Every finding on record at Avir at Coronado

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plans for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 4 of 5 residents (Resident #1, Resident #2, Resident #3, Resident #5) reviewed for care plans.The facility failed to ensure the comprehensive care plans for Resident #1, Resident #2, Resident #3, Resident #5 described the resident's goals for admission and desired outcomes, preference and potential for future discharge, and an assessment of their desire to return to the community. These failures could place the residents at risk of not receiving adequate care.Findings included: Record review of Resident #1's Face Sheet reviewed on 7/25/2026 reflected a [AGE] year-old male, with an admission date of 10/12/2020. Resident #1 had diagnoses which included: Vascular Dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain), Pseudobulbar Affect (brain condition marked by sudden, uncontrollable episodes of laughing or crying that don't match how a person is actually feeling), Schizoaffective disorder (a combination of schizophrenia symptoms, such as hallucinations or delusions, and major mood disorder symptoms, such as depression or mania), Dysphagia (trouble swallowing), General anxiety disorder (excessive, ongoing anxiety and worry that are difficult to control and interfere with day-to-day activities), Thrombocytopenia (low blood platelet count), Seizures (sudden, abnormal burst of electrical activity in the brain that temporarily changes behavior, movements, feelings, or awareness), Cortical blindness (damage to the occipital cortex), Cerebral infarction (brain or retinal cell death due to loss of blood flow), Aphasia (brain disorder that affects speech, comprehension, how someone reads, and write usually due to stroke or head injury), Need for assistance with personal care (daily activities such as bathing, dressing & mobility). Record review of Resident #1's MDS dated [DATE] reflected CAA triggers of Cognitive loss/Dementia, Visual Function, Communication, ADL function, and psychotropic drug use and were to be addressed in the care plan within 7 days of completing the MDS and CAA. Record review of Resident #1's undated Care Plan reviewed on 7/25/2026 reflected no assessment for a resident's return to the community, desired outcomes, preference and potential for future discharge was located. The undated care plan lacked documentation about the areas of Cognitive loss/Dementia, Visual Function, Communication, ADL function, and psychotropic drug use to be addressed. Record review of Resident #2's face sheet reviewed on 7/25/2026 reflected a [AGE] year-old male, with an admission date of 05/05/2022. Resident #2 had diagnoses which included: Wernicke Encephalopathy (severe neurological disorder caused by Vitamin B1 deficiency), Aphasia (brain disorder that affects speech, comprehension, how someone reads, and write usually due to stroke or head injury), Schizoaffective disorder (a combination of schizophrenia symptoms, such as hallucinations or delusions, and major mood disorder symptoms, such as depression or mania), Extrapyramidal and movement disorders (drug-induced movement disorders involving dystonia, akathisia, and parkinsonism), Dementia (loss of memory), General anxiety disorder (excessive, ongoing anxiety and worry that are difficult to control and interfere with day-to-day activities), Intermittent explosive disorder (sudden, repeated bouts of extreme anger, verbal aggression, or physical violence that are completely out of proportion to the trigger), Epilepsy (chronic brain disorder characterized by recurring, unprovoked seizures, abnormal electrical brain activity, and physical or sensory symptoms). Record review of Resident #2's undated Care Plan reviewed on 7/25/2026 reflected no assessment for a residents return to the community, desired outcomes, preference and potential for future discharge was located. Record review of Resident #3's face sheet reviewed on 7/25/2026 reflected a [AGE] year-old male, with an admission date of 09/27/2025. Resident #3 had diagnoses which included: Parkinson's Disease (movement disorder of the nervous system that worsens over time), Vascular Dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain), Dysphagia (trouble swallowing), Need for assistance with personal care (daily activities such as bathing, dressing & mobility). Record review of Resident #3's undated Care Plan reviewed on 7/25/2026 reflected no assessment for a residents return to the community, desired outcome, preference and potential for future discharge was documented. In an interview on 7/25/2026 at 9:47 A.M. with DON B, she stated that the team had a meeting with Resident #3 and his family to discuss discharge the day prior (7/24/2026). DON B stated the RP and Resident #3 wanted him to remain in the facility. In an interview on 7/25/2026 at 10:39 A.M. with Resident #3, he stated he did not want to leave the facility. Record review of resident #5's face sheet reviewed on 7/25/2026, reflected a [AGE] year-old male, with an admission date of 6/20/2023. Resident #5 had diagnoses which included: Alzheimer's Disease with early onset (A rare form of dementia affecting individuals under the age of 65, often presenting with memory loss, language difficulties, and vision changes), Dysphagia (trouble swallowing), Pre-excitation syndrome (cardiac ventricles activate earlier than normal), Bipolar disorder (extreme shifts in mood, energy, and activity levels marked by highs and lows), Schizoaffective disorder (a combination of schizophrenia symptoms, such as hallucinations or delusions, and major mood disorder symptoms, such as depression or mania). Record review of Resident #5's MDS dated [DATE] reflected CAA triggers of Cognitive loss/Dementia, Communication, psychosocial well-being, pressure ulcer, and pain and these triggers were to be addressed in the care plan within 7 days of completing the MDS and CAA. Record review of Resident #5's undated Care Plan reviewed on 7/25/2026 reflected no assessment for a residents return to the community, desired outcomes, preference and potential for future discharge was located. The undated care plan lacked documentation of Cognitive loss/Dementia, Communication, psychosocial well-being, pressure ulcer, and pain to be addressed. In an interview on 7/25/2026 at 12:05 P.M. with Resident #5's RP, she stated Resident #5 could not speak but he had no wounds or pressure sores. RP stated she had not seen him in pain. She stated staff knew what they were supposed to do. In an interview on 7/25/2026 at 3:55 P.M. with LVN D, she stated she did not look at the care plans to know what interventions were needed for each resident. She stated staff communicated and utilized reports that were updated consistently to provide care. LVN D stated she had no concerns and felt the residents' needs were all met. In an interview on 7/25/2026 at 6:26 P.M. with ADON C, she stated DON B was responsible for the documentation in the care plans. ADON C stated Resident #1 had no discharge plans and was at the facility for long-term care. She stated Resident #1 was legally blind and the facility staff provided him with assistance. ADON C stated Resident #1's room was arranged for him, and he had timers for interventions. ADON C stated Resident #1's room was marked so staff knew how to keep the furniture where it needed to go so he would know where it was. She stated further interventions were frequent checks and to make sure his needs were met. ADON C stated Resident #1 would let staff know about what he needed. She stated staff monitored for side effects of the psychotropic meds. ADON C stated Resident #1 saw psychiatry services. She stated the pharmacy and doctor review all the medications and staff did a GDR if the doctor suggested. ADON C stated Resident #1 was continent and had a sitter that came and did the showers with him. She stated that staff helped feed him and he made his needs known. ADON C stated staff did not use the care plan for needs but rather communicated across shifts, had meetings, ran reports and made sure everyone was following through with interventions. ADON C stated the care plan was supposed to be the plan of care, but staff communicated with each other, and the residents' needs were met. ADON C stated Resident #2 had no plans to discharge. ADON C stated Resident #5 was nonverbal and staff did a pain scale for pain assessment. ADON C stated Resident #2 had scheduled and PRN medications for pain. She stated he had no pressure injury, and staff were unable to complete the cognitive interview. ADON C stated Resident #5 had weight gain and was on nutrition supplements as an intervention. ADON C stated the facility met the needs of the residents and did what they were supposed to do. In an interview on 7/25/26 at 6:58 P.M. with DON B, she stated she did the care plans because her MDS nurse was new and still learning how to do them. DON B stated when the new company switched them over to the new system, she had to put all the care plans in manually and she did not receive any assistance. DON B stated there had been no resident effects because staff did not use the care plan for communication on resident needs. DON B stated staff communicated the needs and monitored the residents. DON B stated her and her MDS nurse were going through each care plan to ensure they were corrected as she knew this information was to be included. In an interview on 7/25/2026 at 7:26 P.M. with ADM A, he stated that DON B had to complete all the care plans immediately when the new company took over. ADM A stated the discharge information, and triggers were to be in the care plan, but he did not believe there to be any negative resident effects. Record review of the facility's Care Plans, Comprehensive Person-Centered policy dated 2001 reflected, 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.3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.c. includes the residents stated goals upon admission and desired outcomes.

Based on interview and record review, the facility failed to ensure that the resident had the right to receive mail, and to receive letters, packages and other materials delivered to the facility for the residents unopened for 1 of 7 (Resident #7) reviewed for resident rights. The facility failed to ensure that Resident #7 received his mail and packages unopened. This failure could affect residents by placing them at risk of not receiving packages unopened that could result in residents experiencing diminished psychosocial well-being and quality of life.The findings included:Record review of Resident #7's face sheet dated 07.01.2026 revealed a [AGE] year-old male was admitted to the facility on 02.09.2026 with the diagnoses that included Diabetes Mellitus type II, (chronic condition where the body cannot use insulin properly) and End State Renal Disease (final stage of kidney disease) Record Review of Resident #7's Quarterly MDS dated 06.24.2026 revealed Section C-Cognitive Status indicated the resident had a BIMS score of 15 (cognitively intact). During an interview on 07.03.2026 at 12:50 pm Resident #7 stated the BOM had opened his mail and taken copies of his insurance cards, and he did not like that. Resident #7 stated on more than one occasion his packages had been opened before being brought to him. Resident #7 stated he felt this violated his rights to privacy. During an interview on 07.03.2026 at 10:16 am the BOM stated she only opened mail when it pertained to insurance and the residents agree to that when they sign the admission packet. The BOM stated she let the residents know when she opened their mail and then made a copy of their insurance cards. The BOM stated she had not opened any resident packages. The BOM stated she was aware of Resident #7's package being opened recently. The BOM stated she was not aware how it happened. The BOM stated she was not the person who passed out packages but thought the maintenance workers thought it was theirs and opened it by mistake. The BOM stated the package was delivered to Resident #7 opened. During an interview on 07.03.2026 at 4:06 pm the ADMN stated he thought it was okay for the BOM to open mail containing insurance cards and to make copies of the insurance cards. The ADM stated all residents sign an admission agreement allowing the mail to be opened, if it was related to insurance. The ADMN stated he was not aware of any packages being opened before given to the residents. The ADMN stated there was no process for monitoring the mail or packages being opened prior to residents receiving them. Record review of Resident #7's admission Agreement, signed on 02.10.2026 revealed. Opening and Reading of Resident's Mail: The Resident and the Responsible Party hereby acknowledge, and the Resident understands that as a Resident of the Facility, the Resident has the right to privacy in written communications and the right to send and receive mail promptly that is unopened. Record review of facility's policy titled, Resident Rights without a date revealed:Policy statementEmployees shall treat all residents with kindness, respect and dignity.Policy Interpretation and Implementation Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to:A dignified existence;Be treated with respect, kindness and dignity;.cc. access to a telephone, mail, email;dd. communicates in person and by mail, email and telephone with privacy.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests and rodents. The facility failed to ensure an effective pest control program was in place to keep American roaches out of the facility. This failure could affect all 68 residents by placing them at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life.Findings included:Record review of invoice of pest control company, dated 06/03/2026, revealed roaches were reported in rooms 215, 236, 237, 238, 240, 241. The report revealed the following: American Roach activity.As discussed with the Administrator and Maintenance Director, during previous visits:- The primary contributing factor continues to be the lack of caulking around the bases of many toilets throughout the facility. Unsealed toilets bases and plumbing penetration provide direct access points for American Roaches, allowing them to travel freely throughout the building. - Sealing plumbing access points and properly caulking toilet bases would significantly reduce roach sighting and provide a long-term solution to the recurring issue.- Applied a granular roach bait to plumbing access points in all reported rooms.- Placed glue boards behind toilets in the affected rooms to monitor activity.- While these measures will help reduce activity, sealing entry points remains the most effective long-term solution.In an observation on 06/15/2026 at 2:15 pm, there was an American roach in the hallway by the door of the secured unit and there were 3 American roaches inside the entrance of the conference room. In an observation on 06/15/2026 at 4:00 pm, an American roach was in the bathroom in the conference room. In observations on 06/16/2026 at 11:30 pm, of Rooms 215, 236, 237, 238, 240, 241 that were listed in the pest control company report, revealed none of the toilets in those rooms were sealed as suggested in the report. In observations throughout the facility, there were no toilets observed that had been sealed. In an interview on 06/16/2026 at 11:45 am, Residents #3 and #4 who resided in room [ROOM NUMBER], stated they have seen roaches in their room in the past, but have not seen any today. In an interview on 06/16/2026 at 11:47 am, Resident #7 reported that she had seen roaches in her room. In an interview on 06/16/2026 at 11:49 am, Resident #5 who resides in room [ROOM NUMBER] said he has seen roaches in his room. In an interview on 06/16/2026 at 1:10 pm, Resident #6 who resided in room [ROOM NUMBER] said she has seen roaches in her room. In an observation on 06/16/2026 at 2:10 pm, there were 2 American roaches observed in hallway 2 and 2 American roaches in vacant room [ROOM NUMBER]. In an observation on 06/16/2026 at 1:02 pm, there was 1 American roach in the hallway 5. In an observation on 06/16/2026 at 1:05 pm, in hallway 6, there was 1 American roach in the lobby area, in the hallway, and in a storage closet. In an interview and observation on 06/16/2026 at 2:22 pm, Resident #1 in room [ROOM NUMBER] stated she sees roaches in her room and throughout the facility. In an observation of room [ROOM NUMBER] there was 1 American roach in the room.In an interview on 06/16/2026 at 1:30 pm, the Director of Nursing reported there have been issues with roaches in the facility. She said the pest control company has been coming to the facility. She said staff have been instructed to report if they see roaches. She was not aware of the recommendations of the pest control company.In an observation on 06/16/2026 at 1:48 pm, in room [ROOM NUMBER], the floor had been torn up with 2 holes in the floor. In room [ROOM NUMBER], the floor and toilet and been removed and there was no covering the pipe where the toilet had been. In an interview on 06/16/2026 at 1:50 pm, the Administrator said he was aware of the pest control recommendations for sealing the toilets, but they are still working on correcting issues with the recent past annual survey that still needed to be completed by a certain date. He said they plan to seal the toilets once the other issues have been completed. He said there had been a water leak in rooms [ROOM NUMBERS] about 3 months ago and the floor had to be taken up and there were holes in the floor through the concrete that had been dug exposing the facility to dirt to fix the water pipes. He said it had been this way for 3 months and that could be a potential entry point for the roaches also. In an interview on 06/17/2026 at 2:00 pm, the Maintenance Director said the pest control company treats the facility monthly. He plans to seal the toilets as recommended by the pest control company but has to first finish the issues found by the recent annual survey. He said there was a water leak in rooms [ROOM NUMBERS] and holes had to be dug through the concrete in the rooms to reach the pipes exposing the dirt. He said the walls and floors needed to be replaced in those rooms. Record review of the facility policy Pest Control, dated as revised May 2008, revealed the following [in part]: Policy Statement: Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation:1. The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on interviews and record review, the facility failed to ensure the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents for 6 (03/07/2026, 03/16/2026, 04/04/2026, 04/11/2026, 04/18/2026, and 04/19/2026) of 54 days (03/01/2026 - 04/24/2026) reviewed for DON coverage. The facility failed to ensure the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents on 03/07/2026, 03/16/2026, 04/04/2026, 04/11/2026, 04/18/2026, and 04/19/2026.This failure leaves residents without the nursing administrative oversight that only the DON can provide.Findings include:During an interview on 04/23/2026 at 5:40 p.m., the DON stated she was falling behind on monitoring the nurses had performed their assessments and making sure the care plans were updated because she was having to work at night as a CNA and nurse to fill in open shifts. She stated she knew that she was not supposed to serve as a charge nurse when there were more than 60 residents but there were times when they did not have any other staff able to fill in the unassigned shifts. During an interview on 04/23/2026 at 6:24 p.m., the RCN stated the DON was getting behind on the comprehensive care plans. She stated changes in leadership nurses and turnover staff had led to the DON having to work on the floor as a nurse and CNA at times. She stated she was aware the DON should not work as a charge nurse when there were over 60 residents in the facility. She stated the DON not being able to monitor the nurses were performing assessments and making sure the care plans were updated could disrupt resident care.During an interview on 04/24/2026 at 8:25 a.m., the ADMN stated he was aware that the DON had been working on the floor helping fill in open CNA and nursing shifts. The ADMN stated he was responsible for ensuring the staff positions were filled. He stated he had attempted to hire nurses and CNAs. He stated the obstacle in filling the CNA and nursing positions were that the facility could not offer competitive wages as other nursing homes in the area. He stated he has lost staff members in the last couple of months and was trying to hire more. He stated the facility had over 60 residents and the DON should not be working on the floor as a CNA or charge nurse, but it was better to have the shifts filled to perform resident care.Review of daily staffing schedule revealed DON worked as a charge nurse on 03/07/2026, 03/16/2026, 04/04/2026, 04/11/2026, 04/18/2026, and 04/19/2026.Record review of facility policy titled, Staffing, Sufficient and Competent Nursing dated August 2022, reflected: The director of nursing services (DNS) may serve as the charge nurse only when the average daily occupancy of the facility is 60 or fewer residents.

Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 7 of 19 (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) resident rooms observed for environmental conditions. The facility failed to ensure rooms 231 B, 233 A, 234 A, 234 B had mattresses that the nonpermeable outer cover was intact and not peeling. The facility failed to ensure rooms 201, 209, 210, and 218's sinks had hot water.These failures could place residents at risk for diminished quality of life, discomfort, and safety.Findings included:During an observation on 04/22/2026 at 8:57 a.m., room [ROOM NUMBER]'s hot water temperature was 74.1 degrees F in the sink.During an observation on 04/22/2026 at 8:59 a.m., room [ROOM NUMBER]'s hot water temperature was 73.9 degrees F in the sink.During an observation on 04/22/2026 at 9:10 a.m., room [ROOM NUMBER]'s hot water temperature was 74.3 degrees F in the sink.During an observation on 04/22/2026 at 9:13 a.m., room [ROOM NUMBER]'s hot water temperature was 74.1 degrees F in the sink.During an observation and interview on 04/21/2026 at 2:13 p.m., Resident #72's mattress had cracks and the nonpermeable outer cover was peeking on the top half of the mattress. Resident #72 stated his mattress was peeling and it bothered him when he slept on it because he could feel the cracks. room [ROOM NUMBER] B mattress did not have sheets on it and the protective nonpermeable outer cover was cracked and peeled throughout the whole mattress. Resident #26 was not in the room at the time of the observation of his mattress in room [ROOM NUMBER] B.During an interview on 04/22/2026 at 8:49 a.m., Resident #53's family member stated they had concerns with the facility not having hot water for residents and their family members to wash their hands. Resident #53's family member stated they had spoken to the ADMN about the hot water issue on Hall 1 before when Resident #53 resided on that hall and Resident #53 was moved rooms because of the hot water issue. Resident #53's family member stated they felt sorry for the other residents who continued to reside on hall 1 because they did not have hot water in their bathroom. Resident #53's family member stated the hot water issue had been going on for a while but did not know exactly how long. During an observation and interview on 04/22/2026 at 9:51 a.m., Resident #27 stated his mattress was peeling and it was uncomfortable to sleep on because of the cracks and peeling. Resident #27's, room [ROOM NUMBER] A, mattress was observed and the nonpermeable outer cover was cracked and peeling.During an observation and interview on 04/22/2026 at 9:58 a.m., Resident #53's bed had a mattress where the protective nonpermeable outer cover was cracked and peeling. Resident #53 stated the mattress was uncomfortable because she could feel the cracked and peeling mattress.During an interview on 04/22/2026 at 10:05 a.m., Houskeeper H said some of the mattresses had cracks and were peeling. She said she had not reported it, but she was sure management was aware. Housekeeper H said she used disinfect spray to sanitize the mattresses. During an interview on 04/22/2026 at 11:50 a.m., Resident #26 stated his mattress had been that way for some time and he had reported it to staff. He said the mattress was miserable to sleep on because of the cracks and peeling.During a confidential group interview on an undisclosed date and time, 3 of 15 residents interviewed stated they had no hot water in their rooms. They stated that the Maintenance Director was aware of the issue and it had not been fixed. The AD present in the meeting stated the 3 residents all resided on the same hallway. During an interview on 04/23/2026 at 2:44 p.m., the ADMN stated he had been replacing the mattresses as needed but corporate would only let him order 4 mattresses per month. He stated he continued to work on replacing all of the mattresses that needed it in the facility. He stated he was not currently aware of any residents that were sleeping on cracked and peeling mattresses. The ADMN stated residents should have mattresses that were not cracked or peeling and that were comfortable. He said a potential negative outcome was the mattresses were not comfortable for the residents and the staff would not be able to sanitize the mattresses properly. During an interview on 04/23/2026 at 6:28 p.m., the Maintenance Director stated he was aware of the hot water not working on Hall 1. He stated he was informed about the issue on 04/07/2026 and called out a repair company the next day. He stated he had received a quote including the scope of work and was waiting for corporate to approve the repairs. He stated residents could use hand sanitizer and cold water to wash their hands to help prevent infection spread. He stated he would want to have access to hot water if he resided in the building and a reasonable person would want hot water to function to wash their hands and face. He stated the issue with the hot water continued at that time.During an interview on 04/24/2026 at 8:25 a.m., the ADMN stated he was aware of the hot water issues in the building including multiple halls. He stated the Maintenance Director had gotten an estimate on the work needed to correct the issue and the facility was waiting for the scope of work to be approved by upper management before the repairs could be made. He stated staff and residents could use cold water to wash their hands and then utilize the hand sanitizer in the hall to help prevent infections in the time being. He stated a reasonable person would want hot water in the sink to wash their hands and face for comfort. During an interview on 04/24/2026 at 9:55 a.m., the DON stated the mattresses were being replaced when the staff found a new one. She stated a potential negative outcome was that the mattresses were not comfortable and infection control risk. Record review on 04/23/2026 of estimate to correct hot water issue, dated 04/08/2026, reflected scope of work included remove existing receptacle, wiring, and box. Relocate to above water heater as to be accessible. Install new box, wiring, and receptacle. Provide new cord set to connect water heater. Excludes any drywall repair, paint, etc.Record review on 04/24/2026 of facility policy titled Homelike Environment, dated February 2021, reflected The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment.

Based on observation, interview, and record review, the facility failed to provide each resident with a nourishing, well-balanced diet to meet the daily nutritional and special dietary needs for 21 of 73 residents reviewed for food and nutrition services. The facility did not provide 21 residents on a regular diet who were supposed to be served refried beans for lunch or offer a comparable substitute when they ran out of refried beans. This failure could place residents who ate food from the kitchen at risk of not having their nutritional needs met and possible weight Findings included:Record review of the posted menu dated 4/21/26 revealed the following menu for a regular diet. Soft tacos, refried beans, tortilla soup and Brownie. Observation of food preparation and service in the kitchen on 4/21/26 at 11:21 am revealed that the facility failed to have enough refried beans or a comparable substitute which resulted in 21 residents not receiving refried beans. After 17 residents were served their tray without refried beans, the Dietary Manager provided rice to the 4 last trays/residents. In an interview on 4/21/26 at 12:00 pm, the DM said there were 53 residents who received a regular diet. She was going to try to find out who the residents were who did not receive refried beans and give them some rice. In an interview on 4/22/26 at 2:49 pm, the Dietician said that rice was not an appropriate substitute for refried beans and she would not have approved that substitution. She said that when the kitchen runs out of food, a nutritional equivalent substitute should be provided. The Dietician said when she visits the facility, they review the substitution log. The Dietician said the failure had the potential for residents not to have their nutritional needs met. In an interview and record review on 4/23/26 at 10:18 am, the DM said she did not know why they ran out of refried beans. The menus were followed for the number of residents they were serving, and the correct portion size was used. The DM said she did not know why when they ran out of refried beans, a substitute wasn't provided at that time. The DM was asked if rice was a comparable nutritional substitute for refried beans, she said she was not sure and that she should have called the Dietician before she made the substitute. Record review of the substitution log for April 2026 was blank. The DM said she had not filled it out yet for the month. The DM said the failure had the potential for residents not to have their nutritional needs met. In an interview on 4/23/26 at 10:52 am, the DON said the nurses check each resident's tray before it was served to make sure they were getting the right textures. They depend on the kitchen to make sure they were receiving the correct calories. She said a potential negative outcome would be residents would have weight loss. The DON said there were no residents identified that was having weight loss related to food or food portions served. In an interview on 4/23/26 at 2:44 pm, the ADMN said the kitchen prepared the correct amount of refried beans, as the menu shows the correct amount to make for the facility census. They must have given the residents too large of a portion of refried beans. He said they went back and found the residents who did not receive the refried beans on their tray and gave them rice. Record review of CMS-802 Resident Matrix, dated 4/21/26, revealed there were no residents identified as having excessive weight loss, except for one resident whose excessive weight loss was unrelated to nutrition. Record review of the facility policy Substitutions, dated as revised April 2007, revealed the following [in part]: Policy Statement: Food substitutions will be made as appropriate or necessary.Policy Interpretation and Implementation:1. The food service manager, in conjunction with the clinical dietician, may make food substitutions as appropriate or necessary. The food services shift supervisor on duty will make substitutions only when unavoidable. 2. The food services manager will maintain an exchange list identifying the seven (7) exchanges of food groups. When in doubt about an appropriate substitution, the food services manager will consult with the dietitian prior to making the substitution.

Based on interview and record review, the facility failed to consider the views of the resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility or to demonstrate their response and rationale for such response for 12 of 15 confidential residents reviewed for meeting grievances.The facility failed to provide a verbal or written response to the Resident Council addressing the grievances reported from their meetings on May 2025, August 2025, September 2025, January 2026, February 2026, and March 2026, which included issues with nursing services, dietary services, and housekeeping services. This failure could place residents at risk of unresolved grievances, a decreased sense of self-worth, and a decline in quality of life.Findings included:Record review on 04/23/2026 of the Grievance logs for May 2025 reflected the Resident Council filed one grievance involving bed sheets not being changed for a month or more. Record review reflected there was no name or group listed in notification of representative and the date resolved was 5/25/2025.Record review of the Grievance logs for August 2025 reflected the Resident Council filed one grievance involving housekeepers not being respectful of residents still sleeping in the morning by making too much noise and hitting the mop on trash cans repeatedly. Record review reflected there was no name or group listed in notification of representative and the date resolved was 8/25/2025.Record review of the Grievance logs for September 2025 reflected the Resident Council filed seven grievances. The first grievance involved residents asking if the exterminator could come more often. There was the ADMN's name listed in notification of representative and the date resolved was 9/26/2025. The second grievance involved the heater in the shower room needed to be fixed before winter. There was the ADMN's name listed in notification of representative and the date resolved was 9/26/2025. The third grievance involved staff talking too loudly in the hallway during the morning. There was the ADMN's name listed in notification of representative and the date resolved was 9/26/2025. The fourth grievance involved wanting to have boiled eggs instead of powdered eggs. There was the ADMN's name listed in notification of representative and the date resolved was 9/27/2025. The fifth grievance involved requesting more outside activities. There was the ADMN's name listed in notification of representative and the date resolved was 9/27/2025. The sixth grievance involved requesting beds be made daily with fresh sheets. There was the ADMN's name listed in notification of representative and the date resolved was 9/26/2025. The seventh grievance involved nursing staff who made negative remarks about other staff members. There was the ADMN's name listed in notification of representative and the date resolved was 9/26/2025.Record review of the Grievance logs for January 2026 reflected the Resident Council filed four grievances. The first grievance involved the staff talking too loud in the halls. There was no name or group listed in notification of representative and date 1/4/2026. The second grievance involved staff banging carts into the walls and slamming medication drawers. There was the ADMN's name listed in notification of representative and the date resolved was 1/4/2026. The third grievance involved staff asking residents to label their own personal items and the council wanted laundry staff to label them. There was no name or group listed in notification of representative and date 1/4/2026. The fourth grievance involved not being served toast because the bread was too soft or too hard. There was the ADMN's name listed in notification of representative and the date resolved was 1/4/2026. Record review of the Grievance logs for February 2026 reflected the Resident Council filed four grievances. The first grievance involved meal trays not being picked up timely and left in the hallway overnight. There was no name or group listed in notification of representative and the date resolved was 3/1/2026. The second grievance involved a night nurse aide spending too much time with one resident and being loud in his room. There was no name or group listed in notification of representative and the date resolved was 3/1/2026. The third grievance involved nurse aides not paying attention to the residents during shower chair transfers. There was no name or group listed in notification of representative and the date resolved was 3/1/2026. The fourth grievance involved daily menus not being posted and meals being changed at the last minute. There was no name or group listed in notification of representative and the date resolved was 3/1/2026.Record review of the Grievance logs for March 2026 reflected the Resident Council filed three grievances. The first grievance involved not getting showers on Saturdays. There was no name or group listed in notification of representative and the date resolved was 3/30/2026. The second grievance involved the dinner trays not being picked up at night. There was no name or group listed in notification of representative and the date resolved was 3/30/2026. The third grievance involved the menu not being followed and residents were not notified until the last minute about the changes. There was no name or group listed in notification of representative and the date resolved was 3/30/2026.During a confidential group interview on an undisclosed date and time, 12 of 15 residents stated they attended Resident Council meetings regularly. The 12 of 15 residents stated no one had gotten back with them about their grievances in the past. They stated some of the issues continued and they would like to be notified about what the facility was doing to resolve those issues. During an interview on 04/23/2026 at 1:06 p.m., the AD stated she attended Resident Council meetings and was invited to the meetings by the resident council members. She stated the council liked her writing the minutes about the meetings for them. She stated she would then write concerns on a grievance form and give the grievance form to the ADMN. She stated she had not gotten any form of resolution back in writing or verbally after she gave the grievance form to the ADMN. She stated she did not know how the information should be relayed to the resident council members. She stated she recently kept a copy of the grievance forms and would give two copies to the ADMN so that he could give one to the department head that the grievance involved. She stated the resident council should get notified about what was done to correct their grievances so that they felt their concerns were heard.During an interview on 04/24/2026 at 8:25 a.m., the ADMN stated he was responsible for grievances at the facility. He stated he received the resident council's grievances from the AD. He stated he would get with the department head that the grievance was about and work with them to resolve the issue. He stated sometimes he would attempt to figure out who had made the grievance and notify them about the resolution. He stated he had gotten back to the Resident Council President before but did not address the resident council because he was not invited to those meetings. He stated the grievances were voiced in the managers' meetings and the AD was present for those. He stated he expected the AD to relay the resident council's grievance resolutions to the council members.Record review of facility's policy titled, Resident Council, dated February 2021, reflected, The purpose of the resident council is to provide a forum for: a. residents, families and resident representatives to have input in the operation of the facility; b. discussion of concerns and suggestions for improvement; c. consensus building and communication between residents and facility staff.6. A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern.Record review of the facility's policy titled, Grievances/Complaints, Filing, dated April 2017, reflected, 12. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems. a. The administrator, or his or her designee, will make such reports orally within _____ working days of the filing of the grievance or complaint with the facility. b. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, for 1 of 1 kitchen as evidence by: The facility failed to ensure:A. The floors throughout the kitchen were clean and free from dirt and food crumbs. B. The stand that the mixer was on was clean and free from dirt and food crumbs. C. The plastic container that contained the food thickener was free from spilled food and not soiled. D. The convection oven and stove were clean on the inside and outside. E. The shelf above the stove was clean and not soiled with food crumbs and dust. F. The refrigerator was clean and free of food crumbs and dust. G. The stand that held the residents' plates was clean and free of food crumbs. These failures could place residents at risk for foodborne illness, compromised nutritional health status, and being served food items that may not be fresh, taste stale, or be contaminated.In an observation on 4/21/26 at 9:13 am, during the initial tour of kitchen, the floors throughout the kitchen were soiled with dirt and food crumbs especially around the baseboards of the kitchen. The stand that the mixer was on was soiled with dirt and food crumbs and underneath the stand there was a food thickener or flour in a pile. The plastic container that contained the food thickener had spilled dried food and dust on the outside of the container with a plastic scoop lying on the top of the container. The convection oven and the stove had dried baked on food on the inside and grease and dust on the outside of the appliances. On top of the convection oven there were additional oven shelves that were covered with old baked food and grease. The shelf above the stove was soiled with food crumbs and dust. The bottom shelf of the refrigerator was soiled with food crumbs. The stand that held the resident's plates was soiled with had food crumbs. In an interview on 4/23/26 at 2:05 pm, the findings of the initial tour were discussed with the DM. She said that it was her expectation for the kitchen to be clean after every meal. The DM said potential negative outcomes of not keeping the kitchen free of food crumbs, and dirt/dust could attract pests and lead to sickness. In an interview on 04/23/2026 at 2:44 pm, the ADMN said it was his expectation for the kitchen to be clean. A policy regarding kitchen sanitization was requested but not provided by time of exit from the Dietary Manager on 4/23/2026 at 2:05 pm.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 4 of 18 (Resident #2, 3, 4, 33) residents reviewed for care plans. The facility failed to develop a comprehensive care plan for Resident #2 that included her Diagnoses of Anxiety and Major Depressive Disorder. The facility failed to develop a comprehensive care plan for Resident #3 that included smoking cigarettes. The facility failed to develop a comprehensive care plan for Resident #4 that included orders for flushing her Gastrostomy tube This failure could place residents at risk of infection, injury, unmet psychosocial needs and not receiving needed care to maintain optimal level of physical and emotional health. Findings included: Resident #2Record review of Resident #2 face sheet, dated 4/24/26, on 4/24/26 revealed a [AGE] year-old female, readmitted on [DATE]. Diagnoses included dementia (a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia and mood disorders, such as depression or mania), bipolar disorder (a mental health condition characterized by significant mood swings, including manic (or hypomanic) and depressive episodes), major depressive disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), and anxiety disorder (a mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS score of 2, indicating severe cognitive impairment. Section I revealed active diagnosis of anxiety disorder and depression. Record review of Resident #2's care plan, dated 11/01/2025, on 4/24/26 revealed there was no care plan addressing the diagnosis of Major Depressive Disorder and Anxiety Disorder. During an interview on 04/24/2026 at 9:53 a.m., the DON said she was responsible for the care plans. The DON said there should have been care plans for Major Depressive Disorder and Anxiety, but stated it was not there. Resident #3Record review of Resident #3's face sheet, dated 4/24/26, 04/04/2026 revealed a [AGE] year-old male, admitted [DATE]. He had a primary diagnosis of unspecified sequelae of cerebral infarction (stroke). Record review of Resident #3's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, indicated cognitively intact. During an interview on 04/22/2026 at 9:34 a.m., Resident #3 said he smoked and had no issues with the smoking process. Record review of Resident #3's care plan, last revised 1/20/26, revealed no care plan that addressed smoking. During an interview and record review with the ADMN and DON on 4/24/26 at 9:46 am, both said Resident #3 wmoked and there should have been a care plan specifically for smoking. The care plan was reviewed and they both said there was no care plan that addressed Resident #3's smoking status. The DON said she would add it to the care plan and stated that she had assessed Resident #3 for safe smoking and there was not a negative outcome since he did not require any special safety precautions. Resident #4Record review of Resident #4 s electronic face sheet, dated 04/24/2026, on 04/24/2026 reflected a [AGE] year-old female, admitted [DATE], with diagnoses including neuro genic bladder (urinary bladder does not function properly due to trauma, disease, or injury to the nervous system), dysphagia (difficulty swallowing), nontraumatic cerebral hemorrhage (a type of stroke caused by bleeding in the brain). Record review of Resident #4's admission MDS assessment, dated 03/14/2026, reflected a BIMS score of 00 indicating she was severely cognitively impaired. Further review reflected Resident #4 had gastrostomy tube (a tube placed directly in the stomach through the abdominal wall to deliver nutrition, fluids and medications, or to drain the stomach contents) since admission. Record review of Resident #4's Physician Orders, dated 04/23/2026, reflected an order with a start date of 4/21/26 monitor and assess non used gastrostomy tube and flush every 12 hours with 30 milliliters of fluid every 12 hours as needed. Record review of Resident #33's comprehensive care plan on 04/24/2026 reflected no focus, goal, or interventions related to flushing the resident's unused gastrostomy tube. During an observation and attempted interview on 4/22/24 at 1:30 p.m., Resident #4 was not interviewable and did not answer direct questions when asked about her care. During observation of ADL care, it was observed that the resident had a gastrostomy tube that was plugged. During an interview with the DON on 04/23/2026 at 2:00 p.m. she stated she was responsible for updating resident care plans and she should have updated Resident 4's care plan to reflect the changes in his care. She stated she was responsible for all the care plans in the facility and Resident #4 had not had a negative outcome due to the failure to update her care plan. She stated failure to develop, update, and implement care plans could result in a resident not getting the care they need. She stated Resident #4 had not had a significant weight loss since admission and was eating a diet from the kitchen and taking her medication orally. Resident #33Record review of Resident #33's electronic face sheet, dated 04/24/2026, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] for diagnosis including neuromuscular dysfunction of bladder (urinary bladder does not function properly due to trauma, disease, or injury to the nervous system), and UTI (bladder infection). Record review of Resident #33's admission MDS assessment, dated 03/05/2026, reflected a BIMS score of 15 indicating she was cognitively intact. Further review reflected Resident #33 had an indwelling catheter (tube to drain urine from the bladder) and was always incontinent of bowel movement. Record review of Resident #33's Physician Orders, dated 04/22/2026, reflected an order to change foley catheter every 24 hours as needed for neuromuscular dysfunction of bladder. Further review reflected an order dated 02/20/2026 to monitor urinary output every shift related to neuromuscular dysfunction of bladder. Record review of Resident #33's Comprehensive Care Plan on 04/24/2026 reflected no focus, goal, or interventions related to foley catheter care. During an interview on 04/23/2026 at 6:24 p.m., the RCN stated she expected comprehensive care plans to have all care needs present. She stated changes in leadership nurses and turn over in staff had led to the care plan issues. She stated she did monitor the DON and care plans and had identified issues with the care plans but had not been able to implement her action plan she had come up with in March. She stated not having completed comprehensive care plans could disrupt continuity of care for the residents. Record review on 4/24/26 of the facility's policy titled: Care Plans - Comprehensive Person Centered dated revised March 2022, revealed the following: The comprehensive, person-centered care plan includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including; services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; any specialized services to be provided as a result of PASARR recommendations; and which professional services are responsible for each element of care; includes the resident's stated goals upon admission and desired outcomes; builds on the resident's strengths; and reflects currently recognized standards of practice for problem areas and conditions. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan: when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 (Resident #37, Resident #54 and Resident #67) of 5 residents reviewed for resident rights. The facility failed to:Ensure Resident #37's ileostomy collection bag was obscured from view.Ensure Resident #54's urinary catheter collection bag was obscured from view.Ensure Resident #67 colostomy and indwelling urinary collection bags were emptied and obscured from view.These failures could place residents at risk for feeling uncomfortable and disrespected, leading to isolation and deterioration in general health conditions.Findings included:Record review of Resident #37's undated face sheet revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. Resident #37 was admitted with the medical diagnoses of personal history of malignant neoplasm of large intestine (colon cancer), and abdominal distention (enlarged abdomen).Record review of Resident #37's Comprehensive MDS, dated [DATE], Section C - Cognitive Patterns, subsection C0500 BIMS Score Summary revealed Resident #37 scored a 15 out of 15 indicating intact cognition. Section H - Bladder and Bowel, subsection H0100 Appliances, C Ostomy (including urostomy, ileostomy, and colostomy) Yes was entered. Record review of Resident #37's care plan, dated 04/23/2026, revealed, Problem: I have a colostomy related to malignant neoplasm of the large intestines. Goal: I prefer to perform my own colostomy care and change my bag independently . Approach: [Resident] will report any decrease in output to the nurse; monitor abdomen for distention/bowel sounds.; observe the stoma (a surgically created opening on the abdomen at redirects feces out of the body to an external collection device) and surrounding skin for any s/s of skin breakdown or infection; provide assistance as needed.During an observation on 04/22/2026 at 9:45 a.m., Resident #37 was walking down the hallway and other staff and residents were present. His shirt was raised showing an ileostomy (a surgically created opening in the abdominal wall that connects the small intestine to the outside of the body) bag. Record review of Resident #54's undated face sheet revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Resident #54 was admitted with the medical diagnoses of neuromuscular dysfunction of bladder (difficulty in controlling the muscles of the urinary bladder), retention of urine (inability to completely empty the bladder), and urinary tract infection.Record review of Resident #54's Quarterly MDS, dated [DATE], Section C - Cognitive Patterns, subsection C0500 BIMS Score Summary revealed Resident #54 scored a 15 out of 15 indicating intact cognition. Section H - Bladder and Bowel, subsection H0100 Appliances, C Ostomy (including urostomy, ileostomy, and colostomy) Yes was entered. Record review of Resident #54's physician orders, dated 01/20/2026, revealed, Privacy bag for urinary drainage bag at all times while in bed, while walking or in wheelchair every shiftRecord review of Resident #54's care plan, dated 12/01/2025, revealed Problem: EBP: r/t foley catheter . Goal: [Resident's] dignity will be maintained .During an observation on 04/21/2026 at 11:24 a.m., Resident #54 was lying in bed with a urinary catheter collection bag hanging on the door side of the bed and not in a privacy bag, visible to anyone walking by her room. During an observation on 04/21/2026 at 2:37 p.m., Resident #54 was lying in bed. The urinary catheter collection bag was hanging on the left side of the bed and not in a privacy bag. During an observation on 04/22/2026 at 9:42 a.m., Resident #54 was sitting in a chair in her room. She had a urinary catheter collection bag attached to the right side of the chair that was not in a privacy bag. Record review of Resident #67's undated face sheet revealed a [AGE] year-old female, admitted on [DATE] and readmitted on [DATE]. Resident #67 was admitted with medical diagnoses of dementia (inability to think, remember, and make decisions, affecting daily life), dehydration, constipation, and lower abdominal pain. Record review of Resident #67's Quarterly MDS, dated [DATE], Section C - Cognitive Patterns, subsection C0500 BIMS Score Summary revealed Resident #67 scored a 6 out of 15 indicating moderately impaired cognition. Section H - Bladder and Bowel, subsection H0100 Appliances, C Ostomy (including urostomy, ileostomy, and colostomy) Yes was entered. Record review of Resident #67's care plan, dated 07/04/2025, revealed, Problem: [Resident] has a [indwelling urinary] catheter (a tube inserted into the urinary bladder held in place by an inflated balloon to drain urine from the bladder into a collection bag) related to neuromuscular disorder of the bladder. Goal: [Resident] will not have s/s of urosepsis (fever, pain on the lower sides of my back where my kidneys are located, nausea, vomiting, extreme tiredness) related to recurring urinary infections .; Approach: [indwelling urinary] bag to have a privacy bag. Problem: [Resident] has a colostomy. Goal: [Resident's] colostomy will be managed without complication . ; Approach: Provide colostomy care every shift and prn. Provide full staff assistance with colostomy care. During an observation on 04/21/2026 at 12:17 p.m., Resident #67 wheeled self into dining room. Resident #67's shirt was not pulled down in the back causing the front of her shirt to expose the colostomy (a surgically created opening in the abdominal wall that connects the large intestines to the outside of the body) bag that appeared to be more than 3/4 full of liquid stool to full view of other residents in the dining room. Resident #67's urinary collection bag hanging under her wheelchair was approximately 1/2 full and not in a privacy bag. Observed one staff member assist Resident #67 to sit farther back in her wheelchair but did not cover the colostomy bag or take the resident to empty the bags.During an observation and interview on 04/21/2026 at 12:24 p.m., the visible colostomy bag was brought to the DON's attention. The DON's response was Oh good lord. The DON then removed Resident #67 from the dining room. During an observation and interview on 04/22/206 at 11:07 a.m., Resident #67 was sitting in her wheelchair in her room. Resident #67 allowed assessment of the colostomy bag. The collection bag appeared to be approximately 1/2 full. Resident #67 stated the bag was due to be changed Friday. Resident #67 stated she experienced occasional itching around the colostomy bag's adhesive and when the bag was too full it caused pain and discomfort due to pulling on her skin. Resident #67 denied knowing the colostomy and urinary collection bags were not covered when she was in the dining room on 04/21/2026. She stated she did not like it when the colostomy bag was not covered. During an interview on 04/24/2026 at 8:31 a.m., CNA E stated she had worked at the facility for 4 years. She stated CNAs were trained and checked off on colostomy care skills. CNA E stated training was provided by the nursing staff. She stated it was not acceptable for a resident to leave a room with a collection bag visible and not empty. She stated Resident #67's colostomy bag fills up fast. CNA E stated she checked and emptied colostomy and urinary collection bags during rounds every 2 hours. She stated the failure may have occurred due to some just don't check them or take the time to empty them and some don't think to pull the resident's shirt down to cover the collection bag. During an interview on 04/24/2026 at 9:55 a.m., LVN B stated she had worked in the facility for 4 years. She stated CNAs and nurses were responsible for colostomy care. LVN B stated collection bags were checked every 2 hours during rounds. She stated it was not acceptable for a resident to be brought out of their room with the colostomy or urinary collection bags visible. She explained training was provided by initial CNA or nursing education and reinforced on the job by the nurses. LVN B stated an effect on residents of failing to cover collection bags was some might not like to see it. LVN B denied receiving complaints from residents with colostomy or urinary collection bags about bags not being covered. During an interview on 04/24/2026 at 10:02 a.m., LVN C stated all nursing staff were responsible for checking and providing care of colostomy and urinary collection bags. She stated the nurses provided training to the CNAs on colostomy and urinary catheter care. LVN C stated it was not acceptable for a colostomy collection bag to be exposed or a urine collection bag to not have a privacy cover. She explained she had offered privacy bags and provided them when needed. She stated Resident #67's constant body movement frequently caused her clothing to ride up. LVN C stated she expected staff to make sure to pull the resident's shirt down to cover the colostomy bag. During an interview on 04/24/2026 at 10:29 a.m., the DON stated when she took Resident #67 out of the dining room on 04/21/2026 she took the resident to her room, emptied her colostomy bag and assisted the resident to change her shirt. The DON stated the bag was 90% air and appeared over 1/2 full due to stool sticking to the inside of the bag. She stated Resident #67 had a one-piece appliance and the nurses changed it every 3 days. The DON denied reports from Resident #67 complaining of pain or discomfort associated with stool in the bag. The DON explained the colostomy bag should be emptied as needed, checked every 2 hours during rounds, and at least once a shift. She stated skills check offs for colostomy and urinary catheter care were done annually. The DON stated all nursing staff were responsible for monitoring the contents of collection bags. She stated effects on a resident for failure to provide cover of collection bags was a dignity issue, and a resident may not feel as pretty, or may feel self-conscious. The DON stated her expectations were for staff to keep an eye on it and for staff to know their resident's needs. Record review of the facility policy titled, Colostomy/Ileostomy Care, updated 02/2026, revealed, Preparation 1a. CNAs may empty and assist with routine ostomy care.Record review of the facility policy titled, Dignity, revised 02/2021, revealed, 1. Residents are treated with dignity and respect at all times . 5e. provided with a dignified dining experience . and 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a. helping the resident to keep urinary catheter bags covered;Record review of the National Library of Medicine article titled, Colostomy Care, dated 05/28/2023, page 4, accessed on 04/22/2026, at https://www.ncbi.nlm.nih.gov/books/NBK560503/, revealed, As a rule, the stoma (surgically created opening in the skin that connects to part of the body's digestive or urinary system) bag should be emptied when it is filled up to 1/3rd to prevent peeling off of the baseplate from the skin and leaks.

Based on interview, and record review, the facility failed to accurately assess each resident's status for 1 of 19 (Resident #4) residents reviewed for assessment accuracy. The facility failed to ensure the assessment information in Resident #4' s admission MDS, dated [DATE], was accurate. This failure could place residents at risk of not receiving the proper care and services due to inaccurate assessment records. Findings included: Record review of Resident #4's electronic face sheet, dated 04/24/2026, reflected a [AGE] year-old female, admitted [DATE], diagnoses included dysphagia (difficulty swallowing) and nontraumatic cerebral hemorrhage (a type of stroke caused by bleeding in the brain). Record review of Resident #4's admission MDS assessment, dated 03/14/2026,0n 04/24/2026 reflected a BIMS score of 00 indicating she was severely cognitively impaired. Further review reflected Resident #4 had gastrostomy tube (a tube placed directly in the stomach through the abdominal wall to deliver nutrition, fluids and medications , or to drain the stomach contents) since admission. The MDS assessment documented the resident had a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. The MDS documented, Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident as partial to moderate assistance. Record review of Resident #4's Physician Orders, dated 04/23/2026, reflected an order with a start date of 4/21/2026 to monitor and assess non-used gastrostomy tube (a tube placed directly into the stomach to deliver nutrition, fluids and medication and flush every 12 hours with 30 milliliters of fluid every 12 hours as needed. The resident's regular diet was Mechanical Soft texture, Regular consistency. Record review of Resident #33's Comprehensive Care Plan on 04/24/2026 reflected no focus, goal, or interventions related to weight loss or gastrostomy tube feedings. During an interview on 04/24/2026 at 9:30 a.m., the MDS coordinator stated she was responsible for MDS assessments. She stated she answered MDS assessment questions to the best of her ability. The MDS coordinator stated she made a mistake in the documentation when she did the MDS. The MDS coordinator stated she did not believe any negative effect occurred to the resident #4 from coding MDS assessment incorrectly for weight loss. She stated she had mistakenly coded the assessment incorrectly. She stated she monitored that MDS assessments were correct. She stated she referred to the RAI manual when she had questions regarding documentation for the MDS. The MDS coordinator stated she could refer directly to the RAI manual for any questions that she might have through a link in her computer program for completing the MDS. During an interview on 04/23/2026 at 1:00 p.m., the DON stated the MDS coordinator was responsible for MDS assessments. She stated her expectation was for the MDS assessment to be completed in a timely manner and for them to be accurate. Record review of the Policy titled Resident Assessment date revised 3/2026 stated in part. 1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements:a. OBRA required assessments - conducted for all residents in the facility:(1) admission Assessment (Comprehensive);(2) Quarterly Assessment;(3) Annual Assessment (Comprehensive);(4) Significant Change in Status Assessment (SCSA) (Comprehensive);(5) Significant Correction to Prior Comprehensive Assessment (SCPA) (Comprehensive);(6) Significant Correction to Prior Quarterly Assessment (SCQA); and(7) Discharge Assessment (return anticipated and return not anticipated).b. PPS required assessments - conducted (in addition to the OBRA required assessments) for residents for whom the facility receives Medicare Part A SNF benefits:(1) 5-day Assessment;(2) Interim Payment Assessment; and(3) Part A PPS Discharge Assessment.2. The RAI User's Manual (Chapter 2) provides detailed information on timing and submission of assessments.3. A comprehensive assessment includes:a. completion of the Minimum Data Set (MDS);b. completion of the care area assessment (CAA) process; andc. development of the comprehensive care plan.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #33) of 2 residents reviewed for catheter care.The facility failed to ensure Resident #33's indwelling urinary catheter tubing was secured to her leg, and her catheter bag was emptied every shift. These failures could place residents at risk of catheter tubing leakage, resulting in cross-contamination and development of infections.Findings included: Record review of Resident #33's electronic face sheet, dated 04/24/2026, reflected a [AGE] year-old female, admitted [DATE], with diagnoses including neuromuscular dysfunction of bladder (urinary bladder does not function properly due to trauma, disease, or injury to the nervous system) and UTI (bladder infection). Record review of Resident #33's admission MDS assessment, dated 03/05/2026, reflected a BIMS score of 15 indicating she was cognitively intact. Further review reflected Resident #33 had an indwelling catheter (tube to drain urine from the bladder) and was always incontinent of bowel movement. Record review of Resident #33's Physician Orders, dated 04/22/2026, reflected an order to change indwelling urinary catheter every 24 hours as needed for neuromuscular dysfunction of bladder. Further review reflected an order dated 02/20/2026 to monitor urinary output every shift related to neuromuscular dysfunction of bladder.Record review of Resident #33's MAR, dated April 2026, reflected, There was no urine output documented the day shift on 04/09/2026, 04/14/2026, 04/19/2026, or 04/22/2026.Record review of Resident #33's Comprehensive Care Plan on 04/24/2026 reflected no focus, goal, or interventions related to foley catheter care.Record review of Resident #33's Progress Notes, dated 04/21/2026, indwelling urinary catheter was changed because resident complained of pain in abdomen and resident felt better after catheter was changed. Further review reflected on 04/22/2026 foley catheter was leaking and catheter changed. During an interview on 04/21/2026 at 3:32 p.m., Resident #33 was lying in her bed. She stated her foley catheter had to be replaced the day before because it was hurting her. She stated it hurt sometimes when she was transferred from the bed to the chair.During an observation on 04/22/2026 at 3:25 p.m., Resident #33's foley catheter was leaking into a brief and there was no securement device holding the tubing in place on Resident #33's leg. LVN A removed and replaced foley catheter and no infection control concerns were observed during foley catheter change. LVN A did not place a securement device for indwelling urinary catheter tubing during the catheter change.During an observation and interview on 04/23/2026 at 10:07 a.m., Resident #33 was lying in her bed in her room. The DON was present during observation and Resident #33 did not have a privacy bag over her catheter bag. There was no tape securing the catheter to her leg. Resident #33 stated she continued to have pain when they moved and staff sat her wrong in the wheelchair. She stated she did not know how long the tape had been off her leg or if they had put tape on her leg when they changed out her catheter out the day before. Resident #33 stated she would like there to be a privacy bag so that her family did not see her urine when they visited. She stated she was unaware the bag was not covered.During an interview on 04/23/2026 at 10:20 a.m., the DON stated she expected for nurses to secure the catheter tubing to a resident's leg when they had a catheter. She stated not securing could cause discomfort and leaking if the tubing was being pulled during care. She stated the nurses were responsible for making sure the catheter was secured to the leg. She stated she expected there to be a privacy bag covering the catheter bag. She stated the nurses were responsible for making sure there was a privacy bag in place. During a telephone interview on 04/23/2026 at 3:37 p.m., LVN A stated she had changed out Resident #33's indwelling urinary catheter on 04/22/2026. She stated there was no securement device from the catheter she had removed and she did not get one during the catheter change. She stated she should have secured the catheter tubing but was nervous from being watched and had forgotten to do so. She stated the catheter bag should have a privacy bag on it. She stated the nurse aides emptied the catheter bags and would tell the nurses the output so it could be documented in the chart. She stated she did not know why there were no documented outputs in the MAR on 04/09/2026, 04/14/2026, or 04/19/2026. She stated if outputs were not documented then she could not prove the outputs were taken or the bag had been emptied. She stated on 04/22/2026 the indwelling urinary had been leaking. She stated indwelling urinary catheters could leak due to the tubing not being secured if the catheter tubing was being pulled on during transfers. She stated the catheter she removed was leaking because there was another port for another bag to be connected to and no other bag had been secured to that port. During a follow-up interview on 04/23/2026 at 5:40 p.m., the DON stated urine output should be documented on the MAR when a resident had a indwelling urinary catheter. She stated she did not know why the output was not documented on certain days. She stated she would expect for a progress note to be in the system to explain why no output documented. She stated she did not believe any negative outcome had occurred from the indwelling urinary catheter not being on Resident #33's care plan because nurses looked at physician orders and the MAR to determine care needed. She denied the indwelling urinary catheter privacy bag or securement device not being present would be because those items had not been care planned. She stated not having a privacy bag could cause the resident to be embarrassed from other residents and visitors seeing urine in bag. She stated not having the securement device could cause the catheter tubing to become loose if the tubing was being pulled during resident care. She stated she was responsible for updating the care plans monitored by the RCN. She stated she monitored the nurses documented tasks on the MAR after they had performed the tasks and completed the tasks. She stated she was only one person and could not monitor everything along with helping on the floor to provide resident care.Record review of the facility policy, Catheter Care, Urinary dated July 2024, reflected The purpose of this procedure is to prevent catheter-associated urinary tract infections.If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment, as ordered.Maintain an accurate record of the resident's daily output, per facility policy and procedure.Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks.Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.).Documentation The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given. 2. The name and title of the individual(s) giving the catheter care. 3. All assessment data obtained when giving catheter care.

Based on observation, interviews and record review, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible and systematically organized for 1 of 19 (Resident #54) residents reviewed for nursing assessments. The facility failed to ensure readmission Assessment was included in the medical record for Resident #54 after hospitalization on 4/18/2026 per facility policy.This failure could put residents at risk of records not being completed and staff not having all information needed to provide quality care to its residents.Findings included:Record review of Resident #54'a electronic face sheet, dated 04/22/2026, reflected she was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses including diastolic congestive heart failure (left lower chamber in the heart cannot fill with blood properly reducing blood flow to the body), atrial fibrillation (irregular heartbeat that can prevent the heart from pumping blood effectively), and hypertension (high blood pressure). Record review of Resident #54's quarterly MDS assessment, dated 03/24/2026, reflected she was readmitted from acute care hospital on [DATE]. Her BIMS score was a 14 indicating cognitively intact. Record review of Resident #54's clinical record accessed on 04/22/2026 reflected no evidence that a readmission assessment had been performed or any vital signs had been documented on 04/18/2026, 04/19/2026, 04/20/2026 or 04/21/2026.Record review of Resident #54's progress notes reflected on 04/18/2026 at 6:39 p.m., Resident #54 arrived back to the facility from being hospitalized for sepsis (widespread inflammation and damage to organs from body's immune system overacting to an infection) and a UTI. on 04/22/2026 at 1:15 p.m., Resident #54 was transported after facility staff called 911 after resident became nonresponsive. During an interview and observation on 04/21/2026 at 11:24 a.m., Resident #54 was lying in her bed. She stated she had been transferred to the facility on [DATE] after being hospitalized for a weak heart.During an interview on 04/22/2026 at 4:05 p.m., LVN A stated the nurse who admitted a resident was responsible for obtaining vital signs during the admission assessment. She stated the admitting nurse would put in an order to take daily vital signs for three days. She stated she was present when Resident #54 was readmitted on [DATE] but it was change of shift and she gave over responsibility of the resident to another nurse. She stated the oncoming nurse should have finished up the readmission including performing an assessment on the resident and putting in the order for daily vital signs. She stated taking vital signs for three days was to help reduce rehospitalization risk. During an interview on 04/22/2026 at 4:19 p.m., LVN D stated she had not taken vital signs including blood pressure and pulse on Resident #54 because there was no order to take the blood pressure or pulse. She stated she did not know why the blood pressure had not been taken prior to that morning because she did not work every day. She stated typically the admission nurse would get orders when a resident was admitted to the facility. She stated the admitting nurse should perform an assessment on a resident when they arrive at the facility including vital signs.During a telephone interview on 04/23/2026 at 9:40 a.m., the MD stated he expected the nurses to perform assessments when a resident was admitted or readmitted into the facility. He stated he did not expect nurses to continue to take vital signs unless there were orders to do so after the readmission. He stated the nurse not performing a nursing assessment or taking the vital signs did not have any negative effect on Resident #54 and would not have prevented her hospitalization on 04/22/2026. During an interview on 04/23/2026 at 5:40 p.m., the DON stated she expected the nurse to perform an assessment on the resident when they were readmitted into the facility including vital signs. She stated the nurses should perform daily vital signs for three days to help prevent rehospitalization. She stated she monitored that nurses were performing those assessments but there was only one of her and she was having to help out working on the floor. She stated she was falling behind on monitoring that the nurses were completing the assessments.Record review of the facility's policy titled Return to Acute/Hospital -Readmission, dated 04/17/2026, reflected This policy establishes the criteria, process, documentation requirements, and follow-up procedures for transferring a nursing facility resident to an acute care hospital. The facility will make every effort to manage changes in condition in-house when clinically appropriate to reduce avoidable hospitalizations.READMISSION.On Return (within 4 hours): Assessment, med reconciliation, infection screen, notify provider, update care plan.Record review of facility policy titled, Staffing, Sufficient and Competent Nursing dated August 2022, reflected: Licensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including: a. assuring resident safety; b. attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident; c. assessing, evaluating, planning and implementing resident care plans; and d. responding to resident needs.

Based on interview and record review, the facility, with a capacity of more than 120 beds, failed to employ a qualified social worker on a full-time basis for 1 of 1 facility reviewed for qualified staffing. The facility failed to ensure they had a full-time licensed Social Worker. This failure could affect all residents of the facility by placing them at increased risk of psychosocial decline and poor quality of life. Findings included:During an interview on 04/23/2026 at 09:30 a.m., the SSD stated she was working to get her license in the state of Texas. She stated she had a master's degree in social work from [NAME] Rico and then was licensed in the state of New York. She stated she was working with the state of Texas to get reciprocity (licensure by endorsement) but was not licensed at this time. She stated she had been working for the facility performing Social Work duties since December of 2025. She stated she had corporate support, but she did not come to the facility and all communication was over the phone or virtual. During a telephone interview on 04/23/2026 at 6:34 p.m., the VP of HR stated she was unfamiliar with the regulations for a Social Worker in the state of Texas and would have to review regulations before she could answer any questions about whether they needed to be licensed.During an interview on 04/24/2026 at 8:18 a.m., the ADMN stated his expectation was to have a full-time social worker that was licensed. He stated the SSD was working on getting her license transferred to the state of Texas and she was one of the best Social Service employees he has ever worked with. He stated she only had to take a test to become licensed in Texas. He stated no other SW was in the building to perform SW duties, but the SSD did have corporate oversite. He stated he did not see any negative effect on the residents and felt that the SSD was going above and beyond for the residents at the facility. The ADMN stated he was responsible for ensuring the staff positions were filled.Record review of the job description for Social Services, dated 12/12/2025, reflected Licensure preferred.Record review of the job posting for Social Services Director, no date, reflected Licensure required.Record review of the facility policy titled, Social Services dated September 2021, reflected Not all medically-related social services are provided by a qualified social worker. However, the facility is responsible for ensuring that all residents are provided these services whether by a staff member or through referrals to an outside agency. Record review of Form 3740 titled Bed Classification dated 04/24/2026 revealed the facility had a licensed capacity of 188 resident beds.

Based on observation, record review, and interview, the facility failed to store drugs and biologicals in locked compartments during medication storage inspection for 1 (medication Cart #1) of 1 medication cart reviewed for storage. The facility failed to store drugs and biologicals in locked and secured while unattended. This failure could place residents at risk of drug diversion.Findings included:During an observation on 10/14/2025 at 1:00 PM, medication cart #1 was observed unlocked outside of the nurse's station, prior to entering the hallway. Residents and staff were observed approximately within 10 feet of the cart out of eyesight from staff, with unlocked drawers facing outward. On top of the unsupervised cart were observed a butter knife, nail clippers, mouth wash and an unopened package of petrolatum dressing. The top drawers were observed as having glucometers, lancets, lab draw kits with included needles, hand sanitizer, zinc oxide skin protectant creams, and moisture barrier creams. The second drawer contained OTC medications such as Milk of Magnesia, cough suppressant, fish oil, gas relief tablets, B-Vitamins, Colace tablets (for constipation), Vitamin D tablets, Acid Reducing tablets, Melatonin (sleep aid), and Senna tablets (constipation). The fourth right hand drawer contained packs of AA batteries. During an interview on 10/14/2025 at 1:05 PM, the DON stated medication cart #1 was from the previous covid floor and was the isolation cart. The DON stated residents had access to knives from the kitchen and did not feel there was a risk of harm. She stated that residents could have gotten into the cart for over-the-counter meds. She stated the nurses on the floor were to monitor the cart. She stated even though it was considered an isolation cart that was no longer being used, it still needed to be locked. She stated residents could have possibly gotten the medications and taken them, which would have been harmful, causing an allergic reaction or an overdose. The DON stated the potential harm to residents was they could take the knife and harm themselves as well as the clippers, with the potential to cut themselves. She stated she did not know who placed them on top of the cart, leaving them accessible to the residents. During an interview 10/14/2025 at 5:45 PM, LVN-A stated that another Medication Aid was out of a cream, and she had taken it from medication cart #1. She stated they should have locked medication cart #1 back after taking the cream out and should have locked the cart after use. During an interview on 10/15/2025 at 11:58 PM, the ADMN stated that all medication carts should have been locked when not in use. He stated the nurses on shift should have monitored the cart and to have always been aware of the possibility of unlocked carts. He stated the responsibility ultimately was his in the end, as he was over the DON and ADON. The ADMN stated, the potential harm to residents was that residents and/or staff could have taken medications and/or over the counter drugs out of the cart. The ADMN stated it could have caused a medication diversion or misappropriation of property as well as a possible overdose or allergic reaction. The ADMN stated the failure to lock the cart was the staff being too busy to take the time to lock the medication cart when done. He stated his expectations were to have kept all medication carts locked, even an isolation cart. Record review of the facility policy Medication Labeling and Storage, dated February 2025, revealed: Policy: The facility stores all medications and biologicals in locked compartments. Only authorized personnel have access to keys. Policy Interpretation and ImplementationMedication Storage.2. The nursing staff is responsible for maintain medication storage and preparation areas in a clean, safe, and sanitary manner.4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and treys or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and describes the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 6 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6) reviewed for comprehensive person-centered care plans. 1. The facility failed to develop a care plan based on assessed needs with measurable objectives in the areas of Hospice, Encephalopathy, Seborrheic dermatitis, Anxiety Disorder, Trisomy 21, Hepatitis B, Hyperlipidemia, Gastro-esophageal reflux disease, without esophagitis, Fatty Live, and Unspecified Convulsions, Dementia for Resident #1. 2. The facility failed to develop a care plan based on assessed needs with measured objectives in the areas of malnutrition, Schizoaffective Disorder, Cerebral infarction, Seizure Disorder, Hyperlipidemia, GERD, Pruritus, and Generalized Anxiety Disorder for Resident # 3. The facility failed to develop a care plan based on assessed needs with measured objectives in the areas of Traumatic brain injury, Urinary incontinence, Depression, Anxiety, Post-traumatic Stress Disorder, Schizoaffective disorder, Pruritus, Alcohol dependence, Cannabis dependence, Dementia, Insomnia, Dysphagia, Aphasia, Dysphagia, Cognitive communication deficit and Wernicke's encephalopathy for Resident #3. 4. The facility failed to develop a care plan based on assessed needs with measured objectives in the areas of Bipolar disorder, atrial fibrillation, ADL deficits, Fracture of unspecified metatarsal bones, Unspecified open wound of left great toe without damage to nail, Mixed hyperlipidemia, Nicotine dependence, Anxiety disorder, Essential (primary) hypertension, Heart Failure, and Unspecified sequelae of unspecified cerebrovascular disease for Resident #4. 5. The facility failed to develop a care plan based on assessed needs with measured objectives in the areas of Alzheimer's Disease, ADL deficits, Major Depressive Disorder, Nutritional status, Delirium, Cognitive communication deficit, Dysphagia, Cardiac murmur, Essential (primary) hypertension, Type 2 diabetes mellitus, and Hyperlipidemia for Resident #5. 6. The facility failed to develop a care plan based on assessed needs with measured objectives in the areas of Drug Dependency, Generalized anxiety disorder, GERD, Insomnia, Hyperlipidemia, and Essential (primary) hypertension for Resident #6. These failures could place residents at risk for not receiving care and services to meet their needs.The findings include: 1. Record review of Resident #1's Facesheet, dated 07/09/2025, revealed a [AGE] year-old male, with an admission date into the facility of 05/08/2025. Resident #1 had diagnoses which included Encephalopathy (a broad range of conditions that cause brain dysfunction, leading to altered consciousness, cognitive impairment, and neurological symptoms), unspecified, Seborrheic dermatitis (common, long-term skin condition that causes scaly patches, inflamed skin, and dandruff), Anxiety Disorder (mental health condition characterized by excessive, uncontrollable, and often irrational worry about everyday events or activities), Polyosteoarthritis, unspecified (arthritis affecting multiple joints, but without further detail about the specific joints involved), Trisomy 21 (a genetic disorder where a person has three [3] copies of chromosome 21 instead of the usual two [2], Alzheimer's Disease (most common form, where a person experienced the effects of more than one type of dementia), unspecified, Hepatitis B (a viral infection that affects the liver, causing inflammation and potential long-term damage), Hyperlipidemia (condition where there are elevated levels of lipids, including cholesterol and triglycerides, in the blood), Gastro-esophageal reflux disease, without esophagitis (occurs when stomach acid flows back into the esophagus but does not cause inflammation or damage [esophagitis], Fatty Liver (condition where there's an excessive buildup of fat in the liver), and Unspecified Convulsions (sudden, involuntary muscle contractions or spasms where the specific cause or type was no identified). Record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1's BIMS score was not calculated. Section C0100, Should Brief Interview for Mental Status (C0200 - C0500) be Conducted was coded 0 for No - resident was rarely/never understood; therefore, BIMS score was not determined. Section I - Active Diagnoses revealed Resident #1 had medically complex conditions, with diagnoses which include GERD, Hyperlipidemia, Arthritis, Non-Alzheimer's Dementia, Seizure Disorder, Encephalopathy, Viral Hepatitis B, and Trisomy 21. Record review of Resident #1's Care Plan, with recent review of 05/14/2025, revealed objectives that lacked the ability to be evaluated, quantified, and verified were: death with dignity (Hospice); [Resident #1] will maintain highest level of practicable well-being (Trisomy 21); [Resident #1] will be prescribed the lowest effective dose of medication (Dementia); and [Resident #1] needs will be met as evidenced by staff to monitor and learn his way of communication. Further review of comprehensive care plan revealed there was no evidence of a focus, objective, or interventions related to Seborrheic dermatitis, Anxiety Disorder, Polyosteoarthritis, unspecified, Hepatitis B, Hyperlipidemia, Gastro-esophageal reflux disease, without esophagitis, Fatty Live, and Unspecified Convulsions. 2. Record review of Resident #2's Facesheet, dated 07/09/2025, revealed a [AGE] year-old male, with an admission date into the facility of 10/12/2020. Resident #2 had diagnoses which included Vascular Dementia (a decline in thinking and reasoning skills caused by conditions that damage blood vessels in the brain, reducing blood flow and oxygen supply to the brain cells), Schizoaffective Disorder (mental health condition characterized by a combination of schizophrenia symptoms [like hallucinations and delusions] and mood disorder symptoms [like mania or depression]), Generalized Anxiety Disorder (mental health condition characterized by excessive, uncontrollable, and often irrational worry about everyday events or activities), Pruritus (the medical term for itching, a sensation that prompts the urge to scratch), GERD (digestive disorder where stomach acid flows back into the esophagus, causing symptoms like heartburn or regurgitation), Aphasia (a language disorder that affects the ability to communicate), Cerebral infarction (a condition where a part of the brain was damaged due to a lack of blood supply), Other seizures (sudden, temporary change in brain activity that can cause a variety of effects, including changes in behavior, movement, sensation, and awareness), Cortical blindness (a condition where vision loss occurs due to damage to the brain's visual processing centers rather than the eyes themselves), Major Depression (A serious mental illness characterized by persistent feelings of sadness and loss of interest in activities impacting daily life), and Hyperlipidemia (condition where there are elevated levels of lipids, including cholesterol and triglycerides, in the blood). Record review of Resident #2's Annual MDS, dated [DATE], revealed Resident #2's BIMS score was 10, which indicated moderate impairment. Section I - Active Diagnoses revealed Resident #2 had medically complex conditions, with diagnoses of Schizophrenia, Vascular Dementia, Schizoaffective Disorder, Cortical blindness, GERD, and Aphasia. Record review of Resident #2's Care Plan, with recent review of 07/08/2025, revealed objectives that lacked the ability to be evaluated, quantified, and verified were: [Resident #2] will not exhibit signs of malnutrition or dehydration (weight loss/Nutritional Status; [Resident #2] will be prescribed the lowest effective dose of medication (Schizoaffective disorder); [Resident #2] will communicate daily with staff (cerebral infarction); [Resident #2] will have fewer episodes of verbal behaviors; [Resident #2] will not injure self, secondary to seizure disorder; [Resident #2] will be encouraged to make decisions with assistance (Dementia and schizoaffective disorder); [Resident #2] will have No cardiac complications through the next review date (hyperlipidemia); [Resident #2] Will have positive experiences in daily routine. Without overly demanding task and without becoming overly stressed (dementia); and [Resident #2] Will not have discomfort due to GERD. Further review of comprehensive care plan revealed there was no evidence of a focus, objective, or interventions related to Pruritus, and Generalized Anxiety Disorder. 3. Record review of Resident #3's Facesheet, dated 07/09/2025, revealed a [AGE] year-old male, with an admission date into the facility of 05/05/2022. Resident #3 had diagnoses which included Wernicke's encephalopathy (a serious brain disorder caused by thiamine [vitamin B1] deficiency, often linked to chronic alcohol abuse), Acute respiratory failure with hypoxia (a serious condition where the lungs cannot adequately option donate the blood, leading to dangerously low oxygen levels in the body), Schizoaffective disorder (mental health condition characterized by a combination of schizophrenia symptoms [like hallucinations and delusions] and mood disorder symptoms [like mania or depression], Post-traumatic Stress Disorder (A mental health condition that can develop after experiencing or witnessing a traumatic event), Anxiety Disorder (mental health condition characterized by excessive, uncontrollable, and often irrational worry about everyday events or activities), Pruritus (the medical term for itching, a sensation that prompts the urge to scratch), Alcohol dependence, in remission, Cannabis (marijuana) dependence, in remission, Dementia (A general term for a decline in mental ability impacting memory, thinking, and behavior, that interferes with daily life), Insomnia (a common sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or both, leading to inadequate or poor-quality sleep), Enuresis (involuntary urination typically occurring during sleep, in those who are typically expected to have bladder control), Dysphagia (difficulty swallowing), Cognitive communication deficit (communication difficulties stemming from impairments in cognitive skills like attention, memory, and problem solving rather than primary language or speech problem), and Aphasia (a language disorder that affects the ability to communicate) following cerebral infarction. Record review of Resident #3's Quarterly MDS, dated [DATE], revealed Resident #3's BIMS score was 09, which indicated moderate impairment. Section I - Active Diagnoses revealed Resident #3 had Other Neurological Condition, as I0020 was coded 07. Active diagnoses were not documented as Sections 15400 through 18000 were left blank. Record review of Resident #3's Care Plan, with recent review of 12/13/2024, revealed objectives that lacked the ability to be evaluated, quantified, and verified were: [Resident #3] will make safe appropriate decisions (traumatic brain injury); [Resident #3] will interact with other residents during activities of choosing, such as bingo and parties; resident will have decreased episodes of urinary incontinence at night; [Resident #3] will not exhibit signs of drug related side effects or adverse drug reactions (Anxiety); Resident will reduce level of restlessness and anxiety; [Resident #3] needs/wants will be met at all times (Cognitive communication deficits); [Resident #3] will be more alert and oriented as possible (dementia); [Resident #3] will have fewer episodes of verbal aggression, and [Resident #3] will express/exhibit satisfaction. Further review of comprehensive care plan revealed there was no evidence of a focus, objective, or interventions related Post-traumatic Stress Disorder, Schizoaffective disorder, Pruritus, Alcohol dependence, in remission, Cannabis dependence, in remission, Insomnia, Dysphagia, Aphasia, Dysphagia, and Wernicke's encephalopathy. 4. Record review of Resident #4's Face sheet, dated 07/09/2025, revealed a [AGE] year-old female, with an admission date into the facility of 04/23/2025. Resident #4 had diagnoses which included Fracture of unspecified metatarsal bones (the five long bones in the midfoot located between the tarsal bones of the ankle and the phalanges [toe bones], left foot, initial encounter for closed fracture - 1st, 2nd, 3rd heads, Unspecified open wound of left great toe without damage to nail, subsequent encounter (after treatment for fracture), presence of cardiac pacemaker (a small battery powered device implanted in the chest to regulate a slow or irregular heartbeat), Mixed hyperlipidemia (condition characterized by elevated levels of both cholesterol and triglycerides in the blood), Nicotine dependence, unspecified, Bipolar disorder (A mental health condition characterized by extreme shifts in mood, energy, and activity levels impacting a person's ability to carry out daily tasks), Anxiety disorder (mental health condition characterized by excessive, uncontrollable, and often irrational worry about everyday events or activities), Essential (primary) hypertension (a condition characterized by persistently high blood pressure without a known secondary cause), Unspecified atrial fibrillation (type of irregular heartbeat where the heart's upper chambers beat chaotically and rapidly, causing the heart to beat irregularly and often too fast), Heart failure (introduction where the heart can't pump enough blood to meet the body's needs), and Unspecified sequelae of unspecified cerebrovascular disease (long-term aftereffects or complications resulting from a stroke or other cerebrovascular event where the specific type of disease and the resulting conditions are not identified). Record review of Resident #4's admission MDS, dated [DATE], revealed Resident #4's BIMS score was 14, which indicated intact cognition. Section I - Active Diagnoses revealed Resident #4 had medically complex conditions, with diagnoses of arterial fibrillation, Heart failure, Hyperlipidemia, Anxiety disorder, Bipolar disorder, Essential (Primary) Hypertension, Unspecified sequelae of unspecified cerebrovascular disease, and presence of cardiac pacemaker. Record review of Resident #4's Care Plan, with recent review of 04/23/2025, revealed objectives that lacked the ability to be evaluated, quantified, and verified were: [Resident #4] will interact and converse appropriately with staff, other residents, and visitors (Bipolar disorder); [Resident #4] will not exhibit signs of activity intolerance (atrial fibrillation); resident will perform tasks at the highest practical level (ADL). Further review of comprehensive care plan revealed there was no evidence of a focus, objective, or interventions related to: Fracture of unspecified metatarsal bones, Unspecified open wound of left great toe without damage to nail, Mixed hyperlipidemia, Nicotine dependence, Anxiety disorder, Essential (primary) hypertension, Heart Failure, and Unspecified sequelae of unspecified cerebrovascular disease. 5. Record review of Resident #5's Facesheet, dated 07/09/2025, revealed a [AGE] year-old male, with an admission date into the facility of 12/15/2023. Resident #3 had diagnoses which included Alzheimer's Disease (most common form, where a person experienced the effects of more than one type of dementia), Cognitive communication deficit (communication difficulties stemming from impairments in cognitive skills like attention, memory, and problem solving rather than primary language or speech problem), Dysphagia (difficulty swallowing), Cardiac murmur, unspecified (an extra or unusual sound heard during a heartbeat, often described as a whooshing or swishing noise caused by turbulent blood flow through the heart), Essential (primary) hypertension (a condition characterized by persistently high blood pressure without a known secondary cause), Type 2 diabetes mellitus (a chronic metabolic disorder where the body does not properly use insulin, leading to high blood sugar levels), Hyperlipidemia (condition where there are elevated levels of lipids, including cholesterol and triglycerides, in the blood), and Major Depressive Disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and difficulty functioning in daily life). Record review of Resident #5's Quarterly MDS, dated [DATE], revealed Resident #5's BIMS score was 08, which indicated moderate impairment. Section I - Active Diagnoses revealed Resident #5 had Non-Traumatic Brain Dysfunction with diagnoses of Alzheimer's Disease, Type 2 diabetes mellitus, Hyperlipidemia, Major Depressive Disorder, Essential (primary) hypertension, and Cardiac murmur, unspecified Record review of Resident #5's Care Plan, with recent review of 06/11/2024, revealed objectives that lacked the ability to be evaluated, quantified, and verified were: Resident will show no signs of distress related to impaired memory; Resident will perform the following task at the highest practical level: diabetic snack on time and maintain stable weight; Benefit without side effects (related to psychotropic drug use for major depressive disorder) and express exhibit satisfaction, Resident will be as alert and oriented as possible (dementia/delirium); and have fewer episodes of depression. Further review of comprehensive care plan revealed there was no evidence of a focus, objective, or interventions related to: Cognitive communication deficit, Dysphagia, Cardiac murmur, Essential (primary) hypertension, Type 2 diabetes mellitus, and Hyperlipidemia. 6. Record review of Resident #6's Facesheet, dated 07/10/2025, revealed a [AGE] year-old male, with an admission date into the facility of 07/24/2024 . Resident #6 had diagnoses which included Generalized anxiety disorder (mental health condition characterized by excessive, uncontrollable, and often irrational worry about everyday events or activities), Type 2 diabetes mellitus (a chronic metabolic disorder where the body does not properly use insulin, leading to high blood sugar levels), GERD (digestive disorder where stomach acid flows back into the esophagus, causing symptoms like heartburn or regurgitation), Insomnia (a common sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or both, leading to inadequate or poor-quality sleep), Hyperlipidemia (condition where there are elevated levels of lipids, including cholesterol and triglycerides, in the blood), and Essential (primary) hypertension (a condition characterized by persistently high blood pressure without a known secondary cause). Record review of Resident #6's Quarterly MDS, dated [DATE], revealed Resident #6's BIMS score was 15, which indicated intact cognition. Section I - Active Diagnoses revealed Resident #6 had an amputation and active diagnoses were Type 2 diabetes mellitus, Hyperlipidemia, Essential (primary) hypertension, and acquired absence of right leg below knee. Record review of Resident #6's Care Plan, with recent review of 08/14/2024, revealed objectives that lacked the ability to be evaluated, quantified, and verified were: [Resident #6] will decrease his dependency on illegal drugs as a method of coping; and [Resident #6] will interact without threatening, screaming at, or cursing at persons. Further review of the comprehensive care plan revealed there was no evidence of a focus, objective, or interventions related to: GERD, Insomnia, Hyperlipidemia, and Essential (primary) hypertension. During an interview on 07/10/2025 at 2:40 p.m., the Clinical Case Manager said the residents' goals and outcomes were developed through the IDT process. The Clinical Case Manager said she was aware the outcomes were not measurable as written in the care plans of the residents in the sample. The Clinical Case Manager said if the outcome could not be measured, the IDT could not measure the resident's progress or lack of progress in the area of service that was provided. The Clinical Case Manager said the IDT was responsible to ensure the outcomes were measurable. During an interview on 07/10/2025 at 4:06 p.m., the Administrator said she expected all outcomes in the residents' care plans to be measurable. The Administrator said outcomes needed to be measurable to ensure all services were be provided in the highest quality possible. The Administrator said the IDT needed a way to determine the residents were benefiting from the services. Record review of the facility's policy, Comprehensive Care Plans, dated 01/02/2024, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the residence comprehensive assessment.

Based on interview and record review, the facility failed to ensure the comprehensive care plan was prepared by an interdisciplinary team, that included but not limited to a nurse aide with the responsibility for the resident for 6 of 6 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6) reviewed for care plans. The facility failed to ensure the nurse aides with responsibility for the residents were invited and attended the resident care plan conferences. This failure could place residents at risk for not receiving the care and services to meet their needs.The findings include: 1. Record review of Resident #1's Facesheet, dated 07/09/2025, revealed a [AGE] year-old male, with an admission date into the facility of 05/08/2025. Resident #1 had a diagnosis which included Encephalopathy (a broad range of conditions that cause brain dysfunction, leading to altered consciousness, cognitive impairment, and neurological symptoms), unspecified. Record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1's BIMS score was not calculated. Section C0100, Should Brief Interview for Mental Status (C0200 - C0500) be Conducted was coded 0 for No - resident was rarely/never understood; therefore, BIMS score was not determined. 2. Record review of Resident #2's Facesheet, dated 07/09/2025, revealed a [AGE] year-old male, with an admission date into the facility of 10/12/2020. Resident #2 had diagnosis which included Vascular Dementia (a decline in thinking and reasoning skills caused by conditions that damage blood vessels in the brain, reducing blood flow and oxygen supply to the brain cells). Record review of Resident #2's Annual MDS, dated [DATE], revealed Resident #2's BIMS score was 10, which indicated moderate impairment. 3. Record review of Resident #3's Facesheet, dated 07/09/2025, revealed a [AGE] year-old male, with an admission date into the facility of 05/05/2022. Resident #3 had a diagnosis which included Wernicke's Encephalopathy (a serious brain disorder caused by thiamine [vitamin B1] deficiency, often linked to chronic alcohol abuse) Record review of Resident #3's Quarterly MDS, dated [DATE], revealed Resident #3's BIMS score was 09, which indicated moderate impairment. 4. Record review of Resident #4's Facesheet, dated 07/09/2025, a [AGE] year-old female, with an admission date into the facility of 04/23/2025. Resident #4 had a diagnosis which included Fracture of unspecified metatarsal bones (the five long bones in the midfoot located between the tarsal bones of the ankle and the phalanges [toe bones], left foot, initial encounter for closed fracture - 1st, 2nd, 3rd heads). Record review of Resident #4's admission MDS, dated [DATE], revealed Resident #4's BIMS score was 14, which indicated intact cognition. 5. Record review of Resident #5's Facesheet, dated 07/09/2025, revealed a [AGE] year-old male, with an admission date into the facility of 12/15/2023. Resident #5 had a diagnosis which included Alzheimer's Disease (most common form, where a person experienced the effects of more than one type of dementia). Record review of Resident #5's Quarterly MDS, dated [DATE], revealed Resident #5's BIMS score was 08, which indicated moderate impairment. 6. Record review of Resident #6's Facesheet, dated 07/10/2025, revealed a [AGE] year-old male, with an admission date into the facility of 07/24/2024 . Resident #6 had a diagnosis which included Generalized anxiety disorder (mental health condition characterized by excessive, uncontrollable, and often irrational worry about everyday events or activities). Record review of Resident #6's Quarterly MDS, dated [DATE], revealed Resident #6's BIMS score was 15, which indicated intact cognition. During an interview on 07/10/2025 at 9:45 a.m., CNA B said she did not attend or participate in care planning or care plan meetings. CNA B said no one asked for her input related to the goals and interventions in the residents' care plans. CNA B said her input would be valuable because she had built a good rapport with the residents she worked with. CNA B said she knew her residents very well and provided the services they needed. During an interview on 07/10/2025 at 2:40 p.m., the Clinical Case Manager said the social worker was responsible for inviting the members of the IDT to the care plan meetings. The Clinical Case Manager said the CNAs did not participate in the IDT meetings. The Clinical Case Manager said she would obtain the CNAs' input through documentation from the residents' electronic records. The Clinical Case Manager said she would talk with the staff on the floor, but did not document her conversations. During an interview on 07/10/2025 at 2:50 p.m., the Social Worker said she sent out the invites to the members of the IDT care plan meetings. The Social Worker said CNAs attending the meetings had not been customary in the two (2) years she had been at the facility. The Social Worker said the CNAs were not invited because of their job responsibilities and their need to be on the floor to provide direct care. The Social Worker said if she needed information from a CNA, she would interview or talk to them because the CNAs worked very closely with the residents. The Social Worker said CNAs should attend the care plan meetings and be involved in the develop of the plan in her opinion. The Social Worker said the CNAs involvement in the IDT progress would be valuable because the CNAs knew and saw factual information and the IDT would not risk the likelihood of making information up. The Social Worker said the CNAs knew the residents' customs, habits, when they were upset, valuable information for interventions, and paid attention to the residents' needs. During an interview on 07/10/2025 at 3:10 p.m., CNA E said she did not participate in the IDT care plan meetings. CNA E said no one asked for her input for care plan development. During an interview on 07/10/2025 at 3:21 p.m., CNA F said she did not participate in the IDT meeting to develop care plans, and no one asked for her input. CNA F said she thought the social worker should ask for her input because she knew the residents' personalities and behaviors. During an interview on 07/10/2025 at 3:36 p.m., the DON said she was aware the CNAs did not attend the IDT care plan meetings. The DON said the CNAs involvement was necessary to ensure all individual information was included in the care plan by the staff who knew the residents the best. During an interview on 07/10/2025 at 4:06 p.m., the Administrator said she was aware the CNAs did not participate as members of the IDT. The Administrator said CNAs should attend because they knew more about the residents than the social worker or activity director because they worked more and spent more time with each resident. The Administrator said the CNAs knew the residents' habits, personalities, personal choices, and individual details. The Administrator said CNAs would help the facility provide better and higher quality services. Record review of the facility's policy, Comprehensive Care Plans, dated 01/02/2024, revealed, The comprehensive Care plan will be prepared by an interdisciplinary team, that includes but is not limited to. c. Nurse aide with responsibility for the resident.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitization. 1. The facility failed to ensure ground meat was thawed properly. 2. The facility failed to ensure the cook performed hand hygiene appropriately when preparing food. 3. The facility failed to ensure foods were sealed and/or labeled properly. 4. The facility failed to ensure the foods were not stored past expiration date. Thess failures could place residents that eat out of the kitchen at risk for contamination and foodborne illnesses. Findings included: During an observation of the kitchen on [DATE] between 2:15 p.m. - 2:50 p.m. revealed the following: Sink: 1 plastic dish sitting in a sink with 4 tubes of ground meat sitting vertically in the dish that was filled with water and water running into the container. The ground meat was not submerged in the water with approximately 30% of ground meat outside of the water and water was running in the middle of the 4 tubes and not covering the meat. Pantry: *1 clear plastic bag not sealed and was open to air held an opened bag of potato chips dated [DATE] & [DATE]. *7 expired bottles of Lemon Juice from concentrate with written date of ,d+[DATE] on the outside of the bottles. Manufacture date on the bottle lids was [DATE]. Refrigerator #1: *1 clear plastic bag not sealed and was open to air held an opened bag of pink circular meat. There was no description on the bag. *1 expired bottle of Lemon Juice from concentrate with written date of ,d+[DATE] on the outside of the bottle. Manufacture date on the bottle lid was [DATE]. Refrigerator #2: *1 sealed plastic container of grape jelly with no date on label. Freezer # 1: *1 box of 3 containers of whipped topping sitting on the floor on its side to the left of freezer door. *1 bag of a circular breaded item with no description and no date. *2 bags of what appeared to be frozen pancakes with no description and no date. During an interview on [DATE] at 2:53 p.m., the cook stated bags of food being stored should be sealed. He stated after opening food item it should be labeled with open date. He stated if foods were not stored in their original container, then they should have item description on them. He stated no food should be stored on the floor. The cook stated meat should be dethawed in the refrigerator, but meat would need to be placed in the refrigerator several days before needed to dethaw in the refrigerator. He stated he had been rotating the meat during the thawing process due to all the meat was not submerged in the water in dish in sink. He stated he had started defrosting the meat about an hour prior. He stated he was responsible for storing, labeling, and preparing foods. During an observation on [DATE] at 4:11 p.m., the cook started pureeing foods for diner service. He donned gloves without washing his hands and began pureeing meat entree. He added all ingredients into the blender until food item was appropriate consistency He then moved food into container and covered with foil prior to putting item into the freezer. He took blender to the dish room and removed his gloves. The cook rinsed out blender prior to running through the dish washer and he did not wash hands before touching sanitized blender. He then [NAME] blender back to puree station and put down on counter. He reached into a bucket of water solution and pulled out a rag then wiped down counter under blender and bottom of blender machine. He put blender back together then put gloves on his hands. He did not perform hand hygiene prior to putting on gloves. He then started on pureeing the rest of dinner items. During an interview on [DATE] at 6:45 p.m., the cook stated he should have washed his hands when changing out gloves during food preparation. He stated he had just forgotten to do so when being observed. He stated he was a train wreck and nervous. He stated not labeling food items with date and description could cause the wrong food item to be given to residents with allergies to that food item and could cause the residents to get sick. He stated not storing food items appropriately could cause residents to be sick. During an interview on [DATE] at 3:29 p.m., the DM stated food stored outside of the original container should be labeled with food description and date. She stated no food should be stored on the floor and should be stored at least 6 inches off of the floor. She stated foods should not be stored in the pantry or in the refrigerator past the manufacture's expiration date and the date the manufacturer had on container was the expiration date. The DM stated she expected for food items to be disposed of when item passed the expiration date. She stated anyone who puts up food items off the delivery truck and during food preparation were responsible for making sure items were stored correctly with appropriate label. She stated she does monitor that food was labeled, stored at least 6 inches off of the floor and not expired. She stated she last monitored the kitchen the week prior. The DM stated packages of food should be stored in sealed containers after opened. She stated ground meat should be thawed submerged under running water. She stated kitchen staff should wash hands with soap and water during glove changes. She stated she expected for HH to be done when moving from one task to another in the kitchen and not performing could lead to cross contamination and bacteria spread. She stated she had been working for the facility for approximately one week and will be monitoring the kitchen at least ,d+[DATE] times a week. She stated not labeling food appropriately with description of food item and dates could lead to allergic reaction. She stated she would have thrown food away without date on label because staff would not know when food should be disposed of. The DM stated not thawing out meat correctly could lead to some of the food being in the danger zone for longer than appropriate time and could cause bacteria to grow. During a telephone interview on [DATE] at 5:00 p.m., the dietician stated foods stored outside of their original container should be labeled with description and date. She stated foods should be stored 6 inches above the floor. She stated foods should be disposed of and not kept past the expiration date. She stated packages of food items should be sealed so not to expose food to the elements. She stated typically frozen meat was thawed during the cooking process, in the cooler or under cold running water. She stated not submerging frozen meat could more than likely cause it to thaw unevenly and cause foodborne illness. She stated every time gloves were changed during food preparation then HH should be performed in between glove changes. She stated the dietary manager monitors that kitchen staff store, prepare and prepare food appropriately. She stated she was available for training and does observe how staff store and prepare food. She stated the kitchen staff had been changing and there was a new DM which could have led to failures of HH, meat thawing, and food storage or staff may have forgotten their training. She stated she felt more education was needed. She stated that not storing food appropriately and not performing HH correctly could lead to illness from bacteria. During an interview on [DATE] at 9:39 a.m., the ADMN stated she expected for kitchen staff to follow policies on food storage, preparation, and hand hygiene. She stated the DM monitored that kitchen staff were following the facility's policy. She stated not storing and preparing food appropriately could cause residents to get sick. Record Review of facility's policy titled Food Preparation and Handling dated 2018 revealed: Procedure: 1. General Guidelines a. Use clean, sanitized surfaces, equipment and utensils. b. Wash hands properly before beginning food preparation . 2. Thawing Foods a. Thaw meat, poultry and fish in a refrigerator at 41 F or less. b. Foods may also be thawed using the following procedures: i. Completely submerged under running water at a temperature of 70 F or below with sufficient water velocity to agitate and float off loosened food particles into the overflow: 1. For a period of time that does not allow thawed portions of ready-to-eat food to rise above 41 F; or 2. For a period of time that does not allow thawed portions of a raw animal food requiring cooking to be above 41 F for more than four hours including the time the food is exposed to the running water and the time needed for preparation for cooking. Record Review of facility's policy titled Handwashing/Hand Hygiene dated [DATE] revealed: Hand hygiene must be performed prior to donning and after doffing gloves. Record Review of facility's policy titled Preventing Foodborne Illness - Food Handling dated [DATE] revealed: All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents .Potentially hazardous foods held in the danger zone (41 F to 135 F) for more than 4 hours (if being prepared from ingredients at room temperature) or 6 hours (if cooked and then cooled) will be discarded. Record Review of facility's policy titled Food Storage dated 2018 revealed: 1. Dry storage rooms .d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated .2. Refrigerators .d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage .e. Use all leftovers within 72 hours. Discard items that are over 72 hours old .3. Freezers .c. Store all foods on racks or shelves off the floor. Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed on [DATE] revealed: ,d+[DATE].11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents; (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act S 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date. ,d+[DATE].13 Thawing. Except as specified in (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (A) Under refrigeration that maintains the FOOD temperature at 5oC (41oF) or less Pf; or (B) Completely submerged under running water: (1) At a water temperature of 21oC (70oF) or below Pf, (2) With sufficient water velocity to agitate and float off loose particles in an overflow Pf, and

Based on interview and record review, the facility failed to ensure residents/resident's representative had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he/ she preferred for 2 of 23 residents (Resident #29 and Resident #44) reviewed for antipsychotic consents. 1. The facility failed to ensure Resident #29 or their representative signed consent for antipsychotic medication Seroquel (quetiapine) (an antipsychotic medication used to treat mental health disorders, such as schizophrenia) prior to administering medication and after dosage increased and prior to administering new dosage ordered by physician. 2. The facility failed to ensure Resident #44's or their representative signed consent for antipsychotic medication Seroquel (quetiapine) prior to administering medication. These failures could affect residents by placing them at risk of not being informed of their health status, to make informed decisions regarding their care. Findings included: Resident #29 Record review of Resident #29's electronic face sheet dated 02/19/2025 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and most recently on 08/21/2022 with diagnoses to include: schizoaffective disorder, bipolar type (mental health condition that includes hallucinations and delusions, depression and mania). Record review of Resident #29's quarterly MDS dated [DATE] revealed: BIMS score of 09 which indicated moderate cognitive impairment. Further review of the MDS Section N-Medications revealed Resident #29 was taking antipsychotic medication. Record review of Resident #29's physician order dated 10/14/2024 revealed: quetiapine tablet 100mg 1 tablet to be administered twice a day orally. Record review of Resident #29's MAR dated October 2024 revealed Resident #29 received Seroquel (quetiapine) 100mg twice a day starting the night of 10/14/2024 - 10/31/2024 Record review of Resident #29's MAR dated November 2024 revealed Resident #29 received Seroquel (quetiapine) 100mg twice a day from 11/01/2024 - 11/30/2024. Record review of Resident #29's MAR dated December 2024 revealed Resident #29 received Seroquel (quetiapine) 100mg twice a day from 12/01/2024 - 12/31/2024. Record review of Resident #29's MAR dated January 2025 revealed Resident #29 received Seroquel (quetiapine) 100mg twice a day from 01/01/2025 - 01/31/2025. Record review of Resident #29's MAR dated February 2025 revealed Resident #29 received Seroquel (quetiapine) 100mg twice a day from 02/01/2025 - 02/19/2025. Record review of Resident #29's HHSC Form 3713 Consent for Antipsychotic or Neuroleptic Medication Treatment dated 03/31/2023 for Seroquel revealed no evidence of a signature by Resident #24 or their representative. Further review revealed a verbal consent obtained by CCN on 04/05/2023 for dosage of 50mg in the AM and 100mg in the PM. No evidence that side effects were went over with Resident #29's representative and side effects were not listed on the form. Record review of Resident #29's electronic medical chart revealed no evidence Resident #29 or his representative consented to increased dosage of Seroquel on or before 10/14/2024. Attempted a telephone interview on 02/17/2025 at 11:10 a.m., Resident #29's representative did not answer phone call and no return call. Resident #44 Record review of Resident #44's electronic face sheet dated 02/19/2025 revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: neurocognitive disorder with Lewy bodies (Protein deposits called Lewy bodies develop in nerve cells in the brain. The protein deposits affect brain regions involved in thinking, memory and movement), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest that affects how people feel, think and behave). Record review of Resident #44's quarterly MDS dated [DATE] revealed: BIMS score of 07 which indicated severe cognitive impairment. Further review of the MDS Section N-Medications revealed Resident #44 was taking antipsychotic medication. Record review of Resident #44's physician order dated 05/15/2024 revealed: quetiapine tablet 25mg 1 tablet to be administered once a day orally at bedtime. Further review of physician order revealed quetiapine was discontinued on 05/22/2024. Record review of Resident #44's physician order dated 08/09/2024 revealed: quetiapine tablet 25mg 1 tablet to be administered once a day orally at bedtime. Further review of physician order revealed quetiapine was discontinued on 08/21/2024. Record review of Resident #44's physician order dated 09/12/2024 revealed: quetiapine tablet 25mg 1 tablet to be administered once a day at bedtime. Record review of Resident #44's MAR dated May 2024 revealed Resident #44 received Seroquel (quetiapine) 25mg once a day starting the night of 05/15/2024 - 05/21/2024. Record review of Resident #44's MAR dated August 2024 revealed Resident #44 received Seroquel (quetiapine) 25mg once a day from 08/09/2024 - 08/31/2024. Record review of Resident #44's MAR dated September 2024 revealed Resident #44 received Seroquel (quetiapine) 25mg once a day from 09/01/2024 - 09/30/2024. Record review of Resident #44's MAR dated October 2024 revealed Resident #44 received Seroquel (quetiapine) 25mg once a day from 10/01/2024 - 10/24/2024 & 10/26/2024 - 10/31/2024. Record review of Resident #44's MAR dated November 2024 revealed Resident #44 received Seroquel (quetiapine) 25mg once a day from 11/01/2024 - 11/30/2025. Record review of Resident #44's electronic medical chart revealed no evidence Resident #44, or his representative consented to antipsychotic medication Seroquel on or before 05/15/2024. During an interview on 02/19/2025 at 4:20 p.m., LVN A stated that nurses were responsible for obtaining medication consent for psychoactive medications. She stated nurses get the consent prior to giving the medication. She stated sometimes the DON will assist with getting psychoactive medications. LVN A stated there was a form that would be filled in on the electronic medical system under the observations section. She stated after form filled out then the process would be to print the form and get a physical signature on the form. She stated it was okay to get a verbal consent if person not available in person to sign the form and when a verbal was obtained the DON would be notified. She stated as far as she knew, there was not another process for medications like Seroquel that were antipsychotics. During an interview on 02/19/2025 at 5:08 p.m., the DON stated it was the nurse's responsibility for getting consents signed for psychoactive medications. She stated those consents should be obtained prior to giving psychoactive medication to the resident. She stated she was not able to find a consent for Seroquel medication on Resident #44. She stated she was unaware that verbal consents were not appropriate for Seroquel medication on Resident #29. She stated she could not find a consent with updated dosage for Resident #29. She verified that the consent for Seroquel on Resident #29 did not have physical signature on the form. She stated what might have led to Resident #44 not having consent on file could be that he had been discontinued from that medication in the past but then restarted back on that medication. The DON stated the effect of not obtaining consent prior to medication administration could cause residents or their representatives not being provided information of the side effects of the medication or not being notified that the resident was ordered that medication. She stated she was responsible for monitoring that the appropriate medications had consents. She stated she had just started monitoring that those consents were completed during the daily morning meetings. During an interview on 02/19/2025 at 5:11 p.m., the CCN stated her expectation would be for consents to be obtained by nurses prior to administering Seroquel to a resident. She stated the reason she obtained a verbal consent on Resident #29's Seroquel on 04/05/2023 was because there was not a policy in place for anti-psychotic medications at that time. She stated there was a policy written on July 2024 about anti-psychotic medication consents. She stated she had been instructed on 04/05/2023 that verbal consent was appropriate. She stated consents needed to be done timely. She stated not obtaining consent for over a year was not timely. She stated there were barriers to obtaining the consents such as family not responding to telephone messages, emails, or written letters. She stated she felt representatives and families were scared to respond because representatives were afraid the facility was reaching out for financial reasons. She stated some of the facility's residents do not have guardians that makes the process timelier and more difficult. She stated no negative affect occurred to residents or their representatives from consents not physically being signed. She stated the facility ensures that residents and their representatives make an informed decision to medication by facility sending out information via letters, emails, and attempting to communicate with them verbally over the telephone. She stated the DON was responsible for monitoring medication consents were properly obtained or her designee. She stated she felt staff needed more education on antipsychotic medication consents and lack of knowledge may have led to the failure. Record review of facility's admission agreement dated 02/22/2022 revealed: Resident's rights under Texas law .You have a right: . 9) to retain the services of a physician of your choice, at your own expense or through a healthcare plan, and to have a physician explain to you, in language you understand, your complete medical condition, the recommended treatment, and the expected results of the treatment Record review of facility policy titled Psychoactive Medications dated July 2024 revealed A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics .9. Consent must be obtained from the resident or resident representative prior to administering a psychotropic medication (excluding an emergency). a. A consent form for antipsychotic/neuroleptic medication utilizing Texas form 3713 must be completed and signed by the resident or resident representative. Consent must be obtained in writing. Review of LTCR Provider letter titled Consent for Antipsychotic and Neuroleptic Medications dated May 5, 2022, accessed on 02/19/2025 at https://www.hhs.texas.gov/sites/default/files/documents/pl2022-11.pdf, revealed The prescriber of the medication, the prescriber's designee, or the NF' s medical director must complete Section I of Form 3713. HHSC cannot specify who can be the designee for the prescriber. Prescribers should consult their own board, such as the Texas Medical Board, to determine who can act as their designee. A prescriber can delegate the completion of Form 3713, Section I, if the prescriber's license permits it . The resident or the resident's legally authorized representative must sign Section II of Form 3713 (Consent for Antipsychotic or Neuroleptic Medication Treatment). The rule requires consent in writing by the resident or by a person authorized by law to consent on behalf of the resident. Verbal consent does not meet the rule requirements. NF staff cannot sign on behalf of the resident. Review of drugs.com accessed on 02/19/2024 at https://www.drugs.com/seroquel.html, revealed Seroquel .Drug class: Atypical antipsychotics .Seroquel may cause serious side effects. Call your doctor at once if you have: uncontrolled muscle movements in your face (chewing, lip smacking, frowning, tongue movement, blinking or eye movement); breast swelling and tenderness, nipple discharge, impotence, missed menstrual periods; trouble swallowing, severe constipation; painful or difficult urination; high blood pressure, fast, slow or uneven heart rate; a light-headed feeling, sudden numbness or weakness, severe headache; blurred vision, eye pain or redness, seeing halos around lights; a seizure, feeling unusually hot or cold; signs of infection - fever, chills, sore throat, body aches, unusual tiredness, loss of appetite, bruising or bleeding; severe nervous system reaction - very stiff (rigid) muscles, high fever, sweating, confusion, fast or uneven heartbeats, tremors, feeling like you might pass out; underactive thyroid - tiredness, depressed mood, dry skin, thinning hair, decreased sweating, weight gain, puffiness in your face, feeling more sensitive to cold temperatures; high blood sugar - increased thirst, increased urination, dry mouth, fruity breath odor; or low white blood cell counts - fever, mouth sores, skin sores, sore throat, cough. Common Seroquel side effects may include speech problems; dizziness; drowsiness; tiredness; feeling like you might pass out; lack of energy; fast heartbeats; increased appetite; weight gain; upset stomach; vomiting; constipation; stomach pain; nausea; abnormal liver function tests; sore throat; stuffy nose; dry mouth; or difficulty moving.

45216 Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 23 residents (Residents #23, #26, #36, #39, #53, and #62) reviewed for care plans in that: 1. The facility failed to define measurable objectives on Resident #23's care plan regarding the problems of resisting care, visual function, oral hygiene, pain, mobility, cognitive loss, and daily tasks. 2. The facility failed to define measurable objectives on Resident #26's care plan regarding the problems of psychotropic drugs, psychosocial well-being, pain, mood, behaviors, activities of daily living and daily tasks. 3. The facility failed to define measurable objectives on Resident #36's care plan regarding the problems of mobility and daily tasks and failed to address on Resident #36's comprehensive care plan the care areas of visual function and communication triggered on the MDS. 4. The facility failed to define measurable objectives on Resident #39's care plan regarding the problems of visual function, self-care deficits, decreased cognition, and daily tasks and the care areas of dental care and communication triggered on the MDS. 5. The facility failed to define measurable objectives on Resident #53's care plan in regard to the problems of daily tasks, pain, ADL function, and impaired cognition. 6. The facility failed to define measurable objectives on Resident #62's comprehensive care plan regarding the problems of self-care related to mobility and impaired cognition, and daily tasks. These failures could affect residents and place them at risk for not having their needs and preferences met. Findings included: Resident #23 Review of Resident #23's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes mellitus (non-insulin dependent diabetes), heartburn, enterocolitis (inflammation of the colon), difficulty sleeping, high blood cholesterol, rapid heart rate, swelling, weakness, anxiety, absence of right and left legs below the knees, pancreatitis (inflammation of the pancreas), and high blood pressure. Review of Resident #23's Admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #23 scored 99 indicating the resident was unable to complete the interview. Further review revealed the following care area triggered Section M - Skin Conditions, sub-section M1200. Skin and Ulcer/Injury Treatments: number 16. Pressure Ulcer/Injury indicated item B. Pressure reducing device on bed was selected. MDS Section V - Care Area Assessment (CAA) Summary B. Care Planning Decision column revealed 16. Pressure Ulcer was selected. Review of Resident #23's Quarterly MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score Resident #23 scored 15 out of 15 indicating cognition was intact. Review of Resident #23's care plan reviewed/revised 01/27/25 revealed the following: *Problem I resist care resisted taking medications/injections with an objective of I will make an informed choice about the benefits of care, options in care, and possible consequences/outcomes for resisting care. *Problem visual function with an objective of Resident will have optimal visual acuity. *Problem Oral/Dental Status with an objective of Maintain oral hygiene/status. *Problem I am at risk for pain R/T my multiple comorbidities with an objective of I will be as comfortable as possible. *Problem ADL Functional/Rehab Potential with an objective of I will achieve maximum functional mobility. *Problem I have cognitive loss related to my diagnosis of anxiety with an objective of I will be as alert and oriented as possible. *Problem The following Tasks will be documented in POC CareAssist with an objective of The Resident will perform the following tasks at their highest practicable level. Approaches/Interventions included Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, I prefer to take my Bath/Shower on M/W/F My preferred time to Bath/Shower is days Once A Day on Mon, Wed, Fri; 06:00 AM - 06:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and Weekly skin Observations Flowsheet ADL Once Daily on Mon, Wed, Fri 06:00 AM - 06:00 PM. Resident #26 Review of Resident #26's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of high blood cholesterol, cholecystitis (inflammation of the gall bladder), anxiety, difficulty sleeping, dementia, kidney disease, depression, high blood pressure, chest pain, heart failure, Type 2 diabetes (non-insulin dependent diabetes), ascites (fluid build-up in the abdomen), and constipation (inability to have a bowel movement) Review of Resident #26's Admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #26 scored 11 out of 15 indicating moderate cognitive impairment. Review of Resident #26's care plan, reviewed/revised 02/04/25, revealed the following: *Problem Psychotropic Drug Use with an unmeasurable objective of Benefit without side effects. *Problem Psychosocial Well-Being with an unmeasurable objective of Resident will express/exhibit satisfaction. *Problem I am at risk for pain related to aging process and dx of diabetes with an unmeasurable objective of Resident will be as comfortable as possible. *Problem Mood State with an unmeasurable objective of Resident will express/exhibit satisfaction. *Problem I have inappropriate verbal outbursts such as yelling out related to my dementia with an unmeasurable objective of I will be encouraged to communicate with the staff for my needs. *Problem ADL Functional/Rehab Potential with an unmeasurable objective of I will achieve maximum functional mobility. *Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level. Approaches/Interventions included Bowel Movement Every Shift; 1 SHIFT 1 06:00 AM - 06:00 PM, SHIFT 1 06:00 PM - 06:00 AM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, HS Snack At Bedtime; 06:00 PM - 06:00 AM, I prefer to take my Bath/Shower on Monday Wednesday Friday My preferred time to Bath/Shower is 6a-6p Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and The staff member who does my bath will document skin issues in the POC Once A Day on Mon, Wed, Fri 06:00 AM - 06:00 PM. Resident #36 Review of Resident #36's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes (non-insulin dependent diabetes), dementia, depression, difficulty walking, pain, high blood pressure, weakness, heart failure, arthritis, paranoid schizophrenia, and swelling. Review of Resident #36's Admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #36 scored 10 out of 15 indicating moderate cognitive impairment. Review of Resident #36's care plan, reviewed/revised 02/04/25, revealed the following: *Problem I have self-care deficits R/T impaired mobility and impaired cognition with an unmeasurable objective of I will achieve maximum functional mobility. *Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of I prefer to take my Bath/Shower on Monday Wednesday Friday My preferred time to Bath/Shower is 6a-6p Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, weekly skin observation during showers Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM. Review of Resident #36's Care Area Assessment (CAA) list generated from the Admission MDS, dated [DATE], revealed the following care areas triggered and selected in MDS Section V - Care Area Assessment (CAA) Summary B. Care Planning Decision column, were not addressed on Resident #36's comprehensive care plan: Visual Function triggered by entry in MDS Section B Hearing, Speech, and Vision, sub-section B1000 Vision, Ability to see in adequate light (with glasses or other visual appliances) code 1. Impaired - sees large print, but not regular print in newspapers/books was selected and sub-section B1200 Corrective Lenses (contacts, glasses, or magnifying glass) used in completing B1000, Vision code 1. Yes was selected. Communication triggered by entry in MDS Section B Hearing, Speech, and Vision, Sub-section B0200 Hearing - Ability to hear (with hearing aid or hearing appliances if normally used) code 2. Moderate difficulty - speaker has to increase volume and speak distinctly was selected. Resident #39 Review of Resident #39's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of high blood pressure, dementia, Alzheimer's disease (a brain disorder that destroys memory and thinking skills), weakness, anxiety, high blood cholesterol, macular degeneration (an eye disease that affects central vision), and Vitamin D deficiency. Review of Resident #39's Admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #39 scored 10 out of 15 indicating moderate cognitive impairment. Review of Resident #39's care plan reviewed/revised 02/04/25 revealed the following: *Problem I have decreased Visual Function and require glasses at times with an unmeasurable objective of Resident will have optimal visual ability. *Problem I have deficits in self-care. ADL Function/Rehab Potential with an unmeasurable objective of Resident will achieve maximum functional mobility. *Problem I have Cognitive Loss related to Dementia with an unmeasurable objective of I will be as alert and oriented as possible. *Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level. Approach/Interventions included: Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, I prefer to take my Bath/Shower on M/W/F My preferred time to Bath/Shower is 6a-6p Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and weekly skin observation during showers Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM. Review of Resident #39's Care Area Assessment (CAA) list generated from the Admission MDS dated [DATE] revealed the following care areas triggered and selected in MDS Section V - Care Area Assessment (CAA) Summary B. Care Planning Decision column, were not addressed on Resident #39's comprehensive care plan: Dental Care MDS Section L - Oral/Dental Status, sub-section L0200. Dental A. Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose) and D. Obvious or likely cavity or broken natural teeth were selected. Communication was triggered by entry in MDS Section B Hearing, Speech, and Vision, Sub-section B0200 Hearing - Ability to hear (with hearing aid or hearing appliances if normally used) code 1. Minimal difficulty - difficulty in some environments (e.g. when person speaks softly or setting is noisy) was selected. Resident #53 Review of Resident #53's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes (non-insulin dependent diabetes), human immunodeficiency virus, myalgia (muscle pain), major depressive disorder, paranoid schizophrenia, chronic obstructive pulmonary disease (a group of lung diseases that cause airway obstruction), cardiac pacemaker, rapid heart rate, atrial fibrillation (irregular beating of upper chamber of the heart), heart failure, high blood cholesterol, cellulitis (bacterial infection affecting the skin and underlying tissues), respiratory disease, chronic leg ulcers, and hemorrhoids. Review of Resident #53's Admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #53 scored 12 out of 15 indicating moderate cognitive impairment. Review of Resident #53's comprehensive care plan, reviewed/revised 12/05/24, revealed the following: *Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level. Approach/Interventions included Bowel Movement Every Shift; SHIFT 1 06:00 AM - 06:00 PM, SHIFT 1 06:00 PM - 06:00 AM. *Problem I am at risk for pain with the unmeasurable objective of I will be as comfortable as possible for the next 90 days. Problem ADL Functional/Rehab Potential with an unmeasurable objective of I will achieve maximum functional mobility . *Problem I have impaired cognition r/t fluctuations in cognition with an unmeasurable objective of Resident will be as alert and oriented as possible . *Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level . and Approach/Interventions of I prefer to take my Bath/Shower on M/W/F My preferred time to Bath/Shower is 6a-6p Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, HS Snack At Bedtime; 06:00 PM - 06:00 AM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and weekly skin observation Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM. Resident #62 Review of Resident #62's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes (non-insulin dependent diabetes), dementia, depression, difficulty walking, pain, high blood pressure, weakness, heart failure, arthritis, paranoid schizophrenia, and swelling. Review of Resident #62's Admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #62 scored 10 out of 15 indicating moderate cognitive impairment. Review of Resident #62's comprehensive care plan, reviewed/revised 02/04/25, revealed the following: *Problem I have self-care deficits R/T impaired mobility and impaired cognition with an unmeasurable objective of I will achieve maximum functional mobility. *Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of I prefer to take my Bath/Shower on Monday Wednesday Friday My preferred time to Bath/Shower is 6a-6p Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, weekly skin observation during showers Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM. During an interview on 02/19/2025 at 2:30 PM, the MDS coordinator stated she was responsible for completing the initial comprehensive care plan and the DON and ADON were responsible for updating the care plans. The MDS coordinator stated her expectation was care plans should include resident's diagnosis, medications, diet, physician orders and any resident care needs. The MDS coordinator stated that objectives should be specific and measurable, and interventions should be a specific task for staff and/or residents that accomplishes objectives. During an interview on 02/19/25 at 12:07 PM, the Regional Nurse Consultant stated her expectations of care plan were for the care plan to look like the resident. She stated if she were a nurse coming in to provide care, she would want to know what was documented on the care plan. The RNC stated if a resident needed assistance or was a fall risk for example, that information should be on the care plan. The RNC explained the objectives should be based on what a nurse would expect to assess when interventions were followed. She stated the DON was responsible for the initial care plan and the ADON/MDS Coordinator contributed to revisions based on the comprehensive assessment. The RNC stated the CAA's should be addressed on the comprehensive care plan. She stated the DON was ultimately responsible for the accuracy of the care plans. The RNC stated in response to an example of an objective for pain, the RNC stated she did not agree with use of a pain scale because pain was subjective data. She explained staff should be able to identify pain by a resident's facial expressions or behavior. The RNC stated she trained staff to recognize pain or discomfort by being observant. Review of the facility policy titled Comprehensive Care Plans, undated, revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives . that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: item 2. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the care plan., and 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. 48883

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 26 of 26 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26) reviewed for infection control. 1. The facility failed to isolate COVID-19 positive Residents #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, and #15, after they tested positive for COVID-19 and continued to cohort with negative tested Residents #4, #6, #16, and #17 on the same unit. Resident #4 (negative) was cohorted with Resident #12 (positive) in the same room. 2. The facility failed to ensure staff changed PPE between working with COVID-19 positive and COVID-19 negative residents. 3. The facility failed to ensure Resident #18 stayed in quarantine while being COVID-19 positive which resulted in Residents #19, #20, #21, #22, #23, #24, #25 and #26 being exposed. 4. The facility failed to ensure proper PPE was being worn by CNA-F while in Resident #19's room. 5. The facility failed to ensure proper PPE technique when CNA A failed to complete hand hygiene after providing care to a COVID-19 positive Resident #3's, and before providing care to a COVID-19 negative Resident #4. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of a pattern with potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for exposure to COVID-19 which could result in serious illness, hospitalization and/or death. Findings Include: Side B was broken down into two units: Unit 1 from [DATE] to [DATE] was the facilities Hot zone that housed COVID positive residents. Unit 1, from [DATE] until time of exit was the step-down unit for the male locked unit (cold) Unit 2, starting [DATE] to time of exit, male locked unit was hot. During an observation on [DATE] at 10:35 AM Side A of the building housed one COVID 19 positive, Resident #18 and eight COVID 19 negative, Residents ##19, #20, #21, #22, #23, #24, #25 and #26. Side B of the building Unit 2 male locked unit had 16 total residents, COVID positive's #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, and #15 and COVID negative #4, #6, #16, and #17 at this time Resident #2 had passed. 1. Record review of Resident #2's quarterly MDS, dated [DATE], reflected an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Cerebral ischemia, hypertension, and dementia. Record review of the facility resident tracking log, dated [DATE] on [DATE], titled COVID+ Residents, reflected Resident #2 was COVID-19 tested on [DATE], and positive test results were received on [DATE]. Record review on [DATE] of Resident #2's progress notes reflected on [DATE] Resident #2 tested positive for COVID-19. On [DATE] Resident #2 was taken to local ER due to low O2 stats/saturation. On [DATE] Resident #2 expired associated to COVID-19. During an interview on [DATE] at 2:10 PM, the MD stated Resident #2 was sent to theER on [DATE] because the resident was unresponsive. The MD stated Resident #2 was intubated and moved to the ICU at the local community hospital. The MD stated Resident #2 expired on [DATE] with complications associated to COVID-19. 2. Record review of Resident #1's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Parkinsonism, schizophrenia, and muscle weakness. Record review of the facility resident tracking log, dated [DATE] on [DATE], titled COVID+ Residents, reflected Resident #1 was COVID-19 tested on [DATE], and positive test results were received on [DATE]. 3. Record review of Resident #3's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Metabolic encephalopathy, history of falling and altered mental status. Record review of the facility's resident tracking log, dated [DATE] on [DATE], titled COVID+ Residents, reflected Resident #3 was COVID-19 tested on [DATE], and positive test results were received on [DATE]. 4. Record review of Resident #4's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Dementia, Schizoaffective disorder, and muscle weakness. Record review of the facility's resident tracking log, dated [DATE] to [DATE], titled COVID- Residents, reflected Resident #4 was COVID-19 tested on [DATE], and negative test results were received on [DATE]. 5. Record review of Resident #5's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Dementia, schizoaffective disorder, and bipolar disorder. Record review of the facility's resident tracking log, dated [DATE] on [DATE], titled COVID+ Residents, reflected Resident #5 was COVID-19 tested on [DATE], and positive test results were received on [DATE]. 6. Record review of Resident #6's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Dementia, Schizoaffective disorder, and bipolar disorder. Record review of the facility's resident tracking log, dated [DATE] to [DATE], titled COVID- Residents, reflected Resident #6 was COVID-19 tested on [DATE], and negative test results were received on [DATE]. 7. Record review of Resident #7's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Alzheimer's Disease, type 2 diabetes mellitus and hypertension. Record review of the facility's resident tracking log, dated [DATE] on [DATE], titled COVID+ Residents, reflected Resident #7 was COVID-19 tested on [DATE], and positive test results were received on [DATE]. 8. Record review of Resident #8's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Dementia, anxiety, and alcohol abuse. Record review of the facility's resident tracking log, dated [DATE] on [DATE], titled COVID+ Residents reflected Resident #8 was COVID-19 tested on [DATE], and positive test results were received on [DATE]. 9. Record review of Resident #9's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Parkinsonism, type 2 diabetes mellitus and muscle weakness. Record review of the facility's resident tracking log, dated [DATE] on [DATE], titled COVID+ Residents reflected Resident #9 was COVID-19 tested on [DATE], and positive test results were received on [DATE]. 10. Record review of Resident #10's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included traumatic subdural hemorrhage, muscle weakness and epilepsy. Record review of the facility's resident tracking log, dated [DATE] on [DATE], titled COVID+ Residents reflected Resident #10 was COVID-19 tested on [DATE], and positive test results were received on [DATE]. 11. Record review of Resident #11's quarterly MDS, dated [DATE], reflected an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Dementia, cognitive communication deficit and anxiety disorder. Record review of the facility's resident tracking log, dated [DATE] on [DATE], titled COVID+ Residents reflected Resident #11 was COVID-19 tested on [DATE], and positive test results were received on [DATE]. 12. Record review of Resident #12's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Dementia, muscle weakness and anxiety disorder. Record review of the facility's resident tracking log, dated [DATE] on [DATE], titled COVID+ Residents reflected Resident #12 was COVID-19 tested on [DATE], and positive test results were received on [DATE]. 13. Record review of Resident #13's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included schizophrenia, bipolar disorder, and muscle weakness. Record review of the facility's resident tracking log, dated [DATE] on [DATE], titled COVID+ Residents reflected Resident #13 was COVID-19 tested on [DATE], and positive test results were received on [DATE]. 14. Record review of Resident #14's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Dementia, type 2 diabetes mellitus and epilepsy. Record review of the facility's resident tracking log, dated [DATE] on [DATE], titled COVID+ Residents reflected Resident #14 was COVID-19 tested on [DATE], and positive test results were received on [DATE]. 15. Record review of Resident #15's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Dementia, Metabolic encephalopathy, and muscle wasting. Record review of the facility's resident tracking log, dated [DATE] on [DATE], titled COVID+ Residents, reflected Resident #15 was COVID-19 tested on [DATE], and positive test results were received on [DATE]. 16. Record review of Resident #16's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Dementia, muscle weakness and anxiety. Record review of the facility's resident tracking log, dated [DATE] to [DATE], titled COVID- Residents reflected Resident #16 was COVID-19 tested on [DATE], and negative test results were received on [DATE]. 17. Record review of Resident #17's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Dementia, type 2 diabetes mellitus and depression. Record review of the facility resident tracking log, dated [DATE] to [DATE], titled COVID- Residents reflected Resident #17 was COVID-19 tested on [DATE], and negative test results were received on [DATE]. 18. Record review Resident #18's face sheet, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Human immunodeficiency virus (HIV) disease, type 2 diabetes mellitus and obesity. Record review of Resident #18's quarterly MDS assessment, dated [DATE], reflected he had a BIMS score 12 out of 15, which indicated he had no cognitive impairment. During an observation on [DATE] at 1:10 PM, Resident #18 was observed in his wheelchair coming from hallway 6 across the nurses' station and back to hallway 2 where his room was. No mask was being worn by Resident #18 while being out of his room, touching the handrails, coughing, and touching the nurses stating, exposing Residents #19, #20, #21, #22, #23, #24, #25 and #26 to COVID-19 Record review of the facility's resident tracking log, dated [DATE] on [DATE], titled COVID Residents Testing log, reflected Residents #19, #20, #21, #22, #23, #24, #25 and #26 were all COVID negative. During an interview on [DATE] at 1:20 PM, Resident #18 stated he was on isolation because he was COVID positive. He stated he didn't have any symptoms and was feeling good. He stated he left his room because he could not fit onto the toilet in his room, so he went to the restroom in his old room. He stated he went to room [ROOM NUMBER] located on hall 6. He stated he didn't really ask to go to his old room to use the toilet and knew he should stay in his room but when he needed to go, he needed to go; so, he went. He stated there was no other resident in his old room. 19. Record review Resident #19's face sheet, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease, Parkinson's disease, and depressive disorder. Record review of Resident #19's quarterly MDS assessment, dated [DATE], reflected he had a BIMS score 99, which indicated he could not complete the interview. During an observation on [DATE] at 12:20 PM, revealed CNA-F was serving food to Resident #19 with no goggles or face shield on. During an interview on [DATE] at 12:25 PM, the DON stated that she was the infection preventionist and that Resident #19 was not COVID positive, but he was on isolation because his roommate was previously COVID positive, so he was considered exposed (warm). She stated that's why all the signage was on the door. She stated Resident #18 was positive for COVID and was on quarantine to protect the other residents in the building from being exposed to COVID. 20. Record review of Resident #20's face sheet, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, cognitive communication deficient and bipolar disorder. Record review of Resident #20's quarterly MDS assessment, dated [DATE], reflected she had a BIMS score 9 out of 15, which indicated moderate cognitive impairment. 21. Record review of Resident #21's face sheet, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, cognitive communication deficient and bipolar disorder. Record review of Resident #21's quarterly MDS assessment, dated [DATE], reflected she had a BIMS score 11 out of 15, which indicated moderate cognitive impairment. 22. Record review Resident #22's face sheet, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included chronic pain due to trauma, quadriplegia, and lack of coordination. Record review of Resident #22's quarterly MDS assessment, dated [DATE], reflected he had a BIMS score 13 out of 15, which indicated no cognitive impairment. 23. Record review Resident #23's face sheet, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included heart failure, type 2 diabetes mellitus, and acute kidney failure. Record review of Resident #23's quarterly MDS assessment, dated [DATE], reflected she had a BIMS score 9 out of 15, which indicated moderate cognitive impairment. 24. Record review Resident #24's face sheet, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her Diagnoses included Alzheimer's disease, cognitive communication deficient and dysphagia. Record review of Resident #24's quarterly MDS assessment, dated [DATE], reflected she had a BIMS score, 5 out of 15 which indicated severe cognitive impairment. Record review of the facility resident tracking log, dated [DATE] on [DATE], titled COVID+ Residents, reflected Resident #24 was COVID-19 tested on [DATE], and positive test results were received on [DATE]. Indicating the first resident to test positive in the facility. 25. Record review Resident #25's face sheet, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included dementia, schizoaffective disorder, and anxiety disorder. Record review of Resident #25's quarterly MDS assessment, dated [DATE], reflected he had a BIMS score 7 out of 15, which indicated severe cognitive impairment. 26. Record review Resident #26's face sheet, dated [DATE], reflected an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included dementia, anxiety disorder and type 2 diabetes mellitus. Record review of Resident #26's quarterly MDS assessment, dated [DATE], reflected he had a BIMS score 9 out of 15, which indicated moderate cognitive impairment. Record review of the facility's COVID testing log, on [DATE], indicated on [DATE] the facility conducted COVID-19 testing on 17 residents who were on the facility's male memory care unit. Upon receiving the results, the facility moved Resident #1 identified as positive to the hot zone for isolation. During observation on [DATE] at 10:45 AM to 12:15PM, CNA A and CNA B working on the memory unit wore the same PPE while working with all 16 residents regardless of Covid status. During an observation on [DATE] at 11:20 AM, CNA A wore a gown and mask, no face shield, goggles, or gloves were worn. CNA A wiped Resident #3's (COVID Positive) nose with a tissue and did not use hand sanitizer or change PPE. CNA A then tried to stop Resident #4 (COVID negative) from trying to get items out of the community refrigerator located in the dining room. Resident #4 touched multiple juice cups and other cups. At 11:30 AM items from the refrigerator were then served to residents in the dining room for lunch. During an observation on [DATE] at 10:55 AM, Resident #5 (COVID positive) was sitting in his room and was on the B side of the room. Resident #4 was (COVID negative) in the same room on the A side of the room. Neither resident was wearing a face mask. During an observation on [DATE] at 11:20 AM, Resident #4 (COVID negative) was sitting at the lunch table with Resident #5 (COVID positive) to eat lunch. The residents shared the table together for approximately 10 minutes before staff moved Resident #4 to be at a table with another table. Both residents were within arm's reach of each other. During an interview on [DATE] at 2:15 PM, the DON stated the facility had the means to keep the Covid positive residents separated from exposed residents. She stated the facility chose not to separate the residents on the locked memory care unit. She stated the exposed residents on the locked memory care unity would eventually become COVID positive regardless. During an interview on [DATE] at 1:55 PM, CNA A stated the unit was much a hot unit (unit housing COVID positive residents). She stated all the residents hang out the same and we treat them all the same. She stated that all the residents were exposed. During a follow-up interview on [DATE] at 2:15 PM, the DON stated there were 16 total residents on the hot COVID unit. She stated there were 12 COVID positive residents (#1, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15) and 4 COVID negative residents (#4, #6, #16, and #17). She stated the COVID-19 infection prevention policy was the policy they used for much everything COVID related. She stated there was no quarantine or isolation separate policy this was the policy they used regarding both isolation and quarantine. She stated they were following all CDC guidelines they could, but regarding the male locked unit it was more difficult to keep the residents quarantined. During an interview on [DATE] at 2:55 PM, CNA B stated she wore all her PPE the entire time she was on the unit, which included mask, face shield/goggles, gown, and gloves. She stated all the residents were exposed, so they were all getting treated the same. She stated she had not removed her PPE since getting to work. She stated Resident #2 normally used his walker. She stated she noticed after being diagnosed with COVID, Resident #2 seemed a little unstable on his walker and to prevent Resident #2 from falling she would put him in a wheelchair. During an interview on [DATE] at 8:20 PM, CNA B stated everyone on the unit was much COVID positive. He stated he was not sure why the facility did not move the positive residents over to the other locked unit when Resident #1 first tested positive. He stated the facility had a locked unit and the staffing, to him, was enough to cover a second locked unit. He stated each night he got to the facility, it's a hot zone. He stated he went to work and treated every resident the same. He stated some of the residents did have symptoms and he only knew of one that went to the hospital. During an interview on [DATE] at 8:30 PM, CNA D stated she had been working the unit the past few nights, maybe a week. She stated the unit was treated like a hot zone. She stated she never saw PPE boxes outside of each room, PPE was only located at the entrance of the unit not really for each individual resident. She stated she kept the same PPE on while on the unit the entire time and treated every resident the same because they were either hot or exposed. She stated she was not sure why the facility did not move the covid positive residents. She stated there was a locked unit with no one on it and the facility was using agency staff to help cover shifts, so the facility could have covered the shifts if they needed to. During an interview on [DATE] at 9:00 PM, RN E stated she was not sure why the facility did not move the first positive resident. She stated she was told by the DON it was how the corporate company worked and it was in the facility policy to work the unit that way. She stated she was not sure why Resident #4 and Resident #5, one negative and one positive were roomed together. She stated she guessed the facility could have moved Resident #5 to another room, but she was not sure how that would have affected him. She stated all the residents got COVID. She stated she believed the facility had another locked unit and had the staff to move the residents. During an interview on [DATE] at 10:15 AM, LVN B stated it was her first day back in a week. She stated she needed to get an updated COVID list for Side A of the building. She stated she knew a few of the residents were good to be removed from isolation and were allowed to be out of their rooms. She stated all the COVID room doors should be closed. She stated she was not sure why all the doors were not closed. She stated she was not sure how COVID got in the building, but it spread very quickly. She stated the PPE required to go into any hot or warm room was, gloves, gown, N95 and face shield/goggles. During a follow-up interview on [DATE] at 1:57 PM, the DON stated the facility required PPE for hot zone or warm zone was mask, gown, and gloves. She stated that was what every employee should put on if they entered a resident's room who was COVID positive or suspected of COVID. She stated, oh yeah, face shield and or goggles should be worn, I forgot about that. She stated she did not know her staff were not wearing goggles. She stated CNA F should have been wearing goggles or a face shield while in Resident #19's room. She stated she did not know Resident #18 was leaving his room to go use the restroom in his old room. She stated she was going to fix his toilet seat immediately, so he did not leave his room anymore because he was exposing other residents. Record review of Covid-19 testing from [DATE] through [DATE] for the male memory care unit reflected: [DATE]-1 Covid-19 positive of 17 residents [DATE]- 1 additional Covid-19 positive residents [DATE] -4 additional Covid-19 positive residents [DATE] - 2 additional Covid-19 positive residents [DATE]- 4 additional Covid-19 positive residents [DATE]- 1 additional Covid-19 positive resident. Record review of the facility's, undated, COVID-19 Infection Prevention policy reflected, 7. Placement and Response to Newly Identified COVID-19 Infected residents. A. Residents with signs or symptoms consistent with COVID-19 who have had close contact of those who test positive should be placed (isolated) in a single-person room, if possible, and the door should be kept closed (if safe to do so). Record review of the facility's, undated, Use Personal Protective Equipment (PPE) When Care for Patients with Confirmed or Suspected COVID-19 reflected: Before caring for patients with confirmed or suspected COVID-19 Healthcare Personnel (HCP) must wear: Face Shield or Goggles, N95 or higher respirator, one pair of clean non-sterile gloves, and isolation gown. Record review of the facility's Infection Control Policy, Before moving a positive resident to a COVID19 unit, consider if the COVID19 unit staff can manage the secure unit resident safely. If not, then the resident must remain on the secure unit for his/her protection as a higher priority. This was determined to be an Immediate Jeopardy (IJ) was identified on [DATE]. The DON and Administrator were notified. The Administrator was provided with the IJ template on [DATE] at 5:44 PM The following Plan of Removal submitted by the facility was accepted on [DATE] at 6:20 PM: Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on [DATE]th, 2024. Plan of Removal: F880: Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Immediate Actions Taken for Those Residents Identified: Action: COVID negative residents will be temporarily moved to another hall (off the secured unit). Residents will continue to be tested per policy. As residents of the secure unit recover, they will be relocated to the negative cohort secure unit. Residents will be moved back into the secured unit if they test positive or there are no longer COVID+ residents on the male secured unit. The negative residents, who have not tested positive within the last 30-days, are separated on their own hall, residents are residing in separate rooms, staff was wearing masks and eye protection. Testing Policy: Testing will occur every three days, until the facility had been COVID free for 14-days. Person(s) Responsible: Administrator, Director of Nursing, and/or Designee Date: [DATE] 2. How the Facility Identified Other Possibly Effected Residents: Action: Residents in the secured unit were tested on [DATE]. Four (4) residents were identified as COVID negative (Residents #4, #6, #16, and #17). Person(s) Responsible: Director of Nursing and Assistant Director of Nursing Date: [DATE] 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Administrator and Director of Nursing educated by Clinical Resource Nurse over COVID policy as it related to isolation protocol (COVID positive residents will not cohort with negative residents.) The facility policy was developed based on the CDC's recommendation & guidance. PPE must be donned correctly before entering the patient area (e.g., isolation rooms or isolation unit if cohorting). PPE should be doffed when leaving an individual patient room or isolation unit if cohorting. PPE must remain in place and be worn correctly for the duration of work in contaminated areas and should not be adjusted during patient care. If cohorting, positive residents' gown and gloves should be changed following patient care. PPE includes NIOSH approved respirator, well-fitting face masks, gowns, gloves, eye protection (goggles or face shields). N95 masks may be worn for the duration of the shift when used solely for source control but should be changed when soiled or compromised. Other PPE should be changed when it becomes soiled. https://www.cdc.gov/infection-control/hcp/core-practices/index.html and https://www.cdc.gov/covid/hcp/infection-control/index.html#cdc_infection_control_background_1_recommended_routine_infection_prevention_and_control_ipc_practices_during_the_covid_19_pandemic (section 1) Person(s) Responsible: Clinical Resource Nurse Date: [DATE] Action: Administrator and Director of Nursing educated by Clinical Resource Nurse over COVID policy as it related to isolation protocol (COVID positive residents will not cohort with negative residents.) The facility policy was developed based on the CDC's recommendation & guidance. PPE must be donned correctly before entering the patient area (e.g., isolation rooms or isolation unit if cohorting). PPE should be doffed when leaving an individual patient room or isolation unit if cohorting. PPE must remain in place and be worn correctly for the duration of work in contaminated areas and should not be adjusted during patient care. If cohorting positive residents' gown and gloves should be changed following patient care. PPE includes NIOSH approved respirator, well-fitting face masks, gowns, gloves, eye protection (goggles or face shields). N95 masks may be worn for the duration of the shift when used solely for source control but should be changed when soiled or compromised. Other PPE should be changed when it becomes soiled. https://www.cdc.gov/infection-control/hcp/core-practices/index.html and https://www.cdc.gov/covid/hcp/infection-control/index.html#cdc_infection_control_background_1_recommended_routine_infection_prevention_and_control_ipc_practices_during_the_covid_19_pandemic (section 1) All staff will be educated prior to working their next shift. Any new or temporary staff (agency) will be educated prior to working their first shift. Person(s) Responsible: Administrator, Director of Nursing, and/or Designee Date: [DATE] 4. How the Corrective Actions Will be Monitored, by whom and for how long: Action: Administrator, Director of Nursing, Assistant Director of Nursing, and/or Designee will observe the secured unit x2 daily, until COVID resolves to monitor for correct PPE usage (staff should wear gown, eye protection, and N95 mask when caring for COVID positive residents) and proper hand hygiene. Director of Nursing, Assistant Director of Nursing, and/or Designee will continue to test per protocol and will follow isolation guidelines per the facility policy. Person(s) Responsible: Administrator, Director of Nursing, Assistant Director of Nursing, and/or Designee Date: [DATE] Action: Ad hoc QAPI performed with Medical Director informing him of the IJ template for F880 and the facility's plan to remove immediacy. Person(s) Responsible: Administrator Date: [DATE] Monitoring of the Plan of Removal included the following: During an observation on [DATE] at 4:30 AM walked facility, two sides to the building. Side A where most of the residents were and no locked units. There were 6 total covid positive residents on this side. Most residents were out of bed, walking around or sitting in the dining room. Side B had the male locked units and some residents who were removed from the hot unit that were on that side of the building for their covid outbreak. Both sides, all staff were wearing facemasks. During an interview on [DATE] at 4:50 AM DON stated that the facility had been organized by: Side A was no hot or warm unit, individual rooms with individual residents on quarantine. Side B was broken down into two units: Unit 1, locked unit with 4 negative residents currently. One CNA required only to wear mask and face shield. Unit 2, male locked unit with currently 12 positives that always have a CNA and a Nurse on the unit in full PPE. During an interview on [DATE] at 4:45 AM, CNA G stated yes she did get in-serviced before she started her shift on [DATE]. She stated she stays on the unit 1 all the time. She stated there were only 4 negative residents on this unit at this time. She stated the DON's education included all the PPE required to wear while in the facility, were on unit 1, and what to wear on unit 2. She stated a mask must be always worn while in the facility. She stated her entire shift she was to wear a mask and face shield/goggles the entire time on the unit. She stated she would change her gloves and hand hygiene anytime she needed to any form of patient care with the resident. She stated if she was needed on unit 2, she was to don the PPE, in order of [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 12 (Resident #1) residents reviewed for elopement. The facility failed to provide supervision for Resident #1, who was care planed for wandering in unsafe places, to prevent him from eloping from the facility on 04/18/2024. The facility was unaware Resident #1 had exited the facility, the last time he was seen by an employee was 2:00 PM, and as a result, the resident was missing for approximately 6 and half hours and was located by assistance from law enforcement. An Immediate Jeopardy (IJ) was identified on 04/26/2024. While the IJ was lowered on 04/27/2024 at 3:30 PM, the facility remained out of compliance at a severity level of no actual harm with a scope of isolated, due to the facility's need to evaluate the effectiveness of their corrective actions. This failure could affect residents who were identified as elopement risks and placed them at risk of serious bodily harm, physical impairment, or death. Findings include: Record review of Resident #1's face sheet dated 04/24/2024 revealed [AGE] year-old male admitted on [DATE] with diagnoses of Alzheimer's disease, type 2 diabetes mellitus (body does not make enough insulin or does not use insulin well), hypertension (high blood pressure), and Major Depressive Disorder. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed: Section C- Cognitive Patterns indicated Resident #1 had a BIMS score of 7 meaning severe cognitive impairment. Section E- Behavior revealed Resident #1 had not exhibited and wandering. Section GG- Functional Abilities and Goals revealed Resident #1 required supervision or touching assistance for eating, hygiene, dressing, transferring and walking. Section M- Skin Conditions revealed Resident #1 had no skin conditions. Record review of Resident #1's Care plan dated 04/18/2024 revealed: Problem Start Date 12/19/2023: Behavioral Symptoms Goal: Resident will have fewer episodes of Depression and wandering in unsafe places Approach: Start Date 12/19/2023 Approach Start Date: 12/19/2023 Always ask for help if resident becomes abusive/resistive; Start Date: 12/19/2023 Convey acceptance of resident during periods of inappropriate behavior; Start Date: 12/19/2023 Encourage diversional activities; Start Date: 12/19/2023 Keep environment calm and relaxed; Start Date: 12/19/2023 Redirect resident as needed; Start Date: 12/19/2023 Remove from public area when behavior is unacceptable Problem Start Date: 12/19/2023: Falls/Safety Risk/Elopement Risk Goal: Resident will remain free of injuries related to falls and will remain in a safe environment Approach: Start Date- 12/19/2023 Assess resident's footwear for proper fit and non skid soles; Start Date: 12/19/2023 Encourage use of call light; Start Date: 12/19/2023 Instruct resident on safety measures; Start Date: 12/19/2023 Keep call light in reach: Start Date: 12/19/2023 Orthostatic hypotension precautions; Start Date: 12/19/2023 PT referral; Problem Start Date: 12/19/2023: Delirium Goal: Resident will be as alert and oriented as possible. Approach: Start Date: 12/19/2023 Assess for constipation; Start Date: 12/19/2023 Assess for Pain; Start Date: 12/19/2023 Minimize distraction; Start Date: 12/19/2023 Orient PRN; Start Date: 12/19/2023 Rule out acute illnesses Problem Start Date: 12/19/2023 Category: Cognitive Loss/ Dementia Cognitive Loss-related Alzheimer disease. Goal: Resident will be as alert and oriented as possible Approach: Approach Start Date: 12/19/2023 Anticipate needs and observe for nonverbal cues; Start Date: 12/19/2023 Approach in calm manner; Start Date: 12/19/2023 Explain what you intend to do while providing care; Introduce self-Created; Start Date: 12/19/2023 Orient PRN to person, place and time. Record review of the facility's document titled Accidents/Incidents dated 04/23/2024 revealed Resident #1 had an elopement on 04/18/2024. During an interview on 04/25/2024 at 4:55 PM CNA F stated she remembered seeing Resident #1 in the dining area around 1:30 PM on 04/18/2024. During an interview on 04/25/2024 at 2:15 PM, OT L stated she had visited with Resident #1 on 04/18/2024 around 2:00 PM. She stated he had come into the therapy area and was happy and talkative. OT L stated she could not believe that Resident #1 left the building. During an interview on 04/25/2024 at 5:45 PM CNA I stated she was working Hall 1 and placed Resident #1's tray in his room approximately 4:45pm. CNA I stated she assumed he was in the dining room watching television, playing games or reading books. CNA I stated she got distracted with another resident and did not go look for Resident #1. CNA I stated she later went back into Resident #1's room and his tray had not been touched. CNA I stated she figured the resident was still reading or playing games, so she left his tray for it to be re-heated when he was ready to eat. CNA I stated she should have gone and looked for the resident, but she did not. Record review of Resident #1's progress notes revealed: Date & Time: 04/18/2024 at 8:00 PM, Documented by LVN B [Recorded as Late Entry on 0411912024 12:36AM] nurse went into resident room to give him his medication. resident wasn't in his. nurse and staff went to all rooms and living area looking for him. nurse notified ADMN and DON that resident couldn't be found. administrator notified police. police came to facility and look in all rooms. nurse notified resident [family member] to report resident left the facility without telling anyone. resident was found at salvation army and bring back to facility. resident was wearing shorts, gray shirt and black shoes and his glasses. resident stated he got upset and took off walking and went a crunch (sic) that took him to the [local homeless shelter] resident was taking to hospital for eval and treatment. resident [family member] notified he has returned and sent to hospital to get check out and will be moved to room [resident room] in station 2 unit. nurse in unit aware of the transfer and has his medications. waiting for resident return. Date & Time: 04/19/2024 at 3:06 AM Documented by LVN U: Resident returned via facility transport staff to secured unit. Assessed resident upon return, no open wounds, lesions, or immediate bruising observed. Resident range of motion WNL. Hand grasps strong, able to push and pull with hands and feet. States nothing happened to him during his departure. Resident denies pain, weakness, or feelings of sickness. Does not appear to be in distress. Resident made comfortable in their new room and offered a tray of food. Resident states that he's going to rest. Plan of care continues. During an interview on 04/24/2024 at 12:20 PM, LVN B stated she worked the night of 04/18/2024. LVN B stated when she started her shift at 6:00 PM and she would pass medications on Hall 2 and then would pass medications on Hall 1. LVN B stated she went into Resident # 1's room about 7:30 PM to give him his evening medications and discovered he was not in his room and his meal tray had not been touched. LVN B stated she immediately went to search for Resident #1. LVN B stated she asked staff if they had seen Resident #1 and asked them to look for him. LVN B stated when he was not in his usual places, she then called a CODE PINK, which was the code for missing resident. LVN B stated she then contacted the DON and ADMN around 8:00 PM and contacted law enforcement after speaking with DON. LVN B stated she was not aware of how long resident had been gone. During an interview on 04/24/2024 at 1:20 PM LVN D stated there were a handful of residents who were assessed as being safe to sign themselves out of the facility, and Resident #1 was not one of those residents. LVN D stated Resident #1 was not appropriate to be out of facility unsupervised. LVN D stated that Resident # 1 likes to wander around the building. LVN D stated the facility had two dining areas, but the facility was only using one dining area. LVN D stated Resident #1 called the dining area that was not being used his library and would go read books in there because it was quiet. LVN D stated if he was not in that dining area reading books, he would be in the other dining area playing video games. LVN D stated it was common for staff to leave Resident #1's meal trays in his room because he would come back to his room when he saw meals were being delivered. LVN D stated she had worked the day shift on 04/18/2024, she remembered seeing Resident #1 around lunch time but did not remembering him after that. During an interview on 04/24/2024 at 1:58 PM the SW stated some residents were able to sign themselves out of the facility on a pass, if deemed safe to be out of facility on their own. The SW stated nursing assessed residents on their fall risk, BIMS, and cognitive ability. The SW stated Resident #1 was not safe to be out of facility on his own. The SW stated she was not aware of how Resident #1 got out of the facility or the time frame he was gone. The SW stated Resident #1 should not have been able to exit the building because the staff at the nurse's station and the AD should have been monitoring the doors. The SW stated Resident #1 had sunburn on his nose related to the elopement. The SW stated resident could have fallen, gotten hurt or killed. During an interview on 04/24/2024 at 2:25 PM, the DON stated she was notified, around 8:30PM on 04/18/2024, that Resident #1 was missing and arrived at facility a little before 9:00 PM. The DON stated she helped with getting a head count to verify all residents were in building. The DON stated law enforcement officers were going from room to room conducting searches. The DON stated law enforcement located Resident #1 at the local homeless shelter about 9:00pm. The DON stated Resident #1 was sent to Emergency Department to be assessed. The DON stated she talked with the Medical Director, and he gave an order for Resident #1 to be admitted to the secure unit when he returned from the emergency room . The DON stated Resident # 1 returned from the Emergency Department around 2:30 AM and was placed in the secure unit for safety. The DON stated that no other interventions were attempted prior to placing him in the secure unit. The DON stated she had talked with Resident #1's family representative, and they were on board for placing Resident #1 in the secure unit. The DON stated they were not sure what time Resident #1 had exited the building. The DON stated OT L stated they had seen Resident #1 about 2:00 PM, and a resident stated they saw him walk out the front door with someone around 2:30 PM. The DON stated the effect on Resident #1 could have been an injury from being out of the building on his own. The DON stated she did not know if Resident #1 would be safe out of the facility on his own. The DON stated all staff were responsible for monitoring the doors to ensure residents were not getting out of the building. The DON stated what led to failure of Resident #1 getting out of the building was that he was sneakier than anticipated. During an observation and interview on 04/24/2024 at 3:30PM, Resident # 1 was sitting in his room on his bed in the secure unit. Resident #1 stated he was not sure how he got out of the building, or which door he walked out. Resident #1 stated he saw an open door and just walked out. Resident # 1 stated he did not remember if he walked out with anyone. During an interview on 04/24/2024 at 4:50 PM, the Medical Director stated Resident #1 was placed in secure unit due to concerns for his safety when he returned from the emergency department after his elopement. The Medical Director stated Resident #1 was not safe to be out of the facility without having supervision. Review of google maps https://www.google.com/maps, accessed on 04/25/2024, revealed the distance between the facility to the local homeless shelter was 3 to 4 miles (depend on route taken). The resident would have had to walk down highly traffic streets with speed limits of 35 to 55 mph, cross busy intersections, and cross railroad tracks. During an interview on 04/26/2024at 11:35 AM, Deputy Fire Chief stated there were eleven trains that traveled thru the city between the hours of 6:00 AM and 6 PM per day and there were ten trains that traveled thru the city between 6:00 PM and 6:00 AM per day. During an interview on 04/26/2024 at 12:15 PM, the AD stated prior to Resident #1's elopement some residents and visitors had the door code. The AD stated that some of their residents appear to be visitors so they could walk out with vendors or visitors, and no one would know they were a resident. The AD stated prior to the elopement the facility did not have a process for monitoring the doors. Record review of the facility policy titled Wandering and Elopements, dated September 1, 2023, revealed: The facility will ensure that residents who exhibit wandering behavior and or/or are at risk for elopement received adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care. Definitions 'Wandering' is random or repetitive locomotion that may be goal-directed (e.g., The person appears to be searching for something such as an exit or person), non-goal directed, or animals. 'Elopement' occurs when a resident leaves the premises or safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so . Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering. Resident will be assessed by the IDT for risk of Elopement and unsafe wandering on admission, readmission, quarterly, and//or with a change of condition (e.g., increased agitation, changes in mobility, wandering). A person-centered care plan will be developed. Based on the risk factors that identified in the risk assessment. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, and minimize risk associated with hazards will be added to the residents' care planning. Appropriate staff. Provided to help prevent accidents or elements. Nursing staff. Response interventions, and document accordingly. Changes we made. Indicated changes of condition. Any changes are new interventions, so we communicated to relevant staff. Record review of the facility policy titled Emergency Procedure-Missing Resident, dated September 1, 2023, revealed: Resident elopement resulting in a missing resident is considered a center emergency. This was determined to be an Immediate Jeopardy (IJ) on 04/26/2024 at 1:45 PM. The Administration was informed of the IJ. The Administrator was provided with the IJ template on 04/26/2024 at 3:45 PM. Record review of Plan of Removal accepted on 04/27/2024 at 12:08 PM reflected the following: 689: Accidents, Hazards, Supervision & Devices The facility failed to ensure Resident #1 received adequate supervision to prevent resident elopement. Residents at risk for elopement can be affected by this deficiency. Immediate Action: Action: Resident #1 was sent to the hospital for evaluation when he arrived back to the nursing facility 4/18/2024, no new orders received. Resident was assessed upon returning from the hospital on 4/19/2024. Resident was reassessed for being an elopement risk on 4/18/2024 and placed in the secured unit for safety. Medical Director notified of the incident. Person(s) Responsible: Charge Nurse and Director of Nursing Date: 4/18/2024-4/19/2024 Action: Resident head count performed throughout the center to ensure no other residents were identified as missing. No other residents noted missing. Person(s) Responsible: Director of Nursing Date: 4/18/2024 Action: All doors verified in working order. No issues noted with the door functions. Additionally, 4/15/2024, 4/16/2024, & 4/17/2024 the doors were checked for functionality with no concerns. Gates checked for functionality: 4/26/2024; No concerns, all gates are functioning properly. Person(s) Responsible: Maintenance Director & Designee Date: 4/18/2024; 4/26/2024 Action: Mock elopement drills performed each shift in 24 hours. Person(s) Responsible: Director of Nursing Date: 4/19/2024, 4/21/2024, & 4/23/2024 Steps to Ensure Compliance: Action: Signage present on doors that state, Attention visitors please do not allow anyone to exit the building with you that did not come in with you, help us keep our residents safe, any questions please contact a staff member, thank you. Person(s) Responsible: Director of Nursing Date: 4/26/2024 Action: All residents in house received an updated elopement assessment. Ensured all care plans match the updated elopement assessment and are person-centered. Person(s) Responsible: Director of Nursing and/or Designee Date: 4/18/2024 Action: All staff educated: Wandering & Elopement/Missing Resident Policy (to include adequate supervision to prevent accidents or elopements and when delivering meal trays in either dining area or in residents rooms staff should ensure residents are located and aware of meal. Any meal tray picked up that is not eaten staff need to verify resident is located and aware meal tray is ready. Charge nurse will be notified immediately if resident is not observed and informed. All staff educated prior to working their next shift. All new and temporary staff educated prior to working their first shift. Person(s) Responsible: Director of Nursing, Administrator, and/or Designee Date: 4/19/2024 Action: Certified Nurses Aides, Certified Medication Aides, and Charge Nurses educated on the resident profile to inform them of the level of supervision, elopement risk, and educated over accuracy of documentation. The type and frequency of resident supervision may vary among residents as determined by the residents' assessed needs and the identified hazards in the environment. All Certified Nurses Aides, Certified Medication Aides, and Charge Nurses will be educated prior to working their next shift. All new and temporary staff educated prior to working their first shift. Person(s) Responsible: Director of Nursing and/or Designee Date: 4/26/2024 Action: If resident is not observed during medication pass, meal times, and/or routine resident care rounds the charge nurse will be notified and the center will initiate a search for the resident immediately. The clinical staff will know to perform this action through education. All Certified Nurses Aides, Certified Medication Aides, and Charge Nurses will be educated prior to working their next shift. All new and temporary staff educated prior to working their first shift. Person(s) Responsible: Administrator, Director of Nursing, and/or Designee Date: 4/26/2024 Action: Action items in the above plan of removal will be monitored for effectiveness daily, x7 days a week, for 1 month and until deemed by QAPI committee that the facility is in substantial compliance. If any changes are needed, they will be brought to the QAPI committee and discussed for a plan action. Person(s) Responsible: Administrator, Director of Nursing, and/or Designee Date: 4/27/2024 Action: Ad hoc QAPI performed with Medical Director to review the Immediate Jeopardy template and the facility's plan to lower the Immediate Jeopardy. Person(s) Responsible: Administrator Date: 4/26/20 Surveyors monitored the facility's Plan of Removal ad confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from 04/27/2024 at 12:08 PM. to 04/27/2024 at 3:18 PM as follows: Action: Resident #1 was sent to hospital on 04/18/2024 -Record review of Resident #1's progress note dated 04/18/24 at 8:00 pm signed by LVN B revealed 'resident was taking to [a local] hospital for eval and treatment. resident [family member] notified he has returned and sent to hospital to get check out and will be moved to room [ROOM NUMBER] in station 2 unit. -Reviewed Discharge Instruction from hospital dated 04/18/2024 at 10:17 pm Action: Resident #1 elopement risk assessment on 04/18/2024 -Record review of elopement risk assessment completed on 04/18/2024 at 09:40 am indicating resident was an elopement risk. Action: Resident #1 placed in secured unit on 04/18/2024 oRecord review of Orders- 04/18/2024 order stating admit to secure unit due to high elopement risk and poor safety awareness. oObservation- 04/27/24 at 1:10 pm observed resident #1 resting in bed on the secure unit with no issue noted. Action: doors in working orders on oRecord review on 04/15/2024- verified check off sheets for all doors and gates checked my maintenance man. 04/27/24 at 1:30 pm. Interview with Maintenance stated he had performed the checks daily since 04/15/24. oRecord review on 04/16/2024- verified check off sheets for all doors and gates oRecord review on 04/17/2024- verified check off sheets for all doors and gates oRecord review on 04/18/2024- verified check off sheets for all doors and gates oRecord review on 04/26/2024- verified check off sheets for all doors and gates Action: gates functioning properly oObservation on 04/27/2024 at 1:35 pm all doors were locked, and gates functioned properly. Action: Mock Elopement drills on each shift oRecord review on 04/19/2024- verified sign in sheet performed at 11:00 am oRecord review on 04/21/2024- verified sign in sheet performed at 1:00 pm and verified sign in sheet performed at 8:00 pm oRecord review on 04/23-/2024 verified sign in sheet performed at 8:00 pm oDuring an interview on 04/27/24 at 12:25 pm CNA C confirmed he had participated in a Mock elopement drill. CNA works day shift on station1 Verified Mock drill sign sheet he participated on 04/21/24. oDuring an interview on 04/27/24 at 1:30 pm LVN M confirmed he had participated in a Mock elopement drill. Verified Mock drill sign sheet she participated in on 04/23/24. LVN works day shift on station 1. oDuring an interview on 04/27/24 at 1:35 pm LVN N confirmed he had participated in a Mock elopement drill. Verified Mock drill sign sheet she participated in on 04/23/24. LVN works day shift on station 2. oDuring an interview on 04/27/24 at 2:00 pm LVN P confirmed she had participated in a Mock elopement drill on 04/21/24. Verified Mock drill sign sheet she participated in on 04/21/24. LVN works day shift on station 1. Action: of signage on ALL doors oObservation on 04/27/24 at 12:00 pm Observed sign on main entrance when entered facility. oObservation on 04/27/24 at 1:35 pm Observed sign on back entrance. Action: no elopements since 04/18 oDuring an interview no residents have eloped since 04/18 stated by Administrator & Clinical Resource Nurse List of all residents that required change in elopement assessment oRecord review of random sample of residents at risk for elopement that care plans were person-centered (specifically residents not in locked unit) 12 outside secure unit and 17 inside total of 29 residents who are elopement risk; 10 of those 12 residents not on the locked were, previously, no elopement risk Review: oRecord review of Resident #16- verified elopement risk assessment completed 04/19/24 and care plan was initiated 04/24/2024 o Record review of Resident #17- verified elopement risk assessment completed 04/19/24 and care plan was already in place. oRecord review of Resident #18- verified elopement risk assessment completed 04/19/24 and care plan was initiated 04/19/2024 Copy of inservice & signature sheet oRecord review of Wandering & Elopement/Missing Resident Policy oRecord review Resident profiles regarding level of supervision, Type/frequency of supervision, elopement risk, accuracy of documentation, Types of identified hazards in the environment, Verify inservice o1 nurse on each station & on each shift = total of 4 nurses oDuring an interview on 4/27/24 at 1:30 pm via phone interview LVN M confirmed he had received in-services on Wandering & Elopement/Missing Resident Policy and Resident profiles. LVN works night shift on station 1 oDuring an interview on 04/27/24 at 1:35 pm via phone interview LVN N confirmed he had received in-services on Wandering & Elopement/Missing Resident Policy and Resident profiles. LVN works night shift on station 2 oDuring an interview on 04/27/24 at 2:00 pm LVN P demonstrated how to pull up a resident's profile and identified if a resident was an elopement risk. LVN confirmed she had received in-services on Wandering & Elopement/Missing Resident Policy and Resident profiles. LVN works day shift on station 2 oDuring an interview on 04/27/24 at 2:40 pm LVN E demonstrated how to pull up a resident's profile and identified if a resident is an elopement risk. LVN confirmed she had received in-services on Wandering & Elopement/Missing Resident Policy and Resident profiles. LVN works day shift on station 1 o2 nurse aides on each station & on each shift Total of 8 aides if 12H shift oDuring an interview on 04/27/24 at 12:20 pm CNA R demonstrated how to pull up a resident's profile and identified if a resident is an elopement risk. CNA confirmed she had received in-services on Wandering & Elopement/Missing Resident Policy and Resident profiles. CNA works day shift on station 1 oDuring an interview on 04/27/24 at 12:25 pm CNA C demonstrated how to pull up a resident's profile and identified if a resident is an elopement risk. CNA confirmed she had received in-services on Wandering & Elopement/Missing Resident Policy and Resident profiles. CNA works day shift on station 1 oDuring an interview on 04/27/24 at 1:00 pm CNA H demonstrated how to pull up a resident's profile and identified if a resident is an elopement risk. CNA confirmed she had received in-services on Wandering & Elopement/Missing Resident Policy and Resident profiles. CNA works day shift on station 2 oDuring an interview on 04/27/24 at 1:10 pm CNA T confirmed she had received in-services on Wandering & Elopement/Missing Resident Policy and Resident profiles. CNA works night shift on station 2 oDuring an interview on 04/27/24 at 2:45 pm CNA S confirmed during a phone interview that she had received in-services on Wandering & Elopement/Missing Resident Policy and Resident profiles. CNA works night shift on station 1 oDuring an interview on 04/27/24 at 2:50 pm A CNA confirmed during a phone interview that she had received in-services on Wandering & Elopement/Missing Resident Policy and Resident profiles. CNA works night shift on station 1 Interview charge nurses if any residents not observed during Medication pass, Mealtimes, Routine resident care rounds, and Ask what these are & how to document the rounds oDuring an interview on 04/27/24 at 1:30 pm via phone interview LVN M confirmed he understands what to do If resident is not observed during medication pass, mealtimes, and/or routine resident care rounds. LVN works night shift on station 1 oDuring an interview on 04/27/24 at 1:35 pm via phone interview LVN N confirmed she understands what to do If resident is not observed during medication pass, mealtimes, and/or routine resident care rounds. LVN works night shift on station 2 oDuring an interview on 04/27/24 at 2:00 pm LVN P confirmed she understands what to do If resident is not observed during medication pass, mealtimes, and/or routine resident care rounds. LVN works day shift on station 2 oDuring an interview on 04/27/24 at 2:40 pm LVN E confirmed she understands what to do If resident is not observed during medication pass, mealtimes, and/or routine resident care rounds. LVN works night shift on station 1 Action: adhoc QAPI & Medical Director notified of IJ oRecord reviewed sign is QAPI sheet where medical Director was informed o04/27/24 at 12:26 observed Administrator give in-service to dietary staff regarding Wandering & Elopement/Missing Resident Policy and Abuse and Neglect. The Immediate Jeopardy was removed on 04/27/2024 at 3:30 PM, the facility remained out of compliance at a level of no actual harm and a scope of isolated, due to the facility monitoring the effectiveness of their Plan of Removal. The ADMN was informed of this at 3:30PM.

Based on observation, interview, and record review the facility failed to protect the resident's right to be free from abuse and neglect for 4 of 4 residents (Resident #1, Resident #79, Resident #53, Resident #57) reviewed for abuse and neglect. 1. The facility failed to follow physician's orders to prevent Resident #1 who had an indwelling catheter received appropriate treatment and services to prevent a urinary tract infection and complications associated with an indwelling catheter. 2. The facility failed to follow physician's orders to prevent Resident #79's stage 4 pressure ulcer to his sacrum from developing osteomyelitis, and his right heel pressure ulcer to deteriorate from a stage 3 to a stage 4. 3. The facility failed to have sufficient staff with necessary competencies and failed to have interventions in place to provide resident care with aggressive with physical behaviors. R53 assaulted residents on multiple occasions on Station 2/Hall 6 (women secured locked unit), that led to resident injuries that required medical treatment. 4. The facility failed to have interventions in place to prevent Resident #57 from being abused by other residents on Station 2/Hall 2 (men secured locked unit), due to lack of staff with competencies to provide care with resident with aggressive behaviors int he locked unit. An Immediate Jeopardy (IJ) was identified on 02/22/23. While the IJ was removed on 02/24/23, the facility remained out of compliance at a severity level of actual harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could place residents at risk of infections, worsening of wounds, injuries, emotional distress, and even death. Findings include: 1. Resident #1 Record review of Resident #1 face sheet dated 02/20/2023 revealed a [AGE] year-old female admitted on [DATE] with a most recent admitted [DATE] with the following diagnosis: Unspecified fracture of left shaft/femur, Non-ST elevation myocardial infarction (heart attack due to inadequate blood to the heart), gram negative sepsis (bacteria in the blood), neurogenic bladder (deficiency in bladder control due to brain, spinal cord or nerve problem) and urinary tract infection, site not specified (infection in any part of the urinary system). Review of Resident #1 physician orders dated 10/13/2022 revealed Foley Catheter: Size (10cc) FR (16) Diagnosis: Neurogenic bladder (lack bladder control due to brain, spine, or nerve problems) Review of Resident #1's physician order dated 10/21/2022 revealed: Foley Catheter: May obtain urine sample via Foley Catheter Port as needed when a Urine Analysis is ordered. (If Foley Catheter has been in place greater than 14 days, change Foley Catheter before obtaining urine.) Review of Resident #1's physician order dated 10/21/2022 revealed: Foley Catheter: Provide catheter care every shift. Review of Resident #1's physician order dated 10/21/2022 revealed: Foley Catheter: Change catheter and drainage bag as needed for indications of blockage, increased sediment, infection, displacement as needed. Record review of Resident #1 Discharge MDS Section C dated 09/19/2022 revealed in Section H (bladder and bowel) that she was frequently incontinent, 7 or more times episodes of incontinent, but 1 episode of continent). Record review of Resident #1 Quarterly MDS dated [DATE] revealed in Section C (Cognitive Patterns) a BIMS Score of 15 indicating no cognitive impairment and in Section H (bladder and bowel) that resident had an indwelling catheter. Record review of Resident #1 electronic care plan accessed on 02/20/2022 revealed the following: Problem - Resident #1 has Indwelling Foley Catheter: Goal - Resident will not show signs of urinary infection or urethral trauma. Interventions - Change catheter every per MD order, document urinary output; record the amount, type, color and odor, observe for leakage, keep catheter system a closed system as much as possible, position bag below level of bladder, provide catheter care as scheduled and PRN. Problem- Resident #1 has a urinary tract infection. Goal- resident will not exhibit signs of a urinary tract infection. Interventions- Administer Bactrim DS (antibiotic), encourage fluids, keep perineal area clean and dry and report signs or UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain, difficulty urinating, low back pain/flank pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine and blood in urine). Initiated date of 10/15/2022 and revised date of 01/31/2023. Record review of Resident #1 most recent significant change MDS Section C dated 01/30/2023 revealed she had the ability to express ideas and wants and was able to understand others clearly. Resident #1 had a BIMS of 14 out of score of 15 which indicated an intact cognition. Resident #1 was extensive assistance for activities of daily living (ADL) except for eating where she required supervision. Record review of Resident #1 significant change MDS on 01/30/2023 revealed Resident #1 had an indwelling catheter reported in section H: Bladder and Bowel. Observation and interview on 02/18/2023 at 10:15 AM, Resident #1's catheter bag was full and overflowing with urine and backflowing up the tubing. The catheter bag was leaking on the floor. Resident reported that it had not been drained in 2 days. The resident's urine was cloudy, with sediment visible in tubing and bag. There was a thick cloudy substance in the tubing that appeared to be puss. Observation and interview on 02/18/2023 at 10:16 AM, with the DON present Resident #1's catheter tubing and bag was visualized. The DON said that the thick cloudy substance in the resident's catheter bag and tubing appeared to be a puss like substance. She said that she was going to have it changed immediately. Interview on 02/18/2023 at 1:20pm, DON stated indwelling catheter bags should always be covered. She also stated catheter bags that are full of urine backflowing in the catheter tubing placed the resident at risk for infections. She stated she did not know the reason for Resident #1's overflowing catheter bag with urine backflowing into the catheter tubing. Observation on 02/18/2023 at 3:58pm, Resident #1 continued to have an indwelling catheter with an overfilled catheter bag with urine backflowing in the catheter tubing. The bag continued to be leaking urine onto the floor. The urine was cloudy, with sediment visible in tubing and bag. There was a thick cloudy substance in the tubing that appeared to be puss. This observation was reported to the Corporate Regional Resource Nurse-J. Observation and interview on 02/19/2023 at 8:35 am, Resident #1's catheter bag had been emptied; however, the Foley catheter and tubing had not been changed and was observed to be crusted with sediment and puss like substance visible in the tubing. There was a trash bag on the floor under the uncovered catheter bag. Resident #1 stated that the trash bag was placed to catch leaking urine from the catheter bag. Interview on 02/19/2023 at 9:45 am, RN-V stated she had not gone to Resident #1's catheter bag to check if it had been drained or changed during previous day's shift. She reported it was delegated to her, but she was busy and had not had a chance to do it. Interview on 02/19/2023 at 10:02 am, Corporate Regional Resource Nurse-J-J stated she had instructed RN-V to change Resident #1's catheter bag. She stated that RN-V reported that it had been changed. She collected a UA sample while changing it and would notify the physician. She stated that the catheter should have been changed due to the sediment. She said that she could see where there was an issue for concern. Interview on 02/19/2023 at 11:04 am, DON stated she asked LVN-O and RN-V to change Resident #1's catheter, tubing and bag yesterday afternoon. She could not remember the exact time, but it was after lunch. She said she went back to Resident #1's rooms yesterday afternoon and it continue to not be completed. She then asked them again to complete the task. She stated this failure placed the residents at risk for an infection. Interview on 02/19/2023 at 3:10pm, RN-V said she did not change Resident #1's catheter tubing but only changed the bag. She said she obtained a urine sample for an ordered UA from the catheter tubing that continued to have sediment and puss like substance but not from the bag. Interview and observation on 02/19/23 03:15 PM, Corporate Regional Resource Nurse-J-J stated she instructed RN-V to change Resident #1's entire catheter on 02/18/2023. Observation and interview on 02/19/2023 at 11:20 am, Resident #1 was speaking with surveyor without any distress. Observation on 02/19/2023 at 2:57 pm, with Corporate Clinical Company Leader RN-I present, Resident #1 was observed unresponsiveness with emesis on chest . Corporate Clinical Company Leader RN-I stated she had to check Resident #1's pulse because she wasn't sure if she was alive. Interview on 02/19/2023 about 3:00pm, Resident #56 (Resident #1's roommate) said Resident #1 received her lunch tray about 12:00 pm and almost immediately started to throw up. Resident #56 then called for help, but no one came until about 2:00 pm. Resident #56 said she told the staff that Resident #1 needed assistance, the staff was Assistant Administrator in Training who removed Resident #1's tray and stated, I can't help you and left the room. Review of Resident #56's quarterly MDS dated [DATE] revealed Section C Cognitive Patterns BIMS Score of 15 indicating no cognitive impairment. Observation on 02/19/2023 at 3:25pm, Resident #1 was transferred to a local hospital via EMS. Interview on 02/19/2023 at 4:34pm, the DON said she looked at Resident #1's catheter yesterday (02/18/2023) and it appeared to have puss and sediment in the catheter tubing and catheter bag entry hub. She said it was her expectation that it was to be changed. She made an additional request for the catheter to be changed this morning by RN-V. DON stated she discovered Resident #1 left the facility (to the hospital) without a changed catheter tubing but only a changed catheter bag. It was her expectation that it was changed yesterday. Interview on 02/20/2023 at 3:57pm, CNA-Z stated Resident #1 had puss in her catheter tubing when she drained the catheter bag and performed incontinent care about 2 weeks ago. She stated she notified RN-V of the puss in resident's catheter tubing at that time. Interview on 02/20/2023 at 04:04 PM, Resident #56 (Resident #1's roommate) said she pressed the call light frequently and it takes a while to answer. She said the lady who came to answer the call light after two hours had long dark hair and was part of administration but did not work the floor. Resident #56 (Resident #1's roommate) said that this staff went to the Resident #1 and said Oh, My God, when she saw the resident. Resident #56 (Resident #1's roommate) said that the staff stated she could not help Resident #1 and left the room. Resident #56 (Resident #1's roommate) said she thought the staff was coming back but never did. Resident #56 (Resident #1's roommate) said she could hear Resident #1 throwing up and gurgling. Resident #56 (Resident #1's roommate) said no one changed their catheters. She said yesterday (02/19/2023) the staff just changed the bag. Resident #56 (Resident #1's roommate) said the regional nurse did in fact tell the nurse to just change the bag until she got caught up and that she could change it later. Resident #56 (Resident #1's roommate) said it was the same nurse who told her in Spanish to butt out and put her hand to her mouth as in telling her to hush and she cut her eyes. Interview on 02/20/23 04:34 PM, RN-V stated while in Resident's room that she was short of staff 02/19/2023 and behind. She said when the regional nurse came, she told her to change the catheter bag only. She said she was often short staffed or without staff and can do what she can do. She said she is trying hard and stays for the residents. Interview on 02/21/2023 at 4:46 PM, with Resident #1's Family Members A and B revealed when they would come to see her, she would look malnourished, and her catheter bag was always full. Record review of Resident #1's vital reports, dated 02/21/2023, provided by Corporate Clinical Leader RN-H revealed no evidence of catheter care, drainage of catheter bag and amount of urine obtained during drainage on 48 occasions between 01/18/23 and 02/19/23. Record review of Resident #1's hospital record History and Physical dated 02/19/2023 at 8:48pm, revealed the following physician's notes- We sent her to the ICU Again, clinically it just seems to be a very ill patient, who was sent from the nursing home for an honestly a [NAME] reason at this point. At any rate from what I can gather she had left sided weakness from a prior stroke, but today currently it seems like she is not moving the right side, so we will get MRI of the brain. She does have a UTI in her labs, which will be treated. Record review of Resident #1's hospital records dated 02/19/2023 revealed Resident #1 was admitted into the hospital's ICU with diagnosis of UTI & rule out stroke. Record reviewed on Resident #1's hospital records labs, assessment and plan dated 02/19/2022 revealed, Resident #1 had a primary diagnosis of Urinary Tract Infection, with orders to check cultures, place her on ceftriaxone (antibiotic) Record review of Resident #1's hospital records dated 02/21/2023 revealed Resident #1 had a diagnosis of Sepsis (A life threatening complication or infection. Sepsis occurs when chemicals released in the bloodstream to fight an infection throughout the body. This can result in multi organ system failure and even death). Records review of Resident #1's hospital records dated 02/21/2023 Assessment and Plan revealed: 1. UTI in the setting on chronic indwelling foley catheter. Urine culture grew E coli. Blood cultures grew gram positive cocci. Start IV Vancomycin and Rocephin for empiric treatment. 2. Bacteremia: Blood culture grew gram positive cocci. Start IV Vancomycin (antibiotic) and Rocephin (antibiotic) for empiric treatment. 2. Resident #79 Review of Resident #79's electronic Face Sheet dated revealed he was a [AGE] year-old male admitted to the facility 11/15/22. He had diagnoses which included heart failure, end stage renal disease, current long-term use of antibiotics, acute osteomyelitis (infection of the bone caused by bacteria), pressure ulcer of right heel stage 4, chronic pain, pressure ulcer of sacral region, systemic lupus erythematosus (inflammatory disease caused when the immune system attacks its own tissues causing fatigue and pain), major depressive disorder, dependence on renal dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), dependence on supplemental oxygen, chronic atrial fibrillation (irregular heart beat), Methicillin resistant Staphylococcus aureus (certain type of bacteria resistant to treatment by many common antibiotics), and Type 2 diabetes mellitus . Review of Resident #79's Admission MDS dated [DATE] revealed: Section C: Cognitive Patterns BIMS Score of 15 indicating no cognitive decline; Section G Functional Status indicated extensive/2+ person physical assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions indicated one Stage 3 pressure ulcer present upon admission and one Unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar present upon admission. Review of Resident #79's Quarterly MDS dated [DATE] revealed: Section M: Skin Conditions indicated two Stage 4 pressure ulcers present upon admission, and one Unstageable pressure ulcer that was not present upon admission. Review of Resident #79's Care Plan last revised 1/30/23 revealed: Problem: Resident has a pressure ulcer to sacrum r/t immobility. Goal: Resident's ulcer will heal without complications. Approach: use cushion provided by family for pressure reduction when resident is in chair; conduct a systematic skin inspection daily during treatment ; Problem: Pressure Sores/Skin Care. Goal: Prevent/Heal pressure sores and skin breakdown. Approach: follow facility skin care protocol; preventative measures use cushioned boots for heels while in bed as tolerated, off load heels while in bed; report to charge nurse any redness or skin breakdown immediately; treatment as ordered; turn and reposition every 2 hours and PRN; Problem: Resident has a pressure ulcer to right heel r/t immobility. Goal: Resident's ulcer will not increase in size. Ulcer will not exhibit signs of infection. Approach: . conduct a systematic skin inspection during treatment . Review of Resident #79's electronic orders revealed: Multivitamin plus Minerals 1 tablet by mouth daily (start date 11/15/22) Left heel cleanse with ns or wound cleanser and apply sure-prep two times daily for preventative (start date 11/25/22) Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing every day until resolved (start date 11/25/22) Cleanse right heel with normal saline or wound cleanser, apply sure-prep to heel two times daily for preventative (start date 11/25/22) Ascorbic acid (vitamin c) 500mg 1 tablet by mouth daily (start date 11/29/22) Pro-Stat AWC (amino acids-protein hydrolys) 17-100 gram-kcal/30ml give 30ml by mouth twice a day (start date 11/29/22) Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing as needed until resolved (twice a day - PRN, morning, bedtime) (start date 11/29/22) Cleanse right heel with normal saline or wound cleanser apply anasept to wound and secure with a bordered dressing daily (start date 12/29/22) Use cushioned boots while in bed as tolerated (start date 1/3/23) Ertapenem 1 gram intravenously daily for 42 days r/t osteomyelitis (start date 1/13/23 end date 2/24/23) Site 1: Sacrum Review of Resident #79's Wound Management Wound History dated 11/15/2022 at 8:08 am revealed: Pressure Ulcer to Sacrum present on admission. Review of Resident #79's Wound Care Physician Progress Notes dated 12/01/2022 revealed: Stage 4 Pressure Wound Sacrum Full Thickness measured 1.7cm in length by 0.7cm in width with 1.2cm in depth. Review of Resident #79's Wound Care Physician Progress Note dated 01/12/2023 revealed: The histology report from the biopsy of the sacrum taken on 01/05/2023 indicates acute osteomyelitis. Review of Resident #79's physicians orders dated 11/25/2022 revealed: Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing every day until resolved. Review of Resident #79's physicians orders dated 11/29/2022 revealed: Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing as needed until resolved. Review of Resident #79's Treatment Administration Record from November 2022 to February 2023 revealed no evidence of treatments on 12/02/2022, 12/25/2022, 12/26/2022, 01/01/2023, 01/05/2023, 01/08/2023, 01/11/2023, 01/19/2023, 02/04/2023, 02/08/2023, 02/11/2023, 02/19/2023 Review of Resident #79's electronic record revealed no evidence of reposition every 2 hours and as needed and conduction of systematic skin inspection daily between 11/25/2022 and 12/29/2022. Site 2: Right Heel Review of Resident #79's Wound Management Detail Report dated 11/15/2022 at 8:11am by LVN-AE revealed: Stage 3 pressure ulcer to right heel measured 0.3cm in length by 0.3cm in width with 0.1cm in depth. Review of Resident #79's Wound Management Wound History dated 11/25/2022 at 7:33am revealed: Pressure Ulcer to right heel present on admission and healed. Review of Resident #79's Wound Care Physician Progress Notes dated 12/01/2022 revealed: Unstageable due to necrosis (death of cells in body tissues) of the Right Heel measured 1cm in length by 1.1cm in width with no measurable depth. Review of Resident #79's Wound Care Physician Progress Notes dated 12/29/2022 revealed deterioration to a Stage 4 Pressure Wound of the Right Heel. Review of Resident #79's Wound Management Wound History dated 12/29/2022 at 2:31am revealed: Pressure Ulcer to right heel present on admission. Review of Resident #79's Wound Management Detail Report dated 02/23/2023 at 7:11pm by Corporate Clinical Company Leader RN-I revealed: Stage 4 Pressure Ulcer to right heel measured 0.5cm in length by 0.6cm in width with unmeasurable depth. The wound had necrotic tissue type. Review of Resident #79's skin assessment records revealed no evidence of systematic skin inspection during treatment between 11/25/2022 and 12/29/2022. During an observation on 02/20/23 at 3:25 PM of Resident #79's wound care revealed RN-V completed wound care with the assistance of MDS-RN and LVN Q. RN-V failed to change gloves after removing sacrum dirty wound dressing and beginning to apply treatment and clean dressing to sacrum. RN-V also failed to perform hand hygiene before applying new gloves to begin treatment to right heel. Following the treatment, RN-V was unable to be located for an interview. Interview on 2/24/23 at 4:48 PM, LVN-Q stated wound care with Resident #79 on 2/20/23 performed by RN-V went badly. She stated she did not see RN-V wash hands or use sanitizer at any time before or during the dressing changes, but she did see her change her gloves in between each wound. LVN-Q stated that was not the correct procedure for hand hygiene during wound care and could lead to recontamination of the wound. She stated that RN-V was feeling overwhelmed but that was not an excuse. She stated that it was just overall not good. In an interview on 2/21/23 at 11:35 AM, Corporate Clinical Company Leader RN-H stated Resident #79 was admitted to facility on 11/15/22 with stage 3 to sacrum and stage 3 to right heel and that both wounds were documented on admission. Corporate Clinical Company Leader RN-H stated that in her investigation of the Resident #79's chart, it appeared that the wound care/treatment nurse at the time documented the right heel wound was healed on 11/25/22 even though the wound was never healed. She stated the right heel wound was re-identified as a stage 4 on 12/29/22. She stated that because the wound was documented as healed it went one month without treatment or observation leading to it decline to a stage 4. She stated that Resident #79's sacral wound was a stage 3 on admission but had declined to a stage 4. She stated the documentation stating the wound was improving even with the presence of osteomyelitis was strictly referring to the wound bed appearance from her understanding. Corporate Clinical Company Leader RN-H stated the resident was diagnosed with osteomyelitis at the site of the sacral wound by the wound care physician. She stated the staff was supposed to do skin sweeps weekly to check wounds and get measurements and the wound care doctor saw residents weekly as well. The staff did their checks on the residents that the doctor did not see. The measurements were documented in the wound management section of the chart. Corporate Clinical Company Leader RN-H stated wound care was documented on the treatment administration record only unless something was wrong or there were changes. If there was something different with a wound, she stated a prudent nurse would document in a focused observation note or progress note what was observed, notify the doctor of the change in the resident's condition, then document that the doctor was notified. She stated the wound care physician's progress notes were uploaded into the resident's EMR electronically and that he was able to put his own orders in remotely. She stated if someone did transcribe orders for him it would be the nurse who did rounds with him while he was in the building seeing residents, normally the wound care/treatment nurse when the facility had one or the DON. If the resident was a new admission and the wound care physician was giving orders, the admitting nurse would be responsible for transcribing the orders and verifying everything was in the resident's chart correctly. Corporate Clinical Company Leader RN-H stated when an order was put into the facility's charting program it went directly onto the MAR. She stated during the morning meeting, the staff should have been going over all new orders received to make sure all orders had been signed and verified and that nothing had been missed during rounds. Corporate Clinical Company Leader RN-H stated all information regarding wounds had been provided or would be found in focused observation notes. In an interview on 02/22/23 at 09:57 AM , LVN-AE the former wound care nurse for the facility, stated that on weekends RN-V would not do wound care for the residents on Station 1. When LVN-AE would ask RN-V why it was not being done, RN-V would say it was because she would be frustrated and that she was one person and could not get them (treatments) done. LVN-AE did not understand why because RN-V always had a med aide, so that would have left her free to do the treatments. LVN-AE stated that the wounds would have the same dressing on them on Monday that she put on the residents on Friday. LVN-AE stated she worked Monday through Friday as the treatment/wound care nurse. LVN-AE reported RN-V to the DON and the former Administrator, then later reported it to Regional Nurse Consultant and others who no longer work for the company. She was told by all of them that they would talk to RN-V. LVN-AE stated it never got corrected. LVN-AW felt the residents did not receive wound care as ordered by the physician when she was not in building. LVN-AE stated that every Thursday the wound care physician would see residents but by the time he arrived, she had a week to make them look better, so he did not make comments that the residents' wounds were worse. LVN-AE stated she got conflicting information from DON's regarding skin assessments. LVN-AE stated at first, she would do skin assessments on wound care residents, then was told the nurses were supposed to do skin assessments and she was only supposed to do the wound management (measurements, wound descriptions). LVN-AE said she left the facility because the facility was not willing to change and hold RN-V accountable for wound care, and she was afraid of losing her license due to the wounds in the facility. In an interview on 2/22/23 at 10:25 AM, LVN-P stated since the wound care nurse quit whoever was working the floor was responsible for wound care for the residents. She stated typically, there was a charge nurse and a med nurse on the day shift, and they helped each other out with the residents. LVN-P stated Station 1 had 6 residents getting wound care at that time. When wound care was done, she stated she only signed off on the TAR and she never put a progress note in just to state the wound care had been done. She stated if there were changes to the wound it was documented in a progress note, the doctor was notified, she would notify the family and continue the treatment or write orders if any new orders were given. She stated a nurse always rounded with the wound care doctor when he saw the residents. She stated he was in the facility weekly, and she rounded with him last week because there was no one else to do it. LVN-P stated until the facility hired a new wound care nurse, she believed the DON was going to take over rounding with him. In an interview on 2/22/23 at 10:49 AM, Corporate Clinical Company Leader RN-H stated that she was not aware skin assessments were not being done accurately and treatments were not being done until surveyors arrived at the facility. She stated the facility was currently in the process of revising their wound care program to address wound care management, assessments, treatments, and care planning issues the facility had been experiencing. In an interview on 2/23/23 at 11:35 AM, the Wound Care Physician stated that his expectation was that his orders would be followed and the wound care for the residents would be done. Wound Care Physician stated that if a resident's wound care was not done as ordered over the weekend that when he came to the facility on Thursday, the wounds would have time for improvement by the time he saw them again if the treatments were started back up on Monday. He stated he did rounds with the floor nurses when he saw the residents. 3. Resident #53 Record review of Resident #53's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. She resided on Station 1 Hall 6 which was a Woman's secured unit (the average age of the women residents on Station 1 Hall 6 was [AGE] years). Diagnosis included: anoxic brain damage; diffuse traumatic brain injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness; epilepsy and epileptic syndromes with seizures of localized onset; restlessness and agitation; post-traumatic stress disorder; repeated falls; muscle weakness (generalized); insomnia due to other mental disorder; major depressive disorder; anxiety disorder; dysphagia (difficulty in swallowing), altered mental status; pain; adult sexual abuse. Record review of Resident #53's Quarterly MDS, dated [DATE], revealed the BIMS score was blank indicating inability to obtain a Brief Interview for Mental Status; Section E: Behavior indicated no psychosis, presence of physician behavior symptoms directed toward others, significant risk for physical illness or injury on self and others, rejection of care, wandering that places resident at significant risk of getting to a potentially dangerous place and intrusion on privacy of activity of others. Record review of Resident #53's Care Plan, last edited on 02/13/23 revealed: Problem: I have periods of time where I am in constant motion/movement. Problem: I get frustrated because of my physical condition and may reach out to grab or hit others. Goal. To not hit other residents. Approach. Patient placed on 1:1 observation for at least 72 hours to prevent injury to others, will keep her separated from arms reach from other residents, put gloves on resident to prevent any injury if she reaches out. Problem: I have anxiety related to anoxic brain injury as evidence by I fidget constantly, grab at others, lick my hands and rub it on things and people, sit to stand frequently, stand up rapidly and attempt to walk with no regards to surroundings. Problem: Behavioral Symptoms - licking her hands and trying to touch others, invading others space, grabbing at others, sitting and or lying-in other residents' beds when they are not in them. Goal. Resident will have less than 5 bad outcomes due to grabbing at people and toward staff or other residents over the next 90 days. Approach: 15-minute checks, I will have increased supervision due to my behavior or grabbing at things and swinging my arms, I rest better with a quiet calm environment at night, Problem: Falls. Approach. Ordered an oversize bean bag for positioning. Review of Resident #53's electronic record from April 2022 to February 2023 revealed no evidence of documented 15-minute checks and no evidence of physician's order for 1:1 level of supervision. Record review of Resident #53's transfer documentation packet, faxed on 04/19/2022 from previous facility revealed: resident required a locked facility that has more supervision and brain training support. On 04/21/22, Resident #53 was transferred from a sister facility requiring 1:1 supervision due to being threat to herself and others. Record review of Nurse Practitioner progress note, dated 06/10/22, revealed Resident #53 was transferred fro [TRUNCATED]

Based on observation, interview, and record review the facility failed to protect the resident's right to be free from abuse and neglect for 4 of 4 residents (Resident #1, Resident #79, Resident #53, Resident #57) reviewed for abuse and neglect. 1. The facility failed to follow physician's orders to prevent Resident #1 who had an indwelling catheter received appropriate treatment and services to prevent a urinary tract infection and complications associated with an indwelling catheter. 2. The facility failed to follow physician's orders to prevent Resident #79's stage 4 pressure ulcer to his sacrum from developing osteomyelitis, and his right heel pressure ulcer to deteriorate from a stage 3 to a stage 4. 3. The facility failed to have sufficient staff with necessary competencies and failed to have interventions in place to provide resident care with aggressive with physical behaviors. R53 assaulted residents on multiple occasions on Station 2/Hall 6 (women secured locked unit), that led to resident injuries that required medical treatment. 4. The facility failed to have interventions in place to prevent Resident #57 from being abused by other residents on Station 2/Hall 2 (men secured locked unit), due to lack of staff with competencies to provide care with resident with aggressive behaviors int he locked unit. An Immediate Jeopardy (IJ) was identified on 02/22/23. While the IJ was removed on 02/24/23, the facility remained out of compliance at a pattern of actual harm, due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could place residents at risk of infections, worsening of wounds, injuries, emotional distress, and even death. Findings include: 1. Resident #1 Record review of Resident #1 face sheet dated 02/20/2023 revealed a [AGE] year-old female admitted on [DATE] with a most recent admission date of 11/20/2022 with the following diagnosis: Unspecified fracture of left shaft/femur, Non-ST elevation myocardial infarction (heart attack due to inadequate blood to the heart), gram negative sepsis (bacteria in the blood), neurogenic bladder (deficiency in bladder control due to brain, spinal cord or nerve problem) and urinary tract infection, site not specified (infection in any part of the urinary system). Review of Resident #1 physician orders dated 10/13/2022 revealed Foley Catheter: Size (10cc) FR (16) Diagnosis: Neurogenic bladder (lack bladder control due to brain, spine, or nerve problems) Review of Resident #1's physician order dated 10/21/2022 revealed: Foley Catheter: May obtain urine sample via Foley Catheter Port as needed when a Urine Analysis is ordered. (If Foley Catheter has been in place greater than 14 days, change Foley Catheter before obtaining urine.) Review of Resident #1's physician order dated 10/21/2022 revealed: Foley Catheter: Provide catheter care every shift. Review of Resident #1's physician order dated 10/21/2022 revealed: Foley Catheter: Change catheter and drainage bag as needed for indications of blockage, increased sediment, infection, displacement as needed. Record review of Resident #1 Discharge MDS Section C dated 09/19/2022 revealed in Section H (bladder and bowel) that she was frequently incontinent, 7 or more times episodes of incontinent, but 1 episode of continent). Record review of Resident #1 Quarterly MDS dated [DATE] revealed in Section C (Cognitive Patterns) a BIMS Score of 15 indicating no cognitive impairment and in Section H (bladder and bowel) that resident had an indwelling catheter. Record review of Resident #1 electronic care plan accessed on 02/20/2022 revealed the following: Problem - Resident #1 has Indwelling Foley Catheter: Goal - Resident will not show signs of urinary infection or urethral trauma. Interventions - Change catheter every per MD order, document urinary output; record the amount, type, color and odor, observe for leakage, keep catheter system a closed system as much as possible, position bag below level of bladder, provide catheter care as scheduled and PRN. Problem- Resident #1 has a urinary tract infection. Goal- resident will not exhibit signs of a urinary tract infection. Interventions- Administer Bactrim DS (antibiotic), encourage fluids, keep perineal area clean and dry and report signs or UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain, difficulty urinating, low back pain/flank pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine and blood in urine). Initiated date of 10/15/2022 and revised date of 01/31/2023. Record review of Resident #1 most recent significant change MDS Section C dated 01/30/2023 revealed she had the ability to express ideas and wants and was able to understand others clearly. Resident #1 had a BIMS of 14 out of score of 15 which indicated an intact cognition. Resident #1 was extensive assistance for activities of daily living (ADL) except for eating where she required supervision. Record review of Resident #1 significant change MDS on 01/30/2023 revealed Resident #1 had an indwelling catheter reported in section H: Bladder and Bowel. Observation and interview on 02/18/2023 at 10:15 AM, Resident #1's catheter bag was full and overflowing with urine and backflowing up the tubing. The catheter bag was leaking on the floor. Resident reported that it had not been drained in 2 days. The resident's urine was cloudy, with sediment visible in tubing and bag. There was a thick cloudy substance in the tubing that appeared to be puss. Observation and interview on 02/18/2023 at 10:16 AM, with the DON present Resident #1's catheter tubing and bag was visualized. The DON said that the thick cloudy substance in the resident's catheter bag and tubing appeared to be a puss like substance. She said that she was going to have it changed immediately. Interview on 02/18/2023 at 1:20pm, DON stated indwelling catheter bags should always be covered. She also stated catheter bags that are full of urine backflowing in the catheter tubing placed the resident at risk for infections. She stated she did not know the reason for Resident #1's overflowing catheter bag with urine backflowing into the catheter tubing. Observation on 02/18/2023 at 3:58pm, Resident #1 continued to have an indwelling catheter with an overfilled catheter bag with urine backflowing in the catheter tubing. The bag continued to be leaking urine onto the floor. The urine was cloudy, with sediment visible in tubing and bag. There was a thick cloudy substance in the tubing that appeared to be puss. This observation was reported to the Corporate Regional Resource Nurse-J. Observation and interview on 02/19/2023 at 8:35 am, Resident #1's catheter bag had been emptied; however, the Foley catheter and tubing had not been changed and was observed to be crusted with sediment and puss like substance visible in the tubing. There was a trash bag on the floor under the uncovered catheter bag. Resident #1 stated that the trash bag was placed to catch leaking urine from the catheter bag. Interview on 02/19/2023 at 9:45 am, RN-V stated she had not gone to Resident #1's catheter bag to check if it had been drained or changed during previous day's shift. She reported it was delegated to her, but she was busy and had not had a chance to do it. Interview on 02/19/2023 at 10:02 am, Corporate Regional Resource Nurse-J-J stated she had instructed RN-V to change Resident #1's catheter bag. She stated that RN-V reported that it had been changed. She collected a UA sample while changing it and would notify the physician. She stated that the catheter should have been changed due to the sediment. She said that she could see where there was an issue for concern. Interview on 02/19/2023 at 11:04 am, DON stated she asked LVN-O and RN-V to change Resident #1's catheter, tubing and bag yesterday afternoon. She could not remember the exact time, but it was after lunch. She said she went back to Resident #1's rooms yesterday afternoon and it continue to not be completed. She then asked them again to complete the task. She stated this failure placed the residents at risk for an infection. Interview on 02/19/2023 at 3:10pm, RN-V said she did not change Resident #1's catheter tubing but only changed the bag. She said she obtained a urine sample for an ordered UA from the catheter tubing that continued to have sediment and puss like substance but not from the bag. Interview and observation on 02/19/23 03:15 PM, Corporate Regional Resource Nurse-J-J stated she instructed RN-V to change Resident #1's entire catheter on 02/18/2023. Observation and interview on 02/19/2023 at 11:20 am, Resident #1 was speaking with surveyor without any distress. Observation on 02/19/2023 at 2:57 pm, with Corporate Clinical Company Leader RN-I present, Resident #1 was observed unresponsiveness with emesis on chest . Corporate Clinical Company Leader RN-I stated she had to check Resident #1's pulse because she wasn't sure if she was alive. Interview on 02/19/2023 about 3:00pm, Resident #56 (Resident #1's roommate) said Resident #1 received her lunch tray about 12:00 pm and almost immediately started to throw up. Resident #56 then called for help, but no one came until about 2:00 pm. Resident #56 said she told the staff that Resident #1 needed assistance, the staff was Assistant Administrator in Training who removed Resident #1's tray and stated, I can't help you and left the room. Review of Resident #56's quarterly MDS dated [DATE] revealed Section C Cognitive Patterns BIMS Score of 15 indicating no cognitive impairment. Observation on 02/19/2023 at 3:25pm, Resident #1 was transferred to a local hospital via EMS. Interview on 02/19/2023 at 4:34pm, the DON said she looked at Resident #1's catheter yesterday (02/18/2023) and it appeared to have puss and sediment in the catheter tubing and catheter bag entry hub. She said it was her expectation that it was to be changed. She made an additional request for the catheter to be changed this morning by RN-V. DON stated she discovered Resident #1 left the facility (to the hospital) without a changed catheter tubing but only a changed catheter bag. It was her expectation that it was changed yesterday. Interview on 02/20/2023 at 3:57pm, CNA-Z stated Resident #1 had puss in her catheter tubing when she drained the catheter bag and performed incontinent care about 2 weeks ago. She stated she notified RN-V of the puss in resident's catheter tubing at that time. Interview on 02/20/2023 at 04:04 PM, Resident #56 (Resident #1's roommate) said she pressed the call light frequently and it takes a while to answer. She said the lady who came to answer the call light after two hours had long dark hair and was part of administration but did not work the floor. Resident #56 (Resident #1's roommate) said that this staff went to the Resident #1 and said Oh, My God, when she saw the resident. Resident #56 (Resident #1's roommate) said that the staff stated she could not help Resident #1 and left the room. Resident #56 (Resident #1's roommate) said she thought the staff was coming back but never did. Resident #56 (Resident #1's roommate) said she could hear Resident #1 throwing up and gurgling. Resident #56 (Resident #1's roommate) said no one changed their catheters. She said yesterday (02/19/2023) the staff just changed the bag. Resident #56 (Resident #1's roommate) said the regional nurse did in fact tell the nurse to just change the bag until she got caught up and that she could change it later. Resident #56 (Resident #1's roommate) said it was the same nurse who told her in Spanish to butt out and put her hand to her mouth as in telling her to hush and she cut her eyes. Interview on 02/20/23 04:34 PM, RN-V stated while in Resident's room that she was short of staff 02/19/2023 and behind. She said when the regional nurse came, she told her to change the catheter bag only. She said she was often short staffed or without staff and can do what she can do. She said she is trying hard and stays for the residents. Interview on 02/21/2023 at 4:46 PM, with Resident #1's Family Members A and B revealed when they would come to see her, she would look malnourished, and her catheter bag was always full. Record review of Resident #1's vital reports, dated 02/21/2023, provided by Corporate Clinical Leader RN-H revealed no evidence of catheter care, drainage of catheter bag and amount of urine obtained during drainage on 48 occasions between 01/18/23 and 02/19/23. Record review of Resident #1's hospital record History and Physical dated 02/19/2023 at 8:48pm, revealed the following physician's notes- We sent her to the ICU Again, clinically it just seems to be a very ill patient, who was sent from the nursing home for an honestly a bogus reason at this point. At any rate from what I can gather she had left sided weakness from a prior stroke, but today currently it seems like she is not moving the right side, so we will get MRI of the brain. She does have a UTI in her labs, which will be treated. Record review of Resident #1's hospital records dated 02/19/2023 revealed Resident #1 was admitted into the hospital's ICU with diagnosis of UTI & rule out stroke. Record reviewed on Resident #1's hospital records labs, assessment and plan dated 02/19/2022 revealed, Resident #1 had a primary diagnosis of Urinary Tract Infection, with orders to check cultures, place her on ceftriaxone (antibiotic) Record review of Resident #1's hospital records dated 02/21/2023 revealed Resident #1 had a diagnosis of Sepsis (A life threatening complication or infection. Sepsis occurs when chemicals released in the bloodstream to fight an infection throughout the body. This can result in multi organ system failure and even death). Records review of Resident #1's hospital records dated 02/21/2023 Assessment and Plan revealed: 1. UTI in the setting on chronic indwelling foley catheter. Urine culture grew E coli. Blood cultures grew gram positive cocci. Start IV Vancomycin and Rocephin for empiric treatment. 2. Bacteremia: Blood culture grew gram positive cocci. Start IV Vancomycin (antibiotic) and Rocephin (antibiotic) for empiric treatment. 2. Resident #79 Review of Resident #79's electronic Face Sheet dated revealed he was a [AGE] year-old male admitted to the facility 11/15/22. He had diagnoses which included heart failure, end stage renal disease, current long-term use of antibiotics, acute osteomyelitis (infection of the bone caused by bacteria), pressure ulcer of right heel stage 4, chronic pain, pressure ulcer of sacral region, systemic lupus erythematosus (inflammatory disease caused when the immune system attacks its own tissues causing fatigue and pain), major depressive disorder, dependence on renal dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), dependence on supplemental oxygen, chronic atrial fibrillation (irregular heart beat), Methicillin resistant Staphylococcus aureus (certain type of bacteria resistant to treatment by many common antibiotics), and Type 2 diabetes mellitus . Review of Resident #79's admission MDS dated [DATE] revealed: Section C: Cognitive Patterns BIMS Score of 15 indicating no cognitive decline; Section G Functional Status indicated extensive/2+ person physical assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions indicated one Stage 3 pressure ulcer present upon admission and one Unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar present upon admission. Review of Resident #79's Quarterly MDS dated [DATE] revealed: Section M: Skin Conditions indicated two Stage 4 pressure ulcers present upon admission, and one Unstageable pressure ulcer that was not present upon admission. Review of Resident #79's Care Plan last revised 1/30/23 revealed: Problem: Resident has a pressure ulcer to sacrum r/t immobility. Goal: Resident's ulcer will heal without complications. Approach: use cushion provided by family for pressure reduction when resident is in chair; conduct a systematic skin inspection daily during treatment ; Problem: Pressure Sores/Skin Care. Goal: Prevent/Heal pressure sores and skin breakdown. Approach: follow facility skin care protocol; preventative measures use cushioned boots for heels while in bed as tolerated, off load heels while in bed; report to charge nurse any redness or skin breakdown immediately; treatment as ordered; turn and reposition every 2 hours and PRN; Problem: Resident has a pressure ulcer to right heel r/t immobility. Goal: Resident's ulcer will not increase in size. Ulcer will not exhibit signs of infection. Approach: . conduct a systematic skin inspection during treatment . Review of Resident #79's electronic orders revealed: Multivitamin plus Minerals 1 tablet by mouth daily (start date 11/15/22) Left heel cleanse with ns or wound cleanser and apply sure-prep two times daily for preventative (start date 11/25/22) Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing every day until resolved (start date 11/25/22) Cleanse right heel with normal saline or wound cleanser, apply sure-prep to heel two times daily for preventative (start date 11/25/22) Ascorbic acid (vitamin c) 500mg 1 tablet by mouth daily (start date 11/29/22) Pro-Stat AWC (amino acids-protein hydrolys) 17-100 gram-kcal/30ml give 30ml by mouth twice a day (start date 11/29/22) Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing as needed until resolved (twice a day - PRN, morning, bedtime) (start date 11/29/22) Cleanse right heel with normal saline or wound cleanser apply anasept to wound and secure with a bordered dressing daily (start date 12/29/22) Use cushioned boots while in bed as tolerated (start date 1/3/23) Ertapenem 1 gram intravenously daily for 42 days r/t osteomyelitis (start date 1/13/23 end date 2/24/23) Site 1: Sacrum Review of Resident #79's Wound Management Wound History dated 11/15/2022 at 8:08 am revealed: Pressure Ulcer to Sacrum present on admission. Review of Resident #79's Wound Care Physician Progress Notes dated 12/01/2022 revealed: Stage 4 Pressure Wound Sacrum Full Thickness measured 1.7cm in length by 0.7cm in width with 1.2cm in depth. Review of Resident #79's Wound Care Physician Progress Note dated 01/12/2023 revealed: The histology report from the biopsy of the sacrum taken on 01/05/2023 indicates acute osteomyelitis. Review of Resident #79's physicians orders dated 11/25/2022 revealed: Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing every day until resolved. Review of Resident #79's physicians orders dated 11/29/2022 revealed: Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing as needed until resolved. Review of Resident #79's Treatment Administration Record from November 2022 to February 2023 revealed no evidence of treatments on 12/02/2022, 12/25/2022, 12/26/2022, 01/01/2023, 01/05/2023, 01/08/2023, 01/11/2023, 01/19/2023, 02/04/2023, 02/08/2023, 02/11/2023, 02/19/2023 Review of Resident #79's electronic record revealed no evidence of reposition every 2 hours and as needed and conduction of systematic skin inspection daily between 11/25/2022 and 12/29/2022. Site 2: Right Heel Review of Resident #79's Wound Management Detail Report dated 11/15/2022 at 8:11am by LVN-AE revealed: Stage 3 pressure ulcer to right heel measured 0.3cm in length by 0.3cm in width with 0.1cm in depth. Review of Resident #79's Wound Management Wound History dated 11/25/2022 at 7:33am revealed: Pressure Ulcer to right heel present on admission and healed. Review of Resident #79's Wound Care Physician Progress Notes dated 12/01/2022 revealed: Unstageable due to necrosis (death of cells in body tissues) of the Right Heel measured 1cm in length by 1.1cm in width with no measurable depth. Review of Resident #79's Wound Care Physician Progress Notes dated 12/29/2022 revealed deterioration to a Stage 4 Pressure Wound of the Right Heel. Review of Resident #79's Wound Management Wound History dated 12/29/2022 at 2:31am revealed: Pressure Ulcer to right heel present on admission. Review of Resident #79's Wound Management Detail Report dated 02/23/2023 at 7:11pm by Corporate Clinical Company Leader RN-I revealed: Stage 4 Pressure Ulcer to right heel measured 0.5cm in length by 0.6cm in width with unmeasurable depth. The wound had necrotic tissue type. Review of Resident #79's skin assessment records revealed no evidence of systematic skin inspection during treatment between 11/25/2022 and 12/29/2022. During an observation on 02/20/23 at 3:25 PM of Resident #79's wound care revealed RN-V completed wound care with the assistance of MDS-RN and LVN Q. RN-V failed to change gloves after removing sacrum dirty wound dressing and beginning to apply treatment and clean dressing to sacrum. RN-V also failed to perform hand hygiene before applying new gloves to begin treatment to right heel. Following the treatment, RN-V was unable to be located for an interview. Interview on 2/24/23 at 4:48 PM, LVN-Q stated wound care with Resident #79 on 2/20/23 performed by RN-V went badly. She stated she did not see RN-V wash hands or use sanitizer at any time before or during the dressing changes, but she did see her change her gloves in between each wound. LVN-Q stated that was not the correct procedure for hand hygiene during wound care and could lead to recontamination of the wound. She stated that RN-V was feeling overwhelmed but that was not an excuse. She stated that it was just overall not good. In an interview on 2/21/23 at 11:35 AM, Corporate Clinical Company Leader RN-H stated Resident #79 was admitted to facility on 11/15/22 with stage 3 to sacrum and stage 3 to right heel and that both wounds were documented on admission. Corporate Clinical Company Leader RN-H stated that in her investigation of the Resident #79's chart, it appeared that the wound care/treatment nurse at the time documented the right heel wound was healed on 11/25/22 even though the wound was never healed. She stated the right heel wound was re-identified as a stage 4 on 12/29/22. She stated that because the wound was documented as healed it went one month without treatment or observation leading to it decline to a stage 4. She stated that Resident #79's sacral wound was a stage 3 on admission but had declined to a stage 4. She stated the documentation stating the wound was improving even with the presence of osteomyelitis was strictly referring to the wound bed appearance from her understanding. Corporate Clinical Company Leader RN-H stated the resident was diagnosed with osteomyelitis at the site of the sacral wound by the wound care physician. She stated the staff was supposed to do skin sweeps weekly to check wounds and get measurements and the wound care doctor saw residents weekly as well. The staff did their checks on the residents that the doctor did not see. The measurements were documented in the wound management section of the chart. Corporate Clinical Company Leader RN-H stated wound care was documented on the treatment administration record only unless something was wrong or there were changes. If there was something different with a wound, she stated a prudent nurse would document in a focused observation note or progress note what was observed, notify the doctor of the change in the resident's condition, then document that the doctor was notified. She stated the wound care physician's progress notes were uploaded into the resident's EMR electronically and that he was able to put his own orders in remotely. She stated if someone did transcribe orders for him it would be the nurse who did rounds with him while he was in the building seeing residents, normally the wound care/treatment nurse when the facility had one or the DON. If the resident was a new admission and the wound care physician was giving orders, the admitting nurse would be responsible for transcribing the orders and verifying everything was in the resident's chart correctly. Corporate Clinical Company Leader RN-H stated when an order was put into the facility's charting program it went directly onto the MAR. She stated during the morning meeting, the staff should have been going over all new orders received to make sure all orders had been signed and verified and that nothing had been missed during rounds. Corporate Clinical Company Leader RN-H stated all information regarding wounds had been provided or would be found in focused observation notes. In an interview on 02/22/23 at 09:57 AM , LVN-AE the former wound care nurse for the facility, stated that on weekends RN-V would not do wound care for the residents on Station 1. When LVN-AE would ask RN-V why it was not being done, RN-V would say it was because she would be frustrated and that she was one person and could not get them (treatments) done. LVN-AE did not understand why because RN-V always had a med aide, so that would have left her free to do the treatments. LVN-AE stated that the wounds would have the same dressing on them on Monday that she put on the residents on Friday. LVN-AE stated she worked Monday through Friday as the treatment/wound care nurse. LVN-AE reported RN-V to the DON and the former Administrator, then later reported it to Regional Nurse Consultant and others who no longer work for the company. She was told by all of them that they would talk to RN-V. LVN-AE stated it never got corrected. LVN-AW felt the residents did not receive wound care as ordered by the physician when she was not in building. LVN-AE stated that every Thursday the wound care physician would see residents but by the time he arrived, she had a week to make them look better, so he did not make comments that the residents' wounds were worse. LVN-AE stated she got conflicting information from DON's regarding skin assessments. LVN-AE stated at first, she would do skin assessments on wound care residents, then was told the nurses were supposed to do skin assessments and she was only supposed to do the wound management (measurements, wound descriptions). LVN-AE said she left the facility because the facility was not willing to change and hold RN-V accountable for wound care, and she was afraid of losing her license due to the wounds in the facility. In an interview on 2/22/23 at 10:25 AM, LVN-P stated since the wound care nurse quit whoever was working the floor was responsible for wound care for the residents. She stated typically, there was a charge nurse and a med nurse on the day shift, and they helped each other out with the residents. LVN-P stated Station 1 had 6 residents getting wound care at that time. When wound care was done, she stated she only signed off on the TAR and she never put a progress note in just to state the wound care had been done. She stated if there were changes to the wound it was documented in a progress note, the doctor was notified, she would notify the family and continue the treatment or write orders if any new orders were given. She stated a nurse always rounded with the wound care doctor when he saw the residents. She stated he was in the facility weekly, and she rounded with him last week because there was no one else to do it. LVN-P stated until the facility hired a new wound care nurse, she believed the DON was going to take over rounding with him. In an interview on 2/22/23 at 10:49 AM, Corporate Clinical Company Leader RN-H stated that she was not aware skin assessments were not being done accurately and treatments were not being done until surveyors arrived at the facility. She stated the facility was currently in the process of revising their wound care program to address wound care management, assessments, treatments, and care planning issues the facility had been experiencing. In an interview on 2/23/23 at 11:35 AM, the Wound Care Physician stated that his expectation was that his orders would be followed and the wound care for the residents would be done. Wound Care Physician stated that if a resident's wound care was not done as ordered over the weekend that when he came to the facility on Thursday, the wounds would have time for improvement by the time he saw them again if the treatments were started back up on Monday. He stated he did rounds with the floor nurses when he saw the residents. 3. Resident #53 Record review of Resident #53's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. She resided on Station 1 Hall 6 which was a Woman's secured unit (the average age of the women residents on Station 1 Hall 6 was 76 years). Diagnosis included: anoxic brain damage; diffuse traumatic brain injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness; epilepsy and epileptic syndromes with seizures of localized onset; restlessness and agitation; post-traumatic stress disorder; repeated falls; muscle weakness (generalized); insomnia due to other mental disorder; major depressive disorder; anxiety disorder; dysphagia (difficulty in swallowing), altered mental status; pain; adult sexual abuse. Record review of Resident #53's Quarterly MDS, dated [DATE], revealed the BIMS score was blank indicating inability to obtain a Brief Interview for Mental Status; Section E: Behavior indicated no psychosis, presence of physician behavior symptoms directed toward others, significant risk for physical illness or injury on self and others, rejection of care, wandering that places resident at significant risk of getting to a potentially dangerous place and intrusion on privacy of activity of others. Record review of Resident #53's Care Plan, last edited on 02/13/23 revealed: Problem: I have periods of time where I am in constant motion/movement. Problem: I get frustrated because of my physical condition and may reach out to grab or hit others. Goal. To not hit other residents. Approach. Patient placed on 1:1 observation for at least 72 hours to prevent injury to others, will keep her separated from arms reach from other residents, put gloves on resident to prevent any injury if she reaches out. Problem: I have anxiety related to anoxic brain injury as evidence by I fidget constantly, grab at others, lick my hands and rub it on things and people, sit to stand frequently, stand up rapidly and attempt to walk with no regards to surroundings. Problem: Behavioral Symptoms - licking her hands and trying to touch others, invading others space, grabbing at others, sitting and or lying-in other residents' beds when they are not in them. Goal. Resident will have less than 5 bad outcomes due to grabbing at people and toward staff or other residents over the next 90 days. Approach: 15-minute checks, I will have increased supervision due to my behavior or grabbing at things and swinging my arms, I rest better with a quiet calm environment at night, Problem: Falls. Approach. Ordered an oversize bean bag for positioning. Review of Resident #53's electronic record from April 2022 to February 2023 revealed no evidence of documented 15-minute checks and no evidence of physician's order for 1:1 level of supervision. Record review of Resident #53's transfer documentation packet, faxed on 04/19/2022 from previous facility revealed: resident required a locked facility that has more supervision and brain training support. On 04/21/22, Resident #53 was transferred from a sister facility requiring 1:1 supervision due to being threat to herself and others. Record review of Nurse Practitioner progress not[TRUNCATED]

Based on the observations, interviews and record review, the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 4 residents (Resident # 1, Resident #79) reviewed for pressure ulcers. The facility failed to prevent Resident #1 from developing 5 new pressure ulcers (Stage IV to right ischium, Stage IV to left Ischium, Stage IV to Left Heel, Stage IV to right heel, and Not Stage to sacrum) while she resided in the facility. The facility failed to promote healing and prevent Resident #79's Stage IV pressure ulcer to his sacrum from developing osteomyelitis (an infection in the bone caused by bacteria) The facility failed to promote healing and prevent Resident #79's right heel pressure ulcer from deteriorating from Stage III to Stage IV. An Immediate Jeopardy (IJ) was identified on 2/22/2023 at 4:58 PM. While the IJ was removed on 2/24/2023 at 6:48 PM, the facility remained out of compliance at actual harm that was not immediate jeopardy with a scope of pattern due to the facility's need to monitor the implementation and effectiveness of its plan of removal. These failures placed residents at risk of pain, worsening of wounds, wound infection, emotional distress, harm or even death. The findings were: Review of The National Pressure Injury Advisory Panel (NPIAP) accessed on 03/14/2023 https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf revealed: Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Resident #1 Review of Resident #1's electronic face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with a most recent admission date of 11/20/2022 with the following diagnosis: Unspecified fracture of left shaft of the femur (long, straight portion of the upper leg bone), Non ST elevation myocardial infraction (heart attack due to inadequate blood to the heart), gram negative sepsis (bacteria in the blood), neurogenic bladder (deficiency in bladder control due to brain, spinal cord or nerve problem) and urinary tract infection, site not specified (infection in any part of the urinary system). Review of Resident #1's admission MDS, dated [DATE], revealed: Section C: Cognitive Patterns BIMS Score of 9 indicating moderate cognitive impairment; Section G: Functional Status limited/one-person assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions of no pressure ulcers. Review of Resident #1's Significant Change MDS dated [DATE], revealed: Section C: Cognitive Patterns BIMS Score of 14 indicating cognitively intact; Section G: Functional Status: extensive/two + persons assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions indicated two Stage III pressure ulcers, one Stage IV pressure ulcer, and two Unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar. Site 1: Right buttock/ischium Review of Resident #1's Wound Management Detail Report dated 07/28/2022 at 4:08pm by LVN-AD revealed: Pressure Ulcer to Right Buttock, not present on admission. Unstageable measured 2.8cm in length by 2.8cm in width with unmeasurable depth. Review of Resident #1's Wound Management Detail Report dated 02/16/2023 at 5:44pm by LVN-Q revealed: Stage IV measured 4cm in length by 6cm in width with 2.5 measurable depth. Review of Resident #1's wound care physician progress notes revealed the following: 7/28/22 Initial exam of Right Ischium: Unstageable Pressure Ulcer 2.8cm x 2.8cm x unmeasurable depth; surgical debridement performed 11/24/22 Change of staging Right Ischium: Stage IV 4.6cm x 6.0cm x 2.0cm; surgical debridement performed 2/16/23 Last available progress note Right Ischium: 4cm x 6cm x 2.5cm; surgical debridement performed Site 2: Left buttock/ischium Review of Resident #1's Wound Management Detail Report dated 08/04/22 at 3:24pm by LVN-AD revealed: Unstageable Pressure Ulcer to Left Buttock, not present on admission. Measured 4.5cm in length by 4cm in width with no measurable depth. Review of Resident #1's Wound Management Detail Report dated 02/16/2023 at 5:50pm by LVN-Q revealed: Stage III measured 1.7cm in length by 4.2cm in width with 0.5cm measurable depth. Review of Resident #1's wound care physician progress notes revealed the following: 8/04/22 Initial exam of Left Ischium: Stage II Pressure Ulcer 4.5cm x 4.0cm x unmeasurable depth; no debridement done 8/11/22 Change of Staging of Left Ischium: Unstageable Pressure Ulcer: 3.2cm x 1.5cm x 0.2cm; surgical debridement performed 11/10/22 Change of Staging of Left Ischium: Stage III 4.5cm x 2.5cm x 1cm; surgical debridement performed 2/16/23 Change of Staging of Left Ischium: Stage IV 1.7cm x 4.2cm x 0.5cm; surgical debridement performed Site 3: Left heel Review of Resident #1's Wound Management Detail Report dated 11/17/2022 at 9:17am by LVN-AE revealed: Unstageable - Deep Tissue Pressure Ulcer left heel not present on admission measured 5.5cm in length by 5cm in width with no measurable depth. Review of Resident #1's Wound Management Detail Report dated 02/16/23 at 5:54pm by LVN-Q revealed: Stage IV measured 3cm in length by 4cm in width with no measurable depth. Review of Resident #1's wound care physician progress notes revealed the following: 11/17/22 Initial exam of Left Heel: Unstageable DTI Pressure Injury 5.5cm x 5.0cm x unmeasurable depth; no debridement done 12/8/22 Change in Staging of Left Heel: Unstageable Pressure Ulcer 5.5cm x 5.0cm x unmeasurable depth; no debridement done 2/16/23 last available progress note for Left Heel: Unstageable Pressure Ulcer 3cm x 4cm x unmeasurable depth; no debridement done Site 4: Right heel Review of Resident #1's Wound Management Detail Report dated 11/17/2022 at 9:15am by LVN-AE revealed: Pressure Ulcer Right Heel not present on admission measured 5cm in length by 7cm in width and no measurable depth. Review of Resident #1's Wound Management Detail Report dated 02/16/23 at 5:52pm by LVN-Q revealed: Stage IV measured 2.7cm in length by 3.8cm in width and no measurable depth. Review of Resident #1's wound care physician progress notes revealed the following: 11/17/22 Initial exam of Right Heel: Unstageable DTI Pressure Injury 5cm x 7cm x unmeasurable depth; no debridement done 12/8/22 Change in Staging of Right Heel: Unstageable Pressure Ulcer 5cm x 7cm x unmeasurable depth; no debridement done 12/29/22 Change in Staging of Right Heel: Stage IV Pressure Ulcer 5.5cm x 5cm x unmeasurable depth; surgical debridement performed 2/16/23 last available progress note for Right Heel: Stage IV 2.7cm x 3.8cm x unmeasurable depth; no debridement done Site 5: Sacrum Review of Resident #1's Wound Management Detail Report dated 11/09/22 at 12:50 PM by LVN-AE revealed: Pressure Ulcer Sacrum not present on admission measured 10cm in length by 8cm in width and no measurable depth Review of Resident #1's Wound Management Detail Report dated 2/09/23 at 2:36 PM by LVN-AE revealed: Pressure Ulcer Sacrum not present on admission measured 1.5cm in length by 1cm in width and no measurable depth Review of Resident #1's electronic orders revealed: Ascorbic acid (vitamin c) tablet; 500mg 1 tab oral once a day (start date 10/08/22) Wound Treatment Order: Location: Pressure Wound of the Left Ischium Partial Thickness. Clean with Normal Saline/Wound Cleanser. Apply: collagen then Calcium Alginate with silver. Cover with Primary Dressing: bordered foam dsg. Once a day (start date 10/20/22) Wound Treatment Order: Location: Unstageable of the Right Ischium Full Thickness. Clean with Normal Saline/Wound Cleanser. Apply collagen Calcium Alginate with silver. Cover with bordered foam dsg. Once a Day. (start date 10/20/22) Wound Treatment Order: Location: Pressure Wound of the Left Ischium Partial Thickness. Clean with Normal Saline/Wound Cleanser. Apply: collagen then Calcium Alginate with silver. Cover with Primary Dressing: bordered foam dsg. Twice a Day-PRN (start date 11/29/22) Wound Treatment Order: Location: Unstageable of the Right Ischium Full Thickness. Clean with Normal Saline/Wound Cleanser. Apply collagen Calcium Alginate with silver. Cover with bordered foam dsg. Twice A Day - PRN (start date 11/29/22) Cleanse sacrum with normal saline or wound cleanser apply thin layer of triad, yellow tube, to wound two times a day. Every Shift (start date 12/29/22) Cleanse left heel with normal saline or wound cleanser apply calcium alginate to wound bed surrounding necrotic tissue and secure with bordered dsg as needed. Every Shift (start date 2/10/23) Cleanse left heel with normal saline or wound cleanser apply calcium alginate to wound bed surrounding necrotic tissue and secure with bordered dsg daily. Once A Day. Morning 06:00 AM - 06:00 PM (start date 2/10/23) Cleanse right heel with normal saline or wound cleanser apply calcium alginate to wound bed and secure with bordered dsg as needed. Every Shift - PRN (start date 2/10/23) Cleanse right heel with normal saline or wound cleanser apply calcium alginate to wound bed and secure with bordered dsg daily. Once A Day. Morning 06:00 AM - 06:00 PM (start date 2/10/23) Review of Resident #1's Comprehensive Care Plan dated 01/31/2023 revealed: Problem: Resident has a pressure ulcer to left buttock related to immobility and desensitized skin. Goal: Resident's ulcer will heal without complication. Approach: Conduct a systematic skin inspection daily by nurse with daily dsg change.; Problem: Resident has a pressure ulcer to left heel related to immobility. Goal: Resident's ulcer will not increase in size. Approach: Conduct a systematic skin inspection during daily treatment . Use heel protectors as tolerated or cushion under legs as tolerated to relieve pressure on the heels.; Problem: Resident has a pressure ulcer to right buttock related to immobility and desensitized skin. Goal: Resident's ulcer will heal without complication. Approach: Conduct a systematic skin inspection daily by nurse with daily dsg change.; Problem: pressure Ulcer Sacrum Stage III. Goal: Area will show improvement in the next 14 days. Approach: Turn every 2 hours and prn. In an interview on 02/19/2023 at 2:38 PM, Corporate Clinical Company Leader RN-I stated the facility would accept responsibility for Resident #1's pressure ulcers and that they were facility acquired. She stated that she could not find any documentation that they were not acquired in the facility. Corporate Clinical Company Leader RN-I stated that the failure of the facility to prevent Resident #1 from developing new pressure ulcers could result in an infection and that the failure was due to ongoing staffing issues. In an interview on 02/22/23 at 09:57 AM, LVN-AE the former wound care nurse for the facility, stated that on weekends RN-V would not do wound care for the residents on Station 1. LVN-AE stated that Resident #1's wound got worse because RN-V would have the wrong dressings on the resident. LVN-AE stated that Resident #1's sacrum was to be left open to air per physician orders, but she would come back on Monday and there would be a dressing (silicone border dressing) covering the wound and when she would remove the dressing, it would take the new healing skin off. She stated Resident #1 did not show pain, just that her wounds would be worse. In an interview on 2/23/23 at 11:35 AM, the Wound Care Physician stated that his expectation was that his orders would be followed and the wound care for the residents would be done. He stated that all of Resident #1's wounds were facility acquired. Review of Resident #1's electronic record from 05/20/2022 to 02/23/2023 revealed no evidence of physician's progress note demonstratiting the resident's pressure ulcers were clinically unavoidable. Resident #79 Review of Resident #79's electronic Face Sheet revealed he was a [AGE] year-old male admitted to the facility 11/15/22. He had diagnoses which included heart failure, end stage renal disease, current long-term use of antibiotics, acute osteomyelitis (an infection in the bone caused by bacteria), pressure ulcer of right heel stage 4, chronic pain, pressure ulcer of sacral region, systemic lupus erythematosus (inflammatory disease caused when the immune system attacks its own tissues causing fatigue and pain), major depressive disorder, dependence on renal dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), dependence on supplemental oxygen, chronic atrial fibrillation (irregular heart beat), Methicillin resistant Staphylococcus aureus (certain type of bacteria resistant to treatment by many common antibiotics), and Type 2 diabetes mellitus. Review of Resident #79's admission MDS dated [DATE] revealed: Section C: Cognitive Patterns BIMS Score of 15 indicating no cognitive decline; Section G Functional Status indicated extensive/2+ person physical assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions indicated one Stage III pressure ulcer present upon admission and one Unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar present upon admission. Review of Resident #79's Quarterly MDS dated [DATE] revealed: Section C: Cognitive Patterns BIMS Score of 11 indicating moderate cognitive decline; Section G Functional Status indicated extensive/2+ person physical assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions indicated two Stage IV pressure ulcers present upon admission, and one Unstageable pressure ulcer that was not present upon admission. Site 1: Sacrum Review of Resident #79's Wound Management Wound History dated 11/15/2022 at 8:08 am revealed: Pressure Ulcer to Sacrum present on admission. Review of Resident #79's Wound Care Physician Progress Notes dated 12/01/2022 revealed: Stage 4 Pressure Wound Sacrum Full Thickness measured 1.7cm in length by 0.7cm in width with 1.2c in depth. Review of Resident #79's Wound Care Physician Progress Note dated 01/12/2023 revealed: The histology report from the biopsy of the sacrum taken on 01/05/2023 indicates acute osteomyelitis. Site 2: Right Heel Review of Resident #79's Wound Management Detail Report dated 11/15/2022 at 8:11am by LVN-AE revealed: Stage III pressure ulcer to right heel measured 0.3cm in length by 0.3cm in width with 0.1cm in depth. Review of Resident #79's Wound Management Wound History dated 11/25/2022 at 7:33am revealed: Pressure Ulcer to right heel present on admission and healed. Review of Resident #79's Wound Management Wound History dated 12/29/2022 at 2:31am revealed: Pressure Ulcer to right heel present on admission. Review of Resident #79's Wound Management Detail Report dated 02/23/2023 at 7:11pm by Corporate Clinical Company Leader RN-I revealed: Stage IV Pressure Ulcer to right heal measured 0.5cm in length by 0.6cm in width with unmeasurable depth. The wound had necrotic tissue type. Review of Resident #79's skin assessment records revealed no evidence of systematic skin inspection during treatment between 11/25/2022 and 12/29/2022. Review of Resident #79's Wound Care Physician Progress Notes dated 12/01/2022 revealed: Unstageable due to necrosis (death of cells in body tissues) of the Right Heel Full Thickness measured 1cm in length by 1.1cm in width with no measurable depth. Review of Resident #79's Wound Care Physician Progress Notes dated 12/29/2022 revealed deterioration to a Stage IV Pressure Wound of the Right Heel. Review of Resident #79's electronic orders revealed: Multivitamin plus Minerals 1 tablet by mouth daily (start date 11/15/22) Left heel cleanse with ns or wound cleanser and apply sure-prep two times daily for preventative (start date 11/25/22) Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing every day until resolved (start date 11/25/22) Cleanse right heel with normal saline or wound cleanser, apply sure-prep to heel two times daily for preventative (start date 11/25/22) Ascorbic acid (vitamin c) 500mg 1 tablet by mouth daily (start date 11/29/22) Pro-Stat AWC (amino acids-protein hydrolys) 17-100 gram-kcal/30ml give 30ml by mouth twice a day (start date 11/29/22) Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing as needed until resolved (twice a day - PRN, morning, bedtime) (start date 11/29/22) Cleanse right heel with normal saline or wound cleanser apply anasept to wound and secure with a bordered dressing daily (start date 12/29/22) Use cushioned boots while in bed as tolerated (start date 1/3/23) Ertapenem 1 gram IV daily for 42 days r/t osteomyelitis (start date 1/13/23 end date 2/24/23) Review of Resident #79's Treatment Administration Records from November 2022 to February 2023 revealed no evidence of wound treatments completed on 12/02/2022, 12/25/2022, 12/26/2022, 01/01/2023, 01/05/2023, 01/08/2023, 01/11/2023, 01/19/2023, 02/04/2023, 02/08/2023, 02/11/2023, 02/19/2023. Review of Resident #79's electronic record revealed no evidence of reposition every 2 hours and as needed and conduction of systematic skin inspection daily between 11/25/2022 and 12/29/2022. Review of Resident #79's Care Plan last revised 1/30/23 revealed: Problem: Pressure Sores/Skin Care. Goal: Prevent/Heal pressure sores and skin breakdown. Approach: follow facility skin care protocol; preventative measures use cushioned boots for heels while in bed as tolerated, off load heels while in bed; report to charge nurse any redness or skin breakdown immediately; treatment as ordered; turn and reposition every 2 hours and PRN; Problem: Resident has a pressure ulcer to right heel r/t immobility. Goal: Resident's ulcer will not increase in size. Ulcer will not exhibit signs of infection. Approach: . conduct a systematic skin inspection during treatment .; Problem: Resident has a pressure ulcer to sacrum r/t immobility. Goal: Resident's ulcer will heal without complications. Approach: use cushion provided by family for pressure reduction when resident is in chair; conduct a systematic skin inspection daily during treatment . Observation on 2/18/23 at 3:30 PM Resident #79 was lying in bed, turned slightly onto his left side with heels floated on pillows and heel protectors to bilateral feet. Observation on 2/19/23 at 10:30 AM Resident #79 was lying in bed flat on his back with heels floated on pillows, bilateral heel protectors were in place. Observation on 2/20/23 at 9:40 AM Resident #79 was sitting in Geri-chair in dialysis suite with pillows elevating feet. Resident #79 had 2 blankets covering his legs because he stated that room was always cold, surveyor unable to verify if heel protectors were in place. Observation on 02/20/23 3:25 PM: RN-V gathered supplies as ordered from treatment cart and placed in resealable plastic bag with resident #79's name written on it and carried bag to resident's room. MDS-RN and LVN-Q entered room and donned gloves. LVN-Q used hand sanitizer prior to entering resident room. MDS-RN was not observed to use hand sanitizer after entering Resident #79's room. RN-V used hand sanitizer, cleaned tray table with sanitizer wipes and placed wax paper on cleaned tabletop without donning gloves. RN-V removed 2 6inx6in foam border dressing from package and dropped on wax paper, removed 3 saline ampules, 1 can of wound spray, 1 tube of barrier cream, 4inx4in gauze, calcium alginate packing, and cotton tipped applicators from resealable plastic bag and placed on wax paper without donning gloves. RN-V saturated 4x4 gauze with saline without donning gloves. RN-V donned clean gloves. Resident #79 assisted onto his left side by MDS-RN. Dirty dressing and soiled packing removed by MDS-RN; soiled dressing was dated 2/18/23. Wound appeared beefy red inside, wound edges well-defined and healthy looking, area surrounding wound was bright red and irritated in appearance, area appeared larger than size of foam border dressing (6x6in) but no measurements were taken during this dressing change. Without changing soiled gloves, RN-V cleaned wound with saline soaked gauze, patted area dry with dry gauze, opened calcium alginate package and used cotton tipped applicator to pack calcium alginate packing into wound. Clean 6inx6in foam border dressing placed over wound. Resident rolled onto his back then LVN-Q stated, don't forget you have to date time and initial the dressing. RN-V assisted resident back onto his left side and RN-V dated and initialed the clean dressing. RN-V did not change gloves in between dirty and clean dressing. RN-V removed her gloves and donned a clean pair. LVN-Q held Resident #79's leg by the calf while RN-V removed Resident #79's right heel dressing, soiled dressing did not appear to have a date and initial on it. RN-V sprayed wound cleanser on right heel wound, applied wound cleanser to wound with cotton tipped applicator, and applied a clean 6inx6in foam bordered dressing. RN-V dated and initialed the clean dressing to Resident #79's right heel. RN-V removed her gloves. RN-V donned clean gloves and removed dressing to left heel, wound cleanser and gauze used to clean left heel. MDS-RN stated that there were no orders for the treatment or dressing to the left heel, but the staff do them as a preventative measure. RN-V removed her gloves, collected trash, and left the room. Surveyor attempted to find RN-V for an interview regarding the wound care, but she was unable to be located. Interview on 2/24/23 at 4:48 PM, LVN-Q stated wound care with Resident #79 on 2/20/23 performed by RN-V went badly. She stated she did not see RN-V wash hands or use sanitizer at any time before or during the dressing changes, but she did see her change her gloves in between each wound. LVN-Q stated that was not the correct procedure for hand hygiene during wound care and could lead to recontamination of the wound. She stated that RN-V was feeling overwhelmed but that was not an excuse. She stated that it was just overall not good. In an interview on 2/21/23 at 11:35 AM, Corporate Clinical Company Leader RN-H stated Resident #79 was admitted to facility on 11/15/22 with stage 3 to sacrum and stage 3 to right heel and that both wounds were documented on admission. Corporate Clinical Company Leader RN-H stated that in her investigation of the Resident #79's chart, it appeared that the wound care/treatment nurse at the time documented the right heel wound was healed on 11/25/22 even though the wound was never healed. She stated the right heel wound was re-identified as a stage 4 on 12/29/22. She stated that because the wound was documented as healed it went one month without treatment or observation leading to it progress to a stage 4. She stated that Resident #79's sacral wound was a stage 3 on admission but had worsened to a stage 4. She stated the documentation stating the wound was improving even with the presence of osteomyelitis was strictly referring to the wound bed appearance from her understanding. Corporate Clinical Company Leader RN-H stated the resident was diagnosed with osteomyelitis at the site of the sacral wound by the wound care physician. She stated the staff was supposed to do skin sweeps weekly to check wounds and get measurements and the wound care doctor saw residents weekly as well. The staff did their checks on the residents that the doctor did not see. The measurements were documented in the wound management section of the chart. Corporate Clinical Company Leader RN-H stated wound care was documented on the treatment administration record only unless something was wrong or there were changes. If there was something different with a wound, she stated a prudent nurse would document in a focused observation note or progress note what was observed, notify the doctor of the change in the resident's condition, then document that the doctor was notified. She stated the wound care physician's progress notes were uploaded into the resident's EMR electronically and that he was able to put his own orders in remotely. She stated if someone did transcribe orders for him it would be the nurse who did rounds with him while he was in the building seeing residents, normally the wound care/treatment nurse when the facility had one or the DON. If the resident was a new admission and the wound care physician was giving orders, the admitting nurse would be responsible for transcribing the orders and verifying everything was in the resident's chart correctly. Corporate Clinical Company Leader RN-H stated when an order was put into the facility's charting program it went directly onto the MAR. She stated during the morning meeting, the staff should have been going over all new orders received to make sure all orders had been signed and verified and that nothing had been missed during rounds. Corporate Clinical Company Leader RN-H stated all information regarding wounds had been provided or would be found in focused observation notes. In an interview on 02/22/23 at 09:57 AM, LVN-AE the former wound care nurse for the facility, stated that on weekends RN-V would not do wound care for the residents on Station 1. When LVN-AE would ask RN-V why it was not being done, RN-V would say it was because she would be frustrated and that she was one person and could not get them (treatments) done. LVN-AE did not understand why because RN-V always had a med aide, so that would have left her free to do the treatments. LVN-AE stated that the wounds would have the same dressing on them on Monday that she put on the residents on Friday. LVN-AE stated she worked Monday through Friday as the treatment/wound care nurse. LVN-AE reported RN-V to the DON and the former Administrator, then later reported it to Regional Nurse Consultant and others who no longer work for the company. She was told by all of them that they would talk to RN-V. LVN-AE stated it never got corrected. LVN-AW felt the residents did not receive wound care as ordered by the physician when she was not in building. LVN-AE stated that every Thursday the wound care physician would see residents but by the time he came, she had a week to make them look better, so he did not make comments that the residents' wounds were worse. LVN-AE stated she got conflicting information from DON's regarding skin assessments. LVN-AE stated at first, she would do skin assessments on wound care residents, then was told the nurses were supposed to do skin assessments and she was only supposed to do the wound management (measurements, wound descriptions). LVN-AE said she left the facility because the facility was not willing to change and hold RN-V accountable for wound care, and she was afraid of losing her license due to the wounds in the facility. In an interview on 2/22/23 at 10:25 AM, LVN-P stated since the wound care nurse quit whoever was working the floor was responsible for wound care for the residents. She stated typically, there was a charge nurse and a med nurse on the day shift, and they helped each other out with the residents. LVN-P stated Station 1 had 6 residents getting wound care at that time. When wound care was done, she stated she only signed off on the TAR and she never put a progress note in just to state the wound care had been done. She stated if there were changes to the wound it was documented in a progress note, the doctor was notified, she would notify the family and continue the treatment or write orders if any new orders were given. She stated a nurse always rounded with the wound care doctor when he saw the residents. She stated he was in the facility weekly, and she rounded with him last week because there was no one else to do it. LVN-P stated until the facility hired a new wound care nurse, she believed the DON was going to take over rounding with him. In an interview on 2/22/23 at 10:49 AM, Corporate Clinical Company Leader RN-H stated that she was not aware skin assessments were not being done accurately and treatments were not being done until surveyors arrived at the facility. She stated the facility was currently in the process of revising their wound care program to address wound care management, assessments, treatments, and care planning issues the facility had been experiencing. In an interview on 2/23/23 at 11:35 AM, the Wound Care Physician stated that his expectation was that his orders would be followed and the wound care for the residents would be done. Wound Care Physician stated that if a resident's wound care was not done as ordered over the weekend that when he came to the facility on Thursday, the wounds would have time for improvement by the time he saw them again if the treatments were started back up on Monday. He stated he did rounds with the floor nurses when he saw the residents. Review of facility policy Prevention of Pressure Injuries revised May 2022 revealed: Purpose: The purpose of this protocol is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Prevention: Skin Care 1. Keep the skin clean and hydrated. 2. Clean promptly after episodes of incontinence. 3. Avoid alkaline soaps and cleansers. 4. Use a barrier product to protect skin from moisture. 5. Use incontinence products with high absorbency. 6. Do not rub or otherwise cause friction on skin that is at risk of pressure injuries. 7. Use facility-approved protective dressings for at risk individuals. Nutrition 1. Conduct nutritional screenings for residents at risk. 2. Conduct a comprehensive nutritional assessment for any res[TRUNCATED]

41653 41871 41944 Based on observation, interview, and record review the facility failed to have enough qualified staff to provide adequate care for residents with mental and psychosocial disorders for 13 of 13 residents (Resident #6, Resident #9, Resident #15, Resident #36, Resident #38, Resident #40, Resident #43, Resident #53, Resident #57, Resident #74, Resident #83, Resident #88, and Resident #199) reviewed for staffing behavioral health needs. 1. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #43, Resident #53 and Resident #74 to prevent a resident-to-resident physical altercation that led to injuries that required treatment of Resident #43 and Resident #53 on 12/03/22. 2. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #40 and Resident #53 to prevent a resident-to-resident physical altercation that led to an injury that required treatment of Resident #40 on 12/21/22. 3. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #9 and Resident #53 to prevent a resident-to-resident physical altercation that led that required treatment to an injury of Resident #9 on 12/21/22. 4. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #6 and Resident #40 to prevent a resident-to-resident physical altercation that led to an injury that required medical treatment of Resident #40 on 01/01/23. 5. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residentson Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #40, Resident #53 and Resident #74 to prevent a resident-to-resident physical altercation that led to an injury that required treatment of Resident #53 on 01/26/23. 6. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 2 (men secured locked unit) to meet the needs of Resident #57 and Resident #83 to prevent a resident-to-resident physical altercation that led to an injury that required treatment of Resident #57 on 01/06/23. 7. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 2 (men secured locked unit) to meet the needs of Resident #57 and Resident #88 to prevent a resident-to-resident physical altercation that led to an injury that required treatment of Resident #57 on 02/04/23. 8. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 2 (men secured locked unit) to meet the needs of Resident #38 and Resident #199 to prevent a resident-to-resident physical altercation that led that required treatment to an injury of Resident #38 on 01/22/23. 9. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #15 and Resident #53 to prevent a resident-to-resident physical altercation on 11/26/22. 10. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #36 and Resident #40 to prevent a resident-to-resident physical altercation on 12/04/22. 11. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #40 and Resident #74 to prevent a resident-to-resident physical altercation on 12/06/22. 12. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station /Hall 6 (women secured locked unit) to meet the needs of Resident #6 and Resident #53 to prevent a resident-to-resident physical altercation on 12/20/22. 13. The facility failed to ensure there was sufficient staffingwith necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on . on Hall 200/Unit 2 (women secured locked unit) to meet the needs of Resident #6 to prevent her from eating Styrofoam during lunch on 02/18/23. Resident #6 had a history of ingesting inedible objects. An IJ was identified on 02/22/2023. The IJ template was provided to the facility on [DATE] at 4:56pm While the IJ was removed on 02/24/2023, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy because the facility needed to continue to evaluate the effectiveness of their corrective actions. These failures could place residents at risk for being provided care by staff who are not trained to care for resident with identified behavioral issues. Findings include: Record review of Facility assessment dated [DATE], Part 3, titled Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies revealed: Staff: Licensed nurses: Station 2 (Station 2 has 6 halls): LVN/RN Days: 2 and Nights: 2 (12hour shifts). Direct Care Staff/CNAs: Station 2: Days 6, Nights 4 (12-hour shifts). Station 2 Hall 6 (Women's Secured Unit) In an observation on 02/14/23 at 11:00 am, Station 2 Hall 6 had 6 residents with known behaviors including 1 resident who required 1:1 supervision. One CNA was observed on the hall. Station 2 Hall 1 (Men's Secured Unit) In an observation on 02/14/23 at 11:47 am, Station 2 Hall 1 had 14 residents with known behaviors. 1 agency CNA, ADON, and LVN-T were observed on the hall. In an interview on 02/14/23 at 11:00 am, CNA-E said she worked 6am to 6pm and worked 12 hours by herself on the women's secured unit, with 1 resident requiring 1:1 supervision. A staff member would come in every 2 hours to check on her. She said she did not feel safe working alone and was unable to prevent resident to resident altercations. CNA-E stated she had received training in the past for Alzheimer's/dementia but not for residents with aggressive behaviors. In an interview on 02/14/23 at 11:47 am, LVN-T said the facility usually had 2 staff on the men's secured unit and 1 staff on the women's secured unit during the day shift. She floated between the 2 units but spent the majority of her time on the men's unit as that was where her desk as. She said 1 staff on the women's secured unit as not enough to protect the residents. She said staff was cut back from 2 staff to 1 staff on the women's unit about a month ago. Resident #53 Record review of Resident #53's electronic face sheet, dated 02/23/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. She was being housed on the women's secured unit (the average age of the residents was [AGE] years). Diagnosis included: anoxic brain damage; diffuse traumatic brain injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness; epilepsy and epileptic syndromes with seizures of localized onset; restlessness and agitation; post-traumatic stress disorder; repeated falls; muscle weakness (generalized); insomnia due to other mental disorder; major depressive disorder; anxiety disorder; dysphagia (difficulty in swallowing), altered mental status; pain; adult sexual abuse. Record review of Resident #53's Quarterly MDS, dated [DATE], revealed the BIMS score was blank. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. None of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavior symptoms directed towards others - behavior of this type occurred 1 to 3 days, B. Verbal behaviors symptoms directed towards others - behavior not exhibited, C. Other behavioral symptoms not directed towards others - behavior of this type occurred 1 to 3 days. E0900: Wandering - 1 (Behavior of this type occurred 1 to 3 days). Section G: Functional Status. G0110. Activities of Daily Living Assistance: H. Eating: 3 (extensive assistance). G0120 Bathing: Self-Performance: 4 (Total dependence) G0300: Balance during transitions and walking: A. Moving from seated to standing position - 1 (not steady, but able to stabilize without human assistance). B. Walking (with assistive device is used) - 1 (Not steady, but able to stabilize without human assistance). Section P0100: Physical Restraints: Not used. Record review of Resident #53's Care Plan, last edited on 02/13/23 revealed: Problem: I have periods of time where I am in constant motion/movement. Problem: I get frustrated because of my physical condition and may reach out to grab or hit others. Goal. To not hit other residents. Approach. Patient placed on 1:1 observation for at least 72 hours to prevent injury to others, will keep her separated from arms reach from other residents, put gloves on resident to prevent any injury if she reaches out. Problem: I have anxiety related to anoxic brain injury as evidence by I fidget constantly, grab at others, lick my hands and rub it on things and people, sit to stand frequently, stand up rapidly and attempt to walk with no regards to surroundings. Problem: Behavioral Symptoms - licking her hands and trying to touch others, invading others space, grabbing at others, sitting and or lying-in other residents' beds when they are not in them. Goal. Resident will have less than 5 bad outcomes due to grabbing at people and toward staff or other residents over the next 90 days. Approach: 15-minute checks, I will have increased supervision due to my behavior or grabbing at things and swinging my arms, I rest better with a quiet calm environment at night, Problem: Falls. Approach. Ordered an oversize bean bag for positioning. Record review of Resident #53's transfer documentation packet, faxed on 04/19/2023 from previous facility revealed: resident required a locked facility that has more supervision and brain training support. On 04/21/22, Resident #53 was transferred from a sister facility requiring 1:1 supervision due to being threat to herself and others. Record review of Nurse Practitioner progress note, dated 06/10/22, revealed Resident #53 was transferred from other facility due to not being able to continually provide the 1:1 care and attention that she requires. Record review of Social Worker progress note, dated 09/12/22 at 5:27 pm, revealed: SW expressed to Family Member J, facility is not able to meet resident needs and SW will need to talk with Family Member J regarding plans to transition resident to another facility. Record review of Social Worker progress note, dated 10/01/22 at 10:33 am, revealed: SW expressed to Family Member J, facility is not able to meet resident needs. 1. Review of facility investigation on 12/03/22 at 3:53 pm, Resident #53 slapped the face of Resident #43, and Resident #74 retaliated. A record review of the Provider Investigation Report revealed Resident #43 was sitting in the recliner minding her own business and for no reason Resident #53 slapped Resident #43 in the face. This in turn upset Resident #74 who scratched Resident #53 on the arm. Resident #42 had slight redness noted to the left side of her face. Resident #53 had several scratch marks to her upper right arm. Resident #53 was placed on increased supervision with staff. Record review of Resident #53's progress note dated 12/03/22 at 4:39 am, revealed Resident #53 had multiple behaviors throughout the evening and night. Grabbing at residents. Attempting to remove snacks from other residents. Walking on knees and crawling on the floor. Attempting to hit and kick staff during care. Removing clothes and brief and walking down hall. Walks to exit door of secured unit 1 and slaps and then tries to open locked door. No documentation resident was on 1:1 supervision. Record review of Resident #53's progress note dated 12/03/22 at 3:53 pm, revealed Resident #53 hit another resident across the face. (Resident was not identified.) Record review of Resident #53's progress note dated 12/03/22 at 5:46pm, revealed another resident was yelling get away, get away. Resident #53 hit another resident in the face and the other resident scratched at Resident #53's upper arm. Residents were separated. Resident #53 then went toward another resident and attempted to hit her, but the LVN intervened. (Other residents were not identified.) Record review of Resident #53's progress note dated 12/03/22 at 6:05 pm, revealed Resident #53 was on 1:1 supervision. Record review of Resident #53's progress note dated 12/03/22 at 6:43pm, LVN-T documented in Resident #53's progress notes per DON, resident to be 1:1. If no staff available to be 1:1 then resident can be on Q (every) 15-minute checks. Record Review of Resident #53's progress note dated 12/03/22 at 10:15 pm, revealed Resident #53 was on 15-minute checks. During an interview on 02/17/23 at 9:45 am, the Interim Administrator stated she could not provide documentation of who or how may staff were working on the women's secured unit at that time of the incident or documentation of 15-minute checks. 2. Review of facility investigation on 12/21/22 at 11:25 am, Resident #53 scratched Resident #9 on the forehead. A record review of the Provider Investigation Report revealed, Resident #9 was sitting in a chair when Resident #53 approached her and brushed Resident #9 on her forehead, causing a small 2cm X 1cm scratch. The facility stated Resident #53 did not intend to hurt Resident #9 as both residents were acting per their norm. Record review of Resident #53's progress note, dated 12/21/22 at 5:35 am, revealed resident #53 had multiple behaviors throughout the shift, including crawling on the floor, pulling and trying to remove the keypad cover, attempting to open doors, removing pants and brief and walking naked in the hallway, pulling a sign off the door, grabbing at residents and attempting to take their snacks, refusing evening medications, and attempting to climb in bed with another resident. Resident received Diazepam 15mg and it was documented it was not effective. Record review of Resident #53's progress notes, dated 12/21/22 at 12:09 pm, revealed Resident #53 scratched another resident in the face. Resident also attempted to grab and hit the nurse. 3. Review of facility investigation on 12/21/22 at 1:52 pm, Resident #53 reached out her arm causing a skin tear to Resident #9. A record review of the Provider Investigation Report revealed, Resident #53 was ambulating in the hallway and reached out grabbing Resident #9's arm causing a small 1cm X 2cm skin tear to her forearm. The facility stated it is normal for Resident #53 to reach out and grab objects and people within reach. Record review of progress notes, dated 12/21/22 at 9:40 pm, revealed Resident #53 was non-stop agitated and should have been on 1:1 observation. Resident #53 scratched and pulled the hair of the LVN on duty. Upon discussion with the ADON, Resident #53 was to be monitored until further notice. Record review of progress notes revealed no documentation of resident being placed on 1:1 observation. 5. Review of facility investigation on 01/26/23 at 7:00 pm, Resident #53 made contact with Resident #40's face and Resident #74 retaliated. A record review of the Provider Investigation Report revealed, Resident #40 walked to close to Resident #53 who flailed her hands making contact with Resident #40's face. Resident #74 intervened and scratched Resident #53 on her elbow. The scratch was visible. Resident #53 was placed on 1:1 observation until she went to sleep. Record review of Resident #53's progress note dated 01/26/23 at 7:00 pm revealed, an unknown resident was sitting in a chair watching TV when Resident #53 walked past the unknown resident and hit her on the jaw with a closed fist. Record review of Resident #53's progress note dated 01/26/23 at 7:10 pm revealed, Resident #53 walked past resident #40 and attempted to slap her. Resident #74 grabbed Resident #53's right elbow causing a 1.5cm X 0.5cm superficial scratch. Resident #53 was already currently on 1:1 monitoring. 9. Review of facility investigation on 11/26/22 at 4:00 pm, Resident #53 pulled the hair of Resident #15 and Resident #74 retaliated. A record review of the Provider Investigation Report revealed, Resident #74 was in the hallway when Resident #53 attempted to hit her, Resident #74 hit Resident #53 on the arm. Resident #15 was sitting at the dining room table and Resident #53 came up and pulled Resident #15's hair. Resident #53 was placed on 15-minute checks. Record review of Resident #53's progress note dated 11/26/22 at 3:50 pm, revealed Resident #53 was walking in the dining room and pulled Resident #15's hair. Resident #74 hit Resident #53 on the right arm after she pull Resident #15's hair. No documentation that Resident #53 was placed on 15-minute checks. 12. Review of facility investigation on 12/20/22 at 1:15 pm, Resident #53 reached out towards Resident #6 and Resident #6 reached out toward #53 swiping her in the face. A record review of the Provider Investigation Report revealed, Resident #53 unknowingly/unintentionally reached out (per her norm) toward Resident #6 brushing her face, in return Resident #6 swatted at Resident #53 in reaction and was instructed to not do that anymore. No injury noted. Record review of Resident #53's progress note dated 12/20/22 at 3:07 pm, revealed Resident #53 was in the dining room reaching out towards Resident #6. Resident #6 slapped Resident #53 in the face on the right cheek. No injury. Residents were separated. Resident #6 Record review of Resident #6's electronic face sheet accessed on 02/14/22 revealed an [AGE] year-old female whose most recent admitted was 12/20/21 to the female secured locked unit with diagnosis to include: Alzheimer's Disease, macular degeneration (deterioration of the retina of the eye that causes vision loss), and hypertension (high blood pressure). Record review of Resident #6's Quarterly MDS, dated [DATE], revealed a BIMS score interview was 00 which indicated severe cognitive impairment. Further review of MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. Other behavioral symptoms not directed toward others - behavior not exhibited. E0800 Rejection of care - behavior did not occur, E0900 Wandering - behavior occurred 1-3 days. Section G: Functional Status: G0110. Activities of Daily Living Assistance: H. Eating:1. Self-Performance - Supervision. 2. Support: set up help only. Record review of Resident's #6's Care Plan dated 11/02/22 revealed the following problems and approaches: At risk for elopement - (problem start date 01/12/23) Requires secure unit placement. Attempted to take out of the secure unit. She started to wander aimlessly throughout all halls and rooms placing her at risk for other residents becoming aggressive towards her. Goal: Resident will be safe throughout her surroundings for 90 days. Approaches: Secure unit placement evaluation quarterly and prn. Elopement assessment quarterly and prn, Problem: (start date 01/05/23) Resident has physically abusive behavioral symptoms. Resident was hit by another resident and in return hit the other resident several times in defense. Goal resident will not harm self or others secondary to physically abusive behavior. Approach: avoid over stimulation, noise, crowding, and other physically aggressive residents), Avoid power struggles with resident, divert resident's behavior by encouraging resident to move to another common area away from distraction and other potentially aggressive residents who might provoke an unwanted response from resident #6 such as aggression, maintain a calm environment and approach, Problem: (start date 12/16/2019) I have impaired vision related to macular degeneration. Goal: I will not have accidents as a result of eye disease. Approaches: Assist as needed with ADL's and toileting Problem: At risk for falls, Goal: I will be free of falls Approaches included: increase staff supervision with intensity based on resident needs. 13. In an observation and interview on 02/18/23 at 12:43 pm during lunch on the Women's Secured Unit, the Assistant Administrator in Training was assisting Resident #53, she was attempting to spoon feed her, while the resident was constantly standing up and down, attempting to leave the table, and grabbing at her and other residents. The Director of Rehab was watching the rest of the residents, attempting to assist Resident #6 who was eating Styrofoam. Resident #40 was attempting to eat a piece of uncut chicken fried steak with the plastic fork sticking through the middle of it. There was no nurse present in the dining room during this time. The Director of Rehab attempted to get the Styrofoam from Resident #6 but never succeeded. The Assistant Administrator in Training and DOR said Resident #40 was supposed to eat finger foods due to the resident not allowing them to assist her with eating. A record review of Resident #6's Get to Know Me information, not dated, prepared by the Social Worker, revealed For all meals take everything off her tray; just leave the plate and just a spoon - if not, she will hoard everything in sight and chew on napkin and plastics. Resident #40 Record review of Resident #40's electronic face sheet accessed on 02/14/22 revealed a [AGE] year-old female whose most recent admitted was 01/06/23 to the female secured locked unit with diagnosis to include: fractured left hip, osteoporosis (disease of bone that makes them brittle), history of falling, Alzheimer's Disease, and major depressive disorder. Record review of Resident #40's Annual MDS dated , dated 01/11/23, revealed a BIMS score interview was 00 which indicated severe cognitive impairment. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. other behavioral symptoms not directed toward others - behavior not exhibited. Section E 0800 Rejection of care: behavior did not occur. Section E 0900 Wandering - behavior did not occur. Section G: Functional Status: G0110. Activities of Daily Living Assistance: H. Eating:1. Self-Performance. 2. Self-performance - Set up help only. Section K: Swallowing/Nutrition Status: K0100. Swallowing Disorder: Z. none of the above. Record review of resident #40's Care Plan revealed the following problems and approaches: Problem: Mood state - start date 01/06/23 resident exhibits socially inappropriately disruptive behavioral symptoms. Resident wanders about without direction and becomes physically aggressive (hitting, kicking etc.) when she gets near other residents or staff in her path as well as being hit by resident's she provokes with her unwanted behavior. Goal: Resident will not harm self or others secondary to socially inappropriate, disruptive behavior of opportunistically hitting or kicking residents who get in her pathway or reach while she wanders. Approach: Assess whether the behavior endangers the resident or others. Intervene, if necessary, by moving resident to a safe area, to wander, avoid over stimulation (noise, crowding and other physically aggressive residents, when resident begins to reach for, hit, kick, or grab others, provide for basic needs pain, hunger toileting, too hot/cold etc. Problem: behavioral symptoms: (start date 09/09/22) I pace up and down the halls frequently with no regards to others in my path. 08/01/22 I walked up behind another resident and got hit in the stomach. 08/17/22 I pushed another resident in the hallway while I was pacing up and down the hall. 08/26/22 I hit another resident in the face while walking in the hallway. 12/04/22 Hit by another resident. Goal: I will have less than 3 episodes of physical aggression with other people in my path over the next 90 days. Approaches: I will be redirected to least crowded areas when pacing. I will have increased monitoring and a referral to a behavioral center. 4. Review of facility investigation on 01/01/23 at 4:50 pm, Resident #40 hit Resident #6, and Resident #6 hit Resident #40 back. A record review of the Provider Investigation Report revealed, Resident #40 approached Resident #6's wheelchair and bumped the wheelchair with her foot making contact with the back of Resident #6's head. Resident #6 turned around in reaction and made contact with Resident #40's face. No injury noted per report. Record review of Resident #40's progress notes, dated 01/01/23 at 6:32pm, revealed Resident #40 kicked another resident's wheelchair and tapped her lightly on the head. That resident turned around and hit Resident #40 on the left eye and on her back several times. Resident #40 had redness under her left eye and redness to her upper back. 11. Review of facility investigation on 12/06/22, Resident #40 kicked Resident #74 and Resident #74 retaliated hitting Resident #40's back. A record review of the Provider Investigation Report revealed, Resident #74 was unintentionally kicked in the leg by Resident #40. Resident #74 then hit Resident #40 in the right shoulder. No injury reported. Record review of Resident #40's progress notes dated 12/06/22 at 5:40 pm, revealed Resident #40 kicked Resident #74 in the right leg. Resident #74 hit Resident #40 in the back. No injury reported. Resident #43 Record review of Resident #43's face sheet in the electronic medical record, accessed on 02/14/22 revealed a [AGE] year-old female whose most recent admitted was 10/14/22 to the female secured locked unit with diagnosis to include: Alzheimer's Disease, schizoaffective Disorder (a mental health condition), and hypertension (high blood pressure). Record review of Resident #43's Significant Change in Status MDS dated [DATE], revealed her BIMS score interview was 00 which indicated severe cognitive impairment. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. other behavioral symptoms not directed toward others - behavior not exhibited. Section E0800 Rejection of care: behavior did not occur. Section E0900 Wandering - behavior did not occur. Section G: Functional Status: G0110. Activities of Daily Living Assistance: H. Eating:1. Self-Performance - set up help. 2. Support: 1-person physical assist. Section K: Swallowing/Nutrition Status: K0100. Swallowing Disorder: Z. none of the above. Record review of Resident #43's Care Plan revealed the following problems and approaches: Problem: (start date 08/23/21) I have a history of aimless wandering increasing safety concerns. 12/03/22 Behavior from another resident. Goal: I will have less than 2 episodes of wandering into others space over the next 90 days. Approaches: I will be redirected if I walk up to someone and invade their personal space, I will be redirected as needed when wandering to prevent me from going into an unsafe area, I will reside in the secured unit. Problem Start Date: 08/10/2021 Category: Falls. I am at risk for falls related to unsteadiness. Approaches: I will be encouraged to wear footwear that fit properly and have non-skid soles. I will be redirected from areas I don't need to be in. Problem: for elopement- (start date 01/11/23). Goal - Resident will not wander out of designated secure area over the next 90 days. Approach: Secure Unit Placement. Secure unit evaluation quarterly and PRN, elopement assessment quarterly and PRN Risk related to Alzheimer's /dementia. Resident #74 Record review of Resident #74's Face Sheet document in the electronic medical record accessed on 02/14/22 revealed an [AGE] year-old female whose most recent admitted was 01/06/23 to the female secured locked unit with diagnosis to include: dementia with behavioral disturbance, major depressive disorder, and delusional disorder. Record review of Resident #74's Annual MDS dated [DATE], revealed a BIMS score interview was 00 which indicated severe cognitive impairment. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. other behavioral symptoms not directed toward others - behavior not exhibited. Section E0800 Rejection of care: behavior did not occur. Section E0900 Wandering -behavior did not occur. Section G: Functional Status: G0110. Activities of Daily Living Assistance: H. Eating:1. Self-Performance - supervision. 2. Support: set up help only. Section K: Swallowing/Nutrition Status: K0100. Swallowing Disorder: Z. none of the above. Record review of Resident #74's Care Plan revealed the following problems and approaches: Problem: At risk for elopement - (start date 01/11/23). Goal: Resident will be kept safe in surroundings. Approaches: continuous placement in secure unit, elopement assessment quarterly and nail care weekly. Problem: Behavioral symptoms - resident exhibits verbal and physical aggression when other residents invade her space and surroundings. Goal: Resident will not show behaviors of aggression. Approaches: Remove and provide a quiet place, staff will encourage rapport with other residents, staff will encourage redirection when resident exhibiting bouts of verbal/ physical aggression, I will have increased supervision until reviewed by psych services., I will be assisted to a quiet place when things become too loud for me, Keep environment calm and relaxed. Resident #9 Record review of Resident #9's Annual Assessment MDS, dated [DATE], revealed Resident #9 was admitted to the facility on [DATE]. Diagnosis include dementia [TRUNCATED]

Based on observation, interview, and record review the facility failed to have enough qualified staff to provide adequate care for residents with mental and psychosocial disorders for 13 of 13 residents (Resident #6, Resident #9, Resident #15, Resident #36, Resident #38, Resident #40, Resident #43, Resident #53, Resident #57, Resident #74, Resident #83, Resident #88, and Resident #199) reviewed for staffing behavioral health needs. 1. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #43, Resident #53 and Resident #74 to prevent a resident-to-resident physical altercation that led to injuries that required treatment of Resident #43 and Resident #53 on 12/03/22. 2. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #40 and Resident #53 to prevent a resident-to-resident physical altercation that led to an injury that required treatment of Resident #40 on 12/21/22. 3. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #9 and Resident #53 to prevent a resident-to-resident physical altercation that led that required treatment to an injury of Resident #9 on 12/21/22. 4. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #6 and Resident #40 to prevent a resident-to-resident physical altercation that led to an injury that required medical treatment of Resident #40 on 01/01/23. 5. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residentson Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #40, Resident #53 and Resident #74 to prevent a resident-to-resident physical altercation that led to an injury that required treatment of Resident #53 on 01/26/23. 6. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 2 (men secured locked unit) to meet the needs of Resident #57 and Resident #83 to prevent a resident-to-resident physical altercation that led to an injury that required treatment of Resident #57 on 01/06/23. 7. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 2 (men secured locked unit) to meet the needs of Resident #57 and Resident #88 to prevent a resident-to-resident physical altercation that led to an injury that required treatment of Resident #57 on 02/04/23. 8. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 2 (men secured locked unit) to meet the needs of Resident #38 and Resident #199 to prevent a resident-to-resident physical altercation that led that required treatment to an injury of Resident #38 on 01/22/23. 9. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #15 and Resident #53 to prevent a resident-to-resident physical altercation on 11/26/22. 10. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #36 and Resident #40 to prevent a resident-to-resident physical altercation on 12/04/22. 11. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #40 and Resident #74 to prevent a resident-to-resident physical altercation on 12/06/22. 12. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station /Hall 6 (women secured locked unit) to meet the needs of Resident #6 and Resident #53 to prevent a resident-to-resident physical altercation on 12/20/22. 13. The facility failed to ensure there was sufficient staffingwith necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on . on Hall 200/Unit 2 (women secured locked unit) to meet the needs of Resident #6 to prevent her from eating Styrofoam during lunch on 02/18/23. Resident #6 had a history of ingesting inedible objects. An IJ was identified on 02/22/2023. The IJ template was provided to the facility on [DATE] at 4:56pm While the IJ was removed on 02/24/2023, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy because the facility needed to continue to evaluate the effectiveness of their corrective actions. These failures could place residents at risk for being provided care by staff who are not trained to care for resident with identified behavioral issues. Findings include: Record review of Facility assessment dated [DATE], Part 3, titled Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies revealed: Staff: Licensed nurses: Station 2 (Station 2 has 6 halls): LVN/RN Days: 2 and Nights: 2 (12hour shifts). Direct Care Staff/CNAs: Station 2: Days 6, Nights 4 (12-hour shifts). Station 2 Hall 6 (Women's Secured Unit) In an observation on 02/14/23 at 11:00 am, Station 2 Hall 6 had 6 residents with known behaviors including 1 resident who required 1:1 supervision. One CNA was observed on the hall. Station 2 Hall 1 (Men's Secured Unit) In an observation on 02/14/23 at 11:47 am, Station 2 Hall 1 had 14 residents with known behaviors. 1 agency CNA, ADON, and LVN-T were observed on the hall. In an interview on 02/14/23 at 11:00 am, CNA-E said she worked 6am to 6pm and worked 12 hours by herself on the women's secured unit, with 1 resident requiring 1:1 supervision. A staff member would come in every 2 hours to check on her. She said she did not feel safe working alone and was unable to prevent resident to resident altercations. CNA-E stated she had received training in the past for Alzheimer's/dementia but not for residents with aggressive behaviors. In an interview on 02/14/23 at 11:47 am, LVN-T said the facility usually had 2 staff on the men's secured unit and 1 staff on the women's secured unit during the day shift. She floated between the 2 units but spent the majority of her time on the men's unit as that was where her desk as. She said 1 staff on the women's secured unit as not enough to protect the residents. She said staff was cut back from 2 staff to 1 staff on the women's unit about a month ago. Resident #53 Record review of Resident #53's electronic face sheet, dated 02/23/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. She was being housed on the women's secured unit (the average age of the residents was 76 years). Diagnosis included: anoxic brain damage; diffuse traumatic brain injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness; epilepsy and epileptic syndromes with seizures of localized onset; restlessness and agitation; post-traumatic stress disorder; repeated falls; muscle weakness (generalized); insomnia due to other mental disorder; major depressive disorder; anxiety disorder; dysphagia (difficulty in swallowing), altered mental status; pain; adult sexual abuse. Record review of Resident #53's Quarterly MDS, dated [DATE], revealed the BIMS score was blank. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. None of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavior symptoms directed towards others - behavior of this type occurred 1 to 3 days, B. Verbal behaviors symptoms directed towards others - behavior not exhibited, C. Other behavioral symptoms not directed towards others - behavior of this type occurred 1 to 3 days. E0900: Wandering - 1 (Behavior of this type occurred 1 to 3 days). Section G: Functional Status. G0110. Activities of Daily Living Assistance: H. Eating: 3 (extensive assistance). G0120 Bathing: Self-Performance: 4 (Total dependence) G0300: Balance during transitions and walking: A. Moving from seated to standing position - 1 (not steady, but able to stabilize without human assistance). B. Walking (with assistive device is used) - 1 (Not steady, but able to stabilize without human assistance). Section P0100: Physical Restraints: Not used. Record review of Resident #53's Care Plan, last edited on 02/13/23 revealed: Problem: I have periods of time where I am in constant motion/movement. Problem: I get frustrated because of my physical condition and may reach out to grab or hit others. Goal. To not hit other residents. Approach. Patient placed on 1:1 observation for at least 72 hours to prevent injury to others, will keep her separated from arms reach from other residents, put gloves on resident to prevent any injury if she reaches out. Problem: I have anxiety related to anoxic brain injury as evidence by I fidget constantly, grab at others, lick my hands and rub it on things and people, sit to stand frequently, stand up rapidly and attempt to walk with no regards to surroundings. Problem: Behavioral Symptoms - licking her hands and trying to touch others, invading others space, grabbing at others, sitting and or lying-in other residents' beds when they are not in them. Goal. Resident will have less than 5 bad outcomes due to grabbing at people and toward staff or other residents over the next 90 days. Approach: 15-minute checks, I will have increased supervision due to my behavior or grabbing at things and swinging my arms, I rest better with a quiet calm environment at night, Problem: Falls. Approach. Ordered an oversize bean bag for positioning. Record review of Resident #53's transfer documentation packet, faxed on 04/19/2023 from previous facility revealed: resident required a locked facility that has more supervision and brain training support. On 04/21/22, Resident #53 was transferred from a sister facility requiring 1:1 supervision due to being threat to herself and others. Record review of Nurse Practitioner progress note, dated 06/10/22, revealed Resident #53 was transferred from other facility due to not being able to continually provide the 1:1 care and attention that she requires. Record review of Social Worker progress note, dated 09/12/22 at 5:27 pm, revealed: SW expressed to Family Member J, facility is not able to meet resident needs and SW will need to talk with Family Member J regarding plans to transition resident to another facility. Record review of Social Worker progress note, dated 10/01/22 at 10:33 am, revealed: SW expressed to Family Member J, facility is not able to meet resident needs. 1. Review of facility investigation on 12/03/22 at 3:53 pm, Resident #53 slapped the face of Resident #43, and Resident #74 retaliated. A record review of the Provider Investigation Report revealed Resident #43 was sitting in the recliner minding her own business and for no reason Resident #53 slapped Resident #43 in the face. This in turn upset Resident #74 who scratched Resident #53 on the arm. Resident #42 had slight redness noted to the left side of her face. Resident #53 had several scratch marks to her upper right arm. Resident #53 was placed on increased supervision with staff. Record review of Resident #53's progress note dated 12/03/22 at 4:39 am, revealed Resident #53 had multiple behaviors throughout the evening and night. Grabbing at residents. Attempting to remove snacks from other residents. Walking on knees and crawling on the floor. Attempting to hit and kick staff during care. Removing clothes and brief and walking down hall. Walks to exit door of secured unit 1 and slaps and then tries to open locked door. No documentation resident was on 1:1 supervision. Record review of Resident #53's progress note dated 12/03/22 at 3:53 pm, revealed Resident #53 hit another resident across the face. (Resident was not identified.) Record review of Resident #53's progress note dated 12/03/22 at 5:46pm, revealed another resident was yelling get away, get away. Resident #53 hit another resident in the face and the other resident scratched at Resident #53's upper arm. Residents were separated. Resident #53 then went toward another resident and attempted to hit her, but the LVN intervened. (Other residents were not identified.) Record review of Resident #53's progress note dated 12/03/22 at 6:05 pm, revealed Resident #53 was on 1:1 supervision. Record review of Resident #53's progress note dated 12/03/22 at 6:43pm, LVN-T documented in Resident #53's progress notes per DON, resident to be 1:1. If no staff available to be 1:1 then resident can be on Q (every) 15-minute checks. Record Review of Resident #53's progress note dated 12/03/22 at 10:15 pm, revealed Resident #53 was on 15-minute checks. During an interview on 02/17/23 at 9:45 am, the Interim Administrator stated she could not provide documentation of who or how may staff were working on the women's secured unit at that time of the incident or documentation of 15-minute checks. 2. Review of facility investigation on 12/21/22 at 11:25 am, Resident #53 scratched Resident #9 on the forehead. A record review of the Provider Investigation Report revealed, Resident #9 was sitting in a chair when Resident #53 approached her and brushed Resident #9 on her forehead, causing a small 2cm X 1cm scratch. The facility stated Resident #53 did not intend to hurt Resident #9 as both residents were acting per their norm. Record review of Resident #53's progress note, dated 12/21/22 at 5:35 am, revealed resident #53 had multiple behaviors throughout the shift, including crawling on the floor, pulling and trying to remove the keypad cover, attempting to open doors, removing pants and brief and walking naked in the hallway, pulling a sign off the door, grabbing at residents and attempting to take their snacks, refusing evening medications, and attempting to climb in bed with another resident. Resident received Diazepam 15mg and it was documented it was not effective. Record review of Resident #53's progress notes, dated 12/21/22 at 12:09 pm, revealed Resident #53 scratched another resident in the face. Resident also attempted to grab and hit the nurse. 3. Review of facility investigation on 12/21/22 at 1:52 pm, Resident #53 reached out her arm causing a skin tear to Resident #9. A record review of the Provider Investigation Report revealed, Resident #53 was ambulating in the hallway and reached out grabbing Resident #9's arm causing a small 1cm X 2cm skin tear to her forearm. The facility stated it is normal for Resident #53 to reach out and grab objects and people within reach. Record review of progress notes, dated 12/21/22 at 9:40 pm, revealed Resident #53 was non-stop agitated and should have been on 1:1 observation. Resident #53 scratched and pulled the hair of the LVN on duty. Upon discussion with the ADON, Resident #53 was to be monitored until further notice. Record review of progress notes revealed no documentation of resident being placed on 1:1 observation. 5. Review of facility investigation on 01/26/23 at 7:00 pm, Resident #53 made contact with Resident #40's face and Resident #74 retaliated. A record review of the Provider Investigation Report revealed, Resident #40 walked to close to Resident #53 who flailed her hands making contact with Resident #40's face. Resident #74 intervened and scratched Resident #53 on her elbow. The scratch was visible. Resident #53 was placed on 1:1 observation until she went to sleep. Record review of Resident #53's progress note dated 01/26/23 at 7:00 pm revealed, an unknown resident was sitting in a chair watching TV when Resident #53 walked past the unknown resident and hit her on the jaw with a closed fist. Record review of Resident #53's progress note dated 01/26/23 at 7:10 pm revealed, Resident #53 walked past resident #40 and attempted to slap her. Resident #74 grabbed Resident #53's right elbow causing a 1.5cm X 0.5cm superficial scratch. Resident #53 was already currently on 1:1 monitoring. 9. Review of facility investigation on 11/26/22 at 4:00 pm, Resident #53 pulled the hair of Resident #15 and Resident #74 retaliated. A record review of the Provider Investigation Report revealed, Resident #74 was in the hallway when Resident #53 attempted to hit her, Resident #74 hit Resident #53 on the arm. Resident #15 was sitting at the dining room table and Resident #53 came up and pulled Resident #15's hair. Resident #53 was placed on 15-minute checks. Record review of Resident #53's progress note dated 11/26/22 at 3:50 pm, revealed Resident #53 was walking in the dining room and pulled Resident #15's hair. Resident #74 hit Resident #53 on the right arm after she pull Resident #15's hair. No documentation that Resident #53 was placed on 15-minute checks. 12. Review of facility investigation on 12/20/22 at 1:15 pm, Resident #53 reached out towards Resident #6 and Resident #6 reached out toward #53 swiping her in the face. A record review of the Provider Investigation Report revealed, Resident #53 unknowingly/unintentionally reached out (per her norm) toward Resident #6 brushing her face, in return Resident #6 swatted at Resident #53 in reaction and was instructed to not do that anymore. No injury noted. Record review of Resident #53's progress note dated 12/20/22 at 3:07 pm, revealed Resident #53 was in the dining room reaching out towards Resident #6. Resident #6 slapped Resident #53 in the face on the right cheek. No injury. Residents were separated. Resident #6 Record review of Resident #6's electronic face sheet accessed on 02/14/22 revealed an [AGE] year-old female whose most recent admission date was 12/20/21 to the female secured locked unit with diagnosis to include: Alzheimer's Disease, macular degeneration (deterioration of the retina of the eye that causes vision loss), and hypertension (high blood pressure). Record review of Resident #6's Quarterly MDS, dated [DATE], revealed a BIMS score interview was 00 which indicated severe cognitive impairment. Further review of MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. Other behavioral symptoms not directed toward others - behavior not exhibited. E0800 Rejection of care - behavior did not occur, E0900 Wandering - behavior occurred 1-3 days. Section G: Functional Status: G0110. Activities of Daily Living Assistance: H. Eating:1. Self-Performance - Supervision. 2. Support: set up help only. Record review of Resident's #6's Care Plan dated 11/02/22 revealed the following problems and approaches: At risk for elopement - (problem start date 01/12/23) Requires secure unit placement. Attempted to take out of the secure unit. She started to wander aimlessly throughout all halls and rooms placing her at risk for other residents becoming aggressive towards her. Goal: Resident will be safe throughout her surroundings for 90 days. Approaches: Secure unit placement evaluation quarterly and prn. Elopement assessment quarterly and prn, Problem: (start date 01/05/23) Resident has physically abusive behavioral symptoms. Resident was hit by another resident and in return hit the other resident several times in defense. Goal resident will not harm self or others secondary to physically abusive behavior. Approach: avoid over stimulation, noise, crowding, and other physically aggressive residents), Avoid power struggles with resident, divert resident's behavior by encouraging resident to move to another common area away from distraction and other potentially aggressive residents who might provoke an unwanted response from resident #6 such as aggression, maintain a calm environment and approach, Problem: (start date 12/16/2019) I have impaired vision related to macular degeneration. Goal: I will not have accidents as a result of eye disease. Approaches: Assist as needed with ADL's and toileting Problem: At risk for falls, Goal: I will be free of falls Approaches included: increase staff supervision with intensity based on resident needs. 13. In an observation and interview on 02/18/23 at 12:43 pm during lunch on the Women's Secured Unit, the Assistant Administrator in Training was assisting Resident #53, she was attempting to spoon feed her, while the resident was constantly standing up and down, attempting to leave the table, and grabbing at her and other residents. The Director of Rehab was watching the rest of the residents, attempting to assist Resident #6 who was eating Styrofoam. Resident #40 was attempting to eat a piece of uncut chicken fried steak with the plastic fork sticking through the middle of it. There was no nurse present in the dining room during this time. The Director of Rehab attempted to get the Styrofoam from Resident #6 but never succeeded. The Assistant Administrator in Training and DOR said Resident #40 was supposed to eat finger foods due to the resident not allowing them to assist her with eating. A record review of Resident #6's Get to Know Me information, not dated, prepared by the Social Worker, revealed For all meals take everything off her tray; just leave the plate and just a spoon - if not, she will hoard everything in sight and chew on napkin and plastics. Resident #40 Record review of Resident #40's electronic face sheet accessed on 02/14/22 revealed a [AGE] year-old female whose most recent admission date was 01/06/23 to the female secured locked unit with diagnosis to include: fractured left hip, osteoporosis (disease of bone that makes them brittle), history of falling, Alzheimer's Disease, and major depressive disorder. Record review of Resident #40's Annual MDS dated , dated 01/11/23, revealed a BIMS score interview was 00 which indicated severe cognitive impairment. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. other behavioral symptoms not directed toward others - behavior not exhibited. Section E 0800 Rejection of care: behavior did not occur. Section E 0900 Wandering - behavior did not occur. Section G: Functional Status: G0110. Activities of Daily Living Assistance: H. Eating:1. Self-Performance. 2. Self-performance - Set up help only. Section K: Swallowing/Nutrition Status: K0100. Swallowing Disorder: Z. none of the above. Record review of resident #40's Care Plan revealed the following problems and approaches: Problem: Mood state - start date 01/06/23 resident exhibits socially inappropriately disruptive behavioral symptoms. Resident wanders about without direction and becomes physically aggressive (hitting, kicking etc.) when she gets near other residents or staff in her path as well as being hit by resident's she provokes with her unwanted behavior. Goal: Resident will not harm self or others secondary to socially inappropriate, disruptive behavior of opportunistically hitting or kicking residents who get in her pathway or reach while she wanders. Approach: Assess whether the behavior endangers the resident or others. Intervene, if necessary, by moving resident to a safe area, to wander, avoid over stimulation (noise, crowding and other physically aggressive residents, when resident begins to reach for, hit, kick, or grab others, provide for basic needs pain, hunger toileting, too hot/cold etc. Problem: behavioral symptoms: (start date 09/09/22) I pace up and down the halls frequently with no regards to others in my path. 08/01/22 I walked up behind another resident and got hit in the stomach. 08/17/22 I pushed another resident in the hallway while I was pacing up and down the hall. 08/26/22 I hit another resident in the face while walking in the hallway. 12/04/22 Hit by another resident. Goal: I will have less than 3 episodes of physical aggression with other people in my path over the next 90 days. Approaches: I will be redirected to least crowded areas when pacing. I will have increased monitoring and a referral to a behavioral center. 4. Review of facility investigation on 01/01/23 at 4:50 pm, Resident #40 hit Resident #6, and Resident #6 hit Resident #40 back. A record review of the Provider Investigation Report revealed, Resident #40 approached Resident #6's wheelchair and bumped the wheelchair with her foot making contact with the back of Resident #6's head. Resident #6 turned around in reaction and made contact with Resident #40's face. No injury noted per report. Record review of Resident #40's progress notes, dated 01/01/23 at 6:32pm, revealed Resident #40 kicked another resident's wheelchair and tapped her lightly on the head. That resident turned around and hit Resident #40 on the left eye and on her back several times. Resident #40 had redness under her left eye and redness to her upper back. 11. Review of facility investigation on 12/06/22, Resident #40 kicked Resident #74 and Resident #74 retaliated hitting Resident #40's back. A record review of the Provider Investigation Report revealed, Resident #74 was unintentionally kicked in the leg by Resident #40. Resident #74 then hit Resident #40 in the right shoulder. No injury reported. Record review of Resident #40's progress notes dated 12/06/22 at 5:40 pm, revealed Resident #40 kicked Resident #74 in the right leg. Resident #74 hit Resident #40 in the back. No injury reported. Resident #43 Record review of Resident #43's face sheet in the electronic medical record, accessed on 02/14/22 revealed a [AGE] year-old female whose most recent admission date was 10/14/22 to the female secured locked unit with diagnosis to include: Alzheimer's Disease, schizoaffective Disorder (a mental health condition), and hypertension (high blood pressure). Record review of Resident #43's Significant Change in Status MDS dated [DATE], revealed her BIMS score interview was 00 which indicated severe cognitive impairment. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. other behavioral symptoms not directed toward others - behavior not exhibited. Section E0800 Rejection of care: behavior did not occur. Section E0900 Wandering - behavior did not occur. Section G: Functional Status: G0110. Activities of Daily Living Assistance: H. Eating:1. Self-Performance - set up help. 2. Support: 1-person physical assist. Section K: Swallowing/Nutrition Status: K0100. Swallowing Disorder: Z. none of the above. Record review of Resident #43's Care Plan revealed the following problems and approaches: Problem: (start date 08/23/21) I have a history of aimless wandering increasing safety concerns. 12/03/22 Behavior from another resident. Goal: I will have less than 2 episodes of wandering into others space over the next 90 days. Approaches: I will be redirected if I walk up to someone and invade their personal space, I will be redirected as needed when wandering to prevent me from going into an unsafe area, I will reside in the secured unit. Problem Start Date: 08/10/2021 Category: Falls. I am at risk for falls related to unsteadiness. Approaches: I will be encouraged to wear footwear that fit properly and have non-skid soles. I will be redirected from areas I don't need to be in. Problem: for elopement- (start date 01/11/23). Goal - Resident will not wander out of designated secure area over the next 90 days. Approach: Secure Unit Placement. Secure unit evaluation quarterly and PRN, elopement assessment quarterly and PRN Risk related to Alzheimer's /dementia. Resident #74 Record review of Resident #74's Face Sheet document in the electronic medical record accessed on 02/14/22 revealed an [AGE] year-old female whose most recent admission date was 01/06/23 to the female secured locked unit with diagnosis to include: dementia with behavioral disturbance, major depressive disorder, and delusional disorder. Record review of Resident #74's Annual MDS dated [DATE], revealed a BIMS score interview was 00 which indicated severe cognitive impairment. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. other behavioral symptoms not directed toward others - behavior not exhibited. Section E0800 Rejection of care: behavior did not occur. Section E0900 Wandering -behavior did not occur. Section G: Functional Status: G0110. Activities of Daily Living Assistance: H. Eating:1. Self-Performance - supervision. 2. Support: set up help only. Section K: Swallowing/Nutrition Status: K0100. Swallowing Disorder: Z. none of the above. Record review of Resident #74's Care Plan revealed the following problems and approaches: Problem: At risk for elopement - (start date 01/11/23). Goal: Resident will be kept safe in surroundings. Approaches: continuous placement in secure unit, elopement assessment quarterly and nail care weekly. Problem: Behavioral symptoms - resident exhibits verbal and physical aggression when other residents invade her space and surroundings. Goal: Resident will not show behaviors of aggression. Approaches: Remove and provide a quiet place, staff will encourage rapport with other residents, staff will encourage redirection when resident exhibiting bouts of verbal/ physical aggression, I will have increased supervision until reviewed by psych services., I will be assisted to a quiet place when things become too loud for me, Keep environment calm and relaxed. Resident #9 Record review of Resident #9's Annual Assessment MDS, dated [DATE], revealed Resident #9 was admitted to the facility on [DATE]. Diagnosis include [NAME][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 4 of 4 Residents (Resident #1, Resident #79, Resident #53, Resident #57) reviewed for administration quality of care, in that: 1. Resident #1 had an indwelling urinary catheter that had not been drained for 2 days causing backflow of urine due to nursing staff not following physician's orders and the facility's lack fo administrative monitoring an ensuring resient care. The catheter tubing had sediment and puss like substance in tubing. Resident #1 became unresponsive, sent to hospital, initial diagnosis of UTI, and admitted to ICU due to nursing staff neglecting to follow physician's orders. 2. Resident #1 had five facility acquired pressure ulcers that progressed to Stage III and Stage IV due to nursing staff neglecting to follow physician's orders. Facility administrative personnel did not monitor and ensure nursing staff followed physician orders and provided residents care to attain highest practicable well-being. 3. Resident #79 had one Stage III pressure ulcer upon admit that worsened to have osteomyelitis due to nursing staff neglecting to follow physician's orders. The facility's administration did not ensure it's resident skin assessments and wound treatments were completed by nursing staff and monitored by administrative personnel for effectiveness and completeness 4. The facility's administrative personnel did not ensure nursing staff were sufficiently staffed in the women's secured locked hall for resident safety. Station 2 Hall 6 was a women's secured locked hall with six (6) female residents with known behaviors with one (Resident #53) of the six (6) women required 1:1 level of supervision. The facility failed to staff the Hall with more than one trained staff consistently. The staff utilized a gait belt around Resident #53 to redirect, restraint her movement, and prevent altercations from other residents. 5. The facility's administrative personnel did not ensure nursing staff were sufficiently staffed in the men's secured locked hall for resident safety. Station 2 Hall 2 was a men's secured locked hall with fourteen (14) male residents with known behaviors. On 01/06/2023, there was a resident/resident altercation and no staff were located on the hall. An Immediate Jeopardy (IJ) was identified on 02/23/2023. The IJ template was provided to the facility on [DATE] at 10:28am. While the IJ was removed on 02/24/2023, the facility remained out of compliance at a scope of pattern and a severity of actual harm because the facility's need to evaluate the effectiveness of their corrective actions. These failures placed residents at risk of physical and psychological harm due to lack of oversight by facility administration. The findings included: 1. Record review of Resident #1 face sheet revealed a [AGE] year-old female admitted on [DATE] with a most recent admitted [DATE] with the following diagnoses: Unspecified fracture of left shaft/femur, Non ST elevation myocardial infraction (heart attack due to inadequate blood to the heart), gram negative sepsis (bacteria in the blood), neurogenic bladder (deficiency in bladder control due to brain, spinal cord or nerve problem) and urinary tract infection, site not specified (infection in any part of the urinary system). Review of Resident #1's Significant Change in Status MDS dated [DATE] revealed: Section C Cognitive Patterns BIMS Summary Score of 14 indicating no cognitive impairment; Section H Bladder and Bowel indicated indwelling catheter Record review of Resident #1 electronic care plan accessed on 02/20/2022 revealed the following: Problem - Resident #1 has Indwelling Foley Catheter: Goal - Resident will not show signs of urinary infection or urethral trauma. Interventions - Change catheter every per MD order, document urinary output; record the amount, type, color and odor, observe for leakage, keep catheter system a closed system as much as possible, position bag below level of bladder, provide catheter care as scheduled and PRN. Problem- Resident #1 has a urinary tract infection. Goal- resident will not exhibit signs of a urinary tract infection. Interventions- Administer Bactrim DS (antibiotic), encourage fluids, keep perineal area clean and dry and report signs or UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain, difficulty urinating, low back pain/flank pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine and blood in urine. Initiated date of 10/15/2022 and revised date of 01/31/2023. Review of Resident #1 physician orders dated 10/13/2022 to 10/21/2022 revealed -Foley Catheter: Size (10cc) FR (16) Diagnosis: Neurogenic bladder (lack bladder control due to brain, spine, or nerve problems). -May obtain urine sample via Foley Catheter Port as needed when a Urine Analysis is ordered. (If Foley Catheter has been in place greater than 14 days, change Foley Catheter before obtaining urine.) -Provide catheter care every shift. -Change catheter and drainage bag as needed for indications of blockage, increased sediment, infection, displacement as needed. Record review of Resident #1's vital reports revealed no evidence of catheter care, drainage of catheter bag and amount of urine obtained during drainage on 48 occasions between 01/18/23 and 02/19/23. During observations between 02/18/2023 at 10:15 am to 02/18/2023 at 3:58, Resident #1 was observed to have an indwelling catheter bag that was full and overflowing with urine that was backflowing in the catheter tubing as well as urine leaking onto the floor on three (3) occasions. The catheter bag was dated 01/12. The urine was cloudy, with sediment (matter that settles to the bottom of a liquid) visible in tubing and bag. There was a thick cloudy substance in the tubing that appeared to be puss. Interview on 02/18/2023 at 10:16 AM, the DON stated Resident #1's catheter tubing and bag appeared to be a puss like substance and required to be changed immediately. The DON stated Resident #1's catheter bag should always been covered and that the bag being completely full to where it is overflowing places resident at risk for infection. She stated she did not know the rationale for the catheter bag to be overflowing with urine and backflowing in the catheter tubing. During an observation 02/19/2023 at 8:35 am, Resident #1's catheter bag had been emptied; however, the foley catheter tubing had not been changed and was observed to be crusted with sediment and puss like substance visible in the tubing. During an interview on 02/19/2023 at 8:40 am, the DON stated she delegated the task for changing Resident #1's catheter but did not know rationale for the task to not have been completed. Interview on 02/19/2023 at 10:02 am, Corporate Regional Resource Nurse-J-J stated she had instructed RN-V to change Resident #1's catheter bag. She stated that RN-V reported that it had been changed. She collected a UA sample while changing it and would notify the physician. She stated that the catheter should have been changed due to the sediment. She said that she could see where there was an issue for concern. During an interview on 02/19/2023 at 10:02 am, Corporate Clinical Company Leader RN-I stated Resident #1's catheter should have been changed due to the sediment alone. She said that she could see where there was an issue for concern. Interview on 02/19/2023 at 11:04 am, the DON stated she went back to Resident #1's rooms on 02/18/2023 in the afternoon and the task to change the catheter continues to not be completed. She then asked nursing staff again to complete the task. She stated this failure placed the residents at risk for an infection. Observation and interview on 02/19/2023 at 11:20 am, Resident #1 was speaking with surveyor without any distress. Observation on 02/19/2023 at 2:57 pm, Resident #1 was observed unresponsiveness with emesis (the action or process of vomiting) on chest by surveyors and Corporate Clinical Company Leader RN-I. Corporate Clinical Company Leader RN-I stated she had to check Resident #1's pulse because she wasn't sure if she was alive. Interview on 02/19/2023 about 3:00pm, Resident #56 (Resident #1's roommate) said Resident #1 received her lunch tray about 12:00 pm and almost immediately started to throw up. Resident #56 then called for help, but no one came until about 2:00 pm. Resident #56 said that she told the staff that Resident #1 needed assistance, the staff was Assistant Administrator in Training who removed Resident #1's tray and stated, I can't help you and left the room. Review of Resident #56's quarterly MDS dated [DATE] revealed Section C Cognitive Patterns BIMS Score of 15 indicating no cognitive impairment. During an interview on 02/19/2023 at 3:10pm, RN-V stated she did not change Resident #1's catheter tubing but just changed the bag. She stated she obtained a urine sample from the catheter tubing that was observed to be crusted with sediment and puss like substance visible in the tubing. During an interview on 02/19/2023 at 3:15pm, Corporate Regional Resource Nurse-J-J stated that she instructed RN-V to change Resident #1's entire catheter and not just the bag. She stated she did not verify the task was completed. Observation on 02/19/2023 at 3:25pm, Resident #1 was transferred to community hospital via EMS. Interview on 02/19/2023 at 4:34pm, DON said she looked at Resident #1's catheter yesterday (02/18/2023) and it appeared to have puss and sediment in the catheter tubing and catheter bag entry hub. She said it was her expectation that it was to be changed. She made an additional request for the catheter to be changed this morning by RN-V. The DON stated that she discovered that the Resident #1 left the facility (to the hospital) without a changed catheter tubing but only changed catheter bag. It was her expectation that it was changed yesterday. During an interview on 02/19/2023 at 4:34 pm, the DON stated that Resident #1's catheter appeared to have puss and sediment in the catheter tubing and catheter bag entry hub. She stated it was her expectation that catheter to be changed 02/18/2023. She stated Resident #1 left the facility to the community hospital without the catheter being changed. Interview on 02/20/2023 at 3:57pm, CNA-Z stated Resident #1 had puss in her catheter tubing when she drained the catheter bag and performed incontinent care about 2 weeks ago. She stated she notified RN-V of the puss in resident's catheter tubing at that time. Interview on 02/20/2023 at 04:04 PM, Resident #56 (Resident #1's roommate) said she pressed the call light frequently and it takes a while to answer. She said that the lady that came to answer the call light after two hours. She had long dark hair and was part of administration but did not work the floor. Resident #56 said that this staff went to the Resident #1 and said Oh, My God, when she saw the resident. Resident #56 said that the staff stated she couldn't help Resident #1 and left the room. Resident #56 said she thought the staff was coming back but never did. Resident #56 said that she could hear Resident #1 throwing up and gurgling. Resident #56 said no one changed their catheters. She said that yesterday (02/19/2023) the staff just changed the bag. Resident #56 said that the regional Hispanic nurse did in fact tell the nurse to just change the bag until she got caught up and that she could change it later. Resident #56 said it was the same nurse that told her in Spanish to butt out and put her hand to her mouth as in telling her to hush and she cut her eyes. Interview on 02/20/23 04:34 PM, RN-V stated while in Resident's room that she was short of staff 02/19/2023 and behind. She said that when the regional nurse came, she told her to change the catheter bag only. She said that she is often short staffed or without staff and can do what she can do. She said she is trying hard and stays for the residents. During an interview on 02/21/2023 at 1:24 pm, Corporate Clinical Leader RN-SB stated that not changing a catheter could place a resident at risk for an infection. She stated that Resident #1's entire catheter system should have been changed and not just the bag. She stated the failure was due to the RN not using appropriate nursing judgement. During an interview on 02/21/2023 at 1:30 pm, Corporate Regional Resource Nurse-J stated she directed RN-V to change Resident #1's bag at the beginning of the shift and then later told RN-V to change the entire catheter. She stated that it appeared to be changed. She stated that the catheter should be changed any time there is puss or sediment in the tubing or bag. She stated that the catheter had not been changed prior to Resident #1 found unresponsiveness. She stated that the failure could result in infection, sepsis, and pain. During an interview on 02/21/2023 at 2:50 pm, Corporate Clinical Leader RN-VR stated that Resident #1's record had inaccurate documentation due to days of no documentation of Resident #1's catheter care including urine output. Record review of hospital record dated 02/19/2023 at 8:48pm History and Physical, revealed the following physician's notes- We sent her to the ICU Again, clinically it just seems to be a very ill patient, who was sent from the nursing home for an honestly a [NAME] reason at this point. At any rate from what I can gather she had left sided weakness from a prior stroke, but today currently it seems like she is not moving the right side, so we will get MRI of the brain. She does have a UTI in her labs, which will be treated. Record review of Resident #1's community hospital records revealed dated 02/19/2023, Resident #1 was admitted into community hospital ICU with diagnosis of UTI & rule out stroke. Record reviewed on Resident #1's community hospital records labs, assessment and plan dated 02/19/2022 revealed, Resident #1 had a primary diagnosis of Urinary Tract Infection, with orders to check cultures, place her on ceftriaxone (antibiotic) Record review of hospital records dated 02/21/2023 revealed that Resident #1 had a diagnosis of Sepsis (A life threatening complication or infection. Sepsis occurs when chemicals released in the bloodstream to fight an infection throughout the body. This can result in multi organ system failure and even death). Records review of hospital records dated 02/21/2023 Resident #1's Assessment and Plan revealed: 1.UTI in the setting on chronic indwelling foley catheter. Urine culture grew E coli. Blood cultures grew gram positive cocci. Start IV Vancomycin and Rocephin for empiric (preventative and protective) treatment. 2.Bacteremia: Blood culture grew gram positive cocci. Start IV Vancomycin (antibiotic) and Rocephin (antibiotic) for empiric treatment 2. Review of Resident #1's Admission MDS, dated [DATE], revealed Section C: Cognitive Patterns BIMS Score of 9 indicating moderate cognitive impairment; Section G: Functional Status limited/one-person assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions of no pressure ulcers. Review of Resident #1's Significant Change MDS dated [DATE], revealed Section C: Cognitive Patterns BIMS Score of 14 indicating cognitively intact; Section G: Functional Status: extensive/two + persons assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions indicated two Stage III pressure ulcers, one Stage IV pressure ulcer, and two Unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar. Site 1: Right buttock/ischium Review of Resident #1's Wound Management Detail Report dated 07/28/2022 at 4:08pm by LVN-AD revealed: Pressure Ulcer to Right Buttock, not present on admission. Unstageable measured 2.8cm in length by 2.8cm in width with unmeasurable depth. Review of Resident #1's Wound Management Detail Report dated 02/16/2023 at 5:44pm by LVN-Q revealed: Stage IV measured 4cm in length by 6cm in width with 2.5 measurable depth. Review of Resident #1's physicians orders dated 10/20/2022 for pressure wound of right ischium (buttock) revealed: Clean with Normal Saline/Wound Cleanser. Apply: collagen then Calcium Alginate with silver. Cover with Primary Dressing: bordered foam dsg. Once a day Review of Resident #1's physicians orders dated 10/20/2022 for pressure wound of right ischium (buttock) revealed: Clean with Normal Saline/Wound Cleanser. Apply collagen Calcium Alginate with silver. Cover with bordered foam dsg. As needed twice a day Review of Resident #1's Comprehensive Care Plan dated 01/31/2023 revealed: Problem: Resident has a pressure ulcer to right buttock related to immobility and desensitized skin. Goal: Resident's ulcer will heal without complication. Approach: Conduct a systematic skin inspection daily by nurse with daily dsg change. Site 2: Left buttock/ischium Review of Resident #1's Wound Management Detail Report dated 08/04/22 at 3:24pm by LVN-AD revealed: Pressure Ulcer to Left Buttock, not present on admission. Measured 4.5cm in length by 4cm in width with no measurable depth. Review of Resident #1's Wound Management Detail Report dated 02/16/2023 at 5:50pm by LVN-Q revealed: Stage III measured 1.7cm in length by 4.2cm in width with 0.5cm measurable depth. Review of Resident #1's physicians orders dated 10/20/2022 for pressure wound of left ischium (buttock) revealed: Clean with Normal Saline/Wound Cleanser. Apply: collagen then Calcium Alginate with silver. Cover with Primary Dressing: bordered foam dsg. Once a day Review of Resident #1's physicians orders dated 11/29/2022 for pressure wound of left ischium (buttock) revealed: Clean with Normal Saline/Wound Cleanser. Apply: collagen then Calcium Alginate with silver. Cover with Primary Dressing: bordered foam dsg. As Needed twice a day. Review of Resident #1's Comprehensive Care Plan dated 01/31/2023 revealed: Problem: Resident has a pressure ulcer to left buttock related to immobility and desensitized skin. Goal: Resident's ulcer will heal without complication. Approach: Conduct a systematic skin inspection daily by nurse with daily dsg change. Site 3: Left heel Review of Resident #1's Wound Management Detail Report dated 11/17/2022 at 9:17am by LVN-AE revealed: Unstageable - Deep Tissue Pressure Ulcer left heel not present on admission measured 5.5cm in length by 5cm in width with no measurable depth. Review of Resident #1's Wound Management Detail Report dated 02/16/23 at 5:54pm by LVN-Q revealed: Stage IV measured 3cm in length by 4cm in width with no measurable depth. Review of Resident #1's physician orders dated 02/10/2023 revealed: Cleanse left heel with normal saline or wound cleanser apply calcium alginate to wound bed surrounding necrotic tissue and secure with bordered dsg as needed. Once a day in the morning and as needed every shift Review of Resident #1's Comprehensive Care Plan dated 01/31/2023 revealed: Problem: Resident has a pressure ulcer to left heel related to immobility. Goal: Resident's ulcer will not increase in size. Approach: Conduct a systematic skin inspection during daily treatment . Use heel protectors as tolerated or cushion under legs as tolerated to relieve pressure on the heels. Site 4: Right heel Review of Resident #1's Wound Management Detail Report dated 11/17/2022 at 9:15am by LVN-AE revealed: Pressure Ulcer Right Heel not present on admission measured 5cm in length by 7cm in width and no measurable depth. Review of Resident #1's Wound Management Detail Report dated 02/16/23 at 5:52pm by LVN-Q revealed: Stage IV measured 2.7cm in length by 3.8cm in width and no measurable depth. Review of Resident #1's physician orders dated 02/10/2023 revealed: Cleanse right heel with normal saline or wound cleanser apply calcium alginate to wound bed surrounding necrotic tissue and secure with bordered dsg as needed. Once a day in the morning and as needed every shift Review of Resident #1's physician orders dated 10/08/22 revealed: Ascorbic acid (vitamin c) tablet; 500mg 1 tab oral once a day Review of Resident #1's Comprehensive Care Plan dated 01/31/2023 revealed: Problem: Resident has a pressure ulcer to right heel related to immobility. Goal: Resident's ulcer will not increase in size. Ulcer will not exhibit signs of infection Approach: .Conduct a systematic skin inspection during daily treatment Use heel protectors as tolerated or cushion under legs as tolerated to relieve pressure on the heels. Site 5: Sacrum 12/29/22 Cleanse sacrum with normal saline or wound cleanser apply thin layer of triad, yellow tube, to wound two times a day. Every Shift Review of Resident #1's Comprehensive Care Plan dated 01/31/2023 revealed: Problem: pressure Ulcer Sacrum Stage III. Goal: Area will show improvement in the next 14 days. Approach: Turn every 2 hours and prn. 3. Review of Resident #79's electronic Face Sheet dated revealed he was a [AGE] year-old male admitted to the facility 11/15/22. He had diagnoses which included heart failure, end stage renal disease, current long-term use of antibiotics, acute osteomyelitis, pressure ulcer of right heel stage 4, chronic pain, pressure ulcer of sacral region, systemic lupus erythematosus, major depressive disorder, dependence on renal dialysis, dependence on supplemental oxygen, chronic atrial fibrillation, Methicillin resistant Staphylococcus aureus, and Type 2 diabetes mellitus. Review of Resident #79's Admission MDS dated [DATE] revealed Section C: Cognitive Patterns BIMS Score of 15 indicating no cognitive decline; Section G Functional Status indicated extensive/2+ person physical assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions indicated one Stage III pressure ulcer present upon admission and one Unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar present upon admission. Review of Resident #79's Quarterly MDS dated [DATE] revealed Section M: Skin Conditions indicated two Stage IV pressure ulcers present upon admission, and one Unstageable pressure ulcer that was not present upon admission. Site 1: Sacrum Review of Resident #79's Wound Management Wound History dated 11/15/2022 at 8:08 am revealed: Pressure Ulcer to Sacrum present on admission. Review of Resident #79's Wound Care Physician Progress Notes dated 12/01/2022 revealed: Stage 4 Pressure Wound Sacrum Full Thickness measured 1.7cm in length by 0.7cm in width with 1.2c in depth. Review of Resident #79's Wound Care Physician Progress Note dated 01/12/2023 revealed: The histology report from the biopsy of the sacrum taken on 01/05/2023 indicates acute osteomyelitis. Review of Resident #79's physicians orders dated 11/25/2022 revealed: Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing every day until resolved. Cleanse right heel with normal saline or wound cleanser, apply sure-prep to heel two times daily for preventative. Left heel cleanse with ns or wound cleanser and apply sure-prep two times daily for preventative Review of Resident #79's physicians orders dated 11/29/2022 revealed: Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing as needed until resolved. Review of Resident #79's Treatment Administration Record from November 2022 to February 2023 revealed no evidence of treatments on 12/02/2022, 12/25/2022, 12/26/2022, 01/01/2023, 01/05/2023, 01/08/2023, 01/11/2023, 01/19/2023, 02/04/2023, 02/08/2023, 02/11/2023, 02/19/2023 Review of Resident #79's Care Plan last revised 1/30/23 revealed: Problem: Resident has a pressure ulcer to sacrum r/t immobility. Goal: Resident's ulcer will heal without complications. Approach: use cushion provided by family for pressure reduction when resident is in chair; conduct a systematic skin inspection daily during treatment . Review of Resident #79's electronic record revealed no evidence of reposition every 2 hours and as needed and conduction of systematic skin inspection daily between 11/25/2022 and 12/29/2022. Site 2: Right Heel Review of Resident #79's Wound Management Detail Report dated 11/15/2022 at 8:11am by LVN-AE revealed: Stage III pressure ulcer to right heel measured 0.3cm in length by 0.3cm in width with 0.1cm in depth. Review of Resident #79's Wound Management Wound History dated 11/25/2022 at 7:33am revealed: Pressure Ulcer to right heel present on admission and healed. Review of Resident #79's Wound Care Physician Progress Notes dated 12/01/2022 revealed: Unstageable due to necrosis (death of cells in body tissues) measured 1cm in length by 1.1cm in width with no measurable depth. Review of Resident #79's Wound Care Physician Progress Notes dated 12/29/2022 revealed deterioration to a Stage IV Pressure Wound of the Right Heel. Review of Resident #79's Wound Management Wound History dated 12/29/2022 at 2:31am revealed: Pressure Ulcer to right heel present on admission. Review of Resident #79's Wound Management Detail Report dated 02/23/2023 at 7:11pm by Corporate Clinical Company Leader RN-I revealed: Stage IV Pressure Ulcer to right heal measured 0.5cm in length by 0.6cm in width with unmeasurable depth. The wound had necrotic tissue type. Review of Resident #79's physician orders dated 12/29/2022 revealed: Cleanse right heel with normal saline or wound cleanser apply anasept (antibiotic) to wound and secure with a bordered dressing daily. Review of Resident #79's physician orders dated 01/03/2023 revealed: Use cushioned boots while in bed as tolerated Review of Resident #79's Treatment Administration Record from November 2022 to February 2023 revealed no evidence of treatments on 12/03/2022, 12/25/2022, 12/26/2022, 01/01/2023, 01/05/2023, 01/08/2023, 01/11/2023, 01/19/2023, 02/04/2023, 02/08/2023, 02/11/2023, 02/19/2023 Review of Resident #79's Care Plan last revised 1/30/23 revealed: Problem: Pressure Sores/Skin Care. Goal: Prevent/Heal pressure sores and skin breakdown. Approach: follow facility skin care protocol; preventative measures use cushioned boots for heels while in bed as tolerated, off load heels while in bed; report to charge nurse any redness or skin breakdown immediately; treatment as ordered; turn and reposition every 2 hours and PRN Problem: Resident has a pressure ulcer to right heel r/t immobility. Goal: Resident's ulcer will not increase in size. Ulcer will not exhibit signs of infection. Approach: . conduct a systematic skin inspection during treatment . Review of Resident #79's skin assessment records revealed no evidence of systematic skin inspection during treatment between 11/25/2022 and 12/29/2022. Review of Resident #79's physicians orders dated 11/29/2022 revealed: Ascorbic acid (vitamin c) 500mg 1 tablet by mouth daily. Pro-Stat AWC (high-calorie, complete protein liquid for Advance Wound Care) 17-100 gram-kcal/30ml give 30ml by mouth twice a day. Review of Resident #79's physician orders dated from 01/13/2023 to 02/24/2023 revealed: Ertapenem (strong antibiotic to treat serious infections) 1 gram IV daily for 42 days related to osteomyelitis In an interview on 02/19/2023 at 2:38 PM, Corporate Clinical Company Leader RN-I stated the facility owned Resident #1's pressure ulcers and that they were facility acquired. She stated that she could not find any documentation that they were not acquired in the facility. Corporate Clinical Company Leader RN-I stated that the failure of the facility to prevent Resident #1 from developing new pressure ulcers could result in an infection and that the failure was due to ongoing staffing issues. During an interview on 02/20/2023 at 2:30pm, Corporate Clinical Company Leader RN-I stated her expectations were for skin assessments to be completed weekly and the nursing staff were not consistence with documenting the treatments with the interim and acting DON monitoring. She stated these failures were due to communications between staff members. She stated that the lack of communication negative impacts the continuity of care. During an observation on 02/20/23 at 3:25 PM of Resident #79's wound care revealed RN-V completed wound care with the assistance of MDS-RN and LVN Q. RN-V failed to change gloves after removing sacrum dirty wound dressing and beginning to apply treatment and clean dressing to sacrum. RN-V had to be reminded by LVN-Q to date and initial new dressing to the sacrum. RN-V also failed to perform hand hygiene before applying new gloves to begin treatment to right heel. Following the treatment, RN-V was unable to be located for an interview. In an interview on 2/21/23 at 11:35 AM, Corporate Clinical Company Leader RN-H stated in her investigation of the Resident #79's chart, it appeared that the wound care/treatment nurse at the time documented the right heel wound was healed on 11/25/22 even though the wound was never healed. She stated the right heel wound was re-identified as a stage 4 on 12/29/22. She stated that because the wound was documented as healed that it went one month without treatment or observation leading to it progress to a stage 4. She stated that Resident #79's sacral wound was a stage 3 on admission but had progressed to a stage 4. She stated If there was something different with a wound that a prudent nurse should have document in a focused observation note or progress note what was observed, notify the doctor of the change in the resident's condition, then document that the doctor was notified. She stated it was her expectation that if someone did transcribe orders for Wound Care Doctor that it would be the nurse who did rounds with him or if the resident was a new admission and the wound care physician was giving orders, the admitting nurse would be responsible for transcribing the orders and verifying everything was in the resident's chart correctly. She stated that during the morning meeting, it was her expectation that the staff should have been going over all new orders received to make sure all orders had been signed and verified and that nothing had been missed during rounds. During an interview on 02/22/2023 at 9:57am, WC LVN-MB stated that she reported to Corporate Regional Resource Nurse-J, previous administrator, and previous DON the concerns of lack of wound care during the days WC LVN-MB was not scheduled. In an interview on 2/22/23 at 10:49 AM, Corporate Clinical Company Leader RN-H stated that she was not aware that skin assessments were not being done accurately and treatments were not being done until surveyors arrived at the facility. 4. Record review of Resident #53's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. She resided on Station 1 Hall 6 which was a Woman's secured unit (the average age of the women residents on Station 1 Hall 6 was [AGE] years). Diagnosis included: anoxic brain damage; diffuse traumatic brain injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness; epilepsy and epileptic syndromes with seizures of localized onset; restlessness and agitation; post-traumatic stress disorder; repeated falls; muscle weakness (generalized); insomnia due to other mental disorder; major depressive disorder; anxiety disorder; dysphagia (difficulty in swallowing), altered mental status; pain; adult sexual abuse. Record review of Resident #53's Quarterly MDS, dated [DATE], revealed the BIMS score was blank indicating inability to obtain a Brief Interview for Mental Status. During observation and interview at 02/14 [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 4 of 4 Residents (Resident #1, Resident #79, Resident #53, Resident #57) reviewed for administration quality of care, in that: 1. Resident #1 had an indwelling urinary catheter that had not been drained for 2 days causing backflow of urine due to nursing staff not following physician's orders and the facility's lack fo administrative monitoring an ensuring resient care. The catheter tubing had sediment and puss like substance in tubing. Resident #1 became unresponsive, sent to hospital, initial diagnosis of UTI, and admitted to ICU due to nursing staff neglecting to follow physician's orders. 2. Resident #1 had five facility acquired pressure ulcers that progressed to Stage III and Stage IV due to nursing staff neglecting to follow physician's orders. Facility administrative personnel did not monitor and ensure nursing staff followed physician orders and provided residents care to attain highest practicable well-being. 3. Resident #79 had one Stage III pressure ulcer upon admit that worsened to have osteomyelitis due to nursing staff neglecting to follow physician's orders. The facility's administration did not ensure it's resident skin assessments and wound treatments were completed by nursing staff and monitored by administrative personnel for effectiveness and completeness 4. The facility's administrative personnel did not ensure nursing staff were sufficiently staffed in the women's secured locked hall for resident safety. Station 2 Hall 6 was a women's secured locked hall with six (6) female residents with known behaviors with one (Resident #53) of the six (6) women required 1:1 level of supervision. The facility failed to staff the Hall with more than one trained staff consistently. The staff utilized a gait belt around Resident #53 to redirect, restraint her movement, and prevent altercations from other residents. 5. The facility's administrative personnel did not ensure nursing staff were sufficiently staffed in the men's secured locked hall for resident safety. Station 2 Hall 2 was a men's secured locked hall with fourteen (14) male residents with known behaviors. On 01/06/2023, there was a resident/resident altercation and no staff were located on the hall. An Immediate Jeopardy (IJ) was identified on 02/23/2023. The IJ template was provided to the facility on [DATE] at 10:28am. While the IJ was removed on 02/24/2023, the facility remained out of compliance at a scope of pattern and a severity of actual harm because the facility's need to evaluate the effectiveness of their corrective actions. These failures placed residents at risk of physical and psychological harm due to lack of oversight by facility administration. The findings included: 1. Record review of Resident #1 face sheet revealed a [AGE] year-old female admitted on [DATE] with a most recent admission date of 11/20/2022 with the following diagnoses: Unspecified fracture of left shaft/femur, Non ST elevation myocardial infraction (heart attack due to inadequate blood to the heart), gram negative sepsis (bacteria in the blood), neurogenic bladder (deficiency in bladder control due to brain, spinal cord or nerve problem) and urinary tract infection, site not specified (infection in any part of the urinary system). Review of Resident #1's Significant Change in Status MDS dated [DATE] revealed: Section C Cognitive Patterns BIMS Summary Score of 14 indicating no cognitive impairment; Section H Bladder and Bowel indicated indwelling catheter Record review of Resident #1 electronic care plan accessed on 02/20/2022 revealed the following: Problem - Resident #1 has Indwelling Foley Catheter: Goal - Resident will not show signs of urinary infection or urethral trauma. Interventions - Change catheter every per MD order, document urinary output; record the amount, type, color and odor, observe for leakage, keep catheter system a closed system as much as possible, position bag below level of bladder, provide catheter care as scheduled and PRN. Problem- Resident #1 has a urinary tract infection. Goal- resident will not exhibit signs of a urinary tract infection. Interventions- Administer Bactrim DS (antibiotic), encourage fluids, keep perineal area clean and dry and report signs or UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain, difficulty urinating, low back pain/flank pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine and blood in urine. Initiated date of 10/15/2022 and revised date of 01/31/2023. Review of Resident #1 physician orders dated 10/13/2022 to 10/21/2022 revealed -Foley Catheter: Size (10cc) FR (16) Diagnosis: Neurogenic bladder (lack bladder control due to brain, spine, or nerve problems). -May obtain urine sample via Foley Catheter Port as needed when a Urine Analysis is ordered. (If Foley Catheter has been in place greater than 14 days, change Foley Catheter before obtaining urine.) -Provide catheter care every shift. -Change catheter and drainage bag as needed for indications of blockage, increased sediment, infection, displacement as needed. Record review of Resident #1's vital reports revealed no evidence of catheter care, drainage of catheter bag and amount of urine obtained during drainage on 48 occasions between 01/18/23 and 02/19/23. During observations between 02/18/2023 at 10:15 am to 02/18/2023 at 3:58, Resident #1 was observed to have an indwelling catheter bag that was full and overflowing with urine that was backflowing in the catheter tubing as well as urine leaking onto the floor on three (3) occasions. The catheter bag was dated 01/12. The urine was cloudy, with sediment (matter that settles to the bottom of a liquid) visible in tubing and bag. There was a thick cloudy substance in the tubing that appeared to be puss. Interview on 02/18/2023 at 10:16 AM, the DON stated Resident #1's catheter tubing and bag appeared to be a puss like substance and required to be changed immediately. The DON stated Resident #1's catheter bag should always been covered and that the bag being completely full to where it is overflowing places resident at risk for infection. She stated she did not know the rationale for the catheter bag to be overflowing with urine and backflowing in the catheter tubing. During an observation 02/19/2023 at 8:35 am, Resident #1's catheter bag had been emptied; however, the foley catheter tubing had not been changed and was observed to be crusted with sediment and puss like substance visible in the tubing. During an interview on 02/19/2023 at 8:40 am, the DON stated she delegated the task for changing Resident #1's catheter but did not know rationale for the task to not have been completed. Interview on 02/19/2023 at 10:02 am, Corporate Regional Resource Nurse-J-J stated she had instructed RN-V to change Resident #1's catheter bag. She stated that RN-V reported that it had been changed. She collected a UA sample while changing it and would notify the physician. She stated that the catheter should have been changed due to the sediment. She said that she could see where there was an issue for concern. During an interview on 02/19/2023 at 10:02 am, Corporate Clinical Company Leader RN-I stated Resident #1's catheter should have been changed due to the sediment alone. She said that she could see where there was an issue for concern. Interview on 02/19/2023 at 11:04 am, the DON stated she went back to Resident #1's rooms on 02/18/2023 in the afternoon and the task to change the catheter continues to not be completed. She then asked nursing staff again to complete the task. She stated this failure placed the residents at risk for an infection. Observation and interview on 02/19/2023 at 11:20 am, Resident #1 was speaking with surveyor without any distress. Observation on 02/19/2023 at 2:57 pm, Resident #1 was observed unresponsiveness with emesis (the action or process of vomiting) on chest by surveyors and Corporate Clinical Company Leader RN-I. Corporate Clinical Company Leader RN-I stated she had to check Resident #1's pulse because she wasn't sure if she was alive. Interview on 02/19/2023 about 3:00pm, Resident #56 (Resident #1's roommate) said Resident #1 received her lunch tray about 12:00 pm and almost immediately started to throw up. Resident #56 then called for help, but no one came until about 2:00 pm. Resident #56 said that she told the staff that Resident #1 needed assistance, the staff was Assistant Administrator in Training who removed Resident #1's tray and stated, I can't help you and left the room. Review of Resident #56's quarterly MDS dated [DATE] revealed Section C Cognitive Patterns BIMS Score of 15 indicating no cognitive impairment. During an interview on 02/19/2023 at 3:10pm, RN-V stated she did not change Resident #1's catheter tubing but just changed the bag. She stated she obtained a urine sample from the catheter tubing that was observed to be crusted with sediment and puss like substance visible in the tubing. During an interview on 02/19/2023 at 3:15pm, Corporate Regional Resource Nurse-J-J stated that she instructed RN-V to change Resident #1's entire catheter and not just the bag. She stated she did not verify the task was completed. Observation on 02/19/2023 at 3:25pm, Resident #1 was transferred to community hospital via EMS. Interview on 02/19/2023 at 4:34pm, DON said she looked at Resident #1's catheter yesterday (02/18/2023) and it appeared to have puss and sediment in the catheter tubing and catheter bag entry hub. She said it was her expectation that it was to be changed. She made an additional request for the catheter to be changed this morning by RN-V. The DON stated that she discovered that the Resident #1 left the facility (to the hospital) without a changed catheter tubing but only changed catheter bag. It was her expectation that it was changed yesterday. During an interview on 02/19/2023 at 4:34 pm, the DON stated that Resident #1's catheter appeared to have puss and sediment in the catheter tubing and catheter bag entry hub. She stated it was her expectation that catheter to be changed 02/18/2023. She stated Resident #1 left the facility to the community hospital without the catheter being changed. Interview on 02/20/2023 at 3:57pm, CNA-Z stated Resident #1 had puss in her catheter tubing when she drained the catheter bag and performed incontinent care about 2 weeks ago. She stated she notified RN-V of the puss in resident's catheter tubing at that time. Interview on 02/20/2023 at 04:04 PM, Resident #56 (Resident #1's roommate) said she pressed the call light frequently and it takes a while to answer. She said that the lady that came to answer the call light after two hours. She had long dark hair and was part of administration but did not work the floor. Resident #56 said that this staff went to the Resident #1 and said Oh, My God, when she saw the resident. Resident #56 said that the staff stated she couldn't help Resident #1 and left the room. Resident #56 said she thought the staff was coming back but never did. Resident #56 said that she could hear Resident #1 throwing up and gurgling. Resident #56 said no one changed their catheters. She said that yesterday (02/19/2023) the staff just changed the bag. Resident #56 said that the regional Hispanic nurse did in fact tell the nurse to just change the bag until she got caught up and that she could change it later. Resident #56 said it was the same nurse that told her in Spanish to butt out and put her hand to her mouth as in telling her to hush and she cut her eyes. Interview on 02/20/23 04:34 PM, RN-V stated while in Resident's room that she was short of staff 02/19/2023 and behind. She said that when the regional nurse came, she told her to change the catheter bag only. She said that she is often short staffed or without staff and can do what she can do. She said she is trying hard and stays for the residents. During an interview on 02/21/2023 at 1:24 pm, Corporate Clinical Leader RN-SB stated that not changing a catheter could place a resident at risk for an infection. She stated that Resident #1's entire catheter system should have been changed and not just the bag. She stated the failure was due to the RN not using appropriate nursing judgement. During an interview on 02/21/2023 at 1:30 pm, Corporate Regional Resource Nurse-J stated she directed RN-V to change Resident #1's bag at the beginning of the shift and then later told RN-V to change the entire catheter. She stated that it appeared to be changed. She stated that the catheter should be changed any time there is puss or sediment in the tubing or bag. She stated that the catheter had not been changed prior to Resident #1 found unresponsiveness. She stated that the failure could result in infection, sepsis, and pain. During an interview on 02/21/2023 at 2:50 pm, Corporate Clinical Leader RN-VR stated that Resident #1's record had inaccurate documentation due to days of no documentation of Resident #1's catheter care including urine output. Record review of hospital record dated 02/19/2023 at 8:48pm History and Physical, revealed the following physician's notes- We sent her to the ICU Again, clinically it just seems to be a very ill patient, who was sent from the nursing home for an honestly a bogus reason at this point. At any rate from what I can gather she had left sided weakness from a prior stroke, but today currently it seems like she is not moving the right side, so we will get MRI of the brain. She does have a UTI in her labs, which will be treated. Record review of Resident #1's community hospital records revealed dated 02/19/2023, Resident #1 was admitted into community hospital ICU with diagnosis of UTI & rule out stroke. Record reviewed on Resident #1's community hospital records labs, assessment and plan dated 02/19/2022 revealed, Resident #1 had a primary diagnosis of Urinary Tract Infection, with orders to check cultures, place her on ceftriaxone (antibiotic) Record review of hospital records dated 02/21/2023 revealed that Resident #1 had a diagnosis of Sepsis (A life threatening complication or infection. Sepsis occurs when chemicals released in the bloodstream to fight an infection throughout the body. This can result in multi organ system failure and even death). Records review of hospital records dated 02/21/2023 Resident #1's Assessment and Plan revealed: 1.UTI in the setting on chronic indwelling foley catheter. Urine culture grew E coli. Blood cultures grew gram positive cocci. Start IV Vancomycin and Rocephin for empiric (preventative and protective) treatment. 2.Bacteremia: Blood culture grew gram positive cocci. Start IV Vancomycin (antibiotic) and Rocephin (antibiotic) for empiric treatment 2. Review of Resident #1's admission MDS, dated [DATE], revealed Section C: Cognitive Patterns BIMS Score of 9 indicating moderate cognitive impairment; Section G: Functional Status limited/one-person assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions of no pressure ulcers. Review of Resident #1's Significant Change MDS dated [DATE], revealed Section C: Cognitive Patterns BIMS Score of 14 indicating cognitively intact; Section G: Functional Status: extensive/two + persons assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions indicated two Stage III pressure ulcers, one Stage IV pressure ulcer, and two Unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar. Site 1: Right buttock/ischium Review of Resident #1's Wound Management Detail Report dated 07/28/2022 at 4:08pm by LVN-AD revealed: Pressure Ulcer to Right Buttock, not present on admission. Unstageable measured 2.8cm in length by 2.8cm in width with unmeasurable depth. Review of Resident #1's Wound Management Detail Report dated 02/16/2023 at 5:44pm by LVN-Q revealed: Stage IV measured 4cm in length by 6cm in width with 2.5 measurable depth. Review of Resident #1's physicians orders dated 10/20/2022 for pressure wound of right ischium (buttock) revealed: Clean with Normal Saline/Wound Cleanser. Apply: collagen then Calcium Alginate with silver. Cover with Primary Dressing: bordered foam dsg. Once a day Review of Resident #1's physicians orders dated 10/20/2022 for pressure wound of right ischium (buttock) revealed: Clean with Normal Saline/Wound Cleanser. Apply collagen Calcium Alginate with silver. Cover with bordered foam dsg. As needed twice a day Review of Resident #1's Comprehensive Care Plan dated 01/31/2023 revealed: Problem: Resident has a pressure ulcer to right buttock related to immobility and desensitized skin. Goal: Resident's ulcer will heal without complication. Approach: Conduct a systematic skin inspection daily by nurse with daily dsg change. Site 2: Left buttock/ischium Review of Resident #1's Wound Management Detail Report dated 08/04/22 at 3:24pm by LVN-AD revealed: Pressure Ulcer to Left Buttock, not present on admission. Measured 4.5cm in length by 4cm in width with no measurable depth. Review of Resident #1's Wound Management Detail Report dated 02/16/2023 at 5:50pm by LVN-Q revealed: Stage III measured 1.7cm in length by 4.2cm in width with 0.5cm measurable depth. Review of Resident #1's physicians orders dated 10/20/2022 for pressure wound of left ischium (buttock) revealed: Clean with Normal Saline/Wound Cleanser. Apply: collagen then Calcium Alginate with silver. Cover with Primary Dressing: bordered foam dsg. Once a day Review of Resident #1's physicians orders dated 11/29/2022 for pressure wound of left ischium (buttock) revealed: Clean with Normal Saline/Wound Cleanser. Apply: collagen then Calcium Alginate with silver. Cover with Primary Dressing: bordered foam dsg. As Needed twice a day. Review of Resident #1's Comprehensive Care Plan dated 01/31/2023 revealed: Problem: Resident has a pressure ulcer to left buttock related to immobility and desensitized skin. Goal: Resident's ulcer will heal without complication. Approach: Conduct a systematic skin inspection daily by nurse with daily dsg change. Site 3: Left heel Review of Resident #1's Wound Management Detail Report dated 11/17/2022 at 9:17am by LVN-AE revealed: Unstageable - Deep Tissue Pressure Ulcer left heel not present on admission measured 5.5cm in length by 5cm in width with no measurable depth. Review of Resident #1's Wound Management Detail Report dated 02/16/23 at 5:54pm by LVN-Q revealed: Stage IV measured 3cm in length by 4cm in width with no measurable depth. Review of Resident #1's physician orders dated 02/10/2023 revealed: Cleanse left heel with normal saline or wound cleanser apply calcium alginate to wound bed surrounding necrotic tissue and secure with bordered dsg as needed. Once a day in the morning and as needed every shift Review of Resident #1's Comprehensive Care Plan dated 01/31/2023 revealed: Problem: Resident has a pressure ulcer to left heel related to immobility. Goal: Resident's ulcer will not increase in size. Approach: Conduct a systematic skin inspection during daily treatment . Use heel protectors as tolerated or cushion under legs as tolerated to relieve pressure on the heels. Site 4: Right heel Review of Resident #1's Wound Management Detail Report dated 11/17/2022 at 9:15am by LVN-AE revealed: Pressure Ulcer Right Heel not present on admission measured 5cm in length by 7cm in width and no measurable depth. Review of Resident #1's Wound Management Detail Report dated 02/16/23 at 5:52pm by LVN-Q revealed: Stage IV measured 2.7cm in length by 3.8cm in width and no measurable depth. Review of Resident #1's physician orders dated 02/10/2023 revealed: Cleanse right heel with normal saline or wound cleanser apply calcium alginate to wound bed surrounding necrotic tissue and secure with bordered dsg as needed. Once a day in the morning and as needed every shift Review of Resident #1's physician orders dated 10/08/22 revealed: Ascorbic acid (vitamin c) tablet; 500mg 1 tab oral once a day Review of Resident #1's Comprehensive Care Plan dated 01/31/2023 revealed: Problem: Resident has a pressure ulcer to right heel related to immobility. Goal: Resident's ulcer will not increase in size. Ulcer will not exhibit signs of infection Approach: .Conduct a systematic skin inspection during daily treatment Use heel protectors as tolerated or cushion under legs as tolerated to relieve pressure on the heels. Site 5: Sacrum 12/29/22 Cleanse sacrum with normal saline or wound cleanser apply thin layer of triad, yellow tube, to wound two times a day. Every Shift Review of Resident #1's Comprehensive Care Plan dated 01/31/2023 revealed: Problem: pressure Ulcer Sacrum Stage III. Goal: Area will show improvement in the next 14 days. Approach: Turn every 2 hours and prn. 3. Review of Resident #79's electronic Face Sheet dated revealed he was a [AGE] year-old male admitted to the facility 11/15/22. He had diagnoses which included heart failure, end stage renal disease, current long-term use of antibiotics, acute osteomyelitis, pressure ulcer of right heel stage 4, chronic pain, pressure ulcer of sacral region, systemic lupus erythematosus, major depressive disorder, dependence on renal dialysis, dependence on supplemental oxygen, chronic atrial fibrillation, Methicillin resistant Staphylococcus aureus, and Type 2 diabetes mellitus. Review of Resident #79's admission MDS dated [DATE] revealed Section C: Cognitive Patterns BIMS Score of 15 indicating no cognitive decline; Section G Functional Status indicated extensive/2+ person physical assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions indicated one Stage III pressure ulcer present upon admission and one Unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar present upon admission. Review of Resident #79's Quarterly MDS dated [DATE] revealed Section M: Skin Conditions indicated two Stage IV pressure ulcers present upon admission, and one Unstageable pressure ulcer that was not present upon admission. Site 1: Sacrum Review of Resident #79's Wound Management Wound History dated 11/15/2022 at 8:08 am revealed: Pressure Ulcer to Sacrum present on admission. Review of Resident #79's Wound Care Physician Progress Notes dated 12/01/2022 revealed: Stage 4 Pressure Wound Sacrum Full Thickness measured 1.7cm in length by 0.7cm in width with 1.2c in depth. Review of Resident #79's Wound Care Physician Progress Note dated 01/12/2023 revealed: The histology report from the biopsy of the sacrum taken on 01/05/2023 indicates acute osteomyelitis. Review of Resident #79's physicians orders dated 11/25/2022 revealed: Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing every day until resolved. Cleanse right heel with normal saline or wound cleanser, apply sure-prep to heel two times daily for preventative. Left heel cleanse with ns or wound cleanser and apply sure-prep two times daily for preventative Review of Resident #79's physicians orders dated 11/29/2022 revealed: Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing as needed until resolved. Review of Resident #79's Treatment Administration Record from November 2022 to February 2023 revealed no evidence of treatments on 12/02/2022, 12/25/2022, 12/26/2022, 01/01/2023, 01/05/2023, 01/08/2023, 01/11/2023, 01/19/2023, 02/04/2023, 02/08/2023, 02/11/2023, 02/19/2023 Review of Resident #79's Care Plan last revised 1/30/23 revealed: Problem: Resident has a pressure ulcer to sacrum r/t immobility. Goal: Resident's ulcer will heal without complications. Approach: use cushion provided by family for pressure reduction when resident is in chair; conduct a systematic skin inspection daily during treatment . Review of Resident #79's electronic record revealed no evidence of reposition every 2 hours and as needed and conduction of systematic skin inspection daily between 11/25/2022 and 12/29/2022. Site 2: Right Heel Review of Resident #79's Wound Management Detail Report dated 11/15/2022 at 8:11am by LVN-AE revealed: Stage III pressure ulcer to right heel measured 0.3cm in length by 0.3cm in width with 0.1cm in depth. Review of Resident #79's Wound Management Wound History dated 11/25/2022 at 7:33am revealed: Pressure Ulcer to right heel present on admission and healed. Review of Resident #79's Wound Care Physician Progress Notes dated 12/01/2022 revealed: Unstageable due to necrosis (death of cells in body tissues) measured 1cm in length by 1.1cm in width with no measurable depth. Review of Resident #79's Wound Care Physician Progress Notes dated 12/29/2022 revealed deterioration to a Stage IV Pressure Wound of the Right Heel. Review of Resident #79's Wound Management Wound History dated 12/29/2022 at 2:31am revealed: Pressure Ulcer to right heel present on admission. Review of Resident #79's Wound Management Detail Report dated 02/23/2023 at 7:11pm by Corporate Clinical Company Leader RN-I revealed: Stage IV Pressure Ulcer to right heal measured 0.5cm in length by 0.6cm in width with unmeasurable depth. The wound had necrotic tissue type. Review of Resident #79's physician orders dated 12/29/2022 revealed: Cleanse right heel with normal saline or wound cleanser apply anasept (antibiotic) to wound and secure with a bordered dressing daily. Review of Resident #79's physician orders dated 01/03/2023 revealed: Use cushioned boots while in bed as tolerated Review of Resident #79's Treatment Administration Record from November 2022 to February 2023 revealed no evidence of treatments on 12/03/2022, 12/25/2022, 12/26/2022, 01/01/2023, 01/05/2023, 01/08/2023, 01/11/2023, 01/19/2023, 02/04/2023, 02/08/2023, 02/11/2023, 02/19/2023 Review of Resident #79's Care Plan last revised 1/30/23 revealed: Problem: Pressure Sores/Skin Care. Goal: Prevent/Heal pressure sores and skin breakdown. Approach: follow facility skin care protocol; preventative measures use cushioned boots for heels while in bed as tolerated, off load heels while in bed; report to charge nurse any redness or skin breakdown immediately; treatment as ordered; turn and reposition every 2 hours and PRN Problem: Resident has a pressure ulcer to right heel r/t immobility. Goal: Resident's ulcer will not increase in size. Ulcer will not exhibit signs of infection. Approach: . conduct a systematic skin inspection during treatment . Review of Resident #79's skin assessment records revealed no evidence of systematic skin inspection during treatment between 11/25/2022 and 12/29/2022. Review of Resident #79's physicians orders dated 11/29/2022 revealed: Ascorbic acid (vitamin c) 500mg 1 tablet by mouth daily. Pro-Stat AWC (high-calorie, complete protein liquid for Advance Wound Care) 17-100 gram-kcal/30ml give 30ml by mouth twice a day. Review of Resident #79's physician orders dated from 01/13/2023 to 02/24/2023 revealed: Ertapenem (strong antibiotic to treat serious infections) 1 gram IV daily for 42 days related to osteomyelitis In an interview on 02/19/2023 at 2:38 PM, Corporate Clinical Company Leader RN-I stated the facility owned Resident #1's pressure ulcers and that they were facility acquired. She stated that she could not find any documentation that they were not acquired in the facility. Corporate Clinical Company Leader RN-I stated that the failure of the facility to prevent Resident #1 from developing new pressure ulcers could result in an infection and that the failure was due to ongoing staffing issues. During an interview on 02/20/2023 at 2:30pm, Corporate Clinical Company Leader RN-I stated her expectations were for skin assessments to be completed weekly and the nursing staff were not consistence with documenting the treatments with the interim and acting DON monitoring. She stated these failures were due to communications between staff members. She stated that the lack of communication negative impacts the continuity of care. During an observation on 02/20/23 at 3:25 PM of Resident #79's wound care revealed RN-V completed wound care with the assistance of MDS-RN and LVN Q. RN-V failed to change gloves after removing sacrum dirty wound dressing and beginning to apply treatment and clean dressing to sacrum. RN-V had to be reminded by LVN-Q to date and initial new dressing to the sacrum. RN-V also failed to perform hand hygiene before applying new gloves to begin treatment to right heel. Following the treatment, RN-V was unable to be located for an interview. In an interview on 2/21/23 at 11:35 AM, Corporate Clinical Company Leader RN-H stated in her investigation of the Resident #79's chart, it appeared that the wound care/treatment nurse at the time documented the right heel wound was healed on 11/25/22 even though the wound was never healed. She stated the right heel wound was re-identified as a stage 4 on 12/29/22. She stated that because the wound was documented as healed that it went one month without treatment or observation leading to it progress to a stage 4. She stated that Resident #79's sacral wound was a stage 3 on admission but had progressed to a stage 4. She stated If there was something different with a wound that a prudent nurse should have document in a focused observation note or progress note what was observed, notify the doctor of the change in the resident's condition, then document that the doctor was notified. She stated it was her expectation that if someone did transcribe orders for Wound Care Doctor that it would be the nurse who did rounds with him or if the resident was a new admission and the wound care physician was giving orders, the admitting nurse would be responsible for transcribing the orders and verifying everything was in the resident's chart correctly. She stated that during the morning meeting, it was her expectation that the staff should have been going over all new orders received to make sure all orders had been signed and verified and that nothing had been missed during rounds. During an interview on 02/22/2023 at 9:57am, WC LVN-MB stated that she reported to Corporate Regional Resource Nurse-J, previous administrator, and previous DON the concerns of lack of wound care during the days WC LVN-MB was not scheduled. In an interview on 2/22/23 at 10:49 AM, Corporate Clinical Company Leader RN-H stated that she was not aware that skin assessments were not being done accurately and treatments were not being done until surveyors arrived at the facility. 4. Record review of Resident #53's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. She resided on Station 1 Hall 6 which was a Woman's secured unit (the average age of the women residents on Station 1 Hall 6 was 76 years). Diagnosis included: anoxic brain damage; diffuse traumatic brain injury with loss of consciousness

Based on the observations, interviews and record review, the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 4 residents (Resident # 1, Resident #79) reviewed for pressure ulcers. The facility failed to prevent Resident #1 from developing 5 new pressure ulcers (Stage IV to right ischium, Stage IV to left Ischium, Stage IV to Left Heel, Stage IV to right heel, and Not Stage to sacrum) while she resided in the facility. The facility failed to promote healing and prevent Resident #79's Stage IV pressure ulcer to his sacrum from developing osteomyelitis (an infection in the bone caused by bacteria) The facility failed to promote healing and prevent Resident #79's right heel pressure ulcer from deteriorating from Stage III to Stage IV. An Immediate Jeopardy (IJ) was identified on 2/22/2023 at 4:58 PM. While the IJ was removed on 2/24/2023 at 6:48 PM, the facility remained out of compliance at actual harm that was not immediate jeopardy with a scope of pattern due to the facility's need to monitor the implementation and effectiveness of its plan of removal. These failures placed residents at risk of pain, worsening of wounds, wound infection, emotional distress, harm or even death. The findings were: Review of The National Pressure Injury Advisory Panel (NPIAP) accessed on 03/14/2023 https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf revealed: Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Resident #1 Review of Resident #1's electronic face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with a most recent admitted [DATE] with the following diagnosis: Unspecified fracture of left shaft of the femur (long, straight portion of the upper leg bone), Non ST elevation myocardial infraction (heart attack due to inadequate blood to the heart), gram negative sepsis (bacteria in the blood), neurogenic bladder (deficiency in bladder control due to brain, spinal cord or nerve problem) and urinary tract infection, site not specified (infection in any part of the urinary system). Review of Resident #1's Admission MDS, dated [DATE], revealed: Section C: Cognitive Patterns BIMS Score of 9 indicating moderate cognitive impairment; Section G: Functional Status limited/one-person assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions of no pressure ulcers. Review of Resident #1's Significant Change MDS dated [DATE], revealed: Section C: Cognitive Patterns BIMS Score of 14 indicating cognitively intact; Section G: Functional Status: extensive/two + persons assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions indicated two Stage III pressure ulcers, one Stage IV pressure ulcer, and two Unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar. Site 1: Right buttock/ischium Review of Resident #1's Wound Management Detail Report dated 07/28/2022 at 4:08pm by LVN-AD revealed: Pressure Ulcer to Right Buttock, not present on admission. Unstageable measured 2.8cm in length by 2.8cm in width with unmeasurable depth. Review of Resident #1's Wound Management Detail Report dated 02/16/2023 at 5:44pm by LVN-Q revealed: Stage IV measured 4cm in length by 6cm in width with 2.5 measurable depth. Review of Resident #1's wound care physician progress notes revealed the following: 7/28/22 Initial exam of Right Ischium: Unstageable Pressure Ulcer 2.8cm x 2.8cm x unmeasurable depth; surgical debridement performed 11/24/22 Change of staging Right Ischium: Stage IV 4.6cm x 6.0cm x 2.0cm; surgical debridement performed 2/16/23 Last available progress note Right Ischium: 4cm x 6cm x 2.5cm; surgical debridement performed Site 2: Left buttock/ischium Review of Resident #1's Wound Management Detail Report dated 08/04/22 at 3:24pm by LVN-AD revealed: Unstageable Pressure Ulcer to Left Buttock, not present on admission. Measured 4.5cm in length by 4cm in width with no measurable depth. Review of Resident #1's Wound Management Detail Report dated 02/16/2023 at 5:50pm by LVN-Q revealed: Stage III measured 1.7cm in length by 4.2cm in width with 0.5cm measurable depth. Review of Resident #1's wound care physician progress notes revealed the following: 8/04/22 Initial exam of Left Ischium: Stage II Pressure Ulcer 4.5cm x 4.0cm x unmeasurable depth; no debridement done 8/11/22 Change of Staging of Left Ischium: Unstageable Pressure Ulcer: 3.2cm x 1.5cm x 0.2cm; surgical debridement performed 11/10/22 Change of Staging of Left Ischium: Stage III 4.5cm x 2.5cm x 1cm; surgical debridement performed 2/16/23 Change of Staging of Left Ischium: Stage IV 1.7cm x 4.2cm x 0.5cm; surgical debridement performed Site 3: Left heel Review of Resident #1's Wound Management Detail Report dated 11/17/2022 at 9:17am by LVN-AE revealed: Unstageable - Deep Tissue Pressure Ulcer left heel not present on admission measured 5.5cm in length by 5cm in width with no measurable depth. Review of Resident #1's Wound Management Detail Report dated 02/16/23 at 5:54pm by LVN-Q revealed: Stage IV measured 3cm in length by 4cm in width with no measurable depth. Review of Resident #1's wound care physician progress notes revealed the following: 11/17/22 Initial exam of Left Heel: Unstageable DTI Pressure Injury 5.5cm x 5.0cm x unmeasurable depth; no debridement done 12/8/22 Change in Staging of Left Heel: Unstageable Pressure Ulcer 5.5cm x 5.0cm x unmeasurable depth; no debridement done 2/16/23 last available progress note for Left Heel: Unstageable Pressure Ulcer 3cm x 4cm x unmeasurable depth; no debridement done Site 4: Right heel Review of Resident #1's Wound Management Detail Report dated 11/17/2022 at 9:15am by LVN-AE revealed: Pressure Ulcer Right Heel not present on admission measured 5cm in length by 7cm in width and no measurable depth. Review of Resident #1's Wound Management Detail Report dated 02/16/23 at 5:52pm by LVN-Q revealed: Stage IV measured 2.7cm in length by 3.8cm in width and no measurable depth. Review of Resident #1's wound care physician progress notes revealed the following: 11/17/22 Initial exam of Right Heel: Unstageable DTI Pressure Injury 5cm x 7cm x unmeasurable depth; no debridement done 12/8/22 Change in Staging of Right Heel: Unstageable Pressure Ulcer 5cm x 7cm x unmeasurable depth; no debridement done 12/29/22 Change in Staging of Right Heel: Stage IV Pressure Ulcer 5.5cm x 5cm x unmeasurable depth; surgical debridement performed 2/16/23 last available progress note for Right Heel: Stage IV 2.7cm x 3.8cm x unmeasurable depth; no debridement done Site 5: Sacrum Review of Resident #1's Wound Management Detail Report dated 11/09/22 at 12:50 PM by LVN-AE revealed: Pressure Ulcer Sacrum not present on admission measured 10cm in length by 8cm in width and no measurable depth Review of Resident #1's Wound Management Detail Report dated 2/09/23 at 2:36 PM by LVN-AE revealed: Pressure Ulcer Sacrum not present on admission measured 1.5cm in length by 1cm in width and no measurable depth Review of Resident #1's electronic orders revealed: Ascorbic acid (vitamin c) tablet; 500mg 1 tab oral once a day (start date 10/08/22) Wound Treatment Order: Location: Pressure Wound of the Left Ischium Partial Thickness. Clean with Normal Saline/Wound Cleanser. Apply: collagen then Calcium Alginate with silver. Cover with Primary Dressing: bordered foam dsg. Once a day (start date 10/20/22) Wound Treatment Order: Location: Unstageable of the Right Ischium Full Thickness. Clean with Normal Saline/Wound Cleanser. Apply collagen Calcium Alginate with silver. Cover with bordered foam dsg. Once a Day. (start date 10/20/22) Wound Treatment Order: Location: Pressure Wound of the Left Ischium Partial Thickness. Clean with Normal Saline/Wound Cleanser. Apply: collagen then Calcium Alginate with silver. Cover with Primary Dressing: bordered foam dsg. Twice a Day-PRN (start date 11/29/22) Wound Treatment Order: Location: Unstageable of the Right Ischium Full Thickness. Clean with Normal Saline/Wound Cleanser. Apply collagen Calcium Alginate with silver. Cover with bordered foam dsg. Twice A Day - PRN (start date 11/29/22) Cleanse sacrum with normal saline or wound cleanser apply thin layer of triad, yellow tube, to wound two times a day. Every Shift (start date 12/29/22) Cleanse left heel with normal saline or wound cleanser apply calcium alginate to wound bed surrounding necrotic tissue and secure with bordered dsg as needed. Every Shift (start date 2/10/23) Cleanse left heel with normal saline or wound cleanser apply calcium alginate to wound bed surrounding necrotic tissue and secure with bordered dsg daily. Once A Day. Morning 06:00 AM - 06:00 PM (start date 2/10/23) Cleanse right heel with normal saline or wound cleanser apply calcium alginate to wound bed and secure with bordered dsg as needed. Every Shift - PRN (start date 2/10/23) Cleanse right heel with normal saline or wound cleanser apply calcium alginate to wound bed and secure with bordered dsg daily. Once A Day. Morning 06:00 AM - 06:00 PM (start date 2/10/23) Review of Resident #1's Comprehensive Care Plan dated 01/31/2023 revealed: Problem: Resident has a pressure ulcer to left buttock related to immobility and desensitized skin. Goal: Resident's ulcer will heal without complication. Approach: Conduct a systematic skin inspection daily by nurse with daily dsg change.; Problem: Resident has a pressure ulcer to left heel related to immobility. Goal: Resident's ulcer will not increase in size. Approach: Conduct a systematic skin inspection during daily treatment . Use heel protectors as tolerated or cushion under legs as tolerated to relieve pressure on the heels.; Problem: Resident has a pressure ulcer to right buttock related to immobility and desensitized skin. Goal: Resident's ulcer will heal without complication. Approach: Conduct a systematic skin inspection daily by nurse with daily dsg change.; Problem: pressure Ulcer Sacrum Stage III. Goal: Area will show improvement in the next 14 days. Approach: Turn every 2 hours and prn. In an interview on 02/19/2023 at 2:38 PM, Corporate Clinical Company Leader RN-I stated the facility would accept responsibility for Resident #1's pressure ulcers and that they were facility acquired. She stated that she could not find any documentation that they were not acquired in the facility. Corporate Clinical Company Leader RN-I stated that the failure of the facility to prevent Resident #1 from developing new pressure ulcers could result in an infection and that the failure was due to ongoing staffing issues. In an interview on 02/22/23 at 09:57 AM, LVN-AE the former wound care nurse for the facility, stated that on weekends RN-V would not do wound care for the residents on Station 1. LVN-AE stated that Resident #1's wound got worse because RN-V would have the wrong dressings on the resident. LVN-AE stated that Resident #1's sacrum was to be left open to air per physician orders, but she would come back on Monday and there would be a dressing (silicone border dressing) covering the wound and when she would remove the dressing, it would take the new healing skin off. She stated Resident #1 did not show pain, just that her wounds would be worse. In an interview on 2/23/23 at 11:35 AM, the Wound Care Physician stated that his expectation was that his orders would be followed and the wound care for the residents would be done. He stated that all of Resident #1's wounds were facility acquired. Review of Resident #1's electronic record from 05/20/2022 to 02/23/2023 revealed no evidence of physician's progress note demonstratiting the resident's pressure ulcers were clinically unavoidable. Resident #79 Review of Resident #79's electronic Face Sheet revealed he was a [AGE] year-old male admitted to the facility 11/15/22. He had diagnoses which included heart failure, end stage renal disease, current long-term use of antibiotics, acute osteomyelitis (an infection in the bone caused by bacteria), pressure ulcer of right heel stage 4, chronic pain, pressure ulcer of sacral region, systemic lupus erythematosus (inflammatory disease caused when the immune system attacks its own tissues causing fatigue and pain), major depressive disorder, dependence on renal dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), dependence on supplemental oxygen, chronic atrial fibrillation (irregular heart beat), Methicillin resistant Staphylococcus aureus (certain type of bacteria resistant to treatment by many common antibiotics), and Type 2 diabetes mellitus. Review of Resident #79's Admission MDS dated [DATE] revealed: Section C: Cognitive Patterns BIMS Score of 15 indicating no cognitive decline; Section G Functional Status indicated extensive/2+ person physical assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions indicated one Stage III pressure ulcer present upon admission and one Unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar present upon admission. Review of Resident #79's Quarterly MDS dated [DATE] revealed: Section C: Cognitive Patterns BIMS Score of 11 indicating moderate cognitive decline; Section G Functional Status indicated extensive/2+ person physical assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions indicated two Stage IV pressure ulcers present upon admission, and one Unstageable pressure ulcer that was not present upon admission. Site 1: Sacrum Review of Resident #79's Wound Management Wound History dated 11/15/2022 at 8:08 am revealed: Pressure Ulcer to Sacrum present on admission. Review of Resident #79's Wound Care Physician Progress Notes dated 12/01/2022 revealed: Stage 4 Pressure Wound Sacrum Full Thickness measured 1.7cm in length by 0.7cm in width with 1.2c in depth. Review of Resident #79's Wound Care Physician Progress Note dated 01/12/2023 revealed: The histology report from the biopsy of the sacrum taken on 01/05/2023 indicates acute osteomyelitis. Site 2: Right Heel Review of Resident #79's Wound Management Detail Report dated 11/15/2022 at 8:11am by LVN-AE revealed: Stage III pressure ulcer to right heel measured 0.3cm in length by 0.3cm in width with 0.1cm in depth. Review of Resident #79's Wound Management Wound History dated 11/25/2022 at 7:33am revealed: Pressure Ulcer to right heel present on admission and healed. Review of Resident #79's Wound Management Wound History dated 12/29/2022 at 2:31am revealed: Pressure Ulcer to right heel present on admission. Review of Resident #79's Wound Management Detail Report dated 02/23/2023 at 7:11pm by Corporate Clinical Company Leader RN-I revealed: Stage IV Pressure Ulcer to right heal measured 0.5cm in length by 0.6cm in width with unmeasurable depth. The wound had necrotic tissue type. Review of Resident #79's skin assessment records revealed no evidence of systematic skin inspection during treatment between 11/25/2022 and 12/29/2022. Review of Resident #79's Wound Care Physician Progress Notes dated 12/01/2022 revealed: Unstageable due to necrosis (death of cells in body tissues) of the Right Heel Full Thickness measured 1cm in length by 1.1cm in width with no measurable depth. Review of Resident #79's Wound Care Physician Progress Notes dated 12/29/2022 revealed deterioration to a Stage IV Pressure Wound of the Right Heel. Review of Resident #79's electronic orders revealed: Multivitamin plus Minerals 1 tablet by mouth daily (start date 11/15/22) Left heel cleanse with ns or wound cleanser and apply sure-prep two times daily for preventative (start date 11/25/22) Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing every day until resolved (start date 11/25/22) Cleanse right heel with normal saline or wound cleanser, apply sure-prep to heel two times daily for preventative (start date 11/25/22) Ascorbic acid (vitamin c) 500mg 1 tablet by mouth daily (start date 11/29/22) Pro-Stat AWC (amino acids-protein hydrolys) 17-100 gram-kcal/30ml give 30ml by mouth twice a day (start date 11/29/22) Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing as needed until resolved (twice a day - PRN, morning, bedtime) (start date 11/29/22) Cleanse right heel with normal saline or wound cleanser apply anasept to wound and secure with a bordered dressing daily (start date 12/29/22) Use cushioned boots while in bed as tolerated (start date 1/3/23) Ertapenem 1 gram IV daily for 42 days r/t osteomyelitis (start date 1/13/23 end date 2/24/23) Review of Resident #79's Treatment Administration Records from November 2022 to February 2023 revealed no evidence of wound treatments completed on 12/02/2022, 12/25/2022, 12/26/2022, 01/01/2023, 01/05/2023, 01/08/2023, 01/11/2023, 01/19/2023, 02/04/2023, 02/08/2023, 02/11/2023, 02/19/2023. Review of Resident #79's electronic record revealed no evidence of reposition every 2 hours and as needed and conduction of systematic skin inspection daily between 11/25/2022 and 12/29/2022. Review of Resident #79's Care Plan last revised 1/30/23 revealed: Problem: Pressure Sores/Skin Care. Goal: Prevent/Heal pressure sores and skin breakdown. Approach: follow facility skin care protocol; preventative measures use cushioned boots for heels while in bed as tolerated, off load heels while in bed; report to charge nurse any redness or skin breakdown immediately; treatment as ordered; turn and reposition every 2 hours and PRN; Problem: Resident has a pressure ulcer to right heel r/t immobility. Goal: Resident's ulcer will not increase in size. Ulcer will not exhibit signs of infection. Approach: . conduct a systematic skin inspection during treatment .; Problem: Resident has a pressure ulcer to sacrum r/t immobility. Goal: Resident's ulcer will heal without complications. Approach: use cushion provided by family for pressure reduction when resident is in chair; conduct a systematic skin inspection daily during treatment . Observation on 2/18/23 at 3:30 PM Resident #79 was lying in bed, turned slightly onto his left side with heels floated on pillows and heel protectors to bilateral feet. Observation on 2/19/23 at 10:30 AM Resident #79 was lying in bed flat on his back with heels floated on pillows, bilateral heel protectors were in place. Observation on 2/20/23 at 9:40 AM Resident #79 was sitting in Geri-chair in dialysis suite with pillows elevating feet. Resident #79 had 2 blankets covering his legs because he stated that room was always cold, surveyor unable to verify if heel protectors were in place. Observation on 02/20/23 3:25 PM: RN-V gathered supplies as ordered from treatment cart and placed in resealable plastic bag with resident #79's name written on it and carried bag to resident's room. MDS-RN and LVN-Q entered room and donned gloves. LVN-Q used hand sanitizer prior to entering resident room. MDS-RN was not observed to use hand sanitizer after entering Resident #79's room. RN-V used hand sanitizer, cleaned tray table with sanitizer wipes and placed wax paper on cleaned tabletop without donning gloves. RN-V removed 2 6inx6in foam border dressing from package and dropped on wax paper, removed 3 saline ampules, 1 can of wound spray, 1 tube of barrier cream, 4inx4in gauze, calcium alginate packing, and cotton tipped applicators from resealable plastic bag and placed on wax paper without donning gloves. RN-V saturated 4x4 gauze with saline without donning gloves. RN-V donned clean gloves. Resident #79 assisted onto his left side by MDS-RN. Dirty dressing and soiled packing removed by MDS-RN; soiled dressing was dated 2/18/23. Wound appeared beefy red inside, wound edges well-defined and healthy looking, area surrounding wound was bright red and irritated in appearance, area appeared larger than size of foam border dressing (6x6in) but no measurements were taken during this dressing change. Without changing soiled gloves, RN-V cleaned wound with saline soaked gauze, patted area dry with dry gauze, opened calcium alginate package and used cotton tipped applicator to pack calcium alginate packing into wound. Clean 6inx6in foam border dressing placed over wound. Resident rolled onto his back then LVN-Q stated, don't forget you have to date time and initial the dressing. RN-V assisted resident back onto his left side and RN-V dated and initialed the clean dressing. RN-V did not change gloves in between dirty and clean dressing. RN-V removed her gloves and donned a clean pair. LVN-Q held Resident #79's leg by the calf while RN-V removed Resident #79's right heel dressing, soiled dressing did not appear to have a date and initial on it. RN-V sprayed wound cleanser on right heel wound, applied wound cleanser to wound with cotton tipped applicator, and applied a clean 6inx6in foam bordered dressing. RN-V dated and initialed the clean dressing to Resident #79's right heel. RN-V removed her gloves. RN-V donned clean gloves and removed dressing to left heel, wound cleanser and gauze used to clean left heel. MDS-RN stated that there were no orders for the treatment or dressing to the left heel, but the staff do them as a preventative measure. RN-V removed her gloves, collected trash, and left the room. Surveyor attempted to find RN-V for an interview regarding the wound care, but she was unable to be located. Interview on 2/24/23 at 4:48 PM, LVN-Q stated wound care with Resident #79 on 2/20/23 performed by RN-V went badly. She stated she did not see RN-V wash hands or use sanitizer at any time before or during the dressing changes, but she did see her change her gloves in between each wound. LVN-Q stated that was not the correct procedure for hand hygiene during wound care and could lead to recontamination of the wound. She stated that RN-V was feeling overwhelmed but that was not an excuse. She stated that it was just overall not good. In an interview on 2/21/23 at 11:35 AM, Corporate Clinical Company Leader RN-H stated Resident #79 was admitted to facility on 11/15/22 with stage 3 to sacrum and stage 3 to right heel and that both wounds were documented on admission. Corporate Clinical Company Leader RN-H stated that in her investigation of the Resident #79's chart, it appeared that the wound care/treatment nurse at the time documented the right heel wound was healed on 11/25/22 even though the wound was never healed. She stated the right heel wound was re-identified as a stage 4 on 12/29/22. She stated that because the wound was documented as healed it went one month without treatment or observation leading to it progress to a stage 4. She stated that Resident #79's sacral wound was a stage 3 on admission but had worsened to a stage 4. She stated the documentation stating the wound was improving even with the presence of osteomyelitis was strictly referring to the wound bed appearance from her understanding. Corporate Clinical Company Leader RN-H stated the resident was diagnosed with osteomyelitis at the site of the sacral wound by the wound care physician. She stated the staff was supposed to do skin sweeps weekly to check wounds and get measurements and the wound care doctor saw residents weekly as well. The staff did their checks on the residents that the doctor did not see. The measurements were documented in the wound management section of the chart. Corporate Clinical Company Leader RN-H stated wound care was documented on the treatment administration record only unless something was wrong or there were changes. If there was something different with a wound, she stated a prudent nurse would document in a focused observation note or progress note what was observed, notify the doctor of the change in the resident's condition, then document that the doctor was notified. She stated the wound care physician's progress notes were uploaded into the resident's EMR electronically and that he was able to put his own orders in remotely. She stated if someone did transcribe orders for him it would be the nurse who did rounds with him while he was in the building seeing residents, normally the wound care/treatment nurse when the facility had one or the DON. If the resident was a new admission and the wound care physician was giving orders, the admitting nurse would be responsible for transcribing the orders and verifying everything was in the resident's chart correctly. Corporate Clinical Company Leader RN-H stated when an order was put into the facility's charting program it went directly onto the MAR. She stated during the morning meeting, the staff should have been going over all new orders received to make sure all orders had been signed and verified and that nothing had been missed during rounds. Corporate Clinical Company Leader RN-H stated all information regarding wounds had been provided or would be found in focused observation notes. In an interview on 02/22/23 at 09:57 AM, LVN-AE the former wound care nurse for the facility, stated that on weekends RN-V would not do wound care for the residents on Station 1. When LVN-AE would ask RN-V why it was not being done, RN-V would say it was because she would be frustrated and that she was one person and could not get them (treatments) done. LVN-AE did not understand why because RN-V always had a med aide, so that would have left her free to do the treatments. LVN-AE stated that the wounds would have the same dressing on them on Monday that she put on the residents on Friday. LVN-AE stated she worked Monday through Friday as the treatment/wound care nurse. LVN-AE reported RN-V to the DON and the former Administrator, then later reported it to Regional Nurse Consultant and others who no longer work for the company. She was told by all of them that they would talk to RN-V. LVN-AE stated it never got corrected. LVN-AW felt the residents did not receive wound care as ordered by the physician when she was not in building. LVN-AE stated that every Thursday the wound care physician would see residents but by the time he came, she had a week to make them look better, so he did not make comments that the residents' wounds were worse. LVN-AE stated she got conflicting information from DON's regarding skin assessments. LVN-AE stated at first, she would do skin assessments on wound care residents, then was told the nurses were supposed to do skin assessments and she was only supposed to do the wound management (measurements, wound descriptions). LVN-AE said she left the facility because the facility was not willing to change and hold RN-V accountable for wound care, and she was afraid of losing her license due to the wounds in the facility. In an interview on 2/22/23 at 10:25 AM, LVN-P stated since the wound care nurse quit whoever was working the floor was responsible for wound care for the residents. She stated typically, there was a charge nurse and a med nurse on the day shift, and they helped each other out with the residents. LVN-P stated Station 1 had 6 residents getting wound care at that time. When wound care was done, she stated she only signed off on the TAR and she never put a progress note in just to state the wound care had been done. She stated if there were changes to the wound it was documented in a progress note, the doctor was notified, she would notify the family and continue the treatment or write orders if any new orders were given. She stated a nurse always rounded with the wound care doctor when he saw the residents. She stated he was in the facility weekly, and she rounded with him last week because there was no one else to do it. LVN-P stated until the facility hired a new wound care nurse, she believed the DON was going to take over rounding with him. In an interview on 2/22/23 at 10:49 AM, Corporate Clinical Company Leader RN-H stated that she was not aware skin assessments were not being done accurately and treatments were not being done until surveyors arrived at the facility. She stated the facility was currently in the process of revising their wound care program to address wound care management, assessments, treatments, and care planning issues the facility had been experiencing. In an interview on 2/23/23 at 11:35 AM, the Wound Care Physician stated that his expectation was that his orders would be followed and the wound care for the residents would be done. Wound Care Physician stated that if a resident's wound care was not done as ordered over the weekend that when he came to the facility on Thursday, the wounds would have time for improvement by the time he saw them again if the treatments were started back up on Monday. He stated he did rounds with the floor nurses when he saw the residents. Review of facility policy Prevention of Pressure Injuries revised May 2022 revealed: Purpose: The purpose of this protocol is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Prevention: Skin Care 1. Keep the skin clean and hydrated. 2. Clean promptly after episodes of incontinence. 3. Avoid alkaline soaps and cleansers. 4. Use a barrier product to protect skin from moisture. 5. Use incontinence products with high absorbency. 6. Do not rub or otherwise cause friction on skin that is at risk of pressure injuries. 7. Use facility-approved protective dressings for at risk individuals. Nutrition 1. Conduct nutritional screenings for residents at risk. 2. Conduct a comprehensive nutritional assessment for any resident at risk of pressure injury who is screened to be at risk for malnutrition, and for all adult residents with a pressure injury. 3. Establish and implement a nutrition care plan for any resident with or at risk of a pressure injury who is malnourished or at risk of malnutrition. 4. Provide optimal hydration, nutrient, protein, and caloric requirements as established by current practice guidelines. 5. Monitor resident for weight loss and intake of foods and fluids. 6. Include nutritional supplements in the resident's diet to increase calories and p [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and complications associated with an indwelling catheter for number 1 of 2 (Resident #1) reviewed for catheters. The facility failed to empty Resident #1's urinary catheter bag for two days, allowing the bag to fill overflowing up into the tubing that was inserted in the resident's bladder. The facility also failed to change the catheter when sediment was observed. Resident #1 was sent to a local hospital and diagnosed with sepsis (life threatening medical emergency related to the body's response to an infection) and a UTI. An IJ was identified on 02/22/2023. The IJ template was provided to the facility on [DATE] at 4:55pm. While the IJ was removed on 02/24/2023, the facility remained out of compliance at a scope of isolated and a severity level of actual harm because the facilities need to complete in service training and evaluate their effectiveness of their plan of removal. This failure placed residents at risk of not receiving care and services to prevent urinary tract infections or other issues related to bladder Functioning. Findings included: Record review of Resident #1 face sheet dated 02/20/2023 revealed a [AGE] year-old female admitted on [DATE] with a most recent admitted [DATE] with the following diagnoses: Unspecified fracture of left shaft/femur (bone in the thigh), Non ST elevation myocardial infraction (heart attack due to inadequate blood to the heart), gram negative sepsis (bacteria in the blood), neurogenic bladder (deficiency in bladder control due to brain, spinal cord or nerve problem) and urinary tract infection, site not specified (infection in any part of the urinary system). Record review of Resident #1 Discharge Minimum Data Set (MDS) Section C dated 09/19/2022 revealed in Section H (bladder and bowel) that she was frequently incontinent, 7 or more times episodes of incontinent, but 1 episode of continent). Record review of Resident #1 Quarterly Minimum Data Set (MDS) Section C dated 11/15/2022 revealed in Section H (bladder and bowel) that resident had an indwelling catheter. Observation and interview on 02/18/2023 at 10:15 AM, Resident #1's catheter bag was overflowing, urine in the tubing backing up. The catheter bag was leaking on the floor. Resident reported that it had not been drained in 2 days. The resident's urine was cloudy, with sediment visible in tubing and bag. There was a thick cloudy substance in the tubing that appeared to be puss. The DON was present with observation and visualized the catheter tubing and bag. When asked she said what she thought it was, she said that it appeared to be a puss like substance. She said that she was going to have it changed immediately. Interview on 02/18/2023 at 1:20pm, the DON stated that indwelling catheter bags should always be covered. She also stated that catheter bags that are full of urine backflowing in the catheter tubing place the resident at risk for infections. She stated she did not know reason for overflow catheter bag with urine backflowing into the catheter . She said it was the nurses responsibility to change it. Observation on 02/18/2023 at 3:58pm, revealed Resident #1 continued to have an indwelling catheter with an overfilled catheter bag with urine backflowing in the catheter tubing. The bag continued to be leaking urine onto the floor. The urine was cloudy, with sediment visible in tubing and bag. There was a thick cloudy substance in the tubing that appeared to be puss. This observation was reported to the Corporate Regional Resource Nurse-J Observation and interview on 02/19/2023 at 8:35 am, revealed Resident #1's catheter bag had been emptied; however, the catheter had not been changed and was observed to be crusted with sediment and puss like substance visible in the tubing. There was a trash bag on the floor under the uncovered catheter bag. Resident #1 stated that the trash bag was placed to catch the leaking urine from the catheter bag . Interview on 02/19/2023 at 9:45 am, RN-V stated she had not gone to check Resident #1's catheter bag to check see if it had been drained or changed during previous day's shift. She reported it was delegated to her, but she was busy and had not had a chance to do it. Interview on 02/19/2023 at 10:02 am, Corporate Regional Resource Nurse-J-J stated she had instructed RN-V to change Resident #1's catheter bag. She stated that RN-V reported that it had been changed. She collected a UA sample while changing it and would notify the physician . She stated that the catheter should have been changed due to the sediment. She said that she could see where there was an issue for concern. Interview on 02/19/2023 at 11:04 am, the DON stated she asked LVN-O and RN-V to change Resident #1's catheter bag yesterday afternoon. She could not remember the exact time, but it was after lunch. She said she went back to Resident #1's rooms yesterday afternoon and it continued to not be completed. She then asked them again to complete the task. She stated this failure placed the residents at risk for an infection. Interview on 02/19/2023 at 3:10pm, RN-V said she did not change Resident #1's catheter tubing but only changed the bag. She said she obtained a urine sample for an ordered UA from the catheter tubing that continued to have sediment and puss like substance but not from the bag. Interview and observation on 02/19/23 03:15 PM, Corporate Regional Resource Nurse-J-J stated she instructed RN-V to change Resident #1's entire catheter on 02/18/2023. Observation and interview on 02/19/2023 at 11:20 am, Resident #1 was speaking with surveyor without any distress. Observation on 02/19/2023 at 2:57 pm, Resident #1 was observed unresponsiveness with emesis (vomiting) on chest by surveyors and Corporate Clinical Company Leader RN-I. Corporate Clinical Company Leader RN-I stated she had to check Resident #1's pulse because she wasn't sure if she was alive. Interview on 02/19/2023 about 3:00pm, Resident #56 (Resident #1's roommate) said Resident #1 received her lunch tray about 12:00 pm and almost immediately started to throw up. Resident #56 then called for help, but no one came until about 2:00 pm. Resident #56 said that she told the staff that Resident #1 needed assistance, the staff was Assistant Administrator in Training who removed Resident #1's tray and stated, I can't help you and left the room. Observation on 02/19/2023 at 3:25pm, Resident #1 was transferred to community hospital via EMS. Interview on 02/19/2023 at 4:34pm, the DON said she looked at Resident #1's catheter yesterday (02/18/2023) and it appeared to have puss and sediment in the catheter tubing and catheter hub. She said it was her expectation that it was to be changed. She made an additional request for the catheter to be changed this morning by RN-V. The DON stated that she discovered that the Resident #1 left the facility (to the hospital) without a changed catheter tubing but only changed catheter bag. It was her expectation that it was changed yesterday. Interview on 02/20/2023 at 3:57pm, CNA-Z stated Resident #1 had puss in her catheter tubing when she drained the catheter bag and performed incontinent care about 2 weeks ago. She stated she notified RN-V of the puss in resident's catheter tubing at that time. Interview on 02/20/2023 at 04:04 PM, Resident #56 (Resident #1's roommate) said she presses the call light frequently and it takes a while to answer. She said that the lady that came to answer the call light after two hours of pressing it. She had long dark hair and was part of administration but did not work the floor. Resident #56 said that this staff went to the Resident #1 and said Oh, My God, when she saw the resident. Resident #56 said that the staff stated she couldn't help Resident #1 and left the room. Resident #56 said she thought the staff was coming back but never did. Resident #56 said that she could hear Resident #1 throwing up and gurgling. Resident #56 said no one changed their catheters. She said that yesterday (02/19/2023) the staff just changed the bag. Resident #56 said that the regional Hispanic nurse did in fact tell the nurse to just change the bag until she got caught up and that she could change it later. Resident #56 said it was the same nurse that told her in Spanish to butt out and put her hand to her mouth as in telling her to hush and she cut her eyes. Interview on 02/20/23 04:34 PM, RN-V stated while in Resident's room that she was short of staff on 02/19/2023 and behind. She said that when the regional nurse came, she told her to change the catheter bag only. She said that she is often short staffed or without staff and can do what she can do. She said she is trying hard and stays for the residents. Interview on 02/21/2023 at 4:46 PM, interview with Resident #1 family members A and B revealed that when they would come to see her, she would look malnourished , and her catheter bag was always full. Review of Resident #1 physician orders dated 10/13/2022 revealed Foley Catheter: Size (10cc) FR (16) Diagnosis: Neurogenic bladder (lack bladder control due to brain, spine, or nerve problems) Review of Resident #1's physician order dated 10/21/2022 revealed: Foley Catheter: May obtain urine sample via Foley Catheter Port as needed when a Urine Analysis is ordered. (If Foley Catheter has been in place greater than 14 days, change Foley Catheter before obtaining urine.) and Foley Catheter: Provide catheter care every shift. Record review of Resident #1 electronic orders accessed on 02/20/2023 revealed there were orders to address her indwelling catheter. Resident #1 did have orders to change foley catheter and drainage bag as needed for indications of blockage, increased sediment, infection and displaced, as needed. Record review of Resident #1 electronic care plan accessed on 02/20/2022 revealed the following: Problem - Resident #1 has Indwelling Foley Catheter: Goal - Resident will not show signs of urinary infection or urethral trauma. Interventions - Change catheter every per MD order, document urinary output; record the amount, type, color and odor, observe for leakage, keep catheter system a closed system as much as possible, position bag below level of bladder, provide catheter care as scheduled and PRN. Problem- Resident #1 has a urinary tract infection. Goal- resident will not exhibit signs of a urinary tract infection. Interventions- Administer Bactrim DS (antibiotic), encourage fluids, keep perineal area clean and dry and report signs or UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain, difficulty urinating, low back pain/flank pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine and blood in urine. Initiated date of 10/15/2022 and revised date of 01/31/2023. Record review of Resident #1 most recent significant change Minimum Data Set (MDS) Section C dated 01/30/2023 revealed she had the ability to express ideas and wants and was able to understand others clearly. Resident #1 had a Brief Interview for Mental Status (BIMS) of 14 out of score of 15 which indicated an intact cognition. Resident #1 was extensive assistance for activities of daily living (ADL) except for eating where she required supervision. Record review of Resident #1 significant change MDS on 01/30/2023 revealed Resident #1 had an indwelling catheter reported in section H: Bladder and Bowel. Record review of Resident #1's vital reports, dated 02/21/2023, provided by Corporate Clinical Leader RN-H revealed the following documentation concerning Resident #1's catheter being drained, and the amount of urine noted, between 01/18/2023 until 02/19/2023, was not documented or done on- o 01/20/2023 on day or night shift o 01/21/2023 on day or night shift o 01/22/2023 on day or night shift o 01/23/2023 on day shift o 01/24/2023 on day or night shift o 01/25/2023 on day or night shift o 01/26/2023 on day or night shift o 01/27/2023 on day shift o 01/28/2023 on day or night shift o 01/29/2023 on day or night shift o 01/30/2023 on day or night shift o 01/31/2023 on day or night shift o 02/01/2023 on day or night shift o 02/02/2023 on day shift o 02/03/2023 on day shift o 02/04/2023 on day or night shift o 02/05/2023 on day shift o 02/06/2023 on day or night shift o 02/07/2023 on day or night shift o 02/08/2023 on day shift o 02/09/2023 on day or night shift o 02/10/2023 on day or night shift o 02/11/2023 on day or night shift o 02/12/2023 on day shift o 02/13/2023 on day or night shift o 02/14/2023 on day or night shift o 02/15/2023 on day or night shift o 02/16/2023 on day shift Record review of hospital record dated 02/19/2023 at 8:48pm History and Physical, revealed the following physician's notes- We sent her to the ICU Again, clinically it just seems to be a very ill patient, who was sent from the nursing home for an honestly a bogus reason at this point. At any rate from what I can gather she had left sided weakness from a prior stroke, but today currently it seems like she is not moving the right side, so we will get MRI of the brain. She does have a UTI in her labs, which will be treated. Record review of Resident #1's community hospital records revealed dated 02/19/2023, Resident #1 was admitted into community hospital ICU with diagnosis of UTI & rule out stroke. Record reviewed on Resident #1's community hospital records labs, assessment and plan dated 02/19/2022 revealed, Resident #1 had a primary diagnosis of Urinary Tract Infection, with orders to check cultures, place her on ceftriaxone (antibiotic) Record review of hospital records dated 02/21/2023 revealed that Resident #1 had a diagnosis of Sepsis (A life threatening complication or infection. Sepsis occurs when chemicals released in the bloodstream to fight an infection throughout the body. This can result in multi organ system failure and even death). Records review of hospital records dated 02/21/2023 Resident #1's Assessment and Plan revealed: 1. UTI in the setting on chronic indwelling foley catheter. Urine culture grew E coli. Blood cultures grew gram positive cocci. Start IV Vancomycin and Rocephin (antibiotics). 2. Bacteremia: Blood culture grew gram positive cocci. Start IV Vancomycin (antibiotic) and Rocephin (antibiotic). Record review of the facilitates policy titled Catheter Care, Urinary; dated September 2014 revealed: Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Preparations: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. General Guidelines: 1. Following aseptic insertion of the urinary catheter, maintain a closed drainage system. 2. If it breaks in aseptic technique, disconnection or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment, as ordered. Input/Output: 1. Observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to the physician or supervisor. 2. Maintain an accurate record of the resident's daily output, per facility policy and procedure. Maintaining Unobstructed Urine Flow: 1. Check the resident frequently to be sure he/she is not lying on the catheter and to keep the catheter and tubing free of kinks. 2. Unless specifically ordered, do not apply a clamp to the catheter. 3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine tubing and drainage from flowing back into the urinary bladder. Infection Control: 1. Use standard precautions when handling manipulating the drainage system. 2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. a. Do not clean the periurethral area with antiseptics to prevent catheter associated UTI's while the catheter is in place. Routine hygiene. b. Be sure the catheter tubing and drainage are kept off the floor. c. Empty the drainage bag regularly using a separate, clean collection container for each resident. d. Empty the collection bag at least every 8 hours. Changing Catheters: 1. Changing indwelling catheters or drainage bags as routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstructions, or when the closed system is compromised. Complication: 1. Observe the resident for complications associated with urinary catheters. a. If the resident indicates that his/her bladder is full or that he/she needs to void, notify the physician. b. Check the urine for unusual appearance (color, blood). c. Notify the physician or supervisor in the event of bleeding, or if the catheter is accidently removed, d. Report any complications that the resident may have of burning, tenderness, or pain in the urinary area. e. Observe for signs or symptoms of urinary tract infection or urinary retention. Report findings to the physician or supervisor immediately. Specimen Collection: 1. If a small volume of urine is needed for a urinalysis or culture, cleanse the port with a disinfectant and aspirate from the needless port using a sterile syringe ir cannula adapter. Documentation: The following information should be recorded in the resident's medical record. 1. The date and time the catheter care was given. 2. The name and title of the individual giving the care 3. All assessment data obtained when giving catheter care. 4. Character of urine such as color (straw colored, dark, or red) clarity (cloudy, solid particles, or blood, and odor. 5. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. 6. Any problems or complaints made by the resident related to the procedure. 7. How the resident tolerated the procedure. 8. If the resident refused the procedure, the reasons why the interventions taken. 9. The signature and title of the person recording the data. Reporting: 1. Notify the supervisor if the resident refuses the procedure. 2. Report the information in accordance with the facility policy and professional standards of practice. Record review of U.S. National Library of Medicine Medline Plus (https://medlineplus.gov/ency/article/003981.htm) electronically accessed on 03/01/2023 revealed the following: Indwelling catheter care. When to Call the Doctor. A urinary tract infection is the most common problem for people with an indwelling urinary catheter. Call your health care provider if you have signs of an infection, such as: Pain around your sides or lower back. Urine smells bad, or it is cloudy or a different color. Fever or chills. A burning sensation or pain in your bladder or pelvis. Discharge or drainage from around the catheter where it is inserted into your body. You do not feel like yourself. Feeling tired, achy, and have a hard time focusing. Also call your provider if: Your urine bag is filling up quickly, and you have an increase in urine. Urine is leaking around the catheter. You notice blood in your urine. Your catheter seems blocked and not draining. You notice grit or stones in your urine. You have pain near the catheter. You have any concerns about your catheter. Changing Your Catheter, you will need to change the catheter about every 4 to 6 weeks. Always wash your hands with soap and water before changing it. When to Call the Doctor. Your catheter seems blocked. You notice grit or stones in your urine. Your supplies do not seem to be working (balloon is not inflating or other problems). You notice a smell or change in color in your urine, or your urine is cloudy. You have signs of infection (a burning sensation when you urinate, fever, or chills). This was determined to be an Immediate Jeopardy (IJ) on 02/22/2023 at 4:55 pm. The Interim Administrator, Corporate Survey Resource Personnel, Corporate Regional [NAME] President of Operations, and two (2) Corporate Clinical Company Leader RNs were notified. The Interim Administrator was provided with the IJ template on 02/22/2023 at 4:55 pm. The following Plan of Removal was accepted on 02/23/2023 at 7:58pm and included: Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on 2/22/2023. Action 1: Resident #1 discharged to an acute care hospital for further evaluation on 2/19/2023. Action 2: The Director of Nursing and or/designee will in-service all nurses regarding resident assessment and charting/documentation. The Director of Nursing and/or designee will in-service all nurses regarding foley catheter care. The Director of Nursing and/or designee will in-service all CNAs, TNAs, Hospitality Aides regarding reporting foley catheters holding sediment/being foggy to the charge nurse and ensuring that they are emptying the bag as needed. If the CNAs, TNAs, Hospitality Aides feel as if their concerns are not being followed through, they are to report immediately to the Director of Nursing this will be made evident through communication with the CNAs, TNAs, Hospitality Aides and their Director of Nursing. If the CNAs, TNAs, Hospitality Aides feel as if the charge nurse and nursing administration is not following up they should immediately report to their administrator. How will the facility ensure that care needs are being communicated up the chain? The facility will ensure care needs are communicated up the chain through open communication, rounding and speaking with staff/listening to their concerns, and facility's communication with their corporate support team. How will missed treatments be communicated from shift to shift? Nurses will be in-serviced to communicate, this communication can be verbal, 72-hour report/facility activity report (72-hour report/facility activity report contains new orders, progress notes written, discontinued orders, event reports, vitals outside of normal range, opened or created observations), and/or via telephone, to their nursing administration regarding missed treatments, as well as, communicating shift to shift on missed treatments. Who will be monitoring that the nurses have an understanding of the importance to communicate identified issues with other shifts and administration? The Director of Nursing, Administrative Nurses, and Administrator will monitor that the nurses have the understanding of the importance to communicate via writing on the 72-hour report/facility activity report, verbally, and/or via telephone identified issues with other shifts and administration by education, morning clinical meetings/review of the 72-hour report/activity report with nurses, nursing administration, and administration, and nursing-to-nurse report. How will the facility ensure that Nurses and CNA's have a good understanding of individual resident care needs and who is monitoring their competency? Nurses and Nurse Aides will have a good understanding of individual care needs by understanding on how to pull the residents' care plans from the electronic medical record. This action will be in-serviced. The Director of Nursing and/or designee will ensure competency through requesting staff to demonstrate understanding, at random, 3 times weekly, for 4 weeks. All indicated staff will be in-service immediately prior to working their next shift. All new and temporary (internal/external agency) staff will be in-serviced over the above information, the administrator and/or Director of Nursing will ensure this by checking the schedule and ensuring a designee will in-service the material for anyone on the schedule that has yet to be in-serviced. Date: 2/23/2023 Person(s) Responsible: Administrator and Director of Nursing Action 3: On 2/20/2023 the Clinical Company Leaders, Regional Resource Nurse-J, and/or designee completed foley catheter rounds to ensure all foley catheters are in good condition and changed those that were needed. All residents' orders with indwelling catheters were reviewed by Clinical Company Leaders, Regional Resource Nurse-J, and/or designee. Clinical Company Leaders, Regional Resource Nurse-J, and/or designee validated the foley/suprapubic catheter order set was entered in the resident's chart. No additional identified areas of concern on 2/20/2023. Date: 2/22/2023 Person(s) Responsible: Clinical Company Leaders, Regional Resource Nurse-J, and/or designee Action 4: Three times a week Director of Nursing will complete random audits on foley catheters and foley catheter documentation for 4 weeks. Director of Nursing will share findings with administrator and educate staff/perform a skills check off as needed. Date: 2/22/2023 Person(s) Responsible: Director of Nursing and Administrator Action 5: Ad Hoc QAPI meeting performed with administrator, DON, corporate team and Medical Director. Date: 2/22/2023 Person(s) Responsible: Administrator Monitoring of facilities Plan of Removal through observations, interviews, and record reviews from 02/23/2023 at 7:58pm to 02/24/2023 at 6:48pm revealed: Resident #1 was transferred to local acute care hospital for further evaluation on 02/19/2023. Facility provided documentation of completion of foley catheter rounds ; and Ad Hoc QAPI meeting performed. Interviews on from 02/23/2023 at 7:58pm to 02/24/2023 at 6:48pm with 5 CNAs, 2 TNAs, and 1 Hospitality aide revealed they had been educated on foley catheters and communication. Interviews on from 02/23/2023 at 7:58pm to 02/24/2023 at 6:48pm with 7 nurses revealed they had been educated foley catheter care and communication The Interim Administrator, Corporate Survey Resource Personnel, Corporate Regional [NAME] President of Operations, and two (2) Corporate Clinical Company Leader RNs were informed the Immediate Jeopardy was removed on 02/24/2023 at 6:48pm. The facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and complications associated with an indwelling catheter for number 1 of 2 (Resident #1) reviewed for catheters. The facility failed to empty Resident #1's urinary catheter bag for two days, allowing the bag to fill overflowing up into the tubing that was inserted in the resident's bladder. The facility also failed to change the catheter when sediment was observed. Resident #1 was sent to a local hospital and diagnosed with sepsis (life threatening medical emergency related to the body's response to an infection) and a UTI. An IJ was identified on 02/22/2023. The IJ template was provided to the facility on [DATE] at 4:55pm. While the IJ was removed on 02/24/2023, the facility remained out of compliance at a scope of isolated and a severity level of actual harm because the facilities need to complete in service training and evaluate their effectiveness of their plan of removal. This failure placed residents at risk of not receiving care and services to prevent urinary tract infections or other issues related to bladder Functioning. Findings included: Record review of Resident #1 face sheet dated 02/20/2023 revealed a [AGE] year-old female admitted on [DATE] with a most recent admitted [DATE] with the following diagnoses: Unspecified fracture of left shaft/femur (bone in the thigh), Non ST elevation myocardial infraction (heart attack due to inadequate blood to the heart), gram negative sepsis (bacteria in the blood), neurogenic bladder (deficiency in bladder control due to brain, spinal cord or nerve problem) and urinary tract infection, site not specified (infection in any part of the urinary system). Record review of Resident #1 Discharge Minimum Data Set (MDS) Section C dated 09/19/2022 revealed in Section H (bladder and bowel) that she was frequently incontinent, 7 or more times episodes of incontinent, but 1 episode of continent). Record review of Resident #1 Quarterly Minimum Data Set (MDS) Section C dated 11/15/2022 revealed in Section H (bladder and bowel) that resident had an indwelling catheter. Observation and interview on 02/18/2023 at 10:15 AM, Resident #1's catheter bag was overflowing, urine in the tubing backing up. The catheter bag was leaking on the floor. Resident reported that it had not been drained in 2 days. The resident's urine was cloudy, with sediment visible in tubing and bag. There was a thick cloudy substance in the tubing that appeared to be puss. The DON was present with observation and visualized the catheter tubing and bag. When asked she said what she thought it was, she said that it appeared to be a puss like substance. She said that she was going to have it changed immediately. Interview on 02/18/2023 at 1:20pm, the DON stated that indwelling catheter bags should always be covered. She also stated that catheter bags that are full of urine backflowing in the catheter tubing place the resident at risk for infections. She stated she did not know reason for overflow catheter bag with urine backflowing into the catheter . She said it was the nurses responsibility to change it. Observation on 02/18/2023 at 3:58pm, revealed Resident #1 continued to have an indwelling catheter with an overfilled catheter bag with urine backflowing in the catheter tubing. The bag continued to be leaking urine onto the floor. The urine was cloudy, with sediment visible in tubing and bag. There was a thick cloudy substance in the tubing that appeared to be puss. This observation was reported to the Corporate Regional Resource Nurse-J Observation and interview on 02/19/2023 at 8:35 am, revealed Resident #1's catheter bag had been emptied; however, the catheter had not been changed and was observed to be crusted with sediment and puss like substance visible in the tubing. There was a trash bag on the floor under the uncovered catheter bag. Resident #1 stated that the trash bag was placed to catch the leaking urine from the catheter bag . Interview on 02/19/2023 at 9:45 am, RN-V stated she had not gone to check Resident #1's catheter bag to check see if it had been drained or changed during previous day's shift. She reported it was delegated to her, but she was busy and had not had a chance to do it. Interview on 02/19/2023 at 10:02 am, Corporate Regional Resource Nurse-J-J stated she had instructed RN-V to change Resident #1's catheter bag. She stated that RN-V reported that it had been changed. She collected a UA sample while changing it and would notify the physician . She stated that the catheter should have been changed due to the sediment. She said that she could see where there was an issue for concern. Interview on 02/19/2023 at 11:04 am, the DON stated she asked LVN-O and RN-V to change Resident #1's catheter bag yesterday afternoon. She could not remember the exact time, but it was after lunch. She said she went back to Resident #1's rooms yesterday afternoon and it continued to not be completed. She then asked them again to complete the task. She stated this failure placed the residents at risk for an infection. Interview on 02/19/2023 at 3:10pm, RN-V said she did not change Resident #1's catheter tubing but only changed the bag. She said she obtained a urine sample for an ordered UA from the catheter tubing that continued to have sediment and puss like substance but not from the bag. Interview and observation on 02/19/23 03:15 PM, Corporate Regional Resource Nurse-J-J stated she instructed RN-V to change Resident #1's entire catheter on 02/18/2023. Observation and interview on 02/19/2023 at 11:20 am, Resident #1 was speaking with surveyor without any distress. Observation on 02/19/2023 at 2:57 pm, Resident #1 was observed unresponsiveness with emesis (vomiting) on chest by surveyors and Corporate Clinical Company Leader RN-I. Corporate Clinical Company Leader RN-I stated she had to check Resident #1's pulse because she wasn't sure if she was alive. Interview on 02/19/2023 about 3:00pm, Resident #56 (Resident #1's roommate) said Resident #1 received her lunch tray about 12:00 pm and almost immediately started to throw up. Resident #56 then called for help, but no one came until about 2:00 pm. Resident #56 said that she told the staff that Resident #1 needed assistance, the staff was Assistant Administrator in Training who removed Resident #1's tray and stated, I can't help you and left the room. Observation on 02/19/2023 at 3:25pm, Resident #1 was transferred to community hospital via EMS. Interview on 02/19/2023 at 4:34pm, the DON said she looked at Resident #1's catheter yesterday (02/18/2023) and it appeared to have puss and sediment in the catheter tubing and catheter hub. She said it was her expectation that it was to be changed. She made an additional request for the catheter to be changed this morning by RN-V. The DON stated that she discovered that the Resident #1 left the facility (to the hospital) without a changed catheter tubing but only changed catheter bag. It was her expectation that it was changed yesterday. Interview on 02/20/2023 at 3:57pm, CNA-Z stated Resident #1 had puss in her catheter tubing when she drained the catheter bag and performed incontinent care about 2 weeks ago. She stated she notified RN-V of the puss in resident's catheter tubing at that time. Interview on 02/20/2023 at 04:04 PM, Resident #56 (Resident #1's roommate) said she presses the call light frequently and it takes a while to answer. She said that the lady that came to answer the call light after two hours of pressing it. She had long dark hair and was part of administration but did not work the floor. Resident #56 said that this staff went to the Resident #1 and said Oh, My God, when she saw the resident. Resident #56 said that the staff stated she couldn't help Resident #1 and left the room. Resident #56 said she thought the staff was coming back but never did. Resident #56 said that she could hear Resident #1 throwing up and gurgling. Resident #56 said no one changed their catheters. She said that yesterday (02/19/2023) the staff just changed the bag. Resident #56 said that the regional Hispanic nurse did in fact tell the nurse to just change the bag until she got caught up and that she could change it later. Resident #56 said it was the same nurse that told her in Spanish to butt out and put her hand to her mouth as in telling her to hush and she cut her eyes. Interview on 02/20/23 04:34 PM, RN-V stated while in Resident's room that she was short of staff on 02/19/2023 and behind. She said that when the regional nurse came, she told her to change the catheter bag only. She said that she is often short staffed or without staff and can do what she can do. She said she is trying hard and stays for the residents. Interview on 02/21/2023 at 4:46 PM, interview with Resident #1 family members A and B revealed that when they would come to see her, she would look malnourished , and her catheter bag was always full. Review of Resident #1 physician orders dated 10/13/2022 revealed Foley Catheter: Size (10cc) FR (16) Diagnosis: Neurogenic bladder (lack bladder control due to brain, spine, or nerve problems) Review of Resident #1's physician order dated 10/21/2022 revealed: Foley Catheter: May obtain urine sample via Foley Catheter Port as needed when a Urine Analysis is ordered. (If Foley Catheter has been in place greater than 14 days, change Foley Catheter before obtaining urine.) and Foley Catheter: Provide catheter care every shift. Record review of Resident #1 electronic orders accessed on 02/20/2023 revealed there were orders to address her indwelling catheter. Resident #1 did have orders to change foley catheter and drainage bag as needed for indications of blockage, increased sediment, infection and displaced, as needed. Record review of Resident #1 electronic care plan accessed on 02/20/2022 revealed the following: Problem - Resident #1 has Indwelling Foley Catheter: Goal - Resident will not show signs of urinary infection or urethral trauma. Interventions - Change catheter every per MD order, document urinary output; record the amount, type, color and odor, observe for leakage, keep catheter system a closed system as much as possible, position bag below level of bladder, provide catheter care as scheduled and PRN. Problem- Resident #1 has a urinary tract infection. Goal- resident will not exhibit signs of a urinary tract infection. Interventions- Administer Bactrim DS (antibiotic), encourage fluids, keep perineal area clean and dry and report signs or UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain, difficulty urinating, low back pain/flank pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine and blood in urine. Initiated date of 10/15/2022 and revised date of 01/31/2023. Record review of Resident #1 most recent significant change Minimum Data Set (MDS) Section C dated 01/30/2023 revealed she had the ability to express ideas and wants and was able to understand others clearly. Resident #1 had a Brief Interview for Mental Status (BIMS) of 14 out of score of 15 which indicated an intact cognition. Resident #1 was extensive assistance for activities of daily living (ADL) except for eating where she required supervision. Record review of Resident #1 significant change MDS on 01/30/2023 revealed Resident #1 had an indwelling catheter reported in section H: Bladder and Bowel. Record review of Resident #1's vital reports, dated 02/21/2023, provided by Corporate Clinical Leader RN-H revealed the following documentation concerning Resident #1's catheter being drained, and the amount of urine noted, between 01/18/2023 until 02/19/2023, was not documented or done on- o 01/20/2023 on day or night shift o 01/21/2023 on day or night shift o 01/22/2023 on day or night shift o 01/23/2023 on day shift o 01/24/2023 on day or night shift o 01/25/2023 on day or night shift o 01/26/2023 on day or night shift o 01/27/2023 on day shift o 01/28/2023 on day or night shift o 01/29/2023 on day or night shift o 01/30/2023 on day or night shift o 01/31/2023 on day or night shift o 02/01/2023 on day or night shift o 02/02/2023 on day shift o 02/03/2023 on day shift o 02/04/2023 on day or night shift o 02/05/2023 on day shift o 02/06/2023 on day or night shift o 02/07/2023 on day or night shift o 02/08/2023 on day shift o 02/09/2023 on day or night shift o 02/10/2023 on day or night shift o 02/11/2023 on day or night shift o 02/12/2023 on day shift o 02/13/2023 on day or night shift o 02/14/2023 on day or night shift o 02/15/2023 on day or night shift o 02/16/2023 on day shift Record review of hospital record dated 02/19/2023 at 8:48pm History and Physical, revealed the following physician's notes- We sent her to the ICU Again, clinically it just seems to be a very ill patient, who was sent from the nursing home for an honestly a [NAME] reason at this point. At any rate from what I can gather she had left sided weakness from a prior stroke, but today currently it seems like she is not moving the right side, so we will get MRI of the brain. She does have a UTI in her labs, which will be treated. Record review of Resident #1's community hospital records revealed dated 02/19/2023, Resident #1 was admitted into community hospital ICU with diagnosis of UTI & rule out stroke. Record reviewed on Resident #1's community hospital records labs, assessment and plan dated 02/19/2022 revealed, Resident #1 had a primary diagnosis of Urinary Tract Infection, with orders to check cultures, place her on ceftriaxone (antibiotic) Record review of hospital records dated 02/21/2023 revealed that Resident #1 had a diagnosis of Sepsis (A life threatening complication or infection. Sepsis occurs when chemicals released in the bloodstream to fight an infection throughout the body. This can result in multi organ system failure and even death). Records review of hospital records dated 02/21/2023 Resident #1's Assessment and Plan revealed: 1. UTI in the setting on chronic indwelling foley catheter. Urine culture grew E coli. Blood cultures grew gram positive cocci. Start IV Vancomycin and Rocephin (antibiotics). 2. Bacteremia: Blood culture grew gram positive cocci. Start IV Vancomycin (antibiotic) and Rocephin (antibiotic). Record review of the facilitates policy titled Catheter Care, Urinary; dated September 2014 revealed: Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Preparations: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. General Guidelines: 1. Following aseptic insertion of the urinary catheter, maintain a closed drainage system. 2. If it breaks in aseptic technique, disconnection or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment, as ordered. Input/Output: 1. Observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to the physician or supervisor. 2. Maintain an accurate record of the resident's daily output, per facility policy and procedure. Maintaining Unobstructed Urine Flow: 1. Check the resident frequently to be sure he/she is not lying on the catheter and to keep the catheter and tubing free of kinks. 2. Unless specifically ordered, do not apply a clamp to the catheter. 3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine tubing and drainage from flowing back into the urinary bladder. Infection Control: 1. Use standard precautions when handling manipulating the drainage system. 2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. a. Do not clean the periurethral area with antiseptics to prevent catheter associated UTI's while the catheter is in place. Routine hygiene. b. Be sure the catheter tubing and drainage are kept off the floor. c. Empty the drainage bag regularly using a separate, clean collection container for each resident. d. Empty the collection bag at least every 8 hours. Changing Catheters: 1. Changing indwelling catheters or drainage bags as routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstructions, or when the closed system is compromised. Complication: 1. Observe the resident for complications associated with urinary catheters. a. If the resident indicates that his/her bladder is full or that he/she needs to void, notify the physician. b. Check the urine for unusual appearance (color, blood). c. Notify the physician or supervisor in the event of bleeding, or if the catheter is accidently removed, d. Report any complications that the resident may have of burning, tenderness, or pain in the urinary area. e. Observe for signs or symptoms of urinary tract infection or urinary retention. Report findings to the physician or supervisor immediately. Specimen Collection: 1. If a small volume of urine is needed for a urinalysis or culture, cleanse the port with a disinfectant and aspirate from the needless port using a sterile syringe ir cannula adapter. Documentation: The following information should be recorded in the resident's medical record. 1. The date and time the catheter care was given. 2. The name and title of the individual giving the care 3. All assessment data obtained when giving catheter care. 4. Character of urine such as color (straw colored, dark, or red) clarity (cloudy, solid particles, or blood, and odor. 5. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. 6. Any problems or complaints made by the resident related to the procedure. 7. How the resident tolerated the procedure. 8. If the resident refused the procedure, the reasons why the interventions taken. 9. The signature and title of the person recording the data. Reporting: 1. Notify the supervisor if the resident refuses the procedure. 2. Report the information in accordance with the facility policy and professional standards of practice. Record review of U.S. National Library of Medicine Medline Plus (https://medlineplus.gov/ency/article/003981.htm) electronically accessed on 03/01/2023 revealed the following: Indwelling catheter care. When to Call the Doctor. A urinary tract infection is the most common problem for people with an indwelling urinary catheter. Call your health care provider if you have signs of an infection, such as: Pain around your sides or lower back. Urine smells bad, or it is cloudy or a different color. Fever or chills. A burning sensation or pain in your bladder or pelvis. Discharge or drainage from around the catheter where it is inserted into your body. You do not feel like yourself. Feeling tired, achy, and have a hard time focusing. Also call your provider if: Your urine bag is filling up quickly, and you have an increase in urine. Urine is leaking around the catheter. You notice blood in your urine. Your catheter seems blocked and not draining. You notice grit or stones in your urine. You have pain near the catheter. You have any concerns about your catheter. Changing Your Catheter, you will need to change the catheter about every 4 to 6 weeks. Always wash your hands with soap and water before changing it. When to Call the Doctor. Your catheter seems blocked. You notice grit or stones in your urine. Your supplies do not seem to be working (balloon is not inflating or other problems). You notice a smell or change in color in your urine, or your urine is cloudy. You have signs of infection (a burning sensation when you urinate, fever, or chills). This was determined to be an Immediate Jeopardy (IJ) on 02/22/2023 at 4:55 pm. The Interim Administrator, Corporate Survey Resource Personnel, Corporate Regional [NAME] President of Operations, and two (2) Corporate Clinical Company Leader RNs were notified. The Interim Administrator was provided with the IJ template on 02/22/2023 at 4:55 pm. The following Plan of Removal was accepted on 02/23/2023 at 7:58pm and included: Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on 2/22/2023. Action 1: Resident #1 discharged to an acute care hospital for further evaluation on 2/19/2023. Action 2: The Director of Nursing and or/designee will in-service all nurses regarding resident assessment and charting/documentation. The Director of Nursing and/or designee will in-service all nurses regarding foley catheter care. The Director of Nursing and/or designee will in-service all CNAs, TNAs, Hospitality Aides regarding reporting foley catheters holding sediment/being foggy to the charge nurse and ensuring that they are emptying the bag as needed. If the CNAs, TNAs, Hospitality Aides feel as if their concerns are not being followed through, they are to report immediately to the Director of Nursing this will be made evident through communication with the CNAs, TNAs, Hospitality Aides and their Director of Nursing. If the CNAs, TNAs, Hospitality Aides feel as if the charge nurse and nursing administration is not following up they should immediately report to their administrator. How will the facility ensure that care needs are being communicated up the chain? The facility will ensure care needs are communicated up the chain through open communication, rounding and speaking with staff/listening to their concerns, and facility's communication with their corporate support team. How will missed treatments be communicated from shift to shift? Nurses will be in-serviced to communicate, this communication can be verbal, 72-hour report/facility activity report (72-hour report/facility activity report contains new orders, progress notes written, discontinued orders, event reports, vitals outside of normal range, opened or created observations), and/or via telephone, to their nursing administration regarding missed treatments, as well as, communicating shift to shift on missed treatments. Who will be monitoring that the nurses have an understanding of the importance to communicate identified issues with other shifts and administration? The Director of Nursing, Administrative Nurses, and Administrator will monitor that the nurses have the understanding of the importance to communicate via writing on the 72-hour report/facility activity report, verbally, and/or via telephone identified issues with other shifts and administration by education, morning clinical meetings/review of the 72-hour report/activity report with nurses, nursing administration, and administration, and nursing-to-nurse report. How will the facility ensure that Nurses and CNA's have a good understanding of individual resident care needs and who is monitoring their competency? Nurses and Nurse Aides will have a good understanding of individual care needs by understanding on how to pull the residents' care plans from the electronic medical record. This action will be in-serviced. The Director of Nursing and/or designee will ensure competency through requesting staff to demonstrate understanding, at random, 3 times weekly, for 4 weeks. All indicated staff will be in-service immediately prior to working their next shift. All new and temporary (internal/external agency) staff will be in-serviced over the above information, the administrator and/or Director of Nursing will ensure this by checking the schedule and ensuring a designee will in-service the material for anyone on the schedule that has yet to be in-serviced. Date: 2/23/2023 Person(s) Responsible: Administrator and Director of Nursing Action 3: On 2/20/2023 the Clinical Company Leaders, Regional Resource Nurse-J, and/or designee completed foley catheter rounds to ensure all foley catheters are in good condition and changed those that were needed. All residents' orders with indwelling catheters were reviewed by Clinical Company Leaders, Regional Resource Nurse-J, and/or designee. Clinical Company Leaders, Regional Resource Nurse-J, and/or designee validated the foley/suprapubic catheter order set was entered in the resident's chart. No additional identified areas of concern on 2/20/2023. Date: 2/22/2023 Person(s) Responsible: Clinical Company Leaders, Regional Resource Nurse-J, and/or designee Action 4: Three times a week Director of Nursing will complete random audits on foley catheters and foley catheter documentation for 4 weeks. Director of Nursing will share findings with administrator and educate staff/perform a skills check off as needed. Date: 2/22/2023 Person(s) Responsible: Director of Nursing and Administrator Action 5: Ad Hoc QAPI meeting performed with administrator, DON, corporate team and Medical Director. Date: 2/22/2023 Person(s) Responsible: Administrator Monitoring of facilities Plan of Removal through observations, interviews, and record reviews from 02/23/2023 at 7:58pm to 02/24/2023 at 6:48pm revealed: Resident #1 was transferred to local acute care hospital for further evaluation on 02/19/2023. Facility provided documentation of completion of foley catheter rounds ; and Ad Hoc QAPI meeting performed. Interviews on from 02/23/2023 at 7:58pm to 02/24/2023 at 6:48pm with 5 CNAs, 2 TNAs, and 1 Hospitality aide revealed they had been educated on foley catheters and communication. Interviews on from 02/23/2023 at 7:58pm to 02/24/2023 at 6:48pm with 7 nurses revealed they had been educated foley catheter care and communication The Interim Administrator, Corporate Survey Resource Personnel, Corporate Regional [NAME] President of Operations, and two (2) Corporate Clinical Company Leader RNs were informed the Immediate Jeopardy was removed on 02/24/2023 at 6:48pm. The facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 2 of 25 residents (Resident #4 and Resident #25) reviewed for accidents and supervision. The facility failed to: A. Take reasonable precautions and provide adequate supervision and interventions to prevent Resident #4 from being physically harmed by Resident #24, when Resident #24 had increasing behaviors of anxiousness, agitation, and threatening behaviors over a period of approximately three weeks, which resulted in Resident #24 hitting Resident #4 in the face requiring emergency medical attention at a local hospital for Resident #4 on 09/16/22. B. Take reasonable precautions and provide adequate supervision and interventions when Resident #21 was witnessed by staff to be experiencing escalated behaviors of both physical and verbal aggression directed towards Resident #25 on 09/02/2022 and 09/09/2022 and on 09/14/2022 Resident #21 hit Resident #25 in the face . Resident #21 sustained a small red scratch across bridge of nose and a light purple discoloration under and by the nose on both sides. These failures could place residents at risk for resident-to-resident altercations that could result in serious physical and psychosocial harm and require emergency treatment and/or hospitalization . Findings include: In an interview on 09/16/2022 at 10:00am, the DON said that on 08/16/2022 the facility merged an all-female secure unit with an all-male secure unit. Resident #4 Record review of Resident #4's electronic face sheet, dated 09/22/2022 revealed that she was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses to include, .Major depressive disorder, Alzheimer's disease with early onset, Cognitive Communication Deficit, Seizures . Record review of Resident #4's most recent quarterly MDS dated [DATE] indicated she had unclear speech and rarely/never made herself understood. Section C indicated Resident #4 was Severely cognitively impaired. Section E indicated Resident #4 had no known behaviors. Section G indicated Resident #4 required supervision and setup help only for locomotion on the unit and did not require any mobility devices. Section I included the following diagnoses of Alzheimer's disease, depression, and a [CONDITION(S)] Disorder. Record review of Resident #4's care plan with a last care Conference date of 08/10/2022, revealed the following: .Problem: Start Date: 09/09/2022 Behavioral Symptoms-I pace up and down the halls frequently with no regards to others in my path. 8/1/22 I walked up behind another resident and got hit in the stomach. 8/17/2022 I pushed another resident in the hallway while I was pacing up and down the hall. 08/26/2022 I hit another resident in the face while walking in the hallway. Goal: I will have less than 3 episodes of physical aggression with other people in my path over the next 90 days .Approach: .I become stressed at times with loud noises such as others yelling and or loud televisions .I will be redirected to a quiet area when behavior is unacceptable .Problem Start Date: 09/09/2022 .I have behavior symptoms as evidenced by my wandering related to Alzheimer's disease. I reside in a secure unit. I wander into other resident's rooms and take their belongings. Edited: 09/15/2022 .Goal: My dignity will be maintained and I will wander about the secure unit without occurrence of significant injury over the next 90 days .Edited 09/12/2022 .Approach: Assist me in reorientation to room and secure unit with verbal cues .Observe my location with visual checks at least every 2 hours .Problem Start Date: 09/19/2022 .I have a laceration to my left eyebrow area r/t I was hit in the face by another resident when I went into his room uninvited. Goal: My laceration will heal with no redness swelling, drainage within the next 2 weeks .Approach: I will have my laceration monitored for redness, swelling or drainage . Record review of Resident #4's Event Report dated 09/16/2022 at 6:56pm, revealed the following: .Event Report: [Resident #4] .Event Date: 09/16/2022 at 6:55pm, Completed by LVN N .Description: Hit in face by another resident .Event Details: .CNA saw resident walking down the hallway. She then heard another resident say I'm going to hit you again if you don't get out of my room CNA said resident was hanging onto doorknob .Event was not witnessed .Describe Injury Laceration to left eyebrow area .Treatment Call 9-1-1, First Aid, Assessment and Physician Order/Treatment .New intervention immediately implemented to prevent reoccurrence: Increased monitoring for aggressor. ON called social worker and local mental health facility . Record review of Resident #4's nursing progress notes revealed the following entries: .09/16/2022 at 6:02pm The resident was transferred via ambulance from facility to [Local Hospital] due to altercation with another resident that occurred on the day shift .Electronically Signed LVN O .09/16/2022 7:03pm (late entry) CNA saw resident walking down the hallway. She then heard another resident say, I'm going to hit you again if you don't get out of my room. CNA N said resident was hanging onto doorknob of that resident's room. She immediately removed resident from his room and called me. Resident has approx. 2cm laceration to left eyebrow with moderate bleeding. Area cleaned with NS; pressure applied to stop bleeding. Dressing applied. ADMIN and DON notified. 911 called. Resident continued ambulating throughout unit. No other injuries noted. Resident left facility at 6:20pm on stretcher with EMS. [family member] notified, [Physician C] notified . electronically signed by LVN M .09/16/2022 at 9:45pm .This nurse called [Local Hospital] spoke with [Hospital RN] the resident is ready to come back to the facility. She received four sutures to the wound on her forehead/eyebrow area this nurse gave condition report on the resident to the facility administrator . Resident #24 Record review of Resident #24's electronic face sheet, dated 09/22/2022 revealed that he was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses to include, .Paranoid [CONDITION(S)], Patient's noncompliance with other medical treatment and regimen, Alcohol dependence, in remission, Unspecified dementia without behavioral disturbance . Record review of Resident #24's most recent quarterly MDS dated [DATE] indicated he had clear speech, was able to make self-understood, and had the ability to understand others. Section C indicated Resident #24 was moderately cognitively impaired with a BIMS score of 10. Section E indicated Resident #24 had verbal behaviors directed toward others (e.g., threatening others, screaming at others, cursing at others) and section E0800 did not indicate Resident #24 had rejected care or wandered. Section G indicated Resident #24 required supervision and setup help only for locomotion on the unit and did not require any mobility devices. Section N revealed Resident #24 had received an antipsychotic and antianxiety medication during a 7 day look back. Record review of Resident #24's care plan with a last care Conference date of 06/29/2022, revealed the following: .Problem: Start Date: 03/27/2022 Behavioral Symptoms-I have behavioral Symptoms of wandering . Goal: I will have fewer episodes of wandering .Approach: Redirect resident as needed .Remove from public area when behaviors is unacceptable 03/27/2022 .Problem Start Date 03/27/2022 [CONDITION(S)] Drug Use .Edited 06/29/2022 .Goal: Benefit without side effects .Monitor target behaviors per [CONDITION(S)] flowsheets .Problem: Mood State Edited 07/21/2022 .Goal I will express/exhibit satisfaction .Approach: .Meds as ordered Record review of Resident #24's electronic physician orders dated 08/22/2022 thru 09/22/2022, unsigned revealed the following: .Start Date: 03/25/2022- Open Ended .Senior Psychiatric and Psychological Services to Evaluate and Treat as Needed .Start Date: [MEDICATION(S)] ([MEDICATION(S)] microspheres) suspension .25mg/2mL; amt: 25mg; Intramuscular .DX: Paranoid [CONDITION(S)] .Once a day on Every Wednesday 2 weeks; Bedtime .ordered by [PNP M] .Start Date: 03/25/2022 [MEDICATION(S)] tablet; 15mg; amt: 1 oral DX: Paranoid [CONDITION(S)] .Twice a day .Ordered by: [Physician C] .[MEDICATION(S)] tablet extended release 12 hr; 100mg; amt: 1 tablet; oral DX: Paranoid [CONDITION(S)] .Ordered by: [PNP M] . Start date: [MEDICATION(S)] .; 0.5mg; amt: 1 oral DX: paranoid [CONDITION(S)] three times a day .Ordered By: [PNP M] . According to the National Alliance on Mental Illness, .[MEDICATION(S)] Extended-release injectable suspension: 25 mg .Generic Name: [MEDICATION(S)], is a medication that works in the brain to treat [CONDITION(S)] .[MEDICATION(S)] rebalances [MEDICATION(S)] and serotonin to improve thinking, mood, and behavior . One of the long-acting injectable forms, known as [MEDICATION(S)](R), should be received every 2 weeks as ordered by your healthcare provider . Missing doses of [MEDICATION(S)] may increase your risk for a relapse in your symptoms . [MEDICATION(S)](R) ([MEDICATION(S)] long-acting injection) should be received every 2 weeks. It should be administered by your health care professional through an injection into your upper arm or buttocks area. The medication effects last for approximately 2 weeks . Accessed on 10/03/2022 https://www.nami.org/About-Mental-Illness/Treatments/Mental-Health-Medications/Types-of-Medication/[MEDICATION(S)]-([MEDICATION(S)]). According to the National Alliance on Mental Illness, .[MEDICATION(S)] ([MEDICATION(S)]) .is a medication that works in the brain to treat [CONDITION(S)] .[MEDICATION(S)] rebalances [MEDICATION(S)] and serotonin to improve thinking, mood, and behavior .symptoms of [CONDITION(S)] include .hallucinations, delusions, disorganized thinking, little desire to be around other people . Missing doses of [MEDICATION(S)] may increase your risk for a relapse in your symptoms. Do not stop taking [MEDICATION(S)] or change your dose without talking with your healthcare provider first. For [MEDICATION(S)] to work properly, it should be taken every day as ordered by your healthcare provider .Accessed on 10/03/2022 https://www.nami.org/About-Mental-Illness/Treatments/Mental-Health-Medications/Types-of-Medication/[MEDICATION(S)]-([MEDICATION(S)]) According to the National Alliance on Mental Illness, .[MEDICATION(S)] ([MEDICATION(S)]) .is a mood stabilizer medication that works in the brain. It is approved for the treatment of [CONDITION(S)] 1 disorder (also known as manic depression) .Symptoms of depression include .psychomotor agitation (nervous energy) .symptoms of [CONDITION(S)] include: Feeling irritable or high . Missing doses of [MEDICATION(S)] may increase your risk for a relapse in your mood symptoms . Accessed on 10/03/2022 https://www.nami.org/About-Mental-Illness/Treatments/Mental-Health-Medications/Types-of-Medication/[MEDICATION(S)]-([MEDICATION(S)]). According to the National Alliance on Mental Illness, .[MEDICATION(S)] is a benzodiazepine. It is approved for the treatment of panic disorder .also commonly used to treat difficulty sleeping and alcohol withdrawal . Benzodiazepines, such as [MEDICATION(S)], are often used for short periods of time only. They may produce emotional and/or physical dependence (addiction) even when used as recommended. With input from you, your health care provider will assess how long you will need to take the medicine. Do not stop taking [MEDICATION(S)] without talking to your healthcare provider first. Stopping [MEDICATION(S)] abruptly may result in one or more of the following withdrawal symptoms: irritability, nausea, tremor, dizziness, blood pressure changes, rapid heart rate, and seizures. Withdrawal reactions may occur when dosage reduction occurs for any reason .Accessed on 10/03/2022 https://www.nami.org/About-Mental-Illness/Treatments/Mental-Health-Medications/Types-of-Medication/[MEDICATION(S)]-([MEDICATION(S)]) Record review of Resident #24's August MAR revealed Resident #24 had an order for [MEDICATION(S)] 400mg; amount to administer 400mg; intramuscular .Once a day every 28 days .Start 04/11/2022 End Date 08/18/2022 .08/01/2022 revealed Resident #24 did not receive this medication due to Not administered: Drug Item Unavailable, Called Pharmacy Waiting on prior authorization .[LVN N] .On 08/18/2022, an order was placed on MAR for [MEDICATION(S)] 25mg/2mL; administer 25mg intramuscular once a day on Friday, every two weeks; review of the MAR for 08/19/2022 revealed there was no administration record for this medication and this order was discontinued on 08/24/2022 and reentered to reflect the same order [MEDICATION(S)] 25mg/2mL; administer 25mg intramuscular once a day on Wednesday, every two weeks and review of the MAR for 08/24/2022,revealed there was no administration of this medication and no reason/comment charted. Review of Resident #24's medications for [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] did not reflect any missed doses or refusals. According to the National Alliance of Mental Illness, .[MEDICATION(S)] ([MEDICATION(S)]) is a medication that works in the brain to treat [CONDITION(S)] .It is a second-generation antipsychotic .[MEDICATION(S)] rebalances [MEDICATION(S)] and serotonin to improve thinking, mood and behavior . Accessed on 10/03/2022. https://www.nami.org/About-Mental-Illness/Treatments/Mental-Health-Medications/Types-of-Medication/[MEDICATION(S)]-([MEDICATION(S)]) Record review of Resident #24's September MAR revealed Resident #24 had the following refusal of medications or there was no documentation to show the medication had been administered: [MEDICATION(S)] 100mg 6 doses: 09/01, 09/03, 09/04, 09/07, 09/08, 09/12. [MEDICATION(S)] 0.5mg 11 doses: 09/01 nighttime dose, 09/03 morning and afternoon dose, 09/04 morning and afternoon dose, 09/07 nighttime dose, 09/08 morning dose, 09/09 afternoon dose, 09/12 nighttime dose, 09/13 afternoon dose, 09/14 afternoon dose. [MEDICATION(S)] 15mg 6 doses: 09/01 evening dose, 09/03 morning dose, 09/04 morning dose, 09/07 evening dose, 09/08 morning dose, 09/12 evening dose. [MEDICATION(S)] 25mg IM 1 dose on 09/07/2022 Record review of Resident #24's Point of Care History from dates 08/16/2022 thru 09/17/2022, revealed the following behaviors were charted for Resident #24: Screaming at others: 08/27/2022 08/28/2022 09/17/2022 Threatening Others: 08/19/2022 The resident was very upset just walking next to hospitality aid or even looking at the hospitality aid and attacked the aid a few times and would lift his left fist to the aid to threaten to hit the aid. I would get in between the two and redirect the resident as the aid walked the other direction to get the resident back to his room . [agency CNA 2] . 08/26/2022 Cursing at others: 09/12/2022 (yelled for several hour) [Agency CNA] Pacing: 09/12/2022 09/14/2022 Making Disruptive Sounds: 09/14/2022 Hitting Others: 09/16/2022 hit a resident in the face once [TNA E] Record review of Resident #24's psychiatric evaluation/management visits by [PNP M] revealed the following: 8/12/2022: (*Prior to merge of units) Patient reports to 'just fine' Staff report no behavioral problems .He is pleasant and says he has been doing well. He says he has been sleeping well. He denies any needs. No acute emotional distress noted .Diagnosis: Paranoid [CONDITION(S)], generalized anxiety disorder .patient has shown mild improvement in response to treatment. 08/18/2022 .Patient is very agitated today. He is sitting in the common area. He is yelling and not easily redirected. Staff says he has been agitated since they moved residents from the female unit in and has escalated today. He calms some after he eats but then begins yelling again in the shower. Order given for [MEDICATION(S)] ([MEDICATION(S)]) 10mg now .One time order for [MEDICATION(S)] IM given now for extreme agitation and aggression. Patient is generally non-compliant with medications .Behavior was uncooperative, hostile and agitation .Mood was angry and anxious .Diagnosis: Paranoid [CONDITION(S)], Generalized Anxiety Disorder .Comments: Yelling and aggressive with self, staff, and other residents. Record review of Resident #24's event report revealed the following: . Event Date 09/16/2022 at 6:36pm .Completed by: [LVN N] .Description: hit another resident in the face . Event Details: aggressive/combative behavior .Was resident or others injures during the behavioral episode? Yes .other resident had laceration to left eyebrow . Does resident exhibit or complain of any of the following? Anger .Behavioral Symptoms .Physical Behavior directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing .): not exhibited in last 7 days .Verbal Behavioral Symptoms (e.g., threatening others, screaming at others, cursing at others) directed towards others: Behavior not exhibited in last 7 days (*refer to nursing note on 09/14/2022). Other behavior symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, throwing food, verbal/vocal symptoms like screaming, disruptive sounds) .Behavior not exhibited in last 7 days . Behavior Symptoms put others at risk for injury Did any of the identified symptoms(s) put others at significant risk for physical injury? Yes .Rejection of Care Presence and Frequency Did the resident reject evaluation or care (e.g., .taking medications .) Behavior not exhibited . Further review of the event report indicated that Resident #24 had received daily for seven days his antipsychotic, antianxiety and antidepressant medications for seven days (refer to September MAR for evidence there was only 5 days for his antipsychotic and 3 days of administration for the anti-anxiety) .Notes: .CNA heard resident say 'I am going to hit you again if you don't get out of my room. CNA said another resident was hanging onto doorknob of the resident's room, bleeding from her head. She immediately removed resident from his room and called me. Resident immediately went to his bed and laid down. DON, Administrator notified. [Physician C] and [PNP M] notified. Resident is no under increased level of supervision. Social worker on scene. Electronically signed [LVN N] . Record review of Resident #24's nursing progress notes revealed the following entries: 8/20/2022 6:15am Late Entry; .Reported by staff that when supper tray was brought to resident in his room resident knocked tray in air yelling 'get that out it's poison!' Unable to redirect. Electronically signed [LVN L]. 09/01/2022 10:00pm, .The resident refused all scheduled night medications, past several attempts to administer them . electronically signed [LVN O] .10:10pm notified [PNP M] of refusal of HS meds. No new orders . Electronically signed [LVN O]. 09/02/2022 at 6:00pm Mood is Anxious Electronically signed [LVN O] 09/07/2022 at 10:00pm .He REFUSED his night medications past several attempts to administer them. Notified [Physician C] and [PNP M]. No complains of pain, no behaviors/emotional distress noted. He is asleep in bed . Electronically signed [LVN O]. 09/11/2022 at 12:00am .Mood: Anxious, Irritable, Angry .Behavior Guarded, agitated, paranoid . electronically signed [LVN O]. 09/13/2022 at 12:00am .Behavior Guarded, agitated . Electronically Signed [LVN O] 09/14/2022 at 5:33pm .Resident threatened Administrator. No physical touch noted. Electronically Signed [RN B] 09/16/2022 at 7:09pm .CNA heard resident say, 'I am going to hit you again if you don't get out of my room'. CNA said another resident was hanging onto doorknob of the resident's room, bleeding from her head. She immediately removed resident from his room and called me. Resident immediately went to his bed and laid down. DON, Administrator notified. [Physician C] and [PNP M] notified. Resident is not under increased level of supervision. Social worker on scene. Electronically signed [LVN N] 09/16/2022 at 7:11pm .SW informed by nursing staff and Administrator; resident hit a female resident who wandered in his room [Local Law Enforcement] present to visit with resident regarding incident with assault. Resident adamantly stating she walked in my room to police .Per staff, resident had been having delusions of someone harming him and seemed to be in a vigilant and attack mode off and on throughout the week. Resident typically self-isolates and very rarely leaves his room. It is difficult for SW and staff to assess and have a rapport with resident due to resident refusal to talk with staff. Resident mood typically antisocial, irritable, exhibiting self-isolating behavior . Electronically signed [SW]. Observation on 09/19/2022 at 10:18am revealed Resident #4 continued with pacing and wandering up and down secure unit #1. Resident #4 was noted to have sutures to her left eyebrow and purple/greenish discoloration to her left eye and orbit. In an interview on 09/14/2022 at 11:20am, CNA R said that she always works Unit 1. CNA R said that there had been a big change since the facility had merged the females in with the males a few weeks ago. CNA R said yesterday 09/13/2022, Resident #24 was pacing and he started getting agitated at [Resident #9] for screaming and [Resident #25] for pacing/wandering and started screaming Shut up, shut up, Shut up! CNA R said that the facility removed [Resident #9] from the secured unit due to her screaming and yelling on 09/13/2022, but there were still residents that were triggers for Resident #24 and Resident #21, to become verbally and physically aggressive towards. In an interview on 09/14/2022 at 12:00pm, TNA S said that yesterday [Resident #24] became very upset on the unit and had verbal aggression towards two staff members and kept yelling shut up, shut up, which is usually a warning he gives you before he snaps. In an interview on 09/19/2022 at 9:00am, the Administrator reported that Resident #24 had hit Resident #4 in the face on Friday evening 09/16/2022, which sent Resident #4 to the hospital where she received four sutures to her left eyebrow and Resident #24 was placed on line-of-sight monitoring until 09/17/2022, whe n he was sent to a local psychiatric hospital. The Administrator indicated that the police were notified. The Administrator said that there were two staff members on the unit at the time of the incident and that the CNAs did not see Resident #4 wander into Resident #24's room until TNA E overheard Resident #24 threatening to hit Resident #4 again if she did not leave his room. In an interview on 09/19/2022 at 4:30pm, LVN N said that she was working when the resident-to-resident altercation occurred with Resident #4 and Resident #24. LVN N said that TNA E had come to her and informed her that there had been an incident. TNA E said she was walking down the hall and heard Get out of my room or I am gonna hit you again if you don't get out of my room. LVN N said that TNA E found Resident #4 in Resident #24's room and removed her from Resident #24's room. LVN N said TNA E reported that Resident #4 was bleeding. In an interview on 09/19/2022 at 12:33pm, CNA R said that she always works secure unit 1 and had worked at the facility for three and half years. CNA R said that she had worked last Wednesday on 09/14/2022 and noted that Resident #24 was pacing up and down the hallways and that Resident #4 would wander into Resident #24's room often. CNA R said that Resident #4 is easily redirected when found wandering but unless staff are looking down the hallway and not distracted by other residents it is hard to see her go into other rooms. CNA R said that Resident #24 will usually give verbal warnings and will yell for residents that wander to get out his room and that is the staff's cue to get in there and see what is going on. CNA R said that since the facility combined the females and the male secure units in mid-August it has been a lot, especially for [Resident #24]. CNA R said that Resident #24 prefers a calm, quiet atmosphere and does not like his space invaded. CNA R said that Resident #9 had a known behavior of screaming and yelling; Resident #4 was very prone to wander into other rooms and would require redirection multiple times throughout the day. CNA R said she had notified both the Administrator and the DON when behaviors had started increasing on unit 1 since the females and males had been combined in mid-August and was told to redirect. CNA R said she had expressed concern last week to the DON about the increased behaviors with Resident #24 and the facility finally removed Resident #9 from the secure unit. CNA R said that had helped but there were still other residents that were triggers, specifically residents that had a behavior of wandering. CNA R said that she had worked last Saturday when Resident #24 was transferred to the local psychiatric hospital and that Resident #24 voiced to her I shouldn't have hit her, I shouldn't have hit her referring to Resident #4. CNA R said Resident #24 was sent to the local psychiatric hospital by a police escort due to the facility feeling it was unsafe to have a staff member transport Resident #24. CNA R felt that due to the increased behaviors with the females, specifically residents that were prone to wandering, it was difficult to supervise the hallway at all times with other tasks needing to be done. CNA R said it would be easy for wandering residents to go into another resident's room without staff seeing it unless they strictly monitor the hallways at all times. CNA R said that initially when the units were combined, they were staffing 3-4 aides, but indicated that there had been a dispute between two staff members soon after the merge and one of those staff members was taken off the unit, which left 3 and then eventually it has dwindled down to 2 staff on the unit. CNA R said only if staff call and tell the DON or Administrator to let them know it is getting out of hand will they send an additional person, which often times had been the Administrator. CNA R said that she had reported multiple times via her phone to the DON regarding the increased behaviors that residents were experiencing since the merge of the two units and was just told to report it to your nurse and redirect. CNA R said in addition she had verbalized to both the Administrator and to the DON multiple times on the phone and in person that this was getting out of hand and it was too much to handle. It was unfair to women and men, they (males) were not used to the stimulation from the females; I have requested the mesh stop signs and they said they would see what they could do and I have been asking for black tape to put on the floor so residents would walk around it thinking it was a hole in the floor. I mentioned it definitely more than once and was just told 'we will look into it; we will see what we can do'. CNA R said that neglect was not doing something that you know should be doing and it could be harmful or hurtful to a resident. CNA R said that she charts on behaviors each shift and reports to her charge nurse every day. CNA R said that she feels that Resident #24 and Resident #4's incident could have been prevented when Resident #24 was showing signs of increased agitation and verbally yelling to other residents. In an interview on 09/19/2022 at 2:17pm, RN B said that she knew Resident #24 was agitated last week because a lot of the women wander and walk into other resident's rooms; we are often redirecting. RN B said that there are always two CNAs on the secure unit and that if she is not busy, she will go onto the unit and help as well. RN B said that she has seen Resident #24 agitated and knew that sometimes when she offered his [MEDICATION(S)], he would refuse it. RN B said that [MEDICATION(S)] is to help him with his anxiety. RN B said that sometimes she charts the refusal and sometimes she doesn't but anytime medications are refused, the physician should be notified . RN B said she has seen Resident #4 go up and get really close to other residents in the secure unit and said she cannot make sense with her speech. RN B said staff attempt to redirect her and I would explain to Resident #24 that [Resident #4] is unaware of the wandering and doesn't understand what she is doing and he would not comment but would just go back to reading his bible. RN B said that if he is left alone, Resident #24 is okay but when people just keep going into his room, he becomes very aggravated. RN B said he is a big man and I do feel that he could hurt someone. RN B said yes, I was scared of him. RN B said that interventions for Resident #4 and Resident #24 were just to continually watch and supervise. RN B said she was aware that Resident #24 had a history of being physically aggressive but was not aware it was with other residents. RN B said that she had heard him verbalize to resident's that had wandered into his room get out of my room and said Resident #24 often verbalized things that did not make sense. RN B said she recalled Resident #24 refusing some of his psychiatric medications and that the implications to his medication refusal were symptoms coming back and indicated psychotic symptoms. RN B said that I think he would be really calm if he kept a routine regimen . (referencing Resident #24's medications) RN B said that she had not notified Physician C when Resident #24 refused his medications and said she was not aware that was facility protocol. RN B said that it happens a lot with him, so she wasn't sure. RN B said that Resident #24 would stay in his room but would get upset when someone entered his room. RN B said that it would upset Resident #24 because it violated his territory and said that she had witnessed Resident #24 last week, threaten the Administrator with his fist and said she charted it but did not think she quoted what Resident #24 said but mentioned he threatened he would hit him [the Administrator]. In an interview on 09/19/2022 at 4:00pm, CNA T said that she works at the facility through an agency and works regularly at the facility, specifically on the secure units. CNA T said that since the facility combined the females with the males on secure unit 1 it has been more difficult to supervise the unit due to the increased number of behaviors and residents requiring supervision on the unit. CNA T said that the women roam a lot and it was difficult to keep them out of the men's rooms. CNA T said that lately the men, specifically Resident #24 had been getting agitated and aggressive verbally with yelling at residents to get out of his room or get away from him. CNA T said that when Resident #24 comes out of his room and sits in a chair in the common area, he will yell at the female residents get away from me, get out. In an interview on 09/19/2022 at 4:30pm, LVN N said that TNA E reported to her Friday evening (9/16/2022) that there had been an incident. LVN N said that TNA E reported she was walking down the hall and heard Resident #24 say get out of my room or I am gonna hit you again if you don't get out of my room. LVN N said TNA E reported that she removed Resident #4 from Resident #24's room and reported to me. LVN N said she cleaned her forehead and stopped the bleeding; the DON came onto the unit at that time and we decided to send Resident #4 out and Resident #24 was on his bed resting. LVN N said that the facility had implemented line of sight after the incident and that the police showed up, the DON, the social worker, and the Administrator so she personally did not interview Resident #24 about what had happened and indicated that he seemed like he did not want to be approached. LVN N said that Resident #4 is unable to verbalize what had happened due to having unclear speech. LVN N said that she had seen Resident #24 previously that day and he seemed fine to her and indicated that he just doesn't like people going in his room. LVN N said that since the units were combined wi [TRUNCATED]

Based on observation, 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 1 (Resident #9) of 25 residents reviewed for quality of care. The facility failed to: A. Identify that Resident #9 continued with an unresolved infection to her right foot that required additional medical attention, intravenous antibiotics, and the removal of a foreign body to her right foot in the emergency department. This failure placed residents at risk for medical complications [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings Included: Record review of Resident #9's electronic face sheet, dated 09/22/2022 revealed that she was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Centers for Disease Control and Prevention, (CDC), [CONDITION(S)] is .[CONDITION(S)] is a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin. If untreated, it can spread and cause serious health problems.[CONDITION(S)] is treated with antibiotics. Most [CONDITION(S)] infections can be treated with oral antibiotics (taken by mouth). More serious infections may need to be treated in the hospital with intravenous (IV) antibiotics, which are given directly into a vein . Record review of Resident #9's admission MDS dated [DATE] indicated a BIMS score of 13, which indicated minimal cognitive impairment. Section E did not indicate Resident #9 had exhibited any behaviors. Section G indicated Resident #9 required limited assistance by one staff member for transfers, extensive assistance for dressing by two persons, extensive assistance by one staff member for toileting, extensive assistance of two persons for personal hygiene and supervision by one staff for eating. Section H indicated she was frequently incontinent of bladder and occasionally incontinent of bowel. Section J indicated that she received scheduled pain medication and indicated no fall history. Section M revealed resident was at risk for developing a pressure injury. Section N revealed Resident #9 received antipsychotics, and an antidepressant. Record review of Resident #9's care plan dated 03/16/22 with a most recent care plan review date of 07/28/2022, revealed the following: .08/05/2022 .Problem: Start Date: 08/05/2022 [CONDITION(S)] .Goal: Resident will be as alert and oriented as possible .Approach .assess for pain .R/O acute illness .Problem Behavioral Symptoms 08/02/2022 I frequently holler out to leave facility, and sometimes just randomly with no reason .Goal: I will communicate with staff what I am needing reducing my hollering to less than two times a day .Approach: Staff will redirect resident with likes and preferences .watching television, Dr. Pepper, food preferences, emotional attention and support, I will notify staff if I have trouble hearing .Problem 07/27/2022 Category Falls: Resident is at risk for falls due to history of falls .Goal I will have less than 3 actual falls over the next 90 days .Approach: I will have a low bed and fall mat next to my bed due to my behavior of crawling out on to the floor from my bed .09/04/2022 .Problem: 09/20/2022 Category Falls: I am at likely risk for falls as I do not notify staff via call light or verbally before I attempt to get out of bed or my wheelchair .Goal: I will not, to the extent practicable, experience more than 3 falls in 90 days .Approach: Keep bed in lowest position with brakes locked .Teach resident safety measures such as call light use and or verbal notification before attempting to exit bed or wheelchair . Observation on 09/15/2022 at approximately 8:15 p.m. revealed a voice from behind Resident #9's closed door yelling out. Upon opening the door by the surveyor Resident #9 was found lying on the tile floor on her right side. Resident #9 was yelling for help, the bed was in a low position and the fall mattress was in place; her call light was not in reach. Resident #9 had a fearful, grimaced look on her face. The [NAME] President of Operations was witness to the incident as well and notified the DON to provide assistance for Resident #9. Observation and assessment by the DON on 09/15/2022 at 8:28 p.m. revealed Resident #9's right foot was noted to have swelling, redness covering the entire dorsal (top part of foot) aspect of her foot, warmth was present and a wound on her right toe was observed on the second joint of her right toe that was circular in shape and there was a yellow substance that covered the entire wound bed. In addition, Resident #9's right foot had a small pinpoint darkened area on the bottom of her foot. Record review of the nursing progress notes for Resident #9 revealed the following: .09/10/2022 at 7:49pm Resident is being monitored for an active infection .Infection Type: [CONDITION(S)] .Location: [blank] .Resident is receiving [MEDICATION(S)] 500mg, Oral Administration .The resident has experienced the following signs/symptoms of infection during this shift: Purulent discharge (white, yellow or brown fluid that might be slightly thick in texture) or drainage from wound electronically signed LVN Q. 09/06/2022 at 3:18pm .Resident is being monitored for an active infection .Infection Type Skin/Soft Tissue Infection Right toe .Resident is receiving antibiotic [MEDICATION(S)], resident has received treatment for 3 days .Skin hot to touch, pus from wound. electronically signed by LVN N 09/03/2022 at 3:49pm Dressing change to right second toe. Redness and yellow slough surrounding perimeter of approximately 3mm, red, wet, wound. Cleansed with NS and nurse [LVN A] applied silver gel to wound. Contacted [Physician C], awaiting orders at this time . electronically signed LVN A. 09/03/2022 at 5:07pm .Orders received. [MEDICATION(S)] (an antibiotic, generic name [MEDICATION(S)])500mg TID for 7 days for right second toe wound. electronically signed by LVN A. Record review of Resident #9's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)](an antibiotic) capsule; 500mg Amount to Administer: 1; oral Frequency three times a day .Diagnosis [blank] .Start/End Date 09/03/2022-09/10/2022. Record revealed Resident #9 was administered the medication for seven days three times a day with only one missed dose on 09/06/2022 for an unknown, undocumented reason. Record review of Resident #9's Treatment Administration Record for September 2022, revealed the following: .Wound Treatment Order: Location: Right second toe, clean with normal Saline/Wound Cleanse Cover with Primary Dressing (island dressing or gauze) .Daily; Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .Start/End Date: 09/03/2022-09/15/2022 (DC Date) .Treatment was not done on four dates for unknown, undocumented reasons .0907/22, 0908/22, 09/11/22, and 09/13/22). In an interview on 09/15/2022 at 8:28pm, Resident #9 voiced that she was in pain all over and could not recall how long she had been on the floor. In an interview on 09/15/2022 at 8:40 p.m., LVN D said she had been in to administer medications to Resident #9 and indicated that she had been exhibiting behaviors throughout the day and into the evening where she was intentionally putting herself on the floor. LVN D said she had observed her on the floor just a few minutes ago but that she figured that was where she wanted to be. LVN D stated she was aware that Resident #9 was on the tile floor and said that the floor is hard and is probably uncomfortable but did not feel it was neglectful due to the fact that Resident #9 was intentionally putting herself onto the floor. In an interview on 09/15/2022 at 8:45 p.m., the DON said, I thought she was still receiving antibiotics for [CONDITION(S)] in her right foot but it [the MAR] shows she completed the course on 09/10/2022. The DON said RN B charted in a progress note that a skin assessment was done on 09/13/2022 but nothing was documented about redness, warmth or swelling to the right lower extremity or a wound on her right second toe. The DON did validate that Resident #9 had been verbal all day with screaming and that she had been throwing herself forward in her wheelchair and would end up on the floor but that if Resident #9 was found on the floor, her expectation is that staff should have assisted her into bed. During an interview on 09/15/2022 at approximately 9:15 p.m., the DON stated Resident #9 was going to be sent out to the Emergency Department for further evaluation for pain and the redness to her right foot. The DON stated she thought Resident #9 was still receiving antibiotics for the [CONDITION(S)] to her right lower extremity but after reviewing her records, the records indicated she had finished her course of antibiotics on 09/10/2022 and her foot was still showing signs of infection. Record review of Resident #9's hospital emergency room records dated 09/15/2022 revealed the following: .Emergency Department note .Triage Chief Complaint [CONDITION(S)] right foot brought in from [nursing facility]home by ambulance. [Facility Name] called due to [CONDITION(S)] on right foot XXX[AGE] year-old female presented to emergency department by ambulance from [Facility Name] for evaluation of right foot [CONDITION(S)]. Upon exam patient has foot, notice there was a piece of metal shaving in patient's plantar/ball aspect of the right foot. Piece of metal shaving was approximately 5mm in depth. Which was removed here in the ER. Dorsal aspect (on top of) of the right foot notice redness and swelling . Further review of emergency department records revealed Resident #9 had received intra venous antibiotics for the [CONDITION(S)] in her right foot, a [CONDITION(S)] shot, was discharged back to the nursing facility with a prescription for oral antibiotics and to follow up with her primary care physician for further evaluation regarding the [CONDITION(S)] in her right foot. Record review of Resident #9's nursing progress notes revealed the following: .09/13/2022 at 4:49pm .Skin assessment for Resident .left forearm with dried small cut about an inch in length with steri-strips in place .Bruise on right bicep, bruise on right forearm, left lower leg skin tear .bruise on left shin .cut on right shin with dressing in place .Resident tolerated skin assessment and was calm. No yelling during assessment .*(no documentation regarding right lower extremity or wound on second right toe) .09/15/2022 at 10:00pm .This nurse was notified by DON that resident was going to be sent out to the ER d/T RLE swelling and uncontrolled pain. electronically signed LVN D. 09/16/2022 at 1:00am .[Local Hospital] called and stated that resident was ready to return to facility, X-ray 3 views of right knee and 3 views of right foot was done with no fractures .medications given were [MEDICATION(S)] (an antibiotic) IVPB (intravenous piggy back) .Diagnosis [CONDITION(S)] of right foot and foreign body in the right foot was removed and will be returning with prescription for [MEDICATION(S)] (an antibiotic) 500mg QID x 10 days Record review of Resident #9's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .Resident #9 received this medication four times a day with 2 missed doses on 09/19/2022 and on 09/20/2022, the medication was discontinued. In an interview on 09/16/2022 at 2:30pm, LVN A said that she had performed the treatment to Resident #9's right second toe yesterday on 09/15/2022 after Resident #9 came out of the shower room and she recalled her foot was red, her skin was peeling, the wound itself looked wet, looked like slough (the yellow/white material in the wound bed) was around it. It was absolutely not resolved; cannot recall what the order was but I think it was to clean and cover with just a basic order, normal saline; it did occur to me that it might need a more thorough order from [Physician C], but at the time I was doing the treatment, I was just trying to get so many things done at one time. LVN A said she was in the middle of her medication pass and it was impossible to try and be all these different places at once; LVN A said she did not have time to contact Physician C about Resident #9's right foot still showing signs of infection. LVN A said she recalled Resident #9 being treated with antibiotics for a foot infection the last time I worked the secure unit, cannot recall exact date and honestly still thought she was receiving antibiotics . In an observation and interview on 09/19/2022 at 3:44 p.m., LVN F performed wound care to Resident #9's right toe and foot. The observation revealed Resident #9's right foot to be improved showing little signs of redness and swelling on the dorsal (top part of foot). LVN F said there was no warmth to the foot and observation of the wound bed to the right second toe no longer had the yellow slough present and there was a healthy pink wound bed noted. Resident #9 said her foot felt much better and her pain had improved. In an interview on 09/19/2022 at 2:17pm, RN B said she did not notify Physician C when she worked on 09/13/22 and 09/14/2022 regarding Resident #9's right foot still having signs of infection. RN B said she performed a skin assessment on 09/13/2022 and recalled the whole toe was red on Resident #9's right foot. RN B said signs of infection are redness, swelling and warmth and thought it was getting better , so it didn't alert me to contact the doctor. RN B said she felt it was still in the healing process and just needed more time but said that Physician C would look at it on his next visit at the facility. RN B said she was unsure when that date would be. RN B said Physician C usually was in the facility on Thursday or Fridays. Record review on 09/19/2022 of a photograph from 09/03/2022, taken and provided by RN B revealed Resident #9's right foot and second toe to have redness and an open area on the second joint of the right second toe. The opening was noted to have a small amount of yellow substance present in the wound bed and there was peeling skin noted to the base of the right second toe. The dorsal (top of foot) area had minimal redness to it. In an interview on 09/20/2022 at 3:58pm, Physician C recalled being initially notified of Resident #9 having a possible infection in her right foot on 09/03/2022, he gave a telephone order for antibiotics and Physician C said he had not been contacted regarding the continued redness, warmth and swelling in Resident #9's right foot until Thursday evening on 09/15/2022, when he was contacted by the DON and a FaceTime video call was performed to evaluate Resident #9's right foot. Physician C said that his expectation would be that if a foot continued with redness and warmth after completing a course of antibiotics, he would expect to be notified to ensure additional orders were not necessary. In an interview on 09/21/2022 at 5:10pm, the DON said that her expectation for staff if a skin assessment reveals warmth, redness or swelling her expectation is for the physician to be notified and to chart it in a progress note. The DON said continued redness and warmth indicate that there is still inflammation and the doctor needs to be notified. The DON said, If not addressed, the condition could worsen. In an interview at exit, on 09/26/2022 at 1:30 p.m., the [NAME] President of Operations indicated that the facility did not have a specific policy regarding quality of care. Record review of the facility policy entitled Resident Examination and assessment dated 2001, revised February 2014 revealed the following: .The purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan .2. Notify the physician of any abnormalities such as, but not limited to: .e. wounds or rashes on the resident's skin; and f. worsening pain, as reported by the resident

Based on observation, interview and record review the facility failed to protect the resident's right to be free from abuse and neglect for 8 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #9, and Resident #10) of 8 residents reviewed for abuse and neglect. 1. The facility failed to ensure Hall 100/Unit 1 (male secured locked unit) had sufficient staffing to prevent Resident #6, a resident with known history of stealing food of wrong texture, from a choking episode that led to hospitalization . 2. The facility failed to prevent Resident #5 from abusing Resident #2 on Hall 200/Unit 2 (male secured locked unit) that led to hospitalization of Resident #2 and Resident #5. 3. The facility failed to prevent Resident #4 from abusing Resident #1 on Hall 200/Unit 2 (male secured locked unit) that led to hospitalization of Resident #4 and Resident #1. 4. The facility failed to prevent Resident #3 from abusing Resident #1 on Hall 200/Unit2 (male secured locked unit) that led to an injury of Resident #1. 5. The facility failed to prevent Resident #9 from abusing Resident #1 on Hall 200/Unit2 (male secured locked unit). 6. The facility failed to protect Resident #10 from abusing Resident #1 that led to a fracture for Resident #1. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern with actual harm that is not immediate, due to the facility's need to evaluate the effectiveness of their corrective systems. These failures could place residents at risk for choking, resident-to-resident altercations, serious harm in the event of an emergency, hospitalization s, and even death. Findings include: Record review of the facility assessment dated [DATE] Part 3 titled Facility Resourced Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies revealed: Staff: Licensed nurses: Station 2: LVN/RN Days: 2 and Nights: 2 Direct Care Staff/CNAs: Station 2: Days 8, Evenings 8, Nights 5. Resident #6 Record review of Resident #6's electronic face sheet, accessed on [DATE], revealed an [AGE] year-old male admitted on [DATE] to Hall 100/Unit 1 (male secured locked unit) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's Quarterly MDS, dated [DATE], revealed a BIMS score interview was not performed. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of [CONDITION(S)]: B. Delusions. E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others occurred 1 to 3 days. B. Verbal behavioral symptoms directed towards others occurred 1 to 3 days. Section G: Functional Status: G0110. Activities of Daily Living Assistance: H. Eating:1. Self-Performance Supervision. 2. Support: One-person physical assist. Section K: Swallowing/Nutrition Status: K0100. Swallowing Disorder: A. Loss of liquids/solids from mouth when eating or drinking. K0510: Nutritional Approaches: C. Mechanically altered diet. D. Therapeutic Diet. Record review of Resident's #6's Care Plan, dated [DATE], revealed: Problem: Nutritional Status Diet. Goal: Maintain Stable Weight. Approach: Diet as ordered: Dysphagia advanced pureed, carbohydrate consistent, and Report problems to charge nurse. Further review of the Care Plan revealed no evidence of interventions to prevent resident choking or stealing food. Record review of Provider Investigation Report, dated [DATE], revealed on [DATE] at approximately 07:30 PM, [Resident #6] was found unresponsive with no pulse and no reparations. Staff immediately started CPR. [Resident #6] responsive at time of transport. [Resident #6] expelled a portion of food. [Resident #6] is on a pureed diet. [Resident #6] was sent to the emergency room after staff performed CPR. [Resident #6] did respond to paramedics that arrived shortly after the 911 call was placed. During a random observation on [DATE] at 12:40 PM on Hall 100/Unit 1 (male secured locked unit) revealed 9 residents sitting in the dining room. TNA M assisted unsampled resident with eating lunch. CNA G assisted unsampled resident with eating lunch. No nurse was observed in the dining room. Resident #6 sat next to CNA G and was redirected continuously not to grab food from other residents' plates. During an interview attempt on [DATE] at 12:45 PM Resident #6 was unable to answer any questions due to his level of cognitive impairment. During an interview on [DATE] at 11:00 AM, the DON stated Station 2 had 6 wings: Hall 100/Unit 1 (male secured locked unit), Hall 200/Unit 2 (male secured locked unit), Hall 300, Hall 400, Hall 500, and Hall 600/Unit 3 (female secured locked unit). The DON stated Station 2 always had 2 CNAs on each of the 3 secured locked units. She stated the facility tried to keep the same staff on the same units for continuity of care. The DON stated station 2 was to be staffed with 2 nurses at night and day, 8 CNAs for days and evenings, and 5 CNAs at night. She stated licensed nurses' shifts were: Day shift 6:00 AM to 6:00 PM and night shift 6:00 PM to 6:00 AM. She stated CNA shifts were: Day shift 6:00 AM to 2:00 PM, Evening shift 2:00 PM to 10:00 PM, and Night shift 10:00 PM to 06:00 AM. During an interview on [DATE] at 5:00 PM, TNA J stated she was CPR and [MEDICATION(S)] maneuver certified but most of the other TNAs were not. She stated worked Hall 100/unit 1 (male secured locked unit) on [DATE] when Resident #6 choked. TNA J stated LVN B was on the unit at the time of the incident. She stated generally the nurse was at the nurse's station and not easily accessible. She stated the nurse working Hall 100/Unit1 (male secured locked unit) was available and started CPR. TNA J stated there had been times when she was the only staff on Hall 100/Unit1 (male secured locked unit) but she could not state the exact dates and if an emergency occurred, she would not be able to get help. She stated she would have scream until someone heard her. She stated the nurse would be at the nurses' station located off Hall 100/Unit1 (male secured locked unit) passed the locked doors and she would not be able to get help. She stated if a TNA that was not CPR and [MEDICATION(S)] maneuver certified and was alone on Hall 100/Unit1 (male secured locked unit) it would be a very unsafe environment. She stated Hall 100/Unit1 (male secured locked unit) was often staffed with only 1 TNA. TNA J stated she believed failure occurred because the facility did not have enough staff to prevent Resident #6 to get the food from the other resident's room. TNA J stated she was not aware that Resident #6 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . TNA J stated she had not done or received any training at all. She stated she was not trained on abuse and neglect. During an interview on [DATE] at 12:45 PM, CNA G stated the facility was never staffed with 2 CNAs per unit. She stated she worked units' alone multiple shifts, but she could not state the exact dates. She stated Resident #6 had always tried to steal food and he had to be constantly monitored during mealtimes. She did not state if she reported this to DON or Administrator. CNA G stated she had been trained on abuse and neglect. She stated she would report abuse to the Administrator. During an interview on [DATE] at 12:55 PM, TNA M stated she had been a TNA since [DATE]. She stated she was not CPR certified and had not received any training regarding resident's behaviors or abuse and neglect. She stated she worked alone on units almost every shift but could not state the exact dates. She stated Hall 100/Unit 1 (male secured lock unit) had 2 (unsampled) residents that required feeding assistance and one resident who stole food. She stated she would assist one resident eating and the other resident waited until she was done before she could assist him with eating. She stated she also had to redirect Resident #6 continuously while assisting residents with eating. She stated nurses were never on the units during mealtimes. She stated multiple residents had voiced concerns about their care and safety but could not state exactly which resident voiced or when. She did not state if she reported this to DON or Administrator. Record review of grievance log revealed no evidence of residents complaining about their concerns for their care and safety. During an interview on [DATE] at 10:00 AM, CNA H stated she worked the units/halls alone multiple times but could not state the exact dates. She stated the facility kept putting staff on Hall 100/Unit 1 (male secured locked unit) that did not know the residents. She stated that Hall 100/Unit 1 (male secured locked unit) had 2 residents that required assistance with meals. She stated Resident #6 had always tried to steal food and it was worse after he started a pureed diet. She did not state if she reported this to DON or Administrator. She stated she had been trained on abuse and neglect. She stated she would report abuse to the Administrator. During an interview on [DATE] at 10:10 AM, CNA I stated she was an agency aide and had worked every hall in the facility. She stated she never received any training regarding behaviors or abuse and neglect. She stated she did not know that Resident #6 needed to be monitored for stealing food and was to be monitored at mealtimes. Record review of the facility employee timecards for [DATE] at 7:30 PM revealed Station 2 had 2 LVNs, 2 CNAs (1 of the 2 was Agency), and 5 TNAs working with a census of 111. Record review of the facility daily staff schedule, dated [DATE], revealed there were 2 TNAs assigned to Hall 100/Unit 1 (male secured locked unit) without the supervision of a CNA and census of 12 residents with known behaviors. Resident #5 Record review of Resident #5's electronic face sheet, accessed on [DATE], revealed an [AGE] year-old male admitted to the facility on [DATE] to Hall 200/Unit2 (male secured locked unit) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's Discharge MDS, dated [DATE], revealed a BIMS score of 07, which indicated severe cognitive impairment. The MDS revealed: Section E: Behavior: E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others occurred 1 to 3 days. B. Verbal behavioral symptoms directed towards others occurred 1 to 3 days. C. Other behavioral symptoms not directed towards others occurred 4 to 6 days. E0800. Rejection of Care: Occurred 1 to 3 days. E0900 Wandering: occurred 1 to 3 days. Section N: medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . A. Antipsychotic 7. Record review of Resident's #5's Care Plan, dated [DATE], revealed the objectives that lacked the ability to be evaluated or quantified were: Problem: Mood State Goal: Resident will express/exhibit satisfaction. Approach: Assess, monitor, and document mood, Be reassuring and listen to concerns, Meds as ordered. Problem: Behavioral Symptoms. Goals: I will have fewer episode of physical aggression. Approach: Staff will redirect as needed. Staff will notify physician with any increase in behaviors. Problem: [CONDITION(S)] Drug Use. Goal: Benefit without side effects. Approach: Refer to Social Services if needed, Gradual dose reduction, Monitor for side effects, Monitor target behaviors. Record review of Resident #5's electronic progress note, dated [DATE] at 4:54 PM by the ADON, revealed Resident #5 was placed on one-on-one monitoring to which Administrator did while removing Resident to his office to deescalate the situation. Resident #2 Record review of Resident #2's electronic face sheet, accessed on [DATE], revealed an [AGE] year-old male admitted on [DATE] to Hall 200/Unit2 (male secured locked unit) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's Discharge MDS, dated [DATE], for Resident # 2 revealed a BIMS interview was not performed. The MDS revealed: Section E: Behavior: E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others occurred 1 to 3 days. B. Verbal behavioral symptoms directed towards others occurred 1 to 3 days. Section N: medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Antidepressant 7. Record review of Resident's #2's Care Plan, dated [DATE], revealed the objectives lacked the ability to be evaluated or quantified were: Problem: [CONDITION(S)] Drug Use. Goal: Benefit without side effects. Approach: Refer to Social Services if needed, Gradual dose reduction, Monitor for side effects, Monitor target behaviors. Problem: Psychosocial Well-Being Goal: Resident will express/exhibit satisfaction Approach: Allow to express feelings, Listen carefully and be non-judgmental, Keep topics of conversation light and cheerful, Customary routines adhered to: (specify). Problem: Mood State Goal: Resident will express/exhibit satisfaction. Approach: Assess, monitor, and document mood, Be reassuring and listen to concerns, Meds as ordered. Resident #4 Record review of Resident #4's electronic face sheet, accessed on [DATE], revealed a [AGE] year-old male admitted to the facility on [DATE] to Hall 200/Unit2 (male secured locked unit) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's Discharge MDS, dated [DATE], revealed a BIMS score of 08, which indicated moderate cognition impairment. The MDS revealed: Section E: Behavior: E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others occurred 1 to 3 days. B. Verbal behavioral symptoms directed towards others occurred 1 to 3 days. E0900 Wandering: occurred 1 to 3 days. Section N: medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . A. Antipsychotic 7 C. Antidepressant 7. Record review of Resident's #4's Care Plan, dated [DATE], revealed: Problem: Resident exhibits wandering. Goal: Resident will wander safely within specified boundaries over the next 90 days. Approach: Remove resident from other resident's rooms and unsafe situations, Assess resident for placement in a specially designed therapeutic unit, and Avoid over-stimulation. Problem: Behavioral Symptoms [DATE] aggression towards others and impulsiveness Goal: Resident will have less than 3 episodes of Verbal and/or physical aggression towards others over the next 90 days. Approach: Remove from public area when behavior is unacceptable, Keep environment calm and relaxed, Encourage diversional activities, Redirect me when I am in the day room around others if they get to close to me, and staff will assist me to a quiet area if I become inappropriate with others. Record review of progress note dated [DATE] at 3:42 pm by LVN-A revealed: Resident left facility by way of of facility van. Resident alert, apprehensive to leave facility. Took no belongings to [local psychiatric hospital.] Resident #3 Record review of Resident #3's electronic face sheet, accessed on [DATE], revealed a [AGE] year-old male admitted [DATE] to Hall 200/Unit 2 (male secured locked unit) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's Quarterly MDS, dated [DATE], revealed a BIMS interview was not performed. The MDS revealed: Section E: Behavior: E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others occurred 1 to 3 days. Section N: medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . A. Antipsychotic 7 B. Antianxiety 7 C. Antidepressant. Record review of Resident #3's Care Plan, dated [DATE], revealed: Problem: I was exhibiting physically aggressive behavior towards others. Goal: I will have less than 2 physical altercations over the next 90 days. Approach: Assist me to a quiet area when I become agitated to reduce stimuli and monitor for pain, injuries. Resident #9 Record review of Resident #9's electronic face sheet, accessed on [DATE], revealed a [AGE] year-old male admitted on [DATE] to Hall 200/Unit 2 (male secured locked unit) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #9's Discharge MDS, dated [DATE], revealed a BIMS interview was not performed. The MDS revealed: Section N: medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . A. Antipsychotic 7 C. Antidepressant 7. Record review of Resident #9's Care Plan, dated [DATE], revealed: Problem: Mood remains agitated and anxious. Goal: Resident will express/exhibit less anxiousness and agitation. Approach: Assess, monitor, and document mood, Be reassuring and listen to concerns, Encourage group activities, and Meds as ordered. Resident #10 Record review of Resident #10's electronic face sheet, accessed on [DATE], revealed a [AGE] year-old male admitted on [DATE] to Hall 200/Unit 2 (male secured locked unit) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #10's Quarterly MDS, dated [DATE], revealed a BIMS score of 07, which indicated moderate cognitive impairment. The MDS revealed: Section E: Behavior: E0200 Behavior Symptoms: B. Verbal behavior symptoms directed towards others occurred 1 to 3 days. Section N: medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Antidepressant 7. Record review of Resident #10's Care Plan, dated [DATE], revealed: Problem: Behavioral Symptoms Goal: Resident will have fewer episodes of wandering. Approach: Always ask for help if resident becomes abusive/resistive, Encourage diversional activities, and Remove from public area when behavior is unacceptable. Resident #1 Record review of Resident #1's electronic face sheet, accessed on [DATE], revealed a [AGE] year-old male admitted on [DATE] on Hall 200/Unit2 (male secured locked unit) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Discharge MDS, dated [DATE], for Resident #1 revealed a BIMS score of 03, which indicated severe cognitive impairment. The MDS revealed: Section E: Behavior: E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others occurred 1 to 3 days. B. Verbal behavioral symptoms directed towards others occurred 1 to 3 days. E0900 Wandering: occurred 1 to 3 days. Section N: medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Antidepressant 7. Record review of Resident's #1's Care Plan, dated [DATE], revealed: Problem: Resident exhibits wandering as evidence by resident went out the side gate to the front door Goal: Resident will wander safely within specified boundaries. Approach: Place resident in a secure environment, Remove resident from other resident's rooms and unsafe situations, and Avoid over-stimulation. Record review of the Provider Investigation Report, dated [DATE], revealed on [DATE], at 2:00 PM, [Resident #5] was leaning against the door frame with arms crossed and an agitated expression on his face arguing with a nurse stating. 'Get him out of my room.' ADON got closer and was able to see why they were unable to move [Resident #2]. [Resident #2] was sent to the emergency room for a suspected fracture of the hip. [Resident #5] stated, 'He was eating my snacks, so he told him to get out. When [Resident # 2] did not leave, I pushed him' room. [Resident #2] was assessed and 911 called. Resident went to the hospital and was later admitted for [CONDITION(S)] with no fracture noted. Record review of the facility employee timecards for [DATE] at 2:35 PM revealed Station 2 had 2 LVNs, 6 CNAs (5 agency and 1 TNA) working with a census of 110. Record review of facility staff schedule, dated [DATE], revealed there was 1 agency CNA working Hall 200/Unit 2 (male secured locked unit), which had a census of 18 residents which included Resident #2 and Resident #5. Record review of the Provider Investigation Report, dated [DATE], revealed on [DATE] at 7:00 PM agency [CNA C] reporter she was sitting at the desk in the day room (CNA E was helping the residents come in from smoking) when she heard [Resident #4] yelling 'get the hell out of my room'. [CNA C] entered room [ROOM NUMBER]. [Resident #1] was lying on the floor in the room. [Resident #4] was pulling [Resident #1] by his legs. [CNA C] separated the residents. [Resident #1] started kicking at [CNA C] so that he could proceed to have further contact with [Resident #4.] [Resident #4] pushed [CNA C] out of the way to get back to physical contact with [Resident #1] again. [Resident #4] made second contact with [Resident #1]. Per [CNA C's] statement [Resident #4] pulled at [Resident #1's] arm and face. [CNA C] stepped in between residents to separate the residents again. Nurse was called and assessment begun. 911 was called for [Resident #1]. All appropriate notifications made. Resident was sent out with EMS to the hospital. [Resident #4] received increase in supervision until he was sent to a behavior health hospital on [DATE] early morning. During an interview on [DATE] at 4:00 PM, the Administrator stated Resident #4 was placed on every 15-minute checks immediately following the resident-to-resident altercation and continued until he was discharged to a local behavior health hospital on [DATE]. The Administrator stated the only interventions the facility had implemented to protect Resident #1 from abuse was consultation with psychiatric services and playing the radio because Resident #1 liked to dance. He stated Resident #4 had been aggressive on [DATE] and his [MEDICATION(S)] and [MEDICATION(S)] were increased, then he was aggressive again on [DATE] and his [MEDICATION(S)] was increased. He stated he felt the facility had provided proper interventions. During an interview on [DATE] at 5:30 PM, CNA C stated she was on Hall 200/Unit 2 (male secured locked unit) alone when on [DATE] when Resident #1 and Resident #4 got into a resident-to-resident altercation. She stated the charge nurse was not on the unit and rarely was on the unit. She stated she was at the desk and heard Resident #4 yelling from room [ROOM NUMBER]. She stated when she entered, she saw Resident #1 was lying in the floor and Resident #4 was dragging him across the room. She stated she attempted to separate the residents but Resident #1 was still lying on the floor kicking and Resident #4 pushed her out of the way and grabbed Resident #1 by the arms and face. CNA C stated she separated them again and CNA E came in from being outside with the residents who were smoking. She stated CNA E then ran to get help from a nurse. She stated CNA E had to go through 2 locked doors to get help and then return through 2 locked doors with the nurse. CNA C stated she was an agency CNA and she had not received any special training to work with residents with behaviors or abuse and neglect. She stated she had no orientation to the facility, and she did not sign any training or orientation paperwork. She stated she had worked halls alone with no other aides many times, but she could not state the exact dates. She stated it was rare that she worked with another CNA. She did not state if she reported this to DON or Administrator. CNA C stated she was not aware that Resident #4 or Resident #1 had any history of behaviors. During an interview on [DATE] at 5:30 PM, CNA E stated she was an agency CNA and she had not received any specialized training to work with residents with behaviors or abuse and neglect. She stated she did not work specific halls in the facility, and she had worked every hall in the facility. She stated the nurses were very hard to locate and were only on the hall to pass medications. She stated sometimes she received report from the CNA leaving from the previous shift, but not often. She stated when she worked alone, she had to take residents out for their smoke break and leave the rest of the residents on the hall unattended, but she could not state the exact dates. She did not state if she reported this to DON or Administrator. CNA E stated she was not aware that Resident #4 or Resident #1 had any history of behaviors. CNA E stated on [DATE] she had been outside with the residents on their smoke break when she re-entered the building and heard CNA C screaming for help. She stated she ran to get help from a nurse through 2 locked doors then go back through 2 locked doors with the nurse to return to the residents. CNA E stated she was not aware that Resident #4 or Resident #1 had any history of behaviors. Record review of the facility employee timecards for [DATE] at 6:58 PM revealed Station 2 had 2 LVNs, 5 CNAs (4 of the 5 were agency, and 1 TNA) working with a census of 108. Record review of the facility staff schedule, dated [DATE], revealed there were 2 agency CNAs working Hall 200/Unit 2 (male secured locked unit), which had a census of 18 residents with known aggressive behaviors. Record review of the Provider Investigation Report, dated [DATE], revealed on [DATE] at 5:45 PM, CNA reported she heard a commotion and saw [Resident #3] sitting in a dining room chair with [Resident #1] standing over him. Both residents were immediately separated. [Resident #1] sustained red marks to the nose and left cheek and a nosebleed. [Resident #3] assessment showed 1.5 x 1.5 bump/bruise to left eye, 2.5 cm x 2 cm bruise/redness to right side of neck, and no other injuries. [Resident #1] upper lip appeared slightly swollen. An abrasion to the right side of the neck. [Resident #1] was placed on 15-minute checks with increased supervision while out in the common area. Record review of the facility employee timecards for [DATE] at 5:45 PM revealed Station 2 had 2 LVNs, 4 CNAs (1 agency and 4 TNAs) working with a census of 108. Record review of facility staff schedule, dated [DATE], revealed there was 1 agency CNA working Hall 200/Unit 2 (male secured locked unit), which had a census of 18 residents with known aggressive behaviors. Record review of the Provider Investigation Report, dated [DATE], revealed on [DATE] at 3:15 PM, CNA reported [Resident #9] hit [Resident #1] in the face multiple times. CNA separated and notified the nurse. [Resident #1] had a 1.8 cm x 2.8 cm discolored raised area under his left eye and a superficial abrasion 0.8 cm x 2.8 cm to neck under left ear. [Resident #10] was placed on 15-minute checks. During a telephone interview on [DATE] at 12:15 PM, TNA N stated she no longer worked for the facility. She stated she voiced her concerns about working alone on the hall's multiple times to the Administrator and the DON. She stated she received no CNA training and no training regarding behaviors or abuse and neglect. She stated she worked alone most of her shifts, but she could not state the exact dates. She stated she was alone on Hall 200/Unit 2 (male secured locked unit) when Resident #1 and Resident #3 got into resident-to-resident altercation on [DATE]. She stated she had to scream for help and a LVN P at the nurse's station behind the locked doors heard her and came to help her. She stated after the altercation, Resident #3 was placed on every 15-minute checks. She stated the facility did not provide another staff member to help. She stated she was required to perform 15-minute checks on Resident #9 and care for the other residents alone for the rest of her shift. Record review of 15-minute check documentation revealed no signatures of who performed the checks. The document just provided the location of Resident #9 every 15-minutes. Record review of the facility employee timecards for [DATE] at 3:55 PM revealed Station 2 had 2 LVNs, 1 CNAs, and 1 TNAs working with a census of 108. Record review of the facility staff schedule, dated [DATE], revealed 7 nursing aides. Record review of the facility staff schedule, dated [DATE], revealed there was 1 TNA working Hall 200/Unit 2 (male secured locked unit), without the supervision of a CNA, with a census of 18 residents with known aggressive behaviors. Record review of the Provider Investigation Report, dated [DATE], revealed on [DATE] at 4:29 PM, [Resident #10] pushed [Resident #1] against the wall and [Resident #1] slid down the wall. [Resident #1] complained of lower back pain. X-ray results showed acute L1 compression fracture. During a telephone interview on [DATE] at 5:00 PM, TNA O stated she was working Hall 200/Unit 2 (male secured locked unit) alone on [DATE] when Resident #9 and Resident #1 got into a resident-to-resident altercation. She stated the nurse was not on the unit. She stated a CNA had come to the unit to relieve her for a lunch break. She stated if the CNA had not come, she would have had to leave the unit unsupervised to go get help. She stated the nurses were only on the unit while passing medications. She stated she always worked the halls alone, but she could not state the exact dates. She stated she received no training and was thrown into working the halls alone. She stated she voiced her concerns about working alone, especially because she was pregnant, with the Administrator and the DON. She stated she was aware of the resident behaviors but only because she had worked on Hall 200/Unit 2 (male secured locked unit) since she was hired. She stated she left the facility because she felt unsafe and uncomfortable. She stated she was not trained on abuse and neglect. Record review of the facility employee timecards for [DATE] at 4:29 PM revealed Station 2 had 2 LVNs, 2 CNAs, and 5 TNAs working with a census of 108. Record review of the facility staff schedule, dated [DATE], revealed there was 1 TNA working Hall 200/Unit 2 (male secured locked unit), without the supervision of a CNA, with a census of 18 residents with known aggressive behaviors. Record review of 15-minute check documentation revealed no signatures of who performed the checks. The document just provided the location of Resident #10 every 15-minutes. During an interview on [DATE] at 1:30 PM, Resident #8 stated the facility never had enough staff. He stated all the residents were always arguing and fighting and no one did anything about it. Resident #8 stated he did not feel free from abuse and neglect. He stated he hated living in the facility. The resident stated that he had spoken to the Administrator and the DON multiple times. During an interview on [DATE] at 1:45 PM, Resident #7 stated he was blind and never got the help he needed. He stated he was left alone all day and became agitated because no one helped him. He stated he could never find anyone and there were many tasks he was not capable of doing on his own. He stated there was no need to report it because no one cared. Resident #7 stated he did not feel free from abuse and neglect. During an interview on [DATE] at 2:40 PM, the DON stated TNAs completed an 8-hour online course, they received in house training with a CNA, and skills check offs were completed by the DON, ADON or CNAs. She stated TNAs could do all resident care tasks alone without CNA supervision. She stated she never staffed just 1 TNA alone on a unit. She stated that she did staff 2 TNAs on units without CNA supervision. She stated TNAs were not CPR or [MEDICATION(S)] maneuver certified. She stated if an emergency did happen there was always a nurse on the unit. The DON stated the facility was always adequality staffed but did not provide evidence to prove adequate staffing. During an interview on [DATE] at 3:00 PM, with agency CNA D she stated she had worked on a unit alone during multiple shifts, but she could not state the exact dates. CNA D stated that she was an agency CNA and was not oriented to the facility or the residents. She stated she did not receive any facility or specialized training

Based on observation, interview, and record review the facility to have enough qualified staff to provide adequate care for residents with mental and psychosocial disorders for 8 of 8 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #9, and Resident #10) reviewed for staffing. 1. The facility failed to ensure there was sufficient staffing on Hall 100/Unit 1 (male secured locked unit) to meet the needs of Resident #6 to ensure he was supervised and did not have access to food that was the wrong texture, which resulted in a choking episode requiring emergency services and hospitalization . 2. The facility failed to ensure there was sufficient staffing on Hall 200/Unit 2 (male secured locked unit) to meet the needs of Resident #2 and Resident #5 to prevent a resident-to-resident altercation that led to hospitalization of Resident #2 and Resident #5. 3. The facility failed to ensure there was sufficient staffing on Hall 200/Unit 2 (male secured locked unit) to meet the needs of Resident #1 and Resident #4 to prevent a resident-to-resident altercation that led to hospitalization of Resident #4 and Resident #1. 4. The facility failed to ensure there was sufficient staffing on Hall 200/Unit2 (male secured locked unit) to meet the needs of Resident #1 and Resident #3 to prevent a resident-to-resident altercation that led to an injury of Resident #1. 5. The facility failed to ensure there was sufficient staffing on Hall 200/Unit2 (male secured locked unit) to meet the needs of Resident #1 and Resident #9 to prevent a resident-to-resident altercation. 6. The facility failed to ensure there was sufficient staffing on Hall 200/Unit2 (male secured locked unit) to meet the needs of Resident #1 and Resident #10 to prevent a resident-to-resident altercation that led to a fracture for Resident #1. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern with actual harm that is not immediate, due to the facility's need to evaluate the effectiveness of their corrective systems. These failures could place residents at risk for choking resident-to-resident altercations, serious harm in the event of an emergency, hospitalization s, and death. Findings include: Record review of facility assessment dated [DATE] Part 3 titled Facility Resourced Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies revealed: Staff: Licensed nurses: Station 2: LVN/RN Days: 2 and Nights: 2 Direct Care Staff/CNAs: Station 2: Days 8, Evenings 8, Nights 5. Resident #6 Record review of Resident #6's electronic face sheet accessed on [DATE] revealed an [AGE] year-old male admitted on [DATE] to Hall 100/Unit 1 (male secured locked unit) with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's Quarterly MDS, dated [DATE], revealed a BIMS score interview was not performed. Further review of MDS, revealed: Section E: Behavior: E0100. Potential Indicators of [CONDITION(S)]: B. Delusions. E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others occurred 1 to 3 days. B. Verbal behavioral symptoms directed towards others occurred 1 to 3 days. Section G: Functional Status: G0110. Activities of Daily Living Assistance: H. Eating:1. Self-Performance Supervision. 2. Support: One-person physical assist. Section K: Swallowing/Nutrition Status: K0100. Swallowing Disorder: A. Loss of liquids/solids from mouth when eating or drinking. K0510: Nutritional Approaches: C. Mechanically altered diet. D. Therapeutic Diet. Record review of Resident's #6's Care Plan dated [DATE] revealed: Problem: Nutritional Status Diet. Goal: Maintain Stable Weight. Approach: Diet as ordered: Dysphagia advanced pureed, carbohydrate consistent, and Report problems to charge nurse. Further review of Care Plan revealed no evidence of interventions to prevent resident choking or stealing food. The Care Plan showed no evidence of supervision needs for Resident #6. Record review of Provider Investigation Report dated [DATE] revealed on [DATE] at approximately 07:30 pm, [Resident #6] was found unresponsive with no pulse and no reparations. Staff immediately started CPR. [Resident #6] responsive at time of transport. [Resident #6] expelled a portion of food. [Resident #6] is on a pureed diet. [Resident #6] was sent to the emergency room after staff performed CPR. [Resident #6] did respond to paramedics that arrived shortly after the 911 call was placed. During a random observation on [DATE] at 12:40 PM on Hall 100/Unit 1 (male secured locked unit) revealed 9 residents sitting in the dining room. TNA M assisted unsampled resident with eating lunch. CNA G assisted unsampled resident with eating lunch. No nurse was observed in the dining room. Resident #6 sat next to CNA G and was redirected continuously not to grab food from other residents' plates. During an interview attempt on [DATE] at 12:45 PM Resident #6 was unable to answer any questions due to his level of cognitive impairment. During an interview on [DATE] at 11:00 AM, DON stated Station 2 had 6 wings: Hall 100/Unit 1 (male secured locked unit), Hall 200/Unit 2 (male secured locked unit), Hall 300, Hall 400, Hall 500, and Hall 600/Unit 3 (female secured locked unit). The DON stated that Station 2 always had 2 CNAs on each of the 3 secured locked units. She stated the facility tried to keep the same staff on the same units for continuity of care. DON stated station 2 was to be staffed with 2 nurses at night and day, 8 CNAs for days and evenings, and 5 CNAs at night. She stated licensed nurses' shifts were: Day shift 6:00 AM to 6:00 PM and night shift 6:00 PM to 6:00 AM. She stated CNA shifts were: Day shift 6:00 AM to 2:00 PM, Evening shift 2:00 PM to 10:00 PM, and Night shift 10:00 PM to 06:00 AM. During an interview on [DATE] at 5:00 PM, TNA J stated she was CPR certified and [MEDICATION(S)] maneuver certified but most of the other TNAs were not. She stated she was working Hall 100/unit 1 (male secured locked unit) on [DATE] when Resident #6 choked. TNA J stated LVNB was on the unit at the time of the incident. She stated generally the nurse was at the nurse's station and not easily accessible. She stated LVN B was working Hall 100/Unit1 (male secured locked unit) was available and started CPR. TNA J stated there had been times when she was the only staff on Hall 100/Unit1 (male secured locked unit) but she could not state the exact dates and if an emergency occurred, she would not be able to get help. She stated she would have to scream until someone heard her. She stated the nurse would be at the nurses' station located off Hall 100/Unit1 (male secured locked unit) passed the locked doors and she would not be able to get help. She stated if a TNA that was not certified was alone on Hall 100/Unit1 (male secured locked unit) it would be a very unsafe environment. She stated Hall 100/Unit1 (male secured locked unit) was often staffed with only 1 TNA. TNA J stated she believed failure occurred because the facility did not have enough staff to prevent Resident #6 to get the food from the other resident's room. TNA J stated she was not aware that Resident #6 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . TNA J stated she had not done or received any training at all. During an interview on [DATE] at 12:45 PM, CNA G stated the facility was never staffed with 2 CNAs per unit. She stated she worked units' alone multiple shifts, but she could not state the exact dates. She stated Resident #6 had always tried to steal food and he had to be constantly monitored during mealtimes. She did not state if she reported this to DON or Administrator. During an interview on [DATE] at 12:55 PM, TNA M stated she had been a TNA since [DATE]. She stated she was not CPR certified and had not received any training regarding resident's behaviors. She stated she worked alone on units almost every shift but could not state the exact dates. She stated Hall 100/Unit 1 (male secured lock unit) had 2 (unsampled) residents that required feeding assistance and Resident #6 who stole food. She stated she would assist one resident eating and the other resident waited until she was done before she could assist him with eating. She stated she also had to redirect Resident #6 continuously while assisting residents with eating. She stated nurses were never on the units during mealtimes. She stated multiple residents had voiced concerns about their care and safety but could not state exactly which resident voiced or when. She did not state if she reported this to DON or Administrator. Record review of grievance log revealed no evidence of residents complaining about their concerns for their care and safety. During an interview on [DATE] at 10:00 AM, CNA H stated that she had worked the units/halls alone multiple times but could not state the exact dates. She stated the facility kept putting staff on Hall 100/Unit 1 (male secured locked unit) that did not know the residents. She stated that Hall 100/Unit 1 (male secured locked unit) had 2 (unsampled) residents that required assistance with meals. She stated Resident #6 had always tried to steal food and it was worse after he started a pureed diet. She did not state if she reported this to DON or Administrator. During an interview on [DATE] at 10:10 AM, CNA I stated she was an agency aide and had worked every hall in the facility. She stated she never received any training regarding behaviors. She stated she did not know that Resident #6 needed to be monitored for stealing food and was to be monitored at mealtimes. Record review of the facility employee timecards for [DATE] at 7:30 pm revealed that Station 2 had 2 LVNs, 2 CNAs (1 of the 2 was Agency), and 5 TNAs working with a census of 111. Record review of the facility daily staff schedule dated [DATE] revealed there were 2 TNAs assigned Hall 100/Unit 1 (male secured locked unit) without the supervision of a CNA and census of 12 residents with known behaviors. Resident #2 Record review of Resident #2's electronic face sheet accessed on [DATE] for Resident #2 revealed an [AGE] year-old male admitted on [DATE] to Hall 200/Unit2 (male secured locked unit) with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's Discharge MDS dated [DATE] for Resident # 2 revealed a BIMS interview was not performed. Further review of MDS dated [DATE] revealed: Section E: Behavior: E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others occurred 1 to 3 days. B. Verbal behavioral symptoms directed towards others occurred 1 to 3 days. Section N: medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Antidepressant 7. Record review of Resident's #2's Care Plan dated [DATE] revealed the objectives lacked the ability to be evaluated or quantified were: Problem: [CONDITION(S)] Drug Use. Goal: Benefit without side effects. Approach: Refer to Social Services if needed, Gradual dose reduction, Monitor for side effects, Monitor target behaviors. Problem: Psychosocial Well-Being Goal: Resident will express/exhibit satisfaction Approach: Allow to express feelings, Listen carefully and be non-judgmental, Keep topics of conversation light and cheerful, Customary routines adhered to: (specify). Problem: Mood State Goal: Resident will express/exhibit satisfaction. Approach: Assess, monitor, and document mood, Be reassuring and listen to concerns, Meds as ordered. Resident #5 Record review of Resident #5's electronic face sheet accessed on [DATE] for Resident #5 revealed an [AGE] year-old male admitted on [DATE] to Hall 200/Unit2 (male secured locked unit) with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's Discharge MDS dated [DATE] revealed a BIMS score of 07 indicating severe cognitive impairment. Further review of MDS revealed: Section E: Behavior: E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others occurred 1 to 3 days. B. Verbal behavioral symptoms directed towards others occurred 1 to 3 days. C. Other behavioral symptoms not directed towards others occurred 4 to 6 days. E0800. Rejection of Care: Occurred 1 to 3 days. E0900 Wandering: occurred 1 to 3 days. Section N: medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . A. Antipsychotic 7. Record review of Resident's #5's Care Plan dated [DATE] revealed the objectives that lacked the ability to be evaluated or quantified were: Problem: Mood State Goal: Resident will express/exhibit satisfaction. Approach: Assess, monitor, and document mood, Be reassuring and listen to concerns, Meds as ordered. Problem: Behavioral Symptoms. Goals: I will have fewer episode of physical aggression. Approach: Staff will redirect as needed. Staff will notify physician with any increase in behaviors. Problem: [CONDITION(S)] Drug Use. Goal: Benefit without side effects. Approach: Refer to Social Services if needed, Gradual dose reduction, Monitor for side effects, Monitor target behaviors. Resident #4 Record review of Resident #4's electronic face sheet accessed on [DATE] revealed a [AGE] year-old male admitted on [DATE] to Hall 200/Unit2 (male secured locked unit) with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's Discharge MDS dated [DATE] for Resident #4 revealed a BIMS score of 08 indicating moderate cognition impairment. Further review of MDS revealed: Section E: Behavior: E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others occurred 1 to 3 days. B. Verbal behavioral symptoms directed towards others occurred 1 to 3 days. E0900 Wandering: occurred 1 to 3 days. Section N: medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . A. Antipsychotic 7 C. Antidepressant 7. Record review of Resident's #4's Care Plan dated [DATE] revealed: Problem: Resident exhibits wandering. Goal: Resident will wander safely within specified boundaries over the next 90 days. Approach: Remove resident from other resident's rooms and unsafe situations, Assess resident for placement in a specially designed therapeutic unit, and Avoid over-stimulation. Problem: Behavioral Symptoms [DATE] aggression towards others and impulsiveness Goal: Resident will have less than 3 episodes of Verbal and/or physical aggression towards others over the next 90 days. Approach: Remove from public area when behavior is unacceptable, Keep environment calm and relaxed, Encourage diversional activities, Redirect me when I am in the day room around others if they get to close to me, and staff will assist me to a quiet area if I become inappropriate with others. Resident #3 Record review of Resident #3's electronic face sheet accessed on [DATE] for Resident #3 revealed a [AGE] year-old male admitted [DATE] to Hall 200/Unit 2 (male secured locked unit) with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's Quarterly MDS dated [DATE] for Resident #3 revealed a BIMS interview was not performed. Further review of MDS revealed: Section E: Behavior: E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others occurred 1 to 3 days. Section N: medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . A. Antipsychotic 7 B. Antianxiety 7 C. Antidepressant. Record review of Resident #3's Care Plan dated [DATE] for Resident #3 revealed: Problem: I was exhibiting physically aggressive behavior towards others. Goal: I will have less than 2 physical altercations over the next 90 days. Approach: Assist me to a quiet area when I become agitated to reduce stimuli and Monitor for pain, injuries. Resident #9 Record review of Resident #9's electronic face sheet accessed on [DATE] revealed a [AGE] year-old male admitted on [DATE] to Hall 200/Unit 2 (male secured locked unit) with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #9's Discharge MDS dated [DATE] revealed a BIMS interview was not performed. Further review of MDS revealed: Section N: medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . A. Antipsychotic 7 C. Antidepressant 7. Record review of Resident #9's Care Plan dated [DATE] revealed: Problem: Mood remains agitated and anxious. Goal: Resident will express/exhibit less anxiousness and agitation. Approach: Assess, monitor, and document mood, Be reassuring and listen to concerns, Encourage group activities, and Meds as ordered. Resident #10 Record review of Resident #10's electronic face sheet accessed on [DATE] revealed a [AGE] year-old male admitted on [DATE] to Hall 200/Unit 2 (male secured locked unit) with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #10's Quarterly MDS dated [DATE] revealed a BIMS score of 07 indicating moderate cognitive impairment. Further review of MDS revealed: Section E: Behavior: E0200 Behavior Symptoms: B. Verbal behavior symptoms directed towards others occurred 1 to 3 days. Section N: medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Antidepressant 7. Record review of Resident #10's Care Plan dated [DATE] revealed: Problem: Behavioral Symptoms Goal: Resident will have fewer episodes of wandering. Approach: Always ask for help if resident becomes abusive/resistive, Encourage diversional activities, and Remove from public area when behavior is unacceptable. Resident #1 Record review of Resident #1's electronic face sheet accessed on [DATE] revealed a [AGE] year-old male admitted on [DATE] on Hall 200/Unit2 (male secured locked unit) with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Discharge MDS dated [DATE] for Resident #1 revealed a BIMS score of 03 indicating severe cognitive impairment. Further review of MDS revealed: Section E: Behavior: E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others occurred 1 to 3 days. B. Verbal behavioral symptoms directed towards others occurred 1 to 3 days. E0900 Wandering: occurred 1 to 3 days. Section N: medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Antidepressant 7. Record review of Resident's #1's Care Plan dated [DATE] revealed: Problem: Resident exhibits wandering as evidence by resident went out the side gate to the front door Goal: Resident will wander safely within specified boundaries. Approach: Place resident in a secure environment, Remove resident from other resident's rooms and unsafe situations, and Avoid over-stimulation. Record review of the Provider Investigation Report dated [DATE], revealed on [DATE] at 2:00 pm, [Resident #5] was leaning against the door frame with arms crossed and an agitated expression on his face arguing with a nurse stating. Get him out of my room. [ADON] got closer and was able to see why they were unable to move [Resident #2]. [Resident #2] was sent to the emergency room for a suspected fracture of the hip. [Resident #5] stated, He was eating my snacks, so he told him to get out. When [Resident #2] did not leave, I pushed him room. [Resident #2] was assessed and 911 called. [Resident #2] went to the hospital and was later admitted for [CONDITION(S)] with no fracture noted. Record review of Resident #5's electronic progress note dated [DATE] at 4:54 PM by the ADON revealed Resident #5 was placed on one-on-one monitoring to which Administrator did while removing Resident to his office to deescalate the situation. Record review of the facility employee timecards for [DATE] at 2:35 PM revealed Station 2 had 2 LVNs, 6 CNAs (5 agency and 1 TNA) working with a census of 110. Record review of the facility staff schedule dated [DATE] revealed there was 1 agency CNA working Hall 200/Unit 2 (male secured locked unit), which had a census of 18 residents including Resident #2 and Resident #5. Record review of Provider Investigation Report dated [DATE], revealed on [DATE] at 7:00pm agency [CNA C] reported she was sitting at the desk in the day room (CNA E was helping the residents come in from smoking) when she heard [Resident #4] yelling get the hell out of my room. [CNA C] entered room [ROOM NUMBER]. [Resident #1] was lying on the floor in the room. [Resident #4] was pulling [Resident #1] by his legs. [CNA C] separated the residents. [Resident #1] started kicking at CNA A so that he could proceed to have further contact with Resident #4. Resident #4 pushed [CNA C] out of the way to get back to physical contact with [Resident #1] again. [Resident #4] made second contact with [Resident #1]. Per [CNA C's] statement [Resident #4] pulled at [Resident #1's] arm and face. [CNA C] stepped in between residents to separate the residents again. Nurse was called and assessment begun. 911 was called for [Resident #1]. All appropriate notifications made. Resident was sent out with EMS to the hospital. [Resident #4] received increase in supervision until he was sent to a behavior health hospital on [DATE] early morning. During an interview on [DATE] at 4:00 PM, the Administrator stated Resident #4 was placed on every 15-minute checks immediately following the resident-to-resident altercation and continued until he was discharged to a local behavior health hospital on [DATE]. Administrator stated the only interventions the facility had implemented to protect Resident #1 from further altercations was consultation with psychiatric services and playing the radio because Resident #1 liked to dance. He stated Resident #4 had been aggressive on [DATE] and his [MEDICATION(S)] and [MEDICATION(S)] was increase, then he was aggressive again on [DATE] and his [MEDICATION(S)] was increased. He stated he felt the facility had provided proper interventions. During an interview on [DATE] at 5:30 PM, CNA C stated she was on Hall 200/Unit 2 (male secured locked unit) alone when on [DATE] when Resident #1 and Resident #4 got into resident-to-resident altercation. She stated the charge nurse was not on the unit and rarely was on the unit. She stated she was at the desk and heard Resident #4 yelling from room [ROOM NUMBER]. She stated when she entered, she saw Resident #1 was lying in the floor and Resident #4 was dragging him across the room. She stated she attempted to separate the residents but Resident #1 was still lying on the floor kicking and Resident #4 pushed her out of the way and grabbed Resident #1 by the arms and face. CNA C stated she separated them again and CNA E came in from being outside with the residents who were smoking. She stated CNA E then ran to get help from a nurse. She stated CNA E had to go through 2 locked doors to get help and then return through 2 locked doors with the nurse. CNA C stated she was an agency CNA and she had not received any special training to work with residents with behaviors. She stated she had no orientation to the facility, and she did not sign any training or orientation paperwork. She stated she had worked halls alone with no other aides many times, but she could not state the exact dates. She stated it was rare that she worked with another CNA. She did not state if she reported this to DON or Administrator. CNA A stated she was not aware that Resident #4 or Resident #1 had any history of behaviors. During an interview on [DATE] at 5:30 PM, CNA E stated she was an agency CNA and she had not received any specialized training to work with residents with behaviors. She stated she did not work specific halls in the facility, so she had worked every hall in the facility. She stated the nurses were very hard to locate and are only on the hall to pass medications. She stated sometimes she received report from the CNA leaving from the previous shift, but not often. She stated when she worked alone, she had to take residents out for their smoke break and leave the rest of the residents on the hall unattended, but she could not state the exact dates. She did not state if she reported this to DON or Administrator. CNA E stated she was not aware that Resident #4 or Resident #1 had any history of behaviors. CNA E stated on [DATE] she had been outside with the residents on their smoke break when she re-entered the building and heard CNA C screaming for help. She stated she ran to get help from a nurse through 2 locked doors then go back through 2 locked doors with the nurse to return to the residents. CNA E stated she was not aware that Resident #4 or Resident #1 had any history of behaviors. Record review of the facility employee timecards for [DATE] at 6:58 PM revealed Station 2 had 2 LVNs, 5 CNAs (4 of the 5 were agency, and 1 TNA) working with a census of 108. Record review of the facility staff schedule dated [DATE] revealed there were 2 agency CNAs working Hall 200/Unit 2 (male secured locked unit), which had a census of 18 residents with known aggressive behaviors. Record review of the Provider Investigation Report dated [DATE], revealed on [DATE] at 5:45 PM, CNA reported she heard a commotion and saw [Resident #3] sitting in a dining room chair with [Resident #1] standing over him. Bothe residents were immediately separated. [Resident #1] sustained red marks to the nose and left cheek and a nosebleed. [Resident #3] assessment showed 1.5 x 1.5 bump/bruise to left eye, 2.5 cm x 2 cm bruise/redness to right side of neck, and no other injuries. [Resident #1] upper lip appeared slightly swollen. an abrasion to the right side of the neck. [Resident #1] was placed on 15-minute checks with increased supervision while out in the common area. Record review of the facility employee timecards for [DATE] at 5:45 PM revealed Station 2 had 2 LVNs, 4 CNAs (1 agency and 4 TNAs) working with a census of 108. Record review of the facility staff schedule dated [DATE] revealed there was 1 agency CNA working Hall 200/Unit 2 (male secured locked unit), which had a census of 18 residents with known aggressive behaviors. Record review of the Provider Investigation Report dated [DATE], revealed on [DATE] t 3:15 PM, CNA reported [Resident #9] hit [Resident #1] in the face multiple times. CNA separated and notified the nurse. [Resident #1] had a 1.8 cm x 2.8 cm discolored raised area under his left eye and a superficial abrasion 0.8 cm x 2.8 cm to neck under left ear. [Resident #10] was placed on 15-minute checks. During a telephone interview on [DATE] at 12:15 PM, TNA N stated she no longer worked for the facility. She stated she voiced her concerns about working alone on the hall's multiple times to the Administrator and the DON. She stated she left the facility because she felt the staff and the residents were in danger. She stated she received no CNA training and no training regarding behaviors. She stated she worked alone most of her shifts, but she could not state the exact dates. She stated she was alone on Hall 200/Unit 2 (male secured locked unit) when Resident#1 and Resident #3 got into resident-to-resident altercation on [DATE]. She stated she had to scream for help and LVN P at the nurse's station behind the locked doors heard her and came to help her. She stated after the altercation, Resident #3 was placed on every 15-minute checks. She stated the facility did not provide another staff member to help. She stated she was required to perform 15-minute checks on Resident #3 and care for the other residents alone for the rest of her shift. Record review of 15-minute check documentation revealed no signatures of who performed the checks. The document just provided the location of Resident #9 every 15-minutes. Record review of the facility employee timecards for [DATE] at 3:55 PM revealed Station 2 had 2 LVNs, 1 CNAs, and 1 TNAs working with a census of 108. Record review of the facility staff schedule dated [DATE] revealed 7 nursing aides, Record review of the facility staff schedule dated [DATE] revealed there was 1 TNAs working Hall 200/Unit 2 (male secured locked unit), without the supervision of a CNA, with a census of 18 residents with known aggressive behaviors. Record review of the Provider Investigation Report dated [DATE] revealed on [DATE] at 4:29 PM, [Resident #10] pushed [Resident #1] against the wall and [Resident #1] slid down the wall. [Resident #1] complained of lower back pain. X-ray results showed acute L1 compression fracture. During a telephone interview on [DATE] at 5:00 PM, TNA O stated she was working Hall 200/Unit 2 (male secured locked unit) alone on [DATE] when Resident #9 and Resident #1 got into a resident-to-resident altercation. She stated the nurse was not on the unit. She stated a CNA had come to the unit to relieve her for a lunch break. She stated if the CNA had not come, she would have had to leave the unit unsupervised to go get help. She stated the nurses are only on the unit while passing medications. She stated she always worked the halls alone, but she could not state the exact dates. She stated she received no training and was thrown into working the halls alone. She stated she voiced her concerns about working alone, especially because she was pregnant with the Administrator and the DON. She stated she was aware of the resident behaviors but only because she had worked on Hall 200/Unit 2 (male secured locked unit) since she was hired. She stated she left the facility because she felt unsafe and uncomfortable, and she felt the residents were not safe. Record review of the facility employee timecards for [DATE] at 4:29 PM revealed Station 2 had 2 LVNs, 2 CNAs, and 5 TNAs working with a census of 108. Record review of the facility staff schedule dated [DATE] revealed there was 1 TNAs working Hall 200/Unit 2 (male secured locked unit), without the supervision of a CNA, with a census of 18 residents with known aggressive behaviors. Record review of 15-minute check documentation revealed no signatures of who performed the checks. The document just provided the location of Resident #10 every 15-minutes. During an interview on [DATE] at 1:30 PM, Resident #8 who resided on Hall 100/Unit 1 (male secured locked unit) stated the facility never had enough staff. He stated all the residents were always arguing and fighting and no one did anything about it. He stated he hated living in the facility. Resident stated that he had spoken to the Administrator and the DON multiple times. During an interview on [DATE] at 1:45 PM, Resident #7 who resided on hall 400 stated he was blind and never got the help he needed. He stated he was left alone all day and became agitated because no one helps him. He stated he could never find anyone and many tasks he was not capable of doing on his own. He stated there was no need to report it because no one cared. During an interview on [DATE] at 2:40 PM, DON stated TNAs completed an 8-hour online course, they received in house training with a CNA, and skills check offs were completed by the DON, ADON, or CNAs. She stated TNAs can do all resident care task alone without CNA supervision. She stated that she never staffed just 1 TNA alone on a unit. She stated that she did staff 2 TNAs on units without CNA supervision. She stated TNAs are not first aide or CPR certified. She stated if an emergency did happen there is always a nurse on the unit. DON stated the facility is always adequality staffed but did not provide evidence to prove adequate staffing. During an interview on [DATE] at 3:00 PM, with agency CNA D she stated she had worked on a unit alone during multiple shifts, but she could not state the exact dates. CNA D stated that she was an agency CNA and was not oriented to the [TRUNCATED]

Based on observations, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 1 residents (Resident #6) reviewed for accidents and supervision. The facility failed to ensure there was sufficient staffing on Hall 100/Unit 1 (male secured locked unit) to meet the needs of Resident #6 to ensure he was supervised and did not have access to food that was the wrong texture, which resulted in a choking episode requiring emergency services and hospitalization . An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with actual harm that is not immediate, due to the facility's need to evaluate the effectiveness of their corrective systems. These failures could place residents at risk for choking resident-to-resident altercations, serious harm in the event of an emergency, hospitalization s, and death. Findings include: Record review of facility assessment dated [DATE] Part 3 titled Facility Resourced Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies revealed: Staff: Licensed nurses: Station 2: LVN/RN Days: 2 and Nights: 2 Direct Care Staff/CNAs: Station 2: Days 8, Evenings 8, Nights 5. Resident #6 Record review of Resident #6's electronic face sheet accessed on [DATE] revealed an [AGE] year-old male admitted on [DATE] to Hall 100/Unit 1 (male secured locked unit) with diagnosis to include: [CONDITION(S)], dementia, difficulty swallowing, and depression. Record review of Resident #6's Quarterly MDS, dated [DATE], revealed a BIMS score interview was not performed. Further review of MDS, revealed: Section E: Behavior: E0100. Potential Indicators of [CONDITION(S)]: B. Delusions. E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others occurred 1 to 3 days. B. Verbal behavioral symptoms directed towards others occurred 1 to 3 days. Section G: Functional Status: G0110. Activities of Daily Living Assistance: H. Eating:1. Self-Performance Supervision. 2. Support: One-person physical assist. Section K: Swallowing/Nutrition Status: K0100. Swallowing Disorder: A. Loss of liquids/solids from mouth when eating or drinking. K0510: Nutritional Approaches: C. Mechanically altered diet. D. Therapeutic Diet. Record review of Resident's #6's Care Plan dated [DATE] revealed: Problem: Nutritional Status Diet. Goal: Maintain Stable Weight. Approach: Diet as ordered: Dysphagia advanced pureed, carbohydrate consistent, and Report problems to charge nurse. Further review of Care Plan revealed no evidence of interventions to prevent resident choking or stealing food. The Care Plan showed no evidence of supervision needs for Resident #6. During an interview attempt on [DATE] at 12:45 PM Resident #6 was unable to answer any questions due to his level of cognitive impairment. Record review of Provider Investigation Report dated [DATE] revealed on [DATE] at approximately 07:30 pm, [Resident #6] was found unresponsive with no pulse and no reparations. Staff immediately started CPR. [Resident #6] responsive at time of transport. [Resident #6] expelled a portion of food. [Resident #6] is on a pureed diet. [Resident #6] was sent to the emergency room after staff performed CPR. [Resident #6] did respond to paramedics that arrived shortly after the 911 call was placed. During an observation on [DATE] at 12:40 PM on Hall 100/Unit 1 (male secured locked unit) revealed 9 residents sitting in the dining room. TNA M assisted one unsampled resident with eating lunch. CNA G assisted one unsampled resident with eating lunch. No nurse was observed in the dining room. Resident #6 sat next to CNA G and was redirected continuously not to grab food from other residents' plates. During an Observation on [DATE] 04:45 PM Hall 100/Unit 1 (male secured locked unit) had 1 Business Office Manager and 1 Assistant Business Office Manager staffed. No nurse was observed on Hall 100/Unit 1 (male secured locked unit). During an interview on [DATE] at 11:00 AM, DON stated Station 2 had 6 wings: Hall 100/Unit 1 (male secured locked unit), Hall 200/Unit 2 (male secured locked unit), Hall 300, Hall 400, Hall 500, and Hall 600/Unit 3 (female secured locked unit). The DON stated that Station 2 always had 2 CNAs on each of the 3 secured locked units. She stated the facility tried to keep the same staff on the same units for continuity of care. DON stated station 2 was to be staffed with 2 nurses at night and day, 8 CNAs for days and evenings, and 5 CNAs at night. She stated licensed nurses' shifts were: Day shift 6:00 AM to 6:00 PM and night shift 6:00 PM to 6:00 AM. She stated CNA shifts were: Day shift 6:00 AM to 2:00 PM, Evening shift 2:00 PM to 10:00 PM, and Night shift 10:00 PM to 06:00 AM. During an interview on [DATE] at 2:40 PM, DON stated TNAs completed an 8-hour online course, they received in house training with a CNA, and skills check offs were completed by the DON, ADON, or CNAs. She stated TNAs can do all resident care task alone without CNA supervision. She stated that she never staffed just 1 TNA alone on a unit. She stated that she did staff 2 TNAs on units without CNA supervision. She stated TNAs are not CPR and [MEDICATION(S)] maneuver certified. She stated if an emergency did happen there is always a nurse on the unit. DON stated the facility is always adequality staffed but did not provide evidence to prove adequate staffing. During an interview on [DATE] at 3:00 PM, with CNA D she stated she had worked on a unit alone during multiple shifts, but she could not state the exact dates. CNA D stated that she was an agency CNA and was not oriented to the facility or the residents. She stated she did not receive any facility or specialized training for residents with behavioral or psychological issues. CNA D stated it was impossible to take care of the residents appropriately with only on CNA. She stated she was concerned about the residents in the facility's safety. She did not state if she reported this to DON or Administrator. During an interview on [DATE] at 4:00 PM, the administrator stated the facility was short staffed. During an interview on [DATE] at 5:00 PM, TNA J stated she was CPR and [MEDICATION(S)] maneuver certified but most of the other TNAs were not. She stated she was working Hall 100/unit 1 (male secured locked unit) on [DATE] when Resident #6 choked. TNA J stated LVN-B was on the unit at the time of the incident. She stated generally the nurse was at the nurse's station and not easily accessible. She stated LVN B was working Hall 100/Unit1 (male secured locked unit) was available and started CPR. TNA J stated there had been times when she was the only staff on Hall 100/Unit1 (male secured locked unit) but she could not state the exact dates and if an emergency occurred, she would not be able to get help. She stated she would have to scream until someone heard her. She stated the nurse would be at the nurses' station located off Hall 100/Unit1 (male secured locked unit) passed the locked doors and she would not be able to get help. She stated if a TNA that was not certified was alone on Hall 100/Unit1 (male secured locked unit) it would be a very unsafe environment. She stated Hall 100/Unit1 (male secured locked unit) was often staffed with only 1 TNA. TNA J stated she believed failure occurred because the facility did not have enough staff to prevent Resident #6 to get the food from the other resident's room. TNA J stated she was not aware that Resident #6 had a history of stealing food and required enhanced supervision around food. TNA J stated she had not done or received any training at all. During a confidential interview on [DATE] at 11:30 AM, an anonymous staff member stated they were uncomfortable with things happening at the facility. The anonymous staff member stated the facility was always short staffed and did not have the staff to appropriately care for the residents with the behavior issues that were being admitted . The anonymous staff member stated they felt that the facility did not having adequate staff to care for the residents. The anonymous staff member did not state if she reported this to DON or Administrator. During an interview on [DATE] at 5:25 PM, TNA K stated she was not CPR and [MEDICATION(S)] maneuver certified. She stated there had been several times she worked the units alone, but she could not state the exact dates She stated the nurses were rarely on the unit and the nurses were at the nurse's station passed the locked doors. She stated in an emergent situation she would stay with resident and scream for help. TNA K stated if no one came for help she would have to leave the resident unattended, punch in the key code, and push the door open to call for help. TNA K stated she had felt she had been put in an unsafe situation many times. She stated she took an 8-hour course online and CNAs showed her what to do but felt like she was thrown in without adequate training. She stated she did not remember doing any specialized training on caring for residents with behavioral issues. She did not state if she reported this to DON or Administrator. During an interview on [DATE] at 11:50 AM, the DON stated agency CNAs did not receive any specialized training from the facility. She stated CNAs were given a verbal change of shift report regarding the resident's care needs by the CNAs from the previous shift. During an interview on [DATE] at 12:15 PM, CNA F stated she had worked in the facility for 2 years. She stated she worked the units alone most of her shifts. She stated it was unsafe and 1 staff was not enough to properly handle the resident behaviors. She stated the facility placed too many untrained staff on the units which leaded to resident altercations. She stated the nurses were only available during medication pass. She did not state if she reported this to DON or Administrator. During an interview on [DATE] at 12:30 PM, TNA L stated she had been a TNA for 7 weeks. She stated she was never trained or checked off on her skills. She stated she followed a CNA for one shift then was placed alone to work on a unit. She stated she worked the units alone most of her shifts, but she could not state the exact dates. She stated she used her personal cell phone to call for help when she needed it. She stated the facility did not staff the units with consistent staff which she believed contributed to the resident behaviors. She stated the facility did not do any activities with the residents. TNA C stated she felt the residents were very unsafe and the facility needed to get some help. She stated she had addressed her concerns with the administrator and the DON. During an interview on [DATE] at 12:45 PM, CNA G stated the facility was never staffed with 2 CNAs per unit/hall. She stated she worked units alone multiple shifts, but she could not state the exact dates. She stated Resident #6 had always tried to steal food and he had to be constantly monitored during mealtimes. She did not state if she reported this to DON or Administrator. During an interview on [DATE] at 12:55 PM, TNA M stated she had been a TNA since [DATE]. She stated she was not CPR and [MEDICATION(S)] maneuver certified and had not received any training regarding resident's behaviors. She stated she worked alone on units almost every shift but could not state the exact dates. She stated Hall 100/Unit 1 (male secured lock unit) had 2 (unsampled) residents that required feeding assistance and Resident #6 who stole food. She stated she would assist one resident eating and the other resident waited until she was done before she could assist him with eating. She stated she also had to redirect Resident #6 continuously while assisting residents with eating. She stated nurses were never on the units during mealtimes. She stated multiple residents had voiced concerns about their care and safety but could not state exactly which resident voiced or when. She did not state if she reported this to DON or Administrator. During a telephone interview on [DATE] at 5:00 PM, TNA O stated the nurses are only on the unit while passing medications. She stated she always worked the halls alone, but she could not state the exact dates. She stated she received no training and was thrown into working the halls alone. She stated she voiced her concerns about working alone, especially because she was pregnant with the Administrator and the DON. She stated she left the facility because she felt unsafe and uncomfortable. During an interview on [DATE] at 5:30 PM, CNA C stated she was an agency CNA and she had not received any special training to work with residents with behaviors. She stated she had no orientation to the facility, and she did not sign any training or orientation paperwork. She stated she had worked halls alone with no other aides many times, but she could not state the exact dates. She stated it was rare that she worked with another CNA. She did not state if she reported this to DON or Administrator. During an interview on [DATE] at 05:55 PM, LVN A stated she was covering as a nurse aide for hall 300 as well as being the nurse on duty for Hall 100/Unit 1 (male secured locked unit), Hall 200/Unit 2 (male secured locked unit), and half of Hall 300. She stated the other nurse was covering as a nurse aide for hall 400 as well as being the nurse on duty for Hall 600/Unit 3 (male secured locked unit) and hall 300. She stated that on occasion she had to work as nurse and aide, but she could not state the exact dates. She stated that it was crazy because she had 37 residents and 8 blood sugars to be completed on her shift. She stated that she came in early and left late for many shifts. She stated that the regular staff knew the resident's triggers, but the agency staff did not know the resident's triggers. She stated that she had told management that she would not be able to train a new nurse properly. During a telephone interview on [DATE] at 12:15 PM, TNA N stated she no longer worked for the facility. She stated she voiced her concerns about working alone on the hall's multiple times to the Administrator and the DON. She stated she left the facility because she felt the staff and the residents were in danger. She stated she received no CNA training and no training regarding behaviors. She stated she worked alone most of her shifts, but she could not state the exact dates. During an interview on [DATE] at 5:30 PM, CNA E stated she was an agency CNA and she had not received any specialized training to work with residents with behaviors. She stated she did not work specific halls in the facility, so she had worked every hall in the facility. She stated the nurses were very hard to locate and are only on the hall to pass medications. She stated sometimes she received report from the CNA leaving from the previous shift, but not often. She stated when she worked alone, she had to take residents out for their smoke break and leave the rest of the residents on the hall unattended, but she could not state the exact dates. She did not state if she reported this to DON or Administrator. During an interview on [DATE] at 10:00 AM, CNA H stated that she had worked the units/halls alone multiple times but could not state the exact dates. She stated the facility kept putting staff on Hall 100/Unit 1 (male secured locked unit) that did not know the residents. She stated that Hall 100/Unit 1 (male secured locked unit) had 2 (unsampled) residents that required assistance with meals. She stated Resident #6 had always tried to steal food and it was worse after he started a pureed diet. She did not state if she reported this to DON or Administrator. During an interview on [DATE] at 10:10 AM, agency CNA I stated she was an agency aide and had worked every hall in the facility. She stated she never received any training regarding behaviors. She stated she did not know that Resident #6 needed to be monitored for stealing food and was to be monitored at mealtimes. During an interview on [DATE] at 3:00 PM, the DON stated that she was responsible for making the licensed nurses and nurse aides schedules. She stated the facility was using agency aides to help cover. She stated she believed the facility had enough staff. She stated the TNAs had worked at the facility for a long time, they have had online course for CNA and were placed with a CNA for on-the-job training. She stated the staff used personal phones because it was quicker since the staff already had cell phones in their pockets. She stated the facility was in process of getting all TNAs and CNAs certified for CPR. She stated the facility should always schedule a CNA with TNA, but there was not an abundance of CNAs available. DON stated when new residents were admitted the facility tried to see who the resident would interact with best. She stated the IDT team visited with the residents and find out what the residents enjoy. She stated with the residents that had been in the facility a while would be reevaluated to see what kind of activities should be incorporated. Record review of the facility employee timecards for [DATE] at 7:30 pm revealed that Station 2 had 2 LVNs, 2 CNAs (1 of the 2 was Agency), and 5 TNAs working with a census of 111. Record review of the facility daily staff schedule dated [DATE] revealed there were 2 TNAs assigned Hall 100/Unit 1 (male secured locked unit) without the supervision of a CNA and census of 12 residents with known behaviors. Record review of grievance log revealed no evidence of residents complaining about their concerns for their care and safety. Record review of agency CNA D's employee file revealed no evidence of facility or specialized training for residents with behavioral or psychological issues Record review of TNA J's employee file revealed no evidence of training related to resident behaviors or competency skills checkoffs or CPR and [MEDICATION(S)] maneuver certification. Record review of TNA K's employee file revealed no evidence of training related to resident behaviors or competency skills checkoffs or CPR and [MEDICATION(S)] maneuver certification. Record review of TNA L's employee file revealed no evidence of competency skills checkoffs or CPR and [MEDICATION(S)] maneuver certification. Record review of TNA M's employee file revealed no evidence of training related to resident behaviors or competency skills checkoffs or CPR and [MEDICATION(S)] maneuver certification. Record review of TNA O's employee file revealed no evidence of training related to resident behaviors or competency skills checkoffs or CPR and [MEDICATION(S)] maneuver certification. Record review of agency CNA C's employee file revealed no evidence of training related to resident behaviors. Record review of TNA N's employee file revealed no evidence of training related to resident behaviors or competency skills checkoffs or CPR and [MEDICATION(S)] maneuver certification. Record review of agency CNA E's employee file revealed no evidence of training related to resident behaviors. Record review of agency CNA I's employee file revealed no evidence of training related to resident behaviors. Record review of TNA F's employee file revealed no evidence of competency skills checkoffs. Record review of the facility's policy Staffing revised [DATE] revealed: Policy Statement: Our center provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the center assessment. Policy Interpretation and Implementation: 1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. 2. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. Record review of facilities policy Behavior Assessment, Intervention, and Monitoring revised [DATE] revealed: Policy Statement: 1. Behavioral symptoms will be identified using facility-approved screening tools and the comprehensive assessment Assessment: 1. As part of the initial assessment, the nursing staff and attending physician will identify individuals with a history of impaired cognition, altered behavior, or mental illness. 2. As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family, and caregivers, review of medical record and general observation: a. The residents' usual patterns of cognition, mood, and behavior; B. the resident's usual method of communication things like pain, hunger, thirst, and other physical discomforts; and c. The residents typical or past responses to stress, fatigue, fear, anxiety, frustration, and other triggers .Management: 1. The IDT team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented if necessary to protect the resident and others from harm .11. The Director of Nursing will evaluated whether the staffing needs have changed based on acuity of the residents and their plans of care. Additional staff and/or staff training will be provided if it determined that the needs of resident cannot be met with the current of staff or staff training. The Vice President of Operations, Administrator, and Director of Nurses were notified on [DATE] at 12:00 PM that an Immediate Jeopardy was identified, and a Plan of Removal was requested at that time. This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The Vice President of Operations, Administrator, and Director of Nurses were notified. The Administrator as provided with the IJ template on [DATE] at 12:00 PM. The following Plan of Removal was accepted on [DATE] at 11:00 AM and included: Actions: A. The facility failed to provide supervision to prevent choking episodes: Action 1: Assigned unit staff will ensure snacks are out of reach of residents in the secured unit who lack the capacity to know their appropriate diet texture. Snacks will be handed out upon receipt and residents will be monitored and/or snacks will be behind a locked door and/or cabinet. Staff education and testing to verify understanding. Agency and new staff will be educated and tested prior to working their next/first shift. Test results will be reviewed, and any missed questions will be reviewed with staff members, and they will be re-educated. Date Initiated: [DATE], revisiting/completing [DATE] Action 2: Residents' diet orders will be available and accessible at each nurses' station and each secured unit on Matrix Care (Electronic Charting System). Staff will be able to validate diets and ensure residents are receiving the appropriate diet texture. All direct care staff has access to the resident's diet orders through Matrix Care. The Resident's diet orders are updated by charge nurses and communicated with dietary through a communication form. Director of Nursing will review any diet order changes during the clinical meeting. Staff is aware of any changes by the shift-to-shift report, education, care plan updating, and documentation. Date Initiated: [DATE], revisiting/completing [DATE] Action 3: Staff assigned to the specified unit/areas will redirect and monitor residents' consumption of meals/snacks to ensure residents are consuming their appropriate diet texture. The staff has been educated through formal in-servicing and employee-to-employee reports regarding resident #6's tendencies to grab food that is inappropriate for his diet texture. A monitoring form will be located on each unit that includes the date, time, staff name, and whether monitoring occurred or not. Director of Nursing, Administrator, and designee will ensure Agency and new staff will be educated and tested before working their next/first shift. Test results will be reviewed, and any missed questions will be reviewed with staff members and re-educated. Date Initiated: [DATE], revisiting/completing [DATE] Action 4: The Director of Nursing, Administrator, and/or designee will ensure employees are in-serviced and educated regarding residents' diet orders, snack accessibility, passing of snacks, and monitoring residents' consumption of snacks, and mealtime monitoring. In-service records will be checked against the employee roster to ensure 100% completion. Date Initiated: [DATE], revisiting/completing [DATE] Action 5: Testing will be completed regarding residents' diet orders, snack accessibility, passing of snacks, and monitoring residents' consumption of snacks. Testing will be checked against the employee roster to ensure 100% completion. If test results are below par, employees will be reeducated. Director of Nursing, Administrator, and/or designee will be responsible for Action 5. Date Initiated: [DATE], revisiting/completing [DATE] Action 6: At random, x 5 days weekly, IDT members (and/or designee) will rotate and monitor a meal and/or snack pass to ensure compliance with the above actions. Director of Nursing, Administrator and/or designee will be responsible for ensuring this action is completed. Date Initiated: [DATE], revisiting/completing [DATE] Action 7: Director of Nursing updating care plan regarding resident #6's history of stealing food and appropriate interventions to reduce the risk of future incidents. I will be monitored while I eat, staff will set up my tray for all snacks/meals, and I will consume my appropriate diet texture (puree). Interventions will be assessed for effectiveness quarterly. Date Initiated: [DATE] B. The Facility failed to provide supervision to prevent resident-to-resident altercations. Action 1: Minimum of 2 scheduled staff members for both ,d+[DATE] and ,d+[DATE] shifts on each secured unit, one scheduled staff member for ,d+[DATE] with the nurse rotating units for assistance, breaks, and coverage. If coverage is ineffective through incident and accident tracking and trending and/or staff and resident interviews, staff shall be added to the identified areas of concern. Administrator Director of Nursing, Assistant Director of Nursing, will be responsible for ensuring adequate staffing. Date: Initiated on [DATE], ensured through [DATE], and on-going Action 2: Continue to request, schedule, and utilize our staff and our contingency staff, agency, our corporate Mobile Clinical Support Nurses/Mobile Certified Aides, and continue with our internal and corporate recruiting and retention program to recruit and retain sufficient staff. Contingency Staff: Department heads, and other employees that have completed TNA education/course or can work in the role of a hospitality aide to assist with care needs. Mobile Clinical Support Nurses/Mobile Certified Aides: Nurses and CNAs employed by corporate deployed to Corporation nursing homes around Texas. Sufficient staff: Adequate in numbers and education to meet the needs/acuity of our current secured units. Date: Continual, revisited [DATE] & [DATE], and on-going until facility's staffing is sufficient Action 3: At a minimum, Administrator and Director of Nursing will be on a daily staffing call x5 days, starting [DATE], (Monday through Friday, Friday to cover Saturday and Sunday, Monday to recap the weekend), and on-going with no stop date, to ensure adequate staffing is scheduled and anticipated with a contingency plan in place, with Regional Nurse Manager, and Regional Vice President of Operations. Staffing is discussed during a morning-clinical meeting between IDT, as well. Staffing calls will include: 1. Per secured unit-Census, 2. The remainder of station 2's census, 3. station 1's- Census, 4. Staffing breakdown (by discipline) for each individual unit, 5. Staffing (by discipline) for the remainder of station 2, 6. Staffing (by discipline) for sides 1, 7. (When off admission hold) pending admissions for the day, 8. Planned discharges that day. Staffing will be appropriate/adequate and identified through a review of the facility assessment, employee and resident interviews/conversations, incident and accident tracking, and the QAPI process. Date: Initiated [DATE], continuing [DATE], and ongoing until facility's staffing is sufficient Action 4: Regional Vice President of Operations, in-serviced Administrator, and Director of Nursing, on Adequate and sufficient supervision/staffing. Date: Initiated/Completed [DATE] Action 5: Administrator, Director of Nursing, Social Worker, or designee in-servicing all staff (including external staff such as agency or Mobile Clinical Support Nurses/Mobile Certified Aides) on Behavioral Health Services, Behavioral Assessment, Intervention, and Monitoring, and Managing Behaviors. All new staff (internal or external) will be in-serviced prior to the first shift by Administrator, Director of Nursing, Social Worker, or designee. Ensuring all staff completion prior to the next shift worked by tracking against the staff roster. Date: Initiated [DATE], continuing [DATE], and completed [DATE]. Action 6: A test to ensure competency of Behavioral Health Services, Behavioral Assessment, Intervention, and Monitoring, and Managing Behaviors. Ensuring all staff completion prior to the next shift worked by tracking against the staff roster. If staff does not meet standards on test, they will be re-in-service to ensure competency by Administrator Director of Nursing, Social Worker, or designee. Date: Initiated [DATE], continuing [DATE], and completed [DATE]. Action 7: Administrator, Director of Nursing, and/or a designee in-servicing all staff (including external staff such as agency or Mobile Clinical Support Nurses/Mobile Certified Aides) on Incidents and Accidents Policy, Resident to Resident Altercation Policy, and Abuse/Neglect Policy. Ensuring all staff completion, prior to next shift worked, by tracking against the staff roster. Date: Initiated [DATE], continuing [DATE], and completed [DATE]. Action 8: A test to ensure competency of Incidents and Accidents Policy, Resident to Resident Altercation Policy, and Abuse/Neglect Policy. Ensuring all staff completion, prior to next shift worked, by tracking against the staff roster. If staff does not meet standards on test they will be re-inserviced to ensure competency by Administrator, Director of Nursing, Social Worker, or designee. Date: Initiated [DATE], continuing [DATE], and completed [DATE]. Action 9: Agency LVNs and CNAs have an orientation packet and are educated before working their assigned shift by the Director of Nursing, Assistant Director of Nursing, and/or designee. Agency Orientation Packet includes: Agency orientation guidelines, center map with identified areas, electronic charting system directions, Policies: Abuse Prevention Program, Resident Rights, Behavioral Health Services, Behavioral Assessment, Intervention, and Monitoring, and Managing Behaviors. Temporary Nursing Aides and Hospitality Aides have been checked off through the Temporary Nursing Aide Check-Offs and have been in-serviced and tested in accordance with the above noted education actions. Date: Initiated [DATE], continuing [DATE], and completed [DATE]. Action 10: Tracking and trending resident-to-resident altercations by location, time of incident, residents involved, staff present at time of incident, investigation, interventions, and care plan updates, daily, x5 days (Monday through Friday, Monday to cover weekend incidents) to be completed by the IDT during morning clinical meeting to establish root causes and better understand/prevent behaviors/altercations. These results will be shared during monthly QAPI meeting. Communication with direct care s [TRUNCATED]

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 14 (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) out of 14 residents reviewed for infection control. The facility failed to isolate COVID-19 positive Residents #1, #2, #3, #4, #5, #6, #7, #8, and #9 after they tested positive for COVID-19 and continued to cohort with negative tested Residents #10, #11, #12, #13, and #14 all on the same unit. Resident # 4 (positive) with Resident #12 (negative) in the same room. The facility failed to change PPE in between working with COVID + and COVID - residents. The facility staff did not remove gloves or gown in between each resident. An Immediate Jeopardy (IJ) was identified on 12/28/21. While the IJ was removed on 12/29/21, the facility remained out of compliance at a severity level of potential for more than minimal harm. and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal. These failures placed residents at risk for exposure to COVID-19 which could result in serious illness, hospitalization , and/or death. Findings Included: Review of Resident #1's MDS, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's MDS, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's MDS, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's MDS, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's MDS, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's MDS, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's MDS, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's MDS, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's MDS, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's MDS, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's MDS, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #12's MDS, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #13's MDS, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's MDS, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE]. He diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility resident tracking log dated 12/26/21 on 12/27/21, titled COVID+ Residents, revealed, Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, and Resident #9 were COVID-19 tested on [DATE] and positive test results were received on 12/26/21 . Review of the facility resident tracking log dated 12/26/21 on 12/27/21, titled COVID-Residents revealed, Resident #10, Resident #11, Resident #12, Resident #13, and Resident #14 were COVID-19 tested on [DATE] and negative results were received on 12/26/21. Review of the facility resident tracking log dated 12/27/21 on 12/28/21, titled COVID+ Residents, revealed, Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, and Resident #9, Resident #12, and Resident #13, were COVID-19 tested on [DATE] and positive test results were received on 12/27/21 . In an observation 12/27/21 at 1:30 PM, the facility consisted of 5 halls and the hot unit was unit 1. Upon entry to the unit, all PPE was donned before going through the locked doors to get onto the locked unit. Unit 1 consisted of 14 residents. Resident #1, 3, 5, 13, and 14 were all gathered in the common area within proximity of each other, not 6 feet apart. Residents #3 and Resident #14 were sitting at a table together watching TV. Residents #1, 3, and 5 were COVID 19 positive residents and Resident #13 and #14 were COVID-19 negative residents. There were no signs informing staff how to don and doff PPE throughout the hall. There were no PPE carts containing face shields and gowns located throughout the hall. There were 3 (CNA-A, TNA-A, and LVN-C) staff who were observed wearing N95 masks, face shields, gowns, and gloves while providing care to negative and positive COVID-19 residents. The staff were observed not taking PPE off in-between positive and negative residents' rooms (All rooms). The staff were doing med pass, feeding the residents, and doing patient care, such as helping residents in and out of bed. There were no receptacles anywhere on the unit to doff PPE. The staff were not encouraging social distancing or wearing mask. LVN-C was doffing all PPE in trash bins in a courtyard located between Unit 1 (hot) and Unit 2 (cold). In an observation 12/27/21 at 1:35 PM, Resident #4 (positive) and Resident # 14 (negative) were in the same room together. During an interview on 12/27/21 at 1:20PM with CNA-A, she was confused because the positive and negative COVID-19 residents were not separated. She stated she was told at first on 12/25/21 that everyone on the unit had tested positive, so she treated everyone as positive, by not removing any PPE at any time, only changing her gloves. She stated however, later in the day she was informed by the DON that only about half of the residents were positive and some were negative, sometime in the afternoon, she could not remember an exact time. She stated she was not sure why they had not been separated. She stated she does not know who is positive and who is negative on the unit. She stated she was told not to remove her PPE for any resident, not even in between rooms. She stated that she and TNA-E stay on the unit all day, and that only the LVN-C can leave the unit because LVN-C was covering both unit 1, unit 2, and unit 5. During an interview on 12/27/21 at 9:50 AM with the DON she stated they had 10 positive residents now. She stated starting on 12/25/21 her nurse called her at about 10:30PM and stated Resident #15 was not feeling well so she COVID tested him, the nurse stated that his results were positive. The DON stated she went up to the facility and was there by 11 pm where she moved the Resident #15, who was on unit 4, to another hallway separated from everyone else. She stated she started mass testing on 12/26/21 on all resident and staff, this was where she found that 9 more residents came back positive and 5 employees came back positive. She stated that the Residents #1-9 are on the all-male memory care unit with the other negative Residents #10-14. She stated there is a courtyard that is shared between unit 1 and unit 2 where the nurse works both units, and she don and doffs outside in the courtyard. She stated that on unit 1 where the majority of her COVID positives are, due to the positive residents being on a memory care unit, it is hard to keep them all in their rooms and with their mask on. She stated the reason for not separating the positives from negatives was because they had no secure unit to move the negatives from positive residents. She stated if she had a secure unit, that was clean and had no other residents then she would have moved the negatives. She stated she felt that due to the exposure time that the negative residents on that unit would become positive eventually. During an interview on 12/28/21 at 1:18 PM LVN-D stated that she was told this is a COVID unit. She stated she was told that all residents on this unit are positive. She stated she has treated this entire units as a COVID unit. She stated this morning even during med pass she went from room to room wearing the same PPE, she stated she never changes any of her PPE while on the unit no matter what room she is in because she is treating the entire unit as a COVID unit. She stated that she did not know there were any residents that were COVID negative back on the unit. She reached out to her DON at this point and found out that Residents #10, #11, and #14 were still testing negative even though they were still on the hot unit. Review of the facility resident tracking log dated 12/28/21 on 12/28/21, titled COVID+ Residents, revealed, Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #12, and #13. Resulting in two new positive residents #12 and #13. Review of the facility's policy on 12/27/21, Titled: COVID-19 Response for Nursing Facilities version 4.0 dated 7/20/21- Page 28 Immediate Actions (0-24hours) During an Interview on 12/28/21 at 11:38 AM with DON and Administrator, they both stated, and confirmed together, the infection control policy they are using is the COVID-19 Response for Nursing Facilities, version 4.0, dated 7/20/21. The DON stated that is the guidance she was sent by corporate to use as her infection control policy. Prevent Further disease spread Determine number of residents potentially infected o Determine number of staff potentially infected o Determine who has been tested Create an isolation wing/unit for residents with a COVID-19 positive status o Identify a separate, well-ventilated area to use as an isolation area. This NF area should be an isolated wing, unit, or floor that provides meaningful separation between COVID-19 positive residents and the space where the NF cares for residents who are COVID-19 negative or untested and asymptomatic. A curtain or a moveable screen does not provide meaningful separation. Page 30 Care for residents who are infected o Isolate residents who are infected o Identify cohorts with the same status (exposed, infected) o Determine level of required care o Determine if hospitalization and transport are required o Notify local health care/EMS o Track signs/symptoms o Work with your LHD or DSHS to establish a resident recovery plan, including when a resident is considered recovered and next steps for care. The Administrator was notified on 12/28/21 at 2:40 PM an IJ situation was identified due to the above failures and an IJ template was provided. The Plan of Removal was accepted on 12/29/21 at 9:48 AM and reflected: Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on December 28th, 2021. Definitions: Cold rooms/areas: Residents that have not been exposed to COVID-19, testing negative on outbreak testing, and are not symptomatic. Warm rooms/areas: Residents with an unknown COVID status (new admissions that are not vaccinated), residents that have been exposed to COVID but are testing negative, symptomatic residents that are continuing to test negative. Hot rooms/areas: Confirmed COVID-19 positive. Identified Concern: The facility's failure to isolate positive and follow recommended infection control practices placed 5 negative residents at risk of contracting the COVID19 virus which could result in serious illness, hospitalization , and/or death. 1. Immediate Action: COVID positive residents will be identified through outbreak testing (if the resident tests positive), and through daily observation and assessment for signs or symptoms of COVID-19. 2. Immediate Action: Move the COVID unknown residents off the secured unit into warm rooms. Assign dedicated staff to ensure residents' safety. All residents who are negative but have been in contact with those that have tested positive will be moved into warm rooms. o Administrator, DON, and/or designee to move COVID unknown residents off the secured unit, these residents are fully vaccinated. o Completed: 12/28/2021 3. Immediate Action: Designated hot, warm, and cold zones, in which will be labeled with the signage in which is outlined below. Staff will redirect residents to their perspective areas that coincide with their COVID-19 status. COVID-19 positive residents will not be in common areas, they will reside in the hot unit/hot rooms, with meaningful separation from the warm and cold residents. Warm residents will have meaningful separation from cold residents, as well. o Completed: 12/28/2021 4. Immediate Action: Ensure there is proper PPE to include: gowns, N-95, surgical masks, and eye protection outside of the hot and warm rooms/unit. Ensure there are receptacles in each warm room so employees can doff between caring for warm residents. Ensure there are receptacles available for doffing outside hot unit and hot rooms. o Administrator, DON, and/or designee will observe PPE bins outside of residents in warm and hot areas to ensure proper PPE is available every shift. o Completed: 12/28/2021, and ongoing monitoring 5. Immediate Action: Ensure proper CDC signage is outside of each hot and warm room regarding the PPE donning and doffing and appropriate PPE attire, which includes: gown, N-95, and eye protection. Ensure door/COVID positive area is indicated via signage and floor tape. o Administrator, DON, and/or designee to round center once a day to ensure appropriate signage is in place to indicate warm and hot areas. o Completed: 12/28/2021 6. Immediate Action: Ensure staff is educated prior to working their next shift on: cohorting/separating COVID positive, COVID unknown, and COVID negative residents. Ensure staff is educated on proper PPE, when to don and doff and how to properly don and doff. Ensure staff is educated on physical distancing. o Staff will show return demonstration regarding donning and doffing o Staff will show competency by completing a test o Staff currently in house completed 12/28/2021 and will continue prior to employee's shifts until 100% compliant. 7. Immediate Action: Ensure staff working in COVID positive area/rooms are doffing PPE before leaving room/area to work with residents in warm or cold areas. Ensure staff is donning and doffing PPE after working with each warm resident, for their status is unknown, in the receptacles in the warm/hot residents' rooms which will prevent other residents from coming into contact with the discarded PPE. o Random rounds to be completed by DON, administrator or designee in warm/hot zones to ensure staff is properly doffing when exiting area, to be completed every shift for 5 days to ensure substantial compliance. o Completed: 12/28/2021 and continued monitoring to ensure compliance. 8. Immediate Action: Educate residents on physical distancing, encourage residents to stay in their rooms, and redirect residents regarding physical distancing. o Completed: 12/28/2021 9. Immediate Action: ADHOC QAPI meeting performed with MD completed 12/28/2021. Informed MD of immediate jeopardy and read through POR. MD has no other suggestions at this time. 10. Center will review education, competencies, test results, PPE and signage rounds, during their upcoming QAPI meeting, and as needed thereafter. Monitoring of the plan of removal revealed: Verification In an observation on 12/29/21 at 8:45 AM revealed the facility moved all COVID-19 negative residents to the Warm unit on unit 5 and left all COVID-19 positive residents on unit 1. With dedicated staff to unit 5 and unit 1 for COVID Hot and warm zones. In an observation on 12/29/21 at 9:20 AM revealed the facility had moved the doffing PPE bins from the shared courtyard onto unit 1 behind a locked door where no resident could get into the bins. The unit now only contained positive residents and was a true hot zone. Review of Resident #1-9, progress notes, dated 12/26/21 to 12/29/21, revealed the residents were being monitored for chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea every shift (Day, Evening, and Night) for COVID-19 screening. Review of the facility's in-service on 12/28/21 and 12/29/21, titled Inservice Training Report, dated 12/28/21 and 12/29/21, revealed, staff were educated on COVID-19 active case policy and procedure, definitions for policy interpretation, HHSC reporting process, isolation categories, standard precautions, PPE donning and doffing, and hand hygiene. Interviews conducted on 12/29/21 with staff across all shifts (6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM, and 10:00 PM to 6:00 AM), included with DON, LVN A, LVN B, LVN C, LVN D, EVS A, TNA A, TNA B, RN A, Transport A, CNA A, ADMIN, AAD A, HK A, and HK B. Staff confirmed they received in-service training on 12/29/21 to include training on: - Hot, cold, warm zones within a facility and preventing the spread of infection per current policy; - PPE utilization during an outbreak according to CDC guidelines; - Return demonstration regarding PPE will be used to determine competency - [Facility name] policy and CDC guidelines pertaining to infection control and isolation protocol; - Positive COVID results and isolation criteria; - Hand hygiene; and - HHSC reporting processes Interview with the Administrator on 12/28/21 at 1:15 PM revealed the IJ occurred because the infection control policies and procedures were not followed. He stated he observed staff and residents while walking around the facility. He stated he walked around the facility several times a day. He stated she had staff complete competencies regarding infection control such as YouTube videos, education, and return demonstrations, which he started right after IJ was called on 12/28/21. He stated the DON completed the staff competences and return demonstrations as well as himself. He stated the DON supervised administrative staff by completing competencies with return demonstrations, having constant communication, and having administrative staff follow up with their department staff. He stated to prevent the occurrence of another IJ, staff were in-serviced on the facility COVID-19 plan and the size of the COVID unit was increased to prevent the delay of isolating COVID-19 positive residents. In an observation on 12/29/21 at 2:05 PM witnessed administrator and DON doing random rounds on all units and quizzing the employees on: signage, donning, doffing, and proper PPE. The Administrator was informed the IJ was removed on 12/29/21 at 2:40 p.m The facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal.

Based on interviews and record reviews the facility failed to protect the resident's right to be free from sexual abuse for four (4) (Residents' #7, #8, #9, and #12) of sixteen (16) residents reviewed for abuse and neglect, as evidenced by: The facility failed to: a) Protect Resident #12 (unable to consent) from Resident #8 being sexually inappropriate with him on 06/11/21, Resident #8 was observed by facility staff to display inappropriate sexual behavior with Resident #12 when guiding Resident #12's hand on Resident #8's penis in an up/down motion. b) Protect Resident #9, on 7/14/21, from exposure to Resident #8 standing over him, masturbating while Resident #9 was lying in his bed. (Resident #9 unable to consent). c) Protect Resident #7 and #8 from being sexually inappropriate, (Resident #7 is unable to consent) with one another on an unknown date the mid part of July 2021, unknown date around the end of July 2021 and on 7/28/21; specifically Resident #7 and Resident #8 were witnessed being fully exposed from the waist down and engaged in inappropriate sexual activity that ranged from Resident #7 having his hand on Resident #8's erect penis moving in an upward and downward motion, Resident #7's hand being observed in the anal region of Resident #8's body moving in an upward and downward motion and Resident #7 having his erect penis between Resident #8's buttocks. An Immediate Jeopardy (IJ) existed from 6/11/21 until 8/11/21. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. These failures placed residents at risk of unwanted sexual advances, abuse and mistreatment. Findings Included: Resident #7 Review of Resident #7's face sheet dated 8/18/21 indicated he was a [AGE] year old male, who was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #7's Quarterly Minimum Data Set (MDS) assessment, dated 7/09/21, revealed Section B, hearing, Speech, and Vision, Resident #7 was rarely/never understood or rarely/never had the ability to understand others. Section C revealed Resident #7 was unable to perform a Brief Interview for Mental Status (BIMS), therefore a staff assessment for mental status was obtained and indicated there was a memory problem and that the resident was able to recall the location of his own room, and his cognitive skills for daily decision making were moderately impaired (decisions poor; cues/supervision required) and Resident #7 was noted to have disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas Section E Behavior revealed Resident #7 had not displayed any behaviors. Section G revealed that Resident #7 required supervision and setup help with activities of daily living except for dressing, toilet use, personal hygiene and bathing, which required extensive assistance of one staff member. Resident #7's Care Plan revealed the following: Problem Start Date: 6/20/2019, Category: Behavioral Symptoms .I have episodes of inappropriate behavior. I leave my room naked and need reminding to get some clothes on. I leave my room with my pants half down and without my shoes on. Goal: I will have less than (1) episodes of inappropriate behavior and no injuries to myself or others over the next 90 days .Approach .Redirect prn. Assist with ADL's to prevent exposure and falls .Observe my interaction with other residents to prevent offensive behavior or negative resident to resident interaction .Edited 7/27/2021 Category: Behavioral Symptoms .Problem start date: 01/03/2020, Resident has episodes of hitting other residents and staff members .Goal: Resident will not harm self or others and will have decreased episodes of hitting others through next review date. Approach .Assess whether the behavior endangers the resident and/or others. Intervene if necessary. Edited 7/27/21 . Problem start date: 08/13/2021, Category: Behavioral Symptoms: I have inappropriate sexual behaviors at times. Created 8/13/21 by [LVN G] goal: Goal Target Date 11/1/21 I will have no episodes of inappropriate behaviors .Approach: Staff will redirect me as needed, ensure I am taking my medications, and notify physician with any increase in behaviors Electronically signed [LVN G] Record review of Resident #7's progress notes revealed the following: 7/29/21 at 9:35am, Resident has had increased sexual activity. [Physician A] notified, new orders received for Depo 1mL monthly. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Electronically signed by [Former DON]. 7/30/21 at 2:11pm, Resident was moved to Unit 2 on 7/29/21 and is adjusting well to the change of environment. No immediate problems were noted at this time. Will continue to monitor. Electronically signed by LVN I. In an interview on 8/16/21 at 1:47 pm, Family Member B said that she had not been notified of any inappropriate sexual behaviors in June or July. Family Member B did recall receiving a phone call about moving her brother to another room, Family Member B did not recall who called her, but did say it was due to the fact he had too much stuff and needed a bigger room. Resident #8 Review of Resident #8's face sheet dated 8/18/21 indicated he was a [AGE] year old male, who was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's Significant Change Minimum Data Set (MDS) assessment, dated 7/30/21, revealed Section B, hearing, Speech, and Vision, Resident #8 was able to make himself understood and he had the ability to understand with clear comprehension. Section C revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated he was cognitively intact. Section E Behavior revealed Resident #8 had physical behavioral symptoms directed towards others ( .abusing others sexually) and other behavioral symptoms not directed toward others ( public sexual acts ) that had occurred within the past 1-3 days. Section E0500 indicated that the resident was at significant risk for physical illness or injury; E0600 impact on Others revealed a zero entered, which indicated there was not a risk of impact to others for physical injury, intrusion of privacy or activity of others and disruption of care or living environment. Section G revealed that Resident #8 required supervision and setup help with activities of daily living except for dressing, personal hygiene and bathing, which required the assistance of one staff member. Resident #8 did not require the use of any mobility devices. Section N revealed that Resident #8 had not received any injections within the past 7 days. Section Q indicated that Resident #8 participated in the assessment. Section V indicated that Care Areas were triggered and required a care plan decision for Behavioral Symptoms. Record review of Resident #8's care plan revealed a care plan addressing Resident #8's behaviors was not implemented until 8/12/21, which revealed the following: Problem start date: 8/12/21 Category: Behavioral Symptoms I have inappropriate sexual behaviors towards others. Created 8/12/21 by [LVN G], Goal: .I will have no inappropriate sexual behaviors towards others .Approach: staff will redirect and/or separate from others as needed. Staff will notify physician with any sexual behaviors. Staff will ensure resident takes prescribed medications Resident #9 Record review of Resident 9's electronic face sheet dated 8/30/21, revealed he was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12 Record review of Resident #12's electronic face sheet dates 8/30/21, revealed he was a [AGE] year old male, admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the facility's Self-report form 3613-A, dated 8/13/21, indicated Resident #12 was not interviewable. Record review of Resident # 8's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Start Date: 7/14/21 End Date: 7/14/21 Refer to Psych services for management of sexual behaviors Once-One Time . Ordered by [Physician A]. Start Date: 7/19/21 End Date: Open Ended- Please refer to senior psych care and or senior psychological care for evaluation and treatment as indicated. [Dx: Other recurrent depressive disorders]. Ordered by [Physician A]. Record review of Resident #8's progress notes revealed the following entries: Date: 7/27/21 at 4:19pm, Social Worker (SW) also spoke with [Family Member A] regarding res. (Resident #8) sexual behaviors and discussed with her intervention plans for res. SW informed [Family Member A], per DON res. Referred to inpatient [psychiatric service] to evaluate behavior and prescribe medications as needed. SW also informed her if psych team recommends inpatient psych res. Will be referred to [Psychiatric Hospital]. Per [Family Member A], she verbalized understanding and consent with treatment plansSW will follow up with [FNP] .with [Psychiatric Service] to help determine treatment plans. Electronically Signed by [SW]. Date: 7/28/21 at 1:56pm Resident (#8) has a history of sexual behaviors. [Physician A] reviewed medications, order received Depo (Depo-Estradiol) 1mL month intramuscular (IM). Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . electronically signed by [Former DON] Record review of an interview with Resident #8, conducted by the RNM on 8/16/21 at 10:30am revealed the following: [Resident #8] statement: Interview performed by: [RNM] [Vice President of Operations], Do you recall being involved with any incidents involving your anus? No. So, no one has ever inserted anything in your behind? Or attempted to? No. Have you been involved in any sexual encounters at the nursing center and if so, with who? Yes, [Resident #7]. What was the occurrence here? He [Resident #7] gave me a 'hand job'. Did you feel like this was consensual? Yes. You didn't force him, and he didn't force you? No.Obtained By: [RNM] and [Vice President of Operations]. In an interview on 8/15/21 at 2:59pm, LVN B said that she had worked at the facility off and on since 2008, she said that she often is assigned to Unit 1, which is a male secure unit. LVN B said that she had been witness to several inappropriate behaviors on Unit #1, specifically she recalled an incident that happened on 6/11/21, she said she recalled the day specifically because it was a day [Physician A] was in the building rounding on the residents'. She said that she and Physician A entered Resident #8's room and found Resident #8 with Resident #12's hand wrapped around Resident #8's erect penis. LVN B said that Resident #8 had his hand wrapped around Resident #12's hand guiding Resident #12's hand up and down in a motion that appeared to be masturbating. LVN B said that Resident #12 was just sitting there he did not seem distressed, appeared to be going along with it. LVN B said that Resident #12 was severely cognitively impaired and was not able to make his own decisions. LVN B said that she intervened and instructed Resident #8 that the actions were inappropriate, and she said Resident #8 began pulling his pants back up. LVN B said she immediately informed the DON and due to Physician A being right there with me, she did not have to call him he already was witness to it. LVN B said that when she notified the Former DON, she seemed kind of giddy as if it was funny to her, and specifically instructed LVN B not to chart it because nobody was in distress. LVN B said she did not notify any family members at the direction of the former DON and after the communication to the Former DON, Physician A responded to her and that is how you keep state out of your building. LVN B said it appeared he was in agreement with the Former DON and agreed not to document anything in the chart. The Former DON had stressed to LVN B that as long as both residents were not in any distress and they were okay, there was nothing to chart. LVN B said she disagreed with the Former DON but due to previous circumstances, she followed her direction and did not chart it for fear of retaliation. She said that the Former DON had a Persnickety attitude and she had crossed her before and had multiple shifts taken away from her. LVN B said that she needed the shifts and therefore followed her direction even though she knew it was not right. LVN B said that she personally did not notify the Administrator regarding the incident. LVN B said that Resident #8 is often redirected due to masturbating in inappropriate places, she said often times he will be at the doorway in his room, peaking his head out and masturbating. She said that he is redirected to his side of the room and offered the privacy curtain. LVN B said that Resident #7 will often masturbate in his room, but no knowledge of any sexual behaviors towards other residents. In an interview on 8/15/21 at 5:05PM, Physician A said that he had received a phone call from the RNM on 8/11/21 informing him that the facility was being investigated for a compliance hotline complaint about several things that have happened in the building and it included resident to resident sexual behavior. A couple of resident to resident altercations that had caused harm and were not reported either, elopements, that he had no knowledge of and should have been notified immediately and that documentation had been deleted from the clinical records by the Former DON. Physician A said that he was notified regarding several of the incidents that were being investigated, however he assumed the Former DON and Administrator were reporting accurately to the state. Physician A said that the knowledge he had regarding several residents (unable at the time of the interview to recall all the resident's by name) with inappropriate sexual behaviors was through a telephone call by the Former DON. Physician A said that she had notified him that there had been some exhibitions, male residents had been pleasuring themselves and exposing themselves in front of other residents and that he gave verbal orders to start the residents on medications to control their sexual behaviors, which was a medication called Depo [MEDICATION(S)]. Physician A said that the purpose of this medication is to cancel out the [MEDICATION(S)] effect and reduces the libido of the male residents. Physician A said that he recalled Resident #8 having inappropriate locations of masturbation and did not recall Resident #8 having himself fully exposed with Resident #12, however did recall walking in the room and finding Resident #8 having an erection but was fully clothed. Physician A said that Resident #8 had known behaviors that were inappropriate, now that I recall, the one young resident, he was very young, [AGE] years old, (Resident #8), was having exhibitions that were inappropriate on the patio, not in the privacy in his room. Physician A said that Resident #8 was also known to be found in other resident's rooms pleasuring himself, verbally harassing the staff during ADL care such as showers. Physician A said he had received different reports on different dates regarding the inappropriate sexual behaviors between Resident #7 and resident #8. Physician A did recall Resident #8 being mentioned in more than one. Physician A said that it is abnormal for Resident #8 to have public sexual display in the inappropriate places he had been found. Physician A said that in regards to being notified, he said that he wasn't necessarily reported with a list of problems that I (the surveyor) was addressing, but that he had not been given notification immediately, it was several weeks later for some of the incidents. Physician A said that he did recall rounding with LVN B back the first part of June, unable to recall the exact date, but said that he did witness LVN B report to the Former DON regarding the inappropriate sexual behavior between Resident #8 and Resident #12, however Physician A did not recall the DON advising LVN B to not document the incident and then Physician A commented that he could not be 100% sure that he witnessed LVN B talking to the Former DON. Record review of Resident #8's progress notes revealed the following entry on 6/11/21: 6/11/21 3:49PM, Resident was seen by [Physician A] today. No new orders. No complaints noted at this time. Electronically signed by the Former ADON. In an interview on 8/16/21 at 3:00pm, Family Member A indicated that she did not have medical power of attorney for Resident #8 and that she did not make medical decisions for him. Family Member A said that Resident #8 makes all his own medical decisions. Family Member A did indicate that she had been contacted by the Administrator and informed her that Resident #8 had been having inappropriate sexual behaviors that ranged from masturbation in other resident's rooms to an inappropriate sexual act with a man that had Alzheimer's. Family Member A said that the facility told her that if the behaviors continued Resident #8 would have to be discharged and that they were going to have him evaluated and maybe start some new medication, but did not explain what the medication was or what it was for. In an interview on 8/16/21 at 2:21pm, NA H said that she had worked Unit #1 regularly and that she was unable to recall the exact date but thought it was about a month ago (Mid July 2021), Resident #7 had been getting in Resident #8's bed regularly, which was not unusual behavior for Resident #7 to forget where his room was and crawl in another residents bed, however on one occasion NA H said that she witnessed Resident #7 to have his brief pulled down and Resident #8 had his underwear pulled down, both male residents were exposed and Resident #7 had his penis erect and it was between Resident #8's buttocks, NA H did not feel that there was penetration and felt that she intervened right as the act was occurring. NA H said that she had informed LVN C, LVN D and LVN B. NA H said that there was another incident that involved Resident #7 and Resident #8 just a couple of weeks ago and that she witnessed Resident #8 have his underwear down and they were in the doorway of Resident #8's room. Resident #7 was behind Resident #8 and Resident #7 had his hand in the area of Resident #8's anus and Resident #7's hand was observed going in an upward and downward motion. NA H said that she did not visibly see any penetration to Resident #8 and Resident #8 was not trying to get away from Resident #7. NA H said that she separated the two residents and was traumatized by the incident. She said that the van driver came in and saw that she was upset and immediately went and reported it to the former ADON. NA H said that the former ADON never came and discussed anything with her regarding the incident, nor the Former Administrator. In an interview on 8/18/21 at 10:25am, CNA A said that she had witnessed Resident #7 and Resident #8 be sexually inappropriate with each other. CNA A said that she was working about two and a half weeks ago (End of July) and was charting in the hallway. CNA A said that she just happened to go down to the end of the hall and caught Resident #7 in Resident #8's room. CNA A said that she saw Resident #8's hand on top of Resident #7's hand, and that Resident #7 was holding Resident #8's erect penis and Resident #8 was guiding Resident #7's hand up and down Resident #8's penis. CNA A also recalled an incident, unable to recall the exact date, with Resident #8 being found in Resident #9's room. Resident #9 was in bed and Resident #8 was standing over Resident #9 masturbating. CNA A said that she reported the incident to the former DON and ADON and was told he was on birth control and that is all she knew was done about it. CNA A said that when there are inappropriate behaviors, she reports it to her charge nurse or the DON. In an interview on 8/18/21 at 10:45am, LVN D said that the secure units are sometimes staffed with two CNAs or NAs, however, there have been many times that there has only been one aid on the secure unit to supervise residents. LVN D said that she has on multiple occasions walked in and found residents being sexually inappropriate. LVN D said that one specific incident was between Resident #8 and Resident #12, could not recall the exact date, but witnessed Resident #8 grab Resident #12's buttocks. LVN D said she redirected Resident #8 and explained that touching other residents was inappropriate. LVN D said that she told the Administrator immediately about the behavior and the Administrator and the DON came on to the unit and spoke to Resident #8 and was instructed that they (former administrator and DON) would take care of it. In an interview on 8/17/21 at 3:19pm, Resident #8 said that he had come from another long-term care facility, was not certain why he had to move from that facility and did not care that he was on a male secure unit. Resident was alert and oriented and was able to recall his name, the date, where he was at, nursing facility, town, state; was able to recall who the president is currently. Resident #8 said that he had had sexual interactions with male residents on the secure male unit, specifically Resident #8 named [Resident #7]. Resident #8 said that the sexual interactions took place in his room more than once and Resident #7 had given me a hand job. Resident #8 said that the sexual interactions with Resident #7 made him feel bad and that he did not want to be touched by Resident #7. Resident #8 indicated that he was scared when Resident #7 touched his penis. Resident #8 said that Resident #7 had touched him on his butt with his penis and that he had not told any staff members because he was scared. Resident #8 said he did not want to be touched there. Resident #8 denied being inappropriate sexually with any other residents on the male unit, specifically Resident #12. Resident #8 stated that Resident #7 no longer resided on the unit and that made him feel good. Attempted phone interviews with the Former DON at the phone number provided by the facility; were: 8/16/21 at 2:14pm, voicemail message left. 8/18/21 at 4:03pm, voicemail message left. In an interview on 8/18/21 at 5:20pm, the former DON said that she had been suspended pending an investigation that she was not sure what for and that her and that she voluntarily resigned from the facility and was no longer employed at the facility. The Former DON said that she did not have any knowledge of any resident's in the building having inappropriate sexual behaviors. The Former DON said that I know there have been innuendos, but nothing specific. The Former DON was asked if she specifically had any knowledge of Resident #7, Resident #8 having inappropriate sexual behaviors towards other residents on the secure male unit #1, she replied No Ma'am. When asked by the surveyor, Without a doubt, you have no knowledge of any staff member ever reporting inappropriate sexual behavior's to you with Resident #7, Resident #8?, the Former DON replied, I don't know now; I know [Resident #8] was wanting to engage and [Resident #7], I never .I know that sexual behavior residents have sexual behaviors, and that is the type of residents that they [the facility] took. At this time of the interview, the Former DON was read by the surveyor a progress note dated 7/28/21 Date: 7/28/21 at 1:56pm Resident has a history of sexual behaviors. [Physician A] reviewed medications, order received Depo (Depo-Estradiol) 1mL month intramuscular (IM). Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . electronically signed by [Former DON] and the Former DON confirmed that her name was correct as the electronically signed signature as [Former DON] and stated that sounds like my progress note. The Former DON said the inappropriate sexual behavior was probably having his [Resident #8's] hands in his pants and pleasuring himself more in the common areas verses in his room privately. I honestly do not remember what his inappropriate sexual behaviors could have been, he was talked to several times regarding his inappropriate comments while receiving a shower by the aides. (the Former DON could not recall what he was specifically talked to about). The Former DON was asked if Resident #8 exposed himself often in front of other residents? The Former DON replied, It was enough to where, it got my attention. The Former DON could not recall what staff, specifically got her attention. The Former DON said that when I would go and investigate it, no one would ever come out and say that there were inappropriate sexual behaviors. The Former DON said that Resident #8 had admitted to the facility in April 2021 and was admitted on the all-male secure unit #1 due to being at a previous facility where he had displayed inappropriate sexual behaviors towards female residents. The Former DON said that Resident #8 always has a look of smiling, it is hard to tell if he really knows. The Former DON said that she did not recall when his inappropriate sexual behaviors began, it was all hearsay, he would ask people if he could pleasure them or if they would pleasure him. Hearsay, the former DON said was from the nurses. The Former DON did not feel the need to investigate and report hearsay to the abuse coordinator since it is just hearsay, you could spend all day on hearsay, and it depends on the content and what you heard. The Former DON denied NA H reporting anything to the former ADON regarding Resident #7 and Resident #8. The Former DON denied any knowledge of LVN B reporting any alleged allegations involving Resident #8 being inappropriate with Resident #12. The Former DON replied when asked if she had ever instructed her staff to not document or tell staff that she would document an incident with I have helped them with charting if they needed help. The Former DON was asked if she was involved in the room change for Resident #7, she replied I am sure. The Former DON said that the reason Resident #7 was moved to the secure unit #2 was because Resident #7 and Resident #8 was observed gravitating more towards each other, it seemed to be happening more frequently. The former DON said that when I walked onto the unit, they were together, may have been in common areas, one time when I walked onto the common area, [Resident #7] was standing with his hands in his pants, not a behavior, that was normal to me, I'm not sure what I would have reported to state. The Former DON said that she participated in facility internal investigations, she would perform head to toe assessments, might do safe surveys for the residents, I would do lots of interviews, reportable events to the state would be allegations of abuse/neglect, unwitnessed falls, injuries of unknown origin, misappropriation of property, most of the time the administrator would determine if it needed to be self-reported. In an interview on 8/17/21 at 12:59pm, the Social Worker said that she recalled when Resident #8 was admitted to the facility and that at the time, he did not seem to have any sexual inappropriate behaviors, however he had begun over the past several weeks to display inappropriate sexual behaviors. The Social Worker said that a night nurse, unable to recall exact name, had verbalized to her in passing one morning that Resident #8 had been sexually inappropriate. The Social Worker said at that time, she did not clarify anything else and soon after the Former DON and Former ADON had discussed in a morning meeting the inappropriate behaviors and the need to have him evaluated by psychiatric services and possibly send him to a psychiatric hospital. The Social Worker referenced her progress notes and explained that she had been in contact with his grandmother regarding his care and potential need for psychiatric evaluation at a local psychiatric hospital. The Social Worker said that the Former ADON expressed that she had a background in psychiatric nursing and she trusted the Former DON and her judgement and it appeared that they were handling the situation appropriately to her knowledge. The social worker said she did not realize that the psychiatric consult had not been obtained until a few days ago on 8/12/21. In an interview on 8/17/21 at 2:40pm, the FNP said that she had recently performed a psychiatric evaluation for Resident #8. The FNP said that she did not receive a lot of information from him, he basically just answered yes and no to the questions she asked. She did indicate that due to his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The FNP said that the facility had expressed to her that he had been having some inappropriate sexual behaviors. The FNP said that she was aware of the medication Depo [MEDICATION(S)] that had been ordered for Resident #8 by Physician A. She said that she had seen the medication be used for overtly sexual behaviors in male residents. The FNP said that she understood that Resident #8's plan of care moving forward was that the facility was currently looking to find placement for him in another long-term care facility that could better manage his inappropriate sexual behaviors. The FNP said that the Depo [MEDICATION(S)] has [MEDICATION(S)] in it, so it decreased the male's [MEDICATION(S)] levels and decreased their sexual impulses. The FNP said that male residents should still be able to achieve an erection but not as often as they normally would and that it is in a sense a form of a chemical castration but not as potent. Record review of the facility's interview with the Former Administrator, performed by the Vice President of Operations, revealed the following: Date 8/12/21 at 6:22PM, Interview: [Former Administrator], Which sexual incidents were you aware of? [Resident #8 was performing 'oral' on other residents. Educated resident and spoke to him as well. Attempted phone interviews with the Former Administrator at the phone number provided by the facility; were: 8/16/21 at 2:15pm, voicemail message left. 8/18/21 at 4:03pm, voicemail message left. Record review of the facility's policy entitled, Abuse Prevention Program, dated June 2021, revealed the following: Policy Statements: 1. The Administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures. 2. Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms .5. Our Center will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor and to the Abuse Prevention Coordinator immediately. 6. Our Center will protect residents from harm, reprisal, discrimination or coercion during investigations of abuse allegations. 7. All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as [TRUNCATED]

Based on interview and record review the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for 1 (Resident #1) of 3 residents reviewed for accidents. On 8/28/20 CNA A failed to ensure safe use of Hoyer lift with Resident #1. CNA A failed to operate the Hoyer lift with two staff per facility policy and failed to ensure all the straps of the sling were secure causing Resident #1 to have a fall from the sling and Hoyer lift. This failure was determined to be past non-compliance due to the facility having implemented action that corrected the non-compliance prior to the beginning of the investigation. This failure placed residents at risk of injury due to accidents. Findings: Record review of Resident #1's electronic face sheet accessed on 9/1/20 revealed a [AGE] year old female who was originally admitted on [DATE] with a most recent admission of 9/12/20 with the following Diagnosis: [REDACTED]. Resident #1 was discharged to a local hospital on [DATE] and was no longer at the facility. Record review of Resident #1's most recent quarterly Minimum (MDS) data set [DATE] revealed Resident #1 had adequate hearing and could easily understand others and make herself understood. Resident #1 had a Brief Interview for Mental Status score of 15 out of 15 which indicated an intact cognition. Resident #1 did not have a history of behaviors or rejecting care. Resident #1 could eat with supervision but needed extensive assistance with two persons for most other activities of daily living including transfers. Resident #1 also utilized a wheelchair for mobility. Record review of Resident #1's Care plan revealed a problem area of activities of daily living with the following goal: My activities of daily living needs will be anticipated and met; I will be clean, dry, and my dignity will be maintained without injury over the next 90 days. With one the following approaches: Resident requires a 2 assist with transfers with a Hoyer. This care plan was initiated on 1/18/19 and was discontinued 8/29/20 after her transfer to a local hospital. Record review of Resident #1's most recent event report dated 8/28/20 at 8:50 am revealed Resident #1 had a fall in her room which afterwards she verbally expressed excruciating pain at a 10 out of 10 pain scale. The event report revealed bruising to the right knee. Resident #1 was alert and had strong extremity movement in all extremities except for the right lower extremity. The event report also stated the use of a Hoyer lift as a contributing factor to the fall. Review of the vital signs record on the event report were the following Temperature 97.5 degrees Fahrenheit, pulse of 97 beats per minute (normal rage for an adult is 60-100), respiration 22 breaths per minute (normal range of respirations is 12-18), blood pressure was 128/81 millimeters of mercury (normal range of blood pressure is 90/60-120/80), oxygen saturation at 97% which was with in normal limits, and Resident #1 rated her pain at a 10 out 10 and she had also vomited once. The event report revealed she was taken to a local hospital via emergency medical services. (Note the increase in pulse, respiration, blood pressure, and the vomiting are indicators that confirm her report of severe pain). Record review of the Resident #1's progress notes for 8/28/20 revealed two entries. The first entry was at 9:00 am revealed a fall with right knee pain, notification of Resident #1 physician, order received to transport to local hospital, and attempt made to notify Resident #1 responsible party. The second entry is at 9:28 am revealed Resident #1 had vomiting and that she was taken to a local hospital via emergency transportation. In an interview on 8/31/20 at 5:22 pm Family member A stated the facility called her the morning of 8/28/20 and left a voicemail notifying her Resident #1 was injured. She called the facility and spoke with the director of nursing (DON) and the DON told her that certified nurse aide (CNA) A was using the Hoyer lift alone and her mother had a fall and was transported to a local hospital for precaution. Family member A stated Resident #1 right femur was confirmed broken by the doctor at 11:05 am via x-ray. Family member A stated at 11:35 am she got to see the right leg and it had a lot of swelling, bruising, and a knot above the knee on outer leg and Resident #1 was in a lot of pain. Family member A stated Resident #1 needed surgery for [REDACTED]. In a telephone interview on 9/1/20 at 2:45 pm CNA A stated she was transferring Resident #1 from the bed to her wheelchair via a Hoyer lift and she was doing so alone which she has done before in the past and is a common practice for the facility. CNA A did state it was facility policy to use a Hoyer lift with two people. CNA A stated Resident #1 requested to have a sheet in the sling as the sling hurts her legs and CNA A did place a sheet in the sling for her. CNA A stated as she began to lift Resident #1 off the bed she moved the foot of the bed over and then Resident #1 lower part of the sling came undone and Resident #1 slid out of the sling onto the bed and then slid off the bed to the floor. CNA A then called for help, and Resident #1 was complaining of pain. Record review of statement from interview with CNA A signed by the DON with no date but provided to this surveyor on 9/1/20 by the DON revealed CNA A stated she had heard before she was to have two people for a Hoyer lift but believed she could do it alone. CNA A confirmed there was a nurse on the station with her, but she did not seek out help from her because Resident #1 was ready to get up. CNA A also used a sheet between Resident #1 and the sling at the request of Resident #1. CNA A also stated she did not check to see if the sling was on properly and thinks the feet part is why she slid. In an interview on 9/1/20 at 1:45 pm the DON stated that CNA A admitted to operating the Hoyer lift alone even though CNA A knew it required two people to operate. The DON stated an inspection of the Hoyer lift and sling was done after the fall and it was determined the Hoyer lift and the sling did not malfunction, but that CNA A did not properly hook the sling to the lift. The DON stated a Hoyer lift should always been done with at least 2 people, but CNA A choose to do it alone and it resulted in an injury to Resident #1. The DON stated CNA A was a long-time employee of [AGE] years and knew operating the Hoyer lift alone was against facility policy, CNA A was placed on leave, had not been allowed to return, and was scheduled to be terminated on 9/5/20. Record review of a written statement provided on 9/3/20 by the DON revealed the incident that occurred on 8/28/20 in which a staff member used a Hoyer lift to transfer a Resident #1 resulted in a fall with injury due to noncompliance with policy. Factors that contributed to the incident: 1. CNA A transported the resident with only herself present. 2. A sheet was placed over the sling per the resident request because the sling hurts her skin. 3. CNA A did not seek the assistance of the certified medication aide or nurse who were available to help because she felt that she could perform the task alone. Education provided to staff: 1. Residents are not assigned a personal sling and no other slings should be used that is purchased for our type of lift. 2. Competency assessments with a lecture piece and a return demonstration with emphasis on: a. Types of lifts. b. Appropriate sling. c. Role of each member present. d. How to verify that the resident is safe to transfer once the sling is placed under the resident. e. Making sure the sling is secured to the Hoyer lift. 3. Education provided to each resident that requires a Hoyer lift to educate the resident on refusing transfer with less than two staff present. Compliance: 1. 91% of staff have completed Hoyer proficiency. 2. Remaining 9% have been given instructions that they will not engage in Hoyer transfers until proven competency. CNA A was terminated due to the circumstances and not following policy. As the DON, I do not feel I can educate on not following policy and procedures. Record review of in service and competency check sheets revealed 8/28/20 education was started with staff and all except for 9-10% of staff had been in serviced by 8/30/20. In an interview on 9/1/20 at 4:00 pm Resident #3 stated he needs a Hoyer lift for transfers and in the past staff would occasionally use the lift alone, but since 8/28/20 he has always had two people to operate the Hoyer lift. Resident #3 stated the facility did in service him to refuse a Hoyer lift transfer if a staff person was trying to operate the Hoyer lift alone. In an interview on 9/1/20 at 4:30 pm registered nurse (RN) A stated since 8/28/20 the facility has in-serviced them on Hoyer lifts and the role of the second person. RN A stated the in-service was a demonstration in service with her having to do a return demonstration. In an observation and interview on 9/2/20 at 1:45 pm CNA B and CNA C was observed transferring a resident from her wheelchair to her bed. CNA B and CNA C did not deviate from the steps laid out in the facility's policy for Using a Mechanical Lift. CNA B and CNA C stated they had attended a staff meeting where they were given reading material, demonstration, and a group participation activity with return demonstration on how to operate the lift and the role of the second person. CNA B and CNA C stated even before the in service they knew not to use a blanket or anything between the resident and the sling and to not operate the Hoyer lift alone. Record review of facility policy dated 2001 with a revision date of 2019 revealed the following: Using a Mechanical Lift, Purpose the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufactures' s training or instructions. General Guidelines 1. At least two (2) nursing assistants required to safely move a resident with a mechanical lift . Steps in the Procedure .12. Attach sling straps to sling bar, according to manufacturer's instructions. a. Make sure the sling is securely attached to the clips and that it is properly balanced . c. Before resident is lifted, double check the security of the sling attachment. d. Examine all hooks, clips, or fasteners. e. Check the stability of the straps . 13. Lift the resident 2 inches from the surface to check the stability of the attachments, the fit of the sling and weight distribution . Record review of the facility's Hoyer user instruction manual dated 2015 revealed the following: .3. Safety precautions .DO NOT lift a patient unless you are trained and competent to do so . Never operate the lift with loose or missing parts or fasteners .5. Operating instructions .10. Slings: The selected sling is attached to the spreader bar hooks .

Based on observation, interview, and record review the facility failed to provide adequate supervision for 1 (Resident 88) of 29 residents reviewed for supervision. The facility failed to provide adequate monitoring and supervision for Resident 88 when he was allowed to leave the locked unit unsupervised to go smoke in an area off the locked unit even when Resident 88 was a known elopement risk. The facility did not know Resident 88 was missing from the locked unit and facility for over 2 hours. These failures resulted in an Immediate Jeopardy (IJ) situation on 12/13/2019. While the IJ was removed on 12/14/2019, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm at a scope of isolated due to the facility needing more time to monitor the plan of removal for effectiveness. This failure could place residents at risk of leaving the facility unsupervised and places them in situations that could result in serious injury or death. Findings: Review of Resident 88's Face sheet, dated 12/13/19, revealed he was admitted on [DATE], was [AGE] year-old male with [DIAGNOSES REDACTED]. Review of Resident 88's MDS (Minimum Data Set), dated 11/11/19 revealed BIM's (Brief Interview for Mental Status) of 10, usually understands others and is understood, requires limited assistance with everyday ADL's (activities of daily living) and has a history of wandering, inattention, disorganized thinking and refusing care. Review of Resident 88's Care Plan, dated 8/12/19, revealed Resident 88 has impaired decision making related to dementia with facility staff to determine if decisions made by the resident endanger the resident and intervene if necessary and is an elopement risk as evidenced by prior attempts to leave the facility, with facility staff to have resident smoke in courtyard on secured unit with supervision of one staff at all times. Review of Resident 88's Physician order [REDACTED]. On start date of 08/25/19 physican orders as follows: Admit to secured unit. In an interview on 12/13/19 at 8:30 a.m. the Administrator reported an elopement last night (12/12/19) for Resident 88. Certified Nurse Aide (CNA) A had changed work duties with another CNA after administration had left for the day. Around 8:30 p.m. CNA A let Resident 88 off the locked unit, so he could go smoke on a patio that is separate from the locked unit. It was reported by another Resident that Resident 88 exited the building around 8:30 p.m. Resident 88 then walked to his old home (20 blocks, or approximately 2 miles distance) which involved crossing two major road ways along with railroad tracks. Once he realized the home was no longer his he went to the neighbor's house and she called his sister to come pick him up. The facility did not realize Resident 88 was missing till around 10:30 p.m., and when they were calling his responsible party she was calling them to let them know she was going to get him. The Administrator acknowledged it was common practice to let residents leave the locked unit on their own to go smoke on the patio that is not on the locked unit. They are supervised while smoking but no one walks them to the patio or walks with them when they return to the locked unit. The Administrator also included that CNA A had been placed on suspension, in-servicing had been implemented, and smokers on the locked unit will not be allowed to leave the locked unit anymore and will remain on the locked unit patio to smoke. Record review of temperatures for 12/12/19 from 8:00 p.m. to 11:00 p.m. temperatures ranged from 49 to 48 degrees Fahrenheit. Sunset occurred at 5:35 p.m. https://www.wunderground.com/history/daily/us/tx/abilene/KABI/date/2019-12-12 On 12/13/19 at 11:14 a.m. the Administrator and DON (Director of Nursing) were informed an IJ (Immediate Jeopardy) was identified. The IJ Template was provided to the Administrator at that time. In an interview on 12/13/19 at 11:20 a.m. Administrator stated that on 12/12/19, Resident 88 was let out of locked Unit #2 by CNA A (Certified Nursing Assistant) for Resident 88 to walk to smoking area without staff accompanying him. Stated that Resident 88 must have got out the front door with family members (of another resident) when they were exiting the building. Stated she is unsure why Resident 88 was not known to be missing between the time of leaving facility and being returned by police and sister. Observation on 12/13/19 at 11:45 AM Resident 88 was observed ambulating within locked Unit # 2 with 1 to 1 staff walking with him. In an interview on 12/13/19 at 11:49 AM Resident 88 stated that he left facility because he wanted to go home and stated he wanted to see his dogs. Resident 88 was not able to provide details of how he got out of facility and stated, he walked out by himself. In an interview on 12/13/19 at 12:08 p.m. Resident 88's sister stated on 12/12/19 at approximately 10:30 p.m. facility staff contacted her by phone and informed her that Resident 88 was missing from facility and informed her that police were contacted to locate. Stated that shortly after call was received from facility she received a call from her brother's (Resident 88) previous neighbor who informed her that Resident 88 was at her home. Sister then stated she informed facility who stated they would inform police. Sister arrived at the neighbor's house with police already at residence and Resident 88 found sitting at kitchen table talking with police. Stated that when she was at neighbor's home she was informed that Resident 88 was provided some water. Resident 88 was escorted back to facility by sister and he stated that he was not cold stated he had on long pair of pants, a shirt and a [NAME]et, stated he voiced he was hungry and stated he voiced he had soreness to his lower extremities. In an interview on 12/13/19 at 12:45 p.m. CNA B stated that on 12/12/19 at approximately 6:00 p.m. CNA A arrived on Unit 2 and stated he came to Unit 2 to chill. CNA B stated she took her break around 6:20 p.m. until around 6:50 p.m. and when she returned CNA A was sitting on couch in common area talking with another aide working on this date. Stated she informed CNA A that she was going to go out onto the non-secure halls to help staff since they were running behind, and CNA A was sitting in locked Unit #2 (CNA A was on schedule to work as float for all halls and locked units). CNA B stated that she was assisting with showers on the un-secured halls and did not observe Resident 88 ambulating in the un-secured areas of the facility. CNA B stated that she is not aware when it was decided that residents would be taken to smoking area away from the locked units, stated she is unsure when it was decided to have Resident 88 walk by himself to smoking area away from his locked unit and stated she had observed Resident 88 and other residents residing on secured Unit #2 walking to smoking area away from locked by themselves in the past (there are 4 residents on Unit #2 who use smoking area). CNA B stated that she does not recall the facility performing training regarding walking residents to smoking area if they leave the locked units. CNA B stated that Resident 88 had told her in the past you can leave me alone when smoking outside and stated that she observed Resident 88 confused on several occasions. In an interview on 12/13/19 at 2:07 p.m. DON stated that after the incident with Resident 88, she became aware that aides, during the evening shift, were allowing residents to leave the locked unit by themselves to walk over to smoking area (not in secured units), stated that she believes evening staff are not escorting residents due to laziness. Stated that her expectations are that staff should have escorted these residents to smoke area and then back to locked unit. Stated that the facility has changed procedure (starting on 12/13/19) to residents are not to leave their secured units and will smoke in areas located off the secured unit. Stated that when she interviewed CNA's A and B regarding switching scheduled work areas she was informed that CNA A told CNA B to go work out in the unsecured halls and he would work in Unit 2. DON stated that CNA A had worked Unit #2 in the past and was aware of Resident 88's elopement attempts. DON stated that her expectations are that staff are to work assignments assigned by DON and if changes are requested that charge nurse on duty and/or DON is to be spoken to prior to changing assignments. DON stated that nurses working the evening shift of 12/12/19 were agency. Observation on 12/13/19 at 2:34 PM Resident 88 was observed outside of Locked Unit #2 smoking in courtyard with 1 to 1 staff present. In an interview on 12/13/19 at 2:43 p.m. LVN A (Licensed Vocational Nurse) stated that she did work last night (12/12/19) but was not in Unit #2 when Resident 88 was let out of unit to smoke. LVN A stated that she has witnessed aides letting resident's out of locked units, unattended, to go to smoking area. In an interview on 12/13/19 at 3:04 p.m. Unlicensed nurse aide A working in secured Unit #1 stated that there is only one resident on Unit #1 who smokes, and this resident is not allowed to go off unit. Stated that staff escort this resident to secured patio that is located on unit. Stated that resident on Unit #1 does not voice wanting to smoke but is asked (by staff) if he wants to go to smoking area at scheduled smoke breaks. Stated she has not witnessed other resident's being let out of locked units but has not been employed with facility very long (stated approximately 5 to 6 months). In an interview on 12/13/19 at 4:32 p.m. CNA A (via phone call) stated when he arrived for work on 12/12/19 he was assigned to work as a floater (mainly on the un-secure halls) and stated that when his co-worker went on break in Unit 2 he went to cover while she was gone. Stated that (his co-worker) must have been caught out in the unsecured halls because she never returned to Unit #2 after her break. CNA A did not state if co-worker on break notified him that she would not be coming back to Unit #2. CNA A stated he had let Resident 88 out of unit by himself to walk to smoking area and then later in conversation stated that he is unsure if he was actually the one who let Resident 88 out of unit. Stated that Resident #88 was let out of secured Unit #2 sometime around the 6:30 p.m. smoke break and stated he is not going to give specific times because he is not sure of the actual time that incident occurred. Stated Resident 88 was let out of locked unit with other resident's (who smoke) to walk to smoking area and stated I think he stayed out in the lobby (un-secure area) until approximately 8 or 9 p.m. and that is when he thinks Resident 88 left the facility. CNA A stated that he was busy assisting residents back to their rooms and that is why he did not notice Resident 88 didn't return to Unit #2 from smoke break. Stated that Resident 88 is always roaming the halls and asking for a cigarette every 5 minutes. He stated he did not notice he wasn't being bugged by Resident 88 until the nurse came into unit and couldn't find Resident 88 to administer his evening medications. Stated that the residents in locked units were always allowed to be let out by themselves to walk to smoking areas (since he started at facility). Record review of facility Smoking policy, not dated, revealed (in part) the following: this facility will supervise all residents smoking for the safety of all residents and employees . supervised smoking times for residents are scheduled and limited to 15-minute increments per smoking session Supervision of smoking residents will be shared responsibility of all departments inquiries concerning smoking regulations should be referred to the administrator Record review of facility List of residents who smoke, not dated, revealed under heading Smoke Break Locations all residents are to take breaks at Main sitting area off Hall 3 at 9:00 a.m., 11:00 a.m., 2:15 p.m., 4:00 p.m., 6:30 p.m. and 8:30 p.m. Record review of facility policy with no date of origin revealed Abuse and Neglect Policy and Procedure Policy Interpretation and Implementation Prevention . 4. Supervision will be provided for those individuals with known special needs: a. Impaired individuals with known elopement risk . b. Supervised smoking will be provided for all residents of a facility . Identify The IJ Plan of Removal was accepted on 12/13/19 and included: Review of the facility Plan of Removal documented: The following immediate action was taken on 12/12/19: 1. Physician and family were notified on 12/12/19. 2. Police notified of elopement 12/12/19. 3. Resident was located and returned to the facility by sister. Resident assessment head to toe-was conducted with no negative outcomes, and resident was placed on 1:1 to ensure safety and emotional stability of selected resident. 4. Suspended the CNA that let the select resident to smoke off the locked unit and pending investigation. 5. Immediately implemented and reinforced Secure Unit Residents smoking process in the secured unit court yard. 6. In service on Abuse Neglect/Elopement/smoking supervision/assignment of duties/change of designated smoking for secure unit resident/to staff that were in house at the time the incident occurred, after this, no staff will work until in serviced on the above to include policy and procedures of said in services. 7 QAPI meeting was conducted the night of this incident with DON/ADM/ADON/ Medical Director. 8. QAPI meeting with IDT. 9. In service will continue until all oncoming staff is completed. 10. Residents identified as smokers in secured units' care planned to be monitored for smoking sessions in secured courtyard with the care plan task added to P[NAME] (Plan of Correction) for verification per shift by certified nursing assistant. 11. All entry codes updated by maintenance supervisor 11. Letters mailed to responsible parties that our door codes have been updated, and will not be provided, will need to be buzzed in and out of the facility for safety of our residents, to include entry to our secured units. MONTORING 10 . Monitor the first smoking activity after incident on AM shift 11 . Continue to monitor the smoking activity in secured units x 24 hours and randomly after that. 12 All new employees will be in serviced at time of hire regarding facilities guidelines on smoking/not changing assignments/abuse and Neglect/elopement to include supervision of these duties 13. Weekend RN, will monitor on Saturday and Sunday to ensure supervised smoking is occurring in the secured unit courtyards. Record review of Personnel schedule and timecard punches on 12/14/19 revealed that the CNA A who had been suspended was not on duty. Record Review of letters concerning updated door codes mailed to responsible parties verified on 12/14/19 at 11:30 pm. Observation and interview of all staff on duty, 6 am-2 pm shift, Administrator, 4 RN's, 3 LVN's, 1 medication aide, and 9 CNA's and 2 housekeepers on 12/14/19 at 11:30 am revealed that they were able to appropriately answer questions regarding the in-service on the new smoking policy and abuse/neglect. On 12/14/19 at 1:30 pm the 9 CNA's from the 2-10 shift were interviewed regarding the new smoking policy and abuse neglect and they were all able to answer appropriately. Smoking on the secure unit was observed, with supervision provided by both secure units as described in the POR (one CNA from each unit was in the smoking area with their residents until smoking was completed). The Administrator and DON were notified that the IJ was lowered on 12/14/19 at 1:50 pm. The facility remained out of compliance with a scope and severity of isolated, Potential for more than minimal harm.

Based on observation, interview and record review the facility failed to ensure resident having a pressure sore receive the necessary treatment and services to promote healing and prevent new sores from developing for 1 of 6 residents reviewed for pressure ulcers (Resident #7). Resident #7 was admitted on [DATE] with a stage II pressure ulcer to his coccyx and is On 3/23/16 the pressure ulcer had deteriorated to unstageable. The physician was not informed of the deterioration and no alternate treatments obtained and no new interventions provided. On 3/29/16 it was discovered that Resident #7 had an unstageable pressure ulcer to his right heel and a Deep Tissue Injury to his left heel. These failures resulted in an immediate jeopardy situation on 04/06/16. While the IJ was removed on 04/08/16, the facility remained out of compliance at actual harm with the scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of the plan of removal. Thirty residents with or at risk for pressure ulcers could be placed at increased risk for developing new pressure ulcers or worsening of existing pressure ulcers, infection and death. The findings included: Resident #7 Record review of Resident #7 ' s admission record dated 04/05/16 revealed that he was a [AGE] year-old male admitted to the facility on [DATE] from an acute care hospital with the [DIAGNOSES REDACTED]. Record review of Resident #7 ' s admission resident (MDS) data set [DATE] at 6:00 PM revealed that the resident was alert, able to make self understood, he was independent for cognitive skills for decision making, he had the ability to understand others .It revealed under his activities of daily living self-performance that his mobility was independent, that he required extensive assistance with transfers and toileting. It revealed that he was always incontinent of bowel and bladder. It revealed that skin condition is warm, dry with poor turgor. It revealed that he had a stage II 1 cm pressure ulcer to his coccyx. Skin treatments were revealed as pressure redistribution devices, turning/repositioning program, wound care, ulcer care and applications of ointments/medicines other than feet. It revealed a risk for altered nutritional status related to a decrease in appetite, depression and risk for dehydration due to risk of [MEDICAL CONDITIONS] and internal bleeding. It revealed under the nurse ' s notes/comments that Resident was alert and oriented, voices no complaints of pain or discomfort, respiration is even and non-labored. No distress noted, will continue to monitor. Record review of Resident #7 ' s initial care plan dated 03/17/16 revealed: Pressure Ulcer Risk, to provide pressure device, turn and reposition. Pressure Ulcer coccyx treatment, per M.D. order. under pressure sore (pressure ulcer) section, N/A was written. The initial care plan revealed that with toileting the resident was incontinent. The initial care plan did not have a nurse ' s signature. Record review of Resident #7 ' s physician ' s telephone order dated 03/17/16 at 5:52 PM revealed that resident was admitted to nursing home, to continue home meds .Resident was a Hospice resident with the [DIAGNOSES REDACTED]. The order did not address treatment for [REDACTED]. The Physician Telephone Order was signed by Hospice Nurse B. Record review of Resident #7 ' s Skilled Nursing Notes ranging from dates 03/18/16 through 03/21/16 under nursing assessment skin that it was warm and intact. There was no documentation of pressure ulcers. The skilled notes did not mention the Stage 2 to the coccyx. Record review of Resident #7 ' s care plan undated revealed: Focus: Resident is at risk for skin breakdown as evidenced by nutritional concerns and limited mobility. Admit on 3/17/16 with a stage 2 to coccyx. Goal: The resident will not show signs of further skin breakdown thru Quarterly review period. Target date is 6/19/16. Interventions: Apply barrier cream with each cleansing, Assist resident in repositioning every 2 hours . Observe skin condition with ADL care daily and report abnormalities. Obtain dietician consult as needed/ordered. During an interview with the DON A on 4/8/16 at 4:00 PM she stated that she was unable to locate a dietary consult or a skin assessment tool (Braden/Norton scale) for Resident #7. She stated that I guess they were'nt done. She stated that every resident admitted to the facility should have an assessment tool to assess the resident's risk for skin breakdown. Record review of Resident #7 ' s Admission Skin assessment dated [DATE] revealed Prevention Devices and Care: A pressure redistribution mattress, Presence of skin concerns: yes with the location of coccyx pressure ulcer documented on the anatomical man ., Narrative notes: coccyx skin breakdown, redness to buttock. Signed by a LVN (unable to decipher signature). The facility could not provide any other weekly skin assessment notes for Resident #7. Record review of Resident #7 ' s Admission Minimum (MDS) data set [DATE] revealed the resident was able to hear adequately, make self understood, and sometimes understood others. His BIMS score was 8, indicating the resident had moderate cognitive impairment. He was totally dependent with 2-person staff assist for bed mobility. For transfers, dressing, and personal hygiene the resident was totally dependent with 1-person staff assist and toilet use the resident was totally dependent with 2-person assist. The resident was totally dependent with bathing and required 1 person assist. The resident had a urinary catheter and that resident was always incontinent of bowel. Skin conditions revealed that resident was at risk for developing pressure ulcers and that resident had 1 or more unhealed pressure ulcers at stage I or higher. Resident #7 had 2 stage II pressure ulcers and that 2 of these were present upon admission. Skin and ulcer treatments revealed: pressure reducing device for bed, turning/repositioning program, pressure ulcer care, application of nonsurgical dressings and application of ointments and medications other than to feet. RN A completed this section for this MDS. During an interview on 04/08/16 at 11:10 AM with RN A (who did the MDS dated [DATE]) she stated that Resident #7 would not let her look at his wounds. She stated that the look back period for the MDS dated [DATE] was from 03/17/16 to 03/28/16. She revealed that the data she used for the pressure ulcers was information that she had obtained on the weekly decubitus report dated 03/31/16 that she received from LVN B who was the treatment nurse. She stated that she should have obtained the data prior to 03/31/16 due to the look back period being from 03/17/16 to 03/28/16. She stated that she did not notice that the date on the weekly decubitus report 03/31/16 so the MDS dated [DATE] under section M ' s information is incorrect. She stated that due to using the data from the report dated 3/31/16, that she cannot say that the pressure ulcers documented were present on admission. She stated that all residents at risk for pressure ulcer development should have preventative measures in place. She stated that they should have a pressure reducing device for the bed and should float heels. Record review of Resident #7 ' s weekly decubitus (pressure ulcer) report dated 03/31/16 completed by LVN B revealed Resident #7 had an unstageable wound to his coccyx with a stage size this week of 2.5cm x 2cm with 0.8cm x 0.8cm slough. It revealed a second pressure ulcer stage of DTI to the left heel with stage size this week 1.5cm x 1cm remains intact. The report revealed a third pressure ulcer that was unstageable to the right heel with stage size this week of 3cm x 3.5cm with 1cm x 1cm open at 1 o ' clock with drainage. It revealed treatment to this as Silver Alginate on Mondays, Wednesdays, and Fridays with dressing. The DTI revealed treatment by skin prep only Mondays, Wednesdays and Fridays and p.r.n. The unstageable to the coccyx revealed Silver Alginate with dressing every Monday, Wednesday and Friday. According to the NCUAP (National Pressure Ulcer Advisory Panel) www.npuap.org on 4/15/16, A Stage 2 pressure ulcer: partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. A Deep Tissue Injury (DTI): Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. An Unstageable pressure ulcer: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Silver alginate : and a dressing treatment for [REDACTED]. (<http://patient.info/doctor/pressure-ulcers-pro>)(accessed on 4/15/16) Record review of Resident #7 ' s Treatment Administration Record (TAR) beginning on 03/18/16 revealed to cleanse stage II at coccyx with NS, apply Silver Alginate dressing, change every Monday, Wednesday, Friday until healed, and weekly skin assessment. There was no documentation the treatment had been done on Monday 3/21/16. During an interview on 4/6/16 at 2:45 PM LVN B said that he was the treatment nurse at the facility and had been treating Resident #7 ' s pressure ulcers beginning on 3/23/16. He stated that he hadn ' t seen the wound until he assessed the wound on 3/23/16, it was unstageable at that time and not a stage 2 as he had read in the resident ' s record. He stated that he performed the treatment as ordered for the stage 2. He stated that he thought that he notified the ADON or the DON about the wound having been unstageable but cannot be sure. He stated that he does not remember if he notified the physician or Hospice about the change. He stated that he did not document that the pressure ulcer to the coccyx was a stage 2 and that he didn ' t obtain a physician order [REDACTED]. He stated that the resident did not have heel floaters in place until 3/29/16. He stated that he should have documented that the pressure ulcer to the coccyx was unstageable on 3/23/16 and should have obtained physicians orders to treat the unstageable ulcer to the resident ' s coccyx. Record review of Resident #7 ' s nurse ' s progress notes dated 03/29/16 at 11:00 AM revealed that, Hospice Nurse here and reported ulcers to heel. Upon assessment noted a DTI to left outer heel 1.5 x 1 cm intact and right heel unstageable 3 x 3.5 cm with skin dry, black 1 open at 1 o ' clock. Serosanguineous drainage noted at 6 o ' clock. New orders received Silver Alginate to right heel and skin prep to left heel Mondays, Wednesdays, Fridays and as needed . Was unable to read nurse ' s signature for this entry. Record review of Resident #7 ' s Monthly Nursing Summary dated 03/30/16 revealed: bed mobility, dressing, toileting, personal hygiene, and bathing; the resident was totally dependent with 1-person physical assist for these tasks. It revealed that the resident was incontinent of bowel and bladder at all times. Skin condition: revealed skin thin, fragile with poor turgor, stage II at coccyx, unstageable ulcer at right heel. Signed by LVN H on 03/30/16. Record review of Resident #7 ' s Order Summary Report dated 04/06/16 revealed Order Summary: Air mattress to bed every day and night shift for fragile skin with an order date of 04/01/16 and start date of 04/01/16. It revealed an order to clean left outer heel DTI with NS, apply skin prep every Monday, Wednesday and Friday, and p.r.n. on every day shift with an order date of 03/29/16 and a start date of 03/29/16. It revealed an order to clean right heel unstaged with NS, apply Silver Alginate with dressing every Monday, Wednesday, Friday, and as needed on every day shift with an order date of 03/29/16 and a start date of 03/29/16. It revealed an order to cleanse 1 cm round stage II at coccyx with NS, apply Silver Alginate and cover with a padded Allevyn dressing, change every Monday, Wednesday and Friday on the day shift until healed with an order date of 03/22/16 and a start date of 03/22/16. It revealed an order to float heels every shift for ulcered feet with an order date of 03/29/16 and a start date of 03/29/16. Allevyn is a type of foam dressing to cover a wound and support moist wound healing (<http://www.dressings.org/Dressings/allevyn.she>. ) (accessed on 4/15/16) During an interview on 4/4/16 at 11:40 PM with Resident #7 ' s daughter and son-in-law, they stated that they were concerned about the care that the resident was getting. They stated that staff had not been in his room this evening for at least 3 hours. They stated that Resident #7 called them several times a day since he had been admitted from his cell phone, having told them that he can ' t get any assistance with repositioning. During an interview on 4/4/16 at 11:45 PM Resident #7 stated that staff had not been in his room this evening for at least 3 hours to assist him with repositioning. He stated that he has to reposition a lot because he has bed sores and they hurt. He stated that staff takes a long time to answer the call lights when he has called them to assist him to reposition and that sometimes they turn off the call light in the room and say that they will be right back and not return. He stated that the staff did not check on him or reposition him every 2 hours. During an interview on 4/4/16 at 11:40 a.m., LVN D stated that she works the night shift 6PM to 6AM. She stated that for at least the past month that Station 1 has been short staffed. On a couple of occasions, the past 2 Saturdays, on 3/26/16 and on 4/2/16 she stated that residents on Station 1 had not been checked on, repositioned every 2 hours,or incontinent care provided especially the residents who required 2 person assistance. She stated that when she comes on shift, through observations during her rounds and interviews with CNA ' s assigned that residents are left soiled, wet and unchanged. She stated that she was worried about the resident ' s and the lack of care they were receiving. She stated that Resident #7 was one of those residents who do not get turned and repositioned as he should be. She stated that the administration was aware of the short staffing and nothing had changed. In an interview on 4/6/16 at 2:00 p.m. CNA H who works 6a-2p on Station 1 said there are major problems on the 10p-6a shift. CNA H said nothing gets done on the 10p-6a shift. CNA H said she could not remember the date but one night within the last couple of weeks LVN P was the only staff on Station 1 on the 6p-6a shift and that when she (CNA H) arrived at 6:00 a.m. the residents were wet. CNA H said she was told there were no CNAs on that side during the night. She stated that she had found Resident #7 was twisted up in his bed and had not been repositioned. During an observation of Resident #7 ' s pressure ulcers and interviews on 4/6/16 at 2:30 PM with LVN B and Hospice Nurse B, the resident was turned on his right side by LVN B and Hospice Nurse B. LVN B removed the dressing to Resident #7 ' s coccyx. The wound was square shaped, darkened, non blanching over the coccyx measuring approximately 4cm by 5cm with a circular nickel sized opened area in the wound with wound bed covered with white substance, unable to view the wound bed Hospice Nurse B stated that when the resident had come into the facility on [DATE], he had a 1cm circle stage 2 (from a blister) with a visible wound bed and surrounding skin that was blanchable, that this wound had deteriorated since her last skin assessment on 3/17/16. She stated that the Hospice nurses assess Resident #7 at least 2 days a week and as needed. She stated that since the resident was receiving wound care from the facility staff that she did not assess the wound to avoid discomfort for the resident. The resident was repositioned on his back. LVN B removed the resident ' s sock to his left foot. The left heel revealed a Deep Tissue Injury (dark Purple and boggy to touch) measuring approximately 1.5 cm in length and 2.5 cm in width. LVN B had touched this wound bed and Resident #7 flinched and yelled out in pain. The Right heel was revealed and dressing removed by LVN B. the right heel wound was approx. 4cm by 4cm rounded with dark yellow, pink drainage. The wound bed was covered with a clear white film and had a darkened area thoughout the wound bed with the surrounding skin non blanching (color change with pressure applied to indicate circulation). The resident moaned with removal of the right heel dressing and wound assessment. Hospice Nurse B stated that the wounds to both heels were not present on admission on 3/17/16. Resident #7 stated that he got those about a week after he was admitted . She stated that she discovered the new wounds to his heels when she made a visit on 3/29/16 and reported the wounds to the charge nurse on duty that day, unsure of name. She stated that the resident did not have heel floaters in place since he had been admitted so she ordered heel floaters and an air mattress for the resident on 3/29/16 and the air mattress was delivered on 4/1/16 by a hospice vendor. LVN B stated that the wound to the coccyx had not really changed much since he had first seen it on 3/23/16 maybe just the non-blanching part darkened a little more . The heel floaters and air mattress were in place at the time of observation. Record review of Resident #7 ' s TAR for 04/01/16 to 04/30/16 revealed a treatment to cleanse 1 cm round stage II at coccyx with NS, apply Silver Alginate, cover with padded ALLEVYN dressing, change Monday, Wednesday, Friday until healed every day shift with a start date of 03/23/16 at 0700 hours. There was no documentation the treatment was provided on 4/4/16. It revealed to clean left outer heel DTI with NS, apply skin prep every Monday, Wednesday, Friday and p.r.n. on the day shift. There was no documentation that the wound care was performed on Monday 04/04/16 by a lack of initials. It revealed clean right heel unstageable with NS, apply Silver Alginate with dressing every Monday, Wednesday, Friday and as needed on the day shift No documentation was found on Monday 04/04/16 of wound care treatment. It revealed to float heels every shift for ulcered feet. The date 04/04/16 did not have any documentation to indicate it was performed on that date as ordered. During an interview with LVN B on 4/7/16 at 4:30 PM, he stated that on Monday 4/4/16 he was pulled as the treatment nurse for the day to work as a charge nurse on Station 2. He stated that the charge nurses on Station 1 were responsible for wound care for the residents when he was not available. He stated that he did not tell the charge nurses on Station 1 that they would have to do their own wound care, that the ADON or the DON did. During an interview on 4/7/16 at 1:15 PM Physician E said that he was familiar with Resident #7. He stated that no one had reported any pressure ulcers to either coccyx or heels to him. He stated that preventative measures should be put in place for any resident at risk for pressure ulcer development. He stated that he turned over Resident #7 ' s care to Physician A on 4/5/16, the facility ' s new medical director. During an interview with Physician A on 4/7/16 at 4:40 PM, he stated that he assumed care of Resident #7 on 4/5/16 and that was the first day that he assessed the resident and reviewed his clinical record. He said that a facility needs to have a system in place for pressure ulcer prevention when a resident was admitted with a risk for pressure ulcer development. Record review of facility policy titled Skin Integrity Management with a revision date of 03/15/16 revealed: Policy: The implementation of a new individual patient skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed. Notify Medical Director, Center Nurse Executive and Center Executive Director if deviation from protocol is requested by physician/mid level provider, managed care company or others. Purpose: To provide safe and effective care, to prevent the occurrence of pressure ulcers, manage treatment and promote healing of all wounds. Practice standards: .2. Complete comprehensive evaluation of patient upon admission/readmission to the center. 2.1: Complete risk evaluation on admission/readmission weekly for the first month, quarterly and with significant change in condition. 3: Identify patient's skin integrity status and need for prevention, intervention or treatment modalities through review of all appropriate assessment information. 3.2: Perform skin inspection on admission/readmission and weekly. Document on treatment administration record. 4. Including prevention and wound treatments as indicating. 4.1: Implement pressure ulcer prevention for identified risks. 4.2: Determine the need for supports surface for bed and chair. 4.3: Determine the need for heel protectors and heel lift devices, and utilize per manufacturer ' s guidelines. 4.4: Implement skin/wound care guidelines as applicable. 5. Review comorbid conditions that may affect healing. 6. Notify Dietician and/or Rehabilitation Services as indicated. 7. Notify physician/mid level provider to obtain orders. 8. Notify patient family and healthcare decision maker of plan of care. 9. Review care plan weekly and revise as indicated . 11. Document daily monitoring of ulcer site with or without a dressing . During an interview on 4/6/16 at 4:15 PM, the Administrator, DON, and Regional VP were informed of the identified Immediate Jeaopardy. On 4/8/16 at 4:50 PM, a Plan of Removal was accepted and included the following: Quality of Care related to Pressure Ulcers Corrective Action · Resident # 7 was admitted under Hospice Services on 03/17/16, with documented stage 2 community acquired wound on his coccyx. On 03/17/16, Hospice nurse visited Resident upon admission, and nurse LVN H, reviewed admission orders [REDACTED]. On 03/29/16, Resident acquired pressure ulcers with a deep tissue injury on his left heel and right heel unstageable. On 03/29/16, treatment orders received for bilateral heels. On 04/05/16, Physician A, assessed Resident #7 and was notified regarding current wound status. He recommended no change in the current treatment orders and documented wounds were unavoidable and non-healing. On 04/07/16, Physician A changed the treatment order to Santyl daily for coccyx, Santyl daily to right heel and continue the skin prep to left heel. Identification · On 04/06/16, ADON, conducted an audit of all Residents with wounds to identify that the wound treatment order is in place, implemented per physician's order [REDACTED]. This audit revealed that these wounds have treatment orders in place, nutrition assessment, and care plans were evident. · On 04/06/16, ADON conducted a facility wide skin assessment audit for all other Residents to identify any skin breakdown not addressed or intervened. Systemic measures · On 04/06/16, LVNs and RNs and Certified Nursing Assistants were re-educated on turning and repositioning, floating heels, notification of wounds. LVNs and RNs also re-educated on physician ' s notification for worsening wounds, initiating treatment, accuracy of the TAR, care plan, and physician orders [REDACTED]. Nurses and CNAs that did not receive the re-education will be re-educated prior to returning to work. · On 04/06/16, DON, and/or Assistant Director of Nurses or designee has begun and will continue to review new admission and readmission with wounds during clinical meetings to ensure the treatment orders are evident, matches the TAR and being carried out as written. Any changes to wound status, skin condition will be reviewed to ensure a notification to physician and responsible party. · On 04/06/16, LVN B, Wound Treatment Nurse, and Assistant Director of Nurses or designee conducted wound rounds to ensure proper assessment of the wound, treatment, and communication to the physician and family for any changes in condition starting on 04/06/16. · Licensed Registered Nurses will complete weekly skin assessments to verify the current status of Resident ' s skin and any new areas will be communicated to physician and family. LVN B, Wound Treatment Nurse, will monitor compliance with skin assessments three times per week for four weeks, then two times per week for two months starting on 04/06/16. · The nurse management team DON, and ADON, or RN designee will conduct audits of physician's order [REDACTED]. · On 04/07/16, the Center initiated every two hour turning and repositioning validation by the CNA. The validation forms will be monitored by management team members, including Charge Nurses, Central Supply Coordinator, Dementia Program Manager, Staffing Coordinator, Night Shift Nurse Supervisor, Assistant Administrator, Administrator, Recreational Assistant, and designees if needed. These will be reviewed for these management team members daily for seven days, three times per week for one month, and weekly for two months. Quality Assurance and Monitoring · The nurse management team, RN/DON and RN/ADON, will monitor systems including prevention of pressure ulcers, accurate wound assessment, wound treatment provisions per physician's order [REDACTED]. · On 04/06/16, the Administrator held an Ad Hoc Performance Improvement QA meeting with the Medical Director and performance improvement team, which included the Administrator, the Assistant Administrator, Director of Nurses, Assistant Director of Nurses, to review the performance improvement measures outlined in this document. See attached document to outline Center ' s performance improvement plan. The committee reviewed the results of the audits in which compliance is achieved. · On 04/07/16 and appropriate corrective measures were put in place. Committee will continue with the performance improvement audits for monitoring the compliance and report on the next committee meeting monthly for three months or until compliance is achieved as determined by the committee. The Nurse Management team, RN, DON, and ADON or designee will conduct audit of physician's order [REDACTED]. · Beginning 04/06/16, RN, DON, or designee will provide a list of Residents with pressure ulcers weekly to the Registered Dietician to ensure the Residents are assessed for nutritional status and interventions to promote wound healing. RN, DON, Director of Nurses or designee will review with the Registered Dietician during Center visits on any Resident that had a change in condition or Residents who have a high risk for pressure ulcers to ensure nutritional assessments and interventions are placed to prevent and promote wound healing. · Administrator and DON will report findings of audits in a monthly performance improvement meeting monthly for three months or until substantial compliance is determined by the committee. The performance improvement committee consists of, but is not limited to the Administrator, the Director of Nurses, the Assistant Director of Nurses, and the Medical Director. Please accept this statement as the Center ' s allegation of compliance effective 04/07/16. The Plan of Removal was verified by observations on 4/8/16 of Nursing management skin assessments, record reviews of inservices pertaining to pressure ulcers, wound assessments and repositioning, skin assessments performed, and conducted interviews with 4 CNA ' s, 3 LVNs regarding turning and repositioning every 2 hours and accurate documentation on ADL sheets and skin assessments. 2 residents were interviewed regarding answering of call lights, turning and repositioned and skin assessments. On 4/8/16 at 5:15 PM, the Immediate Jeopardy was removed and the Administrator was informed the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy, because the facility was monitoring the plan of removal. On 4/8/16, lists provided by the Regional VP identified 21 resident ' s on Station 1 who were at risk for pressure ulcer development and 9 residents on Station 1 with documented pressure ulcers.

Based on observations, interviews and record review the facility failed to ensure the physicians of 3 of 3 residents, reviewed for physician notification of changes, (Resident # ' s 2, 7 and 8), were notified of significant changes in health status as evidenced by: A. Failure to notify the physician of Resident #7 ' s worsened pressure ulcer to the coccyx and the development of 2 new pressure ulcers to both of the resident ' s heels. Resident #7 was admitted on [DATE] with a stage II pressure ulcer to his coccyx and is On 3/23/16 the pressure ulcer had deteriorated to unstageable. The physician was not informed of the deterioration and no alternate treatments obtained and no new interventions provided. On 3/29/16 it was discovered that Resident #7 had an unstageable pressure ulcer to his right heel and a Deep Tissue Injury to his left heel. These failures resulted in an immediate jeopardy situation on 04/06/16. While the IJ was removed on 04/08/16, the facility remained out of compliance at actual harm with the scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of the plan of removal. B. Failure to notify the physician that Resident #2, was in severe pain and out of [MEDICATION NAME] C. Failure to timely notify the physician of Resident #8, who had a [DIAGNOSES REDACTED]. This failure could affect 56 residents by placing them at risk of their physician's not being consulted when they have had changes in their conditions which could cause a delay in treatment and a decline in their health. The findings include: A. Resident #7 Record review of Resident #7 ' s admission record dated 04/05/16 revealed that he was a [AGE] year-old male admitted to the facility on [DATE] from an acute care hospital with the [DIAGNOSES REDACTED]. Record review of Resident #7 ' s admission resident (MDS) data set [DATE] at 6:00 PM revealed that the resident was alert, able to make self understood, he was independent for cognitive skills for decision making, he had the ability to understand others .It revealed under his activities of daily living self-performance that his mobility was independent, that he required extensive assistance with transfers and toileting. It revealed that he was always incontinent of bowel and bladder. It revealed that skin condition is warm, dry with poor turgor. It revealed that he had a stage II 1 cm pressure ulcer to his coccyx. Skin treatments were revealed as pressure redistribution devices, turning/repositioning program, wound care, ulcer care and applications of ointments/medicines other than feet. It revealed a risk for altered nutritional status related to a decrease in appetite, depression and risk for dehydration due to risk of [MEDICAL CONDITIONS] and internal bleeding. It revealed under the nurse ' s notes/comments that Resident was alert and oriented, voices no complaints of pain or discomfort, respiration is even and non-labored. No distress noted, will continue to monitor. Record review of Resident #7 ' s initial care plan dated 03/17/16 revealed: Pressure Ulcer Risk, to provide pressure device, turn and reposition. Pressure Ulcer coccyx treatment, per M.D. order. under pressure sore (pressure ulcer) section, N/A was written. The initial care plan revealed that with toileting the resident was incontinent. The initial care plan did not have a nurse ' s signature. Record review of Resident #7 ' s physician ' s telephone order dated 03/17/16 at 5:52 PM revealed that resident was admitted to nursing home, to continue home meds .Resident was a Hospice resident with the [DIAGNOSES REDACTED]. The order did not address treatment for [REDACTED]. The Physician Telephone Order was signed by Hospice Nurse B. Record review of Resident #7 ' s Skilled Nursing Notes ranging from dates 03/18/16 through 03/21/16 under nursing assessment skin that it was warm and intact. There was no documentation of pressure ulcers. The skilled notes did not mention the Stage 2 to the coccyx. Record review of Resident #7 ' s care plan undated revealed: Focus: Resident is at risk for skin breakdown as evidenced by nutritional concerns and limited mobility. Admit on 3/17/16 with a stage 2 to coccyx. Goal: The resident will not show signs of further skin breakdown thru Quarterly review period. Target date is 6/19/16. Interventions: Apply barrier cream with each cleansing, Assist resident in repositioning every 2 hours . Observe skin condition with ADL care daily and report abnormalities. Obtain dietician consult as needed/ordered. During an interview with the DON A on 4/8/16 at 4:00 PM she stated that she was unable to locate a dietary consult or a skin assessment tool (Braden/Norton scale) for Resident #7. She stated that I guess they were'nt done. She stated that every resident admitted to the facility should have an assessment tool to assess the resident's risk for skin breakdown. Record review of Resident #7 ' s Admission Skin assessment dated [DATE] revealed Prevention Devices and Care: A pressure redistribution mattress, Presence of skin concerns: yes with the location of coccyx pressure ulcer documented on the anatomical man ., Narrative notes: coccyx skin breakdown, redness to buttock. Signed by a LVN (unable to decipher signature). The facility could not provide any other weekly skin assessment notes for Resident #7. Record review of Resident #7 ' s Admission Minimum (MDS) data set [DATE] revealed the resident was able to hear adequately, make self understood, and sometimes understood others. His BIMS score was 8, indicating the resident had moderate cognitive impairment. He was totally dependent with 2-person staff assist for bed mobility. For transfers, dressing, and personal hygiene the resident was totally dependent with 1-person staff assist and toilet use the resident was totally dependent with 2-person assist. The resident was totally dependent with bathing and required 1 person assist. The resident had a urinary catheter and that resident was always incontinent of bowel. Skin conditions revealed that resident was at risk for developing pressure ulcers and that resident had 1 or more unhealed pressure ulcers at stage I or higher. Resident #7 had 2 stage II pressure ulcers and that 2 of these were present upon admission. Skin and ulcer treatments revealed: pressure reducing device for bed, turning/repositioning program, pressure ulcer care, application of nonsurgical dressings and application of ointments and medications other than to feet. RN A completed this section for this MDS. During an interview on 04/08/16 at 11:10 AM with RN A (who did the MDS dated [DATE]) she stated that Resident #7 would not let her look at his wounds. She stated that the look back period for the MDS dated [DATE] was from 03/17/16 to 03/28/16. She revealed that the data she used for the pressure ulcers was information that she had obtained on the weekly decubitus report dated 03/31/16 that she received from LVN B who was the treatment nurse. She stated that she should have obtained the data prior to 03/31/16 due to the look back period being from 03/17/16 to 03/28/16. She stated that she did not notice that the date on the weekly decubitus report 03/31/16 so the MDS dated [DATE] under section M ' s information is incorrect. She stated that due to using the data from the report dated 3/31/16, that she cannot say that the pressure ulcers documented were present on admission. She stated that all residents at risk for pressure ulcer development should have preventative measures in place. She stated that they should have a pressure reducing device for the bed and should float heels. Record review of Resident #7 ' s weekly decubitus (pressure ulcer) report dated 03/31/16 completed by LVN B revealed Resident #7 had an unstageable wound to his coccyx with a stage size this week of 2.5cm x 2cm with 0.8cm x 0.8cm slough. It revealed a second pressure ulcer stage of DTI to the left heel with stage size this week 1.5cm x 1cm remains intact. The report revealed a third pressure ulcer that was unstageable to the right heel with stage size this week of 3cm x 3.5cm with 1cm x 1cm open at 1 o ' clock with drainage. It revealed treatment to this as Silver Alginate on Mondays, Wednesdays, and Fridays with dressing. The DTI revealed treatment by skin prep only Mondays, Wednesdays and Fridays and p.r.n. The unstageable to the coccyx revealed Silver Alginate with dressing every Monday, Wednesday and Friday. According to the NCUAP (National Pressure Ulcer Advisory Panel) www.npuap.org on 4/15/16, A Stage 2 pressure ulcer: partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. A Deep Tissue Injury (DTI): Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. An Unstageable pressure ulcer: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Silver alginate : and a dressing treatment for [REDACTED]. (<http://patient.info/doctor/pressure-ulcers-pro>)(accessed on 4/15/16) Record review of Resident #7 ' s Treatment Administration Record (TAR) beginning on 03/18/16 revealed to cleanse stage II at coccyx with NS, apply Silver Alginate dressing, change every Monday, Wednesday, Friday until healed, and weekly skin assessment. There was no documentation the treatment had been done on Monday 3/21/16. During an interview on 4/6/16 at 2:45 PM LVN B said that he was the treatment nurse at the facility and had been treating Resident #7 ' s pressure ulcers beginning on 3/23/16. He stated that he hadn ' t seen the wound until he assessed the wound on 3/23/16, it was unstageable at that time and not a stage 2 as he had read in the resident ' s record. He stated that he performed the treatment as ordered for the stage 2. He stated that he thought that he notified the ADON or the DON about the wound having been unstageable but cannot be sure. He stated that he does not remember if he notified the physician or Hospice about the change. He stated that he did not document that the pressure ulcer to the coccyx was a stage 2 and that he didn ' t obtain a physician order [REDACTED]. He stated that the resident did not have heel floaters in place until 3/29/16. He stated that he should have documented that the pressure ulcer to the coccyx was unstageable on 3/23/16 and should have obtained physicians orders to treat the unstageable ulcer to the resident ' s coccyx. Record review of Resident #7 ' s nurse ' s progress notes dated 03/29/16 at 11:00 AM revealed that, Hospice Nurse here and reported ulcers to heel. Upon assessment noted a DTI to left outer heel 1.5 x 1 cm intact and right heel unstageable 3 x 3.5 cm with skin dry, black 1 open at 1 o ' clock. Serosanguineous drainage noted at 6 o ' clock. New orders received Silver Alginate to right heel and skin prep to left heel Mondays, Wednesdays, Fridays and as needed . Was unable to read nurse ' s signature for this entry. Record review of Resident #7 ' s Monthly Nursing Summary dated 03/30/16 revealed: bed mobility, dressing, toileting, personal hygiene, and bathing; the resident was totally dependent with 1-person physical assist for these tasks. It revealed that the resident was incontinent of bowel and bladder at all times. Skin condition: revealed skin thin, fragile with poor turgor, stage II at coccyx, unstageable ulcer at right heel. Signed by LVN H on 03/30/16. Record review of Resident #7 ' s Order Summary Report dated 04/06/16 revealed Order Summary: Air mattress to bed every day and night shift for fragile skin with an order date of 04/01/16 and start date of 04/01/16. It revealed an order to clean left outer heel DTI with NS, apply skin prep every Monday, Wednesday and Friday, and p.r.n. on every day shift with an order date of 03/29/16 and a start date of 03/29/16. It revealed an order to clean right heel unstaged with NS, apply Silver Alginate with dressing every Monday, Wednesday, Friday, and as needed on every day shift with an order date of 03/29/16 and a start date of 03/29/16. It revealed an order to cleanse 1 cm round stage II at coccyx with NS, apply Silver Alginate and cover with a padded Allevyn dressing, change every Monday, Wednesday and Friday on the day shift until healed with an order date of 03/22/16 and a start date of 03/22/16. It revealed an order to float heels every shift for ulcered feet with an order date of 03/29/16 and a start date of 03/29/16. Allevyn is a type of foam dressing to cover a wound and support moist wound healing (<http://www.dressings.org/Dressings/allevyn.she>. ) (accessed on 4/15/16) During an interview on 4/4/16 at 11:40 PM with Resident #7 ' s daughter and son-in-law, they stated that they were concerned about the care that the resident was getting. They stated that staff had not been in his room this evening for at least 3 hours. They stated that Resident #7 called them several times a day since he had been admitted from his cell phone, having told them that he can ' t get any assistance with repositioning. During an interview on 4/4/16 at 11:45 PM Resident #7 stated that staff had not been in his room this evening for at least 3 hours to assist him with repositioning. He stated that he has to reposition a lot because he has bed sores and they hurt. He stated that staff takes a long time to answer the call lights when he has called them to assist him to reposition and that sometimes they turn off the call light in the room and say that they will be right back and not return. He stated that the staff did not check on him or reposition him every 2 hours. During an interview on 4/4/16 at 11:40 a.m., LVN D stated that she works the night shift 6PM to 6AM. She stated that for at least the past month that Station 1 has been short staffed. On a couple of occasions, the past 2 Saturdays, on 3/26/16 and on 4/2/16 she stated that residents on Station 1 had not been checked on, repositioned every 2 hours,or incontinent care provided especially the residents who required 2 person assistance. She stated that when she comes on shift, through observations during her rounds and interviews with CNA ' s assigned that residents are left soiled, wet and unchanged. She stated that she was worried about the resident ' s and the lack of care they were receiving. She stated that Resident #7 was one of those residents who do not get turned and repositioned as he should be. She stated that the administration was aware of the short staffing and nothing had changed. In an interview on 4/6/16 at 2:00 p.m. CNA H who works 6a-2p on Station 1 said there are major problems on the 10p-6a shift. CNA H said nothing gets done on the 10p-6a shift. CNA H said she could not remember the date but one night within the last couple of weeks LVN P was the only staff on Station 1 on the 6p-6a shift and that when she (CNA H) arrived at 6:00 a.m. the residents were wet. CNA H said she was told there were no CNAs on that side during the night. She stated that she had found Resident #7 was twisted up in his bed and had not been repositioned. During an observation of Resident #7 ' s pressure ulcers and interviews on 4/6/16 at 2:30 PM with LVN B and Hospice Nurse B, the resident was turned on his right side by LVN B and Hospice Nurse B. LVN B removed the dressing to Resident #7 ' s coccyx. The wound was square shaped, darkened, non blanching over the coccyx measuring approximately 4cm by 5cm with a circular nickel sized opened area in the wound with wound bed covered with white substance, unable to view the wound bed Hospice Nurse B stated that when the resident had come into the facility on [DATE], he had a 1cm circle stage 2 (from a blister) with a visible wound bed and surrounding skin that was blanchable, that this wound had deteriorated since her last skin assessment on 3/17/16. She stated that the Hospice nurses assess Resident #7 at least 2 days a week and as needed. She stated that since the resident was receiving wound care from the facility staff that she did not assess the wound to avoid discomfort for the resident. The resident was repositioned on his back. LVN B removed the resident ' s sock to his left foot. The left heel revealed a Deep Tissue Injury (dark Purple and boggy to touch) measuring approximately 1.5 cm in length and 2.5 cm in width. LVN B had touched this wound bed and Resident #7 flinched and yelled out in pain. The Right heel was revealed and dressing removed by LVN B. the right heel wound was approx. 4cm by 4cm rounded with dark yellow, pink drainage. The wound bed was covered with a clear white film and had a darkened area thoughout the wound bed with the surrounding skin non blanching (color change with pressure applied to indicate circulation). The resident moaned with removal of the right heel dressing and wound assessment. Hospice Nurse B stated that the wounds to both heels were not present on admission on 3/17/16. Resident #7 stated that he got those about a week after he was admitted . She stated that she discovered the new wounds to his heels when she made a visit on 3/29/16 and reported the wounds to the charge nurse on duty that day, unsure of name. She stated that the resident did not have heel floaters in place since he had been admitted so she ordered heel floaters and an air mattress for the resident on 3/29/16 and the air mattress was delivered on 4/1/16 by a hospice vendor. LVN B stated that the wound to the coccyx had not really changed much since he had first seen it on 3/23/16 maybe just the non-blanching part darkened a little more . The heel floaters and air mattress were in place at the time of observation. Record review of Resident #7 ' s TAR for 04/01/16 to 04/30/16 revealed a treatment to cleanse 1 cm round stage II at coccyx with NS, apply Silver Alginate, cover with padded ALLEVYN dressing, change Monday, Wednesday, Friday until healed every day shift with a start date of 03/23/16 at 0700 hours. There was no documentation the treatment was provided on 4/4/16. It revealed to clean left outer heel DTI with NS, apply skin prep every Monday, Wednesday, Friday and p.r.n. on the day shift. There was no documentation that the wound care was performed on Monday 04/04/16 by a lack of initials. It revealed clean right heel unstageable with NS, apply Silver Alginate with dressing every Monday, Wednesday, Friday and as needed on the day shift No documentation was found on Monday 04/04/16 of wound care treatment. It revealed to float heels every shift for ulcered feet. The date 04/04/16 did not have any documentation to indicate it was performed on that date as ordered. During an interview with LVN B on 4/7/16 at 4:30 PM, he stated that on Monday 4/4/16 he was pulled as the treatment nurse for the day to work as a charge nurse on Station 2. He stated that the charge nurses on Station 1 were responsible for wound care for the residents when he was not available. He stated that he did not tell the charge nurses on Station 1 that they would have to do their own wound care, that the ADON or the DON did. During an interview on 4/7/16 at 1:15 PM Physician E said that he was familiar with Resident #7. He stated that no one had reported any pressure ulcers to either coccyx or heels to him. He stated that preventative measures should be put in place for any resident at risk for pressure ulcer development. He stated that he turned over Resident #7 ' s care to Physician A on 4/5/16, the facility ' s new medical director. During an interview with Physician A on 4/7/16 at 4:40 PM, he stated that he assumed care of Resident #7 on 4/5/16 and that was the first day that he assessed the resident and reviewed his clinical record. He said that a facility needs to have a system in place for pressure ulcer prevention when a resident was admitted with a risk for pressure ulcer development. Record review of facility policy titled Skin Integrity Management with a revision date of 03/15/16 revealed: Policy: The implementation of a new individual patient skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed. Notify Medical Director, Center Nurse Executive and Center Executive Director if deviation from protocol is requested by physician/mid level provider, managed care company or others. Purpose: To provide safe and effective care, to prevent the occurrence of pressure ulcers, manage treatment and promote healing of all wounds. Practice standards: .2. Complete comprehensive evaluation of patient upon admission/readmission to the center. 2.1: Complete risk evaluation on admission/readmission weekly for the first month, quarterly and with significant change in condition. 3: Identify patient's skin integrity status and need for prevention, intervention or treatment modalities through review of all appropriate assessment information. 3.2: Perform skin inspection on admission/readmission and weekly. Document on treatment administration record. 4. Including prevention and wound treatments as indicating. 4.1: Implement pressure ulcer prevention for identified risks. 4.2: Determine the need for supports surface for bed and chair. 4.3: Determine the need for heel protectors and heel lift devices, and utilize per manufacturer ' s guidelines. 4.4: Implement skin/wound care guidelines as applicable. 5. Review comorbid conditions that may affect healing. 6. Notify Dietician and/or Rehabilitation Services as indicated. 7. Notify physician/mid level provider to obtain orders. 8. Notify patient family and healthcare decision maker of plan of care. 9. Review care plan weekly and revise as indicated . 11. Document daily monitoring of ulcer site with or without a dressing . During an interview on 4/6/16 at 4:15 PM, the Administrator, DON, and Regional VP were informed of the identified Immediate Jeaopardy. On 4/8/16 at 4:50 PM, a Plan of Removal was accepted and included the following: Quality of Care related to Pressure Ulcers Corrective Action · Resident # 7 was admitted under Hospice Services on 03/17/16, with documented stage 2 community acquired wound on his coccyx. On 03/17/16, Hospice nurse visited Resident upon admission, and nurse LVN H, reviewed admission orders [REDACTED]. On 03/29/16, Resident acquired pressure ulcers with a deep tissue injury on his left heel and right heel unstageable. On 03/29/16, treatment orders received for bilateral heels. On 04/05/16, Physician A, assessed Resident #7 and was notified regarding current wound status. He recommended no change in the current treatment orders and documented wounds were unavoidable and non-healing. On 04/07/16, Physician A changed the treatment order to Santyl daily for coccyx, Santyl daily to right heel and continue the skin prep to left heel. Identification · On 04/06/16, ADON, conducted an audit of all Residents with wounds to identify that the wound treatment order is in place, implemented per physician's order [REDACTED]. This audit revealed that these wounds have treatment orders in place, nutrition assessment, and care plans were evident. · On 04/06/16, ADON conducted a facility wide skin assessment audit for all other Residents to identify any skin breakdown not addressed or intervened. Systemic measures · On 04/06/16, LVNs and RNs and Certified Nursing Assistants were re-educated on turning and repositioning, floating heels, notification of wounds. LVNs and RNs also re-educated on physician ' s notification for worsening wounds, initiating treatment, accuracy of the TAR, care plan, and physician orders [REDACTED]. Nurses and CNAs that did not receive the re-education will be re-educated prior to returning to work. · On 04/06/16, DON, and/or Assistant Director of Nurses or designee has begun and will continue to review new admission and readmission with wounds during clinical meetings to ensure the treatment orders are evident, matches the TAR and being carried out as written. Any changes to wound status, skin condition will be reviewed to ensure a notification to physician and responsible party. · On 04/06/16, LVN B, Wound Treatment Nurse, and Assistant Director of Nurses or designee conducted wound rounds to ensure proper assessment of the wound, treatment, and communication to the physician and family for any changes in condition starting on 04/06/16. · Licensed Registered Nurses will complete weekly skin assessments to verify the current status of Resident ' s skin and any new areas will be communicated to physician and family. LVN B, Wound Treatment Nurse, will monitor compliance with skin assessments three times per week for four weeks, then two times per week for two months starting on 04/06/16. · The nurse management team DON, and ADON, or RN designee will conduct audits of physician's order [REDACTED]. · On 04/07/16, the Center initiated every two hour turning and repositioning validation by the CNA. The validation forms will be monitored by management team members, including Charge Nurses, Central Supply Coordinator, Dementia Program Manager, Staffing Coordinator, Night Shift Nurse Supervisor, Assistant Administrator, Administrator, Recreational Assistant, and designees if needed. These will be reviewed for these management team members daily for seven days, three times per week for one month, and weekly for two months. Quality Assurance and Monitoring · The nurse management team, RN/DON and RN/ADON, will monitor systems including prevention of pressure ulcers, accurate wound assessment, wound treatment provisions per physician's order [REDACTED]. · On 04/06/16, the Administrator held an Ad Hoc Performance Improvement QA meeting with the Medical Director and performance improvement team, which included the Administrator, the Assistant Administrator, Director of Nurses, Assistant Director of Nurses, to review the performance improvement measures outlined in this document. See attached document to outline Center ' s performance improvement plan. The committee reviewed the results of the audits in which compliance is achieved. · On 04/07/16 and appropriate corrective measures were put in place. Committee will continue with the performance improvement audits for monitoring the compliance and report on the next committee meeting monthly for three months or until compliance is achieved as determined by the committee. The Nurse Management team, RN, DON, and ADON or designee will conduct audit of physician's order [REDACTED]. · Beginning 04/06/16, RN, DON, or designee will provide a list of Residents with pressure ulcers weekly to the Registered Dietician to ensure the Residents are assessed for nutritional status and interventions to promote wound healing. RN, DON, Director of Nurses or designee will review with the Registered Dietician during Center visits on any Resident that had a change in condition or Residents who have a high risk for pressure ulcers to ensure nutritional assessments and interventions are placed to prevent and promote wound healing. · Administrator and DON will report findings of audits in a monthly performance improvement meeting monthly for three months or until substantial compliance is determined by the committee. The performance improvement committee consists of, but is not limited to the Administrator, the Director of Nurses, the Assistant Director of Nurses, and the Medical Director. Please accept this statement as the Center ' s allegation of compliance effective 04/07/16. The Plan of Removal was verified by observations on 4/8/16 of Nursing management skin assessments, record reviews of inservices pertaining to pressure ulcers, wound assessments and repositioning, skin assessments performed, and conducted interviews with 4 CNA ' s, 3 LVNs regarding turning and repositioning every 2 hours and accurate documentation on ADL sheets and skin assessments. 2 residents were interviewed regarding answering of call lights, turning and repositioned and skin assessments. On 4/8/16 at 5:15 PM, the Immediate Jeopardy was removed and the Administrator was informed. The facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy, because the facility was monitoring the plan of removal. B. Resident #2 Record review of Resident #2 ' s admission record dated 03/30/16 revealed that she was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2 ' s Minimum Data Set for quarterly review on 03/22/16 indicated in section C for cognitive patterns, a BIMS score of 15 indicating the resident is cognitively intact. In section E it revealed no behavioral symptoms. In section J under pain management it revealed that resident received scheduled pain medication regimen. It revealed the resident received p.r.n. medications. It revealed that resident ' s pain frequency was frequently. It revealed the pain effect on function was present and had limited day-to-day activities for pain. Pain intensity revealed an 8 of 0-10 pain scale. Record review of Resident #2's care plan with a print date of 03/30/16 revealed Focus: Resident exhibits or is at risk for alteration in comfort related to chronic back pain/restless leg syndrome. The goal is the resident will achieve acceptable level of pain control within 90 days with a target date of 04/14/16 with interventions. Advised resident to request pain medication before pain becomes severe, encourage and assist resident to eliminate additional stressor sources of discomfort, medicate resident as ordered for pain and monitor effectiveness and monitor for side effects and report to physician as indicated, monitor frequency of episodes of breakthrough pain to determine for the need of pain medication adjustment, monitor for nonverbal signs and symptoms of pain and medicate as ordered, complete pain assessment per protocol. Assist resident to position of comfort, monitor for change in mood or mental status, monitor for nonverbal signs of

Based on observation, interview and record review the facility failed to provide necessary care and services to attain and/or maintain physical, mental, and psychosocial well-being for 2 of 21 residents reviewed for quality of care (Resident #2 and #8). A. The facility failed to recognize and assess a change in condition for Resident #8 when he developed [MEDICAL CONDITION] 4/1/16. B. The facility failed to reorder Resident #2 ' s prescription pain medication in a timely manner and the resident did not have her medication available when she experienced pain for 3 days. This failure caused 2 residents to have decreased quality of care by not receiving appropriate care and services needed to maintain physical, mental and psychosocial well-being. This failure can also affect 113 residents who receive care at the facility. Findings included: Resident #8 Record review of Resident #8 ' s Admission Record with print date 4/6/16, revealed he was a [AGE] year old male originally admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. Record review of a Skilled Nursing PPS Note dated 3/17/16 at 5:45 p.m. revealed a report was received by the facility from the hospital that Resident #8 would be arriving with a left shoulder sling due to recent shoulder surgery, he had a history of [REDACTED]. Record review of Resident #8 ' s Admission Resident Data Set (facility ' s admission assessment) dated 3/17/16 revealed he was admitted to the facility at 7:30 p.m. on that day. Documentation indicated he required extensive one-person assistance with bed mobility, transfer and toileting. Documentation indicated no presence of [MEDICAL CONDITION] to his lower extremities. Record review of Resident #8 ' s Admission MDS (Medical Data Set) dated 3/24/16 revealed he required extensive assistance with his ADLs (activities of daily living) including toilet use, he had no behaviors, he was always continent of bowel, he had an indwelling catheter at the time of the assessment, and he had a BIMS (Brief Interview for Mental Status) score of 12, indicating that his cognitive function was moderately impaired. Documentation on the MDS indicated Resident #8 had [MEDICAL CONDITION] or other heart dysrhymythmias and heart failure ([MEDICAL CONDITION] and/or [MEDICAL CONDITIONS]). Record review of Resident #8 ' s care plans with target date of 7/4/16 revealed no plan for assessing and managing symptoms of [MEDICAL CONDITION]/[MEDICAL CONDITION]. Record review of Resident #8 ' s Resident Data Set (facility ' s admission assessment) dated 3/27/16, following his discharge from the hospital, revealed no documentation of presence of [MEDICAL CONDITION]. Under the heading of Cardiovascular, the box that would have indicated presence of [MEDICAL CONDITION] was not checked. Attempts to interview LVN H who signed Resident #8 ' s Resident Data Set (facility admission assessment) dated 3/27/16 for Resident #8 ' s readmission to the facility on [DATE] were unsuccessful. LVN H was not on duty during dates and times of investigation and did not return phone calls in which messages were left on 3/30/16 at 4:30 p.m., 4/8/16 at 4:50 p.m. and 4/15/16 at 12:30 p.m. Record review of physician's order [REDACTED].#8 did not have orders for a diuretic. Observations, interviews and record review from 4/1/16-4/8/16 revealed Resident #8 was experiencing increased [MEDICAL CONDITION]. Record review of the following Licensed Nurses Progress Notes revealed: 4/1/16 at 9PM: Noted 2+--3+ pedal [MEDICAL CONDITION] bilateral-bedrest encouraged . Note signed by LVN H. 4/2/16 at 2AM: Noted 3+ [MEDICAL CONDITION] at lower extremities bilateral-foot of bed elevated . Note signed by LVN H. Record review of the following Skilled Nursing PPS Notes revealed: 4/3/16 3+ [MEDICAL CONDITION] was documented on the checklist. The narrative note did not address the [MEDICAL CONDITION]. 4/4/16 at 5:15 a.m. Nurse ' s note is not legible. In an interview on 4/8/15 at 9:45 a.m. LVN C identified the note dated 4/4/16 at 5:15 a.m. as her note and said Resident #8 called his sister that morning and told her he was not getting his water pill. He had 3+ [MEDICAL CONDITION] in his lower legs. LVN C said she told Resident #8 he gets his water pill during the day. 4/4/16 at 11:00 p.m. Resident continues to hang legs off bed. [MEDICAL CONDITION] +3 to both feet and lower legs-encouraged to prop legs up . Nurse signature not legible. 4/5/16 at 6:00 p.m. Resident alert and oriented with some confusion this day shift .MD ' s office contacted this evening for med clarification will follow up in a.m . Note was signed by LVN O. The note did not identify the medication that was to be clarified. 4/5/16 at 8 PM. 3+ pedal [MEDICAL CONDITION] continues. Requested and received [MEDICATION NAME] 10/325 mg .Resting in bed with feet in bed . Note signed by LVN H. 4/5/16 at 11PM Physician C paged re: [MEDICAL CONDITION] Note signed by LVN H. 4/6/16 at 4 AM Physician C ' s call service returned call-reports MD (Physician C) cannot be contacted. Will follow up in AM as planned . Note signed by LVN H. Record review of the following Licensed Nurses Progress Notes revealed: 4/6/16 6A-6P 1200 (12:00 p.m.) .Resident bilateral lower extremities continue with 3+ [MEDICAL CONDITION]. MD (Physician C) called to follow up on clarification of meds. Awaiting for return call .Wound nurse made aware of weeping to bilateral legs . Note signed by LVN O. 4/6/16 6A-6P 2000 (8:00 p.m.) Nurse made aware of MD ' s (Physician C ' s) orders this evening to continue [MEDICATION NAME] and [MEDICATION NAME] in which clarification received . Note was unsigned. Record review of physician ' s telephone order dated 4/6/16 at 19:50 (7:50 p.m.) revealed an order for [REDACTED]. 4/7/16 no time documented: Initial dose of [MEDICATION NAME] and [MEDICATION NAME] was given this a.m. with no adverse reaction. Note signed by LVN E. Record review of Licensed Nurses Progress Notes revealed: 4/7/16 2330 (11:30 p.m.) resident continued with 3+ [MEDICAL CONDITION] to bilateral lower extremities. Nurse signature not legible. Record review of a Licensed Nurses Progress Note dated 4/8/16 at 3:20 p.m. revealed Resident #8 ' s nephew was visiting and that he was notified of the [MEDICAL CONDITION]. Note signed by RN F. Additional record review of the Licensed Nurses Progress Notes on 4/8/16 revealed Resident #8 continued to have 3+ [MEDICAL CONDITION] with oozing of fluid to his bilateral lower extremities and telephone conversations being held between the facility and Resident #8 ' s sister requesting his transfer to the hospital. Record review of telephone orders dated 4/8/16 and confirmed by RN F revealed multiple changes to the dosage and frequency of the [MEDICATION NAME] from 10:05 a.m. until 8:12 p.m. Record review of a telephone order dated 4/8/16 at 10:30 p.m. revealed an order to send Resident #8 to the ER for evaluation of bilateral leg [MEDICAL CONDITION]. In an interview and observation on 4/7/16 at 1:50 p.m. Resident #8 and his sister said he had not had any diuretics ([MEDICATION NAME] or [MEDICATION NAME]) until today, since he had returned from the hospital on [DATE]. Resident #8 showed this surveyor his feet and legs which were extremely swollen and the inside of his left ankle had multiple red marks just below the top layer of his skin. Resident #8 said he kept telling the nurses he was not getting the [MEDICATION NAME] he was supposed to be taking. Resident #8 ' s sister said she came to the facility yesterday (indicating 4/6/16) and spoke with the DON who said she did not know anything about the situation, but that she would get a clarification and that on this day (4/7/16) Resident #8 began receiving [MEDICATION NAME] and [MEDICATION NAME]. Record review of Resident #8 ' s Medication Administration Record [REDACTED]. In an interview on 4/13/16 at 4:30 p.m. Resident #8 ' s sister said on 4/8/16 his legs were so swollen that water was running out of them and at the ER, when they put him on the exam table, the water ran off of the table onto the floor. She said the ER staff could not find pulses with the Doppler in his feet or legs. The sister said CNA C told her she had told the nurse about Resident #8 ' s legs. In an interview on 4/15/16 at 11:20 a.m. Resident #8 ' s nephew said he went to see his uncle on the afternoon of 4/8/16 and noticed his ankles were quite, quite swollen . He said he touched his uncle ' s leg to see if he had [MEDICAL CONDITION] and noted that his TED ([MEDICAL CONDITION] disease) hose were soaking wet. (Per Medtronic.com accessed on 4/21/16 at <http://www.medtronic.com/content/dam/covidien/library/us/en/product/vascular-compression/t.e.d.-anti-embolism-stockings-patient-guide.pdf>, Indications for use of TED hose/stockings are to help prevent the formation of [MEDICAL CONDITION] (blood clots) and to promote increased blood flow to the legs). The nephew asked his uncle if he had wet himself and Resident #8 said no it was just his legs. The nephew said he went to the nurse ' s station and asked Resident #8 ' s nurse (only able to identify the nurse by a description) to go to the room with him. The nephew said she was quite surprised and said she didn ' t know anything about Resident #8 ' s legs and went back to the nurse ' s station. He does not know what she did from there. The nephew said about five minutes after the nurse left the room Resident #8 ' s CNA (could not provide the name) came into the room and informed him that the nurse was aware of Resident #8 ' s legs because she herself had told the nurse about them. The nephew said he got his uncle to elevate his legs. He said he had never seen his uncle ' s legs like that before. He said the [MEDICAL CONDITION] was 4+ or worse and that he was obviously in fluid overload. He said that his uncle is usually lucid except when he is sick and then he gets a little confused. He said his uncle was having some confusion that day due to his fluid status. He said his uncle did go to the nurses that day, 4/8/16, and told them he wanted to go to the hospital because he was miserable. The nephew said when they got Resident #8 to the hospital after 10:30 p.m. on 4/8/16, the fluid was running out of his legs onto the exam table and onto the floor. Record review of nurses notes and physician ' s telephone orders for 4/8/16 during the period in which the nephew ' s visit was said to have occurred indicated the nurse on duty was RN F. A. Resident #2 Record review of Resident #2 ' s admission record dated 03/30/16 revealed that she was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2 ' s Minimum Data Set for quarterly review on 03/22/16 indicated in section C for cognitive patterns, a BIMS score of 15 indicating the resident is cognitively intact. In section E it revealed no behavioral symptoms. In section J under pain management it revealed that resident received scheduled pain medication regimen. It revealed the resident received p.r.n. medications. It revealed that resident ' s pain frequency was frequently. It revealed the pain effect on function was present and had limited day-to-day activities for pain. Pain intensity revealed an 8 of 0-10 pain scale. Record review of Resident #2 ' s care plan with a print date of 03/30/16 revealed Focus: Resident exhibits or is at risk for alteration in comfort related to chronic back pain/restless leg syndrome. The goal is the resident will achieve acceptable level of pain control within 90 days with a target date of 04/14/16 with interventions. Advised resident to request pain medication before pain becomes severe, encourage and assist resident to eliminate additional stressor sources of discomfort, medicate resident as ordered for pain and monitor effectiveness and monitor for side effects and report to physician as indicated, monitor frequency of episodes of breakthrough pain to determine for the need of pain medication adjustment, monitor for nonverbal signs and symptoms of pain and medicate as ordered, complete pain assessment per protocol. Assist resident to position of comfort, monitor for change in mood or mental status, monitor for nonverbal signs of pain, increased agitation, grimaces and resistance care. Record review for Resident #2 ' s medication review report dated 02/26/16 revealed an order for [REDACTED]. This was for date range of 03/01/16 to 03/31/16. Record review of Resident #2 ' s Medication Administration Record [REDACTED]. The administration record indicated the administration of the medications on the other dates as indicated by numeric pain score for pain level and initials by LVNs administering the medication. Record review of Resident #2 ' s medication administration for 01/01/16 through 01/31/16 revealed that Resident #2 was administered [MEDICATION NAME] 50 mg 2 tablets by mouth every 6 hours as needed for pain every day for the month of January 2016 with the exception of 01/15/16 and 01/20/16. The remainder of the dates indicated administration of 2 tablets p.r.n. by mouth at bedtime as indicated by initials from the LVNs. Record review of Resident #2 ' s Medication Administration Record [REDACTED]. Documentation indicated that the resident did not receive [MEDICATION NAME] 50 mg 2 tablets again until 03/16/16. During an interview with LVN E on 03/29/16 at 3:00 PM, she stated that Resident #2 ' s [MEDICATION NAME] was out sometime on Friday 3/11/16 because she overhead an ADON and LVN G talking about it. She stated that she worked the day shift on the weekend of 03/10/16 through 03/12/16. She stated that Resident #2 complained to her of pain on 03/10/16. She stated she told the resident that her [MEDICATION NAME] was not available and they would have to contact the physician to get a refill and it would probably be on Monday 3/14/16 due to it being a triplicate order requiring a physician ' s handwritten prescription. She stated that she offered the resident Tylenol and the resident refused. She stated that she did not call the doctor to refill the [MEDICATION NAME] over the weekend. LVN E stated that usually the night nurses count and check medications and p.r.n. medications and reorder the medications on the night shift when a resident is running low. She stated that this was the first time she worked this station and worked the hall in which Resident #2 resided on. She stated that the E-kit did not have [MEDICATION NAME] available for the weekend of Friday 3/11/16 through Sunday 3/13/16. During an interview with Resident #2 on 03/30/16 at 9:55 AM, she stated that she takes [MEDICATION NAME] 50 mg 2 tablets every night to assist her with pain at night to her back and lower legs. She stated that on Friday, 03/11/16, she took Tylenol because the staff told her the [MEDICATION NAME] was not available. She said the Tylenol didn ' t help nor does it ever help with her back pain. She stated that she uses her walker to get around and get in and out of the room. She stated the weekend of 03/11/16 through 03/14/16 her [MEDICATION NAME] was not available. She stated that she stayed in bed all weekend hurting and miserable. I told all the nursing staff throughout the weekend about my pain. She stated that she was offered Tylenol, but she refused it because it was not effective for her. She stated that the night nurses told her that they weren ' t going to fill it until Monday. She stated she was upset and just trying to make the best of it. She stated when my daughter had called the facility and spoke with the Director of Nurses about me being out of my pain medications all weekend long, the Director of Nurses ordered them and I got my dose as soon as it came in the evening of Monday 03/14/16. She stated that I do as much as I can for myself to stay active as long as I can and my pain allows me to. During an interview on 03/30/16 at 9:40 AM, the DON stated that she was not aware Friday, 03/11/16 that Resident #2 was out of her pain medication [MEDICATION NAME]. She stated the normal process was the night shift nurses count and make sure that all medications are ordered that are going to be running out usually within the week and order them ahead of time. She stated that Resident #2 ' s daughter called her in the afternoon of 03/14/16 and complained that her mother had been out of her pain medication all week long and was in a lot of pain. The DON stated that she called and ordered the medication immediately and offered Resident #2 some Tylenol until the medication came in. The DON stated that she gave the medication at around 4:00 PM on 03/14/16, two tablets of [MEDICATION NAME] as soon as it came in. She stated that a resident should not run out of p.r.n. pain medication and that she has in-serviced her nurses about ordering and reordering medication and pain management. During an interview with FNPA on 03/30/16 at 10:40 AM she stated that she was familiar with Resident #2 and her pain management and that she had recently ordered a scheduled [MEDICATION NAME] at bedtime to control her pain. She stated that she wasn ' t aware that Resident #2 ran out and was not on call the weekend of 03/11-03/13/16. She stated that the facility should have a system in place to prevent residents from running out of medications including p.r.n. pain medications. She said it could be debilitating for resident to be without their pain medication for a couple of days and decrease her level of function. Record review of the facility ' s Assessment: Nursing policy and procedure dated 3/15/16 revealed: Policy: A nursing assessment will be performed by a licensed nurse for all patients upon admission. Routine and focused assessments will be performed on an ongoing basis as needed . Purpose: To determine patient ' s condition and clinical needs. Practice Standards: 1. Upon admission, complete a nursing assessment within 24 hours . 1.1 .and expanded nursing assessment within three to five days . 3. Utilize assessment data to develop the care plan . 4. Notify physician/mid-level provider of assessment results as indicated. 5. Document physician/mid-level provider notification and response if indicated. Record review of the facility ' s policy titled Pain Management with a revision date of 3/15/16 revealed: Purpose: To maintain the highest possible level of comfort for patients by providing a system to identify, assess, treat, and evaluate pain. To design a plan of care to achieve an optimal balance between pain reif and preservation of function, in accordance with patient directed goals. Record review of the facility ' s policy titled Reordering, Changing, and Discontinuing Medication Orders with a revision date of 3/1/11 revealed: Policy: the center will communicate any medication reorders, changes, or discontinuations to the pharmacy in accordance with pharmacy guideline and state/federal regualtions. Purpose: to assure a standardized process for the communication of medication order refills, changes, and or discontinuation to the pharmacy. To comply with state/federal regualtions CMS form 672 dated 3/29/16 revealed a census of 113 residents.

Based on observation, interviews, and record review the facility failed to ensure 1 of 7 residents (Resident #9) reviewed for weight loss maintained acceptable parameters of nutritional status (body weight) as evidenced by: The facility failed to consistently monitor Resident #9 ' s percentages of daily meal intake, failed to monitor Resident #9 ' s weight and failed to initiate dietary interventions to address the weight loss. Resident #9 lost 18.9 pounds in 1 month and an additional 5.6 pounds in 9 days. This failure affected Resident #9 and could potentially affect 14 residents, placing them at risk for unidentified severe weight loss, skin breakdown, and dehydration due to inadequate nutritional intake. Findings included: Record review of an Admission Record dated 4/7/16 (print date), revealed Resident #9 was an [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #9 ' s Admission MDS (Medical Data Set) dated 3/9/15 revealed he required extensive assistance with his ADLs (Activities of Daily Living), including eating. His weight was documented as 174 pounds. His BIMS (Brief Interview for Mental Status) score was 1 indicating his cognitive function was severely impaired. Behavior symptoms were listed as physical behavior symptoms directed toward others occurring 4-6 days, verbal behavioral symptoms directed toward others occurring 4-6 days and other behavioral symptoms not directed toward others occurring daily. Documentation on the MDS indicated Resident #9 had had one fall with no injury and two falls with minor injury since his admission and that he used a wheelchair for locomotion. The MDS revealed no [DIAGNOSES REDACTED]. Record review of Resident #9 ' s care plan with target date of 6/14/16 revealed the following: Focus: resident is at nutritional risk due to cognitive loss. Goal: resident will consume 75% of at least 3 meals every day x 90 days. Interventions included: assist .(if he is willing) to place dentures in mouth for meals .; evaluate for proper consistency of diet; honor food preferences within meal plan; encourage 100% consumption of all fluids provided; encourage resident to chew and swallow each bit; offer/encourage fluids of choice; supervise/assist as needed with meals. Focus: resident requires assistance and/or is independent for ADL care in .eating .Goal: ADL care needs will be anticipated and met in order to maintain the highest practicable level of functioning and physical well-being x 90 days. Interventions included: .requires 1 person assistance with eating . Record review of Skilled Nursing PPS Notes and Licensed Nurses Progress Notes from 2/29/16-3/14/16 revealed Resident #9 had episodes of aggressive behavior toward staff during incontinent care, when picking him up from sitting in the floor and placing him in a wheelchair, and redirecting him to sit back into the wheelchair when he attempted to get up and walk. Record review of Resident #9 ' s MAR (Medication Administration Record) dated 3/1/16-3/31/16 (listed here in the order of entry on the MAR) revealed resident received a one-time dose of [MEDICATION NAME] 10 mg by intramuscular (IM) injection given at 2:00 a.m. on 3/6/16 for agitation, a one-time dose of [MEDICATION NAME] 10 mg IM given at 10:00 p.m. on 3/7/16 for agitation, [MEDICATION NAME] 10 mg IM every 12 hours as needed given at 5:00 p.m. for agitation on 3/7/16. Documentation on the MAR indicated [REDACTED]. Record review of a telephone order dated 3/8/16 at 6:48 p.m. revealed an order to discontinue [MEDICATION NAME] 10 mg IM every 12 hours as needed and start [MEDICATION NAME] 25 mg twice a day. Order was confirmed by LVN Q. Record review of Resident #9 ' s weight on the facility ' s Point/Click/Care (PCC) computer system revealed Resident #9 was not weighed upon admission and had been weighed one time, 3/10/16 at 2:10 p.m., from his admission on 2/29/16 to 4/11/16. His height was recorded as 68 with a weight of 174.5 pounds. Additional weight records for Resident #9 were requested, facility did not provide. During an interview on 4/12/16 at 11:30 AM The DON said when a resident was admitted , the facility normally weighed the resident weekly for 4 weeks and then monthly for a few months or until the physician specified differently. The DON said that they only had 1 weight on record for Resident #9, but that they weighed him again on the afternoon of 4/11/16 and his weight was 155.6 (indicating an 18.9 pound weight loss (10% loss) in approximately one month (33 days) which indicated a severe weight loss). Record review of Resident #9 ' s clinical records including nurses notes and physician's order [REDACTED]. Record review of a Skilled Nursing PPS note dated 3/14/16 at 7:10 p.m. revealed: out per ambulance to (behavioral hospital). Note signed by LVN D. Record review of a Resident (MDS) data set [DATE] at 3:45 p.m. indicated Resident #9 was discharged from the behavioral hospital and readmitted to the facility. Documentation on the Data Set indicated Resident #9 was alert, lethargic with slow movement, lack of energy, and poor appetite, recent weight loss, inability to feed self, increased confusion, tremors present, weakness present, dependent on staff for provision of fluid intake and dementia. His skin condition was documented to be warm, dry, pale, bruises/ecchymosis, and poor turgor. Signed by LVN R. No weight was documented. Record review of the Discharge Medication Reconciliation Order and Continuing Care Plan from the behavioral hospital dated 3/30/16 indicated, Resident #9 returned to the facility with orders for [MEDICATION NAME] 5 mg po hs (by mouth at bedtime) for agitation, and a decrease in [MEDICATION NAME] to 25 mg po hs (by mouth at bedtime) for anxiety. Record review of Resident #9 ' s MAR from 3/30/16-3/31/16 upon return from the behavioral hospital and his April MAR indicated [REDACTED]. Record review of Nurse ' s Notes from 3/30/16 to 4/3/16 (the last entry until 4/19/16) and Physician telephone orders, revealed no documentation related to obtaining a clarification for the frequency in which [MEDICATION NAME] was to be administered or of weight being addressed. Record review of a Licensed Nurses Progress Note dated 4/20/16 revealed: 1630 (4:30 p.m.) Medical Director notified via voicemail of transcription error of [MEDICATION NAME] dosing. No orders given. Notes signed by ADON. 1900 (7:00 p.m.) Medical Director returned call. Verified with MD [MEDICATION NAME] order. Order received to d/c (discontinue) current [MEDICATION NAME] order and change to [MEDICATION NAME] 25 mg every evening to start 4/21/16 at bedtime. Dose to be held on 4/20/16 at hs (bedtime). Record review of a Dietitian recommendation dated 3/31/16 revealed regular liberalized diet with chopped meat. Review of the Dietitian Consult dated 4/7/16, accepted and signed by the Medical Director revealed: Dietitian ' s Concern: diet texture toleration. Recommendation: 1. Resident eats better on a pureed diet. Recommend to downgrade diet to pureed. 2. Have SLP assess for dysphagia. In an interview on 4/7/16 at 4:10 p.m. Resident #9 ' s son said his dad had lost a lot of weight since his admission to the facility. The son said he is concerned about his somnolence and was wondering if the [MEDICATION NAME] was too strong. The son said his sister told him that the last several times she ' s been to visit their dad he ' s been sleeping. He said he was not informed about the increased risks and side-effects for the use of antipsychotics in individuals with dementia and no prior mental illness. The son said when they started the [MEDICATION NAME] he went crazy on that and that he wasn ' t falling at the current rate before [MEDICATION NAME] was initiated . The son said Resident #9 had fallen a couple of times while still at home. He said Resident #9 was a little hard to deal with, but became more combative on [MEDICATION NAME]. The son said the therapist at the behavioral hospital said to keep him on the current medications or he will go back to where he was. In an interview on 4/8/16 at 4:25 p.m. Resident #9 ' s daughter said when he was admitted to the facility on [DATE] Resident #9 walked into the building. She said after 2-3 days in the facility he has not walked again . The daughter said he is always out of it-asleep . She said the family visits and tries to wake him up but he doesn ' t wake up for long. She said Resident #9 ' s sister visited and couldn ' t wake him up. The daughter said this morning at 9:00 he was awake in his wheelchair, but went back to sleep in 20 minutes. The daughter said Resident #9 is getting Ensure three times a day, but he has lost 2 clothes sizes. Record review of Resident #9 ' s physician orders [REDACTED]. In an interview on 4/11/16 at 3:25 p.m. CNA K said the dietary intake for each resident is recorded in the ADL book. Record review of the binder in which all ADLs, including percentages of meals eaten each day, were documented for residents in the unit on which Resident #9 resided revealed no records for the month of April for Resident #9. ADL records were requested from the Administrator and DON on 4/11/16 for March and April. The April ADL record was not provided. Record review of the facility-provided ADL record for March contained no documentation of ADLs through 3/9/16. March 1-9 was blank. Meal percentage was not documented until 3/11/16 indicating Resident #9 ate 100% at breakfast on 3/11, 3/12, and 3/13. Documentation indicated at lunch he ate 75% on 3/11, 100% on 3/12 and 25% on 3/13. There was no documentation on 3/14/16 for percentage of meals eaten prior to his discharge to the behavioral hospital at 7:10 p.m. Documentation indicated upon Resident #9 ' s return from the behavioral hospital on [DATE] he ate 100% of his dinner meal. Documentation on 3/31/16 indicated he ate 25% of his breakfast and lunch. There was no documentation of percentage eaten at dinner. There was no documentation on the record that indicated Resident #9 was refusing meals. During surveyor observations of Resident #9 on 4/6/16 at 10:00 a.m. and 3:50 p.m.; on 4/7/16 at 2:45 p.m. and 3:40 p.m.; on 4/8/16 at 3:40 p.m.; on 4/11/16 at 11:45 a.m., 2:10 p.m. and 3:25 p.m.; on 4/12/16 at 11:40 a.m.; and on 4/20/16 at 3:45 p.m. and 4:20 p.m. Resident #9 was seen sitting in a wheelchair with his eyes closed. He responded one time when spoken to by briefly opening his eyes but he immediately shut them. His clothes were loose-fitting. Observation on 4/11/16 at 11:55 a.m. revealed Resident #9 sitting in a wheelchair in the dining area with his eyes closed and his hands in his lap. In an interview on 4/11/16 at 11:55 a.m. CNA L said Resident #9 has been pretty much like that all day . In an interview on 4/11/16 at 2:10 p.m. CNA L said Resident #9 ate only 3 or 4 bites at lunch. In an interview on 4/12/16 at 11:25 a.m. CNA L said Resident #9 had lost a lot of weight-he had not been eating much. CNA L said staff has been spoon-feeding him and he gets health shakes. CNA L said Resident #9 fed himself at breakfast this morning and he at 100%. She said she would try seeing how he did at lunch feeding himself, and maybe he would eat more that way. Observation and interview on 4/20/16 at 4:35 revealed RNA making multiple attempts to awaken Resident #9 to weigh him. The RNA reported his weight as 150 pounds, (indicating an additional 5.6 pound weight loss in 9 days for a total weight loss of 24.5 pounds (14% loss) in 42 days which indicated severe weight loss). Record review of Resident #9 ' s clinical records from 3/10/16-4/21/16 including Nurses Notes, physician progress notes [REDACTED]. Observation on 4/20/16 at 4:47 p.m. revealed undated ADL records had been placed in the ADL Binder for Resident #9. In an interview on 4/20/16 at 4:47 p.m. CNA V said she believed they were the April ADL sheets for Resident #9 and when they were printed the date did not print on the top. She went through the sheets for the other residents residing on that unit and revealed they were all dated 4/1/16-4/30/16. Record review of the ADL record for Resident #9, assumed to be for April 2016, revealed documentation had begun on day 11. Days 1-10 were blank. The record revealed the following meal percentages consumed: Day 11: breakfast 25%; lunch 75%; dinner 25%. Day 12: breakfast 75%; lunch 25%; dinner25% Day 13: breakfast no percentage documented, and no documentation of refusal; lunch 50%; dinner no percentage documented and no documentation of refusal Day 14: breakfast 75%; lunch 25%; dinner 25% Day 15: breakfast 25%; lunch 25%; dinner 25% Day 16: breakfast 75%; lunch 50%; dinner 50% Day 17: breakfast 50%; lunch 25%; dinner 50% Day 18: breakfast 50%; lunch 25%; dinner 50% Day 19: breakfast 50%; lunch 50%; dinner 50% Day 20: breakfast 25%; lunch no percentage documented and no documentation of refusal Out of 29 meals from 4/11/16-through lunch on 4/20/16 Resident #9 was documented to have consumed: 100% of 0 meals; 75% of 4 meals; 50% of 10 meals; and 25% of 12 meals. Intaked was not documented for three meals during this timeframe. There was no documentation in the Bedtime Snack percentage section to indicate Resident #9 had been offered, eaten or refused a bedtime snack. Record review of the facility Weights and Heights policy and procedure dated 11/30/15 revealed: Policy: Patients are weighed upon admission and/or readmission, then weekly for four weeks and monthly thereafter. Additional weights may be obtained at the discretion of the interdisciplinary care team. Hospital weight will not serve as admission or re-admission weight . Purpose: To obtain baseline weight and identify significant weight change; to determine possible causes of significant weight change . Record review of the facility Nutrition and Care Process policy and procedure dated 12/1/15 revealed: Policy: Patients/Residents are visited and assess upon admission and routinely thereafter. Purpose: To assure that each patient/resident receives timely, individualized, and consistent nutritional care. Process: Dietitian or non-dietitian designee visits each patient/resident as part of the assessment process. 2. Nutrition assessment is completed by the Dietitian or the non-dietitian designee upon admission and with changes in nutritional status. Generally, a nutrition assessment is completed in conjunction with a MDS 3.0 OBRA assessment. 2.1 The Dietitian completes a comprehensive or further assessment for any patients/residents determined to be of nutrition concern. 3. Patients/Residents with a nutrition [DIAGNOSES REDACTED]. 5. A system is developed to manage and prioritize nutrition documentation. Review [MEDICATION NAME] related to side effects and warnings from the Food and Drug Administration website accessed on 4/12/16 at <http://www.fda.gov/downloads/drugs/drugsafety/ucm 6.pdf> revealed the following: ¿ Medication Guide [MEDICATION NAME] (SER-oh-[MEDICATION NAME]) (quetiapine [MEDICATION NAME]) [MEDICATION NAME] can cause serious side effects, including: .sleepiness, drowsiness, difficulty swallowing . Review of [MEDICATION NAME] related to side effects and warnings on the Food and Drug Administration website accessed on 4/12/16 at <http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm 0.htm> revealed: Common side effects of [MEDICATION NAME] include: lack of energy, dry mouth, sleepiness . Per the Administrator-provided list of new admissions on 4/5/16 at 4:00 p.m., 14 residents had been admitted to the facility from 3/1/16-3/31/16.

Based on observation, interviews, and record review the facility failed to ensure 1 of 2 residents (Resident #9) reviewed for psychoactive medication use remained free from unnecessary drugs as evidenced by: The facility failed to provide clinical indication for the use of [MEDICATION NAME] and [MEDICATION NAME] (antipsychotics), failed to document monitoring of specific target behaviors and side effects associated with the use of [MEDICATION NAME] and [MEDICATION NAME] for Resident #9, failed to ensure Resident #9 did not receive duplicative medications ([MEDICATION NAME] and [MEDICATION NAME]) from the same classification of medications (second generation atypical antipsychotics) and failed to ensure Resident #9 received [MEDICATION NAME] in the correct dosage upon return from a behavioral hospital. Resident #9 exhibited severe weight loss, decreased ability to walk, increased somnolence, experienced two falls after [MEDICATION NAME] was started on 3/6/16 and six falls after [MEDICATION NAME] was discontinued and [MEDICATION NAME] was started on 3/9/16. This failure could place 42 residents with a [DIAGNOSES REDACTED]. Findings included: Record review of an Admission Record dated 4/7/16 (print date), revealed Resident #9 was an [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #9 ' s Admission MDS (Medical Data Set) dated 3/9/15 revealed he required extensive assistance with his ADLs (Activities of Daily Living). His BIMS (Brief Interview for Mental Status) score was 1 indicating his cognitive function was severely impaired. Behavior symptoms were listed as physical behavior symptoms directed toward others occurring 4-6 days, verbal behavioral symptoms directed toward others occurring 4-6 days and other behavioral symptoms not directed toward others occurring daily. Documentation on the MDS indicated Resident #9 had had one fall with no injury and two falls with minor injury since his admission and that he used a wheelchair for locomotion. The MDS revealed no [DIAGNOSES REDACTED]. Record review of a Level 1 Preadmission Assessment and Resident Review (PASRR) dated 2/26/16 completed by the facility ' s Admission Director revealed no evidence or indication of mental illness. Record review of Resident #9 ' s Admission physician's order [REDACTED]. Record review of physician telephone orders revealed: 3/5/16 at 1:20 a.m. [MEDICATION NAME] ([MEDICATION NAME]) 10 mg IM x 1 now for severe agitation. 3/6/16 at 10:10 p.m. [MEDICATION NAME] tablet 10 mg inject 10 mg intramuscularly STAT for anxiety; other (see nurse admin notes) related to unspecified dementia without behavioral disturbance. 3/6/16 at 10:21 p.m. [MEDICATION NAME] tablet 10 mg inject 10 mg intramuscularly every 12 hours as needed for anxiety related to unspecified dementia without behavioral disturbance. Record review of two telephone orders dated 3/8/16 at 6:48 p.m. revealed orders to discontinue [MEDICATION NAME] 10 mg IM every 12 hours as needed for anxiety related to unspecified dementia without behavioral disturbance and start [MEDICATION NAME] 25 mg 1 tablet by mouth two times a day for anxiety related to dementia behavior disturbance related to unspecified dementia without behavior disturbance . Order was confirmed by LVN Q. Record review of Resident #9 ' s MAR indicated [REDACTED]. Documentation on the MAR indicated [REDACTED]. Record review of Resident #9 ' s care plan with target date of 6/14/16 revealed he was at risk for falls and had three falls from 2/29/16 to 3/9/16 and another five falls between 3/10/16 and 3/13/16. Record review of a Licensed Nurse Progress Note dated 4/20/16 at 3:20 a.m. revealed resident fell resulting in a skin tear to his right elbow, abrasions to right posterior ribcage and complaints of neck and right hip pain. Resident was transferred to the hospital via ambulance. Record review of Skilled Nursing PPS Notes revealed: 2/29/16 No time documented--Resident #9 was admitted to a secured/locked unit. No documentation of behaviors. Note signed by LVN R. 8:15 p.m. Resident #9 was confused and fell hitting his head. Note signed by LVN P. 3/1/16 No time documented-Resident pacing on unit adjusting well to unit .no physical/verbal aggression this shift. Signature not legible. 11:00 p.m. Quiet in bed, eyes closed. Signature not legible. Record review of additional Skilled Nursing PPS Notes revealed: 3/2/16 No time documented-Resident #9 was displaying exit seeking behaviors, pacing and trying doors. Easily redirected . Went out to secured garden with corporate nurse who redirected him from the gate. Resident returned inside after 15 minutes and went to his room. Signature not legible. No time documented-Resident alert and confused walks with unsteady gait at night .takes evening meds without difficulty. Note signed by LVN T. 3/3/16 6A-6P-- .pleasant and cooperative .Note signed by LVN R. 2300 (11:00 p.m.) resting quietly eyes closed. Note signed by LVN T. 3/4/16 6a-6P No exit seeking behavior today. Ambulates on unit ad lib. Visits with staff and peers. Accepting placement well. Note signed by LVN R. 11:00 p.m. notable for severe restlessness, wandering, particularly intrusive upon other residents, resists care, repeatedly refusing medications, voices complete and utter disorientation and exhibits hallucinatory reference to things that are not there. Signature not legible. There was no documentation indicating that redirection was attempted or that staff assessed Resident #9 ' s needs. 3/5/16 6A-6P Ambulating on unit ad lib. No signs/symptoms of pain or discomfort. Visiting with peers .feeds self. Appetite good. Note signed by LVN R. 2:30 p.m. grandkids visited. Resident became tearful as did the family. Redirection effective. Note signed by LVN R. There was no documentation to indicate the type of redirection that was effective. 3/6/16 1:00 a.m. increasing agitation and intrusive to others ' rooms .very difficult to redirect. Attempts by nursing to de-escalate are largely without success and resident ' s refusal of medications includes overt physical threats, turning head away covering mouth .becomes so agitated, assaultive and resistant to redirection that physician covering for physician D is contacted by phone and advised that resident is said to be (word not legible) and paradoxical with most agents including [MEDICATION NAME] and/or (next word not legible-appears to start with the letter z ). Initially physician ordered [MEDICATION NAME] injection but it was found this could not be carried out at once. Physician was re-contacted and a second order obtained for [MEDICATION NAME] ([MEDICATION NAME]) 10 mg IM x 1 for severe agitation. Administered with assist of able CNAs x 2 and within 30 minutes a most welcome amelioration is obtained. Signature not legible. There was no documentation indicating the type of redirection or assessment of Resident #9 ' s needs. 2:30 a.m. resting quietly supine in bed, (next word not legible) with eyes closed. Signature not legible. No time documented-- Approx 6:00 AM resident fell , unwitnessed. Note signed by LVN S. 7:35 a.m. resident resting quietly in day area, eyes closed. Resident easily aroused denies pain and discomfort, no agitation noted. Note signed by LVN S. 8:30 Resident tolerated meds without incident .ate 75% of breakfast, resident up wandering unit ad lib, no concerns with ambulation noted, continues to deny pain and discomfort .Note signed by LVN S. 12:00 p.m. resident sitting on loveseat in day area watching the show on the t.v., pleasant and calm. 3/7/16 1PM-no behaviors documented. 10:30 p.m. while attempting to give resident his evening medications resident attempted to strike this nurse with a closed fist. Resident is frequently resistant to care and physically aggressive with staff. Note signed by LVN T. The note did not include documentation of the administration of IM [MEDICATION NAME] as indicated on the MAR for this date and time. There was no documentation indicating attempts to redirect/type of redirection attempted or assessment of Resident #9 ' s needs. Late entry 5PM-resident with physical aggression-hitting, kicking, grabbing, pinching twisting limbs of staff during incontinent of bowels care. Multiple times with verbal redirection unsuccessful each attempt. [MEDICATION NAME] 10 mg IM left deltoid-tolerated fair. Note signed by LVN K. There was no documentation indicating the type of verbal redirection attempted or assessment of Resident #9 ' s needs. Late entry 6PM resident somewhat calmer. Eating supper meal. Note signed by LVN K. 3/8/16 12:30 p.m. up for meals, ambulatory, agitated throwing meal tray, combative with staff, attempts to redirect not effective, IM [MEDICATION NAME] given. Normal for this resident is calm and quiet .will purposefully sit self on floor. Frequently will sit on his knees and reach out to objects .able to make most basic needs known .he enjoys being on the floor at times. Note signed by LVN R. There was no documentation to indicate type of redirection attempted or assessment of Resident #9 ' s needs. Record review of Resident #9 ' s March MAR indicated [REDACTED]. Continuation of Record Review of Skilled Nursing PPS Notes revealed: 3/8/16 4:00 p.m. sitting on couch in day area, eyes closed .no aggression at this time. Note signed by LVN R. Record review of a Skilled Nursing PPS note dated 3/8/16 at 9:20 p.m. revealed: Received telephone order to d/c (discontinue) [MEDICATION NAME] and start [MEDICATION NAME] 25 mg 1 by mouth twice daily. Note signed by LVN Q. Record review of Resident #9 ' s MAR indicated [REDACTED]. Documentation on the MAR indicated [REDACTED]. Record review of Additional Skilled Nursing PPS Notes revealed: 3/8/16 8:30 p.m. called to resident room by CNA .resident on floor .assisted resident to bed, resident kicking and punching staff, no other concerns .Note signed by LVN Q. 9:10 p.m. This nurse passing meds noted resident on the floor again, no injury. Note signed by LVN Q. 3/9/16 5:00 a.m. resident was combative, uncooperative with care and restless throughout entire shift. Note signed by LVN T. There was no documentation indicating if redirection was attempted or needs assessed. No time documented-initial dose of [MEDICATION NAME] given-meds had to be crushed today, not understanding directions. More confused today .still likes to sit on the floor. Assist of 3 for transfer today. Resident combative. Assisted to bed-eyes closed .complained of pain in left hip area when he tries to walk with assistance. Needs must be anticipated and met by staff today. Requiring increased assistance with all ADLs. Has numerous bruises to arms, hip area, buttocks, various stages of fading. Possible delayed injuries from fall of 3/6/16. Had an appointment with Physician D yesterday, it had to be cancelled due to aggression and combativeness .son in agreement with psych eval .and of getting xray .gave verbal consent for psych eval with Psychiatrist. Note signed by LVN R. 3/10/16 5:00 p.m. Resident having difficulty walking, favoring left hip stood up and fell .slid to buttocks, did not hit head. Note signed by LVN E. 3/11/16 No time documented--CNA reports another resident stated this resident stood up and fell , pointing to buttock as to where he landed .two CNAs attempted to lift resident back to wheelchair. Resident grabbed onto sink pulling away from CNAs and wheelchair, almost causing another fall. Resident remains agitated after sitting in wheelchair. Again stands up, this time falling into couch and CNA help lower him to seat. Resting quietly with eyes closed at this time .Psychiatrist notified. Behavioral Hospital notified. Note signed by LVN E. There was no documentation indicating attempts to redirect or to assess/anticipate resident ' s needs when he stood up from the wheelchair. 11:00 p.m. Resident resting quietly eyes closed, feet hanging off lowered bed. This nurse placed a mattress on floor next to bed to ensure against any injury in event of fall. Note signed by LVN T. 3/12/16 2 pm-Resident in wheelchair. Continues to get up unassisted. Resident very unsteady. Resident unable to re-direct. Resident becomes very physical and verbal aggressive with staff, hitting and slapping staff especially when doing peri-care. Staff attempt to re-approach with different staff or at a later time, resident continues to be physically aggressive and verbally aggressive toward staff. Note signed by LVN Q. 3:10 pm .Resident on floor in day room. CNA and this nurse attempted x 3 to get resident up. Resident started kicking both nurse and CNA not allowing us to get him up. This nurse called for assistance to help with resident. Call placed to MD on call, awaiting reply. Resident assisted back to wheelchair by CNA and other nurse. Note signed by LVN Q. There was no documentation to indicate redirection attempts or to assess reason resident was on floor. Additional Skilled Nursing PPS Notes revealed: 6:10 p-Resident in dining room continues to stand without assistance. Noted resident to be urinating on floor during meal service, attempted to re-direct unsuccessful .resident ambulating without assisted device and unsteady gait. Note signed by LVN Q. There was no documentation indicating the type of redirection attempted or whether Resident #9 was assessed for his needs when attempting to stand up prior to his urination in the floor. 7:50 pm-Resident was found on floor on mat. CNA and this nurse attempted to assist back to bed when resident punch/kick staff. Staff, this nurse and CNA step back to allow resident to calm down and reapproach, no change in behavior noted. Call placed to DON. Note signed by LVN Q. 8:20 p-DON called stating to this nurse to leave resident alone. If we are the ones agitating him that we need to leave him alone. This nurse stated that staff is trying to take care of him, change him during pericare is when resident becomes more physical aggressive to staff. Note signed by LVN Q. 3/13/16 1200 pm-Resident stood up out of wheelchair grabbed hold of freezer door. Staff attempted to assist resident into chair. Resident began swinging at staff and grabbed freezer door again and started leaning backwards and lowering self toward floor. Gait belt placed on resident and staff was able to assist resident into wheelchair without difficulty. Signature not legible. There was no documentation indicating that Resident #9 ' s needs were assessed when attempting to stand up. 1:30 p.m. Informed by CNA resident stood up out of wheelchair and fell backwards onto floor hitting back of his head. Resident noted laying flat on his back legs outward no signs/symptoms of discomfort noted upon assessment. Resident noted with 4cm in diameter soft mass without abrasion in the center to back of resident ' s head, bilateral grips equal, right pupil dilated, MD on call notified with new order to send to hospital ER for eval. Signature not legible. 5:13 p.m. Received call from ER, resident CT of head and neck showed no changes and no acute injury. Resident will be discharged back to facility. Signature not legible. 9:00 p-resident received back from hospital .attempt x 2 to assess and take vital signs, resident became extremely agitated, will step back and attempt again later. Behavioral Hospital will be out in AM for eval and possible admission .Note signed by LVN Q. 3/14/16 7:10 pm-out per ambulance to behavioral hospital. Note signed by LVN D. Record review of a Resident Data Set (facility ' s admission assessment) dated 3/30/16 at 3:45 p.m. indicated Resident #9 was discharged from the behavioral hospital and readmitted to the facility. Documentation on the Data Set indicated Resident #9 was alert, lethargic with slow movement, lack of energy, and poor appetite, recent weight loss, inability to feed self, increased confusion, tremors present, weakness present, dependent on staff for provision of fluid intake and dementia. His skin condition was documented to be warm, dry, pale, bruises/ecchymosis, and poor turgor. Signed by LVN R. Record review of Skilled Nursing PPS Notes from 3/31/16 to 4/3/16 revealed: 3/31/16 No time documented-sitting in day room with eyes closed. Note signed by LVN R. 11:00 p.m. Resident propel in wheelchair by staff. Extensive assist with all ADLs Note signed by LVN T. 4/1/16 No time documented-Ate breakfast 75%. Spoon fed per staff .Needs must be anticipated and met by staff. Has been very subdued and quite .Note signed by LVN R. 11:30 p.m. Resident resting quietly, eyes closed .Note signed by LVN T. 4/3/16 4:30 a.m. Resident awake and restless entire night-stripping off clothing, urinating on floor and resistive to care. There was no documentation indicating attempts to redirect or to assess Resident #9 ' s needs. The above nurse ' s note was the last note documented until 4/19/16. Record review of the Discharge Medication Reconciliation Order and Continuing Care Plan from the behavioral hospital dated 3/30/16 indicated, Resident #9 returned to the facility with orders for [MEDICATION NAME] 5 mg p.o hs for agitation, and [MEDICATION NAME] 25 mg po hs for anxiety. Record review of Resident #9 ' s MAR from 3/30/16-3/31/16 upon return from the behavioral hospital and his April MAR indicated [REDACTED]. Record review of Nurse ' s Notes from 3/30/16 to 4/3/16 (the last entry until 4/19/16) and Physician telephone orders, revealed no documentation related to obtaining a clarification for the dosage/frequency in which [MEDICATION NAME] was to be administered. In an interview on 4/12/16 at 11:30 a.m. the DON said to ensure the accuracy of residents ' readmission orders [REDACTED]. The DON said if there is a conflict or question in the changes to medications on readmission, the nurse is to contact the physician for clarification. In an interview on 4/21/16 at 8:10 a.m. the ADON said when Resident #9 left for the behavioral hospital, he was not deleted out of the system and when he came back the admitting nurse did not re-enter the orders but picked back up the previous orders so the change in [MEDICATION NAME] was not caught. The ADON said she verified all the other orders and that they are correct. During an observation on 4/21/16 at 8:20 a.m. LVN G pulled up the history of orders for Resident #9 which revealed RN D had entered the new order for [MEDICATION NAME] 5 mg at bedtime effective 3/30/16 but the [MEDICATION NAME] order of 25 mg two times per day remained unchanged with a start date of 3/9/16. In an interview on 4/21/16 at 8:25 a.m. the Administrator said RN D had resigned from the company. Observation on 4/6/16 at 3:50 p.m. revealed Resident #9 sitting in a wheelchair in the day room with his eyes closed. He did not respond when spoken to. His clothes were loose-fitting. In an interview on 4/6/16 at 3:55 p.m. CNA M said today was the first time with Resident #9 since he came back from the behavioral hospital. CNA M said Resident #9 had refused care in the past but that he has had no concerns today. Observation on 4/7/16 at 2:45 p.m. revealed Resident #9 sitting in a wheelchair in the day room with his eyes closed and hands in his lap. He did not respond when spoken to. In an interview on 4/7/16 at 3:40 p.m. LVN M said Resident #9 would probably talk to this surveyor. She said he likes to sit with his eyes shut. LVN M said Resident #9 will cooperate with medications. She said she has only been at the facility for six days, so could give no other information. Observation on 4/7/16 at 3:42 p.m. revealed Resident #9 in a wheelchair in the day room. His eyes were closed. His eyes briefly flickered open when this surveyor called his name, but he quickly closed them. He did not respond further after multiple attempts to get his attention. In an interview on 4/7/16 at 4:10 p.m. Resident #9 ' s son said he is concerned about his somnolence and was wondering if the [MEDICATION NAME] was too strong. The son said his sister told him that the last several times she ' s been to visit their dad he ' s been this way. He said he was not informed about the increased risks and side-effects for the use of antipsychotics in individuals with dementia and no prior mental illness. The son said when they started the [MEDICATION NAME] he went crazy on that and that he wasn ' t falling at the current rate before [MEDICATION NAME] was initiated . The son said Resident #9 had fallen a couple of times while still at home. He said Resident #9 was a little hard to deal with, but became more combative on [MEDICATION NAME]. The son said the therapist at the behavioral hospital said to keep him on the current medications or he will go back to where he was. Observation on 4/8/16 at 3:40 p.m. revealed Resident #9 sitting in a wheelchair in the day room with eyes closed. In an interview on 4/8/16 at 4:25 p.m. Resident #9 ' s daughter said when he was admitted to the facility on [DATE] Resident #9 walked into the building. She said after 2-3 days in the facility he has not walked again . The daughter said he is always out of it-asleep . She said the family visits and tries to wake him up but he doesn ' t wake up for long. She said Resident #9 ' s sister visited and couldn ' t wake him up. The daughter said this morning at 9:00 he was awake in his wheelchair, but went back to sleep in 20 minutes. The daughter said the medicines meant to calm him down make him hallucinate and she feels like a lot of the problem is the medications. She said the Social Worker is supposed to set up an appointment with the new Medical Director and she wants him to review the medications. Observation on 4/11/16 at 11:55 a.m. revealed Resident #9 sitting in a wheelchair in the dining area with his eyes closed and his hands in his lap. In an interview on 4/11/16 at 11:55 a.m. CNA L said Resident #9 has been pretty much like that all day . In an interview on 4/11/16 at 1:05 PM, Corporate RN A stated that agitation and anxiety are not appropriate diagnoses by themselves for the use of antipsychotics for a resident with a [DIAGNOSES REDACTED]. She stated that staff should track all behaviors and interventions and document them. She stated that other interventions need to be attempted and documented before giving a resident an antipsychotic. Observation on 4/11/16 at 2:10 p.m. revealed CNA L propelling Resident #9 ' s wheelchair to a desk in the day area to sit beside her while she was charting. Resident #9 was observed trying to stand up from the wheelchair and weakly took hold of CNA L ' s arm. She called him by name and said sit back down. She pulled a magazine out of a drawer and handed it to him asking him if he would like to look at it. Resident #9 calmed down. In an interview on 4/11/16 at 2:12 p.m. CNA L said she had worked with Resident #9 ever since he ' s been here . She said when Resident #9 is awake he ' s fine if redirected. She said if he has his mind on one thing, it can be hard to redirect, but that she has had no problems with his behavior during incontinent care. CNA L said today Resident #9 has only had about 15 minutes of being awake and trying to stand up. A Behavior Monitoring Record for March was requested on 4/11/16; facility did not provide. Record review of the April Behavior Monitoring Record located on Resident #9 ' s MAR indicated [REDACTED]. Three episodes of anxiety due to dementia were documented on 4/8/16, with intervention of assess discomfort/need/respond, and the outcome was documented improved. In an interview on 4/11/16 at 12:00 p.m. LVN E said the CNAs do not document the residents ' behaviors. She said the CNAs report behaviors to the nurses and the nurses document the behaviors on the behavior monitoring record located on the resident ' s MAR. LVN E looked through the MAR for April and said Resident #9 doesn ' t have the new version that was effective April 2016 for some reason. She said the old versions are in the book and some staff fill them out but not everyone is filling them out consistently so they aren ' t complete/accurate. She said the facility started a new form on April 1st and Resident #9 is supposed to have the new ones on his MAR. In an interview on 4/11/16 at 2:15 p.m. Corporate RN D said the behavior tracking records wouldn ' t be on the MAR, but did not say where they should be located. Observation on 4/12/16 at 11:40 revealed Resident #9 sitting in the day area with his eyes closed. He opened his eyes and briefly responded when spoken to, then closed his eyes again. During an interview on 4/12/16 at 11:55 AM Corporate RN A stated that she could not find any documented ADL/Behavior sheets for the Month of April 2016 for Resident #9. In an interview on 4/7/16 at 4:10 p.m. Resident #9 ' s son said Resident #9 had lost a lot of weight since his admission to the facility. In an interview on 4/8/16 at 4:25 p.m. Resident #9 ' s daughter said Resident #9 has lost 2 clothes sizes. Record review of Resident #9 ' s weight on the facility ' s Point/Click/Care (PCC) computer system revealed Resident #9 had been weighed one time, 3/10/16 at 2:10 p.m., since his admission on 2/29/16. His height was recorded as 68 with a weight of 174.5 pounds. During an interview on 4/12/16 at 11:30 AM the DON stated that they only had 1 weight on record for Resident #9 obtained on 3/10/16. She said that he was weighed on 4/11/16 and his current weight was 155.6 pounds. The DON said that when a resident was admitted , the facility normally weighed the resident weekly for 4 weeks and then monthly for a few months or until the physician specified differently. During observation on 4/20/16 at 4:35 RNA weighed Resident #9. His new weight was 150 pounds. In an interview on 4/11/16 at 2:10 p.m. CNA L said Resident #9 ate only 3 or 4 bites at lunch. In an interview on 4/12/16 at 11:25 a.m. CNA L said Resident #9 had lost a lot of weight-he had not been eating much. CNA L said staff has been spoon-feeding him and he gets health shakes. CNA L said Resident #9 fed himself at breakfast this morning and he at 100%. She said she would try seeing how he did at lunch feeding himself, and maybe he would eat more that way. A baseline Abnormal Involuntary Movement Scale (AIMS) for individuals receiving [MEDICAL CONDITION] medications was requested but not provided. Facility provided a Pressure Ulcer Risk Assessment. Record review of Resident #9 ' s care plan with target date of 6/14/16 revealed the following: Interventions for risk of complications related to the use of [MEDICAL CONDITION] drugs: AIMS testing per protocol; complete behavior monitoring flow sheet; gradual dose reduction as ordered; monitor for changes in mental status and functional level and report to MD as indicated; monitor for continued need of medication as related to behavior and mood; monitor for side effects and consult physician and/or pharmacist as needed; provide informed consent to the healthcare decision maker. Interventions for risk for elopement related to dementia, cognitive loss. He is ambulatory and wanders : .encourage participation in positive meaningful activity programs of choice; engage resident in active conversation as a form of redirection; if unable to redirect resident, stay with resident and provide support and supervision until able to redirect . Interventions related to physical aggression as evidenced by kicking at staff; hitting and punching staff, rolling self off of bed to floor and resisting assist up off floor: approach resident in a calm friendly manor (manner); assess and manage unmet needs such as pain, toileting, fatigue and hunger; divert resident by giving alternative objects or activity; document interventions and resident ' s response .if first refused care and/or medication, re-approach (Resident #9) at a later time, allowing him to calm down; inpatient psychiatric hospital; maintain safe environment; (Resident #9) likes to place self on floor and sit on floor at times .frequently reaches out for objects; psychiatric consult. Record review of the facility ' s Psychotherapeutic Medication Use policy and procedure dated 5/4/15 revealed: Policy: The Center identifies underlying factors (e.g., environmental and psychosocial stressors, treatable medical conditions, etc.) that may contribute to changes in the patient ' s behavior. Whenever possible and clinically appropriate, Center staff will recommend non-drug approaches such as behavioral interventions, environmental modifications, or alternative approaches to care to assist in the treatment or modification of the patient ' s behavior. If drug therapy with a psychotherapeutic drug is indicated, the physician/mid-level provider, Center staff, and consultant pharmacist work together in selecting the most effective drug with the fewest potential side effects, lowest risk of adverse drug reactions, and in the lowest effective dose for that patient. Staff will comply with the Psychopharmacologic Dosage Guidelines created by the Centers for Medicare and Medicaid Services (CMS) and all federal and state applicable law relating to the use of psychotherapeutic medications. Purpose: To ensure patients are prescribed psychotherapeutic drugs for appropriate indications, dosages, length of treatment, and duration; to encourage the use of non-pharmacologic interventions and minimize the use of psychotherapeutic medications, including antipsychotics, for patients with challenging behaviors; to support the involvement of patients and family members in discussions associated with the use of psychotherapeutic medications at this Center. Process: When a physician/mid-level provider orders a psychotherapeutic medication for a patient, he/she: 1.1 Conducts a comprehensive assessment of the patient, and 1.2 Documents in the clinical record that the psychotherapeutic medication is necessary to treat a specific condition as described in the State Operations Manual. If a physician/mid-level provider orders a psychotherapeutic medication in the absence of a [DIAGNOSES REDACTED]. Center staff and/or physician/mid-level provider informs the resident and/or the resident representative of the initiation, reason for prescribing and risks associated with the use of psychotherapeutic medication . Center staff monitor the patient ' s behavior using a behavioral monitoring for(m) per nursin

Based on observation, interviews, and record review the facility failed to ensure 1 of 5 residents (Resident #9) reviewed for accuracy of antipsychotic medication administration was free of significant medication errors as evidenced by: Facility failed to accurately transcribe a change in Resident #9 ' s dosage/frequency of [MEDICATION NAME] upon his return from a behavioral hospital. Resident #9 received 50 mg daily of [MEDICATION NAME] instead of the ordered 25 mg daily from 3/31/16 through 4/19/16 which resulted in increased somnolence, decreased dietary intake and weight loss. This failure affected Resident #9 and could affect 42 residents receiving antipsychotics by increasing their risk for [MEDICAL CONDITION], sleepiness, drowsiness, difficulty swallowing, weakness, dizziness, new or worsened agitation or aggression, tardive dyskinesia (involuntary movements) and stroke that could lead to death. Findings Included: Record review of an Admission Record dated 4/7/16 (print date), revealed Resident #9 was an [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of a Level 1 Preadmission Assessment and Resident Review (PASRR) dated 2/26/16 completed by the facility ' s Admission Director revealed no evidence or indication of mental illness. Record review of Resident #9 ' s Admission MDS (Medical Data Set) dated 3/9/15 revealed he required extensive assistance with his ADLs (Activities of Daily Living). His BIMS (Brief Interview for Mental Status) score was 1 indicating his cognitive function was severely impaired. Behavior symptoms were listed as physical behavior symptoms directed toward others occurring 4-6 days, verbal behavioral symptoms directed toward others occurring 4-6 days and other behavioral symptoms not directed toward others occurring daily. The MDS revealed no [DIAGNOSES REDACTED]. Documentation on the MDS indicated Resident #9 had been administered an antipsychotic three days in the seven day lookback period indicating the medication was started on our about 3/6/16 or 3/7/16. Record review of Resident #9 ' s care plan with target date of 6/14/16 revealed the following: Focus: Resident #9 was at risk for complications related to the use of [MEDICAL CONDITION] drugs. Goal: Resident #9 will have the smallest most effective dose without side effects x 90 days. Interventions: AIMS testing per protocol; complete behavior monitoring flow sheet; gradual dose reduction as ordered; monitor for changes in mental status and functional level and report to MD as indicated; monitor for continued need of medication as related to behavior and mood; monitor for side effects and consult physician and/or pharmacist as needed; provide informed consent to the healthcare decision maker. Record review of a Skilled Nursing PPS Note dated 3/14/16 at 7:10 p.m. revealed: out per ambulance to behavioral hospital. Note signed by LVN D. Record review of a Resident Data Set (facility ' s admission assessment) dated 3/30/16 at 3:45 p.m. indicated Resident #9 was discharged from the behavioral hospital and readmitted to the facility. Documentation on the Data Set indicated Resident #9 was alert, lethargic with slow movement, lack of energy, and poor appetite, recent weight loss, inability to feed self, increased confusion, tremors present, weakness present, dependent on staff for provision of fluid intake and dementia. His skin condition was documented to be warm, dry, pale, bruises/ecchymosis, and poor turgor. Signed by LVN R. Record review of the Discharge Medication Reconciliation Order and Continuing Care Plan from the behavioral hospital dated 3/30/16 indicated, Resident #9 returned to the facility with orders including [MEDICATION NAME] 25 mg po hs (by mouth at bedtime) for anxiety. Record review of Resident #9 ' s MAR from 3/30/16-3/31/16 upon return from the behavioral hospital and his April MAR dated 4/1/16-4/30/16 revealed, with the exception of the 9:00 a.m. dose on 4/8/16, he had received [MEDICATION NAME] 25 mg by mouth two times per day for anxiety related to unspecified dementia without behavioral disturbance through 4/19/16. The initials in the box beside the 4/8/16 morning dose were circled. Each of the other boxes during this timeframe was initialed beside the 9:00 a.m. and 9:00 p.m. entry for the [MEDICATION NAME]. In an interview on 4/20/16 at 4:00 p.m., LVN E said that the nurses mark their initials in the box under the date and time for a medication dose on the MAR. She said that the initials in the box meant that the dose had been administered. She said that if the box did not have initials or if the box had initials that had been circled, it meant that the dose was either held or not given. LVN E said that she had given Resident #9 ' s scheduled dose of [MEDICATION NAME] 25 mg this morning. She said that he had another dose scheduled for 9:00 PM for the night nurse to administer. Record review of Nurse ' s Notes from 3/30/16 to 4/3/16 (the last entry until 4/19/16) and Physician telephone orders, revealed no documentation related to obtaining a clarification for the frequency in which [MEDICATION NAME] was to be administered. Record review of Licensed Nurses Progress Notes dated 4/20/16 revealed: 4:30 p.m. Medical Director notified via voicemail of transcription error of [MEDICATION NAME] dosing. No orders given. Note signed by ADON. 7:00 p.m. Medical Director returned call. Verified with MD [MEDICATION NAME] order. Order received to d/c (discontinue) current [MEDICATION NAME] order and change to [MEDICATION NAME] 25 mg every evening to start 4/21/16 at bedtime. Dose to be held on 4/20/16 at hs (bedtime). In an interview on 4/12/16 at 11:30 a.m. the DON said to ensure the accuracy of residents ' readmission orders [REDACTED]. The DON said if there is a conflict or question in the changes to medications on readmission, the nurse is to contact the physician for clarification. In an interview on 4/20/16 at 4:25 PM, RN E said after having reviewed Resident #9 ' s MAR and physician orders, there was a transcription error and that the resident should have only been given [MEDICATION NAME] 25 mg daily at 9:00 p.m. according to the discharge medication form from the behavioral hospital. She said that this was a medication error. In an interview on 4/21/16 at 8:10 a.m. the ADON said when Resident #9 left for the behavioral hospital, he was not deleted out of the computer system and when he came back the admitting nurse did not re-enter the orders but picked back up the previous orders so the change in [MEDICATION NAME] was not caught. The ADON said she verified all the other orders and they were correct. During an observation on 4/21/16 at 8:20 a.m. LVN G pulled up the history of orders for Resident #9 which revealed RN D had entered the new order for [MEDICATION NAME] 5 mg at bedtime effective 3/30/16 but the [MEDICATION NAME] order of 25 mg two times per day remained unchanged with a start date of 3/9/16. In an interview on 4/21/16 at 8:25 a.m. the Administrator said RN D had resigned from the company. The following surveyor observations of Resident #9 from 4/6/16-4/20/16 revealed: Observation on 4/6/16 at 3:50 p.m. revealed Resident #9 sitting in a wheelchair in the day room with his eyes closed. He did not respond when spoken to. His clothes were loose-fitting. Observation on 4/7/16 at 2:45 p.m. revealed Resident #9 sitting in a wheelchair in the day room with his eyes closed and hands in his lap. He did not respond when spoken to. Observation on 4/7/16 at 3:42 p.m. revealed Resident #9 in a wheelchair in the day room. His eyes were closed. His eyes briefly flickered open when this surveyor called his name, but he quickly closed them. He did not respond further after multiple attempts to get his attention. In an interview on 4/7/16 at 4:10 p.m. Resident #9 ' s son said he is concerned about his somnolence and was wondering if the [MEDICATION NAME] was too strong. The son said his sister told him that the last several times she ' s been to visit their dad he ' s been sleeping. He said he was not informed about the increased risks and side-effects for the use of antipsychotics in individuals with dementia and no prior mental illness. The son said Resident #9 wasn ' t falling at the current rate before [MEDICATION NAME] was initiated . The son said Resident #9 had fallen a couple of times while still at home. The son said the therapist at the behavioral hospital said to keep him on the current medications or he will go back to where he was. The son said Resident #9 had lost a lot of weight since his admission to the facility. Observation on 4/8/16 at 3:40 p.m. revealed Resident #9 sitting in a wheelchair in the day room with eyes closed. In an interview on 4/8/16 at 4:25 p.m. Resident #9 ' s daughter said when he was admitted to the facility on [DATE] Resident #9 walked into the building. She said after 2-3 days in the facility he has not walked again . The daughter said he is always out of it-asleep . She said the family visits and tries to wake him up but he doesn ' t wake up for long. She said Resident #9 ' s sister visited and couldn ' t wake him up. The daughter said this morning at 9:00 he was awake in his wheelchair, but went back to sleep in 20 minutes. The daughter said the medicines meant to calm him down make him hallucinate and she feels like a lot of the problem is the medications. She said the Social Worker is supposed to set up an appointment with the new Medical Director and she wants him to review the medications. Resident #9 ' s daughter said Resident #9 has lost 2 clothes sizes. Observation on 4/11/16 at 11:55 a.m. revealed Resident #9 sitting in a wheelchair in the dining area with his eyes closed and his hands in his lap. In an interview on 4/11/16 at 11:55 a.m. CNA L said Resident #9 had been pretty much like that all day . In an interview on 4/11/16 at 2:12 p.m. CNA L said today Resident #9 had only had about 15 minutes of being awake and trying to stand up. Observation on 4/12/16 at 11:40 revealed Resident #9 sitting in the day area with his eyes closed. He opened his eyes and briefly responded when spoken to, then closed his eyes again. In an interview on 4/11/16 at 2:10 p.m. CNA L said Resident #9 ate only 3 or 4 bites at lunch. In an interview on 4/12/16 at 11:25 a.m. CNA L said Resident #9 had lost a lot of weight-he had not been eating much. CNA L said staff has been spoon-feeding him and he gets health shakes. Record review of Resident #9 ' s weight on the facility ' s Point/Click/Care (PCC) computer system revealed Resident #9 had not been weighed on admission on 2/29/16 and had been weighed one time, 3/10/16 at 2:10 p.m. His height was recorded as 68 with a weight of 174.5 pounds. There was no documentation to indicate Resident #9 was weighed prior to his transfer to the behavioral hospital on [DATE] or was weighed upon his readmission to the facility on [DATE]. In an interview on 4/12/16 at 11:30 a.m. The DON said when a resident was admitted , the facility normally weighed the resident weekly for four weeks and then monthly for a few months or until the physician specified differently. The DON said Resident #9 had just been weighed again on the afternoon of 4/11/16 and his weight was 155.6 pounds. During an observation on 4/20/16 at 4:20 p.m. the RNA weighed Resident #9 and reported his weight was now 150 pounds which indicated he had lost an additional 5.6 pounds in 9 days indicating a total weight loss of 24.5 pounds from 3/10/16 to 4/20/16. Record review of the facility provided ADL record for March revealed Resident #9 ' s dinner meal intake on 3/30/16 upon return from the behavioral hospital was 100%. Documentation on 3/31/16 indicated he ate 25% of his breakfast and lunch. There was no documentation of percentage eaten at dinner. There was no documentation on the record that indicated Resident #9 was refusing meals. Record review of an undated ADL record on 4/20/16 for Resident #9 revealed documentation had begun on day 11. Days 1-10 were blank. The record revealed out of 29 meals from 4/11/16-through lunch on 4/20/16 Resident #9 was documented to have consumed: 100% of 0 meals; 75% of 4 meals; 50% of 10 meals; and 25% of 12 meals. Intake was not documented for three meals during this timeframe. In an interview on 4/20/16 at 4:47 p.m. CNA V said she believed the ADL records were for April 2016 for Resident #9 and when they were printed the date did not print on the top. She went through the records for the other residents residing on that unit and revealed they were all dated 4/1/16-4/30/16. Record review of the facility ' s Medication Administration: General policy and procedure dated 3/15/16 revealed: Policy: .Accepted standards of practice will be followed. Medication will not be borrowed from another patient. Purpose: To provide a safe, effective medication administration process. Practice Standards 4. If discrepancies, including medication not available, notify physician/mid-level provider and/or pharmacy as indicated . 7. Monitor patient for adverse reactions and effectiveness of medication. 7.1 Notify physician/mid-level provider for adverse reactions or lack of response to medication. 8. Document: 8.1 Administration of medication on Medication Administration Record (MAR); 8.2 Patient ' s response to medication; 8.2.1 Notification of physician/mid-level provider, if applicable . Review [MEDICATION NAME] related to side effects and warnings from the Food and Drug Administration website accessed on 4/12/16 at <http://www.fda.gov/downloads/drugs/drugsafety/ucm 6.pdf> revealed the following: ¿ Medication Guide [MEDICATION NAME] (SER-oh-[MEDICATION NAME]) (quetiapine [MEDICATION NAME]) ¿ [MEDICATION NAME] may cause serious side effects, including: 1. risk of death in the elderly with dementia. Medicines like [MEDICATION NAME] can increase the risk of death in elderly people who have memory loss (dementia). [MEDICATION NAME] is not for treating [MEDICAL CONDITION] in the elderly with dementia. [MEDICATION NAME] can cause serious side effects, including: [MEDICAL CONDITION], sleepiness, drowsiness, difficulty swallowing, weakness, dizziness, new or worsened agitation or aggression, tardive dyskinesia (involuntary movements) and stroke that can lead to death. Per documentation provided by the facility Administrator on 4/12/16, 42 residents were receiving antipsychotic medications.

Based on observation, interview and record review the facility failed to ensure 3 of 8 residents (Resident #1, #2, and #9) reviewed for elopement risk received adequate supervision to prevent elopement. Resident #1, a risk for elopement, exited the facility from the secure unit, on 12/16/15. A bystander called 911 when Resident #1 was found on the ground a block away from the facility. Resident #1 had fallen and fractured her hip. Resident #2, a risk for elopement, exited the facility on 1/10/16 between 1:15 a.m. and 2:00 a.m. Staff found Resident #2 after 3:00 a.m., approximately one mile from the facility, having fallen. Resident #2 was hospitalized due to his injuries which consisted of abrasions, contusions and a left dislocated shoulder. Resident #9, a risk for elopement, exited the facility from the secured unit on 1/19/16. Resident #9 while wearing a wander guard bracelet, exited the secure unit, and exited the 24-hour monitored front door. Resident #9 was found 75 to 100 yards from the front door by a staff member. An Immediate Jeopardy (IJ) was identified on 01/08/16. While the IJ was removed on 1/15/16, the facility remained out of compliance at a level of actual harm and a scope of pattern, due to the facility monitoring the implementation of the Plan of Removal. This failure placed 38 residents on the 3 secure units at risk of leaving the facility without staff being aware, placing the residents at risk of serious injury or death. Findings included: Resident #1 Record review of the Admission face sheet undated revealed an admitted [DATE]. Resident #1 was an [AGE] year-old female with [DIAGNOSES REDACTED]. Record review of the Social Worker review dated 7/29/15 revealed that Resident #1 had poor decision making skills and was oriented to person. The section addressing Wandering behavior was left unanswered (blank). Record review of nurses ' progress note for Resident #1 dated 9/2/15 at 3:00 a.m. revealed the following: Resident awoke, wandering around Hall 6, escorted to room .3:30 a.m. resident pushed enter button and entered secure unit. Resident escorted to her room in Hall 6. Record review of nurses ' progress note dated 9/2/15 at 11:30 a.m. resident had wander guard in her pocket, replaced on wrist Record review of the physician orders [REDACTED]. Record review of the MDS dated [DATE] identified Resident #1 with a BIMS (Brief Interview for Mental Status) score of 3, indicating moderate (Severe (0-7) Moderate (8-12) Intact (13-15)) cognitive impairment, was ambulatory, and required supervision. Resident #1 was not identified as a wander risk on this document. Record review of the Care plans dated 12/2/15 for Resident #1 did not address wandering, elopement risk or falls. Record review of local EMS run sheet dated 12/16/15 at 7:09 p.m. revealed the following: Chief complaint; right hip pain secondary to fall. History: Resident found sitting on the ground . Alert, confused. Repeats self often. Skin normal color, cool and dry .Right hip pain, increased with movement, no obvious deformity, but severe pain on palpation . In an interview on 12/23/15 at 3:30 p.m. CNA A said that on 12/16/15 Resident #1 was upset and wanting to leave to go home. CNA A stated that she took Resident #1 to the patio to walk and calm down. CNA A said that she checked the back gate it was secured, shut and locked. CNA A walked around the back patio with Resident #1. CNA A reported that she told Resident #1 that it was too cold and dark to be outside, to come inside where it was warm and they entered the facility. CNA A said that Resident #1 said she was going to use the restroom and went down the hallway. CNA A went to assist another resident and that at the same time a restroom was flooded. CNA A said that the last time she saw Resident #1 was approximately 7 p.m. In an interview on 12/23/15 at 4:10 p.m. CNA C said that she was assigned to the secure unit on 12/16/15 when Resident #1 eloped. CNA C said that Resident # 1 had been upset and wanted to leave the unit to go home . CNA A had informed the ADON A. ADON A came and checked the resident, and after he left the unit Resident #1 said she was heading to bed. At the same time another resident was entering others rooms, CNA A went to help that resident & I (CNA C) was watching the residents in the dining room. Another aide (CNA B) entered the unit with a resident to visit on the unit. CNA C said that about 20 minutes later a bathroom flood. CNA C said she went to assist with the flooding and CNA A was watching in the dining room and talking to CNA B. CNA C said she left the unit to get towels and a plunger to clean the flood. CNA C said that no one (resident) was around when she left the unit; she said she was gone about a minute. After fixing the toilet, and cleaning up the mess, CNA A left the unit to get some air freshener and was gone about 5 minutes. About 10 minutes after CNA A returned, CNA B and the other visiting resident exited the unit. About 5 minutes later the ADON A came into the unit and asked about Resident #1 and informed us that she (Resident #1) was at the hospital. In an interview on 1/8/16 at 1:21 p.m. ADON A said that a nurse had called in so ADON A was on call and took over the spot (Hall 3). CNA A came to him and said that Resident #1 was having issues. ADON A said he went on the secure unit to assess Resident # 1 and found her upset and wanting to go home. ADON A said that he was concerned and told CNA A and CNA B both, do not let Resident #1 out of your site, I will come back and check on her. ADON A said that was around 7:00 p.m. or maybe a little before. No one was at the nurse ' s station and that the two nurses (ADON A and an LVN) were giving medications at that time. At around 7:35 p.m. he heard a page for a phone call, it was a local hospital telling me that they had Resident #1 in the emergency room . Resident #1 had been found approximately a block away at the intersection of 14th and Clinton and that Emergency Medical Services (EMS) had picked her up. ADON A said that she was alright but had fallen and had a broken hip. ADON A said that he then called and notified the family, Administrator, Director of Nurses and physician. ADON A said that he then went to the secure unit and found the two CNAs and asked where Resident #1 was? The CNA ' s both responded that Resident #1 was in her room. ADON A said that he told the CNAs that the resident was at a local hospital emergency room . The ADON A said that he educated the CNAs that if they were told to keep a resident in line of site, it meant line of site, Not think you know where someone is. When questioned about exit seeking behaviors the ADON A reported that Resident #1 did not have a history of exit seeking and that she did not have a wander guard bracelet on at the time of the incident. When asked how Resident #1 was able to get out of the secure unit and out of the building, ADON A said I do not know . When asked if there was anything else he could have done differently, the ADON A said that he could have added additional staff and put Resident #1 on one-to-one monitoring. Record review of the incident report dated 12/16/15 revealed that at approximately 7:35 p.m. Facility received a phone call from a local hospital to report Resident #1 was at the hospital, found by bystander 1 block away from the facility at 14th and Clinton. Condition prior to incident: Alert but confused, resident on Transitions secure unit, ambulates independently. Review of the facility Incident/Accident report dated 12/16/15 and completed by the Administrator revealed the following; Staff reported Resident #1 missing from secure unit after being notified by local hospital emergency room that missing resident was in their emergency room . Resident #1 was last seen by staff at approximately 7 p.m. Director of Nursing and Administrator conducted a complete visualization of all residents in the facility verifying that there were no other missing residents. DON, ADM, Director of Maintenance checked all secure unit doors, gates windows and wander guard alarmed doors were in working order and functioning properly. DON conducted an in-service of all staff regarding elopement procedures and visualization of residents. Resident #1 ' s responsible party and doctor were notified. Review of the facility Incident/Accident report dated 12/16/15: Result of investigation; Resident #1 suffered a fractured right hip as a result of elopement. Resident #1 has a history of wandering the building and staff did not notice her missing. Additional interventions and actions to prevent/minimize potential reoccurrence listed on the Incident/Accident Report dated 12/16/15 and completed by ADM revealed the following: 1. Wanderguards were ordered and will be placed on secure unit residents at risk for elopement as identified by the interdisciplinary team. 2. Until wanderguards are placed, a staff member has been assigned to the Unit 2 Nursing station to watch all secure unit doors to ensure no secure unit resident exits from the unit without staff supervision. 3. Key pads have had their codes changed and code guards have been ordered for all keypads to ensure that no residents can inadvertently view/learn the door codes. Resident #2 Record review of face sheet dated 04/27/15 revealed that Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with a readmitted [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #2 elopement risk assessment dated [DATE] revealed that resident's mobility status was ambulatory with a cane. His cognition was alert, behavior was that resident is oriented, able to make decisions, and verbalizes and demonstrates acceptance of placement. It revealed the resident exhibits routine or sporadic confusion, anxiety, or disorientation. It revealed the resident expresses anger or is resistant related to placement, sample of wanting to go home or to work or somewhere else. It revealed that the resident had wanted to leave the facility to socialize or a history of going out to socialize. Under the resident's risk potential for elopement; it is checked not at risk, indicating the resident is not at risk. In the additional comment, it states the resident is not at risk for elopement, signed by DON B on 11/16/15. Question #2, 5, 6 and 10 were checked yes. The directions state that if yes on items 1 or 2, 3 to 5, in combination with any items 6 to 11, that resident should be marked at risk. It states that if it is yes on any one item 6 to 11, resident is at risk, however the elopement risk assessment additional comments stated: Resident is not a risk for elopement. Resident #2 should have been identified as at risk for elopement based on the facility's tool. Record review of Resident 2's care plans dated 12/12/15 revealed that Resident #2 was at risk for falls and impaired mobility requiring the use of a cane for balance with a [DIAGNOSES REDACTED]. The risk for elopement and resident signing himself in and out to go to the store was not care planned. Record review of Resident 2's social service note dated 12/31/15 revealed the resident came into the social worker's office and wanted the door closed and locked due to people being after him. Social Worker A and MDS coordinator attempted to calm the resident down. He continued to say that there was a hit on him and he was going to die. He explained he could not stay at the facility tonight because someone was going to kill him. The resident was very unsteady on his feet and allowed staff to retrieve his wheelchair. The resident stated that he needed $50 so that he could leave for the night. The Social Worker A discussed discharge planning, not leaving AMA versus with the doctor's order and the potential of consequence. The resident became angry stating you do not understand. Someone will kill me tonight. Social Worker A attempted to calm the resident down and provide support, unsuccessfully. The primary care physician was notified due to increase in delusions and gave okay to look at a behavioral hospital. Record review of Resident #2 ' s quarterly Minimum (MDS) data set [DATE] revealed, in Section C for cognitive patterns, a BIMS score (Brief Interview for Mental Status) of 12, indicating moderate cognitive impairment. It revealed acute onset mental status change. In Section E, titled Behaviors, it revealed that resident had hallucinations and delusions, which were potential indicators of psychosis. In Section G, Functional Status, it revealed that the resident was not steady with moving from seated to standing position, walking, turning around, moving on and off the toilet, and surface-to-surface transfer, but able to stabilize without staff assistance. It revealed that the resident had functional limitation in range of motion on both sides, upper and lower extremities. It revealed that the resident uses a cane, walker, and wheelchair for mobility devices. In Section J, it revealed that the resident had pain almost constantly and receives p.r.n. pain medication. In Section J, Health Conditions, it revealed the resident had shortness of breath or trouble breathing with exertion such as walking, bathing, and transferring; shortness of breath or trouble breathing, when lying flat. In Section J, Fall History, it revealed that the resident has had one fall since previous MDS assessment with two or more injuries which including skin tears, abrasions, lacerations, bruises, hematomas, and fall-related injuries that caused the resident to complain of pain. Record review of Resident 2's social service review dated 01/03/16, for review reason of quarterly review, revealed that Resident 2's cognition is moderately impaired, that Resident 2 exhibits disorganized thinking. The resident demonstrates disorganized thinking at times. He has poor safety awareness. Staff to assist and redirect as needed. Signed by Social Worker A. Record review of Resident #2 physician orders, with a date range of 01/01/2016 through 01/31/16, revealed an order for [REDACTED]. It revealed an order for [REDACTED]. It revealed an order for [REDACTED].#3 tablet 300/30 mg; give two tablets by mouth every four hours as needed for pain, with a start date of 08/18/15. Record review of Resident #2 Medication Administration Record for 01/01/16 through 01/31/16 revealed that on 01/09/16 at 8:00 p.m. Resident #2 was administered two tablets of Tylenol with codeine #3 for the reason of pain. It revealed that Resident #2 received Ambien 5 mg one tablet on 01/09/16 for complaints of insomnia. Further record review revealed that Resident #2 did not have any prior administrations of Ambien 5 mg for the month of January 2016. It revealed that the resident received two as-needed doses at bedtime for the month of December 2015. Record review of Resident #2 p.r.n. medication flow sheet, under Section Nurse's Noted, undated, revealed that on 01/09/16, at 8:00 p.m., Resident #2 was administered two tablets of Tylenol #3 for complaints of shoulder pain with a reassessment at 9:00 p.m. by LVN B documenting effective pain relief. It revealed that at 8:00 p.m. Resident #2 was given Ambien 5 mg for complaints of insomnia by LVN B and was documented as not effective at 10:00 p.m. Record review of nursing notes for Resident #2 on 01/10/16, at 1:15 a.m., revealed observed resident standing at nurses' station simply looking around and did not complain of anything or request or verbalize any need. Signed by LVN B. On 01/10/16, at 2:00 a.m., it revealed resident not seen since 1:15 a.m. Search of building began. Signed by LVN B. On 01/10/16, at 2:30 a.m., not found at station 1, code yellow announced, search began at station 2 and outside building. Search of neighborhood began staff in their vehicles. Signed by LVN B. On 01/10/16, at 3:15 a.m., messages left on the voice mails of the administrator, the DON, and the ADON phones. Signed by LVN B . According to wunderground.com, on 1/10/16 the temperature in Abilene between 12:52 a.m. and 2:52 a.m. was 27 degrees Fahrenheit (F), with a wind-chill of 19.5 - 23 degrees F. <http://www.wunderground.com/history/airport/KABI/2016/1/10/DailyHistory.html?req_city=Abilene&req_state=TX&req_statename=&reqdb.zip= &reqdb.magic=1&reqdb.wmo= > (accessed on 2/6/16) Nurse ' s note dated 01/10/16, at 3:20 a.m., received call from CNA D found resident at North Second and Grape Street. Found him lying in the grass near the curb. The resident told CNA D he had been hit by a car. Reported to 9-1-1. Signed by LVN B. Nurse ' s note dated 01/10/16, at 3:50 a.m., emergency responder's returned call reports arriving at Hendricks ER. DON B notified and message left on voice mail of the administrator. Signed LVN B. Nurses note dated 01/10/16, at 6:20 a.m., report received from ER nurse that they are to do surgery today or tomorrow to fix his dislocation of his left shoulder. I asked if he had thought he had been hit by a car. She stated no, do not think so. Signed by LVN B. On 01/10/16, at 10:10 a.m. the ADON A documented, at approximately 9:30 (a.m.), I visited the resident at the hospital. He stated he was doing okay. I asked if he was hurting and he said not right now. I asked him what happened and he said I tripped over my own feet. He also stated that they were going to take him in for surgery this evening . Nurse ' s note dated 01/10/16, at 3:10 p.m., doctor had been notified at 3:10(a.m.) of elopement/hospitalization . Signed by LVN B. Nurse ' s note dated 01/10/16, untimed, revealed resident did not elope. Resident is his own responsible party and signed himself out. Signed by ADON B. Record review of facility's investigation tool dated 01/11/16, received from the Administrator on 01/14/16, revealed the description of the investigation. The investigative process consists of interviewing staff and having contact with Resident# 2 prior to and following the occurrence of resident search. Additionally, interviews were conducted with Resident #2 and hospital staff nurse. A review of the relevant documents, such as medical records, was conducted and pertinent information related to the investigation: #1 code yellow was called and internal and external search conducted until resident located. #2 verification of on-site census. #3 staff statements obtained and reviewed. #4 review of relief for temporary absence form. #5 review of resident chart and care plan. #6 resident interviewed by ADON A. #7 review of hospital medical records for resident. #8 review of DADS' guidelines for missing persons and neglect. Title Interview Notes/Key Documents. Interview notes were obtained from all staff members involved, residents, or others with pertinent knowledge of the care and services provided to Resident #2. Key documents reviewed consisted of: #1 staff witness statements. #2 resident interviews conducted by ADON A. #3 hospital records. #4 release for temporary absence. #5 resident care plan and medical records. Results/Findings revealed that Resident #2 was a [AGE] year-old male originally admitted to the facility on [DATE] with Resident #2's [DIAGNOSES REDACTED].#2 is alert and oriented x3. A review of his most recent Minimum Data Set showed a BIMS score of 12. On 01/10/15, the following occurred: . Record review of the ambulance service for Resident #2 dated 01/10/16 revealed that he was a [AGE] year-old male, had been picked up by the EMS services at 3:24 a.m., on 01/10/16, with primary impression of traumatic injury, abrasions to knees secondary to fall, and injuries from fall from slipping, tripping, stumbling on a street or highway. It revealed the resident was alert and oriented to person and time. It revealed the resident had a hematoma to his forehead, both eyes from a previous fall (12/31/15). It revealed limited range of motion to both upper and lower extremities. The comments revealed EMS arrived on scene. A [AGE] year-old male found sitting in a vehicle, in the passenger side, in the drive of the fire station. A bystander was passing the intersection of North Second and Grape and seen the patient lying down in the grass on the East side of Grape Street. He helped patient into his vehicle and pulled into Station 1. Resident #2 is a resident of the facility and left the facility without the nursing staff knowledge. The patient stated he has walked up to the store on North First to buy something to eat. The patient stated he was walking back to the nursing facility and fell . Resident #2 stated several cars drove passed him, but did not see him. He was not able to get up on his own. The facility was notified and they confirmed that they had been looking for the patient. The resident was transported to a local hospital via stretcher. Record review of Resident #2 ' s history and physical (from the hospital) dated 01/10/16 revealed a chief complaint of a fall. It revealed Resident #2 has been several times in the emergency room recently due to falls, with his most recent time being last week. The patient still had some bilateral periorbital ecchymosis. Today, the patient states he was walking away from the nursing facility when he tripped and fell . He landed on his knees, caught himself with his hands, and then stated that he did hit his head. He had a headache for some time following this fall. The patient presented to the emergency room where he was found to have bruising on his face from his prior fall, as well as a new blemish on his right forehead. The patient also has a separated shoulder and was found to have a dislocated left shoulder that was not able to be relocated with multiple attempts in the Emergency Department. A Physician B was consulted in the emergency room that planned surgical intervention for his shoulder in the coming days. The patient is a moderately poor historian. He has had some headache and is having some pain over his knees where he fell on them .Assessment and Plan: #1 left shoulder dislocation. The patient will be admitted to medical surgical unit for continued monitoring .This patient was seen at 5:00 a.m. on 01/10/16. Signed by Physician A. Record review of Resident 2's hospital operative report dated 01/10/16 revealed a preoperative [DIAGNOSES REDACTED]. Procedure: Left reverse total shoulder arthroplasty . Signed by Physician B. Record review of a witness statement by CNA D dated 01/10/16 revealed I saw Resident 2 walking around from 10:00 p.m. to midnight. A co-worker has asked me if I had seen him around 2:00 a.m. because he was not in his room. Other staff walked in the building to find him, and I drove around the building in my car to try and find him outside. I found him sitting on the sidewalk on North Second and Grape Street. He told me he was on the ground because a car had hit him. Because he said this and because he was in front of the fire station, I decided to knock on the door of the fire station to get immediate medical attention. The firehouse had a phone that I used and directed me to 9-1-1. I waited until after the police and firemen were with him before I went back to work. Signed by CNA D. During an interview on 01/11/16, at 3:10 p.m., with hospital RN revealed that the resident had a left shoulder replacement on 01/10/16 due to dislocation. During an interview on 01/11/16, at 3:15 p.m., Resident #2 revealed that he did leave the facility the previous night, 01/10/16. He stated no one was at the nurses' desk to sign out. He stated he walked outside of the door in front of the nurses' station at station 1. The resident revealed that he remembers it was cold, he was not wearing a jacket, and that he was walking to South First and back attempting to go to the store. Observation of the resident during the interview revealed that he had a hematoma to his forehead and bilateral black eyes. Resident #2 stated that was from the week before when he fell in the hallway on his face. It was observed that Resident #2 was going to sleep during the interview. An observation during the interview revealed a left shoulder dressing with left arm immobile. He had dressings to both knees. During an interview on 01/11/16, at 3:55 p.m., with the Administrator, he stated that there have not been any elopement attempts since 12/16/15. The administrator stated that Resident #2 is his own responsible party and checked himself out on a regular basis for walks, and that staff became aware about 2:00 a.m. on 1/10/16 that the resident was not in the facility. He said another staff member went searching in a personal vehicle and saw him at the fire station around 3:00. He stated another staff member said the last they saw Resident #2 was at station 1 nursing desk about 1:15 a.m. The administrator stated that his investigation is in progress and that he has not reported this incident to DADS. He stated he did not believe it was a reportable incident. The Administrator stated that he does not consider this incident an elopement because Resident 2 is his own responsible party. The administrator stated that Resident #2 usually does not check himself out during that time of the day. The administrator stated he was told that the resident had slept most of the day and was restless on the night of 01/09/16 and the early morning hours of 01/10/16. The administrator stated the dislocated shoulder had nothing to do with this incident or fall and that the resident was uninjured from this occurrence. He stated the resident had a chronic dislocated shoulder. The administrator stated that no one knew that the resident was leaving the facility and his sign-out sheet was at the nurses' desk that Resident #2 normally signs out. The administrator stated we would not expect anyone to go out at that time of the night. The administrator stated that there was no policy and procedure regarding a resident having been able to sign him/herself out of the facility on pass. During an interview on 01/12/16, at 12:40 p.m., with a local store manager four blocks from the facility revealed that Resident #2 comes into his store about three to four times a week. He stated that he has noticed that the resident has had bruises and that his legs were swollen. He stated the resident usually uses a cane and his legs are wrapped with some type of dressing. He stated some days he could see visible sores on his legs. The manager stated that the resident walked slowly dragging his feet and that he was afraid that the resident was going to fall in his store. He stated that the resident would dig in his trash looking for lottery tickets, and that the resident would trip easily. The manager stated that he and other staff members at the store would have to call the facility to come pick the resident up on many occasions due to the resident being too tired to walk back to the facility. The manager stated he has been working at this store since August 2015 and is very familiar with Resident #2. During an interview on 01/12/16, at 2:15 p.m., with ADON A, he revealed that he went to see Resident #2 at the hospital at approximately 8:00 a.m. on 01/10/16. He stated that he talked to the charge nurse and then talked to the resident and the resident told him he was all right and then told him what had happened. That he did not get hit by a car and tripped on his own feet. The ADON A stated that Resident #2's orientation was fine. The ADON A stated that he assumed that there were no new injuries by this fall due to his chronic dislocated left shoulder and the fall from the week before. He stated that he did not speak with the hospital nursing staff or ER physician regarding the injuries the resident sustained [REDACTED].>During a phone interview on 1/13/16 at 1:10 p.m. with Physician B B (identifier), he revealed that on the afternoon of 1/10/16, he performed a left reversal Shoulder arthroplasty due to Resident 2 ' s unstable shoulder. He stated that the resident ' s left shoulder could not be reduced in the emergency department on 1/10/16 and required surgical intervention. He stated that the resident had Chronic left shoulder dislocations and that the resident had a fall on 12/31/15 which required an emergency room visit to reset his shoulder. The Physician B stated that the fall in the early hours on 1/10/16 could have caused his shoulder to become dislocated and created further damage in which could not be repositioned in the emergency department, requiring surgical intervention. The Physician B stated that the resident should have been monitored by nursing staff after he was administered narcotic pain medications, Wafarin, and Ambien. He stated that due to the resident ' s Chronic medical conditions and fall risk, that the Resident should not have been allowed to leave the facility, especially due to his high risk and history of falls. During an interview with DON B on 1/14/16 at 1:25 p.m., she stated that residents, who leave the facility regularly, especially without the facility ' s knowledge, should have a care plan in place addressing that issue. She stated that residents on blood thinners, narcotics and insomnia medications should be monitored for adverse effects to prevent injury to themselves or other residents. Resident #9 Record review of the Admission face sheet revealed an admitted [DATE]. Resident #9 was a [AGE] year-old female with [DIAGNOSES REDACTED]. Record review of the MDS dated [DATE] identified Resident #9 with a BIMS (Brief Interview for Mental Status) score of 3 (Severe (0-7) Moderate (8-12) Intact (13-15)), was ambulatory, and required supervision. Resident #9 was identified as a wander risk. Record review of the Elopement risk assessment dated [DATE] revealed Question #4, 5, 7 and 11 were checked yes. The directions state that if yes on items 1 or 2, 3 to 5, in combination with any items 6 to 11, that resident should be marked at risk. It states that if it is yes on any one item 6 to 11, resident is at risk, the elopement risk assessment additional comments stated: Resident is a risk for elopement. Record review of the Elopement risk assessment dated [DATE] revealed Question #5, 7, 8, 9 and 11 were checked yes. The directions state that if yes on items 1 or 2, 3 to 5, in combination with any items 6 to 11, that resident should be marked at risk. It states that if it is yes on any one item 6 to 11, resident is at risk, the elopement risk assessment additional comments stated: Resident is a risk for elopement. Wander guard added. Care plan for 11/19/15 until the one dated 1/20/16 Record review of the care plan for Resident #9 dated 1/20/16 revealed that Resident #9 had a history of [REDACTED]. Record review of Nurse ' s Progress notes dated 1/19/15 at 2:05 p.m. revealed the following: CNA called nurse to nurses desk and stated that Resident #9 was out front of building standing in the parking lot. CNA brought Resident #9 back inside and assisted resident to room, full head-to-toe assessment done. No injuries noted Moved into the Transitions secure unit . Record review of elopement risk assessment dated [DATE] revealed Resident #9 to be ambulatory, alert, d

Based on interview and record review, the facility failed to implement their policies and procedures for neglect prevention for 1 of 10 residents (Resident #2) reviewed for incidents of neglect as evidenced by: a. The facility failed to thoroughly investigate and report when resident #2 eloped from the facility and was injured on 1/10/16. An Immediate Jeopardy (IJ) was identified on 01/08/16. While the IJ was removed on 1/15/16, the facility remained out of compliance at a level of potential for more than minimal harm and a scope of pattern, due to the facility monitoring the implementation of the Plan of Removal. This failure placed 38 residents on the 3 secure units at risk of leaving the facility without staff being aware, placing the residents at risk of serious injury or death. Findings included: Resident #2 Record review of face sheet dated 04/27/15 revealed that Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with a readmitted [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #2 elopement risk assessment dated [DATE] revealed that resident's mobility status was ambulatory with a cane. His cognition was alert, behavior was that resident is oriented, able to make decisions, and verbalizes and demonstrates acceptance of placement. It revealed the resident exhibits routine or sporadic confusion, anxiety, or disorientation. It revealed the resident expresses anger or is resistant related to placement, sample of wanting to go home or to work or somewhere else. It revealed that the resident had wanted to leave the facility to socialize or a history of going out to socialize. Under the resident's risk potential for elopement; it is checked not at risk, indicating the resident is not at risk. In the additional comment, it states the resident is not at risk for elopement, signed by DON B on 11/16/15. Question #2, 5, 6 and 10 were checked yes. The directions state that if yes on items 1 or 2, 3 to 5, in combination with any items 6 to 11, that resident should be marked at risk. It states that if it is yes on any one item 6 to 11, resident is at risk, however the elopement risk assessment additional comments stated: Resident is not a risk for elopement. Record review of Resident 2's care plans dated 12/12/15 revealed that Resident #2 was at risk for falls and impaired mobility requiring the use of a cane for balance with a [DIAGNOSES REDACTED]. The risk for elopement and resident signing himself in and out to go to the store was not care planned. Record review of Resident 2's social service note dated 12/31/15 revealed the resident came into the social worker's office before the meeting and wanted the door closed and locked due to people being after him. Social Worker A and MDS coordinator attempted to calm the resident down. He continued to say that there was a hit on him and he was going to die. He explained he could not stay at the facility tonight because someone was going to kill him. The resident was very unsteady on his feet and allowed staff to retrieve his wheelchair. The resident stated that he needed $50 so that he could leave for the night. The Social Worker A discussed discharge planning, not leaving AMA versus with the doctor's order and the potential of consequence. The resident became angry stating you do not understand. Someone will kill me tonight. Social Worker A attempted to calm the resident down and provide support, unsuccessfully. The primary care physician was notified due to increase in delusions and gave okay to look at a behavioral hospital. Record review of Resident #2 ' s quarterly Minimum (MDS) data set [DATE] revealed, in Section C for cognitive patterns, a BIMS score (Brief Interview for Mental Status) of 12, indicating moderate cognitive impairment. It revealed acute onset mental status change. In Section E, titled Behaviors, it revealed that resident had hallucinations and delusions, which were potential indicators of [MEDICAL CONDITION]. In Section G, Functional Status, it revealed that the resident was not steady with moving from seated to standing position, walking, turning around, moving on and off the toilet, and surface-to-surface transfer, but able to stabilize without staff assistance. It revealed that the resident had functional limitation in range of motion on both sides, upper and lower extremities. It revealed that the resident uses a cane, walker, and wheelchair for mobility devices. In Section J, it revealed that the resident had pain almost constantly and receives p.r.n. pain medication. In Section J, Health Conditions, it revealed the resident had shortness of breath or trouble breathing with exertion such as walking, bathing, and transferring; shortness of breath or trouble breathing, when lying flat. In Section J, Fall History, it revealed that the resident has had one fall since previous MDS assessment with two or more injuries which including skin tears, abrasions, lacerations, bruises, hematomas, and fall-related injuries that caused the resident to complain of pain. Record review of Resident 2's social service review dated 01/03/16, for review reason of quarterly review, revealed that Resident 2's cognition is moderately impaired, that Resident 2 exhibits disorganized thinking. The resident demonstrates disorganized thinking at times. He has poor safety awareness. Staff to assist and redirect as needed. Signed by Social Worker A. Record review of Resident #2 physician orders, with a date range of 01/01/2016 through 01/31/16, revealed an order for [REDACTED]. Record review of Resident #2 Medication Administration Record [REDACTED]. It revealed that Resident #2 [MEDICATION NAME] mg one tablet on 01/09/16 for complaints of [MEDICAL CONDITION]. Further record review revealed that Resident #2 did not have any prior administrations [MEDICATION NAME] mg for the month of January 2016. It revealed that the resident received two as-needed doses at bedtime for the month of December 2015. Record review of Resident #2 p.r.n. medication flow sheet, under Section Nurse's Noted, undated, revealed that on 01/09/16, at 8:00 p.m., Resident #2 was administered two tablets of Tylenol #3 for complaints of shoulder pain with a reassessment at 9:00 p.m. by LVN B documenting effective pain relief. It revealed that at 8:00 p.m. Resident #2 was [MEDICATION NAME] mg for complaints of [MEDICAL CONDITION] by LVN B and was documented as not effective at 10:00 p.m. Record review of nursing notes for Resident #2 on 01/10/16, at 1:15 a.m., revealed observed resident standing at nurses' station simply looking around and did not complain of anything or request or verbalize any need. Signed by LVN B. On 01/10/16, at 2:00 a.m., it revealed resident not seen since 1:15 a.m. Search of building began. Signed by LVN B. On 01/10/16, at 2:30 a.m., not found at station 1, code yellow announced, search began at station 2 and outside building. Search of neighborhood began staff in their vehicles. Signed by LVN B. On 01/10/16, at 3:15 a.m., messages left on the voice mails of the administrator, the DON, and the ADON phones. Signed by LVN B . According to wunderground.com, on 1/10/16 the temperature in Abilene between 12:52 a.m. and 2:52 a.m. was 27 degrees Fahrenheit (F), with a wind-chill of 19.5 - 23 degrees F. http://www.wunderground.com/history/airport/KABI/2016/1/10/DailyHistory.html?req_city=Abilene&req_state=TX&req_statename=&reqdb.zip= &reqdb.magic=1&reqdb.wmo= (accessed on 2/6/16) Nurse ' s note dated 01/10/16, at 3:20 a.m., received call from CNA D found resident at North Second and Grape Street. Found him lying in the grass near the curb. The resident told CNA D he had been hit by a car. Reported to 9-1-1. Signed by LVN B. Nurse ' s note dated 01/10/16, at 3:50 a.m., emergency responder's returned call reports arriving at Hendricks ER. DON B notified and message left on voice mail of the administrator. Signed LVN B. Nurses note dated 01/10/16, at 6:20 a.m., report received from ER nurse that they are to do surgery today or tomorrow to fix his dislocation of his left shoulder. I asked if he had thought he had been hit by a car. She stated no, do not think so. Signed by LVN B. On 01/10/16, at 10:10 a.m. the ADON A documented, at approximately 9:30 (a.m.), I visited the resident at the hospital. He stated he was doing okay. I asked if he was hurting and he said not right now. I asked him what happened and he said I tripped over my own feet. He also stated that they were going to take him in for surgery this evening . Nurse ' s note dated 01/10/16, at 3:10 p.m., doctor had been notified at 3:10(a.m.) of elopement/hospitalization . Signed by LVN B. Nurse ' s note dated 01/10/16, untimed, revealed resident did not elope. Resident is his own responsible party and signed himself out. Signed by ADON B. Record review of facility's investigation tool dated 01/11/16, received from the Administrator on 01/14/16, revealed the description of the investigation. The investigative process consists of interviewing staff and having contact with Resident# 2 prior to and following the occurrence of resident search. Additionally, interviews were conducted with Resident #2 and hospital staff nurse. A review of the relevant documents, such as medical records, was conducted and pertinent information related to the investigation: #1 code yellow was called and internal and external search conducted until resident located. #2 verification of on-site census. #3 staff statements obtained and reviewed. #4 review of relief for temporary absence form. #5 review of resident chart and care plan. #6 resident interviewed by ADON A. #7 review of hospital medical records for resident. #8 review of DADS' guidelines for missing persons and neglect. Title Interview Notes/Key Documents. Interview notes were obtained from all staff members involved, residents, or others with pertinent knowledge of the care and services provided to Resident #2. Key documents reviewed consisted of: #1 staff witness statements. #2 resident interviews conducted by ADON A. #3 hospital records. #4 release for temporary absence. #5 resident care plan and medical records. Results/Findings revealed that Resident #2 was a [AGE] year-old male originally admitted to the facility on [DATE] with Resident #2's [DIAGNOSES REDACTED].#2 is alert and oriented x3. A review of his most recent Minimum Data Set showed a BIMS score of 12. On 01/10/15, the following occurred: . Record review of the ambulance service for Resident #2 dated 01/10/16 revealed that he was a [AGE] year-old male, had been picked up by the EMS services at 3:24 a.m., on 01/10/16, with primary impression of traumatic injury, abrasions to knees secondary to fall, and injuries from fall from slipping, tripping, stumbling on a street or highway. It revealed the resident was alert and oriented to person and time. It revealed the resident had a hematoma to his forehead, both eyes from a previous fall. It revealed limited range of motion to both upper and lower extremities. The comments revealed EMS arrived on scene. A [AGE] year-old male found sitting in a vehicle, in the passenger side, in the drive of the fire station. A bystander was passing the intersection of North Second and Grape and seen the patient lying down in the grass on the East side of Grape Street. He helped patient into his vehicle and pulled into Station 1. Resident #2 is a resident of the facility and left the facility without the nursing staff knowledge. The patient stated he has walked up to the store on North First to buy something to eat. The patient stated he was walking back to the nursing facility and fell . Resident #2 stated several cars drove passed him, but did not see him. He was not able to get up on his own. The facility was notified and they confirmed that they had been looking for the patient. The resident was transported to a local hospital via stretcher. Record review of Resident #2 ' s history and physical (from the hospital) dated 01/10/16 revealed a chief complaint of a fall. It revealed Resident #2 has been several times in the emergency room recently due to falls, with his most recent time being last week. The patient still had some bilateral periorbital ecchymosis. Today, the patient states he was walking away from the nursing facility when he tripped and fell . He landed on his knees, caught himself with his hands, and then stated that he did hit his head. He had a headache for some time following this fall. The patient presented to the emergency room where he was found to have bruising on his face from his prior fall, as well as a new blemish on his right forehead. The patient also has a separated shoulder and was found to have a dislocated left shoulder that was not able to be relocated with multiple attempts in the Emergency Department. A Physician B was consulted in the emergency room that planned surgical intervention for his shoulder in the coming days. The patient is a moderately poor historian. He has had some headache and is having some pain over his knees where he fell on them .Assessment and Plan: #1 left shoulder dislocation. The patient will be admitted to medical surgical unit for continued monitoring .This patient was seen at 5:00 a.m. on 01/10/16. Signed by Physician A. Record review of Resident 2's hospital operative report dated 01/10/16 revealed a preoperative [DIAGNOSES REDACTED]. Procedure: Left reverse total shoulder arthroplasty . Signed by Physician B. Record review of a witness statement by CNA D dated 01/10/16 revealed I saw Resident 2 walking around from 10:00 p.m. to midnight. A co-worker has asked me if I had seen him around 2:00 a.m. because he was not in his room. Other staff walked in the building to find him, and I drove around the building in my car to try and find him outside. I found him sitting on the sidewalk on North Second and Grape Street. He told me he was on the ground because a car had hit him. Because he said this and because he was in front of the fire station, I decided to knock on the door of the fire station to get immediate medical attention. The firehouse had a phone that I used and directed me to 9-1-1. I waited until after the police and firemen were with him before I went back to work. Signed by CNA D. During an interview on 01/11/16, at 3:10 p.m., with hospital RN revealed that the resident had a left shoulder replacement on 01/10 due to dislocation. During an interview on 01/11/16, at 3:15 p.m., Resident #2 revealed that he did leave the facility the previous night, 01/10/16. He stated no one was at the nurses' desk to sign out. He stated he walked outside of the door in front of the nurses' station at station 1. The resident revealed that he remembers it was cold, he was not wearing a jacket, and that he was walking to South First and back attempting to go to the store. Observation of the resident during the interview revealed that he had a hematoma to his forehead and bilateral black eyes. Resident #2 stated that was from the week before when he fell in the hallway on his face. It was observed that Resident #2 was going to sleep during the interview. An observation during the interview revealed a left shoulder dressing with left arm immobile. He had dressings to both knees. During an interview on 01/11/16, at 3:55 p.m., with the Administrator, he stated that there have not been any elopement attempts since 12/16/15. The administrator stated that Resident #2 is his own responsible party and checked himself out on a regular basis for walks, and that staff became aware about 2:00 a.m. on 1/10/16 that the resident was not in the facility. He said another staff member went searching in a personal vehicle and saw him at the fire station around 3:00. He stated another staff member said the last they saw Resident #2 was at station 1 nursing desk about 1:15 a.m. The administrator stated that his investigation is in progress and that he has not reported this incident to DADS. He stated he did not believe it was a reportable incident. The Administrator stated that he does not consider this incident an elopement because Resident 2 is his own responsible party. The administrator stated that Resident #2 usually does not check himself out during that time of the day. The administrator stated he was told that the resident had slept most of the day and was restless on the night of 01/09/16 and the early morning hours of 01/10/16. The administrator stated the dislocated shoulder had nothing to do with this incident or fall and that the resident was uninjured from this occurrence. He stated the resident had a chronic dislocated shoulder. The administrator stated that no one knew that the resident was leaving the facility and his sign-out sheet was at the nurses' desk that Resident #2 normally signs out. The administrator stated we would not expect anyone to go out at that time of the night. During an interview on 01/12/16, at 12:40 p.m., with a local store manager four blocks from the facility revealed that Resident #2 comes into his store about three to four times a week. He stated that he has noticed that the resident has had bruises and that his legs were swollen. He stated the resident usually uses a cane and his legs are wrapped with some type of dressing. He stated some days he could see visible sores on his legs. The manager stated that the resident walked slowly dragging his feet and that he was afraid that the resident was going to fall in his store. He stated that the resident would dig in his trash looking for lottery tickets, and that the resident would trip easily. The manager stated that he and other staff members at the store would have to call the facility to come pick the resident up on many occasions due to the resident being too tired to walk back to the facility. The manager stated he has been working at this store since August 2015 and is very familiar with Resident #2. During an interview on 01/12/16, at 2:15 p.m., with ADON A, he revealed that he went to see Resident #2 at the hospital at approximately 8:00 a.m. on 01/10/16. He stated that he talked to the charge nurse and then talked to the resident and the resident told him he was all right and then told him what had happened. That he did not get hit by a car and tripped on his own feet. The ADON A stated that Resident #2's orientation was fine. The ADON A stated that he assumed that there were no new injuries by this fall due to his chronic dislocated left shoulder and the fall from the week before. He stated that he did not speak with the hospital nursing staff or ER physician regarding the injuries the resident sustained [REDACTED].>During a phone interview on 1/13/16 at 1:10 p.m. with Physician B B (identifier), he revealed that on the afternoon of 1/10/16, he performed a left reversal Shoulder arthroplasty due to Resident 2 ' s unstable shoulder. He stated that the resident ' s left shoulder could not be reduced in the emergency department on 1/10/16 and required surgical intervention. He stated that the resident had Chronic left shoulder dislocations and that the resident had a fall on 12/31/15 which required an emergency room visit to reset his shoulder. The Physician B stated that the fall in the early hours on 1/10/16 could have caused his shoulder to become dislocated and created further damage in which could not be repositioned in the emergency department, requiring surgical intervention. The Physician B stated that the resident should have been monitored by nursing staff after he was administered narcotic pain medications, Wafarin, and Ambien. He stated that due to the resident ' s Chronic medical conditions and fall risk, that the Resident should not have been allowed to leave the facility, especially due to his high risk and history of falls. During an interview with DON B on 1/14/16 at 1:25 p.m., she stated that residents, who leave the facility regularly, especially without the facility ' s knowledge, should have a care plan in place addressing that issue. She stated that residents on blood thinners, narcotics and [MEDICAL CONDITION] medications should be monitored for adverse effects to prevent injury to themselves or other residents. Immediate Jeopardy (IJ) was identified on 1/8/16 at 2:15 p.m. and the Administrator, DON and Regional Nurse Consultant were notified. Record review of the facility policy titled Elopement dated 10/15/15 revealed the following: POLICY: Genesis Healthcare Centers will prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all patients through the following: · . · Prevention of occurrences · Identification of possible incidents or allegations which need investigation; · Investigation of incidents and allegations; . DEFINITIONS: Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness PURPOSE To ensure that Center staff are doing all that is within their control to prevent occurrences of abuse, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property for all patients. PROCESS 1. The Administrator, or designee, is responsible for operationalizing policies and procedures that prohibit abuse, mistreatment, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property . 4. Actions to prevent abuse, mistreatment, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property will include: . 4.3 Identifying, correcting, and intervening in situations in which abuse, neglect, and/or misappropriation of patient property is more likely to occur. 5. Staff will identify events-such as suspicious bruising of patients, occurrences, patterns, and trends that may constitute abuse-and determine the direction of the investigation. This also includes patient-to-patient abuse . 5.3 Injuries of unknown origin will be investigated to determine if abuse or neglect is suspected. 6. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property, the Administrator or designee will perform the following . 6.1 Enter allegation into Risk Management System (RMS). 6.2 Immediately, not to exceed 24 hours, notify the Texas Department of Aging and Disability Services either: 6.2.1 Online at report incident online . 6.3.10 The immediate action taken to protect other people and to prevent occurrences of similar incidents while you conduct and complete investigation . 7. The Center will protect patients from further harm during an investigation. 7.1 Provide the patient with a safe environment by identifying persons with whom he/she feels safe and conditions that would feel safe. 8. The Administrator and Director of Nursing will review all allegations of abuse that were reported to the state on a monthly basis to: 8.1 Identify situations which have a potential for risk; and 8.2 Determine what preventive measures will be implemented by staff . Record review of the facility policy titled Wandering Device Policy dated 5/2004 revealed the following: Policy; when a resident has potential for elopement and is utilizing a wandering device, the device will be maintained in a manner to protect their safety. Procedure: Exit doors in the facility should have alarms. Door alarms will be tested by the maintenance department per the policies of the department. Results of the tests will be recorded and kept by the maintenance department . When any door is not activating, an employee will monitor the door until it is repaired. Record review of the facility policy titled Elopement dated 10/15/15 revealed the following: POLICY: Genesis Healthcare Centers will prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all patients through the following: · . · Prevention of occurrences · Identification of possible incidents or allegations which need investigation; · Investigation of incidents and allegations; . DEFINITIONS: Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness PURPOSE To ensure that Center staff are doing all that is within their control to prevent occurrences of abuse, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property for all patients. PROCESS 1. The Administrator, or designee, is responsible for operationalizing policies and procedures that prohibit abuse, mistreatment, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property . 4. Actions to prevent abuse, mistreatment, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property will include: . 4.3 Identifying, correcting, and intervening in situations in which abuse, neglect, and/or misappropriation of patient property is more likely to occur. 5. Staff will identify events-such as suspicious bruising of patients, occurrences, patterns, and trends that may constitute abuse-and determine the direction of the investigation. This also includes patient-to-patient abuse . 5.3 Injuries of unknown origin will be investigated to determine if abuse or neglect is suspected. 6. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property, the Administrator or designee will perform the following . 6.1 Enter allegation into Risk Management System (RMS). 6.2 Immediately, not to exceed 24 hours, notify the Texas Department of Aging and Disability Services either: 6.2.1 Online at report incident online . 6.3.10 The immediate action taken to protect other people and to prevent occurrences of similar incidents while you conduct and complete investigation . 7. The Center will protect patients from further harm during an investigation. 7.1 Provide the patient with a safe environment by identifying persons with whom he/she feels safe and conditions that would feel safe. 8. The Administrator and Director of Nursing will review all allegations of abuse that were reported to the state on a monthly basis to: 8.1 Identify situations which have a potential for risk; and 8.2 Determine what preventive measures will be implemented by staff . Record review of the facility's policy titled Elopement of a Patient, received from the administrator on 01/10/16, revealed that patient will be evaluated for elopement risk upon admission, readmission, quarterly, and with a change in condition as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Elopement occurs when a patient leaves the premises without authorization and/or any necessary supervision to do so. State definitions for elopement vary. Follow state definitions if different. Purpose: To provide process for managing patients at risk for elopement. Process: 1. Assessment evaluation. Identify a patient's elopement risk by reviewing the following: Upon admission, readmission, quarterly, or with significant change in condition as defined by non-electronic medical record system. 2. The elopement evaluation. Complete the elopement evaluation for patients identified at risk. An interdisciplinary elopement prevention care plan will be developed with the family and patient participation. Individual risk factors and patterns will be identified and addressed within the care plan. Obtain a current photograph of the resident and complete the elopement risk identification form for all patients at risk for elopement and place in a binder that is easily accessible to staff 5. Quality assurance performance. Performance improvement: The Safety Committee will review all incidents of elopement; conduct a root analysis cause, correct systems to prevent further incidents, and forward information to the Quality Improvement Committee for further discussion. Sign in and out records will be maintained and used whenever patient leaves center/ground along with family or recreational staff. Staff will be trained on the center's door security system and then required response to sounding door alarm. Security system checks will be conducted routinely and documented to ensure function of wander systems, trigger bracelets, door alarms, and security cameras. Elopement drills will be conducted a minimum of twice per year and documented on the elopement drill documentation form. Elopement drills will be reviewed 6. WanderGuard procedure. Addendum for the nursing facility. #1 functionality of individual WanderGuard System will be tested every shift and will be conducted by treatment nurse and/or designee and noted on the TARs. #2 documented WanderGuard placement checks will be conducted every shift by the charge nurse and/or designee and documented on the TARs. Record review of the facility policy titled Elopement dated 6/26/2006 and revised 05/09/2008 revealed the following: Policy: it is the policy of this facility to protect residents from wandering away from the facility and to begin an immediate search if a resident is found missing. Fundamental information .Elopement, for purposes of this policy and procedure, is defined as that situation where a resident with impaired decision-making ability, who is oblivious to his or her own safety, needs and therefore at risk for injury outside the confines of the facility. Has the resident left the facility without the knowledge of staff. When a patient or resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired; wanders away, walks away, runs away, escapes, or otherwise leaves a caregiving facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge. http://www.elopement.org/ NIEPR Definition for Elopement (National Institute for Elopement Prevention and Protection) .Residents in the secured unit will be deemed at risk for elopement. Residents identified as at risk of elopement will be reassessed quarterly and as needed throughout the Resident Assessment Instrument (RAI) process with behavior monitoring documentation, as indicated. Resident's risk will also be reassessed whenever an elopement event occurs. A plan of care will be developed and updated as indicated by assessment to reduce risk of elopement, such as: Alert bracelet (obtain a physician's order for an alarm/alert bracelet); Assignment to a room away from exits that are commonly utilized; . The frequency of visual checks will be established in accordance with the resident's needs. Facility may record on the Medication Administrati

Based on interview and record review, the facility failed to implement their written policies and procedures for neglect prevention for 1of 10 residents (Resident #2) reviewed for incidents of neglect as evidenced by: a. The facility failed to thoroughly investigate and report when resident #2 eloped from the facility and was injured on 1/10/16. An Immediate Jeopardy (IJ) was identified on 01/08/16. While the IJ was removed on 1/15/16, the facility remained out of compliance at a level of potential for more than minimal harm and a scope of pattern, due to the facility monitoring the implementation of the Plan of Removal. This failure placed 38 residents on the 3 secure units at risk of leaving the facility without staff being aware, placing the residents at risk of serious injury or death. Findings included: Record review of the facility policy titled Elopement dated 10/15/15 revealed the following: POLICY: Genesis Healthcare Centers will prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all patients through the following: · . · Prevention of occurrences · Identification of possible incidents or allegations which need investigation; · Investigation of incidents and allegations; . DEFINITIONS: Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness PURPOSE To ensure that Center staff are doing all that is within their control to prevent occurrences of abuse, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property for all patients. PROCESS 1. The Administrator, or designee, is responsible for operationalizing policies and procedures that prohibit abuse, mistreatment, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property . 4. Actions to prevent abuse, mistreatment, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property will include: . 4.3 Identifying, correcting, and intervening in situations in which abuse, neglect, and/or misappropriation of patient property is more likely to occur. 5. Staff will identify events-such as suspicious bruising of patients, occurrences, patterns, and trends that may constitute abuse-and determine the direction of the investigation. This also includes patient-to-patient abuse . 5.3 Injuries of unknown origin will be investigated to determine if abuse or neglect is suspected. 6. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property, the Administrator or designee will perform the following . 6.1 Enter allegation into Risk Management System (RMS). 6.2 Immediately, not to exceed 24 hours, notify the Texas Department of Aging and Disability Services either: 6.2.1 Online at report incident online . 6.3.10 The immediate action taken to protect other people and to prevent occurrences of similar incidents while you conduct and complete investigation . 7. The Center will protect patients from further harm during an investigation. 7.1 Provide the patient with a safe environment by identifying persons with whom he/she feels safe and conditions that would feel safe. 8. The Administrator and Director of Nursing will review all allegations of abuse that were reported to the state on a monthly basis to: 8.1 Identify situations which have a potential for risk; and 8.2 Determine what preventive measures will be implemented by staff . Resident #2 Record review of face sheet dated 04/27/15 revealed that Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with a readmitted [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #2 elopement risk assessment dated [DATE] revealed that resident's mobility status was ambulatory with a cane. His cognition was alert, behavior was that resident is oriented, able to make decisions, and verbalizes and demonstrates acceptance of placement. It revealed the resident exhibits routine or sporadic confusion, anxiety, or disorientation. It revealed the resident expresses anger or is resistant related to placement, sample of wanting to go home or to work or somewhere else. It revealed that the resident had wanted to leave the facility to socialize or a history of going out to socialize. Under the resident's risk potential for elopement; it is checked not at risk, indicating the resident is not at risk. In the additional comment, it states the resident is not at risk for elopement, signed by DON B on 11/16/15. Question #2, 5, 6 and 10 were checked yes. The directions state that if yes on items 1 or 2, 3 to 5, in combination with any items 6 to 11, that resident should be marked at risk. It states that if it is yes on any one item 6 to 11, resident is at risk, however the elopement risk assessment additional comments stated: Resident is not a risk for elopement. Record review of Resident 2's care plans dated 12/12/15 revealed that Resident #2 was at risk for falls and impaired mobility requiring the use of a cane for balance with a [DIAGNOSES REDACTED]. The risk for elopement and resident signing himself in and out to go to the store was not care planned. Record review of Resident 2's social service note dated 12/31/15 revealed the resident came into the social worker's office before the meeting and wanted the door closed and locked due to people being after him. Social Worker A and MDS coordinator attempted to calm the resident down. He continued to say that there was a hit on him and he was going to die. He explained he could not stay at the facility tonight because someone was going to kill him. The resident was very unsteady on his feet and allowed staff to retrieve his wheelchair. The resident stated that he needed $50 so that he could leave for the night. The Social Worker A discussed discharge planning, not leaving AMA versus with the doctor's order and the potential of consequence. The resident became angry stating you do not understand. Someone will kill me tonight. Social Worker A attempted to calm the resident down and provide support, unsuccessfully. The primary care physician was notified due to increase in delusions and gave okay to look at a behavioral hospital. Record review of Resident #2 ' s quarterly Minimum (MDS) data set [DATE] revealed, in Section C for cognitive patterns, a BIMS score (Brief Interview for Mental Status) of 12, indicating moderate cognitive impairment. It revealed acute onset mental status change. In Section E, titled Behaviors, it revealed that resident had hallucinations and delusions, which were potential indicators of [MEDICAL CONDITION]. In Section G, Functional Status, it revealed that the resident was not steady with moving from seated to standing position, walking, turning around, moving on and off the toilet, and surface-to-surface transfer, but able to stabilize without staff assistance. It revealed that the resident had functional limitation in range of motion on both sides, upper and lower extremities. It revealed that the resident uses a cane, walker, and wheelchair for mobility devices. In Section J, it revealed that the resident had pain almost constantly and receives p.r.n. pain medication. In Section J, Health Conditions, it revealed the resident had shortness of breath or trouble breathing with exertion such as walking, bathing, and transferring; shortness of breath or trouble breathing, when lying flat. In Section J, Fall History, it revealed that the resident has had one fall since previous MDS assessment with two or more injuries which including skin tears, abrasions, lacerations, bruises, hematomas, and fall-related injuries that caused the resident to complain of pain. Record review of Resident 2's social service review dated 01/03/16, for review reason of quarterly review, revealed that Resident 2's cognition is moderately impaired, that Resident 2 exhibits disorganized thinking. The resident demonstrates disorganized thinking at times. He has poor safety awareness. Staff to assist and redirect as needed. Signed by Social Worker A. Record review of Resident #2 physician orders, with a date range of 01/01/2016 through 01/31/16, revealed an order for [REDACTED]. Record review of Resident #2 Medication Administration Record [REDACTED]. It revealed that Resident #2 [MEDICATION NAME] mg one tablet on 01/09/16 for complaints of [MEDICAL CONDITION]. Further record review revealed that Resident #2 did not have any prior administrations [MEDICATION NAME] mg for the month of January 2016. It revealed that the resident received two as-needed doses at bedtime for the month of December 2015. Record review of Resident #2 p.r.n. medication flow sheet, under Section Nurse's Noted, undated, revealed that on 01/09/16, at 8:00 p.m., Resident #2 was administered two tablets of Tylenol #3 for complaints of shoulder pain with a reassessment at 9:00 p.m. by LVN B documenting effective pain relief. It revealed that at 8:00 p.m. Resident #2 was [MEDICATION NAME] mg for complaints of [MEDICAL CONDITION] by LVN B and was documented as not effective at 10:00 p.m. Record review of nursing notes for Resident #2 on 01/10/16, at 1:15 a.m., revealed observed resident standing at nurses' station simply looking around and did not complain of anything or request or verbalize any need. Signed by LVN B. On 01/10/16, at 2:00 a.m., it revealed resident not seen since 1:15 a.m. Search of building began. Signed by LVN B. On 01/10/16, at 2:30 a.m., not found at station 1, code yellow announced, search began at station 2 and outside building. Search of neighborhood began staff in their vehicles. Signed by LVN B. On 01/10/16, at 3:15 a.m., messages left on the voice mails of the administrator, the DON, and the ADON phones. Signed by LVN B . According to wunderground.com, on 1/10/16 the temperature in Abilene between 12:52 a.m. and 2:52 a.m. was 27 degrees Fahrenheit (F), with a wind-chill of 19.5 - 23 degrees F. http://www.wunderground.com/history/airport/KABI/2016/1/10/DailyHistory.html?req_city=Abilene&req_state=TX&req_statename=&reqdb.zip= &reqdb.magic=1&reqdb.wmo= (accessed on 2/6/16) Nurse ' s note dated 01/10/16, at 3:20 a.m., received call from CNA D found resident at North Second and Grape Street. Found him lying in the grass near the curb. The resident told CNA D he had been hit by a car. Reported to 9-1-1. Signed by LVN B. Nurse ' s note dated 01/10/16, at 3:50 a.m., emergency responder's returned call reports arriving at Hendricks ER. DON B notified and message left on voice mail of the administrator. Signed LVN B. Nurses note dated 01/10/16, at 6:20 a.m., report received from ER nurse that they are to do surgery today or tomorrow to fix his dislocation of his left shoulder. I asked if he had thought he had been hit by a car. She stated no, do not think so. Signed by LVN B. On 01/10/16, at 10:10 a.m. the ADON A documented, at approximately 9:30 (a.m.), I visited the resident at the hospital. He stated he was doing okay. I asked if he was hurting and he said not right now. I asked him what happened and he said I tripped over my own feet. He also stated that they were going to take him in for surgery this evening . Nurse ' s note dated 01/10/16, at 3:10 p.m., doctor had been notified at 3:10(a.m.) of elopement/hospitalization . Signed by LVN B. Nurse ' s note dated 01/10/16, untimed, revealed resident did not elope. Resident is his own responsible party and signed himself out. Signed by ADON B. Record review of facility's investigation tool dated 01/11/16, received from the Administrator on 01/14/16, revealed the description of the investigation. The investigative process consists of interviewing staff and having contact with Resident# 2 prior to and following the occurrence of resident search. Additionally, interviews were conducted with Resident #2 and hospital staff nurse. A review of the relevant documents, such as medical records, was conducted and pertinent information related to the investigation: #1 code yellow was called and internal and external search conducted until resident located. #2 verification of on-site census. #3 staff statements obtained and reviewed. #4 review of relief for temporary absence form. #5 review of resident chart and care plan. #6 resident interviewed by ADON A. #7 review of hospital medical records for resident. #8 review of DADS' guidelines for missing persons and neglect. Title Interview Notes/Key Documents. Interview notes were obtained from all staff members involved, residents, or others with pertinent knowledge of the care and services provided to Resident #2. Key documents reviewed consisted of: #1 staff witness statements. #2 resident interviews conducted by ADON A. #3 hospital records. #4 release for temporary absence. #5 resident care plan and medical records. Results/Findings revealed that Resident #2 was a [AGE] year-old male originally admitted to the facility on [DATE] with Resident #2's [DIAGNOSES REDACTED].#2 is alert and oriented x3. A review of his most recent Minimum Data Set showed a BIMS score of 12. On 01/10/15, the following occurred: . Record review of the ambulance service for Resident #2 dated 01/10/16 revealed that he was a [AGE] year-old male, had been picked up by the EMS services at 3:24 a.m., on 01/10/16, with primary impression of traumatic injury, abrasions to knees secondary to fall, and injuries from fall from slipping, tripping, stumbling on a street or highway. It revealed the resident was alert and oriented to person and time. It revealed the resident had a hematoma to his forehead, both eyes from a previous fall. It revealed limited range of motion to both upper and lower extremities. The comments revealed EMS arrived on scene. A [AGE] year-old male found sitting in a vehicle, in the passenger side, in the drive of the fire station. A bystander was passing the intersection of North Second and Grape and seen the patient lying down in the grass on the East side of Grape Street. He helped patient into his vehicle and pulled into Station 1. Resident #2 is a resident of the facility and left the facility without the nursing staff knowledge. The patient stated he has walked up to the store on North First to buy something to eat. The patient stated he was walking back to the nursing facility and fell . Resident #2 stated several cars drove passed him, but did not see him. He was not able to get up on his own. The facility was notified and they confirmed that they had been looking for the patient. The resident was transported to a local hospital via stretcher. Record review of Resident #2 ' s history and physical (from the hospital) dated 01/10/16 revealed a chief complaint of a fall. It revealed Resident #2 has been several times in the emergency room recently due to falls, with his most recent time being last week. The patient still had some bilateral periorbital ecchymosis. Today, the patient states he was walking away from the nursing facility when he tripped and fell . He landed on his knees, caught himself with his hands, and then stated that he did hit his head. He had a headache for some time following this fall. The patient presented to the emergency room where he was found to have bruising on his face from his prior fall, as well as a new blemish on his right forehead. The patient also has a separated shoulder and was found to have a dislocated left shoulder that was not able to be relocated with multiple attempts in the Emergency Department. A Physician B was consulted in the emergency room that planned surgical intervention for his shoulder in the coming days. The patient is a moderately poor historian. He has had some headache and is having some pain over his knees where he fell on them .Assessment and Plan: #1 left shoulder dislocation. The patient will be admitted to medical surgical unit for continued monitoring .This patient was seen at 5:00 a.m. on 01/10/16. Signed by Physician A. Record review of Resident 2's hospital operative report dated 01/10/16 revealed a preoperative [DIAGNOSES REDACTED]. Procedure: Left reverse total shoulder arthroplasty . Signed by Physician B. Record review of a witness statement by CNA D dated 01/10/16 revealed I saw Resident 2 walking around from 10:00 p.m. to midnight. A co-worker has asked me if I had seen him around 2:00 a.m. because he was not in his room. Other staff walked in the building to find him, and I drove around the building in my car to try and find him outside. I found him sitting on the sidewalk on North Second and Grape Street. He told me he was on the ground because a car had hit him. Because he said this and because he was in front of the fire station, I decided to knock on the door of the fire station to get immediate medical attention. The firehouse had a phone that I used and directed me to 9-1-1. I waited until after the police and firemen were with him before I went back to work. Signed by CNA D. During an interview on 01/11/16, at 3:10 p.m., with hospital RN revealed that the resident had a left shoulder replacement on 01/10 due to dislocation. During an interview on 01/11/16, at 3:15 p.m., Resident #2 revealed that he did leave the facility the previous night, 01/10/16. He stated no one was at the nurses' desk to sign out. He stated he walked outside of the door in front of the nurses' station at station 1. The resident revealed that he remembers it was cold, he was not wearing a jacket, and that he was walking to South First and back attempting to go to the store. Observation of the resident during the interview revealed that he had a hematoma to his forehead and bilateral black eyes. Resident #2 stated that was from the week before when he fell in the hallway on his face. It was observed that Resident #2 was going to sleep during the interview. An observation during the interview revealed a left shoulder dressing with left arm immobile. He had dressings to both knees. During an interview on 01/11/16, at 3:55 p.m., with the Administrator, he stated that there have not been any elopement attempts since 12/16/15. The administrator stated that Resident #2 is his own responsible party and checked himself out on a regular basis for walks, and that staff became aware about 2:00 a.m. on 1/10/16 that the resident was not in the facility. He said another staff member went searching in a personal vehicle and saw him at the fire station around 3:00. He stated another staff member said the last they saw Resident #2 was at station 1 nursing desk about 1:15 a.m. The administrator stated that his investigation is in progress and that he has not reported this incident to DADS. He stated he did not believe it was a reportable incident. The Administrator stated that he does not consider this incident an elopement because Resident 2 is his own responsible party. The administrator stated that Resident #2 usually does not check himself out during that time of the day. The administrator stated he was told that the resident had slept most of the day and was restless on the night of 01/09/16 and the early morning hours of 01/10/16. The administrator stated the dislocated shoulder had nothing to do with this incident or fall and that the resident was uninjured from this occurrence. He stated the resident had a chronic dislocated shoulder. The administrator stated that no one knew that the resident was leaving the facility and his sign-out sheet was at the nurses' desk that Resident #2 normally signs out. The administrator stated we would not expect anyone to go out at that time of the night. During an interview on 01/12/16, at 12:40 p.m., with a local store manager four blocks from the facility revealed that Resident #2 comes into his store about three to four times a week. He stated that he has noticed that the resident has had bruises and that his legs were swollen. He stated the resident usually uses a cane and his legs are wrapped with some type of dressing. He stated some days he could see visible sores on his legs. The manager stated that the resident walked slowly dragging his feet and that he was afraid that the resident was going to fall in his store. He stated that the resident would dig in his trash looking for lottery tickets, and that the resident would trip easily. The manager stated that he and other staff members at the store would have to call the facility to come pick the resident up on many occasions due to the resident being too tired to walk back to the facility. The manager stated he has been working at this store since August 2015 and is very familiar with Resident #2. During an interview on 01/12/16, at 2:15 p.m., with ADON A, he revealed that he went to see Resident #2 at the hospital at approximately 8:00 a.m. on 01/10/16. He stated that he talked to the charge nurse and then talked to the resident and the resident told him he was all right and then told him what had happened. That he did not get hit by a car and tripped on his own feet. The ADON A stated that Resident #2's orientation was fine. The ADON A stated that he assumed that there were no new injuries by this fall due to his chronic dislocated left shoulder and the fall from the week before. He stated that he did not speak with the hospital nursing staff or ER physician regarding the injuries the resident sustained [REDACTED].>During a phone interview on 1/13/16 at 1:10 p.m. with Physician B B (identifier), he revealed that on the afternoon of 1/10/16, he performed a left reversal Shoulder arthroplasty due to Resident 2 ' s unstable shoulder. He stated that the resident ' s left shoulder could not be reduced in the emergency department on 1/10/16 and required surgical intervention. He stated that the resident had Chronic left shoulder dislocations and that the resident had a fall on 12/31/15 which required an emergency room visit to reset his shoulder. The Physician B stated that the fall in the early hours on 1/10/16 could have caused his shoulder to become dislocated and created further damage in which could not be repositioned in the emergency department, requiring surgical intervention. The Physician B stated that the resident should have been monitored by nursing staff after he was administered narcotic pain medications, Wafarin, and Ambien. He stated that due to the resident ' s Chronic medical conditions and fall risk, that the Resident should not have been allowed to leave the facility, especially due to his high risk and history of falls. During an interview with DON B on 1/14/16 at 1:25 p.m., she stated that residents, who leave the facility regularly, especially without the facility ' s knowledge, should have a care plan in place addressing that issue. She stated that residents on blood thinners, narcotics and [MEDICAL CONDITION] medications should be monitored for adverse effects to prevent injury to themselves or other residents. Immediate Jeopardy (IJ) was identified on 1/8/16 at 2:15 p.m. and the Administrator, DON and Regional Nurse Consultant were notified. Record review of the facility policy titled Wandering Device Policy dated 5/2004 revealed the following: Policy; when a resident has potential for elopement and is utilizing a wandering device, the device will be maintained in a manner to protect their safety. Procedure: Exit doors in the facility should have alarms. Door alarms will be tested by the maintenance department per the policies of the department. Results of the tests will be recorded and kept by the maintenance department . When any door is not activating, an employee will monitor the door until it is repaired. Record review of the facility's policy titled Elopement of a Patient, received from the administrator on 01/10/16, revealed that patient will be evaluated for elopement risk upon admission, readmission, quarterly, and with a change in condition as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Elopement occurs when a patient leaves the premises without authorization and/or any necessary supervision to do so. State definitions for elopement vary. Follow state definitions if different. Purpose: To provide process for managing patients at risk for elopement. Process: 1. Assessment evaluation. Identify a patient's elopement risk by reviewing the following: Upon admission, readmission, quarterly, or with significant change in condition as defined by non-electronic medical record system. 2. The elopement evaluation. Complete the elopement evaluation for patients identified at risk. An interdisciplinary elopement prevention care plan will be developed with the family and patient participation. Individual risk factors and patterns will be identified and addressed within the care plan. Obtain a current photograph of the resident and complete the elopement risk identification form for all patients at risk for elopement and place in a binder that is easily accessible to staff 5. Quality assurance performance. Performance improvement: The Safety Committee will review all incidents of elopement; conduct a root analysis cause, correct systems to prevent further incidents, and forward information to the Quality Improvement Committee for further discussion. Sign in and out records will be maintained and used whenever patient leaves center/ground along with family or recreational staff. Staff will be trained on the center's door security system and then required response to sounding door alarm. Security system checks will be conducted routinely and documented to ensure function of wander systems, trigger bracelets, door alarms, and security cameras. Elopement drills will be conducted a minimum of twice per year and documented on the elopement drill documentation form. Elopement drills will be reviewed 6. WanderGuard procedure. Addendum for the nursing facility. #1 functionality of individual WanderGuard System will be tested every shift and will be conducted by treatment nurse and/or designee and noted on the TARs. #2 documented WanderGuard placement checks will be conducted every shift by the charge nurse and/or designee and documented on the TARs. Record review of the facility policy titled Elopement dated 6/26/2006 and revised 05/09/2008 revealed the following: Policy: it is the policy of this facility to protect residents from wandering away from the facility and to begin an immediate search if a resident is found missing. Fundamental information .Elopement, for purposes of this policy and procedure, is defined as that situation where a resident with impaired decision-making ability, who is oblivious to his or her own safety, needs and therefore at risk for injury outside the confines of the facility. Has the resident left the facility without the knowledge of staff. When a patient or resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired; wanders away, walks away, runs away, escapes, or otherwise leaves a caregiving facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge. http://www.elopement.org/ NIEPR Definition for Elopement (National Institute for Elopement Prevention and Protection) .Residents in the secured unit will be deemed at risk for elopement. Residents identified as at risk of elopement will be reassessed quarterly and as needed throughout the Resident Assessment Instrument (RAI) process with behavior monitoring documentation, as indicated. Resident's risk will also be reassessed whenever an elopement event occurs. A plan of care will be developed and updated as indicated by assessment to reduce risk of elopement, such as: Alert bracelet (obtain a physician's order for an alarm/alert bracelet); Assignment to a room away from exits that are commonly utilized; . The frequency of visual checks will be established in accordance with the resident's needs. Facility may record on the Medication Administration Record [REDACTED]. Door alarms, if applicable, will be tested daily and the results recorded on designated logs . 25.The charge nurse will maintain current time-specific documentation in the resident's medical record including the date and the time the resident was last seen, all actions taken to find the resident, and all parties notified . Plan of removal was accepted 01/15/16 at 5:46 p.m. and included: Quality of Care Corrective Action: Incident on 12/16/15: On 12/16/15, the doors and windows at the 600 hall secured unit were inspected and found to be secured. The outside fence and gate were also inspected and found to be closed and secured. The keypad locking mechanisms to the hall doors of all three secured units and front door WanderGuard System were found to be functioning properly. On 12/16/15, the interim Director of Nursing Services (DNS) and Administrator (ADM) conducted a head count and all residents were accounted for. On 12/16/15, the Administrator conducted door security and WanderGuard System checks and the doors and/or WanderGuard System were operational. On 12/16/15, the licensed nurse checked all residents with WanderGuard bracelets to ensure placement and functionality and revealed all in place and functioning properly. Residents' treatment records showed checks of the WanderGuard bracelets had been completed and the residents' pictures were evident in the elopement binders. On 12/16/15, the interim DNS went to the hospital and interviewed Resident #1. who stated, I waited until they were not looking and I snuck out the door. I followed a man out the glass doors and then went out the front door. On 12/16/15, interim DNS reeducated the secured unit staff regarding increased visualizations of residents, elopement policies and procedures, and door security. On 12/17/15, a staff member of the facility was assigned to monitor the exit doors of three secured units at all times. The use of the staff member to monitor the exit doors was discontinued on 12/18/15 after the placement of the WanderGuard bracelets to residents and assessed the secured unit who were assessed to have exit-seeking behaviors. On 12/17/15, the access codes to the secured unit were changed by the Maintenance Director. Signage was placed on the doors of the secured units to instruct family and visitors to contact a staff member for assistance when going through the door. On 12/17/15 and 12/18/15, the facility staff members were reeducated by the interim DNS and the nurse practice educator regarding the changing of secured unit codes. Security of codes is handled by staff members only and procedures for when non-staff members were observed exiting the unit without assistance. On 12/17/15, additional WanderGuard bracelets were ordered by the administrator. Incident o

Based on interview, observation and record review, the Administrator and DON failed to ensure the facility was administered in a manner, which enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well-being for 3 of 10 residents (Resident #1, 2, and 9) reviewed for elopement risks. The facility Administrator failed to implement the facility ' s abuse/neglect policy by failing to investigate and report an incident of resident elopement for Resident # 2. The Administrator and the Director of Nurses (DON) failed to implement the facility ' s elopement policy. This failure resulted in identification an Immediate Jeopardy (IJ) on 1/8/15 at 2:15 pm. While the IJ was removed on 1/29/15 at 5:45 pm, the facility remained out of compliance at a Level of Actual Harm at a Pattern because the facility had not had time to monitor their Plan of Removal for effectiveness. This failure placed 38 residents on the 3 secure units at risk of leaving the facility without staff being aware, placing the residents at risk of serious injury or death. Findings included: In an interview on 1/8/16 at 2:10 p.m. the Administrator was questioned about the IJ and said that he did not know what the facility policy was regarding elopement that he would need to look for it. When asked about how he evaluates policies and procedure to ensure their effectiveness the Administrator said the evaluation was part of the QAA procedure. The Administrator said that he was not sure about the policy for elopement, but felt like there was one. When questioned about what he would expect the staff to do in the event of an elopement he replied, I would expect them to conduct a room-to-room search, closets behind doors, bathroom etc. clear a room and go to the next one. Nursing service to determine who is missing and from where, get a copy of their picture and what they were last wearing, then search the grounds and then farther out if needed. When questioned about when he became aware of a missing resident, the Administrator said he was notified within 15 minutes of the facility being notified by the hospital. The Administrator said he did not know how the resident left the building; he said that the Resident told the DON that she followed a visitor out of the secure unit. The Administrator said that corrective measures he put in place included changing the key pad codes, reevaluated elopement risk assessments, IDT Ad Hoc meeting for ideas, added wanderguard bracelets to those at risk of following others out of the secure units, held in services on elopement, and added a staff member to watch the front door because the front door wander guard system was not working. In an interview on 1/8/16 at 2:30 p.m. , The DON was questioned about the IJ and said that she did not know what the facility policy was regarding elopement that she would need to look for it. When questioned about what she would expect the staff to do in the event of an elopement she replied, I would expect them to conduct a room-to-room search, check a room and go to the next one. Nursing service to determine who is missing and from where, get a copy of their picture and what they were last wearing, then search the grounds and then farther out if needed, call the police for more help, notify the Administrator, DON, physician and the family. When questioned about staff training for elopement the DON replied that she would need to look; but she hoped so. When asked how the IJ happened the DON replied I don ' t know . When questioned about resources the DON said that she was not sure, but I would hope policies and procedures. Resident #1 Record review of the Admission face sheet undated revealed an admitted [DATE]. Resident #1 was an [AGE] year-old female with [DIAGNOSES REDACTED]. Record review of the Social Worker review dated 7/29/15 revealed that Resident #1 had poor decision making skills and was oriented to person. The section addressing Wandering behavior was left unanswered (blank). Record review of nurses ' progress note for Resident #1 dated 9/2/15 at 3:00 a.m. revealed the following: Resident awoke, wandering around Hall 6, escorted to room .3:30 a.m. resident pushed enter button and entered secure unit. Resident escorted to her room in Hall 6. Record review of nurses ' progress note dated 9/2/15 at 11:30 a.m. resident had wander guard in her pocket, replaced on wrist Record review of the physician orders [REDACTED]. Record review of the MDS dated [DATE] identified Resident #1 with a BIMS (Brief Interview for Mental Status) score of 3, indicating moderate (Severe (0-7) Moderate (8-12) Intact (13-15)) cognitive impairment, was ambulatory, and required supervision. Resident #1 was not identified as a wander risk on this document. Record review of the Care plans dated 12/2/15 for Resident #1 did not address wandering or elopement risk. Record review of local EMS run sheet dated 12/16/15 at 7:09 p.m. revealed the following: Chief complaint; right hip pain secondary to fall. History: Resident found sitting on the ground . Alert, confused. Repeats self often. Skin normal color, cool and dry .Right hip pain, increased with movement, no obvious deformity, but severe pain on palpation . In an interview on 12/23/15 at 3:30 p.m. CNA A said that on 12/16/15 Resident #1 was upset and wanting to leave to go home. CNA A stated that she took Resident #1 to the patio to walk and calm down. CNA A said that she checked the back gate it was secured, shut and locked. CNA A walked around the back patio with Resident #1. CNA A reported that she told Resident #1 that it was too cold and dark to be outside, to come inside where it was warm and they entered the facility. CNA A said that Resident #1 said she was going to use the restroom and went down the hallway. CNA A went to assist another resident and that at the same time a restroom was flooded. CNA A said that the last time she saw Resident #1 was approximately 7 p.m. In an interview on 12/23/15 at 4:10 p.m. CNA C said that she was assigned to the secure unit on 12/16/15 when Resident #1 eloped. CNA C said that Resident # 1 had been upset and wanted to leave the unit to go home . CNA A had informed the ADON A. ADON A came and checked the resident, and after he left the unit Resident #1 said she was heading to bed. At the same time another resident was entering others rooms, CNA A went to help that resident & I (CNA C) was watching the residents in the dining room. Another aide (CNA B) entered the unit with a resident to visit on the unit. CNA C said that about 20 minutes later a bathroom flood. CNA C said she went to assist with the flooding and CNA A was watching in the dining room and talking to CNA B. CNA C said she left the unit to get towels and a plunger to clean the flood. CNA C said that no one (resident) was around when she left the unit; she said she was gone about a minute. After fixing the toilet, and cleaning up the mess, CNA A left the unit to get some air freshener and was gone about 5 minutes. About 10 minutes after CNA A returned, CNA B and the other visiting resident exited the unit. About 5 minutes later the ADON A came into the unit and asked about Resident #1 and informed us that she (Resident #1) was at the hospital. In an interview on 1/8/16 at 1:21 p.m. ADON A said that a nurse had called in so ADON A was on call and took over the spot (Hall 3). CNA A came to him and said that Resident #1 was having issues. ADON A said he went on the secure unit to assess Resident # 1 and found her upset and wanting to go home. ADON A said that he was concerned and told CNA A and CNA B both, do not let Resident #1 out of your site, I will come back and check on her. ADON A said that was around 7:00 p.m. or maybe a little before. No one was at the nurse ' s station and that the two nurses (ADON A and an LVN) were giving medications at that time. At around 7:35 p.m. he heard a page for a phone call, it was a local hospital telling me that they had Resident #1 in the emergency room . Resident #1 had been found approximately a block away at the intersection of 14th and Clinton and that Emergency Medical Services (EMS) had picked her up. ADON A said that she was alright but had fallen and had a broken hip. ADON A said that he then called and notified the family, Administrator, Director of Nurses and physician. ADON A said that he then went to the secure unit and found the two CNAs and asked where Resident #1 was? The CNA ' s both responded that Resident #1 was in her room. ADON A said that he told the CNAs that the resident was at a local hospital emergency room . The ADON A said that he educated the CNAs that if they were told to keep a resident in line of site, it meant line of site, Not think you know where someone is. When questioned about exit seeking behaviors the ADON A reported that Resident #1 did not have a history of exit seeking and that she did not have a wander guard bracelet on at the time of the incident. When asked how Resident #1 was able to get out of the secure unit and out of the building, ADON A said I do not know . When asked if there was anything else he could have done differently, the ADON A said that he could have added additional staff and put Resident #1 on one-to-one monitoring. Record review of the incident report dated 12/16/15 revealed that at approximately 7:35 p.m. Facility received a phone call from a local hospital to report Resident #1 was at the hospital, found by bystander 1 block away from the facility at 14th and Clinton. Condition prior to incident: Alert but confused, resident on Transitions secure unit, ambulates independently. Review of the facility Incident/Accident report dated 12/16/15 and completed by the Administrator revealed the following; Staff reported Resident #1 missing from secure unit after being notified by local hospital emergency room that missing resident was in their emergency room . Resident #1 was last seen by staff at approximately 7 p.m. Director of Nursing and Administrator conducted a complete visualization of all residents in the facility verifying that there were no other missing residents. DON, ADM, Director of Maintenance checked all secure unit doors, gates windows and wander guard alarmed doors were in working order and functioning properly. DON conducted an in-service of all staff regarding elopement procedures and visualization of residents. Resident #1 ' s responsible party and doctor were notified. Review of the facility Incident/Accident report dated 12/16/15: Result of investigation; Resident #1 suffered a fractured right hip as a result of elopement. Resident #1 has a history of wandering the building and staff did not notice her missing. Additional interventions and actions to prevent/minimize potential reoccurrence listed on the Incident/Accident Report dated 12/16/15 and completed by ADM revealed the following: 1. Wanderguards were ordered and will be placed on secure unit residents at risk for elopement as identified by the interdisciplinary team. 2. Until wanderguards are placed, a staff member has been assigned to the Unit 2 Nursing station to watch all secure unit doors to ensure no secure unit resident exits from the unit without staff supervision. 3. Key pads have had their codes changed and code guards have been ordered for all keypads to ensure that no residents can inadvertently view/learn the door codes. Resident #2 Record review of face sheet dated 04/27/15 revealed that Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with a readmitted [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #2 elopement risk assessment dated [DATE] revealed that resident's mobility status was ambulatory with a cane. His cognition was alert, behavior was that resident is oriented, able to make decisions, and verbalizes and demonstrates acceptance of placement. It revealed the resident exhibits routine or sporadic confusion, anxiety, or disorientation. It revealed the resident expresses anger or is resistant related to placement, sample of wanting to go home or to work or somewhere else. It revealed that the resident had wanted to leave the facility to socialize or a history of going out to socialize. Under the resident's risk potential for elopement; it is checked not at risk, indicating the resident is not at risk. In the additional comment, it states the resident is not at risk for elopement, signed by DON B on 11/16/15. Question #2, 5, 6 and 10 were checked yes. The directions state that if yes on items 1 or 2, 3 to 5, in combination with any items 6 to 11, that resident should be marked at risk. It states that if it is yes on any one item 6 to 11, resident is at risk, however the elopement risk assessment additional comments stated: Resident is not a risk for elopement. Record review of Resident 2's care plans dated 12/12/15 revealed that Resident #2 was at risk for falls and impaired mobility requiring the use of a cane for balance with a [DIAGNOSES REDACTED]. The risk for elopement and resident signing himself in and out to go to the store was not care planned. Record review of Resident 2's social service note dated 12/31/15 revealed the resident came into the social worker's office before the meeting and wanted the door closed and locked due to people being after him. Social Worker A and MDS coordinator attempted to calm the resident down. He continued to say that there was a hit on him and he was going to die. He explained he could not stay at the facility tonight because someone was going to kill him. The resident was very unsteady on his feet and allowed staff to retrieve his wheelchair. The resident stated that he needed $50 so that he could leave for the night. The Social Worker A discussed discharge planning, not leaving AMA versus with the doctor's order and the potential of consequence. The resident became angry stating you do not understand. Someone will kill me tonight. Social Worker A attempted to calm the resident down and provide support, unsuccessfully. The primary care physician was notified due to increase in delusions and gave okay to look at a behavioral hospital. Record review of Resident #2 ' s quarterly Minimum (MDS) data set [DATE] revealed, in Section C for cognitive patterns, a BIMS score (Brief Interview for Mental Status) of 12, indicating moderate cognitive impairment. It revealed acute onset mental status change. In Section E, titled Behaviors, it revealed that resident had hallucinations and delusions, which were potential indicators of [MEDICAL CONDITION]. In Section G, Functional Status, it revealed that the resident was not steady with moving from seated to standing position, walking, turning around, moving on and off the toilet, and surface-to-surface transfer, but able to stabilize without staff assistance. It revealed that the resident had functional limitation in range of motion on both sides, upper and lower extremities. It revealed that the resident uses a cane, walker, and wheelchair for mobility devices. In Section J, it revealed that the resident had pain almost constantly and receives p.r.n. pain medication. In Section J, Health Conditions, it revealed the resident had shortness of breath or trouble breathing with exertion such as walking, bathing, and transferring; shortness of breath or trouble breathing, when lying flat. In Section J, Fall History, it revealed that the resident has had one fall since previous MDS assessment with two or more injuries which including skin tears, abrasions, lacerations, bruises, hematomas, and fall-related injuries that caused the resident to complain of pain. Record review of Resident 2's social service review dated 01/03/16, for review reason of quarterly review, revealed that Resident 2's cognition is moderately impaired, that Resident 2 exhibits disorganized thinking. The resident demonstrates disorganized thinking at times. He has poor safety awareness. Staff to assist and redirect as needed. Signed by Social Worker A. Record review of Resident #2 physician orders, with a date range of 01/01/2016 through 01/31/16, revealed an order for [REDACTED]. Record review of Resident #2 Medication Administration Record [REDACTED]. It revealed that Resident #2 [MEDICATION NAME] mg one tablet on 01/09/16 for complaints of [MEDICAL CONDITION]. Further record review revealed that Resident #2 did not have any prior administrations [MEDICATION NAME] mg for the month of January 2016. It revealed that the resident received two as-needed doses at bedtime for the month of December 2015. Record review of Resident #2 p.r.n. medication flow sheet, under Section Nurse's Noted, undated, revealed that on 01/09/16, at 8:00 p.m., Resident #2 was administered two tablets of Tylenol #3 for complaints of shoulder pain with a reassessment at 9:00 p.m. by LVN B documenting effective pain relief. It revealed that at 8:00 p.m. Resident #2 was [MEDICATION NAME] mg for complaints of [MEDICAL CONDITION] by LVN B and was documented as not effective at 10:00 p.m. Record review of nursing notes for Resident #2 on 01/10/16, at 1:15 a.m., revealed observed resident standing at nurses' station simply looking around and did not complain of anything or request or verbalize any need. Signed by LVN B. On 01/10/16, at 2:00 a.m., it revealed resident not seen since 1:15 a.m. Search of building began. Signed by LVN B. On 01/10/16, at 2:30 a.m., not found at station 1, code yellow announced, search began at station 2 and outside building. Search of neighborhood began staff in their vehicles. Signed by LVN B. On 01/10/16, at 3:15 a.m., messages left on the voice mails of the administrator, the DON, and the ADON phones. Signed by LVN B . According to wunderground.com, on 1/10/16 the temperature in Abilene between 12:52 a.m. and 2:52 a.m. was 27 degrees Fahrenheit (F), with a wind-chill of 19.5 - 23 degrees F. <http://www.wunderground.com/history/airport/KABI/2016/1/10/DailyHistory.html?req_city=Abilene&req_state=TX&req_statename=&reqdb.zip= &reqdb.magic=1&reqdb.wmo= > (accessed on 2/6/16) Nurse ' s note dated 01/10/16, at 3:20 a.m., received call from CNA D found resident at North Second and Grape Street. Found him lying in the grass near the curb. The resident told CNA D he had been hit by a car. Reported to 9-1-1. Signed by LVN B. Nurse ' s note dated 01/10/16, at 3:50 a.m., emergency responder's returned call reports arriving at Hendricks ER. DON B notified and message left on voice mail of the administrator. Signed LVN B. Nurses note dated 01/10/16, at 6:20 a.m., report received from ER nurse that they are to do surgery today or tomorrow to fix his dislocation of his left shoulder. I asked if he had thought he had been hit by a car. She stated no, do not think so. Signed by LVN B. On 01/10/16, at 10:10 a.m. the ADON A documented, at approximately 9:30 (a.m.), I visited the resident at the hospital. He stated he was doing okay. I asked if he was hurting and he said not right now. I asked him what happened and he said I tripped over my own feet. He also stated that they were going to take him in for surgery this evening . Nurse ' s note dated 01/10/16, at 3:10 p.m., doctor had been notified at 3:10(a.m.) of elopement/hospitalization . Signed by LVN B. Nurse ' s note dated 01/10/16, untimed, revealed resident did not elope. Resident is his own responsible party and signed himself out. Signed by ADON B. Record review of facility's investigation tool dated 01/11/16, received from the Administrator on 01/14/16, revealed the description of the investigation. The investigative process consists of interviewing staff and having contact with Resident# 2 prior to and following the occurrence of resident search. Additionally, interviews were conducted with Resident #2 and hospital staff nurse. A review of the relevant documents, such as medical records, was conducted and pertinent information related to the investigation: #1 code yellow was called and internal and external search conducted until resident located. #2 verification of on-site census. #3 staff statements obtained and reviewed. #4 review of relief for temporary absence form. #5 review of resident chart and care plan. #6 resident interviewed by ADON A. #7 review of hospital medical records for resident. #8 review of DADS' guidelines for missing persons and neglect. Title Interview Notes/Key Documents. Interview notes were obtained from all staff members involved, residents, or others with pertinent knowledge of the care and services provided to Resident #2. Key documents reviewed consisted of: #1 staff witness statements. #2 resident interviews conducted by ADON A. #3 hospital records. #4 release for temporary absence. #5 resident care plan and medical records. Results/Findings revealed that Resident #2 was a [AGE] year-old male originally admitted to the facility on [DATE] with Resident #2's [DIAGNOSES REDACTED].#2 is alert and oriented x3. A review of his most recent Minimum Data Set showed a BIMS score of 12. On 01/10/15, the following occurred: . Record review of the ambulance service for Resident #2 dated 01/10/16 revealed that he was a [AGE] year-old male, had been picked up by the EMS services at 3:24 a.m., on 01/10/16, with primary impression of traumatic injury, abrasions to knees secondary to fall, and injuries from fall from slipping, tripping, stumbling on a street or highway. It revealed the resident was alert and oriented to person and time. It revealed the resident had a hematoma to his forehead, both eyes from a previous fall. It revealed limited range of motion to both upper and lower extremities. The comments revealed EMS arrived on scene. A [AGE] year-old male found sitting in a vehicle, in the passenger side, in the drive of the fire station. A bystander was passing the intersection of North Second and Grape and seen the patient lying down in the grass on the East side of Grape Street. He helped patient into his vehicle and pulled into Station 1. Resident #2 is a resident of the facility and left the facility without the nursing staff knowledge. The patient stated he has walked up to the store on North First to buy something to eat. The patient stated he was walking back to the nursing facility and fell . Resident #2 stated several cars drove passed him, but did not see him. He was not able to get up on his own. The facility was notified and they confirmed that they had been looking for the patient. The resident was transported to a local hospital via stretcher. Record review of Resident #2 ' s history and physical (from the hospital) dated 01/10/16 revealed a chief complaint of a fall. It revealed Resident #2 has been several times in the emergency room recently due to falls, with his most recent time being last week. The patient still had some bilateral periorbital ecchymosis. Today, the patient states he was walking away from the nursing facility when he tripped and fell . He landed on his knees, caught himself with his hands, and then stated that he did hit his head. He had a headache for some time following this fall. The patient presented to the emergency room where he was found to have bruising on his face from his prior fall, as well as a new blemish on his right forehead. The patient also has a separated shoulder and was found to have a dislocated left shoulder that was not able to be relocated with multiple attempts in the Emergency Department. A Physician B was consulted in the emergency room that planned surgical intervention for his shoulder in the coming days. The patient is a moderately poor historian. He has had some headache and is having some pain over his knees where he fell on them .Assessment and Plan: #1 left shoulder dislocation. The patient will be admitted to medical surgical unit for continued monitoring .This patient was seen at 5:00 a.m. on 01/10/16. Signed by Physician A. Record review of Resident 2's hospital operative report dated 01/10/16 revealed a preoperative [DIAGNOSES REDACTED]. Procedure: Left reverse total shoulder arthroplasty . Signed by Physician B. Record review of a witness statement by CNA D dated 01/10/16 revealed I saw Resident 2 walking around from 10:00 p.m. to midnight. A co-worker has asked me if I had seen him around 2:00 a.m. because he was not in his room. Other staff walked in the building to find him, and I drove around the building in my car to try and find him outside. I found him sitting on the sidewalk on North Second and Grape Street. He told me he was on the ground because a car had hit him. Because he said this and because he was in front of the fire station, I decided to knock on the door of the fire station to get immediate medical attention. The firehouse had a phone that I used and directed me to 9-1-1. I waited until after the police and firemen were with him before I went back to work. Signed by CNA D. During an interview on 01/11/16, at 3:10 p.m., with hospital RN revealed that the resident had a left shoulder replacement on 01/10 due to dislocation. During an interview on 01/11/16, at 3:15 p.m., Resident #2 revealed that he did leave the facility the previous night, 01/10/16. He stated no one was at the nurses' desk to sign out. He stated he walked outside of the door in front of the nurses' station at station 1. The resident revealed that he remembers it was cold, he was not wearing a jacket, and that he was walking to South First and back attempting to go to the store. Observation of the resident during the interview revealed that he had a hematoma to his forehead and bilateral black eyes. Resident #2 stated that was from the week before when he fell in the hallway on his face. It was observed that Resident #2 was going to sleep during the interview. An observation during the interview revealed a left shoulder dressing with left arm immobile. He had dressings to both knees. During an interview on 01/11/16, at 3:55 p.m., with the Administrator, he stated that there have not been any elopement attempts since 12/16/15. The administrator stated that Resident #2 is his own responsible party and checked himself out on a regular basis for walks, and that staff became aware about 2:00 a.m. on 1/10/16 that the resident was not in the facility. He said another staff member went searching in a personal vehicle and saw him at the fire station around 3:00. He stated another staff member said the last they saw Resident #2 was at station 1 nursing desk about 1:15 a.m. The administrator stated that his investigation is in progress and that he has not reported this incident to DADS. He stated he did not believe it was a reportable incident. The Administrator stated that he does not consider this incident an elopement because Resident 2 is his own responsible party. The administrator stated that Resident #2 usually does not check himself out during that time of the day. The administrator stated he was told that the resident had slept most of the day and was restless on the night of 01/09/16 and the early morning hours of 01/10/16. The administrator stated the dislocated shoulder had nothing to do with this incident or fall and that the resident was uninjured from this occurrence. He stated the resident had a chronic dislocated shoulder. The administrator stated that no one knew that the resident was leaving the facility and his sign-out sheet was at the nurses' desk that Resident #2 normally signs out. The administrator stated we would not expect anyone to go out at that time of the night. During an interview on 01/12/16, at 12:40 p.m., with a local store manager four blocks from the facility revealed that Resident #2 comes into his store about three to four times a week. He stated that he has noticed that the resident has had bruises and that his legs were swollen. He stated the resident usually uses a cane and his legs are wrapped with some type of dressing. He stated some days he could see visible sores on his legs. The manager stated that the resident walked slowly dragging his feet and that he was afraid that the resident was going to fall in his store. He stated that the resident would dig in his trash looking for lottery tickets, and that the resident would trip easily. The manager stated that he and other staff members at the store would have to call the facility to come pick the resident up on many occasions due to the resident being too tired to walk back to the facility. The manager stated he has been working at this store since August 2015 and is very familiar with Resident #2. During an interview on 01/12/16, at 2:15 p.m., with ADON A, he revealed that he went to see Resident #2 at the hospital at approximately 8:00 a.m. on 01/10/16. He stated that he talked to the charge nurse and then talked to the resident and the resident told him he was all right and then told him what had happened. That he did not get hit by a car and tripped on his own feet. The ADON A stated that Resident #2's orientation was fine. The ADON A stated that he assumed that there were no new injuries by this fall due to his chronic dislocated left shoulder and the fall from the week before. He stated that he did not speak with the hospital nursing staff or ER physician regarding the injuries the resident sustained [REDACTED].>During a phone interview on 1/13/16 at 1:10 p.m. with Physician B , he revealed that on the afternoon of 1/10/16, he performed a left reversal Shoulder arthroplasty due to Resident 2 ' s unstable shoulder. He stated that the resident ' s left shoulder could not be reduced in the emergency department on 1/10/16 and required surgical intervention. He stated that the resident had Chronic left shoulder dislocations and that the resident had a fall on 12/31/15 which required an emergency room visit to reset his shoulder. The Physician B stated that the fall in the early hours on 1/10/16 could have caused his shoulder to become dislocated and created further damage in which could not be repositioned in the emergency department, requiring surgical intervention. The Physician B stated that the resident should have been monitored by nursing staff after he was administered narcotic pain medications, Wafarin, and Ambien. He stated that due to the resident ' s Chronic medical conditions and fall risk, that the Resident should not have been allowed to leave the facility, especially due to his high risk and history of falls. During an interview with DON B on 1/14/16 at 1:25 p.m., she stated that residents, who leave the facility regularly, especially without the facility ' s knowledge, should have a care plan in place addressing that issue. She stated that residents on blood thinners, narcotics and [MEDICAL CONDITION] medications should be monitored for adverse effects to prevent injury to themselves or other residents. Immediate Jeopardy (IJ) was identified on 1/8/16 at 2:15 p.m. and the Administrator, DON and Regional Nurse Consultant were notified. Resident #9 Record review of the Admission face sheet revealed an admitted [DATE]. Resident #9 was a [AGE] year-old female wit

Based on observation, interview and record review the facility failed to ensure 3 of 33 residents (Resident #1, #2, and #4) reviewed for elopement risk received adequate supervision to prevent elopement. Resident #1, who the facility had assessed to be at risk for elopement and wore a wander guard bracelet, exited the facility on [DATE] without the wander guard alarm sounding, and was returned by facility staff. Resident #1 left the facility again on the morning of [DATE] and was returned by staff, who noticed the wander guard alarm did not sound. On [DATE] after 9:45 a.m. Resident #1 left the faciity on ce again without staff being aware. Police were called at 10:32 a.m. by a concerned citizen who found Resident #1 one mile from the facility, confused and only able to provide her name. The resident was transported to the hospital for assessment. The facility was unaware Resident #1 was missing when they were contacted by Adult Protective Services (APS) at 12:00 p.m. and informed she was at the hospital. Resident #2, who had a history of [REDACTED]. His adjustment to the new unit was not monitored. Five days later, on [DATE] Resident #2 left the facility without staff being aware. A concerned citizen notified the facility there was a man in a wheelchair two blocks away, in need of supervision. Resident #4 who had been on the Secured Unit in building two was transferred to a room in the unsecured hall in building one on [DATE]. A wander guard device was placed on Resident #4's wheelchair at the time of transfer. Treatment Nurse B who was assigned the task to check the wander guards for placement and functionality Monday thru Friday was unaware that Resident #4 had a wander guard device. His wander guard device was not placed on the TAR nor was the device checked for placement or functionality from the days of [DATE] thru [DATE] as per facility's new system. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of potential for more than minimal harm and a scope of pattern, due to the facility monitoring the implementation of the Plan of Removal. This failure placed 14 residents at risk of leaving the facility without staff being aware, placing the residents at risk of serious injury or death. Findings include: Resident #1 Record review of an undated face sheet for Resident #1 revealed she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Wandering/ Elopement Risk Assessment Tool dated [DATE] documented under Behaviors revealed the following; Question #4; Currently takes medication which may cause confusion, the facility answered yes, Question #5; Exhibits routine or sporadic confusion, anxiety or disorientation, the facility answered yes, Residents at risk for elopement if the answer is yes, on any item (question) ,[DATE] or in combination with any item ,[DATE] . Based on the responses of the Elopement Risk Assessment Tool Resident #1 was considered at risk for Elopement. Review of Resident #1's Care Plan dated [DATE] documented the problem/need; Resident #1 does wander throughout the facility and has a history of verbal aggression, she wears a wander guard bracelet. Goal; Resident #1 will wander safely in facility. Approaches; Activities staff to visit with Resident and provide diversional activities; In an interview on [DATE] at 2:50 p.m. with CNA F she said that on Friday [DATE] she and another nurse aide went outside and Resident #1 followed them out the door and her wander guard device did not make the alarms on the door sound. She said that she told DON B and she saw her write something on her hand so she thought that DON B took care of it. She said that before Resident #1 eloped the facility did not really have a system in place to check the functionality of the wander guards except if the resident went to the door and the alarm did not sound that would mean the wander guard bracelet was no longer working. In an interview on [DATE] at 8:50 a.m. with housekeeper A, she said that she found Resident #1 outside earlier that Saturday morning that she eloped (,[DATE]). She said that when she took Resident #1 back into the facility the door alarm did not go off. She said that was about 9:45 a.m. She said when she took the resident back into the facility she told CNA F that Resident #1 had been outside of the facility walking around the laundry area. She said that she told CNA F that she needed to watch out for her because she had already been outside and her wander guard wasn't working. She said that CNA F said okay I got it. She said that she looked in on Resident #1 after that but she never saw her in her room. She said that she just thought that the resident was out walking up and down the halls like she usually did. Review of the Incident/Accident report dated [DATE] and completed by DON B revealed the following; Resident #1 exited the building, was found by police and taken to the emergency room for assessment. Facility notified by hospital that Resident #1 was currently in the ER. Result of investigation; No injuries as a result of elopement. The wander guard system was working however the resident's wander guard device had expired in February 2015 and was not alarming at the door. Resident #1 has a history of wandering the building and staff did not notice her missing. She had left the building earlier that morning (,[DATE]) but was seen by housekeeping staff and returned to her room. The housekeeping staff member did not tell the charge nurse that the wander alarm didn't go off. Resident #1 was assessed for the Secured Unit, a physician's order was obtained and Resident #1 was moved to the Secured Unit on [DATE]. Resident #1 stated she didn't wander far that she didn't mean to leave that she was just out walking. Daily checks of the wander guard devices were not being done because the facility did not have the testing instrument. Additional interventions and actions to prevent/minimize potential reoccurrence listed on the Incident/Accident Report dated [DATE] and completed by DON B revealed the following: Residents will be placed on TAR's or wound nurse to check alarm bands daily. Notebooks compiled identifying elopement risk, residents by name and picture, will be at each nurse's station and at the receptionist desk. All residents with wander guards had their bracelets checked for expiration date. This date is listed on their assessments and in identification book. In an interview on [DATE] at 3:10 p.m. with LVN A she said that she was working on Saturday (,[DATE]) Resident #1 eloped. She said that she had seen Resident #1 earlier in the day around 9:00 a.m. when she was passing out medication. She said that she was not aware that Resident #1 left the facility until she received a phone call from APS stating that Resident #1 was in the emergency room at the local hospital. She said that the PD had picked her up and had taken her to the ER for an evaluation. She said that she was never told by anyone that Resident #1 had been out of the facility earlier that morning. She said that the facility did not have a working system in place until Resident #1 eloped. In an interview on [DATE] at 4:45 p.m. with the Adult Protective Service (APS) Worker regarding Resident #1 she said that a concerned citizen saw the resident and called the local Police Department (PD). She said the PD contacted her as she was the APS worker on call that weekend. She said that when the PD found Resident #1 which was reported as 10:32 a.m. that she was at Fourteenth Street and Mockingbird Lane. She said that Resident #1 was unable to tell the police officer anything but her name. She said that the police officer told her that Resident #1 was confused, her clothing was soiled and that he saw some dried blood on her clothing. She said that Resident #1 was taken to the emergency room (ER) at the local hospital to be evaluated. She said that she called the ER and spoke with the nurse who was caring for Resident #1 and she was told that the resident had a bracelet on her wrist that she identified as a wandering device. She said the ER nurse told her that Resident #1 had no form of identification on her person when she came into the ER. She said that because she is familiar with the wander guard bracelets she asked the ER nurse if the device had anything written on it. She said the ER nurse told her that it had an expiration date of February 2015. The APS worker said she called the nursing home nearest the location where Resident #1 had been found and the person on the phone stated that the resident was a resident at the facility. She said the facility was unaware that Resident #1 had left the premises. Observation on [DATE] at 5:40 p.m. of the area surrounding the facility in a one mile radius of the location Resident #1 was found by the PD (Fourteenth Street and Mockingbird Lane) revealed a high traffic area. There were numerous large dogs seen roaming freely, unattended without collars or leashes. Fourteenth Street is not a through street from the facility to Mockingbird Lane. The street comes to a dead end with rails up at the end of the street blocking access across a large ditch. There is a cross walk over the ditch that connects close to fourteenth Street which leads out to Mockingbird Lane. Review of nurse's notes for Resident #1 revealed the following: [DATE] at 12:00 p.m. The facility received a call from Adult Protective Services stating Resident #1 was found outside the facility and was taken to the emergency room for evaluation. The Administrator, the Assistant Administrator, the Director of Nursing was notified at this time. [DATE] at 1:20 p.m., Notified Responsible Party that Resident was found by Police Department and taken to the emergency room . Resident was not injured and is currently still in the emergency room . [DATE] at 3:30 p.m. Resident returned to the facility via facility van, escorted to her room by staff. New order for Cipro 500 mg one by mouth twice a day for seven days for urinary tract infection. [DATE] at 5:35 p.m. Received a call back from Physician with orders to transfer Resident #1 to Secured Unit for admission. Review of a Physician's Telephone Order dated [DATE] written by LVN A revealed, regarding Resident #1,Transfer resident from room (in unsecured unit) to Secure Unit; diagnosis; elopement. Record review of Resident #1's care plan updated on [DATE] revealed the following, Resident was found outside of building without supervision. Approaches; Resident #1 admitted to the Secured Unit per physician orders due to lack of safety awareness. Resident was transferred to the Secured Unit per physician orders on [DATE] due to lack of safety awareness. The care plan dated [DATE] created by Social Services (SS), revealed the following: Interventions; assess for elopement. Encourage meaningful activities program of choice. Provide picture identification and description of resident to offices, staff located near exits, utilize and monitor security bracelet per protocol. Observation on [DATE] at 2:00 p.m. of Resident #1 was on the Secured Unit, she was walking up and down the hall. She said that she was bored and that the activities were for 3 or 4 year old children and she was not interested in participating. This writer asked her what she would like to do in the way of activities she said I like to sleep. When this writer asked her about her elopement and trip to the emergency room two weeks ago she said I don't remember being out of the facility or a trip to the emergency room . Review of the Facility Provider Investigation Report Summary dated [DATE] (regarding Resident #1) revealed on [DATE] at (time unknown) the resident had wandered outside the door on the sidewalk between the laundry room and smoking porch earlier that day, she was on facility property and within eyesight of staff at all times. Housekeeper brought her back into the building on the wrong hall and told CNA that resident had gotten outside but the alarm didn't sound. She took resident to her room and told her CNA that the resident had wandered out the door and needed to be watched but she didn't mention the alarm not sounding. CNA did not tell the charge nurse, nor did the housekeeper, the resident began wandering the building again (which she does all the time) and got outside again without the alarm sounding. She wandered approximately one mile away before she was noticed by neighbor who called the police and the facility was notified. The Provider Investigation Report Post-Investigation Action dated [DATE] revealed, The facility purchased new testers for the wander guards to enable timely, daily testing. On-going in-service which will be repeated with staff monthly for 90 days and issue will be discussed in the Quality Assurance (QA) meetings over the next 90 days. Residents identified as exit seeking risk are being transferred to a Secured Unit within the facility. Will conduct Missing Resident Drill and report results to QA meetings for oversight on proper procedure. In an interview on [DATE] at 2:30 p.m. with ADON A she said that when she was in charge of the wander guards about six months ago she put them on the Treatment Administration Record's (TAR's) and they were checked every day. She said that Administrator B (who no longer works at the facility) use to go around and visually check that the resident's wander guards were in place. She said that she doesn't know when they stopped that system. In an interview on [DATE] at 1:25 p.m. with Administrator A and MCO B the Administrator said that Resident #1 was found outside of the facility by a member of the housekeeping staff earlier that morning. She said that the housekeeper brought Resident #1 back into the facility to station two (Resident #1 lived in building one). She said that the housekeeper told a Certified Nursing Assistant (CNA) that the alarm did not go off when Resident #1 walked out the door. She said that prior to Resident #1's elopement the facility did not have a system in place to monitor the wander guard devices. She said that if a resident got close to the doors the alarms would sound if these were functioning properly. She said that was the only thing they had in place. She said that had to purchase a tester to check the functionality of the wander guard bracelets. She said that you can point the tester at the wander guard device and if the device blinked four green blinks on the tester the wander guard device was functioning properly. If the device blinked a red light on the tester that means that the device is still functional but doesn't have too much juice. She said that a constant red light on the tester meant that the device is no longer functional. She said that they were not going to take any chances in the future they were going to change out the wander guard devices with any red blinking lights on the tester. Resident #2 Record review of an undated admission face sheet of Resident #2 revealed he was an [AGE] year old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. Record review of the Quarterly assessment dated [DATE] revealed that Resident #2 was alert, his cognitive skills for decision making was severely impaired, he had poor appetite, he had the ability to understand and was usually understood. His behavioral symptoms were; wandering, verbally and physically abusive, and occasionally rejects care. He moves all extremities but had left sided weakness in both his upper and lower extremities. Record review of the Elopement Risk assessment dated [DATE] written by DON B revealed that Resident #2 was currently in the Secured Unit, he was non-ambulatory and was currently in a wheelchair and has had no recent (last six months) attempts of elopement. Record review of Social Service progress notes dated [DATE] written by SS revealed that Resident #2 was being relocated to a room outside the Secured Unit into the unsecured hall. Resident#2 no longer met criteria to reside on the Secured Unit. On [DATE] at 2:05 p.m., review of the 24 hour report dated [DATE], [DATE], and [DATE] with the DON B, revealed there was documentation on the twenty four (24) hour report that indicated Resident #2 was transferred out of the Secured Unit to room in the unsecured hall. There was no other documentation regarding Resident #2's adjustment out of the Secured Unit. DON B said that she was not sure why the nurses did not document Resident #2's adjustment to the unsecured hall from the Secured Unit. She said that the nurses should have documented in the nurses notes. In an interview on [DATE] at 1:55 p.m. with LVN C she said that she was working that Saturday morning ([DATE]) Resident #2 eloped from the facility. She said that a concerned citizen came into the facility and said there was a man in a wheelchair about two blocks away that looked like he needed to be supervised. She said she went out to check on him and she identified him as Resident #2. She said that she brought him back to the facility. She said that she assessed the resident and he did not have any injuries. She said that he was thirsty and she gave him some water. She said that Resident #2 was transferred back into the Secured Unit that day. Record review of nurse's notes dated [DATE] revealed that Resident #2 was transferred off of the Secured Unit to a room in the unsecured hall on Friday, [DATE] at 4:00 p.m. There was no other documentation in the nurse's notes until the elopement on [DATE]. There was no documentation of his adjustment to the unsecured unit. No observations or assessments were documented. There was no telephone or written physician's order for Resident #2 to be transferred out of the Secured Unit or transfer back to the Secured Unit. There was no documentation that the POA was notified of the transfer off the Secured Unit and it was discovered that the telephone number the facility had for the POA was no longer valid as the POA had been deceased for an undetermined amount of time. The consent to be transferred back to the Secure Unit was given by his sister at a later time. Review of the nurse's notes dated [DATE] written by LVN D revealed that Resident #2 left the facility out the front door, wheeled himself about two blocks. He was brought back to the facility by another LVN. Resident #2 gave his address and said that he was going home. Resident #2 was transferred back into the Secured Unit on [DATE]. (There was no time documented in the nurse's notes of the times of the elopement or the return of Resident #2 back to the facility). There was no documentation in the nurse's notes that Resident #2's Physician or his Power of Attorney (POA) was notified of his elopement. Record review of the Elopement Risk assessment dated [DATE] by ADON B for Resident #2, revealed that Resident #2 was recently transferred from the Secured Unit due to no elopement attempts. Resident transfers self from bed to wheelchair by himself and is able to propel himself in the wheelchair. Resident #2 wanders in and out of other resident rooms. Observation/interview on [DATE] at 11:30 a.m. Resident #2 was on the Secured Unit, he was sitting in a wheelchair in the dining room. He was observed propelling himself in the wheelchair. He said I am waiting for my wife to show up to have lunch. In an interview on [DATE] at 2:30 p.m. with Certified Nursing Assistant (CNA) K regarding Resident #2 she said that he has not made any attempt to propel himself in the wheelchair in the Secured Unit. She said that she was unaware that he was capable of doing that. She said that she did not work in the Secured Unit very often and was surprised that he was able to elope from the facility. In an interview on [DATE] at 1:25 p.m. with the Administrator and Manager of Clinical Operations (MCO) the Administrator said that Resident #2 was transferred from the Secured Unit to a room on the unsecured hall on [DATE] after a Wandering Risk Assessment was completed. She said that Resident #2 had not had any wandering behaviors for the last six months. She said that she was not the Administrator of the facility at the time of Resident #2's elopement. She called in the Assistant Administrator to the office who stated that she was out of town when the decision was made to transfer Resident #2 out of the Secured Unit. Director of Nurses (DON) B was called into the office and she said that she was the nurse that did the Risk Assessment on Resident #2. She said that she felt because there had been no exit seeking behavior in the last six months and because Resident #2 was unable to self-propel his wheelchair that it was safe to transfer him out of the Secured Unit to a room in the unsecured hall. When this writer asked about documentation in the nurses notes regarding Resident #2's adjustment from the Secured Unit to the unsecured hall she said that the nurses should have documented something regarding his adjustment off the unit. Observation on [DATE] at 2:45 p.m. of station two in building two revealed there was no wander guard notebook located at nurses station two as per an earlier interview with the administrator. In an interview on [DATE] at 2:50 p.m. with LVN E she said that she was unaware that there was a wander guard book located at the nurse's station (station two). She said that she could not recall being in-serviced on such book. In an interview on [DATE] at 2:55 p.m. with the Assistant Administrator she said that she did not make a wander guard notebook for station two (building two). She said that she just made one for station one (building one) and the receptionist (note at the time of this interview the receptionist was not at the receptionist desk). Resident #4 Record review of an undated admission face sheet of Resident #4 revealed he was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record Review of Resident #4's MDS dated [DATE] revealed that Resident #4 was alert but confused. His speech was slurred and often times mumbles. He was usually able to express himself and had the ability to sometimes understand others. He had a Brief Interview for Mental Status (BIMS) score of 03 which is indicative of severe impairment. Resident #4 was totally dependent on one staff person to assist him with bed mobility, eating, and toileting. He required total dependence of two staff for transfers as he required a Hoyer lift. He required extensive assistance of one person for personal hygiene and bathing. He used a wheelchair for mobility and required assistance of one staff member to move between locations. Resident #4 had not exhibited any wandering behaviors. Record review of the Nurses Notes dated [DATE] revealed Resident #4 was transferred from the Secured Unit (building two) to a room in the non-secured hall in (building one) on Friday [DATE]. A wander guard device was attached to his wheelchair at that time. In an interview on [DATE] at 4:30 p.m. with DON B she said that She was the one who did the risk assessment on Resident #4. She said that she had applied the wander guard to his wheelchair. She said that Resident #4 was capable of propelling his wheelchair and she wanted to monitor him to ensure he did not make attempts to elope. In an interview on [DATE] with ADON A at 6:25 p.m. she said that Resident #4 has not been ambulatory for over a year. She said that he has to be transferred with a Hoyer lift. This writer asked why Resident #4 was wearing a wander guard if he was not at risk for elopement. She said that he was capable of propelling his wheelchair out the door. Record review of Resident #4's TAR's revealed there was no wander guard listed. The days from [DATE] through [DATE] Resident #4's wander device had not been checked for placement or functionality. There was no documentation in the TAR as per facilities new system. Review on [DATE] at 3:00 p.m. of the Notebook at Nurses Station One titled Wander guards revealed that Resident #4 was identified in the notebook via a photograph that indicated he was wearing a wander guard device. There was no date listed on the photo of Resident #4 identifying the expiration date of the wander guard device. Observation on [DATE] at 3:05 p.m. revealed that Resident #4 was in the lobby in building one, close to the nurse's station. Resident #4 did have a wander guard device located on his wheelchair. In an interview/observation on [DATE] at 3:10 p.m. with Treatment Nurse B she said that since Resident #1's elopement she had been given the assignment to do a daily check of those residents that had a wander guard device. She said that she checked for placement and functionality of any resident that resided on Station One that was wearing a wander guard device. She said that the Residents that wore wander guard devices were placed on the Treatment Administration Record (TAR) and it was her responsibility to check those residents Monday thru Friday. She said that on the weekends it was the Charge nurses responsibility. When this writer asked Treatment Nurse B about Resident #4's wander guard she said that she was unaware that resident #4 had a wander guard device. She said that Resident #4 was transferred from the Secured Unit in the other building, station two on Friday [DATE]. Treatment Nurse B and this writer identified that Resident #4 did have a wander guard device on his wheelchair. The device was checked for functionality and date of expiration. At that time a TAR was created by Treatment Nurse B for Resident #4 to have the wander guard device checked each shift for placement and daily for functionality. Record review of the facility policy titled Wandering Device Policy dated ,[DATE] revealed the following: Policy; When a resident has potential for elopement and is utilizing a wandering device, the device will be maintained in a manner to protect their safety. Procedure: 1. A doctor's order will be obtained and a care plan developed when the resident is assessed to benefit from the use of a wandering device. 2. It is recommended that a log will be maintained at the nurse's station and in the front office with the name of those residents utilizing a device. The facility Administrator will designate the individual responsible for maintaining the log. 3. If transponders are utilized, devices will be tested with the Transponder Tester weekly and documented by the administrator's designee in a log. 4. Devices not working will be replaced. An adequate supply should be available. 5. Exit doors in the facility should have alarms. Door alarms will be tested by the maintenance department per the policies of the department. Results of the tests will be recorded and kept by the maintenance department. 6. Devices will be replaced on the resident's dominant wrist, if possible. 7. Staff members should be trained during orientation and at least annually thereafter on the wandering device alert system. This should include education on the use of the device, location of the monitor, and how to and who should answer the alarm, and how to silence monitors. 8. When a door activator is not working, all residents who are an elopement risk will be monitored more frequently until the activation is repaired. 9. When any door is not activating, an employee will monitor the door until it is repaired. Record review of the facility policy titled Elopement dated [DATE] and revised [DATE] revealed the following: Policy: it is the policy of this facility to protect residents from wandering away from the facility and to begin an immediate search if a resident is found missing. Fundamental information .Elopement, for purposes of this policy and procedure, is defined as that situation where a resident with impaired decision-making ability, who is oblivious to his or her own safety, needs and therefore at risk for injury outside the confines of the facility. Has the resident left the facility without the knowledge of staff. Wandering, is defined as locomotion with no discernible, rational purpose, either walking or in a wheelchair. The wandering resident may be oblivious to his or her physical or safety needs. Procedure: Assessment; 1. The resident will be assessed for risk of elopement upon admission, 2. The family will be interviewed for previous history of elopement and responses recorded in the medical record. 3. Residents in the secured unit will be deemed at risk for elopement. 4. Residents identified as at risk of elopement will be reassessed quarterly and as needed throughout the Resident Assessment Instrument (RAI) process with behavior monitoring documentation, as indicated. 5. Resident's risk will also be reassessed whenever an elopement event occurs. 6. A plan of care will be developed and updated as indicated by assessment to reduce risk of elopement, such as: · Alert bracelet (obtain a physician's order for an alarm/alert bracelet); · Assignment to a room away from exits that are commonly utilized; · Sign on resident's room with his/her name in large letters. · Place a stop sign on exit door; · Engagement in group activities for supervision; · Assignment to supervised dining program; · Distract resident with items he/she enjoys i.e. photos, games, television program, conversation, meaningful tasks to resident i.e. folding clothing, food preparation, manipulation of safe tools etc. 7. The frequency of visual checks will be established in accordance with the resident's needs. Facility may record on the Medication Administration Record (MAR)/Treatment Administration Record (TAR) or other form of documentation. Prevention 8. The facility will have a system of identification of all residents . 9. This facility uses the following resident identification system (specify): (Document was left Blank). 10 Resident assessed as at risk for elopement with or without current exit seeking behavior will have a photograph taken and placed in medical record or as designated by facility. A second photograph will be maintained in a binder at the receptionist desk or as designated by the facility. Photographs will be reviewed and updated during resident's quarterly assessment or on an as needed basis. 11 Resident or responsible party will be given instruction on the facility leave of absence or out-on-pass policy. 12 The licensed nurse will observe that each resident's wander device is in place each shift, if applicable. Document findings on the MAR/TAR or other form of documentation. 13 Maintenance staff will maintain a roster of residents with alarm bracelets devices, check bracelet alarm device monthly and replace according to manufactures directions. Document findings on preventative maintenance record or other designated record. 14 Door alarms, if applicable, will be tested daily and the results recorded on designated logs . 23. Staff will notify the charge nurse of any elopement attempt . 25.The charge nurse will maintain current time-specific documentation in the resident's medical record including the date and the time the resident was last seen, all actions taken to find the resident, and all parties notified. Post Elopement Assessment and Action: 28. After the resident is located, the charge nurse will assess for changes in condition. Assessment may include, but not limited to, observed behav

Based on observation, interview and record review the facility failed to ensure 3 of 33 residents (Resident #1, #2, and #4) reviewed for elopement risk received adequate supervision to prevent elopement. Resident #1, who the facility had assessed to be at risk for elopement and wore a wander guard bracelet, exited the facility on [DATE] without the wander guard alarm sounding, and was returned by facility staff. Resident #1 left the facility again on the morning of [DATE] and was returned by staff, who noticed the wander guard alarm did not sound. On [DATE] after 9:45 a.m. Resident #1 left the faciity on ce again without staff being aware. Police were called at 10:32 a.m. by a concerned citizen who found Resident #1 one mile from the facility, confused and only able to provide her name. The resident was transported to the hospital for assessment. The facility was unaware Resident #1 was missing when they were contacted by Adult Protective Services (APS) at 12:00 p.m. and informed she was at the hospital. Resident #2, who had a history of [REDACTED]. His adjustment to the new unit was not monitored. Five days later, on [DATE] Resident #2 left the facility without staff being aware. A concerned citizen notified the facility there was a man in a wheelchair two blocks away, in need of supervision. Resident #4 who had been on the Secured Unit in building two was transferred to a room in the unsecured hall in building one on [DATE]. A wander guard device was placed on Resident #4's wheelchair at the time of transfer. Treatment Nurse B who was assigned the task to check the wander guards for placement and functionality Monday thru Friday was unaware that Resident #4 had a wander guard device. His wander guard device was not placed on the TAR nor was the device checked for placement or functionality from the days of [DATE] thru [DATE] as per facility's new system. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of potential for more than minimal harm and a scope of pattern, due to the facility monitoring the implementation of the Plan of Removal. This failure placed 14 residents at risk of leaving the facility without staff being aware, placing the residents at risk of serious injury or death. Findings include: Resident #1 Record review of an undated face sheet for Resident #1 revealed she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Wandering/ Elopement Risk Assessment Tool dated [DATE] documented under Behaviors revealed the following; Question #4; Currently takes medication which may cause confusion, the facility answered yes, Question #5; Exhibits routine or sporadic confusion, anxiety or disorientation, the facility answered yes, Residents at risk for elopement if the answer is yes, on any item (question) ,[DATE] or in combination with any item ,[DATE] . Based on the responses of the Elopement Risk Assessment Tool Resident #1 was considered at risk for Elopement. Review of Resident #1's Care Plan dated [DATE] documented the problem/need; Resident #1 does wander throughout the facility and has a history of verbal aggression, she wears a wander guard bracelet. Goal; Resident #1 will wander safely in facility. Approaches; Activities staff to visit with Resident and provide diversional activities; In an interview on [DATE] at 2:50 p.m. with CNA F she said that on Friday [DATE] she and another nurse aide went outside and Resident #1 followed them out the door and her wander guard device did not make the alarms on the door sound. She said that she told DON B and she saw her write something on her hand so she thought that DON B took care of it. She said that before Resident #1 eloped the facility did not really have a system in place to check the functionality of the wander guards except if the resident went to the door and the alarm did not sound that would mean the wander guard bracelet was no longer working. In an interview on [DATE] at 8:50 a.m. with housekeeper A, she said that she found Resident #1 outside earlier that Saturday morning that she eloped (,[DATE]). She said that when she took Resident #1 back into the facility the door alarm did not go off. She said that was about 9:45 a.m. She said when she took the resident back into the facility she told CNA F that Resident #1 had been outside of the facility walking around the laundry area. She said that she told CNA F that she needed to watch out for her because she had already been outside and her wander guard wasn't working. She said that CNA F said okay I got it. She said that she looked in on Resident #1 after that but she never saw her in her room. She said that she just thought that the resident was out walking up and down the halls like she usually did. Review of the Incident/Accident report dated [DATE] and completed by DON B revealed the following; Resident #1 exited the building, was found by police and taken to the emergency room for assessment. Facility notified by hospital that Resident #1 was currently in the ER. Result of investigation; No injuries as a result of elopement. The wander guard system was working however the resident's wander guard device had expired in (MONTH) (YEAR) and was not alarming at the door. Resident #1 has a history of wandering the building and staff did not notice her missing. She had left the building earlier that morning (,[DATE]) but was seen by housekeeping staff and returned to her room. The housekeeping staff member did not tell the charge nurse that the wander alarm didn't go off. Resident #1 was assessed for the Secured Unit, a physician's order was obtained and Resident #1 was moved to the Secured Unit on [DATE]. Resident #1 stated she didn't wander far that she didn't mean to leave that she was just out walking. Daily checks of the wander guard devices were not being done because the facility did not have the testing instrument. Additional interventions and actions to prevent/minimize potential reoccurrence listed on the Incident/Accident Report dated [DATE] and completed by DON B revealed the following: Residents will be placed on TAR's or wound nurse to check alarm bands daily. Notebooks compiled identifying elopement risk, residents by name and picture, will be at each nurse's station and at the receptionist desk. All residents with wander guards had their bracelets checked for expiration date. This date is listed on their assessments and in identification book. In an interview on [DATE] at 3:10 p.m. with LVN A she said that she was working on Saturday (,[DATE]) Resident #1 eloped. She said that she had seen Resident #1 earlier in the day around 9:00 a.m. when she was passing out medication. She said that she was not aware that Resident #1 left the facility until she received a phone call from APS stating that Resident #1 was in the emergency room at the local hospital. She said that the PD had picked her up and had taken her to the ER for an evaluation. She said that she was never told by anyone that Resident #1 had been out of the facility earlier that morning. She said that the facility did not have a working system in place until Resident #1 eloped. In an interview on [DATE] at 4:45 p.m. with the Adult Protective Service (APS) Worker regarding Resident #1 she said that a concerned citizen saw the resident and called the local Police Department (PD). She said the PD contacted her as she was the APS worker on call that weekend. She said that when the PD found Resident #1 which was reported as 10:32 a.m. that she was at Fourteenth Street and Mockingbird Lane. She said that Resident #1 was unable to tell the police officer anything but her name. She said that the police officer told her that Resident #1 was confused, her clothing was soiled and that he saw some dried blood on her clothing. She said that Resident #1 was taken to the emergency room (ER) at the local hospital to be evaluated. She said that she called the ER and spoke with the nurse who was caring for Resident #1 and she was told that the resident had a bracelet on her wrist that she identified as a wandering device. She said the ER nurse told her that Resident #1 had no form of identification on her person when she came into the ER. She said that because she is familiar with the wander guard bracelets she asked the ER nurse if the device had anything written on it. She said the ER nurse told her that it had an expiration date of (MONTH) (YEAR). The APS worker said she called the nursing home nearest the location where Resident #1 had been found and the person on the phone stated that the resident was a resident at the facility. She said the facility was unaware that Resident #1 had left the premises. Observation on [DATE] at 5:40 p.m. of the area surrounding the facility in a one mile radius of the location Resident #1 was found by the PD (Fourteenth Street and Mockingbird Lane) revealed a high traffic area. There were numerous large dogs seen roaming freely, unattended without collars or leashes. Fourteenth Street is not a through street from the facility to Mockingbird Lane. The street comes to a dead end with rails up at the end of the street blocking access across a large ditch. There is a cross walk over the ditch that connects close to fourteenth Street which leads out to Mockingbird Lane. Review of nurse's notes for Resident #1 revealed the following: [DATE] at 12:00 p.m. The facility received a call from Adult Protective Services stating Resident #1 was found outside the facility and was taken to the emergency room for evaluation. The Administrator, the Assistant Administrator, the Director of Nursing was notified at this time. [DATE] at 1:20 p.m., Notified Responsible Party that Resident was found by Police Department and taken to the emergency room . Resident was not injured and is currently still in the emergency room . [DATE] at 3:30 p.m. Resident returned to the facility via facility van, escorted to her room by staff. New order for Cipro 500 mg one by mouth twice a day for seven days for urinary tract infection. [DATE] at 5:35 p.m. Received a call back from Physician with orders to transfer Resident #1 to Secured Unit for admission. Review of a Physician's Telephone Order dated [DATE] written by LVN A revealed, regarding Resident #1,Transfer resident from room (in unsecured unit) to Secure Unit; diagnosis; elopement. Record review of Resident #1's care plan updated on [DATE] revealed the following, Resident was found outside of building without supervision. Approaches; Resident #1 admitted to the Secured Unit per physician orders due to lack of safety awareness. Resident was transferred to the Secured Unit per physician orders on [DATE] due to lack of safety awareness. The care plan dated [DATE] created by Social Services (SS), revealed the following: Interventions; assess for elopement. Encourage meaningful activities program of choice. Provide picture identification and description of resident to offices, staff located near exits, utilize and monitor security bracelet per protocol. Observation on [DATE] at 2:00 p.m. of Resident #1 was on the Secured Unit, she was walking up and down the hall. She said that she was bored and that the activities were for 3 or 4 year old children and she was not interested in participating. This writer asked her what she would like to do in the way of activities she said I like to sleep. When this writer asked her about her elopement and trip to the emergency room two weeks ago she said I don't remember being out of the facility or a trip to the emergency room . Review of the Facility Provider Investigation Report Summary dated [DATE] (regarding Resident #1) revealed on [DATE] at (time unknown) the resident had wandered outside the door on the sidewalk between the laundry room and smoking porch earlier that day, she was on facility property and within eyesight of staff at all times. Housekeeper brought her back into the building on the wrong hall and told CNA that resident had gotten outside but the alarm didn't sound. She took resident to her room and told her CNA that the resident had wandered out the door and needed to be watched but she didn't mention the alarm not sounding. CNA did not tell the charge nurse, nor did the housekeeper, the resident began wandering the building again (which she does all the time) and got outside again without the alarm sounding. She wandered approximately one mile away before she was noticed by neighbor who called the police and the facility was notified. The Provider Investigation Report Post-Investigation Action dated [DATE] revealed, The facility purchased new testers for the wander guards to enable timely, daily testing. On-going in-service which will be repeated with staff monthly for 90 days and issue will be discussed in the Quality Assurance (QA) meetings over the next 90 days. Residents identified as exit seeking risk are being transferred to a Secured Unit within the facility. Will conduct Missing Resident Drill and report results to QA meetings for oversight on proper procedure. In an interview on [DATE] at 2:30 p.m. with ADON A she said that when she was in charge of the wander guards about six months ago she put them on the Treatment Administration Record's (TAR's) and they were checked every day. She said that Administrator B (who no longer works at the facility) use to go around and visually check that the resident's wander guards were in place. She said that she doesn't know when they stopped that system. In an interview on [DATE] at 1:25 p.m. with Administrator A and MCO B the Administrator said that Resident #1 was found outside of the facility by a member of the housekeeping staff earlier that morning. She said that the housekeeper brought Resident #1 back into the facility to station two (Resident #1 lived in building one). She said that the housekeeper told a Certified Nursing Assistant (CNA) that the alarm did not go off when Resident #1 walked out the door. She said that prior to Resident #1's elopement the facility did not have a system in place to monitor the wander guard devices. She said that if a resident got close to the doors the alarms would sound if these were functioning properly. She said that was the only thing they had in place. She said that had to purchase a tester to check the functionality of the wander guard bracelets. She said that you can point the tester at the wander guard device and if the device blinked four green blinks on the tester the wander guard device was functioning properly. If the device blinked a red light on the tester that means that the device is still functional but doesn't have too much juice. She said that a constant red light on the tester meant that the device is no longer functional. She said that they were not going to take any chances in the future they were going to change out the wander guard devices with any red blinking lights on the tester. Resident #2 Record review of an undated admission face sheet of Resident #2 revealed he was an [AGE] year old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. Record review of the Quarterly assessment dated [DATE] revealed that Resident #2 was alert, his cognitive skills for decision making was severely impaired, he had poor appetite, he had the ability to understand and was usually understood. His behavioral symptoms were; wandering, verbally and physically abusive, and occasionally rejects care. He moves all extremities but had left sided weakness in both his upper and lower extremities. Record review of the Elopement Risk assessment dated [DATE] written by DON B revealed that Resident #2 was currently in the Secured Unit, he was non-ambulatory and was currently in a wheelchair and has had no recent (last six months) attempts of elopement. Record review of Social Service progress notes dated [DATE] written by SS revealed that Resident #2 was being relocated to a room outside the Secured Unit into the unsecured hall. Resident#2 no longer met criteria to reside on the Secured Unit. On [DATE] at 2:05 p.m., review of the 24 hour report dated [DATE], [DATE], and [DATE] with the DON B, revealed there was documentation on the twenty four (24) hour report that indicated Resident #2 was transferred out of the Secured Unit to room in the unsecured hall. There was no other documentation regarding Resident #2's adjustment out of the Secured Unit. DON B said that she was not sure why the nurses did not document Resident #2's adjustment to the unsecured hall from the Secured Unit. She said that the nurses should have documented in the nurses notes. In an interview on [DATE] at 1:55 p.m. with LVN C she said that she was working that Saturday morning ([DATE]) Resident #2 eloped from the facility. She said that a concerned citizen came into the facility and said there was a man in a wheelchair about two blocks away that looked like he needed to be supervised. She said she went out to check on him and she identified him as Resident #2. She said that she brought him back to the facility. She said that she assessed the resident and he did not have any injuries. She said that he was thirsty and she gave him some water. She said that Resident #2 was transferred back into the Secured Unit that day. Record review of nurse's notes dated (MONTH) (YEAR) revealed that Resident #2 was transferred off of the Secured Unit to a room in the unsecured hall on Friday, (MONTH) 2, (YEAR) at 4:00 p.m. There was no other documentation in the nurse's notes until the elopement on [DATE]. There was no documentation of his adjustment to the unsecured unit. No observations or assessments were documented. There was no telephone or written physician's order for Resident #2 to be transferred out of the Secured Unit or transfer back to the Secured Unit. There was no documentation that the POA was notified of the transfer off the Secured Unit and it was discovered that the telephone number the facility had for the POA was no longer valid as the POA had been deceased for an undetermined amount of time. The consent to be transferred back to the Secure Unit was given by his sister at a later time. Review of the nurse's notes dated [DATE] written by LVN D revealed that Resident #2 left the facility out the front door, wheeled himself about two blocks. He was brought back to the facility by another LVN. Resident #2 gave his address and said that he was going home. Resident #2 was transferred back into the Secured Unit on [DATE]. (There was no time documented in the nurse's notes of the times of the elopement or the return of Resident #2 back to the facility). There was no documentation in the nurse's notes that Resident #2's Physician or his Power of Attorney (POA) was notified of his elopement. Record review of the Elopement Risk assessment dated [DATE] by ADON B for Resident #2, revealed that Resident #2 was recently transferred from the Secured Unit due to no elopement attempts. Resident transfers self from bed to wheelchair by himself and is able to propel himself in the wheelchair. Resident #2 wanders in and out of other resident rooms. Observation/interview on [DATE] at 11:30 a.m. Resident #2 was on the Secured Unit, he was sitting in a wheelchair in the dining room. He was observed propelling himself in the wheelchair. He said I am waiting for my wife to show up to have lunch. In an interview on [DATE] at 2:30 p.m. with Certified Nursing Assistant (CNA) K regarding Resident #2 she said that he has not made any attempt to propel himself in the wheelchair in the Secured Unit. She said that she was unaware that he was capable of doing that. She said that she did not work in the Secured Unit very often and was surprised that he was able to elope from the facility. In an interview on [DATE] at 1:25 p.m. with the Administrator and Manager of Clinical Operations (MCO) the Administrator said that Resident #2 was transferred from the Secured Unit to a room on the unsecured hall on [DATE] after a Wandering Risk Assessment was completed. She said that Resident #2 had not had any wandering behaviors for the last six months. She said that she was not the Administrator of the facility at the time of Resident #2's elopement. She called in the Assistant Administrator to the office who stated that she was out of town when the decision was made to transfer Resident #2 out of the Secured Unit. Director of Nurses (DON) B was called into the office and she said that she was the nurse that did the Risk Assessment on Resident #2. She said that she felt because there had been no exit seeking behavior in the last six months and because Resident #2 was unable to self-propel his wheelchair that it was safe to transfer him out of the Secured Unit to a room in the unsecured hall. When this writer asked about documentation in the nurses notes regarding Resident #2's adjustment from the Secured Unit to the unsecured hall she said that the nurses should have documented something regarding his adjustment off the unit. Observation on [DATE] at 2:45 p.m. of station two in building two revealed there was no wander guard notebook located at nurses station two as per an earlier interview with the administrator. In an interview on [DATE] at 2:50 p.m. with LVN E she said that she was unaware that there was a wander guard book located at the nurse's station (station two). She said that she could not recall being in-serviced on such book. In an interview on [DATE] at 2:55 p.m. with the Assistant Administrator she said that she did not make a wander guard notebook for station two (building two). She said that she just made one for station one (building one) and the receptionist (note at the time of this interview the receptionist was not at the receptionist desk). Resident #4 Record review of an undated admission face sheet of Resident #4 revealed he was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record Review of Resident #4's MDS dated [DATE] revealed that Resident #4 was alert but confused. His speech was slurred and often times mumbles. He was usually able to express himself and had the ability to sometimes understand others. He had a Brief Interview for Mental Status (BIMS) score of 03 which is indicative of severe impairment. Resident #4 was totally dependent on one staff person to assist him with bed mobility, eating, and toileting. He required total dependence of two staff for transfers as he required a Hoyer lift. He required extensive assistance of one person for personal hygiene and bathing. He used a wheelchair for mobility and required assistance of one staff member to move between locations. Resident #4 had not exhibited any wandering behaviors. Record review of the Nurses Notes dated [DATE] revealed Resident #4 was transferred from the Secured Unit (building two) to a room in the non-secured hall in (building one) on Friday [DATE]. A wander guard device was attached to his wheelchair at that time. In an interview on [DATE] at 4:30 p.m. with DON B she said that She was the one who did the risk assessment on Resident #4. She said that she had applied the wander guard to his wheelchair. She said that Resident #4 was capable of propelling his wheelchair and she wanted to monitor him to ensure he did not make attempts to elope. In an interview on [DATE] with ADON A at 6:25 p.m. she said that Resident #4 has not been ambulatory for over a year. She said that he has to be transferred with a Hoyer lift. This writer asked why Resident #4 was wearing a wander guard if he was not at risk for elopement. She said that he was capable of propelling his wheelchair out the door. Record review of Resident #4's TAR's revealed there was no wander guard listed. The days from [DATE] through [DATE] Resident #4's wander device had not been checked for placement or functionality. There was no documentation in the TAR as per facilities new system. Review on [DATE] at 3:00 p.m. of the Notebook at Nurses Station One titled Wander guards revealed that Resident #4 was identified in the notebook via a photograph that indicated he was wearing a wander guard device. There was no date listed on the photo of Resident #4 identifying the expiration date of the wander guard device. Observation on [DATE] at 3:05 p.m. revealed that Resident #4 was in the lobby in building one, close to the nurse's station. Resident #4 did have a wander guard device located on his wheelchair. In an interview/observation on [DATE] at 3:10 p.m. with Treatment Nurse B she said that since Resident #1's elopement she had been given the assignment to do a daily check of those residents that had a wander guard device. She said that she checked for placement and functionality of any resident that resided on Station One that was wearing a wander guard device. She said that the Residents that wore wander guard devices were placed on the Treatment Administration Record (TAR) and it was her responsibility to check those residents Monday thru Friday. She said that on the weekends it was the Charge nurses responsibility. When this writer asked Treatment Nurse B about Resident #4's wander guard she said that she was unaware that resident #4 had a wander guard device. She said that Resident #4 was transferred from the Secured Unit in the other building, station two on Friday [DATE]. Treatment Nurse B and this writer identified that Resident #4 did have a wander guard device on his wheelchair. The device was checked for functionality and date of expiration. At that time a TAR was created by Treatment Nurse B for Resident #4 to have the wander guard device checked each shift for placement and daily for functionality. Record review of the facility policy titled Wandering Device Policy dated ,[DATE] revealed the following: Policy; When a resident has potential for elopement and is utilizing a wandering device, the device will be maintained in a manner to protect their safety. Procedure: 1. A doctor's order will be obtained and a care plan developed when the resident is assessed to benefit from the use of a wandering device. 2. It is recommended that a log will be maintained at the nurse's station and in the front office with the name of those residents utilizing a device. The facility Administrator will designate the individual responsible for maintaining the log. 3. If transponders are utilized, devices will be tested with the Transponder Tester weekly and documented by the administrator's designee in a log. 4. Devices not working will be replaced. An adequate supply should be available. 5. Exit doors in the facility should have alarms. Door alarms will be tested by the maintenance department per the policies of the department. Results of the tests will be recorded and kept by the maintenance department. 6. Devices will be replaced on the resident's dominant wrist, if possible. 7. Staff members should be trained during orientation and at least annually thereafter on the wandering device alert system. This should include education on the use of the device, location of the monitor, and how to and who should answer the alarm, and how to silence monitors. 8. When a door activator is not working, all residents who are an elopement risk will be monitored more frequently until the activation is repaired. 9. When any door is not activating, an employee will monitor the door until it is repaired. Record review of the facility policy titled Elopement dated [DATE] and revised [DATE] revealed the following: Policy: it is the policy of this facility to protect residents from wandering away from the facility and to begin an immediate search if a resident is found missing. Fundamental information .Elopement, for purposes of this policy and procedure, is defined as that situation where a resident with impaired decision-making ability, who is oblivious to his or her own safety, needs and therefore at risk for injury outside the confines of the facility. Has the resident left the facility without the knowledge of staff. Wandering, is defined as locomotion with no discernible, rational purpose, either walking or in a wheelchair. The wandering resident may be oblivious to his or her physical or safety needs. Procedure: Assessment; 1. The resident will be assessed for risk of elopement upon admission, 2. The family will be interviewed for previous history of elopement and responses recorded in the medical record. 3. Residents in the secured unit will be deemed at risk for elopement. 4. Residents identified as at risk of elopement will be reassessed quarterly and as needed throughout the Resident Assessment Instrument (RAI) process with behavior monitoring documentation, as indicated. 5. Resident's risk will also be reassessed whenever an elopement event occurs. 6. A plan of care will be developed and updated as indicated by assessment to reduce risk of elopement, such as: · Alert bracelet (obtain a physician's order for an alarm/alert bracelet); · Assignment to a room away from exits that are commonly utilized; · Sign on resident's room with his/her name in large letters. · Place a stop sign on exit door; · Engagement in group activities for supervision; · Assignment to supervised dining program; · Distract resident with items he/she enjoys i.e. photos, games, television program, conversation, meaningful tasks to resident i.e. folding clothing, food preparation, manipulation of safe tools etc. 7. The frequency of visual checks will be established in accordance with the resident's needs. Facility may record on the Medication Administration Record (MAR)/Treatment Administration Record (TAR) or other form of documentation. Prevention 8. The facility will have a system of identification of all residents . 9. This facility uses the following resident identification system (specify): (Document was left Blank). 10 Resident assessed as at risk for elopement with or without current exit seeking behavior will have a photograph taken and placed in medical record or as designated by facility. A second photograph will be maintained in a binder at the receptionist desk or as designated by the facility. Photographs will be reviewed and updated during resident's quarterly assessment or on an as needed basis. 11 Resident or responsible party will be given instruction on the facility leave of absence or out-on-pass policy. 12 The licensed nurse will observe that each resident's wander device is in place each shift, if applicable. Document findings on the MAR/TAR or other form of documentation. 13 Maintenance staff will maintain a roster of residents with alarm bracelets devices, check bracelet alarm device monthly and replace according to manufactures directions. Document findings on preventative maintenance record or other designated record. 14 Door alarms, if applicable, will be tested daily and the results recorded on designated logs . 23. Staff will notify the charge nurse of any elopement attempt . 25.The charge nurse will maintain current time-specific documentation in the resident's medical record including the date and the time the resident was last seen, all actions taken to find the resident, and all parties notified. Post Elopement Assessment and Action: 28. After the resident is located, the charge nurse will assess for changes in condition. Assessment may include, but not limited to, observed b (TRUNCATED)

Based on observation, interview, and record review, the facility failed to implement interventions based on the comprehensive assessment to prevent development of pressure sores for 1 of 32 residents reviewed for pressure sores. (Resident #20) Resident #20 was admitted without pressure sores and was at risk for the development of pressure sores. The resident developed 2 facility-acquired pressure sores that were not identified until the one to the right heel was a stage 2 (dark fluid-filled blister) with dark colored areas around the wound bed and a deep tissue injury with non blanching surrounding skin to the left lateral heel. The facility did not evaluate or provide the resident with repositioning or pressure relief prior to the discovery of the pressure sores. This failure could place 125 residents with pressure sores or that are at risk for the development of new pressure sores and decline in existing pressure sores. Findings included: Review of Resident #20 ' s Medication Review Report dated 10/30/15, revealed that she was a [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. An admission Braden scale for predicting pressure sore risk dated 10/27/15 indicated Resident #20 was at risk for pressure sore development. Review of Resident #20 ' s admission Resident (MDS) data set [DATE] revealed that the resident was frequently incontinent of urine with occasional incontinence of bowel. It revealed that the resident had a pink area around the coccyx and no pressure ulcers were present at the time of admission. It revealed under skin treatments: use pressure redistribution devices for the bed. There was no initial/admission care plan in Resident #20 ' s record. A care plan initiated and received on 11/4/15 from DON A, dated on 11/4/15 indicated for Resident #20: Cognitive Communication and behavior: Cognitive skills for decision making- moderately impaired, Skin Integrity as manifested by: Poor bed mobility, Bowel incontinence, Bladder incontinence, and Bedfast a large part of the time. The Goals were: Have skin that shows/demonstrates healing in the next 90 days, Cooperate with skin treatment for [REDACTED]. The approaches/needs were monitor nutritional status and provide Ensure 1 can BID (twice a day), Get out of bed with assistance for meals, use pressure relieving device and instruct use of call light. Keep resident clean and dry, and Observe for skin improvement or deterioration weekly . ADL (activities of daily living) Function as manifested by: Needs assist-maximum A weekly skin assessment for Resident #20 dated 10/27/15 indicated: Texture- skin is fragile , Prevention Devices and Care- turning schedule, pressure redistribution mattress, moisture barrier, cushion (pressure redistribution), and foot/heel elevator. the assessment revealed no pressure ulcers. Review of facility ' s TAR (treatment administration record) revealed no records for Resident #20. Resident #20 ' s initial physician orders [REDACTED]. During an interview on 11/4/15 at 9:40 a.m., the family member (daughter) of Resident #20 stated that the resident was admitted to the facility last week to receive therapy after the resident had suffered a ruptured ulcer. She stated that Resident #20 had been in bed at least 21 hours of every day, only getting to sit up with meals and for therapy. She stated that the facility has not been checking on the resident and multiple times different family members had to go to the nurse ' s desk to ask the staff to change her diaper and clothing due to incontinent episodes. The family member stated that the staff would bring meals in and set them beside the resident in bed and that she was not assisted with eating. She stated that on occasion, the staff did not bring a tray during meal times. She said that she was concerned for the resident so a family member has had to stay to make sure they assist the resident with her ADL ' s (activities of daily living). She stated that she was afraid that they were not getting Resident #20 up enough out of bed and that she is getting weaker. The family member stated that she has stayed up at the facility on numerous occasions and the staff didn ' t even come in the room for 7 hours on one day this past weekend. She stated that she had to go to the nursing desk to request assistance and she was told to use the call light by a nurse. She stated that she went back to the resident ' s room and pulled the call light and it was 45 minutes before any staff came. She stated that the resident had been complaining of her feet and back hurting for 2 days. She stated that they had reported it on several shifts and that the resident was given a pain medication for her pain. She stated that the staff never looked at Resident #20's feet. During observations on 11/4/15 at 10:00 a.m., 11:45 a.m. and 1:27 p.m., Resident #20 was lying in bed on her back, with her eyes closed. Resident #20 had no pillows or other pressure relieving devices to the heels/feet. During the following observations and interviews on 11/4/15, at 3:50 p.m., Resident #20 ' s call light was activated. Within 2 minutes CNA J had went in to the resident ' s room. The resident ' s family member was in the room and stated that she is complaining of sharp, burning pains to both heels. CNA J removed the blanket from the resident ' s feet and lifted up her right foot. A quarter sized dark fluid filled blister was observed with dark red surrounding skin. CNA J lifted the left heel and on the outer side of the left heel, a dime sized, dark purple, discolored spot was discovered. Resident #20 had no pillows or other pressure relieving devices in place. The family member stated that the resident has restless legs and moves them constantly on the bed. CNA J stated that she will get the nurse. The family member stated that she had told them many times that the resident was having pain to her heels. Treatment Nurse B entered the room and assessed the resident ' s feet. She stated that the skin around the blister on the right heel is not blanching (remaining red when pressed by a finger, indicating skin breakdown). The treatment nurse stated that the left foot, outer heel, was boggy (soft to touch) and not blanching around the dark spot. She left the room and returned with a heel lift (a device used to elevate the heels off of the bed to reduce pressure to the heels). The family member for Resident #20 stated that the resident did not have any bed sores when she came to this facility 8 days ago and was very upset about the development of the sores. The resident stated that her pain level was an 8 out of 10 on the pain scale to both heels. Treatment Nurse B stated that she would let the charge nurse know to bring her some pain medication. During an interview on 11/05/15 at 10:35 a.m., DON A said she was not aware of Resident #20's pressure sores that were discovered on 11/4/15. She stated that she had asked all nursing staff on the morning of 11/5/15 if there were any new pressure sores and she was told that there was not. She stated that she did not find any documentation on Resident #20 ' s pressure sores and that Treatment Nurse B told her that she is working on it. DON A said she was not aware pillows or other pressure relieving devices were not being used per the weekly skin assessment interventions. She stated that she did know that there was not an initial care plan in Resident #20 ' s record until the care plan dated 11/4/15. Record review of Resident #20 ' s clinical record revealed no documentation on the newly developed pressure ulcers to both feet as of 11/5/15 at 10:00 a.m. During a phone interview with Physician C on 11/5/15 at 10:00 a.m., he revealed that he had not been informed of the new pressure ulcers discovered on 11/4/15 for Resident #20. He stated that he should be notified according to the facility ' s policy and as long as the staff were managing the ulcers, that he didn ' t see a problem with contacting him immediately upon the discovery of the pressure ulcers. He stated that preventative measure should be put in place according to the facility ' s policy upon resident admission. During an interview on 11/5/15 at 10:25 a.m., Treatment Nurse B stated that she has not yet charted on the pressure ulcers discovered on Resident #20 yesterday. She stated that since it was so late the day before that she has not contacted Physician C yet. During an interview and an observation on 11/5/15 at 1:10 p.m., DON A stated that she had assessed Resident #20 ' s new pressure ulcer. She stated that the ulcer to the right heel was a stage 2 clear fluid filled blister and that she didn ' t see a sore to the left foot/heel. Resident #20 was in the physical therapy department on a stationary bike. DON A performed an assessment to the resident ' s feet. The right heel had a half-dollar sized fluid filled blister to her right heel with dark purple discoloration noted to the surrounding skin. DON A assessed the left heel, this surveyor pointed out the dark, discolored, dime sized sore to the outer left heel. The area was surrounded by non-blanching red skin and boggy to touch according to DON A ' s re-assessment. She stated that she didn ' t find it in her earlier assessment and that she would call that sore a deep tissue injury (A pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. These [MEDICAL CONDITION] may herald the subsequent development of a Stage III-IV pressure ulcer even with optimal treatment. (National Pressure Ulcer Advisory Panel, 2002). During an interview on 11/5/15 at 2:00 p.m., Treatment Nurse B stated that she had received orders for [MEDICATION NAME] Ag (a type of medicated dressing) to apply to the right heel and to leave the left heel open to air. Record review of Resident #20 ' s ADL Record for October 2015 dates 10/28/15 through 10/31/15 revealed the following: Bed mobility- required limited assistance by one staff, Transfers, Walking, Locomotion -all marked N/A (not applicable) . Personal Hygiene and Bathing- extensive assistance by one staff During an interview on 11/5/15 at 1:30 p.m., LVN B stated that the aides chart on the ADLs Record for each resident and if there is a N/A (not applicable) then the task did not occur. She stated that Resident #20 spends most of the time bed bound and has only been getting up for therapy and a few meals. During a phone interview on 11/06/15 at 3:50 PM, Physician A stated that he is the Medical Director at the facility. He stated that when a resident is admitted and found to be at risk for developing pressure ulcers according to a tool used at facilities, that preventative measures should be in place per facility policy. He stated that the physician should be notified in a timely manner in order for treatment to be initiated if a pressure ulcer exists. Record review of the facility ' s policy titled Pressure Ulcer Prevention and Management dated 08/31/11 revealed: Policy: It is the policy of this facility that any Resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the Resident ' s clinical condition makes the development unavoidable. Any Resident who has a pressure ulcer will receive the necessary treatment and services to promote healing, prevent infection, prevent new ulcers from development. Nursing staff along with other staff is responsible for the prompt reporting of any skin related problems to the nurse in charge. Physicians will be notified promptly at the first occurrence of a pressure ulcer or other skin related problems or if the condition of the wound deteriorates or fails to improve with treatment. The CMS form 672 dated 10/29/15 indicated 125 residents were at risk for pressure ulcer development/worsening.

Based on observations, interviews and record reviews, the facility failed to provide an environment as free of accident hazards as possible, and adequate supervision to prevent accidents for 1 of 6 residents (Resident #1) reviewed for cognitive impairment in one of the facility's secure units. Resident #1 drank aftershave lotion that was left at his bedside by unknown persons. Resident #1 aspirated the aftershave lotion, causing damage to his lungs. Resident #1 died 9 days after this incident. This failure could affect 43 Resident residents residing in the facility's two locked Alzheimer ' s units. Findings include: Review of Resident #1's clinical record "Face Sheet" dated [DATE] documented he was an [AGE] year old male who was originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #1's clinical record "Care Plan" dated [DATE] documented "...family requests that Resident #1 has a secure area in his room to keep his personal belongings...maintenance to provide lock to top drawer of nightstand...family educated on importance of securing potentially hazardous items in locked drawer..." Review of the facility's "Report of Alleged Incident/Accident" dated [DATE] documented that CNA #B responded to an alarm sounding and saw Resident #1 drinking out of an aftershave bottle. CNA #B removed the aftershave and reported the incident to LVN #A. Review of the facility's "Incident/Accident Investigation Interview" dated [DATE] and signed by CNA #B documented "...I responded to the bed alarm...I saw Resident #1 drinking from a bottle of aftershave...I took it away and then reported what happened to the charge nurse LVN #A..." Review of the facility's "Provider Investigation Report" dated [DATE] documented a statement from CNA #B "...around 4:00 p.m. she was finishing passing snacks and heard a chair alarm sounding. She went down to Resident #1's room where the alarm was sounding ...he was still in bed. His pad had just moved as he repositioned himself in bed. When she walked in the room, she observed him drinking aftershave and had spilled some aftershave on his shirt. CNA #B stated that she has never seen this aftershave before. She had seen a bottle like the one he was drinking from locked up in the shower room on a previous occasion. She did not know that the bottle was labeled with Resident#6's name on it. She had no knowledge of where this bottle came from as they did not perform any showers on this date during the 2:00 p.m. to 10:00 p.m. shift and the shower room was locked. She stated that hazards such as aftershave are always locked up. She does not know how Resident #1 got the bottle of aftershave. Resident #1 was wandering frequently on this date as was Resident#6. A little while after she observed him drinking the aftershave, Resident #1 threw up and had a large but soft bowel movement. Immediately upon seeing him consume the aftershave, CNA #B took the bottle away and went to get LVN #A who immediately came down to assess Resident #1. While LVN #A was calling the physician about the incident, CNA #B cleaned up Resident #1, the ambulance came and Resident #1 was transported to the hospital. CNA #B and her partner began searching for and removing any other hazards in Unit I. " In an interview on [DATE] at 11:55 a.m. CNA #B stated that the incident with Resident #1 drinking aftershave happened between 3:30 p.m. and 4:30 p.m. CNA #B stated that she heard a tab alarm sounding off and walked into Resident #1 ' s room and saw him drinking aftershave. CNA #B stated that she took the aftershave away from Resident #1 and put it into the bathroom and called LVN #A for assistance. CNA #B stated that LVN #A got Resident #1 up into his wheelchair and assessed Resident #1. CNA #B stated that after assessing Resident #1, she placed Resident #1 back into bed and LVN #A placed oxygen on Resident #1. CNA #B stated that she heard the tab alarm sounding again and went to Resident #1 ' s room and saw him standing beside his bed and he vomited all down the front of her shirt and pants and she took Resident #1 into the restroom and called for help and then Resident #1 had a large bout with diarrhea. CNA #B stated that as she was assisting Resident #1 back to bed is when his spouse and daughter arrived. In a telephone interview on [DATE] at 3:28 p.m. Resident #1's spouse stated that after drinking the aftershave lotion, Resident #1 was moaning and groaning in bed. Resident #1's spouse stated that LVN #A used her personal cell phone to make a call to the physician and the time was 4:38 p.m. and it was time stamped on her cell phone. Resident #1's spouse stated that the physician at the hospital stated that Resident #1 contracted chemical pneumonitis because of the chemicals in the aftershave that he aspirated into his lungs. She stated that the physician from the hospital stated that he would discharge Resident #1 back to the facility on hospice services and that he husband would die from this incident. In a telephone interview on [DATE] at 3:40 p.m. Resident #1's daughter confirmed the date and time stamp of 4:38 p.m. on [DATE] on her mother's telephone when LVN #A used the cell phone to call Resident #1's physician. Review of the facility's "Provider Investigation Report" dated [DATE] documented a signed statement from LVN #A ".....CNA #B came down to the nurse ' s station after answering the alarm and informed LVN #A that Resident #1 had consumed some aftershave. LVN #A went down to the resident ' s room and took vital signs, when he did this he smelled the aftershave on the breath of Resident #1 ....LVN #A observed the bottle of aftershave and it looked as if there was one-fourth of the bottle remaining. It was a green bottle that said "Macho" on the label. The bottle was labeled with Resident #6's name on it, which is another resident residing on that same unit. Resident #1's oxygen saturation was just below 90 during the assessment. Resident #1's physician was called who told the nurse to monitor Resident #1 and if his vital signs became abnormal he was to send him to the emergency room . Resident #1 had a big bout of diarrhea, which was cleaned. Resident #1 was ordered thickened liquids, which the aftershave was not thickened, so the resident was coughing occasionally. Resident #1 complained of not feeling well and his oxygen saturation dropped to 86% on 5 LPM (liters per minute), so LVN #A made the determination to send Resident #1 to the emergency room . This was about a half hour after the physician said he could send Resident #1 to the emergency room if vital signs changed. The paramedics arrived and the resident was taken to the local emergency room . The bottle of aftershave was given to the paramedics. LVN #A stated that Resident #1's and Resident #6 ' s family are both bringing in items that are non-allowable and both families have to be re-educated on not bringing those items in frequently by himself and the staff .... " This document was signed and dated by LVN #A. Review of Resident #1's clinical record "Nurse's Notes" dated [DATE] at 7:20 a.m. documented vital signs as blood pressure ,[DATE], pulse 72, respiratory rate 18, temperature 97.6, and oxygen saturation at 95% on room air. Review of Resident #1 ' s clinical record "Nurse's Notes" dated [DATE] at 1:15 p.m. documented vital signs as blood pressure ,[DATE], temperature 97.3, pulse rate 91, and oxygen saturation at 96% on room air. Review of Resident #1 ' s clinical record "Nurse's Notes" dated [DATE] at 5:20 p.m. documented "...CNA #B responded to alarm going off; upon entering Resident #1's room, he was drinking out of aftershave lotion bottle. CNA #B removed bottle and reported to this nurse (LVN #A). Upon assessment noted breath smelling of aftershave lotion; VS (Vital Signs) 97.2 (temperature), 101 (pulse), 20 (respirations), ,[DATE] (blood pressure), oxygen saturation (O2 sat) 87% (normal is 90 - 100%) on room air; lungs clear, cough noted; oxygen given at 2LPM via n/c (nasal cannula); O2 sat up to 90%; stated "I don't feel good" . No complaints of abdominal pain, no complaints of nausea/vomiting; large episode of diarrhea reported by CNA #B; resident confused; Physician called for advice; order to monitor and send to ER (emergency room ) if V/S (vital signs) decline; wife at bedside...." signed by LVN #A. Review of Resident #1's clinical record "Nurse's Notes" dated [DATE] at 5:25 p.m. documented "...V/S 97.5, 104, 20, ,[DATE] O2 sat 89% on O2 at 2LPM via n/c; O2 increased to 3 LPM via n/c..." signed by LVN #A. Review of Resident #1's clinical record "Nurse's Notes" dated [DATE] at 5:30 p.m. documented "...V/S 97.3, 106, 20, ,[DATE]; O2 sat 88% on O2 3LPM via n/c; O2 increased at 3LPM via n/c...stated "I don't feel good" no complaints of abdominal pain, no complaints of nausea/vomiting, no diarrhea noted/reported by wife at bedside... " signed by LVN #A. Review of Resident #1's clinical record "Nurse's Notes" dated [DATE] at 5:35 p.m. documented "...V/S 97.7, 101, 20, ,[DATE], O2 sat 91% at O2 3LPM via n/c; continue with non-productive cough; no complaints of abdominal discomfort..." signed by LVN #A. Review of Resident #1's clinical record "Nurse ' s Notes" dated [DATE] at 5:45 p.m. documented "...V/S 97.3, 98, 20, ,[DATE], O2 sat 86% on 3LPM via n/c; O2 increased to 5LPM via n/c; 911 called; wife at bedside..." Review of Resident #1's clinical record "Nurse ' s Notes" dated [DATE] at 5:50 p.m. documented "...Fire department and ambulance here... " signed by LVN #A. In an interview on [DATE] at 10:05 a.m. LVN #A stated that he was sitting outside the unit at the main nurse's station charting, when CNA #B came to him and told him that Resident #1 had drank some aftershave, he stated that the bottle was a green, long-necked bottle. LVN #A stated that Resident #1's pulse rate was increased and his oxygen saturation decreased to 85% on the oxygen concentrator at 2LPM via nasal cannula. LVN #A stated that he called Resident #1's physician. LVN #A stated that Resident #1 was up in a wheelchair in the dining room of the secure unit. LVN #A stated that Resident #1 smelled strongly of aftershave while assessing him in the wheelchair. LVN #A stated that Resident #1's physician told him to monitor Resident #1 and if his vital signs became abnormal to send to the emergency room . LVN #A stated that he increased Resident #1's oxygen to 3LPM and his oxygen saturation started to fluctuate and then his oxygen saturation dropped while on ,[DATE]LPM and he made the decision to send Resident #1 to the local emergency room via EMS (emergency medical service). LVN #A stated that Resident #1's normal mode of transportation was by wheelchair since he was so unsteady on his feet walking. In a telephone interview on [DATE] at 11:50 a.m. Resident #1's physician stated that it was reported to him that Resident #1 had drank some aftershave lotion and was not sure of the amount and that he called the facility and spoke with LVN #A and ordered to watch Resident #1 very closely and that LVN #A had reported to him that Resident #1's vital signs were within normal limits and stable. Resident #1 ' s physician stated that he ordered LVN #A to rush Resident #1 to the emergency room right away if Resident #1 develops any signs or symptoms of respiratory distress. In a telephone interview on [DATE] at 5:15 p.m. the attending physician at the local hospital stated that the outcome would have been the same even if Resident #1 had been sent to the emergency room sooner. The attending physician stated that his expectation would have been to send any resident immediately to the emergency room if the resident drank aftershave or any other non-consumable substance. Review of the hospital ' s " Emergency Physician Record " dated [DATE] and untimed documented Resident #1 had acute shortness of breath, bilateral lower lobe pneumonia and acute respiratory failure and was signed by the Emergency Department Medical Director. Review of the hospital's "History and Physical" dated [DATE] at 8:58 p.m. documented "...The patient is an [AGE] year old nursing home resident who has advanced Alzheimer disease. He wandered into his neighbor's room, drank the neighbor's aftershave, Macho brand. It was probably less than half of a bottle, which would consist of alcohol, water, and polyethylene. He might have aspirated as he has a problem with swallowing and aspiration. He had been on a thickened liquid diet...After ingestion of the aftershave, he was brought to the emergency room . He is in respiratory distress...likely aspiration of aftershave lotion with chemical pneumonitis and acquired [DIAGNOSES REDACTED], systemic inflammatory response syndrome and tachycardia. Review of Resident #1's hospital clinical record documented on [DATE] at 11:45 a.m. "...hospice consult...patient is appropriate for hospice care once he transfers back to the facility...the family is in agreement with admitting to hospice services once he transfers back to the facility..." Review of Resident #1's facility's clinical record "Nurse's Notes" dated [DATE] at 4:15 p.m. documented the resident was received back into facility. Review of Resident #1's facility clinical record "Record of Death" documented that Resident #1 was pronounced dead on [DATE] at 10:10 p.m. The "Record of Death" documented the principle cause of death as respiratory failure. Review of the facility's "In-service Education" dated [DATE] documented "...Non-allowables in rooms...items that must be secure; never leave it in room...remove item...give to charge nurse..." There was no evidence of prohibited items listed in this in-service record. Review of the facility's letter sent to families from the Administrator undated documented "...Items NOT allowed in the resident ' s room, unless there is a locking device in place, to include (but are not limited to the following): ....hot water bottles, heating pads, electric blankets, throw rugs or rugs of any kind, hot plates, coffee makers, toasters, irons, extension cords, wipes containing bleach or other disinfectants/cleaning supplies/cleaning chemicals, aerosol cans such as: hair spray, deodorant, room deodorant, bug spray, etc ...disposable razors, personal hygiene products/grooming products, cleaning supplies/cleaning chemicals, electronic cigarettes, medications of any kind that are not ordered for bedside use, and any product that has keep out of reach of children... " The Administrator stated that he had sent this letter out the past week ([DATE] through [DATE]). CMS Form 672 dated [DATE] documented 43 resident that reside in the facility's two secure units.

Based on interview, observation, and record review, the facility failed to ensure that 1 (Resident #1) of 5 residents reviewed for accidents received adequate supervision and assistance devices to prevent accidents. The facility failed to provide an alternative intervention once the staff realized the resident was capable of putting the side rail down while she was on a standard nursing facility bed with an air mattress in place. The resident put her side rail down, fell from the bed and sustained a subdural hematoma to the left side of the brain. This failure could affect 38 residents in the facility that required side rails. The findings included: 1. Record review of Resident #1's medical record face sheet revealed she was a [AGE] year old female who was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 2. Review of the Residents Minimum (MDS) data set [DATE] revealed the resident was alert but had short and long term memory problems and had moderately impaired cognitive skills and decision-making. The resident could usually understand others and usually made herself understood. The resident required 2 or more staff for assistance with bed mobility, transfers, and toileting. The resident had no history of previous falls in the past 3 months. 3. Record review of Resident ID #1's care plan dated 09-28-10 revealed the following: Problem onset: Impaired mobility due to [DIAGNOSES REDACTED] from CVA and weakness from hospitalization . The approaches included encourage resident to use side rails. The next problem onset stated potential for fall related to impaired balance due to CVA and [DIAGNOSES REDACTED] (paralysis to left side) use of antidepressant. The approaches included to use call light, remind resident to call for staff on all transfers and assist resident with all transfers. On 10-25-10 (after the fall) the following statement was added to the care plan: Problem onset-Resident let side rail down, fell found on left side, laceration to right arm and forehead at hairline. Approaches included to remove the side rails and use a low bed with matt. 4. Review of nurse's notes on 08-04-10 at 2200 (10 PM) revealed the resident was attempting to put the side rail down and hit the top of her left hand, causing a 1.5 centimeter skin tear. 5. Review of the nurse's notes dated 10-21-10 at 8:00 PM for Resident #1 revealed the resident was assisted to bed by two CNA's on to her air mattress. The resident started to scoot herself into the side rail and the nurse notes stated the resident also puts the rail down. The nurse explained to her that she needed the side rails due to the slick surface of the air mattress and a possibe fall if she did not leave the side rai up. The nurses notes then stated the resident does not appear to understand. 6. Review of Resident ID #1's medical record revealed she was sent to the hospital on 10-24-10 at 5:30 AM after being found on her floor beside the bed. According to the nurse's notes LVN "A" walked in the resident's room to take the residents blood sugar and the resident was found lying face down on the floor beside the bed. Blood was pooling from the left side of the head. The nurse noted a puncture wound to the outside of the left brow area measuring approximately 1.0 centimeters (cm) and a 2 inch laceration to the right forearm. 911 was called at that time and the resident was sent to the hospital. 7. Interview with a family member on 10-27-10 at 1:00 PM revealed they were unaware that Resident ID #1 was capable of putting the side rail down until after her fall on 10-24-10. 8. Interview with the resident's roommate on 10-27-10 at 10:15 AM revealed she had watched Resident ID #1 "take that side rail down from day one, hated it and was very vocal about it." The roommate stated she had never seen her fall in the past and slept through the fall on 10-24-10. The roommate stated she was a very sound sleeper and did not hear or see her fall. 9. During an interview on 10-28-10 at 12:25 PM with this LVN "A" stated once she found Resident ID #1, she would only moan, would not respond verbally and once the EMS arrived, they performed a glucose level on the resident with a reading of 26. (Normal glucose is 70-120). LVN "A" stated that she did note the side rail was down when she found the resident and she appeared to have fallen out of bed. 10. Interview on 10-28-10 at 4:25 AM with Nurse Aide "B" who was working on Resident ID #1's hall that morning revealed she had been into the resident's room around 5:15 AM because the resident had become "restless" and was trying to put the side rail down at the time and was also grabbing at her Foley catheter. Nurse Aide "B" stated she redirected the resident to lay back down and ensured the side rail was up before she left the room. Further interview with Nurse Aide "B" revealed the resident was capable of putting the side rail down and frequently did so at night. Nurse Aide "B" stated the resident never fell out of bed but did not like the side rail being up. Nurse Aide "B" stated she had informed the charge nurses in the past that the resident was capable of putting the side rail down. The nurse aide stated Resident ID #1 had never tried to climb out of bed in the past but just did not like the side rail being up. Nurse Aide "B" stated she did not like to be in the bed, she liked to sit up in her wheelchair and watch TV. 11. Interview with Charge Nurse "C" on 10-28-10 at 4:40 AM revealed she was aware the resident put the side rail down at times. Nurse "C" stated she feared that the resident would fall out of bed due to the air mattress because it was slick. She stated they would sometimes put pillows between the side rail and the resident to prevent her from trying to put the side rail down. Charge Nurse "C" also stated that she had at one time seen the resident sitting at the end of the bed with the side rail up and at that time had redirected the resident to lay back down in bed. Charge Nurse "C" stated she never recalled telling the administrative nursing staff that the resident was capable of putting the side rail down, however, she stated the day charge nurse was aware because they had talked about it in the past. 12. Interview with the DON on 10-28-10 at 11:15 AM revealed she was unaware the resident could put the side rail down until she was sent to the hospital on 10-24-10 with injuries. The DON stated if she had known the resident had been putting her side rail down while she was on the air bed, she would have placed the resident on a low bed with a possible mat on the floor. She stated the administrator and her Assistant Director of Nursing knew nothing of her putting the rail down until after the fall. 13. Review of the hospital records dated 10-25-10 revealed the resident had sustained a subdural hematoma, status [REDACTED]. Her neurological examination revealed significant aphasia (unable to speak) and inability to follow commands, but she did easily arouse. The resident was on Plavix (blood thinner) and the physician documented that any surgical intervention would be very risky. 14. Observation of Resident ID #1 on 10-28-10 at 10:30 AM revealed the resident was lying in her hospital bed unresponsive to verbal stimuli. The resident eyes remained closed and would not follow commands when asked by the hospital charge nurse. 15. Review of the "Physician order [REDACTED].