Every finding on record at Aztec Healthcare

Based on record review and interview, the facility failed to ensure advanced directives (code status; documents providing an individual's wishes for emergency and lifesaving care) were accurate within the Electronic Health Record (EHR) for 1 (R #21) of 2 (R #16 and #21) residents reviewed for advance directives, when: The facility failed to ensure R #21's advance directive forms and EHR contained matching and consistent information regarding the residents' end-of-life wishes.The facility staff did not update the resident's advanced directives in the EHR after the resident completed their Medical Orders for Scope of Treatment (MOST; a legal document which outlines the care the resident wants when they become incapacitated and unable to speak for themselves) form. The facility staff failed to honor R #21's do not resuscitate (DNR; lifesaving measures are not desired) status, performed cardiopulmonary resuscitation (CPR; an emergency procedure that combines chest compression with artificial ventilation) for 17 minutes, and attempted to use the automated external defibrillator (AED; a portable medical device designed to analyze a person's heart rhythm and deliver an electric shock if necessary) on the resident.If staff are not aware of a resident's code status, then staff may administer CPR and other life-saving interventions without the resident's consent or in contradiction to the resident's expressed wishes. The findings are: A. Record review of R #21's face sheet revealed R #21 was admitted into the facility on [DATE] with the following diagnoses: Encephalopathy (a degenerative brain disease that alters brain function or structure),Type 2 diabetes mellitus (DM2; a disease in which the body cannot make or properly use insulin),Shock (a life-threatening medical condition in which the body's organs and tissues do not receive enough blood flow, leading to oxygen deprivation and potential organ failure). B. Record review of R #21's baseline care plan, dated [DATE], revealed R #21's code status was not included in R #21's plan of care. C. Record review of R #21's MOST form, dated [DATE], revealed R #21's code status was do not resuscitate (DNR; lifesaving measures are not desired). D. Record review of R #21's nursing progress notes, dated [DATE] at 6:55 pm, revealed the following: Certified Nursing Assistant (CNA) entered R #21's room at 5:55 pm to deliver a dinner tray and observed R #21 unresponsive and sitting in his wheelchair. R #21 did not have a pulse or respirations (breathing). The nurse reported to R #21's room. Staff placed R #21 on the floor and initiated CPR.Staff called 911 and notified Emergency Medical Services (EMS). Facility nursing staff administered chest compressions. The facility nursing staff placed the AED pads on R #21, but the AED did not shock R #21. The facility nursing staff continued CPR until EMS arrived at 6:09 pm. EMS staff called a physician at a local hospital, and the physician called the time of R #21's death at 6:13 pm. E. On [DATE] at 12:41 pm, during an interview, the Director of Nursing (DON) stated it was the Social Services Directors' (SSD's) responsibility to ensure MOST forms are updated in the resident's EHR. F. On [DATE] at 12:52 pm, during an interview, the SSD stated the residents' MOST forms are uploaded into the residents' EHR after the MOST form was signed by the physician. The SSD stated a resident's MOST form and code status did not become active until a physician signed it. G. On [DATE] at 1:39 pm, during an interview, the Administrator (ADM) stated it was the expectation that all resident MOST forms were completed, and staff honored each resident's wishes regarding code status and treatment. H. On [DATE] at 3:49 pm, during an interview, Licensed Practical Nurse (LPN) #3 stated she initiated CPR on R #21 immediately after assessing R #21 and noted R #21 was not breathing and did not have a pulse. LPN #3 stated facility nursing staff transferred R #21 to the floor, she initiated CPR, and another staff member called 911. She stated additional facility nursing staff arrived and applied the AED to R #21. The facility nursing staff continued chest compressions and ventilations with an Ambu bag (a hand-held manual resuscitator used to provide positive-pressure ventilation to patients who are not breathing or are breathing inadequately). LPN #3 stated EMS arrived approximately 9 to 10 minutes after she initiated CPR on R #21. LPN #3 stated she reviewed R #21's top banner (banner across the front page of the EHR that contains important health related information for the resident) in the electronic health record and saw the resident's code status was a full code (lifesaving procedures desired). The LPN stated she did not review R #21's MOST form. LPN #3 stated nursing staff rely on an accurate top banner to determine a resident's code status. I. On [DATE] at 4:11 pm, during an interview, the Assistant Director of Nursing (ADON) stated the facility nursing staff should know each resident's code status in case of an emergency. The ADON said the residents' code status was located on the top banner in their EHR, and the MOST form was located in the documents section in the EHR. J. On [DATE] at 4:29 pm, during an interview, Certified Nursing Assistant (CNA) #4 stated staff communicated a resident's code status with each other, but a resident's code status should be accurate on the top banner in the EHR. K. On [DATE] at 4:39 pm, during an interview, CNA #5 stated she could locate a resident's code status on the top banner in the EHR, but she was unfamiliar with the MOST form. L. On [DATE] at 4:48 pm, during an interview, Registered Nurse (RN) #1 stated a resident's code status should be accurate on the top banner in the EHR and match the MOST form located in the EHR. M. On [DATE] at 6:15 pm, during an interview with the ADON and the Administrator, the ADON stated staff enter the resident's code status once they have a physician order. The MOST form may not be available to staff for a couple days while they waited for the physician to sign the MOST form. The ADON stated the MOST form became effective once it was signed by the physician. The Administrator confirmed the ADON's statement. Based on interviews and record review, an Immediate Jeopardy (IJ) was identified. The facility ADM was notified in person on [DATE] at 7:09 pm. The facility took corrective action by providing an acceptable Plan of Removal (POR). The POR was approved on [DATE] at 4:18 pm. Corrective action for affected resident:R #21 discharged from the facility on [DATE]. No corrective action can be taken.Actions taken to identify residents potentially affected by the deficient practice:Director of nursing or designee will complete a comprehensive advanced directive audit to verify the following:All current residents have been offered the opportunity to complete an advanced directive; Current residents who have formulated an advanced directive have a physician order for code status in the EHR that matches all resident's wishes on the current advanced directive as completed/signed by the resident/resident representative (RP).System Corrections:The administrator has implemented a process change wherein all licensed nurses are responsible to enter the physician order for a resident's code status consistent with the resident's advanced directive (MOST form).Director of nursing or designee will complete education with licensed nurses and social services director before the start of next scheduled shift regarding the process change and expectations for honoring a resident's right to execute an advanced directive and have the advanced directive followed as executed by the resident/RP, including:Social services director is responsible to inform resident or resident representative of their right to form an advanced directive and facilitate completion of the advanced directive (MOST form). The resident's code status request becomes valid when the resident/resident representative signs the advanced directive.The nurse is responsible to obtain and enter the physician order for the code status that matches the resident's wishes as directed on the advanced directive (MOST form) into the electronic health record on the date the MOST form was completed by the resident. This should be completed as soon as practicable after the resident/resident representative has signed the advanced directive.The social services director is responsible to ensure the code status order matches the MOST form and that the MOST form has been entered into the electronic medical record. This will be verified by the social services director or designee each time a new MOST form is executed.Administrator alleges removal of immediacy on [DATE]. Implementation of the POR was verified onsite on [DATE], and the IJ was removed on [DATE] at 6:59 pm. The scope and severity were reduced from a J to a G. Implementation of the POR was verified by the following:Record review of the facility's Quality Assurance and Performance Improvement Plan (QAPI; a structured framework used in healthcare to enhance the quality of care provided to patients) meeting minutes and Plan of Removal documentation dated [DATE] revealed the facility convened an ad hoc (when necessary or needed) QAPI meeting to review the Immediate Jeopardy related to advanced directives and code status accuracy. The review included the Administrator, Director of Nursing, Regional Nurse Consultant, and Medical Director, and addressed implementation of corrective actions to ensure resident advance directives were honored. Record review of the facility's Comprehensive Advance Directive audit dated [DATE] revealed the facility conducted a facility-wide audit of resident advance directives and corresponding code status orders. The audit identified multiple residents with discrepancies between the documented advance directives (including MOST forms) and physician orders for code status, as well as residents with missing or incomplete advance directive documentation.Record review of an in-service, dated [DATE] and titled Timely MOST and Code Status Order Entry, revealed the facility provided education to staff regarding the resident's right to formulate an advance directive and to have that directive honored. On [DATE] at 5:12 pm, during an interview, RN #2 stated he received training related to a resident's code status, where to locate a resident's code status, and the facility nursing staff is responsible to obtain and enter the physician order for the code status that matches the resident's wishes as directed on the MOST form when the resident completes it. On [DATE] at 5:14 pm, during an interview, the SSD stated she received training on the DNR status of the residents in the facility according to the POR, including when a resident's MOST form becomes effective upon completion by the resident. On [DATE] at 5:26 pm, during an interview, LPN #5 stated she had received training on the DNR status of the residents in the facility, including the facility nursing staff is responsible to obtain and enter the physician order for the code status that matches the resident's wishes as directed on the MOST form when the resident completes it. On [DATE] at 5:27 pm, during an interview, Housekeeper (HK) #1 stated he received education and training regarding resident advanced directives and MOST forms. On [DATE] at 5:38 pm, during an interview, the ADON stated she had received training on the DNR status of the residents in the facility, when the MOST form becomes effective, and updating the top banner in the EHR to match the resident's MOST form.

Based on record reviews, observations, and interviews, the facility failed to meet professional standards of practice for 2 (R #1 and R #2) of 2 (R #1 and R #2) residents, when: R #1 was administered oxygen (O2) without a physician's order. R #2 used a foley catheter (a thin, sterile tube inserted into the bladder to drain urine) without a physician's order. These deficient practices are likely to result in residents not maintaining their optimal health as planned by their medical provider. The findings are: R #1: A. Record review of the facility's Oxygen Administration Policy, dated 06/2020, revealed the following: A physician's order is required to initiate O2 therapy, The order should include the O2 flow rate, method of administration, usage of therapy, and indication for use. B. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses: Malignant neoplasm of brain (cancerous tumor of the brain), Epilepsy (a seizure disorder). C. Record review of R #1's physician orders, dated 04/06/26, revealed an order for O2 use was not present. D. On 04/06/2026 at 1:43 PM, during an observation, an O2 concentrator (medical device delivering supplemental oxygen through a nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs) or a mask) was present in R #1's room. R #1 was observed lying in bed using O2 via a nasal cannula (NC). E. On 04/06/2026 at 3:59 PM, during an observation, R #1 was observed lying in bed using O2 via an NC. F. On 04/07/2026 at 3:34 PM, during an interview, the Assistant Director of Nursing (ADON) stated R #1 did not have physician's order for O2 use. She stated it was her expectation residents who require O2 have a physician orders for O2 use. G. On 04/07/26 at 4:21 PM, during an interview, the Director of Nursing (DON) stated it was his expectation all residents on O2 therapy have a physician order to administer the correct liter flow of O2. R #2:H. Record review of facility's Catheter Policy, dated 03/2020, revealed the following: Ensuring residents are not given indwelling catheters unless medically necessary, and unless there is valid medical justification, Residents receive the appropriate care and services to prevent infections to the extent possible. I. Record review of R #2' face sheet revealed R #2 was admitted into the facility on [DATE]. J. Record review of R #2's physician orders, dated 04/06/26, revealed an order for a foley catheter was not present. K. On 04/06/2026 at 1:29 PM, during an observation, a catheter collection bag (also called a drainage bag; a device connected to the catheter tubing and collects urine) was observed hanging from R #2's bed, indicating R #2 utilized a foley catheter. L. On 04/06/2026 at 1:36 PM, during an interview, Licensed Practical Nurse #1 (LPN) stated R #2 did not have a physician's order for a foley catheter. M. On 4/6/2026 at 4:27 PM, during an interview, the DON stated R #2 did not have a physician's order for foley catheter use. The DON stated if a resident does not have a physician's order for a foley catheter, the resident could develop complications in care.

Based on observation, record review, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment (to prevent the development and transmission of communicable diseases and infections) for 1 (R #4) of 1(R #4) residents, when: The facility failed to follow the required Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) by not wearing appropriate personal protective equipment (PPE; protective clothing, face masks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) when providing direct care to the resident.This deficient practice is likely to result in repeated and ongoing exposure of residents to increased risk of infection, cross-contamination, and injury. The findings are: A. Record review of the facility's Enhanced Precautions Infection Policy, dated 04/01/2024, revealed the following:To ensure the use of appropriate personal protective equipment to improve infection control as required in the care of residents,Designed to prevent transmission of multidrug-resistant organisms and employ targeted gown and glove use. B. Record review of R #4's face sheet revealed an admission date of 02/27/2023 with the following diagnoses: Peripheral vascular disease (PVD; poor circulation),Muscle weakness (reduction in the power exerted by muscles),Congestive heart failure (CHF; impaired heart function). C. Record review of R #4's Comprehensive Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 03/06/2026, revealed the following: R #4 had an active diagnosis of a wound infection. D. Record review of R #4's physician orders, dated 01/20/26, revealed the following: Cleanse bilateral lower extremity (BLE; right and left lower leg), Cleanse lower legs with normal saline, apply Silvadene External Cream (a topical antimicrobial used to prevent and treat infections) 1% (percent), Wrap with kerlix gauze (100% cotton, prewashed, fluff-dried woven gauze designed for wound care) and report any changes if wound worsens. E. On 04/07/2026 at 9:01 AM, during an observation, signage was posted at the entrance of R #4's room indicating R #4 was on EBP and staff where required to wear PPE when providing care to R #4. F. On 04/07/2026 at 9:06 AM, during an observation, Certified Nursing Assistant (CNA) #1 was observed providing direct care to R #4 and not wearing PPE. G. On 04/07/2026 at 9:11 AM, during an interview, CNA #1 stated she was providing care to R #4 and was not wearing PPE. CNA #1 stated she should wear PPE when providing care to R #4. H. On 04/07/2026 at 9:33 AM, during an interview, the Director of Nursing (DON) stated it is his expectation all staff providing care follow the EBP guidelines. The DON stated if staff do not follow the required EBP, transmission of infection could occur.

Based on record review and interview, the facility failed to ensure residents received the necessary treatment and services to prevent the development and worsening of pressure ulcers (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin) for 1 (R #1) of 1 (R #1) resident when staff failed to: Begin wound care after identification of a coccyx (tailbone area; base of spine) wound.Administer wound care for R #1's coccyx pressure ulcer as ordered.Notify the facility Wound Care Nurse (WCN) and administrative nursing staff of R #1's worsening pressure ulcer and of the development of a new pressure wound on R #1's left ischial (hip bone) in a timely manner. These deficient practices likely resulted in R #1's pressure ulcer worsening with necrotic tissue (dead tissue) which required hospitalization for advanced wound care treatment. The findings are: A. Record review of R #1's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 10/24/25, revealed R #1 was admitted into the facility on [DATE] from the hospital. B. Record review of R #1's progress notes, revealed the following:Dated 10/23/25, R #1 had a treatable skin/wound present with dry skin to his lower left leg and healing from cellulitis (deep inflammation of the tissues just under the skin; caused by infection).Dated 10/24/25, nutrition note, R #1 did not have any wounds present per the facility wound report.Dated 10/25/25, R #1 had a treatable skin/wound present but additional information was not provided.Dated 10/27/25, R #1 had a treatable skin/wound present but additional information was not provided.Dated 10/28/25, R #1 had blood on his gown from his buttock. Staff documented R #1 had a new wound to his coccyx/sacrum. C. Record review of R #1's physician orders, dated October 2025, revealed the record did not contain wound care orders from 10/28/25 through 11/06/25. D. Record review of R #1's weekly skin checks, dated October 2025, revealed the following:Dated 10/29/25, staff documented a skin tear (a type of injury where the skin is torn from the body) to R #1's sacrum and the left and right gluteal folds (crease formed between the buttocks and the upper thigh). E. Record review of R #1's care plan revealed the following:Date Initiated: 11/06/25.Problem: Resident has potential /actual impairment to skin integrity related to fragile skin.Interventions: Apply barrier cream to buttocks every shift; Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short; Pressure relieving/reducing mattress, pillows, to protect the skin while in bed; Pressure relieving/reducing mattress, pillows, to protect the skin while up in chair; Keep skin clean and dry. Use lotion on dry skin. Resident consistently self-determines to refuse wound assessment/wound care and offloading measures. F. Record review of R #1's MDS, dated [DATE] revealed the following:R #1 did not have any wound or pressure ulcer (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin) present.R #1 was at risk of developing wounds/pressure ulcers.R #1 did not have any behaviors or behavior related concerns that would contribute to the development of a wound/pressure ulcer.R #1 required the use of a wheelchair.R #1 required substantial/maximal assistance for activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating). G. Record review of R #1's physician orders, dated November 2025, revealed the following orders: The record did not contain wound care orders from 10/28/25 through 11/06/25.Coccyx/sacrum wound: Start date 11/06/25: An order to cleanse with normal saline, skin prep (liquid when applied to the skin forms a protective film or barrier), and apply Medi-honey (medical grade honey used for wounds healing). Place super absorbent silicone dressing (foam dressing for wounds) every day shift Monday, Wednesday. and Friday. Order discontinued on 11/13/25.Coccyx/sacrum wound: Start date 11/13/25: An order to cleanse with normal saline, pack wound with Dakins soaked (an antiseptic solution used for wound cleaning and debridement) packing. Place alginate (super absorbent dressing for wounds) dressing over wound bed, skin prep, and cover with silicone foam dressing, every day shift for wound care. Order discontinued on 12/01/25. H. Record review of R #1's Treatment Administration Record (TAR), dated November 2025, revealed the following: Coccyx/sacral wound: Dated 11/09/25 through 11/15/25: Staff did not document they administered wound care on 11/10/25. Staff did not document a code to show why the treatment was not administered.Coccyx/sacral wound: Dated 11/16/25 through 11/22/25: Staff did not document they administered wound care on 11/19/25. Staff did not document a code to show why the treatment was not administered.Coccyx/sacral wound: Dated 11/26/25 through 11/30/25: Staff did not document they administered wound care on 11/29/25 and 11/30/25. Staff did not document a code to show why the treatment was not administered. I. Record review of R #1's weekly skin checks, dated November 2025, revealed the following:Dated 11/05/25, staff documented skin tears to R #1's sacrum and perineal area (region located between the thighs in the front to the lower back). The skin tears were improving with assistance from staff in activities of daily living. Staff did not document any description for the resident's left and right gluteal fold skin tears.Dated 11/12/25, staff documented moisture associated skin damage (MASD; inflammation or loss of the top layer of skin due to continuous or prolonged moisture) to both right and left gluteal fold. Staff cleaned the area and applied wound dressing. Staff documented a Stage 3 pressure wound (full thickness skin loss that extends into deeper tissue and fat but not into muscle, tendon, or bone) to sacrum.Dated 11/21/25, staff documented MASD to both right and left gluteal fold. Staff cleaned the area and applied wound dressing. Staff documented a Stage 3 pressure wound to sacrum. J. Record review of R #1's wound assessments, dated November 2025, completed by the facility's Wound Care Nurse, revealed the following:Coccyx/sacral wound: Dated 11/04/25, the wound was moisture associated skin damage (MASD) from incontinence (loss of bladder or bowel control). The size of the wound was .50 length, .50 width, unknown depth. No odor or signs of infection.The WCN did not document an assessment for the week of 11/10/25.Coccyx/sacral wound: Dated 11/18/25, R #1's had a Stage 3 pressure ulcer, which measured 2.30 length, 4.30 width and unknown depth. There was heavy purulent excaudate (a thick, milky discharge that typically indicates an infection) with signs of infection. K. Record review of R #1's Nurse Practitioner (NP) notes, dated November 2025, revealed the following:R #1's NP evaluation, dated 11/06/25, was not available in R #1's electronic health record.Dated 11/13/25, revealed R #1 had a Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) to coccyx/sacrum, 100 percent slough (yellow stringy tissue adhered to wound bed), moderate purulent drainage. Measurements 4.6 centimeters (cm), by 3.1 cm. Wound culture (testing for infection in the wound) ordered and noted infection in the wound. The NP note indicated an initial wound evaluation for R #1's coccyx/sacrum, completed on 11/06/25, with the measurements 1.9 cm by 3.6 cm with a depth of 0.3 cm. The NP note indicated R #1's coccyx/sacrum wound required ongoing debridement (the removal of damaged tissue or foreign objects from a wound) since 11/06/25. The NP stated deep tunneling (a narrow channel or pathway that extends from the wound opening into deeper tissue layers which can complicate healing and increase the risk of infection) of R #1's coccyx/sacrum wound was present as of 11/13/25. The NP note did not address any other wound/skin issue.The record did not contain any other evaluations by the NP. L. Record review of R #1's Medical Doctor (MD) encounter progress note, dated 11/18/25, indicated R #1's coccyx/sacrum wound was infected and required antibiotics. M. Record review of R #1's nursing progress note, dated 11/20/25, revealed R #1 refused intravenous (IV; into the vein) antibiotic medications. The NP and nursing educated R #1 on the importance of IV antibiotics due to his worsening coccyx/sacrum wound, which was infected. Due to R #1's infected coccyx/sacrum wound and his refusal of antibiotics, R #1 was discharged to the hospital on [DATE]. N. Record of R #1's discharge MDS revealed R #1 was discharged to the hospital on [DATE] with one unhealed Stage 3 (full thickness skin loss that extends into deeper tissue and fat but not into muscle, tendon, or bone) pressure ulcer. O. Record review of R #1's hospital records revealed the following:Dated 11/20/25, R #1 had a pressure ulcer with osteomyelitis (bone infection) to the coccyx/sacrum with hematuria (blood in the urine) and multifactorial sepsis (a complex and life-threatening condition caused by more than one of cause of where the body's immune response to infection leads to severe organ dysfunction). Dated 11/21/25, R #1's coccyx/sacrum had a strong odor with necrotic (dead) tissue present. R #1's coccyx/sacrum wound was measured to be 3 cm by 4.5 cm with a depth of 2 cm.Dated 11/22/25, R #1's coccyx/sacrum wound had developed necrotic yellow and gray tissue with deep red moist tissue. Debridement was scheduled so a wound VAC (vacuum assisted closure; applying negative pressure through a specialized device, which helps remove excess fluid and increase blood flow to the affected area, accelerating the healing process). P. Record review of R #1's readmission records revealed the following:An entry MDS, dated [DATE], R #1 was admitted into the facility from the hospital on [DATE].A completed admission MDS, with all care areas and treatments, was not completed after R #1's re-admission into the facility on [DATE]. Q. Record review of R #1's nursing progress notes, dated 12/05/25, revealed R #1 was re-admitted into the facility on [DATE] with wound VAC. R. Record review of R #1's care plan, in place after re-admission on [DATE], revealed the following:Initiated on 10/24/25:Focus: R #1 has the potential for skin tears related to fragile skin and decreased mobility.Interventions: R #1 needs a pressure-relieving mattress, pillows, to protect the skin while in bed.Initiated on 11/06/25:Focus: R #1 has potential/actual impairment to skin integrity related to fragile skin.Interventions: Apply barrier cream to buttocks every shift. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. R #1 needs a pressure relieving/reducing mattress, pillows, to protect the skin while in bed. R #1 needs a pressure relieving/reducing mattress, pillows, to protect the skin while up in chair. Educate resident/family/caregivers of factors and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Keep skin clean and dry- use lotion on dry skin. S. Record review of R #1's nursing progress notes, dated 12/11/25, indicated R #1's coccyx/sacrum wound VAC was discontinued due to the resident having osteomyelitis and not receiving antibiotic medications. The NP's recommendation was to remove the wound vacuum. T. Record review of R #1's physician orders, dated December 2025, revealed the following:Coccyx/sacral wound: Dated 12/05/25: An order for wound vacuum. Flush with vashe (wound cleanser), cleanse with normal saline (NS), and apply wound vacuum. Change three days a week and as needed (PRN). Discontinued on 12/11/25. Coccyx/sacral wound: Dated 12/11/25: An order to cleanse with NS, pack with calcium alginate rope (highly absorbent dressing for managing deep wounds and maintaining a moist environment), skin prep, and apply silicone foam dressing (foam dressing for wounds). Change three days a week and PRN. Discontinued on 12/26/25.Coccyx/sacral wound: Dated 12/26/25: An order for wound vacuum, flush with vashe, and cleanse with NS. Change every three days and as needed. Discontinued on 12/31/25. Coccyx/sacral wound: Dated 12/31/25: An order to flush with vashe, cleanse with NS, pack with alginate rope, skin prep, and apply silicone foam dressing. Change every three days a week and as needed. U. Record review of R #1's TAR, dated December 2025, revealed the following: Coccyx/sacral wound: Dated 12/08/25 and 12/10/25: Staff completed the wound vacuum treatment. The order was discontinued on 12/11/25.Coccyx/sacral wound: Dated 12/11/25 and 12/26/25: Pack with calcium alginate rope (highly absorbent wound dressing made from seaweed fibers, designed to fill deep or narrow wounds while promoting moist healing) and apply silicone foam dressing. Staff did not document they administered wound care on 12/15/25 and 12/17/25. Staff did not document a code to show why the treatment was not administered. V. Record review of R #1's weekly skin checks, dated December 2025, revealed the following:Dated 12/26/25, staff documented a pressure wound to left buttock. There were no other skin issues identified. W. Record review of R #1's wound assessments completed by the facility's Wound Care Nurse revealed the following:Coccyx/sacral wound: Dated 12/09/25, the wound was a Stage 3 pressure ulcer, which measured 3.0 length, 4.0 width and 4.70 depth. There was heavy purulent excaudate with signs of infection.Coccyx/sacral wound: Dated 12/29/25, the wound was a Stage 3 pressure ulcer, which measured 3.0 length, 4.0 width and 5.0 depth. There was heavy purulent excaudate noted with signs of infection.There were no other wound assessments completed for R #1 during December 2025. X. Record review of R #1's care plan revealed the following:Focus: R #1 has potential/actual impairment to skin integrity related to fragile skin.Interventions, initiated on 01/09/26: R #1 consistently self-determines to refuse wound assessment/wound care and offloading measures. Resident educated on risks of self-determined choices and expressed understanding and indicates he can take care of himself.Interventions, initiated on 01/14/26: R #1 re-educated on importance of asking for staff assistance with bed mobility/repositioning to reduce risk for skin damage related to shearing (injury where layers of the skin and underlying tissue slide past each other, causing deep tissue damage). R #1 expressed understanding and wishes to self-determine when he asks for assistance.Interventions, initiated on 01/15/26: R #1 re-educated/re-offered air mattress to help with pressure reduction and assist with wound healing/prevention. R #1 educated on risks of non-use. R #1 continues to decline air mattress. Y. Record review R #1's nursing progress note, dated 01/14/26, revealed the following: Staff completed a change in condition evaluation (the process of assessing and documenting any deviations from a patient's baseline health status) for a new skin wound/pressure ulcer.Staff documented they assisted R #1 back to his chair after his shower and the Wound Care Nurse observed sores on the resident's backside. Z. Record review of R #1's physician orders, dated January 2026, revealed the following:Left ischial wound: Dated 01/14/26, an order to cleanse R #1's wound to left buttock with normal saline and apply zinc to peri area of wound. Apply Dakin's (an antiseptic solution used for wound cleaning and debridement) soaked gauze and cover with silicone foam dressing. AA. Record review of R #1's TAR, dated January 2026, revealed the following:Coccyx/sacral wound: Staff did not document they completed the wound care to flush with vashe, pack with alginate rope, and apply silicone dressing every three days and as needed on 01/02/26, 01/07/26, 01/09/26, and 01/12/26. Left Ischial/buttock wound: Staff did not document they administered wound care on 01/15/26 and 01/16/26. Staff did not document a code to show why the treatment was not administered. BB. Record review of R #1's weekly skin checks, dated January 2026, revealed the following:Dated 01/02/26, staff documented right buttock pressure wound and edema on right lower leg.Dated 01/12/26, staff documented right buttock pressure wound and edema on right lower leg.R #1's Left Ischial/buttock wound was not identified nor documented during January 2026 skin checks. CC. Record review of R #1's wound assessments completed by the facility's Wound Care Nurse revealed the following:Coccyx/sacral wound: Dated 01/09/26, the wound was a Stage 3 pressure ulcer, which measured 3.0 length, 4.0 width and 5.0 depth. There was heavy purulent excaudate noted with signs of infection.Coccyx/sacral wound: Dated 01/14/26, the wound was a Stage 3 pressure ulcer, which measured 3.0 length, 4.0 width and 5.0 depth. There was heavy purulent excaudate noted with signs of infection.Left ischial wound: Dated 01/15/26, the wound was unstageable and measured 5.0 cm length, 10.0 cm width and the depth was unknown. The wound was 70% (percent) slough (dead, non-viable tissue) and was boggy (mushy or spongy-feeling area of the skin can be a sign of deep tissue injury and infection). DD. Record review of R #1's progress notes dated 01/16/26 indicated R #1 was sent to the hospital on [DATE] due to a change in mental status related to a low blood pressure. EE. Record review of R #1's hospital records, dated 01/16/26 through 01/18/26, indicated the following:Chief complaint: leg pain and wound check.Patient reported left buttock and bilateral extremity pain which became progressively worse the past week. Patient in significant pain. R #1 underwent incision and drainage of left ischial ulcer and debridement (medical procedure to remove dead, damaged, or infected tissue from a wound to promote healing and prevent infection) of approximately: length 8 cm, width 5 cm, and 5 cm depth of necrotic tissue.Wound cultures have grown E. coli (bacterial infection) sensitive to ceftriaxone (antibiotic).R #1 will return to the operating room for additional debridement. After surgical debridement, R #1's wound was determined to be full thickness (wound extends into the deep layers of the skin). R #1's wound measurements were a length of 8.9 cm, a width of 8.9 cm, and a depth of 6.7 cm. FF. On 01/27/26 at 11:01 am during an interview, Certified Nursing Assistant (CNA) #1 stated R #1 had a wound on his bottom, and she thought it was on the right side under the right butt cheek. She stated the first time she saw the right buttock wound was sometime in December 2025, and she believed she reported it to the nurses. CNA #1 stated R #1 did not like to be turned in bed, but he would allow the nursing staff to turn him slowly for brief changes. CNA #1 confirmed R #1 experienced significant pain when he was respositioned in bed. GG. On 01/27/26 at 11:15 am, during an interview, CNA #5 stated he changed R #1 a few times, but he did not recall if R #1 had a wound. He stated R #1 was able to move on his own in bed and transfer himself. HH. On 01/27/26 at 11:43 am, during an interview, CNA #4 stated she worked with R #1 and saw two wounds on his buttocks. CNA #4 confirmed R #1 would refuse care at times due to pain. She stated she could not remember exactly when she saw the wounds, but there was a lot of redness around the wound. She stated one of the wounds had a smell to it, which she informed the nurse about. She stated if the wounds were worse or something had changed, she would notify the nurse about it. II. On 01/27/26 at 12:48 pm, during an interview, the Assistant Director of Nursing (ADON) stated she learned of R #1's left ischial wound on 01/14/26 from the WCN. The ADON stated she was unaware of R #1's wound prior to 01/14/26. The ADON stated the wound did not develop overnight, and it was missed by staff. The ADON stated staff should have notified the WCN and herself sooner. The ADON stated it was expected staff would provide R #1's wound care orders consistently. JJ. On 01/27/26 at 12:52 pm, during an interview, the Wound Care Nurse stated nurses who identify wounds were responsible to enter the basic orders for wound care. She stated orders should have been in place for the first wound on R #1's sacrum/coccyx on 10/28/25. She stated she was not aware of the first wound on R #1's sacrum/coccyx until 11/04/25, when she completed a wound evaluation. The WCN stated staff did not complete any orders or treatment for R #1's sacrum/coccyx wound from 10/29/25 to 11/07/25. She stated the treatments were also not completed on 11/10/25 or 11/12/25. The WCN stated the R #1's coccyx/sacrum wound had an odor present and looked infected when she did her wound assessment on 11/18/25. She stated R #1 was sent out to the hospital on [DATE] because the wound had osteomyelitis. She stated she was responsible for the wound care being completed and for weekly wound assessments, and the nurses were also responsible for the wound care. She stated all staff were responsible for reporting any new or changed skin issues they observe. She stated wound assessments should be completed by the nurses weekly. The WCN stated wound care should be done and completed as ordered, unless R #1 refused the wound care. The WCN stated R #1 did refuse care, including the air mattress because he did not like it. She stated R #1 refused IV antibiotics because he wanted a pill form of the antibiotic. She stated R #1 would also refuse to turn in bed. The WCN stated she identified R #1's left ischial wound on 01/14/26. She stated she was shocked because of how R #1's left ischial wound was presented. The WCN stated there was not any information about R #1's left ischial wound in the electronic health record, and she was not aware of the findings on the 12/26/25 skin check. She stated she was unaware of how long the left ischial wound had been there. The WCN stated it was the responsibility of each nurse to complete a weekly skin assessment. The WCN stated the facility nursing staff should have notified her of R #1's left ischial wound sooner, but they did not. KK. On 01/28/26 at 1:00 pm, during an interview, R #1 confirmed he required facility staff assistance when moving, including when he was in bed. LL. On 03/12/26 at 12:29 pm, during an interview, the ADON stated there should not have been any delays regarding R #1's Coccyx/sacral wound treatment. MM. On 03/12/26 at 12:55 pm, during an interview, the ADON stated the WCN initially documented the wrong location for R #1's wound on 12/26/25. She stated the facility nurses did not understand the skin assessment processes, which is something she is now working on. The ADON confirmed R #1's left ischial wound should have been identified sooner with wound care treatment orders provided before 01/14/26. The ADON also confirmed the wound care treatment for R #1 did not meet her expectations. The ADON stated wound care treatment orders should be followed and documented on the TAR. The ADON stated if staff left a resident's TAR blank without specific codes, she could not determine if the wound care was completed as ordered. NN. On 03/12/26 at 12:56 pm, during an interview, the Director of Nursing (DON) stated staff should document wound care treatments on the residents' TAR when they completed the treatment or enter a code to show the resident refused.

Based on record review and interview, the facility failed to ensure the Minimum Data Set Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) was accurate for 1 (R #2) of 1 (R #2) resident reviewed for MDS accuracy. This deficient practice could result in failure to provide adequate care and treatment of the resident's needs. The findings are: A. Record review of R #2's face sheet, undated, revealed the resident was admitted into the facility on [DATE] with the following diagnoses: Unspecified dementia, unspecified severity, with other behavioral disturbance (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), Unspecified symptoms and signs involving cognitive functions and awareness (problems with thinking, memory, or awareness that are noticed). B. Record review of R # 2's MDS, dated [DATE], revealed the following: Staff documented a Brief Interview for Mental Status (BIMS; screening for cognitive impairment) should be conducted. Staff did not document any answers for the BIMS section. C. On 02/09/26 at 4:08 PM, during an interview, the MDS Coordinator (MDSC) stated she was responsible for the completion of R #2's MDS assessments. She stated it was her expectation R #2's MDS assessments be fully completed, and staff should not leave the sections unanswered.

PAST NOT COMPLIANCE Based on record review and interview, the facility failed to notify the physician, for 1 (R #7) of 1 (R #7) resident reviewed, of the results of the resident's ordered chest X-ray, complete blood count (CBC; a blood test that measures the number and type of cells in the blood), and comprehensive metabolic panel (CMP; a group of tests to measure various substances in the blood) following a change in condition. This deficient practice likely resulted in delayed treatment for pneumonia (a lung infection that makes it difficult for a person to breathe) and likely contributed to R #7's death. The findings are: A. Record review of R #7's hospital discharge report, dated [DATE], revealed R #7 was a [AGE] year old male with history of liver cirrhosis (chronic liver damage leading to scarring and liver failure), esophageal varices (abnormal veins that usually develop when the blood to the liver is blocked) and chronic left arm deformity, presenting with concern for gastrointestinal (GI; digestive tract) bleed. He initially presented with confusion, falls, and weakness. He was given cefepime (antibiotic) and vancomycin (antibiotic) for possible pneumonia. B. Record review of R #7's facility Face Sheet revealed the resident was admitted to the facility on [DATE]. C. Record review of R #7's care plan, dated [DATE], revealed R #7 had an advanced directive of Full Code (life saving procedures desired.) D. Record review of R #7's Medication Administration Record, dated [DATE], revealed R #7 was prescribed and received the following medications: 1. Furosemide (a diuretic, water pill; medication to help the kidneys remove extra salt and water through urine) 20 mg daily, 2. Pantoprazole (medication used to reduced stomach acid) 40 mg daily for gastroesophageal reflux disease (GERD; A digestive disease in which stomach acid or bile irritates the food pipe lining), 3. Lactulose (laxative) 10 grams (g) / 15 milliliters (ml) three times daily for constipation, 4. Midodrine (medication used to treat low blood pressure) 5 mg three times daily for orthostatic hypotension (low blood pressure.) E. Record review of R #7's change in condition (CIC) assessment, dated [DATE], revealed staff reported the resident experienced a change in medical condition due to constant unproductive cough that started at midnight. Staff documented, I heard the resident persistent coughing, unproductive cough, weak. Staff notified the Medical Provider at 5:00 am, and the Medical Provider ordered the resident to be sent to the hospital for a chest x-ray, CBC, CMP, and Robitussin (cough medicine) 10 ml every four hours as needed. F. Record review of R #7's diagnostic results of the X-ray, CBC, and CMP revealed the results were faxed to the facility on [DATE] at 1:52 PM. The lab results included the following: 1. Red blood cell count: 2.37 (normal 4.30 to 5.90), 2. Hemoglobin: 8.4 (normal 13.9 to 17.5), 3. Hematocrit: 25.2 (normal 41.0 to 53.0), 4. Sodium: 124 (normal 137 to 145), 5. Potassium: 2.8 (normal 3.5 to 5.1), 6. Chloride: 95 (normal 98 to 107), 7. Chest x-ray: Small infusions with basilar (build-up of fluid between lungs and diaphragm) predominant airspace opacities (gray area of lungs.) Worse compared to [DATE]. G. Record review of Staff Member (SM) #1's written statement revealed SM #1 received the lab results on [DATE] at 1:53 PM and emailed the results to the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on [DATE] at 1:58 PM. SM #1 also printed a hard copy of the results and left it at the nurse's station. H. Record review of R #7's medical record revealed there were not any new orders for the resident from [DATE] to [DATE]. I. Record review of R #7's CIC assessment, dated [DATE], revealed staff reported a CIC due to expiratory wheezing (a whistling sound that occurs when you exhale and indicates a partial or mild blockage in your airway. It is often caused by a narrowing of the smaller airways). The physician was notified on [DATE] at 3:36 pm, and it was recommended that R #7 get a chest x-ray. J. On [DATE] at 3:29 PM during an interview, the ADON stated R #7 was sent for labs and a chest x-ray on [DATE] due to persistent and unproductive cough. She stated the lab results and chest x-ray were faxed to the facility on the same day ([DATE]), and the receptionist was responsible to get the labs to the staff. The ADON stated the lab results were left on the keyboard at the nurse's station on [DATE]. She stated she [ADON] should have sent the lab results to the Physician on [DATE], but she did not. The ADON stated staff should have notified the resident's physician the same day regarding the abnormal lab results, but they did not. The ADON reviewed the R #7's lab results and stated R #7's potassium was critically low. She stated R #7 should have been sent to the hospital since he was on a lasix (furosemide) and did not have a potassium supplement ordered. The ADON stated the physician ordered the resident to be sent out for a chest x-ray after the CIC on [DATE]; however, staff noted an x-ray was done on [DATE], but the labs needed to be reviewed. The ADON stated staff notified the Physician on [DATE] of the resident's x-ray results from [DATE]. The ADON stated the Physician suspected R #7 had pneumonia and ordered Levaquin (an antibiotic.) K. Record review of R #7's Medication Administration Record revealed an order, started on [DATE], for Levaquin 250 mg. Give two tablets by mouth one time a day for infection for 10 days. L. Record review of R #7's nursing progress notes, dated [DATE], revealed staff found the resident unresponsive and breathless on [DATE] at 12:53 AM. R #7 was unable to be revived despite emergency care including cardiopulmonary resuscitation (CPR; an emergency procedure that combines chest compression with artificial ventilation). R #7 passed away. M. On [DATE] at 1:40 PM during an interview, R #7's Physician stated staff did not notify him of the x-ray results and blood test results that were ordered on [DATE]. The Physician stated if staff had notified him, then he would have ordered antibiotics to treat R #7's pneumonia. He confirmed staff did not notify him of the abnormal potassium results. He stated he also would have ordered a potassium supplement and follow-up testing for the low potassium. He stated staff notified him of the chest x-ray results from [DATE] which showed the resident had pneumonia, and he ordered Levaquin. The Physician stated R #7's death was not unexpected, and he should have been on palliative care (specialized medical care for people living with a serious or chronic illness.) Based upon record review and interview, the incident was identified as Past Non-Compliance (PNC) Immediate Jeopardy (IJ). The facility Administrator was notified of the IJ on [DATE] at 3:55 pm. Based on the facility's investigation of R #7's death, the following interventions were implemented and placed in an Improvement Action Plan prior to survey investigation which included: Facility sweep of residents with diagnostic orders and verify physician notification. Completed [DATE]. - No residents were identified as having non-compliance. Staff education on appropriate follow-up/notification of lab results. Completed [DATE]. - Record review of In-service training report, dated [DATE], revealed a summary of training to include ensuring Change of Condition (COC) assessments and reporting, inputting admission orders and progress notes, complete lab tracking sheet at the end of the shift, and reporting lab and imaging results to MD. The training was signed by ten nurses (RN/LPNs) and one CNA. Process changes for delivery of diagnostic results to include face-to-face receipt of results. Completed [DATE]. - On [DATE] at 8:50 am during interview with the Director of Nursing (DON), she confirmed the process for diagnostic results delivery was changed to include a hot handoff (receptionist must physically hand the results to a nurse). The DON also confirmed they have added a tracker and auditing book to monitor results. Implementation of new tracking for diagnostic orders. Completed [DATE]. - On [DATE] at 8:50 am during interview with the DON, she confirmed they added a tracker and auditing book to monitor results. - Record review of the tracker revealed sections to include date of COC, lab tracker with drawn and result dates, and Physician notification. Ad Hoc QAPI meeting to discuss and approve Improvement Action Plan. Completed [DATE]. Continuing audits reported at QAPI meetings. On-going. Surveyor verified the implementation of the Improvement Action Plan and did not identify any further non-compliance with samples residents.

PAST NON-COMPLIANCE Based on record review and interview, the facility failed to notify the physician, for 1 (R #7) of 1 (R #7) resident reviewed, of the results of the resident's ordered chest X-ray, complete blood count (CBC; a blood test that measures the number and type of cells in the blood), and comprehensive metabolic panel (CMP; a group of tests to measure various substances in the blood) following a change in condition. This deficient practice likely resulted in delayed treatment for pneumonia (a lung infection that makes it difficult for a person to breathe) and likely contributed to R #7's death. The findings are: A. Record review of R #7's hospital discharge report, dated [DATE], revealed R #7 was a [AGE] year old male with history of liver cirrhosis (chronic liver damage leading to scarring and liver failure), esophageal varices (abnormal veins that usually develop when the blood to the liver is blocked) and chronic left arm deformity, presenting with concern for gastrointestinal (GI; digestive tract) bleed. He initially presented with confusion, falls, and weakness. He was given cefepime (antibiotic) and vancomycin (antibiotic) for possible pneumonia. B. Record review of R #7's facility Face Sheet revealed the resident was admitted to the facility on [DATE]. C. Record review of R #7's care plan, dated [DATE], revealed R #7 had an advanced directive of Full Code (life saving procedures desired.) D. Record review of R #7's Medication Administration Record, dated [DATE], revealed R #7 was prescribed and received the following medications: 1. Furosemide (a diuretic, water pill; medication to help the kidneys remove extra salt and water through urine) 20 mg daily, 2. Pantoprazole (medication used to reduced stomach acid) 40 mg daily for gastroesophageal reflux disease (GERD; A digestive disease in which stomach acid or bile irritates the food pipe lining), 3. Lactulose (laxative) 10 grams (g) / 15 milliliters (ml) three times daily for constipation, 4. Midodrine (medication used to treat low blood pressure) 5 mg three times daily for orthostatic hypotension (low blood pressure.) E. Record review of R #7's change in condition (CIC) assessment, dated [DATE], revealed staff reported the resident experienced a change in medical condition due to constant unproductive cough that started at midnight. Staff documented, I heard the resident persistent coughing, unproductive cough, weak. Staff notified the Medical Provider at 5:00 am, and the Medical Provider ordered the resident to be sent to the hospital for a chest x-ray, CBC, CMP, and Robitussin (cough medicine) 10 ml every four hours as needed. F. Record review of R #7's diagnostic results of the X-ray, CBC, and CMP revealed the results were faxed to the facility on [DATE] at 1:52 PM. The lab results included the following: 1. Red blood cell count: 2.37 (normal 4.30 to 5.90), 2. Hemoglobin: 8.4 (normal 13.9 to 17.5), 3. Hematocrit: 25.2 (normal 41.0 to 53.0), 4. Sodium: 124 (normal 137 to 145), 5. Potassium: 2.8 (normal 3.5 to 5.1), 6. Chloride: 95 (normal 98 to 107), 7. Chest x-ray: Small infusions with basilar (build-up of fluid between lungs and diaphragm) predominant airspace opacities (gray area of lungs.) Worse compared to [DATE]. G. Record review of Staff Member (SM) #1's written statement revealed SM #1 received the lab results on [DATE] at 1:53 PM and emailed the results to the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on [DATE] at 1:58 PM. SM #1 also printed a hard copy of the results and left it at the nurse's station. H. Record review of R #7's medical record revealed there were not any new orders for the resident from [DATE] to [DATE]. I. Record review of R #7's CIC assessment, dated [DATE], revealed staff reported a CIC due to expiratory wheezing (a whistling sound that occurs when you exhale and indicates a partial or mild blockage in your airway. It is often caused by a narrowing of the smaller airways). The physician was notified on [DATE] at 3:36 pm, and it was recommended that R #7 get a chest x-ray. J. On [DATE] at 3:29 PM during an interview, the ADON stated R #7 was sent for labs and a chest x-ray on [DATE] due to persistent and unproductive cough. She stated the lab results and chest x-ray were faxed to the facility on the same day ([DATE]), and the receptionist was responsible to get the labs to the staff. The ADON stated the lab results were left on the keyboard at the nurse's station on [DATE]. She stated she [ADON] should have sent the lab results to the Physician on [DATE], but she did not. The ADON stated staff should have notified the resident's physician the same day regarding the abnormal lab results, but they did not. The ADON reviewed the R #7's lab results and stated R #7's potassium was critically low. She stated R #7 should have been sent to the hospital since he was on a lasix (furosemide) and did not have a potassium supplement ordered. The ADON stated the physician ordered the resident to be sent out for a chest x-ray after the CIC on [DATE]; however, staff noted an x-ray was done on [DATE], but the labs needed to be reviewed. The ADON stated staff notified the Physician on [DATE] of the resident's x-ray results from [DATE]. The ADON stated the Physician suspected R #7 had pneumonia and ordered Levaquin (an antibiotic.) K. Record review of R #7's Medication Administration Record revealed an order, started on [DATE], for Levaquin 250 mg. Give two tablets by mouth one time a day for infection for 10 days. L. Record review of R #7's nursing progress notes, dated [DATE], revealed staff found the resident unresponsive and breathless on [DATE] at 12:53 AM. R #7 was unable to be revived despite emergency care including cardiopulmonary resuscitation (CPR; an emergency procedure that combines chest compression with artificial ventilation). R #7 passed away. M. On [DATE] at 1:40 PM during an interview, R #7's Physician stated staff did not notify him of the x-ray results and blood test results that were ordered on [DATE]. The Physician stated if staff had notified him, then he would have ordered antibiotics to treat R #7's pneumonia. He confirmed staff did not notify him of the abnormal potassium results. He stated he also would have ordered a potassium supplement and follow-up testing for the low potassium. He stated staff notified him of the chest x-ray results from [DATE] which showed the resident had pneumonia, and he ordered Levaquin. The Physician stated R #7's death was not unexpected, and he should have been on palliative care (specialized medical care for people living with a serious or chronic illness.) Based upon record review and interview, the incident was identified as Past Non-Compliance (PNC) Immediate Jeopardy (IJ). The facility Administrator was notified of the IJ on [DATE] at 3:55 pm. Based on the facility's investigation of R #7's death, the following interventions were implemented and placed in an Improvement Action Plan prior to survey investigation which included: Facility sweep of residents with diagnostic orders and verify physician notification. Completed [DATE]. - No residents were identified as having non-compliance. Staff education on appropriate follow-up/notification of lab results. Completed [DATE]. - Record review of In-service training report, dated [DATE], revealed a summary of training to include ensuring Change of Condition (COC) assessments and reporting, inputting admission orders and progress notes, complete lab tracking sheet at the end of the shift, and reporting lab and imaging results to MD. The training was signed by ten nurses (RN/LPNs) and one CNA. Process changes for delivery of diagnostic results to include face-to-face receipt of results. Completed [DATE]. - On [DATE] at 8:50 am during interview with the Director of Nursing (DON), she confirmed the process for diagnostic results delivery was changed to include a hot handoff (receptionist must physically hand the results to a nurse). The DON also confirmed they have added a tracker and auditing book to monitor results. Implementation of new tracking for diagnostic orders. Completed [DATE]. - On [DATE] at 8:50 am during interview with the DON, she confirmed they added a tracker and auditing book to monitor results. - Record review of the tracker revealed sections to include date of COC, lab tracker with drawn and result dates, and Physician notification. Ad Hoc QAPI meeting to discuss and approve Improvement Action Plan. Completed [DATE]. Continuing audits reported at QAPI meetings. On-going. Surveyor verified the implementation of the Improvement Action Plan and did not identify any further non-compliance with samples residents.

Based on record review and interview, the facility failed to assist 1 (R #3) out of 3 (R #1, 2 and 3) residents reviewed for activities of daily living (ADLs; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating). This deficient practice could likely cause a resident to feel like they are a burden and embarrassed. The findings are: A. Record review of the face sheet for R #3 revealed the resident was admitted to the facility on [DATE] and discharged on [DATE]. The resident had the following diagnoses: - Left lower foot amputation, - Type II diabetes (affects how your body uses insulin), - Circulatory issues (diseases that can affect your heart and blood vessels), - Diabetic neuropathy (type of nerve damage that can occur when you have diabetes), - Stomach cancer. - This is not an all inclusive list. B. Record review of the admission Minimum Data Set (MDS; standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) for R #3, dated 06/16/24, indicated the resident required partial, moderate assistance for toileting. C. Record review of the admission care plan for R #3, dated 05/14/24 to 07/17/24, revealed the care plan did not indicate R #3 was non-weight bearing with her legs. D. Record review of a grievance, dated 07/05/24, revealed R #3 reported to a staff member that she needed to go to the bathroom, and Certified Nursing Assistant (CNA) #2 told her to go in her brief. R #3 reported she did not want to do that. E. Record review of a written statement by CNA #2, dated 07/04/24, revealed CNA #2 stated she was told over and over that R #3 was a fall risk and non-weight bearing on her left foot. CNA #2 stated R #3 had difficulty with bowel movements in her wheelchair so I let her in bed so it's easier for her. This has been good for her. CNA #2 stated when R #3 mentioned she would have a bowel movement soon, CNA #2 told R #3 to let her know when she was finished. F. Record review of a written statement by CNA #4, dated 02/05/24, indicated she worked the same hall with CNA #2. She stated R #3 frequently asked to be transferred to the toilet, but she could not bear weight on her legs at all. CNA #4 stated staff usually changed R #3's brief or offered the resident a bed pan. She stated often R #3 will not void or defecate after staff transfer her to the toilet. G. On 09/09/24 at 2:31 pm, during an interview with Family Member (FM) #2, she stated the facility Administrator called her immediately after the incident, and the Administrator told her the CNA was suspended while they investigated the incident. FM #2 stated the Administrator verified the CNA told her mother to go to the bathroom in her brief. H. On 09/10/24 at 12:45 pm, during an interview with the Corporate Nurse (CN), she stated the Activities Assistant (AA) answered R #3's call light. The CN stated R #3 asked the AA if she would change her and then told the AA that CNA #4 told her to just go in her brief and she would change when she was done. The CN stated staff should provide R #3 the opportunity to go to the bathroom in the toilet. The CN stated it was hit and miss with R #3 using the toilet. The CN stated the resident had a partial foot amputation so there was a weight bearing issue on that foot, but the resident was not a non-weight bearing status. She stated the resident would use the toilet, and she would also use her brief. She stated staff should take residents who can get up to the toilet when they needed to go. The facility took corrective action immediately with CNA #2 and retrained all staff on 07/08/24. CNA #2 was also retrained on dignity and resident rights on 07/26/24. Due to the facility taking immediate correction action, the facility will be cited at past non-compliance. Facility was in compliance as of 07/26/24. 1. The facility started an investigation into the incident after the grievance was submitted on 07/05/24. During the investigation, CNA #2 was suspended pending the results of the investigation. The outcome was for CNA #2 to be retrained on dignity and resident rights. 2. Record review of a corrective action memo, issued on 07/05/24 by Interim Director of Nursing (DON), indicated the allegations occured and was a lack of dignity, against resident rights, and against their facility policy. 3. Record review of the employee education sign-in sheets, dated 07/08/24, for abuse and neglect, customer service, and care intervention indicated CNA #2 went to the training. 4. Record review of a training record, dated 07/26/24, indicated R #2 received dignity and privacy training. 5. Resident interviews were conducted with the residents residing on the same hall. Interviews did not identify any other resident who were told by staff to use the bathroom in their brief.

Based on interview and record review the facility failed to keep residents free from abuse for 4 (R #27, R #28, R #56 and R #134) of 5 (R #20, R #27, R # 28, R #54 and R #134) residents reviewed for abuse when staff failed to: 1. Prevent emotional trauma as a result of not immediately removing the deceased body of R #27's roommate or moving R #27 from the room while waiting for the funeral home. 2. Physical abuse by the same Certified Nurse Aide (CNA) for R #27, 38, 56, and 134. The findings are: Findings for R #27 A. Record review of R #27's face sheet, dated [DATE], revealed she was admitted to the facility on [DATE] for multiple diagnoses including but not limited to: - Need for assistance with personal care. - Lack of coordination. - Morbid obesity (severe) due to excess calories (imbalance between the number of calories consumed and the number of calories burned). B. Record review of R #27's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS; a screening for cognitive impairment. Scores range from 00 to 15) score of 15, cognitively intact. C. On [DATE] at 1:55 pm during an interview, R #27 stated she was R #136's roommate since [DATE]. She stated her roommate (R #136) passed away on [DATE], and staff left her in the room with the body. R #27 stated she asked staff to move the body, but they did not. She stated an unknown CNA stood behind the privacy curtain, told her Rest in peace, [Name of R #27], turned off the light, walked out of the room, and shut the door. She stated since that day she had panic attacks and did not want another roommate. She stated she was scared and had anxiety about being in a room with another deceased roommate. R #27 revealed she told the Assistant Director of Nursing (ADON) about the incident, but she did not receive a response from the ADON. D. Record review of a nursing progress note for R #136, dated [DATE], revealed R #136 passed away on [DATE] at 1:24 am, and the body was removed from the room at 3:00 am. E. On [DATE] at 11:49 am, during an interview, the Assistant Director of Nursing (ADON) confirmed R #136 was deceased and left in R #27's room from 1:24 am to 3:00 am. The ADON stated she did not believe it to be best practice to leave a resident in the room with a deceased roommate. Findings related to CNA #4 R #134 F. Record review of R #134 face sheet, dated [DATE], revealed she was admitted to the facility on [DATE] with multiple diagnoses including, but not limited to: - Malignant neoplasm of unspecified site of unspecified female breast (breast cancer). - Type 2 diabetes with diabetic neuropathy (nerve damage that develops gradually and caused by long-term high blood sugar levels). - Muscle weakness. - Unsteadiness on feet. - Need for assistance with personal care. - Dependence on dialysis (a blood purifying treatment given when kidney function is not optimum). - Lack of coordination. G. Record review of the facility incident report, dated [DATE], revealed R #134 reported CNA #4 entered her room, kicked her on her lower leg, and hit her kidney to wake her up on [DATE] around 8:30 pm. R #134 stated she was unsure if she wanted to report it. There were no injuries noted. H. On [DATE] at 11:49 am, during an interview with the ADON, she stated CNA #4 was suspended pending investigation on [DATE] with a return date of [DATE]. I. Record review of Corrective Action Memo for CNA #4, dated [DATE], revealed CNA #4 reported she attempted to wake R #134 several times, but R #134 did not wake up. CNA #4 reported she tapped the resident on the shoulder, and it startled the resident. J. Record review of the facility's In-Service Training for Abuse/Neglect training, dated [DATE], and the facility's Customer Service/Care Interaction training, dated [DATE], revealed CNA #4 was in attendance. R #28 K. Record review for R #28's face sheet, dated [DATE], revealed she was admitted to the facility on [DATE] with multiple diagnoses including but not limited to: - Parkinson, unspecified (not a single disease, but a term for a group of conditions that affect movement and mimics Parkinson disease). - Chronic respiratory failure with hypoxia (an ongoing condition that affects your ability to breathe and process oxygen). - Need for assistance with personal care. - Other dysphasia (trouble swallowing). - Unsteadiness on feet. - Morbid obesity due to excess calories (imbalance between the number of calories consumed and the number of calories burned). - Rheumatoid arthritis, unspecified (chronic inflammatory disease that affects the joints). - Depression (feeling of sadness). L. Record review of a grievance report for R #28, dated [DATE], revealed the resident stated the night before [[DATE] thru [DATE]] was the worst night she ever had. R #28 reported CNA #4 yelled at her and told her to stay off the call light. R #28 stated CNA #4 said she would return to help her. R #28 stated CNA #4 shoved her, was very aggressive, and hurt her when she (CNA #4) changed her. M. On [DATE] at 1:17 pm, during an interview, R #28 stated a female staff was rough with her during care, but she was unable to recall the CNA's name. She stated the CNA worked nights. R #28 stated she had bruises from the CNA. She stated the police came and took a report from her. She stated she knew the CNA was fired. R #28 stated she felt like the call light was there so she could get help, not to make her feel like a problem. N. Record review of the staff schedule, dated [DATE], showed CNA #4 worked on R #28's unit on [DATE] during the 7:00 pm to 7:00 am shift. O. Record review of timecard for CNA #4 revealed the last shift she worked at the facility was the evening shift on [DATE] at 6:02 pm until morning of [DATE] at 6:01 am. P. Record review of the Police Department Field Case Report, dated [DATE], revealed the following: - Name of CNA #4. - Name victim: R #28. - Officer received a report from R #28, She advised she was resting in bed. She stated the CNA (her name) told her to keep off her call light. When the CNA #4 came to turn her, she shoved her over to the side very roughly. - During an interview, R #28 told the Officer, [Name of CNA #4] was in a bad mood. She yelled at me for using the call light. R #28 told the Officer that CNA #4 was very aggressive and rough with her when she (CNA #4) came to turn her (R #28). The resident stated the CNA shoved her to the point it caused bruising and pain. Q. Record review of the Police Department Field Case Supplement, dated [DATE] revealed the following: - R #28 stated she pressed her call light throughout the shift, and it upset CNA #4. The resident stated CNA #4 started to yell and scream at her and told her not to press her call light button. R #28 told the Officer CNA #4 shoved her when she (CNA #4) changed her (R #28). The resident showed the Officer how it occurred with her hand, in a palm strike type manner. R #28 stated CNA #4 hit/shoved R #28's right leg, and it was so hard it caused her leg to hit her other leg. - R #28 showed the officer her right outer thigh, and a large amount of bruising was noted on her leg. It covered approximately seven inches in length, along with multiple inches wide. - R #28 showed the officer her left inner leg, and the officer observed a lot of bruising. - R #28 stated CNA #4 caused the bruising. - There were two photographs of the right leg bruising and left leg bruising. R. Record review of the Police Department Field Case, Supplemental Narrative, dated [DATE], revealed an arrest warrant was obtained for CNA #4 for one count of battery (the unlawful application of physical force to another person without their consent). S. On [DATE] at 11:49 am, during an interview with the ADON, she stated they suspended CNA #4 pending investigation when the incident was reported on [DATE], and they terminated CNA #4's employment at the facility on [DATE]. T. On [DATE] at 11:31 am, during an interview with Director of Nursing (DON), she stated CNA #4 came back to work on [DATE] and was placed on the 200 hall. She stated, that after CNA #4 returned, a staff member reported to her (the DON) that R #28 voiced concerns about the CNA. The DON stated she spoke with R #28, and the resident told her about the terrible night she had with CNA #4. She stated R #28 reported CNA #4 scolded her for using her call light too many times, and when CNA #4 turned her, she (CNA #4) shoved her (R #28) on her hip area. The DON stated staff assessed R #28 and filed a grievance form. She stated during R #28's assessment, staff noted slight bruising on the resident's right side hip area. The DON stated she immediately suspended CNA #4 again, and staff did a skin sweep on the hall that CNA #4 worked. The DON stated that was when they found the bruising on R #56. R # 56 U. Record review of R #56's face sheet, dated [DATE], revealed she was admitted to the facility on [DATE] with multiple diagnoses that including but not limited to: - Fracture of the neck right femur (broken hip). - Adult failure to thrive (a condition that affects appetite, weight, and activity). - Need for assistance with personal care. - Unspecified dementia, unspecified severity, with psychotic disturbance (caused by damage to or loss of nerve cells and their connections in the brain). - Muscle wasting and atrophy, not elsewhere classified, multiple sites (loss of muscle leading to its shrinking and weakening). - Other symptoms and signs involving cognitive functions and awareness (difficulty in understanding or making sense of one's surroundings). V. Record review of a Shower Sheet for R #56, dated [DATE], did not identify any skin injury. W. Record review of Change in Condition Evaluation for R #56, dated [DATE], revealed resident had swelling with purple/black discoloration to her right lower arm. X. Record review of nursing progress notes for R #56, dated [DATE], revealed the resident was sent out for a right arm x-ray due to suspicion of a fracture. Y. Record review of the Diagnostic Radiology Report for R #56, dated [DATE], revealed the following: - Reason for exam: bruising and swelling of right forearm. - No fractures or dislocation. Z. Record review of the Police Department Case Report, dated [DATE], revealed: - R #56 had major bruising and trauma to her right forearm, on or around [DATE] [sic]. R #56 did not have any injuries prior to receiving care from CNA #4, and CNA #4 was the only staff who cared for the resident on [DATE] [sic]. Additionally, there was not an obvious medical cause for the injury, no blood drawn, and R #56 did not have any clotting disorders or medical conditions which would cause her to bruise spontaneously. - Pictures were part of the file and showed bruising of the resident's right forearm, with a visible bump to the right forearm. - According to the detective, the injuries on R #56 appeared to be consistent with her arm having been grabbed aggressively. AA. On [DATE] at 10:24 am during interview with the Regional Nurse Consultant (RNC), she confirmed the last time CNA #4 worked at the building was the evening of [DATE] thru the morning of [DATE]. The RNC stated R #56 had skin discoloration on [DATE], and the Physician felt the injury was latent (existing but not yet developed) in showing bruising. She also stated CNA #4 worked with R #56 independently on the evening shift of [DATE]. She stated the CNAs worked in pairs the evening of [DATE], and they did not report any incident of falls or other concerns, as it related to the bruising on R #56's arm. The RNC stated they felt that it was very likely that CNA #4 also hurt R #56, due to the other allegations/injury identified with R #28.

Based on record review and interview, the facility staff failed to report incidents to the State Agency (SA) in which the management received an allegation of employee-to-resident abuse/neglect and submit a five day follow-up report (a report detailing the facility's investigation, conclusion, and corrections for incidents reported to the SA) for 5 residents (R #28, #45, #56, #133, and #134) of 7 (R #20, #27, #28, #45, #56, #133 and #134) residents reviewed for abuse. If the facility fails to report incidents and follow-ups to the SA, then it could likely impact the safety and well-being of the residents. The findings are: Resident #133 A. Record review of the nursing progress notes for R #133, dated on 01/08/24, indicated Nurse #7 informed Nurse #8 she could not find R #133 in the facility. Nurse #8 notified the Assistant Director of Nursing (ADON) that R #133 was missing for several hours. R #133 entered the facility smelling of alcohol. A blood alcohol content (BAC; a test to determine the amount of alcohol in a person's bloodstream. A blood alcohol content of 0.08% or greater would indicate legally intoxicated) was completed, and R #133 had a BAC of 0.209%. B. On 06/05/24 at 11:37 am, during an interview with the Assistant Director of Nursing (ADON), she stated staff notified her R #133 was intoxicated. She stated she also received a report of concerns that Certified Nursing Assistant (CNA) #4 and CNA #5 drank alcohol and smoked cigarettes with R #133 during the night shift (when the resident had a BAC of 0.209%). The ADON stated staff reported to her that R #133, CNA's #4, and CNA #5 hung out in one of the CNA's car off and on all evening. She stated R #133 did not tell her where he got the alcohol. The ADON stated they discharged R #133 from the facility and suspended CNA #4 and CNA #5. The ADON stated she did not know why she did not report the incident to the SA. 47899 Resident #134 C. Record review of the facility's incident report, dated 03/04/24, showed the facility reported an incident to the SA regarding CNA #4 and R #134, but they did not submit the five day follow-up investigation. Resident #28 D. Record review of the health facility incident report, dated 03/08/24, showed the facility reported an incident to the SA regarding CNA #4 and R #28, but they did not submit the five day follow-up investigation. Resident #56 D. Record review of the health facility incident report, dated 03/08/24, showed the facility reported an incident to the SA regarding CNA #4 and R #56, but they did not submit the five day follow-up investigation. 48645 Resident #45 E. Record review of the health facility incident report, dated 04/15/24, showed the facility reported an incident to the SA regarding CNA #2 and R #45, but they did not submit the 5 day follow-up investigation. F. On 06/05/24 at 11:49 am and 12:25 pm, during an interview with the ADON, she stated she sent the five day follow-up investigations to the SA via the online reporting system, but she did not realize there was an error which did not allow them to be transmitted.

Based on record review and interview, the facility failed to meet professional standards of quality for any of the residents who resided on 100, 200 hallways.This deficient practice could cause any of the residents on those two hallways to not have their needs met, which could cause issues like skin breakdown, infections, falls, and dehydration. The findings are: A. Record review of the nursing progress notes for R #133, dated on 01/08/24, indicated Nurse #7 informed Nurse #8 she could not find R #133 in the facility. Nurse #8 notified the Assistant Director of Nursing (ADON) that R #133 was missing for several hours. R #133 entered the facility smelling of alcohol. A blood alcohol content (BAC; a test to determine the amount of alcohol in a person's bloodstream. A blood alcohol content of 0.08% or greater would indicate legally intoxicated) was completed, and R #133 had a BAC of 0.209%. Nurse #8 also notified the Assistant Director of Nursing (ADON) that Certified Nursing Assistant (CNA) #5 was missing for several hours. B. Record review of a statement by CNA #8, dated 01/08/24, revealed CNA #8 worked the night shift that evening/night on 01/07/24 to 01/08/24. The statement revealed around 10 pm we noticed both girls (CNA #4 and #5) missing after multiple call lights had gone off for a significant time. The statement revealed hours passed between the times CNA #8 saw either CNA. The statement also revealed CNA #8 received a text message on his phone around 3:01 am from CNA #4 that stated let us know when our lights goes off. CNA #8 documented the CNAs returned a short time later, did rounds, and went home. C. Record review of a statement made by Nurse #7, dated 01/08/24, revealed CNA #5, CNA #4, and R #133 went in and out of the facility all night and sat in one of their cars, with the music blasting during the the night shift on 01/07/24 to 01/08/24. Nurse #7 stated she went to one of the CNA's car window after a couple hours, but the CNAs ignored her and turned the music up. Nurse #7 documented CNA #4 was upset at her for knocking on the car window, and CNA #4 told her you have no right coming to my car. The statement revealed Nurse #7 informed CNA #4 that she (Nurse #7) was the charge nurse and had the right to tell them something. The statement also revealed the other CNAs working that evening answered call lights on CNA #4's and CNA #5's hallways. D. Record review of a statement made by CNA #9, dated 01/08/24, revealed CNA #9 witnessed CNA #5 and CNA #4 take a two-and-a-half hour break and then go out to their cars for another hour, during the night shift on 01/07/24 to 01/08/24. The statement revealed the charge nurse went out to their car and knocked on their windows, but they ignored her. CNA #9 documented CNA #4 and #5 then left shift at 4:45 am. E. On 06/04/24 at 6:24 pm during an interview with CNA #5, she stated she and CNA #4 took at least five or six smoke breaks on the night shift on 01/07/24 to 01/08/24. She stated it was cold that night so they sat in CNA #4's car. She stated they were just smoking when R #133 came out and invited himself into the car. CNA #5 said R #133 seemed pretty out of it already. She stated Nurse #7 came out and knocked on the window. She stated CNA #4 got mad at the nurse, and they never rolled down the window. F. On 06/05/24 at 7:48 am during an interview with Nurse #7, she stated CNA #5 and CNA #4 did not work their floor most of the night on the night shift on 01/07/24 to 01/08/24. She stated they sat outside in one of their cars and smoked. She stated there was a concern they were also drinking alcohol. She stated she confronted the CNAs in their car by knocking on the window, but they ignored her and turned up their music. She stated the other CNAs working that night witnessed the incident, and they were very frustrated. She stated the CNAs were gone for three hours at one point. Nurse #7 stated she felt the CNAs abandoned their job. She stated she spoke with day nurse, and it was reported to ADON. G. On 06/05/24 at 11:37 am, during an interview with the ADON, she stated she found out at 6:00 am on 01/08/24 what happened that evening. She said the night nurse reported it to the day nurse, and the day nurse reported it to her. She stated they tested R #133's BAC, and he was intoxicated. The ADON stated the resident would not say where he got the alcohol. The ADON stated she had CNA #5 and CNA #4 come in and give statements, and she suspended CNA #5 and CNA #4 after she got the statements from the CNAs and staff members working on the night shift on 01/07/24 to 01/08/24. She stated the CNAs sat outside in their car smoking, and they hung out with the resident. She stated the two CNAs told her they were outside at least six times that evening, but it was not clear how long they were outside. H. On 06/06/24 at 10:13 am, during an interview with CNA #10, she stated she worked the dayshift on 01/08/24. CNA #10 stated that when she came that morning for her shift, her residents had not been taken care of. She stated some of them were soaking wet, but she could not recall which residents. She stated at least half the residents on her hall needed something when she started her shift. She stated the sheets on a few of the residents' beds had urine rings from multiple incontinent episodes, and some of the residents had a brief that was soaked through.

Based on observation, interview and record review, the facility failed to keep residents free from accidents for 2 (R #14 and R #58 ) of 2 (R #14 and R #58) residents reviewed when staff failed to: 1. Ensure R #14's fall mat (a safety feature placed along the side of the bed to prevent injury) was picked up when the resident was not in bed. 2. Ensure staff checked placement of the wanderguard for R #58. These deficient practices could likely result injury or death to residents due to tripping on the floor mats and eloping from the facility. The findings are: A. Record review for R #14's face sheet, dated 06/04/24, revealed she was admitted to the facility on [DATE] for multiple diagnoses including but not limited to: - Cerebral infarction due to thrombosis of right posterior cerebral artery (Stroke due to a blood clot). - Abnormal posture (rigid body movements and chronic abnormal positions of the body). - Unsteadiness on feet. - Muscle weakness. - Pain, unspecified. - Wedge compression fracture of T9 T10 vertebra (a type of compression fracture that occurs when one side of your vertebrae collapses and creates a wedge shape). - Wedge encounter compression fracture of T9 T10 vertebra. (a type of compression fracture that occurs when one side of your vertebrae collapses and creates a wedge shape). B. On 06/04/24 at 10:46 am, during an observation and interview, R #14 sat in her room in her wheelchair and fall mats were on the floor. She stated she could not move around in her room due to the mats on the floor. R #14 pointed to the fall mats on the floor. She stated, They are in the way all the time. I can't move in here. They hang me up. C. On 06/06/24 at 12:30 pm, during an observation of R #14's room, two fully opened fall mats were on the floor. R #14 sat in her wheelchair and was not in her bed. D. On 06/07/24 at 8:46 am, during an interview with the Assistant Director of Nursing (ADON), she stated staff leave the fall mats on the floor even when R #14 was out of bed. She stated it would prevent an injury from a fall, but she never thought about it being a fall hazard. 35632 E. On 06/03/24 at 1:30 pm, an observation revealed a staff member watched and observed R #58. F. On 06/03/24 at 1:30 pm, during an interview with hospitality aide #1, she stated she was currently on a one-to-one (one person monitoring another person) with R #58. She stated she tried to stay away from the resident, because he can become agitated. G. Record review of the annual Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) for R #58, dated 03/27/24, revealed a Brief Interview for Mental Status (BIMS; a screening for cognitive impairment. Scores range from 00 to 15) score of 7, severe cognitive impairment. H. Record review of the nursing progress note for R #58, dated 5/4/24, indicated R #58 told an unknown Certified Nursing Assistant (CNA) he was packing his belongings, because he wanted to leave the facility. Staff notified the ADON and placed a wanderguard on the resident's right leg. I. Record review of the physician orders for R #58 indicated an order, dated 05/05/24, to check wander guard placement to right ankle and function, every shift, two times a day for elopement (leaving without others knowledge). J. Record review of the elopement evaluation for R #58, dated 05/06/24, indicated the resident scored a 15, imminent (high) risk of elopement. K. Record review of the nursing progress note for R #58, dated 06/02/24 at 2:39 am, indicated R#58, left the facility with a visitor of a different unknown resident on 06/01/24. The visitor took R #58 to his home in Arizona and dropped him off. Facility staff were not aware R #58 was not at the facility until dinner time when they were not able to locate him. Facility staff located the resident and picked him up. The resident returned to the facility and was unharmed. L. On 06/05/24 at 11:37 am, during an interview with ADON, she stated she saw the order for a wanderguard and to check placement, dated 05/05/24. She stated R #58 would not let facility staff check the placement of his wanderguard, so that was not done. She stated the resident must have taken the wanderguard off at some point, because he did not have one on when he eloped on 06/01/24.

Based observation, record review, and interview the facility failed to have the Interdisciplinary Team (IDT; a facility team composed of various professionals who review and determine resident needs and abilities) determine if residents could self-administer medication for 1 (R #73) of 1 (R #73) residents randomly sampled. This deficient practice is likely to result in residents self-administering medication inappropriately or incorrectly which could cause harm. The findings are: A. Record review of R #73's care plan, dated 05/05/24, revealed the plan did not state the resident could self-administer medication. B. Record review of R #73's active physician's orders, as of 06/04/24, revealed the resident did not have an order for self-administering medications. C. On 06/04/24 at 8:55 am, during an observation, R #73 ate her breakfast while lying in bed. R #73 took a medication cup with five tablets in it and swallowed the medication one at a time. Further observation revealed staff members were not present inside the resident's room or outside her door. D. On 06/04/24 at 9:00 am, during an interview with R #73, she stated she liked to take her morning medications after she ate, and the staff member left them with her to take after she finished eating. R #73 further stated she needed to take her medications one at a time, because she choked on them if she took them all together. E. On 06/05/24 at 12:06 pm, during an interview with the Director of Nursing (DON), she stated that if a resident was allowed to administer their own medications, then it would be documented in the resident's physician orders and care plan. The DON stated R #73's physician's orders and care plan did not contain the information, and the resident was not allowed to administer her own medications. The DON further stated it was expected for staff to observe the resident take medications and not to leave the medication with the resident.

Based on record review and interview, the facility failed to develop a comprehensive, person-centered plan which included information about fall interventions used for 1 (R #14) of 1 (R #14) residents reviewed for care plans. This deficient practice could likely result in residents not receiving the care needed to reach their highest practicable level of wellbeing. The findings are: A. Record review for R #14's face sheet, dated 06/04/24, revealed she was admitted to the facility on [DATE] for multiple diagnoses including but not limited to: - Cerebral infarction due to thrombosis of right posterior cerebral artery (Stroke due to a blood clot). - Abnormal posture (refers to rigid body movements and chronic abnormal positions of the body). - Unsteadiness on feet. - Muscle weakness. - Pain, unspecified. - Wedge compression fracture of T9 T10 vertebra (a type of compression fracture that occurs when one side of your vertebrae collapses and creates a wedge shape). - Wedge encounter compression fracture of T9 T10 vertebra (a type of compression fracture that occurs when one side of your vertebrae collapses and creates a wedge shape). B. On 06/04/24 at 10:46 am, during an observation, R #14 sat in her room in her wheelchair and fall mats were on the floor. C. On 06/06/24 at 12:30 pm, during an observation of R #14's room, two fully opened fall mats were on the floor. D. Record review of R #14's care plan, dated 02/13/24, revealed the care plan did not address the resident's use of fall mats as an intervention for falls. E. On 06/07/24 at 8:46 am, during an interview with the Assistant Director of Nursing (ADON), she stated staff leave the fall mats on the floor even when R #14 was out of bed. She stated the mats prevented the resident from receiving an injury from a fall. F. On 06/07/24 at 8:49 am during an interview, the Director of Nursing (DON) stated staff did not document the use of fall mats in R #14's care plan.

Based on observation, interview and record review, the facility failed to provide proper infection control practices when staff failed to ensure collection bags are kept off the floor for 2 (R #1 and R #2) of 3 (R #1, R #2, and R #3) residents. If the facility is not using proper infection control practices the residents are likely to acquire infections. The findings are: A. Record review of the facility policy, Catheter-Care of, revised 06/20, revealed staff instructed to take care to ensure the collection bag does not touch the floor at any time. B. Record review of labs of R #1's cultures obtained of his urine revealed pseudomonas putida (an uncommon cause of skin and soft tissue infections. It is often associated with trauma or immunocompromised state) and enterococcus faecalis (species can cause a variety of infections, including urinary tract infections) organisms grew in his urine. C. Record review of R #1's physician orders revealed R #1 an order, dated 03/02/24, for ciprofloxacin HCI (antibiotic that treats infections) oral tablet, 500 milligrams (MG), twice daily for seven days to treat a urinary infection. D. On 03/04/24 at 1:55 pm, observation revealed R #1's collection bag lay on the floor. E. On 03/04/24 at 2:25 pm, observation revealed R #2's collection bag lay on the floor. F. On 03/04/24 at 4:00 pm, during an interview, the Assistant Director of Nursing (ADON) confirmed collection bags should not lie on the floor. The ADON stated collection bags should hang at gravity level, hooked onto the chair or bed to keep collection bags off the floor.

Based on record review and interview, the facility failed to create an accurate Baseline Care Plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for baseline care plans. This deficient practice could likely result in a decline in the resident's condition due to staff not being aware of the care residents need and residents not being able to attain or maintain their highest practical level of wellbeing. The findings are: A. Record review of R #1's face sheet revealed he was admitted into the facility on [DATE]. B. Record review of R #1's Care Plan, dated 1/31/24, revealed staff did not develop a Baseline Care Plan which included catheter care within 48 hours of admission. C. On 03/05/34 at 2:37 pm, during an interview with the Assistant Director of Nursing (ADON), she confirmed there was not a baseline care plan for catheter care within 48 hours of the resident's admission. The ADON stated staff missed it, and she added catheter care to the resident's care plan on 3/4/24.

Based on record review and interview, the facility failed to ensure that residents received necessary treatment and service to prevent development and promote healing of pressure wounds (damaged skin caused by pressure, shear or friction) for 1 (R #19) of 3 ( R #11, 19, and 125) residents reviewed for pressure ulcers. This deficient practice likely resulted in a facility acquired pressure wound becoming necrotic (death of living tissue) before treatment was initiated. The findings are: A. Record review of R# 19's medical record revealed that resident was admitted to the facility on [DATE] and diagnoses indicated the following: Hypertension (high blood pressure), Benign Prostatic Hyperplasia (the prostate is enlarged), Altered Mental Status (brain malfunction that affects behavior and awareness), Malignant Neoplasm of Prostate (prostate cancer), Parkinson's disease (is a condition that affects the brain and causes problems with movement, balance, and coordination), Depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities), Dysphagia (condition with difficulty in swallowing food or liquid), Dementia (condition that affect the brain's ability to think, remember, and function normally). This is not an all inclusive list. B. Record review of the Braden Scale for predicting pressure sore risk dated 02/09/23 indicated that R #19 scored a 12 which is a high risk for developing a pressure sore. Section 1 indicated that sensory perception was very limited and this would hinder is ability to respond to stimuli, 2. Moisture and R #19 scored very moist which means his skin is moist. 3. Indicated that R #19 is chairfast which means his ability to walk is severely limited or non-existent. He is unable to bear weight and must be assisted into chair or wheelchair. 4 Indicated that for mobility R #19 is very limited. He is limited in his ability to change and control body position independently and make frequent or significant changes. Section 5 Nutrition is adequate which indicated that he eats over half his meals. Section 6 indicated that for friction and shear R #19 has a problem in this area and requires moderate to maximum assistance in moving. He frequently slides down in bed or chair and requires frequent repositioning with maximum assist. C. On 02/08/23 at 8:43 am, during an interview with Wound Care Nurse, she stated that wounds for R #19 were brought to her attention last week on 02/03/23. She stated that she was asked to look at the wounds after a dressing had fallen off. She stated that when she saw the wounds they were on the Ischium (forms the lower and back region of the hip bone) and one of them was necrotic (death of living tissue) unstageable (refers to an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar) and the other was a stage II (partial thickness loss of the first two layers of the skin, the epidermis and dermis). She stated that someone had been treating it because there was a dressing on it. She stated that she had not been made aware of any wound on R #19 prior to 02/03/23. She stated that she can assume that the wounds had been identified before 02/03/23 and they (nursing staff) were just treating them. Before 02/03/23 there were no orders for treatment, no change in condition completed and she didn't think the family was notified. Wound Care Nurse confirmed that R #19 was not being treated for any wounds to her knowledge prior to 02/03/23. D. Record review of skin assessments indicated weekly skin assessments completed by nurses on 01/13/23, 01/20/23 and 01/27/23 no skin impairments (nothing on the skin) were noted. E. Record review of the Certified Nursing Assistant (CNA) documentation to monitor the skin revealed that on the following dates it was noted that R #19 had an open area to his skin: 01/28/23, 01/29/23, 01/30/23, 02/02/23, 02/04/23, 02/06/23, 02/07/23 and on 02/08/23. No indication on this documentation if the nurse was notified. F. Record review of the nursing progress notes dated 02/03/23 indicated that R #19 had a wound care assessment on 02/03/23, physician informed, and orders obtained. Teaching to nurse and CNAs on repositioning q (every) 2 hours with incontinent care if needed, skin checks, wound care. G. Record review of the wound care assessment dated [DATE] indicated that there are two wounds. Left Ischium (forms the lower and back region of the hip bone) with minimal thin, tan exudate (a mass of cells and fluid that has seeped out of blood vessels) with no odor. The wound appearance is black, necrotic tissue 70% necrotic and 30% granulation (the primary type of tissue that will fill in a wound that is healing). Surrounding tissue is bright red and macerated (happens when your skin is broken down by moisture). Length is 4.3 cm (centimeters) width is 3.5 cm and no depth is noted. The right Ischium wound was noted as having no exudate, no odor, the wound appearance is red granulation tissue 80% granulation and 20% slough (necrotic tissue that needs to be removed from the wound for healing to take place) and the surrounding tissue is pink. The wound size is Length 3.0 cm width 3.2 cm and the depth is 0.3 cm. H. Record review dated 02/03/23 of a Change In Condition (CIC) progress note indicated the following: Reported on this CIC Evaluation are/were: Skin wound or ulcer Nursing observations, evaluation, and recommendations are: Resident observed to have skin breakdown near gluteal fold (fold of the buttock or horizontal gluteal crease) on left side. Pressure ulcer unstageable due to necrosis noted. Area cleansed and dressings placed. Right side same area has stage II ulcer. Wound care completed. I. Record review of the nursing progress notes for R #19 did not reveal any wound care for the pressure wounds on the Ischium prior to 02/03/23. J. Record review of the physician orders indicated the following: -Stage 2 Right Ischium pressure ulcer: Cleanse with wound cleanser, pat dry with gauze, apply thera honey to wound bed (treatment for wounds), cover with alginate (maintains a moist microenvironment, minimize bacterial infection at the wound site, and facilitate wound healing) then with foam dressing (foam dressings are used to provide a moist wound environment, most commonly in wounds with moderate-to-heavy exudate) of choice qod (every other day) and prn (as needed) for loose or soiled dressing every day shift every other day for wound care on 02/03/23. -Wound care to Left Ischium: Cleanse with wound Vashe (cleansing, irrigating, moistening, debridement and removal of foreign material), pat dry with gauze, apply derm/syn (donates moisture to dry or minimally exudating wounds for an optimal moist environment) to necrotic area, apply (sic) honey (for dry to moderately exuding wounds) to nonnecrotic area, cover with calcium alginate (highly absorptive) and foam dry dressing of choice qod and prn for loose or soiled dressing every day shift every other day for wound care on 02/03/23. K. On 02/10/23 at 9:20 am, during an interview with Registered Nurse (RN) #2, stated that they do weekly skin assessments on shower days and they have to lay their eyes on the residents skin to do the assessment. She stated that last week was when she became aware of R #19's wounds. When asked if the wound was present before last week she stated she couldn't recall. She stated that on 02/03/23 a CNA (doesn't remember who) called her into see the wound and asked if she was aware of it. She stated that there were no physician orders to treat the wound prior to 02/03/23. On 02/03/23 she did notify the DON, physician and the family. RN #2 stated that wound had necrosis (death of tissue cells) and redness on the wound when she saw it on 02/03/23. L. On 02/08/23 at 1:43 pm, during an interview with Director of Nursing (DON) she stated that she was first notified of the wound Friday afternoon which was 02/03/23. She was notified by the nurse working him (R #19) that day. The DON stated that the nurses that had been working with him did not indicate a problem and the skin check's reflect this. She stated that the CNA's had not brought up any skin issues either. M. On 02/08/23 at 2:18 pm, during an interview with the Physician he stated that R #19 has unavoidable wounds and they are unlikely to heal. He stated that he doesn't recall exactly when he was notified about the wound but stated he has known about it for awhile maybe two weeks. Physician confirmed that he did not provide wound orders until 02/03/23. N. On 02/09/23 at 1:43 pm, during an interview with CNA #8, she stated that the last time (didn't remember when that was) that she worked with R #19 he had some redness. She stated that if she had seen any redness on the resident, she would have noted that on the skin monitoring sheet and wound inform the nurse about it. CNA #8 could not recall if she had notified the nurse about any wounds or redness for R #19.

Based on observation and interview, the facility failed to distribute food under sanitary conditions by not transporting resident meals, covered, when serving meals to residents in their rooms. This deficient practice could likely affect any of the 76 residents served meals in their rooms, identified on the resident census list provided by the Administrator (ADM) on 02/06/23. If the facility fails to adhere to safe food handling practices residents are likely to be exposed to foodborne illnesses (illness caused by food contaminated with bacteria {a large group of single-cell microorganisms that can cause infections and disease in animals and humans}, viruses {infectious agent of small size and simple composition that can multiply only in living cells of animals, plants, or bacteria} parasites {an organism that lives on or in a host organism and gets its food from or at the expense of its host}, or toxins {any poisonous substance produced by bacteria, animals, or plants}) and could also likely result in having food not being served at a palatable (pleasant to taste) and appetizing temperature. The findings are: A. On 02/09/23 at 12:46 PM during an observation of meals being served to residents in their rooms, several meals were observed on a stainless-steel rolling utility cart in the hallway of the 100 unit of the facility. Each plated meal was observed to be covered by an insulated food dome and on an individual tray. Certified Nursing Aide (CNA) #1 was observed to uncover a meal and carry the plated meal into a resident's room without the dome cover. CNA #1 then returned to the cart in the hallway to retrieve the cutlery and drinks for the same resident from the individual tray on the cart. CNA #1 repeated this process for the next resident's meal on the cart, again uncovering the resident's food on the cart and walking the uncovered, plated meal to the resident's room. CNA #1 then moved the cart with the plated meals further down the 100 hall, and continued the same process of uncovering individual plates and walking the uncovered food into the residents' rooms of the 100 unit. B. On 02/09/23 at 12:55 pm, during an interview, CNA #1 confirmed she was walking uncovered plates from the hallway into the rooms, stating the food slides around [on the tray] and that they [the trays] were bulky and heavy. CNA #1 stated the food should be uncovered in the room, not in the hallway.

Based on record review and interview, the facility failed to create an accurate Baseline Care Plan within 48 hours of admission for 1 (R #60) of 8 (R #'s 4, 41, 47, 51, 60, 63, 67 and 176) residents reviewed for Baseline Care Plans. This deficient practice could likely result in a decline in the residents condition due to staff not being aware of needed care and/or residents not being able to attain or maintain their highest practicable level of well-being. The finding are: Findings for Resident #60 A. Record review of Face Sheet dated 10/02/22 for R #60 revealed an initial admitted [DATE] and included the following diagnoses: Dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), Need for Assistance with Personal Care, Muscle Weakness, Symptoms and Signs Involving Cognitive Functions and Awareness (ability to process incoming information), Chronic Kidney Disease, and Age-related Physical Debility (physical weakness). B. Record review of Minimum Data Set (MDS) dated [DATE] for R #60 revealed, Section G - Functional Status: .I. Toilet use - how resident uses the toilet room, commode, bedpan . Limited Assistance with one person physical assist . Section H - Bladder and Bowel: Occasionally incontinent . C. Record review of Baseline Care Plan dated 06/19/22 for R #60 revealed care plan was not developed within 48 hours of admission and did not include the need for assistance with personal care or Activities of Daily Living (ADL). [comprehensive care plan for ADL assistance was not created until 07/19/22] D. On 02/10/23 at 12:07 pm during an interview with the Assistant Director of Nursing (ADON), she stated that R #60 does not have a baseline care plan because she was a long term care resident that returned and her care plan that was in place was reviewed/revised as needed.

Based on record review and interview, the facility failed to ensure that the care plan had been developed and implemented for 2 (R #35 and R #60) residents of 3 (R #35, R#60, and R #16) residents reviewed for comprehensive care plans by: 1. Not developing a comprehensive care plan for R #60 within 7 days of completion of the comprehensive assessment [Minimum Data Set - MDS - clinical assessment that describes a person's overall condition] or within 21 days of admission for R #60. 2. Not including a resident or resident representative in care plan meetings for R #35. These deficient practices has the potential result of staff members not having the updated information needed from residents, their representatives, and the MDS, and could likely result in residents not having their Activities of Daily Living (ADLs) and other medical needs appropriately met and resident feelings of embarrassment, depression, or not feeling valued. Findings for R #60 A. Record review of Face Sheet dated 10/02/22 for R #60 revealed an initial admitted [DATE] and included the following diagnoses: Dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life), Tinea Unguium (fungal infection of the nails), Hypertension (high blood pressure), Sequelae of Cerebral Infarction (condition or consequence of having a stroke), Gastro-Esophageal Disease (heartburn), Osteoarthritis (swelling of one or more joints that results in chronic pain), Kyphosis (abnormality of the spine causing excessive curvature of the upper back and causes pain and stiffness), Age-related Osteopososis (condition that causes bones to become weak and brittle), Chronic Kidney Disease (gradual loss of kidney function), Age-related Physical Debility (physical weakness), and Adult Failure to Thrive (a state of decline that affects older adults resulting in poor nutrition, weight loss, inactivity, depression [persistent feeling of sadness and loss of interest] and decreasing functional ability). B. Record review of Minimum Data Set (MDS) dated [DATE] for R #60 revealed that Care Plans for the following areas were triggered: Cognitive Loss/Dementia, Communication, Urinary Incontinence and Indwelling Catheter (medical device used to drain urine from the bladder), Falls, and Pressure Ulcers (injuries to skin and underlying tissue that form due to prolonged pressure on the skin). C. Record review of Care Plans for R #60 revealed the following dates for Care Plan development: 1. Falls - 06/19/22 [9 days after admission] 2. Dementia; Pressure Ulcers; Hypertension; and ADL care - 07/19/22 [33 days after completion of MDS]3. Communication; Urinary Incontinence; History of CVA (Cerebral Vascular Accident - stroke); Gastro-Esophageal Reflux Disease; Osteoarthritis; Osteoporosis; and Chronic Kidney Disease - 09/16/22 [64 days after completion of MDS] 45426 Findings for R #35 D. Record review of R #35's face sheet revealed R #35 has the following diagnoses: quadriplegia, C1-C4 incomplete (paralysis that still has some signals getting through to both arms and legs, starting in the high cervical nerves), and other recurrent depressive disorders. These diagnoses are not all inclusive and does not include all of R #35's diagnoses. E. On 02/07/23 at 9:11 am, during an observation and an interview with the resident, R #35 was observed in bed in his room and reported he had not been going to any meetings when asked if he had been participating in his care planning. F. Record review of R #35's electronic medical record revealed care plans with revision dates of 10/30/22 and 01/27/23. No care planning conference notes for October 2022 were found. No documentation indicating a care planning conference invitation was provided to R #35 or his family representative for January 2023 was found. No care planning notes for January 2023 were found. G. On 02/08/23 at 9:04 am, during an interview, Social Services Assistant (SSA) stated she recently started the position and had not conducted a care planning meeting with R #35 since starting the position. She stated that R #35's quarterly care planning conference which was due in October 2022 had been canceled. SSA also stated a quarterly care conference planning meeting due in January 2023 did not occur and should have been scheduled. She was unsure why the January 2023 care plan meeting for R #35 did not happen. H. On 02/08/23 at 9:04 am, during an interview with SSA, the care planning conference invitations and notes for R #35 were requested for October 2022 and January 2023. No care planning conference invitation for January 2023 was provided and no care planning notes for October 2022 or January 2023 were provided.

Based on record review and interview, the facility failed to ensure that 1 (R #184) of 1 (R #184) resident received appropriate pain management when the facility staff failed to request access to the pyxis (a locked medication dispensing device that can be accessed with proper authority to remove medications in case of an emergency) in time for R #184 to receive next dose of pain medication. This deficient practice likely resulted in R #184 experiencing severe pain and causing unnecessary distress in which R #184 felt only option for relief was to return to the hospital. The findings are: A. On 01/10/22 at 9:46 am during interview with R #184 daughter (D), she stated that her mother was discharged from hospital and transferred to the facility on [DATE] and that she accompanied R #184 from hospital to the facility, they arrived about 5:00 pm and upon arrival she spoke with the admitting nurse and verified R #184's orders for pain medication. D stated that she emphasized to the admitting nurse that R #184 required pain medication every four hours and stressed how important it was that R #184 receive her pain medication and that the next dose would be due about 8:00 pm. D stated that she was assured by the nurse the the medication would be available and provided to R #184 in a timely manner. D stated that she spoke with her mother several times by phone between 8:00 pm and 10:00 pm and learned that R #184 had not received any pain medication since arrival. D stated that during their last conversation, R #184 was tearful and in great pain. D stated she then called the facility and told them she was coming to the facility to remove R #184 from the facility. D stated that she called for an ambulance. D arrived just before the ambulance at about 11:00 pm. She found R #184 crying and in pain. When the ambulance arrived, D insisted that R #184 be removed and transported to the nearest hospital. B. Record review of R #184 face sheet printed 01/04/22 revealed she was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Cervical (neck and upper back) Disc (a fluid filled sac that is located between each neck/back bone to act as a cushion) Disorder with [CONDITION(S)] (spinal cord injury) Pain due to internal orthopedic (bone) prosthetic devices (implants to support and stabilize a portion of the body) Other Intervertebral Disc Degeneration (decline, breakdown) Lumbar (lower back) region Unspecified Dementia (decline in mental status accompanied by memory loss) Anxiety Disorder (frequent-sometimes severe-nervousness and fear) C. Record review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Order date 12/04/2021 17:38 (5:38 pm) [MEDICATION(S)]-Acetaminophen (a pain medication that combines a mild narcotic with a non-narcotic pain reliever) 7.5-325 MG (milligrams) Give 1 tablet by mouth every 4 hours as needed for pain 1-2 every 4 hrs (hours) as needed for pain. D. Record review of daily care notes revealed date and times R#178 arrived and left the facility as: 12/04/21 1901 (7:01 pm) Note Text Res (resident) arrived at facility via facility transport at 1700 (5:00 pm) 12/04/21 2300 (11:00 pm) Due to patient's meds (medications) not coming in and nurse unable to access ekit (a supply of frequently used medications available for emergency use) without code from pharmacy. Resident left AMA (against medical advice) citing she wanted pain meds (narcotics) Resident left via ambulance and was taken to (initials of area hospital). Resident daughter came to remove her from the building. Daughter and resident were notified that pharmacy was in the final phase of approving the narcotic and it would be soon. Offered resident option to wait approx (approximately) 5 or 10 more minutes to be able to receive pain medication. Resident's daughter called staff rude names and threatened staff with lawsuit. All attempts to calm the daughter were met with hostility. E. On 01/06/22 during interview with Director of Nursing (DON), stated, the facility has a Pyxis from which a nurse would be able to draw most prescribed medications. DON stated that R #184 was admitted to the facility on a weekend and any medications she might have needed should have been drawn from the Pyxis. She further stated that the narcotic medication prescribed to R #184 for pain could have been drawn from the Pyxis following authorization and a code provided by (name of pharmacy service). She stated that R #184 was removed from the facility before an authorization code could be received from the pharmacy. F. On 01/10/22 at 11:44 am during interview with (name of pharmacy service) Pharmacy Tech (PhT) she stated that the pharmacy record indicated that a prescription for R #184 for [MEDICATION(S)]-Acetaminophen 7.5-325 MG pain medication had been received from the facility on 12/04/21 at about 6:00 pm. PhT stated the pharmacy did not receive a request from the facility nurse to draw R #184's pain medication from the Pyxis unit 10:32 pm (2.5 hours after when the pain medications was expected to be administered). PhT stated that this request for authorization code was approved/provided at 11:22 pm. Pharmacy Tech confirmed ordered medications were not delivered to the facility prior to R #184's discharge. Based on record review and interview, the facility failed to ensure that 1 (R #184) of 1 (R #184) resident received appropriate pain management when the facility staff failed to request access to the Pyxis (a locked medication dispensing device that can be accessed with proper authority to remove medications in case of an emergency) in time for R #184 to receive next dose of pain medication. This deficient practice likely resulted in R #184 experiencing severe pain and causing unnecessary distress in which R #184 felt only option for relief was to return to the hospital. The findings are: A. On 01/10/22 at 9:46 am during interview with R #184 daughter (D), she stated that her mother was discharged from hospital and transferred to the facility on [DATE] and that she accompanied R #184 from hospital to the facility, they arrived about 5:00 pm and upon arrival she spoke with the admitting nurse and verified R #184's orders for pain medication. D stated that she emphasized to the admitting nurse that R #184 required pain medication every four hours and stressed how important it was that R #184 receive her pain medication and that the next dose would be due about 8:00 pm. D stated that she was assured by the nurse the the medication would be available and provided to R #184 in a timely manner. D stated that she spoke with her mother several times by phone between 8:00 pm and 10:00 pm and learned that R #184 had not received any pain medication since arrival. D stated that during their last conversation, R #184 was tearful and in great pain. D stated she then called the facility and told them she was coming to the facility to remove R #184 from the facility. D stated that she called for an ambulance. D arrived just before the ambulance at about 11:00 pm. She found R #184 crying and in pain. When the ambulance arrived, D insisted that R #184 be removed and transported to the nearest hospital. B. Record review of R #184 face sheet printed 01/04/22 revealed she was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Cervical (neck and upper back) Disc (a fluid filled sac that is located between each neck/back bone to act as a cushion) Disorder with [CONDITION(S)] (spinal cord injury) Pain due to internal orthopedic (bone) prosthetic devices (implants to support and stabilize a portion of the body) Other Intervertebral Disc Degeneration (decline, breakdown) Lumbar (lower back) region Unspecified Dementia (decline in mental status accompanied by memory loss) Anxiety Disorder (frequent-sometimes severe-nervousness and fear) C. Record review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Order date 12/04/2021 17:38 (5:38 pm) [MEDICATION(S)]-Acetaminophen (a pain medication that combines a mild narcotic with a non-narcotic pain reliever) 7.5-325 MG (milligrams) Give 1 tablet by mouth every 4 hours as needed for pain 1-2 every 4 hrs (hours) as needed for pain. D. Record review of daily care notes revealed date and times R#178 arrived and left the facility as: 12/04/21 1901 (7:01 pm) Note Text Res (resident) arrived at facility via facility transport at 1700 (5:00 pm) 12/04/21 2300 (11:00 pm) Due to patient's meds (medications) not coming in and nurse unable to access ekit (a supply of frequently used medications available for emergency use) without code from pharmacy. Resident left AMA (against medical advice) citing she wanted pain meds (narcotics) Resident left via ambulance and was taken to (initials of area hospital). Resident daughter came to remove her from the building. Daughter and resident were notified that pharmacy was in the final phase of approving the narcotic and it would be soon. Offered resident option to wait approx (approximately) 5 or 10 more minutes to be able to receive pain medication. Resident's daughter called staff rude names and threatened staff with lawsuit. All attempts to calm the daughter were met with hostility. E. On 01/06/22 during interview with Director of Nursing (DON), stated, the facility has a Pyxis from which a nurse would be able to draw most prescribed medications. DON stated that R #184 was admitted to the facility on a weekend and any medications she might have needed should have been drawn from the Pyxis. She further stated that the narcotic medication prescribed to R #184 for pain could have been drawn from the Pyxis following authorization and a code provided by (name of pharmacy service). She stated that R #184 was removed from the facility before an authorization code could be received from the pharmacy. F. On 01/10/22 at 11:44 am during interview with (name of pharmacy service) Pharmacy Tech (PhT) she stated that the pharmacy record indicated that a prescription for R #184 for [MEDICATION(S)]-Acetaminophen 7.5-325 MG pain medication had been received from the facility on 12/04/21 at about 6:00 pm. PhT stated the pharmacy did not receive a request from the facility nurse to draw R #184's pain medication from the Pyxis unit 10:32 pm (2.5 hours after when the pain medications was expected to be administered). PhT stated that this request for authorization code was approved/provided at 11:22 pm. Pharmacy Tech confirmed ordered medications were not delivered to the facility prior to R #184's discharge.

This is a repeat deficiency from a Recertification survey completed on 04/01/21. Based on record review, interviews, and video surveillance observation, the facility failed to keep resident free from neglect for 1 (R #1) of 3 (R #1, 4 and 5) residents reviewed for abuse and neglect. R #1 had two falls on 07/07/21, where he experienced an unintentional fall to the floor near the activity room, in which a chair landed on his back. After the fall, there was no documentation in the medical record that he had been assessed after that fall, nor was he assessed after the second fall later that same day. This deficient practice resulted in R #1 being sent to the hospital on two separate occasions the following day 07/08/21, in which it was discovered that he had multiple bruising, multiple fractures, and was COVID-19 (a contagious disease caused by severe acute respiratory syndrome) positive. The findings are: A. Record review of admission record indicated that he was admitted with an original date of 12/31/20. R #1 had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] force or a violent blow to the head) symptoms. B. Record review of medication physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Record review of R #1's MDS (Minimum Data Set, a comprehensive assessment) dated 02/28/21, revealed the following: Section C: Cognitive Patterns - Resident was unable to complete Brief Interview for Mental Status [BIMS, a screen used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur. BIMS is a mandatory interviewing tool for skilled nursing centers]. He was indicated as having memory problems. Section G: Functional Status - Resident was indicated as needing supervision with set-up help only for bed mobility, transfers, walk in his room, walk in the corridors, locomotion on the unit, and eating. He was coded as needing Limited assistance with 1 person to assist for dressing, toilet use, and personal hygiene. D. Record review of Physical Therapy (PT) Evaluation and Plan of Treatment dated 05/20/21, revealed the following: Reason for Referral/Current Illness: Patient is a 66 yo (year old) male who present with paralysis (complete or partial loss of muscle function) to the right UE (upper extremity), he was reported to have increased risk for falls with [CONDITION(S)] (swelling) on both his legs. He exhibits some signs of altered cognitive status (changes in his brain function, such as confusion, loss of alertness) and slow to follow directions. E. Record review of R #1's Quarterly MDS dated [DATE], indicated the following: Section C - Cognitive Patterns - BIMS score of 8 (considered mildly impaired); Section G - Functional Status - R #1 was coded as needing limited assistance (needing help) with 1 person assist for bed mobility, and dressing; Supervision with set-up to 1 person assist for transfers, walking in room, walking in corridor, locomotion on unit, eating, and toilet use; and Extensive assistance (the resident would not be able to perform or complete the task without help) with 1 person assist for personal hygiene. Section G 0300- Balance During Transitions and Walking - R #1 was indicated as not being steady (on his feet), but was able to stabilize (stand himself up) without staff assistance when moving from a seated to a standing position, or walking, or turning around, moving on and off the toilet seat and from surface-to-surface transfer (transfer between bed and chair or wheelchair). Section J - Health Conditions - Resident was indicated as having shortness of breath with exertion (a physical or mental effort), when sitting at rest and when lying flat. R #1 was coded as having a fall since admission with a major injury. Findings for 07/06/21, 07/07/21, and 07/08/21: F. On 09/14/21, record review of Nursing Progress Notes revealed the following: 1. On 07/06/21 at 10:42 am, Resident has increase in lethargy (a lack of energy and enthusiasm). O2 (oxygen) sats (saturation) [a measurement of blood oxygen level] drops below 90% (O2 sats considered normal anywhere from 88% to 100%) when sleeping but rise to over 90% when aroused. Physician notified, no new orders received. Continue to monitor. Documented by Registered Nurse (RN) #3. 2. On 07/07/21 at 5:17 pm, Late Entry: Note Text: Resident [was] witnessed in activities area approaching [a] chair. [He] Sat down on [the] floor [a fall is when there is a change of plane] before reaching the chair. Resident denied pain. Assisted up and to the couch without incident. No further assessment deemed necessary at this time. Cont [continue] to monitor. Documented by Registered Nurse (RN) #1. a. RN #1 did not document that the resident hit the chair and that the chair had fallen on top of R #1, when this incident occurred. G. On 09/15/21 record review of R #1's Progress Notes revealed the following: 1. An IDT (Interdisciplinary Team) Note dated 07/16/21 at 11:57 am, revealed the following: IDT met today to review resident for a fall that happened on 07/07/21 at 11:50 am. The resident was ambulating (walking around) over to a chair in the activity area and reached for it. When reaching for the chair he fell forward hitting the chair and then fell back and the chair fell on top of the resident. The staff helped him up and ambulated him to the couch in the area. It did not appear resident had injuries at this time per the interview of the nurse and staff member. The resident was found later to have bruising [blood or bleeding under the skin] when assessed by EMTs (Emergency Medical Technicians). [During the time of the EMTs assessment, they were applying electrodes (leads, used to monitor the heart) to R #1's right chest and shoulder area. R #1 was observed at that time, to have the bruising on his right chest and shoulder area.] R #1 was sent to the hospital . 2. An IDT Note dated 07/16/21 at 12:16 pm, revealed the following: IDT met today to review resident for a [second] fall on 07/07/21 at 14:30 (2:30 pm). The resident was found in his room on his knees leaning against the night stand, the resident did not appear to have injuries. On 07/08/21 R #1 was sent to the hospital at 10:15 am, due to having difficulty breathing. H. On 09/15/21 at 1:10 pm, during an interview, RN #1, stated that on 07/07/21, R #1 looked like he was obviously not feeling well. She stated that his oxygen saturation levels were low, she did not say how low they were, while he was resting, she was unaware if R #1 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that on 07/06/21 at 10:40 am, according to her nurses note, she had notified R #1's physician while he was making his rounds, about R #1's low oxygen saturations. She stated that she never saw the physician go into R #1's room, nor did he write a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if she had completed a nursing assessment following the fall by initiating the neurological tests or completed the documentation of completing an incident report of the fall, she stated, No. When asked about the staffing of the facility the day of 07/07/21, RN #1 stated that she was taking care of the 100, 200 and 300 halls, which had a total of 60 residents for her to take care of with the Certified Nursing Assistants (CNA) on Unit A. She said that the other RN, who was scheduled to work with her on Unit A that day, worked on Unit B instead, because a nurse did not show up for her 12-hour shift. When asked if she was aware that on 07/07/21 at around 2:30 pm, R #1 was found to be on his knees near his bedside table. She stated, No. No one told me. When asked if it wouldn't have been the CNA's responsibility to tell her about the fall when R #1 was found on his knees. She stated, Yes, it would have been their responsibility to tell me. When asked if she remembered telling the oncoming nursing shift, that would have started at 6:00 pm, about R #1's fall that day, she stated that she did not remember saying anything to the next shift. I. Record review of R #1's vital signs revealed the following: a. Blood Pressure (BP) Summary, there was no documentation of a BP for 07/07/21; b. Pulse Summary, there was no documentation of a pulse or heart rate for 07/07/21; c. Respiration Summary, there was no documentation of respirations for 07/07/21; d. Temperature Summary, there was no documentation of a temperature being taken for 07/07/21; and e. Pain Level Summary, there was no documentation of a pain level assessed for 07/07/21. J. On 09/16/21 at 2:30 pm, during observation of the video surveillance film, dated 07/07/21, the following was observed: 1. At 11:52 am, R #1 was observed walking around near the activity room, dietary staff were preparing and providing nourishment drinks to the residents. RN #1 was observed sitting at the nurses' station, [which had a view of the activity room]. At 11:53 am, R #1 was observed to be walking independently near the activity area to a table and chair. He was observed to be reaching for the chair with his left hand [his right hand is contracted (a permanent tightening of the muscles, tendons, skin, and nearby tissues)] he missed touching the chair. He leaned forward over the chair and hit his right chest area and then over compensated and fell backward, with the chair falling on top of him. The CNA was observed to remove the chair, right after the fall. By the time the nurse reached the resident, the chair had already been removed from lying on top of the resident. The nurse and CNA were observed to be assisting the resident up and walking him toward the couch which was nearby. R #1 was noted to be sitting on the edge of the couch for a approximately 30 to 40 minutes. There was no nurse or CNA observed to be taking R #1's vital signs or assessing his condition, nor conducting neurological tests on him. CNA's were observed walking around the nurses' station doing various tasks. At 12:00 pm, seven (7) minutes after R #1's fall, RN #1 was seen offering R #1 a glass of water. At 12:34 pm, RN #1 was observed walking with R #1 to his room on the 200 hall. He was never observed by video to be outside of his room the rest of the day. K. Record review of R #1's Nursing Notes dated 07/08/21 at 1:43 pm, indicated the following: Note Text: PT (patient) hypoxic (having low oxygen levels) with bradycardic (abnormal slow heart rate), with lethargy (sluggish, having no energy) this morning. [Name of Physician] notified. Orders to send to ER (emergency room ) for evaluation. Oxygen via nasal cannula applied at 3 L. (liters) EMS (Emergency Medical Services) called [to transport R #1 to the hospital]. When EMS arrived [the nursing staff and the ambulance staff noticed at the same time the]large bruising (bleeding or blood under the skin) to [R #1's] upper right chest .No report this morning of bruising or recent falls . L. Record review of the EMS report dated 07/08/21 at 10:20 am, revealed the following: Narrative: CC (Chief Complaint): AMS (altered mental status), [CONDITION(S)] (having low blood pressure), Hypoxemia (a low level of oxygen in the blood), hematoma (a collection of blood outside of the blood vessels); H (History): Per staff, the pt (patient) has a heart rate of 30 (normal between 60 - 100). Staff also notes that the Pt's SPO2 (oxygen saturation) was at 73% RA (room air, not on oxygen) this morning at 0630. Staff states it was charted but the pt was not placed on O2 at that time. Staff states she saw the chart and check his O2 which was at 60. That is when they placed him on 3 L NC (liters per nasal cannula) and called EMS. Staff also states the pt has not been acting himself for the past two weeks. Staff is unable to give further history on pt as he is not their regular pt. A (Assessment): Upon arrival pt is found sitting in chair with all ABCs (airway, breathing, circulation) intact. Pt is alert and responsive, however, the pt does not answer questions appropriately and has some garbled speech. Unable to palp [palpate] radial pulses on scene. While attempting to place electrodes for 12-lead, it is noted that the pat has a large hematoma covering the R (right) right side of his chest spreading into his R shoulder area. Staff is just as surprised as EMS to find it. Pt's abdomen appears distended. Pt has pitting [CONDITION(S)] to bilateral lower extremities (it occures when excess fluid builds up in the body, causing swelling; when pressure is applied to the swollen area, a pit or indentation, will remain.) Pt's R arm is contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff), he is unable to use it, unknown if this is baseline . M. Record review of R #1's Emergency Documentation dated 07/08/21 at 11:00 am, revealed the following: Reassessment/Reevaluation - .Chest x-ray demonstrating atelectasis (partial or complete collapse of the lung) on my visualization interpretation .CT (an x-ray made using a form of tomography in which a computer controls the motion of the X-ray source and detectors, processes the data and produces the image) without evidence of [CONDITION(S)] (bleeding inside the skull). Labs are unremarkable apart from mild [CONDITION(S)] (blood low in iron) .Urinalysis is concerning for urinary tract infection. Patient is currently awake, alert and oriented .Positive COVID-19 test .Patient adamant that he would like to go back to the facility . N. Record review of the facility's Post-Trip/Pre-Trip Inspection (of the transportation van) dated 07/08/21, R #1 was picked up at the local hospital at 1600 (4:00 pm) and transferred back to the facility. O. On 09/16/21 at 12:30 pm, during an interview, the Director of Social Services stated that she had received the report from the hospital around 4:30 pm. She stated that the staff member from the hospital never mentioned that R #1 had the multiple injuries or fractures. The hospital staff member who had called the report, did say that R #1 did have a urinary tract infection and that he was COVID positive. P. On 09/16/21 at 4:45 am, during an interview, RN #3, who was the 6 pm to 6 am nurse on 07/08/21, stated that she had remembered when R #1 was transported back to the facility that afternoon. She stated that she had been waiting in her vehicle, until her evening shift began at 6:00 pm, and she saw R #1 and an employee with him, walking around the buildings. She stated, I thought that was weird. [There was no documentation in the chart to indicate when R #1 returned from the hospital, he was not assessed by the nursing staff, nor were vital signs obtained.] RN #3 stated that when she received her report about R #1 from the day shift nurse, she was aware that R #1 had gone to the hospital earlier that morning. The day nurse said that he had just returned from the hospital and was diagnosed positive with COVID. When asked if she had assessed or were vital signs taken upon R #1's return from the hospital, she said that she did not. She stated that she saw R #1 about 6:30 pm that evening, during her rounds, and that he was not in any distress, he was sitting on the edge of his bed. Q. Record review of R #1's Nurses Notes dated 07/08/21 at 9:58 pm, approximately 3 hours after R #1 returned from the hospital, indicated the following: Resident has been transferred via EMS to [Name of hospital]. His oxygen saturation was 77 % on RA (room air, normal is 88 % to 100%). Applied nasal cannula. SaO2 did not increased. Applied non-rebreather (a device used to assist in the delivery of high concentration of oxygen) at 6 LPM (liters per minute). Oxygen saturation increased to 90% .Lung sounds diminished (in) all lung fields. Left lower lobe coarse (lower-pitched and moist-sounding) lung sounds; VS (vital signs) [blood pressure] 131/80 - [heart rate] 110 -Respirations 20/minute. Temperature 98.9. Resident was seated at [the] bedside. He stated that he had no pain. No signs of pain/discomfort/distress noted. Notified [name of physician], of R #1 low oxygen saturation levels, who ordered resident to be transferred [back] to [the] ER at [name of hospital] .EMS transferred resident to [name of local hospital]. R. On 09/13/21 at 12:30 pm, during an interview, a Case Manager (CM) from the local hospital stated that R #1 had been transferred to the local hospital emergency room twice in one day on 07/08/21. During the second visit to the ER, R #1 was found per additional x-rays, to have the following multiple injuries: mildly displaced fracture (broken bone) of the sternum and manubrium [the sternum is the long bony structure that anchors the ribs in the chest; and the manubrium is the top of the sternum]; mild T10 ([MEDICATION(S)]-10) vertebrae compression fracture [this would occur when the bony or vertebral body in the spine collapses, in the middle of the back, which could lead to severe pain, deformity and loss of height]; right medial clavicle (collarbone, one of the bones in the shoulder) fracture; Contusion to the right chest wall (a chest wall bruise, caused by [MEDICATION(S)] trauma such as a fall); a possible stroke (an interruption of blood to the brain); Covid positive; urinary tract infection (having bacteria either of the kidneys, or bladder); and a right compressive hemi-diaphragm (the diaphragm is the main muscle that separates the chest cavity from the abdomen which is used in breathing). The CM stated that R #1 spent the majority of his time while in the hospital in the Intensive Care Unit (ICU) and Progress Care Unit, which is the step-down unit of ICU, due to all of his injuries. She stated that R #1 had been intubated (a tube inserted down the throat and into the lungs to help with breathing, while on a breathing machine) and that he had also received a PEG (percutaneous endoscopic gastostomy) feeding tube to receive nutrition directly through the stomach. R #1 was transferred from the local hospital to another hospital, due to needing a procedure that the local hospital could not perform, due to R #1's length of time of being intubated. S. On 09/15/21 at 11:20 am, during an interview, the facility's Regional Nurse Consultant (RNC) stated that she was aware that R #1 normally walks around the nursing station, but that lately in the last few days he had become lethargic. She confirmed that she was aware that after R #1's falls that were reported on 07/07/21, there was no nursing documentation of resident's assessment, or a neurological examination was conducted nor were vital signs obtained following the falls. She stated that usually nursing documentation should take place for 72 hours for residents who had either a fall, were on antibiotics or had a change of condition. T. Record review of the facility's policy and procedure titled Abuse Prevention and Prohibition Program, last revised on 08/2020, revealed the following: Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment .in accordance with federal and state requirements .Prevention: Staff, residents and families will be able to report concerns, incidents and grievances without fear of retribution or retaliation .The Facility maintains adequate staffing on all shifts to ensure that the needs of each resident are met .Physical Neglect: .Inadequate provision of care .Leaving someone unattended who needs supervision .

This is a past non-compliance deficiency for an incident that occurred on 02/26/20 and was corrected on 02/28/20. Based on record review, observation, and interview, the facility failed to provide after hour snacks that met a resident's required textured diet (an appropriate consistency of food that can be easily chewed and swallowed) for 1 (R #225) of 3 (R #'s 9, 59, & 225) residents reviewed for diet consistency. This deficient practice likely resulted in a choking incident. The findings are: A. Record review of the care plan revealed that R #225 was diagnosed with the following pertinent diagnosis: traumatic subdural hemorrhage without loss of consciousness [ a collection of blood outside the brain], dysarthria [a motor speech disorder that occurs when someone can't coordinate or control the muscles used for speaking], cerebral infarction [a brain lesion in which a cluster of brain cells die when they don't get enough blood], [CONDITION(S)] (COPD) [a chronic [CONDITION(S)] lung disease that causes obstructed airflow from the lungs], alteration in mental status [general changes in brain function, such as confusion, loss of alertness, or disorientation], other symptoms and signs involving cognitive functions [brain-based skills which are needed in acquisition of knowledge] and awareness, and need for assistance with personal care. B. Record review of physician orders, date 1/16/2020, revealed that R #225 was prescribed to receive foods of a National Dysphagia 1 (Pureed) texture [foods should be pureed and pudding-like], Nectar-thick liquids consistency [easily pourable and comparable to apricot nectar]. C. Record review of the State of New Mexico, Division of Health Improvement reported incident # revealed that on 02/26/20, R# 225 was given a banana that was pureed [made into a paste or thick liquid] by a nurse at the nurse's station. Shortly after taking a bite, he stood up and began to aspirate [inhalation of a substance or object into the lungs]. The [MEDICATION(S)] maneuver [a first-aid procedure for dislodging an obstruction from a person's windpipe in which a sudden strong pressure is applied on the abdomen] was administered, and some banana substance was removed prior to the EMS [Emergency Medical Services] team arriving. The resident passed away shortly after being loaded in the EMS vehicle. D. Record review of the Death Investigation Summary, date 03/12/20, revealed that the cause of death for R #225 was Asphyxia [being deprived of oxygen] due to aspiration of food bolus [in this instance a mass of food] (banana). E. On 03/29/21 at approximately 12:30 pm, during an interview, Kitchen Aide #1 stated that a kitchen staff member is required to stock the nurse's station with textured snacks. He then retrieved a binder that revealed a daily delivery of snacks at the nurse's station where 2 staff members sign off on the delivery. E. On 03/31/21 at 8:05 am, during an interview, when asked to explain how to puree a banana, the Dietary Manager confirmed with her staff as they stood around that the process to puree a banana was to put it in the blender and add milk to make it like a pudding. Depending on the desired consistency, you should add thick-it [a product that thickens]. When asked if the nurse's station is stocked with textured snacks [snacks that have been mechanically altered and prepared to meet the appropriate texture prescribed for the ease of swallowing that meets each resident's needs], the Dietary Manager confirmed that they have implemented a process where all textured foods are prepared by the kitchen staff and the textured snacks are stocked at the nurse's station every day. When snacks are delivered to the nurse's station, the dietary staff and a nurse must sign off that the nurse's station has received the appropriate snacks. An education was provided for all staff members, [on 02/28/20], where they were educated on all dietary textures. She also mentioned that a list of residents and their dietary texture needs is placed at the nurse's station with a list of foods that explains what texture category they fall under. This process was implemented as a result of R #225's death. F. On 03/31/21 at 9:00 am, during an interview, RN #3 stated that the refrigerator has a lock on it for safety purposes but it is stocked with snacks every day and when snacks are delivered, the nursing staff are required to confirm and sign-off that all textures of snacks are available. There is also a list of residents and their diet. Next to the fridge is also an educational tool that indicates what food falls under each dietary texture. G. On 03/31/21 at 9:00 am, observation of the nurse's station confirmed that the nursing staff was provided with a list of resident's textured diets along with a list of foods that meet textured requirements. Observation of the refrigerator confirmed that textured snacks were made available for staff to provide residents without the need to alter. H. On 03/31/21 at 4:32 pm, during an interview, when asked to explain the incident, LPN #1 (Licensed Practical Nurse) stated that she was working the night shift and sometime after dinner R# 225 requested something to eat. She reviewed his diet order and looked for something that would meet his diet needs. The kitchen door was locked. He pointed to a banana and LPN #1 smashed it with a fork or spoon and added water. Shortly after eating the banana, he began to cough and LPN #1 performed the [MEDICATION(S)] maneuver [a first aid procedure designed to dislodge an obstruction form an individuals windpipe]. Emergency services were called and R #225 passed away in route to the hospital. LPN #1 stated that there were no food options available to meet the resident's diet. After the incident, a fridge was placed at the nurse's station and a procedure was started where nursing staff are required to sign-off when kitchen staff stock the fridge. An education was completed with all staff and staff were instructed that only kitchen staff are allowed to prepare textured food and drinks. During onsite investigation of this complaint it was found that this deficiency had been corrected based upon the following: 1. Record review of document where dietary aid and nursing staff confirm that a variety of snacks are available at all times of the day. 2. Observation of [MEDICATION(S)] fridge in both nurse's station confirms that a variety of textured foods were available. 3. Observation of the resident list with resident textured diet. 4. Observation of educational aid indicating food and food texture. 5. Record review of training that was provided to all staff members.

Based on record review and interview, the facility failed to prevent resident neglect for 1 (R #1) of 3 (R #'s 1, 2, and 3) residents reviewed for elopement. This deficient practice resulted in R #1 to wander from the facility at night undetected resulting in a fall that caused injuries and is likely to affect other residents that may elope from the facility. The findings are: Findings related to R #1: [NAME] Record review of R #1's medical record revealed the following: 1. The Admission Record dated 08/31/16, indicated the following Diagnoses: [REDACTED]. pressure), constipation, other abnormalities of gait (a person's manner of walking), unsteadiness on feet, other lack of coordination, adult failure to thrive, and repeated falls. 2. The physician orders [REDACTED]. 3. The Annual Minimum Data Set ((MDS) dated [DATE], and Quarterly MDS dated [DATE], revealed the following: a. The Annual MDS dated [DATE], indicated the following: 1. Section 3: Cognitive Patterns: the Brief Interview for Mental Status (BIMS) score was 3 out of 15, (This indicates the higher the score, the lower the impairment to the cognitive (this refers to the ability of the brain to think and reason) response. Scores closer to 0 indicate severe cognitive impact.) 2. Section [NAME] - Behavior: E0900. Wandering - Presence & Frequency, Has the resident wandered? 0 was indicated, Behavior not exhibited. E1000. Wandering - Impact, Does the wandering place the resident at significant risk of getting to a potentially dangerous place? No indication was documented. 3. Section G - Functional Status: (R #1) was coded under Walking in room and corridor and Locomotion on unit and off unit, as (1) needing Supervision - oversight, encouragement or cueing and (1) Setup help only. G0300 Balance During Transitions and Walking, For Support R #1 was coded as (1) Not steady, to stabilize without staff assistance. G0600. Mobility Devices - Cane/crutch were indicated. 4. The Quarterly MDS dated [DATE], indicated the following: 1. Section 3: Cognitive Patterns: the Brief Interview for Mental Status (BIMS) score was 3 out of 15, 2. Section [NAME] - Behavior: E0900. Wandering - Presence & Frequency, Has the resident wandered? (1) was indicated, Behavior of this type occurred 1 to 3 days. 3. Section G - Functional Status: (R #1) was coded under Walking in room and corridor and Locomotion on unit and off unit, as (1) needing Supervision - oversight, encouragement or cueing and for support R #1 was coded as a (2) One person physical assist. G0600. Mobility Devices - Cane/crutch and Wheelchair (manual or electric). B. Record review of R #1's medical record indicated that an elopement had occurred on 02/10/19, the facility at that time did not self-report the incident to the State until 06/28/19, following an audit. The Complaint Narrative Investigation Report (5 day) revealed the following: Brief summary of incident: On 02/10/19, (Name of R #1) was found in the back of the facility near the shed attempting to walk up a hill. (Name of R #1) was redirected back into the facility. Facility Action after the incident: Facility initiated elopement protocol and located (R #1) was on the facility campus facility near the shed attempting to walk up a hill .(R #1) was assessed and did not have injuries. Upon re-entrance to the facility, (R #1) was immediately provided with a roam alert bracelet. Prior to this incident, (R #1) had never attempted to leave the facility. A wandering risk assessment has been completed, and (R #1) is a high risk. On 06/28/19, Director of Nursing (DON) completed an audit related to another incident and found this incident. DON completed an updated wandering risk assessment, checked placement of (Name of R #1) roam alert and added R #1 to facility elopement book. Administrator and DON found while auditing residents at this facility with roam alerts and completing interviews with nurses, it was identified that further education was needed with nursing staff on what constitutes an elopement. Education has been started and will be completed by 07/05/19 .Conclusion: There is no evidence of abuse or neglect currently. Facility is unable to substantiate abuse or neglect as a result of this occurrence. C. Record review of R #1's care plan revealed the following: a. The Focus: Name of (R #1) is at risk for eloping and not knowing where he was (disoriented to place), date initiated 02/11/19. b. Intervention/Tasks: (Indicated as) RESOLVED: Wander Alert: Roam alert to left ankle, date initiated 02/11/19; Wander Alert: Device # Model, date initiated 02/11/19; and Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate, date initiated: 02/11/19. Findings related to R #1's care plan revision following the audit dated 06/26/19 c. Roam alert on for safety to alert staff on my need to go outside the building. Check roam alert as ordered, date initiated 06/26/19. No other documentation was found in the medical record. D. On 12/17/19 at 9:30 am, during interview, the Administrator stated that R #1 was walking out the door on 10/28/19. While he was walking out, Anonymous A #15 was calling staff on his cell phone to tell them (the nursing staff) that R #1 was outside. The Administrator stated since A#15 had eyes on R #1, it was considered a witnessed elopement. E. On 12/17/19 at 2:20 pm, during an interview, A #15 stated he was working on 10/28/19 and was about to leave work (through the front door). A #15 stated someone from the transportation van had pulled up and said, a resident got out of the building and is laying on the ground, out near the entrance as you pull into the complex. A #15 did not see R #1 (as he was walking out of the building), and he did not hear any alarms going off inside the building. A #15 stated he told two unknown Certified Nursing Aides (CNAs), that a resident needed help outside. A #15 said the incident occurred around 7:30 pm. He further stated it was dark and cold outside at the time of the incident. F. Record review of A #15 typed witness statement (undated and un timed) revealed the following: I saw (Name of R #1) as he was leaving the building through the front door as the alarm went off. I followed (Name of R #1) as he crossed the parking lot. I called for assistance from other staff as I continued to follow him and calling for him to stop. One staff member went to get a wheelchair to help get him back to the building. (Name of R #1) fell over near the sign (signage at the street, indicating name of facility). Staff were there to assist him up and into the transport van that was returning to the building. (Name of R #1) was then returned to the building. [NAME] On 12/17/19 at 2:45 pm, during interview, A #15 was shown the typed letter he signed, and was asked if that was his signature? He said, Yes, but he stated he did not want to sign it, because the typed letter management wanted him to sign was not true. A #15 was asked, why did he sign it, if it wasn't true? He stated, he explained to the facility management that he didn't see R #1 on 10/28/19, and the letter they wanted him to sign wasn't true, but management told him, well this is the story we're going with, and then had him sign it. When A #15 was asked who had him sign the typed witness statement, he would not disclose the name. However, he did state the person who had him sign it , still works at the facility. H. On 12/17/19 at 3:05 pm, during an interview, A #11 stated that on 10/28/19, she was driving back to the facility with A #9. As A #11 was turning onto the facility's campus, they noticed a car on the side of the road with their car door open. They saw a woman standing over a person on the side of the road. The person turned out to be R #1. A #9 got out of the van and covered R #1 with a blanket. A #11 and A #9 assisted R #1 into the van, then drove back to the facility. When A #11 was asked if they had heard any alarms going off in the building at the time, she stated, No. I. On 12/18/19 at 11:00 am, during a telephone interview, A #9 stated while she was riding back to the facility with A #11 in the transport van on 10/28/19, around 7:30 pm. As they were turning onto the facility's campus, they noticed a car with their door open and a lady was standing over someone. A #9 stated she got out of the van and noticed there was a person laying on the street. The lady standing beside R #1 said, I found him (R #1) just laying here by himself. A #9 stated she didn't know who the lady was, but remembered it was dark and cold outside. A #9 believed the temperature was around 38 degrees at the time of the incident. R #1 told A #9 that he was cold, so A #9 got a blanket out of the van and covered him up. A #9 stated that R #1 had a cut over his right eye and the blood appeared dried and putty-like. A #9 said the cut looked bad enough that R #1 might need stitches. A #'s 9 and 11, were able to get R #1 into van and took him back to the facility. The distance from where R #1 was found, and the front door to the facility is approximately .2 miles (1056 feet). [NAME] On 12/18/19 at 2:45 pm, during an interview, A #12 explained how the wanderguards (the system that alerts caregivers to the specific resident when they approach a monitored exit) work and who's responsible for making sure they're working correctly. A #12 reported, the facility has two maintenance workers (MW). The (MWs) A #'s,13 and 14 check the bar receivers on the walls throughout the facility by using a scanner to make sure they are working correctly. They check the receivers weekly. The wanderguard readers are located at the front entrance, the maintenance hall to the Assisted Living, the employee entrance, and the transportation back exit. There were no wanderguard receivers on the emergency door exits, however every time the emergency doors are opened, the alarm goes off at the closest nurse's station. A #12 stated, every resident's wander guard was checked nightly by the nurses and CNA's. The nurses use the same scanner as the MWs to make sure that the resident's wander guards are working correctly. A #12 reported he has worked at the facility for sixteen months. During that time, he reported he has only had one wanderguard that didn't work. A #12 reported he keeps two extra wander guards in his office in case one doesn't work. K. On 12/18/19 at 4:20 pm, during an interview, the Administrator was asked, who typed up the witness statement that A #15 was asked to sign regarding the incident on 10/28/19. The Administrator replied, I don't know. It may have been A #15's immediate supervisor. During the interview, the Administrator was informed about the statement she reported about R #1's elopement on 10/28/19, verses what A #15 reported. She was informed about the discrepancies. She did not respond or make any other comments. L. On 12/18/19 at 5:20 pm, during a telephone interview, A #4 reported there was a staff person from the kitchen who had said there was a resident somewhere out in the parking lot that needed help. When A#4 went outside, she said, the van driver and another staff person (unknown) were already helping R #1 into the van. A #4 said R #1's' face was black and blue, and he had what looked like dried blood on his face. M. On 12/18/19 at 6:00 pm, during an interview, A #1, stated she didn't know how R #1 got out of the building on 10/28/19. None of the staff heard an alarm go off. A #1 said there's usually 3 nurses working on the evening shift, but that night there were only 2 nurses working. On the night of 10/28/19, A #1 was working the south side (left side) of the building, and the other nurse (unknown) was working on the north side (right side) of the building. A #1 believes R #1 must have walked out of the front door (center of the building), because the only way someone can hear the front door alarm going off is if they are close to the front door. A #1 reported, that night both nurses may have been too far away to hear the alarm going off. When asked, did anyone hear the alarm going off around the time of the incident. She replied, No. She reported, all the doors should have codes on them in order to get in and out of the building, so something like this never happens again. A #1 reported, normally the alarms go off constantly, which makes it hard to know which staff person is responsible to check when an alarm is going off. It's unclear if the front door alarm went off when R #1 eloped on 10/28/19. N. On 01/13/20 at 7:30 pm, during an interview, A #3, was asked, when a wander guard alarm goes off who was responsible for checking to see who set it off? He responded, when an alarm goes off, whoever is closest to the door checks to see who set off the alarm. When asked, what if all the staff are in resident's rooms, how would they know who's closest to the door? A #3 just shrugged his shoulders. He reported, everyone knows who the elopement risks are, so all the nurses and CNA's know which resident's they need to keep an extra close eye on. He reported, the alarms don't go off as much now that R #1, and R #13 are no longer at the facility. O. On 01/13/20 at 7:40 pm, during an interview, A #2 was asked, who is responsible to check when an alarm goes off, she replied, whoever hears an alarm going off responds. P. On 01/13/20 at 7:45 pm, during an interview, A #6 was asked, who is responsible to check when an alarm goes off, she replied, when anybody hears an alarm going off they respond. She reported, there are certain residents' rooms however, that if the front door alarm were to go off, the nurse or CNA's may not be able to hear it. Q. On 01/13/20 at 7:55 pm, during an interview, A #4 reported, staff seem to be more vigilant now when door alarms go off. She reported, the front door alarm however, needs to be set to go off at the nurse's station, like all the other door alarms. She reported, if they are short staffed, there's still a potential where staff would not hear if the front door alarm went off. This is concerning R. On 01/13/20 at 8:10 pm, during an interview, DON, when asked, if the facility was short staffed, and no one was able to hear the front door alarm go off, what would happen? She replied, well someone should hear it. S. On 01/14/20 at 12:15 pm, during an interview, the DON stated that R#1 and R#13, were transported to a lock down facility in the state. The DON reported, they did not get Doctors Orders for the transfer, but she said she did speak with an Admissions person at the facility, about the transfers. When asked, if she documented her conversation anywhere, she responded, no! T. On 01/14/20 at 11:30 am, during a telephone interview, Administrator reported since our last visit, they added 1:1 CNA's for R #1 and R #13. They also put in 3 bids to upgrade the front door alarm system. DON reported R #1 and R #13, were moved to a locked facility on 01/03/20, for their protection. The DON reported both families were okay with the move. Administrator reported she will have CNA's, or other staff personnel stationed at the front door hallway 24/7, until the new front door alarm system is installed. She stated that will begin right away. U. On 01/14/20 at 12:15 pm, received document from DON forwarded by Administrator approval for the Echo (Company) for a bid for $16,000 to upgrade all doors for wanderguards. Received document from DON stating the main entrance doorway will be monitored 24/7 by a scheduled staff member. This intervention will continue until the new wanderguard alarm system has been installed. V. On 01/14/20 at 12:15 pm, the Activities Director was observed sitting in the front door hallway, as instructed by the Administrator. W. On 01/14/20 at 2:00 pm, during an interview, A #12 was asked, how did he increase the volume on the front door alarm, as reported by the Administrator. He responded, there is no volume to turn up for the front door alarm, I informed him what the Administrator reported, but he shook his head and said, there's no volume knob to turn up, so I have no idea what she was talking about. X. On 01/14/20 at 2:15 pm, during an interview, A #8, was asked, if an alarm goes off, who is responsible to check on it? She responded,whoever is closest, but it's usually someone on the north side of the building responds. She reported, she believes someone on the north side of the building usually verifies if someone is responding to an alarm. When asked, who is responsible for checking to see if wanderguards are working correctly. She replied, I think the nurses do. A #8 reported, she hears the alarms going off about once or twice a night. She reported, she tells the residents to just stay away from all the doors. Y. On 01/14/20 at 5:40 pm, during an interview, A #7, was asked, if an alarm goes off who is responsible to check if someone is trying to elope? She replied, whoever is closest. When asked, could she guarantee staff could hear the front door alarm going off at night, if they were short staffed and no one was near the front door? She replied, well, no I couldn't guarantee it. She reported the facility is very hectic during dinner service, and they are frequently short staff at that time. When asked, who is responsible to check if the wanderguards are working correctly. She replied, I think the nurses check. Z. On 01/15/20 at 10:35 am, during an interview, A #9, when asked who was responsible to check when an alarm goes off? She replied, I would see where it is. When asked what if you were busy with a resident, and the alarm went off? She responded, I would hope someone would respond to it. When asked, who was responsible to check if the wanderguards are working correctly? She reported, she doesn't check them, but she thinks the nurses do, but she wasn't sure. A[NAME] On 01/15/20 at 6:30 pm, during interview, Regional Manager reported as part of the alarm upgrade, they are installing MAG Locks which will automatically lock the doors where an alarm goes off. The alarm will go off when a resident who wears a wanderguard gets too close to an exit door would. This would prevent that resident from eloping. BB. Record Review of the facility's policy titled Abuse and Neglect, with a revision date of (MONTH) (YEAR), revealed the following: Definitions - Neglect, as defined at 483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

Based on record review, interview, and observation, the facility failed to ensure: 1. The front door wander guard alarm system could be heard throughout the facility; 2. The flooring in the Activities Room was damaged and peeling upwards, which presents a tripping hazard. This deficient practice is likely to have led to an elopement of a resident who sustained injuries that required hospitalization . There was a potential tripping hazard for residents that reside in the facility. The findings are: [NAME] Record review R #1's Admission Record dated 08/31/16, indicated the following Diagnoses: [REDACTED]. pressure), constipation, other abnormalities of gait (a person's manner of walking), unsteadiness on feet, other lack of coordination, adult failure to thrive, and repeated falls. B. Record review of R #1's physician orders [REDACTED]. C. Record review of R #1's Annual Minimum Data Set ((MDS) dated [DATE], and Quarterly MDS dated [DATE], revealed the following: Findings related to the Annual MDS dated [DATE]: 1. Section 3: Cognitive Patterns: the Brief Interview for Mental Status (BIMS) score was 3 out of 15, (This indicates the higher the score, the lower the impairment to the cognitive (this refers to the ability of the brain to think and reason) response. Scores closer to 0 indicate severe cognitive impact.) 2. Section [NAME] - Behavior: E0900. Wandering - Presence & Frequency, Has the resident wandered? 0 was indicated, Behavior not exhibited. E1000. Wandering - Impact, Does the wandering place the resident at significant risk of getting to a potentially dangerous place? No indication was documented. 3. Section G - Functional Status: (R #1) was coded under Walking in room and corridor and Locomotion on unit and off unit, as (1) needing Supervision - oversight, encouragement or cueing and (1) Setup help only. G0300 Balance During Transitions and Walking, For Support R #1 was coded as (1) Not steady, able to stabilize without staff assistance. G0600. Mobility Devices - Cane/crutch were indicated. Findings related to the Quarterly MDS dated [DATE]: 4. Section 3: Cognitive Patterns: the Brief Interview for Mental Status (BIMS) score was 3 out of 15, 5. Section [NAME] - Behavior: E0900. Wandering - Presence & Frequency, Has the resident wandered? (1) was indicated, Behavior of this type occurred 1 to 3 days. 6. Section G - Functional Status: (R #1) was coded under Walking in room and corridor and Locomotion on unit and off unit, as (1) needing Supervision - oversight, encouragement or cueing and for support R #1 was coded as a (2) One person physical assist. G0600. Mobility Devices - Cane/crutch and Wheelchair (manual or electric). D. Record review of R #1's medical record indicated that an elopement had occurred on 02/10/19, the facility at that time did not self-report the incident to the State until 06/28/19, following an audit. The Complaint Narrative Investigation Report (5 day) revealed the following: Brief summary of incident: On 02/10/19, (Name of R #1) was found in the back of the facility near the shed attempting to walk up a hill. (Name of R #1) was redirected back into the facility. Facility Action after the incident: Facility initiated elopement protocol and located (R #1) was on the facility campus facility near the shed attempting to walk up a hill .(R #1) was assessed and did not have injuries. Upon re entrance to the facility, (R #1) was immediately provided with a roam alert bracelet. Prior to this incident, (R #1) had never attempted to leave the facility. A wandering risk assessment has been completed, and (R #1) is a high risk. On 06/28/19, Director of Nursing (DON) completed an audit related to another incident and found this incident. DON completed an updated wandering risk assessment, checked placement of (Name of R #1) roam alert and added R #1 to facility elopement book. Administrator and DON found while auditing residents at this facility with roam alerts and completing interviews with nurses, it was identified that further education was needed with nursing staff on what constitutes an elopement. Education has been started and will be completed by 07/05/19 .Conclusion: There is no evidence of abuse or neglect currently. Facility is unable to substantiate abuse or neglect as a result of this occurrence. E. Record review of R #1's care plan revealed the following: a. The Focus: Name of (R #1) is at risk for eloping and not knowing where he was (disoriented to place), date initiated 02/11/19. b. Intervention/Tasks: (Indicated as) RESOLVED: Wander Alert: Roam alert to left ankle, date initiated 02/11/19; Wander Alert: Device # Model, date initiated 02/11/19; and Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate, date initiated: 02/11/19. F. Record Review of the facility's policy titled Abuse and Neglect, with a revision date of (MONTH) (YEAR), revealed the following: Definitions - Neglect, as defined at 483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Findings related to R #1's care plan revision following the audit dated 06/26/19: c. Roam alert on for safety to alert staff on my need to got outside the building. Check roam alert as ordered, date initiated 06/26/19. No other documentation was found in the medical record. [NAME] On 12/17/19 at 9:30 am, during interview, the Administrator stated that R #1 was walking out the door on 10/28/19. While he was walking out, Anonymous A #15 was calling staff on his cell phone to tell them that R #1 was outside. The Administrator stated since A #15 had eyes on R#1 at all times, it was considered a witnessed elopement. H. On 12/17/19 at 2:20 pm, during an interview, A #15 stated he was working on 10/28/19 and was about to leave work (through the front door). A #15 stated someone from the transportation van had pulled up and said, a resident got out of the building and is laying on the ground, out near the entrance as you pull into the complex. A #15 reported, he did not see R #1 (as he was walking out of the building), and he did not hear any alarms going off. A #15 stated he told two unknown Certified Nursing Aides (CNAs), that a resident needed help outside. A #15 said that the incident occurred around 7:30 pm. He further stated that it was dark and cold outside at the time of the incident. I. Record review of A #15 typed witness statement (undated and un timed) revealed the following: I saw (Name of R #1) as he was leaving the building through the front door as the alarm went off. I followed (Name of R #1) as he crossed the parking lot. I called for assistance from other staff as I continued to follow him and calling for him to stop. One staff member went to get a wheelchair to help get him back to the building. (Name of R #1) fell over near the sign (signage at the street, indicating name of facility). Staff were there to assist him up and into the transport van that was returning to the building. (Name of R #1) was then returned to the building. [NAME] On 12/17/19 at 2:45 pm, during interview, A #15 was shown the typed letter that he signed, and was asked if that was his signature? A #15 said, Yes, but he stated he did not want to sign it, because the typed letter management wanted him to sign was not true. A #15 was asked, why did he sign it, if it wasn't true? A #15 stated he explained to the facility management that he didn't see R #1 on 10/28/19, and that the letter they wanted him to sign wasn't true, but management told him, well this is the story we're going with, and then had him sign it. When A #15 was asked who had him sign the typed witness statement, he would not disclose the name. However, A #15 did state the person who had him sign it, still works at the facility. K. On 12/17/19 at 3:05 pm, during an interview, A #11 reported, that on 10/28/19, she was driving back to the facility with A #9. As A #11 was turning onto the facility's campus, they noticed a car on the side of the road with their car door open. They saw a woman standing over a person on the side of the road. The person turned out to be R #1. A #9 got out of the van and covered R #1 with a blanket. A #11 and A #9, assisted R #1 into the van, then drove back to the facility. When A #11 was asked if they had heard any alarms going off in the building at the time, she stated, No. L. On 12/18/19 at 11:00 am, during a telephone interview, A #9 reported, she was riding back to the facility with A #11 in the transport van on 10/28/19, around 7:30 pm. As they were turning onto the facility's campus, they noticed a car with their door open and a lady was standing over someone. A #9 reported, she got out of the van and noticed there was a person laying on the street. The lady standing beside R #1 said, I found him (R #1) just laying here by himself. A #9 stated she did not know who the lady was, but remembered it was dark and cold outside. A #9 believed the temperature was around 38 degrees at the time of the incident. R #1 told A #9 that he was cold, so she got a blanket out of the van and covered him up. A #9 stated that R #1 had a cut over his right eye and the blood appeared dried and putty-like. A #9 said the cut looked bad enough that R #1 might need stitches. A #9 and A #11, were able to get R #1 into van and took him back to the facility. The distance from where R #1 was found, and the front door to the facility is approximately .2 miles (1056 feet). A #9 asked if she heard the alarm going off at the facility, and she said, No! M. On 12/18/19 at 5:20 pm, during a telephone interview, A #4 reported there was a staff person from the kitchen who had said there was a resident somewhere out in the parking lot that needed help. When A #4 went outside, she said, the van driver and another staff person (unknown) were already helping R #1 into the van. A #4 said R #1's' face was black and blue, and he had what looked like dried blood on his face. N. On 12/18/19 at 6:00 pm, during an interview, A #1, stated she didn't know how R #1 got out of the building on 10/28/19. None of the staff heard an alarm go off. A #1 said there's usually 3 nurses working on the evening shift, but that night there were only 2 nurses working. On the night of 10/28/19, A #1 was working the south side (left side) of the building, and the other nurse (unknown) was working on the north side (right side) of the building. A #1 believes R #1 must have walked out of the front door (center of the building), because the only way someone can hear the front door alarm going off is if they are close to the front door. A #1 reported, that night both nurses may have been too far away to hear the alarm going off. When asked, did anyone hear the alarm going off around the time of the incident. She replied, No. She reported, all the doors should have codes on them in order to get in and out of the building, so something like this never happens again. A #1 reported, normally the alarms go off constantly, which makes it hard to know which staff person is responsible to check when an alarm is going off. It's unclear if the front door alarm went off when R #1 eloped on 10/28/19. O. On 01/13/20 at 7:30 pm, during an interview, A #3, was asked, when a wanderguard alarm goes off who was responsible for checking to see who set it off? He responded, when an alarm goes off, whoever is closest to the door checks to see who set off the alarm. When asked, what if all the staff are in resident's rooms, how would they know who's closest to the door? A #3 just shrugged his shoulders. He reported, everyone knows who the elopement risks are, so all the nurses and CNA's know which resident's they need to keep an extra close eye on. He reported, the alarms don't go off as much now that R #1, and R #13 are no longer at the facility. P. On 01/13/20 at 7:40 pm, during an interview, A #2 was asked, who is responsible to check when an alarm goes off, she replied, whoever hears an alarm going off responds. Q. On 01/13/20 at 7:45 pm, during an interview, A #6 was asked, who is responsible to check when an alarm goes off, she replied, when anybody hears an alarm going off they respond. She reported, there are certain residents' rooms however, that if the front door alarm were to go off, the nurse or CNA's may not be able to hear it. R. On 01/13/20 at 7:55 pm, during an interview, A #4 reported, staff seem to be more vigilant now when door alarms go off. She reported, the front door alarm however, needs to be set to go off at the nurse's station, like all the other door alarms. She reported, if they are short staffed, there's still a potential where staff would not hear if the front door alarm went off. This is concerning S. On 01/13/20 at 8:10 pm, during an interview, DON, when asked, if the facility was short staffed, and no one was able to hear the front door alarm go off, what would happen? She replied, well someone should hear it. Findings for floor damage: T. On 12/16/19 at 1:30 pm, during observation of the facility, a potential tripping hazard was noted in the Activities Room near the exit door. The tile floors were peeling upwards (approximately 1/2 inch). U. On 12/18/19 at 1:45 pm, during an interview, the Administrator was informed about the tile floors in the activity room, and she confirmed the company would be replacing the floors throughout the facility, but was unsure when. V. On 01/13/20 at 7:30 pm, during observation of the facility, it was noted that the tile floors in the activity room were peeling upward.

The facility failed to ensure that residents were free from abuse by other residents. Tracking of resident-to-resident abuse incidents was inconsistent, and residents who exhibited assaultive behaviors (R #s 28, 87 and 111) were not evaluated for the appropriateness of their placement among vulnerable residents. The result was other residents' feelings of fearfulness about these residents. This deficient practice resulted in an Immediate Jeopardy (IJ) at a scope and severity of level K being identified on [DATE] at 2:07 pm. The facility administrator was notified at that time. The facility took corrective action by providing an acceptable Plan of Removal on [DATE] at 3:36 pm. Based on the Plan of Removal, interventions included: 1. Maintaining the assaultive residents within sight of staff at all times, to begin immediately. 2. In consultation with the Medical Director, transfer of the assaultive residents out of the facility once arrangements could be made. Based on the Plan of Removal and interview, the IJ was lifted on [DATE] at 3:36 pm. This resulted in the scope and severity being reduced from level K to level H. Based on interview and record review, the facility failed to ensure that resident's were free from verbal and physical abuse, creating fear for 4 (R #s 13, 51, 91, and 104) of 8 (R #s 13, 28, 30, 51, 87, 91, 104 and 111) residents reviewed for abuse by: 1. Not ensuring that residents with abusive behaviors were appropriately admitted into the facility, and received continued psychiatric services to ensure that other residents were not at risk of these assaultive behaviors. 2. Not investigating and tracking assaultive behaviors to determine frequency and scope of the abuse. 3. Not advising the Medical Director of resident to resident assaults in the facility. This deficient practice is likely to result in residents experiencing feelings of intimidation and fear of assaultive residents. The findings are: A. Record review of facility Incident Reports under the category Resident to Resident (physical contact made) from [DATE] to [DATE] found no reported incidents involving R #s 28, 87 or 111. B. Record review of the Concerns 2015 book, designated by the facility as the grievance book, found no grievances related to resident-to-resident altercations for the year. Findings related to resident (R) #28: C. On [DATE] at 8:30 am, during interview with Residents R #13 and R #104, they stated that they were both fearful about the behaviors of another resident who was sitting in the dining room for breakfast, pointing to R #28. R #13 stated that he (R #28) had tried to knock her down on one occasion (she was unable to say when) while she was walking around in the nursing home. D. On [DATE] at 9:50 am, during interview with the Director of Nursing (DON), who shares the Abuse Coordinator role with the Administrator, she stated that grievances should all be present in the grievance book and that there was no other place that they would be. She stated that no concerns about R #28 had been brought to her attention by other residents. The DON stated that R #28 is volatile and becomes upset if staff touches or attempts to move his wheelchair, but that she was not aware of problems with other residents. She stated that nursing staff was trained on handling altercations, by separating the residents, etc. She stated that nursing staff was also trained on handling grievances by filling out the grievance forms. E. On [DATE] at 10:46 am, during interview with CMA (Certified Medication Aide) #1, she stated that R #28 gets irate sometimes, particularly when another resident is in his way or bumps into him. She stated that he often shouts profanities, and that staff try to separate the residents and diffuse the situation. F. On [DATE] at 10:50 am, during interview with CNA (Certified Nurse Aide) #4, she stated that R #28 doesn't like for anyone to bump his wheelchair or block his way. She stated that he gets angry and yells, kicks, and swings his arms, and that he has made physical contact with other residents during these outbursts. She stated that he kicked R #30 once, and she believes that he kicked another resident who has since died . She stated that, when staff observes this behavior, they attempt to remove other residents from his reach, since moving R #28 himself tends to escalate his behavior. G. On [DATE] at 11:40 am, during interview with R #30, she stated that she had been kicked by R #28 on one occasion. She stated that she sat at his table in the dining room, and he kicked her. She reported that she had not been injured. She stated that staff had not witnessed the incident, but that she had reported it to staff after the fact. She stated that she had heard that the resident had assaulted other residents as well, but didn't know whom. H. Record review of R #30's Progress Notes dated [DATE] revealed, The resident and another female resident were sitting a table at which male resident usually sits in the dining room. The male resident entered the dining room in his wheelchair and came up to sit at the table. He then kicked the female's walker and her left leg above the ankle. The female resident also kicked the male resident in return. No injuries were sustained by either resident. The residents involved agree with the details of this account. The female subsequently made statements of an aggressive nature to this RN regarding hypothetical future encounters with the male resident. She was advised by this RN to avoid future contact with the male resident. I. On [DATE] at 12:10 pm, during interview with the Administrator, she stated that when an altercation between residents occurs, the staff first separate the residents and ascertain that there are no injuries. She stated that, on occasion, a resident will be sent to another facility for a behavioral health consult. She did not recall if R #28 having been sent for a consult, but stated that she would check. The administrator was unable to provide the requested information by the end of the survey. J. On [DATE] at 12:54 pm, during interview with Licensed Practical Nurse (LPN #1), she stated that R #28 had a history of [REDACTED]. She stated that, while he has [MEDICAL CONDITION] (weakness on one side of his body), his good arm has considerable strength, and that he would be able to cause physical harm to another resident if he chose to. LPN #1 stated that she had overheard R #13 and R #104 expressing fear of R #28 earlier that morning ([DATE]). K. On [DATE] at 3:58 pm, during interview with R #51, she stated that she had observed aggressive behaviors of R #28. She stated that she had intervened when she witnessed R #28 kicking a [AGE] year-old resident, and had managed to get the other resident away from R #28. She stated that the incident had occurred in February 2015, and was unwitnessed by staff, but that she had reported it to the DON. She stated that assaultive behaviors of R #28 occur pretty frequently. R #51 stated, He only has one good arm, and I never let myself get close to him. He has tried to hit me many times, but I try to stay away from him. She reported altercations involving R #28 in the dining room, stating, If someone brushes against his chair he just goes bananas. She reported that when R #28 has outbursts, he begins yelling and cursing and swinging his arm. L. Record review of Progress Note documents for R #28 revealed the following: 1. A note dated [DATE] indicating, (Resident) became agitated in dining room and was wheeling himself toward another resident to hit them, (resident) was intercepted by CNA and reoriented before contact made. 2. A note dated [DATE] indicating, Resident refuse vitals (vital sign check), refuse PO (oral) medication, kitchen staff report resident have kick a walker and another resident's shin for sitting at his table in the DR (dining room), resident re-educated to not kick other resident, the other resident claims to have kick resident back in the shin, no injury noted to both parties. 3. A note dated [DATE] for R#28 indicated, Reports by CNA, resident aggressive and having altercation with another resident reports of this resident kicking another resident this morning without injury to either party, resident (educated) to not kick other residents, resident is territorial and unable to vocally express needs. 4. A note dated [DATE] for R#28 indicated , .(Resident) went to dining room. Received a call a few minutes later that he was trying to kick two female residents in the dining room. Nurse went to DR (dining room) and moved females away from his range and attempted to talk to him. Pt. (patient) just began cussing and trying to hit nurse . Unable to redirect, soothe or calm him. Pt. uses his left arm, which is still very strong when he hits. MD (medical doctor) faxed. 5. A note dated [DATE] for R#28 indicated, Staff reported pt trying to kick another male resident who is very limited in what he can do for himself. MD recently increased [MEDICATION NAME]; wife has been notified via phone conversation. Notified SS (Social Services). Pt gets angry at staff, other residents, male, female and is belligerent . 6. A note dated [DATE] for R#28 indicated, Reported by restorative staff that resident was kicking a female resident who was in his way while he was on his way to the dining room for lunch, no injuries noted . M. Record review of a Physician's Progress Note for R #28, written by the Medical Director, who was also the resident's primary care physician, on [DATE], indicated FU (follow-up) depression, increased aggression, anger issues, hit another resident . N. On [DATE] at 1:10 pm, during interview with the Administrator, she stated that in addition to Progress Notes, staff must complete an incident report when altercations occur. When they have done so, she (as Abuse Coordinator) receives an email and can follow up. She stated that there had been problems with R #28 when he was first admitted (in [DATE]), but that I haven't heard much personally in the past few months. She stated that the DON, who is the other Abuse Coordinator, would have more information on how reporting was being managed, and interventions used by nursing staff to keep residents safe. O. On [DATE] at 1:13 pm, during interview with the DON, she acknowledged that incident reports had only been filed for 3 of the 6 incidents for which Progress Notes had indicated an altercation concerning R #28. She stated that she was unaware that R #28 had exhibited aggression toward other residents on so many occasions. She stated that, had she known how frequently R #28 had exhibited assaultive behavior, she would have pressed to have a psychological evaluation of R #28 done. P. On [DATE] at 4:10 pm, during interview with R #13, she stated, I am scared to death that (R #28) will sneak up behind me and put a knife in my back. She said that staff in the dining room hurry to get R #28 whatever he wants, so that he doesn't get mad or upset. Q. On [DATE] at 4:49 pm, during interview, the Medical Director stated that he was not aware of any incidents of R #28's aggression toward other residents. He stated that he had been aware that the R #28 has been resistant to care, but not physically aggressive. Findings related to R #87: R. On [DATE] at 3:58 pm, during interview with R #51, she stated that R #87 becomes assaultive in the dining room. She stated that he rolls his wheelchair over to her table, and tries to take her and other residents' coffee, stating, He gets abusive with staff and other residents . anybody that gets in his way. He is pretty verbally abusive too. He has also tried to hit me when I was sitting at a table near the front of the dining room. S. Record review of the Progress Notes for R #87 revealed the following: 1. A note dated [DATE] indicating, Resident was not cooperative with care today. He attempted to hit other residents at dinner and tried to steal their food. When CNAs assisted him to bed, he swung his arms at them and cussed. He hit one CNA on her abdomen, pinched both of her breasts and called her a 'b****.' 2. A note dated [DATE] indicating, The resident attacks other residents by grabbing other residents and holding on. He will not be redirected and says 'You son of a b****!.' He is endangering himself and others. Repeats phrases such as 'G*d d***' incessantly. 3. A note dated [DATE] indicating, .Did approach another resident and was making trets (sic) but no contact nurse did intervene (sic) and other resident was upset but was able to be calmed down still cursing at no one . 4. Notes indicating that, during the past week, the resident had been aggressive or combative toward staff on [DATE], [DATE], [DATE], [DATE] and [DATE]. T. Record review of R #87's care plan, dated [DATE] indicated resident has hx (history) of inappropriate sexual advances towards another resident E/B (evidenced by) grabbing, touching. U. On [DATE] at 4:40 pm, during interview with the DON, she stated that no incidents regarding altercations between R #87 and other residents had been reported to her. After review of the Progress Notes dated [DATE] and [DATE], indicating R #87 had assaulted or attempted to assault other residents she stated that incident reports had never been filed on those occasions, and that she was unaware of them. V. On [DATE] at 4:49 pm, during interview, the Medical Director, who is the resident's primary care physician, denied knowledge of R #87's abusive behaviors. Findings for R #111 W. Record review of the Nursing Progress Notes and Care Conference Record for R #111 revealed the following: 1. Progress Note dated [DATE] indicated: R #111 stood up and was walking, Staff #10 told him to sit down and R #111 yelled SHUT UP and R #111 then cussed at Staff #10. Staff #10 told him to not say that and R #111 walked over to the nurse's station and stated he was going to slap Staff #10. R #111 raised his hand to slap Staff #10 and CNA #12 caught R #111 before he could do it. 2. Progress Note dated [DATE] indicated: R #111 was combative when staff would try to redirect him. 3. Progress Note dated [DATE] indicated: R #111 pushed another male resident against the wall. R #111 then got a floor mat and was slinging it at the resident. R #111 seemed more confused and agitated today. 4. Progress Note dated [DATE] indicated: R #111 asked CNA #12 to move a chair out at the nurse's station. The CNA #12 told R #111 that the chair at the nurse's station was not for him to sit in. R #111 made a fist at CNA #12 and acted like he was going to hit her. Another resident told R #111 to move away from the nurse's station and he raised his fist at her and told her to shut up and called her names in Spanish. 5. Progress Note dated [DATE] indicated: R #111 was going into another resident's room and CNA #12 tried to redirect him. R #111 squeezed her hand really hard. The nurse tried to assist CNA #12 and R #111 then pushed the CNA #12. 6. Progress Note dated [DATE] indicated the following: This nurse was called to memory care by CNA #12 at 1910 (7:10 pm). CNA #12 reports that resident's roommate was sitting on resident's bed. Resident became upset and CNA #12 witnessed resident strike roommate's chest with an open hand several times, then sit beside roommate on bed and proceed to shove roommate. CNA #12 was able to safely remove roommate from room all while resident yelled and attempted to strike CNA #12. A second CNA #13 assisted in redirecting resident, resident became combative with CNA #13 as well. 7. Progress Note dated [DATE] indicated: R #111 continued to approach a female resident and was calling her Emma (not her name). R #111 then became very angry at the female resident and staff and struck one staff member in the chest. 8. Progress Note dated [DATE] indicated: R #111 became aggressive with CNA #14 and came at her with a raised fist. R #111's roommate walked by him and he stated, get out of here, c******. 9. Progress Note dated [DATE] indicated: R #111 came out of his room around 1530 (3:30 pm) and pushed another resident with force causing the resident to fall to the ground. R #111 then shook another resident's hand with force as she was walking by with family. 10. Progress Note dated [DATE] indicated: R #111 was agitated and was threatening staff and other resident's. R #111 wants keys to the gate. R #111 made threats that he would break windows and furniture until someone gave him the keys. X. On [DATE] at 10:22 am, during interview, RN #1 stated that staff have tried to re-direct R #111 when he becomes aggressive. There was an incident in the van during transport in which he became aggressive and, because of this incident, he was assessed at (Name of Psychiatric Hospital) but (Name of hospital) would not accept him. RN #1 stated that R#111 will not cooperate with Occupational Therapy (OT) or Physical Therapy (PT) and he will not stay in his wheelchair. He is aggressive with others and will usually target his roommate R #91. He also has sexual behaviors towards the women residents. Some of the staff have been hit and R #111 will also cuss at the staff. Y. On [DATE] at 1:15 pm, during interview, RN #1 stated that some of the female resident's are afraid of R #111 along with some of the staff. RN #1 stated that the other resident's don't say that they are afraid verbally, but you can see it in their behavior. She stated that she knows when the resident's are afraid and upset because they won't come out of their room after an incident has occurred with R #111. Z. On [DATE] at 10:57 am, during interview, the Charge Nurse stated that (name of psychiatric hospital) would not accept R #111 because of his aggressiveness and that they (staff) are still looking for a place to move him. She also stated that R #111 was impulsive and staff are trying to figure out what triggers his aggressive behavior. AA. On [DATE] at 9:21 am, during interview, RN #1 stated that yesterday ([DATE]) R #111 became violent and they had to call the police. BB. On [DATE] at 11:58 am, during interview, the DON stated that R #111 has sundowner's (sundowner's is the name given to an ailment that causes symptoms of confusion after sundown. in some residents that suffer from Alzheimer 's Disease or Dementia.) really bad but that they have not identified any other triggers. They (the staff) monitor him very closely on the unit and check in when he wakes up to see what mood he was in. The DON also stated, (I) think that the other resident's on the unit are afraid of him (R #111), especially when he becomes loud and agitated. The DON also stated that he did hit his roommate once. CC. On [DATE] at 4:00 pm, during interview, CNA #1 stated that R #111, tends to get aggressive with women, it's like he can hear you but it doesn't sink in. CNA #1 stated that R #111 was also verbally and physically aggressive and used profanity a lot. CNA #1 stated that on [DATE], R #111 became aggressive and was sent out (of the facility) and that she had heard that he had taken his shoe off and hit another staff member. CNA #1 stated that the staff member was charting at the kiosk when R #111 came up behind her and hit her. CNA #1 stated that a few of the them get scared, referring to the resident's, and that R #111's roommate doesn't want to go to bed because R #111 is in there. DD. On [DATE] at 4:07 pm, during interview, CNA #2 stated, We do the best we can to redirect him. CNA #2 confirmed R #111 was verbally aggressive to staff calling them names such as stupid and liars. CNA #2 stated that she had witnessed R #111 become physically aggressive with residents. She stated, Yes, I have physically seen him numerous times. He targets his roommate (R #91) more than anyone else. I have seen (Name of R#111) push (Name of R #91). I've seen (Name of R #111) take his fall mat and slap (Name of R #91) with it. (Name of R #111) tries to go in the women's rooms and we try to let him know it's not allowed. CNA #2 stated that R #111 was very physical with staff, he is very unpredictable. On [DATE] in the evening time, (Name of R #111) hit one of the medication aides on the arm with his shoe as she walked down the hall. Then (Name of R #111) came and swung his shoe at me, he did not hit me. Then, the other aide was charting and he took his shoe and slapped her hand with it. That's when I went to tell the nurse, and when I came back he had rolled up a magazine and hit her two more times with force, that's when we decided to get authorities involved. CNA #2 stated that a few resident's are afraid of R #111 and that they have made comments to that effect. When (Name of R #91) got hit with a fall mat he said, This place is dangerous, and he doesn't really talk. (Name of R #91) doesn't know what to do when (Name of R #111) gets that way, he just freezes. CNA #2 stated that they (staff) can't turn their backs on R #111 what so ever. CNA #2 said that she was afraid of R #111. He could hurt me if he wanted to, if I wasn't on my guard. I try to be on my guard with him. I'm trying to keep them (residents) safe. EE. On [DATE] at 4:19 pm, during interview, RN #1 stated, I made a note on what he (R #111) did today. RN #1 confirmed that R #111 tried to slap her while at the nurse's station. RN #1 stated, I tried to ignore his behavior. That is not the first time they had to stop him from trying to hit me. RN #1 stated that R #111 was aggressive with resident's. She stated, (Name of R #111) has pushed some of the other residents when he's trying to walk. We keep the resident's away from him. RN #1 stated that the other resident's are afraid of him. One of the resident's was very afraid of him. She stated that she can tell, because he (Name of R #91) will walk around him (Name of R #111). FF. On [DATE] at 4:49 pm, during interview, the Medical Director stated that he was aware of R #111's aggressive behaviors and that he has a history of physically assaulting others and has displayed sexual behavior towards staff. The Medical Director stated that he has been made aware of R #111 behaviors and that there had been 7 or 8 incidents reported to him about his (R #111) aggressiveness.

The facility failed to ensure that its Policies and Procedures related to Abuse and Neglect were consistently implemented. Incidents of resident-to-resident physical and verbal abuse, mentioned in residents' progress notes and by other residents and staff members, did not always result in incident reports being filed for 3 identified assaultive residents (R #28, R #87 and R #111). Consequently, the Administrator and Director of Nursing (DON), the facility's Abuse Coordinators, were not aware and were unable to follow up on the number or severity of resident-to-resident assaults. This deficient practice resulted in an Immediate Jeopardy (IJ) at a scope and severity of level K being identified on [DATE] at 2:07 pm. The Administrator was notified at that time. The facility took corrective action by providing an acceptable Plan of Removal on [DATE] at 3:36 pm. Based on the Plan of Removal, interventions included: 1. Maintaining the assaultive residents within sight of staff at all times, to begin immediately. 2. In consultation with the Medical Director, transfer of the assaultive residents out of the facility once arrangements could be made. Based on the Plan of Removal and interview, the IJ was lifted on [DATE] at 3:36 pm. This resulted in the scope and severity being reduced from level K to level H. Based on interview and record review, the facility failed to implement its policies and procedures that prohibit abuse of residents, affecting 8 residents (R #13, #28, #30, #51, #87 #91, #104 and #111) of 8 residents (R #13, #28, #30, #51, #87, #91, #104 and #111) reviewed for abuse with the potential to impact the psychological well-being of all 81 residents listed on the resident census provided by the administrator on [DATE]. Staff failed to file incident reports related to numerous assaultive resident behaviors, or to notify the Administrator and DON of the incidents, leading to a systemic failure to recognize and address the full extent of the problem. This deficient practice resulted in multiple residents expressing fearfulness of other residents and non-verbal residents exhibiting fearful behaviors. The findings are: A. Record review of the facility's Policy document related to Abuse and Neglect, dated February 2013 and revised [DATE] revealed the following: 1. Residents must not be subjected to abuse by anyone, including, but not limited to, center staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. 2. Alleged or suspected violations involving any mistreatment, neglect or abuse including injuries of unknown origin will be reported immediately to the center administrator and to other officials in accordance with state law . 3. The center will have evidence that all alleged or suspected violations are thoroughly investigated and will prevent further potential abuse while the investigation is in progress. Results of all investigations will be reported to the administrator or designated representative and to other officials in accordance with state law . B. Record review of the facility's Procedure document related to Abuse and Neglect, dated February 2013 revealed the following: 1. Purpose: . To ensure that the center has in place an effective system that, regardless of the source, prevents mistreatment, neglect and abuse of residents . . To ensure that all identified incidents of alleged or suspected abuse / neglect are promptly investigated and reported . To identify and remedy any abusive situations . 2. If a staff member receives an allegation of abuse, neglect or misappropriation of resident property, or witnesses suspected abuse, neglect or misappropriation of resident property, the staff member will immediately report this to a supervisor. 3. Notification procedures: Notify the center administrator immediately of any incidents of resident abuse . 4. The investigation team (social worker, the administrator and the director of nursing services) will review all incidents no later than the next working day following the incident. Findings related to resident (R) #28: C. On [DATE] at 8:30 am, during interview with Residents R #13 and R #104, they stated that they were both fearful about the behaviors of another resident who was sitting in the dining room for breakfast, pointing to R #28. R #13 stated that he (R #28) had tried to knock her down on one occasion (she was unable to say when) while she was walking around in the nursing home. D. On [DATE] at 9:50 am, during interview with the Director of Nursing (DON), who shares the Abuse Coordinator role with the Administrator, she stated that grievances should all be present in the grievance book and that there was no other place that they would be. She stated that no concerns about R #28 had been brought to her attention by other residents. The DON stated that R #28 is volatile and becomes upset if staff touches or attempts to move his wheelchair, but that she was not aware of problems with other residents. She stated that nursing staff was trained on handling altercations, by separating the residents, etc. She stated that nursing staff was also trained on handling grievances by filling out the grievance forms. E. On [DATE] at 10:46 am, during interview with CMA (Certified Medication Aide) #1, she stated that R #28 gets irate sometimes, particularly when another resident is in his way or bumps into him. She stated that he often shouts profanities, and that staff try to separate the residents and diffuse the situation. F. On [DATE] at 10:50 am, during interview with CNA (Certified Nurse Aide) #4, she stated that R #28 doesn't like for anyone to bump his wheelchair or block his way. She stated that he gets angry and yells, kicks, and swings his arms, and that he has made physical contact with other residents during these outbursts. She stated that he kicked R #30 once, and she believes that he kicked another resident who has since died . She stated that, when staff observes this behavior, they attempt to remove other residents from his reach, since moving R #28 himself tends to escalate his behavior. G. On [DATE] at 11:40 am, during interview with R #30, she stated that she had been kicked by R #28 on one occasion. She stated that she sat at his table in the dining room, and he kicked her. She reported that she had not been injured. She stated that staff had not witnessed the incident, but that she had reported it to staff after the fact. She stated that she had heard that the resident had assaulted other residents as well, but didn't know whom. H. Record review of R #30's Progress Notes dated [DATE] revealed, The resident and another female resident were sitting a table at which male resident usually sits in the dining room. The male resident entered the dining room in his wheelchair and came up to sit at the table. He then kicked the female's walker and her left leg above the ankle. The female resident also kicked the male resident in return. No injuries were sustained by either resident. The residents involved agree with the details of this account. The female subsequently made statements of an aggressive nature to this RN regarding hypothetical future encounters with the male resident. She was advised by this RN to avoid future contact with the male resident. I. On [DATE] at 12:10 pm, during interview with the Administrator, she stated that when an altercation between residents occurs, the staff first separate the residents and ascertain that there are no injuries. She stated that, on occasion, a resident will be sent to another facility for a behavioral health consult. She did not recall if R #28 having been sent for a consult, but stated that she would check. The administrator was unable to provide the requested information by the end of the survey. J. On [DATE] at 12:54 pm, during interview with Licensed Practical Nurse (LPN #1), she stated that R #28 had a history of [REDACTED]. She stated that, while he has [MEDICAL CONDITION] (weakness on one side of his body), his good arm has considerable strength, and that he would be able to cause physical harm to another resident if he chose to. LPN #1 stated that she had overheard R #13 and R #104 expressing fear of R #28 earlier that morning ([DATE]). K. On [DATE] at 3:58 pm, during interview with R #51, she stated that she had observed aggressive behaviors of R #28. She stated that she had intervened when she witnessed R #28 kicking a [AGE] year-old resident, and had managed to get the other resident away from R #28. She stated that the incident had occurred in February 2015, and was unwitnessed by staff, but that she had reported it to the DON. She stated that assaultive behaviors of R #28 occur pretty frequently. R #51 stated, He only has one good arm, and I never let myself get close to him. He has tried to hit me many times, but I try to stay away from him. She reported altercations involving R #28 in the dining room, stating, If someone brushes against his chair he just goes bananas. She reported that when R #28 has outbursts, he begins yelling and cursing and swinging his arm. L. Record review of Progress Note documents for R #28 revealed the following: 1. A note dated [DATE] indicating, (Resident) became agitated in dining room and was wheeling himself toward another resident to hit them, (resident) was intercepted by CNA and reoriented before contact made. 2. A note dated [DATE] indicating, Resident refuse vitals (vital sign check), refuse PO (oral) medication, kitchen staff report resident have kick a walker and another resident's shin for sitting at his table in the DR (dining room), resident re-educated to not kick other resident, the other resident claims to have kick resident back in the shin, no injury noted to both parties. 3. A note dated [DATE] for R#28 indicated, Reports by CNA, resident aggressive and having altercation with another resident reports of this resident kicking another resident this morning without injury to either party, resident (educated) to not kick other residents, resident is territorial and unable to vocally express needs. 4. A note dated [DATE] for R#28 indicated , .(Resident) went to dining room. Received a call a few minutes later that he was trying to kick two female residents in the dining room. Nurse went to DR (dining room) and moved females away from his range and attempted to talk to him. Pt. (patient) just began cussing and trying to hit nurse . Unable to redirect, soothe or calm him. Pt. uses his left arm, which is still very strong when he hits. MD (medical doctor) faxed. 5. A note dated [DATE] for R#28 indicated, Staff reported pt trying to kick another male resident who is very limited in what he can do for himself. MD recently increased [MEDICATION NAME]; wife has been notified via phone conversation. Notified SS (Social Services). Pt gets angry at staff, other residents, male, female and is belligerent . 6. A note dated [DATE] for R#28 indicated, Reported by restorative staff that resident was kicking a female resident who was in his way while he was on his way to the dining room for lunch, no injuries noted . M. Record review of a Physician's Progress Note for R #28, written by the Medical Director, who was also the resident's primary care physician, on [DATE], indicated FU (follow-up) depression, increased aggression, anger issues, hit another resident . N. On [DATE] at 1:10 pm, during interview with the Administrator, she stated that in addition to Progress Notes, staff must complete an incident report when altercations occur. When they have done so, she (as Abuse Coordinator) receives an email and can follow up. She stated that there had been problems with R #28 when he was first admitted (in [DATE]), but that I haven't heard much personally in the past few months. She stated that the DON, who is the other Abuse Coordinator, would have more information on how reporting was being managed, and interventions used by nursing staff to keep residents safe. O. On [DATE] at 1:13 pm, during interview with the DON, she acknowledged that incident reports had only been filed for 3 of the 6 incidents for which Progress Notes had indicated an altercation concerning R #28. She stated that she was unaware that R #28 had exhibited aggression toward other residents on so many occasions. She stated that, had she known how frequently R #28 had exhibited assaultive behavior, she would have pressed to have a psychological evaluation of R #28 done. P. On [DATE] at 4:10 pm, during interview with R #13, she stated, I am scared to death that (R #28) will sneak up behind me and put a knife in my back. She said that staff in the dining room hurry to get R #28 whatever he wants, so that he doesn't get mad or upset. Q. On [DATE] at 4:49 pm, during interview, the Medical Director stated that he was not aware of any incidents of R #28's aggression toward other residents. He stated that he had been aware that the R #28 has been resistant to care, but not physically aggressive. Findings related to R #87: R. On [DATE] at 3:58 pm, during interview with R #51, she stated that R #87 becomes assaultive in the dining room. She stated that he rolls his wheelchair over to her table, and tries to take her and other residents' coffee, stating, He gets abusive with staff and other residents . anybody that gets in his way. He is pretty verbally abusive too. He has also tried to hit me when I was sitting at a table near the front of the dining room. S. Record review of the Progress Notes for R #87 revealed the following: 1. A note dated [DATE] indicating, Resident was not cooperative with care today. He attempted to hit other residents at dinner and tried to steal their food. When CNAs assisted him to bed, he swung his arms at them and cussed. He hit one CNA on her abdomen, pinched both of her breasts and called her a 'b****.' 2. A note dated [DATE] indicating, The resident attacks other residents by grabbing other residents and holding on. He will not be redirected and says 'You son of a b****!.' He is endangering himself and others. Repeats phrases such as 'G*d d***' incessantly. 3. A note dated [DATE] indicating, .Did approach another resident and was making trets (sic) but no contact nurse did intervene (sic) and other resident was upset but was able to be calmed down still cursing at no one . 4. Notes indicating that, during the past week, the resident had been aggressive or combative toward staff on [DATE], [DATE], [DATE], [DATE] and [DATE]. T. Record review of R #87's care plan, dated [DATE] indicated resident has hx (history) of inappropriate sexual advances towards another resident E/B (evidenced by) grabbing, touching. U. On [DATE] at 4:40 pm, during interview with the DON, she stated that no incidents regarding altercations between R #87 and other residents had been reported to her. After review of the Progress Notes dated [DATE] and [DATE], indicating R #87 had assaulted or attempted to assault other residents she stated that incident reports had never been filed on those occasions, and that she was unaware of them. V. On [DATE] at 4:49 pm, during interview, the Medical Director, who is the resident's primary care physician, denied knowledge of R #87's abusive behaviors. Findings for R #111 W. Record review of the Nursing Progress Notes and Care Conference Record for R #111 revealed the following: 1. Progress Note dated [DATE] indicated: R #111 stood up and was walking, Staff #10 told him to sit down and R #111 yelled SHUT UP and R #111 then cussed at Staff #10. Staff #10 told him to not say that and R #111 walked over to the nurse's station and stated he was going to slap Staff #10. R #111 raised his hand to slap Staff #10 and CNA #12 caught R #111 before he could do it. 2. Progress Note dated [DATE] indicated: R #111 was combative when staff would try to redirect him. 3. Progress Note dated [DATE] indicated: R #111 pushed another male resident against the wall. R #111 then got a floor mat and was slinging it at the resident. R #111 seemed more confused and agitated today. 4. Progress Note dated [DATE] indicated: R #111 asked CNA #12 to move a chair out at the nurse's station. The CNA #12 told R #111 that the chair at the nurse's station was not for him to sit in. R #111 made a fist at CNA #12 and acted like he was going to hit her. Another resident told R #111 to move away from the nurse's station and he raised his fist at her and told her to shut up and called her names in Spanish. 5. Progress Note dated [DATE] indicated: R #111 was going into another resident's room and CNA #12 tried to redirect him. R #111 squeezed her hand really hard. The nurse tried to assist CNA #12 and R #111 then pushed the CNA #12. 6. Progress Note dated [DATE] indicated the following: This nurse was called to memory care by CNA #12 at 1910 (7:10 pm). CNA #12 reports that resident's roommate was sitting on resident's bed. Resident became upset and CNA #12 witnessed resident strike roommate's chest with an open hand several times, then sit beside roommate on bed and proceed to shove roommate. CNA #12 was able to safely remove roommate from room all while resident yelled and attempted to strike CNA #12. A second CNA #13 assisted in redirecting resident, resident became combative with CNA #13 as well. 7. Progress Note dated [DATE] indicated: R #111 continued to approach a female resident and was calling her Emma (not her name). R #111 then became very angry at the female resident and staff and struck one staff member in the chest. 8. Progress Note dated [DATE] indicated: R #111 became aggressive with CNA #14 and came at her with a raised fist. R #111's roommate walked by him and he stated, get out of here, c******. 9. Progress Note dated [DATE] indicated: R #111 came out of his room around 1530 (3:30 pm) and pushed another resident with force causing the resident to fall to the ground. R #111 then shook another resident's hand with force as she was walking by with family. 10. Progress Note dated [DATE] indicated: R #111 was agitated and was threatening staff and other resident's. R #111 wants keys to the gate. R #111 made threats that he would break windows and furniture until someone gave him the keys. X. On [DATE] at 10:22 am, during interview, RN #1 stated that staff have tried to re-direct R #111 when he becomes aggressive. There was an incident in the van during transport in which he became aggressive and, because of this incident, he was assessed at (Name of Psychiatric Hospital) but (Name of hospital) would not accept him. RN #1 stated that R#111 will not cooperate with Occupational Therapy (OT) or Physical Therapy (PT) and he will not stay in his wheelchair. He is aggressive with others and will usually target his roommate R #91. He also has sexual behaviors towards the women residents. Some of the staff have been hit and R #111 will also cuss at the staff. Y. On [DATE] at 1:15 pm, during interview, RN #1 stated that some of the female resident's are afraid of R #111 along with some of the staff. RN #1 stated that the other resident's don't say that they are afraid verbally, but you can see it in their behavior. She stated that she knows when the resident's are afraid and upset because they won't come out of their room after an incident has occurred with R #111. Z. On [DATE] at 10:57 am, during interview, the Charge Nurse stated that (name of psychiatric hospital) would not accept R #111 because of his aggressiveness and that they (staff) are still looking for a place to move him. She also stated that R #111 was impulsive and staff are trying to figure out what triggers his aggressive behavior. AA. On [DATE] at 9:21 am, during interview, RN #1 stated that yesterday ([DATE]) R #111 became violent and they had to call the police. BB. On [DATE] at 11:58 am, during interview, the DON stated that R #111 has sundowner's (sundowner's is the name given to an ailment that causes symptoms of confusion after sundown. in some residents that suffer from Alzheimer 's Disease or Dementia.) really bad but that they have not identified any other triggers. They (the staff) monitor him very closely on the unit and check in when he wakes up to see what mood he was in. The DON also stated, (I) think that the other resident's on the unit are afraid of him (R #111), especially when he becomes loud and agitated. The DON also stated that he did hit his roommate once. CC. On [DATE] at 4:00 pm, during interview, CNA #1 stated that R #111, tends to get aggressive with women, it's like he can hear you but it doesn't sink in. CNA #1 stated that R #111 was also verbally and physically aggressive and used profanity a lot. CNA #1 stated that on [DATE], R #111 became aggressive and was sent out (of the facility) and that she had heard that he had taken his shoe off and hit another staff member. CNA #1 stated that the staff member was charting at the kiosk when R #111 came up behind her and hit her. CNA #1 stated that a few of the them get scared, referring to the resident's, and that R #111's roommate doesn't want to go to bed because R #111 is in there. DD. On [DATE] at 4:07 pm, during interview, CNA #2 stated, We do the best we can to redirect him. CNA #2 confirmed R #111 was verbally aggressive to staff calling them names such as stupid and liars. CNA #2 stated that she had witnessed R #111 become physically aggressive with residents. She stated, Yes, I have physically seen him numerous times. He targets his roommate (R #91) more than anyone else. I have seen (Name of R#111) push (Name of R #91). I've seen (Name of R #111) take his fall mat and slap (Name of R #91) with it. (Name of R #111) tries to go in the women's rooms and we try to let him know it's not allowed. CNA #2 stated that R #111 was very physical with staff, he is very unpredictable. On [DATE] in the evening time, (Name of R #111) hit one of the medication aides on the arm with his shoe as she walked down the hall. Then (Name of R #111) came and swung his shoe at me, he did not hit me. Then, the other aide was charting and he took his shoe and slapped her hand with it. That's when I went to tell the nurse, and when I came back he had rolled up a magazine and hit her two more times with force, that's when we decided to get authorities involved. CNA #2 stated that a few resident's are afraid of R #111 and that they have made comments to that effect. When (Name of R #91) got hit with a fall mat he said, This place is dangerous, and he doesn't really talk. (Name of R #91) doesn't know what to do when (Name of R #111) gets that way, he just freezes. CNA #2 stated that they (staff) can't turn their backs on R #111 what so ever. CNA #2 said that she was afraid of R #111. He could hurt me if he wanted to, if I wasn't on my guard. I try to be on my guard with him. I'm trying to keep them (residents) safe. EE. On [DATE] at 4:19 pm, during interview, RN #1 stated, I made a note on what he (R #111) did today. RN #1 confirmed that R #111 tried to slap her while at the nurse's station. RN #1 stated, I tried to ignore his behavior. That is not the first time they had to stop him from trying to hit me. RN #1 stated that R #111 was aggressive with resident's. She stated, (Name of R #111) has pushed some of the other residents when he's trying to walk. We keep the resident's away from him. RN #1 stated that the other resident's are afraid of him. One of the resident's was very afraid of him. She stated that she can tell, because he (Name of R #91) will walk around him (Name of R #111). FF. On [DATE] at 4:49 pm, during interview, the Medical Director stated that he was aware of R #111's aggressive behaviors and that he has a history of physically assaulting others and has displayed sexual behavior towards staff. The Medical Director stated that he has been made aware of R #111 behaviors and that there had been 7 or 8 incidents reported to him about his (R #111) aggressiveness.

The facility failed to ensure that the resident environment was as free from accident hazards. Bathroom water temperatures on the 100- and 300- units, and shower room temperatures on the A- and B- wings, were noted to be in excess of 120 degrees Fahrenheit (F). This deficient practice resulted in an Immediate Jeopardy at a Scope & Severity of L being identified on 12/01/15 at 12:00 pm. The Administrator was notified at that time. The facility took corrective action by providing an acceptable Plan of Removal on 12/01/15 at 2:30 pm. Based on the Plan of Removal, interventions included: 1. Immediate shut-off of water heaters supplying water to the affected areas. 2. Inspection of and service to the water heaters by a plumbing firm within one hour. 3. Installation of a device to regulate water temperature. 4. In-service of maintenance staff on calibration of thermometers used to test water temperature. 5. Daily water temperature checks. Based on the Plan of Removal and interview, the IJ was lifted on 12/01/15 at 2:30 pm. This resulted in the scope and severity being reduced from level L to level F. Based on observation and interview, the facility failed to ensure that water accessible to residents was maintained below 120 degrees F. This deficient practice is likely to result in burn injuries affecting all 81 residents in the facility as identified on the Resident Census provided by the Administrator on 11/30/15. The findings are: A. On 12/01/15 at 9:24 am, during interview with R #81, regarding her bathroom water temperature, she stated Be careful of that hot water. It'll burn you. B. On 12/01/15 at 9:25 am, during observation in the bathroom R #38, the water temperature was measured with an immersion (probe) thermometer. The reading was 132.4 degrees F. C. On 12/01/15 at 9:26 am, during observation in the bathroom of R #17, the water temperature reading was 131.0 degrees F. D. On 12/01/15 at 9:38 am, during observation in the bathroom of room R #95, the water temperature reading was 133.3 degrees F. E. On 12/01/15 at 9:46 am, during observation of the bathroom of room R #82, the water temperature reading was 127.6 degrees F. F. On 12/01/15 at 10:37 am, accuracy of the utilized thermometer was verified by submerging it into a glass of ice water to ensure calibration. The reading was 32.2 degrees F. G. On 12/01/15 at 11:05 am, during interview with the Maintenance Technician #1 he stated that the Maintenance Director was not presently in the building. Upon request, the Maintenance Technician checked the water temperature in room 306 using a laser thermometer pointed at the stream of water. He obtained fluctuating readings between 112 and 115 degrees F. The surveyor's probe thermometer registered 133.2 degrees F. at that time. Maintenance Technician #1 returned at 11:10 am with the facility's immersion (probe) thermometer and obtained a reading of 133.1 degrees F. in room 306, and 132.2 degrees F. in room 303. The Maintenance Technician was unable to state the acceptable hot water temperature for resident bathrooms, but stated Well, less than that. I wouldn't want to wash my hands in that. H. On 12/01/15 at 10:30 am, during observation of the 100 hall resident bathrooms, the following water temperatures were measured: 1. The bathroom water temperature in R #7's room read 123.3 degrees. 2. The bathroom water temperature in R #16 read 121.7 degrees. I. On 12/01/15 at 11:05 am, during observation of the 100 Unit Shower Room, the shower water temperature was measured at 120.7 degrees. J. On 12/01/15 at 11:10 am, during observation of the 200 Unit Shower Room, the shower water temperature was measured at 120.4 degrees. K. On 12/01/15 at 11:15 am, during observation of the 400 Unit Shower Room, the shower water temperature was measured at 120.7 degrees. L. On 12/01/15 at 11:50 am, during interview with the Maintenance Director, he stated that the water heater located in the center of the facility provides hot water to all of the rooms and that the temperature was set at 120 degrees to account for the time it takes for the water to travel to the resident's rooms. The Maintenance Director stated that by the time the water gets down there (to the resident rooms), the water is cooler (than 120 degrees). The MD stated that he does not calibrate the thermometers that he uses to check water temperatures throughout the facility but that he has two thermometers that he uses. When asked how he ensured the accuracy of the thermometers if he did not calibrate them, the Maintenance Director stated that I just go by what the thermometer says. M. On 12/01/15 at 11:55 am, during interview with Maintenance Technician #1, he stated that he did not know how to calibrate the thermometer to ensure accurate temperature readings. N. On 12/01/15 at 11:55 am, during interview with Maintenance Technician #2, he stated that he did not know how to calibrate the thermometer to ensure accurate temperature readings. O. On 12/01/15 at 12:48 pm, during interview with (Name of Water Heater Company) Representative, he stated that the facility informed him that the water temperatures were too hot. The Representative stated that he discovered that the water heater needed a tempering valve which would ensure that water was constantly circulating and would maintain the water at a more consistent temperature.

Based on observation, interview and record review, the administration of the facility failed to manage and coordinate resident care in a manner that would enable each resident to attain or maintain his or her highest practicable physical, mental and psychosocial well being, for all 81 residents in the facility as identified on the Alphabetical Census provided by the Administrator on 11/30/15 by failing to ensure that residents were free from abuse. This deficient practice likely contributed to poor resident outcomes with respect to quality-of-life, quality-of-care, health, safety and comfort. The findings are: Refer to F223 and F226: A. Record review of the facility's Policy document related to Abuse and Neglect, dated September 2013 revealed the following: 1. Residents must not be subjected to abuse by anyone, including, but not limited to, center staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. 2. Alleged or suspected violations involving any mistreatment, neglect or abuse including injuries of unknown origin will be reported immediately to the center administrator and to other officials in accordance with state law . 3. The center will have evidence that all alleged or suspected violations are thoroughly investigated and will prevent further potential abuse while the investigation is in progress. Results of all investigations will be reported to the administrator or designated representative and to other officials in accordance with state law . B. Record review of Physician's Progress Note for R #28, written by the Medical Director, also the residents primary care physician on 06/23/15, indicated FU (follow-up) depression, increased aggression, anger issues, hit another resident . The Plan section of the note indicated Increase [MEDICATION NAME] 75 mg PO (by mouth) QD (daily). C. On 12/03/15 at 1:13 pm, during interview, the DON stated that incident reports had not been filed for 3 of the 6 incidents of physical aggression toward other residents found in R #28's progress notes. She stated that she was unaware that R #28 had exhibited aggression toward other residents on so many occasions. She stated that, had she known how frequently R #28 had exhibited assaultive behavior, she would have pressed to have a psychological evaluation of R #28 done. D. Record review of the Concerns 2015 (grievances) book, designated by the facility as the grievance book, found no grievances related to resident-to-resident altercations for the year. E. On 12/03/15 at 4:40 pm, during interview, the DON stated that there were no incidents regarding altercations between R #87 and other residents that had been reported to her. She stated that other residents do not like R #87, because he swears at them and tries to steal their food. She stated that certain residents try to get away from him. She was shown the Progress Notes dated 10/18/15 and 04/09/15, indicating R #87 had assaulted or attempted to assault other residents, and stated that incident reports had never been filed on those occasions, and that she was unaware of them. F. On 12/02/15 at 10:57 am, during interview, the Charge Nurse stated that (name of psychiatric hospital) would not accept him because of his aggressiveness. They (staff) are still looking for a place to move him. She also stated that R #111 was impulsive and they are trying to figure out what triggers him. G. On 12/03/15 at 11:58 am, during interview, the DON stated that R #111 has sundowners really bad. Other than that they have not identified any other triggers. They (the staff) monitor him very closely on the unit. They will always check in when he wakes up to see what mood he was in. The DON also stated, (I) think that the other resident's on the unit are afraid of him, (R #111) especially when he becomes loud and agitated. The DON also stated that he did hit his roommate once. H. On 12/03/15 at 4:49 pm, during interview, the Medical Director stated that he has been aware of R #111 aggressive behaviors. He has a history of assaulting physically and has displayed sexual behavior towards staff. The Medical Director stated that he has been made aware of R #111 behaviors and there have been 7 or 8 incidents with his aggressiveness.

Based on record review and interviews the facility failed to ensure 1 (R #5) of 1 (R #5) resident who had fallen was maintained at their highest practicable physical, mental, and psychosocial well being. This resident "fell backward in wheelchair (w/c) while attended by Certified Nursing Assistant (CNA). She has pain in her left shoulder. Resident transported for x-ray. The anti-tip bars at the rear of the w/c was found to be loose and able to rotate allowing the w/c to fall backward." This deficient practice likely caused the resident to sustain a fractured left humerus. The findings are: A. Record review for resident #5 revealed the following: 1. April 2013 Incident/Accident Log indicated that the resident had a fall on 04/24/13. 2. Incident Report dated 04/24/13 at 12:03 pm indicated, "The resident fell backward in wheel chair while attended by Certified Nursing Assistant (CNA). She has pain in her left shoulder. Resident transported for x-ray. The anti-tip bars at the rear of the w/c was found to be loose and able to rotate allowing the w/c to fall backward." 3. (Name of Hospital) Emergency Department Note indicated, "Patient arrived by w/c via private auto from (name of nursing home). ...fell out of w/c this morning...complains of left upper arm pain. Sent to radiology for x-ray." 4. X-Ray report dated 04/24/13 indicated, "Left Humeral neck fracture (Fx)." 5. Incident Internal Investigation Follow-up Report dated 04/24/13 at 3:57 pm indicated, "Resident had a fall at 12:00 pm today, 04/24/13. She was sent to the hospital for X-rays. She was found to have a Proximal Humerus Fracture of her left arm. She was returned to the facility at 3:30 pm on the same day. Staff are working with her to manage her pain." 6. Physician order [REDACTED]. Give 1-2 tablet as needed. [DIAGNOSES REDACTED]. B. Interviews for resident #5 revealed the following: 1. On 08/08/13 at 11:30 am, during interview, CNA #1 stated, "I was getting her up in the morning. I was using a mechanical lift. When I put her in the w/c, it fell backwards. The little legs that was suppposed to keep the chair from tipping slid to the side causing the chair to fall backwards. She went to the hospital and had a fractured shoulder." 2. On 08/08/13 at 11:40 am, during interview, the Maintenance Director stated, "When this happened (the incident), I just happened to be standing by the nurses station. They (nursing staff) said she had fallen backwards in her chair. I asked if she had anti-tip bars on her w/c. The nurse said that they (anti-tip bars) were on the chair, but they were turned outward. I looked at the chair and the locking buttons were not engaged so the bars were turning outward. Whoever put them on did not ensure that they were clipped in place to secure the legs." 3. On 08/08/13 at 11:50 am, Registered Nurse (RN) #1 stated, "This was an equipment problem. Some of the anti-tip bars on the back of the wheelchairs are not reliable. That's what happens when you have old equipment and try to piece things together. She tipped backwards and broke her humerus. I told maintenance that the bars were twisted. It happened that they were not locked into place."

Based on record review and interview, the facility failed to ensure that the assistive device (wheelchair) that was being used by 1 (R #5) of 1 (R #5) resident to prevent accidents was maintained in safe working condition. The resident fell while being placed in her wheelchair (w/c) because the anti-tip lock was not secure. This resident "fell backward in wheelchair while attended by Certified Nursing Assistant (CNA). She has pain in her left shoulder. Resident transported for x-ray. The anti-tip bars at the rear of the (w/c) was found to be loose and able to rotate allowing the w/c to fall backward." This deficient practice likely caused the resident to sustain a fractured left humerus. The findings are: A. Record review for resident #5 revealed the following: 1. April 2013 Incident/Accident Log indicated that the resident had a fall on 04/24/13. 2. Incident Report dated 04/24/13 at 12:03 pm indicated, "The resident fell backward in wheel chair while attended by Certified Nursing Assistant (CNA). She has pain in her left shoulder. Resident transported for x-ray. The anti-tip bars at the rear of the w/c was found to be loose and able to rotate allowing the w/c to fall backward." 3. (Name of Hospital) Emergency Department Note indicated, "Patient arrived by w/c via private auto from (name of nursing home). ...fell out of w/c this morning...complains of left upper arm pain. Sent to radiology for x-ray." 4. X-Ray report dated 04/24/13 indicated, "Left Humeral neck fracture (Fx)." 5. Incident Internal Investigation Follow-up Report dated 04/24/13 at 3:57 pm indicated, "Resident had a fall at 12:00 pm today, 04/24/13. She was sent to the hospital for X-rays. She was found to have a Proximal Humerus Fracture of her left arm. She was returned to the facility at 3:30 pm on the same day. Staff are working with her to manage her pain." 6. Physician order [REDACTED]. Give 1-2 tablet as needed. [DIAGNOSES REDACTED]. B. Interviews for resident #5 revealed the following: 1. On 08/08/13 at 11:30 am, during interview, CNA #1 stated, "I was getting her up in the morning. I was using a mechanical lift. When I put her in the w/c, it fell backwards. The little legs that was suppposed to keep the chair from tipping slid to the side causing the chair to fall backwards. She went to the hospital and had a fractured shoulder." 2. On 08/08/13 at 11:40 am, during interview, the Maintenance Director stated, "When this happened (the incident), I just happened to be standing by the nurses station. They (nursing staff) said she had fallen backwards in her chair. I asked if she had anti-tip bars on her w/c. The nurse said that they (anti-tip bars) were on the chair, but they were turned outward. I looked at the chair and the locking buttons were not engaged so the bars were turning outward. Whoever put them on did not ensure that they were clipped in place to secure the legs." 3. On 08/08/13 at 11:50 am, Registered Nurse (RN) #1 stated, "This was an equipment problem. Some of the anti-tip bars on the back of the wheelchairs are not reliable. That's what happens when you have old equipment and try to piece things together. She tipped backwards and broke her humerus. I told maintenance that the bars were twisted. It happened that they were not locked into place."

Based on record review and interview, the facility to ensure that the patient care equipment (wheelchair) was maintained in safe working condition for 1 (R #5) of 1 (R #5) resident who fell while being placed in her w/c because the anti-tip lock was not secure. This resident "fell backward in wheelchair (w/c) while attended by Certified Nursing Assistant (CNA). She has pain in her left shoulder. Resident transported for x-ray. The anti-tip bars at the rear of the (w/c) was found to be loose and able to rotate allowing the w/c to fall backward." This deficient practice likely caused the resident to sustain a fractured left humerus. The findings are: A. Record review for resident #5 revealed the following: 1. April 2013 Incident/Accident Log indicated that the resident had a fall on 04/24/13. 2. Incident Report dated 04/24/13 at 12:03 pm indicated, "The resident fell backward in wheel chair while attended by Certified Nursing Assistant (CNA). She has pain in her left shoulder. Resident transported for x-ray. The anti-tip bars at the rear of the w/c was found to be loose and able to rotate allowing the w/c to fall backward." 3. (Name of Hospital) Emergency Department Note indicated, "Patient arrived by w/c via private auto from (name of nursing home). ...fell out of w/c this morning...complains of left upper arm pain. Sent to radiology for x-ray." 4. X-Ray report dated 04/24/13 indicated, "Left Humeral neck fracture (Fx)." 5. Incident Internal Investigation Follow-up Report dated 04/24/13 at 3:57 pm indicated, "Resident had a fall at 12:00 pm today, 04/24/13. She was sent to the hospital for X-rays. She was found to have a Proximal Humerus Fracture of her left arm. She was returned to the facility at 3:30 pm on the same day. Staff are working with her to manage her pain." 6. Physician order [REDACTED]. Give 1-2 tablet as needed. [DIAGNOSES REDACTED]. B. Interviews for resident #5 revealed the following: 1. On 08/08/13 at 11:30 am, during interview, CNA #1 stated, "I was getting her up in the morning. I was using a mechanical lift. When I put her in the w/c, it fell backwards. The little legs that was suppposed to keep the chair from tipping slid to the side causing the chair to fall backwards. She went to the hospital and had a fractured shoulder." 2. On 08/08/13 at 11:40 am, during interview, the Maintenance Director stated, "When this happened (the incident), I just happened to be standing by the nurses station. They (nursing staff) said she had fallen backwards in her chair. I asked if she had anti-tip bars on her w/c. The nurse said that they (anti-tip bars) were on the chair, but they were turned outward. I looked at the chair and the locking buttons were not engaged so the bars were turning outward. Whoever put them on did not ensure that they were clipped in place to secure the legs." 3. On 08/08/13 at 11:50 am, Registered Nurse (RN) #1 stated, "This was an equipment problem. Some of the anti-tip bars on the back of the wheelchairs are not reliable. That's what happens when you have old equipment and try to piece things together. She tipped backwards and broke her humerus. I told maintenance that the bars were twisted. It happened that they were not locked into place."

Based on observation, record review, and interviews the facility failed to ensure 2 (R #1 and R #2) of 2 (R #1 and R #2) residents who were identified at risk for falls, maintained their highest practicable physical, mental, and psychosocial well being. The facility also failed to ensure these residents who were identified to be in the facilities locked Memory Care Alzheimer's Unit remained free from significant accidents. The resident (identified as R #1) was complaining of neck pain, after falling, which resulted in the resident being admitted to the hospital. This resident sustained [REDACTED]. It occurs at the base of the odontoid between the level of the [MEDICATION NAME] ligament (a thick, strong band, which arches across the ring of the atlas-the first cervical vertebrae and the C2 vertebral body) [MEDICAL CONDITION] which now has to be stabilized with a specialized Halo Traction immobilizing mechanism. This resident has experienced pain, and a change in condition which has impacted her daily activities of daily living (ADLs). The resident now has to wear a Halo immobilizer 24/7 and it cannot be taken off to perform her daily activities. Another resident (identified as R #2) was also complaining of neck pain after falling, was sent to the emergency room , and sustained significant bruising to her face. This deficient practice likely caused the residents to experience an adverse outcome in which the resident (R #1) sustained a significant injury to her neck and is complaining of pain, and resident (R #2) sustained significant bruising to her face. The findings are: A. Observations, record review and interviews for resident R #1 revealed the following information: 1. On 07/23/13 at 1:00 pm, R #1 was observed to be asleep in bed wearing a large black padded Halo immobilizer that covered her entire head. 2. On 07/24/13 at 8:05 am, she was observed sitting in the locked memory care unit in a recliner chair with her feet up. She was observed to have a black Halo immobilizer on which had a Velcro strap covering her forehead, and two bars (one on each side of her head) supporting the device. She was observed to not be able to freely turn her head side to side or maneuver around independently. 3. On 07/24/13 at 3:00 pm, she was observed to be laying in bed asleep. She was observed to be wearing the Halo at this time. 4. On 07/25/13 at 7:55 am, she was observed to be sitting in the memory care locked unit at the dining room table. She was observed to be non-interviewable at this time. The Halo immobilizer was observed to be on at this time and preventing the resident from turning her head from side to side. 5. The Face Sheet (no date identified) indicated the resident is [AGE] years old. It further indicated admitting [DIAGNOSES REDACTED]. 6. Comprehensive Care Plan dated 03/06/13 indicated, "Resident has impaired cognitive function/dementia or impaired thought processes related to Alzheimer's evidenced by short term memory loss and disorientation...Resident has impaired visual function." 7. Comprehensive Care Plan dated 04/03/13 indicated, "Resident is at risk for falls related to history of falls." 8. Nursing Dietary Notes dated April 2013 indicated, her weight was only 85 pounds. 9. Quarterly MDS (Minimum Data Set) dated 04/02/13 (before the resident fell and fractured her neck) Take out preceding colored statement. Extraneous information. indicated, the residents "Vision was Moderately Impaired." The MDS indicated the resident (prior to the fall she sustained on 06/21/13) Take out preceding colored statement. Extraneous information. was able to perform her activities of daily living (ADLs) such as bed mobility, transferring, walking in room, and personal hygiene only with limited assistance." 10. Fall Risk Data Collection document dated 06/03/13 and 06/04/13 indicated, the resident was a "High risk for falls...History of falls within last six months...Vision is impaired...Frequently incontinent of urine...The Gait/balance analysis indicated the resident is unable to independently come to a standing position...She requires hands on assistance to move from place to place...She exhibits loss of balance while standing...She uses an assistive device which is a walker." 11. Incident Report dated 06/21/13 indicated, "Resident found laying on the floor in her room on her stomach...No witnesses...Bleeding noted under her face..2x1 lac (laceration) over her left eye and 10 cm (centimeter) skin tear on her left hand and wrist...She c/o (complained of pain)... "I fell down and my head and finger hurts...Level of pain: "Hurts a little more." 12. Nursing Progress Notes dated 06/21/13 indicated, "Resident fell and was found on the floor in her room...Had been using her walker..." Prior to this incident, the nursing notes indicated that the resident was up walking with her front wheeled walker, making her needs known, doing well with no complaints of pain. She was only requiring assistance of one person for ADLs, hugging staff, and was sitting up in the day area. 13. Pain Data Collection document dated 06/21/13 indicated, the resident experienced pain to the face, "Laceration to face, 2x1 cm. At medial (middle) corner of her eyebrow. Left hand 10 cm skin tear back of hand and wrist, unable to approximate. Right hand (back) complained of pain to the right index finger knuckle." 14. Ambulance Run Report dated 06/27/13 indicated, "Trauma-suspicion of fx (fracture)/dislocation... Patient complains of pain in neck (chief complaint). Pt. (patient) has pain in her neck. Assessment indicated pain to neck and C-spine." 15. Hospital emergency room record dated 06/21/13 indicated, "The patient reports bruise laceration pain swelling to the forehead...Pain severity is moderate...Worse with palpitation...(+) bleeding, (+) confusion, (+) contusions, (+) swelling, (+) tenderness...Examination revealed (+) localized spinal tenderness, (+) painful spinal percussion..Pain over neck, tenderness." 16. Hospital History and Physical dated 06/21/13 indicated, "This is a [AGE] year old...with a C1-C2 fracture...She has a partially minimally displaced type 2 odontoid fracture in the C2 body...She is not a surgical candidate..." 17. Hospital Cervical Spine Diagnostic Imaging Report dated 06/21/13 indicated, "[MEDICAL CONDITION] posterior (toward the rear) arch are seen...Impression: Type II odontoid fracture and C1 posterior arch fractures." 18. After the incident on 06/21/13 the nursing notes indicated how uncomfortable she was by pulling at her Halo, complaining of pain, and requiring maximum assistance from staff to do her ADL's." 19. Nursing Admit Re-admit Data Collection Document dated 06/25/13 indicated, "Resident fell and was transported to the hospital for evaluation and they found a C-1 and C-2 fracture...Resident is to wear a nonsurgical Halo at all times...The residents "prior" level of function (prior to the fall on 06/21/13) was that the resident was ambulatory with a FWW (front wheeled walker), she was able to transfer herself with little to no assistance, she was continent of bowel and bladder, she did require assistance of only one staff member with ADLs 20. Nursing Progress Notes indicated the following: a. On 06/26/13, "Her face continues to have bruising that is turning more yellow and is spreading around her left eye and forehead." b. On 06/27/13, "Pt. (patient) c/o (complained of) pain: I don't like this thing (holding brace). My neck hurts..No pain scale but frowning, facial grimacing...Wants to get up and walk, pulling on her brace...Concerns for Halo that has shifted; patient has been pulling and tugging on it, saying it is too tight...Halo was noted to be out of place and bothering resident...Patient was found pulling on Halo this a.m. stating it was too tight and her neck was hurting...During the day, the Halo has moved from original position and it is sitting higher up on forehead, and pushing up into her neck and chin." c. On 06/28/13, "Eyes are bloodshot...Pt. pulling on Halo in different places, says it's too tight...Pt. too weak to stand to walk back to chair...was too weak...Resident has a Halo for her C1 neck fx (fracture)...She has been sitting in a recliner due to her agitation and pulling on her Halo...She c/o discomfort when toileted...c/o pain from halo and neck discomfort. She was c/o of a H/A (headache) and discomfort from the Halo...she was restless tonight...Cannot care for herself...Very weak, able to voice when in pain; is sometimes restless, and anxious. Halo bothers her." d. On 06/29/13, "Stated pain in back, unable to give clear answer...Frequently pulls at Halo straps, sometimes opening 1st layer." e. On 06/30/13, "Pt. c/o head/neck hurting; no pain scale given, but has facial grimacing, and frown on face, tugging on Halo device...Resident states she is experiencing head pain, and would like her Halo traction device removed; still tugging on device and yelling for help." f. On 07/01/13, "If she removed the Halo, she could injure herself and stop breathing, and or die...Pt. cannot bathe, dress, groom or toilet herself...cannot find her own room...c/o leg and head hurting...no pain scale. Frowning, furrowed brow...Up in recliner for dinner and was grimacing." g. On 07/02/13, "Resident crying and trying to remove her Halo...cannot bathe, dress, or groom herself, cannot sit on toilet alone or transfer alone...Not understanding what the brace is for...The staff walk her as far as she will tolerate once a shift, with a two person assist...confused about her brace." h. On 07/04/13, "Halo device must be worn 24 hours a day the rest of her life...she is small, fragile woman with a history of dementia...severe confusion...Pt. c/o neck hurting when taken to the bathroom" i. On 07/05/13, "Resident agitated, tried to get self out of bed, shouting, right leg shaking...Pt. still confused and believes her neck is NOT broken...pulls and tugs on Halo device...c/o neck pain, no pain scale...furrowed brow, facial grimacing." j. On 07/06/13, "C/O neck pain earlier...no pain scale used, but pt. with facial grimacing." k. On 07/07/13, "C/O neck pain..pulling at her Halo and trying to lean sideways in the recliner...Pt. will state her neck hurts...unable to perform ADL's due to fracture neck and Halo device." l. On 07/08/13, "Resident states pain in lower back...unable to give number." m. On 07/09/13, "Resident wearing Halo and is restless tonight. n. On 07/13/13, "Resident restless and c/o neck pain...Trying to get up and down from her chair, is very unstable...unable to redirect...resident complaining of back pain refusing to sit anywhere, states 'It hurts.'" o. On 07/18/13, "Neck pain, head hurts; facial grimace." p. On 07/22/13, "Pt. is "wobbly" in appearance when she walks...pt. tugs on Halo." 21. On 07/23/13 at 1:05 pm, during interview, Licensed Practical Nurse (LPN) #1 stated, "She (referring to R #1) wouldn't be interviewable anyway, because of her advanced dementia and she has a long history of multiple falls." 22. On 07/23/13 at 1:20 pm, the Interim Director of Nursing Services (DNS) stated, "This was a unwitnessed fall. She (referring to R #1) got of bed by herself from what I know. She was found on the floor by the CNA. Early that day, I was told she was up walking up and down the halls. Then she was on the floor with her head against the bed." 23. On 07/23/13 at 2:00 pm, during interview, CNA #1 stated, "I was just coming on the unit. I was only on the locked unit for five minutes and I heard an alarm going off in (name of R #1's) room. The CNA (identified as CNA #2) was yelling for me. She was on the unit by herself. When I walked in (name of R #1's) room, I saw her on the floor. She was laying about two feet away from her bed. She was laying face down and there was blood coming from around her face. It was a lot of blood coming from above her left eye. I noticed she also had a very large skin tear on her right arm." 24. On 07/23/13 at 2:40 pm, during interview, Registered Nurse (RN) #1 stated, "I was working on the 100 Station A unit that day. At the time of this incident, the nurse (identified as RN #2) was out here on Station A. She got a phone call saying that the resident fell . She (name of R #1) was ambulatory walking with a walker prior to this. She does have Alzheimer's. Cognitively, I think she can she express herself. You really have to observe her though." 25. On 07/23/13 at 3:45 pm, during interview, CNA #2 stated, "At the time of the incident, (referring to 06/21/13) I was working by myself on that unit. I was setting up for dinner around 4:30 pm. I was getting everyone up by myself, and also handing out juices. (Name of R #1) walked up to me with her walker saying she wanted to go lay down. I told her we will eat dinner soon. She said 'I really want to go lay down.' She was walking at this time with her walker. So, I took her to her room and helped her to bed. Then after laying her down, I went back into the dining room and starting passing out juices to the residents....I heard an alarm going off in (name of R #1's) room. She was laying face down on the floor. She was face down with her legs behind her. I noticed some blood. The resident was saying 'My neck really hurts'. Prior to this incident, the resident was able to walk by herself with a walker." 26. On 07/24/13 at 8:40 am, during interview, RN #3 stated, "I just got report the next morning 06/22/13 that she (R #1) was in the hospital. I was told she had a C-1 neck fracture. She was ambulatory with a walker off and on prior to the fall. She had really poor safety awareness. She was ambulating independently at her usual baseline." 27. On 07/24/13 at 9:00 am, during interview, RN #2 stated, "I had only one CNA who was scheduled back on the locked unit that day. I walked in and the resident was flat on her stomach with her head turned to the right. She had a laceration to her inner eyebrow. It was bleeding like crazy. I was having trouble getting the bleeding stopped. It was almost dinner time. Around 5:00 pm, or so, I was out on Station A making phone calls and the CNA (identified as CNA #2) called me from the locked unit saying the resident just threw up. Since she fell , I thought she now had a head injury. I wanted to get her evaluated because she fell from standing up. I'm sure she hit her head. The next day I came in, I found out she had a fracture, a neck fracture. I thought she had a head injury with cranial pressure because she threw up. She has had previous falls. The problem is, this is an Alzheimer's unit and people don't remember that they can't walk. You can't have enough staff to do 1:1. She wants the Halo off. She doesn't like it. When she starts pulling at it, I know she is in pain." 28. On 07/24/13 at 10:30 am, during interview, the Administrator stated, "On a memory unit, there are people with Alzheimer, Dementia, and confusion. I was hearing concerns from the CNAs such as 'I had to work alone last night on the unit' I said, that should never happen." 29. On 07/24/13 at 3:00 pm, during interview, RN #1 stated, "The Halo immobilizer that she wears is basically an apparatus she wears from the ribs to the top of head. We can't remove it at all. She has to wear is 24/7." 30. On 07/24/13 at 3:45 pm, during interview, Family member #1 of R #1 stated, "She (referring to R #1) was complaining of pain in her neck saying 'My neck hurts. My neck hurts.' They found at the hospital that she had a broken vertebrae. She also had a gash on her forehead. When all of this happened, it really made me wonder as far as what really happened. I had no idea. All I was told, was that she was laying down and decided to get up. When she got to this hospital she kept complaining of pain to her neck. She is blind in both eyes, she is deaf, and she has Alzheimer's and on top of this, now this has happened. Now she has to wear this Halo device for twelve weeks. It has been rubbing sores on her everywhere because of the brace." 31. On 07/24/13 at 4:45 pm, during interview, the facility Medical Director Physician stated, "She is pretty debilitated, she has dementia and is very hard of hearing, nearly blind and tends to get up by herself. With this fall, she sustained a [MEDICAL CONDITION] and second vertebral bodies. It is considered an unstable fracture. Now, she cannot get up by herself without assistance. Prior to this, she was up walking with a walker and she had some falls, but nothing like this... ." B. Observations, record review and interviews for resident R #2 revealed the following information: 1. On 07/24/13 at 8:05 am, observation of the resident revealed her to be sitting in the locked memory care unit dining room. She was observed to have a very large dark bruise on the left side of her face. It extended from the top of her left eyelid, down the bridge of her nose and across her entire cheekbone. 2. On 07/24/13 at 12:30 pm, a second observation was made. The resident was seen sitting in the locked memory care unit at the dining table in a wheelchair. Again, with a very dark purple bruise to her face 3. Face Sheet (not dated) indicated, [DIAGNOSES REDACTED]. 4. Comprehensive Care Plan dated 02/22/13 indicated the resident has impaired cognitive function/dementia or impaired thought processes related to dementia...The resident has limited physical mobility related to weakness...Resident is at risk for falls related to a history or falls." 5. Fall Risk evaluation documents dated 06/04/13, 06/24/13, 07/17/13, and on 07/18/13 indicated, that the resident is at a high risk for falls. It further indicated, "Resident has [MEDICAL CONDITION] and has fallen several times since she had been here. She doesn't realize that she can't walk and needs to use a wheelchair. She had a walker for a while but she forgot it most of the time." 6. Incident Report dated 06/04/13 indicated, "Resident got up out of her wheelchair...and she fell ...Level of pain: 'Hurts a little'" 7. Incident Report dated 07/17/13 indicated, "I (referring to RN #1) was assisting (name of CNA #3) with another resident...and (name of CNA #4) returned from lunch and saw (name of R #2) on the floor...Resident replied, "My back hurts, and when your back hurts, everything hurts...Resident states pain in back." 8. Incident Report dated 07/18/13 indicated, "Summoned to dining/activity area of Alzheimer's unit; aides say they heard a cup fall, found patient on floor. Patient laying on right side with obvious bruising and small cut to left side of forehead. Patient complained of pain in neck, and left leg...Patient could not give reason/details of fall...was taken to the hospital...Level of pain: 'Hurts even more.' 9. Ambulance Run Report dated 07/18/13 indicated, "Patient fell out of her chair and has contusions (an injury in which the skin is not broken; bruise) to her left eye and cheek...Primary Impression: Pain...Bruising to face...Large contusion to patient eye and cheek." 10. Hospital emergency room record dated 07/18/13 indicated, "Patient presents with a complaint of fall. The patient reports abrasion to the left face." 11. Hospital Discharge Report dated 07/18/13 indicated, "Your [DIAGNOSES REDACTED]." 12. Nursing Notes indicated the following incidents where the resident was complaining of pain and having significant bruising: a. On 07/18/13, "Resident appears to be experiencing some pain related to fall this a.m...breathing guarded, agitated." b. On 07/21/13, "Healing laceration to left face at eye level, ecchymotic (bruising) areas around left eye and area of Zygomatic arch (the formation on each side of the cheeks)." 13. On 07/25/13 at 11:00 am, during interview (regarding the incident that occurred on 06/04/13) CNA #2 stated, "I was in a room with another resident getting her ready for bed. I was not there to witness it. I was working by myself on the locked unit. I came out of the room I was in, and (Name of R #2) was on the floor by her wheelchair. She had a skin tear. One other resident was behind her trying to help her up. I had to go call the nurse who was on the other unit." 14. On 07/25/13 at 11:15 am, during interview (regarding the fall that occurred on 07/17/13) CNA #3 stated, "I was helping the nurse with another resident in her room. We were with that resident for at least thirty minutes. The other CNA (identified as CNA #4) walked in the unit and found (name of R #2) on the floor. The other CNA, (CNA #4) was at lunch and not on the unit at the time." 15. On 07/25/13 at 11:28 am, during interview (regarding the fall that occurred on 07/17/13) CNA #4 stated, "I was at lunch at the time this happened and I came back and I saw feet going up. When I went around the corner, a resident was holding (name of R #2's) hand to calm her down from her fall and to ease her down to the floor. The next day when I came on at 2:00 pm, (name of R #2) came back from the hospital and she had a lot of bruising to her face." 16. On 07/25/13 at 12:30 pm, during interview (regarding the fall that occurred on 07/18/13) CNA #5 stated, "I heard a loud noise and I looked out of the room I was in and (name of R #2) was on the floor...She was saying her neck hurt. I could see a large bump on her eye right above her eye brow. She was already starting to bruise on her face. She was saying 'my face hurts'. Her face at this time was showing a really big black eye and bruising to her face. No-one saw her fall or how she fell and she was not able to tell us." 17. On 07/25/13 at 1:55 pm, during interview RN #1 stated, (regarding the incident that occurred on 07/17/13), "She (referring to R #2) was found on the floor. (Name of CNA #4) was not on the unit and was coming in from her lunch and found her on the floor. I don't know how she fell . She was not able to tell us what happened. I was in a residents room with a CNA helping her to the bathroom and the other CNA was at lunch."

Based on observation, record review, and interviews the facility failed to ensure there was adequate staffing supervision in the facilities locked Memory Care Alzheimer's Unit to ensure 2 (R #1 and R#2 ) of 2 (R #1 and R #2) residents who were identified as being a very high risk for falls, remained free from accidents. The resident (identified as R #1) was complaining of neck pain, after falling, which resulted in the resident being admitted to the hospital. This resident sustained [REDACTED]. It occurs at the base of the odontoid between the level of the transverse ligament and the C2 vertebral body) fracture of the neck which now has to be stabilized with a specialized Halo Traction (a ring with points that make contact with the skull around the head circumference, with the intention of immobilizing the entire head and neck region) immobilizing mechanism. Another resident (identified as R #2) was also complaining of neck pain after falling, was sent to the emergency room , and sustained significant bruising to her face. This deficient practice likely caused the residents to experience an adverse outcome in which the resident (R #1) sustained a significant injury to her neck and resident (R #2) sustained significant bruising to her face. The findings are: A. Record review and interviews for resident R #1 revealed the following information: 1. The Face Sheet (no date identified) indicated the resident is [AGE] years old. It further indicated admitting [DIAGNOSES REDACTED]. 2. Physician orders [REDACTED]." 3. Comprehensive Care Plan dated 03/06/13 indicated, "Resident has impaired cognitive function/dementia or impaired thought processes related to Alzheimer's evidenced by short term memory loss and disorientation...Resident has impaired visual function." 4. Comprehensive Care Plan dated 04/03/13 indicated, "Resident is at risk for falls related to history of falls." 5. Quarterly MDS (Minimum Data Set) dated 04/02/13 indicated, the residents "Vision was Moderately Impaired." It further indicated that the resident could not recall any words such as the correct year, month, or day of the week to determine mental status. The MDS indicated the resident (prior to the fall she sustained on 06/21/13) was able to perform her activities of daily living (ADLs) such as bed mobility, transferring, walking in room, and personal hygiene only with limited assistance." 6. Fall Risk Data Collection document dated 06/03/13 indicated, the resident was a "High risk for falls...History of falls within last six months...Vision is impaired...Frequently incontinent of urine...The Gait/balance analysis indicated the resident is unable to independently come to a standing position...She requires hands on assistance to move from place to place...She exhibits loss of balance while standing...She uses an assistive device which is a walker." 7. Incident Report dated 06/03/13 indicated, "Resident yelling for help. CNA (Certified Nursing Assistant) found resident in sitting position on top of floor mat next to bed...denies hitting head...resident stated she needed to use the restroom...Mental status was disoriented, confused, impaired memory, gait balance, impaired vision, and weakness." 8. Fall Risk Data Collection document dated 06/04/13 also indicated the resident was a "Very high risk for falls." 9. Second Incident Report dated 06/21/13 indicated, "Resident (identified as R #1) found laying on the floor in her room on her stomach...No witnesses...Bleeding noted under her face..2x1 lac (laceration) over her left eye and 10 cm (centimeter) skin tear on her left hand and wrist...She c/o (complained of pain)... "I fell down and my head and finger hurts...Level of pain: "Hurts a little more." 10. Nursing Progress Notes dated 06/21/13 indicated, "Resident fell and was found on the floor in her room...Had been using her walker..." Prior to this incident, the nursing notes indicated that the resident was up walking with her front wheeled walker, making her needs known, doing well with no complaints of pain. She was only requiring assistance of one person for ADLs, hugging staff, and was sitting up in the day area. 11. Pain Data Collection document dated 06/21/13 indicated, the resident experienced pain to the face, "Laceration to face, 2x1 cm. At medial (middle) corner of her eyebrow. Left hand 10 cm skin tear back of hand and wrist, unable to approximate. Right hand (back) complained of pain to the right index finger knuckle." 12. Fall Risk Data Collection document dated 06/21/13 indicated "Recent Fall...The resident experienced a suspected blow to the head...Neurochecks should be conducted...Resident had a fracture related to fall...The resident has had falls since admission...Resident is a High risk for falls." 13. Nursing Admit Re-admit Data Collection Document dated 06/25/13 indicated, "Resident fell and was transported to the hospital for evaluation and they found a C-1 and C-2 fracture...Resident is to wear a nonsurgical Halo at all times...The residents "prior" level of function (prior to the fall on 06/21/13) was that the resident was ambulatory with a FWW (front wheeled walker), she was able to transfer herself with little to no assistance, she was continent of bowel and bladder, she did require assistance of only one staff member with ADLs." 14. Ambulance Run Report dated 06/27/13 indicated, "Trauma-suspicion of fx (fracture)/dislocation... Patient complains of pain in neck (chief complaint). Pt. (patient) has pain in her neck. Assessment indicated pain to neck and C-spine." 15. Hospital emergency room record dated 06/21/13 indicated, "The patient reports bruise laceration pain swelling to the forehead...Pain severity is moderate...Worse with palpitation...(+) bleeding, (+) confusion, (+) contusions, (+) swelling, (+) tenderness...Examination revealed (+) localized spinal tenderness, (+) painful spinal percussion..Pain over neck, tenderness." 16. Hospital History and Physical dated 06/21/13 indicated, "This is a [AGE] year old...with a C1-C2 fracture...She has a partially minimally displaced type 2 odontoid fracture in the C2 body...She is not a surgical candidate..." 17. Hospital Cervical Spine Diagnostic Imaging Report dated 06/21/13 indicated, "Fracture of the C1 posterior (toward the rear) arch are seen...Impression: Type II odontoid fracture and C1 posterior arch fractures." 18. On 07/23/13 at 1:05 pm, during interview, Licensed Practical Nurse (LPN) #1 stated, "She (referring to R #1) wouldn't be interviewable anyway, because of her advanced dementia and she has a long history of multiple falls." 19. On 07/23/13 at 1:20 pm, during interview, the Interim Director of Nursing Services (DNS) stated, "This was a unwitnessed fall. She (referring to R #1) got of bed by herself from what I know. She was found on the floor by the CNA. Early that day, I was told she was up walking up and down the halls. Then she was on the floor with her head against the bed...She started to complain about her neck hurting so she was sent out. The CNA was the one who found her on the floor. At this time of the incident, we were only running a nurse and a aide on our locked unit. The nurse works on the locked unit and unit A. I was aware that she (name of R #1) has had falls before but this is the first one with significant injuries." 20. On 07/23/13 at 2:00 pm, during interview, CNA #1 stated, "I was just coming on the unit. I was only on the locked unit for five minutes and I heard an alarm going off in (name of R #1's) room. The CNA (identified as CNA #2) was yelling for me. She was on the unit by herself. When I walked in (name of R #1's) room, I saw her on the floor. She was laying about two feet away from her bed. She was laying face down and there was blood coming from around her face. It was a lot of blood coming from above her left eye. I had to come out of the locked unit to the other unit (Station A) to get the nurse. We then got her back in bed using a bath blanket. I noticed she also had a very large skin tear on her right arm. After all this, the nurse just said to listen for the bed alarm. I went back to doing my med pass. I came back out onto Station A and stayed on that unit. There was supposed to be two staff members at all times on the locked unit, but there has been a lot of shortage. There has only been one staff member. Many times, they will pull someone from another unit to come work that unit. On that particular day (referring to 06/21/13) we were short on all halls. The CNA (referring to CNA #2) was back there by herself. There has been a shortage of staff within the last couple of months. Even before (name of R #1) fell , there were times where there was only one staff." 21. On 07/23/13 at 2:40 pm, during interview, Registered Nurse (RN) #1 stated, "I was working on the A unit that day. At the time of this incident, the nurse (identified as RN #2) was out here on Station A. She got a phone call saying that the resident (identified as R #1) fell . The night of this incident, there was only one CNA on that locked unit. She (name of R #1) was ambulatory walking with a walker prior to this. She does have Alzheimer's." 22. On 07/23/13 at 3:45 pm, during interview, CNA #2 stated, "For the last month, I have been working on the locked unit by myself. Staffing has been a problem. At the time of the incident, (referring to 06/21/13) I was working by myself on that unit. There was no other CNA. Right before dinner, I was setting up for dinner around 4:30 pm. I was getting everyone up by myself, and also handing out juices. (Name of R #1) walked up to me with her walker saying she wanted to go lay down. I told her we will eat dinner soon. She said 'I really want to go lay down.' She was walking at this time with her walker. So, I took her to her room and helped her to bed. Then after laying her down, I went back into the dining room and starting passing out juices to the residents. Then, the med tech came back to the unit. She was only on the unit about four minutes. I heard an alarm going off in (name of R #1's) room. She was laying face down on the floor. She was face down with her legs behind her. I noticed some blood. I yelled for the med tech to call the nurse who was not on the unit but who was on Station A unit. Before this time, I was alone on the unit. The nurse (identified as RN #2) came in and said "Oh dear." Me and the med tech put the resident up in sitting position. The resident was saying 'My neck really hurts'. After this, both the med tech and the nurse left me alone on the unit. I went to go get people ready for dinner. So, I went to pass trays. I went back to check on the resident and she was trying to get up out of bed saying my neck hurts. This was about 5:30 pm. So, I sat her in a geri chair and wheeled her in the geri chair to the dining room. She took some sips of a healthshake and she said 'I don't feel good' and then threw up. I called the nurse again who was not on the locked unit and said the resident was now throwing up. When I told the nurse the resident had thrown up, the nurse came back to the locked unit. After the incident, I was left alone to care for the other fourteen residents by myself. Prior to this incident, the resident was able to walk by herself with a walker. I was on the unit alone many times. No-one was there to watch everyone. There was no staff there on the locked unit besides me to ensure the safety of those residents. I feel like I was thrown in a boat with no bottom and told to sink or swim. The only way to communicate with a nurse was to punch in the code to the other unit and yell down the hall saying I need help." 23. On 07/24/13 at 8:40 am, during interview, RN #3 stated, "I just got report the next morning 06/22/13 that she (R #1) was in the hospital. I was told she had a C-1 neck fracture. She was ambulatory with a walker off and on prior to the fall. She had really poor safety awareness. She was ambulating independently at her usual baseline. With a head laceration, it bleeds a lot...before this incident occurred, it was supposed to be two people on that locked unit at all times. In my opinion, I don't believe that with the acuity level of the residents on the locked unit, I don't think it is feasible for only one aide to give adequate care to residents." 24. On 07/24/13 at 9:00 am, during interview, RN #2 stated, "I had only one CNA who was scheduled back on the locked unit. At around 4:30 pm, I had to come out to the other unit, Station A to take care of six residents, then I have the whole 300 hall as well. It was 4:45 pm, when the med tech (identified as CNA #1) stepped out and said (name of R #1) fell . I walked in and the resident was flat on her stomach with her head turned to the right. She had a laceration to her inner eyebrow. It was bleeding like crazy. I was having trouble getting the bleeding stopped. It was almost dinner time. Around 5:00 pm, or so, I was out on Station A making phone calls and the CNA (identified as CNA #2) called me from the locked unit saying the resident just threw up. Since she fell , I thought she now had a head injury. I wanted to get her evaluated because she fell from standing up. I'm sure she hit her head. The next day I came in, I found out she has a fracture, a neck fracture. I thought she had a head injury with cranial pressure because she threw up. She has had previous falls. The problem is, this is an Alzheimer's unit and people don't remember that they can't walk. It's not a safe place with people with behaviors with one person back there is not safe. Everyone including Administration is aware of it." 25. On 07/24/13 at 10:30 am, during interview, the Administrator stated, "Prior to the incident, there was always supposed to be two people back there on the locked unit at all times. Our policy is to always have two people back there at all times. I can't say with full assurance that there were always two people back there on the locked unit...On a memory unit, there are people with Alzheimer, Dementia, and confusion. I was hearing concerns from the CNAs such as 'I had to work alone last night on the unit' I said, that should never happen." 26. On 07/24/13 at 3:45 pm, during interview, Family member #1 of R #1 stated, "She (referring to R #1) was complaining of pain in her neck saying 'My neck hurts. My neck hurts.' They found at the hospital that she had a broken vertebrae. She also had a gash on her forehead. When all of this happened, it really made me wonder as far as what really happened. I had no idea. All I was told, was that she was laying down and decided to get up. When she got to this hospital she kept complaining of pain to her neck. She is blind in both eyes, she is deaf, and she has Alzheimer's and on top of this, now this has happened. When I do visit her, it doesn't seem like there is very many staff in the locked unit. She can make her needs known and she can say that she hurts a lot. The night she was in the hospital, she was saying that her neck hurt. Now she has to wear this Halo device twelve weeks. It has been rubbing sores on her everywhere because of the brace." 27. On 07/24/13 at 4:45 pm, during interview, the facility Medical Director Physician stated, "She Who is she? is pretty debilitated, she has dementia and is very hard of hearing, nearly blind and tends to get up by herself. With this fall, she sustained a fracture of the first and second vertebral bodies. It is considered an unstable fracture. Now, she cannot get up by herself without assistance. Prior to this, she was up walking with a walker and she had some falls, but nothing like this." B. Record review and interviews for resident #2 revealed the following information: 1. Face Sheet (not dated) indicated, [DIAGNOSES REDACTED]. 2. Comprehensive Care Plan dated 02/22/13 indicated the resident has impaired cognitive function/dementia or impaired thought processes related to dementia...The resident has limited physical mobility related to weakness...Resident is at risk for falls related to a history or falls." 3. Fall Risk evaluation documents dated 06/04/13, 06/24/13, 07/17/13, and on 07/18/13 indicated, that the resident is at a high risk for falls. It further indicated, "Resident has Alzheimer's disease and has fallen several times since she had been here. She doesn't realize that she can't walk and needs to use a wheelchair. She had a walker for a while but she forgot it most of the time." 4. Incident Report dated 06/04/13 indicated, "Resident got up out of her wheelchair...and she fell ...Level of pain: 'Hurts a little'" 5. Facility Investigation Report dated 06/04/13 (regarding the fall on 06/04/13) indicated, "Be sure two CNAs are on the unit (referring to the locked Alzheimer's unit). Make sure there are enough people to watch the unit carefully. Result of the investigation indicated that there was only one CNA on unit at the time the resident fell ." 6. Incident Report dated 07/17/13 indicated, "I (referring to RN #1) was assisting (name of CNA #3) with another resident...and (name of CNA #4) returned from lunch and saw (name of R #2) on the floor...Resident replied, "My back hurts, and when your back hurts, everything hurts...Resident states pain in back." 7. Incident Report dated 07/18/13 indicated, "Summoned to dining/activity area of Alzheimer's unit; aides say they heard a cup fall, found patient on floor. Patient laying on right side with obvious bruising and small cut to left side of forehead. Patient complained of pain in neck, and left leg...Patient could not give reason/details of fall...was taken to the hospital...Level of pain: 'Hurts even more' 8. Ambulance Run Report dated 07/18/13 indicated, "Patient fell out of her chair and has contusions (an injury in which the skin is not broken; bruise) to her left eye and cheek...Primary Impression: Pain...Bruising to face...Large contusion to patient eye and cheek." 9. Hospital emergency room record dated 07/18/13 indicated, "Patient presents with a complaint of fall. The patient reports abrasion to the left face." 10. Hospital Discharge Report dated 07/18/13 indicated, "Your [DIAGNOSES REDACTED]." 11. On 07/25/13 at 11:00 am, during interview (regarding the incident that occurred on 06/04/13) CNA #2 stated, "I was in a room with another resident getting her ready for bed. I was not there to witness it. There was no other staff working with me on the unit at that time. I was working by myself on the locked unit. I came out of the room I was in, and (Name of R #2) was on the floor by her wheelchair. She had a skin tear. One other resident was behind her trying to help her up. I had to go call the nurse who was on the other unit." 12. On 07/25/13 at 11:15 am, during interview (regarding the fall that occurred on 07/17/13) CNA #3 stated, "I was helping the nurse with another resident in her room. We were with that resident for at least thirty minutes. The other CNA (identified as CNA #4) walked in the unit and found (name of R #2) on the floor. The other CNA (CNA #4) was at lunch and not on the unit at the time. When they are short staffed on the locked unit, they pull me from another unit to go work back there." 13. On 07/25/13 at 11:28 am, during interview, (regarding the fall that occurred on 07/17/13) CNA #4 stated, "I was at lunch at the time this happened and I came back and I saw feet going up. When I went around the corner, a resident was holding (name of R #2's) hand to calm her down from her fall and to ease her down to the floor. The next day when I came on at 2:00 pm, (name of R #2) came back from the hospital and she had a lot of bruising to her face." 14. On 07/25/13 at 12:30 pm, during interview (regarding the fall that occurred on 07/18/13) CNA #5 stated, "An orientee and another CNA (who was not identified) went into one residents room to get them up and I was in another residents room. The nurse was on the other unit Station A. The nurse was not on the unit at the time. I heard a loud noise and I looked out of the room I was in and (name of R #2) was on the floor...She was saying her neck hurt. I could see a large bump on her eye right above her eye brow. She was already starting to bruise on her face. She was saying 'my face hurts'. Her face at this time was showing a really big black eye and bruising to her face. No-one saw her fall or how she fell and she was not able to tell us. There were problems with short staffing on the locked unit. There was not always a nurse on the unit. The nurse would be up front on station A. A few times we were short staffed with just one person meaning just one CNA on the unit, and times when I have had to work by myself on the locked unit." 15. On 07/25/13 at 1:55 pm, during interview RN #1 stated, (regarding the incident that occurred on 07/17/13), "She (referring to R #2) was found on the floor. (Name of CNA #4) was not on the unit and was coming in from her lunch and found her on the floor. I don't know how she fell . She was not able to tell us what happened. I was in a residents room with a CNA helping her to the bathroom and the other CNA was at lunch." C. Review of the Facilities Policy and Procedure regarding "Fallen or Injured Resident" revised 10/08 indicated, "Monitor the resident's condition and the effectiveness of the interventions put in place to prevent further falls."

Based on record review and interview, the facility failed ensure sufficient staffing on the locked Memory care unit was available for 2 (R#s 1 and 2) of 5 (#s 1, 2, 3, 4 and 5) residents. This deficient practice likely caused 2 residents (R #1 and 2) to sustain injuries which may have been avoided if more than one staff member was working on the the unit. The findings are: A. Review of the Staffing Guidelines revised May 2008 revealed: "Two staff members should be on the unit at all times in case a resident requires one-to-one attention." B. Review of the staffing schedule for June 8, 2013 - June 30, 2013 revealed the following: 1. On 06/14/13, 06/16/13, 06/21/13, 06/22/13, 06/24/13, 06/25/13, 06/26/13, 06/27/13 and 06/28/13 there was one full time Certified Nursing Assistant (CNA) scheduled to work the day shift (6:00 am - 2:00 pm); one Licensed Nurse whose time was divided between the locked unit and unit A. Also scheduled was a Certified Medication Aide (CMA) who was scheduled for a twelve hour shift (6:00 am - 6:30 pm) whose time was divided between the locked unit and unit A. 2. On 06/13/13, 06/15/13, 06/16/13, 06/18/13, 06/19/13, 06/20/13, 06/21/13, 06/24/13, 06/25/13, 06/26/13, 06/27/13 and 06/28/13 there was one full time Certified Nursing Assistant (CNA) scheduled to work the evening shift (2:00 pm - 10:00 pm); one Licensed Nurse whose time was divided between the locked unit and hall A. Also scheduled was a Certified Medication Aide (CMA) who was scheduled for a twelve hour shift (6:00 am - 6:30 pm) whose time was divided between the locked unit and unit A. 3. The schedule for July 2013 indicated that on 07/05/13, 07/11/13 and 07/12/13, two CNAs were on the schedule to work for the evening shift (2:00 pm - 10:00 pm). One of the CNAs name had a circle around it which indicated that one of the CNAs did not report to work (as per the DON on 07/23/13 at 5:30 pm). 4. There was no documentation to indicate that the locked unit was staffed with two CNAs on these days. C. Interviews regarding the staffing revealed the following information: 1. On 07/23/13 at 1:15 pm, during interview, the Assistant Director of Nursing Service (ADSN) stated, "We are supposed to staff two CNAs back there (locked unit) at all times...that has always been our policy... ." 2. On 07/23/13 at 1:20 pm, during interview, the Interim Director of Nursing Service (DNS) stated, "I didn't feel one aide and a nurse who was in and out of the unit was sufficient...I made some changes. The changes made were to move a nurse into the unit full time and have a minimum of two staff back there (on locked unit) at all times. It wasn't staffed with two that day (day of the incident)...The nurse was not on the unit that day, and there was only one CNA. There was some serious deficits. There was suppose to be two CNAs..." 3. On 07/23/13 at 2:00 pm, during interview, Certified Medication Aide (CMA) #1 stated "I entered the unit with my med cart around 4:00 pm and heard an alarm. I heard (Name of CNA #2) yelling. When I got back there (to resident R #1's room), I saw her (R#1) laying on the floor. (Name of CNA #2) was on the unit alone. I went out to the unit A station to get (Name of Registered Nurse (RN) #2). After that, I came out of the locked unit at 4:30 pm to go to unit A to do med pass, I stayed on the A unit. I did not go back to the locked unit. There is supposed to be two CNAs at all times but there has been a lot of shortage. There has only been one CNA. The CNA worked back there by herself the day this occurred (day of incident). Before (Name of R #1) fell , there were times where there was only one staff on the locked unit." 4. On 07/23/13 at 2:40 pm, during interview, RN #1 stated "At the time of the incident, there was no nurse in the locked unit. "The nurse that works memory care (locked unit) also works on unit A. At that time (time of incident), both nurses were out here (unit A) out of the locked unit. We would go periodically on memory care (locked unit). That night (name of RN #2) was at nurses station A. There was only one CNA working the night of the incident. With the acuity level of the residents it is not feasible to have one CNA on that unit." 5. On 07/23/13 at 3:45 pm, during interview, CNA #2 stated "For the last month, I have been working on the unit by myself. Getting staff for that unit is a problem. I was working by myself on that unit that evening (referring to 06/21/13). I get really frustrated with it. Before the Med Tech/CMA came back there, I was alone on the unit. The med tech went and got the nurse. The med tech left, and the nurse both left. After the incident, I was left alone again to care for the other fourteen residents by myself. I was on the unit many times alone. When I had to toilet someone, no-one was there to watch everyone. Since I was alone, I put them (residents) in front of the TV in the dining room. I have asked for help. I tried everything. The nurse said 'We'll do our best. Stop badgering me.' I don't feel like I can my job effectively. I have to set up dining room, pass out trays, clean up after dinner, do three activities, and do my work as well. I feel like I was thrown in a boat with no bottom and told to sink or swim. I've asked for help from anyone who would listen. The only way to communicate with a nurse was to punch in the code (to enter/exit the locked unit) and yell down the hall saying I need help. Out of the eight hours maybe the nurse would spend 5 minutes back there (locked unit) to pass med's. There is no way to get a hold of anyone. The CMA may spend 25-30 minutes to pass out med's. The rest of the seven hours I'm by myself." 6. On 07/24/13 at 8:40 am, during interview, RN #3 stated, "Even before the incident, there was supposed to be two people on the locked unit at all times. It can be an aide and a nurse, or med aide; a minimum of two people, on days and evenings." When asked 'Have there been days when you've had to work with one CNA? the nurse stated "Yes, when I was on evenings, a few months ago." When asked "In your professional opinion with the acuity level of the residents, is it feasible for one CNA to give adequate care to all of the residents? The nurse stated "Not with this population....I would say no. They need two (CNAs) due to the poor safety awareness of the residents. One CNA is not enough." 7. On 07/24/13 at 9:00 am, during interview, RN #2 stated, "I come in at 2:00 pm. On the day of the incident (referring to 06/21/13), I stayed back there until I got report. At 4:30 pm, I have to come out to the other unit (Station A) to take care of the residents. (Name of R#1) fell about 4:45 pm. When I went back to the unit, I had only one CNA scheduled. (Name of CNA #2) was scheduled on that unit. There was a Med Tech/CMA. She works on both halls too. (locked unit and unit A). She had 3:00 pm meds to give back there. She usually is back there from 2:50 pm to 3:00 pm. I came out (to unit A) to re-start medications at 4:30 pm. The CMA had stepped off the unit too. She was not on the unit when (Name of R#1) fell . There were several incidents over the past several months where we didn't have two people back there. We only had one. After the Med Techs leave around 7:00 pm, basically there would be only one CNA...I would stay back there as much as possible, but it's difficult because I had as many people on unit A as I had on the locked unit to care for. I average 30 patients between the two units. It is very difficult to get the work done with one CNA....Sometimes, I feel like I have to be in one place and I'm in another place. It's a Alzheimer's unit. People back there can't remember that they can't walk. Because I work both units, I rely heavily on the CNA....We have some people with very unpredictable mood swings and who are aggressive. I don't want someone getting boxed into a corner. It's not safe for one person to be back there with people with behaviors." 8. On 07/24/13 at 10:30 am, during interview, the Administrator stated, "Our Policy is to always have two people back there at all times... Prior to the incident (referring to 06/21/13) there were always supposed to be two people back there...I've been here since 04/24/13 and then I started to say 'You guys make sure there are at least two people back there.' I think there was a shortage of staff...I can't say with full assurance there were always two people back there...When there was a shortage in staff, our previous DNS had the responsibility of calling people in. I don't think she did it. I never want one person back there...I was hearing concerns from one CNA saying "I had to work alone last night on the unit.' I said 'That should never happen.' The day she (R#1) fell , the CNA told me she worked alone by herself." 9. On 07/24/13 at 12:08 pm, during interview, CMA #2 stated "I work 6:00 am - 6:30 pm. I cover the locked unit and as well as unit A. I spend about an hour on the locked unit for morning meds and about one hour for evening meds...There is usually about 16 resident back there. Most of my time is spent out on unit A...My job is mainly to pass meds... Ten of my hours are spent out on the Unit A. The nurse that works back there covers two units too." 10. On 07/24/13 at 3:45 pm, during phone interview, when asked if she had any concerns about staff, Family Member #1 of R #1 stated, "It doesn't seem like there is very many staff in the locked unit when I'm there to visit."

Based on record review and interviews the facility failed to ensure 1 (R #1) of 1 (R #1) residents was properly assessed after having fallen forward out of her wheelchair, landing on her knees, and sustaining injuries in the facility van when the van was moving. The resident was complaining of pain, was moved by staff without first being assessed for injuries, and continued to be transported on the floor of the van back to the nursing home. The resident sustained [REDACTED]. This deficient practice likely caused the resident to experience an adverse outcome in which the resident sustained [REDACTED]. A. Medical Record review identified: 1. Face Sheet dated 11/18/11 indicated [DIAGNOSES REDACTED]. 2. Falls Data Collection Tool (no date) indicated the resident was a high risk for falls. 3. Pain Data Collection Tool (no date) indicated the resident expresses pain by "Vocal expressions with movement saying 'Oh ow, ow, ow'...has facial grimaces by distorted expressions...braces herself by grabbing at her blankets and gripping tightly...verbal complaints 'Ouch, oh this hurts...Characteristics of pain: Stabbing, aching, throbbing and burning." 4. Initial Interdisciplinary Data Collection Tool dated 02/05/13 indicated the resident weighed 216.0 pounds, was oriented to person, place, and time and was non weight bearing. 5. The MDS (Minimum Data Set) dated 01/28/13 indicated the resident had a short term memory problem and her Cognitive skills for daily decision making was modified independence...She required extensive assistance with Activities of daily living (ADL) for bed mobility, transfers, dressing, toilet use, and personal hygiene. 6. Daily Skilled Notes dated 02/07/13 indicated at 6:00 am, the resident was "Alert and oriented and in a very good mood smiling and laughing with staff." 7. Daily Skilled Notes dated 02/07/13 indicated at 8:30 pm, "During transport, resident slipped out of her wheelchair onto the van floor when the brakes were applied at a traffic stop. Pain to the right hip. RLE (right lower extremity) appeared to have an abnormal rotation or deformity (a deviation from the normal shape or size). Vital signs: BP (blood pressure) was 160/100, Pulse was 60 and irregular." 8. Daily Skilled Notes from 02/16/13 through 02/25/13 indicated, "Medicated for pain per orders, pain decreased but not completely relieved...Resident is in extreme pain with movement...Has been in her room and bed bound all shift with a Bledsoe (a name of a specific type of leg brace) brace on her left lower extremity...Resident has not been eating well...Refused to get out of bed when it was attempted...Refused to get out of bed...She states that she is to afraid to get out of bed...Poor appetite...Admits anxiety about condition...Continues with poor appetite." 9. Fax Communication to Physician document dated 02/07/13 indicated, "(name of R #1) slipped out of her wheelchair onto the floor of the van during transport back to the facility. Fall resulted in a Fx (fracture) of right hip." 10. A facility Incident Report dated 02/07/13 at 7:00 pm indicated, "Alleged Nature of Incident: Slipped or fell to floor of van, legs wedged against partician. Slipped out of wheelchair during transport...Part of body allegedly injured: Right hip and Right knee...Pain to the right hip..." 11. A Written statement dated 02/07/13 by the Human Resource Director (who was also identified as the driver of the facility transportation van) indicated, "At approximately 5:30 pm,...I told her (name of Licensed Practical Nurse (LPN) #1) I would go get (name of R #1) from the hospital...I began to brake and slow the van down...I had not yet come to a complete stop when I heard a 'thud' and heard (name of R #1) cry out...I came to a complete stop and saw (name of Certified Nursing Assistant (CNA #1)) on the floor with the resident...I then pulled the vehicle over to the side of the road...(name of R #1) was sitting upright on the floor of the van...She kept saying 'My leg hurts'...she was sitting directly beneath the wheelchair...(name of CNA #1) and I tried to lift her but we were unable to do so...I made the decision to continue the transport...I drove back to the facility with (name of CNA #1) sitting next to (name of R #1)...When we arrived (name of LPN #1) entered the van and she, (name of CNA #1) and I tried to lift (name of R #1) into the chair but were not successful...Another nurse (identified as Registered Nurse (RN) #1) was called to assist...Once out of the van, (name of RN #1), (name of LPN #1) and CNA were unable to use the lift machine to lift (name of R #1) from her wheelchair into her bed...Due to her weight they were unable to get a sling (a type of device used to transfer someone) under her...(name of RN #1) made decision to call 911..." 13. A written document provided by the Administrator dated 02/07/13 as part of the facility Investigation indicated, "On February 7th...while stopping at a stop light, (name of Human Resources Director) heard resident "cry out" once he came to a complete stop, he turned around and saw resident and CNA on the floor...He pulled over and he and the CNA were unable to lift (name of R #1) back into her wheelchair...At that time, he continued the drive back to the nursing home..." 14. Facility Investigation Interview (no date) conducted with CNA #1 indicated, "How did it happen? CNA #1 responded by stating, 'Not sure. Seat belt came unbuckled.'...Asked (name of Human Resources Director) 'why me?' because I had never had (name of R #1) as a resident and I had never been on transport. I've never had to transport with a resident. I wasn't sure if I had done everything right as far as buckling (name of R #1) in...Did seatbelt come unbuckled? I did notice when she (the resident) fell , that the buckle was undone." 15. A written statement dated 02/07/13 by CNA #1 indicated, "Once in the back of the van, I hooked the hook's by the wheels, and put the seat belt around the resident. I have never done a transport, and wasn't sure if I was doing it right, but I heard a click so I thought the resident was securely in her seat...We were coming up to the last light out of town and I heard the resident kind of moaning...I noticed the seat belt was no longer together..." 16. A written statement (no date) by RN #1 indicated, "(name of R #1s) legs were against the partician and bent to the side...She was breathing very heavily...She only cried in pain when we moved her...She did say 'it hurt like hell.'" 17. Admitting Hospital History and Physical dated 02/07/13 indicated, "On 02/07/13 she was discharged back to (name of the nursing facility)...When she was...sitting up in the wheelchair, somehow the wheelchair was dislodged while she was in and she fell and has significant injuries...In the Emergency Department, she was found to have a right-sided hip fracture and also left tibial plateau fracture...Currently the patient does complain of a lot of pain...She mainly complains of pain in her hip...General Appearance: Appears to be in distress (mental or physical suffering or anguish) due to pain...she has significant pain on mild movement of right lower extremity." 18. Admitting Hospital Departmental Report dated 02/07/13 indicated, "In the transport, she (referring to R #1) was sitting up in her wheelchair, the wheelchair somehow became dislodged and she fell , resulting in a right hip fracture and a left tibial plateau fracture....She was taken to the operating room on 02/10/13 for repair of her right hip." 19. emergency room record dated 02/07/13 indicated "Pt. (patient) reportedly was injured when her wheelchair dislodged from the securing device in the (name of facility) wheelchair van. Pt. reportedly slid striking her knee and right hand...The patient complains of bilateral (pertaining to both sides) knee pain from a wheelchair accident...Patient describes the pain as a 6/10 (on a scale of 1 to 10 with 10 being the highest level of pain)...The patient reports bruise deformity (a major difference in the shape of a body part) discoloration, pain, and swelling to the left lower leg. There is/are also bruises and pain and swelling on the right lower leg and pain on the left hip...The pain is characterized as: aching...The mechanism of injury was: fall from wheelchair." 20. Orthopedic Consultation record dated 02/07/13 indicated, "The patient...sustained injuries to bilateral (pertaining to both sides) lower extremities last night when she fell from a wheelchair while being transported to the nursing facility...The patient reports pain at the right hip and left knee. The pain at the hip is a sharp pain...Physical examination reveals Bilateral Upper extremities: There are multiple bruises present...Right Lower Extremity: She holds it in a shortened rotated position...She has tenderness at the thigh...Pain with log rolling...Multiple imaging views of the right hip demonstrate a displaced fracture at the intertrochanteric (area between the greater and lesser trochanters of the femur) region with severe osteoarthritis of the right hip...X-rays of the left tibia (the inner and larger bone of the leg between the knee and ankle) and fibula (smaller bone of the leg from the ankle to the knee) reveal irregularity at the proximal (nearest to the point of attachment) tibial metaphysis (the growth zone during development of a bone) consistent with possible tibial plateau fracture...CT (computed tomography) scan of the left knee...demonstrates impacted fracture (a fracture in which the jagged ends of the broken bone are wedged together) of the tibial plateau. Impression: Right femoral fracture, left tibial plateau fracture, nondisplaced. 21. Physician admission orders Non weight bearing to LLE (lower left extremity)...Rehab Potential...is poor." 22. Physician Documentation note dated 02/17/13 indicated, "On the way back fell out of WC (wheelchair) sustained Rt. (right) femoral neck fracture, also fracture tibial plateau..." 23. physician progress notes [REDACTED]. "Appetite is down...Plan is up in Hoyer lift....Change Hydrocodone to Oxycodone 5 mg (milligrams) 2 tabs (tablets) po (by mouth) q (every) 4 hours prn (as needed) for pain...Lt. (left) tibial plateau fracture, Rt. (right) hip fracture..." B. Interviews identified: 1. On 02/26/13 at 1:00 pm, during interview, R #1 stated, "I broke a hip and both of my legs got hurt really bad...I really don't care to talk about it...It was something I don't want to remember...There were two people, a man and a woman...They never put the seat belt across me that I can remember...The man driver took a curve and my chair flew out with me in it and I fell hard onto my knees...I told them as I was laying there like a pretzel 'you have to help me'... He stopped the van and they both tried to help me get up but they couldn't...I came all the way back to the nursing home and then I had to go back to the hospital...I spent nine more days there and I had to have hip surgery...I was sitting in my wheelchair when I was in the van and I don't remember anyone putting the brakes on my wheelchair...I don't know if the brakes were on or not...Before all this happened, I was able to get myself around in my wheelchair and I could use my arms...I just don't want to talk about this anymore...I'm really upset this has happened to me." 2. On 02/26/13 at 1:30 pm, during interview the Administrator stated, "At around 7:30 pm, I got a call saying she (referring to R #1) fell in the van...The driver moved to the side of the road and he and the CNA tried to lift the resident back into her wheelchair...That is something that states in our falls policy, is that you do not move a resident without first being assessed...As soon as she fell , 911 should have been called...We identified this as poor judgement on part of our staff...The RN who did assess her had felt something was wrong with her hip and decided to send her back to the hospital...The family had only been notified by the hospital earlier that morning that her mother was going to be discharged back here to the nursing home on 02/07/13...In my opinion, the nurse didn't want to call the family saying, 'Um your mom just fell in the van, but she's ok' so they held off until they assessed her and 911 had been called...The daughter had walked in the nursing home that evening and was handed the phone...She (the residents daughter) was not notified until she got here to the nursing home later that night of what happened to her mother...The daughter was very upset." 3. On 02/26/13 at 2:00 pm, during interview, the Human Resource Director stated, "(name of CNA #1) secured the two restraints on the wheelchair from behind and I secured the two in the front...The CNA was seated in front of the resident with her back to the resident...Before the intersection, I heard a 'thud' and I pulled forward to stop the van...When I turned around, she (the resident) was on the van floor...She was on her left side with her legs bent...We (referring to the HR Director and CNA #1) tried to pick her up but she was to heavy for us...I got behind her and basically tried to lift her and the CNA was in front...She was just way to heavy...There was no way the two of us would be able to lift her...So, I drove back to the nursing home and she was on the floor...(Name of CNA #1) was next to her..." 4. On 02/26/13 at 2:40 pm, during interview, CNA #1 stated, "I didn't know much about her (referring to R #1)...I worked on a different unit...She wasn't my resident...I was asked by (name of HR Director) to go on the transport and I was thinking 'why me'...I had never gone on a transport before...I never got any training on transporting a resident...When we got her into the van, I asked the driver (referring to the HR Director) 'How do we get these hooks loose? I wasn't even aware of how to work the latches to hook them to her wheelchair...He told me 'push the red button' so I did and it came loose...At this point, he had to show me how they went on...It was already dark by this time and I thought I heard the seat belt click so I assumed the seat belt was secured...I was seated in front of her (the resident) and she was behind me in her wheelchair...As I turned to check on her I could see she was slouching down in her chair...I heard her fall directly out of her wheelchair..She fell on her knees...I scooted her to her bottom and she was leaning against me with her back...She hit her legs on the metal part of the van...She was saying that her knee was hurting a lot...I honestly don't know if the seat belt got loose...I didn't see the seat belt still attached when she fell forward so I don't know if it came undone or not...I had to move her a little bit so I could try to get underneath her...The driver then pulled over and we both had to move her around because her legs were bent...He got behind her and I was in front and we tried to move her but we couldn't...He drove back to the nursing home while I was trying to hold her up on the floor of the van...Once we got to the nursing home, it took four people to get her up and she was complaining of pain." 5. On 02/26/13 at 3:00 pm, during interview, LPN #1 stated, "At around 5:00 pm on 02/07/13, I got a call from the ER (emergency room ) nurse that we needed to make arrangements to transport her (referring to R #1) back to the nursing home so (name of HR Director) volunteered to go with a CNA....At around 7:05 pm, he (the HR Director) called me saying 'there was a problem and the resident slipped out of her wheelchair but that she was ok...I met him at the front entrance of the nursing home...When I saw her, the CNA was trying to support the residents upper torso and her (the resident) legs were up against the partician of the van...She had verbal complaints of knee and leg pain...We did a four person manual lift on her and put her back into her wheelchair...(name of RN #1) knew how to support her legs and because of her level of pain that she was expressing, we were not able to get a sling (device used to lift a person) under her body to safely move her to her bed so we had to call 911 to send her back to the hospital..." 6. On 02/27/13 at 9:00 am, during interview, the Social Services Director stated, "When I was told what happened to the resident, I feel like I was just thrown into all of this...I was asking the staff who called the family? I was the one who gave the family member a heads up as to what happened with the resident falling in the van...Prior to this, no-one had even called the family...I think perhaps people were intimidated by the family member and they just were afraid to tell her...She (the family member of R #1) actually arrived here at the facility later that evening, not knowing what happened and someone had just handed her the telephone and that is when I was the one to tell her what happened...She was very upset...Understandably, she was asking how long ago did this even happen to her mother and why wasn't she called right away? It would have definitely been my expectation for the staff to notify the family immediately of an incident...The staff should have notified her immediately, but I don't believe that was ever done." 7. On 02/27/13 at 9:30 am, during interview RN #2 stated, "I think she has declined significantly...She used to get up in her wheelchair and go to the dining room for meals...Now she is refusing and not wanting to get up...She now has an immobilizer (a type of leg brace) in place for her broken leg and she is not wanting to do much any more...She used to enjoy activities such as bingo which was her favorite, but now, nothing." 8. On 02/27/13 at 11:45 am, during interview, the Staff Development Coordinator stated, "It would have been up to the van driver to ensure all the locks were on and working. Not the CNA." 9. On 02/27/13 at 12:00 noon, the Physical Therapist stated, "She (the resident) was refusing to walk a lot of times...She was primarily non ambulatory without the use of a machine...The CNAs couldn't handle her safely without a machine...Once in her wheelchair though, she could get around by herself...She could lock the brakes herself...She was very alert and she knows her decision making...I think now, with all that has happened to her, she has declined significantly...She liked going to bingo and the outings they had here...She ate in the dining room every day and could get herself from her room to the dining room...Cognitively, she is very alert and she knows what she wants and she know this is her home..." 10. On 02/27/13 at 1:00 pm during interview the family member of R #1 stated, "The issue is, they were transporting her (referring to R #1) back from the emergency room . I last talked to my mom at 5:30 pm on February 7th and I told her I would be in the nursing home later that night to check in on her. She said 'Ok' and I heard nothing from the nursing home at all in between. At 9:00 pm, I got to the nursing home and one nurse met me at the door and looked at me and said 'something is really wrong'. I said what's wrong? That nurse told me, 'I can't believe you don't know' so we went towards the Human Resource office and someone was on the phone who said 'this is her daughter.' So, I got on the phone and the Social Services Director was on the other end of the phone and she told me that my mother had slid out of her wheelchair onto the van floor on the way back from the hospital...She didn't have any explanation and I didn't get a lot of information...When they brought my mother back to the nursing home I was being told that the staff got her off the van floor and put her in the wheelchair and brought her in but that she needed to go back to hospital...When I got there to the nursing home at 9:00 pm, she was already in the emergency room and was in being seen in imaging...My mother told me they we driving and came to a light and he (referring to the human resources director) pushed on the brakes, and she felt like she was going around a curve...She said that the driver put on the brakes and she flew out of her wheel chair and landed very hard...I don't understand why they didn't just stop and call 911 right then and there...That was my biggest concern and why wasn't I notified immediately...So, when I got back to the nursing home later that evening, not even knowing what happened, my mother had already been taken back to the emergency room ...She had a right broken hip and a left tibia and fibula fracture of the left leg...The following morning she had to have surgery on her hip and a brace placed on her left leg...I was never notified when this happened...I was made aware at 9:00 pm that night when I went to the facility and by then, she was already taken back to the ER." 11. On 02/27/13 at 2:15 pm during interview RN #1 stated, "When this happened, LPN #1 came and got me...When I saw her (the resident) in the van, she was on the floor...The CNA was behind her and the residents legs were turned...She (the resident) was complaining of shortness of breath and complaining of pain...When I assessed her she said 'I hurt everywhere'...her legs were bent back and she did have pain...she was able to verbalize her pain to me...It took four people to get her back in the wheelchair...Once we brought her inside, I was still supporting her legs and she was in a lot of pain...I said to call 911 because of the pain she was having...I could feel something wasn't quite right with her leg and her hip area...I can't say for sure what it was but due to her pain in that area I said we need to send her out." C. Review of the Facility "Fallen or Injured Resident" Procedure revised 10/12/12 indicated, "Procedure: Do not move the resident...Take the resident's blood pressure, pulse and respirations to help assess the resident's condition...The charge nurse needs to observe the resident and perform a full body exam to determine if there may be suspected fracture and direct whether to move the resident...Do not attempt to move the resident if hip fracture is suspected..."

Based on record review and interviews the facility failed to ensure 1 (R #1) of 1 (R #1) residents was properly assessed after having fallen forward out of her wheelchair, landing on her knees, and sustaining injuries in the facility van when the van was moving. The resident was complaining of pain, was moved by staff without first being assessed for injuries, and continued to be transported on the floor of the van back to the nursing home. The resident sustained [REDACTED]. This deficient practice likely caused the resident to experience an adverse outcome in which the resident sustained [REDACTED]. A. Medical Record review identified: 1. Face Sheet dated 11/18/11 indicated [DIAGNOSES REDACTED]. 2. Falls Data Collection Tool (no date) indicated the resident was a high risk for falls. 3. Pain Data Collection Tool (no date) indicated the resident expresses pain by "Vocal expressions with movement saying 'Oh ow, ow, ow'...has facial grimaces by distorted expressions...braces herself by grabbing at her blankets and gripping tightly...verbal complaints 'Ouch, oh this hurts...Characteristics of pain: Stabbing, aching, throbbing and burning." 4. Initial Interdisciplinary Data Collection Tool dated 02/05/13 indicated the resident weighed 216.0 pounds, was oriented to person, place, and time and was non weight bearing. 5. The MDS (Minimum Data Set) dated 01/28/13 indicated the resident had a short term memory problem and her Cognitive skills for daily decision making was modified independence...She required extensive assistance with Activities of daily living (ADL) for bed mobility, transfers, dressing, toilet use, and personal hygiene. 6. Daily Skilled Notes dated 02/07/13 indicated at 6:00 am, the resident was "Alert and oriented and in a very good mood smiling and laughing with staff." 7. Daily Skilled Notes dated 02/07/13 indicated at 8:30 pm, "During transport, resident slipped out of her wheelchair onto the van floor when the brakes were applied at a traffic stop. Pain to the right hip. RLE (right lower extremity) appeared to have an abnormal rotation or deformity (a deviation from the normal shape or size). Vital signs: BP (blood pressure) was 160/100, Pulse was 60 and irregular." 8. Daily Skilled Notes from 02/16/13 through 02/25/13 indicated, "Medicated for pain per orders, pain decreased but not completely relieved...Resident is in extreme pain with movement...Has been in her room and bed bound all shift with a Bledsoe (a name of a specific type of leg brace) brace on her left lower extremity...Resident has not been eating well...Refused to get out of bed when it was attempted...Refused to get out of bed...She states that she is to afraid to get out of bed...Poor appetite...Admits anxiety about condition...Continues with poor appetite." 9. Fax Communication to Physician document dated 02/07/13 indicated, "(name of R #1) slipped out of her wheelchair onto the floor of the van during transport back to the facility. Fall resulted in a Fx (fracture) of right hip." 10. A facility Incident Report dated 02/07/13 at 7:00 pm indicated, "Alleged Nature of Incident: Slipped or fell to floor of van, legs wedged against partician. Slipped out of wheelchair during transport...Part of body allegedly injured: Right hip and Right knee...Pain to the right hip..." 11. A Written statement dated 02/07/13 by the Human Resource Director (who was also identified as the driver of the facility transportation van) indicated, "At approximately 5:30 pm,...I told her (name of Licensed Practical Nurse (LPN) #1) I would go get (name of R #1) from the hospital...I began to brake and slow the van down...I had not yet come to a complete stop when I heard a 'thud' and heard (name of R #1) cry out...I came to a complete stop and saw (name of Certified Nursing Assistant (CNA #1)) on the floor with the resident...I then pulled the vehicle over to the side of the road...(name of R #1) was sitting upright on the floor of the van...She kept saying 'My leg hurts'...she was sitting directly beneath the wheelchair...(name of CNA #1) and I tried to lift her but we were unable to do so...I made the decision to continue the transport...I drove back to the facility with (name of CNA #1) sitting next to (name of R #1)...When we arrived (name of LPN #1) entered the van and she, (name of CNA #1) and I tried to lift (name of R #1) into the chair but were not successful...Another nurse (identified as Registered Nurse (RN) #1) was called to assist...Once out of the van, (name of RN #1), (name of LPN #1) and CNA were unable to use the lift machine to lift (name of R #1) from her wheelchair into her bed...Due to her weight they were unable to get a sling (a type of device used to transfer someone) under her...(name of RN #1) made decision to call 911..." 13. A written document provided by the Administrator dated 02/07/13 as part of the facility Investigation indicated, "On February 7th...while stopping at a stop light, (name of Human Resources Director) heard resident "cry out" once he came to a complete stop, he turned around and saw resident and CNA on the floor...He pulled over and he and the CNA were unable to lift (name of R #1) back into her wheelchair...At that time, he continued the drive back to the nursing home..." 14. Facility Investigation Interview (no date) conducted with CNA #1 indicated, "How did it happen? CNA #1 responded by stating, 'Not sure. Seat belt came unbuckled.'...Asked (name of Human Resources Director) 'why me?' because I had never had (name of R #1) as a resident and I had never been on transport. I've never had to transport with a resident. I wasn't sure if I had done everything right as far as buckling (name of R #1) in...Did seatbelt come unbuckled? I did notice when she (the resident) fell , that the buckle was undone." 15. A written statement dated 02/07/13 by CNA #1 indicated, "Once in the back of the van, I hooked the hook's by the wheels, and put the seat belt around the resident. I have never done a transport, and wasn't sure if I was doing it right, but I heard a click so I thought the resident was securely in her seat...We were coming up to the last light out of town and I heard the resident kind of moaning...I noticed the seat belt was no longer together..." 16. A written statement (no date) by RN #1 indicated, "(name of R #1s) legs were against the partician and bent to the side...She was breathing very heavily...She only cried in pain when we moved her...She did say 'it hurt like hell.'" 17. Admitting Hospital History and Physical dated 02/07/13 indicated, "On 02/07/13 she was discharged back to (name of the nursing facility)...When she was...sitting up in the wheelchair, somehow the wheelchair was dislodged while she was in and she fell and has significant injuries...In the Emergency Department, she was found to have a right-sided hip fracture and also left tibial plateau fracture...Currently the patient does complain of a lot of pain...She mainly complains of pain in her hip...General Appearance: Appears to be in distress (mental or physical suffering or anguish) due to pain...she has significant pain on mild movement of right lower extremity." 18. Admitting Hospital Departmental Report dated 02/07/13 indicated, "In the transport, she (referring to R #1) was sitting up in her wheelchair, the wheelchair somehow became dislodged and she fell , resulting in a right hip fracture and a left tibial plateau fracture....She was taken to the operating room on 02/10/13 for repair of her right hip." 19. emergency room record dated 02/07/13 indicated "Pt. (patient) reportedly was injured when her wheelchair dislodged from the securing device in the (name of facility) wheelchair van. Pt. reportedly slid striking her knee and right hand...The patient complains of bilateral (pertaining to both sides) knee pain from a wheelchair accident...Patient describes the pain as a 6/10 (on a scale of 1 to 10 with 10 being the highest level of pain)...The patient reports bruise deformity (a major difference in the shape of a body part) discoloration, pain, and swelling to the left lower leg. There is/are also bruises and pain and swelling on the right lower leg and pain on the left hip...The pain is characterized as: aching...The mechanism of injury was: fall from wheelchair." 20. Orthopedic Consultation record dated 02/07/13 indicated, "The patient...sustained injuries to bilateral (pertaining to both sides) lower extremities last night when she fell from a wheelchair while being transported to the nursing facility...The patient reports pain at the right hip and left knee. The pain at the hip is a sharp pain...Physical examination reveals Bilateral Upper extremities: There are multiple bruises present...Right Lower Extremity: She holds it in a shortened rotated position...She has tenderness at the thigh...Pain with log rolling...Multiple imaging views of the right hip demonstrate a displaced fracture at the intertrochanteric (area between the greater and lesser trochanters of the femur) region with severe osteoarthritis of the right hip...X-rays of the left tibia (the inner and larger bone of the leg between the knee and ankle) and fibula (smaller bone of the leg from the ankle to the knee) reveal irregularity at the proximal (nearest to the point of attachment) tibial metaphysis (the growth zone during development of a bone) consistent with possible tibial plateau fracture...CT (computed tomography) scan of the left knee...demonstrates impacted fracture (a fracture in which the jagged ends of the broken bone are wedged together) of the tibial plateau. Impression: Right femoral fracture, left tibial plateau fracture, nondisplaced. 21. Physician admission orders Non weight bearing to LLE (lower left extremity)...Rehab Potential...is poor." 22. Physician Documentation note dated 02/17/13 indicated, "On the way back fell out of WC (wheelchair) sustained Rt. (right) femoral neck fracture, also fracture tibial plateau..." 23. physician progress notes [REDACTED]. "Appetite is down...Plan is up in Hoyer lift....Change Hydrocodone to Oxycodone 5 mg (milligrams) 2 tabs (tablets) po (by mouth) q (every) 4 hours prn (as needed) for pain...Lt. (left) tibial plateau fracture, Rt. (right) hip fracture..." B. Interviews identified: 1. On 02/26/13 at 1:00 pm, during interview, R #1 stated, "I broke a hip and both of my legs got hurt really bad...I really don't care to talk about it...It was something I don't want to remember...There were two people, a man and a woman...They never put the seat belt across me that I can remember...The man driver took a curve and my chair flew out with me in it and I fell hard onto my knees...I told them as I was laying there like a pretzel 'you have to help me'... He stopped the van and they both tried to help me get up but they couldn't...I came all the way back to the nursing home and then I had to go back to the hospital...I spent nine more days there and I had to have hip surgery...I was sitting in my wheelchair when I was in the van and I don't remember anyone putting the brakes on my wheelchair...I don't know if the brakes were on or not...Before all this happened, I was able to get myself around in my wheelchair and I could use my arms...I just don't want to talk about this anymore...I'm really upset this has happened to me." 2. On 02/26/13 at 1:30 pm, during interview the Administrator stated, "At around 7:30 pm, I got a call saying she (referring to R #1) fell in the van...The driver moved to the side of the road and he and the CNA tried to lift the resident back into her wheelchair...That is something that states in our falls policy, is that you do not move a resident without first being assessed...As soon as she fell , 911 should have been called...We identified this as poor judgement on part of our staff...The RN who did assess her had felt something was wrong with her hip and decided to send her back to the hospital...The family had only been notified by the hospital earlier that morning that her mother was going to be discharged back here to the nursing home on 02/07/13...In my opinion, the nurse didn't want to call the family saying, 'Um your mom just fell in the van, but she's ok' so they held off until they assessed her and 911 had been called...The daughter had walked in the nursing home that evening and was handed the phone...She (the residents daughter) was not notified until she got here to the nursing home later that night of what happened to her mother...The daughter was very upset." 3. On 02/26/13 at 2:00 pm, during interview, the Human Resource Director stated, "(name of CNA #1) secured the two restraints on the wheelchair from behind and I secured the two in the front...The CNA was seated in front of the resident with her back to the resident...Before the intersection, I heard a 'thud' and I pulled forward to stop the van...When I turned around, she (the resident) was on the van floor...She was on her left side with her legs bent...We (referring to the HR Director and CNA #1) tried to pick her up but she was to heavy for us...I got behind her and basically tried to lift her and the CNA was in front...She was just way to heavy...There was no way the two of us would be able to lift her...So, I drove back to the nursing home and she was on the floor...(Name of CNA #1) was next to her..." 4. On 02/26/13 at 2:40 pm, during interview, CNA #1 stated, "I didn't know much about her (referring to R #1)...I worked on a different unit...She wasn't my resident...I was asked by (name of HR Director) to go on the transport and I was thinking 'why me'...I had never gone on a transport before...I never got any training on transporting a resident...When we got her into the van, I asked the driver (referring to the HR Director) 'How do we get these hooks loose? I wasn't even aware of how to work the latches to hook them to her wheelchair...He told me 'push the red button' so I did and it came loose...At this point, he had to show me how they went on...It was already dark by this time and I thought I heard the seat belt click so I assumed the seat belt was secured...I was seated in front of her (the resident) and she was behind me in her wheelchair...As I turned to check on her I could see she was slouching down in her chair...I heard her fall directly out of her wheelchair..She fell on her knees...I scooted her to her bottom and she was leaning against me with her back...She hit her legs on the metal part of the van...She was saying that her knee was hurting a lot...I honestly don't know if the seat belt got loose...I didn't see the seat belt still attached when she fell forward so I don't know if it came undone or not...I had to move her a little bit so I could try to get underneath her...The driver then pulled over and we both had to move her around because her legs were bent...He got behind her and I was in front and we tried to move her but we couldn't...He drove back to the nursing home while I was trying to hold her up on the floor of the van...Once we got to the nursing home, it took four people to get her up and she was complaining of pain." 5. On 02/26/13 at 3:00 pm, during interview, LPN #1 stated, "At around 5:00 pm on 02/07/13, I got a call from the ER (emergency room ) nurse that we needed to make arrangements to transport her (referring to R #1) back to the nursing home so (name of HR Director) volunteered to go with a CNA....At around 7:05 pm, he (the HR Director) called me saying 'there was a problem and the resident slipped out of her wheelchair but that she was ok...I met him at the front entrance of the nursing home...When I saw her, the CNA was trying to support the residents upper torso and her (the resident) legs were up against the partician of the van...She had verbal complaints of knee and leg pain...We did a four person manual lift on her and put her back into her wheelchair...(name of RN #1) knew how to support her legs and because of her level of pain that she was expressing, we were not able to get a sling (device used to lift a person) under her body to safely move her to her bed so we had to call 911 to send her back to the hospital..." 6. On 02/27/13 at 9:00 am, during interview, the Social Services Director stated, "When I was told what happened to the resident, I feel like I was just thrown into all of this...I was asking the staff who called the family? I was the one who gave the family member a heads up as to what happened with the resident falling in the van...Prior to this, no-one had even called the family...I think perhaps people were intimidated by the family member and they just were afraid to tell her...She (the family member of R #1) actually arrived here at the facility later that evening, not knowing what happened and someone had just handed her the telephone and that is when I was the one to tell her what happened...She was very upset...Understandably, she was asking how long ago did this even happen to her mother and why wasn't she called right away? It would have definitely been my expectation for the staff to notify the family immediately of an incident...The staff should have notified her immediately, but I don't believe that was ever done." 7. On 02/27/13 at 9:30 am, during interview RN #2 stated, "I think she has declined significantly...She used to get up in her wheelchair and go to the dining room for meals...Now she is refusing and not wanting to get up...She now has an immobilizer (a type of leg brace) in place for her broken leg and she is not wanting to do much any more...She used to enjoy activities such as bingo which was her favorite, but now, nothing." 8. On 02/27/13 at 11:45 am, during interview, the Staff Development Coordinator stated, "It would have been up to the van driver to ensure all the locks were on and working. Not the CNA." 9. On 02/27/13 at 12:00 noon, the Physical Therapist stated, "She (the resident) was refusing to walk a lot of times...She was primarily non ambulatory without the use of a machine...The CNAs couldn't handle her safely without a machine...Once in her wheelchair though, she could get around by herself...She could lock the brakes herself...She was very alert and she knows her decision making...I think now, with all that has happened to her, she has declined significantly...She liked going to bingo and the outings they had here...She ate in the dining room every day and could get herself from her room to the dining room...Cognitively, she is very alert and she knows what she wants and she know this is her home..." 10. On 02/27/13 at 1:00 pm during interview the family member of R #1 stated, "The issue is, they were transporting her (referring to R #1) back from the emergency room . I last talked to my mom at 5:30 pm on February 7th and I told her I would be in the nursing home later that night to check in on her. She said 'Ok' and I heard nothing from the nursing home at all in between. At 9:00 pm, I got to the nursing home and one nurse met me at the door and looked at me and said 'something is really wrong'. I said what's wrong? That nurse told me, 'I can't believe you don't know' so we went towards the Human Resource office and someone was on the phone who said 'this is her daughter.' So, I got on the phone and the Social Services Director was on the other end of the phone and she told me that my mother had slid out of her wheelchair onto the van floor on the way back from the hospital...She didn't have any explanation and I didn't get a lot of information...When they brought my mother back to the nursing home I was being told that the staff got her off the van floor and put her in the wheelchair and brought her in but that she needed to go back to hospital...When I got there to the nursing home at 9:00 pm, she was already in the emergency room and was in being seen in imaging...My mother told me they we driving and came to a light and he (referring to the human resources director) pushed on the brakes, and she felt like she was going around a curve...She said that the driver put on the brakes and she flew out of her wheel chair and landed very hard...I don't understand why they didn't just stop and call 911 right then and there...That was my biggest concern and why wasn't I notified immediately...So, when I got back to the nursing home later that evening, not even knowing what happened, my mother had already been taken back to the emergency room ...She had a right broken hip and a left tibia and fibula fracture of the left leg...The following morning she had to have surgery on her hip and a brace placed on her left leg...I was never notified when this happened...I was made aware at 9:00 pm that night when I went to the facility and by then, she was already taken back to the ER." 11. On 02/27/13 at 2:15 pm during interview RN #1 stated, "When this happened, LPN #1 came and got me...When I saw her (the resident) in the van, she was on the floor...The CNA was behind her and the residents legs were turned...She (the resident) was complaining of shortness of breath and complaining of pain...When I assessed her she said 'I hurt everywhere'...her legs were bent back and she did have pain...she was able to verbalize her pain to me...It took four people to get her back in the wheelchair...Once we brought her inside, I was still supporting her legs and she was in a lot of pain...I said to call 911 because of the pain she was having...I could feel something wasn't quite right with her leg and her hip area...I can't say for sure what it was but due to her pain in that area I said we need to send her out." C. Review of the Facility "Fallen or Injured Resident" Procedure revised 10/12/12 indicated, "Procedure: Do not move the resident...Take the resident's blood pressure, pulse and respirations to help assess the resident's condition...The charge nurse needs to observe the resident and perform a full body exam to determine if there may be suspected fracture and direct whether to move the resident...Do not attempt to move the resident if hip fracture is suspected..."