Every finding on record at Avir at Lubbock

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 1 of 1 kitchen reviewed for dietary services, in that: The facility failed on 01/28/26 to seal food stored in the dry storage and food stored in the refrigerator. This failure could place residents at risk for food contamination and foodborne illness.Findings included: The following observation was made on 05/14/2026 at 11:25 a.m. during the tour of the kitchen: Dry Storage:Spaghetti noodles stored in zip lock bag not sealed.Garlic powder with lid open.Salt with spout open. Refrigerated Storage:Prepared drink on a metal sheet pan with no cover.Plate of salad with no date.Package of turkey breast lunch meat with no date and not sealed. During an interview on 05/14/2026 at 12:29 p.m., the DM stated all food in the refrigerator should be sealed and dated. She stated all dry storage food should be sealed and closed. During an interview on 05/15/2026 at 01:50 p.m., the DM stated the purpose of sealing all food stored was to keep it fresh and no contaminants get in the food. She stated all staff were responsible for dating and sealing stored food. She stated all staff have been trained in food storage. She stated the potential negative outcome could be something getting into the food, food contamination and could make the residents sick. During an interview on 05/15/2026 at 02:25 p.m., the ADM stated he was not aware food was not properly stored. He stated the purpose of dating and sealing stored food was to maintain a sanitary condition. He stated everyone was responsible for dating and sealing stored food. He stated all staff have been trained in food storage. He stated the potential negative outcome could be preliminary expiration, freshness and possible expose to cross contamination. Record review of the facility's policy, titled Food Receiving and Storage, dated revised November 2022, reflected the following: Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices.Policy Interpretation and Implementation: .Dry Food Storage.4. Dry foods that are stored in bins are removed from original packaging, labeled and dated ( use by date) .Refrigerated/Frozen Storage1. All foods stored in the refrigerator or freezer 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 interview and record review, the facility failed to follow their own established smoking policy for 3 of 11 residents reviewed for smoking. (Residents #25, #43, #49)The facility failed to follow smoking policy for Residents #25, #43, #49.This failure could place residents at risk of smoking while unsupervised.Findings include:1. Record review of Resident #25's face sheet dated 05/15/2026 indicated she was [AGE] years old and admitted to the facility on [DATE] and readmitted on [DATE]. Resident #25 had diagnoses which included hepatic encephalopathy (damaged liver allows toxins to build up in blood), anxiety (feeling of fear or worry), depression (mental illness) and hypertension (high blood pressure).Record review of Resident #25's annual MDS assessment dated [DATE], indicated she had a BIMS score of 09, which indicated she had mild cognitive impairment. The MDS indicated Resident #25 used tobacco. Record review of Resident #25's Care Plan Report dated 04/23/2026 revealed no care plan for smoking.Record review of Resident #25's Safe Smoking assessment dated [DATE] indicated Resident #25 needed facility to store lighter and cigarettes. Safe Smoking Assessment further revealed Resident #25 was safe to smoke without supervision.2. Record review of Resident #43's face sheet dated 05/15/2026 indicated he was [AGE] years old and admitted to the facility on [DATE] and readmitted on [DATE]. Resident #43 had diagnoses which included heart failure, diabetes (high blood sugar), anxiety (feeling of fear and worry) and hypertension (high blood pressure).Record review of Resident #43's quarterly MDS assessment dated [DATE], indicated he had a BIMS score of 14, which indicated no cognitive impairment. The MDS indicated Resident #25 used tobacco. Record review of Resident #43's Care Plan Report dated 03/20/2026 indicated he was a smoker.Record review of Resident #43's Safe Smoking assessment dated [DATE] indicated Resident #43 needed facility to store lighter and cigarettes. Safe Smoking Assessment further revealed Resident #43 was safe to smoke without supervision.3. Record review of Resident #49's face sheet dated 05/15/2026 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #49 had diagnoses which included cerebral infarction (stroke), depression (mental illness) and hypertension (high blood pressure).Record review of Resident #49's annual MDS assessment dated [DATE], indicated he had a BIMS score of 13, which indicated no cognitive impairment. The MDS indicated Resident #25 used tobacco. Record review of Resident #49's Care Plan Report dated 03/06/2026 indicated he was a smoker.Record review of Resident #49's Safe Smoking assessment dated [DATE] indicated Resident #49 needed facility to store lighter and cigarettes. Safe Smoking Assessment further revealed Resident #49 was safe to smoke without supervision.During an interview on 05/15/2026 at 12:48 p.m. LVN D stated all resident smoking were to be supervised. She stated smoking supplies were kept in a box at the nurse's station. She stated the previous ADM allowed residents to smoke unsupervised. She stated she had been trained in the facility smoking policy. She stated staff supervise residents according to the smoking schedule. She stated housekeeping supervisor supervises them at 01:00 p.m.During an observation on 05/15/2026 at 01:05 p.m. revealed the HSK supervisor was outside observing smoking while the residents smoked.During an interview on 05/15/2026 at 01:08 p.m., the HSK Supervisor stated she was scheduled to supervise smoking. She stated all residents had their own cigarettes and lighters. She stated she did not hand out any smoking supplies. She stated it was her understanding the residents stopped by the nurse's station for supplies before going outside. She stated she had been trained on the facility smoking policy.During an interview on 05/15/2026 at 01:15 p.m., Resident #38 stated he keeps cigarettes in his nightstand. He stated he currently was out of cigarettes and has no cigarettes in his room at this time. He stated he did have a lighter in his pants pocket. He stated he had not been told he could not keep his smoking supplies in his room.During an interview and observation on 05/15/2026 at 01:25 p.m., Resident #49 stated he keeps cigarettes and lighter in his nightstand. Surveyor observed cigarettes and lighter in the top drawer of the nightstand. He stated he had not been told he could not keep his smoking supplies in his room. During an interview on 05/15/2026 at 01:30 p.m., Resident #25 stated she keeps her cigarettes and lighter in her room. She stated if you give the nurses your cigarettes and lighter they will take them. She stated she doesn't remember being told she could not have supplies in her room.During an interview on 05/15/2026 at 02:00 p.m., the DON stated the smoking policy was for all residents to be supervised while smoking. He stated staff were to keep smoking supplies at the nurse's station. He stated he was not aware residents had smoking supplies in their rooms. He stated residents were notified of the smoking policy. He stated all staff have been trained on the facility smoking policy. He stated the smoking schedule has an assigned department at each time to make sure smoking was supervised. He stated the potential negative outcome could be burns from unsupervised smoking.During an interview on 05/15/2026 at 02:25 p.m., the ADM stated residents were not to have smoking supplies in their rooms. He stated the smoking residents have been told the facility smoking policy several times. He stated all staff had been trained on the facility smoking policy. He stated he was not aware residents had smoking supplies in their rooms. He stated the potential negative outcome could be unauthorized smoking.Record review of the facility policy titled Smoking Policy - Resident dated October 2022 reflected the following: Policy Statement - This facility shall establish and maintain safe resident smoking practices.Policy Interpretation and Implementation.14. Residents may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision.

Based on observations, interviews, and record reviews, the facility failed to ensure the reasonable accommodation of resident needs and preferences for 1 of 22 residents (Resident #6) reviewed for call light placement. The facility failed to ensure the resident call light system was within reach for Resident #6 on 05/14/2026 and 05/15/2026. This failure could place residents at risk of not receiving the necessary assistance they need to maintain their highest level of independence. Findings included: Record review of Resident #6's face sheet dated 05/15/2026 revealed an [AGE] year-old-female admitted on [DATE] with the following diagnoses: dementia (memory loss), chronic obstructive pulmonary disease (lung disease that makes it hard to breathe), depression (illness that involves the body, mood and thoughts), hypertension (high blood pressure), and hyperlipidemia (high cholesterol). Record review of Resident #6's comprehensive MDS dated [DATE] revealed Resident #6 had a BIMS score of 03 which indicated severe cognitive impairment. The MDS further revealed Resident #6 had limited range of motion - bilateral lower extremity. Resident #6 required partial/moderate assistance with activities of daily living. Record review of Resident #6's care plan dated 03/10/2026 revealed a focus area Resident #6 had activity of daily living self-care performance deficit related to dementia. Interventions with activities of daily living with substantial assistance of one. During an observation on 05/14/2026 at 02:12 p.m. Resident #6 was lying in bed and her call light was hanging on the bed frame under the head of bed. During an interview on 05/14/2026 at 03:20 p.m. LVN C stated Resident #6 call light should always be in reach. She stated she was not sure why the call light was not within reach. She stated Resident #6 was able to use call light if available. During an observation on 05/15/2026 at 10:13 a.m. Resident #6 was lying in bed and her call light was tucked in-between the mattress and bedframe at the head of bed. During an interview on 05/15/2026 at 12:35 p.m. CNA E stated the purpose of a call light was for the residents to call when they needed help or assistance with something. She stated there was no reason a resident should not have a call light in reach. She stated she was not aware Resident #6 did not have her call light. She stated she had been trained on call light placement. She stated everyone was responsible for making sure the residents had call light in reach. She stated the potential negative outcome could be falls, possible chocking and the residents not being able to call for help. During an interview on 05/15/2026 at 12:48 p.m. LVN D stated a residents call light should always be within reach. She stated there was no reason a resident would not have a call light. She stated she was not aware Resident #6 did not have her call light. She stated she had been trained on call light placement. She stated she monitors residents every two hours by making walking rounds. She stated the potential negative outcome could be a resident getting hurt. During an interview on 05/15/2026 at 02:00 p.m. the DON stated the purpose of a call light was for the residents to notify staff of needing assistance. He stated the call light should be placed near the resident. He stated there was no reason for a resident to not have a call light. He stated all staff had been trained on call light placement. He stated all staff were responsible for ensuring residents have call lights. He stated he was not aware Resident #6 did not have her call light. He stated the potential negative outcome could be resident dignity. During an interview on 05/15/2026 at 02:25 p.m. the ADM stated the purpose of the call light was to allow the resident to call for assistance. He stated there was no reason at resident would not have a call light. He stated the call light system must be available for all residents. He stated he was not aware Resident #6 did not have her call light. He stated all staff had been trained on call light placement. He stated all staff were responsible for making sure residents have access to call light. He stated the potential negative outcome could be residents not being able to call for assistance when needed. Record review of the facility's policy, titled Call System, Residents revised date 1/2025, reflected the following: Policy - Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station.Policy Interpretation and Implementation1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 24 residents hand sinks (room [ROOM NUMBER] and room [ROOM NUMBER]) in that: The facility failed to ensure the hot water in the hand sink in room [ROOM NUMBER] was at a comfortable temperature.The facility failed to ensure the hot and cold water in the hand sink in room [ROOM NUMBER] was functioning properly. These failures could lead to residents experiencing a diminished quality of life and a lack of home-like environment and/or comfort. The findings include: During a confidential interview on 05/13/2026 at 09:30 AM the confidential resident stated there was no warm water in the hand sinks in the residents' bedrooms. The resident stated they often had to wash their hands with cold water, causing their hands to feel cold. The resident stated they felt the facility did not take the cold water issues seriously. The resident stated they would like the water to be warm to wash their hands and face. During an observation on 5/13/2026 at 10:00 AM the hot water in Resident room [ROOM NUMBER] remained cold after allowing the water to run for several minutes. During an observation on 05/13/2026 at 10:30 AM the hot water in Resident room [ROOM NUMBER] remained cold after allowing the water to run for several minutes. During an observation on 05/14/2026 at 2:55 PM, the hot water at the shared hand sink in room [ROOM NUMBER] was checked with a water thermometer and noted to be 73.6 degrees Fahrenheit.During an observation on 05/14/2026 at 3:05 PM, the hot water at the shared hand sink in room [ROOM NUMBER] was checked with a water thermometer and noted to be 70.5 degrees Fahrenheit.During an interview on 05/15/2026 at 12:00 PM the MD stated he completed water temperature checks weekly on the shared hand sinks in residents' rooms. The MD stated he did not complete temperature checks on every hand sink but completed spot checks. The MD stated he kept temperature logs to verify his weekly checks, and he would locate the logs for verification. The MD stated he was not aware of any recent issues with water temperatures in any of the hand sinks in resident rooms. The MD stated all maintenance requests were reported in the facility's online system. The MD stated he did not have any recent reports concerning water temperatures. The MD stated residents could also verbally report any concerns to him directly. The MD stated all staff were responsible for reporting maintenance repair needs to the online system or by communicating with him directly. The MD stated hot water temperatures in the shared hand sinks in residents' rooms should have been between 100 and 110 degrees Fahrenheit. The MD stated he was not aware the hot water temperature in resident room # 1 was 73.6 degrees Fahrenheit and resident room [ROOM NUMBER] was 70.5 degrees Fahrenheit. The MD stated he received training upon hire regarding safe and comfortable water temperatures. The MD stated he was responsible for ensuring all water temperatures were adequate. The MD stated it was important for water temperatures to be adequate to provide comfort to the residents. During an interview and observation on 05/15/2026 at 12:20 PM the MD completed a check of the hot water in the shared hand sink in resident room [ROOM NUMBER]. The MD obtained a temperature, with a digital thermometer, of 70 degrees Fahrenheit. The MD then ran the cold water which began to turn warm. The MD stated the water valves must have been switched after a recent repair, transposing the hot and cold water valves. The MD obtained a hot water temperature of 100 degrees Fahrenheit on the cold water side of the hand sink. The MD stated he would work to correct the issues as soon as possible. The MD stated he would also follow up on resident room [ROOM NUMBER] to verify the hot water temperature and make any necessary repairs. During an interview on 05/15/2026 at 12:30 PM the ADM stated the MD was responsible for ensuring water temperatures were adequate throughout the facility. The ADM stated hot water temperatures should have been between 100 and 110 degrees Fahrenheit in residents' rooms. The ADM stated he was not aware of any recent reports of low hot water temperatures. The ADM stated all maintenance repair requests were submitted in the facility's online reporting system, and the MD was responsible for completing these repair requests. The ADM stated the MD also completed regular checks on water temperature and should have had a log to verify these temperature checks. The ADM stated he was not aware the cold and hot water valves were transposed in resident room # 6. The ADM stated a toilet was repaired in the shared bathroom of resident room [ROOM NUMBER], and it was possible it was not put back together correctly after the plumbing repair, transposing the hot and cold valves. The ADM stated it was his expectation that hot water temperatures were kept within the adequate temperature range. The ADM stated if water temperatures were not within an adequate temperature range, it may not be comfortable for the resident. The ADM stated if the hot water and cold water valves were transposed, this could be unfamiliar to the resident and could cause discomfort. During an interview on 05/15/2026 at 1:0 PM the DON stated the MD was responsible for completing regular water temperature checks and completing any necessary repairs. The DON stated all staff were responsible for reporting any needed repairs to the MD either directly or through the facility's online reporting system, The DON stated he was not aware of any concerns regarding hot water temperatures. The DON stated he was not certain what the hot water temperature range was. The DON stated it was important to maintain adequate water temperatures to ensure comfort levels for residents. The DON stated if water temperatures were below an adequate range, this could be uncomfortable to the resident. Record review of facility policy pertaining to Maintenance Requests was requested from the ADM on 05/15/2026 at 12:30 PM and 05/19/2026 2:44 PM, and the policy was not provided.

Based on interviews and record reviews, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with an accurate PASRR Level I for 1 of 24 residents (Resident #10) reviewed for PASRR screening, in that:Resident #10 did not have an accurate and updated PASRR Level 1 assessment, reflecting a diagnosis of mental illness. This failure could place residents, with an inaccurate PASRR Level 1 and no PASRR Level 2 Evaluation, at risk for not receiving care and services to meet their needs. The findings included: Record review of Resident #10's electronic face sheet dated 05/14/2026 revealed a [AGE] year-old female initially admitted to the facility on [DATE]. The face sheet included the following diagnoses: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (primary) (weakness or paralysis on one side of the body resulting from a stroke), Major Depressive Disorder, recurrent, severe without psychotic features (a mood disorder that causes a persistent feeling of sadness and loss of interest), Major Depressive Disorder, recurrent, mild, and Cognitive Communication Deficit. Record review of Resident #10's Annual MDS dated [DATE], under section I (Active Diagnoses), indicated Resident #10 had a Psychotic/Mood Disorder of Anxiety and Depression (other than Bipolar). It was also indicated under Section I, other, an active diagnosis of Major Depressive Disorder, recurrent, mild. Additionally, under Section C Cognitive Patterns, Resident #10's MDS revealed a BIMS of 15, indicating the resident was cognitively intact. Record review of Resident #10's care plan dated 05/13/2026, under Diagnoses indicated Resident #10 had a diagnosis of Major Depressive Disorder, recurrent, severe without psychotic features and Major Depressive Disorder, recurrent, mild. The care plan included a focus area that stated, (Resident) has depression r/t Disease Process Major Depressive D/O on psychotropic medication. Date Initiated: 01/06/2026. Record review of Resident #10's physician's Order Summary as of 05/14/2026 revealed under Diagnoses Major Depressive Disorder, recurrent, severe with psychotic features and Major Depressive Disorder, recurrent, mild. Resident #10 was prescribed Cymbalta Oral Capsule Delayed Release Particles 60 MG (Duloxetine HCl) related to Major Depressive Disorder, recurrent, mild. Record review of Resident #10's PASRR Level 1 Screening dated 07/28/2024 revealed the following: under section C (PASRR Screening), C0090 Primary Diagnosis of Dementia: NO, under section C (PASRR Screening), C0100 Mental Illness: NO. Record review of Resident #10's Diagnosis Report, dated 05/14/2026, revealed the following under Diagnosis: Major Depressive Disorder recurrent, Severe without Psychotic Features with an onset date of 07/23/2023 and Major Depressive Disorder recurrent, mild with an onset date of 02/15/2024. During an interview on 05/15/2026 at 12:30 PM the ADM stated the MDS nurse was responsible for ensuring PASRR Level 1 screenings were accurate upon admission and for requesting an updated PASRR Level 1 screening when a resident received a new mental illness diagnosis. The ADM stated the MDS nurse was not available for interview as she was currently on leave. The ADM stated he was not aware Resident #10 did not have an accurate PASRR Level 1 screening, reflecting a mental illness diagnosis. The ADM stated the facility's MDS nurse was new and was not working at the facility at the time of the PASRR screening for Resident #10. The ADM stated Resident #10 did have an active diagnosis of Major Depressive Disorder, and this should have been indicated as a mental illness diagnosis on Resident #10's PASRR. The ADM stated he did not know why it was not accurate, and he stated he would follow up as soon as possible. The ADM stated PASRR screenings were reviewed during the admission process and should have been updated if any changes arose. The ADM stated it was his expectation for all residents' PASRR Level 1 screenings to be accurate and updated. The ADM stated he and facility staff have received training on PASRR. The ADM stated if a resident's PASRR Level 1 screening was not accurate, the resident may have had a delay in receiving services for which they may have qualified for. During an interview on 05/15/2026 at 1:00 PM the DON stated the MDS nurse was usually responsible for PASRR screenings and ensuring they were completed and accurate. The DON stated the MDS nurse was on leave and was unavailable for interview. The DON stated Resident 10 did have a diagnosis of Major Depressive Disorder. The DON stated he was not aware if a diagnosis of Major Depressive Disorder would classify as a mental illness and stated he would follow up. The DON stated when a resident was admitted to the facility with a diagnosis of a mental illness, or if the resident received a new diagnosis of a mental illness, it was his expectation that a new PASRR Level 1 screening was requested for the resident. The DON stated he did not know why this was not completed for Resident #10, and he stated he would follow up as soon as possible. The DON stated staff received training on PASRR upon hire. The DON stated if a resident did not have an accurate PASRR Level 1, it could affect the resident receiving services from which they may benefit. During an interview on 05/15/2026 at 1:30 PM the Regional MDS coordinator stated she verified that Resident #10's current PASRR Level 1 screening was not accurate as it did not reflect the resident's diagnosis of a mental illness. The Regional MDS Coordinator stated the resident had an active diagnosis of Major Depressive Disorder, and she stated this should have been reflected as a mental illness on Resident #10's PASRR Level 1 screening. The Regional MDS Coordinator stated she did not know why the PASRR Level 1 screening was not accurate. The Regional MDS Coordinator stated Resident #10's PASRR was since updated on 05/15/2026 to reflect the [NAME] illness diagnosis, and she stated the facility would follow up to ensure the resident was assessed for the PASRR Level 2 Evaluation. Record review of the facility's policy titled, PASRR, dated 1/20/2026 revealed the following: Purpose:The aim of the PASRR program is to identify residents with Mental Illness (Ml), Intellectual Disability (ID), or Developmental Disability (DD)/Related Conditions (RC) and to ensure they are properly placed, whether in community or in a Nursing Facility (NF) and to ensure they receive the services they require for their Ml, or ID/DD.Procedure:2. When it is determined that a PL1 was filled out incorrectly, the MOS Coordinator, Social Worker or designee will reach out to the hospital/responsible case worker and ask them to correct the form.a. If the referring case worker is unwilling/unable to correct the PL1 that contains a potential error, the social worker or designee will complete and submit a form 1012 (Ml) or new PL1 (ID/DD). A subsequent positive PL1 will be entered according to 1012 findings (Ml).3. When it is determined that an individual's diagnosis was changed and/or a state surveyor determines the PL1 was incorrect, the social worker or designee will complete and submit a form 1012 (Ml) or new PL1 (ID/DD). A subsequent positive PL1 will be entered according to 1012 findings.

Based on observations, interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 2 of 24 residents (Resident #12 and Resident #39) reviewed for care plans. The facility failed to develop an accurate, consistent, and completed care plan for Resident #12, specific to Resident #12's dietary needs ordered by the physician.The facility failed to develop an accurate, consistent, and completed care plan for Resident #39, specific to Resident #39's PASRR needs and services. This failure could place residents at risk of not receiving the care required to meet their individualized needs. Findings include: Resident #12Record review of Resident #12's face sheet, dated 05/15/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #12 had diagnoses which included unspecified Dementia, unspecified severity, with other behavioral disturbances (a decline in cognitive abilities that affects a person's daily functioning), Type 2 Diabetes (when the body doesn't use insulin well and can't keep blood sugar at normal levels),unspecified protein-calorie malnutrition (when the body does not get enough protein and calories to stay healthy and function properly), and vitamin deficiency. Record review of Resident #12's admission MDS assessment, dated 01/29/2026, revealed in Section C - Cognitive Patterns, Resident #12 had a BIMS score of 07, which indicated moderate cognition impairment. The MDS assessment indicated under Section GG - Functional Abilities, Resident #12 was independent in eating. Additionally, under Section I - Active Diagnoses, Resident #12 showed to have active diagnoses of Diabetes, Dementia, Malnutrition, and vitamin deficiency. The MDS assessment, under Section K - Swallowing/Nutritional Status did not indicate any diet restrictions or specifications. Section K also indicated Resident #12 had no weight loss. Record review of the current care plan for Resident #12, undated, revealed the following Focus areas: I have a Dx. of Diabetes Mellitus. Date Initiated: 01/26/2026, with a Goal that stated, I will have no complications related to diabetes through the review date. The Interventions/Tasks included the following: Dietary consult for nutritional regimen and ongoing monitoring. Date Initiated: 01/26/2026 . Discuss mealtimes, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan, compliance with nutritional regimen. Date Initiated: 01/26/2026 . I am receiving a Regular Diet with Thin liquids. Date Initiated: 02/03/2026, with a Goal that stated, I will maintain my weight Date Initiated: 02/03/2026. The Interventions/Tasks included: Monitor % of meals eaten. Date Initiated: 02/03/2026.Regular Diet as ordered. Date Initiated: 02/03/2026.Thin liquids as ordered. Date Initiated: 02/03/2026. The resident has a potential nutritional problem r/t disease process, medications. He is on a regular diet. Date Initiated: 04/29/2026, with a Goal that stated, The resident will not develop complications related to malnutrition, including skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, impaired mobility through review date. Date Initiated: 04/29/2026. The interventions/Tasks included the following: Explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage the resident to comply. Explain consequences of refusal, obesity/malnutrition risk factors. Date Initiated: 04/29/2026. Monitor/record/report to MD (medical director) PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Date Initiated: 04/29/2026.Provide and serve diet as ordered. Date Initiated: 04/29/2026. RD to evaluate and make diet change recommendations PRN. Date Initiated: 04/29/2026. Record review of Resident #12's active physician's order, dated 05/15/2026, revealed an order that stated the following: Large Portions diet Regular texture, Regular consistency, Double Portions. Order start date: 02/04/2026. Record review of Resident #12's Vitals/Weights Report, dated 05/15/2026, revealed the following weights for the resident:5/13/2026 - 158.0 lbs. 4/29/2026 - 150.0 lbs.4/13/2026 - 150.0 lbs. 4/06/2026 - 150.0 lbs.02/02/2026 - 132 lbs. Record review of Resident #12's lunch meal ticket, dated 05/14/2026, indicated Resident #12 received a Regular diet with Double Portions. Resident #39Record review of Resident #39's face sheet, dated 05/15/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #39 had diagnoses which included hypertensive emergency (severe increase in blood pressure that leads to acute damage to target organs), schizophrenia (serious mental health condition that affects how people think, feel, and behave, resulting in symptoms such as hallucinations, delusions, and disorganized thinking), and schizoaffective disorder, bipolar type (mental health condition that combines symptoms of schizophrenia with episodes of mania or depression). Record review of Resident #39's annual MDS assessment, dated 07/10/2025, revealed in Section C - Cognitive Patterns, Resident #39 had a BIMS score of 10, which indicated moderate cognition impairment. Additionally, under Section I - Active Diagnoses, Resident #39 showed to have active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Record review of Resident #39's active physician's order, dated 05/15/2026, revealed active diagnoses of the following: schizophrenia and schizoaffective disorder, bipolar type. Record review of Resident #39's PASRR Level 1 Screening dated 03/16/2023 revealed the following: under section C (PASRR Screening), C0090 Primary Diagnosis of Dementia: NO, under section C (PASRR Screening), C0100 Mental Illness: YES. Record review of Resident #39's PASRR Level 2 Evaluation Screening dated 0 3/16/2023 indicated Resident #39 was not interested in being enrolled in a community based program. Record review of the current care plan for Resident #39, undated, revealed the following active diagnoses: schizophrenia, and schizoaffective disorder, bipolar type. There were no Focus areas found addressing Resident #39's PASRR level 1 screening or PASRR level 2 evaluation. During an interview on 05/13/2026 at 11:00 AM Resident #12 stated he received a regular diet, and he asked for more food sometimes at meals due to being hungry. Resident #12 stated he did not feel he had enough on his plate some meals. Resident #12 stated he was able to get a second portion of food when he asked, so he never felt hungry after he finished his meals. Resident #12 stated he had weight loss prior to coming to the facility, but he did not think he had lost any weight recently. Resident #12 did not know what his diet order was. During an observation and interview on 05/13/2026 at 1:00 PM Resident #12 was observed to receive double portions during his lunch meal. Resident #12 was observed to receive double portion of chicken, rice, squash and red peppers and a dinner roll. Resident #12 stated he was full and had plenty to eat. During an observation and interview on 05/14/2026 at 12:20 PM Resident #12 was observed to receive double portions during his lunch meal. Resident #12 was observed to receive double portions of pork chops, brussels sprouts, red beans, and cornbread. Resident #12 stated he also requested a salad because he was still hungry. Dietary staff were observed requesting a salad for Resident #12. During an interview on 05/15/2026 at 12:30 PM, the ADM stated the MDS nurse was responsible for ensuring care plans were updated when a resident's physician's orders were changed or updated reflecting a new diet order. The ADM stated Resident #12's active physician order reflected double portions at meals. The ADM stated this should have been reflected on Resident #12's care plan as well. The ADM stated when Resident #12's physician ordered a dietary change, the care plan should have been updated as soon as possible. The ADM stated care plan reviews were completed as changes occurred, and during quarterly reviews. The ADM stated he was not aware Resident #12's care plan did not reflect double portions. The ADM stated he did not know why the care plan was not updated to reflect double portions. The ADM stated he was not aware Resident #39's care plan did not reflect the PASRR level1 screening or PASRR level 2 evaluation. The ADM stated if Resident #39 had a positive PASRR Level 1 screening indicating a mental illness, this should have been reflected on the care plan. The ADM stated he did not know why the care plan did not reflect this. The ADM stated the MDS nurse was new and on leave, and she was not available for interview. The ADM stated nursing staff received training on care plans upon hire and received regular in-service trainings. The ADM stated it was his expectation that care plans were updated as soon as any changes or updates were received. The ADM stated Resident #12 did not have any recent weight loss, and the he believed the diet order was due to the resident's preference. The ADM stated if care plans were not accurate, it could affect a resident receiving their preference in care. During an interview on 05/15/2026 at 1:00 PM, the DON stated the MDS nurse was responsible for ensuring care plans were updated with any changes to dietary orders. The DON stated he was not aware Resident #12's care plan did not reflect his physician order for double portions. The DON stated the care plan should have reflected the resident's physician order. The DON stated all staff received training on care plans, upon hire. The DON stated care plans were reviewed regularly when changes occurred and during quarterly reviews. The DON stated Resident #12 did not have any recent weight loss. The DON stated he believed the resident's diet order for double portions was due to the resident stating he was still hungry and requesting additional food at meals. The DON stated he did not know why the care plan was not updated. The DON stated Resident #39's care plan should have reflected the positive PASRR level 1 screening and the PASRR level 2 evaluation. The DON did not know why Resident #39's care plan did not reflect the PASRR. The DON stated the MDS nurse was new and was not working at the time Resident #12's new diet order was received. The DON stated the MDS nurse was not currently available for interview as she was on leave. The DON stated it was his expectation that care plans were updated and accurate. The DON stated if a care plan was not updated or accurate, a resident's preference may not be honored and the resident may not be happy. Record review of the facility's, updated 12/2024, policy titled, Care Planning- Interdisciplinary. Team reflected the following: Policy Statement:The interdisciplinary team is responsible for the development of resident care plans.Policy Interpretation and Implementation:l. Resident care plans are developed according to the timeframes and criteria established by S483.21.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices based on the comprehensive assessment of residents for 1 (Resident #11) of 22 residents reviewed for weight assessment. The facility failed to follow physician orders for weekly weights for Resident #11. This failure placed residents at risk of weight loss and overall decline in health.Record review of the admission record for Resident #11, dated 05/14/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: severe dementia with agitation (cognitive decline with emotional distress), depression (mood disorder that causes feelings of sadness and loss of interest in activities), schizoaffective disorder- bipolar type (a mental health condition with severe mood swings), and protein-calorie malnutrition (undernutrition caused by inadequate intake or absorption). Record review of Resident #11's Quarterly MDS Assessment, dated, 02/22/26, reflected Resident #11 had a BIMS score of 0, indicating she had severe cognitive impairment. Section K - Swallowing/Nutritional Status revealed Resident #11's weight was 120 pounds. Record review of #11's current Physician Orders dated 05/14/26 reflected the following: Weekly weights every Wednesday, with a start date of 01/21/26. Record review of Progress Note for Resident #11, dated 03/20/26, reflected Resident #11's BMI (a measure of body fat based on height and weight) was within normal limits, the resident was on a regular diet with regular texture, and the resident had been eating approximately 76-100% of meals. Weights were notated as follows: 3/18/2026 - 119.0 lbs2/23/2026 - 120.0 lbs1/21/2026 - 120.2 lbs1/19/2026 - 118.0 lbs Record review of Resident #11's Treatment Administration Records dated 1/1/2026 - 5/13/2026 reflected missing weekly weight assessments for the following dates: 1/28/20262/11/20263/11/20263/25/20264/08/20264/22/2026 Observation and interview during the initial tour on 05/13/2026 at 11:02 AM, Resident #11 was seated in the dining area of the secured unit. Resident #11 was dressed and well-groomed and did not appear underweight or emaciated. During an observation of the noon meal, Resident #11 was observed to be assisted by a facility staff member to eat her lunch and had consumed approximately 75% of the meal. Resident #11 did not respond coherently when spoken to. During an interview on 05/15/2026 at 12:35 PM, the DON stated he was not aware that weekly weights had not been obtained for Resident #11 on 1/28/2026, 2/11/2026, 3/11/2026, 3/25/2026, 4/08/2026 and 4/22/2026, according to the physician's order. The DON stated Resident #11's weight had been stable, and weekly weights had been implemented, along with other interventions to avoid weight changes for the resident. He stated nursing administration was responsible to assure that physician's orders were being followed. He stated the facility had recently implemented a new procedure for resident weight assessments and the ADON was assigned to monitor weight assessments for accuracy and completion. He stated prior to the new procedure, various CNA's were requested to obtain resident weight assessments throughout the month. The DON stated a designated CNA was now assigned to obtain all weights on residents, with the assistance of the ADON. He stated his expectation of staff was to follow all physician's orders as written. The DON stated a potential negative outcome for failure to follow physician's orders was a potential delay in resident care. During an interview on 05/15/2026 at 1:50 PM, the ADON stated she had been assigned the task of monitoring resident weights, assuring weights were obtained accurately, and inputting resident weights into the electronic health record, beginning 05/01/2026. She stated she was unaware that Resident #11's weekly weights had been occasionally missed during the timeframe prior to being assigned to monitor resident weights. She stated Resident #11 had significant cognitive impairment and would refuse to be weighed two out of three times when staff would attempt to weigh her. The ADON stated she was responsible for assuring the designated CNA obtained weights accurately and timely. She stated she was responsible for recording the resident's weights in the electronic health record and informing the DON of any significant weight changes. The ADON stated a potential negative outcome for failure to follow physician's orders was a resident could have a decline in health. During an interview on 05/15/2026 at 2:06 PM, the ADM stated he was not aware the physician's order for weekly weights had not been followed for Resident #11. He stated the DON was responsible to assure all physician's orders were being followed at all times. He stated his expectation of staff was to follow physician's orders with accuracy and timely completion. The ADM stated a potential negative outcome for failure to follow physician's orders was missed frequency on an order for a resident's care. Record review of the facility-provided policy titled, Physician Orders, revised February 2025, revealed: 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.Supervision by a Physician.5. Physician orders are essential for the comprehensive care of the residents . Record review of the facility-provided policy titled, Weight Assessment and Intervention, revised 05/12/25, revealed: PolicyResident weights are monitored for undesirable or unintended weight loss or gain.Policy Interpretation and Implementation.2. Weights are recorded in the resident's electronic health record .

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 22 residents (Resident #6) reviewed for infection control. 1. The facility failed to store oxygen nasal cannula off the floor.2. CNA E failed to replace nasal cannula after finding it on the floor. These failures could place residents at risk for cross contamination and infection.Findings included: Record review of Resident #6's face sheet dated 05/15/2026 revealed an [AGE] year-old-female admitted on [DATE] with the following diagnoses: dementia (memory loss), chronic obstructive pulmonary disease (lung disease that makes it hard to breathe), depression (illness that involves the body, mood and thoughts) atrial fibrillation (irregular heartbeat), hypertension (high blood pressure), and hyperlipidemia (high cholesterol). Record review of Resident #6's comprehensive MDS dated [DATE] revealed Resident #6 had a BIMS score of 03 which indicated severe cognitive impairment. The MDS further revealed Resident #6 received oxygen therapy. Record review of Resident #6 care plan dated 03/10/2026 revealed a focus area Resident #6 was at risk for respiratory infections/distress related to diagnosis of chronic obstructive pulmonary disease with interventions to administer oxygen as ordered. Record review of Resident #6 physician orders dated 05/15/2026 revealed an order for oxygen at 2-3 liters via nasal cannula to keep oxygen saturations over 90 percent as needed for shortness of breath dated 03/18/2026. During an observation on 05/14/2026 at 03:15 p.m. observed Resident #6's nasal cannula laying on the floor beside the bed. During an interview on 05/14/2026 at 03:20 p.m., LVN C stated resident oxygen tubing should be stored in bag on oxygen concentrator while not in use. During an observation on 05/15/2026 at 10:57 a.m. observed Resident #6's nasal cannula laying on the floor beside the bed. During an interview on 05/15/2026 at 12:35 p.m., CNA E stated oxygen nasal cannula should be stored in the bag on her oxygen concentrator. She stated she was not aware the tube was on the floor until she went into Resident #6 room to assist her with noon meal. She stated she picked the oxygen nasal cannula up and placed it back on the resident. She stated she did clean the tubing with an incontinent wipe before placing it on resident nose. She stated the incontinent wipes did not have any type of disinfectant. She stated the incontinent wipes were skin use. She stated she had been trained in oxygen tubing storage. She stated she should have replaced the nasal cannula. She stated the potential negative outcome could be infection and cross contamination. During an interview on 05/15/2026 at 12:48 p.m., LVN D stated oxygen nasal cannula was to be stored in the bag on the oxygen concentrator. She stated if the oxygen nasal cannula was found on the floor it should be replaced. She stated that incontinent wipes do not have disinfectants, they were used to clean skin. Stated she had been trained on oxygen storage and use. She stated the potential negative outcome could be infection control.During an interview on 05/15/2026 at 02:00 pm, the DON stated the oxygen nasal cannula should be stored in the bag on the oxygen concentrator when not in use. He stated if found on the floor, staff should replace it. He stated all staff had been trained on oxygen cannula storage and use. He stated if the CNA finds the oxygen nasal cannula on the floor, they should notify the charge nurse to change it out. He stated the purpose of the oxygen nasal cannula was to deliver supplemental oxygen. He stated the LVN was responsible for oxygen monitoring and use. He stated the potential negative outcome could be a lapse in oxygen administration and infection control. He stated incontinent wipes were not a disinfectant wipe.During an interview on 05/15/2026 at 02:25 p.m., the ADM stated the purpose of an oxygen nasal cannula was to provide oxygen to residents from an oxygen concentrator. He stated the oxygen nasal cannula should be stored in a bag on the oxygen concentrator. He stated if found on floor the oxygen nasal cannula should be replaced. He stated cleaning oxygen nasal cannula with an incontinent wipe does not disinfect it. He stated all staff had been trained in oxygen use and storage. He stated the DON was responsible for monitoring residents on oxygen. He stated the potential negative outcome could be cross contamination and infection control.Record review of the facility policy titled, Infection Prevention and Control Program, with dated March 2022 reflected the following: Policy Statement: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.Policy Interpretation and Implementation.11. Prevention of Infectiona. Important facets of infection prevention include:(1) identifying possible infections or potential complications of existing infections;(2) instituting measures to avoid complications or dissemination; .

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly for 2 of 2 medication carts (Station 1 medication cart and Station 2 medication cart), reviewed for medication storage. 1. The medication cart assigned to Station 1 contained two loose pills.2. The medication cart assigned to Station 2 contained four loose pills. This failure could place residents at risk of not receiving prescribed medications as ordered and place the facility at risk of drug diversions.1. On 05/14/26 at 11:03 AM an observation of the medication cart for Station 1 was conducted with MA A. Two loose pills were found in drawer of the medication cart. MA A placed the pills in a dispensing cup and took them to the DON for identification. The DON identified the medication as Carbidopa-Levodopa 25-100 (1 tablet) and Zofran 4mg (1 tablet). MA A destroyed the loose pills by crushing them and placing them in the sharps container. During an interview on 05/14/26 at 11:10 AM, MA A stated the medication cart should not contain loose pills. She stated she was responsible for the cart when she came on duty and stated, Once I get the keys, it's mine. She stated she usually checked the cart at the beginning of the shift for loose or expired medications and cleaned the cart prior to medication pass. MA A stated she had been trained through in-services on proper medication storage, and her cart was randomly spot checked for loose or expired medication by the DON and audited monthly by the pharmacy consultant. She stated a potential negative outcome for loose pills on the cart was not having enough medication and running out too soon for the pharmacy to refill the medication. 2. On 05/14/26 at 11:16 AM an observation of the medication cart for Station 2 was conducted with MA B. Four loose pills were found in the drawers of the medication cart. MA B placed the pills in a dispensing cup and took them to the DON for identification. The DON identified the medication as Allopurinol 100 mg (1 tablet), Metoprolol 25mg (1 tablet), Lasix 20 mg (1 tablet), and Amlodipine 5 mg (1 tablet). MA B destroyed the loose pills by crushing them and placing them in the sharps container. During an interview on 05/14/26 at 11:22 AM, MA B stated the medication cart should not contain loose pills. She stated she was responsible for the medication cart during her shift, and she usually checked the cart for cleanliness and loose medications at the beginning of each shift. MA B stated she had been trained on proper storage of medications on the cart and random spot checks of the cart were conducted by nursing administration. She stated the carts were also audited by the pharmacy consultant, but she did not recall how often the audits occurred. MA B stated a potential negative outcome for loose pills on the cart was that a resident could miss a dose of medication. During an interview on 05/15/26 at 12:35 PM, the DON stated he was not aware there were loose medications on the carts. He stated medications should be stored securely at all times. The DON stated medication aides and nurses were responsible for the proper storage of medication on the carts. He stated staff were in-serviced on proper medication storage by nursing administration and random cart checks were conducted by himself and the ADON. The DON stated the pharmacy consultant also conducted cart audits monthly. He stated a potential negative outcome for loose medications on the cart would be running out of a resident's medication, which could cause a resident to miss a medication. During an interview on 05/15/26 at 2:06 PM, the ADM stated he was not aware there were loose medications on the carts. He stated it was the responsibility of the charge nurse and medication aide to assure medications were properly stored on the medication carts. The ADM stated proper storage of medications on the carts was monitored through periodic cart audits conducted by nursing administration and the pharmacy consultant. He stated his expectation of staff for proper medication storage was to follow policy for securing medications and keep the carts in compliance by not having loose medications. The ADM stated a potential negative outcome for loose medications on the cart was inventory control issues. Record review of the facility-provided policy titled, Medication Labeling and Storage; revised February 2023 revealed:Policy Interpretation and ImplementationMedication Storage1. Medications and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received.2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

Based on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse and neglect for two of five residents (Resident #1, Resident #2) reviewed for abuse and neglect. The facility failed to ensure a safe environment free from sexual abuse when Resident #2, who had a history of inappropriate sexual behaviors, placed her hand inside Resident #1's panties. The facility's DON failed to implement interventions upon Resident #2's admission on [DATE], when LVN F informed him Resident #2 was masturbating, and after Resident #2 inappropriately touched him on his pants. The Immediate Jeopardy (IJ) was identified on 09/04/25 at 6:18 PM. The IJ template was provided to the facility's Administrator and DON on 09/04/25 at 6:18 PM. While the immediacy was removed on 09/05/25 at 6:07 PM, the facility remained out of compliance at a scope of pattern and severity level of no actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems, and because all their staff had not been trained on 09/05/25. These failures could affect residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm. Findings include: Resident #2 Record review of Resident #2's face sheet current as of 09/03/25, revealed a [AGE] year-old-female who was admitted to the facility on [DATE]. Resident #2 diagnoses included unspecified dementia severe with agitation (a behavioral and emotional state of dementia characterized by behaviors like restlessness, pacing, shouting, aggression, and repetitive actions), mood disorder due to known physiological condition (a mental disorder characterized by persistent changes in mood), and schizoaffective disorder bipolar type (mental health condition episodes that combines mania and depression). Review of Resident #2's Physician's Active Orders dated 08/22/25 included Psychiatric and Psychological services to evaluate and treat as needed. Record review of Resident #2's admission Comprehensive MDS, dated [DATE] revealed the following: *Section C Brief Interview for Mental Status (BIMS) revealed a score of 1 which indicated the resident's cognition was severely impaired. *Section E-Behavior: Physical behavioral symptoms directed towards other (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred 1 to 3 days. Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, packing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) occurred 1 to 3 days. Wandering-Presence & Frequency: Has the resident wandered? This was coded with a 0 to indicate this behavior was not exhibited. *Mobility Devices: none of the devices (cane, walker, wheelchair, limb prosthesis) were used. *Functional Abilities-Mobility: Walk 10 feet, once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. This was coded an 88, which meant she had not attempted due to medical condition or safety concerns. Record review of Resident #2's Care Plan dated 08/24/25 revealed her inappropriate sexual behavior was included in her plan after she was found with her hand in Resident #1's panties on 08/23/25. This plan included: *Problem: will not exhibit socially inappropriate/disruptive behavior pattern, specifically impulsive sexual behavior. This would be addressed by approaching Resident #2 and removing her from resident's room and unsafe situations. Maintain a calm environment and calm approach to the resident. Assess whether the behavior endangers the resident and/or others and intervene if necessary. *Problem: has a history of touching other residents inappropriately: This would be addressed through staff and by redirection. *Record review of Resident #2's Event Report dated 08/23/25 indicated Resident #2 was involved in an incident alleging she had her hand down the pants of Resident #1. This incident was witnessed by LVN F, the residents were separated by CNA C and CNA DD, and Resident #2 was placed on one-to-one observation with the nursing staff (1:1, defined as a staff member constantly with the resident and documents at 15-minute intervals). Resident #2, who was in Resident #1's room when this incident occurred was removed from Resident #1's room. This report indicated Resident #2 was assessed and there were no signs of trauma. On 09/02/25 at 9:40 am FNP T gave LVN F orders for Resident #2 to have labs, Senior Psych referral and Aricept 5 mg. q hs. On 09/02/25 at 10:37 am PNP gave LVN F order for Resident #2's Remeron to be change to HS, and to change Paxil to am, and have nursing to monitor for over sedation. PNP added the diagnosis of Alzhelmer's late onset to Resident #2's diagnosis. *The Facility Event Summary Report dated 08/23/25 indicated on 08/23/24 Resident #2 was found with her hand in Resident #1's pantie. After this incident, Resident #1 and Resident #2 were placed on 1:1 observation provided by the nursing staff. The residents were assessed and there were no signs of trauma, and the FNP and PNP were notified of this incident on 08/23/25. Review of Resident #2's Senior PsychCare dated 08/26/25 indicated the facility had requested a referral for psych services. The Senior PsychCare dated 08/26/25 indicated the PNP obtained verbal consent from FM for psych services. Record review of Resident #2's admission documents from her previous facility included the following Progress Notes: *Effective date of 08/03/25 at 8:25 PM that was marked out indicated “Late Entry”, Resident #2 was found in male resident's room sitting on the side of his bed and was playing with male resident's pubic hair that was sticking outside of his brief. The resident was removed and redirected from the room. *Effective date of 08/03/25 at 8:32 PM indicated Resident #2 was placed on 1:1 with monitoring tech, who would be with her and documenting on her progress. *Effective date of 08/03/25 at 7:56 PM indicated Resident #2 went into a male resident's room, he was slightly exposed and she was leaning over and touching him on his peri area. Staff said his brief was on but had it slightly moved to the side and he was not stopping her. Resident #2 was removed immediately and her hand washed. Resident #2 was impulsive and confused. *Effective date 07/16/25, Resident #2 was kissing a male resident, and they were immediately separated. Record review of FNP T's Progress Note dated 09/02/25 indicated Resident #2 was a [AGE] year-old lady who was transferred from a facility to her current facility. The current facility's nursing staff had reported hypersexual behavior to included that Resident #2 was found in a resident's room with her hand down female resident's pants (Resident #1). FNP T noted she would consult with the psychiatric team and check labs. During an interview on 09/03/25 at 10:40 am, Resident #2 was asked a series of questions; however, her verbal responses were not understood. Instead, Resident #2 smiled each time she was asked a question, including if she had touched Resident #1 on her private area. Resident #1 Record review of Resident #1's Face Sheet current as of 09/03/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnosis included dementia mild with mood disturbances (emotional or behavioral changes, such as anxiety, apathy, depression or irritability), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). Record review of Resident #1's admission Comprehensive MDS, dated [DATE] revealed the following: *Section C, Brief Interview for Mental Status (BIMS) score revealed a score of 00, which indicated the resident's cognition was severely impaired. *Section E-Behavior, Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred 1 to 3 days. *Wandering-Presence & Frequency: Has the resident wandered? This was coded with a 0 to indicate this behavior was not exhibited. *Functional Abilities-Mobility, walk 10 feet, once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. This was coded a 6, which meant she could complete this activity by herself with no assistance from a helper. Record review of Resident #1's Care Plan dated 08/12/25 included: *Problem: updated on 08/23/25 to include due to impaired cognition, Resident #1 is at risk for unwanted sexual advances from other residents. This would be addressed by ensuring client safety. *Problem, on 08/12/25 the plan included that she had physically aggressive behavior towards others. The plan included cueing resident to maintain space between self and others and assisting resident in moving self away while interacting with others. Record review of Resident #1's Observation Detail List Report noted by LVN N on 08/23/25 at 11:18 am indicated Resident #2 was witnessed with her hand down Resident #1's pants, in Resident #1's room. The nursing staff immediately entered the room and separated Resident #1 and #2. Resident #2 was placed on 1:1 observation due to this allegation. Resident #1, was assessed and she had no signs of trauma. Record review of Resident #1's Progress Notes indicated the following: *The ADON noted that on 08/26/25 Resident #1's Interdisciplinary Team met and discontinued her 1:1 observation. *The DON noted that on 08/23/25 Resident #1 (who was on 1:1 observation) was involved in an incident in which resident (Resident #2) was witnessed with her hand down resident #1's pants in Resident #1's room. Nursing staff entered the room, separated Resident #1 and #2, and removed Resident #2 from Resident #1's room. Resident #1 was assessed and there were no signs of trauma. *The DON noted on 08/22/25 that Resident #1 (who was the aggressor) was involved in an altercation with Resident #9, by slapping her on her back. Resident #9 responded by slapping Resident #1 in the face near her eye. The residents were separated and Resident #1 was placed on 1:1 observation until she could be cleared by psychiatric services. During an observation on 09/03/25 at 10:45 am revealed Resident #2 entered Resident # 7's room, and there were no CNAs present in the area. LVN L, who was at the end of the hallway, was notified that Resident #2 was in Resident #7's room. LVN L went to Resident #2, who was in Resident #7's room, and redirected and escorted her to leave the room and go to the dining/lobby area. During an interview on 09/03/25 at 11:15 AM, Resident #1 indicated nobody hurt her and she could not recall being touched on her body by Resident #2. During an interview on 09/05/25 at 11:23 AM, FM S indicated he was informed that Resident #1 was touched on the buttock by a resident but never informed that she was fondled in her private area by a resident. During an interview on 09/04/25 at 3:04 PM, CNA A indicated she started her shift on 08/22/25 at 6 PM and worked until 6 am on 08/23/25. During this shift, CNA A said she was assigned as Resident #1's 1:1 observation, which meant she had to watch her closely and keep her out of residents' room. CNA A said before she left the faciity on [DATE] at 6 am, she informed a CNA, whose name she could not recall, that she was leaving and transferring her observation to the next shift. CNA A said Resident #1 was asleep in her bed when she left. During an interview on 09/03/25 at 10:46 AM, CNA C indicated on 08/23/25 she was working with CNA P; however, CNA O, who was assigned as Resident #1's 1:1 observation had not started her shift at 6 am, instead she started at 7 am. CNA C said her and CNA P provided ADL care to the residents to get them ready for breakfast. CNA C said she saw Resident #1 in the dining/lobby area and saw Resident #2 going into Resident #1's room, where she sat and fell asleep on Resident #1's recliner. CNA C said she did not redirect Resident #2 to leave Resident #1's room because she has a history of becoming upset, and because Resident #1 was not in her room. CNA C said she did not see Resident #1 return to her room, while Resident #2 slept on her recliner. CNA C said she was unaware that Resident #2 had to be watched closer due to inappropriate sexual behavior, and she knew Resident #1 had behaviors of aggression and was supposed to be watched closer per FM's request. During an interview on 09/04/25 at 10:48 AM, CNA P indicated she worked on 08/23/25 and was directed by DON to keep an eye on Resident #1 due to inappropriate touching; however, she was not assigned as her 1:1 observation. CNA P said she worked with CNA C and they assisted residents with their ADLs to get them ready for breakfast. CNA P said CNA O was supposed to start her shift at 6 am and carry out Resident #1's 1:1 observation; however, she did not arrive until 7 AM. CNA P said she assisted Resident #1 with her ADLs and took her to the dining table because Resident #2 had entered Resident #1's room. CNA P said it was easier to take Resident #1 out of her room than Resident #2, which was why she allowed Resident #2 to stay in the room. CNA P said she informed LVN F, who was administering medications, that she was leaving Resident #2 in Resident #1's room. CNA P said at approximately 7 AM CNA O entered the memory unit and asked for the whereabouts of Resident #1 and replied that Resident #1 was supposed to be in the dining area. And that's when, LVN F yelled out for staff to get Resident #2 because she was foundling Resident #1 in her room and asked who was Resident #1's 1:1 observation. CNA P said she entered Resident #1's room and saw Resident #1 standing with her pants unbuckled and in front of Resident #2, who was sitting on the recliner and holding Resident #1 by her wrist. CNA P said earlier in the morning, she dressed Resident #1 and left her pants unbuckled because they did not fit her. CNA P said upon the start of her shift on 08/23/25 at 6 am, she knew Resident #1 was on 1:1 observation; however, she was not assigned to her and continued to care for the residents. CNA P said she was unaware that Resident #2 had a history of sexual behaviors. At 1:34 PM CNA P stated she had never implemented 1:1 observation for anyone. She stated she was working on 08/23/25 and does not recall anyone informing her that they were leaving, and that they had been the 1:1 observation for Resident # 1. She stated on 08/23/25 she was the person who assisted Resident #1 with dressing and then sat her at the dining room table. During an interview on 9/04/25 at 1:30 PM LVN L stated they are informed by the DON or the ADON that a resident is on 1:1 supervision. She stated that 1:1 supervision is a level of supervision that means that the staff is like the resident's “shadow” or like their “leash”. She stated 1:1 supervision means that the staff must be close enough to verbally and physically intervene. She stated she was not responsible for assigning staff to 1:1 supervision. LVN L stated the DON or the ADON would make those assignments. She stated she is unaware of any documentation that staff must complete while they were on 1:1 supervision with residents. She stated the DON or ADON would be the person to let them (staff) know when the resident is no longer on 1:1 supervision. She stated the PNP was the only person that could take the resident off 1:1 supervision. She stated she had not had any special training but from her nursing experience she knew what 1:1 supervision looked like. During an interview on 09/05/25 at 10:35 AM, LVN F indicated on 08/23/25 she was in the hallway parallel to Resident #1's doorway as she prepared the next medication administration, when she witnessed Resident #1 standing in front of her recliner rocking back and forth, and Resident #2's hand inside her pantie. Resident #2, who was inside Resident #1's room, was sitting on Resident #1's recliner as she fondled Resident #1. LVN F said she said she yelled out to the CNAs “come get them” and questioned who was assigned as Resident #1's 1:1 observation. LVN F indicated she had not been given the responsibility of assigning 1:1 staff to residents in need of closer supervision, which had been the responsibility of DON and ADON. LVN F stated on 08/22/25 Resident #2 was a new admission to the facility. LVN F said she entered Resident #2's room and saw her masturbating. LVN F said she called the previous facility and spoke to LVN DD, who informed her Resident #2 had a history of being sexually inappropriate with the male residents, because she would go into their rooms and touch their private parts, and that's why she was transferred out of the facility. LVN F said she informed the DON that Resident #2 was masturbating; therefore, she could not conduct her heat-to-toe assessment, and that's when the DON entered her room and Resident #2 grabbed his pants. LVN F said Resident #2 was not assigned special supervision; however, Resident #1 had been on 1:1 observation since 08/21/25 due to an incident of aggression. During an interview on 09/04/21 at 1:41 PM, The DON said on 08/22/24 Resident #2 was admitted to the facility, and when he assessed her in the room by himself, she went for his belt buckle and he had to move her hand away. The DON said he asked LVN F to supervise Resident #2's assessment and nothing else happened during this assessment. The DON said he was unaware Resident #2 had a history of inappropriate sexual behaviors prior to her admission to the facility; however, he was informed that Resident #2 had to move from her previous facility due to being the victim of unwanted sexual advances by the male residents. The DON indicated if a resident has an incident of aggression the charge nurse will notify him, and then he will direct them to keep them separated and to place the aggression on 1:1 observation and would not be removed unit the resident's assessed by psych services. The DON said the facility's central office reviewed Resident #2's file and directed the facility to accept her as a new admission. The DON confirmed on 08/23/25 Resident #1 was on 1:1 observation due to hitting a resident on 08/22/25. The DON said a CNA should have been within arm's reach of Resident #1, which would have prevented Resident #1 from being inappropriately touched by Resident #2. The DON said he and his staff were unaware that Resident #2 had a history of inappropriate sexual behaviors. The DON said on 08/23/25 he was informed by LVN F Resident #2 had her hand inside Resident #2's pants, and Resident #1 did not have a 1:1 observation at the time of this incident. During an interview on 09/04/25 at 10:48 AM, CNA E indicated she was unaware Resident #2 had a history of inappropriate sexual behavior. During an interview on 09/04/25 at 11:41 PM, the admission Coordinator indicated Resident #2 was approved as a transfer to the facility by their Central Intake Team. This approval was sent to her via an email on 08/21/25, and Resident #2 was admitted to the facility on [DATE]. admission Coordinator said she did not review Resident #2's notes in the admission packet and confirmed Resident #2's admission transfer notes included 3 incidents of inappropriate sexual behavior (08/03/25 x 2 and 07/16/25). During an interview on 09/04/25 at 12:05 PM, the SW indicated she was unaware Resident #2 had a history of inappropriate sexual behavior; however, after Resident #2 touched Resident #1 inappropriately, she was placed on 1:1 observation. During an interview on 09/04/25 at 12:35 PM, the MDS Coordinator indicated she was unaware Resident #2 had a history of inappropriate sexual behavior; however, after Resident #2 touched Resident #1 inappropriately, she was placed on 1:1 observation. The MDS Coordinator said she does not assign residents 1:1 observation, nor does she include 1:1 or watch closely in a resident's care plan. The MDS Coordinator said she did not include Resident #1's inappropriate sexual behavior in her care plan, because she was not informed during her admission. During an interview on 09/04/25 at 1:19 PM, FNP U indicated on 08/21/25 she was informed Resident #1 had an incident of aggression, and that's when she was placed on 1:1 observation, until psych services could evaluate her. After this incident, FNP U said she was informed Resident #1 was inappropriately touched by Resident #2, who put her hand in her pants. FNP U said on 08/23/25 Resident #1 was supposed to be on 1:1 observation, and Resident #2 should not have had the opportunity to put her hand in her pants. The facility must ensure each resident receives adequate supervision and assistance to prevent this type of accident from happening. During an interview on 09/04/25 at 2:18 PM, the Administrator indicated he received an email that at the previous facility that the male residents were after Resident #2 sexually; therefore, she was approved by his central office to admit Resident #2. The administrator said he did not review Resident #2's file upon her admission to the facility. The Administrator indicated that the facility's investigation indicated LVN F witnessed Resident #2 with her hand inside Resident #1's panties. The Administrator said CNA A, who was assigned as Resident #1's 1:1 observation, should not have left her shift until she was replaced by a staff. During an interview on 09/04/25 at 3:47 PM, PNP indicated Resident #2 had a history of inappropriate sexual behavior, because on 08/22//25 LVN F found her masturbating, and she touched the DON on his pants during her assessment. PNP said he ordered Paxil that had to go through the facility's physician because she had not been approved for psych services. On 08/26/25 PNP said he received the approval for Resident #2's psych services. PNP said he was informed by the DON that Resident #2 had not displayed inappropriate sexual activity; therefore, PNP dc the need for 1:1 observation because the Paxil was showing good results. PNP said as of 09/04/25, he had not sent the facility his notes on his assessment with Resident #2. During an interview on 09/05/25 at 10:35 AM, FNP T indicated Resident #2, who had a history of inappropriate sexual behaviors, should have been assigned a 1:1 observation or watched closely for 3 to 5 days , and should have had her inappropriate sexual behaviors care planned for her safety and the safety of others. FNP T said the observations should have been noted every 15 minutes for 72 hours, because they did not know if the resident will could be violent or hypersexual. FNP T said if Resident #1 was on 1:1 observation, then Resident #2 should never have had the opportunity to put her hand inside Resident #1's pants and panties. During an interview on 9/05/25 at 12:59 PM the DON stated that on 08/23/25 Resident #2 was placed on 1:1 supervision but they did not have documentation of that action. He stated because of the IJ they will now keep documentation of all residents who were placed on 1:1 supervision. He stated because of the IJ all residents in the secure unit were assessed by him and the SDON with no negative findings. He stated the ADON conducted safe surveys with no negative findings. He stated when the IJ was called on 09/04/25 the IDT team that included the department heads (the ADM, DON, BOM, Admissions Coordinator, HR, the DM, HK Supervisor, MDS Coordinator, and the ADM) trained all the staff on the ANE policy, 1:1 supervision (to include what it meant, the transfer process, how close they needed to be, when they could leave and documentation), and the Resident-to Resident Policy. He stated that residents who are placed on 1:1 supervision will need to ensure that they are close enough to intervene. He stated if the resident is sleeping the staff can be outside of the door and check every 15 minutes and use a flashlight so that the resident is not disturbed. He stated the 1:1 would be randomly checked to ensure that the documentation is up to date, staff are within the right distance and interventions are being followed. He stated during the week he and the ADON would do the random audits for 1:1 supervision but on the weekend, he had a RN supervisor. He stated he gave staff the opportunity to ask questions if they needed to. He stated Admissions was trained on reviewing the paperwork prior to accepting a resident in the facility. He stated before any resident is admitted to the facility their admission paperwork will be reviewed by the appropriate people in the IDT. He stated they did participate in a QAPI meeting that addressed all the components of the IJ. Record review of the facility's Abuse, Neglect and Exploitation revised on 08/05/25 indicated “it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, . “Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercation. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitate or enabled through the use of technology.” “Criminal sexual abuse is serious bodily injury/harm shall be considered to have occurred if the conduct causing the injury is conducted described in section 2241 (relating to aggravated sexual abuse) or section 2242 (relating to sexual abuse of Title 18, United States Cod, or any similar offense under State law. In other works , serious bodily injury includes sexual intercourse with a resident by force or incapacitation or through threats of harm to the resident or others or any sexual act involving a child. Serious bodily injury also includes sexual intercourse with a resident who is incapable of declining to participate in the sexual act or lac the ability to understand the nature of the sexual act.” “Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that ae necessary to avoid physical harm, pain , mental anguish, or emotional distress. “Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury of harm. The Administrator and DON were notified on 09/04/25 at 6:18 PM that an IJ situation was identified due to the above failures and the IJ template was provided. The following Plan of Removal was accepted on 09/05/2025 at 10:46AM: “Plan of Removal 09/05/2025 Per the information provided in the IJ template given to the facility Administrator and DON on 09/04/25 at 6:18 PM The facility failed to ensure a safe environment free from sexual abuse when Resident #2, who had a history of inappropriate sexual behaviors, placed her hand inside Resident #1's panties. The facility's DON failed to implement interventions upon Resident #2's admission on [DATE], when LVN F informed him Resident #2 was masturbating, and after Resident #2 inappropriately touched him on his pants. Residents residing in the memory unit received a skin assessment and/or a safe survey on 8/23/2025 with no additional negative findings.Person(s) Responsible: Charge Nurse, social services, and/or designee Date: 8/26/2025 Education provided to Administrator and Director of Nursing on the Abuse & Neglect Policy, 1:1 (employees should remain on 1:1, when placed on 1:1, without fail, until 1:1 is discontinued), Resident-to-Resident Policy, reviewing admission paperwork and care planning/educating staff, when needed, on sexual behaviors and interventions.Person(s) Responsible: Regional [NAME] President of Operations and/or Regional Nurse Consultant Date: 8/23/2025 All staff educated on the Abuse & Neglect Policy, 1:1 (employees should remain on 1:1, when placed on 1:1, without fail, until 1:1 is discontinued), and Resident-to-Resident Policy.Schedules will be reviewed and the Administrator, Director of Nursing, and/or a Designated staff member will be responsible to ensure all staff will be educated prior to working their next shift.Person(s) Responsible: Administrator, Director of Nursing, and/or Designee. Date: 9/4/2025 Referrals/admissions will be reviewed prior to admission to ensure high risk history, such as sexual or physical aggression, and care plans/interventions will be put into place and staff will be communicated with prior to/at admission. Care plans can be found in Matrix in the plan of care.Person(s) Responsible: admission Coordinator, Administrator, Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 9/4/2025 When residents are placed on 1:1, Administrator, Director of Nursing, Assistant Director of Nursing, and/or Designee will spot check, daily, Monday-Friday and a designee such as a charge nurse and/or weekend supervisor will spot check, daily, Saturday and Sunday, to ensure staff are following policy and education provided.Person(s) Responsible: Administrator, Director of Nursing, Assistant Director of Nursing, and/or DesigneeDate: 9/4/2025 QAPI— Action: Ad hoc QAPI performed with Medical Director, notified of the Immediate Jeopardy template and the facility's plan to remove it. No additional recommendations at this time. Person(s) Responsible: AdministratorDate: 9/4/2025 On 09/05/25 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview on 09/05/25 at 11:09 AM, the DON said the in-services indicated observation levels will be implemented by CNAs, nurses, ADONs, DON, SW, and other staff (activity director, housekeepers, and office staff as needed. During an interview on 09/05/25 the admission Coordinator was in-serviced to ensure referrals for new admissions are reviewed prior to admission. If a resident is identified with a history of sexual or physical aggression, this will be care planned to include interventions for staff to follow. During an interview on 9/05/25 at 12:59 PM the DON stated that on 08/23/25 Resident #2 was placed on 1:1 supervision but they did not have documentation of that action. He stated because of the IJ they will now keep documentation of all residents who were placed on 1:1 supervision. He stated because of the IJ all resident

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 two of five residents (Resident #1, Resident #2) reviewed for abuse, neglect, and exploitation. The facility failed to implement their policies and procedures for identifying and addressing at admission Resident #2's history of inappropriate sexual behavior to prevent Resident #2, from placing her hand inside Resident #1's pantie. The Immediate Jeopardy (IJ) was identified on 09/04/25 at 6:18 PM. The IJ template was provided to the facility's Administrator and DON on 09/04/25 at 6:18 PM. While the immediacy was removed on 09/05/25 at 6:07 PM, the facility remained out of compliance at a scope of pattern and severity level of no actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems, and because all their staff had not been trained on 09/05/25. These failures could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm.Findings include: Resident #2Record review of Resident #2's face sheet current as of 09/03/25, revealed a [AGE] year-old-female who was admitted to the facility on [DATE]. Resident #2 diagnoses included unspecified dementia severe with agitation (a behavioral and emotional state of dementia characterized by behaviors like restlessness, pacing, shouting, aggression, and repetitive actions), mood disorder due to known physiological condition (a mental disorder characterized by persistent changes in mood), and schizoaffective disorder bipolar type (mental health condition episodes that combines mania and depression). Review of Resident #2's Physician's Active Orders dated 08/22/25 included Psychiatric and Psychological services to evaluate and treat as needed. Record review of Resident #2's admission Comprehensive MDS, dated [DATE] revealed the following: *Section C Brief Interview for Mental Status (BIMS) revealed a score of 1 which indicated the resident's cognition was severely impaired. *Section E-Behavior: Physical behavioral symptoms directed towards other (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred 1 to 3 days. Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, packing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) occurred 1 to 3 days. Wandering-Presence & Frequency: Has the resident wandered? This was coded with a 0 to indicate this behavior was not exhibited. *Mobility Devices: none of the devices (cane, walker, wheelchair, limb prosthesis) were used. *Functional Abilities-Mobility: Walk 10 feet, once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. This was coded an 88, which meant she had not attempted due to medical condition or safety concerns. Record review of Resident #2's Care Plan dated 08/24/25 revealed her inappropriate sexual behavior was included in her plan after she was found with her hand in Resident #1's panties on 08/23/25. This plan included: *Problem: will not exhibit socially inappropriate/disruptive behavior pattern, specifically impulsive sexual behavior. This would be addressed by approaching Resident #2 and removing her from resident's room and unsafe situations. Maintain a calm environment and calm approach to the resident. Assess whether the behavior endangers the resident and/or others and intervene if necessary. *Problem: has a history of touching other residents inappropriately: This would be addressed through staff and by redirection. *Record review of Resident #2's Event Report dated 08/23/25 indicated Resident #2 was involved in an incident alleging she had her hand down the pants of Resident #1. This incident was witnessed by LVN F, the residents were separated by CNA C and CNA DD, and Resident #2 was placed on one-to-one observation with the nursing staff (1:1, defined as a staff member constantly with the resident and documents at 15-minute intervals). Resident #2, who was in Resident #1's room when this incident occurred was removed from Resident #1's room. This report indicated Resident #2 was assessed and there were no signs of trauma. On 09/02/25 at 9:40 am FNP T gave LVN F orders for Resident #2 to have labs, Senior Psych referral and Aricept 5 mg. q hs. On 09/02/25 at 10:37 am PNP gave LVN F order for Resident #2's Remeron to be change to HS, and to change Paxil to am, and have nursing to monitor for over sedation. PNP added the diagnosis of Alzhelmer's late onset to Resident #2's diagnosis. *The Facility Event Summary Report dated 08/23/25 indicated on 08/23/24 Resident #2 was found with her hand in Resident #1's pantie. After this incident, Resident #1 and Resident #2 were placed on 1:1 observation provided by the nursing staff. The residents were assessed and there were no signs of trauma, and the FNP and PNP were notified of this incident on 08/23/25. Review of Resident #2's Senior PsychCare dated 08/26/25 indicated the facility had requested a referral for psych services. The Senior PsychCare dated 08/26/25 indicated the PNP obtained verbal consent from FM for psych services. Record review of Resident #2's admission documents from her previous facility included the following Progress Notes: *Effective date of 08/03/25 at 8:25 PM that was marked out indicated Late Entry, Resident #2 was found in male resident's room sitting on the side of his bed and was playing with male resident's pubic hair that was sticking outside of his brief. The resident was removed and redirected from the room. *Effective date of 08/03/25 at 8:32 PM indicated Resident #2 was placed on 1:1 with monitoring tech, who would be with her and documenting on her progress. *Effective date of 08/03/25 at 7:56 PM indicated Resident #2 went into a male resident's room, he was slightly exposed and she was leaning over and touching him on his peri area. Staff said his brief was on but had it slightly moved to the side and he was not stopping her. Resident #2 was removed immediately and her hand washed. Resident #2 was impulsive and confused. *Effective date 07/16/25, Resident #2 was kissing a male resident, and they were immediately separated. Record review of FNP T's Progress Note dated 09/02/25 indicated Resident #2 was a [AGE] year-old lady who was transferred from a facility to her current facility. The current facility's nursing staff had reported hypersexual behavior to included that Resident #2 was found in a resident's room with her hand down female resident's pants (Resident #1). FNP T noted she would consult with the psychiatric team and check labs. During an interview on 09/03/25 at 10:40 am, Resident #2 was asked a series of questions; however, her verbal responses were not understood. Instead, Resident #2 smiled each time she was asked a question, including if she had touched Resident #1 on her private area. During an interview on 09/04/25 at 3:47 PM, PNP indicated Resident #2 had a history of inappropriate sexual behavior, because on 08/22//25 LVN F found her masturbating, and she touched the DON on his pants during her assessment. PNP said he ordered Paxil that had to go through the facility's physician because she had not been approved for psych services. On 08/26/25 PNP said he received the approval for Resident #2's psych services. PNP said he was informed by the DON that Resident #2 had not displayed inappropriate sexual activity; therefore, PNP dc the need for 1:1 observation because the Paxil was showing good results. PNP said as of 09/04/25, he had not sent the facility his notes on his assessment with Resident #2. Resident #1Record review of Resident #1's Face Sheet current as of 09/03/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnosis included dementia mild with mood disturbances (emotional or behavioral changes, such as anxiety, apathy, depression or irritability), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). Record review of Resident #1's admission Comprehensive MDS, dated [DATE] revealed the following: *Section C, Brief Interview for Mental Status (BIMS) score revealed a score of 00, which indicated the resident's cognition was severely impaired. *Section E-Behavior, Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred 1 to 3 days. *Wandering-Presence & Frequency: Has the resident wandered? This was coded with a 0 to indicate this behavior was not exhibited. *Functional Abilities-Mobility, walk 10 feet, once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. This was coded a 6, which meant she could complete this activity by herself with no assistance from a helper. Record review of Resident #1's Care Plan dated 08/12/25 included: *Problem: updated on 08/23/25 to include due to impaired cognition, Resident #1 is at risk for unwanted sexual advances from other residents. This would be addressed by ensuring client safety. *Problem, on 08/12/25 the plan included that she had physically aggressive behavior towards others. The plan included cueing resident to maintain space between self and others and assisting resident in moving self away while interacting with others. Record review of Resident #1's Observation Detail List Report noted by LVN N on 08/23/25 at 11:18 am indicated Resident #2 was witnessed with her hand down Resident #1's pants, in Resident #1's room. The nursing staff immediately entered the room and separated Resident #1 and #2. Resident #2 was placed on 1:1 observation due to this allegation. Resident #1, was assessed and she had no signs of trauma. Record review of Resident #1's Progress Notes indicated the following: *The ADON noted that on 08/26/25 Resident #1's Interdisciplinary Team met and discontinued her 1:1 observation. *The DON noted that on 08/23/25 Resident #1 (who was on 1:1 observation) was involved in an incident in which resident (Resident #2) was witnessed with her hand down resident #1's pants in Resident #1's room. Nursing staff entered the room, separated Resident #1 and #2, and removed Resident #2 from Resident #1's room. Resident #1 was assessed and there were no signs of trauma. *The DON noted on 08/22/25 that Resident #1 (who was the aggressor) was involved in an altercation with Resident #9, by slapping her on her back. Resident #9 responded by slapping Resident #1 in the face near her eye. The residents were separated and Resident #1 was placed on 1:1 observation until she could be cleared by psychiatric services. During an observation on 09/03/25 at 10:45 am revealed Resident #2 entered Resident # 7's room, and there were no CNAs present in the area. LVN L, who was at the end of the hallway, was notified that Resident #2 was in Resident #7's room. LVN L went to Resident #2, who was in Resident #7's room, and redirected and escorted her to leave the room and go to the dining/lobby area. During an interview on 09/03/25 at 11:15 AM, Resident #1 indicated nobody hurt her and she could not recall being touched on her body by Resident #2. During an interview on 09/05/25 at 11:23 AM, FM S indicated he was informed that Resident #1 was touched on the buttock by a resident but never informed that she was fondled in her private area by a resident. During an interview on 09/04/25 at 3:04 PM, CNA A indicated she started her shift on 08/22/25 at 6 PM and worked until 6 am on 08/23/25. During this shift, CNA A said she was assigned as Resident #1's 1:1 observation, which meant she had to watch her closely and keep her out of residents' room. CNA A said before she left the faciity on [DATE] at 6 am, she informed a CNA, whose name she could not recall, that she was leaving and transferring her observation to the next shift. CNA A said Resident #1 was asleep in her bed when she left. During an interview on 09/03/25 at 10:46 am, CNA C indicated on 08/23/25 she was working with CNA P; however, CNA O, who was assigned as Resident #1's 1:1 observation had not started her shift at 6 am, instead she started at 7 am. CNA C said her and CNA P provided ADL care to the residents to get them ready for breakfast. CNA C said she saw Resident #1 in the dining/lobby area and saw Resident #2 going into Resident #1's room, where she sat and fell asleep on Resident #1's recliner. CNA C said she did not redirect Resident #2 to leave Resident #1's room because she has a history of becoming upset, and because Resident #1 was not in her room. CNA C said she did not see Resident #1 return to her room, while Resident #2 slept on her recliner. CNA C said she was unaware that Resident #2 had to be watched closer due to inappropriate sexual behavior, and she knew Resident #1 had behaviors of aggression and was supposed to be watched closer per FM's request. During an interview on 09/04/25 at 10:48 AM, CNA P indicated she worked on 08/23/25 and was directed by DON to keep an eye on Resident #1 due to inappropriate touching; however, she was not assigned as her 1:1 observation. CNA P said she worked with CNA C and they assisted residents with their ADLs to get them ready for breakfast. CNA P said CNA O was supposed to start her shift at 6 am and carry out Resident #1's 1:1 observation; however, she did not arrive until 7 AM. CNA P said she assisted Resident #1 with her ADLs and took her to the dining table because Resident #2 had entered Resident #1's room. CNA P said it was easier to take Resident #1 out of her room than Resident #2, which was why she allowed Resident #2 to stay in the room. CNA P said she informed LVN F, who was administering medications, that she was leaving Resident #2 in Resident #1's room. CNA P said at approximately 7 AM CNA O entered the memory unit and asked for the whereabouts of Resident #1 and replied that Resident #1 was supposed to be in the dining area. And that's when, LVN F yelled out for staff to get Resident #2 because she was foundling Resident #1 in her room and asked who was Resident #1's 1:1 observation. CNA P said she entered Resident #1's room and saw Resident #1 standing with her pants unbuckled and in front of Resident #2, who was sitting on the recliner and holding Resident #1 by her wrist. CNA P said earlier in the morning, she dressed Resident #1 and left her pants unbuckled because they did not fit her. CNA P said upon the start of her shift on 08/23/25 at 6 am, she knew Resident #1 was on 1:1 observation; however, she was not assigned to her and continued to care for the residents. CNA P said she was unaware that Resident #2 had a history of sexual behaviors. At 1:34 PM CNA P stated she had never implemented 1:1 observation for anyone. She stated she was working on 08/23/25 and does not recall anyone informing her that they were leaving, and that they had been the 1:1 observation for Resident # 1. She stated on 08/23/25 she was the person who assisted Resident #1 with dressing and then sat her at the dining room table. During an interview on 9/04/25 at 1:40 PM CNA E stated that she has never been any resident's 1:1 staff. She stated they are typically informed by the DON or the previous shift staff may tell them if a resident is on 1:1 supervision. She stated the DON would tell them if a resident was off 1:1 supervision. She stated she had been trained by the facility staff that they stay until relief comes. She stated she did not know when, but the training had occurred since she had been at the facility. During an interview on 09/05/25 at 10:35 AM, LVN F indicated on 08/23/25 she was in the hallway parallel to Resident #1's doorway as she prepared the next medication administration, when she witnessed Resident #1 standing in front of her recliner rocking back and forth, and Resident #2's hand inside her pantie. Resident #2, who was inside Resident #1's room, was sitting on Resident #1's recliner as she fondled Resident #1. LVN F said she said she yelled out to the CNAs come get them and questioned who was assigned as Resident #1's 1:1 observation. LVN F indicated she had not been given the responsibility of assigning 1:1 staff to residents in need of closer supervision, which had been the responsibility of DON and ADON. LVN F stated on 08/22/25 Resident #2 was a new admission to the facility. LVN F said she entered Resident #2's room and saw her masturbating. LVN F said she called the previous facility and spoke to LVN DD, who informed her Resident #2 had a history of being sexually inappropriate with the male residents, because she would go into their rooms and touch their private parts, and that's why she was transferred out of the facility. LVN F said she informed the DON that Resident #2 was masturbating; therefore, she could not conduct her heat-to-toe assessment, and that's when the DON entered her room and Resident #2 grabbed his pants. LVN F said Resident #2 was not assigned special supervision; however, Resident #1 had been on 1:1 observation since 08/21/25 due to an incident of aggression. During an interview on 09/04/21 at 1:41 PM, The DON said on 08/22/24 Resident #2 was admitted to the facility, and when he assessed her in the room by himself, she went for his belt buckle and he had to move her hand away. The DON said he asked LVN F to supervise Resident #2's assessment and nothing else happened during this assessment. The DON said he was unaware Resident #2 had a history of inappropriate sexual behaviors prior to her admission to the facility; however, he was informed that Resident #2 had to move from her previous facility due to being the victim of unwanted sexual advances by the male residents. The DON indicated if a resident has an incident of aggression the charge nurse will notify him, and then he will direct them to keep them separated and to place the aggression on 1:1 observation and would not be removed unit the resident's assessed by psych services. The DON said the facility's central office reviewed Resident #2's file and directed the facility to accept her as a new admission. The DON confirmed on 08/23/25 Resident #1 was on 1:1 observation due to hitting a resident on 08/22/25. The DON said a CNA should have been within arm's reach of Resident #1, which would have prevented Resident #1 from being inappropriately touched by Resident #2. The DON said he and his staff were unaware that Resident #2 had a history of inappropriate sexual behaviors. The DON said on 08/23/25 he was informed by LVN F Resident #2 had her hand inside Resident #2's pants, and Resident #1 did not have a 1:1 observation at the time of this incident. During an interview on 09/04/25 at 10:48 AM, CNA E indicated she was unaware Resident #2 had a history of inappropriate sexual behavior. During an interview on 09/04/25 at 11:41 PM, the admission Coordinator indicated Resident #2 was approved as a transfer to the facility by their Central Intake Team. This approval was sent to her via an email on 08/21/25, and Resident #2 was admitted to the facility on [DATE]. admission Coordinator said she did not review Resident #2's notes in the admission packet and confirmed Resident #2's admission transfer notes included 3 incidents of inappropriate sexual behavior (08/03/25 x 2 and 07/16/25). During an interview on 09/04/25 at 12:05 PM, the SW indicated she was unaware Resident #2 had a history of inappropriate sexual behavior; however, after Resident #2 touched Resident #1 inappropriately, she was placed on 1:1 observation. During an interview on 09/04/25 at 12:35 PM, the MDS Coordinator indicated she was unaware Resident #2 had a history of inappropriate sexual behavior; however, after Resident #2 touched Resident #1 inappropriately, she was placed on 1:1 observation. The MDS Coordinator said she does not assign residents 1:1 observation, nor does she include 1:1 or watch closely in a resident's care plan. The MDS Coordinator said she did not include Resident #1's inappropriate sexual behavior in her care plan, because she was not informed during her admission. During an interview on 09/04/25 at 1:19 PM, FNP U indicated on 08/21/25 she was informed Resident #1 had an incident of aggression, and that's when she was placed on 1:1 observation, until psych services could evaluate her. After this incident, FNP U said she was informed Resident #1 was inappropriately touched by Resident #2, who put her hand in her pants. FNP U said on 08/23/25 Resident #1 was supposed to be on 1:1 observation, and Resident #2 should not have had the opportunity to put her hand in her pants. The facility must ensure each resident receives adequate supervision and assistance to prevent this type of accident from happening. During an interview on 09/04/25 at 2:18 PM, the Administrator indicated he received an email that at the previous facility that the male residents were after Resident #2 sexually; therefore, she was approved by his central office to admit Resident #2. The administrator said he did not review Resident #2's file upon her admission to the facility. The Administrator indicated that the facility's investigation indicated LVN F witnessed Resident #2 with her hand inside Resident #1's panties. The Administrator said CNA A, who was assigned as Resident #1's 1:1 observation, should not have left her shift until she was replaced by a staff. During an interview on 09/04/25 at 3:47 PM, PNP indicated Resident #2 had a history of inappropriate sexual behavior, because on 08/22//25 LVN F found her masturbating, and she touched the DON on his pants during her assessment. PNP said he ordered Paxil that had to go through the facility's physician because she had not been approved for psych services. On 08/26/25 PNP said he received the approval for Resident #2's psych services. PNP said he was informed by the DON that Resident #2 had not displayed inappropriate sexual activity; therefore, PNP dc the need for 1:1 observation because the Paxil was showing good results. PNP said as of 09/04/25, he had not sent the facility his notes on his assessment with Resident #2. During an interview on 09/05/25 at 10:35 AM, FNP T indicated Resident #2, who had a history of inappropriate sexual behaviors, should have been assigned a 1:1 observation or watched closely for 3 to 5 days , and should have had her inappropriate sexual behaviors care planned for her safety and the safety of others. FNP T said the observations should have been noted every 15 minutes for 72 hours, because they did not know if the resident will could be violent or hypersexual. FNP T said if Resident #1 was on 1:1 observation, then Resident #2 should never have had the opportunity to put her hand inside Resident #1's pants and panties. During an interview on 9/05/25 at 12:59 PM the DON stated that on 08/23/25 Resident #2 was placed on 1:1 supervision but they did not have documentation of that action. He stated because of the IJ they will now keep documentation of all residents who were placed on 1:1 supervision. He stated because of the IJ all residents in the secure unit were assessed by him and the SDON with no negative findings. He stated the ADON conducted safe surveys with no negative findings. He stated when the IJ was called on 09/04/25 the IDT team that included the department heads (the ADM, DON, BOM, Admissions Coordinator, HR, the DM, HK Supervisor, MDS Coordinator, and the ADM) trained all the staff on the ANE policy, 1:1 supervision (to include what it meant, the transfer process, how close they needed to be, when they could leave and documentation), and the Resident-to Resident Policy. He stated that residents who are placed on 1:1 supervision will need to ensure that they are close enough to intervene. He stated if the resident is sleeping the staff can be outside of the door and check every 15 minutes and use a flashlight so that the resident is not disturbed. He stated the 1:1 would be randomly checked to ensure that the documentation is up to date, staff are within the right distance and interventions are being followed. He stated during the week he and the ADON would do the random audits for 1:1 supervision but on the weekend, he had a RN supervisor. He stated he gave staff the opportunity to ask questions if they needed to. He stated Admissions was trained on reviewing the paperwork prior to accepting a resident in the facility. He stated before any resident is admitted to the facility their admission paperwork will be reviewed by the appropriate people in the IDT. He stated they did participate in a QAPI meeting that addressed all the components of the IJ. Record review of the facility's Abuse, Neglect and Exploitation revised on 08/05/25 indicated it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, . Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercation. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitate or enabled through the use of technology. Criminal sexual abuse is serious bodily injury/harm shall be considered to have occurred if the conduct causing the injury is conducted described in section 2241 (relating to aggravated sexual abuse) or section 2242 (relating to sexual abuse of Title 18, United States Cod, or any similar offense under State law. In other works , serious bodily injury includes sexual intercourse with a resident by force or incapacitation or through threats of harm to the resident or others or any sexual act involving a child. Serious bodily injury also includes sexual intercourse with a resident who is incapable of declining to participate in the sexual act or lac the ability to understand the nature of the sexual act. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that ae necessary to avoid physical harm, pain , mental anguish, or emotional distress. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury of harm. The Administrator and DON were notified on 09/04/25 at 6:18 PM that an IJ situation was identified due to the above failures and the IJ template was provided. The following Plan of Removal was accepted on 09/05/2025 at 10:46AM: Plan of Removal 09/05/2025 Per the information provided in the IJ template given to the facility Administrator and DON on 09/04/25 at 6:18 PMThe facility failed to ensure a safe environment free from sexual abuse when Resident #2, who had a history of inappropriate sexual behaviors, placed her hand inside Resident #1's panties. The facility's DON failed to implement interventions upon Resident #2's admission on [DATE], when LVN F informed him Resident #2 was masturbating, and after Resident #2 inappropriately touched him on his pants. Residents residing in the memory unit received a skin assessment and/or a safe survey on 8/23/2025 with no additional negative findings.Person(s) Responsible: Charge Nurse, social services, and/or designee Date: 8/26/2025 Education provided to Administrator and Director of Nursing on the Abuse & Neglect Policy, 1:1 (employees should remain on 1:1, when placed on 1:1, without fail, until 1:1 is discontinued), Resident-to-Resident Policy, reviewing admission paperwork and care planning/educating staff, when needed, on sexual behaviors and interventions.Person(s) Responsible: Regional [NAME] President of Operations and/or Regional Nurse ConsultantDate: 8/23/2025 All staff educated on the Abuse & Neglect Policy, 1:1 (employees should remain on 1:1, when placed on 1:1, without fail, until 1:1 is discontinued), and Resident-to-Resident Policy.Schedules will be reviewed and the Administrator, Director of Nursing, and/or a Designated staff member will be responsible to ensure all staff will be educated prior to working their next shift.Person(s) Responsible: Administrator, Director of Nursing, and/or Designee.Date: 9/4/2025Referrals/admissions will be reviewed prior to admission to ensure high risk history, such as sexual or physical aggression, and care plans/interventions will be put into place and staff will be communicated with prior to/at admission. Care plans can be found in Matrix in the plan of care.Person(s) Responsible: admission Coordinator, Administrator, Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 9/4/2025When residents are placed on 1:1, Administrator, Director of Nursing, Assistant Director of Nursing, and/or Designee will spot check, daily, Monday-Friday and a designee such as a charge nurse and/or weekend supervisor will spot check, daily, Saturday and Sunday, to ensure staff are following policy and education provided.Person(s) Responsible: Administrator, Director of Nursing, Assistant Director of Nursing, and/or DesigneeDate: 9/4/2025 QAPI-Action: Ad hoc QAPI performed with Medical Director, notified of the Immediate Jeopardy template and the facility's plan to remove it. No additional recommendations at this time. Person(s) Responsible: AdministratorDate: 9/4/2025On 09/05/25 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview on 09/05/25 at 11:09 AM, the DON said the in-services indicated observation levels will be implemented by CNAs, nurses, ADONs, DON, SW, and other staff (activity director, housekeepers, and office staff as needed. During an interview on 09/05/25 the admission Coordinator was in-serviced to ensure referrals for new admissions are reviewed prior to admission. If a resident is identified with a history of sexual or physical aggression, this will be care planned to include interventions for staff to follow. During an interview on 9/05/25 at 12:59 PM the DON stated that on 08/23/25 Resident #2 was placed on 1:1 supervision but they did not have documentation of that action. He stated because of the IJ they will now keep documentation of all residents who were placed on 1:1 supervision. He stated because of the IJ all residents in the memory unit were assessed by him and the SDON with no negative findings. He stated the ADON conducted safe surveys with no negative findings. He stated when the IJ was called on 09/04/25 the IDT team that included the department heads (the ADM, DON, BOM, Admissions Coordinator, HR, the DM, HK Supervisor, MDS Coordinator, and the ADM) trained all the staff on the ANE policy, 1:1 supervision (to include what it meant, the transfer process, how close they needed to be, when they could leave and documentation), and the Resident-to Resident Policy. He stated that residents who are placed on 1:1 supervision will need to ensure that they are close enough to intervene. He stated if the resident is sleeping the staff can be outside of the door and check every 15 minutes and use a flashlight so that the resident is not disturbed. He stated the 1:1 would be randomly checked to ensure that the documentation is up to date, staff are within the right distance and interventions are being followed. He stated during the week he and ADON would do the random audits for 1:1 supervision but on the weekend, he had an RN supervisor. He stated he gave staff the opportunity to ask questions if they needed to. He stated Admissions was trained in reviewing the paperwork prior to accepting a resident in the facility. He stated before any resident is admitted to the facility their admission paperwork will be reviewed by the appropriate people in the IDT. He stated they did participate in a QAPI meeting that addressed all the components of the IJ. During an interview on 9/05/25 at 2:07 PM the DON stated they di

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents and/or hazards as possible for 2 of 5 residents (Resident #1, Resident #2) reviewed for supervision. The facility failed to ensure Resident #1, and Resident #2 received supervision to prevent Resident #2, who had a history of sexual behaviors, from sexually abusing Resident #1, when she put her hand in her panties. Resident #1 was on one to one (1:1) supervision due to a previous incident of aggression with a different resident; however, she was allowed to alone in her room with Resident #2. The Immediate Jeopardy (IJ) was identified on 09/04/25 at 6:18 PM. The IJ template was provided to the facility's Administrator and DON on 09/04/25 at 6:18 PM. While the immediacy was removed on 09/05/25 at 6:07 PM, the facility remained out of compliance at a scope of pattern and severity level of no actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems, and because all their staff had not been trained on 09/05/25. These failures could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm, due to lack of supervision.Findings include: Resident #2 Record review of Resident #2's face sheet current as of 09/03/25, revealed a [AGE] year-old-female who was admitted to the facility on [DATE]. Resident #2 diagnoses included unspecified dementia severe with agitation (a behavioral and emotional state of dementia characterized by behaviors like restlessness, pacing, shouting, aggression, and repetitive actions), mood disorder due to known physiological condition (a mental disorder characterized by persistent changes in mood), and schizoaffective disorder bipolar type (mental health condition episodes that combines mania and depression). *Record review of Resident #2's admission Comprehensive MDS, dated [DATE] revealed the following: Section C Brief Interview for Mental Status (BIMS) score revealed a score of 1 which indicated the resident's cognition was severely impaired. Section E-Behavior: Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred 1 to 3 days. Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, packing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) occurred 1 to 3 days. Functional Abilities-Mobility: Walking 10 feet, once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. This was coded an 88, which meant she had not attempted due to medical condition or safety concerns. *Record review of Resident #2's Care Plan, dated 08/24/25 revealed her inappropriate sexual activity was included in her plan after she was found with her hand in Resident #1's panties on 08/23/25. Problem: will not exhibit socially inappropriate/disruptive behavior pattern, specifically impulsive sexual behavior. This would be addressed by approaching Resident #2 and removing her from resident's room and unsafe situations. Maintain a calm environment and calm approach to the resident. Assess whether the behavior endangers the resident and/or others and intervene if necessary. Problem: has a history of touching other residents inappropriately: This would be addressed through staff and by redirection. *Record review of Resident #2's Event Report dated 08/23/25 indicated Resident #2 was involved in an incident alleging she had her hand down the pants of Resident #1. This incident was witnessed by LVN F, the residents were separated by CNA C and CNA DD, and Resident #2 was placed on one-to-one observation with the nursing staff (1:1, defined as a staff member constantly with the resident and documents at 15-minute intervals). Resident #2, who was in Resident #1's room when this incident occurred was removed from Resident #1's room. This report indicated Resident #2 was assessed and there were no signs of trauma. On 09/02/25 at 9:40 am FNP T gave LVN F orders for Resident #2 to have labs, Senior Psych referral and Aricept 5 mg. q hs. On 09/02/25 at 10:37 am PNP gave LVN F order for Resident #2's Remeron to be change to HS, and to change Paxil to am, and have nursing to monitor for over sedation. PNP added the diagnosis of Alzheimer's late onset to Resident #2's diagnosis. Resident #1: Record review of Resident #1's Face Sheet current as 0f 09/03/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnosis included dementia mild with mood disturbances (emotional or behavioral changes, such as anxiety, apathy, depression or irritability), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), insomnia (trouble sleeping). *Record review of Resident #1's admission Comprehensive Minimum Data Set, dated [DATE] revealed: Section C, Brief Interview for Mental Status (BIMS) score revealed a score of 00, which indicated the resident's cognition was severely impaired. Section E-Behavior, Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred 1 to 3 days. Wandering-Presence & Frequency: Has the resident wandered? This was coded with a 0 to indicate this behavior was not exhibited. Functional Abilities-Mobility, walking 10 feet, once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. This was coded a 6, which meant she could complete this activity by herself with no assistance from a helper. *Record review of Resident #1's Care Plan dated 08/12/25 included: Problem: updated on 08/23/25 to include due to impaired cognition, Resident #1 is at risk for unwanted sexual advances from other residents. This would be addressed by ensuring client safety. Problem, on 08/12/25 the plan included that she had been physically aggressive towards others. The plan included cueing resident to maintain space between self and others and assisting resident in moving self away while interacting with others. *Record review of Resident #1's Observation Detail List Report noted by LVN N on 08/23/25 at 11:18 am indicated Resident #2 was witnessed with her hand down Resident #1's pants, in Resident #1's room. The nursing staff immediately entered the room and separated Resident #1 and #2. Resident #2 was placed on 1:1 observation due to this allegation. Resident #1 was assessed and she had no signs of trauma. *Record review of Resident #1's Progress Notes indicated the following: On 08/26/25 Resident #1's Interdisciplinary Team met and discontinued her 1:1 observation. 08/23/35 Resident #1 (who was on 1:1 observation) was involved in an incident in which resident (Resident #2) was witnessed with her hand down resident #1's pants in Resident #1's room. Nursing staff entered the room, separated Resident #1 and #2, and removed Resident #2 from Resident #1's room. Resident #1 was assessed and there were no signs of trauma. During an interview on 09/03/25 at 10:40 am, Resident #2 was asked a series of questions; however, her verbal responses were not understood. Instead, Resident #2 smiled each time she was asked a question, including if she had touched Resident #1 on her private area. During an interview on 09/03/25 at 10:46 am, CNA C indicated on 08/23/25 she was working with CNA P; however, CNA O, who was assigned as Resident #1's 1:1 observation had not started her shift at 6 am, instead she started at 7 am. CNA C said her and CNA P provided ADL care to the residents to get them ready for breakfast. CNA C said she saw Resident #1 in the living/dining area and saw Resident #2 go into Resident #1's room, where she sat and fell asleep on Resident #1's recliner. CNA C said she did not redirect Resident #2 to leave Resident #1's room because she has a history of becoming upset, and because Resident #1 was not in her room. CNA C said she did not see Resident #1 return to her room, while Resident #2 slept on her recliner. CNA C said she was unaware that Resident #2 had to be watched closer due to inappropriate sexual behavior, and she knew Resident #1 had behaviors of aggression and was supposed to be watched closer per FM's request. During an interview on 9/04/25 at 1:34 PM CNA P stated that prior to 08/23/25, she had never done 1:1 observation. She stated she was working on 08/23/25. She stated she did not recall anyone specifically telling her that they were leaving, and they were the 1:1 staff for Resident # 1. She stated on 08/23/25 she was the person to get Resident #1 dressed and she sat her at the dining room table. During an interview on 09/03/25 at 11:15 AM, Resident #1 indicated nobody had hurt her and she could not recall being touched on her body by Resident #2. During an interview on 09/04/25 at 10:48 AM, CNA E indicated she was unaware Resident #1 had a history of inappropriate sexual behavior. During an interview on 09/04/25 at 10:48 AM, CNA P indicated she worked on 08/23/25 and was directed by DON to keep an eye on Resident #1 due to inappropriate touching; however, she was not assigned as her 1:1 observation. CNA P said she worked with CNA C and they assisted residents with their ADLs to get them ready for breakfast. CNA P said CNA O was supposed to start her shift at 6 am and carry out Resident #1's 1:1 observation; however, she did not arrive until 7 AM. CNA P said she assisted Resident #1 with her ADLs and took her to the dining table because Resident #2 had entered Resident #1's room. CNA P said it was easier to take Resident #1 out of her room than Resident #2, which was why she allowed Resident #2 to stay in the room. CNA P said she informed LVN F, who was administering medications, that she was leaving Resident #2 in Resident #1's room. CNA P said at approximately 7 AM CNA O entered the memory unit and asked for the whereabouts of Resident #1 and CNP replied that Resident #1 was supposed to be in the dining area. And that's when, LVN F yelled out for staff to get Resident #2 because she was foundling Resident #1 in her room and asked who was Resident #1's 1:1 observation. CNA P said she entered Resident #1's room and saw Resident #1 standing with her pants unbuckled and in front of Resident #2, who was sitting on the recliner and holding Resident #1 by her wrist. CNA P said earlier in the morning, she dressed Resident #1 and left her pants unbuckled because they did not fit her. CNA P said upon the start of her shift on 08/23/25 at 6 am, she knew Resident #1 was on 1:1 observation; however, she was not assigned to her and continued to care for the residents. CNA P said she was unaware that Resident #2 had a history of sexual behaviors. At 1:34 PM CNA P stated she had never implemented 1:1 observation for anyone. She stated she was working on 08/23/25 and does not recall a night CNA informing her that she was leaving, and that they had been the 1:1 observation for Resident # 1. She stated on 08/23/25 she was the person who assisted Resident #1 with dressing and then sat her at the dining room table. During an interview on 09/04/25 at 11:41 PM, the admission Coordinator indicated Resident #2 was approved as a transfer to the facility by their Central Intake Team. This approval was sent to her via email on 08/21/25, and Resident #2 was admitted to the facility on [DATE]. The admission Coordinator said she did not review Resident #2's notes in the admission packet; and then confirmed Resident #2's admission transfer notes did include 3 incidents of inappropriate sexual behavior 08/03/25 - two incidents, and one incident on 07/16/25. During an interview on 09/04/25 at 12:05 PM, the SW indicated she was unaware Resident #2 had a history of inappropriate sexual behavior; however, after Resident #2 touched Resident #1 inappropriately, she was placed on 1:1 observation. During an interview on 09/04/25 at 12:35 PM, the MDS Coordinator indicated she was unaware Resident #2 had a history of inappropriate sexual behavior; however, after Resident #2 touched Resident #1 inappropriately, she was placed on 1:1 observation. The MDS Coordinator said she does not assign residents 1:1 observation, nor does she include 1:1 or watch closely in a resident's care plan. The MDS Coordinator said she did not include Resident #1's inappropriate sexual behavior in her care plan, because she was not informed during her admission. During an interview on 09/04/25 at 1:19 PM, the FNP U indicated on 08/21/25 she was informed Resident #1 had an incident of aggression, and that's when she was placed on 1:1 observation, until psych services could evaluate her. After this incident, FNP U said she was informed Resident #1 was inappropriately touched by Resident #2, who put her hand in her pants. FNP U said on 08/23/25 Resident #1 was supposed to be on 1:1 observation, and Resident #2 should not have had the opportunity to put her hand in her pants. The facility must ensure each resident receives adequate supervision and assistance to prevent this type of accident from happening. During an interview on 09/04/21 at 1:41 PM, the DON indicated if a resident has an incident of aggression the charge nurse will notify him, and then he will direct them to keep them separated and to place the aggressor on 1:1 observation and would not be removed unit the resident's assessed by psych services. The DON said the facility's central office reviewed Resident #2's file and directed the facility to accept her as a new admission. The DON said on 08/22/24 Resident #2 was admitted to the facility, and when he assessed her in the room by himself, she went for his belt buckle, and he had to move her hand away. The DON said he asked LVN F to supervise his assessment of Resident #2's and nothing else happened. The DON said he was unaware Resident #2 had a history of inappropriate sexual behaviors prior to her admission to the facility; however, he was informed that Resident #2 had to move from her previous facility due to being the victim of unwanted sexual advances by the male residents. The DON indicated on 08/23/25 Resident #1 was on 1:1 observation due to hitting a resident on 08/22/25. The DON said a CNA should have been within arm's reach of Resident #1, which would have prevented Resident #1 from being inappropriately touched by Resident #2. The DON said he and his staff were unaware that Resident #2 had a history of inappropriate sexual behaviors. The DON said on 08/23/25 he was informed by LVN F Resident #2 had her hand inside Resident #1's pants, and that Resident #1 did not have a 1:1 observation at the time of this incident. During an interview on 9/04/25 at 1:40 PM CNA E stated that she has never been any resident's 1:1 staff. She stated they are typically informed by the DON or the previous shift staff may tell them if a resident is on 1:1 supervision. She stated the DON would tell them if a resident was off 1:1 supervision. She stated she had been trained by the facility staff that they stay until relief comes. She stated she did not know when, but the training had occurred since she had been at the facility. During an interview on 09/04/25 at 2:18 PM, the Administrator indicated that the facility's investigation included that LVN F witnessed said she witnessed Resident #2 with her hand inside Resident #1's panties. The Administrator said CNA A, who was assigned as Resident #1's 1:1 observation, should not have left her shift until she was replaced by a staff. During an interview on 09/04/25 at 3:04 PM, CNA A indicated she started her shift on 08/22/25 at 6 PM and worked until 6 AM on 08/23/25. During this shift, CNA A said she was assigned as Resident #1's 1:1 observation, which meant she had to watch her closely and keep her out of residents' room. CNA A said before she left the faciity on [DATE] at 6 am, she informed a CNA, whose name she could not recall, that she was leaving and transferring her observation to the next shift. CNA A said Resident #1 was asleep in her bed when she left. During an interview on 09/04/25 at 3:47 PM, PNP indicated Resident #2 had a history of inappropriate sexual behavior, because on 08/22//25 LVN F found her masturbating, and she touched the DON on his pants during her assessment. PNP said he ordered Paxil that had to go through the facility's physician because she had not been approved for psych services. On 08/26/25 PNP said he received the approval for Resident #2's psych services. PNP said he was informed by the DON that Resident #2 had not displayed inappropriate sexual activity; therefore, PNP dc the need for 1:1 observation because the Paxil was showing good results. PNP said as of 09/04/25, he had not sent the facility his notes on his assessment with Resident #2. During an interview on 09/05/25 at 10:35 PM, FNP T indicated Resident #2, who had a history of inappropriate sexual behaviors, should have been assigned a 1:1 observation or watched closely for 3 to 5 days, and should have had her inappropriate sexual behaviors care planned for her safety and the safety of others. FNP T said the observations should have been noted every 15 minutes for 72 hours, because you don't know if the resident will could be violent or hypersexual. FNP T said if Resident #1 was on 1:1 observation, then Resident #2 should never have had the opportunity to put her hand inside Resident #1's pants and panties. During an interview on 09/05/25 at 10:35 AM, LVN F indicated on 08/23/25, Resident #2 was not assigned special observation; however, Resident #1 was on 1:1 observation due to an incident of aggression on 08/21/25. On 08/23/25 LVN F said she was in the hallway parallel to Resident #1's doorway as she prepared the next medication administration, when she witnessed Resident #1 standing in front of her recliner rocking back and forth and Resident #2's hand inside her pantie. Resident #2, who was inside Resident #1's room, was sitting on Resident #1's recliner as she fondled Resident #1. LVN F said she said she yelled out to the CNAs “come get them” and questioned who was assigned as Resident #1's 1:1 observation. LVN F indicated she was not informed CNA O was not starting her shift at 6 AM, had not been given the responsibility of assigning 1:1 staff to residents in need of closer supervision, which had been the responsibility of DON and ADON. The facility's policy and procedure, Observation Levels, dated 04/2024 indicated “It is the policy of the facility that staff monitoring is instituted to maintain the safety of each resident and provided by a system of progressive intensity of resident observation and oversight. The use of the level that provide each resident with optimal level of safety in the least restrictive manner will be utilized. Resident will be routinely observed in compliance with physician orders and/or clinical protocols.” The level of supervision included: Standard observation (assess and document at no less than every two hours). Minimum level of observation for all residents. Line of sight (assess and document at 15-minute intervals). A level of observation wherein the resident remains in staff view. A specific staff member may be assigned, and the line-of-sight observation is maintained by staff in person and not through video monitoring. One to one (staff member constantly with the resident and documents at 15-minute intervals). Consist of One-to-one with a resident never farther away than 10 or less feet. The residents must remain within this parameter. A licensed nurse my place a resident ton line-of-sight or one-on-one and increase the level of observation at any time as clinically necessary. In all cases the least restrictive clinically appropriate intervention will be implemented. The license nurse my not decrease the level of observation until conferring with the director of nursing/designee and/or physician. The procedure includes three levels of resident observation are used. The levels are designated to provide increasing intensity of observation, precaution, and oversight commensurate with physician and staff. The appropriate observation level is implemented: After evaluation and assessment, a level of observation may be instituted by the attending physician or registered nurse. If a registered nurse institutes an observation level, the attending physician is notified as soon as possible. The physician's order shall include the Observation Level and the reason for the monitoring. The charge nurse will assign staff to perform the standard observation level on a designated set of residents. Resident online of sight or one on one will be assigned specific staff. The charge nurse will assign staff to perform the standard observation level on a specific designated set of residents. Resident online of sight or one on one will be assigned specific staff. The nurse will arrange for staff to be relieved for breaks and meals. Assigned staff will complete the resident observations as rounds are made and document on the rounds from. Staff will observe the resident's location and note the residents' behavior. Rounds are not to be documented in advance. In addition to recording the whereabouts of resident at ordered intervals, the purpose of observation is to provide a system of progressive intensity of resident observation, precaution and oversight based on resident acuity, severity and type of symptoms, and overall needs. The order of observation level is communicated to all staff. Staff must hand-off responsibility for maintaining observation of assigned resident of any break or potential interruption in completing assigned rounds. The Administrator and DON were notified on 09/04/25 at 6:18 PM that an IJ situation was identified due to the above failures and the IJ template was provided. The following Plan of Removal was accepted on 09/05/2025 at 10:46AM: “Plan of Removal 09/05/2025 The facility failed to provide the “planned” or “scheduled” 1:1 supervision for resident #1 that resulted in exposing her to a hazard of being inappropriately / sexually touched by resident #2. 1. On 08/23/25 Resident #2, who was the aggressor that put her hand inside Resident #1's panties, was placed on 1:1 observation. Resident #1, who was supposed to be on 1:1 observation when Resident #2 put her hand in her panties, was returned to 1:1 observation. On 08/26/25, Resident #2 was taken off of 1:1 observation after IDT's review.Person(s) Responsible: Administrator, Director of Nursing, and/or DesigneeDate: 8/26/2025 2. Residents residing in the memory unit received a skin assessment and/or a safe survey on 8/23/2025 with no additional negative findings.Person(s) Responsible: Charge Nurse, social services, and/or designeeDate: 8/23/2025 3. Education was provided to the Administrator and the Director of Nursing on the Abuse & Neglect Policy, 1:1 (employees should remain on 1:1, when placed on 1:1, without fail, until 1:1 is discontinued), and the Resident-to-Resident Policy.Person(s) Responsible: Regional [NAME] President of Operations and/or Regional Nurse ConsultantDate: 9/4/2025 4. All staff educated on the Abuse & Neglect Policy, 1:1 (employees should remain on 1:1, when placed on 1:1, without fail, until 1:1 is discontinued), and Resident-to-Resident Policy.Schedules will be reviewed and the Administrator, Director of Nursing, and/or a Designated staff member will be responsible to ensure all staff will be educated prior to working their next shift.Person(s) Responsible: Administrator, Director of Nursing, and/or Designee Date: 9/4/2025 5. When residents are placed on 1:1, Administrator, Director of Nursing, Assistant Director of Nursing, and/or Designee will spot check, daily, Monday-Friday and a designee such as a charge nurse and/or weekend supervisor will spot check, daily, Saturday and Sunday, to ensure staff are following policy and education provided.Person(s) Responsible: Administrator, Director of Nursing, Assistant Director of Nursing, and/or DesigneeDate: 9/4/2025 6. QAPI— Action: Ad hoc QAPI performed with Medical Director, notified of the Immediate Jeopardy template and the facility's plan to remove it. No additional recommendations at this time.Person(s) Responsible: AdministratorDate: 9/4/2025 7. During an interview on 9/05/25 at 12:59 PM the DON stated that on 08/23/25 Resident #2 was placed on 1:1 supervision but they did not have documentation of that action. He stated because of the IJ they will now keep documentation of all residents who were placed on 1:1 supervision. He stated because of the IJ all residents in the secure unit were assessed by him and the SDON with no negative findings. He stated the ADON conducted safe surveys with no negative findings. He stated when the IJ was called on 09/04/25 the IDT team that included the department heads (the ADM, DON, BOM, Admissions Coordinator, HR, the DM, HK Supervisor, MDS Coordinator, and the ADM) trained all the staff on the ANE policy, 1:1 supervision (to include what it meant, the transfer process, how close they needed to be, when they could leave and documentation), and the Resident-to Resident Policy. He stated that residents who are placed on 1:1 supervision will need to ensure that they are close enough to intervene. He stated if the resident is sleeping the staff can be outside of the door and check every 15 minutes and use a flashlight so that the resident is not disturbed. He stated the 1:1 would be randomly checked to ensure that the documentation is up to date, staff are within the right distance and interventions are being followed. He stated during the week he and the ADON would do the random audits for 1:1 supervision but on the weekend, he had a RN supervisor. He stated he gave staff the opportunity to ask questions if they needed to. He stated Admissions was trained on reviewing the paperwork prior to accepting a resident in the facility. He stated before any resident is admitted to the facility their admission paperwork will be reviewed by the appropriate people in the IDT. He stated they did participate in a QAPI meeting that addressed all the components of the IJ. On 09/05/25 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Observation on 09/05/25 at 7:55 AM revealed CNAs B, C and DON were working on the memory unit. The DON, who was monitoring, said he was filling in because CNA M was not able to work her shift, and ADON, would also fill in as needed. The DON said there was not a resident in this unit, who was on 1:1 observation or a special level of observation. The staff were expected to monitor and prevent Resident #2 from entering a resident's room. The memory unit had a 3-foot-tall wall that is approximately 12 feet wide and separates the living/dining area from the hallway, which allowed staff to see the residents in the living/dining area and the hallway. Resident #2 did not enter a resident's room. Observation on 09/05/25 at 8:05 AM, revealed Resident #2 was observed walking around the living/dining area and the CNAs were in the hallway and living/dining area observing approximately 9 Residents, including Residents #1 and #2. Resident #2 did not enter a resident's room. Observation on 09/05/25 at 10:06 AM, CNAs, B, C, and DON, who was monitoring, were on duty, and Resident #2 was walking from the hallway to the living/dining area. Resident #2 did not enter a resident's room. Observation on 09/05/25 at 11:21 AM, CNAs, B, C, and DON, who was monitoring, were on duty, and Resident #2 was walking from the hallway to the living/dining area. Resident #2 did not enter a resident's room. Observation on 09/05/25 at 11:23 AM, CNAs, B, C, and DON, who was monitoring, were on duty, and Resident #2 was standing near the CNAs. Resident #2 did not enter a resident's room. Observation on 09/05/25 at 2:10 PM, CNAs, B, C, and LVN F, who was monitoring, were on duty, and Resident #2 was walking in the living/dining area. Resident #2 did not enter a resident's room. Observation on 09/05/25 at 4:55 PM, CNAs B and C, and MA G, who was monitoring, were in the memory care unit, and Resident #2 was walking in the hallway. Resident #2 did not enter a resident's room. Interview on 09/05/25 at 12:57 PM, the DON indicated Resident #2 was the only one identified with sexual behaviors; however, since 08/23/25 she had not made any attempts to touch a resident or staff inappropriately. *Record Review of Resident #2's Event Report dated 09/03/25 indicated: On 08/24/25 at 10:54 AM. Resident #2 was being monitored on the memory unit on, and she was wandering among the common areas with 1:1 assigned staff member. She exhibits no signs of agitation or pain. She has minimal verbal exchanges and has been minimal in complete thoughts and sentences. On 08/24 at 4:22 PM Resident #2 only makes visual contact nonverbal, in good spirit, affect appropriate, and can't assist with questions to complete any SW admission assessments. On 08/26/25 at 10:56 AM revealed Resident #2's Interdisciplinary Team met and discontinued her 1:1 observation. On 09/02/05 LVN F received orders from FNP T, who was in the facility, to complete Resident #2 a CBC, CMP, TSH, A1C, senior psych referral, and Aricept 5mg q hs. This report included that on On 09/02/25 at 10:37 AM LVN F received orders from PNP to change Remeron to HS, change Paxil to AM, monitor for over sedation, and add history of Alzheimer's late onset. *Review Resident #2's FNP T's Progress Note dated 09/02/25 indicated Resident #2 was taking Aricept 5 mg at bedtime orally once a day. This assessment indicated Resident #2 required memory care unit, Aricept, and psych consult. During interview conducted with staff on duty on 09/05/25 from 10:06 PM until 5:01 PM that worked on the 6 AM to 6 PM shift (FNP T at 10:06 PM, LVN F at 10:35 AM , DON at 11:09 PM, ADON at 11:32 PM, CNA H at 1:06 pm, LVN I at 1:36 PM, CNA HH at 1:56 PM, LVN F at 1:49 PM, SW at 2:12 PM, CNA P at 2:32 PM, Activity Director at 2:50 PM, MA J at 2:58 PM, CNA II, at 3:23 PM, Admissions Coordinator at 3:29 PM, HK Supervisor at 4:45 PM, MA G at 5:42 PM), and 6 pm to 6 am shifts (RN Z at 5:51 PM, and CNA and CNA D at 1:28 PM). These staff were in-serviced on preventing Abuse, Neglect, and Exploitation, Levels of Observation, and Resident to Resident Altercat

Based on observations, interviews, and record review, the facility failed to ensure each resident drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 12 residents (Resident #3) reviewed for pharmacy services. The facility failed to monitor, review and reconcile Resident #3 medication administration record from on 8/21/25 which resulted in an official unknown count of (Hydrocodone) to be unaccounted for.This failure could places at an increased risk of drug diversion and misuse of resident medications or possibly make resident medication unavailable to meet their clinical needs.Findings included:Resident #3Record review of Resident #3's face sheet, 9/03/25, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include muscle weakness, pneumonia (infection in the lung), intellectual disability (disability that affects cognitive ability), nonspecific skin eruption (skin rash). Record review of Resident #3's Comprehensive Minimum Data Set, dated [DATE], revealed the following: *Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was severely impaired. *Section N Medications revealed Resident #3 took the following high-risk medications: none checked to include opioids. Record review of Resident #3's care plan, dated 7/14/25, did not have a care plan for pain.Record review of Resident #3's physician order, undated, revealed the following:Hydrocodone -acetaminophen 5-325 mg; 1 tab Q 6 hr prn for pain; diagnosis: pneumonia; order start date: 5/09/25 and end date: open ended.Resident #3's MAR for May 2025 and June 2025 revealed that Resident #3 was not administered any hydrocodone-acetaminophen 5-325 mg prn.Resident #3's MAR for July 2025 revealed that Resident #3 was administered any hydrocodone-acetaminophen 5-325 mg prn 1 time by LVN L on 07/25/25 at 10:45 AM. Resident #3's MAR for August 2025 revealed that Resident #3 was administered any hydrocodone-acetaminophen 5-325 mg prn 5 times: *(8/18/25) by LVN K at 7:19 PM, *(8/19/25) by LVN F at 11:57 AM, *(8/25/25) by LVN L at 9:20 AM, *(8/27/25) by LVN F at 3:18 PM and, *(8/28/25) by LVN F at 1:12 PM. Resident #3's MAR for September 2025 revealed that Resident #3 was not administered any hydrocodone-acetaminophen 5-325 mg prn as of 09/04/25.Record review of Resident #3's progress notes, dated 06/01/25-09/03/25, revealed: *08/28/25 at 2:32 PM LVN F documented: Resident #3 was heard making noises and she found Resident #3 on the floor. Resident #3 was assessed and assisted to the geriatric chair. There were no visible injuries and ROM was intact. Pain medication was administered with efficacy. Further review of progress notes revealed there were no additional progress notes regarding Resident #3's pain, pain administration, or missing pain medications. Record review of Resident #3's Controlled Drug Receipt /Record/ Disposition Form, dated 5/06//25 revealed that out of an 8-quantity card of Hydrocodone 5-325 mg facility staff administered 8 tabs between the date of 05/09/25 and 07/27/25. Record review of Resident #3's Controlled Drug Receipt /Record/ Disposition Form, dated 8/14/25 revealed that out of a 60-quantity card of Hydrocodone 5-325 mg facility staff administered 12 tabs between the date of 08/15/25 and 08/20/25. Record review of Resident #3's Controlled Drug Receipt /Record/ Disposition Form, dated 8/15/25 revealed that out of a 30-quantity card of Hydrocodone 5-325 mg facility staff administered 5 tabs between the date of 08/15/25 and 09/04/25. Record review of Resident #3's Controlled Drug Receipt /Record/ Disposition Form, dated 8/15/25 revealed that out of a 26-quantity card of Hydrocodone 5-325 mg facility staff administered 26 tabs between the date of 08/22/25 and 09/02/25. Record review of Resident #3's Controlled Drug Receipt /Record/ Disposition Form, dated 8/15/25 revealed that out of a 30-quantity card of Hydrocodone 5-325 mg facility staff administered 0 tabs had been administered from the 30-count card. Record review of Resident #3's Controlled Drug Receipt /Record/ Disposition Form, dated 8/15/25 revealed that out of a 30-quantity card of Hydrocodone 5-325 mg facility staff administered 0 tabs had been administered from the 30-count card. Record review of Resident #3's pain assessments, dated 05/01/25-09/05/25, revealed the following:Resident #3 had a pain level of 4 out of 10 on 05/09/25 documented by LVN K.Resident #3 had a pain level of 4 out of 10 on 06/07/25 documented by LVN N.Resident #3 had a pain level of 4 out of 10 on 06/09/25 documented by LVN K.Resident #3 had a pain level of 2 out of 10 on 06/11/25 documented by LVN N.Resident #3 had a pain level of 4 out of 10 on 06/16/25 documented by MA J.Resident #3 had a pain level of 4 out of 10 on 06/22/25 documented by LVN N.Resident #3 had a pain level of 2 out of 10 on 07/03/25 documented by (space was left blank).Resident #3 had a pain level of 2 out of 10 on 07/05/25 documented by LVN N.Resident #3 had a pain level of 4 out of 10 on 07/23/25 documented by LVN X.Resident #3 had a pain level of 7 out of 10 on 07/26/25 documented by (space left blank).Resident #3 had a pain level of 4 out of 10 on 08/01/25 documented by RN Y.Resident #3 had a pain level of 2 out of 10 on 08/11/25 documented by LVN N.Resident #3 had a pain level of 2 out of 10 on 08/12/25 documented by LVN N.Resident #3 had a pain level of 2 out of 10 on 08/14/25 documented by RN Z.Resident #3 had a pain level of 4 out of 10 on 08/16/25 documented by LVN N.Resident #3 had a pain level of 4 out of 10 on 08/17/25 documented by LVN N.Resident #3 had a pain level of 8 out of 10 on 08/19/25 documented by (space left blank).Resident #3 had a pain level of 4 out of 10 on 08/22/25 documented by LVN K.Resident #3 had a pain level of 5 out of 10 on 08/29/25 documented by LVN N.Resident #3 had a pain level of 5 out of 10 on 09/03/25 documented by LVN N.Record review of the Facility's Event Report, dated 08/21/25 revealed:Event Details: resident number three's medication missing.Root Cause Analysis:Staff training needed in proper medication handling. Staff training on narcotic medication policy. Nursing staff not following policy and procedure on medication narcotic count and shift change handoff. Nursing staff conducted improper receival of medication. During an interview on 09/03/25 at 3:45 PM, Resident #3 was unable to answer any questions regarding pain administration.During an interview on 09/05/25 at 8:52 AM Family Member V stated he did not have any concerns regarding pain administration. During an interview on 9/03/25 at 11:01 AM the ADON stated the medication aides and nurses provided all medications at the facility. She sated the medication aides provide all the scheduled controlled medications, and the nurses were responsible for providing the PRN controlled medications. She stated at shift change the nurses and medication aides should count the medication cards and then count then count the medications/pills individually. She said the narcotics were in the locked medication carts. She stated the medication aides, and the nurses employed at the facility were the only people who have access to the medication carts. She stated typically medications were typically delivered to the facility at 3 or 4 in the morning. She stated the nurse on duty will receive the medications and keep a receipt. She stated once the medications were received then the other nurse from the other station will observe and sign as a witness and then the medication goes into a lock box on the medication cart. She stated that on 8/21/25 Resident #3's medication (Hydrocodone) could not be accounted for. She stated she and the DON searched everywhere for the medication. She stated LVN L and LVN N were the nurses on duty. She stated LVN N was coming on shift and LVN L was leaving. She stated she was unsure if the count was correct the morning 08/21/25. She reported there were a total of 3 carts on station II (medication aide cart, nurses cart, and a nurse's cart for memory care) and 2 carts on station II (medication cart and nurses' cart). She stated there were different keys for each cart. She stated at the time of the interview she was unsure when the medication (Hydrocodone) for Resident #2 had been filled. The ADON stated Resident #3 medication (Hydrocodone) would have been on the Nurses cart as it was a PRN medication. The ADON stated once it was reported to her, then the DON, HHSC and Regional Nurse Consultant were notified. She sated additional training over shift change medication counts were conducted. She stated because of the missing Hydrocodone they started checking the medication carts throughout the day. The ADON stated Resident #3 had Hydrocodone available and did not miss any doses of the Hydrocodone. She stated they did not find out what happened to the Hydrocodone and assumed that possibly hospice did not deliver the Hydrocodone. She stated LVN F was the nurse that received the Hydrocodone from hospice. The ADON stated hospice did not leave a count sheet associated with the Hydrocodone, so they used one from the facility. The ADON stated before 08/21/25 she had not received any other reports from any of the other nurses that the count was off. She stated there would have been 1 card that contained 30 tabs of the Hydrocodone missing. The ADON stated she believed LVN K would have been the nurse on duty the night before the morning of 08/21/25 but she did not speak with her about the incident. During an interview on 9/03/25 at 11:42 AM the LVN L stated on any given day there was at least a medication aide and a nurse for each station. She stated the medication aide, and the nurse were the staff that provide medications to the residents at the facility. LVN L sated the morning of 08/21/25 she and LVN N did not count the medications that morning. She stated she did not have a reason why she and the other nurse did not count medications that morning. She stated she remembered receiving report the morning of 08/21/25. She stated when shift change came the evening of 8/21/25, the same nurse, LVN N, came in for her 6:00 PM shift and they counted the narcotics. She stated during count was when they realized that a blister pack of Resident #2's Hydrocodone was missing. LVN L stated they notified the ADON immediately. LVN L stated the DON was also notified immediately. LVN L stated she, the ADON and DON looked everywhere for the missing Hydrocodone and was unable to locate it. She stated she could not locate the count sheet that would have been associated with it. She stated LVN N did not help with the search and allowed them to handle the search as she was coming on to her shift. She stated Resident #3 does not appear to be in pain often but there were times when she will give him the medication prior to wound care. She stated because of the missing medication they received verbal training about making sure they count during shift change and hold each other responsible. No other reprimands were given according to LVN L. She stated the morning of 08/21/25 was the first time they did not count the medications as they normally count at each shift change. She stated she did not know what happened to the missing medications. LVN L stated she did report to the ADON and the DON that they (LVN L and LVN N) did not count the medications the morning of 08/21/25. LVN L stated she was familiar with the Medication Label and Storage policy. She stated the potential negative outcome for not counting medications at shift change or unaccounted medications was the resident may not have their medications when they needed it, especially if they were scheduled medications. She stated the system to monitor controlled medications was counting the medications at shift change. She stated even if they go on break and another nurse will have access to the cart they would count the medications. She stated she was trained by the ADON when she started to count medications at shift change but was trained again after the Hydrocodone went missing on 08/21/25. She stated she believed they signed inservices but was not for sure as they sign a lot of inservices. LVN L stated she did not know when the Hydrocodone went missing. She stated LVN K was the last nurse that signed the Hydrocodone out and administered to Resident #3. LVN L stated the nurses were responsible for ensuring that the medications were accounted for, and she did not have a reason they did not count the medication the morning of 08/21/25. She stated she was unsure if she worked the day before but believed she did. She stated she had not had any issues or concerns with narcotic counts being inaccurate before 08/21/25. During an interview on 9/03/25 at 2:25PM the LVN N stated when she comes in for her scheduled shift, they (nurses or medication aides) on duty will discuss what happened that day. After she receives her verbal report then they will count the narcotics on the cart. LVN N stated on 08/21/25 when she came in for her 6:00 PM shift she initiated the narcotic count and during the count they realized that there was missing 30 count of Resident #3's PRN Hydrocodone. She stated the ADON was notified immediately. She stated the ADON and DON came over to station II and looked for the missing Hydrocodone's and did not find them. LVN N stated she did not know where the missing Hydrocodone was and who could have had them. She stated she and LVN L did not count the morning of 08/21/25 and did not have a reason why they did not count. She stated Resident #3 had Hydrocodone available and would not have missed any medications. She stated because Resident #3's Hydrocodone was missing they received training about making sure they count each time they do shift change. LVN N stated the morning of 08/21/25 was the only time she can recall of not counting the medication at shift change. She stated they normally counted the narcotics during each shift change. She stated the missing 30 count of Hydrocodone's were the ones that hospice brought in. LVN N sated she was unaware that Resident #3's Hydrocodone was missing until shift change on 08/21/25. She sated the potential negative outcome for not counting the narcotics at shift change and resident medications not being accounted for was all parties involved could get in trouble. She stated it could affect the residents because they could be in pain and suffer. LVN N stated she does not administer Resident #3 Hydrocodone normally as he does not appear to be in a lot of pain. She stated Resident #3 typically went to bed and did exhibit signs of continuous pain. During an interview on 9/03/25 at 2:36 PM the LVN F stated the week of 08/21/25 she picked up an extra shift that week. She stated all medications counted that week were accounted for and she did not have any discrepancies. She stated she believed it would have been on 08/20/25 when she worked. She stated she remembered that she observed two blister packs from hospice when she was on duty. She stated she remembered observing the two blister packs from hospice because they look different then the ones they normally receive from the pharmacy. She stated they were shiny and foil like. She stated when LVN N came on duty she gave report, and they counted the medication. LVN F stated she was unsure when the Hydrocodone came to the facility, but she assisted MA J receive the medications. She stated once they receive the medication, they complete paperwork and place the narcotics in the lock box on the medication cart. She stated on the unknown date she was in the restroom and that was why MA J was receiving the medication. She stated normally the nurses received the PRN narcotics. LVN L stated she was not 110 percent sure it was MA J who received the medication, but it could have been MA CC. During an interview on 9/03/25 at 3:54 PM Hospice RN EE stated Resident #3 was admitted to hospice on 08/14/25 for the diagnosis of protein calorie malnutrition. Hospice RN EE stated she delivered a quantity of 60 Hydrocodone. She stated when medications were dropped off, they document in their notes. She stated observing her notes the Hydrocodone was delivered to the facility on [DATE] to MA J. Hospice RN EE stated she visited with Resident #3 last week and she did not have any indication that Resident #3 was in any pain. She stated she counted the Hydrocodone last week and noted that she counted 99 tabs. She stated she was notified when Resident #3's Hydrocodone went missing as the facility staff were trying to determine how many Hydrocodone tabs were dropped off. She stated she confirmed to the facility staff that she dropped off 60 Hydrocodone tabs (2 30 count cards) on 08/14/25 During an interview on 9/03/25 at 4:27 PM the ADON stated she was able to contact the pharmacy. She said on 05/6/25 Resident #3 received a 3 day supply to include 8 tabs of Hydrocodone. She stated on 08/14/25 hospice provided the facility 60 tabs (two cards) of Hydrocodone for Resident #3. She stated on the same date (08/14/25) Resident #3 received 116 tabs of Hydrocodone for Resident #3 from the pharmacy. During an interview on 9/05/25 at 12:59 PM the DON stated he was familiar with the facility's Medication Storage Policy to include accounting for resident medications. He stated the purpose of counting medications, specifically narcotics and controlled medications at shift change was to prevent discrepancies and ensuring that no medications were not missing. He stated the potential negative outcome of not counting medications each day at shift change was possible drug diversions. The DON stated he was unaware that LVN L and LVN N did not conduct a medication count the morning of 08/21/25. He stated he was unaware that the documentation in the EMR for Resident #1 was different from what was documented as administered on the paper count sheets for Resident #8. He stated on 08/21/25 he was informed that there was 1 blister pack containing 30 tabs of Hydrocodone delivered by hospice. He stated he was unaware that according to the EMR in comparison to the amount of Hydrocodone that the facility had received that 75 pills (Hydrocodone) were unaccounted for. The DON stated he was unaware that there were 43 pills (Hydrocodone) unaccounted for if he went by the paper count sheet and the amount of Hydrocodone that the facility had received. The DON stated examining the EMR and paper count sheet he was unable to determine how many pills (Hydrocodone) was missing and which total was accurate because there were too many discrepancies. He stated the system to monitor resident medications and prevention for drug diversion was during each shift change the nurses and medication aides count all medication cards and the individual pills for each resident. He stated the staff should be placing the number of medications (controlled and narcotics) administered and what is remaining on the narcotic count sheet and in the residents EMR. The DON stated because of Resident #3's missing medications on 08/21/25 they added prevention measures such as counting the cards as well as the pills. He stated they have started conducting random audits throughout the day. He stated he added that the medication cards should be numbered and have the corresponding number on an associated narcotic count sheet. The DON stated before 08/21/25 the staff only were to count the specified medications and place it on the narcotic count sheet. The DON stated he had been trained and all his staff (nurses and medication aides) have been trained to count medications (narcotics and controlled) at shift change. The DON stated he also expected the staff to count if there was an identified discrepancy. The DON stated he had observed shift change in the facility, but he did not have a specific date or time. He stated when he observed shift change, he observed his staff counting the medications and there were no issues identified. The DON stated he expected immediate notification if there was a discrepancy in medication counts during shift change. He stated he expected during each shift change a medication count must be conducted with no exceptions. He stated he expected the nurses and medication aides to adequately reflect the same as the resident's EMR and on the paper count sheet and what was dispensed to the resident. The DON stated each nurse and medication aide was responsible for medications counts during each shift, accurate documentation, and accounting for all resident medications. The DON stated he was not given, nor did he have a reason why the EMR, paper count sheets and what was given to the resident did not match. The DON stated he did not have a reason why the medication count was not conducted on 08/21/25. He stated he did not know where Resident #3's Hydrocodone was and did not have anyone that he suspected taking the medication. He stated because of his investigation he concluded that the Hydrocodone was missing. He stated he implemented training for his nurses and medication aides regarding counting medications, and documentation in the EMR. He stated all staff that administered medications were trained before their next shift. During an interview on 9/05/25 at 2:07 PM the ADM stated he was familiar with the facility's policy, Medication and Storage, to include accounting for medications. He stated the purpose of counting medications daily at each shift change was to ensure that all medications specifically narcotics and controlled medications were accounted for. He stated the potential negative outcome of not ensuring that medications were accounted for was the medication could not potentially be available for the resident tot receive. The ADM stated he was unaware that the staff (LVN L and LVN N) did not conduct medication count the morning of 08/21/25 but he was notified that there was 1 card containing 30 count of Hydrocodone for Resident #3 could not be located. He stated he was unaware that Resident #3's EMR, paper count sheets and what was administered was not consistent. He stated he was unaware until the HHSC investigator notified him. He stated he was unaware if examining Resident #3's EMR and the total amount of Hydrocodone received by the facility that 75 Hydrocodone would be unaccounted for. He stated he was unaware there were 43 Hydrocodone missing if he only examined the paper count sheet and the total amount of Hydrocodone the facility received for Resident #3. The ADM stated he would be unable to determine which total was accurate because there was room for doubt. He stated the system to monitor resident medications, specifically narcotics and controlled medications was every nurse and medication aide should be counting medications during each shift change. He stated he had never observed a shift change at the facility. He stated he expected medication such as the controlled and narcotics should be counted during each shift change and all documentations should be accurate, consistent and reflect what was administered to the resident. He stated the nurse that accepted the shift was responsible for the medication counts to be accurate and was also responsible for ensuring that the documentation was consistent and accurate. The ADM stated he did not have a reason for Resident #3's medication paper count sheet and EMR not being accurate or consistent with what was administered. He stated he did not have a reason why LVN L and LVN N did not conduct the medication count on 08/21/25. During an interview on 9/05/25 at 3:54 PM the ADON stated the purpose of counting medications and documenting the administration of medications was to ensure there were no holes in the resident records and to ensure there were no missing medications. The ADON stated she was unaware that LVN L and LVN N did not count the medications the morning of 08/21/25. The ADON stated she was unaware that Resident #3 EMR did not reflect the administration of Resident #3 Hydrocodone accurately. She stated she was made aware after investigator intervention. She stated she was unaware that according to Resident #3's EMR and the amount of Hydrocodone delivered to the facility that 75 Hydrocodone was unaccounted for and that if using the paper count sheets in comparison to the amount of medication that had been received that 43 Hydrocodone pills was unaccounted for. She stated she believed that the paper count sheet and missing Hydrocodone was more accurate but did not have any physical evidence to support this assumption as there were identified holes in the EMR. The ADON stated they were doing random audits on the medication to ensure that staff were documenting and that medications do not go missing again. She stated before Resident #3's Hydrocodone went mission on 08/21/25 the nurses and medication aides should have been completing counts at shift change. She stated they were not as management completing audits nor were they counting the medication cards. The ADON stated prior to 08/21/25 she had observed nurses counting medications at shift change. She did not observe any concerns when she observed nurses completing shift change medication counts. The ADON stated she was trained, and her nursing staff had been trained to document accurately and count narcotics at shift change. The ADON stated she was trained by the Regional Nurse Consultant. She stated she was unsure actual date and time, but that counting medications and documentation was a part of standard nursing practices. The ADON stated the nurses and medication aides should be counting narcotics at shift change and anytime they take a break and leave another nurse or medication aide in charge of the medication cart. The ADON stated she expected if the medications count was off the staff should reported immediately. She expected that the nurse coming on shift to visualize the pills while the nurse who was leaving will verify on the paper count sheet. She stated she did not have a reason why LVN L and LVN N did not count Resident #3's Hydrocodone on 08/21/25. She stated she did not have a reason why the EMR and paper count sheet for Resident #3 did not reflect an accurate administration of Resident #3's Hydrocodone. The ADON stated the medication aides and nurses were responsible for ensuring that accurate documentation was reflected in the resident's EMR and on the paper count sheet. She stated it was the medication aide and the nurse's responsibility to ensure that the narcotics and controlled medications were counted during each shift and on breaks. During an interview on 9/09/25 at 10:04 AM the Pharmacy Supervisor stated he was the head pharmacist and only oversaw providing the facility medications. He stated the monitoring and facility visits was conducted by the Pharmacy Consultant. He stated he was not notified that Resident #3 had medications (Hydrocodone) missing on 08/21/25. He stated he reviewed his on-call notes, and it does not appear that the on call was notified either. He stated he provided the facility Hydrocodone for Resident #3 on 05/06/25 (8 tablets) and on 08/14/25 (116 tablets). During an interview on 9/10/25 at 11:07 AM the Pharmacy Consultant stated he was not initially notified that Resident #3's Hydrocodone was missing. He stated he called the facility on 09/09/25 after the HHSC called and was notified at that time. He stated different facilities policy were different. He stated that he was familiar with being notified as this would help with him assisting with suggesting intervention and prevention techniques. He stated he assist the facility where they need him when medications were unaccounted for. The Pharmacy Consultant stated he had conducted medication cart audits but had never observed any discrepancies with the documentation. The Pharmacy Consultant stated the potential negative outcome for medications not being accounted for was the resident may not have the medication available when they needed it. He stated a potential negative outcome for not being notified of missing medications was he would not know what was going on. An attempted interview was attempted on 09/05/25 at 9:40 AM and the attempt was unsuccessful, a voice message was left and text message sent with return call information. Record review of the following inservice were conducted between 09/03/2-09/05/25:Record review of the facility's inservice, Medication Handling and Documentation, dated 08/21/25, revealed 9 signatures; Medication Storage (dated January 2018) was attached. Record review of the facility's inservice, Controlled Substance Policy, dated 08/21/25, revealed 9 signatures; Miscellaneous Special Situations Policy (dated 6/1/22) was attached. Record review of the facility's inservice, ANE, dated 08/21/25, revealed 18 signatures; ANE Policy (dated October 2023) was attached. Record review of the facility's policy, Miscellaneous Special Situation, dated 6/1/22, revealed:Policy:All discrepancies, suspected loss in or diversion of medications, irrespective, of drug type, or class, or immediately investigated and report filed.ProceduresImmediately upon discovery or suspicion of discrepancy, suspected loss of diversion, the administrator, Director of Nursing and consulted pharmacist are notified an investigation conducted.Discrepancy in a drug countThe DON investigates the discrepancy and researches all the records related to the medication administration and the supply of the medication, including medication reconciliation. Medication reconciliation is made from the last known day and time of reconciliation shift count, and receipt of medication. A thorough search and all drug store areas, the residence room, and other locations where medications may have been used during the medication administration are made to locate any missing containers or medication supply.Any corrective action that the DON feels as appropriate should be taken.Loss of a supply of a medicationDocument the loss in the investigation process. Notify the prescriber in family if the doses have been missed.Record review of the facility's policy, Medication Storage in the facility, dated January 2018, revealed:Policy: medication is included in the drug enforcement administration classification is controlled. Substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations.ProceduresAt each shift change or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses and his documented. Any discrepancy and controlled substance counts is reported to the Director of Nursing immediately the director or designated investigates and makes every reasonable effort to reconcile all reported discrepancies. The Director of Nursing documents in reconcilable discrepancies and a report to the administrator. If I made a discrepancy your pattern of discrepancies occur, or if there is parent, criminal activity, the Director of Nursing notifies the administrator and consultant pharmacist immediately. The administrator, consultant pharmacist in or directive nursing determine whether other actions are needed.Controlled substance inventory is regularly reconciled to the medication administration, record, and documentation. Current controlled substance accountability records are kept in the MAR, or designated book.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly for 3 of 5 medication carts (1 nurses medication cart for memory care on Station 2, 1 nurses medication cart for Station 2 and 1 medication aide cart for Station 1), reviewed for medication storage.The facility failed to maintain proper medication storage after the following was found:The nurse medication cart located on Station 2 contained medication Lorazepam (2MG/ML; dated 8/11/25) that required refrigeration for Resident #4. The nurse's medication cart for Memory care located on Station 2 contained medication (2MG/ML; dated 8/03/25) that required refrigeration for Resident #6. The medication aide cart for Station 1 contained medication Lorazepam (unable to see the dose) that required refrigeration for Resident #5. This failure could place residents at risk of not receiving prescribed medications that are not effective or that could expire faster than the printed date.Findings included: An observation of Station II memory medication cart was conducted on 09/04/25 at 6:21 AM revealed Resident #6's Lorazepam 2MG/ML; dated 8/03/25 with a refrigeration sticker across the front. located on the cart. Observations of the Station II nurses medication cart on 09/4/25 revealed the following: *At 6:14 AM revealed Resident #4's Lorazepam 2MG/ML; dated 8/11/25 with a refrigeration sticker across the front, located on the cart. LVN L stated she was going to place the medication in the refrigerator, LVN L left to place the medication in the refrigerator.*At 6:21 AM revealed Resident #6's Lorazepam 2MG/ML; dated 8/03/25 with a refrigeration sticker across the front, located on the cart. *6:36 AM revealed Resident #5's Lorazepam (unable to see the dose) located on the medication cart. The label was not legible to read. The resident's last name only was handwritten at the top along with the name of the medication (Ativan). The label on the box appeared to be damaged by an unknown liquid. The investigator could not identify the directions, resident's name, dose amount, and who the medication was prescribed to. The date filled on the box was 02/05/25 and the label on the bottle inside was also not legible. During an interview on 9/05/25 at 9:56 AM the FNP T stated liquid Lorazepam had to be stored at a certain temperature or it would lose the effectiveness. She stated she was unaware that there was liquid Lorazepam that was being stored in the cart. She stated she had not been in the facility for the past 30 days as she was on medical leave. FNP T stated proper storage of liquid Lorazepam was common nursing knowledge. During an interview on 9/05/25 at 12:59 PM the DON stated he was familiar with the facility's medication storage policy. He stated each resident medication labels should include frequency, time and day the resident should receive the medication, when the medication was opened, quantity of the medication, name of the medication, name of the resident, route and any special instructions. He stated he could not observe the expected and required information on Resident #5's Lorazepam, but it had been discarded and reordered. He stated the purpose of proper storage and labeling was to ensure resident safety. He stated the potential negative outcome for not practicing proper storage and labeling, specifically refrigerating the Lorazepam and ensuring that medications had the proper labeling was the Lorazepam could have an adverse effect for the resident receiving the medication. He stated the medication could also be improperly administered to the residents. He stated he had been trained that if there was a medication that had been out for an unknown time, he had been trained to immediately remove the medication as he does not know how long it was out. He stated that he was in the process of discarding and reordering Resident #4 and Resident #6 PRN Lorazepam. He stated the facility's system to monitor proper storage, and labeling was conducting cart audits. He stated they were conducting random cart audits, but he stated they did not observe or check the residents Lorazepam. He stated he had been trained to adhere to pharmacy/medication labels. The DON stated he could not say that his nurses had formally been trained at the facility on proper storage and labeling, but it was a standard nursing practice taught in nursing school. He stated he did not have a reason and was unsure why Resident #5's Lorazepam was not labeled correctly and why none of the liquid Lorazepam was not refrigerated as instructed on the medication label. He stated that he expected all pharmacy labels to be adhered to and all special instructions such as refrigeration to be followed. He stated the nurses and medication aides were responsible for ensuring that that there was always proper labeling and storage for all medications in the facility. He stated the filled date listed on the medication was the date the medication came to the facility. During an interview on 9/05/25 at 2:07 PM the ADM stated he was familiar with the facility's policy, Medication Storage and Labeling, and although the policy was not specific a medication label should include resident name, medication name, dose, directions of administration, expiration, and at least the physician's name. He stated he was unable to see the required identified information on Resident #5's Lorazepam. He stated Resident #5's medication should have been destroyed and reordered. He stated a pharmacist was the only person to label the medications and it was his expectation if the staff observe medications that they cannot read the label, then they should contact the pharmacist. He stated he expected if medications required refrigeration they should be placed in the refrigerator. He stated the potential negative outcome for not properly storing medications was the resident could have a adverse reaction. The ADM stated if the medication was marked for refrigeration, then upon receipt of the medication it should be placed in the refrigerator immediately. He stated if the medication was not to be refrigerated then the system was to place the medication on the cart and ensure that the label was legible. The ADM stated he had been trained and his nursing staff had been trained to adhere to pharmacy labels. He stated he did not have a reason why the boxes of Lorazepam were not in the refrigerator but not having them in the refrigerator could potentially cause the medication to break down and not be as effective. He stated the nurse or medication aide who was assigned to the residents' medications were responsible for ensuring that the medications were stored and labeled properly. He stated the filled by date indicated on the medication was the date the facility received the medication. During an interview on 9/05/25 at 3:54 PM the ADON stated she was familiar with the facility's Medication Storage Policy. She stated resident medications should include the following: resident's name (first and last), DOB, medication name, dosage, route, order number, date received, date opened and how much should be dispensed. The ADON stated she could not see all of the identifying and expected information on Resident #5's Lorazepam. The ADON stated hospice brought it the facility in the condition observed. The ADON stated she did see Resident #5's name (last name) and stated it was a common last name. The ADON stated the purpose of proper labeling of resident's medication was to make sure the medication was stored properly and given to the correct resident. The ADON stated if the resident's medication was not stored properly or labeled the staff could give the medication to the wrong resident. The ADON stated not refrigerating the Lorazepam could affect the Lorazepam's effectiveness and its' potency. The ADON stated she had been trained if refrigerated medications had been left out and they do not know how long it had been left out then they should discard and order a replacement. The ADON stated the medication was not initially discarded but since then had been discarded. The ADON stated initially the medications had been placed in the refrigerator. The ADON stated she does not believe any of the residents received Lorazepam after the identified deficient practice. She stated Resident #5 will generally refuse his Lorazepam. The ADON stated the facility's system to monitor medication label, and storage was to conduct medication cart audits. The ADON stated they were supposed to conduct the audits either once a week or once every two weeks. The ADON stated the Pharmacy Consultant also will conduct medication cart audits. The ADON stated she had not noticed the liquid Lorazepam in medication carts nor Resident #5's Lorazepam not being labeled properly. The ADON stated she had been trained that to adhere to medication/pharmacy labels. She stated it was a nursing standard. The ADON stated she expected for her nurses and medication aides to pay attention to the medications in their medication cart. She stated if medications were to be in the refrigerator she expected the nurses and medication aides to place them in the refrigerator. The ADON stated there was no reason why the liquid Lorazepam was not in the refrigerator. The ADON stated the reason why Resident #5's Lorazepam was not labeled correctly was because hospice brought it to the facility in that condition. The ADON stated all nursing staff and medication aides were responsible for ensuring that the medication labels were adhered to and stored properly. The ADON stated the filled date listed on the resident's medication was the date the medication was brought to the facility. During an interview on 9/09/25 at 1:53 PM LVN L stated she was familiar with the facility's policy, Medication Storage and labeling, and the purpose of following the policy was to ensure that medications were stored properly. She stated medication should be at the proper temperature before administration. LVN L stated the potential negative outcome for not properly storing medications was the Lorazepam could evaporate or not have as potency and effectiveness. LVN L stated then the medication would not work for the resident. LVN L stated she had been trained if the medication was left out then the medication would need to be placed in the refrigerator. LVN L stated the system to monitor medication storage was to place the Lorazepam in the refrigerator once it was received or they identify in the medication carts. LVN L stated she had been trained to adhere to pharmacy labels and the nurses were responsible for ensuring that all medications were stored properly. LVN L stated she did not have a reason why Resident #4 and Resident #6 Lorazepam was on the medication cart and not in the refrigerator as instructed on the medication label. LVN L stated the filled date on the medication label was not normally the date the facility received the medication because the facility would not receive the medication until the following day at 3:00 AM or 4:00 AM.During an interview on 9/10/25 at 11:07 AM the Pharmacy Consultant stated he was unaware that the facility had liquid Lorazepam that was not being stored in the refrigerator. He stated he was unsure what the potential negative outcome was for the resident if the liquid Lorazepam was not stored in the refrigerator as the pharmacy label instructed. He stated it may depend on the manufacturer and that some manufacturers require for the medication to be sat out prior to administration of the dose. The Pharmacy Consultant did not provide a potential negative outcome for not having a legible label but stated that if the label was not legible then the facility staff needed to call the pharmacy and get a replacement. Record review of the facility's policy, Medication Storage in the facility, dated January 2018, revealed:Policy: medication is included in the drug enforcement administration classification is controlled. Substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations.ProceduresControlled substances that require refrigeration are stored within a lock box within the refrigerator. This box must be attached to the inside of the refrigerator. A controlled substance accountability record is prepared by the pharmacy/facility for all schedule II, III, IV, and V medications, including those in emergency supply. The following information is completed on the accountability form upon dispensing or receipt of a controlled substance or use of a controlled substance: name of the resident, name, strength, and dosage form of the medication, date received, quantity received, and name of the person receiving the medication.

Based on observation, interview, and record review, the facility failed to review and revise resident's comprehensive care plans by the interdisciplinary team after each assessment for 1 (Resident #8) of 12 residents reviewed for comprehensive care plans. The facility failed to update or add interventions to Resident #8's care plan regarding aggressive and physical behaviors toward other residents that occurred on 08/05/25 and 08/29/25. These failures could result in residents not receiving the care that they need.Findings Included:Record review of Resident #8's face sheet, dated 09/03/25, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), psychotic disturbance (mental health condition characterized by loos of touch with reality), mood disturbance (significant change in a person's emotional state), anxiety (increased worry), cognitive communication deficit (Difficulty communicating), depressive episodes (periods of significant low mood or loss of interest that can interfere with daily life), and schizoaffective disorder (mental health condition that combines symptoms of schizophrenia and mood disorder). Record review of Resident #8's Comprehensive Minimum Data Set, dated [DATE], revealed the following: *Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was severely impaired. *Section E did not reveal any coded behaviors.Record review of Resident #8's physician orders, undated, revealed the following:*Hydroxyzine tablet; 25 mg 1tablet PO Every 8 hours PRN; diagnosis: pain: 01/03/25 and end date: open ended.*Ativan- Benadryl Topical gel; 1 mg/25mg/ ML; 4 clicks (1ML); topically every 8 hours as needed; diagnoses: anxiety: 7/23/25 and end date 08/06/25.*Rexulti; .5 mg; once a morning; diagnosis: dementia: 09/02/25 and end date: open ended.Resident #8's care plan, dated 6/19/25 revealed the following:*Resident #8 had a focus with the category behavioral symptoms for resident use of physical aggression. (7/28/25) The goal was for Resident #8 to maintain appropriate space and not to engage in physical aggression. Interventions included managing Resident #8's space with other residents and redirect Resident #8 to maintain distance and not to be physically aggressive.*Resident #8 had a focus with the category of physical aggression. Resident #8at physically aggressive behaviors at times (6/19/25). The goal was for Resident #8, not to harm residents with physical abusive behavior. Resident #8 would be monitored frequently to avoid further altercations. Interventions included assisting the resident with placement in an alternative therapeutic unit. Assess whether the resident's behavior was dangerous to other residents and intervene as necessary. Avoid overstimulation. Convey attitude of acceptance towards the resident. And maintain a calm environment and approach to the resident. Obtain a psychiatric consult if needed and provide activities and daily schedule that resembles the resident prior lifestyle.Record review of Resident #8's progress notes, dated 06/01/25-09/03/25, revealed the following:*08/6/25 at 9:16 AM the DON documented Resident #8 was assessed and found to have no issues or signs of trauma. Resident #8 was witnessed to be the aggressor in an incident involving another resident and was separated in place on one-to-one supervision. After residence were separated the representatives and families of the residence were notified of the incident and the need for an alternative placement. FNP U was notified with no new orders given and PNP was notified for a follow up with no new current orders at this time. The DON and administrator were also notified.*08/22/25 at 10:11 AM the SW documented a phone call was placed to a behavioral rehabilitation center. Was notified by the behavior rehabilitation center. That Resident #8 was clinically denied admission.*08/29/25 at 6:00 PM the DON documented Resident #8 was involved in an altercation with another resident. Resident #8 was witnessed, striking another resident in the face after the other resident was seen speaking to Resident #8. What was said was not able to be determined or it or if it had relevance to the instigation of the incident. Both residents were immediately separated, and Resident #8 was placed on one-to-one observations. Both residents were evaluated for signs of trauma or neurological changes or signs of abrasion, redness, or bruising. There were no signs able to be seen or presented upon resident assessment. Resident #8 representative was notified and approved for the need for alternative placement.*09/01/25 at 1:20 PM the DON documented Resident #8 was still actively being considered for alternate placement due to behaviors.*09/02/25 at 10:50 AM the SW documented Resident #8 1:1 supervision was discontinued after the IDT met.During an interview on 09/03/25 at 3:50 PM, Resident #8 was unable to participate in an interview as he did not answer any questions related to the incident that occurred on 08/29/25. He was able to tell the investigator that he felt safe and wanted to walk. During an interview on 09/04/25 at 1:45 PM, Resident #8 did not answer the investigator's questions incidents of aggression. He stated he was enjoying his walk. During an interview on 09/05/25 at 3:30 PM, Resident #8 was unable to participate in an interview as he did not answer any questions related to the incident that occurred on 08/29/25. He smiled at the investigator when asked any questions. During an interview on 9/05/25 at 12:07 PM the MDS Coordinator stated she was familiar with the facility's Care Plan policy. She stated they typically spoke about resident incidents in the morning meetings. The MDS Coordinator stated she honestly did not remember details about the incidents of aggression that involved Resident #8 on 08/05/25 and 08/29/25. The MDS Coordinator stated she only remembered discussions about finding 1:1 staff for Resident #8. The MDS coordinator stated she was unaware that Resident #8's care plan was not revised after 08/05/25 and 08/29/25. The MDS Coordinator stated she believed Resident #8's aggressive behavior was new. The MDS Coordinator stated the facility's system to monitor care plan revisions was they met to discuss resident's care plans. She stated when they have the resident's care conference (meeting) then they would update the resident's care plan. She stated care plan meetings are conducted weekly. She stated that they were not conducted every week for each resident, but each resident had a scheduled care plan meeting annually, quarterly and as needed. The MDS Coordinator if an event happens before the quarterly or annual meeting then they should meet to discuss the event. The MDS Coordinator stated incidents of aggression should be updated and addressed in the resident's care plan. The MDS Coordinator stated Resident #8 last care plan meeting was 06/19/25 and his next meeting would have been 09/19/25. The MDS Coordinator stated she was trained by another MDS Coordinator when she started. She stated she started as the facility's MDS Coordinator 3 years ago. The MDS Coordinator stated she expect for all resident care plans to have everything to do with the resident, especially if it had to do with resident behaviors. The MDS Coordinator stated specifically regarding behaviors the care plan should tell staff what type of behavior the resident was demonstrating, interventions, and goals for the resident. The MDS Coordinator stated the potential negative outcome for not updating or revising a resident care plan was more behaviors could reoccur. The MDS Coordinator stated the SW would have been responsible and she did not have a reason why Resident #8's care plan was not updated or revised. During an interview on 9/05/25 at 12:19 PM the SW stated Resident #8 had a history of aggression and it typically happens with female staff and residents The SW stated she was familiar with the facility's policy regarding care plans and their revisions. She stated care plan revisions were conducted on a 90 day basis. The SW stated once the residents were admitted she (the SW) will enter the initial care plan for behaviors. She stated after her initial entry then the MDS Coordinator would update when it was time. The SW stated a care plan allowed residents, family and staff to come together and go over changes. She stated resident care plans addressed needs such as dietary, medications, psychiatric care, podiatry needs and behaviors. She stated when care plans are revised then the staff would be oriented to the changes and would know what behaviors to monitor. The SW did not give a potential negative outcome for not revising resident care plans. She stated she believed that she updated Resident #8's care plan. The SW stated the IDT monitors resident care plans and revisions but that she would specifically put in the care plan for behaviors. The SW stated she had not received training at the facility for care plan and revisions but that she had previous experience with care plans. The SW stated she expected if a behavior or a concern had not initially been cared planned then she would put a care plan in the resident's EMR. She stated if a care plan, concern, or care area had already been entered in the resident's care plan then it should be revised and customized to meet the Resident's needs. The SW stated the date of the care plan was an indication to know when the residents care plan had been implemented, changed or revised. The SW stated the MDS Coordinator was responsible for care plan revisions. The SW stated she asked the MDS Coordinator if she (the SW) to be the one to revise Resident #8's care plan and she was told by the MDS Coordinator that she would update Resident #8's care plan. The SW stated she recalled she completed the revisions for Resident #8. During an interview on 9/05/25 at 12:59 PM the DON stated he was not familiar with the facility's Care Plan policy. He stated the purpose of resident care plans and care plan revisions was so that there was a continuity of care and so staff could provide quality care. He stated the resident care plan involved active problems and a history of resident problems. The DON stated the entire clinical team used the care plan to provide care to the residents in the facility. The DON stated the potential negative outcome of not revising resident care plans was there could be a lapse in resident care. The DON stated he was unaware that Resident #8's care plan was not revised. He stated he reviewed the care plan after the act of aggression involving Resident #8 on 08/05/25 and on 08/29/25. He stated he did not know there was a way to show that he reviewed the care plan. The DON stated the system to monitor care plan revision and ensure that resident's care plans were implemented and revised was the nurse who receives the resident and conducts their initial assessments will start the care plan. He stated mostly the SW and MDS Coordinator would implement and revise the care plans regarding behavior. He stated depending on the day it was possible that he would get around to reviewing the care plans for the residents in the facility, but that he could try to review care plans more often. He stated he had not been trained on care plan revisions. He stated as the DON he expected the care plan should reflect an accurate overview of the residents and that the care plan should set the resident up for their best positive outcome. He stated care plans should be conducted annually, quarterly, after an incident, and or any change whether it was positive or negative. He stated the care plan should be removed if an issue was resolved. The DON stated he was unsure who was responsible for care plan revisions. He stated he did not have a reason why Resident #8 care plan was not revised after the incident of aggression on 08/05/25 and 08/29/25. During an interview on 9/05/25 at 2:07 PM the ADM stated he was familiar with the facility's care plan policy. He stated the IDT uses the care plan to determine what type of care and monitoring was needed for the residents. He stated the care plan included ADL, code status, behaviors, and acute issues such as infections or wounds. He stated the potential negative outcome of not revising resident care plan was appropriate care would not be provided to the resident. The ADM stated he was unaware that Resident #8's care plan was not updated after his incidents of aggression on 08/05/25 and 08/29/25 He stated the facility's system to monitor care plan revisions was to ensure they were completed annually, every 90 days or any time there is an incident. The ADM stated the IDT was responsible for care plan revisions. He stated the IDT could include the MDS Coordinator, DON, ADON, Rehabilitation, activities and a Nurse/CNA that provide care for the resident. The ADM stated specifically the revision for Resident #8 regarding behavior should have happened at the time of the incident by the DON or designee. He stated he did not have a reason why Resident #8's care plan was not completed after the incident of aggression on 08/05/25 and 08/29/25. During an interview on 9/05/25 at 3:54 PM the ADON stated she was familiar with the facility policy regarding care plan and revisions. She stated the initial care plan was completed by the DON and then from there the IDT updated them in morning meetings and then the MDS Coordinator will update the resident care plan accordingly. She stated she was unaware that Resident #8's care plan was not updated after he had an altercation with other residents on 08/05/25 and 08/29/25. The ADON stated the potential negative outcome for not revising a resident's care plan was things could be missed and then they (the facility) could have a bigger issue. She sated care plan revisions she had some training, bits and pieces here and there. She stated she had [NAME] had a formal class before. The ADON stated she expected that when care plan revision were needed, she expected that they all meet as a team in the morning meetings so that they all ensure that the residents were getting the proper care that they needed. The ADON stated she did not have a reason why the care plan was not revised, and that the IDT team would be responsible for care plans revisions as it was a group effort. Record review of the facility's policy, Comprehensive Care Plans, dated July 2025, revealed:PolicyIt is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives in time frames to meet a residence medical, nursing, and mental and psychosocial needs in all services that are identified in the residence, comprehensive assessment and the professional standards of quality. The comprehensive care plan will describe, at minimum, the following: The services that are to be furnished to attain or maintain the residence, high practical, physical, mental and psychosocial well-being. Resident specific interventions that reflect the residence needs and preferences in align with the residence, culture identity, as indicated. The comprehensive care plan will be reviewed and revised by the IDT after each comprehensive and quarterly MDS assessment. The comprehensive care plan will include measurable objectives and timeframe to meet the residence needs as identified in the residence comprehensive assessment. The objectives will be utilized to monitor the residence progress. Alternative interventions will be documented as needed.

Based on interview and record review, the facility failed to ensure each resident's drug regimen be free from unnecessary drugs without adequate indications for its use for 2 of 12 (Resident #4 and Resident #6) reviewed for unnecessary medications.The facility failed to ensure that Resident #4 PRN orders for psychotropic drugs (Lorazepam (2MG/ML) were limited to 14 days and or provide a physician's rationale indicating that it was appropriate for the PRN order to exceed the 14 day stop date.The facility failed to ensure that Resident #6 PRN orders for psychotropic drugs (Lorazepam (2MG/ML) were limited to 14 days and or provide a physician's rationale indicating that it was appropriate for the PRN order to exceed the 14 day stop date.This failure could lead to residents being prescribed medications without indication and place residents at risk of unnecessary side effects and a decline in overall health.Findings included:Resident #4 Record review of Resident #4's face sheet, dated 09/0325, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnosis of generalized anxiety disorder (increased worry), psychosis (mental health condition characterized with by false contact with reality. Record review of Resident #4's Comprehensive MDS, dated [DATE], revealed the following: *Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was severely impaired. *Section N Medications revealed Resident #4 took the following high-risk medications: Anti-anxietyResident #4's care plan, dated 6/19/25 revealed the following:Resident #4 had a focus for psychotropic drug use specifically that Resident #4 had potential for complications related to antidepressant medications, specifically Lorazepam. (initiated 7/9/25) The goal was for Resident #4 to be free from side effects to the medication and to not exhibit side effects from taking antianxiety medications. Staff should monitor resident's functional status each shift. Staff should monitor resident's mood and response to medication. Staff should monitor side effects such as sedation, drowsiness, dizziness, nausea and vomiting. The staff should have a pharmacy review monthly. Record review of Resident #4's physician orders, undated, revealed the following:*Lorazepam .5 mg/ML; .25 ML every 6 hours prn diagnosis: generalized anxiety; order start date: 12/18/24 and end date: open ended.Record review of #4's medication consent, dated 08/28/24, revealed Resident #4's MAR for July 2025 revealed that Resident #4 was not administered Lorazepam .5 mg/ML: .25 ML prn.Resident #4's MAR for August 2025 revealed that Resident #4 was administered Lorazepam .5 mg/ML: .25 ML prn on the following dates:*08/01/25 at 11:27 AM by LVN W *08/01/25 at 6:29 PM by RN Y (doses effective), *08/05/25 at 2:46 PM by LVN F (dose effective), and *08/25/25 at 4:06 PM by LVN L (dose effective).Resident #4's MAR for September 2025 revealed that Resident #4 was not administered Lorazepam .5 mg/ML.Record review of Resident #4's Consultant Pharmacist Recommendation, dated 08/28/24, signed by the Pharmacy Consultant revealed:In accordance with state and federal guidelines, psychotropic drugs, PRN, orders for psychotropic drugs are limited to 14 days, except when the attending position or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. Then here she should document the rationale in the resident medical record and indicate the duration for the PRN order. Response: Continue PRN use for 90 days, as the benefit outweighs the risk.Record review of Resident #4's progress notes, dated 06/01/25-09/03/25, revealed the following:*08/01/25 at 4:33 PM, LVN W documented Resident #4 was witnessed rolling himself from the edge of the bed onto his fall mat and appeared to be confused. The resident was given .25 ml of lorazepam to help with anxiety and agitation. Further review reviewed there were no additional progress notes regarding lorazepam, medication administration or anxiety. During an interview on 09/05/25 at 10:31 AM, Resident #4 did not contribute any information related to the specific failure. Resident #6 Record review of Resident #6's face sheet, dated 09/19/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), generalized anxiety (increased worry) and cognitive communication deficit (difficulty communicating). Record review of Resident #6's Quarterly MDS, dated [DATE], revealed: *Section C Brief Interview for Mental Status score revealed a score of 02, which indicated the resident's cognition was severely impaired. Section N Medications revealed Resident #6 did not take high-risk medications, to include anti-anxiety. Record review of Resident #6's physician orders, undated, revealed the following:*Lorazepam 2 mg/ ML;.25 ML Every 4 hours PRN; diagnosis: pain: 08/03/25 and end date: open ended.Record review of Resident #6's updated prescription order, dated 09/09/25, revealed:*Lorazepam 2 mg/ ML;.25 ML Every 4 hours PRN; diagnosis: Generalized anxiety: 09/09/25 and end date: 09/23/25Record review of Resident #6's MAR for August and September 2025 revealed that Resident #6 was not administered Lorazepam .5 mg/ML.Record review of Resident #6's Consultant Pharmacist Recommendation, dated 08/25/25, signed by the Pharmacy Consultant revealed:In accordance with state and federal guidelines, psychotropic drugs, PRN, orders for psychotropic drugs are limited to 14 days, except when the attending position or prescribing practitioner believes that it is appropriate for the PR in order to be extended beyond 14 days. Then here she should document the Russian now and the resident medical record and indicate the duration for the PRN order. Response (no response documented)Record review of Resident #6's care plan, dated 5/22/25 revealed Resident #6 did not have a care plan regarding prn medications and or anti-anxiety (Lorazepam) medication administration. Record review of Resident #6's progress notes, dated 08/3/25 at 1:31 PM written by LVN W revealed Resident #6 hospice nurse came and evaluated her (Resident #6). LVN W stated Resident #6 was transitioning and the hospice nurse would order comfort medications (specific medication was not indicated). During an interview on 09/05/25 at 10:27 AM, Resident #6 was unable to participate in an interview as she was sleep.During an interview on 09/05/25 at 5:10 PM, Resident #6 did not answer the investigator's questions. She blinked at the investigator and the investigator thanked her for her time and exited the room. During an interview on 9/05/25 at 9:56 AM the FNP T stated she was unaware that Resident #4 and Resident #6 did not have a 14 day stop date for their PRN Lorazepam. She stated she generally does not order that medication but hospice or the psychiatric provider would order Lorazepam. FNP T stated she was not very fond of benzodiazepines. She stated it was a medication that was on the high-risk list for elderly residents. FNP T stated Lorazepam was not used for pain but given for anxiety. FNP T stated she did not have any information regarding Resident #4 having a 90 day stop date and the physician order not being updated. She stated the purpose of having a 14 day stop date was to ensure that they followed guideline, and it was a standard for PRN medications in that class. During an interview on 9/05/25 at 11:50 AM Hospice RN DD stated she was unaware that Resident #6 did not have a 14 day stop date. Hospice RN DD stated she was familiar with the concept that PRN antianxiety and antipsychotic should not exceed the 14 days stop date. She stated she was unsure of the purpose of the 14 day stop date for PRN antianxiety and antipsychotic medications. Hospice RN DD stated facility staff may have told her about the 14 day stop date but she did not remember. She stated she was aware that antianxiety and antipsychotics could cause excessive sleepiness, sedation or increase agitation in elderly patients. Hospice RN DD stated she was aware the same medications could cause hallucinations. Hospice RN DD stated the Lorazepam prescribed to Resident #6 was not for pain but should have been for anxiety. During an interview on 9/05/25 at 12:59 PM the DON stated he was familiar with the facility's Antipsychotic Medication policy. The DON stated that the purpose of a 14 day stop date on PRN antianxiety or antipsychotics was so that they could reference if there was a need for the medication or if the medication needed to be changed. He stated after the 14 day stop date they could assess the resident and determine if there was a need for a GDR. The DON stated the potential negative outcome for not ensuring that there were 14 day stop date for antianxiety and antipsychotic medications was the resident could experience a nontherapeutic outcome from the medication. He said for example, the resident may not be comfortable as the medication was intended for. The DON stated he was unaware that Resident #4 and Resident #6 PRN Lorazepam did not have a 14 day stop date. He stated it was brought to his attention by the ADON. He stated he was told the ADON that it was still the facility's responsibility to ensure that there was a 14 day stop date even if the medication was added by hospice. He stated there was not a system in place to monitor PRN antianxiety and antipsychotic medications, but it would take staff teaching and training. The DON stated he had been trained that PRN antianxiety and antipsychotic medications should have a 14 day stop date. He stated had not received a formal training, but it was apart of nursing standard practice. The DON stated all his staff have not been trained. He stated he did not have a physical list of who had not or had been trained. The DON stated he expected PRN antianxiety and antipsychotics to have a 14 day stop date and after the 14 days the resident to be evaluated by a physician, medication changes implemented if necessary and medication to be ordered timely. He stated he did not have a reason why Resident #4 and Resident #6 PRN Lorazepam did not have a 14 day stop date but that he was responsible for ensure the appropriate stop date was implemented and reflected in the resident's physician orders. He stated he was unaware there had been a 90-day recommendation for Resident #4 but expected the recommendation of the doctors to be reflected in the resident's physician's order. During an interview on 9/05/25 at 2:07 PM the ADM stated he was familiar with the facility's policy, Antipsychotic Medications, and the purpose of having a 14 day stop date on PRN antianxiety and antipsychotics was to make sure there was a review on the necessity of the medications. He stated the potential negative outcome of not have the required 14 day stop date for the PRN antianxiety or antipsychotic was could potentially receive a medication that they do not need. The ADM stated he was unaware Resident #4 and Resident #6 PRN Lorazepam did not have a 14 day stop date. He stated he was unaware that Resident #4 had a recommendation for a 90 day stop date and his physician order was not updated. He stated his staff had been trained on the requirement of a 14 day stop date and he knew about the requirement because of his nursing experience. The ADM stated he expected a 14 day stop date to be implemented and if the medication was ordered by hospice the nurse needed to ask for the 14 day stop date. He stated he did not have a reason why there was not a 14 day stop date for Resident #4 and Resident #6 but whoever took the orders were responsible. During an interview on 9/05/25 at 3:54 PM the ADON stated she was familiar with the facility's Antipsychotic Medication Policy. She stated the purpose of having a 14 day stop date for PRN antipsychotics and antianxiety medications was to monitor if the medication was still needed for the resident. The ADON stated they do not want to snow their residents. The ADON stated using the term snow means that the resident would be either too groggy or overly sedated. The ADON stated the potential negative outcome for not having the 14 day stop date for PRN antipsychotic and antianxiety was the residents could potentially be overly sedated. The ADON stated she was unaware that Resident #4 and Resident #6 did not have a 14 day stop date for their PRN Lorazepam. She stated the system to monitor PRN antipsychotics and antianxiety medications was they should run reports and stay on top of them and let the hospice providers know. The ADON stated she would have to let the PNP know about the 14 day stop date. The ADON stated prior to the date of the interview (09/05/25) they did not have a system in place to monitor. The ADON stated she had been trained that PRN antipsychotics and antianxiety medications should have a 14 day stop date. The ADON stated her nurses should also know as it was apart of nursing in long term care. The ADON stated she or her nurses had not had any specific formal training from the facility. The ADON stated she did not think anything of the 14 day stop date as she thought since it was prescribed and apart of hospice it would be considered apart of palliative care. The ADON stated she expected her nurses to pay attention to the stop date when the medication was ordered. She stated the nurse receiving the order should ensure that the PRN medication had the 14 day stop date and should be reordered timely. The ADON stated there was no reason why Resident #4 and #6 PRN Lorazepam did not have a 14 day stop date. The ADON stated she assumed it was hospice that ensured there was a 14 day stop date but that it should be whichever nurse enters the order in the resident's EMR. The ADON stated she would follow up with the HHSC investigator on the purpose of the Lorazepam for Resident #6. The ADON stated Lorazepam was not typically used for pain. The ADON stated she did not have a reason why Resident #4's physician order was not updated to reflect the 90 day stop date that was indicated on the pharmacy recommendation from 2024, but that she expected the resident's physician order to be updated and reflect the recommendation from the Pharmacy Consultant and the assigned doctor. The ADON stated she would have expected the hospice provider to update the resident's EMR. She stated she is unsure if the hospice provider had access to the facility's EMR system. During an interview on 9/10/25 at 11:07 AM the Pharmacy Consultant stated he was unsure if he had already identified the lack of a 14 day stop date for Resident #4 and Resident #6. He stated he would have look at his notes and he was not where he could access the notes. He stated any documentation needed would have to be requested from the facility. He stated he does regimen reviews and if he identified there was a PRN antianxiety or antipsychotic, he generally would let the facility and doctor know through written notification. The Pharmacy Consultant stated the potential negative outcome for not having a 14 day stop date was the resident could receive the medication longer than he or she needed. Record review of the facility's policy, Use of Psychotropic Medications, dated July 2025, revealed:PolicyIt is the intent of this policy to ensure that residents only receive psychotropic medication's when other non-pharmacological interventions are clinically contraindicated. Additionally, this medication should only be used to treat the residence, Medical Center, and not used for discipline or staff convenience, which would deem it as a chemical restraint.Psychotropic medication's use on a PRN basis must have a diagnose specific condition and indication for the PRN use document in the residence medical record in a subjected to the limitations as noted: PRN orders for psychotropic medication, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner, believes it is appropriate to extend the order beyond the 14 days. The medical records should include documentation from the physician or prescriber for the rationale for the extended time. And indicate a specific duration. PRN orders for antipsychotic medication's only, shall be limited to 14 days with no exception. If the attending physician or prescribing practitioner, believes it is appropriate to write a new order for the PRN antipsychotic, they must first evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate.

Based on observations, interviews, and record review, the facility failed to provide ADL (Activities of Daily Living) care to a resident who is unable to carry out activities of daily living and receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 5 residents (Resident#1, #2, and #3) observed for ADL care to ensure they were receiving appropriate hygiene in that: The facility failed to provide showers for Residents #1, #2, and #3 on their scheduled shower days. This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. The findings included: Resident #1: Record review of Resident #1's face sheet revealed an [AGE] year-old female with an admitted [DATE] with diagnoses that included: Dementia in other diseases classified elsewhere (mental decline that affects thinking, memory, reasoning, personality, mood and behavior), Urinary tract infection, generalized anxiety disorder, Parkinsonism (nervous system disorder due to reduced levels of dopamine), and Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (partial or complete paralysis of one side of the body due to a stroke). Record review of Resident #1's MDS dated [DATE] of Section C- Cognitive patterns revealed a BIMS score of 15 which indicated the resident was cognitively intact. Section GG-Functional Abilities and Goals revealed the resident required supervision/touching assistance to shower/bathe herself. Record review of Resident #1's care plan dated 9/4/2024 revealed a problem area with a category of general that reflected, the following Tasks will be document in POC CareAssist. The goal reflected, The Resident will perform the following tasks at their highest practicable level. The Approach reflected, I prefer to take my Bath/Shower on TTS. My preferred time to Bath/Shower is Dayshift. Flowsheet: ADL Once A Day on Tue, Thu, Sat; 06:00 AM - 06:00 PM. The discipline indicated Nursing. Record review of Resident #1's Point of Care Completion Summary (POC) from March 2025 indicated Resident #1 did not receive a shower on 3/20/2025, as scheduled. The document indicated Resident #1's last shower was on 3/18/2025. Record review of Resident #1's progress notes from March 2025 did not include a progress note from 3/20/2025 to indicate Resident #1 refused a shower on this date. Resident #2: Record review of Resident #2's face sheet revealed an [AGE] year-old female with an admitted [DATE] with diagnoses that included the following: Metabolic encephalopathy (problems with metabolism that cause brain dysfunction), Atherosclerotic heart disease of native coronary artery without angina pectoris (blockages in the arteries of the heart,), Unspecified dementia moderate protein-calorie malnutrition, muscle weakness, and Essential (primary) hypertension (high blood pressure ). Record review of Resident #2's MDS dated [DATE] of Section C- Cognitive patterns revealed a BIMS score of 6 which indicated the resident was moderately, cognitively impaired. Section GG-Functional Abilities and Goals revealed the resident required substantial/maximum assistance to shower/bathe herself. Record review of Resident #2's care plan dated 10/1/2024 revealed a problem area with a category of general that reflected, the following Tasks will be document in POC CareAssist. The goal stated, The Resident will perform the following tasks at their highest practicable level. The Approach reflected, I prefer to take my Bath/Shower on TTS. My preferred time to Bath/Shower is Dayshift. Flowsheet: ADL Once A Day on Tue, Thu, Sat; 06:00 AM - 06:00 PM. The discipline indicated Nursing. Record review of Resident #2's Point of Care Completion Summary (POC) from March 2025 indicated Resident #2 did not receive a shower on 3/20/2025, as scheduled. The document indicated Resident #2's last shower was on 3/18/2025. Record review of Resident #2's progress notes from March 2025 did not include a progress note from 3/20/2025 to indicate Resident #2 refused a shower on this date. Resident #3: Record review of Resident #3's face sheet revealed a [AGE] year-old female with an admitted [DATE] with diagnoses that included the following: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (partial or complete paralysis of one side of the body due to a stroke), Overactive bladder, Major depressive disorder (mood disorder), Generalized anxiety disorder, Transient cerebral ischemic attack (blood flow to the brain is temporarily cut off), and diabetes. Record review of Resident #3's MDS dated [DATE] of Section C- Cognitive patterns revealed a BIMS score of 12 which indicated the resident was slightly, cognitively impaired. Section GG-Functional Abilities and Goals revealed the resident required partial/moderate assistance to shower/bathe herself. Record review of Resident #3's care plan dated 07/26/2024 revealed a problem area with a category of general that stated, the following Tasks will be document in POC CareAssist. The goal stated, The Resident will perform the following tasks at their highest practicable level. The Approach stated, I prefer to take my Bath/Shower on TTS. My preferred time to Bath/Shower is Dayshift. Flowsheet: ADL Once A Day on Tue, Thu, Sat; 06:00 AM - 06:00 PM. The discipline indicated Nursing. Record review of Resident #3's Point of Care Completion Summary (POC) from March 2025 indicated Resident #3 did not receive a shower on 3/18/2025 or 3/20/2025, as scheduled. The document indicated Resident #3's last shower was on 3/15/2025. Record review of Resident #3's progress notes from March 2025 did not include a progress note from 3/18/2025 or 3/20/2025 to indicate Resident #3 refused a shower on this date. During an interview on 3/21/2025 at 10:33 AM Resident #3 stated she had not had a shower all week. Resident #3 stated she recently moved to a new room, and she had not had a shower any day during the week of 03/17/2025 - 03/21/2025. Resident #3 stated she did not want a shower on this day because she was already dressed, and the staff did not ask her if she wanted a shower. Resident #3 stated she did not refuse a shower this week, but her shower days were on Tuesday, Thursday, and Saturday. Resident #3 stated she did not know why she did not receive a shower this week, and she thought the staff may have forgotten about her. Resident #3 stated she liked to take a shower and she would have liked to shower on her scheduled shower days. Resident #3 stated she did not want a shower on this day, when asked by the surveyor, since she was already dressed for the day. Resident #3 stated staff helped her get dressed on this day and brushed her hair. Resident #3 did not appear unkempt or dirty. During an Interview on 03/21/2025 at 10:39 AM, Resident #1 stated that she had not had a shower in 3 days. Resident #1 stated she did not have a shower any day during the week of 03/17/2025 - 03/21/2025. Resident #1 stated she requested a CNA to give her a shower on 03/20/2025, but the CNA denied giving her a shower. Resident #1 stated her shower days were Tuesday, Thursday, and Saturday. Resident #1 confirmed the current day was Friday, and she stated she did not receive a shower on Tuesday or Thursday. Resident #1 stated she never refused a shower before and she enjoyed taking a shower on her shower days. Resident #1 stated she was upset that staff refused to give her a shower after she requested one on 03/20/2025. Resident #1 was still in her nightgown, but she did not appear unkempt or dirty. During an Interview on 03/21/2025 at 10:45 AM, Resident #2 stated she had not had a shower in a couple of days. Resident #2 stated she did not know why she had not showered, and she wanted a shower. Resident #2 stated she did not refuse to take a shower this week. Resident #2 stated she had not been dressed for the day since she had not had a shower yet. Resident #2 stated she reported this to the nursing staff, and she was waiting for someone to come back to give her a shower. Resident #2 stated she asked for a shower on the previous day (Thursday 3/20/2025), but the CNA told her it was not her shower day. Resident #2 was unsure of her shower days. Resident #2 was still in her pajamas, but she did not appear unkempt or dirty. During an observation on 03/21/2025 at 10:43 AM CNA A was heard asking Resident #2 if she wanted to take a shower. Resident #2 told CNA A that she did want a shower, and she wanted a shower yesterday, but the staff did not give her one. CNA A advised Resident #2 she would give her a shower and told her she would be back soon to get her. During an observation on 03/21/2025 at 10:44 AM CNA A was heard telling Resident #2 that she would be back soon to take her to the shower room. Resident #1 told CNA A that she was upset that the staff from the previous day (Thursday) refused to give her a shower. Resident #1 told CNA A that her shower days were Tuesday, Thursday, and Saturday, and she had not had a shower since last Saturday (3/15/2025). CNA A told Resident #1 she did not know why the staff refused to give her a shower yesterday and stated she did not work that day (03/20/2025). CNA A stated, I know you did not get a shower yesterday, but I will give you one today. During an interview on 3/21/2025 at 3:15PM CNA F stated CNAs were responsible for ensuring residents received showers on their scheduled shower days. CNA F stated when CNAs arrive for their shift, they reviewed a printout of the scheduled showers for each day. CNA F stated this list was printed out by each charge nurse for the morning shifts. CNA F stated she completed 3 showers for residents on that day (03/21/2025), and all showers had been completed for the day. CNA F stated Resident #1 and Resident #2 were showered on that day (03/21/2025) since they did not receive a shower on Thursday (3/20/2025). CNA F did not know why the residents did not receive a shower on their scheduled shower day, Thursday. CNA F stated she did not work on Thursday, 3/20/2025. CNA F stated if a resident refused a shower they were supposed to notify the charge nurse, so it could be documented. CNA F stated if a resident refuses a shower on their scheduled shower days, they were supposed to ask the resident the following day if they would like to shower. CNA F stated all residents had the right to take a shower, if they wanted to. CNA F stated if a resident is not bathed regularly they were at risk of skin breakdown, infections, and bad hygiene which could upset the resident. During an interview on 03/21/2025 at 3:30 PM LVN A stated it was expected that all CNAs worked together to ensure all residents receive a shower on their scheduled shower days. LVN A stated if a resident refused to shower the CNAs were supposed to notify the charge nurse, so it could be documented. LVN A stated if a resident refused a shower the nursing staff would attempt to ask the resident later in the day to see if they changed their mind, and if they still didn't want to shower it should have been documented. LVN A stated she worked on the previous day, 3/20/2025, but she could not recall what residents received showers. LVN A stated Resident #1, Resident #2, and Resident #3 did not refuse showers normally, to her knowledge. LVN A stated Resident #1 and Resident #2 received showers on 3/21/2025. LVN A stated she did not know why Resident #1 and Resident #2 did not receive showers on their scheduled shower day, 3/20/2025. LVN A stated each resident had the right to have a shower if they want it. LVN A stated if a resident was not bathed regularly, they would be at risk of infection or skin breakdown. During an interview on 03/21/2025 at 4:10 PM CNA A stated it was expected that all CNAs worked with each other to ensure all residents were bathed on their scheduled shower days. CNA A stated when she first arrived for her shift each day, she checked the shower list for the day to plan each resident's shower. CNA A stated when she arrived on 3/21/2025, she was told, by an unknown staff, that showers were not completed the previous day. CNA A stated she was told the CNA who worked the previous day, just didn't want to do it. CNA A stated she had to plan showers for the residents scheduled for Friday and Thursday since the CNA did not bathe residents the previous day, 3/20/2025. CNA A stated she was off the previous day, 3/20/2025. CNA A stated Resident #1 and Resident #2 advised her that they did not get showers on the previous day, so she had to shower them on that day (3/21/2025). CNA A stated Resident #3 was not on the list for showers, and she thought it was because she had recently been moved to a new hallway. CNA A stated she would ensure Resident #3 was added to the shower list. CNA A stated she did not realize Resident #3 was overlooked. CNA A stated if a resident refused to shower, they would ask the resident again later, and then reported it to a nurse to be documented. CNA A stated all residents had the right to have a shower if they wanted it. CNA A stated it was expected that all residents were bathed on their scheduled days. CNA A stated she received in-service training regarding ensuring residents are bathed regularly, within the past month. CNA A stated if a resident was not bathed regularly, they could be at risk of infection, skin breakdown, and body odor. During an interview on 03/21/2025 at 4:30 PM CNA B stated she worked the previous day, 3/20/2025, and was job shadowing as she just started working at the facility. CNA B stated she heard Resident #1 ask an unknown CNA to help her shower. CNA B stated the resident was refused a shower on that day. CNA B stated she was unaware of the resident's scheduled shower days until she arrived on 3/21/2025 and found out Resident #1 should have received a shower on 3/20/2025. CNA B stated the unknown CNA told CNA B that it was not her job to give residents showers, and that was why she was not going to do it. CNA B stated she ensured Resident #1 received a shower on 3/21/2025. CNA B stated she received training upon her hire regarding ensuring residents were bathed regularly. CNA B stated if a resident was not bathed regularly, the resident was at risk of infection, body odor, and a decline in health. CNA B stated if residents were not bathed regularly, full skin assessments could be overlooked for the resident. During an interview on 03/24/2025 at 11:47 AM CNA E stated it was expected that all CNAs ensure residents were bathed on their scheduled shower days. CNA E stated they had a daily list of each resident's shower schedule according to the day. CNA E stated she worked on 3/20/2025. CNA E could not recall who received showers on 3/20/2025. CNA E stated she did not recall any residents asking for a shower that day (3/20/2025) or being declined a shower. CNA E stated all residents had the right to have a shower if they wanted it. CNA E stated she did not recall any residents refusing a shower on 3/20/2025. CNA E stated if a resident refused a shower, she would have reported it to the charge nurse so it could be documented. CNA E stated she did not recall bathing Resident #1, Resident #2, or Resident #3 on 3/20/2025. CNA E stated she did not recall those residents refusing a shower on 3/20/2025. CNA E stated she did not know why the residents did not receive a shower on 3/20/2025. CNA E stated she received in-service training regarding ensuring residents were bathed regularly, within the past month. CNA E stated if residents were not bathed regularly, they were at risk of infection or skin breakdown. During an interview on 03/24/2025 at 1:00 PM CNA C stated it was the CNAs responsibility to ensure all residents were bathed on their scheduled shower days. CNA C stated all residents had a right to shower when they want to. CNA C stated a resident should never be refused a shower. CNA C stated she received in-service training on bathing residents within the past month. CNA C stated if a resident was not bathed regularly, the resident could be at risk of infection. During an interview on 03/24/2025 at 1:30 PM CNA D stated it was expected for CNAs to check the bathing schedule when they arrived, to plan for their day. CNA D stated she thought Resident #1, Resident #2, and Resident #3 were on the Tuesday, Thursday, and Saturday schedule for showers. CNA D stated she worked on 3/20/2025. CNA D stated she did not know which residents received showers on 03/20/2025, as she left before noon that day. CNA D stated she did not recall any residents refusing showers. CNA D stated if a resident refused a shower, they were supposed to ask the resident again later, and if the resident still refused they were supposed to notify the nurse so it could be documented. CNA D stated each resident had the right to receive a shower when they wanted it. CNA D stated she received in-service training on ensuring residents were bathed on their scheduled days, within the past month. CNA D stated if a resident is not bathed regularly they were at risk for bad hygiene or infection. During an interview on 03/24/2025 at 2:07 PM, the DON stated that he expected that all resident's would receive a shower on their scheduled shower days. The DON stated that each resident had a right to be bathed when they wanted. The DON stated it was the CNAs responsibility to bathe residents on their scheduled days. The DON stated it was the nursing staff's responsibility to ensure this was completed each day. The DON stated that he had not known that showers were not provided on 3/20/2025. The DON stated that the policy stated to provide showers to promote cleanliness and promote healing of the resident's skin. The DON stated that all nursing staff were provided training recently on ensuring residents were bathed regularly. The DON stated he was not aware Resident #3 was not on the shower list for the resident's schedule days, and he planned to update the shower schedule asap to ensure Resident #3 was added. The DON stated if a resident refused a shower there should have been a progress note entered by the nurse. The DON stated each resident was encouraged to bathe on their scheduled shower days, but it should have been reported to the nurse if they still refused. The DON stated a resident should have never been refused a shower if they requested it, even if it was outside of their scheduled day. The DON stated it was never acceptable for a staff to refuse to bathe a resident, and if the staff needed help, they should have notified the DON or ADM. The DON stated all staff were aware they should have bathed residents daily, as scheduled, and asked for help when needed, as this was communicated to staff daily. The DON stated every CNA was responsible for ensuring all residents on each hallway received showers, as schedule, regardless of which hallway they were assigned to each day. The DON stated if a resident was not bathed regularly it would be a concern. The DON stated the resident could be at risk for infection and skin breakdown if they were not bathed regularly. During an interview on 03/24/2025 at 2:35 PM, the ADM stated that all CNAs were responsible for ensuring each resident was bathed on their scheduled shower days. The ADM stated the CNA should have checked their shower list each day, when they arrived, and the charge nurse and DON should have ensured this was being done. The ADM stated all nursing staff should be aware of the importance of bathing each resident regularly as this was communicated upon hire as well as in the in-service training the staff received within the past month. The ADM stated each resident has a right to receive a shower if they want it, and no resident should ever be refused a shower even if it was not their scheduled shower day. The ADM stated staff were encouraged to ask for help when needed. The ADM stated if a resident refused a shower, it should have been documented by the nursing staff and the resident should have been offered a shower the following day. The ADM stated if a resident isn't bathed regularly, the resident could be at risk of infection or skin breakdown. Review of the facility's policy and procedure titled, Activities of Daily Living (ADLs), Supporting, date revised March 2018, revealed: Policy Statement: Residents will provide 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. 1. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. a. The existence of a clinical diagnosis or condition does not alone justify a decline in a resident's ability to perform ADLs. 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). 3. Care and services to prevent and/or minimize functional decline will include appropriate pain management, as well as treatment for depression and symptoms of depression. 4. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate. Review of the facility's policy and procedure titled, Bath, Shower/Tub, date revised February 2018, revealed: Purpose: The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Documentation 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. 3. All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. 4. How the resident tolerated the shower/tub bath. 5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data. Reporting 1. Notify the supervisor if the resident refuses the shower/tub bath. 2. Notify the physician of any skin areas that may need to be treated. 3. Report other information in accordance with facility policy and professional standards of practice.

Based on observation, interview, and record review the facility failed to ensure that its medication error rate was less than 5 percent. The facility had a medication error rate of 9.38% based on 3 errors out of 32 opportunities, which involved 2 of 7 residents (Resident #6 and Resident #10) reviewed for medication administration. 1. LVN A failed to administer Resident #6's Certizine medication according to physician orders, resulting in Resident #6 receiving the medication late. 2. LVN A failed to verify the dosage on Resident #6's Simethicone 125 mg medication order prior to administering the medication, resulting in Resident #6 being underdosed. 3. LVN A failed to verify the dosage on Resident #10's vitamin D3 125 mcg medication order prior to administering the medication, resulting in Resident #10 being underdosed. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. Findings included: Resident #6 Record review of Resident #6's face sheet dated 03/12/25 revealed an [AGE] year-old female with an admitted [DATE] with the following diagnoses: neuropathy (nerve damage), congestive heart failure (condition where the heart does not pump adequately), and gastroparesis (digestive condition). Record review of Resident #6's current physicians orders revealed an order with a start date of 01/23/25 for Certizine 10 mg; amount: 1 tablet; oral; once a morning at 07:00 AM. Further record review revealed an order with a start date of 06/12/22 for Simethicone chewable tablet 125 mg; amount 1 tablet four times daily. During a medication administration observation on 03/12/25 at 8:59 AM for Resident #6, LVN A dispensed one Cirtizine 10 mg tablet and one Simethicone 80 mg tablet into a medication cup and administered the medications to Resident #6. Resident #10 Record review of Resident #10's face sheet dated 03/12/25 revealed an [AGE] year-old female with an admitted [DATE] with the following diagnoses: metabolic encephalopathy (a change in brain function due to an underlying condition), protein-calorie malnutrition (change in body composition due to reduced nutrients, and hypertension (high blood pressure). Record review of Resident #10's current physicians orders revealed an order with a start date of 08/16/23 for Cholecalciferol (vitamin D3) 125 mcg tablet (5,000 unit); amount: 1 tablet; oral once a morning 07:00 AM-10:00 AM. During a medication administration observation on 03/12/25 at 9:13 AM for Resident #10, LVN A dispensed one vitamin D3 25 mcg tablet into a medication cup and administered the medication to Resident #10. During an interview and observation on 03/12/25 at 12:32 PM, LVN A stated she was asked by nursing administration to take over medication pass for another staff member after 8:00 AM, which caused Resident #6's 7:00 AM medication to be administered late. LVN A pulled the bottle of Simethicone 80 mg from the top drawer of the medication cart and compared it to the physicians order for Resident #6. She stated, The order was for Simethicone 125 mg. The correct dosage was not given. LVN A pulled the bottle of vitamin D3 25 mcg from the top drawer of the medication cart and compared it to the physicians order for Resident #10. She stated, The order was for vitamin D3 125 mcg. I didn't read the order right. LVN A stated her protocol for a medication error was to report the error to her nurse manager and notify the physician. She stated she had been trained on accuracy of medication administration in her nursing education by verifying the right medication, right patient, right dosage, right time and right route. LVN A stated a potential negative outcome for failure to give medication at the right time was that it could interact with other medications. LVN A stated a potential negative outcome for failure to give the correct dosage of medication was that it could lower the therapeutic value and cause a resident to become sick. During an interview on 03/13/25 at 9:28 AM, ADON A stated she was notified by LVN A of the medication errors for Resident #6 and Resident #10. She stated the physicians were notified and orders were clarified in the electronic medical record for each resident. She stated staff were trained to verify dosage with medication orders prior to administration of medications and to report medication errors immediately to nursing administration. During an interview on 03/13/25 at 10:42 AM, the DON stated he was not aware that medication errors were made during the observation of medication pass. He stated staff were trained on accuracy of medication administration through competency checks conducted by the facility educator. He stated accuracy of medication administration was monitored through computer-based reconciliations of physicians orders and through periodic staff competency checks. The DON stated he was responsible to assure staff were properly trained on accurate medication administration. He stated a potential negative outcome for failure to administer medications according to physicians orders would be harm to the resident on multiple levels, such as death, depending on which medication is given. During an interview on 03/13/25 at 10:42 AM, the ADM stated he was not aware that medication errors were made during the observation of medication pass. He stated it was the DON's responsibility to assure staff were trained on accurate medication administration. He stated his expectation of staff for accurate medication administration was that medications were given on time and according to physician's orders. The ADM stated a potential negative outcome for medication errors was adverse reactions for residents. Record review of the facility-provided policy titled Specific Medication Administration Procedures, revised January 2018 revealed: Policy To administer medication in a safe and effective manner. Procedures . C. Review 5 Rights (3) times: 1) Prior to removing the medication package/container from the cart/drawer; a. Check MAR/TAR for order. 2) Prior to removing the medication from the container a. Check the label against the order on the MAR. 3) After the dose has been prepared and before returning the medication to storage.

Based on observation, interview, and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 meal reviewed for palatability. 1) The facility failed to provide food that was palatable, attractive and at appetizing temperatures for 3 of 3 food forms served (Regular, Mechanical Soft, and Pureed) at 1 of 1 meal observed (03/12/2025 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During confidential individual interviews, 3 of 5 residents voiced concerns related to food palatability and temperature. One Resident stated, this morning I didn't eat my breakfast because it had no taste. Another Resident stated, it's the lunch and the dinner that's not always good, the flavor, the food is cold sometimes. One other Resident stated that the other food was cold, the scrambled eggs, I just ate my oat meal and that was it. During the confidential Resident Council interviews held on 03/12/2025 at 09:57 AM, 4 of 10 residents voiced concerns related to food palatability, temperature and appearance. Residents stated some of the food, Mashed Potatoes had no taste. It was further stated the meals were cold, and bread was hard as a rock. Residents stated pork steak were hard to chew. It was also stated the food was very bland, lacked flavor and was cold, especially breakfast. Observation on 03/12/2025 at 12:01 PM the test trays arrived at the conference room and sampling began at 12:01 PM and were sampled by three surveyors with the following results. Pork steak 138 F Was hard and poor flavoring. Mashed Potato 133.2 F No taste. Baked Beans 119 F Cold. Bread Puree 86.3 F Poor appearance - flat on the plate. On 03/13/2025 at 10:39 AM an interview was conducted with CNA C, stated the cooks were responsible for making sure that the food was warm before served. She stated no in-service training had on food palatability till date. She also stated they have heard complaints from residents regarding cold food and on a regular basis, all I do was to warm up their food using the microwave. She added residents would easily get sick when served with cold food. She stated some residents were vocal individually about the poor foods and she had not come across any food policy. On 03/13/2025 at 10:57 AM an interview was conducted with DM A, he stated, Once the food gets out of the kitchen, we have no control over it, because it takes time for it to get to the residents, but my cooks were responsible for making sure that the food was warm/hot before it leaves. He also added been trained on food handling. He further stated, received complaints from the residents, an ongoing issue, about cold food and taste. He stated food comes from the steamer to an insulated cart, remained hot till served by the nurses. He stated residents could start losing weight and not eat the food if foods were not palatable. He stated that he had the policy. On 3/13/2025 at 11:49 AM an interview was conducted with the ADM. Regarding food palatability, he stated, it was combination of both dietary and nursing, that food should not get cold in between. He stated No, I don't know why that happened, part of the things I would look at. He stated food was cold, due to the time interval the carts were left at the units before the meals were served and would get managerial staffs involved in meal services. He stated that the Dietary Manager was responsible for the food palatability. He added that he expected staff to serve nutritive food. He added that residents could experience a reduction in quality of life and experience weight loss if the food was not palatable. Record review of the Resident Advisory Council Agenda and Minutes dated 01/03/2025 revealed the following, . dietary still have some concerns Record review of the Resident Advisory Council Agenda and Minutes dated 03/07/2025 revealed the following, . dietary still have some concerns Record review of the facility's policy labeled Food Handling, revised June 2019, revealed the following documentation, Policy: to ensure that all food served by the facility is of good quality and safe for consumption

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 7 of 12 residents (Residents #3, #28, #46, #40, #62, #6 and #10) reviewed for infection control. 1. MA A failed to sanitize the blood pressure cuff between resident use for Resident #3 and Resident #28. 2. LVN B failed to utilize hand hygiene between glove changes during wound care on Residents #46, #40, and #62. 3. LVN B failed to utilize enhanced barrier precautions during wound care for Residents #46, #40 and #62. 4. LVN A failed to utilize hand hygiene between residents during medication administration for Resident #6 and Resident #10. These failures could place residents at risk for cross contamination and infection. The findings include: During a medication administration observation on 3/12/2025 at 7:34 AM, MA A used the blood pressure cuff to take Resident #3's blood pressure. At 7:43 AM, MA A used the same blood pressure cuff to take Resident #28's blood pressure. No sanitation of equipment was conducted before or after using the blood pressure cuff on Resident #28 or Resident #3. Record review of Resident #62's care plan revealed Problem: I require enhanced barrier precautions due to the following: I am at increased risk of a MDRO acquisition due to having a wound . Approach Start Date: 11/05/2024 .Staff will wear PPE during high-contact activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, incontinent care, wound care of any type requiring a dressing. Record review of Resident #62's physician orders revealed a wound care order dated 1/28/2025 for LLE Vascular Ulceration Clean with Normal Saline/Wound Cleanser pat dry Calcium Alginate and cover with silicone superabsorbent dressing Daily and PRN in the event of dislodgement. During a wound care observation on 3/12/2025 at 8:47AM, LVN B failed to follow the enhanced barrier precaution signs outside Resident #62's door and did not don PPE gear prior to starting wound care. LVN B removed the dirty dressing to Resident #62s left leg and doffed dirty gloves. LVN B donned cleaned gloves without performing hand hygiene between the glove change. LVN B failed to change gloves after cleaning the wound on Resident #62's left leg and opened the wound supplies with dirty gloves. LVN B dressed Resident #62's left leg without changing gloves or performing hand hygiene. During a medication administration observation on 3/12/25 at 8:59 AM, LVN A prepared morning medications for Resident #6. LVN A entered the resident room and administered the prepared medications to Resident #6. LVN A returned to the medication cart and prepared morning medications for Resident #10 without performing hand hygiene. LVN A entered the resident room and administered the prepared medications to Resident #10. Record review of Resident #46's care plan revealed Problem start date 03/09/2025: I require enhanced barrier precautions due to the following: I am at increased risk of a MDRO acquisition due to having a wound . Approach Start Date: 3/09/2025 .Staff will wear PPE during high-contact activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, incontinent care, wound care of any type requiring a dressing. Record review of Resident #46's physician orders revealed a wound care order dated 3/07/2025 for Wound Treatment Order: Location: coccyx Clean with Normal Saline/Wound Cleanser Place calcium alginate and cover daily and a physician order dated 2/26/2026 for Wound Treatment Order: Location: right ischium Clean with Normal Saline/Wound Cleanser Apply: petroleum gauze Cover with Primary Dressing: bordered gauze. During a wound care observation on 3/12/2025 at 9:00AM, LVN B failed to follow the enhanced barrier precaution signs outside Resident #46's door and did not don PPE gear prior to starting wound care. LVN B removed Resident #46's dirty dressing to right hip and coccyx. LVN B doffed dirty gloves and donned clean gloves without performing hand hygiene between the glove change. LVN B cleaned right hip wound and doffed dirty gloves, and donned clean gloves without performing hand hygiene between the glove change. LVN B dressed right hip and doffed dirty gloves. LVN B donned clean gloves without performing hand hygiene between the glove change. LVN B cleaned coccyx wound and doffed dirty gloves. LVN B donned clean gloves without preforming hand hygiene between the glove change. Record review of Resident #40's care plan revealed Problem start date 10/28/2024: I require enhanced barrier precautions due to the following: I am at increased risk of a MDRO acquisition due to having a wound . Approach Start Date: 10/28/2024 .Staff will wear PPE during high-contact activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, incontinent care, wound care of any type requiring a dressing. Record review of Resident #40's physician orders revealed a wound care order dated 12/20/2024 Wound Treatment Order Right hip Clean with Normal Saline/Wound Cleanser Apply calcium alginate Cover and a physician order dated 12/20/2024 Wound Treatment Order: Location: right thigh Clean with Normal Saline/Wound Cleanser Apply: calcium alginate Cover with Primary Dressing: foam dressing During a wound care observation on 3/12/2025 at 9:14 AM, LVN B failed to follow the enhanced barrier precaution signs outside Resident #40's door and did not don PPE gear prior to starting wound care. LVN B removed Resident #40's dirty dressings to right hip and right thigh. LVN B doffed dirty gloves and donned clean gloves without performing hand hygiene between the glove change. LVN B cleaned Resident #40's nonhealing surgical wound and doffed dirty gloves, and donned clean gloves without performing hand hygiene between the glove change. LVN B dressed Resident #40's right hip wound and doffed dirty gloves. LVN B donned clean gloves without performing hand hygiene between the glove change. LVN B cleaned Resident #40's right thigh wound and doffed dirty gloves. LVN B donned clean gloves without performing hand hygiene between the glove change and finished dressing Resident #40's right thigh wound. During an interview on 3/12/25 at 9:24 AM with LVN A, she stated she did not sanitize her hands between Resident #6 and Resident #10 while performing medication pass because she got in a hurry. She stated she had been trained in her nursing education to perform hand hygiene before and after contact with a resident and before handling medications. LVN A stated a potential negative outcome of failure to perform hand hygiene during medication pass was that a resident could get sick from cross-contamination. During an interview on 3/12/2025 at 9:45 AM with LVN B, she stated she had been at the facility for two weeks. She stated she had not received formal training on wound care, infection control or handwashing at this facility but she had training previously in her nursing career. She stated she was aware she needed to wash her hands between glove changes but was nervous and forgot. She stated she was not aware she needed to utilize EBP on residents with wounds. She stated she did see the signs outside of Resident #40, #46 and #62's rooms but did not see that it stated wound care as a reason for utilizing EBP. She stated handwashing is the most important part of infection control. She stated her infection preventionist was the DON. She stated she had infection control training in her nursing career. During an interview on 3/13/2025 at 11:08 AM with MA A, she stated she had been trained on infection control and her last training was sometime last year. She stated she had been trained to clean her equipment after each use and between residents. She stated she was aware she didn't do that after administering medication, but she had been nervous and had forgotten. She stated the potential negative outcome would be spreading infection between residents. During an interview on 3/13/25 at 10:42 AM with the DON, he stated staff had been trained on proper hand hygiene during medication pass. He stated hand hygiene should be performed prior to contact with a resident and after the administration of medications. He stated staff were trained on hand hygiene during medication pass through competency checks and rounds conducted by nursing administration. The DON stated his expectation of staff was to follow hand hygiene protocol during resident care. He stated a potential negative outcome for failure to properly sanitize hands during medication administration was the spread of infection. During a second interview on 3/13/2025 at approximately 12:15 PM with the DON, he stated he was the infection preventionist. He stated there was a hand hygiene training done about a month ago and the last infection control training had been the annual competencies. He stated staff had been trained on EBP and the last training would be in the competencies but was unsure of the date. The DON stated EBP was utilized for residents that have wounds, invasive tubes such as urinary catheters. He stated EBP is used to minimize the risk of infection between residents. He stated the potential negative outcome of staff not utilizing EBP could be the transfer of bacteria from one resident to the next. He stated his expectation of staff was for hand hygiene to occur between glove changes. He stated the potential negative outcome of not utilizing hand hygiene between glove changes could be transferring bacteria from one resident to the next. The DON stated staff had been trained to clean equipment between resident use. He stated the potential negative outcome of not cleaning the equipment could be spread of infection and germs. The DON stated compliance with infection control was monitored by doing walking rounds and ensure they are doing their handwashing. He stated he has done spot checks where he observed the staff perform incontinence care or wound care. He stated they also had a trainer and educator who would assist with the staff training. During an interview on 3/13/25 at 11:12 AM with the ADM, he stated was not aware that staff were not following protocol for hand hygiene during medication administration. He stated it was the responsibility of the DON to assure staff were trained on hand hygiene during medication administration. He stated his expectation of staff was to assure hand hygiene was performed at the correct times and according to policy. The ADM stated a potential negative outcome for failure to perform hand hygiene during medication administration was spreading infection. During a second interview on 3/13/2025 at approximately 12:55 PM with the ADM, he stated the DON was the infection preventionist. He stated staff have been trained on EBP. He stated EBP was used on residents who have wounds, dialysis ports, feeding tube or catheters. He stated they were used to prevent the spread of infection and the negative outcome of not following the EBP could be the spread of infection. The ADM stated staff should be utilizing hand hygiene after removing their gloves. He stated the potential negative outcome of not performing hand hygiene could be the spread of infection. He stated the wound care nurse had been trained on EBP and hand hygiene. The ADM stated staff had been trained to clean the equipment between resident use. He stated they needed to use the disinfecting wipes. He stated the potential negative outcome of not cleaning the equipment between resident use could be the spread of infection. The ADM stated the DON monitors compliance with infection control practices. Record review of facility policy titled Handwashing/Hand Hygiene last revised 1/20/2023 revealed: This facility considers hand hygiene the primary means to prevent the spread of infections. . 5. Hand hygiene must be performed prior to donning and after doffing gloves. 6. Hand hygiene is the final step after removing and disposing of personal protective equipment. Record review of facility policy titled Enhanced Barrier Precautions last revised 4-1-2024 revealed: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistance organisms . b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) . 4. High-contact resident care activities include .h. Wound care: any skin opening requiring a dressing. Record review of facility policy titled Cleaning and Disinfection of Resident-Care Equipment undated, revealed: Policy: Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection . Reusable multiple-resident items are items that may be used multiple times for multiple residents. Examples include stethoscopes, blood pressure cuffs, feeding tube pumps, and oxygen concentrators. b. Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident. Record review of the facility policy titled Specific Medication Administration Procedures, last revised January 2018 revealed: Policy To administer medication in a safe and effective manner. Procedures F. Cleanse hands using antimicrobial soap and water or facility-approved hand sanitizer before beginning a med pass, before handling medication, and before contact with resident. . O. When finished with each resident, wash hands with antimicrobial soap and water or use facility-approved hand sanitizer. 49305

Based on observation, interview and record review, the facility failed to ensure the rights of the residents to be free from abuse and neglect for 3 of 6 residents (Resident #1, #2, and #3) reviewed for abuse A. The facility failed to keep Resident #2 safe from abuse when Resident #1 pulled her out of bed after already exhibiting increased aggressive behavior on 11/14/24. B. The facility failed to keep Resident #3 safe from abuse when Resident #1 grabbed her in the face after already exhibiting increased aggressive behavior on 11/14/24. C. The facility failed to keep Resident #1 safe from an unknown nighttime staff when allegations of abuse was made on 11/23/24 by Resident #1 and Family Member M to CNA A, C, the Assistant Activity Director, LVN B and a confidential individual. An Immediate Jeopardy (IJ) was identified on 11/27/24 at 12:49 PM. The IJ template was provided to the facility on [DATE] at 12:49 PM. While the IJ was removed on 11/27/24 at 1:28 PM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern because all staff had not been trained on 11/27/24. This failure could place residents at risk for serious psychosocial harm from abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Resident #1 Record Review of Resident #1's face sheet, dated 11/22/24, revealed an [AGE] year-old male that was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss). Record Review of Resident #1's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 00, indicating the resident was severely cognitively impaired. Section E revealed Resident #1 exhibited physical behavior (hitting, kicking, pushing, scratching, grabbing, and abusing) during the review [E0200]. The identified symptoms placed the resident at significant risk for physical illness or injury [E0500]. The identified symptoms placed others at risk for physical injury, significantly intruded on the privacy or activity of others, and significantly disrupted care or living environment. Record review of Resident #1's progress notes dated from 09/22/24- 11/22/24 revealed the following: The Social Worker documented on 11/14/24 at 6:35 PM that she received a message from staff (unidentified) that a staff (unidentified) was punched in the face. LVN N documented on 11/14/24 at 8:30 PM that Resident #1 hit the day certified nursing aide (unidentified) in the face and opened a skin tear on both arms. LVN N documented on 11/14/24 at 8:40 PM that Resident #1 was becoming agitated again, hit a certified nursing aide (unidentified) in the chest. Resident #1 was pacing and yelling in intervals. Record review of Resident #1's care plan, dated 11/22/24, revealed a focused area, initiated on 11/22/24, Resident #1 had a history of aggressive behavior towards others. The goal initiated on 11/22/24, was Resident #1 would have fewer than 3 episodes of aggressive behavior before the next review date. The interventions initiated 11/22/24 included keeping the environment calm, relaxed, convey acceptance of the resident during periods of inappropriate behavior, remove from public area when behavior was unacceptable, and to ask for help when his behavior becomes unacceptable. Record review of the facility event summary report, dated 08/26/24-11/26/24, revealed the following: Resident #1 had aggressive/combative resident-to-resident aggression on 11/16/24 and 2 unwitnessed falls on 11/23/24. Record review of the facility event summary report dated 08/26/24-11/26/24, did not reveal any documentation regarding his resident-to-resident altercation that occurred on 11/14/24 with Resident # 2 and Resident #3. Record review of Resident #1's hospice progress notes did not reveal any information about Resident #1's and Family Member B's allegation of ANE. There was no information regarding Resident #1's resident-to-resident altercation with Resident #2 (pulling her out if bed). There was no information regarding Resident #1's resident-to-resident altercation with Resident # (grabbing her in her face). The notes did reveal the following: On 11/23/24 at 5:39 AM a call was placed by LVN N to hospice requesting a nurse visit. The progress note indicated that LVN N stated Resident #1 rolled out of bed and had an abrasion to his right eyebrow, a cut on his lip and a skin tear to the bridge of his nose. On 11/23/24 Hospice Nurse T assessed Resident #1. Hospice Nurse T observed Resident #1's nose and lower swollen. She observed steri strips to the face and nose. State surveyor attempted to interview LVN N on 11/27/24 at 8:34 AM and the attempt was unsuccessful. State surveyor left a message. During an interview on 11/26/24 at 9:30 AM, the Regional Nursing Consultant stated during the entrance conference that an injury of unknown origin or bruising should be investigated and reported to HHSC. She said if the bruising could be explained, a progress note would be entered by the nurse who identified the bruising and explain where the bruising came from. She said all efforts would be documented in the resident's electronic medical record. During an interview on 11/26/24 at 10:00 AM, Family Member M stated she was told by facility staff that Resident #1 had told them a nighttime staff had hit him the weekend off 11/23/24 and that she was notified that Resident #1 had a fall. She said she did not know the full name of the staff who reported this information to her nor did she know the name of the staff that allegedly hit Resident #1. She said Resident #1 told her that a woman had hit him. She said the same staff reported that another female resident had hit Resident #1. She said she did not tell anyone specifically about what the facility staff and Resident #1 told her, but that staff knew because she (Family Member M) was vocal about it. A confidential interview revealed that Resident #1 had a fall the weekend of 11/23/24. They said they could not remember if it was a Friday or a Saturday. They said when they came to work, Resident #1 was quiet and not as active as he once was. They said that Resident #1 gestured with his hand that staff had hit him on top of the head. They asked Resident #1 if it was an overnight staff that had hit him, and Resident #1 stopped answering questions when they started asking for details. They stated Family Member M had expressed in the past that she did not feel that the overnight staff were taking care of Resident #1. They said the weekend that they came in for their shift, and Resident #3 allegedly fell he (Resident #1) did have a cut on his eye and his lip. They said when they attempted to get Resident #1 up for breakfast, Resident #1 was sleepy, and she had to get a wheelchair to roll him to the table. They said they did not know if this was from the fall. They stated that the morning Resident #1 fell , a hospice nurse (unknown) and LVN B were assessing Resident #1. They said the hospice nurse (unknown) said the injuries that Resident #1 sustained were not consistent with a fall. They said that the hospice nurse (unknown) did not say what specifically the injuries looked like they came from. They stated that the same day, Resident #1 did not eat. They said when Resident #1 told them that he had been hit by staff, they told CNA A. They said CNA A told them the injuries looked like injuries from a fall, and CNA compared Resident #1 to another resident with a similar fall. They said that Family Member M told them that Resident #1 had expressed to her that he had been hit by night staff. They said that they did not report the allegations that Resident #1 reported to them nor the concerns that Family Member M reported to them because their phone was not working. They stated they did not use the facility phone because the on-call staff never answered the phone when they called from the facility phone. They said the previous day, they had tried to call the on-call phone from the facility for a staffing concern, and the staff did not answer. They said they had been trained to call the ADM, who was the abuse coordinator if they witnessed or suspected ANE. They said they had been taught to contact the abuse coordinator immediately. They said that they did not contact the ADM, who was the abuse coordinator, because it was the weekend. They said they could not remember if they reported the allegations of ANE to LVN B, but the nurse typically does not stay in the locked unit. They said they did mention the accusations of ANE regarding Resident #1 to the Assistant Activity Director. They said no one had asked them anything about the nature of the fall. During an interview on 11/26/24 at 3:06 PM, CNA A stated that she did not know much about the fall that occurred on 11/23/24 involving Resident #1. They said CNA O told her that Resident #1 had an unwitnessed fall when she came on shift. She said CNA O told her that LVN N was helping her do rounds and change residents. She said CNA O said that she and LVN N had come out of Resident #1's room, and he had fallen. CNA A said she did not remember a staff member telling her that Family Member M had concerns about the injuries, but that Family Member M did express to her that she had concerns about the injuries that Resident #1 sustained. CNA A said that when Family Member M said that she did not think the injuries were consistent with a fall, she encouraged Family Member M to talk to LVN B because as a certified nurse aide she had been trained to refer family concerns to her nurse. CNA A said Resident #1's face was beat up. She said Resident #1 had steri-strips (reinforces skin closure) all over his face. She said he had a busted lip and a cut by his eye. CNA A said she was unaware of Resident #1 having any physical altercations with female residents where he was not the aggressor. CNA A said Resident #1 was aggressive, and all staff knew about it, which had been reported to management. CNA A said Resident #1 had punched her in the face. She said she could not remember the exact date but that it was documented in Resident #1's progress notes. She said they did not receive any instructions on handling Resident #1. She said she felt if his behaviors had been addressed, his behaviors wouldn't have continued to escalate. She said no one had interviewed her regarding Resident #1's behaviors or Family Member M's allegations. CNA said that she had been trained to report ANE as soon as possible to the ADM. During an interview on 11/26/24 at 3:55 PM, the Assistant Activity Director stated that she had experience with Resident #1 and his aggressive behavior. She said when Resident #1 had his resident-to-resident altercation on 11/16/24, she was assisting taking him out of the memory unit to calm down. She said Resident #1 saw an exit door and attempted to exit. She said she tried to redirect him, but he grabbed her hair and pulled it. She said they ultimately got him back to the unit. She said that Resident #1 punched another staff member in the face before that incident. She said she had not received any training specific to Resident #1 on responding to his aggressive behaviors. She said on Saturday, 11/23/24, she went into the memory unit and noticed Resident #1 was at the dining room table with his head down. She thought this was odd because Resident #1 was usually up and pacing around. She said CNA P told her that Resident #1 had fallen. She said she had asked if Family Member M had been notified and was told that attempts had been made, but they were unsuccessful because Family Member M's phone was off. The Assistant Activity Director said that later in the day (11/23/24), Family Member M came to the facility and said to her that Resident #1 reported to her (Family Member M) that someone came into his room at night and hit him. She said it was around lunchtime when she (Family Member M) told her that Resident #1 made the allegation. The Assistant Activity Director stated she told the aides (she did not disclose who) that were working the memory unit and that the aides said that it looked like someone hit Resident #1. She said she told the aides to get a nurse to explain Resident #1's injuries to Family Member M. She said the nurse (LVN B) told Family Member M it was a fall, and it was documented. The Assistant Activity Director told LVN B that Family Member M thought someone had beaten Resident #1 up. She was told that the documentation reflected that Resident #1 had a fall. The Assistant Activity Director said the abuse coordinator was the SW. She said she did not report the allegations of abuse to the SW because the SW was not at the facility. She said she had been trained on what to do if they suspect or witnessed abuse. She said that she had been taught to call the ADM. She said that she did not report the allegations of ANE to the ADM because she was not there when the incident allegedly happened. She said no one had interviewed her to ask her about her knowledge of the incident regarding allegations of abuse. She said she was unaware of any physical altercations that involved Resident #1. During an interview on 11/26/24 at 8:20 PM, LVN B stated the abuse coordinator was the ADM. She stated she had ANE training. She said she had been trained that if she witnessed or suspected abuse, she needed to report the allegation to the ADM as soon as possible. She said that on the day (11/23/24), Resident #1 fell on the overnight shift. He had also fallen on her shift (a day shift). She said CNA A said that she had found Resident #1 on the floor. She said she assessed Resident #1 and called Hospice out for assistance. She said she notified Family Member M. Family Member M was upset because Resident #1 had fallen on the overnight shift. LVN B said it was around 1:00 PM when Resident #1 had fallen on her shift. LVN B said she did not have details about Resident #1's first fall. She said Family Member M was upset. She said that she could tell by her body language but that she was speaking in Spanish to CNA A. LVN B said it was relayed to her from CNA A that Family Member M did not believe the lacerations, cuts, and gashes had come from a fall and that he looked like he had been punched. She said Resident #1 had a history of falls. LVN B said she did not report the allegations that CNA A had translated from Family Member B to the ADM because Family Member B was concerned with the overnight fall. She (LVN B) was sure that Resident #1 did not get punched on her shift, and that Family Member M said she would take Resident #1 home. She said that she was told that Resident #1 had a history of falls, according to the hospice nurse who came out and was not sure why Resident #1's falling was an issue. LVN B said she was unaware that Resident #1 had any physical altercations with female residents in the locked unit. She said Resident #1 never said he had been hit by staff when she interacted with him. She said she was unaware of any incidents that involved Resident #1 and other female residents. She said that since his admission, she had never received any training on how to deal with Resident #1's aggressive behavior. She said she had never been interviewed regarding Resident #1's behaviors or the allegations of ANE. She said the potential negative outcome of not reporting allegations of ANE to the abuse coordinator was that the abuse could continue. She said Resident #1 had told her that he fell . She said she documented what happened during her shift but did not document the information regarding Family Member M because she knew no one punched Resident #1 on her shift. She said that although it may sound silly, she felt that Family Member M wanted to take Resident #1. During an interview on 11/26/24 at 8:25 AM, Hospice Nurse S did not provide any information that supports the facility's deficient practice. She reported that she did not have any concerns with staff treatment, nor did she suspect or witness ANE. She was unaware of any allegations that Family Member M made. She said that she was the nurse who came out when he had behaviors on 11/14/24. She said there were discussions to send him to a behavioral center, but it was decided and, in her opinion, not beneficial for Resident #1 because of his diagnosis of dementia. She said she never said that his injuries were inconsistent with a fall. During an interview on 11/26/24 at 8:38 AM, Hospice Nurse T did not provide any information that supports the facility's deficient practice. She reported that she did not have any concerns with staff treatment, nor did she suspect or witness ANE. She was unaware of any allegations that Family Member M made. She said she came out on 11/23/24 when Resident #1 had his 2nd fall; this was her first time meeting Resident #1. She said that she never expressed that she felt that Resident #1's injuries were inconsistent with any of his falls. During an interview on 11/27/24 at 9:30 AM, CNA C stated that she did not know any details about Resident #1's fall on 11/23/24. She said she heard about Resident #1 punching CNA A but knew nothing about that incident. She said she knew that Resident #1 had been aggressive since he came to the facility. She said she heard that Resident #1 had a broken nose and that someone had been hitting him on top of the head. She said she heard it was a nighttime staff that was hitting him. She said she was told this on 11/26/24 by CNA A. She said she did not report what CNA A told her to the abuse coordinator because she was told that it had already been reported to the state. She said she had no proof that the allegation of ANE had been reported but was told that was why the state was in the facility. She said she had been trained that all allegations of abuse should be reported to the abuse coordinator as soon as possible. She said she received abuse training within the last year when she took her CNA classes. She said the potential negative outcome of not reporting allegations of abuse could allow abuse to continue. During an interview on 11/27/24 at 9:23 AM, the ADM stated he was unaware of Family Member M's allegations of abuse. He said none of the incidents were investigated because he was unaware of the incidents. Preventive measures were not put in place to protect Resident #1 after the allegations of abuse because he was unaware of the incident. He was unaware that Resident #1 had aggressive behaviors before admission. He said that there were discussions about sending Resident #1 to a behavior facility, but after consulting with Hospice, it was recommended by Hospice that pharmaceutical attempts should be taken first. Regarding the injury of unknown origin, he said he was unaware of the injury and that the staff did not know where it came from. He said this was not reported to him. Resident #2 Record Review of Resident #2's face sheet, dated 11/27/24, revealed an [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted on [DATE], with the following diagnoses: dementia (memory loss), anxiety (increased worry), and cognitive communication (difficulty communicating). Record Review of Resident #2's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score was blank. Section E did not reveal any documented behaviors for Resident #2. Record Review of Resident #2's Brief Interview for Mental Status (BIMS) dated 11/27/24 revealed the summary score was 99, indicating the resident was severely cognitively impaired. Record Review of Resident #2's Quarterly MDS assessment dated [DATE], revealed under Section E did not reveal any documented behaviors for Resident #2. Record review of Resident #2's care plan, dated 08/22/24, revealed a focused area, initiated on 10/01/24, that indicated Resident #2 had socially inappropriate/disruptive behaviors as evidenced by abusing the staff. The goal initiated on 10/31/24, Resident #2 will not harm self or others. The interventions initiated 10/01/24 included assessing the resident for placement, assess whether the behavior endangers the resident and others, avoid over stimulation, praise for acceptable behavior, and maintain a calm environment. Record review of Resident #2's progress notes dated from 08/27/24- 11/27/24 did not reveal any information regarding her resident-to-resident altercation on 11/14/24 with Resident #1. Record review of the facility event summary report dated 08/26/24-11/26/24, did not reveal any documentation regarding his resident-to-resident altercation that occurred on 11/14/24 with Resident #2 and Resident #1. Record review of Resident #2 EMR did not reveal any assessments conducted on 11/4/24. During an interview on 11/26/24 at 9:07 AM Family Member R stated they did not have any concerns with the treatment of Resident #2. She said she did not get to visit often. She said that she has not received any notifications of ANE. She said she only received notification when Resident #2 had fallen or if they had sent Resident #2 out to the hospital. She said no incidents involving Resident #2 and any of her peers had been reported to her. During an interview on 11/26/24 at 3:06 PM, CNA A stated she had been trained on what to do if she suspected or witnessed abuse. She stated she had been instructed to report all allegations of ANE to the ADM, who was the abuse coordinator, as soon as she suspected or witnessed abuse CNA A said she was unaware of Resident #1 having any physical altercations with female residents where he was not the aggressor. CNA A said Resident #1 was aggressive, and all staff knew about it, which had been reported to management. CNA A said Resident #1 had punched her in the face. She said she could not remember the exact date but that it was documented in Resident #1's progress notes. She said on the same day he punched her in the face, Resident #1 had increased behaviors. She said she heard Resident #2 yelling. When she walked into Resident #2's room, she observed Resident #1 attempting to pull Resident #2 out of bed. She said Resident #2's bed was lowered to the floor with a bedside mat next to it. She said she observed Resident #1 standing on the mat next to Resident #2's bed, and he had her by her (Resident #2's) legs. CNA said that Resident #2 was screaming, and Resident #1 was accusing them (staff) of restraining Resident #2 and that he would call the police. CNA A said she attempted to redirect Resident #1, but he tried to hit her. She said she blocked the first hit from Resident #1. She said he then tried to grab the fire extinguisher and said he would hit her. She said Resident #1 grabbed a chair, and because other residents were close, she went to grab the chair from him. She said that when she got the chair from him, and she was putting it down, Resident #1 hit her hard in the face, and she started crying. She said that on the same date that Resident #1 hit her he also tried to pull Resident #2 out of bed. She said the Former DON wanted to send Resident #1 to a behavior center but was told by the ADM that they wanted to try other things. She said she told the ADM that Resident #1 and the other residents in the locked unit were not safe. She said she did tell the ADM about Resident #1 hitting her and pulling Resident #2 out of bed. CNA A said she was unsure if a nurse physically assessed any of the residents because she was told to go home and leave. She said they did not receive any instructions on handling Resident #1. She said she felt if his behaviors had been addressed, his behaviors wouldn't have continued to escalate. She said no one had interviewed her regarding Resident #1's behaviors or his interactions with Resident #2. She said she was alone in the memory unit during the time the incident occurred. During an interview on 11/26/24 at 4:30 PM, the SW stated she was not present when Resident #1 grabbed Resident #3 in the face. She said that she was notified by staff but did not remember the staff who reported the information. She stated she had never observed Resident #1 grab anyone but had observed Resident #1 being redirected. During an interview on 11/27/24 at 9:30 AM, CNA C stated that she said she knew that Resident #1 had been aggressive since he came to the facility. She said she did not see the incident but had heard about Resident #1 trying to pull Resident #2 out of bed because he thought she (Resident #2) shouldn't have been in bed. She was unsure of the date of the incident. CNA C said she was unaware if Resident #1 actually made contact with Resident #2. She said no one ever interviewed or asked about the resident-to-resident altercation between Resident #1 and Resident #2. During an interview on 11/27/24 at 9:23 AM, the ADM stated he was unaware of an incident where Resident #1 tried to pull Resident #2 out of bed. He said none of the incidents were investigated because he was unaware of the incidents. He said no preventative measures were put in place to safeguard Resident #2 from Resident #1. During an interview on 11/27/24 at 1:05 PM, Resident #2 was unable to answer any questions about the alleged incident between her and Resident #1. She turned her head and refused to speak. Resident #3 Record Review of Resident #3's face sheet, dated 11/27/24, revealed an [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of dementia (memory loss), anxiety (increased worry), and cognitive communication deficit (difficulty communicating). Record Review of Resident #3's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 03, indicating the resident was severely cognitively impaired. Section E did not reveal any documented behaviors for Resident #3. Record Review of Resident #3's Quarterly MDS assessment dated [DATE], revealed under Section E did not reveal any documented behaviors for Resident #3. Record review of Resident #3's progress notes dated from 08/27/24- 11/27/24 did not reveal any information regarding her resident-to-resident altercation on 11/14/24 with Resident #1. Record review of Resident #3's care plan, dated 06/12/24, revealed a focused area, initiated on 10/01/24, Resident #3 had physically abusive behavior symptoms. The goal initiated on 11/06/24, was Resident #3 would not physically abuse other residents, visitors, and staff. The interventions initiated 10/01/24 included assess whether the resident's behavior endangers the resident or others, convey an attitude of acceptance towards the resident, maintain a calm environment, and allow extra time to process information. Record review of the facility event summary report dated 08/26/24-11/26/24, did not reveal any documentation regarding his resident-to-resident altercation that occurred on 11/14/24 with Resident #1. Record review of Resident #3 EMR did not reveal that any assessments were conducted on 11/14/24. During an interview on 11/26/24 at 3:06 PM, CNA A stated Resident #1 had punched her in the face. She said she could not remember the exact date but that it was documented in Resident #1's progress notes. She said on the same day he punched her in the face, Resident #1 had increased behaviors. She said that on the same date that Resident #1 hit her in the face, he grabbed Resident #3 in the face. She said the ADM and the SW were present when Resident #1 grabbed Resident #3 in the face. She said Resident #1 did it so fast that she could not intervene. She said Resident #3 exclaimed, Why did he do that? She said the Former DON wanted to send Resident #1 to a behavior center but was told by the ADM that they wanted to try other things. She said she told the ADM that Resident #1 and the other residents in the locked unit were not safe. She said she did not tell the ADM about Resident #1 grabbing Resident #3 in the face because he was present when Resident #1 grabbed Resident #3 in the face. CNA A said she was unsure if a nurse physically assessed any of the residents because she was told to go home and leave. She said they did not receive any instructions on handling Resident #1. She said she felt if his behaviors had been addressed, his behaviors wouldn't have continued to escalate. She said no one had interviewed her regarding Resident #1's behaviors or his interaction with Resident #3. CNA A said that she was the only staff in the memory unit when the incidents occurred. During an interview on 11/27/24 at 9:23 AM, the ADM stated he said he was unaware of an incident where Resident #1 grabbed Resident #3 in the face. He said none of the incidents were investigated because he was unaware of the incidents. He said no preventative measures were put in place to safeguard Resident #3 from Resident #1. During an interview on 11/27/24 at 1:17 PM, Resident #3 stated she could not remember the date or the name of the male resident who grabbed her in the face. She said it hurt. She said that the male resident was no longer in the facility, and she was glad because him grabbing her scared her. She said she did not know why he grabbed her, but he was mean. During an interview on 11/27/24 at 9:23 AM, the ADM stated that regarding resident-to-resident altercations, he expected staff to separate them and ensure the residents were calm and safe. He said they should immediately notify the abuse coordinator. He said the potential negative outcome is that if steps were missed or done out of order, something could happen to the residents or escalate the incidents. He said not reporting resident-to-resident altercations or handling them appropriately could cause an inability for barriers and interventions to be put in place to protect residents. He said if an incident occurs on the weekend, the staff should respond the same. He said there was an on-call system that staff have been trained to use, but unfortunately, the phone was with a staff that no longer worked at the facility. He said the on-call telephone had just been returned to the facility on [DATE]. He said his phone number was posted everywhere, so staff still should be able to reach him, and he would answer phone calls from the facility. He said staff have been trained to send a text and to keep calling if they do not get an answer. He said he had no documentation to reflect the staff training to keep calling if they do not get an answer. He said he verbalized this in ANE training. He said if there was an allegation of ANE, notifications should be made to the physician, abuse coordinator, and the police if actual abuse occurred. He said the potential negative outcome of not following the abuse policy could be that interventions could not be put in place to protect the residents and prevent abuse. He said residents should be assessed by a nurse for mental concerns and physical injuries. He said if residents were not assessed, there could be an untreated mental concern or untreated issue. He said that an investigation should be conducted if there were abuse allegations. He said the failure to conduct investigations of ANE could prevent them from knowing how something occurred and what occurred and hurt the ability to prevent abuse from happening again. He said prevention measures should be put in place. He said that the aggressor should be monitored depending on the situation and that no additional aggressive behavior should be allowed. He said he was the abuse coordinator, and all things (allegations of ANE and resident-to-resident altercations) should be reported to him within an hour or as soon as possible. He said allegations of abuse, resident-to-resident altercations, assessments, and notifications to the family should be documented. He said the nurse working on the incident would be responsible for documentation, assessments, and notifications. He said he, as the abuse coordinator, was responsible for investigating and reporting to HHSC. On 11/27/24 at 12:49 PM an IJ situation was identified due to the above failures and the IJ template was provided. The following Plan of Removal submitted by the facility was accepted on 11/27/24 at 2:30 PM: Plan of Removal: F607: Develop/Implement Abuse/Neglect, etc. Policies 1. Immediate A [TRUNCATED]

Based on interviews and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect for 3 of 6 residents (Resident #1, #2, and #3) reviewed for abuse. A. The ADM failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC and documenting his investigation/prevention measures regarding Resident #1 by an unknown nighttime staff on 11/23/24 . CNA A, C, the Assistant Activity Director, LVN B, and a confidential individual failed to follow the facility's abuse policy by not reporting the allegation of abuse involving Resident #1, reported by Resident #1 and Family Member M on 11/23/24 to the abuse preventionist between the dates of 11/23/24-11/27/24. B. The ADM failed to follow the facility's abuse policy by not reporting the incident to HHSC and investigating an injury of an unknown origin involving Resident #1 that occurred and that was documented on 11/11/24. C. The ADM failed to follow the facility's abuse policy by not reporting the resident-to-resident altercation (Resident #1 attempted to pull Resident #2 out of bed) that occurred on 11/14/24 between Resident #1 and Resident #2 to HHSC and documenting his investigation/prevention measures regarding Resident #2. D. The ADM failed to follow the facility's abuse policy by not notifying Family Member R of the resident-to-resident altercation (Resident #1 attempted to pull Resident #2 out of bed) that occurred on 11/14/24 between Resident #1 and Resident #2. E. The ADM failed to follow the facility's abuse policy by not assessing Resident #2 for mental and physical effect after the resident-to-resident altercation (Resident #1 attempted to pull Resident #2 out of bed) that occurred on 11/14/24 between Resident #1 and Resident #2. F. The ADM failed to follow the facility's abuse policy by not reporting the resident-to-resident altercation (Resident #1 grabbed Resident #3 in the face) that occurred on 11/14/24 between Resident #1 and Resident #3 to HHSC and documenting his investigation/prevention measures regarding Resident #3. G. The ADM failed to follow the facility's abuse policy by not assessing Resident #3 for mental and physical effect after the resident-to-resident altercation (Resident #1 grabbed Resident #3 in the face) that occurred on 11/14/24 between Resident #1 and Resident #3. An Immediate Jeopardy (IJ) was identified on 11/27/24 at 12:49 PM. The IJ template was provided to the facility on [DATE] at 12:49 PM. While the IJ was removed on 11/27/24 at 1:28 PM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern because all staff had not been trained on 11/27/24. These failures could place residents as risk for abuse and neglect. Findings included: Record review of the facility policy, Abuse Investigation and Reporting, revised October 2023 revealed: Policy Statement The facility will provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Policy Interpretation and Implementation The facility will develop and implement written policies and procedures that: o Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; and o Establish policies and procedures to investigate any such allegations; and The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. The facility will provide ongoing oversight and supervision of staff to ensure that its policies are implemented as written. Abuse Prohibition Plan Components II. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; C. Ensuring an assessment of the resources needed to provide care and services to all residents is included in the facility assessment; G. Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur; and H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. III. Identification of Abuse, Neglect and Exploitation The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations. Possible indicators of abuse include, but are not limited to: 1. Resident, staff, or family report of abuse; 2. Physical marks such as bruises or patterned appearances such as a handprint, belt, or ring mark on a resident's body; 3. Physical injury of a resident, of unknown source; IV. Investigation of Alleged Abuse, Neglect and Exploitation An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include: o Identifying staff responsible for the investigation; o Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); o Investigating different types of alleged violations; o Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; o Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and o Providing complete and thorough documentation of the investigation. V. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: Responding immediately to protect the alleged victim and integrity of the investigation; Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; Increased supervision of the alleged victim and residents; Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; Protection from retaliation; VI. Reporting/Response The facility will have written procedures that include: o Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; Defining how care provision will be changed and/or improved to protect residents receiving services; Training of staff on changes made and demonstration of staff competency after training is implemented; Identification of staff responsible for implementation of corrective actions; The expected date for implementation; and Identification of staff responsible for monitoring the implementation of the plan. B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. Management 1. The resident and family/representatives will be informed of the resident's condition as well as the potential risks and benefits or proposed interventions. 2. Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities. 3. Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. The care plan will include, as a minimum: a. A description of the behavioral symptoms, including: (1) Frequency; (2) Intensity; (3) Duration; (4) Outcomes; (5) Location; (6) Environment; and (7) Precipitating factors or situations. 4. Non-pharmacologic approaches will be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms. 5. The Director of Nursing, or designee, will evaluate whether the staffing needs have changed based on acuity of the residents and their plans of care. Additional staff and/or staff training will be provided if it determined that the needs of the residents cannot be met with the current level of staff or staff training. Record review of the facility policy, Behavioral Assessment, Intervention and Monitoring, revised December 2021 revealed: Policy Statement 1. The center will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Policy Interpretation and Implementation Assessment 1. As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations: a. The resident's usual patterns of cognition, mood and behavior; b. The resident's typical or past responses to stress, fatigue, fear, anxiety, frustration and other triggers; and 2. New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others. Record review of the facility policy, Resident-to Resident Altercations, revised October 2023 revealed: Policy Statement All altercations, including those that may represent resident-to-resident abuse, shall be investigated, and reported to the Nursing Supervisor, the Director of Nursing Services and to the Administrator. Policy Interpretation and Implementation Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of such incidents shall be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to the Administrator. If two residents are involved in an altercation, the nursing staff will: a. Separate the residents, and institute measures to calm the situation up to and/or including 1:1 supervision of the offending resident; Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; Review the events with the Nursing Supervisor and Director of Nursing, and possible measures to try to prevent additional incidents; Make any necessary changes in the care plan approaches to any or all of the involved individuals; Document in each resident's clinical record all interventions and their effectiveness; o Residents may only be released from 1:1 supervision once deemed safe by one or a combination of the following: Complete a Report of Incident/Accident form and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record; If, after carefully evaluating the situation, it is determined that care cannot be readily given within the facility, transfer the resident; and Report incidents, findings, and corrective measures to HHSC or other appropriate agencies if indicated as outlined in our facility's abuse reporting policy. Inquiries concerning resident-to-resident altercations should be referred to the Director of Nursing Services or to the Administrator. There were no provider investigation reports available for review that involved any of the residents listed in the sample as of 11/26/24. Resident #1 Record Review of Resident #1's face sheet, dated 11/22/24, revealed an [AGE] year-old male that was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss). Record Review of Resident #1's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 00, indicating the resident was severely cognitively impaired. Section E revealed Resident #1 exhibited physical behavior (hitting, kicking, pushing, scratching, grabbing, and abusing) during the review [E0200]. The identified symptoms placed the resident at significant risk for physical illness or injury [E0500]. The identified symptoms placed others at risk for physical injury, significantly intruded on the privacy or activity of others, and significantly disrupted care or living environment. Record review of Resident #1's progress notes dated from 09/22/24- 11/22/24 revealed the following: LVN N documented on 11/10/24 at 11:47 PM that Resident #1 was urinating on the floor and when he was redirected, he hit the certified nurse's aide in the face and began to tear up the air mattress machine in his room. LVN N documented on 11/11/24 at 4:49 PM that Resident #1 continued to go into other residents' rooms hitting on walls and moving closet doors. LVN N documented on 11/11/24 at 5:53 AM that a certified nursing aide (unidentified) and she observed 2 small abrasions approx., 2 cm in size. One was located by his left eye and the other was above his left eye. LVN N documented that it was unknown how Resident #1 received the abrasions. She documented that Resident #1 continued to go into other residents' rooms and when he was redirected, he would lift his hands/arm up as if he was going to hit staff . The Social Worker documented on 11/14/24 at 6:35 PM that she received a message from staff (unidentified) that a staff (unidentified) was punched in the face. LVN N documented on 11/14/24 at 8:30 PM that Resident #1 hit the day certified nursing aide (unidentified) in the face and opened a skin tear on both arms. LVN N documented on 11/14/24 at 8:40 PM that Resident #1 was becoming agitated again, hit a certified nursing aide (unidentified) in the chest. Resident #1 was pacing and yelling in intervals. LVN Q documented on 11/16/24 at 5:45 PM that Resident #1 initiated aggression towards another resident (unidentified) and the resident returned a hit back. She documented that Resident #1 was taken out of the memory unit to calm down. Resident #1 attempted to exit the facility and when staff tried to redirect/intervene he became aggressive. Record review of Resident #1's care plan, dated 11/22/24, revealed a focused area, initiated on 11/22/24, Resident #1 had a history of aggressive behavior towards others. The goal initiated on 11/22/24, was Resident #1 would have fewer than 3 episodes of aggressive behavior before the next review date. The interventions initiated 11/22/24 included keeping the environment calm, relaxed, convey acceptance of the resident during periods of inappropriate behavior, remove from public area when behavior was unacceptable, and to ask for help when his behavior becomes unacceptable. Record review of the facility event summary report, dated 08/26/24-11/26/24, revealed the following: Resident #1 had aggressive/combative resident-to-resident aggression on 11/16/24 and 2 unwitnessed falls on 11/23/24. Record review of the facility event summary report dated 08/26/24-11/26/24, did not reveal any documentation regarding his resident-to-resident altercation that occurred on 11/14/24 with Resident # 2 and Resident #3 . Record review of Resident #1's hospice progress notes did not reveal any information about Resident #1's and Family Member B's allegation of ANE. There was no information regarding Resident #1's resident-to-resident altercation with Resident #2 (pulling her out if bed). There was no information regarding Resident #1's resident-to-resident altercation with Resident # (grabbing her in her face). The notes did reveal the following: On 11/23/24 at 5:39 AM a call was placed by LVN N to hospice requesting a nurse visit. The progress note indicated that LVN N stated Resident #1 rolled out of bed and had an abrasion to his right eyebrow, a cut on his lip and a skin tear to the bridge of his nose. On 11/23/24 Hospice Nurse T assessed Resident #1. Hospice Nurse T observed Resident #1's nose and lower swollen. She observed steri strips to the face and nose. State surveyor attempted to interview LVN N on 11/27/24 at 8:34 AM and the attempt was unsuccessful. State surveyor left a message. During an interview on 11/26/24 at 9:30 AM, the Regional Nursing Consultant stated during the entrance conference that an injury of unknown origin or bruising should be investigated and reported to HHSC. She said if the bruising could be explained, a progress note would be entered by the nurse who identified the bruising and explain where the bruising came from. She said all efforts would be documented in the resident's electronic medical record . During an interview on 11/26/24 at 10:00 AM, Family Member M stated she was told by facility staff that Resident #1 had told them a nighttime staff had hit him the weekend off 11/23/24 and that she was notified that Resident #1 had a fall. She said she did not know the full name of the staff who reported this information to her nor did she know the name of the staff that allegedly hit Resident #1. She said Resident #1 told her that a woman had hit him. She said the same staff reported that another female resident had hit Resident #1. She said she did not tell anyone specifically about what the facility staff and Resident #1 told her, but that staff knew because she (Family Member M) was vocal about it . A confidential interview revealed that Resident #1 had a fall the weekend of 11/23/24. They said they could not remember if it was a Friday or a Saturday. They said when they came to work, Resident #1 was quiet and not as active as he once was. They said that Resident #1 gestured with his hand that staff had hit him on top of the head. They asked Resident #1 if it was an overnight staff that had hit him, and Resident #1 stopped answering questions when they started asking for details. They stated Family Member M had expressed in the past that she did not feel that the overnight staff were taking care of Resident #1. They said the weekend that they came in for their shift, and Resident #3 allegedly fell he (Resident #1) did have a cut on his eye and his lip. They said when they attempted to get Resident #1 up for breakfast, Resident #1 was sleepy, and she had to get a wheelchair to roll him to the table. They said they did not know if this was from the fall. They stated that the morning Resident #1 fell , a hospice nurse (unknown) and LVN B were assessing Resident #1. They said the hospice nurse (unknown) said the injuries that Resident #1 sustained were not consistent with a fall. They said that the hospice nurse (unknown) did not say what specifically the injuries looked like they came from. They stated that the same day, Resident #1 did not eat. They said when Resident #1 told them that he had been hit by staff, they told CNA A. They said CNA A told them the injuries looked like injuries from a fall, and CNA compared Resident #1 to another resident with a similar fall. They said that Family Member M told them that Resident #1 had expressed to her that he had been hit by night staff. They said that they did not report the allegations that Resident #1 reported to them nor the concerns that Family Member M reported to them because their phone was not working. They stated they did not use the facility phone because the on-call staff never answered the phone when they called from the facility phone. They said the previous day, they had tried to call the on-call phone from the facility for a staffing concern, and the staff did not answer. They said they had been trained to call the ADM, who was the abuse coordinator if they witnessed or suspected ANE. They said they had been taught to contact the abuse coordinator immediately. They said that they did not contact the ADM, who was the abuse coordinator, because it was the weekend. They said they could not remember if they reported the allegations of ANE to LVN B, but the nurse typically does not stay in the locked unit. They said they did mention the accusations of ANE regarding Resident #1 to the Assistant Activity Director. They said no one had asked them anything about the nature of the fall . During an interview on 11/26/24 at 3:06 PM, CNA A stated that she did not know much about the fall that occurred on 11/23/24 involving Resident #1. They said CNA O told her that Resident #1 had an unwitnessed fall when she came on shift. She said CNA O told her that LVN N was helping her do rounds and change residents. She said CNA O said that she and LVN N had come out of Resident #1's room, and he had fallen. CNA A said she did not remember a staff member telling her that Family Member M had concerns about the injuries, but that Family Member M did express to her that she had concerns about the injuries that Resident #1 sustained. CNA A said that when Family Member M said that she did not think the injuries were consistent with a fall, she encouraged Family Member M to talk to LVN B because as a certified nurse aide she had been trained to refer family concerns to her nurse. CNA A said Resident #1's face was beat up. She said Resident #1 had steri-strips (reinforces skin closure) all over his face. She said he had a busted lip and a cut by his eye. CNA A said she was unaware of Resident #1 having any physical altercations with female residents where he was not the aggressor. CNA A said Resident #1 was aggressive, and all staff knew about it, which had been reported to management. CNA A said Resident #1 had punched her in the face. She said she could not remember the exact date but that it was documented in Resident #1's progress notes. She said they did not receive any instructions on handling Resident #1. She said she felt if his behaviors had been addressed, his behaviors wouldn't have continued to escalate. She said no one had interviewed her regarding Resident #1's behaviors or Family Member M's allegations. CNA said that she had been trained to report ANE as soon as possible to the ADM. During an interview on 11/26/24 at 3:55 PM, the Assistant Activity Director stated that she had experience with Resident #1 and his aggressive behavior. She said when Resident #1 had his resident-to-resident altercation on 11/16/24, she was assisting taking him out of the memory unit to calm down. She said Resident #1 saw an exit door and attempted to exit. She said she tried to redirect him, but he grabbed her hair and pulled it. She said they ultimately got him back to the unit. She said that Resident #1 punched another staff member in the face before that incident. She said she had not received any training specific to Resident #1 on responding to his aggressive behaviors. She said on Saturday, 11/23/24, she went into the memory unit and noticed Resident #1 was at the dining room table with his head down. She thought this was odd because Resident #1 was usually up and pacing around. She said CNA P told her that Resident #1 had fallen. She said she had asked if Family Member M had been notified and was told that attempts had been made, but they were unsuccessful because Family Member M's phone was off. The Assistant Activity Director said that later in the day (11/23/24), Family Member M came to the facility and said to her that Resident #1 reported to her (Family Member M) that someone came into his room at night and hit him. She said it was around lunchtime when she (Family Member M) told her that Resident #1 made the allegation. The Assistant Activity Director stated she told the aides (she did not disclose who) that were working the memory unit and that the aides said that it looked like someone hit Resident #1. She said she told the aides to get a nurse to explain Resident #1's injuries to Family Member M. She said the nurse (LVN B) told Family Member M it was a fall, and it was documented. The Assistant Activity Director told LVN B that Family Member M thought someone had beaten Resident #1 up. She was told that the documentation reflected that Resident #1 had a fall. The Assistant Activity Director said the abuse coordinator was the SW. She said she did not report the allegations of abuse to the SW because the SW was not at the facility. She said she had been trained on what to do if they suspect or witnessed abuse. She said that she had been taught to call the ADM. She said that she did not report the allegations of ANE to the ADM because she was not there when the incident allegedly happened. She said no one had interviewed her to ask her about her knowledge of the incident regarding allegations of abuse. She said she was unaware of any physical altercations that involved Resident #1. During an interview on 11/26/24 at 8:20 PM , LVN B stated the abuse coordinator was the ADM. She stated she had ANE training. She said she had been trained that if she witnessed or suspected abuse, she needed to report the allegation to the ADM as soon as possible. She said that on the day (11/23/24), Resident #1 fell on the overnight shift. He had also fallen on her shift (a day shift). She said CNA A said that she had found Resident #1 on the floor. She said she assessed Resident #1 and called Hospice out for assistance. She said she notified Family Member M. Family Member M was upset because Resident #1 had fallen on the overnight shift. LVN B said it was around 1:00 PM when Resident #1 had fallen on her shift. LVN B said she did not have details about Resident #1's first fall. She said Family Member M was upset. She said that she could tell by her body language but that she was speaking in Spanish to CNA A. LVN B said it was relayed to her from CNA A that Family Member M did not believe the lacerations, cuts, and gashes had come from a fall and that he looked like he had been punched. She said Resident #1 had a history of falls. LVN B said she did not report the allegations that CNA A had translated from Family Member B to the ADM because Family Member B was concerned with the overnight fall. She (LVN B) was sure that Resident #1 did not get punched on her shift, and that Family Member M said she would take Resident #1 home. She said that she was told that Resident #1 had a history of falls, according to the hospice nurse who came out and was not sure why Resident #1's falling was an issue. LVN B said she was unaware that Resident #1 had any physical altercations with female residents in the locked unit. She said Resident #1 never said he had been hit by staff when she interacted with him. She said she was unaware of any incidents that involved Resident #1 and other female residents. She said that since his admission, she had never received any training on how to deal with Resident #1's aggressive behavior. She said she had never been interviewed regarding Resident #1's behaviors or the allegations of ANE. She said the potential negative outcome of not reporting allegations of ANE to the abuse coordinator was that the abuse could continue. She said Resident #1 had told her that he fell . She said she documented what happened during her shift but did not document the information regarding Family Member M because she knew no one punched Resident #1 on her shift. She said that although it may sound silly, she felt that Family Member M wanted to take Resident #1. During an interview on 11/26/24 at 8:25 AM, Hospice Nurse S did not provide any information that supports the facility's deficient practice. She reported that she did not have any concerns with staff treatment, nor did she suspect or witness ANE. She was unaware of any allegations that Family Member M made. She said that she was the nurse who came out when he had behaviors on 11/14/24. She said there were discussions to send him to a behavioral center, but it was decided and, in her opinion, not beneficial for Resident #1 because of his diagnosis of dementia. She said she never said that his injuries were inconsistent with a fall. During an interview on 11/26/24 at 8:38 AM, Hospice Nurse T did not provide any information that supports the facility's deficient practice. She reported that she did not have any concerns with staff treatment, nor did she suspect or witness ANE. She was unaware of any allegations that Family Member M made. She said she came out on 11/23/24 when Resident #1 had his 2nd fall; this was her first time meeting Resident #1. She said that she never expressed that she felt that Resident #1's injuries were inconsistent with any of his falls. During an interview on 11/27/24 at 9:30 AM, CNA C stated that she did not know any details about Resident #1's fall on 11/23/24. She said she heard about Resident #1 punching CNA A but knew nothing about that incident. She said she knew that Resident #1 had been aggressive since he came to the facility. She said she heard that Resident #1 had a broken nose and that someone had been hitting him on top of the head. She said she heard it was a nighttime staff that was hitting him. She said she was told this on 11/26/24 by CNA A. She said she did not report what CNA A told her to the abuse coordinator because she was told that it had already been reported to the state. She said she had no proof that the allegation of ANE had been reported but was told that was why the state was in the facility. She said she had been trained that all allegations of abuse should be reported to the abuse coordinator as soon as possible. She said she received abuse training within the last year when she took her CNA classes. She said the potential negative outcome of not reporting allegations of abuse could allow abuse to continue. During an interview on 11/27/24 at 9:23 AM, the ADM stated he was unaware of Family Member M's allegations of abuse. He said none of the incidents were investigated because he was unaware of the incidents. Preventive measures were not put in place to protect Resident #1 after the allegations of abuse because he was unaware of the incident. He was unaware that Resident #1 had aggressive behaviors before admission. He said that there were discussions about sending Resident #1 to a behavior facility, but after consulting with Hospice, it was recommended by Hospice that pharmaceutical attempts should be taken first. Regarding the injury of unknown origin, he said he was unaware of the injury and that the staff did not know where it came from. He said this was not reported to him. Resident #2 Record Review of Resident #2's face sheet, dated 11/27/24, revealed an [AGE] year-old female that was init [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being, for 1 of 1 resident (Resident #63) reviewed for mental health services, in that: The facility failed to administer a dose of Resident #63's Risperidone (antipsychotic used for bipolar and schizophrenic disorder) for a week. There were behavior changes as consequences to the medication being discontinued. This failure affected one resident and placed resident at risk of emotional distress, negative behavior changes, and diminished quality of life. Findings include: Resident #63 Record reviewed Resident #63's face sheet revealed that the resident was a [AGE] year-old female and admitted [DATE] with the following diagnoses: Alzheimer's disease, depression, schizoaffective disorder, bipolar disease, insomnia, hypothyroidism, anxiety, muscle weakness, high blood pressure. Record Review of Resident 63's MDS dated revealed that Resident #63 had a BIMS of 9 meaning Resident #63 is mildly impaired. Section C for Cognitive patterns was left blank and incomplete. Section D for Mood was left incomplete. Section E for Behavior stated that Resident #63 did not display behaviors of delusions or hallucinations and the remainder was left blank and incomplete. Record Review of Resident #63's Medication Administration Record dated 12/10/2023-1/09/2024, revealed no documented evidence Resident #63 was given Risperidone 1 mg for day or night on the dates of 12/28/2023-1/09/2024. During an interview with the Family Member of Resident #63 on 02/06/2024 at 10:10 am. The Family Member stated that a couple of weeks ago the facility discontinued Resident #63's Risperidone and it had caused her to have negative behavior changes such as agitation, shaking, mood swings, etc. The Family member stated that when he had called and spoke with the Clinical Resource Nurse, he was told that because Medicaid did not pay as much for the residents that were taking antipsychotics, the facility took Resident #63 off the medication. The Family Member stated that Resident #63 started to see things and hear voices. Family Member stated that it made him angry to see Resident #63 suffer the way she did. Family Member stated that he had to go to Resident #63's doctor and get him to contact the facility to get the facility to put Resident #63 back on the medication and it took Resident #63 about a week to get balanced back on the medication again. The medication was restarted a week later after 1/09/2024 after Resident #63 began to display delusions. Family Member stated that Resident #63 had been taking the medication since 1986 due to a diagnosis of bipolar with schizophrenia. During an interview with the DON on 02/08/2024 at 2:02 pm. The DON stated that the reason that Resident #63 was removed from the medication was due to a failed GDR. The DON stated that the pharmacy recommended that she come off the medication. The DON stated that the facility spoke to the PCP, and he was in agreement with the pharmacy. The DON stated that once Resident #63 started to show negative behavior changes, she was put back on the medication by the doctor. The DON stated that Resident #63 was admitted to the facility with the Risperidone and had been taking the medication since 1986. The DON stated that pharmacy did not want Resident #63 on the medication due to improper diagnosis. The DON stated that she had gotten with the family member and got paperwork that he had received for psych services to put Resident #63 back on the medication due to the diagnosis of bipolar and schizophrenia disorder. The DON stated that the repercussions of abruptly stopping the medication was negative behaviors and withdrawals. The DON stated that proper tapering of the medication was needed. The DON stated that proper tapering would mean to dose the medication down before stopping it all together. The DON stated that Resident #63 was not tapered down and should have been. The DON stated that Resident #63 was doing fine until all the medication came out of her system and then she started to show negative behaviors. During an interview with the Clinical Resource Nurse on 02/08/2024 at 2:16 pm. The Clinical Resource Nurse stated that Resident #63 had been taken off the medication due to pharmacy recommendations to do a GDR. The Clinical Resource Nurse stated he was not sure if it was the PCP or the psych doctor who approved Resident #63 to come off the Risperidone. The Clinical Resource Nurse stated that usually with that medication the resident would need to be tapered off the medication but because it was such a low dose, then the resident should have been fine have been taken off the medication all at once. The Clinical Resource Nurse stated that to taper a medication off that the dosage is slowly dropped over a course of time. The Clinical Resource Nurse stated that Resident #63 was not tapered down because she was on a low dosage. The Clinical Resource Nurse stated that the doctor wanted to see how Resident #63 would do without the medication. The Clinical Resource Nurse stated that Resident #63 started to show negative behaviors. The Clinical Resource Nurse stated that the family member was saying that Resident #63 was calling all hours of the night, and that is what she would do before she was put on the medication many years ago. The Clinical Resource Nurse stated that the family member stated that he did not want Resident #63 off the medication. The Clinical Resource Nurse stated that he told family member that the facility would contact him next time if they ever decided to take Resident #63 off any medications. The Clinical Resource Nurse stated that Resident #63 came into the facility with the medication when she was admitted to the facility. The Clinical Resource Nurse stated the family member did go to the original psych doctor to get the paperwork to show Resident #63 was schizophrenic and bipolar. During an interview with the Administrator on 02/08/2024 at 2:30 pm. The Administrator stated that he was made aware of the Resident #63 had been taken off her medication because the family member contacted corporate and then corporate sent him an email. The Administrator stated that Resident #63 diagnoses is Alzheimer's, bipolar, and schizophrenic. The Administrator stated that Resident #63 was admitted into the facility on Risperidone and had been taking the medication since 1987. The Administrator stated that by coming off the medication without tapering could cause the resident to bring on depression and all symptoms of schizophrenia. The Administrator stated that if they were going to take Resident #63 off the medication, she should have been tapered off. The Administrator stated that he is not sure who told them to take Resident #63 off the medication and that he only learned of the situation after the fact. The Administrator stated that the family member should have been contacted about taking Resident #63 off the medication. Record review of the facility policy, titled Pharmacy Services, Overview, Revised April 2007, revealed the following documentation, Policy Statement. The facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medication, and biologicals, and the services of a licensed pharmacist. Policy Interpretation and Implementation. 3. The facility shall contract with a licensed pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support resident's needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but it's not limited to, collaborating with the facility and Medical Director to . f. Help the facility assure that medications are requested, received, and administered in a timely manner as ordered by authorized prescribers. h. Collaborate with the staff and practitioners to address and resolve medication related needs or problems. l. Help the facility develop a process for receiving, transcribing, and recapitulating medication orders. Record review of the facility policy, titled Adverse Consequences and Medication Error, Overview, Revised April 2014, revealed: Policy Statement: The interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication related problems such as adverse drug reactions and side effects. Adverse consequences shall be reported to the Attending Physician and Pharmacist. 2. An adverse consequence is defined as an unpleasant symptom or event that is due to or associated with a medication, such as an impairment or decline in an individual's mental or physical condition or functional or psychological status. An adverse consequence may include a). adverse drug/medication reaction. 5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professionals' providing services.

Based on observation, interview and/or record review the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of new pressure ulcers/injuries for 2 of 3 residents (Resident #1 and Resident #2) reviewed for pressure injuries, in that: 1. LVN A failed to implement proper wound care techniques and implement adequate infection control practices to promote wound healing during observation of wound care on 11/29/2023. 2. LVN A failed to follow orders for wounds for providing wound care for Resident #1 and Resident #2, leaving wounds open to air and exposed to bacteria and possible infection. 3. Facility staff failed to treat and cover wounds for Resident #1 and Resident #2 4. Facility failed to follow doctors' orders of providing a wound culture (is a test to find germs such as bacteria, a virus, or a fungus that can cause an infection) for Resident #1 This failure could cause resident wounds to worsen, spread of infection, loss of limb, and possible sepsis leading to death. This failure was determined to be an Immediate Jeopardy situation that was identified on 12/01//2023 at 12:00 p.m. While the IJ was removed on 12/01/2023 at 8:15 pm, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The findings included: Record Review of Resident #1's face sheet documented he was a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #1 was admitted with a diagnosis which includes: acute respiratory failure - difficult to breath on your own, quadriplegia - paralysis of all four limbs, tracheostomy - an opening in the windpipe from outside of the neck to help oxygen reach the lungs, contracture to left ankle - inability to move foot to a neutral position, contracture to right knee - can no longer move is stiff, contracture to right ankle - inability to move foot to a neutral position, abnormalities of gait and mobility -unable to walk in typical way, obstructive and reflux uropathy - urine cannot drain through the urinary tract, rash and other nonspecific skin eruption - skin reaction to an irritant, urinary calculus - solid particles in the urinary system, pain - mild to severe discomfort, pressure ulcer of other site (unstageable) - sore on a specific area of skin from pressure resulting in the lack of blood flow and oxygen to tissue, muscle weakness - lack of muscle strength, unspecified disorder of eye and adnexa - eye and surrounding structure disorder, acid reflux - stomach acid or bile irritating the stomach lining , muscle spasms - involuntary movement, cardiac arrhythmias - improper beating of the heart, vitamin Deficiency - too little of one or more vitamin, hypokalemia - low blood level, dysphagia - difficulty speaking, hypoxemia - low level of oxygen in the blood, persistent vegetative state - a person shows no sign of awareness, cognitive communication deficit - difficulty with thinking, chronic respiratory failure shortness of breath, diffuse traumatic brain injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving - brain dysfunction trauma to the brain. Record review of Resident #1's Annual Minimum Data Set (MDS) dated [DATE] documented that Resident #1's BIMS (Brief Interview for Mental Status) was left blank and incomplete. Record Review of Resident #1 Annual MDS dated [DATE] revealed: On the section for risk of pressure ulcers/injuries indicated Resident #1 is at risk for pressure ulcers. On the section under skin conditions: Current number of unhealed pressure ulcers/ Injuries at each stage was left blank and not complete. Record Review of Resident #1 Care Plan dated 11/22/2018 revealed Resident #1 had a pressure ulcer and states Resident #1 was not as mobile as he used to be, his skin is fragile and he is at risk for skin tears, bruising, pressure wounds with interventions of monitor for signs and symptoms of skin breakdown or bruising, notify doctor of any skin breakdown or bruising, may wear boots for preventions per family request, Resident #1 has contractures and was unable to float heels, wound care as ordered. Resident #1 needs assist bars for psychological comfort and to establish bed boundaries. Resident #1 needs help from staff with turning and uses his assist bars for some repositioning with interventions of: assist bar will be reviewed at least quarterly to ensure they are still needed, check on and reposition when giving care and prn, staff to ensure that assist bars are up X 2/4 and secured when in bed, treat with respect and dignity. Resident #1 had urinary incontinence with interventions of: motor and report red areas noted, provide cheerful dialogue while cleansing to encourage and maintain self-esteem, provide incontinent care every 2 hours and as toileting pattern indicates. Resident #1 had ADLs functional status/rehabilitation potential with the interventions of: consistent approach amongst caregivers, monitor for presence of pain/intolerance during self-care, provide adequate rest periods between activities, report a further deterioration in status to physician. Resident #1 had a self-care deficit with traumatic brain injury. Resident #1 requires total assistance with ADLs with interventions of may utilize Geri chair (a large padded chair that is designed to help seniors with limited mobility) to get out of bed, provide assistance x2 with bathing/showering three times a week, incontinent of bowel and requires x 2 assist with peri-care, requires x1 assist with dressing, requires x1 assist with eating, Resident #1 has enteral feedings, requires x2 assist with bathing. Requires x2 toileting, requires x2 assist with transfers, requires x2 assist with transfers with lift, requires x2 assist with bed mobility, turn, and reposition x2 assist every 2 hours. Resident #1 had interventions in place for weekly head to toe skin check. Resident #1 had a pressure ulcer to right buttocks with immobilization with interventions of; apply dressings as doctor ordered: clean, apply Santyl and calcium alginate and foam dressing, assess pressure ulcer for staged, size, (length, width, and depth), presence/absence of granulation tissue and epithelialization,(development of new epidermis and granulation tissue. Granulation tissue is new connective tissue with new, fragile, thin-walled capillaries) and condition of surrounding skin daily, conduct a systematic skin inspection weekly, report any signs of any further skin breakdown, keep clean and dry as possible, minimize skin exposure to moisture. Resident #1 had a pressure ulcer on left upper back with immobilization with interventions of: apply dressing per doctor orders, clean, apply Santyl and calcium alginate and foam dressing daily to left upper back, assess the pressure ulcer for stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization, and condition of surrounding skin every day. Keep clean and dry as possible, minimize skin exposure to moisture, keep linens clean, dry as possible, minimize skin exposure to moisture, keep linens clean, dry, and wrinkle free, keep resident off left upper back. Record Review of Resident #2's face sheet documented he was a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 was admitted with a diagnosis which includes: post-traumatic seizures - occurs after head trauma, quadriplegia - paralysis of all four limbs, unspecified injury of right foot - injury or damage to body part, tachycardia - rapid or irregular heartbeat, elevation of liver transaminase levels - abdominal pain or swelling , hyperosmolality and hypernatremia - electrolyte problems, granulomatous disorder of the skin and subcutaneous tissue - raised bumps under skin, non-pressure chronic ulcer of skin of other sites with fat layer exposed - open area of skin, seborrheic dermatitis - scaly red patches of skin, muscle spasms - involuntary movement, pain - mild to severe discomfort, hypokalemia - low blood level, contracture right hip - shortening or hardening of muscles, contracture left hip - shortening or hardening of muscles, contracture right knee - shortening or hardening of muscles, contracture left knee - shortening or hardening of muscles, contracture right and left ankle - shortening or hardening of muscles, muscle wasting and atrophy - wasting of muscle, generalized muscle weakness - decreased in strength, acid reflux - stomach acid or bile irritating the stomach lining, contracture of right wrist - shortening or hardening of muscles, concussion with loss of consciousness - injury caused by head trauma, persistent vegetative state - no sign of awareness, personal history of traumatic brain injury - brain trauma , tracheostomy - an opening in the windpipe from outside of the neck to help oxygen reach the lungs, gastrostomy - an opening into the stomach from the abdominal wall, made surgically for the introduction of food. Record review of Resident #2's Annual Minimum Data Set (MDS) dated [DATE] documented that Resident #2's BIMS (Brief Interview for Mental Status) was left blank and incomplete. Record Review of Resident #2 Annual MDS (Minimum Data Set) dated 11/06/2023 revealed that Resident #2 was listed as a risk of pressure ulcers. On the section under unhealed pressure ulcer/injuries is listed as Resident #2 does not have any pressure ulcers when he does have pressure injuries. Record Review of Resident #2 Care Plan dated 11/15/2023 revealed Resident #2 had a risk for pressure ulcers due to impaired sensory perception. Resident #2 is at risk for skin breakdown as evidenced by contractures, moisture/excessive perspiration, nutritional concerns, limited mobility, incontinence with interventions of; consider specialty mattress or bed, elevate heels, and use protectors as able, skin assessment and inspection every shift with close attention to heels, use pillows between knees and bony prominences to avoid direct contact. Resident #2 had a risk for pressure ulcer due to moisture, has MASD to left groin with interventions of assess for other moisture problem areas such as in skin folds, avoid hot water, use mild soap and soft cloths or packaged cleanser wipes, check incontinence pads frequently (every 2-3 hours) and change as needed, moisture dry unbroken skin, skin assessment and inspection every shift with close attention to heels, use moisture barrier ointments (protective skin barriers), wound care as ordered. Resident #2 had a risk for pressure ulcer due to bedfast/mobility with interventions of Braden scale as needed and quarterly, consider specialty bed, elevate heels off bed or use heel protectors, notify doctor and resident representatives of any skin issues, position prone if appropriate or elevate head of bed no more than 30 degrees, position with pillows to elevate pressure points off the bed, pressure reducing mattress, skin assessment weekly, skin inspection each incontinent episode and during bath, report changes to charge nurse, turn and reposition every 2 to 3 hours and as needed. Resident #2 had a risk for pressure ulcer due to friction and shear with interventions of: minimum of 2 people plus draw sheet to lift resident while in bed, skin assessment and inspection every shift with close attention to heels. Resident #2 needed assistance for psychological comfort and to establish bed boundaries. Resident #2 required assistance from staff for repositioning with interventions of: assist bar will be reviewed at least quarterly, to ensure they are still needed, check on and reposition when giving care and as needed, staff to ensure that assist bars are up X1/4 and secured when in bed, treat with respect and dignity. Resident #2 had urinary incontinence with interventions of: monitor and report red areas noted, provide cheerful dialogue while cleansing to encourage maintained self-esteem, provide incontinent care every two hours and as voiding pattern indicates. Resident #2 required assistance with ADLs and is unable to perform any on his own with interventions of: may use Geri chair (a large padded chair that is designed to help seniors with limited mobility) to enable getting out of bed, provide assistance x2 with bathing/showering three times a week, incontinent of bowel and bladder and requires x 2 assist with peri-care, requires x1 assist with dressing, requires x 1 with eating and has enteral feedings, requires x 2 assist with bathing, requires x 2 assist with toileting, requires x 2 assist with transfers, requires x 2 assist with bed mobility, turn and reposition x 2 every 2 hours. Resident #2 had interventions in place for weekly head to toe skin check (Licensed Nurse). Resident #2 had non-healing surgical wound with previous gastrostomy with interventions of: assess condition of surrounding skin, report emergencies of skin excoriation, dressing changes per physician order, observe and report signs of localized infection, pain, redness, swelling, tenderness, loss of function, heat at the infected area. Observe and report signs of sepsis (fever, lassitude, or malaise, change in mental status, tachycardia, hypotension, anorexia, nausea, vomiting, diarrhea, headache, lymph node), record the amount, type, consistency, color, and odor of drainage from the wound. Record the location (size, length, width, and depth), color, and presence/absence of granulation tissue and epithelization of surgical wound. Use principles of infection control and universal/standard precautions. Resident #2 had chronic wound to left groin with interventions of need protectors/float heels, pain medication as needed for comfort, re-evaluation for improvement in 14 days, supplements as ordered, treatments and medication as ordered. Resident #2 had pressure ulcer left four toes with interventions of apply dressing per doctor order: clean, calcium alginate, cover with foam dressing. Assess resident for pain related to pressure ulcer or its treatment. Prevent or treat pain by keeping foot in boot. Conduct a systematic skin inspection daily, report any signs of any further skin worsening. Keep clean and dry as possible. Minimize skin exposure to moisture, keep resident off toes. Reduce friction injuries by using protective boots. Use protective boot to relieve pressure on the heels. Resident #2 had infection of the foot with interventions of assess and record if resident's feet are desensitized to pain and/or pressure. During an Observation of Resident #2 on 11/29/2023 at 11:15 AM. Observed Resident #2 lying in bed on back with head of bed elevated. Resident #2 was in a brief only, no shirt or pants. Resident #2 has top sheet lying on left side of body. Resident #2 is nonverbal but able to answer yes and no questions by nodding head or blinking eyes. Resident #2's left foot moving up and down on bed. Observed Resident #2 with four toes bloody with no skin on ends of toes. Observed Resident #2's pinkie toe with dime size scab to top and side of toe. Resident #2 had the sheet under foot had blood. There was blood on right lower leg and heel. Observed Resident #2's call light on the floor at head of bed. Resident #2's hands are contracted, and resident cannot use hands. During an observation and interview with CNA B on 11/29/2023 beginning at 11:25 AM. CNA B stated she went in room to change Resident #2, the roommate to Resident #1. CNA B went to check on Resident #2 and noticed blood on sheet and Resident #2's' toes. CNA B stated she last worked on Sunday and Resident #2's toes were not like that. CNA B stated she had never seen his toes like that. CNA B stated she does not know what happened or when it happened. CNA B stated she came on shift at 06:30 AM and took a break at 10:00 AM and does not remember seeing his foot like that. CNA B stated the wound nurse made rounds that morning (12/01/2023). CNA B stated Resident #2 was not able to use a regular call light. CNA B stated Resident #2 might be able to use a pressure pad call light, but he probably would not use that either. CNA B stated Resident #2 has wound to his Left groin. During incontinent care surveyor attempted to observe wound to left groin but Resident #2 refused to relax his leg. Left groin with thick bloody drainage. Surveyors were unable to see wound. CNA B stated she was told it was from the use of briefs rubbing leg due to Resident #2 constantly moving leg. CNA B stated there was an ABD pad in groin and she removed ABD pad. Observed minimal bloody drainage on ABD pad. Resident #2 had old pressure wound to buttocks that had been healed. Resident #2's crack to buttocks was red no open areas noted. Resident #2 had open area to right hip the size and shape of a black-eyed pea. Resident #2 wound not covered, no drainage wound bed pink. Resident #2 had a dried gauze to lower abdomen with an unknown substance on it. The gauze was tinted yellow and pink. CNA B stated she was not sure where that came from. Resident #2 had strong body odor smell. CNA B gathered all dirty linen and left resident lying flat in bed with only brief on. Resident was uncovered with curtain at end of bed. CNA B left the room with the sack of dirty linen. CNA B pushed door to room all the way open on her way out of the room. CNA B returned to room and pulled curtain 1/2 way on left side of bed. CNA B repositioned Resident #2 and raised head of bed and covered resident with a sheet. CNA B went to Resident #1 to change resident. Observed Resident #1 lying on back in bed with only a sheet covering his lower body and curtain was end of bed. Resident #1 right foot was hanging off the left side of the bed. CNA B and LVN A performed incontinent care for Resident #1. Resident #1 had pressure ulcer to right buttock open to air, bloody drainage noted to bed pad. Resident had wound to coccyx covered with foam dressing with date 11-28-23. LVN A stated she had not done wound care for resident today. She stated his wound care was daily. Resident #1 turned to right side. Observed Resident #1 had large area to left bottom shoulder blade. LVN A stated 2 weeks ago resident had a scratch there from his lift and now he had that. LVN A stated, I just don't see how a scratch turned to this. LVN A stated Resident #1 had been on an air mattress since she went to work there. Resident #1 with a wound to left lower shoulder blade upper circle covered in black eschar, yellowish green below the black and large red beefy area below that. Bloody drainage noted on bed pad, left open and not covered. When resident was turned to right there was a strong foul odor coming from the wound. The wound was open to air. CNA B placed gloved hand on open wound several times during incontinent care. Resident #1 has small black eyed pea size wound to left hip. Open to air. No drainage noted. Wound bed is pink. CNA B and LVN A repositioned Resident #1 and covered with a sheet. During an interview with LVN A on 11/29/2023 at 12:24 PM. LVN A stated she did not have any orders for dressing for Resident #2. LVN A stated she text (wound nurse) again to check on orders. During an observation of Resident #2. Observed Resident #2 on 11/29/2023 at 1:40 PM left foot wrapped with foam gauze and secured with tegaderm due to resident constant movement of foot. During an observation for wound care for Resident #1 on 11/29/2023 at 1:55 PM provided by LVN A assisted by CNA B. LVN A stated she did do the wound care for Resident #1. LVN A stated she placed alginate to wound bed, covered with foam dressing and covered with tegaderm due to Resident #1's constant foot movement. LVN A stated she did not measure wounds. LVN A gathered wound supplies and placed on bedside table. No observation of BST being sanitized and no barrier. LVN A changed gloves. No observation of hand washing or ABHR. LVN A donned gloves and placed saline in 3 cups. LVN A then placed gauze in all 3 cups. LVN A placed Santyl in medicine cup. LVN A placed all supplies on foot of resident's bed on used bed pad. LVN A removed old dressing to coccyx using a q-tip. LVN A placed old dressing on bed pad behind resident she cleaned wound with normal saline and gauze. LVN A cleaned out to inner wound. LVN A then opened calcium alginate packed and placed on bed pad beside dirty gauze and old dressing. LVN A tore off small piece and placed inside of wound. She covered wound with foam dressing. Resident #1 wounds were measured as listed: right buttocks: 3.5 width x 3.5 and superficial. Wound shows to have grown from what is documented. Resident #1 back shoulder is measuring: 5 x 5.5 from length to width and the depth is 1.25. As per documentation it shows that the wound on the shoulder has also grown in a week. Resident #1's coccyx wound is measuring to be: 1.5 cm in length, 2.5 cm in width, and 1.0 in depth, which indicate the wound has grown since last week. LVN A cleaned bottom cheek wound from [NAME] to enter. LVN A placed used gauze on bed pad behind Resident #1. LVN A applied Santyl to wound bed with q-tip. LVN A used calcium alginate from package laying in pile of used gauze and covered wound. LVN A covered with foams dressing. LVN A dated and initialed dressing and removed gloves. LVN A removed gloves. LVN A turned Resident #1 on right side. Observed Resident #1 left shoulder wound uncovered with brownish discharge on bed pad and foul odor from wound. Resident #1 shoulder wound measured 5cmX5 1/2 cm X 1 1/4 cm. LVN A cleaned wound from outer to inner wound. LVN A applied Santyl to wound bed and covered with calcium alginate and foam dressing. LVN A gathered trash and removed gloves and repositioned Resident #1. LVN A grabbed suction and dropped it on the floor and then picked up the tubing and placed it in the trash. Observed no additional tubing in the drawer. LVN A removed gloves and exited the room to go get more supplies. No observation of hand washing. LVN A returned to the room. LVN A donned gloves and suctioned Resident #1's trach and change residents inner canula. LVN A repositioned Resident #1 and doffed gloves. LVN A cleaned BST placing unused supplies in box on BST. LVN A washed hands. LVN A stated Resident #1 was not able to rub dressing off his shoulder. LVN A stated the only movement Resident #1 does was when he coughs, and he moves his legs. LVN A stated the only way it could be rubbed off was when staff turn Resident #1. LVN A stated the pressure ulcer to left hip had no orders. LVN A was told to leave it open to air and monitor it. Observed pressure ulcer to left hip was black eyed pea size and shape and the wound bed was superficial and pink. No observation of hand washing or ABHR during glove changes during wound care. No observation of glove changed when going from dirty to clean. During an Interview with CNA B on 11/29/2023 at 2:10 PM. CNA B stated if the dressing comes off a wound, she would notify the nurse. CNA B stated when Resident #1's family visited the other day, CNA B had showered Resident #1 and his family member had noticed the wounds on Resident #1's shoulder and bottom. CNA B stated she covered wound with a dressing and notified the charge nurse. CNA B stated the family member went to DON to complain about the wounds. CNA B stated the DON told her she was not allowed to cover any wounds. During an interview with the DON on 11/29/2023 at 4:19 PM. DON stated she did a skin sweep last Friday and passed out shower sheets for staff to use. DON stated the staff have not been completing the shower sheets. DON stated she does not have any shower sheets to provide for evidence of shower sheets being completed. During an Interview with LVN A for infection control practices on 11/30/2023 at12:50 PM. LVN A stated that she had been trained in infection control practices. LVN A stated that she has had in-services for infection control practices. LVN A stated that the facility will do verbal refreshers with the staff randomly by just walking up to them and asking random infection control questions. LVN A stated that the facility does provide in-services and they are approximately monthly. LVN A stated that they will also go over infection control in the monthly meeting and that was covered by the Administrator and the DON. LVN A stated that they just had skills check for hand washing at the beginning of the month. LVN A stated that the Nurse Educator was the one who oversaw the skills check. LVN A stated that she did not learn to use a dirty paper towel to turn off the faucet at this particular facility, but she did learn to do that when she worked at another facility. LVN A stated that it was a mistake that she should not have made. LVN A stated that the negative potential outcome for not using proper infection control practices is cross contamination, potential infection, exposure to bacteria. LVN A stated that when she was cleaning the wound for Resident #1, she did not drag, she used a half-moon one swipe method and she started from furthest away from the wound working her way to the wound so that she would not bring anything from outside of the wound to the inside of the wound. LVN A stated that her thought process is to get everything outside of the wound cleaned so that she did not contaminate the wound itself. LVN A stated that she has never been trained in wound care by the facility, she just tried to use her best judgement. LVN A stated that the Nurse Educator will train in wound care if needed but just has not gotten to it yet. LVN A stated that the negative potential outcome for improperly cleaning a wound could be cross contamination, sepsis, further wound damage, or worse infection. During an interview on 11/30/2023 at 1:36 PM, NP M stated she saw Resident #2 on 11/29/2023, around 7:15 AM and saw the wounds on his toes. She stated the wounds on his toes looked fresh and she notified LVN A. She stated, LVN A had walked off when she was doing the assessment on Resident #2. She stated she can do the wound care but cannot cover the wounds. She stated she told LVN A that it would be okay until she could get it covered with a bandage, because she did not have a bandage available at the time, she was doing the assessment. NP M stated she would have expected the wounds to be covered before 12:26 PM. During an interview on 11/30/2023 at 1:36 PM, NP M stated this is her second week for seeing Resident #1. She stated Resident #1's wounds developed over a period of a few days is how she understood it. She stated some of them were significant wounds, she debrided his shoulder wound and stated, that was the worst one. She stated, I ordered a culture of Resident #1's shoulder, and it came back positive, and Resident #1 was started on Levaquin (an antibiotic that is used to treat bacterial infections), this medication was used to treat a respiratory infection and wound. NP M stated the wound did have an odor when she saw it on 11/29/23. She stated she has taken care of Resident #1 one time before with his heel and that was the only pressure injury he had had. NP M stated those are true pressure injuries on bony points. She states she does not know if they could have been prevented. During an interview with DON on 11/30/2023 at 3:56 PM. DON stated there was no wound culture done for left shoulder wound on Resident #1. DON stated the only culture done was a sputum culture (test to detect and identify bacteria or fungi that infects the lungs or breathing passages) from Resident #1 trach on 11/22/2023. During an Interview with NP M on 11/30/2023 at 4:24 PM. FNP stated she spoke with LVN A, and she stated the culture did come back and Resident #1 was started on Levaquin(an antibiotic that is used to treat bacterial infections). NP M stated it was good that Levaquin covered both cultures. Record Review of facility provided policy labeled, Wound Care, date revised in June 2022, revealed. Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 1. Verify that there is a physician's order for the procedure. 2. Review the resident's care plan to assess for any special needs for the resident. A). For example, the resident may have PRN orders for pain medication to be administered prior to wound care. 3. Assemble the equipment and supplies as needed. Date and initialed all bottles and jars upon opening. Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure. 1. Dressing material, as indicated. 2. Disposable cloths, as indicated. 3. Antiseptic (as ordered). 4. Personal Protective Equipment Steps in the Procedure: 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. 2. Perform hand hygiene. 3. Position Resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on clean gloves. Loosens tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Perform hand hygiene. 6. Put on clean gloves. Gowns will only be necessary if soiling of your skin or clothing with blood, urine, feces, or other body fluids is likely. Masks and eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely. 7. Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers. 8. Pour liquid solutions directly or gauze sponges on their papers. 9. Wash wound in a circular motion from the inside out with ordered wound cleanse. Use additional gauze and repeat as needed with fresh gauze each time. 10. Apply treatments and dress wound as ordered by physician. 11. [NAME] tape with initials, time, and date and apply to dressing. 12. Remove the disposable cloth next to the resident and discard into the designated container. 13. Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Perform hand hygiene. 14. Reposition the bed covers. Make the resident comfortable. Use supportive devices as instructed. 15. Place the call light within easy reach of the resident. 16. Sanitize overbed table. 17. Return the overbed table to its proper position. 18. Sanitize scissors. 19. Perform hand hyge3eine. 20. If the resident desires, return the door and curtains to the open position and if visitors are waiting, tell them that they may now enter the room. Documentation: The following information should be recorded in the resident's medical record. 1. The type of wound care given. 2. The date and time the wound care was given. 3. The name and title of the individual performing the wound care. 4. Any change in the resident's condition. 5. All assessment data (wound bed color, size, drainage, etc.) obtained when inspecting the wound. 6. Assess the resident for pain and medicate as ordered. 7. Any problems or complaints made by the resident related to the procedure. 8. If the resident refused the treatment and the reasons why. 9. The signature and site of the person recording the data. Reporting: 1. Notify the supervisor if the resident refuses the wound care. 2. Report other information in accordance with center policy and professional standards of practice. Record Review of facility provided wound log for Resident #1, labeled, Facility Wound Summary Report, dated 11/22/2023, revealed: It listed Resident #1 as having three wounds as listed below: 1. Pressure injury to the coccyx with the size of 1.2 X0.7. Nothing listed [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure that residents had the right to be free from neglect for 4 of 5 residents who required blood sugar monitoring and administration of insulin (Residents #1, 2, 3, 4); in that: 1) The facility failed to effectively monitor Resident #1's blood sugars and take appropriate actions related to blood sugar results, which resulted in the hospitalization of Resident #1 with a diagnosis of metabolic acidosis. Staff failed to notify nursing supervisory staff and physician of Resident #1's refusals of blood sugar testing and insulin in order to receive further instructions on what to do. This failure resulted in the identification of an IJ on 4/15/23 at 5:25 PM. While the 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 isolated. The facility failed to provide adequate documentation related to Medication Administration Records for Residents #1, 2, 3 and 4, who required blood sugar monitoring and insulin administration. These failures could place residents at risk for elevated levels of glucose which could result in harm, impairment, or death. The findings include: Resident #1 Record review of the Physician Order Report for male Resident #1 dated 4/10/2023 - 4/10/2023 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. Diagnoses listed were type 2 diabetes mellitus with ketoacidosis without coma (blood sugar disorder), hyperlipidemia, unspecified (elevated cholesterol), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (mental disorder), essential (primary) hypertension (high blood pressure), acute kidney failure, unspecified, personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits (stroke), and vascular dementia, severe, and other behavioral disturbance (mental disorder). Further record review of this Physician Order Report for Resident #1 revealed that the resident had the following orders documented as Order type - Prescription. Start date 4/6/2023 - End date Open-ended. Description. Humalog U-100Insulin (insulin lispro) solution; 100 unit/mL; amt: Per Sliding Scale; If Blood Sugar is less than 60, call MD. If Blood Sugar is 61 to 150, give 0 Units. If Blood Sugar is 151 to 250, give 3 Units. If Blood Sugar is 251 to 350, give 5 Units. If Blood Sugar is 351 to 450, give 7 Units. If Blood Sugar is 451 to 500, give 10 Units. If Blood Sugar is greater than 500, call NP/PA. Subcutaneous Before Meals and At Bedtime 06:30 AM, 11:30 AM, 04:30 PM, 08:00 PM. Ordered by Physician A. Order type - Prescription. Start date 4/6/2023 - End date Open-ended. Description. Lantus Solostar U-100 insulin (insulin glargine) insulin pen; 100 unit/mL (3ml); amt: 25; Subcutaneous [DX: type 2 diabetes mellitus with ketoacidosis without coma] Once a morning; Morning 7:00 AM-10:00 AM. Ordered by Physician A . Record review of the MDS documentation for Resident #1 revealed the resident's admission MDS was not due. Record review of the current care plan for Resident #1 dated 4/14/23 revealed a Problem start date: 4/6/23. Category: diagnosis diabetes. Created: 4/14/23. Created by DON. The goal listed was, No complications. Created: 4/14/23. Created by: DON. Approaches listed were as follows, Approach start date: 4/6/23 FSBS checked per physician's order. Created: 4/14/23. Created by: DON. Approach start date: 4/6/23. Meds as ordered. Created: 4/14/23. Created by: DON. Approach start date: 4/6/23. Observe for S/S of hypo/hyper glycemia (high and low blood sugar). Created: 4/14/23. Created by: DON. The care plan documented, Last review/revised: 4/14/23 at 3:11 PM by DON. Record review of the MAR for Resident #1 dated 4/1/23 - 4/14/23 documented the following regarding the resident's ordered Lantus and sliding scale Humalog insulin: Record review of 4/6/23 at 8:00 PM revealed there was no documentation on the MAR of any blood sugar testing conducted or insulin administered. The area was blank. Record review of the Progress Notes for Resident #1 dated 4/6/23 on admission at 5:22 PM documented that the resident's blood sugar was tested , and it was 203 and 3 units of insulin was administered prior to dinner - Admission Observation by LVN C. Further record review of the MAR revealed the following: On 4/7/23 at 6:30 AM his blood sugar was checked, and it was 142 and no insulin was given or required. At 11:30 AM his blood sugar was 163 and he was given three units of Humalog with LVN A. At 4:30P, His blood sugar was 264 and five units of Humalog was given by LVN A. At 8:00 PM. The blood sugar was 361 and the resident was given seven units of Humalog. It was given by LVN B. On 4/8/23 the resident refused his Lantus and refused blood sugar checks at 6:30 AM and was combative with LVN A. At 11:30 AM he refused his blood sugar and was combative with LVN A. At 4:30 PM his blood sugar was 201 and he received three units of Humalog insulin. At 8 PM his blood sugar was 400 and he was given seven units of insulin by LVN B. On 4/9/23 the resident refused his Lantus and refused blood sugar testing at 6:30 AM from LVN A. There was no documentation at 11:30 AM regarding blood sugar checks or insulin administered. At 4:30 PM the resident's blood sugar was 120 and required no sliding scale insulin by LVN F. At 8:00 PM the resident's blood sugar was 500 and receive 10 units of Humalog from LVN B. Record review of the Resident Progress Notes for Resident #1 dated 4/10/23 documented the following: 04/10/2023 5:40AM. called to the room by CNA, resident was reported to be having seizure like activity, he had jerking movements to his arms, he did not respond to verbal stimuli, this seizure like activity lasted around 1 min. Notified DON, called (Physician A) office, left message with answering service, on call to return call LVN B. 04/10/2023 6:02AM. NP A, returned call, rec (received) orders to send to ER, (hospital). BS reading hi. called (Ambulance service) amb (ambulance), awaiting amb. LVN B Record review of the hospital records for Resident #1, dated 4/10/23 revealed that a reason for the ER/hospital visit, chief complaint was altered mental status. Visit Diagnosis was diabetic, ketoacidosis with coma associated with type one diabetes mellitus, primary and dementia, unspecified, dementia, severity, unspecified, dementia, type, unspecified, whether behavioral, psychotic or mood, disturbance or anxiety. It further documented that the resident had the following diagnosis/hospital problems: acute metabolic encephalopathy, primary 4/10/23 and present on admission. AKI (acute kidney injury) date noted 4/10/23 and present on admission. DKA (diabetic ketoacidosis) date noted 2/23/23 and present on admission . Further record review revealed the following history, Visit date/time: 4/10/23 at 6:45 AM. Mode of arrival: ambulance . History. CC: altered mental status. HPI: (Resident #1) is an [AGE] year-old male who has a history of seizure from nursing home history is obtain strictly from EMS, the patient is comatose, cannot contribute to his care, is a chronic resident of a nursing home, he has a known dementia, and probably a seizure disorder is as speculated from his Depakote prescription. At any rate he is also diabetic. He noted this morning that he was not himself and had a minute seizure not witnessed by EMS, happened prior to arrival by EMS. EMS arrived at the scene and found him to be comatose. They gave him Narcan and he was transferred here for further care. He is D stick by EMS (obtain blood glucose reading) and in ER is high. no precipitating factor for this event is known. No further history available for this immediate illness. Reviewed his previous records and recent hospitalization Physical exam. Neuro: . does not open his eyes. Does not respond to pain. Does not respond to his verbalization. Does not speak. Labs. Comprehensive metabolic panel. Abnormal. Collected: 4/10/23 at 7:06 AM. Specimen: blood. Potassium 6.1 on a normal scale of 3.5-5.1 mmol/L . carbon dioxide 8 on a normal scale of 21-32 mmol/L. Glucose 1,030 on a normal scale of 74-106 mg/dL. Urinalysis with Microscopic if indicated. Abnormal . Collected: 4/10/23 at 7:06 AM. Specimen: urine. Blood, urine moderate. Glucose, urine 100 mg/dL. Ketones, urine 40 mg/dL. Disposition. Clinical impression: Final Diagnosis: diabetic ketoacidosis with coma associated with type one diabetes mellitus. Dementia, unspecified, dementia, severity, unspecified, dementia type, and specified, whether behavioral, psychotic, or mood disturbance or anxiety. Comment. Clinical impression: diabetic ketoacidosis with coma associated with type one diabetes mellitus. Clinical impression: dementia, unspecified, dementia, severity, unspecified, dementia type, unspecified, whether behavioral, psychotic, or mood disturbance or anxiety. Expected patient class: in patient. Level of service: ICU. Discharge summary note. Discharge summary. Service: palliative care. Death summary. date of death : 4/15/2023. Time of death: 1929 (7:29 PM) Cause of death: renal failure, metabolic acidosis, lactic acidosis. Other contributing factors: Principal problem: acute metabolic encephalopathy. Active problems: . diabetes myelitis. DKA (diabetic [NAME] acidosis) . Hospital Course: (Resident #1) is a [AGE] year old male who was admitted on [DATE]. Patient is currently living at (Nursing Facility), he has a significant past medical history of poorly controlled diabetes mellitus, hypertension . severe vascular dementia He presented to the ER via EMS with altered mental status, and possible seizure .4/12 (2023) patients functional and Neuro status continue to decline. patient transferred to palliative care unit for comfort care, symptom management and discharge planning. Patient continued to decline, and death pronounced on 4/15/23 . Record review of facility clinical records for Resident #1 revealed there was prior documentation of a history of hospitalization for ketoacidosis. The documentation was as follows: Record review of Hospital, History and Physical for Resident #1 dated 2/23/23 revealed the following documentation, Date of admission: 2/23/23. Reason for admission: DKA. Chief complaint: multiple episodes of nausea/vomiting. History of present illness. He was recently placed in a nursing home for this past Friday (2/17/23) who presented to (Hospital ER) via EMS from nursing home for elevated blood glucose. Upon arrival to (Hospital ER) blood glucose was recorded at 581. and found to be in metabolic acidosis. He will be admitted to MICU (intensive care) under the care of the intensivists for continued DKA management and insulin. Record review of the face sheet for Resident #1 from his previous discharging facility, Nursing Facility B, revealed that he was admitted to the facility on [DATE] from the hospital. His primary admission diagnosis was type 2 diabetes mellitus with ketoacidosis without coma. Record review of a NP B visit to Resident #1 at Nursing Facility B dated 3/14/23 revealed the following documentation, .confused, refuses meds/Accu checks, hitting staff. Assessment/Plan. 1. Ketoacidosis. 2. diabetes mellitus Lantus and SSI refused. Record review of the Resident Progress Notes at Nursing Facility B for Resident #1 dated 4/5/23 revealed that the resident was referred to his current facility. On 4/14/23 at 5:18 PM an interview was conducted with charge nurse LVN C. Regarding Resident #1 she stated, she conducted his admission. She added that he was oriented to self and family. He had a diagnosis of diabetes mellitus and a history of diabetic ketoacidosis. He could be combative. He refused medications, insulin, and food. She stated she only had one hour with him and conducted a blood sugar check and administered three units of insulin. LVN C also stated she was present at the time Resident #1 was sent to theER on [DATE]. Regarding Resident #1 on 4/10/23, she stated, the night nurse said that he had a seizure. Staff checked his blood sugar two times, and it was high on the glucometer scale. Staff did contact On-call, NP A and were told send him to the ER. She stated the resident had no other seizure activity before he left. LVN C stated that she went back and reviewed the notes for the resident and saw he had refused blood sugar checks. Regarding the protocol if a resident refused blood sugar checks, she stated, she would attempt multiple times, and could usually get the resident to consent to blood sugar testing. She added that if the blood sugar was high, she would contact the family to help persuade the resident to take the insulin. If she still could not accomplish that, she would contact the Provider, then follow their instructions. She stated she would call the doctor at a blood sugar of 500. On 4/14/23 at 7:19 PM an interview was conducted with the Director of Nurses regarding Resident #1 incident. She stated the resident was admitted on the sixth (4/06/23). On Saturday and Sunday (4/08/23 and 4/09/23) he refused his morning blood sugar checks and insulin. LVNs attempted blood sugar checks at lunch, dinner and bedtime and he took his sliding scale insulin. She stated that at approximately 5:40 AM on 4/10/23, staff noted seizure activity. Resident #1 was sent to the ER and had high blood sugar. She added that the resident was administered insulin at bedtime to cover spikes in blood sugar levels. Regarding insulin refusal procedures, she stated, staff would try to re-approach and give it again. She added at bedtime the resident's blood sugar was elevated, and he was administered sliding scale insulin in order to prevent spikes in his blood sugar levels. She stated he was AC and HS blood sugar test. On 4/14/23 at 7:56 PM an observation was made of Resident #1 at the hospital. Visitors were present and the resident was sleep and not responsive to touch or sound, had IV medications, oxygen and a catheter. On 4/14/23 at 8:02 PM an interview was conducted with hospital charge nurse, RN A regarding seizures. She stated that Resident #1 was on PRN medication for seizures. She stated, he had a seizure dosage and anxiety dosage. She stated that the resident had been placed on palliative care. On 4/15/23 at 10:20 AM an interview was conducted with the Director of Nurses regarding staff that were present on 4/10/23, during Resident #1's incident. She stated staff were LVN B, CNA A and CNA B. On 4/15/23 at 11:58 AM an interview was conducted with LVN B regarding Resident #1's incident on 4/10/23. She stated, staff called her back to the dementia unit, and said the resident was having a seizure. LVN C checked his blood sugar and said it displayed high on the glucometer, with no specific number as to what the specific blood sugar was. She stated she had not heard that he refused blood sugar checks. She added that on a couple of occasions he would not take his pills for her. Regarding the 8:00PM blood sugar result of 500 on 4/09/23, she stated she followed the sliding scale insulin order because the blood sugar was not over 500. She added that the resident took his medications the first nights in the facility. She stated the last night he was in the facility; he still spit out his pills in the presence of his wife. Regarding procedures on refusals, she stated, residents had the right to refuse. She added she would call the doctor if blood sugar checks were high, and the resident did not take the insulin. She stated the night Resident #1's blood sugar was high (4/09/23 at 8:00PM), she expected it to come down later (after receiving the insulin). She further stated she was not aware of any seizure activity with Resident #1 earlier in the shift on 4/09/23. On 4/15/23 at 12:14 PM an interview was conducted with CNA A. She stated on the morning of 4/10/23 staff were making rounds on the dementia unit, and she saw Resident #1 jerking. She added the other CNA went to get the nurse. This occurred at the end of the shift. She stated the resident was normally up and walking. She further stated at the beginning of the night/evening shift on 4/9/23, the resident was discovered in another resident's bed and was sluggish. She added that this observation was reported to the nurse (LVN B), and she took the resident's blood sugar at that time. Regarding Resident #1's demeanor she stated, the resident had behaviors and was physically combative. On 4/15/23 at 12:24 PM an interview was conducted with the Nurse Practitioner for Physician A, NP A. Regarding what she expected from staff related to Resident #1 refusing insulin and blood sugar testing. She stated, staff should have called her. She added patients could refuse medications and they would tell staff to offer it again. Regarding a resident missing their Lantus insulin, she stated, staff needed to have contacted the NP/Physician. She added she had checked 3 nurses on her phone contact app and could not say that she had been contacted regarding Resident #1's refusals. She stated diabetic coma, increased blood sugars, or nothing could happen if a resident did not receive their insulin. On 4/15/23 at 12:38 PM an interview was conducted with LVN A regarding Resident #1. Regarding the blank blood sugar result area in the MAR for 4/9/23 at 11:30 AM, she stated the resident, in general, was combative with her and would tell her to stop and get away. She stated she tried a couple of times to administer the insulin and take blood sugar checks but did not remember why the area was blank on the MAR. She added that weekend (4/8/23 and 4/9/23) the facility was short staffed, and she had to take on CNA duties. Regarding Resident #1 refusing his Lantus, she stated she typically tried to convince residents, but he was not letting her get close. Regarding anyone contacted about Resident #1 refusing Lantus and his blood sugar checks. She stated she honestly did not think she (LVN A) did contact anyone, only the wife. Regarding the facility procedure if long-acting insulin is not given, she stated, notify the physician and the family. She added she should have contacted the physician and the family but did not contact them. She stated residents could end up in the hospital with hypoglycemia as a result of not receiving their insulin. Regarding any facility training she received regarding insulin and when or who to report to regarding refusals. She stated she had not received any training or in-services regarding those subjects. She stated that she had worked in the facility since August 2022. On 4/15/23 at 1:17 PM an interview was conducted with the Director of Nurses, and she stated she had conducted in-services on insulin and notifications but could not find the folder they were in. On 4/15/23 at 1:46 PM an interview was conducted with the Director of Nursing regarding glucose monitoring. She stated, if it were her, she would have called someone about the refusals of blood sugar checks and insulin. She added that in a previous in-service, she instructed staff to notify on refusals. She added if it was a couple of times, staff should contacted someone. Regarding what she expected staff to have done in that situation regarding the missed insulin and refusals for Resident #1, she stated, she expected staff to notify someone. She added if it were her, she would contact the nurse practitioner, the on-call NP/Physician and the family. She added it was basic nursing knowledge to know who and when to notify. Regarding whom was responsible to ensure that staff notify the appropriate people regarding refusals and the lack of administration of insulin, she stated, the DON and the nurses. She stated increased blood sugars could result from residents not receiving their insulin and blood sugar checks not conducted. On 4/15/23 at 2:44 PM an interview was conducted with the Director of Nurses regarding LVN A informing her or a supervisor about Resident #1 refusing blood sugar checks and Lantus. She stated, LVN A did not inform her of the refused Lantus. She stated she did not know until 5:40 AM (4/10/23) when the resident was sent out to the ER, and she started looking at the charting. She added if a resident's blood sugar check was over 500, the glucometer display reads high. On 4/16/23 at 12:48 PM an interview was conducted with LVN A and she stated she remembered she told the Director of Nurses on Saturday 4/8/23 of Resident #1's refusal of blood sugar checks and insulin and the ADON was present. She added the Director of Nurses told her the resident had a right to refuse and did not mention anything about calling the nurse practitioner or physician. She further stated she had not received any in-services on insulin refusals or physician notifications guidelines. She stated her supervisor was the Director of Nurses. She further stated it was correct that she did not call the doctor or nurse practitioner regarding Resident #1's refusals of blood sugar testing and insulin. Regarding her orientation at the time she was hired, she stated it was more like being introduced to the system and not an orientation or training. She added there was no competency reviews conducted and she was trained on the floor one day with a senior nurse. She further stated her second day she was on the floor on her own. On 4/16/23 at 1:30 PM, an interview was conducted with the Director of Nurses and she stated there was a chart audit of blood sugar checks and insulin conducted on 4/15/23 and additional issues were discovered. She stated physicians were notified of those issues. Regarding if NP A and Physician A were aware or had any knowledge of the refusals of insulin by Resident #1, she stated neither had any prior knowledge of the refusals of insulin. On 4/16/23 at 2:00 PM an interview was conducted with the Director of Nurses, and she stated she was in the facility last Saturday, 4/8/23 and denied being told about Resident #1's refusal of insulin on 4/08/23. She stated she was not aware of the refusals until Monday (4/10/23). Regarding orientation of new nurses, she stated, the training was conducted by the ADONs. Nursing administration gear the training to the nurse to determine when they were ready. Regarding competency reviews of nurses, she stated, they were conducted by nurse management if something specific or issue occurs. She added, she had the conducting of annual nurse competencies on her list to do but had not been able to do them. She further stated the facility had no overall system in place to monitor staff actions related to blood sugar checks and refusals (blood sugar checks/insulin). Regarding why the issue happened with Resident #1, she stated, the nurses did not notify anyone in order to seek guidance as to what to do next. She stated she defined supervisor as the DON and ADON and at times it could be situational. She stated, she had not found anyone LVN A reported Resident #1's refusals to; staff or physician. Resident #2 Record review of the Physician Order Report: 4/16/23-4/16/23 for female Resident #2 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. Further record review revealed that the resident had diagnoses of end-stage renal disease (kidney disease) and diabetes mellitus due to underlying condition with diabetic chronic kidney disease. Record review of the Physician Order Report revealed that the resident had the following orders, Order type - Prescription. Start date 3/9/23. End date - Open ended. Description. Humalog U-100 insulin (insulin lispro) Solution; 100 unit/mL; amt: per sliding scale; If blood sugar is less than 60, call MD. If blood sugar is 150 to 200 give two units. If blood sugar is 201 to 250 give four units. If blood sugar is 251 to 300, give six units. If blood sugar is 301 to 350, give eight units. If blood sugar is 351 to 400, give 10 units. If blood sugar is 401 to 450, give 12 units. If blood sugar is greater than 450, give zero units. If blood sugar is greater than 450, call MD. Subcutaneous. [DX: diabetes mellitus due to underlying condition with diabetic chronic kidney disease] Before meals and at bedtime; 7:30 AM, 12:30 PM, 4:30 PM, 8:00 PM Record review of the most recent quarterly MDS assessment for Resident #2, dated 3/23/23 documented that the resident had a BIMS score of 15 indicating that she was cognitively intact. Further record review of the MDS revealed that the resident had an active diagnosis of diabetes mellitus. Documentation under the area Medications revealed that the resident received insulin injections seven times in the last seven days. Record review of the care plan for Resident #2, Last Reviewed/Revised: 3/29/23.revealed a Problem, documented as, Problems start date: 3/10/23. Category: diagnosis diabetes. Edited: 3/29/23. The listed Approaches included, Approach start date: 3/10/23 FSBS checked as ordered. Created: 3/13/23. Approach start date: 3/10/23. Meds as ordered. Created: 3/13/23 and Approach start date: 3/10/23. Observe for S/S of hypo/hyper glycemia. Created: 3/13/23 . Record review of the MAR for Resident #2 dated 4/1/23-4/14/23 revealed that under the Humalog administration, there was a refusal of blood sugar checks on 4/9/23 at 12:30 PM by LVN A. There were also refusals of blood sugar testing documented on the following days and times, 4:30 PM on 4/3/23, 4/4/23, and 4/12/23 by LVN A. The reason for the refusals was documented that the resident would not wake up from her nap. There were also blank spaces with no documentation regarding blood sugar checks or insulin on the following days and times: 8:00 PM on 4/4/23, 4/8/23, and 4/12/23. Record review of the Resident Progress Notes for Resident #2 dated 3/16/23 to 4/14/23 had no documentation regarding the blank areas on the MAR. Resident #3 Record review of the Physician Order Report: 4/16/23-4/16/23 for female Resident #3 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of other cerebral infarction (heart attack), and major depressive disorder. Further record review of the Physician Order Report revealed the resident had the following orders: Order Type - Prescription. Start date - 5/12/22. End date - Open ended. Trulicity (dulaglutide) pen injector; 0.75 mg/0.5 ml; amt: 0.5 ml; sub cutaneous. [DX: type two diabetes mellitus without complications] once a day on Wednesday; 7:00 AM - 10:00 AM. Order type - Prescription. Start date - 7/26/22. End date - Open ended. Description. Humalog U - 100 insulin (insulin lispro) solution; 100 unit/ml; amt: per sliding scale; If blood sugar is less than 60, call MD. If blood sugar is 150 to 200, give two units. If blood sugar is 201 to 250, get four units. If blood sugar is 251 to 300, gives six units. If blood sugar is 301 to 350, give eight units. If blood sugar is 351 to 400, give 10 units. If blood sugar is greater than 400, call NP/PA. Subcutaneous [DX: type two diabetes mellitus without complications] Twice a day; morning, 7:00 AM to 10:00 AM, bedtime 7:00 PM to 10:00 PM. Record review of the MAR for Resident #3 dated 4/1/20 23-4/14/2023 revealed the following documentation: Humalog administration revealed there was no documentation for the bedtime 7 PM - 10 PM blood sugar testing or insulin administration (Blank) on 4/4/23, 4/7/23, 4/8/23, 4/12/23, and 4/13/23. There was no documentation as to why these areas were blank. Record review of the most recent quarterly MDS for Resident #3 dated 3/2/23 documented that the resident had a BIM's score of 14 indicating that she was cognitively intact. An active diagnosis was documented as diabetes mellitus. Further record review of the MDS revealed that the resident received five insulin injections within the last seven days. Record review of the care plan for Resident #3 Last Reviewed/Revised: 3/8/23. Revealed a Problem as follows: Problem, start date: 5/18/20. Category: diagnosis. Resident has diabetes type 2 edited: 3/8/23. The Approaches listed included, Approach start date: 5/18/20. FSBS checked as ordered. Created: 5/18/20. Approach start date: 5/18/20. Meds as ordered. Created: 5/18/20. Approach start date: 5/18/20. Observe for S/S of hypo/hyperglycemia. Created: 5/18/20 . Record review of the Resident Progress Notes for Resident #3 dated 3/16/23 to 4/14/23 had no documentation regarding the blank areas on the MAR. Resident #4 Record review of the Physician Order Report dated 4/16/23-4/16/23 for female Resident #4 revealed she was admitted to the facility on [DATE] and was [AGE] years old. Documented diagnoses were end-stage renal disease and type two diabetes mellitus with other skin ulcer. Further record review of the Physician Order Report revealed the following orders: Order type - Prescription. Start date - 5/18/22. End date - Open ended. Description. Insulin lispro Insulin pen; 100 unit/ML; AMT: per sliding scale; If blood sugar is less than 70, call NP/PA. If blood sugar is 70 to 150, give 0 units. If blood sugar is 151 to 200, give two units. If blood sugar is 201 to 250, give four units. If blood sugar is 251 to 300, give six units. If blood sugar is 300 to 350, give eight units. If blood sugar is 351 to 400, give 10 units. If blood sugar is 401 to 450, gives 12 units. If blood sugar is 450 to 500, give 14 units. If blood sugar is greater than 501, called NP/PA. Subcutaneous. [DX: type two diabetes myelitis without complications] Before meals, and at bedtime; 7:30 AM, 11:30 AM, 4:30 PM, 8:00 PM Order type - Prescription. Start date - 4/11/23. End date - Open ended. Description. Lantus U-100 insulin (insulin glargine) solution; 100 units/ML; amount AMT: 20 units; subcutaneous. [DX: type two diabetes mellitus without complications] Twice a day; morning, 7:00 AM - 10:00 AM, bedtime, 7:00 PM - 10:00 PM Record review of the most recent quarterly, MDS Resident #4 revealed that the resident had a BIMS score of 14 indicating she was cognitively intact. Further record review of the MDS revealed that the resident had an active diagnosis of diabetes mellitus. Record review revealed that the resident received insulin injections six times in the last seven days. Record review of the care plan for Resident #4 revealed that it was Last Reviewed/Revised: 3/7/23. There was a documented Problem stating, Problem Start Date: 06/08/2022. Category: Endocrine Disorders. Resident has an impaired endocrine system r/t diabetes. Edited: 03/07/2023. The approaches listed for this problem were geared toward resident education of diabetes. Record review of the MAR documentation for Resident #4 revealed the following documentation for insulin lispro: there were documented refusals of blood sugar testing on 4/4/23 at 11:30 AM and 4:30 PM by the ADON and 4/8/23 at 11:30 AM by LVN D. There was no documentation of blood sugar testing or insulin administration (blank) on 4/6/23 at 8:00 PM and 4/12/23 at 7:30 AM and 11:30 AM. Record review of the MAR for Lantus U - 100 revealed the resident refused her Lantus on 4/6/23 at 7:00 AM to 10:00 AM. There was no documentation of blood sugar testing or administration of Lantus (blank) on 4/6/23 at 7 PM to 10 PM bedtime. Record review of the Resident Progress Notes for Resident #4 dated 3/16/23 to 4/14/23 had no documentation regarding the blank areas on the MAR. On 4/16/23 at 3:02 PM the DON stated that she was not aware of refusals and missing documentation for the residents listed on the MAR chart audit until the facility conducted a chart audit on 4/15/23. The audit included Residents #2, #3 and #4. Record review of the most recent in-service documentation for Abuse (Neglect) Education dated 3/26/23 and 3/31/23 reveal that LVN A attended being servic [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 4 of 5 residents who required blood sugar monitoring and administration of insulin (Residents #1, 2, 3, 4); in that: The facility failed to effectively monitor Resident #1's blood sugars and take appropriate actions related to blood sugar results, which resulted in the hospitalization of Resident #1 with a diagnosis of metabolic acidosis. Staff failed to notify nursing supervisory staff and physician of Resident #1's refusals of blood sugar testing and insulin in order to receive further instructions on what to do. This failure resulted in the identification of an IJ on 4/15/23 at 5:25 PM. While the 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 isolated. The facility failed to provide adequate documentation related to Medication Administration Records for Residents #1, 2, 3 and 4, who required blood sugar monitoring and insulin administration. These failures could place residents at risk for elevated levels of glucose which could result in harm, impairment, or death. The findings include: Resident #1 Record review of the Physician Order Report for male Resident #1 dated 4/10/2023 - 4/10/2023 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. Diagnoses listed were type 2 diabetes mellitus with ketoacidosis without coma (blood sugar disorder), hyperlipidemia, unspecified (elevated cholesterol), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (mental disorder), essential (primary) hypertension (high blood pressure), acute kidney failure, unspecified, personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits (stroke), and vascular dementia, severe, and other behavioral disturbance (mental disorder). Further record review of this Physician Order Report for Resident #1 revealed that the resident had the following orders documented as Order type - Prescription. Start date 4/6/2023 - End date Open-ended. Description. Humalog U-100Insulin (insulin lispro) solution; 100 unit/mL; amt: Per Sliding Scale; If Blood Sugar is less than 60, call MD. If Blood Sugar is 61 to 150, give 0 Units. If Blood Sugar is 151 to 250, give 3 Units. If Blood Sugar is 251 to 350, give 5 Units. If Blood Sugar is 351 to 450, give 7 Units. If Blood Sugar is 451 to 500, give 10 Units. If Blood Sugar is greater than 500, call NP/PA. Subcutaneous Before Meals and At Bedtime 06:30 AM, 11:30 AM, 04:30 PM, 08:00 PM. Ordered by Physician A. Order type - Prescription. Start date 4/6/2023 - End date Open-ended. Description. Lantus Solostar U-100 insulin (insulin glargine) insulin pen; 100 unit/mL (3ml); amt: 25; Subcutaneous [DX: type 2 diabetes mellitus with ketoacidosis without coma] Once a morning; Morning 7:00 AM-10:00 AM. Ordered by Physician A . Record review of the MDS documentation for Resident #1 revealed the resident's admission MDS was not due. Record review of the current care plan for Resident #1 dated 4/14/23 revealed a Problem start date: 4/6/23. Category: diagnosis diabetes. Created: 4/14/23. Created by DON. The goal listed was, No complications. Created: 4/14/23. Created by: DON. Approaches listed were as follows, Approach start date: 4/6/23 FSBS checked per physician's order. Created: 4/14/23. Created by: DON. Approach start date: 4/6/23. Meds as ordered. Created: 4/14/23. Created by: DON. Approach start date: 4/6/23. Observe for S/S of hypo/hyper glycemia (high and low blood sugar). Created: 4/14/23. Created by: DON. The care plan documented, Last review/revised: 4/14/23 at 3:11 PM by DON. Record review of the MAR for Resident #1 dated 4/1/23 - 4/14/23 documented the following regarding the resident's ordered Lantus and sliding scale Humalog insulin: Record review of 4/6/23 at 8:00 PM revealed there was no documentation on the MAR of any blood sugar testing conducted or insulin administered. The area was blank. Record review of the Progress Notes for Resident #1 dated 4/6/23 on admission at 5:22 PM documented that the resident's blood sugar was tested , and it was 203 and 3 units of insulin was administered prior to dinner - Admission Observation by LVN C. Further record review of the MAR revealed the following: On 4/7/23 at 6:30 AM his blood sugar was checked, and it was 142 and no insulin was given or required. At 11:30 AM his blood sugar was 163 and he was given three units of Humalog with LVN A. At 4:30P, His blood sugar was 264 and five units of Humalog was given by LVN A. At 8:00 PM. The blood sugar was 361 and the resident was given seven units of Humalog. It was given by LVN B. On 4/8/23 the resident refused his Lantus and refused blood sugar checks at 6:30 AM and was combative with LVN A. At 11:30 AM he refused his blood sugar and was combative with LVN A. At 4:30 PM his blood sugar was 201 and he received three units of Humalog insulin. At 8 PM his blood sugar was 400 and he was given seven units of insulin by LVN B. On 4/9/23 the resident refused his Lantus and refused blood sugar testing at 6:30 AM from LVN A. There was no documentation at 11:30 AM regarding blood sugar checks or insulin administered. At 4:30 PM the resident's blood sugar was 120 and required no sliding scale insulin by LVN F. At 8:00 PM the resident's blood sugar was 500 and receive 10 units of Humalog from LVN B. Record review of the Resident Progress Notes for Resident #1 dated 4/10/23 documented the following: 04/10/2023 5:40AM. called to the room by CNA, resident was reported to be having seizure like activity, he had jerking movements to his arms, he did not respond to verbal stimuli, this seizure like activity lasted around 1 min. Notified DON, called (Physician A) office, left message with answering service, on call to return call LVN B. 04/10/2023 6:02AM. NP A, returned call, rec (received) orders to send to ER, (hospital). BS reading hi. called (Ambulance service) amb (ambulance), awaiting amb. LVN B Record review of the hospital records for Resident #1, dated 4/10/23 revealed that a reason for the ER/hospital visit, chief complaint was altered mental status. Visit Diagnosis was diabetic, ketoacidosis with coma associated with type one diabetes mellitus, primary and dementia, unspecified, dementia, severity, unspecified, dementia, type, unspecified, whether behavioral, psychotic or mood, disturbance or anxiety. It further documented that the resident had the following diagnosis/hospital problems: acute metabolic encephalopathy, primary 4/10/23 and present on admission. AKI (acute kidney injury) date noted 4/10/23 and present on admission. DKA (diabetic ketoacidosis) date noted 2/23/23 and present on admission . Further record review revealed the following history, Visit date/time: 4/10/23 at 6:45 AM. Mode of arrival: ambulance . History. CC: altered mental status. HPI: (Resident #1) is an [AGE] year-old male who has a history of seizure from nursing home history is obtain strictly from EMS, the patient is comatose, cannot contribute to his care, is a chronic resident of a nursing home, he has a known dementia, and probably a seizure disorder is as speculated from his Depakote prescription. At any rate he is also diabetic. He noted this morning that he was not himself and had a minute seizure not witnessed by EMS, happened prior to arrival by EMS. EMS arrived at the scene and found him to be comatose. They gave him Narcan and he was transferred here for further care. He is D stick by EMS (obtain blood glucose reading) and in ER is high. no precipitating factor for this event is known. No further history available for this immediate illness. Reviewed his previous records and recent hospitalization Physical exam. Neuro: . does not open his eyes. Does not respond to pain. Does not respond to his verbalization. Does not speak. Labs. Comprehensive metabolic panel. Abnormal. Collected: 4/10/23 at 7:06 AM. Specimen: blood. Potassium 6.1 on a normal scale of 3.5-5.1 mmol/L . carbon dioxide 8 on a normal scale of 21-32 mmol/L. Glucose 1,030 on a normal scale of 74-106 mg/dL. Urinalysis with Microscopic if indicated. Abnormal . Collected: 4/10/23 at 7:06 AM. Specimen: urine. Blood, urine moderate. Glucose, urine 100 mg/dL. Ketones, urine 40 mg/dL. Disposition. Clinical impression: Final Diagnosis: diabetic ketoacidosis with coma associated with type one diabetes mellitus. Dementia, unspecified, dementia, severity, unspecified, dementia type, and specified, whether behavioral, psychotic, or mood disturbance or anxiety. Comment. Clinical impression: diabetic ketoacidosis with coma associated with type one diabetes mellitus. Clinical impression: dementia, unspecified, dementia, severity, unspecified, dementia type, unspecified, whether behavioral, psychotic, or mood disturbance or anxiety. Expected patient class: in patient. Level of service: ICU. Discharge summary note. Discharge summary. Service: palliative care. Death summary. date of death : 4/15/2023. Time of death: 1929 (7:29 PM) Cause of death: renal failure, metabolic acidosis, lactic acidosis. Other contributing factors: Principal problem: acute metabolic encephalopathy. Active problems: . diabetes myelitis. DKA (diabetic [NAME] acidosis) . Hospital Course: (Resident #1) is a [AGE] year old male who was admitted on [DATE]. Patient is currently living at (Nursing Facility), he has a significant past medical history of poorly controlled diabetes mellitus, hypertension . severe vascular dementia He presented to the ER via EMS with altered mental status, and possible seizure .4/12 (2023) patients functional and Neuro status continue to decline. patient transferred to palliative care unit for comfort care, symptom management and discharge planning. Patient continued to decline, and death pronounced on 4/15/23 . Record review of facility clinical records for Resident #1 revealed there was prior documentation of a history of hospitalization for ketoacidosis. The documentation was as follows: Record review of Hospital, History and Physical for Resident #1 dated 2/23/23 revealed the following documentation, Date of admission: 2/23/23. Reason for admission: DKA. Chief complaint: multiple episodes of nausea/vomiting. History of present illness. He was recently placed in a nursing home for this past Friday (2/17/23) who presented to (Hospital ER) via EMS from nursing home for elevated blood glucose. Upon arrival to (Hospital ER) blood glucose was recorded at 581. and found to be in metabolic acidosis. He will be admitted to MICU (intensive care) under the care of the intensivists for continued DKA management and insulin. Record review of the face sheet for Resident #1 from his previous discharging facility, Nursing Facility B, revealed that he was admitted to the facility on [DATE] from the hospital. His primary admission diagnosis was type 2 diabetes mellitus with ketoacidosis without coma. Record review of a NP B visit to Resident #1 at Nursing Facility B dated 3/14/23 revealed the following documentation, .confused, refuses meds/Accu checks, hitting staff. Assessment/Plan. 1. Ketoacidosis. 2. diabetes mellitus Lantus and SSI refused. Record review of the Resident Progress Notes at Nursing Facility B for Resident #1 dated 4/5/23 revealed that the resident was referred to his current facility. On 4/14/23 at 5:18 PM an interview was conducted with charge nurse LVN C. Regarding Resident #1 she stated, she conducted his admission. She added that he was oriented to self and family. He had a diagnosis of diabetes mellitus and a history of diabetic ketoacidosis. He could be combative. He refused medications, insulin, and food. She stated she only had one hour with him and conducted a blood sugar check and administered three units of insulin. LVN C also stated she was present at the time Resident #1 was sent to theER on [DATE]. Regarding Resident #1 on 4/10/23, she stated, the night nurse said that he had a seizure. Staff checked his blood sugar two times, and it was high on the glucometer scale. Staff did contact On-call, NP A and were told send him to the ER. She stated the resident had no other seizure activity before he left. LVN C stated that she went back and reviewed the notes for the resident and saw he had refused blood sugar checks. Regarding the protocol if a resident refused blood sugar checks, she stated, she would attempt multiple times, and could usually get the resident to consent to blood sugar testing. She added that if the blood sugar was high, she would contact the family to help persuade the resident to take the insulin. If she still could not accomplish that, she would contact the Provider, then follow their instructions. She stated she would call the doctor at a blood sugar of 500. On 4/14/23 at 7:19 PM an interview was conducted with the Director of Nurses regarding Resident #1 incident. She stated the resident was admitted on the sixth (4/06/23). On Saturday and Sunday (4/08/23 and 4/09/23) he refused his morning blood sugar checks and insulin. LVNs attempted blood sugar checks at lunch, dinner and bedtime and he took his sliding scale insulin. She stated that at approximately 5:40 AM on 4/10/23, staff noted seizure activity. Resident #1 was sent to the ER and had high blood sugar. She added that the resident was administered insulin at bedtime to cover spikes in blood sugar levels. Regarding insulin refusal procedures, she stated, staff would try to re-approach and give it again. She added at bedtime the resident's blood sugar was elevated, and he was administered sliding scale insulin in order to prevent spikes in his blood sugar levels. She stated he was AC and HS blood sugar test. On 4/14/23 at 7:56 PM an observation was made of Resident #1 at the hospital. Visitors were present and the resident was sleep and not responsive to touch or sound, had IV medications, oxygen and a catheter. On 4/14/23 at 8:02 PM an interview was conducted with hospital charge nurse, RN A regarding seizures. She stated that Resident #1 was on PRN medication for seizures. She stated, he had a seizure dosage and anxiety dosage. She stated that the resident had been placed on palliative care. On 4/15/23 at 10:20 AM an interview was conducted with the Director of Nurses regarding staff that were present on 4/10/23, during Resident #1's incident. She stated staff were LVN B, CNA A and CNA B. On 4/15/23 at 11:58 AM an interview was conducted with LVN B regarding Resident #1's incident on 4/10/23. She stated, staff called her back to the dementia unit, and said the resident was having a seizure. LVN C checked his blood sugar and said it displayed high on the glucometer, with no specific number as to what the specific blood sugar was. She stated she had not heard that he refused blood sugar checks. She added that on a couple of occasions he would not take his pills for her. Regarding the 8:00PM blood sugar result of 500 on 4/09/23, she stated she followed the sliding scale insulin order because the blood sugar was not over 500. She added that the resident took his medications the first nights in the facility. She stated the last night he was in the facility; he still spit out his pills in the presence of his wife. Regarding procedures on refusals, she stated, residents had the right to refuse. She added she would call the doctor if blood sugar checks were high, and the resident did not take the insulin. She stated the night Resident #1's blood sugar was high (4/09/23 at 8:00PM), she expected it to come down later (after receiving the insulin). She further stated she was not aware of any seizure activity with Resident #1 earlier in the shift on 4/09/23. On 4/15/23 at 12:14 PM an interview was conducted with CNA A. She stated on the morning of 4/10/23 staff were making rounds on the dementia unit, and she saw Resident #1 jerking. She added the other CNA went to get the nurse. This occurred at the end of the shift. She stated the resident was normally up and walking. She further stated at the beginning of the night/evening shift on 4/9/23, the resident was discovered in another resident's bed and was sluggish. She added that this observation was reported to the nurse (LVN B), and she took the resident's blood sugar at that time. Regarding Resident #1's demeanor she stated, the resident had behaviors and was physically combative. On 4/15/23 at 12:24 PM an interview was conducted with the Nurse Practitioner for Physician A, NP A. Regarding what she expected from staff related to Resident #1 refusing insulin and blood sugar testing. She stated, staff should have called her. She added patients could refuse medications and they would tell staff to offer it again. Regarding a resident missing their Lantus insulin, she stated, staff needed to have contacted the NP/Physician. She added she had checked 3 nurses on her phone contact app and could not say that she had been contacted regarding Resident #1's refusals. She stated diabetic coma, increased blood sugars, or nothing could happen if a resident did not receive their insulin. On 4/15/23 at 12:38 PM an interview was conducted with LVN A regarding Resident #1. Regarding the blank blood sugar result area in the MAR for 4/9/23 at 11:30 AM, she stated the resident, in general, was combative with her and would tell her to stop and get away. She stated she tried a couple of times to administer the insulin and take blood sugar checks but did not remember why the area was blank on the MAR. She added that weekend (4/8/23 and 4/9/23) the facility was short staffed, and she had to take on CNA duties. Regarding Resident #1 refusing his Lantus, she stated she typically tried to convince residents, but he was not letting her get close. Regarding anyone contacted about Resident #1 refusing Lantus and his blood sugar checks. She stated she honestly did not think she (LVN A) did contact anyone, only the wife. Regarding the facility procedure if long-acting insulin is not given, she stated, notify the physician and the family. She added she should have contacted the physician and the family but did not contact them. She stated residents could end up in the hospital with hypoglycemia as a result of not receiving their insulin. Regarding any facility training she received regarding insulin and when or who to report to regarding refusals. She stated she had not received any training or in-services regarding those subjects. She stated that she had worked in the facility since August 2022. On 4/15/23 at 1:17 PM an interview was conducted with the Director of Nurses, and she stated she had conducted in-services on insulin and notifications but could not find the folder they were in. On 4/15/23 at 1:46 PM an interview was conducted with the Director of Nursing regarding glucose monitoring. She stated, if it were her, she would have called someone about the refusals of blood sugar checks and insulin. She added that in a previous in-service, she instructed staff to notify on refusals. She added if it was a couple of times, staff should contacted someone. Regarding what she expected staff to have done in that situation regarding the missed insulin and refusals for Resident #1, she stated, she expected staff to notify someone. She added if it were her, she would contact the nurse practitioner, the on-call NP/Physician and the family. She added it was basic nursing knowledge to know who and when to notify. Regarding whom was responsible to ensure that staff notify the appropriate people regarding refusals and the lack of administration of insulin, she stated, the DON and the nurses. She stated increased blood sugars could result from residents not receiving their insulin and blood sugar checks not conducted. On 4/15/23 at 2:44 PM an interview was conducted with the Director of Nurses regarding LVN A informing her or a supervisor about Resident #1 refusing blood sugar checks and Lantus. She stated, LVN A did not inform her of the refused Lantus. She stated she did not know until 5:40 AM (4/10/23) when the resident was sent out to the ER, and she started looking at the charting. She added if a resident's blood sugar check was over 500, the glucometer display reads high. On 4/16/23 at 12:48 PM an interview was conducted with LVN A and she stated she remembered she told the Director of Nurses on Saturday 4/8/23 of Resident #1's refusal of blood sugar checks and insulin and the ADON was present. She added the Director of Nurses told her the resident had a right to refuse and did not mention anything about calling the nurse practitioner or physician. She further stated she had not received any in-services on insulin refusals or physician notifications guidelines. She stated her supervisor was the Director of Nurses. She further stated it was correct that she did not call the doctor or nurse practitioner regarding Resident #1's refusals of blood sugar testing and insulin. Regarding her orientation at the time she was hired, she stated it was more like being introduced to the system and not an orientation or training. She added there was no competency reviews conducted and she was trained on the floor one day with a senior nurse. She further stated her second day she was on the floor on her own. On 4/16/23 at 1:30 PM, an interview was conducted with the Director of Nurses and she stated there was a chart audit of blood sugar checks and insulin conducted on 4/15/23 and additional issues were discovered. She stated physicians were notified of those issues. Regarding if NP A and Physician A were aware or had any knowledge of the refusals of insulin by Resident #1, she stated neither had any prior knowledge of the refusals of insulin. On 4/16/23 at 2:00 PM an interview was conducted with the Director of Nurses, and she stated she was in the facility last Saturday, 4/8/23 and denied being told about Resident #1's refusal of insulin on 4/08/23. She stated she was not aware of the refusals until Monday (4/10/23). Regarding orientation of new nurses, she stated, the training was conducted by the ADONs. Nursing administration gear the training to the nurse to determine when they were ready. Regarding competency reviews of nurses, she stated, they were conducted by nurse management if something specific or issue occurs. She added, she had the conducting of annual nurse competencies on her list to do but had not been able to do them. She further stated the facility had no overall system in place to monitor staff actions related to blood sugar checks and refusals (blood sugar checks/insulin). Regarding why the issue happened with Resident #1, she stated, the nurses did not notify anyone in order to seek guidance as to what to do next. She stated she defined supervisor as the DON and ADON and at times it could be situational. She stated, she had not found anyone LVN A reported Resident #1's refusals to; staff or physician. Resident #2 Record review of the Physician Order Report: 4/16/23-4/16/23 for female Resident #2 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. Further record review revealed that the resident had diagnoses of end-stage renal disease (kidney disease) and diabetes mellitus due to underlying condition with diabetic chronic kidney disease. Record review of the Physician Order Report revealed that the resident had the following orders, Order type - Prescription. Start date 3/9/23. End date - Open ended. Description. Humalog U-100 insulin (insulin lispro) Solution; 100 unit/mL; amt: per sliding scale; If blood sugar is less than 60, call MD. If blood sugar is 150 to 200 give two units. If blood sugar is 201 to 250 give four units. If blood sugar is 251 to 300, give six units. If blood sugar is 301 to 350, give eight units. If blood sugar is 351 to 400, give 10 units. If blood sugar is 401 to 450, give 12 units. If blood sugar is greater than 450, give zero units. If blood sugar is greater than 450, call MD. Subcutaneous. [DX: diabetes mellitus due to underlying condition with diabetic chronic kidney disease] Before meals and at bedtime; 7:30 AM, 12:30 PM, 4:30 PM, 8:00 PM Record review of the most recent quarterly MDS assessment for Resident #2, dated 3/23/23 documented that the resident had a BIMS score of 15 indicating that she was cognitively intact. Further record review of the MDS revealed that the resident had an active diagnosis of diabetes mellitus. Documentation under the area Medications revealed that the resident received insulin injections seven times in the last seven days. Record review of the care plan for Resident #2, Last Reviewed/Revised: 3/29/23.revealed a Problem, documented as, Problems start date: 3/10/23. Category: diagnosis diabetes. Edited: 3/29/23. The listed Approaches included, Approach start date: 3/10/23 FSBS checked as ordered. Created: 3/13/23. Approach start date: 3/10/23. Meds as ordered. Created: 3/13/23 and Approach start date: 3/10/23. Observe for S/S of hypo/hyper glycemia. Created: 3/13/23 . Record review of the MAR for Resident #2 dated 4/1/23-4/14/23 revealed that under the Humalog administration, there was a refusal of blood sugar checks on 4/9/23 at 12:30 PM by LVN A. There were also refusals of blood sugar testing documented on the following days and times, 4:30 PM on 4/3/23, 4/4/23, and 4/12/23 by LVN A. The reason for the refusals was documented that the resident would not wake up from her nap. There were also blank spaces with no documentation regarding blood sugar checks or insulin on the following days and times: 8:00 PM on 4/4/23, 4/8/23, and 4/12/23. Record review of the Resident Progress Notes for Resident #2 dated 3/16/23 to 4/14/23 had no documentation regarding the blank areas on the MAR. Resident #3 Record review of the Physician Order Report: 4/16/23-4/16/23 for female Resident #3 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of other cerebral infarction (heart attack), and major depressive disorder. Further record review of the Physician Order Report revealed the resident had the following orders: Order Type - Prescription. Start date - 5/12/22. End date - Open ended. Trulicity (dulaglutide) pen injector; 0.75 mg/0.5 ml; amt: 0.5 ml; sub cutaneous. [DX: type two diabetes mellitus without complications] once a day on Wednesday; 7:00 AM - 10:00 AM. Order type - Prescription. Start date - 7/26/22. End date - Open ended. Description. Humalog U - 100 insulin (insulin lispro) solution; 100 unit/ml; amt: per sliding scale; If blood sugar is less than 60, call MD. If blood sugar is 150 to 200, give two units. If blood sugar is 201 to 250, get four units. If blood sugar is 251 to 300, gives six units. If blood sugar is 301 to 350, give eight units. If blood sugar is 351 to 400, give 10 units. If blood sugar is greater than 400, call NP/PA. Subcutaneous [DX: type two diabetes mellitus without complications] Twice a day; morning, 7:00 AM to 10:00 AM, bedtime 7:00 PM to 10:00 PM. Record review of the MAR for Resident #3 dated 4/1/20 23-4/14/2023 revealed the following documentation: Humalog administration revealed there was no documentation for the bedtime 7 PM - 10 PM blood sugar testing or insulin administration (Blank) on 4/4/23, 4/7/23, 4/8/23, 4/12/23, and 4/13/23. There was no documentation as to why these areas were blank. Record review of the most recent quarterly MDS for Resident #3 dated 3/2/23 documented that the resident had a BIM's score of 14 indicating that she was cognitively intact. An active diagnosis was documented as diabetes mellitus. Further record review of the MDS revealed that the resident received five insulin injections within the last seven days. Record review of the care plan for Resident #3 Last Reviewed/Revised: 3/8/23. Revealed a Problem as follows: Problem, start date: 5/18/20. Category: diagnosis. Resident has diabetes type 2 edited: 3/8/23. The Approaches listed included, Approach start date: 5/18/20. FSBS checked as ordered. Created: 5/18/20. Approach start date: 5/18/20. Meds as ordered. Created: 5/18/20. Approach start date: 5/18/20. Observe for S/S of hypo/hyperglycemia. Created: 5/18/20 . Record review of the Resident Progress Notes for Resident #3 dated 3/16/23 to 4/14/23 had no documentation regarding the blank areas on the MAR. Resident #4 Record review of the Physician Order Report dated 4/16/23-4/16/23 for female Resident #4 revealed she was admitted to the facility on [DATE] and was [AGE] years old. Documented diagnoses were end-stage renal disease and type two diabetes mellitus with other skin ulcer. Further record review of the Physician Order Report revealed the following orders: Order type - Prescription. Start date - 5/18/22. End date - Open ended. Description. Insulin lispro Insulin pen; 100 unit/ML; AMT: per sliding scale; If blood sugar is less than 70, call NP/PA. If blood sugar is 70 to 150, give 0 units. If blood sugar is 151 to 200, give two units. If blood sugar is 201 to 250, give four units. If blood sugar is 251 to 300, give six units. If blood sugar is 300 to 350, give eight units. If blood sugar is 351 to 400, give 10 units. If blood sugar is 401 to 450, gives 12 units. If blood sugar is 450 to 500, give 14 units. If blood sugar is greater than 501, called NP/PA. Subcutaneous. [DX: type two diabetes myelitis without complications] Before meals, and at bedtime; 7:30 AM, 11:30 AM, 4:30 PM, 8:00 PM Order type - Prescription. Start date - 4/11/23. End date - Open ended. Description. Lantus U-100 insulin (insulin glargine) solution; 100 units/ML; amount AMT: 20 units; subcutaneous. [DX: type two diabetes mellitus without complications] Twice a day; morning, 7:00 AM - 10:00 AM, bedtime, 7:00 PM - 10:00 PM Record review of the most recent quarterly, MDS Resident #4 revealed that the resident had a BIMS score of 14 indicating she was cognitively intact. Further record review of the MDS revealed that the resident had an active diagnosis of diabetes mellitus. Record review revealed that the resident received insulin injections six times in the last seven days. Record review of the care plan for Resident #4 revealed that it was Last Reviewed/Revised: 3/7/23. There was a documented Problem stating, Problem Start Date: 06/08/2022. Category: Endocrine Disorders. Resident has an impaired endocrine system r/t diabetes. Edited: 03/07/2023. The approaches listed for this problem were geared toward resident education of diabetes. Record review of the MAR documentation for Resident #4 revealed the following documentation for insulin lispro: there were documented refusals of blood sugar testing on 4/4/23 at 11:30 AM and 4:30 PM by the ADON and 4/8/23 at 11:30 AM by LVN D. There was no documentation of blood sugar testing or insulin administration (blank) on 4/6/23 at 8:00 PM and 4/12/23 at 7:30 AM and 11:30 AM. Record review of the MAR for Lantus U - 100 revealed the resident refused her Lantus on 4/6/23 at 7:00 AM to 10:00 AM. There was no documentation of blood sugar testing or administration of Lantus (blank) on 4/6/23 at 7 PM to 10 PM bedtime. Record review of the Resident Progress Notes for Resident #4 dated 3/16/23 to 4/14/23 had no documentation regarding the blank areas on the MAR. On 4/16/23 at 3:02 PM the DON stated that she was not aware of refusals and missing documentation for the residents listed on the chart audit until the facility conducted a chart audit on 4/15/23. The audit included Residents #2, #3 and #4. Record review of the National Library [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure the resident's right to be free from abuse for one (Resident #1) of six residents reviewed for abuse. The Administrator failed ensure Resident #1, who was named an alleged victim of abuse was safe from CNA E who was named as the alleged perpetrator. CNA E worked the remainder of his shift after being named as the alleged perpetrator. As a result of the facility's failures, Resident #1 had continued exposure to CNA E as well as the remaining 79 residents in the facility. On 12/30/22 at 5:04 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 12/31/22 at 3:12 PM, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place all residents who were exposed to CNA E by placing them at risk for abuse. Findings Included: Record review of Resident #1's undated face sheet revealed an [AGE] year-old-female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include unspecified dementia (impaired ability to remember), psychotic disorder with delusions (condition to affect the mind), disorder to bone structure (condition affecting the bone structure) and pain. Record review of Resident #1's Quarterly Minimum Data Set, dated dated [DATE], revealed: Section C for Brief Interview for Mental Status score revealed a score of 02, which indicated the resident's cognition was severely impaired. Record review of Resident #1's Physician Order Report, dated 11/30/22-12/30/22, revealed: Order Type: Radiology Start Date: 12/26/22 End Date: 12/26/22 Description: RT Forearm; RT Wrist; Other Test: (Portable x-ray due to wheelchair bound in nursing home, of the hand wrist and forearm r/t pain) Ordered by: MD Order Type: Prescription Start Date: 1/21/11 End Date: Open Ended Description: Gabapentin 100 mg DX:pain Ordered by: MD Order Type: Prescription Start Date: 08/07/20 End Date: 12/26/22 Description: acetaminophen 500 mg 2 tabs Dx: Low back pain Ordered by: MD Record Review of Resident #1's care plan, undated, revealed the following: Problem Problem Start date: 08/04/2021 Category: Behavioral Symptoms Residents has socially inappropriate/ disruptive behavioral symptoms . Problem Problem Start Date 01/20/21 Category: Diagnosis Resident bones are osteopenic and are at increased risk of fracture Edited 10/28/21 Edited by : The DON Problem Resident #1 has behaviors. She will pull at other residents shirts. She will try to pinch other residents. Edited: 10/28/2022 Edited by: The DON Record review of the facility provider investigator report, dated 12/25/22, revealed the following documentation: Charge nurse did not complete event for the allegation of abuse, instead documented the bruises identified to wrist and hand. Upon further investigation xrays were ordered, physician and family notified of allegation and event added to EMR for abuse allegation. Record review of the Hospital records with the service dated 12/28/22 revealed the following: Per EMS, they said she was being assisted when someone pulled too hard. Though they are unclear about when this exactly happened she does have localized pain Her xray to the right forearm revealed oblique spiral fracture distal right ulnar diaphysis. Record review of the facility policy, Abuse Prevention Program, dated June 2021, revealed the following documentation: Policy Statements: (1) The Administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures. (2) Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. (7) All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by Center management. Findings of abuse investigations will also be reported. Training and Prevention: (5) The following are some examples of actual abuse/neglect and signs and symptoms of abuse/neglect that should be promptly reported. However, this listing is not all-inclusive. Other signs and symptoms or actual abuse/neglect may be apparent. When in doubt, report it. a. Signs of Actual Physical Abuse: i. Welts or bruises; ii. Abrasions or lacerations; iii. Fractures, dislocations or sprains of questionable origin; Identification: Assessment and Recognition of Abuse: 1. The nurse will assess the individual and document related findings. Assessment data will include: a. Injury assessment (bleeding, bruising deformity, swelling etc.); b. Pain assessment; 2. The nurse will report findings to the physician. As needed, the physician will assess the resident/patient to verify or clarify such findings, especially if the cause or source of the problem is unclear. 3. The physician will help identify individuals with a history of having been abused or neglected, or those showing evidence of possible abuse or neglect; for example, someone admitted from home or the hospital with multiple pressure ulcers and severe under-nutrition. 6. As indicated, the physician will evaluate the resident or refer him or her for evaluation; for example, to rule out sexual assault or fracture, or to assess the possible causes of bruises. Investigation: Role of the Administrator: 1. The Administrator has the overall responsibility for the coordination and implementation of our Center's abuse prevention program policies and procedures. The Administrator is the Abuse Prevention Coordinator. In the absence of the Administrator the Director of Nursing will serve in this capacity. 2. The Administrator has the authority to delegate coordination and implementation of various components of these policies and procedures to other individuals within the Center. These may include: a. The Director of Nursing Services; b. The Director of Social Services; c. The Director of Staff Development; d. The Director of Risk Management; e. The Assistant Administrator; f. The Medical Director; g. The Quality Assessment and Assurance Committee; and h. Other staff members as determined by the Administrator. 3. If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. 6. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 7. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. Role of the Investigator: 1. The individual conducting the investigation will, at a minimum: e. Interview the resident (as medically appropriate); Reporting: All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the Center Administrator, or his/her designee, to the following persons or agencies as required: 3. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. Response: Protection of Residents During Abuse Investigations 1. During abuse investigations, residents will be protected from harm by the following measures: a. Employees accused of participating in the alleged abuse will be immediately suspended until the findings of the investigation have been reviewed by the Administrator. During an interview with the Administrator on 12/30/22 at 09:07 AM, she stated that she was notified on Christmas day of the incident concerning Resident #1 around 6:00 PM. She said she spoke with CNA B and CNA E. She stated that both staff did not provide any information. She stated she later found out after further investigation that the incident that allegedly caused the injury (fracture to Resident #1) to the resident actually occurred on 12/24/22. She said she instructed LVN A to assess Resident #1 at this time (6:00 PM) and when she did, she was told that the resident had bruising on her hands. She stated she was unsure why LVN A did not do the event (report the allegation of abuse) as instructed. She stated her expectation was for the event to include the details of the allegation. The Administrator said that she did not give instructions for an X-ray. She stated that she started interviewing everyone who worked and included it in her report provided to the surveyor. She said she suspended CNA E verbally. She stated she never interviewed the alleged victim (Resident #1). When asked why she had not interviewed the resident, she stated the resident was majority Spanish speaking. She said she would typically have her social worker conduct that interview but was unsure if the social worker interviewed Resident #1. She stated the DON worked the night of 12/26/22, and she followed up on the x-ray. She stated the x-ray was not done in a timely manner because there was confusion about who was supposed to do which duties. She stated the ADON printed the face sheet and obtained the order from the doctor. She stated the issue was no one ever called the x-ray company was never called. During an interview with Resident #1 on 12/30/22 at 10:07 AM, at the local hospital she stated that she fell . She said that someone told her she had a right arm cut. Resident #1 was able to tell the surveyor her name and the name of her daughters. She could not remember the president's name but could tell the surveyor that she was in the hospital. She stated that her arm was hurting and that she was in pain and has been hurting for a couple of days. An observation of Resident # 1 on 12/30/22 at 10:07 AM revealed that she was in bed located in the local hospital. Her right arm had a soft splint. Surveyor was unable to see any bruising or swelling at the time of the observation. During an interview with the Hospital RN on 12/30/22 at 10:15 AM, she reported that she does not know much about the incident (concerning Resident #1 and the fracture) but only what was passed to her in the report from the previous nurse. She stated Resident #1 was not oriented to time or place. She said the resident was admitted on suspected abuse. She stated it was noted in the computer system that someone pulled too hard on her arm. She stated it was hard to say what could have caused the injury. She stated anything could have caused the injury from a fall or someone twisting the resident's arm. During an interview with the Hospital Social Worker on 12/30/22 at 10:17 AM, she revealed that it was reported to her by the medical staff that Resident # 1 was okay medically to go back to the facility, but there were concerns if the return back to the facility was safe. She stated that in her electronic medical record that someone pulled on Resident #1 arm, and until they heard back about the result of the allegation, she was not going to release the resident back to the facility. During an interview with CNA B on 12/30/22 at 12:07 PM, she stated the initial incident that may have caused the injury to Resident #1 occurred on 12/24/22 around the facility dinner time. She said CNA E was coming down the hall, and he was redirecting Resident #1 to go to the table and eat. She stated that Resident #1 used her right hand and went to hit CNA E. She said she could not see if CNA E grabbed or blocked the resident from hitting him. She stated the resident did not appear to be in any pain. She stated that CNA E pushed the resident whle in her wheelchair to the table to eat. She reported the resident ate without any incident and did not complain of any pain. She stated the resident utilized her hand for the remainder of the meal. She stated that the resident speaks Spanish the majority of the time. She said she was under the impression that CNA E reported it and charted it. She reported that Resident #1 does have behaviors where she will hit staff and try to hit residents. She stated that she had been trained in reporting abuse, neglect, and exploitation. She said she did not report anything because she was under the impression that CNA E did. She reported she had not had specific training on Resident #1 behaviors. During an interview with LVN A on 12/30/22 at 12:17 PM, she stated that the incident with Resident #1 occurred on 12/25/22. She said that a certified nurse aide, whom she has difficulty pronouncing her name, which she later identified as CNA A, reported to her that the family member of Resident #1 complained about a staff member grabbing Resident #1 arm on 12/26.22. She stated that she did assess the resident at this time of the report. She stated that the resident had bruising on her hand (on both hands). She said that she noted bruising on her right arm but was unable to note the size. She reported the incident to the Administrator because she was the abuse coordinator on 12/25/22 (not sure of the exact time). She reported that she was under the impression that the alleged incident with the staff member had occurred earlier in the day. She stated that when this was reported to the Administrator, the Administrator asked to speak with the nurses' aides that were present. She said as a result of the incident, she notified the doctor via text the same day she was informed on 12/25/22. She was unable to confirm the time as she was not familiar with how to screenshot and send on her phone. She stated the Administrator, or the doctor did not instruct her to get an x-ray of the resident. She said that she was not instructed to send or ensure that CNA E was to leave the facility. She stated the Administrator could have told CNA E, but she could not hear the conversation. She stated that the resident was not in pain when the incident was reported to her. She did not suspect that her arm was broken because she was able to move her arm at the time of the assessment. She stated she did not follow up with the x-rays because she was off on 12/26/22 and 12/27/22. She said that if a resident goes untreated, this could cause complications. She stated this could have caused issues with the resident nerves, and the resident could potentially lose the function of the injured hand. She said that she had been trained in how to report abuse, neglect, and exploitation. During an interview with CNA E on 12/30/22 at 12:29 PM, he stated that when he worked on 12/24/22, it was a regular day. He described regular, meaning nothing out of the ordinary happened. He stated nothing out of the ordinary occurred on 12/24/22 or 12/25/22. He said he was not sure what had happened. He stated Resident #1 tried to hit him. He stated the resident reached behind her while he was pushing her in her wheelchair. He said he was unsure which hand it was but that it may have been her left hand. He stated that the resident tried to pinch and grab him. He said she reached and tried to grab his pant leg. She stated that it was for a split second when this happened. He stated that he believed the resident was okay but that she was angry with him. He said he had been trained on reporting abuse, neglect, and exploitation. He was able to name who the abuse coordinator was (The Administrator). He stated the following day (12/25/22) when he worked that, he was asked to speak with the Administrator by LVN A, and he told her (the Administrator) the best he could what happened with Resident #1. He stated he reported that he did not know what happened to Resident #1. He stated that after speaking with the Administrator, he was not asked to leave the facility. He said he finished the remainder of his shift and left after 7:00 PM. He stated he had not specifically been trained on Resident #1 behaviors and how to deal with them. During an interview with CNA A on 12/30/22 at 12:37 PM, she stated that she learned about the incident with Resident #1 on 12/25/22. She said she was unsure of the exact time, but it had to be right after breakfast and before 11:00 AM when she got off that day. She stated she was going through memory care that day but was not assigned to work in that area of the facility on that day. She stated that Resident #1 got her attention when she walked through the memory unit and said her arm was hurting. When she asked the resident what happened, the resident stated she did not know what happened. CNA A stated she had Resident #1 move her arm, and the resident was able to move her arm up, down, and all around. She said that she had asked CNA B what had happened to the resident and was told that she did not know what had happened. She reported that she told LVN B, who was also in the dining area, when the resident complained that her arm hurt. She stated at this time, Resident #1 never named any staff specifically. She said on 12/26/22, Resident #1 was telling MA A that her arm was broken. She stated that Resident #1 never reported to MA A which staff member had broken her arm. She said that Resident #1 daughter and niece came to visit on 12/26/22. CNA A stated that she was not aware if an X-ray had been conducted. She stated the family had mentioned that they were told that Resident #1 would get an X-ray. During an interview with the Resident # 1's Family Member on 12/30/22 at 12:43 PM, she stated that she was notified on Christmas night at 9:00 PM that had bruising on the top of her hands. She said she was initially told the bruises came from her mother banging her hands on the wheelchair. She stated this was reported to her on 12/25/22 late evening. She stated she did not believe this because her mother was a larger woman, and there was not enough room for this to occur. She said that she and another family member visited her mother the next day (12/26/22). She stated that when she tried to touch her mother, her mother guarded her right arm and yelled. She said that she could see on the top and the bottom of her mother's arms what appeared to be fingerprints. She stated she was told that her mother would receive an X-ray. She said she had taken pictures of her mother's hand but could not get a clear picture of the underside of her hand because her mother was in so much pain. She stated the next day, on the 27th in the morning, she was called by the local hospital and was told that her mother was being admitted to the hospital. She stated she was not told why her mother was being admitted . She said lunch time on 12/27/22, she was told that her mom had a spiral fracture and that the plan was to splint it and then put it in a hard cast. She stated she was told by the hospital staff that a staff member had pulled too hard on her mother and that X-rays were not done. She said that she asked the nurse at the hospital for her mother to receive a spiral fracture, which meant someone had to twist her arm, and she was told this was correct. She was unable to identify which nurse at the hospital told her this. She stated that she was not told why the x-rays were not done at the facility when the bruising was initially found. She said that she was told by the Administrator that the staff working with her mother when the incident happened would not work with her. She stated that they would be terminated, which was the only reason she would be okay with her mother returning to the facility. She said that she was told that the staff was uncooperative, which was why they would not return to work. She stated her mother was in pain on 12/26/22, and two staff and a nurse were present. She identified the staff as CNA A, CNA D, and LVN B. She said she was not sure who initially notified her that her mother had hurt her arm on the wheelchair. She stated she could not remember if it was the nurse, a CNA, or the Administrator. During an interview with the Administrator on 12/30/22 at 1:29 PM, she stated that CNA E was supposed to leave the building when the allegation was made around 12/25/22 at 6:30 PM. She said that she had talked to him at around 6:30 PM. She stated she was unaware that he had finished his shift. During an interview with CNA D on 12/30/22 at 1:33 PM, she stated that she did not work Friday (12/23/22), Saturday (12/24/22), or Sunday (12/25/22). She said that when she came to work on Monday (12/26/22), she received a report from the overnight worker. She stated that she was told that Resident #1's arm was bruised and that she complained of pain. She stated she had spoken with the resident in Spanish and asked her what was wrong and what had happened to her arm. She stated the resident grimaced and said she did not know what happened and that her arm was broken. She said the medication aide was present and was on the phone with the Administrator and instructed the resident to do a series of exercises, such as moving her arm and fingers. She said the resident called her crazy in Spanish because she was in pain. She stated this occurred around 8:00 AM or 8:30 AM. She stated she was told that an x-ray had been ordered for the resident. She stated the resident did not get an x-ray on 12/26/22 and was unsure why. She said she was uncertain if it was because of the holiday. She stated that there were no office workers at the facility that day, and this was because it was a holiday. She assumed that was why the x-ray was not conducted that day. She stated it was her understanding that the x-ray was ordered on 12/26/22. During an interview with the NP on 12/30/22 at 2:21 PM, she stated that she was not notified of Resident #1 fracture until 12/27/22. She said she initially ordered a soft splint, but after thinking about it more, she ordered that she go to the emergency room and get a heavy-duty splint. She stated she was unaware of the source of the injury and was not told that the resident was a potential victim of abuse. She stated that failure to treat the injury could have further impaired mobility, worsened, and have potentially put the resident at risk for infection. She stated the resident's specific injury was from direct trauma. She reported with her osteoporosis, the resident was at higher risk of broken bones. She said even squeezing or holding could harm the resident. During an interview with MD on 12/30/22 at 2:57 PM, he stated that he was notified via text message at 9:17 PM on 12/25/22 that Resident #1 had bruises on the back of both hands and was not in pain. He said he was not told that the resident was a potential victim of abuse. He stated if he had been notified that the resident was an alleged victim of abuse, he would have ordered an x-ray and notified the state entity. He said failure to address the injury could cause severe arthritis and severe pain. He stated an injury of this nature could be caused by someone grabbing the resident and twisting the area. During an interview with CNA C on 12/30/22 at 3:09 PM, she stated that she did not know much about the incident with Resident #1 and her fractured arm, but it was being discussed amongst other CNAs. She stated that she was told that a CNA was really mean to one of the residents. She said that it was easy to figure out which CNA it was because, as a worker, you know which workers were rough. She stated the resident never expressed any pain when she was around the resident. On 12/30/22 the Administrator and DON they were notified that the facility would be placed in immediate jeopardy status due to failure to keep the resident safe from abuse. The following Plan of Removal submitted by the facility was accepted on 12/31/22 at 11:58 AM: Record review of the facility Plan of Removal revealed the following: Problem: Facility failed to ensure that Resident #1 was free from abuse. On 12/25/22 at 6:15 pm the Administrator was notified of an allegation of abuse. The staff member finished his shift and worked until 7:11 pm. The Administrator failed to follow up to ensure that CNA E was not around the resident. The LVN A on duty stated she was not instructed for CNA E to leave the facility. CNA E indicated that he was not instructed that he would be suspended until after his shift. Interviews with Resident #1 of the resident indicated Resident #1 was in pain to the point where she would not allow them to move her arm. Interviews with the medical professionals indicated that the type of fracture is a result of direct trauma, squeezing and twisting action. Like residents identified: All residents in memory care unit 12/25/22 Plan Regional [NAME] President suspended the Administrator today 12/30/22 at 6:30 pm for failure to follow up that the alleged CNA E was not around resident. The DON was in-serviced by the Nurse Educator 12/30/22 on Abuse/neglect and injury of unknown origin - reporting timely- suspending immediately and ensuring suspension by briefing the licensed nurse on assignment. The Administrator was in-serviced today 12/30/22 by the Regional [NAME] President on investigating incidents of unknown origin and on immediately suspending and ensuring suspension of any CNA E by briefing the licensed nurse on assignment. DON assessed all residents in the memory unit for any signs of physical trauma. Staff were in-serviced report any abuse/neglect/resident behaviors to their Licensed nurse immediately. Licensed nurses were in-serviced on reporting abuse and neglect immediately and ensuring to suspend the AP immediately and ensuring the AP exits the center immediately. NOTE: All education has been completed approximately _100___% No staff will clock in until education has been completed. Inservice was completed on event documentation to ensure accurate information was communicated to the attending physician/designee and Responsible Party to include Medical record documentation education indicating significant change and to always be specific on reporting any allegations of abuse/neglect to the attending in order for physician to respond as needed. Weekend RN was in-serviced and will follow up on any event (Incident Report) to ensure clinical review on a daily basis. DON/designee does this M-F. This is addressing to prevent any delay in treatment of the resident. The Abuse prevention coordinator/designee is ultimately responsible to ensure the Alleged Perpetrator (AP) is escorted out of the facility by his supervisor. The DON and the Administrator were in-serviced on this by the Clinical Resource Nurse. The charge nurses were in-serviced if there is an allegation of abuse, suspend immediately and escort out of the center. In-service licensed nurses on radiology results notification to attending physician immediately to include nurse assignment responsibility. Do not assume anyone else is taking care of your resident orders, if you are assigned to this resident it is ultimately your responsibility to inform the MD and follow up. Education was provided to the licensed nurses on X ray portal. If there are no results, the Licensed nurse will call the imaging company to inquire about x-ray and results pending Inservice on head to toe assessments to include pain. Licensed nurses Assessment competencies were completed to ensure licensed staff are competent on assessments and reporting abuse/neglect Inserviced on abuse and neglect policy/timely reporting/who the abuse coordinator is, suspension immediately, removing AP off the floor, exiting the center immediately and consequences of not reporting timely. -All Competencies were completed on abuse/neglect-test- all Educated on SBAR significant change- pain assessment and reporting to attending License Nurses. On 12/31/22 at 12:45 PM the Final Plan of Removal was approved. Record review of the facility policy and Inservice attached, Abuse/ Neglect/ Injury of unknown injury, dated 12/30/22, revealed the following documentation: Must be reported timely asap as soon as incident happens. Abuse does not have to be true but must be reported immediately and AP suspended, escorted out of the facility by the charge nurse. It is the abuse prevention coordinator responsibility to ensure that the AP is out of the building. If the Administrator is not there or out then the DON assumes that responsibility. Record review of the facility's policy and Inservice attached, Accidents and Incidents- Investigating and Reporting, dated July 2017, revealed the following documentation: Policy Statements: All accidents or incidents involving residents, employees, visitors, vendors etc., occurring on our premises shall be investigated and reported to the administrator. A handwritten statement was written at the bottom stating: Any xray results should be called in to the MD immediately. Family and DON should be made aware as well (along with any other orders from the MD) If no results are received document date, time and person you spoke with Record review of the facility's policy, inservice and signature sheets attached, Incident Report follow up Inservice for weekend RN, dated 12/31/22, revealed the following documentation: Weekend RN will be responsible for reviewing incident reports for the last 72 hours and ensure appropriate notifications, treatment and follow up are done. Weekend RN will give report of incident reports on Monday morning to the Admin, DON or designee. Record review of the facility's policy, inservice and signature sheets attached, Daily Work Assignments , dated August 2006, revealed the following documentation: Policy Statements: All nursing service personnel shall follow daily work assignments and perform assigned duties in accordance with professional standards of practice and facility policy. Record review of the facility's policy, inservice and signature sheets attached, SBAR Communication Form, dated 2014, revealed the following documentation: Before calling the physician/NP/PA/ other health care professional the resident must be evaluated, vital signs checked, review record and have relevant information available when reporting. SBAR is an acronym used to remind the staff to assess the Situation, Background, Appearance & Review and Notify. Record review of the facility's policy, inservice and signature sheets attached, Resident Rights, dated February 2021, revealed the following documentation: Policy Statements: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation: (1) Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: (c.) be free from abuse Record review of Abuse and Neglect Skills test completed for all employees dated 12/30/22 included the following purpose: All residents must be free of abuse and neglect and it is the nurses aide's responsibility to be able to identify what abuse/neglect is, report abuse /neglect in a timely and appropriate manner with no fear of reprisal, know who to who to report their knowledge of abuse/neglect; how to identify stress in themselves and others and appropriate interviews for catastrophic reactions. Record review of the facility's policy, inservice and signature sheets attached, Behaviors, undated, revealed the following documentation: When handling residents that have behaviors do not pull backwards, leave them alone, do not grab. May need to dodge residents swing, leave them alone to preven [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure the resident had the right to be free from abuse for 1 of 5 residents (Resident #1), reviewed. The facility failed to ensure a safe environment free from abuse for Resident #1 when staff used a taser to scare Resident #1 when resident was displaying behaviors. This failure was determined to be past non-compliance, with an immediate jeopardy situation that was identified on 06/14/2021 and removed on 06/17/2021 due to the facility implementing actions which corrected the non-compliance prior to the beginning of the investigation. This failure could affect residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotion distress, and death. Findings include: Record review on 06/16/2021 at 1:00 pm of Resident #1 face sheet documented he is a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 resides in the memory care unit. Record review of Resident #1 annual Minimum Data Set, dated dated dated [DATE] documented behaviors as physical behavioral symptoms directed towards others as one indicating behavior of this type occurred 1 to 3 days. Verbal behavioral symptoms directed towards other as one indicating behavior of this type occurred 1 to 3 days. Behavior wandering presence and frequency as 3 of behavioral of this type occurred daily with Brief Interview Mental Status (BIMS) score 00. Record review of Resident #1 progress notes revealed staff did not document any behaviors for Resident #1 on the day of the incident 06/14/2021. Record review of the facility Provider Investigation Report dated 06/15/2021 documented the incident happened on 06/14/2021 at approximately between 8:30 pm. Documented Resident #1 was upset and hitting staff. CNA B called for help from LVN A to settle down Resident #1. Resident #1 was given his medication but spit them on the floor. Through the commotion, it was stated LVN A had a taser gun and used it on Resident #1. On 06/15/2021, police were called to verify the marks on Resident #1 were from a taser gun. CNA C reported that CNA B and LVN A were trying to scare Resident #1 with the taser gun and Resident #1 backed into the gun then said ouch. The Provider Investigation Report documented LVN A did not report the incident. A body assessment was completed of Resident #1 found two small spots that may be from taser gun. During an interview with administrator on 06/16/2021 at 10:25 am revealed ADON received a text from LVN D asking, Who was tased last night? At that time the morning meeting ended to begin the investigation process. ADON went to assess Resident #1 then administrator started interviewing staff for the investigation. Administrator stated she interviewed CNA C, CNA E, and CNA B, as well as leaving a message for LVN A to return her call. Administrator stated that she had called the police, notified the physician, the family, and reported to HHSC. Administrator stated during her interview with CNA C, it was reported that when CNA C came to work around 10 pm on 06/14/2021, CNA B reported to CNA C there was an incident with Resident #1, where he had punched her in the ribs then LVN A came into the room and fired off a taser and Resident #1 accidentally backed up into the taser. Administrator then interviewed CNA E and learned that she heard LVN A, had responded to an incident. Where Resident #1 punched CNA B so LVN A held a taser up in the air and fired it off to scare Resident #1. Administrator then interviewed CNA B and informed her of the allegation and that a thorough investigation would be completed. Administrator stated that CNA B denied that the incident had occurred. Administrator stated management staff immediately started in-servicing staff on the following: weapons at work, abuse and neglect, timely and correcting reporting events. Administrator stated the facility has contacted senior psych services to come to the facility and educate staff about caring for resident with behaviors. Administrator stated they have a Quality Assessment Performance Improvement Committee meeting scheduled for today 06/16/2021 with their medical director and corporate, and management staff to further discuss the issues and plans related to the incident. Administrator stated the facility will continue with training and in-service for staff. Administrator stated the facility completed skin assessment on all resident in the memory care unit on 06/15/2021 and will continue all residents on station 2 and will complete by the end of the day on 06/16/2021. During an interview with CNA C on 06/16/2021 at 11:48 am, revealed that when arriving for work on 06/14/2021 at 10:00 pm, CNA B, Showed me where Resident #1 had punched her in the ribs and the red area on her side. Then CNA B stated Resident #1 was upset and upper cut her in the ribs. Later when CNA B was leaving she came back to the desk and whispers in my ear, there was an incident where Resident #1 had hit me and while he was swinging LVN A had been threatening Resident #1 with a taser and he backed up into it. When asked about the facility policy for bringing a weapon to work she stated, Yes, it never registered in my mind a taser as a weapon, I was thing more a gun or a knife. I knew LVN A had a taser because she had talked about it, maybe as far back as November when she mentioned the taser. LVN A would say, if someone were ever to attack me, I have a taser and I will [NAME] them. CNA C stated, After this incident the facility did in-service all of us. 0n 06/15/2021 about weapons at work and that we are not allowed to bring weapons to work, different types of weapons and what is considered a weapon, abuse and neglect, and reporting incidents timely. Record Review of interview worksheet dated 06/16/2021 provided by facility documented CNA C was told by CNA B that LVN A had taser Resident #1 last night. CNA C stated that she knew LVN A had a taser because she saw it at another time. During an interview with LVN D on 06/16/2021 at 3:15 pm revealed she received a text at 11:04v pm on 06/14/2021 received a text from CNA C stating LVN A had accidentally tased a resident. LVN D stated she did not see the text until 6/15/2021 while getting ready for work. LVN D stated when she arrived at work no one was talking about the incident, so she sent ADON a text asking about the incident with Resident #1. ADON called me to ask about the information that I had on the incident. I was trying to speak in code because I was outside with Resident #2. Resident #2 spoke up and said, I saw the lady take it our and touch Resident #1 on the thigh and I saw Resident #1 shaking around, he demonstrated the shaking while making a buzzing noise. Resident #2 is the room mate to Resident #1. LVN D stated she was fully aware you could not bring any weapons prior to the incident however the facility has made it perfectly clear after the incident, We cannot bring a weapon of any kind to the facility. We know and we have been trained to leave a resident alone if the resident is agitated to walk away, step back, get another staff to help if needed. The facility has trained us since the incident on weapons at work, abuse and neglect, report in a timely manner. We received these in-services at 06/15/2021. Record Review of interview worksheet dated 06/15/2021 provided by facility documented the following: CNA C text about 11:04 PM that LVN A accidentally tased a resident. LVN D did not see the text until the next morning around 6:30 AM. LVN D called CNA C at 6:45 am and asked what are you talking about? CNA C told LVN D that LVN A tased Resident #1 because he was fighting the CNA B. LVN D asked if this was reported. CNA C stated LVN A self-reported. LVN D got to work and staff was in the morning meeting so LVN D text ADON and asked who got tased last night? During an interview with CNA E on 06/16/2021 at 3:28 pm revealed she could hear Resident #1 banging on the door in the unit and she went in the unit and assisted him to a chair in the dining room. CNA B told her that Resident #1 was, Acting up and keeps getting out of his chair. Then LVN A was saying Resident #1 was being violent and hit CNA B in the ribs, had spit out his meds and did not know what to do. CNA E stated that LVN A stated, she had brought her taser into work and set it off in the air to try and scare Resident #1 but that did not work. CNA E stated later in the evening LVN A was saying, She was tired of this and she was quitting, or they were going to fire me. CNA E stated that she was aware of the policy that weapons could not be brought to work but was unclear about bringing a taser into the facility until LVN A mentioned it that evening. The facility in-serviced all of us on 06/15/2021 about weapons at work, abuse and neglect, and reporting. During an interview with NA F on 06/16/2021 at 4:38 pm revealed she overheard CNA B telling CNA C about the incident with Resident #1 where LVN A had pulled out a taser trying to scare Resident #1 after he had hit staff. Record Review of interview worksheet dated 06/15/2021 provided by facility documented NA F provided a statement that she heard LVN A was trying to scare resident #1 because he was hitting staff. LVN A had the taser out and Resident #1 backed up into it. NA F signed the interview worksheet after providing the facility her statement. Observation on 06/16/2021 at 12:45 pm Resident #1 walking in the secure unit and observed two small red areas on the right lower lateral side of the knee. Resident unable to answer questions. Not interview able. During an interview on 06/16/2021 at 12:45 pm, attempted interview with Resident #1, however; unable to answer any questions just stated Hi. Record review of progress notes dated 06/14/2021 for Resident #1 revealed staff did not make any entries in progress notes for Resident #1 on this day. During an interview with Resident #2 on 06/16/2021 at 1:00 PM. Resident #2 stated his roommate Resident #1 was going through his drawers, the lady came in to stop him by the would not stop so the other lady came in and, Took that pink thing out hit him with it and his body jerked. Resident #2 demonstrated how Resident #1 body was jerking. Record review of Resident #2 MDS BIMS score 7 dated 06/17/2021 documented. During an interview with CNA B on 06/16/2021 at 7:23 pm revealed CNA B went into Resident #1 room and he was going through his roommate's things and throwing everything on the floor. I was trying to redirect him, and he was swaying his arms around and upper cut me on my right side of my ribs. I called for LVN A to come help to redirect Resident #1 to bed. CNA B stated she knew that LVN A had a taser in her bag for protection since working overnight but never saw LVN A take the taser out of her bag and did not see Resident #1 back up into the taser. CNA B denied telling staff about the incident. CNA B stated that she knew that LVN A had a taser in her bag while at work for the past three to four months. CNA B knew that there was a policy about weapons while at work and she thought that meant more of a gun or a knife. CNA B verified that she had been ban from the facility and had turned in her letter of resignation before being terminated. Record Review of interview worksheet 06/15/2021 provided by facility documented CNA B denied seeing a taser during the incident on 06/14/2021. During an interview with LVN A on 06/17/2021 at 7:55 am revealed Resident #1 was combative that night and CNA B was in the room trying to redirect him. Resident #1 was getting forceful with CNA B and I heard that he had hit CNA B. LNV A stated at first that, To be honest I had the stun gun in my pocket but did not use it on Resident #1, I did have the flashlight on and I did shine the light directly in his eyes and that startled him, he jumped and made a noise. LVN A stated, This was a scary event because Resident #1 had just hit CNA B and I was afraid that he was going to hit me. LVN A continues to deny the incident of using the stun gun. The call ended. LVN A called back at 08:30 am on 06/17/2021 and provided the following information. I don't know I thought if he just hears the noise it would bring, him a little back to reality and be compliant. I do not remember it going off or him coming in contact with it, but I did fire it off in the air to make the noise. It is a possibility that he did back into the stun gun, but I do not recall that happening, but I did fire it off in the air to make the noise. When LVN A was asked do you think it was appropriate to fire it off in the air, she replied I do think so because of the assault he had done on CNA B, then stated, No, it probably wasn't appropriate. I just wanted to get his attention and for him to calm down. LVN A verified the taser as hot pink, small, and with a flashlight on the end of it. LVN A verified knowing about no weapons at work, there is a sign posted no weapons but has a picture of a gun LVN A verified that she was ban from the facility. LVN A did not provide a written statement. Record review of policy and procedure acknowledgement date 12/07/2020 signed by LVN A acknowledging that LVN A to read and review the above policies furthermore agree to adhere to and comply with all said policies. Included in the policies is the workplace violence prevention dated December 2019. 3. Firearms, weapons, and other dangerous devices or substances are strictly prohibited on facility premises. Possession of the same will result in termination. During an interview with NP on 06/17/2021 at 10:50 am revealed NP states that the facility did notify her of the incident between staff and Resident #1 and the possible use of a taser used on Resident #1. NP ordered labs, EKG, and Echo if needed based on EKG results. NP stated that she went to the facility and completed an assessment on Resident #1. She observed two small burned areas to the outside of his right left near his knee. She ordered it to be treated with antibiotic ointment and band aide. She stated that her concerns for Resident #1 when staff used the taser would have been possible fall, possible electrical issues in the heart, [CONDITION(S)], or even worse injuries. She stated due to the EKG results there is no need for an Echo at this time. Record review of progress note for Resident #1 by NP dated 06/16/2021 documented called by nursing staff to urgently see patient today. He had aggressive behavior on the evening of 06/14/2021. It has been reported that he hit nurse and CNA. Nurse pulled out a personal taser and accidentally tased the resident #1 to his right outer knee. Small burn about the size of a quarter is noted to the right knee, it is dry with no redness or blister. Order given to Nurse for TAO and band aid. Resident #1 is in no distress. When asked if he needs anything, he states he wants to blow bubbles. LPD, DHHS, State Board of Nursing are investigating the incident. Nursing denies any issues today. She states that he often needs redirection. During an interview with Medical Director on 06/17/2021 at 1:26 pm revealed the facility has zero tolerance for weapons. It is against policy rules and no reason to ever use one on a resident. We held a meeting yesterday, we will continue to educate staff, continue in servicing staff. We are brain storming on how to continue to educate and train staff and what to do and the correct things to do. When we can and cannot use medications for residents, and that medications can never be forced on residents and can not force a resident to do anything that they do not want to do. Staff involved will be terminated. Stated that he knows that the facility has done a lot of in-servicing and education after the incident and will continue to educate staff. During an interview with ADON on 06/17/2021 at 1:55 pm she stated that she received a call from LVN A on 06/14/2021 in the evening that Resident #1 was acting out and states that she had advised LVN A to call the physician. LVN A never mentioned that staff member had been hit or that there had been an incident with herself and a resident. ADON stated the next morning on 06/15/2021 at 9:12 am in the morning meeting she received a text from CNA D asking who got tased. ADON replied What are you talking about? LVN D someone in the unit. ADON replied They better not have. ADON showed the message to the administrator they ended the meeting and started the investigation ADON went to assess the resident and noticed pea size dots and a line connecting them on the right outer knee on Resident #1. ADON stated Resident #1 was unable to communicate due to his dementia. ADON stated that she called the regional nurse and reported the incident. ADON stated that the police arrived at the facility, she then escorted the police to Resident #1 room so that they could look at the resident's leg. ADON stated that the officer stated that it looked like an injury consistent with taser marks and that he would call the crime unit to come out and take pictures of the resident's leg. ADON stated that she was present when the officer talked to Resident #2 and Resident #2 told the officer, Resident #1 was going through my things and that girl was trying to get him to stop but Resident #1 got mad and the other lady came in and touched him with that thing. It was a pink one and he jerked. Resident #2 demonstrated how Resident #1 body was jerking. ADON stated that she spoke with CNA B who denied the allegations. ADON stated that she immediately started in-servicing the staff on weapons at work, abuse and neglect, timely reporting. ADON stated we did in-servicing on these topics because I wanted everyone to understand that they can not have a weapon in the building. I wanted them to tell me what abuse and neglect is and when to report any incident. Staff should have reported the incident immediately. ADON reported they have a scheduled in-service dated today 06/17/2021 on Dealing with Residents with Behaviors, Psych concerns and dementia and how to de-escalate. Record review of written statement dated 06/15/2021 documented she witnessed Resident #2 stating to the police that his roommate was going through his stuff and that the CNA B came in and tried to stop him but then he got mad and the CNA B. Then another lady (LVN A) came in and she hit him with a pink thing and it made him shake (resident did motion of shaking. Resident #2 also stated that was wrong and against the law. I know because I'm a good guy. Observations were made on 06/17/2021 at 2:30 pm, senior psych services (third party vendor) was in the facility conducting mandatory in-service on De-Escalation training for angry, hostile, or non-compliant behavior. The third party vendor had scheduled to be in the facility prior to investigation entrance date. Record review of the facility's policy abuse prevention program dated revised May 2020 documented: Policy statement 2. Our resident's have the right to be free from abuse, neglect, misappropriation of property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. 5. Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing Services immediately. Firearms and other Weapons: Policy statement Our facility prohibits employees, residents, visitors, vendors, or others from possessing firearms or other weapons while in/on our facilities premises. Policy Interpretation and Implementation 1. Our facility prohibits any employee, resident, visitor, vendor, or any other individual from possessing any firearms or other weapons designed to do bodily harm. (e.g. knives with blades longer than4 inches, brass knuckles, explosives, etc.) while in or on our facility premises. It was determined these failures placed Resident #1 in an immediate jeopardy (IJ) a situation from 06/14/2021 through 06/17/2021. The facility took the following action to correct the non-compliance from 06/15/2021 through 06/17/2021: the following documents were reviewed In-serviced the facility staff on firearms, weapons, abuse and reporting in a timely manner dated 06/15/2021. In-serviced staff on De-Escalation training for angry, hostile, or non-compliant behavior dated 06/17/2021. The facility interviewed staff and obtained witness statements, made notifications to police, family, and physician. Dated 06/15/2021. Completed skill test for staff on abuse and neglect dated 06/17/2021.

Tag: F689 S/S= IJ Based on interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent elopement for 1 of 5 Residents (Resident #1) reviewed for accident hazards and supervision. The facility failed to ensure Resident #1 was being supervised during the evening shift change while at the facility and the resident eloped from the facility. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12-12-2020 at 4:01 PM. While the IJ was removed on 12-13-2020 at 3:45 PM, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy identified due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could have the potential to affect all the residents in the facility by placing them at risk for elopement resulting in serious injury, serious impairment or death. The evidence is as follows: -Resident #1: Review of Resident #1's face sheet reveals a [AGE] year-old male admitted on [DATE] with the following Diagnoses: [REDACTED]. Record review: Review of Resident #1's Comprehensive Care Plan reveals: Problem - Problem Start Date: 08/11/20; Category: Behavioral Symptoms; {Resident #1} has elopement behaviors. He has attempted elopement from other facilities. He has attempted elopement from home. He has had successful elopement from this facility. He will be placed in the Memory Care Unit for his safety. Edited: 12/10/20 by DON. Goal - Long term goal target date: 02/16/2021: {Resident #1} will have no elopement attempts x 90 days. Edited: 11/16/2020 by RN #1. Approach - Approach Start Date: 12/10/2020: {Resident #1} will move to memory care secure unit; Approach Start Date: 12/09/2020: {Resident #1} will be placed on one on one monitoring for remainder of COVID unit stay. Review of Resident #1's MDS dated [DATE] revealed a BIMS score of 3 with indicated the resident's cognition was severely impaired per staff assessment. Review of Resident #1's nurse's notes from 11/30/20 to 12/08/20 reveal no documentation of one on one precautions for elopement. Review of a written statement provided by TFN #2 reveal that Resident #1 was not one on one status prior to the elopement on 12/08/20. Review of a written statement provided by TFN #1 reveal that Resident #1 was no one on one status prior to the elopement on 12/08/2020. Review of a written statement provided by TFN #4 reveal that Resident #1 was placed on one on one precautions after his elopement on 12/08/20. In an interview on 12/12/20 at 11:45 AM, DON revealed Task Force emergency staffing is assisting the facility at this time due to low staffing related to COVID. DON stated the nurse's working the COVID unit on 12/08/2020 were Task force nurses and were deployed right after the incident. DON stated it has been difficult to obtain further information regarding the incident due to the nurse's no longer working for the Task Force. DON stated it is unconfirmed exactly how Resident #1 eloped from the facility. DON stated it was reported to her that Resident #1 had eloped from the facility during shift change on 12/08/2020 and was found in front of the building. DON stated Resident #1 was approximated to be outside for 5-10 minutes. Resident was immediately brought back inside the facility and a head-to-toe assessment was performed revealing no injuries. DON stated MD and Responsible Party were immediately notified. During an observation on 12/12/20 at 12:55 PM, Resident #1 was observed wandering the hallway in the memory care unit. In an interview on 12/12/20 at 1:05 PM, CNA #1 confirmed Resident #1 wanders the hall in the memory care unit. CNA #1 stated Resident #1 goes outside to smoke during smoke breaks and is accompanied by a staff member at all times. In a phone interview on 12/12/20 at 2:08 PM, Task Force Nurse (TFN) #1 stated on 12/08/20 during shift change around 6:15 PM, Resident #1 was found by one of their staff members one block North of the facility attempting to cross {a 7-lane road with moderate to heavy traffic}. TFN #1 stated Resident #1 was brought back to the facility and a head to toe assessment was performed. No injuries were noted to Resident #1 and his MD and RP were made aware of the incident. TFN #1 stated Resident #1 left the secured COVID unit one more time that night and was found wandering the hallway in the facility. Resident #1 was then placed on one on one precautions for elopement. TFN #1 stated the facility made it known that Resident #1 was in the memory care unit prior to his stay on the COVID unit. TFN #1 stated Resident #1 was not on elopement precautions prior this incident. TFN #1 stated it was unknown how Resident #1 eloped from the facility as no one saw him exit the facility. TFN #1 stated 2 Crucial Care Nurses were on shift at this time and were let go from their program the following day. In an interview on 12/12/20 at 2:52 PM, ADM stated Resident #1 was supposed to be one on one, but the Task Force Nurses were not following directions. ADM stated Resident #1 was moved to the COVID unit on 11/30/20 and stayed in bed most of the time. ADM stated it wasn't until Monday 12/07/20 that Resident #1 started wandering in the halls again. ADM stated Resident #1 was on elopement precautions in the memory care unit prior to being moved to the COVID unit. In an interview on 12/12/20 at 3:16 PM, CNA #2 stated Resident #1 was not one on one prior to the elopement on 12/08/20. CNA #2 stated the nurse was responsible for keeping an eye on him. CNA #2 denied any training regarding elopement prior to this event. In a phone interview on 12/12/20 at 4:05 PM, CNA #3 stated she was placed one on one with Resident #1 on 12/09/20 and 12/10/20 for the 6am - 6pm shift. CNA #3 stated Resident #1 was not one on one prior to his elopement on 12/08/20 in the evening. CNA #3 confirmed receiving elopement training prior to this event. Attempted to contact three times TFN #2 via phone at number provided by TFN#1. No answer. Voicemail left for a call back regarding this incident three times. No call back was received. Review of the facilities policy and procedure titled Emergency Procedure - Missing Resident with a revised dated of May 2020 revealed the following: Policy Statement: Resident elopement resulting in a missing resident is considered a facility emergency. Policy Interpretation and Implementation: 1. Residents at risk for wandering and/or elopement will be monitored and staff will take necessary precautions to ensure their safety Review of facilities policy and procedure titled Wandering, Unsafe Resident with a revised date of August 2014 revealed the following: Policy Statement: The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement The ADM was notified of the Immediate Jeopardy (IJ) on 12-12-2020 at 4:01 PM. The ADM was emailed a copy of the completed Immediate Jeopardy (IJ) template. ADM verbally verified that she received the template via email. On 12-12-2020 at 7:47 PM, the facility provided a plan of removal and it was accepted on 12-13-2020 at 3:45 PM. It documented the following: Plan of Removal Corrective Actions Identification of Residents at Risk Systemic Change(s) Monitoring -Plan of Removal: Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on December 12, 2020 for F689: Facility failed to prevent potential serious injury, serious harm, serious impairment or death to a resident that eloped from the facility. Resident tested positive on 11/30/2020 and was moved to COVID-19 hall to ensure not to infect other residents. On December 7, 2020 Task Force nurse notified Infection Nurse on resident's aggressive behavior and resident was put on a one-on-one staff watch. On December 10, 2020 at 7:40 AM, Administrator was notified by Task Force Nurse Manager of resident out of the building the previous evening but was told resident was in the parking lot. Administrator investigated to learn that information was being given of different times, and different places of said resident for Task Force nurses. Throughout the day, 12/10/2020 Administrator continued to ask for written statements of what happened and/or to speak with individuals involved. Administrator has text messages from Task Force Nurse Manager who could not confirm if resident was off the property or not. At about 6:15 PM on 12/10/2020 a Task Force nurse walked up to Administrator in parking lot and communicated that resident was off the property. Administrator immediately sent in an elopement report to State. -Corrective Actions: 1. Action: On December 10, 2020 an in-service/education was conducted with the team and documented, and a complete body assessment was done on said resident. a. The facility immediately informed the resident's family, consulted with the resident's physician; and initiated an elopement risk assessment on all residents completed 12/12/20. b. Resident care plan was updated to reflect incident. 2. Action: On December 10, 2020 resident continued to have one-to-one staff until IDT review resident's COVID status and decided resident recovered and returned to the secure memory care unit. 3. Action: In-service/Education was initiated on 12/12/2020 for communication of Steps for Resident exit seeking. 4. Action: If a secure memory care resident(s) has COVID positive we will develop a COVID positive area inside the secure memory care unit divided by barriers. The COVID area will be staffed with dictated employees. -Identification of Residents at Risk: All exit seeking residents have the potential to be affected. No resident has been affected. Resident returned safe and unharmed. -Systemic Change(s): Validation will be obtained by conducting quarterly assessments and using the Steps for Residents Exit Seeking education. -Monitoring: Resident has been replaced to the secure memory care unit. Administrator, DON, and/or designee will monitor exit seeking residents weekly, and ensure quarterly elopement assessments are completed, continued in-services/education of exit seeking communication with residents. If issues are identified, the Administrator or Director of Nursing will address at that time and provide training and guidance. The information will be brought to the Quality Assurance Performance Improvement (QAPI) monthly x3 and as needed. The QAPI will review, at minimum, in-service documentation to validate. Attachment - In-services Record review of in-service training for staff were completed. Review revealed that most staff members were in-serviced via phone or in person. During an interview on 12/13/2020 at 12:12 PM with RN #2 revealed in-service training today regarding elopement precautions and verbalized understanding of training and steps to prevent elopement. During an interview on 12/13/2020 at 12:20 PM with LVN #1 revealed LVN was in-serviced on 12/12/20 and again on 12/13/20 for elopement precautions and how to care for residents with elopement precautions and COVID-19 and verbalized understanding of training and steps needed to prevent elopement. During an interview on 12/13/2020 at 12:24 PM with CNA #1 revealed CNA was in-serviced today regarding elopement precautions and what to do if a resident in the memory care unit is diagnosed with [REDACTED]. During an interview on 12/13/2020 at 12:28 PM with CNA #4 revealed training received today regarding elopement precautions and one-to-one status for residents in the COVID unit and verbalized understanding of training and steps needed to prevent elopement. During an interview on 12/13/2020 at 12:34 PM with TFN #3 revealed she was in-serviced when she came to work today regarding elopement precautions and what to do if a resident in the memory care unit develops COVID and she verbalized understanding of training and steps needed to prevent elopement . During an interview on 12/13/2020 at 12:45 PM with DON revealed all staff members were being in-serviced in person or she was calling them to go over the elopement precautions. Immediate Jeopardy was removed on 12-13-2020 at 3:45 PM. The facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status for 1 of 9 residents (Resident #2) reviewed for weight loss in that: Resident #2 had an unexplained forty-eight-pound weight loss (30%) from [DATE] to [DATE] (48 days facility did not develop) and the facility did not develop or implement effective interventions to address resident #2's significant weight loss. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm but was not an IJ at a scope of isolation due to the facility's need to complete in service training and evaluate the effectiveness of their plan of removal. This deficient practice could affect residents with unplanned weight loss and place them at risk of not having their nutritional needs addressed. The findings include: Record review on [DATE] of resident #2's electronic record revealed resident #2 was [AGE] years-old male, who was admitted to the facility on [DATE]. On [DATE] resident #2 coded at the facility and was taken to the hospital via EMS transport where resident #2 was pronounced expired. Resident #2's [DIAGNOSES REDACTED]. Resident #2's record did not indicate type of diet specifics. Record review on [DATE] of resident #2's hospital documentation in PCC listed as other documents, titled History & Physical Report dated [DATE] resident #2's assessment includes frail and indicates monitor electrolytes closely. Record review on [DATE] of resident #2's medical record under other documents revealed a blank titled page containing two dates: one on the bottom of the page (handwritten) dated [DATE] and one at the top of the page (handwritten) dated ,[DATE] and handwritten on form indicates a height as 73 and a weight as 72kg/ 158lbs. Record review on [DATE] of resident #2's Patient Transportation form from the hospital to the facility dated [DATE] documented weight as 72.1kg and height 6'1. Record review on [DATE] of resident #2's Prehospital Care Report Summary record dated [DATE] provided from EMS, documented resident #2's weight as 110 lbs., 49.9kg (approx.) at the time of transport to hospital during code and subsequent expiring at hospital. Record review on [DATE] of resident #2 Care Plan dated [DATE] revealed: Category Nutritional status resident #2 is at nutritional risk: infection, wounds, decreased intake. Category dehydration/ fluid maintenance at risk for S/S of dehydration r/t decreased intake, medications, infection. Record review on [DATE] of resident #2's care plan dated [DATE] revealed: Resident is at risk for GI complications of n/v, constipation. Record review on [DATE] of resident #2's care plan dated [DATE] documents problem category-general, description reads: Breakfast (percentage eaten) frequency: once daily, lunch (percentage eaten) frequency once daily, dinner (percentage eaten) frequency once daily, and HS snack at bedtime. Record review on [DATE] of resident #2's Vitals Medical Record dated from [DATE] through [DATE] revealed all areas of the weight record blank. Record review on [DATE] of resident #2's Vitals Report dated from [DATE] through [DATE] detailing in % the meals and snacks eaten: Percentage value only allowed by drop down forced selection. [DATE] no lunch meal recorded, and bedtime snack percentage ,[DATE]% [DATE] no breakfast meal recorded, and lunch percentage ,[DATE]% (acceptable range noted as ,[DATE]%-,[DATE]%) [DATE] no snack recorded [DATE] no breakfast or lunch recorded [DATE] no breakfast, lunch, dinner, or snack recorded [DATE] no breakfast or lunch recorded and bedtime snack percentage ,[DATE]% [DATE] bedtime snack recorded ,[DATE]% [DATE] no lunch recorded [DATE] no breakfast or lunch recorded [DATE] recorded resident refused dinner and bedtime snack [DATE] no breakfast or lunch recorded [DATE] no breakfast or lunch recorded [DATE] no dinner or bedtime snack recorded, and lunch recorded ,[DATE]% (acceptable range noted as ,[DATE]%-,[DATE]%) [DATE] no breakfast or lunch recorded [DATE] no lunch, dinner or bedtime snack recorded [DATE] bedtime snack recorded ,[DATE]% [DATE] dinner and bedtime snack recorded ,[DATE]% (acceptable range noted as ,[DATE]%-,[DATE]%) [DATE] no breakfast or lunch recorded and bedtime snack at ,[DATE]% [DATE] no breakfast or lunch recorded and dinner and bedtime snack ,[DATE]% (acceptable range noted as ,[DATE]%-,[DATE]%) [DATE] no breakfast or lunch recorded and bedtime snack ,[DATE]% [DATE] no breakfast or lunch recorded and dinner ,[DATE]% (acceptable range noted as ,[DATE]%-,[DATE]%) [DATE] no breakfast or lunch recorded and dinner ,[DATE]% (acceptable range noted as ,[DATE]%-,[DATE]%) [DATE] no breakfast or lunch recorded and dinner ,[DATE]% (acceptable range noted as ,[DATE]%-,[DATE]%) [DATE] no dinner or bedtime snack noted [DATE] no breakfast, lunch, dinner, or bedtime snack recorded [DATE] no breakfast, lunch, dinner, or bedtime snack recorded [DATE] dinner recorded ,[DATE]% (acceptable range noted as ,[DATE]%-,[DATE]%) [DATE] dinner recorded none (acceptable range noted as ,[DATE]%-,[DATE]%), lunch recorded ,[DATE]% [DATE] bedtime snack recorded ,[DATE]% [DATE] breakfast none (acceptable range noted as ,[DATE]%-,[DATE]%), no lunch recorded [DATE] bedtime snack recorded ,[DATE]% [DATE] lunch recorded as: not taken refused, and no dinner recorded [DATE] lunch recorded at ,[DATE]% [DATE] no breakfast or lunch recorded [DATE] no breakfast or lunch recorded [DATE] no dinner or bedtime snack recorded [DATE] breakfast recorded ,[DATE]% (acceptable range noted as ,[DATE]%-,[DATE]%), no lunch recorded [DATE] no breakfast or lunch recorded, and dinner recorded ,[DATE]% (acceptable range noted as ,[DATE]%-,[DATE]%) [DATE] no breakfast or lunch recorded [DATE] no breakfast or lunch recorded, and dinner was recorded twice; one noted amount: none and the other noted ,[DATE]% (acceptable range noted as ,[DATE]%-,[DATE]%) [DATE] no breakfast or lunch recorded, and dinner recorded ,[DATE]% (acceptable range noted as ,[DATE]%-,[DATE]%) [DATE] no breakfast, lunch, dinner, or bedtime snack recorded [DATE] no breakfast, lunch, dinner, or bedtime snack recorded Record review on [DATE] of documentation titled: Daily Activities Tracking form and a second form titled: Dietitian/Nursing/Physician communication Form; dietitian was requesting weights on resident #2 for nutritional recommendations (print outs provided via email to administrator from dietitian and then provided to this surveyor on [DATE]), Form reads as follow: ,[DATE] lists resident #2 and requests height and weight and diet [DATE] lists resident #2 and requests add height, weight, and diet [DATE] lists resident #2 and request says ensure heights, weights, and diets are entered [DATE] list resident #2 and requests is: obtain weight. Record review on [DATE] of in-service dated [DATE] titled Performance Improvement Plan: Privileged work Document conducted by interim ADON/RN addressing admission assessments and included the form titled: The 4 C's of Good Charting Change-Recognize a change of condition? New Med? New Order? Any change . Chart-Document the change Communicate- Notify appropriate parties .DON, Admin, NP, Hospice, family, or Responsible Party Chart-Then Chart it! What did they say? Document the Response! Were there new orders, etc. -You'll never go wrong with your charting if you follow this! Record review on [DATE] of morning stand up meeting form implemented by administrator B used to ensure documentation is completed in 24 hours. Form provided for dates[DATE], [DATE], [DATE] and [DATE] indicate resident #2 has missing documentation in record. During an interview [DATE] at 11:10am representative 1 stated resident #2 was not eating right at the facility because the resident weighed about 162 lbs. prior to admission at the facility and stated resident #2 was also dehydrated and it was devastating to see resident #2 when EMS transported him to the hospital the night the resident went into [MEDICAL CONDITION] and expired. Representative 1 stated the residents' weight was only 90 lbs. the night he expired. In addition, representative 1 reported resident #2's eyes looked sunken in and condition of his body was malnourished in appearance to which the representative had not been informed of by the facility even though the representative had made repeated requests to be informed of any issues or changes. During an interview on [DATE] at 11:42am with representative 2 confirmed the same concerns as representative 1 spoke about and added there were many times representative 1 & 2 called the facility to check the status of resident #2 but their messages would not be returned. During an interview on [DATE] at 3:21pm CNA B stated, it was very sad and heartbreaking to see how resident #2 looked when first meeting him, which was in late November, and stated resident #2 didn't eat or drink much, however CNA B pushed fluids and continually offered something to eat during her shifts. During an interview on [DATE] at 2:00pm RN A stated resident #2 appeared to be frail and not feeling good. RN A said she only worked on the day shift prior to resident #2 expiring. During an interview [DATE] at 2:55pm CNA L stated, during the night shift, fluids would be pushed to resident #2 and snacks offered but resident #2 seemed to be giving up and appeared very fragile. CNA L stated she only worked with resident #2 the last two days in November. During an interview [DATE] at 3:13pm RN K stated she only worked at the end of November and said resident #2 appeared to be frail, however she did not receive any report of change in condition on resident #2 during rounds. During an interview [DATE] at 4:44pm the Dietitian stated their corporate office has not let the dietitians go into the facility due to COVID and is working from home only. The dietitian stated multiple requests were sent to the nursing staff at the facility to obtain height and weight on resident #2 but none were returned, and no updates were entered in system to allow accurate nutritional guidance and care planning. In addition, the dietitian stated no staff reported directly via phone or email correspondence to indicate weight loss, change in condition, or concerns regarding resident #2. During an interview [DATE] at 10:20am Nurse Practitioner (NP) stated the communication from the facility has been very poor and no notifications have been received about resident #2's weight loss or related nutritional concerns. The NP stated the expectation is to have received a call from the facility regarding any change in condition or concerns and this did not occur for resident #2. During an interview on [DATE] at 9:10am the Director of Nurses (DON) stated there should have been a 24-hour report done and documented on resident #2's condition and nutritional status and confirmed the facility policy requirements of obtaining admission weight, then weekly for 3 weeks thereafter and reporting any issues to interdisciplinary team promptly when concern presented and then care planned by team. In addition, the DON clarified the expectations of staff to report and document percentage of meals daily and to report any pattern of less than 50% of one or more meals over a couple days. The DON also verified no weight documentation on resident #2 in the system since being admitted to the facility and no report documented as given to physician or the resident's representative regarding weight loss or nutritional concerns. During an interview on [DATE] at 10:15am LVN O stated resident #2 was frail and weak but seemed stable overall, however resident #2 was on a regular diet and not eating very well. LVN O also stated resident #2's spouse had provided him with some ensure and [MEDICATION NAME] supplement drinks a few times, but he would only drink ,[DATE] sips. LVN O did state that if a resident experienced a change of condition, they would inform the physician, DON, NP, and responsible party. LVN O stated the CNAs are responsible for recording food intake and that no CNA informed her resident #2 was not eating his meals. During an interview on [DATE] at 11:58am Administrator A confirmed the staff expectation is to report any changes of condition residents experience to the appropriate team members for interventions and make the proper notifications to representatives or family when indicated. Administrator A also read aloud the policy regarding weight assessment and interventions and confirmed the weights on resident #2 should have been done according to the policy as well as reported to physician, dietitian, family and documented in resident #2's record with the care plan updated to reflect all interventions. During an interview [DATE] at 12:21pm CNA G stated they had reported multiple times to the nurses that resident #2 was not eating well and reported to dietary staff that resident #2 needs pureed foods not mechanical because of tooth loss and denture issues but was told to follow process of reporting to nurses having them fill out the proper form, which would include the dietitian. However, CNA G said they repeatedly reported but texture was never changed. During an interview [DATE] at 1:54pm RN H stated resident #2 did not appear to be doing well and was having some confusion, disorientation and was eating less than 50% of meals offered. RN H stated that liquids and food were being offered frequently but resident #2 had little interest. During an interview [DATE] at 2:02pm the Medical Director confirmed the facility failure on resident #2's nutritional management and reiterated the expectations of the nursing staff to report changes to physician, dietitian, and family/representatives. Medical director said the weights should have been carried out according to facility policy, including expecting interventions to be done and all information documented in resident #2's record, with a root cause analysis (RCA) done to determine the reason for the lack of appetite and intake. Further stating that if an RCA were done and a determination made whether medical intervention i.e., Appetite stimulant etc. was needed or dietary changes made, the resident could have benefited from this approach and the primary care physician would have been alerted to follow up more closely. During an interview [DATE] at 2:43pm the Administrator B stated the facility had not properly intervened or ensured proper weight management for resident #2 and further elaborated about just visiting via phone with the medical director, who relayed the earlier conversation he had with this surveyor regarding the facilities expectations on assessments, reporting and intervening. Administrator B agreed the facility had failed at this process and that both Administrator B and the Medical Director will be meeting more in depth soon to go over education, training, and further steps to take to ensure this process gets back on the right track. During an interview on [DATE] at 1:14pm with resident #3, who was resident #2's former roommate, stated resident #2 would not eat much but does not recall resident #2 complaining about meals either. During an interview [DATE] at 3:10pm the Social Worker A stated resident #2 really wanted to go home but during the time at the facility resident #2 declined in participation with therapy and had low spirits with a sense of just giving up. Record review on [DATE] of facility's policy Titled Weight Assessment and Intervention Dated (revised [DATE]) Policy Statement reads The interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Policy Interpretation and Implementation: weight assessment reads 1. The nursing staff will measure the resident weights on admission, and weekly for three weeks thereafter. If no weight concerns are noted at that point, weights will be measured monthly thereafter, 2. Weights on all residents will be completed by the 5th of the month unless the physician orders [REDACTED]. 4. Weight will be transcribed to the individual resident weight record and entered into the clinical computer software by the 10th of the month. 5. Any weight change of 5% or more since the last weight assessment will be taken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal must be confirmed in writing. 8. The threshold for significant unplanned weight and undesired weight loss will be based on the following criteria (where percentage of body weight loss= (usual weight-actual weight) / (usual weight) x100): 1-month-5% weight loss is significant; greater than 5% is severe. 3-months - 7.5% weight loss is significant; greater the 7.5% is severe. 6 months-10% weight loss is significant; greater than 10% is severe. 9. All residents with a significant weight change or with a significant change of condition, will be placed on weekly weights for a minimum of one month or until stable. 10. If the weight change is desirable, this will be documented and no change in the care plan will be necessary. Analysis reads: 1. Assessment information shall be analyzed by the interdisciplinary team and conclusions shall be made regarding: Residents target weight range (including rationale if different from ideal body weight); Approximate calorie, protein and other nutrient needs compared with the resident's current intake; The relationship between current medical condition or clinical situation and recent fluctuations in weight; and Whether and to what extent weight stabilization or improvement can be anticipated. Care Planning-1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort will include the Physician, nursing staff, the Dietitian, the Consultant pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: The identified causes of weight loss; Goals and benchmarks for improvements; and Time frames and parameters for monitoring and reassessment. Record review on [DATE] of policy titled Change in a Resident's Condition or Status Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status Policy Interpretation and Implementation 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): d. significant change in resident's physical/emotional/mental condition; 2. A significant change of condition is a major decline or improvement in the resident's status that: b. Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and/or revision to the care plan. 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: b. There is a significant change in the resident's physical, mental, or psychosocial status; 5. Except in medical emergencies, notifications will be made within (24) hours of a change occurring in the resident's medical/mental condition or status; 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status; 9. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MDS RAI Instruction Manual. Record review on [DATE] of facility policy titled Weighing and Measuring the Resident Purpose: The purpose of this procedure was to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a baseline height in order to determine the ideal weight of the resident. Preparation: 4. Weight is usually measured upon admission and monthly during the resident's stay. 5. When weighing the resident, the following guidelines will promote accurate weight assessment across time. Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individual (s) who performed the procedure. 3. The height and weight of the resident. Reporting: 1. Significant weight loss/gain to the nurse supervisor.2. The threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria (where percentage of body weight loss= (usual weight - actual weight) / (usual weight)x 100); a. 1 month-5% weight loss is significant; greater than 5% is severe. b. 3 months-7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months-10% weight loss is significant; greater than 10% is severe. Facility's Plan of Removal was accepted on [DATE] at 11:05 A.M. Observations on [DATE] from 12:45 pm to 1:30 pm during the noon meal revealed residents in Station 2 were offered their meals. In addition, residents in need of assistance with their meal received one-on-one with facility's CNA. Review of residents' meal ticket/diet on [DATE] matched up with the meal offered to residents. Interview on [DATE] with facility's Director of Nurses, Assistant Director of Nurses/LVN, 2 LVNs/charge nurses, 1 Registered Nurse, and 3 CNAs indicated they were in-serviced from [DATE] to [DATE] on Action Plan-Weight Loss, specifically weighing a newly admitted resident weekly for 4 weeks; addressing resident's nutrition interventions to avoid weight loss and dehydration; care pathway on what to do if a resident has poor intake; resident's weight assessment and interventions; charting resident's documentation; notifying residents' physician of clinical problems; notification of a change in residents condition or status, An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm but was not an IJ at a scope of isolation due to the facility's need to complete in service training and evaluate the effectiveness of their plan of removal.

Based on interview, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for 1 of 1 resident (Resident #2) reviewed for post-surgical care. The facility nursing staff failed to obtain doctor's order for staple removal allowing resident #2's post-surgical staples to be in left hip from admission on [DATE] through [DATE] when resident #2 went into [MEDICAL CONDITION] at the facility and subsequently expired at hospital. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm but was not an IJ at a scope of isolation due to the facility's need to complete in service training and evaluate the effectiveness of their plan of removal. This failure has the potential to place all residents with surgical wounds at risk for poor wound healing, increased pain, and infection. Findings include: Record review on [DATE] of resident #2's electronic record revealed resident #2 was [AGE] year-old male and was admitted to the facility on [DATE] for rehabilitation care after suffering a fall at home that resulted in a left [MEDICAL CONDITION] and surgical intervention. Resident #2's [DIAGNOSES REDACTED]. During an interview on [DATE] at 11:10am when informed Resident #2 still had staples in his left hip when he expired on [DATE]. Representative #1 stated they had no idea that his staples were still intact and wanted this to be investigated to determine what went wrong. During an interview on [DATE] at 3:21 pm, CNA B stated they worked with resident #2 for only two-day shifts, [DATE] and [DATE], CNA B stated it was very sad to see resident #2's condition and the staples were still in the left hip, imbedded in appearance with crusty looking steri-strips intact over the staples. Record review on [DATE] of resident #2's physicians orders in EMAR system during investigation confirmed no order provided to remove staples documented. During an interview on [DATE] at 1:52pm, staff DD (Orthopedic Surgeons office) stated the 2-week follow-up appointment was marked a no show and that resident #2 had never made it to the clinic to have the staples removed. Staff DD stated the orthopedic surgeon will always take staples out at the 2 weeks visit. The only exception is if the resident were unable to make appointment then the surgeon would request a picture of the surgical site and then direct nursing staff to remove staples. Staff DD confirmed this orthopedic doctor did not receive any information regarding resident #2. Staff DD stated the hospital record shows their Nurse Practitioner (NP) having written the discharge orders and summary which included the 2 weeks follow up visit. Staff DD stated the NP would have left the discharge information at hospital to be provided to the facility. Record review on [DATE] of in-service dated [DATE] titled Performance Improvement Plan: Privileged work Document conducted by Interim DON, addressed admission assessments, and included the form titled The 4 C's of Good Charting Change-Recognize a change of condition? New Med? New Order? Any change . Chart-Document the change Communicate- Notify appropriate parties .DON, Admin, NP, Hospice, family, or Responsible Party Chart-Then Chart it! What did they say? Document the Response! Were there new orders, etc. -You'll never go wrong with your charting if you follow this! During an interview on [DATE] at 9:10am, Director Of Nurses (DON) stated there should have been follow up on admission orders [REDACTED]. DON stated a nurse should have noticed the staples and called for an order to remove staples. During an interview on [DATE] at 10:15am, LVN O confirmed on and off treating resident's staples from the time of admission [DATE] through being transferred to the COVID unit [DATE]. LVN O confirmed thinking the staples had been in too long and tried to find surgeon information in hospital paperwork and passed the information to an oncoming nurse nurse name not recalled. LVN O stated, normally surgeons want staples removed in ,[DATE] weeks after surgery. During an interview [DATE] at 10:20am, NP stated the communication from the facility has been very poor and no notifications have been received about resident #2's staples. NP stated the expectation is to have received a call from the facility regarding any change in condition and NP would have directed the nursing staff to ensure staples were removed and skin was clean and dry. During an interview on [DATE] at 11:58am with Administrator A confirmed the staff expectation is to follow-up with physician when/if there is not an admission order for care such as staple removal. Administrator A stated, Nursing staff should have called and verified anything missing to ensure proper care for resident #2. During an interview on [DATE] at 1:18pm with Licensed Vocational Nurse (LVN) I, confirmed resident #2's staples should not have been in that long and said there is a process for orders to be obtained and staff should have reported. During an interview on [DATE] at 1:30 pm with Interim ADON/RN stated, they worked at the facility from [DATE] to [DATE] and was never informed of any issues regarding resident #2's staples. Interim ADON/RN stated, if notified (she) would have directed the treating nurse to call the physician. During an interview [DATE] at 2:02pm, Medical Director (MD) confirmed the facility failed to obtain an order to remove resident #2's staples timely. MD stated, ,[DATE] days is as long as the staples should be in. MD reiterated nursing staff failed to follow expected nursing care by not reporting this to resident #2's physician. Revview on [DATE] of Lippincott's Nursing Procedures 6 addition (2017): Stitches and staples are used to keep wounds together during healing. They need to be removed within ,[DATE] days. The specific removal date depends on the location of the stitches or staples. Removal should not be delayed. Over a joint: ,[DATE] days. Facility's Plan of Removal was accepted on [DATE] at 11:05 A.M. Observations on [DATE] from 12:45 pm to 1:30 pm indicated there were no residents in the facility identified as having staples due to a medical procedure. Review of Resident Roster dated [DATE] did not included admissions from the hospital. Interview on [DATE] with facility's Director of Nurses, Assistant Director of Nurses/LVN, 2 LVNs/charge nurses, 1 Registered Nurse, and 3 CNAs indicated they were in-serviced from [DATE] to [DATE] on Action Plan-Weight Loss, specifically weighing a newly admitted resident weekly for 4 weeks; addressing resident's nutrition interventions to avoid weight loss and dehydration; care pathway on what to do if a resident has poor intake; resident's weight assessment and interventions; charting resident's documentation; notifying residents' physician of clinical problems; notification of a change in residents condition or status. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm but was not an IJ at a scope of isolation due to the facility's need to complete in service training and evaluate the effectiveness of their plan of removal.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections; affecting 19 of 21 residents (Residents #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 and #19), in that: a) There was co-mingling of quarantined and non-quarantined residents in a common area. Quarantined Residents and non-quarantined residents were eating together in the same dining room. Residents were observed coughing and not wearing mask in this common/communal area (Residents #3, 4, 5, 9, 10, 11, 12, 13, 16, 17, 18 and 19). b) PPE (personal protective equipment - face masks, face shields, gowns) was not worn in a manner to prevent the transmission of infections. (CNA #1, #2, #6 and #7, LVN #1, Screener). PPE was not stored in a manner to prevent contamination of the PPE, resident use equipment and/or its surroundings. (mask, face shield, gowns). c) Communication of resident quarantine status was not adequate. Dietary staff were unaware of all residents currently on quarantine and quarantined residents were not consistently served meals on disposable dishware (Residents #11, 14, 16 and 17). These failures resulted in the identification of an IJ on 8/11/20 at 3:23 PM. While the IJ was removed, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not Immediate Jeopardy and a scope of pattern. These problems could result in the spread of COVID-19 related infections, including, but not limited to related pneumonia, vomiting, diarrhea, respiratory distress and death. The findings include: >Co-mingling quarantined with non-quarantined residents in common/communal areas: Background: Record review of the facility's Residents and Employees with Possible Exposures list revealed that the following residents were Exposed prior to 7/9/20 by the Therapy Director: #14, #11 . It further documented residents possibly exposed on 7/20/20 by CNA #3 were: Residents #4, #5, #10, #9, #6 and #7. On 7/29/20 at 9:38 AM an interview was conducted with the DON regarding residents who had tested positive for COVID-19. She stated that Residents #11 and #14 tested positive on 7/15/20 and were transferred to a facility with a COVID unit for care. She added that Resident #11 had returned (7/28/20). Record review of the discharging facility's nurse notes for Resident #11 revealed the following, .7/27/20 1:06 AM. Primary Diagnosis .COVID-19 .Infection Monitoring and Evaluation: Active Infection .COVID-19, Short of Breath, Resident on Isolation . On 8/12/20 at 4:05 PM the DON stated that it looks like they (discharging facility) did not test (Resident #11 for COVID-19). Record review of the nurse notes revealed that on 8/10/20 Resident #14 was readmitted to the facility (room [ROOM NUMBER]) from another nursing facility. Record review of the face sheet revealed that Resident #17 (8/11/20) was admitted to the facility from the community. Interview with the DON on 8/12/20 at 4:05 PM revealed Resident #16 (8/08/20) was admitted from home. Co-mingling Issues: Record review of the email from the DON dated 7/30/20 at 10:18 AM it stated that the tables in the small dining room were square and 42.5 inches. It further stated they were 5 feet between each table. On 7/29/20 at 8:42 AM an interview was conducted with LVN #1 regarding the residents and CNAs present in the small dining room. She stated that the residents were on isolation (#3, 4, 9, 11 and 12). She identified CNA #1 as the CNA who was assisting Residents #11 and #4 with eating. Both residents had Styrofoam dinnerware and both were seated at the same square table at opposite ends. Resident #11 was seated in a wheelchair and Resident #4 was seated in a reclined wheelchair. CNA #2 was identified as the CNA that was assisting Resident #3 who was also eating from Styrofoam dishware. The resident was in a wheelchair and obese. It was further noted in the dining room that there were two residents at the same table one being Resident #9 who had Styrofoam dishware and was obese and in a wheelchair. She was seated at the same square dining room table opposite Resident #12 who was eating from regular dishware. Resident #12 was not quarantined. On 7/29/20 at 9:03 AM it was noted that there were residents in the small dining room without masks on and the breakfast meal was over. There were six residents present: Residents #9, #12, #4, #11, #3 and #13. Resident #9 was noted at this time to be coughing and had no mask on. Resident #9 was seated at the table with Resident #12. Resident #4 was seated at the table with Resident #11. This table was next to resident #9 and #12's table. On 7/29/20 at 9:12 AM Resident #4 was observed in the small dining room in his reclined wheelchair and making a congested sound. On 7/29/20 at 9:22 AM in the small dining room it was noted that Resident #4 coughed and was not wearing a mask. Four residents were in the dining room at this time. Resident #9 was also in the dining room with no mask on. She coughed in her hand. There were two residents nearby sitting at a table, Residents #4 and #11, who were present but were not wearing masks. There was no staff intervention to move these residents, offer them a mask or ensure Resident #9 washed her hands after she coughed in them. On 7/29/20 at 9:23 AM Resident #11 was observed in the small dining room coughing and she had no mask on at the time. She was seated at the table with Resident #4 who also did not have a mask on. Record review of the current physician orders for Resident #4 revealed that the resident was admitted to hospice on 1/07/20. Record review of the progress notes for Resident #11 dated 7/28/20 3:35 PM and created by the DON revealed the following documentation, Resident arrived back from . at approximately 2:30 PM after being sent there for COVID positive care. Residents eyes are matted together, her face is not clean, and she is obviously congested . On 7/29/20 at 9:47 AM Resident #11(COVID +) was observed in the small dining room at the same table with Resident #4. Resident #9 was also in the small dining room at the table next to them. Resident #11 was rubbing her nose and sniffling. None had on masks. On 7/29/28 12:17 PM Resident #9 was in the small dining room in her wheelchair. The resident was coughing and was served her lunch on Styrofoam dishware. The resident was making no consistent attempt to cover her mouth as she coughed. She coughed in her hand. It was also noted that at the next table over was Resident #11 who now had on a surgical mask and was offering no resistance to the mask. On 7/29/20 at 3:53 PM an interview was conducted with the DON. The DON was asked the reason why quarantined and non-quarantined residents were eating together in the small dining room. She stated, We have too many (quarantined residents) to feed them in their rooms. When ask about Resident #11's coughing she stated, I assessed her when she came back, and she had no cough then. -On 8/11/20 at 5:35 PM an interview was conducted with the DON. When asked about Resident #11 she stated, She is still on isolation (quarantined for COVID-19). Record review of the discharging facility's nurse notes for Resident #11 revealed the following, .7/27/20 1:06 AM. Primary Diagnosis .COVID-19 .Infection Monitoring and Evaluation: Active Infection .COVID-19, Short of Breath, Resident on Isolation . Record review of the email from the DON dated 7/30/20 at 10:18 AM it stated that the tables in the small dining room were square and 42.5 inches. It further stated they were 5 feet between each table. On 8/11/20 at 3:58 PM Resident #11 was observed in the small dining room with no mask on and seated in her wheelchair. Resident #10, who was not currently on quarantine, was also seated in the small dining room with no mask. On 8/11/20 at 5:25 PM it was noted that there were three residents in the large dining room seated at separate tables (42.5 inches square). Resident #11 was seated at a table and was wearing a mask. Resident #13 and #18, who were not currently on quarantine, were present and were not wearing masks. On 8/12/20 at 8:55 AM, in the small dining room, Resident #11 was feeding herself. Residents #18, #13, #5, #19 and Resident #9 were present and were not currently quarantined . On 8/12/20 at 12:59 PM it was also noted in the small dining room that all the residents, six, required assistance with eating. These residents were not quarantined except for Resident #11. On 8/12/20 at 4:05 PM the DON was interview regarding how staff are trying to ensure that quarantined and non-quarantine residents do not co-mingle. She stated, During in-services we tell them to try to keep residents in their room. We offer a mask. They are urged to stay in their rooms. Dementia Unit: -On 8/11/20 at 3:53 PM observations were made in the dementia unit. There were 13 residents wandering in the lobby/dining area of the unit and had no masks on. On 8/12/20 at 8:45 AM in the dementia unit it was noted that rooms 47 (Resident #17) and 51 (Resident #16) had PPE storage cabinets outside the rooms. All residents were wandering in the dining room. CNA #8 stated at this time, We got him (Resident #17) yesterday (8/11/20) and her (Resident #16) Saturday (8/08/20). We have no (biohazard) boxes in their rooms. They (dementia residents) drag them around. They are out there (biohazard storage room located outside of the unit). She stated referring to the residents, They won't stay in their rooms. On 8/12/20 at 9:47 AM the DON was asked her plan for quarantining the two residents that were new admits on the dementia unit, Resident #16 and Resident #17. She stated, We can't really quarantine them. They had them COVID tested . They were APS cases. We knew they would not comply. We monitor all signs and symptoms of COVID. They had to be negative before they got here. Record review of the current clinical record for Resident #16 and Resident #17 revealed that there was a negative COVID-19 lab test for Resident #17 (dated 8/05/20), but there was no documentation of COVID-19 testing for Resident #16. On 8/12/20 at 4:05 PM the DON was interviewed. Regarding Resident #16 she stated, Our Marketer said they (APS) didn't do that (test for COVID status) since they came from home. She further stated that the resident was taken from her home where she often wandered the community. The DON was then asked if she had made any attempts to get the resident tested since her arrival on Saturday (8/08/20). She stated, No, no attempts at testing. On 8/11/20 at 5:40 PM an interview was conducted with the DON. When asked what type of plan was in place for COVID-19? She stated, We don't except COVID-19 positive residents. New admits are not excepted unless they have a negative test. We quarantine them for 10 to 14 days. [MEDICAL TREATMENT] residents are tested , or we don't take them. On 8/12/20 at 4:15 PM the Assistant Administrator was asked about documentation of the facility's policy of not admitting any residents that were COVID positive. She stated, It's our internal policy, it's not written. >PPE (personal protective equipment) not wore properly: -On 7/29/20 at 8:40 AM the surveyor entered the facility and the Entrance Screener had on a surgical facemask but his nose was exposed throughout the screening. - On 7/29/20 at 8:42 AM it was noted that two staff members were assisting residents with eating in the small dining room. CNA #1 had her surgical mask pulled completely off her nose and mouth and had no face shield on. She was assisting Residents #11 and #4 with eating. The other staff member, CNA #2, had her nose exposed from her surgical mask and had no face shield on. She was assisting Resident #3 with eating. At this time, an interview was conducted with LVN #1 regarding the residents and CNAs present in the small dining room. She stated that the residents were on isolation. On 7/29/20 at 1:00 PM an interview was conducted with CNA #1 related to her lack of a facemask and face shield when feeding residents breakfast. She stated We're supposed to wear them (mask and face shields) with patient care. I don't know what happened this morning. I know mine (face shield) was off because I saw it on the back of my chair. -On 7/29/20 at 9:07 AM LVN #1 was observed donning a disposable gown and did not secure it at the waist. She entered room [ROOM NUMBER] and had her N95 masks on top of her surgical mask. When she left the room, she pulled the N 95 mask down and placed it under her chin along her neck. Record review of the 7/20/20 Progress Notes for the residents residing in room [ROOM NUMBER] (Residents #1 and #2) revealed that they had been in contact with a COVID positive employee. On 7/29/20 at 9:23 AM LVN #1 was observed wearing a surgical facemask and putting her N95 mask on top. She then placed it under her chin. Again on 7/29/20 at 11:30 AM in room [ROOM NUMBER] LVN #1 was observed donning an N95 mask over her surgical facemask and then later pushing the N95 mask under her chin. Record review of the facility In Service Tracking, Post In-Service Attendance date of 5/15/20 revealed that an in-service labeled COVID precautions and PPE were attended by staff including LVN #1. -On 8/11/20 at 3:53 PM observations were made in the dementia unit. There were 13 residents in the lobby/dining area of the unit and had no masks on. CNA #6 had her nose out of her surgical mask but was wearing a face shield. On 8/11/20 at 5:20 PM an observation was made of the dementia unit. It was also noted that CNA #6 still had her nose out of her surgical mask but was wearing a face shield. They were serving residents their evening meal. On 8/12/20 at 2:47 PM an observation was made of the dementia unit. CNA #6 had her nose exposed from her surgical mask and she was wearing a face shield that was tilted outward from her face. -On 8/12/20 at 12:05 PM CNA #7 was seated at Nurse Station 1 and her mask was off of her nose. >PPE storage: Background: On 7/29/20 at 9:03 AM it was noted that room [ROOM NUMBER] had red and yellow biohazardous boxes present in the room. The residents who resided in this room were Residents #1 and #2. LVN #1 stated at this time that these residents were in contact with a CNA that was COVID positive. She stated regarding room [ROOM NUMBER] that the resident residing there was Resident #3. She stated that she was a new admit and she would be in quarantined for 14 days since she had come from the hospital. There were quarantine PPE storage cabinets in the corridors outside of these resident rooms On 7/29/20 at 9:27 AM it was noted that there were quarantine PPE storage cabinets in the corridors outside of the following resident rooms. LVN #1 stated these residents came in contact with the COVID positive staff member (CNA #3) recently: room [ROOM NUMBER] (Resident #4), room [ROOM NUMBER] (Resident #5), room [ROOM NUMBER] (Resident #6 and #7), room [ROOM NUMBER] (Resident #8 and #9) and room [ROOM NUMBER] (Resident #10). She stated regarding Resident #11, She's not on isolation. -On 7/29/20 at 10:50 AM an observation was made of room [ROOM NUMBER] and it was noted that there was a disposable gown on the chair near the door. This disposable gown was outer side down, on top of a mechanical lift sling. On 7/29/20 at 12:14 PM at room [ROOM NUMBER] it was noted that there were two disposable gowns on a chair in the room. There was no identification on the gowns as to who they belonged to. These gowns were on top of the mechanical lift sling in the chair and next to red biohazard boxes. At this time CNA #1 stated related to the gowns, One in the chair is mine and the other is LVN #2's. On 7/29/20 at 11:30 AM in room [ROOM NUMBER] there were as a disposable gown in the seat of a chair crumpled with no identification. There was a face shield on top of bagged medical equipment on a shelf near the entrance. The face shield was face down with no identification on it. On 7/29/20 at 12:10 PM CNA #1 was asked about the disposable gown in the chair in room [ROOM NUMBER]. She stated, I've been in and out with Resident #2. It's my gown. It was noted at this time this gown again was in a chair on the A bed side. Also, at this time LVN #1 stated, Each staff member has their own gown. When asked about the equipment underneath the face shield on the shelf she stated, Those are his (Resident #2's)[MEDICAL CONDITION] kits. She was unable to determine if the face shield was clean or soiled. The face shield was stored on top of the bag [MEDICAL CONDITION] with the outside face portion down on top of them. -On 7/29/20 at 3:45 PM in room [ROOM NUMBER] Resident #1 was in bed A. The resident had [MEDICAL CONDITION] [DEVICE]. Resident #2 was in bed B and also had [MEDICAL CONDITION] [DEVICE]. Resident #1's over bed table had a box of T- drain sponges, [MEDICAL CONDITION] and an N 95 mask on it. There was no staff in the room. The package containing the (Gentlecare)[MEDICAL CONDITION] tubing had been placed on top of the N95 mask. The outside of the mask was facing up. -On 7/29/20 at 3:50 PM room [ROOM NUMBER] had a PPE supply storage cart outside of the room. There was a used surgical facemask on top of the cart with the interior of the mask facing up. It was also noted that there was a box of extra-large gloves stored on top of this mask. The facemask was noted to be used because it was pinched and formed at the nose/bridge area and the pleats were fully expanded out. -On 8/11/20 at 3:58 PM it was also noted in the small dining room that there was a cloth mask hung on the wall cabinet lower door in the small dining room. Also, in the small dining room there were two face shields left face down on the counter that were soiled with white spots and splatter along the bottom and had no names on them. One of the two face shields had bent plastic portion on both sides. On 8/11/20 at 4:34 PM 2 unlabeled and soiled face shields were observed again face down on the counter in the small dining room. On 8/11/20 at 4:36 PM CNA #4 was asked who these two face shields belong to. She stated, I don't know. >Communication of Resident Quarantine Status Inadequate On 8/11/20 at 5:35 PM an interview was conducted with the DON. At that time, she identified Residents #11, #14 and #15 as being quarantined. She added that Resident #15 was admitted on [DATE]. -On 8/12/20 at 8:55 AM in the small dining room Resident #11 was served her meal on a regular dishware tray. There was no service on Styrofoam/disposable dishware in this dining area. Record review of the nurse notes revealed that on 7/28/20 Resident #11 was readmitted to the facility (room [ROOM NUMBER]) from another nursing facility. -On 8/12/20 at 12:15 PM an observation was made of the dementia unit. All the residents were served on regular dishware trays in the lobby/dining room, including new admissions Residents #16 and #17. Record review of the face sheet revealed that Resident #17 (8/11/20) was admitted to the facility from the community. Interview with the DON on 8/12/20 at 4:05 PM revealed Resident #16 (8/08/20) was admitted from home. On 8/12/20 at 12:17 PM an interview was conducted with the Dietary Manager regarding the quarantine residents in the facility. She stated, For all of them everything is paper (Styrofoam/disposable). When asked who the quarantine residents were, she stated, Residents #11, #14 and #15? She was then asked how she received information as to who was quarantined and who was not. She stated, I get the information in the morning meetings. I thought that the paper (disposable) service was for hospital readmits only. She was not aware that Resident #16 and #17 were new admissions that were on quarantine. -On 8/12/20 at 12:55 PM Resident #14 had a regular dishware meal tray (non-disposable dishware) in her room and a noon meal tray that was Styrofoam/disposable on her over bed tray table. Record review of the nurse notes revealed that on 8/10/20 Resident #14 was readmitted to the facility (room [ROOM NUMBER]) from another nursing facility. >Infection Control Noncompliance - Interviews On 8/11/20 at 4:45 PM an interview was conducted with the Assistant Administrator regarding their noncompliance in infection control. The she was asked, how do you think this incident, IJ, came about? She stated, Policies were not followed. They were not following the guidelines. On 8/11/20 at 5:40 PM an interview was conducted with the DON regarding their noncompliance in infection control. When asked how she thought this incident, IJ, came about? She stated, Laziness. Not thinking. They were not thinking a face shield would be contaminated when stored on objects. We had too many (quarantined residents) that needed assistance with eating in the small dining room. >Policy: Record review of the facility policy labeled Infection Prevention and Control Program, revised April 2020, revealed the following documentation, Policy Statement. An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Record review of the facility policy labeled Isolation - Categories Of Transmission Based Precautions, Revised January 2012, revealed the following documentation, Policy Statement. 1. Standard precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infectious status. Transmission based precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others . Policy Interpretation and Implementation. 1. Transmission based precautions will be used whenever measures more stringent than standard precautions are needed to prevent or control the spread of infection. 2. Based on CDC definitions, three types of transmission-based precautions (airborne, droplet and contact) have been established . Droplet precautions. 1. In addition to standard precautions, implement droplet precautions for an individual documented or suspected to be infected with microorganisms transmitted by droplets . They can be generated by the individual coughing, sneezing, talking or by the performance of procedures such as sectioning . 4. Masks. a. In addition to standard precautions, put on a mask when entering the room or cubicle. 5. Resident transport. a. Limit movement of Resident from the room to essential purposes only. b. If transport or movement from the room is necessary, place a mask on the infected individual and encourage the resident to follow respiratory hygiene/cough etiquette to minimize dispersal of droplets . Record review of the current facility COVID-19 Plan revealed a document labeled Sequence for Putting on Personal Protective Equipment (PPE). The document stated, . 2. Mask or respirator. Secure elastic bands at middle of head and neck. Fit flexible band to nose bridge. Fit snug to face and below chin. Fit check respirator . www.cdc.gov/coronavirus . Record review of the current facility COVID-19 Plan revealed a document labeled How To Remove Personal Protective Equipment PPE Example 1. There are a variety of ways to safely remove PPE without contaminating your clothes, skin, or mucous membranes with potentially infectious materials . 4. Mask or respirator. Front of mask/respirator is contaminated - DO NOT TOUCH! If your hands get contaminated during mask/respirator removal, immediately wash your hands or use an alcohol-based hand sanitizer. Grasp bottom ties or elastics of the mask/respirator then the ones at the top and remove without touching the front. Discard in a waste container .CDC. Record review of the current facility COVID-19 Plan revealed a document labeled Do's and Don'ts for wearing N 95 respirators in non-surgical healthcare settings . Don't . Don't touch the front of the N 95 respirator as it is contaminated after use don't snap the straps as they may spread germs. Don't share your N95 respirator with others; germs can spread that way. Don't leave an N 95 respirator hanging around your neck . APIC (APIC Association for Professionals in Infection Control and Epidemiology) . Record review of the Personal Protective Equipment PPE Competency Validation Form, included in the facility's COVID-19 Plan revealed the following, Donning and doffing of personal protective equipment . Checklist. Donning PPE . 3. Don gown: fully covering torso from neck to knees, arms to end of wrist, wraps around back. 4. Tie/fasten in back of neck and waist . 5. Don Mask/Respirator . 7. Fit snug to face and below chin . Doffing PPE . 21. Remove mask/respirator . Grasp bottom, untie lower ties first and upper ties last. Avoiding touching front of mask/respirator. 22. Discard waste in appropriate garbage or if applicable store mask for reuse per facility policy . b. Respirator/facemask should be extended under chin. Both mouth and nose should be protected . Record review of the current facility COVID-19 Plan revealed a document labeled Do's and don'ts for wearing procedure mask in non-surgical healthcare settings . Don't. Don't reuse; toss it after wearing once . Record review of the in-service documentation attached to the facility's plan of removal dated 8/12/20 revealed an in-service given to staff labeled Admit/Readmit of COVID Positive Residents. Attached to the in-service sign in sheet was the policy reviewed labeled Draft Policy and Procedure: COVID-19 testing residents admitted from hospitals during COVID-19 pandemic. The policy documented the following, . Purpose. Provide guidance to nursing facility administration regarding COVID-19 testing and making decisions about excepting hospital discharges to their facility during a COVID-19 pandemic . Policy. During the resident referral process, the COVID-19 status of referred residents will be requested from the hospital or the referring physician. If the resident is admitted without testing, the director of nursing (or designee) will obtain physician orders to proceed with COVID-19 testing upon admission . Record review the facility policy labeled Policy: Isolation Precautions for COVID-19, Policy: 11.005, Date Revised: April 10, 2020, revealed the following documentation, Policy: to ensure that cross-contamination does not occur due to contaminated dishware and utensils, residents testing positive for COVID-19 will be served using disposable serving ware and in their rooms. If disposables are not available, the facility will ensure that plates, cups, trays, and/or utensils have been properly disinfected after usage. Procedure: 1. Nutrition and foodservice will prepare meals and place the designated menu items on disposable plates, cups, napkins, and bowls all meals. Plastic utensils will be sent . 6. All food items entering the room at meal time should be thrown away in the resident's room after completion of the meal. Nothing should leave the COVID-19 positive resident's room and return to the dining area our kitchen . The Assistant Administrator was notified of an immediate jeopardy on 8/11/20 at 3:23 PM. The Plan of Approval was accepted on 8/12/20 at 3:03 PM detailing the following: Plan of Removal Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on August 11, 2020 for failure to 1) Follow CMS and CDC guidance addressing infection control to prevent the development and spread of COVID-19. 2) The facility failed to follow CMS guidance for long-term care facilities regarding ensuring quarantine measures were followed for residents with signs and symptoms or exposure to COVID-19. 3) Prevent co-mingling of quarantined and non-quarantined residents in a common area. 4) Store and dispose of soiled linens/clothing and refuse in a manner to prevent the spread of infections. 5) Don PPE (personal protective equipment) in a manner to prevent the transmission of infections 6) Store PPE in a manner to prevent contamination of the PPE, resident use equipment and/or its surroundings. 7) Handle or transport linen in a manner to prevent the spread of infections. 8) The facility failed to ensure effective prevention of the development and spread of COVID-19, as evidenced by observations of residents in the small dining room, other resident common areas observed and observations of resident rooms. Corrective Actions: 1. Action: On August 11, 2020 an in-service was conducted with the Director of Nursing regarding (PPE) the requirement for all nursing facility personnel to wear a facemask as well as required PPE at all times while inside the center, following the infection control to prevent the development and spread of COVID-19, and to follow the guidance of CMS and CDC for long-term care facilities regarding ensuring quarantine measures are followed for residents with signs and symptoms exposure to COVID-19. Completed 08/11/2020 2. Action: On August 11, 2020 an in-service was initiated by the Director of Nursing on guidance CMS and CDC infection control prevention and spread of COVID-19. The in-services will continue each shift to ensure all staff has the training. This in-service will include the requirement to notify the charge nurse, DON and the MD to ensure the obtaining of the appropriate surveillance, protection/PPE, Isolation, communication, and evaluation of residents. Validation of understanding is being accomplished by the Director of Nursing conducting random staff interviews to ensure understanding of procedure and/or guidance of CMS and CDC on prevention the development of COVID-19 and/or CMS guidance for long-term care facilities regarding ensuring quarantine measures are followed for residents with signs and symptoms or exposure to COVID-19. Any identified issues/concerns will be addressed immediately at that moment as corrective action. No staff will be allowed to work until their in-service is completed. The Director of Nursing or designee may conduct the in-services in person or on the phone. Initiated: 08/11/2020 Completion Date 08/13/2020 then on-going. 3. Action: On August 11, 2020 an in-service on CMS and CDC addressing infection control guidance was initiated with staff on preventing co-mingling of quarantined and non-quarantined residents in a common area. The in-services will continue each shift to ensure all staff has the training. The Director of Nursing or designee may conduct the in-services in person or on the phone. No staff will be allowed to work until their in-service is completed. Completion date: August 13, 2020 and on-going. 4. Action: On August 11, 2020 an in-service on Biohazard waste/linens, and linen infection control was initiated with staff on isolation, discontinuing, storing and disposing of soiled linens with the infection prevention and control program. Sugar bags are provided and will be used in place of the yellow isolation bags to help prevent the spread of COVID-19. The in-services will continue each shift to ensure all staff has the training. The Director of Nursing or designee may conduct the in-services in person or on the phone. No staff will be allowed to work until their in-service is completed. Completion date: August 13, 2020 and on-going. 5. Action: On August 11, 2020 an in-service on Handling of Quarantined residents was initiated with staff on donning and doffing of PPE to prevent the spread of COVID-19. The in-services will continue each shift to ensure all staff has the training. The Director of Nursing or designee may conduct the in-services in person or on the phone. No staff will be allowed to work until their in-service is completed. Completion date: August 13, 2020 and on-going. 6. Action: On August 11, 2020 an in-service was initiated with staff on storing PPE in a manner to prevent contamination of the PPE, resident used equipment and/or it's surroundings. The in-services will continue e (TRUNCATED)

Based on record review and interview, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of five residents (R#1) reviewed for accident hazards and falls. 1) The facility did not provide supervision necessary to prevent R#1 from falling twice within 24 hours and sustaining a laceration to her forehead. Resident # 1 who had a history of [REDACTED]. Resident 1 fell and sustained a laceration to the forehead that required sutures. On the following day R#1 fell again and sustained a laceration to the forehead that required sutures. This failure could place residents at risk for falls and injuries. Record review of Resident 1's (R#1's) Resident Face Sheet indicated she was an [AGE] year-old female with [DIAGNOSES REDACTED]. Record review of (R#1's) Annual Minimum Data Set ((MDS) dated [DATE] indicated her date of admission as 02/06/18 and included the following: Section B R#1 had unclear speech, is rarely/never understood, and rarely/never understands; Section C R#1 had short and long-term memory problems, and her cognitive skills for decision making was severely impaired-never/rarely makes decisions, and her Brief Interview For Mental Status (BIMS) was blank; Section G R#1 required extensive assistance-resident involved in activity, and staff providing weight-bearing support with two+-person physical assist for bed mobility, transfers, dressing, and toilet use; she required extensive assistance-resident involved in activity, and staff providing weight-bearing support with one-person physical assist for locomoting on the unit, eating and personal hygiene; and limited assistance-resident highly involved in activity and staff providing guided maneuvering of limbs or other non-weight bearing assistance for walking in room and corridor; R#1's balance during transitions and walking was not stead, and only able to stabilize with staff assistance for moving from seated to standing position, walking, turning around and facing the opposite direction while walking, moving on and off toilet, and surface-to-surface transfer (transfer between bed and chair or wheelchair); and she normally used a wheelchair. Record review of R#1's Care Plan dated 10/29/19 indicated: Problem, R#1 was at risk for falls due to cognitive loss, lack of safety awareness, and limited mobility; Long Term Goal, R#1 will have no falls with major for 90 days; Approach start dated 11/15/18 and included on 10/29/19, R#1 indicated R#1 will have increased staff supervision with intensity based on resident needs. R#1's plan included: Problem, R#1's activities of daily living (ADL) Functional/Rehabilitation Potential indicated self-care deficit due to limited mobility and requires assistance with ADLs; Long Term Goal, indicated R#1's ADLs would be anticipated and met by being clean, dry and her dignity maintained without injury for the next 90 days; Approach start date was 03/16/19 and indicated R#1 required one-person assist for transfers, bed mobility, etc. This plan included Problem, R#1 is at risk for falls due to cognitive loss, lack of safety awareness, and limited mobility; Long Term Goals indicated R#1 would have no fall with major injury for 90 days; Approach, providing verbal cues for safety and sequencing when needed, and increase staff supervision with intensity (approach dated 11/15/18) based on resident need, etc. During an interview on 11/26/19 at 5:22 PM with R#1's Responsible Party indicated since R#1's admission to this facility on 02/06/2018, R#1 had several falls with injuries requiring visits to the emergency room . The visits for this year have included approximately 5 to 6 visits (11/26/19, 11/25/19, 11/04/19, 09/01/19, 05/15/19 and 02/20/19). Record Review of R#1's Event Report dated 11/25/19 at 10:36 PM indicated CNA#1 left memory unit to report to LVN #1 that R#1 was found lying face forward on the floor and blood was noted on hands and on the floor next to face. R#1 had sustained an open wound to forehead, above left eye. R#1 was sent to the l emergency room , NP was called, and a message was left. Record Review of R#1's Emergency Department Report dated 11/25/19 indicated R#1 had PMHx of severe dementia, Alzheimer's, and HTN, who experiences frequent mechanical falls presenting to the ED via EMS from facility for a complaint of a laceration status [REDACTED].#1 was in facility's memory care unit and was unable to communicate due to her sever dementia, and report by nursing home staff indicated this is R#1's stable dementia baseline and denied any acute changes since the fall. EMS reports that the facility staff found R#1 on the ground face down and report they are unsure if she had any L[NAME]; however, was found awake and alert by staff. EMS report the R#1 sustained a laceration above the left eye (that required 4 sutures), and report that they noted no other injuries or obvious deformities. Medical Decision Making/Course indicated R#1 had a fall of unknown etiology, and had differential [DIAGNOSES REDACTED]. R#1 has significant dementia and is unable to contribute to history or physical exam. Record Review of R#1's Event Report dated 11/26/19 at 12:46 PM indicated R#1 was sitting in a chair when she fell face forward onto the floor. R#1 sustained a laceration to the right side of her forehead, Nurse Practioner (NP) was notified and order was received to send R#1 to the emergency department (ED). Record Review of R#1's Emergency Department Report dated 11/26/19 indicated R#1 was an [AGE] year-old female with history of Alzheimer's, hypertension, and type 2 diabetes mellitus who presents to the ED via EMS from facility status [REDACTED]. R#1's history is limited secondary to Alzheimer's and being non-verbal at baseline information obtained primarily form EMS. EMS state the R#1 had a witnessed fall today, was sitting in a chair and fell forward, hitting head on tile floor and leading to laceration on forehead. EMS denies R#1 experienced any loss of consciousness and is not on any blood thinners. R#1 was staying in facility's memory care unit and had an unwitnessed fall yesterday (11/25/19) from the bed, leading to a laceration over left eye. R#1's laceration is constant in presentation and moderate in severity. There are no reported modifying factors. Medical Decision Making/Course indicated R#1 had a witnessed fall at facility. This is R#1s fifth fall since (MONTH) and EM staff have expressed concern due to the nature of recurrent falls and status at facility. During an interview on 11/26/19 at 4:27 PM CNA 3 indicated on 11/25/19 at approximately 9:15 PM she was conducting her last round early, so she could help CNA 4 conduct her last round in Hall 200. CNA 3 indicated on 11/25/19 at 9:15 PM she checked R#4 who was dry; checked R#7 who was dry; checked R#1 who was wet and had to change brief, which caused her to wake up but afterwards fell back to sleep; checked R#5 who was wet and had to be changed and as she exited her bedroom, R#8 reported R#1 was on the floor. CNA 3 entered R#1's bedroom as R#2, who is not R#1's roommate, exited this room, In the room CNA 3 found R#1 lying on the floor next to the entry door, and observed blood on R#1's head. CNA 3 left the memory care unit to go to Hall 200, so she could notify LVN1. LVN 1 assessed R#1 and sent her to the hospital. CNA 3 indicated she suspects R#2, who has a history of entering other residents' rooms and sitting on their beds, went into R#1's bedroom and awaken R#1, who got up from her bed and fell . CNA 3 indicated last night (11/26/19 after R#1's two incidents on 11/25/19 and 11/26/19), between the hours of 6 PM to 9 PM, R#1 entered and awaken 5 of 12 residents, and each time she had to redirect R#2 to exit their bedrooms. CNA 3 indicated she is unable to supervise R#2 when she is providing other residents incontinent care, because she is the only staff on duty after activity director leaves at approximately 4:30 PM. In addition, CNA 3 indicated she leaves the 12 residents unsupervised in the secure unit for approximately 30 minutes to help CNA in Hallway 200, when they are short a CNA, and this has happened on a few occasions. During an interview on 11/26/19 at 7:04 PM LVN 1 indicated on 11/25/19 at approximately 10:30 PM CNA 3 left the memory care unit and went to Hall 200 and informed her that R#1 was on the floor. LVN 1 indicated she entered R#1's bedroom and found her lying face forward on the floor, and blood was visible on her hands and on the floor next to her face. LVN 1 indicated she assessed R#1, who had sustained a scratch across the bridge of her nose and an open area on her forehead above her left eye. LVN 1 indicated R#1 had blood running down her face, she applied pressure to the laceration, and directed CNA 3 to get help. Shortly afterwards, nurse from station 1 arrived and assisted R#1, while LVN 1 notified DON and called 911 to transport R#1 to the hospital. LVN 1 indicated she has a video monitor above the nurses' station, which streams live video of the memory care unit hallway; however, she rarely sits and watches the monitor due to caring for residents on Hall 200. During an interview on 12/02/19 at 10:00 AM CNA 6 indicated she was working the memory care unit on 11/26/19 when at approximately 10:30 AM R#1 fell on to the floor and sustained a cut to her forehead that was bleeding. Afterwards, CNA 6 left the unit to report incident to LVN 2, who was working in Hall 200. CNA 6, who did not witness this fall, indicated she was not in the area because she was in the hallway assisting another resident. CNA 6 indicated she was the only CNA to 12 residents, and the other person in the unit was the volunteer. CNA 6 indicated all the residents need to be supervise because some of them wander into other residents' bedrooms, and some are unsteady and need assistance when moving around. During an interview on 11/27/19 at 9:18 AM with LVN 2 indicated on 11/26/19 at approximately 10:30 AM she was caring for residents on Hall 200 when CNA 6 left memory care unit and went to Hall 200 to inform her that R#1 fell face down on the unit's dining floor. Afterwards, LVN 2 went to the unit where she observed R#1 on the floor bleeding from her head, and there was a lady (volunteer) standing next to her. LVN 2indicated she assessed R#1's head, cleaned her wound, conducted her vitals, called 911, assisted CNA 6 in transferring R#1 to her bed and directed CNA 6 to stay with R#1 until she was transported to the hospital. LVN 2 indicated the volunteer reported that R#1 was sitting in a chair and then fell forward to the floor. LVN 2 indicated she cares for resident in Hall 200 and supervise residents in the memory care unit. LVN 2 added that when the only CNA on duty must leave the unit she will supervise residents. LVN 2 added that there is usually one CNA on duty unless the activity director is providing activities. LVN 2 indicated on 10/01/19 the memory care unit had two CNAs and activity director on duty; however, by the second week of (MONTH) 2019 there was one CNA and activity director on duty, who she thinks is not a CN[NAME] In addition, LVN 2 indicated R#1 and R#4 including other residents are unsteady when they walk, and for that reason require closer supervision in the unit. During an interview on 11/27/19 at 11:22 AM Volunteer 1, who is part of a ministry group that visits facility memory care for approximately 1 hour, indicated on 11/26/19 at approximately 10:30 AM she was singing to the residents in the memory care unit's dining area when she noticed R#1, who was sitting on a sofa chair against the dining area's wall was leaning forward. Volunteer 1 indicated R#1's leaning forward in the chair bothered her because in the past she has seen residents lean forward and she feared they would fall. Volunteer 1 added that she did not redirect R#1, who she does not know, to sit back in her chair because it is not her job, she is not trained, nor was she asked to supervise the residents. Volunteer 1 indicated there was only one CNA on the unit, and she was in the hallway, but was not sure exactly where and what she was doing. During an interview with the facility's Activity Director on 12/02/19 at 8:55 AM indicated her shift starts at 10 AM in the memory care unit; however, she leaves the unit at 11:30 AM to document information pertaining to the residents. After lunch she will return to memory care unit and stay there until 4:30 PM. In the memory care unit activity director offers activities including music, singing, folding laundry, and playing games, and several of the residents, including R#1 will participate. Activity director indicated she worked Monday 11/25/19 but did not work on Tuesday 11/26/19. During an interview with R#1's Nurse Practioner (NP 1) on 11/27/19 at 8:55 AM indicated R#1, who has been to the emergency room multiple times since admission to this nursing home, has no sense of judgement and has an unsteady gait. NP 1 indicated she spoke to facility's nursing staff and requested R#1, who is a high risk for falls, be placed on 1-to-1 supervision, which she noted in R#1's progress notes. Record review of R#1's fall history revealed the following: Event Report dated 02/20/19 at 5:58 AM indicated R#1 was found on the floor on her left side in her room by the CNA at 3:55 AM and sustained a scrape to her right knee and red area to the left wrist. Event Report dated 05/15/19 at 10:58 AM indicated R#1, who is ambulatory, missed a step and fell face forward in another resident's room, per housekeeper's statement, and sustained a laceration; however, this report did not specify the location. Event Report dated 09/01/19 at 8:28 AM indicated R#1 fell when attempting to get up from bed and sustained a large raised area noted to left side of forehead with a small amount of bleeding. And Event Report dated 11/04/19 at 10:20 AM indicated R#1 was ambulating in the dining room when she tripped over another resident's feet, she was caught by staff and she did not fall to the floor; however, R#1 sustained a fracture to her great right toe. Observation of the memory care unit on 11/26/19 at 2:40 PM revealed the following: at 2:40 PM the memory unit included a hallway with double doors at each end that were kept locked and required a security code to enter or exit this area. In addition, there were 7 bedrooms occupied with residents, and a dining area. And on duty was CNA 1 to 11 residents (R#1, R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, and R#11, but did not include R#1 who was at the hospital) Observation of the memory care unit on 11/27/19 at 7:16 AM revealed the following: from 6:40 AM to 7:16 AM there was not a nurse at station 2 in Hall 200 monitoring the video, which streams live video of the memory care unit. This nurses station was approximately 40 feet from the secured double doors leading into the memory care unit, and once inside the secured double doors it was approximately 35 feet to the dining area. At 6:50 AM resident, R#1 was lying in her bed, and she had a visible bruise to her lower chin area, and a tape over lacerations to her left and right forehead. At 11:45 AM R#1 had sutures to the left and right side of her forehead and bruising to her chin and was sitting at a dining table with two staff. During an interview with CNA 2 on 11/26/19 at 6:45 PM indicated the following residents displayed the following behaviors: R#1 becomes combative and must have two CNAs when providing her incontinent care, and R#2 has a history of wandering into other residents' bedrooms, and at times becomes agitate when redirected. During an interview with CNA 5 on 11/27/19 at 7:51 AM indicated she normally works Hall 200, and if there are enough CNAs in Hall 200 she will assist CNA 6 in the memory care unit by supervising residents, while CNA 6 conducts incontinent care. CNA 5 indicated there are usually 2 CNAs in the memory care unit, if there's not 2 CNAs then its 1 CNA and the activity director. CNA 5 indicated all residents in unit need supervision, especially residents R#1, R#2, R#3, R#4, R#5, R#10 and R#11 because they like to wander in the unit. In addition, R#1 likes to sit on tables and individual's lap, and recently observed R#1 sit on a coffee table but managed to get to her before she fell . And R#4 will go into other individuals' dresser drawers, into the trash cans and linen cart. CNA 5 indicated she has not observed a nurse sitting at Hall 200 nurses' station watching the video monitor, which monitors the memory care unit. During an interview with CNA 1 at 11/26/19 at 6:22 PM, indicated she has worked in the memory care unit, where she must provide incontinent care every two hours for 6 of 12 residents. CNA 1 indicated each resident in need of incontinent care takes her approximately 10 to 15 minutes, which is a total of one hour every two hours and without the assistance of another CN[NAME] CNA 1 indicated the activity director offers activities to residents in the dining area for a few hours and is not a CN[NAME] In addition, CNA 1 indicated she redirects R#2 to exit other residents' bedrooms, which occurs more often between the hours of 6 PM to 10 PM, when she is the only staff on duty and activity director has left the unit at approximately 5 PM; however, today (11/26/19) activity director did not work at the memory care unit, nor was she replaced with another staff. During an interview with CNA 7 at 11/27/19 at 11:00 AM CNA 7 indicated she normally works Hall 200 but has assisted in memory care unit as needed. CNA 7 indicated the following residents display the following behaviors: R#1 has a history of wandering, also has an unsteady gait at times and will get up and out of her chair and take off walking fast; R#2 has a history of wandering and walks a lot; R#4 has a history of wandering and an unsteady gait, and R#7 likes to wander, and has to be watched closer due getting up and out of her chair unassisted. During an interview with LVN 3 on 12/02/19 at 10:59 AM indicated she oversaw the facility's staffing schedule, including memory care unit, until approximately 12/02/19 when it was assigned to a different facility staff. LVN 3 indicated the shifts for the memory care unit are 6 AM to 2 PM, 2 PM to 10 PM, and 10 PM to 6 AM. LVN 3 indicated she had cared for residents in the memory care unit and understands the nurse assigned to Hall 2 is also assigned to memory care unit. In addition, LVN 3 indicated there is 1 CNA and an activity director who work at the memory care unit; however, when incontinent care is provided to resident, R#1, the CNA should ask for help from staff in Hall 200 due to R#1 becoming combative. LVN 3 indicated one CNA should be able to care for 12 residents in the memory care unit, but it depends on who is working. LVN 3 clarified memory unit staff included CNAs, 5 and 6 who alternate working 6 AM to 2 PM shifts, CNAs 1 and 3 who alternate working 2 PM to 10 PM shifts, and CNAs 8 and 9 who alternate working 10 PM to 6 AM shifts. Record Review of the facility's staffing schedule, which was clarified by LVN 3, indicated on 11/25/19 CNA 5 was scheduled to work from 6 AM to 2 PM, CNA 3 was scheduled to work from 2 PM to 10 PM, and CNA 8 was scheduled to work from 10 PM to 6 AM; however, this schedule did not include activity director's hours. On 11/26/19 CNA 5 was scheduled to work from 6 AM to 2 PM, CNA 1 was scheduled to work from 2 PM to 10 PM, and CNA 8 was scheduled to work from 10 PM to 6 AM; however, this schedule did not include activity director's hours. During an interview with facility's RN/MDS Coordinator on 12/02/19 at 1:25 PM indicated if she receives information on a documented fall, she will follow-up with appropriate codes. RN/MDS Coordinator indicated RN#1 requires a floor mat, a low bed, and close observation, in addition all residents in the memory care unit should not be left unsupervised, unless they are in their bed asleep and monitored every hour. In addition, RN/MDS Coordinator indicated she was unaware of memory care's CNA leaving residents unsupervised to assist CNA in Hall 200. During an interview with facility's RN/ADON, at 12/02/19 at 1:25 PM indicated level of supervision in the memory care unit should include 2 staff, before and after R#1's injuries occurred (11/25/19 and 11/26/19). RN/ADON indicated Hall 200's floor nurse should assist with the supervision of residents when CNA in the memory care unit needs a break and was unaware a CNA was leaving residents unsupervised in the unit to assist a CNA in Hall 200, when they were short a CN[NAME] RN/ADON indicated the staffing for memory care should consist of 2 CNAs and activity director on 6 AM to 2 PM shifts, and 2 PM to 10 PM should consist of one CNA and activity director. RN/ADON indicated the volunteer who was singing to the residents on 11/26/19, when R#1 sustained her 2nd laceration to her forehead, was not trained to care for the residents. During an interview with facility's DON on 12/02/19 at 3 PM indicated Event Report dated 11/25/19 confirmed CNA 1 failed to report R#2 was exiting R#1's bedroom, when she entered and found R#1 on the floor. In addition, DON was unaware that nurses were supposed to monitor residents in the memory care unit from nurses' station 2 through the video monitor, or that a CNA was leaving residents unsupervised from 9:30 PM to 10 PM to assist a CNA in Hall 200. Record Review of facility's policy and procedure for The Facility's Safety and Supervision policy dated 2001 and revised (MONTH) (YEAR) included resident safety and supervision and assistance to prevent accidents are facility wide priorities. The facility oriented-approach indicated then accident hazards are identified, the OAPI/Safety Committee shall evaluate and analyze the causes of the hazard and develop strategies to mitigate or remove the hazards to the extent possible. The facility's Interdisciplinary team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The facility would implement interventions to reduce accident risks and hazards shall include the following: Communicating specific interventions to all relevant staff; assigning responsibility for carrying out interventions; providing training, as necessary; ensuring that interventions are implemented; and documenting interventions. The facility would monitor the effectiveness of interventions to included; ensuring that intervention is implemented correctly and consistently; evaluating the effectiveness of interventions; modifying or replacing interventions as needed; and evaluating the effectiveness of new or revised interventions. This report indicated the systems approach to safety included resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environments. In addition, the type and frequency of resident supervision may vary among residents over time for the same resident. Record Review of facility's policy and procedure for Falls and Fall Risk Managing dated 2001 and revised (MONTH) (YEAR) indicated based on previous evaluation and current data, the staff will identify interventions related to the resident's specific risks and cause to try to prevent the resident from falling and try to minimize complications from falling. This report indicated that if falling recurs despite initial intervention, staff will implement additional or different interventions, or indicate why the current approach remains relevant. During an interview with facility's Administrator on 12/02/19 at 3:19 PM indicated R#1's physician had expressed concerns that she was not supervised appropriately, which led to her sustaining numerous injuries, including one on 11/25/19 at approximately 10:30 PM (sustained a laceration to the forehead), and one on 11/26/19 at 10:30 AM (sustained a laceration to the opposite side of the forehead). Administrator indicated he called R#1's responsible party and requested they provided supervision to prevent another injury. In addition, Administrator confirmed there were issues he would be addressing, which included level of supervision, staffing, appropriately documenting behaviors and incident reports.

Based on observations interview and record review the facility failed to implement it's written policy and procedure for neglect for 2 of 15 residents ( # 5 and #12) reviewed for neglect. The facility failed to implement it's policy and procedure for neglect for Resident # 5 and Resident #12. The facility failed to address interventions related to falls as per the resident's care plan. The facility failed to provide adequate supervision on the memory unit to observe resident safety. The facility failed to initiate or provide a complete neurological assessment (neuro check) as per their policy after each resident's fall. The facility failed to update the assessment, plan of care and intervention to address the needs of resident #5 and 12's frequent falls. Resident #5 had twelve falls in 7 months and resident #12 had twelve falls in a two month period. An IJ was identified on 08/03/17. While the IJ was lowered on 08/04/17 the facility remained out of compliance at a scope of a pattern and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. This failure resulted in resident #5 sustaining a shoulder dislocation, a fractured rib, [MEDICAL CONDITION] and other multiple head injuries and bruises. This failure also resulted in Resident #12 sustaining bruises and lacerations. Failure to provide adequate supervision in the memory could lead to the prevention of falls. The failure to follow and or update the care plan for accident/falls could lead to increased falls and accidents. Failure to provide neuro checks after falls with suspected head injuries could prevent the facility with needed medical information to determine future and prevent future accidents. These failures places residents at risk for severe injury after a fall, such as fractures, lacerations, head injuries including death. The finding include: On 08/01/17 at 9:15 a.m. initial tour observation in facility Secured Memory Unit with facility Medical Record personal observed Resident #5 laying on a mattress on the floor without a fall matt, no call light in reach. Resident was asleep. Medical Records personal revealed Resident # 5 is confused has [DIAGNOSES REDACTED]. Record review of Resident # 5 current physician order [REDACTED]. Resident # 5 [DIAGNOSES REDACTED]. Record review of Resident #5 Minimum Data Set (MDS) Reentry 5 day scheduled assessment dated [DATE] reflected Brief Interview for Mental Status (BIMs) total available score (00-15) documented score of 06 (severely impaired.) Activity of Daily Living Transfer: extensive assistance of two person assist. Walking in room and corridor: extensive assistance of two person assist. Mobility device: wheelchair. Balance during Transitions and Walking: Not steady, only able to stabilize with staff assistance. Urinary and Bowel Toileting Program No. Urinary Continence: always incontinent. Bowel Continence: always incontinent. Fall History on Admission /Entry or Reentry. Minimum Data Set (MDS) Version 3.0 Section C: BIMS (Brief Interview for Mental Status) Score 00-15: 13 -15 = person is intact cognitively 9 - 12 = person is moderately impaired 0- 7 = person is severely impaired Review of John Hopkins Medicine Health Library (www.hopkinsmedicineregarding) Neurological assessment assess the sensory neuron motor responses to determine whether the nervous system is impaired, motor sensory skills, balance and coordination mental status and level of awareness and interaction with the environment, reflexes and functioning. Record review of Resident # 5 only Fall Risk Assessment reflected Fall Risk Assessment completed date 09/01/16 total score 16 (total score above 10 represents High Risk. Record review of Resident # 5 facility Event Tracking Log as well as the facility RMS-(Event Summary Report) reflected fall list. 01/16/17 at 7:30 p.m. 01/22/17at 8:10 p.m., 01/23/17 at 7:15 p.m., 03/05/17 at 3:05 p.m., 03/13/17at 3:30p.m., 03/31/17 at 6:10 a.m. 04/01/17 at 12:55 p.m., 04/04/17 at 2:30 a.m., 04/21/17 at 9:00 p.m., 06/16/17at 5:30 p.m., 06/21/17 at 5:15 a.m. , and 7/17/17 6:30 p.m. Fall #1- Record review of Resident #5 Event Summary Report (RMS) dated 01/16/17 at 7:30 p.m., reflected unwitnessed fall with no injuries in resident bathroom. Resident confused. Area titled Circumstances: resident got herself up to the bathroom and fell while she was in the bathroom. Preventive measures in place prior to fall: frequent observation, education. Working with PT since [MEDICAL CONDITION]. RMS revealed no toileting plan and no alarm. Record review did not reflect observation schedule times or Neurological assessment was not initiated according to the Facility Neurological Assessment Policy. Fall #2- Record review of Resident #5 RMS dated 01/22/17 at 8:10 a.m., reflected unwitnessed fall with injuries Bruise, pain on the coccyx. In resident bathroom Area titled Circumstances revealed resident was in bed then woke up without notifying the aids and went to the bathroom and fell on her bottom. Preventive measures in place prior to fall: observation, education, bed alarm. Confused with poor safety awareness, Wandering. RMS revealed no toileting plan and Alarm record review reflected the following no observation schedule time or Neurological assessment was not initiated to the facility policy. Fall # 3- Record review of Resident #5 RMS dated 01/23/17 at 7:15 p.m., reflected un-witnessed fall, with Head injury. Area titled Circumstances: resident was in the hall way attempting to stand up from her wheelchair. Preventative measures in place prior to this fall: tab alarm in use, frequent observation. Intervention: assessment, neuro (neurological) check. RMS revealed no toileting plan. Record review reflected the following no observation schedule time or Neurological assessment was not initiated according to the facility policy. Fall # 4-Record review of Resident #5 RMS dated 03/05/17 at 3:05 p.m. un-witnessed, fall with injury Bruise Area titled Circumstances: resident resting in bed when she woke up and walked to the rest room without pulling the call light, fell at the bathroom door, just heard her call for help to find her on the floor, confused. Preventive measures in place prior to this fall: frequent observation, call light within reach, room close to nurse's station. Intervention: assessment, assisted back to bed. RMS revealed no toileting plan and no Alarm. Record review reflected the following, no observation schedule time. Neurological assessment initiated 03/05/17 at 4:05 p.m. reflected a change in blood pressure from 124/52 at 4:35 p.m. to a blood pressure of 80/54. The Neurological assessment was not completed according to the facility policy. Fall # 5- Record review of Resident # 5 RMS dated 03/13/17 at 3:30 p.m., reflected witnessed fall with injury of Hematoma to the back of head Area titled Circumstances: Resident up at nurse station attempted to stand without locking wheelchair causing resident to fall back words hitting the back of her head on the wall. Intervention: assessment, first aide, neuros (Neurological Assessment). RMS revealed no toileting plan, and no Alarm. Record review reflected the following, no observation schedule time or Neurological assessment was not initiated according to the facility policy. Fall # 6- Record review of Resident #5 RMS dated 03/31/17 at 6:10 a.m., reflected fall, unobserved injury, Bruise, Area titled Circumstances: Possibly caused by resident letting herself fall back in wheelchair when continuously standing up. Hitting arm rest over and over. Resident room, confused, poor safety awareness. Preventive measures in place prior to this fall: call light within reach frequent observation. RMS revealed no toileting plan, and no Alarm. Record review reflected the following, no observation schedule time or Neurological assessment was not initiated according to the facility policy. Fall # 7-Record review of Resident #5 RMS dated 04/01/17 at 12:55 p.m., reflected witnessed fall, No injury, Location: dining room Area titled Circumstance: resident walking with her wheelchair, then went down and landed on her bottom. Confused, Poor safety Awareness, Wandering. Preventive measures in place prior to this fall: call light within reach, frequent observation. RMS revealed no toileting plan and no Alarm. Record review reflected the following, no observation schedule time or Neurological assessment was not initiated according to the facility policy. Fall # 8- Record review of Resident #5 RMS dated 04/04/17 at 2:30 a.m., reflected un-witnessed fall with injury hematoma to head Location: resident room. Area titled Circumstances: Heard noise and someone saying help. Found resident on floor in front of dresser holding head assisted back to bed. Has approx. 4cm (centimeter) raised red area on back of head. Preventive measures in place prior to this fall: call light within reach, frequent observation. Intervention: assessment, and assist back to be bed. RMS revealed no toileting plan and no Alarm. Record review reflected the following, no observation schedule time. Record review of Resident #5 Neurological assessment initiated 04/04/17 at 4:05 p.m. area titled right and left Pupil size and reaction was blank.The Neurological assessment was not completed according to the facility policy. Fall # 9- Record review of Resident #5 RMS dated 04/21/17 at 9:00 a.m., un-witnessed fall, with Cut / laceration, Dislocation, Area titled Circumstances Resident found lying in floor in front of closet. Noted laceration above eyebrow, resident complain of pain left shoulder. Intervention: assessment, first aide, sent to ER (emergency room ) laceration sutured, left shoulder x-rayed, immobilized placed due to dislocation. Preventive measures in place prior to this fall: room near nurse station, call light within reach, and frequent observation, confused, poor safety awareness. Wandering. RMS revealed no toileting plan and no Alarm. Record review reflected the following, no observation schedule time. The Neurological assessment was not initiated according to the facility policy. Fall # 10- Record review of Resident #5 RMS dated 06/16/17 at 5:30 a.m., un-witnessed fall with injury Fracture. Area titled Circumstances resident was up in wheelchair, got up without assistance, and fell . MD contacted and x-ray ordered noted fx. (Fracture). The X-ray dated 6/16/17 Impression: acute 7-th rib fracture with minimal displacement posterior laterally. Healed rib fracture at 8-th and 9-th ribs posterior laterally. MD notified and Merri Walker ordered and implemented. Preventive measures in place prior to this fall: tab alarm, call light within reach, and frequent observation. Alarm is assigned to resident while in bed. Therapy will continue to treat. RMS revealed no toileting plan and alarm yes. Record review revealed the following, no observation schedule time. The Neurological assessment was not initiated or completed according to the facility policy. Record review of Resident # 5 Physician called back on x-ray of ribs. Physician inquiring why is it that since resident has been at this facility that she is having multiple falls and none were noted at previous facility? DON explained that resident Dementia appears to be progressively worse since previous facility. His response was to 'figure out a way to keep her from falling, put her in a Merri walker, can y'all not do that.' Explained our policy was to not have restraints he said last resort is a Merri walker et (and) gave the order. On 08/02/17 at 8:02 a.m. observed of Resident # 5 sitting in a merri walker at dining room table, well groomed, diet served as ordered per menu resident asssist self ate 100%. On 8/3/17 at 10:00 AM observed Resident #5 being pushed into the main dining room by unidentified CNA. Resident #5 was in a merri-walker with anti-tip PVC pipes on each side and black Velcro arm/leg weight attached to each side of merri-walker. Resident #5 was having a hard time getting merri-walker over the threshold going into the dining room and CNA had to turn the merri-walker slightly sideways to get through the doorway. Resident #5 was appropriately groomed, dressed with proper footwear. Surveyor confirmed with CNA that resident was Resident #5. On 08/03/17 at 3:46 p.m. observation of Resident # 5 in her room on mattress on floor, no fall matt or fall alarm observed call light in reach. Fall # 11- Record review of Resident #5 RMS dated 06/21/17 at 5:15 a.m., un-witnessed fall, with injury abrasion, area titled Circumstances: heard resident yell out. Resident found sitting on the floor against the wall and beside the bed. Confused, poor safety awareness, Wandering. Preventive measures in place prior to this fall: frequent observation, all light within reach. RMS revealed out of low bed to floor mattress, no toileting plan and no Alarm. Record review revealed the following, no observation schedule time. The Neurological assessment was not initiated or completed according to the facility policy. Fall # 12- Record review of Resident #5 RMS dated 07/17/17 at 6:30 p.m., witnessed Fall with injury Cut/ laceration, skin tear. Confused, poor safety awareness, Wandering. Circumstances Resident reaching et (and) rocking Merry walker until tipped over the left side resident hit head on corner of bed wheel going down, resident immediately became unresponsive labor uneven breathing noted of 108 upon assessment. A Nurse in training initiated first aid to locate where all the blood was pooling from and to monitor pulse et (and) loc (level of consciousness) while myself called for ER transportation et notified proper chain of people. Intervention: added immediately after fall and care plan update: assessment, sent to ER for treatment. Preventive measures in place prior to this fall: merry walker, call light within reach. RMS revealed no toileting plan and no Alarm. Record review revealed the following, no observation schedule time. The Neurological assessment was not initiated or completed according to the facility policy. Record review of Resident # 5 Care Plan Goal: will have no falls with injury x 90 days. Date initiated 09/02/16 Revised on 06/20/17 1. Assess for change in medical status, pain status, and mental status and report MD as indicated. initiated 09/02/16 2. Leave mattress on floor for her safety date initiated 06/26/17. 3. Tab alarm for bed for resident safety initiated 09/02/16 4. Medication evaluation as needed initiated 09/02/16 5. Provide verbal cues for safety and sequencing when needed initiated 09/02/16. 6. Provide verbal cues for proper pacing and energy conservation technique initiated 09/02/16. 7. Provide resident/ caretaker education for safe technique initiated 09/02/16. 8. Place call light within reach at all times initiated 09/02/16. 9. Remind resident to use call light when attempting to ambulate or transfer initiated 09/02/16. 10. When resident is in bed, place all necessary personal items within reach initiated 09/02/16. 11. Monitor for and assist toileting needs initiated 09/02/16. 12. Encourage resident to attend all activities that maximize their full potential while meeting their need to socialize initiated 09/02/16. On 08/02/17 at 8:09 a.m. interview with facility DON revealed the facility doesn't have an incontinent management program. On 08/02/17 at 9:40 a.m. interview with facility DON revealed Resident # 5 falls are around change of shift time. The facility DON revealed there has been no Activity Director in the Memory unit but she thinks one has been hired. On 08/03/17 at 8:34 a.m. interview with L.V.N # 2 revealed Resident # 5 increased falls is because she is very confused. When she was in her wheelchair she would try to get up all the time. She would get up in her room and try to go to the bathroom. L.V.N. # 2 revealed Resident # 5 is not on a scheduled toileting program or incontinent management program. L.V.N # 2 said They try to take her. L.V.N # 2 revealed Resident # 5 had a bed alarm a long time ago she cannot remember why they stop using it. L.V.N. # 2 revealed Resident # 5 is now in a Merry Walker after her fall in June the Dr. called and wanted the Merry Walker. L.V.N. # 2 revealed prior to the Merry Walker they put her mattress on the floor and she was working with therapy. L.V.N. # 2 revealed when a fall occurs they do an assessment, incident report (RMS) and do follow-up to incident for 72 hours and do neuro checks if they hit their head. Notify Dr. and family. L.V.N. # 2 revealed she does not do the residents Fall Risk Assessments. L.V.N. # 2 revealed they (staff) cannot observe residents in the dining room (common area) from the nurse station and if the nurse aide is in a room with a resident the residents cannot be seen. On 08/03/17 at 4:12 p.m. interview with C.N.A. # 5 revealed she works on hall 200 and she does not go to the unit to work or help. C.N.A. # 5 revealed there is one C.N.A. that works in the unit and one L.V.N. for Hall 200 and the Unit. (Memory). (The memory unit is separate from Hall 200.) On 08/03/17 at 4:12 p.m. interview with C.N.A. # 6 revealed she only works on Hall 200 and only goes to the unit (memory) to work the unit when the C.N.A. working day off. On 08/03/17 at 4:20 p.m. interview with L.V.N. # 3 revealed Resident # 5 increased falls is because she needs to be watched closely but it is difficult because she works hall 200 and the unit also. On 08/03/17 at 5:05 p.m. interview with facility DON regarding Resident # 5 only one Fall Risk assessment dated in 09/16. Facility DON revealed the facility Fall Risk Assessment has been discontinued and she will have to look in Resident #5 chart for a paper Fall Risk Assessment and her neuro checks are in the chart. Facility DON revealed the 12 falls in 7 months are because of her [DIAGNOSES REDACTED]. Resident # 5 does not sleep well we have tried and given her [MEDICATION NAME] and benzodiazepines with the supervision of the nurse practitioner so not to chemical restrain her. Resident # 5 is restless and wanders. The facility DON revealed Resident # 5 has a lot of falls in June but they implemented, a low bed and a mattress on the floor and a Merri walker on 06/20/17. Resident # 5 receives therapy PT physical therapy and OT occupational therapy. The facility DON revealed the facility initiated bed alarm on 09/2016 but she does not have it now it was discontinues. The facility DON revealed. Interventions for Resident # 5 was Low bed/ mattress on floor, on 06/26/17, Care Plan up dates, Merri Walker 06/20/17, bed alarm on 09/16 and discontinued on 03/31/17. Facility DON revealed Resident # 5 was in a Geri chair from 04/22/17 to 05/26/17 because she could not position in wheelchair with sling due to fall and shoulder dislocation. The facility Don revealed Resident neuro checks are only two and they are in the chart. On 08/03/17 at 5:35 p.m. facility DON revealed the Fall Risk Assessment has been retired because it was incorporated with the Nurse Assessment form. Nurse Assessment form reviewed with DON revealed: 3. Falls fall history on admission /Entry or reentry: F a1.Did the resident have a fall any time in the month prior to admission/ reentry. Fa2.Did the resident have a fall any time in the last 2-6 months prior to admission / reentry. A3. Did the resident have a fall related to a fall in the 6 month prior to admission/ reentry? The facility DON revealed the Nursing Assessment with this Falls Following as listed above DON stated no this is not it. (Fall Risk Assessment) Resident # 12 Closed Record review of Resident # 12 current physician order [REDACTED]. Resident 12 [DIAGNOSES REDACTED]. Closed Record review of Resident #12 Minimum Data Set ((MDS) dated [DATE] Admission assessment reflected Brief Interview for Mental Status (BIMs) total available score (00-15) documented score of 04 (severely impaired) Activity of Daily Living Transfer: Limited assistance of one person assist. Walking in room and corridor: Activity did not occur. Mobility device: wheelchair. Urinary Toileting Program: No. Urinary Continence: frequently incontinent. Bowel Toileting Program: No. Bowel Continence: frequently incontinent. On further review of Resident # 12 MDS resident had a fall in the last month prior to Admission and had a fall in the last 2-6 month prior to admission. Record review of Resident #5 Care Plan initiated 02/06/17 did not address fall prevention and or interventions related to Resident # 12 falls. Record review of Resident #12 facility Event Tracking Log as well as the facility RMS (Event Summary Report) dated 02/07/17at 10:00 a.m. 03/03/17 at 8:00 a.m. 03/13/17 at 10:00 a.m.,03/14/17 at 2:40 p.m. 03/15/17 at 2:55 a.m. 03/18/17 at 2:00 a.m.03/21/17 at 3:25 p.m. 03/28/17 at 7:10 p.m., 03/31/17 4:25 p.m. 04/02/17at 8:30 p.m., 04/03/17 at 4:00 a.m. 04/07/17. Fall #1- Closed Record review of Resident # 12. RMS dated 02/07/17 at 10:00 a.m., reflected un-witnessed fall with injury skin tear, in dining room. Confused, poor safety awareness, Wandering. Area titled Circumstances: Resident tried to get out of wheelchair leaned on table and table gave way. Preventive measures in place prior to this fall: tab alarm, call light in use, frequent observation. Intervention: assessment and first aide. RMS revealed no toileting plan, and Alarm yes. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 2- Closed Record review of Resident # 12. RM dated 03/03/17 at 8:00 a.m., reflected un-witnessed fall in dining room no injury, Confused, poor safety awareness. Area titled Circumstances: Resident found lying his right side on bathroom floor. He was going to the bathroom and fell . He is weak and unsteady when ambulating. RMS revealed no toileting plan, and no Alarm. Record review reflected the following, no observation schedule time. The Neurological assessment initiated 03/05/17 at 4:05 p.m. was not completed according to the facility policy. Fall # 3- Closed Record review of Resident # 12. RMS dated 03/13/17 at 10:00 a.m. reflected un-witnessed fall, Injury skin tear Confused, wandering. Area titled Circumstances: was going to the bathroom. Preventive measures in place prior to this fall: call light within reach frequent observation. RMS revealed no toileting plan, and Alarm yes. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 4- Closed Record review of Resident # 12. RMS dated 03/14/17 at 2:40 p.m., reflected un-witnessed fall no injury in resident bathroom confused, poor safety awareness. Area titled Circumstances: was going to bathroom without help. Investigation: Preventive measures in place prior to this fall: bed alarm, call light within reach. Investigation: assessment. RMS revealed no toileting plan, and Alarm yes. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 5- Closed Record review of Resident # 12. RMS dated 03/15/17 at 2:55 a.m., reflected un-witnessed fall, no injury in resident bathroom, poor safety awareness, wandering. Area title Circumstances: Bed alarm going off just as nurse stepped into the bathroom resident slipped and fell on his bottom. Intervention: assessment, assist to bathroom. Preventive measures in place prior to this fall: bed alarm, call light within reach. RMS revealed no toileting plan, and Alarm yes. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 6 - Closed Record review of Resident # 12. RMS dated 03/18/17 at 2:00 a.m., un-witnessed fall, Injury Abrasion and skin tear in resident room. Confused, poor safety awareness. Area title Circumstances: going to bathroom without assistance. Preventive measures in place prior to this fall: bed alarm, call light within reach frequent observation Investigation added immediately after fall and care plan update: assessment assist to bathroom, alarm reapplied. RMS revealed no toileting plan, alarm yes and sounding. Record review reflected the following, no observation schedule time. The Neurological assessment initiated 03/18/17 at 2:00 a.m. was not completed according to the facility policy. Fall # 7- Closed Record review of Resident # 12. RMS dated 03/21/17 at 3:25 p.m., reflected un-witnessed Fall Injury no injury in resident's room. Confused, poor safety awareness, wandering. Area titled Circumstances: I was down the hall and the aide who was assigned to the unit was busy changing another resident. She heard a big crash and went to see where it came from when she heard the resident calling for help. He was on the floor behind his door. Preventive measures in place prior to this fall: tab alarm, call light, frequent observation. Intervention: assessment, assisted to bathroom, alarm reapplied. RMS revealed no toileting plan, and Alarm yes. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 8- Closed Record review of Resident # 12. RMS dated 03/28/17 at 7:10 p.m., reflected un-witnessed fall, with injury skin tear, resident room. Confused, poor safety awareness, Wandering. Area titled Circumstances: resident was coming back from the bathroom when he (resident) fell . Preventive measures in place prior to this fall: alarm, call light within reach, education, frequent observation. Intervention: assessment, first aide to skin tear. RMS revealed no toileting plan, and Alarm yes. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 9- Closed Record review of Resident # 12. RMS dated 03/31/17 at 4:25 p.m., reflected un-witnessed fall, Injury, abrasion, skin tear in resident room. Confused, poor safety awareness. Area titled Circumstances: resident was in his room attempting to stand up. Preventive measures in place prior to this fall: call light within reach, tab alarm frequent monitoring. Intervention: assessment, first aide. RMS revealed no toileting plan, and Alarm yes. Record review reflected the following, no observation schedule time. The Neurological assessment initiated 03/31/17 at 4:25 p.m. was not completed according to the facility policy. Neurological assessment not initiated according to the facility policy. Fall # 10- Closed Record review of Resident # 12. RMS dated 03/31/17 at 4:25 p.m., reflected unwitnessed fall with injury abrasion skin tear in resident room Preventive measures in place prior to this fall: call light within reach, tab alarm frequent monitoring. Intervention: assessment, first aide. Intervention: assessment and first aide. RMS revealed no toileting plan, and Alarm yes. And sounding. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 11- Closed Record review of Resident # 12. RMS dated 04/02/17 at 8:30 p.m., un-witnessed fall, with injury bruise in resident room. Area titled Circumstances: staff found him (resident) on the floor at the doorway to the bathroom, he stated he was going to the bathroom when he fell . Preventive measures in place prior to this fall: tab alarm, call light within reach. Intervention: assessment, first aide. X-ray obtained right hip- negative for fracture. RMS revealed no toileting plan, and Alarm yes and sounding. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 12- Closed Record review of Resident # 12. RMS dated 04/03/17 at 4:00 a.m., fall, un-witnessed no injury resident room. Confused, poor safety awareness, wandering. Area titled Circumstances: resident was found on the floor by the bed. Preventive measures in place prior to this fall: alarm, frequent observation call light within reach, Intervention: added immediately after fall and care plan updated: assessment, assist back to bed. RMS revealed no toileting plan, and Alarm yes and sounding. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 13- Closed Record review of Resident # 12. RMS dated 04/07/17 at 10:00 a.m., reflected un-witnessed fall, Injury skin tear in resident room Comatose Area title Circumstances: resident found sitting on floor with blanket wrapped around him. Preventive measures in place prior to this fall: alarm, call light within reach observation, Intervention: added immediately after fall and care plan updated: assessment, first aide. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. On 08/07/17 at 11:44 a.m. interview with facility DON regarding Resident # 12 neuro checks. Facility DON revealed He does not have any Neuro checks unless they are in the closed record. On 08/07/17 at 4:27 p.m. interview with facility DON regarding Resident # 12 having 13 falls in 2 months. Facility DON said I was hired on 03/20/17 and I was in orientation for two weeks. I started on 04/03/17. I knew he had a history of [REDACTED]. Record review of the facility Accidents/ Incidents Policy and Procedure date revised 11/28/16. 2. Assessment, Medical Assessment, Documentation: 2.1.4 Any patient who sustains an injury to the head and /or has an un-witnessed fall will be observed for neurological abnormalities by performing neuro (neurological) checks according to the Assessment: Neurological policy and procedure after the accident / incident occurs. The physician /APN (advanced practice nurse) /PA (physician assistance) will be notified of any abnormal findings. 2.1.6. The Nurse will: Document the accident / Incident in the patient's chart; Documentation will include all pertinent information, date, place, notification, and initial and ongoing assessment; Document the accident / Incident in the patient's chart; Documentation will include all pertinent information, date, place, notification, and initial and ongoing assessment. Record review of facility Abuse Prohibition revised date 04/07/17 Policy: . will prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation foe all residents. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptom. The Center will implement an abuse prohibition program through the following: Prevention of occurrences; Identification of possible incidents or allegation which need investigation; Investigation of incidents and allegations; Protection of patients during investigation; and Reporting of incidents, investigation, and Center response to the results of their investigations. Federal Definitions: Injury of unknown source are defined a

Based on observations interview and record review the facility failed ensure each resident receives adequate supervision and devices to prevent accidents for 2 of 15 residents (#5, #12) reviewed for accidents and supervision. The facility failed to update the assessment, plan of care and intervention to address the needs of resident #5 and 12's frequent falls. Resident #5 had twelve falls in 7 months and resident #12 had twelve falls in a two month period. The facility failed to address interventions related to falls as per the resident's care plan. The facility failed to provide adequate supervision on the memory unit to observe resident safety. The facility failed to initiate or provide a complete neurological assessment (neuro check) as per their policy after each resident's fall. An IJ was identified on 08/03/17. While the IJ was lowered on 08/04/17 the facility remained out of compliance at a scope of a pattern and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. This failure resulted in resident #5 sustaining a shoulder dislocation, a fractured rib, head lacerations and other multiple head injuries and bruises. This failure also resulted in Resident #12 sustaining bruises and lacerations. Failure to provide adequate supervision in the memory could lead to the prevention of falls. The failure to follow and or update the care plan for accident/falls could lead to increased falls and accidents. Failure to provide neuro checks after falls with suspected head injuries could prevent the facility with needed medical information to determine future and prevent future accidents. These failures places residents at risk for severe injury after a fall, such as fractures, lacerations, head injuries including death. The finding include: On 08/01/17 at 9:15 a.m. initial tour observation in facility Secured Memory Unit with facility Medical Record personal observed Resident #5 laying on a mattress on the floor without a fall matt, no call light in reach. Resident was asleep. Medical Records personal revealed Resident # 5 is confused has [DIAGNOSES REDACTED]. Record review of Resident # 5 current physician order [REDACTED]. Resident # 5 [DIAGNOSES REDACTED]. Record review of Resident #5 Minimum Data Set (MDS) Reentry 5 day scheduled assessment dated [DATE] reflected Brief Interview for Mental Status (BIMs) total available score (00-15) documented score of 06 (severely impaired.) Activity of Daily Living Transfer: extensive assistance of two person assist. Walking in room and corridor: extensive assistance of two person assist. Mobility device: wheelchair. Balance during Transitions and Walking: Not steady, only able to stabilize with staff assistance. Urinary and Bowel Toileting Program No. Urinary Continence: always incontinent. Bowel Continence: always incontinent. Fall History on Admission /Entry or Reentry. Minimum Data Set (MDS) Version 3.0 Section C: BIMS (Brief Interview for Mental Status) Score 00-15: 13 -15 = person is intact cognitively 9 - 12 = person is moderately impaired 0- 7 = person is severely impaired Review of John Hopkins Medicine Health Library (www.hopkinsmedicineregarding) Neurological assessment assess the sensory neuron motor responses to determine whether the nervous system is impaired, motor sensory skills, balance and coordination mental status and level of awareness and interaction with the environment, reflexes and functioning. Record review of Resident # 5 only Fall Risk Assessment reflected Fall Risk Assessment completed date 09/01/16 total score 16 (total score above 10 represents High Risk. Record review of Resident # 5 facility Event Tracking Log as well as the facility RMS-(Event Summary Report) reflected fall list. 01/16/17 at 7:30 p.m. 01/22/17at 8:10 p.m., 01/23/17 at 7:15 p.m., 03/05/17 at 3:05 p.m., 03/13/17at 3:30p.m., 03/31/17 at 6:10 a.m. 04/01/17 at 12:55 p.m., 04/04/17 at 2:30 a.m., 04/21/17 at 9:00 p.m., 06/16/17at 5:30 p.m., 06/21/17 at 5:15 a.m. , and 7/17/17 6:30 p.m. Fall #1- Record review of Resident #5 Event Summary Report (RMS) dated 01/16/17 at 7:30 p.m., reflected unwitnessed fall with no injuries in resident bathroom. Resident confused. Area titled Circumstances: resident got herself up to the bathroom and fell while she was in the bathroom. Preventive measures in place prior to fall: frequent observation, education. Working with PT since hip fracture. RMS revealed no toileting plan and no alarm. Record review did not reflect observation schedule times or Neurological assessment was not initiated according to the Facility Neurological Assessment Policy. Fall #2- Record review of Resident #5 RMS dated 01/22/17 at 8:10 a.m., reflected unwitnessed fall with injuries Bruise, pain on the coccyx. In resident bathroom Area titled Circumstances revealed resident was in bed then woke up without notifying the aids and went to the bathroom and fell on her bottom. Preventive measures in place prior to fall: observation, education, bed alarm. Confused with poor safety awareness, Wandering. RMS revealed no toileting plan and Alarm record review reflected the following no observation schedule time or Neurological assessment was not initiated to the facility policy. Fall # 3- Record review of Resident #5 RMS dated 01/23/17 at 7:15 p.m., reflected un-witnessed fall, with Head injury. Area titled Circumstances: resident was in the hall way attempting to stand up from her wheelchair. Preventative measures in place prior to this fall: tab alarm in use, frequent observation. Intervention: assessment, neuro (neurological) check. RMS revealed no toileting plan. Record review reflected the following no observation schedule time or Neurological assessment was not initiated according to the facility policy. Fall # 4-Record review of Resident #5 RMS dated 03/05/17 at 3:05 p.m. un-witnessed, fall with injury Bruise Area titled Circumstances: resident resting in bed when she woke up and walked to the rest room without pulling the call light, fell at the bathroom door, just heard her call for help to find her on the floor, confused. Preventive measures in place prior to this fall: frequent observation, call light within reach, room close to nurse's station. Intervention: assessment, assisted back to bed. RMS revealed no toileting plan and no Alarm. Record review reflected the following, no observation schedule time. Neurological assessment initiated 03/05/17 at 4:05 p.m. reflected a change in blood pressure from 124/52 at 4:35 p.m. to a blood pressure of 80/54. The Neurological assessment was not completed according to the facility policy. Fall # 5- Record review of Resident # 5 RMS dated 03/13/17 at 3:30 p.m., reflected witnessed fall with injury of Hematoma to the back of head Area titled Circumstances: Resident up at nurse station attempted to stand without locking wheelchair causing resident to fall back words hitting the back of her head on the wall. Intervention: assessment, first aide, neuros (Neurological Assessment). RMS revealed no toileting plan, and no Alarm. Record review reflected the following, no observation schedule time or Neurological assessment was not initiated according to the facility policy. Fall # 6- Record review of Resident #5 RMS dated 03/31/17 at 6:10 a.m., reflected fall, unobserved injury, Bruise, Area titled Circumstances: Possibly caused by resident letting herself fall back in wheelchair when continuously standing up. Hitting arm rest over and over. Resident room, confused, poor safety awareness. Preventive measures in place prior to this fall: call light within reach frequent observation. RMS revealed no toileting plan, and no Alarm. Record review reflected the following, no observation schedule time or Neurological assessment was not initiated according to the facility policy. Fall # 7-Record review of Resident #5 RMS dated 04/01/17 at 12:55 p.m., reflected witnessed fall, No injury, Location: dining room Area titled Circumstance: resident walking with her wheelchair, then went down and landed on her bottom. Confused, Poor safety Awareness, Wandering. Preventive measures in place prior to this fall: call light within reach, frequent observation. RMS revealed no toileting plan and no Alarm. Record review reflected the following, no observation schedule time or Neurological assessment was not initiated according to the facility policy. Fall # 8- Record review of Resident #5 RMS dated 04/04/17 at 2:30 a.m., reflected un-witnessed fall with injury hematoma to head Location: resident room. Area titled Circumstances: Heard noise and someone saying help. Found resident on floor in front of dresser holding head assisted back to bed. Has approx. 4cm (centimeter) raised red area on back of head. Preventive measures in place prior to this fall: call light within reach, frequent observation. Intervention: assessment, and assist back to be bed. RMS revealed no toileting plan and no Alarm. Record review reflected the following, no observation schedule time. Record review of Resident #5 Neurological assessment initiated 04/04/17 at 4:05 p.m. area titled right and left Pupil size and reaction was blank.The Neurological assessment was not completed according to the facility policy. Fall # 9- Record review of Resident #5 RMS dated 04/21/17 at 9:00 a.m., un-witnessed fall, with Cut / laceration, Dislocation, Area titled Circumstances Resident found lying in floor in front of closet. Noted laceration above eyebrow, resident complain of pain left shoulder. Intervention: assessment, first aide, sent to ER (emergency room ) laceration sutured, left shoulder x-rayed, immobilized placed due to dislocation. Preventive measures in place prior to this fall: room near nurse station, call light within reach, and frequent observation, confused, poor safety awareness. Wandering. RMS revealed no toileting plan and no Alarm. Record review reflected the following, no observation schedule time. The Neurological assessment was not initiated according to the facility policy. Fall # 10- Record review of Resident #5 RMS dated 06/16/17 at 5:30 a.m., un-witnessed fall with injury Fracture. Area titled Circumstances resident was up in wheelchair, got up without assistance, and fell . MD contacted and x-ray ordered noted fx. (Fracture). The X-ray dated 6/16/17 Impression: acute 7-th rib fracture with minimal displacement posterior laterally. Healed rib fracture at 8-th and 9-th ribs posterior laterally. MD notified and Merri Walker ordered and implemented. Preventive measures in place prior to this fall: tab alarm, call light within reach, and frequent observation. Alarm is assigned to resident while in bed. Therapy will continue to treat. RMS revealed no toileting plan and alarm yes. Record review revealed the following, no observation schedule time. The Neurological assessment was not initiated or completed according to the facility policy. Record review of Resident # 5 Physician called back on x-ray of ribs. Physician inquiring why is it that since resident has been at this facility that she is having multiple falls and none were noted at previous facility? DON explained that resident Dementia appears to be progressively worse since previous facility. His response was to 'figure out a way to keep her from falling, put her in a Merri walker, can y'all not do that.' Explained our policy was to not have restraints he said last resort is a Merri walker et (and) gave the order. On 08/02/17 at 8:02 a.m. observed of Resident # 5 sitting in a merri walker at dining room table, well groomed, diet served as ordered per menu resident asssist self ate 100%. On 8/3/17 at 10:00 AM observed Resident #5 being pushed into the main dining room by unidentified CNA. Resident #5 was in a merri-walker with anti-tip PVC pipes on each side and black Velcro arm/leg weight attached to each side of merri-walker. Resident #5 was having a hard time getting merri-walker over the threshold going into the dining room and CNA had to turn the merri-walker slightly sideways to get through the doorway. Resident #5 was appropriately groomed, dressed with proper footwear. Surveyor confirmed with CNA that resident was Resident #5. On 08/03/17 at 3:46 p.m. observation of Resident # 5 in her room on mattress on floor, no fall matt or fall alarm observed call light in reach. Fall # 11- Record review of Resident #5 RMS dated 06/21/17 at 5:15 a.m., un-witnessed fall, with injury abrasion, area titled Circumstances: heard resident yell out. Resident found sitting on the floor against the wall and beside the bed. Confused, poor safety awareness, Wandering. Preventive measures in place prior to this fall: frequent observation, all light within reach. RMS revealed out of low bed to floor mattress, no toileting plan and no Alarm. Record review revealed the following, no observation schedule time. The Neurological assessment was not initiated or completed according to the facility policy. Fall # 12- Record review of Resident #5 RMS dated 07/17/17 at 6:30 p.m., witnessed Fall with injury Cut/ laceration, skin tear. Confused, poor safety awareness, Wandering. Circumstances Resident reaching et (and) rocking Merry walker until tipped over the left side resident hit head on corner of bed wheel going down, resident immediately became unresponsive labor uneven breathing noted of 108 upon assessment. A Nurse in training initiated first aid to locate where all the blood was pooling from and to monitor pulse et (and) loc (level of consciousness) while myself called for ER transportation et notified proper chain of people. Intervention: added immediately after fall and care plan update: assessment, sent to ER for treatment. Preventive measures in place prior to this fall: merry walker, call light within reach. RMS revealed no toileting plan and no Alarm. Record review revealed the following, no observation schedule time. The Neurological assessment was not initiated or completed according to the facility policy. Record review of Resident # 5 Care Plan Goal: will have no falls with injury x 90 days. Date initiated 09/02/16 Revised on 06/20/17 1. Assess for change in medical status, pain status, and mental status and report MD as indicated. initiated 09/02/16 2. Leave mattress on floor for her safety date initiated 06/26/17. 3. Tab alarm for bed for resident safety initiated 09/02/16 4. Medication evaluation as needed initiated 09/02/16 5. Provide verbal cues for safety and sequencing when needed initiated 09/02/16. 6. Provide verbal cues for proper pacing and energy conservation technique initiated 09/02/16. 7. Provide resident/ caretaker education for safe technique initiated 09/02/16. 8. Place call light within reach at all times initiated 09/02/16. 9. Remind resident to use call light when attempting to ambulate or transfer initiated 09/02/16. 10. When resident is in bed, place all necessary personal items within reach initiated 09/02/16. 11. Monitor for and assist toileting needs initiated 09/02/16. 12. Encourage resident to attend all activities that maximize their full potential while meeting their need to socialize initiated 09/02/16. On 08/02/17 at 8:09 a.m. interview with facility DON revealed the facility doesn't have an incontinent management program. On 08/02/17 at 9:40 a.m. interview with facility DON revealed Resident # 5 falls are around change of shift time. The facility DON revealed there has been no Activity Director in the Memory unit but she thinks one has been hired. On 08/03/17 at 8:34 a.m. interview with L.V.N # 2 revealed Resident # 5 increased falls is because she is very confused. When she was in her wheelchair she would try to get up all the time. She would get up in her room and try to go to the bathroom. L.V.N. # 2 revealed Resident # 5 is not on a scheduled toileting program or incontinent management program. L.V.N # 2 said They try to take her. L.V.N # 2 revealed Resident # 5 had a bed alarm a long time ago she cannot remember why they stop using it. L.V.N. # 2 revealed Resident # 5 is now in a Merry Walker after her fall in June the Dr. called and wanted the Merry Walker. L.V.N. # 2 revealed prior to the Merry Walker they put her mattress on the floor and she was working with therapy. L.V.N. # 2 revealed when a fall occurs they do an assessment, incident report (RMS) and do follow-up to incident for 72 hours and do neuro checks if they hit their head. Notify Dr. and family. L.V.N. # 2 revealed she does not do the residents Fall Risk Assessments. L.V.N. # 2 revealed they (staff) cannot observe residents in the dining room (common area) from the nurse station and if the nurse aide is in a room with a resident the residents cannot be seen. On 08/03/17 at 4:12 p.m. interview with C.N.A. # 5 revealed she works on hall 200 and she does not go to the unit to work or help. C.N.A. # 5 revealed there is one C.N.A. that works in the unit and one L.V.N. for Hall 200 and the Unit. (Memory). (The memory unit is separate from Hall 200.) On 08/03/17 at 4:12 p.m. interview with C.N.A. # 6 revealed she only works on Hall 200 and only goes to the unit (memory) to work the unit when the C.N.A. working day off. On 08/03/17 at 4:20 p.m. interview with L.V.N. # 3 revealed Resident # 5 increased falls is because she needs to be watched closely but it is difficult because she works hall 200 and the unit also. On 08/03/17 at 5:05 p.m. interview with facility DON regarding Resident # 5 only one Fall Risk assessment dated in 09/16. Facility DON revealed the facility Fall Risk Assessment has been discontinued and she will have to look in Resident #5 chart for a paper Fall Risk Assessment and her neuro checks are in the chart. Facility DON revealed the 12 falls in 7 months are because of her [DIAGNOSES REDACTED]. Resident # 5 does not sleep well we have tried and given her melatonin and benzodiazepines with the supervision of the nurse practitioner so not to chemical restrain her. Resident # 5 is restless and wanders. The facility DON revealed Resident # 5 has a lot of falls in June but they implemented, a low bed and a mattress on the floor and a Merri walker on 06/20/17. Resident # 5 receives therapy PT physical therapy and OT occupational therapy. The facility DON revealed the facility initiated bed alarm on 09/2016 but she does not have it now it was discontinues. The facility DON revealed. Interventions for Resident # 5 was Low bed/ mattress on floor, on 06/26/17, Care Plan up dates, Merri Walker 06/20/17, bed alarm on 09/16 and discontinued on 03/31/17. Facility DON revealed Resident # 5 was in a Geri chair from 04/22/17 to 05/26/17 because she could not position in wheelchair with sling due to fall and shoulder dislocation. The facility Don revealed Resident neuro checks are only two and they are in the chart. On 08/03/17 at 5:35 p.m. facility DON revealed the Fall Risk Assessment has been retired because it was incorporated with the Nurse Assessment form. Nurse Assessment form reviewed with DON revealed: 3. Falls fall history on admission /Entry or reentry: F a1.Did the resident have a fall any time in the month prior to admission/ reentry. Fa2.Did the resident have a fall any time in the last 2-6 months prior to admission / reentry. A3. Did the resident have a fall related to a fall in the 6 month prior to admission/ reentry? The facility DON revealed the Nursing Assessment with this Falls Following as listed above DON stated no this is not it. (Fall Risk Assessment) Resident # 12 Closed Record review of Resident # 12 current physician order [REDACTED]. Resident 12 [DIAGNOSES REDACTED]. Closed Record review of Resident #12 Minimum Data Set ((MDS) dated [DATE] Admission assessment reflected Brief Interview for Mental Status (BIMs) total available score (00-15) documented score of 04 (severely impaired) Activity of Daily Living Transfer: Limited assistance of one person assist. Walking in room and corridor: Activity did not occur. Mobility device: wheelchair. Urinary Toileting Program: No. Urinary Continence: frequently incontinent. Bowel Toileting Program: No. Bowel Continence: frequently incontinent. On further review of Resident # 12 MDS resident had a fall in the last month prior to Admission and had a fall in the last 2-6 month prior to admission. Record review of Resident #5 Care Plan initiated 02/06/17 did not address fall prevention and or interventions related to Resident # 12 falls. Record review of Resident #12 facility Event Tracking Log as well as the facility RMS (Event Summary Report) dated 02/07/17at 10:00 a.m. 03/03/17 at 8:00 a.m. 03/13/17 at 10:00 a.m.,03/14/17 at 2:40 p.m. 03/15/17 at 2:55 a.m. 03/18/17 at 2:00 a.m.03/21/17 at 3:25 p.m. 03/28/17 at 7:10 p.m., 03/31/17 4:25 p.m. 04/02/17at 8:30 p.m., 04/03/17 at 4:00 a.m. 04/07/17. Fall #1- Closed Record review of Resident # 12. RMS dated 02/07/17 at 10:00 a.m., reflected un-witnessed fall with injury skin tear, in dining room. Confused, poor safety awareness, Wandering. Area titled Circumstances: Resident tried to get out of wheelchair leaned on table and table gave way. Preventive measures in place prior to this fall: tab alarm, call light in use, frequent observation. Intervention: assessment and first aide. RMS revealed no toileting plan, and Alarm yes. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 2- Closed Record review of Resident # 12. RM dated 03/03/17 at 8:00 a.m., reflected un-witnessed fall in dining room no injury, Confused, poor safety awareness. Area titled Circumstances: Resident found lying his right side on bathroom floor. He was going to the bathroom and fell . He is weak and unsteady when ambulating. RMS revealed no toileting plan, and no Alarm. Record review reflected the following, no observation schedule time. The Neurological assessment initiated 03/05/17 at 4:05 p.m. was not completed according to the facility policy. Fall # 3- Closed Record review of Resident # 12. RMS dated 03/13/17 at 10:00 a.m. reflected un-witnessed fall, Injury skin tear Confused, wandering. Area titled Circumstances: was going to the bathroom. Preventive measures in place prior to this fall: call light within reach frequent observation. RMS revealed no toileting plan, and Alarm yes. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 4- Closed Record review of Resident # 12. RMS dated 03/14/17 at 2:40 p.m., reflected un-witnessed fall no injury in resident bathroom confused, poor safety awareness. Area titled Circumstances: was going to bathroom without help. Investigation: Preventive measures in place prior to this fall: bed alarm, call light within reach. Investigation: assessment. RMS revealed no toileting plan, and Alarm yes. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 5- Closed Record review of Resident # 12. RMS dated 03/15/17 at 2:55 a.m., reflected un-witnessed fall, no injury in resident bathroom, poor safety awareness, wandering. Area title Circumstances: Bed alarm going off just as nurse stepped into the bathroom resident slipped and fell on his bottom. Intervention: assessment, assist to bathroom. Preventive measures in place prior to this fall: bed alarm, call light within reach. RMS revealed no toileting plan, and Alarm yes. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 6 - Closed Record review of Resident # 12. RMS dated 03/18/17 at 2:00 a.m., un-witnessed fall, Injury Abrasion and skin tear in resident room. Confused, poor safety awareness. Area title Circumstances: going to bathroom without assistance. Preventive measures in place prior to this fall: bed alarm, call light within reach frequent observation Investigation added immediately after fall and care plan update: assessment assist to bathroom, alarm reapplied. RMS revealed no toileting plan, alarm yes and sounding. Record review reflected the following, no observation schedule time. The Neurological assessment initiated 03/18/17 at 2:00 a.m. was not completed according to the facility policy. Fall # 7- Closed Record review of Resident # 12. RMS dated 03/21/17 at 3:25 p.m., reflected un-witnessed Fall Injury no injury in resident's room. Confused, poor safety awareness, wandering. Area titled Circumstances: I was down the hall and the aide who was assigned to the unit was busy changing another resident. She heard a big crash and went to see where it came from when she heard the resident calling for help. He was on the floor behind his door. Preventive measures in place prior to this fall: tab alarm, call light, frequent observation. Intervention: assessment, assisted to bathroom, alarm reapplied. RMS revealed no toileting plan, and Alarm yes. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 8- Closed Record review of Resident # 12. RMS dated 03/28/17 at 7:10 p.m., reflected un-witnessed fall, with injury skin tear, resident room. Confused, poor safety awareness, Wandering. Area titled Circumstances: resident was coming back from the bathroom when he (resident) fell . Preventive measures in place prior to this fall: alarm, call light within reach, education, frequent observation. Intervention: assessment, first aide to skin tear. RMS revealed no toileting plan, and Alarm yes. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 9- Closed Record review of Resident # 12. RMS dated 03/31/17 at 4:25 p.m., reflected un-witnessed fall, Injury, abrasion, skin tear in resident room. Confused, poor safety awareness. Area titled Circumstances: resident was in his room attempting to stand up. Preventive measures in place prior to this fall: call light within reach, tab alarm frequent monitoring. Intervention: assessment, first aide. RMS revealed no toileting plan, and Alarm yes. Record review reflected the following, no observation schedule time. The Neurological assessment initiated 03/31/17 at 4:25 p.m. was not completed according to the facility policy. Neurological assessment not initiated according to the facility policy. Fall # 10- Closed Record review of Resident # 12. RMS dated 03/31/17 at 4:25 p.m., reflected unwitnessed fall with injury abrasion skin tear in resident room Preventive measures in place prior to this fall: call light within reach, tab alarm frequent monitoring. Intervention: assessment, first aide. Intervention: assessment and first aide. RMS revealed no toileting plan, and Alarm yes. And sounding. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 11- Closed Record review of Resident # 12. RMS dated 04/02/17 at 8:30 p.m., un-witnessed fall, with injury bruise in resident room. Area titled Circumstances: staff found him (resident) on the floor at the doorway to the bathroom, he stated he was going to the bathroom when he fell . Preventive measures in place prior to this fall: tab alarm, call light within reach. Intervention: assessment, first aide. X-ray obtained right hip- negative for fracture. RMS revealed no toileting plan, and Alarm yes and sounding. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 12- Closed Record review of Resident # 12. RMS dated 04/03/17 at 4:00 a.m., fall, un-witnessed no injury resident room. Confused, poor safety awareness, wandering. Area titled Circumstances: resident was found on the floor by the bed. Preventive measures in place prior to this fall: alarm, frequent observation call light within reach, Intervention: added immediately after fall and care plan updated: assessment, assist back to bed. RMS revealed no toileting plan, and Alarm yes and sounding. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 13- Closed Record review of Resident # 12. RMS dated 04/07/17 at 10:00 a.m., reflected un-witnessed fall, Injury skin tear in resident room Comatose Area title Circumstances: resident found sitting on floor with blanket wrapped around him. Preventive measures in place prior to this fall: alarm, call light within reach observation, Intervention: added immediately after fall and care plan updated: assessment, first aide. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. On 08/07/17 at 11:44 a.m. interview with facility DON regarding Resident # 12 neuro checks. Facility DON revealed He does not have any Neuro checks unless they are in the closed record. On 08/07/17 at 4:27 p.m. interview with facility DON regarding Resident # 12 having 13 falls in 2 months. Facility DON said I was hired on 03/20/17 and I was in orientation for two weeks. I started on 04/03/17. I knew he had a history of [REDACTED]. Record review of the facility Accidents/ Incidents Policy and Procedure date revised 11/28/16. 2. Assessment, Medical Assessment, Documentation: 2.1.4 Any patient who sustains an injury to the head and /or has an un-witnessed fall will be observed for neurological abnormalities by performing neuro (neurological) checks according to the Assessment: Neurological policy and procedure after the accident / incident occurs. The physician /APN (advanced practice nurse) /PA (physician assistance) will be notified of any abnormal findings. 2.1.6. The Nurse will: Document the accident / Incident in the patient's chart; Documentation will include all pertinent information, date, place, notification, and initial and ongoing assessment; Document the accident / Incident in the patient's chart; Documentation will include all pertinent information, date, place, notification, and initial and ongoing assessment. Record review of facility Abuse Prohibition revised date 04/07/17 Policy: . will prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation foe all residents. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptom. The Center will implement an abuse prohibition program through the following: Prevention of occurrences; Identification of possible incidents or allegation which need investigation; Investigation of incidents and allegations; Protection of patients during investigation; and Reporting of incidents, investigation, and Center response to the results of their investigations. Federal Definitions: Injury of unknown source are defined as an injury with both of the following conditions. The source of the

Based on observations interview and record review the facility failed to implement it's written policy and procedure for neglect for 2 of 15 residents ( # 5 and #12) reviewed for neglect. The facility failed to implement it's policy and procedure for neglect for Resident # 5 and Resident #12. The facility failed to address interventions related to falls as per the resident's care plan. The facility failed to provide adequate supervision on the memory unit to observe resident safety. The facility failed to initiate or provide a complete neurological assessment (neuro check) as per their policy after each resident's fall. The facility failed to update the assessment, plan of care and intervention to address the needs of resident #5 and 12's frequent falls. Resident #5 had twelve falls in 7 months and resident #12 had twelve falls in a two month period. An IJ was identified on 08/03/17. While the IJ was lowered on 08/04/17 the facility remained out of compliance at a scope of a pattern and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. This failure resulted in resident #5 sustaining a shoulder dislocation, a fractured rib, [MEDICAL CONDITION] and other multiple head injuries and bruises. This failure also resulted in Resident #12 sustaining bruises and lacerations. Failure to provide adequate supervision in the memory could lead to the prevention of falls. The failure to follow and or update the care plan for accident/falls could lead to increased falls and accidents. Failure to provide neuro checks after falls with suspected head injuries could prevent the facility with needed medical information to determine future and prevent future accidents. These failures places residents at risk for severe injury after a fall, such as fractures, lacerations, head injuries including death. The finding include: On 08/01/17 at 9:15 a.m. initial tour observation in facility Secured Memory Unit with facility Medical Record personal observed Resident #5 laying on a mattress on the floor without a fall matt, no call light in reach. Resident was asleep. Medical Records personal revealed Resident # 5 is confused has [DIAGNOSES REDACTED]. Record review of Resident # 5 current physician order [REDACTED]. Resident # 5 [DIAGNOSES REDACTED]. Record review of Resident #5 Minimum Data Set (MDS) Reentry 5 day scheduled assessment dated [DATE] reflected Brief Interview for Mental Status (BIMs) total available score (00-15) documented score of 06 (severely impaired.) Activity of Daily Living Transfer: extensive assistance of two person assist. Walking in room and corridor: extensive assistance of two person assist. Mobility device: wheelchair. Balance during Transitions and Walking: Not steady, only able to stabilize with staff assistance. Urinary and Bowel Toileting Program No. Urinary Continence: always incontinent. Bowel Continence: always incontinent. Fall History on Admission /Entry or Reentry. Minimum Data Set (MDS) Version 3.0 Section C: BIMS (Brief Interview for Mental Status) Score 00-15: 13 -15 = person is intact cognitively 9 - 12 = person is moderately impaired 0- 7 = person is severely impaired Review of John Hopkins Medicine Health Library (www.hopkinsmedicineregarding) Neurological assessment assess the sensory neuron motor responses to determine whether the nervous system is impaired, motor sensory skills, balance and coordination mental status and level of awareness and interaction with the environment, reflexes and functioning. Record review of Resident # 5 only Fall Risk Assessment reflected Fall Risk Assessment completed date 09/01/16 total score 16 (total score above 10 represents High Risk. Record review of Resident # 5 facility Event Tracking Log as well as the facility RMS-(Event Summary Report) reflected fall list. 01/16/17 at 7:30 p.m. 01/22/17at 8:10 p.m., 01/23/17 at 7:15 p.m., 03/05/17 at 3:05 p.m., 03/13/17at 3:30p.m., 03/31/17 at 6:10 a.m. 04/01/17 at 12:55 p.m., 04/04/17 at 2:30 a.m., 04/21/17 at 9:00 p.m., 06/16/17at 5:30 p.m., 06/21/17 at 5:15 a.m. , and 7/17/17 6:30 p.m. Fall #1- Record review of Resident #5 Event Summary Report (RMS) dated 01/16/17 at 7:30 p.m., reflected unwitnessed fall with no injuries in resident bathroom. Resident confused. Area titled Circumstances: resident got herself up to the bathroom and fell while she was in the bathroom. Preventive measures in place prior to fall: frequent observation, education. Working with PT since [MEDICAL CONDITION]. RMS revealed no toileting plan and no alarm. Record review did not reflect observation schedule times or Neurological assessment was not initiated according to the Facility Neurological Assessment Policy. Fall #2- Record review of Resident #5 RMS dated 01/22/17 at 8:10 a.m., reflected unwitnessed fall with injuries Bruise, pain on the coccyx. In resident bathroom Area titled Circumstances revealed resident was in bed then woke up without notifying the aids and went to the bathroom and fell on her bottom. Preventive measures in place prior to fall: observation, education, bed alarm. Confused with poor safety awareness, Wandering. RMS revealed no toileting plan and Alarm record review reflected the following no observation schedule time or Neurological assessment was not initiated to the facility policy. Fall # 3- Record review of Resident #5 RMS dated 01/23/17 at 7:15 p.m., reflected un-witnessed fall, with Head injury. Area titled Circumstances: resident was in the hall way attempting to stand up from her wheelchair. Preventative measures in place prior to this fall: tab alarm in use, frequent observation. Intervention: assessment, neuro (neurological) check. RMS revealed no toileting plan. Record review reflected the following no observation schedule time or Neurological assessment was not initiated according to the facility policy. Fall # 4-Record review of Resident #5 RMS dated 03/05/17 at 3:05 p.m. un-witnessed, fall with injury Bruise Area titled Circumstances: resident resting in bed when she woke up and walked to the rest room without pulling the call light, fell at the bathroom door, just heard her call for help to find her on the floor, confused. Preventive measures in place prior to this fall: frequent observation, call light within reach, room close to nurse's station. Intervention: assessment, assisted back to bed. RMS revealed no toileting plan and no Alarm. Record review reflected the following, no observation schedule time. Neurological assessment initiated 03/05/17 at 4:05 p.m. reflected a change in blood pressure from 124/52 at 4:35 p.m. to a blood pressure of 80/54. The Neurological assessment was not completed according to the facility policy. Fall # 5- Record review of Resident # 5 RMS dated 03/13/17 at 3:30 p.m., reflected witnessed fall with injury of Hematoma to the back of head Area titled Circumstances: Resident up at nurse station attempted to stand without locking wheelchair causing resident to fall back words hitting the back of her head on the wall. Intervention: assessment, first aide, neuros (Neurological Assessment). RMS revealed no toileting plan, and no Alarm. Record review reflected the following, no observation schedule time or Neurological assessment was not initiated according to the facility policy. Fall # 6- Record review of Resident #5 RMS dated 03/31/17 at 6:10 a.m., reflected fall, unobserved injury, Bruise, Area titled Circumstances: Possibly caused by resident letting herself fall back in wheelchair when continuously standing up. Hitting arm rest over and over. Resident room, confused, poor safety awareness. Preventive measures in place prior to this fall: call light within reach frequent observation. RMS revealed no toileting plan, and no Alarm. Record review reflected the following, no observation schedule time or Neurological assessment was not initiated according to the facility policy. Fall # 7-Record review of Resident #5 RMS dated 04/01/17 at 12:55 p.m., reflected witnessed fall, No injury, Location: dining room Area titled Circumstance: resident walking with her wheelchair, then went down and landed on her bottom. Confused, Poor safety Awareness, Wandering. Preventive measures in place prior to this fall: call light within reach, frequent observation. RMS revealed no toileting plan and no Alarm. Record review reflected the following, no observation schedule time or Neurological assessment was not initiated according to the facility policy. Fall # 8- Record review of Resident #5 RMS dated 04/04/17 at 2:30 a.m., reflected un-witnessed fall with injury hematoma to head Location: resident room. Area titled Circumstances: Heard noise and someone saying help. Found resident on floor in front of dresser holding head assisted back to bed. Has approx. 4cm (centimeter) raised red area on back of head. Preventive measures in place prior to this fall: call light within reach, frequent observation. Intervention: assessment, and assist back to be bed. RMS revealed no toileting plan and no Alarm. Record review reflected the following, no observation schedule time. Record review of Resident #5 Neurological assessment initiated 04/04/17 at 4:05 p.m. area titled right and left Pupil size and reaction was blank.The Neurological assessment was not completed according to the facility policy. Fall # 9- Record review of Resident #5 RMS dated 04/21/17 at 9:00 a.m., un-witnessed fall, with Cut / laceration, Dislocation, Area titled Circumstances Resident found lying in floor in front of closet. Noted laceration above eyebrow, resident complain of pain left shoulder. Intervention: assessment, first aide, sent to ER (emergency room ) laceration sutured, left shoulder x-rayed, immobilized placed due to dislocation. Preventive measures in place prior to this fall: room near nurse station, call light within reach, and frequent observation, confused, poor safety awareness. Wandering. RMS revealed no toileting plan and no Alarm. Record review reflected the following, no observation schedule time. The Neurological assessment was not initiated according to the facility policy. Fall # 10- Record review of Resident #5 RMS dated 06/16/17 at 5:30 a.m., un-witnessed fall with injury Fracture. Area titled Circumstances resident was up in wheelchair, got up without assistance, and fell . MD contacted and x-ray ordered noted fx. (Fracture). The X-ray dated 6/16/17 Impression: acute 7-th rib fracture with minimal displacement posterior laterally. Healed rib fracture at 8-th and 9-th ribs posterior laterally. MD notified and Merri Walker ordered and implemented. Preventive measures in place prior to this fall: tab alarm, call light within reach, and frequent observation. Alarm is assigned to resident while in bed. Therapy will continue to treat. RMS revealed no toileting plan and alarm yes. Record review revealed the following, no observation schedule time. The Neurological assessment was not initiated or completed according to the facility policy. Record review of Resident # 5 Physician called back on x-ray of ribs. Physician inquiring why is it that since resident has been at this facility that she is having multiple falls and none were noted at previous facility? DON explained that resident Dementia appears to be progressively worse since previous facility. His response was to 'figure out a way to keep her from falling, put her in a Merri walker, can y'all not do that.' Explained our policy was to not have restraints he said last resort is a Merri walker et (and) gave the order. On 08/02/17 at 8:02 a.m. observed of Resident # 5 sitting in a merri walker at dining room table, well groomed, diet served as ordered per menu resident asssist self ate 100%. On 8/3/17 at 10:00 AM observed Resident #5 being pushed into the main dining room by unidentified CNA. Resident #5 was in a merri-walker with anti-tip PVC pipes on each side and black Velcro arm/leg weight attached to each side of merri-walker. Resident #5 was having a hard time getting merri-walker over the threshold going into the dining room and CNA had to turn the merri-walker slightly sideways to get through the doorway. Resident #5 was appropriately groomed, dressed with proper footwear. Surveyor confirmed with CNA that resident was Resident #5. On 08/03/17 at 3:46 p.m. observation of Resident # 5 in her room on mattress on floor, no fall matt or fall alarm observed call light in reach. Fall # 11- Record review of Resident #5 RMS dated 06/21/17 at 5:15 a.m., un-witnessed fall, with injury abrasion, area titled Circumstances: heard resident yell out. Resident found sitting on the floor against the wall and beside the bed. Confused, poor safety awareness, Wandering. Preventive measures in place prior to this fall: frequent observation, all light within reach. RMS revealed out of low bed to floor mattress, no toileting plan and no Alarm. Record review revealed the following, no observation schedule time. The Neurological assessment was not initiated or completed according to the facility policy. Fall # 12- Record review of Resident #5 RMS dated 07/17/17 at 6:30 p.m., witnessed Fall with injury Cut/ laceration, skin tear. Confused, poor safety awareness, Wandering. Circumstances Resident reaching et (and) rocking Merry walker until tipped over the left side resident hit head on corner of bed wheel going down, resident immediately became unresponsive labor uneven breathing noted of 108 upon assessment. A Nurse in training initiated first aid to locate where all the blood was pooling from and to monitor pulse et (and) loc (level of consciousness) while myself called for ER transportation et notified proper chain of people. Intervention: added immediately after fall and care plan update: assessment, sent to ER for treatment. Preventive measures in place prior to this fall: merry walker, call light within reach. RMS revealed no toileting plan and no Alarm. Record review revealed the following, no observation schedule time. The Neurological assessment was not initiated or completed according to the facility policy. Record review of Resident # 5 Care Plan Goal: will have no falls with injury x 90 days. Date initiated 09/02/16 Revised on 06/20/17 1. Assess for change in medical status, pain status, and mental status and report MD as indicated. initiated 09/02/16 2. Leave mattress on floor for her safety date initiated 06/26/17. 3. Tab alarm for bed for resident safety initiated 09/02/16 4. Medication evaluation as needed initiated 09/02/16 5. Provide verbal cues for safety and sequencing when needed initiated 09/02/16. 6. Provide verbal cues for proper pacing and energy conservation technique initiated 09/02/16. 7. Provide resident/ caretaker education for safe technique initiated 09/02/16. 8. Place call light within reach at all times initiated 09/02/16. 9. Remind resident to use call light when attempting to ambulate or transfer initiated 09/02/16. 10. When resident is in bed, place all necessary personal items within reach initiated 09/02/16. 11. Monitor for and assist toileting needs initiated 09/02/16. 12. Encourage resident to attend all activities that maximize their full potential while meeting their need to socialize initiated 09/02/16. On 08/02/17 at 8:09 a.m. interview with facility DON revealed the facility doesn't have an incontinent management program. On 08/02/17 at 9:40 a.m. interview with facility DON revealed Resident # 5 falls are around change of shift time. The facility DON revealed there has been no Activity Director in the Memory unit but she thinks one has been hired. On 08/03/17 at 8:34 a.m. interview with L.V.N # 2 revealed Resident # 5 increased falls is because she is very confused. When she was in her wheelchair she would try to get up all the time. She would get up in her room and try to go to the bathroom. L.V.N. # 2 revealed Resident # 5 is not on a scheduled toileting program or incontinent management program. L.V.N # 2 said They try to take her. L.V.N # 2 revealed Resident # 5 had a bed alarm a long time ago she cannot remember why they stop using it. L.V.N. # 2 revealed Resident # 5 is now in a Merry Walker after her fall in June the Dr. called and wanted the Merry Walker. L.V.N. # 2 revealed prior to the Merry Walker they put her mattress on the floor and she was working with therapy. L.V.N. # 2 revealed when a fall occurs they do an assessment, incident report (RMS) and do follow-up to incident for 72 hours and do neuro checks if they hit their head. Notify Dr. and family. L.V.N. # 2 revealed she does not do the residents Fall Risk Assessments. L.V.N. # 2 revealed they (staff) cannot observe residents in the dining room (common area) from the nurse station and if the nurse aide is in a room with a resident the residents cannot be seen. On 08/03/17 at 4:12 p.m. interview with C.N.A. # 5 revealed she works on hall 200 and she does not go to the unit to work or help. C.N.A. # 5 revealed there is one C.N.A. that works in the unit and one L.V.N. for Hall 200 and the Unit. (Memory). (The memory unit is separate from Hall 200.) On 08/03/17 at 4:12 p.m. interview with C.N.A. # 6 revealed she only works on Hall 200 and only goes to the unit (memory) to work the unit when the C.N.A. working day off. On 08/03/17 at 4:20 p.m. interview with L.V.N. # 3 revealed Resident # 5 increased falls is because she needs to be watched closely but it is difficult because she works hall 200 and the unit also. On 08/03/17 at 5:05 p.m. interview with facility DON regarding Resident # 5 only one Fall Risk assessment dated in 09/16. Facility DON revealed the facility Fall Risk Assessment has been discontinued and she will have to look in Resident #5 chart for a paper Fall Risk Assessment and her neuro checks are in the chart. Facility DON revealed the 12 falls in 7 months are because of her [DIAGNOSES REDACTED]. Resident # 5 does not sleep well we have tried and given her [MEDICATION NAME] and benzodiazepines with the supervision of the nurse practitioner so not to chemical restrain her. Resident # 5 is restless and wanders. The facility DON revealed Resident # 5 has a lot of falls in June but they implemented, a low bed and a mattress on the floor and a Merri walker on 06/20/17. Resident # 5 receives therapy PT physical therapy and OT occupational therapy. The facility DON revealed the facility initiated bed alarm on 09/2016 but she does not have it now it was discontinues. The facility DON revealed. Interventions for Resident # 5 was Low bed/ mattress on floor, on 06/26/17, Care Plan up dates, Merri Walker 06/20/17, bed alarm on 09/16 and discontinued on 03/31/17. Facility DON revealed Resident # 5 was in a Geri chair from 04/22/17 to 05/26/17 because she could not position in wheelchair with sling due to fall and shoulder dislocation. The facility Don revealed Resident neuro checks are only two and they are in the chart. On 08/03/17 at 5:35 p.m. facility DON revealed the Fall Risk Assessment has been retired because it was incorporated with the Nurse Assessment form. Nurse Assessment form reviewed with DON revealed: 3. Falls fall history on admission /Entry or reentry: F a1.Did the resident have a fall any time in the month prior to admission/ reentry. Fa2.Did the resident have a fall any time in the last 2-6 months prior to admission / reentry. A3. Did the resident have a fall related to a fall in the 6 month prior to admission/ reentry? The facility DON revealed the Nursing Assessment with this Falls Following as listed above DON stated no this is not it. (Fall Risk Assessment) Resident # 12 Closed Record review of Resident # 12 current physician order [REDACTED]. Resident 12 [DIAGNOSES REDACTED]. Closed Record review of Resident #12 Minimum Data Set ((MDS) dated [DATE] Admission assessment reflected Brief Interview for Mental Status (BIMs) total available score (00-15) documented score of 04 (severely impaired) Activity of Daily Living Transfer: Limited assistance of one person assist. Walking in room and corridor: Activity did not occur. Mobility device: wheelchair. Urinary Toileting Program: No. Urinary Continence: frequently incontinent. Bowel Toileting Program: No. Bowel Continence: frequently incontinent. On further review of Resident # 12 MDS resident had a fall in the last month prior to Admission and had a fall in the last 2-6 month prior to admission. Record review of Resident #5 Care Plan initiated 02/06/17 did not address fall prevention and or interventions related to Resident # 12 falls. Record review of Resident #12 facility Event Tracking Log as well as the facility RMS (Event Summary Report) dated 02/07/17at 10:00 a.m. 03/03/17 at 8:00 a.m. 03/13/17 at 10:00 a.m.,03/14/17 at 2:40 p.m. 03/15/17 at 2:55 a.m. 03/18/17 at 2:00 a.m.03/21/17 at 3:25 p.m. 03/28/17 at 7:10 p.m., 03/31/17 4:25 p.m. 04/02/17at 8:30 p.m., 04/03/17 at 4:00 a.m. 04/07/17. Fall #1- Closed Record review of Resident # 12. RMS dated 02/07/17 at 10:00 a.m., reflected un-witnessed fall with injury skin tear, in dining room. Confused, poor safety awareness, Wandering. Area titled Circumstances: Resident tried to get out of wheelchair leaned on table and table gave way. Preventive measures in place prior to this fall: tab alarm, call light in use, frequent observation. Intervention: assessment and first aide. RMS revealed no toileting plan, and Alarm yes. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 2- Closed Record review of Resident # 12. RM dated 03/03/17 at 8:00 a.m., reflected un-witnessed fall in dining room no injury, Confused, poor safety awareness. Area titled Circumstances: Resident found lying his right side on bathroom floor. He was going to the bathroom and fell . He is weak and unsteady when ambulating. RMS revealed no toileting plan, and no Alarm. Record review reflected the following, no observation schedule time. The Neurological assessment initiated 03/05/17 at 4:05 p.m. was not completed according to the facility policy. Fall # 3- Closed Record review of Resident # 12. RMS dated 03/13/17 at 10:00 a.m. reflected un-witnessed fall, Injury skin tear Confused, wandering. Area titled Circumstances: was going to the bathroom. Preventive measures in place prior to this fall: call light within reach frequent observation. RMS revealed no toileting plan, and Alarm yes. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 4- Closed Record review of Resident # 12. RMS dated 03/14/17 at 2:40 p.m., reflected un-witnessed fall no injury in resident bathroom confused, poor safety awareness. Area titled Circumstances: was going to bathroom without help. Investigation: Preventive measures in place prior to this fall: bed alarm, call light within reach. Investigation: assessment. RMS revealed no toileting plan, and Alarm yes. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 5- Closed Record review of Resident # 12. RMS dated 03/15/17 at 2:55 a.m., reflected un-witnessed fall, no injury in resident bathroom, poor safety awareness, wandering. Area title Circumstances: Bed alarm going off just as nurse stepped into the bathroom resident slipped and fell on his bottom. Intervention: assessment, assist to bathroom. Preventive measures in place prior to this fall: bed alarm, call light within reach. RMS revealed no toileting plan, and Alarm yes. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 6 - Closed Record review of Resident # 12. RMS dated 03/18/17 at 2:00 a.m., un-witnessed fall, Injury Abrasion and skin tear in resident room. Confused, poor safety awareness. Area title Circumstances: going to bathroom without assistance. Preventive measures in place prior to this fall: bed alarm, call light within reach frequent observation Investigation added immediately after fall and care plan update: assessment assist to bathroom, alarm reapplied. RMS revealed no toileting plan, alarm yes and sounding. Record review reflected the following, no observation schedule time. The Neurological assessment initiated 03/18/17 at 2:00 a.m. was not completed according to the facility policy. Fall # 7- Closed Record review of Resident # 12. RMS dated 03/21/17 at 3:25 p.m., reflected un-witnessed Fall Injury no injury in resident's room. Confused, poor safety awareness, wandering. Area titled Circumstances: I was down the hall and the aide who was assigned to the unit was busy changing another resident. She heard a big crash and went to see where it came from when she heard the resident calling for help. He was on the floor behind his door. Preventive measures in place prior to this fall: tab alarm, call light, frequent observation. Intervention: assessment, assisted to bathroom, alarm reapplied. RMS revealed no toileting plan, and Alarm yes. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 8- Closed Record review of Resident # 12. RMS dated 03/28/17 at 7:10 p.m., reflected un-witnessed fall, with injury skin tear, resident room. Confused, poor safety awareness, Wandering. Area titled Circumstances: resident was coming back from the bathroom when he (resident) fell . Preventive measures in place prior to this fall: alarm, call light within reach, education, frequent observation. Intervention: assessment, first aide to skin tear. RMS revealed no toileting plan, and Alarm yes. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 9- Closed Record review of Resident # 12. RMS dated 03/31/17 at 4:25 p.m., reflected un-witnessed fall, Injury, abrasion, skin tear in resident room. Confused, poor safety awareness. Area titled Circumstances: resident was in his room attempting to stand up. Preventive measures in place prior to this fall: call light within reach, tab alarm frequent monitoring. Intervention: assessment, first aide. RMS revealed no toileting plan, and Alarm yes. Record review reflected the following, no observation schedule time. The Neurological assessment initiated 03/31/17 at 4:25 p.m. was not completed according to the facility policy. Neurological assessment not initiated according to the facility policy. Fall # 10- Closed Record review of Resident # 12. RMS dated 03/31/17 at 4:25 p.m., reflected unwitnessed fall with injury abrasion skin tear in resident room Preventive measures in place prior to this fall: call light within reach, tab alarm frequent monitoring. Intervention: assessment, first aide. Intervention: assessment and first aide. RMS revealed no toileting plan, and Alarm yes. And sounding. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 11- Closed Record review of Resident # 12. RMS dated 04/02/17 at 8:30 p.m., un-witnessed fall, with injury bruise in resident room. Area titled Circumstances: staff found him (resident) on the floor at the doorway to the bathroom, he stated he was going to the bathroom when he fell . Preventive measures in place prior to this fall: tab alarm, call light within reach. Intervention: assessment, first aide. X-ray obtained right hip- negative for fracture. RMS revealed no toileting plan, and Alarm yes and sounding. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 12- Closed Record review of Resident # 12. RMS dated 04/03/17 at 4:00 a.m., fall, un-witnessed no injury resident room. Confused, poor safety awareness, wandering. Area titled Circumstances: resident was found on the floor by the bed. Preventive measures in place prior to this fall: alarm, frequent observation call light within reach, Intervention: added immediately after fall and care plan updated: assessment, assist back to bed. RMS revealed no toileting plan, and Alarm yes and sounding. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. Fall # 13- Closed Record review of Resident # 12. RMS dated 04/07/17 at 10:00 a.m., reflected un-witnessed fall, Injury skin tear in resident room Comatose Area title Circumstances: resident found sitting on floor with blanket wrapped around him. Preventive measures in place prior to this fall: alarm, call light within reach observation, Intervention: added immediately after fall and care plan updated: assessment, first aide. Record review reflected the following, no observation schedule time or Neurological assessment not initiated according to the facility policy. On 08/07/17 at 11:44 a.m. interview with facility DON regarding Resident # 12 neuro checks. Facility DON revealed He does not have any Neuro checks unless they are in the closed record. On 08/07/17 at 4:27 p.m. interview with facility DON regarding Resident # 12 having 13 falls in 2 months. Facility DON said I was hired on 03/20/17 and I was in orientation for two weeks. I started on 04/03/17. I knew he had a history of [REDACTED]. Record review of the facility Accidents/ Incidents Policy and Procedure date revised 11/28/16. 2. Assessment, Medical Assessment, Documentation: 2.1.4 Any patient who sustains an injury to the head and /or has an un-witnessed fall will be observed for neurological abnormalities by performing neuro (neurological) checks according to the Assessment: Neurological policy and procedure after the accident / incident occurs. The physician /APN (advanced practice nurse) /PA (physician assistance) will be notified of any abnormal findings. 2.1.6. The Nurse will: Document the accident / Incident in the patient's chart; Documentation will include all pertinent information, date, place, notification, and initial and ongoing assessment; Document the accident / Incident in the patient's chart; Documentation will include all pertinent information, date, place, notification, and initial and ongoing assessment. Record review of facility Abuse Prohibition revised date 04/07/17 Policy: . will prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation foe all residents. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptom. The Center will implement an abuse prohibition program through the following: Prevention of occurrences; Identification of possible incidents or allegation which need investigation; Investigation of incidents and allegations; Protection of patients during investigation; and Reporting of incidents, investigation, and Center response to the results of their investigations. Federal Definitions: Injury of unknown source are defined a

Based on observation, interview and record review it was determined that the facility failed to ensure that a resident who entered the facility failed to ensure that a resident who entered the facility without a pressure sore does not develop a pressure sore unless the individual clinical condition demonstrates that they were unavoidable for one Resident # 3. In addition the facility failed to ensure a resident receives the necessary treatment and services to prevent new pressure ulcers from developing for one Resident #3 of 9 residents reviewed for pressure ulcers. Resident # 3 was re-admitted to the facility on [DATE]. Resident # 3 Admission assessment dated [DATE], skin assessment dated [DATE] and admission physician orders [REDACTED].# 3 had pressure ulcers on admission. This failure could have affected the 16 residents dependent on oxygen therapy. Findings include: On 09/29/15 at 9:10 a.m. on initial tour L.V.N. # 5 revealed Resident #3 did not have Pressure Ulcers and because Resident # 3 is on Hospice we don ' t do much with him we do not turn, his wife feeds him. On 09/30/2015 at 10:40 a.m. Observation of resident care Resident # 3 oxygen (02) was re-positioned to the proper position by L.V.N. # 4. Surveyor observed Resident # 3 facial grimacing during 02 cannula tubing repositioning. No cannula tubing ear wrap observed. Surveyor asked L.V.N.# 4 to remove O2 tubing off Resident # 3 ears to allow observation behind Resident #3 ears. Surveyor observed an open area behind and at the top of Resident #3 left ear revealed, full thickness skin loss involving damage to subcutaneous tissue formed a small crater showing a yellow fatty substance at the bottom of the crater with drainage and contained Resident # 3 scalp hair was matted and stuck in the open draining area. Observation of Resident # 3 right ear revealed a bright red spot behind and at the top of the right ear. Clinical Practice Guide lines U.S. Department of Health and Human Services Public Health Service Agency for Health Care Policy and Research. Definition: a pressure sore is any lesion caused by unrelieved pressure resulting in damage of underlying tissue. Pressure Ulcer staged as follows: Stage III pressure sore. - Full thickness skin loss involving damaged of subcutaneous tissue that may extend down to, but not through underlying fascia (yellow color fatty tissue).The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. On 09/30/15 at 10:45 p.m. interview with L.V.N # 4 revealed she observed the open area behind Resident # 3 when observed by Surveyor. On 09/30/15 at 1:15 p.m. interview with L.V.N. # 5 revealed she did not know about the open area behind Resident # 3 left ear. No one had reported it to her. L.V.N. # 5 also revealed at 1:25 p.m. she had assessed Resident # 3 open area behind his left ear, she was waiting on Hospice to assess the area. On 09/30/15 at 3:00 p.m. interview with R.N. # 1 treatment nurse revealed today was the first time anyone knew about the pressure sore behind his ear and his wife did not know. R.N. # 1 revealed the facility called hospice to assess the area. On 09/30/15 at 3:15 p.m. interview with L.V.N. # 4 revealed she did not know about the open area behind Resident # 3 left ear and no one had reported it to her. Record review of Resident # 3 face sheet reflected [AGE] year old male admitted [DATE] Re-admitted [DATE]. Resident #3 most current MDS (Minium Data Set) significant change of condition assessment dated [DATE] reflected Bims ( brief interview for mental status) total score 00-15 documented score was blank. Dx. Diabetes type II, abdominal pain dysphagia, muscle weaknes,s hypertension, lack of coodination, Depression, Dementia and History falls. Record review of Resident # 3 nurse notes dated 09/29/15 to 09/27/15 did not reflect open area (pressure sore) behind left ear pressure sore. Record review of Resident #3 Licensed Nurses progress note dated 09/11/15 reflected Hospice to pain med- [MEDICATION NAME] R hip fx. - no surgery, Full Code, Alzheimers, DM, hip fx R, HTN, [MEDICAL CONDITION] past smoker,Incontinent, Dc [MEDICATION NAME] per Hospice. Record review of Resident # 3 Gentiva Hospice Nursing Clinical note, Physician Contacted Re: pressure sore behind left ear about size of ball pen. Date/time: 09/30/15 at 1540 p.m. Order Change: message left with office staff. Record review of Resident #3 Braden Scale - for predicting Pressure Sore Risk dated 09/11/15 Resident # 3 coded score of 12. Total score of 12 or less represents High Risk. Record review of Resident #3 MDS (Minimum Data Set) resident assessment and care screening document dated 09/17/15 reflected Risk of Pressure Ulcer: coded 1 = yes. Unhealed Pressure Ulcer: coded 0 = No. Weight and Height B. Weight: code was blank. Record review of Resident # 3 Re-admission plan of care dated 09/11/15, document reflected Resident is at risk for skin breakdown related to : Incontinence, immobility, fragile skin, cognitive impairment and physical impairment and other Fx. (fracture) Right hip, no surgery performed non-weight bearing. The re-admission care plan dated 09/11/15 did not reflect Pressure ulcer. Record review of Resident # 3 care plan dated 03/31/15 update dated 09/30/15 reflect intervention to change 02 to P.R.N. as needed. Nurse note dated 09/30/15 reflected 02 discontinues per hospice. Physician orders [REDACTED].# 3 02 (oxygen). Record review of Resident # 3 Skin assessment dated [DATE] document reflected Presence of skin concerns: none. Stage only if Pressure Ulcer / Do not down stage (see pressure ulcer assessment): Stage I, Stage II, Stage III, Stage IV: document reflected, all areas were blank. Record review of Resident # 3 Re-admission Physician orders [REDACTED]. Record review of Resident #3 physician order [REDACTED]. Resident # 3 care plan dated 03/31/15 update dated 09/30/15 reflected Rt upper ear, stg. (stage) II from n/c (nasal cannula). O2 change ' d to PRN d/t sats (oxygen saturation) up 90% on r/a (room air). Record review of Resident # 3 Quarterly Nutrition Assessment was dated 06/10/15, reflected the Resident # 3 last Nutrition Assessment by the facility Registered Dietitian was complete on 06/10/15. Resident # 3 was determined on 09/11/15 by the facility complement of the Braden Scale - for predicting Pressure Sore Risk. Resident # 3 Nutrition: scored a 2 indication probably inadequate rarely eats a complete meal and generally eats only about ½ of any food offered. Resident # 3 Braden Scale total score was 12 the Total score of 12 or less represents High Risk pressure sores. On 10/01/15 Observation at 10:43 a.m. of R.N. # 1 treatment nurse measuring Resident # 3 full thickness skin loss involving damage to subcutaneous tissue formed a small crater showing a yellow fatty substance behind his right ear. R.N. treatment nurse revealed the area measured 1 ½ centimeter. On 10/01/15 at 10:43 a.m. Interview with R.N. # 1 Treatment Nurse said I treated it this a.m. I treated the left ear even if the TAR said right ear. On 10/01/15 at 10:45 observation of TAR reflected treatment was for right ear not left ear where the open are was. On 10/01/15 at 10:48 a.m. observation R.N. #1 treatment nurse measured Resident # 3 left ear behind and at top of ear an open area. R.N. # 3 stated open area behind and at the top of Resident #1 left ear measured 1.5 cm. Observed open area behind left ear continued to be matted with Resident #3 drainage and scalp hair. Record review on 10/01/15 at 10:43 a.m. of Resident # 3 TAR (treatment administration record) and Physician order [REDACTED].# 3 effected left open area behind and at the top of ear. Record review of Resident # 3 physician order [REDACTED].O. Dr. McPherson/ S.GunnFNP On 10/02/15 Record review of facility NP (nurse practitioner) assessed dated 10/01/15 of Resident # 3 Stage III pressure sore behind and at top of left ear. This assessment was following Surveyor intervention. Facility Pressure Ulcer Prevention and Measurement: Policy: It is the policy of this facility that any resident who enters the facility without pressure ulcers does not develop pressure sores unless the resident ' s clinical condition makes the development unavoidable. Any resident who has pressure ulcer will receive the necessary treatment and services to promote healing, prevent infection, prevent new ulcers from development. Functional Information: To provide routine prevention measure and care specific to resident ' s individual risk factors/ needs. To prevent skin breakdown and to administer care / treatments as ordered by the physician. Definitions: Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Risk factors: Risk factors that increase a resident ' s susceptibility to develop or to not heal pressure ulcers include, but are not limited to: 1. Severe chronic [MEDICAL CONDITION] obstructive disease. 2. Diabetes 3. Diabetic [MEDICAL CONDITION] 4. Generalized [MEDICAL CONDITION] or lower extremity arterial insufficiency 5. Chronic bowel incontinence 6. Chronic urinary incontinence 7. [MEDICAL CONDITION] 8. [MEDICAL CONDITION] 9. Sepsis 10. [MEDICAL CONDITION] 11. Chronic or end stage renal, liver and or [MEDICAL CONDITIONS] disease 12. Disease or drug - related immunosuppression The resident receives two or more of the following treatment: 1. Steroid therapy 2. [MEDICAL CONDITION] 3. [MEDICAL CONDITION] 4. [MEDICAL TREATMENT] 5. Head of the bed elevated the majority of the day due to medical condition or treatment Other risk factors include: 1. Impairment or decreased mobility 2. Decreased functional ability 3. Refusal of some aspects of care and treatment 4. Under nutrition, mal-nutrition, hydration deficits 5. History of healed pressure sore 6. Cognitive impairment 7. Incontinence (chronic diarrhea) Prevention: 6. Monitor nutrition intake and weight loss and provide intervention as applicable Intervention: 2. If pressure ulcer are identified, license nurse will: * Assess the wound *Notify the Physician and obtain treatment order as indicated. *Notify family or responsible party * update care plan * Document goal progress and effects of interventions. Record review of the Facility Pressure Ulcer Prevention and Measurement, Resident # 3 did qualify for 6 of the facility 24 listed Risk factors that increase a resident ' s susceptibility to develop or to not heal pressure ulcers include. Resident # 3 care plan dated 03/31/15, 09/11/15 or 09/30/15 did not reflect interventions related to Pressure Ulcer Prevention and Measurement. The facility 672, Resident Census 69 and Condition of Residents, dated 09/29/15 and signed by the DON.