and time). Resident #2 has also complained about care from CNA D and doesn't want either NA C or CNA D to care for her. The DON stated she communicated with the Administrator Resident #2's concerns (unknown date and unknown time). During an interview on 5/13/2021 at 4:13 p.m., the BOM confirmed Resident #2 complained on 5/06/2021 that staff (unknown) kept turning off her call light when she put the call light on without assisting her. The BOM stated the resident's family called and spoke to her and was very upset about the incident, The BOM stated immediately after finishing the conversation with Resident #2 she walked straight from the conversation to the Administrator's office and informed her of Resident #2's concern. The BOM stated the Administrator responded by stating, Resident #2 isn't happy about a lot of things. The BOM stated to the Administrator who was the Abuse Coordinator, I know, but I feel like we have to do something. During an interview on 5/14/2021 at 11:25 a.m., the DON confirmed she was aware of Resident #2's grievance. The DON stated she was clocking out and going home in the evening on 5/04/2021 and saw CNA D with a Hoyer lift outside of Resident #2's room. The DON stated she assumed Resident #2 had been changed and the situation was resolved. The DON stated she was not aware of a call light issue or complaint about staff turning off the call light without assisting the resident. The DON stated she doesn't investigate if she feels like she can resolve a problem. The DON stated she would investigate if a resident were to say I am being abused or someone hit me because that would be a completely different ball game and I wouldn't hesitate to tell my staff to hit the door. During an interview on 5/14/2021 at 1:18 p.m., the Administrator stated an example of abuse/neglect was staff not answering a call light or turning it off without attending to the resident leaving them soiled. The Administrator stated RN G called her at home and stated Resident #2 was not soiled (unknown date and unknown time). The Administrator confirmed she also spoke with Resident #2's family member (unknown date and unknown time) who was really upset about the resident being soiled and call lights turned off. The Administrator explained to the family member that staff would change Resident #2 immediately. The Administrator stated knowing that RN G had been in the resident room and the resident was just waiting for a CNA to finish with another resident she did not consider the grievance and complaint as neglect. The Administrator stated she felt like Resident #3 tended to exaggerate. The Administrator stated she wanted to see if what the resident reported was true and stated I do not want to call her a liar, but she sees things differently. I do not have staff here who would ignore a resident. The Administrator stated she had Resident #2 moved to a different hallway away from NA C and CNA D and Resident #2 was content on the new hallway. The Administrator stated Resident #2's behaviors were much better on the new hallway. When asked why she thought Resident #2's behaviors would improve on a new hallway away from NA C and CNA D? The Administrator stated that the new staff baby Resident #2 more. Their voices were not so stern. The Administrator confirmed she herself would not want to be spoken to in such a manner, with a stern voice. The Administrator stated she did not take written statements, or interview other staff who might have observed the incident or other residents because the resident didn't say she felt like she had any harm and the problem had been resolved as a grievance. c. Record review of a face sheet for Resident #3, dated 5/13/2021, revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's quarterly MDS dated [DATE], revealed the resident had a BIMS' score of 10 (maximum score 15) which indicated a moderate cognitive impairment without the signs and symptoms of [CONDITION(S)], [CONDITION(S)] or other behaviors. Resident #3 required the assistance of 1-2 staff for care. Record review of Resident#3's Care Plan created on 1/02/2019 revealed the resident should be encouraged to express thoughts and feelings and encouraged to participate in decision making and tasks of daily living. Record review of a facility grievance, dated 5/01/2021 revealed Resident #3 voiced to nurse, LVN G that CNA B had made {an} ugly comment about her leg not working and that she should just chop it off. The grievance was made and signed by the DON who assigned the investigation to herself on 5/03/2021. The DON signed off on the grievance as resolved on 5/03/2021. During an interview on 5/12/2021 at 10:55 a.m. on the 300-hallway with Resident #3 who stated CNA A had been rough with care since she made a complaint about CNA A's mother, CNA B. Resident #3 stated, CNA A would not get me out of bed when asked for assistance and stated, If you push the button (call light) and nobody comes, you know why. Resident #3 stated she did not want to talk about the complaint against CNA B because she had already caused enough trouble by making the complaint. The resident became emotional with tears and added, I cannot do anything to suit, CNA B. She constantly takes the little blanket off my feet and puts the blanket where I can't reach it. She says I am freezing out my roommate (with the air-conditioning). She takes my (food) tray away before I am done with my food. CNA B asked me if I am finished (with the food) but I know better than to say no. She will take my food anyway. Since they (unknown) talked to CNA B, I get attitude from CNA A. I feel terrorized. CNA B is always yelling. I jump when I hear any loud noise because I am scared it's her. When asked if she felt safe, Resident #3 stated, I know there will be pain. I want to ask for someone else (to provide care) but I am afraid If I say anything I won't get changed and I will have to sit in my own waste. Resident #3 she had reported her concerns to LVN G and had talked to the DON about them. During an interview on 5/12/2021 at 1:19 p.m., LVN G stated Resident #3 informed her on 5/1/2021 that on 4/30/2021, CNA B told the resident to cut off her leg because it was more of a bother than a help due to a contracture of the leg that was caused by a stroke. LVN G stated she reported the complaint immediately to the DON on 4/30/2021 via telephone. The DON responded by stating CNA B didn't mean it seriously and it was just a joke. The DON gave LVN G instructions to go with CNA B into the Resident #3's and have CNA B apologize. During an interview on 5/12/2021 at 2:34 p.m., Restorative Aide MM stated on an unknown date approximately 2 weeks ago, Resident #3 told her CNA A and CNA B were rough with her and that CNA B told her to chop off her leg because it was contracted. Restorative Aide MM stated Resident #3 looked like she was going to cry when she told the aide about the incident. She further stated the resident tries very hard to straighten her contractured leg and even though it's been a couple of weeks since the incident, Resident #3 keeps talking about it. CNA B stated she reported it to LVN G who was the Charge Nurse who responded she was going to report the incident. Restorative Aide MM stated the Abuse Coordinator was the Administrator and added I am a single mom and I worry about my job. During an interview on 5/12/2021 at 5:44 p.m. the DON confirmed LVN G had reported that Resident #3 was upset about a comment CNA B made about the resident's leg in which CNA B stated This darn leg of yours, you need to cut if off. The DON stated she talked to LVN G and CNA B. The DON stated after talking to both LVN G and CNA B she decided to have CNA B apologize to the resident. This occurred over the weekend (unknown date) and the DON stated she reported the incident to the Administrator during morning meeting on Monday (unknown date). The DON stated she investigated the situation by talking to CNA B about the situation. CNA B stated she was playing with the resident. The DON confirmed she did not suspend CNA B or remove her from resident care while she investigated, did not take any written witness statements and did not interview other staff or residents because Resident #3 was fine with the kidding and did not follow up or monitor Resident #3. The DON stated she asked Resident #3 if she was okay with CNA B continuing her care and she said she was fine with it. During an interview on 5/12/2021 at 2:29 p.m., the Administrator confirmed she was previously aware and had been informed that Resident #3 was upset that CNA B told her to cut off her leg. She stated she did not know who informed her or when she was informed. The Administrator stated when she spoke to Resident #3, she reminded the resident that she herself makes comments about her leg and plays around with talking about her leg and the resident responded with Yeah, but I wasn't playing that day. It is not funny, and I do not want to play like that. The Administrator asked Resident #3 again if she thought CNA B was mean or joking and the resident replied joking. She asked Resident #3 if she felt unsafe and the resident replied no. The Administrator confirmed she did not suspend CNA B from work or remove her from resident care and did not perform an investigation because the resident was fine with the incident and understood it was a joke. The Administrator stated Resident #3 never used the word abuse and didn't indicate she was harmed. The Administrator stated based on her conversation with Resident #3 she did not feel like there was any abuse. During an interview on 5/13/2021 at 2:27 p.m., the Speech Pathologist stated several residents had complained about CNA A, CNA B and NA C. Specifically, Resident #3 complained that CNA A and CNA B had complained about the residents bowel movements and stated, this is [OBSCENITY] ing bullshit, I am tired of this. The Speech Pathologist stated she filled out a grievance form and listed the resident as anonymous to try to protect the resident. The Speech Pathologist stated she signed her own name on the grievance and handed the grievance to the Administrator personally on 4/19/2021. The Administrator stated Thank you at the time she turned it in. The Administrator later called her back into the office and stated she needed the name of the resident. The Speech Pathologist identified Resident #3. The Administrator responded with, Okay, I just needed to know because I need to filter them because sometimes certain residents fill out a lot of grievance papers. The Speech Pathologist stated she was never asked to give any additional information other than what was written on the grievance and when she was asked to identify the resident. The Speech Pathologist stated she was not asked to write a written statement and had not been interviewed. Record review of a text message from the Rehabilitation Director and the Speech Pathologist dated 4/19/2021 at 4:30 p.m., that read Administrator wanted to talk to you about a grievance. During an interview on 5/14/2021 at 1:15 p.m., the Administrator stated she was not aware of any grievance from the Speech Pathologist or anyone else regarding CNA A and CNA B abusing or mistreating Resident #3 prior to surveyor intervention. The Administrator stated she had never received any grievances from the Speech Pathologist. d. Record review of Resident #4's face sheet, dated 5/15/2021 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's quarterly MDS dated [DATE] revealed a BIMS' score of 9 (maximum score 15) which indicated a moderate cognitive impairment. Resident #4 required the assistance of 1 staff member for care. Record review of Resident #4's Care Plan created 5/03/2019 and last revised on 3/27/2020 revealed the resident's call light should be within reach and the resident should be encouraged to use the call light for assistance. The Care Plan indicated the resident needed prompt response to all requests for assistance to prevent falls. Further review of the Care Plan revealed that staff should refrain from making negative comments related to the odor from the ostomy site during care. During an interview on 5/12/2021 at 10:50 a.m. on the 300-hallway, with Resident #4 stated two morning female staff members, identified as mother and daughter, CNA A and CNA B (also identified by description), were rough when they provided care (unknown dates and times). Resident #4 stated she had asked the two CNA's to slow down and be careful, but she received no verbal response to her request. Resident #4 stated she had not told anyone because she was afraid to say anything. During an interview on 5/12/2021 at 6:34 p.m., the DON stated Resident #4 made a complaint last week (unknown date) that CNA A and CNA B would not let her go to bed. The DON stated she asked Resident #4 to just humor the two CNA's and stay up for just 30 minutes. The DON confirmed she did not investigate the incident. The DON stated the two CNA's were Spanish aggressive and spoke aggressively as was part of her culture , but the DON did not consider it abuse. The DON gave an example, Go take a shower in a stern, demanding tone of voice. During an interview on 5/14/2021 at 2:34 p.m., the Administrator stated after receiving information from this surveyor that Resident #4 had stated CNA A and CNA B were rough with care, she interviewed Resident #4. The Administrator stated during the interview Resident #4 did not use the word rough. Resident #4 said the CNA's were fast. The Administrator stated, when she asked her if she felt safe, she said yes, CNA A and CNA B just need to slow down. The Administrator stated since the Resident did not use the word rough during the interview, she didn't think there was any abuse and did not investigate further. e. Record review of Resident #5's face sheet, dated 5/16/2021 revealed a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's quarterly MDS dated [DATE] revealed a BIMS score of 8 (maximum score of 15) which indicated a moderate cognitive impairment with inattentiveness (difficulty focusing attention) without symptoms of [CONDITION(S)] or other behaviors. Resident #5 required the assistance of 1-2 staff members for care. Record review of Resident #5's Care Plan, dated 1/27/2021 revealed the resident had made statements that she was going to starve herself and refused to discuss the issues with psychological services. During an interview on 5/12/2021 at 10:34 a.m. on the 300-hallway Resident #5 stated she didn't like living at the nursing facility and didn't feel safe. She stated NA C was rough with me and he hurts my roommate, Resident #16 when providing care (unknown date and time). Resident #5 stated Resident #16 cried out like she was being hurt when NA C was taking care of her. She also stated staff (refused to give names) said she was fat when providing care and that makes her feel bad. Resident #5 stated she had talked to the DON at one time about the rough care but did not remember when this conversation occurred. She stated the DON stated because she was fat, the care may be rough which in turn made the resident feel bad. The resident stated she was afraid of getting in trouble for talking to this surveyor and turned her head to the side and refused to answer further questions. During an interview on 5/12/2021 at 5:44 p.m., the DON stated Resident #5 just wanted to stay in bed all the time. At one time, Resident #5 indicated she wanted to lose weight and prior to admission had planned on getting gastric surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated she had exhausted her attempts to get Resident #5 out of bed. The DON stated the resident was refusing meals, only drinking sodas and loosing excess weight. The DON stated she suggested psych services to the resident, and she refused. The DON stated, Resident #5 had finally agreed to eat as long as she was allowed to stay in bed. The DON stated she told Resident #5 if you don't help yourself, we can't help you. The DON stated she was not aware of anyone calling the resident fat and that had not been disclosed to her by the resident. During an interview on 5/14/2021 at 2:34 p.m., the Administrator confirmed she did not thoroughly investigate Resident #5's concerns because when the interviewed Resident #5 the resident stated she felt safe now. The Administrator stated although Resident #5 indicated NA C was rough with her roommate, Resident #16, the Administrator did not feel like there was any abuse. The Administrator stated the resident gave her a blank stare and then eventually stated CNA A was rough with her roommate. Resident #5 stated the roommate said ow and no during care by CNA A. The Administrator confirmed the roommate was not interviewable due to cognitive status, but sometimes is able to answer simple questions. The Administrator stated she asked the roommate if she felt safe and she responded with oh yeah. The Administrator stated she told Resident #5 to come to her for any concerns. f. Record review of Resident #6's face sheet, dated 5/15/2021, revealed an [AGE] year-old-female, admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's admission MDS, dated [DATE] revealed a BIMS score of 15 (maximum score 15) which indicated the resident was completely cognitively intact. During an interview on 5/13/2021 at 2:27 p.m., the Speech Pathologist stated Resident #6 was in tears on Monday 5/3/2021. Resident #6 stated that the weekend had been terrible because staff had been ignoring call lights, when the staff would come, she would ask for assistance and the staff would never come back. Resident #6 stated she needed help in the bathroom and NA C came into her room. Resident #6 reported that she screamed at him to get out because she didn't want NA C to take care of her because he was male and because he shook her roommate Resident #7 right before Resident #7 had to go to the hospital. Resident #6 informed the Speech Pathologist she didn't tell anyone about the incident because she wasn't comfortable reporting it. The Speech Pathologist stated she had filled out a grievance which she had previously been instructed to do and on 5/03/2021 put it directly on top of the Administrator's desk. The Speech Pathologist stated the Administrator did not follow up with any questions. During an interview on 5/13/2021 at 4:43 p.m., Resident #6 stated NA C came into their room and shook her roommate Resident #7 with his hands because Resident #7 kept pressing the call light. Resident #6 stated the resident had been hurting and crying out. Resident #6 stated NA C was also rough with her. She had told him she didn't want a man taking care of her and didn't feel comfortable with a man touching her privately, so she had asked him to leave the room and get a woman. Resident #6 stated he left at that time but came back in later. Resident #6 stated she screamed at him and told him to get out and he pulled her depends up really hard and fast. Resident #6 became emotional and started crying and stated, there might be someone that can't stop him like I can. Resident #6 stated she didn't report the incident to anyone that she can remember because it was upsetting. Record review of Resident #7's face sheet, dated 5/15/2021, revealed an [AGE] year-old-female admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #7's quarterly MDS, dated [DATE] revealed a BIMS score of 9 (maximum score 15) which indicated the resident had a moderate cognitive impairment. During an interview on 5/13/2021 at 5:11 p.m. Resident #7 stated NA C got upset with me because I asked for something trivial. I do not really know what I did, but he grabbed me by the shoulders, one hand on each side of her arms and shook me. Resident #7 stated NA C lost his cool really easily. Resident #7 stated she looked at her skin for days and never saw a bruise, so she decided to let it go. Resident #7 stated NA C and CNA D used threats and intimidation on her and indicated the threats were they wouldn't do something for the resident that she needed. Resident #7 stated, CNA D turned off her call light without doing what Resident #7 asked the CNA to do and then exited the room the room aggressively. CNA D also refused to fill the residents water jug. Resident #7 stated her roommate, Resident #6, had been upset about the situation and reported it to someone in therapy. Resident #7 stated she was worried about getting someone in trouble by reporting the incident. During an interview on 5/14/2021 at 1:15 p.m., the Administrator stated she was not aware an any grievance or concern from the Speech Pathologist or anyone else regarding Resident # 6 or Resident #7 prior to surveyor intervent [TRUNCATED]

Based on interview and record review the facility failed to implement written policies and procedures to prevent abuse for 7 of 15 (Resident #1, #2, #3, #4, #5, #6, and #7) reviewed for abuse; The facility failed to ensure the Administrator thoroughly investigated and followed the facility's abuse policy and procedures when: 1. The Administrator failed to conduct a thorough investigation, obtain written witness statement, interview witnesses of the abuse allegations, and failed to protect Resident #1, #2, #3, #4, #5, #6, and #7 from the alleged perpetrators during the investigation. Although the facility was aware of the allegations of abuse, staff continued to work and have direct contact with the residents. 2. The Administrator failed to report allegations of abuse to the State Survey Agency (HHS) immediately but no later than 2 hours after the incident and failed to notify the Attending Physician and Medical Director of the abuse allegations. An Immediate Jeopardy (IJ) was identified on 5/14/2021. While the IJ was removed on 5/20/2021, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility was still monitoring the effectiveness of the Plan of Removal. These failures resulted in a delay in identifying abuse within the facility which caused emotional and mental psychosocial harm to the residents and placed residents at risk for continued abuse. The findings were: Record review of the facility Resident Abuse Policy dated July 2018 revealed: A4. When an alleged or suspected case of exploitation, neglect, injuries of unknown source or abuse is reported, the Community Administrator, or his/her designee, will notify the following persons or agencies per the current state/federal reporting requirements of such incident .a). The State licensing/certification agency responsible fore surveying/licensing the community c) law enforcement officials d) the resident's attending physician and e) the Community Medical Director. 9. Written statements from witnesses, if any, shall be provided to the Administrator within 24 hours of the occurrence of such incident. 11. Upon receiving information concerning report of abuse, the designated Community Abuse Coordinator will request that a representative of the social services department/designees monitor the resident's emotions concerning the incident as well as the resident's reactions to his/her involvement in the investigation. Further review of a facility policy, titled Resident Abuse Policy dated July 2018 revealed: C. Abuse Investigations: All reports of resident abuse, neglect and injuries which have an unknown source (defined by state regulations) shall be promptly and thoroughly investigated by the Community Management. 2. The management-appointed individual conducting the investigation will, at a minimum a0 review the resident's medical record to determine events leading up to the incident, b)interview the person(s) reporting the incident c). interview any witnesses to the incident d) interview the resident (as medically appropriate) e) interview team members who have had contact with the resident during the period of the alleged incident f). interview the resident's roommate, family members and visitors g) interview other residents to whom the accused team member provides care of services and h) review all events leading up to the alleged incident 4. Witness reports will be reduced to writing. Witnesses will be required to sign and date such reports (Note: a copy of such reports shall be attached to the Provider Investigation Report) per current state/federal reporting requirements. 6. Team members of this community who have an allegation against them of resident abuse may be reassigned to non-resident care duties or suspended from duty until the results of the investigation have been reviewed by the Administrator/designee. 1a. Record review of a face sheet for Resident #1, dated 5/13/2021, revealed the resident was a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's quarterly MDS, dated [DATE], revealed that the resident had a BIMS' score of 5 which indicated the resident was severely cognitively impaired and was unable to recall words and phrases after minutes, had no documented behaviors and required the assistance of 1-2 staff members for care. During an interview on 5/12/2021 at 5:25 p.m., with Resident #1 revealed the resident had childlike mannerisms and speech in which he repeated what was spoken to him. Resident #1 was unable to be interviewed due to his intellectual disability and cognitive status. During an interview on 5/12/2021 at 1:19 p.m. LVN G stated during change of report she learned (unknown source) that Resident #1 complained that a staff member pulled his hair over the weekend (5/8/2021-5/9/2021). LVN G stated she reported it to the DON on 5/10/2021. The DON responded with That's hard to prove, it could have been a joke. During an interview on 5/13/2021 at 2:27 p.m., the Speech Pathologist stated she was standing in the 300-hallway on 12/20/2020 near the therapy area when she heard a someone talking aggressively to Resident #1. The Speech Pathologist looked in the direction of the commotion and witnessed CNA B tell Resident #1 in an aggressive manner to go to his room. The resident stated he did not want to go to his room, so CNA B got in Resident #1's face, yelled at the resident and began moving the resident's wheelchair. She also witnessed CNA B aggressively remove Resident #1's hand from his wheelchair. CNA A was observing from 3 feet away and a MA (unknown) was also in the hallway. CNA B stopped what she was doing when she saw she was being observed. Approximately 10 minutes later CNA A was sitting at the nurse's station and said something to Resident #1. The resident responded with no. CNA A then responded with yes and kept going back and forth with the resident and wouldn't let it go. The Speech Pathologist stated she informed the Administrator when the incident occurred either 12/20/2020 or 12/21/2020 via text. The Administrator called her back within 30 minutes of the notification and stated, Yeah, we have been getting some complaints about CNA B. Thank you for letting me know. Record review of a text message dated Sunday, 12/20/2020 between the Speech Pathologist to the Administrator revealed a message that read: Hi, Administrator! Sorry to bother you today, but if you have a moment, I'd like to talk to you about something I saw today at the facility. There was no response from the Administrator via text. During an interview on 5/14/2021 at 1:15 p.m., the Administrator stated she was not aware an any grievance from the Speech Pathologist or anyone else regarding CNA A and CNA B abusing or mistreating Resident #1 prior to surveyor intervention and therefore had not reported to the State Reporting Agency the allegations The Administrator stated she had no concerns about the way staff talk to Resident #1. During an interview on 5/14/2021 at 5:44 p.m. the DON stated she did not have any knowledge of complaints of abuse or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/10/2021, LVN G informed her Resident #1 stated CNA B pulled his hair. The DON stated she talked to Resident #1 and he said someone touched his hair. The DON stated you just have to know Resident # 1. The DON confirmed she did not suspend CNA B or remove her from resident care during the investigation and did not interview other residents or additional staff. The DON stated other people would have reported it if they had a concern. The DON stated several residents had expressed concerns about CNA A and CNA B talking to them loudly and the Administrator had spoken to the two CNA's in her office to talk to them about it. The DON indicated Resident #1 had behaviors and repeated things he heard. The DON stated she does not remember if she notified the Administrator. The DON stated she was trained to report abuse to the Administrator immediately. b. Record review of a face sheet for Resident #2, dated 5/13/2021, revealed a [AGE] year-old-female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's quarterly MDS, dated [DATE], revealed that the resident had a BIMS' score of 12 which indicated a moderate cognitive impairment without signs and symptoms of [CONDITION(S)], [CONDITION(S)] or other behaviors. Resident #2 required the assistance of 1-2 staff members for care. Record review of a facility grievance dated 5/4/2021 revealed a family member of Resident #2 called and said Resident #2 needed to be changed since beginning of shift and stated CNA D just turns off light and (unknown staff) promised to change but did not. The Administrator signed the document and dated it as received on 5/04/2021. The document indicated Resident #2 was unhappy when NA C and CNA D cared for her and yells at them to get out of her room. The plan to resolve the grievance was to move Resident #2 to a different hallway. During an interview on 5/12/2021 at 1:41 p.m., Resident #2 stated she moved from the 300 to the 200-hallway because she wanted to get away from CNA C and CNA D. She stated, They are real mean[OBSCENITY] s to me. Resident #2 stated NA C and CNA D also didn't do what they were supposed to do for her. She stated, she would rather not give any further details because she was afraid of what would happen. Resident #2 stated she had the Administrators cell phone number and tried to reach her without success, so she called her family member and informed them of what had occurred. During an interview on 5/12/2021 at 5:31 p.m. RN N stated Resident #2 complained about not being changed in a 4-hour window and complained that CNA D was rude (date unknown). RN N stated he had a hard time believing it was true because he had been up and down the hallway and into the resident room and Resident #1 had never said anything to me about it prior. The Resident's family member called RN N and was upset. RN N stated he notified the Administrator via telephone that Resident #2 had said staff was rude. He stated he didn't know how the Administrator responded. During an interview on 5/12/2021 at 6:34 p.m., the DON stated Resident #2 first had issues with NA C family member who no longer works at the facility. The DON stated she honored Resident #2's request to not work with him. Then Resident #2 complained NA C was too rough (unknown date and time). Resident #2 has also complained about care from CNA D and doesn't want either NA C or CNA D to care for her. The DON stated she communicated with the Administrator Resident #2's concerns (unknown date and unknown time). During an interview on 5/13/2021 at 9:28 p.m., Resident #2's family member stated Resident #2 had called upset and stated staff members NA C and CNA D were taking away the resident's call light from her and treating her bad. The family member stated he called the facility and spoke to RN G who assured him NA C and CNA D would be removed from caring for Resident #2. The next day, NA C and CNA D were again taking care of Resident #2. The family member stated he again called the facility and spoke to the BOM and requested that Resident #2 be moved off of the 300-hallway so that she would not be cared for by NA C and CNA D. The family member stated the Administrator did not return his calls until 5/12/2021. During an interview on 5/13/2021 at 4:13 p.m., the BOM confirmed Resident #2 complained on 5/06/2021 that staff (unknown) kept turning off her call light when she put them on without assisting her. The BOM stated the resident's family member called and spoke to her and was very upset about the incident and then came to the facility to see the resident. The BOM stated immediately after finishing the conversation with Resident #2, she walked straight from the conversation to the Administrator's office and informed her of Resident #2's concern. The BOM stated the Administrator responded by stating, Resident #2 isn't happy about a lot of things. The BOM stated to the Administrator, I know, but I feel like we have to do something. During an interview on 5/14/2021 at 11:25 a.m., the DON confirmed she was aware of Resident #2's grievance and complaints about not getting changed. The DON stated she was clocking out on 5/04/2021 (unknown time) and going home and saw CNA D with a Hoyer lift. The DON stated she assumed Resident #2 had been changed and the situation was resolved. The DON stated she was not aware of a call light issue of complaint about staff turning off the call light without assisting the resident. The DON stated she doesn't investigate if she feels like she can resolve a problem. If a resident were to say, I am being abused or someone hit me that would be a completely different ball game and I wouldn't hesitate to tell my staff to hit-the-door. During an interview on 5/14/2021 at 1:18 p.m., the Administrator stated an example of abuse/neglect was staff not answering a call light or turning it off without attending to the resident leaving them soiled. The Administrator stated RN G called her at home and stated Resident #2 was not soiled. The Administrator confirmed she also spoke with Resident #2's family member who was really upset. The Administrator explained to the family member that staff would change Resident #2 immediately. The Administrator stated knowing that RN G had been in the resident room and the resident was just waiting for a CNA to finish with another resident was not neglect. The Administrator stated she felt like Resident #2 tends to exaggerate. The Administrator stated she wanted to see if what the resident reported was true and stated I do not want to call her a liar, but she sees things differently. I do not have staff here who would ignore a resident. The Administrator stated she had Resident #2 moved to a different hallway away from NA C and CNA D and Resident #2 was content on the new hallway. The Administrator stated Resident #2's behaviors were much better on the new hallway. When asked why she thought Resident #2's behaviors would improve on a new hallway away from NA C and CNA D? The Administrator stated that the new staff baby Resident #2 more. Their voices were not so stern. The Administrator confirmed she herself would not want to be spoken to in such a manner with a stern voice. The Administrator stated she did not report the incident to the State Survey Agency (HHS) because the resident didn't say she felt like she had any harm. During an interview on 5/14/2021 at 1:18 p.m., the Administrator stated an example of abuse/neglect was staff not answering a call light or turning it off without attending to the resident leaving them soiled. The Administrator stated RN G called her at home and stated Resident #2 was not soiled. The Administrator confirmed she also spoke with Resident #3's family member who was really upset about the resident being soiled and call lights turned off. The Administrator explained to the family member that staff would change Resident #3 immediately. The Administrator stated knowing that RN G had been in the resident room and the resident was just waiting for a CNA to finish with another resident was not neglect. The Administrator stated she felt like Resident #3 tends to exaggerate. The Administrator stated she wanted to see if what the resident reported was true and stated I do not want to call her a liar, but she sees things differently. I do not have staff here who would ignore a resident. The Administrator stated she had Resident #2 moved to a different hallway away from NA C and CNA D and Resident #2 was content on the new hallway. The Administrator stated Resident #2's behaviors were much better on the new hallway. When asked why she thought Resident #2's behaviors would improve on a new hallway away from NA C and CNA D? The Administrator stated that the new staff baby Resident #2 more. Their voices were not so stern. The Administrator confirmed she herself would not want to be spoken to in such a manner with a stern voice. The Administrator stated she did not take written statements, or interview other staff who might have observed the incident or other residents because the resident didn't say she felt like she had any harm and the problem had been resolved as a grievance. c. Record review of a face sheet for Resident #3, dated 5/13/2021, revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's quarterly MDS dated [DATE], revealed the resident had a BIMS' score of 10 which indicated a moderate cognitive impairment without the signs and symptoms of [CONDITION(S)], [CONDITION(S)] or other behaviors. Resident #3 required the assistance of 1-2 staff for care. Record review of a facility grievance, dated 5/01/2021, revealed Resident #3 voiced to nurse, LVN G that CNA B had made {an} ugly comment about her leg not working and that she should just chop it off. The grievance was made and signed by the DON who assigned the investigation to herself on 5/03/2021. The DON signed off on the grievance as resolved on 5/03/2021. During an interview on 5/12/2021 at 10:55 a.m. on the 300-hallway with Resident #3 who stated CNA A had been rough with care since she made a complaint about CNA B. Resident #3 stated, CNA A would not get me out of bed when asked for assistance and stated, If you push the button (call light) and nobody comes, you know why. Resident #3 stated she did not want to talk about the complaint against CNA B because she had already caused enough trouble by making the complaint. The resident became emotional with tears and added, I cannot do anything to suit, CNA B. She constantly takes the little blanket off my feet and puts the blanket where I can't reach it. She says I am freezing out my roommate (with the air-conditioning). She takes my (food) tray away before I am done with my food. CNA B asked me if I am finished (with the food) but I know better than to say no. She will take my food anyway. Since they (unknown) talked to CNA B, I get attitude from CNA A. I feel terrorized. CNA B is always yelling. I jump when I hear any loud noise because I am scared it's her. When asked if she felt safe, Resident #3 stated, I know there will be pain. I want to ask for someone else (to provide care) but I am afraid If I say anything I won't get changed and I will have to sit in my own waste. Resident #3 she had reported her concerns to LVN G and had talked to the DON about them. During an interview on 5/12/2021 at 1:19 p.m., LVN G stated Resident #3 informed her on 5/1/2021 that on 4/30/2021, CNA B told the resident to cut off her leg because it was more of a bother than a help due to a contracture of the leg that was caused by a stroke. LVN G stated she reported the complaint immediately to the DON on 4/30/2021 via telephone. The DON responded by stating CNA B didn't mean it seriously and it was just a joke. The DON gave LVN G instructions to go with CNA B into the Resident #3's and have CNA B apologize. During an interview on 5/12/2021 at 2:34 p.m., Restorative Aide MM stated on an unknown date approximately 2 weeks ago, Resident #3 told her CNA A and CNA B were rough with her and that CNA B told her to chop off her leg because it was contracted. Restorative Aide MM stated Resident #3 looked like she was going to cry when she told the aide about the incident. She further stated the resident tries very hard to straighten her contractured leg and even though it's been a couple of weeks since the incident, Resident #3 keeps talking about it. CNA B stated she reported it to LVN G who was the Charge Nurse who responded she was going to report the incident. Restorative Aide MM stated the Abuse Coordinator was the Administrator and added I am a single mom and I worry about my job. During an interview on 5/12/2021 at 5:44 p.m. the DON confirmed LVN G had reported that Resident #3 was upset about a comment CNA B made about the resident's leg in which CNA B stated This darn leg of yours, you need to cut if off. The DON stated she talked to LVN G and CNA B. The DON stated after talking to both LVN G and CNA B she decided to have CNA B apologize to the resident. This occurred over the weekend (unknown date) and the DON stated she reported the incident to the Administrator during morning meeting on Monday (unknown date). The DON stated she investigated the situation by talking to CNA B about the situation. CNA B stated she was playing with the resident. The DON confirmed she did not suspend CNA B or remove her from resident care while she investigated, did not take any written witness statements and did not interview other staff or residents because Resident #3 was fine with the kidding. The DON stated she asked Resident #3 if she was okay with CNA B continuing her care and she said she was fine with it. During an interview on 5/12/2021 at 2:29 p.m., the Administrator confirmed she was previously aware and had been informed that Resident #3 was upset that CNA B told her to cut off her leg. She stated she did not know who informed her or when she was informed. The Administrator stated reminded Resident #3 that she plays around with talking about her leg and the resident responded with Yeah, but I wasn't playing that day. It is not funny, and I do not want to play like that. The Administrator asked Resident #3 again if she thought CNA B was mean or joking and the resident replied joking. She asked Resident #3 if she felt unsafe and the resident replied no. The Administrator confirmed she did not suspend CNA B from work or remove her from resident care and did not perform an investigation because the resident was fine with the incident and understands it was a joke. The Administrator stated she did not feel like it was abuse. During an interview on 5/13/2021 at 2:27 p.m., the Speech Pathologist stated several residents had complained about CNA A, CNA B and NA C. Specifically, Resident #3 complained that CNA A and CNA B had complained about the residents bowel movements and stated, this is [OBSCENITY] ing bullshit, I am tired of this. The Speech Pathologist stated she filled out a grievance form and listed the resident as anonymous to try to protect the resident. The Speech Pathologist stated she signed her own name on the grievance and handed the grievance to the Administrator personally on 4/19/2021. The Administrator stated Thank you at the time she turned it in. The Administrator later called her back into the office and stated she needed the name of the resident. The Speech Pathologist identified Resident #3. The Administrator responded with, Okay, I just needed to know because I need to filter them because sometimes certain residents fill out a lot of grievance papers. The Speech Pathologist stated she was never asked to give any additional information other than what was written on the grievance and when she was asked to identify the resident. The Speech Pathologist stated she was not asked to write a written statement and had not been interviewed. Record review of a text message from the Rehabilitation Director and the Speech Pathologist dated 4/19/2021 at 4:30 p.m., that read Administrator wanted to talk to you about a grievance. During an interview on 5/14/2021 at 1:15 p.m., the Administrator stated she was not aware of any grievance from the Speech Pathologist or anyone else regarding CNA A and CNA B abusing or mistreating Resident #3 prior to surveyor intervention. The Administrator stated she had never received any grievances from the Speech Pathologist. d. Record review of Resident #4's face sheet, dated 5/15/2021 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's quarterly MDS dated [DATE] revealed a BIMS' score which indicated a moderate cognitive impairment. Resident #4 required the assistance of 1 staff member for care. During an interview on 5/12/2021 at 10:50 a.m. on the 300-hallway with Resident #4 stated two morning female staff members, identified as mother daughter and mother, CNA A and CNA B (also identified by description), were rough when they provided care (unknown dates and times). Resident #4 stated she had asked the two CNA's to slow down and be careful, but she received no verbal response to her request. Resident #4 stated she had not told anyone because she was afraid to say anything. During an interview on 5/14/2021 at 2:34 p.m., the Administrator stated after receiving information from this surveyor that Resident #4 had stated CNA A and CNA B were rough with care, she interviewed Resident #4. The Administrator stated during the interview Resident #2 did not use the word rough, she said they were fast. Administrator said, when I asked her if she felt safe, she said yes, CNA A and CNA B just need to slow down. The Administrator stated since Resident #4 did not use the word rough during the interview, she didn't think there was any abuse. During an interview on 5/12/2021 at 6:34 p.m., the DON stated Resident #4 made a complaint last week (unknown date) that CNA A and CNA B would not let her go to bed. The DON stated she asked Resident #4 to just humor the two CNA's and stay up for just 30 minutes. The DON confirmed she did not investigate the incident. The DON stated the two CNA's were Spanish aggressive and spoke aggressively as part of their culture, but the DON did not consider it abuse. The DON gave an example, Go take a shower in a stern, demanding tone of voice. During an interview on 5/14/2021 at 2:34 p.m., the Administrator stated after receiving information from this surveyor that Resident #4 had stated CNA A and CNA B were rough with care, she interviewed Resident #4. The Administrator stated during the interview Resident #2 did not use the word rough. She said they were fast. When I asked her if she felt safe, she said yes, CNA A and CNA B just need to slow down. The Administrator stated since the Resident did not use the word rough during the interview, she didn't think there was any abuse and did not investigate further. e. Record review of Resident #5's face sheet, dated 5/16/2021 revealed a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's quarterly MDS dated [DATE] revealed a BIMS' score which indicated a moderate cognitive impairment with inattentiveness (difficulty focusing attention) without symptoms of [CONDITION(S)] or other behaviors. Resident #5 required the assistance of 1-2 staff members for care. During an interview on 5/12/2021 at 10:34 a.m., on the 300-hallway with Resident #5 who stated she didn't like living at the nursing facility and didn't feel safe. Resident #5 stated CNA A was rough with me and he hurts my roommate when providing care (unknown date and time). Resident #5 stated Resident #16 cried out that she was being hurt when CNA A was taking care of her. She also stated staff (refused to give names) said she was fat when providing care and that makes her feel bad. Resident #5 stated she had talked to the DON at one time about the rough care but did not remember when this conversation occurred. She stated, the DON stated because she was fat, the care may be rough which in turn made the resident feel bad. Resident #5 stated she was afraid of getting in trouble for talking to this surveyor and turned her head to the side and refused to answer further questions. During an interview on 5/14/2021 at 2:34 p.m., the Administrator confirmed she did not thoroughly investigate rough care or abuse because she interviewed Resident #5 after receiving information from this surveyor that CNA A was rough with care and did not feel like there was any abuse. The Administrator stated the resident gave her a blank stare and then eventually stated CNA A was rough with her roommate. Resident #5 stated the roommate said ow and no during care by CNA A. The Administrator confirmed the roommate was not interviewable due to cognitive status, but sometimes is able to answer simple questions. The Administrator stated she asked the roommate if she felt safe and she responded with oh yeah. The Administrator stated she told Resident #5 to come to her for any concerns. f. Record review of Resident #6's face sheet, dated 5/15/2021, revealed an [AGE] year-old-female, admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's admission MDS, dated [DATE] revealed a BIMS' score which indicated the resident was completely cognitively intact. During an interview on 5/13/2021 at 2:27 p.m., the Speech Pathologist stated Resident #6 was in tears on Monday 5/3/2021. Resident #6 stated that the weekend had been terrible because staff had been ignoring call lights, when the staff would come, she would ask for assistance and the staff would never come back. Resident #6 stated she needed help in the bathroom and NA C came into her room. Resident #6 reported that she screamed at him to get out because she didn't want NA C to take care of her because he was male and because he shook her roommate Resident #7 right before Resident #7 had to go to the hospital. Resident #6 informed the Speech Pathologist she didn't tell anyone about the incident because she wasn't comfortable reporting it. The Speech Pathologist stated she had filled out a grievance which she had previously been instructed to do and on 5/03/2021 put it directly on top of the Administrator's desk. The Speech Pathologist stated the Administrator did not follow up with any questions. During an interview on 5/13/2021 at 4:43 p.m., Resident #6 stated NA C came into their room and shook her roommate Resident #7 with his hands because Resident #7 kept pressing the call light. Resident #6 stated the resident had been hurting and crying out. Resident #6 stated NA C was also rough with her. She had told him she didn't want a man taking care of her and didn't feel comfortable with a man touching her privately, so she had asked him to leave the room and get a woman. Resident #6 stated he left at that time but came back in later. Resident #6 stated she screamed at him and told him to get out and he pulled her depends up really hard and fast. Resident #6 became emotional and started crying and stated, there might be someone that can't stop him like I can. Resident #6 stated she didn't report the incident to anyone that she can remember because it was upsetting. Record review of Resident #7's face sheet, dated 5/15/2021, revealed an [AGE] year-old-female admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #7's quarterly MDS, dated [DATE] revealed a BIMS score of 9 (maximum score 15) which indicated the resident had a moderate cognitive impairment. During an interview on 5/13/2021 at 5:11 p.m. Resident # [TRUNCATED]

Based on interview and record review, the facility failed to ensure that all allegations involving abuse and neglect, were reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials including the State Survey agency (HHS), in accordance with State law through established procedures for 7 of 7 residents (Resident # 1, #2, #3, #4, #5, #6 and #7) reviewed for abuse, in that; 1. The facility failed to report to the State Survey Agency (HHS) within two hours an allegation of abuse to Resident #1 when LVN G reported to the DON that Resident #1 indicated CNA B pulled his hair and when a Speech Pathologist reported to the Administrator that she had witnessed CNA B get in Resident #1's face, yell and then aggressively remove Resident #1's hands from his wheelchair. 2. The facility failed to report to the State Survey Agency (HHS) within two hours an allegation of neglect and emotional abuse to Resident #2 when Resident #2, a family member, RN and the BOM reported to the Administrator that CNA D had turned off Resident #2's call light without assisting the resident resulting in emotional distress to the Resident #2. 3. The facility failed to report to the State Survey Agency (HHS) within two hours an allegation of physical, verbal and emotional abuse when Resident #3 reported to LVN and the DON that CNA B told her to cut off her leg if it was causing her so much pain. When CNA A told Resident #3 if no one answered her call light she would know why after she reported the abuse from CNA B and when CNA A and CNA B would take away the residents food before she was finished in response to the report of abuse. The facility again failed to report within two hours when these allegations were reported to the Administrator by a State Surveyor. 4. The facility failed to report to the State Survey Agency (HHS) within two hours an allegation of abuse when Resident #4 stated CNA A and CNA B were rough with care which was reported to the Administrator by a State Surveyor on 5/12/2021. 5. The facility failed to report to the State Survey Agency (HHS) within two hours an allegation of abuse when Resident #5 reported CNA C was rough with care to herself and to her roommate, Resident #16 which was reported to the Administrator by a State Surveyor. 6. The facility failed to report to the State Survey Agency (HHS) within two hours an allegation of abuse when Resident #6 reported to PTA OO that she had witnessed NA shake her roommate, Resident #7 after becoming frustrated. An Immediate Jeopardy (IJ) was identified and the Administrator was notified on 5/14/2021 at 4:06 p.m. While the IJ was removed on 5/20/2021, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility was still monitoring the effectiveness of the Plan of Removal. These failures affected residents who made outcries of abuse and placed them at risk for continued and/or unrecognized abuse and emotional distress. The findings include: 1. Record review of a face sheet for Resident #1, dated 5/13/2021, revealed the resident was a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's quarterly MDS, dated [DATE], revealed that the resident had a BIMS' score which indicated the resident was severely cognitively impaired and was unable to recall words and phrases after minutes, had no documented behaviors and required the assistance of 1-2 staff members for care. During an interview on 5/12/2021 at 5:25 p.m., with Resident #1 revealed the resident had child like mannerisms and speech in which he repeated what was spoken to him. Resident #1 was unable to be interviewed due to his intellectual disability and cognitive status. During an interview on 5/12/2021 at 1:19 p.m. LVN G stated she heard during change of report (unknown source) that Resident #1 complained that a staff member pulled his hair over the weekend (5/8/2021-5/9/2021). LVN G stated she reported it to the DON on 5/10/2021. The DON responded with That's hard to prove, it could have been a joke. During an interview on 5/14/2021 at 5:44 p.m. the DON did not have any knowledge of complaints of abuse or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/10/2021, LVN G informed her Resident #1 stated CNA B pulled his hair. The DON talked to Resident #1 and he said someone touched his hair. The DON stated does not remember if she notified the Administrator. The DON stated she was trained to report abuse to the Administrator immediately. During an interview on 5/13/2021 at 2:27 p.m., the Speech Pathologist stated she was standing in the 300-hallway on 12/20/2020 near the therapy area when she heard a someone talking aggressively to Resident #1. The Speech Pathologist looked in the direction of the commotion and witnessed CNA B tell Resident #1 in an aggressive manner to go to his room. The resident did not want to go to his room, so CNA B got in Resident #1's face, yelled at the resident and began moving the resident's wheelchair. She also witnessed CNA B aggressively remove Resident #1's hand from his wheelchair. CNA A was observing from 3 feet away and a MA (unknown) was also in the hallway. CNA B stopped what she was doing when she saw she was being observed. Approximately 10 minutes later CNA A was sitting at the nurse's station and said something to Resident #1. The resident responded with no. CNA A then responded with yes and kept going back and forth with the resident and wouldn't let it go. The Speech Pathologist stated she informed the Administrator when the incident occurred either 12/20/2020 or 12/21/2020 via text. The Administrator called her back within 30 minutes of the notification and stated, Yeah, we have been getting some complaints about CNA B. Thank you for letting me know. Record review of a text message dated Sunday, 12/20/2020 between the Speech Pathologist to the Administrator revealed a message that read: Hi, Administrator! Sorry to bother you today, but if you have a moment, I'd like to talk to you about something I saw today at the facility. There was no response from the Administrator via text. During an interview on 5/14/2021 at 1:15 p.m., the Administrator stated she was not aware an any grievance from the Speech Pathologist or anyone else regarding CNA A and CNA B abusing or mistreating Resident #1 prior to surveyor intervention. The Administrator stated she had no concerns about the way staff talk to Resident #1. 2. Record review of a face sheet for Resident #2, dated 5/13/2021, revealed a [AGE] year-old-female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's quarterly MDS, dated [DATE], revealed that the resident had a BIMS' score of 12 which indicated a moderate cognitive impairment without signs and symptoms of [CONDITION(S)], [CONDITION(S)] or other behaviors. Resident #2 required the assistance of 1-2 staff members for care. Record review of a facility grievance dated 5/4/2021 revealed a family member of Resident #2 called and said Resident #2 needed to be changed since beginning of shift and stated CNA D just turns off light and (unknown staff) promised to change but did not. The Administrator signed the document and dated it as received on 5/04/2021. The document indicated Resident #2 was unhappy when NA C and CNA D care for her and yells at them to get out of her room. The plan to resolve the grievance was to move Resident #2 to a different hallway. During an interview on 5/12/2021 at 1:41 p.m., Resident #2 stated she moved from the 300 to the 200-hallway because she wanted to get away from CNA C and CNA D. She stated, They are real mean[OBSCENITY] s to me. Resident #2 stated NA C and CNA D also didn't do what they were supposed to do for her. She stated, she would rather not give any further details because she was afraid of what would happen. Resident #2 stated she had the Administrators cell phone number and tried to reach her without success, so she called her family member and informed them of what had occurred. During an interview on 5/12/2021 at 5:31 p.m. RN N stated Resident #2 complained about not being changed in a 4-hour window and also complained that CNA D was rude (date unknown). The Resident's family member also called upset. RN N stated he notified the Administrator via telephone that Resident #2 had said staff was rude. He stated he didn't know how the Administrator responded. During an interview on 5/12/2021 at 6:34 p.m., the DON stated Resident #2 first had issues with NA C brother who no longer works at the facility. The DON stated she honored Resident #2's request to not work with him. Then Resident #2 complained NA C was too rough (unknown date and time). Resident #2 has also complained about care from CNA D and doesn't want either NA C or CNA D to care for her. The DON stated she communicated with the Administrator Resident #2's concerns (unknown date and unknown time). During an interview on 5/13/2021 at 9:28 p.m., Resident #2's family member stated Resident #2 had called upset and stated a mother and son staff members (NA C and CNA D) were taking away the resident's call light from her and treating her bad. The family member stated he called the facility and spoke to RN G who assured him NA C and CNA D would be removed from caring for Resident #2. The next day, NA C and CNA D were again taking care of Resident #2. The family member stated he called again called the facility and spoke to the BOM and requested that Resident #2 be moved off of the 300-hallway so that she would not be cared for by NA C and CNA D. The family member stated the Administrator did not return his calls until 5/12/2021. During an interview on 5/13/2021 at 4:13 p.m., the BOM confirmed Resident #2 complained on 5/06/2021 that staff (unknown) kept turning off her call light when she put them on without assisting her. The BOM stated the resident's called and spoke to her and was very upset about the incident and then came to the facility to see the resident. The BOM stated immediately after finishing the conversation with Resident #3, she walked straight from the conversation to the Administrator's office and informed her of Resident #3's concern. The BOM stated the Administrator responded by stating, Resident #3 isn't happy about a lot of things. The BOM stated to the Administrator, I know, but I feel like we have to do something. During an interview on 5/14/2021 at 1:18 p.m., the Administrator stated an example of abuse/neglect was staff not answering a call light or turning it off without attending to the resident leaving them soiled. The Administrator stated RN G called her at home and stated Resident #2 was not soiled. The Administrator confirmed she also spoke with Resident #3's family member who was really upset. The Administrator explained to the family member that staff would change Resident #3 immediately. The Administrator stated knowing that RN G had been in the resident room and the resident was just waiting for a CNA to finish with another resident was not neglect. The Administrator stated she felt like Resident #3 tended to exaggerate. The Administrator stated she wanted to see if what the resident reported was true and stated I do not want to call her a liar, but she sees things differently. I do not have staff here who would ignore a resident. The Administrator stated she had Resident #2 moved to a different hallway away from NA C and CNA D and Resident #2 was content on the new hallway. The Administrator stated Resident #2's behaviors were much better on the new hallway. When asked why she thought Resident #2's behaviors would improve on a new hallway away from NA C and CNA D? The Administrator stated that the new staff baby Resident #2 more. Their voices were not so stern. The Administrator confirmed she herself would not want to be spoken to in such a manner with a stern voice. The Administrator stated she did not report the incident to the State Survey Agency (HHS) because the resident didn't say she felt like she had any harm. 3. Record review of a face sheet for Resident #3, dated 5/13/2021, revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's quarterly MDS dated [DATE], revealed the resident had a BIMS' score of 10 which indicated a moderate cognitive impairment without the signs and symptoms of [CONDITION(S)], [CONDITION(S)] or other behaviors. Resident #3 required the assistance of 1-2 staff for care. Record review of a facility grievance, dated 5/01/2021, revealed Resident #3 voiced to nurse, LVN G that CNA B had made {an} ugly comment about her leg not working and that she should just chop it off. The grievance was made and signed by the DON who assign the investigation to herself on 5/03/2021. The DON signed off on the grievance as resolved on 5/03/2021. During an interview on 5/12/2021 at 10:55 a.m. on the 300-hallway with Resident #3 who stated CNA A had been rough with care since she made a complaint about CNA A's mother, CNA B. Resident #3 stated, CNA A would not get me out of bed when asked for assistance and stated, If you push the button (call light) and nobody comes, you know why. Resident #3 stated she did not want to talk about the complaint against CNA B because she was already caused enough trouble by making the complaint. The resident became emotional with tears and added, I cannot do anything to suit, CNA B. She constantly takes the little blanket off my feet and puts the blanket where I can't reach it. She says I am freezing out my roommate (with the air-conditioning). She takes my (food) tray away before I am done with my food. CNA B asked me if I am finished (with the food) but I know better than to say no. She will take my food anyway. Since they (unknown) talked to CNA B, I get attitude from CNA A. I feel terrorized. CNA B is always yelling. I jump when I hear any loud noise because I am scared it's her. When asked if she felt safe, Resident #3 stated, I know there will be pain. I want to ask for someone else (to provide care) but I am afraid If I say anything I won't get changed and I will have to sit in my own waste. Resident #3 she had reported her concerns to LVN G and had talked to the DON about them. During an interview on 5/12/2021 at 2:34 p.m., Restorative Aide MM stated on an unknown date approximately 2 weeks ago, Resident #3 told her CNA A and CNA B were rough with her and that CNA B told her to chop off her leg because it was contracted. Restorative Aide MM stated Resident #3 looked like she was going to cry when she told the aide about the incident. She further stated the resident tries very hard to straighten her contractured leg and even though it's been a couple of weeks since the incident, Resident #3 keeps talking about it. CNA B stated she reported it to LVN G who was the Charge Nurse who responded she was going to report the incident. Restorative Aide MM stated the Abuse Coordinator was the Administrator and added I am a single mom and I worry about my job. During an interview on 5/12/2021 at 1:19 p.m., LVN G stated Resident #3 informed her on 5/1/2021 that on 4/30/2021, CNA B told the resident to cut off her leg because it was more of a bother than a help due to a contracture of the leg that was caused by a stroke. LVN G stated she reported the complaint immediately to the DON on 4/30/2021 via telephone. The DON responded by stating CNA B didn't mean it seriously and it was just a joke. The DON gave LVN G instructions to go with CNA B into the Resident #3's and have CNA B apologize. During an interview on 5/12/2021 at 5:44 p.m. the DON confirmed LVN G had reported that Resident #3 was upset about a comment CNA B made about the resident's leg in which CNA B stated This darn leg of yours, you need to cut if off. The DON stated she talked to LVN G and CNA B. The DON stated after talking to both LVN G and CNA B she decided to have CNA B apologize to the resident. This occurred over the weekend (unknown date) and the DON stated she reported the incident to the Administrator during morning meeting on Monday (unknown date). During an interview on 5/12/2021 at 2:29 p.m., the Administrator confirmed she was previously aware and had been informed that Resident #3 was upset that CNA B told her to cut off her leg. She stated she did not know who informed her or when she was informed. The Administrator stated reminded Resident #3 that she plays around with talking about her leg and the resident responded with Yeah, but I wasn't playing that day. It is not funny, and I do not want to play like that. The Administrator asked Resident #3 again if she thought CNA B was mean or joking and the resident replied joking. She asked Resident #3 if she felt unsafe and the resident replied no. The Administrator confirmed she did not report this incident to the State Reporting Agency (HHS) because the resident was fine with the incident and understands it was a joke. The Administrator stated she did not feel like it was abuse. During an interview on 5/13/2021 at 2:27 p.m., the Speech Pathologist stated several residents had complained about CNA A, CNA B and NA C. Specifically Resident #3 complained that CNA A and CNA B had complained about the residents bowel movements and stated, this is [OBSCENITY] ing bullshit, I am tired of this. The Speech Pathologist stated she filled out a grievance form and listed the resident as anonymous to try to protect the resident. The Speech Pathologist stated she signed her own name on the grievance and handed the grievance to the Administrator personally on 4/19/2021. The Administrator stated Thank you at the time she turned it in. The Administrator later called her back into the office and stated she needed the name of the resident. The Speech Pathologist identified Resident #3. The Administrator responded with, Okay, I just needed to know because I need to filter them because sometimes certain residents fill out a lot of grievance papers. Record review of a text message from the Rehabilitation Director and the Speech Pathologist dated 4/19/2021 at 4:30 p.m., that read Administrator wanted to talk to you about a grievance. During an interview on 5/14/2021 at 1:15 p.m., the Administrator stated she never received a grievance or complaint from the Speech Therapist regarding Resident #3 or any other resident. The Administrator stated she did not feel like Resident's #3's complaints were abuse and therefore had not reported the allegations to the State Reporting Agency until surveyor intervention. 4. Record review of Resident #4's face sheet, dated 5/15/2021 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's quarterly MDS dated [DATE] revealed a BIMS' score which indicated a moderate cognitive impairment. Resident #4 required the assistance of 1 staff member for care. During an interview on 5/12/2021 at 10:50 a.m. on the 300-hallway with Resident #4 stated two morning female staff members, identified as mother daughter and mother, CNA A and CNA B (also identified by description), were rough when they provided care (unknown dates and times). Resident #4 stated she had asked the two CNA's to slow down and be careful, but she received no verbal response to her request. Resident #4 stated she had not told anyone because she was afraid to say anything. During an interview on 5/14/2021 at 2:34 p.m., the Administrator stated after receiving information from this surveyor that Resident #4 had stated CNA A and CNA B were rough with care, she interviewed Resident #4. The Administrator stated during the interview Resident #2 did not use the word rough, she said they were fast. Administrator said, when I asked her if she felt safe, she said yes, CNA A and CNA B just need to slow down. The Administrator stated since Resident #4 did not use the word rough during the interview, she didn't think there was any abuse and therefore did not report the allegations to the State Reporting Agency until surveyor intervention. 5. Record review of Resident #5's face sheet, dated 5/16/2021 revealed a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's quarterly MDS dated [DATE] revealed a BIMS' score which indicated a moderate cognitive impairment with inattentiveness (difficulty focusing attention) without symptoms of [CONDITION(S)] or other behaviors. Resident #5 required the assistance of 1-2 staff members for care. During an interview on 5/12/2021 at 10:34 a.m., on the 300-hallway with Resident #5 who stated she didn't like living at the nursing facility and didn't feel safe. Resident #5 stated CNA A was rough with me and he hurts my roommate when providing care (unknown date and time). Resident #5 stated Resident #16 cried out that she was being hurt when CNA A was taking care of her. She also stated staff (refused to give names) said she was fat when providing care and that makes her feel bad. Resident #5 stated she had talked to the DON at one time about the rough care but did not remember when this conversation occurred. She stated, the DON stated because she was fat, the care may be rough which in turn made the resident feel bad. Resident #5 stated she was afraid of getting in trouble for talking to this surveyor and turned her head to the side and refused to answer further questions. During an interview on 5/14/2021 at 2:34 p.m., the Administrator confirmed she did not report rough care or abuse to the State Survey Agency (HHS) because she interviewed Resident #5 after receiving information from this surveyor that CNA A was rough with care. The Administrator stated the resident gave her a blank stare and then eventually stated CNA A was rough with her roommate. Resident #5 stated the roommate said ow and no during care by CNA A. The Administrator confirmed the roommate was not interviewable due to cognitive status, but sometimes is able to answer simple questions. The Administrator stated she asked the roommate if she felt safe and she responded with oh yeah. The Administrator stated she told Resident #5 to come to her for any concerns. 6. Record review of Resident #6's face sheet, dated 5/15/2021, revealed an [AGE] year-old-female, admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's admission MDS, dated [DATE] revealed a BIMS' score which indicated the resident was completely cognitively intact. Record review of Resident #7's face sheet, dated 5/15/2021, revealed an [AGE] year-old-female admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #7's quarterly MDS, dated [DATE] revealed a BIMS' score which indicated the resident had a moderate cognitive impairment. During an interview on 5/13/2021 at 2:27 p.m., the Speech Pathologist stated Resident #6 was in tears on Monday 5/3/2021. Resident #6 stated that the weekend had been terrible because staff had been ignoring call lights, when the staff would come, she would ask for assistance and the staff would never come back. Resident #6 stated she needed help in the bathroom and NA C came into her room. Resident #6 reported that she screamed at him to get out because she didn't want NA C to take care of her because he was male and because he shook her roommate Resident #7 right before Resident #7 had to go to the hospital. Resident #6 informed the Speech Pathologist she didn't tell anyone about the incident because she wasn't comfortable reporting it. The Speech Pathologist stated she had filled out a grievance which she had previously been instructed to do and on 5/03/2021 put it directly on top of the Administrator's desk. The Speech Pathologist stated the Administrator did not follow up with any questions. During an interview on 5/14/2021 at 1:15 p.m., the Administrator stated she was not aware an any grievance or concern from the Speech Pathologist or anyone else regarding Resident # 6 or Resident #7 prior to surveyor intervention, so she had not reported the incident prior to surveyor intervention. During an interview on 5/12/201 at 6:34 p.m. the DON stated she had received multiple complaints about CNA A, CNA B, NA C and CNA D. The DON stated these complaints were discussed in morning meetings with the Administrator. The DON further stated she did not feel like any of the resident complaints were abuse. She stated she was trained to report any suspicion of abuse immediately to the Administrator. The DON stated, she communicated frequently throughout the day with the Administrator. During an interview on 5/12/2021 at 7:00 p.m. the Administrator was notified of multiple resident allegations of abuse including abuse to Resident #1, #2, #3, #4, and #5 by CNA A, CNA B, NA C and CNA D. The Administrator denied knowledge of all allegations of abuse. The Administrator stated: - We see so much from Resident #1. He makes false allegations. -Resident #3 has behavior problems. I think she is prejudice. She is one of the 'City Name Locals'. The culture here is different -CNA A and CNA B are my best workers. They are firmer with the residents. They don't baby the residents. -Resident #5 is a [NAME] [NAME] She just wants to lie in her bed and not eat. I see her several times a day. She is being seen by psych for behaviors. I'm sorry but I don't think her complaint has any teeth. Record review of TULIP on 5/13/2021 at 11:00 a.m. revealed the facility had not self-reported any of the allegations of abuse concerning Resident #1, #2. #3, #4, #5, #6, or #7 which were reported to the Administrator on 5/12/2021 or were reported to the Administrator by residents, family members, BOM or staff. During an interview on 5/13/2021 at 12:42 p.m., the Administrator stated she stayed at the facility last on 5/12/2021 after being informed of the allegations of abuse and interview residents who were awake on the 300-hallway. As a result, she was going to split up CNA A and CNA B and split up NA C and CNA D and have them work in separate hallways instead of together on the same hallway. The Administrator also reminded staff and resident that she is the Abuse Coordinator and gave an in-service called soft touch reminding staff to be gentle with care. The Administrator confirmed she did not report to the State Survey Agency any of the allegations which had been reported to her on 5/12/2021 because she did not believe the allegations were abuse. During an interview on 5/13/2021 at 3:56 p.m., the ADON confirmed she had not performed Guardian Angel Rounds this week on the 300-hallway. The ADON stated she didn't think she would be able to provide documentation on the monitoring form that Guardian Angel Rounds had been performed for the month of May. She stated, I want to be honest. I don't think I did them. The ADON stated the Guardian Angel Rounds were an opportunity to check on the residents in their rooms and see if they had any concerns or anything they wanted to talk about. The ADON stated she thought the IJ the current resident complaints were a miscommunication between staff and residents, and she based on opinion of the fact that she had never witnessed abuse or had abuse reported to her. During an interview on 5/14/2021 at 11:35 a.m., the DON stated she had read and was familiar with the facility abuse policy. She stated she had been trained to respond to a abuse complaint by ensuring the resident was safe, initiating the investigation of the complaint, reporting to the Administrator any complaint and then the Administrator would take over and make decisions about reporting to State Agencies. The DON stated she felt like she had let her residents down and felt confused about why the IJ situation had occurred. The DON stated she felt there was a communication issues and it was concerning that staff and residents felt afraid to talk. The DON stated that staff was monitored by her niece, the ADON and confirmed she was the ADON direct supervisor, but this monitoring was not documented. The DON stated it was ultimately her responsibility for monitoring the nursing team. The DON confirmed the Guardian Angel Monitoring of residents was not actively performed every day. The DON stated not performing Angel rounds and checking on resident issues and complaints was not acceptable. The DON confirmed the ADON did not tell her the rounds were not being performed. During an interview on 5/14/2021 at 12:40 p.m. the Administrator confirmed she was the Abuse Coordinator and stated a grievance is something that can be fixed and did not cause harm. An allegation is something that caused harm or is not right. An incident that needs to be reported is intentional. Abuse is intentional. Neglect is intentional. The Administrator stated she follows the facility abuse policy. When she received an allegation of abuse/neglect or exploitation she immediately reports the allegation to the State Survey Agency and to Corporate. The Administrator stated she did not follow the report to the State Survey Agency because she did not have proof the allegations were truthful. The Administrator stated she did review the allegations with Corporate who agreed not to report. During an interview on 5/14/2021 at 12:55 p.m. the Administrator stated she monitored the facility by assigning and reviewing Guardian Angel Rounds, by working on the floor with staff and by communicating with the DON. The Administrator confirmed she was aware that Guardian Angel Rounds were not being completed on a daily basis by her management team but did not reveal how long it had not been completed. The Administrator stated, Guardian Angel Rounds was a program in which a member of the management team was assigned 5 resident rooms in which to check in with each day. The Angel was supposed to contact the resident in their room and check to see if the resident had any concerns and see if there were any environmental concerns. The Administrator stated she had re-assigned the Guardian Angel Assignments this week, but was unsure which staff monitored the 300-hallway. The Administrator stated she talked to staff and told them it had to be done. She monitors the monitoring notes for any concerns. The Administrator confirmed it was her responsibility to monitor staff and ensure the Guardian Angel Rounds were getting completed, The Administrator stated, I know my employees pretty well and did not have any concerns. During an interview on 5/14/2021 at 1:09 p.m. the Administrator confirmed she did not have a written method or way to document allegations of abuse or completed investigations to give this surveyor as requested. When asked how she keeps track of allegations of abuse she replied, all allegations are reported immediately and then [TRUNCATED]

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse were thoroughly investigated, failed to take corrective action and prevent further potential abuse for 7 of 7 residents (Resident #1, #2, #3, #4, #5, #6 and #7) reviewed for abuse: The Administrator, who is the Abuse Coordinator, failed to thoroughly investigate and prevent further potential abuse and mistreatment by allowing the alleged perpetrators to remain in the facility and allowed them to have direct contact with the residents while the investigation process was occurring when: 1. The Speech Pathologist reported to the Administrator that she had witnessed CNA B get in Resident #1's face, yell and then aggressively remove the resident's hand from the wheelchair. 2. Resident #2, a family member, RN G and the BOM reported to the Administrator that CNA D had turned off Resident #2's call light without assisting the resident resulting in emotion distress to Resident #2. 3. Resident #3 reported CNA B told her to cut off her leg if it was causing her so much pain which resulted in emotional distress and depression to the resident. 4. Resident #4 made an allegation of abuse when she reported CNA A and CAN B were rough with care. 5. Resident #5 made an allegation of abuse when she reported NA C was rough with care for herself and her roommate, Resident #16. 6. Resident #6 made an allegation of physical abuse when she reported that CNA C shook her roommate out of frustration which caused emotional distress to Resident #6. An Immediate Jeopardy (IJ) was identified and the Administrator was notified on 5/14/2021. While the IJ was removed on 5/20/2021, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility was still monitoring the effectiveness of the Plan of Removal. These failures affected residents who made outcries of abuse and placed them at risk for continued and/or unrecognized abuse and emotional distress. The findings include: 1. Record review of a face sheet for Resident #1, dated 5/13/2021 revealed the resident was a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's quarterly MDS, dated [DATE], revealed that the resident had a BIMS' score which indicated the resident was severely cognitively impaired and was unable to recall words and phrases after minutes, had no documented behaviors and required the assistance of 1-2 staff members for care. Record review of Resident #1's Care Plan created on 5/22/2018 and last revised on 4/01/2020 revealed the resident had an impaired cognitive function or impaired thought process with impaired decision making and required staff to present just one thought, idea, question or command at a time. During an interview on 5/12/2021 at 1:19 p.m. LVN G stated she learned during change of report (unknown source) that Resident #1 complained that a staff member pulled his hair over the weekend (5/8/2021-5/9/2021). LVN G stated she reported it to the DON on 5/10/2021. The DON responded with That's hard to prove, it could have been a joke. During an interview on 5/12/2021 at 5:25 p.m., with Resident #1 revealed the resident had childlike mannerisms and speech in which he repeated what was spoken to him. Resident #1 was unable to be interviewed due to his intellectual disability and cognitive status. During an interview on 5/14/2021 at 5:44 p.m. the DON stated she did not have any knowledge of complaints of abuse or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/10/2021, LVN G informed her Resident #1 stated CNA B pulled his hair . The DON stated she talked to Resident #1 and he said someone touched his hair. The DON stated you just have to know Resident # 1 . The DON confirmed she did not suspend CNA B or remove her from resident care during the investigation and did not interview other residents or additional staff. The DON stated other people would have reported it if they had a concern. The DON stated several residents had expressed concerns about CNA A and CNA B talking to them loud and the Administrator had spoken to the two CNA's in her office to talk to them about it. The DON indicated Resident #1 had behaviors and repeated things he heard. The DON stated she does not remember if she notified the Administrator. The DON stated she was trained to report abuse to the Administrator immediately. During an interview on 5/13/2021 at 2:27 p.m., the Speech Pathologist stated she was standing in the 300-hallway on 12/20/2020 near the therapy area when she heard a someone talking aggressively to Resident #1. The Speech Pathologist looked in the direction of the commotion and witnessed CNA B tell Resident #1 in an aggressive manner to go to his room. The resident did not want to go to his room, so CNA B got in Resident #1's face, yell at the resident and began moving the resident's wheelchair. She also witnessed CNA B aggressively remove Resident #1's hand from his wheelchair. CNA A was observing from 3 feet away and a MA (unknown) was also in the hallway. CNA B stopped what she was doing when she saw she was being observed. Approximately 10 minutes later CNA A was sitting at the nurse's station and said something to Resident #1. The resident responded with no. CNA A then responded with yes and kept going back and forth with the resident and wouldn't let it go. The Speech Pathologist stated she informed the Administrator when the incident occurred either 12/20/2020 or 12/21/2020 via text. The Administrator called her back within 30 minutes of the notification and stated, Yeah, we have been getting some complaints about CNA B. Thank you for letting me know. The Speech Pathologist stated she had never been asked to write a written statement and had not been asked for details of the event she had witnessed. Record review of a text message dated Sunday, 12/20/2020 between the Speech Pathologist to the Administrator revealed a message that read: Hi, Administrator! Sorry to bother you today, but if you have a moment, I'd like to talk to you about something I saw today at the facility. There was no response from the Administrator via text. During an interview on 5/14/2021 at 1:15 p.m., the Administrator stated she was not aware an any grievance from the Speech Pathologist or anyone else regarding CNA A and CNA B abusing or mistreating Resident #1 prior to surveyor intervention, so she had not investigated or removed any staff from contact with the resident. The Administrator stated she had no concerns about the way staff talk to Resident #1. During an interview on 5/14/2021 at 5:44 p.m. the DON stated she did not have any knowledge of complaints of abuse or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/10/2021, LVN G informed her Resident #1 stated CNA B pulled his hair . The DON stated she talked to Resident #1 and he said someone touched his hair. The DON stated you just have to know Resident # 1. The DON indicated Resident #1 had behaviors and repeated things he heard. The DON confirmed she did not perform an investigation or remove any staff from contact with the Resident. The DON stated she does not remember if she notified the Administrator. The DON stated she was trained to report abuse to the Administrator immediately. 2. Record review of a face sheet for Resident #2, dated 5/13/2021, revealed a [AGE] year-old-female admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's quarterly MDS, dated [DATE], revealed that the resident had a BIMS' score which indicated a moderate cognitive impairment without signs and symptoms of [CONDITION(S)], [CONDITION(S)] or other behaviors. Resident #2 required the assistance of 1-2 staff members for care. During an interview on 5/12/2021 at 1:41 p.m., Resident #2 stated she moved from the 300 to the 200-hallway because she wanted to get away from CNA C and CNA D. She stated, They are real mean[OBSCENITY] s to me. Resident #2 stated NA C and CNA D also didn't do what they were supposed to do for her. She stated, she would rather not give any further details because she was afraid of what would happen. Resident #2 stated she had the Administrators cell phone number and tried to reach her without success, so she called her family member and informed them of what had occurred. During an interview on 5/12/2021 at 5:31 p.m. RN N stated Resident #1 complained about not being changed for a 4-hour window and also complained that CNA D was rude (date unknown). RN N stated he had a hard time believing it was true because he had been up and down the hallway and into the resident room and Resident #1 had never said anything to me about it prior. The Resident's son called upset. RN N stated he notified the Administrator via telephone that Resident #2 had said staff was rude. He stated he didn't know how the Administrator responded. RN G confirmed he had completed abuse training upon hire and as ongoing training on the facility computerized training program. He further stated he was trained to report abuse/neglect immediately to the Administrator. During an interview on 5/12/2021 at 6:34 p.m., the DON stated Resident #2 first had issues with NA C family member who no longer works at the facility. The DON stated she honored Resident #2's request to not work with him. Then Resident #2 complained NA C was too rough (unknown date and time). Resident #2 has also complained about care from CNA D and doesn't want either NA C or CNA D to care for her. The DON confirmed she did not perform an investigation. The DON stated she communicated with the Administrator Resident #2's concerns (unknown date and unknown time). During an interview on 5/13/2021 at 9:28 p.m., Resident #2's family member stated Resident #2 had called upset and stated (NA C and CNA D were taking away the resident's call light from her and treating her bad. The family member stated he called the facility and spoke to RN G who assured him NA C and CNA D would be removed from caring for Resident #2. The next day, NA C and CNA D were again taking care of Resident #2. The family member stated he called again called the facility and spoke to the BOM and requested that Resident #2 be moved off of the 300-hallway so that she would not be cared for by NA C and CNA D. The family member stated the Administrator did not return his calls until 5/12/2021. During an interview on 5/13/2021 at 4:13 p.m., the BOM confirmed Resident #2 complained on 5/06/2021 that staff (unknown) kept turning off her call light when she put them on without assisting her. The BOM stated the resident's called and spoke to her and was very upset about the incident and then came to the facility to see the resident. The BOM stated immediately after finishing the conversation with Resident #3, she walked straight from the conversation to the Administrator's office and informed her of Resident #3's concern. The BOM stated the Administrator responded by stating, Resident #3 isn't happy about a lot of things. The BOM stated to the Administrator, I know, but I feel like we have to do something. During an interview on 5/14/2021 at 11:25 a.m., the DON confirmed she was aware of Resident #2's grievance. The DON stated she was clocking out and going home and saw CNA D with a Hoyer lift. The DON stated she assumed Resident #2 had been changed and the situation was resolved. The DON stated she was not aware of a call light issue of complaint about staff turning off the call light without assisting the resident. The DON stated she doesn't investigate if she feels like she can resolve a problem. If a resident were to say I am being abused or someone hit me that would be a completely different ball game and I wouldn't hesitate to tell my staff to hit the door. During an interview on 5/14/2021 at 1:18 p.m., the Administrator stated an example of abuse/neglect was staff not answering a call light or turning it off without attending to the resident leaving them soiled. The Administrator stated RN G called her at home and stated Resident #2 was not soiled. The Administrator confirmed she also spoke with Resident #2's family member who was really upset about the resident being soiled and call lights turned off. The Administrator explained to the family member that staff would change Resident #2 immediately. The Administrator stated knowing that RN G had been in the resident room and the resident was just waiting for a CNA to finish with another resident was not neglect. The Administrator stated she felt like Resident #2 tends to exaggerate. The Administrator stated she wanted to see if what the resident reported was true and stated I do not want to call her a liar, but she sees things differently. I do not have staff here who would ignore a resident. The Administrator stated she had Resident #2 moved to a different hallway away from NA C and CNA D and Resident #2 was content on the new hallway. The Administrator stated Resident #2's behaviors were much better on the new hallway. When asked why she thought Resident #2's behaviors would improve on a new hallway away from NA C and CNA D? The Administrator stated that the new staff baby Resident #2 more. Their voices were not so stern. The Administrator confirmed she herself would not want to be spoken to in such a manner with a stern voice. The Administrator stated she did not take written statements, suspend any staff from contact with the resident, interview other staff who might have observed the incident or other residents because the resident didn't say she felt like she had any harm and the problem had been resolved as a grievance. 3. Record review of a face sheet for Resident #3, dated 5/13/2021, revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's quarterly MDS dated [DATE], revealed the resident had a BIMS' score which indicated a moderate cognitive impairment without the signs and symptoms of [CONDITION(S)], [CONDITION(S)] or other behaviors. Resident #3 required the assistance of 1-2 staff for care. Record review of a facility grievance, dated 5/01/2021 revealed Resident #3 voiced to nurse, LVN G that CNA B had made {an} ugly comment about her leg not working and that she should just chop it off. The grievance was made and signed by the DON who assign the investigation to herself on 5/03/2021. The DON signed off on the grievance as resolved on 5/03/2021. During an interview on 5/12/2021 at 10:55 a.m. on the 300-hallway with Resident #3 who stated CNA A had been rough with care since she made a complaint about CNA A's mother, CNA B. Resident #3 stated, CNA A would not get me out of bed when asked for assistance and stated, If you push the button (call light) and nobody comes, you know why. Resident #3 stated she did not want to talk about the complaint against CNA B because she was already caused enough trouble by making the complaint. The resident added, I cannot do anything to suit, CNA B. She constantly takes the little blanket off my feet and puts the blanket where I can't reach it. She says I am freezing out my roommate (with the air-conditioning). She takes my (food) tray away before I am done with my food. CNA B asked me if I am finished (with the food) but I know better than to say no. She will take my food anyway. Since they (unknown) talked to CNA B, I get attitude from CNA A. I feel terrorized. CNA B is always yelling. I jump when I hear any loud noise because I am scared it's her. When asked if she felt safe, Resident #3 stated, I know there will be pain. I want to ask for someone else (to provide care) but I am afraid If I say anything I won't get changed and I will have to sit in my own waste. Resident #3 she had reported her concerns to LVN G and had talked to the DON about them. During an interview on 5/12/2021 at 2:34 p.m., Restorative Aide MM stated on an unknown date approximately 2 weeks ago, Resident #3 told her CNA A and CNA B were rough with her and that CNA B told her to chop off her leg because it was contracted. Restorative Aide MM stated Resident #3 looked like she was going to cry when she told the aide about the incident. She further stated the resident tries very hard to straighten her contractured leg and even though it's been a couple of weeks since the incident, Resident #3 keeps talking about it. CNA B stated she reported it to LVN G who was the Charge Nurse who responded she was going to report the incident. Restorative Aide MM stated the Abuse Coordinator was the Administrator and added I am a single mom and I worry about my job. During an interview on 5/12/2021 at 1:19 p.m., LVN G stated Resident #3 informed her on 5/1/2021 that on 4/30/2021, CNA B told the resident to cut off her leg because it was more of a bother than a help due to a contracture of the leg that was caused by a stroke. LVN G stated she reported the complaint immediately to the DON on 4/30/2021 via telephone. The DON responded by stating CNA B didn't mean it seriously and it was just a joke. The DON gave LVN G instructions to go with CNA B into the Resident #3's and have CNA B apologize. During an interview on 5/12/2021 at 5:44 p.m. the DON confirmed LVN G had reported that Resident #3 was upset about a comment CNA B made about the resident's leg in which CNA B stated This darn leg of yours, you need to cut if off. The DON stated she talked to LVN G and CNA B. The DON stated after talking to both LVN G and CNA B she decided to have CNA B apologize to the resident. This occurred over the weekend (unknown date) and the DON stated she reported the incident to the Administrator during morning meeting on Monday (unknown date). The DON stated she investigated the situation by talking to CNA B about the situation. CNA B stated she was playing with the resident. The DON confirmed she did not suspend CNA B or remove her from resident care while she investigated, did not take any written witness statements and did not interview other staff or residents because Resident #3 was fine with the kidding. The DON stated she asked Resident #3 if she was okay with CNA B continuing her care and she said she was fine with it. During an interview on 5/12/2021 at 2:29 p.m., the Administrator confirmed she was previously aware and had been informed that Resident #3 was upset that CNA B told her to cut off her leg. She stated she did not know who informed her or when she was informed. The Administrator stated reminded Resident #3 that she plays around with talking about her leg and the resident responded with Yeah, but I wasn't playing that day. It is not funny, and I do not want to play like that. The Administrator asked Resident #3 again if she thought CNA B was mean or joking and the resident replied joking. She asked Resident #3 if she felt unsafe and the resident replied no. The Administrator confirmed she did not suspend CNA B from work or remove her from resident care and did not perform an investigation because the resident was fine with the incident and understands it was a joke. The Administrator stated she did not feel like it was abuse. During an interview on 5/13/2021 at 2:27 p.m., the Speech Pathologist stated several residents had complained about CNA A, CNA B and NA C. Specifically Resident #3 complained that CNA A and CNA B had complained about the residents bowel movements and stated, this is [OBSCENITY] ing bullshit, I am tired of this. The Speech Pathologist stated she filled out a grievance form and listed the resident as anonymous to try to protect the resident. The Speech Pathologist stated she signed her own name on the grievance and handed the grievance to the Administrator personally on 4/19/2021. The Administrator stated Thank you at the time she turned it in. The Administrator later called her back into the office and stated she needed the name of the resident. The Speech Pathologist identified Resident #3. The Administrator responded with, Okay, I just needed to know because I need to filter them because sometimes certain residents fill out a lot of grievance papers. Record review of a text message from the Rehabilitation Director to the Speech Pathologist dated 4/19/2021 at 4:30 p.m., that read Administrator wanted to talk to you about a grievance. During an interview on 5/14/2021 at 1:15 p.m., the Administrator stated she was not aware an any grievance from the Speech Pathologist or anyone else regarding CNA A and CNA B abusing or mistreating Resident #3 prior to surveyor intervention. The Administrator stated she had never received any grievances from the Speech Pathologist. 4. Record review of Resident #4's face sheet, dated 5/15/2021 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's quarterly MDS dated [DATE] revealed a BIMS' score which indicated a moderate cognitive impairment. Resident #4 required the assistance of 1 staff member for care. During an interview on 5/12/2021 at 10:50 a.m. ,on the 300-hallway with Resident #4 stated two morning female staff members, identified as mother daughter and mother, CNA A and CNA B (also identified by description), were rough when they provided care (unknown dates and times). Resident #4 stated she had asked the two CNA's to slow down and be careful, but she received no verbal response to her request. Resident #4 stated she had not told anyone because she was afraid to say anything. During an interview on 5/12/2021 at 6:34 p.m., the DON stated Resident #4 made a complaint last week (unknown date) that CNA A and CNA B would not let her go to bed. The DON stated she asked Resident #4 to just humor the two CNA's and stay up for just 30 minutes. The DON confirmed she did not investigate the incident or suspend any staff from contact with the resident. The DON stated the two CNA's were Spanish aggressive and spoke aggressively as was part of her was part of their culture, but the DON did not consider it abuse. During an interview on 5/14/2021 at 2:34 p.m., the Administrator stated after receiving information from this surveyor that Resident #4 had stated CNA A and CAN B were rough with care, she interviewed Resident #4. The Administrator stated during the interview Resident #2 did not use the word rough. She said they were fast. When I asked her if she felt safe, she said yes, CNA A and CNA B just need to slow down. The Administrator stated since the Resident did not use the word rough during the interview, she didn't think there was any abuse and did not investigate further or suspend any staff from contact with the resident. 5. Record review of Resident #5's face sheet, dated 5/16/2021 revealed a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's quarterly MDS dated [DATE] revealed a BIMS' score which indicated a moderate cognitive impairment with inattentiveness (difficulty focusing attention) without symptoms of [CONDITION(S)] or other behaviors. Resident #5 required the assistance of 1-2 staff members for care. Record review of Resident #5's Care Plan revealed the resident had made statements that she was going to starve herself and refused to discuss the issues with psychological services. During an interview on 5/12/2021 at 10:34 a.m., on the 300-hallway with Resident #5 who stated she didn't like living at the nursing facility and didn't feel safe. She stated NA C was rough with me and he hurts my roommate, Resident #16 when providing care (unknown date and time). Resident #5 stated Resident #16 cried out like she was being hurt when NA C was taking care of her. She also stated staff (refused to give names) said she was fat when providing care and that makes her feel bad. Resident #5 stated she had talked to the DON at one time about the rough care but did not remember when this conversation occurred. She stated the DON stated because she was fat, the care may be rough which in turn made the resident feel bad. The resident stated she was afraid of getting in trouble for talking to this surveyor and turned her head to the side and refused to answer further questions. During an interview on 5/14/2021 at 2:34 p.m., the Administrator confirmed she did not thoroughly investigate rough care or abuse and did not remove or suspend any staff from contact with Resident #5 because she interviewed Resident #5 after receiving information from this surveyor that CNA A was rough with care and did not feel like there was any abuse. The Administrator stated the resident gave her a blank stare and then eventually stated CNA A was rough with her roommate. Resident #5 stated the roommate said ow and no during care by CNA A. The Administrator confirmed the roommate was not interviewable due to cognitive status, but sometimes is able to answer simple questions. The Administrator stated she asked the roommate if she felt safe and she responded with oh yeah. The Administrator stated she told Resident #5 to come to her for any concerns. 6. Record review of Resident #6's face sheet, dated 5/15/2021, revealed an [AGE] year-old-female, admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's admission MDS, dated [DATE] revealed a BIMS' score which indicated the resident was completely cognitively intact. During an interview on 5/13/2021 at 2:27 p.m., the Speech Pathologist stated Resident #6 was in tears on Monday 5/3/2021. Resident #6 stated that the weekend had been terrible because staff had been ignoring call lights, when the staff would come, she would ask for assistance and the staff would never come back. Resident #6 stated she needed help in the bathroom and NA C came into her room. Resident #6 reported that she screamed at him to get out because she didn't want NA C to take care of her because he was male and because he shook her roommate Resident #7 right before Resident #7 had to go to the hospital. Resident #6 informed the Speech Pathologist she didn't tell anyone about the incident because she wasn't comfortable reporting it. The Speech Pathologist stated she had filled out a grievance which she had previously been instructed to do and on 5/03/2021 put it directly on top of the Administrator's desk. The Speech Pathologist stated the Administrator did not follow up with any questions. During an interview on 5/13/2021 at 4:43 p.m., Resident #6 stated NA C came into their room and shook her roommate Resident #7 with his hands because Resident #7 kept pressing the call light. Resident #6 stated the resident had been hurting and crying out. Resident #6 stated NA C was also rough with her. She had told him she didn't want a man taking care of her and didn't feel comfortable with a man touching her privately, so she had asked him to leave the room and get a woman. Resident #6 stated he left at that time but came back in later. Resident #6 stated she screamed at him and told him to get out and he pulled her depends up really hard and fast. Resident #6 became emotional and started crying and stated, there might be someone that can't stop him like I can. Resident #6 stated she didn't report the incident to anyone that she can remember because it was upsetting. Record review of Resident #7's face sheet, dated 5/15/2021, revealed an [AGE] year-old-female admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #7's quarterly MDS, dated [DATE] revealed a BIMS score of 9 (maximum score 15) which indicated the resident had a moderate cognitive impairment. During an interview on 5/13/2021 at 5:11 p.m. Resident #7 stated NA C got upset with me because I asked for something trivial. I do not really know what I did, but he grabbed my by the shoulders, one hand on each side of her arms and shook me. Resident #7 stated NA C lost his cool really easily. Resident #7 stated she looked at her skin for days and never saw a bruise, so she decided to let it go. Resident #7 stated NA C and CNA D used threats and intimidation on her and indicated the threats were they wouldn't do something for the resident that she needed. CNA D turned off my call light without doing what Resident #7 called her to do and slammed out of the room. CNA D would also refuse to fill the residents water jug. Resident #7 stated her roommate, Resident #6 had been upset about the situation and reported it to someone in therapy. Resident #7 stated she was worried about getting someone in trouble by reporting the incident. During an interview on 5/14/2021 at 1:15 p.m., the Administrator stated she was not aware an any grievance or concern from the Speech Pathologist or anyone else regarding Resident # 6 or Resident #7 prior to surveyor intervention, so she had not investigated and had not suspended or removed any staff from contact with the residents. During an interview on 5/12/201 at 6:34 p.m. the DON stated she had received multiple complaints about CNA A, CNA B, NA C and CNA D. The DON stated these complaints were discussed in morning meetings with the Administrator. The DON further stated she did not feel like any of the resident complaints were abuse. She stated she was trained to report any suspicion of abuse immediately to the Administrator. The DON stated, she communicated frequently throughout the day with the Administrator. During an interview on 5/12/2021 at 7:00 p.m. the Administrator was notified of multiple resident allegations of abuse including abuse to Resident #1, #2, #3, #4, and #5 by CNA A, CNA B, NA C and CNA D. The Administrator denied knowledge of all allegations of abuse. The Administrator stated: - We see so much from Resident #1. He makes false allegations. -Resident #3 has behavior problems. I think she is prejudice. She is one of the 'City Name Locals'. The culture here is different -CNA A and CNA B are my best workers. They are firmer with the residents. They don't baby the residents. -Resident #5 is a [NAME] [NAME] She just wants to lie in her bed and not eat. I see her several times a day. She is being seen by psych for behaviors. I'm sorry but I don't think her complaint has any teeth. Record review of TULIP on 5/13/2021 at 11:00 a.m. revealed the facility had not self-reported any of the allegations of abuse concerning Resident #1, #2. #3, #4, #5, #6, or #7 which were reported to the Administrator on 5/12/2021 or were reported to the Administrator by residents, family members, BOM or staff. During an interview on 5/13/2021 at 12:42 p.m., the Administrator confirmed she did not suspend any staff members and did not investigate any of these allegations of abuse because she they were reported to her as concerns and not abuse. After interviewing multiple residents on the 300-hallway last night, 5/12/2021 she had identified [TRUNCATED]

Based on interview and record review, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 7 of 15 residents (Residents ##1, #2, #3, #4, #5, #6, and #7) reviewed for abuse: The Administrator, who was the facility Abuse Coordinator, failed to incorporate the facility's abuse policies and procedures when: 1. The Administrator failed to identify abuse for Resident's #1, #2, #3, #4, #5, #6, and #7. 2. The Administrator failed to Investigate allegations of abuse and failed to protect Resident's #1, #2, #3, #4, #5, #6, and #7 from abuse when she failed to remove the alleged perpetrators from continued access to the residents. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility still monitoring the effectiveness of the Plan of Removal. These failures resulted in resident abuse, a fear of reporting abuse and a delay in identifying abuse within the facility which caused emotional and psychosocial harm to the residents. The findings were: 1a. Record review of a face sheet for Resident #1, dated [DATE] revealed the resident was a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 1:19 p.m. LVN G stated she learned during change of report (unknown source) that Resident #1 complained that a staff member pulled his hair over the weekend ([DATE]-[DATE]). LVN G stated she reported it to the DON on [DATE]. The DON responded with That's hard to prove, it could have been a joke. During an interview on [DATE] at 5:44 p.m. the DON stated she did not have any knowledge of complaints of abuse or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], LVN G informed her Resident #1 stated CNA B pulled his hair. The DON stated she talked to Resident #1 and he said someone touched his hair. The DON stated several residents had expressed concerns about CNA A and CNA B talking to them loudly and the Administrator had spoken to the two CNA's in her office to talk to them about it. The DON indicated Resident #1 had behaviors and repeated things he heard. During an interview on [DATE] at 2:27 p.m., the Speech Pathologist stated she was standing in the 300-hallway on [DATE] near the therapy area when she heard a someone talking aggressively to Resident #1. The Speech Pathologist looked in the direction of the commotion and witnessed CNA B tell Resident #1 in an aggressive manner to go to his room. The resident stated to CNA B that he did not want to go to his room, so CNA B got in Resident #1's face, yelled at the resident and began moving the resident's wheelchair. She also witnessed CNA B aggressively remove Resident #1's hand from his wheelchair. CNA A was observing from 3 feet away and a MA (unknown) was also in the hallway. CNA B stopped what she was doing when she saw she was being observed. Approximately 10 minutes later CNA A was sitting at the nurse's station and said something to Resident #1. The resident responded with no. CNA A then responded with yes and kept going back and forth with the resident and wouldn't let it go. The Speech Pathologist stated she informed the Administrator when the incident occurred either [DATE] or [DATE] via text. The Administrator called her back within 30 minutes of the notification and stated, Yeah, we have been getting some complaints about CNA B. Thank you for letting me know. The Speech Pathologist stated this incident really shook her. She stated, I have seen and heard harsh voice before, but this was to the point of abuse. The Speech Pathologist stated she had not been interviewed, had not been asked to give a witness statement and had not been asked to give any other details to the witnessed event. Record review of a Provider Investigative Report dated [DATE] after surveyor intervention revealed Resident #1 had confirmed allegations of abuse. During an interview on [DATE] at 1:49 the Administrator stated she should have marked the report as unconfirmed instead of confirmed and indicated confirmed had been marked in error. The Administrator confirmed she had not interviewed the Speech Pathologist about her grievances and witnessed abuse because she didn't feel like it was her responsibility. The Speech Pathologist was a contract worker and the Speech Pathologists manager should be the one to interview her. The Administrator stated the Speech Pathologist was required to report abuse to the Administrator. The Administrator stated she was unable to confirm the allegations of abuse because there were no other witnesses to confirm. 1b. Record review of a face sheet for Resident #2, dated [DATE], revealed a [AGE] year-old-female admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a facility grievance dated [DATE] revealed a family member of Resident #2 called and said Resident #2 needed to be changed since beginning of shift and stated CNA D just turns off light and (unknown staff) promised to change but did not. The Administrator signed the document and dated it as received on [DATE]. The document indicated Resident #2 was unhappy when NA C and CNA D care for her and yells at them to get out of her room. The plan to resolve the grievance was to move Resident #2 to a different hallway. During an interview on [DATE] at 1:41 p.m., Resident #2 stated she moved from the 300 to the 200-hallway because she wanted to get away from CNA C and CNA D. She stated, They are real mean[OBSCENITY] s to me. Resident #2 stated NA C and CNA D also didn't do what they were supposed to do for her. Resident #2 also stated that CNA B was bossy. She stated, she would rather not give any further details because she was afraid of what would happen. Resident #2 stated she had talked to the DON who stated she would take care of it, but nothing improved. Resident #2 stated she had the Administrators cell phone number and tried to reach her without success, so she called her family member and informed them of what had occurred. During an interview on [DATE] at 5:31 p.m. RN N stated Resident #2 complained about not being changed in a 4-hour window and also complained that CNA D was rude (date unknown). RN N stated he had a hard time believing it was true because he had been up and down the hallway and into the resident room and Resident #2 had never said anything to him about it prior. The Resident's family member was upset when he called and spoke to RN N about the concern. RN N stated he notified the Administrator via telephone that Resident #2 had said staff was rude. He stated he didn't know how the Administrator responded. During an interview on [DATE] at 4:13 p.m., the BOM confirmed Resident #2 complained on [DATE] that staff (unknown) kept turning off her call light when she put the call light on without assisting her. The BOM stated the resident's family called and spoke to her and was very upset about the incident, The BOM stated immediately after finishing the conversation with Resident #2 she walked straight from the conversation to the Administrator's office and informed her of Resident #2's concern. The BOM stated the Administrator responded by stating, Resident #2 isn't happy about a lot of things. The BOM stated to the Administrator who was the Abuse Coordinator, I know, but I feel like we have to do something. During an interview on [DATE] at 1:18 p.m., the Administrator stated an example of abuse/neglect was staff not answering a call light or turning it off without attending to the resident leaving them soiled. The Administrator stated RN G called her at home and stated Resident #2 was not soiled (unknown date and unknown time). The Administrator confirmed she also spoke with Resident #2's family member (unknown date and unknown time) who was really upset about the resident being soiled and call lights turned off. The Administrator explained to the family member that staff would change Resident #2 immediately. The Administrator stated knowing that RN G had been in the resident room and the resident was just waiting for a CNA to finish with another resident she did not consider the grievance and complaint as neglect. The Administrator stated she felt like Resident #3 tended to exaggerate. The Administrator stated she wanted to see if what the resident reported was true and stated I do not want to call her a liar, but she sees things differently. I do not have staff here who would ignore a resident. The Administrator stated she had Resident #2 moved to a different hallway away from NA C and CNA D and Resident #2 was content on the new hallway. The Administrator stated Resident #2's behaviors were much better on the new hallway. When asked why she thought Resident #2's behaviors would improve on a new hallway away from NA C and CNA D? The Administrator stated that the new staff baby Resident #2 more. Their voices were not so stern. The Administrator confirmed she herself would not want to be spoken to in such a manner, with a stern voice. The Administrator stated she did not take written statements, or interview other staff who might have observed the incident or other residents because the resident didn't say she felt like she had any harm and the problem had been resolved as a grievance. 1c. Record review of a face sheet for Resident #3, dated [DATE], revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 10:55 a.m. on the 300-hallway with Resident #3 who stated CNA A had been rough with care since she made a complaint about CNA A's mother, CNA B. Resident #3 stated, CNA A would not get me out of bed when asked for assistance and stated, If you push the button (call light) and nobody comes, you know why. Resident #3 stated she did not want to talk about the complaint against CNA B because she had already caused enough trouble by making the complaint. The resident became emotional with tears and added, I cannot do anything to suit, CNA B. She constantly takes the little blanket off my feet and puts the blanket where I can't reach it. She says I am freezing out my roommate (with the air-conditioning). She takes my (food) tray away before I am done with my food. CNA B asked me if I am finished (with the food) but I know better than to say no. She will take my food anyway. Since they (unknown) talked to CNA B, I get attitude from CNA A. I feel terrorized. CNA B is always yelling. I jump when I hear any loud noise because I am scared it's her. When asked if she felt safe, Resident #3 stated, I know there will be pain. I want to ask for someone else (to provide care) but I am afraid If I say anything I won't get changed and I will have to sit in my own waste. Resident #3 she had reported her concerns to LVN G and had talked to the DON about them. During an interview on [DATE] at 2:29 p.m., the Administrator confirmed she was previously aware and had been informed that Resident #3 was upset that CNA B told her to cut off her leg. She stated she did not know who informed her or when she was informed. The Administrator stated when she spoke to Resident #3, she reminded the resident that she herself makes comments about her leg and plays around with talking about her leg and the resident responded with Yeah, but I wasn't playing that day. It is not funny, and I do not want to play like that. The Administrator asked Resident #3 again if she thought CNA B was mean or joking and the resident replied joking. She asked Resident #3 if she felt unsafe and the resident replied no. The Administrator confirmed she did not suspend CNA B from work or remove her from resident care and did not perform an investigation because the resident was fine with the incident and understood it was a joke. The Administrator stated Resident #3 never used the word abuse and didn't indicate she was harmed. The Administrator stated based on her conversation with Resident #3 she did not feel like there was any abuse. During an interview on [DATE] at 2:27 p.m., the Speech Pathologist stated several residents had complained about CNA A, CNA B and NA C. Specifically, Resident #3 complained that CNA A and CNA B had complained about the residents bowel movements and stated, this is [OBSCENITY] ing bullshit, I am tired of this. The Speech Pathologist stated she filled out a grievance form and listed the resident as anonymous to try to protect the resident. The Speech Pathologist stated she signed her own name on the grievance and handed the grievance to the Administrator personally on [DATE]. The Administrator stated Thank you at the time she turned it in. The Administrator later called her back into the office and stated she needed the name of the resident. The Speech Pathologist identified Resident #3. The Administrator responded with, Okay, I just needed to know because I need to filter them because sometimes certain residents fill out a lot of grievance papers. The Speech Pathologist stated she was never asked to give any additional information other than what was written on the grievance and when she was asked to identify the resident. The Speech Pathologist stated she was not asked to write a written statement and had not been interviewed. Record review of a text message from the Rehabilitation Director and the Speech Pathologist dated [DATE] at 4:30 p.m., that read Administrator wanted to talk to you about a grievance. During an interview on [DATE] at 1:15 p.m., the Administrator stated she was not aware of any grievance from the Speech Pathologist or anyone else regarding CNA A and CNA B abusing or mistreating Resident #3 prior to surveyor intervention. The Administrator stated she had never received any grievances from the Speech Pathologist. Record review of a Provider Investigative Report dated [DATE] after surveyor intervention for Resident #3 revealed the Administrator had unconfirmed the allegation of abuse. During an interview with the Administrator on [DATE] at 1:54 p.m. the Administrator stated the DON had completed a grievance at the time it occurred, but LVN G brought it back up because Resident #3 commented to her the comment hurt her feelings. The Administrator stated the resident had moods and gets depressed, thinks about the comment and then gets depressed again. The Administrator stated she couldn't make a judgement for Resident #3, but the resident stated she didn't feel abused and that is why she unconfirmed abuse. The Administrator confirmed the facility abuse policy indicated someone didn't have to use the word abuse and it could absolutely still be abuse. Record review of a facility grievance, dated [DATE] revealed Resident #3 voiced to nurse, LVN G that CNA B had made {an} ugly comment about her leg not working and that she should just chop it off. The grievance was made and signed by the DON who assigned the investigation to herself on [DATE]. The DON signed off on the grievance as resolved on [DATE]. 1d. Record review of Resident #4's face sheet, dated [DATE] revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 10:50 a.m. on the 300-hallway, with Resident #4 stated two morning female staff members, identified as mother and daughter, CNA A and CNA B (also identified by description), were rough when they provided care (unknown dates and times). Resident #4 stated she had asked the two CNA's to slow down and be careful, but she received no verbal response to her request. Resident #4 stated she had not told anyone because she was afraid to say anything. During an interview on [DATE] at 2:34 p.m., the Administrator stated after receiving information from this surveyor that Resident #4 had stated CNA A and CNA B were rough with care, she interviewed Resident #4. The Administrator stated during the interview Resident #4 did not use the word rough. Resident #4 said the CNA's were fast. The Administrator stated, when she asked her if she felt safe, she said yes, CNA A and CNA B just need to slow down. The Administrator stated since the Resident did not use the word rough during the interview, she didn't think there was any abuse and did not investigate further. Record review of a Provider Investigative Report dated [DATE] after surveyor intervention for Resident #4 revealed: Investigative summary unconfirmed. A Review of the supporting documents revealed the facility Administrator had not included any interviews that were negative from any of the residents or staff members whom had indicated concerns about resident treatment. During an interview with the Administrator on [DATE] at 2:01 p.m. the Administrator stated there was no evidence of abuse to Resident #4. The Administrator confirmed none of the interviews with residents who stated staff were rough and rude were included in the investigative packet. The Administrator stated those interviews were considered but were not part of the investigation 1e. Record review of Resident #5's face sheet, dated [DATE] revealed a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 10:34 a.m. on the 300-hallway Resident #5 stated she didn't like living at the nursing facility and didn't feel safe. She stated NA C was rough with me and he hurts my roommate, Resident #16 when providing care (unknown date and time). Resident #5 stated Resident #16 cried out like she was being hurt when NA C was taking care of her. She also stated staff (refused to give names) said she was fat when providing care and that makes her feel bad. Resident #5 stated she had talked to the DON at one time about the rough care but did not remember when this conversation occurred. She stated the DON stated because she was fat, the care may be rough which in turn made the resident feel bad. The resident stated she was afraid of getting in trouble for talking to this surveyor and turned her head to the side and refused to answer further questions. During an interview on [DATE] at 2:34 p.m., the Administrator confirmed she did not thoroughly investigate Resident #5's concerns because when she interviewed Resident #5 the resident stated she felt safe now. The Administrator stated although Resident #5 indicated NA C was rough with her roommate, Resident #16, the Administrator did not feel like there was any abuse. The Administrator stated the resident gave her a blank stare and then eventually stated CNA A was rough with her roommate. Resident #5 stated the roommate said ow and no during care by CNA A. The Administrator confirmed the roommate was not interviewable due to cognitive status, but sometimes is able to answer simple questions. The Administrator stated she asked the roommate if she felt safe and she responded with oh yeah. The Administrator stated she told Resident #5 to come to her for any concerns. Record review of a Provider Investigative Report dated [DATE] after surveyor intervention revealed Resident #5 had confirmed allegations of abuse. During an interview on [DATE] at 1:49 the Administrator stated she should have marked the report as unconfirmed instead of confirmed and indicated confirmed had been marked in error. The Administrator stated she was unable to confirm the allegations of abuse because there were no witnesses to confirm abuse. 1f. Record review of Resident #6's face sheet, dated [DATE], revealed an [AGE] year-old-female, admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 2:27 p.m., the Speech Pathologist stated Resident #6 was in tears on Monday [DATE]. Resident #6 stated that the weekend had been terrible because staff had been ignoring call lights, when the staff would come, she would ask for assistance and the staff would never come back. Resident #6 stated she needed help in the bathroom and NA C came into her room. Resident #6 reported that she screamed at him to get out because she didn't want NA C to take care of her because he was male and because he shook her roommate Resident #7 right before Resident #7 had to go to the hospital. Resident #6 informed the Speech Pathologist she didn't tell anyone about the incident because she wasn't comfortable reporting it. The Speech Pathologist stated she had filled out a grievance which she had previously been instructed to do and on [DATE] put it directly on top of the Administrator's desk. The Speech Pathologist stated the Administrator did not follow up with any questions. During an interview on [DATE] at 4:43 p.m., Resident #6 stated NA C came into their room and shook her roommate Resident #7 with his hands because Resident #7 kept pressing the call light. Resident #6 stated the resident had been hurting and crying out. Resident #6 stated NA C was also rough with her. She had told him she didn't want a man taking care of her and didn't feel comfortable with a man touching her privately, so she had asked him to leave the room and get a woman. Resident #6 stated he left at that time but came back in later. Resident #6 stated she screamed at him and told him to get out and he pulled her depends up really hard and fast. Resident #6 became emotional and started crying and stated, there might be someone that can't stop him like I can. Resident #6 stated she didn't report the incident to anyone that she can remember because it was upsetting. Record review of Resident #7's face sheet, dated [DATE], revealed an [AGE] year-old-female admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 5:11 p.m. Resident #7 stated NA C got upset with me because I asked for something trivial. I do not really know what I did, but he grabbed me by the shoulders, one hand on each side of her arms and shook me. Resident #7 stated NA C lost his cool really easily. Resident #7 stated she looked at her skin for days and never saw a bruise, so she decided to let it go. Resident #7 stated NA C and CNA D used threats and intimidation on her and indicated the threats were they wouldn't do something for the resident that she needed. Resident #7 stated, CNA D turned off her call light without doing what Resident #7 asked the CNA to do and then exited the room the room aggressively. CNA D also refused to fill the residents water jug. Resident #7 stated her roommate, Resident #6, had been upset about the situation and reported it to someone in therapy. Resident #7 stated she was worried about getting someone in trouble by reporting the incident. During an interview on [DATE] at 1:15 p.m., the Administrator stated she was not aware an any grievance or concern from the Speech Pathologist or anyone else regarding Resident # 6 or Resident #7 prior to surveyor intervention. Record review of a Provider Investigative Report dated [DATE] after surveyor intervention revealed Resident #7 had confirmed allegations of abuse. During an interview on [DATE] at 1:49 the Administrator stated she should have marked the report as unconfirmed instead of confirmed and indicated confirmed had been marked in error. The Administrator stated she was unable to confirm the allegations of abuse because there were no witnesses to confirm abuse. Record review of a facility grievance created after surveyor intervention and dated [DATE] after and resolved by the Administrator on [DATE] revealed there was a facility complaint Residents down the 300-hall. The findings of the investigation revealed [Staff] need more training on customer service and take more time with each resident when caring for them/tone of voice/compassionate care. The Administrator and DON will in-service and provide education and ask the Ombudsman for culture sensitivity {training} for residents. Coach {staff} on care and spot check monitor. 1 on 1 education for CNA A and NA C. Resident's #3, #4 and #5 all expressed they are fine with CNA A, CNA B and NA C providing care and feel safe. During an interview on [DATE] at 12:45 p.m. an anonymous resident stated there were 4 aides, identified as CNA A, CNA B, NA C and CNA D in the facility who yell and say nasty things. The Resident stated he/she had witnessed CNA C get frustrated and lose his cool and lift a resident (unknown) too hard. Normally NA A was a gentle person but became frustrated when his mother CNA D made him do most of the work. CNA D does not change the residents when they needed changing. CNA A and CNA are mean and rough. They shout and they make the residents jump when they are working. The Resident stated he/she had told CNA A and CNA B not to be so mean to people. CNA B said something bad back. CNA A and CNA B called the residents stupid, especially Resident #4. They took all their frustrations out on Resident #4. CNA A and CNA B team up and pick on Resident #1 and say mean and ugly things to him. One time, Resident #15 was crying because his wife had just died and accidentally soiled himself. CNA A and CNA B got mad at him. I can tell they are mad because of the tone of voice they use when they talk, and they say bad words in Spanish which he/she was able to understand. They jerk residents around and are not very discreet about it. The anonymous resident stated many residents complain about the treatment they receive in the shower room from CNA A and CNA B. Some of the residents are afraid to shower. The Resident stated he/she had told three different nurses (unknown names) and nobody had done anything to help. I don't bother talking to the DON any longer because she says everything is fine and makes excuses and says it's because of the staffing shortage. I told the Administrator in [DATE], she talked to CNA D, but things are still the same. The Resident stated, Sometimes I just cry. It feels hopeless. These people shouldn't be treated like this. The Resident stated it was very important for this surveyor to keep his/her identify anonymous because they were afraid. During an interview on [DATE] at 6:34 p.m. the DON stated she had received multiple complaints about CNA A, CNA B, NA C and CNA D (unknown dates and times). The DON stated these complaints were discussed in morning meetings with the Administrator. The DON further stated she did not feel like any of the resident complaints were abuse. She stated she was trained to report any suspicious of abuse immediately to the Administrator. The DON stated, she communicated frequently throughout the day with the Administrator. During an interview on [DATE] at 7:00 p.m. the Administrator was notified of multiple resident allegations of abuse including abuse to Resident #1, #2, #3, #4, and #5 by CNA A, CNA B, NA C and CNA D. The Administrator denied knowledge of all allegations of abuse. The Administrator stated: - We see so much from Resident #1. He makes false allegations. -Resident #3 has behavior problems. I think she is prejudice. She is one of the 'City Name Locals'. The culture here is different -CNA A and CNA B are my best workers. They are firmer with the residents. They don't baby the residents. -Resident #5 is a [NAME] [NAME] She just wants to lie in her bed and not eat. I see her several times a day. She is being seen by psych for behaviors. I'm sorry but I don't think her complaint has any teeth. During an interview on [DATE] at 11:25 a.m., the DON stated she had received complaints about CNA A, CNA B, NA C and CNA D, The DON stated she doesn't remember who made the complaints or the specifics of the complaints and does not keep a log. She stated never was the word abuse or disrespect used when she received a report about other staff. The DON stated she communicated with the Administrator verbally and via text daily throughout the day. The DON stated she tells the Administrator everything and they discuss issues and concerns. During an interview on [DATE] at 12:40 p.m. the Administrator confirmed she was the Abuse Coordinator and stated a grievance is something that can be fixed and did not cause harm. An allegation is something that caused harm or is not right. An incident that needs to be reported is intentional. Abuse is intentional. Neglect is intentional. The Administrator stated she follows the facility abuse policy. When she received an allegation of abuse/neglect or exploitation she immediately performs an investigation of the allegation. She stated if the investigation is very clear and there are witnesses and everything matches up then it shows her the results and she documents everything. The Administrator stated none of these allegations were abuse. 2a. During an interview on [DATE] at 2:27 p.m., the Speech Pathologist stated she was standing in the 300-hallway on [DATE] near the therapy area when she heard a someone talking aggressively to Resident #1. The Speech Pathologist looked in the direction of the commotion and witnessed CNA B tell Resident #1 in an aggressive manner to go to his room. The resident stated to CNA B that he did not want to go to his room, so CNA B got in Resident #1's face, yelled at the resident and began moving the resident's wheelchair. She also witnessed CNA B aggressively remove Resident #1's hand from his wheelchair. CNA A was observing from 3 feet away and a MA (unknown) was also in the hallway. CNA B stopped what she was doing when she saw she was being observed. Approximately 10 minutes later CNA A was sitting at the nurse's station and said something to Resident #1. The resident responded with no. CNA A then responded with yes and kept going back and forth with the resident and wouldn't let it go. The Speech Pathologist stated she informed the Administrator when the incident occurred either [DATE] or [DATE] via text. The Administrator called her back within 30 minutes of the notification and stated, Yeah, we have been getting some complaints about CNA B. Thank you for letting me know. The Speech Pathologist stated this incident really shook her. She stated, I have seen and heard harsh voice before, but this was to the point of abuse. The Speech Pathologist stated she had not been interviewed, had not been asked to give a witness statement and had not been asked to give any other details to the witnessed event. Record review of a text message dated Sunday, [DATE] between the Speech Pathologist to the Administrator revealed a message that read: Hi, Administrator! Sorry to bother you today, but if you have a moment, I'd like to talk to you about something I saw today at the facility. There [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure that the resident had the right to be free from neglect for 2 residents (Residents # 2 and 4) of 9 residents reviewed for neglect related to falls. The facility failed to provide services to prevent harm when they: 1.) Failed to implement individualized interventions after Resident # 2's 19 falls over 11 months. Resident # 2 sustained a fall on 1/24/2017. The resident was transferred to a local hospital on [DATE] where she was diagnosed with [REDACTED]. 2.) Failed to implement appropriate individualized interventions for Resident # 4 to prevent further falls. Resident # 4 sustained 6 falls within a 4 month period. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 3/17/17. While the IJ was removed on 3/20/16, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. This deficient practice placed 35 residents with a history of falls at risk for future falls and could result in injury or death. The findings were: 1. Record review of Resident #2's Face Sheet dated 03/15/17, revealed Resident #2 was admitted to the facility on [DATE] and was readmitted on [DATE] and 01/29/2017 with the [DIAGNOSES REDACTED]. Record review of Resident #2's Fall Risk Evaluation (FRE) dated 02/6/17 revealed a score of 28 where a resident who scored a 10 or higher was at risk for falls. Record review of Resident #2's Comprehensive Annual Minimum Data Set ((MDS) dated [DATE], Brief Interview for Mental Status (BIMS) score of 7 (where 0-7 is severely impaired), Comprehensive, Annual MDS dated [DATE] (date of [MEDICAL CONDITION]) BIMS score of 4, Comprehensive, Significant Change MDS dated [DATE], BIMS score of 5 and a Quarterly MDS dated [DATE], BIMS score of 3. Record review of Resident #2's Comprehensive Annual Minimum Data Set ((MDS) dated [DATE], Activities of Daily Living (ADL) score of 7 (where 0-7 is severely impaired), Comprehensive, Annual MDS dated [DATE] (date of [MEDICAL CONDITION]) BIMS score of 4, Comprehensive, Significant Change MDS dated [DATE], BIMS score of 5 and a Quarterly MDS dated [DATE], BIMS score of 3. During an interview on 03/14/17 at 10:15 a.m., with LVN O revealed Resident #2 was not interviewable, had a [DIAGNOSES REDACTED]. Record review of Resident #2's Care Plan dated 3/15/17 revealed that she fell on [DATE] and 11/27/17 and the intervention included re-education. Care Plan Problem: I have had a history of [REDACTED]. 12/4/16 acute fall in facility had been toileted prior to this. Had an actual fall on 1/24 trying to stand and fell , moved resident to common area. 2/6/17 actual fall witnessed by employee going down the hall and fell forward, educated staff on proper transferring. Care Plan Goals: My number of falls will be reduced through next review date. Target date 5/24/17 Care Plan Interventions: Toileting q 2 hrs (. or PRN, keep in common area while awake for close observation, non-skid socks at all times, anti-roll back to wheelchair, drop wheelchair to aid in positioning, incontinent care program to attempt to decrease falls, toilet resident to assist to bed, after each fall episode evaluate current interventions and modify interventions according to IDT recommendations. Notify MD/NP and RP of fall and resulting assessment and interventions, complete fall documentation packet per facility protocol, for fall unobserved by staff or fall with potential/actual injury to the head, initiate neuro checks per protocol, monitor for changes in condition, document and report to MD/NP swelling, pain, lethargy, abnormal neural vital signs, change in functional ability, such as endurance, transfer, ambulation, etc .Document every shift for every 72 hours, the results of the targeted assessment related to the fall including pain. Standard of care in place unless otherwise noted: bed in low and locked position, call light within reach, personal items and fluids close at hand, clear clean pathways, and uncluttered surroundings, nightlight on/adequate lighting. Observation of Resident #2 on 03/14/17 at 3:30 p.m. revealed the resident was in bed, unable to answer questions. Resident seemed confused, unable to verbalize if she had eaten lunch. Record review of the facility's Fall Investigation included a Fall Worksheet and Fall Investigation Worksheet from 03/27/16 to 02/06/17 revealed Resident #2 had fallen a total of 21 times. The Fall Reports revealed the following: (1) 03/27/16 at 1:45 a.m., Resident #2 had an unwitnessed fall, fell face first sustaining a laceration to the bridge of her nose. She was reported to be alert. Intervention: Resident #2 to wear non-skid socks. Record Review of Resident #2's Fall Investigation Worksheet dated 03/27/16 revealed the resident did not have Episodes of Sundowning checked off and indicated that the resident required supervision. In the section entitled Number of falls, the facility reported 1+ falls in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 03/27/16 revealed the FSW, Section entitled: Nurse Manager Completes section 16-22, which addressed: If resident was placed on falling star program, was placed on Incident/Accident Log, Update Individual Fall Record, Care Plan updated, Rehabilitation screen, Medications reviewed, was not completed and/or signed. During an interview on 3/20/17 at 7:20 p.m., the Administrator confirmed the Fall Report was not fully completed (DON or the Nurse Manager did not fill out or sign the report). The Administrator also stated, she only knew what was on the report. (2) 04/25/16 at 5:00 p.m., Resident #2 fell , unwitnessed and found lying on the floor, noted to be confused. No injury noted. Intervention: Resident #2 was wheeled closer to the nursing station. Resident #2 has a FRE score of 22. Record Review of Resident's #2's Fall Investigation Worksheet dated 04/25/16 revealed it did not have Sundowning checked off, resident had Cognitive Impairment checked off and the section for number falls in the past 30 days and number of falls in the past 31 to 180 days was not filled out, however there was 1 documented fall in the past 30 days. Record Review of Resident #2's Fall Worksheet dated 04/25/16 revealed it did not have the Nurse Managers section completed or signed. (3) 04/26/16 at 3:45 p.m., Resident #2 fell unwitnessed, found lying on the floor next to nursing station, confused. Bruising to left and right elbow and red area noted to lower back. Intervention: Therapy evaluation for wheelchair, possible drop seat. Offer food, drinks, water, toileting and pain medications Record Review of Resident #2's Fall Investigation Worksheet dated 04/26/16 did not have Episodes of Sundowning checked off, resident had Cognitive Impairment, Anxiety Disorder, [MEDICAL CONDITION] and [MEDICAL CONDITION] marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 2 falls documented in the past 30 days. Record Review of Resident #2's Fall Worksheet dated 04/26/16 did not have the Nurse Managers section completed or signed. (4) 04/28/2016 at 9:30 p.m., Resident #2 was witnessed, slipping off bed with her pants down, confused with BM stains noted. No injury noted. Intervention: Resident to be toileted every two hours. Residents #2's FRE 24. Record Review of Resident #2's Fall Investigation Worksheet dated 04/28/16 did not have Episodes of Sundowning checked off, resident had Cognitive Impairment, Anxiety Disorder, [MEDICAL CONDITION] and [MEDICAL CONDITION] marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 3 falls documented in the past 30 days. Record Review of Resident #2's Fall Worksheet dated 04/28/16 did not have the Nurse Managers section completed or signed. Interview on 3/17/17 at 2:20 pm., Upon request of toileting documentation, the DON did not provide the requested documentation, and stated none was available. The DON revealed the resident was not being toileted according to her interventions. (5) 04/29/16 at 9:00 p.m., Resident #2 fell unwitnessed, off her wheelchair, found lying on the floor, noted to be alert/confused. No injuries noted. Residents #2's FRE 24, neuromuscular weakness noted. Intervention: Toilet resident more frequently, tilt wheelchair, place resident infront of nursing station. Record Review of Resident #2's Nurses Progress Notes dated 04/29/16 (no time noted), revealed resident had a head contusion. Record Review of Resident #2's Fall Investigation Worksheet dated 04/29/16 did not have Episodes of Sundowning checked off, resident had Cognitive Impairment, Anxiety Disorder and [MEDICAL CONDITION] marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 3 falls documented in the past 30 days and 1 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 04/29/16 did not have the Nurse Managers section completed or signed. (6) 05/04/2016 at 4:00 p.m., Resident #2 fell unwitnessed, found lying on the floor, confused with her wheelchair behind her, noted resident trying to sit in her wheelchair. No injuries noted. FRE 29. Intervention: Hydration aide asked to supervise resident, ambulate resident once every shift using gait belt with wheelchair behind her. Record Review of Resident #2's Nurses Progress notes dated 05/04/16 (no time noted) revealed, the resident was unable to voice her needs or wants and unable to follow commands. Record Review of Resident #2's Fall Investigation Worksheet dated 05/04/16 did not have Episodes of Sundowning checked off, Dementia was listed as a diagnosis. Cognitive Impairment, Anxiety Disorder and [MEDICAL CONDITION] were marked off. The section for number of falls in the past 30 days indicated there were 5 to 10 falls and number of falls in the past 31 to 180 days was not filled out, however there was 4 falls documented in the past 30 days and 1 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 05/04/16 did not have the Nurse Managers section completed or signed. (7) 06/10/16 at 11:00 a.m., Resident #2 fell unwitnessed (noted) , seen trying to get out of wheelchair, resident fell on her buttocks, noted to be confused. Resident was noted wearing her non-skid socks. Resident # 2 noted trying to get something to drink. No injuries noted. Intervention: Provide resident with shoes. Review of Resident #2's Incident/Action Plan (IAAP) dated 06/10/16 the following was on a toileting program, Rehab/Restorative and Behavioral program. Record Review of Resident #2's Fall Investigation Worksheet dated 06/10/16 did not have Episodes of Sundowning checked off, Dementia was listed as a diagnosis. Cognitive Impairment and Anxiety Disorder was marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 5 falls documented in the past 30 days and 1 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 06/10/16 did not have the Nurse Managers section completed or signed. (8) 07/11/16 at 6:00 p.m., Resident #2 (unwitnessed fall) was reported to be self toileting, missed the toilet seat and landed on her buttocks, was wearing her non-skid socks, noted to be alert. No injuries noted. Intervention: Already on every two hour toileting, resident educated on, when I get out of my wheelchair and attempt ambulation, I will be taken to the bathroom to see is that meets my need. Resident toileted and showered. Review of Resident #2's Incident/Action Plan (IAAP) dated 07/11/16 the following were not applicable (NA): the toileting program, Rehab/Restorative and Behavioral program. Record Review of Resident's #2's Fall Investigation Worksheet dated 07/11/16 did not have Episodes of Sundowning checked off, Dementia was listed as a diagnosis. Cognitive Impairment, Delerium and [MEDICAL CONDITION] were marked off. The section for number of falls indicated there were 2 falls in the past 30 days and number of falls in the past 31 to 180 days was not filled out, however there was 1 fall documented in the past 30 days and 6 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 07/11/16 did not have the Nurse Managers section completed or signed. (9) 07/27/16 at 1:50 p.m., Resident #2 was witnessed as she stood up from wheelchair and it slipped underneath her, resident grabbed side door and went down, noted to be alert and oriented to person (x1). No injuries noted. Pain Assessment (PA) score 2. Intervention: Non-skid socks at all times, reminders to lock wheel chair during transfers. Review of Resident #2's Incident/Action Plan (IAAP) dated 07/27/16 was blank. Record Review of Resident #2 Fall Investigation Worksheet dated 07/27/16 did not have Episodes of Sundowning checked off. Cognitive Impairment, Delerium and [MEDICAL CONDITION] were marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 1 fall documented in the past 30 days and 7 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 07/27/16 did not have the Nurse Managers section completed or signed. (10) 09/13/2016 at 9:00 p.m., Resident #2 has an unwitnessed fall, was found lying flat on her back in front of wheelchair. She was noted to be confused and sustained a superficial scratch to her right-middle back to left scapula measuring 8 cm by 3.5 cm. Intervention: Non-skid socks at all times, leave door to room open/cracked while resident is in there. Review of Resident #2's Incident/Action Plan (IAAP) dated 09/13/16 was blank. Record Review of Resident #2's Nurses Progress Note dated 09/13/16 at 1:10 p.m., revealed resident bumped head against breakroom door, while walking through doorway from dining room into breakroom. Record Review of Resident #2's Fall Investigation Worksheet dated 09/13/16 did not have Episodes of Sundowning checked off. Anxiety Disorders was marked off. Resident was described as restless, combative, having Dementia with behavioral disturbances and Cognitive communication deficient and requiring supervision. The section for number of falls indicated there was 2 falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there were 0 falls documented in the past 30 days and 9 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 09/13/16 did not have the Nurse Managers section completed or signed. (11) 11/08/2016 at 2:45 p.m., Resident #2 was witnessed slipping down against a wall during a one person assist while toileting. Resident was noted to be confused and sustained a superficial scratch to her back while sliding down wall with the toilet paper holder. FRE 17, PA 2. Intervention: Continue to monitor resident. Review of Resident #2's Incident/Action Plan (IAAP) dated 11/8/16 revealed the resident was on a toileting program. Record Review of Resident's #2 Fall Investigation Worksheet dated 11/08/16 did not have Episodes of Sundowning checked off. Anxiety Disorders and Cognitive Impairment were marked off. A [DIAGNOSES REDACTED]. The section for number of falls indicated there were 1 fall in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 0 falls documented in the past 30 days and 10 fall in the past 31 to 180 days. (12) 11/15/16 at 7:15 p.m., Resident #2 had an unwitnessed fall was found confused and lying on her right side by lobby, resident reported attempting to walk. resident sustained [REDACTED]. Her PA was reported at a 0. Intervention: Ice pack to forehead, toileting, bladder training program. Review of Resident #2's Incident/Action Plan (IAAP) dated 11/15/16 revealed the resident was not on a toileting program. Record Review of Resident #2's Fall Investigation Worksheet dated 11/15/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment, [MEDICAL CONDITION] and [MEDICAL CONDITION] were marked off. Resident was noted as requiring supervision. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 1 falls documented in the past 30 days and 10 fall in the past 31 to 180 days. (13) 12/04/16 at 8:50 p.m., Resident #2 had an unwitnessed fall, found confused, on the floor lying on her right side at end of bed, facing the bed with BM in her brief. Resident attempting to self-toilet. FRE 26, PA 1. Intervention: two person assist for all Activities of Daily Living (ADL's). Recommendation: a Stool C & S, [MEDICAL CONDITION] labs ordered. Record Review of Resident #2's Nurses Progress notes dated 12/04/16 at 9:50 p.m., revealed, the resident has increased confusion and the resident was unable to focus on nurse for a long time Review of Resident #2's Incident/Action Plan (IAAP) dated 12/04/16 was not completed. Note at 10:20 pm noted resident with increased confusion. Record Review of Resident #2's Fall Investigation Worksheet dated 12/04/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment, Alzheimer's and Depression were marked off. Resident was described as having increased confusion with weakness and requiring supervision. The section for number of falls indicated there was 2 falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there were 2 falls documented in the past 30 days and 10 fall in the past 31 to 180 days. Record Review of Resident's #2 Fall Worksheet dated 12/04/16 did not have the Nurse Managers section completed or signed. (14) 12/10/16 at 11:45 a.m., Resident #2 had an unwitnessed fall was found confused, lying on her right side, next to her wheelchair in the dining room. No injuries or pain noted. FRE 18. Intervention: Resident reminded not to get up out of chair (resident with Dementia), Remind aides to always put on non-skid socks and shoes at all times. Record Review of Resident #2's Nurses Progress notes dated 12/10/16 at 11:45 a.m., revealed, the resident was reminded not to get out of her chair without help. Review of Resident #2's Incident/Action Plan (IAAP) dated 12/10/16 revealed the resident was not on a toileting program, Rehab/Restorative or Behavioral program or had any safety precautions or devices. Record Review of Resident's #2 Fall Investigation Worksheet dated 12/10/16 did not have Episodes of Sundowning checked off. Cognitive Impairment was marked off. The section for number of falls indicated there was 1 fall in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 4 falls documented in the past 30 days and 9 fall in the past 31 to 180 days. Record Review of Resident's #2 Fall Worksheet dated 12/10/16 did not have the Nurse Managers section completed or signed. (15) 12/18/16 at 9:35 p.m., Resident #2 had an unwitnessed fall, found confused, on the floor against the wall across from the bathroom sitting up with back and head against the wall. No injuries noted. FRE 20, PA 2. Intervention: Toileting every two hours as needed, informed resident on the use of the call light with demonstration. Resident noted to have verbalized understanding. Review of Resident #2's Incident/Action Plan (IAAP) dated 12/18/16 revealed the resident was not on a toileting program, Rehab/Restorative or Behavioral program. Record Review of Resident #2's Nurses Progress notes dated 12/18/16 at 9:35 p.m., revealed resident was alert and oriented to person. Record Review of Resident #2's Fall Investigation Worksheet dated 12/18/16 did not have Episodes of Sundowning checked off. Anxiety Disorders was marked off and a [DIAGNOSES REDACTED]. Resident was described as requiring supervision. The section for number of falls indicated there were 3 falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 2 falls documented in the past 30 days and 12 fall in the past 31 to 180 days. Record Review of Resident's #2 Fall Worksheet dated 12/04/16 did not have the Nurse Managers section completed or signed. (16) 12/28/16 at 11:30 p.m., Resident #2 had an unwitnessed fall, she was found confused and sitting on the floor beside the bed (in low position, with wheels locked). FRE 20, PA 2. Intervention: Resident to wear non-skid socks when in bed, room to be clutter free, staff to check resident frequently. Review of Resident #2's Incident/Action Plan (IAAP) dated 12/28/16 revealed the resident was on a toileting program. It also revealed she was not on a Rehab/Restorative or Behavioral program. Record Review of Resident #2's Fall Investigation Worksheet dated 12/28/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment were marked off. Resident had a Dementia [DIAGNOSES REDACTED]. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 3 falls documented in the past 30 days and 12 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 12/28/16 did not have the Nurse Managers section completed or signed. (17) 12/30/16 at 10:00 p.m., Resident #2 had an unwitnessed fall, reportedly fell out of bed and hit her head on the edge of her night stand. Resident noted to be alert and sustained a head injury, bump and scrape to forehead. Intervention: Encourage the use of the call light when in need of assistance. Review of Resident #2's Incident/Action Plan (IAAP) dated 12/30/16 revealed the resident was on a toileting program. Record Review of Resident #2's Fall Investigation Worksheet dated 12/30/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment and Delerium were marked off. The section for number of falls indicated there were 2 falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 4 falls documented in the past 30 days and 12 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 12/30/16 did not have the Nurse Managers section completed or signed. (18) 12/31/16 at 6:40 p.m., Resident #2 had an unwitnessed fall reported to have fallen attempting to self-transfer to the toilet in the bathroom and hit her head on the bathroom cabinet. Resident noted as confused and sustained a head injury, abrasion to the back of her head and scalp. PA 4. Intervention: Moved to common area for close observations, and one to one monitoring and hourly rounding while in bed (marked out and note not appropriate). During an interview on 3/17/17 at 2:20 p.m., the DON revealed the reason for changing the intervention from one on one monitoring to moving resident to the common area was due to the staff were unable to sustain the intervention. Record Review of Resident #2's Nurses Progress notes dated 12/31/16 at 6:45 a.m., revealed the resident's pupils were sluggish to respond to light with speech slightly slurred. A large bluish discoloration and bump measuring approximately 4 cm by 4 cm to forehead. Resident was transported to the ER at 7:30 a.m. Record Review of Resident #2's Fall Investigation Worksheet dated 12/31/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment and Delerium were marked off and Dementia was indicated as a diagnosis. Resident was described as requiring supervision. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 6 falls documented in the past 30 days and 12 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 12/31/16 did not have the Nurse Managers section completed or signed. (19) 01/01/17 at 9:40 p.m., Resident #2, unwitnessed fall, found lying confused on her back, beside bed with the wheelchair leaned forward on top of her. No injuries noted. Intervention: One to one monitoring and hourly rounding while in bed (marked out and note not appropriate), Moved to nursing station and other common areas for close observation. Record Review of Resident #2's Fall Investigation Worksheet dated 01/01/17 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment and Delerium were marked off. Resident was described as requiring supervision. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out. (20) 01/24/16 at 3:00 p.m., Resident #2 sustained an unwitnessed fall. She was reported to be sitting in her wheelchair when she attempted to stand up and fell to the right side. Resident reported to be alert and oriented to person, with a PA 10 and FRE 20. Intervention: Ice pack to forehead, toileting. Provider Investigation Report for Resident# 2 revealed there were two nurses at the nursing station during the time of her fall, neither nurse witnessed the fall. Physician Assistant was in the premises and evaluated the resident. Resident noted to have facial grimacing when transferred to a chair. On 1/24/17, a right X-ray was ordered, along with knee X-ray, the results were both negative. Resident was still noted to have pain, PA ordered [MEDICATION NAME]. On 1/25/17 resident still noted to be guarding leg with facial grimacing. Dr. Notified and ordered a full pelvic X-ray. The X-rays came back with a faint subcapital nondisplaced [MEDICAL CONDITION] femoral neck. Doctor was notified and resident as sent to ER. The report also states the injury was very likely caused by the fall. Provider Action Post-Investigation: Continue to monitor residents to ensure their needs are met, when they are not able to verbalize them. Record Review of Resident #2's Fall Investigation Worksheet dated 1/24/16 did not have Episodes of Sundowning checked off. Anxiety Disorders and [MEDICAL CONDITION] were marked off. Resident was described as requiring supervision. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 4 falls documented in the past 30 days and 15 fall in the past 31 to 180 days Interventions: One to one monitoring and hourly rounding while in bed (marked out and note not appropriate), moved to common area for close observation. Record review of Resident #2's Daily Skilled Nurse's Note dated 1/31/2017 at 1:00 p.m. revealed resident returned to the facility at 1:00 p.m. via stretcher and EMS. Resident was alert and unable to clearly communicate, alert and oriented to person, displaying disorganized thinking .Resident was transferred to bed by EMS with a 16 French Foley Catheter. Surgical wound to Right Hip and a Stage I pressure ulcer to Left Sacrum. Resident required extensive assist with transfers, mobility, toileting and ADL's. Resident incontinent of bowel and bladder and demonstrates confusion. FRE of 28. (21) 02/06/2017 (no time given), CNA was wheeling Resident #2 down a hill leaving a clinic. Resident was reported to have leaned forward and fell . Resident was noted to be confused, a bruise was noted. FRE 28. Interventions: Staff education on how to wheel residents through bumps, hills, or inclines. Record Review of Resident #2's Nurses Progress notes dated 2/06/17 at 1:00 p.m., revealed Resident was assessed, a bruise to the right eyebrow and bruise to her right lower thigh was noted. Record Review of Resident #2's Fall Investigation Worksheet dated 02/06/17 did not have Episodes of Sundowning checked off. Anxiety Disorders and Cognitive Impairment were marked off. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there were 1 falls documented in the past 30 days and 19 fall in the past 31 to 180 days. During an interview on 3/17/17 at 9:30 a.m., the Administrator revealed Resident #2 used to walk prior to her [MEDICAL CONDITION]. She stated the floor mat was removed due to the possibility of the resident tripping. She also stated that the resident's have the right to fall. During an interview on 3/17/17 at 2:04 p.m., the DON revealed, the facility's policies and procedures on fall prevention consisted of tracking and trending resident falls. DON stated falls were discussed during the morning meetings, any yellow tickets (fall screens for OT, PT, ST) were brought up. She also stated that after each fall, Physical Therapy would do a screen, working off incident reports reviewed each morning. She went on to state that for Resident #2, a Fall Risk Assessment was done and she was evaluated for a special chair. She also stated, the resident had Sundowners (Sundowners syndrome is an ailment that causes symptoms of confusion after sundown. These symptoms appear in people who suffer from [MEDICAL CONDITION] or other forms of dementia. During an interview on 3/17/17 at 3:30 p.m., OTA/Rehabilitation Director stated an evaluation is scheduled after all falls during the Weekly At Risk (WAR) meeting. She went on to state Falls, Weight loss, Behaviors and New Admissions and any triggers are discussed during this interdisciplinary team meeting. She stated that staff were trained on: Why falls occur, what are the circumstances for example: at the same time each day, from a chair when a resident is reaching and how to prevent that from occurring. She also stated that Resident #2's falls mostly occurred in the evenings. During an interview on 3/20/17 at 7:20 p.m., with the Administrator, all 21 fall reports were reviewed one by one. The Administrator revealed, she only knew what was on the paperwork. When she was asked if there was anything else that could have been done to prevent the falls? She stated, Yes, she was put on toileting program to prevent further falls. 2. Resident #4 was admitted on [DATE] and re-admitted [DATE] with the following Diagnoses: [REDACTED]. Record Review of Resident #4's Quarterly MDS assessment dated [DATE] which revealed a BIMS score of 1 (0-7 severely impaired) and an Annual MDS assessment dated [DATE] which revealed a BIMS score of 3. Both of these assessments revealed the residents needs for extensive assistance with ADL's. Record Review for Resident #4's Care Plan dated 3/15/17 revealed: Care Plan Problem:

Based on observation, interview, and record review the facility failed to implement its policies and procedures that prohibit neglect of residents for 2 residents (Residents # 2 and 4) of 9 residents reviewed for neglect related to falls. The facility failed to provide services to prevent harm when they: 1.) Failed to implement individualized interventions after Resident # 2's 19 falls over 11 months. Resident # 2 sustained a fall on 1/24/2017. The resident was transferred to a local hospital on [DATE] where she was diagnosed with [REDACTED]. 2.) Failed to implement appropriate individualized interventions for Resident # 4 to prevent further falls. Resident # 4 sustained 6 falls within a 4 month period. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 3/17/17. While the IJ was removed on 3/20/16, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. This deficient practice placed 35 residents with a history of falls at risk for future falls and could result in injury or death. The findings were: 1. Record review of Resident #2's Face Sheet dated 03/15/17, revealed Resident #2 was admitted to the facility on [DATE] and was readmitted on [DATE] and 01/29/2017 with the [DIAGNOSES REDACTED]. Record review of Resident #2's Fall Risk Evaluation (FRE) dated 02/6/17 revealed a score of 28 where a resident who scored a 10 or higher was at risk for falls. Record review of Resident #2's Comprehensive Annual Minimum Data Set ((MDS) dated [DATE], Brief Interview for Mental Status (BIMS) score of 7 (where 0-7 is severely impaired), Comprehensive, Annual MDS dated [DATE] (date of [MEDICAL CONDITION]) BIMS score of 4, Comprehensive, Significant Change MDS dated [DATE], BIMS score of 5 and a Quarterly MDS dated [DATE], BIMS score of 3. Record review of Resident #2's Comprehensive Annual Minimum Data Set ((MDS) dated [DATE], Activities of Daily Living (ADL) score of 7 (where 0-7 is severely impaired), Comprehensive, Annual MDS dated [DATE] (date of [MEDICAL CONDITION]) BIMS score of 4, Comprehensive, Significant Change MDS dated [DATE], BIMS score of 5 and a Quarterly MDS dated [DATE], BIMS score of 3. During an interview on 03/14/17 at 10:15 a.m., with LVN O revealed Resident #2 was not interviewable, had a [DIAGNOSES REDACTED]. Record review of Resident #2's Care Plan dated 3/15/17 revealed that she fell on [DATE] and 11/27/17 and the intervention included re-education. Care Plan Problem: I have had a history of [REDACTED]. 12/4/16 acute fall in facility had been toileted prior to this. Had an actual fall on 1/24 trying to stand and fell , moved resident to common area. 2/6/17 actual fall witnessed by employee going down the hall and fell forward, educated staff on proper transferring. Care Plan Goals: My number of falls will be reduced through next review date. Target date 5/24/17 Care Plan Interventions: Toileting q 2 hrs (. or PRN, keep in common area while awake for close observation, non-skid socks at all times, anti-roll back to wheelchair, drop wheelchair to aid in positioning, incontinent care program to attempt to decrease falls, toilet resident to assist to bed, after each fall episode evaluate current interventions and modify interventions according to IDT recommendations. Notify MD/NP and RP of fall and resulting assessment and interventions, complete fall documentation packet per facility protocol, for fall unobserved by staff or fall with potential/actual injury to the head, initiate neuro checks per protocol, monitor for changes in condition, document and report to MD/NP swelling, pain, lethargy, abnormal neural vital signs, change in functional ability, such as endurance, transfer, ambulation, etc .Document every shift for every 72 hours, the results of the targeted assessment related to the fall including pain. Standard of care in place unless otherwise noted: bed in low and locked position, call light within reach, personal items and fluids close at hand, clear clean pathways, and uncluttered surroundings, nightlight on/adequate lighting. Observation of Resident #2 on 03/14/17 at 3:30 p.m. revealed the resident was in bed, unable to answer questions. Resident seemed confused, unable to verbalize if she had eaten lunch. Record review of the facility's Fall Investigation included a Fall Worksheet and Fall Investigation Worksheet from 03/27/16 to 02/06/17 revealed Resident #2 had fallen a total of 21 times. The Fall Reports revealed the following: (1) 03/27/16 at 1:45 a.m., Resident #2 had an unwitnessed fall, fell face first sustaining a laceration to the bridge of her nose. She was reported to be alert. Intervention: Resident #2 to wear non-skid socks. Record Review of Resident #2's Fall Investigation Worksheet dated 03/27/16 revealed the resident did not have Episodes of Sundowning checked off and indicated that the resident required supervision. In the section entitled Number of falls, the facility reported 1+ falls in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 03/27/16 revealed the FSW, Section entitled: Nurse Manager Completes section 16-22, which addressed: If resident was placed on falling star program, was placed on Incident/Accident Log, Update Individual Fall Record, Care Plan updated, Rehabilitation screen, Medications reviewed, was not completed and/or signed. During an interview on 3/20/17 at 7:20 p.m., the Administrator confirmed the Fall Report was not fully completed (DON or the Nurse Manager did not fill out or sign the report). The Administrator also stated, she only knew what was on the report. (2) 04/25/16 at 5:00 p.m., Resident #2 fell , unwitnessed and found lying on the floor, noted to be confused. No injury noted. Intervention: Resident #2 was wheeled closer to the nursing station. Resident #2 has a FRE score of 22. Record Review of Resident's #2's Fall Investigation Worksheet dated 04/25/16 revealed it did not have Sundowning checked off, resident had Cognitive Impairment checked off and the section for number falls in the past 30 days and number of falls in the past 31 to 180 days was not filled out, however there was 1 documented fall in the past 30 days. Record Review of Resident #2's Fall Worksheet dated 04/25/16 revealed it did not have the Nurse Managers section completed or signed. (3) 04/26/16 at 3:45 p.m., Resident #2 fell unwitnessed, found lying on the floor next to nursing station, confused. Bruising to left and right elbow and red area noted to lower back. Intervention: Therapy evaluation for wheelchair, possible drop seat. Offer food, drinks, water, toileting and pain medications Record Review of Resident #2's Fall Investigation Worksheet dated 04/26/16 did not have Episodes of Sundowning checked off, resident had Cognitive Impairment, Anxiety Disorder, [MEDICAL CONDITION] and [MEDICAL CONDITION] marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 2 falls documented in the past 30 days. Record Review of Resident #2's Fall Worksheet dated 04/26/16 did not have the Nurse Managers section completed or signed. (4) 04/28/2016 at 9:30 p.m., Resident #2 was witnessed, slipping off bed with her pants down, confused with BM stains noted. No injury noted. Intervention: Resident to be toileted every two hours. Residents #2's FRE 24. Record Review of Resident #2's Fall Investigation Worksheet dated 04/28/16 did not have Episodes of Sundowning checked off, resident had Cognitive Impairment, Anxiety Disorder, [MEDICAL CONDITION] and [MEDICAL CONDITION] marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 3 falls documented in the past 30 days. Record Review of Resident #2's Fall Worksheet dated 04/28/16 did not have the Nurse Managers section completed or signed. Interview on 3/17/17 at 2:20 pm., Upon request of toileting documentation, the DON did not provide the requested documentation, and stated none was available. The DON revealed the resident was not being toileted according to her interventions. (5) 04/29/16 at 9:00 p.m., Resident #2 fell unwitnessed, off her wheelchair, found lying on the floor, noted to be alert/confused. No injuries noted. Residents #2's FRE 24, neuromuscular weakness noted. Intervention: Toilet resident more frequently, tilt wheelchair, place resident infront of nursing station. Record Review of Resident #2's Nurses Progress Notes dated 04/29/16 (no time noted), revealed resident had a head contusion. Record Review of Resident #2's Fall Investigation Worksheet dated 04/29/16 did not have Episodes of Sundowning checked off, resident had Cognitive Impairment, Anxiety Disorder and [MEDICAL CONDITION] marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 3 falls documented in the past 30 days and 1 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 04/29/16 did not have the Nurse Managers section completed or signed. (6) 05/04/2016 at 4:00 p.m., Resident #2 fell unwitnessed, found lying on the floor, confused with her wheelchair behind her, noted resident trying to sit in her wheelchair. No injuries noted. FRE 29. Intervention: Hydration aide asked to supervise resident, ambulate resident once every shift using gait belt with wheelchair behind her. Record Review of Resident #2's Nurses Progress notes dated 05/04/16 (no time noted) revealed, the resident was unable to voice her needs or wants and unable to follow commands. Record Review of Resident #2's Fall Investigation Worksheet dated 05/04/16 did not have Episodes of Sundowning checked off, Dementia was listed as a diagnosis. Cognitive Impairment, Anxiety Disorder and [MEDICAL CONDITION] were marked off. The section for number of falls in the past 30 days indicated there were 5 to 10 falls and number of falls in the past 31 to 180 days was not filled out, however there was 4 falls documented in the past 30 days and 1 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 05/04/16 did not have the Nurse Managers section completed or signed. (7) 06/10/16 at 11:00 a.m., Resident #2 fell unwitnessed (noted) , seen trying to get out of wheelchair, resident fell on her buttocks, noted to be confused. Resident was noted wearing her non-skid socks. Resident # 2 noted trying to get something to drink. No injuries noted. Intervention: Provide resident with shoes. Review of Resident #2's Incident/Action Plan (IAAP) dated 06/10/16 the following was on a toileting program, Rehab/Restorative and Behavioral program. Record Review of Resident #2's Fall Investigation Worksheet dated 06/10/16 did not have Episodes of Sundowning checked off, Dementia was listed as a diagnosis. Cognitive Impairment and Anxiety Disorder was marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 5 falls documented in the past 30 days and 1 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 06/10/16 did not have the Nurse Managers section completed or signed. (8) 07/11/16 at 6:00 p.m., Resident #2 (unwitnessed fall) was reported to be self toileting, missed the toilet seat and landed on her buttocks, was wearing her non-skid socks, noted to be alert. No injuries noted. Intervention: Already on every two hour toileting, resident educated on, when I get out of my wheelchair and attempt ambulation, I will be taken to the bathroom to see is that meets my need. Resident toileted and showered. Review of Resident #2's Incident/Action Plan (IAAP) dated 07/11/16 the following were not applicable (NA): the toileting program, Rehab/Restorative and Behavioral program. Record Review of Resident's #2's Fall Investigation Worksheet dated 07/11/16 did not have Episodes of Sundowning checked off, Dementia was listed as a diagnosis. Cognitive Impairment, Delerium and [MEDICAL CONDITION] were marked off. The section for number of falls indicated there were 2 falls in the past 30 days and number of falls in the past 31 to 180 days was not filled out, however there was 1 fall documented in the past 30 days and 6 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 07/11/16 did not have the Nurse Managers section completed or signed. (9) 07/27/16 at 1:50 p.m., Resident #2 was witnessed as she stood up from wheelchair and it slipped underneath her, resident grabbed side door and went down, noted to be alert and oriented to person (x1). No injuries noted. Pain Assessment (PA) score 2. Intervention: Non-skid socks at all times, reminders to lock wheel chair during transfers. Review of Resident #2's Incident/Action Plan (IAAP) dated 07/27/16 was blank. Record Review of Resident #2 Fall Investigation Worksheet dated 07/27/16 did not have Episodes of Sundowning checked off. Cognitive Impairment, Delerium and [MEDICAL CONDITION] were marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 1 fall documented in the past 30 days and 7 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 07/27/16 did not have the Nurse Managers section completed or signed. (10) 09/13/2016 at 9:00 p.m., Resident #2 has an unwitnessed fall, was found lying flat on her back in front of wheelchair. She was noted to be confused and sustained a superficial scratch to her right-middle back to left scapula measuring 8 cm by 3.5 cm. Intervention: Non-skid socks at all times, leave door to room open/cracked while resident is in there. Review of Resident #2's Incident/Action Plan (IAAP) dated 09/13/16 was blank. Record Review of Resident #2's Nurses Progress Note dated 09/13/16 at 1:10 p.m., revealed resident bumped head against breakroom door, while walking through doorway from dining room into breakroom. Record Review of Resident #2's Fall Investigation Worksheet dated 09/13/16 did not have Episodes of Sundowning checked off. Anxiety Disorders was marked off. Resident was described as restless, combative, having Dementia with behavioral disturbances and Cognitive communication deficient and requiring supervision. The section for number of falls indicated there was 2 falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there were 0 falls documented in the past 30 days and 9 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 09/13/16 did not have the Nurse Managers section completed or signed. (11) 11/08/2016 at 2:45 p.m., Resident #2 was witnessed slipping down against a wall during a one person assist while toileting. Resident was noted to be confused and sustained a superficial scratch to her back while sliding down wall with the toilet paper holder. FRE 17, PA 2. Intervention: Continue to monitor resident. Review of Resident #2's Incident/Action Plan (IAAP) dated 11/8/16 revealed the resident was on a toileting program. Record Review of Resident's #2 Fall Investigation Worksheet dated 11/08/16 did not have Episodes of Sundowning checked off. Anxiety Disorders and Cognitive Impairment were marked off. A [DIAGNOSES REDACTED]. The section for number of falls indicated there were 1 fall in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 0 falls documented in the past 30 days and 10 fall in the past 31 to 180 days. (12) 11/15/16 at 7:15 p.m., Resident #2 had an unwitnessed fall was found confused and lying on her right side by lobby, resident reported attempting to walk. resident sustained [REDACTED]. Her PA was reported at a 0. Intervention: Ice pack to forehead, toileting, bladder training program. Review of Resident #2's Incident/Action Plan (IAAP) dated 11/15/16 revealed the resident was not on a toileting program. Record Review of Resident #2's Fall Investigation Worksheet dated 11/15/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment, [MEDICAL CONDITION] and [MEDICAL CONDITION] were marked off. Resident was noted as requiring supervision. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 1 falls documented in the past 30 days and 10 fall in the past 31 to 180 days. (13) 12/04/16 at 8:50 p.m., Resident #2 had an unwitnessed fall, found confused, on the floor lying on her right side at end of bed, facing the bed with BM in her brief. Resident attempting to self-toilet. FRE 26, PA 1. Intervention: two person assist for all Activities of Daily Living (ADL's). Recommendation: a Stool C & S, [MEDICAL CONDITION] labs ordered. Record Review of Resident #2's Nurses Progress notes dated 12/04/16 at 9:50 p.m., revealed, the resident has increased confusion and the resident was unable to focus on nurse for a long time Review of Resident #2's Incident/Action Plan (IAAP) dated 12/04/16 was not completed. Note at 10:20 pm noted resident with increased confusion. Record Review of Resident #2's Fall Investigation Worksheet dated 12/04/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment, Alzheimer's and Depression were marked off. Resident was described as having increased confusion with weakness and requiring supervision. The section for number of falls indicated there was 2 falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there were 2 falls documented in the past 30 days and 10 fall in the past 31 to 180 days. Record Review of Resident's #2 Fall Worksheet dated 12/04/16 did not have the Nurse Managers section completed or signed. (14) 12/10/16 at 11:45 a.m., Resident #2 had an unwitnessed fall was found confused, lying on her right side, next to her wheelchair in the dining room. No injuries or pain noted. FRE 18. Intervention: Resident reminded not to get up out of chair (resident with Dementia), Remind aides to always put on non-skid socks and shoes at all times. Record Review of Resident #2's Nurses Progress notes dated 12/10/16 at 11:45 a.m., revealed, the resident was reminded not to get out of her chair without help. Review of Resident #2's Incident/Action Plan (IAAP) dated 12/10/16 revealed the resident was not on a toileting program, Rehab/Restorative or Behavioral program or had any safety precautions or devices. Record Review of Resident's #2 Fall Investigation Worksheet dated 12/10/16 did not have Episodes of Sundowning checked off. Cognitive Impairment was marked off. The section for number of falls indicated there was 1 fall in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 4 falls documented in the past 30 days and 9 fall in the past 31 to 180 days. Record Review of Resident's #2 Fall Worksheet dated 12/10/16 did not have the Nurse Managers section completed or signed. (15) 12/18/16 at 9:35 p.m., Resident #2 had an unwitnessed fall, found confused, on the floor against the wall across from the bathroom sitting up with back and head against the wall. No injuries noted. FRE 20, PA 2. Intervention: Toileting every two hours as needed, informed resident on the use of the call light with demonstration. Resident noted to have verbalized understanding. Review of Resident #2's Incident/Action Plan (IAAP) dated 12/18/16 revealed the resident was not on a toileting program, Rehab/Restorative or Behavioral program. Record Review of Resident #2's Nurses Progress notes dated 12/18/16 at 9:35 p.m., revealed resident was alert and oriented to person. Record Review of Resident #2's Fall Investigation Worksheet dated 12/18/16 did not have Episodes of Sundowning checked off. Anxiety Disorders was marked off and a [DIAGNOSES REDACTED]. Resident was described as requiring supervision. The section for number of falls indicated there were 3 falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 2 falls documented in the past 30 days and 12 fall in the past 31 to 180 days. Record Review of Resident's #2 Fall Worksheet dated 12/04/16 did not have the Nurse Managers section completed or signed. (16) 12/28/16 at 11:30 p.m., Resident #2 had an unwitnessed fall, she was found confused and sitting on the floor beside the bed (in low position, with wheels locked). FRE 20, PA 2. Intervention: Resident to wear non-skid socks when in bed, room to be clutter free, staff to check resident frequently. Review of Resident #2's Incident/Action Plan (IAAP) dated 12/28/16 revealed the resident was on a toileting program. It also revealed she was not on a Rehab/Restorative or Behavioral program. Record Review of Resident #2's Fall Investigation Worksheet dated 12/28/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment were marked off. Resident had a Dementia [DIAGNOSES REDACTED]. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 3 falls documented in the past 30 days and 12 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 12/28/16 did not have the Nurse Managers section completed or signed. (17) 12/30/16 at 10:00 p.m., Resident #2 had an unwitnessed fall, reportedly fell out of bed and hit her head on the edge of her night stand. Resident noted to be alert and sustained a head injury, bump and scrape to forehead. Intervention: Encourage the use of the call light when in need of assistance. Review of Resident #2's Incident/Action Plan (IAAP) dated 12/30/16 revealed the resident was on a toileting program. Record Review of Resident #2's Fall Investigation Worksheet dated 12/30/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment and Delerium were marked off. The section for number of falls indicated there were 2 falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 4 falls documented in the past 30 days and 12 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 12/30/16 did not have the Nurse Managers section completed or signed. (18) 12/31/16 at 6:40 p.m., Resident #2 had an unwitnessed fall reported to have fallen attempting to self-transfer to the toilet in the bathroom and hit her head on the bathroom cabinet. Resident noted as confused and sustained a head injury, abrasion to the back of her head and scalp. PA 4. Intervention: Moved to common area for close observations, and one to one monitoring and hourly rounding while in bed (marked out and note not appropriate). During an interview on 3/17/17 at 2:20 p.m., the DON revealed the reason for changing the intervention from one on one monitoring to moving resident to the common area was due to the staff were unable to sustain the intervention. Record Review of Resident #2's Nurses Progress notes dated 12/31/16 at 6:45 a.m., revealed the resident's pupils were sluggish to respond to light with speech slightly slurred. A large bluish discoloration and bump measuring approximately 4 cm by 4 cm to forehead. Resident was transported to the ER at 7:30 a.m. Record Review of Resident #2's Fall Investigation Worksheet dated 12/31/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment and Delerium were marked off and Dementia was indicated as a diagnosis. Resident was described as requiring supervision. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 6 falls documented in the past 30 days and 12 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 12/31/16 did not have the Nurse Managers section completed or signed. (19) 01/01/17 at 9:40 p.m., Resident #2, unwitnessed fall, found lying confused on her back, beside bed with the wheelchair leaned forward on top of her. No injuries noted. Intervention: One to one monitoring and hourly rounding while in bed (marked out and note not appropriate), Moved to nursing station and other common areas for close observation. Record Review of Resident #2's Fall Investigation Worksheet dated 01/01/17 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment and Delerium were marked off. Resident was described as requiring supervision. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out. (20) 01/24/16 at 3:00 p.m., Resident #2 sustained an unwitnessed fall. She was reported to be sitting in her wheelchair when she attempted to stand up and fell to the right side. Resident reported to be alert and oriented to person, with a PA 10 and FRE 20. Intervention: Ice pack to forehead, toileting. Provider Investigation Report for Resident# 2 revealed there were two nurses at the nursing station during the time of her fall, neither nurse witnessed the fall. Physician Assistant was in the premises and evaluated the resident. Resident noted to have facial grimacing when transferred to a chair. On 1/24/17, a right X-ray was ordered, along with knee X-ray, the results were both negative. Resident was still noted to have pain, PA ordered [MEDICATION NAME]. On 1/25/17 resident still noted to be guarding leg with facial grimacing. Dr. Notified and ordered a full pelvic X-ray. The X-rays came back with a faint subcapital nondisplaced [MEDICAL CONDITION] femoral neck. Doctor was notified and resident as sent to ER. The report also states the injury was very likely caused by the fall. Provider Action Post-Investigation: Continue to monitor residents to ensure their needs are met, when they are not able to verbalize them. Record Review of Resident #2's Fall Investigation Worksheet dated 1/24/16 did not have Episodes of Sundowning checked off. Anxiety Disorders and [MEDICAL CONDITION] were marked off. Resident was described as requiring supervision. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 4 falls documented in the past 30 days and 15 fall in the past 31 to 180 days Interventions: One to one monitoring and hourly rounding while in bed (marked out and note not appropriate), moved to common area for close observation. Record review of Resident #2's Daily Skilled Nurse's Note dated 1/31/2017 at 1:00 p.m. revealed resident returned to the facility at 1:00 p.m. via stretcher and EMS. Resident was alert and unable to clearly communicate, alert and oriented to person, displaying disorganized thinking .Resident was transferred to bed by EMS with a 16 French Foley Catheter. Surgical wound to Right Hip and a Stage I pressure ulcer to Left Sacrum. Resident required extensive assist with transfers, mobility, toileting and ADL's. Resident incontinent of bowel and bladder and demonstrates confusion. FRE of 28. (21) 02/06/2017 (no time given), CNA was wheeling Resident #2 down a hill leaving a clinic. Resident was reported to have leaned forward and fell . Resident was noted to be confused, a bruise was noted. FRE 28. Interventions: Staff education on how to wheel residents through bumps, hills, or inclines. Record Review of Resident #2's Nurses Progress notes dated 2/06/17 at 1:00 p.m., revealed Resident was assessed, a bruise to the right eyebrow and bruise to her right lower thigh was noted. Record Review of Resident #2's Fall Investigation Worksheet dated 02/06/17 did not have Episodes of Sundowning checked off. Anxiety Disorders and Cognitive Impairment were marked off. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there were 1 falls documented in the past 30 days and 19 fall in the past 31 to 180 days. During an interview on 3/17/17 at 9:30 a.m., the Administrator revealed Resident #2 used to walk prior to her [MEDICAL CONDITION]. She stated the floor mat was removed due to the possibility of the resident tripping. She also stated that the resident's have the right to fall. During an interview on 3/17/17 at 2:04 p.m., the DON revealed, the facility's policies and procedures on fall prevention consisted of tracking and trending resident falls. DON stated falls were discussed during the morning meetings, any yellow tickets (fall screens for OT, PT, ST) were brought up. She also stated that after each fall, Physical Therapy would do a screen, working off incident reports reviewed each morning. She went on to state that for Resident #2, a Fall Risk Assessment was done and she was evaluated for a special chair. She also stated, the resident had Sundowners (Sundowners syndrome is an ailment that causes symptoms of confusion after sundown. These symptoms appear in people who suffer from [MEDICAL CONDITION] or other forms of dementia. During an interview on 3/17/17 at 3:30 p.m., OTA/Rehabilitation Director stated an evaluation is scheduled after all falls during the Weekly At Risk (WAR) meeting. She went on to state Falls, Weight loss, Behaviors and New Admissions and any triggers are discussed during this interdisciplinary team meeting. She stated that staff were trained on: Why falls occur, what are the circumstances for example: at the same time each day, from a chair when a resident is reaching and how to prevent that from occurring. She also stated that Resident #2's falls mostly occurred in the evenings. During an interview on 3/20/17 at 7:20 p.m., with the Administrator, all 21 fall reports were reviewed one by one. The Administrator revealed, she only knew what was on the paperwork. When she was asked if there was anything else that could have been done to prevent the falls? She stated, Yes, she was put on toileting program to prevent further falls. 2. Resident #4 was admitted on [DATE] and re-admitted [DATE] with the following Diagnoses: [REDACTED]. Record Review of Resident #4's Quarterly MDS assessment dated [DATE] which revealed a BIMS score of 1 (0-7 severely impaired) and an Annual MDS assessment dated [DATE] which revealed a BIMS score of 3. Both of these assessments revealed the residents needs for extensive assistance with ADL's. Record Review for Resident #4's Care Plan dated 3/15/17 revealed: Care

Based on observation, interview and record review the facility failed to maintain all resident assessments completed within the previous 15 months in the resident ' s active record and use the results of the assessments to review and revise the resident ' s comprehensive care plan for 3 of 14 residents (#s 1, 2, and 4) reviewed for falls in that: 1. Resident #2 had a total of 21 falls. The facility did not reevaluate and revise the care plan for falls and Resident #2 continued to fall. 2. Resident #1 had 7 falls. The facility did not reevaluate and revise the care plan for falls and Resident #1 continued to fall. 3. Resident #4 had a total of 6 falls from the period between 11/6/16 and 2/20/17. The facility did not reevaluate and revise the care plan for falls and Resident #4 continued to fall. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 3/17/17. While the IJ was removed on 3/20/16, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. This deficient practice could affect 35 residents who had a history of [REDACTED]. Findings were: 1. Record review of Resident #2's Face Sheet dated 03/15/17, revealed Resident #2 was admitted to the facility on [DATE] and was readmitted on [DATE] and 01/29/2017 with the [DIAGNOSES REDACTED]. Record review of Resident #2's Fall Risk Evaluation (FRE) dated 02/6/17 revealed a score of 28 where a resident who scored a 10 or higher was at risk for falls. Record review of Resident #2's Comprehensive Annual Minimum Data Set ((MDS) dated [DATE], Brief Interview for Mental Status (BIMS) score of 7 (where 0-7 is severely impaired), Comprehensive, Annual MDS dated [DATE] (date of [MEDICAL CONDITION]) BIMS score of 4, Comprehensive, Significant Change MDS dated [DATE], BIMS score of 5 and a Quarterly MDS dated [DATE], BIMS score of 3. Record review of Resident #2's Comprehensive Annual Minimum Data Set ((MDS) dated [DATE], Activities of Daily Living (ADL) score of 7 (where 0-7 is severely impaired), Comprehensive, Annual MDS dated [DATE] (date of [MEDICAL CONDITION]) BIMS score of 4, Comprehensive, Significant Change MDS dated [DATE], BIMS score of 5 and a Quarterly MDS dated [DATE], BIMS score of 3. During an interview on 03/14/17 at 10:15 a.m., with LVN O revealed Resident #2 was not interviewable, had a [DIAGNOSES REDACTED]. Record review of Resident #2's Care Plan dated 3/15/17 revealed that she fell on [DATE] and 11/27/17 and the intervention included re-education. Care Plan Problem: I have had a history of [REDACTED]. 12/4/16 acute fall in facility had been toileted prior to this. Had an actual fall on 1/24 trying to stand and fell , moved resident to common area. 2/6/17 actual fall witnessed by employee going down the hall and fell forward, educated staff on proper transferring. Care Plan Goals: My number of falls will be reduced through next review date. Target date 5/24/17 Care Plan Interventions: Toileting q 2 hrs (. or PRN, keep in common area while awake for close observation, non-skid socks at all times, anti-roll back to wheelchair, drop wheelchair to aid in positioning, incontinent care program to attempt to decrease falls, toilet resident to assist to bed, after each fall episode evaluate current interventions and modify interventions according to IDT recommendations. Notify MD/NP and RP of fall and resulting assessment and interventions, complete fall documentation packet per facility protocol, for fall unobserved by staff or fall with potential/actual injury to the head, initiate neuro checks per protocol, monitor for changes in condition, document and report to MD/NP swelling, pain, lethargy, abnormal neural vital signs, change in functional ability, such as endurance, transfer, ambulation, etc .Document every shift for every 72 hours, the results of the targeted assessment related to the fall including pain. Standard of care in place unless otherwise noted: bed in low and locked position, call light within reach, personal items and fluids close at hand, clear clean pathways, and uncluttered surroundings, nightlight on/adequate lighting. Observation of Resident #2 on 03/14/17 at 3:30 p.m. revealed the resident was in bed, unable to answer questions. Resident seemed confused, unable to verbalize if she had eaten lunch. Record review of the facility's Fall Investigation included a Fall Worksheet and Fall Investigation Worksheet from 03/27/16 to 02/06/17 revealed Resident #2 had fallen a total of 21 times. The Fall Reports revealed the following: (1) 03/27/16 at 1:45 a.m., Resident #2 had an unwitnessed fall, fell face first sustaining a laceration to the bridge of her nose. She was reported to be alert. Intervention: Resident #2 to wear non-skid socks. Record Review of Resident #2's Fall Investigation Worksheet dated 03/27/16 revealed the resident did not have Episodes of Sundowning checked off and indicated that the resident required supervision. In the section entitled Number of falls, the facility reported 1+ falls in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 03/27/16 revealed the FSW, Section entitled: Nurse Manager Completes section 16-22, which addressed: If resident was placed on falling star program, was placed on Incident/Accident Log, Update Individual Fall Record, Care Plan updated, Rehabilitation screen, Medications reviewed, was not completed and/or signed. During an interview on 3/20/17 at 7:20 p.m., the Administrator confirmed the Fall Report was not fully completed (DON or the Nurse Manager did not fill out or sign the report). The Administrator also stated, she only knew what was on the report. (2) 04/25/16 at 5:00 p.m., Resident #2 fell , unwitnessed and found lying on the floor, noted to be confused. No injury noted. Intervention: Resident #2 was wheeled closer to the nursing station. Resident #2 has a FRE score of 22. Record Review of Resident's #2's Fall Investigation Worksheet dated 04/25/16 revealed it did not have Sundowning checked off, resident had Cognitive Impairment checked off and the section for number falls in the past 30 days and number of falls in the past 31 to 180 days was not filled out, however there was 1 documented fall in the past 30 days. Record Review of Resident #2's Fall Worksheet dated 04/25/16 revealed it did not have the Nurse Managers section completed or signed. (3) 04/26/16 at 3:45 p.m., Resident #2 fell unwitnessed, found lying on the floor next to nursing station, confused. Bruising to left and right elbow and red area noted to lower back. Intervention: Therapy evaluation for wheelchair, possible drop seat. Offer food, drinks, water, toileting and pain medications Record Review of Resident #2's Fall Investigation Worksheet dated 04/26/16 did not have Episodes of Sundowning checked off, resident had Cognitive Impairment, Anxiety Disorder, [MEDICAL CONDITION] and [MEDICAL CONDITION] marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 2 falls documented in the past 30 days. Record Review of Resident #2's Fall Worksheet dated 04/26/16 did not have the Nurse Managers section completed or signed. (4) 04/28/2016 at 9:30 p.m., Resident #2 was witnessed, slipping off bed with her pants down, confused with BM stains noted. No injury noted. Intervention: Resident to be toileted every two hours. Residents #2's FRE 24. Record Review of Resident #2's Fall Investigation Worksheet dated 04/28/16 did not have Episodes of Sundowning checked off, resident had Cognitive Impairment, Anxiety Disorder, [MEDICAL CONDITION] and [MEDICAL CONDITION] marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 3 falls documented in the past 30 days. Record Review of Resident #2's Fall Worksheet dated 04/28/16 did not have the Nurse Managers section completed or signed. Interview on 3/17/17 at 2:20 pm., Upon request of toileting documentation, the DON did not provide the requested documentation, and stated none was available. The DON revealed the resident was not being toileted according to her interventions. (5) 04/29/16 at 9:00 p.m., Resident #2 fell unwitnessed, off her wheelchair, found lying on the floor, noted to be alert/confused. No injuries noted. Residents #2's FRE 24, neuromuscular weakness noted. Intervention: Toilet resident more frequently, tilt wheelchair, place resident infront of nursing station. Record Review of Resident #2's Nurses Progress Notes dated 04/29/16 (no time noted), revealed resident had a head contusion. Record Review of Resident #2's Fall Investigation Worksheet dated 04/29/16 did not have Episodes of Sundowning checked off, resident had Cognitive Impairment, Anxiety Disorder and [MEDICAL CONDITION] marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 3 falls documented in the past 30 days and 1 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 04/29/16 did not have the Nurse Managers section completed or signed. (6) 05/04/2016 at 4:00 p.m., Resident #2 fell unwitnessed, found lying on the floor, confused with her wheelchair behind her, noted resident trying to sit in her wheelchair. No injuries noted. FRE 29. Intervention: Hydration aide asked to supervise resident, ambulate resident once every shift using gait belt with wheelchair behind her. Record Review of Resident #2's Nurses Progress notes dated 05/04/16 (no time noted) revealed, the resident was unable to voice her needs or wants and unable to follow commands. Record Review of Resident #2's Fall Investigation Worksheet dated 05/04/16 did not have Episodes of Sundowning checked off, Dementia was listed as a diagnosis. Cognitive Impairment, Anxiety Disorder and [MEDICAL CONDITION] were marked off. The section for number of falls in the past 30 days indicated there were 5 to 10 falls and number of falls in the past 31 to 180 days was not filled out, however there was 4 falls documented in the past 30 days and 1 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 05/04/16 did not have the Nurse Managers section completed or signed. (7) 06/10/16 at 11:00 a.m., Resident #2 fell unwitnessed (noted) , seen trying to get out of wheelchair, resident fell on her buttocks, noted to be confused. Resident was noted wearing her non-skid socks. Resident # 2 noted trying to get something to drink. No injuries noted. Intervention: Provide resident with shoes. Review of Resident #2's Incident/Action Plan (IAAP) dated 06/10/16 the following was on a toileting program, Rehab/Restorative and Behavioral program. Record Review of Resident #2's Fall Investigation Worksheet dated 06/10/16 did not have Episodes of Sundowning checked off, Dementia was listed as a diagnosis. Cognitive Impairment and Anxiety Disorder was marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 5 falls documented in the past 30 days and 1 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 06/10/16 did not have the Nurse Managers section completed or signed. (8) 07/11/16 at 6:00 p.m., Resident #2 (unwitnessed fall) was reported to be self toileting, missed the toilet seat and landed on her buttocks, was wearing her non-skid socks, noted to be alert. No injuries noted. Intervention: Already on every two hour toileting, resident educated on, when I get out of my wheelchair and attempt ambulation, I will be taken to the bathroom to see is that meets my need. Resident toileted and showered. Review of Resident #2's Incident/Action Plan (IAAP) dated 07/11/16 the following were not applicable (NA): the toileting program, Rehab/Restorative and Behavioral program. Record Review of Resident #2's Fall Investigation Worksheet dated 07/11/16 did not have Episodes of Sundowning checked off, Dementia was listed as a diagnosis. Cognitive Impairment, Delerium and [MEDICAL CONDITION] were marked off. The section for number of falls indicated there were 2 falls in the past 30 days and number of falls in the past 31 to 180 days was not filled out, however there was 1 fall documented in the past 30 days and 6 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 07/11/16 did not have the Nurse Managers section completed or signed. (9) 07/27/16 at 1:50 p.m., Resident #2 was witnessed as she stood up from wheelchair and it slipped underneath her, resident grabbed side door and went down, noted to be alert and oriented to person (x1). No injuries noted. Pain Assessment (PA) score 2. Intervention: Non-skid socks at all times, reminders to lock wheel chair during transfers. Review of Resident #2's Incident/Action Plan (IAAP) dated 07/27/16 was blank. Record Review of Resident #2 Fall Investigation Worksheet dated 07/27/16 did not have Episodes of Sundowning checked off. Cognitive Impairment, Delerium and [MEDICAL CONDITION] were marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 1 fall documented in the past 30 days and 7 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 07/27/16 did not have the Nurse Managers section completed or signed. (10) 09/13/2016 at 9:00 p.m., Resident #2 has an unwitnessed fall, was found lying flat on her back in front of wheelchair. She was noted to be confused and sustained a superficial scratch to her right-middle back to left scapula measuring 8 cm by 3.5 cm. Intervention: Non-skid socks at all times, leave door to room open/cracked while resident is in there. Review of Resident #2's Incident/Action Plan (IAAP) dated 09/13/16 was blank. Record Review of Resident #2's Nurses Progress Note dated 09/13/16 at 1:10 p.m., revealed resident bumped head against breakroom door, while walking through doorway from dining room into breakroom. Record Review of Resident #2's Fall Investigation Worksheet dated 09/13/16 did not have Episodes of Sundowning checked off. Anxiety Disorders was marked off. Resident was described as restless, combative, having Dementia with behavioral disturbances and Cognitive communication deficient and requiring supervision. The section for number of falls indicated there was 2 falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there were 0 falls documented in the past 30 days and 9 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 09/13/16 did not have the Nurse Managers section completed or signed. (11) 11/08/2016 at 2:45 p.m., Resident #2 was witnessed slipping down against a wall during a one person assist while toileting. Resident was noted to be confused and sustained a superficial scratch to her back while sliding down wall with the toilet paper holder. FRE 17, PA 2. Intervention: Continue to monitor resident. Review of Resident #2's Incident/Action Plan (IAAP) dated 11/8/16 revealed the resident was on a toileting program. Record Review of Resident's #2 Fall Investigation Worksheet dated 11/08/16 did not have Episodes of Sundowning checked off. Anxiety Disorders and Cognitive Impairment were marked off. A [DIAGNOSES REDACTED]. The section for number of falls indicated there were 1 fall in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 0 falls documented in the past 30 days and 10 fall in the past 31 to 180 days. (12) 11/15/16 at 7:15 p.m., Resident #2 had an unwitnessed fall was found confused and lying on her right side by lobby, resident reported attempting to walk. resident sustained [REDACTED]. Her PA was reported at a 0. Intervention: Ice pack to forehead, toileting, bladder training program. Review of Resident #2's Incident/Action Plan (IAAP) dated 11/15/16 revealed the resident was not on a toileting program. Record Review of Resident #2's Fall Investigation Worksheet dated 11/15/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment, [MEDICAL CONDITION] and [MEDICAL CONDITION] were marked off. Resident was noted as requiring supervision. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 1 falls documented in the past 30 days and 10 fall in the past 31 to 180 days. (13) 12/04/16 at 8:50 p.m., Resident #2 had an unwitnessed fall, found confused, on the floor lying on her right side at end of bed, facing the bed with BM in her brief. Resident attempting to self-toilet. FRE 26, PA 1. Intervention: two person assist for all Activities of Daily Living (ADL's). Recommendation: a Stool C & S, [MEDICAL CONDITION] labs ordered. Record Review of Resident #2's Nurses Progress notes dated 12/04/16 at 9:50 p.m., revealed, the resident has increased confusion and the resident was unable to focus on nurse for a long time Review of Resident #2's Incident/Action Plan (IAAP) dated 12/04/16 was not completed. Note at 10:20 pm noted resident with increased confusion. Record Review of Resident #2's Fall Investigation Worksheet dated 12/04/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment, Alzheimer's and Depression were marked off. Resident was described as having increased confusion with weakness and requiring supervision. The section for number of falls indicated there was 2 falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there were 2 falls documented in the past 30 days and 10 fall in the past 31 to 180 days. Record Review of Resident's #2 Fall Worksheet dated 12/04/16 did not have the Nurse Managers section completed or signed. (14) 12/10/16 at 11:45 a.m., Resident #2 had an unwitnessed fall was found confused, lying on her right side, next to her wheelchair in the dining room. No injuries or pain noted. FRE 18. Intervention: Resident reminded not to get up out of chair (resident with Dementia), Remind aides to always put on non-skid socks and shoes at all times. Record Review of Resident #2's Nurses Progress notes dated 12/10/16 at 11:45 a.m., revealed, the resident was reminded not to get out of her chair without help. Review of Resident #2's Incident/Action Plan (IAAP) dated 12/10/16 revealed the resident was not on a toileting program, Rehab/Restorative or Behavioral program or had any safety precautions or devices. Record Review of Resident #2's Fall Investigation Worksheet dated 12/10/16 did not have Episodes of Sundowning checked off. Cognitive Impairment was marked off. The section for number of falls indicated there was 1 fall in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 4 falls documented in the past 30 days and 9 fall in the past 31 to 180 days. Record Review of Resident's #2 Fall Worksheet dated 12/10/16 did not have the Nurse Managers section completed or signed. (15) 12/18/16 at 9:35 p.m., Resident #2 had an unwitnessed fall, found confused, on the floor against the wall across from the bathroom sitting up with back and head against the wall. No injuries noted. FRE 20, PA 2. Intervention: Toileting every two hours as needed, informed resident on the use of the call light with demonstration. Resident noted to have verbalized understanding. Review of Resident #2's Incident/Action Plan (IAAP) dated 12/18/16 revealed the resident was not on a toileting program, Rehab/Restorative or Behavioral program. Record Review of Resident #2's Nurses Progress notes dated 12/18/16 at 9:35 p.m., revealed resident was alert and oriented to person. Record Review of Resident #2's Fall Investigation Worksheet dated 12/18/16 did not have Episodes of Sundowning checked off. Anxiety Disorders was marked off and a [DIAGNOSES REDACTED]. Resident was described as requiring supervision. The section for number of falls indicated there were 3 falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 2 falls documented in the past 30 days and 12 fall in the past 31 to 180 days. Record Review of Resident's #2 Fall Worksheet dated 12/04/16 did not have the Nurse Managers section completed or signed. (16) 12/28/16 at 11:30 p.m., Resident #2 had an unwitnessed fall, she was found confused and sitting on the floor beside the bed (in low position, with wheels locked). FRE 20, PA 2. Intervention: Resident to wear non-skid socks when in bed, room to be clutter free, staff to check resident frequently. Review of Resident #2's Incident/Action Plan (IAAP) dated 12/28/16 revealed the resident was on a toileting program. It also revealed she was not on a Rehab/Restorative or Behavioral program. Record Review of Resident #2's Fall Investigation Worksheet dated 12/28/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment were marked off. Resident had a Dementia [DIAGNOSES REDACTED]. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 3 falls documented in the past 30 days and 12 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 12/28/16 did not have the Nurse Managers section completed or signed. (17) 12/30/16 at 10:00 p.m., Resident #2 had an unwitnessed fall, reportedly fell out of bed and hit her head on the edge of her night stand. Resident noted to be alert and sustained a head injury, bump and scrape to forehead. Intervention: Encourage the use of the call light when in need of assistance. Review of Resident #2's Incident/Action Plan (IAAP) dated 12/30/16 revealed the resident was on a toileting program. Record Review of Resident #2's Fall Investigation Worksheet dated 12/30/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment and Delerium were marked off. The section for number of falls indicated there were 2 falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 4 falls documented in the past 30 days and 12 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 12/30/16 did not have the Nurse Managers section completed or signed. (18) 12/31/16 at 6:40 p.m., Resident #2 had an unwitnessed fall reported to have fallen attempting to self-transfer to the toilet in the bathroom and hit her head on the bathroom cabinet. Resident noted as confused and sustained a head injury, abrasion to the back of her head and scalp. PA 4. Intervention: Moved to common area for close observations, and one to one monitoring and hourly rounding while in bed (marked out and note not appropriate). During an interview on 3/17/17 at 2:20 p.m., the DON revealed the reason for changing the intervention from one on one monitoring to moving resident to the common area was due to the staff were unable to sustain the intervention. Record Review of Resident #2's Nurses Progress notes dated 12/31/16 at 6:45 a.m., revealed the resident's pupils were sluggish to respond to light with speech slightly slurred. A large bluish discoloration and bump measuring approximately 4 cm by 4 cm to forehead. Resident was transported to the ER at 7:30 a.m. Record Review of Resident #2's Fall Investigation Worksheet dated 12/31/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment and Delerium were marked off and Dementia was indicated as a diagnosis. Resident was described as requiring supervision. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 6 falls documented in the past 30 days and 12 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 12/31/16 did not have the Nurse Managers section completed or signed. (19) 01/01/17 at 9:40 p.m., Resident #2, unwitnessed fall, found lying confused on her back, beside bed with the wheelchair leaned forward on top of her. No injuries noted. Intervention: One to one monitoring and hourly rounding while in bed (marked out and note not appropriate), Moved to nursing station and other common areas for close observation. Record Review of Resident #2's Fall Investigation Worksheet dated 01/01/17 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment and Delerium were marked off. Resident was described as requiring supervision. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out. (20) 01/24/16 at 3:00 p.m., Resident #2 sustained an unwitnessed fall. She was reported to be sitting in her wheelchair when she attempted to stand up and fell to the right side. Resident reported to be alert and oriented to person, with a PA 10 and FRE 20. Intervention: Ice pack to forehead, toileting. Provider Investigation Report for Resident# 2 revealed there were two nurses at the nursing station during the time of her fall, neither nurse witnessed the fall. Physician Assistant was in the premises and evaluated the resident. Resident noted to have facial grimacing when transferred to a chair. On 1/24/17, a right X-ray was ordered, along with knee X-ray, the results were both negative. Resident was still noted to have pain, PA ordered [MEDICATION NAME]. On 1/25/17 resident still noted to be guarding leg with facial grimacing. Dr. Notified and ordered a full pelvic X-ray. The X-rays came back with a faint subcapital nondisplaced [MEDICAL CONDITION] femoral neck. Doctor was notified and resident as sent to ER. The report also states the injury was very likely caused by the fall. Provider Action Post-Investigation: Continue to monitor residents to ensure their needs are met, when they are not able to verbalize them. Record Review of Resident #2's Fall Investigation Worksheet dated 1/24/16 did not have Episodes of Sundowning checked off. Anxiety Disorders and [MEDICAL CONDITION] were marked off. Resident was described as requiring supervision. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 4 falls documented in the past 30 days and 15 fall in the past 31 to 180 days Interventions: One to one monitoring and hourly rounding while in bed (marked out and note not appropriate), moved to common area for close observation. Record review of Resident #2's Daily Skilled Nurse's Note dated 1/31/2017 at 1:00 p.m. revealed resident returned to the facility at 1:00 p.m. via stretcher and EMS. Resident was alert and unable to clearly communicate, alert and oriented to person, displaying disorganized thinking .Resident was transferred to bed by EMS with a 16 French Foley Catheter. Surgical wound to Right Hip and a Stage I pressure ulcer to Left Sacrum. Resident required extensive assist with transfers, mobility, toileting and ADL's. Resident incontinent of bowel and bladder and demonstrates confusion. FRE of 28. (21) 02/06/2017 (no time given), CNA was wheeling Resident #2 down a hill leaving a clinic. Resident was reported to have leaned forward and fell . Resident was noted to be confused, a bruise was noted. FRE 28. Interventions: Staff education on how to wheel residents through bumps, hills, or inclines. Record Review of Resident #2's Nurses Progress notes dated 2/06/17 at 1:00 p.m., revealed Resident was assessed, a bruise to the right eyebrow and bruise to her right lower thigh was noted. Record Review of Resident #2's Fall Investigation Worksheet dated 02/06/17 did not have Episodes of Sundowning checked off. Anxiety Disorders and Cognitive Impairment were marked off. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there were 1 falls documented in the past 30 days and 19 fall in the past 31 to 180 days. During an interview on 3/17/17 at 9:30 a.m., the Administrator revealed Resident #2 used to walk prior to her [MEDICAL CONDITION]. She stated the floor mat was removed due to the possibility of the resident tripping. She also stated that the residents have the right to fall. During an interview on 3/17/17 at 2:04 p.m., the DON revealed, the facility's policies and procedures on fall prevention consisted of tracking and trending resident falls. DON stated falls were discussed during the morning meetings, any yellow tickets (fall screens for OT, PT, ST) were brought up. She also stated that after each fall, Physical Therapy would do a screen, working off incident reports reviewed each morning. She went on to state that for Resident #2, a Fall Risk Assessment was done and she was evaluated for a special chair. She also stated, the resident had Sundowners (Sundowners syndrome is an ailment that causes symptoms of confusion after sundown. These symptoms appear in people who suffer from [MEDICAL CONDITION] or other forms of dementia. During an interview on 3/17/17 at 3:30 p.m., OTA/Rehabilitation Director stated an evaluation is scheduled after all falls during the Weekly At Risk (WAR) meeting. She went on to state Falls, Weight loss, Behaviors and New Admissions and any triggers are discussed during this interdisciplinary team meeting. She stated that staff were trained: Why falls occur, what are the circumstances for example: at the same time each day, from a chair when a resident is reaching and how to prevent that from occurring. She also stated that Resident #2's falls mostly occurred in the evenings. During an interview on 3/20/17 at 7:20 p.m., with the Administrator, all 21 fall reports were reviewed one by one. The Administrator revealed, she only knew what was on the paperwork. When she was asked if there was anything else that could have been done to prevent the falls? She stated, Yes, she was put on toileting program to prevent further falls. 2. Review of Resident #1's face sheet dated 3/15/17 revealed she was admitted originally on 7/22/16, 1/6/17 and re-admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #1 readmitted with a s/p right [MEDICAL CONDITION] on 1/4/17. Review of Resident #1's Care Plan dated 3/11/17 revealed she was at risk for falls and had a history of [REDACTED]. Review of Resident #1 Admission MDS dated [DATE] revealed no indicators for falls. Review of Resident #1 Significant Change MDS dated [DATE] revealed no in

Based on record review and interview, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 3 of 14 residents (Resident #1, 2, 3) whose comprehensive care plans and assessments were reviewed in that: 1. Resident #3's comprehensive care plan did not accurately reflect her order for 2.0 cal supplement 4 times per day for her significant weight loss and her [MEDICATION NAME] two times per day for wound healing. 2. Resident #2 has a total of 21 falls over a period from 03/27/16 to 01/24/17 with the latter resulting in a Right [MEDICAL CONDITION] and consequent ORIF. Her last reported fall was on 02/06/2017. The resident's care plans were not updated and did not provide modified and effective interventions better suited to meet this residents increasing needs including declining cognition to prevent any further falls and serious injuries, or reflect the numerous falls and injuries sustained. 3. Resident #1's care plan did not indicate any falls or fractures prior to 2/7/17 and they were not updated with appropriate interventions. 4. Resident #4 had a total of 6 falls from the period between 11/6/16 to 2/20/17, this resident was not provided with modified and effective interventions on his out-dated care plans that were better suited to meet this residents needs. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 3/17/17. While the IJ was removed on 3/20/16, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. This deficient practice could affect 2 residents at the facility who were on 2.0 med pass and [MEDICATION NAME] on the 400 hall and could result in a decrease in metabolic muscle mass, and 35 residents with falls that could result in further falls, serious injury and declining health . The findings were: 1. Review of Resident #3's face sheet (dated 3/15/17) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's initial MDS assessment (dated 2/20/17) revealed her BIMS score of 15 (cognitively intact) and her weight was 124. Further review of Resident #2's 14 day MDS assessment revealed her BIMS score of 15 (cognitively intact), her weight was 118 and she had 2 pressure area (spine 2/27/17 and heel 30/6/17) in house. Review of Resident #3's telephone order (dated 2/27/17) revealed an order for [REDACTED]. Review of Resident #3's Care Plan (dated 3/9/17) revealed no documentation for the 2.0 calorie supplement for weight loss or the [MEDICATION NAME] for wound care. Interview on 3/16/17 at 2:10 p.m. with the DON confirmed Resident #3 was not receiving her 2.0 calorie supplement for weight loss or the [MEDICATION NAME] for wound care. The DON revealed the staff compared and reviewed last months orders and MARS' on 2/24/17, instead of the last day of the month and did not catch it until surveyor intervention. 2. Record review of Resident #2's Face Sheet dated 03/15/17, revealed Resident #2 was admitted to the facility on [DATE] and was readmitted on [DATE] and 01/29/2017 with the [DIAGNOSES REDACTED]. Record review of Resident #2's Comprehensive Annual Minimum Data Set ((MDS) dated [DATE], Brief Interview for Mental Status (BIMS) score of 7 (where 0-7 is severely impaired), Comprehensive, Annual MDS dated [DATE] (date of [MEDICAL CONDITION]) BIMS score of 4, Comprehensive, Significant Change MDS dated [DATE], BIMS score of 5 and a Quarterly MDS dated [DATE], BIMS score of 3. Record review of Resident #2's Fall Risk Evaluation (FRE) dated 02/6/17 revealed a score of 28 where a resident who scored a 10 or higher was at risk for falls. Record review of Resident #2's Comprehensive Annual Minimum Data Set ((MDS) dated [DATE], Activities of Daily Living (ADL) score of 7 (where 0-7 is severely impaired), Comprehensive, Annual MDS dated [DATE] (date of [MEDICAL CONDITION]) BIMS score of 4, Comprehensive, Significant Change MDS dated [DATE], BIMS score of 5 and a Quarterly MDS dated [DATE], BIMS score of 3. During an interview on 03/14/17 at 10:15 a.m., with LVN O revealed Resident #2 was not interviewable, had a [DIAGNOSES REDACTED]. Record review of Resident #2's Care Plan dated 3/15/17 revealed that she fell on [DATE] and 11/27/17 and the intervention included re-education. Care Plan Problem: I have had a history of [REDACTED]. 12/4/16 acute fall in facility had been toileted prior to this. Had an actual fall on 1/24 trying to stand and fell , moved resident to common area. 2/6/17 actual fall witnessed by employee going down the hall and fell forward, educated staff on proper transferring. Care Plan Goals: My number of falls will be reduced through next review date. Target date 5/24/17 Care Plan Interventions: Toileting q 2 hrs (. or PRN, keep in common area while awake for close observation, non-skid socks at all times, anti-roll back to wheelchair, drop wheelchair to aid in positioning, incontinent care program to attempt to decrease falls, toilet resident to assist to bed, after each fall episode evaluate current interventions and modify interventions according to IDT recommendations. Notify MD/NP and RP of fall and resulting assessment and interventions, complete fall documentation packet per facility protocol, for fall unobserved by staff or fall with potential/actual injury to the head, initiate neuro checks per protocol, monitor for changes in condition, document and report to MD/NP swelling, pain, lethargy, abnormal neural vital signs, change in functional ability, such as endurance, transfer, ambulation, etc .Document every shift for every 72 hours, the results of the targeted assessment related to the fall including pain. Standard of care in place unless otherwise noted: bed in low and locked position, call light within reach, personal items and fluids close at hand, clear clean pathways, and uncluttered surroundings, nightlight on/adequate lighting. Observation of Resident #2 on 03/14/17 at 3:30 p.m. revealed the resident was in bed, unable to answer questions. Resident seemed confused, unable to verbalize if she had eaten lunch. Record review of the facility's Fall Investigation included a Fall Worksheet and Fall Investigation Worksheet from 03/27/16 to 02/06/17 revealed Resident #2 had fallen a total of 21 times. The Fall Reports revealed the following: (1) 03/27/16 at 1:45 a.m., Resident #2 had an unwitnessed fall, fell face first sustaining a laceration to the bridge of her nose. She was reported to be alert. Intervention: Resident #2 to wear non-skid socks. Record Review of Resident #2's Fall Investigation Worksheet dated 03/27/16 revealed the resident did not have Episodes of Sundowning checked off and indicated that the resident required supervision. In the section entitled Number of falls, the facility reported 1+ falls in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 03/27/16 revealed the FSW, Section entitled: Nurse Manager Completes section 16-22, which addressed: If resident was placed on falling star program, was placed on Incident/Accident Log, Update Individual Fall Record, Care Plan updated, Rehabilitation screen, Medications reviewed, was not completed and/or signed. During an interview on 3/20/17 at 7:20 p.m., the Administrator confirmed the Fall Report was not fully completed (DON or the Nurse Manager did not fill out or sign the report). The Administrator also stated, she only knew what was on the report. (2) 04/25/16 at 5:00 p.m., Resident #2 fell , unwitnessed and found lying on the floor, noted to be confused. No injury noted. Intervention: Resident #2 was wheeled closer to the nursing station. Resident #2 has a FRE score of 22. Record Review of Resident's #2's Fall Investigation Worksheet dated 04/25/16 revealed it did not have Sundowning checked off, resident had Cognitive Impairment checked off and the section for number falls in the past 30 days and number of falls in the past 31 to 180 days was not filled out, however there was 1 documented fall in the past 30 days. Record Review of Resident #2's Fall Worksheet dated 04/25/16 revealed it did not have the Nurse Managers section completed or signed. (3) 04/26/16 at 3:45 p.m., Resident #2 fell unwitnessed, found lying on the floor next to nursing station, confused. Bruising to left and right elbow and red area noted to lower back. Intervention: Therapy evaluation for wheelchair, possible drop seat. Offer food, drinks, water, toileting and pain medications Record Review of Resident #2's Fall Investigation Worksheet dated 04/26/16 did not have Episodes of Sundowning checked off, resident had Cognitive Impairment, Anxiety Disorder, [MEDICAL CONDITION] and [MEDICAL CONDITION] marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 2 falls documented in the past 30 days. Record Review of Resident #2's Fall Worksheet dated 04/26/16 did not have the Nurse Managers section completed or signed. (4) 04/28/2016 at 9:30 p.m., Resident #2 was witnessed, slipping off bed with her pants down, confused with BM stains noted. No injury noted. Intervention: Resident to be toileted every two hours. Residents #2's FRE 24. Record Review of Resident #2's Fall Investigation Worksheet dated 04/28/16 did not have Episodes of Sundowning checked off, resident had Cognitive Impairment, Anxiety Disorder, [MEDICAL CONDITION] and [MEDICAL CONDITION] marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 3 falls documented in the past 30 days. Record Review of Resident #2's Fall Worksheet dated 04/28/16 did not have the Nurse Managers section completed or signed. Interview on 3/17/17 at 2:20 pm., Upon request of toileting documentation, the DON did not provide the requested documentation, and stated none was available. The DON revealed the resident was not being toileted according to her interventions. (5) 04/29/16 at 9:00 p.m., Resident #2 fell unwitnessed, off her wheelchair, found lying on the floor, noted to be alert/confused. No injuries noted. Residents #2's FRE 24, neuromuscular weakness noted. Intervention: Toilet resident more frequently, tilt wheelchair, place resident infront of nursing station. Record Review of Resident #2's Nurses Progress Notes dated 04/29/16 (no time noted), revealed resident had a head contusion. Record Review of Resident #2's Fall Investigation Worksheet dated 04/29/16 did not have Episodes of Sundowning checked off, resident had Cognitive Impairment, Anxiety Disorder and [MEDICAL CONDITION] marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 3 falls documented in the past 30 days and 1 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 04/29/16 did not have the Nurse Managers section completed or signed. (6) 05/04/2016 at 4:00 p.m., Resident #2 fell unwitnessed, found lying on the floor, confused with her wheelchair behind her, noted resident trying to sit in her wheelchair. No injuries noted. FRE 29. Intervention: Hydration aide asked to supervise resident, ambulate resident once every shift using gait belt with wheelchair behind her. Record Review of Resident #2's Nurses Progress notes dated 05/04/16 (no time noted) revealed, the resident was unable to voice her needs or wants and unable to follow commands. Record Review of Resident #2's Fall Investigation Worksheet dated 05/04/16 did not have Episodes of Sundowning checked off, Dementia was listed as a diagnosis. Cognitive Impairment, Anxiety Disorder and [MEDICAL CONDITION] were marked off. The section for number of falls in the past 30 days indicated there were 5 to 10 falls and number of falls in the past 31 to 180 days was not filled out, however there was 4 falls documented in the past 30 days and 1 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 05/04/16 did not have the Nurse Managers section completed or signed. (7) 06/10/16 at 11:00 a.m., Resident #2 fell unwitnessed (noted) , seen trying to get out of wheelchair, resident fell on her buttocks, noted to be confused. Resident was noted wearing her non-skid socks. Resident # 2 noted trying to get something to drink. No injuries noted. Intervention: Provide resident with shoes. Review of Resident #2's Incident/Action Plan (IAAP) dated 06/10/16 the following was on a toileting program, Rehab/Restorative and Behavioral program. Record Review of Resident #2's Fall Investigation Worksheet dated 06/10/16 did not have Episodes of Sundowning checked off, Dementia was listed as a diagnosis. Cognitive Impairment and Anxiety Disorder was marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 5 falls documented in the past 30 days and 1 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 06/10/16 did not have the Nurse Managers section completed or signed. (8) 07/11/16 at 6:00 p.m., Resident #2 (unwitnessed fall) was reported to be self toileting, missed the toilet seat and landed on her buttocks, was wearing her non-skid socks, noted to be alert. No injuries noted. Intervention: Already on every two hour toileting, resident educated on, when I get out of my wheelchair and attempt ambulation, I will be taken to the bathroom to see is that meets my need. Resident toileted and showered. Review of Resdeint #2's Incident/Action Plan (IAAP) dated 07/11/16 the following were not applicable (NA): the toileting program, Rehab/Restorative and Behavioral program. Record Review of Resident's #2's Fall Investigation Worksheet dated 07/11/16 did not have Episodes of Sundowning checked off, Dementia was listed as a diagnosis. Cognitive Impairment, Delerium and [MEDICAL CONDITION] were marked off. The section for number of falls indicated there were 2 falls in the past 30 days and number of falls in the past 31 to 180 days was not filled out, however there was 1 fall documented in the past 30 days and 6 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 07/11/16 did not have the Nurse Managers section completed or signed. (9) 07/27/16 at 1:50 p.m., Resident #2 was witnessed as she stood up from wheelchair and it slipped underneath her, resident grabbed side door and went down, noted to be alert and oriented to person (x1). No injuries noted. Pain Assessment (PA) score 2. Intervention: Non-skid socks at all times, reminders to lock wheel chair during transfers. Review of Resident #2's Incident/Action Plan (IAAP) dated 07/27/16 was blank. Record Review of Resident #2 Fall Investigation Worksheet dated 07/27/16 did not have Episodes of Sundowning checked off. Cognitive Impairment, Delerium and [MEDICAL CONDITION] were marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 1 fall documented in the past 30 days and 7 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 07/27/16 did not have the Nurse Managers section completed or signed. (10) 09/13/2016 at 9:00 p.m., Resident #2 has an unwitnessed fall, was found lying flat on her back in front of wheelchair. She was noted to be confused and sustained a superficial scratch to her right-middle back to left scapula measuring 8 cm by 3.5 cm. Intervention: Non-skid socks at all times, leave door to room open/cracked while resident is in there. Review of Resident #2's Incident/Action Plan (IAAP) dated 09/13/16 was blank. Record Review of Resident #2's Nurses Progress Note dated 09/13/16 at 1:10 p.m., revealed resident bumped head against breakroom door, while walking through doorway from dining room into breakroom. Record Review of Resident #2's Fall Investigation Worksheet dated 09/13/16 did not have Episodes of Sundowning checked off. Anxiety Disorders was marked off. Resident was described as restless, combative, having Dementia with behavioral disturbances and Cognitive communication deficient and requiring supervision. The section for number of falls indicated there was 2 falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there were 0 falls documented in the past 30 days and 9 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 09/13/16 did not have the Nurse Managers section completed or signed. (11) 11/08/2016 at 2:45 p.m., Resident #2 was witnessed slipping down against a wall during a one person assist while toileting. Resident was noted to be confused and sustained a superficial scratch to her back while sliding down wall with the toilet paper holder. FRE 17, PA 2. Intervention: Continue to monitor resident. Review of Resident #2's Incident/Action Plan (IAAP) dated 11/8/16 revealed the resident was on a toileting program. Record Review of Resident's #2 Fall Investigation Worksheet dated 11/08/16 did not have Episodes of Sundowning checked off. Anxiety Disorders and Cognitive Impairment were marked off. A [DIAGNOSES REDACTED]. The section for number of falls indicated there were 1 fall in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 0 falls documented in the past 30 days and 10 fall in the past 31 to 180 days. (12) 11/15/16 at 7:15 p.m., Resident #2 had an unwitnessed fall was found confused and lying on her right side by lobby, resident reported attempting to walk. resident sustained [REDACTED]. Her PA was reported at a 0. Intervention: Ice pack to forehead, toileting, bladder training program. Review of Resident #2's Incident/Action Plan (IAAP) dated 11/15/16 revealed the resident was not on a toileting program. Record Review of Resident #2's Fall Investigation Worksheet dated 11/15/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment, [MEDICAL CONDITION] and [MEDICAL CONDITION] were marked off. Resident was noted as requiring supervision. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 1 falls documented in the past 30 days and 10 fall in the past 31 to 180 days. (13) 12/04/16 at 8:50 p.m., Resident #2 had an unwitnessed fall, found confused, on the floor lying on her right side at end of bed, facing the bed with BM in her brief. Resident attempting to self-toilet. FRE 26, PA 1. Intervention: two person assist for all Activities of Daily Living (ADL's). Recommendation: a Stool C & S, [MEDICAL CONDITION] labs ordered. Record Review of Resident #2's Nurses Progress notes dated 12/04/16 at 9:50 p.m., revealed, the resident has increased confusion and the resident was unable to focus on nurse for a long time Review of Resident #2's Incident/Action Plan (IAAP) dated 12/04/16 was not completed. Note at 10:20 pm noted resident with increased confusion. Record Review of Resident #2's Fall Investigation Worksheet dated 12/04/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment, Alzheimer's and Depression were marked off. Resident was described as having increased confusion with weakness and requiring supervision. The section for number of falls indicated there was 2 falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there were 2 falls documented in the past 30 days and 10 fall in the past 31 to 180 days. Record Review of Resident's #2 Fall Worksheet dated 12/04/16 did not have the Nurse Managers section completed or signed. (14) 12/10/16 at 11:45 a.m., Resident #2 had an unwitnessed fall was found confused, lying on her right side, next to her wheelchair in the dining room. No injuries or pain noted. FRE 18. Intervention: Resident reminded not to get up out of chair (resident with Dementia), Remind aides to always put on non-skid socks and shoes at all times. Record Review of Resident #2's Nurses Progress notes dated 12/10/16 at 11:45 a.m., revealed, the resident was reminded not to get out of her chair without help. Review of Resident #2's Incident/Action Plan (IAAP) dated 12/10/16 revealed the resident was not on a toileting program, Rehab/Restorative or Behavioral program or had any safety precautions or devices. Record Review of Resident's #2 Fall Investigation Worksheet dated 12/10/16 did not have Episodes of Sundowning checked off. Cognitive Impairment was marked off. The section for number of falls indicated there was 1 fall in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 4 falls documented in the past 30 days and 9 fall in the past 31 to 180 days. Record Review of Resident's #2 Fall Worksheet dated 12/10/16 did not have the Nurse Managers section completed or signed. (15) 12/18/16 at 9:35 p.m., Resident #2 had an unwitnessed fall, found confused, on the floor against the wall across from the bathroom sitting up with back and head against the wall. No injuries noted. FRE 20, PA 2. Intervention: Toileting every two hours as needed, informed resident on the use of the call light with demonstration. Resident noted to have verbalized understanding. Review of Resident #2's Incident/Action Plan (IAAP) dated 12/18/16 revealed the resident was not on a toileting program, Rehab/Restorative or Behavioral program. Record Review of Resident #2's Nurses Progress notes dated 12/18/16 at 9:35 p.m., revealed resident was alert and oriented to person. Record Review of Resident #2's Fall Investigation Worksheet dated 12/18/16 did not have Episodes of Sundowning checked off. Anxiety Disorders was marked off and a [DIAGNOSES REDACTED]. Resident was described as requiring supervision. The section for number of falls indicated there were 3 falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 2 falls documented in the past 30 days and 12 fall in the past 31 to 180 days. Record Review of Resident's #2 Fall Worksheet dated 12/04/16 did not have the Nurse Managers section completed or signed. (16) 12/28/16 at 11:30 p.m., Resident #2 had an unwitnessed fall, she was found confused and sitting on the floor beside the bed (in low position, with wheels locked). FRE 20, PA 2. Intervention: Resident to wear non-skid socks when in bed, room to be clutter free, staff to check resident frequently. Review of Resident #2's Incident/Action Plan (IAAP) dated 12/28/16 revealed the resident was on a toileting program. It also revealed she was not on a Rehab/Restorative or Behavioral program. Record Review of Resident #2's Fall Investigation Worksheet dated 12/28/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment were marked off. Resident had a Dementia [DIAGNOSES REDACTED]. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 3 falls documented in the past 30 days and 12 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 12/28/16 did not have the Nurse Managers section completed or signed. (17) 12/30/16 at 10:00 p.m., Resident #2 had an unwitnessed fall, reportedly fell out of bed and hit her head on the edge of her night stand. Resident noted to be alert and sustained a head injury, bump and scrape to forehead. Intervention: Encourage the use of the call light when in need of assistance. Review of Resident #2's Incident/Action Plan (IAAP) dated 12/30/16 revealed the resident was on a toileting program. Record Review of Resident #2's Fall Investigation Worksheet dated 12/30/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment and Delerium were marked off. The section for number of falls indicated there were 2 falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 4 falls documented in the past 30 days and 12 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 12/30/16 did not have the Nurse Managers section completed or signed. (18) 12/31/16 at 6:40 p.m., Resident #2 had an unwitnessed fall reported to have fallen attempting to self-transfer to the toilet in the bathroom and hit her head on the bathroom cabinet. Resident noted as confused and sustained a head injury, abrasion to the back of her head and scalp. PA 4. Intervention: Moved to common area for close observations, and one to one monitoring and hourly rounding while in bed (marked out and note not appropriate). During an interview on 3/17/17 at 2:20 p.m., the DON revealed the reason for changing the intervention from one on one monitoring to moving resident to the common area was due to the staff were unable to sustain the intervention. Record Review of Resident #2's Nurses Progress notes dated 12/31/16 at 6:45 a.m., revealed the resident's pupils were sluggish to respond to light with speech slightly slurred. A large bluish discoloration and bump measuring approximately 4 cm by 4 cm to forehead. Resident was transported to the ER at 7:30 a.m. Record Review of Resident #2's Fall Investigation Worksheet dated 12/31/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment and Delerium were marked off and Dementia was indicated as a diagnosis. Resident was described as requiring supervision. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 6 falls documented in the past 30 days and 12 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 12/31/16 did not have the Nurse Managers section completed or signed. (19) 01/01/17 at 9:40 p.m., Resident #2, unwitnessed fall, found lying confused on her back, beside bed with the wheelchair leaned forward on top of her. No injuries noted. Intervention: One to one monitoring and hourly rounding while in bed (marked out and note not appropriate), Moved to nursing station and other common areas for close observation. Record Review of Resident #2's Fall Investigation Worksheet dated 01/01/17 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment and Delerium were marked off. Resident was described as requiring supervision. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out. (20) 01/24/16 at 3:00 p.m., Resident #2 sustained an unwitnessed fall. She was reported to be sitting in her wheelchair when she attempted to stand up and fell to the right side. Resident reported to be alert and oriented to person, with a PA 10 and FRE 20. Intervention: Ice pack to forehead, toileting. Provider Investigation Report for Resident# 2 revealed there were two nurses at the nursing station during the time of her fall, neither nurse witnessed the fall. Physician Assistant was in the premises and evaluated the resident. Resident noted to have facial grimacing when transferred to a chair. On 1/24/17, a right X-ray was ordered, along with knee X-ray, the results were both negative. Resident was still noted to have pain, PA ordered [MEDICATION NAME]. On 1/25/17 resident still noted to be guarding leg with facial grimacing. Dr. Notified and ordered a full pelvic X-ray. The X-rays came back with a faint subcapital nondisplaced [MEDICAL CONDITION] femoral neck. Doctor was notified and resident as sent to ER. The report also states the injury was very likely caused by the fall. Provider Action Post-Investigation: Continue to monitor residents to ensure their needs are met, when they are not able to verbalize them. Record Review of Resident #2's Fall Investigation Worksheet dated 1/24/16 did not have Episodes of Sundowning checked off. Anxiety Disorders and [MEDICAL CONDITION] were marked off. Resident was described as requiring supervision. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 4 falls documented in the past 30 days and 15 fall in the past 31 to 180 days Interventions: One to one monitoring and hourly rounding while in bed (marked out and note not appropriate), moved to common area for close observation. Record review of Resident #2's Daily Skilled Nurse's Note dated 1/31/2017 at 1:00 p.m. revealed resident returned to the facility at 1:00 p.m. via stretcher and EMS. Resident was alert and unable to clearly communicate, alert and oriented to person, displaying disorganized thinking .Resident was transferred to bed by EMS with a 16 French Foley Catheter. Surgical wound to Right Hip and a Stage I pressure ulcer to Left Sacrum. Resident required extensive assist with transfers, mobility, toileting and ADL's. Resident incontinent of bowel and bladder and demonstrates confusion. FRE of 28. (21) 02/06/2017 (no time given), CNA was wheeling Resident #2 down a hill leaving a clinic. Resident was reported to have leaned forward and fell . Resident was noted to be confused, a bruise was noted. FRE 28. Interventions: Staff education on how to wheel residents through bumps, hills, or inclines. Record Review of Resident #2's Nurses Progress notes dated 2/06/17 at 1:00 p.m., revealed Resident was assessed, a bruise to the right eyebrow and bruise to her right lower thigh was noted. Record Review of Resident #2's Fall Investigation Worksheet dated 02/06/17 did not have Episodes of Sundowning checked off. Anxiety Disorders and Cognitive Impairment were marked off. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there were 1 falls documented in the past 30 days and 19 fall in the past 31 to 180 days. During an interview on 3/17/17 at 9:30 a.m., the Administrator revealed Resident #2 used to walk prior to her [MEDICAL CONDITION]. She stated the floor mat was removed due to the possibility of the resident tripping. She also stated that the residents have the right to fall. During an interview on 3/17/17 at 2:04 p.m., the DON revealed, the facility's policies and procedures on fall prevention consisted of tracking and trending resident falls. DON stated falls were discussed during the morning meetings, any yellow tickets (fall screens for OT, PT, ST) were brought up. She also stated that after each fall, Physical Therapy would do a screen, working off incident reports reviewed each morning. She went on to state that for Resident #2, a Fall Risk Assessment was done and she was

Based on observation, interview, and record review the facility failed to ensure that residents receive adequate supervision and assistance devices to prevent accidents for 2 (Residents # 2 and 4) of 9 residents reviewed for falls in that: The facility: 1.) Failed to re-evaluate interventions after Resident # 2's 21 falls from 03/27/16 to 2/06/17. Resident # 2 sustained a fall on 1/24/2017. The resident was transferred to a local hospital on [DATE] where she was diagnosed with [REDACTED]. 2.) Failed to implement appropriate individualized interventions for Resident # 4 to prevent further falls. Resident # 4 sustained 6 falls within a 4 month period. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 3/17/17. While the IJ was removed on 3/20/16, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. This deficient practice placed 35 residents with a history of falls at risk for future falls and could result in injury or death. The findings were: 1. Record review of Resident #2's Face Sheet dated 03/15/17, revealed Resident #2 was admitted to the facility on [DATE] and was readmitted on [DATE] and 01/29/2017 with the [DIAGNOSES REDACTED]. Record review of Resident #2's Fall Risk Evaluation (FRE) dated 02/6/17 revealed a score of 28 where a resident who scored a 10 or higher was at risk for falls. Record review of Resident #2's Comprehensive Annual Minimum Data Set ((MDS) dated [DATE], Brief Interview for Mental Status (BIMS) score of 7 (where 0-7 is severely impaired), Comprehensive, Annual MDS dated [DATE] (date of Hip Fracture) BIMS score of 4, Comprehensive, Significant Change MDS dated [DATE], BIMS score of 5 and a Quarterly MDS dated [DATE], BIMS score of 3. Record review of Resident #2's Comprehensive Annual Minimum Data Set ((MDS) dated [DATE], Activities of Daily Living (ADL) score of 7 (where 0-7 is severely impaired), Comprehensive, Annual MDS dated [DATE] (date of Hip Fracture) BIMS score of 4, Comprehensive, Significant Change MDS dated [DATE], BIMS score of 5 and a Quarterly MDS dated [DATE], BIMS score of 3. During an interview on 03/14/17 at 10:15 a.m., with LVN O revealed Resident #2 was not interviewable, had a [DIAGNOSES REDACTED]. Record review of Resident #2's Care Plan dated 3/15/17 revealed that she fell on [DATE] and 11/27/17 and the intervention included re-education. Care Plan Problem: I have had a history of [REDACTED]. 12/4/16 acute fall in facility had been toileted prior to this. Had an actual fall on 1/24 trying to stand and fell , moved resident to common area. 2/6/17 actual fall witnessed by employee going down the hall and fell forward, educated staff on proper transferring. Care Plan Goals: My number of falls will be reduced through next review date. Target date 5/24/17 Care Plan Interventions: Toileting q 2 hrs (. or PRN, keep in common area while awake for close observation, non-skid socks at all times, anti-roll back to wheelchair, drop wheelchair to aid in positioning, incontinent care program to attempt to decrease falls, toilet resident to assist to bed, after each fall episode evaluate current interventions and modify interventions according to IDT recommendations. Notify MD/NP and RP of fall and resulting assessment and interventions, complete fall documentation packet per facility protocol, for fall unobserved by staff or fall with potential/actual injury to the head, initiate neuro checks per protocol, monitor for changes in condition, document and report to MD/NP swelling, pain, lethargy, abnormal neural vital signs, change in functional ability, such as endurance, transfer, ambulation, etc .Document every shift for every 72 hours, the results of the targeted assessment related to the fall including pain. Standard of care in place unless otherwise noted: bed in low and locked position, call light within reach, personal items and fluids close at hand, clear clean pathways, and uncluttered surroundings, nightlight on/adequate lighting. Observation of Resident #2 on 03/14/17 at 3:30 p.m. revealed the resident was in bed, unable to answer questions. Resident seemed confused, unable to verbalize if she had eaten lunch. Record review of the facility's Fall Investigation included a Fall Worksheet and Fall Investigation Worksheet from 03/27/16 to 02/06/17 revealed Resident #2 had fallen a total of 21 times. The Fall Reports revealed the following: (1) 03/27/16 at 1:45 a.m., Resident #2 had an unwitnessed fall, fell face first sustaining a laceration to the bridge of her nose. She was reported to be alert. Intervention: Resident #2 to wear non-skid socks. Record Review of Resident #2's Fall Investigation Worksheet dated 03/27/16 revealed the resident did not have Episodes of Sundowning checked off and indicated that the resident required supervision. In the section entitled Number of falls, the facility reported 1+ falls in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 03/27/16 revealed the FSW, Section entitled: Nurse Manager Completes section 16-22, which addressed: If resident was placed on falling star program, was placed on Incident/Accident Log, Update Individual Fall Record, Care Plan updated, Rehabilitation screen, Medications reviewed, was not completed and/or signed. During an interview on 3/20/17 at 7:20 p.m., the Administrator confirmed the Fall Report was not fully completed (DON or the Nurse Manager did not fill out or sign the report). The Administrator also stated, she only knew what was on the report. (2) 04/25/16 at 5:00 p.m., Resident #2 fell , unwitnessed and found lying on the floor, noted to be confused. No injury noted. Intervention: Resident #2 was wheeled closer to the nursing station. Resident #2 has a FRE score of 22. Record Review of Resident's #2's Fall Investigation Worksheet dated 04/25/16 revealed it did not have Sundowning checked off, resident had Cognitive Impairment checked off and the section for number falls in the past 30 days and number of falls in the past 31 to 180 days was not filled out, however there was 1 documented fall in the past 30 days. Record Review of Resident #2's Fall Worksheet dated 04/25/16 revealed it did not have the Nurse Managers section completed or signed. (3) 04/26/16 at 3:45 p.m., Resident #2 fell unwitnessed, found lying on the floor next to nursing station, confused. Bruising to left and right elbow and red area noted to lower back. Intervention: Therapy evaluation for wheelchair, possible drop seat. Offer food, drinks, water, toileting and pain medications Record Review of Resident #2's Fall Investigation Worksheet dated 04/26/16 did not have Episodes of Sundowning checked off, resident had Cognitive Impairment, Anxiety Disorder, Manic Depression and Schizophrenia marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 2 falls documented in the past 30 days. Record Review of Resident #2's Fall Worksheet dated 04/26/16 did not have the Nurse Managers section completed or signed. (4) 04/28/2016 at 9:30 p.m., Resident #2 was witnessed, slipping off bed with her pants down, confused with BM stains noted. No injury noted. Intervention: Resident to be toileted every two hours. Residents #2's FRE 24. Record Review of Resident #2's Fall Investigation Worksheet dated 04/28/16 did not have Episodes of Sundowning checked off, resident had Cognitive Impairment, Anxiety Disorder, Manic Depression and Schizophrenia marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 3 falls documented in the past 30 days. Record Review of Resident #2's Fall Worksheet dated 04/28/16 did not have the Nurse Managers section completed or signed. Interview on 3/17/17 at 2:20 pm., Upon request of toileting documentation, the DON did not provide the requested documentation, and stated none was available. The DON revealed the resident was not being toileted according to her interventions. (5) 04/29/16 at 9:00 p.m., Resident #2 fell unwitnessed, off her wheelchair, found lying on the floor, noted to be alert/confused. No injuries noted. Residents #2's FRE 24, neuromuscular weakness noted. Intervention: Toilet resident more frequently, tilt wheelchair, place resident infront of nursing station. Record Review of Resident #2's Nurses Progress Notes dated 04/29/16 (no time noted), revealed resident had a head contusion. Record Review of Resident #2's Fall Investigation Worksheet dated 04/29/16 did not have Episodes of Sundowning checked off, resident had Cognitive Impairment, Anxiety Disorder and Schizophrenia marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 3 falls documented in the past 30 days and 1 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 04/29/16 did not have the Nurse Managers section completed or signed. (6) 05/04/2016 at 4:00 p.m., Resident #2 fell unwitnessed, found lying on the floor, confused with her wheelchair behind her, noted resident trying to sit in her wheelchair. No injuries noted. FRE 29. Intervention: Hydration aide asked to supervise resident, ambulate resident once every shift using gait belt with wheelchair behind her. Record Review of Resident #2's Nurses Progress notes dated 05/04/16 (no time noted) revealed, the resident was unable to voice her needs or wants and unable to follow commands. Record Review of Resident #2's Fall Investigation Worksheet dated 05/04/16 did not have Episodes of Sundowning checked off, Dementia was listed as a diagnosis. Cognitive Impairment, Anxiety Disorder and Schizophrenia were marked off. The section for number of falls in the past 30 days indicated there were 5 to 10 falls and number of falls in the past 31 to 180 days was not filled out, however there was 4 falls documented in the past 30 days and 1 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 05/04/16 did not have the Nurse Managers section completed or signed. (7) 06/10/16 at 11:00 a.m., Resident #2 fell unwitnessed (noted) , seen trying to get out of wheelchair, resident fell on her buttocks, noted to be confused. Resident was noted wearing her non-skid socks. Resident # 2 noted trying to get something to drink. No injuries noted. Intervention: Provide resident with shoes. Review of Resident #2's Incident/Action Plan (IAAP) dated 06/10/16 the following was on a toileting program, Rehab/Restorative and Behavioral program. Record Review of Resident #2's Fall Investigation Worksheet dated 06/10/16 did not have Episodes of Sundowning checked off, Dementia was listed as a diagnosis. Cognitive Impairment and Anxiety Disorder was marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 5 falls documented in the past 30 days and 1 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 06/10/16 did not have the Nurse Managers section completed or signed. (8) 07/11/16 at 6:00 p.m., Resident #2 (unwitnessed fall) was reported to be self toileting, missed the toilet seat and landed on her buttocks, was wearing her non-skid socks, noted to be alert. No injuries noted. Intervention: Already on every two hour toileting, resident educated on, when I get out of my wheelchair and attempt ambulation, I will be taken to the bathroom to see is that meets my need. Resident toileted and showered. Review of Resident #2's Incident/Action Plan (IAAP) dated 07/11/16 the following were not applicable (NA): the toileting program, Rehab/Restorative and Behavioral program. Record Review of Resident's #2's Fall Investigation Worksheet dated 07/11/16 did not have Episodes of Sundowning checked off, Dementia was listed as a diagnosis. Cognitive Impairment, Delerium and Manic Depression were marked off. The section for number of falls indicated there were 2 falls in the past 30 days and number of falls in the past 31 to 180 days was not filled out, however there was 1 fall documented in the past 30 days and 6 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 07/11/16 did not have the Nurse Managers section completed or signed. (9) 07/27/16 at 1:50 p.m., Resident #2 was witnessed as she stood up from wheelchair and it slipped underneath her, resident grabbed side door and went down, noted to be alert and oriented to person (x1). No injuries noted. Pain Assessment (PA) score 2. Intervention: Non-skid socks at all times, reminders to lock wheel chair during transfers. Review of Resident #2's Incident/Action Plan (IAAP) dated 07/27/16 was blank. Record Review of Resident #2 Fall Investigation Worksheet dated 07/27/16 did not have Episodes of Sundowning checked off. Cognitive Impairment, Delerium and Manic Depression were marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 1 fall documented in the past 30 days and 7 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 07/27/16 did not have the Nurse Managers section completed or signed. (10) 09/13/2016 at 9:00 p.m., Resident #2 has an unwitnessed fall, was found lying flat on her back in front of wheelchair. She was noted to be confused and sustained a superficial scratch to her right-middle back to left scapula measuring 8 cm by 3.5 cm. Intervention: Non-skid socks at all times, leave door to room open/cracked while resident is in there. Review of Resident #2's Incident/Action Plan (IAAP) dated 09/13/16 was blank. Record Review of Resident #2's Nurses Progress Note dated 09/13/16 at 1:10 p.m., revealed resident bumped head against breakroom door, while walking through doorway from dining room into breakroom. Record Review of Resident #2's Fall Investigation Worksheet dated 09/13/16 did not have Episodes of Sundowning checked off. Anxiety Disorders was marked off. Resident was described as restless, combative, having Dementia with behavioral disturbances and Cognitive communication deficient and requiring supervision. The section for number of falls indicated there was 2 falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there were 0 falls documented in the past 30 days and 9 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 09/13/16 did not have the Nurse Managers section completed or signed. (11) 11/08/2016 at 2:45 p.m., Resident #2 was witnessed slipping down against a wall during a one person assist while toileting. Resident was noted to be confused and sustained a superficial scratch to her back while sliding down wall with the toilet paper holder. FRE 17, PA 2. Intervention: Continue to monitor resident. Review of Resident #2's Incident/Action Plan (IAAP) dated 11/8/16 revealed the resident was on a toileting program. Record Review of Resident's #2 Fall Investigation Worksheet dated 11/08/16 did not have Episodes of Sundowning checked off. Anxiety Disorders and Cognitive Impairment were marked off. A [DIAGNOSES REDACTED]. The section for number of falls indicated there were 1 fall in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 0 falls documented in the past 30 days and 10 falls in the past 31 to 180 days. (12) 11/15/16 at 7:15 p.m., Resident #2 had an unwitnessed fall was found confused and lying on her right side by lobby, resident reported attempting to walk. resident sustained [REDACTED]. Her PA was reported at a 0. Intervention: Ice pack to forehead, toileting, bladder training program. Review of Resident #2's Incident/Action Plan (IAAP) dated 11/15/16 revealed the resident was not on a toileting program. Record Review of Resident #2's Fall Investigation Worksheet dated 11/15/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment, Schizophrenia and Manic Depression were marked off. Resident was noted as requiring supervision. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 1 falls documented in the past 30 days and 10 fall in the past 31 to 180 days. (13) 12/04/16 at 8:50 p.m., Resident #2 had an unwitnessed fall, found confused, on the floor lying on her right side at end of bed, facing the bed with BM in her brief. Resident attempting to self-toilet. FRE 26, PA 1. Intervention: two person assist for all Activities of Daily Living (ADL's). Recommendation: a Stool C & S,[DIAGNOSES REDACTED] labs ordered. Record Review of Resident #2's Nurses Progress notes dated 12/04/16 at 9:50 p.m., revealed, the resident has increased confusion and the resident was unable to focus on nurse for a long time Review of Resident #2's Incident/Action Plan (IAAP) dated 12/04/16 was not completed. Note at 10:20 pm noted resident with increased confusion. Record Review of Resident #2's Fall Investigation Worksheet dated 12/04/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment, Alzheimer's and Depression were marked off. Resident was described as having increased confusion with weakness and requiring supervision. The section for number of falls indicated there was 2 falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there were 2 falls documented in the past 30 days and 10 fall in the past 31 to 180 days. Record Review of Resident's #2 Fall Worksheet dated 12/04/16 did not have the Nurse Managers section completed or signed. (14) 12/10/16 at 11:45 a.m., Resident #2 had an unwitnessed fall was found confused, lying on her right side, next to her wheelchair in the dining room. No injuries or pain noted. FRE 18. Intervention: Resident reminded not to get up out of chair (resident with Dementia), Remind aides to always put on non-skid socks and shoes at all times. Record Review of Resident #2's Nurses Progress notes dated 12/10/16 at 11:45 a.m., revealed, the resident was reminded not to get out of her chair without help. Review of Resident #2's Incident/Action Plan (IAAP) dated 12/10/16 revealed the resident was not on a toileting program, Rehab/Restorative or Behavioral program or had any safety precautions or devices. Record Review of Resident's #2 Fall Investigation Worksheet dated 12/10/16 did not have Episodes of Sundowning checked off. Cognitive Impairment was marked off. The section for number of falls indicated there was 1 fall in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 4 falls documented in the past 30 days and 9 fall in the past 31 to 180 days. Record Review of Resident's #2 Fall Worksheet dated 12/10/16 did not have the Nurse Managers section completed or signed. (15) 12/18/16 at 9:35 p.m., Resident #2 had an unwitnessed fall, found confused, on the floor against the wall across from the bathroom sitting up with back and head against the wall. No injuries noted. FRE 20, PA 2. Intervention: Toileting every two hours as needed, informed resident on the use of the call light with demonstration. Resident noted to have verbalized understanding. Review of Resident #2's Incident/Action Plan (IAAP) dated 12/18/16 revealed the resident was not on a toileting program, Rehab/Restorative or Behavioral program. Record Review of Resident #2's Nurses Progress notes dated 12/18/16 at 9:35 p.m., revealed resident was alert and oriented to person. Record Review of Resident #2's Fall Investigation Worksheet dated 12/18/16 did not have Episodes of Sundowning checked off. Anxiety Disorders was marked off and a [DIAGNOSES REDACTED]. Resident was described as requiring supervision. The section for number of falls indicated there were 3 falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 2 falls documented in the past 30 days and 12 fall in the past 31 to 180 days. Record Review of Resident's #2 Fall Worksheet dated 12/04/16 did not have the Nurse Managers section completed or signed. (16) 12/28/16 at 11:30 p.m., Resident #2 had an unwitnessed fall, she was found confused and sitting on the floor beside the bed (in low position, with wheels locked). FRE 20, PA 2. Intervention: Resident to wear non-skid socks when in bed, room to be clutter free, staff to check resident frequently. Review of Resident #2's Incident/Action Plan (IAAP) dated 12/28/16 revealed the resident was on a toileting program. It also revealed she was not on a Rehab/Restorative or Behavioral program. Record Review of Resident #2's Fall Investigation Worksheet dated 12/28/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment were marked off. Resident had a Dementia [DIAGNOSES REDACTED]. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 3 falls documented in the past 30 days and 12 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 12/28/16 did not have the Nurse Managers section completed or signed. (17) 12/30/16 at 10:00 p.m., Resident #2 had an unwitnessed fall, reportedly fell out of bed and hit her head on the edge of her night stand. Resident noted to be alert and sustained a head injury, bump and scrape to forehead. Intervention: Encourage the use of the call light when in need of assistance. Review of Resident #2's Incident/Action Plan (IAAP) dated 12/30/16 revealed the resident was on a toileting program. Record Review of Resident #2's Fall Investigation Worksheet dated 12/30/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment and Delerium were marked off. The section for number of falls indicated there were 2 falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 4 falls documented in the past 30 days and 12 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 12/30/16 did not have the Nurse Managers section completed or signed. (18) 12/31/16 at 6:40 p.m., Resident #2 had an unwitnessed fall reported to have fallen attempting to self-transfer to the toilet in the bathroom and hit her head on the bathroom cabinet. Resident noted as confused and sustained a head injury, abrasion to the back of her head and scalp. PA 4. Intervention: Moved to common area for close observations, and one to one monitoring and hourly rounding while in bed (marked out and note not appropriate). During an interview on 3/17/17 at 2:20 p.m., the DON revealed the reason for changing the intervention from one on one monitoring to moving resident to the common area was due to the staff were unable to sustain the intervention. Record Review of Resident #2's Nurses Progress notes dated 12/31/16 at 6:45 a.m., revealed the resident's pupils were sluggish to respond to light with speech slightly slurred. A large bluish discoloration and bump measuring approximately 4 cm by 4 cm to forehead. Resident was transported to the ER at 7:30 a.m. Record Review of Resident #2's Fall Investigation Worksheet dated 12/31/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment and Delerium were marked off and Dementia was indicated as a diagnosis. Resident was described as requiring supervision. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 6 falls documented in the past 30 days and 12 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 12/31/16 did not have the Nurse Managers section completed or signed. (19) 01/01/17 at 9:40 p.m., Resident #2, unwitnessed fall, found lying confused on her back, beside bed with the wheelchair leaned forward on top of her. No injuries noted. Intervention: One to one monitoring and hourly rounding while in bed (marked out and note not appropriate), Moved to nursing station and other common areas for close observation. Record Review of Resident #2's Fall Investigation Worksheet dated 01/01/17 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment and Delerium were marked off. Resident was described as requiring supervision. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out. (20) 01/24/16 at 3:00 p.m., Resident #2 sustained an unwitnessed fall. She was reported to be sitting in her wheelchair when she attempted to stand up and fell to the right side. Resident reported to be alert and oriented to person, with a PA 10 and FRE 20. Intervention: Ice pack to forehead, toileting. Provider Investigation Report for Resident# 2 revealed there were two nurses at the nursing station during the time of her fall, neither nurse witnessed the fall. Physician Assistant was in the premises and evaluated the resident. Resident noted to have facial grimacing when transferred to a chair. On 1/24/17, a right X-ray was ordered, along with knee X-ray, the results were both negative. Resident was still noted to have pain, PA ordered Tramadol. On 1/25/17 resident still noted to be guarding leg with facial grimacing. Dr. Notified and ordered a full pelvic X-ray. The X-rays came back with a faint subcapital nondisplaced fracture of the right femoral neck. Doctor was notified and resident as sent to ER. The report also states the injury was very likely caused by the fall. Provider Action Post-Investigation: Continue to monitor residents to ensure their needs are met, when they are not able to verbalize them. Record Review of Resident #2's Fall Investigation Worksheet dated 1/24/16 did not have Episodes of Sundowning checked off. Anxiety Disorders and Manic Depression were marked off. Resident was described as requiring supervision. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 4 falls documented in the past 30 days and 15 fall in the past 31 to 180 days Interventions: One to one monitoring and hourly rounding while in bed (marked out and note not appropriate), moved to common area for close observation. Record review of Resident #2's Daily Skilled Nurse's Note dated 1/31/2017 at 1:00 p.m. revealed resident returned to the facility at 1:00 p.m. via stretcher and EMS. Resident was alert and unable to clearly communicate, alert and oriented to person, displaying disorganized thinking .Resident was transferred to bed by EMS with a 16 French Foley Catheter. Surgical wound to Right Hip and a Stage I pressure ulcer to Left Sacrum. Resident required extensive assist with transfers, mobility, toileting and ADL's. Resident incontinent of bowel and bladder and demonstrates confusion. FRE of 28. (21) 02/06/2017 (no time given), CNA was wheeling Resident #2 down a hill leaving a clinic. Resident was reported to have leaned forward and fell . Resident was noted to be confused, a bruise was noted. FRE 28. Interventions: Staff education on how to wheel residents through bumps, hills, or inclines. Record Review of Resident #2's Nurses Progress notes dated 2/06/17 at 1:00 p.m., revealed Resident was assessed, a bruise to the right eyebrow and bruise to her right lower thigh was noted. Record Review of Resident #2's Fall Investigation Worksheet dated 02/06/17 did not have Episodes of Sundowning checked off. Anxiety Disorders and Cognitive Impairment were marked off. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there were 1 falls documented in the past 30 days and 19 fall in the past 31 to 180 days. During an interview on 3/17/17 at 9:30 a.m., the Administrator revealed Resident #2 used to walk prior to her hip fracture. She stated the floor mat was removed due to the possibility of the resident tripping. She also stated that the residents have the right to fall. During an interview on 3/17/17 at 2:04 p.m., the DON revealed, the facility's policies and procedures on fall prevention consisted of tracking and trending resident falls. DON stated falls were discussed during the morning meetings, any yellow tickets (fall screens for OT, PT, ST) were brought up. She also stated that after each fall, Physical Therapy would do a screen, working off incident reports reviewed each morning. She went on to state that for Resident #2, a Fall Risk Assessment was done and she was evaluated for a special chair. She also stated, the resident had Sundowners (Sundowners syndrome is an ailment that causes symptoms of confusion after sundown. These symptoms appear in people who suffer from Alzheimer's Disease or other forms of dementia. During an interview on 3/17/17 at 3:30 p.m., OTA/Rehabilitation Director stated an evaluation is scheduled after all falls during the Weekly At Risk (WAR) meeting. She went on to state Falls, Weight loss, Behaviors and New Admissions and any triggers are discussed during this interdisciplinary team meeting. She stated that staff were trained on: Why falls occur, what are the circumstances for example: at the same time each day, from a chair when a resident is reaching and how to prevent that from occurring. She also stated that Resident #2's falls mostly occurred in the evenings. During an interview on 3/20/17 at 7:20 p.m., with the Administrator, all 21 fall reports were reviewed one by one. The Administrator revealed, she only knew what was on the paperwork. When she was asked if there was anything else that could have been done to prevent the falls? She stated, Yes, she was put on toileting program to prevent further falls. 2. Resident #4 was admitted on [DATE] and re-admitted [DATE] with the following Diagnoses: [REDACTED]. Record Review of Resident #4's Quarterly MDS assessment dated [DATE] which revealed a BIMS score of 1 (0-7 severely impaired) and an Annual MDS assessment dated [DATE] which revealed a BIMS score of 3. Both of these assessments revealed the residents needs for extensive assistance with ADL's. Record Review for Resident #4's Care Plan dated 3/15/17 revealed: Care Plan Problem: Acute Care Plan; Actual fall (no date gi

Based on observations, interviews, and record reviews the facility Administrator failed to provide oversight in a manner that enabled the use of the facility's resources effectively and efficiently to attain or maintain the highest practicable physical well-being for 3 of 14 residents identified with falls with major injuries (Resident #2, 1 and 4). A. The Director of Nurses (DON) failed to prevent facility policies and procedures regarding falls with major injuries. B. The Administrator failed to supervise the Director of Nurses (DON) to ensure she was monitoring tracking, trending and identifying and providing modified and effective interventions better suited to meet these Resident's (# 2, 1 and 4) increasing needs including declining cognition to prevent any further falls and serious injuries. 1. Resident #2 had a total of 21 falls over a period from 03/27/16 to 01/24/17 with the latter resulting in a Right [MEDICAL CONDITION] and consequent ORIF. Her last reported fall was on 02/06/2017. Although the Administrator and DON stated that these falls were addressed in their daily and weekly meetings, the resident continued to fall and the same interventions were kept in place, no new interventions were implemented. The resident was not provided modified and effective interventions better suited to meet this residents increasing needs including declining cognition to prevent any further falls and serious injuries. 2. Resident #1 had 7 falls and was not provided modified and effective interventions that were better suited to meet this residents needs. 3. Resident #4 had a total of 6 falls from the period between 11/6/16 to 2/20/17, this Resident was not provided with modified and effective interventions that were better suited to meet this residents needs. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 3/17/17. While the IJ was removed on 3/20/16, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. This deficient practice could affect 35 residents who have a history of falls and are at risk for falls, and could result in injury or death. The findings were: 1. Record review of Resident #2's Face Sheet dated 03/15/17, revealed Resident #2 was admitted to the facility on [DATE] and was readmitted on [DATE] and 01/29/2017 with the [DIAGNOSES REDACTED]. Record review of Resident #2's Fall Risk Evaluation (FRE) dated 02/6/17 revealed a score of 28 where a resident who scored a 10 or higher was at risk for falls. Record review of Resident #2's Comprehensive Annual Minimum Data Set ((MDS) dated [DATE], Brief Interview for Mental Status (BIMS) score of 7 (where 0-7 is severely impaired), Comprehensive, Annual MDS dated [DATE] (date of [MEDICAL CONDITION]) BIMS score of 4, Comprehensive, Significant Change MDS dated [DATE], BIMS score of 5 and a Quarterly MDS dated [DATE], BIMS score of 3. Record review of Resident #2's Comprehensive Annual Minimum Data Set ((MDS) dated [DATE], Activities of Daily Living (ADL) score of 7 (where 0-7 is severely impaired), Comprehensive, Annual MDS dated [DATE] (date of [MEDICAL CONDITION]) BIMS score of 4, Comprehensive, Significant Change MDS dated [DATE], BIMS score of 5 and a Quarterly MDS dated [DATE], BIMS score of 3. During an interview on 03/14/17 at 10:15 a.m., with LVN O revealed Resident #2 was not interviewable, had a [DIAGNOSES REDACTED]. Record review of Resident #2's Care Plan dated 3/15/17 revealed that she fell on [DATE] and 11/27/17 and the intervention included re-education. Care Plan Problem: I have had a history of [REDACTED]. 12/4/16 acute fall in facility had been toileted prior to this. Had an actual fall on 1/24 trying to stand and fell , moved resident to common area. 2/6/17 actual fall witnessed by employee going down the hall and fell forward, educated staff on proper transferring. Care Plan Goals: My number of falls will be reduced through next review date. Target date 5/24/17 Care Plan Interventions: Toileting q 2 hrs (. or PRN, keep in common area while awake for close observation, non-skid socks at all times, anti-roll back to wheelchair, drop wheelchair to aid in positioning, incontinent care program to attempt to decrease falls, toilet resident to assist to bed, after each fall episode evaluate current interventions and modify interventions according to IDT recommendations. Notify MD/NP and RP of fall and resulting assessment and interventions, complete fall documentation packet per facility protocol, for fall unobserved by staff or fall with potential/actual injury to the head, initiate neuro checks per protocol, monitor for changes in condition, document and report to MD/NP swelling, pain, lethargy, abnormal neural vital signs, change in functional ability, such as endurance, transfer, ambulation, etc .Document every shift for every 72 hours, the results of the targeted assessment related to the fall including pain. Standard of care in place unless otherwise noted: bed in low and locked position, call light within reach, personal items and fluids close at hand, clear clean pathways, and uncluttered surroundings, nightlight on/adequate lighting. Observation of Resident #2 on 03/14/17 at 3:30 p.m. revealed the resident was in bed, unable to answer questions. Resident seemed confused, unable to verbalize if she had eaten lunch. Record review of the facility's Fall Investigation included a Fall Worksheet and Fall Investigation Worksheet from 03/27/16 to 02/06/17 revealed Resident #2 had fallen a total of 21 times. The Fall Reports revealed the following: (1) 03/27/16 at 1:45 a.m., Resident #2 had an unwitnessed fall, fell face first sustaining a laceration to the bridge of her nose. She was reported to be alert. Intervention: Resident #2 to wear non-skid socks. Record Review of Resident #2's Fall Investigation Worksheet dated 03/27/16 revealed the resident did not have Episodes of Sundowning checked off and indicated that the resident required supervision. In the section entitled Number of falls, the facility reported 1+ falls in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 03/27/16 revealed the FSW, Section entitled: Nurse Manager Completes section 16-22, which addressed: If resident was placed on falling star program, was placed on Incident/Accident Log, Update Individual Fall Record, Care Plan updated, Rehabilitation screen, Medications reviewed, was not completed and/or signed. During an interview on 3/20/17 at 7:20 p.m., the Administrator confirmed the Fall Report was not fully completed (DON or the Nurse Manager did not fill out or sign the report). The Administrator also stated, she only knew what was on the report. (2) 04/25/16 at 5:00 p.m., Resident #2 fell , unwitnessed and found lying on the floor, noted to be confused. No injury noted. Intervention: Resident #2 was wheeled closer to the nursing station. Resident #2 has a FRE score of 22. Record Review of Resident's #2's Fall Investigation Worksheet dated 04/25/16 revealed it did not have Sundowning checked off, resident had Cognitive Impairment checked off and the section for number falls in the past 30 days and number of falls in the past 31 to 180 days was not filled out, however there was 1 documented fall in the past 30 days. Record Review of Resident #2's Fall Worksheet dated 04/25/16 revealed it did not have the Nurse Managers section completed or signed. (3) 04/26/16 at 3:45 p.m., Resident #2 fell unwitnessed, found lying on the floor next to nursing station, confused. Bruising to left and right elbow and red area noted to lower back. Intervention: Therapy evaluation for wheelchair, possible drop seat. Offer food, drinks, water, toileting and pain medications Record Review of Resident #2's Fall Investigation Worksheet dated 04/26/16 did not have Episodes of Sundowning checked off, resident had Cognitive Impairment, Anxiety Disorder, [MEDICAL CONDITION] and [MEDICAL CONDITION] marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 2 falls documented in the past 30 days. Record Review of Resident #2's Fall Worksheet dated 04/26/16 did not have the Nurse Managers section completed or signed. (4) 04/28/2016 at 9:30 p.m., Resident #2 was witnessed, slipping off bed with her pants down, confused with BM stains noted. No injury noted. Intervention: Resident to be toileted every two hours. Residents #2's FRE 24. Record Review of Resident #2's Fall Investigation Worksheet dated 04/28/16 did not have Episodes of Sundowning checked off, resident had Cognitive Impairment, Anxiety Disorder, [MEDICAL CONDITION] and [MEDICAL CONDITION] marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 3 falls documented in the past 30 days. Record Review of Resident #2's Fall Worksheet dated 04/28/16 did not have the Nurse Managers section completed or signed. Interview on 3/17/17 at 2:20 pm., Upon request of toileting documentation, the DON did not provide the requested documentation, and stated none was available. The DON revealed the resident was not being toileted according to her interventions. (5) 04/29/16 at 9:00 p.m., Resident #2 fell unwitnessed, off her wheelchair, found lying on the floor, noted to be alert/confused. No injuries noted. Residents #2's FRE 24, neuromuscular weakness noted. Intervention: Toilet resident more frequently, tilt wheelchair, place resident infront of nursing station. Record Review of Resident #2's Nurses Progress Notes dated 04/29/16 (no time noted), revealed resident had a head contusion. Record Review of Resident #2's Fall Investigation Worksheet dated 04/29/16 did not have Episodes of Sundowning checked off, resident had Cognitive Impairment, Anxiety Disorder and [MEDICAL CONDITION] marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 3 falls documented in the past 30 days and 1 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 04/29/16 did not have the Nurse Managers section completed or signed. (6) 05/04/2016 at 4:00 p.m., Resident #2 fell unwitnessed, found lying on the floor, confused with her wheelchair behind her, noted resident trying to sit in her wheelchair. No injuries noted. FRE 29. Intervention: Hydration aide asked to supervise resident, ambulate resident once every shift using gait belt with wheelchair behind her. Record Review of Resident #2's Nurses Progress notes dated 05/04/16 (no time noted) revealed, the resident was unable to voice her needs or wants and unable to follow commands. Record Review of Resident #2's Fall Investigation Worksheet dated 05/04/16 did not have Episodes of Sundowning checked off, Dementia was listed as a diagnosis. Cognitive Impairment, Anxiety Disorder and [MEDICAL CONDITION] were marked off. The section for number of falls in the past 30 days indicated there were 5 to 10 falls and number of falls in the past 31 to 180 days was not filled out, however there was 4 falls documented in the past 30 days and 1 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 05/04/16 did not have the Nurse Managers section completed or signed. (7) 06/10/16 at 11:00 a.m., Resident #2 fell unwitnessed (noted) , seen trying to get out of wheelchair, resident fell on her buttocks, noted to be confused. Resident was noted wearing her non-skid socks. Resident # 2 noted trying to get something to drink. No injuries noted. Intervention: Provide resident with shoes. Review of Resident #2's Incident/Action Plan (IAAP) dated 06/10/16 the following was on a toileting program, Rehab/Restorative and Behavioral program. Record Review of Resident #2's Fall Investigation Worksheet dated 06/10/16 did not have Episodes of Sundowning checked off, Dementia was listed as a diagnosis. Cognitive Impairment and Anxiety Disorder was marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 5 falls documented in the past 30 days and 1 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 06/10/16 did not have the Nurse Managers section completed or signed. (8) 07/11/16 at 6:00 p.m., Resident #2 (unwitnessed fall) was reported to be self toileting, missed the toilet seat and landed on her buttocks, was wearing her non-skid socks, noted to be alert. No injuries noted. Intervention: Already on every two hour toileting, resident educated on, when I get out of my wheelchair and attempt ambulation, I will be taken to the bathroom to see is that meets my need. Resident toileted and showered. Review of Resident #2's Incident/Action Plan (IAAP) dated 07/11/16 the following were not applicable (NA): the toileting program, Rehab/Restorative and Behavioral program. Record Review of Resident's #2's Fall Investigation Worksheet dated 07/11/16 did not have Episodes of Sundowning checked off, Dementia was listed as a diagnosis. Cognitive Impairment, Delerium and [MEDICAL CONDITION] were marked off. The section for number of falls indicated there were 2 falls in the past 30 days and number of falls in the past 31 to 180 days was not filled out, however there was 1 fall documented in the past 30 days and 6 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 07/11/16 did not have the Nurse Managers section completed or signed. (9) 07/27/16 at 1:50 p.m., Resident #2 was witnessed as she stood up from wheelchair and it slipped underneath her, resident grabbed side door and went down, noted to be alert and oriented to person (x1). No injuries noted. Pain Assessment (PA) score 2. Intervention: Non-skid socks at all times, reminders to lock wheel chair during transfers. Review of Resident #2's Incident/Action Plan (IAAP) dated 07/27/16 was blank. Record Review of Resident #2 Fall Investigation Worksheet dated 07/27/16 did not have Episodes of Sundowning checked off. Cognitive Impairment, Delerium and [MEDICAL CONDITION] were marked off. The section for number of falls in the past 30 days and falls in the past 31 to 180 days was not filled out, however there was 1 fall documented in the past 30 days and 7 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 07/27/16 did not have the Nurse Managers section completed or signed. (10) 09/13/2016 at 9:00 p.m., Resident #2 has an unwitnessed fall, was found lying flat on her back in front of wheelchair. She was noted to be confused and sustained a superficial scratch to her right-middle back to left scapula measuring 8 cm by 3.5 cm. Intervention: Non-skid socks at all times, leave door to room open/cracked while resident is in there. Review of Resident #2's Incident/Action Plan (IAAP) dated 09/13/16 was blank. Record Review of Resident #2's Nurses Progress Note dated 09/13/16 at 1:10 p.m., revealed resident bumped head against breakroom door, while walking through doorway from dining room into breakroom. Record Review of Resident #2's Fall Investigation Worksheet dated 09/13/16 did not have Episodes of Sundowning checked off. Anxiety Disorders was marked off. Resident was described as restless, combative, having Dementia with behavioral disturbances and Cognitive communication deficient and requiring supervision. The section for number of falls indicated there was 2 falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there were 0 falls documented in the past 30 days and 9 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 09/13/16 did not have the Nurse Managers section completed or signed. (11) 11/08/2016 at 2:45 p.m., Resident #2 was witnessed slipping down against a wall during a one person assist while toileting. Resident was noted to be confused and sustained a superficial scratch to her back while sliding down wall with the toilet paper holder. FRE 17, PA 2. Intervention: Continue to monitor resident. Review of Resident #2's Incident/Action Plan (IAAP) dated 11/8/16 revealed the resident was on a toileting program. Record Review of Resident's #2 Fall Investigation Worksheet dated 11/08/16 did not have Episodes of Sundowning checked off. Anxiety Disorders and Cognitive Impairment were marked off. A [DIAGNOSES REDACTED]. The section for number of falls indicated there were 1 fall in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 0 falls documented in the past 30 days and 10 fall in the past 31 to 180 days. (12) 11/15/16 at 7:15 p.m., Resident #2 had an unwitnessed fall was found confused and lying on her right side by lobby, resident reported attempting to walk. resident sustained [REDACTED]. Her PA was reported at a 0. Intervention: Ice pack to forehead, toileting, bladder training program. Review of Resident #2's Incident/Action Plan (IAAP) dated 11/15/16 revealed the resident was not on a toileting program. Record Review of Resident #2's Fall Investigation Worksheet dated 11/15/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment, [MEDICAL CONDITION] and [MEDICAL CONDITION] were marked off. Resident was noted as requiring supervision. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 1 falls documented in the past 30 days and 10 fall in the past 31 to 180 days. (13) 12/04/16 at 8:50 p.m., Resident #2 had an unwitnessed fall, found confused, on the floor lying on her right side at end of bed, facing the bed with BM in her brief. Resident attempting to self-toilet. FRE 26, PA 1. Intervention: two person assist for all Activities of Daily Living (ADL's). Recommendation: a Stool C & S, [MEDICAL CONDITION] labs ordered. Record Review of Resident #2's Nurses Progress notes dated 12/04/16 at 9:50 p.m., revealed, the resident has increased confusion and the resident was unable to focus on nurse for a long time Review of Resident #2's Incident/Action Plan (IAAP) dated 12/04/16 was not completed. Note at 10:20 pm noted resident with increased confusion. Record Review of Resident #2's Fall Investigation Worksheet dated 12/04/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment, Alzheimer's and Depression were marked off. Resident was described as having increased confusion with weakness and requiring supervision. The section for number of falls indicated there was 2 falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there were 2 falls documented in the past 30 days and 10 fall in the past 31 to 180 days. Record Review of Resident's #2 Fall Worksheet dated 12/04/16 did not have the Nurse Managers section completed or signed. (14) 12/10/16 at 11:45 a.m., Resident #2 had an unwitnessed fall was found confused, lying on her right side, next to her wheelchair in the dining room. No injuries or pain noted. FRE 18. Intervention: Resident reminded not to get up out of chair (resident with Dementia), Remind aides to always put on non-skid socks and shoes at all times. Record Review of Resident #2's Nurses Progress notes dated 12/10/16 at 11:45 a.m., revealed, the resident was reminded not to get out of her chair without help. Review of Resident #2's Incident/Action Plan (IAAP) dated 12/10/16 revealed the resident was not on a toileting program, Rehab/Restorative or Behavioral program or had any safety precautions or devices. Record Review of Resident's #2 Fall Investigation Worksheet dated 12/10/16 did not have Episodes of Sundowning checked off. Cognitive Impairment was marked off. The section for number of falls indicated there was 1 fall in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 4 falls documented in the past 30 days and 9 fall in the past 31 to 180 days. Record Review of Resident's #2 Fall Worksheet dated 12/10/16 did not have the Nurse Managers section completed or signed. (15) 12/18/16 at 9:35 p.m., Resident #2 had an unwitnessed fall, found confused, on the floor against the wall across from the bathroom sitting up with back and head against the wall. No injuries noted. FRE 20, PA 2. Intervention: Toileting every two hours as needed, informed resident on the use of the call light with demonstration. Resident noted to have verbalized understanding. Review of Resident #2's Incident/Action Plan (IAAP) dated 12/18/16 revealed the resident was not on a toileting program, Rehab/Restorative or Behavioral program. Record Review of Resident #2's Nurses Progress notes dated 12/18/16 at 9:35 p.m., revealed resident was alert and oriented to person. Record Review of Resident #2's Fall Investigation Worksheet dated 12/18/16 did not have Episodes of Sundowning checked off. Anxiety Disorders was marked off and a [DIAGNOSES REDACTED]. Resident was described as requiring supervision. The section for number of falls indicated there were 3 falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 2 falls documented in the past 30 days and 12 fall in the past 31 to 180 days. Record Review of Resident's #2 Fall Worksheet dated 12/04/16 did not have the Nurse Managers section completed or signed. (16) 12/28/16 at 11:30 p.m., Resident #2 had an unwitnessed fall, she was found confused and sitting on the floor beside the bed (in low position, with wheels locked). FRE 20, PA 2. Intervention: Resident to wear non-skid socks when in bed, room to be clutter free, staff to check resident frequently. Review of Resident #2's Incident/Action Plan (IAAP) dated 12/28/16 revealed the resident was on a toileting program. It also revealed she was not on a Rehab/Restorative or Behavioral program. Record Review of Resident #2's Fall Investigation Worksheet dated 12/28/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment were marked off. Resident had a Dementia [DIAGNOSES REDACTED]. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 3 falls documented in the past 30 days and 12 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 12/28/16 did not have the Nurse Managers section completed or signed. (17) 12/30/16 at 10:00 p.m., Resident #2 had an unwitnessed fall, reportedly fell out of bed and hit her head on the edge of her night stand. Resident noted to be alert and sustained a head injury, bump and scrape to forehead. Intervention: Encourage the use of the call light when in need of assistance. Review of Resident #2's Incident/Action Plan (IAAP) dated 12/30/16 revealed the resident was on a toileting program. Record Review of Resident #2's Fall Investigation Worksheet dated 12/30/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment and Delerium were marked off. The section for number of falls indicated there were 2 falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 4 falls documented in the past 30 days and 12 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 12/30/16 did not have the Nurse Managers section completed or signed. (18) 12/31/16 at 6:40 p.m., Resident #2 had an unwitnessed fall reported to have fallen attempting to self-transfer to the toilet in the bathroom and hit her head on the bathroom cabinet. Resident noted as confused and sustained a head injury, abrasion to the back of her head and scalp. PA 4. Intervention: Moved to common area for close observations, and one to one monitoring and hourly rounding while in bed (marked out and note not appropriate). During an interview on 3/17/17 at 2:20 p.m., the DON revealed the reason for changing the intervention from one on one monitoring to moving resident to the common area was due to the staff were unable to sustain the intervention. Record Review of Resident #2's Nurses Progress notes dated 12/31/16 at 6:45 a.m., revealed the resident's pupils were sluggish to respond to light with speech slightly slurred. A large bluish discoloration and bump measuring approximately 4 cm by 4 cm to forehead. Resident was transported to the ER at 7:30 a.m. Record Review of Resident #2's Fall Investigation Worksheet dated 12/31/16 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment and Delerium were marked off and Dementia was indicated as a diagnosis. Resident was described as requiring supervision. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 6 falls documented in the past 30 days and 12 fall in the past 31 to 180 days. Record Review of Resident #2's Fall Worksheet dated 12/31/16 did not have the Nurse Managers section completed or signed. (19) 01/01/17 at 9:40 p.m., Resident #2, unwitnessed fall, found lying confused on her back, beside bed with the wheelchair leaned forward on top of her. No injuries noted. Intervention: One to one monitoring and hourly rounding while in bed (marked out and note not appropriate), Moved to nursing station and other common areas for close observation. Record Review of Resident #2's Fall Investigation Worksheet dated 01/01/17 did not have Episodes of Sundowning checked off. Anxiety Disorders, Cognitive Impairment and Delerium were marked off. Resident was described as requiring supervision. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out. (20) 01/24/16 at 3:00 p.m., Resident #2 sustained an unwitnessed fall. She was reported to be sitting in her wheelchair when she attempted to stand up and fell to the right side. Resident reported to be alert and oriented to person, with a PA 10 and FRE 20. Intervention: Ice pack to forehead, toileting. Provider Investigation Report for Resident# 2 revealed there were two nurses at the nursing station during the time of her fall, neither nurse witnessed the fall. Physician Assistant was in the premises and evaluated the resident. Resident noted to have facial grimacing when transferred to a chair. On 1/24/17, a right X-ray was ordered, along with knee X-ray, the results were both negative. Resident was still noted to have pain, PA ordered [MEDICATION NAME]. On 1/25/17 resident still noted to be guarding leg with facial grimacing. Dr. Notified and ordered a full pelvic X-ray. The X-rays came back with a faint subcapital nondisplaced [MEDICAL CONDITION] femoral neck. Doctor was notified and resident as sent to ER. The report also states the injury was very likely caused by the fall. Provider Action Post-Investigation: Continue to monitor residents to ensure their needs are met, when they are not able to verbalize them. Record Review of Resident #2's Fall Investigation Worksheet dated 1/24/16 did not have Episodes of Sundowning checked off. Anxiety Disorders and [MEDICAL CONDITION] were marked off. Resident was described as requiring supervision. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there was 4 falls documented in the past 30 days and 15 fall in the past 31 to 180 days Interventions: One to one monitoring and hourly rounding while in bed (marked out and note not appropriate), moved to common area for close observation. Record review of Resident #2's Daily Skilled Nurse's Note dated 1/31/2017 at 1:00 p.m. revealed resident returned to the facility at 1:00 p.m. via stretcher and EMS. Resident was alert and unable to clearly communicate, alert and oriented to person, displaying disorganized thinking .Resident was transferred to bed by EMS with a 16 French Foley Catheter. Surgical wound to Right Hip and a Stage I pressure ulcer to Left Sacrum. Resident required extensive assist with transfers, mobility, toileting and ADL's. Resident incontinent of bowel and bladder and demonstrates confusion. FRE of 28. (21) 02/06/2017 (no time given), CNA was wheeling Resident #2 down a hill leaving a clinic. Resident was reported to have leaned forward and fell . Resident was noted to be confused, a bruise was noted. FRE 28. Interventions: Staff education on how to wheel residents through bumps, hills, or inclines. Record Review of Resident #2's Nurses Progress notes dated 2/06/17 at 1:00 p.m., revealed Resident was assessed, a bruise to the right eyebrow and bruise to her right lower thigh was noted. Record Review of Resident #2's Fall Investigation Worksheet dated 02/06/17 did not have Episodes of Sundowning checked off. Anxiety Disorders and Cognitive Impairment were marked off. The section for number of falls in the past 30 days and number falls in the past 31 to 180 days was not filled out, however there were 1 falls documented in the past 30 days and 19 fall in the past 31 to 180 days. During an interview on 3/17/17 at 9:30 a.m., the Administrator revealed Resident #2 used to walk prior to her [MEDICAL CONDITION]. She stated the floor mat was removed due to the possibility of the resident tripping. She also stated that the residents have the right to fall. During an interview on 3/17/17 at 2:04 p.m., the DON revealed, the facility's policies and procedures on fall prevention consisted of tracking and trending resident falls. DON stated falls were discussed during the morning meetings, any yellow tickets (fall screens for OT, PT, ST) were brought up. She also stated that after each fall, Physical Therapy would do a screen, working off incident reports reviewed each morning. She went on to state that for Resident #2, a Fall Risk Assessment was done and she was evaluated for a special chair. She also stated, the resident had Sundowners (Sundowners syndrome is an ailment that causes symptoms of confusion after sundown. These symptoms appear in people who suffer from [MEDICAL CONDITION] or other forms of dementia. Interview on 03/17/17 at 2:20 p.m., the DON revealed no new information regarding interventions or procedures implemented for Resident #2's falls from 11/08/16 to 1/24/17. At 2:30 p.m., DON stated, this resident has Dementia and gets confused, combative and redirection is hard. She went on to state Resident #2 suffers from Sundowners and her falls were mostly in the afternoons. She also stated, she would have liked to have found other fall interventions. During an interview on 3/17/17 at 3:30 p.m., OTA/Rehabilitation Director stated an evaluation is scheduled after all falls during the Weekly At Risk (WAR) meeting. She went on to state Falls, Weight loss, Behaviors and New Admissions and any triggers are discussed during this interdisciplinary team meeting. She stated that staff were

Based on interview and record review, the facility failed to maintain an effective Quality Assurance (QA) program that systematically reviewed quality of care related to services for the 35 residents who fell . In addition, the QA committee did not systematically identify all significant concerns, regarding falls and weight loss. They consequently did not follow their policies to ensure facility systems were efficiently placed to prevent residents form sustaining falls and weight loss. Cross Reference to F 223, F 226, F 279, F 280, F 323, and F 490 for related Immediate Jeopardy. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 3/17/17. While the IJ was removed on 3/20/16, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. This deficient practice placed 35 residents at the facility with a history of falls at risk for continued falls and 4 residents with weight loss at risk for continued weight loss and could result in injury or death. Findings Include: Interview on 3/17/17 at 2:04 p.m., the DON revealed, the facility's policies and procedures on fall prevention consisted of, Looking for other interventions via scenarios. DON stated falls were discussed during the morning meetings, any yellow tickets (fall screens for OT, PT, ST) were brought up. She also stated that after each fall, Physical Therapy would do a screen, working off incident reports reviewed each morning. She went on to state that for Resident #2, a Fall Risk Assessment was done and she was evaluated for a special chair. She also stated, the resident had Sundowners (Sundowners syndrome is an ailment that causes symptoms of confusion after sundown. These symptoms appear in people who suffer from [MEDICAL CONDITION] or other forms of dementia. Interview on 03/17/17 at 2:20 p.m., the DON revealed no new information regarding interventions or procedures implemented for Resident #2's falls from 11/08/16 to 1/24/17. At 2:30 p.m., DON stated, this resident has Dementia and gets confused, combative and redirection is hard. She went on to state Resident #2 suffers from Sundowners and her falls were mostly in the afternoons. She also stated, she would have liked to have found other fall interventions. Interview on 3/17/17 at 3:30 p.m., OTA/Rehabilitation Director stated an evaluation is scheduled after all falls during the Weekly At Risk (WAR) meeting. She went on to state Falls, Weight loss, Behaviors and New Admissions and any triggers are discussed during this interdisciplinary team meeting. She stated that staff were trained on: Why falls occur, what are the circumstances for example: at the same time each day, from a chair when a resident is reaching and how to prevent that from occurring. She also stated that Resident #2's fall mostly occurred in the evenings. During an interview on 3/20/17 at 7:20 p.m., with the Administrator, all 21 fall reports were reviewed one by one. The Administrator revealed, she only knew what was on the paperwork. When she was asked if there was anything else that could have been done to prevent the falls? She stated, Yes, she was put on toileting program. When asked if Resident #2's needs were met, she stated, It does not appear too. Review of the Quality Indicators prior to the survey, revealed the following: The state average of residents with falls with major injuries was 3.6%. The National average was 3.5%. The facility average was 9.4%. Group national percentile 96%. The Administrator was notified on 3/17/2017 at 6:35 p.m. of the Immediate Jeopardy for the above failures and a Plan of Removal was requested. The facility's Plan of Removal was provided by the Administrator on 3/19/2017 and included the following steps to be taken by the facility: a. Residents who reside in the facility will have a fall risk evaluation, begin updating fall risk evaluations on 3/17/17 TARGET DATE for completion: 03/19/17 Results will be assessed and evaluated by IDT team by 3/20/2017. Fall Risk Care Plans will be completed for our current residents by 3/21/2017 and on an ongoing basis to be monitored weekly during our WAR meeting (Weekly At Risk). b. Residents who are at increased risk for falls will be referred to therapy for screening, evaluation, treatment. Restorative program will be implemented and/or appropriate referrals to specialists if necessary. Screens completed 03/18/17. TARGET DATE for remaining items: 03/21/17 c. Fall incident reports will be reviewed in the morning clinical meetings as an ongoing expectation by the IDT members for new or additional interventions, care plans will be updated with interventions following a fall. WAR (Weekly At Risk) Meeting will be held weekly to include in depth discussion about interventions in place to determine if they are effective or need to be revisited. TARGET DATE for initial determinations: 03/21/2017 d. Staff members will be educated to call a member of nursing administration with falls when they occur to ensure care plan is initiated and interventions implemented e. Notification will be added to Point of Care for the CNA's and the dashboard of Point Click Care for Nurses to alert, started 03/18/17, TARGET DATE for completion: 03/21/17 f. Staff education to include: Fall Prevention Program, Abuse and Neglect, and Care planned Interventions by 3/20/2017 g. An Ad Hoc QAPI meeting was held 3/17/17 with the Medical Director and Administrator to review Plan of Removal. h. Activity Director to implement individualized busy boxes such as simple hand held items to aid in redirection, baby dolls, etc. as appropriate for residents' with cognitive deficits. TARGET DATE for completion: 03/21/17. Care plans will be updated to reflect the intervention and staff will be trained with returned demonstration of understanding on the process on an ongoing basis. TARGET DATE: 03/21/17 i. MDS will complete a significant change or change of condition, as appropriate, for all residents who have a fall with injury on an ongoing basis. This is completed to date and will be ongoing. j. On an ongoing basis, the IDT Team will discuss residents who are refusing current interventions during our WAR (Weekly At Risk) meeting to develop interventions to include additional snacks, activities, therapy and/or restorative plans, and ideas from resident's family to ensure resident's unmet needs are being addressed. Evaluation of the individual resident's restorative plan will be reviewed and adjusted to ensure that the plan is appropriate and effective. Care plans will be updated and staff trained on new measures on an ongoing basis. TARGET DATE: 03/22/17 k. Residents who have triggered high for being at risk for falls who are currently on a Restorative plan will have the evaluated by the IDT team to be completed by 3/20/2017. Cognition levels through BIMS scores will be reviewed to ensure that plan is appropriate. TARGET DATE: 03/21/17. l. A wheelchair audit will be conducted on all wheelchairs to evaluate for safety and will be completed in full by 3/20/2017. m. Staff will be trained upon hire and retrained on an ongoing basis on new and appropriate interventions for falls as identified during the weekly WAR meeting. INITIATED: 03/17/17 and an ongoing basis. Education will begin on 3.17.17 and continue each shift until 100% of the staff is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. Verification of the Plan of Removal was a follows: Observations and interview of facility staff conducted on 3/19/2017 and 3/20/2017 confirmed that fall risk assessments were completed for all residents residing at the facility, and that residents assessed to be at fall risk were evaluated by therapy services (PT/OT/ST). Observation of staff training regarding fall intervention and abuse and neglect was completed on 3/20/17. Interviews on this date confirmed staff knowledge regarding fall prevention and abuse and neglect. Observed the maintenance supervisor ensuring that the wheel-chairs used by the residents were safe and in good working condition. Reviewed updated MDS's and Care Plans of residents at risk for falls. The facility began corrective actions 3/19/17 at 1:49 p.m. and completed corrective actions on 3/20/17 at 6:47 p.m. Sixteen LVN's, twelve Hospitality Aides, six Kitchen staff, two MDS staff, two Activity staff, twelve CNA's, two CMA's, two Housekeepers, two Laundry Aides, two Business personnel and one Restorative Aide were in-serviced on the Fall Prevention Program and Abuse/Neglect Policy. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 3/17/17. While the IJ was removed on 3/20/16, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. According to information provided by the administrator on 3/20/17, there were 35 residents with a history of falls and at risk for future falls. Record review of the facility's weights for March of 2017 revealed 4 residents with significant weight loss.

Based on observation, interview, and record review, the facility failed to ensure that a resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 2 of 14 residents (#s 3 and 2) reviewed for weight loss in that: 1. Resident #3 had a significant weight loss of 8.6% in 30 days and her interventions of 2.0 calorie supplement and [MEDICATION NAME] were not administered as ordered. 2. Resident #2 had a severe weight loss of 31.2 pounds and 16.5% in 34 days and a recommendation for an increase in [MEDICATION NAME] (an appetite stimulant) was not implemented. This deficient practice could place 4 residents with significant weight loss at risk for further nutritional and muscle decline. The findings were: 1. Review of Resident #3's face sheet (dated 3/15/17) revealed that she was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's Initial MDS dated [DATE] revealed her weight was 124 pounds and her 14 day MDS dated [DATE] revealed her weight was 118 pounds. Review of Resident #3's telephone order (dated 2/27/17) revealed an order for [REDACTED]. Review of Resident #3's Care Plan dated 3/9/17 revealed I have potential nutritional problems related to decreased intake. Current weight is 113.0 pounds. Regular diet/thin liquids. No interventions of the 2.0 cal supplement or the [MEDICATION NAME] packet with documented. Review of Resident #3's weekly weights: 2/14/17-123.8 2/16/17-123.8 2/23/17-118.1 3/2/17-113.2 3/7/17-113.0 3/15/17-113.4 3/16/17-113.4 Review of Resident #3's February 2017 MAR indicated [REDACTED]. Further review revealed documentation that the 2.0 calorie supplement 60 cc 4 times a day and [MEDICATION NAME] packet (nutritional supplement) give 1 packet by mouth 2 times a day for wound healing mix with 6 ounces of water twice a day, was administered 1 day in February 2017. Review of Resident #3's March 2017 MAR indicated [REDACTED]. Review of the Diet Type Report dated 3/14/17 revealed Resident #3 was on House Supplement 2.0 calorie 60 cc 4 times a day. Review of weight records revealed that Resident #3's February 2017 weight revealed she weighed 123.8 and that her March 2017 weight was 113.2 equaling to a 8.6% weight loss in 1 month. Observation on 3/14/17 at 8 a.m. in Resident #3's room, her meal tray did not reveal she had 2.0 calorie supplement or the [MEDICATION NAME] packet (nutritional supplement). Observation on 3/15/17 at 8:26 a.m. in Resident #3's room, her meal tray did not reveal she had 2.0 calorie supplement or the [MEDICATION NAME] packet (nutritional supplement). Observation on 3/17/17 at 8:41 a.m. in Resident #3's room, her meal tray did not reveal she had 2.0 calorie supplement or the [MEDICATION NAME] packet (nutritional supplement). Interview on 3/16/17 at 2:10 p.m. with the DON confirmed Resident #3 was not receiving her 2.0 calorie supplement for weight loss or the [MEDICATION NAME] for wound care. The DON revealed the staff compared and reviewed last months orders and MARs on 2/24/17 instead of the last day of the month and did not catch it until surveyor intervention. Interview on 3/17/17 at 9:38 a.m. with the MDS/Care Plan RN Coordinator confirmed Resident #3's Care Plan was not documented for administration of 2.0 calorie supplement for weight loss or the [MEDICATION NAME] for wound care. Interview on 3/17/17 at 1:18 p.m. with Resident #3 revealed her comfortable weight was 130-145 pounds and the weight loss was not intentional. She said she would like to gain weight. Interview on 3/20/17 at 10:26 p.m. with the Dietician revealed she would add a fortified meal plan to Resident #3's diet (after surveyor intervention). 2. Record review of Resident #2's Face Sheet dated 03/15/17, revealed Resident #2 was admitted to the facility on [DATE] at a weight of 172.2 lbs and was readmitted on [DATE] and 01/29/2017 with the [DIAGNOSES REDACTED]. Record review of Resident #2's 2/20/16 Comprehensive MDS revealed she weighed 165 lbs with a loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Record Review of Resident #2's Care Plan dated 3/15/17 addressed weight concerns. Review of Resident #2's Dietary Progress Note dated 2/20/17 revealed her weight was 165.2 lbs, a weight loss of 8.4 lbs in 1 month and a loss of 18.2 lbs and 9.9% in 6 months. Poor appetite is noted, Resident on [MEDICATION NAME] 15 mg and on a Mechanical Soft Diet with no sugar packets on tray. RD recommended to increase [MEDICATION NAME] if not contraindicated and Nutritional Cups BID. Goal: Slow weight loss x 1 month. Review of Resident #2's Dietary Progress Note dated 2/27/17 revealed the resident was eating some of the Nutritional Cups. Goal: Slow weight loss x 1 month. RD note did not follow-up on her recommendations for an increase in [MEDICATION NAME]. Record Review of Resident #2's Weight Change Notification dated 3/10/17 revealed a note for an increase in [MEDICATION NAME]. This note was signed by the MD on 3/14/17. Record Review of Resident #2's Order Summary Report dated for March 2017 revealed this resident was still on [MEDICATION NAME] 15 mg one tablet by mouth at bedtime for anorexia. The dosage had not been increased. Record review of Resident #2's Nutritional Meal Intake dated 03/16/17 revealed, the resident was being offered the Nutritional Cups when the resident refused meals and when her PO intake was less than 50%. Interview on 3/16/17 at 10:30 a.m., DON revealed she reviewed Resident #2's chart and checked to see if there were any orders for the increase in [MEDICATION NAME]. There weren't any. Interview on 03/20/17 at 9:15 a.m., with the RD revealed she was aware of the residents severe weight loss. She also revealed that slow weight loss times one month means 3-4 % weight loss in 1 month. She then stated that Resident #2 had stopped eating in February and she recommended that they increase her [MEDICATION NAME] and was not aware if the recommendation had been reviewed and implemented and she would re-evaluate the resident. Review of Resident #2's Dietary Progress Note dated 03/20/17 revealed resident had poor appetite, Receiving [MEDICATION NAME] at 30 mg. Resident refuses to eat, encourage PO intake. Recommended Med Pass 60 cc TID (due to poor PO-intake). Goal: Slow weight loss of 3-4% x 1 month. Record review of the facility's weights for March of 2017 revealed 4 residents with significant weight loss.