Every finding on record at Avir at Paris

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 3 of 3 residents reviewed for care plans. (Resident #1, Resident #2, Resident #3).The facility did not develop the initial plan of care within seven (7) days of the comprehensive MDS or within twenty-one (21) days of admission for Resident #1, Resident #2 and Resident #3. This failure could place residents at risk of not having individual needs met and place them at risk of not receiving appropriate care and interventions to meet their current needs. Findings included: Record review of Resident #1's face sheet dated 08/25/2026 revealed an admission date of 07/19/2026 with diagnoses that included cerebral infarction with left sided hemiplegia (a stroke that occurred due to blocked blood flow that caused damage to the left side of the body), Diabetes Mellitus Type II (a condition that occurs when the body does not produce or process insulin resulting in blood sugar changes), Hypertensive heart disease with heart failure (a condition where the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), pulmonary embolism (a blood clot that blocks and stops blood flow to an artery in the lung) and dysphagia (difficulty swallowing). Record review of Resident #1's comprehensive admission MDS dated [DATE] revealed Resident #1 had no hearing, speech, communication or vision deficits and a BIMS score of 14 which indicated intact cognition. Resident #1 required a wheelchair for mobility, set-up assistance with eating, maximum assistance with toileting, bathing, dressing, bed mobility and transfers. Record review of Resident #1's care plan revealed two focus areas to include Code Status which was initiated 08/03/2026, and Trauma Informed Care Screening which was initiated 08/05/2026. Resident #1's care plan did not identify all the focus areas per care area assessments as identified on the admission MDS dates 07/23/2026. Record review of Resident #1's assessments revealed no completed Multidisciplinary Care Conference assessment. During an interview with Resident #1 and his family member on 08/26/2026 at 10:48 a.m., Resident #1 stated he had attended a meeting with his family, the Administrator and the DON to discuss their concerns about his therapy program and ADL functional needs on 08/19/2026, but he was not informed of and did not attend an interdisciplinary care plan meeting to address all of his medical needs, preferences and interventions to meet his needs. Record review of Resident #2's face sheet dated 08/26/2026 revealed Resident #2 was admitted on [DATE] with diagnoses which included prostate cancer, hyperlipidemia (elevated levels of fats in the blood stream), hypertension (high blood pressure), and heart failure (a condition where the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). Record review of Resident #2's comprehensive admission MDS dated [DATE] revealed no hearing or speech deficits and that Resident #2 was understood by others, usually understood what was said to him and had a BIMS score of 3 which indicated severe cognitive impairment. Resident #2 required the use of a wheelchair for mobility, was independent in eating, toileting, dressing, bed mobility and transfers and required set-up assistance in bathing. Record review of Resident #2's care plan revealed a focus area for Code Status which was initiated 08/03/2026, activity involvement initiated 08/05/2026, weight loss initiated 08/11/2026, pressure ulcer, smoker status, cognitive status and sleep behavior which were initiated 08/18/2026. Resident #2's care plan did not reflect all the focus areas per care area assessments as indicated on the comprehensive admission MDS dated [DATE]. Record review of Resident #2's assessments revealed no completed Multidisciplinary Care Conference Assessment. During an attempted interview with Resident #2 on 08/26/2026 at 9:27 a.m., Resident #2 was unable to respond to questions of participation in an interdisciplinary care plan meeting due to low cognitive functioning. Resident #2 had no identified responsible party. Record review of Resident #3's face sheet dated 08/26/2026 revealed a [AGE] year-old male admitted [DATE] with diagnoses which included epilepsy (a chronic brain disorder causing sudden bursts of abnormal electrical activity in the brain), vascular dementia (a decline in thinking and memory skills caused by blockage or reduced blood flow and oxygen to the brain), dysphagia (difficulty swallowing), atherosclerotic heart disease (a condition where fatty plaque builds up in the arteries that supply blood to the heart), cerebral infarction (a medical emergency that happens when a blocked blood vessel cuts off blood and oxygen to the brain) and pervasive developmental disorder (a group of developmental delays that affect social and communication skills). Record review of Resident #3's comprehensive MDS dates 08/06/2026 revealed Resident #3 was usually understood and usually understood what was said to him with a BIMS score of 4 which indicated severe cognitive impairment. Resident #3 required a wheelchair for mobility, was independent in bed mobility, transfers, supervision with toileting, moderate assistance in eating, and total dependence in dressing and bathing. Record review of Resident #3's care plan revealed a focus area for Code Status that was initiated on 08/03/2026, a focus area for falls trauma history that were initiated on 08/05/2026. Resident #3's care plan did not reflect all the focus areas per the care area assessments as indicated on the comprehensive admission MDS dated [DATE]. Record review of #3's assessments revealed no evidence that the Multidisciplinary Care Conference assessment was completed. During an attempted interview with Resident #3 on 08/26/2026 at 10:15 a.m., Resident #3 was unable to confirm attendance or participate in a care plan meeting due to low cognitive functioning. During an interview on 08/26/2026 at 12:49 p.m., Resident #3's family member confirmed that she had not been informed of or attended a care plan meeting for Resident #3.During an interview on 08/26/2026 at 12:30 p.m., the DON stated that evidence for completed care plan review meetings was documented under the Multidisciplinary Care Conference assessment. The DON stated that any staff member in attendance at the meeting could have initiated and completed the Multidisciplinary Care Conference assessment. The DON stated she was not aware that the forms were not being completed for each meeting held, and that they should be completed quarterly and as needed. The DON stated she was responsible for ensuring the Care Plan meeting are held and proper documentation completed.During an interview on 08/26/2026 at 3:30 p.m., the Administrator stated that he expects a member of the interdisciplinary team to complete the required documentation at each care plan meeting and that he expects the meetings to include multiple staff members and occur quarterly and as needed for each resident. The Administrator stated that the DON was responsible for ensuring the care plan meetings were documented properly and he was ultimately responsible for ensuring the meetings took place. Record review of the facility policy titled Care Plans, Comprehensive Person-Centered, revised March 2022, revealed 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.

Based on interview and record review, the facility failed to provide care and services based on the comprehensive assessment and consistent with the needs and choices for 1 of 3 (Resident # 1) residents reviewed for activities of daily living, in that:The facility failed to develop and implement the restorative care plan for Resident #1 as recommended by the DON during the care plan meeting held 08/19/2026 to maintain functional status after being discharged from physical and occupational therapy services on 08/04/2026. This failure placed residents at risk of decreased abilities in activities of daily living, strengthening, mobility and transfers. The findings were:Record review of Resident #1's face sheet dated 08/25/2026 revealed an admission date of 07/19/2026 with diagnoses that included cerebral infarction with left sided hemiplegia (a stroke that occurred due to blocked blood flow that caused damage to the left side of the body), Diabetes Mellitus Type II (a condition that occurs when the body does not produce or process insulin resulting in blood sugar changes), Hypertensive heart disease with heart failure (a condition where the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), pulmonary embolism (a blood clot that blocks and stops blood flow to an artery in the lung) and dysphagia (difficulty swallowing). Record review of Resident #1's comprehensive admission MDS dated [DATE] revealed Resident #1 had no hearing, speech, communication or vision deficits and a BIMS score of 14 which indicated intact cognition. Resident #1 required a wheelchair for mobility, set-up assistance with eating, maximum assistance with toileting, bathing, dressing, bed mobility and transfers to include shower transfers.Record review of Resident #1's care plan initiated 08/03/2026 did not identify a focus area for ADL functional needs. Record review of the Administrator's progress note dated 08/19/2026 revealed a meeting was held with the Administrator, DON, resident and resident family member to discuss his functional decline after discharge from therapy physical and occupational services on 08/03/2026. Record review of the physical therapy Discharge summary dated [DATE] revealed that a restorative program or functional maintenance program were not indicated. The progress note revealed that the facility would develop and implement a restorative nursing program to address Resident #1's functional maintenance needs. During an interview on 08/26/2026 at 10:48 a.m., Resident #1 stated he had not received any therapy services since he was discharged from physical and occupational therapy on 08/04/2026 and no one had reviewed a restorative therapy program with him. Resident #1 stated that he feels weaker and requires more assistance in transfers.During an interview on 08/25/2026 at 2:00 p.m., the DOR stated she was notified by the DON on 08/25/26 to develop a restorative therapy program for Resident #1 and noted that the facility did not have a restorative or functional maintenance program in place to implement the program.During an interview on 08/26/26 at 3:15 p.m., the DON stated that it was determined at the care plan meeting held on 08/19/2026 for Resident #1's assessed needs that a restorative nursing program would be initiated and that she had received the program specifics from the DOR on 08/25/2026. The DON stated that a Restorative Aide position had been created but it had not been filled yet and that they would have to provide the services until someone is officially hired. The DON stated she does not know why the DOR had not been told earlier to develop a restorative therapy program for Resident #1.During an interview on 08/26/2026 at 3:30 p.m., the Administrator stated that he was not aware the restorative program had not been developed or implemented per the care plan meeting for Resident #1 that was held on 08/19/2026. The Administrator stated that delay in therapy could cause the resident to lose strength and ADL abilities that were necessary to facilitate the discharge to home setting.Record review of the facility policy titled Activities of Daily Living (ADL), revised February 2025, revealed Policy Statement, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs), and Policy Interpretation and Implementation, 6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice.

Based on interview and record review, the facility failed to ensure each resident received an accurate assessment, which was reflective of the resident's status for one (Residents #27) of four residents reviewed for accuracy of assessments. The facility failed to ensure Resident #27's (a discharged resident) most recent quarterly and discharge assessments accurately reflected his physical behaviors directed at others. This failure could place residents at risk of not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health.Findings included: Review of Resident #27's Face Sheet, dated 12/02/25, reflected a male, admitted on [DATE], and having diagnoses of congestive heart failure (a condition in which the heart cannot pump enough blood, causing fluid to build up in the body), stroke (a blood clot in the brain, causing brain damage), schizoaffective disorder (a condition with symptoms of hallucinations/delusions combined with mood problems), depression, dementia with agitation, and adjustment disorder (emotional and behavioral problems in response to stress) with anxiety and depression. A family member was listed as his responsible party. Review of Resident #27's quarterly MDS, dated [DATE], reflected the staff assessment of his mental status indicated he had a memory problem, and moderately impaired daily decision-making skills, no delirium, and no physical, verbal, or other behavioral symptoms, as well as no rejection of care in the seven-day look-back period. The document reflected Resident #27 required substantial/maximal assistance (helper does more than half the effort) for most of his ADLs. The document was electronically signed by the MDS Coordinator. Review of Resident #27's discharge MDS, dated [DATE], reflected he was discharged to an acute care hospital. The staff assessment of his mental status indicated he had a memory problem, and moderately impaired daily decision-making skills, no delirium, and no physical, verbal, or other behavioral symptoms, as well as no rejection of care in the seven-day look-back period. The document reflected Resident #27 required substantial/maximal assistance (helper does more than half the effort) for most of his ADLs. The document was electronically signed by the MDS Coordinator. Review of Resident #27's discharge MDS, dated [DATE], reflected he was discharged to an acute care hospital. The staff assessment of his mental status indicated he had a memory problem, and moderately impaired daily decision-making skills, no delirium, and no physical, verbal, or other behavioral symptoms, as well as no rejection of care in the seven-day look-back period. The document reflected Resident #27 was dependent on staff for toileting hygiene, putting on footwear, hygiene, refused lower body dressing, and was not bathed/showered due to his condition. The document was electronically signed by the MDS Coordinator. Review of Resident #27's care plans reflected the following:- A history of, and potential for showing signs of delusions/ hallucinations, and having conversation with someone who is not there. Dated 04/22/25, revised 09/02/25 by the MDS Coordinator- Memory recall problem due to stroke. Dated 01/22/24, revised 09/02/25 by the MDS Coordinator- Potential to exhibit physically and verbally abusive behavior, with examples of hitting, shoving, scratching, and making sexually inappropriate comments toward staff. A note that Resident #27 struck another resident was made on 09/02/24. Dated 08/14/23, and revised 09/02/25 by the MDS Coordinator.- Socially inappropriate and disruptive behavior, including speaking very loudly, frequent inappropriate comments in others, and can become aggressive at times. Dated 07/03/23, and revised 09/02/25 by the MDS Coordinator.- Refusing to take medications almost daily, and refusing labs. Dated 12/22/22, and revised on 09/02/25 by the MDS Coordinator. Review of Resident #27's progress notes reflected the following:- 08/09/2025 at 9:10 AM by LVN D Made x2 attempts to give medication and assess resident this AM. Residentattempted to punch nurse in the face when trying to check radial pulse. Resident was also verbally aggressive with nurse. (.)- 08/09/2025 at 1:10 PM by LVN D When nurse entered room to check on resident. Resident asked for ice water.When nurse attempted to hand resident ice water he clawed her arm. Spoke with (Resident #27's responsible party) regarding med refusals and aggressive behaviors this shift.- 08/09/2025 at 2:55 PM by LVN D Entered resident's room to provide peri-care as resident had a BM. Resident assisted in turning over and was allowing staff to clean him. While cleansing resident he started swung fist hitting this nurse in the jaw. Resident then refused to allow staff to finishing cleaning him or placing a new brief. Provider, (Resident #27's responsible party), NP, DON, and admin notified of behavior. NP suggest referring resident to psych facility.- 08/09/2025 at 4:58 PM by LVN D (Name of portable diagnostic company) came to do EKG . Resident initially attempted to hit tech with open hand but tech was able to move out of the way. Resident did end up allowing tech to place stickers and wires. However resident would not stay still during test. Resident continues to refuse pericare. Spoke (Resident #27's responsible party) regarding continued behaviors and NPs recommendation to refer to psych facility. (Responsible party) was agreeable with recommendation.- 08/09/2025 at 7:00 PM by LVN E Noted (Resident #27's responsible party) came in the facility and checked in with the resident's behavioral status. (.) Noted continues with constant verbal and physical redirection r/t occasionally swatted staff during assisting his shower. (.)- 08/10/2025 at 9:23 AM by LVN D Resident refused meds this AM. NP aware. (Responsible party) aware of continued refusals. Resident is calm until staff enters room and then becomes verbally aggressive. Resident does not respond to redirection or education regarding behaviors or medications. Attempts to educate resident on importance of medication compliance due to cardiac history is unsuccessful. Resident states that he has a nursing and doctor degree and does not need any medicine. Resident just states, I have good pressure. Nothing is wrong with my heart. (.)- 08/10/2025 at 8:31 PM by LVN E (.)Noted continues with redirections verbally r/t occasional increased in verbalaggression towards staff. (.)- 08/15/2025 at 8:47 AM by RN F Resident continues with AM med refusals. 2 attempts made by nurse and with2nd attempt resident raises fisted arm toward nurse. (.)- 08/27/2025 at 9:38 PM by LVN E (.) called (Resident #27's responsible party), RP for resident and discussedresident's behavior and new orders. (.) Noted x 3 staff assisted with HS care, and tolerated and resident attempted to swat on one of the staff CNAs. Noted verbally redirected and tolerated. (.)- 09/02/2025 at 9:00 PM by LVN E Noted resident with multiple attempts along with staff assistance was able toassist him in his low bed, HOB elevated at around 7pm. Noted resident continues with combative behavior and attempted multiple times to physicallyredirect [sic] his behavior, and responsive most times. (.)Noted per NP telephone order to transfer resident to ER. (.) An interview on 12/03/25 at 2:09 PM with the ADON revealed Resident #27 was often agitated and the staff never knew when it was coming. She gave the example of one time when she went into his room on her room rounds, and told him she was going to check in his refrigerator. She said he seemed fine, but when she was leaving the room, a can of soda was flying at her head. She said it missed her, but it scared her. She said it was typical of Resident #27 to seem fine with what was going on, then kick or punch someone with no warning. The ADON said if he verbalized no, staff knew to get away from him immediately. An interview on 12/04/25 at 9:04 AM with LVN G revealed she had been hit by Resident #27. She said he had hit other staff, so all of the staff were aware he could do that, but she let her guard down for a moment, and he hit her hard in the jaw. An interview on 12/04/25 at 11:22 AM with CNA A revealed Resident #27 hit all the time. He said the resident would punch anyone who went into his room, unless they really understood how to talk to him. He said he usually was able to gain cooperation with Resident #27 by talking to him about the work the resident used to do, but he had punched him before. An interview on 12/04/25 at 11:36 AM with LVN D revealed Resident #27 was pretty aggressive, would rarely take his medications, and was frequently combative. She said he would have waves when his combativeness was daily, then he might be that way a couple of times a week. An interview on 12/04/25 at 12:30 PM with RN I revealed she had worked with Resident #27 as a night nurse, and he was usually in bed and would sometimes ask her for a pain reliever, and would cooperate with her when she gave it to him, because he had asked her for it. She said she had heard some pretty horrible stories about him though. She said that she was aware of him punching a nurse in the face, and frequently hitting or kicking staff, and that she heard that he once had picked up a pill crusher and hit a staff member in the head with it, causing her to need sutures. She said that he used to kick staff with boots, but his family member came and took them away from him, and he only wore soft shoes after that. An interview on 12/04/25 at 12:48 PM with CNA J revealed Resident #27 was flirtatious with her, and did not give her many problems, but she was aware he could get violent at any time. She said he would refuse care sometimes, and she would just leave him alone until he was ready. She said she often got called to help with him, because he was combative with other staff. A telephone interview on 12/04/25 at 2:14 PM with the MDS Coordinator revealed she did not document the behaviors in the MDS because in the RAI manual it said if the behavior was already existent, and careplanned, it was not to be recorded in the MDS. During a telephone interview on 12/04/25 at 2:33 PM with the MDS Coordinator she confirmed that she had believed that the rule about not documenting behaviors in the MDS was for both the section regarding refusal of care, and the section about behaviors affecting the resident or others. She said the accuracy of the MDS was important because it was a direct reflection of the care the resident received, and inaccuracies could potentially affect the accuracy of the care plans, as well. An interview on 12/04/25 at 2:38 PM with the Regional MDS Coordinator revealed she needed to check the RAI manual, but she thought that behaviors should be recorded in the MDS, and the section regarding refusals was the only part where they would not be recorded if they were already recorded. She said the section regarding behaviors affecting the resident or others were, in part, recorded by observation, so if a resident was observed having a behavior during the lookback period, it would be recorded in the MDS, regardless of whether it was an already-known behavior. After a few minutes she returned to confirm that it was only the rejection of care section that if it was care-planned it did not have to be coded in the MDS. She said the accurate assessments were important for patient care, reimbursement and care planning. Review of the facility Resident Assessments policy, revised in March of 2022, reflected: 8. All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. Review of the current Centers for Medicare and Medicaid Services Long-Term Care Resident Assessment Instrument 3.0 User's Manual Version 1.20.1, October 2025, reflected: Section E: Behavior: Intent: The items in this section identify behavioral symptoms in the last seven days that may cause distress to the resident, or may be distressing or disruptive to facility residents, staff members or the care environment. These behaviors may place the resident at risk for injury, isolation, and inactivity and may also indicate unrecognized needs, preferences or illness. Behaviors include those that are potentially harmful to the resident themself. The emphasis is identifying behaviors, which does not necessarily imply a medical diagnosis. Identification of the frequency and the impact of behavioral symptoms on the resident and on others is critical to distinguish behaviors that constitute problems from those that are not problematic. Once the frequency and impact of behavioral symptoms are accurately determined, follow-up evaluation and care plan interventions can be developed to improve the symptoms or reduce their impact. This section focuses on the resident's actions, not the intent of their behavior. Because of their interactions with residents, staff may have become used to the behavior and may underreport or minimize the resident's behavior by presuming intent (e.g., Resident A doesn't really mean to hurt anyone. They're just frightened.). Resident intent should not be taken into account when coding for items in this section. (.) E0200: Behavioral Symptom-Presence & Frequency: Subsequent assessments and documentation can be compared to baseline to identify changes in the resident's behavior, including response to interventions.Steps for Assessment 1. Review the medical record for the 7-day look-back period. 2. Interview staff, across all shifts and disciplines, as well as others who had close interactions with the resident during the 7-day look-back period, including family or friends who visit frequently or have frequent contact with the resident. 3. Observe the resident in a variety of situations during the 7-day look-back period. Coding Instructions Code 0, behavior not exhibited: if the behavioral symptoms were not present in the last 7 days. Use this code if the symptom has never been exhibited or if it previously has been exhibited but has been absent in the last 7 days. Code 1, behavior of this type occurred 1-3 days: if the behavior was exhibited 1-3 days of the last 7 days, regardless of the number or severity of episodes that occur on any one of those days. Code 2, behavior of this type occurred 4-6 days, but less than daily: if the behavior was exhibited 4-6 of the last 7 days, regardless of the number or severity of episodes that occur on any of those days. Code 3, behavior if this type occurred daily: if the behavior was exhibited daily, regardless of the number or severity of episodes that occur on any of those days. Coding Tips and Special Populations Code based on whether the symptoms occurred and not based on an interpretation of the behavior's meaning, cause or the assessor's judgment that the behavior can be explained or should be tolerated. Code as present, even if staff have become used to the behavior or view it as typical or tolerable. Behaviors in these categories should be coded as present or not present, whether or not they might represent a rejection of care. Review of the instructions within the MDS form (Resident #27's Quarterly MDS, referenced in record review above) reflected: Section E0200 Behavior Symptom Presence and Frequency: Note presence of symptoms and their frequency. (.) A. Physical behavioral symptoms directed toward others (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually) B. Verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others) C. Other behavioral symptoms not directed toward others (e.g. physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) E0800: Rejection of care- Presence and Frequency: Did the resident reject evaluation or care (e.g. bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident's goals for health and well-being? Do not include behaviors that have already been addressed (e.g by discussion or care planning with the resident or family), and determined to be consistent with resident values, preferences, or goals.

Based on observation, interview and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #1 and Resident #20) of 14 residents reviewed for call lights. Staff failed to ensure Resident #1 and Resident #20's call bells were within reach. This failure could place residents at risk for decreased self-worth, quality of life, and dignity.Findings included:1. Review of Resident #1's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses in part including dementia, restlessness and agitation, unspecified lack of coordination, weakness, and a history of traumatic brain injury (brain injury caused by outside force). Review of Resident #1's Comprehensive Care Plan revised 11/28/25 reflected Resident #1 had a history of falling. An intervention with start date 3/04/24 stated, keep call light in reach at all times.Review of Resident #1's MDS assessment dated [DATE] reflected that the resident was severely cognitively impaired. Resident #1 required partial/moderate assistance with mobility and at least substantial assistance with self-care activities.2. Review of Resident #20's face sheet dated 12/02/25 reflected a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses in part of pneumonitis (inflammation of the lungs), weakness, and paraplegia (paralysis affecting the legs). Review of Resident #20's Comprehensive Care Plan revised 10/07/25 reflected Resident #20 had a history of falling. An intervention with start date 3/24/25 stated, keep call light in reach at all times. Review of Resident #20's MDS assessment dated [DATE] reflected that the resident was moderately cognitively impaired. Resident #20 was dependent on assistance with mobility and required at least partial/moderate assistance with self-care activities. In an observation and interview on 12/02/2025 at 9:04 a.m., Resident #1 was noted laying sideways in his bed and his call bell was observed curled up and hung on the wall past the foot of the bed and out of the reach of the resident. A fall mat was observed beside the bed. Resident #1 stated his brief was wet, and he needed assistance. Resident #1 did not answer when asked further questions about his call bell. Staff were informed of Resident #1's request, and CNA A came promptly to assist the resident. In an observation on 12/02/25 at10:56 a.m., Resident #20 was observed in bed. His call bell cord was wrapped around the siderail of the bed with the push-pad hanging down from the bed approximately 2 feet and out of reach of Resident #20. In a follow-up observation and interview on 12/03/25 at 11:57 a.m., Resident #20 was observed in bed, and his call bell remained out of reach in the same location as seen on 12/02/25 at 10:56 a.m Resident #20 stated that he wanted more water to drink but that his call bell was on the floor somewhere. He expressed frustration with being unable to call for assistance and stated, there is a law about that. He did not know how long his call bell had been out of reach. He stated his call bell was typically within reach. Resident #20 stated he could not walk or otherwise obtain assistance without using his push-pad call bell. In an observation on 12/02/25 at 12:02 p.m., CNA A walked into the room and Resident #20 told him he wanted his drink refilled. Resident #20's call bell was not within his reach. CNA A took the cup and left the room without changing the placement of the call bell. CNA A returned shortly with the drink and began preparing the resident for incontinence care and transfer.In an interview on 12/02/25 at 12:08 p.m., CNA A stated that he had observed Resident #1s call bell hanging on the wall this morning (12/02/25) when he was asked to assist him with incontinence care around 9 a.m He stated the call bell should have been within the resident's reach and that, I am guessing someone may have hung it up when changing his bed and forgot to give it back to him. He stated staff check for the placement of the call bell before leaving a residents' room, and he had placed the call bell back within reach of Resident #1 when he finished providing care. CNA A stated that Resident #20's call bell, which was found hanging down from the bed, was supposed to be on the bed but if he moved his pillow or something, it might have fallen off. He stated the risk of a resident not having their call light was, we would just have to check on them periodically because it will slide off at times. In an interview on 12/02/2025 at 12:10 p.m., CNA B stated that Resident #20's call bell was hanging down from his bed and not within his reach when she came into the room today (12/02/25) at approximately 12:05 p.m. to assist CNA A with providing care. She stated that staff monitored the placement of residents' call bells continuously. She stated that without his call light being in reach Resident #20 was at risk for, not being able to call for help and us not knowing if he needed anything.In an interview on 12/02/2025 at 1:40 p.m., RN C stated she was Resident #1s nurse today (12/02/25) and she was not aware that he was without his call bell being within reach at any time today. She reported that all staff monitored the call bell placement with every patient interaction. She reported that Resident #20's call bell should always be within his reach and that without it he would be at risk of not being able to get assistance.In an interview on 12/02/2025 at 2:04 p.m., the ADM stated that, the standard is for the call bell to be within reach and that a resident without their call bell within reach was at risk for, his needs may not be met immediately. She stated the expectation was that all staff would monitor the placement of call bells. She reported she would be implementing immediate staff training on the need for residents' call bells to be within reach.In an interview on 12/03/2025 at 2:12 p.m., the ADON stated that all staff had received training upon hire on the need for residents' call bells to be within reach. She reported it is the expectation that the call bell be placed within the reach of the resident. She stated the risk of a resident not being able to reach their call light was, a lot of things can happen and they can't get their needs met.Review of the facility policy titled Call System, Residents, with revision date September 2022, revealed, Each resident is provided with a means to call staff directly for assistance from his/her bed .

Based on interviews and record reviews, the facility failed to ensure a gradual dose reduction was attempted for 1 of 4 residents (Resident #15) reviewed for unnecessary medications/ gradual dose reduction. The facility failed to do a gradual dose reduction or document contraindication for a gradual dose reduction for Resident #15's ordered Risperdal 2mg orally twice daily ordered 08/14/2023 and Risperdal Consta suspension extended release 25mg/ml (2ml) intramuscular every 14 days ordered 02/22/2024. These failures could place residents at risk for possible psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: Review of the resident face sheet revealed, Resident #15 was a [AGE] year-old male that admitted on [DATE] with the diagnoses of schizoaffective disorder (mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania), seizure disorder, and cerebral infarction (stroke). Review of Resident #15'squarterly MDS dated [DATE] indicated Resident #15 had a BIMS (brief interview of mental status) of 00, which indicated a severe cognitive impairment. The MDS revealed Resident #15 had short- and long-term memory impairment. The MDS revealed Resident #15 required limited assistance with ADLs. No hallucinations, delusions, behavior, rejection of care or wandering was noted on the MDS. Resident #15 received antipsychotic medication 7 days out of 7 days. Review of Resident #15's physician consolidated orders dated 09/01/2024 to 09/30/2024 revealed the following: * Risperdal 2 mg orally twice daily originally ordered on 08/14/2023. *Risperdal Consta suspension extended release 25mg/2ml. Give 2ml intramuscularly every 14 days original order date 02/22/2024. Review of Resident #15's MAR (medication reconciliation record) for September 2024 revealed the following refusals: Risperdal 2mg twice daily 09/02/2024-a.m. dose 09/03/2024-a.m. dose 09/04/2024-a.m. dose 09/06/2024-a.m. dose 09/07/2024-a.m. dose 09/08/2024-a.m. dose 09/11/2024- a.m. dose 09/12/2024- a.m. dose 09/16/2024- a.m. dose 09/17/2024- a.m. dose Risperdal Consta 2ml intramuscular injection 09/19/24 Further review revealed Risperdal Consta 2ml intramuscular injection was administered on 09/05/2024. Record review of the consultant pharmacist recommendations for January through September 2024 and August to December 2023 revealed there was not a GDR for Resident #15's Risperdal 2mg oral twice daily medication nor a GDR for the Risperdal Consta 2ml intramuscular injection. During an interview on 10/02/2024 at 1:15p.m., RPH D stated she made recommendations for the decrease of Resident #15's Risperdal 2mg orally twice daily to be decreased to 1mg in the morning and 2 mg at bedtime. She stated she sent the recommendation to the facility on [DATE] after the DON informed her the GDR for Resident #15 were late. She stated she understood the GDR was supposed to be done every 6 months for the 1st year and annually thereafter for antipsychotic medications. She stated the facility had a lot of GDRs that were out of compliance when she took the building over and she was trying to gradually get everyone on a schedule. She stated it was important to do GDRs so the resident will be on the lowest effective dose of psychotropic medications. During an interview on 10/02/2024 at 2:00 p.m., the DON stated she could not find the GDR for Resident #15 due in February and August 2024 for his Risperdal 2mg orally twice daily. She stated she could not find the GDR for Resident #15's Risperdal Consta 2 ml intramuscularly every 14 days that was due in August. She stated she called the pharmacist after the surveyor asked about the GDR for Resident #15. She stated it was important for GDR to be done so residents did not suffer ill effects of psychotropic medications. She stated she would have to make a system to check behind the pharmacist and ensure the GDRs are done on all residents timely. Review of a facility policy titled 'Psychoactive Medications' dated 07/2024 indicated . Residents who use psychotropic medications shall be evaluated for gradual dose reduction unless clinically contraindicated, in a effort to discontinue these drugs.

Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 16 residents reviewed for medications. (Resident #26) The facility failed to ensure Resident #26 received his full eight-week course of Mavyret (antiviral medication used to treat Hepatitis C, which is a disease of the liver caused by a virus that causes damage to the liver) ordered by the Infectious Disease physician and started on 11/15/23. This failure could cause prolonged illness and increased recovery time for residents. Findings included: Record review of Resident #26's face sheet dated 9/30/24 indicated he was [AGE] years old and admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses including Chronic Hepatitis C, encephalopathy (any brain disease that alters brain function or structure). Record review of Resident #26's significant change MDS assessment dated [DATE] indicated he had a BIMS of 4, which indicated he had severe cognitive impairment and required moderate staff assistance to supervision for most ADLs. The MDS indicated Resident #26 had cirrhosis (chronic liver damage from a variety of causes leading to scarring and liver failure). Record review of Resident #26's undated care plan indicated he had a diagnosis of Hepatitis C with an intervention to administer medications per MD orders with a start date of 11/17/23. Record review of Resident #26's Progress Notes dated 11/01/23 indicated RN B received a call from the Specialty Pharmacy to notify the facility of new orders for Mavyret 100/40 mg 3 tabs daily for sixty days from the Infectious Disease doctor. RN B documented the Specialty Pharmacy would send a 30-day supply pending approval. Record review of Resident #26's Progress Notes dated 11/15/23 written by * indicated LVN A documented the new medication for treatment of Resident #26's Hepatitis C was received from the Specialty Pharmacy and the Infectious Disease doctor was notified of the initial dose. LVN A documented she notified Resident #26's primary care physician for order clarification of discontinuing the resident's atorvastatin and pantoprazole until the completion of Mavyret eight-week treatment for chronic Hepatitis C. LVN A documented the medication was to be given daily with food and MUST AVOID ANY MISSED DOSES FOR successful treatment of chronic Hepatitis C and MARs updated. Record review of Resident #26's order history from 11/01/23 revealed an order for Mavyret 100-40 mg three tablets once daily with food with a start date of 11/15/23 and an end date of 12/12/23 entered by LVN A. Record review of Resident #26's MAR dated 11/01/23-11/30/23 indicated Mavyret 100-40 mg 3 tablets once daily with food for Chronic viral Hepatitis C with a start date of 11/15/23 and an end date of 12/12/23. The MAR indicated Resident #26 received the medication 11/16/23 through 11/19/23 and 11/28/23 through 11/30/23. Record review of Resident #26's progress notes dated 11/19/23-11/27/23 indicated he was admitted to the hospital on 11/19/23 and returned to the facility on [DATE] with diagnoses of respiratory failure and metabolic encephalopathy (brain dysfunction caused by a chemical imbalance in the blood that affects the brain). Record review of Resident #26's hospital Infectious Disease Progress Note dated 11/20/23 documented his assessment and plan included Resident #26 had cirrhosis with Hepatitis C and he was on a direct antiviral therapy, Mavyret, and the hospital was going to call his nursing facility and would continue the medication. On 11/23/23, the Infectious Disease Progress Note indicated his assessment and plan included Resident #26 had an underlying cirrhosis and Hepatitis C and he was receiving treatment and he had his medication from the nursing facility, and they would continue the medication. Record review of Resident #26's MAR dated 12/01/23-12/31/23 indicated Mavyret 100-40 mg 3 tablets once daily with food for Chronic viral Hepatitis C with a start date of 11/15/23 and an end date of 12/12/23. The MAR indicated Resident #26 received the medication 12/01/23 through 12/12/23. Record review of Resident #26's Infectious Disease physician's progress note dated 5/28/24 indicated Resident #26 failed his first treatment of Mavyret for his Hepatitis C because he only received four weeks of an eight-week treatment. During an interview on 10/01/24 at 10:07 AM, the Specialty Pharmacy stated they delivered a 28-day supply of Resident #26's Mavyret on 11/15/23. The Specialty Pharmacy said the physician had ordered a 28-day supply with one refill of the medication and it was not refilled. During an interview on 10/01/24 at 12:24 PM, LVN A said she had worked at the facility for 3-4 years until February 2024. LVN A said she was the infection control nurse and worked from home and would come to facility 1-2 days a week. LVN A said she vaguely remembered the order for Resident #26 starting on Mavyret. LVN A said Mavyret was an antiviral medication for his Hepatitis C. LVN A said it seemed like they had some trouble getting the medication, but she did not really remember. LVN A said, maybe Resident #26 had a reaction to the medication or maybe he only received 4 weeks of the Mavyret because he was supposed to go back to the Infectious Disease doctor to see if he was going to continue the medication. LVN A said it seemed like maybe Resident #26 went into the hospital and thought the hospital stopped the medication. LVN A said if Resident #26 was supposed to get 8 weeks of the medication and he did not complete it, it could have kept his Hepatitis C from being controlled. LVN A said she remembered they were in constant communication with the Infectious Disease doctor's nurse during that time. LVN A said she was the infectious disease nurse at that time, and she was on top of it, but it had been almost a year and she just could not remember the specifics. Attempted to call RN B on 10/01/24 at 1:50 PM and 4:35 PM, there was no answer and was unable to leave a message. During an interview on 10/01/24 at 2:35 PM, LVN C said she did not remember much about Resident #26 taking Mavyret for his Hepatitis C. LVN C said she did not remember much about the medication, but she did remember they took the medication to the hospital when he admitted to the hospital shortly after starting the Mavyret. LVN C said she did not remember exactly how long Resident #26 was supposed to have taken the Mavyret, but she thought it was ordered for a couple of months. LVN C said if the Mavyret was ordered for eight weeks and he only received four weeks of the medication, then it could have affected his Hepatitis C and lab results, and the medication would not have effectively treated Resident #26's Hepatitis C as it was meant to. During an interview on 10/01/24 at 4:58 PM, the Regional Nurse said she did not work at the facility in November of 2023, but in reviewing Resident #26's chart, it appeared the nurse made a transcription error and only put the Mavyret in for 28 days when it appeared to have been ordered for 8 weeks. The Regional Nurse said she was still trying to get the original order from the Infectious Disease Physician. During an interview on 10/02/24 at 10:25 AM, LVN AA, the Infectious Disease doctor's nurse, said she had called the facility and spoke to LVN A on 1/08/24 to see what day Resident #26 was scheduled to complete his Mavyret to determine when labs would need to be drawn. LVN AA said LVN A told her Resident #26 had completed the medication on 12/12/23. LVN AA said she told LVN A that Resident #26 should not have completed the medication until 1/10/24 by her calculations. LVN AA said LVN A said she would check on it and call her back. LVN AA said LVN A called her back and said it looked like he had gone into the hospital and then it was not restarted when he returned to the facility. LVN AA said Resident #26 was ordered Mavyret for a total of 8 weeks to treat his Hepatitis C. LVN AA said after learning Resident #26 did not complete the course of treatment, LVN AA informed the Infectious Disease doctor, and he ordered labs. LVN AA said they checked his viral load (the amount of virus in an infected person's blood) that week and none was detected and then they repeated the lab at 3 months (standard procedure) and his viral load was high, which indicated the 4 weeks of Mavyret did not cure his Hepatitis C. LVN AA said Resident #26 had to receive another 12-week course of treatment for his Hepatitis C. LVN AA said by Resident #26 not receiving the correct duration of the medication, it resulted in failed treatment of his Hepatitis C and he had to receive another course of treatment. LVN AA said the Specialty Pharmacy will only fill a month at a time for the medication due to the cost of the medication and that was why it was called into the Pharmacy as a 28 day with one refill. LVN AA said she had spoken with RN B and LVN A prior to Resident #26 starting Mavyret and explained the duration of the medication was for eight weeks and the importance of not missing any doses. During an interview on 10/02/24 at 12:50 PM, the DON said she started work at the facility in February of 2024. The DON said she was not working at the facility in November of 2023, but since then, Resident #26's Infectious Disease doctor had ordered another treatment for Resident #26's Hepatitis C. The DON said Resident #26 completed the new treatment and his Hepatitis C was in remission. The DON said Resident #26's end result of not completing the ordered eight-week course of Mavyret resulted in Resident #26 having a failed treatment for his Hepatitis C. The DON said at the time of when Resident #26's Mavyret was ordered in November 2023, there was no oversight, lack of documentation, and everything that could have gone wrong did and it resulted in Resident #26 not receiving the full course of the medication. The DON said they now have systems in place to prevent these types of things from happening in the future. During an interview on 10/02/24 at 1:17 PM, the ADM said she came to the facility in January 2024 and did not have any firsthand knowledge of Resident #26's missed medication issue, but it appeared the nurse that entered the medication order into the software, made a transcription error in the order. The ADM said it could have delayed Resident #26's treatment of his Hepatitis C by not completing the prescribed course of the medication. The ADM said she would expect staff to transcribe medication orders correctly and follow the physician's orders. Record review of the facility's policy titled Specific Medication Administration Procedures dated 6/01/22, indicated . the purpose was to administer oral medications in a safe, accurate, and effective manner . review and confirm medication orders for each individual resident on the Medication Administration Record prior to administering medications to each resident .

Based on observation, interview, and record review, the facility failed to ensure residents who had a urinary catheter, received appropriate treatment and services to prevent urinary tract infections to the extent possible for 1 of 4 residents reviewed for catheter care. (Resident #81). The facility failed to provide physician ordered catheter care for Resident #81 by not emptying the Resident #81's foley catheter once a shift while on an antibiotic for a urinary tract infection. This failure could place residents at risk for urinary tract infections, pain, confusion, and sepsis (infections that spread to the blood). Findings included: Record review of an undated face sheet revealed Resident #81 was a [AGE] year-old-male admitted to the facility on [DATE] with the diagnoses of obstructive uropathy (is blockage of urinary flow, which can affect one or both kidneys depending on the level of obstruction), traumatic brain injury (an injury to the brain caused by an external force), and paraplegia (paralysis of legs and lower body). Record review of an MDS dated [DATE] revealed Resident #81 had a BIMS of 15 which indicated no cognitive impairment. Resident #81 required extensive assistance with transfer and toileting. The MDS indicated Resident #81 had an indwelling foley catheter. Record review of Resident #81's progress note written by LVN C on 09/16/2024, revealed Resident #81 was vomiting in his room .manual heart rate was 174. He complained of severe abdominal pain to his upper quadrants. Abdominal distension was noted. Foley catheter was draining well. The MD was called and ordered Resident #81 was to be sent to the emergency room . Resident #81 was diagnosed with a urinary tract infection. Record review of Resident #81's progress note written by LVN C on 09/25/2024 at 10:00 a.m., Resident #81 was readmitted to the facility following being hospitalized for a urinary tract infection. The resident readmitted with an order for Augmentin 875/125 mg twice daily for 5 days. Record review of September 2024 consolidated MD orders revealed an order to empty foley catheter twice daily and record output dated 2/20/2023. Record review of Resident #81's TAR for September 2024 indicated the following: *700 cc's of urine emptied on the night shift on 09/29/2024. *2700 cc's of urine emptied on the morning shift on 09/30/2024. During an observation and interview on 09/30/2024 at 7:00 a.m., Resident #81's foley catheter bag contained over 2000 cc of urine. Resident #81 stated his abdomen was hurting and asked if his foley catheter was full. He stated the nurses often forget to empty his catheter bag. During an interview on 09/30/2024 at 10:30 a.m., LVN C stated Resident #81 had 2300 ccs of urine in his catheter bag when she emptied it at around 7:30 a.m. She stated that was not good for the resident. She stated the foley catheter was an anti-reflux (will not back flow urine into the bladder) catheter, but that his bladder had nowhere to empty when the bag was that full. That allowed stagnant urine to stay in his bladder and could cause a further urinary tract infection. During an interview on 10/02/2024 at 10:00 a.m., the DON stated catheter care including emptying the foley catheter should be done twice daily. She stated Resident #81 may need to have his catheter emptied three times a day. She stated not having the catheter emptied and allowing it to be so full that his bladder could not empty promoted bacteria growth that could lead to urinary tract infections. During an interview on 10/02/2024 at 11:00 a.m., the ADM stated it was her expectation that the nurses followed the MD orders and empty catheters at least twice a shift and if they see it needs to be done more often, they do it using their nursing judgement. She stated it was never acceptable to allow a resident with a catheter to have over 2000 ccs of urine in their drainage bag. Review of the facility policy dated April 2018, indicated the staff and physicians will monitor the individual for complications of an indwelling catheter such as a symptomatic urinary tract infection, urosepsis, or urethral erosion or pain, and complications related to foley catheter usage.

Based on interview and record review, the facility failed to ensure the resident's right to participate in the development and implementation of his or her person-centered plan of care, for 1 of 7 residents (Resident #1, Resident #2, and Resident #3) reviewed for care plans. The facility did not have a quarterly care plan meetings to discuss Resident #1, Resident #2, or Resident #3's care. This failure could cause residents not to be able to participate in the planning of their care, not receiving the care they want or need, and not being informed of all services offered by the facility. The findings included: 1. Record review of the face sheet dated 9/28/23 indicated Resident #1 was admitted to the facility on [DATE] with diagnoses including dementia, muscle weakness, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), lack of coordination, and history of falling. Record review of the MDS dated [DATE] indicated Resident #1 was understood by others and understood others. The MDS indicated Resident #1 had a BIMS of 10 and was moderately cognitively impaired. The MDS indicated Resident #1 required supervision with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. Record review of the care plan last revised 9/25/23 indicated Resident #1 had been identified as having Mental Illness PASRR positive status related to bipolar disorder/major depressive disorder/mood disorder. The care plan indicated she was currently receiving routine case management and individual skills training. Record review of the care conference report dated 9/28/23 indicated Resident #1's last three care conferences were held on 1/03/23, 7/06/22, and 7/15/20. During an interview on 9/27/23 at 2:33 p.m. Resident #1 said the last care plan meeting/care conference she had was approximately a year ago. Resident #1 said she would definitely want to be invited to her care plan meetings. Resident #1 said she felt the facility should give her a schedule she could put on her door telling her how often her care plan meetings were being held, on what days, and at what time so she could remember and attend. 2. Record review of the face sheet dated 9/28/23 indicated Resident #2 was admitted to the facility on [DATE] with diagnoses including reduced mobility, weakness, narcissistic personality disorder (a disorder in which a person has an inflated sense of self-importance), lack of coordination, and anxiety disorder. Record review of the MDS dated [DATE] indicated Resident #2 was understood by others and understood others. The MDS indicated Resident #2 had a BIMS of 15 and was cognitively intact. The MDS indicated Resident #1 required supervision with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. Record review of the care plan last revised 8/10/23 indicated Resident #2 did not adjust easily to changes in routine related to manipulative behaviors associated with narcissistic personality disorder. Record review of the care conference report dated 9/28/23 indicated Resident #2 had not had a care conference since admission to the facility. During an interview on 9/27/23 at 2:30 p.m. Resident #2 said she did not know what a care plan meeting/care conference was and asked surveyor to explain it. After explaining a care plan meeting was a meeting including nursing, activities, therapy, management, etc. to discuss a resident's goals and care Resident #2 said she had not had a care plan meeting. Resident #2 said she would be interested in attending her care plan meetings. Resident #2 said the facility was aware of what her goals were as she had expressed them when throwing a fit. 3. Record review of the face sheet dated 9/28/23 indicated Resident #3 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), muscle weakness, unsteadiness on feet, lack of coordination, and generalized anxiety disorder. Record review of the MDS dated [DATE] indicated Resident #3 was understood by others and understood others. The MDS indicated Resident #3 had a BIMS of 12 and was moderately cognitively impaired. The MDS indicated Resident #3 required limited assistance with toileting and personal hygiene. The MDS indicated Resident #3 required supervision with bed mobility, transfers, and dressing. Record review of the care plan last revised on 9/28/23 indicated Resident #3 was at risk for injury from decrease in activities of daily living. Record review of the care conference report dated 9/28/23 indicated Resident #3's last three care conferences were 6/08/22, 7/23/20, and 5/22/19. During an interview on 9/27/23 at 2:25 p.m., Resident #3 said she had not had a recent care plan meeting. Resident #3 said the last care plan meeting she remembered having was after she moved into the facility. Resident #3 said she would like the opportunity to attend her care plan meetings and have a say in her care. During an interview on 9/28/23 at 9:49 a.m., the DON said the AD was responsible for scheduling care plan meetings. The DON said the AD invited residents and their families to the care plan meetings. The DON said care plan meetings are held weekly on Wednesdays. The DON said each resident should have a quarterly care plan meeting. The DON said residents and their families were supposed to be invited to all care plan meetings. The DON said the facility had been behind on care plan meetings as they had not had an MDS coordinator. The DON said after the facility was cited for residents not being invited to care plan meetings and part of their POC was to get care plan meetings caught up. The DON said the AD had taken over scheduling care plan meetings at that point. The DON said the facility was working on getting all care plans up to date. During an interview on 9/28/23 at 10:07 a.m., the AD said she and the DON took over care plan meetings and scheduling them after being cited by state approximately a couple months ago. The AD said she invited the residents in person to their care plan meetings and called the families to invite them to the care plan meetings. The AD said care plan meetings were held weekly at the facility. The AD said each resident should have a quarterly care plan meeting. Record review of facility's Care Plans, Comprehensive Person-Center policy dated 2001 indicated, A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident .The Interdisciplinary Team in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .Each resident's comprehensive, person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: a. Participate in the planning progress. b. Identify individuals or roles to be included. c. Request meetings. d. Request revisions to the plan of care. e. Participate in establishing the expected goals and outcomes of care. f. Participate in determining the type, amount, frequency, and duration of care .The care planning process will: a. Facilitate resident and/or representative involvement .The interdisciplinary Team must review and updated the care plan: .d. At least quarterly, in conjunction with the required quarterly MDS assessment . Record review of the facility's Resident Participation-Assessment/Care Plans revised February 2021 indicated, The resident and hir or her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. The resident and his or her legal representative are encouraged to attend and participate in the resident's assessment and in the development of the residents person-centered care plan .

Based on interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of each resident for 44 of 44 residents who resided in the facility. The Administrator failed to follow abuse policies and report incidents of abuse. The Administrator failed to follow abuse policies and protect Resident #39 from further abuse by allowing CNA B to work when she was supposed to be suspended for an allegation of abuse. The Administrator failed to ensure residents were not fearful of retaliation. The Administrator allowed CNA B to work during suspension from an alleged abuse allegation. The Administrator was aware of multiple staff verbally abusing residents and did not place any protective measures in place. An Immediate Jeopardy (IJ) situation was identified on 8/23/2023 at 5:15 p.m. The IJ template was provided to the facility on [DATE] at 5:56 p.m. While the IJ was removed on 8/25/2023 at 3:53 p.m., the facility remained out of compliance at no actual harm with the potential for more than minimal harm that is not immediate jeopardy and at a scope of widespread due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could residents at an increased risk for abuse, further abuse, increased anxiety, emotional distress, depression, neglect, and retaliation. Findings included: 1)Record review of Resident #41's face sheet dated 08/22/2023, indicated Resident #41 was a [AGE] year old female admitted to the facility on [DATE], with a diagnoses which include gastroesophageal reflux disease without esophagitis (acid reflux), weakness, moderate intellectual disabilities (difficulty in social situations and problems with social cues and judgment), moderate protein-calorie malnutrition (is the state of inadequate intake of food) pain unspecified, iron deficiency anemia unspecified (occurs when your body doesn't have enough iron to produce hemoglobin), cocaine abuse, uncomplicated. Record review of Resident # 41's Comprehensive MDS assessment dated [DATE], indicated Resident #41 was understood and was able to understand others. The MDS assessment indicated Resident #41 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #41 had no delusions or hallucinations. The MDS assessment indicated Resident #41 had no physical, verbal, or other behavioral symptoms directed toward others. Record review of Resident #41's a care plan with dated 08/09/2023, indicated Resident #41 exhibits socially inappropriate disruptive behavioral symptom, guarded behavior, attention seeking, and embellishes the truth. Record review of Resident #41's progress notes from 05/09/23 through 08/23/23 revealed no documented incidents regarding Resident #41 having had coffee thrown at her or an attempted stabbing with a fork. During Resident council meeting on 08/22/23 at 3:00 PM, revealed Resident #41 stated that she was afraid of Resident #29 because he had poured coffee on her and attempted to stab her in the eye with a fork. Resident #41 stated staff witnessed the incidents, and she called the Administrator to report what had happened. Resident #41 stated that CNA A had witnessed the incidents. During an interview on 8/22/23 at 4:03 PM, Resident # 41 stated she didn't know the exact date the incident occurred. Resident # 41 stated Resident # 29 tried to pour coffee on her after supper. Resident # 41 stated she jumped back quickly but the coffee got on her feet. Resident # 41 stated she told CNA A and CNA A told him to quit. Resident # 41 stated Resident #29 had a fork and tried to hit her in the eye with the fork. Resident # 41 stated she jumped down and Resident #29 missed her. Resident # 41 stated both incidents occurred on the same day in June. Resident #41 stated she told CNA A. Resident # 41 stated CNA A told Resident # 29 he couldn't do that; he would be in jail. Resident #41 stated CNA A witnessed both incidents. During an interview on 8/22/23 at 4:42 PM, CNA A stated she witnessed both incidents. CNA A stated the incident were Resident # 29 poured coffee on Resident #41 happened in the hallway, she intervened and reported it to the charge nurse because ADM was not in the building. CNA A stated she could not remember who the charge nurse was. CNA A stated the incident with the fork happened at the nurse's station with multiple staff members around that witnessed the incident. CNA A stated she intervened and notified the charge nurse due to the Administrator not being in the building. CNA A stated the Administrator was the abuse coordinator. CNA A stated she could not remember the exact date of the incidents, but it was the end May or the first of June. CNA A stated she could not remember the charge nurse she reported the incident to. CNA A stated she could not remember the other staff members that were present. and she could not remember who the charge nurse was. During an interview on 8/22/23 at 8:42 AM, the Administrator stated she investigated the incidents and Resident #41 said it did not happen. The Administrator stated she talked to the staff and the staff said they did not witness the either incident. The Administrator stated she can't remember when the incidents happened, it was back in April. The Administrator stated it had been a long ago, it was not a new allegation, it is an old allegation. The Administrator stated still to this day Resident # 41 says it did not happen. During an interview on 08/23/23 at 9:20 AM, Resident #41 stated the Administrator asked her if she was ok after both incidents, each time and she asked if she wanted to go to the hospital. Resident #41 stated the nurses did assessments on her and she did not have any injuries. Resident #41 stated she had to move out of the way to avoid injuries when both incidents occurred. During an interview on 08/23/23 at 11:45 AM, CNA A stated she was unsure the date the incidents happened but indicated was a couple of months ago. CNA A stated Resident #29 threw coffee on Resident #41 in the hallway as staff was picking up the dinner trays in the dining room. CNA A stated Resident # 29 used a fork and attempted to stab Resident #41 at the nurse's station. CNA A said Resident #41 was able to jump back to miss getting hurt. CNA A stated she told Resident # 29 he couldn't do that, and he listened. CNA A stated she took the fork from Resident #29. During an interview on 08/23/23 at 4:12 PM, RN D stated the incidents wasn't reported to her. RN D stated Resident# 41 is on the other side of facility. 2) Record review of a face sheet dated 8/25/2023 indicated Resident #39 was a [AGE] year-old-male who originally admitted on [DATE], then readmitted on [DATE] with the diagnoses of diffuse traumatic brain injury with loss of consciousness (injury to the brain resulting from a violent blow or jolt to the head or body), Bipolar disorder (mental illness that causes extreme mood swings from high to low), and other schizophrenia (a severe brain disorder that affects how people perceive and interact with reality, often causing hallucinations, delusions, and social withdrawal). Record review of a Quarterly MDS dated [DATE] indicated Resident #39 was understood by other and understood others. The MDS indicated in the Temporal Orientation section of the MDS indicated Resident #39 answered the month accurate within 5 days. The MDS indicated Resident #39 had no behaviors of inattention, disorganized thinking, or altered level of consciousness. The MDS in Section I indicated Resident #39's active diagnosis included traumatic brain dysfunction. The MDS indicated in Section N Resident #39 received antipsychotic medications on a routine basis. The MDS in Section O indicated Resident #39 did not receive any psychological therapy. During an anonymous telephone interview on 8/23/2023 at 3:04 p.m., the person said the incident between Resident #41 and Resident #29 occurred in July. The person indicated Resident #29 threw coffee on Resident #41's face and hit her on her arm. The person also indicated Resident #29 had attempted to stab Resident #41 with a fork. The person said it was hard to intervene with Resident #29 due to his aggressiveness. The person indicated the Administrator was not present when the incident occurred, but she was notified by phone. The person also said Resident #'s 41, 11, and 21 had voiced fearing retaliation with the Administrator. The person said numerous staff feared voicing any concerns or report abuse to the Administrator for fear of the loss of their jobs. The person said she had witnessed the Administrator yell at Resident #'s 12, 11, 21, and 10 when asking for their resident funds. The person indicated the Administer yelled for them to get out of her office. The person indicated on around July 23, 2023, or July 24, 2023, CNA B refused to change Resident #39 and began cursing him. The person indicated Resident #39 informed the Administrator of the allegation. The person indicated CNA B was allowed to continue to work with the residents and was never sent home for suspension. The person said CNA B boasted the Administrator had sent her a text indicating you are suspended, but I need you so If state comes hide then leave and do not let Resident #39 see you. During an anonymous telephone interview on 8/23/2023 at 3:30 p.m., the person indicated she was aware of the Administrator and other employees being allowed to verbally abuse the residents. The person indicated she had heard CNA s B and F tell residents to, sit your mother fucking ass down. The person said the Administrator would yell and curse at the residents to get out of her office. The person said the maintenance supervisor has told a resident to keep your fucking ass in this room. The person said employees have voiced concerns that the corporate regional director covers for the Administrator, so the employees feel as though there was no one to reach out to tell their concerns. The person said CNA A was allowed to work during her suspension period. The person said lastly the verbal abuse, and retaliation was so horrible at the facility. During a confidential group meeting on 8/22/2023 at 3:00 p.m., residents voiced concern of retaliation when reporting allegations. Record review of CNA A's Employee Timecard report dated 7/01/2023- 7/31/2023 time reporting period was created on 8/23/2023 by the BOM. The report indicated CNA A worked: 7/23/2023 from 6:34 a.m. to 2:02 p.m., there were no other punch times for this day. 7/24/2023 from 2:02 a.m. to 9:44 a.m. with a lunch of 9:44 a.m. to 10:30 a.m. then 10:30 a. m. - 2:17 p.m. 7/25/2023 from 7:34 a.m. to 2:05 p.m. there were no other punch times for this day. 7/26/2023 from 7:36 a.m. to 9:50 a.m. with a lunch 9:50 a.m. to 10:48 a.m. then 10:48 a.m. to 2:07 p.m. 7/27/2023 from 1:01 a.m. to 2:54 a.m. with a lunch 2:54 a.m. to 3:55 a.m. then from 3:55 a.m. to 7:39 a.m. then 2:59 p.m. to 8:11 p.m. During an interview on 8/24/2023 at 4:05 p.m., the DON said the Administrator was the abuse coordinator and she handled the abuse allegations. An attempted telephone interview on 08/25/23 at 4:33 p.m. with the Administrator, was unsuccessful. Record review of the Abuse Prevention Program policy and procedure dated June 2021 indicated 1. The Administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures. 2. Our residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. 5. Our center will condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor and to the Abuse Prevention Coordinator immediately. 6. Our center will protect resident from harm, reprisal, discrimination, or coercion during investigations of abuse allegations. 7. All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by Center management. Findings of abuse investigations will also be reported. Investigation .6. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. The Administrator/Corporate Regional Director was notified on 8/2323 at 5:45 p.m., that an Immediate Jeopardy situation was identified due to the above failure. The Administrator/Corporate Regional Director was provided the Immediate Jeopardy template on 8/23/2023 at 5:56 p.m. The facility's Plan of Removal was accepted on 8/24/2023 at 3:46 p.m. and included: Action: Regional Director of Operations reviewed intake #438802. Employee identified as allegedly abusing the resident has suspension paperwork in place, resident was assessed and interviewed and states the following: Do you feel safe here: yes Do you feel kike staff is treating you with respect: yes Do you feel comfortable reporting to staff any problems or concerns: yes Any questions for me: no Date: 7/26/2023 Person responsible: Regional Director of Operations Action: Administrator received 1:1 education with the Regional Director of Operations regarding Abuse/Neglect Reporting. Administrator and Director of Nursing received 1:1 education regarding suspending of alleged perpetrators until the investigation is completed. Alleged perpetrators can then return to work if the allegation is confirmed, inconclusive, or unfounded. Date: 8/24/2023 at 4:40 p.m. Action: Administrator has been suspended pending an investigation by the Regional Director of Operations. Parties assisting with the investigation include Regional Director of Operations and the Chief Nursing Officer. Date 8/23/2023 at 4:40 p.m. Action: Maintenance Director, and 2 CNAs have been suspended pending investigation to include: verbal abuse towards resident (s). Date: 8/23/2023 by 4:40 p.m. Action: Resident safe surveys completed on all residents that can answer the questions, remainder of the resident (who cannot answer) received head-to-toe assessments. Resident safe survey interviews to include fear of retaliation/comfortable reporting issues related. Date 8/23/2023 Action: Employee (all) interviews conducted to include: Have you ever witnessed an employee physically, sexually, or verbally abuse a resident? (If yes proceed to further questions) If yes, who was the employee, who was the resident, and when about did this occur? Were there other witnesses to this event? Did you report this information to anyone and if so, to who? Date: 8/23/2023 Action: Education provided: All staff-abuse/neglect (key takeaway: thorough investigations and fully completing event reports, person centered care plan interventions, who the abuse coordinator is and when to report-Administrator and immediately, documentation/assessment/follow up.) All staff have been educated on the corporate compliance line. If the Administrator is unavailable, they can call the compliance line and/or notify the Director of Nursing. All staff-Resident to resident altercation policy (key takeaway: how to respond and what order to respond-ensure resident safety by separating the residents, staying with the aggressor, and notify charge nurse and abuse coordinator). All Staff-Corporate Compliance Line education provided to all staff to understand if they report something and they feel as if appropriate action has not taken place, to reach out to the compliance line. Any issues with the abuse coordinator/administrator to reach out to the compliance line. Nurses-Education provided regarding documentation of events/incidents in the medial record and documented follow up regarding the events. All staff to be in-serviced prior to working their next/first shift. Date 8/23/2023 by 4:00 p.m. Action: All resident has been given the corporate compliance line and informed they should call that number if they are fearful of retaliation within the facility and need t report abuse/neglect. Date: 8/24/2023 Action Item: Ad hoc QAPI meeting with Medical Director, Administrator, and Director of Nursing completed regarding IJ templates and Plan of Removal Date: 8/23/2023 by 2:00 p.m. Corporate compliance line is monitored by the corporate compliance office. This officer is not affiliated with the center. Once the facility is made aware of an allegation of abuse/neglect by an outside entity (such as our partners at HHSC and The Ombudsman) the facility will initiate an investigation and follow the abuse and neglect policy/protocol. On 8/25/2023 the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record of the Employee memorandum indicated CNA A was provided a suspension dated 7/23/2023. Record review of a safe survey with Resident #39 dated 7/26/2023. Record review of the safe survey results for the residents. Record review of the attestation from the MDS nurse ensured all care plans were reviewed for the last 30 days for resident-to-resident altercations. Record review of the attestation from the ADON nurse ensured all progress notes and/or event reports for the previous 30 days. Record review of the attestation from the Corporate RN indicated she ensured the progress notes and/or event reports. Record review of the signed In-service sign in sheet indicated the Regional Director of Operations in-serviced the Administrator and the DON was provided material related to reporting allegations of abuse to HHSC, completing through investigations, follow the abuse policy, implementation of interventions, suspending alleged perpetrators dated 8/23/2023. Record review of an employee memorandum indicated the Administrator was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of an employee memorandum indicated the Maintenance supervisor was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of an employee memorandum indicated the CNA B was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of an employee memorandum indicated the CNA F was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of the employee Abuse Questionnaires. Record review of the Abuse and Neglect In-service dated 8/23/2023 indicated to report abuse from vendors, family, or staff toward our residents. Record review of the Abuse prevention program resident-to-resident altercations with retaliation towards residents was a form of abuse and could lead to termination. Record review of the Ad Hoc QAPI meeting completed with the Medical Director was completed on 8/23/2023 at 2:00 p.m. with the physician, the Administrator, Regional Director of Operations, and the Survey Resource staff. Interview of Licensed Nurses (LVN C, LVN E, LVN H, LVN S, LVN AA, LVN DD, RN D, Infection Preventionist, ADON, DON) were performed. During the interviews all licensed nurses were able to correctly identity abuse, when to respond, when to report, who to report to, retaliation, protection, and documentation. Licensed Nurses were able to provide education regarding documentation of event or incident and follow up in the medical records. Licensed Nurses were able to identify whom to contact when they feel appropriate action has not taken place on issues that have been reported. Interview of all staff (DA W, Cook P, Housekeeper X, Housekeeper Y, Housekeeper Z, NA BB, NA CC, CNA A, CNA B, CNA F, CNA T, CNA U, CNA V, MA L, AD, DM, DOR, BOM, and Housekeeping Supervisor) were performed. During the interviews all staff were able to correctly identify abuse, when to respond, when to report, who to report to, retaliation, protection, and documentation. All employees were interviewed to inquire about incidents of abuse. All staff members were able to identify whom to contact when they feel appropriate action has not taken place on issues that have been reported. Interview with the residents (Resident #3, #4, #5, #6, #8, #9, #10, #11, #12, #13, #14, #15, #16, #18, #20, #23, #24, #25, #27, #28, #30, #31, #32, #33, #34, #35, #36, #38, #39, #40, #41, #42, #43, #44, #247) were completed. All residents were able to identify the number they should call if they were fearful of retaliation within the facility and needed to report abuse or neglect. Interview with the DON was completed. The DON was able to correctly identify when and how to report abuse or neglect and how to investigate allegation and implement interventions. On 8/25/2023 at 3:53 p.m., the Regional Director of Operations was notified the Immediate Jeopardy was removed; however, the facility remained out of compliance at no actual harm with the potential for more than minimal harm that is not iImmediate jeopardy and at a scope of widespread due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. 46061

Based on interview and record review, the facility failed to ensure an allegation of suspected abuse was thoroughly investigated for 2 of 12 (Resident #'s 39 and 41) residents reviewed for abuse. The facility failed to thoroughly investigate when the administrator received a report that Resident #29 attempted to stab Resident #41 in the eye with a fork and threw coffee on her. The facility failed to thoroughly investigate when Resident #39 reported an allegation of abuse regarding CNA B. The facility failed to report the Resident #'s 39 and 41's allegations of abuse to HHSC. This failure resulted in an Immediate Jeopardy (IJ) identified on 08/23/23. While the IJ was removed on 08/25/23, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective system This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: 1.Record review of Resident #41's face sheet dated 08/22/2023, indicated Resident #41 was a [AGE] year old female admitted to the facility on [DATE], with a diagnoses which include gastroesophageal reflux disease without esophagitis (acid reflux), weakness, moderate intellectual disabilities (difficulty in social situations and problems with social cues and judgment), moderate protein-calorie malnutrition (is the state of inadequate intake of food) pain unspecified, iron deficiency anemia unspecified (occurs when your body doesn't have enough iron to produce hemoglobin), cocaine abuse, uncomplicated. Record review of Resident # 41's Comprehensive MDS assessment dated [DATE], indicated Resident #41 was understood and was able to understand others. The MDS assessment indicated Resident #41 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #41 had no delusions or hallucinations. The MDS assessment indicated Resident #41 had no physical, verbal, or other behavioral symptoms directed toward others. Record review of Resident #41's a care plan with dated 08/09/2023, indicated Resident #41 exhibits socially inappropriate disruptive behavioral symptom, guarded behavior, attention seeking, and embellishes the truth. Record review of Resident #41's progress notes from 05/09/23 through 08/23/23 revealed no documented incidents regarding Resident #41 having coffee threw at her or attempted stabbing with a fork. During Resident council meeting on 08/22/23 at 3:00 PM, revealed Resident #41 stated that she was afraid of Resident #29 because he had poured coffee on her and attempted to stab her in the eye with a fork. Resident #41 stated staff witnessed the incidents, and she called the Administrator to report what had happened. Resident #41 stated that CNA A had witnessed the incidents. During an interview on 8/22/23 at 4:03 PM, Resident # 41 stated she didn't know the exact date the incident occurred. Resident # 41 stated Resident # 29 tried to pour coffee on her after supper. Resident # 41 stated she jumped back quickly but the coffee got on her feet. Resident # 41 stated she told CNA A and CNA A told him to quit. Resident # 41 stated Resident #29 had a fork and tried to hit her in the eye with the fork. Resident # 41 stated she jumped down and Resident #29 missed her. Resident # 41 stated both incidents occurred on the same day in June. Resident #41 stated she told CNA A. Resident # 41 stated CNA A told Resident # 29 he couldn't do that; he would be in jail. Resident #41 stated CNA A witnessed both incidents. During an interview on 8/22/23 at 4:42 PM, CNA A stated she witnessed both incidents. CNA A stated the incident were Resident # 29 poured coffee on Resident #41 happened in the hallway, she intervened and reported it to the charge nurse because ADM was not in the building. CNA A stated she could not remember who the charge nurse was. CNA A stated the incident with the fork happened at the nurse's station with multiple staff members around that witnessed the incident. CNA A stated she intervened and notified the charge nurse due to the Administrator not being in the building. CNA A stated the Administrator was the abuse coordinator. CNA A stated she could not remember the exact date of the incidents, but it was the end May or the first of June. CNA A stated she could not remember the charge nurse she reported the incident to. CNA A stated she could not remember the other staff members that were present. and she could not remember who the charge nurse was. During an interview on 8/22/23 at 8:42 AM, the Administrator stated she investigated the incidents and Resident #41 said it did not happen. The Administrator stated she talked to the staff and the staff said they did not witness the either incident. The Administrator stated she can't remember when the incidents happened, it was back in April. The Administrator stated it had been a long ago, it was not a new allegation, it is an old allegation. The Administrator stated still to this day Resident # 41 says it did not happen. During an interview on 08/23/23 at 9:20 AM, Resident #41 stated the Administrator asked her if she was ok after both incidents, each time and she asked if she wanted to go to the hospital. Resident #41 stated the nurses did assessments on her and she did not have any injuries. Resident #41 stated after the incidents she had to move out of the way to avoid injuries when both incidents occurred. During an interview on 08/23/23 at 11:45 AM, CNA A stated she was not for sure when the incidents happened. CNA A stated staff were picking up trays during dinner that was when Resident #29 threw the coffee on Resident # 41 in the hallway. CNA A stated Resident # 29 got a fork from somewhere and tried to stab Resident #41 at the nurse's station. He did not go to her room. CNA A stated she told Resident # 29 he couldn't do that, and he listened. CNA A stated she took the fork and got rid of it. CNA A stated she wasn't aware of any further incidents. During an interview on 08/23/23 at 4:12 PM RN D stated the incidents wasn't reported to her. RN D stated Resident# 41 is on the other side of facility. 2)Record review of a face sheet dated 8/25/2023 indicated Resident #39 was a [AGE] year-old-male who originally admitted on [DATE], then readmitted on [DATE] with the diagnoses of diffuse traumatic brain injury with loss of consciousness (injury to the brain resulting from a violent blow or jolt to the head or body), Bipolar disorder (mental illness that causes extreme mood swings from high to low), and other schizophrenia (a severe brain disorder that affects how people perceive and interact with reality, often causing hallucinations, delusions, and social withdrawal). Record review of a Quarterly MDS dated [DATE] indicated Resident #39 was understood by other and understood others. The MDS indicated in the Temporal Orientation section of the MDS indicated Resident #39 answered the month accurate within 5 days. The MDS indicated Resident #39 had no behaviors of inattention, disorganized thinking, or altered level of consciousness. The MDS in Section I indicated Resident #39's active diagnosis included traumatic brain dysfunction. The MDS indicated in Section N Resident #39 received antipsychotic medications on a routine basis. The MDS in Section O indicated Resident #39 did not receive any psychological therapy. During an anonymous telephone interview on 8/23/2023 at 3:04 p.m., the person said the incident between Resident #41 and Resident #29 occurred in July. The person indicated Resident #29 threw coffee on Resident #41's face and hit her on her arm. The person also indicated Resident #29 had attempted to stab Resident #41 with a fork. The person said it was hard to intervene with Resident #29 due to his aggressiveness. The person indicated the Administrator was not present when the incident occurred, but she was notified by phone. The person also said Resident #'s 41, 11, and 21 had voiced fearing retaliation with the Administrator. The person said numerous staff feared voicing any concerns or report abuse to the Administrator for fear of the loss of their jobs. The person said she had witnessed the Administrator yell at Resident #'s 12, 11, 21, and 10 when asking for their resident funds. The person indicated the Administer yelled for them to get out of her office. The person indicated on around July 23, 2023, or July 24, 2023, CNA B refused to change Resident #39 and began cursing him. The person indicated Resident #39 informed the Administrator of the allegation. The person indicated CNA B was allowed to continue to work with the residents and was never sent home for suspension. The person said CNA B boasted the Administrator had sent her a text indicating you are suspended, but I need you so If state comes hide then leave and do not let Resident #39 see you. During an anonymous telephone interview on 8/23/2023 at 3:30 p.m., the person indicated she was aware of the Administrator and other employees being allowed to verbally abuse the residents. The person indicated she had heard CNA s B and F tell residents to, sit your mother fucking ass down. The person said the Administrator would yell and curse at the residents to get out of her office. The person said the maintenance supervisor has told a resident to keep your fucking ass in this room. The person said employees have voiced concerns that the corporate regional director covers for the Administrator, so the employees feel as though there was no one to reach out to tell their concerns. The person said CNA B was allowed to work during her suspension period. The person said lastly the verbal abuse, and retaliation was so horrible at the facility. During a confidential group meeting on 8/22/2023 at 3:00 p.m., residents voiced concern of retaliation when reporting allegations. Record review of CNA A's Employee Timecard report dated 7/01/2023- 7/31/2023 time reporting period was created on 8/23/2023 by the BOM. The report indicated CNA A worked: 7/23/2023 from 6:34 a.m. to 2:02 p.m., there were no other punch times for this day. 7/24/2023 from 2:02 a.m. to 9:44 a.m. with a lunch of 9:44 a.m. to 10:30 a.m. then 10:30 a. m. - 2:17 p.m. 7/25/2023 from 7:34 a.m. to 2:05 p.m. there were no other punch times for this day. 7/26/2023 from 7:36 a.m. to 9:50 a.m. with a lunch 9:50 a.m. to 10:48 a.m. then 10:48 a.m. to 2:07 p.m. 7/27/2023 from 1:01 a.m. to 2:54 a.m. with a lunch 2:54 a.m. to 3:55 a.m. then from 3:55 a.m. to 7:39 a.m. then 2:59 p.m. to 8:11 p.m. During an interview on 8/24/2023 at 4:05 p.m., the DON said the Administrator was the abuse coordinator and she handled the abuse allegations. An attempted telephone interview on 08/25/23 at 4:33 p.m. with the Administrator, was unsuccessful. Record review of the facility's policy, titled, Abuse Prevention Program, last revised on 06/2021, indicated, . The Administrator is responsible for the overall coordination and implementation of our center's abuse prevention program policies and procedures. Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Our center will not condone any form of resident abuse or neglect. To aide in abuse prevention, all personnel are to report any signs and symptoms of abuse/ neglect to their supervisor and to the Abuse Prevention Coordinator immediately. Our center will protect residents from harm, reprisal, discrimination, or coercion during investigation of abuse allegation. Our center will provide protections for the health, warfare and rights of each resident residing in the center to ensure the reporting of crimes. Develop and implement polices and procedures to aid to our center in preventing abuse, neglect, or mistreatment of our residents. Identify and assess all possible incidents of abuse: investigate and report any allegations of abuse within timeframe as required by federal requirements; protect resident during abuse investigation; the Administrator will suspend immediately any employees who has been accused of resident abuse, pending the outcome of the investigation; 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's Administrator, or his/her designee, to the following person or agencies as required: The Administrator was notified on 08/23/2023 at 1:05 PM, that an immediate jeopardy situation was identified due to the above failures. The Regional Director of Operations and Administrator was provided the immediate jeopardy template on 08/23/23 at 9:47 AM. The template was amended on 08/23/23 at 5:33 and returned to the he Regional Director of Operations and Administrator. The facility's plan of removal was accepted on 8/24/2023 at 3:04 p.m. and included: Action: Resident #29 was discharged from the facility on 8/22/2023 to a safe alternative location and will not return to the facility Date: 8/22/2023 Action: Administrator, Maintenance Director, and 2 CNAs have been suspended pending investigation to include verbal abuse towards resident (s). Date 8/23/2023 Action: Resident safe surveys completed on all residents that can answer the questions, remainder of the resident (who cannot answer) received head-to-toe assessments. Resident safe survey interviews to include fear of retaliation/comfortable reporting issues related. Date 8/23/2023 Action: Progress notes and event reports reviewed to ensure no other additional resident to resident altercations have occurred without appropriate interventions being place in the care plan, notifications made to psychiatric services and the MD. Date: 8/23/2023 by 3:00 p.m. Action: Employee (all) interviews conducted to include: Have you ever witnessed an employee physically, sexually, or verbally abuse a resident? (If yes proceed to further questions) If yes, who was the employee, who was the resident, and when about did this occur? Were there other witnesses to this event? Did you report this information to anyone and if so, to who? Date: 8/23/2023 Action: Residents involved in resident-to-resident altercations, identified in the previous 30-days, had their care plans reviewed to ensure proper interventions are in place. Any identified lacking proper interventions have been reviewed with the IDT and added. Date: 8/23/2023 at 3:00 p.m. Action: Education provided: All staff-abuse/neglect (key takeaway: thorough investigations and fully completing event reports, person centered care plan interventions, who the abuse coordinator is and when to report-Administrator and immediately, documentation/assessment/follow up.) All staff have been educated on the corporate compliance line. If the Administrator is unavailable, they can call the compliance line and/or notify the Director of Nursing. Nurses-Education provided regarding documentation of events/incidents in the medial record and documented follow up regarding the events. All staff to be in-serviced prior to working their next/first shift. Date 8/23/2023 by 4:00 p.m. All staff-Resident to resident altercation policy (key takeaway: how to respond and what order to respond-ensure resident safety by separating the residents, staying with the aggressor, and notify charge nurse and abuse coordinator). All Staff-Corporate Compliance Line education provided to all staff to understand if they report something and they feel as if appropriate action has not taken place, to reach out to the compliance line. Any issues with the abuse coordinator/administrator to reach out to the compliance line. Action: All resident has been given the corporate compliance line and informed they should call that number if they are fearful of retaliation within the facility and need t report abuse/neglect. Date: 8/24/2023 Action: 1:1 education provided to Administrator and Director of Nursing over the PL17-19 regarding abuse/neglect/reporting. Education regarding investigating allegations and implementing interventions. Date:8/23/2003 by 2:00 p.m. Action Item: Ad hoc QAPI meeting with Medical Director, Administrator, and Director of Nursing completed regarding IJ templates and Plan of Removal Date: 8/23/2023 by 2:00 p.m. Corporate compliance line is monitored by the corporate compliance office. This officer is not affiliated with the center. Once the facility is made aware of an allegation of abuse/neglect by an outside entity (such as our partners at HHSC and The Ombudsman) the facility will initiate an investigation and follow the abuse and neglect policy/protocol. On 8/25/2023 the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of Resident #29's medical record indicated he discharged on [DATE] to a sister facility. Record review of an employee memorandum indicated the Administrator was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of an employee memorandum indicated the Maintenance supervisor was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of an employee memorandum indicated the CNA B was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of an employee memorandum indicated the CNA F was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of the safe survey results for the residents. Record review of the employee Abuse Questionnaires. Record review of the education provided regarding documentation of events/incidents in the medical record and documented follow up regarding the events. Record review of the Abuse prevention program resident-to-resident altercations with retaliation towards residents was a form of abuse and could lead to termination. Record review of the 1:1 education provided to Administrator and Director of Nursing over the PL17-19 regarding abuse/neglect/reporting. Record review of the Ad Hoc QAPI meeting completed with the Medical Director was completed on 8/23/2023 at 2:00 p.m. with the physician, the Administrator, Regional Director of Operations, and the Survey Resource staff. Interview of Licensed Nurses (LVN C, LVN E, LVN H, LVN S, LVN AA, LVN DD, RN D, Infection Preventionist, ADON, DON) were performed. During the interviews all licensed nurses were able to correctly identity abuse, when to respond, when to report, who to report to, retaliation, protection, and documentation. Licensed Nurses were able to provide education regarding documentation of event or incident and follow up in the medical records. Interview of all staff (DA W, Cook P, Housekeeper X, Housekeeper Y, Housekeeper Z, NA BB, NA CC, CNA A, CNA B, CNA F, CNA T, CNA U, CNA V, MA L, AD, DM, DOR, BOM, and Housekeeping Supervisor) were performed. During the interviews all staff were able to correctly identify abuse, when to respond, when to report, who to report to, retaliation, protection, and documentation. Interview with the residents (Resident #3, #4, #5, #6, #8, #9, #10, #11, #12, #13, #14, #15, #16, #18, #20, #23, #24, #25, #27, #28, #30, #31, #32, #33, #34, #35, #36, #38, #39, #40, #41, #42, #43, #44, #247) were completed. All residents were able to identify the number they should call if they were fearful of retaliation within the facility and needed to report abuse or neglect. Interview with the DON was completed. The DON was able to correctly identify when and how to report abuse or neglect and how to investigate allegation and implement interventions. On 8/25/2023 at 3:53 p.m., the Regional Director of Operations was notified the Immediate Jeopardy was removed; however, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure the right of the residents to be free from abuse for 3 of 12 residents (Resident #'s 29, 39, and 41) reviewed for abuse. The facility failed to keep Residents #41 and Resident # 39 free from abuse and neglect. The facility failed to implement interventions after each incident between Resident #29 and Resident #41 to prevent further incidents of abuse. The facility failed to protect the resident by allowing CNA B to work after an abuse allegation was made by Resident #39. The facility failed to ensure residents were not fearful of retaliation. The facility failed to protect resident from abuse by staff. This failure resulted in an Immediate Jeopardy (IJ) identified on 08/23/23. While the IJ was removed on 08/25/23, the facility remained out of compliance at no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy at a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective system This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: 1. Record review of Resident #41's face sheet dated 08/22/2023, indicated Resident #41 was a [AGE] year old female admitted to the facility on [DATE], with a diagnoses which include gastroesophageal reflux disease without esophagitis (acid reflux), weakness, moderate intellectual disabilities (difficulty in social situations and problems with social cues and judgment), moderate protein-calorie malnutrition (is the state of inadequate intake of food) pain unspecified, iron deficiency anemia unspecified (occurs when your body doesn't have enough iron to produce hemoglobin), cocaine abuse, uncomplicated. Record review of Resident # 41's Comprehensive MDS assessment dated [DATE], indicated Resident #41 was understood and was able to understand others. The MDS assessment indicated Resident #41 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #41 had no delusions or hallucinations. The MDS assessment indicated Resident #41 had no physical, verbal, or other behavioral symptoms directed toward others. Record review of Resident #41's comprehensive care plan dated 08/09/2023, indicated Resident #41 exhibits socially inappropriate disruptive behavioral symptom, guarded behavior, attention seeking, and embellishes the truth. Record review of Resident #41's progress notes from 05/09/23 through 08/23/23 revealed no documented incidents regarding Resident #41 having coffee thrown at her or an attempted stabbing with a fork. During Resident council meeting on 08/22/23 at 3:00 PM, revealed Resident #41 stated that she was afraid of Resident #29 because he had poured coffee on her and attempted to stab her in the eye with a fork. Resident #41 stated staff witnessed the incidents, and she called the Administrator to report what had happened. Resident #41 stated that CNA A had witnessed the incidents. During an interview on 8/22/23 at 4:03 PM, Resident # 41 stated she didn't know the exact date the incident occurred. Resident # 41 stated Resident # 29 tried to pour coffee on her after supper. Resident # 41 stated she jumped back quickly but the coffee got on her feet. Resident # 41 stated she told CNA A and CNA A told him to quit. Resident # 41 stated Resident #29 had a fork and tried to hit her in the eye with the fork. Resident # 41 stated she jumped down and Resident #29 missed her. Resident # 41 stated both incidents occurred on the same day in June. Resident #41 stated she told CNA A. Resident # 41 stated CNA A told Resident # 29 he couldn't do that; he would be in jail. Resident #41 stated CNA A witnessed both incidents. During an interview on 8/22/23 at 4:42 PM, CNA A stated she witnessed both incidents. CNA A stated the incident were Resident # 29 poured coffee on Resident #41 happened in the hallway, she intervened and reported it to the charge nurse because ADM was not in the building. CNA A stated she could not remember who the charge nurse was. CNA A stated the incident with the fork happened at the nurse's station with multiple staff members around that witnessed the incident. CNA A stated she intervened and notified the charge nurse due to the Administrator not being in the building. CNA A stated the Administrator was the abuse coordinator. CNA A stated she could not remember the exact date of the incidents, but it was the end May or the first of June. CNA A stated she could not remember the charge nurse she reported the incident to. CNA A stated she could not remember the other staff members that were present. and she could not remember who the charge nurse was. During an interview on 8/22/23 at 8:42 AM, the Administrator stated she investigated the incidents and Resident #41 said it did not happen. The Administrator stated she talked to the staff and the staff said they did not witness the either incident. The Administrator stated she can't remember when the incidents happened, it was back in April. The Administrator stated it had been a long ago, it was not a new allegation, it is an old allegation. The Administrator stated still to this day Resident # 41 says it did not happen. During an interview on 08/23/23 at 9:20 AM, Resident #41 stated the Administrator asked her if she was ok after both incidents, each time and she asked if she wanted to go to the hospital. Resident #41 stated the nurses did assessments on her and she did not have any injuries. Resident #41 stated after the incidents she had to move out of the way to avoid injuries when both incidents occurred. During an interview on 08/23/23 at 11:45 AM, CNA A stated she was not for sure when the incidents happened. CNA A stated staff were picking up trays during dinner that was when Resident #29 threw the coffee on Resident # 41 in the hallway. CNA A stated Resident # 29 got a fork from somewhere and tried to stab Resident #41 at the nurse's station. He did not go to her room. CNA A stated she told Resident # 29 he couldn't do that, and he listened. CNA A stated she took the fork and got rid of it. CNA A stated she wasn't aware of any further incidents. During an interview on 08/23/23 at 4:12 PM, RN D stated the incidents wasn't reported to her. RN D stated Resident# 41 is on the other side of facility. 2. Record review of a face sheet dated 8/25/2023 indicated Resident #39 was a [AGE] year-old-male who originally admitted on [DATE], then readmitted on [DATE] with the diagnoses of diffuse traumatic brain injury with loss of consciousness (injury to the brain resulting from a violent blow or jolt to the head or body), Bipolar disorder (mental illness that causes extreme mood swings from high to low), and other schizophrenia (a severe brain disorder that affects how people perceive and interact with reality, often causing hallucinations, delusions, and social withdrawal). Record review of a Quarterly MDS dated [DATE] indicated Resident #39 was understood by other and understood others. The MDS indicated in the Temporal Orientation section of the MDS indicated Resident #39 answered the month accurate within 5 days. The MDS indicated Resident #39 had no behaviors of inattention, disorganized thinking, or altered level of consciousness. The MDS in Section I indicated Resident #39's active diagnosis included traumatic brain dysfunction. The MDS indicated in Section N Resident #39 received antipsychotic medications on a routine basis. The MDS in Section O indicated Resident #39 did not receive any psychological therapy. During an anonymous telephone interview on 8/23/2023 at 3:04 p.m., the person said the incident between Resident #41 and Resident #29 occurred in July. The person indicated Resident #29 threw coffee on Resident #41's face and hit her on her arm. The person also indicated Resident #29 had attempted to stab Resident #41 with a fork. The person said it was hard to intervene with Resident #29 due to his aggressiveness. The person indicated the Administrator was not present when the incident occurred, but she was notified by phone. The person also said Resident #'s 41, 11, and 21 had voiced fearing retaliation with the Administrator. The person said numerous staff feared voicing any concerns or report abuse to the Administrator for fear of the loss of their jobs. The person said she had witnessed the Administrator yell at Resident #'s 12, 11, 21, and 10 when asking for their resident funds. The person indicated the Administer yelled for them to get out of her office. The person indicated on around July 23, 2023, or July 24, 2023, CNA B refused to change Resident #39 and began cursing him. The person indicated Resident #39 informed the Administrator of the allegation. The person indicated CNA B was allowed to continue to work with the residents and was never sent home for suspension. The person said CNA B boasted the Administrator had sent her a text indicating you are suspended, but I need you so If state comes hide then leave and do not let Resident #39 see you. During an anonymous telephone interview on 8/23/2023 at 3:30 p.m., the person indicated she was aware of the Administrator and other employees being allowed to verbally abuse the residents. The person indicated she had heard CNA s B and F tell residents to, sit your mother fucking ass down. The person said the Administrator would yell and curse at the residents to get out of her office. The person said the maintenance supervisor has told a resident to keep your fucking ass in this room. The person said employees have voiced concerns that the corporate regional director covers for the Administrator, so the employees feel as though there was no one to reach out to tell their concerns. The person said CNA B as allowed to work during her suspension period. The person said lastly the verbal abuse, and retaliation was so horrible at the facility. During a confidential group meeting on 8/22/2023 at 3:00 p.m., residents voiced concern of retaliation when reporting allegations. Record review of CNA A's Employee Timecard report dated 7/01/2023- 7/31/2023 time reporting period was created on 8/23/2023 by the BOM. The report indicated CNA A worked: 7/23/2023 from 6:34 a.m. to 2:02 p.m., there were no other punch times for this day. 7/24/2023 from 2:02 a.m. to 9:44 a.m. with a lunch of 9:44 a.m. to 10:30 a.m. then 10:30 a. m. - 2:17 p.m. 7/25/2023 from 7:34 a.m. to 2:05 p.m. there were no other punch times for this day. 7/26/2023 from 7:36 a.m. to 9:50 a.m. with a lunch 9:50 a.m. to 10:48 a.m. then 10:48 a.m. to 2:07 p.m. 7/27/2023 from 1:01 a.m. to 2:54 a.m. with a lunch 2:54 a.m. to 3:55 a.m. then from 3:55 a.m. to 7:39 a.m. then 2:59 p.m. to 8:11 p.m. During an interview on 8/24/2023 at 4:05 p.m., the DON said the Administrator was the abuse coordinator and she handled the abuse allegations. An attempted telephone interview on 08/25/23 at 4:33 p.m. with the Administrator, was unsuccessful. The Administrator was notified on 08/23/2023 at 1:05 PM, that an immediate jeopardy situation was identified due to the above failures. The Regional Director of Operations and Administrator was provided the immediate jeopardy template on 08/23/23 at 9:47 AM. The templete was amended on 08/23/23 at 5:33 and returned to the he Regional Director of Operations and Administrator. The facility's plan of removal was accepted on 8/24/2023 at 3:04 p.m. and included: Action: Resident #29 was discharged from the facility on 8/22/2023 to a safe alternative location and will not return to the facility Date: 8/22/2023 Action: Administrator, Maintenance Director, and 2 CNAs have been suspended pending investigation to include verbal abuse towards resident (s). Date 8/23/2023 Action: Resident safe surveys completed on all residents that can answer the questions, remainder of the resident (who cannot answer) received head-to-toe assessments. Resident safe survey interviews to include fear of retaliation/comfortable reporting issues related. Date 8/23/2023 Action: Progress notes and event reports reviewed to ensure no other additional resident to resident altercations have occurred without appropriate interventions being place in the care plan, notifications made to psychiatric services and the MD. Date: 8/23/2023 by 3:00 p.m. Action: Employee (all) interviews conducted to include: Have you ever witnessed an employee physically, sexually, or verbally abuse a resident? (If yes proceed to further questions) If yes, who was the employee, who was the resident, and when about did this occur? Were there other witnesses to this event? Did you report this information to anyone and if so, to who? Date: 8/23/2023 Action: Residents involved in resident-to-resident altercations, identified in the previous 30-days, had their care plans reviewed to ensure proper interventions are in place. Any identified lacking proper interventions have been reviewed with the IDT and added. Date: 8/23/2023 at 3:00 p.m. Action: Education provided: All staff-abuse/neglect (key takeaway: thorough investigations and fully completing event reports, person centered care plan interventions, who the abuse coordinator is and when to report-Administrator and immediately, documentation/assessment/follow up.) All staff have been educated on the corporate compliance line. If the Administrator is unavailable, they can call the compliance line and/or notify the Director of Nursing. Nurses-Education provided regarding documentation of events/incidents in the medial record and documented follow up regarding the events. All staff to be in-serviced prior to working their next/first shift. Date 8/23/2023 by 4:00 p.m. All staff-Resident to resident altercation policy (key takeaway: how to respond and what order to respond-ensure resident safety by separating the residents, staying with the aggressor, and notify charge nurse and abuse coordinator). All Staff-Corporate Compliance Line education provided to all staff to understand if they report something and they feel as if appropriate action has not taken place, to reach out to the compliance line. Any issues with the abuse coordinator/administrator to reach out to the compliance line. Action: All resident has been given the corporate compliance line and informed they should call that number if they are fearful of retaliation within the facility and need t report abuse/neglect. Date: 8/24/2023 Action: 1:1 education provided to Administrator and Director of Nursing over the PL17-19 regarding abuse/neglect/reporting. Education regarding investigating allegations and implementing interventions. Date:8/23/2003 by 2:00 p.m. Action Item: Ad hoc QAPI meeting with Medical Director, Administrator, and Director of Nursing completed regarding IJ templates and Plan of Removal Date: 8/23/2023 by 2:00 p.m. Corporate compliance line is monitored by the corporate compliance office. This officer is not affiliated with the center. Once the facility is made aware of an allegation of abuse/neglect by an outside entity (such as our partners at HHSC and The Ombudsman) the facility will initiate an investigation and follow the abuse and neglect policy/protocol. On 8/25/2023 the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of Resident #29's medical record indicated he discharged on [DATE] to a sister facility. Record review of an employee memorandum indicated the Administrator was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of an employee memorandum indicated the Maintenance supervisor was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of an employee memorandum indicated the CNA B was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of an employee memorandum indicated the CNA F was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of the safe survey results for the residents. Record review of the employee Abuse Questionnaires. Record review of the education provided regarding documentation of events/incidents in the medical record and documented follow up regarding the events. Record review of the Abuse prevention program resident-to-resident altercations with retaliation towards residents was a form of abuse and could lead to termination. Record review of the 1:1 education provided to Administrator and Director of Nursing over the PL17-19 regarding abuse/neglect/reporting. Record review of the Ad Hoc QAPI meeting completed with the Medical Director was completed on 8/23/2023 at 2:00 p.m. with the physician, the Administrator, Regional Director of Operations, and the Survey Resource staff. Interview of Licensed Nurses (LVN C, LVN E, LVN H, LVN S, LVN AA, LVN DD, RN D, Infection Preventionist, ADON, DON) were performed. During the interviews all licensed nurses were able to correctly identity abuse, when to respond, when to report, who to report to, retaliation, protection, and documentation. Licensed Nurses were able to provide education regarding documentation of event or incident and follow up in the medical records. Licensed Nurses were able to identify whom to contact when they feel appropriate action has not taken place on issues that have been reported. Interview of all staff (DA W, Cook P, Housekeeper X, Housekeeper Y, Housekeeper Z, NA BB, NA CC, CNA A, CNA B, CNA F, CNA T, CNA U, CNA V, MA L, AD, DM, DOR, BOM, and Housekeeping Supervisor) were performed. During the interviews all staff were able to correctly identify abuse, when to respond, when to report, who to report to, retaliation, protection, and documentation. All employees were interviewed to inquire about incidents of abuse. All staff members were able to identify whom to contact when they feel appropriate action has not taken place on issues that have been reported. Interview with the residents (Resident #3, #4, #5, #6, #8, #9, #10, #11, #12, #13, #14, #15, #16, #18, #20, #23, #24, #25, #27, #28, #30, #31, #32, #33, #34, #35, #36, #38, #39, #40, #41, #42, #43, #44, #247) were completed. All residents were able to identify the number they should call if they were fearful of retaliation within the facility and needed to report abuse or neglect. Interview with the DON was completed. The DON was able to correctly identify when and how to report abuse or neglect and how to investigate allegation and implement interventions. Interview with RDO said the employees on the inservice sheets had been educated on abuse/neglect If they signed the sheet for inservice they were educated on abuse and neglect and ways to report and to inform any residents to report to the corporate compliance line and where the number could be found in the building. The RDO showed me the number hanging on hall wall at this time. The Corporate Survey Resource said she would immediately start contacting those employees to go back over the inservice information especially since the Administrator was out of the office for now and the corporate compliance line was always available. Record review of the facility's policy, titled, Abuse Prevention Program, last revised on 06/2021, indicated, . The Administrator is responsible for the overall coordination and implementation of our center's abuse prevention program policies and procedures. Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Our center will not condone any form of resident abuse or neglect. To aide in abuse prevention, all personnel are to report any signs and symptoms of abuse/ neglect to their supervisor and to the Abuse Prevention Coordinator immediately. Our center will protect residents from harm, reprisal, discrimination, or coercion during investigation of abuse allegation. Our center will provide protections for the health, warfare and rights of each resident residing in the center to ensure the reporting of crimes. Develop and implement policies and procedures to aid to our center in preventing abuse, neglect, or mistreatment of our residents. Identify and assess all possible incidents of abuse: investigate and report any allegations of abuse within timeframe as required by federal requirements; protect resident during abuse investigation; the Administrator will suspend immediately any employees who has been accused of resident abuse, pending the outcome of the investigation; 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's Administrator, or his/her designee, to the following person or agencies as required: On 8/25/2023 at 3:53 p.m., the Regional Director of Operations was notified the Immediate Jeopardy was removed; however, the facility remained out of compliance at no actual harm with a potential for more than minimal harm that is not immeidate jeopardy at a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. 33249

Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and establish policies and procedures to report and investigate such allegations, for 2 of 16 residents (Resident's #29 and Resident #41) reviewed for abuse. The facility failed to thoroughly report to the State when the administrator received a report that Resident #29 attempted to stab Resident #41 in the eye with a fork and threw coffee on her. The facility did not implement policy on reporting abuse when Resident #29's family member visited the facility on 08/13/23 and was yelling at resident and threw his personal belongings outside of his room. The facility did not implement their abuse policy and allowed CNA B to work during her suspension period after an allegation of abuse was made by Resident #39. The facility failed to report the allegations of staff to resident abuse. The facility failed to report the Resident #41's allegations of abuse to HHSC. This failure resulted in an Immediate Jeopardy (IJ) identified on 08/23/23. While the IJ was removed on 08/25/23, the facility remained out of compliance at no actual harm with the potential for more than minimal harm that is not immediate joepardy at a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective system This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: 1. Record review of Resident #41's face sheet dated 08/22/2023, indicated Resident #41 was a [AGE] year old female admitted to the facility on [DATE], with a diagnoses which include gastroesophageal reflux disease without esophagitis (acid reflux), weakness, moderate intellectual disabilities (difficulty in social situations and problems with social cues and judgment), moderate protein-calorie malnutrition (is the state of inadequate intake of food) pain unspecified, iron deficiency anemia unspecified (occurs when your body doesn't have enough iron to produce hemoglobin), cocaine abuse, uncomplicated. Record review of Resident # 41's Comprehensive MDS assessment dated [DATE], indicated Resident #41 was understood and was able to understand others. The MDS assessment indicated Resident #41 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #41 had no delusions or hallucinations. The MDS assessment indicated Resident #41 had no physical, verbal, or other behavioral symptoms directed toward others. Record review of Resident #41's a care plan with dated 08/09/2023, indicated Resident #41 exhibits socially inappropriate disruptive behavioral symptom, guarded behavior, attention seeking, and embellishes the truth. Record review of Resident #41's progress notes from 05/09/23 through 08/23/23 revealed no documented incidents regarding Resident #41 having coffee threw at her or attempted stabbing with a fork. During Resident council meeting on 08/22/23 at 3:00 PM, revealed Resident #41 stated that she was afraid of Resident #29 because he had poured coffee on her and attempted to stab her in the eye with a fork. Resident #41 stated staff witnessed the incidents, and she called the Administrator to report what had happened. Resident #41 stated that CNA A had witnessed the incidents. During an interview on 8/22/23 at 4:03 PM, Resident # 41 stated she didn't know the exact date the incident occurred. Resident # 41 stated Resident # 29 tried to pour coffee on her after supper. Resident # 41 stated she jumped back quickly but the coffee got on her feet. Resident # 41 stated she told CNA A and CNA A told him to quit. Resident # 41 stated Resident #29 had a fork and tried to hit her in the eye with the fork. Resident # 41 stated she jumped down and Resident #29 missed her. Resident # 41 stated both incidents occurred on the same day in June. Resident #41 stated she told CNA A. Resident # 41 stated CNA A told Resident # 29 he couldn't do that; he would be in jail. Resident #41 stated CNA A witnessed both incidents. During an interview on 8/22/23 at 4:42 PM, CNA A stated she witnessed both incidents. CNA A stated the incident were Resident # 29 poured coffee on Resident #41 happened in the hallway, she intervened and reported it to the charge nurse because ADM was not in the building. CNA A stated she could not remember who the charge nurse was. CNA A stated the incident with the fork happened at the nurse's station with multiple staff members around that witnessed the incident. CNA A stated she intervened and notified the charge nurse due to the Administrator not being in the building. CNA A stated the Administrator was the abuse coordinator. CNA A stated she could not remember the exact date of the incidents, but it was the end May or the first of June. CNA A stated she could not remember the charge nurse she reported the incident to. CNA A stated she could not remember the other staff members that were present. and she could not remember who the charge nurse was. During an interview on 8/22/23 at 8:42 AM, the Administrator stated she investigated the incidents and Resident #41 said it did not happen. The Administrator stated she talked to the staff and the staff said they did not witness the either incident. The Administrator stated she can't remember when the incidents happened, it was back in April. The Administrator stated it had been a long ago, it was not a new allegation, it is an old allegation. The Administrator stated still to this day Resident # 41 says it did not happen. During an interview on 08/23/23 at 9:20 AM, Resident #41 stated the Administrator asked her if she was ok after both incidents, each time and she asked if she wanted to go to the hospital. Resident #41 stated the nurses did assessments on her and she did not have any injuries. Resident #41 stated after the incidents she had to move out of the way to avoid injuries when both incidents occurred. During an interview on 08/23/23 at 11:45 AM, CNA A stated she was not for sure when the incidents happened. CNA A stated staff were picking up trays during dinner that was when Resident #29 threw the coffee on Resident # 41 in the hallway. CNA A stated Resident # 29 got a fork from somewhere and tried to stab Resident #41 at the nurse's station. He did not go to her room. CNA A stated she told Resident # 29 he couldn't do that, and he listened. CNA A stated she took the fork and got rid of it. CNA A stated she wasn't aware of any further incidents. During an interview on 08/23/23 at 4:12 PM, RN D stated the incidents wasn't reported to her. RN D stated Resident# 41 is on the other side of facility. Record review of the policy on, Abuse Prevention Program, revised June 2021, indicated, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and injuries of unknown source shall be promptly reported to local, state and federal agencies and thoroughly investigated by Center management .The Administrator has the overall responsibility for the coordination and implementation of the Center's abuse prevention program .The alleged violation of abuse, neglect, exploitation or mistreatment will be reported immediately and reported no later than 2 hours if the alleged violation involves abuse. 2. Record review of the face sheet, dated 08/22/23, revealed Resident #29 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of COPD (chronic obstructive pulmonary disease is an inflammatory lung disease that causes obstructed airflow from the lungs), dementia (impaired memory) and Parkinson's disease (disorder that impacts the nervous system and movement). Record review of Resident #29's physician orders indicated lorazepam 1mg three times a day. Record review of the MDS assessment, dated 07/20/23, revealed Resident #29 was usually understood and usually understood others. Resident #29 had a BIMS score of 4 indicating severely impaired. Record review of the comprehensive care plan, edited 08/09/23, revealed Resident #29 had behavioral symptoms combative and elopement. The approach indicated Resident #29 became upset due to his sister came to the facility and was yelling at him and the resident's behaviors stem from his sister visits. Record review of LVN E's progress note dated 08/13/23 indicated Resident #29's family member was in his room throwing Resident #29's clothing outside of the room and yelling at Resident #29. LVN E indicated he notified the nurse supervisor. During an interview on 08/25/23 at 1:42 PM, LVN E stated he was completing his medication pass on 08/13/23 when Resident #29's family member came to the facility. LVN E stated he heard a loud voice and yelling coming from Resident #29's room. LVN E stated when he got closer to the room he observed clothing being thrown out of the room and Resident #29's family member was, Getting loud towards resident and he was upset. LVN E stated he told Resident #29's family member that he would handle the situation if she would tell him what the problem was and then he redirected Resident #29 towards the dresser. LVN E stated he then assisted Resident #29 with picking out what clothing he wanted to wear and stayed with Resident #29 until he calmed down. LVN E stated Resident #29's family member left the building quickly and he notified the DON and Administrator. During an interview on 08/24/23 at 10:23 AM, the DON reported she was not at the facility during the incident so she could not say what happen. The DON reported the Administrator was notified and she was responsible for determining if abuse needed to be reported. During an interview on 08/24/23 at 4:10 PM, the Administrator stated, I would not say the family member was yelling, but if she was yelling at him then it should have been reported. The Administrator stated she should have done an investigation and it should have been reported if it was indicated in the progress note that the family member was yelling at Resident #29. The Administrator stated the importance of reporting abuse was to keep the resident safe and the resident could have been harmed if the incident was not investigated. 3. Record review of a face sheet dated 8/25/2023 indicated Resident #39 was a [AGE] year-old-male who originally admitted on [DATE], then readmitted on [DATE] with the diagnoses of diffuse traumatic brain injury with loss of consciousness (injury to the brain resulting from a violent blow or jolt to the head or body), Bipolar disorder (mental illness that causes extreme mood swings from high to low), and other schizophrenia (a severe brain disorder that affects how people perceive and interact with reality, often causing hallucinations, delusions, and social withdrawal). Record review of a Quarterly MDS dated [DATE] indicated Resident #39 was understood by other and understood others. The MDS indicated in the Temporal Orientation section of the MDS indicated Resident #39 answered the month accurate within 5 days. The MDS indicated Resident #39 had no behaviors of inattention, disorganized thinking, or altered level of consciousness. The MDS in Section I indicated Resident #39's active diagnosis included traumatic brain dysfunction. The MDS indicated in Section N Resident #39 received antipsychotic medications on a routine basis. The MDS in Section O indicated Resident #39 did not receive any psychological therapy. During an anonymous telephone interview on 8/23/2023 at 3:04 p.m., the person said the incident between Resident #41 and Resident #29 occurred in July. The person indicated Resident #29 threw coffee on Resident #41's face and hit her on her arm. The person also indicated Resident #29 had attempted to stab Resident #41 with a fork. The person said it was hard to intervene with Resident #29 due to his aggressiveness. The person indicated the Administrator was not present when the incident occurred, but she was notified by phone. The person also said Resident #'s 41, 11, and 21 had voiced fearing retaliation with the Administrator. The person said numerous staff feared voicing any concerns or report abuse to the Administrator for fear of the loss of their jobs. The person said she had witnessed the Administrator yell at Resident #'s 12, 11, 21, and 10 when asking for their resident funds. The person indicated the Administer yelled for them to get out of her office. The person indicated on around July 23, 2023, or July 24, 2023, CNA B refused to change Resident #39 and began cursing him. The person indicated Resident #39 informed the Administrator of the allegation. The person indicated CNA B was allowed to continue to work with the residents and was never sent home for suspension. The person said CNA B boasted the Administrator had sent her a text indicating you are suspended, but I need you so If state comes hide then leave and do not let Resident #39 see you. During an anonymous telephone interview on 8/23/2023 at 3:30 p.m., the person indicated she was aware of the Administrator and other employees being allowed to verbally abuse the residents. The person indicated she had heard CNA s B and F tell residents to, sit your mother fucking ass down. The person said the Administrator would yell and curse at the residents to get out of her office. The person said the maintenance supervisor has told a resident to keep your fucking ass in this room. The person said employees have voiced concerns that the corporate regional director covers for the Administrator, so the employees feel as though there was no one to reach out to tell their concerns. The person said CNA B was allowed to work during her suspension period. The person said lastly the verbal abuse, and retaliation was so horrible at the facility. During a confidential group meeting on 8/22/2023 at 3:00 p.m., residents voiced concern of retaliation when reporting allegations. Record review of CNA A's Employee Timecard report dated 7/01/2023- 7/31/2023 time reporting period was created on 8/23/2023 by the BOM. The report indicated CNA A worked: 7/23/2023 from 6:34 a.m. to 2:02 p.m., there were no other punch times for this day. 7/24/2023 from 2:02 a.m. to 9:44 a.m. with a lunch of 9:44 a.m. to 10:30 a.m. then 10:30 a. m. - 2:17 p.m. 7/25/2023 from 7:34 a.m. to 2:05 p.m. there were no other punch times for this day. 7/26/2023 from 7:36 a.m. to 9:50 a.m. with a lunch 9:50 a.m. to 10:48 a.m. then 10:48 a.m. to 2:07 p.m. 7/27/2023 from 1:01 a.m. to 2:54 a.m. with a lunch 2:54 a.m. to 3:55 a.m. then from 3:55 a.m. to 7:39 a.m. then 2:59 p.m. to 8:11 p.m. During an interview on 8/24/2023 at 4:05 p.m., the DON said the Administrator was the abuse coordinator and she handled the abuse allegations. An attempted telephone interview on 08/25/23 at 4:33 p.m. with the Administrator, was unsuccessful. The Administrator was notified on 08/23/2023 at 1:05 PM, that an immediate jeopardy situation was identified due to the above failures. The Regional Director of Operations and Administrator was provided the immediate jeopardy template on 08/23/23 at 9:47 AM. The [NAME] was amended on 08/23/23 at 5:33 and returned to the he Regional Director of Operations and Administrator. The facility's plan of removal was accepted on 8/24/2023 at 3:04 p.m. and included: Action: Resident #29 was discharged from the facility on 8/22/2023 to a safe alternative location and will not return to the facility Date: 8/22/2023 Action: Administrator, Maintenance Director, and 2 CNAs have been suspended pending investigation to include verbal abuse towards resident (s). Date 8/23/2023 Action: Resident safe surveys completed on all residents that can answer the questions, remainder of the resident (who cannot answer) received head-to-toe assessments. Resident safe survey interviews to include fear of retaliation/comfortable reporting issues related. Date 8/23/2023 Action: Progress notes and event reports reviewed to ensure no other additional resident to resident altercations have occurred without appropriate interventions being place in the care plan, notifications made to psychiatric services and the MD. Date: 8/23/2023 by 3:00 p.m. Action: Employee (all) interviews conducted to include: Have you ever witnessed an employee physically, sexually, or verbally abuse a resident? (If yes proceed to further questions) If yes, who was the employee, who was the resident, and when about did this occur? Were there other witnesses to this event? Did you report this information to anyone and if so, to who? Date: 8/23/2023 Action: Residents involved in resident-to-resident altercations, identified in the previous 30-days, had their care plans reviewed to ensure proper interventions are in place. Any identified lacking proper interventions have been reviewed with the IDT and added. Date: 8/23/2023 at 3:00 p.m. Action: Education provided: All staff-abuse/neglect (key takeaway: thorough investigations and fully completing event reports, person centered care plan interventions, who the abuse coordinator is and when to report-Administrator and immediately, documentation/assessment/follow up.) All staff have been educated on the corporate compliance line. If the Administrator is unavailable, they can call the compliance line and/or notify the Director of Nursing. Nurses-Education provided regarding documentation of events/incidents in the medial record and documented follow up regarding the events. All staff to be in-serviced prior to working their next/first shift. Date 8/23/2023 by 4:00 p.m. All staff-Resident to resident altercation policy (key takeaway: how to respond and what order to respond-ensure resident safety by separating the residents, staying with the aggressor, and notify charge nurse and abuse coordinator). All Staff-Corporate Compliance Line education provided to all staff to understand if they report something and they feel as if appropriate action has not taken place, to reach out to the compliance line. Any issues with the abuse coordinator/administrator to reach out to the compliance line. Action: All resident has been given the corporate compliance line and informed they should call that number if they are fearful of retaliation within the facility and need t report abuse/neglect. Date: 8/24/2023 Action: 1:1 education provided to Administrator and Director of Nursing over the PL17-19 regarding abuse/neglect/reporting. Education regarding investigating allegations and implementing interventions. Date:8/23/2003 by 2:00 p.m. Action Item: Ad hoc QAPI meeting with Medical Director, Administrator, and Director of Nursing completed regarding IJ templates and Plan of Removal Date: 8/23/2023 by 2:00 p.m. Corporate compliance line is monitored by the corporate compliance office. This officer is not affiliated with the center. Once the facility is made aware of an allegation of abuse/neglect by an outside entity (such as our partners at HHSC and The Ombudsman) the facility will initiate an investigation and follow the abuse and neglect policy/protocol. On 8/25/2023 the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of Resident #29's medical record indicated he discharged on [DATE] to a sister facility. Record review of an employee memorandum indicated the Administrator was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of an employee memorandum indicated the Maintenance supervisor was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of an employee memorandum indicated the CNA B was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of an employee memorandum indicated the CNA F was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of the safe survey results for the residents. Record review of the employee Abuse Questionnaires. Record review of the education provided regarding documentation of events/incidents in the medical record and documented follow up regarding the events. Record review of the Abuse prevention program resident-to-resident altercations with retaliation towards residents was a form of abuse and could lead to termination. Record review of the 1:1 education provided to Administrator and Director of Nursing over the PL17-19 regarding abuse/neglect/reporting. Record review of the Ad Hoc QAPI meeting completed with the Medical Director was completed on 8/23/2023 at 2:00 p.m. with the physician, the Administrator, Regional Director of Operations, and the Survey Resource staff. Interview of Licensed Nurses (LVN C, LVN E, LVN H, LVN S, LVN AA, LVN DD, RN D, Infection Preventionist, ADON, DON) were performed. During the interviews all licensed nurses were able to correctly identity abuse, when to respond, when to report, who to report to, retaliation, protection, and documentation. Licensed Nurses were able to provide education regarding documentation of event or incident and follow up in the medical records. Interview of all staff (DA W, Cook P, Housekeeper X, Housekeeper Y, Housekeeper Z, NA BB, NA CC, CNA A, CNA B, CNA F, CNA T, CNA U, CNA V, MA L, AD, DM, DOR, BOM, and Housekeeping Supervisor) were performed. During the interviews all staff were able to correctly identify abuse, when to respond, when to report, who to report to, retaliation, protection, and documentation. Interview with the residents (Resident #3, #4, #5, #6, #8, #9, #10, #11, #12, #13, #14, #15, #16, #18, #20, #23, #24, #25, #27, #28, #30, #31, #32, #33, #34, #35, #36, #38, #39, #40, #41, #42, #43, #44, #247) were completed. All residents were able to identify the number they should call if they were fearful of retaliation within the facility and needed to report abuse or neglect. Interview with the DON was completed. The DON was able to correctly identify when and how to report abuse or neglect and how to investigate allegation and implement interventions. Record review of the facility's policy, titled, Abuse Prevention Program, last revised on 06/2021, indicated, . The Administrator is responsible for the overall coordination and implementation of our center's abuse prevention program policies and procedures. Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Our center will not condone any form of resident abuse or neglect. To aide in abuse prevention, all personnel are to report any signs and symptoms of abuse/ neglect to their supervisor and to the Abuse Prevention Coordinator immediately. Our center will protect residents from harm, reprisal, discrimination, or coercion during investigation of abuse allegation. Our center will provide protections for the health, warfare and rights of each resident residing in the center to ensure the reporting of crimes. Develop and implement polices and procedures to aid to our center in preventing abuse, neglect, or mistreatment of our residents. Identify and assess all possible incidents of abuse: investigate and report any allegations of abuse within timeframe as required by federal requirements; protect resident during abuse investigation; the Administrator will suspend immediately any employees who has been accused of resident abuse, pending the outcome of the investigation; 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's Administrator, or his/her designee, to the following person or agencies as required: On 8/25/2023 at 3:53 p.m., the Regional Director of Operations was notified the Immediate Jeopardy was removed; however, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not Immediate Jeopardy at a scope of a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. 46061

Based on observations, interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 2 residents' (Resident #6) reviewed for trauma-informed care. 1. The facility did not ensure Resident #30 had a trauma screening that identified possible triggers when Resident #30 had a history of trauma. 2. The facility did not ensure Resident #30 was protected from triggers of previous emotional trauma. Resident #297 yelled at Resident #30 in the dining room. Resident #297 was aggressive and had the same name as a man from Resident #30's past that triggered her previous emotional trauma. 3. The facility did not ensure trauma screenings were completed upon admission to the facility. These failures could put residents at an increased risk for severe psychological distress due to re-traumatization. The findings included: Record review of the face sheet, dated 08/21/23, revealed Resident #30 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of acute on chronic systolic (congestive) heart failure (progressive heart disease that affects pumping action of the heart muscles that can cause fatigue and shortness of breath). Record review of the MDS assessment, dated 06/14/23, revealed Resident #30 had clear speech and was understood by staff. The MDS revealed Resident #30 was able to understand others. The MDS revealed Resident #30 had a BIMS of 15, which indicated no cognitive impairment. The MDS revealed no behaviors or refusal of care. Record review of the comprehensive care plan, edited on 08/10/23, revealed Resident #30 was allegedly hit on the face by another resident. The interventions included: Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). The care plan did not address history of trauma. Record review of the event report, dated 07/09/23, revealed Resident #30 was hit on the left side of her face by another resident, which was unwitnessed. The event report revealed a head-to-toe assessment was completed. During an observation and interview on 08/21/23 at 11:39 AM, Resident #30 was walking down the hallway using a rolling walker. Resident #30 walked to the dining room entrance and turned around and backed out. Resident #30 stated she normally sat at the dining room table closest to the entrance, but she was not going to sit there because the black man [Resident #297], sitting at the end of the table, had hit her previously. Resident #30 stated he was not supposed to sit at the table with her, but he does sit there frequently. Resident #297 wheeled himself away from the dining table and Resident #30 stated she was going to sit down. Resident #30 sat at the dining room and was talking pleasantly with several other residents at the table. During an observation on 08/21/23 at 11:42 AM, Resident #297 wheeled himself back to the dining table sitting near Resident #30. Resident #30 appeared scared with her back turned toward Resident #297 and her eyes opened wide. Resident #297 was attempting to yell and accuse Resident #30 of getting her moved out of his room. Resident #30 continued to ignore Resident #297 and he attempted to reach out to touch Resident #30, unsuccessfully. Several staff members were observed at the dining table during the exchange with no interventions put into place. Resident #30 placed her head down on her hands and started audibly crying with tears rolling down her cheeks. CNA K stopped at the dining table and assisted Resident #30 back to her room. During an interview on 08/21/23 at 11:49 AM, CNA K stated Resident #30 was upset and wanted to go back to her room. CNA K stated she walked with Resident #30 back to her room to make sure she was okay. CNA K stated Resident #30 and several other ladies at the dining room table were afraid of Resident #297 because he talked loudly at them and had a history of hitting other residents. CNA K stated Resident #30 had her support dog in her room and she wanted to be near the dog because it made her feel safe. During an observation and interview on 08/21/23 at 11:57 AM, Resident #30 was sitting up on her bed with a support dog lying beside her. Resident #30 was smiling and visited pleasantly during the interview. Resident #30 stated she had a good relationship with Resident #297 when she first admitted to the facility. Resident #30 stated Resident #297 would come up to her in the dining room and ask her questions because no one could understand him. Resident #30 stated Resident #297 would become angry and started verbally abusing the staff. Resident #30 stated he then started becoming angry and saying mean things to her until one day he hit her. Resident #30 stated staff immediately kept them separated and a few days later Resident #297 was sent to the behavior hospital to have his medications adjusted. Resident #30 stated he was in the hospital for approximately half of July and August 2023. Resident #30 stated he just returned to the facility during the last week, and he was moved to another hallway. Resident #30 also stated signage was placed on the hall that stated do not enter to try and keep Resident #297 off the hallway. Resident #30 stated she did not want to be around Resident #297. Resident #30 stated Resident #297 came straight to the dining table she had been sitting at since returning to the facility. Resident #30 stated she had reported to staff that she felt uncomfortable sitting at the dining room table with Resident #297, but the staff told her Resident #297 had a right to sit at the table. Resident #30 stated she wanted to eat lunch with her friends but was unable to because he was sitting there, and she did not feel safe. Resident #30 stated she reported the situation to RN D, LVN H, ADON, DON, and some CNAs, whose name she was unable to recall. During an interview on 08/21/23 at 2:52 PM, Resident #11 stated she sat the dining room table with Resident #30 and Resident #297. Resident #11 stated Resident #297 had run off 3 of her friends at the dining room table. Resident #11 stated the staff told her You can't claim the table, anyone that wants to sit there can. Resident #11 stated she did not feel safe at the dining room table. Resident #11 stated Resident #297 could have gone off at any second and tried to hit them. Resident #11 stated Resident #297 had tried to hit her several times. Resident #11 stated the facility staff were aware of the situation and have not done anything. During an interview on 08/21/23 at 3:29 PM, LVN H stated no residents have reported feeling unsafe or uncomfortable sitting at the dining room table. LVN H stated Resident #30 became anxious a lot and stayed in her room most of the time. LVN H stated Resident #30 recently obtained her dog and that helped with her anxiety. LVN H stated Resident #30 went to the dining room for lunch and dinner and had not reported feeling unsafe or uncomfortable. LVN H stated she was unsure if Resident #30 and Resident #297 had been eating at the same dining table. LVN H stated Resident #297 had swung at Resident #30 a couple of months ago, but he left the facility for treatment. LVN H stated Resident #297 had his medications adjusted and his demeanor had improved after returning to the facility. During an interview on 08/21/23 at 3:50 PM, Resident #10 stated she was not afraid of Resident #297, but he was always causing trouble at the dining room table. Resident #10 stated Resident #297 talked loudly and got on her nerves. Resident #10 stated Resident #297 had just returned to the facility after being sent out for hitting another resident. During an interview on 08/21/23 at 4:18 PM, the ADON stated Resident #30 admitted from the hospital was pretty much independent with ADLs. The ADON stated Resident #30 was very sweet. The ADON stated Resident #30 had not had many anxiety issues since she obtained her dog. The ADON stated Resident #30 did have some confusion and was occasionally forgetful. The ADON stated Resident #30 had not told her that she felt uncomfortable or unsafe sitting at the dining table with Resident #297. The ADON stated Resident #30 and Resident #297 had an altercation a few months previously but had not had any issues since. The ADON stated no facility staff had reported that Resident #30 did not feel safe or comfortable. The ADON stated Resident #30 normally sat in the dining room for meals with no issues reported. The ADON stated it was reported today that Resident #30 had become upset in the dining room, but she was already out of the dining room and the CNA had comforted Resident #30. The ADON stated she was unaware if any other residents had concerns. The ADON stated the only concerns that had been reported on Resident #297 was he was too loud. During an interview on 08/21/23 at 4:27 PM, the DON stated Resident #30 made up stories every now and then. The DON stated not too long ago one of the residents allegedly hit Resident #30 and it was not observed. The DON stated the incident was not witnessed and it was not proven that it happened. The DON stated she was just made aware, within the last hour, that Resident #30 felt uncomfortable and unsafe in the dining room. The DON stated she was unsure what staff member reported it. The DON stated she was fixing to go talk to Resident #30 because that was what she would normally do. During an interview on 08/21/23 at 5:00 PM, the DON stated a safe survey was completed on Resident #30. The DON stated Resident #30 told her Resident #297 had not been aggressive or spoken rudely to her. The DON stated Resident #30 said the name [NAME] was a trigger for her and she did not deal well with strong, loud personalities because of past traumas. The DON stated she asked Resident #30 if a referral could have been made for psychological services and Resident #30 agreed. During an interview on 08/22/23 at 8:23 AM, Resident #30 stated the DON talked to her yesterday. Resident #30 stated she believed her past trauma was making her feel uncomfortable around Resident #297. Resident #30 stated she had a cousin who threatened to kill the whole family at a wedding, and he had the same name as Resident #297. Resident #30 stated she also remembered getting spanked by her grandfather at young age and the incident had made her fearful of men with strong personalities. Resident #30 stated the relationship with Resident #297 was okay until he hit her. Resident #30 stated she still did not want to sit at the dining room table with Resident #297 because she felt uncomfortable. Resident #30 stated she had never been asked by the facility if she had a history of trauma. During an interview on 08/22/23 at 9:48 PM, the DON stated trauma informed care observations were supposed to have been completed on admission to the facility. The DON stated the electronic charting system was not alerting anyone the observation needed to be completed. The DON stated none of the residents at the facility had a trauma screening completed. During an interview on 08/22/23 at 10:13 AM, the DON stated the Social Worker was responsible for completing the trauma screening on every resident upon admission to the facility. The DON stated the facility had not had a Social Worker since 10/20/22. The DON stated the electronic charting system had a feature that sent an alert to the dashboard that an observation was needed. The DON stated the electronic system was not sending an alert for the trauma screening assessment, so it was not being completed. The DON stated there was no process in place for monitoring to ensure the trauma screen observations were being completed. During an interview on 08/23/23 at 4:15 PM, RN D stated she normally cared for Resident #30. RN D stated Resident #30 had not been eating in the dining room as frequently. RN D stated Resident #297 did not typically sit at the same dining table as Resident #30. RN D stated Resident #30 was social and talkative. RN D stated Resident #30 was pleasant and cooperative and was cognitively intact. RN D stated Resident #30 or other staff member had not reported to her that she felt unsafe or uncomfortable eating lunch at the dining table. RN D stated Resident #30 could have reported that she felt unsafe with Resident #297 prior to being sent to the behavior hospital. RN D stated facility staff did move Resident #297's room away from Resident #30 as an intervention. RN D stated she was unaware of Resident #30's previous history of trauma. During an interview on 08/25/23 at 12:12 PM, the DON stated the system for completing and monitoring trauma screens was broken. The DON stated it was important to ensure trauma screens were completed so staff would know what triggers the residents with a history of trauma and to avoid those triggers to prevent re-traumatization and provide more individualized care. During an interview on 08/25/23 at 3:25 PM, the Director of Social Services stated she oversaw the facility's social services program. The Director of Social Services stated the process for trauma screens was that were to be completed upon admission to the facility. The Director of Social Services stated the facility was responsible for monitoring to ensure trauma screens were completed upon admission. The Director of Social Services stated she did complete random audits and assisted the facility in education training. The Director of Social Services stated none had been completed on trauma informed care since she had been with the company, approximately 2 months. The Director of Social Services stated it was important to ensure trauma screening was completed to identify past trauma and avoid resident triggers to prevent re-traumatization. During an attempted telephone interview on 08/25/23 at 4:33 PM to gather more information, the Administrator did not answer. No phone call was returned upon exit of the facility. Record review of the Trauma Informed Care policy, revised December 2019, revealed 3. Include trauma-informed care as part of the QAPI plan, so that needs, and problem areas are identified and addressed. The policy further revealed 6. Implement universal screening of residents for trauma. The policy revealed 1. As part of the comprehensive assessment, identify history of trauma or interpersonal violence when possible. Identifying past trauma or adverse experiences may involve record review or the use of screening tools.

Based on observation, interviews, and record review the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives and to choose the option he or she prefers for 3 of 5 residents reviewed for right to be informed. (Resident #12, #13, and #39) 1. The facility failed to ensure Resident #12 had a signed psychotropic consent form for ziprasidone (an antipsychotic medication). 2. The facility failed to ensure Resident #13 had signed a psychotropic consent form for Seroquel 100mg (antipsychotic). 3. The facility failed to obtain Resident #39's written consent prior to administration of an anti-psychotic medication. These failures could place residents at risk for treatment or services provided without informed consent. The findings included: 1. Record review of the face sheet, dated 08/25/23, revealed Resident #12 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of unspecified dementia with behaviors (group of symptoms that affects memory, thinking and interferes with daily life), bipolar disorder (serious mental illness characterized by extreme mood swings), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of the MDS assessment, dated 06/23/23, revealed Resident #12 had clear speech and was understood by staff. The MDS revealed Resident #12 was able to understand others. The MDS revealed Resident #12 had a BIMS of 10, which indicated moderately impaired cognition. The MDS revealed Resident #12 had trouble concentration on things, such as reading the newspaper or watching television 12 - 14 days during the 14-day look-back period. The MDS revealed Resident #12 had no behaviors or refusal of care. The MDS revealed Resident #12 received an antipsychotic medication 6 out of 7 days during the look-back period. Record review of the comprehensive care plan, edited on 08/18/23, revealed Resident #12 had a diagnosis of bipolar disorder and took medications. Record review of the physician order report dated 07/25/23 - 08/25/23, revealed Resident #12 had an order, which started on 05/12/23, for ziprasidone 80 mg (antipsychotic) for bipolar disorder. Record review of the Consent for Antipsychotic or Neuroleptic Medication Treatment form, signed by the physician on 04/28/23, revealed no resident or resident representative signature. During an observation and interview on 08/21/23 at 10:28 AM, Resident #12 was sitting up on the side of her bed with clean clothing and her hair combed neatly. Resident #12 stated she was aware she was taking an antipsychotic medication but was unable to remember if she signed a consent form. Resident #12 stated she had no adverse effects from her medication. During an interview on 08/25/23 at 10:07 AM, LVN C stated she was unsure who was responsible for completing the psychotropic medication consents. LVN C stated if a new order was received for a psychotropic medication, she relied on upper management to obtain the consent. LVN C stated it was important to obtain consent prior to administering a psychotropic medication so the residents were aware of the risks and what they were taking. LVN C also stated it was important so the residents could decide to take the medication if they wanted to. During an interview on 08/25/23 at 12:21 PM, the DON stated she was responsible for filling out the psychotropic consent forms and getting them signed by the physician and the resident or responsible party. The DON stated the staff would have made her aware of the new orders, she would have filled out the consent form and sent it to the physician for a signature, then had the resident or responsible party sign. The DON stated the medications were being administered without the consent form being signed per the facilities current process. The DON stated she was thankful it was brought to her attention, and she was now reviewing the current process for obtaining consents. The DON stated it was important to obtain psychotropic consents prior to medication administration so the residents were not given a medication they did not consent to. 2. Record review of the face sheet, dated 08/22/23, revealed Resident #13 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of schizophrenia (affects a person's ability to think, feel and behave clearly), COPD (chronic obstructive pulmonary disease is an inflammatory lung disease that causes obstructed airflow from the lungs), and bipolar (a disorder associated with episodes of mood swings). Record review of the MDS assessment, dated 07/28/23, revealed Resident #13 had clear speech and was understood by staff. The MDS revealed Resident #13 was able to understand others. The MDS revealed Resident #23 had a BIMS of 11, which indicated moderately impaired. The MDS revealed Resident #13 had delusions and received antipsychotic medication for the last 7 days and on a routine basis. Record review of the comprehensive care plan, dated 09/20/22, revealed Resident #13 exhibited mood state and to take meds as ordered. Record review of the comprehensive care plan, dated 09/20/22, revealed Resident #13 exhibited behavioral symptoms and to always ask for help if resident becomes abusive or resistive. Record review of the comprehensive care plan, dated 09/20/22, revealed Resident #13 exhibited psychotropic drug use and to do gradual dose reduction and monitor for side effects. Record review of the order summary report, dated 08/22/23, revealed Resident #13 had an order, which started on 09/08/22, for Seroquel 100mg twice a day (antipsychotic). Record review of the uploaded consent files, dated 06/18/23, revealed Resident #13 had no psychotropic consent form for the antipsychotic medication Seroquel. During an observation and interview on 08/21/23 at 10:01 AM, Resident #13 was sitting in his wheelchair watching television, no behavior issues observed. Resident #13 stated he did not know if he signed a consent form to take the medication. During an interview on 08/24/23 at 10:23 AM, the DON stated she was responsible for making sure the psychotropic consent forms were signed prior to taking the medication. The process was to have the order first, then get the form signed and to begin giving the medication. The importance was to make sure the medication was reviewed for gradual dose reduction and the consent was a requirement. The DON stated if there was no consent, then Resident #13 could have received a medication that he had not agreed to. 3. Record review of a face sheet dated 8/25/2023 indicated Resident #39 was a [AGE] year-old-male who originally admitted on [DATE], then readmitted on [DATE] with the diagnoses of diffuse traumatic brain injury with loss of consciousness (injury to the brain resulting from a violent blow or jolt to the head or body), Bipolar disorder (mental illness that causes extreme mood swings from high to low), and other schizophrenia (a severe brain disorder that affects how people perceive and interact with reality, often causing hallucinations, delusions, and social withdrawal). Record review of the consolidated physician's orders dated 7/25/2023 - 8/25/2023 indicated Resident #39 had an order for quetiapine (antipsychotic medication) 200 mg at bedtime. The physician's order indicated Resident #39's physician prescribed this medication on 2/15/2023. Record review of the comprehensive care plan dated 2/15/2023 and edited on 8/18/2023 indicated Resident #39 used psychotropic drugs and would benefit from the use without side effects. The care plan failed to address Resident #39 consented to the use of Seroquel. Record review of a Quarterly MDS dated [DATE] indicated Resident #39 was understood by other and understood others. The MDS indicated in the Temporal Orientation section of the MDS indicated Resident #39 answered the month accurate within 5 days. The MDS indicated Resident #39 had no behaviors of inattention, disorganized thinking, or altered level of consciousness. The MDS in Section I indicated Resident #39's active diagnosis included traumatic brain dysfunction. The MDS indicated in Section N Resident #39 received antipsychotic medications on a routine basis. The MDS in Section O indicated Resident #39 did not receive any psychological therapy. Record review of Resident #39's electronic medical record on 8/24/2023 indicated there was not a consent for the use of quetiapine (antipsychotic medication). During an interview on 8/24/2023 at 4:05 p.m., the DON said there was not a consent for the use of Resident #39's quetiapine (antipsychotic medication). When the DON was asked had the nursing staff administered the quetiapine without the consent of Resident #39, she replied looks like we have. During an interview on 825/2023 at 10:07 a.m., LVN C said she was unaware of who was responsible for getting the consents for psychotropic drug use. LVN C said she relied on the nurse management team to obtain the consent. LVN C said it was important for residents to know what medications they are receiving, and the risks of the medication. An attempted telephone interview on 08/25/23 at 4:33 p.m. with the Administrator, was unsuccessful. Record review of a Medication Monitoring policy dated 1/2022 indicated .Procedures 10. A resident and/or representative has the right to be informed about the resident's condition; treatment options, relative risks, and benefits of treatment, required monitoring, expected outcomes of the treatment; and has the right to refuse care and treatment. 33249 46061

Based on interview, and record review the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through the means other than a postal service for 8 of 9 confidential residents reviewed for weekend mail delivery. The facility failed to ensure residents received their mail on the weekend. This failure could place residents at risk for not receiving mail in a timely manner that could result in a decline in resident's psychosocial well-being and quality of life. Findings included: During a confidential group interview 8 of the 9 residents stated mail was not being distributed on Saturdays. They stated mail did not get delivered until Monday morning by the BOM. During a telephone interview on 8/24/2023 at 8:25 a.m., the Postmaster stated mail was delivered on Saturdays. During an interview on 08/244/2023 at 8:55 a.m., the BOM stated the residential locked mailbox was located outside the facility. The BOM stated to her knowledge she was the only one that had a key to the mailbox. The BOM stated the mail was not available to the residents on Saturdays. The BOM stated on Monday she would obtain the mail from the mailbox and distributed to the residents. The BOM stated she was unaware of the requirements for the residents to have access to their mail on Saturdays. The BOM stated residents had a right to receive their mail in a timely manner. The BOM said this failure could affect their rights. An attempted telephone interview on 08/25/23 at 4:33 p.m. with the Administrator, was unsuccessful. Record review of the facility's policy titled Resident Rights last revised on 02/2021, indicated, Employees shall treat all residents with kindness, respect, and dignity 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: cc. access to a telephone, mail, and email

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 3 of 16 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]A) reviewed for physical environment. The facility did not ensure the bathroom light worked in room [ROOM NUMBER]. The facility did not ensure the bathroom light worked in room [ROOM NUMBER]. The facility failed to ensure scratches on the wall in room [ROOM NUMBER]A were repaired. The facility failed to ensure the light cover in room [ROOM NUMBER]A was not broken. The facility failed to ensure the 4 chairs in the sitting area were in good repair. The facility failed to ensure the florescent dining room lights were free from dead insects. The facility failed to ensure the patio was clean and free from a weather boxed gazebo. The facility failed to ensure the linen storage room was free from garbage on the floor. The facility failed to ensure resident wheelchairs were clean and free of debris. The facility failed to ensure large furniture was discarded properly. The facility failed to ensure the sidewalk was free from an air conditioning unit. These failures could place the residents at risk for decreased quality of life and infection due to unsanitary conditions. Findings included: 1. During an observation on 08/21/23 at10:01 AM, the bathroom light would not turn on in room [ROOM NUMBER]. During an observation on 08/23/23 at 3:09 PM, the bathroom light would not turn on in room [ROOM NUMBER]. During an observation on 08/21/23 at10:29 AM, the bathroom light would not come on in room [ROOM NUMBER]. During an interview on 08/22/23 at 12:24 PM, CNA B stated she was aware that the bathroom light did not work in room [ROOM NUMBER], and she had reported it to the Maintenance Supervisor on 08/18/23. CNA B stated she was not aware of the light not working in room [ROOM NUMBER]'s bathroom. During an interview on 08/22/23 at 12:05 PM, CNA K stated she was aware of the light not working in room [ROOM NUMBER]'s bathroom and had reported it to the Maintenance Supervisor verbally. CNA K was not able to recall the date she reported the light to the Maintenance Supervisor. CNA K stated she was not aware of the light not working in room [ROOM NUMBER]'s bathroom. During an interview on 08/23/23 at 3:12 PM, RN D stated she was not aware of the bathroom light not working in room [ROOM NUMBER] and room [ROOM NUMBER]. RN D stated the process was to log the issue in the maintenance book and to verbally notify the Maintenance Supervisor as well. RN D stated the importance of having adequate lighting was for safety and could result in a fall hazard. During an interview on 08/23/23 at 5:00 PM, LVN C stated she did not know about the bathroom lights not working in room [ROOM NUMBER] and room [ROOM NUMBER]. LVN C stated, Adequate light could help with seeing things like water in the floor and it was a safety issue. LVN C stated if the bathroom light was not working it could result in residents getting hurt. During an interview on 08/22/23 at 12:36 PM, the Maintenance Supervisor stated he was not aware of the bathroom lights not working. The Maintenance Supervisor stated you could no longer get light bulbs for the residents' bathrooms, and he would have to rewire the fixtures. During an interview on 08/24/23 at 10:23 AM, the DON stated she was not aware of the bathroom lights not working and she expected them to work properly. The DON stated the importance of proper lighting was to make sure residents could see in the bathroom and not fall or get hurt. The DON stated the process was to notify the Maintenance Supervisor immediately and it should have been fixed immediately due to safety. During an interview on 08/24/23 at 4:10 PM, the Administrator stated she did not know the bathroom lights were not working in room [ROOM NUMBER] and room [ROOM NUMBER] and the importance was for the residents to be independent. 2. During an observation on 08/21/2023 at 11:28 AM, the light cover above the bed in room [ROOM NUMBER]A had a hole in it exposing the bulb where the hole was, and there were multiple downward scrapes across the wall next to the bed. During an observation on 08/22/2023 at 10:00 AM, the light cover above the bed in room [ROOM NUMBER]A had a hole in it exposing the bulb where the hole was, and there were multiple downward scrapes across the wall next to the bed. During an observation on 08/23/2023 at 12:07 PM, the light cover above the bed in room [ROOM NUMBER]A had a hole in it exposing the bulb where the hole was, and there were multiple downward scrapes across the wall next to the bed. During an observation on 08/24/2023 at 10:33 AM, the light cover above the bed in room [ROOM NUMBER]A had a hole in it exposing the bulb where the hole was, and there were multiple downward scrapes across the wall next to the bed. During an interview on 08/24/2023 at 3:50 PM, the Maintenance Supervisor said he was aware of the broken light cover and scratches on the wall in room [ROOM NUMBER]A. The Maintenance Supervisor said the staff had notified him verbally a couple weeks ago that the light cover and the scratches on the wall in room [ROOM NUMBER]A needed to be repaired. The Maintenance Supervisor said he had not gotten around to fixing the light cover and the scratches on the wall. The Maintenance Supervisor said he was responsible for repairing the residents' rooms. The Maintenance Supervisor said if a room needed repairs the staff could log it in the maintenance book or tell him verbally. The Maintenance Supervisor said it was important to repair damages to the rooms so the residents would not be harmed. During an interview on 08/25/2023 at 1:22 PM, the DON said she was not aware the light cover was broken and there were scratches on the wall in room [ROOM NUMBER]A. The DON said the Maintenance Supervisor was responsible for repairing the residents' rooms. The DON said it was important for damages to residents' rooms to be fixed so the residents were safe, and they could feel good about themselves and their home. During an attempted phone interview on 08/25/2023 at 4:36 PM, the Administrator did not answer the phone. Record review of the facility's Maintenance log dated between 5/2/23-8/03/23, did not reveal a maintenance request form for room [ROOM NUMBER], room [ROOM NUMBER], or room [ROOM NUMBER]A. 3. During an observation on 8/21/2023 at 9:55 a.m., there were 4 chairs with orange colored vinyl material to the cushions. The vinyl covering was worn and peeling away leaving a black material exposed. The surface of these chairs would not allow for thorough cleaning. During an observation on 8/21/2023 at 1:00 p.m., the dining room florescent light covers had numerous dead white colored insects inside of them. The florescent lights were over the resident dining tables. During an observation on 8/21/2023 at 1:05 p.m., the resident courtyard/patio had a very large cardboard box. The cardboard box appeared discolored and weathered. During an observation on 8/24/2023 at 8:42 a.m., the linen storage room had 2 crumbled Kleenex tissues lying on the floor, 1 plastic bag, and 2 pairs of used gloves (wadded together inside out) lying on the floor. During an observation and interview on 8/24/2023 at 8:45 a.m., the ADON visualized Resident #9's wheelchair. The ADON said the undercarriage was dirty with a white buildup underneath. The ADON said wheelchairs were supposed to be washed on the night shift. The ADON said she had not seen the wheelchair washing schedule and was unsure if the schedule was completed by rooms or by halls. The ADON said the managers monitor for dirty resident equipment during morning rounds. During an observation on 8/24/2023 at 10:40 a.m., there was a window air conditioner sitting half on the sidewalk and half on the ground going to the laundry. During an observation on 8/24/2023 at 10:41 a.m., a couch was sitting on its side on the grass next to the garbage dumpsters. During an interview on 8/24/2023 at 3:35 p.m., the maintenance supervisor said he pulled the air conditioner out of room [ROOM NUMBER] on last Friday and replaced it. The maintenance supervisor said he needed to wash the air conditioner out to ensure it worked well. The maintenance supervisor said he was responsible for cleaning the lights in the dining room. He said he had just not checked them. The maintenance supervisor said insects could fall in the resident's food. The maintenance supervisor said the large box on the patio was a gazebo. The maintenance supervisor said the company was supposed to send help to put the gazebo together, but no one has come to complete the project. The maintenance supervisor said the sofa was thrown in the dumpster. The maintenance supervisor said he was unsure why the sofa was lying on the ground and not in the dumpster. An attempted telephone interview on 08/25/23 at 4:33 p.m. with the Administrator, was unsuccessful. Record review of the Homelike Environment policy, last revised in February 2021, indicated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment; b. comfortable (minimum glare) yet adequate (suitable to the task) lighting c. clean bed and bath linens that are in good condition . 46061 33249

Based on interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 3 of 16 residents (Resident #12, Resident #34, and Resident #247) reviewed for MDS assessment accuracy. The facility did not ensure Resident #12's MDS assessment was accurately coded to reflect her level II PASRR status for mental illness. The facility failed to accurately reflect Resident #34's use of oxygen. The facility failed to accurately document Resident #247's tobacco use. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: 1. Record review of the face sheet, dated 08/25/23, revealed Resident #12 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of bipolar disorder (serious mental illness characterized by extreme mood swings) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of the MDS assessment, dated 12/23/22, indicated Resident #12 was not considered by the state level II PASRR process to have serious mental illness. Record review of the comprehensive care plan, edited on 08/11/23, revealed Resident #12 was identified as having mental illness PASRR positive status related to bipolar disorder and was receiving services. Record review of level II PASSR evaluation, dated 02/18/22, revealed Resident #12 met the PASRR definition of mental illness. During an interview on 08/25/23 at 11:03 AM, the Regional Reimbursement Manager stated the MDS should have accurately reflected the level II PASRR status. The Regional Reimbursement Manager stated she performed random audits to ensure MDS assessments were completed accurately. The Regional Reimbursement Manager stated she was unsure why Resident #12's comprehensive MDS assessment was not accurately coded to reflect the level II PASRR status. The Regional Reimbursement Manager stated it was important to ensure the MDS was accurately coded to paint of a clear picture of the resident's status and help develop the plan of care. Record review of the Resident Assessment Instrument 3.0 User's Manual, last revised October 2019, revealed Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness . 2. Record review of a face sheet dated 08/22/2023, indicated Resident #34 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), non-pressure chronic ulcer of skin of other sites with unspecified severity (long-time open sore on the skin), and asthma (chronic disease that affects millions of people worldwide, making it hard to breathe and causing coughing, wheezing, and chest tightness). Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #34 was understood and understood others. The MDS assessment indicated Resident #34 had a BIMS score of 15, which indicated he was cognitively intact. The MDS assessment did not indicate the use of oxygen therapy in the last 14 days for Resident #34. Record review of the care plan last edited 08/10/2023 indicated Resident #34 had a diagnosis of asthma and was at risk for shortness of breath and respiratory failure. Resident #34 had approaches that indicated to administer oxygen for unrelieved shortness of breath. Record review of the Physician Order Report dated 07/22/2023-08/22/2023 indicated Resident #34 had an order for oxygen at 2 liters per minute via nasal cannula continuously every shift with a start date of 12/19/2022. Record review of the Medication Administration Record dated 06/01/2023-06/30/2023, indicated Resident #34 received oxygen via nasal cannula at 2 liters per minute as ordered for the entire month of June. During an observation on 08/21/2023 at 10:52 AM, Resident #34 was wearing oxygen via nasal cannula at 5 liters per minute. Resident #34 said he wore it all the time because it helped him breathe better. 3. Record review of a face sheet dated 08/22/2023 indicated Resident #247 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (problems with your metabolism cause brain dysfunction), malignant neoplasm of skin (skin cancer), and chronic kidney disease stage 3 (moderate damage to the kidneys and loss of kidney function). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #247 was able to make himself understood and usually understood others. The MDS assessment indicated Resident #247 had a BIMS score of 6, which indicated his cognition was severely impaired. The MDS assessment did not indicate Resident #247 used tobacco. Record review of the care plan last reviewed on 08/08/2023 did not indicate Resident #247 used tobacco or smoked cigarettes. Record review of the Smoking Risk (Acuity) completed on 08/01/2023 indicated Resident #247 used cigarettes and was a safe smoker. The Smoking Risk (Acuity) indicated to initiate the plan of care. During an interview on 08/21/2023 at 11:41 AM, Resident #247 said he smoked. During an interview on 08/25/2023 at 10:55 AM, the Regional Reimbursement Manager said Resident #34's use of oxygen should have been coded on his MDS assessment. The Regional Reimbursement Manager said Resident #247's tobacco use should have been on the MDS assessment because he smoked. The Regional Reimbursement Manager said she performed random audits of the MDS assessments, and she tried to hit the high points like the ADLs, medications, therapy, physician's orders, and behaviors when she reviewed the MDS assessments. The Regional Reimbursement Manager said it was important for the MDS to be coded correctly to pain a clear picture of the resident and what was going on with the resident to care plan appropriately. During an interview on 08/25/2023 at 11:24 AM, the MDS Coordinator said she was aware Resident #247 smoked, and Resident #34 used oxygen. The MDS Coordinator said she guess she missed it. The MDS Coordinator said it was important to accurately code on the MDS assessment because it directed the plan of care and payment for the facility. During an interview on 08/25/2023 at 12:31 PM, the DON said she tried to review the MDS assessments for accuracy when she signed them, but the MDS Coordinator was responsible for completing the MDS assessments and she signed them. The DON said Resident #247's use of tobacco should have been on his MDS assessment, and Resident #34's use of oxygen should have been on the MDS assessment. The DON said it was important for the MDS to be completed accurately because it assisted with developing the plan of care. During an attempted phone interview on 08/25/2023 at 4:36 PM, the Administrator did not answer the phone. Record review of the facility's policy titled, Certifying Accuracy of the Resident Assessment, revised November 2019, indicated, Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment . 47006

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carryout activities of daily living received services to maintain grooming and personal hygiene for 3 of 5 residents (Resident #'s 9, 23, and 38) reviewed for ADLs. The facility did not ensure Resident #9 and #38 was routinely showered. The facility did not ensure Resident #23 was shaved. The facility did not ensure Resident #38 had routine nail care. These failures could place residents at risk for not receiving services/care and a decreased quality of life. Findings included: 1)Record review of a face sheet dated 8/25/2023 indicated Resident #9 was a [AGE] year-old male who originally admitted on [DATE] and readmitted on [DATE] with the diagnoses of need of assistance with personal care, morbid obesity, and lack of coordination. Record review of the consolidated physician orders dated 7/25/2023 - 8/25/2023 indicated Resident #9 was to have nail care on shower days of Tuesday, Thursday, and Saturday on the 6:00 a.m. - 2:00 p.m. shift. The most recent Significant Change MDS dated [DATE] indicated Resident #9 was understood and understood others. The MDS indicated Resident #9 had a BIMS score of 15 indicating his cognition was intact. The MDS indicated Resident #9 did not reject care. The interview for daily preferences on the MDS indicated Resident #9 said choosing a tub bath, shower, bed bath, or sponge bath was very important to him. The MDS indicated Resident #9 required extensive assistance of two staff for transfers, and extensive assistance of one staff with bathing. The MDS indicated Resident #9 was frequently incontinent of urine, and frequently incontinent of bowel. Record review of the comprehensive care plan dated 8/09/2023 indicated a general care plan indicated the following care task will be documented in the computerized program. The goal of the care plan was the resident would perform the follow tasks at their highest practicable level. The approach/intervention included Resident #9 prefers to take his bath/shower on Tuesday, Thursday, and Saturday on the 6:00 a.m. - 2:00 p.m. shift. Record review of the shower sheets provided for Resident #9 indicated he was provided a shower on 6/22/2023, 6/24/2023, and 8/24/2023. Record review of Resident #9's point of care history for bathing indicated: 8/22/2023: unanswered 8/19/2023: not done 8/17/2023: not done 8/15/2023: unanswered 8/12/2023: not done 8/10/2023: not done 8/08/2023: not done 8/05/2023: not done 8/03/2023: unanswered 8/01/2023: not done During an observation on 8/22/2023 at 11:51 a.m., Resident #9's sheets were brown in color and the area smelled of a strong urine odor. During an observation on 8/22/2023 at 3:35 p.m., Resident #9's sheets continued to appear brownish in color and smelled of a strong urine odor. During an observation and interview on 8/23/2023 at 9:15 a.m., Resident #9 said he had not been bathed yet this week. Resident #9 said he could not even remember the last time he had been bathed. Resident #9 smelled of urine and his bed sheets were stained brown in color and smelled of a strong urine odor. During an observation and interview on 8/23/2023 at 12:22 p.m., Resident #9's sheets were stained brown in color. The stain was from the middle of the bed to 12 inches from the end of the mattress. Resident #9's incontinent pads smelled of urine and had black flying insects crawling on the bad. The Administrator was in the room and was asked to view the bed condition. The Administrator shined her phone light on the bed, refused to answer questions, and left the room. During an observation and interview on 8/24/2023 at 8:30 a.m., Resident #9 was sitting in the common area of the nursing home. Resident #9 said he has not yet been bathed this week. Resident #9 continues to smell of urine. Resident #9 said he had asked the Administrator about moving his room to room [ROOM NUMBER]. When asked why do you want to move rooms? Resident #9 responded I would be on B side of the room, maybe I would get bathed on the B side. During an interview on 8/24/2023 at 8:34 a.m., the corporate nurse Resident #9 would be showered today, and she would see if he could move to room [ROOM NUMBER]. During an interview on 8/25/2023 LVN C said nurses were responsible for ensuring bathing was completed. LVN C said the CNAs completed the bathing tasks. LVN C said the process was if the resident refused a bath, then they should tell the nurse. LVN C said then the nurse would follow up. LVN C said she would try and monitor by looking at the residents. LVN C said she could tell by their appearance if they had been bathed. LVN C said Resident #9 preferred his bath on the 2:00 p.m. - 10:00 p.m. shift but she was not allowed to change the shower sheets. LVN C said she made the DON aware of Resident #9's preferences. LVN C said when a resident had not received their showers, they could feel bad and mess with their mental health. 2) Record review of a face sheet dated 8/25/2023 indicated Resident #38 was [AGE] year-old male who was admitted on [DATE] with the diagnoses of non-traumatic subarachnoid hemorrhage (bleeding in the brain caused by a rupture of an intracranial aneurysm), dementia (memory loss disease), and convulsions (sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles and associated especially with brain disorders). Record review of a quarterly MDS dated [DATE] indicated Resident #38 was understood and understood others. The MDS indicated Resident #38's BIMS score was 3 indicating he had severe cognitive impairment. The MDS indicated Resident #38 had no behaviors nor had he rejected any care. The MDS indicated Resident #38 required extensive assistance of one staff member for personal hygiene, and he required total assistance of two staff with bathing. Record review of the consolidated physician orders dated 7/25/2023 - 8/25/2023 indicated Resident #38 had a physician's order dated 7/13/2023 indicating nail care on shower days of Tuesday, Thursday, Saturday on 6:00 a.m. to 2:00 p.m. shift. Record review of the comprehensive care plan dated 1/06/2023 indicated Resident #38 had an ADL function care plan with the goal of Resident #38 would achieve maximum functional mobility. The care plan approaches included dressing and grooming with a to be determined amount of assistance and bathing/hygiene amount of assistance was to be determined as well. The care plan, the following task will be documented in the computerized site with a goal of Resident #38 would perform the following tasks at their highest practicable level. The care plan approaches were Resident #38 preferred to be bathed/showered on Tuesday, Thursday, and Saturday on the 6:00 a.m. - 2:00 p.m. shift. The care plan did not address nail care. Record review of requested bath sheets provided by the DON indicated Resident #38 had a bed bath on 6/22/2023 and 6/24/2023. The DON did not provide shower sheets for July. During an observation on 8/21/2023 at 10:03 a.m., Resident #38 was lying in bed. Resident #38 was not interviewable but he was able to show me both of his hands. Resident #38's fingernails were trimmed but had brown colored material underneath them. Resident #38's hair appears greasy looking with white flaky material resembling dandruff. During an observation on 8/23/2023 at 9:22 a.m., Resident #38's hair remains greasy appearing with white flakey material resembling dandruff. Resident #38's pillowcase seems dingy, discolored, and had loose hairs all over the pillowcase. Resident #38 continues to have brown material underneath his fingernails. During an observation on 8/24/2023 at 8:39 a.m., Resident #38 continues to have brown material underneath his fingernails. Resident #38's hair appeared greasy looking with white flakey material resembling dandruff throughout. During an interview with the ADON on 8/24/2023 at 12:05 p.m., the ADON provided one bath sheet for Resident # 38. The ADON said she had not had time to look for more bath sheets. During an interview on 8/25/2023 at 1:30 p.m., the DON said the nurses know about the shower book with shower sheets the CNAs sign when providing showers. The DON said she was unsure why Resident #'s 9 and 38 had not been bathed. The DON said not bathing could cause skin issues and she wanted their skin clean. 3)Record review of consolidated physician orders dated 08/22/23 indicated Resident #23 was a [AGE] year-old male, readmitted to the facility on [DATE] with a diagnoses including unspecified dementia (progressive memory impairment), hypertension (force of blood against the artery walls is too high) and chronic systolic congestive heart failure (the left heart ventricle is weak). Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #23 made himself understood and was understood by others. The MDS indicated Resident #23 had a BIMS score of 99 indicating he was unable to complete the interview. The MDS did not indicate Resident #23 rejected care. The MDS indicated Resident #23 required extensive one person assist with personal hygiene. Record review of the most recent comprehensive care plan edited 8/10/23 indicated Resident #23 refused to shower more than once weekly. The approach indicated to encourage resident to shower according to the shower schedule. Record review of Resident #23's shower records for July 03, 2023, to August 21, 2023, were not filled out. During an observation and interview on 08/21/23 at 10:29 AM, Resident #23 had long facial hair and stated he had been asking staff to shave his face for a week. During an observation and interview on 08/22/23 at 11:20 AM, Resident #23 had long facial hair and stated he was scheduled for a bath and shave today. Resident #23 stated it made him feel better if he got shaved because he liked to look half decent, and it made him feel better to just be shaved. During an interview on 08/22/23 at 12:05 PM, CNA K stated she had offered Resident #23 a bath and he refused. CNA K does not remember asking Resident #23 about shaving, but stated he normally told her if he wanted his face shaved. CNA K stated she had not noticed Resident #23's long facial hair yesterday when she offered him a shower. CNA K stated the process in place for showering and grooming was to update the shower sheet daily with the resident refusal or if they received. CNA K stated the shower sheets were kept at the nurse's station, CNA K stated if a resident refused a bath, then CNAs were responsible for notifying the charge nurse. During an interview on 08/22/23 at 12:24 PM, CNA B stated Resident #23 often refused his bath. CNA B stated if a resident refused a bath, she would notify the charge nurse and DON. CNA B stated the DON would later talk to the resident to see if they would allow staff to bathe them. During an interview on 08/23/23 at 3:12 PM, RN D stated she was notified verbally every time a resident refused a bath, and she would talk to them. RN D stated Resident #23 refused baths all the time and would notify CNA's when he needed to be shaved. RN D stated CNAs offered to shave Resident #23 on his scheduled bath days. During an interview on 08/24/23 at 10:23 AM, the DON stated if residents refused to take a shower or shave, then she would talk to the resident and try to get them to change their mind. During an interview on 08/24/23 at 4:10 PM, the Administrator stated the process for showers and shaving would need to be discussed with the ADON and DON. The Administrator stated she expected showers and grooming to be done. An attempted telephone interview on 08/25/23 at 4:33 p.m. with the Administrator, was unsuccessful. Record review of an Activities of Daily Living (ADLs) supporting dated March 2018 indicated residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care). Record review of a Bath, Shower/Tub policy and procedure dated February 2018 indicated the purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Record review of a Fingernails/Toenails, care of policy dated February 2018 indicated the purpose of this procedure was to clean the nail bed, to keep nails trimmed, and to prevent infections General Guidelines 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. 46061

Based on observations, interviews, and record reviews the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 4 of 16 (Resident #27, Resident #29, Resident #9 and Resident #38) residents reviewed for monitoring and supervision. The facility failed to properly store wound cleanser leaving it on Resident #'s 9 and 38's bedside tables. The facility failed to properly store wound cleanser leaving it on Resident #'27's bathroom floor. The facility failed to provide supervision and interventions as evidenced by Resident #29's wandering. This failure could place residents at an increased risk for injury and for future resident-resident altercation. The findings included: 1). Record review of a face sheet dated 08/22/2023 revealed, Resident #27 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of schizophrenia (mood disorder characterized by abnormal thought processes and unstable mood), major depression (loss of interest in activities) and pain, unspecified. Record review of Resident #27's Quarterly MDS dated [DATE] indicated she was able to make herself understood and had the ability to understand others. The MDS indicated Resident #27 had a BIMS score of 15 for intact cognition. During an observation on 08/21/23 at 10:49 AM, Resident #27 had a bottle of wound care spray located in her bathroom floor next to the toilet. Observation made of Resident #27's bilateral feet amputated and a bandage on her right ankle. During an observation and interview on 08/22/23 at11:09 AM, Resident #27 had a bottle of wound care spray on the bathroom floor. Resident #27 stated the bottle of wound cleaner had been sitting in the floor since she was admitted to the facility and belong to the last resident that resided in that room. Resident #27 stated that staff had never told her that wound cleaner needed to be in a locked area. Resident #27 stated residents had wandered in her bathroom in the past but never touched the wound care spray that she knew of. During an interview on 08/22/23 at 12:05 PM, CNA K stated she had never gone in Resident #27's bathroom before to notice the wound care spray because resident was independent. During an interview on 08/22/23 at 12:24 PM, CNA B stated she never went in Resident #27's bathroom because resident was independent of care. CNA B stated she had never noticed the wound care spray. During an interview on 08/23/23 at 3:12 PM, RN D stated she was not aware of the wound care spray in Resident #27's bathroom floor and it should not had been in there. RN D stated she made rounds every two hours into each resident room and did not look in the bathroom floor. RN D stated the importance of keeping the wound care spray locked up was to prevent other residents from accidentally drinking it. RN D stated other residents could have gotten hurt if they drunk the wound care spray and she was responsible for checking the rooms to make sure it was picked up. During an interview on 08/24/23 at 10:23 AM, the DON stated, Whomever did the admission for Resident #27 was responsible for making sure the wound care spray was not in the floor. The DON stated she was not aware of the wound care spray being in the bathroom until yesterday and it should not have happened. The DON stated the importance of picking up wound care spray was to prevent other residents from drinking it or spraying it in their eyes. The DON stated it could have resulted in a resident being hospitalized due to drinking the wound care spray. During an interview on 08/24/23 at 4:10 PM, the Administrator stated she expected the wound care spray to be picked up and not in Resident #27's bathroom floor. The Administrator stated other residents could have gotten a hold of the wound care spray and hurt themselves. 2). Record review of the face sheet, dated 08/22/23, revealed Resident #29 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of COPD (chronic obstructive pulmonary disease is an inflammatory lung disease that causes obstructed airflow from the lungs), dementia (impaired memory) and Parkinson's disease (disorder that impacts the nervous system and movement). Record review of Resident #29's physician orders indicated lorazepam 1mg three times a day. Record review of the MDS assessment, dated 07/20/23, revealed Resident #29 was usually understood and usually understood others. Resident #29 had a BIMS score of 4 indicating severely impaired. Record review of the comprehensive care plan, edited 08/09/23, revealed Resident #29 had behavioral symptoms combative and elopement. The approach indicated to always ask for help if resident becomes abusive or resistive. Resident #29 was care planned for behavioral symptoms and the approach was to move resident to a room that had a window on the secure side of the facility opening to the patio area and 1:1 monitoring during times of attempts of leaving. The care plan indicated another approach was to always ask for help if resident became abusive/resistive. Resident #29 was care planned for dementia with agitation. The approach included medication as ordered. Record review of Resident #29's progress note dated 04/16/23 indicated Resident #29 was caught by another staff member allegedly hitting another resident. Record review of Resident #29's progress note dated 05/11/23 indicated Resident #29 was extremely combative and aggressive with staff. Resident #29 was in an empty room attempting to open the window to get out and did not respond well to redirection. The Medical Director was notified, and Resident #29 was given Ativan 0.5mg twice daily routinely. Record review of Resident #29's progress note dated 7/27/23 indicated Resident #29 was next to the open window in his room and redirected to the lobby. Record review of Resident #29's progress note dated 7/28/23 indicated Resident #29 had aggressive behavior manifested from the earlier shift without increased lethargy or somnolence. Resident #29 continued to have exit seeking behaviors. Record review of Resident #29's provider investigation dated 8/10/23 indicated Resident #29 hit another resident in the chin while trying to take his cigarettes from him. Record review of Resident #29's provider investigation dated 8/14/23 indicated Resident #29 went into another resident's room without permission and attempted to take his cell phone, stole a Pepsi. and Smacked the glasses off of a residents face. Resident #29 was taken to the lobby to keep the residents separated. New order received to increase Ativan and pending psych referral. Record review of the 15min supervision checks dated 8-14-23 in the provider investigation report. During an observation and interview on 08/22/23 at 11:08 AM, Resident #29 was in bed watching TV. Resident #29's room window faced the patio area that was closed in with fencing. Resident was not interviewable. During an interview on 08/22/23 at 12:05, CNA K stated Resident #29 wandered into all of the resident's rooms and staff had to redirect resident. CNA K stated if Resident #29 got agitated, staff wound take turns watching him. CNA K stated 2 CNAs worked during the day shift and staffing was never increased for 1:1 supervision. During an interview on 08/22/23 at 12:24 PM, CNA B stated, Staff had to keep an eye on Resident #29 since he got into stuff. CNA B stated staff had to redirect Resident #29 daily and they were often busy on the halls having 2 CNAs on day shift and needed extra help for supervising Resident #29. During an interview on 08/22/23 at 10:52 AM, the MDS Coordinator stated staff tried to monitor/supervise Resident #29, but no other interventions were put in place. The MDS Coordinator stated she would often approach Resident #29 in the hall and ask him what he was looking for and she would get him something to drink to help with redirection. The MDS Coordinator stated Resident #29 was easily redirected out of other residents' rooms and was pending approval for transfer to another facility. During an interview on 8/24/23 at 10:23 AM, the DON stated Resident #29's behaviors had been discussed in the IDT meetings and he was placed on supervision and pending transfer. An interview was attempted on 08/25/23 at 4:33 PM and 4:36 PM with the Administrator and was not successful. 3). Record review of a face sheet dated 8/25/2023 indicated Resident #9 was a [AGE] year-old male who originally admitted on [DATE] and readmitted on [DATE] with the diagnoses of need of assistance with personal care, morbid obesity, and lack of coordination. The most recent Significant Change MDS dated [DATE] indicated Resident #9 was understood and understood others. The MDS indicated Resident #9 had a BIMS score of 15 indicating his cognition was intact. During an observation on 8/22/2023 at 11:04 a.m., there was a bottle of wound cleanser sitting on Resident #9's bedside table. During an observation on 9/22/2023 at 3:35 p.m., the bottle of wound cleanser remained sitting on Resident #9's bedside table. 4). Record review of a face sheet dated 8/25/2023 indicated Resident #38 was [AGE] year-old male who was admitted on [DATE] with the diagnoses of non-traumatic subarachnoid hemorrhage (bleeding in the brain caused by a rupture of an intracranial aneurysm), dementia (memory loss disease), and convulsions (sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles and associated especially with brain disorders). Record review of a quarterly MDS dated [DATE] indicated Resident #38 was understood and understood others. The MDS indicated Resident #38's BIMS score was 3 indicating he had severe cognitive impairment. Record review of the comprehensive care plan dated 1/06/2023 indicated Resident #38 had an ADL function care plan with the goal of Resident #38 would achieve maximum functional mobility. During an observation on 8/21/2023 at 11:04 a.m., a bottle of wound cleanser was sitting on the bedside table of Resident #38. During an observation and interview on 8/22/2023 at 4:05 p.m., LVN C was shown the bottles of wound cleanser sitting on the bedside tables of Resident #38 and Resident #9. LVN C said the wound cleansers should be stored securely to prevent harm if swallowed, and/or sprayed in the eyes of a resident. LVN C removed the bottles of wound cleanser from the rooms. LVN C said all staff were responsible for proper storing of medications. Attempted telephone interview on 08/25/23 at 4:33 p.m. with the Administrator, was unsuccessful. Record review of a Safety and Supervision of Residents policy and procedure dated July 2017 indicated the facility strived to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Facility-Oriented Approach to Safety 1. The facility-oriented approach to safety addresses risks for groups of residents .4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. Resident Risks and Environmental Hazards 1. Due to their complexity and scope certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include: .F. Poison Control. During an interview on 08/22/23 at 12:50 PM, Survey Resource revealed the facility did not have a policy on accidents and hazards policy. 33249

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's needs for 3 of 16 residents (Resident #'s 29, 44, and 247) reviewed for care plans. 1.The facility failed to ensure Resident #247 care plan indicated he smoked. 2. The facility failed to refer Resident #247 to the ENT. 3. The facility did not ensure Resident #44's weight bearing status was care planned. 4.The facility did not ensure Resident #44's desired weight loss was care planned. 5.The facility did not implement a comprehensive care plan to address Resident #29's combative and aggressive behavior. These failures could place residents at risk for unmet care needs and decreased quality of care. Findings included: 1). Record review of a face sheet dated 08/22/2023 indicated Resident #247 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (problems with your metabolism cause brain dysfunction), malignant neoplasm of skin (skin cancer), and chronic kidney disease stage 3 (moderate damage to the kidneys and loss of kidney function). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #247 was able to make himself understood and usually understood others. The MDS assessment indicated Resident #247 had a BIMS score of 6, which indicated his cognition was severely impaired. The MDS assessment did not indicate Resident #247 used tobacco. Record review of the care plan last reviewed on 08/08/2023 did not indicate Resident #247 used tobacco or smoked cigarettes. Record review of the Smoking Risk (Acuity) completed on 08/01/2023 indicated Resident #247 used cigarettes and was a safe smoker. The Smoking Risk (Acuity) indicated to initiate the plan of care. Record review of Resident #247's discharge summary indicated, he was being discharged to the nursing home and he was to keep an appointment with the ENT in 5 days. During an interview on 08/21/2023 at 11:41 AM, Resident #247 said he was waiting to be taken to the doctor to be evaluated for the cancer to his ear and his nose. Resident #247 said he smoked. During an interview on 08/22/2023 at 11:41 AM, the DON said she was not aware Resident #247's hospital discharge summary indicated he needed an appointment with the ENT in 5 days. The DON said the Medical Director did all the referrals. The DON said it was important for the residents to be referred as necessary for them to get appropriate treatment. During an interview on 08/24/2023 at 11:19 AM, the Medical Director said he decided to postpone the referral to ENT N because he had to gather all of Resident #247's clinical record to send to ENT N. The Medical Director said his office had sent ENT N Resident #247's records and a referral for an appointment. The Medical Director said Resident #247 did not have an appointment with ENT N. During an interview on 08/24/2023 at 11:45 AM, ENT N's front desk receptionist said Resident #247 did not have an appointment. The front desk receptionist said she was able to see the ENT N saw Resident #247 while he was hospitalized , but there was no referral from the Medical Director. The Front Desk Receptionist said they had received an oncology report from the Medical Director on 08/04/2023, but not a referral for an appointment with ENT N. During an interview on 08/25/2023 at 11:20 AM, the MDS Coordinator said she had not yet completed the care plans, but she was not allowed to implement the care plan because she was an LVN. The MDS Coordinator said Resident #247's care plan should have included that he smoked. The MDS Coordinator said it was important for his care plan to include that he smoked to make sure he was safe to smoke, and everyone knew that he smoked. During an interview on 08/25/2023 at 12:45 PM, the DON said she completed a lot of the care plans. The DON said the MDS coordinator started the care plan, and she developed it. The DON said Resident #247's care plan should have included that he smoked. The DON said she did not know why it was not in his care plan. The DON said it was important to include in the care plan that Resident #247 so that staff knew if he was eligible to smoke or if he failed the smoking assessment or if he needed a smoking apron. 2) Record review of the face sheet, dated 08/22/23, revealed Resident #29 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of COPD (chronic obstructive pulmonary disease is an inflammatory lung disease that causes obstructed airflow from the lungs), dementia (impaired memory) and Parkinson's disease (disorder that impacts the nervous system and movement). Record review of Resident #29's physician orders indicated lorazepam 1mg three times a day. Record review of the MDS assessment, dated 07/20/23, revealed Resident #29 was usually understood and usually understood others. Resident #29 had a BIMS score of 4 indicating severely impaired. Record review of the comprehensive care plan, edited 08/09/23, revealed Resident #29 had behavioral symptoms combative and elopement. The approach indicated to always ask for help if resident becomes abusive or resistive. Resident #29 was care planned for behavioral symptoms and the approach was to use diverse activities for calming and soothing resident with simple conversation. Resident #29 was care planned for dementia with agitation. The approach included medication as ordered. Record review of Resident #29's progress note dated 04/16/23 indicated Resident #29 was caught by another staff member allegedly hitting another resident. Record review of Resident #29's progress note dated 8/10/23 indicated Resident #29 hit another resident in the chin trying to take his cigarettes from him. Record review of Resident #29's progress note dated 8/14/23 indicated Resident #29 went into another resident's room without permission and attempted to take his cell phone, stole a Pepsi. and Smacked the glasses off of a residents face. During an observation and interview on 08/22/23 at 11:08 AM, Resident #29 was in bed watching TV. Resident #29's room window faced the patio area that was closed in with fencing. Resident was not interviewable. During an interview on 08/22/23 at 10:52 AM, the MDS Coordinator stated she had entered the room on 8/14/23 after Resident #29 had smacked the glasses off a resident's face and stole a Pepsi. The MDS Coordinator stated there was ice scattered all over the floor and a pair of glasses on the floor. The MDS Coordinator stated staff tried to supervise Resident #29 when they could, but no other interventions were put in place. During an interview on 08/22/23 at 4:45 PM, the Corporate MDS Coordinator stated any resident-to-resident altercations should have been added to the current care plan and the DON was responsible for making sure the care plans were correct. The Corporate MDS Coordinator stated Resident #29's care plan was revised on 08/9/23 but it was not person centered to add resident-to-resident altercations. The Corporate MDS Coordinator stated the importance of updating care plans was to help staff understand the interventions that needed to be put in place. During an interview on 08/24/23 at 10:23 AM, the DON stated she was not aware of Resident #29's combative or aggressive behavior towards other residents. The DON stated the combative behavior should have been care planned and she was responsible. The DON stated the importance of updating care plans was to give direction to the nurses and CNA's because they follow care plans to provide resident care. The DON stated, If care plans were not updated, it could have led to more resident incidents. During an interview on 08/24/23 at 4:10 PM, the Administrator stated she expected care plans to have been updated after incidents. The Administrator stated the importance of updating care plans was so staff had interventions in place for resident care and to prevent other incidents from happening. 3). Record review of a face sheet dated 8/25/2023 indicated Resident #44 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of fractured (broken) left ankle and left fibula (outer and usually smaller of the two bones between the knee and the ankle), lymphedema (a build-up of fluid in soft body tissues when the lymph system is damaged or blocked), and protein calorie malnutrition (the state of inadequate intake of food as a source of protein, calories, and other essential nutrients). Record review of the consolidated physician's orders dated 7/25/2023 - 8/25/2023 for Resident #44 did not reveal her non-weight bearing status to the left leg/ankle. Record review of the comprehensive care plan dated 8/08/2023 indicated Resident #44 had a pathological bone fracture to the fibula. The goal of the care plan was Resident #44 would achieve her highest level of mobility. The interventions of activity level per MD order, avoid direct and indirect pressure to area, keep call light within reach, physical therapy referral, remind resident not to ambulate without any assistance, and teach Resident #44 safety measures to prevent falls and injury. During an observation and interview on 8/21/2023 at 10:12 a.m., Resident #44 was lying in bed with a boot to her left leg/foot. Resident #44 said she had a broken ankle and was non-weight bearing until her next appointment with the surgeon. During a telephone interview on 8/24/2023 at 11:24 a.m., the orthopedic clinic nurse indicated Resident #44 was on a non-weight bearing status until her next appointment in September 2024. Record review of Resident #44's weights provided by the DON on 8/24/2023 at 10:45 a.m., indicated Resident #44's weight on admission was 435 pounds, on 8/08/2023 her weight was 407.5, and on 8/22/2023 her weight was 405.5. The DON said she was unaware if the dietician was aware of Resident #44's weight loss. The DON said she had not care planned the desired weight loss. Record review of Resident #44's comprehensive care plan dated 8/24/2023 at 11:25 a.m., the corporate nurse wrote Resident #44 had experienced an expected weight loss related to lymphedema being treated with diuretic therapy (after surveyor intervention). The goal of the care plan was Resident #44 would maintain stable weight without significant adverse effects. Resident #44's care planned interventions included give Lasix (diuretic medication) as ordered, monitor meal intake, and notify the MD if decline in intake occurs, and monitor weights weekly for 4 weeks. During a telephone interview on 8/24/2023 at 2:23 p.m., the dietician said she was unaware Resident #44 had a weight loss. The dietician said she had only the admission weight to review when she was in the facility this week. During an interview on 8/25/2023 at 10:55 a.m., the MDS staff member indicated the acute care plans were completed by the nursing IDT (intradisciplinary team). The MDS staff member said Resident #44's weight loss was identified yesterday. The MDS staff member indicated she believed the care plan of pathological bone fracture with avoid direct and indirect pressure to area was the care plan for no weight bearing status. An attempted telephone interview on 08/25/23 at 4:33 p.m. with the Administrator, was unsuccessful. Record review of the policy and procedure Comprehensive Person-Centered Care Plans dated December 2020 indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet he resident's physical, psychosocial and functional needs is developed and implemented for each resident. The services provided or arranged by the facility, as outlined by the comprehensive care plan, are provided by qualified persons, are culturally competent and trauma informed. 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive, person-centered care plan will: g. Incorporate identified problem areas, h. Incorporate risk factors associated with identified problems. Record review of a Weighing and Measuring the Resident policy and procedure dated March 2011 indicated the purposes of this procedure are 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 to the resident, and to provide a baseline height and in order to determine the ideal weight of the resident Documentation . The following information should be recorded in the residents medical record: 1. The date and time the procedure was performed. 2. The name and title of the individual (s) who performed the procedure. #. The height and weight of the resident Reporting 1. Report significant weight loss/weight gain to the nurse supervisor. 46061 46892

Based on observation, interview, and record review, the facility failed to implement their written policies and procedures to prohibit neglect and abuse for 7 of 13 residents reviewed for abuse. (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7). The facility failed to ensure Resident #1 did not experience humiliation when LVN A threw his nebulizer treatments (medication used to help breathe better) at him. The facility failed to ensure Resident #2 did not feel scared of retaliation and intimidated by staff. The facility failed to ensure Resident #2 did not feel humiliated when CNA D rudely refused to get her out of bed. The facility failed to ensure Resident #3 did not feel humiliated and disrespected when LVN A stated, I can't stomach this wound, and NA B told him not to be needy. The facility failed to ensure Resident #4 did not feel humiliated and scared of retaliation when LVN A told him, I'm done with you. The facility failed to ensure Resident #5 was not scared to report when the CNAs yelled at her because she was scared, she would be yelled at again. The facility failed to ensure Resident #6 was not scared to report LVN A after she told him he acted like a three-year-old and he was sorry. The facility failed to ensure Resident #7 did not feel intimidated and belittled when CNA C yelled and cursed at her. The facility abuse coordinator failed to ensure staff were able to report allegations of abuse without fear of reprisal. This failure resulted in an Immediate Jeopardy (IJ) identified on [DATE] at 3:47PM. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. This failure could place residents at risk of unreported abuse, neglect, exploitation and a decreased quality of life. Findings included: 1. Record review of a face sheet dated [DATE] indicated Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, with agitation (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and panic disorder episodic paroxysmal anxiety (intense feeling of fear and discomfort that begins abruptly and rises to a maximum within minutes). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #1 was understood and was able to understand others. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #1 had no delusions or hallucinations. The MDS assessment indicated Resident #1 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #1 required supervision for bed mobility, transfers, eating, toilet use, and limited assistance for dressing and personal hygiene. Record review of the Physician Order Report dated [DATE] - [DATE] indicated Resident #1 had an order for Ipratropium Bromide and Albuterol (medication used to help breathe better) 0.5mg/3ml liquid; 0.5mg/3ml, 1 vial every 4 hours at 12:00 AM, 04:00 AM, 08:00 AM, 12:00 PM, 04:00 PM, 08:00 PM. Record review of a care plan last revised [DATE] indicated a problem that Resident #1 exhibited verbally abusive behavioral symptoms such as others were threatened, calling 911, screamed at and cursed at staff related to wanting a breathing treatment due to anxiety and shortness of breath with interventions which included convey an attitude of acceptance toward the resident, maintain a calm environment and reassure the resident by checking his oxygen saturations to assure within normal limits and observe for anxiety and attempt to have resident purse breath. During an interview on [DATE] at 9:44 AM, Resident #1 said LVN A was rude to everybody. Resident #1 said he had asked her for a breathing treatment because he felt like he could not breathe. Resident #1 said LVN A grabbed ,d+[DATE] of the nebulizer treatments (medication used to help breathe better) and threw them at him. Resident #1 said he could not remember the date that it happened. Resident #1 said he had gotten used to her being rude that way. Resident #1 said LVN A made him feel humiliated, and he was scared of her retaliating. Resident #1 said he was scared LVN A would get back at him by making him wait until the end for his medicine even if he was the first one in line. Resident #1 said in the past LVN A had made him wait for his medication because she was mad at him. Resident #1 was unable to provide exact dates. Resident #1 said he had told the office staff he was scared LVN A would retaliate against him when he was questioned about the incident with LVN A. Record review of the Provider's Investigation Report dated [DATE] indicated the incident with Resident #1 and LVN A occurred on [DATE]. The Provider's Investigation Report indicated the facility took the following actions post investigation: completed a Head-to-Toe Assessment, Resident Interviews, Staff Interviews, Safe Surveys and Culture sensitivity/Abuse and Neglect Inservice dated [DATE]. The Culture sensitivity/Abuse and Neglect Inservice was not signed by LVN A which indicated she was not in-serviced. Record review of a Performance Improvement Plan implemented on [DATE] indicated LVN A had a 30-day timeline for performance improvement or termination would occur. 2. Record review of a face sheet dated [DATE] indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right sided weakness and paralysis after a stroke), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. The MDS assessment indicated Resident #2 had a BIMS score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #2 had no delusions or hallucinations. The MDS assessment indicated Resident #2 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #2 did not exhibit rejection of care. The MDS assessment indicated Resident #2 required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and supervision for eating. Resident #2 was totally dependent for transfers and bathing. Record review of Resident #2's care plan last revised [DATE] indicated she had a problem of resident must be lifted mechanically and interventions included staff to get resident up out of bed daily ,d+[DATE] times a week and required 2 staff members at all times to use the mechanical lift. Resident #2's care plan indicated she had a history of anxiety and interventions included to allow resident to voice thoughts. Resident #2's care plan indicated that she required 2 staff assistance depending on type of bath or shower, required, ,d+[DATE] staff for dressing/grooming, and ,d+[DATE] staff to provide incontinent care, and her preferred time for bath/shower was once a day on Tuesday, Thursday, and Saturday 2:00 PM- 10:00 PM. Resident #2's care plan indicated to allow her to express her feelings, allow her to participate in daily care and decision/goal making, and to listen carefully and be non-judgmental. Resident #2's care plan did not indicate she refused care. Record review of the electronic health record indicated Resident #2 was discharged to another facility on [DATE]. During an interview on [DATE] at 09:56 AM, the ombudsman said on [DATE] while in the facility she heard screaming and walked into Resident #2's room. The Ombudsman said CNA D yelled at Resident #2, What do you want? Resident #2 said she wanted to get out of bed. CNA D said to Resident #2, you know it ain't your day to get out of bed. Resident #2 said, I know it is not my shower day, but I want to get out of bed to play bingo. CNA D replied to Resident #2 and said, I don't know what to tell you. The Ombudsman said she went and reported this incident to the ADON the same day she witnessed it. During an interview on [DATE] at 3:06 PM, Resident #2 said she moved to a different nursing home approximately 5 days ago. Resident #2 said if she would have stayed at the other facility she would have died . Resident #2 said she had gone without a shower for 10 days, and she told the staff everyday she wanted a shower. Resident #2 said she was told there were not enough CNAs. Resident #2 said CNA C was horrible, cursed and screamed at her, and it broke her heart because she could hear her scream and curse at the resident across the hall from her. Resident #2 said she told him she would jerk him out of his bed, and she could not understand why she talked to everyone like that. Resident #2 said that there were plenty of other residents at the facility that had heard CNA C say the same things to other residents. Resident #2 said when CNA C and another CNA had scrubbed her leg and left a bruise while giving her a shower. Resident #2 said she reported CNA C to the DON, and that did nothing but make CNA C retaliate against her. Resident #2 said when CNA C would go into her room to leave a meal she would not speak to her or make eye contact with her. Resident #2 said the CNAs always told her she could not get up and she could not get showers because they did not have enough staff. Resident #2 said the CNAs told her not to use the call light. Resident # 2 said her family member was very upset and reported this to the DON. Resident #2 said she had to lay in her feces from 11 AM to 7 PM. Resident #2 said she told NA B three times and he kept saying he would be right with her. Resident #2 said that was the most degraded and awful feeling she ever had. Resident #2 was teary eyed. Resident #2 said her family members came to visit her and she was laying in shit. Resident #2 said this messed with her emotions and she would never forget it. Resident #2 said the facility never had the right briefs and her husband would try to supply them so she could get out of bed more. Resident #2 said if her husband did not provide the appropriate size briefs the facility would apply a smaller size and it was causing her belly area to break down. Resident #2 said the CNAs were intimidating, and CNA D was always short and rude. Resident #2 said it was a yucky situation and she felt when she reported the CNAs they retaliated. 3. Record review of a face sheet dated [DATE] indicated Resident #3 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), non-pressure chronic ulcer of skin of other sites with unspecified severity (long-time open sore on the skin), and post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #3 was understood and understood others. The MDS assessment indicated Resident #3 had a BIMS score of 15, which indicated he was cognitively intact. The MDS assessment indicated Resident #3 had no delusions or hallucinations. The MDS assessment indicated Resident #3 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #3 exhibited rejection 1 to 3 days in the 7-day lookback period. The MDS assessment indicated Resident #3 required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene, supervision for eating, and total dependence for bathing. The MDS assessment indicated Resident #3 had an open lesion other than ulcers, rashes, and cuts. Record review of Resident #3's care plan last revised [DATE] indicated he exhibited signs and symptoms of anxiety and agitation and was receiving clonazepam (medication used to treat anxiety), interventions included to allow the resident to voice his thoughts and feelings and to explore with resident the reason for anxiety. Resident #3's care plan indicated to allow him to participate in daily care and decision/goal making and to listen carefully and be non-judgmental. Resident #3's care plan indicated he had open lesions related to a history of chronic abdominal wounds and had interventions which included to cleanse area to left abdomen with normal saline, pat dry, apply calcium alginate with silver (absorbent dressing applied to wounds), cover with pads twice a day and cleanse area to left inguinal area with normal saline, pat dry and apply calcium alginate silver twice daily. During an interview and observation on [DATE] at 1:28 PM, Resident #3 said NA B told him not to be needy, referring to Resident #3 using his call light to request assistance, between 7 AM and 9 AM because these were the busiest times of the day. Resident #3 was unable to provide the exact dates. Resident #3 said LVN A did not perform wound care on him when she worked at night. Resident #3 said he had complained to the Administrator and all the other nurses that LVN A was not performing wound care on him. Resident #3 said after he complained to the Administrator, the ADON accompanied LVN A to watch her perform the wound care. While the ADON was observing the wound care, LVN A told the ADON, I cannot stomach this wound. Resident #3 said the incidents with NA B and LVN A made him feel humiliated and disrespected. Resident #3 was teary during the interview. 4. Record review of Face Sheet dated [DATE] indicated Resident #4 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Chronic obstructive pulmonary disease (a lack of adequate blood supply to brain cells), other seizures (burst of uncontrolled electrical activity between brain cells), unsteadiness on feet, weakness, pain, dementia (brain impairment of memory loss and judgement), schizoaffective disorder (combination of mood disorder such as depression and bipolar disorder), hypertension, (increased blood pressure), chronic kidney disease stage 3 (mild to moderate kidney damage - less likely to filter). Record review of quarterly MDS dated [DATE] indicated Resident #4 understood others and made himself understood. The MDS indicated Resident #4 was moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #4 did not reject evaluation or care. The MDS indicated Resident #4 required supervision and setup with transferring, dressing and limited assistance with personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #4 was care planned for psychosocial well-being. The care plan indicated interventions included Resident #4 was allowed to express feelings, allowed to participate in daily care and decision/goal making, adhere to customary routines, keep topics of conversation light and cheerful, listen carefully and non-judgmental. Resident #4 was care planned for cognitive loss related to dementia. The care plan indicated interventions included Resident #4 was approached in a calm manner, anticipate needs and observe for non-verbal cues. During an interview and observation on [DATE] at 10:49 AM, Resident #4 said LVN A told him she was done with him in a very hateful way. Resident #4 said LVN A was very bully over the residents. Resident #4 said LVN A hurt his feelings and it made him cry. Resident #4 said LVN A was bullying other patients that night and the rest of the patients came forward after him and wrote their statements. Resident #4 did not remember when the incident occurred. Resident #4 said he was very much intimated by LVN A. Resident #4 was teary when recounting the incident. 5. Record review of the Face Sheet dated [DATE] indicated Resident #5 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Transient cerebral ischemic attack (a lack of adequate blood supply to brain cells), infections of the skin and subcutaneous tissue, Chronic Obstructive pulmonary disease (a lack of adequate blood supply to brain cells), Hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the boy that can affect the arms, legs, facial muscles) affecting left dominant side. Record review of the quarterly MDS dated [DATE] indicated Resident #5 had moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #5 did not reject evaluation or care. The MDS indicated Resident #5 required limited assistance with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #5 had episodes of anxiety and had Ativan (medication used to decrease anxiety). The care plan indicated interventions included Resident #5 was allowed to voice thoughts and feelings and to explore with resident the reason for anxiety. During an interview on [DATE] at 2:40 PM, Resident #5 said the CNAs screamed at her, but she was not able to recall who the CNAs were or the date the incident happened. Resident #5 said she was scared to report the CNAs because she did not want them to yell at her again. 6. Record review of Face Sheet dated [DATE] indicated Resident #6 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Diffuse traumatic brain injury, Excoriation (skin picking) disorder, Paraplegic (paralysis of the lower body), Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury, Nausea (urge to vomit), Bipolar Disorder (changes in mood and energy levels), Pain, reduced mobility. Record review of quarterly MDS dated [DATE] indicated Resident #6 understood others and made himself understood. The MDS indicated Resident #6 was cognitively intact with a BIMS score of 15. The MDS indicated Resident #6 did not reject evaluation or care. The MDS indicated Resident #6 required extensive care with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #6 had an activities of daily living (ADL) self-care performance deficit related to paraplegia. The care plan indicated interventions included Resident #6 required assistance x2 for bath/shower 3 times weekly. During an interview and observation on [DATE] at 5:05 PM, Resident #6 said LVN A told him he acted like a 3-year-old. Resident #6 said after LVN A told him he acted like a 3-year-old he said, I'm sorry, and LVN A responded, Yes, you are sorry. Resident #6 said this made him feel intimidated. Resident #6 said he had not reported this to the facility staff because he was scared LVN A would retaliate against him. Resident #6 could not recall when the incident occurred. Resident #6 was tearful during the interview. 7. Record review of the Face Sheet dated [DATE] indicated Resident #7 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Chronic Obstructive Pulmonary Disease (a lack of adequate blood supply to brain cells), Pain, Muscle Weakness, Pressure ulcer of other site - stage 4, Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury), Partial traumatic amputation at knee level - left lower leg, Dementia (brain impairment of memory loss and judgement), DM Type 2 (a chronic condition that affects the way the body processes blood sugar), Personal history of transient ischemic attack (TIA) (a temporary condition that mimics a stroke), cerebral infarction (a lack of adequate blood supply to brain cells) without residual deficits. Record review of the quarterly MDS dated [DATE] indicated Resident #7 understood others and made herself understood. The MDS indicated Resident #7 was cognitively intact with a BIMS score of 13. The MDS indicated Resident #7 did not reject evaluation or care. The MDS indicated Resident #7 required extensive care with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #7 had an activities of daily living (ADL) self-care performance deficit related to amputation at knee level. The care plan indicated interventions included Resident #7 required assistance x2 for bath/shower 3 times weekly. During an interview on [DATE] at 11:19 AM, Resident #7 said CNA C yelled and cursed at her. Resident #7 said CNA C told her, I don't care who you tell, I have been working here for [AGE] years. Resident # 7 said when the CNAs yelled or cursed at her it made her feel intimidated and belittled. Resident #7 did not give exact dates of when this happened. Resident #7 said she had told the DON Resident #7 yelled and cursed at her, but nothing had been done. During an interview on [DATE] at 12:57 PM, CNA D said she worked the 6AM - 2PM shift since December of 2022. CNA D said she had never had any problems with any of the residents, had not been complained on, or accused of any allegations. CNA D said she had never told a resident they needed to stay in the bed. CNA D said no residents had been upset on my hall to my knowledge. CNA D said if a resident was upset with her, she would deescalate by finding out why and go get the DON. CNA D said she did not know the abuse coordinator's name because they switch positions often. CNA D said she had not been rude to residents or told the residents not to use their call lights. CNA D said she had not witnessed any of the staff members being rude to anyone. CNA D said she had never been rude or yelled at Resident #2. During an interview on [DATE] at 2:15 PM, CNA F said no residents reported abuse to her and she had not had any problems with any of the residents. CNA F said, I have not witnessed any type of abuse to the residents by any staff member. During an interview on [DATE] at 02:04 PM, CNA E said she had worked at the facility for one year and worked the 6AM - 2PM shift. CNA E said she had never been suspended or accused of yelling at a resident. CNA E said she never yelled at Resident #2 for staying on the call light. CNA E said she never told a resident they could not get out of bed. CNA E said when Resident #2 asked to get up, we would get her up. CNA E said if Resident #2 asked to get up, I got her up even if it was not her get up day. During an interview on [DATE] at 08:59 AM, Anonymous Staff Member #1 said sometimes the facility was short staffed and it fueled the fire on tolerance with the CNAs. Anonymous Staff Member #1 said the CNAs voices did get raised. Anonymous Staff Member #1 said CNA F raised her voice at the residents. Anonymous Staff Member #1 said the CNAs raising their voices at the residents made her feel uncomfortable. Anonymous Staff Member #1 said she reported these incidents to the ADON on multiple occasions. Anonymous Staff Member #1 said the ADON's response was she was doing in-services with the CNAs. Anonymous Staff Member #1 said, If I was the resident and the CNAs talked to me that way, I would feel intimidated by them and I would be scared to ask them for things. Anonymous Staff Member #1 said she did not feel like she had the authority to effectively delegate tasks or reprimand the CNAs for their actions because she felt like she had no authority. Anonymous Staff Member #1 said there were no consequences for the CNAs actions. Anonymous Staff Member #1 said the CNAs did not answer the call lights. Anonymous Staff Member #1 said the residents should have autonomy and be able to make decisions and the staff should accommodate their requests. During an interview on [DATE] at 2:41 PM, NA B said he had worked at the facility for 3 months on all shifts. NA B said, I have never told a resident not to use their call light between 7 AM and 9 AM because it was busy. NA B said, I never witnessed another CNA be rude or yell. NA B said, In some situations you have to treat people different, they cannot all be treated the same. NA B said LVN A had been a police officer. NA B said LVN A was [NAME] so when she spoke it was a loud voice. NA B said I did not make the comment you need to lose weight to any of the residents. NA B said he always got Resident #2 up and never made her stay in the bed. NA B said it was important to respect their right because this was their home if they want to do something we should do it for them. During an interview on [DATE] at 3:56 PM, Anonymous Staff Member #2 said, she had heard the CNAs yelling and cursing at the residents. Anonymous Staff Member #2 said in the past she had witnessed CNA D, CNA E, CNA F, and CNA C yell and curse at any resident that could express themselves or express their needs. In particular Resident #2, Resident #7 and Resident #6. Anonymous Staff Member said they were very mean to Resident #2. Anonymous Staff Member #2 said she witnessed the incident on [DATE] when CNA D and CNA E yelled and cursed at Resident #7 and Resident #2. Anonymous Staff Member #2 said it was CNA D that told Resident #2 that she could not get up. Anonymous Staff Member #2 said she called the Ombudsman to the nurse's station to hear the incident. Anonymous Staff Member #2 said the facility was the residents' home and the residents should be able to get up when they wanted to do so. Anonymous Staff Member #2 said the residents could become depressed because of isolating them. Anonymous Staff Member #2 said verbal abuse would make the residents feel withdrawn and scared to be at the facility. Anonymous Staff Member #2 said she did not feel like she could report abuse to the Administrator at any time. Anonymous Staff Member #2 said when she reported abuse to the Administrator, the Administrator would throw her under the bus, and tell the CNAs she reported them. The CNAs would then tell her to do things herself. During an interview on [DATE] at 8:20 AM, Anonymous staff member #3 said she no longer employed at the facility, and it had been ,d+[DATE] weeks since the last time she worked. Anonymous staff member #3 said CNA E and CNA F yelled and cursed at the residents. Anonymous staff member #3 said CNA E and CNA F would tell the residents they were not getting them out of bed. Anonymous staff member #3 said CNA E and CNA F would tell Resident #2 and Resident #7 not to ask to get out of bed because they were not going to do it. Anonymous staff member #3 said CNA E and CNA F made Resident #2 and Resident #7 cry many times. Anonymous staff member #3 said it was like an act of congress to get anyone to help him, referring to the CNAs assisting Resident #3 with his ADLs. Anonymous staff member #3 said Resident #3 was scared to ask the CNAs for assistance. Anonymous staff member #3 said she reported the CNAs yelling, cursing, and not assisting the residents to the DON and Administrator over and over again and there were no consequences for the CNAs. During an attempted phone interview with LVN A on [DATE] at 4:40 PM, LVN A did not respond to phone call. During an interview on [DATE] at 06:19 PM, the ADON said she had been the ADON for 6 - 7 weeks. The ADON said she and the DON were responsible for the oversight and monitoring of clinical staff. The ADON said she was not in Resident #3's room when LVN A said she couldn't stomach the wound. The ADON said Resident #3 reported this incident to her and she did the grievance form, and it was signed by the Administrator and DON. The ADON said she had not witnessed nor had any reports of any of the CNA's yelling or cursing at the residents. During an interview on [DATE] at 06:33 PM, the DON said she was not present during the incident with Resident #1. The DON said Resident #1 did not tell her LVN A threw the nebulizer treatments at him. The DON said Resident #1 said the box fell in his lap and was not a big deal. The DON said Resident #1 was scared of LVN A because he asked her for something and instead of giving it, she belittled him. The DON said that she did not recall the incident with Resident #5 other than provided in-services regarding abuse and educate the staff that this is the resident's home, and they have the right to feel safe and secure in the home. The DON said Resident #2 had reported to her that the CNAs did not want to get her out of bed. The DON said there were multiple times Resident #2 would say she did not get a shower. The DON said I am not saying she never missed a shower because there were problems. The DON said I tried to coordinate that people were getting their showers. The DON said she was aware of the incident with Resident #4. The DON said she took his witness statement because he could not write. The DON said Resident #4 was shaking, scared, upset, and crying. The DON said she was not aware of the incidents with Resident # 3, Resident #7. The DON said she had no complaints about NA B, CNA C, CNA D, CNA E, CNA F. The DON said it was important to follow the abuse policy because it was the residents' right not to be abused. The DON said the abuse policy needed to be followed so that people understood they could not abuse the residents. The DON said the abuse policy protected the residents from abuse and gave the facility a guideline to follow so abuse could be identified and reported. The DON said if the residents experienced verbal abuse it could result in them being scared, withdrawn and cause failure to thrive. During an interview on [DATE] at 08:18 PM, The Administrator said Resident #5's family member talked to her and confirmed that the incident with the CNAs yelling at Resident #5 did not happen. The Administrator did not specify how this was confirmed. The Administrator said she protected the residents by educating the staff on abuse and neglect and completing safe surveys on the residents. The Administrator said a family member complained to her that the CNAs would not get Resident #2 out of bed. The Administrator said Resident #2 got out of bed every time she wanted. The Administrator said Resident #1 said the nurse dropped the nebulizer treatments in his lap. The Administrator said that Resident #1 did not want to report the incident because it was not a big deal. The Administrator said a Performance Improvement Plan was started on LVN A at this time ([DATE]). The Administrator said LVN A was terminated after the incident with Resident #4. The Administrator said LVN A was terminated on [DATE]. The Administrator said she was not notified of any abuse allegations involving NA B, CNA C, and CNA D. The Administrator said she was the abuse coordinator. The Administrator said she was not aware that the staff or residents were scared to report abuse allegations to her. The Administrator said it was important to protect the residents from abuse for their safety and to prevent emotional harm. The Administrator said in-services were provided to the staff. The Administrator said she expected all of the staff to follow the abuse policy. The Administrator said it was important to follow the abuse policy to ensure the safety of the residents. The Administrator said not following the abuse policy would not keep the residents safe. The Administrator said it was important to protect the residents from abuse for their safety and to prevent emotional harm. <b [TRUNCATED]

Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 7 of 13 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) reviewed for resident rights. The facility failed to ensure Resident #1 did not experience humiliation when LVN A threw his nebulizer treatments (medication used to help breathe better) at him. The facility failed to ensure Resident #2 did not feel scared of retaliation and intimidated by staff. The facility failed to ensure Resident #2 did not feel humiliated when CNA D rudely refused to get her out of bed. The facility failed to ensure Resident #3 did not feel humiliated and disrespected when LVN A stated, I can't stomach this wound, and NA B told him not to be needy. The facility failed to ensure Resident #4 did not feel humiliated and scared of retaliation when LVN A told him, I'm done with you. The facility failed to ensure Resident #5 was not scared to report when the CNAs yelled at her because she was scared, she would be yelled at again. The facility failed to ensure Resident #6 was not scared to report LVN A after she told him he acted like a three-year-old and he was sorry. The facility failed to ensure Resident #7 did not feel intimidated and belittled when CNA C yelled and cursed at her. This failure resulted in an Immediate Jeopardy (IJ) identified on [DATE] at 3:47PM. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: 1. Record review of a face sheet dated [DATE] indicated Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, with agitation (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and panic disorder episodic paroxysmal anxiety (intense feeling of fear and discomfort that begins abruptly and rises to a maximum within minutes). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #1 was understood and was able to understand others. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #1 had no delusions or hallucinations. The MDS assessment indicated Resident #1 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #1 required supervision for bed mobility, transfers, eating, toilet use, and limited assistance for dressing and personal hygiene. Record review of the Physician Order Report dated [DATE] - [DATE] indicated Resident #1 had an order for Ipratropium Bromide and Albuterol (medication used to help breathe better) 0.5mg/3ml liquid; 0.5mg/3ml, 1 vial every 4 hours at 12:00 AM, 04:00 AM, 08:00 AM, 12:00 PM, 04:00 PM, 08:00 PM. Record review of a care plan last revised [DATE] indicated a problem that Resident #1 exhibited verbally abusive behavioral symptoms such as others were threatened, calling 911, screamed at and cursed at staff related to wanting a breathing treatment due to anxiety and shortness of breath with interventions which included convey an attitude of acceptance toward the resident, maintain a calm environment and reassure the resident by checking his oxygen saturations to assure within normal limits and observe for anxiety and attempt to have resident purse breath. During an interview on [DATE] at 9:44 AM, Resident #1 said LVN A was rude to everybody. Resident #1 said he had asked her for a breathing treatment because he felt like he could not breathe. Resident #1 said LVN A grabbed ,d+[DATE] of the nebulizer treatments (medication used to help breathe better) and threw them at him. Resident #1 said he could not remember the date that it happened. Resident #1 said he had gotten used to her being rude that way. Resident #1 said LVN A made him feel humiliated, and he was scared of her retaliating. Resident #1 said he was scared LVN A would get back at him by making him wait until the end for his medicine even if he was the first one in line. Resident #1 said in the past LVN A had made him wait for his medication because she was mad at him. Resident #1 was unable to provide exact dates. Resident #1 said he had told the office staff he was scared LVN A would retaliate against him when he was questioned about the incident with LVN A. Record review of the Provider's Investigation Report dated [DATE] indicated the incident with Resident #1 and LVN A occurred on [DATE]. The Provider's Investigation Report indicated the facility took the following actions post investigation: completed a Head-to-Toe Assessment, Resident Interviews, Staff Interviews, Safe Surveys and Culture sensitivity/Abuse and Neglect Inservice dated [DATE]. The Culture sensitivity/Abuse and Neglect Inservice was not signed by LVN A which indicated she was not in-serviced. Record review of a Performance Improvement Plan implemented on [DATE] indicated LVN A had a 30-day timeline for performance improvement or termination would occur. 2. Record review of a face sheet dated [DATE] indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right sided weakness and paralysis after a stroke), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. The MDS assessment indicated Resident #2 had a BIMS score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #2 had no delusions or hallucinations. The MDS assessment indicated Resident #2 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #2 did not exhibit rejection of care. The MDS assessment indicated Resident #2 required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and supervision for eating. Resident #2 was totally dependent for transfers and bathing. Record review of Resident #2's care plan last revised [DATE] indicated she had a problem of resident must be lifted mechanically and interventions included staff to get resident up out of bed daily ,d+[DATE] times a week and required 2 staff members at all times to use the mechanical lift. Resident #2's care plan indicated she had a history of anxiety and interventions included to allow resident to voice thoughts. Resident #2's care plan indicated that she required 2 staff assistance depending on type of bath or shower, required, ,d+[DATE] staff for dressing/grooming, and ,d+[DATE] staff to provide incontinent care, and her preferred time for bath/shower was once a day on Tuesday, Thursday, and Saturday 2:00 PM- 10:00 PM. Resident #2's care plan indicated to allow her to express her feelings, allow her to participate in daily care and decision/goal making, and to listen carefully and be non-judgmental. Resident #2's care plan did not indicate she refused care. Record review of the electronic health record indicated Resident #2 was discharged to another facility on [DATE]. During an interview on [DATE] at 09:56 AM, the ombudsman said on [DATE] while in the facility she heard screaming and walked into Resident #2's room. The Ombudsman said CNA D yelled at Resident #2, What do you want? Resident #2 said she wanted to get out of bed. CNA D said to Resident #2, you know it ain't your day to get out of bed. Resident #2 said, I know it is not my shower day, but I want to get out of bed to play bingo. CNA D replied to Resident #2 and said, I don't know what to tell you. The Ombudsman said she went and reported this incident to the ADON the same day she witnessed it. During an interview on [DATE] at 3:06 PM, Resident #2 said she moved to a different nursing home approximately 5 days ago. Resident #2 said if she would have stayed at the other facility she would have died . Resident #2 said she had gone without a shower for 10 days, and she told the staff everyday she wanted a shower. Resident #2 said she was told there were not enough CNAs. Resident #2 said CNA C was horrible, cursed and screamed at her, and it broke her heart because she could hear her scream and curse at the resident across the hall from her. Resident #2 said she told him she would jerk him out of his bed, and she could not understand why she talked to everyone like that. Resident #2 said that there were plenty of other residents at the facility that had heard CNA C say the same things to other residents. Resident #2 said when CNA C and another CNA had scrubbed her leg and left a bruise while giving her a shower. Resident #2 said she reported CNA C to the DON, and that did nothing but make CNA C retaliate against her. Resident #2 said when CNA C would go into her room to leave a meal she would not speak to her or make eye contact with her. Resident #2 said the CNAs always told her she could not get up and she could not get showers because they did not have enough staff. Resident #2 said the CNAs told her not to use the call light. Resident # 2 said her family member was very upset and reported this to the DON. Resident #2 said she had to lay in her feces from 11 AM to 7 PM. Resident #2 said she told NA B three times and he kept saying he would be right with her. Resident #2 said that was the most degraded and awful feeling she ever had. Resident #2 was teary eyed. Resident #2 said her family members came to visit her and she was laying in shit. Resident #2 said this messed with her emotions and she would never forget it. Resident #2 said the facility never had the right briefs and her husband would try to supply them so she could get out of bed more. Resident #2 said if her husband did not provide the appropriate size briefs the facility would apply a smaller size and it was causing her belly area to break down. Resident #2 said the CNAs were intimidating, and CNA D was always short and rude. Resident #2 said it was a yucky situation and she felt when she reported the CNAs they retaliated. 3. Record review of a face sheet dated [DATE] indicated Resident #3 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), non-pressure chronic ulcer of skin of other sites with unspecified severity (long-time open sore on the skin), and post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #3 was understood and understood others. The MDS assessment indicated Resident #3 had a BIMS score of 15, which indicated he was cognitively intact. The MDS assessment indicated Resident #3 had no delusions or hallucinations. The MDS assessment indicated Resident #3 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #3 exhibited rejection 1 to 3 days in the 7-day lookback period. The MDS assessment indicated Resident #3 required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene, supervision for eating, and total dependence for bathing. The MDS assessment indicated Resident #3 had an open lesion other than ulcers, rashes, and cuts. Record review of Resident #3's care plan last revised [DATE] indicated he exhibited signs and symptoms of anxiety and agitation and was receiving clonazepam (medication used to treat anxiety), interventions included to allow the resident to voice his thoughts and feelings and to explore with resident the reason for anxiety. Resident #3's care plan indicated to allow him to participate in daily care and decision/goal making and to listen carefully and be non-judgmental. Resident #3's care plan indicated he had open lesions related to a history of chronic abdominal wounds and had interventions which included to cleanse area to left abdomen with normal saline, pat dry, apply calcium alginate with silver (absorbent dressing applied to wounds), cover with pads twice a day and cleanse area to left inguinal area with normal saline, pat dry and apply calcium alginate silver twice daily. During an interview and observation on [DATE] at 1:28 PM, Resident #3 said NA B told him not to be needy, referring to Resident #3 using his call light to request assistance, between 7 AM and 9 AM because these were the busiest times of the day. Resident #3 was unable to provide the exact dates. Resident #3 said LVN A did not perform wound care on him when she worked at night. Resident #3 said he had complained to the Administrator and all the other nurses that LVN A was not performing wound care on him. Resident #3 said after he complained to the Administrator, the ADON accompanied LVN A to watch her perform the wound care. While the ADON was observing the wound care, LVN A told the ADON, I cannot stomach this wound. Resident #3 said the incidents with NA B and LVN A made him feel humiliated and disrespected. Resident #3 was teary during the interview. 4. Record review of Face Sheet dated [DATE] indicated Resident #4 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Chronic obstructive pulmonary disease (a lack of adequate blood supply to brain cells), other seizures (burst of uncontrolled electrical activity between brain cells), unsteadiness on feet, weakness, pain, dementia (brain impairment of memory loss and judgement), schizoaffective disorder (combination of mood disorder such as depression and bipolar disorder), hypertension, (increased blood pressure), chronic kidney disease stage 3 (mild to moderate kidney damage - less likely to filter). Record review of quarterly MDS dated [DATE] indicated Resident #4 understood others and made himself understood. The MDS indicated Resident #4 was moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #4 did not reject evaluation or care. The MDS indicated Resident #4 required supervision and setup with transferring, dressing and limited assistance with personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #4 was care planned for psychosocial well-being. The care plan indicated interventions included Resident #4 was allowed to express feelings, allowed to participate in daily care and decision/goal making, adhere to customary routines, keep topics of conversation light and cheerful, listen carefully and non-judgmental. Resident #4 was care planned for cognitive loss related to dementia. The care plan indicated interventions included Resident #4 was approached in a calm manner, anticipate needs and observe for non-verbal cues. During an interview and observation on [DATE] at 10:49 AM, Resident #4 said LVN A told him she was done with him in a very hateful way. Resident #4 said LVN A was very bully over the residents. Resident #4 said LVN A hurt his feelings and it made him cry. Resident #4 said LVN A was bullying other patients that night and the rest of the patients came forward after him and wrote their statements. Resident #4 did not remember when the incident occurred. Resident #4 said he was very much intimated by LVN A. Resident #4 was teary when recounting the incident. 5. Record review of the Face Sheet dated [DATE] indicated Resident #5 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Transient cerebral ischemic attack (a lack of adequate blood supply to brain cells), infections of the skin and subcutaneous tissue, Chronic Obstructive pulmonary disease (a lack of adequate blood supply to brain cells), Hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the boy that can affect the arms, legs, facial muscles) affecting left dominant side. Record review of the quarterly MDS dated [DATE] indicated Resident #5 had moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #5 did not reject evaluation or care. The MDS indicated Resident #5 required limited assistance with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #5 had episodes of anxiety and had Ativan (medication used to decrease anxiety). The care plan indicated interventions included Resident #5 was allowed to voice thoughts and feelings and to explore with resident the reason for anxiety. During an interview on [DATE] at 2:40 PM, Resident #5 said the CNAs screamed at her, but she was not able to recall who the CNAs were or the date the incident happened. Resident #5 said she was scared to report the CNAs because she did not want them to yell at her again. 6. Record review of Face Sheet dated [DATE] indicated Resident #6 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Diffuse traumatic brain injury, Excoriation (skin picking) disorder, Paraplegic (paralysis of the lower body), Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury, Nausea (urge to vomit), Bipolar Disorder (changes in mood and energy levels), Pain, reduced mobility. Record review of quarterly MDS dated [DATE] indicated Resident #6 understood others and made himself understood. The MDS indicated Resident #6 was cognitively intact with a BIMS score of 15. The MDS indicated Resident #6 did not reject evaluation or care. The MDS indicated Resident #6 required extensive care with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #6 had an activities of daily living (ADL) self-care performance deficit related to paraplegia. The care plan indicated interventions included Resident #6 required assistance x2 for bath/shower 3 times weekly. During an interview and observation on [DATE] at 5:05 PM, Resident #6 said LVN A told him he acted like a 3-year-old. Resident #6 said after LVN A told him he acted like a 3-year-old he said, I'm sorry, and LVN A responded, Yes, you are sorry. Resident #6 said this made him feel intimidated. Resident #6 said he had not reported this to the facility staff because he was scared LVN A would retaliate against him. Resident #6 could not recall when the incident occurred. Resident #6 was tearful during the interview. 7. Record review of the Face Sheet dated [DATE] indicated Resident #7 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Chronic Obstructive Pulmonary Disease (a lack of adequate blood supply to brain cells), Pain, Muscle Weakness, Pressure ulcer of other site - stage 4, Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury), Partial traumatic amputation at knee level - left lower leg, Dementia (brain impairment of memory loss and judgement), DM Type 2 (a chronic condition that affects the way the body processes blood sugar), Personal history of transient ischemic attack (TIA) (a temporary condition that mimics a stroke), cerebral infarction (a lack of adequate blood supply to brain cells) without residual deficits. Record review of the quarterly MDS dated [DATE] indicated Resident #7 understood others and made herself understood. The MDS indicated Resident #7 was cognitively intact with a BIMS score of 13. The MDS indicated Resident #7 did not reject evaluation or care. The MDS indicated Resident #7 required extensive care with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #7 had an activities of daily living (ADL) self-care performance deficit related to amputation at knee level. The care plan indicated interventions included Resident #7 required assistance x2 for bath/shower 3 times weekly. During an interview on [DATE] at 11:19 AM, Resident #7 said CNA C yelled and cursed at her. Resident #7 said CNA C told her, I don't care who you tell, I have been working here for [AGE] years. Resident # 7 said when the CNAs yelled or cursed at her it made her feel intimidated and belittled. Resident #7 did not give exact dates of when this happened. Resident #7 said she had told the DON Resident #7 yelled and cursed at her, but nothing had been done. During an interview on [DATE] at 12:57 PM, CNA D said she worked the 6AM - 2PM shift since December of 2022. CNA D said she had never had any problems with any of the residents, had not been complained on, or accused of any allegations. CNA D said she had never told a resident they needed to stay in the bed. CNA D said no residents had been upset on my hall to my knowledge. CNA D said if a resident was upset with her, she would deescalate by finding out why and go get the DON. CNA D said she did not know the abuse coordinator's name because they switch positions often. CNA D said she had not been rude to residents or told the residents not to use their call lights. CNA D said she had not witnessed any of the staff members being rude to anyone. CNA D said she had never been rude or yelled at Resident #2. During an interview on [DATE] at 2:15 PM, CNA F said no residents reported abuse to her and she had not had any problems with any of the residents. CNA F said, I have not witnessed any type of abuse to the residents by any staff member. During an interview on [DATE] at 02:04 PM, CNA E said she had worked at the facility for one year and worked the 6AM - 2PM shift. CNA E said she had never been suspended or accused of yelling at a resident. CNA E said she never yelled at Resident #2 for staying on the call light. CNA E said she never told a resident they could not get out of bed. CNA E said when Resident #2 asked to get up, we would get her up. CNA E said if Resident #2 asked to get up, I got her up even if it was not her get up day. During an interview on [DATE] at 08:59 AM, Anonymous Staff Member #1 said sometimes the facility was short staffed and it fueled the fire on tolerance with the CNAs. Anonymous Staff Member #1 said the CNAs voices did get raised. Anonymous Staff Member #1 said CNA F raised her voice at the residents. Anonymous Staff Member #1 said the CNAs raising their voices at the residents made her feel uncomfortable. Anonymous Staff Member #1 said she reported these incidents to the ADON on multiple occasions. Anonymous Staff Member #1 said the ADON's response was she was doing in-services with the CNAs. Anonymous Staff Member #1 said, If I was the resident and the CNAs talked to me that way, I would feel intimidated by them and I would be scared to ask them for things. Anonymous Staff Member #1 said she did not feel like she had the authority to effectively delegate tasks or reprimand the CNAs for their actions because she felt like she had no authority. Anonymous Staff Member #1 said there were no consequences for the CNAs actions. Anonymous Staff Member #1 said the CNAs did not answer the call lights. Anonymous Staff Member #1 said the residents should have autonomy and be able to make decisions and the staff should accommodate their requests. During an interview on [DATE] at 2:41 PM, NA B said he had worked at the facility for 3 months on all shifts. NA B said, I have never told a resident not to use their call light between 7 AM and 9 AM because it was busy. NA B said, I never witnessed another CNA be rude or yell. NA B said, In some situations you have to treat people different, they cannot all be treated the same. NA B said LVN A had been a police officer. NA B said LVN A was [NAME] so when she spoke it was a loud voice. NA B said I did not make the comment you need to lose weight to any of the residents. NA B said he always got Resident #2 up and never made her stay in the bed. NA B said it was important to respect their right because this was their home if they want to do something we should do it for them. During an interview on [DATE] at 3:56 PM, Anonymous Staff Member #2 said, she had heard the CNAs yelling and cursing at the residents. Anonymous Staff Member #2 said in the past she had witnessed CNA D, CNA E, CNA F, and CNA C yell and curse at any resident that could express themselves or express their needs. In particular Resident #2, Resident #7 and Resident #6. Anonymous Staff Member said they were very mean to Resident #2. Anonymous Staff Member #2 said she witnessed the incident on [DATE] when CNA D and CNA E yelled and cursed at Resident #7 and Resident #2. Anonymous Staff Member #2 said it was CNA D that told Resident #2 that she could not get up. Anonymous Staff Member #2 said she called the Ombudsman to the nurse's station to hear the incident. Anonymous Staff Member #2 said the facility was the residents' home and the residents should be able to get up when they wanted to do so. Anonymous Staff Member #2 said the residents could become depressed because of isolating them. Anonymous Staff Member #2 said verbal abuse would make the residents feel withdrawn and scared to be at the facility. Anonymous Staff Member #2 said she did not feel like she could report abuse to the Administrator at any time. Anonymous Staff Member #2 said when she reported abuse to the Administrator, the Administrator would throw her under the bus, and tell the CNAs she reported them. The CNAs would then tell her to do things herself. During an interview on [DATE] at 8:20 AM, Anonymous staff member #3 said she no longer employed at the facility, and it had been ,d+[DATE] weeks since the last time she worked. Anonymous staff member #3 said CNA E and CNA F yelled and cursed at the residents. Anonymous staff member #3 said CNA E and CNA F would tell the residents they were not getting them out of bed. Anonymous staff member #3 said CNA E and CNA F would tell Resident #2 and Resident #7 not to ask to get out of bed because they were not going to do it. Anonymous staff member #3 said CNA E and CNA F made Resident #2 and Resident #7 cry many times. Anonymous staff member #3 said it was like an act of congress to get anyone to help him, referring to the CNAs assisting Resident #3 with his ADLs. Anonymous staff member #3 said Resident #3 was scared to ask the CNAs for assistance. Anonymous staff member #3 said she reported the CNAs yelling, cursing, and not assisting the residents to the DON and Administrator over and over again and there were no consequences for the CNAs. During an attempted phone interview with LVN A on [DATE] at 4:40 PM, LVN A did not respond to phone call. During an interview on [DATE] at 06:19 PM, the ADON said she had been the ADON for 6 - 7 weeks. The ADON said she and the DON were responsible for the oversight and monitoring of clinical staff. The ADON said she was not in Resident #3's room when LVN A said she couldn't stomach the wound. The ADON said Resident #3 reported this incident to her and she did the grievance form, and it was signed by the Administrator and DON. The ADON said she had not witnessed nor had any reports of any of the CNA's yelling or cursing at the residents. During an interview on [DATE] at 06:33 PM, the DON said she was not present during the incident with Resident #1. The DON said Resident #1 did not tell her LVN A threw the nebulizer treatments at him. The DON said Resident #1 said the box fell in his lap and was not a big deal. The DON said Resident #1 was scared of LVN A because he asked her for something and instead of giving it, she belittled him. The DON said that she did not recall the incident with Resident #5 other than provided in-services regarding abuse and educate the staff that this is the resident's home, and they have the right to feel safe and secure in the home. The DON said Resident #2 had reported to her that the CNAs did not want to get her out of bed. The DON said there were multiple times Resident #2 would say she did not get a shower. The DON said I am not saying she never missed a shower because there were problems. The DON said I tried to coordinate that people were getting their showers. The DON said she was aware of the incident with Resident #4. The DON said she took his witness statement because he could not write. The DON said Resident #4 was shaking, scared, upset, and crying. The DON said she was not aware of the incidents with Resident # 3, Resident #7. The DON said she had no complaints about NA B, CNA C, CNA D, CNA E, CNA F. During an interview on [DATE] at 08:18 PM, The Administrator said Resident #5's family member talked to her and confirmed that the incident with the CNAs yelling at Resident #5 did not happen. The Administrator did not specify how this was confirmed. The Administrator said she protected the residents by educating the staff on abuse and neglect and completing safe surveys on the residents. The Administrator said a family member complained to her that the CNAs would not get Resident #2 out of bed. The Administrator said Resident #2 got out of bed every time she wanted. The Administrator said Resident #1 said the nurse dropped the nebulizer treatments in his lap. The Administrator said that Resident #1 did not want to report the incident because it was not a big deal. The Administrator said a Performance Improvement Plan was started on LVN A at this time ([DATE]). The Administrator said LVN A was terminated after the incident with Resident #4. The Administrator said LVN A was terminated on [DATE]. The Administrator said she was not notified of any abuse allegations involving NA B, CNA C, and CNA D. The Administrator said she was the abuse coordinator. The Administrator said she was not aware that the staff or residents were scared to report abuse allegations to her. The Administrator said it was important to protect the residents from abuse for their safety and to prevent emotional harm. The Administrator said it was important to treat the residents with dignity and respect because it was their right. The Administrator said not treating a resident with dignity and respect could affect their well-being and make them feel bad. During an interview on [DATE] at 5:15 PM, LVN A said she had not received notification she was terminated by the facility. LVN A said she quit by not returning to work. LVN A said the last day she worked was [DATE]. LVN A said she quit after she was told she would have to pass out cigarettes during her medication pass time. LVN A said she was not going to stop passing out medications to give the residents their cigarettes. LVN A said she told several of the residents that smoked, including, Resident #4, that she was not going to stop passing out medications to give them their cigarettes. LVN A said after she told them this Resident #4 got really pissed off at her and started yelling and cursing that it was his right to smoke. LVN

Based on observation, interview, and record review, the facility failed to ensure the right of the residents to be free from abuse for 7 of 13 residents reviewed for abuse. (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7) The facility failed to ensure Resident #1 did not experience humiliation when LVN A threw his nebulizer treatments (medication used to help breathe better) at him. The facility failed to ensure Resident #2 did not feel scared of retaliation and intimidated by staff. The facility failed to ensure Resident #2 did not feel humiliated when CNA D rudely refused to get her out of bed. The facility failed to ensure Resident #3 did not feel humiliated and disrespected when LVN A stated, I can't stomach this wound, and NA B told him not to be needy. The facility failed to ensure Resident #4 did not feel humiliated and scared of retaliation when LVN A told him, I'm done with you. The facility failed to ensure Resident #5 was not scared to report when the CNAs yelled at her because she was scared, she would be yelled at again. The facility failed to ensure Resident #6 was not scared to report LVN A after she told him he acted like a three-year-old and he was sorry. The facility failed to ensure Resident #7 did not feel intimidated and belittled when CNA C yelled and cursed at her. This failure resulted in an Immediate Jeopardy (IJ) identified on [DATE] at 3:47PM. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: 1. Record review of a face sheet dated [DATE] indicated Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, with agitation (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and panic disorder episodic paroxysmal anxiety (intense feeling of fear and discomfort that begins abruptly and rises to a maximum within minutes). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #1 was understood and was able to understand others. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #1 had no delusions or hallucinations. The MDS assessment indicated Resident #1 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #1 required supervision for bed mobility, transfers, eating, toilet use, and limited assistance for dressing and personal hygiene. Record review of the Physician Order Report dated [DATE] - [DATE] indicated Resident #1 had an order for Ipratropium Bromide and Albuterol (medication used to help breathe better) 0.5mg/3ml liquid; 0.5mg/3ml, 1 vial every 4 hours at 12:00 AM, 04:00 AM, 08:00 AM, 12:00 PM, 04:00 PM, 08:00 PM. Record review of a care plan last revised [DATE] indicated a problem that Resident #1 exhibited verbally abusive behavioral symptoms such as others were threatened, calling 911, screamed at and cursed at staff related to wanting a breathing treatment due to anxiety and shortness of breath with interventions which included convey an attitude of acceptance toward the resident, maintain a calm environment and reassure the resident by checking his oxygen saturations to assure within normal limits and observe for anxiety and attempt to have resident purse breath. During an interview on [DATE] at 9:44 AM, Resident #1 said LVN A was rude to everybody. Resident #1 said he had asked her for a breathing treatment because he felt like he could not breathe. Resident #1 said LVN A grabbed ,d+[DATE] of the nebulizer treatments (medication used to help breathe better) and threw them at him. Resident #1 said he could not remember the date that it happened. Resident #1 said he had gotten used to her being rude that way. Resident #1 said LVN A made him feel humiliated, and he was scared of her retaliating. Resident #1 said he was scared LVN A would get back at him by making him wait until the end for his medicine even if he was the first one in line. Resident #1 said in the past LVN A had made him wait for his medication because she was mad at him. Resident #1 was unable to provide exact dates. Resident #1 said he had told the office staff he was scared LVN A would retaliate against him when he was questioned about the incident with LVN A. Record review of the Provider's Investigation Report dated [DATE] indicated the incident with Resident #1 and LVN A occurred on [DATE]. The Provider's Investigation Report indicated the facility took the following actions post investigation: completed a Head-to-Toe Assessment, Resident Interviews, Staff Interviews, Safe Surveys and Culture sensitivity/Abuse and Neglect Inservice dated [DATE]. The Culture sensitivity/Abuse and Neglect Inservice was not signed by LVN A which indicated she was not in-serviced. Record review of a Performance Improvement Plan implemented on [DATE] indicated LVN A had a 30-day timeline for performance improvement or termination would occur. 2. Record review of a face sheet dated [DATE] indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right sided weakness and paralysis after a stroke), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. The MDS assessment indicated Resident #2 had a BIMS score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #2 had no delusions or hallucinations. The MDS assessment indicated Resident #2 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #2 did not exhibit rejection of care. The MDS assessment indicated Resident #2 required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and supervision for eating. Resident #2 was totally dependent for transfers and bathing. Record review of Resident #2's care plan last revised [DATE] indicated she had a problem of resident must be lifted mechanically and interventions included staff to get resident up out of bed daily ,d+[DATE] times a week and required 2 staff members at all times to use the mechanical lift. Resident #2's care plan indicated she had a history of anxiety and interventions included to allow resident to voice thoughts. Resident #2's care plan indicated that she required 2 staff assistance depending on type of bath or shower, required, ,d+[DATE] staff for dressing/grooming, and ,d+[DATE] staff to provide incontinent care, and her preferred time for bath/shower was once a day on Tuesday, Thursday, and Saturday 2:00 PM- 10:00 PM. Resident #2's care plan indicated to allow her to express her feelings, allow her to participate in daily care and decision/goal making, and to listen carefully and be non-judgmental. Resident #2's care plan did not indicate she refused care. Record review of the electronic health record indicated Resident #2 was discharged to another facility on [DATE]. During an interview on [DATE] at 09:56 AM, the ombudsman said on [DATE] while in the facility she heard screaming and walked into Resident #2's room. The Ombudsman said CNA D yelled at Resident #2, What do you want? Resident #2 said she wanted to get out of bed. CNA D said to Resident #2, you know it ain't your day to get out of bed. Resident #2 said, I know it is not my shower day, but I want to get out of bed to play bingo. CNA D replied to Resident #2 and said, I don't know what to tell you. The Ombudsman said she went and reported this incident to the ADON the same day she witnessed it. During an interview on [DATE] at 3:06 PM, Resident #2 said she moved to a different nursing home approximately 5 days ago. Resident #2 said if she would have stayed at the other facility she would have died . Resident #2 said she had gone without a shower for 10 days, and she told the staff everyday she wanted a shower. Resident #2 said she was told there were not enough CNAs. Resident #2 said CNA C was horrible, cursed and screamed at her, and it broke her heart because she could hear her scream and curse at the resident across the hall from her. Resident #2 said she told him she would jerk him out of his bed, and she could not understand why she talked to everyone like that. Resident #2 said that there were plenty of other residents at the facility that had heard CNA C say the same things to other residents. Resident #2 said when CNA C and another CNA had scrubbed her leg and left a bruise while giving her a shower. Resident #2 said she reported CNA C to the DON, and that did nothing but make CNA C retaliate against her. Resident #2 said when CNA C would go into her room to leave a meal she would not speak to her or make eye contact with her. Resident #2 said the CNAs always told her she could not get up and she could not get showers because they did not have enough staff. Resident #2 said the CNAs told her not to use the call light. Resident # 2 said her family member was very upset and reported this to the DON. Resident #2 said she had to lay in her feces from 11 AM to 7 PM. Resident #2 said she told NA B three times and he kept saying he would be right with her. Resident #2 said that was the most degraded and awful feeling she ever had. Resident #2 was teary eyed. Resident #2 said her family members came to visit her and she was laying in shit. Resident #2 said this messed with her emotions and she would never forget it. Resident #2 said the facility never had the right briefs and her husband would try to supply them so she could get out of bed more. Resident #2 said if her husband did not provide the appropriate size briefs the facility would apply a smaller size and it was causing her belly area to break down. Resident #2 said the CNAs were intimidating, and CNA D was always short and rude. Resident #2 said it was a yucky situation and she felt when she reported the CNAs they retaliated. 3. Record review of a face sheet dated [DATE] indicated Resident #3 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), non-pressure chronic ulcer of skin of other sites with unspecified severity (long-time open sore on the skin), and post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #3 was understood and understood others. The MDS assessment indicated Resident #3 had a BIMS score of 15, which indicated he was cognitively intact. The MDS assessment indicated Resident #3 had no delusions or hallucinations. The MDS assessment indicated Resident #3 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #3 exhibited rejection 1 to 3 days in the 7-day lookback period. The MDS assessment indicated Resident #3 required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene, supervision for eating, and total dependence for bathing. The MDS assessment indicated Resident #3 had an open lesion other than ulcers, rashes, and cuts. Record review of Resident #3's care plan last revised [DATE] indicated he exhibited signs and symptoms of anxiety and agitation and was receiving clonazepam (medication used to treat anxiety), interventions included to allow the resident to voice his thoughts and feelings and to explore with resident the reason for anxiety. Resident #3's care plan indicated to allow him to participate in daily care and decision/goal making and to listen carefully and be non-judgmental. Resident #3's care plan indicated he had open lesions related to a history of chronic abdominal wounds and had interventions which included to cleanse area to left abdomen with normal saline, pat dry, apply calcium alginate with silver (absorbent dressing applied to wounds), cover with pads twice a day and cleanse area to left inguinal area with normal saline, pat dry and apply calcium alginate silver twice daily. During an interview and observation on [DATE] at 1:28 PM, Resident #3 said NA B told him not to be needy, referring to Resident #3 using his call light to request assistance, between 7 AM and 9 AM because these were the busiest times of the day. Resident #3 was unable to provide the exact dates. Resident #3 said LVN A did not perform wound care on him when she worked at night. Resident #3 said he had complained to the Administrator and all the other nurses that LVN A was not performing wound care on him. Resident #3 said after he complained to the Administrator, the ADON accompanied LVN A to watch her perform the wound care. While the ADON was observing the wound care, LVN A told the ADON, I cannot stomach this wound. Resident #3 said the incidents with NA B and LVN A made him feel humiliated and disrespected. Resident #3 was teary during the interview. 4. Record review of Face Sheet dated [DATE] indicated Resident #4 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Chronic obstructive pulmonary disease (a lack of adequate blood supply to brain cells), other seizures (burst of uncontrolled electrical activity between brain cells), unsteadiness on feet, weakness, pain, dementia (brain impairment of memory loss and judgement), schizoaffective disorder (combination of mood disorder such as depression and bipolar disorder), hypertension, (increased blood pressure), chronic kidney disease stage 3 (mild to moderate kidney damage - less likely to filter). Record review of quarterly MDS dated [DATE] indicated Resident #4 understood others and made himself understood. The MDS indicated Resident #4 was moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #4 did not reject evaluation or care. The MDS indicated Resident #4 required supervision and setup with transferring, dressing and limited assistance with personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #4 was care planned for psychosocial well-being. The care plan indicated interventions included Resident #4 was allowed to express feelings, allowed to participate in daily care and decision/goal making, adhere to customary routines, keep topics of conversation light and cheerful, listen carefully and non-judgmental. Resident #4 was care planned for cognitive loss related to dementia. The care plan indicated interventions included Resident #4 was approached in a calm manner, anticipate needs and observe for non-verbal cues. During an interview and observation on [DATE] at 10:49 AM, Resident #4 said LVN A told him she was done with him in a very hateful way. Resident #4 said LVN A was very bully over the residents. Resident #4 said LVN A hurt his feelings and it made him cry. Resident #4 said LVN A was bullying other patients that night and the rest of the patients came forward after him and wrote their statements. Resident #4 did not remember when the incident occurred. Resident #4 said he was very much intimated by LVN A. Resident #4 was teary when recounting the incident. 5. Record review of the Face Sheet dated [DATE] indicated Resident #5 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Transient cerebral ischemic attack (a lack of adequate blood supply to brain cells), infections of the skin and subcutaneous tissue, Chronic Obstructive pulmonary disease (a lack of adequate blood supply to brain cells), Hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the boy that can affect the arms, legs, facial muscles) affecting left dominant side. Record review of the quarterly MDS dated [DATE] indicated Resident #5 had moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #5 did not reject evaluation or care. The MDS indicated Resident #5 required limited assistance with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #5 had episodes of anxiety and had Ativan (medication used to decrease anxiety). The care plan indicated interventions included Resident #5 was allowed to voice thoughts and feelings and to explore with resident the reason for anxiety. During an interview on [DATE] at 2:40 PM, Resident #5 said the CNAs screamed at her, but she was not able to recall who the CNAs were or the date the incident happened. Resident #5 said she was scared to report the CNAs because she did not want them to yell at her again. 6. Record review of Face Sheet dated [DATE] indicated Resident #6 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Diffuse traumatic brain injury, Excoriation (skin picking) disorder, Paraplegic (paralysis of the lower body), Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury, Nausea (urge to vomit), Bipolar Disorder (changes in mood and energy levels), Pain, reduced mobility. Record review of quarterly MDS dated [DATE] indicated Resident #6 understood others and made himself understood. The MDS indicated Resident #6 was cognitively intact with a BIMS score of 15. The MDS indicated Resident #6 did not reject evaluation or care. The MDS indicated Resident #6 required extensive care with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #6 had an activities of daily living (ADL) self-care performance deficit related to paraplegia. The care plan indicated interventions included Resident #6 required assistance x2 for bath/shower 3 times weekly. During an interview and observation on [DATE] at 5:05 PM, Resident #6 said LVN A told him he acted like a 3-year-old. Resident #6 said after LVN A told him he acted like a 3-year-old he said, I'm sorry, and LVN A responded, Yes, you are sorry. Resident #6 said this made him feel intimidated. Resident #6 said he had not reported this to the facility staff because he was scared LVN A would retaliate against him. Resident #6 could not recall when the incident occurred. Resident #6 was tearful during the interview. 7. Record review of the Face Sheet dated [DATE] indicated Resident #7 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Chronic Obstructive Pulmonary Disease (a lack of adequate blood supply to brain cells), Pain, Muscle Weakness, Pressure ulcer of other site - stage 4, Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury), Partial traumatic amputation at knee level - left lower leg, Dementia (brain impairment of memory loss and judgement), DM Type 2 (a chronic condition that affects the way the body processes blood sugar), Personal history of transient ischemic attack (TIA) (a temporary condition that mimics a stroke), cerebral infarction (a lack of adequate blood supply to brain cells) without residual deficits. Record review of the quarterly MDS dated [DATE] indicated Resident #7 understood others and made herself understood. The MDS indicated Resident #7 was cognitively intact with a BIMS score of 13. The MDS indicated Resident #7 did not reject evaluation or care. The MDS indicated Resident #7 required extensive care with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #7 had an activities of daily living (ADL) self-care performance deficit related to amputation at knee level. The care plan indicated interventions included Resident #7 required assistance x2 for bath/shower 3 times weekly. During an interview on [DATE] at 11:19 AM, Resident #7 said CNA C yelled and cursed at her. Resident #7 said CNA C told her, I don't care who you tell, I have been working here for [AGE] years. Resident # 7 said when the CNAs yelled or cursed at her it made her feel intimidated and belittled. Resident #7 did not give exact dates of when this happened. Resident #7 said she had told the DON Resident #7 yelled and cursed at her, but nothing had been done. During an interview on [DATE] at 12:57 PM, CNA D said she worked the 6AM - 2PM shift since December of 2022. CNA D said she had never had any problems with any of the residents, had not been complained on, or accused of any allegations. CNA D said she had never told a resident they needed to stay in the bed. CNA D said no residents had been upset on my hall to my knowledge. CNA D said if a resident was upset with her, she would deescalate by finding out why and go get the DON. CNA D said she did not know the abuse coordinator's name because they switch positions often. CNA D said she had not been rude to residents or told the residents not to use their call lights. CNA D said she had not witnessed any of the staff members being rude to anyone. CNA D said she had never been rude or yelled at Resident #2. During an interview on [DATE] at 2:15 PM, CNA F said no residents reported abuse to her and she had not had any problems with any of the residents. CNA F said, I have not witnessed any type of abuse to the residents by any staff member. During an interview on [DATE] at 02:04 PM, CNA E said she had worked at the facility for one year and worked the 6AM - 2PM shift. CNA E said she had never been suspended or accused of yelling at a resident. CNA E said she never yelled at Resident #2 for staying on the call light. CNA E said she never told a resident they could not get out of bed. CNA E said when Resident #2 asked to get up, we would get her up. CNA E said if Resident #2 asked to get up, I got her up even if it was not her get up day. During an interview on [DATE] at 08:59 AM, Anonymous Staff Member #1 said sometimes the facility was short staffed and it fueled the fire on tolerance with the CNAs. Anonymous Staff Member #1 said the CNAs voices did get raised. Anonymous Staff Member #1 said CNA F raised her voice at the residents. Anonymous Staff Member #1 said the CNAs raising their voices at the residents made her feel uncomfortable. Anonymous Staff Member #1 said she reported these incidents to the ADON on multiple occasions. Anonymous Staff Member #1 said the ADON's response was she was doing in-services with the CNAs. Anonymous Staff Member #1 said, If I was the resident and the CNAs talked to me that way, I would feel intimidated by them and I would be scared to ask them for things. Anonymous Staff Member #1 said she did not feel like she had the authority to effectively delegate tasks or reprimand the CNAs for their actions because she felt like she had no authority. Anonymous Staff Member #1 said there were no consequences for the CNAs actions. Anonymous Staff Member #1 said the CNAs did not answer the call lights. Anonymous Staff Member #1 said the residents should have autonomy and be able to make decisions and the staff should accommodate their requests. During an interview on [DATE] at 2:41 PM, NA B said he had worked at the facility for 3 months on all shifts. NA B said, I have never told a resident not to use their call light between 7 AM and 9 AM because it was busy. NA B said, I never witnessed another CNA be rude or yell. NA B said, In some situations you have to treat people different, they cannot all be treated the same. NA B said LVN A had been a police officer. NA B said LVN A was [NAME] so when she spoke it was a loud voice. NA B said I did not make the comment you need to lose weight to any of the residents. NA B said he always got Resident #2 up and never made her stay in the bed. NA B said it was important to respect their right because this was their home if they want to do something we should do it for them. During an interview on [DATE] at 3:56 PM, Anonymous Staff Member #2 said, she had heard the CNAs yelling and cursing at the residents. Anonymous Staff Member #2 said in the past she had witnessed CNA D, CNA E, CNA F, and CNA C yell and curse at any resident that could express themselves or express their needs. In particular Resident #2, Resident #7 and Resident #6. Anonymous Staff Member said they were very mean to Resident #2. Anonymous Staff Member #2 said she witnessed the incident on [DATE] when CNA D and CNA E yelled and cursed at Resident #7 and Resident #2. Anonymous Staff Member #2 said it was CNA D that told Resident #2 that she could not get up. Anonymous Staff Member #2 said she called the Ombudsman to the nurse's station to hear the incident. Anonymous Staff Member #2 said the facility was the residents' home and the residents should be able to get up when they wanted to do so. Anonymous Staff Member #2 said the residents could become depressed because of isolating them. Anonymous Staff Member #2 said verbal abuse would make the residents feel withdrawn and scared to be at the facility. Anonymous Staff Member #2 said she did not feel like she could report abuse to the Administrator at any time. Anonymous Staff Member #2 said when she reported abuse to the Administrator, the Administrator would throw her under the bus, and tell the CNAs she reported them. The CNAs would then tell her to do things herself. During an interview on [DATE] at 8:20 AM, Anonymous staff member #3 said she no longer employed at the facility, and it had been ,d+[DATE] weeks since the last time she worked. Anonymous staff member #3 said CNA E and CNA F yelled and cursed at the residents. Anonymous staff member #3 said CNA E and CNA F would tell the residents they were not getting them out of bed. Anonymous staff member #3 said CNA E and CNA F would tell Resident #2 and Resident #7 not to ask to get out of bed because they were not going to do it. Anonymous staff member #3 said CNA E and CNA F made Resident #2 and Resident #7 cry many times. Anonymous staff member #3 said it was like an act of congress to get anyone to help him, referring to the CNAs assisting Resident #3 with his ADLs. Anonymous staff member #3 said Resident #3 was scared to ask the CNAs for assistance. Anonymous staff member #3 said she reported the CNAs yelling, cursing, and not assisting the residents to the DON and Administrator over and over again and there were no consequences for the CNAs. During an attempted phone interview with LVN A on [DATE] at 4:40 PM, LVN A did not respond to phone call. During an interview on [DATE] at 06:19 PM, the ADON said she had been the ADON for 6 - 7 weeks. The ADON said she and the DON were responsible for the oversight and monitoring of clinical staff. The ADON said she was not in Resident #3's room when LVN A said she couldn't stomach the wound. The ADON said Resident #3 reported this incident to her and she did the grievance form, and it was signed by the Administrator and DON. The ADON said she had not witnessed nor had any reports of any of the CNA's yelling or cursing at the residents. During an interview on [DATE] at 06:33 PM, the DON said she was not present during the incident with Resident #1. The DON said Resident #1 did not tell her LVN A threw the nebulizer treatments at him. The DON said Resident #1 said the box fell in his lap and was not a big deal. The DON said Resident #1 was scared of LVN A because he asked her for something and instead of giving it, she belittled him. The DON said that she did not recall the incident with Resident #5 other than provided in-services regarding abuse and educate the staff that this is the resident's home, and they have the right to feel safe and secure in the home. The DON said Resident #2 had reported to her that the CNAs did not want to get her out of bed. The DON said there were multiple times Resident #2 would say she did not get a shower. The DON said, I am not saying she never missed a shower because there were problems. The DON said she tried to coordinate that people were getting their showers. The DON said she was aware of the incident with Resident #4. The DON said she took his witness statement because he could not write. The DON said Resident #4 was shaking, scared, upset, and crying. The DON said she was not aware of the incidents with Resident # 3, Resident #7. The DON said she had no complaints about NA B, CNA C, CNA D, CNA E, CNA F. During an interview on [DATE] at 08:18 PM, The Administrator said Resident #5's family member talked to her and confirmed that the incident with the CNAs yelling at Resident #5 did not happen. The Administrator did not specify how this was confirmed. The Administrator said she protected the residents by educating the staff on abuse and neglect and completing safe surveys on the residents. The Administrator said a family member complained to her that the CNAs would not get Resident #2 out of bed. The Administrator said Resident #2 got out of bed every time she wanted. The Administrator said Resident #1 said the nurse dropped the nebulizer treatments in his lap. The Administrator said that Resident #1 did not want to report the incident because it was not a big deal. The Administrator said a Performance Improvement Plan was started on LVN A at this time ([DATE]). The Administrator said LVN A was terminated after the incident with Resident #4. The Administrator said LVN A was terminated on [DATE]. The Administrator said she was not notified of any abuse allegations involving NA B, CNA C, and CNA D. The Administrator said she was the abuse coordinator. The Administrator said she was not aware that the staff or residents were scared to report abuse allegations to her. The Administrator said it was important to protect the residents from abuse for their safety and to prevent emotional harm. Record review of LVN A's personnel file did not indicate any previous disciplinary actions. LVN A's personnel file did not indicate a termination date. During an interview on [DATE] at 5:15 PM (LVN A returned phone call after facility exit), LVN A said she had not received notification she was terminated by the facility. LVN A said she quit by not returning to work. LVN A said the last day she worked was [DATE]. LVN A said she quit after she was told she would have to pass out cigarettes during her medication pass time. LVN A said she was not going to stop passing out medications to give the residents their cigarettes. LVN A said she told several of the residents that smoked, including, Resident #4, that she was not going to stop passing out medications to give them their cigarettes. LVN A said after she told them this Resident #4 got really pissed off at her and started yelling and cursing that it was his right to smoke. LVN A said she told Resident #4, I am sorry, but I have got to get my medications passed, y'all need to remember smoking is a privilege an [TRUNCATED]

Based on interview and record review the facility failed to ensure the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or options preferred was provided for 9 of 9 residents reviewed for resident rights related COVID-19. (Resident #s 3, 1, 2, 4, 5, 6, 7, 8, and 9) The facility did not obtain informed consent, explain the risks, benefits, and possible serious side effects (serious health complications and death) of [MEDICATION NAME] ( a medication used to treat [DIAGNOSES REDACTED] and suppress the immune system) to Resident #s 3, 1, 2, 4, 5, 6, 7, 8, and 9 or their responsible representatives prior to administering the medication to treat COVID-19 symptoms. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a potential for more than minimal harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not being fully informed and provided the choice to participate or refuse medications or treatments that could cause serious side effects and death. Findings included: 1. Consolidated physician orders [REDACTED].#3 was [AGE] years old, admitted [DATE], re-admitted [DATE] and had [DIAGNOSES REDACTED]. The orders indicated Resident #3 received [MEDICATION NAME] 200 mg (milligrams) two tablets twice daily for one day ([DATE]) then received [MEDICATION NAME] 200 mg one tablet twice daily for five days ([DATE]-[DATE]). The MDS dated [DATE] indicated Resident #3 usually understood others, usually made himself understood, and his cognition was severely impaired. The MDS indicated Resident #3 required limited assistance with bed mobility, transferring, dressing, and bathing; and extensive assistance with toileting and personal hygiene. The care plan updated on [DATE] indicated Resident #3 tested positive for COVID-19. The care plan indicated Resident #3 would not exhibit signs of infection, would have normal vital signs and the absence of COVID-19 symptoms. The care plan did not address Resident #3 receiving [MEDICATION NAME]. The MAR indicated [REDACTED]. A laboratory report dated [DATE] indicated Resident #3 was positive for COVID-19. A nursing note dated [DATE] at 6:50 a.m. indicated Resident #3 was unresponsive and had no pulse or respirations when the nurse went into his room to check his blood sugar. The note indicated the nurse performed a sternal rub and Resident #3 did not respond. The note indicated Resident #3's code status was verified as DNR and the DON was notified. A nursing note dated [DATE] at 6:56 a.m. indicated the DON assessed Resident #3 and he had no pulse, blood pressure, or respirations. The note indicated the resident's family and physician was notified of his expiration. During an interview on [DATE] at 10:17 a.m., LVN C said she worked on [DATE] from 6 a.m. to 10 p.m. and Resident #3 had no signs and symptoms of COVID-19. She said Resident #3 had no cough, no shortness of breath, and no fever. She said Resident #3 was alert and talking at the end of her shift on [DATE]. LVN C said she was shocked when she returned to work and was notified Resident #3 expired. The clinical record dated [DATE] to [DATE] for Resident #3 did not indicate the resident or responsible party was provided information of the possible risks and benefits of [MEDICATION NAME] or the option to refuse the medication prior to administration. 2. Consolidated physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE] and had [DIAGNOSES REDACTED]. The orders indicated Resident #1 received [MEDICATION NAME] 200 mg 2 tablets twice daily for 1 day ([DATE]) then received [MEDICATION NAME] 200 mg 1 tablet daily for 5 days ([DATE]-[DATE]). The MAR indicated [REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 rarely/never made himself understood, rarely/never understood others, and his cognition was severely impaired. The MDS indicated Resident #1 required extensive assistance with transferring, toileting, personal hygiene, and bathing; and total assistance with dressing and eating. The care plan dated [DATE] indicated Resident #1 had an increased risk for COVID-19 related to compromised co-morbidities. The care plan indicated Resident #1 would not exhibit signs of infection, would have normal vital signs and the absence of COVID-19 symptoms. The care plan did not address the resident taking [MEDICATION NAME]. A laboratory report dated [DATE] indicated Resident #1 was positive for COVID-19. The clinical record dated [DATE] to [DATE] for Resident #1 did not indicate the resident or responsible party was provided information of the possible risks and benefits of [MEDICATION NAME] or the option to refuse the medication prior to administration. 3. Consolidated physician orders [REDACTED].#2 was [AGE] years old, admitted o[DATE], re-admitted [DATE] had [DIAGNOSES REDACTED]. The orders indicated Resident #2 received [MEDICATION NAME] 200 mg (milligrams) 1 tablet twice daily for 5 days ([DATE]-[DATE]). The MAR indicated [REDACTED]. The admission MDS dated [DATE] indicated Resident #2 usually made himself understood, usually understood others, and his cognition was moderately impaired. The MDS indicated Resident #2 required limited assistance with bed mobility, transferring, dressing, and personal hygiene; and extensive assistance with toileting and bathing. The care plan dated [DATE] indicated Resident #2 had an increased risk for COVID-19 related to compromised co-morbidities. The care plan indicated Resident #2 would not exhibit signs of infection, would have normal vital signs and the absence of COVID-19 symptoms. The care plan did not address Resident #2 receiving [MEDICATION NAME]. A laboratory report dated [DATE] indicated Resident #2 was positive for COVID-19. The clinical record dated [DATE] to [DATE] for Resident #2 did not indicate the resident or responsible party was provided information of the possible risks and benefits of [MEDICATION NAME] or the option to refuse the medication prior to administration. 4. Consolidated physician orders [REDACTED].#4 was [AGE] years old, admitted [DATE] and had [DIAGNOSES REDACTED]. The orders indicated Resident #4 received [MEDICATION NAME] 200 mg 2 tablets twice daily for 1 day ([DATE]), then [MEDICATION NAME] 200 mg 1 tablet twice daily for 4 days ([DATE]-[DATE]). The MAR indicated [REDACTED]. A laboratory report dated [DATE] indicated Resident #4 was positive for COVID-19. The MDS dated [DATE] indicated Resident #4 usually made herself understood, usually understood others, and her cognition was severely impaired. The MDS indicated Resident #4 required supervision with bed mobility; limited assistance with transferring; and extensive assistance with dressing and personal hygiene. The care plan updated on [DATE], after surveyor intervention, indicated Resident #4 tested positive for COVID-19. The care plan indicated Resident #4 would not exhibit signs of infection, would have normal vital signs and the absence of COVID-19 symptoms. The care plan indicated Resident #4 would be monitored for side effects of [MEDICATION NAME] as specified by her physician. The care plan indicated Resident #4 and/or responsible representative was provided a [MEDICATION NAME] fact sheet. The clinical record dated [DATE] to [DATE] for Resident #4 did not indicate the resident or responsible party was provided information of the possible risks and benefits of [MEDICATION NAME] or the option to refuse the medication prior to administration. 5. Consolidated physician orders [REDACTED].#5 was [AGE] years old, re-admitted [DATE], and had [DIAGNOSES REDACTED]. The orders indicated Resident #5 received [MEDICATION NAME] 200 mg 2 tablets twice daily for 1 day ([DATE]) and received [MEDICATION NAME] 200 mg 1 tablet twice daily for 5 days ([DATE]-[DATE]). The MAR indicated [REDACTED]. The MDS dated [DATE] indicated Resident #5 usually made herself understood, usually understood others, and her cognition was severely impaired. The MDS indicated Resident #5 required extensive assistance with bed mobility and toileting; and total assistance with dressing and personal hygiene. A laboratory report dated [DATE] indicated Resident #5 was positive for COVID-19. The care plan updated on [DATE] indicated Resident #5 tested positive for COVID-19. The care plan indicated Resident #5 would not exhibit signs of infection, would have normal vital signs and the absence of COVID-19 symptoms. The care plan did not address Resident #5 receiving [MEDICATION NAME]. The clinical record dated [DATE] to [DATE] for Resident #5 did not indicate the resident or responsible party was provided information of the possible risks and benefits of [MEDICATION NAME] or the option to refuse the medication prior to administration. 6. Consolidated physician orders [REDACTED].#6 was [AGE] years old, re-admitted [DATE] and had [DIAGNOSES REDACTED]. The orders indicated Resident #6 received [MEDICATION NAME] 200 mg 2 tablets twice daily for 1 day ([DATE]) and received [MEDICATION NAME] 200 mg 1 tablet twice daily for 5 days ([DATE]-[DATE]). The MAR indicated [REDACTED]. The MDS dated [DATE] indicated Resident #6 made herself understood, understood others, and her cognition was severely impaired. The MDS indicated Resident #6 was independent with most ADLs, but required extensive assistance with bathing. A laboratory report dated [DATE] indicated Resident #6 was positive for COVID-19. The care plan updated on [DATE] indicated Resident #6 tested positive for COVID-19. The care plan indicated Resident #6 would not exhibit signs of infection, would have normal vital signs and the absence of COVID-19 symptoms. The care plan did not address Resident #6 receiving [MEDICATION NAME]. The clinical record dated [DATE] to [DATE] for Resident #6 did not indicate the resident or responsible party was provided information of the possible risks and benefits of [MEDICATION NAME] or the option to refuse the medication prior to administration. 7. Consolidated physician orders [REDACTED].#7 was [AGE] years old, re-admitted [DATE] and had [DIAGNOSES REDACTED]. The orders indicated Resident #7 received [MEDICATION NAME] 200 mg 2 tablets twice daily for 1 day ([DATE]) and received [MEDICATION NAME] 200 mg 1 tablet twice daily for 5 days ([DATE]-[DATE]). The MAR indicated [REDACTED]. The MDS dated [DATE] indicated Resident #7 usually understood others, usually made himself understood, and his cognition was severely impaired. The MDS indicated Resident #7 required extensive assistance with bed mobility, transferring, dressing, toileting, and personal hygiene; and total assistance with bathing. A laboratory report dated [DATE] indicated Resident #7 was positive for COVID-19. The care plan updated on [DATE] indicated Resident #7 tested positive for COVID-19. The care plan indicated Resident #7 would not exhibit signs of infection, would have normal vital signs and the absence of COVID-19 symptoms. The care plan did not address Resident #7 receiving [MEDICATION NAME]. The clinical record dated [DATE] to [DATE] for Resident #7 did not indicate the resident or responsible party was provided information of the possible risks and benefits of [MEDICATION NAME] or the option to refuse the medication prior to administration. 8. Consolidated physician orders [REDACTED].#8 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The orders indicated Resident #8 received [MEDICATION NAME] 200 mg twice daily for 6 days ([DATE]-[DATE]). The MDS dated [DATE] indicated Resident #8 usually understood others, usually made himself understood, and his cognition was moderately impaired. The MDS indicated Resident #8 was independent with all ADLs except required extensive assistance with personal hygiene and bathing. A laboratory report dated [DATE] indicated Resident #8 was positive for COVID-19 The care plan updated on [DATE], after surveyor intervention, indicated Resident #8 tested positive for COVID-19. The care plan indicated Resident #8 would not exhibit signs of infection, would have normal vital signs and the absence of COVID-19 symptoms. The care plan indicated Resident #8 would be monitored for side effects of [MEDICATION NAME] as specified by his physician. The care plan indicated Resident #8 and/or responsible representative was provided a [MEDICATION NAME] fact sheet. The clinical record dated [DATE] to [DATE] for Resident #8 did not indicate the resident or responsible party was provided information of the possible risks and benefits of [MEDICATION NAME] or the option to refuse the medication prior to administration. 9. Consolidated physician orders [REDACTED].#9 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The orders indicated Resident #9 received [MEDICATION NAME] 200 mg 2 tablets twice daily for 1 day ([DATE]) and [MEDICATION NAME] 200 mg 1 tablet twice daily for five days ([DATE]-[DATE]). The MAR indicated [REDACTED]. The MDS dated [DATE] indicated Resident #9 made herself understood, understood others, and her cognition was severely impaired. The MDS indicated Resident #9 required extensive assistance with bed mobility, dressing, personal hygiene, and bathing; and total assistance with transferring and toileting. A laboratory report dated [DATE] indicated Resident #9 was positive for COVID-19. The care plan updated on [DATE] indicated Resident #9 tested positive for COVID-19. The care plan indicated Resident #9 would not exhibit signs of infection, would have normal vital signs and the absence of COVID-19 symptoms. The care plan did not address Resident #9 receiving [MEDICATION NAME]. The clinical record dated [DATE] to [DATE] for Resident #9 did not indicate the resident or responsible party was provided information of the possible risks and benefits of [MEDICATION NAME] or the option to refuse the medication prior to administration. During an interview on [DATE] at 12:02 p.m., the DON said she did not obtain verbal or written consent for the administration of [MEDICATION NAME] from residents or their responsible representatives. The DON said she did not obtain informed consent because she did not know it was required. During an interview on [DATE] at 1:25 p.m., the administrator said she was not familiar with [MEDICATION NAME]. The administrator said the DON was responsible for ensuring the nurses were adequately trained on medication administration. A Resident Rights Policy updated on ,[DATE] indicated, Employees shall treat all residents with kindness, respect, and dignity .these rights include the resident's right to .self-determination .be informed of .his or her care planning and treatment . A Requesting, Refusing, and/or Discontinuing Care or Treatment Policy updated on ,[DATE] indicated, Residents have the right to request, refuse, and/or discontinue treatment prescribed by his or her healthcare practitioner .Residents/representatives will be informed (in advance) of .the risks and benefits of the proposed treatment .the resident/representative will be informed of his or her rights to .request, refuse, and/or discontinue treatment . A fact sheet for patients and parent/caregivers emergency use authorization of [MEDICATION NAME] sulfate for treatment of [REDACTED].it is your choice to take [MEDICATION NAME] sulfate or stop it at any time . The administrator was notified on [DATE] at 2:04 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The administrator was provided the IJ template on [DATE] at 2:12 p.m. The facility's Plan of Removal was accepted on [DATE] at 8:45 p.m. and included: 1) Adequately assess and monitor residents prior to and during the administration of [MEDICATION NAME], 2) Educate nurses on what signs to monitor for that could indicate [MEDICATION NAME] complications, 3) Obtain consent prior to administering [MEDICATION NAME] .6. Action: Beginning on [DATE], an in-service was conducted with licensed nurses regarding [MEDICATION NAME] to include resident/responsible party consent, possible side effects, physician notification and physician ordered vital sign monitoring. On [DATE], as of 1:33 p.m., 90% of licensed nurses have been in-serviced. Center staff on leave will be in-serviced prior to returning to work. Completion date: [DATE]. Responsible: Nursing Administration (DON, Interim ADON, RNM) .7. Action: On [DATE] to seek consent, Interim ADON reviewed [MEDICATION NAME] facts with the responsible party for residents Resident #8, Resident #7, Resident #6, Resident #5 and Resident #4. Following review of [MEDICATION NAME] facts each residents' responsible party consented to the continued administration of [MEDICATION NAME]. Interim ADON documented responsible party consent in each residents' EMR. In addition, each residents' care plan was updated to include [MEDICATION NAME] administration. Completion date: [DATE]. Responsible: Interim ADON. 8. Action: Beginning on [DATE], Nursing Administration will begin conducting routine EMR audits, for those residents with orders for [MEDICATION NAME], during each morning clinical meeting to ensure consent obtained prior to administration .QAPI Committee will monitor compliance through audit results. QAPI Committee will develop a Performance Improvement Plan to address identified non-compliance to include licensed nurse education. Completion date: [DATE]. Responsible: Administrator, Director of Nursing, Interim ADON, Regional Nurse Manager . On [DATE] surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Nine LVNs (on all shifts - 6 a.m. to 6 p.m. shift, 6 p.m. to 6 a.m. shift, 6 a.m. to 10 p.m. shift, and 10 p.m. to 6 a.m. shift) and one RN (6 a.m. to 6 p.m. shift on Wednesdays and Thursdays and weekend RN supervisor) said they were in-serviced on obtaining informed consent from the resident and/or the resident's responsible representative prior to administering [MEDICATION NAME]. On [DATE] at 7:05 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice for 9 of 9 residents reviewed for assessments related to COVID-19. (Resident #s 3, 1, 2, 4, 5, 6, 7, 8, and 9). The facility did not develop and implement interventions to assess Resident #s 3, 1, 2, 4, 5, 6, 7, 8, and 9 who were given [MEDICATION NAME] (a medication used for treating [DIAGNOSES REDACTED] and [DIAGNOSES REDACTED] condition such as lupus and [MEDICAL CONDITION] arthritis) to treat COVID 19 (a new respiratory disease which can cause mild to severe illness). LVNs A, C and RN G who provided care to Resident #s 3, 1, 2, 4, 5, 6, 7, 8, and 9 were not trained on [MEDICATION NAME] and did not know how to assess residents receiving [MEDICATION NAME]. The medical director's nurse practitioner indicated residents receiving [MEDICATION NAME] should be assessed for noticeably rapid, strong, or irregular heartbeats and the residents' blood pressure and heart rate should be monitored at least every ,[DATE] hours for the duration of the medication administration. The medical director indicated residents receiving [MEDICATION NAME] were to be assessed for fluctuations in blood pressure and heart rate, as well as signs and symptoms of chest pain or increased shortness of breath at least 3 times a day. Resident #3 died 4 days after starting [MEDICATION NAME] and he did not exhibit any signs and symptoms of COVID 19. The facility did not follow their policy ( FDA emergency use authorization recommendations) of obtaining a baseline electrocardiogram (heart test) and evaluation of renal (kidney) and hepatic (liver) function and continued electrocardiogram monitoring while receiving [MEDICATION NAME] for Resident #s 3, 1, 2, 4, 5, 6, 7, 8, and 9. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for serious complications and possible death. Findings included: 1. Consolidated physician orders [REDACTED].#3 was [AGE] years old, admitted [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. The orders indicated Resident #3 received [MEDICATION NAME] 200 mg (milligrams) 2 tablets twice daily for 1day ([DATE]) [MEDICATION NAME] 200 mg 1 tablet twice daily for 5 days ([DATE]-[DATE]). The MAR indicated [REDACTED]. The MDS dated [DATE] indicated Resident #3 usually understood others, usually made himself understood, and his cognition was severely impaired. The MDS indicated Resident #3 required limited assistance with bed mobility, transferring, dressing, and bathing; and extensive assistance with toileting and personal hygiene. The care plan updated on [DATE] indicated Resident #3 tested positive for COVID-19 and would not exhibit signs of infection, would have normal vital signs and the absence of COVID-19 symptoms. The care plan did not address Resident #3 receiving [MEDICATION NAME]. A laboratory report dated [DATE] indicated Resident #3 was positive for COVID-19. A Continuity of Care report dated [DATE] indicated Resident #3's blood pressure (BP) and pulse while he received [MEDICATION NAME] were obtained as follows: *on [DATE] - pulse was documented at 8:45 a.m. and 10:25 a.m.; no blood pressure documented; *on [DATE] - BP and pulse were documented at 7:56 a.m. and 11:28 p.m.; *on [DATE] - BP was documented at 1:15 p.m. and BP and pulse were documented at 4:24 p.m. and 11:18 p.m.; *on [DATE] - BP and pulse was documented at 8:26 a.m. and 11:52 p.m.; *on [DATE] - BP and pulse were documented at 8:50 a.m. and BP only was documented at 5:46 p.m.; and *on [DATE] - BP and pulse were documented at 1:10 a.m. The clinical record from [DATE] to [DATE] for Resident #3 indicated he did not receive a baseline EKG and laboratory tests to indicate renal and hepatic functioning prior to receiving [MEDICATION NAME]. The record indicated Resident #3 did not receive laboratory tests and EKGs while taking the medication. The record indicated Resident #3 expired in the facility on [DATE] at 6:52 a.m. A nursing note dated [DATE] at 6:50 a.m. indicated Resident #3 was unresponsive and had no pulse or respirations when the nurse went into his room to check his blood sugar. The note indicated the nurse performed a sternal rub and Resident #3 did not respond. The note indicated Resident #3's code status was verified as DNR and the DON was notified. A nursing note dated [DATE] at 6:56 a.m. indicated the DON assessed Resident #3 and he had no pulse, blood pressure, or respirations. The note indicated the resident's family and physician was notified of his expiration. During an interview on [DATE] at 10:17 a.m., LVN C said she worked on [DATE] from 6 a.m. to 10 p.m. and Resident #3 had no signs and symptoms of COVID-19. She said Resident #3 had no cough, no shortness of breath, and no fever. She said Resident #3 was alert and talking at the end of her shift on [DATE]. LVN C said she was shocked when she returned to work and was notified Resident #3 expired. 2. Consolidated physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The orders indicated Resident #1 received [MEDICATION NAME] 200 mg 2 tablets twice daily for 1 day ([DATE]) then received [MEDICATION NAME] 200 mg 1 tablet daily for 5 days ([DATE]-[DATE]). The MAR indicated [REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 rarely/never made himself understood, rarely/never understood others, and his cognition was severely impaired. The MDS indicated Resident #1 required extensive assistance with transferring, toileting, personal hygiene, and bathing; and total assistance with dressing and eating. The care plan dated [DATE] indicated Resident #1 had an increased risk for COVID-19 related to compromised co-morbidities. The care plan indicated Resident #1 would not exhibit signs of infection, would have normal vital signs and the absence of COVID-19 symptoms and would be monitored for side effects of [MEDICATION NAME] as specified by his physician. A Continuity of Care report dated [DATE] indicated Resident #1's blood pressure (BP) and pulse while he received [MEDICATION NAME] were obtained on the following: *on [DATE] - BP and pulse were documented at 6:20 p.m.; and *on [DATE] - BP and pulse were documented at 10:06 a.m., 3:38 p.m., and 11:18 p.m. A laboratory report dated [DATE] indicated Resident #1 was positive for COVID-19. The clinical record from [DATE] to [DATE] for Resident #1 indicated he did not receive a baseline EKG and laboratory tests to indicate renal and hepatic functioning prior to receiving [MEDICATION NAME]. The record indicated Resident #1 did not receive laboratory tests and EKGs while taking the medication. During an observation on [DATE] at 12:45 p.m., Resident #1 was sitting up in his geriatric chair in his room on the hall for residents positive for COVID-19. Resident #1's face was deep red in color and dry. 3. Consolidated physician orders [REDACTED].#2 was [AGE] years old, admitted [DATE], re-admitted [DATE] and had [DIAGNOSES REDACTED]. The orders indicated Resident #2 received [MEDICATION NAME] 200 mg (milligrams) 1 tablet twice daily for 5 days ([DATE]-[DATE]). The MAR indicated [REDACTED]. The admission MDS dated [DATE] indicated Resident #2 usually made himself understood, usually understood others, and his cognition was moderately impaired. The MDS indicated Resident #2 required limited assistance with bed mobility, transferring, dressing, and personal hygiene; and extensive assistance with toileting and bathing. The care plan dated [DATE] indicated Resident #2 had an increased risk for COVID-19 related to compromised co-morbidities and would not exhibit signs of infection, would have normal vital signs and the absence of COVID-19 symptoms. The care plan did not address Resident #2 receiving [MEDICATION NAME]. A Continuity of Care report dated [DATE] indicated Resident #2's blood pressure and pulse were not obtained while he received [MEDICATION NAME]. The report indicated his blood pressure and pulse were last obtained on [DATE]. A laboratory report dated [DATE] indicated Resident #2 was positive for COVID-19. The clinical record from [DATE] through [DATE] for Resident #2 indicated he did not receive a baseline EKG and laboratory tests to indicate renal and hepatic functioning prior to receiving [MEDICATION NAME]. The record indicated Resident #2 did not receive laboratory tests and EKGs while receiving the medication. During an observation and interview on [DATE] at 12:20 p.m., Resident #2 was lying in bed in his room on the hall for residents positive for COVID-19. Resident #2 said his appetite was fair and he did not have a cough or difficulty breathing. 4. Consolidated physician orders [REDACTED].#4 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The orders indicated Resident #4 received [MEDICATION NAME] 200 mg 2 tablets twice daily for 1 day ([DATE]), and [MEDICATION NAME] 200 mg 1 tablet twice daily for 4 days ([DATE]-[DATE]). The MAR indicated [REDACTED]. The MDS dated [DATE] indicated Resident #4 usually made herself understood, usually understood others, and her cognition was severely impaired. The MDS indicated Resident #4 required supervision with bed mobility; limited assistance with transferring; and extensive assistance with dressing and personal hygiene. The care plan updated on [DATE], after surveyor intervention, indicated Resident #4 had tested positive for COVID-19 and would not exhibit signs of infection, would have normal vital signs and the absence of COVID-19 symptoms. The care plan indicated Resident #4 would be monitored for side effects of [MEDICATION NAME] as specified by her physician. A laboratory report dated [DATE] indicated Resident #4 was positive for COVID-19. A Continuity of Care report dated [DATE] indicated Resident #4's blood pressure and pulse were not obtained while she received [MEDICATION NAME]. The report indicated her blood pressure and pulse were last obtained on [DATE]. The clinical record from [DATE] through [DATE] for Resident #4 indicated he did not receive a baseline EKG and laboratory tests to indicate renal and hepatic functioning prior to receiving [MEDICATION NAME]. The record indicated Resident #4 did not receive laboratory tests or EKGs while taking the medication. During an observation on [DATE] at 12:24 p.m., Resident #4 was lying in bed, asleep, with oxygen via nasal cannula at 2 liters/minute . 5. Consolidated physician orders [REDACTED].#5 was [AGE] years old, re-admitted on [DATE] and had [DIAGNOSES REDACTED]. The orders indicated Resident #5 received [MEDICATION NAME] 200 mg 2 tablets twice daily for 1 day ([DATE]) then received [MEDICATION NAME] 200 mg 1 tablet twice daily for 5 days ([DATE]-[DATE]). The MAR indicated [REDACTED]. The MDS dated [DATE] indicated Resident #5 usually made herself understood, usually understood others, and her cognition was severely impaired. The MDS indicated Resident #5 required extensive assistance with bed mobility and toileting; and total assistance with dressing and personal hygiene. The care plan updated on [DATE] indicated Resident #5 had tested positive for COVID-19, would not exhibit signs of infection, would have normal vital signs and the absence of COVID-19 symptoms. The care plan did not address Resident #5 receiving [MEDICATION NAME]. A laboratory report dated [DATE] indicated Resident #5 was positive for COVID-19. A Continuity of Care report dated [DATE] indicated Resident #5's blood pressure and pulse were not obtained while she received [MEDICATION NAME]. The report indicated her blood pressure and pulse were last obtained on [DATE]. The clinical record from [DATE] through [DATE] indicated Resident #5 did not receive a baseline EKG and laboratory tests to indicate renal and hepatic functioning prior to receiving [MEDICATION NAME]. The record indicated Resident #5 did not receive laboratory tests or EKGs while taking the medication. During an observation and interview on [DATE] at 12:18 p.m., Resident #5 said she was sick, but breathing was okay. 6. Consolidated physician orders [REDACTED].#6 was [AGE] years old, re-admitted on [DATE] and had [DIAGNOSES REDACTED]. The orders indicated Resident #6 received [MEDICATION NAME] 200 mg 2 tablets twice daily for 1 day ([DATE]) and received [MEDICATION NAME] 200 mg 1 tablet twice daily for 5 days ([DATE]-[DATE]). The MAR indicated [REDACTED]. The MDS dated [DATE] indicated Resident #6 made herself understood, understood others, and her cognition was severely impaired. The MDS indicated Resident #6 was independent with all ADLs except required extensive assistance with bathing. The care plan updated on [DATE] indicated Resident #6 tested positive for COVID-19. The care plan indicated Resident #6 would not exhibit signs of infection, would have normal vital signs and the absence of COVID-19 symptoms. The care plan did not address Resident #6 receiving [MEDICATION NAME]. A laboratory report dated [DATE] indicated Resident #6 was positive for COVID-19. A Continuity of Care report dated [DATE] indicated Resident #6's blood pressure and pulse were obtained on [DATE] at 7:40 a.m. The clinical record from [DATE] through [DATE] indicated Resident #6 did not receive a baseline EKG and laboratory tests indicating renal and hepatic functioning prior to receiving [MEDICATION NAME]. The record indicated Resident #6 did not receive laboratory tests and EKGs while taking the medication. During an observation and interview on [DATE] at 12:19 p.m., Resident #6 was lying in bed. She was receiving oxygen via nasal cannula at 4 liters/minute and had difficulty breathing. Resident #6's face was flushed, she was coughing, and her finger tips were red-purple in color. Resident #6 said she had decreased appetite and was more tired than usual. 7. Consolidated physician orders [REDACTED].#7 was [AGE] years old, re-admitted [DATE] and had [DIAGNOSES REDACTED]. The orders indicated Resident #7 received [MEDICATION NAME] 200 mg 2 tablets twice daily for 1 day ([DATE]) and received [MEDICATION NAME] 200 mg 1 tablet twice daily for 5 days ([DATE]-[DATE]). The MAR indicated [REDACTED]. The MDS dated [DATE] indicated Resident #7 usually understood others, usually made himself understood, and his cognition was severely impaired. The MDS indicated Resident #7 required extensive assistance with bed mobility, transferring, dressing, toileting, and personal hygiene; and total assistance with bathing. The care plan updated on [DATE] indicated Resident #7 tested positive for COVID-19. The care plan indicated Resident #7 would not exhibit signs of infection, would have normal vital signs and the absence of COVID-19 symptoms. The care plan did not address Resident #7 receiving [MEDICATION NAME]. A laboratory report dated [DATE] indicated Resident #7 was positive for COVID-19. A Continuity of Care report dated [DATE] indicated Resident #7's blood pressure and pulse were not obtained while he received [MEDICATION NAME]. The report indicated his blood pressure and pulse were last obtained on prior to [DATE]. A clinical record from [DATE] through [DATE] for Resident #7 indicated he did not receive a baseline EKG and laboratory tests indicating renal and hepatic function prior to starting [MEDICATION NAME]. The record indicated Resident #7 did not receive laboratory tests and EKGs while taking the medication. During an observation on [DATE] at 12:31 p.m., Resident #7 was lying in bed, asleep and his lunch tray was on his bedside table untouched. 8. Consolidated physician orders [REDACTED].#8 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The orders indicated Resident #8 received [MEDICATION NAME] 200 mg twice daily for 6 days ([DATE]-[DATE]). The MAR indicated [REDACTED]. The MDS dated [DATE] indicated Resident #8 usually understood others, usually made himself understood, and his cognition was moderately impaired. The MDS indicated Resident #8 was independent with all ADLs except required extensive assistance with personal hygiene and bathing. The care plan updated on [DATE], after surveyor intervention, indicated Resident #8 tested positive for COVID-19. The care plan indicated Resident #8 would not exhibit signs of infection, would have normal vital signs and the absence of COVID-19 symptoms. The care plan indicated Resident #8 would be monitored for side effects of [MEDICATION NAME] as specified by his physician. A laboratory report dated [DATE] indicated Resident #8 was positive for COVID-19. A Continuity of Care report dated [DATE] indicated Resident #8's blood pressure and pulse were not obtained while he received [MEDICATION NAME]. The report indicated his blood pressure and pulse were last obtained on [DATE]. The clinical record from [DATE] through [DATE] indicated Resident #8 did not receive a baseline EKG and laboratory test indicating renal and hepatic function prior to starting [MEDICATION NAME]. The record indicated Resident #8 did not receive laboratory tests and EKGs while taking the medication. During an observation on [DATE] at 12:17 p.m., Resident #8 was lying in bed, receiving oxygen therapy via nasal cannula at 2 liters per minute. Resident #8 was lethargic and could not answer any questions. 9. Consolidated physician orders [REDACTED].#9 was [AGE] years old, admitted [DATE] and had [DIAGNOSES REDACTED]. The orders indicated Resident #9 received [MEDICATION NAME] 200 mg 2 tablets twice daily for 1 day (from [DATE] to [DATE]) and received [MEDICATION NAME] 200 mg 1 tablet twice daily for 5 days ([DATE]-[DATE]). The MAR indicated [REDACTED]. The MDS dated [DATE] indicated Resident #9 made herself understood, understood others, and her cognition was severely impaired. The MDS indicated Resident #9 required extensive assistance with bed mobility, dressing, personal hygiene, and bathing; and total assistance with transferring and toileting. The care plan updated on [DATE] indicated Resident #9 had tested positive for COVID-19. The care plan indicated Resident #9 would not exhibit signs of infection, would have normal vital signs and the absence of COVID-19 symptoms. The care plan did not address Resident #9 receiving [MEDICATION NAME]. A Continuity of Care report dated [DATE] indicated Resident #9's blood pressure and pulse were not obtained while she received [MEDICATION NAME]. The report indicated her pulse was last obtained on [DATE] at 9:53 a.m. A laboratory report dated [DATE] indicated Resident #9 was positive for COVID-19. The clinical record from [DATE] through [DATE] indicated Resident #9 did not receive a baseline EKG and laboratory test indicating renal and hepatic function prior to starting [MEDICATION NAME]. The record indicated Resident #9 did not receive laboratory tests or EKGs while taking the medication. During an observation and interview on [DATE] at 12:15 p.m., Resident #9 was lying in bed, receiving oxygen therapy via nasal cannula at 3 liters per minute. Resident #9 said she did not usually require oxygen therapy. During an interview on [DATE] at 10:09 a.m., LVN A said she provided care to the residents who received [MEDICATION NAME]. She said she did not know any information about [MEDICATION NAME]. LVN A said she had not received any training regarding the medication, side effects or possible serious complications to monitor for in residents receiving the medication. During an interview on [DATE] at 10:17 a.m., LVN C said she provided care to residents receiving [MEDICATION NAME]. She said she had not received any training regarding the medication, side effects or possible serious complications to monitor for in residents receiving the medication. During an interview on [DATE] at 1:20 p.m., RN G said she provided care to residents receiving [MEDICATION NAME]. RN G said she had not received any training regarding the medication, side effects or possible serious complications to monitor for in the residents receiving the medication. During an interview on [DATE] at 9:31 a.m., the facility's medical director's nurse practitioner said it was not feasible to check the residents' labs and EKGs while they were receiving [MEDICATION NAME] because of the number of residents positive for COVID-19 in the facility. The nurse practitioner said the facility should monitor the residents receiving [MEDICATION NAME] for noticeably rapid, strong, or irregular heartbeats and the residents' blood pressure and heart rate at least every ,[DATE] hours for the duration of the medication administration. During an interview on [DATE] at 12:10 p.m., the facility's medical director said he prescribed [MEDICATION NAME] to residents with COVID-19 because it was an effective therapy with which he had much experience. He said the benefits of the medication outweighed the risks. He said he had been encouraged by the local health department's infection control physician, to use [MEDICATION NAME] to treat COVID-19 positive residents to prevent an overwhelming burden to the local hospital. The medical director said he gave the facility staff orders to monitor residents for fluctuations in blood pressure and heart rate, as well as signs and symptoms of chest pain or increased shortness of breath. The medical director said he expected these assessments to be completed on residents at least 3 times a day. He said he did not feel outside resources should come into the facility for testing because of the risk of spreading [MEDICAL CONDITION] to the community. During an interview on [DATE] at 1:05 p.m., the DON said the residents who received [MEDICATION NAME] did not have baseline laboratory tests, EKGs, or assessments completed prior to administering the medication. She said the residents did not have increased monitoring while receiving [MEDICATION NAME]. She said some nurses had been trained on [MEDICATION NAME] but not all of them because the facility had new nurses working through the agency staffing company. The DON said the nurses should listen to the residents' heart at least every shift. During an interview on [DATE] at 1:25 p.m., the administrator said she was not familiar with [MEDICATION NAME]. The administrator said the DON was responsible for ensuring the nurses were adequately trained on medication administration. A fact sheet for patients and parent/caregivers emergency use authorization of [MEDICATION NAME] sulfate for treatment of [REDACTED].[MEDICATION NAME] sulfate has not been approved for the treatment of [REDACTED].a baseline electrocardiogram should be obtained to assess for QT interval prolongation (the heart muscle takes longer than normal to recharge between beats) and other abnormalities. Baseline evaluation of renal (kidney) and hepatic (liver) function is recommended .Use with caution with patients with [MEDICAL CONDITION], QT prolongation, a history of ventricular arrhythmias (irregular heart beat), [MEDICAL CONDITION] (low heart rate) .monitor the electrocardiogram during treatment .[MEDICATION NAME] sulfate has been reported to cause severe [DIAGNOSES REDACTED] (low blood sugar) .[MEDICATION NAME] may enhance the effects of hypoglycemic treatment, a decrease in doses of insulin and other antidiabetic drugs may be requires .[MEDICATION NAME] is known to be substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function . The website https://www.fda.gov/safety/medical-product-safety-information/[MEDICATION NAME]-or-chloroquine-covid-19-drug-safety-communication-fda-cautions-against-use posted [DATE] accessed [DATE] indicated [MEDICATION NAME] .should only be used for COVID 19 only when patients can be appropriately monitored in the hospital as required by the EUA or are enrolled in a clinical trial with appropriate screening and monitoring . FDA recommends initial evaluation and monitoring when using [MEDICATION NAME] or chloroquine under the EUA .to treat or prevent COVID-19. Monitoring may include baseline ECG, electrolytes, renal function and hepatic tests . The website https://www.fda.gov/media/ 4/download accessed on [DATE] indicated: .risks associated with [MEDICATION NAME] sulfate include serious heart rhythm problems; low blood sugar, particularly among people with diabetes; [MEDICAL CONDITION] and other blood problems; worsening of [MEDICAL CONDITION] and other neurology (brain) problems; and retina (layer of eye tissue) damage that can cause vision problems. [MEDICATION NAME] sulfate can also interact with other drugs and cause serious problems . The administrator was notified on [DATE] at 2:04 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The administrator was provided the IJ template on [DATE] at 2:12 p.m. The facility's Plan of Removal was accepted on [DATE] at 8:45 p.m. and included: 1) Adequately assess and monitor residents prior to and during the administration of [MEDICATION NAME], 2) Educate nurses on what signs to monitor for the could indicate [MEDICATION NAME] complications, 3) Obtain consent prior to administering [MEDICATION NAME] . 5. Action: On [DATE], to ensure adequate resident assessment prior to and during the administration of [MEDICATION NAME] the Regional Nurse Manager spoke with the facility's medical director. The facility's medical director requests vital signs (to include pulse and blood pressure) be taken TID and to monitor for shortness of breath and chest pain at administration. Each residents' EMR (electronic medical records) has been updated to include this monitoring. Completion date: [DATE]. Responsible: Nursing Administration (DON, Interim ADON, RNM) 6. Action: Beginning on [DATE], an in-service was conducted with licensed nurses regarding [MEDICATION NAME] to include resident/responsible party consent, possible side effects, physician notification and physician ordered vital sign monitoring. On [DATE], as of 1:33 p.m., 90% of licensed nurses have been in-serviced. Center staff on leave will be in-serviced prior to returning to work. Completion date: [DATE]. Responsible: Nursing Administration (DON, Interim ADON, RNM) 7. Action: On [DATE] to seek consent, Interim ADON reviewed [MEDICATION NAME] facts with the responsible party for residents Resident #8, Resident #7, Resident #6, Resident #5 and Resident #4. Following review of [MEDICATION NAME] facts each residents' responsible party consented to the continued administration of [MEDICATION NAME]. Interim ADON documented responsible party consent in each residents' EMR. In addition, each residents' care plan was updated to include [MEDICATION NAME] administration. Completion date: [DATE]. Responsible: Interim ADON 8. Action: Beginning on [DATE], Nursing Administration will begin conducting routine EMR audits, for those residents with orders for [MEDICATION NAME], during each morning clinical meeting to ensure consent obtained prior to administration and EMAR reflects documentation of TID physician ordered vital signs (to include pulse and blood pressure) and shortness of breath and chest pain monitored at administration. QAPI Committee will monitor compliance through audit results. QAPI Committee will develop a Performance Improvement Plan to address identified non-compliance to include licensed nurse education. Completion date: [DATE]. Responsible: Administrator, Director of Nursing, Interim ADON, Regional Nurse Manager . On [DATE] surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Nine LVNs (on all shifts - 6 a.m. to 6 p.m. shift, 6 p.m. to 6 a.m. shift, 6 a.m. to 10 p.m. shift, and 10 p.m. to 6 a.m. shift) and one RN (6 a.m. to 6 p.m. shift on Wednesdays and Thursdays and weekend RN supervisor) said they were in-serviced on assessing residents' vital signs including blood pressure and pulses, for shortness of breath, and for chest pain 3 times a day while they were receiving [MEDICATION NAME]. They said they were in-serviced on the potential complications (including low blood sugars, shortness of breath, chest pain, irregular heartbeats, blood pressure changes, yellowing in the eyes, [MEDICAL CONDITION], bleeding, and altered mental status) to monitor for while the residents received [MEDICATION NAME]. They said if any resident had any complications they would notify the physician immediately. On [DATE] at 7:05 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections was provided for the facility and for 2 of 6 residents reviewed for infection control related to COVID-19. (Residents #1 and #2) The facility did not: *Protect Resident #s 1 and 2 from exposure to COVID-19. Resident #s 1 and 2 tested negative for COVID-19, and were transferred to the positive COVID-19 hall without further testing after having an increase in temperature. *ensure the DON always wore her mask while in the facility after she tested positive for COVID-19; *properly screen staff prior to the start of shift; *ensure staff removed PPE prior to exiting the COVID-19 positive unit; *ensure a dedicated entrance and exit was provided for staff providing care to COVID-19 residents. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 5/6/20. While the IJ was removed on 5/12/20, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for being exposed to COVID-19, health complications, and death. Findings included: 1. Consolidated physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE] and had [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 rarely/never made himself understood, rarely/never understood others, and had severely impaired cognition. The MDS indicated Resident #1 required extensive assistance with transferring, toileting, personal hygiene, and bathing; and total assistance with dressing and eating. The care plan dated 3/20/20 indicated Resident #1 had an increased risk for COVID-19 related to compromised co-morbidities. The care plan indicated Resident #1 would not exhibit signs of infection, would have normal vital signs and the absence of COVID-19 symptoms. A laboratory report dated 4/26/20 indicated Resident #1 was negative for COVID-19. A vital sign report dated 4/24/20 to 5/6/20 indicated Resident #1's had a temperature above 98.6 (normal) on the following days: * 4/27/20 - 99.1; * 4/29/20 - 100.1; * 4/30/20 - 100.5; * 5/1/20 - 99.1; * 5/2/20 - 100.0; * 5/3/20 - 101.2; * 5/4/20 - 100.1; and * 5/6/20 - 100.1. A nursing note dated 4/29/20 at 6:26 p.m., recorded as a late entry on 5/5/20 at 6:32 p.m., indicated Resident #1 developed a temperature, both lungs were clear and he had a dry cough. The note indicated the resident's urine was clear and the physician was aware of Resident #1's transfer to his previous room on the COVID-19 positive unit. A nursing note dated 4/30/20 at 3:00 p.m., recorded as a late entry on 5/5/20 at 7:03 p.m., indicated Resident #1 had a temperature off and on, had a decreased appetite, and a dry cough. A nursing note dated 5/2/20 at 6:34 p.m., recorded as a late entry on 5/5/20 at 6:36 p.m., indicated Resident #1's lung sounds were even and not labored. The note indicated Resident #1 had a temperature off and on and had no other signs or symptoms of COVID-19. A nursing note dated 5/4/20 at 6:21 p.m., recorded as a late entry on 5/5/20 at 6:23 p.m., indicated Resident #1's oxygen saturation was 83% to 88% on room air. The note indicated Resident #1 had a temperature off and on since 4/29/20. The note indicated Resident #1's physician ordered oxygen as needed to keep his oxygen saturation above 90%. During an observation on 5/8/20 at 12:45 p.m., Resident #1 was sitting up in his geriatric chair in his room on the hall for residents positive for COVID-19. Resident #1 had a roommate in his room. Resident #1's face was deep red in color and dry and his respirations were shallow. A laboratory report dated 5/7/20 indicated Resident #1 was positive for COVID-19. 2. Consolidated physician orders [REDACTED].#2 was [AGE] years old, admitted on [DATE], re-admitted on [DATE] and had [DIAGNOSES REDACTED]. The admission MDS dated [DATE] indicated Resident #2 usually made himself understood, usually understood others, and his cognition was moderately impaired. The MDS indicated Resident #2 required limited assistance with bed mobility, transferring, dressing, and personal hygiene; and extensive assistance with toileting and bathing. The care plan dated 3/24/20 indicated Resident #2 had an increased risk for COVID-19 related to compromised co-morbidities. The care plan indicated Resident #2 would not exhibit signs of infection, would have normal vital signs and the absence of COVID-19 symptoms. A laboratory report dated 4/26/20 indicated Resident #2 was negative for COVID-19. A vital sign report dated 4/24/20 to 5/6/20 indicated Resident #2 had a temperature above 98.6 on the following days: *4/28/20 - 100.2 *4/29/20 - 99.1 A nursing note dated 4/28/20 at 1:44 p.m., recorded as a late entry on 5/5/20 at 6:47 p.m., indicated Resident #2 was alert and oriented times 2, and able to communicate his needs. The note indicated Resident #2 had a temperature of 100.2 with occasional dry cough, was feeling tired and did not remember the day or month. The note indicated his baseline was oriented times 3. A nursing note dated 4/30/20 at 2:55 p.m., recorded as a late entry on 5/5/20 at 6:59 p.m., indicated Resident #2 was symptomatic of COVID-19. The note indicated Resident #2 was running a temperature off and on, had fatigue, a headache, and body aches. A laboratory report dated 5/7/20 indicated Resident #2 was positive for COVID-19. During an observation and interview on 5/8/20 at 12:20 p.m., Resident #2 was lying in bed in his room on the hall for residents positive for COVID-19. Resident #2 said his appetite was fair and he did not have a cough or difficulty breathing. During an interview on 5/5/20 at 3:50 p.m., The DON said Resident #1 was transferred to the hall designated for COVID-19 positive residents on 4/29/20 and placed into a room with a resident that was confirmed positive for COVID-19. She said Resident #2 was moved to the hall designated for COVID-19 positive residents on 4/28/20. She said both residents developed a temperature and were transferred to the positive hall because the medical director said to move residents with signs and symptoms of COVID-19 to the positive hall. The DON said Residents #s 1 and 2 were not retested for COVID-19 prior to being transferred to the positive halls. She said there was not a physician order, fax communication, or a nursing note that documented the medical director's instruction to transfer the negative residents to the positive hall. During an interview on 5/5/20 at 3:18 p.m., the administrator said Residents #s1 and 2 were initially negative for COVID-19, then developed symptoms and were moved to the hall with residents positive for COVID-19. She said neither resident was retested for COVID-19 prior to being moved to the positive hall because the medical director did not want the residents retested . The administrator said the DON was the facility's Infection Preventionist, and the regional nurse manager was the backup Infection Preventionist. During an interview on 5/5/20 at 3:24 p.m., the facility's medical director said he did not tell the facility not to retest Residents #1 and #2. He said if residents were originally negative for COVID-19, then developed signs and symptoms of COVID-19, they should have been retested prior to transferring the residents to the hall with the residents positive for COVID-19. 3. A laboratory report dated 4/25/20 indicated the DON was positive for COVID-19. During an interview on 5/6/20 at 10:09 a.m., LVN A said the DON did not wear her face mask at all times while in the facility. During an interview on 5/6/20 at 10:23 a.m., CNA E said the DON did not wear her face mask at all times while in the facility. CNA E said the DON walked around the facility coughing without wearing her mask. During an interview on 5/6/20 at 10:30 a.m., LVN B said the DON did not wear her face mask at all times while in the facility. During an interview on 5/6/20 at 12:02 p.m., the DON said she worked on the positive side only and always wore her N95 mask while in the facility. The DON said she did not have a cough. During an observation and interview on 5/6/20 at 1:20 p.m., RN G walked into the DON's office on the positive hall and was not wearing shoe covers. She said she forgot to put them on prior to entering the positive side. She said she usually forgot to remove them at the end of her shift prior to exiting the facility. RN G left the positive side and walked back into the foyer/front area of the building. She did not remove her gown or gloves prior to exiting the positive side to go into the front area of the building. RN G sat in a chair in the front area of the building with her gown and gloves still on to put on her shoe covers. She said she forgot to remove her gown and gloves prior to exiting the positive side but should have removed them before going into the front area of the building. During an interview on 5/6/20 at 1:22 p.m., the DON said she expected all staff to wear all PPE (personal protective equipment) at all times while in the facility. The DON said all staff should wear gowns, gloves, face shields, N95 masks, and shoe covers while in the facility. During an interview on 5/6/20 at 1:25 p.m., the administrator said she expected all staff including the DON to wear all PPE (gowns, gloves, masks, face shields, and shoe covers) at all times while in the facility. She said staff should remove their PPE prior to exiting the COVID-19 unit. 4. During an observation on 5/5/20 at 1:50 p.m., Staff F had to be prompted to screen the surveyor upon entering the facility. During an interview on 5/6/20 at 10:09 a.m., LVN A said she screened herself when she entered the facility. During an interview on 5/6/20 at 10:17 a.m., LVN C said she screened herself when she entered the facility. During an interview on 5/6/20 at 10:23 a.m., CNA E said staff had to screen themselves when they entered the facility. During an interview on 5/6/20 at 1:05 p.m., the DON said she expected every staff member to be screened by the designated staff member assigned to screen staff prior to entering the facility. During an interview on 5/6/20 at 1:25 p.m., the administrator said the staff member assigned to screen staff or whoever answered the front door was responsible for screening and ensuring every person who entered the facility put on all their PPE. 5. During an interview on 5/6/20 at 10:09 a.m., LVN A said she worked on the positive hall, and entered and exited the facility through the front entrance of the facility. During an interview on 5/6/20 at 10:23 a.m., CNA E said he worked on the positive hall, and all staff entered and exited through the front entrance of the facility. During an interview on 5/6/20 at 10:17 a.m., LVN C said she worked on the positive hall, and entered and exited the facility through the front entrance of the facility. During an interview on 5/6/20 at 1:05 p.m., the DON said staff were previously exiting through the door at the end of the COVID-19 unit, but corporate owners instructed the facility staff to enter and exit through the facility's main front entrance. During an interview on 5/6/20 at 9:50 a.m., the administrator said all staff entered the facility through the front entrance and at the end of their shifts all staff exited through the front entrance of the building. During an interview on 5/6/20 at 1:25 p.m., the administrator said the corporate owners implemented the staff entering and exiting the facility through the main front entrance of the facility. A facility provided CDC guidance titled Interim Infection Prevention and Control Recommendations for Patients suspected or confirmed Coronavirus Disease 2019 in healthcare settings, updated on 4/13/20 and adopted as the facility COVID-19 policy indicated, .Actively screen everyone for fever and symptoms of COVID-19 before they enter the healthcare facility .isolate symptomatic patients as soon as possible .place patients with suspected or confirmed COVID-19 in private rooms with the door closed and with private bathrooms .current data suggest person to person transmission most commonly happens during close exposure to a person infected with [MEDICAL CONDITION] that causes COVID-19, primarily via respiratory droplets produced when the infected person speaks, coughs, or sneezes .as part of source control efforts, healthcare personnel (HCP) should wear a facemask at all times while they are in the healthcare facility .attention should be paid to training and proper donning (putting on), doffing (taking off), and disposal of any PPE .HCP who enter the room of a patient with known or suspected COVID-19 should adhere to Standard Precautions and use a respirator ., gown, gloves, and eye protection .HCP must receive training on and demonstrating an understanding of when to use PPE, what PPE is necessary, how to properly don, use, and doff PPE in a manner to prevent self-contamination, how to properly dispose of or disinfect and maintain PPE . The CDC website at <https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html> accessed 5/13/20 indicated, .Dedicate Space in the Facility to Monitor and Care for Residents with COVID-19. Dedicate space in the facility to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19. Assign dedicated HCP to work only in this area of the facility. Have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, prioritize for testing, transfer to COVID-19 unit if positive). Closely monitor roommates and other residents who may have been exposed to an individual with COVID-19 and, if possible, avoid placing unexposed residents into a shared space with them. Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options may include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. Residents could be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their exposure (or admission). Testing at the end of this period could be considered to increase certainty that the resident is not infected. If an observation area has been created, residents in the facility who develop symptoms consistent with COVID-19 could be moved from their rooms to this location while undergoing evaluation . The CDC website https://www.cdc.gov/quarantine/maritime/definitions-signs-symptoms-conditions-ill-[MEDICATION NAME].html accessed 5/13/20 indicated .CDC considers a person to have a fever when he or she has a measured temperature of at least 100.4 °F . The administrator was notified on 5/6/20 at 2:04 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The administrator was provided the IJ template on 5/6/20 at 2:12 p.m. The facility's Plan of Removal was accepted on 5/7/20 at 8:45 p.m. and included: 1) . Document assessment of two negative COVID residents prior to relocating them to the positive hall, and 5) Ensure DON wears facemask at all times while inside center. 1. Action: On May 6, 2020 an in-service was conducted with the Director of Nursing regarding the requirement for all nursing facility personnel to wear a facemask as well as required PPE at all times while inside the center. Completion date: May 6, 2020. Responsible: Regional Nurse Manager (RNM) 2. Action: Beginning on May 6, 2020, an in-service was conducted with all staff regarding the requirement for all nursing facility personnel to wear a facemask as well as required PPE at all times while inside the center. On May 6, 2020 as of 6:37 p.m., 59% of staff have been in-serviced. Center staff on leave will be in-serviced prior to returning to work. Completion date: May 8, 2020. Responsible: Nursing Administration (DON, Interim ADON, RNM) 3. Action: On April 26, 2020 negative COVID Resident #1 and Resident #2 were moved from the negative to the positive COVID hall due to elevated temperatures. To ensure proper treatment and services, on the morning of May 6, 2020 Gamma laboratory services conducted a lab draw on Resident #1 and Resident #2 for influenza A and B, strep and COVID-19. As of May 6, 2020, at 6:04 p.m. the results are pending. Upon receipt of results attending physician will be notified. Completion date: May 6, 2020. Responsible: Nursing Administration (DON, Interim ADON, RNM) 4. Action: Beginning May 7, 2020, any COVID negative resident identified to be symptomatic will be relocated to designated rooms 33 or 36. The attending physician will be notified of the resident change in condition. Nursing Administration will designate direct care staff to care for the symptomatic resident. Designated staff will enter/exit the center at the end of the hall. A resident will not be moved to the COVID positive unit unless identified to be COVID positive through physician ordered testing. Beginning on May 7, 2020, an in-service was conducted with Administrative and direct care staff regarding this procedure. On May 7, 2020 as of 6:00 p.m., 100% of staff have been in-serviced. Center staff on leave will be in-serviced prior to returning to work. Completion date: May 7, 2020. Responsible: Administrator, Nursing Administration (DON, Interim ADON, RNM) .9. Action: Beginning on May 7, 2020, Administrator and/or Director of Nursing will make alternating center rounds six times a day throughout the center to ensure staff adherence to the use of facemasks. QAPI Committee will be notified of identified non-compliance. QAPI Committee will develop a Performance Improvement Plan to address identified non-compliance to include staff education and/or disciplinary action. Completion date: May 7, 2020. Responsible: Administrator, Director of Nursing, Regional Nurse Manager, RN Supervisor, Regional Vice President . On 5/12/20 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Nine LVNs (on all shifts - 6 a.m. to 6 p.m.; 6 p.m. to 6 a.m.; 6 a.m. to 10 p.m.; and 10 p.m. to 6 a.m.), 1 RN (6 a.m. to 6 p.m. on Wednesdays and Thursdays and weekend RN supervisor), 7 CNAs (on all three shifts), 3 dietary staff, 2 general staff members, 2 housekeeping staff, and the maintenance director said they were in-serviced on donning and doffing all PPE. They were able to verbalize step by step donning and doffing techniques appropriately. They said they were in-serviced on being screened at the beginning of their shifts and donning their PPE prior to reporting to their assigned area. They said they were in-serviced on the entrance and exits approved to use for the positive and negative halls. Five LVNs (all shifts - 6 a.m. to 10 p.m.; 10 p.m. to 6 a.m.; and 6 p.m. to 6 a.m.) said they were in-serviced on what to do if residents who were negative for COVID-19 became symptomatic. They said any residents who were negative and became symptomatic should be moved to Rooms 33 or 36 and isolated. They said the resident's physician should be notified of the resident's change in condition, and the administrator should be notified. They said the residents would not be transferred to the positive unit unless they were identified to be COVID-19 positive though a COVID-19 test. They said staff assigned to provide care for symptomatic residents would enter/exit the facility at the end of the hall and staff assigned to negative, asymptomatic residents would enter/exit the facility through the facility's main entrance. On 5/12/20 at 7:05 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview, and record review, the facility failed to ensure supervision and assistance devices were provided to prevent accidents for 1 of 5 residents reviewed for accidents. (Resident #1) The facility did not provide a safe assistive device, adequate staff and supervision for Resident #1 when transferring her with a mechanical lift. Resident #1 fell and required 3 staples in the back of head. This failure could place residents who required transfer with a mechanical lift at risk for injuries or death. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] indicated Resident #1 was understood by others, understands others and her cognition was severely impaired. The MDS indicated she required total assist performing bed mobility, transfers, dressing, toileting and personal hygiene. The MDS indicated she required 3 staff for assist with bed mobility, transfers and bathing. The MDS indicated Resident #1 was always incontinent of bladder and bowel and had no falls within the past 3 months. A care plan dated 7/31/19 indicated Resident #1 had altered ADL functioning and required 2 staff and a mechanical lift for transfers. The interventions included to have 2 staff to safely transfer the resident using the mechanical lift. A care plan dated 1/9/20 indicated Resident #1 was at risk for falls due to weakness and intermittent confusion. The approach indicated she required 2 staff assistance and supervision with transfers. An accident report dated 1/16/20 at 1:43 p.m., indicated Resident #1 fell backwards out of the mechanical lift sling during a transfer. The report indicated CNA B performed a mechanical lift transfer and while the lift was in the up position it became stuck with Resident #1 in the sling. The report indicated CNA B left the resident to go to the door to get help and the resident slid out of the sling. The report indicated Resident #1 was sent to the hospital and received 3 staples to back of head and sustained no other injuries. A radiology report dated 1/16/20 at 3:09 p.m., indicated Resident #1 had a head CT scan and results indicated no evidence of acute intracranial process. A radiology report dated 1/16/20 at 3:11 p.m., indicated Resident #1 had a cervical CT scan and results indicate no acute traumatic abnormality of the cervical spine. A nursing progress noted dated 1/16/20 at 1:43 p.m., indicated CNA B was transferring Resident #1 to bed with use of mechanical lift and the lift hung. The nursing note indicated CNA B called for help and LVN A entered the room and the resident slipped out and hit her head on the floor. The nursing note indicated Resident #1 was bleeding from the right side of her head and was sent to the hospital. A nursing note dated 1/16/20 at 4:00 p.m., indicated Resident #1 returned to the facility with 3 staples in the back of her head. During an interview on 1/30/20 at 10:03 a.m., CNA B said on 1/16/20 at approximately 1:40 p.m., she was transferring Resident #1 from her chair to the bed. She said the resident was in the air in the sling on the mechanical lift when the lift froze. CNA B said she turned the lift off and back on a couple of times and it was still stuck. The CNA said she was alone in the room, she went to the door to ask for help and when she got to the door she heard Resident #1 hit the floor head first. CNA B said LVN A arrived about the time Resident #1 hit the floor. CNA B said she did not see the resident fall out of the sling. She said the sling was connected to the lift, intact and the resident must have leaned back and slipped out of the sling. CNA B said the lift had froze on her (2) times in the past during transfer with a resident in the sling. She said it usually started working again after it was turned off and back on. CNA B said she reported to LVN A and LVN [NAME] regarding the issues with the lift in the past. The CNA said there was an emergency switch on the lift, but she was in a panic and did not remember to use the switch to lower the lift. CNA B said she should have had another CNA in the room with her during the transfer. CNA B said it was not uncommon for her to transfer Resident #1 alone while using the mechanical lift. CNA B said prior to the incident she used the mechanical lift for transfer of 2 residents without assistance from other staff. CNA B said she was in-serviced 1/16/20 on the facility policy and procedure for transfers using the mechanical lift and no longer attempted to transfer a resident without assistance of another staff. CNA B said the maintenance supervisor was aware of the issues and he looked at the mechanical lift. CNA B said she thought the administrator and DON were aware of the issues because the maintenance supervisor and charge nurses had been informed. She said the lift was removed from the facility immediately after the incident and a new one arrived the following day. CNA B said she was in-serviced on the new lift 1/17/20. During an interview on 1/30/20 at 10:55 a.m., LVN A said on 1/16/20 at around 1:40 p.m., he heard CNA B call for help in Resident #1's room. He said when he entered the room the resident was on the floor and bleeding from the back of her head. He said he called for the ambulance and after she was transported to the hospital he and the RN supervisor removed the faulty mechanical lift from the facility to an outside storage area per the administrator instructions. The LVN said he knew the lift had been locking up while residents were suspended for a couple of months. He said he thought everyone knew about it because it had been going on for a while. LVN A said he never verbally or submitted in writing the malfunction of the mechanical lift. He said he knew CNAs were using the lift on occasion without assistance of another staff member. He said he was in-serviced on the policy for transfers with the mechanical lift and requirement of (2) staff during the transfer. LVN A said he was in-serviced on the use of the new mechanical lift on 1/17/20. During an observation and interview on 1/30/20 at 9:42 a.m., Resident #1 was sitting in a specialty chair. She was unable to recall the events of the incident on 1/16/20 or her injury. Resident #1 was unable to describe how staff transferred her from the bed to chair. During an interview on 1/30/20 at 9:30 a.m., CNA D said she was in another room assisting a resident on 1/16/19 at the time of Resident #1's incident. She said the mechanical lift had froze up on her during transfers for the past 2 to 3 months. She said she had not verbally or submitted in writing the faulty mechanical lift. CNA D said she had asked the maintenance supervisor a couple of times to look at the lift. CNA D said when the lift froze during a transfer she used the emergency switch to release the lift. The CNA said prior to the incident with Resident #1 she used the mechanical lift alone for transfer of 2 residents without assistance from other staff. CNA D said she was in-serviced 1/16/20 on use of the mechanical lift and the policy stated to use 2 staff when transferring with the mechanical lift. CNA D said the mechanical lift was removed from the facility immediately after the incident and a new one arrived the following day. She said she was in-serviced on the new mechanical lift 1/17/20. During an interview on 1/30/20 at 10:23 a.m., CNA C said she used the mechanical lift for 3 residents. She said she used the mechanical lift without assistance of other staff prior to the incident with Resident #1. CNA C said the mechanical lift froze while she was transferring residents at least 3 to 4 times in the past 3 to 4 months. She said the mechanical lift froze while a resident was suspended in the up position and she always used the emergency release switch to lower the resident. CNA C said there had been no injury of a resident while transferred with the mechanical lift during her care. CNA C said she did not personally say anything about the faulty lift to the DON or administrator, but she had reported it to LVN E. She said she transferred residents with the mechanical lift without assistance prior to Resident #1's incident. CNA C said she was in-serviced 1/16/20 on the facility policy for use of the mechanical lift and she now asked for assist of other staff while transferring residents. CNA C said the malfunctioned lift was removed from the facility and she received an in-service 1/17/20 on the new lift. During an interview on 1/30/20 at 10:33 a.m., LVN [NAME] said the CNA complained about the mechanical lift freezing during transferring while residents were suspended for a couple of months. She said she had not submitted anything in writing to the administrative staff because maintenance had been asked to work on the lift and she figured the administrator and DON were aware. She said she thought everyone knew the issue with the mechanical lift. The LVN said the old lift had been removed from the facility and a new one arrived 1/17/20. LVN [NAME] said she had been in-serviced on the use of the new mechanical lift and on the policy for transferring with a lift. LVN [NAME] said she was not aware the CNAs were transferring with the mechanical lift without assistance of another staff member. During an interview on 1/30/20 at 12:33 p.m., the DON said she had not been informed of the faulty mechanical lift prior to the incident. She said she was not aware staff were using the mechanical lift without assist of 2 staff. The DON said the lift was removed from the facility immediately after the incident on 1/16/20. She said the staff were in-serviced on 1/16/20 on use of the mechanical lift and accidents and supervision. She said the staff in-service included the facility policy on transfers with the mechanical lift required 2 staff. The DON said there were 2 mechanical lifts and 1 sit to stand lift in the facility. She said the other lifts were functioning without issues. During an interview on 1/30/20 at 10:43 a.m., the maintenance supervisor said he had been informed by the CNAs about the previous mechanical lift freezing up during transfers. He said he was unable to remember the date he looked at the lift and determined the hydraulics became distressed during transfer because of the weight of the resident and would not function. He said he told the staff when the mechanical lift froze to use the emergency switch to lower the resident to the chair or bed. He said he looked at the lift again per CNAs request for the same issue and was unable to remember the date. The maintenance supervisor said he did not consider the mechanical lift unsafe to use because the emergency switch was functioning and could be used to lower the resident when the hydraulics failed. The maintenance supervisor said he had not spoken to the administrator or submitted anything in writing about issues with the mechanical lift. The maintenance supervisor said a company serviced the lift every 3 months and tested for safety. He said the mechanical lift had been tested prior to the incident and he was unable to recall the date. He said he did not have anything in writing from the service company and a sticker was placed on the side of the mechanical lift and dated. The maintenance supervisor said the old mechanical lift had been trashed and was not at the facility. During an interview on 1/30/20 at 2:03 p.m., The administrator said he was notified on 1/16/20 after the incident occurred with Resident #1 about the faulty mechanical lift. He said he instructed the staff to remove the mechanical lift from the facility and it had since been thrown away. The administrator said after the incident on 1/16/20 the supervising RN conducted an in-service with all staff on facility policy and procedures using mechanical lifts, accidents and supervision. The administrator said the mechanical lift was greater than 8 years old and he did not know the exact date it was purchased. He said he was unaware the mechanical lift was not functioning properly, or he would have already had it removed and purchased a new one. The administrator said he expected 2 staff when transferring residents with a mechanical lift and he was not aware they were not following the policy while using a mechanical lift. The administrator said after the incident on 1/16/20 he submitted a request for purchase of a new lift and contacted a rental agency for a rented mechanical lift to be delivered on 1/17/20. He said the rental was delivered on 1/17/20 and the staff were in-serviced on the use of the new lift. He said the new purchased lift was delivered on 1/30/20 and would be serviced and tested by the testing company and an in-service would be given to all staff prior to use. An inspection and accuracy service statement dated 11/9/19 indicated 3 mechanical lifts were tested and certified for safety. An in-service dated 1/16/20 indicated nursing staff and CNA staff attended training regarding policy and procedures of correct usage of mechanical lifts and procedures for accidents and supervision. A policy titled using a mechanical lift dated (MONTH) 2019 indicated .at least two nursing assistants required to safely move a resident with a mechanical lift.

Based on observation, interview, and record review, the facility failed to implement their written policies to prohibit neglect for 2 of 10 residents reviewed for neglect. (Resident #2 and #5) The facility did not lock the wheels of Resident #2's shower chair before leaving her unattended. She fell from the unlocked chair and sustained a left femoral fracture. The facility did not prevent Resident #5 from rolling off his bed during care. The U-bar (a U shaped bar close to the head of the bed to assist the resident with bed mobility) had been removed and only one staff was providing care (instead of one on each side of the bed). This failure could place 12 residents who use shower chairs and 28 residents who require assistance with ADLs at risk for a decreased quality of life. Findings included: The abuse policy dated 5/5/17 indicated the following: .all investigation shall be conducted by the abuse prohibition coordinator; *the investigation will include interview o the employees, visitors, or residents who may have knowledge of the alleged incident. The interviewer shall document information obtained from the interviewee on the appropriate SLP interview worksheet; *the administrator will immediately notify the regional nurse consultant and the regional vice president of operations and an incident report will be generated and faxed to QA reader, and the team will discuss the details and make a determination regarding the reporting status; and *when an alleged or suspected case of mistreatment, neglect, injuries of an unknown source or abuse is reported, the facility administrator or his/her designee with after conferring with the regional team notify the Department fo Aging and disabilities Services. The Incident/Accident policy dated 9/20/12 indicated the following: * .the DON or designee will interview all witnesses and have them sign that the information is reflective of their statement; *a complete Accident/Incident investigation form must be completed for each occurrence of actual or suspected resident abuse. A written, signed and dated statement must be obtained from the person reporting the incident; *the administrator serves as the abuse coordinator and when an allegation of abuse or actual abuse is identified, the abuse protocol is implemented. The abuse coordinator initiates and conducts a thorough investigation to prevent recurrence; *Accidents/Incidents are reported both internally and externally in accordance with the state and federal guidelines; *interview staff, visitors or resident who have knowledge of the alleged incident and document information obtained from them; *document every step of the investigation in detail; and *a thorough report should contain a description of the alleged wrongdoing, a description of the documents, manuals, and witnesses examined, a summary of the information elicited, determinations as to credibility where there are fact conflicts, and finding of fact based credible evidence. 1. Consolidated physician orders [REDACTED].#2 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent care plan dated 3/22/17 indicated Resident #2 was at risk for falls and was to have staff supervision with intensity based on her need, and supervised showers and transfers. The most recent MDS dated [DATE] indicated Resident #2 was able to make her needs known and understand others. The MDS indicated Resident #2 required extensive to total two person assistance with bed mobility, personal hygiene, and bathing. Resident #2 required total one person assistance with transfers. Resident #2 had range of motion impairment to both sides of her lower extremities. An incident report dated 5/27/17 at 4:00 p.m. indicated Resident #2 was sitting up at the sink in her room for oral care and she leaned forward towards the sink and fell out of the shower chair to the floor, landing on her right side. The administrator and DON both signed off on the incident report. The report indicated Resident #2 said she was brushing her teeth, leaned forward to spit, and slid out of the shower chair. There was one witness listed, CNA B. The interventions listed on the incident investigation for preventing the incident from reoccurring were to re-educate staff and Resident #2 on safety measures to take (nothing listed), and for staff to stay with the resident until she was safely back to her bed or wheelchair. The incident investigation signed by the DON on 5/29/17 at 9:10 a.m., indicated Resident #2 was sitting in a shower chair to brush her teeth and when Resident #2 leaned forward, the shower chair moved backward, causing her to fall. During an interview on 8/21/17 at 12:30 p.m., Resident #2 said a couple of months ago, she had taken a shower and was in a large shower chair with a greenish/blue back on it. CNA B wheeled her to the sink in her room for oral care and did not lock the wheels on the shower chair. Resident #2 said CNA B then left the room to go get someone to assist her with transferring her. Resident #2 said she leaned forward to brush her teeth, and the shower chair shot out from under her towards the wall behind her, and she fell to the floor. Resident #2 said she heard a pop when she fell . Resident #2 said the fall resulted in her fracturing her left femur. Resident #2 said she underwent surgery and was in the hospital for 6 days. Resident #2 said the charge nurse only asked her if she was hurting and did not assess her. Resident #2 said she told the charge nurse she heard a pop when she fell and said her leg started to swell about 5 minutes after the accident. Resident #2 said she was paraplegic and cannot feel anything below her waist. Resident #2 said she received an x-ray about an hour after the incident following a friend's request for an x-ray. During an interview on 8/22/17 at 8:33 a.m., CNA B said about 5-6 weeks ago she assisted Resident #2 with a shower and took Resident #2 back to her room for oral care. CNA B said Resident #2 was in a large shower chair with a greenish/blue back. CNA B said she pushed Resident #2 up to her sink for oral care and locked 3 of 4 wheels on the shower chair and opened the door to get CNA E to help transfer resident #2 back to bed. CNA B said while her back was turned to Resident #2, she heard Resident #2 yell for help, and when she turned, Resident #2 was lying on the floor with some of her body under the sink. CNA B said she called the charge nurse to the room who assessed the resident. During an interview on 8/22/17 at 3:40 p.m., CNA E said she worked the day Resident #2 fell . CNA E said she was in room [ROOM NUMBER] and CNA B left Resident #2's (room [ROOM NUMBER]) room and stood at the doorway or room [ROOM NUMBER] and asked her if she would assist with Resident #2. CNA E said she heard Resident #2 yell out for help. CNA E said when she entered Resident #2's room, Resident #2 was lying on the floor and her shower chair was up against the wall behind where she had been sitting. CNA E said she did not think the shower chair was locked. During an observation on 8/22/17 at 10:10 a.m., the large shower chair that Resident #2 and CNA B both described was in the East shower room. The surveyor locked all wheels on the shower chair and the chair would not roll. During an observation on 8/22/17 at 4:32 p.m., Resident #2 was sitting up in the same shower chair she was in when the incident occurred. Resident #2 confirmed that it was the same chair. Resident #2 was moving about in the chair and leaning forward. The wheels were locked and the chair never moved. During an interview on 8/22/17 at 12:17 p.m., the DON said she assisted in the investigation of Resident #2's fall on 5/27/17. The DON said she took a statement from CNA B, but not Resident #2. The DON said when she asked CNA B what happened, CNA B said she did not lock the wheels on Resident #2's shower chair when she pushed her up to her sink. The DON said anytime a resident is in a shower chair and left unattended, the wheels should be locked. The DON said she thought she conducted an in-service on locking the shower chair wheels when care was provided, but was unable to locate documentation of the in-service. The DON said there was not a thorough investigation conducted into the incident because she did not interview other residents or staff about CNA B's care practices. During an interview on 8/22/17 at 12:30 p.m. the administrator said he interviewed Resident #2 about the incident when she returned from the hospital. The administrator said Resident #2 told him the fall was her fault, because she leaned forward in her shower chair to get her toothbrush instead of asking for assistance. The administrator said he did not report the incident the regulatory agency because Resident #2 could tell him what happened and he did not consider it to be neglect. The administrator said he did not know if the wheels on the shower chair were locked because he did not ask anyone that question. The administrator said he did not document his findings of the investigation. 2. Consolidated physician orders [REDACTED].#5 was [AGE] years old, re-admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #5 usually understood others and was able to make his needs known if prompted or given extra time. The MDS indicated Resident #5 required extensive one person assistance with bed mobility, personal hygiene, and dressing; required total one person assistance with toileting; and required extensive two person assistance with bathing. Resident #5 had range of motion impairment to one side of his upper extremities and both sides of his lower extremities. An incident report dated 8/9/17 at 1:00 p.m. indicated Resident #5 rolled off of his bed during care provided by CNA M and had no apparent injury. The incident report indicated the action taken was staff re-education and resident education. The administrator and the DON both signed off on the incident report. The investigation indicated Resident #5 did not remember that he fell . There was one witness listed, CNA M. The incident investigation (conclusion and interventions of incident) signed by the DON on 8/10/17 at 9:35 a.m. indicated the intervention listed to prevent the incident from reoccurring was to replace the U-bar (assist rail) to the right side of the bed. The clinical assessment on the occurrence section on the incident investigation indicated the right side U-bar (assist rail) on Resident #5's bed was missing. The incident investigation was signed by the administrator with no date or time of signature. The care plan initiated on 3/21/17 indicated Resident #5 had a potential for falls and required assistance with ADLS and transfers. The updated care plan dated 8/10/17, after the incident, indicated Resident #5 had multiple problems to affect his mobility while in bed, history of bilateral above the knee amputation, and had the potential for falls with risk for injury. The care plan with a start date of 9/12/16, revised on 8/10/17, indicated Resident #5 was to have enabler bars and a trapeze bar on his bed to help him turn and reposition. An undated CNA care plan indicated Resident #5 was dependent on two persons for assistance with bed mobility, toileting, and bathing. The CNA care plan was updated on 8/10/17 and indicated Resident #5 was dependent on two persons for assistance with bed mobility, transfers, and bed baths. During an interview on 8/24/17 at 9:44 a.m., CNA M said she provided incontinent care to Resident #5 and washed his chest. She said she was standing on the left side of Resident #5's bed while providing care. She said Resident #5 used his trapeze bar and left side assist rail to assist her with bed mobility. CNA M said during care, Resident #5 kept moving his body back and forth. CNA M said when she rolled Resident #5 to the right side of the bed, facing the window, he continued to move his body and fell off the bed. CNA M said she tried to grab his arm to stop him from falling, but her gloves were wet and they slipped off of him. She said she should have asked for someone to help her give Resident #5 a bed bath. CNA M said after Resident #5 fell , she realized the right side assist bar was not on his bed. During an interview on 8/24/17 at 8:40 a.m., the DON said Resident #5 required two person assistance with bed baths and there should have been two CNAS in the room when Resident #5 fell out of the bed on 8/9/17. She said the right side of Resident #5's bed did not have a U-bar at the time of the fall. The DON said a U-bar was an assist rail. During an interview on 8/24/17 at 1:58 p.m., Resident #5 said he fell off of his bed, on the side the window is on, while CNA M provided care for him. He said the assist rail was not on the side of his bed he fell off of. Resident #5 said the assist rail broke approximately one month ago. During an interview on 8/24/17 at 10:15 a.m., LVN J said Resident #5 used his trapeze bar and his assist rails for bed mobility. LVN J said Resident #5 did not have any injuries after he fell out of his bed on 8/9/17. During an interview on 8/24/17 at 10:20 a.m., the DON said she spoke with CNA M related to Resident #5 falling out of his bed. The DON said CNA M told her she lowered Resident #5 to the floor. The DON said she did not document one on one conversations she had with staff but she should have. The DON said Resident #5 had assist rails on each side of his bed previously, and was unsure how long the right side assist rail had been missing. During an interview on 8/24/17 at 10:48 a.m., the maintenance supervisor said Resident #5's right assist rail was replaced approximately two weeks ago related to being broken. He said he was not notified of the broken assist rail prior to Resident #5 falling out of bed. The maintenance supervisor said he checked Resident #5's room approximately one month ago and as far as he remembers there were two assist rails on Resident #5's bed. During an interview on 8/24/17 at 11:03 a.m., LVN H said Resident #5 uses his assist rails and trapeze bar to help with bed mobility. She said Resident #5 fell out of his bed on 8/9/17 while he received a bed bath. LVN H said she thought Resident #5's bed only had one assist rail at the time of the fall, but was not certain. During an interview on 8/24/17 at 12:03 p.m., the DON said she did not do an in-service with staff after Resident #5's fall on 8/9/17. During an interview on 8/24/17 at 2:23 p.m., the administrator said it was reported to him that on 8/9/17 CNA M was giving Resident #5 a bed bath, the resident rolled out of the bed, and CNA M lowered him to the floor. The administrator said he reviewed the incident report for Resident #5's fall. The administrator said Resident #5 had one assist rail prior to his fall on 8/9/17 and the second assist rail was added after the fall as an intervention to prevent further falls. The administrator said the DON started the investigation process on incidents related to nursing. A maintenance log was reviewed from December 2016 to August 24, 2017 and no entry was made related to Resident #5's assist rail being broken or missing. During an interview on 8/25/17 at 9:05 a.m. the administrator said 12 residents used shower chairs. The CMS 2567 dated 8/21/17 indicated 28 residents required assistance with bathing.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision to prevent injuries for 2 of 10 residents reviewed for accidents. (Resident #2 and #5) The facility did not provide assistance to prevent Resident #2 from falling out of her shower chair and sustaining a fractured left femur. Staff did not supervise Resident #2 to prevent her from smoking E-cigarettes in her room, and did not provide assistance that would prevent Resident #5 from falling from his bed during incontinent care. This failure could place 12 residents who used shower chairs, 28 residents who required assistance with bathing, and 5 residents who smoke E-cigarettes (electronic) at risk for injury. Findings included: 1. Consolidated physician orders [REDACTED].#2 was [AGE] years old, admitted on [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #2 was able to make her needs known and understand others. The MDS indicated Resident #2 required extensive to total two person assistance with bed mobility, personal hygiene, and bathing. Resident #2 required total one person assistance with transfers. Resident #2 had range of motion impairment to both sides of her lower extremities. The most recent care plan dated 3/22/17 indicated Resident #2 was at risk for falls and to have staff supervision with intensity based on her need, and to supervise her showers and transfers. During an interview on 8/21/17 at 12:30 p.m., Resident #2 said a couple of months ago, she had taken a shower and was in a large shower chair with a greenish/blue back on it. CNA B wheeled her to the sink in her room for oral care and did not lock the wheels on the shower chair. Resident #2 said CNA B then left the room to go get someone to assist her with transferring her. Resident #2 said she leaned forward to brush her teeth, and the shower chair shot out from under her towards the wall behind her, and she fell to the floor. Resident #2 said she heard a pop when she fell . Resident #2 said the fall resulted in her fracturing her left femur. Resident #2 said she underwent surgery and was in the hospital for 6 days. Resident #2 said the charge nurse only asked her if she was hurting and did not assess her. Resident #2 said she told the charge nurse she heard a pop when she fell and said her leg started to swell about 5 minutes after the accident. Resident #2 said she was paraplegic and cannot feel anything below her waist. Resident #2 said she received an x-ray about an hour after the incident following a friend's request for an x-ray. During an interview on 8/22/17 at 8:33 a.m., CNA B said about 5-6 weeks ago she had assisted Resident #2 with a shower and had taken Resident #2 back to her room for oral care. CNA B said Resident #2 was in a large shower chair with a greenish/blue back. CNA B said she pushed Resident #2 up to her sink for oral care and locked 3 of 4 wheels on the shower chair and opened the door to get CNA E to help transfer resident #2 back to bed. CNA B said when she turned her back on Resident #2 she heard Resident #2 yell for help and when she turned Resident #2 was lying on the floor with some of her body under the sink. CNA B said she called the charge nurse to the room who assessed her. During an interview on 8/22/17 at 8:55 a.m., LVN K said she did not witness Resident #2's fall but came to her room when the CNA B notified her of the fall. She said when she got to the room, the shower chair had been pushed out of the way, and Resident #2 was lying on the floor, with her head facing the wall and her feet toward the sink. LVN K said she was unsure if the wheels on the shower chair were locked or not prior to her fall. LVN K said Resident #2 denied hitting her head and denied any pain. She said she took Resident #2's vital signs, began neuro checks and did a full body assessment. She said there was a red spot on her right knee. LVN K said Resident #2 could feel some sensations at times as she knew when her catheter had issues. LVN K said she felt she should have gotten an X-ray sooner than she did but notified her family of her fall. She said when Resident #2's family arrived they had asked her to get an X-ray ordered and she had a funny feeling she needed to get an X-ray. During an observation on 8/22/17at 10:10 a.m., the large shower chair that Resident #2 and CNA B both described was in the East shower room. The surveyor locked all wheels on the shower chair and the chair would not roll. During an interview on 8/22/17 at 12:17 p.m., the DON said she assisted in the investigation of Resident #2's fall on 5/27/17. The DON said she took a statement from CNA B, but not Resident #2. The DON said when she asked CNA B what happened, CNA B said she did not lock the wheels on Resident #2's shower chair when she pushed her up to her sink. The DON said anytime a resident is in a shower chair and left unattended, the wheels should be locked. The DON said she thought she conducted an in-service on locking the shower chair wheels when care was provided, but was unable to locate documentation of the in-service. The DON said there was not a thorough investigation conducted into the incident because she did not interview other residents or staff about CNA B's care practices. During an interview on 8/22/17 at 12:30 p.m. the administrator said he interviewed Resident #2 about the incident when she returned from the hospital. The administrator said Resident #2 told him the fall was her fault, because she leaned forward in her shower chair to get her toothbrush instead of asking for assistance. The administrator said he did not report the incident the regulatory agency because Resident #2 could tell him what happened and he did not consider it to be neglect. The administrator said he did not know if the wheels on the shower chair were locked because he did not ask anyone that question. The administrator said he did not document his findings of the investigation. During an interview on 8/22/17 at 3:40 p.m., CNA E said she worked the day Resident #2 fell . CNA E said she was in Room 15 and CNA B left Resident #2's (Room 14) room and stood at the doorway or Room 15 and asked her if she would assist with Resident #2. CNA E said she heard Resident #2 yell out for help. CNA E said when she entered Resident #2's room, Resident #2 was lying on the floor and her shower chair was up against the wall behind where she had been sitting. CNA E said she did not think the shower chair was locked. During an observation on 8/22/17 at 4:32 p.m., Resident #2 was sitting up in the same shower chair she was in when the incident occurred. Resident #2 confirmed that was the same chair. Resident #2 was moving about in the chair and leaning forward and the wheel were locked and the chair never moved. An incident report dated 5/27/17 at 4:00 p.m. indicated Resident #2 was sitting up at the sink in her room for oral care and she leaned forward towards the sink and fallout of the shower chair to the floor landing on her right side. The administrator and DON both signed off on the incident report. The investigation indicated Resident #2 stated she was brushing her teeth and leaned forward to spit and slide out of the shower chair. There was one witness listed, CNA B. The interventions listed on the incident investigation for preventing the incident from reoccurring were to re-educate staff and resident #2 on safety measures to take (nothing listed), and for staff to stay with the resident until she was safely back to her bed or wheelchair. The incident investigation signed by the DON on 5/29/17 at 9:10 a.m., indicated Resident #2 was sitting in a shower chair to brush her teeth and when Resident #2 leaned forward the shower chair moved backward causing her to fall. A radiology report dated 5/27/17 indicated Resident #2 broke her left thigh bone in multiple places and had osteopenia. 2. During an observation on 8/21/17 at 2:20 p.m., Resident #2 had an E-cigarette laying on her bed side table. During an observation on 8/22/17at 10:00 a.m., Resident #2 had an E-cigarette lying on her bed side table. During an observation on 8/22/17 at 11:50 a.m., Resident #2 was lying in bed smoking an E-cigarette. During an interview on 8/23/17 at 10:20 a.m., the administrator said residents who smoke E-cigarettes must follow the same rules as residents who smoke regular cigarettes. The administrator said E-cigarettes must be secured by staff like all other cigarettes. The administrator said the designated smoking area is in the courtyard by the kitchen. The smoking policy dated September 2007 indicated the following: * .residents and visitors shall not be permitted to smoke in any area that is not designated as a smoking area; *all resident smoking paraphernalia must be checked in with the nurse; and *resident smoking paraphernalia will be secured at the nurse's station and provided to the resident at specified smoking times. During an interview on 8/28/17 the DON said 5 residents smoke E-cigarettes. 2. Consolidated physician orders [REDACTED].#5 was [AGE] years old, re-admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #5 usually understood others and was able to make his needs known if prompted or given extra time. The MDS indicated Resident #5 required extensive one person assistance with bed mobility, personal hygiene, and dressing; required total one person assistance with toileting; and required extensive two person assistance with bathing. Resident #5 had range of motion impairment to one side of his upper extremities and both sides of his lower extremities. The care plan dated 3/21/17 indicated Resident #5 had a potential for falls and required assistance with ADLS and transfers. The updated care plan dated 8/10/17, after the incident, indicated Resident #5 had multiple problems to affect his mobility while in bed, history of bilateral above the knee amputation, and had the potential for falls with risk for injury. The care plan with a start date of 9/12/16, updated on 8/10/17, indicated Resident #5 was to have enabler bars and a trapeze bar on his bed to help him turn and reposition. An undated CNA care plan indicated Resident #5 was dependent on two person assistance with bed mobility, toileting, and bathing. The CNA care plan was updated on 8/10/17 and indicated Resident #5 was dependent on two person assistance with bed mobility, transfers, and bed baths. During an interview on 8/24/17 at 8:40 a.m., the DON said Resident #5 required two person assistance with bed baths and there should have been two CNAS in the room when Resident #5 fell out of the bed on 8/9/17. She said the right side of Resident #5's bed did not have a U-bar at the time of the fall. The DON said a U-bar was an assist rail. During an interview on 8/24/17 at 9:44 a.m., CNA M said she provided incontinent care to Resident #5 and washed his chest. She said she was standing on the left side of Resident #5's bed while providing care. She said Resident #5 used trapeze bar and left side assist rail to assist her with bed mobility. CNA M said during care Resident #5 kept moving his body back and forth. CNA M said when she rolled Resident #5 to the right side of the bed, facing the window, he continued to move his body and fell off the bed. CNA M said she tried to grab his arm to stop him from falling but her gloves were wet and they slipped off of him. She said she should have asked for someone to help her give Resident #5 a bed bath. CNA M said after Resident #5 fell she realized the right side assist bar was not on his bed. During an interview on 8/24/17 at 10:15 a.m., LVN J said Resident #5 used his trapeze bar and his assist rails for bed mobility. LVN J said Resident #5 did not have any injuries after he fell out of his bed on 8/9/17. During an interview on 8/24/17 at 10:20 a.m., the DON said she spoke with CNA M related to Resident #5 falling out of his bed. The DON said CNA M told her she lowered Resident #5 to the floor. The DON said she did not document one on one conversations she had with staff but she should have. The DON said Resident #5 had assist rails on each side of his bed previously and was unsure how long the right side assist rail had been missing. During an interview on 8/24/17 at 10:48 a.m., the maintenance supervisor said Resident #5's right assist rail was replaced approximately two weeks ago related to being broken. He said he was not notified of the broken assist rail prior to Resident #5 falling out of bed. The maintenance supervisor said he checked Resident #5's room approximately one month ago and as far as he remembers there were two assist rails on Resident #5's bed. During an interview on 8/24/17 at 11:03 a.m., LVN H said Resident #5 uses his assist rails and trapeze bar to help with bed mobility. She said Resident #5 fell out of his bed on 8/9/17 while he received a bed bath. LVN H said she thought Resident #5's bed only had one assist rail at the time of the fall but was not certain. During an interview on 8/24/17 at 12:03 p.m., the DON said she did not do an in-service with staff after Resident #5's fall on 8/9/17. During an interview on 8/24/17 at 1:58 p.m., Resident #5 said he fell off of his bed, on the side the window is on, while CNA M provided care for him. He said the assist rail was not on the side of his bed he fell off of. Resident #5 said the assist rail broke approximately one month ago. During an interview on 8/24/17 at 2:23 p.m., the administrator said it was reported to him that on 8/9/17 CNA M was giving Resident #5 a bed bath, the resident rolled out of the bed, and CNA M lowered him to the floor. The administrator said he reviewed the incident report for Resident #5's fall. The administrator said Resident #5 had one assist rail prior to his fall on 8/9/17 and the second assist rail was added after the fall as an intervention to prevent further falls. The administrator said the DON started the investigation process on incidents related to nursing. A maintenance log was reviewed from December 2016 to August 24, 2017 and no entry was made related to Resident #5's assist rail being broken or missing. An incident report dated 8/9/17 at 1:00 p.m. indicated Resident #5 rolled off of his bed during care provided by CNA M and had no apparent injury. The incident report indicated the action taken was staff re-education and resident education. The administrator and the DON both signed off on the incident report. The investigation indicated Resident #5 did not remember that he fell . There was one witness listed, CNA M. The incident investigation (conclusion and interventions of incident) signed by the DON on 8/10/17 at 9:35 a.m. indicated the intervention listed to prevent the incident from reoccurring was to replace the U-bar (assist rail) to right side of the bed. The clinical assessment of the occurrence section on the incident investigation indicated the right side U-bar (assist rail) on Resident #5's bed was missing. The incident investigation was signed by the administrator with no date or time of signature. The Incident/Accident policy dated 9/20/12 indicated the following: * .the DON or designee will interview all witnesses and have them sign that the information is reflective of their statement; *a complete Accident/Incident investigation form must be completed for each occurrence of actual or suspected resident abuse. A written, signed and dated statement must be obtained from the person reporting the incident; *the administrator serves as the abuse coordinator and when an allegation of abuse or actual abuse is identified, the abuse protocol is implemented. The abuse coordinator initiates and conducts a thorough investigation to prevent recurrence; *Accidents/Incidents are reported both internally and externally in accordance with the state and federal guidelines; *interview staff, visitors or resident who have knowledge of the alleged incident and document information obtained from them; *document every step of the investigation in detail; and *a thorough report should contain a description of the alleged wrongdoing, a description of the documents, manuals, and witnesses examined, a summary of the information elicited, determinations as to credibility where there are fact conflicts, and finding of fact based credible evidence. During an interview on 8/25/17 at 9:05 a.m. the administrator said 12 residents used shower chairs. The CMS 2567 dated 8/21/17 indicated 28 residents required assistance with bathing.

Based on observation, interview, and record review, the facility failed to ensure necessary treatments and services were provided based on the comprehensive assessment to promote healing of existing pressure injuries and prevent new pressure injuries from developing for 3 of 13 residents reviewed for pressure injuries. (Residents #s 4, 7 and 10) The facility did not notify the physician about an ill-fitting therapist devised splint that caused a pressure injury on the resident's right ankle. The facility did not provide appropriate interventions for Resident #10's facility acquired pressure injury on his right ankle. Resident #10 was admitted to the local hospital on [DATE] due to a non-healing fracture to his right ankle with an infection to the Stage 4 pressure injury. Resident #10 had surgery on 10/18/16 for a mid-thigh above the right knee amputation. The facility did not provide Resident #4 appropriate pressure relieving interventions or appropriate treatments to promote healing of a Stage 3 pressure injury on her right heel. She was admitted with the right heel pressure injury. The facility did not identify Resident #7 had a Stage 2 pressure injury on his left ischial tuberosity (sitting bone). The staff did not become aware of the pressure injury until after surveyor intervention (10/16/16 ) and did not obtain treatment until after surveyor intervention (10/17/16). An Immediate Jeopardy situation was identified on 10/18/16. The Immediate Jeopardy was removed on 10/19/16. The facility remained out of compliance at a pattern of actual harm due to the need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures contributed to the development and worsening of pressure injuries for Residents #s 4, 7 and 10 and placed 2 other residents with pressure injuries at risk for worsening of their pressure injuries. Findings included: 1. An undated face sheet indicated Resident #10 was [AGE] years old, admitted on [DATE] with the [DIAGNOSES REDACTED]. Consolidated physician orders [REDACTED].#10 was to have his heels off loaded every shift. Resident #10 required a splint to his right lower leg/foot to be removed daily for wound care, and then reapplied by nursing or physical therapy. The nurse was to assess for circulation, movement, and sensation in his right leg and foot each shift. The most recent MDS dated [DATE] indicated Resident #10 usually understood others and was usually understood, but was unable to recall. Resident #10 was totally dependent of two staff for bed mobility, transfers, dressing, and toileting. He was totally dependent of one staff for locomotion, personal hygiene, and bathing. Resident #10 had limitation in range of motion for the upper and lower extremity on one side. He was incontinent of both bowel and bladder. Resident #10 was at risk for pressure injuries, with no pressure injuries indicated on this date. A care plan dated 8/06/16 indicated Resident #10 had a history of [REDACTED]. An x-ray report dated 8/13/16 indicated Resident #10 had fractures of both the tibia and fibula (lower leg) with soft tissue swelling A physician order [REDACTED].#10 to be referred to an orthopedic specialist on 8/15/16. A nursing note dated 8/17/16 at 4:00 p.m., indicated Resident #10 returned from the orthopedic physician appointment. Resident #10 had a new order for a thermoplastic posterior resting splint, short leg. The nursing note indicated the splint would be applied when available. A nursing note dated 8/23/16 (timed midnight) indicated Resident #10 continued to wait the arrival of his ordered splint. A care plan start dated 8/24/16 indicated Resident #10 had a fractures of the right tibia and fibula (lower leg) with a [DIAGNOSES REDACTED]. The approaches included be aware of the injury and the potential for other injuries with transfers or positioning, and orthopedic consult and positioning device as ordered. A nursing note dated 8/25/16, (a late entry for 8/24/16) at 4:30 p.m., indicated prior to the placement of Resident #10's splint, the nurse noted a small abrasion on the resident's right outer ankle measuring 0.8 cm x 0.8 cm x less than 0.1 cm. The abrasion had pink granulating tissue with scant amount of serous drainage. A skin assessment dated [DATE] indicated Resident #10 had a new abrasion on his right outer ankle. The wound measured 0.8 cm x 0.8 cm x 0.1 cm. There was no indication of drainage, tissue color, or a peri-wound condition. A physician order [REDACTED].#10 was ordered a splint to be applied to his right lower leg and foot by the physical therapy and the treatment nurse daily. The skilled nurse was ordered to complete circulation, movement, and sensation checks every shift while splint was in-use. The orders indicated to apply calcium alginate and a dry dressing daily to the right ankle abrasion. During an interview on 10/18/16 at 10:10 a.m., the physical therapist said he had an order to build a splint for Resident #10. He said he called the orthopedic physician and devised a splint providing lateral (away from the center of body) and plantar (sole of the foot) support for Resident #10 with the assistance of the LVN C. The physical therapist said he was not ordered to perform wound care. During an interview on 10/18/16 at 9:30 a.m., LVN C said Resident #10's right ankle wound started out as an abrasion. She said she was unsure how Resident #10 acquired an abrasion to his right ankle. LVN C said she and the physical therapist fashioned a splint for Resident #10. LVN C said the local supplier for splints heating element was out and they could not make Resident #10 a splinting device as ordered. LVN C said the wound deteriorated and had eschar to the wound bed. LVN C said she did not culture Resident #10's wound or request the wound care physician to provide a wound care consult. LVN C said Resident #10 had a history of [REDACTED]. LVN C said she was certified by the wound care company for wound care. The treatment administration record dated 8/2016 indicated Resident #10's therapist devised splint/immobilizer was initially applied on 8/24/16 to the right lower leg. The therapist devised splint was removed daily for wound care and reapplied. A skin assessment dated [DATE] indicated Resident #10's right ankle abrasion wound measured 1.0 cm x 0.8 cm x less than 0.1 cm. The wound worsened with slough present. The wound had a scant amount of a thin serous drainage. The wound margins were round with surrounding tissue intact. The skin assessment did not indicate the stage of Resident #10 ' s pressure injury. A nursing note dated 8/29/16 indicated Resident #10's splint was removed and there was slough in the wound bed. The physician was notified. The splint was reapplied by the physical therapist and the treatment nurse. A physician order [REDACTED].#10 ' s right ankle pressure injury. The new order to the right ankle was to clean with wound cleanser, apply Santyl (topical debridement) to wound bed, cover with calcium alginate and dry dressing every day. The splint to his right lower leg and foot was to be removed daily for wound care and then reapplied by physical therapy or nursing. The skin assessments for Resident #10 ' s right ankle pressure injury indicated: *9/05/16 - abrasion measured 0.3 cm x 0.3 cm x 0.1 cm with a scant amount of serous exudate, pink granulation tissue and slough, and the surrounding tissue was intact. The assessment indicated the abrasion was improved. The treatment was indicated to be Santyl to slough only, calcium alginate and a dressing daily. *9/12/16 - abrasion measured 0.4 cm x 0.3 cm x 0.1 cm with serous drainage with pink granulation and scant amount of slough to edges, the surrounding tissue was intact. The treatment was indicated as Santyl to slough, calcium alginate, and a dry dressing daily. The assessment indicated an improved wound. The assessment indicated the physician was not notified. *9/19/16 - measured 3.0 cm x 3.0 cm x undetermined depth and no documentation of the stage of the wound. There was serous drainage with an odor. The wound bed was covered with yellow slough, the margins were round and smooth and the surrounding tissue intact. The current treatment was Santyl, calcium alginate, and a dry dressing daily. The assessment indicated the physician was not notified of the decline. A nursing note dated 9/19/16 at 4:00 p.m., indicated the nurse noted a foul odor before the dressing was removed from Resident #10's ankle. The nurse removed the dressing and measured the wound. The right ankle pressure injury measured 3.0 cm x 3.0 cm x 0.2 cm with thick yellow slough to the entire wound bed. The treatment of [REDACTED]. The splint was reapplied. There was no indication the physician was notified of the foul odor. A skin assessment dated [DATE] indicated Resident #10's right ankle wound was improved. The pressure injury measured 3.0 cm x 3.0 cm x 0.2 cm and had a foul odor with a moderate amount of drainage. The tissue type was pink granulation with slough. The surrounding tissue was at risk. There were no other skin assessments until 10/3/16. A physician order [REDACTED].#10 ' s right ankle treatment order was changed to clean with normal saline, pat dry and apply Santyl to slough, cover with foam, apply skin prep to periwound, wrap with Kerlix (gauze), and secure with tape. A nursing note dated 9/20/16 at 2:00 p.m., indicated the wound care treatment to Resident #10 ' s right ankle was changed. The note indicated the wound was mostly pink with granulating tissue with some slough to the edge of the wound. There was minimal odor. The note indicated the physical therapist and the nurse were present to assist in reapplication of the splint. A skin assessment dated [DATE] indicated Resident #10 had an unstageable pressure injury on his right ankle measuring 4.0 cm x 2.8 cm x 0.5 cm with a scant amount of serous drainage. The wound bed had granulation tissue with smooth edges and the surrounding tissue was intact. The wound was documented as improved and the physician was notified. A nursing note dated 10/03/16 at 6:15 p.m., indicated Resident #10 ' s skin assessment right ankle pressure injury had granulation. The physician was notified with a new order to change treatment to cleanse with normal saline apply [MEDICATION NAME] (antibacterial ointment), cover with 4 x 4 gauze, wrap with Kerlix, and reevaluate in 7 days. A nursing note dated 10/05/16 at 6:30 p.m., indicated upon assessment Resident #10's right outer ankle pressure injury had eschar (necrotic tissue). The note indicated the immobilizer was not stable and initiated a request for therapy to obtain an improved model. The note indicated the immobilizer was leaning and causing more pressure to the lateral side of the resident ' s ankle. The note indicated the physician would assess to determine if debridement was possible (in the morning). A nursing note dated 10/06/16 at 9:30 a.m., indicated the physician was present and assessed Resident #10 ' s right ankle pressure injury. The orders were to administer pain medication every 6 hours routinely. The note indicated the splint was reapplied and the right ankle immobilized again. A history and physical dated 10/06/16 indicated Resident #10's primary physician noted an open pressure injury on his right ankle, at least a Stage 3, but currently unstageable. A nursing note dated 10/06/16 at 4:00 p.m., indicated the physician was present and assessed Resident #10. The physician provided new orders for [MEDICATION NAME] (pain medication) 10/325 milligrams every 6 hours around the clock. The not indicated the right foot was offloaded, secured, and immobilized with the splint. A nursing note dated 10/07/16 at 6:00 p.m., indicated the physician was notified and received an order to discontinue the treatment and initiate the new treatment to the Stage 3/unstageable pressure injury on Resident #10 ' s right ankle. A physician's orders [REDACTED].#10 ' s right ankle ([MEDICATION NAME]). The new treatment for [REDACTED]. A nursing note dated 10/08/16 at 2:00 p.m., indicated Resident #10's right ankle was immobilized using a heel boot. There were no signs of infection to the pressure injury. A skin assessment dated [DATE] indicated Resident #10 ' s right ankle pressure injury measured 2.2 cm x 5.0 cm x 0.2 cm. The wound had a scant serous drainage, smooth margins with 80% granulation tissue and 20% eschar to wound bed. The surrounding tissue was intact. The skin assessment did not indicate the stage of the wound to Resident #10 ' s right ankle. A physician order [REDACTED].#10 required a follow up x-ray to the right ankle due to a follow up to the dislocation and increased pain. A nursing note dated 10/11/16 at 7:00 p.m., indicated Resident #10's x-ray results indicated a gap in the bones of the right ankle. The physician was notified and Resident #10 was sent to the local emergency room . A local hospital history and physical for Resident #10 indicated he was admitted on [DATE]. The assessment indicated Resident #10's right ankle was completely floppy and there was a chronic ulcer on the lateral (outside) aspect of the malleolus (ankle bone) with yellow exudate and slough. The pulses were difficult to palpate. During an interview on 10/17/16 at 4:20 p.m., the hospital's orthopedic nurse manager said Resident #10's wound had yellow slough near the center and exposed bone. The nurse manager said the orthopedic physician would speak to the family today about an amputation in the morning. Photographs obtained on 10/17/16 from the local hospital indicated on 10/12/16 Resident #10's right ankle had a pressure injury measuring 4.5 cm x 3.0 cm x 3.0 cm. A hospital orthopedic consult dated 10/12/16 indicated Resident #10 had a significant wound on the outside of the right ankle and a chronic sub-acute [MEDICAL CONDITION] ankle. The examination of the patient's right lower extremity demonstrated evidence of chronic [MEDICAL CONDITION] and [MEDICAL CONDITION] with mottling of the skin below the knee. He had dry and flaking of skin throughout the lower extremity and had noted wasting of the musculature below the knee. On evaluation he had a large wound over the outside of the ankle overlying the distal fibula which was through skin and deep subcutaneous tissues. There was no significant purulent drainage from the wound. He had gross instability at the ankle. He had pain with attempted passive or active range of motion at the ankle. He had a non-palpable pulse to the posterior tibialis (checked in the inner ankle area). He had diminished sensation involving the outside of the foot including his small toe. The plan indicated his x-rays were highly abnormal in the sense that he had large areas of bony destruction, significant osteopenic appearance throughout the remainder of the foot, and the physician was concerned there were chronic underlying infections that had been going on for quite some time. The findings on his x-rays appeared to be significantly more advanced than previously. He basically had a chronic sub-acute fracture involving the right ankle, which was non-united. He had developed a wound on the outside of the ankle and had some underlying chronic infection involving the right foot and ankle for some time. The physician documented the resident would probably end up needing a [MEDICAL CONDITION] but looking at it, but was concerned the soft tissue might not allow for the knee amputation. During a telephone interview on 10/17/16 at 4:55 p.m., the orthopedic physician said he was consulted for Resident #10 when he arrived at the local hospital. He said Resident #10's foot was injured in August 2016 and Resident #10 was seen once since the right ankle fracture. The orthopedic physician said Resident #10's right ankle pressure injury had a superimposed infection causing even more complications. He said with the family's consent the leg will be amputated tomorrow morning. The orthopedic physician said, To be honest the lack of timely follow-up with the fracture and wound infection had caused bigger problems. During an observation and interview on 10/18/16 at 11:20 a.m., LVN B said she used a heel protector boot, over the therapist devised splinting device and placed the circular foam donut surrounding the splinting device and heel protector boot to maintain alignment of Resident #10's right foot. LVN B said the physician looked at the therapist devised device and made suggestions of another device. LVN B said she notified the DON and the administrator Resident #10's pressure injury declined since using the splint and boot. During an interview on 10/18/16 at 12:52 p.m., RN A (who worked weekends) said she could never obtain a pulse to Resident #10's right foot. She said she conveyed those findings to the previous DON and the nurses. RN A said she placed the heel protector on Resident #10's foot then applied a therapist devised splint that was fashioned from three IV (intravenous) arm boards and orange tape around the boot, and finally a foam donut device was placed around the entire therapist devised device. RN A said she told the physical therapist and the DON the therapist devised splint was not appropriate. RN A said she assessed the wound once daily on her shift. RN A said she did not notify the physician, but relied on the charge nurses to notify the physician. During an interview on 10/18/16 at 12:45 p.m., LVN B said she assessed the alignment of Resident #10's foot at least three times a shift, but did not check the pressure injury during her day shift. LVN B said the treatment for [REDACTED]. LVN B said she would assess the pressure injury one time on the 2:00 p.m. to 10:00 p.m. shift when she worked and perform the wound treatment. During an interview on 10/18/16 at 10:46 p.m., the DON said Resident #10 sustained a fracture several months back. She said Resident #10 saw the orthopedic specialist one time. The DON said Resident #10 had an order for [REDACTED]. The DON said the therapist devised splint rubbed the wound causing the wound to decline. The DON said she did not make weekly skin checks of the current pressure injuries. During an observation and interview on 10/19/16 at 12:00 p.m., the DON said she ordered the splint and it arrived after Resident #10 discharged to the local hospital. The DON was shown the therapist devised splinting device provided by the staff. The DON said she was unaware this sort of device was used. 2. Physician orders [REDACTED].#4 was [AGE] years old, re-admitted [DATE] with [DIAGNOSES REDACTED]. The original admitted was 9/22/09 and the pressure injury was present on admission. A physician order [REDACTED].#4's Stage 3 right heel pressure injury with normal saline, pat dry, and apply calcium alginate foam dressing and a dry dressing daily. The most recent MDS dated [DATE] indicated Resident #4 was usually understood and usually understood others. She was totally dependent for all ADLs. Resident #4 was at risk for pressure injury and she had unhealed pressure injuries. The resident had one Stage 3 and one unstageable pressure injury present upon admission/entry/ or reentry. A care plan dated 9/16/16 indicated: Resident #4 had multiple problems that affected her ability to complete ADLs and transfers, requiring assistance of at least one caregiver to complete bathing, dressing, grooming, transfers, and toileting tasks daily. Resident #4 was at risk for pressure injuries due to nutrition, friction, and shear, and had a pressure injury on her right heel. Interventions included to provide with treatments as ordered by the physician, use of good infection control, record intake after each meal, skin assessment and inspection every shift with close attention to heels, minimum of 2 people plus draw sheet to lift resident while in bed, elevate heels off bed or use heel protectors, consider PT consult for conditioning and wheelchair assessment, consider low air loss bed. Resident #4 had a stage 3 pressure injury on her right heel. Interventions included: provide pressure relieving mattress, Prevalon off-loading boot, turn and reposition when providing care and as physical condition allowed, offloading boot applied when out of bed, and pillow under calf when in bed to offload foot/heel. A Wound Care Specialist Evaluation indicated Resident #4 had the following on her right heel: *8/1/16 - Stage 3 pressure injury measuring 4.0 cm x 6.8 cm X 0.1 cm, with moderate serous drainage. Wound progress deteriorated with findings that indicated deterioration to be offloading. Additional information indicated the physician felt it necessary to recommend Multi podus boot (splint boot for wound healing) for off-loading, as pillow and Prevalon boots (pressure relieving heel protector) had not resulted in improved off-loading. A physician order [REDACTED].#4 ' s right foot at all times and for staff to observe every shift. A Wound Care Specialist Evaluation indicated Resident #4 had the following on her right heel: *8/29/16 - Stage 3 Pressure injury measuring 4.5 cm x 8.0 cm x 0.2 cm with heavy serous drainage. Wound progress deteriorated with finding that indicated non-compliance with off-loading with a recommendation for off-loading boots to be worn at all times. *9/5/16 - Stage 3 pressure injury measuring 4.5 cm x 7.3 cm x 0.2 cm with heavy serous drainage. Wound progress deteriorated with findings that indicated off-loading. Additional information indicated current off-loading measures have not resulted in wound improvement. Please use pillows for off-loading while resident was in the bed. Pillows must be under calves and not in contact with feet or heel wounds. Recommendation: Float heels in bed, off-load wound. Assessment and plan indicated deteriorated due to off-loading, change off-loading device, readdress need for strict off-loading. A nursing note dated 9/5/16 indicated Resident #4 was resting in bed with Podus boot to right foot and no dressing covering the right heel wound. Serous drainage covered cloth portion of the Podus boot and the right heel was covered with slough. During an interview on 10/19/16 at 12:30 p.m., LVN C said on 9/5/16 Resident #4 did not have a dressing covering her right heel and the Podus boot was in place and saturated. She said she took it apart and sent it to laundry and it was not seen again. She said she did not write an order for [REDACTED]. A nursing note dated 9/7/16 indicated Resident #4 was in bed with both feet off-loaded with boots. There was no bandage covering the right heel pressure injury. A physician order [REDACTED].#4 ' s feet when out of bed and offload feet with pillows when in bed, not boots. The order indicated to ensure pillow was under the resident ' s calves. A physician order [REDACTED].#4 ' s left lower foot/heels to off load. Apply Podus boot to resident ' s right foot when out of bed and when in bed remove boots to offload feet pillows under calves. The pillow, mattress, or footboard was not to touch Resident #4 ' s feet or heels. A Wound Care Specialist Evaluation indicated Resident #4 had the following on her right heel: *9/12/16 - Stage 3 pressure injury measuring 6.0 cm x 8.5 cm x 0.2 cm with heavy serous exudate. Wound progress deteriorated with findings that indicated noncompliance with off-loading. Additional information indicated a wound biopsy was preformed due to non-progression of wound. Peripheral vascular studies were not necessary since distal pulses were palpable in the effected extremity. During an interview on 10/18/16 at 10:05 a.m., LVN C said Resident #4 always had bounding pedal pulses and her wound care physician did not want Doppler testing due to the strong pedal pulses indicating good blood flow. She said Resident #4 had a wedge pillow to be used for off-loading while in bed and boots were used when she was out of bed. A nursing note dated 9/12/16 indicated Resident #4 was in bed with both feet/heels off-loaded with pillows. Dressing to right heel was not intact. A physician order [REDACTED].#4 ' s right heel with normal saline, pat dry, apply Santyl to necrotic tissue then apply [MEDICATION NAME] to granulated tissue. Apply foam and wrap daily for three days then re-evaluate. A physician follow up dated 9/19/16 indicated the physician discussed Resident #4's wound care with the wound care nurse. It indicated to continue to apply Santyl with a foam dressing. If no improvement will consider admission to long term acute care for intravenous antibiotics and continued wound care. A Wound Care Specialist Evaluation indicated Resident #4 had the following on her right heel: *9/19/16 - Stage 3 pressure injury measuring 3.0 cm x 7.9 cm x 0.2 cm with moderate serousanguinous exudate, 15% yellow necrotic tissue. Wound progress deteriorated with findings that indicated inadequate offloading and/or use of circumferential elastic wrap. Additional information indicated per facility administrator and primary care physician, dressings were changed and the foot was wrapped. The wound care physician was not involved in the decision making process. Assessment and plan indicated the right heel deteriorated due to inadequate off-loading and/or use of circumferential elastic wrap: as the healthcare provided consulted to provide wound care, the wound care physician could not precisely monitor and document progress of the wound treatment if changes were made without being able to participate in the decision making process. The evaluation indicated to avoid this situation in the future, consult the wound care physician prior to any treatment changes. Add: Do not wrap foot with Kerlix, elastic, or compression. A Weekly skin documentation sheet indicated Resident #4 had the following on her right heel: *9/26/16 - Staging not indicated, pressure injury measuring 3.0 cm x 7.5 cm x 0.2 cm indicated improvement with serous drainage, amount not indicated, no slough, surrounding tissue at risk. A physician order [REDACTED].#4 ' s right heel with normal saline, pat dry, apply Santyl to slough/necrotic tissue then apply [MEDICATION NAME] to granulating tissue, apply foam and wrap with gauze daily. Do not wrap tightly. A weekly skin documentation sheet dated 10/3/16 indicated the right heel wound was 10.0 x 3.5 x 0.2 cm, it had a moderate amount of yellowish exudate the color of the tissue was red and the surrounding skin was macerated. A physician order [REDACTED].#4 ' s right heel with normal saline, apply Santyl to wound bed and skin protectant to peri-wound daily. A Braden scale dated 10/12/16 indicated Resident #4 was at high risk for pressure injuries. During an observation and interview on 10/17/16 at 12:02 p.m., LVN B provided wound care for Resident #4 ' s right heel. She said the measurement was 3.2 cm x 6.9 cm x 0.2 cm with yellow slough to the right side of the wound and the left side was beefy red. She applied [MEDICATION NAME] to the wound bed, and covered with 4 x 4s and wrapped with Kerlix. During observations on 10/16/16, the following was noted: *2:37 p.m., Resident #4 was lying in bed on her back with heel protector to right foot, both legs elevated on pillows; however, both of her heels touched the bed. (She did not have a low air loss mattress) *5:13 p.m., Resident #4 was lying in bed on her back watching television with heel protector to right foot. Both of her heels were touching the bed. *6:00 p.m., Resident #4 was sleeping in bed on her back with heel protector to right foot, both heels were touching the bed. During observations on 10/17/16, the following was noted: *12:51 p.m., Resident #4 was lying in bed on her back eating lunch. No boot/heel protector to right foot. *3:30 p.m., Resident #4 was sleeping in bed on her back. Her left heel was touching the bed. No boots on feet at this time. During an observation and interview on 10/17/16 at 3:48 p.m., Resident #4 was lying on her back being provided incontinent care. LVN B said she had never seen an off-loading boot (Podus) on Resident #4. She said the resident had always worn a heel protector. During observations on 10/17/16, the following was noted: *4:12 p.m., Resident #4 was sleeping in bed, flat on her back. Her feet were not off-loaded. *5:51 p.m., Resident #4 was in bed with a pillow to her right back, her right heel was floated, but the left heel was resting on the bed. A physician order [REDACTED].#4 ' s right heel Stage 3 pressure injury with normal saline, pat dry, apply [MEDICATION NAME] to wound bed and skin protectant to peri- wound, wrap with Kerlix daily. During observation and interview on 10/18/16 at 9:10 a.m., Resident #4's right heel bandage was saturated with yellow, brown, and red drainage. LVN B said it drained this much regularly. While changing the dressing, LVN B said the pressure injury had yellow slough present and she would call the physician for a new order. Yellow slough was noted to the right side of the wound and the left side of the wound was pink in color. The staff documented this as a Stage 3. During an observation on 10/18/16 at 9:36 a.m., Resident #4 was resting in bed. Both heels were touching the pillow. During an interview on 10/17/16 at 2:25 p.m., LVN E said the nurses started doing their own treatments 2 weeks ago. She said Resident #4 did not go outside the facility to a wound care clinic and the wound care physician had not been there in a month. She said they no longer used his services. She said if the nurses thought the wound was bad enough, they would ask the physician to look at it. She said the physicians did not usually look at wounds when making rounds. During an interview on 10/18/16 at 9:50 a.m., CNAs N and Q said they made sure Resident #4 had heel protectors on while in bed. They said they put a blue wedge cushion behind her knees and propped her feet up on pillows. They said there was no way Resident #4 could move her legs if they were elevated prope

Based on observation, interview, and record review, the facility failed to ensure 1 of 1 physical therapist provided services that met professional standards of quality for 1 of 1 resident reviewed for professional services. (Resident #10) The facility did not provide Resident #10 with physical therapy services to include a correct fitting splinting device for his right ankle fracture. The physical therapist constructed a splinting device for Resident #10. The ill-fitting splint contributed to a non-healing ankle fracture and a Stage 4 pressure injury with a superimposed infection. The resident was sent to the hospital and had an above the knee mid-thigh amputation. An Immediate Jeopardy situation was identified on 10/18/16. The Immediate Jeopardy was removed on 10/19/16. The facility remained out of compliance at a pattern of actual harm due to the need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 1 resident with a device at risk for not receiving the care and services that protect their rights, meet their needs, or ensure safety Findings included: An undated face sheet indicated Resident #10 was [AGE] years old, admitted on [DATE] with the [DIAGNOSES REDACTED]. Consolidated physician orders [REDACTED].#10 had an order to off load heels every shift, 12/03/15 assess discoloration to left heel secondary to a skin graft weekly with skin assessment and assess scar tissue to both buttocks each shift. He was ordered a head to toe skin assessment each week on Monday on the 2:00 p.m. to 10:00 p.m. shift. On 8/24/16 Resident #10 was ordered for the skilled nurse to assess for the resident's right foot for circulation, movement, and sensation each shift. An order on 8/30/16 indicated Resident #10 required a splint to right lower leg/foot to be removed daily for wound care, and then reapplied by nursing or physical therapy. The most recent MDS dated [DATE] indicated Resident #10 usually understood others and was usually understood and was unable to recall. Resident #10 required total dependence with two staff assisting with bed mobility, transfers, dressing, and toileting. He required total dependence with one staff assisting with locomotion, personal hygiene and bathing. Resident #10 had limitation in the range of motion for the upper and lower extremity on one side. He was incontinent of both bowel and bladder. Resident #10 was at risk for pressure injuries, with no pressure injuries indicated at present time. A care plan dated 8/13/16 indicated Resident #10 was found to have a right bilateral malleolus fracture of his right lower extremity. The goal was for the fracture to heal without complications. The approaches were to assess for and report pain, be aware of the injury and potential for other injuries, and an orthopedic consult and positioning device as ordered. A nursing note dated 8/13/16 indicated Resident #10 was found to be favoring the right ankle. The right ankle had light [MEDICAL CONDITION] and the physician was notified. The note indicated the physician ordered an x-ray. A physician order [REDACTED].#10 ' s right ankle with three views. An x-ray report dated 8/13/16 indicated Resident #10 had bimalleolar fractures with soft tissue swelling A physician order [REDACTED].#10 was referred to an orthopedic specialist on 8/15/16. A prescription dated 8/17/16 indicated the orthopedic physician ordered Resident #10 a [MEDICAL CONDITION] posterior short leg resting splint due to a right distal fibula fracture. A nursing note dated 8/17/16 at 4:00 p.m., indicated Resident #10 returned from the orthopedic physician ' s appointment. Resident #10 had a new order for a [MEDICAL CONDITION] posterior resting splint short leg. The therapy department was notified. The nursing note indicated the splint would be applied when available. The therapy department notified the local supplier of splints. A physician order [REDACTED].#10 was ordered a splint to be applied to his right lower leg and foot by the physical therapy and the treatment nurse daily. The skilled nurse was ordered to complete circulation, movement, and sensation checks every shift while splint was in-use. The orders indicated to apply calcium alginate and a dry dressing daily to the right ankle abrasion. During an interview on 10/18/16 at 10:10 a.m., the physical therapist said he had an order to build a splint for Resident #10. He said he called the orthopedic physician and devised a splint providing lateral (away from the center of body) and plantar (sole of the foot) support for Resident #10 with the assistance of the LVN C. The physical therapist said he was not ordered to perform wound care. The treatment administration record dated 8/2016 indicated Resident #10's therapist devised splint/immobilizer was initially applied on 8/24/16 to the right lower leg. The therapist devised splint was removed daily for wound care and reapplied. A history and physical dated 10/06/16 indicated Resident #10's primary physician noted an open pressure injury on his right ankle, at least a Stage 3, but currently unstageable. A nursing note dated 10/06/16 at 4:00 p.m., indicated the physician was present and assessed Resident #10. The physician provided new orders for [MEDICATION NAME] (pain medication) 10/325 milligrams every 6 hours around the clock. The note indicated the right foot was offloaded, secured, and immobilized with the splint. A nursing note dated 10/07/16 at 6:00 p.m., indicated the physician was notified and received an order to discontinue the treatment and initiate the new treatment to the Stage 3 /unstageable pressure injury on Resident #10's right ankle. A physician's orders [REDACTED].#10's right ankle ([MEDICATION NAME]). The new treatment for [REDACTED]. A nursing note dated 10/08/16 at 2:00 p.m., indicated Resident #10's right ankle was immobilized using a heal boot. There were no signs of infection to the wound. A skin assessment dated [DATE] indicated Resident #10's right ankle pressure injury measured 2.2 cm x 5.0 cm x 0.2 cm. The wound had a scant serous drainage, smooth margins with 80% granulation tissue and 20% eschar to wound bed. The surrounding tissue was intact. The skin assessment did not indicate the stage of the wound to Resident #10's right ankle. A physician order [REDACTED].#10 required a follow up x-ray to the right ankle due to a follow up to the dislocation and increased pain. A nursing note dated 10/11/16 at 7:00 p.m., indicated Resident #10's x-ray results indicated a gap in the bones of the right ankle. The physician was notified and Resident #10 was sent to the local emergency room . A local hospital history and physical for Resident #10 indicated he was admitted on [DATE]. The assessment indicated Resident #10's right ankle was completely floppy and there was a chronic ulcer on the lateral (outside) aspect of the malleolus (ankle bone) with yellow exudate and slough. The pulses were difficult to palpate. During an interview on 10/17/16 at 4:20 p.m., the hospital's orthopedic nurse manager said Resident #10's wound had yellow slough near the center and exposed bone. The nurse manager said the orthopedic physician would speak to the family today about an amputation in the morning. Photographs obtained on 10/17/16 from the local hospital indicated on 10/12/16 Resident #10's right ankle had a pressure ulcer injury measuring 4.5 cm x 3.0 cm x 3.0 cm. An in hospital orthopedic consult dated 10/12/16 indicated Resident #10 had a significant wound on the outside of the right ankle and a chronic sub-acute [MEDICAL CONDITION] ankle. The examination of the patient's right lower extremity demonstrated evidence of chronic [MEDICAL CONDITION] and [MEDICAL CONDITION] with mottling of the skin below the knee. He had dry and flaking of skin throughout the lower extremity and had noted wasting of the musculature below the knee. On evaluation he had a large wound over the outside of the ankle overlying the distal fibula which was through skin and deep subcutaneous tissues. There was no significant purulent drainage from the wound. He had gross instability at the ankle. He had pain with attempted passive or active range of motion at the ankle. He had a non-palpable pulse to the posterior tibialis (checked in the inner ankle area). He had diminished sensation involving the outside of the foot including his small toe. The plan indicated his x-rays were highly abnormal in the sense that he had large areas of bony destruction, significant osteopenic appearance throughout the remainder of the foot, and the physician was concerned there were chronic underlying infections that had been going on for quite some time. The findings on his x-rays appeared to be significantly more advanced than previously. He basically had a chronic sub-acute fracture involving the right ankle, which was non-united. He had developed a wound on the outside of the ankle and had some underlying chronic infection involving the right foot and ankle for some time. The physician documented the resident would probably end up needing a [MEDICAL CONDITION] but looking at it, but was concerned the soft tissue might not allow for the knee amputation. During a telephone interview on 10/17/16 at 4:55 p.m., the orthopedic physician said he was consulted for Resident #10 when he arrived at the local hospital. He said Resident #10's foot was injured in August 2016 and Resident #10 had been seen once since the right ankle fracture. The orthopedic physician said Resident #10's right ankle pressure injury had a superimposed infection causing even more complications. He said with the family's consent the leg will be amputated tomorrow morning. The orthopedic physician said, To be honest the lack of timely follow-up with the fracture and wound infection had caused bigger problems. During an observation and interview on 10/18/16 at 11:20 a.m., LVN B said she used a heel protector boot, over the therapist devised splinting device and placed the circular foam donut surrounding the splinting device and heel protector boot to maintain alignment of Resident #10's right foot. LVN B said the physician looked at the therapist devised device and made suggestions of another device. LVN B said she notified the DON and the administrator Resident #10 ' s pressure injury had declined since using the splint and boot. During an interview on 10/18/16 at 12:52 p.m., RN A (who worked weekends) said she could never obtain a pulse to Resident #10's right foot. She said she conveyed those findings to the previous DON and the nurses. RN A said she placed the heel protector on Resident #10's foot then applied a therapist devised splint that was fashioned from three IV (intravenous) arm boards and orange tape around the boot, and finally a foam donut device was placed around the entire therapist devised device. RN A said she had told the physical therapist and the DON the device was not appropriate. RN A said she assessed the wound once daily on her shift. RN A said she did not notify the physician but relied on the charge nurses to notify the physician. During an interview on 10/18/16 at 12:45 p.m., LVN B said she assessed the alignment of Resident #10's foot at least three times a shift, but did not check the wound during her day shift. LVN B said the treatment for [REDACTED]. LVN B said she would assess the wound one time on the 2:00 p.m. to 10:00 p.m. shift when she worked and perform the wound treatment. During an interview on 10/18/16 at 10:46 p.m., the DON said Resident #10 sustained a fracture several months back. She said Resident #10 had seen the orthopedic specialist one time. The DON said Resident #10 had an order for [REDACTED]. The DON said the device rubbed the wound causing the wound to decline. The DON said she did not make weekly skin checks of the current pressure injuries. During an observation and interview on 10/19/16 at 12:00 p.m., the DON said she ordered the splint and it arrived after Resident #10 discharge to the local hospital. The DON was provided the therapist devised splinting device provided by the staff. The DON said she was unaware this device was used. During a telephone interview on 10/19/16 at 2:41 p.m., the local splint supply store returned call indicated the therapy department ordered the splint on 8/19/16 but called back on 8/24/16 and cancelled the order. The store personnel indicated the desired splint could be received generally in a week but could be delivered over night as well. The store personnel said she was not provided a reason for the cancellation. The administrator and DON were notified on 10/18/16 at 1:23 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 10/18/16 at 4:15 p.m. and included: Resident (#10) is currently in the hospital. Resident (#9), was evaluated by AMT wound care specialist on 10/18/16, the physician was contacted and the order was changed to clean wound with normal saline, pat dry, apply a nickel thick layer of santyl, apply collagen, calcium alginate, and cover with a dry dressing daily. The facility staff performed a skin sweep of all residents within the facility on 10/17/16 to identify any unknown wounds. Braden scales will be completed on residents within the facility with pressure ulcers by 10/18/16 and care plans will be updated appropriately. An in-service was started on 10/17/16 for licensed nursing staff on new areas of skin breakdown and the proper procedure for identifying and addressing them. The charge nurse is responsible for notifying the physician and family, obtaining treatment orders, transcribing the order to the TAR (treatment administration record), measuring the wound and initiating skin sheets and ensuring that the information is on the 24 hour report. Licensed nursing staff were in-serviced by the AMT wound care specialist on wound identification of tissue types, signs, and symptoms of infection or worsening of wounds, notification of physician and how to properly measure a wound on 10/18/16. Licensed nursing staff will be in-serviced on the current skin system by midnight 10/18/16. On 10/19/16 the surveyors confirmed the POR had been implemented sufficiently to remove the IJ as evidenced by: *On 10/19/16 between 9:00 a.m. and 12:00 noon, seven nurses from all shifts were interviewed and said they were in-serviced on types of wounds, recognizing wound stages, obtaining wound care orders, completing Braden scores, daily assessments during wound care, symptoms of wound infection and/or wound deterioration, and notification of the physician and family. No new wounds were found on the skin sweep and new Braden scales were reviewed. On 10/19/16 at 12:35 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A list provided on 10/19/16 indicated 1 resident had a splinting device.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and assistive devices were provided to prevent accidents for 1 of 8 residents reviewed for falls. (Resident #9) The facility did not provide adequate supervision or fall interventions. Resident #9 fell 3 times between 10/1/16-10/11/16 sustaining a head injury after each fall. The third fall resulted in Resident #9 sustaining a subdural hematoma (blood on the brain), discovered on his 10/11/16 hospitalization . An Immediate Jeopardy situation was identified on 10/26/16 at 10:38 a.m. The Immediate Jeopardy was removed on 10/26/16 at 3:15 p.m. The facility remained out of compliance at a pattern of actual harm due to the need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 36 residents for falls at risk for serious injury, impairment, or death Findings included: Physician orders [REDACTED].#9 was 63, admitted on [DATE], with [DIAGNOSES REDACTED]. His orders indicated he received Coumadin 9 mg daily at 4 p.m. (blood thinner for atrial fibrillation) His INR (international normalized ratio) on 10/11/16 was 2 ( An INR of 2-3 for normal blood thinning levels). The most recent MDS dated [DATE] indicated Resident #9 understood others and had clear comprehension. He was independent with most of his ADLs, but did not ambulate and needed limited assistance with personal hygiene. A care plan entry dated 9/9/16 indicated Resident #9 was at risk for falls due to history of repeated falls. Interventions included increase staff supervision with intensity based on his needs and provide toileting and transfers as needed. The October 2016 MAR indicated Resident #9's Coumadin order changed on 10/5/16, to Coumadin 10 mg on Monday and Friday and Coumadin 9 mg on Tuesday, Wednesday, Thursday, Saturday and Sunday at 4 p.m. daily. The incident/accident reports included the following for Resident #9: * 10/1/16 at 2:20 p.m.- Resident #9 was standing in the doorway lost balance and fell sustaining a 1 cm x 1 cm abrasion to the back of the head. Interventions to prevent incident were to increase staff supervision, and provide toileting and transfers. * 10/8/16 at 1:40 p.m. - Resident #9 lying in the floor on right side, fell off of the bed. 3 cm x 3 cm laceration to right forehead bleeding. Sent to the ER (emergency room ). Interventions- None listed, conclusion page blank. * 10/11/16 at 8:10 p.m.- Resident #9's roommate was hollering, Resident #9 found in the floor, very confused. The report indicated no bed alarm was in use, sent to the hospital. Interventions included increase staff supervision with intensity based on his needs and provide assistance for transfers and toileting. An nursing note dated 10/13/16 at 3:30 p.m., indicated Resident #9 returned from the hospital with [DIAGNOSES REDACTED]. His CT (cat-scan) was repeated and his brain bleed was not any worse so he was being discharged back to the facility. A physician order [REDACTED].#9's Coumadin was discontinued. During an observation and interview on 10/16/16 at 2:45 p.m., Resident #9 was resting in his regular bed at a routine bed heigth. His alarming device was not attached to his clothing and was lying on the floor beside his bed. RN A said Resident #9 had sutures to his right eye brow related to a fall that caused a subdural hematoma. During an observation on 10/17/16 at 11:00 a.m., Resident #9 was in bed and his bed alarm was unattached on the chair next to his bed. During an observation on 10/18/16 at 4:45 p.m., Resident #9 asleep in bed, bed alarm unattached in chair next to bed. During an observation and interview on 10/19/16 at 10:00 a.m., Resident #9 was lying in bed, the bed alarm was unattached on the over bed table. The SW said his alarm was not on him. During an interview on 10/18/16 at 3:00 p.m., the therapy director said Resident #9 was on therapy services. She said he was impulsive and his short term memory had been affected since his falls. She said he complained of confusion and memory problems. She said staff were checking on him often, and verified he could take his bed alarm off. She said therapy did note make any recommendations for falls preventions and said they did not attempt a scoop mattress, bolsters, floor mats or any other alarms since his falls. During an interview on 10/18/16 at 3:20 p.m., the DON said she and the previous DON reviewed the incident/accident reports and ensured the interventions were documented and put into place. She said she reviewed the September 2016 incident reports, but did not look at the October 2016 incident/accidents. She said the interventions were not completed nor implemented for Resident #9. During an interview on 10/18/16 at 3:45 p.m., LVN F said Resident #9's fall interventions included watching him closely and the bed alarm. She said she thought the bed alarm worked effectively. During an interview on 10/19/16 at 10:35 a.m., Corporate Nurse K and the vice president said they were unaware of any serious falls, incident reports not being completed,or interventions not being implemented. They said maybe Resident #9 was an isolated incident. During interviews on 10/26/16 the following was noted: *8:07 a.m.- CNA T said if she saw Resident #9 attempting to get up she would try to assist him, and offered to assist him to the bathroom at times. She denied being inserviced on interventions to prevent Resident #9 from falling. *8:10 a.m.- CNA U said she did not recieve an inservice nor was she instructed on special precautions to take with Resident #9 to prevent him from falling. CNA U said they did not have a CNA care plan or special fall interventions for Resident #9. *8:14 a.m.- CNA V said she did not think Resident #9 had a bed/chair alarm. She denied receiving an inservice or instruction on fall prevention for him. *8:10 a.m.- CNA W said the charge nurse told her to keep an eye on Resident #9, and assist him if he attempted to get up. CNA W said she was not told how often to check on him. CNA W said there was not any special paperwork, CNA care plan on fall interventions for Resident #9. *8:15 a.m.- CNA X said a charge nurse told her to check on Resident #9 more often, than every two hours. She said there was not any paperwork nor an observation sheet for Resident #9. The Accident/Incident System policy updated 7/18/16 indicated that each incident report must be reviewed at the administrator's daily stand up meeting, until all sections of the report are completed The regional nurse consultant and regional vice president are notified via email from QA (quality assurance) reader when an adverse incident occurs so they may follow-up and provide guidance and assist. The administrator and DON were notified on 10/26/16 at 10:38 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 10/26/16 at 12:30 p.m. and included: Resident #9 is currently in the hospital post fall on 10/23/16. SBAR (situation background assessment request) implemented and is added to resident chart. He was observed on the floor on 10/23/16 by staff. On 10/19/16 shoes were changed and gripper socks added and his current flip flops removed. Pharmacy consulting reviewing current meds taken prior to discharge to the hospital and will review again following his return for any med that possess an increase for falls. Pharmacy consultant will converse with physician on meds, doses and [DIAGNOSES REDACTED]. The CNA will monitor every 30 minutes and document on the resident monitoring checks form. Facility will provide resident with a high/low bed on lowest level to the floor and unplug to avoid the ability to raise the bed. The facility performed fall risk assessments on all residents to identify anyone who is a fall risk and ensure appropriate interventions are in place. All residents have care plan to reflect current needs for any falls. Therapy to screen, treat and provide nurse recommendations as deemed necessary for all residents that have a fall. All incident reports reviewed for the last 2 months to ensure interventions are implemented and care planned. Going forward all falls will be reviewed in daily stand up and interventions reviewed by team for appropriateness. Falls will also be reviewed weekly SOC (standard of care) and quarterly QA & A (quality assessment and assurance) meetings. Current needs will be monitored by DON/charge nurse. DON/charge nurse to do daily rounds to ensure interventions for falls are put into place and documented. An in-service was started on 10/26/16 for all nursing staff on fall prevention, call light placement and proper procedure to implement new interventions for each fall. Any staff member that observes a fall or sees someone on the floor will immediately contact the charge nurse. The surveyors confirmed the Plan of Removal was effectively implemented on 10/26/16 as evidenced by: *Nine nurses from all shifts were interviewed and said they were in-serviced on patient safety, call light placement, fall risk assessment, documentation, incident reports, SBAR reports, and the visual check tool. All nurses were able to identify what actions to take for a resident with frequent falls, possible fall interventions they might attempt, the utilization of team work for planning interventions to prevent resident falls, including asking therapy services for suggestions. All nurses knew who to report falls and injuries to, which included: the physician, DON, administrator, family and if a CNA finds the resident the charge nurse. On 10/26/16 at 3:15 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on 10/19/16 at 11:30 a.m., the DON said 36 residents were at risk for falls.

Based on observation, interview, and record review, the facility failed to ensure acceptable parameters of nutrition based on the comprehensive assessment was provided for 1 of 2 residents reviewed for weight loss. (Resident #9) The facility did not provide dietary interventions or consult the dietician when Resident #9 experienced a 6.1% significant weight loss from 9/4/16-10/4/16 (1 month). This failure could place 10 residents with weight changes at risk significant weight loss, illness, skin break down, and nutritional compromise. Findings included: Physician orders [REDACTED].#9 was 63, admitted on [DATE], with [DIAGNOSES REDACTED]. His orders indicated he was on low sodium, low concentrated sugar, mechanical soft diet and nectar thickened liquids. His medication orders included: [MEDICATION NAME] XR (1) 150 mg and [MEDICATION NAME] XR 75 mg (225 mg) every morning for depression. The most recent MDS dated [DATE] indicated Resident #9 understood others and had clear comprehension. His mood assessment indicated he had daily trouble concentrating or watching TV and little interest or pleasure doing things. He was independent with most of his ADLs, but did not ambulate and needed limited assistance with personal hygiene. A care plan entry dated 9/9/16 indicated Resident #9's diet was low sodium, low concentrated sweets, mechanical soft diet. The interventions included providing food he liked to eat and was able to eat. He was to be weighed monthly and then weekly to check for weight loss. The weight log for Resident #9's included the following: * 8/26/16 (admission) - 155 lbs. * 9/4/16- 155.40 lbs. * 10/4/16 - 145.40 lbs. (6.4% significant weight loss in 30 days) A physician progress notes [REDACTED]. No new orders or interventions were written. A nursing note dated 10/13/16 at 3:30 p.m., indicated Resident #9 was returning from the hospital with [DIAGNOSES REDACTED]. He ate 50% of his meal. The TAR and MAR for October 2016 indicated Resident #9 received [MEDICATION NAME] XR 150 mg and 75 mg (10/1-10/11 and 10/14 to present date). No food supplements or appetite stimulants were listed. The weight log for Resident #9's included the following: *10/17/16- 147 lbs. current weight indicated a 5.4% weight loss. During an observation on 10/16/16 at 5:20 p.m., Resident #9 was lying in bed with a plate of food on his over-bed table that was barely touched. He said he did not feel well and was not hungry. No supplements or health shakes were on his tray, no supplements or additional calorie foods noted on his tray card. During an interview on 10/18/16 at 3:45 p.m., LVN F said Resident #9's physician was aware of his weight loss. LVN F said the physician told her Resident #9 had Just given up. She said she did not know if Resident #9 received any food supplements, vitamins, or appetite stimulants. During an observation on 10/17/16 at 12:20 p.m., Resident #9 was lying in bed with a meal tray on his bedside table. He ate 50% of the pork steak and 50% of the mustard greens, and 100% of his pie. No additional food, supplements or health shakes were on his meal tray. During an interview on 10/18/16 at 3:00 p.m., the ST (speech therapist) said Resident #9 was on therapy services due to swallowing issues. She verified he lost weight, but said she was unaware of any food supplements or health shakes being added to his diet since his weight loss. She said he had declined since his admission (8/26/16). During an interview on 10/18/16 at 3:20 p.m., the DON said the previous dietary consultant was let go in September 2016 and the new food company and dietary consultant began on 10/17/16. She said she was aware of Resident #9's weight loss. She said they were weighing him weekly and encouraged him to eat. She verified there was not a dietitian to evaluate Resident #9's weight loss. The DON denied Resident #9 was offered or received any additional food, snacks, health shakes or supplements. During an interview on 10/18/16 at 3:30 p.m., the FSS said Resident #9 did not receive additional food supplements or health shakes. She said he received an evening snack and knew he did not like the thickened liquids he received. A Weight System policy updated 5/21/14 said the standards of care committee would review significant weight losses weekly and document recommendations/interventions and care plans would be updated. The web page, www.fda.gov/downloads/drugs/drugsafety <http://www.fda.gov/downloads/drugs/drugsafety>, accessed on 10/20/16 at 2:30 p.m. indicated: The most common adverse events reported in [MEDICATION NAME] XR short-term were anorexia, asthenia, constipation,dizziness, dry mouth, [MEDICAL CONDITION], nausea, nervousness, somnolence, and sweating. During an interview on 10/18/16 at 3:20 p.m., the DON said 10 residents had weight loss, with 3 of those residents having planned weight loss.

Based on observation, interview, and record review, the facility failed to ensure residents received the necessary treatment and services to promote healing and prevent new pressure sores from developing for 7 of 10 residents reviewed for pressure sores. (Residents #s 1, 4, 5, 9,14,15, and16) The facility did not: *accurately assess Resident #9's pressure sore, did not provide off-loading, and did not communicate with the physician about worsening of the pressure sore or of the new pressure sore. Resident #9 developed one unstageable pressure sore and had another that was non-healing. -accurately assess Resident #s 5, 14, and 1's pressure sores, did not provide appopriate treatment for [REDACTED]. -accurately assess Resident #16's pressure sore and did not provide off-loading, -accurately assess Resident #s 4 and 15's pressure sores and did not provide appropriate treatments. These failures contributed to the development of new, avoidable pressure sores and worsening of existing pressures sores for 7 residents with pressure sores, and placed 3 additional residents with pressure sores at risk for increased healing time, infection, and discomfort. Findings included: 1. Physician orders [REDACTED].#9 was [AGE] years old, and admitted [DATE] with [DIAGNOSES REDACTED]. His orders were to monitor for off-loading of heels every shift, to clean a stage 3 pressure sore on his left outer ankle with normal saline, apply [MEDICATION NAME], wrap with gauze (Kerlix), and clean an unstageable wound to his right heel, apply Santyl and cover with a dressing daily. The most recent MDS dated [DATE] indicated Resident #9 sometimes made himself understood and sometimes understood others. He required extensive assistance of two staff for bed mobility, and was dependent for transfers, and required extensive assistance with locomotion, and was dependent for dressing and personal hygiene. His assessment indicated he was at risk for pressure sores and had one stage 3 pressure sore that measured 0.5 cm x 0.5 cm with eschar. Resident #9's care plan updated 11/2/15 indicated he had a pressure ulcer and to float his heels. His Braden scale (for predicting pressures sores) dated 10/31/15 indicated a score of 18. (16-23 = mild risk for pressure sores). Resident #9's weekly skin documentation included the following: (Right heel) * 11/3/15- eschar 0.8 cm x 0.9 cm, no pain. * 11/17/15- eschar 0.5 cm x 0.5 cm, no pain. * 11/24/15- eschar 0.5 cm x 0.5 cm, no pain. (Left ankle) * 11/3/15- 11/24/15 - 0.2 cm by 0.2 cm depth 0.1 cm - exudate yellow, wound bed pink. Treatment normal saline, [MEDICATION NAME] or triple antibiotic ointment, and dressing foam. His wound measurement and treatment did not change for 4 weeks. During an observation on 12/2/15 at 10:10 a.m., Resident #9 was in bed, his feet were against the foot board and not off-loaded. His right heel had an approximate 3 cm x 4 cm of firm black eschar (an unstageable pressure sore), his left outer ankle had an approximate 3 cm x 2 cm area of black eschar and the skin surrounding the eschar was 2-3 cm in width was red and swollen (unstageable pressure sore with possible infection). Resident #9 had facial grimacing and moaned when his foot and ankle were moved. The treatment nurse and LVN F said he had received pain medication that morning. During an observation on 11/30/15 at 10:05 a.m., Resident #9 was sitting in a Gerichair, his feet were not off-loaded. The ADON said he received [MEDICAL TREATMENT] three times a week, was confused, and had lost weight. During an interview on 12/2/15 at 10:20 a.m., the DON said when she saw Resident #9's left ankle the previous week, it was almost healed and had no eschar. His pressure sores worsened in 6 days. During an interview on 12/3/15 at 12:05 p.m., Resident #9's physician said he had not been called by facility staff or notified of any worsening or new skin breakdown. During an interview on 12/3/15 at 12:45 p.m., Resident #9's family said they had not been notified of any new pressure sores. The family member said she was concerned about his eating, as staff had told her he could feed himself, but she said he was often too weak to eat. She said the last time she visited she fed him and he ate well. During an interview on 12/3/15 at 2:15 p.m., the [MEDICAL TREATMENT] nurse said Resident #9 was not sent with any kind of off-loading pillows or boots for his feet. She said he was currently receiving [MEDICAL TREATMENT] and only had socks on his feet. The [MEDICAL TREATMENT] nurse said if Resident #9 was sent with pillows, cushions or foot boots they would be used to position. She was unaware of any pressure sores to his feet or ankle. She said Resident #9 did complain at times of pain to his feet and ankles. 2. Consolidated physician orders [REDACTED].#1 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The orders indicated a weekly head to toe skin assessment to be completed every Thursday. The most recent MDS dated [DATE] indicated Resident #1 usually understood others and usually made her needs known. Resident #1 required extensive to total assistance from staff with transfers, dressing, toileting, and bathing. Resident #1 had impairments to her lower extremities. The MDS indicated Resident #1 had one stage 2 pressure sore that was not present upon admission. The most recent care plan dated 10/15/15 indicated on 10/29/15 Resident #1 had a stage 2 pressure sore to her right heel measuring 1.2 cm x 1.0 cm x 0.1 cm. The care plan indicated Resident #1 would wear a protective boot to her right foot. An infection report dated 11/18/15 indicated Resident #1 had an infection; the report did not indicate where the infected area was. The report indicated the wound was red, warm, and swollen. The report indicated a culture was obtained on 11/19/15 and on 11/22/15 results were positive [MEDICAL CONDITION] and the physician was notified. The infection report indicated Resident #1 was placed on standard precautions and antibiotic therapy. The most recent Braden score for Resident #1 dated 10/10/15 was 13. (a score of 13-14 represents moderate risk) The weekly skin assessment sheets indicated the following measurements for the pressure sore on Resident #1's right heel: *11/5/15- 1.2 x 1.0 x 0.1 cm; Stage 2 *11/12/15- 1.2 x 1.0 x 0.1 cm; Stage 2 *11/13/15- 5.3 x 11.0 x 0.2 cm; Stage 2 *11/20/15- 5.5 x 10.0 x 0.2 cm; Stage 2 *11/26/15- 5.4 x 10.4 x 0.2cm. Stage 2 During an observation and interview on 11/30/15 at 2:00 p.m., Resident #1 had an open area to her right heel measuring 2.5 x 7.0 cm with a pink and yellow wound bed, and a 1 x 1 cm open area to her right inner ankle area with a yellow wound bed. The treatment nurse said the pressure sore on Resident #1's heel had worsened to a stage 3, and she had not seen the pressure sore on the resident's ankle on her last assessment. During an observation on the following dates and times Resident #1's feet were not off loaded and she was not wearing a protective boot: *11/30/15 at 12:40 p.m.; and *12/1/15 at 8:45 a.m. and 10:00 a.m. During an observation on 12/1/15 at 10:06 a.m. Resident #1 wore a sock on her left foot that had a bloody spot the size of a half dollar to her heel. Resident #1's right heel pressure sore did not have a dressing. During an interview on 12/1/15 at 10:15 a.m., CNA B said she had just given Resident #1 a shower about 15 minutes ago and took her to her room and placed a sock on her right foot and left her in her room. CNA B said she did not tell the nurse she was done with the resident's shower. She said the treatment nurse knew Resident #1 needed a daily dressing change so she did not notify them when she was finished with Resident #1's shower. During an interview on 12/1/15 at 10:16 a.m., the treatment nurse said the nurse aids should notify her when residents are out of the shower and need dressings changed. The treatment nurse said she was unaware Resident #1 needed a dressing replaced to her right foot. The treatment nurse said staff should never place a sock on an open pressure sore to a foot. During an interview on 12/2/15 at 9:30 a.m., the DON said when CNAs finish showering a resident with a pressure sore they should immediately notify the treatment nurse or charge nurse so a dressing can be reapplied. A nurse note dated 11/13/15 at 10:30 a.m. written by the treatment nurse indicated Resident #1 was in the therapy department and PTA C informed her that Resident #1's right foot began bleeding during therapy. The treatment nurse indicated Resident #1's right foot was wrapped in a towel with a blood soaked sock on. The treatment nurse indicated Resident #1 stated the sock was stuck to my heel a little bit ago, but I knocked it loose. When the treatment nurse removed the sock there was tissue stuck to the inner part of the sock. The note indicated Resident #1 said her dressing was removed this morning prior to taking a shower and a sock was placed on her foot without a dressing. Resident #1's right heel stage 2 pressure sore was noted to now be larger and measured 5.6 cm x 11.0 cm x 0.2 cm. A progress note dated 12/2/15 at 4:50 p.m. written by Resident #1's nurse practitioner indicated the wound on the right heel was a stage 2-3 shallow pressure ulcer. An undated skin assessment by RN D provided on 12/3/15 at 8:30 a.m. indicated Resident #1's right heel pressure sore measured 8.2 cm x 4.0 cm. RN D incorrectly documented Resident #1's pressure sore as a stasis ulcer. 3. Physician orders [REDACTED].#5 was [AGE] years old, and admitted [DATE] with [DIAGNOSES REDACTED]. A physician order [REDACTED]. A physician's orders [REDACTED].#5's left foot. The most recent MDS dated [DATE] indicated Resident #5 made herself understood. She had clear comprehension, was totally dependent for bed mobility, transfers, dressing and person hygiene. Her assessment indicated she was at risk for pressure sores but did not have any pressures sores nor did she have pressure sore during her previous MDS assessment. Resident #5's record indicated she was hospitalized from 11/6-11/9/15 for [MEDICAL CONDITION] (high sodium level) and UTI. Resident #5's weekly skin documentation indicated the following: * 11/10/15 (readmission) - No skin issues. * 11/12/15- 1.0 by 1.0 cm, clear fluid filled blister left heel. (Treatment [MEDICATION NAME] of [MEDICATION NAME] every shift.) * 11/19/15 - 1.0 by 1.0 cm, clear fluid filled blister left heel. * 11/27/15 - no measurement clear/pink blister. (intact) During an observation on 11/30/15 at 4:00 p.m., the treatment nurse lifted Resident #5's left foot, and an approximate 5 cm x 3 cm dark, purple/brown boggy (soft) area to her left heel was noted. (This indicated a possible DTI (deep tissue injury, or unstageable pressure sore.) The treatment nurse said the area was not there during her last assessment, (11/27/15) but was clear in color and nearly healed. The treatment nurse applied [MEDICATION NAME] of [MEDICATION NAME] to her left heel. Resident #5's left foot had declined to eschar in 3 days. During an interview on 12/1/15 at 4:40 p.m., the treatment nurse said she had not received any wound care training other than taking care of wounds as a home health nurse. She said she did not stage wounds and would notify the DON or ADON if she found a new skin issue, or if a resident's wound had changed, and she would assess the wound. The treatment nurse said the charge nurses did wound care on the weekends. During an interview on 12/1/15 at 4:50 p.m., the DON said she had not received formal training on pressure sores, but had received a directed inservice on pressure sores. The DON said the weekend RN was becoming wound care certified and she would teach the staff wound care. The DON said she or the ADON observed residents' pressure sores weekly and wounds were discussed in stand up meetings. During an observation and interview on 11/30/15 at 9:45 a.m., the ADON said Resident #5 had an area to her left heel and was receiving treatment for [REDACTED].#2 was sitting in her recliner, with shoes on both feet, and heels not off-loaded. During an observation on 11/30/15 at 11:35 a.m., Resident #5 was sitting in her recliner, asleep, shoes on both feet, heels not off-loaded. During an observation on 11/30/15 at 3:45 p.m., Resident #5 was lying in bed, with heels directly on the mattress, not off-loaded. Following surveyor intervention, a physician order [REDACTED].#5 to the wound care center for wound to the left heel. 4. Current electronic physician orders [REDACTED].#4 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. [MEDICAL TREATMENT] was started March 2015. On 10/23/15 these orders indicated to clean with NS, apply [MEDICATION NAME] and dress daily for a pressure sore to his left heel. The heels were to be floated at all times. The MDS dated [DATE] indicated Resident #4 made himself understood and he understood others. He required limited assistance for bed mobility and required limited to extensive assist for ADLs. A care plan created 11/02/15 indicated Resident #4 had a pressure sore to his left heel identified on 10/23/15. The pressure sore measured 3 cm x 2.7 cm x 0.1 cm with a tan and firm wound bed with a small amount of yellow exudate. The care plan did not include intervention to float Resident #4's heels at all times. A daily pressure sore form dated 11/17/15 through 11/30/15 completed by the treatment nurse indicated each day the pressure sore on Resident #4's left heel was a stage 2 with no necrotic tissue. A weekly skin documentation form completed by the treatment nurse recorded the following information regarding the pressure sore to Resident #4's left heel: On 11/5/15 (documented as the 1st week of assessment) - Stage 2, left heel, 1.0 cm x 0.8 cm with pink granulating tissue. (This assessment conflicts with the 11/2/15 documentation on the care plan which indicated a 3 cm x 2.7 cm x 0.1 cm pressure sore with a tan and firm wound bed, with a small amount of yellow exudate) On 11/12/15 - Stage 2, left heel, 2.2 cm x 2.2 cm x 0.1 cm with pink granulating tissue, size has increased with slow improvement. On 11/19/15 - Stage 2, left heel, 2.2 cm x 2.2 cm x 0.1 cm with dark, tan, firm wound bed. On 11/26/15 - Stage 2, left heel, 2.2 cm x 2.2 cm x 0.1 cm with a dark firm wound bed During an observation and interview on 12/1/15 at 12 p.m., Resident #4 was sitting in his bed with both heels directly on the floor. Resident #4 had a 2.5 cm x 2.5 cm pressure sore, with firm, dark brown/black tissue covering the wound bed (unstageable pressure sore). The skin surrounding the wound was thick and white. The treatment nurse applied [MEDICATION NAME] and a sponge cushion to the wound and wrapped it with Kerlix. The treatment nurse said the wound was usually beefy red. She said he was supposed to keep his foot propped up, but most of the time he kept it on the floor. Resident #4 said his left heel was painful at times. A nutrition care plan edited on 10/7/15 indicated no new interventions regarding a low [MEDICATION NAME] of 3.1. (Normal [MEDICATION NAME] level is 3.5-6.0 g/dl.) A dietary consult dated 11/21/15 recommended Nephro-Vite 1 can daily. (Nephro-Vite is a dietary supplement for renal patients used to provide vitamins that are not obtained through diet.) After surveyor intervention, the treatment nurse obtained a new physician order [REDACTED]. The new order was to clean daily with normal saline, apply Santyl to wound bed, cover with non-adherent dressing, pad with gauze 4 x 4, and wrap with Kerlix, secure with tape, and re-evaluate in 7 days. During an interview on 12/1/15 at 3:30 p.m., the treatment nurse said the DON or ADON staged all pressure sores. The treatment nurse said Resident #4 was offered a pressure relief boot but refused. During interview on 12/1/15 at 5:00 p.m., the DON said the wound bed was yellow, dark brown, and she assessed it as a stage 2 at the present time. During an observation and interview on 12/1/15 at 5:10 p.m., Resident #4 said he had never been asked to wear a pressure relief boot. Resident #4 was sitting in the wheel chair in his room with both feet directly on the floor. 5. Physician orders [REDACTED].#16 was [AGE] years old, and admitted [DATE] with [DIAGNOSES REDACTED]. His orders included to off-load heels every shift. The most recent MDS dated [DATE] indicated Resident #16 usually made himself understood and usually understood others. He required extensive assistance of two staff for bed mobility, and was dependent for transfers, locomotion, eating and personal hygiene. His assessment indicated he was at risk for pressure sores but did not have any pressures sores nor did he have pressure sore during her previous MDS assessment. Resident #16's weekly skin documentation from 11/2/15-11/30/15 indicated no skin issues. During an observation on 12/2/15 at 11:15 a.m., Resident #16 was lying in bed, the treatment nurse raised his left leg and his heel had an approximate 5 cm x 4 cm pressure sore with black firm eschar on his heel (unstageable pressure sore). LVN F said he had a skin graft to his left heel several years ago, and she thought the discoloration was normal for him. His weekly skin assessments did not indicate normal black discoloration on his left heel. During an observation on 12/2/15 at 10:45 a.m., Resident #16 was sitting in his Gerichair in a reclined position. He was wearing socks and house shoes. There was no pillows or off-loading device in use. 6. A computerized physician order [REDACTED].#15 was [AGE] years old, and admitted [DATE] with [DIAGNOSES REDACTED]. A significant change MDS assessment dated [DATE] indicated Resident #15 had no cognitive impairment. The MDS indicated he was always understood, and always understands others. He is mostly independent and only requires limited staff assistance of one staff person for dressing and hygiene. The MDS indicated Resident #15 had one stage III pressure sore. Section M 1200 B. indicated Resident #15 had a pressure relieving device on his bed. A Wound Surveillance Form dated 11/30/15 indicated Resident #15 had a stage II pressure sore to his right upper buttock that developed in the nursing home on 11/17/15. After surveyor intervention during an observation and interview on 12/2/15 at 1:30 p.m. the treatment nurse identified two new stage 2 pressure sores to resident #15's coccyx. The larger pressure sore measured 1 cm x 0.6 cm x 0.1 cm and the second measured 0.3 cm x 0.1 cm x 0.1 cm. The pressure sore to the right buttock measured 1.0 cm x 0.3 cm x 0.3 cm. Resident #15 was lying on a regular pressure reduction mattress. The treatment nurse said she did not know why he was not on a pressure relieving mattress. A physician order [REDACTED].#15 was to receive wound treatment to his right buttock every 3 days and as needed. Staff was to clean with normal saline, pat dry, and apply a duoderm dressing. A Care Plan updated 9/15/15 indicated Resident # 15 would have a mattress overlay on his bed to reduce pressure when he layed on his back. A Braden scale dated 11/1/15 indicated Resident #15 was a mild risk for pressure sore development. 7. A Consolidated Physician order [REDACTED].#14 was [AGE] years old. Her [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #14 required extensive one person assistance with Activities of Daily Living and bed mobility. A care plan created on 11/2/15 with a start date of 10/19/15 said to float heels. A physician telephone order dated 10/19/15 ordered pressure sore treatment for [REDACTED]. Float heels at all times. A physician telephone order dated 11/26/15 indicated to discontinue the skin prep and duoderm treatment and to begin lanoderm skin protectant cream to left and right heels every shift for seven days then re-evaluate. During an observation and interview on 12/2/15 at 11:00 a.m., Resident #14's right heel had no dressing and was not off-loaded. The resident's right heel was hard and pale reddish purple in color, and covered with dry, hard, brown, eschar (unstageable pressure sore). Resident #14 said she would wear pressure relieving boots if she had them. She told the DON no one had ever offered her boots. She was not on a pressure relieving mattress. During an interview on 12/2/15 at 11:53 a.m., the DON said she staged Resident #14's current pressure sore as a stage 1. She said she did not feel comfortable staging the wound. During an interview on 12/2/15 at 12:10 p.m., the ADON said Resident #14's pressure sores to her right and left heels were hard and brown. She said she thought they were a stage one. She described eschar as a scab, hard and brown or black. Weekly Skin documentation on 11/30/15 indicated the treatment nurse performed wound care with [MEDICATION NAME] of [MEDICATION NAME], but the treatment administration record showed she applied lanoderm. During an interview on 12/2/15 at 2:45 p.m., the treatment nurse said she applied the lanoderm, not the [MEDICATION NAME] of [MEDICATION NAME] and she did not know why she signed both treatments. The NPUAP web site at << http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/ >> accessed on 12/3/15 indicated the following: Category/Stage II: Partial thicknessPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister.Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation.*Bruising indicates deep tissue injury. Category/Stage III: Full thickness skin lossFull thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage IV: Full thickness tissue lossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknownFull thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body ' s natural (biological) cover and should not be removed. Suspected Deep Tissue Injury - depth unknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. The undated Pressure Ulcer Policy, provided by the DON on 12/1/15 at 2:30 p.m., described pressure ulcer definitions, skin treatments and wound care documentation. No interventions or nursing care were listed. The policy indicated the wound documentation must be done daily and weekly. Skin rounds completed 12/3/15 indicated there were 10 residents with 21 pressure sores.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services in accordance with the comprehensive assessment and plan of care for 1 of 6 residents reviewed for pain. (Resident #6) Resident #6 was ordered pain medication on 2/2/14 for a swollen jaw and complaints of pain. Resident #6 complained of jaw pain, but did not receive pain medication until 2/4/14, after surveyor intervention. This failure contributed to Resident #6 having unrelieved pain for 2 days. This failure could place 16 residents receiving pain management at risk for unrelieved pain. Findings included: Physician orders [REDACTED]. Resident #6 had an order for [REDACTED]. The most recent MDS dated [DATE] indicated Resident #6 was usually able to understand others and able to make himself understood. His pain assessment indicated no pain. The most recent care plan dated 1/2/14 indicated the following pain intervention: " ...notice any facial grimaces or body language that might indicate that I am in pain ... " and " ...give me my pain medication the way the doctor ordered it... " During an observation and interview on 2/4/14 at 10:05 a.m., Resident #6 was in his room and complained of his mouth hurting. Resident #6's right jaw was swollen with a dark red area to his right upper gum area towards the back of his mouth. He said on 2/3/14 he asked LVN G, the evening charge nurse, for pain medication. Resident #6 said he did not receive any pain medication. During an interview on 2/4/14 at 10:50 a.m., LVN G said on 2/3/14 at approximately 9:30 p.m., Resident #6 complained of jaw pain. She said she did not give him any pain medication because it had not been delivered. LVN G said she did not follow up on his pain medication because the pharmacy usually made a delivery between 10:00 p.m. and 11:00 p.m. During an interview on 2/4/14 at 10:24 a.m., Resident #6 said his right jaw still hurt. During an interview on 2/4/14 at 10:27 a.m., Resident #6 said he told the regional nurse his jaw hurt. During an interview on 2/4/14 at 11:46 a.m., Resident #6 said he was unable to rate the intensity of his pain. He said "my jaw just hurts, it hurts all the time. " Nursing notes for Resident #6 included the following: * 2/2/14 at 1:00 p.m., the resident appears to have swelling to right side of his face/jaw. Reports pain when asked about the area. Doctor notified. * 2/2/14 at 2:00 p.m., Resident's physician here with new orders for [MEDICATION NAME] 500 mg and Tylenol #3 one by mouth every 8 hours as needed for pain. Pharmacy notified. * 2/3/14 at 3:50 p.m., Resident #6 returned to facility, no adverse reactions to antibiotics. Right jaw remains swollen and nose red. No complaints of pain. * 2/4/14 at 00:00 a.m., Resident #6 right jaw and nose remains swollen. * 2/4/14 at 8:00 a.m., Resident #6 upper lip and right jaw noted to be swollen. * 2/4/14 at 10:40 a.m., Resident #6 complained of pain, Tylenol #3 not in facility, pharmacy called and was told they did not send due to no amount requested. Physician notified. During an interview on 2/4/14 at 10:25 a.m., the DON said Resident #6's pain medication was ordered on [DATE]. She did not know why Resident #6 had not received his pain medication. During an interview on 2/4/14 at 10:26 a.m., the regional nurse said she did not know why Resident #6 had not received his pain medication. She said Tylenol #3 was ordered on [DATE] and should be in the facility. During an interview on 2/4/14 at 10:35 a.m., LVN A said at approximately 8:30-9:00 a.m., Resident #6 complained his jaw was hurting. She said she did not tell Resident #6's nurse. She said she should have administered Resident #6's pain medication or reported his request to the ADON or DON. LVN A said she still had not reported Resident # 6's complaint of pain. During an interview on 2/4/14 at 10:37 a.m., LVN F said Resident #6's Tylenol #3 was not in the facility. During an interview on 2/4/14 at 10:42 a.m., the DON said she and the ADON were responsible for checking physician orders [REDACTED]. During an interview on 2/4/14 at 10:55 a.m., LVN F said Resident #6's Tylenol #3 was not delivered because there was no specified number of pills to send, and no refill amount noted on the original physician order. During an interview on 2/4/14 at 11:00 a.m., LVN H said she never followed up on the order for Resident #6's Tylenol #3. During an interview on 2/4/14 at 11:10 a.m., the DON said she expected nurses to follow up on physician orders. She said if a resident's medication was not delivered by the pharmacy, the nurse should make a note on the 24 hour report. The DON said the on-coming nurse would become responsible for follow- up. During an interview on 2/4/14 at 11:25 a.m., the pharmacy director said an order for [REDACTED]. He said he never received a response from the facility. During an interview on 2/4/14 at 11:50 a.m., RN J said she faxed Resident #6's physician order [REDACTED]. A physician order [REDACTED]. " ...order clarification- Tylenol #3 by mouth every 8 hours as needed for pain ... " During an interview on 2/4/14 at 3:00 p.m., LVN G said she administered the initial dose of Tylenol #3 to Resident #6 on 2/4/14 at 2:50 p.m. The pain management policy dated 1/10/11 indicated the following: " ...assessment for pain will be done anytime a resident complains of pain or indicates non-verbally that they are experiencing pain ... " " ...administer [MEDICATION NAME] as ordered, on time and titrate the medication dosage/frequency within prescribed guidelines ... " A list provided by the DON on 2/5/14 indicated 16 residents received as needed pain medications.

Based on observation, interview, and record review, the facility failed to provide treatment and services based on the comprehensive assessment to promote the healing of existing pressure sores and to prevent the development of new pressure sores for 1 of 6 residents reviewed for pressure sores. (Resident #7) Resident #7 was admitted on [DATE] with a Stage IV pressure sore on the sacrum, and on 03/04/13 four new pressure sores were identified. The facility failed to provide a pressure relief mattress per the plan of care to prevent further decline from 12/14/12 until 03/03/13. This failure likely contributed to the decline in Resident #7's existing pressure sore and the development of additional pressure sores and could place 6 residents who were at high risk for pressure sores at risk of developing pressure sores. Findings included: Physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #7 required extensive assistance with bed mobility and was incontinent of bowel. His cognitive status indicated he was severely impaired with disorganized thinking. Resident #7 had 1 Stage IV pressure sore. A Braden scale assessment dated [DATE] indicated Resident #7 was at high risk for skin breakdown. A care plan initiated on 12/26/12 and updated on 02/06/13 indicated staff were to provide Resident #7 padding between pressure areas and provide a pressure relieving device for his bed for a Stage IV pressure sore to his sacrum. A care plan initiated on 03/04/13 indicated staff were to provide Resident #7 padding between pressure areas and provide a pressure relieving device for bed for a Stage III to left gluteal fold, unstageable to right inner thigh, Stage II to the scrotum, and a Stage II to the left inner heel. During an observation and interview on 03/03/13 at 2:26 p.m., Resident #7 was on a regular scoop mattress, not a pressuring reducing mattress. The ADON said the mattress was a regular therapeutic foam mattress. Resident #7 was admitted with a Stage IV pressure sore to his sacrum and buttocks. He had been on that mattress since admission. During observations on 03/04/13 at 8:10 a.m. and 2:15 p.m., Resident #7 was on a low air loss mattress set at 325 pounds. The February 2013 weight log indicated Resident #7's weight was 118 pounds. During an interview on 03/04/13 at 2:10 p.m., LVN A said Resident #7 had 2 new pressure sores, one to his thigh and one to his scrotum. During an observation and interview on 03/04/13 at 2:15 p.m., the ADON said the facility provided Resident #7 with a low air loss mattress. The ADON changed the mattress setting to 120 pounds after surveyor intervention. The Weekly Skin Documentation Form for Resident #7 dated 03/04/13 indicated the following: 1. Stage IV Buttocks/Coccyx (sacrum) - 9 cm by 2 cm with 0.1 cm depth 2. Stage II Scrotum - 1.5 cm by 1.3 cm with 0.1 depth 3. Stage III left gluteal fold - 1.2 cm by 1.4 cm with 0.1 cm depth 4. Stage II left inner heel - 5 cm by 1.2 cm non blanchable 5. Unstageable right inner thigh - 9 cm by 2 cm by 0.1 cm depth with yellow slough (necrotic tissue). During an observation on 03/05/13 at 10:05 a.m. Resident #7 had the following pressure sores: 1. Stage IV Sacrum/buttocks/ischium (back lower part of the hip bone) - 10 cm by 9 cm with 2.1 cm depth (measured). A decline from facility documented measurements on 03/04/13. 2. Stage II Scrotum - approximate size 2 cm by 1 cm 3. Stage II left lower buttocks - approximate size 2 cm by 1 cm 4. Stage II left medial heel - approximate size 1.5 cm by 1.5 cm times 3 areas 5. Unstageable - right posterior thigh - approximate size 8 cm by 1 cm yellow slough. During an interview on 03/15/13 at 12:35 p.m., the DON said she was not going to answer any questions. The DON said the survey team could ask for anything they wanted. No additional information was provided. During an interview on 03/06/13 at 1:15 p.m., the administrator said low air loss mattresses were rented and the DON was authorized to order as needed. The administrator said she was unaware Resident #7 was not on the appropriate mattress. During an interview on 03/06/13 at 1:20 p.m., the DON said she could order low air loss mattresses and it only took a couple hours for delivery. The DON provided guidelines for facility used mattresses. The Mattresses Selection Guide from Direct Supply Equipment & Furnishings indicated a foam mattress was used for up to Stage II wounds and air mattresses often used for Stage III and IV wounds (pg. 5). The Skin System policy dated 02/15/12 indicated Stage III, IV and suspected deep tissue injury, as well as unstageable pressure ulcers require low air loss alternating mattresses. The website, <http://www.npuap.org/wp-content/uploads/2012/03/Final_Quick_Treatment_for_web_2010.pdf>, accessed 03/08/13, indicated a pressure ulcer was localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. Regarding healing the website indicated individuals should be reassessed if the ulcer did not show signs of healing as expected despite adequate local wound care, pressure redistribution, and nutrition. Common Definition of Pressure Ulcers A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. International NPUAP- EPUAP Pressure Ulcer Classification System Category/Stage I: Non-blanchable redness of intact skin Intact skin with non-blanchable [DIAGNOSES REDACTED] of a localized area usually over a bony prominence. Discoloration of the skin, warmth, [MEDICAL CONDITION], hardness or pain may also be present. Darkly pigmented skin may not have visible blanching. Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons. Category/Stage II: Partial thickness skin loss or blister Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising. This category/stage should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation. Category/Stage III: Full thickness skin loss (fat visible) Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some slough may be present. May include undermining and tunneling. Further description: The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage IV: Full thickness tissue loss (muscle/bone visible) Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often include undermining and tunneling. Further description: The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed. Support Surfaces for treatment of [REDACTED]. This section addresses support surface recommendations for individuals with existing pressure ulcers. Refer to the Support Surfaces section in the Prevention Guideline for information on prevention of additional pressure ulcers and general guidance on positioning. Refer to the Glossary in the Clinical Practice Guideline for selected terms and definitions associated with support surfaces. Support surfaces alone neither prevent nor heal pressure ulcers. They are to be used as part of a total program of prevention and treatment. When pressure ulcers deteriorate or fail to heal, the professional should consider replacing the existing support surface with one that will improve pressure redistribution and microclimate (heat and Quick Reference Guide Treatment ?EPUAP-NPUAP 14 moisture control) for the individual. Changing the support surface is only one of several strategies to consider. The individual and his/her pressure ulcer should be re-evaluated. Preventive interventions and local wound care should also be intensified as needed. A significant increase in risk status may also prompt such re-evaluation of the individual and the support surface. General Recommendations Support Surfaces 1. Provide a support surface that is properly matched to the individual's needs for pressure redistribution, shear reduction, and microclimate control. 2. Replace the existing mattress with a support surface that provides better pressure redistribution, shear reduction, and microclimate control for the individual if she or he: * Cannot be positioned off of the ulcer * Has pressure ulcers on two or more turning surfaces (e.g., the sacrum and trochanter), limiting turning options * Fails to heal or demonstrates ulcer deterioration despite appropriate comprehensive care * Is at high risk for additional ulcers During an interview on 03/06/13 at 11:30 a.m., the DON said there were 6 residents at high risk for pressure sores.