Every finding on record at Avir at Emerald Hills

Based on observation, interview and record review the facility failed to ensure that at the time each resident was admitted , the facility had physician orders for the resident's immediate care for 1 resident (Resident #1) of 3 residents reviewed for admission orders. The facility failed to ensure that Resident #1, who was admitted on [DATE] with a suprapubic catheter (medical device inserted in the bladder to help drain urine), had physician orders in place for catheter care. This failure could place residents at risk of not receiving essential care upon admission.Findings included: Record review of Resident #1's NT/ST MDS Assessment, dated 07/01/26, reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE]. The resident's BIMS score was not indicated on this document. Record review of Resident #1's face sheet, dated 07/07/26, reflected the resident's diagnoses included: chronic kidney disease, overactive bladder, and infection and inflammatory reaction due to catheter. Record review of Resident #1's baseline care plan, dated 07/01/26, under Bowel & Bladder did not indicate the resident's use of a suprapubic catheter. Record review of Resident #1's progress notes, dated 07/01/26 at 1:25 p.m. by LVN A, reflected the following: [Resident #1] arrived on stretcher via non-emergency transportation. Alert and Oriented to Name, Place, Time and Situation. [Resident #1]is Enhanced barrier Precautions for Suprapubic catheter and Midline (thin tube placed in small vein to give medication and/or fluids) with solo lumen (internal hollow line used to deliver treatment) on left upper arm. [Resident #1] is on Heart healthy diet,regular texture and thin consistency. Receives antibiotic Gentamicin every 48 hours through midline. No visible signs of any infection at IV sitenoted. [Resident #1] get Eliquis 2.5 mg twice daily and has sustained multiple bruises in result. [Resident #1] has rash in peri area and on sacrum. (triangular bone at the base of spine) Medications are ordered. MD notified and received orders to do BMP, CBC and A1c. Record review of Resident #1's physician orders, dated 07/07/26, reflected in part the following:-Gentamicin 80 mg/50 ML NS injectable 80 mg/50 ml-use 700 mg intravenously every 48 hours related to infection and inflammatory reaction due to indwelling urethral catheter; Order Date: 07/01/26.Further review of this document reflected there was not an order for catheter care. In an observation and interview on 07/07/26 at 11:10 a.m., Resident #1 was sitting in his wheelchair in the room visiting with family. Resident #1 was observed to have a catheter that was hanging below bladder level with a bag cover for privacy. Resident #1 stated he had only been at the facility for about a week and he was concerned about catheter care. Resident #1's family stated Resident #1 was admitted to the facility after being treated in the hospital for a urinary infection with his catheter in place. Resident #1's family stated the urologist recommended Resident #1's catheter be changed every three weeks to reduce the risk of infection, and it was scheduled to be changed yesterday. Resident #1's family stated this was mentioned to one of the nurses, who stated they would notify the MD, and no update had been provided. Resident #1 stated infections caused him a major setback, and he was terrified of getting another one. Resident #1 stated he could not always tell when he had an infection, but it was easy to get one with the suprapubic catheter. In an interview on 07/07/26 at 2:00 p.m., LVN A stated he worked at the facility for 4 years. He stated he worked with Resident #1 and he admitted with a suprapubic catheter. LVN A stated when a resident was admitted with a catheter, the nurses had to confirm with the MD that there was an order in place for standard catheter care. LVN A stated the orders would include care specific to the type of catheter and residents' needs. LVN A stated Resident #1 should have had an order in place; however, he could not recall seeing one in the chart. LVN A stated he knew how to provide standard catheter care naturally based on years of experience and nursing knowledge; however, it was important for nurses to follow MD orders in case there were any special care needs. In an interview on 07/07/26 at 2:42 p.m., the NP stated residents who admitted to the facility with catheters usually had an established urologist and would follow-up with them for catheter replacements. The NP stated the residents would also come with orders from either the urologist or discharging hospital. The NP stated Resident #1 was new to the facility and she had not seen the resident yet. The NP stated if Resident #1 admitted without orders for catheter care, the expectation would have been for the nurses to notify her or the MD, and she would have advised them to immediately contact the resident's urologist. She stated she had not received a call from the facility regarding Resident #1 not having catheter care orders. The NP stated not having orders in place for at least standard catheter care could place the residents at risk of infections. In an interview on 07/07/26 at 3:30 p.m., the DON stated he was unaware that Resident #1 did not have any orders in place for catheter care. The DON stated he got the urologist's phone number from Resident #1's family and he was about to call for an order. The DON stated it was important to have an order for catheter care in place when a resident admits for continuity of care and so that everyone was on the same page regarding the resident's needs. Record review of the facility's policy titled Physician Orders, updated 02/2025, reflected in part the following: PurposeThe purpose of this procedure is to establish uniform guidelines in the receiving and recording of physician orders to ensure the resident receives the necessary care and services.Recording Orders:.admission orders- the licensed nurse will verify admission or readmission order with the physician or physician extender for all residents admitting or readmitting.

Based on interview and record review, the facility failed to ensure a Registered Nurse was on duty in the facility for a minimum of eight consecutive hours a day, seven days a week, for 1 of 4 quarters, (Quarter 1), reviewed for RN coverage. 1. The facility failed to have 8 consecutive hours of RN coverage for 7 of 31 days in October 2025.2. The facility failed to have 8 consecutive hours of RN coverage for 1 of 30 days in November 2025.This failure could affect the residents by placing them at risk for not having their nursing and medical needs met and receiving improper care.Findings included:Record review of the CMS PBJ Staffing Data Report revealed no RN hours for the following dates: 10/02/25, 10/05/25, 10/18/25, 10/19/25, 10/20/25 and 10/21/25.Record review of an excel file, undated, for RN time stamp hours from 10/01/25 through 12/31/25 revealed no RN coverage on the following dates: 10/02/25, 10/05/25, 10/18/25, 10/19/25, 10/20/25 and 10/21/25.Further review of the excel file revealed there was less than 8 hours of RN coverage on the following dates: - 2.00 hours on 10/11/26 - 5.73 hours on 11/01/26Interview on 06/18/26 at 3:49 PM, the DON stated he had been at the facility for about 3 weeks and was not at the facility in October of 2025. He said the staffing coordinator was responsible for scheduling but was unavailable for an interview. The DON stated he did not know why there was no RN coverage on those days in October. He stated they currently had consecutive 8-hour RN coverage during the week with an RN working the 2-10 pm shift and an RN for the weekends. He said there could be a risk to residents because there were some things LVNs could not do, and RNs would supervise. Interview on 06/18/26 at 4:16 PM, the Administrator stated the staffing coordinator was responsible for scheduling RN coverage. He said the risk of not having an RN could be not doing assessments residents may need or follow up for an LVN. He said RNs can do a little more than LVNs can and it could put a dent in care. Record review of the facility policy titled, Staffing, Sufficient and Competent Nursing revised August 2022, revealed .3. A registered nurse provides services at least eight (8) hours every 24 hours, seven (7) days a week.

Based on observation, interview and record review the facility failed to ensure that, a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal care for 2 of 4 residents (Residents #84 and #2) reviewed for ADL care. 1. The facility failed to ensure personal hygiene and grooming, to include hair care and oral care, was provided to Resident #84. 2. The facility failed to ensure nail care, to include trimming and cleaning, was provided to Resident #2. These failures put residents at risk for not receiving the care they require and poor quality of life.Findings included:1.Record review of Resident #84's MDS dated [DATE], revealed the resident was an [AGE] year-old female who admitted on [DATE]. The resident's diagnoses included: anemia (a deficiency of red blood cells that leads to insufficient oxygen delivery to the body), cancer, and high blood pressure. Further review revealed the resident's cognition was intact with a BIMS score of 15 and that the resident had not exhibited behaviors of rejecting care that was necessary for the resident's wellbeing during the assessment period and that the resident was coded as totally dependent for bathing and personal hygiene. Record review of Resident #84's care plan revised 01/26/26 revealed that Resident #84 had an ADL/self-care performance deficiency due to limited range of motion. The care plan listed Resident #84 as totally dependent on staff for personal hygiene and oral care. Observation and interview on 06/16/26 at 10:45 AM revealed that Resident #84 was lying in bed. Her teeth were noted to be a dark brown color, and her hair was matted. Resident #84 stated that she brushed her teeth using dental gum. She stated that she took the dental gum and ran it across her teeth. When asked if she got her teeth cleaned, Resident #84 stated no, but that would be nice. When asked if Resident #84 had seen a dentist, she responded that she had not seen a dentist in her time at the facility. When asked about getting her hair brushed, Resident #84 did not respond, but stated that the staff does help her receive bed baths. Observation on 06/18/26 at 11:50 AM revealed that Resident #84's hair was still matted, and she was lying in bed asleep. In an interview on 06/18/26 at 1:04 PM, CNA B stated that he had worked with Resident #84 for six months. He stated that Resident #84 had sensory issues and did not like using a regular toothbrush. He stated that when staff brushed Resident #84's teeth they tried to do it quickly, but she may refuse. CNA B stated that staff used a sponge brush on the resident's teeth after each meal if they could. CNA B stated thatResident #84 sometimes did not want her hair to get wet. CNA B stated that occasionally Resident #84 would let staff wet her hair with a towel and dry it, but not a deep wash. He stated that Resident #84's family member came in the afternoons and sometimes would brush the resident's hair. In an interview on 06/18/26 at 2:41 PM, Resident #84's RP stated that staff did not come in to brush Resident #84's teeth, and that her hair had gotten so bad that a brush cannot even go through it anymore. The RP stated that she was unable to come up every day to brush Resident #84's teeth and stated that Resident #84 told her that staff will not brush her teeth or brush her hair. The RP stated that she provided Resident #84 with dental gum to try and help since the resident's teeth were not getting brushed. The RP stated that she was unhappy with the care being provided and that the facility had not contacted her about Resident #84 refusing care. Record review of Resident #84's Progress Notes for May 2026 and June 2026 revealed there were no notes for the refusal of oral care, hair maintenance, or conversations with the family for Resident #84. In an interview on 06/18/26 at 3:18 PM, the ADON stated that she had been working there since July 2025. She stated Resident #84's teeth had always been brown. The ADON stated that no one notified her that Resident #84 had been refusing oral care. She stated that if the resident was refusing, the family should be notified, and the facility should be coming up with alternatives. The ADON stated she was unaware that Resident #84 was using dental gum instead of brushing and that this could lead to infection and tooth loss. She stated that the facility would be responsible for getting Resident #84's hair cut if the family refused to cover the cost because her hair was matted, and matted hair could lead to hair loss and head sores. In an interview on 06/18/26 at 3:51 PM, the DON stated that Resident #84 refuses care. He stated that Resident #84 refuses oral care and refuses to have her hair detangled. When asked if the facility was documenting these refusals and documenting conversations with Resident #84's RP, he stated the refusals should be documented and care planned and that he would look for documentation. The DON stated that the risk of residents not getting assistance with their ADLs was that the services help them with everyday life. In an interview on 06/18/26 at 4:17 PM, the Administrator stated that if a resident was refusing ADL care, the staff would notify the nurse, and the nurse was expected to document and encourage the resident to accept ADL care. He stated that if a resident was refusing, there should be interventions in place and that they would speak with the family. The Administrator stated that if ADLs were not being done, the resident was at risk for decline and infection. 2. Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a [AGE] year-old female who admitted on [DATE]. Resident #2's diagnoses included Alzheimer's disease (a type of dementia that affects memory, thinking and behavior), cerebrovascular accident (stroke), and hemiplegia (paralysis) and hemiparesis (weakness) following cerebrovascular disease (stroke) affecting left non-dominant side. Further review of the MDS revealed Resident #2's BIMS score was 12 indicating moderate cognitive impairment, and Resident #2 required partial/moderate assistance with personal hygiene. Record review of Resident #2's care plan, dated 03/19/26, revealed an ADL self-care performance deficit and the resident required maximal assist for personal hygiene/oral hygiene. Record review of Resident #2's progress notes, dated 01/01/26 to 06/18/26, revealed no documentation or refusal of fingernail care. Observation on 06/16/26 at 12:29 PM revealed Resident #2's fingernails on the right hand were long. The pinky nail on the resident's right hand were jagged with a brown and reddish substance underneath and on top of the nails. Resident #2's fingernails on the left hand were long with a brown substance underneath the thumb nail. In an interview on 06/16/26 at 12:34 PM, CNA C stated she noticed Resident #2's nails when the surveyor was talking to the resident. She stated she did not have that part of the hall, so she did not know who was responsible to cut Resident #2's nails. She said they had activities and a nail day where they did clipping, cleaning, and color if the resident wanted color. She said the risk if resident's nails were not trimmed or clean would be infection or they could cut themselves with their fingernails. In an interview on 06/16/26 at 1:32 PM, CNA D said CNAs were responsible for cutting nails on their shower days and Resident #2 had an evening shower. She said the risk would be residents could possibly get sick and she did know Resident #2 used her hands to eat. CNA D said residents could hurt themselves if nails were jagged. In an interview on 06/18/26 at 1:11 PM, LVN E stated when CNAs gave showers they were supposed to do nail care unless the resident was diabetic or they refused. He stated most of the time Resident #2 would let him trim her nails. He said they were long and he trimmed them yesterday. He said there could be dirt and there could be a risk of infection or residents could scratch themselves. In an interview on 06/18/26 at 3:49 PM, the DON stated CNAs do nail care on the days they did showers and if the patient was diabetic the nurse would. The DON said it was an infection risk. He stated they started an in-service. He also stated that he and the ADON would go on the hall on shower days to randomly spot check that nail care was provided. In an interview on 06/18/26 at 4:16 PM, the Administrator stated his expectation was CNAs cut residents' fingernails unless the resident was diabetic and then the nurse would. Record review of facility policy titled Activities of Daily Living (ADL), Supporting, updated February 2025, revealed Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.2.Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:a.hygiene (bathing, dressing, grooming, and oral care);.

Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services for 3 of 3 residents (Resident #65, Resident # 60 and Resident #7) reviewed for urinary catheters.1. Resident #60's catheter bag was observed to be hanging on the back of his wheelchair and was so full it was dragging the ground on 06/16/26.2. Resident #65's catheter bag was observed to be hanging from his bed and was touching the floor on 06/17/26.3. Resident #7's catheter bag was observed hanging from her bed and was touching the ground on 06/18/26.These failures could place residents who use catheters at risk of infection or injury. Findings included:Record review of Resident #60's MDS dated [DATE], revealed that the resident was a [AGE] year-old male who was re-admitted to the facility on [DATE]. His diagnoses included insomnia (difficulty falling asleep), urine retention, and atrial fibrillation (irregular heart rhythm) and was documented to have a catheter. The MDS revealed that he had a BIMS score of 4 (indicating that cognition is severely impaired) and that the resident was dependent on staff for toileting hygiene management and the resident was to have assistance with the maintenance of his catheter bag, including emptying and maintaining cleanliness. Record review of Resident #65's MDS dated [DATE], revealed that he was a [AGE] year-old male who was re-admitted to the facility on [DATE]. His diagnoses included UTI (an infection in any part of the urinary system), anemia (a deficiency of red blood cells that leads to insufficient oxygen delivery to the body), and high blood pressure and was documented to have a catheter. The MDS revealed that he had a BIMS score of 15 (indicating that cognition is intact) and that the resident was to have assistance with the maintenance of his catheter bag, including emptying and maintaining cleanliness. Record review of Resident #7's MDS 04/13/26, revealed that she was an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included anxiety disorder (persistent or excessive worry about various aspects of life), respiratory failure, and idiopathic progressive neuropathy (sensory, motor, and autonomic nerves worsen overtime but the cause is unknown), and was documented to have a catheter. The MDS revealed that she had a BIMS score of 9 (indicating that cognition is moderately impaired) and that the resident was to have assistance with the maintenance of his catheter bag, including emptying and maintaining cleanliness. Observation and interview on 06/16/26 at 11:09 AM revealed that Resident #60 was rolling down the hall and his catheter bag was dragging the floor. Resident #60 stated he wanted to get to his room so that he could lay down. Resident #60's catheter bag was observed to be covered with a blue privacy bag, and the bag was bulging and could be heard as it scraped the floor when Resident #60 rolled his wheelchair forward. In an interview on 06/16/26 at 11:15 AM, CNA A stated that Resident #60's catheter bag was last checked between 8:00 AM-8:30 AM. CNA A stated that Resident #60's catheter bag was set at the lowest setting and that after she emptied the bag it was no longer touching the floor. CNA A stated that she placed the catheter bag a little higher so that when the bag was full it will not drag the ground moving forward and stated that she was responsible for emptying Resident #60's catheter bag and that it should be covered and off the ground. CNA A stated that having the catheter bag dragging on the floor could put the resident at risk for contamination. Observation on 06/17/26 at 2:23 PM revealed that Resident #65 was in bed and his catheter bag was hanging clipped to his bed frame. Resident #65's catheter bag was observed to be touching the floor.In an interview on 06/17/26 at 3:06 PM, LPN A stated that that the catheter bag should not be on the floor dragging, with a privacy bag and that the strap was to be placed on the resident's lap if they were in their wheelchair, so the line was not dragging. He stated that it was an infection control issue if the catheter bag was on the floor, and it could be spreading infection, or someone could step on it, trip, or slipObservation on 06/18/26 at 9:41 AM revealed that Resident #7 was in bed and her catheter bag was hanging clipped to the bed frame. Resident #7's catheter bag was observed touching the floor.In an interview on 06/18/26 at 3:51 PM, the DON stated that the catheter bag placement could be tricky, especially when the resident has a low bed setting. The DON stated that catheter bags needed to be closed properly, in a privacy bag, and off the floor. He stated that having a catheter bag touching the floor could be an infection control risk for residents. Record review of facility policy Catheter Care, Urinary updated July 2024 stated: PurposeThe purpose of this procedure is to prevent catheter-associated urinary tract infections.Infection Control. b.Be sure the catheter tubing and drainage bag are kept off the floor.

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 in one of one kitchen in that:1. One pack of opened lunch meat was undated and unlabeled in refrigerator #2.2. One pack of opened chicken patties was undated and unlabeled in freezer #1.This failure could affect residents who receive meals from the kitchen in that they could be at risk of contracting food borne illnesses.Findings included:Observation on 06/16/26 at 9:27 AM revealed a pack of partially used lunch meat on the top shelf of refrigerator #2 was placed on top of an open box. The package was observed to be unlabeled and undated. During an interview and observation with the Dietary Manager on 06/16/26 at 9:30 AM, a bag of partially used chicken patties was observed to be placed on top of another open box in freezer #1. The bag was not labeled or dated. The Dietary Manager stated that it was the responsibility of all kitchen staff to date and label food if they open them. The Dietary Manager stated that all food should be labeled with the date it was opened and a use by date if applicable. She stated that the risk of not dating or labeling food was that serving undated and unlabeled food to residents could cause them to get sick. The Dietary Manager stated that staff want to ensure food does not go into the danger zone.In an interview on 06/18/26 at 4:27 PM, the Administrator stated that all food should be dated and labeled and that he and the Dietary Manager were responsible for monitoring labeling and dating. The Administrator stated that labeling and dating was done to prevent food spoilage and the risk of it not being done was that it could cause foodborne illness for residents. Record review of facility policy Food Receiving and Storage revised November 2022 stated: .Refrigerated/Frozen Storage1.All foods in the refrigerator are covered, labeled and dated ( use by date).7. Refrigerated foods are labeled, dated, and monitored so they are used by their use-by date, frozen,, or discarded.

Based on observation, interview, and record review the facility failed to promptly notify the ordering physician of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for 1 of 3 residents (Resident #1) reviewed diagnostic services. LVN A failed to ensure x-ray results for Resident #1's swollen left wrist was reported to the physician when they were available in the lab portal at 11:00 PM on 04/07/26. The facility did not check the lab portal for Resident #1's x-ray results until the morning of 04/08/26 around 6AM when LVN B arrived to work, and the x-ray report revealed Resident #1 had a fractured left wrist, which had resulted from a fall. This failure could affect residents by placing them at risk for untreated illnesses, and delays in necessary care and deterioration in condition. Findings included:Record review of Resident #1's MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included non-Alzheimer's dementia and depression. The resident had a BIMS of 6 which indicated her cognition was severely impaired. The MDS reflected Resident #1 was independent with ambulation and required partial to supervision of one staff with other ADLs. Record review of Resident #1's care plan revised on 04/09/26 reflected the resident had an ADL self-care performance deficit. Interventions included providing partial supervision assistance for all ADLs. Record review of Resident #1's progress note dated 04/07/26 documented by LVN A reflected Resident has c/o pain in her left wrist. Her wrist was swollen and painful to touch. Resident was given Tylenol for c/o left wrist pain. order X-Ray.Record review of Resident #1's incident/accident report dated 04/07/26 reflected the following: Incident Description .Resident has swollen wrist that's painful to touch, states she had fell and got herself off the floorImmediate Action TakenOrder for Xray from NP on file, prn pain med given. Record review of 24-hour report dated 04/07/26 reflected the following:.Evening 2-10[Resident #1] x ray left wrist pending resultsNight 10-6 [LVN A initials]L wrist swollen and painful.Record review of Resident #1's x-ray results dated 04/07/26 at 11:06 PM reflected the following: Acute-subacute distal radial and ulnar fractures with displacement (wrist fracture with broken bones in the forearm).Record review of Resident #1's hospital record dated 04/08/26 reflected the following: .Findings:Bones: Acute intra-articular fracture of the distal radius [a break in the wrist joint's main bone that extends in the articular surface]. Acute fracture of the ulnar styloid [a break in the small bony prominence on the pinky side of the wrist] .Keep arm immobilized in splint and sling.Assessment Plan.recommend proceeding with open reduction and internal fixation of her left distal radius fracture (a two-part surgical procedure used to treat severe, displaced bone fractures)During an observation and interview on 04/22/26 at 9:30 AM, Resident #1 was sitting on the side of her bed in her room on the facility's secure unit. The resident had a cast to her left hand. Resident #1 stated something happened about three weeks to a month ago, but she could not give any further details or recall the incident. The resident was asked if she was in any pain and she looked at her cast and said not much. Resident #1 was ambulatory in her room with no assistance, and her gait was steady. During an interview on 04/22/26 at 10:46 AM, LVN B revealed Resident #1 was ambulatory and independent for most of her ADLs and she had moments of confusion. LVN B said the morning of the incident, 04/07/26, during shift change, the night nurse (LVN A) said Resident #1 complained of pain to her left wrist and when they looked at her wrist, it appeared to be swollen and painful to touch so they called the doctor for an x-ray order. LVN B said she asked the resident what happened and the resident was not able give her details. The following day, 04/08/26, LVN B said she noticed Resident #1's x-ray results during the overnight shift but no one had pulled them from the computer, so she called the nurse practitioner about the results, who ordered the resident to be sent to the hospital. LVN B said that throughout her shift the day of the incident, Resident #1 did not complain of pain therefore they did not think the resident had a fracture. During an interview on 04/22/26 at 11:01 AM, LVN A revealed during the change of shift on 04/07/26, Resident #1 complained of pain to her left wrist and the resident said she had fallen overnight and gotten herself back up, so the resident was given some Tylenol. LVN A stated the doctor was contacted and an x-ray was ordered. LVN A said she did not recall if she saw or read the 24-hour report that indicated they were waiting for Resident #1's x-ray results when she arrived for her 10:00 PM to 6:00 AM shift (04/07/26). LVN A further stated she did not recall the events of that night, 04/07/26, and possibly missed checking for the x-ray because she was the nurse over two halls, and there was a lot going on during her shift. During an interview on 04/22/26 at 11:35 AM, the PTA revealed she treated Resident #1 the day of her incident, 04/07/26. She stated the resident did not want to use her left hand that day; however, Resident #1 never complained about pain. She stated Resident #1 just guarded her left hand. The PTA said she did not notice that resident's left wrist was swollen until it was placed next to her other hand, and then they noticed it was slightly swollen. The PTA said she asked Resident #1 what happened, and the resident said she had fallen the night before and got herself back up. The PTA had been made aware by LVN B that they had ordered x-rays for Resident #1's hand. The PTA said they continued to do lower body exercises and the resident never complained of pain during her therapy. During an interview on 04/22/26 at 11:43 AM, the PTA Student said he worked with Resident #1 the morning of the incident, 04/07/26, and the resident did not want to use her left hand. The PTA Student said the nurse told him Resident #1 had a fall overnight and they were waiting for the x-ray company. The PTA Student said the resident was taken back to the therapy gym and she was able to participate in lower extremity exercises and never complained of pain but did notice her left wrist was slightly swollen. During an interview on 04/22/26 at 11:46 AM, the OTA revealed she worked with Resident #1 the day of her incident, 04/07/26, and the resident did not want to use her left hand but participated in therapy with her right hand and never complained of pain in her left hand. The OTA said she had been made aware by the PTA that Resident #1 said she had fallen and they were awaiting x-rays to her wrist. The OTA said she did not notice any swelling to the resident's left hand. During an interview on 04/07/26 at 12:32 PM, the ADON revealed she was told on 04/07/26 by LVN B that they had ordered an x-ray for Resident #1's left hand. The ADON said the x-ray results came in during the night shift (04/07/26) but they were not pulled from the lab portal until the next morning (04/08/26) by LVN B. The ADON said the lab company will call the facility when there are critical labs/x-rays but the company appeared to have called another facility with the similar name with the results of Resident #1's x-rays. The ADON said the charge nurses were still responsible for checking the lab portal each shift and Resident #1's pending x-ray results also should have been on the 24 hour-report for LVN A to see. During an interview on 04/22/26 at 12:40 PM, LVN C revealed she worked the 2:00 PM to 10:00 PM shift the day of Resident #1's incident. She stated she was told Resident #1 had fallen, and the x-ray company completed the resident's x-rays during her shift. She stated the x-ray results for Resident #1 did not come back until after she left the facility for the night. She stated Resident #1 did not complain about wrist pain during her shift. Record review of the facility's Lab and Diagnostic Test Results policy, revised November 2018, reflected the following: Assessment and Recognition1. The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs.2. The staff will process test requisitions and arrange for tests.3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. Procedure.4. Licensed nurse reviews lab/diagnostic results and notification is made to the physician 5. Critical Values: Must be immediately communicated to the provider (within 1 hour) .

Based on observation, interview and record review the facility failed to ensure a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Residents #1) reviewed for respiratory care. The facility failed to ensure there was a physician order for Resident #1's oxygen therapy when the resident admitted to the facility on [DATE].This failure could place residents at risk for respiratory infections. Findings included:Record review of Resident #1's entry MDS dated [DATE] reflected a [AGE] year-old female was admitted on [DATE]. Resident #1 had diagnoses which included: pneumonitis due to inhalation of food and vomit (lung inflammation caused by inhaling food, vomit, or saliva often leading to rapid lung injury due to stomach acid). Record review of Resident #1's baseline care plan dated 04/07/2026 reflected the resident was diagnosed with Pneumonitis due to inhalation of food and vomit. The resident required assistance with ADL functions that included: Set up and clean up assistance for meals, Partial to moderate assistance for rolling left to right, and substantial assistance for sit to stand, toilet transfer, transfers to bed. She will be evaluated for PT, OT, ST, and DMI (identifies patients functional deficits).Record review of Resident #1's PHQ-9 (assesses degree of depression severity) that was completed by the SW on 04/08/2026 at 11:35 AM, reflected that Resident #1 had moderate cognitive impairment with a BIMS score of 11. The resident was referred to for psychological services for an evaluation. She was alert and able to communicate her needs to the staff.Record review of Resident #1's physician orders dated 04/07/2026 reflected admit to SNF, full code, PT, OT, ST, RT to evaluate and treat as indicated. Order dated 04/09/2026 Change O2 tubing water . Change Oxygen administration device NC, and humidifier bottle weekly on Sunday night. every night shift every Sun related to pneumonitis due to inhalation of food and vomit. check oxygen Concentrator filter for placement and clean filter every week and PRN every night shift every Sun related to Pneumonitis due to inhalation of food and vomit. Oxygen at _2_LPM via N/C every shift for SOB and to maintain pulse ox (device, usually clipped to the finger, that measures blood oxygen saturation)> less than 90% related to pneumonitis due to Inhalation of food and vomit (choking during swallowing aspiration pneumonia). Record review of Resident #1's TAR did not reflect an admissions order for Oxygen treatment at the time of record review. The facility provided the physician order that was reflected in Resident #1's TAR prior to exit on 04/09/2026. During an observation and interview on 04/09/2026 at 1:10 PM, Resident #1 was observed awake in her wheelchair wearing NC receiving oxygen via the portable green tank attached to her wheelchair. Observation of the NC and oxygen equipment revealed the tubing was not dated. Resident #1 stated that the NC had not been changed on the oxygen concentrator or portable tank since being admitted on [DATE]. Resident #1 stated that she was receiving oxygen to assist with breathing due to a DX of pneumonia. During an interview on 04/09/2026 at 1:27 PM, LVN-A stated he worked at the facility for two weeks. LVN-A stated he had not changed Resident #1's oxygen tubing during his shift 04/08/2026. LVN-A reviewed Resident #1's file and observed she did not have an order for oxygen use on file. LVN-A stated Resident #1 must have an order for treatments from the MD. LVN-A stated that Resident #1 was receiving continuous oxygen. LVN-A stated that it was the assigned nurses (LVN-A) responsibility to ensure Resident #1' had an order for Oxygen on file, tubing was changed and dated to prevent overuse of treatment equipment. LVN-A stated the oxygen tubing was expected to be changed and dated weekly or as needed. LVN-A stated the equipment should be checked each shift; however, he did not notice the residents' equipment was not dated. During an interview on 04/08/2026 at 1:45 PM, the ADON stated she had worked at the facility for a couple of weeks. She stated she was unaware Resident #1's oxygen equipment was not dated and labeled. The ADON stated it was standard practice for oxygen equipment to be changed and dated once a week and as needed. She stated the expectation was for all nurses to check the oxygen equipment daily during each shift. She stated that failing to date and change the equipment placed residents at risk for infections. She said it was her responsibility to ensure that the task was completed.An interview with the DON was not conducted because the position was vacant.During an interview on 04/08/2026 at 3:00 PM, the Administrator stated the ADON and DON were responsible for monitoring and ensuring resident oxygen equipment was checked every shift. He stated he expected nurses to change and date oxygen tubing as needed and according to facility protocols weekly. The Administrator stated not changing out the equipment at least once a week could place the residents at risk of infection. The Administrator stated that he was hiring for the DON position.During an interview on 04/09/2026 at 12:16 PM, the Administrator stated the policy the facility had only addressed oxygen. He stated in regard to changing the oxygen equipment, they followed the physician's orders. He provided the facility's policy regarding oxygen storage. Record review of the facility's current, undated Oxygen Storage policy reflected the following: It is the policy of this center to maintain appropriate and safe storage of oxygen. The policy did not address the care, maintenance, labeling, and dating of oxygen tubing.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 1 of 6 residents (Resident #3) reviewed for pharmaceutical services. MA A failed to supervise Resident #3 after he left the resident's medications in her room during morning medication administration on 12/09/25. This failure could place the residents at risk of not receiving medications as ordered by the physician. Findings included: Record review of Resident #3's Face Sheet, dated 12/09/25, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #3's Quarterly MDS Assessment, dated 11/14/25, reflected the resident had diagnoses of Medically Complex Conditions (multiple serious medical issues at the same time), Hypertension (high blood pressure), Diabetes Mellitus (condition where the body was unable to control blood sugars properly), and Alzheimer's Disease (brain disease that causes progressive memory loss). The MDS also reflected a BIMS score of 13, indicating she was cognitively intact. Record review of Resident #3's Care Plan, dated 09/09/25, reflected the resident had impaired visual function, cognitive loss/dementia, a swallowing problem, hypertension, Diabetes Mellitus and prescribed an oral hypoglycemic (medications that lower blood sugar), and anemia (low red blood cells) with an intervention to give medications as ordered. Record review of Resident #3's Assessment Notes on 12/09/25 reflected no assessment for self-administration of medications and no assessment that the resident was competent to manage their own medications. Record review of Resident #3's Physician Orders reflected the following orders: Order date: 11/11/25 B12 Active (mecobalamin (vitamin b12)) tablet, chewable; 1,000 mcg; amt: 1 tab; oral Once A Day. Cholecalciferol (vitamin D3) capsule; 50 mcg (2,000 unit); amt: 1 CAP; oral Once A Day. cranberry tablet; 450 mg; amt: 1 Tab; oral Twice A Day. Gabapentin capsule; 400 mg; amt: 1 CAP; oral Twice A Day. Glipizide tablet; 5 mg; amt: 1 TAB; oral; Once A Day. Magnesium oxide [OTC] tablet; 400 mg (241.3 mg magnesium); amt: 1 tab; oral Once A Day. omeprazole [OTC] tablet, delayed release ;20 mg; amt: 1 tab; oral Special Instructions: DO NOT CRUSH; Once A Day. aspirin [OTC] tablet, delayed release; 81 mg; amt: 1 tab; oral Special Instructions: DO NOT CRUSH; Once A Day. Prozac (fluoxetine) capsule; 20 mg; amt: 1 Capsule; oral; Once A Day.Record review of Resident #3's MAR reflected on 12/09/25 at 8:03 AM, she was given the following medications and supplements: cranberry tablet, gabapentin (medication for nerve pain), aspirin, vitamin B12, vitamin D3, glipizide (diabetic medication), magnesium oxide, omeprazole (medication to reduce stomach acid), and Prozac (antidepressant). Observation and interview on 12/09/25 at 8:04 AM revealed MA A took a medication cup into Resident #3's room. Resident #3 was in her wheelchair eating breakfast in her room. MA A left the medication cup with medications on the bedside table. Resident #3 stated she would take them when she was done eating. Observation of the medication cup revealed there were 9 pills/tablets in the cup.Interview on 12/09/25 at 9:25 AM with Resident #3 revealed that staff typically watched her take her medications. Resident #3 stated MA A left the medications because she was busy doing something. Resident #3 stated she took her pills just fine. Interview on 12/09/25 at 11:43 AM with MA A revealed he had left medications in the resident rooms when a resident refused to take them. MA A stated he left the medications in Resident #3's room today (12/09/25). MA A stated he would only leave them if Resident #3 was doing something, but most of the time, she took the medications immediately. MA A stated he did go back to ensure Resident #3 took the medications. MA A stated he was not supposed to leave medications in the room. He stated the risk of leaving medications in the room was that the residents would not take them, or that another resident could take the medication. Interview on 12/09/25 at 2:44 PM with ADON C revealed that staff should never leave medications unattended in resident rooms. ADON C stated the residents could forget or not take the medications. ADON C also stated another resident could take the medications. Interview on 12/09/25 at 3:20 PM with ADON D revealed it was unacceptable to leave medications in the room. ADON D stated staff were to watch all the residents swallow the medications. ADON D stated the risk of leaving medications was the resident could drop them, hoard them, or another resident could take them. Interview on 12/09/25 at 3:32 PM with ADON E revealed medications should never be left in the rooms. She stated if a resident requested to self-administer medications, they must go through a process to ensure it was safe. ADON E revealed there were currently no residents in the facility, who were able to self-administer medications. ADON E stated the risk of leaving medications was the resident not taking the medication. Interview on 12/09/25 at 4:04 PM with the DON revealed it was unacceptable for staff to leave any medications in the rooms. The DON stated the risk was another resident taking it, which could cause harm or even death. The DON stated she was in-servicing staff to prevent this from recurring. Interview on 12/09/25 at 4:25 PM with the Administrator-In-Training revealed it was never safe for medications to be left in rooms because other residents could take it. The Administrator stated he would coordinate with the DON to in-service and educate about not leaving the medications with the resident. Record review of the facility's Administering Medications policy, revised April 2019, reflected the following: 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.

Based on interview, observation, and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 6 residents (Resident #4) reviewed for medication administration.The facility failed to administer Resident #4's Keppra/levetiracetam (an anti-epileptic drug used to treat seizures) as prescribed. This failure could place residents at risk of inadequate therapeutic outcomes, increased adverse side effects, and decline in health. Findings included: Record review of Resident #4's Quarterly MDS assessment, dated 12/03/25, reflected the resident was a [AGE] year-old female who admitted on [DATE]. The resident's diagnoses included cerebral palsy (a permanent neurological disorder that causes muscle and movement problems) and epilepsy (repeated seizures due to abnormal electrical activity in the brain). The MDS also revealed the resident had severe cognitive impairment. The MDS also revealed the Resident #4 was dependent on all ADLs. Record review of Resident #4's Care Plan dated 09/16/25 reflected the following: Problem: [Resident #4] has a seizure disorder. Goal: [Resident #4] will remain free from injury related to seizure activity through review date .Approach: Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness.Record review of Resident #4's physician orders revealed the following:Order date 04/08/24: Keppra (levetiracetam) solution - give 7.5 mL; orally twice a day for epilepsyOrder date 01/31/25: Lactulose solution - give 30 mL; orally every 12 hours, PRNLab order - Order date 9/15/25: Carbamazepine (Tegretol); Keppra level; [DX: Epilepsy, unspecified, intractable, with status epilepticus] Once A Day on the 15th of Every 6th MonthObservation on 12/09/25 at 10:00 AM, revealed LVN B administering medications to Resident #4. LVN B administered 7.5 mL of lactulose (medication for constipation). LVN B did not administer the scheduled dose of Keppra. After medication administration, LVN B checked off the Keppra dose was given on Resident #4's MAR. LVN B did not document that she had administered the lactulose. Interview on 12/09/25 at 1:47 PM with LVN B revealed that after checking the MAR, she confirmed the lactulose was administered instead of the Keppra. She stated the medication bottles looked different, and she was unable to determine why she made the error. LVN B stated Resident #4 did have PRN Lactulose scheduled. LVN B stated she normally gave Resident #4 the Keppra. She stated she could have been nervous. LVN B stated not giving the Keppra put Resident #4 at risk of seizures. She stated it was important to take the Keppra regularly to prevent seizures. LVN B stated she fed Resident #4 lunch, and she had no change in condition or seizures. LVN B stated she had been trained on the medication rights of administration and had completed them during the medication pass. LVN B stated it was a simple error, and she would notify the charge nurse, DON, Guardian, and physician for new orders. Interview on 12/09/25 at 2:44 PM with ADON C revealed that staff were expected to complete the medication rights of administration to prevent medication errors. ADON C stated missing a Keppra dose could put Resident #4 at risk of seizures. ADON C stated she expected her staff to safely administer medications. Interview on 12/09/25 at 3:20 PM with ADON D revealed that staff were expected to complete the 5 rights of medication administration. ADON D stated Keppra was for seizure and seizures could occur if a dose was missed. She stated Resident #4 received an assessment and had no change in condition.Interview on 12/09/25 at 3:32 PM with ADON E revealed that staff were expected to review the MAR and complete the rights of medication administration to prevent errors. ADON E stated Keppra was used for seizures and a missed dose could cause seizure activity. She stated she was made aware of the medication error from LVN B. ADON E revealed the physician was notified and advised to hold this morning's dose of Keppra since it had not been administered. ADON E stated the guardian was also notified and Resident #4 would be put on seizure monitoring for 3 days. ADON E stated in-servicing had been started on medication administration. Interview on 12/09/25 at 4:04 PM with the DON revealed that she expected her staff to complete the 5 rights of medication administration. The DON stated Keppra was used for seizure activity and Resident #4 could have had a seizure if a dose was missed. The DON stated that she was doing in-services to prevent it from happening. Interview on 12/09/25 at 4:25 PM with the Administrator-In-Training revealed that the DON had started in-servicing about medication administration and preventing errors. The Administrator also stated Resident #4 would be on seizure observation for 3 days. Record review of the facility's Administering Medications policy, revised April 2019, reflected the following: .The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Residents #1 and #2) reviewed for infection control. MA A failed to sanitize a re-useable blood pressure cuff between uses on Resident #1 and Resident #2.This failure could place the residents at risk of exposure to infections. Findings included: Record review of Resident #1's Quarterly MDS, dated [DATE] reflected the resident was a [AGE] year-old female who admitted on [DATE]. The resident's diagnoses included progressive neurological condition (brain or nerve disorder that gets worse over time) and hereditary motor and sensory neuropathy (genetic condition that causes the nerves in the arms and legs to slowly lose strength and sensation). The MDS also reflected a BIMS score of 15, indicating she was cognitively intact. Record review of Resident #1's care plan, dated 09/03/25, reflected she had, Increased susceptibility to infection due to nutritional deficiencies and dehydration, evidenced by inadequate oral intake, impaired immune function, and compromised hydration status.Record review of Resident #2's annual MDS dated [DATE], reflected the resident was a [AGE] year-old female who admitted on [DATE]. The resident's diagnoses included Non-Traumatic Brain Dysfunction (The brain not working properly due to a medical problem) and Dementia (Severe mental decline). The MDS also reflected a BIMS score of 12, indicating she had moderate cognitive impairment.Record review of Resident #2's care plan, dated 09/09/25, reflected that she required assistance with ADL functions and had impaired cognition and memory loss. Observation on 12/09/25 at 8:32 AM revealed MA A checked Resident #1's blood pressure with a re-usable blood pressure cuff and returned it to the medication cart without sanitizing it. Observation on 12/09/25 at 8:40 AM revealed MA A checked Resident #2's blood pressure with the same re-useable blood pressure cuff used on Resident #1 without sanitizing the cuff prior to or after using it on Resident #2. Interview on 12/09/25 at 11:43 AM with MA A revealed he did not clean the blood pressure cuff between residents. MA A stated he was never taught that, but it made sense. MA A stated the risk of not cleaning it was transferring bacteria to other residents.Interview on 12/09/25 at 2:44 PM with ADON C revealed blood pressure cuffs should always be sanitized from resident to resident. ADON C stated cross contamination and infection issues could occur if re-useable blood pressure cuffs were not sanitized. Interview on 12/09/25 at 3:20 PM with ADON D revealed blood pressure cuffs should be wiped down between residents. ADON D stated the risk of not cleaning the blood pressure cuff was infections and cross contamination. Interview on 12/09/25 at 3:32 PM with ADON E revealed reusable blood pressure cuffs should be disinfected before each resident. ADON D stated the risk of not disinfecting the blood pressure cuff was spreading infection. Interview on 12/09/25 at 4:04 PM with the DON revealed blood pressure cuffs should be sanitized between residents. She stated there were cleaning wipes in each cart and around the building to clean the blood pressure cuffs. The DON stated the risk of blood pressure cuffs not being sanitized was spreading infection from resident to resident. Interview on 12/09/25 at 4:25 PM with the Administrator-In-Training revealed the risk of blood pressure cuffs not being disinfected was cross contamination to residents. Record review of the facility's Standard Precautions policy, revised September 2022, reflected: .5. Resident-Care Equipment.b. Reusable equipment is not used for the care of more than one resident until it has been appropriately cleaned and reprocessed.

Based on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for one of one resident (Resident #1) reviewed for abuse, neglect, and exploitation. The facility failed to implement their policies and procedures to ensure Resident #1 was free from neglect when the facility failed to have effective interventions and services in place to address the resident's care, which resulted in Resident #1 sustaining injuries of ICH (intracerebral hemorrhage (type of stroke bleeding on the brain tissue due to a ruptured blood vessel), and a closed displaced intertrochanteric fracture of left femur with routine healing Normocytic anemia (is a complex medical condition involving a broken hip bone that has shifted out of place, along with a type of anemia.) An Immediate Jeopardy (IJ) was identified on 06/24/2025 at 4:30 PM While the Immediate Jeopardy was removed on 06/25/24, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm and at a scope of isolated due to the facility's need to implement and monitor the effectiveness of its corrective systems. The failure could place residents at risk for serious injuries, hospitalization, and death. Findings included: Record review of Resident #1's face sheet dated 06/24/2025 reflected the resident was a [AGE] year-old female admitted on [DATE] with active diagnoses that included unspecified cerebral infarction (stroke), displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, Pain, repeated falls, Major depressive disorder (feeling down), and Vascular dementia unspecified severity without behavioral disturbances, Depression, Alzheimer's, and insomnia. Record review of Resident #1's admission MDS assessment dated [DATE] reflected she had minimal difficulty with hearing, clear speech, understood by others and usually understood other. Resident #1's vision was moderately impaired, and she wore corrective lenses. Resident #1 was assessed as having a BIMS score of 08, indicating she was moderately impaired cognitively. She had no mood issues, no behaviors, psychosis, rejection of care or wandering. Resident #1 had no impairments with range of motion to her upper and lower extremities. Resident #1 used a wheelchair for mobility and was dependent on staff for all ADLs to include dressing, hygiene, transfers, eating and basic mobility. Resident #1 was frequently incontinent of bowel and bladder and required substantial/maximal assistance (helper does more than half the effort. (Helper lifts or holds trunk, limbs and provides more than half effort.). Resident #1 scored a 9 on functional abilities for sit to stand and walking 10 ft (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.) Resident #1's fall history on admission MDS reflected that Resident #1 had repeated falls and had fallen with since being admitted . Resident #1 did not sustain any injuries. Record review of Resident #1's discharge MDS assessment dated [DATE] reflected an unplanned discharge to short term general hospital. Resident #1 was dependent on staff for all ADLs to include dressing, hygiene, transfers, eating and basic mobility. Resident #1 was frequently incontinent of bowel and bladder. Resident #1's was not receiving any special treatments. The assessment reflected she had fall history. Record review of Resident #1's change in condition MDS assessment dated [DATE] reflected she needed an interpreter, due to preferred language being Spanish . She had minimal difficulty with hearing and had clear speech. Resident #1 was able to communicate needs to others. Resident #1 was assessed as having a BIMS score of 07, indicating she was severely impaired cognitively. She had no mood issues, behaviors of rejecting care 4 to 6 days of care no wandering. Resident #1 had no impairments with range of motion to her upper and lower extremities. Resident #1 used a wheelchair for mobility and was dependent on staff for all ADLs to include dressing, hygiene, transfers, eating and basic mobility. Resident #1 was always incontinent of bowel and bladder. Active diagnoses dementia, Stroke, Arthritis (crippling in joints), Osteoporosis (fragile bones from aging), displaced intertrochanteric fracture of the left femur, subsequent encounter (displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing,) Vascular dementia unspecified severity without behavioral disturbances, Hip Fracture. Additional diagnoses included Unspecified Sequelae of cerebral infarction (after-effects of a stroke), and repeated falls. Resident #1's was not receiving any special treatments. Assessment reflected she had fall history. Record review of Resident #1's care plan dated 04/15/2025 reflected . The resident has visual and cognitive deficits and needs assistance to pursue activities of choice and Category: created The resident has a /communication problem r/t dementia and primarily Spanish speaking Created: 05/01/2025 .interventions .anticipate needs, ensure availability and functioning of adaptive communication equipment (picture board) ensures safe environment: call light in reach, adequate low glare light, bed in lowest position, wheels locked, avoid isolation .Monitor/document for physical/nonverbal indicators of discomfort or distress, and follow up as needed Resident has impaired visual functioning and is at risk for a decreased in ADL's and Injuries Created: 05/01/2025 . Resident has impaired cognitive function/dementia or impaired thought processes r/t DX vascular dementia Created: 05/01/2025 resident requires pain management with opiate medications r/t terminal status and hip FX . Resident requires Hospice as evidenced by terminal illness of: inter-cerebral hemorrhage Edited: 06/09/2025 . Category: Falls Resident had an actual fall r/t poor safety awareness, attempting to transfer self, weakness, HX falls . Do not leave unattended in bathroom .remind resident to use call light to gain assistance with transfers, continue therapy services, Edited: 05/27/2025 Resident has Post-op site on L hip, skin tear to L elbow edited 6/11/2025, Resident has surgical wound to L hip R/T .Edited: 06/24/2025 Resident #1 was at risk of falls, r/t weakness, poor safety awareness, skin tears, bruising. Skin assessment addressed bruising and tears, fall assessment completed. Record review of Resident #1's physician's orders dated 06/08/2025 reflected admit to Hospice for DX of intracerebral Hemorrhage (bleeding) at Bedtime 8:00 PM . Record review of orders dated 06/09/2025 reflected: Monitor edema (swelling caused by fluid) Twice a Day 6:00 AM - 2:00 PM days, 3:00 PM - 10:00 PM evenings .Opiate (A class of drug used to reduce moderate to severe pain) medications use .monitor for s/sx of constipation (trouble having a bowel movement), delirium (confusion), over-sedation (drowsy/sleep), change in mental status (overall functions cognitively, mentally, emotionally), and reduced respirations (breaths) . Pain Assessment Q-Shift using the Numeric (relating to or expressed as a number or numbers.) or PAIN scale Special Instructions: document results Every Shift Days 6:00 AM - 2:00 PM, Evenings 2:00 PM - 10:00 PM, Nights 10:00 PM - 06:00 AM . order dated. PT/OT/ST to evaluate and treat if indicated . Record review of Resident #1's MD order dated 06/10/2025 reflected Give 1 tablet; 50 mg zinc (220 mg); amt: 1 tab; oral Once a Day. Record review of Resident #1's MD orders dated 06/12/2025 reflected LLE TTWB due to DTI Every Shift Days 06:00 AM - 2:00 PM evenings, 3:00 PM - 10:00 PM evenings Left hip post OP site: Monitor for s/s infection or dehiscence (medical term, dehiscence refers to the separation or splitting open of a surgical wound or incision that was previously closed) if present notify MD Every Shift Days 6:00 AM - 2:00 PM, Evenings 2:00 PM - 10:00 PM, Nights 10:00 PM - 06:00 AM . Record review of Resident #1's MD an order dated 07/08/2025 Other Test: (LEFT Hip X-Ray Unilateral 2-3 V (unilateral radiologic examination of a joint or structure, consisting of 2 to 3 views.) .including pelvis with CD (In a medical context, when you see pelvis with CD it most likely refers to a pelvic CT scan that includes images recorded onto a CD.) Once - One Time 06:00 AM -11:00 PM. Record review of Resident #1's skin assessment note dated 06/10/2025 at 12:23 PM reflected under description (skin tear/Laceration). Record review of Resident #1's progress notes on 04/15/2025 at 10:40 AM by LVN-C reflected Pt was up in w/c reading daily journal in her room. This nurse was informed 10:40 by aid that when she was rounding Pt was attempting to get back in bed self and was caught by the aid before she could hit the floor. Pt was landed on her knees and was put back in bed with the help. Denies pain. ROM TO all ext. ALL parties notified. Fall precautions implemented. Bed in lowest position. encouraged pt to use call light for assistance. Frequent visual monitoring done. will cont. to follow POC. Record review of Resident #1's nursing progress note dated 05/20/2025 at 6:29 PM by RN-S reflected Around 3:40 PM this nurse was aware by CNA that the pt is in the floor. Upon entering the room Resident found on the floor in the bathroom on side lying position, wheelchair is locked next to her. Assisted her back to wheelchair with the help of two person. Vital sign WNL. On assessment noticed small skin tear on It elbow with small amount of blood, dressing done. Notified wound care nurse. alert and orient with her baseline. Vitals WNL. Resident states she fell when transferring from commode to wheelchair herself. Complained of L leg pain, Tylenol 650 mg po given, somewhat effective. NP, DON/ADON notified. RP made aware. Received new order to stat X-ray L Hip from NP. updated on portal. Neuros on progress and within normal limits. Bed in low position. fall precaution maintained. will cont. to monitor. Record review of Resident #1's nursing progress note dated 05/20/2025 at 9:12 PM by RN-S reflected that X-ray of hip shows left femoral neck fracture. MD made aware. Called 911 and sent to [hospital]around 10 PM. Record review of Resident #1's nursing progress note dated 05/20/2025 at 9:43 PM by LVN-M reflected Spoke with [family member] directly about situation he states that he is in route to [hospital name] now and okay with mother being sent in ambulance. Record review of Resident #1's nursing progress note dated 06/08/2025 by LVN-A reflected Resident came back from the hospital on a non-emergency transportation on a stretcher and was transferred from stretcher to bed Resident had a fall in the facility and sustained a left hip fracture. Surgery was performed and has stitches on the left hip. Dressing is intact and surgical incision is showing visible signs of any infection or drainage. Resident is admitted on services [Hospice] visited the facility. [Hospice] is do present the DNR paper. Hospice has ordered to continue with the discharge orders. Resident is on day 1/3 of follow up for new medication (Tramadol) 50 mg every 4 hours for pain. Clarification is needed from hospice for delivery of Tramadol since order came from them. Hospice has also ordered Comfort Kit. Dietary is notified of the resident coming back. No complains of pain is voiced by resident. Oral fluids and call light is in easy reach. no paper. Hospice has ordered to continue with the discharge orders. Record review of Resident #1's nursing progress note dated 06/09/2025 at 1:13 PM by ADON reflected Follow up monitoring Day 1 of 3 of Re-admit with DX: L hip FX SX (symptoms) repair. AAOx1-2 (refers to the level of alertness and orientation, specifically indicating that a person is aware of who they are and where they are but may not know the current date and time (A&Ox1) or also what happened to them (A&Ox2). Spanish speaking. Under [hospice name]. Respiratory even and unlabored. No sob noted. No cough congestion noted. L hip surgical incision dressing CDI. Denies pain or any other discomfort at this time, Abdomen soft and non-distended bsx4. appetite fair. [Family member] present at bedside. Incontinent to B&B. Wound on Coccyx. (The small, triangular bone at the very bottom of the spine.) Wound care in progress. Turned and repositioned at regular intervals. call light and bedside table within reach. Bed in lowest position. Fall precautions implemented through the shift. call light within reach. will cont. to follow POC. Record review of Resident #1's nursing progress note dated 06/11/2025 at 7:36 AM by the ADON reflected IDT review regarding skin tear to right elbow, obtained during assisted dressing with hospice aide, resident noted with thin/fragile skin resulting in increased risk of injury, site appears with steri strips intact no s/s infection or pain present, Geri sleeves applied for safety. Record review of progress note dated 06/11/2025 10:41 AM by LVN-C reflected Follow up monitoring Day 3 of 3 of Re-admit with DX: L hip FX SX repair. AAOx1-2. Resting in bed with HOB elevated to facilitate easy breathing. Spanish speaking. Under [hospice name]. Resp even and unlabored. No sob noted. No cough congestion noted. L hip surgical incision dressing CDI. Medicated with PRN Tramadol. remains effective. Abdomen soft and non-distended bsx4 (Bowel sounds x 4 quadrants refers to the process of listening to the digestive sounds in all four quadrants of the abdomen ) appetite remains poor. D1/3 of new orders of vitamin C, Zinc, House protein, 2.0 supplement, mm with min. Incontinent to B&B. Wound on Coccyx. LLE TTWB r/t DTI. Steri-Strips intact on R elbow. wound care in progress. Off loaded bilateral (in a medical context refers to the process of reducing or removing pressure from the heels on both the right and left sides of the body.) heels when in bed. Turned and repositioned at regular intervals. Ortho appt in am. call light and bedside table within reach. Bed in lowest position. Fall precautions implemented through the shift. call light within reach. will cont. to follow POC. Record review of Resident #1's nursing progress note dated 06/11/2025 at 12:40 PM by the ADON reflected left hip f/u X-ray results received and sent to NP for review NNOs (Neuronal nitric oxide syntheses (NNOS) is an enzyme that produces nitric oxide (NO), a potentially harmful molecule implicated in fetal brain injury under .) obtained, disk received for f/u Ortho appt. Record review of Resident #1's nursing progress notes dated 06/11/2025 at 10:49 AM by the ADON reflected Notified by [family member] of Ortho f/u appt on 6/12/20, f/u X-ray to left hip scheduled for STAT today with CD for appt. tomorrow. Record review of Resident #1's nursing progress notes dated 06/12/2025 at 1:52 PM by the ADON reflected Returned from Ortho appt, staples DC' D steri strips in place, LOTA, TX orders updated. Record review of Resident #1's nursing progress notes dated 06/12/2025 05:11 AM by the ADON reflected (L) hip FX sx repair; surgical dressings on L leg kept CDI; resident slept during shift with respirations even and unlabored. Day 2/3 F/U 2.0 suppository 90 cc TID, house protein 30 cc PO BID, Vit C, Zinc, and MVM with min and skin tear with steri strips. LLE TTWB r/t DTI to (L) heel; no complaints from resident at this time. Bed in low position with call light attached. Record review of Resident #1's nursing progress notes 06/23/2025 at 3:49 AM by LVN-C reflected resident with Steri-Strips to L Hip. LLE TTWB R/T DTI to L heel. Offload bilateral heels while in bed (in a medical context refers to the process of reducing or removing pressure from the heels on both the right and left sides of the body.). No c/o pain. Call-light within reach. Record review of Resident #1's nursing progress notes 06/23/2025 at 10:22 PM by LVN-C reflected Resident with Steri-Strips to L Hip. LLE TTWB R/T DTI to L heel. Offload bilatateral heels while in bed. No c/o pain. Call-light within reach. Record review of Resident #1 event note dated 06/10/25 at 12:23 PM by the ADON reflected IDT review: witnessed: no injuries: skin tear right elbow sent to ER: not indicated all parties aware: yes intervention: Geri sleeves BUE HX of similar events: Physician notified at 10:30 AM, Resident Representative notified at 12:27 PM, Care plan revised. During an interview on 06/24/2025 at 10:15 AM with the ADMIN, revealed that he was familiar with the incident involving Resident #1. The ADMIN stated the incident occurred on 05/20/2025 and he did not investigate or submit a self-report for the incident. The ADMIN said he did not have the staff write a statement detailing the incident, however, he would check for a written statement. The ADMIN was asked to provide names of the staff involved, daily schedules of the staff with their full name documented for the day of the incident, and an employee roster. The ADMIN stated that there were two aides involved and he would provide their names. The ADMIN stated the CNA-F placed resident on the toilet, then told CNA-J that Resident #1 was left on the toilet and follow up with checks on the resident. The ADMIN stated that Resident #1 was left on the toilet for 5 minutes. The ADMIN stated they requested privacy and waived her hand for CNA-F to leave the bathroom. The ADMIN said after 5 minutes had passed CNA-F returned to Resident #1's room to check on her and heard her fall. The ADMIN said CNA-F called out for CNA-J to come and help with the resident to transfer her off the bathroom floor. The ADMIN stated that RN-S assessed Resident #1 and notified the MD, ADMIN, ADON, RNC, and POA. The MD ordered X-rays immediately. The ADMIN stated once the X-ray results were reviewed by the MD, EMS was called, and she was transported to the hospital emergency room. The ADMIN said Resident #1 returned from the hospital with hospice services and assessments for therapy. The ADMIN stated that the facility did not have a DON currently and the RNC and ADON were in charge of the nursing department. The ADMIN stated that the RNC was not at the facility at this time. He stated that the resident requested privacy from the CNA -F and it was granted. During an interview on 06/24/2025 at 10:25 AM the ADON stated that the hospital records located in the Resident #1's clinical file to review. The ADON stated that the POA was notified and later visited Resident #1. The ADON stated that Resident #1 received immediate care after her fall by RN-S and CNA-F. She said Resident #1 had a skin tear to her left elbow. She said RN-S assessed Resident #1, notified the on-call nurse, RNC, ADON, and POA. ADON said the MD ordered immediate X-rays for the resident. The ADON said once the X-ray result was reviewed by the MD, Resident #1 was sent out via emergency transport to the hospital, where it was later confirmed she had a fractured hip. The ADON said hospice services were ordered upon her return to the facility on [DATE]. The ADON stated Resident #1 had a previous fall incident and almost fell, but a CNA (name unknown), was present and prevented the fall. The ADON stated that Resident #1 was assessed, and the facility recorded the incident and followed the fall protocol. The ADON said Resident #1 was assessed for falls, the care plan was updated, and she was placed on 72-hour post fall observation and monitoring as a precaution on 04/15/2025. On 06/24/2025 at 10:30 AM, the ADON provided the names of the staff involved without contact information. During and observation and interview of on 06/24/2025 at 11:13 AM Resident #1, revealed she was Spanish speaking with some English. Resident #1 said she did not know how she fell and did not remember. She stated that she did not know how to use the call light. Resident #1 was lying in bed; a fall mat was next to bed and the call light was in reach. Upon further observation Resident #1's communication board/picture board was not in the room. During an interview on 06/24/2025 at 11:15 AM with the FM, she stated that Resident #1 had dementia and could not use the call light. The FM stated that Resident #1 was unable to use the call light, due to her dementia. FM said Resident #1 required total assistance from staff. The FM said Resident #1 had a communication/picture board for communication. FM said she searched for Resident #1's communication picture board, and it was not in her room. The FM said upon returning to the facility she and the POA installed a video camera to supervise and communicate with Resident #1. The FM said she and the POA had not observed the staff utilizing the picture board to communicate with Resident #1 since returning to the facility on [DATE]. The FM said Resident #1 could respond to some questions, but the picture board was implemented by the facility to assist with communicating her needs to the staff. FM said she later found out by the POA that the communication board sent home at the time of discharge to the hospital. The FM said Resident #1 had declined significantly, she is bed bound most of the day, and receives hospice care due to bleeding on the brain from the fall 05/20/2025. During a phone interview on 06/24/2025 at 11:51 AM with the POA, the POA stated that he received a call from the facility that Resident #1 had fell in the bathroom and the MD ordered X rays. The POA said he arrived at the facility on 05/20/2025 an hour after the call (exact time unknown) and observed 1 shoe of Resident #1 and blood still on the bathroom floor from Resident #1's fall. The POA said Resident #1 could not use the call light, despite ongoing education by the staff, FM, and POA. The POA said Resident #1 was a fall risk from a previous fall in April 2025. The POA said Resident #1 should have never been left on the toilet alone. The POA said the staff were not using the picture board to communicate with Resident #1. The POA said he believes Resident #1 was left alone on the toilet for more than 5 minutes, causing the fall and injuries on 05/20/2025. The POA said after the fall he installed a camera and communicates with Resident #1 via camera. The POA said the staff assigned was aware of Resident #1's needs to be supervised due to falls, yet she left Resident #1 on the toilet unsupervised. The POA said he has observed staff taking 25 minutes to take Resident #1 to the bathroom, then leave the resident alone. POA said Resident #1 was not able to ask for privacy from the staff due to her cognitive decline. The POA said he does not believe that the staff were near the bathroom when Resident #1 fell. POA said he does not know the name of the staff that was working. POA said upon arrival to the hospital he was told that Resident #1 had a femur and hip fracture on the left side, skin tears to the left elbow, bleeding on the brain, and was being monitored. POA said the hospital conducted surgery to repair Resident #1's hip. POA said Resident #1's mental acuteness (awareness) had diminished since the fall. POA said Resident #1 was admitted to the facility to receive care, and now that she fell and was hospitalized , she requires total staff assistance. During a phone interview on 06/24/2025 at 2:10 PM with CNA-F, revealed as she was walking past Resident #1's room she observed the resident trying to get out of bed independently. She went to assist the resident, and she could not understand her response and what she was saying, because the resident was speaking in Spanish. CNA-F said she called CNA-J (a Spanish speaking employee) to communicate Resident #1's needs. CNA-J told CNA-F that Resident #1 wanted to put her pajamas on for bed. CNA-F said once Resident #1 was dressed, she returned the resident to sit in her wheelchair, and she attempted to get out of the chair. CNA-F said she assumed Resident #1 wanted to go to the bathroom, so she assisted. CNA-F said Resident #1 was transferred to the toilet in her bathroom. CNA-F said she remained in the bathroom initially, until Resident #1 gestured with her hand to leave the restroom. CNA-F said she notified CNA-J caring for a patient in another room, that Resident #1 was on the toilet, and to check on her while she resumed care of another resident. CNA-F said about 2 to 3 minutes later as she was walking down the hall, she remembered Resident #1 was on the toilet. CNA-F said as she entered the room, she heard Resident #1 fall. She immediately called RN-S for help. CNA-F said the fall was unwitnessed, and did not think Resident #1 hit her head. CNA-F said Resident #1 was bleeding from her left elbow. CNA- F said Resident #1 was in pain. CNA-F said she did not observe any other injuries, lumps, or bruising to the head. She was in pain. CNA-F said Resident #1 was talking and answering the nurse's questions and responding. CNA-F said she was not familiar with Resident #1's clinical needs nor could she speak Spanish. CNF-A said she did not know that Resident #1 was a fall risk and could not be left alone in the bathroom. She said this was a one-time incident and she gave the resident privacy. During an interview on 06/24/2025 at 2:15 PM with RN-S, revealed she had been working at the facility for 9 months. RN S stated that she was familiar with Resident #1's care and knew that she was a fall risk. RN-S said she worked the day of Resident #1's fall, 05/20/2025. RN-S said CNA-F called for her assistance with a resident that fell, so she immediately responded to the room. RN-S said Resident #1 was found lying on the floor in the bathroom on her left side with a skin tear to the left elbow. RN-S said the resident was alert and communicating with her and she did not lose consciousness. RN-S said the resident understood English and Spanish. RN-S and CNA-F assisted Resident #1 to the wheelchair. RN-S said she called the MD and the on-call nurse to report the incident. RN-S stated that the MD ordered immediate Xray's. RN-S notified the POA, and he wanted to delay sending Resident #1 to the hospital, and she explained that the facility policy was to provide immediate care and transport to the hospital for further assessment of the injuries. RN-S said she gave her Tylenol for pain at 6:25 PM. RN-S said the portable X-ray technician arrived 9:00 PM. RN-S said once the X-ray's were reviewed by the MD resident was sent to the hospital. RN-S said Resident #1's base line prior to fall included providing assistance to stand, eat, and all care. RN-S denied knowledge of Resident #1 having a picture board to communicate with staff. RN-S said Resident #1's cognition was the same after the fall, she had not observed any changes. RN-S said Resident #1 used non-verbal signals to communicate and she could answer yes and no to most questions. She said she was aware that Resident #1 was a fall risk. RN-S said Resident #1 should not be left alone, due to a history of falls and decline in cognition. During an interview on 06/24/2025 at 2:38 PM with CNA-J revealed she had placed Resident 1# in bed and proceeded to assist another resident with care. CNA-J said CNA-F did not tell her that the resident was in the bathroom on the toilet and to monitor. CNA-J stated that Resident #1 requires assistance from the staff with transfers and she could not self-transfer or ambulate. CNA-J said she would not have left Resident #1 unsupervised or alone in the bathroom, due to her diagnosis of Dementia and increased confusion. CNA-J said Resident #1 communicate in Spanish and say yes and no. She does not know how long CNA-F left Resident #1 on the toilet. CNA-J was told about the incident later that evening. CNA-J said CNA-F and the nurse responded to the fall. CNA-J said residents should never be left alone on the toilet, because a frequent movement could result in a fall. During an interview on 06/24/2025 at 5:00 PM with the ADMIN, revealed that that CNA-F notified CNA J to monitor Resident #1 on the toilet. The ADMIN insisted that the resident was being monitored by CNA-J and had been left for 2 to 3 minutes. The ADMIN stated that Resident #1 was a fall risk at her bedside, not in the bathroom, and she had a right to request privacy. The ADMIN said any resident could fall from the toilet and have injuries. The ADMIN returned at 5:34 PM and stated that he was not sure if he had statements, and he had to investigate further because CNA-J's and CNA-F's stories were not adding up. The surveyor stated that in the interview with CNA-F, she stated that the nurse was immediately notified not CNA-J. The ADMIN stated that he may have confused the staff statements with notification of help when Resident #1 fell. During another interview with the ADON on 06/24/2025 at 6:09 PM with the ADON she stated that the resident could use the call light prior to the fall. The surveyor explained that the resident stated she did not know how to use the call light this morning during an interview. The ADON stated that she could before the fall now she couldn't. The ADON was asked about the communication board that was care planned to communicate with the staff. She said she did not know where it was. The surveyor told her the FM stated that the board was sent home upon her discharge to hospital on 5/20/25. She said if they picked the communication board up and did not return, there was nothing she could do. She stated the resident could not communicate. The surveyor asked if pictures of tasks were documented on the board, and she said yes. The surveyor asked if the communication board was care planned currently, she said yes. During an interview with the ADMIN on 06/25/2025 at 12:10 PM he stated that he did not submit a self-report to HHS about the incident, however, he completed the investigation on 05/26/25. Record review of CNA-F written statement dated 5/20/25 (provided by the ADMIN on 06/24/2025 at 5:50 PM ADMIN) reflected CNA-F did not seek further assistance from anyone, and while she was attending to another task, Resident #1 may have been unsupervised longer than 1 to 3 minutes. During a second interview on 06/26/2025 at 11:02 AM the PO, stated that Resident #1 was not able to verbalize how she fell after being asked several times by him, the FM, and the staff. The POA denied hearing Resident #1 say what happened on 05/20/2025, and he never translated or communicated a statement from Resident #1 to the ADMIN or staff at the facility about the fall. During a second interview with the FM on 06/30/2025 at 11:40 AM, she stated that Resident #1 was unable to communicate what happened with the fall, due to her dementia, and injuries after the fall. She stated that she had asked Resident #1 on multiple occasions with the POA, and she couldn't recall what occurred. Record review of facility investigation completed by the ADMIN on 05/26/2025 revealed investigation report Subject: Incident Involving Resident #1 - Bathroom Fall Resulting in Hip Fracture Resident Information: Name: [Resident # 1] Date of Incident: May 20, 2025, Date Reported: May 20, 2025, Cognitive Status: BIM's Score - 8 Primary Language: Spanish and speaks some English. Incident Summary: On May 20, 2025, I, [ADMIN] LNFA, was notified of an X-ray result confirming that Resident # 1 sustained a fractured hip following a fall in the bathroom. Upon notification, I immediately contacted [name] ADON, and [name] ADON-T, to begin reviewing the details of the incident. Narrative of Events: According to documentation and staff interviews: o [CNA-F] escorted [Resident #1] to the restroom. o The resident requested privacy by verbally dismissing CNA-[CNA-F] and pointing to the call light cord, indicating she understood how to call for assistance. [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure the residents received adequate supervision and assistive devices to prevent accidents for 1 resident of 8 residents (Resident #1) reviewed for assistive devices and supervision. The facility failed to ensure Resident #1 received adequate supervision and care in accordance with professional standards when the resident was left attended on the toilet resulting in her falling and sustaining fractures to the Femur and left Hip. Additional injuries included ICH (intracerebral hemorrhage (type of stroke bleeding on the brain tissue due to a ruptured blood vessel), Normocytic anemia (is a complex medical condition involving a broken hip bone that has shifted out of place, along with a type of anemia.) An Immediate Jeopardy (IJ) was identified on 06/24/2025 at 4:30 PM While the Immediate Jeopardy was removed on 06/25/24, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm and at a scope of isolated due to the facility's need to implement and monitor the effectiveness of its corrective systems. The failure could place residents at risk for serious injuries, hospitalization, and death. Findings included: Record review of Resident #1's face sheet dated 06/24/2025 reflected the resident was a [AGE] year-old female admitted on [DATE] with active diagnoses that included unspecified cerebral infarction (stroke), displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, Pain, repeated falls, Major depressive disorder (feeling down), and Vascular dementia unspecified severity without behavioral disturbances, Depression, Alzheimer's, and insomnia. Record review of Resident #1's admission MDS assessment dated [DATE] reflected she had minimal difficulty with hearing, clear speech, understood by others and usually understood other. Resident #1's vision was moderately impaired, and she wore corrective lenses. Resident #1 was assessed as having a BIMS score of 08, indicating she was moderately impaired cognitively. She had no mood issues, no behaviors, psychosis, rejection of care or wandering. Resident #1 had no impairments with range of motion to her upper and lower extremities. Resident #1 used a wheelchair for mobility and was dependent on staff for all ADLs to include dressing, hygiene, transfers, eating and basic mobility. Resident #1 was frequently incontinent of bowel and bladder and required substantial/maximal assistance (helper does more than half the effort. (Helper lifts or holds trunk, limbs and provides more than half effort.). Resident #1 scored a 9 on functional abilities for sit to stand and walking 10 ft (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.) Resident #1's fall history on admission MDS reflected that Resident #1 had repeated falls and had fallen with since being admitted . Resident #1 did not sustain any injuries. Record review of Resident #1's discharge MDS assessment dated [DATE] reflected an unplanned discharge to short term general hospital. Resident #1 was dependent on staff for all ADLs to include dressing, hygiene, transfers, eating and basic mobility. Resident #1 was frequently incontinent of bowel and bladder. Resident #1's was not receiving any special treatments. The assessment reflected she had fall history. Record review of Resident #1's change in condition MDS assessment dated [DATE] reflected she needed an interpreter, due to preferred language being Spanish . She had minimal difficulty with hearing and had clear speech. Resident #1 was able to communicate needs to others. Resident #1 was assessed as having a BIMS score of 07, indicating she was severely impaired cognitively. She had no mood issues, behaviors of rejecting care 4 to 6 days of care no wandering. Resident #1 had no impairments with range of motion to her upper and lower extremities. Resident #1 used a wheelchair for mobility and was dependent on staff for all ADLs to include dressing, hygiene, transfers, eating and basic mobility. Resident #1 was always incontinent of bowel and bladder. Active diagnoses dementia, Stroke, Arthritis (crippling in joints), Osteoporosis (fragile bones from aging), displaced intertrochanteric fracture of the left femur, subsequent encounter (displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing,) Vascular dementia unspecified severity without behavioral disturbances, Hip Fracture. Additional diagnoses included Unspecified Sequelae of cerebral infarction (after-effects of a stroke), and repeated falls. Resident #1's was not receiving any special treatments. Assessment reflected she had fall history. Record review of Resident #1's care plan dated 04/15/2025 reflected . The resident has visual and cognitive deficits and needs assistance to pursue activities of choice and Category: created The resident has a /communication problem r/t dementia and primarily Spanish speaking Created: 05/01/2025 .interventions .anticipate needs, ensure availability and functioning of adaptive communication equipment (picture board) ensures safe environment: call light in reach, adequate low glare light, bed in lowest position, wheels locked, avoid isolation .Monitor/document for physical/nonverbal indicators of discomfort or distress, and follow up as needed Resident has impaired visual functioning and is at risk for a decreased in ADL's and Injuries Created: 05/01/2025 . Resident has impaired cognitive function/dementia or impaired thought processes r/t DX vascular dementia Created: 05/01/2025 resident requires pain management with opiate medications r/t terminal status and hip FX . Resident requires Hospice as evidenced by terminal illness of: inter-cerebral hemorrhage Edited: 06/09/2025 . Category: Falls Resident had an actual fall r/t poor safety awareness, attempting to transfer self, weakness, HX falls . Do not leave unattended in bathroom .remind resident to use call light to gain assistance with transfers, continue therapy services, Edited: 05/27/2025 Resident has Post-op site on L hip, skin tear to L elbow edited 6/11/2025, Resident has surgical wound to L hip R/T .Edited: 06/24/2025 Resident #1 was at risk of falls, r/t weakness, poor safety awareness, skin tears, bruising. Skin assessment addressed bruising and tears, fall assessment completed. Record review of Resident #1's physician's orders dated 06/08/2025 reflected admit to Hospice for DX of intracerebral Hemorrhage (bleeding) at Bedtime 8:00 PM . Record review of orders dated 06/09/2025 reflected: Monitor edema (swelling caused by fluid) Twice a Day 6:00 AM - 2:00 PM days, 3:00 PM - 10:00 PM evenings .Opiate (A class of drug used to reduce moderate to severe pain) medications use .monitor for s/sx of constipation (trouble having a bowel movement), delirium (confusion), over-sedation (drowsy/sleep), change in mental status (overall functions cognitively, mentally, emotionally), and reduced respirations (breaths) . Pain Assessment Q-Shift using the Numeric (relating to or expressed as a number or numbers.) or PAIN scale Special Instructions: document results Every Shift Days 6:00 AM - 2:00 PM, Evenings 2:00 PM - 10:00 PM, Nights 10:00 PM - 06:00 AM . order dated. PT/OT/ST to evaluate and treat if indicated . Record review of Resident #1's MD order dated 06/10/2025 reflected Give 1 tablet; 50 mg zinc (220 mg); amt: 1 tab; oral Once a Day. Record review of Resident #1's MD orders dated 06/12/2025 reflected LLE TTWB due to DTI Every Shift Days 06:00 AM - 2:00 PM evenings, 3:00 PM - 10:00 PM evenings Left hip post OP site: Monitor for s/s infection or dehiscence (medical term, dehiscence refers to the separation or splitting open of a surgical wound or incision that was previously closed) if present notify MD Every Shift Days 6:00 AM - 2:00 PM, Evenings 2:00 PM - 10:00 PM, Nights 10:00 PM - 06:00 AM . Record review of Resident #1's MD an order dated 07/08/2025 Other Test: (LEFT Hip X-Ray Unilateral 2-3 V (unilateral radiologic examination of a joint or structure, consisting of 2 to 3 views.) .including pelvis with CD (In a medical context, when you see pelvis with CD it most likely refers to a pelvic CT scan that includes images recorded onto a CD.) Once - One Time 06:00 AM -11:00 PM. Record review of Resident #1's skin assessment note dated 06/10/2025 at 12:23 PM reflected under description (skin tear/Laceration). Record review of Resident #1's progress notes on 04/15/2025 at 10:40 AM by LVN-C reflected Pt was up in w/c reading daily journal in her room. This nurse was informed 10:40 by aid that when she was rounding Pt was attempting to get back in bed self and was caught by the aid before she could hit the floor. Pt was landed on her knees and was put back in bed with the help. Denies pain. ROM TO all ext. ALL parties notified. Fall precautions implemented. Bed in lowest position. encouraged pt to use call light for assistance. Frequent visual monitoring done. will cont. to follow POC. Record review of Resident #1's nursing progress note dated 05/20/2025 at 6:29 PM by RN-S reflected Around 3:40 PM this nurse was aware by CNA that the pt is in the floor. Upon entering the room Resident found on the floor in the bathroom on side lying position, wheelchair is locked next to her. Assisted her back to wheelchair with the help of two person. Vital sign WNL. On assessment noticed small skin tear on It elbow with small amount of blood, dressing done. Notified wound care nurse. alert and orient with her baseline. Vitals WNL. Resident states she fell when transferring from commode to wheelchair herself. Complained of L leg pain, Tylenol 650 mg P O given, somewhat effective. NP, DON/ADON notified. RP made aware. Received new order to stat X-ray L Hip from NP. updated on portal. Neuros on progress and within normal limits. Bed in low position. fall precaution maintained. will cont. to monitor. Record review of Resident #1's nursing progress note dated 05/20/2025 at 9:12 PM by RN-S reflected that X-ray of hip shows left femoral neck fracture. MD made aware. Called 911 and sent to [hospital]around 10 PM. Record review of Resident #1's nursing progress note dated 05/20/2025 at 9:43 PM by LVN-M reflected Spoke with [family member] directly about situation he states that he is in route to [hospital name] now and okay with mother being sent in ambulance. Record review of Resident #1's nursing progress note dated 06/08/2025 by LVN-A reflected Resident came back from the hospital on a non-emergency transportation on a stretcher and was transferred from stretcher to bed Resident had a fall in the facility and sustained a left hip fracture. Surgery was performed and has stitches on the left hip. Dressing is intact and surgical incision is showing visible signs of any infection or drainage. Resident is admitted on services [Hospice] visited the facility. [Hospice] is do present the DNR paper. Hospice has ordered to continue with the discharge orders. Resident is on day 1/3 of follow up for new medication (Tramadol) 50 mg every 4 hours for pain. Clarification is needed from hospice for delivery of Tramadol since order came from them. Hospice has also ordered Comfort Kit. Dietary is notified of the resident coming back. No complains of pain is voiced by resident. Oral fluids and call light is in easy reach. no paper. Hospice has ordered to continue with the discharge orders. Record review of Resident #1's nursing progress note dated 06/09/2025 at 1:13 PM by ADON reflected Follow up monitoring Day 1 of 3 of Re-admit with DX: L hip FX SX (symptoms) repair. AAOx1-2 (refers to the level of alertness and orientation, specifically indicating that a person is aware of who they are and where they are but may not know the current date and time (A&Ox1) or also what happened to them (A&Ox2). Spanish speaking. Under [hospice name]. Respiratory even and unlabored. No sob noted. No cough congestion noted. L hip surgical incision dressing CDI. Denies pain or any other discomfort at this time, Abdomen soft and non-distended bsx4. appetite fair. [Family member] present at bedside. Incontinent to B&B. Wound on Coccyx. (The small, triangular bone at the very bottom of the spine.) Wound care in progress. Turned and repositioned at regular intervals. call light and bedside table within reach. Bed in lowest position. Fall precautions implemented through the shift. call light within reach. will cont. to follow POC. Record review of Resident #1's nursing progress note dated 06/11/2025 at 7:36 AM by the ADON reflected IDT review regarding skin tear to right elbow, obtained during assisted dressing with hospice aide, resident noted with thin/fragile skin resulting in increased risk of injury, site appears with steri strips intact no s/s infection or pain present, Geri sleeves applied for safety. Record review of progress note dated 06/11/2025 10:41 AM by LVN-C reflected Follow up monitoring Day 3 of 3 of Re-admit with DX: L hip FX SX repair. AAOx1-2. Resting in bed with HOB elevated to facilitate easy breathing. Spanish speaking. Under [hospice name]. Resp even and unlabored. No sob noted. No cough congestion noted. L hip surgical incision dressing CDI. Medicated with PRN Tramadol. remains effective. Abdomen soft and non-distended bsx4 (Bowel sounds x 4 quadrants refers to the process of listening to the digestive sounds in all four quadrants of the abdomen ) appetite remains poor. D1/3 of new orders of vitamin C, Zinc, House protein, 2.0 supplement, mm with min. Incontinent to B&B. Wound on Coccyx. LLE TTWB r/t DTI. Steri-Strips intact on R elbow. wound care in progress. Off loaded bilateral (in a medical context refers to the process of reducing or removing pressure from the heels on both the right and left sides of the body.) heels when in bed. Turned and repositioned at regular intervals. Ortho appt in am. call light and bedside table within reach. Bed in lowest position. Fall precautions implemented through the shift. call light within reach. will cont. to follow POC. Record review of Resident #1's nursing progress note dated 06/11/2025 at 12:40 PM by the ADON reflected left hip f/u X-ray results received and sent to NP for review NNOs (Neuronal nitric oxide syntheses (NNOS) is an enzyme that produces nitric oxide (NO), a potentially harmful molecule implicated in fetal brain injury under .) obtained, disk received for f/u Ortho appt. Record review of Resident #1's nursing progress notes dated 06/11/2025 at 10:49 AM by the ADON reflected Notified by [family member] of Ortho f/u appt on 6/12/20, f/u X-ray to left hip scheduled for STAT today with CD for appt. tomorrow. Record review of Resident #1's nursing progress notes dated 06/12/2025 at 1:52 PM by the ADON reflected Returned from Ortho appt, staples DC' D steri strips in place, LOTA, TX orders updated. Record review of Resident #1's nursing progress notes dated 06/12/2025 05:11 AM by the ADON reflected (L) hip FX sx repair; surgical dressings on L leg kept CDI; resident slept during shift with respirations even and unlabored. Day 2/3 F/U 2.0 suppository 90 cc TID, house protein 30 cc PO BID, Vit C, Zinc, and MVM with min and skin tear with steri strips. LLE TTWB r/t DTI to (L) heel; no complaints from resident at this time. Bed in low position with call light attached. Record review of Resident #1's nursing progress notes 06/23/2025 at 3:49 AM by LVN-C reflected resident with Steri-Strips to L Hip. LLE TTWB R/T DTI to L heel. Offload bilateral heels while in bed (in a medical context refers to the process of reducing or removing pressure from the heels on both the right and left sides of the body.). No c/o pain. Call-light within reach. Record review of Resident #1's nursing progress notes 06/23/2025 at 10:22 PM by LVN-C reflected Resident with Steri-Strips to L Hip. LLE TTWB R/T DTI to L heel. Offload bilateral heels while in bed. No c/o pain. Call-light within reach. Record review of Resident #1 event note dated 06/10/25 at 12:23 PM by the ADON reflected IDT review: witnessed: no injuries: skin tear right elbow sent to ER: not indicated all parties aware: yes intervention: Geri sleeves BUE HX of similar events: Physician notified at 10:30 AM, Resident Representative notified at 12:27 PM, Care plan revised. During an interview on 06/24/2025 at 10:15 AM with the ADMIN, stated the incident occurred on 05/20/2025 and he did not investigate or submit a self-report for the incident. The ADMIN said he did not have the staff write a statement detailing the incident, however, he would check for a written statement. The ADMIN was asked to provide names of the staff involved, daily schedules of the staff with their full name documented for the day of the incident, and an employee roster. The ADMIN stated that there were two aides involved and he would provide their names. The ADMIN stated the CNA-F placed resident on the toilet, then told CNA-J that Resident #1 was left on the toilet and follow up with checks on the resident. The ADMIN stated that Resident #1 was left on the toilet for 5 minutes. The ADMIN stated they requested privacy and waived her hand for CNA-F to leave the bathroom. The ADMIN said after 5 minutes had passed CNA-F returned to Resident #1's room to check on her and heard her fall. The ADMIN said CNA-F called out for CNA-J to come and help with the resident to transfer her off the bathroom floor. The ADMIN stated that RN-S assessed Resident #1 and notified the MD, ADMIN, ADON, RNC, and POA. The MD ordered X-rays immediately. The ADMIN stated once the X-ray results were reviewed by the MD, EMS was called, and she was transported to the hospital emergency room. The ADMIN said Resident #1 returned from the hospital with hospice services and assessments for therapy. The ADMIN stated that the facility did not have a DON currently and the RNC and ADON were in charge of the nursing department. The ADMIN stated that the RNC was not at the facility at this time. He stated that the resident requested privacy from the CNA -F and it was granted. During an interview on 06/24/2025 at 10:25 AM the ADON stated that the hospital records located in the Resident #1's clinical file to review. The ADON stated that the POA was notified and later visited Resident #1. The ADON stated that Resident #1 received immediate care after her fall by RN-S and CNA-F. She said Resident #1 had a skin tear to her left elbow. She said RN-S assessed Resident #1, notified the on-call nurse, RNC, ADON, and POA. ADON said the MD ordered immediate X-rays for the resident. The ADON said once the X-ray result was reviewed by the MD, Resident #1 was sent out via emergency transport to the hospital, where it was later confirmed she had a fractured hip. The ADON said hospice services were ordered upon her return to the facility on [DATE]. The ADON stated Resident #1 had a previous fall incident and almost fell, but a CNA (name unknown), was present and prevented the fall. The ADON stated that Resident #1 was assessed, and the facility recorded the incident and followed the fall protocol. The ADON said Resident #1 was assessed for falls, the care plan was updated, and she was placed on 72-hour post fall observation and monitoring as a precaution on 04/15/2025. On 06/24/2025 at 10:30 AM, the ADON provided the names of the staff involved without contact information. During and observation and interview of on 06/24/2025 at 11:13 AM Resident #1, revealed she was Spanish speaking with some English. Resident #1 said she did not know how she fell and did not remember. She stated that she did not know how to use the call light. Resident #1 was lying in bed; a fall mat was next to bed and the call light was in reach. Upon further observation Resident #1's communication board/picture board was not in the room. During an interview on 06/24/2025 at 11:15 AM with the FM, she stated that Resident #1 had dementia and could not use the call light. The FM stated that Resident #1 was unable to use the call light, due to her dementia. FM said Resident #1 required total assistance from staff. The FM said Resident #1 had a communication/picture board for communication. FM said she searched for Resident #1's communication picture board, and it was not in her room. The FM said upon returning to the facility she and the POA installed a video camera to supervise and communicate with Resident #1. The FM said she and the POA had not observed the staff utilizing the picture board to communicate with Resident #1 since returning to the facility on [DATE]. The FM said Resident #1 could respond to some questions, but the picture board was implemented by the facility to assist with communicating her needs to the staff. FM said she later found out by the POA that the communication board sent home at the time of discharge to the hospital. The FM said Resident #1 had declined significantly, she is bed bound most of the day, and receives hospice care due to bleeding on the brain from the fall 05/20/2025. During a phone interview on 06/24/2025 at 11:51 AM with the POA, the POA stated that he received a call from the facility that Resident #1 had fell in the bathroom and the MD ordered X rays. The POA said he arrived at the facility on 05/20/2025 an hour after the call (exact time unknown) and observed 1 shoe of Resident #1 and blood still on the bathroom floor from Resident #1's fall. The POA said Resident #1 could not use the call light, despite ongoing education by the staff, FM, and POA. The POA said Resident #1 was a fall risk from a previous fall in April 2025. The POA said Resident #1 should have never been left on the toilet alone. The POA said the staff were not using the picture board to communicate with Resident #1. The POA said he believes Resident #1 was left alone on the toilet for more than 5 minutes, causing the fall and injuries on 05/20/2025. The POA said after the fall he installed a camera and communicates with Resident #1 via camera. The POA said the staff assigned was aware of Resident #1's needs to be supervised due to falls, yet she left Resident #1 on the toilet unsupervised. The POA said he has observed staff taking 25 minutes to take Resident #1 to the bathroom, then leave the resident alone. POA said Resident #1 was not able to ask for privacy from the staff due to her cognitive decline. The POA said he does not believe that the staff were near the bathroom when Resident #1 fell. POA said he does not know the name of the staff that was working. POA said upon arrival to the hospital he was told that Resident #1 had a femur and hip fracture on the left side, skin tears to the left elbow, bleeding on the brain, and was being monitored. POA said the hospital conducted surgery to repair Resident #1's hip. POA said Resident #1's mental acuteness (awareness) had diminished since the fall. POA said Resident #1 was admitted to the facility to receive care, and now that she fell and was hospitalized , she requires total staff assistance. During a phone interview on 06/24/2025 at 2:10 PM with CNA-F, revealed as she was walking past Resident #1's room she observed the resident trying to get out of bed independently. She went to assist the resident, and she could not understand her response and what she was saying, because the resident was speaking in Spanish. CNA-F said she called CNA-J (a Spanish speaking employee) to communicate Resident #1's needs. CNA-J told CNA-F that Resident #1 wanted to put her pajamas on for bed. CNA-F said once Resident #1 was dressed, she returned the resident to sit in her wheelchair, and she attempted to get out of the chair. CNA-F said she assumed Resident #1 wanted to go to the bathroom, so she assisted. CNA-F said Resident #1 was transferred to the toilet in her bathroom. CNA-F said she remained in the bathroom initially, until Resident #1 gestured with her hand to leave the restroom. CNA-F said she notified CNA-J caring for a patient in another room, that Resident #1 was on the toilet, and to check on her while she resumed care of another resident. CNA-F said about 2 to 3 minutes later as she was walking down the hall, she remembered Resident #1 was on the toilet. CNA-F said as she entered the room, she heard Resident #1 fall. She immediately called RN-S for help. CNA-F said the fall was unwitnessed, and did not think Resident #1 hit her head. CNA-F said Resident #1 was bleeding from her left elbow. CNA- F said Resident #1 was in pain. CNA-F said she did not observe any other injuries, lumps, or bruising to the head. She was in pain. CNA-F said Resident #1 was talking and answering the nurse's questions and responding. CNA-F said she was not familiar with Resident #1's clinical needs, nor could she speak Spanish. CNF-A said she did not know that Resident #1 was a fall risk and could not be left alone in the bathroom. She said this was a one-time incident and she gave the resident privacy. During an interview on 06/24/2025 at 2:15 PM with RN-S, revealed she had been working at the facility for 9 months. RN S stated that she was familiar with Resident #1's care and knew that she was a fall risk. RN-S said she worked the day of Resident #1's fall, 05/20/2025. RN-S said CNA-F called for her assistance with a resident that fell, so she immediately responded to the room. RN-S said Resident #1 was found lying on the floor in the bathroom on her left side with a skin tear to the left elbow. RN-S said the resident was alert and communicating with her and she did not lose consciousness. RN-S said the resident understood English and Spanish. RN-S and CNA-F assisted Resident #1 to the wheelchair. RN-S said she called the MD and the on-call nurse to report the incident. RN-S stated that the MD ordered immediate Xray's. RN-S notified the POA, and he wanted to delay sending Resident #1 to the hospital, and she explained that the facility policy was to provide immediate care and transport to the hospital for further assessment of the injuries. RN-S said she gave her Tylenol for pain at 6:25 PM. RN-S said the portable X-ray technician arrived 9:00 PM. RN-S said once the X-rays were reviewed by the MD resident was sent to the hospital. RN-S said Resident #1's base line prior to fall included providing assistance to stand, eat, and all care. RN-S denied knowledge of Resident #1 having a picture board to communicate with staff. RN-S said Resident #1's cognition was the same after the fall, she had not observed any changes. RN-S said Resident #1 used non-verbal signals to communicate and she could answer yes and no to most questions. She said she was aware that Resident #1 was a fall risk. RN-S said Resident #1 should not be left alone, due to a history of falls and decline in cognition. During an interview on 06/24/2025 at 2:38 PM with CNA-J revealed she had placed Resident 1# in bed and proceeded to assist another resident with care. CNA-J said CNA-F did not tell her that the resident was in the bathroom on the toilet and to monitor. CNA-J stated that Resident #1 requires assistance from the staff with transfers and she could not self-transfer or ambulate. CNA-J said she would not have left Resident #1 unsupervised or alone in the bathroom, due to her diagnosis of Dementia and increased confusion. CNA-J said Resident #1 communicate in Spanish and say yes and no. She does not know how long CNA-F left Resident #1 on the toilet. CNA-J was told about the incident later that evening. CNA-J said CNA-F and the nurse responded to the fall. CNA-J said residents should never be left alone on the toilet, because a frequent movement could result in a fall. During an interview on 06/24/2025 at 5:00 PM with the ADMIN, revealed that that CNA-F notified CNA J to monitor Resident #1 on the toilet. The ADMIN insisted that the resident was being monitored by CNA-J and had been left for 2 to 3 minutes. The ADMIN stated that Resident #1 was a fall risk at her bedside, not in the bathroom, and she had a right to request privacy. The ADMIN said any resident could fall from the toilet and have injuries. The ADMIN returned at 5:34 PM and stated that he was not sure if he had statements, and he had to investigate further because CNA-J's and CNA-F's stories were not adding up. The surveyor stated that in the interview with CNA-F, she stated that the nurse was immediately notified not CNA-J. The ADMIN stated that he may have confused the staff statements with notification of help when Resident #1 fell. During another interview with the ADON on 06/24/2025 at 6:09 PM with the ADON she stated that the resident could use the call light prior to the fall. The surveyor explained that the resident stated she did not know how to use the call light this morning during an interview. The ADON stated that she could before the fall now she couldn't. The ADON was asked about the communication board that was care planned to communicate with the staff. She said she did not know where it was. The surveyor told her the FM stated that the board was sent home upon her discharge to hospital on 5/20/25. She said if they picked the communication board up and did not return, there was nothing she could do. She stated the resident could not communicate. The surveyor asked if pictures of tasks were documented on the board, and she said yes. The surveyor asked if the communication board was care planned currently, she said yes. During an interview with the ADMIN on 06/25/2025 at 12:10 PM he stated that he did not submit a self-report to HHS about the incident, however, he completed the investigation on 05/26/25. Record review of CNA-F written statement dated 5/20/25 (provided by the ADMIN on 06/24/2025 at 5:50 PM ADMIN) reflected CNA-F did not seek further assistance from anyone, and while she was attending to another task, Resident #1 may have been unsupervised longer than 1 to 3 minutes. During a second interview on 06/26/2025 at 11:02 AM the PO, stated that Resident #1 was not able to verbalize how she fell after being asked several times by him, the FM, and the staff. The POA denied hearing Resident #1 say what happened on 05/20/2025, and he never translated or communicated a statement from Resident #1 to the ADMIN or staff at the facility about the fall. During a second interview with the FM on 06/30/2025 at 11:40 AM, she stated that Resident #1 was unable to communicate what happened with the fall, due to her dementia, and injuries after the fall. She stated that she had asked Resident #1 on multiple occasions with the POA, and she couldn't recall what occurred. Record review of facility investigation completed by the ADMIN on 05/26/2025 revealed investigation report Subject: Incident Involving Resident #1 - Bathroom Fall Resulting in Hip Fracture Resident Information: Name: [Resident # 1] Date of Incident: May 20, 2025, Date Reported: May 20, 2025, Cognitive Status: BIM's Score - 8 Primary Language: Spanish and speaks some English. Incident Summary: On May 20, 2025, I, [ADMIN] LNFA, was notified of an X-ray result confirming that Resident # 1 sustained a fractured hip following a fall in the bathroom. Upon notification, I immediately contacted [name] ADON, and [name] ADON-T, to begin reviewing the details of the incident. Narrative of Events: According to documentation and staff interviews: o [CNA-F] escorted [Resident #1] to the restroom. o the resident requested privacy by verbally dismissing CNA-[CNA-F] and pointing to the call light cord, indicating she understood how to call for assistance. o [Resident #1] has a BIMS of 8, suggesting moderate cognitive impairment, but she has consistently demonstrated the ability to use the call light[TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 5 residents (Resident #10) reviewed for physical environment. The facility staff failed to remove all kitchen coffee from Resident #10's room cups located on the toilet after resident use. The facility staff failed to discard used disposable gloves, and a plastic cup after use. The facility staff failed to ensure Resident #10's incontinent briefs and dirty clothing were properly stored and discarded. The facility staff failed to ensure Resident #10's mattress properly fit her bed and not move from the position. These failures could place residents at risk for a diminished quality of life, cross contamination, falls, injuries, and unsanitary environment. Findings included: Record review of Resident #10's face sheet dated 06/24/2025 reflected the resident was a [AGE] year-old female that was admitted on [DATE] with the following diagnoses: Congestive Heart Failure (heart failure), Dementia (memory decline) in other diseases classified elsewhere, unspecified severity, with psychotic disturbance . Record review of Resident #10's quarterly MDS dated [DATE] reflected she had a BIMS score of 13, indicating she was cognitively intact. The resident mood and behaviors indicated 0 indicating Resident #10 had no mood issues. Record review of Resident #10's care plan dated 05/06/2025 reflected) during MDS assessment resident specifies a preference not to be asked question Q0500 Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? . Assist with repositioning as appropriate .Resident is on diuretic therapy r/t HTN/CHF. May cause dizziness, postural hypotension, fatigue, and an increased risk for falls. Observe or possible side effects q-shift. Created 05/06/2025 .Resident is at risk for falls due to: Hx falls, Mobility impairment, Dementia with poor safety awareness, unsteady gait. Intervention increased staff supervision with intensity based on resident need, edited 06/23/2025 Resident requires hospice as evidenced by terminal illness of Dementia, Edited on 06/23/2025 Resident ADLs Functional Bed Mobility: set-up/sup Assist: 1, Transfers: min Assist: 1, Dressing: min Assist: 1, Eating: set/up Assist: 1, Toileting: touch, Assist: 1, Personal Hygiene: touch Assist: 1, Bathing: touch to min Assist: 1. Resident manages brief changes with setup but leaves soiled briefs and gloves in bathroom, check bathroom frequently for soiled items created on 06/24/2025. Record review of Resident #10's MD orders dated 06/25/25, reflected as follows: Dapagliflozin propanediol 5 mg tablet Once a Day 1 tab, oral, Once A Day E11.22: Type 2 diabetes mellitus with diabetic chronic kidney disease . 05/06/2025 . Furosemide 20 mg tablet Once a Day 1 TAB, oral, Once A Days, Chronic systolic (congestive) heart failure 05/05/2025 Hyoscyamine sulfate 0.125 mg tablet Every 2 Hours - PRN 1 tab, oral, every 2 Hours - PRN, for excessive secretions .Dementia in other diseases classified elsewhere, unspecified severity, with psychotic disturbance. 05/05/2025 .Morphine concentrates 100 mg/5 mL (20 mg/mL) solution Every 1 Hour - PRN 0.5 ml, oral, Every 1 Hour - PRN, for pain/sob. 05/05/2025 .Lisinopril-hydrochlorothiazide 20-25 mg tablet Once a Day 1 TAB, oral, Once A Day, HOLD IF SBP (top number on BP) < 110 OR DBP (bottom number) < 60 I13.0: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease 05/05/2025 .Mirtazapine 7.5 mg tablet At Bedtime 1 tab, oral, At Bedtime F33.1: Major depressive disorder, recurrent, moderate 05/22/2025 .Sertraline 100 mg once 1 tab, oral once a day for Major depressive disorder recurrent moderate, dated 06/25/2025. The following orders are listed to provide a clear picture of Resident #10's clinical conditions that could affect her environmental safety. Record review of Resident #10's hospice sign-in sheet reflected that the hospice aide's last visit was on 6/23/2025. The time in and time out was left blank. In an observation and attempted interview with Resident #10 on 06/24/2025at 11:20 AM, revealed the resident was not in the room. Her bed was observed with the mattress positional off to the left side of the bed with 1/3 of the bed frame exposed with a metal brown frame exposed and a plastic cup under the bed. The bed was not made, there was no pillowcase on the two pillows (1 white pillow and 1 light blue pillow). Observation of Resident #10's bathroom revealed several clear used disposable gloves lying in the sink with a tube of toothpaste, toothbrush, and a plastic 2-ounce clear cup. The toilet was observed with a tan coffee mug and a burgundy coffee mug placed on the back of the toilet frame near the assistance bar. The surveyor observed a shower chair to the immediate right used clothing for laundry (jeans and gray shirt). Further down at the end of the shower was a gray bed pan with disheveled (opened single briefs) briefs that were not covered. In an interview with CNA G on 06/24/2025 at 11:25 AM revealed that she was the assigned CNA for Resident #10. She stated that prior to her going to break at 10:22 AM the room mattress was not moved off the metal frame. CNA G reported that Resident #1 left the gloves in the bathroom sink and she confirmed that the briefs were clean and placed in the bathroom to be accessible for the resident. CNA G stated that staff were expected to check resident's rooms during their shift for environment issues that could result in unsanitary conditions in the room and bathroom. CNA G stated that she was responsible for disposing of the briefs and gloves immediately after use for sanitation purposes, and dirty clothing should be discarded immediately to the laundry. CNA G said Resident #10 was able to ambulate independently, and she was capable of changing her own clothing and briefs. CNA G said, she believes that Resident #10 moved her mattress to the left leaving while moving or getting out of the bed, and this caused the mattress to slide and expose the metal frame. CNA G said Resident #10 the briefs on the floor near the shower, and they were clean, however she was not sure and could not provide information about the dirty clothing left in the shower chair and coffee cups in the bathroom. CNA G said coffee cups should be returned to the kitchen after use. CNA G proceeded to position Resident #10's mattress appropriately over the bed frame. CNA G said all nursing staff (CNA's and Nurses) were responsible for maintaining a clean, safe, and sanitary environment. CNA G stated failing to properly discard PPE, briefs, and laundry could place residents at risk of infections, cross contamination, and reuse of dishes stored in the bathroom and residents could be injured by falling or skin tears from the frame while transferring independently. During an interview and observation with the ADON on 06/24/25 at 11:45 AM concerning Resident #10's room, she observed the concerns in Resident #10's shower. The ADON stated that the resident received hospice care, and the bed was provided by the hospice program. She was not sure when the hospice aide last visited Resident #110. The ADON checked Resident #10's hospice log and the last entry was dated 06/23/2025 and the time in and out were left blank and unknown. The ADON stated that the bed was changed out. In a brief interview on 06/24/2025 at 3:00 PM with the Administrator, he reported that upon being notified by the staff, he has changed out the bedframe, and hospice will be notified. During an interview on 06/26/2025 at 3:00 PM, Resident #10 expressed her satisfaction with living at the facility. She had no concerns with her room being dirty. She showed the surveyor her new bed that the facility had gotten her. She stated the other one kept slipping off the frame. She stated that she was pleased with the services provided by the staff. She stated that her room is always clean when she was showering. She denied ever seeing gloves or briefs on the floor of her bathroom. She stated that housekeeping staff were cleaning her room and shower, and all staff ensured that her call light was in reach. She stated that she wasn't scared of anyone at the facility nor was she fearful of retaliation. In an observation of Resident #10's room revealed an open carton of milk from breakfast and a bag of pretzels on the nightstand that had not been removed from the room or stored properly. Resident #10's bathroom was clean. Record review of the facility's Incontinent Care/Perineal Care policy, dated December 2018, reflected in part: It is the policy of this home that the Administrator or other appropriate designee completes environmental rounds on a regular basis .Discard soiled gloves, sanitize hands. Re-glove prior to touching clean linens / adult brief .Closing steps: Clean and store reusable items and discard disposables per home guideline If gloved, remove and discard gloves following home guideline at the appropriate time to avoid environmental contamination. Record review of the facility's Infection Control Environmental Rounds policy, dated June 2022 reflected: Environment rounds will be an integral part of the daily routine and also will be performed regularly throughout the entire home, with detailed reporting to all units and departments as needed. (It is suggested that a selection of individual units as well as the dietary, laundry, and housekeeping departments be specifically identified for closer scrutiny each month.) .The Administrator / designee will generate reports identifying areas of noncompliance. This report and a corrective action form will be distributed to the supervisors of each area. The corrective action form will be completed by the supervisor and will outline the corrective actions to be taken and the anticipated completion dates Environmental rounds reports will be retained to illustrate the improvement of quality of life within the facility and for review/comparison purposes within the home over a period of time.

Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator of the facility and to other officials including to the State Agency in accordance with State law through established procedures, for one of one resident (Resident #1) reviewed for abuse, neglect and exploitation . The facility failed to report to the state agency when Resident #1 was left unattended in the bathroom and fell sustaining injuries of a fractured femur and fractured left hip. Additionally, the resident was ordered hospice due to another diagnosis of ICH (intracerebral hemorrhage), which is atype of stroke bleeding on the brain tissue due to a ruptured blood vessel. Findings included: Record review of Resident #1's face sheet dated 06/24/2025 reflected the resident was a [AGE] year-old female admitted on [DATE] with active diagnoses that included unspecified cerebral infarction (stroke), displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, Pain, repeated falls, Major depressive disorder (feeling down), and Vascular dementia unspecified severity without behavioral disturbances, Depression, Alzheimer's, and insomnia. Record review of Resident #1's admission MDS assessment dated [DATE] reflected she had minimal difficulty with hearing, clear speech, understood by others and usually understood other. Resident #1's vision was moderately impaired, and she wore corrective lenses. Resident #1 was assessed as having a BIMS score of 08, indicating she was moderately impaired cognitively. She had no mood issues, no behaviors, psychosis, rejection of care or wandering. Resident #1 had no impairments with range of motion to her upper and lower extremities. Resident #1 used a wheelchair for mobility and was dependent on staff for all ADLs to include dressing, hygiene, transfers, eating and basic mobility. Resident #1 was frequently incontinent of bowel and bladder and required substantial/maximal assistance (helper does more than half the effort. (Helper lifts or holds trunk, limbs and provides more than half effort.). Resident #1 scored a 9 on functional abilities for sit to stand and walking 10 ft (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.). Resident #1's fall history on admission MDS reflected that Resident #1 had repeated falls and had fallen with since being admitted . Resident #1 did not sustain any injuries. Record review of Resident #1's care plan dated 04/15/2025 reflected . The resident has visual and cognitive deficits and needs assistance to pursue activities of choice and Category: created The resident has a /communication problem r/t dementia and primarily Spanish speaking Created: 05/01/2025 .interventions .anticipate needs, ensure availability and functioning of adaptive communication equipment (picture board) ensures safe environment: call light in reach, adequate low glare light, bed in lowest position, wheels locked, avoid isolation .Monitor/document for physical/nonverbal indicators of discomfort or distress, and follow up as needed Resident has impaired visual functioning and is at risk for a decreased in ADL's and Injuries Created: 05/01/2025 . Resident has impaired cognitive function/dementia or impaired thought processes r/t DX vascular dementia Created: 05/01/2025 resident requires pain management with opiate medications r/t terminal status and hip FX . Resident requires Hospice as evidenced by terminal illness of: inter-cerebral hemorrhage Edited: 06/09/2025 . Category: Falls Resident had an actual fall r/t poor safety awareness, attempting to transfer self, weakness, HX falls . Do not leave unattended in bathroom .remind resident to use call light to gain assistance with transfers, continue therapy services, Edited: 05/27/2025 Resident has Post-op site on L hip, skin tear to L elbow edited 6/11/2025, Resident has surgical wound to L hip R/T .Edited: 06/24/2025 Resident #1 was at risk of falls, r/t weakness, poor safety awareness, skin tears, bruising. Skin assessment addressed bruising and tears, fall assessment completed. Record review of Resident #1's MD orders dated 06/12/2025 reflected LLE TTWB due to DTI Every Shift Days 06:00 AM - 2:00 PM evenings, 3:00 PM - 10:00 PM evenings Left hip post OP site: Monitor for s/s infection or dehiscence (medical term, dehiscence refers to the separation or splitting open of a surgical wound or incision that was previously closed) if present notify MD Every Shift Days 6:00 AM - 2:00 PM, Evenings 2:00 PM - 10:00 PM, Nights 10:00 PM - 06:00 AM . Record review of Resident #1's MD an order dated 07/08/2025 Other Test: (LEFT Hip X-Ray Unilateral 2-3 V (unilateral radiologic examination of a joint or structure, consisting of 2 to 3 views.) .including pelvis with CD (In a medical context, when you see pelvis with CD it most likely refers to a pelvic CT scan that includes images recorded onto a CD.) Once - One Time 06:00 AM -11:00 PM. Record review of Resident #1's skin assessment note dated 06/10/2025 at 12:23 PM reflected under description (skin tear/Laceration). Record review of Resident #1's nursing progress note dated 05/20/2025 at 6:29 PM by RN-S reflected Around 3:40 PM this nurse was aware by CNA that the pt is in the floor. Upon entering the room Resident found on the floor in the bathroom on side lying position, wheelchair is locked next to her. Assisted her back to wheelchair with the help of two person. Vital sign WNL. On assessment noticed small skin tear on It elbow with small amount of blood, dressing done. Notified wound care nurse. alert and orient with her baseline. Vitals WNL. Resident states she fell when transferring from commode to wheelchair herself. Complained of L leg pain, Tylenol 650 mg P O given, somewhat effective. NP, DON/ADON notified. RP made aware. Received new order to stat X-ray L Hip from NP. updated on portal. Neuros on progress and within normal limits. Bed in low position. fall precaution maintained. will cont. to monitor. Record review of Resident #1's nursing progress note dated 05/20/2025 at 9:12 PM by RN-S reflected that X-ray of hip shows left femoral neck fracture. MD made aware. Called 911 and sent to [hospital]around 10 PM. Record review of Resident #1's nursing progress note dated 05/20/2025 at 9:43 PM by LVN-M reflected Spoke with [family member] directly about situation he states that he is in route to [hospital name] now and okay with mother being sent in ambulance. During an interview on 06/24/2025 at 10:15 AM with the ADMIN, that on 05/20/2025 Resident #1 fell in the bathroom. ADMIN said she was left unattended by CNA-F when Resident #1 requested privacy. The ADMIN stated that RN-S assessed Resident #1 and notified the MD, ADMIN, ADON, RNC, and POA. The MD ordered X-rays immediately. The ADMIN stated once the X-ray results were reviewed by the MD, EMS was called, and she was transported to the hospital emergency room. The ADMIN said Resident #1 returned from the hospital with hospice services and assessments for therapy. The ADMIN stated that he did not investigate or submit a self-report for the incident. The ADMIN said he did not have the staff write a statement detailing the incident, however, he would search for a written statement. During an interview on 06/24/2025 at 10:25 AM the ADON stated that Resident #1 fell off the toilet when CNA-F left her unattended and returned to find the floor. She said Resident #1 had a skin tear to her left elbow. She CNA-F notified the charge nurse RN-S of the fall. She said RN-S assessed Resident #1, notified the on-call nurse, RNC, ADON, and POA. ADON said the MD ordered immediate X-rays for the resident. The ADON said once the X-ray result was reviewed by the MD, Resident #1 was sent out via emergency transport to the hospital, where it was later confirmed she had a fractured hip. The ADON said hospice services were ordered upon her return to the facility on [DATE]. The ADON said that the ADMIN was notified of the incident immediately. The ADON said Resident #1 was assessed for falls, the care plan was updated, and she was placed on 72-hour post fall observation and monitoring as a precaution on 04/15/2025. On 06/24/2025 at 10:30 AM, the ADON provided the names of the staff involved without contact information. During and observation and interview of on 06/24/2025 at 11:13 AM Resident #1, revealed she was Spanish speaking with some English. Resident #1 said she did not know how she fell and did not remember. She stated that she did not know how to use the call light. Resident #1 was lying in bed; a fall mat was next to bed and the call light was in reach. Upon further observation Resident #1's communication board/picture board was not in the room. During a phone interview on 06/24/2025 at 2:10 PM with CNA-F, revealed as she was walking past Resident #1's room she observed the resident trying to get out of bed independently. She went to assist the resident, and she could not understand her response and what she was saying, because the resident was speaking in Spanish. CNA-F said she called CNA-J (a Spanish speaking employee) to communicate Resident #1's needs. CNA-J told CNA-F that Resident #1 wanted to put her pajamas on for bed. CNA-F said once Resident #1 was dressed, she returned the resident to sit in her wheelchair, and she attempted to get out of the chair. CNA-F said she assumed Resident #1 wanted to go to the bathroom, so she assisted. CNA-F said Resident #1 was transferred to the toilet in her bathroom. CNA-F said she remained in the bathroom initially, until Resident #1 gestured with her hand to leave the restroom. CNA-F said she notified CNA-J caring for a patient in another room, that Resident #1 was on the toilet, and to check on her while she resumed care of another resident. CNA-F said about 2 to 3 minutes later as she was walking down the hall, she remembered Resident #1 was on the toilet. CNA-F said as she entered the room, she heard Resident #1 fall. She immediately called RN-S for help. CNA-F said the fall was unwitnessed. CNA-F said she was not familiar with Resident #1's clinical needs, nor could she speak Spanish. CNF-A said she did not know that Resident #1 was a fall risk and could not be left alone in the bathroom. She said this was a one-time incident and she gave the resident privacy. During an interview on 06/24/2025 at 2:15 PM with RN-S, revealed on 05/20/2025 CNA-F called for her assistance with a resident that fell, so she immediately responded to the room. RN-S said Resident #1 was found lying on the floor in the bathroom on her left side with a skin tear to the left elbow. RN-S said the resident was alert and communicating with her and she did not lose consciousness. RN-S said the resident understood English and Spanish. RN-S and CNA-F assisted Resident #1 to the wheelchair. RN-S said she called the MD and the on-call nurse to report the incident. RN-S stated that the MD ordered immediate Xray's. RN-S notified the POA, and he wanted to delay sending Resident #1 to the hospital, and she explained that the facility policy was to provide immediate care and transport to the hospital for further assessment of the injuries. RN-S said she gave her Tylenol for pain at 6:25 PM. RN-S said the portable X-ray technician arrived 9:00 PM. RN-S said once the X-rays were reviewed by the MD resident was sent to the hospital. RN-S denied knowledge of Resident #1 having a picture board to communicate with staff. She said she was aware that Resident #1 was a fall risk. RN-S said Resident #1 should not be left alone, due to a history of falls and decline in cognition. During an interview on 06/24/2025 at 2:38 PM with CNA-J revealed she had placed Resident 1# in bed and proceeded to assist another resident with care. CNA-J said CNA-F did not tell her that the resident was in the bathroom on the toilet and to monitor. CNA-J stated that Resident #1 requires assistance from the staff with transfers and she could not self-transfer or ambulate. CNA-J said she would not have left Resident #1 unsupervised or alone in the bathroom, due to her diagnosis of Dementia and increased confusion. CNA-J said Resident #1 communicate in Spanish and say yes and no. She does not know how long CNA-F left Resident #1 on the toilet. CNA-J was told about the incident later that evening. CNA-J said CNA-F and the nurse responded to the fall. CNA-J said residents should never be left alone on the toilet, because a frequent movement could result in a fall. During an interview on 06/24/2025 at 5:00 PM with the ADMIN, revealed that that CNA-F notified CNA J to monitor Resident #1 on the toilet. The ADMIN insisted that the resident was being monitored by CNA-J and had been left for 2 to 3 minutes. The ADMIN stated that Resident #1 was a fall risk at her bedside, not in the bathroom, and she had a right to request privacy. The ADMIN said any resident could fall from the toilet and have injuries. The ADMIN returned at 5:34 PM and stated that he was not sure if he had statements, and he had to investigate further because CNA-J's and CNA-F's stories were not adding up. The surveyor stated that in the interview with CNA-F, she stated that the nurse was immediately notified not CNA-J. The ADMIN stated that he may have confused the staff statements with notification of help when Resident #1 fell. During another interview with the ADON on 06/24/2025 at 6:09 PM with the ADON she stated that the resident could use the call light prior to the fall. The surveyor explained that the resident stated she did not know how to use the call light this morning during an interview. The ADON stated that she could before the fall now she couldn't. The ADON was asked about the communication board that was care planned to communicate with the staff. She said she did not know where it was. The surveyor told her the FM stated that the board was sent home upon her discharge to hospital on 5/20/25. She said if they picked the communication board up and did not return, there was nothing she could do. She stated the resident could not communicate. The surveyor asked if pictures of tasks were documented on the board, and she said yes. The surveyor asked if the communication board was care planned. During an interview with the ADMIN on 06/25/2025 at 12:10 PM he stated that he did not submit a self-report to HHS about the incident, however, he completed the investigation on 05/26/25. During a second interview on 06/26/2025 at 11:02 AM the POA, stated that Resident #1 was not able to verbalize how she fell after being asked several times by him, the FM, and the staff. The POA denied hearing Resident #1 say what happened on 05/20/2025, and he never translated or communicated a statement from Resident #1 to the ADMIN or staff at the facility about the fall. During a second interview with the FM on 06/30/2025 at 11:40 AM, she stated that Resident #1 was unable to communicate what happened with the fall, due to her dementia, and injuries after the fall. She stated that she had asked Resident #1 on multiple occasions with the POA, and she couldn't recall what occurred. Record review of CNA-F written statement dated 5/20/25 (provided by the ADMIN on 06/24/2025 at 5:50 PM ADMIN) reflected CNA-F did not seek further assistance from anyone, and while she was attending to another task, Resident #1 may have been unsupervised longer than 1 to 3 minutes. Record review of facility investigation completed by the ADMIN on 05/26/2025 revealed investigation report Subject: Incident Involving Resident #1 - Bathroom Fall Resulting in Hip Fracture Resident Information: Name: [Resident # 1] Date of Incident: May 20, 2025, Date Reported: May 20, 2025, Cognitive Status: BIM's Score - 8 Primary Language: Spanish and speaks some English. Incident Summary: On May 20, 2025, I, [ADMIN] LNFA, was notified of an X-ray result confirming that Resident # 1 sustained a fractured hip following a fall in the bathroom. Upon notification, I immediately contacted [name] ADON, and [name] ADON-T, to begin reviewing the details of the incident. Narrative of Events: According to documentation and staff interviews: o [CNA-F] escorted [Resident #1] to the restroom. o the resident requested privacy by verbally dismissing CNA-[CNA-F] and pointing to the call light cord, indicating she understood how to call for assistance. o [Resident #1] has a BIMS of 8, suggesting moderate cognitive impairment, but she has consistently demonstrated the ability to use the call light independently and not have unsteady gate when sitting on the toilet or chair. o CNA- [CNA-F] stepped out of the room and informed [CNA-J] verbally to check on the resident in a bit. o During my follow-up with [CNA-J], she stated she did not hear the instruction from [CNA-F.] o [CNA-F] tended to another resident and, noticing [CNA-J] had not yet checked on [Resident #1], went back to the room within a three to four minutes. o as [CNA-F] approached the bathroom, she heard [Resident #1] fall and immediately entered to assist. Resident Statement: When asked by staff about what happened, [Resident #1] clearly stated she attempted to stand and transfer herself to her wheelchair, which led to her fall. Her [POA], [Resident #], who serves as her Spanish-language translator, confirmed this account, and reiterated it to me directly during a phone conversation on May 21, 2025. Communication and Reporting: o I spoke directly with [CNA-F], [CNA-J], and both ADONs to gather a complete account of the incident. o Following this, I consulted with [RDOA], Regional Director of Operations, and [RNC] RN, Regional Nurse. o It was determined that this incident does not meet the criteria for state reporting, as: o the resident requested privacy and had the cognitive and physical history of using the call light. o the resident explained what occurred and accepted responsibility for her attempt to transfer independently. o the resident was heard clearly by the CNA (did not specify which CNA) falling and the area was free of any hazards. o the resident was safe to be left on the toilet per her care status at the time. Care Plan & Follow-Up: As a preventive measure, I directed the Nursing team to update [Resident #1's] care plan to reflect that she should not be left alone while on the toilet moving forward, regardless of her ability to use the call light. Additionally, I maintained frequent communication with [POA], providing updates via phone and text to ensure transparency and family involvement in her care. Conclusion: This incident was thoroughly reviewed, and all appropriate internal and regional parties were consulted. While unfortunate, the [Resident #1's] own actions contributed to the fall, and steps have been taken to enhance her safety and prevent recurrence. Record Review of the ADMIN's in-service document reflected in-service 6/25/25.Residents designated as a fall risk will be identified in POC under the resident's profile. Residents identified as fall risk are not to be left unattended on the toilet unless otherwise care planned Communication boards are to be kept at bedside and utilized per plan of care if applicable for residents with communication deficit. If residents observed with difficulty communicating notify nurse management for communication board if one is not already in place 1, instructor: [RNC]. Record review of facility policy titled Abuse reportable events dated 12/01/2018 reflected in part Policy: All residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility will provide and ensure the promotion and protection of resident rights. It is everyone's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress Training: The facility will train through orientation and on-going in-services on issues related to abuse/neglect prohibition practices regularly .

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. 1. The facility failed to seal opened items in plastic bags in the dry storage pantry, refrigerator, and freezer areas on [DATE]. 2. The facility failed to ensure expired items in the dry storage pantry, refrigerator and freezer areas were removed on [DATE]. 3. The facility failed to ensure the dented cans in the dry storage area were removed from the shelf on [DATE]. These deficient practices could place residents at risk for cross contamination and other food-borne illnesses . Findings Include: Observation of the facility's kitchen dry storage, refrigerator and freezer areas on [DATE] at 8:40 AM, revealed the following food items were dented cans, unsealed packages and containers , expired , and dented cans. * 1 unsealed clear plastic container of cereal with a clear lid, with date of ,d+[DATE] and use by ,d+[DATE]. The unsealed plastic container was exposed to air. * 1 unsealed clear plastic container of cereal with a clear lid, with date of ,d+[DATE] and use by ,d+[DATE]. The unsealed plastic container was exposed to air. * 1 unsealed clear plastic container of cereal with a clear lid, with date of ,d+[DATE] and use by ,d+[DATE]. The unsealed plastic container was exposed to air. *1 unsealed clear plastic container of cereal with a clear lid, with date of ,d+[DATE] and use by ,d+[DATE]. The unsealed plastic container was exposed to air. * 1 unsealed plastic bag of cereal. The unsealed plastic bag was exposed to air. * 1 unsealed plastic bag of mini marshmallows. The unsealed plastic bag was exposed to air and did not have an expiration date. * 1 unsealed container of 80 oz. oats. The unsealed container was exposed to air. * 1 unsealed package of 10 oz. pasta. The unsealed package was wrapped in plastic wrap and was exposed to air. * 1 unsealed package of fish fry. The unsealed package was exposed to air. * 1 unsealed package of parboiled rice. The unsealed package was exposed to air. * 1 unsealed package of tortillas. The unsealed package was wrapped in plastic wrap and was exposed to air. * 1 dented 10 1b. can of cream style corn. * 1 dented 6 lb. can of tropical fruit. *1 dented 6 lb. can of sliced peaches * 1 dented 6 lb. can of pork and beans. Refrigerator area: * 1 clear plastic container with red lid labeled Grape Jelly was unsealed and exposed to air. Freezer area: *1 unsealed package of 5 hamburger patties labeled use by ,d+[DATE]. The unsealed package was exposed to air. In an interview with the Dietary Manager on [DATE] at 9:53 AM, revealed she had been employed at the facility for 2 months. She stated she was unaware there were expired and unsealed items in the kitchen's dry storage, refrigerator, and freezer areas. The Dietary Manager stated she was unaware there were 4 dented cans stored on the shelves with the other canned food. She stated all kitchen staff were responsible for ensuring all food items in the kitchen's dry pantry, refrigerator, and freezer areas were sealed, labeled and checked for expiration dates. She stated there should not have been any dented cans on the shelf with the other dented cans . She stated the dented cans were to be separated from the other canned food on the shelves and placed in another place in the dry pantry area that was labeled, Dented Cans. She stated there should not be any food items in the kitchen's dry pantry, refrigerator, and freezer areas that were not sealed and expired . The Dietary Manager stated she had a total of 8 staff members who she supervised, and they worked various shifts. She stated the kitchen staff regularly received In-Service trainings on proper food handling, storage which included ensuring all food in the kitchen was dated, labeled, sealed, included food expiration, food handling and sanitization to prevent food-borne illness per the facility's policy. She stated the kitchen staff received in-service trainings at least two times per month on their paydays. She stated she would immediately throw away all expired items and unsealed items that were found in the kitchen. She stated she would audit the dry pantry, refrigerator, and freezer areas to ensure everything in the area was labeled, dated, sealed and check the expiration dates on the food items. The Dietary Manager stated it was her responsibility to oversee everything in the kitchen was audited which included all food items in the kitchen's dry pantry, refrigerator, and freezer areas were labeled correctly, sealed and checked for expiration dates. She stated her expectation was that if staff were to see anything in the kitchen's dry pantry, refrigerator and freezer areas not labeled, they were to place a label on the item (if not expired) and notify her. She stated her expectations were the same for the food items that were unsealed. The Dietary Manager stated if kitchen staff found anything that was unsealed in the kitchen's dry pantry, refrigerator and freezer areas that was not sealed, her expectations were for the staff immediately throw away the item(s) and notify her. She stated if staff saw a dented can on the shelves where the canned items were stored in the dry pantry area, they should immediately place the can(s) in the area in the dry pantry area that was labeled, dented cans. She stated her expectation for her staff, was that they were to use the FIFO (the principle and practice of maintaining precise production and conveyance sequence by ensuring that the first part to enter a process or storage location is also the first part to exit) procedures to ensure there were not any unsealed, and expired food items throughout the kitchen. She stated all staff in the kitchen were to use the First In, First Out Method, which meant kitchen staff should label the food with the dates they store them, and when staff were restocking the shelves, they were to put the older foods in front or on top so they could be used first. She stated this system allowed the kitchen staff to find the food quickly and use it more efficiently. The Dietary Manager stated the items found in the kitchen by the state surveyor was a mistake and she would continue to reeducate the staff to ensure everyone was on the same accord with her expectations in the kitchen and the facility's policy on Food Storage. She stated she would immediately retrain and reeducate all kitchen staff via in-service training on food storage. She stated the risk of someone, which included a resident eating food from the facility kitchen's dry storage, refrigerator and freezer areas, expired foods, dented cans was that they could become ill and become sick due to eating something that could cause food-borne illnesses. She stated there were risks of food borne illness anytime someone ingested food items from the kitchen any items that had not been labeled and stored properly and from dented cans. She stated the harm of someone, which included a resident ingesting food from the facility kitchen's dry storage, refrigerator and freezer areas, expired foods, eating something from a dented can could cause someone to have stomach aches, bowel issues, and food poisoning. She stated the harm of someone, which included a resident eating food from the facility kitchen's dry storage, refrigerator and freezer areas, expired foods, eating something from a dented can could cause bacteria to enter the areas if a container or package was unsealed. She stated insects could also enter any area that was not sealed properly. In an interview with the Dietary Aide on [DATE] at 10:14 AM, she stated she had been employed at the facility for 10 months. She stated she was unaware there were expired and unsealed items in the kitchen's dry storage, refrigerator and freezer areas. She stated she was unaware there were 4 dented cans on the shelves with the other canned food items. She stated all the staff were responsible for storing the items on the shelf and checking the expiration dates, dented cans to make sure there were not any unsealed items in the kitchen. She stated at least 2 times per month, the Dietary Manager in-serviced the kitchen staff on food storage, labeling and dating, removing expired items from the shelves in the dry pantry, freezer, and refrigerator areas and for dented cans and the use of the FIFO method. The Dietary Aide stated per her in-service trainings pertaining to the food items in the dry pantry, refrigerator, and freezer areas needed to be stored properly by labeling the food items, with the date the food item were placed in the proper area and the use by date. She stated the use by date indicated when the food items should be used. She stated if any food item that was in the facility's dry storage, refrigerator, and freezer areas had a use by date and it was expired, the food item should be immediately thrown away and then she would notify the Dietary Manager of what she found. The Dietary Aide stated if something was not labeled, she would label it in and make sure the item was not unsealed, if it were unsealed, she would throw the item away and notify the Dietary Manager. She stated if she found any dented cans in the dry storage area, she would immediately remove the dented can and place it in the Dented Can area in the dry pantry. She stated she would notify the Dietary Manager. She stated there were risks of food borne illness anytime someone ingested food items from the kitchen's dry pantry, refrigerator, and freezer areas any items that had not been labeled, stored, which included dented cans. The Dietary Aide stated if any of the above food were to be ingested by anyone, they could or would become ill and have possible food-borne illnesses. She stated the risk of anyone ingesting any of the aforementioned items, they could have stomach aches and vomiting and have other illnesses. Record review of the facility's policy titled, Food Storage dated, [DATE], and revised, [DATE], reflected: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HAACP guidelines. Procedure: Dry storage rooms a. Keep the storage room well-ventilated with humidity controls to prevent mold growth . d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated . f. Where possible, leave items in the original cartons placed with the date visible. g. Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies, so that the older items are used first . 2. Refrigerators . d. Date, label and tightly seal all refrigerated foods .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 . e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated . Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S ,d+[DATE].18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts ,d+[DATE] - ,d+[DATE].

Based on interview and record review the facility failed to ensure residents' had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 2 of 8 residents (Resident #3 and resident #73) reviewed for advanced directives. The facility failed to ensure Resident #3's and Resident #73's Out-of-Hospital Do Not Resuscitate (OOH-DNR) documents had the Physician's Statements signed by the physician and included the physician's license number, rendering the document invalid. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. Findings include: 1) Record review of Resident #3's face sheet, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #3's Quarterly MDS Assessment, dated [DATE], reflected she had a BIMS score of 03, which indicated severely impaired cognition. Her diagnoses included Alzheimer's Disease (a progressive disease that affects memory and mental functions); Non-Alzheimer's dementia (neurodegenerative disease causing dementia that is not Alzheimer's disease); hypertension (high blood pressure); and depression. Record review of Resident #3's Physician Order Report reflected the following order, dated [DATE],: Code Status: DNR. Record review of Resident #3's Care Plan reflected the following entry initiated [DATE]: Problem: Resident has an order for Do Not Resuscitate (DNR) Goal: Resident/Responsible Party's decision for DNR will be honored through the next review date. Approaches included: All aspects of DNR will be explained to resident or responsible party; In absence of b/p, pulse, respiration, CPR [procedure used in an attempt to revive a person who is at or near death] will not be initiated .Social Services to consult with resident and RP regarding their decision to continue DNR. Record review of Resident #3's Out-Of-Hospital Do-Not-Resuscitate (OOH-DNR) order reflected it was initiated and signed by Resident #3 on [DATE]. The Physician's Statement portion of the document reflected, I am the attending physician of the above-noted person and have noted the existence of this order in the person's medical records. I direct healthcare professionals acting in out-of-hospital settings, including a hospital emergency department, not to initiate or continue resuscitation measures for the person. The document contained an area designated for the physician's signature, date, license number and printed name. This portion was left blank on Resident #3's order. 2) Record review of Resident #73's face sheet, dated [DATE], reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #73's Quarterly MDS Assessment, dated [DATE], reflected she had a BIMS score of 03, which indicated severely impaired cognition. Her diagnoses included Non-Alzheimer's dementia and unspecified dementia with psychotic disturbance (dementia with symptoms such as hallucinations and paranoia). Record review of Resident #73's Physician Order Report reflected the following order, dated [DATE]: Code Status: DNR. Record review of Resident #73's Care Plan reflected the following entry initiated [DATE]: Problem: Resident has an order for Do Not Resuscitate (DNR) Goal: Resident/Responsible Party's decision for DNR will be honored through the next review date. Approaches included: All aspects of DNR will be explained to resident or responsible party; In absence of b/p, pulse, respiration, CPR [procedure used in an attempt to revive a person who is at or near death] will not be initiated .Social Services to consult with resident and RP regarding their decision to continue DNR. Record review of Resident #73's Out-Of-Hospital Do-Not-Resuscitate (OOH-DNR) order reflected it was initiated and signed by her Medical Power of Attorney on [DATE]. The Physician's Statement portion of the document reflected, I am the attending physician of the above-noted person and have noted the existence of this order in the person's medical records. I direct healthcare professionals acting in out-of-hospital settings, including a hospital emergency department, not to initiate or continue resuscitation measures for the person. The document contained an area designated for the physician's signature, date, license number and printed name. This portion was left blank on Resident #73's order. During an interview and record review on [DATE] at 6:52 AM, the DON stated the Social Worker was responsible for monitoring the resident's Advanced Directive and DNR forms. She reviewed Resident #3's and Resident #73's EMR and noted both had physician orders and Care Plans in place for DNR. She confirmed neither resident had physician signatures on their OOH-DNR forms. The DON stated she believed the risk to residents was low because both had active orders not to resuscitate and it was unlikely EMS would be called in the event they became nonresponsive. She stated the facility had never encountered an issue where emergency personnel refused to honor a DNR document. During an interview and record review on [DATE] at 6:55 AM, the DON asked the Social Worker to review the OOH-DNR documents she kept in a binder for the residents. The DON and Social Worker noted the documents in their binder were the same ones located in the residents' EMRs and neither contained a physician's signature. The Social Worker stated she assisted with the initiation of the documents and always ensured they were complete, but some residents arrived with them or had them initiated with hospice companies. She stated she performed audits to ensure they had the forms on file with the orders but had not always checked to ensure the documents were completed if they were initiated before she started there. She stated the risk included emergency personnel may not accept them if they were not completed properly and initiate CPR. The DON and Social Worker stated they planned to conduct a full audit of all resident documents. During an interview on [DATE] at 9:55 AM, the Administrator stated the Social Worker oversaw the advanced directives for the facility. He stated she retrieved the information from the resident's or Responsible parties and ensured they were included in the medical record and should have scanned the records to ensure they were completed. He stated he was aware of the findings and a full audit had been completed and no other incomplete documents were located. He stated the risk to residents was paramedics could question the validity of the DNR order and not follow the resident's wishes. The Administrator stated he felt confident the facility staff would have followed procedures and not called emergency services if a resident had an active DNR order. He stated all staff had received additional in-service training related to DNR orders and were aware of the facility's procedures. Record review of the facility's policy titled, Code Status Listing, dated ,d+[DATE], reflected the following: Policy: It is the policy of this home to allow residents the opportunity to file an advance directive document declaring the resident/family/responsible party's end of life wishes . Procedure .1. Residents will be informed of their opportunity to file advanced directives upon admission and at least annually. 2. Social Services or designee will be responsible to keep the code status list current and updated whenever a change occurs. 3. Interdisciplinary Care Plan Team (IDCPT) will discuss advanced directives with resident/responsible party during quarterly care plan conference and update as necessary.

Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 2 (Residents #1 and #2) of 5 residents reviewed for infection control, in that: PTA B failed to follow droplet precautions for Resident #1 by not donning an N95 mask respirator or eye protection prior to entering the room to perform therapy services. CNA C failed to follow droplet precautions for Resident #2 by not donning eye protection prior to entering the room to provide care services. These failures could affect residents and place them at risk for cross contamination and infections. Findings included: 1. Review of Resident #1's face sheet, dated 08/09/24, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Review of Resident #1's Admission MDS Assessment, dated 07/29/24, reflected she had a BIMS score of 15 indicating no cognitive impairment. Further review revealed she had active diagnoses of depression and a hip fracture. Review of Resident #1's undated Continuity of Care Document reflected a Problem of 2019-nCoV acute respiratory disease with an effective date of 08/02/24. Further review revealed under Results and COVID-19 Test was COVID-19 Test Viral Antigen with a date of 08/01/24 and the word Positive. Review of Resident #1's physician order report for 07/09/24 to 08/09/24 reflected the following: Isolation with droplet precautions for covid-19; Resident to remain in private room, all services to be provided to resident in resident's private room. [DX: 2019-nCoV acute respiratory disease] with a start dated of 08/02/24 and end date of 08/11/24. Review of Resident #1's care plan, dated 08/05/24, reflected the following: Problem: Problem Start Date: 08/02/2024, Category: Nursing, Resident requires isolation control precautions as evidence by droplet isolation precautions related to ____ .Approach: follow infection control policy . Observation on 08/09/24 at 9:15 AM, of Resident #1's room revealed there was a three-drawer-bin on the outside of her room next to her closed door. Inside of the bin was gowns, gloves, masks (both N95 and surgical), and bio-hazard trash bags. There was no eye protection in the drawers. There was a sign posted on the door with the following information written on it: a stop sign with the word stop in it on the top left and right of the page; writing that said DROPLET PRECAUTIONS .EVERYONE MUST: Clean their hands, including before entering and when leaving the room .[a picture with a bottle of ABHR and a drop of it's contents on top of a hand being stretched out towards it] .Make sure their eyes, nose and mouth are fully covered before room entry .[two pictures side by side, one with a person wearing a face shield and one with a person wearing goggles with the word 'or' between them] .Remove face protection before room exit. Resident #1's door was closed each time it was observed. Observation on 08/09/24 at 12:15 PM revealed PTA B entered Resident #1's room with a surgical mask, gown, and gloves on. PTA B did not put on eye protection such as a face shield or goggles or an N95 mask on. There was a box of N95 masks on top of the three-drawer bin outside of Resident #1's room where PTA B retrieved the gown and gloves. There was also a set of face shields in one of the drawers as well. Observation on 08/09/24 at 12:20 PM of Resident #1's room revealed PTA B opened the door to get CNA D's attention. PTA B was observed still wearing a surgical mask, a gown, and gloves. PTA B requested CNA D help him provide incontinent care to Resident #1. CNA D donned a gown, gloves, face shield, and N95 mask before entering Resident #1's room. Interview on 08/09/24 at 12:34 PM, PTA B revealed he was aware Resident #1 had COVID and was positive. PTA B said he wore all PPE including a gown, mask, and gloves into Resident #1's room. PTA B said he saw two boxes of masks on top of the three-drawer bin, one of surgical masks and one of N95 masks so he thought it was optional which one he needed to wear inside the room. PTA B said he did not wear eye protection because he did not think he had to wear that as well even though he saw a face shield was available in one of the drawers for him to wear. PTA B said he was providing therapy services to Resident #1 while he was in her room. Interview on 08/09/24 at 12:37 PM, CNA D revealed she went into Resident #1's room to assist PTA B with providing incontinent care to her. CNA D said when she went into the room, she saw PTA B wearing a surgical mask, gloves, and a gown. CNA D said PTA B was not wearing an N95 mask or any eye protection. 2. Review of Resident #2's face sheet, dated 08/09/24, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Review of Resident #2's Admission MDS assessment, dated 08/01/24, reflected he had a BIMS score of 03, indicating severe cognitive impairment. Further review revealed he had active diagnoses of vascular dementia and a stroke. Review of Resident #2's undated Continuity of Care Document reflected a Problem of 2019-nCoV acute respiratory disease with an effective date of 08/04/24. Further review revealed under Results and COVID-19 Test was COVID-19 Test Viral Antigen with a date of 08/04/24 and the word Positive. Review of Resident #2's care plan, dated 08/04/24, reflected the following: Problem; Problem Start Date: 08/04/2024, Category: Nursing, Resident requires isolation control precautions as evidenced by droplet precautions related to COVID DX 8/4 .Approach: follow infection control policy . Review of Resident #2's physician order report for 07/09/24 to 08/09/24 reflected the following: Isolation with droplet precautions for Covid 19; Resident to remain in room, all services to be provided to resident in resident's private room. [DX: 2019-nCoV acute respiratory disease] with a start dated of 08/05/24 and end date of 08/14/24. Observation on 08/09/24 at 9:16 AM of Resident #2's room revealed there was a three-drawer-bin on the outside of his room next to his closed door. Inside of the bin was gowns, gloves, masks (both N95 and surgical), and bio-hazard trash bags. There was no eye protection in the drawers. There was a sign posted on the door with the following information written on it: a stop sign with the word stop in it on the top left and right of the page; writing that said DROPLET PRECAUTIONS .EVERYONE MUST: Clean their hands, including before entering and when leaving the room .[a picture with a bottle of ABHR and a drop of it's contents on top of a hand being stretched out towards it] .Make sure their eyes, nose and mouth are fully covered before room entry .[two pictures side by side, one with a person wearing a face shield and one with a person wearing goggles with the word 'or' between them] .Remove face protection before room exit. Resident #2's door was closed each time it was observed. Observation on 08/09/24 at 9:30 AM, CNA C entered Resident #2's room r wearing an N95 mask, gown, and gloves. CNA C was observed wearing prescription glasses but no other eye protection such as a face shield or goggles. CNA C entered the room with a trash bag and left the door open to walk into Resident #2's bathroom to replace the trash bag. CNA C was observed to have walked up to Resident #2's bed and provided care, then walked back to the door and closed it. CNA C was still only wearing a N95 mask, gown, and gloves with her prescription glasses. Interview on 08/09/24 at 11:15 AM, CNA C revealed she knew Resident #2 was positive for COVID-19. CNA C said she had to dress up in PPE before entering his room with a blue gown, gloves, and mask. CNA C said she did not put a face shield on to enter Resident #2's room because the IP told her she didn't have to since she wore glasses which would protect her eyes. Interview on 08/09/24 at 1:28 PM, the IP revealed she made rounds during the day to ensure staff were donning and doffing their PPE correctly before and after entering a COVID positive resident's room. The IP said staff were expected to put on the following items when entering a COVID positive resident's room: a gown, a mask, a face shield or eye wear, and gloves. The IP specified that the mask should be a N95 mask. The IP said all PPE supplies were available to all staff throughout the day as when she made rounds in the facility she added supplies to the three-drawer bins located outside of each resident's room. The IP said all staff knew what PPE to put on before entering a COVID positive resident's room because they had been in-serviced so much on exactly what to do. The IP said she had not told one specific person that they could wear glasses instead of a face shield into a COVID positive resident's room. The IP said any COVID positive resident was on droplet precautions. The IP said that the risk of staff not donning the correct PPE was that they could get infected themselves or infect someone else since COVID was based on droplets it was easily transferrable . Review of the facility's undated policy, titled COVID-19 Refresher reflected the following: Facility to follow local health department and CDC guidelines .PPE for COVID + or COVID suspected- N95, gown, gloves, face shield .You should utilize N95s for Covid positive rooms . Interview on 08/09/24 at 11:00 AM, the Administrator revealed the refresher policy was what facility followed along with CDC guidelines for everything related to COVID. Review of website https://www.cdc.gov/covid/hcp/infection-control/index.html, accessed on 08/09/24, revealed the following: .2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection .Personal Protective Equipment .HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).

Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 12 residents (Resident #74) reviewed for MDS assessment accuracy in that: Resident #74's quarterly MDS assessment dated [DATE] was coded incorrectly for insulin injections when he was not receiving insulin. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Review of Resident #74's face sheet dated 02/29/2024 indicated Resident #74 was an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #74 had a diagnoses of chronic kidney disease, Type 2 diabetes mellitus (body does not make enough insulin) with diabetic neuropathy (nerve damage), essential hypertension (high blood pressure), acute kidney failure. Review of Resident #74's quarterly MDS dated [DATE] revealed Resident #74 had a BIMS score of 12 which indicated moderate impairment. The MDS Assessment for Resident #74 revealed Medications: Injections - Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less than 7 days. - It was coded 7 days. Insulin - Insulin Injections - Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days It was coded 7 days. Review of Resident #74's care plan, revised date 01/29/24 revealed Problems: [Resident #74] has a diagnosis of Diabetes Mellitus. Goal: The resident will have no complications related to diabetes through the review date. Approach: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of Resident #74's Physician Orders from November 2023 through February 2024 revealed no orders for insulin. Review of Resident #74's Discontinued Physician Orders revealed insulin lispro solution; 100 unit/ml; amountt: Per Sliding Scale; order date: 09/20/23 discontinued date: 10/03/23. Review of Resident #74's October 2023 and November 2023 MAR revealed no insulin was administered. Interview on 02/27/24 at 11:35 AM with Resident #74 revealed he had a diagnosis of diabetes; however, he does not require insulin. Resident #74 stated he does not recall if he was ever on insulin. He stated he was getting his blood sugar checks but that had stopped months ago, resident could not recall how many months since his blood sugar checks were stopped. Interview on 02/29/24 at 10:00 AM with LVN B revealed he was the nurse assigned to Resident #74. LVN B stated Resident #74 was not on insulin, he stated resident had a physician order for PRN insulin, but it was discontinued around October 2023. He stated Resident #74's blood sugars were stable, and insulin was not needed. He stated Resident #74 was not provided with insulin 7 days a week. Interview on 02/29/24 at 01:26 PM with the MDS Coordinator and the Regional MDS revealed the MDS Coordinators were responsible for completing the MDS assessments and Regional MDS oversees the assessments. The MDS Coordinator stated she would gather all the resident's information during IDT meetings, care plan meetings, and reviewing clinical records to complete the residents initial, quarterly, and annual MDS's. She stated on the resident's MDS they trigger any special treatment the resident was receiving. The MDS Coordinator and Regional MDS reviewed Resident #74's quarterly MDS assessment dated [DATE] and reviewed resident physician orders; and stated the assessment was inaccurate. The Regional MDS stated she reviewed Resident #74's quarterly MDS assessment dated [DATE] and it was also inaccurately coded for insulin. The Regional MDS stated the previous MDS staff coded the incorrect medication treatments, she stated it was her responsibility to ensure MDS assessment were completed correctly. The Regional MDS stated there was no potential risk to the residents if assessments were not accurate. The Regional MDS stated the facility used the RAI manual as a reference and policy. Interview on 02/29/24 at 02:05 PM with the DON revealed the MDS Coordinator was responsible for completing MDS assessments. She stated the Regional MDS oversaw the assessments. She stated Resident #74 was on insulin for a couple of days but then the insulin order was discontinued. She stated her staff were only checking his blood sugars once the insulin order was discontinued. She stated the previous MDS Coordinator might have coded the wrong thing. The DON stated there was no risk to the resident if the MDS assessment was not accurate. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, October 2023, revealed the following: an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment.

Based on observations, interviews, and record reviews the facility failed to develop a comprehensive care plan for 1 (Resident #17) of 5 residents reviewed for comprehensive care plans. The MDS Coordinator failed to care plan to address Resident #17's orthopedic braces. This failure could result in the resident not receiving appropriate care for her fractures. Findings included: Review of Resident #17's undated Admission Record revealed she was a [AGE] year-old female admitted on [DATE] with diagnoses that included fracture of her left knee cap, non-displaced fracture of left arm, and a history of falls. Review of Resident #17's admission MDS, dated [DATE], revealed a BIMS score of 10 indicating she had mild cognitive impairment. Her functions Status indicated she required total assistance with most of her ADLs. Her Health Conditions listed fractures of the arm and knee. Review of Resident #17's care plan, dated 1/27/24, revealed she was at risk for pressure ulcers related to decreased mobility, and a decline in her ADL functions related to her fractured knee cap. The resident was not care planned for orthopedic braces. Observation and interview on 2/27/24 at 11:53 AM Resident #17 stated she had fallen at home, resulting in fractures to her left knee cap, left upper arm, and back. Resident #17 stated she had to wear her leg brace at all times, except to bathe and dress, and her back brace any time she was out of bed. She stated her left arm fracture had healed. Resident #17 stated she had just come from a follow up visit with her orthopedist and had been cleared to start weight bearing on her left leg. She was hopeful she could make better progress with her therapy now. Review of Resident #17's physician orders revealed an order dated 1/22/24 to keep the resident non-weight bearing on her left leg and to please keep immobilizer intact as tolerated to left leg due to left patellar fracture. No orders found addressing the resident's back brace. Review of Resident #17's scanned documents revealed on 2/13/24 her leg immobilizer had been exchanged for a hinged knee brace and to remain non-weight bearing. On 2/27/24 the orthopedist ordered the resident to weight bear as tolerated. Interview on 2/29/24 at 11:35 AM the PTA stated he had worked with Resident #17 since her admission and they had been working on transfers with limited progress because she had been non-weight bearing, but now that she was able to bear weight he expected her to make fast progress. The PTA stated Resident #17 only had to wear her back brace when she was out of bed. Interview on 2/29/24 at 11:40 AM LVN-A stated Resident #17 only wears her back brace when she was out of bed, and she was able to weight bear as tolerated on her left leg. LVN-A was asked to locate the physician order for her back brace care and treatment, he was unable to locate an order. LVN-A was asked how he knew how to treat Resident #17's back brace, he stated he had been told in report that she was to wear it any time she was out of bed. When LVN-A was asked to locate the physician order changing the resident from a leg immobilizer to the hinged leg brace, he could not locate it as well. When asked to locate where in Resident #17's care plan it addressed her leg and back braces he could not locate anything. LVN-A stated the nurses were responsible for updating physician orders when a resident returned from a visit with a new order from the physician. LVN-A stated the nurses could also update the resident's care plan as needed but usually the MDS Coordinator updated the care plan. Interview on 2/29/24 at 2:40 PM the MDS Coordinator stated she was responsible for updating the resident's care plans as their needs changed. She stated she was made aware of the changes that needed to be made during the daily Interdisciplinary Team (IDT) meetings. She stated the nurses could also make changes as needed. Review of the facility's policy Care Plan-Resident, dated December 2018 reflected: The policy of the home was staff must develop a comprehensive care plan to meet the needs of the resident with long-term goals that must be measurable and must relate to the discharge goal.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents had physician orders for the resident's immediate care for 1(Resident #17) of 5 residents reviewed for physician orders in that LVN-A failed to update the physician orders for Resident #17, to reflect changes in the physician's plan of care. This failure could place the resident at risk of not receiving the care intended by the physician. Findings included: Review of Resident #17's undated Admission Record revealed she was a [AGE] year-old female admitted on [DATE] with diagnoses that included fracture of her left kneecap, non-displaced fracture of left arm, and a history of falls. Review of Resident #17's admission MDS, dated [DATE], revealed a BIMS score of 10 indicating she had mild cognitive impairment. Her functions Status indicated she required total assistance with most of her ADLs. Her Health Conditions listed fractures of the arm and knee. Review of Resident #17's care plan, dated 1/27/24, revealed she was at risk for pressure ulcers related to decreased mobility, and a decline in her ADL functions related to her fractured knee cap. Review of Resident #17's physician orders revealed an order dated 1/22/24 to keep the resident non-weight bearing on her left leg and to please keep immobilizer intact as tolerated to left leg due to left patellar fracture. No orders found addressing the resident's back brace. Review of Resident #17's Scanned Documents revealed on 2/13/24 the Physician had changed her leg immobilizer to a hinged knee brace and to remain non-weight bearing. On 2/27/24 the Physician ordered the resident to weight bear as tolerated. Observation and interview on 2/27/24 at 11:53 AM Resident #17 stated she had fallen at home, resulting in fractures to her left kneecap, left upper arm, and back. Resident #17 stated she had to wear her leg brace at all times, except to bathe and dress, and her back brace any time she was out of bed. She stated her left arm fracture had healed. Resident #17 stated she had just come from a follow up visit with her orthopedist and had been cleared to start weight bearing on her left leg. She was hopeful she could make better progress with her therapy now. Interview on 2/29/24 at 11:40 AM LVN-A stated Resident #17 wore her back brace only when she was out of bed, and her leg brace all the time. LVN-A stated Resident #17 was now able to weight bear on her left leg. When asked why Resident #17's physician orders had not been updated to reflect the changes LVN-A stated it was because nursing staff had not done so. When asked how he knew Resident #17 was now able to weight bear, he stated he had seen the order when she returned from her appointment on 2/27/24. When asked if he should have updated the order at that time, LVN-A stated he should have. When asked where the order for Resident #17's back brace was, LVN-A was not able to locate such an order. When asked how he knew Resident #17 had to have her brace on when out of bed, he stated it must have been passed on from nurse to nurse in report. LVN-A stated the risk of not having up to date orders for residents was they might not receive the care intended by the physician. The Administrator provided a policy Medication Orders but did not have a policy on updating physician orders specifically

Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Residents #1) of three residents reviewed for wound care treatment. The facility failed to maintain Resident #1's skin integrity, while removing a bordered dressing, during wound treatment which resulted in the resident sustaining a skin tear that measured 9 cm x 4 cm. This failure could place residents at risk for diminished quality of care and skin injuries. Findings included Review of Resident #1's admission MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS further reflected the resident had severe cognitive impairment with a BIMS score of 5, and she required extensive assistance of two staff members for all ADLs including bed mobility. Review of Resident #1's care plan revised on 08/31/22 revealed the resident had a lymphademic (tissue swelling caused by accumulation of protein rich fluid) ulcer to left posterior (back) upper thigh measuring 2 cm x 1.8 cm x 0.1 cm and an infection related to pressure ulcer left heel. Review of Resident #1's weekly wound assessment documented in the progress notes dated 08/31/22 and completed by the Wound Care Nurse revealed the following, New lymphademic wound to left posterior upper calf 2 cm x 1.8 cm x 0.1. cm 80% granulation and 20% slough. Order to apply silver alginate and cover with bordered dressing. There were no other skin concerns noted to the resident. Observation on 09/01/22 at 11:27 AM revealed Resident #1 was in bed and CNA A and the Wound Care Nurse were repositioning her for wound care treatment. The resident was turned to her left side and there was an unsoiled bandage covering her left heel. On the back of her left thigh was a bordered dressing with only part of the bordered dressing visible as the resident was lying on the other half of the dressing. The Wound Care Nurse began to peel the bordered dressing by the edges of the visible area on the resident's leg. The part of the bordered dressing that was not visible was pulled out from under the resident's leg towards the Wound Care Nurse. As the Wound Care Nurse pulled the bandage out from under the resident it met some resistance and Resident #1 began to say Ow, Ow, Ow! It's burning! It's burning! At that time the Wound Care Nurse said I know. I almost got it. Once the remainder of the dressing had been pulled off the resident's skin, the Wound Care Nurse slightly lifted the resident's left leg and a significant amount of red drainage that appeared to be blood began to drip onto the bed as the Wound Care Nurse tried to contain and clean the red drainage. Once the drainage had stopped the Wound Care Nurse stated Resident #1 had a skin tear that measured 9 cm x 4 cm. Observation of the skin tear revealed fresh blood and the top layer of the resident's skin had been peeled back. The Wound Care Nurse cleaned and covered the area and stated she would have to call the physician to get treatment orders. Observation of the old bordered dressing appeared to be intact and it was not soiled nor contained blood. Attempted to interview Resident #1 on 09/01/22 at 11:40 AM regarding the wound care treatment but was unsuccessful due to the resident's impaired cognition. Interview on 09/01/22 at 1:07 PM with CNA A revealed she saw the drainage from the resident's leg when the Wound Care Nurse pulled the dressing off the resident's thigh, and she heard the resident complain of pain. The CNA further stated it was her first time caring for Resident #1 and about 30 minutes prior to her wound care treatment she had changed the resident's brief and had not seen any skin concerns to her legs, nor had she noticed any blood on the bordered dressing when the Wound Care Nurse took it off. Interview on 09/01/22 at 12:33 PM with the Wound Care Nurse revealed she was not aware how Resident #1's skin tear occurred, but it was not present the day before, 08/31/22. She stated the skin tear was either caused when she pulled the bordered dressing out from under her leg or it was already there. The Wound Care Nurse also said she had assessed the resident's skin the day prior, 08/31/22, and there were no skin tears noted to that area of her leg. She said the proper way to pull a dressing off a resident was to peel the edges slowly to try and keep it from pulling the skin. The Wound Care Nurse also said Resident #1 had already been medicated for pain prior to treatment and maybe she should have stopped when the resident began to complain of pain, but she just wanted to get the treatment done so the resident did not continue to hurt, that is why she pulled the dressing out from under the resident's leg. Interview on 09/01/22 at 2:59 PM with the DON revealed the proper way to pull off a bordered dressing was to start at the corners and work around pulling the dressing away from the skin applying some pressure. The DON said the resident should have been repositioned accordingly to gain as much visibility of the dressing to safely remove it. She also said it was important to safely remove dressings off Resident #1 because she had fragile skin and to prevent incidents. Review of Fundamentals of Nursing, Ninth Edition, dated 2017, page 1227 reflected the following: Skin Integrity and Wound Care .Implementation .4. Remove Tape: Gently push skin away from tape while pulling adhesive from skin a. If dressing sticks on dry dressing, moisten with saline and then remove . Push-pull technique releases the tape from skin, reducing chance of skin damage

Based on observation, interview and record review, the facility failed to ensure the residents had the right to be free from abuse for four (Residents #4, #5, #6, and #7) of 13 residents reviewed for abuse. 1. The facility failed to ensure Resident #4 was free from abuse when she was sexually assaulted by CNA A, who had a history of [REDACTED]. Resident #4 had to be transported to the hospital for a forensic analysis and upon examination, vaginal tearing was noted. 2. The facility failed to ensure Resident #5 was free from abuse when she was sexually abused by CNA A. Resident #5 was so emotionally distraught, she had to go home with her family for two days and was being seen by a psychologist for emotional distress. The resident also started a medication for an antidepressant. 3. The facility failed to ensure Resident #6 was free was from abuse when she was sexually abused by CNA A. Resident #6 was scared. 4. The facility failed to ensure Resident #7 was free of abuse when she was sexually abused by CNA A. Resident #7 would become frightened and scared if she saw CNA A was working on her hall. An Immediate Jeopardy was identified on 11/16/17 as beginning on 02/01/17. The Immediate Jeopardy was removed on 12/01/17. The facility remained out of compliance at severity level of actual harm and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. These failures placed all 88 residents at risk of serious physical harm or injury, and/or serious psychological harm. Findings Included: 1. Review of Resident #4's undated face sheet reflected Resident #4 was [AGE] years old and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #4's Minimum Data Set (MDS) resident assessment, dated 09/18/17, reflected she had severe cognitive impairment. Resident #4 required assistance of one person with activities of daily living (ADLs). Review of the facility's Provider Investigation Report, dated 10/30/17, revealed on the morning of 10/24/17, CNA B entered Resident #4's room and found a used condom under Resident #4's buttocks. Resident #4 was transferred to the hospital for evaluation and CNA A was suspended since he was the male employee assigned to Resident #4. Interview with Administrator Y on 11/15/17 at 9:50 a.m. revealed a rape kit was completed at a local hospital on Resident #4, but the detective stated the rape kit would take months to complete since they were so backed up. She also revealed CNA A had been arrested at the airport a few days ago trying to leave the country, but there was a miscommunication at the airport, and he was able to bond out and leave the country. Interview with LVN C on 11/15/17 at 11:39 a.m. revealed she was Resident #4's nurse on the morning of 10/24/17. She stated she was called to Resident #4's room by CNA B. She stated CNA B rolled Resident #4 and underneath Resident #4's buttocks, between the brief and the bed, was a used condom. She stated CNA B grabbed the condom with a glove and put it in a bag for the police. LVN C stated she notified administrative staff and went with Resident #4 to the hospital. She stated she was present during the rape kit exam and the hospital nurse said there was evidence of vaginal tearing. LVN C stated while they were at the hospital, Resident #4 told her a large black man had laid on top of her. Interview with Resident #4 on 11/15/17 at 11:31 a.m. revealed she had no recall of the incident. 2. Review of CNA A's employee file reflected he was hired on 08/06/15. At the time of employment, a criminal history check revealed he had no convictions that barred employment. Registry checks for the Employee Misconduct Registry (EMR) and Nurse Aide Registry (NAR) were conducted prior to employment and annually and revealed he was employable. There was no evidence of prior counseling related to abuse or mistreatment of [REDACTED]. revealed he matched Resident #4's description of the alleged perpetrator. A termination notice, dated 10/26/17, reflected he was terminated and not eligible for rehire due to allegations of abuse. 3. Review of Resident #5's undated face sheet reflected Resident #5 was a [AGE] year old female who admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #5's MDS resident assessment, dated 10/23/17, reflected she had severe cognitive impairment. Resident #5 did not require assistance with ADLs and was continent of bowel and bladder. Review of the Provider Investigation Report, dated 10/30/17, revealed on the evening of 10/24/17, Resident #5 stated a large black man came into her room the night before and told her he needed to change her brief. Resident #5 told the man she did not wear a brief and in response, he patted her down, kissed her and left the room. CNA A matched the description that Resident #5 reported and he was suspended pending investigation. Review of the Psychologist's Diagnostic Interview, dated 10/24/17, reflected Resident #5 described an incident with a male aide during the night that caused her to feel threatened and unsafe. Resident #5 was tearful and anxious and repeated her description a number of times and appeared to feel worried that she was to blame, emphasizing repeatedly, I am not that type of woman. Recommendations included Psychology services to follow to address patient's anxiety and distress following an interaction with a male aide that she characterized as inappropriate and intrusive and which left her feeling fearful and humiliated. Review of the Change of Condition Report, dated 10/26/17, reflected Resident #5 was very anxious due to a recent incident (10/24/17's incident as listed above) and Resident #5 stayed overnight for two days with family. Review of the Psychologist's progress note, dated 10/27/17, reflected Resident #5 had worsening depression, anxiety, mood instability, and adjustment issues. Resident #5 was started on 5 mg of [MEDICATION NAME] (medication for depression) every night due to worsening affective signs and symptoms. 4. Interview with Administrator Y on 11/15/17 at 3:45 p.m. revealed after the incidents regarding Resident #4 and Resident #5, they completed Safe Surveys with all of the residents and asked questions regarding if they felt safe in the facility. She said no additional incidents were identified. 5. During surveyor interviews with residents, Residents #6 and #7 revealed CNA A had been inappropriate during their care. 6. Review of Resident #6's undated face sheet reflected she admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #6's care plan, dated 07/13/17 and completed by DON Z, revealed female caregivers were to assist resident with shower/personal hygiene. Review of Resident #6's MDS resident assessment, dated 08/24/17, reflected she was cognitively intact. Interview with Resident #6 on 11/15/17 at 11:20 a.m. revealed she was scared of the men here. She stated she did not know what was on their minds. She stated CNA A made her feel sexually uncomfortable because he rubbed her privates too long in the shower. She revealed all the other staff would allow her to wash her privates by herself. She stated it had happened several months ago and she had not told anyone. Interview with Administrator Y on 11/16/17 at 9:15 a.m. revealed she spoke with Resident #6 after the allegation was brought to her attention by surveyors. She stated she went ahead and started an investigation into the matter and notified the detectives about Resident #6's allegation. Review of the facility's Safe Surveys, conducted on 10/24/17, provided no evidence that Resident #6 disclosed the fact that CNA A had sexually assaulted her. 7. Review of Resident #7's undated face sheet reflected she was [AGE] years old and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #7's MDS resident assessment, dated 10/17/17, revealed she was cognitively intact. Interview with Resident #7 on 11/15/17 at 11:45 a.m. revealed when she first admitted to the facility, she was inappropriately touched by CNA A. She stated CNA A's hand would slip during brief changes all over her body. She stated it made her feel terrible and she felt that no one should ever have to feel like that. She stated she reported the incident to various staff members, but she felt like no one cared. Interview with CNA M on 11/15/17 at 1:32 p.m. revealed she was aware Resident #7 did not like CNA A and did not want CNA A to give her showers. She stated it was common knowledge that CNA A was not to give Resident #7 showers, but she was not sure why. Interview with CNA N on 11/15/17 at 4:01 p.m. revealed Resident #7 would refuse to allow CNA A to work with her. She stated an incident occurred probably around (MONTH) (YEAR) when she and CNA A were working together on Hall 100. She stated she was assisting Resident #7 with her shower and Resident #7 kept asking her to cover her up so CNA A would not see her. She stated she told the nurse that day. She added that everyone knew CNA A was not allowed to go into Resident #7's room. She revealed Resident #7 would become frightened and scared if she saw CNA A on her hall. Interview with Administrator Y on 11/16/17 at 9:15 a.m. revealed she spoke with Resident #7 after the allegation was brought to her attention by the surveyors. She stated she started an investigation into the matter and notified the local policy department's detectives about Resident #7's allegation. Review of the facility's Safe Surveys, conducted on 10/24/17, provided no evidence that Resident #7 disclosed the fact that CNA A had sexually assaulted her. 8. During an interview with Administrator Y on 11/15/17 at 9:50 a.m., she revealed she had been looking through information in her office and found additional allegations of sexual abuse in an office drawer. She said the files were labeled as Soft Files' by the prior administrator, Administrator X, and were not corporate documents. She stated she immediately notified corporate to figure out how to rectify the situation. She said the incidents were reported to the State Survey Agency. 9. Review of the facility's Provider Investigation Report, dated 11/13/17, confirmed the new administrator, Administrator Y, reported that on 11/06/17, she was reviewing facility records regarding events that pre-dated her tenure and there were several incidents which were not completely investigated by the former administrator, Administrator X. The incidents of alleged sexual abuse involved Residents #1, #2 and #3. 10. Review of Resident #1's closed clinical record revealed on the undated face sheet that she was [AGE] years old and admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Resident #1 was discharged from the facility on 02/04/17. Review of Resident #1's MDS resident assessment, dated 01/29/17, reflected she was cognitively intact Review of the Provider Investigation Report, dated 11/13/17, revealed on 02/01/17, Administrator X received a telephone call from Resident #1's family member and was informed that Resident #1 had been sexually assaulted. Administrator X interviewed Resident #1 who denied anyone touched her inappropriately, but that she was uncomfortable with CNA A because he had told her he loved her. Administrator X interviewed CNA A who denied saying he loved Resident #1. Administrator X did not interview or do any further investigation into the matter. When Administrator X was interviewed by corporate staff about the matter and why it was not self-reported, he stated his investigation indicated no abuse had in fact occurred. Review of Administrator X's investigation, dated 02/01/17, revealed on 02/01/17 and recorded in a plain Word document, Administrator X received a call from Resident #1's family member stating Resident #1 had been sexually assaulted. Administrator X went to check on the welfare of Resident #1, who denied any staff member had touched her in an inappropriate manner. Resident #1 stated CNA A made her feel uncomfortable when he stated he loved her and touched her shoulder. Administrator X interviewed CNA A about the incident. CNA A had stated he told Resident #1 about the Love of Jesus and perhaps she misunderstood. Resident #1's family was notified that it was not a sexual assault. Administrator X did not investigate the allegation any further. Interview with DON Z on 11/15/17 at 9:35 a.m. revealed she did not remember helping Administrator X or investigating any incident regarding Resident #1 in (MONTH) (YEAR). 11. Review of Resident #2's undated face sheet reflected she was [AGE] years old and admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #2's MDS resident assessment, dated 09/09/17, reflected she had severe cognitive impairment. Review of the Provider Investigation Report, dated 11/13/17, revealed Administrator X and DON Z investigated an incident reported by another resident that Resident #2 was kissed by an employee on 05/17/17. DON Z interviewed Resident #2 and she denied anyone had kissed her. Administrator X interviewed CNA A about the incident because he was the male CNA assigned to that hall. CNA A denied the allegation. Administrator X did not interview any further residents or staff. When Administrator X was interviewed by corporate staff about the matter and why it was not self-reported, and he stated his investigation indicated no abuse had occurred. Review of Administrator X's investigations during his tenure revealed there was no investigative paperwork regarding the incident with Resident #2. There was a statement from CNA A, dated 05/17/17, stating he had not done any unprofessional conduct with any residents. Interview with DON Z on 11/15/17 at 9:35 a.m. revealed in mid (MONTH) (YEAR), another resident alleged Resident #2 had been kissed by an employee. She had been directed by Administrator X to interview Resident #2. She stated Resident #2 denied being kissed by an employee and she documented her interview and gave it to Administrator X, who she assumed completed the investigation. An attempt was made to interview Resident #2 on 11/16/17 at 2:31 p.m.; however, she did not respond to questions. In a subsequent interview with DON Z on 11/15/17 at 1:00 p.m., she revealed after the incident with Resident #2, CNA A was reassigned to care for another group of residents. 12. Review of Resident #3's undated face sheet revealed Resident #3 was [AGE] years old and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #3's MDS assessment dated [DATE] reflected she was moderately cognitively impaired. Review f the Provider Investigation Report, dated 11/13/17, revealed Administrator X and DON Z investigated an incident which happened on 07/11/17. Administrator X was informed that Resident #3 told another employee she had been touched inappropriately by a male staff member. DON Z interviewed Resident #3 who denied anyone had touched her. Resident #3 had dementia. Administrator X interviewed the male CNA assigned to that hall, which was CNA A. CNA A denied any inappropriate behavior. Administrator X was interviewed by corporate staff about his investigation and why it was not self-reported, and he stated his investigation indicated no abuse had occurred. Interview with DON Z on 11/15/17 at 9:35 a.m. revealed in (MONTH) (YEAR), Resident #3 had told a staff member she had been touched inappropriately. She stated Administrator X directed her to interview Resident #3, who denied being touched, but she did have dementia. She stated Administrator X moved CNA A to care for a different set of residents after the incident. 13. During a subsequent interview with DON Z on 11/15/17 at 1:00 p.m., she revealed it was strange how CNA A's name kept coming up in each investigation, but she assumed Administrator X had thoroughly investigated the incidents and would take care of it. She stated CNA A was not suspended with any of the incidents regarding Residents #1, #2, and #3, but reassigned to care for residents either on a different hall or another group of residents. 14. An attempt to interview Administrator X was made on 11/16/17 at 10:08 a.m. via telephone and a voice message was left and the phone call was not returned during the course of the investigation. 15. Interview with CNA A on 11/15/17 at 10:05 a.m. revealed he said he was currently out of the country. He confirmed he was being investigated by the nursing home and the police regarding touching residents inappropriately, but denied he touched any residents including Residents #4 and #5. He stated prior to leaving the country, he was arrested regarding the incidents with Residents #4 and #5, but was able to bond out and fly back home (out of the country). 16. Interview with the Vice President of Operations on 11/15/17 at 10:27 a.m. revealed corporate consultants were involved as needed with allegations and investigations of abuse and neglect. He revealed if the Administrator determined something was reportable, they were expected to let the corporate office know. He stated if DON Z was involved in an investigation and felt it was not reported, she should report the incident. 17. Interview with the RNC on 11/15/17 at 2:45 p.m. revealed she was only contacted by DON Z or Administrator when they have a question about if an allegation is reportable or not. She revealed the corporate was only to be used as a resource and they did not have to tell her or the RDO about every allegation of abuse or neglect. She stated she was recently in-serviced over on reporting incidents. 18. Interview with CNA O on 11/15/17 at 4:15 p.m. revealed on 07/10/17 or 07/11/17, she was working with CNA A on Hall 100. She stated she remembers a couple of residents started screaming that they did not want him in their room. She stated CNA A had come up to her and asked her to finish assisting a resident with incontinent care because she was refusing to allow him to do it. She stated she went into the resident's room and the resident was screaming and crying. She stated she tried to comfort the resident and finished incontinent care. She stated she did not tell anyone. She stated she did not remember the resident's name because the incident occurred around her 4th day working at the facility. 19. Interview with the RDO on 11/16/17 at 9:55 a.m. revealed his role as an RDO was to be a resource to facility Administrators. He stated Administrators were welcome to call him and run questions by him and he would help determine if something was reportable, but he did not have to be contacted with every allegation of abuse or neglect. He stated he did not go behind the Administrators to ensure they did their job, because that was ultimately the Administrator's building and their decision on whether to report. He stated he was only a resource for Administrators. 20. Review of the Resident Abuse, Neglect, and Exploitation and Misappropriation of Resident Property Policy, revised 06/23/17, reflected the following definitions: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain or mental anguish. Sexual abuse: Includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 21. On 11/16/17 at 2:20 p.m., Administrator Y and DON Z were notified of an Immediate Jeopardy (IJ) had been identified. The facility provided an action Plan, dated 11/11/17, reflecting a plan they had initiated prior to the survey to address the above identified incidents: --All department heads educated on Grievance procedure and notification to administrator --Angel rounds to be done daily and communicated in morning meeting of any concerns --Concerns forms will be available in the lobby to ensure all residents, staff, family, and vendors can voice a concern --Weekend manager on duty will report all concerns on Monday in morning meeting --Grievance procedure to be reviewed in next resident council meeting. --Incident and accidents will be initiated according to company policy --Will be reviewed in morning clinical meeting --All incident and accidents will be reviewed by DON to ensure appropriate completion, documentation, intervention, and notification are done within 5 days of the incident. --Charge nurse will notify Administrator of all reportable incidents --Priority rounds will be made on all residents with incident and accident report initiated --Care Plans will be updated with interventions and approached for prevention and reoccurrence. 22. Review of the Safe Surveys conducted on 10/24/17, revealed all interviewable residents had been interviewed. The residents had said they felt safe in the facility. Note: Resident #6 had not disclosed the fact that CNA A had sexually assaulted her. 23. Review of the in-services reflected the following: 10/24/17: All nursing staff were in-serviced over resident rights, prevention of abuse and neglect, and signs of burnout. 11/03/17: Department heads were in-serviced over the grievance process, angel rounds, and how to interview residents and families. 11/06/17: From 4:30 p.m. to 5:00 p.m. revealed DON Z, Administrator Y, ADON D, ADON E were in-serviced over reporting and investigating after and how to complete an investigation. 11/08/17: All department heads were in-serviced over environmental rounds, abuse reporting, angel rounds, and resident rights. 11/11/17: All staff were educated on reporting bruises of unknown origin to the Administrator, reporting falls with injury, and that if the Administrator is unavailable DON Z would be the next person to contact. 11/15/17: All staff were educated on abuse prevention and were given the number for the corporate hotline and the state agency number to report any suspected abuse or neglect. 24. Individual interviews with four CNAs (CNA F, CNA G, CNA H and CNA I) and two RAs (RA J and RA K) covering all shifts revealed they had received in-service training on abuse/neglect, the signs and symptoms of abuse/neglect. They each said they would immediately report incidents to the Administrator. The interviews were conducted on the following dates/times: --CNA F was interviewed on 11/15/17 at 4:15 p.m. --CNA G, CNA H, CNA I, RA J AND RA K were interviewed on 11/16/17 at 9.38 a.m., 10:18 a.m., 10:25 a.m., 10:32 a.m., and 10:32 a.m., respectively. 25. Interview with DON Z on 11/16/17 at 11:06 a.m. revealed she received training by the Corporate Nurse on how to complete an investigation and when to report incidents to the state survey agency. She added that she would do what the Administrator told her to do. 26. Interview with the Administrator Y on 11/15/17 at 3:30 p.m., revealed she received training on how to complete an investigation and how to determine if an incident was reportable and how to report it to the state survey agency. 27. On 12/01/17 at 8:55 a.m., Administrator Y and Regional Nurse Consultant were notified their Action Plan did not provide sufficient evidence the Immediate Jeopardy had been removed. At that time, a Plan of Removal was requested. 28. On 12/01/17 at 1:50 p.m., the facility's Plan of Removal (PoR) was accepted. The PoR reflected the following: --Regional Director of Operations and /or Regional Nurse Consultant will, at least every two weeks for 3 months review and ensure system integrity of the following: Grievances (concern forms), Self-Reporting protocol, Investigation protocol, Angel Rounds, Compliance Hotline, Pinnacle service reports. --New Administrator Y effective 10/9/17. In-service Administrator Y on 11/10/17 on Internal investigation guidelines on allegations of abuse, neglect and exploitation to ensure compliance with federal and state regulation regarding protecting facility patients and resident from abuse, neglect, exploitation and misappropriation of resident property, timely investigation of reporting to state and local agencies all allegations of abuse, neglect, exploitation and misappropriation of resident property. --New DON AA effective 11/20/17 in-serviced on 11/20/17 on Internal investigation guidelines on allegations of abuse, neglect and exploitation to ensure compliance with federal and state regulation regarding protecting facility patients and resident from abuse, neglect, exploitation and misappropriation of resident property, timely investigation of reporting to state and local agencies all allegations of abuse, neglect, exploitation and misappropriation of resident property. --Administrator Y and DON AA in-serviced on notifying RDO and RNC of any significant event per policy to include list of all reportable events --Survey current and discharged residents and send out a report to Compliance officer, Administrator and Regional support team. Negative concerns are sent out immediately to Executive Management team, Administrator Y and DON AA. --Corporate Management Team track and trended all SRI from the facilities. Weekly SRIs are reported to management company. Monthly, the regional Clinical Nurse provides oversight of the reporting system to include review of the log for increasing trends or those who have made 0 self-reports in a 30 day period. --Weekly report to corporate management to going over facility events and self-reports --Administrator Y and DON AA to review all Incident and accidents, Concerns and Self-reports in Morning meeting (daily as of Hire dates) --Staff in-serviced on who to report allegations of abuse and neglect, exploitation and misappropriation of resident property too. Included if the Administrator is unavailable DON Z will be notified next. (10/23-10/24; 11/11) --Staff in-serviced to notify the regional team any allegation of abuse, neglect exploitation and misappropriations of resident property. Regional team numbers posted throughout the facility. (12/1) --Sensitivity Training -- Old lady poem and sensitivity video (11/10) --In-serviced staff on suspicion of a crime, compliance hotline and number to call Texas Health and Human Services for abuse, neglect, exploitation and misappropriation of resident property. (11/15) --In-service staff 12/1/17 on recognizing signs and symptoms of abuse, neglect, exploitation and misappropriation of resident property and to ensure proper follow up. --All abuse/neglect and misappropriation in-services were added to the on-line education management system assignments for ALL staff monthly in addition to the required annual and upon hire which we did previously. This will continue for 12 months or longer based upon guidance from the QAPI committee. (November (YEAR)-November (YEAR)) --Review in QAPI meeting monthly for the next 3 months. --As part of new Requirements direct care staff are involved in Care Plan meetings and QAPI meetings as well --Weekly since 10/23/17 in-servicing staff on abuse and neglect topics --DON AA in serviced staff on abuse and Neglect new guidelines 29. The following observations, interviews and record reviews were conducted to verify the implementation of the facility's Plan of Removal: --Review of DON Z's employee file revealed her last day of employment with the facility was 11/25/17. --Review of the in-services, dated 12/01/17, revealed the staff were in-serviced over abuse/neglect, reporting, and whom to notify if the Administrator is unavailable or if they feel like the allegation is not being investigated. The staff were also in-serviced on where the phone numbers for the corporate office, compliance hotline, and DADs hotline were located. Staff were also educated on if any signs of possible abuse are present, they must take the time to ask the 5 W's (who, what, when, where, and why). --Interviews with MA P, LVN Q, CNA R, CNA S, LVN T, and LVN U on 12/01/17 between 2:00 p.m. and 2:25 p.m. confirmed they had each been in-serviced on 12/01/17 regarding abuse and neglect and reporting. They all revealed they are to contact the Administrator with any allegation of abuse or neglect, but if unable to get a hold of the Administrator they can contact DON Z, RNC, or RDO. They also revealed if they felt like their allegation was not being properly investigated, they can call the corporate compliance hotline or the DADS hotline to self-report. They were all able to properly identify if it was abuse when given a scenario by the surveyor. --Interview with Administrator Y on 12/01/17 at 3:02 p.m. revealed she had been in-serviced over on how to conduct an investigation, abuse/neglect signs and symptoms, and how to deal with residents with difficult behaviors. She stated she was in-serviced on 12/01/17 regarding to notify corporate with every allegation of abuse/neglect and to determine whether it is reportable. She revealed she will also go over it with all management staff at the daily morning meeting. She stated the corporate office will be reviewing the systems in place every two weeks to ensure they are working correctly and also they will be looking at the tracking and trending of reportable events to ensure that a situation like this never happens again. --Interview with DON AA on 12/01/17 at 2:30PM revealed when she started on 11/27/17, she was given education on how to properly investigate an incident and how to report incidents to the state. She stated she was also the alternate abuse preventionist if the Admin was unavailable and her phone was always on. She stated she would ensure the resident was always safe and if she ever had a CNA that kept coming up in investigations, she would make sure she would find out why and always make sure the alleged perp was suspended pending investigation. She stated if she did not feel the Admininstrator was doing her job, she will go to corporate and self report to DADs (known known as HHSC) if she needed to. She stated she did the in-service with the employees today regarding abuse and neglect and made sure they understood to always ask questions and if they felt like there was even a possibility it is abuse, to always report. 30. On 12/01/17, the Immediate Jeopardy (IJ) was removed. On 12/01/17 at 4:00 p.m., Administrator Y and DON AA were informed the IJ was removed. While the IJ was removed on 12/01/17, the facility remained out of compliance at severity level of actual harm and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. 31. Review of the Resident Census, dated 11/15/17, reflected a total census of 88 residents.

Based on interview and record review, the facility failed to have evidence that all alleged abuse violations were investigated thoroughly and residents were protected from further abuse during the investigation for three (Residents #1, #2, and #3) of 13 residents reviewed for abuse and neglect. 1. Former Administrator X and DON Z failed to thoroughly investigate when Resident #1's family stated Resident #1 had been sexually abused by CNA A. They also failed to thoroughly investigate, including interviewing other residents who received care from CNA A, when Resident #1 said CNA A told her he loved her and touched her shoulder. 2. Former Administrator X and DON Z did not thoroughly investigate when another resident reported Resident #2 had been kissed by a male employee. 3. Former Administrator X and DON Z did not thoroughly investigate when Resident #3 had made a sexual abuse allegation against CNA A. 4. Former Administrator X and DON Z failed to protect residents when CNA A was not suspended when abuse allegations were made against him. An Immediate Jeopardy was identified on 11/16/17 as beginning on 02/01/17. The Immediate Jeopardy was removed on 12/01/17. The facility remained out of compliance at severity level of actual harm and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. These failures placed all 88 residents at risk of serious physical harm or injury, and/or serious psychological harm. Findings Included: 1. An interview with Administrator Y on 11/15/17 at 9:50 a.m., revealed she had been looking through information in her office and found allegations of sexual abuse in an office drawer. She said the files were labeled as Soft Files' by the prior administrator, Administrator X, and were not corporate documents. She stated she immediately notified corporate to figure out how to rectify the situation. She said the incidents were reported to the State Survey Agency. 2. Review of the facility's Provider Investigation Report, dated 11/13/17, confirmed the new administrator, Administrator Y, reported that on 11/06/17, she was reviewing facility records regarding events that pre-dated her tenure and there were several incidents which were not completely investigated by the former administrator, Administrator X. The incidents of alleged sexual abuse involved Residents #1, #2 and #3. 3. Review of Resident #1's closed clinical record revealed on the undated face sheet that she was [AGE] years old and admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Resident #1 was discharged from the facility on 02/04/17. Review of Resident #1's MDS resident assessment, dated 01/29/17, reflected she was cognitively intact Review of the Provider Investigation Report, dated 11/13/17, revealed on 02/01/17, Administrator X received a telephone call from Resident #1's family member and was informed that Resident #1 had been sexually assaulted. Administrator X interviewed Resident #1 who denied anyone touched her inappropriately, but that she was uncomfortable with CNA A because he had told her he loved her. Administrator X interviewed CNA A who denied saying he loved Resident #1. Administrator X did not interview or do any further investigation into the matter. When Administrator X was interviewed by corporate staff about the matter and why it was not self-reported, he stated his investigation indicated no abuse had in fact occurred. Review of Administrator X's investigation, dated 02/01/17, revealed on 02/01/17 and recorded in a plain Word document, Administrator X received a call from Resident #1's family member stating Resident #1 had been sexually assaulted. Administrator X went to check on the welfare of Resident #1, who denied any staff member had touched her in an inappropriate manner. Resident #1 stated CNA A made her feel uncomfortable when he stated he loved her and touched her shoulder. Administrator X interviewed CNA A about the incident. CNA A had stated he told Resident #1 about the Love of Jesus and perhaps she misunderstood. Resident #1's family was notified that it was not a sexual assault. Administrator X did not investigate the allegation any further. Interview with DON Z on 11/15/17 at 9:35 a.m. revealed she did not remember helping Administrator X or investigating any incident regarding Resident #1 in (MONTH) (YEAR). 4. Review of Resident #2's undated face sheet reflected she was [AGE] years old and admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #2's MDS resident assessment, dated 09/09/17, reflected she had severe cognitive impairment. Review of the Provider Investigation Report, dated 11/13/17, revealed Administrator X and DON Z investigated an incident reported by another resident that Resident #2 was kissed by an employee on 05/17/17. DON Z interviewed Resident #2 and she denied anyone had kissed her. Administrator X interviewed CNA A about the incident because he was the male CNA assigned to that hall. CNA A denied the allegation. Administrator X did not interview any further residents or staff. When Administrator X was interviewed by corporate staff about the matter and why it was not self-reported, and he stated his investigation indicated no abuse had occurred. Review of Administrator X's investigations during his tenure revealed there was no investigative paperwork regarding the incident with Resident #2. There was a statement from CNA A, dated 05/17/17, stating he had not done any unprofessional conduct with any residents. Interview with DON Z on 11/15/17 at 9:35 a.m. revealed in mid (MONTH) (YEAR), another resident alleged Resident #2 had been kissed by an employee. She had been directed by Administrator X to interview Resident #2. She stated Resident #2 denied being kissed by an employee and she documented her interview and gave it to Administrator X, who she assumed completed the investigation. An attempt was made to interview Resident #2 on 11/16/17 at 2:31 p.m.; however, she did not respond to questions. In a subsequent interview with DON Z on 11/15/17 at 1:00 p.m., she revealed after the incident with Resident #2, CNA A was reassigned to care for another group of residents. 5. Review of Resident #3's undated face sheet revealed Resident #3 was [AGE] years old and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #3's MDS assessment dated [DATE] reflected she was moderately cognitively impaired. Review of the Provider Investigation Report, dated 11/13/17, revealed Administrator X and DON Z investigated an incident which happened on 07/11/17. Administrator X was informed that Resident #3 told another employee she had been touched inappropriately by a male staff member. DON Z interviewed Resident #3 who denied anyone had touched her. Resident #3 had dementia. Administrator X interviewed the male CNA assigned to that hall, which was CNA A. CNA A denied any inappropriate behavior. Administrator X was interviewed by corporate staff about his investigation and why it was not self-reported, and he stated his investigation indicated no abuse had occurred. Interview with DON Z on 11/15/17 at 9:35 a.m. revealed in (MONTH) (YEAR), Resident #3 had told a staff member she had been touched inappropriately. She stated Administrator X directed her to interview Resident #3, who denied being touched, but she did have dementia. She stated Administrator X moved CNA A to care for a different set of residents after the incident. She stated she did not think Administrator X reported the incidents to the state survey agency, but did not know why he did not report each incident. 6. Review of CNA A's employee file reflected he was hired on 08/06/15. At the time of employment, a criminal history check revealed he had no convictions that barred employement. Registry checks for the Employee Misconduct Registry (EMR) and Nurse Aide Registry (NAR) were conducted prior to employment and annually and revealed he was employable. There was no evidence of prior counseling related to abuse or mistreatment of [REDACTED]. revealed he matched Resident #4's description of the alleged perpetrator. A termination notice, dated 10/26/17, reflected he was terminated and not eligible for rehire due to allegations of abuse. 7. During a subsequent interview with DON Z on 11/15/17 at 1:00 p.m., she revealed it was strange how CNA A's name kept coming up in each investigation, but she assumed Administrator X had thoroughly investigated the incidents and would take care of it. She stated CNA A was not suspended with any of the incidents regarding Residents #1, #2, and #3, but reassigned to a different hall or another group of residents. 8. An attempt to interview Administrator X was made on 11/16/17 at 10:08 a.m. via telephone and a voice message was left and the phone call was not returned during the course of the investigation. 9. Interview with the Vice President of Operations on 11/15/17 at 10:27 a.m. revealed corporate consultants were involved as needed with allegations and investigations of abuse and neglect. He revealed if the Administrator determined something was reportable, they were expected to let the corporate office know. He stated if DON Z was involved in an investigation and felt it was not reported, she should report the incident. 10. Interview with the Regional Nurse Consultant (RNC) on 11/15/17 at 2:45 p.m. revealed she was only contacted by DON Z or Administrator when they have a question about if an allegation is reportable or not. She revealed the corporate was only to be used as a resource and they did o not have to tell her or the RDO (Regional Director of Operations) about every allegation of abuse or neglect. She stated she was recently in-serviced over on reporting incidents. 11. Interview with CNA O on 11/15/17 at 4:15 p.m. revealed on 07/10/17 or 07/11/17, she was working with CNA A on Hall 100. She stated she remembers a couple of residents started screaming that they did not want him in their room. She stated CNA A had come up to her and asked her to finish assisting a resident with incontinent care because she was refusing to allow him to do it. She stated she went into the resident's room and the resident was screaming and crying. She stated she tried to comfort the resident and finished incontinent care. She stated she did not tell anyone. She stated she did not remember the resident's name because the incident occurred around her 4th day working at the facility. 12. Interview with the Regional Director of Operations (RDO) on 11/16/17 at 9:55 a.m. revealed his role as an RDO was to be a resource to facility Administrators. He stated Administrators wer welcome to call him and run questions by him and he would help determine if something was reportable, but he did not have to be contacted with every allegation of abuse or neglect. He stated he did not go behind the Administrators to ensure they did their job, because that was ultimately the Administrator's building and their decision on whether to report. He stated he was only a resource for Administrators. 13. Review of the facility's policies included the following: A. Resident Abuse, Neglect, and Exploitation and Misappropriation of Resident Property Policy, revised 06/23/17, reflected included - Definitions - --Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain or mental anguish. --Sexual abuse: Includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. --Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. (3) Duty to Report Violations Internally and to Applicable Agencies. (3.3) Upon receiving an allegation abuse, neglect, exploitation or misappropriation, the Abuse Coordinator will a) notify the Regional Director of Operations and Regional Nurse Consultant, b) initiate an investigation into the allegation, c) in conjunction with the Regional Director of Operations and Regional Nurse Consultant determine whether the allegation is reportable under federal and state regulations, and d) if the allegation is reportable, report such allegation to the State Regulatory Agency B. Internal Investigation Guidelines, revised 09/01/17, reflected the following: Process - (1) Collection only information that is relevant to the facts and circumstances of the incident being investigated. (2) Identify 'Who' was involved (3) Determine 'What' occurred (4) Determine 'When' the incident occurred (5) Determine 'Where' the incident occurred (6) . complete a physical and emotional assessment of the resident, identifying areas of injury. (9) Complete a comprehensive record review . (10) Interview all potential witnesses who may have relevant information. Interview Resident regardless of cognitive status. Interview Resident's roommate regardless of cognitive status. Interview staff members. Conduct Safe Surveys of other residents. Investigation Check List for Allegation of Abuse/Neglect/Exploitation/Misappropriation of Resident Property (1) The alleged perpetrator, if known, is suspended pending investigation. (3) Incident Report is completed. (5) Resident(s) are safe. (6) Notify the RDO at time of occurrence. (7) Notify the RNC at the time of occurrence. (8) Notify the State as directed by State specific guidelines . (11) Conduct Safe Surveys 14. On 11/16/17 at 2:20 p.m., Administrator Y and DON Z , were notfied of an Immediate Jeopardy (IJ) had been identified. The facility provided an action Plan, dated 11/11/17, reflecting a plan they had initiated prior to the survey to address the above identified incidents: --All department heads educated on Grievance procedure and notification to administrator --Angel rounds to be done daily and communicated in morning meeting of any concerns --Concerns forms will be available in the lobby to ensure all residents, staff, family, and vendors can voice a concern --Weekend manager on duty will report all concerns on Monday in morning meeting --Grievance procedure to be reviewed in next resident council meeting. --Incident and accidents will be initiated according to company policy --Will be reviewed in morning clinical meeting --All incident and accidents will be reviewed by DON to ensure appropriate completion, documentation, intervention, and notification are done within 5 days of the incident. --Charge nurse will notify Administrator of all reportable incidents --Priority rounds will be made on all residents with incident and accident report initiated --Care Plans will be updated with interventions and approached for prevention and reoccurrence. 15. Review of the Safe Surveys conducted on 10/24/17, revealed all interviewable residents had been interviewed. The residents had said they felt safe in the facility. 16. Review of the in-services reflected the following: 10/24/17: All nursing staff were in serviced over resident rights, prevention of abuse and neglect, and signs of burnout. 11/03/17: Department heads were in serviced over the grievance process, angel rounds, and how to interview residents and families. 11/06/17: From 4:30 p.m. to 5:00 p.m. revealed DON Z, Administrator Y, ADON D, ADON E were in-serviced over reporting and investigating after and how to complete an investigation. 11/08/17: All department heads were in serviced over environmental rounds, abuse reporting, angel rounds, and resident rights. 11/11/17: All staff were educated on reporting bruises of unknown origin to the Administrator, reporting falls with injury, and that if the Administrator is unavailable DON Z would be the next person to contact. 11/15/17: All staff were educated on abuse prevention and were given the number for the corporate hotline and the state agency number to report any suspected abuse or neglect. 17. Individual interviews with four CNAs (CNA F, CNA G, CNA H and CNA I) and two RAs (RA J and RA K) revealed they had received in-service training on abuse/neglect, the signs and symptoms of abuse/neglect. They each said they would immediately report incidents to the Administrator. The interviews were conducted on the following dates/times: --CNA F was interviewed on 11/15/17 at 4:15 p.m. --CNA G, CNA H, CNA I, RA J AND RA K were interviewed on 11/16/17 at 9.38 a.m., 10:18 a.m., 10:25 a.m., 10:32 a.m., and 10:32 a.m., respectively. 18. Interview with DON Z on 11/16/17 at 11:06 a.m. revealed she received training by the Corporate Nurse on how to complete an investigation and when to report incidents to the state survey agency. She added that she would do what the Administrator told her to do. 19. Interview with the Administrator Y on 11/15/17 at 3:30 p.m., revealed she received training on how to complete an investigation and how to determine if an incident was reportable and how to report it to the state survey agency. 20. On 12/01/17 at 8:55 a.m., Administrator Y and Regional Nurse Consultant were notified their Action Plan did not provide sufficient evidence the Immediate Jeopardy had been removed. At that time, a Plan of Removal was requested. 21. On 12/01/17 at 1:50 p.m., the facility's Plan of Removal (PoR) was accepted. The PoR reflected the following: --Regional Director of Operations and /or Regional Nurse Consultant will, at least every two weeks for 3 months review and ensure system integrity of the following: Grievances (concern forms), Self-Reporting protocol, Investigation protocol, Angel Rounds, Compliance Hotline, Pinnacle service reports. --New Administrator Y effective 10/9/17. In-service Administrator Y on 11/10/17 on Internal investigation guidelines on allegations of abuse, neglect and exploitation to ensure compliance with federal and state regulation regarding protecting facility patients and resident from abuse, neglect, exploitation and misappropriation of resident property, timely investigation of reporting to state and local agencies all allegations of abuse, neglect, exploitation and misappropriation of resident property. --New DON AA effective 11/20/17 in-serviced on 11/20/17 on Internal investigation guidelines on allegations of abuse, neglect and exploitation to ensure compliance with federal and state regulation regarding protecting facility patients and resident from abuse, neglect, exploitation and misappropriation of resident property, timely investigation of reporting to state and local agencies all allegations of abuse, neglect, exploitation and misappropriation of resident property. --Administrator Y and DON AA in-serviced on notifying RDO and RNC of any significant event per policy to include list of all reportable events --Survey current and discharged residents and send out a report to Compliance officer, Administrator and Regional support team. Negative concerns are sent out immediately to Executive Management team, Administrator Y and DON AA. --Corporate Management Team track and trended all SRI from the facilities. Weekly SRIs are reported to management company. Monthly, the regional Clinical Nurse provides oversight of the reporting system to include review of the log for increasing trends or those who have made 0 self-reports in a 30 day period. --Weekly report to corporate management to going over facility events and self-reports --Administrator Y and DON AA to review all Incident and accidents, Concerns and Self-reports in Morning meeting (daily as of Hire dates) --Staff in-serviced on who to report allegations of abuse and neglect, exploitation and misappropriation of resident property too. Included if the Administrator is unavailable DON Z will be notified next. (10/23-10/24; 11/11) --Staff in-serviced to notify the regional team any allegation of abuse, neglect exploitation and misappropriations of resident property. Regional team numbers posted throughout the facility. (12/1) --Sensitivity Training -- Old lady poem and sensitivity video (11/10) --In-serviced staff on suspicion of a crime, compliance hotline and number to call Texas Health and Human Services for abuse, neglect, exploitation and misappropriation of resident property. (11/15) --In-service staff 12/1/17 on recognizing signs and symptoms of abuse, neglect, exploitation and misappropriation of resident property and to ensure proper follow up. --All abuse/neglect and misappropriation in-services were added to the on-line education management system assignments for ALL staff monthly in addition to the required annual and upon hire which we did previously. This will continue for 12 months or longer based upon guidance from the QAPI committee. (November (YEAR)-November (YEAR)) --Review in QAPI meeting monthly for the next 3 months. --As part of new Requirements direct care staff are involved in Care Plan meetings and QAPI meetings as well --Weekly since 10/23/17 in-servicing staff on abuse and neglect topics --DON AA in serviced staff on abuse and Neglect new guidelines 22. The following observations, interviews and record reviews were conducted to verify the implementation of the facility's Plan of Removal: --Review of DON Z's employee file revealed her last day of employment with the facility was 11/25/17. --Review of the in-services, dated 12/01/17, revealed the staff were in-serviced over abuse/neglect, reporting, and whom to notify if the Administrator is unavailable or if they feel like the allegation is not being investigated. The staff were also in-serviced on where the phone numbers for the corporate office, compliance hotline, and DADs hotline were located. Staff were also educated on if any signs of possible abuse are present, they must take the time to ask the 5 W's (who, what, when, where, and why). --Interviews with MA P, LVN Q, CNA R, CNA S, LVN T, and LVN U on 12/01/17 between 2:00 p.m. and 2:25 p.m. confirmed they had each been in-serviced on 12/01/17 regarding abuse and neglect and reporting. They all revealed they are to contact the Administrator with any allegation of abuse or neglect, but if unable to get ahold of the Administrator they can contact DON Z, RNC, or RDO. They also revealed if they felt like their allegation was not being properly investigated, they can call the corporate compliance hotline or the DADS hotline to self-report. They were all able to properly identify if it was abuse when given a scenario by the surveyor. --Interview with Administrator Y on 12/01/17 at 3:02 p.m. revealed she had been in-serviced over on how to conduct an investigation, abuse/neglect signs and symptoms, and how to deal with residents with difficult behaviors. She stated she was in-serviced on 12/01/17 regarding to notify corporate with every allegation of abuse/neglect and to determine whether it is reportable. She revealed she will also go over it with all management staff at the daily morning meeting. She stated the corporate office will be reviewing the systems in place every two weeks to ensure they are working correctly and also they will be looking at the tracking and trending of reportable events to ensure that a situation like this never happens again. --Interview with DON AA on 12/01/17 at 2:30PM revealed when she started on 11/27/17, she was given education on how to properly investigate an incident and how to report incidents to the state. She stated she was also the alternate abuse preventionist if the Admin was unavailable and her phone was always on. She stated she would ensure the resident was always safe and if she ever had a CNA that kept coming up in investigations, she would make sure she would find out why and always make sure the alleged perp was suspended pending investigation. She stated if she did not feel the Administrator was doing her job, she will go to corporate and self report to DADs (known known as HHSC) if she needed to. She stated she did the in-service with the employees today regarding abuse and neglect and made sure they understood to always ask questions and if they felt like there was even a possibility it is abuse, to always report. 23. On 12/01/17, the Immediate Jeopardy (IJ) was removed. On 12/01/17 at 4:00 p.m., Administrator Y and DON AA were informed the IJ was removed. While the IJ was removed on 12/01/17, the facility remained out of compliance at severity level of actual harm and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. 24. Review of the Resident Census, dated 11/15/17 reflected a total census of 88 residents.

Based on observation, interview and record review, the facility failed to implement its written policies and procedures that prohibit and prevent abuse and neglect for seven (Residents #4, #5, #6, #7, #1, #2, and #3) of 13 residents reviewed for abuse. 1. The facility failed to ensure Resident #4 was free from abuse when she was sexually assaulted by CNA A, who had a history of [REDACTED]. Resident #4 had to be transported to the hospital for a forensic analysis and upon examination, vaginal tearing was noted. 2. The facility failed to ensure Resident #5 was free from abuse when she was sexually abused by CNA A. Resident #5 was so emotionally distraught, she had to go home with her family for two days and was being seen by a psychologist for emotional distress. The resident also started a medication for an antidepressant. 3. The facility failed to ensure Resident #6 was free was from abuse when she was sexually abused by CNA A. Resident #6 was scared. 4. The facility failed to ensure Resident #7 was free of abuse when she was sexually abused by CNA A. Resident #7 would become frightened and scared if she saw CNA A was working on her hall. 5. Former Administrator X and DON Z failed to thoroughly investigate when Resident #1's family stated Resident #1 had been sexually abused by CNA A. They also failed to thoroughly investigate, including interviewing other residents who received care from CNA A, when Resident #1 said CNA A told her he loved her and touched her shoulder. 6. Former Administrator X and DON Z did not thoroughly investigate when another resident reported Resident #2 had been kissed by a male employee. 7. Former Administrator X and DON Z did not thoroughly investigate when Resident #3 had made a sexual abuse allegation against CNA A. 8. Former Administrator X and DON Z failed to protect residents when CNA A was not suspended when abuse allegations were made against him. An Immediate Jeopardy was identified on 11/16/17 as beginning on 02/01/17. The Immediate Jeopardy was removed on 12/01/17. The facility remained out of compliance at severity level of actual harm and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. These failures placed all 88 residents at risk of serious physical harm or injury, and/or serious psychological harm. Findings Included: 1. Review of the facility's policies included the following: A. Resident Abuse, Neglect, and Exploitation and Misappropriation of Resident Property Policy, revised 06/23/17, reflected included - Definitions - --Abuse: The willfull infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain or mental anguish. --Sexual abuse: Includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. --Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. (3) Duty to Report Violations Internally and to Applicable Agencies. (3.3) Upon receiving an allegation abuse, neglect, exploitation or misappropriation, the Abuse Coordinator will a) notify the Regional Director of Operations and Regional Nurse Consultant, b) initiate an investigation into the allegation, c) in conjunction with the Regional Director of Operations and Regional Nurse Consultant determine whether the allegation is reportable under federal and state regulations, and d) if the allegation is reportable, report such allegation to the State Regulatory Agency B. Internal Investigation Guidelines, revised 09/01/17, reflected the following: Process - (1) Collection only information that is relevant to the facts and circumstances of the incident being investigated. (2) Identify 'Who' was involved (3) Determine 'What' occurred (4) Determine 'When' the incident occurred (5) Determine 'Where' the incident occurred (6) . complete a physical and emotional assessment of the resident, identifying areas of injury. (9) Complete a comprehensive record review . (10) Interview all potential witnesses who may have relevant information. Interview Resident regardless of cognitive status. Interview Resident's roommate regardless of cognitive status. Interview staff members. Conduct Safe Surveys of other residents. Investigation Check List for Allegation of Abuse/Neglect/Exploitation/Misappropriation of Resident Property (1) The alleged perpetrator, if known, is suspended pending investigation. (3) Incident Report is completed. (5) Resident(s) are safe. (6) Notify the RDO at time of occurrence. (7) Notify the RNC at the time of occurrence. (8) Notify the State as directed by State specific guidelines . (11) Conduct Safe Surveys 2. Review of Resident #4's undated face sheet reflected Resident #4 was [AGE] years old and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #4's Minimum Data Set (MDS) resident assessment, dated 09/18/17, reflected she had severe cognitive impairment. Resident #4 required assistance of one person with activities of daily living (ADLs). Review of the facility's Provider Investigation Report, dated 10/30/17, revealed on the morning of 10/24/17, CNA B entered Resident #4's room and found a used condom under Resident #4's buttocks. Resident #4 was transferred to the hospital for evaluation and CNA A was suspended since he was the male employee assigned to Resident #4. Interview with Administrator Y on 11/15/17 at 9:50 a.m. revealed a rape kit was completed at a local hospital on Resident #4, but the detective stated the rape kit would take months to complete since they were so backed up. She also revealed CNA A had been arrested at the airport a few days ago trying to leave the country, but there was a miscommunication at the airport, and he was able to bond out and leave the country. Interview with LVN C on 11/15/17 at 11:39 a.m. revealed she was Resident #4's nurse on the morning of 10/24/17. She stated she was called to Resident #4's room by CNA B. She stated CNA B rolled Resident #4 and underneath Resident #4's buttocks, between the brief and the bed, was a used condom. She stated CNA B grabbed the condom with a glove and put it in a bag for the police. LVN C stated she notified administrative staff and went with Resident #4 to the hospital. She stated she was present during the rape kit exam and the hospital nurse said there was evidence of vaginal tearing. LVN C stated while they were at the hospital, Resident #4 told her a large black man had laid on top of her. Interview with Resident #4 on 11/15/17 at 11:31 a.m. revealed she had no recall of the incident. Review of CNA A's employee file reflected he was hired on 08/06/15. At the time of employment, a criminal history check revealed he had no convictions that barred employment. Registry checks for the Employee Misconduct Registry (EMR) and Nurse Aide Registry (NAR) were conducted prior to employment and annually and revealed he was employable. There was no evidence of prior counseling related to abuse or mistreatment of [REDACTED]. revealed he matched the description Resident #4 gave of the alleged perpetrator. A termination notice, dated 10/26/17, reflected he was terminated and not eligible for rehire due to allegations of abuse. 3. Review of Resident #5's undated face sheet reflected Resident #5 was [AGE] years old female and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #5's MDS resident assessment, dated 10/23/17, reflected she had severe cognitive impairment. Resident #5 did not require assistance with ADLs and was continent of bowel and bladder. Review of the Provider Investigation Report, dated 10/30/17, revealed on the evening of 10/24/17, Resident #5 stated a large black man came into her room the night before and told her he needed to change her brief. Resident #5 told the man she did not wear a brief and in response, he patted her down, kissed her and left the room. CNA A matched the description that Resident #5 reported and he was suspended pending investigation. Review of the Psychologist's Diagnostic Interview, dated 10/24/17, reflected Resident #5 described an incident with a male aide during the night that caused her to feel threatened and unsafe. Resident #5 was tearful and anxious and repeated her description a number of times and appeared to feel worried that she was to blame, emphasizing repeatedly, I am not that type of woman. Recommendations included Psychology services to follow to address patient's anxiety and distress following an interaction with a male aide that she characterized as inappropriate and intrusive and which left her feeling fearful and humiliated. Review of the Change of Condition Report, dated 10/26/17, reflected Resident #5 was very anxious due to a recent incident (10/24/17's incident as listed above) and Resident #5 stayed overnight for two days with family. Review of the Psychologist's progress note, dated 10/27/17, reflected Resident #5 had worsening depression, anxiety, mood instability, and adjustment issues. Resident #5 was started on 5 mg of [MEDICATION NAME] (medication for depression) every night due to worsening affective signs and symptoms. 4. Interview with Administrator Y on 11/15/17 at 3:45 p.m. revealed after the incidents regarding Resident #4 and Resident #5, they completed Safe Surveys with all of the residents and asked questions regarding if they felt safe in the facility. She said no additional incidents were identified. 5. During surveyor interviews with residents, Residents #6 and #7 revealed CNA A had been inappropriate during their care. 6. Review of Resident #6's undated face sheet reflected she admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #6's care plan, dated 07/13/17 and completed by DON Z, revealed female caregivers were to assist resident with shower/personal hygiene. Review of Resident #6's MDS resident assessment, dated 08/24/17, reflected she was cognitively intact. Interview with Resident #6 on 11/15/17 at 11:20 a.m. revealed she was scared of the men here. She stated she did not know what was on their minds. She stated CNA A made her feel sexually uncomfortable because he rubbed her privates too long in the shower. She revealed all the other staff would allow her to wash her privates by herself. She stated it had happened several months ago and she had not told anyone. Interview with Administrator Y on 11/16/17 at 9:15 a.m. revealed she spoke with Resident #6 after the allegation was brought to her attention by surveyors. She stated she went ahead and started an investigation into the matter and notified the detectives about Resident #6's allegation. Review of the facility's Safe Surveys, conducted on 10/24/17, provided no evidence that Resident #6 disclosed the fact that CNA A had sexually assaulted her. 7. Review of Resident #7's undated face sheet reflected she was [AGE] years old and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #7's MDS resident assessment, dated 10/17/17, revealed she was cognitively intact. Interview with Resident #7 on 11/15/17 at 11:45 a.m. revealed when she first admitted to the facility, she was inappropriately touched by CNA A. She stated CNA A's hand would slip during brief changes all over her body. She stated it made her feel terrible and she felt that no one should ever have to feel like that. She stated she reported the incident to various staff members, but she felt like no one cared. Interview with CNA M on 11/15/17 at 1:32 p.m. revealed she was aware Resident #7 did not like CNA A and did not want CNA A to give her showers. She stated it was common knowledge that CNA A was not to give Resident #7 showers, but she was not sure why. Interview with CNA N on 11/15/17 at 4:01 p.m. revealed Resident #7 would refuse to allow CNA A to work with her. She stated an incident occurred probably around (MONTH) (YEAR) when she and CNA A were working together on Hall 100. She stated she was assisting Resident #7 with her shower and Resident #7 kept asking her to cover her up so CNA A would not see her. She stated she told the nurse that day. She added that everyone knew CNA A was not allowed to go into Resident #7's room. She revealed Resident #7 would become frightened and scared if she saw CNA A on her hall. Interview with Administrator Y on 11/16/17 at 9:15 a.m. revealed she spoke with Resident #7 after the allegation was brought to her attention by the surveyors. She stated she started an investigation into the matter and notified the local policy department's detectives about Resident #7's allegation. Review of the facility's Safe Surveys, conducted on 10/24/17, provided no evidence that Resident #7 disclosed the fact that CNA A had sexually assaulted her. 8. During an interview with Administrator Y on 11/15/17 at 9:50 a.m., she revealed she had been looking through information in her office and found additional allegations of sexual abuse in an office drawer. She said the files were labeled as Soft Files' by the prior administrator, Administrator X, and were not corporate documents. She stated she immediately notified corporate to figure out how to rectify the situation. She said the incidents were reported to the State Survey Agency. 9. Review of the facility's Provider Investigation Report, dated 11/13/17, confirmed the new administrator, Administrator Y, reported that on 11/06/17, she was reviewing facility records regarding events that pre-dated her tenure and there were several incidents which were not completely investigated by the former administrator, Administrator X. The incidents of alleged sexual abuse involved Residents #1, #2 and #3. 10. Review of Resident #1's closed clinical record revealed on the undated face sheet that she was [AGE] years old and admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Resident #1 was discharged from the facility on 02/04/17. Review of Resident #1's MDS resident assessment, dated 01/29/17, reflected she was cognitively intact Review of the Provider Investigation Report, dated 11/13/17, revealed on 02/01/17, Administrator X received a telephone call from Resident #1's family member and was informed that Resident #1 had been sexually assaulted. Administrator X interviewed Resident #1 who denied anyone touched her inappropriately, but that she was uncomfortable with CNA A because he had told her he loved her. Administrator X interviewed CNA A who denied saying he loved Resident #1. Administrator X did not interview or do any further investigation into the matter. When Administrator X was interviewed by corporate staff about the matter and why it was not self-reported, he stated his investigation indicated no abuse had in fact occurred. Review of Administrator X's investigation, dated 02/01/17, revealed on 02/01/17 and recorded in a plain Word document, Administrator X received a call from Resident #1's family member stating Resident #1 had been sexually assaulted. Administrator X went to check on the welfare of Resident #1, who denied any staff member had touched her in an inappropriate manner. Resident #1 stated CNA A made her feel uncomfortable when he stated he loved her and touched her shoulder. Administrator X interviewed CNA A about the incident. CNA A had stated he told Resident #1 about the Love of Jesus and perhaps she misunderstood. Resident #1's family was notified that it was not a sexual assault. Administrator X did not investigate the allegation any further. Interview with DON Z on 11/15/17 at 9:35 a.m. revealed she did not remember helping Administrator X or investigating any incident regarding Resident #1 in (MONTH) (YEAR). 11. Review of Resident #2's undated face sheet reflected she was [AGE] years old and admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #2's MDS resident assessment, dated 09/09/17, reflected she had severe cognitive impairment. Review of the Provider Investigation Report, dated 11/13/17, revealed Administrator X and DON Z investigated an incident reported by another resident that Resident #2 was kissed by an employee on 05/17/17. DON Z interviewed Resident #2 and she denied anyone had kissed her. Administrator X interviewed CNA A about the incident because he was the male CNA assigned to that hall. CNA A denied the allegation. Administrator X did not interview any further residents or staff. When Administrator X was interviewed by corporate staff about the matter and why it was not self-reported, and he stated his investigation indicated no abuse had occurred. Review of Administrator X's investigations during his tenure revealed there was no investigative paperwork regarding the incident with Resident #2. There was a statement from CNA A, dated 05/17/17, stating he had not done any unprofessional conduct with any residents. Interview with DON Z on 11/15/17 at 9:35 a.m. revealed in mid (MONTH) (YEAR), another resident alleged Resident #2 had been kissed by an employee. She had been directed by Administrator X to interview Resident #2. She stated Resident #2 denied being kissed by an employee and she documented her interview and gave it to Administrator X, who she assumed completed the investigation. An attempt was made to interview Resident #2 on 11/16/17 at 2:31 p.m.; however, she did not respond to questions. In a subsequent interview with DON Z on 11/15/17 at 1:00 p.m., she revealed after the incident with Resident #2, CNA A was reassigned to care for another group of residents. 12. Review of Resident #3's undated face sheet revealed Resident #3 was [AGE] years old and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #3's MDS assessment dated [DATE] reflected she was moderately cognitively impaired. Review of the Provider Investigation Report, dated 11/13/17, revealed Administrator X and DON Z investigated an incident which happened on 07/11/17. Administrator X was informed that Resident #3 told another employee she had been touched inappropriately by a male staff member. DON Z interviewed Resident #3 who denied anyone had touched her. Resident #3 had dementia. Administrator X interviewed the male CNA assigned to that hall, which was CNA A. CNA A denied any inappropriate behavior. Administrator X was interviewed by corporate staff about his investigation and why it was not self-reported, and he stated his investigation indicated no abuse had occurred. Interview with DON Z on 11/15/17 at 9:35 a.m. revealed in (MONTH) (YEAR), Resident #3 had told a staff member she had been touched inappropriately. She stated Administrator X directed her to interview Resident #3, who denied being touched, but she did have dementia. She stated Administrator X moved CNA A to care for a different set of residents after the incident. 13. During a subsequent interview with DON Z on 11/15/17 at 1:00 p.m., she revealed it was strange how CNA A's name kept coming up in each investigation, but she assumed Administrator X had thoroughly investigated the incidents and would take care of it. She stated CNA A was not suspended with any of the incidents regarding Residents #1, #2, and #3, but reassigned to care for residents either on a different hall or another group of residents. She stated she did not think Administrator X reported the incidents to the state survey agency, but did not know why he did not report each incident. 14. An attempt to interview Administrator X was made on 11/16/17 at 10:08 a.m. via telephone, but without success. 15. Interview with CNA A on 11/15/17 at 10:05 a.m. revealed he said he was currently out of the country. He confirmed he was being investigated by the nursing home and the police regarding touching residents inappropriately, but denied he touched any residents including Residents #4 and #5. He stated prior to leaving the country, he was arrested regarding the incidents with Residents #4 and #5, but was able to bond out and fly back home (out of the country). 16. Interview with the Vice President of Operations on 11/15/17 at 10:27 a.m. revealed corporate consultants were involved as needed with allegations and investigations of abuse and neglect. He revealed if the Administrator determined something was reportable, they were expected to let the corporate office know. He stated if DON Z was involved in an investigation and felt it was not reported, she should report the incident. 17. Interview with the Regional Nurse Consultant (RNC) on 11/15/17 at 2:45 p.m. revealed she was only contacted by DON Z or Administrator when they have a question about if an allegation is reportable or not. She revealed the corporate was only to be used as a resource and they did o not have to tell her or the RDO (Regional Director of Operations) about every allegation of abuse or neglect. She stated she was recently in-serviced over on reporting incidents. 18. Interview with CNA O on 11/15/17 at 4:15 p.m. revealed on 07/10/17 or 07/11/17, she was working with CNA A on Hall 100. She stated she remembers a couple of residents started screaming that they did not want him in their room. She stated CNA A had come up to her and asked her to finish assisting a resident with incontinent care because she was refusing to allow him to do it. She stated she went into the resident's room and the resident was screaming and crying. She stated she tried to comfort the resident and finished incontinent care. She stated she did not tell anyone. She stated she did not remember the resident's name because the incident occurred around her 4th day working at the facility. 19. Interview with the Regional Director of Operations (RDO) on 11/16/17 at 9:55 a.m. revealed his role as an RDO was to be a resource to facility Administrators. He stated Administrators wer welcome to call him and run questions by him and he would help determine if something was reportable, but he did not have to be contacted with every allegation of abuse or neglect. He stated he did not go behind the Administrators to ensure they did their job, because that was ultimately the Administrator's building and their decision on whether to report. He stated he was only a resource for Administrators. 20. Review of the facility's policies included the following: A. Resident Abuse, Neglect, and Exploitation and Misappropriation of Resident Property Policy, revised 06/23/17, reflected included - Definitions - --Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain or mental anguish. --Sexual abuse: Includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. --Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. (3) Duty to Report Violations Internally and to Applicable Agencies. (3.3) Upon receiving an allegation abuse, neglect, exploitation or misappropriation, the Abuse Coordinator will a) notify the Regional Director of Operations and Regional Nurse Consultant, b) initiate an investigation into the allegation, c) in conjunction with the Regional Director of Operations and Regional Nurse Consultant determine whether the allegation is reportable under federal and state regulations, and d) if the allegation is reportable, report such allegation to the State Regulatory Agency B. Internal Investigation Guidelines, revised 09/01/17, reflected the following: Process - (1) Collection only information that is relevant to the facts and circumstances of the incident being investigated. (2) Identify 'Who' was involved (3) Determine 'What' occurred (4) Determine 'When' the incident occurred (5) Determine 'Where' the incident occurred (6) . complete a physical and emotional assessment of the resident, identifying areas of injury. (9) Complete a comprehensive record review . (10) Interview all potential witnesses who may have relevant information. Interview Resident regardless of cognitive status. Interview Resident's roommate regardless of cognitive status. Interview staff members. Conduct Safe Surveys of other residents. Investigation Check List for Allegation of Abuse/Neglect/Exploitation/Misappropriation of Resident Property (1) The alleged perpetrator, if known, is suspended pending investigation. (3) Incident Report is completed. (5) Resident(s) are safe. (6) Notify the RDO at time of occurrence. (7) Notify the RNC at the time of occurrence. (8) Notify the State as directed by State specific guidelines . (11) Conduct Safe Surveys 21. On 11/16/17 at 2:20 p.m., Administrator Y and DON Z, were notfied of an Immediate Jeopardy (IJ) had been identified. The facility provided an action Plan, dated 11/11/17, reflecting a plan they had initiated prior to the survey to address the above identified incidents: --All department heads educated on Grievance procedure and notification to administrator --Angel rounds to be done daily and communicated in morning meeting of any concerns --Concerns forms will be available in the lobby to ensure all residents, staff, family, and vendors can voice a concern --Weekend manager on duty will report all concerns on Monday in morning meeting --Grievance procedure to be reviewed in next resident council meeting. --Incident and accidents will be initiated according to company policy --Will be reviewed in morning clinical meeting --All incident and accidents will be reviewed by DON to ensure appropriate completion, documentation, intervention, and notification are done within 5 days of the incident. --Charge nurse will notify Administrator of all reportable incidents --Priority rounds will be made on all residents with incident and accident report initiated --Care Plans will be updated with interventions and approached for prevention and reoccurrence. 22. Review of the Safe Surveys conducted on 10/24/17, revealed all interviewable residents had been interviewed. The residents had said they felt safe in the facility. Note: Resident #6 had not disclosed the fact that CNA A had sexually assaulted her. 23. Review of the in-services reflected the following: 10/24/17: All nursing staff were in-serviced over resident rights, prevention of abuse and neglect, and signs of burnout. 11/03/17: Department heads were in-serviced over the grievance process, angel rounds, and how to interview residents and families. 11/06/17: From 4:30 p.m. to 5:00 p.m. revealed DON Z, Administrator Y, ADON D, ADON E were in-serviced over reporting and investigating after and how to complete an investigation. 11/08/17: All department heads were in-serviced over environmental rounds, abuse reporting, angel rounds, and resident rights. 11/11/17: All staff were educated on reporting bruises of unknown origin to the Administrator, reporting falls with injury, and that if the Administrator is unavailable DON Z would be the next person to contact. 11/15/17: All staff were educated on abuse prevention and were given the number for the corporate hotline and the state agency number to report any suspected abuse or neglect. 24. Individual interviews with four CNAs (CNA F, CNA G, CNA H and CNA I) and two RAs (RA J and RA K) revealed they had received in-service training on abuse/neglect, the signs and symptoms of abuse/neglect. They each said they would immediately report incidents to the Administrator. The interviews were conducted on the following dates/times: --CNA F was interviewed on 11/15/17 at 4:15 p.m. --CNA G, CNA H, CNA I, RA J AND RA K were interviewed on 11/16/17 at 9.38 a.m., 10:18 a.m., 10:25 a.m., 10:32 a.m., and 10:32 a.m., respectively. 25. Interview with DON Z on 11/16/17 at 11:06 a.m. revealed she received training by the Corporate Nurse on how to complete an investigation and when to report incidents to the state survey agency. She added that she would do what the Administrator told her to do. 26. Interview with the Administrator Y on 11/15/17 at 3:30 p.m., revealed she received training on how to complete an investigation and how to determine if an incident was reportable and how to report it to the state survey agency. 27. On 12/01/17 at 8:55 a.m., Administrator Y and Regional Nurse Consultant were notified their Action Plan did not provide sufficient evidence the Immediate Jeopardy had been removed. At that time, a Plan of Removal was requested. 28. On 12/01/17 at 1:50 p.m., the facility's Plan of Removal (PoR) was accepted. The PoR reflected the following: --Regional Director of Operations (RDO) and /or Regional Nurse Consultant (RNC) will, at least every two weeks for 3 months review and ensure system integrity of the following: Grievances (concern forms), Self-Reporting protocol, Investigation protocol, Angel Rounds, Compliance Hotline, Pinnacle service reports. --New Administrator Y effective 10/9/17. In-service Administrator Y on 11/10/17 on Internal investigation guidelines on allegations of abuse, neglect and exploitation to ensure compliance with federal and state regulation regarding protecting facility patients and resident from abuse, neglect, exploitation and misappropriation of resident property, timely investigation of reporting to state and local agencies all allegations of abuse, neglect, exploitation and misappropriation of resident property. --New DON AA effective 11/20/17 in-serviced on 11/20/17 on Internal investigation guidelines on allegations of abuse, neglect and exploitation to ensure compliance with federal and state regulation regarding protecting facility patients and resident from abuse, neglect, exploitation and misappropriation of resident property, timely investigation of reporting to state and local agencies all allegations of abuse, neglect, exploitation and misappropriation of resident property. --Administrator Y and DON AA in-serviced on notifying RDO and RNC of any significant event per policy to include list of all reportable events --Survey current and discharged residents and send out a report to Compliance officer, Administrator and Regional support team. Negative concerns are sent out immediately to Executive Management team, Administrator Y and DON AA. --Corporate Management Team track and trended all SRI from the facilities. Weekly SRIs are reported to management company. Monthly, the regional Clinical Nurse provides oversight of the reporting system to include review of the log for increasing trends or those who have made 0 self-reports in a 30 day period. --Weekly report to corporate management to going over facility events and self-reports --Administrator Y and DON AA to review all Incident and accidents, Concerns and Self-reports in Morning meeting (daily as of Hi (TRUNCATED)

Based on observation, interview and record review, the facility failed to ensure the resident was free from neglect for seven (Resident #1, #2, #3, #4, #5, #6, and #7) of 13 residents reviewed for neglect. 1. The facility failed to protect Resident #1, #2, #3, #4, #5, #6, and #7 when multiple allegations of sexual abuse were not thoroughly investigated and reported. 2. The former Administrator X did not thoroughly investigate and report when Resident #1's family stated Resident #1 had been sexually abused by CNA A. 3. The former Administrator X and DON did not thoroughly investigate and report when another resident reported Resident #2 had been kissed by a male employee. 4. The former Administrator X and DON did not thoroughly investigate and report when Resident #3 had made a sexual abuse allegation against CNA A. 5. The facility failed to ensure Resident #4 was free from abuse when she was sexually assaulted by CNA A, who had a history of [REDACTED]. Resident #4 had to be transported to the hospital for a forensic analysis and upon examination, vaginal tearing was noted. 6. The facility failed to ensure Resident #5 was free from abuse when she was sexually abused by CNA A. Resident #5 was so emotionally distraught, she had to go home with her family for two days and was being seen by a psychologist for emotional distress. 7. The facility failed to ensure Resident #6 was free was from abuse when she was sexually abused by CNA A. Resident #6 was scared. 8. The facility failed to ensure Resident #7 was free of abuse when she was sexually abused by CNA A. Resident #7 would become frightened and scared if she saw CNA A was working on her hall. An Immediate Jeopardy was identified on 11/16/17 as beginning on 02/01/17. The Immediate Jeopardy was removed on 12/01/17. The facility remained out of compliance at severity level of actual harm and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. These failures placed all 88 residents at risk of serious physical harm or injury, and/or serious psychological harm. Findings Included: 1 During an interview with Administrator Y on 11/15/17 at 9:50 a.m. , she revealed she had been looking through information in her office and found additional allegations of sexual abuse in an office drawer. She said the files were labeled as Soft Files' by the prior administrator, Administrator X, and were not corporate documents. She stated she immediately notified corporate to figure out how to rectify the situation. She said the incidents were reported to the State Survey Agency. 2. Review of the facility's Provider Investigation Report, dated 11/13/17, confirmed the new administrator, Administrator Y, reported that on 11/06/17, she was reviewing facility records regarding events that pre-dated her tenure and there were several incidents which were not completely investigated by the former administrator, Administrator X. The incidents of alleged sexual abuse involved Residents #1, #2 and #3. 3. Review of Resident #1's closed clinical record revealed on the undated face sheet that she was [AGE] years old and admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Resident #1 was discharged from the facility on 02/04/17. Review of Resident #1's MDS resident assessment, dated 01/29/17, reflected she was cognitively intact. Review of the Provider Investigation Report, dated 11/13/17, revealed on 02/01/17, Administrator X received a telephone call from Resident #1's family member and was informed that Resident #1 had been sexually assaulted. Administrator X interviewed Resident #1 who denied anyone touched her inappropriately, but that she was uncomfortable with CNA A because he had told her he loved her. Administrator X interviewed CNA A who denied saying he loved Resident #1. Administrator X did not interview or do any further investigation into the matter. When Administrator X was interviewed by corporate staff about the matter and why it was not self-reported, he stated his investigation indicated no abuse had in fact occurred. Review of Administrator X's investigation, dated 02/01/17, revealed on 02/01/17 and recorded in a plain Word document, Administrator X received a call from Resident #1's family member stating Resident #1 had been sexually assaulted. Administrator X went to check on the welfare of Resident #1, who denied any staff member had touched her in an inappropriate manner. Resident #1 stated CNA A made her feel uncomfortable when he stated he loved her and touched her shoulder. Administrator X interviewed CNA A about the incident. CNA A had stated he told Resident #1 about the Love of Jesus and perhaps she misunderstood. Resident #1's family was notified that it was not a sexual assault. Administrator X did not investigate the allegation any further. Interview with DON Z on 11/15/17 at 9:35 a.m. revealed she did not remember helping Administrator X or investigating any incident regarding Resident #1 in (MONTH) (YEAR). 4. Review of Resident #2's undated face sheet reflected she was [AGE] years old and admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #2's MDS resident assessment, dated 09/09/17, reflected she had severe cognitive impairment. Review of the Provider Investigation Report, dated 11/13/17, revealed Administrator X and DON Z investigated an incident reported by another resident that Resident #2 was kissed by an employee on 05/17/17. DON Z interviewed Resident #2 and she denied anyone had kissed her. Administrator X interviewed CNA A about the incident because he was the male CNA assigned to that hall. CNA A denied the allegation. Administrator X did not interview any further residents or staff. When Administrator X was interviewed by corporate staff about the matter and why it was not self-reported, and he stated his investigation indicated no abuse had occurred. Review of Administrator X's investigations during his tenure revealed there was no investigative paperwork regarding the incident with Resident #2. There was a statement from CNA A, dated 05/17/17, stating he had not done any unprofessional conduct with any residents. Interview with DON Z on 11/15/17 at 9:35 a.m. revealed in mid (MONTH) (YEAR), another resident alleged Resident #2 had been kissed by an employee. She had been directed by Administrator X to interview Resident #2. She stated Resident #2 denied being kissed by an employee and she documented her interview and gave it to Administrator X, who she assumed completed the investigation. An attempt was made to interview Resident #2 on 11/16/17 at 2:31 p.m.; however, she did not respond to questions. In a subsequent interview with DON Z on 11/15/17 at 1:00 p.m., she revealed after the incident with Resident #2, CNA A was reassigned to care for another group of residents. 5. Review of Resident #3's undated face sheet revealed Resident #3 was [AGE] years old and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #3's MDS assessment dated [DATE] reflected she was moderately cognitively impaired. Review of the Provider Investigation Report, dated 11/13/17, revealed Administrator X and DON Z investigated an incident which happened on 07/11/17. Administrator X was informed that Resident #3 told another employee she had been touched inappropriately by a male staff member. DON Z interviewed Resident #3 who denied anyone had touched her. Resident #3 had dementia. Administrator X interviewed the male CNA assigned to that hall, which was CNA A. CNA A denied any inappropriate behavior. Administrator X was interviewed by corporate staff about his investigation and why it was not self-reported, and he stated his investigation indicated no abuse had occurred. Interview with DON Z on 11/15/17 at 9:35 a.m. revealed in (MONTH) (YEAR), Resident #3 had told a staff member she had been touched inappropriately. She stated Administrator X directed her to interview Resident #3, who denied being touched, but she did have dementia. She stated Administrator X moved CNA A to care for a different set of residents after the incident. She stated she did not think Administrator X reported the incident to the state agency, but did not know why he did not report it. 6. During a subsequent interview with DON Z on 11/15/17 at 1:00 p.m., she revealed it was strange how CNA A's name kept coming up in each investigation, but she assumed Administrator X had thoroughly investigated the incidents and would take care of it. She stated CNA A was not suspended with any of the incidents regarding Residents #1, #2, and #3, but reassigned to care for residents either on a different hall or another group of residents. 7. An attempt to interview Administrator X was made on 11/16/17 at 10:08 a.m. via telephone and a voice message was left and the phone call was not returned during the course of the investigation. 8. Interview with the Vice President of Operations on 11/15/17 at 10:27 a.m. revealed corporate consultants were involved as needed. He revealed if the Administrator determined something was reportable, they were expected to let the corporate office know. He stated if DON Z was involved in an investigation and felt it was not reported, she should report the incident. 9. Interview with the RNC on 11/15/17 at 2:45 p.m. revealed she was only contacted by DON Z or Administrator when they had a question about if an allegation was reportable or not. She revealed corporate was only to be used as a resource and they did not have to tell her or the RDO about every allegation of abuse or neglect. She stated she was recently in-serviced over on reporting incidents. 10. Interview with the RDO on 11/16/17 at 9:55 a.m. revealed his role as an RDO was to be a resource to facility Administrators. He stated Administrators were welcome to call him and run questions by him and he would help determine if something was reportable, but he did not have to be contacted with every allegation of abuse or neglect. He stated he did not go behind the Administrators to ensure they did their job, because that was ultimately the Administrator's building and their decision on whether to report. He stated he was only a resource for Administrators. 11. Review of Resident #4's undated face sheet reflected Resident #4 was [AGE] years old and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #4's MDS assessment dated [DATE] reflected she had severe cognitive impairment. Resident #4 requires assistance of one person with activities of daily living (ADLs). Review of the facility's Provider Investigation Report dated 10/30/17 revealed on the morning of 10/24/17, CNA B entered Resident #4's room and found a used condom under Resident #4's buttocks. Resident #4 was transferred to the hospital for evaluation and CNA A was suspended since he was the male employee assigned to Resident #4. Interview with Administrator Y on 11/15/17 at 9:50 a.m. revealed a rape kit was completed at a local hospital on Resident #4, but the detective stated the rape kit would take months to complete since they were so backed up. She also revealed CNA A had been arrested at the airport a few days ago trying to leave the country, but there was a miscommunication at the airport, and he was able to bond out and leave the country. Interview with LVN C on 11/15/17 at 11:39 a.m. revealed she was Resident #4's nurse on the morning of 10/24/17. She stated she was called to Resident #4's room by CNA B. She stated CNA B rolled Resident #4 and underneath Resident #4's buttocks, between the brief and the bed, was a used condom. She stated CNA B grabbed the condom with a glove and put it in a bag for the police. LVN C stated she notified administrative staff and went with Resident #4 to the hospital. She stated she was present during the rape kit exam and the hospital nurse said there was evidence of vaginal tearing. LVN C stated while they were at the hospital, Resident #4 told her a large black man had laid on top of her. Interview with Resident #4 on 11/15/17 at 11:31 a.m. revealed she had no recall of the incident. 12. Review of CNA A's employee file reflected he was hired on 08/06/15. At the time of employment, a criminal history check revealed he had no convictions that barred employment. Registry checks for the Employee Misconduct Registry (EMR) and Nurse Aide Registry (NAR) were conducted prior to employment and annually and revealed he was employable. There was no evidence of prior counseling related to abuse or mistreatment of [REDACTED]. revealed he matched Resident #4's description of the alleged perpetrator. A termination notice, dated 10/26/17, reflected he was terminated and not eligible for rehire due to allegations of abuse. 13. Review of Resident #5's undated face sheet reflected Resident #5 was a [AGE] year old female who admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #5's MDS resident assessment, dated 10/23/17, reflected she had severe cognitive impairment. Resident #5 did not require assistance with ADLs and was continent of bowel and bladder. Review of the Provider Investigation Report, dated 10/30/17, revealed on the evening of 10/24/17, Resident #5 stated a large black man came into her room the night before and told her he needed to change her brief. Resident #5 told the man she did not wear a brief and in response, he patted her down, kissed her and left the room. CNA A matched the description that Resident #5 reported and he was suspended pending investigation. Review of the Psychologist's Diagnostic Interview, dated 10/24/17, reflected Resident #5 described an incident with a male aide during the night that caused her to feel threatened and unsafe. Resident #5 was tearful and anxious and repeated her description a number of times and appeared to feel worried that she was to blame, emphasizing repeatedly, I am not that type of woman. Recommendations included Psychology services to follow to address patient's anxiety and distress following an interaction with a male aide that she characterized as inappropriate and intrusive and which left her feeling fearful and humiliated. Review of the Change of Condition Report, dated 10/26/17, reflected Resident #5 was very anxious due to a recent incident (10/24/17's incident as listed above) and Resident #5 stayed overnight for two days with family. Review of the Psychologist's progress note, dated 10/27/17, reflected Resident #5 had worsening depression, anxiety, mood instability, and adjustment issues. Resident #5 was started on 5 mg of [MEDICATION NAME] (medication for depression) every night due to worsening affective signs and symptoms. 14. Interview with Administrator Y on 11/15/17 at 3:45 p.m. revealed after the incidents regarding Resident #4 and Resident #5, they completed Safe Surveys with all of the residents and asked questions regarding if they felt safe in the facility. She said no additional incidents were identified. 15. During surveyor interviews with residents, Residents #6 and #7 revealed CNA A had been inappropriate during their care. 16 Review of Resident #6's undated face sheet reflected she admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #6's care plan, dated 07/13/17 and completed by DON Z, revealed female caregivers were to assist resident with shower/personal hygiene. Review of Resident #6's MDS resident assessment, dated 08/24/17, reflected she was cognitively intact. Interview with Resident #6 on 11/15/17 at 11:20 a.m. revealed she was scared of the men here. She stated she did not know what was on their minds. She stated CNA A made her feel sexually uncomfortable because he rubbed her privates too long in the shower. She revealed all the other staff would allow her to wash her privates by herself. She stated it had happened several months ago and she had not told anyone. Interview with Administrator Y on 11/16/17 at 9:15 a.m. revealed she spoke with Resident #6 after the allegation was brought to her attention by surveyors. She stated she went ahead and started an investigation into the matter and notified the detectives about Resident #6's allegation. Review of the facility's Safe Surveys, conducted on 10/24/17, provided no evidence that Resident #6 disclosed the fact that CNA A had sexually assaulted her. 17. Review of Resident #7's undated face sheet reflected she was [AGE] years old and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #7's MDS resident assessment, dated 10/17/17, revealed she was cognitively intact. Interview with Resident #7 on 11/15/17 at 11:45 a.m. revealed when she first admitted to the facility, she was inappropriately touched by CNA A. She stated CNA A's hand would slip during brief changes all over her body. She stated it made her feel terrible and she felt that no one should ever have to feel like that. She stated she reported the incident to various staff members, but she felt like no one cared. Interview with CNA M on 11/15/17 at 1:32 p.m. revealed she was aware Resident #7 did not like CNA A and did not want CNA A to give her showers. She stated it was common knowledge that CNA A was not to give Resident #7 showers, but she was not sure why. Interview with CNA N on 11/15/17 at 4:01 p.m. revealed Resident #7 would refuse to allow CNA A to work with her. She stated an incidnet occurred probably around (MONTH) (YEAR) when she and CNA A were working together on Hall 100. She stated she was assisting Resident #7 with her shower and Resident #7 kept asking her to cover her up so CNA A would not see her. She stated she told the nurse that day. She added that everyone knew CNA A was not allowed to go into Resident #7's room. She revealed Resident #7 would become frightened and scared if she saw CNA A on her hall. Interview with Administrator Y on 11/16/17 at 9:15 a.m. revealed she spoke with Resident #7 after the allegation was brought to her attention by the surveyors. She stated she started an investigation into the matter and notified the local policy department's detectives about Resident #7's allegation. Review of the facility's Safe Surveys, conducted on 10/24/17, provided no evidence that Resident #7 disclosed the fact that CNA A had sexually assaulted her. 18. Interview with CNA O on 11/15/17 at 4:15 p.m. revealed on (MONTH) 10th or 11th, she was working with CNA A on Hall 100. She stated she remembers a couple of residents started screaming that they did not want him in their room. She stated CNA A had come up to her and asked her to finish assisting a resident with incontinent care because she was refusing to allow him to do it. She stated she went into the resident's room and the resident was screaming and crying. She stated she tried to comfort the resident and finished incontinent care. She stated she did not tell anyone. She stated she did not remember the resident's name because the incident occurred around her 4th day working at the facility. 19. Interview with CNA A on 11/15/17 at 10:05 a.m. revealed he said he was currently out of the country. He confirmed was being investigated by the nursing home and the police regarding touching residents inappropriately, but denied he touched any residents including Residents #4 and #5. He stated prior to leaving the country, he was arrested regarding the incidents with Residents #4 and #5, but was able to bond out and fly back home (out of the country). 20. Review of the Resident Abuse, Neglect, and Exploitation and Misappropriation of Resident Property Policy, revised 06/23/17, reflected the following: Definitions - --Abuse: The willfull infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain or mental anguish. --Sexual abuse: Includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. --Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. (3) Duty to Report Violations Internally and to Applicable Agencies. (3.3) Upon receiving an allegation abuse, neglect, exploitation or misappropriation, the Abuse Coordinator will a) notify the Regional Director of Operations and Regional Nurse Consultant, b) initiate an investigation into the allegation, c) in conjunction with the Regional Director of Operations and Regional Nurse Consultant determine whether the allegation is reportable under federal and state regulations, and d) if the allegation is reportable, report such allegation to the State Regulatory Agency 21. On 11/16/17 at 2:20 p.m., Administrator Y and DON Z, were notfied of an Immediate Jeopardy (IJ) had been identified. The facility provided an action Plan, dated 11/11/17, reflecting a plan they had initiated prior to the survey to address the above identified incidents: --All department heads educated on Grievance procedure and notification to administrator --Angel rounds to be done daily and communicated in morning meeting of any concerns --Concerns forms will be available in the lobby to ensure all residents, staff, family, and vendors can voice a concern --Weekend manager on duty will report all concerns on Monday in morning meeting --Grievance procedure to be reviewed in next resident council meeting. --Incident and accidents will be initiated according to company policy --Will be reviewed in morning clinical meeting --All incident and accidents will be reviewed by DON to ensure appropriate completion, documentation, intervention, and notification are done within 5 days of the incident. --Charge nurse will notify Administrator of all reportable incidents --Priority rounds will be made on all residents with incident and accident report initiated --Care Plans will be updated with interventions and approached for prevention and reoccurrence. 22. Review of the Safe Surveys conducted on 10/24/17, revealed all interviewable residents had been interviewed. The residents had said they felt safe in the facility. Note: Resident #6 had not disclosed the fact that CNA A had sexually assaulted her. Refer to Element #5 for additional details. 23. Review of the in-services reflected the following: 10/24/17: All nursing staff were in-serviced over resident rights, prevention of abuse and neglect, and signs of burnout. 11/03/17: Department heads were in-serviced over the grievance process, angel rounds, and how to interview residents and families. 11/06/17: From 4:30 p.m. to 5:00 p.m. revealed DON Z, Administrator Y, ADON D, ADON E were in-serviced over reporting and investigating after and how to complete an investigation. 11/08/17: All department heads were in-serviced over environmental rounds, abuse reporting, angel rounds, and resident rights. 11/11/17: All staff were educated on reporting bruises of unknown origin to the Administrator, reporting falls with injury, and that if the Administrator is unavailable DON Z would be the next person to contact. 11/15/17: All staff were educated on abuse prevention and were given the number for the corporate hotline and the state agency number to report any suspected abuse or neglect. 24. Individual interviews with four CNAs (CNA F, CNA G, CNA H and CNA I) and two RAs (RA J and RA K) revealed they had received in-service training on abuse/neglect, the signs and symptoms of abuse/neglect. They each said they would immediately report incidents to the Administrator. The interviews were conducted on the following dates/times: --CNA F was interviewed on 11/15/17 at 4:15 p.m. --CNA G, CNA H, CNA I, RA J AND RA K were interviewed on 11/16/17 at 9.38 a.m., 10:18 a.m., 10:25 a.m., 10:32 a.m., and 10:32 a.m., respectively. 25. Interview with DON Z on 11/16/17 at 11:06 a.m. revealed she received training by the Corporate Nurse on how to complete an investigation and when to report incidents to the state survey agency. She added that she would do what the Administrator told her to do. 26. Interview with the Administrator Y on 11/15/17 at 3:30 p.m., revealed she received training on how to complete an investigation and how to determine if an incident was reportable and how to report it to the state survey agency. 27. On 12/01/17 at 8:55 a.m., Administrator Y and Regional Nurse Consultant were notifed their Action Plan did not provide sufficient evidence the Immediate Jeopardy had been removed. At that time, a Plan of Removal was requested. 28. On 12/01/17 at 1:50 p.m., the facility's Plan of Removal (PoR) was accepted. The PoR reflected the following: --Regional Director of Operations and /or Regional Nurse Consultant will, at least every two weeks for 3 months review and ensure system integrity of the following: Grievances (concern forms), Self-Reporting protocol, Investigation protocol, Angel Rounds, Compliance Hotline, Pinnacle service reports. --New Administrator Y effective 10/9/17. In-service Administrator Y on 11/10/17 on Internal investigation guidelines on allegations of abuse, neglect and exploitation to ensure compliance with federal and state regulation regarding protecting facility patients and resident from abuse, neglect, exploitation and misappropriation of resident property, timely investigation of reporting to state and local agencies all allegations of abuse, neglect, exploitation and misappropriation of resident property. --New DON AA effective 11/20/17 in-serviced on 11/20/17 on Internal investigation guidelines on allegations of abuse, neglect and exploitation to ensure compliance with federal and state regulation regarding protecting facility patients and resident from abuse, neglect, exploitation and misappropriation of resident property, timely investigation of reporting to state and local agencies all allegations of abuse, neglect, exploitation and misappropriation of resident property. --Administrator Y and DON AA in-serviced on notifying RDO and RNC of any significant event per policy to include list of all reportable events --Survey current and discharged residents and send out a report to Compliance officer, Administrator and Regional support team. Negative concerns are sent out immediately to Executive Management team, Administrator Y and DON AA. --Corporate Management Team track and trended all SRI from the facilities. Weekly SRIs are reported to management company. Monthly, the regional Clinical Nurse provides oversight of the reporting system to include review of the log for increasing trends or those who have made 0 self-reports in a 30 day period. --Weekly report to corporate management to going over facility events and self-reports --Administrator Y and DON AA to review all Incident and accidents, Concerns and Self-reports in Morning meeting (daily as of Hire dates) --Staff in-serviced on who to report allegations of abuse and neglect, exploitation and misappropriation of resident property too. Included if the Administrator is unavailable DON Z will be notified next. (10/23-10/24; 11/11) --Staff in-serviced to notify the regional team any allegation of abuse, neglect exploitation and misappropriations of resident property. Regional team numbers posted throughout the facility. (12/1) --Sensitivity Training -- Old lady poem and sensitivity video (11/10) --In-serviced staff on suspicion of a crime, compliance hotline and number to call Texas Health and Human Services for abuse, neglect, exploitation and misappropriation of resident property. (11/15) --In-service staff 12/1/17 on recognizing signs and symptoms of abuse, neglect, exploitation and misappropriation of resident property and to ensure proper follow up. --All abuse/neglect and misappropriation in-services were added to the on-line education management system assignments for ALL staff monthly in addition to the required annual and upon hire which we did previously. This will continue for 12 months or longer based upon guidance from the QAPI committee. (November (YEAR)-November (YEAR)) --Review in QAPI meeting monthly for the next 3 months. --As part of new Requirements direct care staff are involved in Care Plan meetings and QAPI meetings as well --Weekly since 10/23/17 in-servicing staff on abuse and neglect topics --DON AA in serviced staff on abuse and Neglect new guidelines 29. The following observations, interviews and record reviews were conducted to verify the implementation of the facility's Plan of Removal: --Review of DON Z's employee file revealed her last day of employment with the facility was 11/25/17. --Review of the in-services, dated 12/01/17, revealed the staff were in-serviced over abuse/neglect, reporting, and whom to notify if the Administrator is unavailable or if they feel like the allegation is not being investigated. The staff were also in-serviced on where the phone numbers for the corporate office, compliance hotline, and DADs hotline were located. Staff were also educated on if any signs of possible abuse are present, they must take the time to ask the 5 W's (who, what, when, where, and why). --Interviews with MA P, LVN Q, CNA R, CNA S, LVN T, and LVN U on 12/01/17 between 2:00 p.m. and 2:25 p.m. confirmed they had each been in-serviced on 12/01/17 regarding abuse and neglect and reporting. They all revealed they are to contact the Administrator with any allegation of abuse or neglect, but if unable to get ahold of the Administrator they can contact DON Z, RNC, or RDO. They also revealed if they felt like their allegation was not being properly investigated, they can call the corporate compliance hotline or the DADS hotline to self-report. They were all able to properly identify if it was abuse when given a scenario by the surveyor. --Interview with Administrator Y on 12/01/17 at 3:02 p.m. revealed she had been in-serviced over on how to conduct an investigation, abuse/neglect signs and symptoms, and how to deal with residents with difficult behaviors. She stated she was in-serviced on 12/01/17 regarding to notify corporate with every allegation of abuse/neglect and to determine whether it is reportable. She revealed she will also go over it with all management staff at the daily morning meeting. She stated the corporate office will be reviewing the systems in place every two weeks to ensure they are working correctly and also they will be looking at the tracking and trending of reportable events to ensure that a situation like this never happens again. --Interview with DON AA on 12/01/17 at 2:30PM revealed when she started on 11/27/17, she was given education on how to properly investigate an incident and how to report incidents to the state. She stated she was also the alternate abuse preventionist if the Admin was unavailable and her phone was always on. She stated she would ensure the resident was always safe and if she ever had a CNA that kept coming up in investigations, she would make sure she would find out why and always make sure the alleged perp was suspended pending investigation. She s (TRUNCATED)

Based on interview and record review, former Administrator X and DON Z failed to administer the facility in a manner that enabled 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 three (Residents #1, #2, and #3) of 13 residents reviewed for abuse and neglect. Former Administrator X and DON Z failed to implement the facility's Resident Abuse, Neglect, and Exploitation and Misappropriation of Resident Property Policy and the Internal Investigation Guidelines when Residents #1, #2, and #3 made allegations of abuse involving CNA A. As result of this failure CNA A continued to work at the facility and Residents #4, #5, #6, and #7 were sexually abused by CNA A and suffered severe psychosocial harm including fear, humiliation, anxiety, and depression and/or physical harm. An Immediate Jeopardy was identified on 11/16/17 as beginning on 02/01/17. The Immediate Jeopardy was removed on 12/01/17. The facility remained out of compliance at severity level of actual harm and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. These failures placed all 88 residents at risk of serious physical harm or injury, and/or serious psychological harm Findings included: 1. An interview with Administrator Y on 11/15/17 at 9:50 a.m., revealed she had been looking through information in her office and found allegations of sexual abuse in an office drawer. She said the files were labeled as Soft Files' by the prior administrator, Administrator X, and were not corporate documents. She stated she immediately notified corporate to figure out how to rectify the situation. She said the incidents were reported to the State Survey Agency. 2. Review of the facility's Provider Investigation Report, dated 11/13/17, confirmed the new administrator, Administrator Y, reported that on 11/06/17, she was reviewing facility records regarding events that pre-dated her tenure and there were several incidents which were not completely investigated by the former administrator, Administrator X. The incidents of alleged sexual abuse involved Residents #1, #2 and #3. 3. Review of Resident #1's closed clinical record revealed on the undated face sheet that she was [AGE] years old and admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Resident #1 was discharged from the facility on 02/04/17. Review of Resident #1's MDS resident assessment, dated 01/29/17, reflected she was cognitively intact Review of the Provider Investigation Report, dated 11/13/17, revealed on 02/01/17, Administrator X received a telephone call from Resident #1's family member and was informed that Resident #1 had been sexually assaulted. Administrator X interviewed Resident #1 who denied anyone touched her inappropriately, but that she was uncomfortable with CNA A because he had told her he loved her. Administrator X interviewed CNA A who denied saying he loved Resident #1. Administrator X did not interview or do any further investigation into the matter. When Administrator X was interviewed by corporate staff about the matter and why it was not self-reported, he stated his investigation indicated no abuse had in fact occurred. Review of Administrator X's investigation, dated 02/01/17, revealed on 02/01/17 and recorded in a plain Word document, Administrator X received a call from Resident #1's family member stating Resident #1 had been sexually assaulted. Administrator X went to check on the welfare of Resident #1, who denied any staff member had touched her in an inappropriate manner. Resident #1 stated CNA A made her feel uncomfortable when he stated he loved her and touched her shoulder. Administrator X interviewed CNA A about the incident. CNA A had stated he told Resident #1 about the Love of Jesus and perhaps she misunderstood. Resident #1's family was notified that it was not a sexual assault. Administrator X did not investigate the allegation any further. Interview with DON Z on 11/15/17 at 9:35 a.m. revealed she did not remember helping Administrator X or investigating any incident regarding Resident #1 in (MONTH) (YEAR). 4. Review of Resident #2's undated face sheet reflected she was [AGE] years old and admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #2's MDS resident assessment, dated 09/09/17, reflected she had severe cognitive impairment. Review of the Provider Investigation Report, dated 11/13/17, revealed Administrator X and DON Z investigated an incident reported by another resident that Resident #2 was kissed by an employee on 05/17/17. DON Z interviewed Resident #2 and she denied anyone had kissed her. Administrator X interviewed CNA A about the incident because he was the male CNA assigned to that hall. CNA A denied the allegation. Administrator X did not interview any further residents or staff. When Administrator X was interviewed by corporate staff about the matter and why it was not self-reported, and he stated his investigation indicated no abuse had occurred. Review of Administrator X's investigations during his tenure revealed there was no investigative paperwork regarding the incident with Resident #2. There was a statement from CNA A, dated 05/17/17, stating he had not done any unprofessional conduct with any residents. Interview with DON Z on 11/15/17 at 9:35 a.m. revealed in mid (MONTH) (YEAR), another resident alleged Resident #2 had been kissed by an employee. She had been directed by Administrator X to interview Resident #2. She stated Resident #2 denied being kissed by an employee and she documented her interview and gave it to Administrator X, who she assumed completed the investigation. An attempt was made to interview Resident #2 on 11/16/17 at 2:31 p.m.; however, she did not respond to questions. In a subsequent interview with DON Z on 11/15/17 at 1:00 p.m., she revealed after the incident with Resident #2, CNA A was reassigned to care for another group of residents. 5. Review of Resident #3's undated face sheet revealed Resident #3 was [AGE] years old and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #3's MDS assessment dated [DATE] reflected she was moderately cognitively impaired. Review of the Provider Investigation Report, dated 11/13/17, revealed Administrator X and DON Z investigated an incident which happened on 07/11/17. Administrator X was informed that Resident #3 told another employee she had been touched inappropriately by a male staff member. DON Z interviewed Resident #3 who denied anyone had touched her. Resident #3 had dementia. Administrator X interviewed the male CNA assigned to that hall, which was CNA A. CNA A denied any inappropriate behavior. Administrator X was interviewed by corporate staff about his investigation and why it was not self-reported, and he stated his investigation indicated no abuse had occurred. Interview with DON Z on 11/15/17 at 9:35 a.m. revealed in (MONTH) (YEAR), Resident #3 had told a staff member she had been touched inappropriately. She stated Administrator X directed her to interview Resident #3, who denied being touched, but she did have dementia. She stated Administrator X moved CNA A to care for a different set of residents after the incident. She stated she did not think Administrator X reported the incidents to the state survey agency, but did not know why he did not report each incident. 6. Review of CNA A's employee file reflected he was hired on 08/06/15. At the time of employment, a criminal history check revealed he had no convictions that barred employment. Registry checks for the Employee Misconduct Registry (EMR) and Nurse Aide Registry (NAR) were conducted prior to employment and annually and revealed he was employable. There was no evidence of prior counseling related to abuse or mistreatment of [REDACTED]. revealed he matched the description Resident #4 gave of the alleged perpetrator. A termination notice, dated 10/26/17, reflected he was terminated and not eligible for rehire due to allegations of abuse. 7. During a subsequent interview with DON Z on 11/15/17 at 1:00 p.m., she revealed it was strange how CNA A's name kept coming up in each investigation, but she assumed Administrator X had thoroughly investigated the incidents and would take care of it. She stated CNA A was not suspended with any of the incidents regarding Residents #1, #2, and #3, but reassigned to a different hall or another group of residents. 8. An attempt to interview Administrator X was made on 11/16/17 at 10:08 a.m. via telephone and a voice message was left and the phone call was not returned during the course of the investigation. 9. During the above interview with Administrator Y on 11/15/17 at 9:50 a.m., she also stated the reason she was looked through information in her office, was due to two current alleged incidents of sexual abuse involving Residents #4 and #5. She stated that both incidents also involved CNA A. She said the incidents were reported to the State Survey Agency. 10. Review of Resident #4's undated face sheet reflected Resident #4 was [AGE] years old and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #4's Minimum Data Set (MDS) resident assessment, dated 09/18/17, reflected she had severe cognitive impairment. Resident #4 required assistance of one person with activities of daily living (ADLs). Review of the facility's Provider Investigation Report, dated 10/30/17, revealed on the morning of 10/24/17, CNA B entered Resident #4's room and found a used condom under Resident #4's buttocks. Resident #4 was transferred to the hospital for evaluation and CNA A was suspended since he was the male employee assigned to Resident #4. Interview with Administrator Y on 11/15/17 at 9:50 a.m. revealed a rape kit was completed at a local hospital on Resident #4, but the detective stated the rape kit would take months to complete since they were so backed up. She also revealed CNA A had been arrested at the airport a few days ago trying to leave the country, but there was a miscommunication at the airport, and he was able to bond out and leave the country. Interview with LVN C on 11/15/17 at 11:39 a.m. revealed she was Resident #4's nurse on the morning of 10/24/17. She stated she was called to Resident #4's room by CNA B. She stated CNA B rolled Resident #4 and underneath Resident #4's buttocks, between the brief and the bed, was a used condom. She stated CNA B grabbed the condom with a glove and put it in a bag for the police. LVN C stated she notified administrative staff and went with Resident #4 to the hospital. She stated she was present during the rape kit exam and the hospital nurse said there was evidence of vaginal tearing. LVN C stated while they were at the hospital, Resident #4 told her a large black man had laid on top of her. Interview with Resident #4 on 11/15/17 at 11:31 a.m. revealed she had no recall of the incident. 11. Review of Resident #5's undated face sheet reflected Resident #5 was a [AGE] year old female who admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #5's MDS resident assessment, dated 10/23/17, reflected she had severe cognitive impairment. Resident #5 did not require assistance with ADLs and was continent of bowel and bladder. Review of the Provider Investigation Report, dated 10/30/17, revealed on the evening of 10/24/17, Resident #5 stated a large black man came into her room the night before and told her he needed to change her brief. Resident #5 told the man she did not wear a brief and in response, he patted her down, kissed her and left the room. CNA A matched the description that Resident #5 reported and he was suspended pending investigation. Review of the Psychologist's Diagnostic Interview, dated 10/24/17, reflected Resident #5 described an incident with a male aide during the night that caused her to feel threatened and unsafe. Resident #5 was tearful and anxious and repeated her description a number of times and appeared to feel worried that she was to blame, emphasizing repeatedly, I am not that type of woman. Recommendations included Psychology services to follow to address patient's anxiety and distress following an interaction with a male aide that she characterized as inappropriate and intrusive and which left her feeling fearful and humiliated. Review of the Change of Condition Report, dated 10/26/17, reflected Resident #5 was very anxious due to a recent incident (10/24/17's incident as listed above) and Resident #5 stayed overnight for two days with family. Review of the Psychologist's progress note, dated 10/27/17, reflected Resident #5 had worsening depression, anxiety, mood instability, and adjustment issues. Resident #5 was started on 5 mg of [MEDICATION NAME] (medication for depression) every night due to worsening affective signs and symptoms. 12. Interview with Administrator Y on 11/15/17 at 3:45 p.m. revealed after the incidents regarding Resident #4 and Resident #5, they completed Safe Surveys with all of the residents and asked questions regarding if they felt safe in the facility. She said no additional incidents were identified. 13. During surveyor interviews with residents, Residents #6 and #7 revealed CNA A had been inappropriate during their care. 14. Review of Resident #6's undated face sheet reflected she admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #6's care plan, dated 07/13/17 and completed by DON Z, revealed female caregivers were to assist resident with shower/personal hygiene. Review of Resident #6's MDS resident assessment, dated 08/24/17, reflected she was cognitively intact. Interview with Resident #6 on 11/15/17 at 11:20 a.m. revealed she was scared of the men here. She stated she did not know what was on their minds. She stated CNA A made her feel sexually uncomfortable because he rubbed her privates too long in the shower. She revealed all the other staff would allow her to wash her privates by herself. She stated it had happened several months ago and she had not told anyone. Interview with Administrator Y on 11/16/17 at 9:15 a.m. revealed she spoke with Resident #6 after the allegation was brought to her attention by surveyors. She stated she went ahead and started an investigation into the matter and notified the detectives about Resident #6's allegation. Review of the facility's Safe Surveys, conducted on 10/24/17, provided no evidence that Resident #6 disclosed the fact that CNA A had sexually assaulted her. 15. Review of Resident #7's undated face sheet reflected she was [AGE] years old and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #7's MDS resident assessment, dated 10/17/17, revealed she was cognitively intact. Interview with Resident #7 on 11/15/17 at 11:45 a.m. revealed when she first admitted to the facility, she was inappropriately touched by CNA A. She stated CNA A's hand would slip during brief changes all over her body. She stated it made her feel terrible and she felt that no one should ever have to feel like that. She stated she reported the incident to various staff members, but she felt like no one cared. Interview with CNA M on 11/15/17 at 1:32 p.m. revealed she was aware Resident #7 did not like CNA A and did not want CNA A to give her showers. She stated it was common knowledge that CNA A was not to give Resident #7 showers, but she was not sure why. Interview with CNA N on 11/15/17 at 4:01 p.m. revealed Resident #7 would refuse to allow CNA A to work with her. She stated an incident occurred probably around (MONTH) (YEAR) when she and CNA A were working together on Hall 100. She stated she was assisting Resident #7 with her shower and Resident #7 kept asking her to cover her up so CNA A would not see her. She stated she told the nurse that day. She added that everyone knew CNA A was not allowed to go into Resident #7's room. She revealed Resident #7 would become frightened and scared if she saw CNA A on her hall. Interview with Administrator Y on 11/16/17 at 9:15 a.m. revealed she spoke with Resident #7 after the allegation was brought to her attention by the surveyors. She stated she started an investigation into the matter and notified the local policy department's detectives about Resident #7's allegation. Review of the facility's Safe Surveys, conducted on 10/24/17, provided no evidence that Resident #7 disclosed the fact that CNA A had sexually assaulted her. 16. Interview with Administrator Y on 11/15/17 at 3:45 p.m. revealed after the incidents regarding Resident #4 and Resident #5, they completed Safe Surveys with all of the residents and asked questions regarding if they felt safe in the facility. She said no additional incidents were identified. 17. During surveyor interviews with residents, Residents #6 and #7 revealed CNA A had been inappropriate during their care. 18. Review of Resident #6's undated face sheet reflected she admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #6's care plan, dated 07/13/17 and completed by DON Z, revealed female caregivers were to assist resident with shower/personal hygiene. Review of Resident #6's MDS resident assessment, dated 08/24/17, reflected she was cognitively intact. Interview with Resident #6 on 11/15/17 at 11:20 a.m. revealed she was scared of the men here. She stated she did not know what was on their minds. She stated CNA A made her feel sexually uncomfortable because he rubbed her privates too long in the shower. She revealed all the other staff would allow her to wash her privates by herself. She stated it had happened several months ago and she had not told anyone. Interview with Administrator Y on 11/16/17 at 9:15 a.m. revealed she spoke with Resident #6 after the allegation was brought to her attention by surveyors. She stated she went ahead and started an investigation into the matter and notified the detectives about Resident #6's allegation. Review of the facility's Safe Surveys, conducted on 10/24/17, provided no evidence that Resident #6 disclosed the fact that CNA A had sexually assaulted her. 19. Review of Resident #7's undated face sheet reflected she was [AGE] years old and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #7's MDS resident assessment, dated 10/17/17, revealed she was cognitively intact. Interview with Resident #7 on 11/15/17 at 11:45 a.m. revealed when she first admitted to the facility, she was inappropriately touched by CNA A. She stated CNA A's hand would slip during brief changes all over her body. She stated it made her feel terrible and she felt that no one should ever have to feel like that. She stated she reported the incident to various staff members, but she felt like no one cared. Interview with CNA M on 11/15/17 at 1:32 p.m. revealed she was aware Resident #7 did not like CNA A and did not want CNA A to give her showers. She stated it was common knowledge that CNA A was not to give Resident #7 showers, but she was not sure why. Interview with CNA N on 11/15/17 at 4:01 p.m. revealed Resident #7 would refuse to allow CNA A to work with her. She stated an incident occurred probably around (MONTH) (YEAR) when she and CNA A were working together on Hall 100. She stated she was assisting Resident #7 with her shower and Resident #7 kept asking her to cover her up so CNA A would not see her. She stated she told the nurse that day. She added that everyone knew CNA A was not allowed to go into Resident #7's room. She revealed Resident #7 would become frightened and scared if she saw CNA A on her hall. Interview with Administrator Y on 11/16/17 at 9:15 a.m. revealed she spoke with Resident #7 after the allegation was brought to her attention by the surveyors. She stated she started an investigation into the matter and notified the the local policy department's detectives about Resident #7's allegation. Review of the facility's Safe Surveys, conducted on 10/24/17, provided no evidence that Resident #7 disclosed the fact that CNA A had sexually assaulted her. 20. Interview with CNA A on 11/15/17 at 10:05 a.m. revealed he said he was currently out of the country. He confirmed was being investigated by the nursing home and the police regarding touching residents inappropriately, but denied he touched any residents including Residents #4 and #5. He stated prior to leaving the country, he was arrested regarding the incidents with Residents #4 and #5, but was able to bond out and fly back home (out of the country). 21. Interview with CNA O on 11/15/17 at 4:15 p.m. revealed on 07/10/17 or 07/11/17, she was working with CNA A on Hall 100. She stated she remembers a couple of residents started screaming that they did not want him in their room. She stated CNA A had come up to her and asked her to finish assisting a resident with incontinent care because she was refusing to allow him to do it. She stated she went into the resident's room and the resident was screaming and crying. She stated she tried to comfort the resident and finished incontinent care. She stated she did not tell anyone. She stated she did not remember the resident's name because the incident occurred around her 4th day working at the facility. 22. Review of the facility's policies included the following: A. Resident Abuse, Neglect, and Exploitation and Misappropriation of Resident Property Policy, revised 06/23/17, reflected included - Definitions - --Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain or mental anguish. --Sexual abuse: Includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. --Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. (3) Duty to Report Violations Internally and to Applicable Agencies. (3.3) Upon receiving an allegation abuse, neglect, exploitation or misappropriation, the Abuse Coordinator will a) notify the Regional Director of Operations and Regional Nurse Consultant, b) initiate an investigation into the allegation, c) in conjunction with the Regional Director of Operations and Regional Nurse Consultant determine whether the allegation is reportable under federal and state regulations, and d) if the allegation is reportable, report such allegation to the State Regulatory Agency B. Internal Investigation Guidelines, revised 09/01/17, reflected the following: Process - (1) Collection only information that is relevant to the facts and circumstances of the incident being investigated. (2) Identify 'Who' was involved (3) Determine 'What' occurred (4) Determine 'When' the incident occurred (5) Determine 'Where' the incident occurred (6) . complete a physical and emotional assessment of the resident, identifying areas of injury. (9) Complete a comprehensive record review . (10) Interview all potential witnesses who may have relevant information. Interview Resident regardless of cognitive status. Interview Resident's roommate regardless of cognitive status. Interview staff members. Conduct Safe Surveys of other residents. Investigation Check List for Allegation of Abuse/Neglect/Exploitation/Misappropriation of Resident Property (1) The alleged perpetrator, if known, is suspended pending investigation. (3) Incident Report is completed. (5) Resident(s) are safe. (6) Notify the RDO at time of occurrence. (7) Notify the RNC at the time of occurrence. (8) Notify the State as directed by State specific guidelines . (11) Conduct Safe Surveys 23. On 11/16/17 at 2:20 p.m., Administrator Y and DON Z, were notified of an Immediate Jeopardy (IJ) had been identified. The facility provided an action Plan, dated 11/11/17, reflecting a plan they had initiated prior to the survey to address the above identified incidents: --All department heads educated on Grievance procedure and notification to administrator --Angel rounds to be done daily and communicated in morning meeting of any concerns --Concerns forms will be available in the lobby to ensure all residents, staff, family, and vendors can voice a concern --Weekend manager on duty will report all concerns on Monday in morning meeting --Grievance procedure to be reviewed in next resident council meeting. --Incident and accidents will be initiated according to company policy --Will be reviewed in morning clinical meeting --All incident and accidents will be reviewed by DON to ensure appropriate completion, documentation, intervention, and notification are done within 5 days of the incident. --Charge nurse will notify Administrator of all reportable incidents --Priority rounds will be made on all residents with incident and accident report initiated --Care Plans will be updated with interventions and approached for prevention and reoccurrence. 24. Review of the Safe Surveys conducted on 10/24/17, revealed all interviewable residents had been interviewed. The residents had said they felt safe in the facility. Note: Resident #6 had not disclosed the fact that CNA A had sexually assaulted her. Refer to Element #5 for additional details. 25. Review of the in-services reflected the following: 10/24/17: All nursing staff were in-serviced over resident rights, prevention of abuse and neglect, and signs of burnout. 11/03/17: Department heads were in-serviced over the grievance process, angel rounds, and how to interview residents and families. 11/06/17: From 4:30 p.m. to 5:00 p.m. revealed DON Z, Administrator Y, ADON D, ADON E were in-serviced over reporting and investigating after and how to complete an investigation. 11/08/17: All department heads were in-serviced over environmental rounds, abuse reporting, angel rounds, and resident rights. 11/11/17: All staff were educated on reporting bruises of unknown origin to the Administrator, reporting falls with injury, and that if the Administrator is unavailable DON Z would be the next person to contact. 11/15/17: All staff were educated on abuse prevention and were given the number for the corporate hotline and the state agency number to report any suspected abuse or neglect. 26. Individual interviews with four CNAs (CNA F, CNA G, CNA H and CNA I) and two RAs (RA J and RA K) revealed they had received in-service training on abuse/neglect, the signs and symptoms of abuse/neglect. They each said they would immediately report incidents to the Administrator. The interviews were conducted on the following dates/times: --CNA F was interviewed on 11/15/17 at 4:15 p.m. --CNA G, CNA H, CNA I, RA J AND RA K were interviewed on 11/16/17 at 9.38 a.m., 10:18 a.m., 10:25 a.m., 10:32 a.m., and 10:32 a.m., respectively. 27. Interview with DON Z on 11/16/17 at 11:06 a.m. revealed she received training by the Corporate Nurse on how to complete an investigation and when to report incidents to the state survey agency. She added that she would do what the Administrator told her to do. 28. Interview with the Administrator Y on 11/15/17 at 3:30 p.m., revealed she received training on how to complete an investigation and how to determine if an incident was reportable and how to report it to the state survey agency. 29. On 12/01/17 at 8:55 a.m., Administrator Y and Regional Nurse Consultant were notified their Action Plan did not provide sufficient evidence the Immediate Jeopardy had been removed. At that time, a Plan of Removal was requested. 30. On 12/01/17 at 1:50 p.m., the facility's Plan of Removal (PoR) was accepted. The PoR reflected the following: --Regional Director of Operations (RDO) and /or Regional Nurse Consultant (RNC) will, at least every two weeks for 3 months review and ensure system integrity of the following: Grievances (concern forms), Self-Reporting protocol, Investigation protocol, Angel Rounds, Compliance Hotline, Pinnacle service reports. --New Administrator Y effective 10/9/17. In-service Administrator Y on 11/10/17 on Internal investigation guidelines on allegations of abuse, neglect and exploitation to ensure compliance with federal and state regulation regarding protecting facility patients and resident from abuse, neglect, exploitation and misappropriation of resident property, timely investigation of reporting to state and local agencies all allegations of abuse, neglect, exploitation and misappropriation of resident property. --New DON AA effective 11/20/17 in-serviced on 11/20/17 on Internal investigation guidelines on allegations of abuse, neglect and exploitation to ensure compliance with federal and state regulation regarding protecting facility patients and resident from abuse, neglect, exploitation and misappropriation of resident property, timely investigation of reporting to state and local agencies all allegations of abuse, neglect, exploitation and misappropriation of resident property. --Administrator Y and DON AA in-serviced on notifying RDO and RNC of any significant event per policy to include list of all reportable events --Survey current and discharged residents and send out a report to Compliance officer, Administrator and Regional support team. Negative concerns are sent out immediately to Executive Management team, Administrator Y and DON AA. --Corporate Management Team track and trended all SRI from the facilities. Weekly SRIs are reported to management company. Monthly, the regional Clinical Nurse provides oversight of the reporting system to include review of the log for increasing trends or those who have made 0 self-reports in a 30 day period. --Weekly report to corporate management to going over facility events and self-reports --Administrator Y and DON AA to review all Incident and accidents, Concerns and Self-reports in Morning meeting (daily as of Hire dates) --Staff in-serviced on who to report allegations of abuse and neglect, exploitation and misappropriation of resident property too. Included if the Administrator is unavailable DON Z will be notified next. (10/23-10/24; 11/11) --Staff in-serviced to notify the regional team any allegation of abuse, neglect exploitation and misappropriations of resident property. Regional team numbers posted throughout the facility. (12/1) --Sensitivity Training -- Old lady poem and sensitivity video (11/10) --In-serviced staff on suspicion of a crime, compliance hotline and number to call Texas Health and Human Services for abuse, neglect, exploitation and misappropriation of resident property. (11/15) --In-service staff 12/1/17 on recognizing signs and symptoms of abuse, neglect, exploitation and misappropriation of resident property and to ensure proper follow up. --All abuse/neglect and misappropriation in-services were added to the on-line education management system assignments for ALL staff monthly in addition to the required annual and upon hire which we did previously. This will continue for 12 mon (TRUNCATED)

Based on observation, interview and record review, it was determined the facility failed to ensure one (Resident #1) of eight residents reviewed for quality of care was provided the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care. Resident #1 admitted with two fractures. Within 12 hours of admission she fell . Nursing staff failed to: -- conduct a head-to-toe assessment to determine the extent of the resident's injuries, -- provide Resident #1's physician/NP with an accurate assessment of Resident #1's status and allow the physician/NP to respond appropriately. -- communicate shift-to-shift Resident #1's condition at time of admission, condition following the fall, and change in condition during subsequent hours after the fall. As a result, there was a delay of approximately 14 hours before Resident #1 transferred to hospital and was subsequently identified as sustaining additional fractures; thus, delaying timely care and services. On 11/13/13 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 11/18/13, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because staff were still being in-serviced, and the facility was monitoring the effectiveness of the Plan of Removal. These failures could affect the 13 residents, who resided on the 200 Hall, by placing them at risk for not being adequately assessed with [REDACTED]. in a delay in treatment or [DIAGNOSES REDACTED]. Findings included: Resident #1's Face Sheet, printed on 11/04/13, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's Admission Data, dated 10/25/13, reflected she was admitted to the facility at 2:16 p.m., and was alert, but disoriented to place and time, required limited assistance with transfers and ambulation. Resident #1 was only partially able to bear weight, and she had an abnormal gait. She had bruising/discoloration to her right arm and left and right hands, plus a rash/redness to her left shoulder. Resident #1's Fall Risk evaluation, dated 10/25/13, reflected she was a high fall risk due to mild/moderately impaired cognitive status, required assistance for mobility, required limited assistance for transfers, partial weight bearing status, use of an assistive device (wheelchair), vision (wears glasses), occasional incontinence, and received two or more medications (diuretics, cardiovascular, routine pain, anti-hypertensive, antipsychotic, anti-anxiety, sleeping, or anti-depressant). The evaluation also reflected she had a fall in the last six months. Resident #1's initial Care Plan, dated 10/25/13, reflected a concern for fall/safety risk (Fall Risk score of 10) with a goal of no injury falls. Interventions included encourage to use call light, physical therapy referral, instruct on safety measures, and bed/chair alarm. Resident #1's Nurse's Notes, completed by LVN I and dated 10/25/13 at 11:31 p.m., reflected she admitted to the facility with a fracture to her left upper extremity. She had bruises to her upper extremities with redness to her right shoulder. She was alert and "pleasantly confused" and required "constant monitoring." The Notes reflected "several times" Resident #1 attempted unassisted transfers and was redirected. Her vital signs were blood pressure 154/86, pulse 80, respirations 18, and oxygen saturation level 98% on room air. Resident #1's Nurse's Notes, completed by RN A and dated 10/26/13 for 2:10 a.m. (12 hours after admitting to the facility), reflected Resident #1 was found in her room, near the sitting area, lying on her right side in a fetal position. She told staff she fell . She demonstrated the ability to move all her extremities and with the assistance of two staff, she walked back to her bed. The Notes reflected Resident #1 was "very confused" and had a new abrasion to her outer, lower right arm, measuring 2.0 cm wide by 7.0 cm long, and blue discoloration extending from the right side of her nose to the outer edge of her right eye. She had a bruise to the top of her right shoulder, which was previously there, but now with the movement of her right arm, the resident grimaced. The Note also reflected a small amount of blood was cleaned off the resident, but the site was not indicated. Resident #1's Nurse's Notes, completed by RN A and dated 10/26/13 for 2:20 a.m., reflected her attending physician, Medical Director N, was notified of the fall, and gave an order for [REDACTED]. The Incident/Accident Report, dated 10/26/13, documented Resident #1's fall on 10/26/13 at 2:10 a.m., and noted the abrasion as recorded in the Nurse's Notes. The Report also reflected, "...Also has blue discoloration under OD (right eye). Pupils react very sluggish. Denies pain, but is very confused and unable to respond to questions appropriately." Her vital signs were blood pressure 140/84 (normal blood pressure systolic 100 - 130 mmHg/diastolic 60 - 80 mmHg), pulse 76 (normal resting pulse in adults is between 60 and 80 beats per minute), respirations 18 (adults normal respiratory rate is more than 12 to 20 breaths a minutes) , temperature 96.8 F (normal temperature is 97.5 to 99.5 degrees F) and oxygen saturation level was 95% (normal oxygen saturation level is normally higher than 96%.) An interview with RN A on 11/15/13 at 8:00 a.m. revealed she was the nurse for Resident #1 on the 10:00 p.m. to 6:00 a.m. shift on the night of the fall (10/26/13). RN A stated she discovered Resident #1 on the floor in the sitting room outside of her bedroom with the bed alarm activated. She revealed the resident was lying in a fetal position and with the assistance from a CNA, she placed the resident back in her bed. She stated she observed no swelling of Resident #1's extremities and the only injury was a small abrasion on her right arm. RN A revealed Resident #1 did have discoloration under her eye, but a CNA told her the discoloration was present before the fall. RN A added Resident #1's clinical record did not have any documentation of the discoloration under her eye. RN A stated she contacted Resident #1's attending physician, Medical Director N, after the fall. RN A stated he said if the Resident was hurting, to get x-rays. RN A revealed she completed neuro checks every 15 minutes, then every 30 minutes. She stated Resident #1 did not complain of pain, but the resident appeared uncomfortable. She revealed she attempted to give her a Tylenol (over the counter pain medication), but the resident spit it out. Further review of Resident #1's Nurse's Notes, completed by RN A and dated 10/26/13, for after the fall reflected: - at 3:00 a.m., she vomited a small amount of a yellow substance. - at 5:00 a.m., she had "several" episodes of a small amounts of vomit. The Notes provided no evidence the physician and family were notified of this change of condition. Resident #1's Nurse's Notes, completed by LVN H and dated 10/26/13, reflected: - at 6:15 a.m., x-ray technician notified the nurse Resident #1 was vomiting. The vomit was yellow/green in color. Her vital signs were blood pressure 159/104, blood sugar 194 and oxygen saturation level was on 90% on 2 liters of oxygen (Note: On 10/25/13 blood pressure was 154/86 and oxygen saturation level 98% on room air.) Medical Director N was consulted (3.25 hours after she first experienced an incident of vomiting). The physician gave orders for 4 mg of [MEDICATION NAME] (anti-nausea/vomiting medication) every six hours as needed. The medication was given at that time. The physician was asked if he wanted STAT labs and he replied not at this time. - at 7:30 a.m., her blood pressure was 139/100 and her oxygen saturation level had decreased to 85% on 2 liters of oxygen. She had "wheezes and bronchi sounds were audible" and the oxygen was increased from 2 liters to 3 liters per minute. The notes reflected her respirations were labored, heart rate was 102 and oxygen saturation level ranged from 85% to 90% on 3 liters of oxygen. Resident #1 was "staring into space, lethargic," and refused her breakfast and a milk shake. A voice message was left for Medical Director N. The X-ray Reports, dated 10/26/13, and transcribed at 9:20 a.m., reflected the following: - Right shoulder with two views obtained - no acute fracture. - Right elbow with two views obtained, which reflected the "bones are quite osteoporotic" The impression was [MEDICAL CONDITION] humerus, and "these are non standard films making evaluation difficult. Humeral radiography is probably warranted for further evaluation." The Nurse's notes, completed by LVN H and dated 10/26/13 for 12:30 p.m. (5 hours after the first message was left for Medical Director N), reflected Resident #1's "breathing still labored with audible wheezes and bronchi, oxygen saturation level at 85% on 3 liters of oxygen. Another message was left for Medical Director N. The Notes reflected at 1:00 p.m., the nurse called the Medical Director O, and informed him of Resident #1's condition, and "she did not look well." Medical Director O was notified two messages were left for Medical Director N with no response. Medical Director O gave orders for a STAT chest x-ray and CMP and BMP laboratory tests. The mobile x-ray company was notified and the family was notified. An interview with Medical Director O on 11/14/13 at approximately 11:00 a.m. revealed he recalled being told the nurse had been unable to contact the resident's attending physician. He stated the nurse notified him Resident #1 was not doing well, but her vital signs were stable. Medical Director O revealed he did not remember any mention of a fall or fracture. He stated he would have sent her to the hospital. Medical Director O revealed the Administrator and the DON had his direct cell phone number. The X-Ray Report, dated 10/26/13 and transcribed at 2:59 p.m., reflected two chest views were obtained and compared to a chest view from 07/02/12. The results reflected her bones were "quite osteoporotic." The impression was she had no acute pneumonia, although, there was "some degree of [MEDICAL CONDITIONS]." An interview with LVN H on 11/13/13 at approximately 8:30 a.m. revealed she was on duty on 10/26/13 from 6:00 a.m. to 2:00 p.m. She stated she was informed at shift change that Resident #1 had fallen. LVN H stated upon her assessment, she saw no signs of injury. LVN H revealed she was not told during shift change report that Resident #1 had been vomiting or experiencing diarrhea. She stated she found Resident #1 covered in vomit, so she contacted the previous shift's LVN to ask about the resident's symptoms. She was told by RN A Resident #1 had experienced small amounts of vomit and diarrhea during her shift. She stated she notified Medical Director N regarding the vomiting and diarrhea and he gave an order for [REDACTED]. LVN H added she did not review Resident #1's clinical record to verify it was the fracture she had on admission. She revealed when Resident #1 began experiencing difficulty in breathing, she administered oxygen and a breathing treatment, and her breathing improved. LVN H stated she was unable to reach Medical Director N. She discussed Resident #1's vomiting, diarrhea, and breathing issues with the ADON P, who did not recommend sending Resident #1 to the hospital. LVN H stated the normal process was to explain the situation to the ADON, who would decide to send the Resident to the hospital. LVN H revealed she was instructed by ADON P to keep trying to contact the resident's physician. LVN H stated when she spoke with Medical Director O, she told him the fractured elbow was a fracture the resident admitted with, and she told him about her shortness of breath and lethargy. She stated Medical Director O gave orders for a STAT chest x-ray and laboratory tests. She stated the results of the laboratory tests did not come in prior to the end of her shift. LVN H revealed during the shift change report with the on-coming nurse, she did not tell the nurse about the results of the x-rays obtained that morning, but instead only told the nurse the same information relayed to her during her shift change meeting: Resident #1 had admitted with multiple fractures. An interview with ADON P on 11/13/13 at 10:00 a.m. revealed she was a manager on duty and oversaw things from 11:00 a.m. to 3:00 p.m. She stated she was not a manager on duty full time on the weekends. ADON P revealed if an incident occurred they were to notify the Administrator, DON, and ADON. She stated they try to contact the physician and call the physician again if there was no response. ADON P revealed if there was still no response from the physician, then they contact the Medical Director. She stated if she had known about Resident #1's vomiting and nausea, she would have told the nurse to send the resident to the hospital. ADON P revealed she remembered being told about the resident's difficulty in breathing, and the nurse not being able to contact the physician. She stated she told the nurse to contact Medical Director O. An interview with Resident #1's family member on 11/13/13 at 1:45 p.m. revealed upon arrival at the facility around 1:30 p.m., Resident #1's arm was swollen and her wrist looked "twisted." Her eye was also swollen and black. Resident #1's family member revealed the resident was so short of breath, she could not verbalize. He/She stated around 3:00 p.m., Resident #1 received a breathing treatment, but she continued to be short of breath. Resident #1's family member revealed he/she requested Resident #1 be sent to the hospital and was told by the nurse on duty they were waiting on the results of the additional x-ray and laboratory tests. The family member stated the resident was in pain, but staff would not give her anything because of her elevated blood pressure and breathing issues. He/She revealed the staff eventually gave the resident Tylenol. Resident #1's Nurse's Notes, dated 10/26/13, timed at 4:00 p.m. and completed by RN B, reflected she was "lethargic, arousable." Her vitals signs were temperature 100 degrees F, pulse 110, respirations 22, blood pressure 124/87, and oxygen saturation level at 97% on 2 liters of oxygen. The resident complained of pain in right arm, and it was elevated on a pillow. The resident was given Tylenol 325 mg at 3:45 p.m. The Nurse's Notes, dated 10/26/13 and timed at 5:45 p.m., reflected Medical Director N was notified of the results of the right elbow/arm x-ray that had been available since 9:48 a.m. that morning, and that Resident #1's white blood count was elevated and her potassium was low. Medical Director N gave orders to transfer her to the hospital. At 6:10 p.m., the ambulance service was notified, and the ambulance arrived at 6:45 p.m. At that time, her vitals were temperature 100 degrees F, pulse 110 respirations 20, and blood pressure 130/86. An interview with RN B on 11/13/13 at approximately 2:00 p.m. revealed she was Resident #1's nurse on 10/26/13 for the 2:00 p.m. to 10:00 p.m. shift. RN B stated she did not recall the day shift nurse (LVN H) mentioning Resident #1 had episodes of nausea and vomiting. She revealed during her shift, Resident #1 did not have episodes of nausea and/or vomiting. She further stated LVN H requested she report the results of Resident #1's x-rays to Medical Director N, the resident's attending physician. She said at approximately 4:30 p.m. (2.5 hours after the start of her shift), she left a message for Medical Director N. She stated she waited until 4:30 p.m. to call because she was waiting on the results of the laboratory tests and the x-rays. RN B revealed at 5:45 p.m. Medical Director N returned her call, and she consulted with him regarding the results of the chest x-rays and the laboratory results, which had also come in. She stated he ordered Resident #1 sent to the hospital. RN B said she would not send a resident to the hospital without a physician's orders [REDACTED]. She stated she did not consider Resident #1 to have had that level of change in her condition. RN B revealed if a resident had a fracture, she generally waited to send the resident to the hospital until she spoke with the physician. She stated her assessment of Resident #1 did not reveal any signs/symptoms of vomiting. An interview with the DON on 11/12/13 at 4:30 p.m. revealed she had not been aware the x-rays obtained at the facility had identified a fractured elbow. She stated she was aware the nurse had attempted to call the resident's attending physician without success. The DON revealed sending a resident to the hospital was nursing judgement, but then stated she could "give a reason for the delay, but it would just be an excuse." Resident #1's x-ray reports from the first hospital, dated 10/26/13, reflected a [MEDICAL CONDITION] radius and ulna of her left wrist. During an interview with Resident #1's family member on 11/13/13 at 1:45 p.m., he/she stated Resident #1 was transferred to a second hospital for additional care where she was in initially in the Intensive Care Unit. Resident #1's Trauma Admission/Consultation, from the second hospital dated 10/27/13, reflected, "...Lst night, pt (Resident #1) reportedly fell from bed onto wood floor with injuries to right face and right long bones. Transferred to (second hospital's name) ED (Emergency Department) for the following fractures: R (right) humerus fracture with humeral prosthesis Zygomtatic (cheekbone) arch and max sinus R distal ulna and radius (wrist) fracture L (left pelvis fracture...Right Periorbital [MEDICAL CONDITION]/contusion (surrounding the socket of the eye), Right malar (cheekbone) depression...." Resident #1's Surgical Note, dated 10/27/13, reflected, "...Admit to ICU for trauma in the elderly...." The facility's current, undated Change of Condition Policy and Procedures reflected the "facility staff will assess, record and report any significant change in a resident condition to the attending physician to ensure appropriate care and treatment...Licensed nursing staff will assess and report changes of a residents' (sic) condition to the physician/physician extender in a timely manner. Changes in condition include (but are not limited to): - Falls - Physical changes: injury...- Mental changes: change in cognition/orientation, personality changes...-Abnormal lab results and diagnostic test results...Charge nurse will notify the attending physician/extender of any significant change of condition. The residents' responsible party will also be notified of changes in condition...." On 11/14/13 an IJ was identified. On 11/14/13 at 1:03 p.m., the Administrator, DON, and RNC L were notified of the IJ and a Plan of Removal was requested at that time. On 11/15/13, at 6:00 p.m., the Administrator was notified the facility's Plan of Removal was accepted. The plan reflected: -- A QA Meeting was conducted on 11/14/13 with the Administrator, DON, RN Clinical Constant L and the following present via telephone conference call: Regional Director of Operations, RN Clinical Consultant M and Joint Medical Directors, N and O. -- In-services were conducted by ADON P and ADON Q on 10/29/13 and 10/30/13 regarding neuro-checks, head injuries and ICP injuries; change in condition and transferring residents to the ER, post-accident/incident procedures, admission assessments included fall risk assessments and fall risk interventions to prevent falls, post-incident interventions, emergency responses, bed and chair alarms, and care planning of falls. -- A compete audit of all resident charts was conducted to ensure Fall Risk Assessments had been completed within the last 30 days. The task was completed on or before 11/14/13 at 5:00 p.m. by the DON, ADON P, and ADON Q. All residents with a score greater than 6 were classified as high risk for falls and their care plans were reviewed and updated to reflect appropriate safety measures had been implemented. All such safety measures were confirmed to be in place by visual observations. These tasks were completed by ADON P, ADON Q, LVN J, and LVN K on or before 11/14/13 at 8:00 p.m. -- Fall Risk Assessments for newly admitted residents will be completed within the first eight hours of admission by the admitting nurse. The ADONs will review each new Admission Chart within 72 hours of admission to ensure Fall Risk Assessments are complete, accurate and appropriate intervention are observed in place. -- Fall prevention equipment will be stored in the medical supply closet on Hall 400 and all nurses on all shifts will have access. This practice will be initiated by 11/15/13 at 3:30 p.m. The availability of supplies will be monitored by the Central Supply Coordinator Monday through Friday. -- Residents identified as being at high risk for falls will be communicated to all clinical staff members using the EMR Messaging System/Accunurse System. At the beginning of each shift , the Charge Nurse will make resident assignments to all Nurse Aides. The Nurse Aides are required to use their head-sets to Review Plan of Care for each of their assigned residents. The Plan of Care identifies the resident at high risk for falls and list interventions that are to be in place for each high risk resident. The Charge Nurse is to monitor the Accunurse System prior to the end of each shift to ensure the Nurse Aides have competed their assignments and listened to their residents' plan of care. -- The DON and ADONs (and designated staff as scheduled by the DON) will conduct observation rounds on a daily basis, 7 days per week to ensure appropriate fall prevention measures are in place for each high risk resident. -- The facility began implementation of the Falling Star Program on 11/14/13 and all facility staff members trained on this program to ensure that all staff members are aware of residents at high risk of falls. The Falling Star Program will designate the residents who have a Fall Risk Assessment Score of above six with a star beside their name plate posted on the wall directly outside of each resident room. For new admissions, the admitting Charge Nurse will be responsible for initiating the Falling Star Program for residents assessed as being at high risk for falls. The DON will be responsible for the over-all monitoring of the Falling Star Program. The training of the Falling Star Program was initiated by the DON on 11/15/13 and all staff will be trained prior to their on-coming shift unit all staff have received the training. All staff will be required to successfully complete a post-test. If a staff member fails the test, they will be provided additional information and will be re-issues the post-test until successful completion. Training on the Falling Star Program will be part of New Hire Orientation starting 11/15/13. -- The facility's policy and practice will be that it is mandatory for all nurses to complete an SBAR for every resident fall and significant change in condition. This was effective 11/14/13 at 5:00 p.m. -- The facility's policy and practice will be that nurses are to wait a maximum of 30 minutes to receive a return call from a physician after the nurse has attempted to contact the physician following a resident fall and/or change of condition. After no longer than 30 minutes, a repeat call will be made and a maximum of 15 minutes thereafter will be allowed for a return call from the physician. If the nurse's call is not returned within 45 minutes of the original call, then the nurse will notify the Medical Director and DON (or ADON designee on the on-call schedule). This was effective Interviews with nurses from all three shifts confirmed staff had received in-service training regarding the following information: --Information to include on an SBAR --Information to provide to on-coming nurses at shift change --Components of a comprehensive assessment of a resident --Timeframes for contacting the physician after an incident --Timeframes for notifying the DON/ADON of a fall --Components of Incident/Accident Reports --Facilities "falling star" program The following nurses were interviewed on 11/14/2013 between 9:00 a.m. and 5:00 p.m. and provided appropriate answers regarding the previously identified in-services: RN A RN C The following nurses were interviewed on 11/15/2013 between 8:00 a.m. and 5:00 p.m. and provided appropriate answers regarding the previously identified in-services.: LVN H LVN R LVN S LVN T LVN U LVN V LVN W LVN X LVN Y LVN Z The following staff were interviewed on 11/17/2013 regarding the facility's "Falling Star" program and provided appropriate answers indicating knowledge of the program: CNA CC CNA DD CNA EE The following staff were interviewed on 11/18/2013 regarding the facility's "Falling Star" program and provided appropriate answers indicating knowledge of the program: CNA AA Dietary Manager Housekeeper BB Housekeeping Supervisor Cook FF Observations on 11/17/2013 and 11/18/2013 of resident's rooms and wheelchairs revealed residents identified as being a "fall risk" had a small "star" placed next to their name on the name plate located near the door to their room and attached to their wheelchairs to assist staff in identifying the resident as a "fall risk." The facility's Incident/Accident report, dated 10/31/13, reflected Resident #2 experienced an unwitnessed fall from her wheelchair and sustained substantial injury to her face and was bleeding as a result of these injuries. The report indicated 911 was contacted immediately after the resident was assessed, and the resident was subsequently transported to the hospital for treatment. On 11/18/13 at 5:50 p.m., the Administrator, DON, RNC M, ADON P, and ADON Q, were notified the IJ had been removed. While IJ was removed, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of pattern due to staff were still being in-serviced, and the facility was monitoring the effectiveness of the Plan of Removal. The facility's Resident Roster, dated 10/12/13, reflected 13 residents resided on the 200 Hall.

Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician and an interested family member when there was an accident involving the resident which resulted in injury and required physician intervention and a subsequent significant change in condition for one (Resident #1) of eight residents reviewed for a change in condition. Resident #1 admitted with resolving fractures. Less than 12 hours after admission, the resident was found on the floor. The family was not notified until six hours later. Medical Director N was consulted regarding the initial fall, but did not respond to two additional requests for consults. Nursing staff failed to correctly and timely report the findings of the initial x-ray results. On 11/13/13 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 11/18/13, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because staff were still being in-serviced, and the facility was monitoring the effectiveness of the Plan of Removal. These failures could affect the 13 residents, who resided on the 200 Hall, by placing them at risk for not being adequately assessed with [REDACTED]. in a delay in treatment or [DIAGNOSES REDACTED]. Findings included: Resident #1's Face Sheet, printed on 11/04/13, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's Admission Data, dated 10/25/13, reflected she was admitted to the facility at 2:16 p.m., and was alert, but disoriented to place and time, required limited assistance with transfers and ambulation. Resident #1 was only partially able to bear weight, and she had an abnormal gait. She had bruising/discoloration to her right arm and left and right hands, plus a rash/redness to her left shoulder. Resident #1's Fall Risk evaluation, dated 10/25/13, reflected she was a high fall risk due to mild/moderately impaired cognitive status, required assistance for mobility, required limited assistance for transfers, partial weight bearing status, use of an assistive device (wheelchair), vision (wears glasses), occasional incontinence, and received two or more medications (diuretics, cardiovascular, routine pain, anti-hypertensive, antipsychotic, anti-anxiety, sleeping, or anti-depressant). The evaluation also reflected she had a fall in the last six months. Resident #1's initial Care Plan, dated 10/25/13, reflected a concern for fall/safety risk (Fall Risk score of 10) with a goal of no injury falls. Interventions included encourage to use call light, physical therapy referral, instruct on safety measures, and bed/chair alarm. Resident #1's Nurse's Notes, completed by LVN I and dated 10/25/13 at 11:31 p.m., reflected she admitted to the facility with a fracture to her left upper extremity. She had bruises to her upper extremities with redness to her right shoulder. She was alert and "pleasantly confused" and required "constant monitoring." The Notes reflected "several times" Resident #1 attempted unassisted transfers and was redirected. Her vital signs were blood pressure 154/86, pulse 80, respirations 18, and oxygen saturation level 98% on room air. Resident #1's Nurse's Notes, completed by RN A and dated 10/26/13 for 2:10 a.m. (12 hours after admitting to the facility), reflected Resident #1 was found in her room, near the sitting area, lying on her right side in a fetal position. She told staff she fell . She demonstrated the ability to move all her extremities and with the assistance of two staff, she walked back to her bed. The Notes reflected Resident #1 was "very confused" and had a new abrasion to her outer, lower right arm, measuring 2.0 cm wide by 7.0 cm long, and blue discoloration extending from the right side of her nose to the outer edge of her right eye. She had a bruise to the top of her right shoulder, which was previously there, but now with the movement of her right arm, the resident grimaced. The Note also reflected a small amount of blood was cleaned off the resident, but the site was not indicated. Resident #1's Nurse's Notes, completed by RN A and dated 10/26/13 for 2:20 a.m., reflected her attending physician, Medical Director N, was notified of the fall, and gave an order for [REDACTED]. The Incident/Accident Report, dated 10/26/13, documented Resident #1's fall on 10/26/13 at 2:10 a.m., and noted the abrasion as recorded in the Nurse's Notes. The Report also reflected, "...Also has blue discoloration under OD (right eye). Pupils react very sluggish. Denies pain, but is very confused and unable to respond to questions appropriately." Her vital signs were blood pressure 140/84 (normal blood pressure systolic 100 - 130 mmHg/diastolic 60 - 80 mmHg), pulse 76 (normal resting pulse in adults is between 60 and 80 beats per minute), respirations 18 (adults normal respiratory rate is more than 12 to 20 breaths a minutes) , temperature 96.8 F (normal temperature is 97.5 to 99.5 degrees F) and oxygen saturation level was 95% (normal oxygen saturation level is normally higher than 96%.) An interview with RN A on 11/15/13 at 8:00 a.m. revealed she was the nurse for Resident #1 on the 10:00 p.m. to 6:00 a.m. shift on the night of the fall (10/26/13). RN A stated she discovered Resident #1 on the floor in the sitting room outside of her bedroom with the bed alarm activated. She revealed the resident was lying in a fetal position and with the assistance from a CNA, she placed the resident back in her bed. She stated she observed no swelling of Resident #1's extremities and the only injury was a small abrasion on her right arm. RN A revealed Resident #1 did have discoloration under her eye, but a CNA told her the discoloration was present before the fall. RN A added Resident #1's clinical record did not have any documentation of the discoloration under her eye. RN A stated she contacted Resident #1's attending physician, Medical Director N, after the fall. RN A stated he said if the Resident was hurting, to get x-rays. RN A revealed she completed neuro checks every 15 minutes, then every 30 minutes. She stated Resident #1 did not complain of pain, but the resident appeared uncomfortable. She revealed she attempted to give her a Tylenol (over the counter pain medication), but the resident spit it out. Further review of Resident #1's Nurse's Notes, completed by RN A and dated 10/26/13, for after the fall reflected: - at 3:00 a.m., she vomited a small amount of a yellow substance. - at 5:00 a.m., she had "several" episodes of a small amounts of vomit. The Notes provided no evidence the physician and family were notified of this change of condition. Resident #1's Nurse's Notes, completed by LVN H and dated 10/26/13, reflected: - at 6:15 a.m., x-ray technician notified the nurse Resident #1 was vomiting. The vomit was yellow/green in color. Her vital signs were blood pressure 159/104, blood sugar 194 and oxygen saturation level was on 90% on 2 liters of oxygen (Note: On 10/25/13 blood pressure was 154/86 and oxygen saturation level 98% on room air.) Medical Director N was consulted (3.25 hours after she first experienced an incident of vomiting). The physician gave orders for 4 mg of [MEDICATION NAME] (anti-nausea/vomiting medication) every six hours as needed. The medication was given at that time. The physician was asked if he wanted STAT labs and he replied not at this time. - at 7:30 a.m., her blood pressure was 139/100 and her oxygen saturation level had decreased to 85% on 2 liters of oxygen. She had "wheezes and bronchi sounds were audible" and the oxygen was increased from 2 liters to 3 liters per minute. The notes reflected her respirations were labored, heart rate was 102 and oxygen saturation level ranged from 85% to 90% on 3 liters of oxygen. Resident #1 was "staring into space, lethargic," and refused her breakfast and a milk shake. A voice message was left for Medical Director N. A Nurse's Note, completed by LVN H and dated 10/26/13, at 8:00 a.m., reflected the family was notified of the fall which had occurred approximately six hours earlier. There was no documented evidence the family was notified Resident #1 had experienced incidents of vomiting since the fall, lethargy or audible wheezing and bronchi sounds, or decreased oxygen saturation level. An interview with Resident #1's family member on 11/13/13 at 1:45 p.m. revealed he/she discovered a voice message on their telephone for 2:00 a.m., but there was no additional call from the facility until 8:00 a.m. The X-ray Reports, dated 10/26/13, and transcribed at 9:20 a.m., reflected the following: - Right shoulder with two views obtained - no acute fracture. - Right elbow with two views obtained, which reflected the "bones are quite osteoporotic" The impression was [MEDICAL CONDITION] humerus, and "these are non standard films making evaluation difficult. Humeral radiography is probably warranted for further evaluation." The Nurse's notes, completed by LVN H and dated 10/26/13 for 12:30 p.m. (5 hours after the first message was left for Medical Director N), reflected Resident #1's "breathing still labored with audible wheezes and bronchi, oxygen saturation level at 85% on 3 liters of oxygen. Another message was left for Medical Director N. The Notes reflected at 1:00 p.m., the nurse called the Medical Director O, and informed him of Resident #1's condition, and "she did not look well." Medical Director O was notified two messages were left for Medical Director N with no response. Medical Director O gave orders for a STAT chest x-ray and CMP and BMP laboratory tests. The mobile x-ray company was notified and the family was notified. An interview with Medical Director O on 11/14/13 at approximately 11:00 a.m. revealed he recalled being told the nurse had been unable to contact the resident's attending physician. He stated the nurse notified him Resident #1 was not doing well, but her vital signs were stable. Medical Director O revealed he did not remember any mention of a fall or fracture. He stated he would have sent her to the hospital. Medical Director O revealed the Administrator and the DON had his direct cell phone number. The X-Ray Report, dated 10/26/13 and transcribed at 2:59 p.m., reflected two chest views were obtained and compared to a chest view from 07/02/12. The results reflected her bones were "quite osteoporotic." The impression was she had no acute pneumonia, although, there was "some degree of [MEDICAL CONDITIONS]." An interview with LVN H on 11/13/13 at approximately 8:30 a.m. revealed she was on duty on 10/26/13 from 6:00 a.m. to 2:00 p.m. She stated she was informed at shift change that Resident #1 had fallen. LVN H stated upon her assessment, she saw no signs of injury. LVN H revealed she was not told during shift change report that Resident #1 had been vomiting or experiencing diarrhea. She stated she found Resident #1 covered in vomit, so she contacted the previous shift's LVN to ask about the resident's symptoms. She was told by RN A Resident #1 had experienced small amounts of vomit and diarrhea during her shift. She stated she notified Medical Director N regarding the vomiting and diarrhea and he gave an order for [REDACTED]. LVN H added she did not review Resident #1's clinical record to verify it was the fracture she had on admission. She revealed when Resident #1 began experiencing difficulty in breathing, she administered oxygen and a breathing treatment, and her breathing improved. LVN H stated she was unable to reach Medical Director N. She discussed Resident #1's vomiting, diarrhea, and breathing issues with the ADON P, who did not recommend sending Resident #1 to the hospital. LVN H stated the normal process was to explain the situation to the ADON, who would decide to send the Resident to the hospital. LVN H revealed she was instructed by ADON P to keep trying to contact the resident's physician. LVN H stated when she spoke with Medical Director O, she told him the fractured elbow was a fracture the resident admitted with, and she told him about her shortness of breath and lethargy. She stated Medical Director O gave orders for a STAT chest x-ray and laboratory tests. She stated the results of the laboratory tests did not come in prior to the end of her shift. LVN H revealed during the shift change report with the on-coming nurse, she did not tell the nurse about the results of the x-rays obtained that morning, but instead only told the nurse the same information relayed to her during her shift change meeting: Resident #1 had admitted with multiple fractures. An interview with ADON P on 11/13/13 at 10:00 a.m. revealed she was a manager on duty and oversaw things from 11:00 a.m. to 3:00 p.m. She stated she was not a manager on duty full time on the weekends. ADON P revealed if an incident occurred they were to notify the Administrator, DON, and ADON. She stated they try to contact the physician and call the physician again if there was no response. ADON P revealed if there was still no response from the physician, then they contact the Medical Director. She stated if she had known about Resident #1's vomiting and nausea, she would have told the nurse to send the resident to the hospital. ADON P revealed she remembered being told about the resident's difficulty in breathing, and the nurse not being able to contact the physician. She stated she told the nurse to contact Medical Director O. An interview with Resident #1's family member on 11/13/13 at 1:45 p.m. revealed upon arrival at the facility around 1:30 p.m., Resident #1's arm was swollen and her wrist looked "twisted." Her eye was also swollen and black. Resident #1's family member revealed the resident was so short of breath, she could not verbalize. He/She stated around 3:00 p.m., Resident #1 received a breathing treatment, but she continued to be short of breath. Resident #1's family member revealed he/she requested Resident #1 be sent to the hospital and was told by the nurse on duty they were waiting on the results of the additional x-ray and laboratory tests. The family member stated the resident was in pain, but staff would not give her anything because of her elevated blood pressure and breathing issues. He/She revealed the staff eventually gave the resident Tylenol. Resident #1's Nurse's Notes, dated 10/26/13, timed at 4:00 p.m. and completed by RN B, reflected she was "lethargic, arousable." Her vitals signs were temperature 100 degrees F, pulse 110, respirations 22, blood pressure 124/87, and oxygen saturation level at 97% on 2 liters of oxygen. The resident complained of pain in right arm, and it was elevated on a pillow. The resident was given Tylenol 325 mg at 3:45 p.m. The Nurse's Notes, dated 10/26/13 and timed at 5:45 p.m., reflected Medical Director N was notified of the results of the right elbow/arm x-ray that had been available since 9:48 a.m. that morning, and that Resident #1's white blood count was elevated and her potassium was low. Medical Director N gave orders to transfer her to the hospital. At 6:10 p.m., the ambulance service was notified, and the ambulance arrived at 6:45 p.m. At that time, her vitals were temperature 100 degrees F, pulse 110 respirations 20, and blood pressure 130/86. An interview with RN B on 11/13/13 at approximately 2:00 p.m. revealed she was Resident #1's nurse on 10/26/13 for the 2:00 p.m. to 10:00 p.m. shift. RN B stated she did not recall the day shift nurse (LVN H) mentioning Resident #1 had episodes of nausea and vomiting. She revealed during her shift, Resident #1 did not have episodes of nausea and/or vomiting. She further stated LVN H requested she report the results of Resident #1's x-rays to Medical Director N, the resident's attending physician. She said at approximately 4:30 p.m. (2.5 hours after the start of her shift), she left a message for Medical Director N. She stated she waited until 4:30 p.m. to call because she was waiting on the results of the laboratory tests and the x-rays. RN B revealed at 5:45 p.m. Medical Director N returned her call, and she consulted with him regarding the results of the chest x-rays and the laboratory results, which had also come in. She stated he ordered Resident #1 sent to the hospital. RN B said she would not send a resident to the hospital without a physician's orders [REDACTED]. She stated she did not consider Resident #1 to have had that level of change in her condition. RN B revealed if a resident had a fracture, she generally waited to send the resident to the hospital until she spoke with the physician. She stated her assessment of Resident #1 did not reveal any signs/symptoms of vomiting. An interview with the DON on 11/12/13 at 4:30 p.m. revealed she had not been aware the x-rays obtained at the facility had identified a fractured elbow. She stated she was aware the nurse had attempted to call the resident's attending physician without success. The DON revealed sending a resident to the hospital was nursing judgement, but then stated she could "give a reason for the delay, but it would just be an excuse." Resident #1's x-ray reports from the first hospital, dated 10/26/13, reflected a [MEDICAL CONDITION] radius and ulna of her left wrist. During an interview with Resident #1's family member on 11/13/13 at 1:45 p.m., he/she stated Resident #1 was transferred to a second hospital for additional care where she was in initially in the Intensive Care Unit. Resident #1's Trauma Admission/Consultation, from the second hospital dated 10/27/13, reflected, "...Lst night, pt (Resident #1) reportedly fell from bed onto wood floor with injuries to right face and right long bones. Transferred to (second hospital's name) ED (Emergency Department) for the following fractures: R (right) humerus fracture with humeral prosethesis Zygomtatic (cheekbone) arch and max sinus R distal ulna and radius (wrist) fracture L (left pelvis fracture...Right Periorbital [MEDICAL CONDITION]/contusion (surrounding the socket of the eye), Right malar (cheekbone) depression...." Resident #1's Surgical Note, dated 10/27/13, reflected, "...Admit to ICU for trauma in the elderly...." The facility's current, undated Change of Condition Policy and Procedures reflected the "facility staff will assess, record and report any significant change in a resident condition to the attending physician to ensure appropriate care and treatment...Licensed nursing staff will assess and report changes of a residents' (sic) condition to the physician/physician extender in a timely manner. Changes in condition include (but are not limited to): - Falls - Physical changes: injury...- Mental changes: change in cognition/orientation, personality changes...-Abnormal lab results and diagnostic test results...Charge nurse will notify the attending physician/extender of any significant change of condition. The residents' responsible party will also be notified of changes in condition...." On 11/14/13 an IJ was identifed. On 11/14/13 at 1:03 p.m., the Administrator, DON, and RNC L were notified of the IJ and a Plan of Removal was requested at that time. On 11/15/13, at 6:00 p.m., the Administrator was notified the facility's Plan of Removal was accepted. The plan reflected: -- A QA Meeting was conducted on 11/14/13 with the Administrator, DON, RN Clinical Constant L and the following present via telephone conference call: Regional Director of Operations, RN Clinical Consultant M and Joint Medical Directors, N and O. -- In-services were conducted by ADON P and ADON Q on 10/29/13 and 10/30/13 regarding neuro-checks, head injuries and ICP injuries; change in condition and transferring residents to the ER, post-accident/incident procedures, admission assessments included fall risk assessments and fall risk interventions to prevent falls, post-incident interventions, emergency responses, bed and chair alarms, and care planning of falls. -- A compete audit of all resident charts was conducted to ensure Fall Risk Assessments had been completed within the last 30 days. The task was completed on or before 11/14/13 at 5:00 p.m. by the DON, ADON P, and ADON Q. All residents with a score greater than 6 were classified as high risk for falls and their care plans were reviewed and updated to reflect appropriate safety measures had been implemented. All such safety measures were confirmed to be in place by visual observations. These tasks were completed by ADON P, ADON Q, LVN J, and LVN K on or before 11/14/13 at 8:00 p.m. -- Fall Risk Assessments for newly admitted residents will be completed within the first eight hours of admission by the admitting nurse. The ADONs will review each new Admission Chart within 72 hours of admission to ensure Fall Risk Assessments are complete, accurate and appropriate intervention are observed in place. -- Fall prevention equipment will be stored in the medical supply closet on Hall 400 and all nurses on all shifts will have access. This practice will be initiated by 11/15/13 at 3:30 p.m. The availability of supplies will be monitored by the Central Supply Coordinator Monday through Friday. -- Residents identified as being at high risk for falls will be communicated to all clinical staff members using the EMR Messaging System/Accunurse System. At the beginning of each shift , the Charge Nurse will make resident assignments to all Nurse Aides. The Nurse Aides are required to use their head-sets to Review Plan of Care for each of their assigned residents. The Plan of Care identifies the resident at high risk for falls and list interventions that are to be in place foreach high risk resident. The Charge Nurse is to monitor the Accurnurse System prior to the end of each shift to ensure the Nurse Aides have competed their assignments and listened to their residents' plan of care. -- The DON and ADONs (and designated staff as scheduled by the DON) will conduct observation rounds on a daily basis, 7 days per week to ensure appropriate fall prevention measures are in place for each high risk resident. -- The facility began implementation of the Falling Star Program on 11/14/13 and all facility staff members trained on this program to ensure that all staff members are aware of residents at high risk of falls. The Falling Star Program will designate the residents who have a Fall Risk Assessment Score of above six with a star beside their name plate posted on the wall directly outside of each resident room. For new admissions, the admitting Charge Nurse will be responsible for initiating the Falling Star Program for residents assessed as being at high risk for falls. The DON will be responsible for the over-all monitoring of the Falling Star Program. The training of the Falling Star Program was initiated by the DON on 11/15/13 and all staff will be trained prior to their on-coming shift unit all staff have received the training. All staff will be required to successfully complete a post-test. If a staff member fails the test, they will be provided additional information and will be re-issues the post-test until successful completion. Training on the Falling Star Program will be part of New Hire Orientation starting 11/15/13. -- The facility's policy and practice will be that it is mandatory for all nurses to complete an SBAR for every resident fall and significant change in condition. This was effective 11/14/13 at 5:00 p.m. -- The facility's policy and practice will be that nurses are to wait a maximum of 30 minutes to receive a return call from a physician after the nurse has attempted to contact the physician following a resident fall and/or change of condition. After no longer than 30 minutes, a repeat call will be made and a maximum of 15 minutes thereafter will be allowed for a return call from the physician. If the nurse's call is not returned within 45 minutes of the original call, then the nurse will notify the Medical Director and DON (or ADON designee on the on-call schedule). This was effective Interviews with nurses from all three shifts confirmed staff had received in-service training regarding the following information: --Information to include on an SBAR --Information to provide to on-coming nurses at shift change --Components of a comprehensive assessment of a resident --Timeframes for contacting the physician after an incident --Timeframes for notifying the DON/ADON of a fall --Components of Incident/Accident Reports --Facilities "falling star" program The following nurses were interviewed on 11/14/2013 between 9:00 a.m. and 5:00 p.m and provided appropriate answers regarding the previously identified in-services: RN A RN C The following nurses were interviewed on 11/15/2013 between 8:00 a.m. and 5:00 p.m and provided appropriate answers regarding the previously identified in-services.: LVN H LVN R LVN S LVN T LVN U LVN V LVN W LVN X LVN Y LVN Z The following staff were interviewed on 11/17/2013 regarding the facility's "Falling Star" program and provided appropriate answers indicating knowledge of the program: CNA CC CNA DD CNA EE The following staff were interviewed on 11/18/2013 regarding the facility's "Falling Star" program and provided appropriate answers indicating knowledge of the program: CNA AA Dietary Manager Housekeeper BB Housekeeping Supervisor Cook FF Observations on 11/17/2013 and 11/18/2013 of resident's rooms and wheelchairs revealed residents identified as being a "fall risk" had a small "star" placed next to their name on the name plate located near the door to their room and attached to their wheelchairs to assist staff in identifying the resident as a "fall risk." The facility's Incident/Accident report, dated 10/31/13, reflected Resident #2 experienced an unwitnessed fall from her wheelchair and sustained substantial injury to her face and was bleeding as a result of these injuries. The report indicated 911 was contacted immediately after the resident was assessed, and the resident was subsequently transported to the hospital for treatment. On 11/18/13 at 5:50 p.m, the Administrator, DON, RNC M, ADON P, and ADON Q, were notified the IJ had been removed. While IJ was removed, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of pattern due to staff were still being in-serviced, and the facility was monitoring the effectiveness of the Plan of Removal. The facility's Resident Roster, dated 10/12/13, reflected 13 residents resided on the 200 Hall.

Based on observation, interview and record review, the facility failed to implement their policies and procedures for neglect prevention for one (Resident #1) of eight residents reviewed for neglect. Resident #1 admitted with two fractures. Within 12 hours of admission she fell . Nursing staff failed to: -- conduct a head-to-toe assessment to determine the extent of the resident's injuries, -- provide Resident #1's physician/NP with an accurate assessment of Resident #1's status and allow the physician/NP to respond appropriately. -- communicate shift-to-shift Resident #1's condition at time of admission, condition following the fall, and change in condition during subsequent hours after the fall. As a result, there was a delay of approximately 14 hours before Resident #1 transferred to hospital and was subsequently identified as sustaining additional fractures; thus, delaying timely care and services. On 11/13/13 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 11/18/13, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because staff were still being in-serviced, and the facility was monitoring the effectiveness of the Plan of Removal. These failures could affect the 13 residents, who resided on the 200 Hall, by placing them at risk for not being adequately assessed with [REDACTED]. in a delay in treatment or [DIAGNOSES REDACTED]. Findings included: Resident #1's Face Sheet, printed on 11/04/13, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's Admission Data, dated 10/25/13, reflected she was admitted to the facility at 2:16 p.m., and was alert, but disoriented to place and time, required limited assistance with transfers and ambulation. Resident #1 was only partially able to bear weight, and she had an abnormal gait. She had bruising/discoloration to her right arm and left and right hands, plus a rash/redness to her left shoulder. Resident #1's Fall Risk evaluation, dated 10/25/13, reflected she was a high fall risk due to mild/moderately impaired cognitive status, required assistance for mobility, required limited assistance for transfers, partial weight bearing status, use of an assistive device (wheelchair), vision (wears glasses), occasional incontinence, and received two or more medications (diuretics, cardiovascular, routine pain, anti-hypertensive, antipsychotic, anti-anxiety, sleeping, or anti-depressant). The evaluation also reflected she had a fall in the last six months. Resident #1's initial Care Plan, dated 10/25/13, reflected a concern for fall/safety risk (Fall Risk score of 10) with a goal of no injury falls. Interventions included encourage to use call light, physical therapy referral, instruct on safety measures, and bed/chair alarm. Resident #1's Nurse's Notes, completed by LVN I and dated 10/25/13 at 11:31 p.m., reflected she admitted to the facility with a fracture to her left upper extremity. She had bruises to her upper extremities with redness to her right shoulder. She was alert and "pleasantly confused" and required "constant monitoring." The Notes reflected "several times" Resident #1 attempted unassisted transfers and was redirected. Her vital signs were blood pressure 154/86, pulse 80, respirations 18, and oxygen saturation level 98% on room air. Resident #1's Nurse's Notes, completed by RN A and dated 10/26/13 for 2:10 a.m. (12 hours after admitting to the facility), reflected Resident #1 was found in her room, near the sitting area, lying on her right side in a fetal position. She told staff she fell . She demonstrated the ability to move all her extremities and with the assistance of two staff, she walked back to her bed. The Notes reflected Resident #1 was "very confused" and had a new abrasion to her outer, lower right arm, measuring 2.0 cm wide by 7.0 cm long, and blue discoloration extending from the right side of her nose to the outer edge of her right eye. She had a bruise to the top of her right shoulder, which was previously there, but now with the movement of her right arm, the resident grimaced. The Note also reflected a small amount of blood was cleaned off the resident, but the site was not indicated. Resident #1's Nurse's Notes, completed by RN A and dated 10/26/13 for 2:20 a.m., reflected her attending physician, Medical Director N, was notified of the fall, and gave an order for [REDACTED]. The Incident/Accident Report, dated 10/26/13, documented Resident #1's fall on 10/26/13 at 2:10 a.m., and noted the abrasion as recorded in the Nurse's Notes. The Report also reflected, "...Also has blue discoloration under OD (right eye). Pupils react very sluggish. Denies pain, but is very confused and unable to respond to questions appropriately." Her vital signs were blood pressure 140/84 (normal blood pressure systolic 100 - 130 mmHg/diastolic 60 - 80 mmHg), pulse 76 (normal resting pulse in adults is between 60 and 80 beats per minute), respirations 18 (adults normal respiratory rate is more than 12 to 20 breaths a minutes) , temperature 96.8 F (normal temperature is 97.5 to 99.5 degrees F) and oxygen saturation level was 95% (normal oxygen saturation level is normally higher than 96%.) An interview with RN A on 11/15/13 at 8:00 a.m. revealed she was the nurse for Resident #1 on the 10:00 p.m. to 6:00 a.m. shift on the night of the fall (10/26/13). RN A stated she discovered Resident #1 on the floor in the sitting room outside of her bedroom with the bed alarm activated. She revealed the resident was lying in a fetal position and with the assistance from a CNA, she placed the resident back in her bed. She stated she observed no swelling of Resident #1's extremities and the only injury was a small abrasion on her right arm. RN A revealed Resident #1 did have discoloration under her eye, but a CNA told her the discoloration was present before the fall. RN A added Resident #1's clinical record did not have any documentation of the discoloration under her eye. RN A stated she contacted Resident #1's attending physician, Medical Director N, after the fall. RN A stated he said if the Resident was hurting, to get x-rays. RN A revealed she completed neuro checks every 15 minutes, then every 30 minutes. She stated Resident #1 did not complain of pain, but the resident appeared uncomfortable. She revealed she attempted to give her a Tylenol (over the counter pain medication), but the resident spit it out. Further review of Resident #1's Nurse's Notes, completed by RN A and dated 10/26/13, for after the fall reflected: - at 3:00 a.m., she vomited a small amount of a yellow substance. - at 5:00 a.m., she had "several" episodes of a small amounts of vomit. The Notes provided no evidence the physician and family were notified of this change of condition. Resident #1's Nurse's Notes, completed by LVN H and dated 10/26/13, reflected: - at 6:15 a.m., x-ray technician notified the nurse Resident #1 was vomiting. The vomit was yellow/green in color. Her vital signs were blood pressure 159/104, blood sugar 194 and oxygen saturation level was on 90% on 2 liters of oxygen (Note: On 10/25/13 blood pressure was 154/86 and oxygen saturation level 98% on room air.) Medical Director N was consulted (3.25 hours after she first experienced an incident of vomiting). The physician gave orders for 4 mg of [MEDICATION NAME] (anti-nausea/vomiting medication) every six hours as needed. The medication was given at that time. The physician was asked if he wanted STAT labs and he replied not at this time. - at 7:30 a.m., her blood pressure was 139/100 and her oxygen saturation level had decreased to 85% on 2 liters of oxygen. She had "wheezes and bronchi sounds were audible" and the oxygen was increased from 2 liters to 3 liters per minute. The notes reflected her respirations were labored, heart rate was 102 and oxygen saturation level ranged from 85% to 90% on 3 liters of oxygen. Resident #1 was "staring into space, lethargic," and refused her breakfast and a milk shake. A voice message was left for Medical Director N. The X-ray Reports, dated 10/26/13, and transcribed at 9:20 a.m., reflected the following: - Right shoulder with two views obtained - no acute fracture. - Right elbow with two views obtained, which reflected the "bones are quite osteoporotic" The impression was [MEDICAL CONDITION] humerus, and "these are non standard films making evaluation difficult. Humeral radiography is probably warranted for further evaluation." The Nurse's notes, completed by LVN H and dated 10/26/13 for 12:30 p.m. (5 hours after the first message was left for Medical Director N), reflected Resident #1's "breathing still labored with audible wheezes and bronchi, oxygen saturation level at 85% on 3 liters of oxygen. Another message was left for Medical Director N. The Notes reflected at 1:00 p.m., the nurse called the Medical Director O, and informed him of Resident #1's condition, and "she did not look well." Medical Director O was notified two messages were left for Medical Director N with no response. Medical Director O gave orders for a STAT chest x-ray and CMP and BMP laboratory tests. The mobile x-ray company was notified and the family was notified. An interview with Medical Director O on 11/14/13 at approximately 11:00 a.m. revealed he recalled being told the nurse had been unable to contact the resident's attending physician. He stated the nurse notified him Resident #1 was not doing well, but her vital signs were stable. Medical Director O revealed he did not remember any mention of a fall or fracture. He stated he would have sent her to the hospital. Medical Director O revealed the Administrator and the DON had his direct cell phone number. The X-Ray Report, dated 10/26/13 and transcribed at 2:59 p.m., reflected two chest views were obtained and compared to a chest view from 07/02/12. The results reflected her bones were "quite osteoporotic." The impression was she had no acute pneumonia, although, there was "some degree of [MEDICAL CONDITIONS]." An interview with LVN H on 11/13/13 at approximately 8:30 a.m. revealed she was on duty on 10/26/13 from 6:00 a.m. to 2:00 p.m. She stated she was informed at shift change that Resident #1 had fallen. LVN H stated upon her assessment, she saw no signs of injury. LVN H revealed she was not told during shift change report that Resident #1 had been vomiting or experiencing diarrhea. She stated she found Resident #1 covered in vomit, so she contacted the previous shift's LVN to ask about the resident's symptoms. She was told by RN A Resident #1 had experienced small amounts of vomit and diarrhea during her shift. She stated she notified Medical Director N regarding the vomiting and diarrhea and he gave an order for [REDACTED]. LVN H added she did not review Resident #1's clinical record to verify it was the fracture she had on admission. She revealed when Resident #1 began experiencing difficulty in breathing, she administered oxygen and a breathing treatment, and her breathing improved. LVN H stated she was unable to reach Medical Director N. She discussed Resident #1's vomiting, diarrhea, and breathing issues with the ADON P, who did not recommend sending Resident #1 to the hospital. LVN H stated the normal process was to explain the situation to the ADON, who would decide to send the Resident to the hospital. LVN H revealed she was instructed by ADON P to keep trying to contact the resident's physician. LVN H stated when she spoke with Medical Director O, she told him the fractured elbow was a fracture the resident admitted with, and she told him about her shortness of breath and lethargy. She stated Medical Director O gave orders for a STAT chest x-ray and laboratory tests. She stated the results of the laboratory tests did not come in prior to the end of her shift. LVN H revealed during the shift change report with the on-coming nurse, she did not tell the nurse about the results of the x-rays obtained that morning, but instead only told the nurse the same information relayed to her during her shift change meeting: Resident #1 had admitted with multiple fractures. An interview with ADON P on 11/13/13 at 10:00 a.m. revealed she was a manager on duty and oversaw things from 11:00 a.m. to 3:00 p.m. She stated she was not a manager on duty full time on the weekends. ADON P revealed if an incident occurred they were to notify the Administrator, DON, and ADON. She stated they try to contact the physician and call the physician again if there was no response. ADON P revealed if there was still no response from the physician, then they contact the Medical Director. She stated if she had known about Resident #1's vomiting and nausea, she would have told the nurse to send the resident to the hospital. ADON P revealed she remembered being told about the resident's difficulty in breathing, and the nurse not being able to contact the physician. She stated she told the nurse to contact Medical Director O. An interview with Resident #1's family member on 11/13/13 at 1:45 p.m. revealed upon arrival at the facility around 1:30 p.m., Resident #1's arm was swollen and her wrist looked "twisted." Her eye was also swollen and black. Resident #1's family member revealed the resident was so short of breath, she could not verbalize. He/She stated around 3:00 p.m., Resident #1 received a breathing treatment, but she continued to be short of breath. Resident #1's family member revealed he/she requested Resident #1 be sent to the hospital and was told by the nurse on duty they were waiting on the results of the additional x-ray and laboratory tests. The family member stated the resident was in pain, but staff would not give her anything because of her elevated blood pressure and breathing issues. He/She revealed the staff eventually gave the resident Tylenol. Resident #1's Nurse's Notes, dated 10/26/13, timed at 4:00 p.m. and completed by RN B, reflected she was "lethargic, arousable." Her vitals signs were temperature 100 degrees F, pulse 110, respirations 22, blood pressure 124/87, and oxygen saturation level at 97% on 2 liters of oxygen. The resident complained of pain in right arm, and it was elevated on a pillow. The resident was given Tylenol 325 mg at 3:45 p.m. The Nurse's Notes, dated 10/26/13 and timed at 5:45 p.m., reflected Medical Director N was notified of the results of the right elbow/arm x-ray that had been available since 9:48 a.m. that morning, and that Resident #1's white blood count was elevated and her potassium was low. Medical Director N gave orders to transfer her to the hospital. At 6:10 p.m., the ambulance service was notified, and the ambulance arrived at 6:45 p.m. At that time, her vitals were temperature 100 degrees F, pulse 110 respirations 20, and blood pressure 130/86. An interview with RN B on 11/13/13 at approximately 2:00 p.m. revealed she was Resident #1's nurse on 10/26/13 for the 2:00 p.m. to 10:00 p.m. shift. RN B stated she did not recall the day shift nurse (LVN H) mentioning Resident #1 had episodes of nausea and vomiting. She revealed during her shift, Resident #1 did not have episodes of nausea and/or vomiting. She further stated LVN H requested she report the results of Resident #1's x-rays to Medical Director N, the resident's attending physician. She said at approximately 4:30 p.m. (2.5 hours after the start of her shift), she left a message for Medical Director N. She stated she waited until 4:30 p.m. to call because she was waiting on the results of the laboratory tests and the x-rays. RN B revealed at 5:45 p.m. Medical Director N returned her call, and she consulted with him regarding the results of the chest x-rays and the laboratory results, which had also come in. She stated he ordered Resident #1 sent to the hospital. RN B said she would not send a resident to the hospital without a physician's orders [REDACTED]. She stated she did not consider Resident #1 to have had that level of change in her condition. RN B revealed if a resident had a fracture, she generally waited to send the resident to the hospital until she spoke with the physician. She stated her assessment of Resident #1 did not reveal any signs/symptoms of vomiting. An interview with the DON on 11/12/13 at 4:30 p.m. revealed she had not been aware the x-rays obtained at the facility had identified a fractured elbow. She stated she was aware the nurse had attempted to call the resident's attending physician without success. The DON revealed sending a resident to the hospital was nursing judgement, but then stated she could "give a reason for the delay, but it would just be an excuse." Resident #1's x-ray reports from the first hospital, dated 10/26/13, reflected a [MEDICAL CONDITION] radius and ulna of her left wrist. During an interview with Resident #1's family member on 11/13/13 at 1:45 p.m., he/she stated Resident #1 was transferred to a second hospital for additional care where she was in initially in the Intensive Care Unit. Resident #1's Trauma Admission/Consultation, from the second hospital dated 10/27/13, reflected, "...Lst night, pt (Resident #1) reportedly fell from bed onto wood floor with injuries to right face and right long bones. Transferred to (second hospital's name) ED (Emergency Department) for the following fractures: R (right) humerus fracture with humeral prosethesis Zygomtatic (cheekbone) arch and max sinus R distal ulna and radius (wrist) fracture L (left pelvis fracture...Right Periorbital [MEDICAL CONDITION]/contusion (surrounding the socket of the eye), Right malar (cheekbone) depression...." Resident #1's Surgical Note, dated 10/27/13, reflected, "...Admit to ICU for trauma in the elderly...." The facility's current, undated Abuse Proibition Management Program reflected, "Policy: Our Facility will not condone resident...neglect...h. Neglect is a deprivation of life's necessities of food, water, or shelter, or in a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to the resident...." The facility's current, undated Change of Condition Policy and Procedures reflected the "facility staff will assess, record and report any significant change in a resident condition to the attending physician to ensure appropriate care and treatment...Licensed nursing staff will assess and report changes of a residents' (sic) condition to the physician/physician extender in a timely manner. Changes in condition include (but are not limited to): - Falls - Physical changes: injury...- Mental changes: change in cognition/orientation, personality changes...-Abnormal lab results and diagnostic test results...Charge nurse will notify the attending physician/extender of any significant change of condition. The residents' responsible party will also be notified of changes in condition...." On 11/14/13 an IJ was identifed. On 11/14/13 at 1:03 p.m., the Administrator, DON, and RNC L were notified of the IJ and a Plan of Removal was requested at that time. On 11/15/13, at 6:00 p.m., the Administrator was notified the facility's Plan of Removal was accepted. The plan reflected: -- A QA Meeting was conducted on 11/14/13 with the Administrator, DON, RN Clinical Constant L and the following present via telephone conference call: Regional Director of Operations, RN Clinical Consultant M and Joint Medical Directors, N and O. -- In-services were conducted by ADON P and ADON Q on 10/29/13 and 10/30/13 regarding neuro-checks, head injuries and ICP injuries; change in condition and transferring residents to the ER, post-accident/incident procedures, admission assessments included fall risk assessments and fall risk interventions to prevent falls, post-incident interventions, emergency responses, bed and chair alarms, and care planning of falls. -- A compete audit of all resident charts was conducted to ensure Fall Risk Assessments had been completed within the last 30 days. The task was completed on or before 11/14/13 at 5:00 p.m. by the DON, ADON P, and ADON Q. All residents with a score greater than 6 were classified as high risk for falls and their care plans were reviewed and updated to reflect appropriate safety measures had been implemented. All such safety measures were confirmed to be in place by visual observations. These tasks were completed by ADON P, ADON Q, LVN J, and LVN K on or before 11/14/13 at 8:00 p.m. -- Fall Risk Assessments for newly admitted residents will be completed within the first eight hours of admission by the admitting nurse. The ADONs will review each new Admission Chart within 72 hours of admission to ensure Fall Risk Assessments are complete, accurate and appropriate intervention are observed in place. -- Fall prevention equipment will be stored in the medical supply closet on Hall 400 and all nurses on all shifts will have access. This practice will be initiated by 11/15/13 at 3:30 p.m. The availability of supplies will be monitored by the Central Supply Coordinator Monday through Friday. -- Residents identified as being at high risk for falls will be communicated to all clinical staff members using the EMR Messaging System/Accunurse System. At the beginning of each shift , the Charge Nurse will make resident assignments to all Nurse Aides. The Nurse Aides are required to use their head-sets to Review Plan of Care for each of their assigned residents. The Plan of Care identifies the resident at high risk for falls and list interventions that are to be in place foreach high risk resident. The Charge Nurse is to monitor the Accurnurse System prior to the end of each shift to ensure the Nurse Aides have competed their assignments and listened to their residents' plan of care. -- The DON and ADONs (and designated staff as scheduled by the DON) will conduct observation rounds on a daily basis, 7 days per week to ensure appropriate fall prevention measures are in place for each high risk resident. -- The facility began implementation of the Falling Star Program on 11/14/13 and all facility staff members trained on this program to ensure that all staff members are aware of residents at high risk of falls. The Falling Star Program will designate the residents who have a Fall Risk Assessment Score of above six with a star beside their name plate posted on the wall directly outside of each resident room. For new admissions, the admitting Charge Nurse will be responsible for initiating the Falling Star Program for residents assessed as being at high risk for falls. The DON will be responsible for the over-all monitoring of the Falling Star Program. The training of the Falling Star Program was initiated by the DON on 11/15/13 and all staff will be trained prior to their on-coming shift unit all staff have received the training. All staff will be required to successfully complete a post-test. If a staff member fails the test, they will be provided additional information and will be re-issues the post-test until successful completion. Training on the Falling Star Program will be part of New Hire Orientation starting 11/15/13. -- The facility's policy and practice will be that it is mandatory for all nurses to complete an SBAR for every resident fall and significant change in condition. This was effective 11/14/13 at 5:00 p.m. -- The facility's policy and practice will be that nurses are to wait a maximum of 30 minutes to receive a return call from a physician after the nurse has attempted to contact the physician following a resident fall and/or change of condition. After no longer than 30 minutes, a repeat call will be made and a maximum of 15 minutes thereafter will be allowed for a return call from the physician. If the nurse's call is not returned within 45 minutes of the original call, then the nurse will notify the Medical Director and DON (or ADON designee on the on-call schedule). This was effective Interviews with nurses from all three shifts confirmed staff had received in-service training regarding the following information: --Information to include on an SBAR --Information to provide to on-coming nurses at shift change --Components of a comprehensive assessment of a resident --Timeframes for contacting the physician after an incident --Timeframes for notifying the DON/ADON of a fall --Components of Incident/Accident Reports --Facilities "falling star" program The following nurses were interviewed on 11/14/2013 between 9:00 a.m. and 5:00 p.m and provided appropriate answers regarding the previously identified in-services: RN A RN C The following nurses were interviewed on 11/15/2013 between 8:00 a.m. and 5:00 p.m and provided appropriate answers regarding the previously identified in-services.: LVN H LVN R LVN S LVN T LVN U LVN V LVN W LVN X LVN Y LVN Z The following staff were interviewed on 11/17/2013 regarding the facility's "Falling Star" program and provided appropriate answers indicating knowledge of the program: CNA CC CNA DD CNA EE The following staff were interviewed on 11/18/2013 regarding the facility's "Falling Star" program and provided appropriate answers indicating knowledge of the program: CNA AA Dietary Manager Housekeeper BB Housekeeping Supervisor Cook FF Observations on 11/17/2013 and 11/18/2013 of resident's rooms and wheelchairs revealed residents identified as being a "fall risk" had a small "star" placed next to their name on the name plate located near the door to their room and attached to their wheelchairs to assist staff in identifying the resident as a "fall risk." The facility's Incident/Accident report, dated 10/31/13, reflected Resident #2 experienced an unwitnessed fall from her wheelchair and sustained substantial injury to her face and was bleeding as a result of these injuries. The report indicated 911 was contacted immediately after the resident was assessed, and the resident was subsequently transported to the hospital for treatment. On 11/18/13 at 5:50 p.m, the Administrator, DON, RNC M, ADON P, and ADON Q, were notified the IJ had been removed. While IJ was removed, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of pattern due to staff were still being in-serviced, and the facility was monitoring the effectiveness of the Plan of Removal. The facility's Resident Roster, dated 10/12/13, reflected 13 residents resided on the 200 Hall.

Based on observation, interview and record review, the facility failed to implement their policies and procedures for neglect prevention for one (Resident #1) of eight residents reviewed for neglect. Resident #1 admitted with two fractures. Within 12 hours of admission she fell . Nursing staff failed to: -- conduct a head-to-toe assessment to determine the extent of the resident's injuries, -- provide Resident #1's physician/NP with an accurate assessment of Resident #1's status and allow the physician/NP to respond appropriately. -- communicate shift-to-shift Resident #1's condition at time of admission, condition following the fall, and change in condition during subsequent hours after the fall. As a result, there was a delay of approximately 14 hours before Resident #1 transferred to hospital and was subsequently identified as sustaining additional fractures; thus, delaying timely care and services. On 11/13/13 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 11/18/13, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because staff were still being in-serviced, and the facility was monitoring the effectiveness of the Plan of Removal. These failures could affect the 13 residents, who resided on the 200 Hall, by placing them at risk for not being adequately assessed with [REDACTED]. in a delay in treatment or [DIAGNOSES REDACTED]. Findings included: The facility's current, undated Abuse Prohibition Management Program reflected, "Policy: Our Facility will not condone resident...neglect...h. Neglect is a deprivation of life's necessities of food, water, or shelter, or in a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to the resident...." Resident #1's Face Sheet, printed on 11/04/13, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's Admission Data, dated 10/25/13, reflected she was admitted to the facility at 2:16 p.m., and was alert, but disoriented to place and time, required limited assistance with transfers and ambulation. Resident #1 was only partially able to bear weight, and she had an abnormal gait. She had bruising/discoloration to her right arm and left and right hands, plus a rash/redness to her left shoulder. Resident #1's Fall Risk evaluation, dated 10/25/13, reflected she was a high fall risk due to mild/moderately impaired cognitive status, required assistance for mobility, required limited assistance for transfers, partial weight bearing status, use of an assistive device (wheelchair), vision (wears glasses), occasional incontinence, and received two or more medications (diuretics, cardiovascular, routine pain, anti-hypertensive, antipsychotic, anti-anxiety, sleeping, or anti-depressant). The evaluation also reflected she had a fall in the last six months. Resident #1's initial Care Plan, dated 10/25/13, reflected a concern for fall/safety risk (Fall Risk score of 10) with a goal of no injury falls. Interventions included encourage to use call light, physical therapy referral, instruct on safety measures, and bed/chair alarm. Resident #1's Nurse's Notes, completed by LVN I and dated 10/25/13 at 11:31 p.m., reflected she admitted to the facility with a fracture to her left upper extremity. She had bruises to her upper extremities with redness to her right shoulder. She was alert and "pleasantly confused" and required "constant monitoring." The Notes reflected "several times" Resident #1 attempted unassisted transfers and was redirected. Her vital signs were blood pressure 154/86, pulse 80, respirations 18, and oxygen saturation level 98% on room air. Resident #1's Nurse's Notes, completed by RN A and dated 10/26/13 for 2:10 a.m. (12 hours after admitting to the facility), reflected Resident #1 was found in her room, near the sitting area, lying on her right side in a fetal position. She told staff she fell . She demonstrated the ability to move all her extremities and with the assistance of two staff, she walked back to her bed. The Notes reflected Resident #1 was "very confused" and had a new abrasion to her outer, lower right arm, measuring 2.0 cm wide by 7.0 cm long, and blue discoloration extending from the right side of her nose to the outer edge of her right eye. She had a bruise to the top of her right shoulder, which was previously there, but now with the movement of her right arm, the resident grimaced. The Note also reflected a small amount of blood was cleaned off the resident, but the site was not indicated. Resident #1's Nurse's Notes, completed by RN A and dated 10/26/13 for 2:20 a.m., reflected her attending physician, Medical Director N, was notified of the fall, and gave an order for [REDACTED]. The Incident/Accident Report, dated 10/26/13, documented Resident #1's fall on 10/26/13 at 2:10 a.m., and noted the abrasion as recorded in the Nurse's Notes. The Report also reflected, "...Also has blue discoloration under OD (right eye). Pupils react very sluggish. Denies pain, but is very confused and unable to respond to questions appropriately." Her vital signs were blood pressure 140/84 (normal blood pressure systolic 100 - 130 mmHg/diastolic 60 - 80 mmHg), pulse 76 (normal resting pulse in adults is between 60 and 80 beats per minute), respirations 18 (adults normal respiratory rate is more than 12 to 20 breaths a minutes) , temperature 96.8 F (normal temperature is 97.5 to 99.5 degrees F) and oxygen saturation level was 95% (normal oxygen saturation level is normally higher than 96%.) An interview with RN A on 11/15/13 at 8:00 a.m. revealed she was the nurse for Resident #1 on the 10:00 p.m. to 6:00 a.m. shift on the night of the fall (10/26/13). RN A stated she discovered Resident #1 on the floor in the sitting room outside of her bedroom with the bed alarm activated. She revealed the resident was lying in a fetal position and with the assistance from a CNA, she placed the resident back in her bed. She stated she observed no swelling of Resident #1's extremities and the only injury was a small abrasion on her right arm. RN A revealed Resident #1 did have discoloration under her eye, but a CNA told her the discoloration was present before the fall. RN A added Resident #1's clinical record did not have any documentation of the discoloration under her eye. RN A stated she contacted Resident #1's attending physician, Medical Director N, after the fall. RN A stated he said if the Resident was hurting, to get x-rays. RN A revealed she completed neuro checks every 15 minutes, then every 30 minutes. She stated Resident #1 did not complain of pain, but the resident appeared uncomfortable. She revealed she attempted to give her a Tylenol (over the counter pain medication), but the resident spit it out. Further review of Resident #1's Nurse's Notes, completed by RN A and dated 10/26/13, for after the fall reflected: - at 3:00 a.m., she vomited a small amount of a yellow substance. - at 5:00 a.m., she had "several" episodes of a small amounts of vomit. The Notes provided no evidence the physician and family were notified of this change of condition. Resident #1's Nurse's Notes, completed by LVN H and dated 10/26/13, reflected: - at 6:15 a.m., x-ray technician notified the nurse Resident #1 was vomiting. The vomit was yellow/green in color. Her vital signs were blood pressure 159/104, blood sugar 194 and oxygen saturation level was on 90% on 2 liters of oxygen (Note: On 10/25/13 blood pressure was 154/86 and oxygen saturation level 98% on room air.) Medical Director N was consulted (3.25 hours after she first experienced an incident of vomiting). The physician gave orders for 4 mg of [MEDICATION NAME] (anti-nausea/vomiting medication) every six hours as needed. The medication was given at that time. The physician was asked if he wanted STAT labs and he replied not at this time. - at 7:30 a.m., her blood pressure was 139/100 and her oxygen saturation level had decreased to 85% on 2 liters of oxygen. She had "wheezes and bronchi sounds were audible" and the oxygen was increased from 2 liters to 3 liters per minute. The notes reflected her respirations were labored, heart rate was 102 and oxygen saturation level ranged from 85% to 90% on 3 liters of oxygen. Resident #1 was "staring into space, lethargic," and refused her breakfast and a milk shake. A voice message was left for Medical Director N. The X-ray Reports, dated 10/26/13, and transcribed at 9:20 a.m., reflected the following: - Right shoulder with two views obtained - no acute fracture. - Right elbow with two views obtained, which reflected the "bones are quite osteoporotic" The impression was [MEDICAL CONDITION] humerus, and "these are non standard films making evaluation difficult. Humeral radiography is probably warranted for further evaluation." The Nurse's notes, completed by LVN H and dated 10/26/13 for 12:30 p.m. (5 hours after the first message was left for Medical Director N), reflected Resident #1's "breathing still labored with audible wheezes and bronchi, oxygen saturation level at 85% on 3 liters of oxygen. Another message was left for Medical Director N. The Notes reflected at 1:00 p.m., the nurse called the Medical Director O, and informed him of Resident #1's condition, and "she did not look well." Medical Director O was notified two messages were left for Medical Director N with no response. Medical Director O gave orders for a STAT chest x-ray and CMP and BMP laboratory tests. The mobile x-ray company was notified and the family was notified. An interview with Medical Director O on 11/14/13 at approximately 11:00 a.m. revealed he recalled being told the nurse had been unable to contact the resident's attending physician. He stated the nurse notified him Resident #1 was not doing well, but her vital signs were stable. Medical Director O revealed he did not remember any mention of a fall or fracture. He stated he would have sent her to the hospital. Medical Director O revealed the Administrator and the DON had his direct cell phone number. The X-Ray Report, dated 10/26/13 and transcribed at 2:59 p.m., reflected two chest views were obtained and compared to a chest view from 07/02/12. The results reflected her bones were "quite osteoporotic." The impression was she had no acute pneumonia, although, there was "some degree of [MEDICAL CONDITIONS]." An interview with LVN H on 11/13/13 at approximately 8:30 a.m. revealed she was on duty on 10/26/13 from 6:00 a.m. to 2:00 p.m. She stated she was informed at shift change that Resident #1 had fallen. LVN H stated upon her assessment, she saw no signs of injury. LVN H revealed she was not told during shift change report that Resident #1 had been vomiting or experiencing diarrhea. She stated she found Resident #1 covered in vomit, so she contacted the previous shift's LVN to ask about the resident's symptoms. She was told by RN A Resident #1 had experienced small amounts of vomit and diarrhea during her shift. She stated she notified Medical Director N regarding the vomiting and diarrhea and he gave an order for [REDACTED]. LVN H added she did not review Resident #1's clinical record to verify it was the fracture she had on admission. She revealed when Resident #1 began experiencing difficulty in breathing, she administered oxygen and a breathing treatment, and her breathing improved. LVN H stated she was unable to reach Medical Director N. She discussed Resident #1's vomiting, diarrhea, and breathing issues with the ADON P, who did not recommend sending Resident #1 to the hospital. LVN H stated the normal process was to explain the situation to the ADON, who would decide to send the Resident to the hospital. LVN H revealed she was instructed by ADON P to keep trying to contact the resident's physician. LVN H stated when she spoke with Medical Director O, she told him the fractured elbow was a fracture the resident admitted with, and she told him about her shortness of breath and lethargy. She stated Medical Director O gave orders for a STAT chest x-ray and laboratory tests. She stated the results of the laboratory tests did not come in prior to the end of her shift. LVN H revealed during the shift change report with the on-coming nurse, she did not tell the nurse about the results of the x-rays obtained that morning, but instead only told the nurse the same information relayed to her during her shift change meeting: Resident #1 had admitted with multiple fractures. An interview with ADON P on 11/13/13 at 10:00 a.m. revealed she was a manager on duty and oversaw things from 11:00 a.m. to 3:00 p.m. She stated she was not a manager on duty full time on the weekends. ADON P revealed if an incident occurred they were to notify the Administrator, DON, and ADON. She stated they try to contact the physician and call the physician again if there was no response. ADON P revealed if there was still no response from the physician, then they contact the Medical Director. She stated if she had known about Resident #1's vomiting and nausea, she would have told the nurse to send the resident to the hospital. ADON P revealed she remembered being told about the resident's difficulty in breathing, and the nurse not being able to contact the physician. She stated she told the nurse to contact Medical Director O. An interview with Resident #1's family member on 11/13/13 at 1:45 p.m. revealed upon arrival at the facility around 1:30 p.m., Resident #1's arm was swollen and her wrist looked "twisted." Her eye was also swollen and black. Resident #1's family member revealed the resident was so short of breath, she could not verbalize. He/She stated around 3:00 p.m., Resident #1 received a breathing treatment, but she continued to be short of breath. Resident #1's family member revealed he/she requested Resident #1 be sent to the hospital and was told by the nurse on duty they were waiting on the results of the additional x-ray and laboratory tests. The family member stated the resident was in pain, but staff would not give her anything because of her elevated blood pressure and breathing issues. He/She revealed the staff eventually gave the resident Tylenol. Resident #1's Nurse's Notes, dated 10/26/13, timed at 4:00 p.m. and completed by RN B, reflected she was "lethargic, arousable." Her vitals signs were temperature 100 degrees F, pulse 110, respirations 22, blood pressure 124/87, and oxygen saturation level at 97% on 2 liters of oxygen. The resident complained of pain in right arm, and it was elevated on a pillow. The resident was given Tylenol 325 mg at 3:45 p.m. The Nurse's Notes, dated 10/26/13 and timed at 5:45 p.m., reflected Medical Director N was notified of the results of the right elbow/arm x-ray that had been available since 9:48 a.m. that morning, and that Resident #1's white blood count was elevated and her potassium was low. Medical Director N gave orders to transfer her to the hospital. At 6:10 p.m., the ambulance service was notified, and the ambulance arrived at 6:45 p.m. At that time, her vitals were temperature 100 degrees F, pulse 110 respirations 20, and blood pressure 130/86. An interview with RN B on 11/13/13 at approximately 2:00 p.m. revealed she was Resident #1's nurse on 10/26/13 for the 2:00 p.m. to 10:00 p.m. shift. RN B stated she did not recall the day shift nurse (LVN H) mentioning Resident #1 had episodes of nausea and vomiting. She revealed during her shift, Resident #1 did not have episodes of nausea and/or vomiting. She further stated LVN H requested she report the results of Resident #1's x-rays to Medical Director N, the resident's attending physician. She said at approximately 4:30 p.m. (2.5 hours after the start of her shift), she left a message for Medical Director N. She stated she waited until 4:30 p.m. to call because she was waiting on the results of the laboratory tests and the x-rays. RN B revealed at 5:45 p.m. Medical Director N returned her call, and she consulted with him regarding the results of the chest x-rays and the laboratory results, which had also come in. She stated he ordered Resident #1 sent to the hospital. RN B said she would not send a resident to the hospital without a physician's orders [REDACTED]. She stated she did not consider Resident #1 to have had that level of change in her condition. RN B revealed if a resident had a fracture, she generally waited to send the resident to the hospital until she spoke with the physician. She stated her assessment of Resident #1 did not reveal any signs/symptoms of vomiting. An interview with the DON on 11/12/13 at 4:30 p.m. revealed she had not been aware the x-rays obtained at the facility had identified a fractured elbow. She stated she was aware the nurse had attempted to call the resident's attending physician without success. The DON revealed sending a resident to the hospital was nursing judgement, but then stated she could "give a reason for the delay, but it would just be an excuse." Resident #1's x-ray reports from the first hospital, dated 10/26/13, reflected a [MEDICAL CONDITION] radius and ulna of her left wrist. During an interview with Resident #1's family member on 11/13/13 at 1:45 p.m., he/she stated Resident #1 was transferred to a second hospital for additional care where she was in initially in the Intensive Care Unit. Resident #1's Trauma Admission/Consultation, from the second hospital dated 10/27/13, reflected, "...Lst night, pt (Resident #1) reportedly fell from bed onto wood floor with injuries to right face and right long bones. Transferred to (second hospital's name) ED (Emergency Department) for the following fractures: R (right) humerus fracture with humeral prosthesis Zygomtatic (cheekbone) arch and max sinus R distal ulna and radius (wrist) fracture L (left pelvis fracture...Right Periorbital [MEDICAL CONDITION]/contusion (surrounding the socket of the eye), Right malar (cheekbone) depression...." Resident #1's Surgical Note, dated 10/27/13, reflected, "...Admit to ICU for trauma in the elderly...." The facility's current, undated Change of Condition Policy and Procedures reflected the "facility staff will assess, record and report any significant change in a resident condition to the attending physician to ensure appropriate care and treatment...Licensed nursing staff will assess and report changes of a residents' (sic) condition to the physician/physician extender in a timely manner. Changes in condition include (but are not limited to): - Falls - Physical changes: injury...- Mental changes: change in cognition/orientation, personality changes...-Abnormal lab results and diagnostic test results...Charge nurse will notify the attending physician/extender of any significant change of condition. The residents' responsible party will also be notified of changes in condition...." On 11/14/13 an IJ was identified. On 11/14/13 at 1:03 p.m., the Administrator, DON, and RNC L were notified of the IJ and a Plan of Removal was requested at that time. On 11/15/13, at 6:00 p.m., the Administrator was notified the facility's Plan of Removal was accepted. The plan reflected: -- A QA Meeting was conducted on 11/14/13 with the Administrator, DON, RN Clinical Constant L and the following present via telephone conference call: Regional Director of Operations, RN Clinical Consultant M and Joint Medical Directors, N and O. -- In-services were conducted by ADON P and ADON Q on 10/29/13 and 10/30/13 regarding neuro-checks, head injuries and ICP injuries; change in condition and transferring residents to the ER, post-accident/incident procedures, admission assessments included fall risk assessments and fall risk interventions to prevent falls, post-incident interventions, emergency responses, bed and chair alarms, and care planning of falls. -- A compete audit of all resident charts was conducted to ensure Fall Risk Assessments had been completed within the last 30 days. The task was completed on or before 11/14/13 at 5:00 p.m. by the DON, ADON P, and ADON Q. All residents with a score greater than 6 were classified as high risk for falls and their care plans were reviewed and updated to reflect appropriate safety measures had been implemented. All such safety measures were confirmed to be in place by visual observations. These tasks were completed by ADON P, ADON Q, LVN J, and LVN K on or before 11/14/13 at 8:00 p.m. -- Fall Risk Assessments for newly admitted residents will be completed within the first eight hours of admission by the admitting nurse. The ADONs will review each new Admission Chart within 72 hours of admission to ensure Fall Risk Assessments are complete, accurate and appropriate intervention are observed in place. -- Fall prevention equipment will be stored in the medical supply closet on Hall 400 and all nurses on all shifts will have access. This practice will be initiated by 11/15/13 at 3:30 p.m. The availability of supplies will be monitored by the Central Supply Coordinator Monday through Friday. -- Residents identified as being at high risk for falls will be communicated to all clinical staff members using the EMR Messaging System/Accunurse System. At the beginning of each shift , the Charge Nurse will make resident assignments to all Nurse Aides. The Nurse Aides are required to use their head-sets to Review Plan of Care for each of their assigned residents. The Plan of Care identifies the resident at high risk for falls and list interventions that are to be in place for each high risk resident. The Charge Nurse is to monitor the Accunurse System prior to the end of each shift to ensure the Nurse Aides have competed their assignments and listened to their residents' plan of care. -- The DON and ADONs (and designated staff as scheduled by the DON) will conduct observation rounds on a daily basis, 7 days per week to ensure appropriate fall prevention measures are in place for each high risk resident. -- The facility began implementation of the Falling Star Program on 11/14/13 and all facility staff members trained on this program to ensure that all staff members are aware of residents at high risk of falls. The Falling Star Program will designate the residents who have a Fall Risk Assessment Score of above six with a star beside their name plate posted on the wall directly outside of each resident room. For new admissions, the admitting Charge Nurse will be responsible for initiating the Falling Star Program for residents assessed as being at high risk for falls. The DON will be responsible for the over-all monitoring of the Falling Star Program. The training of the Falling Star Program was initiated by the DON on 11/15/13 and all staff will be trained prior to their on-coming shift unit all staff have received the training. All staff will be required to successfully complete a post-test. If a staff member fails the test, they will be provided additional information and will be re-issues the post-test until successful completion. Training on the Falling Star Program will be part of New Hire Orientation starting 11/15/13. -- The facility's policy and practice will be that it is mandatory for all nurses to complete an SBAR for every resident fall and significant change in condition. This was effective 11/14/13 at 5:00 p.m. -- The facility's policy and practice will be that nurses are to wait a maximum of 30 minutes to receive a return call from a physician after the nurse has attempted to contact the physician following a resident fall and/or change of condition. After no longer than 30 minutes, a repeat call will be made and a maximum of 15 minutes thereafter will be allowed for a return call from the physician. If the nurse's call is not returned within 45 minutes of the original call, then the nurse will notify the Medical Director and DON (or ADON designee on the on-call schedule). This was effective Interviews with nurses from all three shifts confirmed staff had received in-service training regarding the following information: --Information to include on an SBAR --Information to provide to on-coming nurses at shift change --Components of a comprehensive assessment of a resident --Timeframes for contacting the physician after an incident --Timeframes for notifying the DON/ADON of a fall --Components of Incident/Accident Reports --Facilities "falling star" program The following nurses were interviewed on 11/14/2013 between 9:00 a.m. and 5:00 p.m. and provided appropriate answers regarding the previously identified in-services: RN A RN C The following nurses were interviewed on 11/15/2013 between 8:00 a.m. and 5:00 p.m. and provided appropriate answers regarding the previously identified in-services.: LVN H LVN R LVN S LVN T LVN U LVN V LVN W LVN X LVN Y LVN Z The following staff were interviewed on 11/17/2013 regarding the facility's "Falling Star" program and provided appropriate answers indicating knowledge of the program: CNA CC CNA DD CNA EE The following staff were interviewed on 11/18/2013 regarding the facility's "Falling Star" program and provided appropriate answers indicating knowledge of the program: CNA AA Dietary Manager Housekeeper BB Housekeeping Supervisor Cook FF Observations on 11/17/2013 and 11/18/2013 of resident's rooms and wheelchairs revealed residents identified as being a "fall risk" had a small "star" placed next to their name on the name plate located near the door to their room and attached to their wheelchairs to assist staff in identifying the resident as a "fall risk." The facility's Incident/Accident report, dated 10/31/13, reflected Resident #2 experienced an unwitnessed fall from her wheelchair and sustained substantial injury to her face and was bleeding as a result of these injuries. The report indicated 911 was contacted immediately after the resident was assessed, and the resident was subsequently transported to the hospital for treatment. On 11/18/13 at 5:50 p.m., the Administrator, DON, RNC M, ADON P, and ADON Q, were notified the IJ had been removed. While IJ was removed, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of pattern due to staff were still being in-serviced, and the facility was monitoring the effectiveness of the Plan of Removal. The facility's Resident Roster, dated 10/12/13, reflected 13 residents resided on the 200 Hall.