Every finding on record at Avir at San Angelo

Based on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 21 residents (Residents #1) reviewed for abuse.The facility failed to ensure Resident #1 was free from sexual abuse on 7/20/2026 when CNA W confessed to the local police department that he forced Resident #1 to perform oral sex on him on a date.An Immediate Jeopardy (IJ) situation was identified on 08/20/26. While the IJ was removed on 08/22/26, the facility remained out of compliance at a scope of isolation with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for further abuse, physical harm, psychosocial harm, trauma, unrecognized abuse and emotional distress.Findings include: Record review of Resident #1's admission Record, dated 08/17/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Alzheimer's Disease with late onset (a progressive brain disorder that develops in people aged 65 or older), dementia (a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, and behavior), delirium (a serious, sudden change in mental function that causes severe confusion, trouble focusing, and fluctuating awareness of surroundings), and anxiety (an uncomfortable feeling of dread or apprehension of what might happen). Record review of Resident 1's Comprehensive MDS, dated [DATE], revealed Resident #1 was rarely/never understood and BIMS was not completed. Staff interview revealed short- and long-term memory problems with severely impaired decision making-never/rarely made decisions. Section GG - Functional Abilities revealed Resident #1 required total dependence with toileting hygiene, upper and lower body dressing, and shower/bathing. Record review of Resident #1's Care Plan, dated 07/21/2026, revealed a focus area which reflected Resident #1 had an ADL self-care performance deficit. Part of the interventions read in part, dependent on staff for all ADL's. Focus area of severely impaired cognitive function/dementia. Record review of Resident #1's Progress Notes, from June 2026 to July 20, 2026 did not reveal any documentation regarding the allegation of sexual abuse.Observation of video footage from 7/20/2026 reviewed on 8/16/2026 revealed:7:55pm- Resident #1 sitting on the side of the bed at the end. Resident #1's arms were around CNA W's hips. CNA W's shirt was up on left side with skin from the back showing. CNA W's knees were up against the mattress. CNA W's left was elbow visible at about chest high moving back and forth. CNA W's right elbow was at hip high not moving. CNA W's back was slightly arched with hips in a forward position. This occurred approximately for 57 seconds. CNA W stepped back, pulled his shirt down, and adjusted his pants. Grabbed Resident #1 legs and placed her on the bed, covered her up, and placed a fall mat on the floor. Walked out of the room.8:05-Resident #1 was attempting to get out of bed. 8:25- (Family Member AD) walked in the room, CNA W comes in room and the Family Member AD told him he needed to get out of the room. During an interview on 08/17/2026 at 12:44 p.m., Resident #1 did not reply to questions and was unable to complete the interview.During an interview on 8/17/2026 at 1:06 p.m. with Resident #1's (Family Member AD) she stated an incident of sexual abuse occurred on 7/20/2026 at 7:35 p.m. The Family Member AD stated CNA W sat Resident #1 on the end of the bed and you could see him on video thrusting his hips forward toward Resident #1's face with his shirt pulled up and his pants lowered. The Family Member AD stated she was watching the video live, so it didn't record the whole time. Family Member AD stated resident has not been sleeping at night since the incident.During an interview on 8/17/2026 at 5:11 p.m. with the DON, she stated she saw the video but was unsure if it was the same video the police viewed. She stated she could not determine what was going on due to CNA W's back being towards the camera. All she could see was Resident #1 sitting on the side of the bed with her hands placed on the lateral aspect of CNA W's hip leg area. CNA W's arms were bent and not visible. It appeared CNA W's left arm was making a slight up and down motion and his right arm appeared to be making a circular motion. CNA W's shirt was lifted on the left side exposing a small amount of skin. CNA W stepped back from Resident #1 lifted her legs onto the bed. Resident #1 was then observed trying to get out of bed. She stated CNA W had no prior signs of being abusive. The DON stated she had not observed any negative outcomes of Resident #1 due to the sexual abuse allegation.During an interview on 8/18/2026 at 10:16 a.m. with CNA W, he stated he was aware of the sexual abuse allegation. CNA W stated he was not denying the sexual abuse occurred, he was just unsure of what he could say without speaking to an attorney and he would not answer any further questions. During an interview on 8/18/2026 at 11:04 a.m. with Detective R, he stated he could not give provide his investigation paperwork as it was still an open case. Detective R stated CNA W did admit in writing to guilt of sexual assault.Interviews with CNA O, CNA U, CNA M, CNA P, CNA Y, MA C, from 8/17/2026-8/20/2026 revealed the facility did not provide training specific to resident sexual abuse, but did set out the facility abuse, neglect, exploitation policy, for them to review, along with a test to be completed for comprehension.During an interview on 08/19/2026 at 5:05 p.m., the Administrator said his responsibility when it came to allegations of abuse, neglect, or exploitation was to protect the resident, gather information, and proceed with the investigation. The Administrator said he was also responsible for contacting the State Survey Agency and if needed law enforcement. The Administrator said all allegations of abuse would be reported to the State Survey Agency within 2 hours. The administrator stated this was reported by the facility and investigated already. The Administrator said if there were any allegations of sexual abuse, the allegation would be reported to the State Survey Agency, law enforcement, and the physician and responsible parties. The Administrator said he had not received any reports of any type of sexual abuse prior to this allegation. The Administrator stated CNA W was arrested on site after the allegation and was terminated. The Administrator stated a negative outcome of sexual abuse could be emotional or psychological harm. The Administrator said he was familiar with Resident #1, and he had not noticed a change in Resident #1's behavior or emotional or psychological harm.Record review of TULIP revealed a prior self-report related to the allegation of sexual abuse which involved Resident #1 on 7/21/2026.Record review of the facility's action plan, dated 7/21/2026, stated The facility failed to protect Resident #1 from abuse. Action plan stated all staff would be educated and understand that sexual relationships with residents, especially residents with low cognition, was inappropriate and was sexual abuse.Record review of news article, dated 7/24/26, revealed Crime -Man Arrested After Terrible Assault of Nursing Home Resident. The investigator spoke with CNA W, who was on scene, and he said did something terrible to a resident in the nursing home. When the investigator asked if CNA W could describe what he did, CNA W said he couldn't. The investigator suggested it might be easier to write it down. CNA W was given a statement of fact form and wrote, I made a resident give me fellatio (oral sex act).Record review of a copy of the police report, dated 8/19/2026, revealed [in part], police arrived at the facility on 7/21/26 at 12:29am in reference to a sexual assault. After the investigation CNA W was placed under arrest for Aggravated Sexual Assault. Resident #1's Family Member, AD, informed police her [AGE] year-old family member / victim Resident #1 who was non-verbal had dementia and required full-time medical help, and lived at the nursing home. The family member, AD, stated employees at the nursing home allowed family just days earlier to place a camera in Resident #1's room, on today's date (7/20/2026) while viewing live video it showed Resident #1 trying to get onto her bed. The male employee / suspect CNA W hugged Resident #1 and positioned Resident #1 to sit on the bed. CNA W while standing in front of Resident #1, CNA W was seen moving his lower body forward, pulling his shirt up and his hands were seen moving back and forth around Resident #1's head. CNA W was detained to further investigate the incident. CNA W was located inside the facility and told he was detained and placed in handcuffs. Family member, AD, showed the police the video of the incident on the family member's cell phone. The Police stated they observed CNA W standing in front of Resident #1, who was sitting on her bed. Resident #1's upper body could not be seen due to CNA W being bigger in size compared to her. They observed CNA W's midsection in front of Resident #1 face; he then began to motion his hands back and forth and appeared to touch Resident #1 face / head. This continued for about 25 seconds; he then picked up Resident #1's feet and assisted her to lay on the bed and covered her with a blanket. It appeared from the video how CNA W's body movement, that he may have had his penis around Resident #1's facial area or in her mouth. CNA W was escorted into a conference room to be interviewed. After the interview was complete, it was determined CNA W would be placed under arrest for aggravated sexual assault. Aggravated Sexual Assault - CNA W intentionally and knowing without consent penetrated the victim's mouth with his penis, the victim also being [AGE] years old and disabled. CNA W was placed under arrest and booked into jail.Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Program Policy, dated 04/2021, revealed Residents have the right to be from abuse, neglect, misappropriation. This includes but is not limited to freedom from sexual or physical abuse.Record review of the test and in-service related to this incident dated 7/21/2026 revealed the test had one question related to sexual assault and did not address the targeted behavior of sexual abuse- recognizing, reporting or prevention.This was determined to be an Immediate Jeopardy (IJ) on 08/20/2026 at 5:32 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 08/20/2026 at 5:32 p.m. The following Plan of Removal submitted by the facility was accepted on 8/21/2026 at 2:12 p.m.:Action:Resident #1 skin was assessed with no adverse findings, and an emotional assessment was completed for her psychosocial well-being with no adverse findings. Resident will be monitored during her skin assessments for physical alterations that may indicate sexual abuse or self-harm. Behavior monitoring has been added to the nurses' tasks to complete daily to monitor resident for adverse effects from the event for 90 days, if residents continue to show no adverse effects, if resident does show adverse effects monitoring will continue and support will be provided by social services and/or psych services.All Residents, including CNA W's hall, who were able to answer safety questionnaires were questioned about feeling safe/abuse with no other issues identified.Administrator, abuse prevention coordinator, or the Director of Nursing, abuse prevention co-coordinator, educated on Identifying Types of Abuse and Abuse Reporting & Investigating and Abuse, Neglect, Exploitation and Misappropriation Prevention Program with emphasis on abuse investigating, interventions post allegation, suspending an employee, and reporting allegations, including sexual allegations, to include abuse/sexual abuse prevention. All staff educated on Identifying Types of Abuse and Abuse Reporting & Investigating and Abuse, Neglect, Exploitation and Misappropriation Prevention Program:The key takeaway: Sexual abuse is non-consensual sexual conduct of any type with a resident. Sexual abuse includes, but is not limited to: unwanted intimate touching of any kind especially of breasts or perineal area; all types of sexual assault or battery, such as rape, sodomy, and coerced nudity (Staff will know it is inappropriate to place their genitalia into residents mouths or other orifices); forced observation of masturbation and/or pornography; and taking sexually explicit photographs and/or audio/video recordings of a resident(s) and maintaining and/or distributing them (examples: posting on social media). This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident. Staff will know when to report (immediately) and who to report to (abuse prevention coordinator/administrator. Staff will know nonverbal residents may not be able to report abuse like verbal residents may can, education provided to staff to include nonverbal cues to report immediately to charge nurse, administrator, and/or director of nursing. Some nonverbal cues include: withdrawal, fear of specific people (residents, staff, visitors), some examples are residents being withdrawn, not attending activities or meals like they once did, flinching around certain people, avoiding people, increased agitation, refusing care from certain people. A test will be completed for comprehension and understanding. Staff will be educated on the posted hotline number to report abuse to HHSC if administrator and director of nursing are both not responding, [PHONE NUMBER], staff will continue to attempt to reach administrator and director of nursing to inform them of the allegation. To also include abuse prevention.All staff, including new or agency, will be educated and tested prior to working their next shift. 5 staff members and 5 residents will be interviewed, weekly, x4 weeks, for abuse, sexual abuse, and reporting to ensure comprehension and to ensure residents do not feel abused or abused sexually.The facility will ensure residents that are nonverbal are protected through the education provided above. When residents are receiving care from staff during activities of daily living, medication pass, skin assessments, activities, and mealtimes, staff will look for signs such as withdrawal, fear of specific people (residents, staff, visitors), not attending activities or meals like they once did, flinching around certain people, avoiding people, increased agitation, refusing care from certain people. Director of Nursing, Assistant Director of Nursing, and/or Designee will be trained to look for nonverbal cues that residents may be being abused or are afraid of staff such as, withdrawal, fear of specific people (residents, staff, visitors), not attending activities or meals like they once did, flinching around certain people, avoiding people, increased agitation, refusing care from certain people.Director of Nursing, Assistant Director of Nursing, and/or Designee will make unannounced visits while direct care staff are performing care to ensure safety, proper procedure is being followed to include the residents are free from abuse, sexual abuse, or neglect, 5 times a week, x4 weeks. During observation if they feel as if these nonverbal cues are taking place, they will intervene, ensure resident safety, and suspend the potential perpetrator.Ad hoc QAPI performed with Medical Director regarding the Immediate Jeopardy Template and the facility's plan to remove the immediacy. No additional recommendations at this time.Monitoring of the facility's plan of removal included the following:During an interview on 08/21/2026 at 9:50 a.m., the Corporate Compliance Nurse stated education has begun with staff who were present and called in staff members. The Corporate Compliance Nurse said she in-serviced the DON and ADON one-on-one regarding recognizing signs of abuse and making unannounced visits during direct care. The corporate compliance nurse stated the facility had already started monitoring direct care and said any signs of abuse would be reported to the Administrator. During an interview on 8/21/2026 at 10:10 a.m., the DON stated being in-serviced by the Corporate Compliance Nurse regarding nonverbal cures of abuse and monitoring of direct care staff 5 times weekly x 4 weeks. The DON stated residents who were able to be interviewed were interviewed and a skin assessment was completed on all non-verbal residents on 8/20/2026. No concerns were noted.During an interview on 8/21/2026 at 11:10 a.m. with the ADON, she stated the interviews with residents who were interview able and no concerns were noted. The ADON completed skin assessments on residents who were not interview able and there were no concerns noted.During an interview on 08/21/2026 at 3:30 p.m., LVN O, MDS Coordinator, said she was in-serviced on abuse/neglect. LVN O said all allegations to include sexual abuse, needed to be reported to the Administrator immediately after ensuring the resident was safe. LVN O stated she knew how to recognize signs of abuse including sexual abuse. LVN O was able to point out where to locate the contact number posting to report to state survey agency.During an interview on 08/21/2026 at 2:03 p.m., LVN P who worked the 6:00 p.m. to 6:00 a.m. shift, said she was in-serviced on abuse/neglect reporting. LVN P stated she was in serviced on recognizing the signs of abuse including sexual abuse. LVN P said all allegations of abuse/neglect to include sexual abuse were to be reported to the Abuse Coordinator/Administrator and DON immediately as soon as verifying the resident was safe. LVN P was able to point out where to locate the posted contact numbers for the Administrator and HHSC hotline to report abuse.During an interview on 08/21/2026 at 4:28 p.m., CNA H who worked the 6:00 p.m. to 6:00 a.m. shift, said she was in-serviced on abuse/neglect reporting. CNA H stated she was in serviced on recognizing the signs of abuse including sexual abuse. CNA H said all allegations of abuse/neglect to include sexual abuse were to be reported to the Abuse Coordinator/Administrator and DON immediately as soon as verifying the resident was safe. CNA H was able to point out where to locate the posted contact numbers for the Administrator and HHSC hotline to report abuse.During an interview on 08/21/2026 at 4:30 p.m., CNA M who worked the 6:00 p.m. to 6:00 a.m. shift, said she was in-serviced on abuse/neglect reporting. CNA M stated she was in serviced on recognizing the signs of abuse including sexual abuse. CNA M said allegations of abuse/neglect to include sexual abuse were to be reported to the Abuse Coordinator/Administrator and DON immediately as soon as verifying the resident was safe. CNA H was able to point out where to locate the posted contact numbers for the Administrator and HHSC hotline to report abuse.During an interview on 08/21/2026 at 4:35 p.m., CNA P who worked the 6:00 p.m. to 6:00 a.m. shift, said she was in-serviced on abuse/neglect reporting. CNA P stated she was in serviced on recognizing the signs of abuse including sexual abuse. CNA P said all allegations of abuse/neglect to include sexual abuse were to be reported to the Abuse Coordinator/Administrator and DON immediately as soon as verifying the resident was safe. CNA P was able to point out where to locate the posted contact numbers for the Administrator and HHSC hotline to report abuse.During an interview on 08/21/2026 at 4:38 p.m., CNA D who worked the 6:00 a.m. to 6:00 p.m. shift, said she was in-serviced on abuse/neglect reporting. CNA D stated she was in serviced on recognizing the signs of abuse including sexual abuse. CNA D said all allegations of abuse/neglect to include sexual abuse were to be reported to the Abuse Coordinator/Administrator and DON immediately as soon as verifying the resident was safe. CNA D was able to point out where to locate the posted contact numbers for the Administrator and HHSC hotline to report abuse.During an interview on 08/21/2026 at 4:50 p.m., CNA B who worked the 6:00 a.m. to 6:00 p.m. shift, said she was in-serviced on abuse/neglect reporting. CNA B stated she was in serviced on recognizing the signs of abuse including sexual abuse. CNA B said all allegations of abuse/neglect to include sexual abuse were to be reported to the Abuse Coordinator/Administrator and DON immediately as soon as verifying the resident was safe. CNA B was able to point out where to locate the posted contact numbers for the Administrator and HHSC hotline to report abuse.During an interview on 08/21/2026 at 4:58 p.m., LVN S, who worked for agency on the 6:00 a.m. to 6:00 p.m. shift, said she was in-serviced on abuse/neglect reporting. LVN S stated she was in serviced on recognizing the signs of abuse including sexual abuse. LVN S said all allegations of abuse/neglect to include sexual abuse were to be reported to the Abuse Coordinator/Administrator and DON immediately as soon as verifying the resident was safe. LVN S was able to point out where to locate the posted contact numbers for the Administrator and HHSC hotline to report abuse.During an interview on 08/21/2026 at 5:08 p.m., LVN H who worked the 6:00 a.m. to 6:00 p.m. shift, said she was in-serviced on abuse/neglect reporting. LVN H stated she was in serviced on recognizing the signs of abuse including sexual abuse. LVN H said all allegations of abuse/neglect to include sexual abuse were to be reported to the Abuse Coordinator/Administrator and DON immediately as soon as verifying the resident was safe. LVN H was able to point out where to locate the posted contact numbers for the Administrator and HHSC hotline to report abuse.During an interview on 08/21/2026 at 5:18 p.m., RN B who worked the 6:00 a.m. to 6:00 p.m. shift, said she was in-serviced on abuse/neglect reporting. RN B stated she was in serviced on recognizing the signs of abuse including sexual abuse. RN B said all allegations of abuse/neglect to include sexual abuse were to be reported to the Abuse Coordinator/Administrator and DON immediately as soon as verifying the resident was safe. RN B was able to point out where to locate the posted contact numbers for the Administrator and HHSC hotline to report abuse.During an interview on 08/22/2026 at 9:18 a.m. with HSK M, he said he was in-serviced on abuse/neglect reporting. HSK M stated he was in serviced on recognizing the signs of abuse including sexual abuse. HSK M said all allegations of abuse/neglect to include sexual abuse were to be reported to the Abuse Coordinator/Administrator and DON immediately as soon as verifying the resident was safe. HSK M was able to point out where to locate the posted contact numbers for the Administrator and HHSC hotline to report abuse.During an interview on 08/22/2026 at 10:18 a.m., with the Floor Tech, he said he was in-serviced on abuse/neglect reporting. The Floor Tech stated he was in serviced on recognizing the signs of abuse including sexual abuse. Floor Tech stated a test was completed after in-service to ensure comprehension. The Floor Tech said all allegations of abuse/neglect to include sexual abuse were to be reported to the Abuse Coordinator/Administrator and DON immediately as soon as verifying the resident was safe. The Floor Tech was able to point out where to locate the posted contact numbers for the Administrator and HHSC hotline to report abuse.Record review of Trauma Informed PRN Assessment, dated 07/21/2026, revealed the assessment was completed for Resident #1 by the Social Worker. No indications of emotional distress.Record review of Employee Disciplinary Reports, dated 07/21/2026, revealed CNA W was terminated.Record review of the Facility's In-Service training records titled Brief overview of identified concern reviewed/Ad Hoc QAPI dated 8/20/2026, revealed Protection of residents from sexual abuse; additional education of the definition of sexual abuse as non-consensual conduct of any type with a resident; additional education to address nonverbal cues from residents unable to report abuse; updated test for comprehension and understanding; if unable to reach the Administrator or DON, the staff will be contacting HHSC hot line to report abuse; The staff will continue to reach out to the Administrator and DON until they have been notified.Record review of the facility's in-service document, dated 8/21/2026, reflected the Corporate Compliance Nurse conducted one-on-one in-services with the DON and ADON on training topic of recognizing non-verbal cues of abuse and monitoring during direct care. Record review of the Facility's In-Service Training records revealed training was conducted on 8/20/2026. The in-services were, dated 8/20/2026 and 8/21/2026, and included the topics of abuse/neglect/exploitation, sexual abuse, abuse/neglect reporting, and who to report allegations of abuse/neglect to.Record review of Order, dated 8/21/2026, reflected an order for Resident #1 for Behavior Monitoring-Post Incident. No behaviors noted when reviewed on 8/22/2026. Record review of Resident Safe Surveys, dated 8/21/2026, reflected 14 resident surveys were conducted on the hall CNA W worked. The document covered the areas of 1) if you had concerns or complaints would you feel comfortable speaking to the staff about them; 2) do you feel the staff treat you with dignity and respect; 3) do you feel safe and comfortable here; 4) have you witnessed or heard anyone be mistreated (verbal, physical, or sexual); 5) Are you afraid of any resident or visitor; 6) does staff knock prior to entering your room; 7) does the staff introduce themselves to you by name and why they are here; 8) do you know the name of the Administrator and DON; 9) Do you know who the abuse coordinator is; 10) do you know the name of the Ombudsman and how to contact them. No potential abuse was noted.Record review of Resident Skin Assessments, dated 8/20/2026, reflected 17 assessments performed for non-verbal residents with no abnormal findings.Record review of monitoring tool, dated 8/21/2026, revealed 5 staff members were observed providing direct care.The Corporate Compliance Nurse and Administrator were informed that the Immediate Jeopardy was removed on 08/22/2026 at 11:05 a.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for one (Resident #21) of three residents reviewed for PASRR Level 1 screenings. The facility failed to refer Resident #21 to the State-designated authority for a PASRR Level II review when she was admitted with a diagnosis of schizophrenia and a PASRR Level 1 positive for mental illness. This failure could place residents with mental illness at risk of not receiving a PASRR Evaluation, individualized care, or special services to meet their needsFindings include: A record review of Resident #21's face sheet, dated 5/7/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included depression (mental health condition that causes a persistent low mood and loss of interest in activities), anxiety (cognitive decline caused by vessel damage that features panic like episodes), schizophrenia (a serious mental health condition that affects how people think, feel and behave) unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems). A record review of Resident #21's quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 which indicated moderate cognitive impairment. Resident #21's active diagnoses included non-Alzheimer's dementia (cognitive decline caused by brain diseases other than Alzheimer's), depression and schizophrenia. A record review of Resident #21's PASRR Level 1 Screening completed on 7/26/2023 by the referring hospital revealed Resident #21 had an indicator of mental illness. During an interview on 5/7/2026 at 12:15PM with Resident #21 she stated she has been at the facility for a while but was not sure exactly how long. Resident #21 stated she had not received services through PASRR before. During an interview on 5/7/2026 at 2:40 PM, the MDS Coordinator stated Resident #21 had a mental illness diagnosis, thus the PASRR screening was positive. She stated a corrected screening should have been completed and sent to the local authority for evaluation. The MDS Coordinator stated Resident #21 was admitted with the schizophrenia diagnosis. The MDS Coordinator stated she needed to fill out a form to notify the Local Authority of the diagnosis. The MDS Coordinator stated PASRR was her responsibility and she would correct the issue. She stated the risk of PASRR not being accurate could be lack of services for the resident. During an interview on 5/7/26 at 4:49PM, the DON stated she expected the PASRRs to be accurate and timely. She stated if an error on a PASRR was later found, a corrected form was sent. The DON stated the MDS Coordinator was responsible for the accuracy of PASRR documents. She stated residents may not have received the benefits or treatments they needed or were entitled to if the PASRR screening was inaccurate. During an interview on 5/7/2026 at 5:00PM with the Administrator, he stated it was the MDS Coordinator's responsibility to update and follow through with PASRR. He stated the risk of not doing so could lead to a decrease in quality of life and not receiving services that could be beneficial to the residents. During a record review of facility's policy dated 11/2023 titled PASRR revealed:In the event of a positive PL1 that indicates the individual may have ID/DD or MI the MDS Coordinator will notify the LIDDA within 2 calendar days of admission and initiate the PASRR evaluation process.

Based on observations, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one of three residents (Resident #11) and 9 of 47 sharps containers reviewed for accidents and hazards. The facility failed to ensure bed alarm was plugged in while Resident #11 was in bed as indicated on his current comprehensive care plan and current physician's orders. The facility failed to ensure sharps containers were replaced when full in 9 rooms (Rooms: 105, 106, 108, 109, 111, 113, 207, 210, and 401). The failures could place residents at risk for injury.The findings include: 1. Resident #11 A record review of Resident #11's face sheet, dated 05/7/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #11 had diagnoses which included unspecified dementia (A group of thinking and social symptoms which interferes with daily functioning), senile degeneration of the brain (a decline in an individual's memory, behavior, and cognitive abilities), anxiety disorder (excessive, persistent, and uncontrollable fear or worry that disrupts daily life). A record review of Resident #11's quarterly MDS dated [DATE] indicated he had a BIMS score of 4 which indicated severe cognitive impairment. The MDS also indicated she was dependent on staff for transfers and changing positions from sitting to standing. A record review of Resident #2's care plan initiated on 1/12/2026 revealed: 01/12/26 fall-hospice to provide low bed and scoop mattress-family has insisted he have bed/chair alarms, 1/21/2026 fall-pharmacy consult to evaluate medications, 3/17/26 Fall-assess Foley to ensure draining, 04/9/26 Fall-med review, 04/26/26 Fall-do not take resident to the dining room until closer to mealtime, 05/2/2026 Fall-assist to bed shortly after dinner is ended. The care plan initiated on 4/20/2026 revealed: Problem-Resident uses bed and chair alarms related to confusion secondary to demand from family and hospice. Goal- The resident will remain free of complications related to restraint use through the next review date. A record review of Resident #11's May 2026 physician's orders revealed an order with start date of 4/20/2026 resident may have bed and chair alarm to mitigate fall risk per family and hospice demand. Check for placement and functionality of bed and chair alarm two times a day. An observation on 05/7/26 at 1:22pm, revealed Resident #11 was lying in bed with his eyes closed. Resident #11's bed alarm was not plugged into the box that would sound. An observation on 5/7/26 at 2:19pm, revealed Resident #11 was lying in bed with his eyes closed. Resident #11's bed alarm was not plugged into the box that would sound. An observation on 5/7/26 at 3:29pm revealed Resident #11 was lying in bed with his eyes closed. Resident #11's bed alarm was not plugged into the box that would sound. During an interview on 05/7/26 at 4:03 PM, the DON stated the staff unplugged the bed alarm to keep it from sounding when they were getting him up and forgot to plug it back in. The DON stated it was the nurses and CNAs responsibility for ensuring the functionality of alarms. The DON stated the risk related to alarms being unplugged could be staff not aware that the resident was attempting to get out of bed. During an interview on 05/7/2026 at 4:36pm with the Administrator, the Administrator stated the resident was to have a bed alarm as indicated in his care plan and physician's orders. The Administrator stated not having the bed alarms could result in a fall and staff not knowing the resident was not in bed. The Administrator stated it was all staff's responsibility to ensure the alarms are plugged in for the safety of the resident, but the main responsibility fell on the nurse caring for the resident at the time. The Administrator stated they do not have a policy for bed alarms as he does not agree with having them in the facility. A Record review of the facility's Fall Prevention Program Policy revised 8/15/22 reflected Each resident will be assessed for fall risk and will receive care and services in accordance with their Individualized level of risk to minimize the likelihood of falls. When a resident who does not have a history of falling experiences a fall, the facility will update the care plan and interventions. 2. Sharps ContainersObservation on 05/05/2026 at 11:12 AM, revealed the sharps container in room [ROOM NUMBER] was filled up over the full line. Observation on 05/05/2026 at 11:22 AM, revealed the sharps container in room [ROOM NUMBER] AM was filled up over the full line and had needles and gloves sticking out of the top. Observation on 05/05/2026 at 11:30 AM, revealed the sharps container in room [ROOM NUMBER] was filled to the full line. Observation on 05/05/2026 at 11:32 AM, revealed the sharps container in room [ROOM NUMBER] was filled up over the full line. Observation on 05/05/2026 at 11:34 AM, revealed the sharps container in room [ROOM NUMBER] was filled to the full line. Observation on 05/05/2026 at 11:36 AM, revealed the sharps container in room [ROOM NUMBER] was filled up over the full line. Observation on 05/07/2026 at 11:07 AM, revealed the sharps container in room [ROOM NUMBER] was filled to the full line. Observation on 05/07/2026 at 11:10 AM, revealed the sharps container in room [ROOM NUMBER] was filled up over the full line. Observation on 05/07/2026 at 11:12 AM, revealed the sharps container in room [ROOM NUMBER] was filled up over the full line. During an interview on 05/07/2026 at 3:55 PM with the DON, she said all nurses were responsible for changing full sharps containers. The DON said they really needed to remove all sharps containers from the rooms because they were also on the med carts. During an interview on 05/07/2026 at 4:01 PM with LVN E, she said if she noticed a full sharps container she would change it if she had the key. She said she did not have one for the sharps containers in resident rooms. She said she has had for the medication cart. During an interview on 05/07/2026 at 4:20 PM with the Administrator, he said changing out full sharps containers was a nurse function. He said the deficiency could cause preventable injuries to staff, residents, and visitors. Record review of the facility's Sharps Disposal Policy, dated 2001, revealed in part. Designated individuals will be responsible for sealing and replacing containers when they are 75% to 80% full to protect employees from punctures and/or needlesticks when attempting to push sharps into the container.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods were properly stored, labeled, and dated.2. The facility failed to ensure prepared food was discarded after 72 hours (3 days) per facility policy. 3. The facility failed to prevent cross-contamination of food items when pureeing food.4. The facility failed to ensure personal food items were not stored in 1 of 2 of the kitchen refrigerators. 5. The facility failed to ensure the dietary staff wore beard covers while in the kitchen.These failures could place residents who received prepared meals from the kitchen at risk of food borne illness and cross-contamination. The findings included:During the initial tour of the kitchen on 05/05/2026 at 9:00 AM, the following was observed: The DM did not have a beard cover over his beard.Milk Refrigerator:A glass bottle of tea was opened.A container labeled ketchup had a prep date of 12/1 and use by date (UBD) of 12/25.A pitcher labeled lemonade had one date, 5/1.Clean Dish Area:Small plates, small bowls, and salad bowls were faced up and not covered.Muffin pans and baking sheets were faced up and not covered.Dry storage:Paper napkins and plastic spoons were open, not sealed, and not covered.Salad bowls were faced up and not covered.A plastic bag containing 2 different pastas was not labeled and had one date, 4/4/26.A plastic bag labeled fettuccini had one date, 1/10.A plastic bag labeled spiral pasta was not sealed and had one date, 4/8/26. A plastic bin labeled dry milk had one date, prep date 1/15/25.An open bag of powdered sugar was inside another plastic bag. The original bag had UBD 7/19/24. The outside bag had one date, 5/3/26.A bag of powdered sugar had UBD 8/27/24.A bag of powdered sugar had UBD 4/29/25.A plastic bin labeled corn meal had one date, 3/30/26.A plastic bin labeled sugar had one date, 3/30.A plastic bin labeled flour had one date, 4/10/26.A bag of frosted flakes was not sealed.A plastic bin labeled cheerios had one date, 5/3.A plastic bin labeled rice krispies had one date, 4/16.A plastic bin of flakes did not have a label or any dates.Refrigerator #1:A metal storage container labeled tot casserole had one date, 4/2.Dessert bowls labeled fruit cup had one date, 4/30. A bag labeled salisbury steak had one date, 4/12.A bag labeled salad was brown and had one date, opened 5/1.A bag labeled pork had one date, 5/5.A bag labeled cubed ham had one date, 5/4/26. Freezer:A bag labeled beef patties was not sealed.A bag labeled tater tots was not sealed. Cooking/serving utensils, pans, and strainers hung on a hanging rack, above the steam table, and was not covered. During the follow-up visit to the kitchen on 05/06/2026 at 4:10 PM, the DM did not wash the blender after pureeing carrots. He rinsed it with water before pureeing the chicken and broccoli rice casserole.During an interview with the DM on 05/05/2026 at 9:05 AM, he said the tea in the glass bottle in the milk refrigerator belonged to a staff member. He said the staff was aware they are not allowed to store personal items in the milk refrigerator.During an interview with the Administrator on 05/07/2026 at 4:28 PM, he said the DM was responsible for all things pertaining to the kitchen and that it had improved in the last 6 months. During an interview with the DM on 05/07/2026 at 5:00 PM, he said his expectations for labeling all items is: the received date, the open date, and the UBD. He said his staff had been trained in labeling, personal food items, and storage of food items. He said he is aware he should always wear a beard cover in the kitchen. The DM said these deficiencies could cause out-of-date food to be served to residents, cross-contamination, residents to become ill, and a pest problem in the kitchen.Review of the facility policy Employee Hygiene for Food Safety, dated 2023, revealed in part . All employees will: Wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food.Review of the facility policy Food Receiving and Storage, revised November 2022, revealed in part. Dry foods that are stored in bins are removed from original packaging, labeled and dated ( use by date). All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date). Refrigerated foods are labeled, dated and monitored so they are used by their use by date, frozen, or discarded.Review of the facility policy Food Safety and Sanitation, dated 2023, revealed in part. Leftovers are used within 72 hours (or discarded). When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 06/19/2025 revealed: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers .(B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement .Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.

Based on observations, interviews and record review the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpsters reviewed for environment. The facility failed to ensure garbage was placed in a covered dumpster.These failure could affect residents by placing them at risk of illnesses, or be provided an unsafe, unsanitary, and uncomfortable environment.Findings include:Observation on 05/05/2026 at 10:15 AM of garbage area outside, revealed a large rectangle roll off dumpster that did not have a lid and the bags of trash were piled higher than the rim.During an interview on 05/07/2026 at 4:12 PM with the Administrator, he said they do not have a garbage disposal policy. He said he was aware of the roll off dumpster and he had instructed staff not to use it. He said he emailed city offices to get it hauled off. The administrator said that using it for regular daily trash could cause pests and trash could be scattered by the wind and/or pests.

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs and describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #23, and Resident #42) of 12 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #23 for ADL dependence and means to address psychosocial needsThe facility failed to develop a comprehensive person-centered care plan regarding hospice services for Resident #42.This deficient practice could place residents in the facility at risk of not receiving the necessary care or services. Findings include:Findings: Resident #23Record review of Resident #23's face sheet, dated 05/06/2026, had revealed admission to the facility on 2/17/2026. Resident #23 was a [AGE] year-old female with diagnoses of Multiple Myeloma (a type of blood cancer), depression, Parkinsonism (an umbrella term that refers to a group of conditions characterized by similar movement-related symptoms, including slowed movements, stiffness, tremor, and balance issues), and collapsed vertebra. Record review of Resident #23's Comprehensive MDS, dated [DATE] revealed Resident #23 had a BIMS score of 8 which indicated moderate cognitive impairment. Section GG-Functional Abilities, dated 02/24/2026, revealed that Resident #23 was coded as 01, fully dependent, on staff for sections GG0130, which included tasks such as showering/bathing self, toileting hygiene, eating, and personal hygiene. It also reflected that the resident used a manual wheelchair. For sections GG0170 sections G-I, M, and P, the sections were coded as 88, indicating that these tasks would have not been attempted due to a medical condition or safety concern. Section H-Bowel and Bladder under section H0300-Urinary Continence, revealed Resident #23 had been coded as a 3, which indicated that the resident was always incontinent of bladder. Section H0400-Bowel Continence had been coded as a 1, which indicated that the resident had been occasionally incontinent of bowels. Section I-Active Diagnoses in the Last 7 Days Prior to Assessment, section I0020, which was to indicate the primary medical condition of the resident, had been coded as a 13 which was for medically complex conditions. There had also been indicators reflecting that she had an active diagnosis at the time of this MDS assessment of cancer (I0100), Gastroesophageal Reflux Disease (GERD) or ulcer (I1200), Depression (I5800), and Cataracts, Glaucoma, or Macular Degeneration (I6500). Additional active diagnosis included Multiple Myeloma having not achieved remission, Parkinsonism, Constipation, Collapsed Vertebrae, Muscle weakness, acute cough, and abnormal weight loss. Section K-Swallowing/Nutritional Status section K0520-Nutritional Approaches had revealed that while she was a resident at the facility, she would have received a Mechanically Altered died (pureed food, thickened liquids).Record review of Resident #23's most up to date comprehensive care plan, last updated on 5/6/2026, consisted of two focus sections. The first section had not specified whether Resident #23 had been independent from staff assistance or fully dependent on staff for assistance on ADLs. In two columns, there had been two columns, column A labeled Care Area Triggered and column B labeled Care Planning Decision. Review of the care plan showed that the only Care Planning Decision marked that had been listed as a focus area on the Care Plan Report had been interventions/tasks listed for ADLs During an interview with Resident #23 on 5/5/2026 at 3:23pm while she had been in her room, she said that she had been at the facility for about two or three weeks at the time of the interview and had resided at this facility in the past. During an interview with the MDS Coordinator on 5/7/2026 at 5:12pm, she said that she had been the MDS nurse at the facility starting at the end of November 2025. She stated when she had first started at the facility, the care plans were a mess. She stated she had managed the care plan scheduling at times during which the facility had not had a Social Services Director. She stated the issue with the care plans had been identified in Quality Assurance and Performance Improvement and the facility had been trying to get this addressed. The MDS Coordinator said that a care plan should have included just about everything. She said that it was important to look at Section B when creating a care plan so that it could have addressed any visual or hearing limitations of the resident, as well as any other relevant concerns that regarded the resident such as effective and safe behavioral interventions. The MDS Coordinator said other things that should have been included were code status, going over higher-risk medications, and making sure the care plans were individualized in a way which made the resident identifiable without knowing whose care plan it was. The MDS Coordinator said it was important for members of the interdisciplinary team to be present for the care plan meetings, such as the MDS nurse, a nurse who directly cared for the patient, rehab/therapy director, and the social worker. She stated the risk of not having a care plan could lead to decline in quality of care due to staff not knowing residents preferences or care requirements.During an interview with the DON on 5/7/2026 at 4:50pm she had said that her involvement with care plans was that she would attend the meetings to explain medications, health conditions, and discuss care. The DON said the meetings had typically been scheduled once per week. The DON stated that a care plan should include as much as possible with input from the facility's IDT (Interdisiplinary Team). The DON said if a care plan was missing information regarding care and needs of the resident, the resident could have possibly missed out on services that they could have benefited from. During an interview on 5/7/2026 at 5:03pm with the Administrator, he said that he had been involved in care plans as needed. The Administrator said that a care plan would need to focus on the needs of the resident and would have to be individualized as every resident was a unique individual. When asked what could happen if a care plan had been inadequate, he stated That is an open-ended question that I cannot answer.Resident #42Record review of Resident #42's face sheet, dated 05/07/2026, had revealed an admission to the facility on [DATE] and re-admission on [DATE]. Resident #42 was an [AGE] year-old male with diagnoses of Parkinson's Disease (a progressive neurological disorder) and chronic kidney disease (a progressive disease of the kidneys).Record Review of Resident #42's Order Summary, dated 05/07/2026, had revealed an order, dated 03/26/2026, to admit to hospice services: Dx: Parkinson's disease with dyskinesia (G20.B2) Record review of Resident #42's Comprehensive MDS, dated [DATE], revealed the resident received hospice care while a resident in Section O - Special Treatments, Procedures, and Programs, option K1 - Hospice Care was selected. Record review of Resident #42's Comprehensive Care Plan, dated 04/15/2026, revealed hospice care was not included in the care plan. During an interview on 05/07/2026, at 3:55 PM with the DON, she said Resident #42 was on hospice and the MDS Coordinator was responsible for including hospice in the care plan. The DON said the deficiency could prevent Resident #42 from receiving applicable care, mentally and physically. During an interview on 05/07/2026, at 4:05 PM with the MDS Coordinator, she said she was not aware Resident #42 was receiving hospice care. She said she was responsible for verifying the accuracy of care plan and hospice care should have been included in Resident #42's Care Plan. The MDS Coordinator said she did not have an excuse for it not being included. She said she had multiple trainings on accurate care plans over the years she has worked in nursing facilities. During an interview on 05/07/2026, at 4:20 PM with the Administrator, he said hospice care should have been care planned and care plans were part of nursing services, and the DON was responsible. He said the deficiency could result in the resident not receiving the care he needs. Record review of the facility's Care Plans, Comprehensive Person-Centered Policy, dated March 2022, had revealed: Policy Statement - 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.Policy Interpretation and Implementation - The comprehensive, person-centered care plan: .describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being,

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 #8) reviewed for trauma-informed care. The facility failed to ensure Resident #8 had a trauma screening completed upon admission to the facility that identified possible triggers when Resident #8 had a history of trauma. This failure could place residents at an increased risk for psychological distress due to re-traumatization.The findings included: A record review of the face sheet, dated 05/07/26, reflected Resident #8 was a [AGE] year-old female who initially admitted to the facility on [DATE] with a diagnosis of PTSD (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). A record review of the quarterly MDS assessment, dated 04/14/26, revealed Resident #8 had clear speech and was understood by others. The MDS revealed Resident #8 was able to understand others. The MDS reflected Resident #8 had a BIMS score of 14, which indicated intact cognition. The MDS reflected Resident #8 had no behaviors or refusal of care. The MDS revealed Resident #8 had an active diagnosis of PTSD. A record review of the comprehensive care plan, revised 10/9/2025, revealed Resident #8 had a history of hallucinating and delusions related to PTSD. The goal was to not experience distress because of these. No triggers or history were noted in the care plan. A record review of Resident #8's, assessments reviewed on 5/7/2026, revealed no assessment to identify Resident #8's trauma or triggers that could cause re-traumatization. During an interview on 05/07/26 beginning at 3:49 PM, the Social Services Director stated she was responsible for completing the initial trauma informed assessments on admission. The Social Services Director stated she was aware the Trauma Informed Assessment was not completed for Resident #8 and she was going to start working on it, but she just started working at the facility last week. The Social Services Director stated there was no trauma screening completed on admission that she was aware of. The Social Services Director stated it was important to ensure residents were screened for a history of trauma, and potential triggers were identified to maintain the correct environment to prevent triggers that could have caused re-traumatization. The Social Services Director stated it would have been important to know the potential triggers to prevent aggravation, frustration, or other behaviors. During an observation and interview on 05/07/26 beginning at 4:02 PM, revealed Resident #8 was sitting up in the dining room eating a snack. Resident #8 did not want to leave the dining room, unable to complete the interview regarding her PTSD diagnosis. During an interview on 05/07/26 beginning at 1:12 PM, the DON stated the Social Worker was responsible for trauma informed care if the resident had a PTSD diagnosis. The DON stated she reviewed the clinical record for psychotropic medication and behaviors. The DON stated she reviewed the diagnosis to ensure the referral was appropriate for admission to the facility. The DON stated she was responsible for monitoring assessments and making sure they were completed. During an interview on 05/07/26 beginning at 4:41 PM, the Administrator stated his expectation was for the Social Worker to complete the required assessments based on the resident's diagnosis. The Administrator stated the Social Services Director was responsible for completing the initial social history assessment, which included trauma screening questions. The Administrator stated he was unaware that this had not been completed. The Administrator stated that this Social Worker had only been at the facility for about 2 weeks. The Administrator stated it was important to ensure residents were assessed for a history of trauma, and potential triggers were identified to prevent re-traumatizing and maintaining the safety of the residents and staff. Record review of the Trauma Informed Care and Culturally Competent Care policy, revised August 2022, revealed .To address the needs of trauma survivors by minimizing triggers and/or re-traumatization .

Based on observations, interviews and record review the facility failed to ensure a medication error rate of less than 5%, and the medication error rate was 7.14% with 2 errors in 28 opportunities involving 1 staff (LVN D) and 1 resident (Resident #3) reviewed for medication pass. LVN D did not fully administer the crushed medications to Resident #3 via PEG tube. (Percutaneous Endoscopic Gastrostomy, a medical procedure used to insert a feeding tube directly into the stomach through the abdominal wall.) This failure could place residents at risk of not receiving their medications as prescribed according to physician's orders and facility policy and procedures. Findings include: Record review of Resident #3's admission record dated 05/07/2026 indicated she was admitted to the facility on [DATE] with diagnoses of stroke and essential hypertension (high blood pressure). She was [AGE] years of age. Record review of Resident 3's physician's orders dated 05/07/2026 indicated in part: Lisinopril Oral Tablet 40 MG Give 40 mg via PEG-Tube one time a day related to essential hypertension (high blood pressure). Start date 04/18/2026. Carvedilol Oral Tablet 25 MG Give 1 tablet via PEG-Tube two times a day related to essential hypertension. Start date 04/17/2026. Observation and interview on 05/07/2026 at 8:36 AM revealed LVN D administered Resident #3 her medications via PEG tube. The LVN prepared the medications on the medication cart before bringing them into the resident's room. LVN D poured the following medications into a medicine cup and then crushed them one at a time as she poured each medication in an individual cup. The nurse poured one 25mg pill of Carvedilol and one 40mg pill of Lisinopril. The LVN then entered the resident's room and put on some PPE and proceeded to administer the medications. LVN D poured some water into Resident #3's PEG tube with the use of a syringe and then poured the medications one at a time. The LVN was finished, and the cups were observed to have some of the medication residual at the bottom of the cup. LVN D was asked regarding the medication residual left in the cups. The LVN said that she had not poured more water into each cup to try and get the residual because she had done that in the past when she had been observed by a sState surveyor, and the facility had gotten cited for her giving too much water to the resident. LVN D said she agreed that it was more important for the resident to get her full dose of medication but since the facility she had worked at before had gotten a citation for too much water administered she decided not to use more water to get the residual medication that was left in the cup. Interview on 05/07/2026 at 8:54 AM the DON was shown the 30 ml medicine cups that contained the medication residual left over from the Carvedilol and Lisinopril medications. The DON said she believed that the nurse should have attempted to get more of the medication from the cups. The DON said that if the resident did not receive their full dose of the medication, it could lead to the medication not having the effect it was intended to do. The DON said that the resident could possibly have an adverse effect due to them not getting the entire medication as ordered. Interview on 05/07/2026 at 05:55 PM the Administrator was made aware of the medication error rate being 7.14% due to LVN D not fully administering the crushed medications. The Administrator said it was expected for the nurse to administer as much of the medication as possible because if not, that could lead to the resident not receiving the desired outcome. Record review of the facility's policy titled administering medications dated April 2019 indicated in part: Medications are administered in a safe and timely manner and as prescribed. Medications are administered in accordance with prescriber orders, including any required timeframe.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments for 1 of 4 (hall 2 cart) observed for medication storage and security. MA C failed to ensure her medication cart was secured when it was left unattended on 05/05/2026. These failures could place clients at risk for drug diversion or accidental ingestion. Findings included: Observation and interview on 05/05/2026 at 9:14 AM the hall 2 medication cart was seen unlocked and unsupervised. The DON was made aware of the cart unlocked. The cart was inspected with the DON present. On the top drawer were several over the counter medication bottles. Inside the other drawers were some blister packs that contained several prescribed medications. The DON said that it was expected for the staff to lock the medication carts whenever they left the carts unattended. Interview on 05/05/2026 at 9:22 AM MA C said the hall 2 medication cart was the cart she had used today 05/05/2026. The MA said she was sure she had locked the cart when she had stepped away. MA C said she was the only one that had keys for that cart, so it must have been her that left it unlocked. The MA said that if the medication cart was left unlocked and unattended there was a possibility of medications being robbed and residents could have access to the medications as well. Interview on 05/07/2026 at 5:46 PM the DON said it was expected for the medication carts to be locked when left unattended. The DON said that if the cart was left unlocked then there was a possibility of residents getting into the medications in the cart and possibly taking them. Interview on 05/07/2026 at 5:52 PM the Administrator said it was expected for the medication carts to be locked when left unattended. The Administrator said that if the cart was left unlocked, it could lead to medications being stolen or going missing. Review of the facility's policy titled Medication labeling and storage dated 02/2023 indicated in part: The facility stores all medications and biologicals in locked compartment under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Compartments (including, but not limited to, drawers, cabinets, rooms, carts, and boxes) containing medications and biologicals are locked when not in use and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #37) of 3 residents reviewed for infection control. CNA A failed to change her gloves after they became contaminated while assisting Resident #37 with incontinent care. This failure could place residents' risk for cross contamination and the spread of infection. Finding include: Record review of Resident #37's admission record dated 05/05/2026 indicated he was admitted to the facility on [DATE] with diagnoses of dementia and unsteadiness on feet. He was [AGE] years of age. Record review of Resident #37's MDS dated [DATE] indicated in part: Urinary continence = Always incontinent. Bowel continence = Always incontinent. Record review of Resident #37's care plan revised on 05/07/2026 indicated in part: The resident has bowelIncontinence. The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Clean peri-area with each incontinence episode. Observation on 05/05/2026 at 3:02 PM CNA B and CNA A performed incontinent care for Resident #37. Both CNAs washed their hands then put on a pair of new gloves. CNA A undid the resident's brief and took some wipes and wiped the resident's penis and scrotum area. CNA B then assisted with turning Resident #37 on his side, and CNA A then wiped the resident's rectal area. The resident had a bowel movement, CNA A wiped several times until the resident was clean. While still wearing the same gloves, CNA A took a clean brief and fastened it to Resident #37 and then afterwards removed her gloves. Interview on 05/05/2026 at 3:24 PM CNA A said that she should have changed her gloves after they became contaminated when she wiped Resident #37's private areas. The CNA said that she realized that she should have changed gloves before getting the clean items but got nervous and forgot. CNA A said not changing her gloves could have led to the spread if infections. Interview on 05/07/2026 at 5:48 PM the DON said it was expected for the staff to change their gloves and sanitize their hands when going from dirty to clean. The DON said staff not changing their gloves could possibly lead to the spread of infections. Interview on 05/07/2026 at 5:50 PM the Administrator stated and that there was a possible outcome of cross contamination. Record review of the facility document titled Perineal Care dated 2001 indicated in part: The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition. Beginning steps. Wash hands, wear gloves and follow standard precautions if contact with blood or body fluids if likely. If resident is heavily soiled with feces, turn resident on side and clean away feces with tissue, wipes or incontinent brief. Discard soiled gloves along with the soiled brief and/or wipes in trash bag. Cover the resident, provide safety measures and wash hands with soap and water. Discard soiled gloves, sanitize hands. Re-glove prior to touching clean linens/adult brief.

Based on interview and record reviews, the facility failed to ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #1) of 4 residents reviewed for pressure ulcers. The facility failed to obtain treatment orders for wound care upon admission for Resident #1. This failure could place residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing pressure injuries, infection, and pain.Findings included:Record review of Resident #1's face sheet undated revealed [AGE] year-old male admitted [DATE] from another nursing facility. Diagnoses included encounter for orthopedic aftercare following surgical amputation (the need for aftercare and follow up of a patient who has undergone surgical amputation), type 2 diabetes mellitus (metabolic condition where the body develops insulin resistance, causing high blood sugar levels because the cells fail to respond to insulin properly). Unspecified protein calorie malnutrition (the lack of sufficient energy or protein to meet the body's metabolic demands). Record review on 2/12/2026 of Resident #1's discharge orders from 1/28/2026 from discharging facility revealed wounds were present upon discharge and treatment orders were in place prior to admitting to the facility for wounds on left below knee amputation surgical site, unstageable pressure ulcer to right heel, venous ulcer to right calf, and arterial ulcer to right great toe.Record review of Resident #1's comprehensive MDS dated [DATE] revealed it was not completed due to Resident #1 only being in facility for 8 days.Record review of Resident #1's Care Plan dated 1/30/2026 revealed a problem of wound management. The goal was wounds will be free from infection. Intervention included providing wound care per treatment order.Record review of Resident #1's order summary dated January 2026 revealed no orders for wound care had been entered into the electronic health record. Record review of Resident #1's order summary dated February 2026 revealed orders for treatment were entered into the electronic health record on 2/5/2026.Record review of Resident #1's wound assessment completed on 2/5/2026 by Wound Care NP revealed the following wounds: Left below knee amputation surgical site, Unstageable pressure ulcer to right heel, venous ulcer to right posterior (the back or rear side) calf, arterial ulcer to right great toe. Wound assessment stated these wounds were present on admission. Wound care Nurse Practitioner wrote orders for these wounds upon assessment completed on 2/5/2026.Record review of hospital History and Physical dated 2/12/2026 revealed wounds did not have infections, and no new wounds were noted. History and Physical revealed Resident #1 had poor blood flow to the lower right foot and leg. Interview with ADON on 2/12/2026 at 3:00PM revealed facility does not utilize a treatment nurse. ADON stated the charge nurses do their own treatments on their patients. ADON stated orders should be obtained and entered upon admission. ADON stated it was the charge nurse's responsibility to ensure orders are entered correctly upon admission. ADON stated Resident #1's wounds did not worsen while at facility.Interview with DON on 2/13/2026 at 10:30AM revealed nurses have an admission checklist to go by when admitting a resident. DON stated Resident #1 should have had wound care orders upon admission. DON stated the orders from previous facility should have been carried over and any changes communicated with MD. DON stated wound care was being completed for Resident #1 the orders just did not get transcribed into the electronic health record. DON stated the risk of not having orders transcribed into the electronic health record could be nurses not knowing the correct wound care and delayed healing. DON stated his wounds did not worsen while at the facility. Interview on 2/13/2026 at 10:00AM with NP revealed Resident #1 had a history of non-healing wounds in the past that led to amputation of left leg. NP stated Resident #1 had poor circulation in the right leg and wounds may not heal. NP stated admission orders should have been carried over from discharging facility on admission. NP stated the risk of this not being done could be infection and poor wound healing. Interview on 2/13/2026 at 2:00PM with wound care NP revealed that resident admitted to the facility with surgical wound to left below knee amputation site, unstageable pressure ulcer to right heel, venous ulcer to right posterior calf, and arterial ulcer to right great toe. NP stated she wrote treatment orders on 2/5/2026 after she assessed Resident #1's wounds. NP stated she could tell wound care was being completed because the dressings were not soiled like they would have if treatments were not being completed. NP stated the nurses should not wait for her to assess wounds to obtain orders and should obtain them from the MD on admission or carry over previous orders from discharging facility. NP stated the wounds did not show any signs of infection at the time of assessment on 2/5/2026. NP stated the risk of not obtaining orders on admission could be infection, and delay in healing. Interview on 2/16/2026 at 11:00PM with Regional Nurse Consultant revealed treatment orders should have been entered into the electronic health record on the day of admission. RNC stated orders should have been carried over from discharging facility and MD notified to see if changes needed to be made. RNC stated the admitting nurse was responsible for this and the DON should oversee and ensure that it was completed. RNC stated the risk of not obtaining orders on admission could be infection, delayed healing, or improper wound care.Review of facilities policy titled Wound Care with no date revealed:The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.Preparation:Verify that there is a physician's order for this procedure.Review the residents' care plan to assess any special needs of the treatment.Documentation:The following information should be recorded in the residents' medical record:The date wound care was givenThe initials of the individual performing the wound care.Any change in the resident's condition.Any problems or complaints made by the resident related to the procedure.If the resident refused the treatment and the reason why.The signature and title of the person recording the data.

Based on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 12 (Residents #1, #2, and #3) residents reviewed for comprehensive care plans.The facility failed to have a care plan for Resident #1's dialysis, diabetic care, glaucoma, seizures, mental health needs, wound care, blood pressure monitoring, ADL assistance, and vaccine status. The facility failed to have a care plan for Resident #2's mental health and behavioral issues, pain, high blood pressure, hospice services, ADL needs, communication, cognitive status, nutritional status, risk to skin impairment, incontinence, or vaccination status. The facility failed to have a care plan for Resident #3's code status, mental and behavioral needs, kidney disease, pain, dietary or fluid restrictions, low thyroid, hypertension, diabetic care, respiratory needs, ADL needs, risk of falls, range of motion impairment, vision needs, or vaccination status. These failures could place residents at risk for not receiving appropriate care and supervision.Findings included: Resident #1Review of Resident #1's admission Record, dated 11/17/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dialysis, epilepsy, pain, diabetes, history of foot ulcers, depression, glaucoma, and heart failure.Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed:She had impaired vision.She had a BIMS Score of 15 of 15 (indicating she was cognitively intact).She scored a 1 of 27 on her depression screening (is a scale that used to measure the severity of the depression.She used a wheelchair for mobility.She had a therapeutic diet.She was at risk for developing skin sores.She had diabetic foot sores.She received insulin injections 7 of 7 days. She was on an anti-anxiety medication, an antidepressant medication, an anticoagulant, needed hypoglycemic agents, and was on an anticonvulsant.She received at least 2 days of therapy.Review of Resident #1's Order Summary Report, dated 11/17/25 revealed orders:Receive Dialysis services Tuesday - Thursday - Saturday dated 7/15/25Was on a fluid restriction dated 7/15/25Preventative care to left foot dated 11/8/25Blood pressure medications Amlodipine, Clonidine, Lostartan Potassium, and Metoprolol with hold parameters. Start date 7/16/25.Antianxiety medication Buspar start date 7/15/25Blood thinner Apixaban start date 7/13/25The neuropathy medication Gabapentin, start date 7/15/25Glucagon shot as needed for low blood sugar dated 7/15/25Short acting Insulin sliding scale (amount varies depending on blood sugar) dated 9/7/25.Long-acting Insulin dated 7/23/25Antiseizure medication LevetiracetamAnti-depressant medication Mirtazapine, Trazadone, and Sertraline dated 7/15/25Glaucoma eye drops dated 7/13/25Migraine medication Rimegepant Sulfate dated 7/15/25Kidney medication Sevelamer Carbonate dated 7/13/25. Review of Resident #1's care plan initiated 7/20/25 revealed care plans for Resident #1's code status, allergy to latex, and personal care/activity preferences. There was no care plan for dialysis including shunt monitoring and care or fluid restriction; diabetic care including blood sugar checks, dietary restrictions or insulin needs; glaucoma including adaptations for vision; seizures including medications, monitoring labs, or safety precautions; depression and anxiety including medications, side effects and behavior monitoring/ follow up; diabetic foot ulcers including enhanced barrier precautions, wound care, barriers to wound healing; blood pressure monitoring including frequency; ADL assistance needs; risk of complications, and vaccine status. Resident #2Review of Resident #2's admission Record, dated 11/14/25, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including stroke, pain, dementia with behaviors, hypothyroidism (when your thyroid gland doesn't make and release enough hormone into your bloodstream), malnutrition, anxiety, heart problems, arthritis, gout (excessive build-up of uric acid in a joint, frequently the foot, causing pain), closed fracture of the neck bones, and hospice care. Review of Resident #2's admission MDS dated [DATE] showed the following Care Area Assessments: Cognitive Loss/Dementia, Communication, Urinary Continence, Behavioral Symptoms, Falls, Nutritional Status, Pressure Ulcers, and Psychotropic Drug Use. All areas had a care planning decision dated 7/28/25. Review of Resident #2's Quarterly MDS Assessment, dated 8/8/25 revealed:He had a BIMS score of 1 of 15 (indicating severe cognitive impairments).He wandered 1 to 3 days of 7 in the previous 7 days.He used a wheelchair for mobility.He needed substantial or maximum assistance for toileting.He needed partial to moderate assistance for hygiene, bathing, and dressing.He had a catheter and was always incontinent of bowel. He had a prognosis of less than 6 months to live.He had 1 fall with minor injury since the previous assessment.He was on a mechanically altered diet.He was at risk for pressure sores.He needed injections for 3 of 7 days and was on an anti-anxiety medication, an anticoagulant, an opiate medication, an antiplatelet medication, and an anticonvulsant. He received Hospice care.He received at least 2 days of therapy.Review of Resident #2's Order Summary Report, dated 11/14/25, revealed orders:Hospice Care dated 7/17/25Divalprex Sodium for Dementia with other behavior disturbanceAn antianxiety medication Lorazepam dated 9/11/25Blood pressure medications Metoprolol Tartrate, Midodrine with with hold parameters. Dated 7/17/25Pain Medication Morphine Sulfate and Tramadol dated 7/17/25Nicotine Patch dated 7/17/25Arthritis medication Sulfasalazine dated 7/17/25.Review of Resident #2's Care Plan revised 7/17/25 revealed care plans for code status, allergies to Penicillin alcohol and beef, Personalized Care preference. A care plan addressing fall prevention was developed 11/10/25. There was no care plan addressing Resident #2's behaviors, pain, anxiety, high blood pressure, Hospice Services, ADL needs, communication, cognitive status; risk of complications; nutritional status, risk to skin impairment, incontinence, or vaccination status. Resident #3Review of Resident #3's admission Record, dated 11/14/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including stroke, weakness, history of falls, high cholesterol, anxiety, closed fractures, anemia, low thyroid, diabetes, depression, cataract, high blood pressure, paralysis on one side, and kidney disease. Review of Resident #3's Quarterly MDS Assessment, dated 10/23/25, revealed:She had a BIMS score of 12 of 15 (indicating she was moderately cognitively impaired).She had range of motion impairment on one upper extremity.She used a wheelchair for mobility.She needed moderate assistance for toileting, showering, and dressing. She received as-needed pain medication in the 5 days prior to the assessment and reported occasionally experiencing pain. She rated the pain at 5 out of 10.She was on a mechanically altered and therapeutic diet.She was at risk for pressure sores. She received insulin injections for 7 of 7 days, was on an antidepressant and a hypoglycemic.Review of Resident #3's Order Summary Report, dated 11/14/25, revealed orders:Fluid restriction, dated 7/19/25.Oxygen orders (oxygen at 2 liters via nasal cannula as needed for shortness of breath or oxygen saturation less than 90 percent. Do not exceed 4 liters without physician approval if resident was on continuous oxygen), dated 7/30/25.Antidepressants Citalopram and Trazadone.Short Acting Insulin sliding scale, dated 7/18/25.Hypertension medications Isosorbide Mononitrate, Midodine with hold parameters.Low thyroid medication Levothyroxine.Kidney Disease medication Sevelamer Carbonate.Pain Medication Tramadol.Review of Resident #3's Care Plan, initiated 7/23/25 revealed a care plan for Personalized Care.There was no care plans regarding Resident #3's code status, depression, Kidney disease, pain, dietary or fluid restriction, low thyroid, hypertension, diabetic needs, respiratory needs, ADL needs, risk of falls, range of motion impairment, vision needs, or vaccination status. Interview on 11/19/25 at 11:39 a.m. MDS Coordinator D stated she had worked at the facility for two months. She stated her assessment usually was what was required by the MDS Assessment. MDS Coordinator D stated the care plans were a group effort. MDS Coordinator D stated the care plans defined how the facility took care of the resident, whatever procedures were needed. She stated things on the care plan included fall risks, behaviors, and diseases the resident might have that required special attention. MDS Coordinator D stated the facility did not have anyone in the building to do care plans for a while so they were lacking and MDS Coordinator D was trying to get them up to par. MDS Coordinator stated she was working on care plans and they were a work in progress. The MDS Coordinator stated code status, behaviors and dialysis were all things she would expect to see on a care plan.Interview on 11/19/25 at 11:46 a.m. MDS Coordinator E stated care plans needed to be individualized to the resident. MDS Coordinator E stated she was new to the facility so she could not explain the process. MDS Coordinator E said to develop a care plan she would go through the chart looking for a history of falls, any of the Care Assessment Areas, any kind of psychiatric issues, and high-risk medications. MDS Coordinator E said the care plan was usually done right after the MDS Assessment. MDS Coordinator E said the facility was without an MDS Person in the facility for three months and the MDS Assessments were completed remotely by another MDS Coordinator. MDS Coordinator E stated the facility had some areas they could improve on for the care plans. MDS Coordinator E stated the care plan should be interdisciplinary, but no one actually entered the care plan so the MDS Coordinator entered the care plan in as quickly as they could. The MDS Coordinator stated members of the Interdisciplinary Team had the ability to enter their own areas care plan. MDS Coordinator E stated all the management staff had been at the facility for less than 6 months so were new but were all experienced in their position so they would get the care plans corrected.Interview on 11/19/25 at 12:08 p.m. the DON stated she thought there was probably room for improvement with care plans because the facility switched people several times. The DON stated she expected resident risk, elopement risk/attempts, falls or fall risk, risks related to diagnosis or medications. The DON said she expected things that were individual to resident behavioral or other residents' needs like a specialized piece of equipment. The DON stated she saw some of the care plans and thought there was room for improvement. The DON stated she was at the facility for 6 weeks and the corporation brought in a new MDS person. The DON said that many of the residents' needs and expectations were also outlined in the physician orders so the staff would know their expectations. The DON said the facility had a lead CNA who made a paper cheat sheet that was not part of the official resident record that informed the other CNAs, including agency CNAs, what kind of care the residents needed.The Corporate RN was also present and said she expected acute issues like a new onset of a urinary tract infection or other change of condition be care planned. The Corporate RN stated care plans were a work in progress. The Corporate RN stated she started in mid-October, so she did not know what happened to the care plans. The Corporate RN said there was turnover with all management staff including the MDS Coordinator. The Corporate RN said their plan was to work on the care plan, but they had been kind of busy.Review of the facility's policy and procedure on Care Planning - Interdisciplinary Team, updated 12/2024, revealed:The interdisciplinary team is responsible for the development of resident care plans. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team.

Based on observation, interview, and record review 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 2 of 5 residents (Resident #2 and Resident # 3) reviewed for accident and hazards: The facility failed to implement care planned anti-slip strips on the floor in front of Resident # 2's recliner. The facility failed to implement care planned [NAME] sheet (anti-slip device) in Resident #3's wheelchair. This failure could place residents at risk of a diminished quality of life leading to a variety of emotional and physical problems/issues because of accident hazards. Findings included: Review of Resident #2's admission Record, dated 2/3/25, revealed she was an [AGE] year-old female admitted to the facility with diagnoses including dementia, diabetes (a disorder where the body does not use blood sugar properly), and history of falls. Review of Resident #2's Quarterly MDS, dated [DATE], revealed: She had a mental status score of 14 of 15 (indicating she was cognitively intact) She used a wheelchair. She needed supervision or steadying assistance with transfers. She had two or more falls since the previous assessment with no injury. Review of Resident #2's Care Plan, revised on 3/22/23 revealed she had falls related to poor balance and poor communication/comprehension, impaired mobility, depression, anxiety, weakness, and incontinence. The identified goal was she would resume her usual activities without further incident through the review date. Identified interventions included anti-skid strips to floor in front of recliner initiated 7/14/23 and place anti-skid strips in front of dresser/shelfing revised on 4/11/25. Review of Resident #2's Fall Risk Evaluation, dated 6/9/25, revealed she was at risk for falls. Observation and interview on 6/14/25 at 1:21 p.m. of Resident #2's room revealed no anti-skid strips in the room. Resident #2 had a large gash across half of her forehead with stitches. Resident #2 stated the fall happened because she was going through her papers at night and got upset and fell out of her wheelchair. Resident #2 stated she worked herself up. Interview on 6/14/25 at 3:57 p.m. Resident #2's physician stated he did not think the facility could have prevented Resident #2's fall because she was too independent physically and did not like to ask for help. The physician stated he was notified of her 6/9/25 fall. Interview and observation on 6/14/25 at 5:50 p.m. the DON stated Resident #2 should have anti-slip strips. The DON went to Resident #2's room and said she did not have strips in front of her recliner, and she would tell Maintainence to get it done. The DON said the facility was not following their care plan for Resident #2. Interview on 6/14/25 at 6:11 p.m. the DON stated a lot of Resident #2's falls were from her wheelchair. The DON said Resident #2 needed stand-by assistance with transfers and needed help putting her blankets on her when she was in her recliner to go to bed. The DON stated to protect Resident #2 from injury they determined to put in the anti-slip strips, which should have been in place, they had the doctor review her medications and monitored Resident #2's blood pressure closely. The DON stated she had previously in-serviced staff about checking on Resident #2 frequently and making sure her call light was in place. The DON said the nurses were supposed to lay eyes on all high-risk residents. Review of Resident #3's admission Record, dated 6/14/25, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including dementia, history of falls, and unspecified convulsions. Review of Resident #3's Quarterly MDS, dated [DATE], revealed: He had a mental status score of 0 of 15 (indicating he was severely cognitively impaired). He had physical behaviors directed towards others (hitting, kicking, grabbing) four to six times a week. He used a wheelchair. He was dependent on staff for transfers. He had one fall with no injury since the previous assessment. Review of Resident #3's Care Plan, revised 4/11/25, revealed Resident had an actual fall, poor balance, unsteady gait, change in environment. The goal was the resident would resume activities without further incident through the review date. Identified interventions included [NAME] sheet in wheelchair to help aid in positioning. Review of Resident #3's Fall Risk assessment dated [DATE] revealed he scored a 13 and was at risk for falls. Interview and observation on 6/14/25 at 8:03 p.m. the DON checked Resident #3's wheelchair for a [NAME] sheet and stated there was not one on his wheelchair. The DON stated if it was on the care plan it should be on the wheelchair. Interview on 6/14/25 at 6:11 p.m. the DON stated ultimately, she was responsible for making sure all the interventions were in place and for monitoring it was done. The DON said once there was a fall the whole team talked about the fall in the morning meeting and devised a plan and updated the care plan. Review of the facility's policy on Falls - Clinical Protocol, revised 4/2025, revealed: Treatment/Management Based on the preceding assessment, the staff and physician/physician extender will identify pertinent interventions to try to prevent falls and to address the risks of clinically significant consequences of falling. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance). Monitoring/Follow-Up The staff and physician/physician extender will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed. If the individual continues to fall, the staff and physician/physician extender will reevaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. As needed, and after an appropriately thorough review, the physician/ physician extender will document any uncorrectable risk factors and underlying causes.

Based on observation, interview and record review, the facility failed to assist the residents in making appointments to ensure residents receive proper treatment and assistive devices to maintain hearing abilities for one of two residents (Resident #45) reviewed for hearing devices. The facility failed to make an appointment for an audiologist for Resident #45 after the Responsible Party requested one on 8/20/24. This failure could place residents at risk of decreased communication ability, quality of life, and/or social isolation. The findings included: Review of Resident #45's Admission Record, dated 2/29/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including hearing loss. Review of Resident #45's Quarterly MDS Assessment, dated 11/29/24, revealed: She had a BIMS score of 5 of 15 (indicating severe cognitive impairment); She had minimal difficulty hearing (Difficulty in some environments e.g. when person speaks softly or setting is noisy); and She wore hearing aids. Review of Resident #45's Care Plan, dated 6/13/24, revealed she had a communication problem related to hearing deficit. The identified goal was the resident will be able to make basic needs known on a daily basis through the review date. Interventions included: Repeat as necessary; Request clarification from resident to ensure understanding; face when speaking; make eye contact; use alternative communication tools as needed. Refer to audiology for hearing consult as ordered. Review of Resident #45's Order Summary Report, dated 2/19/25, revealed an order dated 5/24/24 for audiological care as needed. Review of the Social Services Note, dated 8/20/24, revealed Resident #45's Responsible Party asked if the Social Worker could set Resident #45 up with an appointment with and audiologist for hearing aids. Interview and observation with Resident #45 on 2/18/25 at 10:13 AM revealed Resident #45 in her room reading a book, there was no television or radio on. Resident #45 stated surveyor would have to speak up because she could not hear anything. Even with speaking up Resident #45 had difficulty understanding surveyor. Surveyor wrote interview on notebook paper and Resident #45 answered verbally. Resident #45 stated staff frequently came into her room and did whatever they were going to do without taking the time to explain what they were doing. Resident #45 said the staff never tried communicating with her through a notebook or a dry erase board. Observation of the room revealed no dry erase and no notebooks near where Resident #45 sat. Resident #45 stated staff don't care to tell me anything, they just come and do what they're going to do. Resident #45 said she felt like a hindrance because no one would explain to her what was going on. Resident #45 stated, that's just harmful to treat someone that way and ignore you. Resident #45 stated she felt her happiness no longer mattered because no one took the time to talk to her. Resident #45 started crying and said the conversation with surveyor would make her feel better for a month. Resident #45 stated she felt like she was not treated like a human and was not important to anyone in the building. Interview on 2/19/25 at 6:25 PM CNA G stated she was aware of Resident #45's needs. CNA G described Resident #45 as very hard of hearing. CNA G said speaking very loudly generally worked for communicating with Resident #45 but the staff had to repeat things a couple of times but it would eventually communicate what was needed. CNA G said she never asked which was Resident #45's good ear or bad ear. CNA G said she had nothing to add about Resident #45's hearing ability. Interview on 2/19/25 at 6:44 PM LVN H stated he worked with Resident #45. LVN H said Resident #45 was hard of hearing. LVN H said Resident #45's right ear was her bad ear. LVN H said to communicate with Resident #45 he would get closer and enunciate and speak louder to her. LVN H said the facility never tried any communication tools with her, but they did use one with a different resident. LVN H said he did not know what kind of hearing loss Resident #45 had. LVN H stated Resident #45 was alert and oriented to person, place and time and had nothing else to add about her abilities. Interview on 2/20/25 at 9:19 AM CNA I stated he almost always worked on Resident #45's hall so he was familiar with Resident #45. CNA said was extremely hard of hearing. CNA I stated to manage Resident #45's hearing they would normally speak louder and get right next to her so Resident #45 could read his lips. CNA I said Resident #45's good side was the left side. CNA I stated he used writing to communicate with a different resident but not with Resident #45. He stated he did not know if would be easier for them (CNA I and Resident #45) because it did not take long to communicate basic stuff. CNA I said he had nothing to add about Resident #45's hearing ability. Interview on 2/20/25 at 9:32 a.m. LVN J said he worked with Resident #45. LVN J said Resident #45 was hard of hearing but he was able to communicate with her. LVN J stated he never had to use communication tools with Resident #45 because if he got at eye level with her, she did not have a problem understanding. LVN J said he had nothing to add about Resident #45's hearing ability. Interview on 2/20/25 at 9:57 AM the Social Worker stated Resident #45 stayed in her room, her cognition was moderately impaired. The Social Worker stated she assessed Resident #45's cognition by completing the MDS Brief Mental Status interview. The Social Worker stated on 8/24/24 Resident #45's Responsible Party wanted the hearing appointment. The Social Worker stated she just hadn't reached out to the audiologist and then she just kind of forgot about it. The Social Worker said to communicate with Resident #45 a person had to get close to Resident #45 on her right side. The Social Worker said she had not tried any other communication tools with Resident #45 because Resident #45 had no problems answering questions once Resident #45 heard what the communicator was trying to communicate. The Social Worker stated she did not know if other communication tools would make communicating with Resident #45 easier because Resident #45's hearing was not assessed. The Social Worker said she usually found out if a resident had changes in hearing if the nurses on the floor told her. Interview on 2/20/25 at 12:03 PM the DON stated her expectation for staff when communicating with the hard of hearing was to get at eye level, speak in a clear voice, and ask one question at a time. The DON stated if the information was complex she would try to break the information down. The DON said Resident #45 would ask her (the DON) for clarification if she (Resident #45) did not understand. The DON was informed of the results of the investigation, and said she did not know if anyone had asked Resident #45 about her hearing and she did not know if Resident #45 was assessed for hearing aids. The Corporate RN, who was with the DON, said the MDS Nurse was required to assess when there was an MDS Assessment due. The Corporate RN stated the Social Worker should have acted quicker. Interview on 2/20/25 at 1:04 p.m. the MDS Coordinator state Resident #45's hearing aides were on Resident #45's nightstand table, were dirty and the batteries needed to be replaced. The MDS Coordinator stated Resident #45 stated the hearing aides were cleaned in the hospital. The MDS Coordinator stated Resident #45's Responsible Party wanted Resident #45 assessed for something stronger. Interview on 2/20/25 at 2:50 p.m. Resident #45's Responsible Party stated the facility supposedly got Resident #45 an appointment later in the month for an audiologist. Resident #45's Responsible Party stated they wanted the audiologist appointment to lessen Resident #45's depression so hopefully Resident #45 would leave her room and join activities more. Interview on 2/20/25 at 6:00 PM The Activity Director and Human Resources Director both said they probably would not leave their room or attend activities if they could not hear what was going on. Observation on 2/20/25 at 6:34 p.m. the Activity Director and Corporate RN, asked Resident #45 if new hearing aids would make a difference in Resident #45 attending activities. Resident #45 looked at surveyor and said, oh no, it's too late for me now. Resident #45 said she missed her old living arrangements where she could have one-on-one conversations with other old ladies. Review of the facility's undated Policy on Social Services revealed: The facility provides medically related social services. The social service program is designed to assist each resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This includes assisting residents in maintaining or improving their abilities to manage their everyday physical, mental, and psychosocial needs. Review of the facility's undated Policy on Accommodation of Needs and Services Provided in the facility revealed: The facility provides residents with services in the facility with reasonable accommodation of individual needs and preferences. If the need arises, the resident will be assisted with arrangements to receive the services outside of the facility.

Based on observation, interview and record review, the facility failed to assist the residents in making appointments to ensure residents receive proper treatment and assistive devices to maintain hearing abilities for one of two residents (Resident #45) reviewed for hearing devices. The facility failed to make an appointment for an audiologist for Resident #45 after the Responsible Party requested one on 8/20/24. This failure could place residents at risk of decreased communication ability, quality of life, and/or social isolation. The findings included: Review of Resident #45's Admission Record, dated 2/29/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including hearing loss. Review of Resident #45's Quarterly MDS Assessment, dated 11/29/24, revealed: She had a BIMS score of 5 of 15 (indicating severe cognitive impairment); She had minimal difficulty hearing (Difficulty in some environments e.g. when person speaks softly or setting is noisy); and She wore hearing aids. Review of Resident #45's Care Plan, dated 6/13/24, revealed she had a communication problem related to hearing deficit. The identified goal was the resident will be able to make basic needs known on a daily basis through the review date. Interventions included: Repeat as necessary; Request clarification from resident to ensure understanding; face when speaking; make eye contact; use alternative communication tools as needed. Refer to audiology for hearing consult as ordered. Review of Resident #45's Order Summary Report, dated 2/19/25, revealed an order dated 5/24/24 for audiological care as needed. Review of the Social Services Note, dated 8/20/24, revealed Resident #45's Responsible Party asked if the Social Worker could set Resident #45 up with an appointment with and audiologist for hearing aids. Interview and observation with Resident #45 on 2/18/25 at 10:13 AM revealed Resident #45 in her room reading a book, there was no television or radio on. Resident #45 stated surveyor would have to speak up because she could not hear anything. Even with speaking up Resident #45 had difficulty understanding surveyor. Surveyor wrote interview on notebook paper and Resident #45 answered verbally. Resident #45 stated staff frequently came into her room and did whatever they were going to do without taking the time to explain what they were doing. Resident #45 said the staff never tried communicating with her through a notebook or a dry erase board. Observation of the room revealed no dry erase and no notebooks near where Resident #45 sat. Resident #45 stated staff don't care to tell me anything, they just come and do what they're going to do. Resident #45 said she felt like a hindrance because no one would explain to her what was going on. Resident #45 stated, that's just harmful to treat someone that way and ignore you. Resident #45 stated she felt her happiness no longer mattered because no one took the time to talk to her. Resident #45 started crying and said the conversation with surveyor would make her feel better for a month. Resident #45 stated she felt like she was not treated like a human and was not important to anyone in the building. Interview on 2/20/25 at 9:57 AM the Social Worker stated Resident #45 stayed in her room, her cognition was moderately impaired. The Social Worker stated she assessed Resident #45's cognition by completing the MDS Brief Mental Status interview. The Social Worker stated on 8/24/24 Resident #45's Responsible Party wanted the hearing appointment. The Social Worker stated she just hadn't reached out to the audiologist and then she just kind of forgot about it. The Social Worker said to communicate with Resident #45 a person had to get close to Resident #45 on her right side. The Social Worker said she had not tried any other communication tools with Resident #45 because Resident #45 had no problems answering questions once Resident #45 heard what the communicator was trying to communicate. The Social Worker stated she did not know if other communication tools would make communicating with Resident #45 easier because Resident #45's hearing was not assessed. The Social Worker said she usually found out if a resident had changes in hearing if the nurses on the floor told her. Interview on 2/20/25 at 2:50 p.m. Resident #45's Responsible Party stated the facility supposedly got Resident #45 an appointment later in the month for an audiologist. Resident #45's Responsible Party stated they wanted the audiologist appointment to lessen Resident #45's depression so hopefully Resident #45 would leave her room and join activities more. Review of the facility's undated Policy on Social Services revealed: The facility provides medically related social services. The social service program is designed to assist each resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This includes assisting residents in maintaining or improving their abilities to manage their everyday physical, mental, and psychosocial needs. Review of the facility's undated Policy on Accommodation of Needs and Services Provided in the facility revealed: The facility provides residents with services in the facility with reasonable accommodation of individual needs and preferences. If the need arises, the resident will be assisted with arrangements to receive the services outside of the facility.

Based on observation and interview the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for physical environment. The facility failed to ensure one of six stove top burners ignited automatically. This failure could place residents at risk of foodborne illnesses and potential for injury to residents and staff. Findings included: During an observation and interview on 02/18/25 at 10:02 AM, the stove in the kitchen was inspected. One of the six burners was noted to not turn on when the knob was turned to the on position by [NAME] E. [NAME] E said the burner had not worked for a while and was not sure what was wrong with it or if it was clogged. The DM attempted to try and light it up manually, but it would not light up. During the time the DM turned the knob you could hear and smell the gas coming out of the pilot, but it would not light the burner. The burner appeared to have a buildup of grease on some sort of gunk on it. The DM said they would try to wash the burner to see if it unclogged it. The DM said he had not reported to the Maintenance department that the burner was not working. During an observation and interview on 02/20/25 at 01:15 PM, the stove top was inspected again with the DM and the burner was still noted to have the built up of grease and gunk on it. The burner knob was tuned on and the burner did not light up. There was a sound of gas passing through to the burner but it would not light up. The DM again said he would try to remove the burner and clean it or call the service repair person. The DM said he had been working at the facility for about 2 years and the burner had been non-functional since then. During an interview on 02/20/25 at 01:22 PM, the Administrator was made aware of the burner in the stove top not working. The Administrator said he had been at the facility for the last 2 months and was not aware of the burner not working. The Administrator said he would look into it and look for a policy regarding essential equipment. During an interview on 02/20/25 at 02:28 PM, the DM said they had washed the burner and that it was working a little better but that the service person was still coming later to completely repair the rest of the parts. The DM stated outcome of the other burner was not working, was a possibility of an explosion or someone getting hurt.

30057 Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 (Residents #14 and #28 and #288) of 4 residents reviewed for infection control in that: CNA F failed to wash her hands and change her gloves after they became contaminated during incontinent care while assisting Resident #14. CNA D used double gloves when she performed incontinent care for Resident #28. RN K failed to wash her hands and change her gloves after they became contaminated during wound care performed on Resident #288. These failures could place resident's risk for cross contamination and the spread of infection. Finding include: RESIDENT 14 Record review of Resident #14's admission record dated 02/20/25 indicated he was admitted to the facility on [DATE] with diagnoses of dementia. He was [AGE] years of age. Record review of Resident #14's care plan dated 11/17/24 indicated in part: Problem: The resident has bowel/bladder incontinence related to dementia, limited mobility. Goal: The resident will not have any complications r/t bowel incontinence. Interventions: Incontinent: Check every two hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. Record review of Resident #14's MDS dated [DATE] indicated in part: BIMS = 04 indicating resident had severe impairment. Urinary continence and bowel continence = Always incontinent. During an observation on 02/18/25 at 02:40 PM CNA A and CNA F transferred Resident #14 from his wheelchair to his bed with the use of a mechanical lift. Resident #14 was in a wheelchair and sitting on top of the lift sling. Both CNAs sanitized their hands and put on some gloves then connected the sling to the machine. After they transferred the resident to the bed they undid the resident's pants and brief. Resident #14 was noted to be wet with urine as it had leaked onto his pants. CNA A took some wet wipes and wiped the resident's penis and scrotum area and then changed her gloves. Both CNAs then turned Resident #14 on his right side and CNA F took some wet wipes and wiped the resident's rectal area. While CNA F wiped Resident #14's rectal area and her gloved hand come in contact with the resident's buttocks and rectal area. While wearing the same gloves she used to wipe the resident's rectal area, CNA F took a new brief and fastened it to the resident and also assisted with changing Resident #14's pants and putting a clean pair of pants on. During an interview on 02/18/25 at 02:55 PM CNA F said she should have changed her gloves and sanitized her hands before she applied the new brief and assisted Resident #14 with his pants. CNA F said there was a possibility of cross contamination and could lead to the spread of infections if her gloves were not changed. RESIDENT 28 Record review of Resident #28's admission record dated 02/20/25 indicated he was admitted to the facility on [DATE] with diagnoses of high blood pressure and type 2 diabetes. He was [AGE] years of age. Record review of Resident #28's care plan dated 01/12/25 indicated in part: Problem: The resident has (specify urge, stress, functional, mixed) bladder incontinence related to Impaired mobility. Goal: The resident will remain free from skin breakdown due to incontinence and brief use. Interventions: Brief use: The resident uses disposable briefs. Change frequently and prn. Incontinent: Check Frequently and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. Record review of Resident #28's MDS dated [DATE] indicated in part: BIMS = 15 indicating resident was cognitively intact. Urinary continence and bowel continence = Always incontinent. During an observation on 02/19/25 at 10:55 AM CNA C and CNA D performed incontinent care for Resident #28. Both CNA's entered the room and put on some PPE due to the resident being on EBP precautions. CNA D was seen putting 2 pair of gloves on. The aides assisted Resident #28 to his bed then removed his shorts and brief. The brief was noted to be wet with urine. CNA D wiped the resident's penis and in between his legs with some wet wipes. Both CNAs then turned the resident on his right side then CNA D took some wipes and wiped the resident's rectal area. Resident #28 had a bowel movement so CNA D wiped the resident's rectal area several times and some of the feces got on the CNA's gloves. CNA D then took the first pair of gloves off and placed a new pair of gloves over the second pair. CNA D then took some barrier cream and applied it to the resident's groin area. CNA D then removed the first pair of gloves and while wearing the second pair she and the other CNA fastened a new brief on the resident, put his shorts on then they removed their gloves. During an interview on 02/19/25 at 05:07 PM CNA D said she was not sure if they were allowed to double glove during resident care. CNA D said she had learned to double glove while she worked at a previous facility. CNA D said if it was not considered safe to use double gloves during resident care then that could lead to cross contamination and the spread of infections. During an interview on 02/20/25 at 03:00 PM the DON said staff were expected to change their gloves when going from dirty to clean or if they came in contact with any bodily fluids. The DON said double gloving was not acceptable as that could lead to cross contamination. The DON said double gloving or not changing their gloves at the appropriate time could lead to the spread of infections and it was not good practice. The DON said the failure probably occurred because of a lack of training. The DON said they would be conducting training on the proper use of glove use and when to change them. RESIDENT #288 Review of Resident #288's Admission Record, dated 2/19/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including heart failure and chronic pain. Review of Resident #288's clinical records revealed the MDS had not been completed yet. Review of Resident #288's Care Plan, Initiated 2/10/25, revealed: Resident is on Enhanced Barrier Precautions related to increased risk of Multi-Drug Resistant Organisms acquisition - resident has a wound Deep Tissue Injury to sacrum, left heel, right great toe, right posterior leg. Venous ulcer to right dorsal foot. Goal: reduce transmission of multi drug-resistant organisms and will have no complications through review date. Interventions included: Ensure the staff have access to alcohol-based hand rub. Resident #288's Order Summary Report, dated 2/19/25, revealed orders dated 2/10/25 for Left Heel Deep Tissue Injury Cleanse with Wound Cleanser, apply Triple Antibiotic Ointment and cover with foam dressing, changed twice weekly and as needed one time a day every Tuesday and Friday for wound care. Observation on 2/19/25 at 3:53 PM revealed RN K slid a bordered bandage into her pocket on her pants. RN K stated she was just doing a little pressure wound on Resident #288. RN K put on a gown, put on gloves and entered the room. RN K had a stack of 4cm x 4cm gauze, 2 packet of triple antibiotic ointment and wound cleanser spray already set up on the bedside table with no barrier The wound care supplies were set up at the end of Resident # 288's bedside table, unevenly mixed with Resident #288's water. There was no barrier and no disinfecting wipes seen. RN K removed the old dressing. RN K described Resident #288's stage I pressure wound as probably 1 mm with 1/2 cm by 1 cm oval wound bed. With the same gloves, RN K took some gauze from the stack of 4 cm x cm gauze, sprayed it with the wound cleanser spray and cleanser spray; she wiped the wound and placed the dirty gauze onto Resident #288's bed. With the same contaminated gloves, RN K took another stack of 4cm x cm gauze, sprayed it with gauze, cleaned the wound and threw it in the resident's trash can. With the same dirty gloves RN K placed some triple antibiotic ointment onto her finger, smeared it onto Resident # 288's wound. Then with the same dirty gloves RN K pulled the bordered dressing out of her pocket and placed it onto Resident #288's heel. With the same contaminated gloves, RN K placed a sock over Resident # 288's heel, pulled off the sock from the other foot, did an edema check, changed the sock and then changed her gloves. RN K hooked the bottle of wound cleanser on her pants without sanitizing them. Interview on 2/19/25 5:01 p.m. RN K stated this was her 1st year of nursing. She stated the wound care could have gone better. RN K said she forgot to set up the bag at the end of the bed for the used wound care supplies and she did not wash her hands because Resident #288 was on Enhanced Barrier Precautions. RN K stated personally she did not like the border dressing used on Resident #288's foot because she had to fold it to make it fit. RN K said she liked to wash her hands at the end of the wound care but felt taking out the trash at the end defeated the purpose RN K said if she put the dirty gauze on the bed she contaminated the bed. RN K stated she was taught to avoid cross contamination as much as possible in nursing school and if cross contamination did happen to disinfect the area as much as possible. RN K stated in the real world it would not be any different. RN K stated she did clean the bedside table with a Sani-cloth wipe prior to setting up wound care supplies, but admitted she put the bandage in her pocket. RN K said there was no barrier between the bedside table and the wound care supplies. RN K said her gloves were dirty through the wound care and she probably should have applied the triple antibiotic ointment with an applicator. RN K said the only training she received when hired was the nurse she shadowed but the Assistant Director of Nursing was very good about answering any questions she had about wound care, but it was more about order clarification. Interview on 2/20/25 at 12:29 p.m. the DON with the Corporate RN present stated her expectation for wound care was the nurse to gather her supplies, put the supplies on wax paper, and have extra gloves. The DON stated she expected the staff to wash their hands, place a trash bag at the foot of the bed, put on gloves, take off the old dressing, take off the old dressing, using alcohol gel, put on clean gloves, clean the wound inner wound to outer wound, change those gloves using alcohol in between, put on the clean dressing, take off the gloves, place excess material into the trash, make sure the resident was comfortable, place a clean glove on, dispose of the trash, and wash hands. Record review of the facility's policy titled Infection prevention program policy and dated 08/21/2024 indicated in part: Purpose: To describe the structure , function and processes in place to prevent healthcare associated infections in patients, visitors and staff and to establish policy, guidelines and responsibilities for [name] Nursing and rehab infection prevention program. Policy: The goal of the infection prevention program and its activities is to improve clinical outcomes and have a multidisciplinary approach within a coordinated and structured program. The infection prevention program (IPP) is established to: Provide a mechanism for the surveillance, prevention and control of infection and to ensure the facility compliance with the requirements of the centers for Medicaid and Medicare. Department of Health and local, state and federal agencies as they relate to infection prevention. Review and provide recommendations in the matters concerning isolation, sanitation and asepsis policies and procedures. Develop, review, revise and approve infection prevention standards and policies and infection prevention procedures. Record review of the facility's policy titled Glove use dated 2012 indicated in part: Purpose: to provide guidelines for the use of gloves for resident and employee protection. When gloves are indicated, disposable single-use gloves (preferably latex free) should be worn. Used gloves should be discarded into the nearest waste receptacle inside the room. Perform hand hygiene after removing gloves. Disposable (single-use) gloves must be replaced as soon as practical when contaminated, torn, punctured, they exhibit signs of deterioration or when their ability to function as a barrier is compromised. When to use gloves - gloves should be used- when touching excretions, secretions, blood, body fluids, mucous membranes or no-intact skin; when the employee's hands have any cuts, scrapes, wounds, chapped skin, dermatitis. Etc, when it is likely that hands will come in contact with blood, body fluids or other potentially infectious material.

Based on Observation, interview and record review the facility failed to ensure the resident the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed for 1 0f 4 residents (Resident #1) reviewed for resident rights. Transfer and the reason for the transfer before the roommate was changed. Based on interview and record review the facility failed to ensure residents legal guardian had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred for 1 of 1 resident (Resident #60) reviewed for resident rights. The facility failed to ensure the Social Worker told Resident #1's representative the reason for his room change following an incident with his roommate on 9/17/24. This failure could place resident's roommate at risk for not being aware of the reason for the change in rooms. Findings included: Record review of Resident #1's Face Sheet (Admission Record) dated 10/03/24 indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's medical history included muscle wasting, dementia, schizoaffective disorder (a mental health condition that includes schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms such as depression and mania), anxiety disorder, and major depressive disorder (depressed mood all or most of the time). Record review of Resident #1's Quarterly MDS assessment dated [DATE] indicated Resident #1 could usually be understood and could usually understand others. The MDS indicated the resident had a BIMS score of 00 which indicated severe cognitive impairment. The assessment indicated Resident #1 displayed physical behaviors directed toward others and did not reject care. The assessment also indicated Resident #1 was dependent on one to two people for moving to and from lying position, turning side to side, and body positioning. Resident #1 was dependent on one to two people for toileting and bathing and was always incontinent of urine and bowel. Record review of Social Worker progress notes indicated the following: -9/17/24 at 5:03 PM Social Worker documented Resident #1's guardian was notified of resident room move. He will be in -9/20/24 the Social Worker documented Resident #1 moved to another room due to current roommate sprinkling him with water due to him making a sucking noise. CNA A reported to the DON and administrator. All parties notified; resident moved to another room. Record review of the provider 5-day investigation report dated 9/18/24 revealed the incident occurred on 9/18/24. Record review of Nursing Progress notes indicated the following: -10/3/24 at 11:40 AM documented notified the guardian of Resident #1 and apologized. The nurse spoke with the guardian to explain what the initial reason for the move of the resident was. Resident #1's roommate stated to a CNA A he throws water on Resident # 1's face to train him like a dog. In an observation on 10/1/24 at 11:00 AM revealed Resident #1 was Sitting in the hallway in his wheelchair with his head bent forward. He did not respond to the surveyor. He did not seem shy away from staff or the surveyor. During an interview with Resident #1's Guardian on 10/3/24 at 9:06 AM she stated she had not been notified of the incident of alleged abuse as the reason for the room change for Resident #1. The Guardian stated she was notified by the Social Worker on 9/17/24, that they wanted to try Resident #1 in another room but was not given the specifics as to why. The Guardian was aware that several facilities are moving patients for a variety of reasons and advised that the guardian did not feel the move would work out but that they could try it and see how it went. The guardian was not told this was due to the presentroommate bullying Resident #1. During an interview with the Social Worker on 10/3/24 at 9:30 AM she said she was informed by the DON that she should call the guardian of Resident # 1 to get permission for a room change, but the DON did not say why they were doing the room change until later in the afternoon. She stated she did not notify the Guardian of the alleged incident between Resident # 1 and his roommate. She stated she would have told the Guardian if she had been informed of the situation. She stated a negative outcome for the resident would be that he would remain in that situation if the Guardian did not give permission for the move. During an interview with the DON on 10/03/24 at 10:00 AM she said the guardian should be notified per facility policy for changes of condition, or a change in the president's plan of care. She stated she thought the Social Worker had notified the guardian of the situation because she thought she was aware of the reason for the move. She stated she should have monitored to ensure that the guardian was informed of the reason for the move. Review of Texas Human Resources Code Section 102.003 Sec. 102.003. RIGHTS OF THE ELDERLY. (a) An elderly individual has all the rights, benefits, responsibilities, and privileges granted by the constitution and laws of this state and the United States, except where lawfully restricted. The elderly individual has the right to be free of interference, coercion, discrimination, and reprisal in exercising these civil rights. (b) An elderly individual has the right to be treated with dignity and respect for the personal integrity of the individual, without regard to race, religion, national origin, sex, age, disability, marital status, or source of payment. This means that the elderly individual: (1) has the right to make the individual's own choices regarding the individual's personal affairs, care, benefits, and services. (2) has the right to be free from abuse, neglect, and exploitation; and (3) if protective measures are required, has the right to designate a guardian or representative to ensure the right to quality stewardship of the individual's affairs. Review of the policy titled Notification of changes, not dated, stated the following in part: The facility will immediately inform the resident and consult with the resident's physician, if appropriate, when changes occur. If known, the facility shall also notify the resident's physician if appropriate and the legal guardian or an interested family member. Notification of change shall include an accident involving the resident A significant change in the resident's mental or psychosocial status such as a deterioration in health mental or psychosocial status, a decision to transfer or discharge a resident, or a change in roommate assignment

Based on interview, and record review the facility failed to ensure Residents were free from abuse a 1 of 6 residents (Resident #1) reviewed for abuse. 1. The facility to protect Resident #1 from Resident #2 pouring water on Resident #1 when he annoyed him. The deficient practices could affect any resident and contribute to further abuse or neglect. Findings included: Record review of Resident #1's Face Sheet (Admission Record) dated 10/03/24 indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's medical history included muscle wasting, dementia, schizoaffective disorder (a mental health condition that includes schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms such as depression and mania), anxiety disorder, and major depressive disorder (depressed mood all or most of the time). Record review of Resident #1's Quarterly MDS assessment dated [DATE] indicated Resident #1 could usually be understood and could usually understand others. The MDS indicated the resident had a BIMS score of 00 which indicated severe cognitive impairment. The assessment indicated Resident #1 displayed physical behaviors directed toward others and did not reject care. The assessment also indicated Resident #1 was dependent on one to two people for moving to and from lying position, turning side to side, and body positioning. Resident #1 was dependent on one to two people for toileting and bathing and was always incontinent of urine and bowel. Record review of the facility reported investigation worksheet and the provider 5-day investigation report dated 9/18/24 revealed the incident occurred on 9/17/24 and that Resident #1 was moved to another room on another hall. The incident was reported by CNA A. Record review of Resident 2's Face Sheet (Admission Record) dated 10/02/24 indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident #2's medical history included dementia with agitation depression and mania, anxiety disorder, diabetes (condition causing increased levels of glucose in the blood which can affect multiple body systems) and high blood pressure. Record review of Resident #2's Quarterly MDS assessment dated [DATE] indicated Resident #2 could be understood and could understand others. The MDS indicated the resident had a BIMS score of 15 which indicated he was cognitively intact. The assessment indicated Resident #2 displayed no behaviors directed toward others and did not reject care. The assessment also indicated Resident #2 used a wheelchair and required maximum assistance to walk ten feet. Resident #2 was independent moving to and from lying position, turning side to side, and body positioning. Resident #2 required minimal or touch assistance of one person for toileting and bathing and was always incontinent of bowel and had a urinary catheter. Record review of Social Worker progress notes indicated the following: -9/20/24 the Social Worker documented Resident #1 moved to another room due to current roommate Resident #2 sprinkling him with water due to him making a sucking noise. CNA A reported to the DON and administrator. All parties notified; resident moved to another room. Observation on 10/1/24 at 11:00 AM revealed Resident #1 was Sitting in the hallway in his wheelchair with his headbent forward. He did not respond to the surveyor. In an interview with CNA A on 9/26/24 at 1:50 PM he stated he reported to the LVN C that Resident #2 told him he sprinkled water in the face of Resident #1 to train him like a dog immediately after it was told to him by Resident #2. In an interview with CNA B on 9/26/24 at 1:40 PM and on 10/1/24 at 3:00 PM, she stated she suspected Resident #2 had poured water on Resident #1 multiple times and she stated she reported her concerns when Administrator called her to investigate the incident. She stated she has never seen him treat anyone else in an abusive manner. CNA B stated she told LVN C about it when she found Resident #1 wet one time. She stated she could not remember when that was and could not give a date or how many times. In an interview with LVN C at 3:00 PM he stated he had not been told of an allegation of abuse to Resident #1 by CNA B. He stated CNA A told him, and he reported it to the administrator who is also the abuse coordinator. In an interview with the Administrator on 10/01/24 3:45 PM. The administrator stated CNA B did not report to him she witnessed abuse or had suspicions of abuse toward Resident #1 by his roommate. He stated his expectation was that suspicion of abuse or allegations of abuse be reported to him immediately. He stated she had been reprimanded and terminated for not reporting immediately. He stated that Resident #2 had been issued a 30-day discharge notice earlier in the month and after talking with CNA B regarding her allegations of abuse Resident #2 was discharged today (10/1/24) with medications and home health and APS was notified. He stated an Inservice had been started on immediate reporting of allegations of suspected abuse or neglect. He stated it was his responsibility to monitor and ensure the facility is doing all that is within control to prevent occurrences of abuse and neglect. Review of the facility's policy Abuse and Neglect Policy and Procedure, not dated stated in part: The Administrator and designee is responsible for maintaining all facility policies that prohibit abuse and neglect to include the following: training of employees, investigation of allegations , and prevention of occurrences.

Based on observation, interview, and record review the facility failed to ensure all alleged violations involving abuse are reported immediately to the Administrator of the facility for 1 of 6 residents (Resident #1) reviewed for abuse. 1. CNA B failed to immediately report her suspicions of abuse when she found Resident #1 Wet . The deficient practices could affect any resident and contribute to further abuse or neglect. Findings included: Record review of Resident #1's Face Sheet (Admission Record) dated 10/03/24 indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's medical history included muscle wasting, dementia, schizoaffective disorder (a mental health condition that includes schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms such as depression and mania), anxiety disorder, and major depressive disorder (depressed mood all or most of the time). Record review of Resident #1's Quarterly MDS assessment dated [DATE] indicated Resident #1 could usually be understood and could usually understand others. The MDS indicated the resident had a BIMS score of 00 which indicated severe cognitive impairment. The assessment indicated Resident #1 displayed physical behaviors directed toward others and did not reject care. The assessment also indicated Resident #1 was dependent on one to two people for moving to and from lying position, turning side to side, and body positioning. Resident #1 was dependent on one to two people for toileting and bathing and was always incontinent of urine and bowel. Record review of the facility reported investigation worksheet and the provider 5-day investigation report dated 9/18/24 revealed the incident occurred on 9/17/24 and that Resident #1 was moved to another room on another hall. The incident was reported by CNA A. Record review of Resident 2's Face Sheet (Admission Record) dated 10/02/24 indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident #2's medical history included dementia with agitation depression and mania, anxiety disorder, diabetes (condition causing increased levels of glucose in the blood which can affect multiple body systems) and high blood pressure. Record review of Resident #2's Quarterly MDS assessment dated [DATE] indicated Resident #2 could be understood and could understand others. The MDS indicated the resident had a BIMS score of 15 which indicated he was cognitively intact. The assessment indicated Resident #2 displayed no behaviors directed toward others and did not reject care. The assessment also indicated Resident #2 used a wheelchair and required maximum assistance to walk ten feet. Resident #2 was independent moving to and from lying position, turning side to side, and body positioning. Resident #2 required minimal or touch assistance of one person for toileting and bathing and was always incontinent of bowel and had a urinary catheter. Record review of Social Worker progress notes indicated the following: -9/20/24 the Social Worker documented Resident #1 moved to another room due to current roommate Resident #2 sprinkling him with water due to him making a sucking noise. CNA A reported to the DON and administrator. All parties notified; resident moved to another room. Observation on 10/1/24 at 11:00 AM revealed Resident #1 was Sitting in the hallway in his wheelchair with his headbent forward. He didnot respond to the In an interview with CNA A on 9/26/24 at 1:50 PM he stated he reported to the LVN C that Resident #2 told him he sprinkled water in the face of Resident #1 to train him like a dog immediately after it was told to him by Resident #2. In an interview with CNA B on 9/26/24 at 1:40 PM and on 10/1/24 at 3:00 PM, she stated she suspected Resident #2 had poured water on Resident #1 multiple times and she stated she reported her concerns when Administrator called her to investigate the incident. She stated she has never seen him treat anyone else in an abusive manner. CNA B stated she told LVN C about it when she found Resident #1 wet one time. She stated she could not remember when that was and could not give a date or how many times. In an interview with LVN C at 3:00 PM he stated he had not been told of an allegation of abuse to Resident #1 by CNA B. He stated CNA A told him, and he reported it to the administrator who is also the abuse coordinator. In an interview with the Administrator on 10/01/24 3:45 PM. The administrator stated CNA B did not report to him she witnessed abuse or had suspicions of abuse toward Resident #1 by his roommate. He stated his expectation was that suspicion of abuse or allegations of abuse be reported to him immediately. He stated she had been reprimanded and terminated for not reporting immediately. He stated that Resident #2 had been issued a 30-day discharge notice earlier in the month and after talking with CNA B regarding her allegations of abuse Resident #2 was discharged today (10/1/24) with medications and home health and APS was notified. He stated an Inservice had been started on immediate reporting of allegations of suspected abuse or neglect. He stated it was his responsibility to monitor and ensure the facility is doing all that is within control to prevent occurrences of abuse and neglect. Review of the facility's policy Abuse and Neglect Policy and Procedure, not dated stated in part: The Administrator and designee is responsible for maintaining all facility policies that prohibit abuse and neglect to include the following: training of employees, investigation of allegations , and prevention of occurrences.

Based on observations, interview, and record review, the facility failed to maintain an environment that was free from accidents and hazards for 31 (All resident on 100 Hall) of which 5 of 31 (Resident #81,82, 20, 40, and 77) had cognitive decline that could still access their sinks, of 90 residents. -Temperature readings for the public restroom on the 100 hall were 128 degrees Fahrenheit. -The temperature reading in the restroom to Resident room [ROOM NUMBER] on the 100 hall was 128 degrees Fahrenheit. -5 residents on the 100 hall had cognitive decline and could access their sinks. An Immediate Jeopardy to residents' health or safety was identified on 12/21/23. The Immediate Jeopardy template was provided to Administrator on 12/21/23 at 7:23PM. While the Immediate Jeopardy was removed on 12/22/23 at 7:38PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a severity level of a pattern as the facility began lowering water heater temperature for 100 hall, testing water temperatures in resident rooms on the 100 hall and in-servicing staff. These failures placed residents at risk of potential 3rd degree burns. Findings include: In an observation on 12/21 2023 at 12:30 PM, water in the sink of 100 hall public restroom was extremely hot. In an observation and interview on 12/21/2023 at 12:46 PM, the Maintenance Director was observed checking water temperature in 100 hall public restroom. He used 2 plastic cups, one inside of another, and at 1 minute the temperature was observed to be 128 degrees Fahrenheit . The Maintenance Director went to room [ROOM NUMBER] and used 2 plastic cups, one inside of another, and within 1 minute the restroom sink water was observed at a temperature of 128 degrees Fahrenheit. The Maintenance Director said, that's too hot. The Maintenance Director said that water temperature would affect all Resident's on hall 100. He said this water temperature could burn the residents. In an interview on 12/21/2023 at 12:51 PM, the Maintenance Director said they cranked up the hot water on hall 100 due to fluctuation in temperature outside and request from staff for cold showers down hall 100. The Maintenance Director said his thermometer for checking water temperatures was one year old. In an interview on 12/21/2023 at 1:40 PM with both the Maintenance Director and the Maintenance Assistant. The Maintenance Director said he spoke with the Maintenance Assistant and said he had changed the water temperature on 12/18/2023 at approximately 10AM and did not notify the Maintenance Director. The Maintenance Assistant said he did not know the staff's name, but she had requested him to turn water temperatures up on hall 100. The Maintenance Assistant said that travel Staff notified him at approximately 8 AM on 12/18/2023. The Maintenance Assistant said he never notified the Maintenance Director that he had increased the water temperatures by 15 degrees to 130 degrees Fahrenheit. The Maintenance Assistant said he did not check water temperatures before or after changing water temperature. Resident #81 Record review of Resident #81's Quarterly MDS, dated [DATE] revealed an [AGE] year-old male, admitted to the facility on [DATE]. Resident #81 had an active diagnosis of dementia . He had a BIMS score of 8 (moderately impaired). During an observation on 12/19/23 at 3:20pm, Resident #81, who resided on 100 hall, was propelling himself down the hallway in his wheelchair. Resident #82 Record review of Resident #82's Quarterly MDS, dated [DATE] revealed a [AGE] year-old female, admitted to the facility on [DATE]. Resident #82 had an active diagnosis of dementia. She had a BIMS score of 3 (severe impairment). During an observation on 12/19/23 at 3:22pm, Resident #82, who resided on 100 hall, was ambulating herself down the hallway in her wheelchair. Resident #20 Record review of Resident #20's Quarterly MDS, dated [DATE] revealed a [AGE] year-old female, admitted to the facility on [DATE]. Resident #20 had an active diagnosis of dementia. She had a BIMS score of 2 (severe impairment). During an observation on 12/19/23 at 12:46pm, Resident #20, who resided on 100 hall, was sitting in her wheelchair in her room. Resident #40 Record review of Resident #40's Quarterly MDS, dated [DATE] revealed an [AGE] year-old female, admitted to the facility on [DATE]. Resident #40 had an active diagnosis of dementia. She had a BIMS score of 5 (severe impairment). During an observation on 12/19/23 at 3:52pm, revealed Resident #40, who resided on 100 hall, was laying in bed asleep with a Wander Gard on her right foot. Resident #77 Record review of Resident #77's Quarterly MDS, dated [DATE] revealed a [AGE] year-old female, admitted to the facility on [DATE]. Resident #77 had an active diagnosis of dementia. She had a BIMS score of 5 (severe impairment). During an observation on 12/19/23 at 11:00 am, Resident #77, who resided on 100 hall, was sitting up in a chair in her room, stating she had just received a bath. In an observation and interview on 12/21/23 at 1:47 PM, the Maintenance Director checked hot water heater for hall 100 that was inside a locked closet inside the locked medication room. The hot water heater was a dial temperature in which Maintenance Supervisor said he reduced temperature immediately after checking water temperatures earlier. He said the water temperature was 130 degrees Fahrenheit. He said he checked for 1 to 2 minutes regularly when checking temperatures. He said he, starts at beginning of hall and works way to end of halls. The Maintenance Director said he checks random rooms and point of care areas on halls and different rooms each week. He said he knew which rooms to check and said, I just remember from week to week. In an observation and interview on 12/21/23 at 1:48 PM with Charge Nurse F said she does not have a key to the hot water heater closet in the medication room. In an interview on 12/21/2023 at 02:16 PM the Maintenance Director said his expectations were that staff wrote requests in maintenance logbook and water temperature checks would be performed before and after temperature change. He said he had no knowledge of the Temperature change. In an interview with DON on 12/22/2023 at 2:45 PM she said, Only Maintenance has keys to hot water heater closets. Record review of the facility's Maintenance Log from 09/01/23 through 12/21/23 revealed there were no issues noted to hot water, nor that Maintenance had addressed any issues regarding hot water. Record review of facility policy Test Water Temperatures, undated, revealed the following [in part]: It is suggested that you review or watch the TELS Masters Training video that accompanies the task. Test water temperatures . Let the hot water run from 3 to 5 mins. . Insert the stem into the stream of running water, so that the sensor is fully immersed. . As the temperature of the water is taken, hold your hand under the running water at about the same time to assess how the water feels on your skin. 1. Ensure patient room water temperatures are between 105 degrees F. and 115 degrees F. (or as specified by state requirements) . Texas 100 degrees F to 110 degrees F. 5. Common area bathrooms, public bathrooms and any other areas having sinks should be checked and recorded as well. This was determined to be an Immediate Jeopardy on 12/21/23 at 7:23PM. Administrator was notified. Administrator was provided the Immediate Jeopardy template on 12/21/23 at 7:23PM. The following Plan of Removal submitted by the facility was accepted on 12/22/23 at 11:38AM. Timeline: 12/21/23 at 12pm, the Maintenance Director lowered the temperature on the hot water heater. At approximately 3pm, the Maintenance Director checked all the water temperatures from 100 hall and they were all logged at safe range of 110 degrees. At approximately 4pm, the Maintenance Director checked water temperatures in resident rooms in the facility. At 7:38PM, the Maintenance Director checked room [ROOM NUMBER] water temperature and it was within safe range, logged at approximately 110 degrees under running water for 3 minutes. 1. Immediate Response: Water temperatures have been checked on 100 hall and rooms logged a safe water temperature range (see attached log). 31 of 90 residents on hall 100 are not at risk. Skin Assessments completed on all residents on hall 100 with no negative findings. AdHoc meeting with Administrator and DON to review issue and community's response plan implemented. 2. Risk Response: Resident/Residents on hallway 100 that received a shower or used thing sink for hand hygiene may potentially be affected by the alleged deficient practice. o Skin audit (sweep) was conducted by the administrative nurses (DON/ADONS/WCN) on current residents with no significant findings identified. Initial skin audit commenced on the evening of 12/21/23 once the concern was identified prior to the immediacy being implement@ 746PM. o Conducted 100% skin sweep of all active residents on hallway 100. There were no adverse effects identified. See above Date Completed: Initial skin sweeps on: 12/21/23 o ADMINISTRATOR and MAINTENANCE DIRECTOR received re-education on the importance ensuring that temperatures of hot water must be maintained less than 110 degrees and that if water temperatures are adjusted that they must be rechecked before and after doing so. ? Maintenance director were re- educated on running water for 3 minutes prior to any temperature check that is completed as per policy. ? Maintenance director was re-educated on holding the thermometer into the stream of running water so that the sensor is fully immersed and allowing the thermometer to register the correct temperature. o Date Completed: 12/21/23 at 8:30pm. o All management staff received education on the expectation hot water temperatures and that they are to be maintained below 110 degrees and if believed to be too hot to notify the Administrator or maintenance director immediately. Date Commenced: 12/21/23 1. ADMINISTRATOR AND MAINTENANCE DIRECTOR received education prior to exiting the facility. 2. All Management staff received education on the staff received education on the hot water temperatures and that they are to be maintained within safe rage 110-115 degrees and report immediately to Administrator and Maintenance Supervisor while preventing use of hot water until temperatures can be checked for safe temperatures. 3. Reviewing the temperatures and temperature logs to identify elevation or deviation from below 110 during the daily clinical meeting held 5 times weekly as well as random checks on weekends to ensure the temperatures are maintained at the appropriate temperature. 4. IDT will review the system & will update appropriate interventions to address the prevention of hot temperature injury. 5. ADMINISTRATOR and or Designee will conduct weekly rounds to ensure that temperature logs, monitoring logs and QA are being conducted on this system. Date commenced:12/21/23 Date completed: 4. Monitoring Response: The administrator or Designee will make daily temperature checks 5 days per week and then random temperature checks on the weekend to ensure the hot water temperatures are below the 110 degree to validate the compliance. Findings will be reported to the ADMIN and reviewed with the QAPI committee for the next 2-3 months to determine compliance or to identify further education and oversight is needed. Monitoring of the facility's Plan of Removal through observations, interviews, and record reviews from 12/21/2023 at 6:00pm to 12/21/2023 at 7:00pm revealed: In an interview on 12/22/23 at 6:00pm, the Administrator and Maintenance Director said the plumber came at 11:30am on 12/22/23 and looked at all 4 hot water heaters. They were ordering digital regulators that were tamper proof and maintain a continuous temperature. Checked a sample of rooms, 2 on each hallway, and all were within limits with a range of 100-105 degrees. The sample of rooms would be rotated each day and documented. The Administrator said he and only the Maintenance Director had access to hot water heaters. They were the only 2 that can test the water daily. The procedure was for the water to run for 3 minutes and hold the digital thermometer under running water. This will be done daily for 4 weeks, testing different rooms daily, and logging results. In-services started yesterday and were on-going until all staff have been in-serviced. Staff will not be able to pick up their paycheck until they were in-serviced to assure all staff are in-serviced. Record review of Water Temperature Log for 12/22/23 revealed all temperatures on the 100 hall within 100 degrees F to 104.6 degrees F. Record review of In-services started on 12/21/23 revealed: -Hot Water Heater Adjustments and Water Temps are on-going. -Safe Water Temps and Testing by the Administrator and Maintenance Director completed on 12/21/23. Record review of Skin Sweep for Hallway 100 dated 12/21/23 did not reveal any concerns relating to burns from hot water. Record review of AdHoc QAPI meeting completed on 12/21/23 with all required members in attendance. The meeting addressed the facility's POR needs. In interviews on 12/22/23 at 6:00 pm of sample staff from both shifts were completed with 2 RNs, 6 LVNs, 4 CNAs, 1 CMA, Housekeeping Supervisor, Human Resource Director, Medical Records, Dietary Manager and Social Worker. They all stated they had been in-serviced. They all said if the water was too hot, they would notify immediately either the Maintenance Director, Administrator, or the DON. They would also document it in the Maintenance Log that was at the nurse's station. They would protect the residents from being burned by hot water. After the POR and Monitoring, Administrator was informed the Immediate Jeopardy was removed on 12/22/23 at 7:38PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a severity level of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 4 residents (Resident #1) reviewed for significant medication errors. The facility failed to ensure Resident #1 received the correct prescribed seizure medication Carbamazepine, which resulted in the resident having a seizure and was transferred to the hospital. Resident #1 missed 6 doses of the medication from 08/11/23 through 08/13/23. This failure resulted in actual harm to Resident #1 on 08/14/23. The noncompliance was determined to be past noncompliance (PNC). The noncompliance began on 08/11/23 and ended on 08/14/23. The facility had implemented the actions that corrected the noncompliance before the surveyor's entrance to the facility on [DATE]. This failure could place residents at risk of complications from deterioration in health, and hospitalization s. Findings include: Record review of Resident #1's face sheet revealed he was a [AGE] year-old male, who was admitted to the facility on [DATE] with diagnoses of epilepsy (seizures), tremors, femur (thigh) fracture, esophagitis (esophagus inflammation), sick sinus syndrome (sinus dysfunction) and presence of cardiac pacemaker. Record review of Resident #1's 5-day Minimum Data Set, dated dated dated [DATE], reflected Section C BIMS was a 1, which indicated she did have cognitive impairment. Section G indicated R#1 required extensive assistance with most activities of daily living and two-person physical assist for bed mobility and transfer. Record review of Resident #1's discharge orders from the hospital dated 08/11/23 reflected, Carbamazepine XR (Tegretol XR) 200 mg 12 hr. tablet-take 5 tablets (1000 mg total) by mouth 2 (two) times a day with meals. Do not crush, chew, or split. Record review of Resident #1's, August 2023 MAR) indicated an order of Carbamazepine ER oral tablet extended release 12-hour 200 mg-Give 5 tablets by mouth two times a day related to epilepsy. The MAR revealed 6 different staff members signed that the medication was not available. These include nurses and medication aides. There was no documentation indicating that pharmacy, doctor, or administration of the facility were notified. Record review of Resident #1's progress notes dated 08/14/2023 at 11:03 AM completed by RN A reflected, I was called to the room by CNA on 300 hall. On entering it was apparent that this patient was having seizures. His face muscle was twitching, his eyes were rolled up and he did respond to my voice calling his name. His [family member] was at his bedside, very emotional. I obtained his V/S (vital signs)-146/68 [blood pressure] P-81, 02 sat of 95% on RA (room air). I stayed with patient and sent word with CNA to have the nurses at the desk call 911 for a patient having seizure. The [family member] apparently was on the phone with 911 operator. She handed me her phone to answer questions that were being asked of regarding his condition. I gave this information including the above V/S. Within a couple minutes the Ems arrived, and they then took V/S again and they were almost identical to those that I had just gotten. [Resident #1] was coming around as they loaded him on the stretcher and whisked him away. Record review of the hospital history and physical dated 08/11/23 for Resident #1 reflected, Seizure 15 minutes. Patient did not get his anticonvulsant medication at nursing home. HPI (history of present illness): Resident is a [AGE] year-old Hispanic male with seizure disorder, developmental delay. Recent fracture of right hip status post a bipolar hip replacement is readmitted to the hospital after he had a 15 minutes seizure at the facility. According to the [family member] the patient was not given his anticonvulsive medications because it ran out, subsequently patient has known seizure disorder. All seizure lasting 15 minutes he presented to hospital ER by PH Z and restarted on his oral medications. [Family member] does not want him to go back to the facility. During interview with the PHY on 09/11/23 at 10:18 a.m., he said he was the primary doctor for Resident #1. He explained Resident #1 had a complex medication regimen. PHY said he completed the history and physical on the resident after transfer to the hospital for seizures on 08/14/23. He stated there was no harm done to Resident #1. He believed the facility tried to get the medication on a weekend. Further interview on 09/13/23 at 10:48 a.m. with the PHY, revealed he was not informed that the facility did not have the seizure medication of Carbamazepine to give Resident #1. The PHY explained Resident #1 had a complex medication regimen and not taking the medicine for 3 days may have caused the seizure or not. He was getting another seizure medication of Phenobarbital 64.8 mg tablet three and one-half (3.5) by mouth once a day at bedtime. Even with the medication the resident had breakthrough seizures sometimes. The PHY stated in some cases pharmacies ran out of ordered meds. The lesson to learn here was the facility should have contacted the family member to get the meds. He said Resident #1 was fine. Review of Resident #1's laboratory values dated 08/08/23 through 08/11/23 (pre and post admission to the facility) for CBC, CMP and UA revealed no concerns. During interview on 09/06/23 at 4:03p.m. with RN A revealed she was present when Resident #1 had a grand mal seizure (unconsciousness and chronic muscle contractions) on 08/14/23 (day Resident #1 was transferred to the hospital). RN A explained she arrived on Monday morning and Resident #1 was a new resident on her hall, admitted on Friday of previous week. At about 8:30 a.m. on 08/14/23, an aide informed her Resident #1 was having a seizure. She immediately ran to the room and observed resident having grand mal seizure. Resident #1's responsible party was at his bedside. The seizure was very intense which made the RP very emotional and hysterical. The RP noted the Resident #1 had small seizures periodically, but he had not had grand mal seizures in over 8 years. RN A stated the RP believed the seizure occurred because Resident #1 did not get his seizure medication of Carbamazepine since admitted [DATE] till 08/14/23 (incident date). RN A said she informed one of the nurses to call 911 but noticed the RP had already called and was on the phone with EMS. The EMS requested to talk to her and she provided the needed information to EMS. Resident #1 was transferred to the hospital for evaluation and treatment. Meanwhile, RN A checked the MAR and found out the Resident #1 did not get his seizure medication of Carbamazepine as ordered that morning. RN A asked MA D who was supposed to give medication and why Resident #1 did not receive the scheduled medication. CMA D said the medication was not available. RN A asked CMA D why she did not tell her or the ADON or DON. CMA D stated she forgot to inform them. RN A explained she was shocked that staff members did not contact the pharmacy, doctor, and administration starting on 08/11/23 (admission) till 08/14/23 (incident date). RN A stated it was the facility policy for the CMA or the nurses to call the pharmacy to inquire why a medication was not available. RN A noted what happened was avoidable and should not have happened. She stated it appeared the staffs involved did not take responsibility to call and find out why the medication was not available. RN A mentioned that the pharmacy received the medication on 08/11/23 and claimed to have called the facility and no one answered. The pharmacy did not call the facility again until 08/13/23 (2 days after initial contact) and talked to LVN E. RN A said there was no record LVN E informed anyone. In an interview with LVN E on 09/07/23 at 2:56p.m., he said he did not remember receiving a call from the pharmacy. He said If he did the information was passed down to the nurse on that hall. He was working on hall 200 and not hall 300 where Resident #1 was residing. LVN E was asked who he passed the information onto and he said he did not remember. In an interview on 09/08/23 at 1:06p.m. with CMA D, she said she has employed in the facility about 3 years. On 08/14/23 she looked at the MAR and saw an order for seizure medication for Resident #1. She looked but could not find the medication. She wrote on the MAR that the medication was not available. CMA D said she did not talk to RN A who was the charge nurse on duty. CMA D explained the facility policy was to notify the nurse, ADON or DON. She said she forgot to notify the nurse or follow the facility policy and took responsibility for what happened. She said she should have done everything to ensure Resident #1 received such significant medication including calling the RP to see if she had it. She was asked if she talked to any staff member that worked on the weekend regarding the medication not being available. CMA D said she had not. She said LVN F worked on the weekend. Review of the MAR for Resident #1 dated August 2023 revealed LVN F signed that ordered seizure medication of Carbamazepine on 08/13/23 was not available. During interview with LVN F on 09/07/23 at 4:06 p.m , he said he worked on 08/13/23 as confirmed by the electronic sign-in sheet. LVN F stated he signed the medication was not available because it was not in stock. He said he did not remember the exact incident. LVN F explained the facility policy was to contact the pharmacy or the ADON to inform them that the medication was not available. LVN F did not remember calling the pharmacy or the ADON. LVN F said his phone did not show any correspondence about the medication. Review of the MAR for Resident #1 dated August 2023 revealed LVN G signed that ordered seizure medication of carbamazepine on 08/11/23 through 08/14/23 was not available. Attempted interviews with LVN G on 09/07/23 at 9:00 a.m., 09/07/23 at 2: 00 p.m., 09/09/23 at 4: 01 p.m. and 09/13/23 at 1:00 p.m. but did not receive a response. During interview on 09/06/23 at 10:12a.m. with DON, she said she was not notified that Resident #1 did not have her seizure medication until 08/14/23 when the Resident #1 was having the seizures. The DON explained it was the facility policy for the staff members (nurses and medication aides) to call the pharmacy to find out why a medication was not available. She said the staff involved did not follow the facility policy. Furthermore, she noted the pharmacy did not contact the facility again after the initial attempt till 2 days later. The DON said she talked to pharmacy to avoid a repeat of what happened. Review of E-Rx new prescription from the pharmacy dated 09/12/23 for the medication Carbamazepine reflected, over max dose (1600 mg) calls for 2000 mg per day. No answer on 08/11/23 at 4:00p.m. On 08/13/23 at 3:08a.m. LVN E will have dayshift clarify with the Doctor During interview on 09/07/23 at 3:14 p.m. with PM Z, she said she was the pharmacist for the facility. PM Z said she was familiar with the medication for Resident #1. She explained the pharmacy received an order for Carbamazepine oral tablet extended release-give 5 tablets by mouth two times a day. On 08/11/23, she contacted the nursing station because she wanted to clarify the dosage which was more than the normal recommended max dose, and no one answered. PM Z said she did not contact the facility again until 08/13/23 at 3:08a.m. She talked to LVN E. She stated LVN E inform her he would inform Resident #1's charge nurse. PM Z did not hear from the facility. PM Z was asked why it took 2 days to contact the facility after the initial call. She said the pharmacy shouldn't have taken that long to request information from the facility regarding the seizure medication. Review of the facility policy undated 01/09/2014, titled Medication ordering and receiving from Pharmacy reflected: Policy: Medication and related products are received from dispensing pharmacy on a timely basis. The facility maintains accurate records of medication and receipt. Procedures: Ordering medication from the dispensing pharmacy . 1) New medications, except for emergency or stat medications, are as follows: a) If needed before next regular delivery, phone the medication order to the pharmacy immediately upon receipt. Inform pharmacy of the need for prompt delivery and request delivery within (4) hours. b) Timely delivery of new orders is required so that medication administration is not delayed. The emergency kit is used when the resident needs medications prior to pharmacy delivery. The facility completed the following corrective actions to address the non-compliance after incident occurred but prior to the surveyor entering. Review of in-services 08/14/23 and 08/23/23 revealed the charge nurses from 2 shifts (6:00a.m. to 6:00p.m. and 6:00p.m. to 6:00a.m. were in-serviced related to medication administration, transcribing physician's orders, rights of medication, reviewing the MAR prior to administering medication, reviewing orders and clarifying with the physician if needed, medication ordering and contacting the pharmacy immediately. Interview with 5 charge nurses and the DON (RN A, LVN E, LVN F, LVN M, LVN N) on the 2 shifts from 09/12/23 at 2: 00p.m. to 09/13/23 at 4: 00p.m. revealed all staff members reported being recently in-serviced on medication ordering, medication administration, notifying the physician, reviewing new orders and ensuring residents were receiving the required and ordered medications. They were able to explain in-services related to notifying the pharmacy immediately if the medication was not available and communicating to the physician or the resident's representative. Review of record revealed there were 3 residents taking seizure medication of Keppra (Residents #4, #5 and #6) from 09/11/23 at 11: 00a.m to 09/13/23 at 3:25p.m. They said they were receiving Keppra and have been receiving their medication without any problem. The residents explained they had not had a seizure and received their medication on time as ordered. During interview with the DON on 09/07/23 at 10:00a.m., she revealed all residents on high-risk medications including seizure meds were reviewed without concerns. She conducted in-services and reeducated nurses on the need to contact the pharmacy and the physician to clarify orders. The DON told the nurses to contact her anytime if there was a problem with any medication issues. She stated she performed cart audits to match medication with administration. The DON explained she designated an ADON to review medication orders (particularly new admission) daily and discuss during the daily meetings with the administration.

Based on interviews and record review the facility failed to ensure residents had the right to be free from abuse for 2 of 4 residents (Resident #1, Resident #2) reviewed for abuse. 1) The facility failed to ensure a safe environment free from abuse for Resident #1. On 07/22/23 at 11:15p.m, CNA A was observed by LVN B cleaning Resident #1's bleeding ear lobe and denied not knowing what happened. Resident #1 was transferred to the hospital and found to have multiple injuries including left ear laceration, left shoulder abrasion, hematoma on the right and left abdomen, hematoma on the left leg, skin tear on the left forearm and bruise on the foreskin of his penis. According to LVNB she saw Resident #1 less than24 hours back and he did not have these fresh new injuries. 2) The Facility failed to ensure a safe environment free from abuse for Resident #2. CNA A was observed on 07/19/23 at 7:06 to 7:18p.m on the video camera physically abusive and aggressive with Resident #2 while trying to provide incontinent care. An IJ was identified on 07/27/23 at 4:05p.m. The IJ template was provided to the facility on [DATE] at 4:05 p.m. While the IJ was removed on 07/28/23 at 4:25p.m, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on effectiveness of the Plan of Removal These failures place residents at risk of physical harm, emotional distress, mental anguish, and death from possible abuse. Findings included: Review of Resident #1's face sheet dated 07/24/23 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included vascular dementia (impaired blood flow to brain) acute and respiratory failure, chronic obstructive pulmonary disease (breathlessness and cough), personal history of covid-19, bipolar disorder (mental disorder), benign prostatic hyperplasia (enlarged prostate), insomnia (sleep disorder), schizophrenia (mental disorder), osteoarthritis (degenerative joint disease), dysarthria and anarthria (impaired speech) and major depressive disorder (loss of interest). Review of the significant change MDS assessment dated [DATE] for Resident #1 revealed he had a brief interview for mental status score of 1 indicating cognitive severe impairment. Resident has minimum difficulty hearing with unclear speech. He usually understood but with impaired vision. Resident #1 has physical behaviors directed towards others e.g., hitting, kicking, pushing, scratching, and grabbing. Resident #1 had contributing active diagnoses of dementia and schizophrenia. The MDS reflected for skin condition: Resident #1 had only 1 documented pressure ulcers (stage2) or wound on admission. Furthermore, the MDS indicated Resident #1 required extensive assistance with most ADLs and transfer. He was frequently incontinent of bowel and bladder. Review of Resident #1's Care Plan dated 06/28/22 reflected Resident #1 has a behavior problem as evidenced by resisting (activity of daily living) ADL assistance. He hits and curses at staff during ADLs. Goal: The resident will have fewer episodes of resisting ADL assistance and will cooperate with staff. Interventions includes: 1) Explain all procedures to resident before starting and allow the resident (10 minutes) to adjust to changes 2) Minimize potential for the resident's disruptive behaviors by offering task which divert attention 3) Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes 4) If reasonably, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Review of the Braden Scale (predictor of pressure sore risk) dated 06/02/23 revealed Resident #1 had a score of 14 which indicated moderate risk for pressure ulcers. Review of the nurse's notes dated 07/23/23 (the day Resident#1 went to hospital), documented by LVN A reflected, Resident observed to be sitting on left side in upright position, both feet on the floor, alert and oriented to person. Resident presents in brief. Moderately sized lacerations to lower left earlobe, estimated 4cm in length, bleeding, small scratch anterior to lower, left earlobe: two small lacerations present to left anterior shoulder; moderately sized skin tear to left forearm, and a large bruise/swelling assessed to resident's lower extremity. Vitals assessed as follows: T97.6, BP 165/80, 02 97%, P 60 and R 24. As per protocol ADON/DON, Administrator, Resident's family member hospice provider notified of incident. (CNAA) asked to complete a witness statement for incident report. Once witness statement completed, floor CNA was asked to go home for remainder of shift. Review of the hospital admission for Resident #1 dated 07/23/23 reflected, Pt came in via EMS w/c/o laceration on left ear, chin, left shoulder and skin tear to left arm. Altered mental status: Given is confused and not able to provide any information, this information is obtained from emergency department provider as well as from medical records. Patient is a resident at local nursing home and he was found confused and with multiple injuries. Given his status patient is sent to the emergency department for further evaluation. Patient is noted to have multiple superficial bruises over the left ER left forearm, left shoulder and left lower extremity and imaging study showed multiple rib fractures as well as lumbar spine fracture. Patient is also noted to be significantly acidotic (acid condition); he was started on BIPAP and initiated treatment with nebulization and received dose of steroid. After this he is being admitted for further management Further review of the Resident #1's hospital medical records dated 07/23/23 reflected, Pt. was brought to ED via EMS with c/o AMS and potential physical abuse. Is non-verbal. Responsive to pain w/laceration on left ear, skin tear on the left forearm, bruises and lacerations on the left shoulder, bruises and abrasion on the left leg, bruise on the foreskin of the penis and hematoma (localized bleeding) on the right and left upper abdominal area. Observation of Resident #1 on 07/24/23 at 2:52p.m in the hospital revealed Resident #1 was lying with IV tubes connected to him. Resident #1 could speak but was unable to articulate clear thoughts. His nurse RNT did a head-to-toe assessment as this surveyor observed. Resident #1's injuries include a bruised penis, left shoulder lacerations, left ear lobe lacerations, a hematoma to left leg and left abdomen, and multiple rib fractures (per RN T). Resident #1 appeared tired and confused. In an interview with RNT on 07/24/23 at 3:06p.m., he said he is the charge nurse taking care of Resident #1 in the hospital. RNT explained Resident #1 was brought to the Emergency department for treatment of suspected physical abuse in the nursing home where he was residing. Resident #1 sustained multiple lacerations and abrasions consistent with physical abuse. He said paramedics informed them the nursing home refused to give details of what happened to the Resident#1. During interview with LVNA on 07/25/23 at 10:54a.m, she said she was the nurse that transferred Resident #1 to the hospital for evaluation and treatment. She stated on 07/23/23 about 11:00p.m, Resident #1 was found with fresh new bruises, lacerations, and abrasion after changing shift with LVNB. The wounds included left ear lacerations, left shoulder abrasions/lacerations, lacerations on the right and left abdomen, lacerations on the leg, skin tear on the left forearm, and extensive bruising on the foreskin of his penis. LVNA explained the wounds were new on the resident having taking care of him on Friday 07/22/23 a day before the incident. She also said LVNB informed her she saw CNA A cleaning the bleeding earlobe of Resident #1. LVNB asked CNAA what happened and CNAA responded I didn't know. LVNB said she notified the physician and received orders to send resident to the hospital to rule out internal injuries. LVNA explained LVNB on 07/18/23 informed her that she was afraid because CNAA threatened to kidnap, rape, put her in the trunk and throw her in the river. She was shocked and immediately went to HR E. LVNA and HR E walked to the ADM's office and informed him of threat from CNAA. LVNA said she did not hear from ADM or aware of any investigation. The ADM didn't talk to her about the issues and CNAA was still reporting to work as if nothing happened. There was no investigation, suspension, or disciplinary actions. LVNA noted she was very concerned when LVNB informed her CNAA pulled a knife on her in the breakroom few days after the rape threat. She noted LVNB was visibly terrified and said she did understand why ADM had not acted on her complaint regarding CNAA. During interview with LVNB on 07/25/23 at 1:47p.m, she said she was familiar and responsible for Resident #1 and Resident #2 during the night shift. On 07/23/23 at about 11:00p.m she walked into Resident#1's room and observed CNA A wiping blood from laceration on Resident #1's earlobe. She asked what happened and CNAA said I don't know. LVNB assessed Resident #1 and found multiple injuries that was no present a day before. She explained Resident #1 looked like he was on a WWF fight. LVNB immediately notified ADON C, ADON D and DON via text which stated, Hey I need to know what to do for (Resident #1) he's dinged up like he's been in a fight. Do I call ADM or EMS?. She said ADON C called her back and instructed to transfer Resident #1 to the hospital for further evaluation and treatment. During an Interview with ADONC on 07/27/23 at 10:58a.m, she said she was one of the ADONs in the facility. On 07/23/23 at 1:31a.m, LVNB texted her informing Resident #1 was found with multiple injuries including bruises, laceration and abrasions which were fresh and new. LVNB mentioned she saw CNAA cleaning Resident #1's bleeding earlobe in his room. She asked CNAA what happened to the Resident #1?. CNAA repeatedly said he did not know. ADONC told LVNB to transfer Resident #1 to the hospital for further evaluation and treatment. ADONC explained she immediately called ADM on 07/23/23 at 1:39 p.m. and informed him of the reported incident. ADM informed her to call hospice nurse and not call EMS. She stated she had already informed LVNB to transfer Resident #1 to the hospital for evaluation and treatment because of the seriousness of the injury after LVNB texted to her. In an interview with Hos Q on 07/26/23 at 8:27a.m, she said she was the Hospice nurse from the agency. On 07/23/23 at about 2:00a.m, she was called by the facility to come and assess Resident #1 because he was found with multiple injuries. She arrived and saw residents with numerous wounds including laceration and abrasions to left leg, left arm, left ear, bruise to foreskin of his penis and swollen left shin. She said Resident #1 appears to be in pain and was given Tramadol because he was grimacing. Hos Q noted the injuries was new and fresh but the resident could not say how he got the injuries. After assessing Resident #1 she called the doctor and received an order for x-ray to see the extent of his injuries. She treated the wounds and left the facility. 2. Review of Resident #2's face sheet dated 07/25/23 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The diagnoses included senile degeneration of the brain, dementia (impaired blood flow to brain), Aphasia (Communication disorder), dysphagia (language disorder), contractures (chronic loss of joint motion), heart failure, seizures), osteoarthritis (degenerative joint disease), and pulmonary embolism (blood clot in the lungs).and depressive disorder (loss of interest). Review of the MDS assessment dated [DATE] for Resident #2 revealed an incomplete brief interview for mental status. Resident has minimum difficulty hearing with unclear speech. He rarely/never understands but with adequate vision. Resident #2 has no documented behavioral issues. Review of nurse's notes dated 07/23/23 reflected, After 10: 00a.m RP resident's family member notified this nurse of watching a man (CNA A) being rough with Resident #2, this nurse told SS and (ADM) notified. Awaiting further instructions at this time Review of hospital admission for Resident #2 dated 07/23/23 reflected, Pt arrived to ED via EMS from facility and was sent by primary care dr. for concerns of internal injuries and to be evaluated for such. Per charge nurse RN, pt. is second individual to arrive today for injuries from the same facility. APS case has been filled for other individual and instructed to file for Pt as well. Pt is at baseline GCS of 14 per EMS. Pt. denies any complaints at this time, pt. is assessed for bruising/injuries, no apparent injuries upon visual assessment. Review of the facility schedule date 07/23/23 revealed CNA A was the only aide assigned to Hall 100 where Resident #1 and Resident #2 were located. Review of three separate video recording of Resident #2 reflected the following: INCIDENT 1 Recording occurred on 07/19/23 from 7:06p.m-7:18pm. The video revealed shows CNA A being physically abusive towards Resident #2, pulling Resident #2 by the arms to flip him over and pulling him by the wrist to not allow Resident#2 to brace himself holding on to the side rails of the bed. Resident #2 tried to fight back but CNAA was relentless in his rough actions towards Resident #2. CNAA grabbed Resident #2 by wrist and pinned him to continue to change him. CNAA aggressively pulled Resident #2's shirt off. INCIDENT 2 Recording occurred on 07/21/23 from 11:44p.m to 11: 48p.m The video revealed CNA A being physically abusive towards Resident #2, pulling him forcefully by the knees to flip the resident unto side and remove his brief. CNAA aggressively pulled the resident by the wrist and pinned wrist and arm under the rail of the bed to continue to change the resident. CNA A removed Resident #2 brief but did not clean resident before putting on new brief. INCIDENT 3 Recording occurred on 07/22/23 from 7:56p.m to 8:05p.m. The video revealed CNA A being physically abusive towards Resident#2, pulling the resident by his knees forcefully flipping him over, grabbing the resident by the wrist to pin him down and flipping him back by forcefully ripping sheets out from under Resident # 2. Approximately at 7:59p.m LVNB entered the room. LVN B stated to CNAA You are being too rough with him in which CNAA replied, I will show you rough. Review of Police report #20230009126 dated 07/23/223 reflected the following: OFFENSE SUMMARY: **************** Injury to Child, Elderly, or Disabled, Serious Bodily Injury CNA A while employed as a CNA at facility Nursing and Rehab and assigned to care for Resident #1, CNA A, intentionally, knowingly, or recklessly caused Resident #1 to have multiple abrasions, severe bruising around the groin, broken ribs on his left side and slipped disc in his spine. Injury to Child, Elderly, or Disabled, Bodily injury CNA A while employed as a CNA at facility Nursing and Rehab and assigned to care for Resident #2, intentionally, knowingly, or recklessly caused Resident #2 to be evaluated for internal injuries from the forceful nature that CNA A treated him with on video. In an attempted interview with CNA A on 07/25/23 at 4:49p.m, he confirmed he was working on hall 100 on 07/23/23 (day of incident). CNA A said he took care of Residents #1 and #2 in the nursing. He was asked if he had a chance to talk to ADM, he said he had not. CNA A ended the call. Several attempts by surveyor to call CNAA back was met with voice message saying the phone was out of services. During interview with Administrator (ADM) on 07/26/23 at 9:54a.m, he confirmed the following: 1) Received video recording from RP showing CNAA physically harming Resident #2 2) LVNB and LVNA notified him of rape threat by CNAA 3) ADON C, LVNA, LVNB notified him of physical abuse of Resident #1 and Resident #2 by CNAA 4) Aware Resident #1 sustain multiple injuries. 5) Did not talk to CNA A about the rape issue or the incidents of physical abuse of Resident #1 and Resident #2 6) Denied not reporting on time. Surveyor tried without success to get some questions answered or timeline on the information during the investigation from ADM. He was reluctant, unwilling, and refused to answer specific question. Review of the facility's undated policy/procedure on abuse/neglect ` reflected: Intent: The facility will develop and operationalized policies and procedure for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property: to include the use f physical or chemical restraint. The purpose is to assure that facility is doing all is within its control to prevent occurrences. Procedure: Prevention: 1) Provide residents, families and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution: and provide feedback regarding the concerns that have been expressed. 2) Identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. This was determined to be an Immediate Jeopardy (IJ) on 7/27/23 at 4:05 pm. The Administrator and DON were notified. The San [NAME] Nursing and Rehab was provided with the IJ template on 7/27/23 at 4:05 PM. The following Plan of Removal was accepted on 7/28/23 at 4:25 PM and included: Please accept the following Plan of Removal of Immediate Jeopardy-Failure to ensure residents are free from abuse/neglect/exploitation. The facility failed to ensure the residents are free from abuse and neglect. 1. The facility's policies and procedures on abuse and neglect is the following: Ensure the resident is safe and report the event to the abuse coordinator immediately. The Abuse coordinator will conduct a brief investigation and report abuse or neglect to HHSC within two hours. 2. On 7/23/23 at 2:22 AM the employee in question was suspended immediately pending investigation and terminated on 7/23/23 at 8:03 PM after discovering evidence of him committing abuse to a resident. 3. All current staff were in-serviced on abuse and neglect and reporting abuse or neglect policy and procedures on 7/23/23. For those on vacation and cannot be reached, they will not return to work without receiving this in-service. 4. LVN B completed abuse and neglect in-service on 7/23/23. DON will provide 1:1 In-service, written disciplinary actions, and LVN proficiency checkoff prior to LVN B working the floor again. 5. Administrator and Designee received 1:1 in-service from Owner/Operator to cover reporting timeframes. 6. The Administrator/Designee is responsible for ensuring that all assigned in-service for abuse and neglect are completed by all staff members. Completion will be reviewed at monthly QAPI meetings. 7. DON/Designee will re-educate the charge nurses on their ability to suspend any employee who is suspected of committing abuse or neglect to a resident or employee will be suspended immediately and escorted out of the building and off the premises pending investigation. This will be completed on 7/28/23. 8. DON/Designee reviewed hall assignments to verify where the CNA and LVN were assigned to and conducted a head-to-toe assessment on all residents they cared for on 7/22/23 and 7/23/23. 9. Complete a resident safe survey on all current residents to ensure they feel safe and free from abuse or neglect by 7/28/23. 10. On 7/27/23, safe surveys were conducted on hall 100 and halls 200,300,400 were completed on 7/28/23. Starting 7/31/23, DON/SW will conduct 10 random safe surveys a week for 3 weeks for the residents to ensure that they continue to feel safe and well taken care of. Findings will be discussed at weekly Committee Meetings and at monthly QAPI Meetings. 11. The residents 1 and 2 who suffered the alleged abuse care plan was not updated or changed due to them discharging and the family placing them in another facility. 12. All possibly affected residents have had care plans updated to reflect potential risk for alteration in mood state and psychosocial well-being related to the alleged incident of abuse in their environment. 13. Prior reportable incidents were reported within the guidelines set forth by HHSC and the Administrator monitored the completion of the investigation. 14. Any staff member suspected of committing abuse/neglect will be suspended immediately and or terminated depending on the outcome of the investigation. 15. Staff who fail to report suspected abuse will be educated on the significance of reporting time and disciplined accordingly. 16. The Administrator/Designee is responsible for ensuring that all assigned in-service for abuse and neglect are completed by all staff members. 17. The Administrator/Designee will monitor all reportable incidents and all reportable incidents will be reported to the Corporate Compliance Officer immediately. All reportable will be discussed weekly at our Committee Meeting. 18. Starting 7/28/23 DON/Designee will conduct 10 random quizzes week for 3 weeks for staff to ensure they are retaining the education on abuse and neglect and reporting procedures. Results will be reviewed during the monthly QAPI meetings, and any incorrect answers will be corrected immediately on the spot. Progress will also be monitored during weekly Committee Meetings. 19. The Medical Director is both resident's physician and he is the one who gave the orders to send them to the emergency room for evaluations. 20. On 7/27/23, Administrator conducted an ad-hoc QAPI meeting to discuss the IJ and assign responsibilities. 21. All adverse findings will be discussed at the QAPI meeting and necessary changes will be made at this time. 22. Residents not on 100 hall who may have been provided care by CNA or LVN were given the safe surveys and will be included in the random safe surveys. 23. All residents on 100 halls will be monitored for 72hrs post discovery of the incidents to ensure there is no retaliation or emotional distress. DON will monitor this compliance. 24. Medical Director was alerted of the IJ on 7/27/23 and Administrator personally spoke with him on 7/28/23 to provide more detail. During an interview on 7/28/23 at 3:25 PM Resident #6 stated that an employee came in this morning around 9:15 and did ask her questions about abuse/neglect, if employees are nice to her, etc. She stated she had good things to say for all questions, and it felt nice to have those questions asked to her because they should be asked by staff occasionally. During an interview on 7/28/23 at 3:35 PM Resident #7 stated that a nurse, can't remember who did come in this morning and speak with her and ask her questions on abuse/neglect. She stated it was nice to have that asked to her because that really showed her that they care and want to change things. During an interview on 7/28/23 at 3:45 PM Resident #8 stated that a nurse came in this morning and did ask him about abuse neglect, he has never had any issues here before. He stated it was nice to hear the facility ask these questions. He stated he likes the facility very much and has no issues with any employee or resident. During an interview on 7/28/23 at 3:55 PM Resident #9 stated she did have a nurse come through this morning to check in on her. She stated the nurse asked questions such as has any employee been rude, disrespectful, neglectful etc to you. She stated she said no. She stated she has never really had an issue with any nurse or another resident. She stated that the facility overall seems very good to her. Record review of QAPI meeting notes/in-service regarding IJ conducted on 7/27/23 at 9:30 AM confirmed by AD. She stated that they did have a sit-down meeting to discuss all the IJ templates and a plan of actions, this included abuse neglect in-services, safe surveys, quizzes, monitoring residents, and background checks. Record review of CNAA Corrective action form dated 7/23/23 employee was terminated due to abuse, signed by administrator, and dated as verbal over the phone on 7/23/23 at 8:00 pm. Record review of in-service dated 7/23/23 for all nursing staff, topic abuse and neglect, signed by all staff and stated that no staff could work until complete. Conducted by DON. In-service covered abuse and neglect. Contents of training were: The abuse preventions coordinator is the administrator and I the administrator cannot be reached; the backup contract is the DON. Their names and phone numbers are posted on the board on 200 hall. If you see or suspect abuse or neglect happing, the first response is to stop it and protect the resident. You must then immediately report to the abuse preventionist. The types of abuse include physical, verbal, emotional, sexual, involuntary seclusion, misappropriation of funds, and neglect or abandonment. Please respond to residents needs in an appropriate time manner. Be respectful and talk to residents politely. Remember customer service is a priority. Record review of in-service dated 7/27/23 for all nursing staff, topic abuse and neglect, signed by all staff and stated that no staff could work until complete. Conducted by Administrator and DON. Contents included the fact that abuse or neglect must be reported to the abuse coordinator immediately. They should not wait for someone else to report it. It is their responsibility to protect the residents of this facility. If they are unsure about weather, it was a case of abuse or neglect-report it anyways! Protect your residents! It is your job as the abuse coordinator to start the investigation ASAP-and report to state within 2 hours. Make sure staff is aware that they must contact you directly and immediately. Make sure your number is posted with postings, in the breakroom, at the nurse's station, in therapy, in the kitchen-everywhere. If at any time they cannot reach you, they should be instructed to call the DON. Make yourself heard. During an interview on 7/28/23 at 4:15 PM DON stated multiple Care quizzes have been given to multiple employees who attended both in-services. She stated that she has been reviewing the quizzes and all employees have no missed one question. She stated the Medical Director was contacted on 7/27/23 regarding the incidents that occurred and the IJ being called in the facility. She stated that LVNB completed abuse and neglect in-service on 7/23/23. DON will provide 1:1 In-service, written disciplinary actions, and LVNB proficiency checkoff prior to LVNB working the floor again. DON stated in-service has been completed at 7/23/23 and a write up documentation. LVNB came in 7/27/23 to go over proficiencies. She stated that on 7/27/23 she and the administrator received 1:1 in-service from [NAME], Owner/Operator to cover reporting timeframes. Record review of a completed resident safety survey dated 7/28/23 on all current residents to ensure they feel safe and free from abuse or neglect by 7/28/23. safe surveys were conducted on hall 100 and halls 200, 300, 400 were completed on 7/28/23. Starting 7/31/23, DON/SW will conduct 10 random safe surveys a week for 3 weeks for the residents to ensure that they continue to feel safe and well taken care of. Findings will be discussed at weekly Committee Meetings and at monthly QAPI Meetings. Document included questions such as, have you ever had or felt neglect/abused by any employee or other resident. Record review of Care Quiz revealed all staff that had attended both in-services on 7/28/23 were provided a Care Quiz to complete. Care quiz completed by LVNJ; all answers answered correctly. No issues. Care quiz was created with questions that were from both in-services. Observation three sampled residents (Resident #3, #4 and #5) revealed no signs of pain or abuse. They appear to be carrying their activities of daily living with incident. They said they felt safe and denied abuse staff or other residents. Interviews regarding abuse and neglect training and reporting on 07/28/23 at 3:25p.m through 5: 00p.m revealed no concerns with staff knowledge. Staffs interviewed were representative of various facility shifts. They were able to provide knowledge and participation of training regarding abuse/neglect in-services and training. The following staffs were interviewed on 07/28/23: LVN A, LVNB, ADON C, ADON D, HRE, CNA F, CNA G, CNA H, LVN I, LVN J, LVNK, CNA L, CNA M, Social Worker, and CNA N. They were knowledgeable of types of abuse/neglect and should report any abuse allegations to charge nurse of resident immediately and to the ADM. They all knew Administrator was the Abuse prevention coordinator with DON as the backup if not able to reach ADM. They knew how to get hold of ADM and DON if not in the facility at time. Interview with LVNB (100 hall) on 07/28/23 at 4:30 PM revealed she was in-serviced on 07/25/23 and 07/28/23 on abuse/neglect and reporting. She was asked what she would have done differently looking back at the incident with Resident #1 and Resident#2, and she stated she would follow protocol and nursing judgement and reported the incident immediately. She stated she was terrified on what CNAA could have done to her for reporting her observation. On 07/28/23 at 4:25p.m, the Administrator was notified the IJ was removed. While the IJ was removed on 7/28/23, the facility remained out of compliance at a severity level of actual harm with the potential for more than minimal harm that is not immediate jeopardy, and a scope of pattern because the facility had not had the opportunity to monitor the effectiveness of the Plan of Removal.

Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, for 2 of 4 residents (Resident #1 and #2) reviewed for neglect. 1) LVN B failed to report physical abuse of Resident #1 after witnessing CNA A 's rough actions with the resident during incontinent. Resident #1 was transferred to the hospital with diagnosis of left ear lacerations, left shoulder abrasion and laceration, a hematoma (localized bleeding) on the right and left abdomen, hematoma (localized bleeding) on the left leg, skin tear on the left forearm and a bruise on the foreskin of his penis. 2) The ADM failed to report serious and multiple injuries on Resident #1 to Police or State Agency. ADON C notified the ADM on 07/23/23 at 1:39a.m. The ADM did not report the incident until 11:28p.m which was more than 9 hours later. 3) The ADM failed to report to the Police, State agency physical abuse of Resident #2 after he was made aware of the incident. LVN A notified the ADM on 07/23/23 at 1:00a.m. The ADM did not report the incident until 12:03 more than 10 hours later. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 07/27/23 at 4:05p.m. While the IJ was removed on 07/28/23 at 4:25p.m, the facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective actions. These failures could place all the residents, who resided in the facility, at risk for abuse and mental anguish. Findings included: Review of Resident #1's face sheet dated 07/24/23 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The diagnoses included vascular dementia (impaired blood flow to brain) acute and respiratory failure, chronic obstructive pulmonary disease (breathlessness and cough), personal history of covid-19, bipolar disorder (mental disorder), benign prostatic hyperplasia (enlarged prostate), and insomnia (sleep disorder), schizophrenia (mental disorder), osteoarthritis (degenerative joint disease), dysarthria and anarthria (impaired speech) and major depressive disorder (loss of interest). Review of the MDS assessment dated [DATE] for Resident #1 revealed he has a brief interview for mental status (BIMS) score of 1 indicating cognitive severe impairment. Resident has minimum difficulty hearing with unclear speech. He usually understands but with impaired vision. Resident #1 required extensive assistance with most ADLs and transfer. He was frequently incontinent of bowel and bladder. Review of Resident #1's Care Plan dated 06/28/22 reflected Resident #1 has a communication problem related vascular dementia and schizophrenia. His speech is unclear and very soft spoken. The goal will be able to make basic needs known on daily basis through review. Interventions includes the following: 1) Allow adequate time to respond. Repeat as necessary. Do not rush. Request clarification from resident to ensure understanding. Face when speaking. Make eye contact. Turn off TV/radio to reduce environmental noise. Ask yes/no questions if appropriate. Use simple, brief, consistent words/cues. Use alternative communication tools as needed. 2) Monitor/document for physical/nonverbal indicators of discomfort and distress and follow up as needed. 3) Encourage resident to continue stating thoughts even if resident is having difficulty. Focus on words or phrase that make sense or responds to the feeling resident is trying to express. Record review of the hospital records for Resident #1 dated 07/23/23 reflected, Pt. was brought to ED via EMS w/c/o (with complain) AMS (altered mental status) and potential physical abuse. Is non-verbal. Responsive to pain. W/(with) lacerations on left ear, skin tear on the left forearm, bruises and lacerations on the left shoulder, bruises and abrasions on the left leg, bruises on the foreskin of the penis and hematoma on the right and left upper abdominal area Per EMS, staff member(s) from the patient's nursing home refused to provide details regarding the patient's condition. They did state the patient did not fall, and internal injuries had to be ruled out. Of note, two other patients from the same nursing home were also brought to the same ED today, at least one to rule out internal injury as well. Review of nurse's notes dated 07/22/23 documented by LVN A reflected, upon entering the resident's room, the resident presented laying in a supine position with eyes open, alert, and oriented to person. Resident #1 was looking up at floor CNA, CNA A, who was clearing off the resident's ear with a wipe. The resident's ear was noticeable bleeding from moderately sized cut on lower left earlobe. This nurse asked the floor CNA, what happened? CNA A responded, I don't know. During an interview with LVNB on 07/25/23 at 1:47p.m, she said she was working on hall 100 where Resident #1 and Resident #2 were residing. On 07/18/23, she was working with CNA A who threatened her. She explained CNA A told her, he was going to kidnap her, put chloroform on her face, take her to secluded place, rape, dismember her, put her in a car trunk and throw her in the River. LVN B stated she was scared to death because of the tone and his look when he was talking. She immediately informed LVN A who was changing shift with her. LVN B said LVNA was just as scared and notified the ADM immediately. She explained the ADM did not take any action. He did not talk to her or LVNA after the report. The ADM did not investigate, suspend, or terminate CNA A employment. CNA A was still on schedule working with her. A few days after his threat, LVNB said CNAA pulled a knife in the break room on her. She screamed but nobody heard her. She was convinced CNA A was going to hurt or kill her and her 2 kids. She was terrified and looking over her shoulders with sleepiness nights looking to see if CNA A would come to attack knowing he knew where she lives. On 07/23/23 at about 11:00p.m, she walked into Resident #1's room and saw CNA A cleaning the resident's bleeding earlobe. She asked him what happened. CNAA responded I don't know. LVNB stated Resident #1 looked like he was in WWF fight. She said Resident #1's wounds were new and fresh because she took care of him less than 24 hours earlier. She was horrified and terrified of CNA A and did not immediately report the incident. She told LVNA what she saw. LVNB notified the ADON C who instructed her to transfer the resident to the hospital. LVNB explained ADM was notified. The ADM informed them not to send Resident #1 to the hospital but to call Hospice nurse to do an assessment. LVNB said she took the advice of ADON C and transferred Resident #1 to hospital for evaluation and treatment because Resident #1's wound was serious. She noted CNA A was asked to write a statement and sent home. LVNB stated CNA A continued to say he didn't know what happened. She believed CNA A did something to the resident because he was the only aide assigned to that hall. Meanwhile, she went to the police to report the threat on her life by CNA A since ADM was not doing anything. The police wanted to come to the facility that night to watch the videos but the ADM told them wait till the morning because it was too late at night for him. During interview with ADON C on 07/27/23 at 10:58a.m. she said she notified the ADM on 07/23/23 at 1:39 a.m. that Resident #1 was found with serious injury. ADON C explained the ADM wanted her to notify hospice agency and not send Resident #1 to the hospital. She exercised nursing judgement and instructed LVNB to transfer Resident#1 to the hospital because of his serious injury including a bleeding earlobe. She noted the picture of the earlobe was sent to her by LVNB. In another interview with LVNB on 07/27/23 at 10:05a.m she stated on 07/22/23 at 11: 15p.m LVNB entered Resident #1's room. LVN B saw CNA A cleaning Resident #1's bleeding earlobe. LVNB stated when asked multiple times to CNA A what happened. CNA A would only reply, I don't know. LVNB stated CNA A was the only aide assigned to that hall all night and the wounds look fresh. LVNB asked Resident #1 what happened, Resident #1 made a motion with hands, like he got into a fight. LVN B asked Resident #1 who he got in a fight with, he pointed to CNA A In an Interview with HR E on 07/26/23 at 9:30a.m, she said she was the Human Services Director and has been employed in the facility for 8 months. On 07/18/23, she was notified by LVNA that CNA A threaten to rape and throw LVNB in the river. HR E explained she went with LVNA to ADM office to talk to him about the incident. She said she was not aware if ADM talked to LVNB or CNA A. Surveyor asked the facility protocol when an employee threaten another.HR E stated she informed ADM and did not talk to LVNB or CNA A. She went on to say she did not know if ADM investigated or reported the incident. Review of Resident #2's face sheet dated 07/25/23 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The diagnoses included senile degeneration of the brain, dementia (impaired blood flow to brain), Aphasia (Communication disorder), dysphagia (language disorder), contractures (chronic loss of joint motion), heart failure, seizures), osteoarthritis (degenerative joint disease), and pulmonary embolism (blood clot in the lungs).and depressive disorder (loss of interest). Review of the MDS assessment dated [DATE] for Resident #2 revealed an incomplete brief interview for mental status (BIMS). Resident has minimum difficulty hearing with unclear speech. He rarely/never understands but with adequate vision. Resident #1 has no documented behavioral issues. In an interview with the RP on 07/25/23 at 11:05a.m, she said she was the family member to Resident #2. She explained she had videos where a staff member was physically abusing her Resident #2. She said she wanted to send me a statement to include I my report to ensure all areas of Resident #2's experienced was covered. Surveyor said it was ok. The following was her statement: My name is RP, (Resident #2) is a resident at (facility) nursing & rehab nursing home. On July 23rd I watched the video from the camera that I have currently in his room at the facility. The camera showed that a CNA A that works there is being rough with Resident #2 assaulting him while he's changing him and changing his sheets being very mean to him also fighting with the nurse that was in there. Her name was (LVN B). She's an RN. She tells him he needs to he's going to get fired. He said they won't get fired. He holds Resident #2 down putting pressure on his arms as well as while he's changing him, he throws him around back-and-forth on the bed. Resident #2 hit his head on the rail of the bed twice Resident #2 is resisting as he's doing this .but he doesn't speak much he is mostly nonverbal. After I see this video, I call the nursing facility and speak to the nurse LVN B and ask her to check Resident #2 out and assess him to make sure that he didn't have any sores. She finds bruises on him on his forearms and his wrists as well as spot on his arm that was bleeding, they sent him to the ER to be fully checked out once he gets to the hospital, they call me and say that they can keep him until we find another place for him to go. I do not want him going back to facility Nursing in Rehab because this is the second time that he's been assaulted by a CNA in the three years that he's been there. The nurse tells me the ADM phone number and I give him a call. His name is ADM. He answers the phone and he's mad that I have his personal number and rude to me on the phone and downplayed the situation as if it wasn't that big of a deal said that he already complained to the state And tells me I guess you can call the cops if you want. I called the police they come to my house and they watched the video and then another cop comes and then they watch the video and other cop comes so they seem to think it was serious what the guy was doing to my Resident #2. They have an open investigation against this guy and I learned that another family had the exact experience as well with their family member at the nursing home. I'm not sure of their names but there's another family that had their family member go to the hospital too. Last night I began looking at the tape from the last couple weeks at the nursing home of the nights that this guy CNA A worked, and there's more videos.he has done us to Resident #2 several times several different occasions several different nights. In another video that I found he wedges Resident #2 's whole arm in between the mattress and the rail of the bed and puts his knee on it so that Resident #2 can't get it out and proceeds to keep changing Resident #2 pamper. Resident #2 is fighting him and resisting at the same time, he also is antagonizing him verbally as he's doing all this ripping the sheets off at one point, he puts the sheets over Resident #2 's face. Resident #2 seems so scared and confused in the video. You can see Resident #2 's hand shaking he's so scared. I have turned in the rest of the videos into the police and hopefully they complete their investigation soon. I had emailed the local Ombudsman here in San [NAME] and he just called me this morning and told me to write this all out in an email and send it to y'all. This nursing home needs to be investigated. I wonder what type of screening they do before they hire people especially CNA 's. This is the second time that this is happened in three years that my Resident #2 has been there, and it is uncalled for and inappropriate on all levels. The videos might be too long for me to email to you as an attachment but I will send a few screenshots of some of the videos. Please feel free to contact me if you have any questions Resident 32 is currently at the hospital staying there until I figure out what nursing home, I'm going to have to switch him to, this is very unfortunate that I have to move him because of what another person caused. He has dementia & is disabled and it's very hard for him to adjust when you move him. The guy ADM is a fill in ADM from when old ADM quit .he doesn't do a whole lot. There are multiple videos I submitted to the police for evidence this is just a few. Record review of the Police report #2023009117 dated 07/23/23 by OFFZ reflected, I, Officer [NAME], D65 was dispatched to hospital for an assault. Upon arriving, I located the charge nurse, RN R, who had called dispatch. RN R stated that she had received three patients from (facility) Nursing and Rehab today. Two patients Resident #1 and Resident #2 who had come in with minimal information as to cause of injuries being told to Paramedics to relay to the ER for further medical care. RN R stated that Resident #! had a broken back and broken ribs discovered from x-rays in addition to other injuries. RN R stated that Resident #1 was admitted due to the extent of injuries. RN R did not have much information about Resident #2 other than the (Facility} Nursing and Rehab had sent him to get checked out for internal injuries due to Resident #2 having a feed tube in his side. I was also provided information for Resident #3 that RN R believed to be related to the incidents with Resident #1 and Resident #2. I gathered RN R's information and the which medics transported Resident #1, Resident #2 and Resident #3. I then called Sgt. PO S with what I had gathered so far to get advise on how to proceed. I then went to Station 2 to speak with Medic 2 Crew. Medic 2 paramedics stated that staff mentioned incidents but did not go into detail. The Paramedics stated that they did not believe that Resident #3 was involved in the incidents. As she had been to the ER the prior night for a broken arm and was not discharged till later in the morning from what they had told as she had overdosed on her medication. I then went to Station 7 to speak with Medic 7 crew who transported both Resident #1 and Resident #2 nursing facility to the hospital. When I arrived and talked with the paramedics one stated that while he was trying to gather information on how the injuries had occurred for Resident #1 that staff did not want to say due to legal reasons telling him to label it as internal injuries. The paramedic then stated that for Resident #1 when they arrived the staff was not open to discussing how Resident #1 was injured as they would typically tell the paramedics if the residents had been combative or had fought another resident but that this was the case this time. After speaking with the crew of Medic 7 I called PO S again to inform him of what the paramedics had told me before heading to facility Nursing and Rehab at the address. After arriving, I spoke with staff who gave me the phone numbers for the DON Staff also stated that Resident #3 was not related to the incidents as she was in a separate hall. I then went out to my vehicle to call (DON) as she was not present the facility. DON stated that she was aware of two incidents that had occurred in the early hours of 07/24/2023 but did not have a lot of the details as she had been notified by the ADM. I gathered her information while she informed me that one of the family members had video of one incident that occurred. DON directed me to talk ADM as he had was going to investigate the incidents. I then went back inside the nursing facility and got the phone number for ADM before returning to my vehicle to call ADM. ADM stated that he had been notified by staff somewhere between 0200 to 0245 in which a CNA A was placed on suspension pending termination from employment. I gathered the information that ADM had on file for CNA A. I then asked ADM what their policy or procedure was for incidents like this and why did they not call the Police or other agency in regard to the incidents to this point. ADM stated that it was up to staff to contact authorities. I finished speaking with ADM when a priority called drop close by in which I cleared from the call to return to service . I then went inside were Officer PO U was talking to LVNB about threats that CNA A had made to her, Case 20230009126. i then went back outside and began to type my report watching in case CNA A decided to return to the facility as LVN B was afraid of retaliation from CNA A. Once Det. PO V arrived, I assisted him by telling him details that I had been told before he began to interview staff that was present in the facility at the time of the incidents. A staff member showed us Resident #1's and Resident #2's rooms which I took photos of starting from the hall working my way inside to where their beds are located. I then attempted to located Resident #1 dirty linens from that night but they had already been washed and did not have any visible stains remaining on his shirt or sheets. I then attempted to locate disposable wipes that LVN B had seen CNA A use to clean up blood from Resident #1 in the dumpster but was unsuccessful. I then waited near Det. PO V and Det. PO X till they had interviewed all the staff present. I then cleared from the call and returned to service. I later uploaded photos taken to [NAME] Database at a later time. In an attempted interview with CNA A on 07/25/23 at 4:49p.m, he confirmed he was working on hall 100. CNA A said he took care of Residents #1 and #2 on hall 100. He was asked if he had a chance to talk to ADM, he said he had not. CNA A hanged up the phone. Several attempts to reconnect with CNA A came with voice message that the phone was out of service. During interview with Administrator (ADM) on 07/26/23 at 9:54a.m, he confirmed the following: 1) Received video recording from RP showing CNA A physically harming Resident #2 2) LVNB and LVNA notified him of rape threat by CNA A 3) ADON C, LVNA, LVNB notified him of physical abuse of Resident #1 and Resident #2 by CNA A 4) Aware Resident #1 sustain multiple injuries. 5) Did not talk to CNA A about the rape issue or the incidents of physical abuse of Resident #1 and Resident #2 6) Denied not reporting on time. Surveyor tried without success to get some questions answered or timeline on the information during the investigation from ADM. He was reluctant, unwilling, and refused to answer specific question. Review of intake investigation worksheet dated 07/23/23 referencing Resident #1 incident was received and created at 11:28a.m about 9 hours after the Incident was reported to ADM. Review of the facility's policy/procedure on abuse/neglect undated reflected: Intent: The facility will develop and operationalized policies and procedure for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property: to include the use f physical or chemical restraint. The purpose is to assure that facility is doing all is within its control to prevent occurrences. Procedure: Reporting/Response: 1) Report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the result of the investigation 2) Report to State nurse aide registry or licensing authorities any knowledge I has of any actions by a court of law which would indicate an employee is unfit foe service . This was determined to be an Immediate Jeopardy (IJ) on 7/27/23 at 4:05 pm. The Administrator and DON were notified and were provided with the IJ template on 7/27/23 at 4:05 PM. The following Plan of Removal was accepted on 7/28/23 at 4:25 PM and included: Please accept the following Plan of Removal of Immediate Jeopardy-Failure to ensure residents are free from abuse/neglect/exploitation. The facility failed to ensure the residents are free from abuse and neglect. 1. The facility's policies and procedures on abuse and neglect is the following: Ensure the resident is safe and report the event to the abuse coordinator immediately. The Abuse coordinator will conduct a brief investigation and report abuse or neglect to HHSC within two hours. 2. On 7/23/23 at 0222 the employee in question was suspended immediately pending investigation and terminated on 7/23/23 at 8:03 after discovering evidence of him committing abuse to a resident. 3. All current staff were in-serviced on abuse and neglect and reporting abuse or neglect policy and procedures on 7/23/23. For those on vacation and cannot be reached, they will not return to work without receiving this in-service. 4. LVN B completed abuse and neglect in-service on 7-23-23. DON will provide 1:1 In-service, written disciplinary actions, and LVN proficiency checkoff prior to LVN B working the floor again. 5. Administrator and Designee received 1:1 in-service from [name], Owner/Operator to cover reporting timeframes. 6. The Administrator/Designee is responsible for ensuring that all assigned in-service for abuse and neglect are completed by all staff members. Completion will be reviewed at monthly QAPI meetings. 7. DON/Designee will re-educate the charge nurses on their ability to suspend any employee who is suspected of committing abuse or neglect to a resident or employee will be suspended immediately and escorted out of the building and off the premises pending investigation. This will be completed on 7/28/23. 8. DON/Designee reviewed hall assignments to verify where the CNA and LVN were assigned to and conducted a head-to-toe assessment on all residents they cared for on 7/22/23 and 7/23/23. 9. Complete a resident safe survey on all current residents to ensure they feel safe and free from abuse or neglect by 7/28/23. 10. On 7/27/23, safe surveys were conducted on hall 100 and halls 200,300,400 were completed on 7/28/23. Starting 7/31/23, DON/SW will conduct 10 random safe surveys a week for 3 weeks for the residents to ensure that they continue to feel safe and well taken care of. Findings will be discussed at weekly Committee Meetings and at monthly QAPI Meetings. 11. The residents 1 and 2 who suffered the alleged abuse care plan was not updated or changed due to them discharging and the family placing them in another facility. 12. All possibly affected residents have had care plans updated to reflect potential risk for alteration in mood state and psychosocial well-being related to the alleged incident of abuse in their environment. 13. Prior reportable incidents were reported within the guidelines set forth by HHSC and the Administrator monitored the completion of the investigation. 14. Any staff member suspected of committing abuse/neglect will be suspended immediately and or terminated depending on the outcome of the investigation. 15. Staff who fail to report suspected abuse will be educated on the significance of reporting time and disciplined accordingly. 16. The Administrator/Designee is responsible for ensuring that all assigned in-service for abuse and neglect are completed by all staff members. 17. The Administrator/Designee will monitor all reportable incidents and all reportable incidents will be reported to the Corporate Compliance Officer immediately. All reportable will be discussed weekly at our Committee Meeting. 18. Starting 7/28/23 DON/Designee will conduct 10 random quizzes week for 3 weeks for staff to ensure they are retaining the education on abuse and neglect and reporting procedures. Results will be reviewed during the monthly QAPI meetings, and any incorrect answers will be corrected immediately on the spot. Progress will also be monitored during weekly Committee Meetings. 19. The Medical Director is both resident's physician and he is the one who gave the orders to send them to the emergency room for evaluations. 20. On 7/27/23, Administrator conducted an ad-hoc QAPI meeting to discuss the IJ and assign responsibilities. 21. All adverse findings will be discussed at the QAPI meeting and necessary changes will be made at this time. 22. Residents not on 100 hall who may have been provided care by CNA or LVN were given the safe surveys and will be included in the random safe surveys. 23. All residents on 100 halls will be monitored for 72hrs post discovery of the incidents to ensure there is no retaliation or emotional distress. DON will monitor this compliance. 24. Medical Director was alerted of the IJ on 7/27/23 and Administrator personally spoke with him on 7/28/23 to provide more detail. Monitoring of the facility's Plan of Removal through observation, interview and record from 07/28/23 at 2: 52p.m to 07/28/23 at 5: 15p.m revealed no concerns. During an interview on 7/28/23 at 3:25 PM Resident #6 stated that an employee came in this morning around 9:15 and did ask her questions about abuse/neglect, if employees are nice to her, etc. She stated she had good things to say for all questions, and it felt nice to have those questions asked to her because they should be asked by staff occasionally. During an interview on 7/28/23 at 3:35 PM Resident #7 stated that a nurse, can't remember who did come in this morning and speak with her and ask her questions on abuse/neglect. She stated it was nice to have that asked to her because that really showed her that they care and want to change things. During an interview on 7/28/23 at 3:45 PM Resident #8 stated that a nurse came in this morning and did ask him about abuse neglect, he has never had any issues here before. He stated it was nice to hear the facility ask these questions. He stated he likes the facility very much and has no issues with any employee or resident. During an interview on 7/28/23 at 3:55 PM Resident #9 stated she did have a nurse come through this morning to check in on her. She stated the nurse asked questions such as has any employee been rude, disrespectful, neglectful etc to you. She stated she said no. She stated she has never really had an issue with any nurse or another resident. She stated that the facility overall seems very good to her. Record review of QAPI meeting notes/in-service regarding IJ conducted on 7/27/23 at 9:30 AM confirmed by AD. She stated that they did have a sit-down meeting to discuss all the IJ templates and a plan of actions, this included abuse neglect in-services, safe surveys, quizzes, monitoring residents, and background checks. Record review of CNA A Corrective action form dated 7/23/23 employee was terminated due to abuse, signed by administrator, and dated as verbal over the phone on 7/23/23 at 8:00 pm. Record review of in-service dated 7/23/23 for all nursing staff, topic abuse and neglect, signed by all staff and stated that no staff could work until complete. Conducted by DON. In-service covered abuse and neglect. Contents of training were: The abuse preventions coordinator is the administrator and I the administrator cannot be reached; the backup contract is the DON. Their names and phone numbers are posted on the board on 200 hall. If you see or suspect abuse or neglect happing, the first response is to stop it and protect the resident. You must then immediately report to the abuse preventionist. The types of abuse include physical, verbal, emotional, sexual, involuntary seclusion, misappropriation of funds, and neglect or abandonment. Please respond to residents needs in an appropriate time manner. Be respectful and talk to residents politely. Remember customer service is a priority. Record review of in-service dated 7/27/23 for all nursing staff, topic abuse and neglect, signed by all staff and stated that no staff could work until complete. Conducted by Administrator and DON. Contents included the fact that abuse or neglect must be reported to the abuse coordinator immediately. They should not wait for someone else to report it. It is their responsibility to protect the residents of this facility. If they are unsure about weather, it was a case of abuse or neglect-report it anyways! Protect your residents! It is your job as the abuse coordinator to start the investigation ASAP-and report to state within 2 hours. Make sure staff is aware that they must contact you directly and immediately. Make sure your number is posted with postings, in the breakroom, at the nurse's station, in therapy, in the kitchen-everywhere. If at any time they cannot reach you, they should be instructed to call the DON. Make yourself heard. During an interview on 7/28/23 at 4:15 PM DON stated multiple Care quizzes have been given to multiple employees who attended both in-services. She stated that she has been reviewing the quizzes and all employees have no missed one question. She stated the Medical Director was contacted on 7/27/23 regarding the incidents that occurred and the IJ being called in the facility. She stated that LVNB completed abuse and neglect in-service on 7/23/23. DON will provide 1:1 In-service, written disciplinary actions, and LVNB proficiency checkoff prior to LVN B working the floor again. DON stated in-service has been completed at 7/23/23 and a write up documentation. LVNB came in 7/27/23 to go over proficiencies. She stated that on 7/27/23 she and the administrator received 1:1 in-service from Owner/Operator to cover reporting timeframes. Record review of a completed resident safety survey dated 7/28/23 on all current residents to ensure they feel safe and free from abuse or neglect by 7/28/23. safe surveys were conducted on hall 100 and halls 200, 300, 400 were completed on 7/28/23. Starting 7/31/23, DON/SW will conduct 10 random safe surveys a week for 3 weeks for the residents to ensure that they continue to feel safe and well taken care of. Findings will be discussed at weekly Committee Meetings and at monthly QAPI Meetings. Document included questions such as, have you ever had or felt neglect/abused by any employee or other resident. Record review of Care Quiz revealed all staff that had attended both in-services on 7/28/23 were provided a Care Quiz to complete. Care quiz compl [TRUN

Based on observations, interview and record review revealed the facility failed to, in response to allegations of abuse, thoroughly investigate the alleged abuse for one (Residents #1) of 4 residents reviewed for resident abuse. 1) The facility failed to thoroughly investigate an incident of physical abuse of Resident #1 when LVN B observed rough action by CNA A while providing incontinent care to o Resident #1. 2) The facility failed to thoroughly investigate an incident of physical abuse of Resident #2 by CNA A. On 07/23/23 at 10:00a.m, ADM was informed by LVNB and RP of video recording of physical abuse of Resident #2. There was no call to police, State agency, no safe surveys/assessment/interviews with residents/staffs until IJ was called. 3) The facility failed to thorough investigate an incident of abuse of Resident #1 by CNA A. On 07/23/23 at 1:39a.m, ADM was informed by ADON C of Resident #1 injuries. CNA was not suspended until 2:22a.m and not terminated until 8:00p.m. The ADM did not call police and did not want Resident #1 sent out to the hospital, but wanted the hospice nurse called instead. The other residents were not assessed or interviewed. This was determined to be an Immediate Jeopardy (IJ) on 7/27/23 at 2:30pm. The Administrator and DON were notified and were provided with the IJ template on 7/27/23 at 2:30 PM. On 07/28/23 at 4:25p.m, the Administrator was notified the IJ was removed. While the IJ was removed on 7/28/23, the facility remained out of compliance at a severity level of actual harm with the potential for more than minimal harm that is not immediate jeopardy, and a scope of pattern because the facility had not had the opportunity to monitor the effectiveness of the Plan of Removal. The failures could place residents involved in abuse incidents at risk of continued abuse, further injury, pain, and physical and emotional distress. Findings included: Review of Resident #1's face sheet dated 07/24/23 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The diagnoses included personal history of covid-19, bipolar disorder (mental disorder), benign prostatic hyperplasia (enlarged prostate), and insomnia (sleep disorder), schizophrenia (mental disorder), osteoarthritis (degenerative joint disease), dysarthria and anarthria (impaired speech) and major depressive disorder (loss of interest), vascular dementia (impaired blood flow to brain) acute and respiratory failure, chronic obstructive pulmonary disease (breathlessness and cough) and depressive disorder (loss of interest). Review of Resident #1's Significant MDS assessment dated [DATE] reflected Resident #1 had a BIMS of 1 indicating severe cognitive impairment. Resident #1 required extensive assistance with most ADLs except personal hygiene. Resident #1 was frequently incontinent of bowel and bladder. Review of Resident #1's undated comprehensive care plan reflected Resident #1's ADL self- care performance deficit related to confusion, dementia, severe cognitive impairment, physical mobility, muscle wasting and atrophy, unawareness of needs. He uses wheelchair for mobility on and off the unit. Interventions included to encourage the resident to participate to the fullest extent possible with each interaction. Review of hospital records for Resident #1 dated 07/23/23 reflected, This nurse spoke with (facility), they stated that patient is brought in due to PHY's request due to potential abuse allegations, and the need to check for internal bleeding. They stated that patient prior to is a X2 assist to his wheelchair, but can freely move himself in the wheelchair, can feed himself (mechanical soft diet) and take his medications. Pt. uses 3 liters of oxygen via NC. Pt. has multiple wounds in various stages of healing, however, new ones per nursing home nurse include left shin, left chest, left ear, and left forearm. According to them, pt. did not fall or have any signs of being combative. Hospice provider is following as patient is a patient of them for heart failure. Pt. is known to be aphasic at times. Here pt. presents non-verbal, contracture, and with bipap present. Family member, pt. MPOA notified of patient being in hospital. Family member states pt. does not have any family in town, and her last visit with him was about a month ago. Care resuming. Review of Police report #20230009126 reflected, Officer [NAME], D65 was dispatched to hospital for an assault. Upon arriving, I located the charge nurse, (RN R), who had called dispatch. RN R stated that she had received three patients from facility Nursing and Rehab today. Two patients (Resident #1 and Resident #2) who had come in with minimal information as to cause of injuries being told to Paramedics to relay to the ER for further medical care . After speaking with the crew of Medic 7 I called Sgt. PO S again to inform him of what the paramedics had told me before heading to facility at facility address. After arriving, I spoke with staff who gave me the phone numbers for the DON. Staff also stated that RN R was not related to the incidents as she was in a separate hall. I then went out to my vehicle to call (DON) she was not present the facility. (DON) stated that she was aware of two incidents that had occurred in the early hours of 07/24/2023 but did not have a lot of the details as she had been notified by the ADM. I gathered her information while she informed me that one of the family members had video of one incident that occurred. DON directed me to talk ADM as he had was going to investigate the incidents. I then went back inside the nursing facility and got the phone number for ADM before returning to my vehicle to call ADM. (ADM) stated that he had been notified by staff somewhere between 0200 to 0245 in which a CNA, CNA A was placed on suspension pending termination from employment. I gathered the information that ADM had on file for CNA A. I then asked ADM what their policy or procedure for incidents like this was and why did they not call the Police or other agency in regards to the incidents to this point. ADM stated that it was up to staff to contact authorities. I finished speaking with ADM when a priority called drop close by in which I cleared from the call to return to service. During interview with LVNA on 07/25/23 at 10:54a.m, she said she received video recording from RP showing physical abuse of Resident #2 by CNA A. She immediately notified ADM. She explained ADM did not tell her to call police or notified them himself. She felt there was no urgency on ADM's part to investigate or notify police considering the seriousness of the abuse and what the video recording showed. LVNA noted ADM had the same altitude of indifference when she reported to him that CNA A threaten to rape LVNB and throw her in the river. He did not investigate or suspend or terminate CNA A employment. LVNA said CNA A continued to work which led to physical abuse of Resident #1 and Resident #2 about 1 week later. In an attempted interview with CNA A on 07/25/23 at 4:49p.m, he confirmed he was working on hall 100. CNA A said he took care of Residents #1 and #2 in the nursing. He was asked if he had a chance to talk to ADM, he said he had not. CNA A hanged up the phone. Several attempts to reconnect came with voice message that the phone was out of services. During interview with LVNB on 07/26/23 at 10:45a.m, she said she was working with CNA A on 07/18/23 when he threatens to rape her and throw in [NAME] River. She informed LVNA. She stated she and LVNA reported the incident to ADM. She believes if ADM has investigated the incident, CNA A could not have physically abuse Resident #1 on 07/22/23 and 07/22/23 about 1 week latter. On 07/22/23 at about 11:15p.m, she entered Resident #1's room. She saw CNA A cleaning Resident #1 earlobe because it was bleeding. LVNB stated that when asked multiple times to CNA A what happened, CNA A would only reply, I don't know. LVNB stated CNA A was the only CNA on that hallway all night and the wounds were fresh. LVNB asked Resident #1 what happened, Resident #1 made a motion with his hands, like he got into a fight. LVNB asked Resident #1 who he got in a fight with, and Resident #1 pointed at CNA A. LVNB explained on 07/23/23, Resident #1 was found with left ear lacerations, left shoulder abrasion and laceration, a hematoma on the right and left abdomen, hematoma on the left leg, skin tear on the left forearm and a bruise on the foreskin of his penis. LVNB said ADM was the abuse coordinator and should have investigated, suspended, or terminated CNA A employment to prevent his subsequent actions on Resident #1. During interview with Administrator (ADM) on 07/26/23 at 9:54a.m, he confirmed the following: 1) ADON C, LVNA, LVNB notified him of physical abuse of Resident #1 and Resident #2 by CNA A 2) Aware Resident #1 sustain multiple injuries. 3) Denied not reporting on time. Surveyor tried without success to get some questions answered or timeline on the information during the investigation from ADM. He was reluctant, unwilling, and refused to answer specific question. In an Interview with HR E on 07/26/23 at 9:30a.m, she said she was the Human Services Director and has been employed in the facility for 8 months. On 07/18/23, she was notified by LVNA that CNA A threaten to rape and throw LVNB in the river. HR E explained she went with LVNA to ADM office to talk to him about the incident. She said she was not aware if ADM talked to LVNB or CNA A. Surveyor asked the facility protocol when an employee threaten another.HR E stated she informed ADM and did not talk to LVNB or CNA A. She went on to say she did not know if ADM investigated or reported the incident. During interview with DON on 07/26/23 at 9:06a.m, she said she was informed by LVNA that CNA A threaten to rape LVNB and throw her to the river. She explained the ADM was informed by LVNA and HR E about the incident before she was aware of the incident. The DON stated she assumed the ADM was investigating the incident. She said she was aware that ADM did not talk to CNA A about the rape incident. The DON stated the facility protocol was to investigate and talk to the parties involved. Remove the staff if necessary and in-serviced is conducted. She said the ADM should have called CNA A and talk to him and write a report and call Police when it was brought to his attention. Review of Resident #2's face sheet dated 07/25/23 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The diagnoses included senile degeneration of the brain, dementia (impaired blood flow to brain), Aphasia (Communication disorder), dysphagia (language disorder), contractures (chronic loss of joint motion), heart failure, seizures), osteoarthritis (degenerative joint disease), and pulmonary embolism (blood clot in the lungs).and depressive disorder (loss of interest). Review of the MDS assessment dated [DATE] for Resident #2 revealed an incomplete brief interview for mental status (BIMS). Resident has minimum difficulty hearing with unclear speech. He rarely/never understands but with adequate vision. Resident #1 has no documented behavioral issues. In an interview with the RP on 07/25/23 at 11:05a.m, she said she was the Responsible party for Resident #2. RP explained on 07/23/23, she watched video recording in the facility of CAN A physically abusing her Resident #2 over several days (on 07/19/23 from 7: 06p.m-7: 18p.m, on 07/21/23 from 11: 44p.m-11: 48p.m, on 07/22/23 from 7: 56p.m to 8:05p.m.). RP stated, the video recording revealed CNA A physically abusing Resident #2 multiple times while providing incontinent care. She immediately notified LVNB and ADM. RP explained ADM was rude and answered how she got his number and seems unconcerned with the welfare of Resident #2. The ADM did not call Police or investigate her legitimate concerns about Resident #2 condition. RP said she reported the incident of Resident #2 abuse to the police. The RP noted Resident #2 was found with bruises by LVNB and transferred to the hospital for check of internal injuries. Review of the facility's policy/procedure on abuse/neglect undated reflected: Intent: The facility will develop and operationalized policies and procedure for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property: to include the use f physical or chemical restraint. The purpose is to assure that facility is doing all is within its control to prevent occurrences. Investigation: Investigate different types of incidents; and identify the staff member responsible for the initial reporting, investigation of alleged violations and reporting of results to the proper authorities. An Immediate Jeopardy (IJ) was identified on 07/28/23 at 4:25 p.m. While the IJ was removed on 07/28/23, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of pattern because the facility was still monitoring the Plan of Removal. This was determined to be an Immediate Jeopardy (IJ) on 7/27/23 at 2:30pm. The Administrator and DON were notified and were provided with the IJ template on 7/27/23 at 2:30 PM. The following Plan of Removal was accepted on 7/28/23 at 3:05 PM and included: Please accept the following Plan of Removal of Immediate Jeopardy-Failure to ensure residents are free from abuse/neglect/exploitation. The facility failed to ensure the residents are free from abuse and neglect. 1. The facility's policies and procedures on abuse and neglect is the following: Ensure the resident is safe and report the event to the abuse coordinator immediately. The Abuse coordinator will conduct a brief investigation and report abuse or neglect to HHSC within two hours. 2. On 7/23/23 at 0222 the employee in question was suspended immediately pending investigation and terminated on 7/23/23 at 2003 after discovering evidence of him committing abuse to a resident. 3. All current staff were in-serviced on abuse and neglect and reporting abuse or neglect policy and procedures on 7/23/23. For those on vacation and cannot be reached, they will not return to work without receiving this in-service. 4. LVN B completed abuse and neglect in-service on 7-23-23. DON will provide 1:1 In-service, written disciplinary actions, and LVN proficiency checkoff prior to LVN B working the floor again. 5. Administrator and Designee received 1:1 in-service from [name], Owner/Operator to cover reporting timeframes. 6. The Administrator/Designee is responsible for ensuring that all assigned in-service for abuse and neglect are completed by all staff members. Completion will be reviewed at monthly QAPI meetings. 7. DON/Designee will re-educate the charge nurses on their ability to suspend any employee who is suspected of committing abuse or neglect to a resident or employee will be suspended immediately and escorted out of the building and off the premises pending investigation. This will be completed on 7/28/23. 8. DON/Designee reviewed hall assignments to verify where the CNA and LVN were assigned to and conducted a head-to-toe assessment on all residents they cared for on 7/22/23 and 7/23/23. 9. Complete a resident safe survey on all current residents to ensure they feel safe and free from abuse or neglect by 7/28/23. 10. On 7/27/23, safe surveys were conducted on hall 100 and halls 200,300,400 were completed on 7/28/23. Starting 7/31/23, DON/SW will conduct 10 random safe surveys a week for 3 weeks for the residents to ensure that they continue to feel safe and well taken care of. Findings will be discussed at weekly Committee Meetings and at monthly QAPI Meetings. 11. The residents 1 and 2 who suffered the alleged abuse care plan was not updated or changed due to them discharging and the family placing them in another facility. 12. All possibly affected residents have had care plans updated to reflect potential risk for alteration in mood state and psychosocial well-being related to the alleged incident of abuse in their environment. 13. Prior reportable incidents were reported within the guidelines set forth by HHSC and the Administrator monitored the completion of the investigation. 14. Any staff member suspected of committing abuse/neglect will be suspended immediately and or terminated depending on the outcome of the investigation. 15. Staff who fail to report suspected abuse will be educated on the significance of reporting time and disciplined accordingly. 16. The Administrator/Designee is responsible for ensuring that all assigned in-service for abuse and neglect are completed by all staff members. 17. The Administrator/Designee will monitor all reportable incidents and all reportable incidents will be reported to the Corporate Compliance Officer immediately. All reportable will be discussed weekly at our Committee Meeting. 18. Starting 7/28/23 DON/Designee will conduct 10 random quizzes week for 3 weeks for staff to ensure they are retaining the education on abuse and neglect and reporting procedures. Results will be reviewed during the monthly QAPI meetings, and any incorrect answers will be corrected immediately on the spot. Progress will also be monitored during weekly Committee Meetings. 19. The Medical Director is both resident's physician and he is the one who gave the orders to send them to the emergency room for evaluations. 20. On 7/27/23, Administrator conducted an ad-hoc QAPI meeting to discuss the IJ and assign responsibilities. 21. All adverse findings will be discussed at the QAPI meeting and necessary changes will be made at this time. 22. Residents not on 100 hall who may have been provided care by CNA or LVN were given the safe surveys and will be included in the random safe surveys. 23. All residents on 100 halls will be monitored for 72hrs post discovery of the incidents to ensure there is no retaliation or emotional distress. DON will monitor this compliance. 24. Medical Director was alerted of the IJ on 7/27/23 and Administrator personally spoke with him on 7/28/23 to provide more detail. Monitoring of the facility's Plan of Removal through observation, interview and record from 07/28/23 at 2:52p.m to 07/28/23 at 5:15p.m revealed no concerns. During an interview on 7/28/23 at 3:25 PM Resident #6 stated that an employee came in this morning around 9:15 and did ask her questions about abuse/neglect, if employees are nice to her, etc. She stated she had good things to say for all questions, and it felt nice to have those questions asked to her because they should be asked by staff occasionally. During an interview on 7/28/23 at 3:35 PM Resident #7 stated that a nurse, can't remember who did come in this morning and speak with her and ask her questions on abuse/neglect. She stated it was nice to have that asked to her because that really showed her that they care and want to change things. During an interview on 7/28/23 at 3:45 PM Resident #8 stated that a nurse came in this morning and did ask him about abuse neglect, he has never had any issues here before. He stated it was nice to hear the facility ask these questions. He stated he likes the facility very much and has no issues with any employee or resident. During an interview on 7/28/23 at 3:55 PM Resident #9 stated she did have a nurse come through this morning to check in on her. She stated the nurse asked questions such as has any employee been rude, disrespectful, neglectful etc to you. She stated she said no. She stated she has never really had an issue with any nurse or another resident. She stated that the facility overall seems very good to her. Record review of QAPI meeting notes/in-service regarding IJ conducted on 7/27/23 at 9:30 AM confirmed by AD. She stated that they did have a sit-down meeting to discuss all the IJ templates and a plan of actions, this included abuse neglect in-services, safe surveys, quizzes, monitoring residents, and background checks. Record review of CNAA Corrective action form dated 7/23/23 employee was terminated due to abuse, signed by administrator, and dated as verbal over the phone on 7/23/23 at 8:00 pm. Record review of in-service dated 7/23/23 for all nursing staff, topic abuse and neglect, signed by all staff and stated that no staff could work until complete. Conducted by DON. In-service covered abuse and neglect. Contents of training were: The abuse preventions coordinator is the administrator and I the administrator cannot be reached; the backup contract is the DON. Their names and phone numbers are posted on the board on 200 hall. If you see or suspect abuse or neglect happing, the first response is to stop it and protect the resident. You must then immediately report to the abuse preventionist. The types of abuse include physical, verbal, emotional, sexual, involuntary seclusion, misappropriation of funds, and neglect or abandonment. Please respond to residents needs in an appropriate time manner. Be respectful and talk to residents politely. Remember customer service is a priority. Record review of in-service dated 7/27/23 for all nursing staff, topic abuse and neglect, signed by all staff and stated that no staff could work until complete. Conducted by Administrator and DON. Contents included the fact that abuse or neglect must be reported to the abuse coordinator immediately. They should not wait for someone else to report it. It is their responsibility to protect the residents of this facility. If they are unsure about weather, it was a case of abuse or neglect-report it anyways! Protect your residents! It is your job as the abuse coordinator to start the investigation ASAP-and report to state within 2 hours. Make sure staff is aware that they must contact you directly and immediately. Make sure your number is posted with postings, in the breakroom, at the nurse's station, in therapy, in the kitchen-everywhere. If at any time they cannot reach you, they should be instructed to call the DON. Make yourself heard. During an interview on 7/28/23 at 4:15 PM DON stated multiple Care quizzes have been given to multiple employees who attended both in-services. She stated that she has been reviewing the quizzes and all employees have no missed one question. She stated the Medical Director was contacted on 7/27/23 regarding the incidents that occurred and the IJ being called in the facility. She stated that LVNB completed abuse and neglect in-service on 7/23/23. DON will provide 1:1 In-service, written disciplinary actions, and LVNB proficiency checkoff prior to LVNB working the floor again. DON stated in-service has been completed at 7/23/23 and a write up documentation. LVNB came in 7/27/23 to go over proficiencies. She stated that on 7/27/23 she and the administrator received 1:1 in-service from Owner/Operator to cover reporting timeframes. Record review of a completed resident safety survey dated 7/28/23 on all current residents to ensure they feel safe and free from abuse or neglect by 7/28/23. safe surveys were conducted on hall 100 and halls 200, 300, 400 were completed on 7/28/23. Starting 7/31/23, DON/SW will conduct 10 random safe surveys a week for 3 weeks for the residents to ensure that they continue to feel safe and well taken care of. Findings will be discussed at weekly Committee Meetings and at monthly QAPI Meetings. Document included questions such as, have you ever had or felt neglect/abused by any employee or other resident. Record review of Care Quiz revealed all staff that had attended both in-services on 7/28/23 were provided a Care Quiz to complete. Care quiz completed by LVNJ; all answers answered correctly. No issues. Care quiz was created with questions that were from both in-services. Observation three sampled residents (Resident #3, #4 and #5) revealed no signs of pain or abuse. They appear to be carrying their activities of daily living with incident. They said they felt safe and denied abuse staff or other residents. Interviews regarding abuse and neglect training and reporting on 07/28/23 at 3:25p.m through 5: 00p.m revealed no concerns with staff knowledge. Staffs interviewed were representative of various facility shifts. They were able to provide knowledge and participation of training regarding abuse/neglect in-services and training. The following staffs were interviewed on 07/28/23: LVN A, LVNB, ADON C, ADON D, HRE, CNA F, CNA G, CNA H, LVN I, LVN J, LVNK, CNA L, CNA M, Social Worker, and CNA N. They were knowledgeable of types of abuse/neglect and should report any abuse allegations to charge nurse of resident immediately and to the ADM. They all knew Administrator was the Abuse prevention coordinator with DON as the backup if not able to reach ADM. They knew how to get hold of ADM and DON if not in the facility at time. Interview with LVNB (100 hall) on 07/28/23 at 4:30 PM revealed she was in-serviced on 07/25/23 and 07/28/23 on abuse/neglect and reporting. She was asked what she would have done differently looking back at the incident with Resident #1 and Resident#2, and she stated she would follow protocol and nursing judgement and reported the incident immediately. She stated she was terrified on what CNAA could have done to her for reporting her observation. On 07/28/23 at 4:25p.m, the Administrator was notified the IJ was removed. While the IJ was removed on 7/28/23, the facility remained out of compliance at a severity level of actual harm with the potential for more than minimal harm that is not immediate jeopardy, and a scope of pattern because the facility had not had the opportunity to monitor the effectiveness of the Plan of Removal.

Based on observation, interview, and record review the facility failed to ensure necessary treatment and services consistent with professional standards of practice to promote healing of a pressure injury was provided based on the comprehensive assessment for 4 of 4 residents reviewed for pressure injury. (Resident's #1, #2, #3, and #4) The facility failed to implement interventions to prevent pressure wounds for 4 Residents. Resident #1 acquired 3 wounds, wound #1 was to the left gluteal stage 3, Wound #2 was to the sacrum, stage 2, and wound #3 was to the right gluteal stage 2. Resident #2 acquired a stage 2 wound to the right gluteal. Resident #3 acquired a stage 2 wound to the right gluteal. Resident #4 acquired a stage 2 wound to the sacrum. The facility failed to turn and reposition Resident #4 daily. This failure could place residents at risk for developing pressure injuries and worsening pressure injuries. Findings included: Record review of Resident #1's electronic face sheet, dated 4/27/2023 revealed he was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses to include Spinal Stenosis (happens when the spaces in the spine narrow and create pressure on the spinal cord and nerve roots) Muscle weakness, and Constipation. Record review of Resident #1's most recent Quarterly MDS dated [DATE] revealed BIMS of 10, which indicated no cognitive impairment. Record review of Resident #1's care plan revised on 2/23/23 regarding ADL care indicated Resident #1 required total assistance of two staff for transfers and extensive physical assistance of two staff for repositioning. The care plan does not notate refusal of repositioning. Record review of Resident #1's care plan initiated 4/27/23 regarding impaired skin integrity indicated Encourage and assist with frequent positioning to prevent pressure to injuries. Record review of the Weekly Non-pressure log dated 4/10/23 indicated that Resident #1 had shearing to the right gluteal. Record review of the Weekly Skin assessment dated [DATE] indicated that Resident #1 has current skin issues with ongoing treatment, no new areas of breakdown noted. Completed by LVN-C (wound care nurse). Record review of the Weekly Skin assessment dated [DATE] indicated that Resident #1 has current skin issues with ongoing treatment, no new areas of breakdown noted. Completed by LVN-C. Record review of the weekly skin assessment dated [DATE] revealed that Resident #1 had no new skin issues. Completed by LVN-C. Record review of WCP-A wound care notes dated 4/25/23 indicated: Resident #1 had 3 wounds, wound #1 (new) was to the left gluteal stage 3, Wound #2 (new) was to the left back stage 2, and Wound #3 (new) was to the right gluteal stage 2. Record review of the Weekly Skin assessment dated [DATE] indicated that Resident #1 has 3 NEW areas of breakdown, Stage 2 to left back, Stage 3 to left buttock, and Stage 2 to right buttock. Completed by LVN-C Record review of the shower log dated 4/18/23 revealed for Resident #1 bed bath was given with pressure sore notated for sacral area. Record review of the progress notes for March, April, and May 2023 did not contain documentation of Resident #1 refusing care. Orders: Cleanse stage II to left back with wc or ns, pat dry, apply collagen ag and cover with silicone foam one time a day and as needed (order date 4/26/23, start date 4/26/23) Cleanse stage III to left glut with wc or ns, pat dry, apply collagen ag and cover with silicone foam one time a day and as needed (order date 4/26/23, start date 4/26/23) Cleanse stage II to right glut with wc or ns, pat dry, apply collagen ag and cover with silicone foam one time a day and as needed (order date 4/26/23, start date 4/26/23) LAL mattress every shift for multiple pressure injuries (order date 4/26/23, start date 4/26/23) Pressure reducing mattress to bed (order date 9/18/20) Wound Consult by Advantage Surgical and Wound Care as needed (order date 12/15/22) Vitamin C 500 MG (Ascorbic Acid) give 1 tablet by mouth one time a day for wound healing (order date 12/08/22, start date 12/09/22) Measurements from facility notes in cm: L glut 2.5x2x0.1 R glut 3.5x0.5x0.1 Lower back 0.7x0.5x0.1 During an observation on 4/28/23 at 10:47 a.m. Resident #1 was lying on his left side. During an observation on 4/28/23 at 12:19 p.m. Resident #1 was lying on his left side. During an observation on 4/28/23 at 1:46 p.m. Resident #1 was lying on his left side. During an interview on 5/5/2023 at 2:05 PM, LVN-C (Wound care nurse) stated that Resident #1 was a difficult case. She stated that he moved a lot in his bed and does not like to stay in the same position for long at all. She stated that he would refuse repositioning but that was not the biggest issue. She stated that he will reposition himself back to his one side right after being repositioned from the other side to help wound healing. She stated that all 3 of Resident #1's wounds happened very fast. She stated he had some shearing to the back sides of his buttocks upper legs that she had been working on. She stated that the wounds were pretty much healed. She stated that the weekly skin assessment on 4/19/23 and the resident was pretty much healed. She stated on 4/24/23 CNA-D called her to Resident #1's room and the wounds were much worse than they were on 4/19/23. She stated Resident #1 did not just have shearing he had open wounds. She stated she called the wound care physician immediately and staged the wounds over the phone with her based on her observations. She stated she looked at the shower log for that past weekend and the skin evaluation form dated 4/22/23 did not indicate any shearing, redness, or sores to the left or right buttock. During an interview on 5/5/2023 at 11:45 AM FM-L stated based on everything she believes Resident # 1 was not repositioned as much as he should have been. She stated that there were a couple of days when staffing seemed a little short to get to him to do repositioning. She stated he only really likes to lay on one side. She stated so there has been times where the staff had repositioned him and within about 30 mins, he would wiggle himself back to his other side. She stated he would also remove the pillow between his legs that they put there; it takes some time, but he would ultimately remove the pillow. She stated she has never heard facility staff offer education on him repositioning himself or the importance of why not to do it. Resident #2 Record review of Resident #2's electronic face sheet, dated 5/3/2023 revealed she was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes, Difficulty in Walking, and Constipation. Record review of Resident #2's most recent MDS dated [DATE] revealed BIMS of 12, which indicated no cognitive impairment. Record review of Resident #2's care plan revised on 4/17/21 regarding ADL care indicated Resident #2 required assistance of one staff for transfers and extensive physical assistance of one staff for repositioning. The care plan did not notate refusal of repositioning. Record review of Resident #2's care plan revised on 4/17/21 regarding limited physical mobility related to weakness indicated Monitor/document/report PRN any signs or symptoms of immobility: contractures forming or worsening, thrombus formation, skin-breakdown . Record review of Resident #2's care plan revised 4/17/21 regarding impaired circulation indicated to follow facility policies/protocols for prevention of skin breakdown (initiated date 10/26/21) Record review of the progress notes for March, April, and May 2023 did not contain documentation of Resident #2 refusing care. During an interview on 5/1/2023 at 12:00 PM, Resident #2 stated she used to have two wounds on the bottom part of her buttocks on both sides. She stated that one side had fully healed and the other was almost done healing. She stated she really was not sure how or why she got the wounds. She stated the only thing she figures was both wounds from sitting 24/7. She stated she doesn't like a bed and doesn't want one, so she sleeps in her recliner. She stated when she wakes up, she goes directly to her wheelchair. She stated that she was told that she has those wounds on her legs because she sits way too much. She stated she only started getting the wounds when her PT ran out and she sits all the time. She stated no nurses or CNA's come by to ask her if she needed help to reposition or just stand for a little bit. She stated she would if she was asked to or got a little help to do so. She stated the staff seems very rushed or busy to help her though. She stated that the changes by the facility after the wounds were discovered was a cushion for her wheelchair, which she uses all the time. Orders: Resident #2 Cleanse stage II to right glut with wc or ns, pat dry, apply zinc oxide every shift and as needed after incontinent episode or showers (order date 04/05/23, start date 04/05/23) Pressure reducing cushion to wheelchair (order date 03/11/20) Pressure reducing mattress to bed (order date 3/11/20) ROHO cushion to WC every shift for ppx (order date 08/17/22, start date 8/17/22) Wound Consult by Advantage Surgical and Wound Care as needed (order date 8/9/22) Measurements from facility notes in cm: R glut 1x1x0.1 During an observation on 5/3/2023 at 10:36 AM, Resident #2 was sitting in same position in her wheelchair, pressure fully on butt and both upper thighs. During an observation on 5/3/2023 at 12:28 PM, Resident #2 was sitting in same position in her wheelchair, pressure fully on butt and both upper thighs. During an observation on 5/3/2023 at 2:37 PM, Resident #2 was l sitting in same position in her wheelchair, pressure fully on butt and both upper thighs. Resident #3 Record review of Resident #3's electronic face sheet, dated 5/3/2023 revealed he was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes, Dementia, and Dysphagia (medical term for swallowing difficulties). Record review of Resident #3's most recent Quarterly MDS dated [DATE] revealed BIMS of 13, which indicated no cognitive impairment. Record review of Resident #3's care plan revised on 12/11/19 regarding ADL care indicated Resident #3 required assistance of two staff for transfers. It does not notate refusal of repositioning. Record review of Resident #3's care plan revised 9/8/21 regarding at risk for skin integrity impairment indicated Follow facility policies/protocols for skin/wound prevention/treatment. Record review of Resident #3's care plan revised 3/8/23 regarding impaired skin integrity indicated Encourage/assist frequent re-positioning avoiding pressure to injury sites. (initiated 12/20/18) Record review of the progress notes for March, April, and May 2023 did not contain documentation of Resident #3 refusing care. During an interview on 5/3/2023 at 12:15 PM, Resident #3 stated that he can't really reposition in his chair on his own. He stated that the couple times he had tried he has fallen out of the chair. He stated he has requested for help to reposition in his chair, but he was either told they would get to him shortly or they never come back to him. He stated he does feel the wound should have been prevented if he didn't sit in his chair all day long and got a little help from the staff. Orders: Resident #3 A+D to bilateral lower legs and buttocks Q shift and PRN incontinent care every shift for dry skin red buttocks (order date 12/21/21, start date 12/22/21) Cleanse stage II to sacrum with wc or ns, pat dry, apply collagen and cover with silicone with foam as needed if comes off or becomes soiled (order date 4/18/23, start date 4/18/23) Cleanse stage II to sacrum with wc or ns, pat dry, apply collagen and cover with silicone with foam one time a day (order date 4/18/23, start date 4/19/23) Low air mattress to help prevent further skin breakdown (order date 7/9/22) Pressure reducing cushion to wheelchair (order date 12/21/21) Wound consult by Advantage Surgical and Wound Care as needed (order date 8/9/22) Measurements from facility notes in cm: Sacrum 0.2x0.2x0.1 During an observation on 5/5/2023 at 10:14 AM Resident #3 was sitting in the same position in his wheelchair, pressure fully on butt and both upper thighs. During an observation on 5/5/2023 at 11:48 AM Resident #3 was sitting in the same position in his wheelchair, pressure fully on butt and both upper thighs. During an observation on 5/5/2023 at 1:03 PM Resident #3 was sitting in the same position in his wheelchair, pressure fully on butt and both upper thighs. Resident #4 Record review of Resident #4's electronic face sheet, dated 5/3/2023 revealed he was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes, Pulmonary Disease, and Osteoarthritis. Record review of Resident #4's most recent Quarterly MDS dated [DATE] revealed BIMS of 15, which indicated no cognitive impairment. Record review of Resident #4's care plan initiated on 4/17/20 regarding ADL care indicated Resident #4 required assistance of one to two staff for transfers (revised 7/25/20) and extensive physical assistance of one staff for repositioning. Record review of Resident #4's undated care plan regarding ADL care indicated Resident #4 does not notate refusal of repositioning. Record review of Resident #4's care plan initiated on 4/17/20 regarding limited physical mobility related to weakness indicated to monitor/document/report PRN any signs and symptoms of immobility: contractures forming or worsening, thrombus formation, skin-breakdown. Record review of Resident #4's care plan initiated on 9/23/22 regarding potential for further alteration in skin integrity impairment indicated to Check resident for incontinence frequently and provide peri care as needed. Keep skin clean and dry, Record review of the progress notes for March, April, and May 2023 did not contain documentation of Resident #4 refusing care. During an interview on 4/28/2023 at 11:45 AM Resident #4 stated he stayed in his wheelchair pretty much all the time. He stated he probably got his wounds from sitting on his butt all day. He stated he wouldn't mind if staff were to help him get up a little each day or work with him in his chair to reposition. He stated staff does not come and ask him if he wants to be repositioned. Orders: Resident #4 Cleanse stage II to right glut with wc or ns, pat dry, apply collagen sheet and hydrocolloid drsg one time a day every other day and PRN if comes off or becomes soiled (order date 4/12/23, start date 4/13/23) Pressure reducing cushion to wheelchair every shift (order date 12/24/19, start date 12/24/19) Wound Consult by Advantage Surgical and Wound Care as needed (order date 9/13/23) Multivitamins-Minerals Tablet give 1 tablet by mouth one time a day for wound care (order date 11/09/21, start date 11/09/21) Vitamin C Tablet 500 MG (Ascorbic Acid) Give 1 tablet by mouth one time a day for wound healing (order date 03/01/23, start date 03/02/23) Measurements from facility notes in cm: R glut 0.4x0.6x0.2 During an observation on 5/12/2023 at 11:14 AM Resident #4 was sitting in the same position in his wheelchair, pressure fully on butt and both upper thighs. During an observation on 5/12/2023 at 12:48 PM Resident #4 was sitting in the same position in his wheelchair, pressure fully on butt and both upper thighs. During an observation on 5/12/2023 at 2:03 PM Resident #4 was sitting in the same position in his wheelchair, pressure fully on butt and both upper thighs. During an interview on 4/27/2023 at 10:45 AM, the DON stated that some of the residents do refuse to be turned or repositioned. She stated that any time this occurs, the nurse/aid was to notate refusal in progress notes of the nursing system. She stated Resident #1 has been known to refuse being repositioned as well as Resident #4. She stated she was not exactly sure how residents were getting wounds. She stated that the wound care nurse (LVN-C) was outstanding and did a great job. She stated the facility has more of a preventative care to wounds issue then a restorative care issue. She stated that once the wounds are discovered they are healed. She stated that Resident #1 was also known to reposition himself after being repositioned. She stated he does not like to lay on his right side. During an interview on 4/27/2023 at 12:25 AM NP-B stated that she has been monitoring all residents and Resident #1 has been one on her radar. She stated that Resident #2, Resident #3, and Resident #4's wounds could have been prevented through repositioning. She stated those residents need to move more and not be in their wheelchairs all day. She stated she doesn't really offer to reposition the residents in wheelchairs because she feels they should be able to reposition themselves. She stated that the expectation is that all residents are to be repositioned every two hours. During an interview on 4/27/2023 at 5:30 PM LVN-C stated as far as the wounds go, she believes that Residents #2, #3, and #4 were all completely preventable. She stated that the residents can be put on all the supplements in the world but if the staff don't reposition them or turn them, help them get up, whatever, it won't make a difference. She stated that when she is around it looks like the staff is doing their jobs but she is technically in a management position so she knows that might make them act busy around her. She stated that as the wound care nurse she has done education with staff about turning/repositioning residents and in-services on skin, but she is not sure what the DON and Administrator have done. She stated the expectation is residents are to be repositioned every two hours. She stated she doesn't really do a lot of reposition rounding because she works on the wounds in the facility pretty much all day long. During an interview on 4/28/2023 at 6:10 AM CNA-D stated that there are a few residents she works very hard to keep cleaned, repositioned and no skin break down. She stated but when the other aid works or staff call in and there is not enough, residents are laying on their backs instead of repositioned, soaked from head to toe in urine and form wounds. She stated the expectation is to reposition residents every 2 hours. She stated this really doesn't always happen. She stated that she may just get to busy to be able to get to all of the residents. She stated she knows she needs to get to every resident because it can cause wounds but sometimes is just not possible. During a phone interview on 5/5/2023 at 10:30 PM WCP-A stated that the Residents #1-4 wounds could have been prevented. She stated that even though Resident #1's wounds came on rapidly, they also could have been prevented. She stated Residents #2-4 need to be moved out of their wheelchairs to really help from getting the wounds on their buttocks and back of thighs. She stated that on multiple occasions, when she was at the facility to do wound care rounds, she had to wait for a good while before anyone could be tracked down to come help her move a resident or help her with a resident in general. She stated this could explain some of the facility acquired wounds within the facility. stated that all wounds were a case-by-case basis. She stated Residents #2, #3, and #4 wounds could have been prevented by repositioning or getting the residents up and moving them. She stated in the care of Resident #1, 4/25/23 was the first time she had ever seen the resident. She stated that LVN-C did call her on the 4/24/23 to discuss the new wounds found on Resident #1, the wounds described over the phone to her by LVN-C were two stage 2 wounds and one stage 3 wound. She stated that on 4/25/23 when she went to the facility to assess the resident, she did confirm that the resident had 2 stage two wounds and one stage three. During an interview on 5/16/23 at 3:15 PM, DPT-G stated that Residents #1-4 were on PT. She stated Resident #2 was on PT but it ended on 4/14/23. She stated that all residents do need assistance. She stated that Resident #3 can maybe wiggle but he needed assistance to adjust and reposition. She stated that Resident #2 was roughly the same probably could wiggle or reposition but really should have assistance to do so. She stated that Resident #1 was a full assist to move and reposition. She stated that Resident #4 would need assistance to move or reposition in his wheelchair. She stated that the wounds were all associated to the lack of movement in general. During an interview on 5/16/23 at 2:55 PM, the DON stated that she was not exactly sure where the wounds were coming from. She stated that there does seem to be an issue in the preventative care vs the restorative care. She stated that the facility's restorative care was perfect, but the prevention of the wounds seems to be an issue. She stated she was not sure if it really comes down to staffing or employees not doing tasks. She stated that when she was at the facility staff seemed very busy and things were getting done, but the residents were still getting wounds. She stated that Residents #2, #3, #4 were all in their wheelchairs pretty much all day long. She stated that she was not sure if staff were assisting them with repositioning or not. She stated that all residents whose care plans state repositioning were to be repositioned every two hours. She stated that this even includes residents who were in their wheelchairs all day long. During an interview on 5/5/23 at 2:20 PM, the ADMIN stated that he feels the wounds within the facility were more related to newer staff that complete everything they were supposed to do but maybe don't do it as well as they should be doing it or as thoroughly. He stated he was not sure if they were rushing through their task. He stated repositioning concerns would be a nursing staff issue and the DON would handle this issue. Record review of the facility's Un-dated Wound Prevention Program Policy: The purpose of this program is to assist the facility in the care, services and documentation related to the occurrence, treatment, and prevention of pressure as well as, non-pressure related wounds. 4. All residents will have the following nursing care procedures implemented: b. Activity- i. As tolerated by the resident encourage ambulation and out of bed activity c. Pressure Relief- ii. As tolerated by the resident encourage mobility iii. As needed position and reposition the resident with pillows and other supportive devices,

Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care, which included tracheostomy care and tracheal suctioning, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #1) reviewed for respiratory and tracheostomy care. On [DATE], the facility failed to ensure that suction supplies were readily available at Resident #1's bedside and on the crash cart when she required suctioning and experienced sudden decreased oxygen saturation. Due to the rapid deterioration in her condition, she was transferred to the emergency room by ambulance where she later died with diagnoses of a collapsed right lung and cardiac arrest. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:19 PM. While the IJ was removed on [DATE] at 6:40 PM, the facility remained out of compliance at a scope of isolated with a severity of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could affect residents with a tracheostomy by placing them at risk of a delay in receiving life-saving treatment which could result in serious injury including death. The findings included: Review of Resident #1's Admission Record dated [DATE] revealed she was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dysphagia (difficulty swallowing), and tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow direct access to the breathing tube and is commonly done in an operating room under general anesthesia) status. Review of Resident #1's Five-day MDS Assessment, dated [DATE] revealed: She did not speak but was able to understand and make herself understood. Her mental status exam scored a 15 of 15 (indicating she was cognitively intact). She needed limited assistance for ADLs including eating. Review of Resident #1's Care Plan, initiated [DATE] revealed: Issue: Resident is at risk for aspiration due to presences of tracheal stoma and neck trauma related to esophageal cancer. Goals: Resident will maintain patent airway and risk for aspirations will decrease as a result of ongoing assessments. Interventions included: Auscultate bowel sounds to evaluate bowel motility; Keep suction setup at bedside at all times; Maintain upright position ,d+[DATE] minutes after meals; Notify MD immediately of noted decrease in cough and/or gag reflex or difficulty swallowing. Resident #1's Initial Care Plan, dated [DATE] revealed she had a cuffless Tracheostomy at 6 mm. Review of Resident #1's Order Summary Report, dated [DATE], revealed: Order dated [DATE] Trach care every shift and as needed. Order dated [DATE] Suction trach every shift and as needed. Order dated [DATE] oxygen at 2 liters per minute as needed. Order dated [DATE] albuterol sulfate via nebulizer (breathing treatment) every 4 hours as needed. Review of Resident #1's Nurse's Notes , revealed the following: Nurse's Notes [DATE] at 4:56 p.m. LVN J wrote: Received this [AGE] year-old female to facility. Resident was awake, alert, with even and non-labored respirations to room air. Resident has Tracheostomy, no Tracheal Tube in place. Stoma (opening) is bruised, with no drainage noted. Lung sounds are diminished. Has order for antibiotic for five days for bronchitis. Alert, oriented, no speech understands what is being said to her, writes down answer to questions answered. Nurse's Note dated [DATE] at 11:35 p.m. LVN L wrote : Nurse attempted to install current Tracheostomy tube in resident's stoma. Resident #1 refused due to size of tube. Resident #1 said that the tracheostomy tube we have is way too big. She said that her doctor ordered her size and that will arrive tomorrow. Nurse's Note dated [DATE] at 4:24 a.m. LVN L wrote: Resident knocking on her bedside table to get nurse's attention. Upon entering her room, writer noted Resident #1 showing signs of shortness of breath. Nurse asked her if she wanted to go to the hospital and she nodded her head yes. Nurse contacted EMS and attempted to call her family. Resident sent to emergency room via ambulance. Nurse's Note dated [DATE] at 2:40 p.m. LVN M wrote: Resident arrived at the facility via facility van, alert and oriented and no complications at this time. Oxygen saturation at 96%. Nurses Note dated [DATE] at 3:43p.m. DON wrote: went to welcome and assess new resident with charge nurse. Resident was alert and oriented. Resident was sitting in a 60-degree angle without her trach mask on. Oxygen saturation at 94% on room air. Resident educated on keeping her trach mask on with oxygen on and to not pick at her stoma on her neck. Resident wrote on a piece of paper I know and smiled. Nurse's Note dated [DATE] at 11:12 a.m. DON wrote: Resident noted lying in bed with head of bed at 45-degree angle. Trach mask was not on resident. It was noted to be hanging on the side rail. New Tubing placed and educated resident on keeping the trach mask on. Resident smiled and mouthed I know. Nurse's Note dated [DATE] at 8:11 a.m. DON wrote: Resident noted lying in bed with head of bed less than 30 degrees and trach mask on bed rail. Educated resident to keep head of bed more than 30 degrees and to wear the trach mask. Resident mouthed I know and sat up slowly to side of bed. Nurse's Note [DATE] at 11:18 a.m. DON wrote: Resident noted lying in bed without trach mask on. Oxygen 94% on room air. Doctor notified of noncompliance of mask with resident. Continuous oxygen changed to oxygen as needed. Resident notified and smiled and mouthed I know. She wrote on paper that she really did not use it at home either. Resident educated on pressing the call light button for assistance if she feels short of breath or in any distress. Resident mouthed I will. Nurse's Note dated [DATE] at 1:45 p.m. LVN D wrote: CNA notified nurse of resident having difficulty breathing. Upon entering room, Resident #1's oxygen mask was not on. It was hanging on the bed and head of bed was less than 30 degrees. Patient education had been implemented of the importance of keeping oxygen in place and keeping head of bed above 90-degree angle. This nurse placed oxygen mask back over trachea and raised head of bed and assessed oxygen level which read at 75% upon assessment, resident was noted in distress. Nurse asked resident if she could breathe at all and she used a hand gesture motioning so/so. Called for assistance, oxygen dropped to 35% with oxygen in place, (nurse) left room to grab crash cart. Ambulance called. Oxygen was dropping but pulse still present reading at 77 and pulse was palpable. Attempted to suction with little success. EMT arrived, assessed resident, and took over care, used ambu-bag. Resident aspirated and EMT placed her on stretcher to transfer her to ER for evaluation. Review of Resident #1's hospital records revealed the following: Resident #1 was admitted [DATE] and discharged [DATE]. HPI: Chief Complaint Patient Presents with: Cardiac Arrest; Respiratory Distress Patient is a [AGE] year-old with past medical history listed below who presents to the emergency department via EMS in cardiac arrest (her heart stopped beating). Upon arrival to the emergency department, patient did not have her tracheostomy device in place. The patient was being bag-valve-masked (mask placed over a patient's mouth to forcibly push air into the lungs when they are unable to breathe on their own) orally upon arrival. CPR was in progress via [NAME] device (machine that did CPR compressions). ACLS (Advanced Cardiac Life Support interventions including CPR, medications and defibrillating or shocking a patient to restart their heart) was then taken over by me. PEA (pulseless electrical activity - condition in which the patient's pulse could not be felt but the cardiac monitor continued to register some electrical activity) on the monitor during first pulse check. Patient was subsequently intubated (breathing tube inserted into the windpipe) through her tracheostomy stoma with a ETT (endotracheal tube or breathing tube) over a [NAME] (device used to help guide the insertion of a breathing tube). Patient had ROSC (return of spontaneous circulation - the restart of a sustained heart rhythm after cardiac arrest) after two rounds of ACLS. Patient went into asystole approximately 10 minutes later and ACLS was initiated. Patient had return of spontaneous circulation after two rounds. CT angiogram (an imaging test that looks at the arteries that supply blood to the heart) of the chest performed on [DATE] showed moderate right pneumothorax (collapsed lung) and mild pneumomediastinum (air in the space between the lungs and around the heart). Troponin I (protein found in the muscles of the heart not normally found in the blood, when the heart is damaged, troponin is sent into the blood stream) was 177.3 pg/ml (normal range is between 0 and 0.04 pg/ml) indicating a heart attack. Assessment: 67 y.o. female .recently in hospital for pneumonia then sent after skilled nursing facility p/w cardiac arrest with prolonged code (medical emergency in which a patient requires resuscitation) and anoxic (without oxygen) brain injury. Problem List: Right Pneumothorax POA: Yes Plan: Cardiac Arrest: With possible anoxic injury, patient was a DNR by her request prior to the event. Given her multiple medical comorbidities (two or more diseases or medical conditions) and declined health and her DNR family wanted to move forward in withdrawing care. Patient to be placed on palliative (form of medical care focused on relieving symptoms without dealing with the cause of the condition) orders and extubated (breathing tube removed). Patient was extubated by day RT at an unknown time. Call placed to hospitalist (doctor employed by the hospital) on [DATE] at 2:16 AM for notification of patient expiration (death). At the time of death Resident #1's diagnosis was right pneumothorax and cardiac arrest. Interview on [DATE] at 5:04 p.m. LVN D confirmed she was Resident #1's nurse on the day shift of [DATE]. LVN D described Resident #1 as noncompliant with her oxygen and would frequently lower the head of her bed; she said Resident #1 was non-verbal but could communicate with notes or mouthing the words. LVN D reported Resident #1 was supposed to be on continuous oxygen. LVN D stated CNA C came to her (LVN D) around 1:30 p.m. and reported Resident #1 could not breathe and needed to be suctioned. LVN D said she went to check on Resident #1. LVN D stated the last time she worked with Resident #1 there was suctioning equipment available in her nightstand drawer. LVN D said she checked the drawer, where the suction catheters were usually stored, and the suction catheter was not there. LVN D reported she sat Resident #1 up, put her oxygen on her and hoped it would help but it did not. LVN D stated she checked the drawers, the closets and there was no suction catheter available. LVN D said she called 911 at 1:45 p.m. on her personal phone while she checked the supply closet for suction catheters, then she went to the nurse's station to print Resident #1's face sheet and physician orders. LVN D recalled she returned down the hallway with the crash cart (cart all facilities have for emergency supplies if someone who is a full code needed emergency services). LVN D stated that she was unable to locate a suction catheter on the crash cart after she got to Resident #1's room with the cart. LVN D stated she called her chain of command but no one on answered. She said all the other clinical staff were also looking for the suction catheters. LVN D said while she was doing this, she tried to call everyone she could think of, but no one answered until finally ADON G answered the phone. LVN D stated by the time ADON G answered Resident #1 was not breathing and turning blue. LVN D stated the other nurses found a tube to suction Resident #1 with. LVN D said the tube was thick. LVN D stated LVN E found whatever tubing was used to suction Resident #1 on the crash cart and she was not sure what it was. During the interview on [DATE] at 5:04 p.m. , LVN D said after Resident #1 was taken by EMS, she sat down at the nurses' station and found the bag of suctioning supplies, but it was not labeled and not put up. LVN D stated the only thing that was significant about [DATE] was the facility was short of nurses and ADON F was on call but would not answer the phone, but the night nurse from the previous evening stayed until noon to help cover the additional hall. She said the weekend RN had called in sick to work that day. LVN D said she never worked with a resident with a Tracheostomy before Resident #1 was admitted to the facility. LVN D said she was not comfortable with the situation but did not say that at the beginning of the shift. She said the other nurses were as new as she was. LVN D said she worked with Resident #1 two days prior and there were plenty of supplies (suction catheters). She said this was her first resident code as a nurse. During the interview on [DATE] at 5:04 p.m., LVN D said the facility had a respiratory therapist come in [DATE] to give an in-service, but that was it. LVN D said she asked the DON for a refresher after Resident #1 was admitted , but all the DON did was give her the handout from the presentation. LVN D stated she messaged ADON G about it and ADON G walked her through it on [DATE]. LVN D said she did not know what she would do differently since no one was answering the phone and she did not know what to do. She said she had not been in those situations before and all she knew was to call her bosses. She said she wished she was more aware of her surroundings to know the supplies were at the nurse's station. LVN D stated she wished she insisted on getting the additional training. At that time, LVN D said the night nurse suctioned Resident #1 the night before but did not communicate the facility was running low on supplies. LVN D said this was her first job as an LVN and her orientation at the facility was three days of training. She recalled the first day she watched the RN do everything; the second day the RN watched her do everything she could do; and the third day she was just watched. LVN D confirmed she was oriented to where the supplies were. She said she thought the nurse who signed for the suctioning equipment got busy and forgot about it . LVN D said she did not know who was responsible for putting up equipment, she assumed whichever nurse signed for it. LVN D stated she was informed of changes of condition on the residents by the 24-hour report or could get on the facility's documentation program. Interview on [DATE] at 5:54 p.m. LVN E confirmed she worked on the day shift on [DATE] . She stated she was working on the 200-hall when she heard LVN D needed help suctioning Resident #1. LVN E said she overheard the staff say they could not find a suctioning catheter and she (LVN E) went to check the storage room. LVN E stated she found aides in there also looking for the suctioning catheters. LVN E stated she knew what the catheter equipment looked like, so she checked and there were not any in the storage room, Resident #1's closet, Resident #1's drawer, or in the equipment bag over Resident #1's head. LVN E stated she tried to tell the aides what the suctioning equipment looked like. LVN E stated she sat Resident #1 up a little higher to see if that would help her breathe a little bit. LVN E disclosed that no one found the suctioning equipment, but she could not remember who said to use a different type of tubing. LVN E described the tubing as having a cover to keep it sterile, but it was not the suctioning catheter. LVN E said the nurse (LVN D) started suctioning Resident #1 and it was working and then the EMTs arrived. LVN E said she remembered Resident #1 oxygen saturations dropped to 30%. LVN E said Resident's #1's oxygen dopped really quick and Resident #1 turned purple as time went on. LVN E said Resident #1 was not coherent or responsive. LVN E said she could not remember anything else because it was traumatizing to watch someone go from walking to essentially suffocating. During the interview on [DATE] at 5:54 p.m., LVN E stated she knew that there was correct suctioning equipment in the building, but no one had communicated with the nurses on duty as to where it was. She stated the correct suctioning catheter looked skinny or thin and was covered by plastic to keep it sterile and had numbers on it. She stated in the packaging it was approximately 6 inches by three inches and when taken out of the bag it was long. LVN E explained there was a thumb hole on the tubing and a wider part that attached to the machine. LVN E stated she was comfortable taking care of residents with tracheostomies because she did so in her previous job. LVN E said the suction catheters were supposed to be stored in the storage room with the rest of the suctioning supplies, but it was at the nurse's station, and no one told them. LVN E stated she thought it should be at the Resident's bed side and not just a catheter. She stated I thought we were supposed to have the catheter on the crash cart at all times for emergencies and I found it weird that it wasn't available. LVN E stated she did not receive any in-services on taking care of tracheostomy residents before Resident #1 was admitted to the facility. She said she did not know where the facility policy was about taking care of residents with tracheostomies. LVN E said there's probably a book somewhere but she was not made aware of where it was. She said she did not know what was expected of her, but she did her best to provide the care she could. During the same interview, LVN E said the only other thing unusual about [DATE] was they were short staffed, so all the nurses had to take an additional ten residents each. She said they called all the management, and no one would come in because they were all out of town. LVN E said the DON came in after 4 p.m. after everything happened. During the interview with LVN E on [DATE] at 5:54 p.m., LVN E stated the only way to know about changes of conditions in residents was to check the 24-hour report book. She said the nurse on the off-going shift was supposed to have written down any new change and it was in the computer. LVN E said she felt it was effective for the most part. Interview on [DATE] at 9:12 a.m. LVN D stated she used what LVN E told her to use to suction out Resident #1. She said she did not know what kind of tubing was used but it was some kind of catheter. LVN D shared it was on the crash cart and was a clear tube. Interview on [DATE] at 9:15 a.m. LVN E said she was not sure what kind of tubing was used to suction Resident #1 because she never got the name of it. She stated the staff had to cut something off the top and it looked like it could go on a breathing treatment or something like that. LVN E said she could not recall whose idea it was to cut off the tip because everything was just so chaotic. LVN E stated she believed the tubing was found in Resident #1's room but it was not the correct suctioning catheter Resident #1 needed. LVN E repeated she did not remember, but it had the protective thing covering the tubing, so it did not fit the suctioning machine. LVN E stated the tubing did not fit on the suctioning machine and the staff had hold it with their hands to create the suction needed. LVN E said when the staff held the tubing on, it did create suction. Interview on [DATE] at 3:01 p.m. CNA A confirmed she worked the day shift on [DATE] . She said she came in from outside around 1:30 PM and the housekeeper said everyone was on Hall 4 and the nurse was worried. CNA A stated she went to Resident #1's room. CNA A said the nurse called 911 and started looking for something small and got something and got the crash cart. CNA A said she heard that Resident #1 needed to be suctioned and she (CNA A) and LVN D went to find the right suctioning piece. CNA A stated common sense says the suctioning piece should have been there; the night nurse told the day shift she suctioned Resident #1. CNA stated we (the staff) tried to find a suction piece and could not. CNA A stated that she looked in both supply rooms and in the closet in Resident #1's room for the suction catheter. CNA A stated LVN D brought the crash cart to Resident #1's room when Resident #1's saturation started dropping. She stated the ambulance had already been called and she went to the door to wait on them. CNA A reported when the EMTs arrived at the facility she let them in and told them they needed to hurry. CNA A shared she sat with LVN D after and the LVN was pissed off because the suctioning equipment should have been in the room and LVN D later found it at the nurse's station. CNA A said the suctioning supplies were not labeled and it just looked like a bag of basic medical supplies CNA A stated she thought the suctioning supplies came in on [DATE]. CNA A stated it was a high adrenaline situation so something things were not as clear as others. CNA A stated she did not see the nurses suction Resident #1 during the incident and she was not able to describe the tubing that was used. Interview on [DATE] at 3:57 p.m. CNA B confirmed she worked the day shift on [DATE] and she was one of the aides assigned to Resident #1's hall. CNA B stated Resident #1 had been in the facility for a week. CNA B said Resident #1 was capable of using the call light and since Resident #1's roommate was a high fall-risk, the aides checked the room often. CNA B revealed Resident #1 was independent with ADLs. CNA B stated on [DATE] around 1:30 p.m. Resident #1 activated her call light and CNA B and CNA C went into Resident #1's room. CNA B said CNA C asked Resident #1 what she needed, and Resident #1 pointed at her throat indicating she wanted her trach suctioned. CNA B stated Resident #1 seemed fine. CNA B said she informed LVN D and LVN D came to the room. CNA B said LVN D put the pulse oximeter on Resident #1's finger and tried to get the suction machine ready. CNA B said the suctioning machine and equipment was on the bedside table but the suction catheter was not. CNA B stated LVN D checked the nightstand drawer and the closet, but the suction catheter was not there. CNA B reported she (CNA B) and LVN D noticed Resident #1's oxygen saturations dropping on the pulse oximeter so LVN D called the ambulance and went out of the room to look for the suction catheter. She said as soon as Resident #1's oxygen saturation dropped to 45%, she (CNA B) started hollering she needed a nurse because she did not know if Resident #1 would run out of oxygen. CNA B said the lowest Resident #1's oxygen saturations got was 30%. CNA B said LVN D asked the other nurses for help. CNA B reported she stayed in the room with Resident #1 and was holding the pulse oximeter on her finger to keep track of her oxygen levels and was holding the oxygen mask to Resident #1's tracheostomy hole so it would help her breathe but the oxygen saturations kept dropping. CNA B said while LVN D called report into the EMT, she believed the other nurses continued to look for the equipment . CNA B said LVN D called everyone and finally got ahold of someone. CNA B said LVN D returned with the crash cart and was told to use a catheter tube as a suction, and they cut it to make it work. CNA B stated then the EMTs arrived, and the staff stepped back. CNA B said she did not know why the suction catheter was not available - if the nurse blanked or what . CNA B said as an aide she monitored for build up for fluid; she said the aides had received some training on tracheotomy care but did not remember when. CNA B clarified that LVN D called 911 as soon as something went wrong. CNA B said the nurses were able to find the piece for suctioning the mouth (yankauer) but could not find what Resident #1 needed and on call told them to use a catheter and it worked. Interview on [DATE] at 4:23 p.m. CNA C confirmed she worked the day shift on [DATE] on Resident #1's hallway. CNA C stated Resident #1 ate in her room and after the meal she was fine, and her color was good. CNA C remembered after lunch trays were picked up Resident #1 activated the call light and tapped her chest communicating that she needed to be suctioned. CNA C said she asked Resident #1 if she needed to be suctioned and Resident #1 nodded 'yes'. CNA C reported at that time, Resident #1 looked normal and was not in distress . CNA C said she told the nurse (LVN D). CNA C said LVN D went into the room and checked the oxygen saturation, and she believed it was at 87%. CNA C said she sat next to Resident #1 and rubbed her back to comfort her and Resident #1's oxygen saturation went down to 77%. CNA C said every time she looked at the oximeter, Resident #1's oxygen saturations went down. CNA C stated LVN D checked the drawer, and the suction end was not in there, she said she (CNA C) went and checked the supply room but did not find anything. CNA C reported she told the 'other nurses present' that LVN D needed help while she was looking for the hose. CNA C said LVN D got the crash cart, and she (CNA C) still could not find the piece she needed. CNA C said LVN D said she found something that worked a little bit about the time the EMTs showed up. CNA C stated she did not know why the equipment was not in the room. CNA C shared she never worked with anyone with a tracheostomy and the staff were reluctant to work with her. Interview on [DATE] at 10:22 a.m. the NP stated she was informed on [DATE] by the DON that Resident #1 started getting hypoxic with her oxygen saturations dropping, the nurse called EMS, and the resident passed in the ER. The NP answered the expectation for tracheostomy care was the DON called in an RT to come do an in-service with the staff. The NP said she was responsible for Resident #1's care. The NP stated she saw Resident #1 the week prior to [DATE] and Resident #1 was alert and calm. The NP stated Resident #1 communicated with a board and was stable, stubborn, and noncompliant with care by constantly sticking her (Resident #1's) finger in the ostomy (hole in Resident #1's throat). The NP said she did not know if there was a specific protocol for tracheostomy care. She stated the expectation for supplies was it was supposed to be at bedside. The NP explained Resident #1's tracheostomy equipment looked different than what the facility normally saw. The NP said Resident #1 only used her breathing treatments and humidified air. The NP stated Resident #1 refused to wear a tracheotomy cuff. The NP stated the facility asked her (the NP) to double check Resident #1's equipment because it was different than what was usually used. The NP stated there should be suctioning cannula always at bedside and she thought Resident #1 did her own suctioning. The NP said she never saw Resident #1 do her own suctioning. The NP said it was hard to say if the missing suctioning cannula contributed to Resident #1's death because Resident #1 had a recent respiratory infection. She said there was nothing else to her knowledge that staff could have used to safely suction Resident #1 . The NP said she did not know if the proper suctioning materials would be expected to be on the crash cart or not, she thought for a minute and said not really because it was not something the facility dealt with. The NP said Resident #1 being hypoxic would have happened regardless and there was no way to tell if suctioning would have prevented the hypoxic episode. Interview on [DATE] at 10:53 a.m. the DON confirmed she was aware of Resident #1 and her care. The DON said Resident #1 asked her (the DON) if she could do her own suctioning and the DON told Resident #1 that the nurses had to do it. The DON said the nurses performed suctioning for Resident #1 and they provided breathing treatments. The DON said Resident #1 would not wear an inner cannula and was non-complaint with her oxygen use because Resident #1 did not wear it all the time at home . The DON said the facility felt they were able to meet Resident #1's care needs. The DON stated ADON F was on-call and there was an RN scheduled to be in the building, so she went out of town. She stated on [DATE] when the facility was short staffed, the nurses called ADON F who could not come into work. The DON said the nurses called all the other nurses they knew to come in and help; she said the nurses called multiple people and no one was available to cover. The DON stated she started calling people mid-morning of [DATE]. The DON said during the day shift, the facility liked to run four nurses plus two medication aides to assist with medications. The DON said she was unable to find coverage, so she started driving to the facility, but she was a few hours away. The DON said the RN had not come in yet. The DON said there was a rotation for the on-call nurse, for the nurse managers and the expectation was if someone called in sick the on-call nurse was to cover the spot. She said her expectation was if the facility called the on-call nurse, that the on-call nurse was to get into the building. During the interview with the DON on [DATE] at 10:53 a.m., she said she was on the phone with ADON G when LVN D called. The DON checked her phone records and said it was 1:43 p.m. on [DATE] when LVN D called. The DON stated she asked ADON G what was wrong and ADON G told her she was not sure; the DON asked ADON G if the ambulance was called, and she (ADON G) said yes. The DON reported LVN D was frantic and hung up on them (the DON and ADON G). The DON stated LVN D mentioned that there was no suctioning equipment available; the DON told LVN D that it was in the drawer. The DON said they (ADON G and the DON) after everything calmed down and LVN D told them she (LVN D) was unable to find anything. The DON said her expectation for tracheostomy care was the nurses checked the drawer for tubing and to replace what they used. The DON informed surveyor there was no one staff specifically designated to check and re-fill the suctioning catheters. The DON said that practice did not work very well on [DATE] because LVN D was unable to find anything. The DON guessed that the night staff did not replace the catheters used. The DON said the drawer was full on [DATE] and there were at least five suctioning kits available. The DON said the catheters were supposed to be used once and thrown away. The DON said the Administrator ordered the right catheters from someone local to make sure the facility had some available and there were ten kits delivered on [DATE] or [DATE]. The DON stated she was not sure where they went after they were delivered. The DON said the staffing coordinator was responsible for ordering equipment but not putting it up because we all help each other. The DON said there was a list of equipment that was supposed to be in the supply room, and it needed to be checked at least once a week. During the interview with the DON on [DATE] at 10:53 a.m. she said typically a yankauer catheter was available to suctioning on the crash cart. (A yankauer catheter is a hard, inflexible tube used to suction fluids from the mouth). The DON said the staff did not use a yaunker catheter. The DON said she was still trying to figure out what the staff used to suctioning Resident #1. The DON said the crash cart was checked for suctioning equipment once weekly by one of the ADONs and the night staff completed a nightly audit. At that time, the DON said training given to the staff about tracheostomy care was a Respiratory Therapist came in [DATE]. The DON said the facility did not have anyone on a tracheostomy at that time and the RT brought a mannequin with tracheostomy kits. The DON said the RT brought tracheostomy care kits and reviewed with the staff how to clean the site and how to suction the resident. The DON said the staff just sat around and watched the nurses. The [TRUNCATED]

Based on interview, observation, and record review, the facility failed to ensure each resident was free from neglect for six (Resident #3, #7, #8, #9, #10, and #11) of nine residents reviewed for neglect related to the facility's inaccurate wandering/elopement tracking system. The facility failed to provide supervision for Resident # 3, who has a history of exit seeking behaviors, to prevent him from eloping from the facility on [DATE]. The facility was unaware the resident had cut off his wander guard and exited the facility at an unknown time after supper, and as a result, the resident made it 44 miles to his family's home before the facility was contacted regarding his whereabouts. The facility failed to ensure Resident #7 was listed in the Wander Guard Book (book with a list of wandering/elopement risk residents with picture and profile of the resident) per facility policy and had orders for her Wander guard. The facility failed to ensure Resident #8's, #9's, and #10's Wander guard was not expired, and Wander/elopement assessments were completed per facility policy. The facility failed to ensure Resident #11 was listed in the Wander guard Book per facility policy. An Immediate Jeopardy was identified on [DATE]. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and at a scope of pattern because the facility was still monitoring the Plan of Removal. These failures could affect 9 residents that were identified as elopement risks and placed them at risk of serious bodily harm, [MEDICATION NAME] physical impairment, or death. Findings included: Closed record review of Resident #3's Admission Record (Face Sheet) dated [DATE] indicated a [AGE] year-old male, admitted on [DATE]. Resident #3's [DIAGNOSES REDACTED]. Closed record review of Resident #3's Quarterly MDS assessment, dated [DATE], indicated the resident had a BIMS of 4 indicating extensive cognitive impairment and no wandering behaviors identified. Resident #3 required supervision and no setup to setup assistance for ADLs. Closed record review of Resident #3's Order Appointing Permanent Guardian of the Person and Estate dated [DATE] indicated Resident #3's daughter was the appointed Guardian of Resident #3. Closed record review of Resident #3's physician progress notes [REDACTED]. It is preferred that the patient has a memory care unit . I think he would benefit most from a memory care unit. Closed record review of Resident #3's physician progress notes [REDACTED]. Daughter states patient had been calling her to come get him and take him home. He was told he would be staying long term at nursing facility but is very forgetful. He has a history of [MEDICAL CONDITION] and behaviors . Closed record review of Resident #3's Wandering/Elopement Risk Evaluation, dated [DATE], indicated the resident was a risk for elopement/wandering, as evidenced by: attempting to leave, packing belongings and stating he was going to leave. Closed record review of Resident #3's physician progress notes [REDACTED]. He is at risk of elopement Closed record review of Resident #3's Nurse's Progress note dated [DATE] indicated Resident #3 was sent to Behavior Hospital for aggression, attempts at elopement, and attempts to remove wander guard. Closed record review of Resident #3's Behavioral Hospital Inpatient Psychiatric Evaluation dated [DATE] with a date of arrival of [DATE], indicated the History of Present Illness included trying to elope from facility. Resident #3 returned to the facility from the Behavioral Hospital on [DATE]. Closed record review of Resident #3's Wandering/Elopement Risk Evaluation, dated [DATE], indicated the resident was a risk for elopement/wandering, as evidenced by: attempt to leave. Closed record review of Resident #3's physician progress notes [REDACTED]. Patient has dementia and is confused much of the time, and frequently calls family to come get him. Had become agitated and aggressive, and Behavioral Hospital was consulted. Patient did attempt to escape the building several times and was transferred to Behavioral Hospital for evaluation and treatment. He returned to facility on [DATE] in stable condition. Closed record review of Progress Notes dated [DATE] for Resident #3 indicated the resident cut off his wander guard with scissors and attempted to leave facility. Resident placed on one on one for elopement risk. Closed record review of Resident #3's undated care plan provided by the DON on [DATE] indicated the following: Problem: -The resident is an elopement risk/wanderer related to history of attempts to leave facility unattended, impaired safety awareness. Date initiated [DATE] Goal: -The resident's safety will be maintained through the review date. Date initiated [DATE]. Target date [DATE] -The resident will not leave facility unattended through the review date. Date initiated [DATE]. Target date [DATE]. Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book . Date initiated [DATE]. -Provide Structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Date initiated [DATE] -Wander Alert: Date initiated: [DATE]. Target Date [DATE] Closed record review of Nurse's Progress Notes dated [DATE] for Resident #3 indicated the resident packed and had belongings by door. Resident #3 said he was leaving. Resident #3 walked out of front door and set off door system with wander guard. Able to redirect resident to come back inside. Family notified. Closed record review of Nurse's Progress Noted dated [DATE] at 8:25 pm for Resident #3 indicated Resident #3's daughter called and said that her cousin had Resident #3 in a town 44 miles away and was taking him to where she (daughter) lived a town 66 miles from the facility. She said that Resident #3 had received a ride after exiting the facility. Facility administration informed. Staff were asked and said they did not hear a wander guard alarm go off. Resident's room was searched, and wander guard was found with nail clippers next to it. Daughter said someone from the family would stay with Resident #3 after she returned with him to the facility. Closed record review of Nurse's Progress Notes dated [DATE] at 10:30pm for Resident #3 indicated the daughter and son returned Resident #3 to the facility and Resident #3 said that he saw the nurse working down the hall and left. He was smiling and laughing. The daughter said Resident #3's son would be staying the night with him. Closed record review of Resident #3's Incident Report dated [DATE] indicated Resident #3 had received a ride from the cousin to Resident #3's house and was later brought to the facility. A head to toe assessment was completed and no injuries were found. Resident #3 was placed on line of sight supervision. Closed record review of Resident #3's physician progress notes [REDACTED]. Patient reportedly eloped the facility yesterday evening. His wander guard had been cut off and was found near his room, next to toenail clippers. He then had someone pick him up outside of the facility and drive him to a town 44 miles away. His daughter then brought him back to the facility . Due to his elopement risk, staff feels he needs to be in a locked facility. Another facility had been contacted to come evaluate him for possible admission to their facility. Closed record review of Resident #3's Physician Discharge note also dated [DATE] indicated the following: .Resident eloped facility after cutting off his wander guard, and it was determined that he needs to be in a locked unit for safety. His family had found placement for him. He would be discharged to another facility on [DATE]. Record review of the Provider Investigation Report dated [DATE] indicated the facility response to the incident for Resident #3 included: -Elopement in-service completed -All wander guards and doors audited to ensure proper function. -Facility will continue to educate on elopements per policy. Closed record review of Resident #3's physician progress notes [REDACTED]. Patient had continued with trying to get out of the facility and required a locked unit for safety. He required one on one supervision. Family did not want him moved, but due to his high risk of elopement, staff is concerned about his safety and are unable to provide one on one supervision. He is alert and oriented. Social worker performed SLUMS cognitive exam due to previous low score on previous exam but given his attempts at exiting the facility he appeared to be more cognitively intact than his score. Record review of Resident #3's notice of 30-Day discharge date d [DATE] indicated he would be discharged related to elopement attempts and the facility not being able to meet his needs. Closed record review of Resident #3's Clinical Physician orders [REDACTED]. -Order date [DATE] Apply wander guard due to elopement risk. -Order date [DATE] Wander guard: check for function everyday every shift discontinued [DATE] -Order date [DATE] Wander guard Check placement every shift. -Order date [DATE] Wander guard to left ankle. -Order date [DATE] Wander guard: check for function everyday morning and before bed. -Order date [DATE] Behavior monitoring for exit seeking behavior. Document the number of times resident exhibited behavior during shift. -Order date [DATE] Wander guard check placement to left wrist every shift. -Order date [DATE] Wander guard: check for function every day to left wrist. -Order date [DATE] Resident required one on one care due to active exit seeking behaviors secondary to dementia diagnosis. Discharge is necessary for the resident's welfare as his needs cannot be met at current facility. -[DATE] Therapy to eval and treat for behaviors . -Order date [DATE] Resident requires line of sight care due to active exit seeking behaviors secondary to dementia diagnosis. Discharge is necessary for the resident's welfare as his needs cannot be met at current facility. Record review of Resident #3's undated one on one log provided by the DON on [DATE] indicated a person assigned to him from [DATE] until his discharge on [DATE] to another facility. During an interview with the DON on [DATE] at 9:20 am, she said that Resident #3 was transferred to another nursing facility after the discharge notice was given to the resident and his family. She said the ombudsman was also notified. During an interview with Resident #3's daughter on [DATE] at 11:09 am, she said that she called the facility after family (cousin) had called her and told her that he had her father in a town 44 miles from the facility and was on his way to her house in a town 66 miles away from the facility. She said after his elopement, she was given a 30-day discharge and she did not appeal the discharge. She said the facility helped her by sending the information she requested to a nursing facility she had found in a different location. She said after the incident her father had a wander guard and had supervision increased. She said after the incident he had not left the facility again. During an interview with the son of Resident #3 on [DATE] at 11:47 am, he said the facility was called and they were surprised when his sister told them Resident #3 was not in the building. He said that 44 miles to the town his sister's cousin lived in was not a short trip. He said he was not aware if the facility gave his sister a 30-day discharge letter. Multiple attempts to contact the cousin of the daughter were made without success from [DATE] through [DATE]. During an interview with CNA L on [DATE] at 3:01 pm, she said on [DATE] she last saw Resident #3 after dinner (6pm-7pm). She said she was working his hall alone and was picking up trays when she heard that a nurse had received a call and been told that he was in a town 44 miles away. She said she was not sure how long he was gone. She said her shift ended prior to him returning to the facility. She said as far as she knew he had not tried leaving prior to the incident. She said she was not familiar with a wander book. She said prior to the incident the resident had a wander guard and after was on supervision and had an extra aid sitting with him. She was able to describe the procedure for resident elopement. During an interview with CMA M on [DATE] at 3:09 pm, he said all he knew was that a nurse had received a call that Resident #3 was missing. He said he usually worked the opposite hall and did not have a lot of interaction with the resident. He said he was aware that Resident #3 had tried to leave at least 2 times prior to the incident and had cut his wander guard off before. He said he was not sure of what interventions were in place. He said he was not familiar with the wander book. He was able to describe the procedure for elopement of a resident. During an interview with LVN C on [DATE] at 4:00 pm, she said on [DATE] she was the nurse working Resident #3's hall and received the phone call from the daughter saying he was in town 44 miles away. She said she had looked for him at 8pm for a blood sugar check and could not find him. She said she started asking the other staff where he was and that was about the time she received the phone call from the daughter. She said the last time she saw him was around 7pm and didn't think nothing of it because he would move about the facility talking to different residents. She said as far as she knew he did not try to leave the facility before the date of the incident. She said she was aware of him having a wander guard and was not sure how long he had the wander guard. She said he did not have any kind of extra supervision as far as she was aware. She said when he arrived back at the facility he said that he was at the nurse's station and saw her down one of the halls, so he left with a Hispanic family who walked out the front door. During an observation on [DATE] at 4:10 pm, no sign was observed at the front door warning visitors of possible residents leaving the facility during their exit. During an interview with the Nurse Consultant on [DATE] at 10:28pm, she said that a comment had been made that Resident #3 had left with a Hispanic family the day of the incident, but their investigation did not indicate that was the case. She said they had not put a sign on the door after the comment but would be putting a sign on the door immediately. During an interview with CMA I on [DATE] at 11:59 am, she said on [DATE] the last time she saw Resident #3 was after supper at about 6pm she said the Resident was known to travel throughout the facility. She said his wander guard was found in his room, but she did not know what it was cut off with. She said around 8:30 pm the daughter called and told them that he was in a town 44 miles away. She said the nurse called the DON. She said the resident had cut off his wander guard in the past with clippers. She said the staff had tried to keep clippers from him and would put up clippers after they had used them post shower or care. She said she had supervised Resident #3 once and during her supervision she was assigned to him and nothing else for a shift. CMA I was able to verbalize procedure for an elopement of resident. She said she was familiar with wander book and named 11 residents she said she could not remember the other residents, but she believed there were at least 15 residents on the list (she named the residents while looking at a current roster of residents in the building). The residents verbalized did not match the Wander guard Book list provided by the DON. She said she knew who elopement risk residents were from daily observations and reports from the nurses. She said by observation she meant residents who would say they want to go home/leave or seemed more confused than usual. During an interview with CNA K on [DATE] at 2:50 pm, she said that on [DATE] a nurse had asked her where Resident #3 was, but she was not sure of the details because she was not working Resident #3's hall. She said the last time she saw him was after supper (7pm) and that after that they could not find him. She said as far as she knew he did not have any interventions in place. She said she was not aware of a wander book. She said she knew that elopement was code green and that a search was started, and nurse's directions are followed after a resident is identified as missing. During an interview with the Social Worker on [DATE] at 2:37 pm, she said that Resident #3 had been given a discharge notice after an elopement where he made it to a town 44 miles away from the facility. She said he had a wander guard in place. She said she helped with the coordination of the placement of Resident #3 after his last elopement on [DATE] and was discharged to a facility with a locked unit on [DATE]. She said he frequently attempted to elope from the building and they had exhausted all interventions prior to issuing the discharge. During an interview with the DON on [DATE] at 8:36 am, she said that new interventions were attempted for Resident #3 after each elopement attempt. She said that he was on one on one supervision after the date of the incident on [DATE] and it was later decided to discharge him to another facility. Record review of Resident #3's MAR printed on [DATE] and provided by the DON indicated the following: -Missing (blank) documentation for exit seeking behavior on the MAR for the following days: [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] -The MAR for (MONTH) (YEAR) through (MONTH) (YEAR) that was filled out and indicated documentation by the nurses as no exit seeking behavior. However, nursing progress note documentation indicated there was on [DATE], [DATE], and [DATE]. During an interview with the DON on [DATE] at 1:10 pm, she said the MAR indicated [REDACTED]. The DON said that in-services for the nurses had been conducted related to the documentation issue since being identified and would be monitoring documentation (MAR) moving forward. Record review of Staff Development/In-service Attendance sheet dated [DATE] indicated staff were in serviced on Elopement Drill. Record review of Elopement drills on [DATE] indicated the following: [DATE]- 13 staff signatures [DATE]- 4 staff signatures [DATE]-10 staff signatures [DATE]- 8 staff signatures . Locate wander guard/elopement book for resident information. During an interview with the Administrator on [DATE] at 10:59 am, she said she was unable to find more sign in sheets for the days provided. She said that she would be requiring all signatures moving forward for elopement drills. She said all staff should have been in-serviced and that there were missing signatures for staff. Record review of the Wander Book on [DATE] provided by the DON indicated the list contained 7 residents at risk for wandering/elopement. Record review of the Orders listing for wander guards dated [DATE] provided by the DON indicated 6 residents were listed as having wander guards. During an interview with LVN A on [DATE] at 12:10 pm, she said she was aware of the wander book, she printed a list she said was the wandering residents in the facility. However, the list did not match the list provided by the DON. The list provided by LVN A was both missing residents and had additional residents that were not on the list provided by the DON. The list contained 12 total residents. During an interview with CNA R on [DATE] at 12:15 pm, she said she doesn't know about a wander book. She said the nurses tell them when someone gets a wander guard. During an interview with CMA D on [DATE] at 12:16 pm, she said she was aware of the wander book and identified 4 residents she said she did not remember the rest of the residents but there were probably 20 residents on the list. The residents verbalized did not match the wander guard Book list provided by the DON. During an interview with LVN V on [DATE] at 12:21 pm, she said she was aware of the wander book, she said the list provided by LVN A was the wandering residents in the facility. However, the list did not match the list provided by the DON. The list provided by LVN A was both missing residents and had additional residents that were not on the list provided by the DON. The list contained 12 total residents. During an interview with CNA O on [DATE] at 12:23 pm, she said she was not familiar with the wander book. During an interview with LVN P on [DATE] at 2:55 pm, She was able to verbalize elopement procedure and identified 8 residents as being on the list. The residents verbalized did not match the wander guard Book list provided by the DON. Record review of Resident #7's Admission Record (Face Sheet) dated [DATE] indicated a [AGE] year-old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #7's Quarterly MDS dated [DATE] indicated a BIMS of 2 indicated extensive cognitive impairment and wandering behaviors. Resident #7 required extensive assistance of one person for ADLs. Record review of Resident #7's Care Plan initiated [DATE] indicated the following: Problem: Elopement Risk Dementia Goal: Resident will not elope from facility. Interventions: Assess resident for risk of elopement Initiate a wander guard for resident Record review of Resident #7's wander/elopement assessment dated [DATE] indicated a low risk for elopement. Record review of Resident #7's wander/elopement assessment dated [DATE] provided by the DON on [DATE] indicated a high-risk wandering/elopement due to history of wandering. During an observation and record review on [DATE] at 3:41 pm, Resident #7 was observed with a wander guard on but was not on the orders list for wander guards or the wander guard Book list provided by the DON. Record review of Resident #7's Order Summary Report and Medication Review report (Physician Consolidated Orders) dated [DATE] provided by the DON indicated the following: Order start date: [DATE] -Behavior Monitoring for exit seeking behavior. -Wander Guard check placement every shift (Revised [DATE]) expiration date added. -Wander Guard: check for function every shift Record review of Resident #7's Nurse's Progress Notes indicated the following: [DATE]- resident was trying to go out the doors stating she wanted to go find her mother. Resident was redirected several times. Resident continued to attempt to go out for approximately 2 hours . [DATE]- Resident tried exiting the building. During an interview with Resident #7's daughter on [DATE] at 12:32 pm, she said that the facility had an alarm on the resident's wheel chair. She said her mother had attempted to leave the building before. During observations and an interview on [DATE] from 3:45pm to 4:01 pm Resident #8, #9, #10 were observed with expired wander guards. The date on the devices were [DATE]. The devices were tested by the ADON and were still functional. The ADON was present during the checks and confirmed that the wander guards were expired. Record review of the Signal Device (wander guard) and Door Alarm Monitoring policy last revised [DATE] indicated the following: Practice Guidelines: b. The silver oxide batteries sealed inside the signaling device are designed to have a constant output until the last two or three days of their life. At this time, they die rapidly and the signaling device must be replaced. The expiration date of the signaling device should be listed on the MAR indicated [REDACTED]. During an interview with the DON on [DATE] at 4:12 pm, she said that her ADON had told her about the expired wander guards and that they had been replaced. Record review of Resident #8's Admission Record (Face Sheet) dated [DATE] indicated a [AGE] year-old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #8's Quarterly MDS dated [DATE] indicated a BIMS of 13 or minimal cognitive impairment. Resident #8 had no behaviors and required extensive assistance of one to two persons for ADLs. Record review of Resident #8's Care Plan provided by the DON on [DATE] indicated the following: Date initiated: [DATE] Problem: Elopement Risk Dementia Interventions: Assess resident for risk of elopement Initiate a wander guard for the resident Record review of Resident #8's elopement assessment dated [DATE] indicated moderate elopement risk. No prior assessment in the 120 days prior to [DATE]. Record review of Resident #8's Consolidated Physician order [REDACTED]. Order start date: [DATE]- Behavior monitoring for exit seeking behavior (revised [DATE]) no changes made. Order start date [DATE]- Check placement and function for wander guard (revised [DATE]) expiration date added. During an interview with Resident #8 on [DATE] at 2:50pm, she was slow to answer questions. She said the year was 2008. She said she was at the facility for 9 days. She said she did not know why she had the wander guard on and she had not tried to leave the facility previously. During an interview with the nurse consultant on [DATE] at 3:23 pm, she said that Resident #8's cognition could fluctuate from morning to evening. She said that they had identified that the resident was reported to have exit seeking behavior by the nurses, but they had not documented any exit seeking behaviors. She said the nurses had been in serviced and Resident #8 would be evaluated for a week to determine if she continued to require the Wander Guard. Record review of Resident #9's Admission Record (Face Sheet) dated [DATE] indicated a [AGE] year-old female with an original admission date of [DATE] and a readmission date of [DATE]. Resident #9's [DIAGNOSES REDACTED]. Record review of Resident #9's Quarterly MDS dated [DATE] indicated a BIMS of 12 or minimal cognitive impairment. Resident #9 had no behaviors and required extensive assistance of one person for ADLs. Record review of Resident #9's Care Plan provided by the DON on [DATE] indicated the following: Problem: Elopement risk Dementia, poor judgement skills. (Date initiated [DATE]) The resident is an elopement risk/wanderer related to impaired safety awareness (Date initiated [DATE]) Interventions Initiate a wander guard . (Date initiated [DATE]) Wander Alert (Date initiated [DATE]) Record review of Resident #9's Consolidate Physician order [REDACTED]. Order start date: [DATE]- Monitor for exit seeking behavior Order start date: Wander guard check for function and placement (revised [DATE]) expiration date added. Record review on [DATE] of Resident #9's nurses notes indicated no exit seeking behavior/wandering in the last 120 days. Record review of Resident #9's Elopement assessment dated [DATE] indicated high risk for elopement. No previous elopement risk assessment in the 120 days prior to [DATE]. During an interview and observation of Resident #9 on [DATE] at 4:12 pm, Resident #9 was in her room watching television. Resident was pleasant and said she had been in the facility since yesterday. She said she guesses she still had the wander guard/bracelet on. The wander guard was on her lower extremity. Resident responded with inappropriate responses for month and year. The resident was a poor historian. Record review of Resident #10's Admission Record (Face Sheet) dated [DATE] indicated a [AGE] year-old male with an original admission date of [DATE] and readmitted on [DATE]. Resident #10's [DIAGNOSES REDACTED]. Record review of Resident #10's care plan provided by the DON on [DATE] indicated the following: Problem: Elopement risk Dementia (initiated [DATE]) Interventions: Assess resident for risk of elopement (initiated [DATE]) Initiate wander guard (initiated [DATE]) Record review of Resident #10's Quarterly MDS dated [DATE] indicated a BIMS of 3 or cognitive impairment. Resident #10 was identified as having verbal behaviors and rejection of care behaviors. Resident #10 required extensive assist of one to two persons for ADLs. Record review of Resident #10's Nurse's Progress Notes indicated the following: [DATE]- Resident in wheelchair propelling up and down the hall then went to the side door and went outside. Brought him back and said it was too hot to be outside. Record review of Resident #10's Consolidated Physician order [REDACTED]. Order start date: [DATE]- Behavior monitoring for exit seeking behavior Order start date: [DATE]- wander guard placement and function (revised [DATE]) expiration date added. Resident #10's wandering/elopement assessments were requested from the DON but were not provided prior to exit on [DATE]. No wandering/elopement assessments were noted in the last 120 days. Record review of Resident #11's Admission Record (Face Sheet) dated [DATE] indicated a [AGE] year-old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #11's Admission MDS dated [DATE] indicated a BIMS of 14 or minimal cognitive impairment. Resident #11 had no behaviors identified and required extensive assistance of one person for ADLs. Record review of Resident #11's Admission Care Plan dated [DATE] indicated the following: Problem: Elopement risk Intervention: Assess resident risk Initiate wander guard Record review of Resident #11's Wandering/Elopement assessment dated [DATE] indicated she was an elopement risk related to hospital report of disorientation and wandering. Resident was disoriented to time, place, and situation. Record review of Resident #11's Consolidated Physician order [REDACTED]. Monitor exit seeking behaviors (initiated [DATE]) Monitor for wander guard placement and function (initiated [DATE] and revised [DATE]) for expiration date. Record review of Resident #11's nurse's notes since admission ([DATE]) were reviewed and no documentation of wandering/elopement behaviors were documented. During an observation on [DATE] at 3:41 pm, Resident #11 had a wander guard on but was not on the wander guard list provided by the DON. During an interview with the Medical Director on [DATE] at 4:30 pm he said that the facility would notify him about wandering residents. He said or

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for six (Resident #3, #7, #8, #9, #10, and #11) of nine residents reviewed for elopements. The facility failed to provide supervision for Resident # 3, who has a history of exit seeking behaviors, to prevent him from eloping from the facility on [DATE]. The facility was unaware the resident had cut off his wander guard and exited the facility at an unknown time after supper, and as a result, the resident made it 44 miles to his family's home before the facility was contacted regarding his whereabouts. The facility failed to ensure Resident #7 was listed in the Wander Guard Book (book with a list of wandering/elopement risk residents with picture and profile of the resident) per facility policy and had orders for her Wander guard. The facility failed to ensure Resident #8's, #9's, and #10's Wander guard was not expired, and Wander/elopement assessments were completed per facility policy. The facility failed to ensure Resident #11 was listed in the Wander guard Book per facility policy. An Immediate Jeopardy was identified on [DATE]. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and at a scope of pattern because the facility was still monitoring the Plan of Removal. These failures could affect 9 residents that were identified as elopement risks and placed them at risk of serious bodily harm, [MEDICATION NAME] physical impairment, or death. Findings included: Closed record review of Resident #3's Admission Record (Face Sheet) dated [DATE] indicated a [AGE] year-old male, admitted on [DATE]. Resident #3's [DIAGNOSES REDACTED]. Closed record review of Resident #3's Quarterly MDS assessment, dated [DATE], indicated the resident had a BIMS of 4 indicating extensive cognitive impairment and no wandering behaviors identified. Resident #3 required supervision and no setup to setup assistance for ADLs. Closed record review of Resident #3's Order Appointing Permanent Guardian of the Person and Estate dated [DATE] indicated Resident #3's daughter was the appointed Guardian of Resident #3. Closed record review of Resident #3's physician progress notes [REDACTED]. It is preferred that the patient has a memory care unit . I think he would benefit most from a memory care unit. Closed record review of Resident #3's physician progress notes [REDACTED]. Daughter states patient had been calling her to come get him and take him home. He was told he would be staying long term at nursing facility but is very forgetful. He has a history of [MEDICAL CONDITION] and behaviors . Closed record review of Resident #3's Wandering/Elopement Risk Evaluation, dated [DATE], indicated the resident was a risk for elopement/wandering, as evidenced by: attempting to leave, packing belongings and stating he was going to leave. Closed record review of Resident #3's physician progress notes [REDACTED]. He is at risk of elopement Closed record review of Resident #3's Nurse's Progress note dated [DATE] indicated Resident #3 was sent to Behavior Hospital for aggression, attempts at elopement, and attempts to remove wander guard. Closed record review of Resident #3's Behavioral Hospital Inpatient Psychiatric Evaluation dated [DATE] with a date of arrival of [DATE], indicated the History of Present Illness included trying to elope from facility. Resident #3 returned to the facility from the Behavioral Hospital on [DATE]. Closed record review of Resident #3's Wandering/Elopement Risk Evaluation, dated [DATE], indicated the resident was a risk for elopement/wandering, as evidenced by: attempt to leave. Closed record review of Resident #3's physician progress notes [REDACTED]. Patient has dementia and is confused much of the time, and frequently calls family to come get him. Had become agitated and aggressive, and Behavioral Hospital was consulted. Patient did attempt to escape the building several times and was transferred to Behavioral Hospital for evaluation and treatment. He returned to facility on [DATE] in stable condition. Closed record review of Progress Notes dated [DATE] for Resident #3 indicated the resident cut off his wander guard with scissors and attempted to leave facility. Resident placed on one on one for elopement risk. Closed record review of Resident #3's undated care plan provided by the DON on [DATE] indicated the following: Problem: -The resident is an elopement risk/wanderer related to history of attempts to leave facility unattended, impaired safety awareness. Date initiated [DATE] Goal: -The resident's safety will be maintained through the review date. Date initiated [DATE]. Target date [DATE] -The resident will not leave facility unattended through the review date. Date initiated [DATE]. Target date [DATE]. Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book . Date initiated [DATE]. -Provide Structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Date initiated [DATE] -Wander Alert: Date initiated: [DATE]. Target Date [DATE] Closed record review of Nurse's Progress Notes dated [DATE] for Resident #3 indicated the resident packed and had belongings by door. Resident #3 said he was leaving. Resident #3 walked out of front door and set off door system with wander guard. Able to redirect resident to come back inside. Family notified. Closed record review of Nurse's Progress Noted dated [DATE] at 8:25 pm for Resident #3 indicated Resident #3's daughter called and said that her cousin had Resident #3 in a town 44 miles away and was taking him to where she (daughter) lived a town 66 miles from the facility. She said that Resident #3 had received a ride after exiting the facility. Facility administration informed. Staff were asked and said they did not hear a wander guard alarm go off. Resident's room was searched, and wander guard was found with nail clippers next to it. Daughter said someone from the family would stay with Resident #3 after she returned with him to the facility. Closed record review of Nurse's Progress Notes dated [DATE] at 10:30pm for Resident #3 indicated the daughter and son returned Resident #3 to the facility and Resident #3 said that he saw the nurse working down the hall and left. He was smiling and laughing. The daughter said Resident #3's son would be staying the night with him. Closed record review of Resident #3's Incident Report dated [DATE] indicated Resident #3 had received a ride from the cousin to Resident #3's house and was later brought to the facility. A head to toe assessment was completed and no injuries were found. Resident #3 was placed on line of sight supervision. Closed record review of Resident #3's physician progress notes [REDACTED]. Patient reportedly eloped the facility yesterday evening. His wander guard had been cut off and was found near his room, next to toenail clippers. He then had someone pick him up outside of the facility and drive him to a town 44 miles away. His daughter then brought him back to the facility . Due to his elopement risk, staff feels he needs to be in a locked facility. Another facility had been contacted to come evaluate him for possible admission to their facility. Closed record review of Resident #3's Physician Discharge note also dated [DATE] indicated the following: .Resident eloped facility after cutting off his wander guard, and it was determined that he needs to be in a locked unit for safety. His family had found placement for him. He would be discharged to another facility on [DATE]. Record review of the Provider Investigation Report dated [DATE] indicated the facility response to the incident for Resident #3 included: -Elopement in-service completed -All wander guards and doors audited to ensure proper function. -Facility will continue to educate on elopements per policy. Closed record review of Resident #3's physician progress notes [REDACTED]. Patient had continued with trying to get out of the facility and required a locked unit for safety. He required one on one supervision. Family did not want him moved, but due to his high risk of elopement, staff is concerned about his safety and are unable to provide one on one supervision. He is alert and oriented. Social worker performed SLUMS cognitive exam due to previous low score on previous exam but given his attempts at exiting the facility he appeared to be more cognitively intact than his score. Record review of Resident #3's notice of 30-Day discharge date d [DATE] indicated he would be discharged related to elopement attempts and the facility not being able to meet his needs. Closed record review of Resident #3's Clinical Physician orders [REDACTED]. -Order date [DATE] Apply wander guard due to elopement risk. -Order date [DATE] Wander guard: check for function everyday every shift discontinued [DATE] -Order date [DATE] Wander guard Check placement every shift. -Order date [DATE] Wander guard to left ankle. -Order date [DATE] Wander guard: check for function everyday morning and before bed. -Order date [DATE] Behavior monitoring for exit seeking behavior. Document the number of times resident exhibited behavior during shift. -Order date [DATE] Wander guard check placement to left wrist every shift. -Order date [DATE] Wander guard: check for function every day to left wrist. -Order date [DATE] Resident required one on one care due to active exit seeking behaviors secondary to dementia diagnosis. Discharge is necessary for the resident's welfare as his needs cannot be met at current facility. -[DATE] Therapy to eval and treat for behaviors . -Order date [DATE] Resident requires line of sight care due to active exit seeking behaviors secondary to dementia diagnosis. Discharge is necessary for the resident's welfare as his needs cannot be met at current facility. Record review of Resident #3's undated one on one log provided by the DON on [DATE] indicated a person assigned to him from [DATE] until his discharge on [DATE] to another facility. During an interview with the DON on [DATE] at 9:20 am, she said that Resident #3 was transferred to another nursing facility after the discharge notice was given to the resident and his family. She said the ombudsman was also notified. During an interview with Resident #3's daughter on [DATE] at 11:09 am, she said that she called the facility after family (cousin) had called her and told her that he had her father in a town 44 miles from the facility and was on his way to her house in a town 66 miles away from the facility. She said after his elopement, she was given a 30-day discharge and she did not appeal the discharge. She said the facility helped her by sending the information she requested to a nursing facility she had found in a different location. She said after the incident her father had a wander guard and had supervision increased. She said after the incident he had not left the facility again. During an interview with the son of Resident #3 on [DATE] at 11:47 am, he said the facility was called and they were surprised when his sister told them Resident #3 was not in the building. He said that 44 miles to the town his sister's cousin lived in was not a short trip. He said he was not aware if the facility gave his sister a 30-day discharge letter. Multiple attempts to contact the cousin of the daughter were made without success from [DATE] through [DATE]. During an interview with CNA L on [DATE] at 3:01 pm, she said on [DATE] she last saw Resident #3 after dinner (6pm-7pm). She said she was working his hall alone and was picking up trays when she heard that a nurse had received a call and been told that he was in a town 44 miles away. She said she was not sure how long he was gone. She said her shift ended prior to him returning to the facility. She said as far as she knew he had not tried leaving prior to the incident. She said she was not familiar with a wander book. She said prior to the incident the resident had a wander guard and after was on supervision and had an extra aid sitting with him. She was able to describe the procedure for resident elopement. During an interview with CMA M on [DATE] at 3:09 pm, he said all he knew was that a nurse had received a call that Resident #3 was missing. He said he usually worked the opposite hall and did not have a lot of interaction with the resident. He said he was aware that Resident #3 had tried to leave at least 2 times prior to the incident and had cut his wander guard off before. He said he was not sure of what interventions were in place. He said he was not familiar with the wander book. He was able to describe the procedure for elopement of a resident. During an interview with LVN C on [DATE] at 4:00 pm, she said on [DATE] she was the nurse working Resident #3's hall and received the phone call from the daughter saying he was in town 44 miles away. She said she had looked for him at 8pm for a blood sugar check and could not find him. She said she started asking the other staff where he was and that was about the time she received the phone call from the daughter. She said the last time she saw him was around 7pm and didn't think nothing of it because he would move about the facility talking to different residents. She said as far as she knew he did not try to leave the facility before the date of the incident. She said she was aware of him having a wander guard and was not sure how long he had the wander guard. She said he did not have any kind of extra supervision as far as she was aware. She said when he arrived back at the facility he said that he was at the nurse's station and saw her down one of the halls, so he left with a Hispanic family who walked out the front door. During an observation on [DATE] at 4:10 pm, no sign was observed at the front door warning visitors of possible residents leaving the facility during their exit. During an interview with the Nurse Consultant on [DATE] at 10:28pm, she said that a comment had been made that Resident #3 had left with a Hispanic family the day of the incident, but their investigation did not indicate that was the case. She said they had not put a sign on the door after the comment but would be putting a sign on the door immediately. During an interview with CMA I on [DATE] at 11:59 am, she said on [DATE] the last time she saw Resident #3 was after supper at about 6pm she said the Resident was known to travel throughout the facility. She said his wander guard was found in his room, but she did not know what it was cut off with. She said around 8:30 pm the daughter called and told them that he was in a town 44 miles away. She said the nurse called the DON. She said the resident had cut off his wander guard in the past with clippers. She said the staff had tried to keep clippers from him and would put up clippers after they had used them post shower or care. She said she had supervised Resident #3 once and during her supervision she was assigned to him and nothing else for a shift. CMA I was able to verbalize procedure for an elopement of resident. She said she was familiar with wander book and named 11 residents she said she could not remember the other residents, but she believed there were at least 15 residents on the list (she named the residents while looking at a current roster of residents in the building). The residents verbalized did not match the Wander guard Book list provided by the DON. She said she knew who elopement risk residents were from daily observations and reports from the nurses. She said by observation she meant residents who would say they want to go home/leave or seemed more confused than usual. During an interview with CNA K on [DATE] at 2:50 pm, she said that on [DATE] a nurse had asked her where Resident #3 was, but she was not sure of the details because she was not working Resident #3's hall. She said the last time she saw him was after supper (7pm) and that after that they could not find him. She said as far as she knew he did not have any interventions in place. She said she was not aware of a wander book. She said she knew that elopement was code green and that a search was started, and nurse's directions are followed after a resident is identified as missing. During an interview with the Social Worker on [DATE] at 2:37 pm, she said that Resident #3 had been given a discharge notice after an elopement where he made it to a town 44 miles away from the facility. She said he had a wander guard in place. She said she helped with the coordination of the placement of Resident #3 after his last elopement on [DATE] and was discharged to a facility with a locked unit on [DATE]. She said he frequently attempted to elope from the building and they had exhausted all interventions prior to issuing the discharge. During an interview with the DON on [DATE] at 8:36 am, she said that new interventions were attempted for Resident #3 after each elopement attempt. She said that he was on one on one supervision after the date of the incident on [DATE] and it was later decided to discharge him to another facility. Record review of Resident #3's MAR printed on [DATE] and provided by the DON indicated the following: -Missing (blank) documentation for exit seeking behavior on the MAR for the following days: [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] -The MAR for (MONTH) (YEAR) through (MONTH) (YEAR) that was filled out and indicated documentation by the nurses as no exit seeking behavior. However, nursing progress note documentation indicated there was on [DATE], [DATE], and [DATE]. During an interview with the DON on [DATE] at 1:10 pm, she said the MAR indicated [REDACTED]. The DON said that in-services for the nurses had been conducted related to the documentation issue since being identified and would be monitoring documentation (MAR) moving forward. Record review of Staff Development/In-service Attendance sheet dated [DATE] indicated staff were in serviced on Elopement Drill. Record review of Elopement drills on [DATE] indicated the following: [DATE]- 13 staff signatures [DATE]- 4 staff signatures [DATE]-10 staff signatures [DATE]- 8 staff signatures . Locate wander guard/elopement book for resident information. During an interview with the Administrator on [DATE] at 10:59 am, she said she was unable to find more sign in sheets for the days provided. She said that she would be requiring all signatures moving forward for elopement drills. She said all staff should have been in-serviced and that there were missing signatures for staff. Record review of the Wander Book on [DATE] provided by the DON indicated the list contained 7 residents at risk for wandering/elopement. Record review of the Orders listing for wander guards dated [DATE] provided by the DON indicated 6 residents were listed as having wander guards. During an interview with LVN A on [DATE] at 12:10 pm, she said she was aware of the wander book, she printed a list she said was the wandering residents in the facility. However, the list did not match the list provided by the DON. The list provided by LVN A was both missing residents and had additional residents that were not on the list provided by the DON. The list contained 12 total residents. During an interview with CNA R on [DATE] at 12:15 pm, she said she doesn't know about a wander book. She said the nurses tell them when someone gets a wander guard. During an interview with CMA D on [DATE] at 12:16 pm, she said she was aware of the wander book and identified 4 residents she said she did not remember the rest of the residents but there were probably 20 residents on the list. The residents verbalized did not match the wander guard Book list provided by the DON. During an interview with LVN V on [DATE] at 12:21 pm, she said she was aware of the wander book, she said the list provided by LVN A was the wandering residents in the facility. However, the list did not match the list provided by the DON. The list provided by LVN A was both missing residents and had additional residents that were not on the list provided by the DON. The list contained 12 total residents. During an interview with CNA O on [DATE] at 12:23 pm, she said she was not familiar with the wander book. During an interview with LVN P on [DATE] at 2:55 pm, She was able to verbalize elopement procedure and identified 8 residents as being on the list. The residents verbalized did not match the wander guard Book list provided by the DON. Record review of Resident #7's Admission Record (Face Sheet) dated [DATE] indicated a [AGE] year-old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #7's Quarterly MDS dated [DATE] indicated a BIMS of 2 indicated extensive cognitive impairment and wandering behaviors. Resident #7 required extensive assistance of one person for ADLs. Record review of Resident #7's Care Plan initiated [DATE] indicated the following: Problem: Elopement Risk Dementia Goal: Resident will not elope from facility. Interventions: Assess resident for risk of elopement Initiate a wander guard for resident Record review of Resident #7's wander/elopement assessment dated [DATE] indicated a low risk for elopement. Record review of Resident #7's wander/elopement assessment dated [DATE] provided by the DON on [DATE] indicated a high-risk wandering/elopement due to history of wandering. During an observation and record review on [DATE] at 3:41 pm, Resident #7 was observed with a wander guard on but was not on the orders list for wander guards or the wander guard Book list provided by the DON. Record review of Resident #7's Order Summary Report and Medication Review report (Physician Consolidated Orders) dated [DATE] provided by the DON indicated the following: Order start date: [DATE] -Behavior Monitoring for exit seeking behavior. -Wander Guard check placement every shift (Revised [DATE]) expiration date added. -Wander Guard: check for function every shift Record review of Resident #7's Nurse's Progress Notes indicated the following: [DATE]- resident was trying to go out the doors stating she wanted to go find her mother. Resident was redirected several times. Resident continued to attempt to go out for approximately 2 hours . [DATE]- Resident tried exiting the building. During an interview with Resident #7's daughter on [DATE] at 12:32 pm, she said that the facility had an alarm on the resident's wheel chair. She said her mother had attempted to leave the building before. During observations and an interview on [DATE] from 3:45pm to 4:01 pm Resident #8, #9, #10 were observed with expired wander guards. The date on the devices were [DATE]. The devices were tested by the ADON and were still functional. The ADON was present during the checks and confirmed that the wander guards were expired. Record review of the Signal Device (wander guard) and Door Alarm Monitoring policy last revised [DATE] indicated the following: Practice Guidelines: b. The silver oxide batteries sealed inside the signaling device are designed to have a constant output until the last two or three days of their life. At this time, they die rapidly and the signaling device must be replaced. The expiration date of the signaling device should be listed on the MAR indicated [REDACTED]. During an interview with the DON on [DATE] at 4:12 pm, she said that her ADON had told her about the expired wander guards and that they had been replaced. Record review of Resident #8's Admission Record (Face Sheet) dated [DATE] indicated a [AGE] year-old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #8's Quarterly MDS dated [DATE] indicated a BIMS of 13 or minimal cognitive impairment. Resident #8 had no behaviors and required extensive assistance of one to two persons for ADLs. Record review of Resident #8's Care Plan provided by the DON on [DATE] indicated the following: Date initiated: [DATE] Problem: Elopement Risk Dementia Interventions: Assess resident for risk of elopement Initiate a wander guard for the resident Record review of Resident #8's elopement assessment dated [DATE] indicated moderate elopement risk. No prior assessment in the 120 days prior to [DATE]. Record review of Resident #8's Consolidated Physician order [REDACTED]. Order start date: [DATE]- Behavior monitoring for exit seeking behavior (revised [DATE]) no changes made. Order start date [DATE]- Check placement and function for wander guard (revised [DATE]) expiration date added. During an interview with Resident #8 on [DATE] at 2:50pm, she was slow to answer questions. She said the year was 2008. She said she was at the facility for 9 days. She said she did not know why she had the wander guard on and she had not tried to leave the facility previously. During an interview with the nurse consultant on [DATE] at 3:23 pm, she said that Resident #8's cognition could fluctuate from morning to evening. She said that they had identified that the resident was reported to have exit seeking behavior by the nurses, but they had not documented any exit seeking behaviors. She said the nurses had been in serviced and Resident #8 would be evaluated for a week to determine if she continued to require the Wander Guard. Record review of Resident #9's Admission Record (Face Sheet) dated [DATE] indicated a [AGE] year-old female with an original admission date of [DATE] and a readmission date of [DATE]. Resident #9's [DIAGNOSES REDACTED]. Record review of Resident #9's Quarterly MDS dated [DATE] indicated a BIMS of 12 or minimal cognitive impairment. Resident #9 had no behaviors and required extensive assistance of one person for ADLs. Record review of Resident #9's Care Plan provided by the DON on [DATE] indicated the following: Problem: Elopement risk Dementia, poor judgement skills. (Date initiated [DATE]) The resident is an elopement risk/wanderer related to impaired safety awareness (Date initiated [DATE]) Interventions Initiate a wander guard . (Date initiated [DATE]) Wander Alert (Date initiated [DATE]) Record review of Resident #9's Consolidate Physician order [REDACTED]. Order start date: [DATE]- Monitor for exit seeking behavior Order start date: Wander guard check for function and placement (revised [DATE]) expiration date added. Record review on [DATE] of Resident #9's nurses notes indicated no exit seeking behavior/wandering in the last 120 days. Record review of Resident #9's Elopement assessment dated [DATE] indicated high risk for elopement. No previous elopement risk assessment in the 120 days prior to [DATE]. During an interview and observation of Resident #9 on [DATE] at 4:12 pm, Resident #9 was in her room watching television. Resident was pleasant and said she had been in the facility since yesterday. She said she guesses she still had the wander guard/bracelet on. The wander guard was on her lower extremity. Resident responded with inappropriate responses for month and year. The resident was a poor historian. Record review of Resident #10's Admission Record (Face Sheet) dated [DATE] indicated a [AGE] year-old male with an original admission date of [DATE] and readmitted on [DATE]. Resident #10's [DIAGNOSES REDACTED]. Record review of Resident #10's care plan provided by the DON on [DATE] indicated the following: Problem: Elopement risk Dementia (initiated [DATE]) Interventions: Assess resident for risk of elopement (initiated [DATE]) Initiate wander guard (initiated [DATE]) Record review of Resident #10's Quarterly MDS dated [DATE] indicated a BIMS of 3 or cognitive impairment. Resident #10 was identified as having verbal behaviors and rejection of care behaviors. Resident #10 required extensive assist of one to two persons for ADLs. Record review of Resident #10's Nurse's Progress Notes indicated the following: [DATE]- Resident in wheelchair propelling up and down the hall then went to the side door and went outside. Brought him back and said it was too hot to be outside. Record review of Resident #10's Consolidated Physician order [REDACTED]. Order start date: [DATE]- Behavior monitoring for exit seeking behavior Order start date: [DATE]- wander guard placement and function (revised [DATE]) expiration date added. Resident #10's wandering/elopement assessments were requested from the DON but were not provided prior to exit on [DATE]. No wandering/elopement assessments were noted in the last 120 days. Record review of Resident #11's Admission Record (Face Sheet) dated [DATE] indicated a [AGE] year-old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #11's Admission MDS dated [DATE] indicated a BIMS of 14 or minimal cognitive impairment. Resident #11 had no behaviors identified and required extensive assistance of one person for ADLs. Record review of Resident #11's Admission Care Plan dated [DATE] indicated the following: Problem: Elopement risk Intervention: Assess resident risk Initiate wander guard Record review of Resident #11's Wandering/Elopement assessment dated [DATE] indicated she was an elopement risk related to hospital report of disorientation and wandering. Resident was disoriented to time, place, and situation. Record review of Resident #11's Consolidated Physician order [REDACTED]. Monitor exit seeking behaviors (initiated [DATE]) Monitor for wander guard placement and function (initiated [DATE] and revised [DATE]) for expiration date. Record review of Resident #11's nurse's notes since admission ([DATE]) were reviewed and no documentation of wandering/elopement behaviors were documented. During an observation on [DATE] at 3:41 pm, Resident #11 had a wander guard on but was not on the wander guard list provided by the DON. During an interview with the Medical Director on [DATE] at 4:30 pm he said that the facility would notify him about wandering residents. He said orders were issued fo

Based on interview and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 4 residents reviewed for transfers (Resident #1). On the morning of 06/16/17, CNA A and CNA B failed to use the mechanical lift for Resident #1, as a result, CNA A and CNA B chose to perform a two person transfer and Resident #1 sustained a fall during the transfer and as a result, sustained bilateral lower extremity fractures of her tibia and fibula. This failure resulted in harm to Resident #1 and could place 11 residents in the facility at risk of injuries due to inappropriate transfers. Findings included: Record review of Resident #1's face sheet, printed 06/15/17, revealed she was a [AGE] year old female, admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Record review of Resident #1's most recent significant change Minimum Data Set ((MDS) dated [DATE] revealed a brief interview of mental status (BIMS) of 99, which indicated that the interview could not be conducted and Resident #1 had severe cognitive impairment. Review of Section G revealed that Resident #1 required the extensive support of two staff for transfers. Section I revealed [DIAGNOSES REDACTED]. Record review of Resident #1's care plan, dated 04/07/17 revealed the following: Problem/Need: Resident's ADL functions: Transfers: Total assistance MAY USE MECHANICAL LIFT WITH TRANSFERS . Record review of Resident #1's Physician Orders for 06/01/2017 did not identify an order for [REDACTED]. Record review of the Activities of Daily Living Care Sheet, given to the surveyor by the Corporate RN on 06/29/17 at 4:00 PM revealed: Scheduled care entries Resident (Resident #1) Transfer: Total Dependence .HOYER (a brand of mechanical lift) . In an interview on 06/29/17 at 2:35 PM with the Corporate RN, she said The facility does not require a physician's order to use a mechanical lift, the staff should go by the activities of daily living (ADL) scheduled care sheet in the kiosk if unsure what type of transfer a resident requires and it is also care planned. She said that Resident #1 required the use of the mechanical lift for all transfers. According to the Federal Drug Administration, Patient lifts are designed to lift and transfer patients from one place to another (e.g., from bed to bath, chair to stretcher) These medical devices provide many benefits, including reduced risk of injury to patients and caregivers when properly used.https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/ucm 2.htm (Accessed on 07/03/2017). Record review of Resident #1's progress notes on 06/16/17 at 1:56PM, performed by Family Nurse Practitioner A, revealed chief complaint patient is a poor historian due to cognitive/psychiatric impairment. Chief complaint/reason for this visit: follow up on fever Patient does report pain to bilateral legs, but denies any abdominal pain, back pain, flank pain or dysuria. Past medical history: osteoarthritis, osteoporosis Review of Systems: positive for Arthralgia and positive for myalgia. Physical Exam .Musculoskeletal: Painful Movement, Decreased range of motion right arm/shoulder due to pain. Skin: Normal Temp, No unusual rashes or lesions .Assessment and Plan: OA(osteoarthritis) pain to bilateral legs: will change Tylenol from PRN to scheduled. Record review of Resident #1's nurses notes revealed the following entries: On 06/18/17, untimed, resident complained of pain to right and left leg. Stated she had fallen on Friday night. two girls picked me up. Cannot recall where or how she fell . Minimal edema (nonpitting) to lower extremity. Bruise to back of right knee. Also having decreased output. (Physician A) nurse practitioner notified at this time pending callback. Signed LVN A. On 06/18/17 at 14:30 (2:30 PM) Spoke with (Family Nurse Practitioner B) (on call for (Physician A)) via exchange service. New order received to x-ray right knee (2 view) Increased pain and bruising. CMMS (local mobile x-ray service) called at this time. Ordered for today. Signed LVN A. On 06/18/17 at 15:00 (3:00 PM) Responsible Party (daughter of Resident #1) notified at this time. Aware of leg pain/bruising. Notified of x-rays. Signed LVN A. On 06/18/17 at 17:45 (5:45 PM) CMMS (local mobile x-ray service) in facility for x-rays. Signed LVN A. On 06/18/17 at 22:08 (10:08 PM) Writer received call from CMMS staff that reported an acute fracture. Report faxed to facility. 2211 (10:11 PM) writer paged Family Nurse Practitioner B for report of X-ray. Family Nurse Practitioner B returned call, writer reported x-ray report. Verbal order given to send resident to emergency room for treatment. 2220 (10:20 PM) Writer called residents daughter to report finding of x-ray and transfer to emergency room . No answer. Message left on answering machine .Signed DON. On 06/18/17 at 2250 (10:50 PM) Non emergent ambulance called pending arrival for transport. Signed DON. On 06/18/17 at 2301 (11:01 PM) EMS (emergency medical services) arrived and in facility. Signed DON. On 06/18/17 at 2306 (11:06 PM) Resident left facility via EMS. Report called to (local hospital). At time of transport noted skin to bilateral shins with 1 cm skin abrasion bilateral, abrasion left knee. Bilateral lower extremity with edema, warm to touch. No unusual deformity or bruising to tibia/fibula of either lower extremity. Resident complained of pain to bilateral legs. Signed DON. On 06/19/17 at 0840 (8:40 AM) Writer received call from residents daughter. She stated the hospital physician reported resident had bilateral leg fractures. Daughter insisted resident fell . Writer informed daughter no fall had been reported at this time. Daughter informed investigation would be conducted and had been reported to DADS . Signed DON. Record review of x ray reports by Hospital A, performed on 06/19/17 at 2:49AM, revealed: Exam Two view of the right tibia and fibula .Impression: Displaced and comminuted fractures involving the proximal tibia and fibula .Two view of the left tibia and fibula .Impression: Displaced and comminuted fractures involving the proximal tibia and fibula. According to the Mayo Clinic, fractures of your shinbone (tibia) - the major weight-bearing bone in your lower leg - and the bone that runs alongside your tibia below your knee (fibula) http://www.mayoclinic.org/diseases-conditions/broken-leg/basics/definition/CON- 562?p=1 (Accessed on 07/05/17). According to dictionary.com, a comminuted fracture is a fracture of a bone in which the separated parts are splintered or fragmented. http://www.dictionary.com/browse/comminuted-fracture (Accessed on 7/5/17). According to medical-dictionary.com, a displaced fracture is a traumatic bone break in which two ends of a fractured bone are separated and out of their normal positions. http://medical-dictionary.thefreedictionary.com/displaced+fracture Accessed on 07/05/17. Attempted phone interview on 06/29/17 at 4:57 PM with LVN A, no answer message left on voicemail. Attempted phone interview on 06/29/17 at 4:58 PM with LVN B, she was unable to be interviewed due to being out of the country. In an interview with the DON on 06/28/17 at 6:15 PM, she said that during the course of her investigation, she was unable to identify what exactly had happened to Resident #1. She said that she had not received any information regarding Resident #1 falling, however, Resident #1 had told the hospital that she had fallen and the daughter had contacted her regarding information about a possible fall. She said she reported immediately to DADS, regarding the injury of Resident #1 and that she and the corporate RN spent the entire week, (06/19/17-06/23/17) conducting an in house facility investigation and could not identify the source of the injury. She said that they interviewed every staff member at the facility and on Thursday June 22, 2017, after returning from being out of town and unable to be reached, CNA A explained that she had been withholding information regarding Resident #1. The DON said that CNA A explained to her that on the morning of 6/16/17, she and CNA B were transferring Resident #1 onto the shower chair in the shower room. She said that they did not use the hoyer lift and that Resident #1 fell on to her knees onto the floor. She said that she and CNA B picked her up and put her onto the shower chair and noticed the two small abrasions on her knee and said Resident #1 did not complain of pain and that they decided not to report the incident. She said that after she had heard about the injury to Resident #1, she knew she had to report it. The DON said at this time, CNA A and CNA B were suspended. CNA A was told in person, however CNA B was unable to be reached, she said she showed up the next morning 6/23/17 to work and was told she could not work and came in later for another interview. The DON said at that time, CNA B still said that her and CNA A had transferred Resident #1 using the Hoyer Lift and that nothing had happened to Resident #1. The DON said at this time, it was explained again that they needed her to tell them exactly what happened, the DON said that CNA B got quiet and just got up from the interview and walked out. The DON said that on 06/23/17 both CNA A and CNA B were both terminated from the facility for failing to report Resident #1's fall that caused serious injury. In an interview on 06/29/17 at 9:10 AM, with Family Nurse Practitioner A, she said that she did see Resident #1 on 06/16/17, that afternoon. She said that she was not real familiar with Resident #1 due to her only coming to the facility about two weeks prior for the first time to round on residents. She said that Resident #1 did not at any time tell her that she had fallen. She complained of pain in her knees, which she knew she had a history of [REDACTED]. She said due to her confusion and cognitive status, she changed her PRN Tylenol that day to routine, 650 mg every 8 hours. She said that there was not anything concerning during the exam that would have prompted an x-ray at that time. In an interview on 06/29/17 at 10:15 AM, CNA C said that Resident #1 always required the mechanical Hoyer Lift to be transferred and that she had no knowledge of Resident #1 having fallen on 06/16/17. In an interview on 06/29/17 at 10:34 AM, CNA D said that Resident #1 always required the mechanical Hoyer Lift to be transferred and that she had no knowledge of Resident #1 having fallen on 06/16/17. In an interview on 06/29/17 at 10:40 AM, CNA E said that Resident #1 always required the mechanical Hoyer Lift to be transferred and that he had no knowledge of Resident #1 having fallen on 06/16/17. In an interview on 06/29/17 at 10:48 AM, CNA F said that Resident #1 always required the mechanical Hoyer Lift to be transferred and that she had no knowledge of Resident #1 having fallen on 06/16/17. In an interview on 06/29/17 at 11:47 AM, CNA G said that Resident #1 always required the mechanical Hoyer Lift to be transferred and that she had no knowledge of Resident #1 having fallen on 06/16/17. Record review of the facility investigation report initiated on 06/18/17 at 11:30 PM by the DON and completed on 06/23/17 revealed that Resident #1 sustained a fall in the shower room on 06/16/17 and that CNA A and CNA B failed to report that Resident #1 had fallen during the transfer onto the shower chair. Resident #1 sustained bilateral tibia and fibula fractures as a result from the fall. Both CNA A and CNA B were terminated for failing to report the incident. In an interview on 06/29/17 at 2:18 PM with CNA A, she said that she was caring for Resident #1 on 06/16/17 and assisted her in the shower room the morning of 06/16/17. She said that Resident #1 always required a hoyer lift for transfers and that the morning of 06/16/17, she and CNA B transferred Resident #1 without using the hoyer lift and during the transfer, CNA B lost her grip with Resident #1 and Resident #1 fell on her knees on the shower room floor. She said that there was not a gait belt used during the transfer either. She said that at the time Resident #1 said that she was not hurt and there was just a tiny abrasion on the front part of her legs. She said that she did not report the incident to anyone or tell anyone about the incident. She said that on Sunday (06/18/17), she went out of town and did not have her cell phone with her, however when she returned from being out of town on Thursday 06/23/17, she saw the missed call from the DON regarding the need to come in for an interview and was informed about Resident #1's injury. She said she came up to the facility the afternoon of 06/23/17 and that is when she reported the incident to the DON regarding Resident #1 falling in the shower on 06/16/17. She said that the facility had two hoyer lifts in the building and they were both in good working order. She said it was wrong for her and CNA B to have transferred Resident #1 without using the hoyer lift and they should have taken the time to go out into the hall and get it, but that they were just in a hurry. In an interview on 06/29/17 at 3:37 PM, CNA B said Resident #1 required the hoyer lift for all transfers. She said that she assisted CNA A with Resident #1's transfer in the shower room on the morning of 06/16/17. She said that the hoyer lift was not used during the transfer and that during the transfer, Resident #1 fell to her knees. She said that the facility had the hoyer lift available and she knew of at least one that was in good working order that day. She said that she and CNA A chose to not use the hoyer lift and just did a two person transfer. She said that it was not the right thing to do, you use the mechanical lift for resident safety and our safety. CNA B said that she did not report the incident to anyone. She said she was interviewed on Thursday 06/22/17 by the DON and was not honest about what happened to Resident #1, then was called back for another interview on Friday 06/23/17 and was told she was fired and left the interview. In an interview on 06/29/17 at 2:35 PM with the Corporate RN, she said that her expectation was that if a resident required the use of a mechanical lift for transfers, that facility staff should always use the mechanical lift. She said that it was unacceptable for CNA A and CNA B to have performed a two person transfer instead of using the mechanical lift on Resident #1 on 06/16/17. Record review of the facility policy entitled Safe Lifting and Movement of Residents dated 2001 and revised December 2013, revealed the following: Policy statement In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 3 Staff will document resident transferring and lifting needs in the care plan 5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary .7.Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. Back-up battery packs on remote chargers shall be provided as needed so that lifts can be used 24 hours a day while batteries are being recharged In an interview on 06/29/17 at 2:35 PM with the Corporate RN, she said that there were 11 mechanical lift transfers in the facility.

Based on observation, interview and record review, the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 5 residents reviewed for skin (Resident #1). The facility failed to: a) Prevent, identify, and treat skin breakdown on Resident #1's right lower extremity resulting from a brace. Resident #1 developed a stage III pressure sore which required debridement and treatment at a wound center. b) Accurately assess Resident # 1 for pressure injuries after the resident had complained that her brace was hurting her right leg. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the inspection. This failure could affect 8 residents, placing them at risk for unidentified or untreated pressure sores. Findings include: Closed record review of Resident #1's face sheet dated 6/9/17 documented she was [AGE] years of age admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's admission assessment dated [DATE] revealed Resident #1 was admitted to the facility for therapy due to fracture of distal femur (leg) and a fractured right humerus (arm). The resident had required surgery with an incision site to right knee. The order stated to change the bandage in 4 days. Resident also had orders to wear a sling to the right arm and a knee immobilizer to the right leg at all times. The skin condition report 2/11/17 revealed the resident had a skin tear to the left buttocks cheek, and left thigh was not open but reddened area measuring 5 inches. The report only had a splint circled on the right leg, no skin assessment noted. Interview with the MDS Coordinator A on 6/8/16 at 3:10 PM revealed the brace was from the top of her right thigh to the ankle. She stated it was worn at all time to keep her knee from bending. She also stated she was unaware that Resident ID #1 had any skin breakdown related to the fully extended brace that was ordered for the right leg. Review of Resident #1's latest MDS assessment dated [DATE], section M (M0100Z) revealed the resident was a risk for pressure sores but a NO on (M0210) resident has stage I or higher pressure ulcer. -She scored a 10 on her BIMS score (moderate cognitive impairment). -She was dependent on staff for all Activities of Daily Living (ADL's). -She had a Foley catheter -She was a two person physical assist due to impairment on right side. Review of Resident #1's Care Plan dated 2/11/17 related to skin concerns revealed that the resident only had a surgical wound and that it was healed on 3/15/17. No documentation was found that the resident had any other skin issues during her stay at the facility. The resident was discharged to the hospital on [DATE] and did not return. Review of Resident #1's Braden Scale dated 2/11/17, 2/15,17, and 3/8/17 documented she scored a 19 which indicated she was at risk for developing a pressure ulcer. Review of the Weekly Wound Tracking Worksheet for Resident #1 March 2017 only had one wound documented on the weekly report which was a surgical wound/rt. (right) knee. The documentation had that this wound healed on 3/14/17. Review of the medical record for Resident ID #1 revealed no documentation that there were open areas from the brace. Review of a nurse aide shower skin check sheet dated 2/13/17 at 5:23 PM revealed Nurse Aide F had documented skin irritation from leg brace. Noticeable skin breakage. There was a skin alert diagram of a body where the aide circled the area to the back of the right thigh of Resident #1. There was no documentation in the nurses' notes or anywhere else in the chart about being notified there was skin breakdown or that the nurse had followed up. Interview with DON C on 6/8/17 at 3:10 PM revealed she was working as the admission coordinator prior to taking the DON position and did not remember any pressure areas for Resident ID #1. She stated she did not work the floor and was not taking care of Resident #1 during that time period. Interview with therapist B on 6/8/17 at 11:30 AM revealed Resident #1 was admitted to the facility for therapy due to the fracture of her right femur. The therapist stated Resident #1 was admitted with orders for the brace to be on at all times but after she developed a sore, the order was for the brace to be on only when out of bed. The therapist stated she never removed or placed the brace on the resident, that she left that up to the CNA's and nurses. She also stated she had never observed the sore. Interview with Director of Rehab E on 6/8/17 at 10:40 AM revealed Resident #1 came into the facility for therapy and had an immobilizer to the right leg. He stated the resident was non-compliant with therapy due to the pain and they would modify her plan so she could tolerate the therapy sessions. He stated she first had an order for [REDACTED]. Interview with Resident ID #1's son on 6/8/17 at 1:40 PM revealed he stated that Resident ID #1 had been complaining about her leg hurting a few weeks prior to her discharge and the nurses' would come in and unstrap the top of the brace and never look underneath her leg to see if there were any open areas. The son stated if the nurses would have raised her leg up to see the underneath side that would have found out why she was hurting. He recalled a few weeks prior to the 2/28/17 MD visit, the resident had a fall out of her wheelchair due to her leg hurting from the brace. The resident was wanting the nurse to look at her leg. He stated his mother was in her wheelchair in the hallway waiting on the nurse to come look at her skin. He stated while she was waiting, she fell out of the wheelchair. The son stated he witnessed the event but could not get to her in time before she fell to the floor. The son also stated that Resident #1 had an open area on the back side of her thigh from the brace. He stated his wife had observed that wound as she was helping with care. Review of the nurses' notes dated 2/15/17 at 8:30 AM it was documented the Resident #1 wanted a skin assessment and the wheelchair was in locked position but the resident repositioned in the wheelchair and fell to the floor. Review of the nurses' noted dated 2/16/17 (no time) there was an entry stating wound to left butt cheek, applied wound cleaner no documentation found for new orders and no documentation on the treatment records, no other documentation or notification to the MD at any time about this wound. Review of a nurses note dated 2/17/17 (unknown time) stating that the nurse saw the resident on her bed with a dry/intact dressing to a skin tear at the posterior left leg and the residents bottom. The nurse stated wound care was done at that time. There were no orders for wound care found and no documentation of the size of the wounds. Review of the physician telephone orders dated 2/23/17 revealed an order to remove brace to right lower extremity every 4 hours and PRN (as needed) for skin checks. Review of the Medication Administration Record [REDACTED]. Interview with Resident ID #1's son on 6/8/17 at 1:40 PM revealed that he met his mother at the MD's office on 2/28/17 for a follow up appointment from the right knee surgery. The son stated that the MD removed the brace and on the back side of the heel area was a wound the size of a silver dollar. He stated it was draining yellow fluid and the MD placed some medicine and a bandage over it. The son stated that the MD wanted her to only have the brace on when she was out of bed due to the wound and he sent back orders for her to have the brace on only when out of bed on 2/28/17. Review of physician progress notes [REDACTED].#1 was seen in his office with family and he sent an order back for the resident to only have the brace on when out of bed. Interview with the DON on 6/8/17 at 3:10 PM revealed the above MD had moved out of state, his office was closed and he was unable to be interviewed. Review of the nurses' notes on 2/28/17 (6A-6P Shift) stated that the resident came back from the MD's office and the resident was to only where the brace to the leg when out of bed. Pain medications as ordered and to continue with therapy. The MD had ordered [MEDICATION NAME] 25 mcgs. The patch was to be changed every 72 hours and to give [MEDICATION NAME] between for break though pain. No skin assessment was documented. Interview with Staff member D (LVN Night Charge Nurse) revealed she worked at the facility full-time and the brace was always on her in bed at night, from the time she was admitted until her discharge on 3/19/17. Review of the last nurses note dated 3/18/17 at 11:30 PM revealed Resident #1 was transported to the emergency room due to chest pain and elevated temperature. She did not return to the facility. Review of the hospital medical record dated 3/19/17 revealed the resident was admitted to the hospital with [REDACTED]. The MD had to debride the wound at that time. Measurements of the wounds (in centimeters) were as follows: 1.5 X 0.8 X 0.1 and 1.5 X 0.5 X 0.1 with wound beds a mixture of granulation tissue. The MD debrided the wound into the subcutaneous level removing exudate approximately 2 X 2 CMs. Review of the National Pressure Sore Associaton (2017 -accessed 6/12/17) define a stage III Pressure Sore as a Full 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. On 06/02/17 at 9:30 AM at the time of the interview with Resident #1's daughter revealed she discharged the resident from the facility on 3/19/17. The daughter stated she moved Resident #1 to a different facility. The daughter stated Resident #1 was still going to wound care a few days a week due to the wound caused by the brace. Review of the Facility's Policy and Procedure for Skin Management Policy dated March 2016 revealed the resident should have a head to toe body evaluation completed on every resident upon admission or readmission and weekly thereafter. These evaluations will be documented on the Weekly Skin Integrity Review form. According to the Census and Condition given to the surveyor on 6/9/17 the facility had a total of 8 pressure sores.

Based on observations, interviews, and record reviews the facility failed to provide adequate supervision and assistance devices to prevent accidents for 2 Residents (#8 and #13) of 11 residents reviewed for falls. The facility failed to: a) provide adequate supervision to prevent accidents for Resident's #8 who had an admission [DIAGNOSES REDACTED]. Since admission the resident had three falls on [DATE], [DATE] and [DATE] with no updated fall reduction interventions. c) ensure staff were supervising Resident #8 (who had a recent Hip Fracture) on [DATE] for bed/chair alarm functionality when the bed alarm was not sounding, due to not being plugged in. Resident #8 fell out of bed with both side rails up. d) ensure staff were supervising Resident #13 for bed/chair alarm placement following a [DATE] fall when chair alarm was not placed in Resident #13's recliner as ordered. e) provide supervision for Resident #13's safety on [DATE] when staff failed to properly secure the resident's lap tray and activate his chair alarm. Resident #13 sustained a fall from his wheelchair. f) establish and implement a system for tracking Physical Therapy referrals due to falls, for recommendations for interventions for residents safety. These failures resulted in Immediate Jeopardy which was identified on [DATE] at 1:45 p.m. While the Immediate Jeopardy was removed on [DATE], the facility remained at a level of no actual harm with the potential for more than minimum harm at a pattern. These failures could result in accidents and injuries to any of the 55 residents who had 1 or more safety devices such as bed side rails, a bed alarm, and a chair alarm. Findings included: Resident #8 Review of Resident #8's Admission Face Sheet dated [DATE] revealed Resident #8 was admitted on [DATE] at 2:00 p.m. with the following Diagnosis: [REDACTED]. Resident #8 was [AGE] years old at the time of the investigation and survey. Review of Resident #8's Physician order [REDACTED]. Due to Resident confusion and an order for [REDACTED]. Review of Resident #8's Evaluation for use of side rails dated [DATE] revealed the following: Side rails were considered due to Resident #8 having a psychotic disorder. Resident #8's need for side rails was attributed to: a history of rolling out of the bed and fear of rolling out of the bed. Side rails were listed to assist Resident #8 with bed mobility, transfer, avoiding rolling out of the bed and for providing a sense of security. Side rails were recommended at the time of the assessment. No further side rail assessment documentation was located in Resident #8's chart. Review of Resident #8's Comprehensive Care Plan dated [DATE] revealed the following facility identified problems /needs for Resident #8; (1) Resident is at risk for falls as evidenced by: Cognitive Impairment; Schizophrenia, Bi-polar Disorder, Physical Impairment, Unsteady gait, Medications- Haldol, Past History of Falls, and Non-compliance. Goals established were listed as: Dignity will be maintained, incidence of falls will be reduced and no occurrences of injury will occur over the next 90 days. Approaches were listed as: Encourage resident to ask for assistance, Ensure call light is in reach, answer promptly, Therapy to evaluate and treat per orders, Anticipate needs, provide prompt assistance, Assure lighting is adequate and areas are free of clutter, Encourage socialization and activity attendance as tolerated, Place bed in lowest position. (2) Other Care plan Problems/ needs dated [DATE] were listed as: a. Resident Requires Assist with Activity's of Daily Living as evidenced by: Impaired mobility and cognition. b. Resident has Impaired Communication as evidenced by: Reduced ability to be understood by others, Reduced ability to understand others, Impaired daily decision making ability. c. Altered thought processes related to: Short term memory deficient, Behaviors, and Disorganized thinking. Review of Resident #8's Fall Risk assessment dated [DATE] revealed a score of 18; (Instructions listed on the form were: If the total score is 10 or greater , the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan.) Review of a facility Incident and Accident Report dated [DATE] at 10:35 a.m. revealed the following written statement by LVN 'A' : "Called to room by Assistant Director of Nursing (ADON), ADON 'A' who stated 'your resident is on the floor'. Went to room, resident lying on floor on her left side, awake and denies any complaints, moves all extremities, no internal or external rotations. Two CNA's at bedside, 'resident slid out of chair'. Chair alarm in place and operating well. Resident Assisted to bed with gait belt and assistance of two staff, bed alarm in place, side rails up times two, and call light in reach."Incident was witnessed. Actions taken: Resident Education. Incident Report was signed by DON and Administrator on [DATE]. Review of Resident #8's Comprehensive Care Plan updated on [DATE] revealed the following facility identified problems /needs for Resident #8; Falls: Increased risk related to: Glaucoma, Bi-polar disorder, Schizophrenia, Dementia with Behaviors, Lack of Coordination, Muscle Weakness, Depression, Non- Compliance (combative), and History of rolling out of bed. Goals established were listed as: Resident will be free of falls for 90 days. Approaches were listed as: Staff will keep resident room free from clutter and spills, Call light within reach, Staff will assess to reduce fall risk, Review drug profile prn with MD and Rx, Avoid relocating the furniture, Offer toileting prn, and encourage to use call light, Assist with ambulation/ transfers prn, report side effects of drugs to MD, Therapy as needed; on Physical therapy/ Occupational therapy (PT/OT), Restorative as needed; Fall Risk Score: 18. On [DATE] the care plan was updated and new approaches were listed as: 1) Refer to PT for screening following fall. ( Resident #8 was already recieving PT Services at this time). 2) Implement chair and bed alarms . (Resident #8 had physician orders [REDACTED]. Review of Resident #8's quarterly Minimum (MDS) data set [DATE] revealed the facility had identified the following: Resident #8 was sometimes understood and could sometimes understand others. Resident #8's vision was identified to be highly impaired. Signs and Symptoms of Delirium were assessed as "Behavior present, fluctuates" for Inattention and Disorganized thinking. Resident #8's Behavioral Symptoms- Presence and frequency was identified as Resident #8 having physical behavioral symptoms directed toward staff and verbal behavioral symptoms directed towards others occurring 1 to 3 days during the assessment period. Resident #8's Functional Status for Activities of Daily Living were identified as the following; Extensive assistance, two person physical assistance: Bed Mobility, Transfer, Toilet use and Bathing. Extensive assistance, one person physical assistance: Walk in corridor, Locomotion on unit, Dressing, Eating, and Personal Hygiene. Resident #8's Functional Limitations in Range of Motion were assessed as: Impairment one side, lower extremity. Resident #8 was frequently incontinent of bowel and bladder. Resident #8 was assessed as 64 inches in height and 99 lbs. in weight. Resident #8's assessment for Physical Restraints: Bed rails were listed as not used. ( Bed rails were not being used as a physical restraint, however bed rails were ordered to enable Resident #8's bed mobility.) Review of a facility Incident and Accident Report for Resident #8 dated [DATE] at 5:45 a.m. revealed the following written statement by Charge Nurse LVN 'B': "CNA reported Resident #8 on the floor, Found resident laying on the floor beside bed with her head resting against other bed (roommates) and feet under her bed, bed alarm was not sounding due to being unplugged. Alarm was working when last checked this shift, Side rails up times two. Resident #8 states left hip hurts at incision site, skin tear to left elbow measuring 0.5cm."Incident was unwitnessed. Actions taken: Care plan revision, First aid and X-ray. Incident Report was signed by DON and Administrator on [DATE]. Review of the facility Fall Investigation Worksheet dated [DATE] revealed: Resident #8's current medications were listed as; Antipsychotic, Antihypertensive. Resident #8 is on medications that can contribute to bruising was checked 'Yes' and NSAIDS were listed. Behavior at the time of this fall was listed as: Restless, Unknown (unwitnessed). Number of falls in the last 30 days was listed as: (1) and number of falls within the last ,[DATE] days was listed as (2). Activity at the time of fall was listed as: Resident got out of bed without calling for assistance. Review of Resident #8's Comprehensive Care Plan dated [DATE] revealed there were no new problems, goals or approaches listed to ensure Resident #8's safety despite the fall on [DATE] when Resident #8 fell out of bed onto the floor with both side rails up. Review of a facility document with the title; Nursing to Therapy dated [DATE] revealed the following: Fall on [DATE], Observed Resident lying on the floor beside her bed with her head against the other bed in the room and her feet under her bed. Bed alarm unplugged; alarm was working when checked earlier this shift. Side rails where up times two. Resident had complaints of her left hip hurting at incision site ( Incision site is in reference to the incision site from surgery following her Left Hip Fracture prior to admission to the facility). Resident had a skin tear on left elbow. Under Therapist recommendations dated [DATE] it stated "On Services." Review of Resident #8's Consolidated Physician orders [REDACTED]. 1) Side rails up when in bed as an enabler; ordered on [DATE] 2) Bed alert pad. Check every shift for proper placement and operation; ordered on [DATE] 3) Personal alarm on when in chair. Visual check every shift. Due to confusion; ordered on [DATE] Review of Resident #8's Care Plan Conference Summary dated [DATE] revealed ,"Fall Risk remains- poor safety awareness." Review of Resident #8's Physician order [REDACTED]. Review of Resident #8's Physician order [REDACTED]. Review of a facility Incident and Accident Report for Resident #8 dated [DATE] at 4:45 p.m. revealed the following written statement by LVN 'C': "Charge nurse heard a banging noise and then heard resident screaming, found resident on the floor, lying on her left side on the lower side of the bed. Resident was able to move all of her extremities. CNA asked her if she hit her head and Resident said 'Yes' . Resident was assisted back to bed. External Hematoma noted on residents left side of her forehead, skin tear noted on residents left elbow and left finger. Neurological checks started." (Written in another person's handwriting was a note stating: "Alarm sounding, Side rails up times two -discovered by charge nurse." )Actions taken: Care plan revision, First aid, Hospice notified, Therapy screening. Incident Report was signed by DON and Administrator on [DATE]. Review of the facility Fall Investigation Worksheet dated [DATE] at 4:45 p.m. revealed: Resident #8's current medications were listed as; Antipsychotic, Antihypertensive and Cardiovascular. Resident #8 is on medications that can contribute to bruising was checked' Yes' and NSAIDS were listed. Change in sleep pattern was checked 'No'. Behavior at the time of this fall was listed as: Unknown (unwitnessed). Change in mental status in the last 90 days, 'Yes'. Increase in confusion. Number of falls in the last 30 days was listed as: (0) and number of falls within the last ,[DATE] days was listed as (1). Activity at the time of fall was listed as: Unknown. Was resident using any assistive device; 'Yes' resident was using side rails. Review of Resident #8's Comprehensive Care Plan updated on [DATE] revealed the following facility identified problems /needs: Resident #8 fell out of her bed onto the floor with both side rails up. Approaches were listed as: Continue previous interventions, (No new interventions were listed on the care plan to increase Resident #8's safety or reduce incidence of falls). Attempts at education hindered by decreased cognitive ability and resident cussing and screaming, referred to PT for screening. (PT screening was explained by the DON to be a process in which PT assessed the resident and makes suggestions or recommendations as to which interventions might be established for each resident. PT screening is not a PT evaluation to determine if a resident is appropriate for PT Services.) Review of a facility "Nursing to Therapy" document dated [DATE] revealed the following: Fall on [DATE], Resident on the floor on her left side, able to move all extremities. Resident admits hitting head and left forehead has Hematoma. Skin tear left elbow and finger. In an observation on [DATE] at 4:20 p.m. Resident #8 was observed resting in bed with her eyes closed. Both full length side rails were observed to be up. Resident #8's bed alarm was observed to be placed under her in the bed and the monitor was observed to be in the ' On ' position. In an interview on [DATE] at 4:30 p.m. with Charge Nurse LVN ' D ' she stated Resident #8 had recently been moved to Hall 100 from the Rehab Hall (Hall 300). She stated Resident #8 had recently had a " major decline " in her cognitive level. She stated she felt Resident #8 was not cognitively able to use the call light to alert staff when she needed help. She stated she monitored Resident #8 closely to ensure she was safe. In an interview on [DATE] at 8:40 a.m. with CNA ' C ' he stated he did not feel Resident #8 was "mentally capable" of using the call light. He stated Resident #8 frequently draped her arm and/or leg over the side rail. He stated she did not like to lie on her left side due to having had a left hip fracture, therefore she laid on her right side the majority of the time. He stated the CNA's put a pillow up by the side rail by Resident #8's head due to Resident #8 scooting herself closer and closer towards the railing, and wanting to protect Resident #8 from hitting her head against the side rail. He stated the CNA's had to frequently reposition Resident #8 for her safety. He stated Resident #8 was identified to only need assistance from one person, but the CNA's usually used two people due to Resident #8, "fighting them". He stated he was working the night of [DATE] when Resident #8 fell and bruised her forehead, and he could tell by the way the sheets were draped over the side rails she had attempted to go over or had gone over the side rails. In an interview on [DATE] at 9:10 a.m. with CNA 'D' she stated Resident #8 had been observed on "multiple occasions" attempting to "scoot" down to the end of the bed and go over the side rails. She stated staff had to intervene and reposition Resident #8 back up in the bed. She stated she felt that Resident #8 had good days and bad days and on her bad days she needed to be monitored more closely due to being "restless". She stated she wasn't sure if Resident #8 was actually attempting to get out of the bed during the observations, however felt Resident #8 was very confused and possibly searching for something. In an observation on [DATE] at 9:40 a.m. revealed from the nursing station to the doorway of Resident #8's room was estimated to be 128 floor tiles. Each floor tiles was observed to be 12 square inches which placed Resident #8's room at the second door from the last room on the hall, and approximately 128 feet from the nursing station. In an interview on [DATE] at 10:15 a.m. with the Physical Therapist he verified nursing services did make referrals for "screening" of residents after falls. He stated the screenings were done by the order they were received. He stated there was not a pre-determined amount of days in which therapy needed to have completed the screening. He stated he was aware Resident #8 had a referral for screening and she had not been screened yet. the Physical Therapist stated residents were referred to therapy services to determine if they are good candidates for strengthening or to make recommendations for assistive devices. Resident # 8's Nursing to Therapy referral was dated [DATE]; as of eight days later on [DATE] at 10:15 a.m. Resident #8 still had not received screening from the Physical Therapy Department to possibly help prevent more falls. In an interview on [DATE] at 11:20 a.m. with CNA 'C' he stated within the last two weeks he was aware of "at least four to five occasions" Resident #8 required staff intervention due to Resident #8 "scooting" to the end of the bed and attempting to go over the side rails. CNA 'C' stated he has reported each episode of finding Resident #8 at the end of her bed, attempting to go over the side rails, to the charge nurse. He stated he has had concerns regarding Resident #8 falling from her bed and becoming injured and therefore when he is not attending to other residents, he stayed at the end of the hall around Resident #8's room. In an observation on [DATE] at 11:50 a.m. of Resident #8's bed alarm it was revealed, CNA ' C ' and a DADS surveyor entered Resident #8's room and triggered Resident #8's bed alarm system. Another DADS surveyor was stationed at the fire doors in the hall way. Another DADS surveyor was stationed at the nursing station. During the observation the DADS surveyor standing at the fire doors was able to hear the bed alarm system " faintly " . During the observation the DADS surveyor at the nursing station was unable to hear the bed alarm unless everything was completely silent. In an interview on [DATE] at 1:20 p.m. with Charge Nurse LVN 'E' she stated the CNA's had been reporting to her regarding having to intervene in Resident #8's attempts to scoot to the bottom of the bed and go over the side rails. She stated Resident #8 has a bed alarm and was monitored closely. Further stating, " But she falls anyway. " Immediate Jeopardy was identified on [DATE] at 1:45 p.m. In an interview/observation on [DATE] at 4:45 p.m. with Charge Nurse LVN ' D ' she stated Resident #8's room had been modified to ensure she was no longer a fall risk. Observation of the room revealed Resident #8's bed had been changed to a low bed, side rails were removed and mats were lying on both sides of the bed. During this observation Charge Nurse LVN ' D ' noticed side rails mounting equipment had been left on the bed and presented a risk for skin tears for Resident #8 and mats that had been placed on the floor beside Resident #8's bed created a potential fall hazard for Resident #8's roommate. She stated she would notify maintenance immediately about the safety hazards. In an interview/observation on [DATE] at 4:55 p.m. with ADON ' B ' she stated during and observation of Resident #8's room, she felt having mats on the floor around Resident #8's bed created a risk for Resident #8's roommate to fall due to being independent with transfers. She also stated she felt the side rail mounting equipment that had been left on the bed created a " real risk for injury " . She stated the issues would be taken care of " immediately " . Review of Resident #8's Physician order [REDACTED]. 1) [DATE] (no documented time) - PT to evaluate and treat due to fall and check for modifications to wheelchair. 2) [DATE] (no documented time) - Low bed with floor mats for safety. 3) [DATE] (no documented time) - Discontinue side rails. 4) [DATE] at 5:40 p.m.-Lap Buddy to wheelchair, release and reposition every 2 hours for 10 minutes. Review of previously reviewed Nursing to Therapy document dated [DATE] revealed PT had completed the therapy screening on Resident #8 on [DATE] (no documented time), and had determined Resident #8 to be " Currently on Hospice Services for terminal process. Appropriate precautions are in place. Received PT/OT in last 30 days and maximum potential reached." Review of Resident #8's Record of Death and Mortician's receipt dated [DATE] at 11:32 p.m. revealed Resident #8 had died . In an interview on [DATE] at 8:45 a.m. with Charge Nurse LVN ' B ' she stated the CNA's had alerted her to Resident #8's multiple attempts to scoot to the end of the bed and try to go over the side rails. She stated when she made rounds she had observed Resident #8 at the end of the bed, and Resident #8 was frequently found with an arm or leg hanging over the side rails. She stated she did not feel that Resident #8 was actually trying to get out of the bed; she stated she felt Resident #8 was confused and restless. She stated " Sometimes residents get confused and try to get out of the bed without first calling for assistance, sometimes even over the side rails."She stated Resident #8 had times when she was very confused, combative and resistant of care. In an interview on [DATE] at 9:15 a.m. with the DON she stated she had been notified of Resident #8's falls. She stated she had not been notified by CNA's or charge nurses regarding concerns of Resident #8 scooting to the end of the bed and attempting to go over the side rails. She stated, " A lot of the residents scoot towards the end of the bed, but it does become a problem when issues are not passed on."She stated she felt the CNA's and charge nurses were viewing Resident #8's behaviors of scooting to the end of the bed and attempting to go over the side rails, as normal behaviors and not realizing the severity. She stated she had an " open door policy " regarding any concerns the staff had with any of the residents, but generally the staff would initially report any concerns to ADON ' A ' . In an interview on [DATE] at 9:30 a.m. with ADON ' A ' she stated she was not aware of observations and concerns regarding Resident #8 attempting to scoot to the end of the bed and go over the side rails. She stated she was aware of Resident #8 frequently having her arm or leg hanging over the side rail, but had not observed the behavior as being a safety issue. She stated she was aware of Resident #8's falls and had been awaiting results from PT screening and recommendations for interventions. In an interview on [DATE] at 10:35 a.m. with ADON ' C ' she stated any of the nursing staff who observes a resident has had a condition change or a fall and feels the PT department might be able to help that resident, can fill out a form ( Nursing referral to Therapy). The forms are then sent to the Physical Therapy Department, she stated " I generally give it to the PT secretary ". Once PT has evaluated the resident they " get back to nursing " and tell them if they recommend any physical therapy. She stated there had not been any set time frame for PT to screen the resident and " get back to nursing " with their recommendations. She stated she did not have a time frame in which she would follow-up with the Physical Therapy Department, stating " There's nothing cut in stone. It's an open back and forth communication between nursing and therapy." Resident # 13 (Closed Record) Review of Resident # 13 MDS 3.0 dated [DATE] revealed he was admitted to the facility on [DATE], Resident # 13 would have been [AGE] years old at the time of the survey. Resident #13 died on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of the physician consolidated orders dated [DATE] for Resident # 13 revealed safety devices to include: 1) Personal alarm on when in recliner 2) Visual checks every 2 hours for toileting 3) A personal alarm to the low bed with mat 4) A lap tray to wheelchair 5) Resident # 13 required 1 person plus the use of the gait belt for transfers Review of the facility Incident/Accident Report dated [DATE] revealed Resident # 13 was observed on the floor between the recliner and the bed. The alarm was plugged into the bed sensor not the recliner. The alarm was functioning correctly. Review of the documented entitled Confidential Employee Corrective Action Form dated [DATE] provided by the facility revealed CNA ' A ' failed to properly check and activated chair alarm when transferring Resident #13 to the recliner on [DATE]. CNA ' A ' failed to follow correct transfer protocol. Review of the facility Incident/Accident Report dated [DATE] revealed Resident # 13 was observed on the floor bedside his wheelchair. Resident # 13 stated he slid from the wheelchair. The lap tray was not in place and the seat belt was not in working condition. Review of the facility document entitled Nursing to Therapy dated [DATE] for resident # 13 was referred to physical therapy for: Observed lying on floor beside wheelchair, stated he slid from the wheelchair on [DATE]-lap tray was not in place, no injuries noted. Documentation under Therapist Recommendation: Therapy screen completed dated on [DATE]. Review of Nurse notes, care plans, physician orders [REDACTED].# 13 chart related to protection from falls. Review of the documented entitled Confidential Employee Corrective Action Form dated [DATE] provided by the facility revealed CNA ' B ' failed to place lap tray on wheelchair and no alarm was placed on the wheelchair. Review of the document entitled Fall Risk Assessment last updated [DATE] revealed Resident #13 scored an 18. Total score of 10 or above represents HIGH RISK. Review of care plans updated [DATE] for Resident # 13 revealed he was at increase risk for falls with staff interventions to include: the use of the low bed with a mat, a visual inspection and bed/recliner alarm to be checked every shift, a lap tray, a gait belt for transfers, and monitor to assure resident's safety, apply and release restraints per physician order. Review of a document entitled Nursing to Therapy dated [DATE] provided by the facility, revealed Resident # 13 was referred to Physical Therapy for fall evaluation. Under Therapist Recommendations dated [DATE] was written Resident deceased . The Nursing to Therapy document was addressed 23 days after it was written and 4 days after Resident # 13 was deceased . Review of the document entitled Physical Restraint Elimination Review dated [DATE] provided by the facility revealed. Resident # 13 was unable to remove the lap tray, and had poor trunk control. Facility Plan to Lift Immediate Jeopardy On [DATE] at 1:40 p.m. an acceptable Plan of Removal of the Immediate Jeopardy (IJ) was submitted. According to this plan, the facility implemented new care plan interventions for Resident #8, including the provision of a low bed and floor mats. The siderails were removed from Resident #8's bed. The resident's bed was placed against a wall, and some of the room furniture was re-arranged to provide a safer environment. These interventions were completed on [DATE] at 3:00 p.m. The facility administrative staff were to review all other residents who had orders for siderails, and a review of all fall accidents which occurred in the previous 30 days were to be reviewed. Residents with siderails were to be assessed to determine whether the siderails presented an accident hazard, and care plan interventions were to be reviewed for residents with falls to determined whether those interventions were appropriate and adequate to minimize resident risk of falls. These assessments were to be completed by [DATE]. The director of nurses was to provide staff inservice on fall prevention and reporting incidents. All staff were to receive the inservice training by [DATE] at 2:00 p.m. Plan of Removal Verification Interview on [DATE] at 3:55 p.m. with CNA ' E ' she was able to explain the in-service conducted by the facility regarding falls, safety hazards, transfers, and reporting to Charge Nurse any and all significant changes/ and or concerns regarding the residents. Observation on [DATE] at 10:00 a.m. revealed the director of nurses presented an inservice class to 10 staff members. The subjects of the inservice included accident hazards, fall risk, and the reporting of potential hazardous situations. Staff were required to complete a written test at the end of the inservice class. Interview on [DATE] at 8:15 a.m. with CNA ' F ' she stated the in-service conducted by the facility covered safety issues, keeping the area free of hazards, transfers, and reporting changes regarding the residents to the Charge Nurse. If the staff did not see any interventions being initiated by the Charge Nurse to report to the Director of Nursing. In an interview on [DATE] at 8:15 a.m. with CMA 'A' stated he had been to the staff inservice and the subject discussed was accident hazards, fall risk, and the reporting of potential hazardous situations or abnormal findings to the ADON or the DON in order to ensure safety of the residents. He stated staff was to report all falls or potential safety hazards to the charge nurse immediately, and if the situation was not rectified, staff was to notify the ADON or DON with their concerns In an interview on [DATE] at 9:00 a.m. with the DON she stated ADON 'C' had been making the nursing referrals to therapy for screening residents following falls. She stated ADON 'C' had not been doing follow-up with the Physical Therapy Department regarding resident screenings. She stated she had not been monitoring ADON 'C' regarding referrals to Physical Therapy. She stated ADON 'C' will now be making a copy of the "Nursing referral to Therapy" document and DON would be receiving a copy. She stated the Physical Therapy Department had not had a specific amount of days to screen residents whom had been referred, that it was open-ended; however since the Immediate Jeopardy, now the Physical Therapy department had 24 hours to screen residents who had been referred to the Physical Therapy Department. She stated the Nursing Department made referrals to Physical Therapy for screening to make recommendations for interventions for the residents. She stated prior to the Immediate Jeopardy she had not been facilitating any new safety interventions for residents in the interim of awaiting their PT screening, stating " We keep monitoring the residents."She stated since the Immediate Jeopardy the facility would be reviewing falls on a daily basis during the morning meeting and interventions would be put into place to ensure the safety of the residents. The Immediate Jeopardy was lowered to potential for more than minimal harm a pattern prior to the exit on [DATE] at 11:30 a.m. According to a printed physician orders [REDACTED].

Based on observations, interviews and record review the administrator, director of nurses, and the charge nurses failed to administer the facility in a manner that enabled it to use resources effectively to attain the highest practicable well being for 2 Residents ( Resident #8 and #13) of 11 residents reviewed for falls. Administrator failed to: a) monitor and supervise the responsibilities of the DON to ensure the DON carried out her responsibilities to direct nursing care to the facility residents. Director of Nursing Services failed to: a) ensure that nursing staff provided adequate supervision to prevent accidents for Resident's #8 who had an admission [DIAGNOSES REDACTED]. The resident had three falls on [DATE], [DATE] and [DATE] after being admitted to the facility. There were no updated fall reduction interventions after these falls. b) educate nursing staff regarding immediately reporting potential accidents and hazards when Charge Nurse's LVN 'B' and LVN 'E' were aware of Resident #8's multiple attempts to scoot to the bottom of the bed and go over the side rails. The Charge Nurse's failed to report concerns for Resident #8's safety to ADON or DON. c) evaluate Resident #8's fall risk factors (History of falls in and out of the facility, [DIAGNOSES REDACTED]. d) monitor and supervise the responsibilities of the charge nurses to ensure the charge nurses carried out their responsibilities of nursing care by supervising the CNA's to protect the facility residents from falls and injuries. g) establish and implement a system for tracking Physical Therapy referrals after Resident's #8 and #13 had "Nursing to Physical Therapy" referral's after falls. The PT referrals were not completed in a timely manner for either resident. Charge Nurses failed to: a) provide adequate supervision to Resident #8 who was identified as a high risk for falls. b) report potential accidents and hazards for Resident #8 when Charge Nurse's LVN 'B' and LVN 'E' were aware of Resident #8's multiple attempts to scoot to the bottom of the bed and go over the side rails and failed to report concerns for Resident #8's safety to ADON or DON. c) supervise CNA's proper utilization of bed/chair alarms and monitoring for functionality when bed alarms. On [DATE] Resident #8 fell out of bed with both side rails up. Staff had not plugged the bed alarm in prior to this incident.. d) supervise Resident #13's safety when CNA's failed to properly secure his lap tray and activate his chair alarm which resulted in Resident #13 falling out of his wheelchair on [DATE]. These failures resulted in Immediate Jeopardy which was identified on [DATE]. While the Immediate Jeopardy was removed on [DATE], the facility remained at a level of no actual harm with the potential for more than minimum harm at a pattern. These failures could result in accidents and injuries to any of the 55 residents who had 1 or more safety devices such as bed side rails, a bed alarm, and a chair alarm. Findings included: Resident #8 Review of Resident #8's Admission Face Sheet dated [DATE] revealed Resident #8 was admitted on [DATE] at 2:00 p.m. with the following Diagnosis: [REDACTED]. Resident #8 was [AGE] years old at the time of the investigation and survey. Review of Resident #8's Physician order [REDACTED]. Review of Resident #8's Evaluation for use of side rails dated [DATE] revealed the following: Side rails were considered due to Resident #8 having a [MEDICAL CONDITION]. Resident #8's need for side rails was attributed to: a history of rolling out of the bed and fear of rolling out of the bed. Side rails were listed to assist Resident #8 with bed mobility, transfer, avoiding rolling out of the bed and for providing a sense of security. Side rails were recommended at the time of the assessment. No further side rail assessment documentation was located in Resident #8's chart. Review of Resident #8's Comprehensive Care Plan dated [DATE] revealed the following facility identified problems /needs for Resident #8; (1) Resident is at risk for falls as evidenced by: Cognitive Impairment; [MEDICAL CONDITION], Bi-polar Disorder, Physical Impairment, Unsteady gait, Medications- [MEDICATION NAME], Past History of Falls, and Non-compliance. Goals established were listed as: Dignity will be maintained, incidence of falls will be reduced and no occurrences of injury will occur over the next 90 days. Approaches were listed as: Encourage resident to ask for assistance, Ensure call light is in reach, answer promptly, Therapy to evaluate and treat per orders, Anticipate needs, provide prompt assistance, Assure lighting is adequate and areas are free of clutter, Encourage socialization and activity attendance as tolerated, Place bed in lowest position. (2) Other Care plan Problems/ needs dated [DATE] were listed as: a. Resident Requires Assist with Activity's of Daily Living as evidenced by: Impaired mobility and cognition. b. Resident has Impaired Communication as evidenced by: Reduced ability to be understood by others, Reduced ability to understand others, Impaired daily decision making ability. c. Altered thought processes related to: Short term memory deficient, Behaviors, and Disorganized thinking. Review of Resident #8's Fall Risk assessment dated [DATE] revealed a score of 18; (Instructions listed on the form were: If the total score is 10 or greater , the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan.) Review of a facility Incident and Accident Report dated [DATE] at 10:35 a.m. revealed the following written statement by LVN 'A' : "Called to room by Assistant Director of Nursing (ADON), ADON 'A' who stated 'your resident is on the floor'. Went to room, resident lying on floor on her left side, awake and denies any complaints, moves all extremities, no internal or external rotations. Two CNA's at bedside, 'resident slid out of chair'. Chair alarm in place and operating well. Resident Assisted to bed with gait belt and assistance of two staff, bed alarm in place, side rails up times two, and call light in reach."Incident was witnessed. Actions taken: Resident Education. Incident Report was signed by DON and Administrator on [DATE]. Review of Resident #8's Comprehensive Care Plan updated on [DATE] revealed the following facility identified problems /needs for Resident #8; Falls: Increased risk related to: [MEDICAL CONDITION], Bi-polar disorder, [MEDICAL CONDITION], Dementia with Behaviors, Lack of Coordination, Muscle Weakness, Depression, Non- Compliance (combative), and History of rolling out of bed. Goals established were listed as: Resident will be free of falls for 90 days. Approaches were listed as: Staff will keep resident room free from clutter and spills, Call light within reach, Staff will assess to reduce fall risk, Review drug profile prn with MD and Rx, Avoid relocating the furniture, Offer toileting prn, and encourage to use call light, Assist with ambulation/ transfers prn, report side effects of drugs to MD, Therapy as needed; on Physical therapy/ Occupational therapy (PT/OT), Restorative as needed; Fall Risk Score: 18. On [DATE] the care plan was updated and new approaches were listed as: 1) Refer to PT for screening following fall. This was not a new intervention Resident #8 was already recieving PT Services. 2) Implement chair and bed alarms . This was not a new intervention becaus Resident #8 had physician orders [REDACTED]. Review of Resident #8's quarterly Minimum (MDS) data set [DATE] revealed the facility had identified the following: Resident #8 was sometimes understood and could sometimes understand others. Resident #8's vision was identified to be highly impaired. Signs and Symptoms of [MEDICAL CONDITION] were assessed as "Behavior present, fluctuates" for Inattention and Disorganized thinking. Resident #8's Behavioral Symptoms- Presence and frequency was identified as Resident #8 having physical behavioral symptoms directed toward staff and verbal behavioral symptoms directed towards others occurring 1 to 3 days during the assessment period. Resident #8's Functional Status for Activities of Daily Living were identified as the following; Extensive assistance, two person physical assistance: Bed Mobility, Transfer, Toilet use and Bathing. Extensive assistance, one person physical assistance: Walk in corridor, Locomotion on unit, Dressing, Eating, and Personal Hygiene. Resident #8's Functional Limitations in Range of Motion were assessed as: Impairment one side, lower extremity. Resident #8 was frequently incontinent of bowel and bladder. Resident #8 was assessed as 64 inches in height and 99 lbs. in weight. Resident #8's assessment for Physical Restraints: Bed rails were listed as not used. ( Bed rails were not being used as a physical restraint, however bed rails were ordered to enable Resident #8's bed mobility.) Review of a facility Incident and Accident Report for Resident #8 dated [DATE] at 5:45 a.m. revealed the following written statement by Charge Nurse LVN 'B': "CNA reported Resident #8 on the floor, Found resident laying on the floor beside bed with her head resting against other bed (roommates) and feet under her bed, bed alarm was not sounding due to being unplugged. Alarm was working when last checked this shift, Side rails up times two. Resident #8 states left hip hurts at incision site, skin tear to left elbow measuring 0.5cm."Incident was unwitnessed. Actions taken: Care plan revision, First aid and X-ray. Incident Report was signed by DON and Administrator on [DATE]. Review of the facility Fall Investigation Worksheet dated [DATE] revealed: Resident #8's current medications were listed as; Antipsychotic, Antihypertensive. Resident #8 is on medications that can contribute to bruising was checked 'Yes' and NSAIDS were listed. Behavior at the time of this fall was listed as: Restless, Unknown (unwitnessed). Number of falls in the last 30 days was listed as: (1) and number of falls within the last ,[DATE] days was listed as (2). Activity at the time of fall was listed as: Resident got out of bed without calling for assistance. Review of Resident #8's Comprehensive Care Plan updated [DATE], Revealed no new problems or interventions listed. No goals or approaches were listed to ensure Resident #8's safety following a fall on [DATE] when Resident #8 fell out of bed onto the floor with both side rails up. Review of a facility document with the title; Nursing to Therapy dated [DATE] revealed the following: Fall on [DATE], Observed Resident lying on the floor beside her bed with her head against the other bed in the room and her feet under her bed. Bed alarm unplugged; alarm was working when checked earlier this shift. Side rails where up times two. Resident had complaints of her left hip hurting at incision site ( Incision site is in reference to the incision site from surgery following her Left [MEDICAL CONDITION] prior to admission to the facility). Resident had a skin tear on left elbow. Under Therapist recommendations dated [DATE] it stated "On Services." (Meaning the resident was currently receiving phyisical therapy). Review of Resident #8's Consolidated Physician orders [REDACTED]. 1) Side rails up when in bed as an enabler; ordered on [DATE] 2) Bed alert pad. Check every shift for proper placement and operation; ordered on [DATE] 3) Personal alarm on when in chair. Visual check every shift. Due to confusion; ordered on [DATE] Review of Resident #8's Care Plan Conference Summary dated [DATE] revealed ,"Fall Risk remains- poor safety awareness." Review of Resident #8's Physician order [REDACTED]. Review of Resident #8's Physician order [REDACTED]. Review of a facility Incident and Accident Report for Resident #8 dated [DATE] at 4:45 p.m. revealed the following written statement by LVN 'C': "Charge nurse heard a banging noise and then heard resident screaming, found resident on the floor, lying on her left side on the lower side of the bed. Resident was able to move all of her extremities. CNA asked her if she hit her head and Resident said 'Yes' . Resident was assisted back to bed. External Hematoma noted on residents left side of her forehead, skin tear noted on residents left elbow and left finger. Neurological checks started." (Written in another person's handwriting was a note stating: "Alarm sounding, Side rails up times two -discovered by charge nurse." )Actions taken: Care plan revision, First aid, Hospice notified, Therapy screening. Incident Report was signed by DON and Admonistrator on [DATE]. Review of the facility Fall Investigation Worksheet dated [DATE] at 4:45 p.m. revealed: Resident #8's current medications were listed as; Antipsychotic, Antihypertensive and Cardiovascular. Resident #8 is on medications that can contribute to bruising was checked' Yes' and NSAIDS were listed. Change in sleep pattern was checked 'No'. Behavior at the time of this fall was listed as: Unknown (unwitnessed). Change in mental status in the last 90 days, 'Yes'. Increase in confusion. Number of falls in the last 30 days was listed as: (0) and number of falls within the last ,[DATE] days was listed as (1). Activity at the time of fall was listed as: Unknown. Was resident using any assistive device; 'Yes' resident was using side rails. Review of Resident #8's Comprehensive Care Plan updated on [DATE] revealed the following facility identified problems /needs for Resident #8: No new interventions were listed on the care plan to increase Resident #8's safety or reduce incidence of falls Resident #8 fell out of her bed onto the floor with both side rails up. Approaches were listed as: Continue previous interventions. Attempts at education hindered by decreased cognitive ability and resident cussing and screaming, referred to PT for screening. (PT screening was explained by the DON to be a process in which PT assessed the resident and made suggestions or recommendations as to which interventions might be established for each resident. According to the DON (PT) screening is not the same as (PT) evaluation to determine if a resident is appropriate for PT Services. Review of a facility "Nursing to Therapy" document dated [DATE] revealed the following: Fall on [DATE], Resident on the floor on her left side, able to move all extremities. Resident admits hitting head and left forehead has Hematoma. Skin tear left elbow and finger. In an observation on [DATE] at 4:20 p.m. Resident #8 was observed resting in bed with her eyes closed. Both full length side rails were observed to be up. Resident #8's bed alarm was observed to be placed under her in the bed and the monitor was observed to be in the ' On ' position. In an interview on [DATE] at 4:30 p.m. with Charge Nurse LVN ' D ' she stated Resident #8 had recently been moved to Hall 100 from the Rehab Hall (Hall 300). She stated Resident #8 had recently had a " major decline " in her cognitive level. She stated she felt Resident #8 was not cognitively able to use the call light to alert staff when she needed help. She stated she monitored Resident #8 closely to ensure she was safe. In an interview on [DATE] at 8:40 a.m. with CNA ' C ' he stated he did not feel Resident #8 was "mentally capable" of using the call light. He stated Resident #8 frequently draped her arm and/or leg over the side rail. He stated she did not like to lie on her left side due to having had a left [MEDICAL CONDITION], therefore she laid on her right side the majority of the time. He stated the CNA's put a pillow up by the side rail by Resident #8's head due to Resident #8 scooting herself closer and closer towards the railing, and wanting to protect Resident #8 from hitting her head against the side rail. He stated the CNA's had to frequently reposition Resident #8 for her safety. He stated Resident #8 was identified to only need assistance from one person, but the CNA's usually used two people due to Resident #8, "fighting them". He stated he was working the night of [DATE] when Resident #8 fell and bruised her forehead, and he could tell by the way the sheets were draped over the side rails she had attempted to go over or had gone over the side rails. In an interview on [DATE] at 9:10 a.m. with CNA 'D' she stated Resident #8 had been observed on "multiple occasions" attempting to "scoot" down to the end of the bed and go over the side rails. She stated staff had to intervene and reposition Resident #8 back up in the bed. She stated she felt that Resident #8 had good days and bad days and on her bad days she needed to be monitored more closely due to being "restless". She stated she wasn't sure if Resident #8 was actually attempting to get out of the bed during the observations, however felt Resident #8 was very confused and possibly searching for something. In an observation on [DATE] at 9:40 a.m. revealed from the nursing station to the doorway of Resident #8's room was estimated to be 128 floor tiles. Each floor tiles was observed to be 12 square inches which placed Resident #8's room at the second door from the last room on the hall, and approximately 128 feet from the nursing station. In an Interview on [DATE] at 10:15 a.m. with Physical Therapist he verified nursing services did make referrals for "screening" of residents after falls. He stated the screenings were done in the order they were received. He stated there was not a pre-determined amount of days in which therapy needed to have completed the screenings. He stated he was aware Resident #8 had a referral for screening and he said she had not been screened yet. The Physical Therapist stated residents were referred to therapy services to determine if they are good candidates for strengthening or to make recommendations for assistive devices. Resident # 8's Nursing to Therapy referral was dated [DATE]; as of eight days later on [DATE] at 10:15 a.m. Resident #8 had not received screening from Physical Therapy Department to possibly help prevent more falls. In an interview on [DATE] at 11:20 a.m. with CNA 'C' he stated within the last two weeks he was aware of "at least four to five occasions" Resident #8 required staff intervention due to Resident #8 "scooting" to the end of the bed and attempting to go over the side rails. CNA 'C' stated he has reported each episode of finding Resident #8 at the end of her bed, attempting to go over the side rails, to the charge nurse. He stated he has had concerns regarding Resident #8 falling from her bed and becoming injured and therefore when he is not attending to other residents, he stayed at the end of the hall around Resident #8's room. In an observation on [DATE] at 11:50 a.m. of Resident #8's bed alarm it was revealed, CNA ' C ' and a DADS surveyor entered Resident #8's room and triggered Resident #8's bed alarm system. Another DADS surveyor was stationed at the fire doors in the hall way. Another DADS surveyor was stationed at the nursing station. During the observation the DADS surveyor standing at the fire doors was able to hear the bed alarm system " faintly " . During the observation the DADS surveyor at the nursing station was unable to hear the bed alarm unless everything was completely silent. In an interview on [DATE] at 1:20 p.m. with Charge Nurse LVN 'E' she stated the CNA's had been reporting to her regarding having to intervene in Resident #8's attempts to scoot to the bottom of the bed and go over the side rails. She stated Resident #8 has a bed alarm and was monitored closely. Further stating, " But she falls anyway. " Immediate Jeopardy was identified on [DATE] at 1:45 p.m. In an interview/observation on [DATE] at 4:45 p.m. with Charge Nurse LVN ' D ' she stated Resident #8's room had been modified to ensure she was no longer a fall risk. Observation of the room revealed Resident #8's bed had been changed to a low bed, side rails were removed and mats were lying on both sides of the bed. During this observation Charge Nurse LVN ' D ' noticed side rails mounting equipment had been left on the bed and presented a risk for skin tears for Resident #8 and mats that had been placed on the floor beside Resident #8's bed created a potential fall hazard for Resident #8's roommate. She stated she would notify maintenance immediately about the safety hazards. In an interview/observation on [DATE] at 4:55 p.m. with ADON ' B ' she stated during and observation of Resident #8's room, she felt having mats on the floor around Resident #8's bed created a risk for Resident #8's roommate to fall due to being independent with transfers. She also stated she felt the side rail mounting equipment that had been left on the bed created a " real risk for injury " . She stated the issues would be taken care of " immediately " . Review of Resident #8's Physician order [REDACTED]. 1) [DATE] (no documented time) - PT to evaluate and treat due to fall and check for modifications to wheelchair. 2) [DATE] (no documented time) - Low bed with floor mats for safety. 3) [DATE] (no documented time) - Discontinue side rails. 4) [DATE] at 5:40 p.m.-Lap Buddy to wheelchair, release and reposition every 2 hours for 10 minutes. Review of previously reviewed Nursing to Therapy document dated [DATE] revealed PT had completed the therapy screening on Resident #8 on [DATE] (no documented time), and had determined Resident #8 to be " Currently on Hospice Services for terminal process. Appropriate precautions are in place. Received PT/OT in last 30 days and maximum potential reached." Review of Resident #8's Record of Death and Mortician's receipt dated [DATE] at 11:32 p.m. revealed Resident #8 had died . In an interview on [DATE] at 8:45 a.m. with Charge Nurse LVN ' B ' she stated the CNA's had alerted her to Resident #8's multiple attempts to scoot to the end of the bed and try to go over the side rails. She stated when she made rounds she had observed Resident #8 at the end of the bed, and Resident #8 was frequently found with an arm or leg hanging over the side rails. She stated she did not feel that Resident #8 was actually trying to get out of the bed; she stated she felt Resident #8 was confused and restless. She stated Sometimes residents get confused and try to get out of the bed without first calling for assistance, sometimes they even go over the side rails. She stated Resident #8 had times when she was very confused, combative and resistant of care. In an interview on [DATE] at 9:15 a.m. with the DON she stated she had been notified of Resident #8's falls. She stated she had not been notified by CNA's or charge nurses regarding concerns of Resident #8 scooting to the end of the bed and attempting to go over the side rails. She stated, " A lot of the residents scoot towards the end of the bed, but it does become a problem when issues are not passed on."She stated she felt the CNA's and charge nurses were viewing Resident #8's behaviors of scooting to the end of the bed and attempting to go over the side rails, as normal behaviors and not realizing the severity. She stated she had an " open door policy " regarding any concerns the staff had with any of the residents, but generally the staff would initially report any concerns to ADON ' A ' . In an interview on [DATE] at 9:30 a.m. with ADON ' A ' she stated she was not aware of observations and concerns regarding Resident #8 attempting to scoot to the end of the bed and go over the side rails. She stated she was aware of Resident #8 frequently having her arm or leg hanging over the side rail, but had not observed the behavior as being a safety issue. She stated she was aware of Resident #8's falls and had been awaiting results from PT screening and recommendations for interventions. In an interview on [DATE] at 10:35 a.m. with ADON ' C ' she stated any of the nursing staff who observes a resident has had a condition change or a fall and feels the PT department might be able to help that resident, can fill out a form ( Nursing referral to Therapy). The forms are then sent to the Physical Therapy Department, she stated " I generally give it to the PT secretary ". Once PT has evaluated the resident they " get back to nursing " and tell them if they recommend any physical therapy. She stated there had not been any set time frame for PT to screen the resident and " get back to nursing " with their recommendations. She stated she did not have a time frame in which she would follow-up with the Physical Therapy Department, stating " There's nothing cut in stone. It's an open back and forth communication between nursing and therapy." Resident # 13 (Closed Record) Review of Resident # 13 MDS 3.0 dated [DATE] revealed he was admitted to the facility on [DATE], Resident # 13 would have been [AGE] years old at the time of the survey. Resident #13 died on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of the physician consolidated orders dated [DATE] for Resident # 13 revealed safety devices to include: 1) Personal alarm on when in recliner 2) Visual checks every 2 hours for toileting 3) A personal alarm to the low bed with mat 4) A lap tray to wheelchair 5) Resident # 13 required 1 person plus the use of the gait belt for transfers Review of the facility Incident/Accident Report dated [DATE] revealed Resident # 13 was observed on the floor between the recliner and the bed. The alarm was plugged into the bed sensor not the recliner. The alarm was functioning correctly. Review of the documented entitled Confidential Employee Corrective Action Form dated [DATE] provided by the facility revealed CNA ' A ' failed to properly check and activated chair alarm when transferring Resident #13 to the recliner on [DATE]. CNA ' A ' failed to follow correct transfer protocol. Review of the facility Incident/Accident Report dated [DATE] revealed Resident # 13 was observed on the floor bedside his wheelchair. Resident # 13 stated he slid from the wheelchair. The lap tray was not in place and the seat belt was not in working condition. Review of the facility document entitled Nursing to Therapy dated [DATE] for resident # 13 was referred to physical therapy for: Observed lying on floor beside wheelchair, stated he slid from the wheelchair on [DATE]-lap tray was not in place, no injuries noted. Documentation under Therapist Recommendation: Therapy screen completed dated on [DATE]. Review of Nurse notes, care plans, physician orders [REDACTED].# 13 chart related to protection from falls. Review of the documented entitled Confidential Employee Corrective Action Form dated [DATE] provided by the facility revealed CNA ' B ' failed to place lap tray on wheelchair and no alarm was placed on the wheelchair. Review of the document entitled Fall Risk Assessment last updated [DATE] revealed Resident #13 scored an 18. Total score of 10 or above represents HIGH RISK. Review of care plans updated [DATE] for Resident # 13 revealed he was at increase risk for falls with staff interventions to include: the use of the low bed with a mat, a visual inspection and bed/recliner alarm to be checked every shift, a lap tray, a gait belt for transfers, and monitor to assure resident's safety, apply and release restraints per physician order. Review of a document entitled Nursing to Therapy dated [DATE] provided by the facility, revealed Resident # 13 was referred to Physical Therapy for fall evaluation. Under Therapist Recommendations dated [DATE] was written Resident deceased . The Nursing to Therapy document was addressed 23 days after it was written and 4 days after Resident # 13 was deceased . Review of the document entitled Physical Restraint Elimination Review dated [DATE] provided by the facility revealed. Resident # 13 was unable to remove the lap tray, and had poor trunk control. Facility Plan to Lift Immediate Jeopardy On [DATE] at 1:40 p.m. an acceptable Plan of Removal of the Immediate Jeopardy (IJ) was submitted. According to this plan, the facility implemented new care plan interventions for Resident #8, including the provision of a low bed and floor mats. The siderails were removed from Resident #8's bed. The resident's bed was placed against a wall, and some of the room furniture was re-arranged to provide a safer environment. These interventions were completed on [DATE] at 3:00 p.m. The facility administrative staff were to review all other residents who had orders for siderails, and a review of all fall accidents which occurred in the previous 30 days were to be reviewed. Residents with siderails were to be assessed to determine whether the siderails presented an accident hazard, and care plan interventions were to be reviewed for residents with falls to determined whether those interventions were appropriate and adequate to minimize resident risk of falls. These assessments were to be completed by [DATE]. The director of nurses was to provide staff inservice on fall prevention and reporting incidents. All staff were to receive the inservice training by [DATE] at 2:00 p.m. Plan of Removal Verification Interview on [DATE] at 3:55 p.m. with CNA ' E ' she was able to explain the in-service conducted by the facility regarding falls, safety hazards, transfers, and reporting to Charge Nurse any and all significant changes/ and or concerns regarding the residents. Observation on [DATE] at 10:00 a.m. revealed the director of nurses presented an inservice class to 10 staff members. The subjects of the inservice included accident hazards, fall risk, and the reporting of potential hazardous situations. Staff were required to complete a written test at the end of the inservice class. Interview on [DATE] at 8:15 a.m. with CNA ' F ' she stated the in-service conducted by the facility covered safety issues, keeping the area free of hazards, transfers, and reporting changes regarding the residents to the Charge Nurse. If the staff did not see any interventions being initiated by the Charge Nurse to report to the Director of Nursing. In an interview on [DATE] at 8:15 a.m. with CMA 'A' stated he had been to the staff inservice and the subject discussed was accident hazards, fall risk, and the reporting of potential hazardous situations or abnormal findings to the ADON or the DON in order to ensure safety of the residents. He stated staff was to report all falls or potential safety hazards to the charge nurse immediately, and if the situation was not rectified, staff was to notify the ADON or DON with their concerns In an interview on [DATE] at 9:00 a.m. with the DON she stated ADON 'C' had been making the nursing referrals to therapy for screening residents following falls. She stated ADON 'C' had not been doing follow-up with the Physical Therapy Department regarding resident screenings. She stated she had not been monitoring ADON 'C' regarding referrals to Physical Therapy. She stated ADON 'C' will now be making a copy of the "Nursing referral to Therapy" document and DON would be receiving a copy. She stated the Physical Therapy Department had not had a specific amount of days to screen residents whom had been referred, th