Every finding on record at Big Spring Center for Skilled Care

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments in accordance with State and Federal laws for 1 of 1 nursing carts (Nurse Cart A) reviewed for medication storage. The facility failed to ensure Nurse Cart A was locked when unattended. This failure could place residents at risk of medication errors or drug diversion. The findings included: During an observation on 08/12/26 at 9:20 AM, Nurse Cart A was observed by the nursing station unlocked and unattended. No staff members were observed within eyesight of the medication cart, and several residents were sitting in the common area within eyesight of the medication cart. Medications were observed in the Nurse's Cart. During an interview on 08/12/26 at 9:23 AM, the ADON stated Nurse Cart A was not her cart, but she got the cart locked anyways. During an interview on 08/12/26 at 9:28 AM, RN A stated she forgot to lock her cart when she was called to the secure unit because the CNA was leaving. RN A stated she had been trained to lock her cart when not in use but did not know the last time she was trained. RN A stated a potential negative outcome to the residents was that they could get into the medications and take something that was not theirs. During an interview on 08/12/26 at 2:02 PM, the DON stated she expected the nurses to lock their carts when they were unattended. The DON stated RN A had been trained on locking the cart when unattended and had copies of in-services that were provided to RN A. The DON stated RN A told her she had no excuses for leaving Nurse Cart A unlocked and unattended. The DON stated a potential risk to the residents was someone could have gotten in there and taken anything. Record review of the facility document titled, In-Service: Locking Medication/Nurse Carts, dated April 2026 reflected the following: Topic: Medication/Nurse Cart SecurityPurpose: To remind all nurses and medication aides of the importance of keeping medication and nurse carts locked and secured whenever they are unattended. Why Is This Important?Medication Carts contain medications and supplies that must be protected from unauthorized access. An unlocked and unattended cart can allow a resident, visitor, or another unauthorized person to access medications. This can result in:-Medications errors-Accidental ingestion-Injury to a resident-Medication diversion-Loss of resident safety-Disciplinary actionBasic Rules:All nurses and medication aides are expected to:.-Lock the cart every time they step away from it-Make sure the cart is actually locked before walking away.RememberEven if you are only stepping away for a minute, the cart must be locked.RN A's signature was noted on the Attendance Roster.Record review of the facility document titled, In-Service: Locking Medication/Nurse Carts, dated June 2026 reflected the following: Topic: Medication/Nurse Cart SecurityPurpose: To remind all nurses and medication aides of the importance of keeping medication and nurse carts locked and secured whenever they are unattended. Why Is This Important?Medication Carts contain medications and supplies that must be protected from unauthorized access. An unlocked and unattended cart can allow a resident, visitor, or another unauthorized person to access medications. This can result in:-Medications errors-Accidental ingestion-Injury to a resident-Medication diversion-Loss of resident safety-Disciplinary actionBasic Rules:All nurses and medication aides are expected to:.-Lock the cart every time they step away from it-Make sure the cart is actually locked before walking away.RememberEven if you are only stepping away for a minute, the cart must be locked.RN A's signature was noted on the Attendance Roster.Record review of the facility policy titled, Medication Storage in the Facility, undated, reflected the following: Policy: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedure:.2. Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications.are allowed unsupervised access to medications. Medications rooms, carts and medications supplies are locked or attended to by persons with authorized access.

Based on observations, interviews, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 4 of 21 residents rooms reviewed for food safety (room [ROOM NUMBER]-1, 309-1, 311-1, and 316-1). 1. The facility did not have a system in place to assist residents in cleaning and maintaining their personal refrigerators to ensure safe food handling and prevent consumption of spoiled and/or expired foods.2. The facility did not have a system in place to ensure the refrigerators were monitored for internal Time Temperature Controlled for Safety cold foods were at 41 F or below.These failures could place residents at risk for food borne illnesses.Findings include:room [ROOM NUMBER]-1 During an observation on 4/22/26 at 10:34 AM, Resident room [ROOM NUMBER]-1 contained a personal refrigerator. The refrigerator contained food items such as five bottles of grape and strawberry jelly, one jar of peanut butter, two jars of swirled peanut butter and jelly, six cans of soda, one bottle of mayonnaise, one tub of sour cream, a jar of pickles, and ten bottles of water. The thermometer inside the refrigerator indicated an internal temperature of 42 F. A temperature log was not located on or around the refrigerator.During an observation on 4/23/26 at 10:50 AM, Resident room [ROOM NUMBER]-1 contained a personal refrigerator. The refrigerator still contained food items such as five bottles of grape and strawberry jelly, one jar of peanut butter, two jars of swirled peanut butter and jelly, six cans of soda, one bottle of mayonnaise, one tub of sour cream, a jar of pickles, and ten bottles of water. The thermometer inside the refrigerator indicated an internal temperature of 42 F. A temperature log was not located on or around the refrigerator.room [ROOM NUMBER]-1During an observation on 4/22/26 at 11:03 AM, Resident room [ROOM NUMBER]-1 contained a personal refrigerator. The refrigerator contained four cans of soda and two containers of unknown food contents. The thermometer inside the refrigerator indicated an internal temperature of 46 F. A temperature log was not located on or around the refrigerator.During an observation on 4/23/26 at 11:40 AM, Resident room [ROOM NUMBER]-1 contained a personal refrigerator. The refrigerator still contained four cans of soda and two containers of unknown food contents. The thermometer inside the refrigerator indicated an internal temperature of 46 F. A temperature log was not located on or around the refrigerator.room [ROOM NUMBER]-1During an observation on 4/22/26 at 11:25 AM, Resident room [ROOM NUMBER]-1 contained a personal refrigerator. The refrigerator contained food items such as two packs of hot link sausages (one package opened and one unopened), a bottle of mustard with an open date written with permanent marker of 04/03/22 , and a bottle of water. A temperature log was not located on or around the refrigerator.During an observation on 4/23/26 at 12:06 PM, Resident room [ROOM NUMBER]-1 contained a personal refrigerator. The refrigerator still contained food items such as two packs of hot link sausages (one package opened and one unopened), with an open date written with permanent marker of 04/03/22, and a bottle of water. A temperature log was not located on or around the refrigerator.room [ROOM NUMBER]-1During an observation on 4/22/26 at 11:33 AM, Resident room [ROOM NUMBER]-1 contained a personal refrigerator. The refrigerator contained food items such as two snack packs of unknown white colored food contents, a container of yogurt, a tub of cream cheese spread, a tub of butter, a bag of chocolate bars, a pack of American cheese singles, a bottle of mayonnaise, a bottle of grape jelly, a pack of shredded cheese, eleven cans of soda with two cans that were damaged and misshaped. A temperature log was not located on or around the refrigerator. During an observation on 4/23/26 at 11:48 AM, Resident room [ROOM NUMBER]-1 contained a personal refrigerator. The refrigerator still contained food items such as two snack packs of unknown white colored food contents, a container of yogurt, a tub of cream cheese spread, a tub of butter, a bag of chocolate bars a pack of American cheese singles, a bottle of mayonnaise, a bottle of grape jelly, a pack of shredded cheese, eleven cans of soda with two cans that were damaged and misshaped. A temperature log was not located on or around the refrigerator.During an interview on 4/24/2026 at 11:54 AM, the ADM stated residents were responsible for maintaining personal refrigerators. The ADM stated this included cleaning the refrigerator, storing food properly, and discarding spoiled food items. The ADM stated if residents were unable to do that, they were supposed to contact family to remove the refrigerator. The ADM stated he thought staff were able to assist residents with the refrigerators and the food in them if they needed help. He stated he did not know what to do if the resident had no family, but he believed there would be a care plan meeting to discuss it. He stated he did not know who supplied the thermometers for the personal refrigerators. He stated he was not aware of a task assigned to staff to check personal refrigerators for safe temperatures and log them on to a temperature log. He stated they must schedule a care plan meeting if residents could not maintain their own refrigerator. The ADM stated there was no system in place to ensure resident's personal refrigerators were consistently maintained. He stated he did not know if the refrigerators were being maintained since staff did not check them. The ADM stated if a resident or resident's family were unable to maintain the personal refrigerator in the resident's room, it was possible expired or spoiled food could be left in the refrigerator and there was a risk of residents consuming the food. He stated it was possible temperatures were not being maintained at or below 41 F since they were not being checked. The ADM stated it was possible that food not being held at or below 41 F could become spoiled. He stated a potential negative outcome was that spoiled food could cause digestion issues and residents could get sick from eating personal food. During an interview on 4/24/2026 at 12:10 PM, the DON stated the policy on personal refrigerators was that residents and their families were to maintain them, clean them, and regularly check them for spoiled food and throw it away. She stated staff had the right to check for expired food and discard it after notifying the residents and getting their permission. She stated personal refrigerators must have an internal thermometer. The DON stated fresh food, and vegetables must be thrown away of they look spoiled. She stated staff could help clean and check for spoiled items if residents were not capable of doing it themselves. She stated the DM checked personal refrigerators to make sure there was nothing spoiled and checked internal temperatures daily during morning rounds. She stated she believed there were temperature logs for the personal refrigerators. She stated she did not know if personal food was required to be dated. She stated staff could check and dispose of expired or rotten food for residents that could not do it themselves and had no help from family. She stated staff would be required to check refrigerators for residents that were not cognitive and had no visitors. She stated there was no daily checklist or task assigned for staff to check refrigerators. She stated a condiment dated from April 2022 would be expired and needed to be thrown away. She stated a potential negative outcome of eating spoiled or expired food could cause residents to have gastrointestinal disturbances. She stated a potential negative outcome of refrigerated food not being stored at or below 41 F would cause the food to become spoiled and residents could get sick from eating spoiled food.During an interview on 4/24/2026 at 12:28 PM, the DM stated she put thermometers in all personal refrigerators and checked temperatures daily during morning rounds. She stated she did not have temperature logs where she would document the temperatures of the refrigerators. She stated she checked for spoiled items and spoke with residents if there was expired or spoiled food that needed to be thrown away. She stated she did not date the food; however, she checked the dates on the food manufacture date to determine if it was expired. She stated she considered mustard dated from April 2022 to be expired and unsafe to eat and she would throw it away. She stated she was not responsible for cleaning refrigerators, but she would report to housekeeping if they needed to be cleaned. She stated she would label the refrigerator to be out of order if it was not tempting at or below 40 F and the freezer needed to be 0 F or below. She stated a possible negative outcome of food not being stored at or below 40 F could cause food spoilage leading to food borne illness. She stated a possible negative outcome of consuming expired food could cause residents to get sick.Record review of the facility's policy titled Personal Refrigerators Policy, Environmental Services Policy and Procedure 2026, revealed: Residents of the facility may place a personal or dormitory size refrigerator in their room if space permits and under Life Safety Code regulations, that the resident room has an adequate electrical system, such as proper outlets, to allow the connection of a refrigerator without overloading the electrical system. The care and maintenance of any refrigerator is the responsibility of the resident and/or responsible party. It is also the responsibility of the resident and/or resident representative to properly store non-facility supplied foods that require refrigeration in their personal refrigerator. If food is expired or appears spoiled or moldy, the facility reserves the right to discard it. Housekeeping can assist the residents and/or family member by inspecting the refrigerators at least weekly and assist with removal of outdated food items and cleanliness.Care and MaintenanceThe resident and/or resident representative should clean and maintain the refrigerators according to the manufacturer's user manual. If needed you can ask facility housekeeping or maintenance staff for assistance.Temperature ControlThe refrigerator compartment should be maintained at temperature of 35-41 degreesThe freezer compartment should be maintained at zero degrees or less, or food frozen to a solid state Temperatures can be monitored by the use of a thermometer designed for a refrigerator/freezer that can be purchased from a department store.Cold Food StorageFood should be stored in the refrigerator/freezer as determined by the food item. Commonly Used Dates- Sell by date - indicates that a product should not be sold after that date if the buyer is to have it at its best quality- Best by or Use by date -the maker's estimate of how long a product will keep at its best quality. They are quality dates only, not safety dates. If stored properly, a food product should be safe. wholesome and of good quality after its Use by or Best by date.- Expired date - the food items should not be consumed and should be discarded if not eaten by the expiration date

Based on interviews and record reviews, the facility failed to coordinate assessments resident Pre-admission Screening and Resident Review (PASARR) to avoid duplicate test and effort for 1 of 24 residents (Resident #13) reviewed for PASARR screening, in that: Resident #13 did not have an accurate and updated PASARR Level 1 (PL1) assessment reflecting a diagnosis of mental illness. This failure could place residents at risk of not receiving care and services to meet their needs.The findings included:Record review of Resident #13's undated face sheet revealed a [AGE] year-old male, originally admitted to the facility on [DATE]. Resident #13 had a medical history of Parkison's disease (a progressive, incurable neurodegenerative disorder), psychotic disorder with hallucinations due to known physiological condition (a mental health state where hallucinations or delusions are directly caused by a physical illness, brain disease, or injury) diagnosed on [DATE], and anxiety (the body's natural response to stress, designed to keep you safe). Record review of Resident #13's quarterly MDS dated [DATE] Section C- Cognitive patterns revealed a BIM's score of 12 which indicated Resident #13 had moderate cognitive impairment. Section I-Active Diagnoses of the MDS revealed Resident #13 had psychotic disorder, depression and anxiety. Record review of Resident #13's care plan with an initiated date of 1/07/2025 revealed Resident #13 had a focus of [Resident #13] requires an anti-psychotic medication. Resident #13 had a goal of [Resident #13] will remain free of drug related complications, including movement disorder, discomfort, hypotension. Interventions for the anti-psychotic goal revealed administer medications as ordered.consult with pharmacy.educated [Resident #13]/family/caregivers about risks, benefits and the side effects. Record review of Resident #13's PASARR Level One (PL1) form dated 4/19/2022 revealed under Section C0100 Mental Illness an answer of No, which indicated Resident #13 did not have a mental illness. There were no additional PL1 screenings provided by the facility for Resident #13. During an interview on 4/23/026 at 3:34pm with the MDS Coordinator, she stated she was responsible for ensuring the PL1's were accurate and updated as needed. She stated Resident #13 did not have another PL1 available. She stated she was not aware Resident #13 had a psychotic disorder diagnosis but that she would consider it a mental illness. She stated that the diagnosis of psychotic disorder was initiated in 2024. She stated she was responsible for ensuing resided had an updated PL1 if there were new diagnosis of mental illness. She stated Resident #13 did not have primary diagnosis of dementia. She stated a potential negative outcome of Residents not having an accurate PL1 could be Residents missing out on services they may qualify for such as equipment, programs or training. She stated the process for a new PL1 would require a form to be filled out and sent to the local state authority for a new PL1 assessment. During an interview on 4/24/2026 at 10:04AM with the ADM, he stated the MDS coordinator was responsible for ensuring the PL1's are accurate and updated. He stated new diagnosis of mental illness are discussed during IDT (interdisciplinary team) meeting that are done weekly. He stated Resident #13's diagnosis must have been missed back on 12/30/2024, but he was unsure as to why it had been missed because he was not the acting ADM at that time. He stated a potential negative outcome of Residents not having an accurate PL1 could prevent Residents from not receiving services they qualify for. Record review of facility policy titled PASRR Level 1 last revised 3/6/2019, revealed; It is the policy of [The Facility] to obtain a PL1 screening form from the RE (referring entity) prior to admission to the NF (nursing facility) .PASRR Program has 3 goals:.3. To ensure individuals receive the required services for their MI (mental illness), ID (intellectual disability) or DD (developmental disability).

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder or had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1of 3 Residents (Resident #34) reviewed for incontinent care. CNA A failed to properly clean peri-area (pubis and vaginal area) and buttocks while providing incontinent care to Resident #34. This failure had the potential to affect residents by placing them at an increased risk of exposure to communicable diseases and infections. Findings include: Record review of the admission record for Resident #34, dated 01/30/26, revealed a [AGE] year-old female who was admitted on [DATE] with the following diagnoses: Alzheimer's Disease (cognitive loss) and muscle weakness. Record review of the quarterly MDS assessment for Resident #34, dated 11/22/25, revealed Resident #34 required supervision or touching assistance for toileting hygiene - the helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. The MDS further revealed Resident #34 was frequently incontinent. Record review of the current care plan for Resident #34, dated 03/25/25, revealed there was a focus area: Resident has occasional bladder incontinence with interventions to provide incontinence care at least every 2 hours. During an observation on 04/23/26 at 10:20 a.m., CNA A provided incontinent care for Resident #34. Resident #34 was lying on her left side facing CNA A. CNA A reached over Resident #34 and cleaned from vaginal area to anus (front to back). No observation of cleaning the buttocks area. LVN removed dirty brief and CNA A placed new brief under resident. CNA A turned resident to back and pulled front of brief between legs and fastened both sides of brief. No observation of CNA A cleaning peri area (pubis area and vaginal area) of Resident #34. During an interview on 04/23/26 at 03:26 p.m., CNA A stated there was no reason why she did not clean Resident #34 buttocks area or her front side. She stated she had been trained in how to do incontinent care. She stated she should have cleaned the front side of Resident #34. She stated the potential negative outcome could be causing urinary tract infection. During an interview on 03/24/26 at 09:58 a.m., DON stated she was responsible for training and monitoring CNAs for proper incontinent care. She stated all staff had been trained. She stated CNA A should have cleaned the residents' front side and then the back side. She stated CNAs do competency skills annually. She stated the potential negative outcome of not properly cleaning a resident could cause skin breakdown, uncomfortable for the resident and increase in resident behaviors. During an interview on 03/24/26 at 10:11 a.m., ADM stated the DON was responsible for training and monitoring CNAs for proper incontinent care. He stated his expectations were for CNAs to properly perform incontinent care. He stated the CNAs do competency skills on hire and annually. He stated the potential negative outcome of improper incontinent care could be skin breakdown. Record review CNA Proficiency Audit dated 02/12/26 for CNA A revealed satisfactory skills for perineal care: male and female. Record review of the facility policy titled, Perineal Care, with dated 05/11/2022 reflected the following: Purpose: This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition.Start .13)Reposition the resident on their back with legs flexed and separated as able .16) Wipe across the pubis area17) Gently perform perineal care wiping from clean urethral area to dirty, rectal area, to avoid contaminating the urethral area - CLEAN to DIRTY!Female resident: Working from front to back, wipe one side of the labia majora, the outside folds of perineal skin that protect the urinary meatus and the vaginal opening. Continue perineal care to the inner thigh. Then wipe the other side.Back20) Reposition the resident to their side21) Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area .

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #34) reviewed for infection control. CNA A did not perform hand hygiene or gloves changes when providing incontinent care to Resident #34. This failure could place residents at risk for cross contamination and infection. Findings included: Record review of the admission record for Resident #34, dated 01/30/26, revealed a [AGE] year-old female who was admitted on [DATE] with the following diagnoses: Alzheimer's Disease (cognitive loss) and muscle weakness. Record review of the quarterly MDS assessment for Resident #34, dated 12/12/25, revealed Resident #34 required supervision or touching assistance for toileting hygiene - the helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. The MDS further revealed Resident #34 was frequently incontinent. Record review of the current care plan for Resident #34, dated 12/09/25, revealed there was a focus area: Resident has occasional bladder incontinence with interventions to provide incontinence care at least every 2 hours. During an observation on 04/23/26 at 10:20 a.m., CNA A provided incontinent care for Resident #34. Resident #34 was lying on her left side facing CNA A. CNA A reached over Resident #34 and cleaned from vaginal area to anus (front to back). Observed bowel on disposable wipes during cleaning. No observation of glove change. LVN removed dirty brief and CNA A placed new brief under resident. CNA A turned resident to back and pulled front of brief between legs and fastened both sides of brief. CNA A repositioned resident in bed and covered her with blanket. CNA A removed gloves and gown, and washed hands. During an interview on 04/23/26 at 03:26 p.m., CNA A stated there was no reason why she did not change her gloves. She stated she got nervous and did not change her gloves because she did not have any extras. She stated she had been trained in how to do incontinent care. She stated she should have changed her gloves when going from dirty to clean. She stated the potential negative outcome could be cross contamination. During an interview on 03/24/26 at 09:58 a.m., DON stated gloves should be changed when going from dirty to clean. She stated she was responsible for training and monitoring CNAs for proper incontinent care. She stated all staff had been trained. She stated gloves should have been changed after cleaning resident and removing dirty brief. She stated CNAs do competency skills annually. She stated the potential negative outcome of not changing gloves could be spread of germs, cross contamination. During an interview on 03/24/26 at 10:11 a.m., ADM stated gloves should be changed anytime they were dirty or contaminated. He stated there was no reason gloves would not be changed and hand hygiene done during incontinent care. He stated gloves should have been changed when CNA A went from dirty to clean. He stated the DON was responsible for training and monitoring incontinent care. He stated the CNAs do competency skills on hire and annually. He stated the potential negative outcome could be cross contamination. Record review CNA Proficiency Audit dated 02/12/26 for CNA A revealed satisfactory skills for perineal care: male and female, proper handwashing, and prevents cross contamination. Record review of the facility policy titled, Perineal Care, with dated 05/11/2022 reflected the following: Purpose: This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition.24) doff gloves and PPE25) Perform hand hygiene. Record review of the facility policy titled, Hand Hygiene, with undated reflected the following: You may use alcohol-based cleaner or soap/water for the following: .Upon and after coming in contact with a resident's intact skin, (e.g. when taking a pulse or blood pressure, and lifting a resident) .You must use soap/water for the following: (alcohol base cleaner is not recommended)When hands are visibly soiled .

Based on interviews and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect for 2 of 5 residents (Resident #1, and #2) reviewed for abuse. A. The Former ADM (Abuse Preventionist) failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC regarding the Resident-to-Resident altercation (between Resident #1 and Resident #2) that occurred on 3/14/25. B. The facility staff (CNA A, E, and LVN C) failed to follow the facility's abuse policy by not reporting the allegation of abuse to the Former ADM (Abuse Preventionist) regarding the Resident-to-Resident altercation (between Resident #1 and Resident #2) that occurred on 3/14/25. C. The facility (the ADON) failed to follow the facility's abuse policy by not assessing Resident #1 and #2 at the time of a Resident-to-Resident altercation that occurred on 03/14/25. These failures could place residents as risk for abuse and neglect. Findings included: Resident #1 Record review of Resident #1's face sheet, dated 03/28/25, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss). Record review of Resident #1's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 2, which indicated the resident's cognition was severely impaired. Section B Hearing, Speech, and Vision revealed Resident #1 had clear speech, usually could make self-understood, and sometimes had the ability to understand others. Section E Behavior revealed Resident #1 had exhibited verbal behaviors (1-3 days) that impacted the resident's care and had impacted the privacy or activity of others. The behaviors indicated had significantly disrupted the care or living environment. Resident #1 also had a presence of wandering behavior that occurred daily, significantly impacted the privacy or activities of others and had worsened. Section V Care Area Assessment (CAA) Summary: Section V CAA Results: 09. Behavioral Symptoms. Record review of Resident #1's physician order's, active as of 3/28/25, revealed: Resident #1 was prescribed Donepezil 10 mg once a day for dementia (start date 2/07/25). Record review of Resident #1's care plan, dated 2/6/25, revealed: Focus (initiated 02/06/25; revised 3/17/25): Resident #1 had a behavior of wandering d/t dementia. Goal (initiated 02/06/25; revised 3/17/25): Resident #1 would not leave the facility unattended through the review period (target date: 5/20/25). Interventions: Distract Resident #1 from wandering by offering pleasant diversions. Identify patterns of wandering. Focus (initiated 03/17/25; revised 3/17/25): Resident #1 had a potential to demonstrate physical behaviors d/t dementia. Goal (initiated 03/17/25; revised 3/17/25): Resident #1 would not harm himself or others through the review period (target date: 5/20/25). Interventions: Assess and address for contributing sensory deficits. Assess and anticipate resident needs. If Resident #1 has physical behaviors immediately intervene. Monitor and notify doctor if he is a danger to himself or others. Record review of Resident #1's progress notes, dated 1/27/25-03/28/25, revealed: On 03/15/25 at 7:00 AM the ADON documented: During rounds this morning CNA A informed me (the ADON) that before she left yesterday (03/14/25) she found Resident #1 and Resident #2 in another resident's room and they were involved in an altercation. CNA A saw Resident #1 hit Resident #2 in the face with his shoe and he (Resident #1) had Resident #2 on the bed where he (Resident #2) couldn't get up. Resident #2 was yelling for help. CNA A separated the residents in different areas, CNA A then went to main nurses station to report and the nurses were not available so she returned to the unit where she kept the residents separated. On 03/15/25 at 7:49 AM the ADON documented: Assessed resident VSS, A/O x 1, ambulatory, speech is appropriate for him, PERRLA, HRRR, BBS clear x 4, Abd soft nondistended, skin assessment- resident denies any injury and no visible injuries noted. During an interview on 03/28/25 at 3:20 PM Resident #1 recalled hitting someone but was unable to report pertinent information such as when, who, or why. Resident #2 Record review of Resident #2's face sheet, dated 03/28/25, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include Alzheimer's (memory loss), dementia (memory loss), cognitive communication deficit (impaired thought process that allow humans to function successfully and interact meaningfully with each other), and wandering. Record review of Resident #2's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was unable to complete the interview. Section B Hearing, Speech, and Vision revealed Resident 2 had clear speech, sometimes could make self-understood, and sometimes had the ability to understand others. Section E Behavior revealed Resident #2 had no behaviors documented other than wandering which occurred daily. Resident #2's wandering significantly intruded on the privacy of others. Section V Care Area Assessment (CAA) Summary: Section V CAA Results: 09. Behavioral Symptoms. Record review of Resident #2's physician order's, dated active as of 03/28/25, revealed: Resident #2 did not take any medication related to behaviors. Record review of Resident #2's care plan, dated 3/25/25, revealed: Focus (initiated 06/01/24; revised 10/29/24): Resident #2 had a behavior of wandering in and out of other's rooms. Goal (initiated 06/01/24; revised 6/21/24): Resident #2 would have fewer behaviors by review date (target date: 6/23/25). Interventions: Anticipate the resident needs, intervene as necessary to protect the rights and safety of others, monitor behavior. Record review of Resident #2's progress notes, dated 1/27/25- 03/28/25, revealed: On 03/15/25 at 7:00 AM the ADON documented: During rounds this morning CNA A informed me (the ADON) that before she (CNA A) left yesterday she found Resident #1 and Resident #2 another resident room and they were involved in an altercation. CNA A saw Resident #1 hit Resident #2 in the face with his shoe. He (Resident #1) had Resident #2 on the bed where he couldn't get up. Resident #2 was yelling for help. CNA A separated the residents in different areas, CNA A then went to main nurses station to report and the nurses were not available so she returned to the unit where she kept the residents separated. I (the ADON) informed administration as so as it was reported to me. On 3/15/25 at 8:22 AM the ADON documented: Assessed resident VSS, A/O x 1, ambulatory, speech is appropriate for him, PERRLA, HRRR, BBS clear x 4, Abd soft nondistended, skin assessment, old scarring and bruising to bilateral arms Resident has new abrasion on top of his nose. No other visible injuries were noted. Cleansed nose with wound cleaner. On 03/17/25 at 4:28 the SW documented: Incident reported on 3/14/25 with resident on resident. SW administered Safe Survey to staff and to POA/RP/families of residents on 400 hall. Trauma Informed assessment completed. Secure Care Pack consult with held with Former ADM, Plan in place to encourage resident to participate in activities off the unit. Resident #2 enjoys helping others and staff can monitor resident while safely assisting others during mealtime. During an interview on 03/28/25 at 3:27 PM, Resident #2 was unable to answer any questions regarding the altercation that occurred on 3/14/25 involving him and Resident #1. During an interview on 3/28/25 at 9:00 AM, the Regional Compliance Nurse stated she was notified on the morning of 3/15/25 that Resident #1 threw a shoe at Resident #2 while being in another resident's room. She said CNA A separated both Resident #1 and #2. CNA A reported that she went to report the incident to the nurse, but no one was at the nurse's station. The Regional Compliance Nurse stated once it was reported to her on 3/15/25, she started her investigation and placed Resident #1 on 1:1 monitoring as he was reported as the aggressor. She said they consulted with psychiatric services to address the behaviors of Resident #1. She said both residents were assessed on 03/15/25. She said CNA A was suspended as a result of the incident (failure to report when the incident occurred on 03/14/25). The Regional Compliance nurse said the Former ADM was terminated for failing to suspend CNA A immediately and for failing to report. The Regional Compliance Nurse stated she suspended CNA A because she failed to report the Resident-to Resident altercation but did not have concerns with her being involved. She said she started in-servicing on ANE to include reporting. She stated she coached CNA A on reporting timely. She stated the altercation between Resident #1 and #2 was a one-time occurrence. During an interview on 03/28/25 at 9:05 AM the Interim ADM stated she had no information regarding the altercation between Resident #1 and #2. She said she had only been at the facility for three days. During an interview on 03/28/25 at 10:00 AM, CNA A was able to name who the abuse coordinator was at the time of the interview, and at the time Resident #1 and #2 had their altercation. She stated she had received ANE training. She said she had been trained on what to do during a resident-to-resident altercation. She stated she knew to separate the residents, prevent and protect them, and report the incident to the charge nurse. She stated the residents involved should be assessed. CNA A stated Resident #1 and #2 had never had an altercation. She stated on 03/14/25, while attending to another resident/task, she heard Resident #1 holler for help. She went to another resident's room, where the noise was coming from. She stated she observed Resident #1 standing over Resident #2, hitting him (alternating with his hand and a shoe in the other hand). She stated she separated the two residents and placed them in their rooms. She stated she went to the nurse's station to call for assistance and to report it, but no one was there. She said she returned to the memory unit, where both residents were in their rooms. She asked Resident #2 if he was ok and in any pain. He (Resident #2) stated no. She stated she proceeded with her day and never saw the nurse for the remainder of the night until she was leaving. She stated there was no further incident for the remainder of the night. She stated the incident occurred at 3:00 PM and had her note in the system by 3:13 PM. She stated the two had never had an altercation but had wandering behaviors. She stated she was trained with her experience to redirect them in the appropriate areas. She stated that Resident #1 would wander, but he was very helpful in helping to get other residents to their beds. She stated Resident #2 also wandered and would go into other residents' rooms and sleep on their beds. She stated she had been trained through experience to redirect him and encourage him to go to his room. She stated on 03/14/25, she did not report the altercation that occurred between Resident #1 and #2 to the charge nurse because no one was at the nurse's station. She stated that night, CNA B relieved her, and she did tell her because it was a part of the report and wanted her to keep an eye on them. She stated the next day when she came in, the ADON came in, and she reported the incident to her. She stated the ADON immediately assessed the resident (Resident #2), and he did not recall the incident. She stated she did not say anything to LVN D because they usually give reports to the staff in the same roles. She stated after she reported the incident to the ADON, she (the ADON) reported it to the Former ADM. CNA A stated the Former ADM thought the incident occurred on the morning of 03/15/25. She stated she completed a witness statement. She stated the following morning, the Regional Compliance Nurse came in and coached her on reporting promptly. She stated although she did not report the incident the day of, she thought she had 24 hours to report. She stated she did not report the incident because after the residents were separated and safe, she became busy and forgot to report it after her first attempt . During an interview on 03/31/25 at 10:36 AM, the ADON was able to name who the abuse coordinator was at the time Resident #1 and #2 had their altercation. She stated she had abuse training. She stated if there was a resident-to-resident altercation, the residents had been trained to separate them. The nurse should complete a head-to-toe assessment for all residents involved. She stated on the afternoon (03/14/25), CNA A went to the nurse's station, but no one was there. She stated CNA A told her that she forgot to tell her that Resident #1 and #2 had an altercation. She stated on 03/14/25, she had gone to the memory unit after the incident and had never been told anything about the altercation between Resident #1 and #2. She stated she was unsure if the oncoming staff was told about the incident. She stated she left on 3/14/25 around 7-8 PM and was never told anything about the altercation. She stated she returned to work the following morning (03/15/25) and was told around 6 or 7 AM by CNA A that Resident #1 and Resident #2 had an altercation. She ensured Resident #1 and #2 were separated, and they were. She stated she assessed both residents. Resident #1 did not have any injuries. Resident #2 did have a mark on his nose. She stated outside of the delay in reporting, she felt that the altercation had been handled correctly. She stated she assessed the residents, but there could have been a delay in treatment if there had been an injury. She stated Resident #1 and #2 had never had an altercation. She stated both residents' wander. She stated Resident #1 would wander but also help other residents get to their rooms. She stated Resident #2 was quiet but would wander and had to be redirected out of the other room. She stated Resident #1 had never exhibited aggression. During an interview on 03/31/25 at 11:15 AM, CNA E stated she relieved CNA A of her duties on 03/14/25. She stated she was told by CNA A Resident #1 and #2 had a physical altercation and to watch them. She said there was no incident the remainder of the evening. She said she did not tell anyone about the incident because she thought it had already been reported. She said she was told by CNA A that the incident had been reported. She said LVN C also knew about it because he had come into the memory unit to check on the residents. She said Resident #1 and #2 were in their rooms the majority of the night. During an interview on 03/31/25 at 11:30 AM, LVN C stated he worked the night of 03/14/25, but the incident between Resident #1 and #2 did not happen during his shift. He stated it was reported to him that Resident #1 and #2 had an altercation. He stated he could not remember by whom, but it had to be the nurse that was going off duty. He stated it was reported to him that Resident #2 had come into Resident #1's room, and Resident #1 told him to get out. He stated he checked on them throughout the night, and there was no incident. He stated both residents were in their rooms throughout the night. He stated he did not report the incident to management because it did not happen on his shift. He stated that he generally would ask if it had been reported but could not say if it had been reported to the abuse coordinator. He was able to report who the abuse coordinator was and who he would report a resident-to-resident altercation to if it occurred on his shift. He stated he would report the incident to the ADM, the ADON, and the DON. During an interview on 03/31/25 at 11:46 AM, the Former ADM stated she was no longer the administrator at the facility. She stated on Saturday (03/15/25) the ADON texted her. She said CNA A heard a noise and followed it to find Resident #1 hitting Resident #2 with a shoe. She stated that neither resident was in their assigned room. CNA A separated the residents. CNA A went to locate a nurse but could not find one. She stated CNA A reported that the incident happened Friday (3/14/25) but reported the incident on Saturday (03/15/25). She stated as soon as CNA A reported the incident, she then reported the incident to HHSC and the Regional Compliance Nurse. She stated they met about the incident and discussed the resident's behaviors. She stated Resident #1 had never done anything aggressive before but had the existing wandering behavior. She stated Resident #2 also had wandering behaviors. She said he would go into others' rooms and lay in their bed, and staff knew to redirect him. She said the altercation between Resident #1 and #2 was a one-off. She stated there were no additional incidents, and the residents sat together during lunch since the incident. She said the staff were doing additional rounds for monitoring. She said CNA A was suspended because of the failure to report. She said she did not suspend her initially that morning because she was unaware that the incident had occurred the day before, and after she found out, she just did not think about it (suspending CNA A). During an interview on 3/31/25 at 1:14 PM with the Regional Compliance Nurse, she stated she was familiar with the facility's abuse policy. She stated the purpose of the abuse policy was to prevent abuse to the residents. She stated the potential negative outcome of not following the abuse policy was that a resident could have been harmed. She stated she was aware that they failed to follow the abuse policy when CNA A did not report the incident to the charge nurse. She stated she was aware that the residents were not assessed at the time of the incident but were assessed as soon as it was reported with no significant injuries. She stated that no other staff knew about the incident before 03/15/25. She stated not reporting the incident could delay treatment if needed and they should report to the appropriate agencies. She said the system they use to monitor following the abuse policy was educating staff. She stated that she had been trained on the abuse policy, and all of the staff had been trained. She stated there were no staff members who have not been trained on the abuse policy. She stated the facility staff were trained annually upon hire. She stated that she expected the abuse policy to be followed. She stated the residents involved should be assessed immediately, and the incident should be reported immediately. She said they were all responsible for following the abuse policy. She said there was no reason why CNA A did not report the incident to the charge nurse. She said the charge nurse (the ADON) did not assess the residents at the time of the incident because she was not notified. During an interview on 03/31/25 at 2:10 PM, the ADM stated she was familiar with the facility's abuse policy. She stated the purpose of the abuse policy was so that the facility staff had guidelines to go by when there was an allegation of abuse or when there was a resident-to-resident altercation. She stated that the potential negative outcome of not following the abuse policy was a resident could get injured, or there could be alternative poor outcomes for the other residents. She stated she was not the Interim ADM at the time of the incident, but since her arrival at the facility, she was made aware that the incident report was not made timely. She stated she was unaware the residents involved were not assessed at the time of the incident. She stated she had been trained on the facility abuse policy, and all staff had been trained. She stated she expected all staff to follow the abuse policy. She stated the administrator was ultimately responsible, but all staff, including department heads, were responsible for following the abuse policy. She stated she was unaware of a reason why the abuse policy was not followed and was shocked that it was not followed. Record review of the facility policy, Abuse/Neglect, dated 03/29/18, revealed: The resident has the right to be free from abuse, neglect Residents should not be subjected to abuse by anyone, including, but not limited to other residents. It is each individual's responsibility to recognize and report actual or alleged abuse. Reporting Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect must report this to the DON, administrator, state and or adult protective services. Facility employees must report all allegations of abuse to the facility administrator. The facility administrator or designee will report to HHSC . If the allegations involve abuse or result in serious bodily injury the report must be made within 2 hours of the allegation. Resident- to Resident The above policy will apply to potential-to-resident abuse. Record review of the facility's policy, Resident to Resident Abuse Investigation Checklist, dated 2003, revealed: Assess resident injury Notify charge nurse and or DON See reporting guidelines to state .

Based on interviews and record review, the facility failed to provide the resident and/or resident representative written notice which specified the duration of the bed-hold policy at the time of transfer of a resident for hospitalization for 2 of 5 residents (Resident #2 and #3) reviewed for transfers. The facility did not ensure Resident #2 and her representative were provided with a written bed-hold policy on the following dates when the resident was transferred from the facility: 2/08/25. The facility did not ensure Resident #3 and her representative were provided with a written bed-hold policy on the following dates when the resident was transferred from the facility: 3/17/25. This failure could place residents at risk of being improperly discharged and placed in unsafe conditions. The findings included: Resident #2 Record review of Resident #2's face sheet, dated 03/28/25, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include Alzheimer's (memory loss), dementia (memory loss), cognitive communication deficit (impaired thought process that allow humans to function successfully and interact meaningfully with each other), and wandering. Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was unable to complete the interview. Section B Hearing, Speech, and Vision revealed Resident #2 had clear speech, sometimes could make self-understood, and sometimes had the ability to understand others. Record review of Resident #2's progress notes, dated 1/27/25- 03/28/25, revealed: On 02/08/25 at 11:17 AM the RN F documented: Resident #2 was transferred to a hospital on [DATE] 11:30 AM related to URI (upper raspatory infection) with hypoxia (lack of oxygen). Record review of Resident #2's census record indicated that she was discharged from the facility and stop billing occurred on the following dates: 2/08/25. During an interview on 03/28/25 at 3:27 PM, Resident #2 was unable to answer any questions regarding bed hold notices. Resident #3 Record review of Resident #3's face sheet, dated 03/28/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include epilepsy (excessive and abnormal brain cell activity that causes seizures), and type 2 diabetes mellitus with ketoacidosis (weakness and fatigue) without coma (a serious complication that can occur in people with both type 1 and type 2 diabetes). Record review of Resident #3's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 12, which indicated the resident's cognition was mildly impaired. Section B Hearing Speech, and Vision revealed Resident #3 had clear speech, could make self-understood, and had the ability to understand others. Record review of Resident #3's progress notes, dated 1/27/25-03/28/25, revealed: On 03/17/25 at 7:26 AM LVN B documented: Resident #3 was transferred to a hospital on [DATE] 7:30 AM related to Resident having seizure, CBG greater than 600. Record review of Resident #3's census record indicated that she was discharged from the facility and stop billing occurred on the following dates: 3/17/25. Resident #3 was not interviewed during the visit d/t her being hospitalized in a different city at the time of the visit. During an interview on 03/31/25 at 12:57 PM, the Regional Compliance nurse stated no bed hold notifications were given for Resident #2 or #3. During an interview on 03/31/25 at 1:14 PM, the Regional Compliance nurse stated she was familiar with the bed hold policy. She stated the issue was they (the facility) had not had a BOM for a few months. She stated if the BOM did not give the notice, then the Former ADM should have been the person to cover the bed hold notice. She stated it would have been admissions to cover the bed holds. She said the potential negative outcome was the resident may not have a place to return to. She stated she was unaware Resident #2 and # 3 had not been given bed hold notices. She stated the system for bed hold notices was the BOM would usually give the notice. She stated she had not identified this as an issue before. She stated the system to monitor bed hold notifications was, the BOM was the person that usually gave them out, and if there was no BOM, the ADM would step in. She stated she had not been trained on bed hold notifications. She stated she expected the bed hold policy to be followed and notices to be given according to the policy. She stated the notices were not given because they did not have a BOM. She stated the Former ADM had not been at the facility very long during the time. She stated they had not had a BOM for the past three months. She stated their corporate team would come twice a week. During an interview on 03/31/25 at 2:10 PM, the ADM stated she was familiar with the bed hold policy. She stated the purpose was to notify residents and their representative there was a room for them to return to. She stated the potential negative outcome was the resident could lose their room to a new admission. She stated she was not concerned about the residents losing their room because they could get a new room, and if they were Medicaid, they generally did not take the residents out of their room. She stated she was unaware that the notices were not given to Residents #2 and #3. She stated the system to monitor and ensure the notices were given was admissions would give the bed hold notices. She stated she had been trained, but it had only been a while. She stated she was the interim ADM and had not been in the facility long. She stated she would not have been at the facility when the bed hold notices would have been given. She stated she expected bed hold notices to be given per policy. She stated the ADM was ultimately responsible because they should know who was admitted and discharged from the facility. She stated the administrator who managed the census would ensure the notice was given. She stated she did not know why the notice was not given. Record review of the facility policy, Bed Hold and In-House Transfer Policy, dated 02/03/05, revealed: One copy each must be given to the resident and his/her family member/legal representative upon admission. One copy each (signed and dated by the resident AND family member) must be given to the resident AND family member each time of transfer for hospitalization or therapeutic leave.

Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 12 of 21 confidential residents. The facility failed to ensure 12 confidential residents were provided access to the Grievance form and provided the procedure for how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings include: Interviews and record review during Resident Council on, 02/1/2025 at 2:00 p.m., 12 confidential residents, stated they did not have access to the Grievance form, they did not know they could file a Grievance anonymously, the Grievance procedure had never been discussed in Resident Council, and they had not observed a posting of the Grievance procedure in prominent locations. Residents attending Resident Council did not know where to acquire a grievance form, who to turn the form into, and what happens once a grievance was filed. The Residents did not know they had the right to receive a written decision once their grievance was resolved Record review of the facility Grievance policy on 2/27/2025 at 11:07 a.m.; according to the facilities' Grievance policy a copy of the Grievance/complaint procedure should be posted on the resident bulletin board. Observation of prominent postings on 2/27/2025 at 11:30 a.m., the facility displayed the information regarding the administrator being the Grievance officer, however, the information displayed did not include instructions regarding the Grievance procedure with any of the prominent postings. Grievance forms were not available and there was no access to submit a Grievance anonymously. Interview with the ADM on 2/27/2024 at 2:35 p.m., the ADM stated she was the Grievance Officer for the facility. The ADM stated she was responsible for the review of Grievances and assign them to department heads. The ADM stated the Grievance form was kept in a folder outside her office; however, she stated the forms availability was not helpful to residents if they did not know where the form is kept. The ADM stated staff completed Grievance forms for Residents, Residents do not ask for forms and complete them on their own. The ADM stated there was no procedure for Residents to submit Grievances anonymously. The ADM stated there is a box outside of her office that could be utilized for filing an anonymous Grievance; however, this procedure had never been evoked. The ADM stated the facility has 72 hours to resolve Grievances once they were submitted. The ADM stated she assigned the Grievance to the appropriate department, that department addresses the grievance with the complainant, resolved the grievance, and explained the resolution to the complainant. The resolution was documented on the Grievance form and the completed form was submitted to the ADM for review. The ADM stated completed Grievance forms were kept in a notebook. The ADM stated she monitored the Grievance process for success by following up with the staff member assigned to resolve the Grievance, the ADM stated she will also meet with the complainant to ensure they were satisfied with the resolution, and Grievances were discussed at morning meeting. The ADM stated she was responsible for ensuring staff were trained on the Grievance process. The ADM stated she was not aware the Grievance procedure was not being discussed in Resident Council. The ADM stated the potential negative outcome for the Grievance policy not being followed was Resident issues will not be resolved. Record Review of the Grievance Policy last updated in 2016. Policy Statement: Residents has the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay, the resident has the right to and the facility must make promote efforts by the facility to resolve grievances the resident may have. 1. The facility will notify residents on how to file a grievance orally, in writing, or anonymously with postings in prominent locations. 2. The grievance official of this facility is the administrator or their designee. 3. The grievance official will: oversee the grievance process, receive, and track grievances to their conclusion, lead any necessary investigations by the facility, maintain the confidentiality of all information associated with grievances, issue written grievances decisions to the resident. 4. The facility will take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated. 5. All grievances involving alleged allegations of neglect, abuse, including injuries of an unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the abuse preventionist. 6. All written grievance decisions will include the date the grievance was received, a summary statement of the residents' grievances, the steps taken to investigate, a summary of findings, a statement as to whether the grievance was confirmed, any corrective action, and the date the written decision was issued. 7. The facility will take appropriate corrective action in accordance with state law if the alleged violation of the residents' rights is confirmed by the facility or outside entity having jurisdiction. 8. Maintain evidence of the grievance results for 3 years.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: The facility failed to store and date foods stored in the refrigerator. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations were made on [DATE] at 09:58 AM during initial observation of the kitchen: Observed the following in the walk-in refrigerator: -Plastic container with mixed fruit open with no label and no date. -Metal bowl covered with tin foil with no label and no date. -Plastic container with lid open with label Taco Bake expired date ,d+[DATE]. -Plastic container with label Pudding expired date ,d+[DATE]. -Plastic container with label Mash Potatoes no date. During an interview on [DATE] at 10:28 AM with DM, she stated all food in the refrigerator was to be sealed and dated. She stated all food should be thrown out or used by the expired date. She stated all staff are responsible for sealing and dating food placed in the refrigerator. She stated all staff have had proper training. She stated the potential negative outcome could be the food going bad and cause food poisoning. During an interview on [DATE] at 10:35 AM with [NAME] A, she stated food placed in refrigerator should be sealed and dated. She stated all food should be used or thrown out by the expired date. She stated she had been trained. She stated the potential negative outcome could be a resident getting sick from eating expired food. During an interview on [DATE] at 11:25 AM with ADM, she stated all food placed in refrigerator should be covered or sealed and dated. She stated the DM is responsible for monitoring the refrigerator along with all dietary staff. She stated everyone should be checking the refrigerator every shift. She stated the potential negative outcome could be a resident getting sick from eating expired or spoiled food. Record review of the facility policy, titled Food Storage and Supplies, dated 2012 reflected the following: All facility storage areas will be maintained in an orderly manner that preserves the conditions of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. Procedure: . 4. Open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened .

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of communicable diseases for 2 of 3 residents (Resident #40 and Resident #51) and 3 of 6 staff (CNA E, CNA H, and CNA I) reviewed for infection control. 1. CNA E failed to follow policy and procedure for handwashing while providing incontinent care for Resident #40. 2. CNA H and CNA I failed to follow policy and procedure for handwashing while providing incontinent care for Resident #51. These failures could place residents at risk for spread of infection and cross contamination. Findings included: Resident #40 Record review of Resident #40s face sheet dated 02/17/25 revealed a [AGE] year-old male with an original admitted [DATE] and a readmitted [DATE] with the following diagnoses: pneumonia, acute respiratory failure, sepsis with septic shock (dramatic drop in blood pressure that can damage the lungs, kidneys, liver, and other organs), anemia (a condition in which the blood does not have enough healthy red blood cells and hemoglobin, a protein found in red blood cells), weakness, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), atherosclerosis (the buildup of fats, cholesterol, and other substances in and other substances in and on the artery walls), muscle wasting, unsteadiness on feet, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), dementia, high blood pressure, rheumatoid arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet), end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), dysphagia, cognitive communication deficit (cognitive impairment), stroke, renal dialysis (a life-saving treatment that filters excess fluids, toxins, and solutes from the blood when the kidneys are no longer able to). Record review of Resident #40's admission MDS dated [DATE] revealed a BIMS score listed as 4 meaning moderate cognitive impairment. The MDS under functional abilities for toileting (The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment), listed Resident #30 as a 3 meaning: Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Record review of Resident #40's Care Plan dated 06/06/23, revealed that Resident #40 was listed as occasional bowel incontinence. During an observation on 02/26/2025 at 11:41 AM, CNA D and CNA E provided incontinent care for Resident #40. CNA D used hand sanitizer prior to gathering supplies. CNA D laid out supplies on a clean towel on the bedside table. CNA D washed hands for 23 seconds before starting incontinent care. CNA D put on clean gloves. CNA E did not wash hands prior to assisting with incontinent care. CNA E put on clean gloves. CNA E removed the front of Resident #40's brief and tucking it in between the legs. CNA D provided incontinent care to the front side of Resident #40. CNA E turned Resident #40 on right side. CNA D removed gloves, discarded them, and used hand sanitizer. CNA D put on clean gloves. Resident #40 had feces on the backside that looked dried. CNA D provided incontinent care to the backside of Resident #40. CNA D and CNA E had run out of wipes. CNA E removed gloves and discarded them in the trash. CNA E did not wash hands. CNA E went to get more wipes and returned to Resident 40's room. CNA E rinsed her hands under the water for 6 seconds but did not use soap. CNA D continued to provide incontinent care to the backside of Resident #40 until he was clean. CNA D removed gloves and discarded them in the trash. CNA D used hand sanitizer and put on clean gloves. CNA D placed a clean brief underneath Resident #40 and laid him back. CNA E gathered dirty linens and placed in bag. CNA D fastened Resident #40's clean brief and covered him up. CNA E gathered all trash in a separate bag. CNA D removed gloves and discarded them in the trash. CNA D washed hands with soap for 24 seconds before rinsing underneath the water. CNA E washed hands with soap for 12 seconds before rinsing under water. During an interview on 02/26/25 at 12:22 PM, CNA D stated that she had been trained in handwashing through Relias, monthly. CNA E stated that she did not know how long she was supposed to wash her hands. CNA E stated that she does not usually count, she just washes her hands. CNA E stated that the negative outcome for not following handwashing process would be that germs could be spread. Resident #51 Record review of Resident #51's face sheet dated 02/05/25 revealed a [AGE] year-old female with an original admitted [DATE] and a readmitted [DATE] with the following diagnoses: type 2 diabetes, cognitive communication deficit (cognitive impairment), muscle wasting, seizures, spondylosis (age related wear and tear of the spinal disks), [NAME] cardia (slower than expected heart rate), anxiety, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), neuromuscular dysfunction of bladder (the nerves that carry messages back and forth between the bladder and the spinal cord and brain do not work the way they should), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), high blood pressure, acid reflux. Record review of Resident #51's admission MDS dated [DATE] revealed a BIMS score of 14, which indicated the resident was cognitively intact. The MDS under functional abilities for toileting (The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment), listed Resident #51 as a 3 meaning: Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Record review of Resident #51's Care Plan dated 05/23/23, revealed that Resident #51 was listed as bowel incontinence. During an observation on 02/26/25 at 11:01 AM, CNA H and CNA I provided peri care for Resident #51. CNA H gathered clean peri care supplies without washing her hands or using clean gloves. Prior to providing peri care, CNA I washed her hands for 5 seconds with soap before rinsing. CNA H washed her hands for 9 seconds with soap before rinsing. CNA H and CNA put on yellow gown and gloves because Resident #51 is listed as enhanced barrier precautions. CNA I had already been by Resident #51 pulling down her blankets and positioning the resident before putting on PPE, while CNA H was washing her hands. Resident #51 had dried feces on her catheter tubing, on the bandage coving a wound on the left upper leg, on her upper right crease, and her backside. CNA H had to use the wipes to scrub Resident #51 because feces were dried on her. CNA H had run out of wipes and had to remove her gown and gloves. CNA H washed her hands for 8 seconds with soap before rinsing her hands. CNA H gathered more wipes to complete the peri care. CNA H put on yellow gown and gloves and continued to provide peri care to the backside of the resident. CNA H had to scrub the backside due to feces being dried on her and Resident #51 kept saying, Ouch, Ouch. CNA I removed dirty gloves, discarded in the trash, and washed her hands for 4 seconds with soap before rinsing her hands under water. CNA I put on clean gloves and continued to assist with the peri care by positioning Resident #51 and gathering trash. CNA H continued to wipe Resident #51's backside a few more times before removing her dirty gloves and disposing them in the trash. CNA H used hand sanitizer and put on clean gloves. CNA I fastened the clean brief on Resident #51. Dried feces were still on Resident #51's backside and on the bandage covering a wound. CNA H removed the draw sheet and replaced with a clean draw sheet. CNA I noticed that feces were on the resident's blanket, and she removed the blanket and told the resident that she would bring back a clean blanket. CNA I removed her dirty gloves and discarded in the trash. CNA I washed her hands for 7 seconds with soap before rinsing her hands with water. CNA H washed her hands with soap for 9 seconds before rinsing under water. During an interview on 02/26/25 at 3:58 PM, CNA H stated that the policy for handwashing stated to wash hands for 20 seconds before rinsing. CNA H stated that she thought she had washed for the entire happy birthday song but could not be sure because she was nervous. CNA H stated that she did realize that the resident had dried feces on her, but she could not get it off. CNA H stated that she would have normally used peri wash to clean the resident, but she did not know if she could since she was being washed. CNA H stated that she had been trained in hand washing and infection control through in-services, monthly. CNA H stated that by not providing proper hand washing techniques she could have spread germs and cross contamination. During an interview on 02/27/25 at 11:20 AM, CNA I stated that she had been trained in hand washing and infection control practices through in-services, monthly. CNA I stated that the DON had provided the training. CNA I stated that she had been in a hurry and was nervous. CNA I stated that the negative outcome of not providing proper handwashing is that it could cause the spread of infections and bacteria that could be passed. During an interview on 02/27/25 at 12:50 PM, the Administrator stated that the policy for handwashing that proper hand washing is required before, during, and after providing care for residents. The Administrator stated that she also expects staff to wash their hands with soap and water after using hand sanitizer three times in a row. The Administrator stated that all residents should be thoroughly cleaned and should not be left with urine or feces on them. The Administrator stated that the DON is responsible for over seeing the training and that all staff have completed it. The Administrator stated that if handwashing is not done then it could spread diseases and illness. The Administrator stated that if urine or feces were left on a resident it could also cause skin breakdown or skin infections. Record review of the facility-provided policy titled, Hand Hygiene, undated, revealed: You may use alcohol-based hand cleanser or soap/water for the following: Before and after entering isolation precaution settings Before and after assisting a resident with personal care (e.g., oral care, bathing) Before and after handling peripheral vascular catheters and other invasive devices Upon and after coming into contact with a resident's intact skin (e.g., when taking a pulse or blood pressure, and lifting a resident) After contact with a resident's mucous membranes and body fluids or excretions After handling soiled or used linens, dressings, bedpans, catheters, and urinals. After removing gloves or aprons. You must use soap/water for the following: (alcohol-based hand cleaner is not recommended) When hands are visibly soiled. Before and after assisting a resident with toileting (hand washing with soap and water). Record review of the facility-provided policy titled, Enhanced Barrier Precautions, undated, revealed: Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multi-drug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP is used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. A single set of PPE cannot be used for more than one patient. EBP are indicated for residents with any of the following: Colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. Record review of the facility-provided policy titled, Perineal Care, dated 04/25/2022, revealed: Introduction: An incontinent resident of urine and/or bowel should be identified, assessed, and provided appropriate treatment and services to restore as much normal bladder/bowel function as possible. It is essential that residents using various devices, absorbent products, external collection devices, etc., be checked (and changed as needed) on a schedule based upon the resident's voiding pattern, professional standards of practice, and the manufacture's recommendations. Skin problems associated with incontinence and moisture can range from irritation to an increased risk of skin breakdown. Moisture may make the skin more susceptible to damage from friction and shear during repositioning. Procedure: 10. Perform hand hygiene 11. [NAME] gloves and all other PPE per standard precautions. 12. Soak towels in a washbasin filled with warm water and facility approved cleansing agent or remove an adequate number of pre-moistened cleansing wipes. 13. Reposition the resident on their back on their back with legs fixed and separated as able. 14. Limit resident exposure to the perineal area, provide privacy at all times. 15. If required, use a towel or extra incontinence pad to protect the mattress cover from being soiled. 16. Wipe across the pubis area 17. Gently perform perineal care, wiping from clean urethral area to dirty rectal area, to avoid contaminating the urethral area, Clean to dirty. 18. If visibly moist, pat the areas dry with a clean, dry towel or washcloth. 19. Doff gloves and PPE Back: 20. Reposition the resident to their side. 21. Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area. 22. If visibly moist, pat the areas dry with a clean, dry towel or washcloth. 23. Note skin changes and apply moisture barrier cream as directed 24. Doff gloves and PPE 25. Perform hand hygiene. Conclude: 26. Provide resident comfort and safety by re-clothing, straightening bedding, adjusting the bed and/or side rails, and placing call light within resident's reach 27. Clean and store reusable items 28. If visibly soiled or contaminated during the procedure, disinfect, or discard the barrier towel on the table 29. Return resident items on the table 30. Tie off the disposable plastic bag of trash and/or linen 31. Perform hand hygiene 32. Thank the resident for assisting in self-care. 33. Document Important Points: If heavily soiled, use an incontinence pad, brief, towel, or wipes to remove soiling, from front to back, prior to performing perineal care. Do not wipe more than once with the same surface. Doffing and discarding of gloves are required if visibly soiled. Always perform hand hygiene before and after glove use PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. For example, staff entering the resident's room to answer a call light, converse with a resident, or provide medications who do not engage in high-contact resident care activity would not need to employ EBP while interacting with the residents. Record review of the facility-provided policy titled, Infection Control Plan, dated 2019, revealed: Infection Control: The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. Preventing Spread of Infection: 3). The facility will require staff to wash their hands after each contact direct resident contact for which hand washing is indicated by accepted professional practice. Record review of the Centers for Disease Control website (www.cdc.gov) article titled Clinical Safety: Hand Hygiene for Healthcare Workers, dated February 27, 2024, revealed: Know how to wash hands with soap and water. . 3. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers.

Based on interview and record review, the facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 5 residents (Resident #49) reviewed for PASRR Level I screenings. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #49. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnoses Post-Traumatic Stress Disorder were present upon Resident #49's admitted on 10/07/24. This failure could place residents who had a mental illness at risk of not receiving a needed assessment PASRR Evaluation, individualized care, or specialized services to meet their needs. Findings included: Record review of Resident #49's face sheet, dated 02/27/25, indicated she was a [AGE] year-old female, admitted to the facility on [DATE], and readmitted most recently on 01/22/25. Her diagnoses included Post-Traumatic Stress Disorder, epilepsy (seizure disorder), diabetes (high blood sugar), depression (feeling of sadness and loss of interest), and anxiety (feeling of fear and worry). Record review of Resident #49's comprehensive MDS assessment, dated 11/25/24, indicated she had a BIMS score of 12, which indicated mildly impaired cognition. Section I - Active Diagnoses indicated Resident #49 had Post Traumatic Stress Disorder. Record review of Resident #49's PASRR Level 1 Screening, dated 10/07/24, indicated that in Section C, Mental Illness was marked as no, which indicated Resident #49 did not have a mental illness. Record review of Resident #49's PASRR Level 1 Screening, dated 11/21/24, indicated that in Section C, Mental Illness was marked as no, which indicated Resident #49 did not have a mental illness. During an interview on 02/27/25 at 9:47 AM, with the MDS nurse, she stated resident #49 had a negative PL1. She stated she was not aware that Resident #49 had diagnosis PTSD on admission. She stated no PASRR evaluation had been done. During an interview on 02/27/25 at 11:10 AM with the MDS nurse, she stated she was not the MDS nurse at the time Resident #49 was admitted to the facility. She stated she is responsible for checking the PASRR for accuracy when residents were admitted . She stated she is responsible for entering the admitting diagnosis into the EMR on admission and checks them with the PASRR received on admission. She stated the MDS nurse was responsible for PASRR corrections. She stated the potential negative outcome is the resident would not be accurately listed as PASRR positive. She stated the only available services for MI residents were only available to people within the community. She stated there were no services available for PTSD. She stated her expectation was to have a hundred percent accuracy. She stated she had been trained on PASRR. During an interview on 02/27/24 at 11:30 AM with the ADM, she said the MDS Coordinator is responsible for completing PASRR evaluations. She stated she expects the PASRR to be completed properly. She stated the potential negative outcome of inaccurate PASRR evaluation could be delay of treatment and referrals for the resident. Record review of the facility policy titled, PASRR Level 1 Screen, revised date 3-6-19 indicated, Policy: It is the policy of Creative Solutions in Healthcare facilities to obtain a PL1 screening form from the RE (referring entity) prior to admission to the NF. The PL1 will be submitted via SimpleLTC timely per PASRR Regulatory timeframes. PASRR is a federally mandated program requiring all states to pre-screen all individuals seeking admission to a Medicaid-certified nursing facility, regardless of payor source or age. The PASRR Program is important because it provides options for individuals to choose where they live, who they live with and the training and therapy they need to live as independently as possible. PASRR Program has 3 Goals: 1. To identify individuals with MI, ID, or DD/RC (this includes adults and children); 2. To ensure appropriate placement whether in a community or in a NF; 3. To ensure individuals receive the required services for their MI, ID or DD . 3. The facility will review the PL1 screening form for completion and correctness prior to admission and submit the PL1 form per regulation. The type of admission is reviewed for correctness .

Based on interview and record review the facility failed to ensure prompt efforts by the facility were made to resolve grievances for the residents for 1 of 6 residents (Resident #1) reviewed for grievances. A. The Social Worker failed to ensure a grievance was filled out and followed up on after Resident #1 requested a room change and reported that she felt uncomfortable because of staff working in the facility. This failure could place residents at risk for decreased quality of life and feelings of neglect. Findings included: 1.Record review of Resident #1's face sheet, dated 10/11/24, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include cognitive communication deficit, muscle weakness and urinary incontinence. Record review of Resident #1's Comprehensive Minimum Data Set, dated dated [DATE], revealed: *Section B0800. Ability to understand others, Resident #1 had clear speech, could make herself understood and usually understood others. *Section C Brief Interview for Mental Status score revealed a score of 12, which indicated the resident's cognition was moderately impaired. Record review of Resident #1's care plan, dated 08/26/24, did not reveal any indication that Resident #1 had any known behaviors, had frequent room change request or anything concerning her cognition. Record review of Resident #1's progress notes for the time period 08/10/24-10/11/24 did not reveal any information regarding Resident #1 reporting the allegation of abuse or filing a grievance regarding staff treatment. Record review of Resident #1's room form, dated 10/02/24, indicated Resident #1 initiated a room change; however, a reason was not revealed. Record review of the facility grievance report, dated from August 2024- October 2024 did not reveal a grievance regarding Resident #1 concern for CNA A. During an interview on 10/11/24 at 9:53 AM, Resident #1 stated that she was in a different hall but requested to be moved to a different hall because the staff in her previous hall was mean to her. She said she could not remember the exact date, but it was a weekend. She said CNA A was the primary staff member who was mean to her. She said she told staff she felt uncomfortable with CNA A but cannot remember who she told. She said no one was mean to her but CNA A was the only person that was. She said she felt dirty because when her adult brief needed to be changed, CNA A told her she would not change her. She said that she had not had any contact with CNA A on her new hall and now felt safe, but when she was in her previous hall, she did not feel safe. She stated no one approached her and asked why she moved. During an interview on 10/11/24 at 1:17 PM, the Social Worker stated that Resident #1 had requested to be moved but that she could not remember the exact date. She stated that she did not remember specifically what Resident #1 said but that she had an issue with a CNA. She stated Resident #1 did not name any specific staff but was uncomfortable with the staff on her hall. She stated she did not file a grievance on the resident's behalf. She stated Resident #1 did not appear upset when she requested to move. She stated Resident #1 had issues in the past with other residents. She stated that she may have documentation to support that Resident #1 had a history of having problems with roommates (Documentation was never provided). She stated that she did not take any further action to investigate why Resident #1 wanted to move. She stated that she had been trained and was familiar with the facility's grievance policy and process. She stated that not addressing grievances according to policy could potentially harm residents or cause their rights not to be upheld. The Social Worker stated she was aware that Resident #1 wanted to move but did not know why. She stated that she had not taken any further actions outside of initiating the room change. She said the facility's system was to follow the grievance policy, and the concern would have been assigned to the appropriate department head. She stated if the policy had been followed, Resident #1's concern would have been assigned to the DON. She stated she had not seen any abnormal activity between staff and Resident #1. She stated that if any resident expressed concern, they should look into the situation thoroughly and get back to the resident who expressed concern. She stated she did follow up with Resident #1 to see if she liked her new placement and was told by Resident #1 that she did like her new placement. She stated she and the ADM was responsible for grievances. She stated she did not follow the grievance policy because Resident #1 did not visibly seem upset. During an interview on 10/11/24 at 1:45 PM, the DON stated that Resident #1 room change was made at her request. She said it was her understanding that Resident #1 told the Social Worker that she wanted to move but did not report a reason why. The DON stated she did not follow up with the Social Worker or Resident #1 to see why Resident #1 wanted to move rooms. She stated that it was the resident's right/choice if she wanted to move rooms. The DON stated she was familiar with and had been trained on the facility policy regarding grievances. She stated that the potential negative outcome of not following the grievance policy could affect customer service and keep residents safe. She stated grievances were how residents express their concerns, and not following the policy compromises their ability to express their concerns. She stated she was unaware that a grievance had not been completed on behalf of Resident #1. She stated that the person who received the complaint should have completed a grievance and then provided it to the Social Worker. The Social Worker would then initiate the process in the EMR system. She stated that the abuse prevention ADM would then review all grievances. She stated that the appropriate department head would receive and address the grievance accordingly. She stated that everyone was responsible for grievances and did not have a reason for the Social worker not following the process. During an interview on 10/11/24 at 2:06 PM, the ADM stated she does not recall that room move for Resident #1. She stated she did not have a reason why the policy was not followed. She stated that even if she was not physically in the facility as the administrator, she was responsible for all activity that occurred in the facility. She stated that because she was not made aware of Resident #1 being upset or alleging that staff made her uncomfortable, she did not follow the abuse policy or grievance policy, investigate. or report the incident to HHSC. She stated that she was assigned to the facility as of 10/01/24, and the incident occurred prior to her transition to becoming the facility administrator. She stated she was familiar with and had been trained on the facility grievance policy. She stated that the potential negative outcome of not following the facility's grievance policy was that the residents could be unhappy. She stated that after the complaint was reported to the Social Worker, it should have been reported to the ADM and DON so that additional actions could be taken. She stated that all staff were responsible for grievances. She said she was unaware of any reason why the Social Worker did not follow the policy. Record review of the facility policy, Resident Rights, dated 2003 revealed: Policy We believe each resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside our facility. We protect and promote the following right of each resident. Each resident is encouraged and assisted, throughout the period of stay, to exercise her rights as a resident and as a citizen, and to this end, may voice grievances . Record review of the facility policy, Grievances, revised 11/2/2016 revealed: The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal . Such grievances include those with respect to care and treatment which as been furnished well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The grievance official of the facility is the administrator or their designee. The grievance official will: oversee the grievance process, receive and track grievances to their conclusion, lead any necessary investigations by the facility, issue written grievance decisions to the resident and coordinate with state and federal agencies as necessaries. As needed, the facility will take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated. All grievances involving alleged violations of neglect, abuse, injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the abuse preventionist.

Based on Interviews and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and neglect for 1 of 6 residents (Resident #1) reviewed for abuse. A. The Social Worker failed to follow the facility's abuse policy by not reporting the allegation/concern to the abuse preventionist when Resident #1 requested a room change and reported that she felt uncomfortable because of staff working in the facility. B. A confidential interview revealed that they did not follow the facility's abuse policy by not reporting the allegation/concern to the abuse preventionist when Resident #1 reported that she felt uncomfortable due to staff treatment from CNA A, CNA D, LVN E, and MA F on an unknown date. C. LVN C failed to follow the facility's abuse policy by not reporting the allegation/concern to the abuse preventionist when an unidentified staff reported that Resident #1 felt uncomfortable/dirty because of staff working in the facility. These failures could place residents as risk for abuse and neglect. Findings included: Record review of the facility policy, Resident Rights, dated 2003 revealed: Policy Each resident is free from mental and physical abuse . Record review of the facility policy, Abuse/ Neglect, revised 03/29/18 revealed: The resident has the right to be free from abuse, neglect, misappropriation of resident property . Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers . The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may continue abuse neglect to any resident in the facility. Prevention The facility will provide the residents, families, and staff an environment free from abuse and neglect. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and or Abuse Preventionist within 24 hours of complaint. Appropriate notification to state and home office will be the responsibility of the administrator and per policy. The facility will be responsible to identify, correct, intervene in situations of possible abuse/neglect. The facility has in place a method to identify occurrences, patterns, and trends that may constitute abuse. All occurrences of potential abuse or criminal behavior will be investigated by the Abuse Preventionist and or designee. Identification Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation MUST report this to the DON, administrator, state and or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the abuse preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and or designee will be called. Record review of the facility policy, Grievances, revised 11/2/2016 revealed: As needed, the facility will take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated. All grievances involving alleged violations of neglect, abuse, injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the abuse preventionist. 1.Record review of Resident #1's face sheet, dated 10/11/24, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include cognitive communication deficit, muscle weakness and urinary incontinence. Record review of Resident #1's Comprehensive Minimum Data Set, dated dated [DATE], revealed: *Section B0800. Ability to understand others, Resident #1 had clear speech, could make herself understood and usually understood others. *Section C Brief Interview for Mental Status score revealed a score of 12, which indicated the resident's cognition was moderately impaired. Record review of Resident #1's care plan, dated 08/26/24, did not reveal any indication that Resident #1 had any known behaviors, had frequent room change request or anything concerning her cognition. Record review of Resident #1's progress notes for the time period 08/10/24-10/11/24 did not reveal any information regarding Resident #1 reporting the allegation of abuse or filing a grievance regarding staff treatment. Record review of Resident #1's room form, dated 10/02/24, indicated Resident #1 initiated a room change; however, a reason was not revealed. Record review of HHSC reporting intake website did not reveal any reports/intakes of abuse involving Resident #1 from September 2024 through 10/11/24. Record review of the facility grievance report, dated from August 2024- October 2024 did not reveal a grievance regarding Resident #1 concern for CNA A. Record review of HHSC reporting intake website did not reveal any reports/intakes of abuse involving Resident #1 from August 2024 through 10/11/24. During an interview on 10/11/24 at 9:53 AM, Resident #1 stated that she was in a different hall but requested to be moved to a different hall because the staff in her previous hall was mean to her. She said she could not remember the exact date, but it was a weekend. She said CNA A was the primary staff member who was mean to her. She said she told staff she felt uncomfortable with CNA A but cannot remember who she told. She said no one was mean to her but CNA A was the only person that was. She said she felt dirty because when her adult brief needed to be changed, CNA A told her she would not change her. She said that she had not had any contact with CNA A on her new hall and now felt safe, but when she was in her previous hall, she did not feel safe. She stated no one approached her and asked why she moved. During an interview on 10/11/24 at 11:43 AM, LVN C stated that she had been trained on ANE. She said if she suspected or witnessed abuse, she had been trained to ensure resident safety and then report it to the ADM. She said Resident #1 was moved from one hall to another because the staff on her original hall made her feel uncomfortable and dirty because she had lice. She stated she did not know the details of Resident #1's complaint, or the staff involved. She stated that she received the information secondhand in report in between shifts. She said she could not remember which staff member had told her the information but that it was the night nurse from a couple of weeks ago. She stated once she received the information, she did not report the information any further. She said she was told that the ADM and the DON already knew about the situation and that rumors were unnecessary. During an interview on 10/11/24 at 12:29 PM, Family Member B stated she was not notified of Resident #1's room change and had not been notified of any allegations of ANE. An unsuccessful attempt to interview CNA A was made on 10/11/24 at 12:40 PM. An unsuccessful attempt to interview LVN E was made on 10/11/24 at 12:43 PM. During an interview on 10/11/24 at 1:17 PM, the Social Worker stated that Resident #1 had requested to be moved but that she did not remember the exact date. She stated that she did not remember specifically what Resident #1 said but that she had an issue with a CNA. She stated Resident #1 did not name any specific staff but was uncomfortable with the staff on her hall. She stated she did not file a grievance on the resident's behalf. She stated Resident #1 did not appear upset when she requested to move. She stated Resident #1 had had issues in the past with other residents. She stated that she may have documentation to support that Resident #1 had a history of having problems with roommates (Documentation was never provided). She stated that she did not take any further action to investigate why Resident #1 wanted to move. The Social Worker stated she was aware that Resident #1 wanted to move but did not know why. She stated that she had not taken any further actions outside of initiating the room change. She stated she had not seen any abnormal activity between staff and Resident #1. She stated that if any resident expressed concern, they should look into the situation thoroughly and get back to the resident who expressed concern. She stated she had been trained on ANE. If she suspects or witnesses abuse, she was instructed to report it to the ADM so that the allegations of ANE could be investigated and reported to HHSC. She could not recall if the room change, and the root cause of Resident #1 ever came up during morning meetings. During an interview on 10/11/24 at 1:45 PM, the DON stated that Resident #1's room change was made at her request. She said it was her understanding that Resident #1 told the Social Worker that she wanted to move but did not report a reason why. The DON stated she did not follow up with the Social Worker or Resident #1 to see why Resident #1 wanted to move rooms. She stated that it was the resident's right/choice if she wanted to move rooms. She stated she was familiar with and had been trained on the facility's abuse policy. She stated she was unaware that there were staff not following the abuse policy. She stated the potential negative outcome of not following the abuse policy was that it could place residents at risk for abuse. She stated that the facility's system to ensure that they were following the policy was to do annual training and frequent training on ANE. She stated that if the staff suspected or witnessed abuse, they should report immediately to the DON and ADM (also the abuse coordinator). She stated that depending on the specific incident, it would have determined how soon the incident needed to be reported to HHSC. She stated that even though it was a suspected rumor, the staff had been trained to report as it was not a place to investigate the instances. She stated that all residents' concerns should start as grievances. It will then go to the ADM as the abuse coordinator to ensure there were no allegations of ANE. She stated that the allegation of abuse would have been identified when the ADM reviewed the grievance. She stated she was not notified that Resident #1 had any issues. She stated she had not observed any abnormal activity between any staff and Resident #1. She stated all staff were responsible for following the facility's abuse policy. She stated that because she was not made aware of Resident #1 being upset or alleging that staff made her uncomfortable, she did not follow the abuse policy or grievance policy, investigate, or report the incident to HHSC. She stated that even if she was not physically in the facility as the DON, she was responsible for all activities that occurred there. A confidential interview revealed that Resident #1 disclosed to them that CNA A, CNA D, LVN E, and MA F would not provide care for her. They said they did not see it personally because it happened when they were not in the facility. They said that Resident #1 said that her brief was dirty, that Resident #1 had lice, and that the staff Resident #1 named would not care for her. They said resident #1 felt dirty when the staff did not provide care. They said resident #1 cried when she told her about the staff being mean. They said they did not report this to their abuse preventionist because everyone at the facility knew about the situation. They said it was being passed in report and everyone at the facility discussed it. They said they did report the incident to LVN C and were told by her that she would address it. They stated they had been trained that if they suspected or witnessed abuse, they were to report it to the ADM immediately. They did not have the exact incident date but believed it happened on 9/28/24. They stated they had heard CNA A can be rude, but they never reported it because everyone knew, and nothing was ever done about it because CNA A was related to LVN E. During an interview on 10/11/24 at 2:06 PM, the ADM stated she does not recall that room move for Resident #1. She stated she was familiar with and had been trained on the facility's abuse policy. She stated the potential negative outcome of not following the facility's abuse policy was the residents could be unhappy. She stated she was unaware that there were any staff in the facility not following the abuse policy. She stated the system to monitor was training the staff to follow the abuse policy. She stated staff were trained upon hire, annually, and anytime there is a facility-reported abuse-related incident. She stated she expected the facility staff to follow the abuse policy. She stated all staff were responsible for following the policy. She stated she did not have a reason why the policy was not followed. She stated that even if she was not physically in the facility as the administrator, she was responsible for all activity that occurred in the facility. She stated that because she was not made aware of Resident #1 being upset or alleging that staff made her uncomfortable, she did not follow the abuse policy or grievance policy, investigate, or report the incident to HHSC. She stated that she was assigned to the facility as of 10/01/24, and the incident occurred prior to her transition to becoming the facility administrator.

Based on interview, and record review, the facility failed to ensure 1 of 4 residents (Resident #1) reviewed for medication administration were free of significant medication errors. CMA A on [DATE] administered Resident #2's medications to Resident #1, which caused her blood pressure (BP) to decrease, and she was sent to the hospital. This failure could place residents at risk for receiving medications that were ordered for a different resident and could have possible adverse reactions. Findings included: Record review of Resident #1's Order Summary Report with active orders as of [DATE] indicated she was admitted to the facility on [DATE] with diagnoses of other specified Hypothyroidism (thyroid gland doesn't produce enough thyroid hormone that can disrupt heart rate, body temperature and all aspects of metabolism), need for assistance with personal care, Alzheimer's disease with late onset (progressive decline in episodic memory, with variable involvement of other cognitive domains), Epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizure), Hyperlipidemia, (high levels of fat particles (lipids) in the blood), Hypertension (force of the blood against the artery walls is too high), and Dementia (group of thinking and social symptoms that interferes with daily functioning). This report included the following orders for the 6 P.M. medication administration: Donepezil HCI tablet 10 mg, give 1 tablet by mouth one time a day related to Alzheimer's disease with late onset; Olanzapine oral tablet 15 mg, given by mouth at bedtime related to psychotic delusions due to known psychological condition; Pravastatin Sodium tablet 40 mg, give one tablet by mouth one time a day related to mixed hyperlipidemia; Gabapentin oral capsule 100 mg, give 1 capsule 100 mg by mouth two times a day for neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet): Keppra tablet 500 mg, give one tablet by mouth two times a day related to Epilepsy, Acetaminophen tablet 325 mg, give 2 tablets by mouth three times a day for pain, and Buspirone HCI oral tablet 10 mg, give 1.5 tablet by mouth three times a day related to dementia. Record review of Resident #1's Medication Administration Record for [DATE] - [DATE] indicated on [DATE], she was scheduled to receive at 7:00 P.M. the following medications: Donepezil HCL tablet 10 milligrams (mg) one time a day related to Alzheimer's disease with late onset, and documented with a 6 by RN A. This MAR indicated the code 6 was for hospitalized ; Olanzapine oral tablet 15 mg, give 15 mg by mouth at bedtime related to psychotic disorder with delusions due to known psychological condition and documented with a 6 by RN A; Pravastatin Sodium Tablet 40 mg, give 1 tablet by mouth one time a day related to mixed hyperlipidemia documented with a 6 by RN A; Gabapentin oral capsule 100 mg, give 1 capsule by mouth two times a day for neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), was documented with a 6 by RN A; Keppra Tablet 500 mg, give 1 tablet by mouth two times a day related to other Epilepsy, was documented with a 6 by RN A; Acetaminophen tablet 325 mg give 1 tablet by mouth three times a day for pain, give two tablets of 325 mg tablets=650 mg, Buspirone HCl oral tablet 10 mg, give 1.5 tablets by mouth three times a day related to unspecified dementia with agitation, was documented with a 6 by RN A. Record review of Resident #2's Order Summary Report with active order as of [DATE] indicated he was admitted to the facility [DATE] with diagnoses of need for assistance with personal care, cognitive communications deficit, hypertension (force of the blood against the artery walls is too high), Alzheimer's disease (a progressive disease that destroys memory and other important functions), and Hyperlipidemia (high levels of fat particles (lipids) in the blood). This report included the following orders for the 6 P.M. medication administration: Atorvastatin Calcium Oral Tablet 40 mg, give 1 tablet by mouth one time a day related to Hyperlipidemia; Levothyroxine Sodium oral tablet 88 MCG related to Hypothyroidism; and Spironolactone oral tablet, give 1 tablet by mouth two times a day for edema/fluid retention. Review of Resident #2's Medication Administration Record for [DATE] - [DATE] indicated he was supposed to be administered Atorvastatin Calcium Oral Tablet 40 mg, give 1 tablet by mouth one time a day related to Hyperlipidemia; Levothyroxine Sodium oral tablet 88 MCG (one millionth of one gram) related to Hypothyroidism; and Spironolactone oral tablet, give 1 tablet by mouth two times a day for edema/fluid retention. Record review of facility's Medication Error dated [DATE] at 6:34 P.M. indicated on [DATE] at 6:30 P.M. the error was wrong medication administered. The description of this error was There was a medication error by incorrect resident that occurred and transferred to ER. The error was caused by a medication precupping (putting medications into a cup prior to medication pass) and administering to the wrong resident. Error was discovered when Certified Medication Aide A and she reported error to LVN A. CMA A stated she identified the medication error within 5 to 10 minutes of administering medications, stopped medication pass, and notified LVN A. LVN A assessed Resident #1, who had a blood pressure (BP) of 67 over 47, which was too low (average blood pressure of ,d+[DATE] is defined as a systolic pressure of less than 120 and a diastolic pressure of less than 80). Record review of Resident #1's Nursing Progress Note written by LVN A on [DATE] at 4:56 P.M., indicated on [DATE] at 9:42 P.M. Upon assessment writer noticed Resident #1s blood pressure (BP) was below normal. No signs of distress noted. Attempted to increase BP with initiating IV fluids while awaiting DON response via phone for further instructions. 24 gauge to left wrist, started 500 ml of 0.9% sodium chloride at 250 ml/hr. No increase in BP after several minutes. Sent to hospital's ER via ambulance per DON. And Physician and responsible party were notified. Record review of Resident #1's SBAR dated [DATE] at 6:30 P.M. indicated her functional status changed because she was hypotensive (low blood pressure, which can cause fainting or dizziness because the brain doesn't receive enough blood), her blood pressure was ,d+[DATE], pulse was 50, respirations were 20, temperature 97.1 and saturation was 96 at room air. Resident #1 was administered with 24 gauge to left wrist 500 ml of 0.9% sodium chloride at 250 mL/hr (volume divided by total time in hours) with no improvement. This included order from MD to send to the ER. Record review of Resident #1's Emergency Department Document dated [DATE] indicated EMS received call from facility that Resident #1 received Spironolactone and her blood pressure was running low. EMS noted Resident 1's pulse rate was 50, oxygen saturation was 94, and blood pressure was ,d+[DATE]. This report indicated complaint for Resident #1 was for hypotensive, and she was transferred to the ER. During an interview on [DATE] at 11:42 A.M. Family Member (FM A) indicated on [DATE] at approximately 9 P.M., LVN A called her to inform her that Resident #1 was sent to the hospital because her blood pressure was low and if she tested ok, she would return to the facility. RP A said LVN A did not inform her that Resident #1 was administered medications that belonged to another resident at approximately 6:30 pm. RP A said the hospital's nurse (unknown name) informed her that facility's staff said they had administered Resident #1 too much Spironolactone (diuretic). FMA asked how much, and the nurse replied 25 mg. That was when RP A informed the hospital nurse that Resident #1 does not take Spironolactone. On [DATE], RP A said she called the facility and spoke to the Administrator and informed him the hospital nurse informed her the facility's staff gave Resident #1 too much Spironolactone, which caused her blood pressure to decrease. The Administrator informed her that CMA A administered Resident #2's medication to Resident #1. RP A said she was upset because the facility on [DATE] did not inform her of Resident' #1s medication error or that they had to start an IV on her before she was sent to the hospital. RP A said facility's staff know they are supposed to call her, especially with giving Resident #1 another resident's medication, that caused her to be administered an IV at the facility. FMA said Resident #1 is ill, frail, confused and could have died . During an interview on [DATE] at 4:24 P.M. with LVN B said she was working on [DATE] when LVN A informed her CMA A administered Resident #2's medications to Resident #1. LVN B said LVN A reported that Resident #1's blood pressure had dropped because she was administered Spironolactone and wanted to know the fastest way to increase her blood pressure. LVN B directed her to notify the physician. Shortly afterwards, LVN B said she saw LVN A with all the supplies for administering an IV. During an interview on [DATE] at 8:01 A.M. CNA A indicated she was working on [DATE] when at approximately 6:30 P.M. she overheard a CMA A say Resident #2's medication was administered to Resident #1. Afterwards, CNA A said she saw LVN A continuously entering Resident #1's room, and LVN A placed an IV on her arm. During an interview on [DATE] at 8:24 A.M. LVN A indicated she was working on [DATE], when at approximately 6:37 P.M. CMA A said she administered Resident #2's medications to Resident #1. LVN A said CMA A got confused with the medications because the cups, which had been set up before she started her shift, had Resident #2's first name and Resident #1's last name, which are almost the same. LVN A said she monitored Resident #1's blood pressure, which remained between ,d+[DATE] and 15 minutes later at ,d+[DATE] (average blood pressure of ,d+[DATE] is defined as a systolic pressure of less than 120 and a diastolic pressure of less than 80). LVN A said she did not call the MD A immediately because Resident #1 did not have any signs or symptoms of distress but did call him later. MD A directed her to send Resident #1 to the hospital's emergency room (ER). LVN A said at 9:50 P.M. she sent Resident #1 to the ER, then notified RP Aat 9:52 P.M. LVN A said CMA A, who normally works as the CNA, was asked to fill in as the CMA, because the CMA scheduled to work had to leave early. LVN said she recalled seeing two cups labeled with Resident #'s last name and Resident #1's last name, which are almost the same. During an interview on [DATE] at 9:17 A.M. CMA A indicated she was asked to fill in as the CMA on [DATE], because the CMA on duty could not work late. CMA A said she went to the facility and directly into the medication room, where she was met by LVN C, who gave her report and directed her to pass the medications. CMA A said she started her medication pass and saw that all the medications were in cups labeled with resident's names in the medication cart. CMA A said in the middle of administering medications, the DON directed her to go to hall 200; even though she told her she was administering medications. CMA A said in hall 200, which was the secured unit, she filled in as the CNA and CMA. Afterwards she returned to the main dining area where she continued administering medications from two medication carts that had cups with medications and labeled with residents' names. CMA A said she administered Resident #1 her medications, but when she walked away, she realized the cup was labeled with Resident #2's first name, which closely matches Resident #1's last name. CMA A said she immediately informed LVN A of this error. During an interview on ,d+[DATE] 24 at 10:42 A.M. with LVN D indicated she was working on [DATE], when she pulled medications for CMA A to store in her carts. LVN D said she did not see medications cup with pills in the medication cart. During an interview on [DATE] at 12:26 P.M. with DON indicated on [DATE] CMA B was assigned to work from 6 A.M. to 4 P.M. and CMA C was assigned to work from 6 P.M. to 7 P.M.; however; she could not work. DON contacted CMA Awho agreed to work as the CMA from 4 P.M. to 7 P.M. DON said she was not aware the medications were placed into cups and labeled with the residents' names. After the medications error involving Resident #1 being administered Resident #2's medications on [DATE] at approximately 6:30 P.M. and CMA A took full responsibility for this error. DON said LVN A left her a message at 6:50 P.M. informing her about the medication error and did not make it sound urgent and to call her at her earliest convenience. DON said later, LVN A informed her that MD A had given an order to administer IV to Resident #1 because her blood pressure was ,d+[DATE] (normal range ,d+[DATE]) for more than an hour. That was when DON called LVN A and directed her to suspend CMA A. During an interview on [DATE] at 11:04 AM, CMA B indicated she worked on [DATE] from approximately 6 A.M. to 2 P.M., when she was informed by DON that CMA A would take over her shift because she had to leave early. CMA B said she asked DON if she could help CMA A with the medications, because she had never administered medications to the residents at the facility, and she was not familiar with the medication carts and process. The DON replied she could help her out, and that was why she set up cups with medications and labeled them with resident's names. CMA B said she recalled labeling a cup with Resident #2's first name and Resident #1's last name, which are very similar. Afterwards, CMA B said she left the facility at 2 P.M. and CMA A started her shift at 4 P.M. Record review of the facility's policy and procedure dated 2003 for Medication Administration Procedures indicated Open the unit dose package only when you are administering medication directly to the resident. Removing the medication from its unit dose packaging in advance lessens the ability to positively identify the medication and increase the chances of drug administration errors and contamination. Before administering the dose, the nurse must make certain to correctly identify the resident to whom the medication is being administered. After the resident has been identified, administer the medication and immediately chart doses administered on the medication administration record. It is recommended that medications be charted immediately after administration, but if facility policy permits, medications may be charted immediately before administration. Initials are to be used. Check marks are not acceptable.

Based on interview and record review, the facility failed to immediately notify the resident's physician and representative(s) when there was a significant change in the resident's physical status for one (Resident #1) of four residents reviewed for changes in condition, in that: The facility failed to immediately notify the Physician (MD A) and Responsible Party (RP A) of a medication error that involved Resident #1 receiving resident#2's medication. This error cause Resident #1's blood pressure to decrease, to be administered and IV, and to be sent to the hospital. This failure placed residents at risk of not having physician (MD) and Responsible Party (RP) input and involvement in their care and treatment decisions. Findings included: Record review of Resident #1's Order Summary Report with active orders as of [DATE] indicated she was admitted to the facility on [DATE] with diagnoses of other specified Hypothyroidism (thyroid gland doesn't produce enough thyroid hormone that can disrupt heart rate, body temperature and all aspects of metabolism), need for assistance with personal care, Alzheimer's disease with late onset (progressive decline in episodic memory, with variable involvement of other cognitive domains), Epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizure), Hyperlipidemia, (high levels of fat particles (lipids) in the blood), Hypertension (force of the blood against the artery walls is too high), and Dementia (group of thinking and social symptoms that interferes with daily functioning). This report included the following orders for the 6 P.M. medication administration: Donepezil HCI tablet 10 mg, give 1 tablet by mouth one time a day related to Alzheimer's disease with late onset; Olanzapine oral tablet 15 mg, given by mouth at bedtime related to psychotic delusions due to known psychological condition; Pravastatin Sodium tablet 40 mg, give one tablet by mouth one time a day related to mixed hyperlipidemia; Gabapentin oral capsule 100 mg, give 1 capsule 100 mg by mouth two times a day for neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet): Keppra tablet 500 mg, give one tablet by mouth two times a day related to Epilepsy, Acetaminophen tablet 325 mg, give 2 tablets by mouth three times a day for pain, and Buspirone HCI oral tablet 10 mg, give 1.5 tablet by mouth three times a day related to dementia. Record review of Resident #1's Medication Administration Record for [DATE] - [DATE] indicated on [DATE], she was scheduled to receive at 7:00 P.M. the following medications: Donepezil HCL tablet 10 milligrams (mg) one time a day related to Alzheimer's disease with late onset, and documented with a 6 by RN A. This MAR indicated the code 6 was for hospitalized ; Olanzapine oral tablet 15 mg, give 15 mg by mouth at bedtime related to psychotic disorder with delusions due to known psychological condition and documented with a 6 by RN A; Pravastatin Sodium Tablet 40 mg, give 1 tablet by mouth one time a day related to mixed hyperlipidemia documented with a 6 by RN A; Gabapentin oral capsule 100 mg, give 1 capsule by mouth two times a day for neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), was documented with a 6 by RN A; Keppra Tablet 500 mg, give 1 tablet by mouth two times a day related to other Epilepsy, was documented with a 6 by RN A; Acetaminophen tablet 325 mg give 1 tablet by mouth three times a day for pain, give two tablets of 325 mg tablets=650 mg, Buspirone HCl oral tablet 10 mg, give 1.5 tablets by mouth three times a day related to unspecified dementia with agitation, was documented with a 6 by RN A. Record review of Resident #2's Order Summary Report with active order as of [DATE] indicated he was admitted to the facility [DATE] with diagnoses of need for assistance with personal care, cognitive communications deficit, hypertension (force of the blood against the artery walls is too high), Alzheimer's disease (a progressive disease that destroys memory and other important functions), and Hyperlipidemia (high levels of fat particles (lipids) in the blood). This report included the following orders for the 6 P.M. medication administration: Atorvastatin Calcium Oral Tablet 40 mg, give 1 tablet by mouth one time a day related to Hyperlipidemia; Levothyroxine Sodium oral tablet 88 MCG related to Hypothyroidism; and Spironolactone oral tablet, give 1 tablet by mouth two times a day for edema/fluid retention. Review of Resident #2's Medication Administration Record for [DATE] - [DATE] indicated he was supposed to be administered Atorvastatin Calcium Oral Tablet 40 mg, give 1 tablet by mouth one time a day related to Hyperlipidemia; Levothyroxine Sodium oral tablet 88 MCG (one millionth of one gram) related to Hypothyroidism; and Spironolactone oral tablet, give 1 tablet by mouth two times a day for edema/fluid retention. Record review of facility's Medication Error dated [DATE] at 6:34 P.M. indicated on [DATE] at 6:30 P.M. the error was wrong medication administered. The description of this error was There was a medication error by incorrect resident that occurred and transferred to ER. The error was caused by a medication precupping (putting medications into a cup prior to medication pass) and administering to the wrong resident. Error was discovered when Certified Medication Aide A and she reported error to LVN A. CMA A stated she identified the medication error within 5 to 10 minutes of administering medications, stopped medication pass, and notified LVN A. LVN A assessed Resident #1, who had a blood pressure (BP) of 67 over 47, which was too low (average blood pressure of ,d+[DATE] is defined as a systolic pressure of less than 120 and a diastolic pressure of less than 80). Record review of Resident #1's Nursing Progress Note written by LVN A on [DATE] at 4:56 P.M., indicated on [DATE] at 9:42 P.M. Upon assessment writer noticed Resident #1s blood pressure (BP) was below normal. No signs of distress noted. Attempted to increase BP with initiating IV fluids while awaiting DON response via phone for further instructions. 24 gauge to left wrist, started 500 ml of 0.9% sodium chloride at 250 ml/hr. No increase in BP after several minutes. Sent to hospital's ER via ambulance per DON. And Physician and responsible party were notified. Record review of Resident #1's SBAR dated [DATE] at 6:30 P.M. indicated her functional status changed because she was hypotensive (low blood pressure, which can cause fainting or dizziness because the brain doesn't receive enough blood), her blood pressure was ,d+[DATE], pulse was 50, respirations were 20, temperature 97.1 and saturation was 96 at room air. Resident #1 was administered with 24 gauge to left wrist 500 ml of 0.9% sodium chloride at 250 mL/hr (volume divided by total time in hours) with no improvement. This included order from MD to send to the ER. Record review of Resident #1's Emergency Department Document dated [DATE] indicated EMS received call from facility that Resident #1 received Spironolactone and her blood pressure was running low. EMS noted Resident 1's pulse rate was 50, oxygen saturation was 94, and blood pressure was ,d+[DATE]. This report indicated complaint for Resident #1 was for hypotensive, and she was transferred to the ER. During an interview on [DATE] at 11:42 A.M. Family Member (FM A) indicated on [DATE] at approximately 9 P.M., LVN A called her to inform her that Resident #1 was sent to the hospital because her blood pressure was low and if she tested ok, she would return to the facility. RP A said LVN A did not inform her that Resident #1 was administered medications that belonged to another resident at approximately 6:30 pm. RP A said the hospital's nurse (unknown name) informed her that facility's staff said they had administered Resident #1 too much Spironolactone (diuretic). FMA asked how much, and the nurse replied 25 mg. That was when RP A informed the hospital nurse that Resident #1 does not take Spironolactone. On [DATE], RP A said she called the facility and spoke to the Administrator and informed him the hospital nurse informed her the facility's staff gave Resident #1 too much Spironolactone, which caused her blood pressure to decrease. The Administrator informed her that CMA A administered Resident #2's medication to Resident #1. RP A said she was upset because the facility on [DATE] did not inform her of Resident' #1s medication error or that they had to start an IV on her before she was sent to the hospital. RP A said facility's staff know they are supposed to call her, especially with giving Resident #1 another resident's medication, that caused her to be administered an IV at the facility. FMA said Resident #1 is ill, frail, confused and could have died . During an interview on [DATE] at 4:24 P.M. with LVN B said she was working on [DATE] when LVN A informed her CMA A administered Resident #2's medications to Resident #1. LVN B said LVN A reported that Resident #1's blood pressure had dropped because she was administered Spironolactone and wanted to know the fastest way to increase her blood pressure. LVN B directed her to notify the physician. Shortly afterwards, LVN B said she saw LVN A with all the supplies for administering an IV. During an interview on [DATE] at 8:01 A.M. CNA A indicated she was working on [DATE] when at approximately 6:30 P.M. she overheard a CMA A say Resident #2's medication was administered to Resident #1. Afterwards, CNA A said she saw LVN A continuously entering Resident #1's room, and LVN A placed an IV on her arm. During an interview on [DATE] at 8:24 A.M. LVN A indicated she was working on [DATE], when at approximately 6:37 P.M. CMA A said she administered Resident #2's medications to Resident #1. LVN A said CMA A got confused with the medications because the cups, which had been set up before she started her shift, had Resident #2's first name and Resident #1's last name, which are almost the same. LVN A said she monitored Resident #1's blood pressure, which remained between ,d+[DATE] and 15 minutes later at ,d+[DATE] (average blood pressure of ,d+[DATE] is defined as a systolic pressure of less than 120 and a diastolic pressure of less than 80). LVN A said she did not call the MD A immediately because Resident #1 did not have any signs or symptoms of distress but did call him later. MD A directed her to send Resident #1 to the hospital's emergency room (ER). LVN A said at 9:50 P.M. she sent Resident #1 to the ER, then notified RP Aat 9:52 P.M. LVN A said CMA A, who normally works as the CNA, was asked to fill in as the CMA, because the CMA scheduled to work had to leave early. LVN said she recalled seeing two cups labeled with Resident #'s last name and Resident #1's last name, which are almost the same. During an interview on [DATE] at 9:17 A.M. CMA A indicated she was asked to fill in as the CMA on [DATE], because the CMA on duty could not work late. CMA A said she went to the facility and directly into the medication room, where she was met by LVN C, who gave her report and directed her to pass the medications. CMA A said she started her medication pass and saw that all the medications were in cups labeled with resident's names in the medication cart. CMA A said in the middle of administering medications, the DON directed her to go to hall 200; even though she told her she was administering medications. CMA A said in hall 200, which was the secured unit, she filled in as the CNA and CMA. Afterwards she returned to the main dining area where she continued administering medications from two medication carts that had cups with medications and labeled with residents' names. CMA A said she administered Resident #1 her medications, but when she walked away, she realized the cup was labeled with Resident #2's first name, which closely matches Resident #1's last name. CMA A said she immediately informed LVN A of this error. During an interview on ,d+[DATE] 24 at 10:42 A.M. with LVN D indicated she was working on [DATE], when she pulled medications for CMA A to store in her carts. LVN D said she did not see medications cup with pills in the medication cart. During an interview on [DATE] at 12:24 P.M. MD A indicated the nurse should have notified him immediately after she was notified of the medication error that involved Resident #1 being administered Resident #2's medication. During an interview on [DATE] at 12:26 P.M. with DON indicated on [DATE] CMA B was assigned to work from 6 A.M. to 4 P.M. and CMA C was assigned to work from 6 P.M. to 7 P.M.; however; she could not work. DON contacted CMA A who agreed to work as the CMA from 4 P.M. to 7 P.M. DON said she was not aware the medications were placed into cups and labeled with the residents' names. After the medications error involving Resident #1 being administered Resident #2's medications on [DATE] at approximately 6:30 P.M. and CMA A took full responsibility for this error. DON said LVN A left her a message at 6:50 P.M. informing her about the medication error and did not make it sound urgent and to call her at her earliest convenience. DON said later, LVN A informed her that MD A had given an order to administer IV to Resident #1 because her blood pressure was ,d+[DATE] (normal range ,d+[DATE]) for more than an hour. That was when DON called LVN A and directed her to suspend CMA A. DON said LVN A should have called MD A immediately and family prior to calling her. During an interview on [DATE] at 11:04 AM, CMA B indicated she worked on [DATE] from approximately 6 A.M. to 2 P.M., when she was informed by DON that CMA A would take over her shift because she had to leave early. CMA B said she asked DON if she could help CMA A with the medications, because she had never administered medications to the residents at the facility, and she was not familiar with the medication carts and process. The DON replied she could help her out, and that was why she set up cups with medications and labeled them with resident's names. CMA B said she recalled labeling a cup with Resident #2's first name and Resident #1's last name, which are very similar. Afterwards, CMA B said she left the facility at 2 P.M. and CMA A started her shift at 4 P.M. Record review of the facility's policy and procedure dated 2003 indicated Medication errors and adverse drug reactions are immediately reported to the resident's Physician. In addition, the Director of Nurses and/or designee should be notified of any medication's errors. The policy and procedure for Medication Incident Report Procedure dated 2003 indicated The attending physician and family member will be promptly notified of any medication administration incident. The policy and procedure for Resident Rights dated [DATE] indicated the resident had the right for Notification of changes, A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative.

Based on interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #3) reviewed for accidents and hazards. NA A used a sliding board to transfer Resident #3 on a sliding board she had not been trained to use. This deficient practice could place residents transferred via sliding board at risk of falls which could result in injury and hospitalization . Findings include: Record review of Resident #3's Admission Record indicated he was admitted to the facility on [DATE]. This report included his diagnoses as pressure ulcer of right heel (caused by factors such as pressure shear and friction) and acquired absence of left leg below the knee. Record review of Resident #3's Admission Minimum Data Set (MDS) assessment dated [DATE] indicated he scored a 14 on his Brief Interview for Mental Status, which indicated he was cognitively intact. This MDS's Functional Abilities and Goals indicated he used a wheelchair; and the area for transfers and toileting were left blank. Record review of Resident #3's Fall-Risk assessment dated [DATE] indicated he was admitted to the facility on [DATE] with diagnoses of pressure ulcer of right heel and acquired absence of left leg below the knee and had scored a 6 (medium risk). And his predisposing conditions included hypotension (can cause fainting or dizziness because the brain doesn't receive enough blood), vertigo (a sensation of motion or spinning that is often described as dizziness), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), loss of limb, seizures (uncontrolled jerking, loss of consciousness, blank stares, or other symptoms caused by abnormal electrical activity in the brain, arthritis (swelling and tenderness in one or more joints, causing joint pain or stiffness that often gets worse with age), osteoporosis, and fractures (the cracking or breaking of a bone). This report indicate Resident #3 could not stand. Record review of Resident #3's Initial Skin assessment dated [DATE] indicated he had no bruises, skin tears, abrasion, lacerations, surgical incision, rash, and other skin findings (unstageable to right heel, no treatment orders at this time). Record review of Resident #3's Event Nurses' Note - Fall dated 05/09/24 and signed by RN B, reflected he had an assisted fall, and he was oriented. The nursing description of the event indicated he had active range of motion to bilateral lower extremities, tender upon touch to left side, physician was notified of finding and received order for portable x-ray to left hip and left femur and continue to monitor per facility's policy and procedures. Resident #3 rated his pain on a scale of 1 to 10 at a 3. This report indicted Resident #3 said the girl was putting me on the toilet with the board, it moved, she held me, and I hurt my hip area. The physician was notified on 05/09/24 at 1 pm. Record review of Skilled Nurses Notes dated 05/08/24 indicated Resident #3 indicated he had no pain in the last 5 days, and for transfers, he needs help with sit to stand, chair/bed to chair transfer, and toilet transfer. Record review of Resident #1's Radiology Report dated 05/09/24 at 4:15 P.M. the x-rays to the left femur indicated he had no definite evidence of acute fracture or dislocation, he had mild osteoporosis (bones are weak and brittle), and mild osteoarthritis (arthritis that occurs when flexible tissue at the ends of bone wears down). Record review of Resident #1's Nursing Progress Report dated 05/10/24 at 4:09 P.M. Indicated his pelvis pain, was due to osteopenia (body does not make new bone as quickly as it reabsorbs old bone, and degenerative disease (function or structure of the affected tissue or organs changes for the worse over time, no acute pathology). Review of MDS dated [DATE] indicated Resident #3 discharged from the facility on 05/10/24 (approximatley 7:43 per family member). During a telephone interview on 05/13/24 at 12:56 P.M., Family Member (FM A) assisted Resident #3 with this interview, and he said he needed to go to the bathroom. That was when Nurse Aide (NA A) directed him to place his arms around her neck as she transferred him from the bed to the wheelchair as he sat and slid across the sliding board. Resident #3 said NA A used the same method to transfer him from his wheelchair to the toilet, but the board slipped, and he landed on the stump causing it to open. Resident #3 said NA A struggled to put him back on the toilet but between them, he was able to slide back onto the board to his wheelchair. Resident #3 said he was at the facility for therapy but due to this injury he asked his family to take him home, because he feared being dropped again. On 05/10/24, Resident #3 said he informed FM A that he was dropped while being transferred and his hip was hurting. FM A said she discharged him from the facilty on 05/10/24 at approximatley 7:43 pm. During an interview on 05/13/24 at 3:07 P.M, with Director of Rehabilitation (DOR) indicated Resident #3's PT evaluation dated 05/09/24 included he reported having fallen during the night while being transferred. On 05/09/24, DOR said he overheard Resident #3 report to Physical Therapist Assistant (PTA A) that he was dropped but she did not see a fall report. DOR said she asked Resident #1 if he was in pain and he said yes on his left leg and hip, and he showed her the scab on his stump that had opened. DOR said Resident #3 should not have been transferred by staff via a sliding board, because there must be an in-service and demonstration on the use of this board by the rehabilitation department. During an interview on 05/13/24 at 3:56 P.M. with PTA A indicated he was teaching Resident #3 on the use of the sliding board, when Resident #1 said he fell off the sliding board and hit the floor, when an NA (tried to transfer him on the sliding board that was in his room.) PTA A said Resident #3 complained of hip pain and pain on his stump, and a gash on his stump, as witnessed by PTA A. During an interview on 05/13/24 at 4:24 P.M. with LVN B indicated she worked caring for Resident #3 from 6 P.M. on 05/08/24 to 6 A.M. on 05/09/24 and the Nurse Aide caring for him was NA A. LVN B said it was not reported to her that Resident #1 had a fall during the night, and if he had one, the NA was responsible for reporting this to her charge nurse. During an interview on 05/13/24 at 7:25 P.M. RN A indicated she was not aware Resident #3 had fallen during the night and did not receive that during her shift report on 05/09/24 at 6 AM. RN A said NA A was the only assigned staff to Hall 100 from 6 P.M. on 05/08/24 to 6 A.M. on 05/09/24, and she never mentioned any issues with transferring Resident #3. During an interview on 05/13/24 at 8:20 A.M. with Nurse Aide (NA A) indicated she was working hall 100, when Resident #3 requested to go to the toilet. NA A said she assisted Resident #3 from his bed to his wheelchair by sliding on his sliding board. In the bathroom, NA A said she transferred Resident #3 from his wheelchair to the toilet using the sliding board. NA A said she was standing behind Resident #3 when his buttocks slipped off. That was when she placed her arms under his arm pits and after struggling, she managed to put him back on the board. NA A said Resident #3 went down a bit, but she squatted and used her leg strength to keep him from falling. Afterwards, NA A said she put him on his wheelchair as he scooted on the sliding board, then transferred him back on his bed in the same manner using the sliding board. NA A said at the start of her shift she didn't receive a shift report, and this was the first time she met Resident #3 was when she transferred him. NA A said she didn't know he had a missing leg. NA A said she did not ask for a second person to assist her with Resident #3's transfer because he told her what to do. NA A said she had not been in-serviced on how to use a sliding board, and this was the first time she had used one to transfer a resident. NA A said she did not report this incident because Resident #3 did not fall to the floor, instead she stopped him from falling on the floor. During an interview on 05/14/24 at 12:26 pm with DON indicated an unintentional change in plane is considered a fall, which includes a resident being assisted to the floor by staff. DON said she was informed on 05/09/24 that Resident #3 sustained a fall while NA A was using a sliding board. DON said NA A was using a sliding board that she had not been trained to use. DON said she did not even know Resident #3 was using a sliding board. Record review of policies and procedures for Preventive Strategies to Reduce Fall Risk dated 10/05/2016 indicated The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintain or improving the resident's mobility. Procedures: After risk is assessed, individualized nursing care plan will be implemented to prevent fall. The resident and family members will be educated on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family, implementing rehabilitation programs to improve functional ability, and care monitoring of medication side effects. Incident Reporting: Reported falls will be thoroughly investigated to assess fall risk factors and contributing factors in order to provide a safe environment for the residents. Education: the importance of calling for assistance during periods of increased risk, and what to do if a fall occurs etc. Record review of Job Description for Student Nurse Aide dated 2010 indicated Ambulate and transfer residents, utilizing appropriate assistive devices and body mechanics. And this position reports directly to the Charge Nurse.

Based on interview and record review the facility failed to ensure the residents had the right to be free from neglect for 2 of 5 residents (Resident #1, Resident #2), reviewed for neglect. CNA A neglected Resident #1 by failing to provide 1 person assistance and clocking out without informing the oncoming shift when she left Resident #1 alone in the facility shower room. CNA A neglected Resident #2 by failing to provide 1 person assistance when she left Resident #2 in a shower chair alone in his restroom shower area when she took Resident #1 to the shower room down the hall. This failure could affect all residents by placing them at risk of neglect, falls, mental anguish and emotional distress. Findings include: Record review of a face sheet dated [DATE] revealed Resident #1 was a [AGE] year-old male and admitted on [DATE] with diagnoses including Parkinson's disease (a progressive disorder that affects the central nervous system), Muscle wasting and atrophy (breakdown of muscles), unspecified abnormalities of gait and mobility, lack of coordination, cognitive communication deficit, muscle weakness. Record review of the quarterly MDS dated [DATE] revealed Resident # 1 had a BIMS of 11 which indicated moderate cognitive impairment. Resident #1 required Supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for toileting hygiene, upper body dressing personal hygiene, Sit to lying, sit to stand, chair/bed to chair transfer and toilet transfer; Substantial/Maximal assistance (helper does more than half the effort. Helper lifts or hold trunk or limbs and provides more than half the effort) for Shower/bathing and tub/shower transfer; and Partial/Moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs but provides less than half the effort) for lower body dressing and putting on/taking off footwear. Resident #1 required use of a manual wheelchair and had a documented history of falls in which 2 or more resulted in no injuries and 1 fall that resulted in an injury. Record review of Resident #1's care plan dated [DATE] revealed a diagnosis of Parkinson's disease with an intervention to monitor for risk of falls; monitor/document/report signs/symptoms of poor coordination, tremors, gait disturbance and decline in range of motion. Focus area: Fall risk with actual falls on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] with interventions: anticipate and meet resident needs, call light within reach and safe environment with even floors, free from spills and/or clutter, working and reachable call light, handrails on walls, personal items within reach. Resident #1 has an ADL self-care performance deficit and requires 1 staff for assistance for bathing, bed mobility, dressing, eating, toilet use, transferring, walking, personal hygiene/oral care, uses wheelchair and encourage resident to use bell to call for assistance. Record review of a face sheet dated [DATE] revealed Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Parkinson's, Cellulitis (bacterial infection involving inner layers of skin), Chronic Obstructive Pulmonary Disease (COPD refers to a group of diseases that cause airflow blockage and breathing-related problems), Muscle Wasting and Atrophy (breakdown of muscle), Muscle Weakness, Lack of coordination, history of falling, abnormal posture. Record review of the quarterly MDS dated [DATE] revealed Resident #2 had a BIMS of 13 which indicated intact cognition. Resident #1 required Substantial/Maximal assistance (helper does more than half the effort. Helper lifts or hold trunk or limbs and provides more than half the effort) for Shower/bathing and personal hygiene; Partial/Moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs but provides less than half the effort) for oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear; Dependent (helper does all the effort. Resident does none of the effort to complete the activity or requires 2 or more helpers) for tub/shower transfer. Resident #1 requires use of a manual wheelchair and has a documented history of falls in which fall that resulted in no injury. Record review of Resident #2's care plan dated [DATE] revealed a diagnosis of Parkinson's disease with an intervention to monitor for risk of falls; monitor/document ability to perform ADLS; Risk of falls due to incontinence, Parkinson's and fluctuating cognition, with interventions that included call light in reach, appropriate footwear, keep bed in lowest position with wheels locked, furniture in locked position, safe environment with even floors, free from spills and/or clutter, working and reachable call light, handrails on walls, personal items within reach, staff x1 to assist with transfers; ADL self-care performance deficit that requires interventions of 1x staff assistance for bathing, bed mobility, dressing, toilet use, transferring and requires use of wheelchair. Resident #2 requires total assist for bathing/showering. Record review of the facility provided Provider Investigation Report, revealed incident date [DATE] at 6:30 a.m. in Hall 200 shower room for Neglect of Resident #1 by alleged perpetrators CNA A and CNA B. Description of the allegation, it is alleged that staff left [Resident #1] in the shower room unattended for approximately 20 minutes. Investigation Summary: On [DATE], [Resident #1] was found unaccompanied in the shower room by day staff coming on shift. When asked why he was in the shower by himself, he stated that a lady had wheeled him in there to shower and left him there by himself. He stated that he had been in there approximately ,d+[DATE] minutes. He was found at approximately 6:04a.m. Staff said to be involved were suspended pending further investigation. Interviews were conducted and it was found that [CNA A] was working the 200 halls on [DATE] and admitted to leaving [Resident #1] in the shower room. Investigation findings: Confirmed. Post investigation provider action: Continued Resident monitoring, continued in-services of abuse/neglect and not leaving residents in the shower room unattended. [CNA A] was terminated, and [CNA B] was allowed to return to work. Record Review of the facility provided Incident Report dated [DATE] at 12:56 p.m. documented by the DON revealed: Received report from staff that while getting residents up for breakfast and doing initial beginning of shift rounds, resident was found to have been left in the shower room unattended. Mental status documented as: orientated to place, person, and situation. No injuries observed post incident. Record review of CNA A's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, I worked hall 200 from 10 p-6a. In the beginning of my last round I asked [Resident #1] if he wanted to take his shower and he denied his shower but asked if I could help him get dressed. I proceeded with assisting him with getting dressed. After helping him I get [Resident #2] up for his shower and while gathering [Resident #2's] things for his shower, [Resident #1] asked if he could use the restroom. I informed him that [Resident #2] was in the shower already and it'd be a little bit and he asked if he could use another residents restroom, but I told him we can't go into another residents room to use their restroom. I told him I was on my way to the big shower room to grab towels for [Resident #2] and if he would like to use the restroom in there. He (Resident #1) agreed, and I took him. I told him I would be back soon and let him take his time while I showered [Resident #2]. I continue to check on him after I'm done with [Resident #2's] shower and he tells me after each time I've asked him, that he's not done yet. I told him to call me on the light when he's ready to get out, but he never does. I go back 3 minutes before 6 am to check on him and he informed me he still wasn't finished. I tell him to still call but it was close to shift change so I didn't know if it would be me or another CNA helping him out the restroom. Within the minutes passing, I'm on my way to tell a nurse but go back to my hall to gather my things before leaving. I do get distracted and made the mistake of not informing a charge nurse and leave the building. [Resident #1] was only in the shower room to use the restroom but never for a shower. Record review of CNA C's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, The morning of [DATE] at approximately 6:04 a.m., upon unlocking shower room I noticed [Resident #1] completed unclothed, shaking from lack of heat on shower chair. My coworker LVN was also present in shower room and noticed patient unclothed in shower chair. I asked [Resident #1] why he was alone in shower room. [Resident #1] stated the girl (night shift aide) left me in here to shower and said she will be back but never followed back I was still waiting. So I assured [Resident #1] I would bathe and dress him to which he thanked me for not leaving patient by himself. Shower was completed. Patient dressed, assisted to chair, assisted to dining room for breakfast. Record review of the LVN's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, This morning upon entering locked shower room, patient [Resident #1] was on the shower chair completely undressed. Lights were on, heater off, water off as well. When this writer asked patient what are you doing in here by yourself? Patient stated, the girls told me to shower and would be back, but they never came back. I have been in here waiting. This writer and other aide (CNA C) repositioned patient on shower chair and bathed patient, clean clothes were put on patient and assisted patient to wheelchair. This writer then informed DON of what happened. [Resident #1] was assisted to dining room for breakfast. Record review of Resident #1's statement taken by the facility ADM, signed, and dated [DATE] from the [DATE] provider investigation report, revealed in part, Patient stated, I was undressed on the shower chair this morning. I say I was in there about 20 minutes alone in the shower. I was scared they wouldn't shower me since I hadn't been showered in 3 or 4 days. She has long black hair, real pretty, I don't remember the color of her shirt. She is one of the sisters that works here. Patient was asked by this writer Have they ever not showered you? Patient responded yes. I was glad [CNA C] came in and found me. Record review of CNA B's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, I was working hall 400, [DATE]. I did not assist [Resident #1]. I had no knowledge of the incident until 20 minutes after 6 a.m. that morning. Record review of the BOM's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, I was serving as a witness to a phone call with [DON] and [CNA A] on [DATE]. During this phone call, [CNA A] stated she was at fault for the entire situation and stated [CNA B] had nothing to do with this as [CNA B] was on another hall. [CNA A] again stated, this is all on me. I did it, [CNA B] doesn't have anything to do with this. Record review of the DOR's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, I spoke with [Resident #1] about what happened [DATE] with the shower room. [Resident #1] stated that a young pretty girl took me in the shower room. I sat in a shower chair. She left because she forgot something. I did ask [Resident #1] if he knew how long and he stated, no but felt like over 30 minutes. I asked him if he got worried about falling or when she would come back and he said no, I knew I would be ok. During an interview with the DON on [DATE] at 6:24 a.m. she stated on [DATE] she was informed by the LVN that she and CNA C found Resident #1 alone in the shower room on a shower chair and was he was nude. The DON stated that Resident #1 stated that he was left alone in the shower room by a female staff who was later identified as CNA A. The DON stated that initially the facility was unsure of which CNA it was because Resident #1 stated it was one of the sisters and CNA A and CNA B were sisters. The DON stated that CNA A stated that she had left Resident #1 on the commode, and he was fully dressed. The DON stated that Resident #1's care plan required assistance with transfers, using the restroom, showers and changing clothes. The DON stated she believed that CNA A neglected Resident #1 when she left Resident #1 alone in the shower room. The DON stated that the risk of CNA A leaving Resident #1 unattended included that Resident #1 could fall and that could result in injuries, and no one would have known to look for him in the shower room. The DON stated that Resident #1 was found on the shower chair and not on the commode and Resident #1 could not have transferred himself from the commode to the shower chair himself at that time. The DON stated Resident #1 had Parkinson's disease and a week prior leading up to the incident he had a decline and was completely dependent on staff. The DON stated that had Resident #1 had any significant health issue like a cardiac arrest and his decline, or if he had fallen or had a significant health issue, being left alone like that could have resulted in death and no one would have known he was in there until he was accidently discovered. The DON stated that all staff were trained on care plans and CNA A had been trained on showering, abuse, and neglect. The DON stated that Resident #1 was deceased and died a few days after the incident. The DON stated there was no reason to believe that the incident had anything to do with his death due to Resident #1 not having any injuries from being left alone. The DON stated that at no time should a resident who required 1 person assist be left alone in the shower room. During an interview on [DATE] at 8:40 a.m. the LVN stated that on [DATE] she arrived shortly after 6 a.m. to assist CNA C with shower duties. The LVN stated that shortly after 6:00 a.m. she entered the shower room behind CNA C. The LVN stated that Resident #1 was found sitting in the shower chair completely nude. The LVN stated Resident #1 stated he had not had a shower yet and said the girls left him in there. The LVN stated that Resident #1 was dry, the heat was off, and it was cold in the shower room. The LVN stated that Resident #1's wheelchair was not within reach and where Resident #1 was seated in the shower chair, the call light was not in reach. The LVN stated that the shower chair was between the commode and shower stall and a few feet forward from the wall where the call light was. The LVN stated that Resident #1 stated he was not cold but stated his skin was cold to the touch and he had goosebumps on his skin. The LVN stated that Resident #1 had an imprint on his buttocks from sitting in the shower chair but had no injuries. The LVN stated that she told CNA C to stay with Resident #1 to get warm towels. The LVN stated that Resident #1 had a recent decline after a hospital stay for a UTI (Urinary Tract Infection) and he was not at his baseline. The LVN stated that had Resident #1 been at his baseline, he still would have required 1 person assistance with his ADLS that included using the toilet, undressing, and showering. The LVN stated that Resident #1 could not have transferred himself from the toilet to the shower chair and required a gait belt for transfers. The LVN stated there was no gait belt on Resident #1 or in the shower room. The LVN stated that Resident #1's clean clothes were on the shower bench and his dirty clothes were thrown on the floor near soiled towels. The LVN stated that Resident #1 had a previous shoulder fracture that would have prevented him from removing his clothes. The LVN stated that CNA A was already gone before she arrived to work that day, and no one was aware that Resident #1 had been left in the shower room. The LVN stated that 1 person assist meant that staff must stay in the room at all times and Resident #1 should not have been left on the toilet alone or on the shower chair. The LVN stated that Resident #1 had no access to towels to cover himself. The LVN stated Resident #1 was upset and stated, I am so glad yall are here. The LVN stated that Resident #1 was at risk for falls and injuries by being left alone in the shower room. The LVN stated that Resident #1 was unsteady on his feet and required staff to be in there. The LVN stated that staff are trained on abuse and neglect and are trained on the care areas for the residents they work with. During an interview on [DATE] at 10:03 a.m. CNA C stated that on [DATE] she arrived at approximately 6 a.m. to assist the LVN with showers in 200 halls. Stated that she entered the shower room to grab supplies and found Resident #1 in the shower chair naked. CNA C stated it was approximately 6:04 a.m. and the LVN came in behind her. CNA C stated that Resident #1 stated that he was left in there by the girl. CNA C stated it was cold, the heat was off, and the water was off. CNA C stated she turned the heat on and turned the water on to warm up after Resident #1 stated he wanted a shower. CNA C stated that Resident #1 required staff to assist with showers, transfers and using the toilet because his gait was not steady, and he had a history of falls. CNA C stated that Resident #1's dirty clothes were on the floor, his clean clothes were on the bench and his wheelchair was against the wall across the shower room and not in reach. CNA C stated that Resident #1 was nude, had no gait belt on and there was no gait belt in the shower room. CNA C stated that Resident #1 required assistance to clean himself after a bowel movement and there was no evidence that he had a bowel movement in the toilet nor was there any feces on Resident #1. CNA C stated Resident #1 stated please, please help me. CNA C stated that Resident #1 stated that CNA A stated she would come back but never came back for him. CNA C stated that it was not possible for Resident #1 to transfer himself, get off the commode or get into the shower chair without assistance. CNA C stated staff had been trained on how to provide showers, not to leave residents alone, abuse and neglect and resident care plans. CNA C stated that Resident #1 should never have been left alone in the shower room and CNA A was gone before she arrived and none of the staff knew Resident #1 had been left alone. During a phone interview on [DATE] at 12:30 p.m. CNA A stated that on [DATE] she was in hall 200 and was in Resident #1 and Resident #2's room. CNA A stated that Resident #1 and Resident #2 are roommates and have a private restroom with shower in their room. CNA A stated that Resident #1 was asked if he wanted a shower, and he denied one. CNA A stated that the roommate, Resident #2 stated he wanted a shower and she put him into the shower chair in the room restroom, undressed him and got him ready to shower. CNA A stated that Resident #1 then asked if she could assist him and get him dressed. CNA A stated she dressed Resident #1 who then asked if he could use the restroom because he needed to have a bowel movement. CNA A stated that she told Resident #1 that Resident #2 was in there and Resident #1 asked if he could use another resident's restroom. CNA A stated she told him he could not use another resident's restroom, but she was going to the shower room to get towels for Resident #2 and asked Resident #1 if he wanted to use the toilet in the shower room and Resident #1 stated yes. CNA A stated that she left Resident #2 in the restroom in his shower chair and took Resident #1 to the shower room and assisted him on the toilet and told him she would return. CNA A stated that she removed Resident #1's pants, moved the shower chair into the shower stall and put Resident #1's wheelchair right in front of him. CNA A stated she told Resident #1 to use the call light if he needed her and she was headed back to assist Resident #2 with his shower. CNA A stated she went back to the resident shared room and showered and dressed Resident #2, before going back to the shower room down the hall for Resident #1. CNA A stated that Resident #1 was still on the commode and stated he was not done, and she told him to use the call light to call when he was finished. CNA A stated that she returned five minutes later, and Resident #1 stated he was not done yet. CNA A stated that she returned to the shower room at 5:57 a.m. and Resident #1 was still on the toilet and stated he was not done. CNA A stated she reminded Resident #1 to use the call light and advised him her shift was almost over and another aide may be the one to assist him. CNA A stated that she left for the day and did not inform anyone that Resident #1 was in the shower room. CNA A stated she meant to tell the nurse that Resident #1 was in the shower room but forgot to. CNA A stated that Resident #1 had a recent decline and was not acting like himself and had pulled some stuff off a shelf in the dining room that day. CNA A stated that Resident #1 care plan stated that he required a one person assist but Resident #1 could transfer himself, undress himself and could get into a shower chair himself. CNA A stated that Resident #2 had to be supervised in the shower per his care plan but that he was in a shower chair and was fine when she left to get towels from the shower room. CNA A stated that she had been trained on Resident #1 and Resident #2's hallway and had been trained on Resident #1 and Resident #2's care plans and they required 1 person assist with showering, toileting, and transfers. CNA A stated that there was no risk of Resident #1 falling because she put his wheelchair in front of him when he was on the commode and the shower chair was out of reach. CNA A stated Resident #2 was not at risk of falling because she put him in the shower chair, and he needed assistance to get out of the shower chair. CNA A stated that Resident #1 was not in the right state of mind and had not been the same the last week or so. CNA A stated that she did not understand why she was being asked about Resident #2 because she was terminated for leaving Resident #1 alone in the shower and Resident #2 was not brought up. CNA A stated she had been trained on care plans, showers, transfers and abuse and neglect. CNA A stated she did nothing wrong except that she left at the end of her shift and did not inform anyone that Resident #1 was left on the commode. Record Review of CNA A's time punch detail revealed CNA A punched in at 6:16 p.m. on [DATE] and clocked out at 6:02 p.m. on [DATE]. During an interview on [DATE] at approximately 12:50 p.m. with the ADM, the ADM stated he had not been aware that CNA A left Resident #2 alone in the resident room restroom in the shower chair when she went to the shower room with Resident #1. The ADM stated that during the facility investigation it was not revealed that Resident #2 was also involved in this incident. The ADM stated that staff should never leave a resident alone in the shower room and that Resident #2 required assistance with his ADLS. During an interview and observation on [DATE] at 1:05 p.m. with Resident #2 revealed he was in his room sitting in his power wheelchair. Resident #2 stated that he has a restroom with a shower in his room. Resident #2 stated that Resident #1 was his roommate before Resident #1 passed away. Resident #2 stated that he remembered the day that CNA A assisted him with a shower. Resident #2 stated that CNA A put him into the shower and then left for a few minutes to get towels. Resident #2 stated that he was not aware that Resident #1 went to the shower room down the hall with CNA A when he was in the shower. Resident #2 stated that CNA A came back and got him out of the shower and put a towel on him to dry. Resident #2 stated that CNA A then left again for about 2 minutes to get him clothes from his room. Resident #2 stated that he felt safe and required assistance to get transferred from his wheelchair into the shower chair and to be dressed. Resident #2 stated that his roommate, Resident #1 needed his wheelchair to get around and needed staff to assist him with transfers. Resident #2 stated that Resident #1 had a history of falls and had been confused around the time leading up to his death. Resident #2 stated that CNA A knew that they both needed assistance with showers and transfers and that Resident #1 had falls in the past because she always worked their hall. During an interview on [DATE] at 1:25 p.m. CNA C stated that Resident #2 needed total assistance for transfers and bathing and Resident #2 was only able to wash his private area. CNA C stated that Resident #2 had a history of falls, and it was not safe to leave him alone in a shower chair. CNA C stated that Resident #2 could bear some weight on his legs and had he attempted to get up from the shower chair alone, he could have fallen on the wet floor. During an interview on [DATE] at 1:35 p.m. the DON stated that she was not aware that CNA A left Resident #2 alone in the shower when she took Resident #1 to the shower room. The DON stated that Resident #2 had a spine curvature and had he leaned to the side or the front he would fall face first and would be injured with no staff to assist because it was not known he had also been left alone. The DON stated that CNA A did not reveal in her facility statement that she left Resident #2 alone and CNA A had been trained to not leave residents alone during showers or if they needed 1 person assist. Record Review of facility provided policy, Toileting, Bedside Commode/Bathroom dated 2023, revealed in part: Become familiar with the ability of the resident to perform toileting procedures independently or amount of assistance needed, type of toileting facility the resident will use, need for monitoring. Assist to bathroom and assuming sitting position on toilet, assist with cleansing following elimination, encourage resident to use holding bars in the bathroom to prevent falls. Record Review of facility provided policy, Bath, Tub/Shower, dated 2023, revealed in part: Become familiar with the type and pattern of bathing, assistance or aids needed. Transport resident via shower chair; remain with the resident if he is weak or assistance is needed in washing, protect from drafts and chilling during bathing. Place call light in reach for resident to call for assistance; remain with the resident if weak. Assist out of the tub or shower, wrap in bath towel, allow to sit on a chair and assist to dry if needed. Assist to dress if needed or supply aids. Assist the resident with transfer to room or location of choice. Record Review of facility provided policy, Abuse/Neglect, Revised [DATE], revealed in part: The resident has the right to be free from abuse, neglect. This includes but not limited to, involuntary seclusion and any physical/chemical restraint note required to treat the resident's medical symptoms. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will train through orientation and on-going in-services on issues related to abuse/neglect prohibition practices regularly. Record Review of CNA A's employee record revealed that CNA A was hired, received, and signed orientation training on [DATE] that included the following topics: Resident dignity and privacy, No abuse, neglect and/or unnecessary restring; Resident abuse, neglect, and mandatory reporting. Record Review of CNA A's employee disciplinary record revealed that CNA A was terminated on [DATE] due to an incident of Neglect on [DATE]. Specific Reason for Disciplinary Action: On [DATE], [CNA A] was suspended pending an investigation into resident neglect: those allegations were substantiated. It was found that [CNA A] left a resident in the shower room, unattended, for at least thirty minutes. This is a violation of the resident's rights, a violation of her job duties/responsibilities and of the Corporate Code of Conduct. Employee confirmed during a neglect investigation that she knowingly left a resident unattended in the shower room and did not report to anyone that resident was in the shower room.

Based on record review and interview the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of resident and misappropriation of resident property for 2 of 2 residents (Resident #1 and Resident #2) reviewed. CNA A neglected Resident #1 by failing to provide 1 person assistance and clocking out without informing the oncoming shift when she left Resident #1 alone in the facility shower room. CNA A neglected Resident #2 by failing to provide 1 person assistance when she left Resident #2 in a shower chair alone in his restroom shower area when she took Resident #1 to the shower room down the hall. This failure could affect all residents by placing them at risk of neglect, falls, mental anguish and emotional distress. Findings include: Record review of a face sheet dated [DATE] revealed Resident #1 was a [AGE] year-old male and admitted on [DATE] with diagnoses including Parkinson's disease (a progressive disorder that affects the central nervous system), Muscle wasting and atrophy (breakdown of muscles), unspecified abnormalities of gait and mobility, lack of coordination, cognitive communication deficit, muscle weakness. Record review of the quarterly MDS dated [DATE] revealed Resident # 1 had a BIMS of 11 which indicated moderate cognitive impairment. Resident #1 required Supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for toileting hygiene, upper body dressing personal hygiene, Sit to lying, sit to stand, chair/bed to chair transfer and toilet transfer; Substantial/Maximal assistance (helper does more than half the effort. Helper lifts or hold trunk or limbs and provides more than half the effort) for Shower/bathing and tub/shower transfer; and Partial/Moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs but provides less than half the effort) for lower body dressing and putting on/taking off footwear. Resident #1 required use of a manual wheelchair and had a documented history of falls in which 2 or more resulted in no injuries and 1 fall that resulted in an injury. Record review of Resident #1's care plan dated [DATE] revealed a diagnosis of Parkinson's disease with an intervention to monitor for risk of falls; monitor/document/report signs/symptoms of poor coordination, tremors, gait disturbance and decline in range of motion. Focus area: Fall risk with actual falls on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] with interventions: anticipate and meet resident needs, call light within reach and safe environment with even floors, free from spills and/or clutter, working and reachable call light, handrails on walls, personal items within reach. Resident #1 has an ADL self-care performance deficit and requires 1 staff for assistance for bathing, bed mobility, dressing, eating, toilet use, transferring, walking, personal hygiene/oral care, uses wheelchair and encourage resident to use bell to call for assistance. Record review of a face sheet dated [DATE] revealed Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Parkinson's, Cellulitis (bacterial infection involving inner layers of skin), Chronic Obstructive Pulmonary Disease (COPD refers to a group of diseases that cause airflow blockage and breathing-related problems), Muscle Wasting and Atrophy (breakdown of muscle), Muscle Weakness, Lack of coordination, history of falling, abnormal posture. Record review of the quarterly MDS dated [DATE] revealed Resident #2 had a BIMS of 13 which indicated intact cognition. Resident #1 required Substantial/Maximal assistance (helper does more than half the effort. Helper lifts or hold trunk or limbs and provides more than half the effort) for Shower/bathing and personal hygiene; Partial/Moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs but provides less than half the effort) for oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear; Dependent (helper does all the effort. Resident does none of the effort to complete the activity or requires 2 or more helpers) for tub/shower transfer. Resident #1 requires use of a manual wheelchair and has a documented history of falls in which fall that resulted in no injury. Record review of Resident #2's care plan dated [DATE] revealed a diagnosis of Parkinson's disease with an intervention to monitor for risk of falls; monitor/document ability to perform ADLS; Risk of falls due to incontinence, Parkinson's and fluctuating cognition, with interventions that included call light in reach, appropriate footwear, keep bed in lowest position with wheels locked, furniture in locked position, safe environment with even floors, free from spills and/or clutter, working and reachable call light, handrails on walls, personal items within reach, staff x1 to assist with transfers; ADL self-care performance deficit that requires interventions of 1x staff assistance for bathing, bed mobility, dressing, toilet use, transferring and requires use of wheelchair. Resident #2 requires total assist for bathing/showering. Record review of the facility provided Provider Investigation Report, revealed incident date [DATE] at 6:30 a.m. in Hall 200 shower room for Neglect of Resident #1 by alleged perpetrators CNA A and CNA B. Description of the allegation, it is alleged that staff left [Resident #1] in the shower room unattended for approximately 20 minutes. Investigation Summary: On [DATE], [Resident #1] was found unaccompanied in the shower room by day staff coming on shift. When asked why he was in the shower by himself, he stated that a lady had wheeled him in there to shower and left him there by himself. He stated that he had been in there approximately ,d+[DATE] minutes. He was found at approximately 6:04a.m. Staff said to be involved were suspended pending further investigation. Interviews were conducted and it was found that [CNA A] was working the 200 halls on [DATE] and admitted to leaving [Resident #1] in the shower room. Investigation findings: Confirmed. Post investigation provider action: Continued Resident monitoring, continued in-services of abuse/neglect and not leaving residents in the shower room unattended. [CNA A] was terminated, and [CNA B] was allowed to return to work. Record Review of the facility provided Incident Report dated [DATE] at 12:56 p.m. documented by the DON revealed: Received report from staff that while getting residents up for breakfast and doing initial beginning of shift rounds, resident was found to have been left in the shower room unattended. Mental status documented as: orientated to place, person, and situation. No injuries observed post incident. Record review of CNA A's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, I worked hall 200 from 10 p-6a. In the beginning of my last round I asked [Resident #1] if he wanted to take his shower and he denied his shower but asked if I could help him get dressed. I proceeded with assisting him with getting dressed. After helping him I get [Resident #2] up for his shower and while gathering [Resident #2's] things for his shower, [Resident #1] asked if he could use the restroom. I informed him that [Resident #2] was in the shower already and it'd be a little bit and he asked if he could use another residents restroom, but I told him we can't go into another residents room to use their restroom. I told him I was on my way to the big shower room to grab towels for [Resident #2] and if he would like to use the restroom in there. He (Resident #1) agreed, and I took him. I told him I would be back soon and let him take his time while I showered [Resident #2]. I continue to check on him after I'm done with [Resident #2's] shower and he tells me after each time I've asked him, that he's not done yet. I told him to call me on the light when he's ready to get out, but he never does. I go back 3 minutes before 6 am to check on him and he informed me he still wasn't finished. I tell him to still call but it was close to shift change so I didn't know if it would be me or another CNA helping him out the restroom. Within the minutes passing, I'm on my way to tell a nurse but go back to my hall to gather my things before leaving. I do get distracted and made the mistake of not informing a charge nurse and leave the building. [Resident #1] was only in the shower room to use the restroom but never for a shower. Record review of CNA C's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, The morning of [DATE] at approximately 6:04 a.m., upon unlocking shower room I noticed [Resident #1] completed unclothed, shaking from lack of heat on shower chair. My coworker LVN was also present in shower room and noticed patient unclothed in shower chair. I asked [Resident #1] why he was alone in shower room. [Resident #1] stated the girl (night shift aide) left me in here to shower and said she will be back but never followed back I was still waiting. So I assured [Resident #1] I would bathe and dress him to which he thanked me for not leaving patient by himself. Shower was completed. Patient dressed, assisted to chair, assisted to dining room for breakfast. Record review of the LVN's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, This morning upon entering locked shower room, patient [Resident #1] was on the shower chair completely undressed. Lights were on, heater off, water off as well. When this writer asked patient what are you doing in here by yourself? Patient stated, the girls told me to shower and would be back, but they never came back. I have been in here waiting. This writer and other aide (CNA C) repositioned patient on shower chair and bathed patient, clean clothes were put on patient and assisted patient to wheelchair. This writer then informed DON of what happened. [Resident #1] was assisted to dining room for breakfast. Record review of Resident #1's statement taken by the facility ADM, signed, and dated [DATE] from the [DATE] provider investigation report, revealed in part, Patient stated, I was undressed on the shower chair this morning. I say I was in there about 20 minutes alone in the shower. I was scared they wouldn't shower me since I hadn't been showered in 3 or 4 days. She has long black hair, real pretty, I don't remember the color of her shirt. She is one of the sisters that works here. Patient was asked by this writer Have they ever not showered you? Patient responded yes. I was glad [CNA C] came in and found me. Record review of CNA B's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, I was working hall 400, [DATE]. I did not assist [Resident #1]. I had no knowledge of the incident until 20 minutes after 6 a.m. that morning. Record review of the BOM's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, I was serving as a witness to a phone call with [DON] and [CNA A] on [DATE]. During this phone call, [CNA A] stated she was at fault for the entire situation and stated [CNA B] had nothing to do with this as [CNA B] was on another hall. [CNA A] again stated, this is all on me. I did it, [CNA B] doesn't have anything to do with this. Record review of the DOR's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, I spoke with [Resident #1] about what happened [DATE] with the shower room. [Resident #1] stated that a young pretty girl took me in the shower room. I sat in a shower chair. She left because she forgot something. I did ask [Resident #1] if he knew how long and he stated, no but felt like over 30 minutes. I asked him if he got worried about falling or when she would come back and he said no, I knew I would be ok. During an interview with the DON on [DATE] at 6:24 a.m. she stated on [DATE] she was informed by the LVN that she and CNA C found Resident #1 alone in the shower room on a shower chair and was he was nude. The DON stated that Resident #1 stated that he was left alone in the shower room by a female staff who was later identified as CNA A. The DON stated that initially the facility was unsure of which CNA it was because Resident #1 stated it was one of the sisters and CNA A and CNA B were sisters. The DON stated that CNA A stated that she had left Resident #1 on the commode, and he was fully dressed. The DON stated that Resident #1's care plan required assistance with transfers, using the restroom, showers and changing clothes. The DON stated she believed that CNA A neglected Resident #1 when she left Resident #1 alone in the shower room. The DON stated that the risk of CNA A leaving Resident #1 unattended included that Resident #1 could fall and that could result in injuries, and no one would have known to look for him in the shower room. The DON stated that Resident #1 was found on the shower chair and not on the commode and Resident #1 could not have transferred himself from the commode to the shower chair himself at that time. The DON stated Resident #1 had Parkinson's disease and a week prior leading up to the incident he had a decline and was completely dependent on staff. The DON stated that had Resident #1 had any significant health issue like a cardiac arrest and his decline, or if he had fallen or had a significant health issue, being left alone like that could have resulted in death and no one would have known he was in there until he was accidently discovered. The DON stated that all staff were trained on care plans and CNA A had been trained on showering, abuse, and neglect. The DON stated that Resident #1 was deceased and died a few days after the incident. The DON stated there was no reason to believe that the incident had anything to do with his death due to Resident #1 not having any injuries from being left alone. The DON stated that at no time should a resident who required 1 person assist be left alone in the shower room. During an interview on [DATE] at 8:40 a.m. the LVN stated that on [DATE] she arrived shortly after 6 a.m. to assist CNA C with shower duties. The LVN stated that shortly after 6:00 a.m. she entered the shower room behind CNA C. The LVN stated that Resident #1 was found sitting in the shower chair completely nude. The LVN stated Resident #1 stated he had not had a shower yet and said the girls left him in there. The LVN stated that Resident #1 was dry, the heat was off, and it was cold in the shower room. The LVN stated that Resident #1's wheelchair was not within reach and where Resident #1 was seated in the shower chair, the call light was not in reach. The LVN stated that the shower chair was between the commode and shower stall and a few feet forward from the wall where the call light was. The LVN stated that Resident #1 stated he was not cold but stated his skin was cold to the touch and he had goosebumps on his skin. The LVN stated that Resident #1 had an imprint on his buttocks from sitting in the shower chair but had no injuries. The LVN stated that she told CNA C to stay with Resident #1 to get warm towels. The LVN stated that Resident #1 had a recent decline after a hospital stay for a UTI (Urinary Tract Infection) and he was not at his baseline. The LVN stated that had Resident #1 been at his baseline, he still would have required 1 person assistance with his ADLS that included using the toilet, undressing, and showering. The LVN stated that Resident #1 could not have transferred himself from the toilet to the shower chair and required a gait belt for transfers. The LVN stated there was no gait belt on Resident #1 or in the shower room. The LVN stated that Resident #1's clean clothes were on the shower bench and his dirty clothes were thrown on the floor near soiled towels. The LVN stated that Resident #1 had a previous shoulder fracture that would have prevented him from removing his clothes. The LVN stated that CNA A was already gone before she arrived to work that day, and no one was aware that Resident #1 had been left in the shower room. The LVN stated that 1 person assist meant that staff must stay in the room at all times and Resident #1 should not have been left on the toilet alone or on the shower chair. The LVN stated that Resident #1 had no access to towels to cover himself. The LVN stated Resident #1 was upset and stated, I am so glad yall are here. The LVN stated that Resident #1 was at risk for falls and injuries by being left alone in the shower room. The LVN stated that Resident #1 was unsteady on his feet and required staff to be in there. The LVN stated that staff are trained on abuse and neglect and are trained on the care areas for the residents they work with. During an interview on [DATE] at 10:03 a.m. CNA C stated that on [DATE] she arrived at approximately 6 a.m. to assist the LVN with showers in 200 halls. Stated that she entered the shower room to grab supplies and found Resident #1 in the shower chair naked. CNA C stated it was approximately 6:04 a.m. and the LVN came in behind her. CNA C stated that Resident #1 stated that he was left in there by the girl. CNA C stated it was cold, the heat was off, and the water was off. CNA C stated she turned the heat on and turned the water on to warm up after Resident #1 stated he wanted a shower. CNA C stated that Resident #1 required staff to assist with showers, transfers and using the toilet because his gait was not steady, and he had a history of falls. CNA C stated that Resident #1's dirty clothes were on the floor, his clean clothes were on the bench and his wheelchair was against the wall across the shower room and not in reach. CNA C stated that Resident #1 was nude, had no gait belt on and there was no gait belt in the shower room. CNA C stated that Resident #1 required assistance to clean himself after a bowel movement and there was no evidence that he had a bowel movement in the toilet nor was there any feces on Resident #1. CNA C stated Resident #1 stated please, please help me. CNA C stated that Resident #1 stated that CNA A stated she would come back but never came back for him. CNA C stated that it was not possible for Resident #1 to transfer himself, get off the commode or get into the shower chair without assistance. CNA C stated staff had been trained on how to provide showers, not to leave residents alone, abuse and neglect and resident care plans. CNA C stated that Resident #1 should never have been left alone in the shower room and CNA A was gone before she arrived and none of the staff knew Resident #1 had been left alone. During a phone interview on [DATE] at 12:30 p.m. CNA A stated that on [DATE] she was in hall 200 and was in Resident #1 and Resident #2's room. CNA A stated that Resident #1 and Resident #2 are roommates and have a private restroom with shower in their room. CNA A stated that Resident #1 was asked if he wanted a shower, and he denied one. CNA A stated that the roommate, Resident #2 stated he wanted a shower and she put him into the shower chair in the room restroom, undressed him and got him ready to shower. CNA A stated that Resident #1 then asked if she could assist him and get him dressed. CNA A stated she dressed Resident #1 who then asked if he could use the restroom because he needed to have a bowel movement. CNA A stated that she told Resident #1 that Resident #2 was in there and Resident #1 asked if he could use another resident's restroom. CNA A stated she told him he could not use another resident's restroom, but she was going to the shower room to get towels for Resident #2 and asked Resident #1 if he wanted to use the toilet in the shower room and Resident #1 stated yes. CNA A stated that she left Resident #2 in the restroom in his shower chair and took Resident #1 to the shower room and assisted him on the toilet and told him she would return. CNA A stated that she removed Resident #1's pants, moved the shower chair into the shower stall and put Resident #1's wheelchair right in front of him. CNA A stated she told Resident #1 to use the call light if he needed her and she was headed back to assist Resident #2 with his shower. CNA A stated she went back to the resident shared room and showered and dressed Resident #2, before going back to the shower room down the hall for Resident #1. CNA A stated that Resident #1 was still on the commode and stated he was not done, and she told him to use the call light to call when he was finished. CNA A stated that she returned five minutes later, and Resident #1 stated he was not done yet. CNA A stated that she returned to the shower room at 5:57 a.m. and Resident #1 was still on the toilet and stated he was not done. CNA A stated she reminded Resident #1 to use the call light and advised him her shift was almost over and another aide may be the one to assist him. CNA A stated that she left for the day and did not inform anyone that Resident #1 was in the shower room. CNA A stated she meant to tell the nurse that Resident #1 was in the shower room but forgot to. CNA A stated that Resident #1 had a recent decline and was not acting like himself and had pulled some stuff off a shelf in the dining room that day. CNA A stated that Resident #1 care plan stated that he required a one person assist but Resident #1 could transfer himself, undress himself and could get into a shower chair himself. CNA A stated that Resident #2 had to be supervised in the shower per his care plan but that he was in a shower chair and was fine when she left to get towels from the shower room. CNA A stated that she had been trained on Resident #1 and Resident #2's hallway and had been trained on Resident #1 and Resident #2's care plans and they required 1 person assist with showering, toileting, and transfers. CNA A stated that there was no risk of Resident #1 falling because she put his wheelchair in front of him when he was on the commode and the shower chair was out of reach. CNA A stated Resident #2 was not at risk of falling because she put him in the shower chair, and he needed assistance to get out of the shower chair. CNA A stated that Resident #1 was not in the right state of mind and had not been the same the last week or so. CNA A stated that she did not understand why she was being asked about Resident #2 because she was terminated for leaving Resident #1 alone in the shower and Resident #2 was not brought up. CNA A stated she had been trained on care plans, showers, transfers and abuse and neglect. CNA A stated she did nothing wrong except that she left at the end of her shift and did not inform anyone that Resident #1 was left on the commode. Record Review of CNA A's time punch detail revealed CNA A punched in at 6:16 p.m. on [DATE] and clocked out at 6:02 p.m. on [DATE]. During an interview on [DATE] at approximately 12:50 p.m. with the ADM, the ADM stated he had not been aware that CNA A left Resident #2 alone in the resident room restroom in the shower chair when she went to the shower room with Resident #1. The ADM stated that during the facility investigation it was not revealed that Resident #2 was also involved in this incident. The ADM stated that staff should never leave a resident alone in the shower room and that Resident #2 required assistance with his ADLS. During an interview and observation on [DATE] at 1:05 p.m. with Resident #2 revealed he was in his room sitting in his power wheelchair. Resident #2 stated that he has a restroom with a shower in his room. Resident #2 stated that Resident #1 was his roommate before Resident #1 passed away. Resident #2 stated that he remembered the day that CNA A assisted him with a shower. Resident #2 stated that CNA A put him into the shower and then left for a few minutes to get towels. Resident #2 stated that he was not aware that Resident #1 went to the shower room down the hall with CNA A when he was in the shower. Resident #2 stated that CNA A came back and got him out of the shower and put a towel on him to dry. Resident #2 stated that CNA A then left again for about 2 minutes to get him clothes from his room. Resident #2 stated that he felt safe and required assistance to get transferred from his wheelchair into the shower chair and to be dressed. Resident #2 stated that his roommate, Resident #1 needed his wheelchair to get around and needed staff to assist him with transfers. Resident #2 stated that Resident #1 had a history of falls and had been confused around the time leading up to his death. Resident #2 stated that CNA A knew that they both needed assistance with showers and transfers and that Resident #1 had falls in the past because she always worked their hall. During an interview on [DATE] at 1:25 p.m. CNA C stated that Resident #2 needed total assistance for transfers and bathing and Resident #2 was only able to wash his private area. CNA C stated that Resident #2 had a history of falls, and it was not safe to leave him alone in a shower chair. CNA C stated that Resident #2 could bear some weight on his legs and had he attempted to get up from the shower chair alone, he could have fallen on the wet floor. During an interview on [DATE] at 1:35 p.m. the DON stated that she was not aware that CNA A left Resident #2 alone in the shower when she took Resident #1 to the shower room. The DON stated that Resident #2 had a spine curvature and had he leaned to the side or the front he would fall face first and would be injured with no staff to assist because it was not known he had also been left alone. The DON stated that CNA A did not reveal in her facility statement that she left Resident #2 alone and CNA A had been trained to not leave residents alone during showers or if they needed 1 person assist. Record Review of facility provided policy, Toileting, Bedside Commode/Bathroom dated 2023, revealed in part: Become familiar with the ability of the resident to perform toileting procedures independently or amount of assistance needed, type of toileting facility the resident will use, need for monitoring. Assist to bathroom and assuming sitting position on toilet, assist with cleansing following elimination, encourage resident to use holding bars in the bathroom to prevent falls. Record Review of facility provided policy, Bath, Tub/Shower, dated 2023, revealed in part: Become familiar with the type and pattern of bathing, assistance or aids needed. Transport resident via shower chair; remain with the resident if he is weak or assistance is needed in washing, protect from drafts and chilling during bathing. Place call light in reach for resident to call for assistance; remain with the resident if weak. Assist out of the tub or shower, wrap in bath towel, allow to sit on a chair and assist to dry if needed. Assist to dress if needed or supply aids. Assist the resident with transfer to room or location of choice. Record Review of facility provided policy, Abuse/Neglect, Revised [DATE], revealed in part: The resident has the right to be free from abuse, neglect. This includes but not limited to, involuntary seclusion and any physical/chemical restraint note required to treat the resident's medical symptoms. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will train through orientation and on-going in-services on issues related to abuse/neglect prohibition practices regularly. Record Review of CNA A's employee record revealed that CNA A was hired, received, and signed orientation training on [DATE] that included the following topics: Resident dignity and privacy, No abuse, neglect and/or unnecessary restring; Resident abuse, neglect, and mandatory reporting. Record Review of CNA A's employee disciplinary record revealed that CNA A was terminated on [DATE] due to an incident of Neglect on [DATE]. Specific Reason for Disciplinary Action: On [DATE], [CNA A] was suspended pending an investigation into resident neglect: those allegations were substantiated. It was found that [CNA A] left a resident in the shower room, unattended, for at least thirty minutes. This is a violation of the resident's rights, a violation of her job duties/responsibilities and of the Corporate Code of Conduct. Employee confirmed during a neglect investigation that she knowingly left a resident unattended in the shower room and did not report to anyone that resident was in the shower room.

Based on interview and record review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for 2 of 5 residents (Resident #1, Resident #2) in that: CNA A failed to provide Resident #1 adequate supervision by failing to provide 1-person assistance when she clocked out without informing the oncoming shift she had left Resident #1 alone in the facility shower room. CNA A failed to provide resident #2 adequate supervision by failing to provide 1-person assistance when she left Resident #2 in a shower chair alone in his restroom shower area when she took Resident #1 to the shower room down the hall. This failure could affect all residents by placing them at risk of falls, lacerations, fractures and pain. Findings include: Record review of a face sheet dated [DATE] revealed Resident #1 was a [AGE] year-old male and admitted on [DATE] with diagnoses including Parkinson's disease (a progressive disorder that affects the central nervous system), Muscle wasting and atrophy (breakdown of muscles), unspecified abnormalities of gait and mobility, lack of coordination, cognitive communication deficit, muscle weakness. Record review of the quarterly MDS dated [DATE] revealed Resident # 1 had a BIMS of 11 which indicated moderate cognitive impairment. Resident #1 required Supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for toileting hygiene, upper body dressing personal hygiene, Sit to lying, sit to stand, chair/bed to chair transfer and toilet transfer; Substantial/Maximal assistance (helper does more than half the effort. Helper lifts or hold trunk or limbs and provides more than half the effort) for Shower/bathing and tub/shower transfer; and Partial/Moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs but provides less than half the effort) for lower body dressing and putting on/taking off footwear. Resident #1 required use of a manual wheelchair and had a documented history of falls in which 2 or more resulted in no injuries and 1 fall that resulted in an injury. Record review of Resident #1's care plan dated [DATE] revealed a diagnosis of Parkinson's disease with an intervention to monitor for risk of falls; monitor/document/report signs/symptoms of poor coordination, tremors, gait disturbance and decline in range of motion. Focus area: Fall risk with actual falls on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] with interventions: anticipate and meet resident needs, call light within reach and safe environment with even floors, free from spills and/or clutter, working and reachable call light, handrails on walls, personal items within reach. Resident #1 has an ADL self-care performance deficit and requires 1 staff for assistance for bathing, bed mobility, dressing, eating, toilet use, transferring, walking, personal hygiene/oral care, uses wheelchair and encourage resident to use bell to call for assistance. Record review of a face sheet dated [DATE] revealed Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Parkinson's, Cellulitis (bacterial infection involving inner layers of skin), Chronic Obstructive Pulmonary Disease (COPD refers to a group of diseases that cause airflow blockage and breathing-related problems), Muscle Wasting and Atrophy (breakdown of muscle), Muscle Weakness, Lack of coordination, history of falling, abnormal posture. Record review of the quarterly MDS dated [DATE] revealed Resident #2 had a BIMS of 13 which indicated intact cognition. Resident #1 required Substantial/Maximal assistance (helper does more than half the effort. Helper lifts or hold trunk or limbs and provides more than half the effort) for Shower/bathing and personal hygiene; Partial/Moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs but provides less than half the effort) for oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear; Dependent (helper does all the effort. Resident does none of the effort to complete the activity or requires 2 or more helpers) for tub/shower transfer. Resident #1 requires use of a manual wheelchair and has a documented history of falls in which fall that resulted in no injury. Record review of Resident #2's care plan dated [DATE] revealed a diagnosis of Parkinson's disease with an intervention to monitor for risk of falls; monitor/document ability to perform ADLS; Risk of falls due to incontinence, Parkinson's and fluctuating cognition, with interventions that included call light in reach, appropriate footwear, keep bed in lowest position with wheels locked, furniture in locked position, safe environment with even floors, free from spills and/or clutter, working and reachable call light, handrails on walls, personal items within reach, staff x1 to assist with transfers; ADL self-care performance deficit that requires interventions of 1x staff assistance for bathing, bed mobility, dressing, toilet use, transferring and requires use of wheelchair. Resident #2 requires total assist for bathing/showering. Record review of the facility provided Provider Investigation Report, revealed incident date [DATE] at 6:30 a.m. in Hall 200 shower room for Neglect of Resident #1 by alleged perpetrators CNA A and CNA B. Description of the allegation, it is alleged that staff left [Resident #1] in the shower room unattended for approximately 20 minutes. Investigation Summary: On [DATE], [Resident #1] was found unaccompanied in the shower room by day staff coming on shift. When asked why he was in the shower by himself, he stated that a lady had wheeled him in there to shower and left him there by himself. He stated that he had been in there approximately ,d+[DATE] minutes. He was found at approximately 6:04a.m. Staff said to be involved were suspended pending further investigation. Interviews were conducted and it was found that [CNA A] was working the 200 halls on [DATE] and admitted to leaving [Resident #1] in the shower room. Investigation findings: Confirmed. Post investigation provider action: Continued Resident monitoring, continued in-services of abuse/neglect and not leaving residents in the shower room unattended. [CNA A] was terminated, and [CNA B] was allowed to return to work. Record Review of the facility provided Incident Report dated [DATE] at 12:56 p.m. documented by the DON revealed: Received report from staff that while getting residents up for breakfast and doing initial beginning of shift rounds, resident was found to have been left in the shower room unattended. Mental status documented as: orientated to place, person, and situation. No injuries observed post incident. Record review of CNA A's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, I worked hall 200 from 10 p-6a. In the beginning of my last round I asked [Resident #1] if he wanted to take his shower and he denied his shower but asked if I could help him get dressed. I proceeded with assisting him with getting dressed. After helping him I get [Resident #2] up for his shower and while gathering [Resident #2's] things for his shower, [Resident #1] asked if he could use the restroom. I informed him that [Resident #2] was in the shower already and it'd be a little bit and he asked if he could use another residents restroom, but I told him we can't go into another residents room to use their restroom. I told him I was on my way to the big shower room to grab towels for [Resident #2] and if he would like to use the restroom in there. He (Resident #1) agreed, and I took him. I told him I would be back soon and let him take his time while I showered [Resident #2]. I continue to check on him after I'm done with [Resident #2's] shower and he tells me after each time I've asked him, that he's not done yet. I told him to call me on the light when he's ready to get out, but he never does. I go back 3 minutes before 6 am to check on him and he informed me he still wasn't finished. I tell him to still call but it was close to shift change so I didn't know if it would be me or another CNA helping him out the restroom. Within the minutes passing, I'm on my way to tell a nurse but go back to my hall to gather my things before leaving. I do get distracted and made the mistake of not informing a charge nurse and leave the building. [Resident #1] was only in the shower room to use the restroom but never for a shower. Record review of CNA C's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, The morning of [DATE] at approximately 6:04 a.m., upon unlocking shower room I noticed [Resident #1] completed unclothed, shaking from lack of heat on shower chair. My coworker LVN was also present in shower room and noticed patient unclothed in shower chair. I asked [Resident #1] why he was alone in shower room. [Resident #1] stated the girl (night shift aide) left me in here to shower and said she will be back but never followed back I was still waiting. So I assured [Resident #1] I would bathe and dress him to which he thanked me for not leaving patient by himself. Shower was completed. Patient dressed, assisted to chair, assisted to dining room for breakfast. Record review of the LVN's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, This morning upon entering locked shower room, patient [Resident #1] was on the shower chair completely undressed. Lights were on, heater off, water off as well. When this writer asked patient what are you doing in here by yourself? Patient stated, the girls told me to shower and would be back, but they never came back. I have been in here waiting. This writer and other aide (CNA C) repositioned patient on shower chair and bathed patient, clean clothes were put on patient and assisted patient to wheelchair. This writer then informed DON of what happened. [Resident #1] was assisted to dining room for breakfast. Record review of Resident #1's statement taken by the facility ADM, signed, and dated [DATE] from the [DATE] provider investigation report, revealed in part, Patient stated, I was undressed on the shower chair this morning. I say I was in there about 20 minutes alone in the shower. I was scared they wouldn't shower me since I hadn't been showered in 3 or 4 days. She has long black hair, real pretty, I don't remember the color of her shirt. She is one of the sisters that works here. Patient was asked by this writer Have they ever not showered you? Patient responded yes. I was glad [CNA C] came in and found me. Record review of CNA B's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, I was working hall 400, [DATE]. I did not assist [Resident #1]. I had no knowledge of the incident until 20 minutes after 6 a.m. that morning. Record review of the BOM's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, I was serving as a witness to a phone call with [DON] and [CNA A] on [DATE]. During this phone call, [CNA A] stated she was at fault for the entire situation and stated [CNA B] had nothing to do with this as [CNA B] was on another hall. [CNA A] again stated, this is all on me. I did it, [CNA B] doesn't have anything to do with this. Record review of the DOR's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, I spoke with [Resident #1] about what happened [DATE] with the shower room. [Resident #1] stated that a young pretty girl took me in the shower room. I sat in a shower chair. She left because she forgot something. I did ask [Resident #1] if he knew how long and he stated, no but felt like over 30 minutes. I asked him if he got worried about falling or when she would come back and he said no, I knew I would be ok. During an interview with the DON on [DATE] at 6:24 a.m. she stated on [DATE] she was informed by the LVN that she and CNA C found Resident #1 alone in the shower room on a shower chair and was he was nude. The DON stated that Resident #1 stated that he was left alone in the shower room by a female staff who was later identified as CNA A. The DON stated that initially the facility was unsure of which CNA it was because Resident #1 stated it was one of the sisters and CNA A and CNA B were sisters. The DON stated that CNA A stated that she had left Resident #1 on the commode, and he was fully dressed. The DON stated that Resident #1's care plan required assistance with transfers, using the restroom, showers and changing clothes. The DON stated she believed that CNA A neglected Resident #1 when she left Resident #1 alone in the shower room. The DON stated that the risk of CNA A leaving Resident #1 unattended included that Resident #1 could fall and that could result in injuries, and no one would have known to look for him in the shower room. The DON stated that Resident #1 was found on the shower chair and not on the commode and Resident #1 could not have transferred himself from the commode to the shower chair himself at that time. The DON stated Resident #1 had Parkinson's disease and a week prior leading up to the incident he had a decline and was completely dependent on staff. The DON stated that had Resident #1 had any significant health issue like a cardiac arrest and his decline, or if he had fallen or had a significant health issue, being left alone like that could have resulted in death and no one would have known he was in there until he was accidently discovered. The DON stated that all staff were trained on care plans and CNA A had been trained on showering, abuse, and neglect. The DON stated that Resident #1 was deceased and died a few days after the incident. The DON stated there was no reason to believe that the incident had anything to do with his death due to Resident #1 not having any injuries from being left alone. The DON stated that at no time should a resident who required 1 person assist be left alone in the shower room. During an interview on [DATE] at 8:40 a.m. the LVN stated that on [DATE] she arrived shortly after 6 a.m. to assist CNA C with shower duties. The LVN stated that shortly after 6:00 a.m. she entered the shower room behind CNA C. The LVN stated that Resident #1 was found sitting in the shower chair completely nude. The LVN stated Resident #1 stated he had not had a shower yet and said the girls left him in there. The LVN stated that Resident #1 was dry, the heat was off, and it was cold in the shower room. The LVN stated that Resident #1's wheelchair was not within reach and where Resident #1 was seated in the shower chair, the call light was not in reach. The LVN stated that the shower chair was between the commode and shower stall and a few feet forward from the wall where the call light was. The LVN stated that Resident #1 stated he was not cold but stated his skin was cold to the touch and he had goosebumps on his skin. The LVN stated that Resident #1 had an imprint on his buttocks from sitting in the shower chair but had no injuries. The LVN stated that she told CNA C to stay with Resident #1 to get warm towels. The LVN stated that Resident #1 had a recent decline after a hospital stay for a UTI (Urinary Tract Infection) and he was not at his baseline. The LVN stated that had Resident #1 been at his baseline, he still would have required 1 person assistance with his ADLS that included using the toilet, undressing, and showering. The LVN stated that Resident #1 could not have transferred himself from the toilet to the shower chair and required a gait belt for transfers. The LVN stated there was no gait belt on Resident #1 or in the shower room. The LVN stated that Resident #1's clean clothes were on the shower bench and his dirty clothes were thrown on the floor near soiled towels. The LVN stated that Resident #1 had a previous shoulder fracture that would have prevented him from removing his clothes. The LVN stated that CNA A was already gone before she arrived to work that day, and no one was aware that Resident #1 had been left in the shower room. The LVN stated that 1 person assist meant that staff must stay in the room at all times and Resident #1 should not have been left on the toilet alone or on the shower chair. The LVN stated that Resident #1 had no access to towels to cover himself. The LVN stated Resident #1 was upset and stated, I am so glad yall are here. The LVN stated that Resident #1 was at risk for falls and injuries by being left alone in the shower room. The LVN stated that Resident #1 was unsteady on his feet and required staff to be in there. The LVN stated that staff are trained on abuse and neglect and are trained on the care areas for the residents they work with. During an interview on [DATE] at 10:03 a.m. CNA C stated that on [DATE] she arrived at approximately 6 a.m. to assist the LVN with showers in 200 halls. Stated that she entered the shower room to grab supplies and found Resident #1 in the shower chair naked. CNA C stated it was approximately 6:04 a.m. and the LVN came in behind her. CNA C stated that Resident #1 stated that he was left in there by the girl. CNA C stated it was cold, the heat was off, and the water was off. CNA C stated she turned the heat on and turned the water on to warm up after Resident #1 stated he wanted a shower. CNA C stated that Resident #1 required staff to assist with showers, transfers and using the toilet because his gait was not steady, and he had a history of falls. CNA C stated that Resident #1's dirty clothes were on the floor, his clean clothes were on the bench and his wheelchair was against the wall across the shower room and not in reach. CNA C stated that Resident #1 was nude, had no gait belt on and there was no gait belt in the shower room. CNA C stated that Resident #1 required assistance to clean himself after a bowel movement and there was no evidence that he had a bowel movement in the toilet nor was there any feces on Resident #1. CNA C stated Resident #1 stated please, please help me. CNA C stated that Resident #1 stated that CNA A stated she would come back but never came back for him. CNA C stated that it was not possible for Resident #1 to transfer himself, get off the commode or get into the shower chair without assistance. CNA C stated staff had been trained on how to provide showers, not to leave residents alone, abuse and neglect and resident care plans. CNA C stated that Resident #1 should never have been left alone in the shower room and CNA A was gone before she arrived and none of the staff knew Resident #1 had been left alone. During a phone interview on [DATE] at 12:30 p.m. CNA A stated that on [DATE] she was in hall 200 and was in Resident #1 and Resident #2's room. CNA A stated that Resident #1 and Resident #2 are roommates and have a private restroom with shower in their room. CNA A stated that Resident #1 was asked if he wanted a shower, and he denied one. CNA A stated that the roommate, Resident #2 stated he wanted a shower and she put him into the shower chair in the room restroom, undressed him and got him ready to shower. CNA A stated that Resident #1 then asked if she could assist him and get him dressed. CNA A stated she dressed Resident #1 who then asked if he could use the restroom because he needed to have a bowel movement. CNA A stated that she told Resident #1 that Resident #2 was in there and Resident #1 asked if he could use another resident's restroom. CNA A stated she told him he could not use another resident's restroom, but she was going to the shower room to get towels for Resident #2 and asked Resident #1 if he wanted to use the toilet in the shower room and Resident #1 stated yes. CNA A stated that she left Resident #2 in the restroom in his shower chair and took Resident #1 to the shower room and assisted him on the toilet and told him she would return. CNA A stated that she removed Resident #1's pants, moved the shower chair into the shower stall and put Resident #1's wheelchair right in front of him. CNA A stated she told Resident #1 to use the call light if he needed her and she was headed back to assist Resident #2 with his shower. CNA A stated she went back to the resident shared room and showered and dressed Resident #2, before going back to the shower room down the hall for Resident #1. CNA A stated that Resident #1 was still on the commode and stated he was not done, and she told him to use the call light to call when he was finished. CNA A stated that she returned five minutes later, and Resident #1 stated he was not done yet. CNA A stated that she returned to the shower room at 5:57 a.m. and Resident #1 was still on the toilet and stated he was not done. CNA A stated she reminded Resident #1 to use the call light and advised him her shift was almost over and another aide may be the one to assist him. CNA A stated that she left for the day and did not inform anyone that Resident #1 was in the shower room. CNA A stated she meant to tell the nurse that Resident #1 was in the shower room but forgot to. CNA A stated that Resident #1 had a recent decline and was not acting like himself and had pulled some stuff off a shelf in the dining room that day. CNA A stated that Resident #1 care plan stated that he required a one person assist but Resident #1 could transfer himself, undress himself and could get into a shower chair himself. CNA A stated that Resident #2 had to be supervised in the shower per his care plan but that he was in a shower chair and was fine when she left to get towels from the shower room. CNA A stated that she had been trained on Resident #1 and Resident #2's hallway and had been trained on Resident #1 and Resident #2's care plans and they required 1 person assist with showering, toileting, and transfers. CNA A stated that there was no risk of Resident #1 falling because she put his wheelchair in front of him when he was on the commode and the shower chair was out of reach. CNA A stated Resident #2 was not at risk of falling because she put him in the shower chair, and he needed assistance to get out of the shower chair. CNA A stated that Resident #1 was not in the right state of mind and had not been the same the last week or so. CNA A stated that she did not understand why she was being asked about Resident #2 because she was terminated for leaving Resident #1 alone in the shower and Resident #2 was not brought up. CNA A stated she had been trained on care plans, showers, transfers and abuse and neglect. CNA A stated she did nothing wrong except that she left at the end of her shift and did not inform anyone that Resident #1 was left on the commode. Record Review of CNA A's time punch detail revealed CNA A punched in at 6:16 p.m. on [DATE] and clocked out at 6:02 p.m. on [DATE]. During an interview on [DATE] at approximately 12:50 p.m. with the ADM, the ADM stated he had not been aware that CNA A left Resident #2 alone in the resident room restroom in the shower chair when she went to the shower room with Resident #1. The ADM stated that during the facility investigation it was not revealed that Resident #2 was also involved in this incident. The ADM stated that staff should never leave a resident alone in the shower room and that Resident #2 required assistance with his ADLS. During an interview and observation on [DATE] at 1:05 p.m. with Resident #2 revealed he was in his room sitting in his power wheelchair. Resident #2 stated that he has a restroom with a shower in his room. Resident #2 stated that Resident #1 was his roommate before Resident #1 passed away. Resident #2 stated that he remembered the day that CNA A assisted him with a shower. Resident #2 stated that CNA A put him into the shower and then left for a few minutes to get towels. Resident #2 stated that he was not aware that Resident #1 went to the shower room down the hall with CNA A when he was in the shower. Resident #2 stated that CNA A came back and got him out of the shower and put a towel on him to dry. Resident #2 stated that CNA A then left again for about 2 minutes to get him clothes from his room. Resident #2 stated that he felt safe and required assistance to get transferred from his wheelchair into the shower chair and to be dressed. Resident #2 stated that his roommate, Resident #1 needed his wheelchair to get around and needed staff to assist him with transfers. Resident #2 stated that Resident #1 had a history of falls and had been confused around the time leading up to his death. Resident #2 stated that CNA A knew that they both needed assistance with showers and transfers and that Resident #1 had falls in the past because she always worked their hall. During an interview on [DATE] at 1:25 p.m. CNA C stated that Resident #2 needed total assistance for transfers and bathing and Resident #2 was only able to wash his private area. CNA C stated that Resident #2 had a history of falls, and it was not safe to leave him alone in a shower chair. CNA C stated that Resident #2 could bear some weight on his legs and had he attempted to get up from the shower chair alone, he could have fallen on the wet floor. During an interview on [DATE] at 1:35 p.m. the DON stated that she was not aware that CNA A left Resident #2 alone in the shower when she took Resident #1 to the shower room. The DON stated that Resident #2 had a spine curvature and had he leaned to the side or the front he would fall face first and would be injured with no staff to assist because it was not known he had also been left alone. The DON stated that CNA A did not reveal in her facility statement that she left Resident #2 alone and CNA A had been trained to not leave residents alone during showers or if they needed 1 person assist. Record Review of facility provided policy, Toileting, Bedside Commode/Bathroom dated 2023, revealed in part: Become familiar with the ability of the resident to perform toileting procedures independently or amount of assistance needed, type of toileting facility the resident will use, need for monitoring. Assist to bathroom and assuming sitting position on toilet, assist with cleansing following elimination, encourage resident to use holding bars in the bathroom to prevent falls. Record Review of facility provided policy, Bath, Tub/Shower, dated 2023, revealed in part: Become familiar with the type and pattern of bathing, assistance or aids needed. Transport resident via shower chair; remain with the resident if he is weak or assistance is needed in washing, protect from drafts and chilling during bathing. Place call light in reach for resident to call for assistance; remain with the resident if weak. Assist out of the tub or shower, wrap in bath towel, allow to sit on a chair and assist to dry if needed. Assist to dress if needed or supply aids. Assist the resident with transfer to room or location of choice. Record Review of facility provided policy, Abuse/Neglect, Revised [DATE], revealed in part: The resident has the right to be free from abuse, neglect. This includes but not limited to, involuntary seclusion and any physical/chemical restraint note required to treat the resident's medical symptoms. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will train through orientation and on-going in-services on issues related to abuse/neglect prohibition practices regularly. Record Review of CNA A's employee record revealed that CNA A was hired, received, and signed orientation training on [DATE] that included the following topics: Resident dignity and privacy, No abuse, neglect and/or unnecessary restring; Resident abuse, neglect, and mandatory reporting. Record Review of CNA A's employee disciplinary record revealed that CNA A was terminated on [DATE] due to an incident of Neglect on [DATE]. Specific Reason for Disciplinary Action: On [DATE], [CNA A] was suspended pending an investigation into resident neglect: those allegations were substantiated. It was found that [CNA A] left a resident in the shower room, unattended, for at least thirty minutes. This is a violation of the resident's rights, a violation of her job duties/responsibilities and of the Corporate Code of Conduct. Employee confirmed during a neglect investigation that she knowingly left a resident unattended in the shower room and did not report to anyone that resident was in the shower room.

Based on interview and record review, the facility failed to ensure that residents received mail for 9 of 12 residents reviewed for rights to forms of communication for 1 of 1 facility reviewed for mail being delivered on Saturdays. The facility failed to: 1.) Ensure that mail had been delivered to all residents on all days that the United Postal Service delivered mail. This failure could result in a decline in the resident's psychosocial well-being and cause them to feel disconnected from family, friends, and current world issues. The findings include: During a confidential interview on 01/24/2024 at 2:00 PM, 12 residents reported that the facility does not deliver mail on the weekends, the resident stated, We only get mail M-F because offices are closed. An interview with BOM on 01/25/2023 at 9:44 AM revealed the mail will be delivered when it was dropped off by the carrier. BOM stated the mail usually gets to the facility around 5-6 PM, Monday through Friday. BOM stated that the mail was supposed to be delivered on Saturdays, but she has never seen it delivered on Saturdays since she has worked for the facility. BOM stated she called the post office and spoke with one of the workers and was told they were shorthanded. BOM stated she had not put in a formal complaint. BOM stated if the mail were to be delivered on Saturday, then the post carrier would leave it at the front and a staff member would put it all in her box until Monday so she could go through the mail and sort it out and then it would be delivered on Monday. BOM stated she worked for the facility for a while. BOM stated she does not work the weekends. BOM stated she only knows the mail had not been delivered on Saturdays because staff will tell her it had not been delivered. BOM stated there was not a designated staff member to pick up the mail if it were to be delivered on Saturdays, just any staff member could pick up the mail. BOM stated she was unsure what the policy stated about residents receiving mail on the weekends. BOM stated the negative potential outcome of residents that had not received their mail is that they may feel that their rights are restricted, An Interview with AD on 1/25/2024 at 10:00 AM. AD stated that she had been working in the facility for two years. AD stated that normally the BOM will go through the mail first to retrieve anything for the business office first and then she will give her what is supposed to be delivered to the residents. She stated that there is not a designated person to pick up mail from the front when mail is delivered on the weekends. AD stated that no formal complaints have been made. AD stated that the mail does come on the weekends but there had been times that it had not been delivered on the weekends. AD stated that had not happened too many times. AD stated that sometimes she will come in to work on the weekends and if she is there, she will pass out the mail, but she is not scheduled to work. AD stated that on the weekends the staff is instructed by the BOM to pick up mail and put it all in the BOM mailbox until she has a chance to go through the mail and then the BOM will do that on Monday. She stated that the negative potential outcome of residents not receiving their mail on weekends could be that they are expecting a certain piece of mail and could not get it when they need it. An Interview with Marketing Administration on 1/25/2024 at 10:12 AM. Marketing Administration Staff stated that she had worked in the facility for nine years. She stated that the mail does get delivered to the facility on the weekends but there are times that they do not get the mail. She stated that the staff is supposed to pick the mail up from the front and put in the BOM mailbox until the BOM gets to work on Monday to go through the mail and then it is passed out to the residents. Marketing Administrator stated that the BOM does not work on the weekends and that she only works Monday -Friday 8 am-5pm. She stated that she is not designated to pass out the mail to the residents, but the Activity Director is designated to pass out the mail after the BOM goes through it, Monday through Friday but not the weekends. An Interview with Administrator, Area Director of Operations, and Regional Nurse on 1/25/2024 at 10:32 AM. Administrator stated that the mail is delivered every day except Sunday. Administrator stated mail is delivered on the weekend and a manager on duty is supposed to pick it up and pass it out to the residents. Administrator stated that Monday-Friday, when the mail is delivered, the BOM will go through the mail and then it will be dispersed to the residents. Area Director of Operations stated that he had not heard of any residents not getting their mail. Administrator stated that she had only been in the facility for a brief time (couple of months) but was unaware of residents not getting mail. Regional Nurse stated that the BOM is now completing a complaint form on the computer on the post office. All staff stated they have not been in the facility long. Area Director of Operations stated that he expects the residents to receive their mail when it is delivered to the facility. Area Director of Operations and Administrator stated that the facility had recently gone through staff changes including Administrator. Administrator stated that she will do an in-service with the staff. An Interview with Post Office Manager on 1/25/2024 at 10:58 AM. Post Office Manager stated that he is not aware of any complaints of the mail not being delivered to the facility. He stated that he had not had any recent complaints of people not receiving their mail on the weekends. He stated that he is in the building and the facility staff could have called or came in to voice their concerns if they had not been receiving their mail. Post Office Manager did look on the computer to confirm that no complaints had been made by the facility at any time. He stated that he had been the manager at this post office for 4 years and he is not aware of any complaints from the facility at all. He stated that he does check up on his mail carriers from time to time by sending other employees out with that carrier or they will do a spot check. He stated that the mail is delivered to the facility on all days if there is mail to be delivered at the facility. Record review of the facility policy titled, Resident Mail Delivery and Distribution, Revised 2011, revealed the following documentation: Standard Statement The health care center will develop a system to deliver and distribute resident mail in accordance with privacy and confidentiality regulations. Practice Guidelines: 1. The Activity Department appoints a specific staff member to coordinate mail delivery every day that the facility receives mail or parcels. 2. All resident mail is delivered to residents unopened.

Based on observation, interview, and record review, the facility did not provide adequate supervision to prevent R#1, who was identified with risk for falls from falling in the dining room. This resulted in a [MEDICAL CONDITION]. This failure could place residents with a fall history at risk for additional falls and injuries. The findings were: Record review of R#1 Admission Record indicated she was an [AGE] year-old female who was admitted to the facility on [DATE]. R#1's [DIAGNOSES REDACTED]. Record review of R#1's Admission Minimum Data Set (MDS) assessment, dated 03/10/20, revealed R#1: -required extensive assistance with two-person physical assist for bed mobility, transfer, dressing, and toilet use, -required limited assistance with one-person physical assist for walking in room and corridor, locomotion on and off the unit, eating and personal hygiene, -was not steady, but able to stabilize without staff assistance when moving from seated to standing position, walking, turning around and facing the opposite direction while walking, and moving on and off the toilet -used a wheelchair -triggered [MEDICAL CONDITION], cognitive loss/dementia, communication, urinary incontinence in the indwelling catheter, psychosocial well-being, activities, falls, nutritional status, dental care, pressure ulcer/injury, and pain. Record review of R#1's Care Plan, initiated 03/11/19, revealed: -she had a fall, the interventions included notifying the charge nurse for increased weakness, attempting to transfer self, potential hazards in room, agitation, non-compliance calling for assistance; -she is at risk for wandering, the interventions included assess for fall risk, distract her form wandering by offering pleasant diversions, structured activities, food, conversation, television, book, 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. If R#1 is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. -Activities of Daily Living (ADL) indicated she required one staff when eating and walking. Record review of R#1's Fall Risk assessment dated [DATE] revealed R#1 was disoriented times 3 at all times, had 1 - 2 falls in the past 2 to 3 months, and required use of assistive devices (cane, wheelchair, walker, furniture). Record review of R#1's Fall Risk assessment dated [DATE] revealed R#1 had intermittent confusion, had 1 - 2 falls in the past 2 to 3 months, had balance problem while standing and walking, decreased muscular coordination, and required use of assistive devices (cane, wheelchair, walker, furniture). Record review of Even Nurses-Note 12 hr. Fall dated 03/05/20 indicated R#1 stood up from wheelchair and attempted to ambulate without assistance and lost her balance and fell on to her left side R#1sustained a skin tear or laceration to left finger approximately 1cm and was bleeding. At the time of this incident, R#1 required 1 staff assist when walking, had unsteady gait, balance problem, and lack of mobility strength. This report indicated R#1's cognition/behavior included cognitive impairment, wanders daily, and required cueing. Fall Nurses-Note 12 hr. dated 03/06/20 and include intervention for 03/05/20 fall was for a low bed. Record review of Weekly Nurses Summary dated 03/06/20 indicated R#1 used a wheelchair and required oversight, encouragement, cueing, and resident nor chair is touched by staff. Report indicated R#1 had dementia and was severely impaired, she does not ask for help when needed, aware of need for device (cane, walker, wheelchair) but does not use it, rarely/never makes decisions, and needs verbal and/or physical cues to complete task. This report indicated R#1 displayed wandering behavior daily, mode of locomotion was a wheelchair, and mode of transfer was with staff assist. Record review of R#1's Fall Risk assessment dated [DATE] revealed R#1 was disoriented times 3 at all times, had 3 or more falls in the past 3 months, was wheelchair bound, had balance problem while standing and walking, decreased muscular coordination, change in gait pattern when walking through doorway, and required use of assistive devices (cane, wheelchair, walker, furniture). Record review of Even Nurses-Note 12 hr. Fall dated 03/11/20 indicated R#1 rolled herself onto the floor, on her back, as witnessed by CNA and nurse. Order for x-ray revealed R#1 did not sustain an injury. At the time of this incident, R#1 required 1 staff assist when transferring and walking, she had unsteady gait, balance problem, and lack of mobility strength. This report indicated R#1's cognition/behavior included cognitive impairment, refuses to call for assistance, wanders, required cueing, and is restless. Record review of Weekly Nurses Summary dated 03/13/20 indicated R#1 used a wheelchair and required oversight, encouragement, cueing, and resident nor chair is touched by staff. Report indicated R#1 has dementia and was severely impaired, does not ask for help when needed, aware of need for device (cane, walker, wheelchair) but does not use it, rarely/never makes decisions, needs verbal and physical cues to complete tasks. This report indicated R#1 displayed wandering behavior daily, mode of locomotion was a wheelchair, and mode of transfer was with staff assist. Record review of Weekly Nurses Summary dated 03/20/20 indicated R#1 used a wheelchair and required oversight, encouragement, cueing, and resident nor chair is touched by staff. Report indicated R#1 has dementia and was severely impaired, does not ask for help when needed, aware of need for device (cane, walker, wheelchair) but does not use it, rarely/never makes decisions, needs verbal and physical cues to complete tasks. This report indicated R#1 displayed wandering behavior daily, mode of locomotion was a wheelchair, and mode of transfer was with staff assist. Record review of Weekly Nurses Summary dated 04/07/20 indicated R#1 used a wheelchair and staff pushed the chair, but resident helps some. Report indicated R#1 has dementia and was severely impaired, does not ask for help when needed, aware of need for device (cane, walker, wheelchair) but does not use it, rarely/never makes decisions, needs verbal and physical cues to complete tasks. This report indicated R#1 displayed wandering behavior daily, mode of locomotion was a wheelchair and able to wheel self and wheeled by others, and mode of transfer was with staff assist. Record review of R#1's 04/13/20 Nursing Progress Report dated 04/13/20 at 7:45 PM R#1 had fallen in the dining room. R#2 who is alert witnessed R#1 walking approximately 15 feet from wheelchair and fell lying on her left sider per ADON. R#1 complained of left shoulder and hip pain. At 8:05 PM R#1 was transferred to a hospital due to falling out of wheelchair while in the dining area. Record review of R#1's eTransfer Form dated 04/13/20 indicated R#1 fell out of her wheelchair while in the dining room. R#1 fell on her left side and complained of left hip and shoulder pain. This report indicated R#1 does not walk, was full weight bearing, was at risk of falls, and utilized a wheelchair. Record review of R#1's hospital's History and Physical dated 04/14/20 indicated she had severe dementia, is wheelchair bound, and oriented to self only. R#1 presented to emergency room for pain of the left hip after a fall. R#1's facility nurse reported R#1 was by herself in the dining area and an oriented resident (R#2) witnessed R#1 leave her wheelchair, walk across the dining room about 15 feet, and falling to the floor. In addition, nurse reported R#1 is wheelchair-bound, and has had bilateral hip replacements in the past. R#1 was transferred to another hospital due to finding on x-ray a nondisplaced left femur fracture. Observation on 04/17/20 at 6 PM of facility's video revealed on 04/13/20 at 7:36 Resident (R#1) was sitting at the dining table with Certified Nurse Aide (CNA#1). CNA#1 assisted R#1 by feeding her a spoonful of food and then got up from the dining table and left the dining room. This left R#1, who was in her wheelchair, by herself as she continued to eat her meal. In addition, R#2, R#3 and R#4 remained in the dining room without any staff present in the dining area. Afterwards, the video's timer revealed at 19:36:56 R#1 stood up and walked away from her wheelchair approximately 4 feet while holding onto the dining table; she turned around and released the table; she attempted to walk away when she lost her balance and fell on to the floor at 19:37:46; at 19:37:59 R#2, who was in her wheelchair, wheeled himself from the dining table towards the nurses' station, and at 19:38:08 ADON#1 and CNA#1 responded by entering dining area and going towards R#1, after R#3 pointed them towards R#1, who was on the floor. Interview on 04/17/20 at 6:20 PM was attempted with Resident #1(R#1), but she did not respond to questions asked of her. Interview on 04/17/20 at 3:37 PM with Resident (R#2) indicated on Monday (04/13/20) he was in the dining room eating his meal, when he saw R#1 walking and then falling to the floor. R#2 added that R#1 fell on her shoulder hard, and he had to go to nurses' station to ask for help because there were no staff in the dining area. R#2 recalled residents, R#3 and R#4 were the other residents in the dining area, and they also asked for help when R#1 fell . R#1 indicated there was nobody in the dining area to stop R#1 from getting up from her chair or from walking. Interview on 04/17/20 at 6:40 PM resident (R#3) recalled he was in the dining room talking to R#4, when R#1 fell on the floor. R#2 indicated there were no staff in the dining area so he [MEDICATION NAME] to alert staff, and when staff entered the dining area he pointed to R#1, who was lying on the floor. Interview 04/17/20 at 7:09 PM Licensed Vocational Nurse (LVN#1) indicated on 04/13/20, when resident (R#1) was found on the floor, she was conducting a blood sugar test at the end of hall 1, specifically room [ROOM NUMBER]. LVN#1 was informed by unknown Certified Nurse Aide (CNA#1) that R#1 was on the dining room floor. LVN#1 went into the dining room and found R#1 on the floor, while as other staff were assisting her, this is when LVN#1 attempted to turn R#1 but stopped after she reported being in pain. Afterwards, LVN#1 called 911; Emergency Medical Service (EMS) responded and assessed R#1; removed her from the floor and transported her to the hospital. LVN#1 indicated Assistant Director of Nurses (ADON #1) informed her R#2 witnessed R#1 walk away from her chair a few feet before falling to the floor. LVN#1 indicated all the CNAs on duty were not working the floors because they were called to a meeting, therefore, they were unable to care for residents. Interview on 04/20/20 at 4:36 PM with Certified Nurse Aide (CNA#2) indicated on 04/13/20 she and the other CNAs were informed over the facility's intercom to go to Administrator's office for a meeting. After this meeting CNA#2 exited the meeting and was walking towards the nurses' station, when she heard R#1 call out for help from the dining area. CNA#2 indicated she and ADON#1 entered the dining room and found R#1 on the dining room floor. CNA#2 placed a pillow under R#1's head as she reported being in pain. CNA#2 indicated as far as she knew R#1 could be left alone and was not sure why she stood up and walked away from her wheelchair, because she had not seen her do that before. CNA#2 indicated R#1m while in her wheelchair, would be placed by the nurses' station because she would refuse to stay in her room. Interview on 04/17/20 at 10:15 AM CNA#3 indicated 0n 04/13 20 she assisted Resident (R#1) with her evening meal in the dining room. CNA#3 indicated R#1 took a few bites, and then she fed her spoonsful of food, until she heard over the intercom a request for all CNAs to report to Administrator's office. CNA#3 indicated she left R#1 by herself at the dining table as she continued to eat her meal. CNA#3 revealed all the CNAs attended a meeting called by the Administrator in his office with the DON, which left ADON#1 and LVN#1 to care for the residents. Interviews on 04/17/20 with Certified Nurse Aides (CNA#3 at 10:15 PM, CNA#5 at 10:40 PM, #6 at 10:34 PM, CNA#7 at 10:46 PM, and CNA#8 on 04/20/20 at 4:21 PM) indicated they were not caring for residents on 04/13/20, when R#1 fell on the dining room floor and broke her femur, because the Administrator requested all CNAs attend a meeting he held in his office with the Director of Nurses (DON). Interview on 04/20/20 at 1 PM with Director of Nurses (DON) indicated Resident (R#1's) first fall in the facility was on 03/05/20, this fall was followed with a mobile x-ray revealing no injury; however, responsible party wanted her sent to the hospital for an x-ray, where the hospital x-ray confirmed she did not have an injury. Afterwards, R#1 continued to complain of pain and an order was received for physical therapy, which was implemented but discontinued after R#1 failed to make progress. DON indicated on 04/13/20 Mrs. Allen was in the dining area, when she got up and walked away from her wheelchair and fell sustaining a fracture to her femur. DON indicated when R#1 fell the CNAs were in a meeting called by Administrator, which she attended as well. DON indicated there was not a signature sheet for this meeting because it was a verbal discussion reminding CNAs to make sure they were conducting 2 hours rounds on the residents. Interview on 04/20/20 at 2:40 PM with facility's Medical Director (MD) indicated Resident (R#1) is an [AGE] year-old female with [DIAGNOSES REDACTED]. MD indicated on 04/13/20 R#1 fell and sustained a fracture to her femur. R#1 was sent to the local hospital and then transported to another hospital for surgeon to evaluate and pursue surgery; however, surgeon decline to perform surgery due to R#1's age and her medical condition. MD indicated R#1 should not have been left unsupervised in the dining area, because even if she is directed not to get up she will get up; however, if staff were in the area they could intervene by assisting her. Administrator confirmed, when resident R#1 fell and broke her femur in the dining area, there were no staff present in the dining room as seen on the facility's video. Review of Facility's policy to Preventive Strategies to Reduce Fall Risk with revision dated of 10/05/16 indicated The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. This policy included nursing care for Place confused residents close to nurses' station for close observation, if possible. Establish frequent nursing rounds on high risk residents. Provide assistive ambulation. Encourage daily exercise. Increase nursing staff.

Based on interviews, observations and record reviews the facility failed to ensure residents were free from neglect for 3 (Resident #34, Resident #35 and Resident #177) of 5 residents whose care was reviewed for neglect. The DON and ADON failed to provide necessary staff and supplies to ensure wound care treatments were conducted, and failed to communicate, monitor and oversee nursing staff to ensure treatments were performed when the treatment nurse was pulled to cover other shifts. These failures resulted in an Immediate Jeopardy (IJ) situation on 09/18/2019. While the IJ was removed on 09/19/2019, the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. These failures placed the residents at risk for developing worsening pressure ulcers,[MEDICAL CONDITION] (infection of the blood), severe pain or death. Findings Included: Review of Resident #34's undated Face Sheet revealed she was a [AGE] year-old female re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #34's Care Plan revised 12/31/18 revealed the following: Focus: Resident #34 has a potential for pressure ulcer development related to lack of mobility strength due to right above the knee amputation. Goal: Resident #34 will have intact skin free of redness, blisters or discoloration. Interventions: Administer [MEDICATION NAME] as ordered, administer medications as ordered, do not massage over bony prominence for peri-care/washing. Follow facility policy/protocols for the prevention/treatment for [REDACTED]. Review of Resident #34's quarterly MDS (minimum data set) dated 04/17/19 revealed she had a BIMS (brief interview for mental status) of 15 indicating she did not have any cognitive impairment and able to make her needs known. Resident #34 skin assessment revealed she did not have a pressure ulcer. Resident #34's 05/08/19 MDS review indicated she had a stage III pressure ulcer. Review of Resident #34's Physician orders [REDACTED].#34 was treated for [REDACTED]. Stage II orders were discontinued on 08/16/19. Orders for treating a stage III began on 08/20/19. Review of Resident #34's Physician orders [REDACTED]. Apply DemaCol AG to wound bed and apply corona cream to area around wound. Cover with pad and sheet daily. Review of Resident #34's Physician orders [REDACTED]. Apply Derminate (cut to fit wound) with Island dressing daily and as needed. Review of Resident #34's weekly pressure ulcer assessment beginning on 04/17/19 through 09/04/19 revealed initial assessment of no pressure ulcer on the right thigh, then progressed to a stage III, then unstageable. Physician orders [REDACTED]. The following skin assessments reveal the following: 04/17/19 no pressure ulcers indicated 05/01/19 no pressure ulcers indicated 05/07/19 pressure ulcer stage III reveals measurements length 0.4 cm x 0.4 cm width x 0 depth 05/13/19 pressure ulcer stage III reveals measurements length 0.8 cm x 0.8 cm width x 0 depth. 06/26/19 pressure ulcer (unstageable) measure length 1.5 cm x 1.5 cm width x 0 depth. 07/03/19 pressure ulcer unstageable measurements length 1.0 cm x 1.0 cm width x 0 depth 07/10/19 pressure ulcer unstageable measurements length 1.0 cm x 0.8 cm width x 0 depth 07/17/19 pressure ulcer unstageable measurements length 1.0 cm x 1.5 cm width x 0 depth 07/22/19 pressure ulcer stage II reveals measurements length 1.2 cm x 1.2 cm width x 0 depth 07/24/19 pressure ulcer stage III reveals measurements length 1.0 cm x 1.5 cm width x 0 depth 07/31/19 pressure ulcer stage II reveals measurements length 0.8 cm x 0.3 cm width x 0 depth 09/04/19 pressure ulcer (unstageable) measure length 1.2 cm x 0.7 cm width x 0.2 depth (last assessment prior to survey) Review of Resident #34's TAR (treatment administration record) revealed during (MONTH) 2019, 4 wound care treatments were missed and (MONTH) 2019, 3 wound care treatments were missed. Review of Resident #34's missing TAR (Treatment Administration Record) in (MONTH) 2019 revealed the following days missed: August 5, (MONTH) 8, (MONTH) 15, and (MONTH) 22 Review of Resident #34's TAR in (MONTH) 2019 revealed the following days missed: September 3, (MONTH) 9, and (MONTH) 13. Review of Wound Care Nurse B's time sheet and TAR revealed the following: August 5, Wound Care Nurse B did not work and treatment was not documented as being done. August 8, Wound Care Nurse B worked but did not document treatment was done. Auguts 15, Wound Care Nurse B worked a night shift and treatment was not documented as being done. August 22, Wound Care Nurse B worked a night shift and treatment was not documented as being done. Time sheet for Wound Care Nurse B's (MONTH) time sheet was not provided by the facility. Review of website accessed on 09/30/19 https://www.woundsource.com described stage II and III pressure ulcers. Stage 2 pressure ulcers are characterized by partial-thickness skin loss into but no deeper than the dermis. Stage 3 pressure ulcers (injuries) involve full-thickness skin loss potentially extending into the subcutaneous tissue layer. During initial tour on 09/17/19 at 10:45 AM Resident #34 said her pressure sore on her bottom was getting worse. She said there were a few times she did not receive wound care treatments or have supplies. During wound care observation and interview with Wound Care Nurse A on 09/18/19 at 11:20 AM Resident #34's wound care revealed she had a dressing covering a pressure ulcer on the fold between her buttock and her right leg. Removal of the dressing revealed a pressure ulcer to be a stage III which included a deep crater with fat tissue visible at the base of the wound, skin around the wound was intact and free of redness or drainage. Wound Care Nurse A said the previous Wound Care Nurse B staged Resident #34's pressure ulcer on her inner thigh as a Stage II. The nurse who covers the weekend and does Resident #34's wound said it was a stage III. Wound Care Nurse A said it was a problem with people agreeing on the staging. Wound Care Nurse A said that was why Wound Care Nurse B quit she said her (Wound Care Nurse B) judgement was in question. Review of wound care assessment conducted on 09/19/19 revealed DON with presence of the Medical Director staged Resident #34's pressure ulcer. Resident #34 had a stage III pressure injury measuring 1.0 cm(centimeters) x 0.5 x0.5. Resident #35 Review of Resident #35's undated Face Sheet revealed she was an [AGE] year-old female re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #35's MDS (minimum data set) dated 12/14/18 revealed she did not have a pressure ulcer. Review of Resident #35's quarterly MDS dated [DATE] revealed she had a BIMS (brief interview for mental status) of 10 indicating she had moderate cognitive impairment and able to make her needs known, Resident #35 had a stage III or greater pressure ulcers and required pressure ulcer skin care. Review of Resident #35's revised Care Plan dated 12/20/18 revealed the following: Focus: Resident #35 has potential for pressure ulcer development related to lack of mobility strength and incontinence. Goal: Resident #35 will have intact skin, free of redness, blisters or discoloration. Intervention: .Resident #35 needs assistance to turn/reposition at least evert 2 hours. Review of Resident #35's weekly pressure ulcer assessments beginning on 04/02/19 through 09/03/19 revealed a pressure ulcer on left buttock/ sacral area stage III progressing to a stage IV indicating the pressure ulcer was worsening. Resident #35's pressure ulcer staging revealed the following: 03/12/19 left inner buttock Sacrum - stage II length 4.0 cm x 0.5 cm width x 0 depth 05/21/19 left inner buttock Sacrum (beginning to stage at III) length 2.0 cm x 1.0 cm width x 0 depth The following weekly skin assessments revealed the following: 08/20/19 left buttock/sacral -pressure ulcer stage III length 1.5 cm x 0.5 cm width x 0 depth 08/23/19 Sacrum - pressure ulcer stage IV length 2.0 cm x 1.0 cm width x 0 depth 09/05/19 Sacrum - pressure ulcer stage IV length 2.0 cm x 1.0 cm width x 0 depth 09/12/19 Sacrum - pressure ulcer stage IV length 2.0 cm x 1.0 cm width x 1.2 cm depth Review of Resident #35's Physician orders [REDACTED]. Pack wound (loosely) with collagen powder, cover with foam dressing and secure with island dressing. One time a day related to pressure ulcer of unspecific site. Review of Resident #35's TAR revealed during (MONTH) 2019 (4) wound care treatments were missed (classified as stage III) and 1 (classified as a stage IV) missed in (MONTH) Review of the wound care treatment missed in (MONTH) 2019 revealed the following: August 5, (MONTH) 8, (MONTH) 15, and (MONTH) 22. Stage III Stage IV treatment missed (MONTH) 30. Review of Wound Care Nurse B's time sheet and the TAR revealed the following: August 5, Wound Care Nurse B did not work and treatment was not documented as being done. August 8, Wound Care Nurse B worked but did not document treatment was done. Auguts 15, Wound Care Nurse B worked a night shift and treatment was not documented as being done. August 22, Wound Care Nurse B worked a night shift and treatment was not documented as being done. The facility did not provide Wound Care Nurse B's (MONTH) time sheet. During wound care observation and interview on 09/18/19 at 11:10 AM Resident #35 had a dressing covering her sacral area. The approximate length and depth of the wound without actual measurement was 2.0 cm x 1.0 cm and depth of the wound was noteable due to collagen inside of the wound. The area around the wound was intact but black within the walls of the wound (resident was African American with dark skin) and without redness or drainage. Depth of the wound was filled with previous collagen filler and unable to determine if bone or tendon was visable. Wound Care Nurse A cleaned the area around the wound and filled the depth of the wound which still had previous treatment collagen filler in the wound. She said she would consider Resident #35's wound to be a stage IV due to the length and width. She then cleaned the wound with normal saline solution and re-applied collagen powder and covered with a dressing. Review of website accessed on 09/30/19 https://advancedtissue.com revealed the stage IV wound definition as: Stage IV wounds may feature extensive loss or damage to tissue, muscles and bones, and often feature muscle and bone that is exposed. Healing a Stage IV wound often includes surgery, as well as wound debridement of some tissue, particularly necrotic or eschar that may be partially or completely covering the wound. Review of wound care assessment conducted on 09/19/19 revealed DON with presence of the Medical Director staged Resident #35's pressure ulcer. Resident #35 had a stage IV sacral pressure injury measuring 2 cm(centimeters) by 1cm and a depth of 1 cm with tunneling 1.2 cm at 10 o'clock position. Resident #177 Review of Resident #177's undated Face Sheet revealed he was a [AGE] year-old male admitted on [DATE] with the [DIAGNOSES REDACTED]. Resident #177 was discharged from facility on 08/14/19. Review of Resident #177's initial Care Plan dated 07/23/19 Focus: Resident #177 has (3) unstageable pressure ulcer to the right and left inner buttock and coccyx area. Goal: Resident #177 will have no signs or symptoms of infections through the review dated. Intervention: [MEDICATION NAME] packet Give one packet by mouth daily Clean with wound cleanser, apply calcium alginate AG with Santyl to wound bed and cover with ABD pads and hyperfix daily. Document location of wound, amount of drainage, peri-wound area pain [MEDICAL CONDITION] record circumference measurement. Review of Resident #177's admission MDS (minimum data set) dated 07/29/19 revealed he had a BIMS (brief interview for mental status) of 12 indicating he had moderate cognitive impairment and able to make his needs known. Resident #177 had three unstageable pressure ulcers and required pressure ulcer skin care. Review of website accessed on 09/30/19 https://advancedtissue.com revealed the definition of unstageable pressure ulcer. Ulcers covered with slough or eschar are by definition unstageable. Review of Resident #177's admission/weekly skin assessment dated [DATE]. Peri area excoriated and bright red, (2 wounds) right inner buttock unstageable pressure ulcer (#1) measuring 10.5 cm x 2.0 cm x 0 depth. (100% necrotic tissue). Right inner buttock (#2) measuring 15 cm x 3.0 cm x 0 depth. Review of Resident #177's weekly skin assessment dated [DATE] right inner buttock (#2) measuring 18 cm x 4.0 cm x 0 depth. (increase of 27 square cm) Review of Resident #177's weekly assessment dated [DATE] revealed right inner buttock pressure ulcer (#1) measured 11.0 cm x 2.5 cm x 0 depth. (increase of 6 square cm) Review of Resident #177's Physician orders [REDACTED]. Apply calcium alginate AG with hydrogel to wound bed. Cover with optilock and [MEDICATION NAME] one time a day. Scrotum clean with wound cleaner apply sting free liquid. Coccyx (unstageable) clean with wound cleaner, pat dry and apply alginate AG with hydrogeal and optilock and [MEDICATION NAME] one time a day, inner buttock (unstageable) clean wound with cleanser, pat dry applies calcium alginate AG with hydrogel to wound bed and cover with optilock and [MEDICATION NAME] one time a day. During an interview on 09/18/19 at 11:10 AM the DON said she had been aware that on some of the days the treatment nurse was pulled to work the night shift due to short staffing. She said she was aware on the days the treatment nurse was pulled there had been resident wound care treatments missed. She said it was her assumption when the previous treatment nurse was pulled to work the night shift that the charge nurses had provided the residents wound care treatments; however, she had not gone back to check if the treatments were completed. She said there was not a specific plan in place for monitoring that the treatments had been completed per the physician orders. She said she was not sure how the charge nurses were informed of the need to do the residents treatments when the treatment nurse was pulled to work the night shift. She said she did not know why the resident physician was not notified about residents' missing wound and/or residents wounds worsening. She said she found the treatment nurse to be very argumentative and defensive when anyone asked a question about a resident wound. She said she had done a random check on a resident following the treatment nurses wound care and upon entering the room she could smell a foul odor coming from the resident wound. She said when she asked the treatment nurse how long the wound had a foul odor; the treatment nurse had responded a couple of days. She said she had the resident immediately sent out to the emergency room and had not returned to the facility due to requiring surgery (later found out Resident #177 required antibiotic therapy) she said right after that Wound Care Treatment Nurse B quit. Review of Resident #177's emergency room admission on 08/14/19 revealed the following: [AGE] year-old-male admitted for dementia, [MEDICAL CONDITIONS] large decubitus wound on buttock,[MEDICAL CONDITION] and general debility. Assessment:[MEDICAL CONDITION] syndrome, ongoing antibiotic therapy with [MEDICATION NAME] and [MEDICATION NAME] for lumbar stage IV decubitus ulcer, infected with Proteus mirabilis and [MEDICATION NAME] faecalis. During an interview on 09/18/19 at 10:00 AM Wound Care Nurse B (former Wound Care Nurse) said she ordered supplies every Thursday but the central supply manager said they were transition between 2 suppliers and sometimes they would run out of some of the supplies she needed and she would go to the nearby retail store to get supplies. She said sometimes she would be on call and come in to do her wound care and was told to go home so she could cover a night shift. She said when she left (when she had to cover night shift) there was no one to continue doing wound care. When this happened, residents did not receive their treatments. She said in regard to staging wounds she considered Resident #35 as a stage III and had a wound care specialist go with her to confirm her wound staging. She said Resident #35 has a stage III and the wound care nurse who comes in on weekends said it was a stage IV. She said she disagreed with the stage IV wound assessment. Review of receipts provided by the facility revealed the following supplies were purchased by Wound Care Nurse B for residents who needed wound care supplies when they were not available at the facility. 06/05/19 wound wash (6) bottles. 07/26/19 (3) bottles of [MEDICATION NAME] (2) bottles of power (unspecified). 08/02/19 (3) packages of diapers, (3) tubes [MEDICATION NAME] ointment, (3) bottles of unspecified lotion. (Date covered and unable to specified date) (3) tubes of [MEDICATION NAME] ointment, (2) bottles of wound wash, (2) rolls of tape, cloth and clear. 08/09/19 (7) boxes of absorbent pads, (4) boxes of 4x4 gauze. 08/21/19 (5) boxes of 4x4 gauze, (8) boxes of gauze pads. During an interview on 09/17/19 at 3:20 PM Central Supply Manager said they were in transition between two suppliers. He said some of the different supplies had to be coordinated to get the same wound care supplies that were ordered. He said he was stocked and should have everything the staff need. He said he knew Wound Care Nurse B went to the nearby retail store to get some supplies and he got what she needed, and she was reimbursed. During an interview on 09/19/19 at 4:50 PM Corporate Operations Manager said the facility was well stocked with supplies, he said Wound Care Nurse B had to go to the nearby retail store to get gauze and other dressings. Corporate Operations Manager said he did not know why Wound Care Nurse B had to go to store to get more supplies. During an interview on 09/18/19 at 9:00 AM Wound Care Nurse A (acting wound care nurse) said she does wound care when she was at work and in charge of the shift. She said she had just recently been asked to be the wound care nurse but had not made up her mind if she wanted the position. She said normally the charge nurses do their own wounds since the facility does not have a wound care nurse right now. She said hopefully the charge nurse will be able to get to all of the wounds and do their charge duties. She said today she came in on her day off (09/17/19) and doing wounds. She said she was not surprised wound care was missed because of being shorthanded. At times if someone was on call they would be pulled to cover a shift. The charge nurse is supposed to cover wound care and she was not sure if it was covered. She said she did agree with the previous wound care nurse (Wound Care Nurse B) treatment assessment, (Wound Care Nurse A) and did not contact physician for any changes when (Wound Care Nurse B) quit. During an interview on 09/18/19 at 9:15 AM ADON said the facility has PRN (as needed) wound care nurses during the weekend and charge nurses are capable of doing wound care. She said in regard to missing slots in the TAR (treatment administration record) she was not surprised there were missing treatments. She said she realized if the MAR indicated [REDACTED]. She said she was not aware there were holes in the TAR treatment record. During an interview on 09/18/19 at 2:28 Medical Director said in relation to notification regarding change in wounds sometimes they do and sometimes they don't, they have protocols in place when they need to tell him of any changes. He said he was not aware of any missed treatments or worsening wounds. During an interview on 09/18/19 at 4:00 PM request DON for facility policy and procedure and wound care protocol returned only with facility policy and procedure and did not supply with the facility protocol regarding wound care. Review of facility's policy and procedure titled Skin Integrity Management, dated (MONTH) 5, 2003, revealed the following: General Guidelines 1. If wound is noted, perform an assessment an initiate a treatment plan as soon as possible. Document resident's chart, area of change, who you notified and treatment applied. 10. Treatment Nurse/designee or Director of Nursing will assess site and evaluate for appropriate stage as listed in this procedure. Notify physician; obtain and order and monitor site daily. Sign off on treatment sheet any treatment completed (i.e., stage I through stage IV) Record review of the facility's policy and procedure titled Abuse/Neglect, dated 2003 revised 5/9/17, revealed the following: The resident has the right to be free from abuse, neglect .It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect . 7. Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . C. Prevention The facility will provide the residents, families, and staff an environment free from abuse and neglect . 3. All reports of abuse or suspicion of abuse/neglect .will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or Abuse Preventionist within 24 hours of complaint. Appropriate notification to state and home office will be the responsibility of the administrator and per policy. 4. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. The facility has in place a method to identify events such as suspicious .occurrences, patterns, and trends . D. Identification The facility will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of events. Opportunities to prevent abuse/neglect will be managed accordingly. E. Reporting 1. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from .neglect .must report this to the DON, administrator, state and/or adult protective services . F. Investigation Comprehensive investigations will be the responsibility of the Administrator and/or Abuse Preventionist. All allegations of .neglect .will be investigated. G. Protection The facility will take necessary measures to protect residents and employees from harm during and following an abuse, neglect, exploitation, mistreatment of [REDACTED]. The IJ was identified on 09/18/19 at 5:20 p.m. The IJ template was provided to facility management. On 09/19/19 at 4:30 PM the Plan of Removal was accepted and included: Interventions: The following residents were assessed on 09/18/19 Resident #34, and #35 new ulcer assessment was completed by DON in the presence of the medical director. Staging of pressure wounds were accurately assessed. All wound orders reviewed and the supply room audited on 09/19/19 to ensure that there were sufficient supplies to complete the ordered treatments. The DON and ADON were in-serviced by the regional nurse on 09/19/19 regarding: - Ensuring that staff is sufficient so that wound treatments are administered/completed as ordered by the physician. The DON/or ADON will supplement and/or assist staff to ensure that all wound treatments are completed in the time frame as ordered by the physician daily. Agency Contract was obtained and agency staff will be utilized (after they have received training on facility wound care P&P) to fill in when facility staffing is not sufficient. One additional LVN/RN full time position has been added to the daily staffing schedule. - The facility will have sufficient stock of supplies needed to complete wound treatments. As supplies are needed, inform the central supply staff member to supply staff and administrator to get the new items in stock as soon as possible. - To ensure that any recommendations from the wound specialist is communicated to the physician after receipt of the recommendation with 24 hours. Licensed Nurses were in-serviced beginning 09/19/19 by DON, ADON and/or Regional nurse regarding the following: - Completing physician ordered wound treatment in the time frame as ordered for resident they are assigned to and documenting on the record administration record it was completed. - If unable to complete ordered treatments per the order, they are to notify the DON and/or ADON immediately. Physicians will be notified of all wound care refusals. - Immediately reporting the DON/or ADON if sufficient treatments/wound care supplies are not in stock. - If a new treatment requires an item not currently stocked, notify the DON or ADON so that the item can be ordered, and notify the physician of the unavailability of the item and obtain a new order with current stocked supplies as an alternative until the new item can be delivered. - Immediately reporting negative changes in skin condition to the physician or nurse practitioner - i.e. new wound or decline of a current wound. In addition, a wound that is not progressing in a positive manner in a two-week time should be reported to the physician or nurse practitioner. - Pressure ulcer prevention - Nurses will be making walking rounds at least every 2 hours to ensure CNAs are elevating heels/feet on pillows and using cushions as needed. Administrative nurses will make rounds randomly through the day to ensure nurses and CNAs are compliant. - All nurses will be in-serviced on facility wound care Policy prior to working their next scheduled shift. Certified nurse aides were in-serviced beginning 09/19/19 by DON, ADON and/or Regional Nurse regarding the following: - Pressure ulcer prevention - turning and repositioning at least every 2 hours, elevating heels/feet on pillows, using cushions as needed or directed. -Verbally reporting any skin changes (redness, new open areas, dressing off or soiled) to the charge nurse immediately as well as documenting reported change on the kiosk. The Medical Director was notified of this plan and monitoring on 09/18/19 Monitoring - The administrator and DON will ensure that daily that there is sufficient staffing, so that wound/skin treatments are completed timely per the physician's orders [REDACTED]. DON and Administrator will meet at the beginning and again at the end of each day. - The DON and/or designee will monitor wound treatment supplies as least weekly to ensure that there are sufficient supplies stocked to perform treatments for the next 7 days. - The DON and/or designee will monitor new physician orders [REDACTED]. Ensure that the items required are in stock or if a new item that is not in stock, the physician has been made aware and an in-stock alternative has been ordered until delivery of the new item. - The DON or designee will monitor the Wound administration record at least 5 times per week to ensure that treatments were completed on the previous day(s) as ordered. - The DON or designee will monitor ulcer assessments daily on PCC and Realtime software to ensure that if an ulcer has experienced a decline that the physician was notified of the negative change. - The DON or designee will review any reports left by the wound specialist and ensure recommendations are communicated to the physician daily. - The DON or designee(s) through daily rounds 5 times per week ensure that residents are being turned and repositioned timely. - The QAPI (Quality Assurance and Performance Improvement) committee will review the findings and make changes to the plan as required. Interview on 09/19/19 at 5:00 PM with the Charge Nurse, ADON and 4 CNAs revealed they could correctly relay the in-service instructions regarding any pressure ulcers, wounds they have encountered during their shift who to notify and how to document their findings. While the IJ was removed on 09/19/19 at 6:00 PM the facility remained out of compliance at a severity level of actual harm with a scope identified as pattern.

Based on observation, interview and record review the facility failed to ensure residents received care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing for 3 (Resident #34, Resident #35 and Resident #177) of 5 residents reviewed for pressure ulcers. A) The facility failed to consult or conduct treatments from a licensed physician prior to providing wound care to Resident #34's whose pressure ulcer worsened in a two month period (August-September 2019), from a stage II to a stage III. Seven wound care treatments were missed during that time period which could have resulted in worsening Resident #34's wound from a stage II to a stage III. Resident #34, who was admitted to the facility without pressure ulcers, developed pressure ulcers and worsened from a stage II to a stage III. B) The facility failed to consult or conduct treatments from a licensed physician prior to providing wound care to Resident #35 whose pressure ulcer worsened in a six month period (March - (MONTH) 2019) from a stage II to a stage IV. The facility failed to address or inform a licensed physician of the change in Resident #35's pressure ulcer, and six wound care treatments were missed which could have resulted in worsening Resident #35's wound from a stage II to a stage IV. Resident #35, whose MDS assessment dated [DATE] revealed she did not have a pressure ulcer, developed a stage IV pressure ulcer on 04/19/19. C) The facility failed to consult or conduct treatments from a licensed physician prior to providing wound care to Resident #177 whose pressure ulcer worsened becoming septic. Resident #177, who was admitted to the facility with 3 unstageable pressure ulcers, had to be sent to an area emergency roiagnom on [DATE] for antibiotic treatment due to becoming septic. These failures resulted in an Immediate Jeopardy (IJ) situation on 09/18/2019. While the IJ was removed on 09/19/2019, the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. These failures placed the residents at risk for developing worsening pressure ulcers,[MEDICAL CONDITION] (infection of the blood), severe pain or death. Findings Included: Review of Resident #34's undated Face Sheet revealed she was a [AGE] year-old female re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #34's Care Plan revised 12/31/18 revealed the following: Focus: Resident #34 has a potential for pressure ulcer development related to lack of mobility strength due to right above the knee amputation. Goal: Resident #34 will have intact skin free of redness, blisters or discoloration. Interventions: Administer [MEDICATION NAME] as ordered, administer medications as ordered, do not massage over bony prominence for peri-care/washing. Follow facility policy/protocols for the prevention/treatment for [REDACTED]. Review of Resident #34's quarterly MDS (minimum data set) dated 04/17/19 revealed she had a BIMS (brief interview for mental status) of 15 indicating she did not have any cognitive impairment and able to make her needs known. Resident #34 skin assessment revealed she did not have a pressure ulcer. Resident #34's 05/08/19 MDS review indicated she had a stage III pressure ulcer. Review of Resident #34's Physician orders [REDACTED].#34 was treated for [REDACTED]. Stage II orders were discontinued on 08/16/19. Orders for treating a stage III began on 08/20/19. Review of Resident #34's Physician orders [REDACTED]. Apply DemaCol AG to wound bed and apply corona cream to area around wound. Cover with pad and sheet daily. Review of Resident #34's Physician orders [REDACTED]. Apply Derminate (cut to fit wound) with Island dressing daily and as needed. Review of Resident #34's weekly pressure ulcer assessment beginning on 04/17/19 through 09/04/19 revealed initial assessment of no pressure ulcer on the right thigh, then progressed to a stage III, then unstageable. Physician orders [REDACTED]. The following skin assessments reveal the following: 04/17/19 no pressure ulcers indicated 05/01/19 no pressure ulcers indicated 05/07/19 pressure ulcer stage III reveals measurements length 0.4 cm x 0.4 cm width x 0 depth 05/13/19 pressure ulcer stage III reveals measurements length 0.8 cm x 0.8 cm width x 0 depth. 06/26/19 pressure ulcer (unstageable) measure length 1.5 cm x 1.5 cm width x 0 depth. 07/03/19 pressure ulcer unstageable measurements length 1.0 cm x 1.0 cm width x 0 depth 07/10/19 pressure ulcer unstageable measurements length 1.0 cm x 0.8 cm width x 0 depth 07/17/19 pressure ulcer unstageable measurements length 1.0 cm x 1.5 cm width x 0 depth 07/22/19 pressure ulcer stage II reveals measurements length 1.2 cm x 1.2 cm width x 0 depth 07/24/19 pressure ulcer stage III reveals measurements length 1.0 cm x 1.5 cm width x 0 depth 07/31/19 pressure ulcer stage II reveals measurements length 0.8 cm x 0.3 cm width x 0 depth 09/04/19 pressure ulcer (unstageable) measure length 1.2 cm x 0.7 cm width x 0.2 depth (last assessment prior to survey) Review of website accessed on 09/30/19 https://www.woundsource.com described stage II and III pressure ulcers. Stage 2 pressure ulcers are characterized by partial-thickness skin loss into but no deeper than the dermis. Stage 3 pressure ulcers (injuries) involve full-thickness skin loss potentially extending into the subcutaneous tissue layer. Review of Resident #34's TAR (treatment administration record) revealed during (MONTH) 2019, 4 wound care treatments were missed and (MONTH) 2019, 3 wound care treatments were missed. Review of Resident #34's missing TAR in (MONTH) 2019 reveal the following days missed: August 5, (MONTH) 8, (MONTH) 15, and (MONTH) 22 Review of Resident #34's TAR in (MONTH) 2019 revealed the following days missed: September 3, (MONTH) 9, and (MONTH) 13. Review of Wound Care Nurse B's time sheet and TAR revealed the following: August 5, Wound Care Nurse B did not work and treatment was not documented as being done. August 8, Wound Care Nurse B worked but did not document treatment was done. Auguts 15, Wound Care Nurse B worked a night shift and treatment was not documented as being done. August 22, Wound Care Nurse B worked a night shift and treatment was not documented as being done. Time sheet for Wound Care Nurse B's (MONTH) time sheet was not provided by the facility. During initial tour on 09/17/19 at 10:45 AM Resident #34 said her pressure sore on her bottom was getting worse. She said there were a few times she did not receive wound care treatments or have supplies. During wound care observation and interview with Wound Care Nurse A on 09/18/19 at 11:20 AM Resident #34's wound care revealed she had a dressing covering a pressure ulcer on the fold between her buttock and her right leg. Removal of the dressing revealed a pressure ulcer to be a stage III which included a deep crater with fat tissue visible at the base of the wound, skin around the wound was intact and free of redness or drainage. Wound Care Nurse A said the previous Wound Care Nurse B staged Resident #34's pressure ulcer on her inner thigh as a Stage II. The nurse who covers the weekend and does Resident #34's wound said it was a stage III. Wound Care Nurse A said it was a problem with people agreeing on the staging. Wound Care Nurse A said that was why Wound Care Nurse B quit she said her (Wound Care Nurse B) judgement was in question. Review of wound care assessment conducted on 09/19/19 revealed DON with presence of the Medical Director staged Resident #34's pressure ulcer. Resident #34 had a stage III pressure injury measuring 1.0 cm(centimeters) x 0.5 x0.5. Resident #35 Review of Resident #35's undated Face Sheet revealed she was an [AGE] year-old female re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #35's MDS (minimum data set) dated 12/14/18 revealed she did not have a pressure ulcer. Review of Resident #35's quarterly MDS dated [DATE] revealed she had a BIMS (brief interview for mental status) of 10 indicating she had moderate cognitive impairment and able to make her needs known, Resident #35 had a stage III or greater pressure ulcers and required pressure ulcer skin care. Review of Resident #35's revised Care Plan dated 12/20/18 revealed the following: Focus: Resident #35 has potential for pressure ulcer development related to lack of mobility strength and incontinence. Goal: Resident #35 will have intact skin, free of redness, blisters or discoloration. Intervention: .Resident #35 needs assistance to turn/reposition at least evert 2 hours. Review of Resident #35's weekly pressure ulcer assessments beginning on 04/02/19 through 09/03/19 revealed a pressure ulcer on left buttock/ sacral area stage III progressing to a stage IV indicating the pressure ulcer was worsening. Resident #35's pressure ulcer staging revealed the following: 03/12/19 left inner buttock Sacrum - stage II length 4.0 cm x 0.5 cm width x 0 depth 05/21/19 left inner buttock Sacrum (beginning to stage at III) length 2.0 cm x 1.0 cm width x 0 depth The following weekly skin assessments revealed the following: 08/20/19 left buttock/sacral -pressure ulcer stage III length 1.5 cm x 0.5 cm width x 0 depth 08/23/19 Sacrum - pressure ulcer stage IV length 2.0 cm x 1.0 cm width x 0 depth 09/05/19 Sacrum - pressure ulcer stage IV length 2.0 cm x 1.0 cm width x 0 depth 09/12/19 Sacrum - pressure ulcer stage IV length 2.0 cm x 1.0 cm width x 1.2 cm depth Review of Resident #35's Physician orders [REDACTED]. Pack wound (loosely) with collagen powder, cover with foam dressing and secure with island dressing. One time a day related to pressure ulcer of unspecific site. Review of Resident #35's TAR revealed during (MONTH) 2019 (4) wound care treatments were missed (classified as stage III) and (MONTH) 2019 2 wound care treatments were missed. (classified as stage IV) Rewiew of the wound care treatment missed in (MONTH) 2019 revealed the following: August 5, (MONTH) 8, (MONTH) 15, and (MONTH) 22. Stage III Stage IV treatment missed (MONTH) 30. Review of Wound Care Nurse B's time sheet and TAR revealed the following: August 5, Wound Care Nurse B did not work and treatment was not documented as being done. August 8, Wound Care Nurse B worked but did not document treatment was done. Auguts 15, Wound Care Nurse B worked a night shift and treatment was not documented as being done. August 22, Wound Care Nurse B worked a night shift and treatment was not documented as being done. During wound care observation and interview on 09/18/19 at 11:10 AM Resident #35 had a dressing covering her sacral area. The approximate length and depth of the wound without actual measurement was 2.0 cm x 1.0 cm and depth of the wound was noteable due to collagen inside of the wound. The area around the wound was intact but black within the walls of the wound (resident was African American with dark skin) and without redness or drainage. Depth of the wound was filled with previous collagen filler and unable to determine if bone or tendon was visable. Wound Care Nurse A cleaned the area around the wound and filled the depth of the wound which still had previous treatment collagen filler in the wound. She said she would consider Resident #35's wound to be a stage IV due to the length and width. She then cleaned the wound with normal saline solution and re-applied collagen powder and covered with a dressing. Review of website accessed on 09/30/19 https://advancedtissue.com revealed the stage IV wound definition as: Stage IV wounds may feature extensive loss or damage to tissue, muscles and bones, and often feature muscle and bone that is exposed. Healing a Stage IV wound often includes surgery, as well as wound debridement of some tissue, particularly necrotic or eschar that may be partially or completely covering the wound. Review of wound care assessment conducted on 09/19/19 revealed DON with presence of the Medical Director staged Resident #35's pressure ulcer. Resident #35 had a stage IV sacral pressure injury measuring 2 cm(centimeters) by 1cm and a depth of 1 cm with tunneling 1.2 cm at 10 o'clock position. Resident #177 Review of Resident #177's undated Face Sheet revealed he was a [AGE] year-old male admitted on [DATE] with the [DIAGNOSES REDACTED]. Resident #177 was discharged from facility on 08/14/19. Review of Resident #177's initial Care Plan dated 07/23/19 Focus: Resident #177 has (3) unstageable pressure ulcer to the right and left inner buttock and coccyx area. Goal: Resident #177 will have no signs or symptoms of infections through the review dated. Intervention: [MEDICATION NAME] packet Give one packet by mouth daily Clean with wound cleanser, apply calcium alginate AG with Santyl to wound bed and cover with ABD pads and hyperfix daily. Document location of wound, amount of drainage, peri-wound area pain [MEDICAL CONDITION] record circumference measurement. Review of Resident #177's admission MDS (minimum data set) dated 07/29/19 revealed he had a BIMS (brief interview for mental status) of 12 indicating he had moderate cognitive impairment and able to make his needs known. Resident #177 had three unstageable pressure ulcers and required pressure ulcer skin care. Review of website accessed on 09/30/19 https://advancedtissue.com revealed the definition of unstageable pressure ulcer. Ulcers covered with slough or eschar are by definition unstageable. Review of Resident #177's admission/weekly skin assessment dated [DATE]. Peri area excoriated and bright red, (2 wounds) right inner buttock unstageable pressure ulcer (#1) measuring 10.5 cm x 2.0 cm x 0 depth. (100% necrotic tissue). Right inner buttock (#2) measuring 15 cm x 3.0 cm x 0 depth. Review of Resident #177's weekly skin assessment dated [DATE] right inner buttock (#2) measuring 18 cm x 4.0 cm x 0 depth. (increase of 27 square cm) Review of Resident #177's weekly assessment dated [DATE] revealed right inner buttock pressure ulcer (#1) measured 11.0 cm x 2.5 cm x 0 depth. (increase of 6 square cm) Review of Resident #177's Physician orders [REDACTED]. Apply calcium alginate AG with hydrogel to wound bed. Cover with optilock and [MEDICATION NAME] one time a day. Scrotum clean with wound cleaner apply sting free liquid. Coccyx (unstageable) clean with wound cleaner, pat dry and apply alginate AG with hydrogeal and optilock and [MEDICATION NAME] one time a day, inner buttock (unstageable) clean wound with cleanser, pat dry applies calcium alginate AG with hydrogel to wound bed and cover with optilock and [MEDICATION NAME] one time a day. During an interview on 09/18/19 at 11:10 AM the DON said she had been aware that on some of the days the treatment nurse was pulled to work the night shift due to short staffing. She said she was aware on the days the treatment nurse was pulled there had been resident wound care treatments missed. She said it was her assumption when the previous treatment nurse was pulled to work the night shift that the charge nurses had provided the residents wound care treatments; however, she had not gone back to check if the treatments were completed. She said there was not a specific plan in place for monitoring that the treatments had been completed per the physician orders. She said she was not sure how the charge nurses were informed of the need to do the residents treatments when the treatment nurse was pulled to work the night shift. She said she did not know why the resident physician was not notified about residents' missing wound and/or residents wounds worsening. She said she found the treatment nurse to be very argumentative and defensive when anyone asked a question about a resident wound. She said she had done a random check on a resident following the treatment nurses wound care and upon entering the room she could smell a foul odor coming from the resident wound. She said when she asked the treatment nurse how long the wound had a foul odor; the treatment nurse had responded a couple of days. She said she had the resident immediately sent out to the emergency room and had not returned to the facility due to requiring surgery (later found out Resident #177 required antibiotic therapy) she said right after that Wound Care Treatment Nurse B quit. Review of Resident #177's emergency room admission on 08/14/19 revealed the following: [AGE] year-old-male admitted for dementia, [MEDICAL CONDITIONS] large decubitus wound on buttock,[MEDICAL CONDITION] and general debility. Assessment:[MEDICAL CONDITION] syndrome, ongoing antibiotic therapy with [MEDICATION NAME] and [MEDICATION NAME] for lumbar stage IV decubitus ulcer, infected with Proteus mirabilis and [MEDICATION NAME] faecalis. During an interview on 09/18/19 at 10:00 AM Wound Care Nurse B (former Wound Care Nurse) said she ordered supplies every Thursday but the central supply manager said they were transition between 2 suppliers and sometimes they would run out of some of the supplies she needed and she would go to the nearby retail store to get supplies. She said sometimes she would be on call and come in to do her wound care and was told to go home so she could cover a night shift. She said when she left (when she had to cover night shift) there was no one to continue doing wound care. When this happened, residents did not receive their treatments. She said in regard to staging wounds she considered Resident #35 as a stage III and had a wound care specialist go with her to confirm her wound staging. She said Resident #35 has a stage III and the wound care nurse who comes in on weekends said it was a stage IV. She said she disagreed with the stage IV wound assessment. During an interview on 09/17/19 at 3:20 PM Central Supply Manager said they were in transition between two suppliers. He said some of the different supplies had to be coordinated to get the same wound care supplies that were ordered. He said he was stocked and should have everything the staff need. He said he knew Wound Care Nurse B went to the nearby retail store to get some supplies and he got what she needed, and she was reimbursed. During an interview on 09/19/19 at 4:50 PM Corporate Operations Manager said the facility was well stocked with supplies, he said Wound Care Nurse B had to go to the nearby retail store to get gauze and other dressings. Corporate Operations Manager said he did not know why Wound Care Nurse B had to go to store to get more supplies. During an interview on 09/18/19 at 9:00 AM Wound Care Nurse A (acting wound care nurse) said she does wound care when she was at work and in charge of the shift. She said she had just recently been asked to be the wound care nurse but has not made up her mind if she wanted the position. She said normally the charge nurses do their own wounds since the facility does not have a wound care nurse right now. She said hopefully the charge nurse will be able to get to all of the wounds and do their charge duties. She said today she came in on her day off (09/17/19) and doing wounds. She said she was not surprised wound care was missed because of being shorthanded. At times if someone was on call they would be pulled to cover a shift. The charge nurse is supposed to cover wound care and she was not sure if it was covered. She said she did agree with the previous wound care nurse (Wound Care Nurse B) treatment assessment, (Wound Care Nurse A) and did not contact physician for any changes when (Wound Care Nurse B) quit. During an interview on 09/18/19 at 9:15 AM ADON said the facility has PRN (as needed) wound care nurses during the weekend and charge nurses are capable of doing wound care. She said in regard to missing slots in the TAR (treatment administration record) she was not surprised there were missing treatments. She said she realized if the MAR indicated [REDACTED]. She said she was not aware there were holes in the TAR treatment record. During an interview on 09/18/19 at 2:28 Medical Director said in relation to notification regarding change in wounds sometimes they do and sometimes they don't, they have protocols in place when they need to tell him of any changes. He said he was not aware of any missed treatments or worsening wounds. During an interview on 09/18/19 at 4:00 PM request DON for facility policy and procedure and wound care protocol returned only with facility policy and procedure and did not supply with the facility protocol regarding wound care. Review of facility's policy and procedure titled. Skin Integrity Management dated (MONTH) 5, 2003 revealed the following: General Guidelines 1. If wound is noted, perform an assessment an initiate a treatment plan as soon as possible. Document resident's chart, area of change, who you notified and treatment applied. 10. Treatment Nurse/designee or Director of Nursing will assess site and evaluate for appropriate stage as listed in this procedure. Notify physician; obtain and order and monitor site daily. Sign off on treatment sheet any treatment completed (i.e., stage I through stage IV) The IJ was identified on 09/18/19 at 5:20 p.m. The IJ template was provided to facility management. On 09/19/19 at 4:30 PM the Plan of Removal was accepted and included: Interventions: The following residents were assessed on 09/18/19 Resident #34, and #35 new ulcer assessment was completed by DON in the presence of the medical director. Staging of pressure wounds were accurately assessed. All wound orders reviewed and the supply room audited on 09/19/19 to ensure that there were sufficient supplies to complete the ordered treatments. The DON and ADON were in-serviced by the regional nurse on 09/19/19 regarding: - Ensuring that staff is sufficient so that wound treatments are administered/completed as ordered by the physician. The DON/or ADON will supplement and/or assist staff to ensure that all wound treatments are completed in the time frame as ordered by the physician daily. Agency Contract was obtained and agency staff will be utilized (after they have received training on facility wound care P&P) to fill in when facility staffing is not sufficient. One additional LVN/RN full time position has been added to the daily staffing schedule. - The facility will have sufficient stock of supplies needed to complete wound treatments. As supplies are needed, inform the central supply staff member to supply staff and administrator to get the new items in stock as soon as possible. - To ensure that any recommendations from the wound specialist is communicated to the physician after receipt of the recommendation with 24 hours. Licensed Nurses were in-serviced beginning 09/19/19 by DON, ADON and/or Regional nurse regarding the following: - Completing physician ordered wound treatment in the time frame as ordered for resident they are assigned to and documenting on the record administration record it was completed. - If unable to complete ordered treatments per the order, they are to notify the DON and/or ADON immediately. Physicians will be notified of all wound care refusals. - Immediately reporting the DON/or ADON if sufficient treatments/wound care supplies are not in stock. - If a new treatment requires an item not currently stocked, notify the DON or ADON so that the item can be ordered, and notify the physician of the unavailability of the item and obtain a new order with current stocked supplies as an alternative until the new item can be delivered. - Immediately reporting negative changes in skin condition to the physician or nurse practitioner - i.e. new wound or decline of a current wound. In addition, a wound that is not progressing in a positive manner in a two-week time should be reported to the physician or nurse practitioner. - Pressure ulcer prevention - Nurses will be making walking rounds at least every 2 hours to ensure CNAs are elevating heels/feet on pillows and using cushions as needed. Administrative nurses will make rounds randomly through the day to ensure nurses and CNAs are compliant. - All nurses will be in-serviced on facility wound care Policy prior to working their next scheduled shift. Certified nurse aides were in-serviced beginning 09/19/19 by DON, ADON and/or Regional Nurse regarding the following: - Pressure ulcer prevention - turning and repositioning at least every 2 hours, elevating heels/feet on pillows, using cushions as needed or directed. -Verbally reporting any skin changes (redness, new open areas, dressing off or soiled) to the charge nurse immediately as well as documenting reported change on the kiosk. The Medical Director was notified of this plan and monitoring on 09/18/19 Monitoring - The administrator and DON will ensure that daily that there is sufficient staffing, so that wound/skin treatments are completed timely per the physician's orders [REDACTED]. DON and Administrator will meet at the beginning and again at the end of each day. - The DON and/or designee will monitor wound treatment supplies as least weekly to ensure that there are sufficient supplies stocked to perform treatments for the next 7 days. - The DON and/or designee will monitor new physician orders [REDACTED]. Ensure that the items required are in stock or if a new item that is not in stock, the physician has been made aware and an in-stock alternative has been ordered until delivery of the new item. - The DON or designee will monitor the Wound administration record at least 5 times per week to ensure that treatments were completed on the previous day(s) as ordered. - The DON or designee will monitor ulcer assessments daily on PCC and Realtime software to ensure that if an ulcer has experienced a decline that the physician was notified of the negative change. - The DON or designee will review any reports left by the wound specialist and ensure recommendations are communicated to the physician daily. - The DON or designee(s) through daily rounds 5 times per week ensure that residents are being turned and repositioned timely. - The QAPI (Quality Assurance and Performance Improvement) committee will review the findings and make changes to the plan as required. Interview on 09/19/19 at 5:00 PM with the Charge Nurse, ADON and 4 CNAs revealed they could correctly relay the in-service instructions regarding any pressure ulcers, wounds they have encountered during their shift who to notify and how to document their findings. While the IJ was removed on 09/19/19 at 6:00 PM the facility remained out of compliance at a severity level of actual harm with a scope identified as pattern.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents, for one Resident (R#3) of six residents reviewed for accidents and supervision. The transport driver did not provide adequate supervision when he left Resident #3 unattended while putting the lift down on the transport van. Resident #3 sustained a nasal bone fracture after going down an incline without assist. This failure resulted in actual harm to R#3 and could place the 58 residents who require transportation in the facility's van at risk for injury The findings were: Record review of R#3's, Admission Record dated 12/01/16 documented he was [AGE] years of age and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of R#3's Quarterly Minimum Data Set (MDS) assessment, dated 10/26/16, documented R#1: -had a brief mental interview for mental status score of 03 (00-07 indicates severe impairment). -required extensive assist from one staff for bed mobility, transfers, dressing, toilet use and personal hygiene. R#3 required supervision with locomotion (how resident moves to and returns from unit off locations (e.g. dining area, activities or treatments). -was frequently incontinent of bladder. -had two falls without injury. R#3's MDS assessment for, Balance during transitions and walking indicated R#3 was unsteady, and only able to to stabilize with staff assistance, when moving from a seated to standing position and during surface-to-surface transfers. Resident #3 required a walker and wheelchair for mobility. Review of R#3's Care Plan revision dated 10/10/16 documented in part: -R#3 has impaired cognitive function/dementia and impaired thought process r/t (related to) short term memory loss, impaired decision making, dementia, difficulty making decisions. Intervention: R#3 may need supervision/assistance with decision making. -R#3 is at high risk for falls r/t poor communication, de-conditioning, gait/balance problems, weakness, lack of coordination. -R#3 has a communication problem r/t stroke, expressive aphasia. Review of Resident #3's Fall Risk assessment dated [DATE] documented a score of 22 which indicated a high risk for falls. Record review of the facility's Incident Log for the period of 9/2016 through 11/2016 documented in part: -11/01/16 - R#3 had an unwitnessed fall due to transferring self to bed without waiting on staff. -11/23/16 - R#3 was placed in bed and he reached over to the O2 (oxygen) concentrator and rolled out of his bed onto mat. -11/28/16 - The van driver parked R#3 (in his wheelchair) by the x-ray area and locked his wheels and told the resident to wait right there while he got the van. As the van driver pulled up, R#3 was propelling himself through the sliding glass doors. The van driver got out of the van and told R#3 to wait and as the van driver was letting the lift of the van down. R#3 continued to propel himself down the incline in front of the clinic and when he got to the place where the cement met the asphalt, R#3's wheelchair stopped and he fell out of his wheelchair landing face down. R#3 had abrasions and was bleeding around his nose and eyes. R#3 was wearing his glasses which caused some of the bleeding and abrasions around his nose and eyes. The van driver called the director of nurses and she took R#3 to the emergency room . The van driver was in-serviced to not leave a resident unattended. The Provider Investigation Report dated 11/28/16 indicated R#3 fell and fractured his nose; this was witnessed by staff. It occurred at 11:00 a.m. at the doctor's office. R#3 needed extensive assist with functional ability and needed no special supervision, he was independently ambulatory and did not have the capacity to make informed decisions. -Description of Allegation: Fall with injury. -Description of injury: fractured nose. -Description of assessment: Bruising and abrasions to the nose and eyes and scabs on left knee. Resident was immediately sent to the emergency room for x-rays after fall. Family and physician were notified. Abuse/neglect in-services interview completed. Meeting with the family held on 11/29/16 to discuss family/employee relations as well as future plans of care. -Investigation summary: no statements, evidence or signs of abuse in the facility. Continue to monitor for resident safety. Review of witness statement by the Director of Nurses (DON) dated 11/29/16 documented: -On Monday, 11/28/16 at 11:23 a.m. she received a call from the van driver. He explained to her that he parked R#3 inside the clinic by the x-ray department area. He said he explained to R#3 that he was going to get the van and pull up so he could load R#3 into the van since it was windy outside. The van driver told the DON he had locked R#3's brakes before leaving him. The van driver then stated that he pulled the van around the circle and parked the van. The van driver said R#3 was going through the sliding doors. He said he placed the van in park and got out and told R#3 to stop and let him get the lift down. As the van driver was opening the van's back door so he could lower the lift, R#3 went down the incline and fell forward onto his face. The van driver stated R#3 was bleeding from his nose area and there were some cuts. The van driver said he went back into the clinic to get help. Review of R#3's CT (computed tomography) of the maxillofacial dated 11/28/16 showed nasal bone fracture to the right midline and appears to be acute fracture of the anterior aspect of the osseous nasal septum. During an interview on 12/09/16 at 1:45 p.m. the DON said the van driver usually waits with the residents to get into the van but he had to go park the van so he had R#3 wait by himself. She said that usually someone else is there to watch the residents. If more than one person goes then we have more than 1 staff go. If a resident is able to wait and is aware (cognizant) then we don't have to stay with the resident, but if a resident isn't alert and aware then we stay with them. R#3 is very impatient. The DON said R#3 could unlock his wheelchair brakes. She said R#3 wheels himself around the halls. She said he goes to his room and transfers himself to bed without assist. We tell him to wait but he doesn't. The van driver did tell R#3 to not leave. She said R#3 thought he was being left and propelled himself out side. During an interview on 12/16/16 at 3:51 p.m. the van driver said he took R#3 to his doctors appointment. He said he told R#3 to wait inside because it was cold and windy. He said he told R#3 he would bring the van around. He said as he was coming around the parking lot he saw R#3 going out the sliding doors. He said he started to lower the lift and R#3 started down the incline. He said he saw R#3 fall and hit his face. He said he went back into the clinic to get help lifting R#3 up. He then called the DON and she told him to take R#3 to the emergency room . He said while he was lowering the lift his back was turned to the R#3. He said he did not see him lose control on the ramp. The van driver said it was his fault; that he was under the assumption R#3 would stop and wait. He said R#3 was cognitively aware but was just impatient. During an interview on 12/19/16 at 12:28 p.m. the Administrator said the van driver should load the residents up, make sure they were buckled in and then drive them to their destination. She said if the van driver feels the resident can wait by themselves then they can. She said only one staff member is sent unless there are multiple stops then they send 2 staff members. She said with R#3 the van driver left R#3 inside the clinic and asked the attendants to watch him. The Administrator said the only thing she could think the van driver could have done different with R#3 was to have taken R#3 with him. She said the driver was concerned with how cold and windy it was outside so he wanted R#3 to wait inside. Review of the facility's Job Description for Transportation Aide dated 2014 documented in part: -Knowledge base: -Ability to comply with company and departmental safety policies and procedures. -Transport residents to/from medical facilities and other activities as needed in a safe manner. -Accountable for residents's care while away from the facility. Review of the facility's policy for Transportation of a Resident dated 2003, documented in part: -Resident must be physically assisted in an out of the vehicle by a trained employee using appropriate transfer techniques. -The resident must never be left unattended in the vehicle. The facility's Resident Roster dated 12/09/16 by the Administrator documented a census of 59 residents and the Administrator said everyone on the roster was transported in the facility's van.