Every finding on record at Brentwood Place One

Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one of four (Resident #4) reviewed for range of motion. The facility failed to apply Resident #4's splints to his left and right hand and braces to right and left foot as ordered by the physician. This failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures. Findings included:Record review of Resident #4's 5-day MDS assessment, dated 02/18/26, reflected a [AGE] year-old male with an admission date of 05/29/20. Resident #4 had BIMS score of 15 which indicated he was cognitively intact. He required substantial to maximum assistance for personal hygiene and had not refused care. He had functional limitation in range of motion upper extremities on both sides but no limitation on lower extremities. Diagnoses included diabetes, cerebral vascular accident (stroke) and hemiplegia (paralysis on one side of the body). He had received occupational therapy (therapy that focus on regaining dexterity and strength in fine motor skills), physical therapy (therapy that aims to improve, maintain and restore physical movement) and restorative nursing services in the 7 days prior to the MDS assessment. Record review of Resident #4's Physician order summary report dated 04/08/26 reflected, Late entry for 2/27 OT Splint orders: Patient to wear resting hand (splint that holds the wrist, thumb, and fingers in neutral position to prevent contractures) to left and a C-Grip (prevent thumb from contracting) to right hand daily, or a tolerated.PT/OT Splint order: Patient to wear bilateral AFO (Ankle-foot brace used to hold the foot in the correct position to help prevent foot drop) daily, or as tolerated with a start date of 03/05/26. Record review of Resident #4's care plan with an initiation date 02/16/26 reflected, Focus.Patient have left hand and a C-roll to right hand and lower extremity bilateral AFO's.Interventions initiated on 03/09/26.Provide Passive Range of motion to lower extremities as tolerated, patient to wear bilateral AFO daily, or as tolerated.Provide Passive Range of Motion to upper extremities daily or as tolerated, apply left resting hand splint daily or tolerated 3-4- hours. Apply right C-grip 3-4 hours. Or as tolerated. Record review of Resident #4's CNA task list dated 03/26/26 through 04/08/26 reflected, Patient to maintain joint Range of motion. Check skin before and after. Report to nursing for any condition. Provide Passive Range of motion to upper extremity or as tolerated. Apply L/R resting hand splint daily or tolerated 3-4- hours. Apply L/R C-grip 3-4 hours. Or as tolerated.Patient to wear bilateral AFO daily or as tolerated. Every day from 03/26/26 through 04/08/26 with the exception of 04/04/26 and 04/05/26 had 15 minutes documented. 04/04/26 and 04/05/26 no time was listed and not applicable was checked. During an observation and interview on 04/07/2026 at 10:30 a.m. Resident #4 was observed lying in bed. Resident was observed to have contractures to his left hand and was unable to open his left hand completely. He had some mobility in his right hand and was able to move his index finger, second finger and thumb but his 3rd and 4th finger were contracted toward the palm of his hand. There was no splint in use. Splints were observed sitting on his chest of drawers and Ankle-Foot orthotics were observed sitting on his wheelchair. Resident #4 stated he used splints on his hands and feet when the staff puts them on him. He stated the staff does not put them on every day. He stated he gets up on Tuesdays and Thursdays and stated he was not sure what time he would be getting up today. During an observation on 04/07/2026 at 01:45 p.m. revealed Resident #4 was lying in bed watching television. No splints were observed on his hands or feet. During an observation and interview on 04/08/2026 at 10:05 a.m. Resident #4 was observed lying in bed. No splints were in use on both hands or his feet. Resident #4 stated no one had put his splints on today. He stated the staff did not get him up yesterday but stated he did not ask them to get him up and stated he did not want to get up today. During an interview on 04/08/2026 at 11:00 AM with the DOR, she stated Resident #4 was not currently on therapy services. She stated he did have orders for splints to bilateral hands and Ankle foot orthotics for both feet to help prevent further contractures. She stated the facility recently lost their restorative aide so she and the MDS nurse had trained the CNAs and Nursing staff on which residents needed splint placement. She stated therapy was also assisting some with splint placement but stated they did not have any way to document when they did the placement of the splints since he was not on therapy services. She stated Resident #4 was pretty good with wearing his splints. She stated she did not assist with his splint placement yesterday and was not sure if anyone from therapy had assisted. During an interview on 04/08/2026 at 11:10 a.m. with CNA B, she stated therapy had trained them on which residents needed splint placement. She stated Resident #4 had hand splints. She stated she had put on the hand's splints before breakfast and then took them off when breakfast came around 7:00 a.m. She stated had not put his ankle splints on. She stated she had not put his hand's splints back on because he only needed them for 15 minutes. She stated it was on their task list for them to put the splints on and take them off but stated she had not been documenting when she put them on and when she took them off. During an observation and interview on 04/08/26 at 11:13 a.m. CNA B entered Resident #4's room and asked the resident if she could put on his hand splints and he stated yes. Resident #4 stated the splints had not been put on him this morning. CNA B placed the splints on both hands but did not offer to put on his ankle foot orthotics. During an interview on 04/08/2026 at 11:40 a.m. the MDS nurse stated they had a restorative aide who had recently left. She stated they had not had a restorative aide for about 3-4 weeks, so they had to move the restorative needs onto the CNAs. She stated the therapy department trained all of the CNAs and Nurse's on which residents had splints, or range of motion needs and placed the tasks on the CNAs task list in the electronic record. She stated the CNAs and the nursing staff were responsible for ensuring the splints were put on the residents and taken off per the required amount of time. She stated the nurses were responsible for checking the skin after the removal of the splints. She stated they had placed all of the splint placement on the day shift. During an interview on 04/08/2026 at 11:55 a.m. with LVN A, she stated she was the 6-2 p.m. charge nurse. She stated they had received training from therapy about which residents required splints. She stated Resident #4 required hand splints and stated she thought he only had to wear them for 15 minutes. She stated the CNAs were responsible for putting on the splints and the nurses were responsible for checking the skin. She stated she thought CNA B had put Resident #4's hand splints on before breakfast which was served around 7:00 a.m. but took them off so he could eat breakfast. She stated she did not know anything about Resident #4's ankle foot orthotics and stated she was not sure what an ankle foot orthotic was. She stated the only splints she was aware of was the hand splints. She stated the purpose of the splints was to prevent worsening contractures. During a follow up interview on 04/08/2026 at 2:01 p.m. with the MDS nurse she stated they eliminated the 15-minute time section from the CNAs task list. She stated that was an old Restorative timing for the amount of time spent for the placement of the splints, not the duration of the use of the splints. She stated they had started in-serving the staff on putting in the time they put on a splint and a time they take it off. During an interview on 04/09/2026 at 10:00 a.m. with the COTA she stated she had worked with Resident #4 when he was on therapy services and upon discharge they had written orders for him to have his ankle foot orthotics on both feet and splints to both hands. She stated they do not write restorative plans any longer since they do not have a restorative program. She stated they had assisted some with putting on the Residents splints since the facility had been without a restorative aide but stated they had not been documenting anywhere on when they put the splints on, take them off, or if they refused. She stated she simply tells the nurse if the resident refused. She stated Resident #4 was pretty good about wearing his splints. She stated ultimately it was the CNAs who were responsible for putting on and taking off the splints once they had received training. During an interview with the DON on 04/09/2026 at 10:30 a.m., she stated when they lost the restorative aide they met with therapy to set up training for the staff on the residents who needed splint placement. She stated originally it was going to be the nurses who were responsible, but then they decided to place it on the CNAs task list to put the splints on and have the nurses perform the skin checks after the splints were removed. She stated they did a poor job communicating the expectations with staff which resulted in staff not understanding the need to document when a splint was placed, when it was taken off, and if the resident refused it. She stated going forward it was going to be placed on the Nursing Administration record so they could assess the skin before they placed the splints and assess when they removed the splints. She stated this way they had a way to see if a resident was allowing them to place the splints and to ensure the splints were still fitting properly or if they needed to be referred back to therapy. She stated the purpose of splints were to help maintain or improve a resident's range of motion. She stated failing to provide range of motion and ordered splints could result in worsening a resident's contracture. Record review of the facility's policy titled, Splinting, revised June 2020, reflected, Purpose- To prevent contractures or decreased tone and to protect joint alignment.RNA staff may apply splints under the supervision on of the Nursing Department.A physician's order will be obtained for the use of a splint.A Care Plan [NAME] be completed initially by OT with specific splinting schedule, application and/or positioning instructions and precautions for RNA and Nursing Staff.The RNA responsible for splint application will document and initial on the Schedule for Splint Application eah time splint is applied and removed.

Based on observation, interview, and record review it was determined the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts observed for medications labeling and storage. The Hall 400/500 medication cart contained an over-the-counter medication bottle of Aspirin CR 81 mg oral tablet with faded and nonvisible expiration date on 04/07/26. This failure could place residents at risk for not receiving the therapeutic benefit of the medication or adverse reaction to expired medication. During observation/interview on 04/07/26 at 10:42 AM of the medication cart for Hall 400/500 with MA C, revealed top-drawer holding over the counter residents' medications. There was a bottle of Aspirin 81 mg CR tablets with faded and nonvisible expiration date. MA C stated he used the same bottle and gave Residents in Hall 400/500 their morning dose of Aspirin 81 mg CR. MA C stated it was his responsibility to check the medication cart daily at the start of the shift to make sure all the medications on the cart were up to date, and if there were expired medication to remove it from the residents' stock. MA C stated giving residents' medication with unknown expiration date, and that may be expired could have a negative effect, because of the outcome the medication potency was reduced, and it was ineffective. Review of 40 residents MARs in the 400/500 halls revealed there were 10 residents receiving Aspirin 81 mg CR daily in the morning. All the 10 residents were administered their morning Aspirin 81 mg on the AM of 04/07/26 by MA C. During an interview on 04/09/26 at 11:50 AM with the DON she stated the charge nurses/MAs were supposed to check the medication carts for any expired medications and the pharmacists checked the medication carts monthly. The DON stated the aspirin bottle with nonvisible expiration date should be removed from the residents' medication stock and replaced with appropriate one. The DON stated this was supposed to be completed to prevent side effects like the medication being ineffective if they were expired, also chemical composition of the medications could change if the medication was expired. Record review of the facility policy titled Medication Storage in the Facility with revised date of January 2026 reflected, . This policy applies to all licensed nurse, medication aides (where permitted), pharmacy staff, providers, and facility leadership.General Medication Storage Requirements. immediately removed any unlabeled, expired, or discontinued medications.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #8) reviewed for infection control. The facility failed to have Resident#8 ,with dialysis permanent catheter ( a medical device used to access the bloodstream for dialysis) and undated dressing, was on enhanced barrier precaution. This failure could place residents at risk for infection and cross contamination. A record review of Resident #8's Quarterly MDS assessment, dated 03/04/26, reflected Resident #8 was a [AGE] year-old male admitted to the facility on [DATE], and readmitted on [DATE]. His diagnoses included hypertension (elevated blood pressure), Renal Insufficiency, Renal Failure, or End-Stage Renal Disease (ESRD), dependent on dialysis treatment, and Non-Alzheimer's Dementia (neurodegenerative disorders that cause cognitive decline, behavioral changes, or memory loss, but are caused by different brain pathologies than Alzheimer's). Resident #8 had a BIMS score of 05 which indicated severe cognitive impairment. Section O - Special Treatments, Procedures, and Programs, part J1 was coded: dialysis. Record review of Resident#8 care plan dated 03/04/26 revealed no indication of permanent central venous catheter for dialysis treatment. Record review of Resident#8 doctor orders dated 04/09/26 revealed no order for EBP or dialysis catheter. In an observation and interview on 04/09/26 at 10:41 AM revealed MA C entered Resident #8's room to check Resident#8's blood pressure. There was no signage of EBP in front of Resident#8 room, or in the room, and no supplies for PPE in the room to indicate to staff member or visitor that Resident#8 supposed to be on EBP, and wear a gown and visit for any high contact with the Resident. MA C sanitized his hands put on gloves but not a gown. MA C checked Resident blood pressure. MA C pulled resident sleeves to check for arteriovenous dialysis access in the resident both upper extremities, and unbuttoned Resident#8's T-shirt to look at the permanent catheter for dialysis access in the left upper chest. Resident#8 had scar tissues in both upper extremities related to old dialysis access. MA C removed his gloves, sanitized his hands and exited the room. Interview revealed MA C did not know that Resident#8 was supposed to be on EBP. In interview with the dialysis clinic charge nurse over the phone on 04/09/26 at 10:55 revealed: Residents with permanent central venous catheter for dialysis treatment, the recommendation for the facility staff members from the dialysis clinic were not to do anything with the permanent central venous catheter for dialysis treatment, and the dialysis clinic nurses were responsible for changing the site dressing with each dialysis treatment. In an interview on 04/09/26 at 11:00 AM, the ADON stated she was the infection preventionist for the facility. The ADON stated any resident with medical devices was supposed to be in EBP including Resident#8 with permanent central venous catheter for dialysis treatment. The ADON stated Resident#8 had been in the facility for many years and used to have an arteriovenous access for dialysis treatment ( a nonmedical device). The ADON stated that it was the responsibility of the charge nurse that assessed Resident#8 after he got the permanent central venous catheter to update the Resident record to reflect the need for EBP. The ADON stated not having Resident#8 on EBP could put the Resident at risk of developing infection. In an interview on 04/09/26 at 3:47 PM with the DON, she stated Resident#8 should had been in EBP related to his permanent central venous catheter for dialysis treatment. The DON stated the charge nurses for Resident#8 either forgot or failed to notice that he was changed from arteriovenous access for dialysis treatment to a permanent central venous catheter for dialysis treatment, so they did not update his status and, did not put him on EBP. She further stated it may be due to poor assessment or lack of recognition. The DON stated she got the physician order and put Resident#8 on EBP. The DON stated the risk to Resident#8 not being in EBP was cross contamination, and development of infection. Record review of the facility's policy, Hand Hygiene/Hand Washing, revised April 1, 2025, reflected, Enhanced Barrier Precaution (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contract resident care activities that are associated with a high risk of MDRO colonization when contact precaution do not otherwise apply and/ or transmission such as presence of indwelling devices (e.g., urinary catheter.vascular catheter .

Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one of six (Residents #3) reviewed for Reasonable Accommodation of Needs. The facility failed to provide a working communication system, that was easily at reach, that would allow Resident #3 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living. Findings include: Review of Resident #3's Quarterly MDS assessment dated [DATE] reflected Resident #3 was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] his diagnoses included hypertension (elevated blood pressure), Alzheimer's disease (is a brain disorder that causes memory loss, thinking problems, behavior changes, and brain cell death), muscle weakness, need for assistance with personal care, and dementia (diseases that affect memory, thinking, and the ability to perform daily activities). Resident#3 had a BIMS Score of 00, which indicated sever cognitive impairment. The MDS also reflected Resident #3 was dependent on staff for ADLs, including bed to wheelchair transfers. Record review of Resident #3's Care Plan dated 06/09/25, reflected the following: Focus: [Resident#1] is risk for falls related to confusion, gait/balance problems, incontinence, poor communication/comprehension, unaware of safety needs. Goal: [Resident#3] will be free of falls through the review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. An observation on 07/22/25 at 2:10 PM revealed Resident #3 was asleep in his bed. Resident #3's call light cord was entangled around the head of the bed frame, with call button on the floor and out of reach of the Resident. In an interview and observation on 07/22/25 at 2:16 PM CNA B entered Resident#3 room, looked for the call light, and pulled the cord that was entangled by the head of bed frame, and clipped the call light button to Resident#3 blanket. CNA B stated the call light should be within the Resident reach and not in the floor. She further stated if there was an emergency, he would not be able to call for help. In an interview on 07/22/25 at 2:45 PM the DON stated her expectation were, the call light to always be within resident reach. She stated it was the responsibility of all the staff to make sure the call light was accessible to the resident before leaving the room. The DON stated the risk to the resident would be the inability to call for help, and it could lead to a fall. In an interview on 07/22/25 at 3:56 PM The Administrator stated everyone in the facility should answers the call light. He stated the call light button is supposed to always be within the resident reach. He stated If there was a delay in the response, the resident could try to get up and had a fall. A record review of the facility's policy with revised date October 24, 2022, titled Communication-Call System revealed I. The Facility will provide a call system to enables residents to alert the nursing staff from their beds and toilet/bathing facilities. Procedure II. Call cords will be placed within the resident's reach in the resident's room.

Based on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 residents (Resident #1 and #Resident #2) of 6 residents reviewed for ADLs. The facility failed to ensure: 1. Resident #1 had her fingernails cleaned and trimmed on 07/22/25.2. Resident #2 had her fingernails cleaned and trimmed on 07/22/25.These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a de Findings included: 1. Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old female initially admitted to the facility on [DATE]and readmitted on [DATE] her diagnoses included hypertension (elevated blood pressure), diabetes mellitus (elevated blood sugar), muscle weakness, need for assistance with personal care, and dementia (diseases that affect memory, thinking, and the ability to perform daily activities). Resident #1's had a BIMS score of 6, which indicated severe cognitive impairment. The MDS assessment indicated Resident #1 required maximum assistance with personal hygiene. Record review of Resident #1's Care Plan dated 05/15/25, reflected the following: Focus: [Resident#1] has an ADL selfcare performance deficit related to Dementia and muscle weakness. Goal: [Resident#1] will maintain current level of function . Personal hygiene. Interventions: Personal hygiene.the Resident requires substantial/maximal assistance (X1) staff participation with personal hygiene . In an observation and interview on 07/22/25 at 10:22 AM revealed Resident #1 was laying in her bed. Resident#1 nails on both hands were approximately 0.4cm in length extending from the tip of her fingers, and jagged. The nails were discolored tan with black matter underneath. Resident #1 stated she would like her fingernails trimmed and cleaned. In an interview on 07/22/25 at 10:25 AM CNA A looked at Resident#1 fingernails and stated she would clean and trim them today after Resident#1 shower. CNA A stated that both CNAs and Nurses were responsible for nailcare. She said that if Resident has diabetes, then nurses trim their fingernails. She stated that if nails were long and dirty, residents may be at risk of infection. 2. Record review of Resident #2's Quarterly MDS assessment dated [DATE] reflected Resident #2 was [AGE] year-old female with initial admission date to facility on 11/16/2017. Resident #2 had diagnoses of Hypertension (elevated blood pressure), and dementia (diseases that affect memory, thinking, and the ability to perform daily activities). Resident #2 had BIMS score of 7 which indicated severe cognitive impairment. Resident #1 needed maximum assistance for personal hygiene. Record review of Resident #2's Comprehensive Care Plan revised on 07/16/25 reflected, Focus: [ Resident #2] has an ADL Self Care, Performance Deficit related to Confusion, fatigue, Impaired balance, limited mobility. Goal: [Resident #2] will maintain current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene through the review date. Intervention: PERSONAL HYGIENE/ORAL CARE: the resident requires extensive assistance (times one) staff participation with personal hygiene . In an observation and attempted interview on 07/22/25 at 11:02 AM revealed Resident #2 was up in her wheelchair in the dining room. The Resident's nails on both hands were approximately 0.4cm in length extending from the tip of her fingers. The nails were discolored tan and had brown colored residue underneath. Resident #2 was not able to participate in interview and just kept looking at her fingernails. In an interview and observation on 07/22/25 at 11:06 AM RN C stated that both nurses and CNAs were responsible for doing nail care for the residents. She stated that fingernails should be trimmed and cleaned on shower days and as needed. She stated that Resident #2 had dirty, untrimmed nails and they will provide nail care to the Resident after lunch. She stated that dirty nails could lead to risk in infections. In an Interview on 07/22/25 at 2:45 PM, the DON stated nail care should be completed as needed and every time aides wash the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated the ADON, and the DON would do the routine rounds to monitor. The DON stated residents having long and dirty could be an infection control issue. Record review of the facility policy titled, Grooming Care of the Fingernails and Toenails undated reflected, Nail care is given to clean and keep the nails trimmed . Fingernail are trimmed by Certified Nursing Assistants except for residents with the following condition A. Diabetes or circulatory impairment of the hands, B. Ingrown, infected, or painful nails .

Based on observation, interviews, and record review the facility failed to provide a safe, clean, comfortable environment, including but not limited to receiving treatments and supports for daily living for 3 of 4 residents (Resident #88, Resident #44 and Resident #92) reviewed for quality of life. The facility failed to provide Resident #88 and Resident #44 a comfortable and warm room above 71 degrees for 1/20/25 and 1/21/25. The facility failed to provide Resident #92 a comfortable and warm room with the temperature above 71 degrees on 1/20/25 through 1/21/25. The facility failed to provide residents who attended a confidential interview in the Rehab/Therapy room, a warm and comfortable room between above 71 degrees on 1/21/25. These failures could affect the residents by causing hypothermia or exacerbating existing conditions. Findings included: A record review of Resident #88's MDS assessment dated [DATE] reflected Resident #88 was a [AGE] year-old female with a BIMS score of 08 of 15, indicating moderate cognitive impairment. Resident #88 was admitted to the facility on [DATE] with diagnoses of Non-Alzheimer's Dementia (a General term for types of progressive loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), Depression (a mental illness that can cause a persistent low mood and loss of interest in activities), Dysphagia (Difficulty swallowing foods or liquids, arising from the throat or Esophagus, ranging from mild difficulty to complete and painful blockage) and Asthma (a condition in which a person's airway becomes inflamed, narrow and swell and produce extra mucus, making it difficult to breath). The review further reflected the resident was partially dependent on staff for ADLs. A record review of Resident #88's Comprehensive Care Plan initiated date 1/9/25 reflected .Resident #88 has an ADL Self Care Performance Deficit r/t muscle weakness and unsteadiness on feet. Date Initiated: 01/06/2024 Revision on: 12/24/2024 o Resident #88 will maintain current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score) through the review date. o BED MOBILITY: Resident #88 requires (Specify Supervision, cueing, weight bearing assistance, lifter sheet, trapeze) to turn and reposition. Date Initiated: 01/06/2024 Revision on: 02/02/2024 o PERSONAL HYGIENE/ORAL CARE: Resident #88 requires partial/moderate assistance (X1) staff participation with personal hygiene and oral care. Date Initiated: 09/12/2024 Revision on: 09/25/2024o DRESSING: Resident #88 requires setup or clean-up assistance (X1) staff participation with upper body dressing and supervision assistance with lower body dressing. Date Initiated: 07/23/2024 Revision on: 08/09/2024 o EATING: Resident #88 is able to (Specify: hold cup, feed self, eat finger foods independently) Date Initiated: 01/06/2024 Revision on: 02/02/2024 o TRANSFERS: Extent/Type of assist may fluctuate within the day or day to day, depending on level of strength, if in pain, mood, etc. May require more staff assist or less. Sit to stand: Independent. Chair/bed to chair: Independent. Toilet transfer: Independent. Tub/shower transfer: Independent. Date Initiated: 04/08/2024 Revision on: 04/12/2024 o TOILET USE: Resident #88 is able to (Specify: wash hands, hold grab bars, wipe self, adjust clothing) Date Initiated: 01/06/2024 Revision on: 02/02/2024 . Observation and interview with Resident #88 in her room on 01/20/25 at 12:14pm revealed her room was colder than the other rooms in the 200 hall. Resident #88 stated she felt weak and was unable to answer other questions. She was sitting on her bed covered with a blanket and sheet. Observation and interview with Resident #88 in her room on 1/21/25 11:05am revealed resident in bed covered with a blanket. Resident #88 popped her head up and stated she was good. She nodded her head up and down when asked if the room temperature was okay, despite the room feeling cold. Observation of Maintenance Director checking the temperature of Resident #88's room on 1/21/25 11:30 am revealed room was tempted at 67 degrees (back outer wall), 68 degrees (side outer wall), and 71 degrees (inner wall where TV was at). The hallway thermostat for the 200 hall was set at79 degrees. A record review of Resident #44's MDS assessment dated [DATE] reflected Resident #44 was a [AGE] year-old male with a BIMS score of 15 of 15, indicating no cognitive impairment. Resident #44 was admitted to the facility on [DATE] with diagnoses of Anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin.), Non-Alzheimer's Dementia (a General term for types of progressive loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), Depression (a mental illness that can cause a persistent low mood and loss of interest in activities), Hypertension (a condition in which the force of blood against the artery walls is too high) and Diabetes. The review further reflected the resident was mostly independent or setup assistance by staff for ADLs. A record review of Resident #44's Comprehensive Care Plan initiated date 11/2/23 reflected . o Resident #44 is resistive to care AEB refuses showers and refusing for housekeeping to clean his room. Date Initiated: 11/02/2023 Revision on: 11/03/2023 o Resident #44 will cooperate with care through next review date. Date Initiated: 11/02/2023 Revision on: 12/02/2024 Target Date: 02/10/2025 o Allow Resident #44 to make decisions about treatment regime, to provide sense of control. Date Initiated: 11/02/2023 Revision on: 11/03/2023 o Encourage as much participation/interaction by the resident as possible during care activities. Date Initiated: 11/02/2023 o If possible, negotiate a time for ADLs so that the resident participates in the decision-making process. Return at the agreed upon time. Date Initiated: 11/02/2023 CNA o If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later . o Resident #44 has an ADL Self Care Performance Deficit r/t medical diagnosis Dementia and Symptoms and Signs involving Cognitive Functions. Date Initiated: 06/03/2023 Revision on: 06/15/2023 o Resident #44 will maintain current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score) through the review date. o TOILET USE: Resident #44 requires supervision/set-up from staff participation to use toilet. Date Initiated: 06/03/2023 Revision on: 06/15/2023 o BATHING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Date Initiated: 06/03/2023 o BATHING: Resident #44 requires partial/moderate assistance from staff participation with bathing. Date Initiated: 11/10/2024 Revision on: 11/26/2024 CNA o BED MOBILITY: Resident #44 requires setup or clean-up assistance to turn and reposition. Date Initiated: 06/03/2023 Revision on: 11/26/2024 CNA o PERSONAL HYGIENE/ORAL CARE: Resident #44 is able to (Specify: rinse and spit, brush teeth, clean dentures) requires setup or clean-up assistance. Date Initiated: 06/03/2023 Revision on: 11/26/2024 o DRESSING: Resident #44 requires SPECIFY: assistance with choices, supervision, cueing, encouragement, physical assistance) to dress. Date Initiated: 06/03/2023 Revision on: 06/15/2023 o EATING: Resident #44 is able to (Specify: hold cup, feed self, eat finger foods independently) Date Initiated: 06/03/2023 Revision on: 06/15/2023o TRANSFERS: Extent/Type of assist may fluctuate within the day or day today, depending on level of strength, if in pain, mood, etc. May require more staff assist or less. Sit to stand: Independent Chair/bed to chair: Independent Toilet transfer: Independent Tub/shower transfer: Independent Date Initiated: 04/12/2024 Revision on: 04/14/2024 . Observation and interview with Resident #44 on 1/21/25 at 11:00 am revealed Resident #44 was covered with 4 blankets and a sheet. He stated that it was freezing in the room. Resident #44 stated that he had complained many times, but nothing had been done. Observation of Maintenance Director checking temperatures of Resident #44's room on 1/21/25 11:30 am revealed 67 degrees (back wall with windows) and 69.4 degrees (side wall with the door to the hallway). The hallway thermostat for the 600 hall was set at 78 degrees. A record review of Resident #92's MDS assessment dated [DATE] reflected Resident #92 was a [AGE] year-old male with a BIMS score of 15 of 15, indicating no cognitive impairment. Resident #92 was admitted to the facility on [DATE] with diagnoses of Schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly) and Other reduced mobility (a person has difficulty moving around due to a condition that is not specifically as a known mobility impairment, but still significantly impact their ability to perform daily activities). The review further reflected the resident required partial/moderate assistance from staff with ADLs. A record review of Resident #92's Comprehensive Care Plan initiated date 11/12/24 reflected . o Acute Pain / Chronic Pain r/t Multiple Fractures and Muscle Spasm. Date Initiated: 02/17/2024 Revision on: 11/12/2024 o Resident Will Report Satisfactory Pain Control Date Initiated: 02/17/2024 Revision on: 03/13/2024 Target Date: 11/24/2024 o Determine level of needed assistance based on ADLs / IADLs evaluation Date Initiated: 02/17/2024 Revision on: 02/17/2024 o Determine Resident's satisfactory pain level Date Initiated: 02/17/2024 Revision on: 02/17/2024 oEvaluate mood / behavior Date Initiated: 02/17/2024 Revision on: 02/17/2024 o Evaluate pain Date Initiated: 02/17/2024 Revision on: 02/17/2024 o Evaluate vital signs Date Initiated: 02/17/2024 Revision on: 02/17/2024 An observation and interview with Resident #92 on 1/21/25 at 11:00 am revealed that he believed the temperature was quite cold in the room. Resident #92 stated it had been this cold in his room since it started getting cold outside last month. He stated that he complained in December, but no one had come to fix the issue. An observation of Maintenance Director checking the temperature of Resident #92's room on 1/21/25 11:30am revealed 67 degrees (back outer wall) and 69.4 degrees (side wall with the door to the hallway). The hallway thermostat for the 600 hall was set at 78 degrees. During a confidential group interview of 6 residents held in the rehab/therapy room on 01/21/25 at 10:00AM revealed that the room was cold during the interview and the residents complained about the cold temperature in the room. An observation and interview with Maintenance Director on 1/21/25 at 11:30am revealed the therapy room temps were 66.9 degrees (large outer wall) and 66.8 (smaller outer wall). The thermostat in the therapy room was set to 68 degrees. He stated that temperatures in rooms vary on resident preferences. Nursed notified him when the thermostat needed to be changed. He or the administrator were the only ones that could change the thermostat. The outer rooms toward the exits had more windows and that contributed to those rooms being colder. The Facility ordered window units for those rooms and were still pending their delivery. He did not know what the risk to the residents was, if their room was cold. A record review of a copy of an email sent from Field Account Representative to Maintenance Brentwood Nursing Center on 1/21/25 at 12:00pm reflected .I checked again with customer service on the status of the remaining AC units. Just to confirm, order was placed on 12/19. Two were delivered, but the remaining 6 are on backorder. ETA 1/27. I will follow up again at the end of the week . A group interview and observation with Resident #92 and Resident # 44 on 1/22/25 at 2:12pm revealed that staff had never asked if they wanted to move rooms when complaining about their room temperature. They stated they would have moved if they had been offered the opportunity to move to a warmer room. They were never provided feedback about what was being done for their cold room. Observation of their room revealed that it was significantly warmer during the interview. They stated in the afternoon of 1/21/25 a window unit was installed in their room. An interview with Director of Rehab on 1/22/25 at 2:38pm revealed that the heater in therapy/rehab room was not working on 1/21/25 and someone worked on it but had not fix it. They came back on 1/22/25 and still could not fix it and would return later that day with the correct part. The heater in the therapy/rehab room had not been working for two days. Per the AC/Heater thermostat in the therapy room, the set temperature was 72 and the actual temperature of the room was 68. She stated there was no risk to the residents having therapy in a cold room. A record review of Oasis Healthcare Partners, Maintenance Log from 12/18/24 to 1/21/25 reflected 1 complaint on 12/30/24 for heater not working .) A record review of Facility's policy, Resident Rooms and Environment Operational Manual - Physical Environment revised on 8/2020 reflected .Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to the following: G. Comfortable temperatures .

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of one resident (Resident #79) reviewed for catheter and incontinence care. 1. The facility failed to ensure RA F maintained the foley catheter drainage bag below Resident #79's bladder while she and CNA G transferred the resident with a mechanical lift on 01/20/25 2. The facility failed to ensure CNA B did not place the urine catheter bag on the bed while performing incontinence care for Resident #79 and failed to maintain the drainage bag below the bladder while she and ADON E transferred the resident with a mechanical lift on 01/21/25. These failures could place residents at risk for not receiving care appropriate to address their incontinence and could increase the risk of urinary tract infections. Findings included: Record review of Resident #79's quarterly MDS assessment, dated 12/04/24, reflected a [AGE] year-old male with an admitted [DATE]. He had a BIMS of 12, which indicted he was moderately cognitively impaired. Resident #79 required substantial/maximum assist with ADLs and was dependent of 2 persons assist with transfers. He had an indwelling catheter and was always incontinent of bowel. Resident #79 had diagnoses which included neurogenic bladder (condition caused by nerve problems affecting the bladder), diabetes and heart failure. Record review of Resident #79's care plan, with a revision date of 09/11/24, reflected, [Resident #79] has indwelling Foley Catheter 16 French (measurement of the circumference of the outer catheter tube) for neuromuscular dysfunction of the bladder .Goal .will show less frequent signs and symptoms of urinary infection through the review period .Interventions .Position catheter bag and tubing below the level of the bladder Record review of Resident #79's Order summary report, dated 01/22/25, reflected .Foley catheter care every shift and as needed . with a start date of 01/20/25. In an observation on 01/20/25 at 02:15 PM RA F and CNA G entered Resident #79's room to transfer him from his wheelchair to the bed with a mechanical lift. Both staff hooked the mechanical sling to the lift. RA F unhooked the urinary drainage bag and handed to bag to the resident. The resident held the urinary drainage bag at his waist level. CNA G then raised the lift. Once the lift went up the resident was in a supine position with his urinary drainage bag laying on his chest. The resident was positioned over the bed and lowered onto the bed. RA F then laid to urinary drainage bag on the bed. Urine was observed in the tube flowing up and down. Both staff rolled the resident side to side to remove the mechanical sling and then fished the urinary drainage bag through the residents' pants to remove his pants. Both staff repositioned the resident and then CNA G placed the urinary drainage bag on the bed rail. In a second observation 01/21/25 at 10:30 AM, CNA B was observed completing incontinent care on resident #79 in preparation of the nurse coming to perform wound care. CNA B had placed the urinary drainage bag on the resident's bed where it remained during the wound care performed by LVN K and ADON E. Once the wound care was completed ADON E and CNA B dressed the resident. ADON E fished the catheter bag through the resident pants leg and placed the mechanical sling under the resident. ADON E then placed the urinary drainage bag on the bedrail while the hooked up the sling to the mechanical lift. ADON E unhooked the catheter bag and handed it to CNA B who laid it on the resident's lap. Once the resident was lifted in the air, the catheter tubing was observed fluctuating back toward the resident. The resident was lowered into his wheelchair and CNA B picked up the urinary drainage bag and hooked it to the front of the wheelchair. In an interview with CNA B on 01/21/25 at 11:25 AM she stated she had been taught to always keep the catheter bag below the bladder. She stated they were not supposed to lay it on the bed because it cannot drain. She stated she had placed it on the bed and on his lap to prevent it from pulling when turning him and when lifting him in the mechanical lift because he had it pulled on before during transfers. She stated the facility had not showed them how they were supposed to position the catheter bag while transferring with the Hoyer lift and was not sure how they should handle the drainage bag during a transfer. In an interview with RA F on 01/21/25 at 11:12 AM she stated they had been taught to keep the catheter bag below the bladder. She stated she did not even think about that when she handed the resident his catheter bag during his transfer on 01/20/25. She stated the facility had not showed them how they were supposed to handle the catheter bag when using the mechanical lift. She stated the risk of having it above the bladder could be urine backing up into his bladder which could cause an infection. In an interview with ADON E on 01/21/25 at 12:17 PM she stated she realized the staff had the urinary drainage bag laying on the bed which is when she placed it on the bed rail. She stated if it remained flat on the bed, it could not drain. She stated it should always be positioned below the bladder and acknowledged when they had it in the resident lap during the transfer it was not below the bladder. She stated if you do not keep it below the bladder there was a risk of the urine backing up into the bladder and causing an infection. She stated she and the DON are responsible for competency checks and stated positioning the urinary drainage bag during transfer was not included, but stated going forward they would include this so staff knew how to handle the catheter during transfers. In an interview with the DON on 01/21/25 at 01:20 PM, she stated the staff were taught to keep the urinary drainage bag below the bladder to ensure proper drainage and prevent urine from backing up into the bladder. She stated she and the ADON do the competency checks on all the CNA staff. She stated proper placement of the foley catheter bag during a Hoyer transfer was not part of their current check off skills, but stated going forward it would be included. She stated the risk of placing the catheter bag in a resident's lap or on the bed could prevent proper drainage and backflow into the bladder and potential spread of germs from the bag itself. Record Review of CNA B's skills check off dated 10/16/24 reflected she was competent in the care of indwelling catheters which included keeping the drainage below the bladder. Record Review of CNA G's skills check off dated 10/16/24 reflected she was competent in the care of indwelling catheters which included keeping the drainage below the bladder. Record Review of RA F's skills check off dated 10/15/24 reflected she was competent in the care of indwelling catheters which included keeping the drainage below the bladder. Record review of the facility's policy, Catheter-care of, dated June 2020, reflected, Daily Catheter Care .Position the catheter, drainage system and bag utilizing gravity to facilitate drainage. The collecting bag will be kept below the level of the bladder .Collection bags should always be kept below the level of the bladder, including during transport .

42971 Based on observation, interview and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 1 (med aid cart hall400/500) of 3 medication carts reviewed for pharmacy services and for 1 (Resident #31) of 5 residents reviewed for pharmacy services in that: The facility failed to ensure: 1- MA responsible for Nurses Cart Hall 500, removed medications in unsecure containers from the Nurses Cart when on 01/20/25 a-controlled medication used for pain had 1 blister seal broken and the pill still inside the broken blister and tapped over. 2- LVN J followed the manufacturer's instructions to prime the Novolog Insulin (Hormone) Pen prior to dialing in required amount of Insulin to be administered to Resident #31 on 01/21/25. These failures placed residents at risk of not receiving full dosage of medication, and place residents at risk of not having the medication available due to possible drug diversion. Findings included: 1- Record review and observation on 01/20/25 at 11:02 AM of medication aid cart hall400/500, with MA N revealed the blister pack for Resident #84's hydrocodone acetaminophen 5-325 mg tablet (controlled medication used for pain) had 1 blister seal broken and the pill still inside the broken blister and tapped over. Interview on 01/20/25 at 11:08 AM, MA N stated the count was done at shift change and the count was correct. She stated she did not check the blister packs during the count. She stated she was unaware when the blister pack seal was broken, and she was not aware of who might have damaged the blister and taped it over. She stated the risk would be a potential for drug diversion. She stated the nurses and med aides were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. She stated when a broken seal was observed, she would report it to the nurse. Interview on 01/21/25 at 1:13 PM, the DON stated she expected if a blister pack medication seal was broken the pill should be discarded. The DON stated it would not be acceptable to keep a pill in a blister pack that was opened. The DON stated the risk would be potential for drug diversion and infection control issue. She stated nurses were responsible for checking the medication blister packs for broken seals during the count on the change of shifts. The DON stated the ADON, and the DON were supposed to check the carts weekly. 2- Record review of Resident #31's, Face sheet, dated 01/22/25 reflected a [AGE] year-old male with an admitted [DATE]. Resident #31 had a diagnosis which included Type 2 diabetes. Record review of Resident #31's Physician Order report dated 01/22/25 reflected, Novolog Flexpen subcutaneous 100 unit/ml .Inject sliding scale .201-250=4 units . An observation on 01/21/25 at 11:55 AM revealed LVN J at the medication cart calibrating a new glucometer in preparation of obtaining Resident #31's finger stick blood sugar. LVN J performed hand hygiene and donned gloves and obtained Resident #31's blood sugar with a reading of 207. LVN J checked the computer to determine the amount of insulin per sliding scale was 4 units of Novolog insulin. LVN J dialed in the amount of insulin required (4 units) without priming the pen and administered the insulin. In an interview with LVN J on 01/21/25 at 12:05 PM she stated she was supposed to [NAME] the pen if she saw an air bubble in the pen. She stated she looked at the pen and did not see any air bubbles, so she just dialed in the required amount of insulin without priming the pen. She stated she was not aware the pen was supposed to be primed before each dose. She stated you [NAME] the pen to remove air, but stated she had not seen air, so she did not see the need to prime the pen. In an interview with the DON on 01/21/25 at 1:15 PM she stated she was not aware of the need to [NAME] the Insulin pen. She stated she would have to get with Corporate to see what their policy was. She stated she was not aware it was a manufacture recommendation. In a follow up interview with DON on 01/22/25 at 1:00 p.m. she stated Corporate had developed a policy after she had reached out to them for insulin Pens. She stated they were to follow the manufactured guideline for the insulin pen, and the guidelines indicated the pen should be primed before each dose to ensure no air and ensure a resident received the full amount of insulin. She stated they would be training all the nursing staff on the new policy. She stated she had also reached out to their pharmacy consultant to ensure when they were checking off staff for competency, they included this procedure. Record review of the facility's policy titled Storage of Medication, dated September 2018, revealed in part .8. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists . Record review of the Facility's policy, Insulin Pen Administration, dated January 2025, reflected, To improve the accuracy of insulin dosing .Insulin pens should be primmed per manufactures' guidelines Always refer to the instructions of the manufacturer when preparing your pen for use as pens from different manufacturers may operate differently . Review of manufacturer instructions for Novolog obtained from https://www.novomedlink.com/ searched on 01/23/25 reflected, .Giving the air shot before each injection .Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: Turn the dose selector to select 2 units .Hold your Novolog FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push-button all the way in. A drop of Insulin should appear at the needle tip, if not .repeat the process .make sure the dose selector is set at 0. Turn the dose selector to number of units you need to inject .

Based on observation, interview, and record review, the facility failed to provide food prepared that conserved nutritive value, flavor, and appearance for 10 residents on pureed diets of 10 residents on pureed diet , reviewed for nutritive value, in that: Cook A did not follow the recipe for the pureed (is cooked food, usually vegetables, fruits, or legumes, that has been ground, pressed, blended, or sieved to the consistency of a creamy paste or liquid) Spaghetti served for lunch service on 1/21/25. This failure could place residents at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: During an observation and interview on 01/22/25 at 12:06 PM, [NAME] A prepared puree meal for lunch. [NAME] A took about one-third pan of regular texture spaghetti that was in the buffet steam table ready to be served. She took the pan to the blender and added all of the regular texture spaghetti to the blender jar and started the blender. After about two minutes of blending the spaghetti, [NAME] A walked to the kitchen sink and took water in a pitcher. The pitcher was about 1/4 full. She came back to the blender and added the water to the spaghetti mixture in the blender. [NAME] A stated, I added some warm water to make it thin. She stated she did not look at the recipe. [NAME] A proceeded to serve meals for the lunch service. During a follow-up interview 01/22/25 at 1:38 PM with [NAME] A revealed she stated she did not look at the standardized recipe binder. She stated that she added water instead of other liquid to adjust the consistency of the pureed spaghetti. She stated that the risk of not following standardized recipe was decreasing the nutritional content of the meal. During an interview on 02/21/205 at 1:40 PM with the Dietary Manager revealed her expectation was all the cooks follow standardized recipe to cook all meals. She stated that if the recipe called for using broth or milk for pureed foods, then [NAME] A should have used it. She stated she provided in-service to cook on following recipes for all meals in the past. She stated that the risk of not following recipe was diluting the nutritional content and compromising on the quality of foods. During an interview on 01/22/25 at 12:51 PM with the Dietitian, she stated that her expectation was that the Cooks and the Dietary Manager should always follow standardized recipes to prepare meals for the residents at the facility. She stated that using broth versus water would not make a lot of difference in the nutrition content of the final product however she stated standardized recipes should always be followed in the facility so that food quality was maintained. She stated that both herself and the Dietary Manager were responsible for conducting in-services for the kitchen staff. Record review of the facility's Pureed Spaghetti with Meat sauce recipe undated indicated .FW 24-25- Day 10-Lunch .Place prepared noodles in a sanitized food pressor. Blend until smooth. Add hot prepared broth if product is too thick .NOTE: .if product needs thinning , gradually add appropriate amount of liquid (No Water) to achieve a smooth pudding or soft mashed potato consistency . Record review of facility's policy titled, Standardized Recipes dated 9/26/2024, reflected, Food products prepared and served by the dietary department will utilize standardized recipes .V. The Dietary Manager or designee will monitor and routinely verify the recipes used by the cooks.

42971 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 2 resident (Resident #38 and Resident #82) of 8 residents observed for infection control, and for 1 closet of 1 closet observed for sanitary environment. The facility failed to ensure: 1- CNA H changed her gloves and performed hand hygiene while providing incontinence care to Resident #38 on 01/21/25. 2- Clean linen closets were kept sanitary on 01/21/25. 3- Resident mattress was cleaned from the bowel movement before putting new fitted sheet on the bed for Resident #82 on 01/21/25. These failures could place residents at risk of cross-contamination and development of infections. Findings included: 1-In an observation on 01/21/25 at 9:30 AM CNA H and CNA I entered Resident #38 's room to transfer her back to bed. Both staff washed their hands and put on gloves and transferred the resident via a mechanical lift from her Geri-chair to the bed. Both staff removed their gloves, washed their hands and re-gloved to provide peri-care. CNA H unfastened the resident brief revealing she had a moderate bowel movement. CNA H rolled the resident on her left side, removed the soiled brief, and wiped the anal area from front to back and then the buttocks, changing to a clean wipe with each swipe. CNA H then pushed the soiled draw sheet under the resident and with soiled gloves placed a clean draw sheet and brief under the resident. Both staff then rolled the resident over and CNA I removed the soiled sheet and pulled the clean the sheet under the resident. Both staff removed their gloves, washed their hands, and put on clean gloves. CNA H then cleaned the resident's perineal area from front to back, revealing bowel movement had oozed up into the resident's vaginal vault. It took several wipes to remove all the bowel movement, with each wipe going toward the clean brief. Once the bowel movement was removed the staff closed the resident brief, repositioned her in bed, offloaded her feet and covered the resident. Both staff then removed their gloves and washed their hands. In an interview on 01/21/25 at 9:45 AM CNA H and CNA I stated they were supposed to clean from front to back. CNA H stated they had been told if a resident had a bowel movement, they could clean the movement off first and then do complete peri care. She stated they should had rolled her back over and cleaned her again and placed a clean brief under her. She stated they were supposed to change their gloves and wash their hands when the gloves were soiled. CNA H stated she did not realize she had soiled gloves on when she put the clean sheet and brief under the resident. In an interview on 01/22/25 at 11:44 AM the DON stated they had trained at length on when staff were to change their gloves and sanitize their hands. She stated even if the staff wipes away the bowel movement first, they still must clean the peri area and then re-clean the anal area since they wipe from front to back. She stated staff needed to change their gloves when they go from dirty to clean. She stated the risk was increased risk of infections. She stated she and the ADON do skills competency with the staff before they ever go on the floor. She stated they would be re-training and observing care to ensure staff compliance. Record review of CNA H's competency check off for hand hygiene and peri-care revealed she was proficient in care as of 10/15/24. Record review of CNA I's competency check off for hand hygiene and peri-care revealed she was proficient in care as of 10/16/24. 2-In an observation on 01/21/25 at 11:22 AM of the clean linen closet in the facility revealed there was a personal handbag placed right above the clean linens on a cart marked as 600 Hall. In an interview and observation on 01/21/25 at 11:25 AM with the Laundry Supervisor revealed personal handbag placed right above the clean linens on a cart marked as 600 Hall in the facility's clean closet. The Laundry Supervisor stated clean linen closet and carts were supposed to have only clean linen and should not had any personal belongings. He stated that the risk of having any other non-sanitary item such as personal handbag can cause cross contamination and infection control lapses. In an interview on 01/21/25 at 11:33 AM with CNA B revealed the handbag in the clean linen closet belonged to her. She stated she knew she could not keep any personal items in the clean linen closet because of risk of infection and cross contamination. In an interview on 01/21/25 at 1:12 PM with the DON revealed that her expectation was that the clean linen closet and cart shall only have clean linens and no other items. She stated that the risk to residents was cross contamination and lapses in infection control. 3- Record review of Resident #82's Quarterly MDS assessment dated [DATE] reflected Resident #82 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included perforation of intestine, colostomy status, and need for assistance with personal care. Resident #84's BIMS score of 13, which indicated Resident #82 was cognitively intact. The MDS assessment indicated Resident #82 required moderate assistance with personal hygiene. Record review of Resident #82's Care Plan dated 06/20/24, reflected the following: Focus: [Resident #82 has an ADL selfcare performance deficit . Goal: will maintain current level of function . Interventions Toilet use: The resident requires partial assistance of one staff participation to use toilet, . Personal hygiene/oral care: The resident requires partial/moderate assistance of one staff participation with personal hygiene . Observation on 01/21/25 at 10:29 AM revealed CNA M entered Resident #82's room for routine check, it smelled bowel movement in the room. She uncovered Resident #82 by removing her blanket, revealed loose bowel movement on the fitted sheet coming from the colostomy bag. CNA M left the room to call the nurse and to bring a clean linen. Resident #82 got out of the bed, she removed the soiled linen including the fitted sheet, she put them in the trash can. Mattress was contaminated with the bowel movement. LVN K and CNA M came back to the room with clean linen. LVN K took resident to the toilet, she cleaned her and changed her colostomy bag. CNA M put a clean fitted sheet without cleaning and disinfecting the mattress. In an interview on 01/21/25 at 10:29 AM, CNA M stated she should clean the mattress using sanitary wipes since the old sheet was soiled with the bowel movement. CNA M stated it slid from her mind because Resident #82 removed the soiled linen when CNA left the room to get the clean linen. CNA M stated failing to clean the mattress properly increased risk for contamination and spread of infections. In an interview on 01/21/25 at 2:13 PM, the DON, stated if the fitted sheet was soiled with the urine or bowel movement, she expected the staff to clean the mattress with wipes before putting clean fitted sheet. She stated failure to do so would potentially lead to cross-contamination and possible spread of infection. She stated that ADON and herself were responsible for ensuring safe practices were utilized to control infection spread by doing routine rounds and random checks. Record review of the facility's policy, Perineal Care, dated June 2020, reflected, Wash hands .Put on gloves .Separate the labia .moving from front to back, on each side of the labia and in the center .using a clean washcloth/cleansing wipe for each stroke .Turn the resident o side .wash, rinse and dry buttocks and per-anal area without contaminating perineal area .Remove gloves. Wash hands or use alcohol-based sanitizer .Note: Do not touch anything with soiled gloves after procedure (i.e., curtain, side rails, clean liens, call bell, etc.) .put on clean gloves .Clean and return all equipment to its proper place .Place soiled linen in proper container .Removed gloves. Wash hands. Record review of the facility's policy titled, Hand Hygiene, dated June 2020, reflected, The facility considers hand hygiene the primary means to prevent the spread of infections Facility Staff .must perform hand hygiene procedures in the following circumstances .Wash hands with soap and water .when soiled with visible dirt or debris .Hand hygiene is always the final step after removing and disposing of personal protective equipment . Record review of the facility policy titled, Laundry - Supply & Storage revised 8/2020 reflected, To ensure that all laundry on premises is supplied and stored properly Record review of the facility policy titled, Infection Prevention and Control Program revised 10/24/2022, reflected, . The ensure the Facility establishes and maintains 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 in accordance with Federal and State requirements. 48560

Based on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 residents ( Resident #7 and #Resident #82 ) of 16 residents reviewed for ADLs. The facility failed to ensure: 1. Resident #7 had her fingernails cleaned and trimmed on 01/20/25. 2. Resident #82 had her fingernails cleaned and trimmed on 01/21/25. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings included: 1. Record review of Resident #7's Quarterly MDS assessment dated [DATE] reflected Resident #7 was [AGE] year-old male with initial admitted to the facility of 5/16/2024. Resident #7 had diagnoses of heart failure, Hypertension, hyperlipidemia, Muscle weakness. Resident #7 had BIMS of 4 which indicated severe genitive impairment. Resident #7 needed moderate assistance for personal hygiene. Record review of Resident #7's Comprehensive Care Plan revised on 5/29/2024 reflected, Focus: [ Resident #7] has an ADL Self Care, Performance Deficit related to Confusion, Impaired balance. Goal: [Resident #7] will maintain current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score) through the review date. Intervention: o PERSONAL HYGIENE/ORAL CARE: the resident requires partial/moderate assistance (times one) staff participation with personal hygiene and oral care. In an observation on 01/20/25 at 3:40 PM with revealed Resident #7 had dirty and jagged nails. Another observation and interview on 01/21/25 8:51 AM with Resident #7 revealed resident fingernails were dirty with black discoloration underneath the nailbed. Resident #7 stated that the staff trim his nails, but he does not remember cleaning them. In an interview and observation on 01/21/25 at 10:42 AM with LVN D stated that both nurses and CNAs were responsible for doing nail care for the residents. She Stated that fingernails should be trimmed and cleaned on shower days and as needed. She stated that Resident #7 had dirty, untrimmed nails and will provide nail care to the resident after the interview ended. She stated that dirty, jagged nails could lead to risk in infections. In an interview on 01/21/25 at 11:38 AM CNA C stated that both CNAs and Nurses were responsible for nailcare. She said that if Resident has diabetes, then nurses trim their fingernails. She stated that if nails were long and dirty, residents may be at risk of infection. She stated that Resident #7 was compliant with care and did not refuse ADL care as far as she knew. 2. Record review of Resident #82's Quarterly MDS assessment dated [DATE] reflected Resident #82 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included perforation of intestine, colostomy status, and need for assistance with personal care. Resident #84's BIMS score of 13, which indicated Resident #82 was cognitively intact. The MDS assessment indicated Resident #82 required moderate assistance with personal hygiene. Record review of Resident #82's Care Plan dated 06/20/24, reflected the following: Focus: [Resident #82 has an ADL selfcare performance deficit . Goal: will maintain current level of function . Interventions Toilet use: The resident requires partial assistance of one staff participation to use toilet, . Personal hygiene/oral care: The resident requires partial/moderate assistance of one staff participation with personal hygiene . In an observation and interview on 01/21/25 at 10:04 AM revealed Resident #82 was laying in her bed. The nails on both hands were approximately 0.4cm in length extending from the tip of her fingers. The nails were discolored tan and had yellow greenish colored residue underside and on the nails' bed. Resident #82 stated it was bowel movement because sometimes she tried to secure the colostomy bag. In an interview on 01/21/25 at 10:29 AM, CNA M stated CNAs and nurses were responsible to clean and cut the residents' nails. CNA M stated did not notice Resident #82's nails. She stated she would do it right then. She stated the risk would be infection control and injury. In an observation on 1/21/25 at 2:05 PM revealed Resident #82's nails were trimmed and clean. In an Interview on 01/21/25 at 2:13 PM, the DON stated nail care should be completed as needed and every time aides wash the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated the ADON, and the DON would do the routine rounds to monitor. The DON stated residents having long and dirty could be an infection control issue. Record review of the facility policy titled, Grooming Care of the Fingernails and Toenails undated reflected, Nail care is given to clean and keep the nails trimmed . Fingernail are trimmed by Certified Nursing Assistants except for residents with the following condition A. Diabetes or circulatory impairment of the hands, B. Ingrown, infected, or painful nails .

Based on observations, interviews, and record review, the facility failed to ensure that residents had a comfortable and homelike environment for one (100 - hall) of six halls reviewed for physical environment. The facility failed to ensure the temperatures on the facility's 100 - hall was maintained at a range of 71 to 81 Fahrenheit when the heating unit would not produce hot air. This failure placed residents at risk of living in an uncomfortable environment leading to a decreased quality of life. Findings included: Observation of the facility's 100-hall on 12/06/24 at 10:49 a.m. revealed a hall thermostat reading of 68 degrees Fahrenheit. In a confidential resident interview on 12/06/24 at 10:51 a.m., a resident stated the last few nights in the facility had been cold. The resident stated they were offered second blankets and had not been told there was an issue with the facility's heating system. The resident stated they were not disturbed by the temperature in their room but was observed to lay in bed and place 2 blankets over their entire body, including their head . Observation with the Maintenance Supervisor on 12/06/24 at 11:05 a.m. revealed the temperature of the 100-hall, taken with a laser thermometer, was 69.6 degrees Fahrenheit. In an interview on 12/06/24 at 11:09 a.m., the Maintenance Supervisor stated he had been the facility's maintenance supervisor for a little over a year. The Maintenance Supervisor stated the facility was kept at a steady 70 degrees Fahrenheit in the winter and 72 degrees Fahrenheit in the summer. The Maintenance Supervisor stated temperatures would be adjusted throughout the day, depending on outside temperatures and at the request of residents. The Maintenance Supervisor stated he checked the facility's temperature daily and would adjust as needed. The Maintenance Supervisor stated he believed a temperature of 70 degrees Fahrenheit was compliant with state and federal rules and he was not aware that the minimum temperature was 71 degrees Fahrenheit. The Maintenance Supervisor stated keeping the facility at temperatures outside of 71 to 81 degrees Fahrenheit could lead to residents being uncomfortable in the facility. The Maintenance Supervisor stated he would adjust the temperature on the 100- hall and monitor to ensure the temperature was within the correct range. On 12/06/24 at approximately 11:15 a.m., the Campus Maintenance Manager approached the state surveyor and the Maintenance Supervisor and stated he had bumped up the temperature on the 100-hall to 72 degrees Fahrenheit and the hall would soon be incompliance. In an interview on 12/06/24 at 12:20 p.m., the ADMIN stated when the temperature of the 100-hall was increased the air conditioner came on and made the hall colder. The ADMIN stated he had the Maintenance Supervisor and the Campus Manager look into the issue, and an issue with the 100-halls heating system was found. The ADMIN stated a pressure switch on the roof was out, which caused the air conditioner to come on when the heat was turned on. The ADMIN stated the switch was replaced and the 100-hall was properly heated, and the temperature was now 71 degrees Fahrenheit. In a follow-up interview on 12/06/24 at 2:11 p.m., the ADMIN stated that had been the facility's administrator for four days. The ADMIN stated it was the expectation for the facility to be in compliance regarding facility temperatures, at all times. The ADMIN stated residents were offered blankets or to move to a more comfortable part of the building when temperature complaints were received. The ADMIN states the Maintenance Supervisor was expected to monitor the facility's temperature to ensure temperatures were at an appropriate level. The ADMIN reiterated that there was a pressure switched that failed, which was why the 100-hall's temperature was low, the repair was made, and the hall was properly heated. The ADMIN stated temperatures that were not within the appropriate range could lead to resident discomfort, especially with low outside temperatures. The ADMIN stated he would in-service facility staff on proper facility temperatures, maintenance request procedures, and would conduct random facility temperature checks to ensure the facility in complaint in the future . Record review of the facility's maintenance logs, dated 09/01/24 to 12/06/24, revealed no documented evidence regarding facility heating unit concerns. Record review of the facility's grievance logs, dated 09/01/24 to 12/06/24, revealed no grievances filed regarding the facility's temperature or residents' rooms being too cold. A related policy was requested from the ADMIN on 12/06/24 at 11:50 a.m., the ADMIN stated the facility did not have a related policy, as it followed the Texas Administrative Code directly.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen in that: The facility failed to ensure the morning cook checked the temperatures of the breakfast food before serving to residents. This failure could place residents who ate the food from the kitchen at risk for food-borne illness Findings included: Observation on 11/07/24 at 7:18 AM revealed [NAME] started to plate hot cereal over the serving line for two residents before checking temperatures of the food on the line. The Dietary Manager asked the cook if she had checked temperatures and she stated, no that she had forgot. The cook disposed of her gloves and went and grabbed the thermometers. The cook washed her hands and put her gloves back on. The cook placed the thermometers in water and started to check the food. The cook checked the temperatures for the scrambled eggs and cheese and the hot cereal. The cook then started back putting the food on the plate to serve to the residents. The food on the line that did not have the temperatures checked included: White Gravy Biscuits sausage patty bacon mechanical/pureed sausage Pureed eggs 2 boiled eggs 2 Fried eggs Interview on 11/07/24 at 8:30AM the [NAME] stated she was rushing because they ran behind this morning. The cook stated that she usually does the temperature checks. Interview on 11/07/24 at 8:35 AM the Dietary Manager stated the cook usually checks the temperatures before serving the residents. The Dietary Manager stated the cook was responsible for checking the temperatures and documenting on the temperature log. The Dietary Manager stated it was important to check the temperatures to make sure the food was not in the danger zone and safe for residents to consume. The Dietary Manager stated residents could get sick from eating undercooked food. Interview over the phone on 11/07/24 at 10:20 AM the Dietitian/Administrator stated Resident could develop a food borne illness if the temperatures not checked before serving the residents. The Dietitian/Administrator stated that the cook was nervous and forgot to check the temperatures. Record review of the temperature logbook for the month of November 2024 reflected the temperatures were checked for three meals a day. Record review of the facility policy revised 12/2020 titled, food temperatures: Operations [NAME], reflected: Policy Foods prepared and served in the facility will be served at proper temperatures to ensure food safety. B. Wash, rinse and sanitize a dial face, metal probe-type thermometer with an alcohol wipe. C. Insert the thermometer into the center of the product. D. Allow time for stabilization. Wait until there is no movement for 15 seconds. Several readings may be required to determine hot and cold spots. E. Record the reading on Food Temperature Log at the beginning of the tray line. F. Take the temperature of each pan of product before serving. G. Re-sanitize the thermometer after each use.

Based on observation, interview, and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status, unless the resident's clinical condition demonstrated that this was not possi ble, for one (Resident #66) of three residents reviewed for nutrition, in that: Resident #66 had a weight loss -11.8% in 30-day period with weekly weight loss intervention not implemented as outlined in the facility policy. This failure could place residents at increased risk of decline in physical health. Findings included: Record Review of Resident #66 MDS dated [DATE] revealed resident was a [AGE] year-old male admitted to the facility on [DATE]. Resident #66 had diagnoses of dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), dysphagia (difficulty swallowing), Cognitive communication deficit (difficulty with thinking and using language). Resident #66 had BIMS score of 3 which indicated that resident had severe cognitive impairment. Record review of Resident #66 weight log included the following: 11/1/2023 20:07 142.0 Lbs 10/5/2023 12:04 129.0 Lbs 9/5/2023 14:40 146.0 Lbs 8/3/2023 12:07 145.0 Lbs Record review of Resident #66's care plan dated 11/5/2023 for weight loss revealed: The resident's weight will stabilize within 4 weeks. Assigned Staff to administer dietary stimulant as ordered. Mirtazapine 7.5 MG Give Resident #66 supplements (House Shake TID with meals). as ordered. Alert nurse if not consuming on a routine basis. Mirtazapine 7.5 MG Resident# 66 has a diet order other than Regular and is at risk for unplanned weight loss or gain. (Puree texture, thin consistency) Resident #66 will maintain ideal weight and receive proper nutrition daily x 90 days. Monitor weight per facility protocol. Offer sub, if resident eats less than 50% or dislikes meal and offer supplement if resident continues to eat less than 50%. RD assess per facility protocol. ST eval and Tx per Physicians orders as condition warrants. Record Review of Dietitian's Progress Note dated 6/14/2023. Resident #66 had weight loss reported d/t decreased progression of condition. Current monthly weight 145.0 pounds, weight loss -13.2% x 90 days/-18.1% x 180 days; 81% of Ideal Body Weight, and BMI =19.13. His current diet order is Regular diet, mech. soft texture, thin liquids, and he is on House shakes. Reported oral intake 50-100% most of the time. No concerns with diet tolerance. Diet order is appropriate. Reported intake is not meeting nutrition needs. Recommend starting an appetite stimulant to enhance increased calories and protein intake. Will continue to encourage oral intake of meals and supplements, will follow up with resident's nutrition status, and nutritional needs. Record Review of Dietitian's Progress Note dated 10/12/2023. Resident #66 had weight loss reported d/t decreased progression of condition. Current monthly weight 129.0#, weight loss -11.8% x 30 days/-19.9% x 180 days; 80% of IBW, and BMI =19.32. His current diet order is Regular diet, puree texture, thin liquids, and House Shakes. Reported oral intake 75-100% most of the time, per nursing. No concerns with diet tolerance. Diet order is appropriate. Reported intake is not meeting nutrition needs. Recommend Ready Care 2.0 at 120cc with med pass TID. Will continue to encourage po intake of meals and supplements, will follow up with resident's nutrition status, and nutritional needs. In an interview with CNA C on 11/28/23 at 11:03 AM revealed that resident #66 is not verbal, he will sometimes understand what is being said but may not react to it. She stated she had not seen any weight loss on Resident #66. CNAC worked on the Resident # 66 hall since October and knew the resident well. She also reported Resident # 66 was sleepy on the day of the interview, so he was not taken to the dining room for activities and needed full assistance with transfers and ADL's. Observation on Observation 11/29/2023 at 12:40 PM revealed that Resident #66 was in the dining room and was fed by CNA A. The resident ate 100% of his meals. Meal ticket was not available for review. Observation on 11/30/2023 at 10:14 AM revealed that Restorative Aide/CNA B weighed Resident # 66 in a wheelchair and weight was 153.2 pounds. In an interview with CNA A on 11/29/2023 12:45 PM revealed that they started feeding Resident #66 recently; about 2 weeks ago since Resident #66 was spilling food and not eating most on his plate. CNA A did not observed any weight loss on Resident #66. He also stated that he was not aware if Resident #66 was on weekly weights. In an interview with LVN A 11/29/2023 at 12:55 PM revealed that Resident # 66's weight was stable. She stated that Resident # 66 messed up while eating by himself; and would not finish his meals. She had noticed that CNA's had recently started feeding Resident# 66. She also reported that if she observed any weight loss or food issues on residents, it was reported to Nursing team and Administrator at the daily morning meeting. In an interview with CNA B Restorative Aide on 11/29/2023 at 12:59 PM revealed she weighed Resident #66 every month. She also revealed that Resident #66 was not on weekly weights currently or for last few months. Resident #66 was weighed with wheelchair and then the wheelchair weight was deducted to obtain Resident# 66's weight. She stated the Nursing team would alert her if any resident was on weekly weight. She stated she was only responsible for weighing residents and notifying the nursing team if she saw any changes in weight from last month. She also stated that ADON's are responsible for documenting weights. In an interview with ADON A on 11/29/2023 at 1:20 PM revealed that he was just promoted to be the ADON A for Resident's #66 Hall. He revealed that he did not believe that Resident #66 was on weekly weights and was not sure if Resident #66 had history of weight loss. He revealed the process of weighing residents in the facility started with CNA / Restorative Aide weighed the residents and handed over the weights to ADON A. ADON A will then enter the weights in the weight log and notify DON, dietitian, physician, and family as needed. He also stated that not following facility policy of weekly weights for resident with significant weight loss will lead to failure to gauge if interventions put forth for weight loss were effective. In an interview with Speech Language Pathologist on 11/29/2023 at 1:45 PM revealed that Resident #66 was on Speech therapy from 8/9/2023-10/7/2023 for oropharyngeal dysphagia (difficulty initiating a swallow). Resident # 66 was triggered on 8/9/2023 for weight loss and dysphagia. Her goal for the Resident # 66 was to safely swallow thin liquids and return to soft and bite sized consistency. She revealed that resident was on Pureed Diet currently related to his swallowing problems. In an interview with Dietitian on 11/29/2023 at 2:25 PM revealed Resident #66 was initially triggered for weight loss in June. She recommended Resident # 66 started on Mirtazapine (appetite stimulant medication) and was implemented by the Following physician in June. She reported that in June Resident # 66 had weight loss -13.2% in 90 days and BMI =19.13. She reported Resident # 66's diet order was Mechanical soft diet with thin liquids; was on House shakes and Resident # 66's food intake was 50-100% of most meals. Dietitian was not aware if resident #66 needed any feeding assistance. Dietitian then revealed that resident was stable for a while and no Intervention were added until October 2023. In October 2023, Resident # 66 had weight loss of weight loss -11.8% x 30 days/-19.9% x 180 days; 80% of IBW, and BMI =19.32. She revealed she recommended Recommend Ready Care 2.0 (supplement) at 120cc with medpass TID. Dietitian added she suspected there was a problem with the scale but reweights were not carried out at the time. Dietitian also stated that she did not look at weekly weights for Resident # 66 and was not sure if Resident # 66 was placed on weekly weight monitoring, although Resident # 66 had significant weight loss since June 2023. Dietitian reported that she was not trained to look at weekly weights on residents unless the resident was newly started on Enteral feedings and had to be monitored. She also stated that she was not aware of the facility policy regarding placing residents with significant weight loss on weekly weights. She also revealed that if any resident was placed on weekly weights, it was the Nursing team that handled weekly weights and she was not responsible for monitoring whether weekly weighing was carried out nor did she look at them during her clinical review. Dietitian also revealed that since she reviewed monthly weights; she based her effectiveness of interventions for residents with significant weight loss on Monthly weights alone. She also revealed that the risk for not weighing residents with significant weight loss could result in failure to determine if added interventions to mitigate weight loss were effective. In an interview with the DON on 11/29/2023 at 2:55 PM revealed that Resident #66 started declining in September of 2023 and the staff fed Resident # 66 since then. She added that Resident # 66 started spilling food while feeding himself and hence was referred to Speech language pathologist for weight loss and dysphagia. She revealed that if any resident had significant weight loss in the facility, Nursing would notify the MD and the Dietitian and follow through with their recommendations. She then revealed that weekly weight protocol would be initiated per facility policy. She also stated she was not sure if Resident # 66 was on weekly weights despite being identified with significant weight loss. She revealed it is usually the dietitian that will recommend weekly weight intervention. In another interview with the DON on 11/29/2023 at 3:30 PM revealed that she read the facility policy that stated that any resident with significant weight loss should be on weekly weights. The DON stated that she was not aware she did not need the Dietitian recommendation to implement weekly weight interventions and it was an oversight from the Nursing team. She stated Inter disciplinary team approach should be used for weight loss intervention with Dietitian recommending diet changes and Nursing team monitoring weekly weights. She also revealed that she had received in-service from the corporate Nursing team just before this interview regarding weekly weight implementation for residents with Significant weights per facility policy. She also stated that not implementing weekly weight for Resident # 66 could result in failure to determine if interventions that were added for mitigating weight loss were effective and could risk resident's physical health. Record review of Resident 66's medical record revealed there was no documentation of weekly weights in his chart and wherever else weights were documented. Review of facility's Assessment and Management of Resident Weights Policy dated 06/2020 revealed that V. (F) Residents with significant weight change will be weighed at least weekly and discussed at the Resident at Risk or other clinical meeting to determine possible causes of weight gain or loss including goals for care.

Based on observation, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #73) of three resident reviewed for respiratory care. The facility failed to ensure Resident #73's nasal cannula, nebulizer mask, and oxygen tubing were dated. The facility failed to ensure Resident #73's nebulizer mask was properly stored. The facility failed to ensure Resident #73 had an order for continuous O2 administration. These failures could place the resident at risk for respiratory infection and not having their respiratory needs met. Findings included: Review of Resident #73's Face Sheet dated 11/28/2023 reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included chronic obstructive pulmonary disease with acute exacerbation, shortness of breath, pulmonary hypertension due to lung diseases and hypoxia (insufficient amount of oxygen in the body), and uncomplicated unspecified asthma. Review of Resident #73's Quarterly MDS assessment dated [DATE] reflected Resident #73 was cognitively intact with a BIMS score of 15. Resident #73's primary reason for admission was debility (physical weakness due to illness) and cardiorespiratory conditions such as chronic obstructive pulmonary disease with acute exacerbation, shortness of breath, hypoxemia (low blood oxygen), and asthma. Review of Resident #73's Comprehensive Care Plan dated 11/26/2023 reflected Resident #73 had Oxygen Therapy continuous 2-4 L NC r/t Respiratory illness (COPD/SOB) or 02 sat below 94% and one of the assigned task was OXYGEN SETTINGS: (Specify: The resident has, O2 via nasal prongs/mask@ (2-4) L continuously. Review of Resident #73's Physician Order dated 12/02/2022 reflected, Oxygen @ 2-4L via N/C as needed to maintain oxygen above 94% as needed for SOB. Review of Resident #73's Physician Order dated 07/30/2023 reflected, Check O2 sat Q shift and PRN every shift. Review of Resident #73's Physician Order dated 07/30/2023 reflected, Change Respiratory Tubing, Mask, Bottled Water, clean filter q7d every night shift every Sun q 7 days. Review of Resident #73's Physician Order dated 07/30/2023 reflected, Change Respiratory Tubing, Mask, Bottled Water, clean filter q7d every night shift every Sun q 7 days. Review of Resident #73's Physician Order dated 09/28/2023 reflected, may have 02 @ 2-4L/min via NC PRN SOB/02 sat<92%. Review of Resident #73's Physician Order dated 11/16/2023 reflected, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally every 6 hours for COPD. Review of Resident #73's Physician Order reflected no order for continuous oxygen administration. Observation and interview with Resident #73 on 11/28/2023 at 10:58 AM revealed resident was in his bed resting. Resident #73 was receiving oxygen supplement at 2 liters per minute via nasal cannula that was connected to the oxygen concentrator, the nasal cannula had no date. The humidifier bottle on the oxygen concentrator also had no date. Resident #73 had a nebulizer machine inside the drawer of the right bedside table. Resident #73 stated he had been with oxygen since he cannot remember. He said he had lung problem that was why he was in oxygen. Observation and interview with Resident #73 on 11/28/2023 at 3:05 PM revealed resident on his bed resting. The nebulizer mask was on the floor between the bed and the oxygen concentrator. The tubing of the nebulizer mask was not dated. According to Resident #73, he had a breathing treatment after lunch but he was not aware what time. He stated the nurse came in and put the mask on him. The resident said the nurse did not come back when it was done so he put the mask on the table and did not notice it fell . Resident #73 added it was hard for him to reach for the plastic bag. Interview and observation with LVN I on 11/28/2923 at 3:10 PM, LVN I stated the nebulizer mask should not be on the floor but instead stored in a plastic bag at the bedside. LVN I said she was not sure what time Resident #73 had his breathing treatment. LVN I stated she did not notice the nebulizer mask was on the floor when she did the shift change round. She said the nebulizer mask could get contaminated and increase the risk of respiratory infections. She added she was about to give him another breathing treatment and would change the nebulizer mask. LVN I pulled the tubing of the nebulizer mask from the nebulizer and said she would dispose of it and bring a new one. No date was noted from the nebulizer mask that was pulled from the nebulizer machine. Interview with DON on 11/29/2023 at 8:09 AM, the DON stated any equipment used for respiratory care must be bagged to ensure cleanliness. The DON said a nebulizer mask on the floor could cause infection and cross contamination. She also said the tubing for the nasal cannula, the tubing for the nebulizer mask, and the humidifier should be dated to ensure the residents were not using old tubings and humidifier. She explained the old tubings and nebulizer mask could lead to infection and compromised oxygen intake. The DON stated whoever was changing the tubings or the nebulizer mask should date them to indicate that the tubings and the mask were changed. According to the DON, the night nurse was responsible in changing the tubings and the mask once a week but whoever saw the mask or even the nasal cannula on the floor should change it and date it. The DON said the nurse must have missed dating the said items. The DON concluded the staff must ensure the tubings and the mask were dated. She said she would continually remind the educate the staff of the importance of a competent respiratory care. Interview with RN G on 11/29/2023 at 8:15 AM, RN G stated she was with the facility for a couple of months. RN G said she was familiar with the care of Resident #73. She added Resident #73 had respiratory problems that is why he was on oxygen and used breathing treatment. RN G said she gave the breathing treatment twice for her shift. She said she was not aware the mask for the breathing treatment was on the floor. She said the mask must be a bagged when not in use. She added the tubings and the mask should be dated to know when they were last changed and when they were supposed to be changed. RN G said she was not sure if the humidifier needed dating. RN G said a resident with oxygen had to have a physician order for oxygen supplement. She said it should be in the system so the staff would know what to do and if the staff were giving the right treatment. Review of Resident #73's Physician Order reflected a new order dated 11/29/2023 at 8:18 AM stating, may have 02 @ 2-4L/min via continuous NC SOB/02 sat<92%. Interview with Resident #73 on 11/29/2023 at 8:41 AM, Resident #73 reiterated the nurse would put on the breathing treatment and when the treatment was done, he would usually put it on the table. He said sometimes it would fall l on the floor. Resident #73 said sometimes he would get something from the drawer and the mask would fall. He said the nebulizer machine and the mask should be placed on top of the table so that when he would get something from the drawer, the mask will not fall. Interview with CNA I on 11/29/2023 at 9:30 AM, CNA I stated anything that the residents used must be clean. CNA I said if the residents were using oxygen, everything used such as nasal cannula and breathing masks should be clean and bagged if not in use. She added if the mask was on the floor, it could cause an infection because the germs from the floor will be inhaled by the resident. She added if ever she saw a mask on the floor, she would tell the nurse so the nurse could replace it before the resident would use it again. CNA I further added there was no five minute rule for the mask, if the mask was on the floor even for one second, it should be changed. Interview on 11/30/2023 at 8:23 AM, the Interim Administrator stated the tubings and the mask must be dated weekly at a to minimum to make sure the staff were changing it. He said the tubings and the mask were being changed to ensure they were in good conditions. The Interim Administrator added the nasal cannula and the mask must be bagged when not in use. He continued if the tubings and the mask were not changed, it could cause respiratory infection and the oxygen intake could be compromised. The Interim Administrator stated there should be a physician order if the resident was using oxygen. He added the nurses, ADON, and the DON were responsible in ensuring the required orders were in place. He said the physician order was done to make sure the staff was following the exact prescription for oxygen administration. He further added if the physician wanted a continuous administration of oxygen, then the system must reflect continuous administration or else the resident will not get the treatment needed. The Interim Administrator specified the expectation were for the staff to make sure to place the mask in a place where it will not fall, to make sure the tubings and the mask were dated, and to make sure the system accurately reflect the physician's order. Interview with the DON at 11/30/2023 at 10:19 AM, the DON stated Resident #73 had been in and out of the facility. She continued that during the last admission, dated 11/15/2023, the nurse must had missed putting the order for continuous oxygen. She acknowledged that she overlooked Resident #73 did not have a physician order for continuous oxygen administration. Record review of facility's policy Oxygen Administration, Nursing Manual - Nursing Care rev. 6/2020 revealed Purpose: To prevent or reverse hypoxemia and provide oxygen to the tissues . I. Initiation of Oxygen: A physician's order is required to initiate oxygen therapy . The order shall include i. Oxygen flow rate ii. Method of administration (e.g. nasal cannula) iii. Usage of therapy (continuous or prn) iv. Titration instructions (if indicated) v. Indication for use . II. Infection Control . A. Will be changed weekly and when visibly soiled . date . oxygen being used . B. Oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect for one (Resident #1) of twenty residents reviewed for neglect. 1) On 07/15/23, LVN A unlocked and opened an exit door to allow Resident #1 to leave a secured unit without supervision. Resident #1 had not been located was not located as of 07/21/23. 2) LVN A failed to evaluate Resident #1's mental status, pertinent medical conditions, mental health diagnoses, risk of harm to self or tried to prevent the departure when Resident #1 stated wanting to leave the facility. 3) LVN A failed to notify the attending physician, on call physician, or medical director of Resident #1's departure from the facility after opening an access-controlled locked door to allow Resident #1 to exit the secured facility. 4) LVN A failed to follow the Abuse Prevention and Prohibition Program policy and failed to follow the policy for Discharge Against Medical Advice. An Immediate Jeopardy (IJ) was identified on 07/20/23. The IJ template was provided to the facility on [DATE] at 4:25 PM. The facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk for harm, serious injury, and death. Findings included: A record review of Resident #1's most recent completed Quarterly MDS assessment dated [DATE] revealed a [AGE] year-old female admitted on [DATE]. The Quarterly MDS assessment dated [DATE] was In Progress. Resident #1 had medically complex conditions and active diagnoses of malnutrition (lack of proper nutrition); psychotic disorder (other than schizophrenia); and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Other active diagnoses included paranoid (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly - delusions and hallucinations are the two symptoms that can involve paranoia) schizophrenia; unspecified osteoarthritis; muscle wasting and atrophy (waste away); cognitive communication deficit; repeated falls; and unspecified abnormalities of gait and mobility. Resident #1's BIMS score reflected 03, which indicated severe impairment. The Quarterly MDS indicated Resident #1 required supervision setup help only with ADLs. Resident #1 was occasionally incontinent of bladder and frequently incontinent of bowel. The Quarterly MDS did not indicate Resident #1 had any behavioral symptoms or rejection of care during the MDS review period. A review of Resident #1's comprehensive care plan, review start date 06/29/23, target completion date 07/06/23 indicated: FOCUS: - [Resident #1] is an elopement risk/wanderer AEB Disorganized thinking and disillusion. GOAL: - [Resident #1] will not leave facility unattended through the review date - [Resident #1] safety will be maintained through the review date INTERVENTIONS: - 11/18/20 [Resident #1] refuses to wear WanderGuard (a monitoring device) - Distract resident from wandering by offering pleasant diversion, structured activities, food, conversation, television, book. Resident prefers: pampered nails, musical entertainment, and movies - 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. FOCUS: - [Resident #1] is PASRR positive and receives MHMR specialized services of service coordination through [a non-profit organization mental, physical, and emotional health services provider] and psychosocial rehabilitative services . is positive for Mental Illness 2/10/20 IDT Meeting: psychosocial rehab to start. GOAL: - [Resident #1] will receive indicated specialized services as ordered through review date. INTERVENTIONS: - IDT meetings with resident, facility staff and [non-profit organization] - Resident to receive psychosocial rehabilitative services per IDT meeting findings - Resident to receive service coordination from [non-profit organization] - Social Services to communicate with resident and [non-profit organization] as needed FOCUS: - [Resident #1] has mood problem related to Schizophrenia and Psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) . has conversations with herself, as well as talks to people about aliens and living on a different planet. GOAL: - [Resident #1] will have improved mood state (happier, calmer appearance, no s/sx of depression, anxiety or sadness) through the review date. INTERVENTIONS: - Administer medications as ordered. Monitor/document for side effects and effectiveness - Behavioral health consults as needed - Monitor/record mood to determine if problems seem to be related to external causes - Monitor/record/report to MD PRN acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/ eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills - Monitor/record/report to MD prn mood patterns s/sx of depression, anxiety, sad mood as per facility behavior monitoring protocols - Monitor/record/report to MD prn risk for harming others: increase danger, labile mood or agitation, feels threatened by others . - Observe for signs and symptoms of mania (periods of over-active and high energy behavior) or hypomania (milder version of mania) racing thoughts or euphoria (extremely joyful and pleasurable); increased irritability; frequent mood changes; pressured speech; flight of ideas; marked change in need for sleep; agitation or hyperactivity (move about constantly, including in situations when it is not appropriate, or excessively fidgets, taps, or talks) Review of Resident #1 progress notes reflected: - 06/16/23 at 10:04 PM: [Resident #1] constantly wanders and is exit seeking while awake . does not spend time in room and is very confused . - Late Entry 7/16/2023 at 9:55 PM [Effective date: 07/15/23 at 08:15 AM], LVN A wrote: [Resident #1] left the building AMA with her red bag . said that the facility has been holding her against her will . refused to sign any paperwork . looked presentable and clean before living . [PCP] notified and said to notify the Police . called the Police. - 07/17/23 at 10:02 AM, the SW wrote: left message for (Ombudsman), to inform of [Resident #1] elopement - 07/17/23 at 12:05 PM, the SW wrote: [Resident #1] elopement was reported to APS (a social services program that provides a support system to elderly and dependent adults who may be subject to ANE) . Previous notes entered by SW on 07/17/23 at 10:02 AM and 07/17/23 at 12:05 PM reflected incorrect documentation and were struck through. Review of Resident #1 progress notes reflected: - 07/18/23 at 9:04 AM, the SW wrote: left message for [Ombudsman] to inform of [Resident #1] decision to go AMA - 07/18/23 at 9:07 AM, the SW wrote: [Resident #1] decision to go AMA was reported to APS . This information was given to the NFA. During a brief entrance conference on 07/18/23 at 8:45 AM, after informed the purpose of investigator visit, the NFA stated . the resident left AMA . the SW reported it . The investigator verbalized understanding and requested to interview the SW. During an interview on 07/18/23 at 9:18 AM, the SW indicated that she worked at SNF for less than two weeks. The SW stated that on Sunday 07/17/23 she received a message to report to the SNF. The SW stated that when she arrived to the SNF there where several other staff members were present and to her [The SW] understanding, were going to look for [Resident #1], to bring back to the SNF, to assist and offer resources to relocate and appropriately discharge from the SNF. The SW stated she drove her personal car to search for Resident #1, did not locate her and returned to the SNF. The SW indicated she stayed around the SNF for about an hour and half, went to receptionist to verify able to leave, and headed home around 3 PM. The SW stated during the drive home, she received a call from the Regional SW, and mentioned that she [SW] . had just left the facility to search for Resident #1. The SW said that the Regional SW said to Notify APS, the Ombudsman, and document. The SW said she understood the purpose of calling APS was to report Resident #1 was not in the SNF and concerned about safety. The SW said that she placed a call to report to APS and left message for Ombudsman on Monday (07/17/23) morning. The SW said she called APS back before 4:00 PM to inform that intent was to file a self-report for the facility and not a complaint against the facility. The SW defined eloped in own words as a person gone off, don't know where and [staff] did not know they [individual eloped] were leaving. The SW gave an example of [leaving] AMA that MD suggested staying at facility and the individual leaves anyway. The SW indicated she was not specifically familiar with the policy regarding a resident leaving AMA but knew where to find the policies for review. The SW stated did not file police report because facility staff filed a police report. During an interview on 07/18/23 at 3:53 PM, the BOM indicated his role/responsibility was to receive payments from guardian over [Resident #1] finances and deposit in trust account. The BOM said had a good rapport with Resident #1. The BOM said his knowledge of Resident #1 leaving the SNF was that she left AMA. The BOM indicated the procedure to follow when a resident desired to leave the SNF AMA, Monday - Friday and management is present, there is a form the resident must fill out . management was not present over the weekend, so it was to my understanding that [Resident #1] just left. The BOM said that Resident #1 verbalized from time to time, over [AGE] years, wanting to leave and go home, but to her knowledge had never left before. The BOM said did not recall or observed [Resident #1] present exit-seeking behavior and did not have a WanderGuard. The BOM said that he was present at the SNF on Saturday (07/15/23) afternoon we he learned that the resident had left. The BOM said he participated in the search parties on Saturday (07/15/23) and Sunday (07/16/23) coordinated by the LCA. The BOM said that Resident #1 might try to go to El Paso because she always talked about it. During an interview on 07/18/2023 at 4:49 PM, the DON stated she was a new hire and her first day was Monday (07/17/23). The DON said that she conducted in-services on Elopement Risks and Wanderguard after she learned that [Resident #1] left the SNF without supervision. The DON was not sure how Resident #1 eloped from or departed from the secured building without proper procedures being followed. The DON stated she would need to become familiar with the SNF policy and procedure but expected staff to follow proper procedure and not provide a resident access through a secured exit if not accompanied by a supervising representative, transportation personnel, or without a physician order. Review of a facility self-reported incident, dated 07/19/23 at 10:21 AM, indicated the NFA first learned of incident on 07/18/23 at 4:00 PM, the date/time incident occurred was 07/18/23 at 4:00 PM. The NFA wrote a brief narrative summary of the reportable incident that [Resident #1] left the facility and refused to sign out AMA or allow the facility to do a proper discharge. The NFA did not name an alleged perpetrator and indicated actions and notifications included police, ombudsman, APS, and doctor. The NFA indicated the incident was reported to the police, in-services were initiated on Elopement vs AMA. During an interview on 07/19/2023 at 12:03 PM, LVN A said that he was employed for with the facility about one year and worked weekend doubles as the charge nurse. LVN A stated he completed ANE training on hire and after one-year employment. LVN A stated he also participated in on-going ANE in-services. LVN A defined neglect in his own words: Is when refuse or do not give care to resident. LVN A defined elope in his own words: resident leaves the building and the nurse did not that [resident] left. LVN A described {leaving} AMA When a resident demanded to leave, but [staff] try to encourage them to stay, but [resident] keep demanding to leave. LVN A stated that the staff should try to explain to the resident the consequences of leaving AMA; then, call the NFA, MD, and the police for further recommendations. LVN A stated he was unsure of specific policy for AMA. LVN A indicated he worked Friday, 07/14/23 through Sunday, 07/16/23. LVN A said was not often assigned to the hall Resident #1 resided on. LVN A said was familiar with Resident #1 by seeing her around the SNF. LVN A described Resident #1 as ambulatory without an assistive device, ate in the dining room without assistance, required standby assistance for showering, was Independent, could verbalize wants and needs, was own responsible party. LVN A indicated was assigned to Resident #1's hall on Saturday (07/15/23) morning and observed resident during morning change of shift rounds (6 AM). LVN A indicated sometime after breakfast, Resident #1 approached [LVN] and stated she wanted to leave the facility. LVN A said that he asked Resident #1 can this wait until Monday, so that SW can assist with the discharge process? Resident #1 replied, do not have to wait . do not understand why being held against my will. LVN A said that Resident #1 would walk away but return shortly and state that she would sue the facility for holding against will. LVN A said that Resident #1 followed [LVN A] around in hallway saying I need you to let me out . you are holding me against my will . I'm a lawyer, I am going to sue this place for holding me against my will. LVN A said Resident #1 continued to repeat over and over that she wanted to leave the facility. LVN A said that he attempted to present Resident #1 with the Statement Releasing the Home from Liability when Resident leaves AMA form and Resident #1 refused to sign. LVN A said that he escorted Resident #1 to the front door, entered the code and allowed Resident #1 to exit - the external gate was propped open, did not need to buzz [Resident #1] out, and the gate closed completely after Resident #1 exited. LVN A stated he completed passing medications. LVN stated he thinks it was sometime around 9AM when he let Resident #1 out of the building. During a continued interview (07/19/2023 at 12:03 PM), LVN A said that he placed an outbound call to the PCP and informed them that Resident #1 wanted to leave and said she was being held against will. LVN A said that the PCP replied to call the police get them involved, follow the protocol for a resident who wanted to leave the SNF. LVN A stated that he attempted to verify with the PCP if the policy he was to follow was for AMA, did not get a response and the call ended. When asked if he [LVN A] followed the procedure to discharge a resident AMA and was an order given by the PCP, LVN A stated that he received a verbal order from the PCP to discharge the resident AMA but did not enter the order into PCC. LVN A said that the PCP did not speak to the resident over the telephone or came come to SNF to discuss and advise potential consequences of discharging AMA. LVN A said that he did not call immediately, but later in the afternoon, placed an outbound call to 911 to report that [Resident #1] left the SNF AMA. LVN A stated that he then placed a call to the RDO to inform that [Resident #1] left AMA and the RDO replied, Have to see about getting [Resident #1] back and do a proper discharge. LVN A said that leadership coordinated a search for Resident #1 on Saturday 07/15/23 and Sunday 07/16/23, to his knowledge Resident #1 was not located. LVN A said he received a case number when police arrived to take a report. LVN A stated that he entered a narrative note on Sunday 07/16/23 as a late entry. LVN A stated that he conducted an in-service with staff Saturday (07/15/23) on Ensure gate is closed. During a phone interview on 07/19/2023 at 4:02 PM, the PCP indicated they received a call Saturday late afternoon that [Resident #1] left the bldg. The PCP stated if [Resident #1] was present at time the call was received, they would attempt to speak with them and encourage them to stay or would have given an order to discharge the resident AMA to a receiving care provider. The PCP reiterated they received the call after the resident was no longer at the SNF. Observation of video surveillance with the RDO on 07/19/20 at 4:18 PM revealed Resident #1 approach the main gate on 07/15/23 at 8:04 AM. Resident #1 paused, reached into a bag and retrieved a piece of paper, approached and handed SG I the piece of paper. It appeared that SG I maintained courtesy toward Resident #1 when redirected and avoided touching [Resident #1]. At 8:07 AM, it was noted that Resident #1 became agitated, began pacing from left to right as SG I tried to redirect; SG C was noted approaching SG I and Resident #1. At 8:08 AM, Resident #1 pushed by SG I and was observed walking off toward the main street, crossed a busy 4 - 6 lane street to the opposite side without regard for traffic. During an interview on 07/20/23 at 12:58 PM, the NFA stated that she became the administrator about a month ago; and just returned to work from vacation on 07/17/23. The NFA described Resident #1 as very intelligent . had a BIMS of 14 . no assistance with walking . been at the facility for about sixteen years. The NFA said first learned about the incident Sunday (07/16/23) night when she reviewed messages via the SNF group text. The NFA said she believed the incident happened on Saturday (07/15/23). Upon return to work on Monday, 07/17/2023, the NFA stated she inquired about what happened (referring to the group chat) and the BOM indicated Resident #1 was very passionate about going home and left the building. The NFA said that it was her understanding that [Resident #1] wanted to go back home to El Paso and left the building. During a phone interview on 07/20/23 at 1:46 PM, SG C indicated that she worked Saturday, 07/15/23. SG C stated on Saturday, 07/15/23 around, 8 AM, she was posted in the [Security] booth when Resident #1 was observed approaching the main gate. SG C said as she logged incoming vehicles, SG I attempted to redirect Resident #1 back on campus. SG C said after all arriving vehicles were logged and okay to enter campus, she tried to assist SG I when Resident #1 pushed past SG I and headed toward the main street. SG C said she attempted to call the secured unit but there was no answer. SG C stated she placed an outbound call to the RDO and informed them that an unidentified resident left off campus without being unsupervised and without a pass to leave campus. SG C said that the RDO asked if the resident was in line of sight and what direction they were headed. SG C stated that she last saw Resident #1 cross to the opposite side of the street and could not see Resident #1 at that time. SG C stated shortly after she spoke with the RDO, the facility staff came out asking about and looking for Resident #1. SG C stated that for anyone walking off campus must present a pass or a badge. Review of the Abuse Prevention and Prohibition Program policy and procedure provided by the facility, revised October 24, 2022, indicated purpose is to ensure the Facility . screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting . neglect . in accordance with federal and state requirements. - Staff is instructed to report any signs of stress from family and other individuals involved with the resident that may lead to .neglect . and intervene as appropriate. - Physical Neglect o f. Inadequate provision of care o g. Caregiver indifference to resident's personal care and needs o i. Leaving someone unattended who needs supervision Review of the Discharge Against Medical Advice policy and procedure provided by the facility revised 06/2020, indicated in part that a resident may discharge themselves from the Facility against the advice of his/her physician. Procedure: - Mitigating circumstances influencing the resident's decision to leave should be evaluated and addressed in an effort to prevent the resident from leaving against medical advice (AMA). - A licensed nurse will notify the attending physician, on call physician, or medical director of the resident's desire to leave the Facility AMA. - The Facility and/or physician will discuss with the resident and/or the resident's personal representative, if applicable, the reason for the AMA decision and will advise them of the potential consequences of the AMA decision. - If the resident demonstrates the following risks, the charge nurse will notify the Administrator/designee, Director of Nursing Services, Attending Physician, Responsible Party, and law enforcement: o A. Resident displays impaired cognition o B. Resident is at risk of harming self or others The facility's Plan of Removal was accepted on 07/21/23 at 4:34 PM and included: All residents have the potential to be affected. 1. LVN A was removed from duty and suspended pending the investigation on July 20, 2023. 2. Training for all licensed nursing staff on Policy and Procedures of the AMA process was initiated on 7/17/2023 and completed on 7/19/23 by DON and will be ongoing until all staff have completed the training. 3. Training for all licensed nursing staff on Closing the front gate was initiated on 7/15/23 by the Maintenance Director and completed on 7/19/23 and will be ongoing until all staff have completed the training. 4. Training for all licensed nursing staff was initiated on 7/17/23, on notification of elopement assessments that trigger for moderate or higher will require DON, ADON and/or MDS notification. Training was conducted by the RNC and completed on 7/19/23 and will be ongoing until all staff have completed the training. 5. DON/ADON/MDS completed audit of all resident elopement assessments on 7/17/23. The outcome confirmed that 18 residents are at imminent risk for elopement. 6. DON/RNC completed audits of all residents with wanderguard on 7/17/23 and updated all elopement binders. The outcome revealed that all imminent risk residents with wandergaurds were intact and functioning. In-Service conducted. 1. Training for all staff in response to resident AMA was initiated on 7/15/23 and completed by the RDO. a. The Facility Staff member who finds that a resident wishes to leave the facility will alert the charge Nurse. The charge nurse will verbalize and document any verbal and/or physical exit seeking behaviors to the oncoming shift and 24hrs report. 2. A licensed nurse will notify the attending physician, on call physician, or medical director of the resident's desire to leave the Facility AMA Training for all licensed nursing staff on completion of accurate elopement assessments initiated on 7/17/23 and will be ongoing until all staff have completed the training. 3. The Facility and/or physician will discuss with the resident and/or the resident's personal representative, if applicable, the reason for the AMA decision and will advise them of the potential consequences of the AMA decision. 4. A licensed nurse will have the resident or the residents' personal representative sign Discharge AMA, or similar form located in the Facility's EHR. A. If the resident or personal representative refuses to sign, the licensed nurse will read the Form to the resident, make a specific notation in the progress notes of the refusal to sign, and have a witness sign the form as acknowledgement of the resident's or resident's personal representative's refusal to sign. If a resident is a has a legal Guardian or a [NAME] of the State, the nurse will notify them of the resident's desire to leave the facility despite the residents' BIMS/cognition level. This resident was not a ward of the State, she was her own responsible party. 5. Nursing staff will document in the progress notes all pertinent information concerning the residents' actions, including the resident's stated reasons for his/her desire to leave the Facility. Implementation of Changes Training for the Multidisciplinary Team was initiated on 7/17/23 on resident's leaving AMA by the Chief Nursing Officer. The changes were started by the RNC. The changes were implemented effective on 7/17/2023 and training was completed on 7/20/2023. Staff will not be allowed to work until they have been fully re-educated. All new hires will be educated on AMA protocol/response prior to working the floor. The DON will ensure competency through signing of in service, verbalization of understanding and completion of returned questionnaire. A licensed nurse will notify the attending physician, on call physician, or medical director of the resident's desire to leave the Facility AMA. Nursing staff will document in the progress notes all pertinent information concerning the resident's actions, including the resident's stated reasons for his/her desire to leave the Facility. Residents with a history of wandering or who IDT have assessed to be at risk for wandering or elopement will have a photograph maintained in their medical record and Elopement/Wandering Risk Binder. Monitoring The NFA/DON/ADON/RNC will be responsible for monitoring the implementation and effectiveness of in-service on 7/15/2023. o The NFA/DON/ADON/RNC will monitor/review all residents with wandergaurds for placement and functioning daily x4 weeks, then weekly thereafter and report any adverse finding monthly during QAPI. o DON/ADON will conduct a daily audit of wander/elopement assessment x4 weeks, then weekly thereafter and report any adverse findings monthly during QAPI. o Residents will be monitored by staff every shift for any exit seeking behaviors. Any changes will be reported to the DON and ADON immediately for appropriate action. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 7/15/2023 and conducted an Ad HOC QAPI regarding the resident who left AMA and the policy and procedure. The Medical Director was notified about the IJ on 7/20/2023, the POR was reviewed and accepted by medical director. Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, NFA, DON, and social services director to review the plan of removal on 7/20/2023. Who is responsible for implementation of process? The DON and NFA will be responsible for implementation of New Process. The New Process/ system was started on 7/17/2023. On 07/21/23 the investigator began monitoring if the facility implemented their plan or removal sufficiently to remove the IJ by: Observation of all residents (total 19) identified as an elopement risk, appropriate placement of WanderGuard to left or right lower extremity and worked appropriately as evidenced by alarm sounding when resident was within approximately 30 feet of the exit door. Interviews conducted with nursing staff scheduled 6a - 2p and 2p - 10p shift on 07/21/23 [CNA D, CNA E, CNA F, LVN B, RN K, LVN L, CMA J, CMA M, CMA N, CNA V, CNA P, CNA O, and MDS] indicated they participated in an in-service training about elopement risk residents, WanderGuards, ANE, AMA process, gate, and door security. Licensed nurses summarized the topic of discussion as policy and procedure for elopement and AMA, steps of procedure, evaluating elopement risk, and building security. identifying, assessing, and monitoring wounds clinical protocol. The CNAs, CMAs, and non-nursing staff [RECPST, MR-CS, BOM] summarized the topic of training in their own words knowing and monitoring elopement risk residents, door and gate code security, and reporting ANE if suspected. Record review of in-services conducted by the DON titled AMA and Elopement Risk Residents/WanderGuard (beginning 07/17/23); and ANE, AMA Policy & Process, and Gate Security (beginning 07/20/23) reflected staff signatures across all shifts and various departments - nursing, housekeeping, dietary, kitchen and therapy, including the RECPST, MR-CS, BOM, and SW participated in the in-service. Review of Post-tests of the AMA Process for CNAs and non-nursing AMA questionnaires dated 07/20/23 revealed passing scores by staff completed. An IJ was identified on 07/20/23. The IJ template was provided to the facility on [DATE] at 4:25 PM. The facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on interview and record review, the facility failed to ensure appropriate discharge information was documented in the medical record by the physician for one (Resident #1) of five residents reviewed for discharges. The facility failed to ensure documentaion was made by the physician for the basis of Resident #1's discharge and/or the specific resident needs that could not be met by the facility. This failure could place residents at risk of being discharged without a safe and effective transition of care, an accurate reason for discharge and inaccurate information communicated to the receiving health care institution or provider. Findings included: Record review of Resident #1's undated admission record revealed he was a [AGE] year-old male with a current admitted [DATE] and a discharge date of [DATE]. The resident's MDS assessment dated [DATE] reflected diagnoses included anxiety disorder, depression, Alzheimer's disease, non-Alzheimer's dementia, and post-traumatic stress disorder. Review of Resident #1's 30-day discharge notification dated 05/22/23 revealed the reason for the discharge was the facility had determined the resident was a danger to himself and to other residents. Review of Resident #1's progress notes dated 05/22/23 revealed the resident was combative with staff and had barricaded himself in the therapy office on 05/22/23. The resident was placed on 1:1 monitoring and subsequently orders were received to transfer Resident #1 to the hospital on 05/22/23. Progress notes dated 05/22/23 reflected Resident #1 was transferred to the hospital on 05/22/23. Review of Resident #1's psychiatric notes dated 05/22/23 revealed services were being terminated due to Resident #1 being transferred out of the facility due to ongoing aggression. The last date of service was 04/28/23 and services provided were psychiatric and medication evaluation. Th notes reflected the resident was not considered to be at risk of harm to self or others at the time services were terminated on 05/22/23. Further review of Resident #1' clinical records revealed there was no physician's documentation related to the basis for the discharge, specific resident needs that could not be met by the facility, attempts to meet the resident's needs and/or services that would be available at the receiving facility to meet the resident's needs. Interview with the Administrator on 06/26/23 at 2:46 p.m. she stated there was no additional information or documentation related to Resident #1's discharge. Interview with Resident #1's primary physician (Physician A) on 06/26/23 at 3:51 p.m. he stated he had not participated in the decision to discharge Resident #1. He stated his understanding was that the resident was discharged to keep other residents safe. He further stated he did not fully understand what all documentation was required when a resident was discharged from the facility. Interview with the DON on 06/26/23 at 6:21 p.m. she stated she was not aware there was not physician documentation regarding Resident #1's discharge. She stated she saw the physician in the facility and assumed the physician had completed whatever documentation that was required. Interview with the Administrator on 06/26/23 at 6:26 p.m. she stated her expectations were for all required discharge documentation to be completed. She further stated she had only worked at the facility for two weeks and had no first-hand knowledge of Resident #1's discharge. Review of the facility's policy/procedure dated 06/2020 and entitled Transfer and Discharge revealed the purpose of the policy/procedure was to ensure residents were transferred and discharged from the facility in compliance with State and Federal laws and to complete, safe, and appropriate discharge planning and provide necessary information to the continuing care provider. The section entitled Documentation reflected when the facility anticipated a discharge the resident's medical record would contain written documentation from the attending physician if the resident was transferred or discharged because it was necessary for the resident's welfare and the resident's needs could not be met in the facility and/or because the safety of individuals in the facility were endangered by the resident's presence or the health of individuals in the facility would otherwise be endangered by the resident's presence.

Based on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances residents had and ensure that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued for two months (January 2023 and March 2023) of two months reviewed of resident council meeting grievances. The facility did not attempt to resolve grievances from the resident council for January 2023 and March 2023. This failure could place residents at risk with unresolved grievances and unmet care needs. Findings included: Review of the Resident Council meeting minutes for 01/26/23 reflected concerns/grievances related to: Nursing: All shifts- Not getting medication time, [resident] would like ot be moved because roommate is naked all the time. CNA's 6/2: Not changing residents, bad odor on hall CNAs 2/10: Not changing resident, bad odor on hall CNAs 10/6: BLANK Dietary: Residents not getting their health shake HK: [Resident] stated HK is not cleaning, staff telling residents they will be back, but do not return, room not being clean, waited for four day, President stated his room was not cleaned for three days. Medication Aides: Not getting medication on time BOM: When they need change he will tell them to come back and when they go back, it is the same thing. Administrator: Need better tables for the dining room Diff resident concerns during mtg: [Resident] needs Heath shake will all meals [Resident] have to chase down 1st and 2nd shifts for pain cream [Resident] ask for a pull, CNA refusing [Resident] coffee is not being served on time at 630A Residents needs bibs for eating time Dietary has an attitude when residents are asking for anything out of the kitchen Food is cold when served Large shower room has BM on floor and is not being cleaned by CNAs of housekeeping No tissues Residents wandering into other residents' rooms [resident] is complaining loud noises from their neighbor CNAs are not answering the call lights on time Too much bad language in the building Leaving residents in the dining room unattended where they might fall There was no resident council meeting documentation for February 2023 provided to the surveyor. Review of the Resident Council meeting minutes for 03/23/23 reflected concerns/grievances related to: Nursing dept short staffed Weekend staff awful, no help, they say it is a ghost town [Resident] says she is not getting regular diet Housekeeping not cleaning bathrooms Laundry-residents not getting clothes back right Clean up in the dark Not cleaning bathroom properly Not moping the room Do not clean window The man in housekeeping is putting the towels in the toilet rather than cleaning the sink Room should be clean everyday Young lady very disrespectful Nurses station phone for residents needs to be fixed. Review of the facility grievances for January 2023, February 2023, March 2023, and April 2023 revealed no grievances related to the resident council meeting concerns. An interview with Resident #2 on 04/12/23 at 3:20 PM revealed she was the vice president of the resident council and they did not know (as a resident council group) what the facility did after the council's concerns were documented. Resident #2 said she tried to follow up with the ADM, but he would just say whatever to make her quiet. She said the previous administrator used to come and let the resident council know what was done to address their concerns and she would have a copy of the resolution and the facility would have a copy. Resident #2 stated, Now, we don't hear nothing. An interview with the ADM on 04/12/23 at 5:20 PM revealed for resident council meeting minutes, For resident council meeting minutes, the typical process for resolution is the department heads talk to them if they were mentioned. In the event of something vague, we tell (resident council) president and let them know what we are doing. Best of my knowledge it is not in writing. Next week starting it will be. The ADM said because he was relatively new, the resident council was not on his radar. And the plan going forward was for him to have the resident council minutes brought to him, then he would disseminate them to the social worker, individual grievance forms would be made and then the resolution would be documented and discussed with the resident council, because you are supposed to go over the previous last months' minutes. A request was made to ADM for a policy on grievances on 04/12/23, but grievance policy was not provided prior to exit.

Based on observation, interview and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two (Residents #1 and #2) of six residents reviewed for activities. The facility did not consistently provide activities to Residents #1 and #2 over the course of two days, including the posted activities on the activity calendar. These failures could result in the residents becoming apathetic (marked indifference to the environment), isolated from others, having a depressed mood, boredom, loneliness, and a decreased quality of life. Findings included: Review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year old female who admitted to the facility on [DATE]. Her active diagnoses included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), schizoaffective disorder (a mental health problem where you experience psychosis as well as mood symptoms) and aphasia (loss of ability to understand or express speech, caused by brain damage). She had no speech, was usually understood and she usually understood others. Resident #1's BIMS score was not assessed due to her not being understood per the assessment. The staff assessment for mental status reflected Resident #1 had long and short-term memory problems but was able to recall the location of her own room. She had severely impaired cognitive skills for decision making. Resident #1 had no signs or symptoms of delirium, no mood issues, no indicators of psychosis, no behaviors, and no rejection of care or wandering. Resident #1 required supervision (oversight, encouragement or cueing) with physical assistance of one staff when she walked and moved about the facility and extensive physical assistance of one staff for all her ADLs. Resident #1 had range of motion impairment on one side of her upper extremities and did not require a mobility device to ambulate. Resident #1 was frequently incontinent of urine and always incontinent of bowel. Review of Resident #1's admission MDS assessment dated [DATE] reflected she was unable to be interviewed for daily preferences. However, the staff assessment for Resident #1's daily and activity preferences were caring for personal belongings, receiving a shower, snacks between meals, family or significant other involvement in car discussions, listening to music, doing things with groups of people and participating in favorite activities. Review of Resident #1's care plan dated (not dated) reflected she was an elopement risk/wandered as evidenced by a history of attempts to leave the facility unattended. Interventions were to distract her by offering pleasant diversions, structured activities, food, conversation, television and books. Resident #1's care plan also reflected that she was dependent on staff for activities, cognitive stimulation, social interactions related to cognitive deficits and physical limitations. Interventions included, Assure that the activities [Resident #1] is attending are: Compatible with physical and mental capabilities; Compatible with known interests and preferences; Adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation); Compatible with individual needs and abilities; and age appropriate. Review of Resident #1's Activity Assessment reflected it was completed on [DATE] and at that time, she was the one who was interviewed about her preferences, not her family. The assessment revealed she was homeless prior to admission to the facility, liked dogs and was Catholic. Then the assessment was not completed due to the assessor indicating Resident #1 had unclear speech. As a result, she was not assessed for her preferred activities or asked what activities were most important to her. There was no updated activity assessment after [DATE] with her family to gain a better sense of what Resident #1's interests were. An interview with Resident #1's family member on [DATE] at 10:02 AM revealed when they go to visit her at the facility, there was an activity calendar present and the facility was supposed to be doing activities, but the family member had not seen any take place in about six months. The family member stated that no one from the facility had ever asked her what Resident #1's favorite or preferred activities were or what interested her. The family member stated that Resident #1 liked puzzles, drawing, coloring, going for walks, [NAME] music and games that were easy cognitively for her to participate in. Observation of the community posted activity calendar in the facility which was outside the entrance of the dining room on the wall on [DATE] at 10:15AM for [DATE] reflected the following for [DATE]: 10:00 AM coffee, 1:00 PM Nail care and 2:00 PM Shave/Hair Cut. An observation of Resident #1 on [DATE] at 11:36 AM revealed she was sitting in the dining room waiting for lunch. She was greeted in English and Spanish, her responses were minimal but she smiled, and said no words. An observation of the facility [DATE] from 1:00 PM through 1:30 PM revealed no activities in progress. The activity calendar reflected Nail Care activity was to be occurring. Resident #1 was observed during this time sitting at a dining room table, sitting and looking around. An observation of the facility [DATE] from 3:00 PM through 3:30 PM revealed no activities in progress. The activity calendar reflected Shave/Haircut activity was to be occurring. Resident #1 remained in the dining room during this time and was at the same table she ate lunch at earlier in the day, with two other residents, sitting with no activities. The next day, an observation of the community posted activity calendar in the facility outside the entrance of the dining room on the wall on [DATE] at 10:15AM for [DATE] reflected the two following activities for the day: 11:00 AM Nature Walk and 3:00 PM Coffee/Snacks. At 11:00 AM, the weather observed outside was nice, with sunshine and a temperature around 70 degrees. An observation of Resident #1 on [DATE] at 10:15 AM revealed she was sitting in the dining room at the same table as the day before with no activities in place. There were 15 other residents in the dining room sitting around tables as well, with no activities in progress or getting prepared to take place. According to the activity calendar, a nature walk was supposed to be taking place. No residents were observed walking with staff outside of the facility. An observation of the facility and dining room on [DATE] from 10:55 AM to 11:30 AM revealed 19 residents sitting in the dining room. No activity taking was place. Resident #1 remained sitting at a table with a couple other residents just staring off. There was a small television on the back wall with the news on low volume. Approximately 15 residents were observed outside the dining room exit door with two staff smoking. An interview with Resident #7 on [DATE] at 11:04 AM revealed she was sitting by herself at a table in the dining room. She said there had been no activities at the facility and nothing had been going on that day. An interview with Resident #8 on [DATE] at 11:06 AM revealed she was sitting by herself at a table in the dining room. She stated there was no activities so far today and the activity director had quit about a month ago and since then, there was hardly anything going on activity wise. Resident #8 she did not know what was scheduled today but nothing has happened. An observation on [DATE] at 11:18 AM revealed after investigator left the dining room and had been interviewing residents about activities, the staff began to play [NAME] music for about ,d+[DATE] minutes in the dining room prior to lunch being served. An observation on [DATE] at 2:28 PM through 3:05 PM revealed about 14 residents sitting at empty dining room tables with no activity occurring. The activity calendar reflected Coffee/Snacks at 3. Resident #1 was observed to be sitting in the same chair she was in at lunchtime. There was no staff observed in the dining, except for some kitchen staff coming and going from the kitchen. No coffee or snacks were passed out to the residents. A follow up observation on [DATE] at 3:18 PM revealed 23 residents in the dining room (including Resident #1). There remained no activity, no food, no drink, no music and no group interaction. A cart was observed inside the only nurses' station and had a pitcher with a blue drink and ice and some Rice Krispies wrapped in cellophane; however, they were not being distributed to the residents. 2. Review of Resident #2's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] and had active diagnosis which included hemiplegia, depression, schizophrenia and generalized anxiety disorder. Resident #2 had no hearing, vision or speech issues and her BIMS score was a 15, which indicated no cognitive impairment. Resident #2 had no signs of delirium, mood issues or behaviors. Resident #2 required supervision only for all ADLs, transfers and mobility and used a walker and wheelchair for ambulation. Review of Resident #2's annual MDS assessment dated [DATE] reflected during an interview about activities preferences, that the following are very important to her: Having books, newspapers and magazines to read, Listening to music, Keeping up with the news, Doing things with groups of people, Going outside to get fresh air when the weather is good, Participating in religious services or practices, Participating in her favorite activities. Review of Resident #2's care plan (not dated), reflected, [Resident #2] is at risk for loneliness, encourage participation in in-room activities. The care plan did not identify what activities Resident #2 preferred and did not elaborate on any other activities interventions. Review of the last quarterly activity assessment completed for Resident #2 was dated [DATE] and reflected she participated in all activities and was an active participant, independent and was also responsive to one-on-one activity visits. The assessment reflected Resident #2 preferred to be with people, made friends easily, enjoyed small groups and initiated conversations. Resident #2 was dependent on staff for wheelchair transport, need large print books and one on one interactions. An interview with Resident #2 on [DATE] at 3:20 PM revealed she was in her room and upset about the activities program. Resident #2 stated, All day long, we do nothing. She said the previous activity director, who everyone liked a lot, had gotten fed up and left around October/[DATE]. Resident #2 said the activity director had been coming out of her own pocket to help buy things for the residents and had a good activities program in place with a lot of activities for the residents to do. Resident #2 said since the activity director left, no one had taken her place and at first the facility management was going to promote a CNA working in the facility, but they did not have their required certification to be an activity director. Resident #2 said, We don't do nothing. We don't Bingo but a few times since she left. Resident #2 said there was supposed to be an activity calendar in every residents' room every month but the one she had was still from [DATE]. Resident #2 felt that the facility had changed the population of residents they began to admit, with more individuals coming in that had mental illness issues. Resident #2 stated, The need for activities is important because it helps keep peoples' minds stimulated. We used to have movie days with snow cones and popcorn .it's sad. Resident #2 said the previous activity director used to ask the residents what they liked in terms of games and activities, She did everything, we had fun with her. Resident #2 said that the past Christmas, for example, the Salvation Army used to come each year and provide for the resident and the activity director handled it, but the past Christmas 2022, nothing. Resident #2 said the residents in the facility get frustrated when there was nothing to do. She stated, I say it's coming, there is going to be some fighting because there is nothing to do. I tell the administrator all the time no one goes to the store for us. He keeps saying he is going to work on it, but nothing happens. Resident #2 stated that no one had ever asked her officially as an assessment what her activity preferences were, but she would like to play Jeopardy, Wheel of Fortune, Noodle Ball exercise, Bingo, President's Bingo and Black History Bingo. Resident #2 stated the previous activity director used to give residents (including herself) packets on a monthly basis that she put together that had seek and find games, current events, word/memory puzzles. When asked if she knew there was a posted nail care activity the day before, Resident #2 stated, I like to have my nails done. No, we did not get no nails done yesterday! When asked if she knew about the posted nature walk activity earlier that morning, Resident #2 responded, No. We used to go outside with the previous activity director and walk around the building, sit at the gazabo, it was nice. Observed activity calendar posted in Resident #2's room by the door revealed it was a calendar from [DATE]. 3. An interview with CNA A on [DATE] at 11:28 AM revealed she knew Resident #1 and it was her third time back at the facility but she was not like she used to be, meaning she used to interact with everything and came to activities but now she was not like her former self. CNA A said she thought Resident #1 may be depressed because before she discharged the last time, her adult child had died , and it was very difficult for her, and she cried a lot. CNA A said that she was a restorative aide at the facility as well as a CNA, and she helped out when she could with activities. CNA A stated she had just now played some [NAME] music for Resident #1 and that she loves that style of music. CNA A stated, I give them a variety (if activities) because we have such a diverse population. I am not the activity director. I think we are due to get one. I step in, they are like family, I don't want to see them with just nothing. I give 110%. An interview with the ADM on [DATE] at 5:20 PM revealed he started employment in his position in [DATE] and the activity director had left around [DATE]. The ADM stated he had interviewed at least a dozen people for the job and had offered it to three, but two of them had fake licenses and the other one decided against it once they realized the population they would be working with. The ADM said there was a hospitality aide who was making sure the activity events happened along with the central supply staff member at times and there was a calendar, however, the hospitality aide had a medical event recently that has caused her to miss work and the central supply was her relative so had been out as well. The ADM said not that the hospitality aide was not available to do activities, he was going to have to figure something out. He felt that the therapy department had helped with the larger events and parties and were a huge support. The ADM said having a population with differing mental health needs and cognitive levels could make it hard to make a useful activities calendar that covers all of them. He said for example, they could try Bingo, but there would only be about five residents who would be able to do it because it involved dexterity. When asked what could be the potential problem with no structured activities occurring in the facility, the ADM replied, I mean in theory, it could affect resident behavior, like cause boredom that could exacerbate behaviors. Interview with LVN D on [DATE] at 10:50 AM revealed the facility did not have an activity director so staff have to step up and do them with the residents. LVN D said staff were talked to by the management the night prior about how to document when they were being done. She said the hospitality aide had a medical emergency and had been off work, so therapy had been coming in and doing music with the residents. LVN D stated the potential problem of not having structured and routine activities for the residents was, What is happening now. Because out facility versus others, this is the behavior facility so part of that can be a problem when they find other things to engage in and you may start seeing more intense behaviors because they are just sitting round and fights can occur. An interview with the RD on [DATE] at 11:44 AM revealed he had thought about the issues related to activities that had been discussed on [DATE] and put an action plan in place going forward. The RD said the person who the facility was going to hired ended up having a fake activity director certification. He said the facility had now identified a CNA who had been helping with activities and would promote her to the activities assistant officially. The RD stated that activities were happening, but they were going to revamp the program and the activity consultant for all the campuses had created a new activity calendar for the facility which was posted. He said there was also new pilot program related to activities the company had been working on that they were going to try out for the first time in the building and it targeted specific behaviors. He said the new activity assistant was trained don it and the activity consultant would be following up on it since she was certified. An interview with CNA B on [DATE] at 1:35 PM revealed the hospitality aide did activities with the residents but was not present today ([DATE]). She said when there were activities, there would usually be music playing and CNA B would dance and sing with the resident, but she had never been asked directly to do activities. CNA B said Resident #1 liked to be around other residents, especially her roommate. An interview with CNA C on [DATE] at 1:53 PM revealed the facility only did activities when State was in the building, It's part of a show and a front for State to make it look like they are doing something. CNA C stated there was a hospitality aide who did transportation for residents and she had seen her and central supply staff so a St. Patrick's Day party and a New Year's party, But it is sporadic, not every day, like for holidays or State visits. I say look at them performing for the State. They will keep it up for a couple of days, then it goes back to the same. CNA C stated activities were important because it would help occupy the residents and make them feel like a part of something. 4. Review of the facility's policy titled, Activities Program (not dated), reflected, Purpose: To encourage residents to participate in activities to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable the resident to maintain the highest attainable social, physical and emotional functioning .Policy: I. The Activity program may address areas including, but not limited to: A. Social activities; B. Indoor and outdoor activities; C. Activities away from the Facility; D. Religious Programs, E. Opportunity for resident involvement for planning activities; F. Creative activities; G. Educational activities; and H. Exercise activities; II. A variety of activities should be offered on a daily basis, which includes weekends and evenings, III. Activities are developed for individual, small group, and large group participation; VI. Progress Notes-A. No less than quarterly, the Director of Activities or his or her designees will make a progress note in the Facility's electronic health record (EHR) as part of the resident's health record that includes the level of participation, perceived benefit, response to interventions outlined in the Care Plan, progress made toward goal and recommendations for activities; .VII. Documentation- A. The Activity department will maintain records of each resident's participation in group, independent, and room visit involvement, Participation will be documented on a daily basis.

Based on observation, interview and record review, the facility failed to ensure the activity program was directed by a qualified professional who was licensed, registered, had qualified work experience or had completed a training course approved by the State for one (AD) of one Activity Director. The facility failed to have a qualified Activity Director. The previous Activity Director left employment six months prior and the facility did not fill the position, only having facility staff try to fill in who were not qualified or had the experience. This failure placed all residents at risk of receiving inappropriate activities. Findings included: Review of the Active Employee List on 04/11/23 did not identify the presence of an Activity Director. An observation of the community posted activity calendar in the facility which was outside the entrance of the dining room on the wall on 04/11/23 at 10:15AM for April 2023 reflected the following on 04/11/23: 10:00 AM coffee, 1:00 PM Nail care and 2:00 PM Shave/Hair Cut. An observation of the facility 04/11/23 from 1:00 PM through 1:30 PM revealed no activities in progress. The activity calendar reflected Nail Care activity was to be occurring. Resident #1 was observed during this time sitting at a dining room table, sitting and looking around. An observation of the facility 04/11/23 from 3:00 PM through 3:30 PM revealed no activities in progress. The activity calendar reflected Shave/Haircut activity was to be occurring. An observation on 04/12/2023 at time of the community posted activity calendar in the facility outside the entrance of the dining room on the wall on 04/12/23 at 10:15AM for April 2023 reflected the two following activities for the day: 11:00 AM Nature Walk and 3:00 PM Coffee/Snacks. At 11:00 AM, the weather observed outside was nice, with sunshine and a temperature around 70 degrees. An observation of the dining room on 04/12/23 at 10:15 AM revealed there were 15 residents in the dining room sitting around tables, with no activities in progress or getting prepared to take place. According to the activity calendar, a nature walk was supposed to be taking place. No residents were observed walking with staff outside of the facility. An observation of the facility and dining room on 04/12/23 from 10:55 AM to 11:30 AM revealed 19 residents sitting in the dining room. No activity taking was place. There was a small television on the back wall with the news on low volume. About 15 residents were observed outside the dining room exit door with two staff smoking. An interview with Resident #7 on 04/12/23 at 11:04 AM revealed she was sitting by herself at a table in the dining room. She said there had been no activities at the facility and nothing had been going on that day. An interview with Resident #8 on 04/12/23 at 11:06 AM revealed she was sitting by herself at a table in the dining room. She stated there was no activities so far today and the activity director had quit about a month ago and since then, there was hardly anything going on activity wise. Resident #8 she did not know what was scheduled today but nothing has happened. An observation on 04/12/23 at 2:28 PM through 3:05 PM revealed about 14 residents sitting at empty dining room tables with no activity occurring. The activity calendar reflected Coffee/Snacks at 3. Resident #1 was observed to be sitting in the same chair she was in at lunchtime. There was no staff observed in the dining, except for some kitchen staff coming and going from the kitchen. No coffee or snacks were passed out to the residents. A follow up observation on 04/12/23 at 3:18 PM revealed 23 residents in the dining room. There remained no activity, no food, no drink, no music and no group interaction. A cart was observed inside the only nurses' station and had a pitcher with a blue drink and ice and some Rice Krispies wrapped in cellophane; however, they were not being distributed to the residents. An interview with Resident #2 on 04/14/23 at 3:20 PM revealed she was in her room and upset about the activities program. Resident #2 stated, All day long, we do nothing. She said the previous activity director, who everyone liked a lot, had gotten fed up and left around October/November 2022. Resident #1 said the activity director had been coming out of her own pocket to help buy things for the residents and had a good activities program in place with a lot of activities for the residents to do. Resident #2 said since the activity director left, no one had taken her place and at first the facility management was going to promote a CNA working in the facility, but they did not have their required certification to be an activity director. Resident #2 said, We don't do nothing. We don't Bingo but a few times since she left. Resident #2 said there was supposed to be an activity calendar in every residents' room every month but the one she had was still from January 2023. Resident #2 felt that the facility had changed the population of residents they began to admit, with more individuals coming in that had mental illness issues. Resident #2 stated, The need for activities is important because it helps keep peoples' minds stimulated. We used to have movie days with snow cones and popcorn .it's sad. Resident #2 said the previous activity director used to ask the residents what they liked in terms of games and activities, She did everything, we had fun with her. Resident #2 said that the past Christmas, for example, the Salvation Army used to come each year and provide for the resident and the activity director handled it, but the past Christmas 2022, nothing. Resident #2 said the residents in the facility get frustrated when there was nothing to do. She stated, I say it's coming, there is going to be some fighting because there is nothing to do. I tell the administrator all the time no one goes to the store for is. He keeps saying he is going to work on it, but nothing happens. Resident #2 stated that no one had ever asked her officially as an assessment what her activity preferences were, but she would like to play Jeopardy, Wheel of Fortune, Noodle Ball exercise, Bingo, President's Bingo and Black History Bingo. Resident #2 stated the previous activity director used to give residents (including herself) packets on a monthly basis that she put together that had seek and find games, current events, word/memory puzzles. When asked if she knew there was a posted nail care activity the day before, Resident #2 stated, I like to have my nails done. No, we did not get no nails done yesterday! When asked if she knew about the posted nature walk activity earlier that morning, Resident #2 responded, No. We used to go outside with the previous activity director and walk around the building, sit at the gazabo, it was nice. Observed activity calendar posted in Resident #2's room by the door on 04/12/23 revealed it was a calendar from January 2023. An interview with the ADM on 04/12/23 at 5:20 PM revealed he started employment in his position in November 2022 and the activity director had left around October 2022. The ADM stated he had interviewed at least a dozen people for the job and had offered it to three, but two of them had fake licenses and the other one decided against it once they realized the population they would be working with. The ADM said there was a hospitality aide who was making sure the activity events happened along with the central supply staff member at times and there was a calendar, however, the hospitality aide had a medical event recently that has caused her to miss work and the central supply was her relative so had been out as well. The ADM said not that the hospitality aide was not available to do activities, he was going to have to figure something out. He felt that the therapy department had helped with the larger events and parties and were a huge support. The ADM said having a population with differing mental health needs and cognitive levels could make it hard to make a useful activities calendar that covers all of them. He said for example, they could try Bingo, but there would only be about five residents who would be able to do it because it involved dexterity. When asked what could be the potential problem with no structured activities occurring in the facility, the ADM replied, I mean in theory, it could affect resident behavior, like cause boredom that could exacerbate behaviors. Interview with LVN D on 04/13/23 at 10:50 AM revealed the facility did not have an activity director so staff have to step up and do them with the residents. LVN D said staff were talked to by the management the night prior about how to document when they were being done. She said the hospitality aide had a medical emergency and had been off work, so therapy had been coming in and doing music with the residents. LVN D stated the potential problem of not having structured and routine activities for the residents was, What is happening now. Because out facility versus others, this is the behavior facility so part of that can be a problem when they find other things to engage in and you may start seeing more intense behaviors because they are just sitting round and fights can occur. An interview with the RD on 04/13/23 at 11:44 AM revealed he had thought about the issues related to activities that had been discussed on 04/12/23 and put an action plan in place going forward. The RD said the person who the facility was going to hired ended up having a fake activity director certification. He said the facility had now identified a CNA who had been helping with activities and would promote her to the activities assistant officially. The RD stated that activities were happening, but they were going to revamp the program and the activity consultant for all the campuses had created a new activity calendar for the facility which was posted. He said there was also new pilot program related to activities the company had been working on that they were going to try out for the first time in the building and it targeted specific behaviors. He said the new activity assistant was trained on it and the activity consultant would be following up on it since she was certified. An interview with CNA B on 04/13/23 at 1:35 PM revealed the hospitality aide did activities with the residents but was not present today (04/13/23). She said when there were activities, there would usually be music playing and CNA B would dance and sing with the residents, but she had never been asked directly to do activities. An interview with CNA C on 04/13/23 at 1:53 PM revealed the facility only did activities when State was in the building, It's part of a show and a front for State to make it look like they are doing something. CNA C stated there was a hospitality aide who did transportation for residents and she had seen her and central supply staff so a St. Patrick's Day party and a New Year's party, But it is sporadic, not every day, like for holidays or State visits. I say look at them performing for the State. They will keep it up for a couple of days, then it goes back to the same. CNA C stated activities were important because it would help occupy the residents and make them feel like a part of something. Review of the facility's policy titled, Activities Program (not dated), reflected, Purpose: To encourage residents to participate in activities to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable the resident to maintain the highest attainable social, physical and emotional functioning. Review of the facility's job description for the Activity Director (not dated) reflected, Responsible for planning, organizing, and implementing a program of activity/leisure pursuits designed to meet the social spiritual, intellectual, emotional, education and physical needs and interests of residents in accordance with the comprehensive resident care plan; Principal Responsibilities: Responsible for developing and implementing comprehensive therapeutic recreation programs and services to meet the psychosocial, physical, and cognitive needs or residents; .Completes a monthly calendar of available activities/recreational programs and posts it in the center; Identified activity preferences and current activity pursuits from interviews and clinical record, Charts individual resident's attendance and participation in group, individual and on-on-one recreational pursuits daily, Plans community activities; .Qualifications: Accreditation as a Certified Activity Director, Completion of a state approved Activity Director training course; Bachelor's degree in recreation therapy or related area; One year experience as an Activity Director in long term care; Two years of experience conducting social/recreational programs within the past five years, one which was full-time in a resident activities program in a health care setting.

Based on observation, interview, and record review, the facility failed to provide a therapeutic diet that takes into account the resident's clinical condition, and preferences, when there is a nutritional indication foods of choice ordered for a [AGE] year-old Korean female resident's therapeutic diet needs to ensure the resident maintained acceptable parameters of nutritional status when there was a nutritional problem for 1 of 6 residents (Resident #43) reviewed for unplanned weight loss. 1. The facility failed to implement the dieticians' and Speech Language Pathologist recommendations which resulted in severe weight loss 18.5%for Resident #43. 2. The facility failed to communicate with the physician the weight loss recommendations made by the dietitian. These failures resulted in an Immediate Jeopardy (IJ) situation on 09/21/2022. While the IJ was removed on 09/23/2022, the facility remained out of compliance at a severity level reflects no actual harm with a potential for minimal harm due to the need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not maintaining their nutritional needs. The findings included: Review of Resident #43's face sheet dated 09/22/2022 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #43's Quarterly MDS assessment dated [DATE] reflected the resident was assessed to have a BIMS score of 5, which indicated severe cognitive impairment. The MDS Nutritional status segment revealed the Loss of 5% or more in the last month or loss of 10% or more in last 6 months and answer, Yes, not on prescribed weight-loss regimen. Review of Resident #43's Comprehensive Care Plan reflected a problem with the start date of 03/14/2022 reflected a nutritional problem related to her BMI is too low and required a goal that resident will eat at least (50) % of her meals. Approaches included were, monitor/document/report to physician significant weight loss: 3 lbs. in 1 week, >5% in one month, >7.5% in 3 months, >10% in 6 months. Provide, serve diet as ordered. Monitor intake and record q meal. Further review of Resident #43's care plan revealed a problem with significant unplanned, unexpected weight loss (7.9%) 90 days food intake. The approach read: add fortified foods to all meals and 2 calorie ounce supplement with medication pass twice a day. The plan read to alert nurse if Resident #43 was not consuming on a routine basis. Review of Resident #43's Consolidated Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Regular diet, Regular texture, thin consistency; Diet customized for individual needs dated 08/12/2022. -Double Desserts for lunch and supper. Add Frozen Nutritional Treat to lunch and supper dated 08/12/2022. -two times a day 90 ml House Supplement for additional calories/protein dated 08/22/2022. -Offer substitute if resident eats <50% dated 03/04/2022. -Resident is at risk for malnutrition related to new admission and Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Dietician to consult as needed, per orders dated 03/04/2022. Record review of Resident #43's electronic medical record revealed only monthly weights were being recorded, and the facility was not following the order for weekly weights suggested for the resident. Record review of a nursing evaluation dated 03/05/2022 revealed a nursing skilled evaluation of Resident #43's who was admitted on [DATE]. The note read, The resident began receiving Skilled Nursing Services with skilled Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Skilled care being provided: Management and Evaluation of Patient Care Plan; Observation and Assessment of Patient; Vital Signs: Blood Pressure 128/82, Temperature 97.7, Respirations 18, and Weight 163.5 lbs. Scale: Standing. Record review of a Nutritional Note dated 05/13/2022, written by the Registered Dietician revealed the following, Text: Resident #43 has experienced a significant weight loss decline x 30 days (-6.0%) and the Registered Dietician notes reflected further, Resident #43's dietician' notes reflected the following: -May wt.: 157 lbs. - April wt.: 167 lbs. Further review of the Registered Dietician's notes dated 05/13/2022 5/13/22 dietician's note revealed Resident #43 was eating >75, Interventions currently in place: Regular texture diet - eating majority of the time >75% per ADL documentation. Resident prefers Korean type foods. Likes Sweets. No family to bring her familiar foods. Korean recipes for typical foods will be provided to kitchen that focus on rice and vegetables and protein. Add two desserts to lunch and supper. Record review of a Nutritional note dated 06/15/2022, written by the Registered Dietician revealed she wrote, Interventions currently in place: Regular texture diet - eating majority of the time >75% per ADL documentation. Resident prefers Korean type foods. Likes Sweets. No family to bring her familiar foods. Korean recipes for typical foods will be provided to kitchen that focus on rice and vegetables and protein. Add two desserts to lunch and supper. The Registered Dietician notes added the following information, significant weight loss decline x 90 days (-7.9%). June wt. 151 lbs. BMI 28.5 May wt.: 157 lbs. April wt.: 167 lbs. Further review of the Registered Dietician's 06/15/2022 notes revealed Resident #43 was eating >75% the majority of the time, still losing weight, Interventions currently in place: Regular texture diet - eating majority of the time >75% per ADL documentation. Resident prefers Korean type foods. Likes Sweets. No family to bring her familiar foods. SLP is known to bring the resident favorite dishes that contain cabbage. Korean recipes for typical foods were provided to kitchen that focus on rice and vegetables and protein. Resident does like sweets. Add two desserts to lunch and supper. Add Frozen Nutritional Treat to Lunch and Supper. Continue to monitor for signs, changes and monitor weekly weights. Record review of a nutritional note dated 07/07/2022, written by the Registered Dietician revealed, Resident #43 has experienced a significant weight loss decline x 90 days (-11.4%). -July wt.: 148 lbs. - June wt. 151 lbs. -April wt.: 167 lbs. Further review of the Registered Dietician's notes read 06/15/2022, Interventions currently in place: Regular texture diet - eating majority of the time >50% per ADL documentation. Resident prefers Korean type foods. Likes Sweets. No family to bring her familiar foods. SLP is known to bring the resident favorite dishes that contain cabbage. Korean recipes for typical foods were provided to kitchen that focus on rice and vegetables and protein. Resident does like sweets. The Registered Dietician listed the following as a plan for weight loss: -Receives two desserts to lunch and supper. -House 2.0 Supplement 90 ml BID added 6/24/22. -Resident may benefit from IV Vitamin Therapy r/t wt. loss. -Consider adding [MEDICATION(S)] for appetite stimulation x 45 days. -Add MVI w/ Minerals daily. -Add Frozen Nutritional Treat to Lunch and Supper. -Continue to monitor for sig changes and monitor weekly weights. Record review of a nursing note dated 07/14/2022 read order for infusion by physician, Alert Charting, late: Resident has been cleared for IV hydration and vitamin therapy by the Facility's Physician. Current meds were reviewed, if any, and all contraindications have been found. Reviewed resident allergies. Order verified. Assessment completed. Resident prepared for IV vitamin infusion. Site prepared per protocol 22g x 1 attempt. IV site secured per protocol no redness or signs of infiltration. Infusion for wellness r/t multiple comorbidities and support immune function and promote nutrition. The physicians order read as follows, Order: 0.9% Normal Saline 250mL, and further notes revealed, Infusion started @ 250mL/hour on dial a flow. Patient in no distress, IV site without redness, [CONDITION(S)], signs of infiltration. Patient comfortable and denies needs. 1830 Infusion complete. Resident tolerated infusion without difficulty or complication. IV discontinued and gauze applied to site. Report of infusion completion. Record review of the Registered Dietician's note dated 07/15/2022 read as follows, Nutritional Note: Resident #43 has a significant weight decline x 90 days: from 167 lbs. to 148 lbs. She is refusing to eat the food provided and all attempts to provide her cultural foods, yet the ADL documentation notes occasional >50%. Further notes revealed the recommended interventions as follows, -IV therapy for nutritional support was given 07/14/22. - It was discussed that monies needs to be obtained to get local food that perhaps the resident will eat. - Will continue to monitor and try to find foods she will eat. Record review of the Registered Dietician's note dated 8/12/2022 reads as follows, Nutritional Note Resident #43 has a significant weight loss decline x 90 days (-8.9%). -August wt.: 143 lbs. -May wt.: 157 lbs. Further review of Registered Dietician's notes revealed, She is refusing to eat the food provided and all attempts to provide her cultural foods, yet the ADL documentation notes occasional >50%. The Registered Dietician's noted that these interventions were in place: A Regular Diet was being provided, and double Desserts for lunch and supper would be provided. The Registered Dietician's notes went on to add, Disposable utensils only on meal trays. Add Frozen Nutritional Treat to lunch and supper. Record review of the Registered Dietician's note dated 09/17/2022 read as follows days Nutritional Note: Resident #43 has a significant weight decline x 90 days (-7.9%). -[DATE] lbs. Re-weigh 137 lbs. -June 151 lbs. The Registered Dietician's notes stated that she estimated nutrient needs for Resident #43 were the following: -1575-1890 kcal -62-76 gm Protein -575-1890 ml The Registered Dietician continued, her notes stating, She is occasionally refusing to eat the food provided. Attempts to provide her Korean foods are being made. ADL documentation indicates some improvement in po intake. The Registered Dietician's noted that these interventions were in place: Regular Diet was being provided, and she said, Efforts are made to purchase Korean foods locally. SLP notes that she will eat this better in bowls. This has been added to tray ticket. Resident enjoys sweets -Double Desserts for lunch and supper. Disposable utensils only on meal trays. Frozen Nutritional Treat to lunch and supper. House Supplement 90 ml BID. MVI w/ Minerals daily. The Registered Dietician wrote goals for Resident #43, she said the resident would eat >50% of meals/desserts/supplements to maintain current weight of 137 lbs. The Registered dietician ordered to have Resident #43 weighed weekly for 3 weeks, and wrote further, It was discussed that monies needs to be obtained to get local food that perhaps the resident will eat. FSM will look into this. Will continue to monitor and try to find foods she will eat. Weekly weight to be monitored x 4 weeks. Review of the Registered Dieticians intervention notes contradicted the times she wanted Resident #43's weights to be checked, she first wrote to check them weekly for 3 weeks and at the end of her note, she wrote to check the residents weighed weekly for 4 weeks. Record review of Registered Dietician's email sent to Dietary Manager dated 05/14/2022 revealed she stated that the email was sent to share Korean diet suggestions. The email read, Korean Americans from South Korea: some foods include: -Rice, noodles, leafy vegetables, kimchi, small fish, grilled beef, [NAME] and vegetable fats Record review of Resident #43's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 2.0 Supplement two times a day= 90 milliliters ordered to start on 06/24/2022, the resident is recorded to have drunk the supplement on the evening of 06/24/2022, and then consecutively 06/25/2022 through 06/30/2022. Resident #43 was recorded by facility staff to have consumed the supplement for the entire month of July 2022, and then in August of 2022, Resident #43 was recorded to have not consumed the supplement for 11 days and was recorded to drink the supplement for the remainder of the month of August 2022. Resident #43's electronic records revealed there had been loggings of 100 % consumption of the supplements up until the beginning of the state survey when it was discovered by surveyor observation that the resident was not intaking the supplement as stated by nursing staff and was found to be left unopened on Resident #43's breakfast and lunch trays on 09/19/2022, 09/20/2022 and 09/23/2022. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 05/18/2022 for Resident #43's health plan read, Patient consumes 25% of meals and snacks. The SLP wrote Resident #43 was referred due to decline in functional activity tolerance during oral intake and weight loss. The SLP's clinical review for weight loss was noted for significant weight loss. The SLP continued to write Resident #43 required maximum encouragement for adequate meal intake and consumed only 25% of the meal. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 05/19/2022 for Resident #43's revealed, the resident had been assessed for meal consumption during breakfast and lunch, and Resident #43 at 0% of her meals. The SLP noted that she tried to offer supplements and Resident #43 refused them. the SLP wrote that Resident #43 requested Korean food and she inquired what the resident likes, and dislikes were, and Resident #43 said she would eat salads, the SLP wrote that she would get the kitchen to provide salad, stated, Discussed likes and dislikes and patient stated she would eat salads, kitchen to provide salad tomorrow for lunch meal. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 05/20/2022 for Resident #43's read, SLP provided ice cream, coke and salad and patient consumed 50% of ice cream and hard-boiled eggs out of the salad. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 05/25/2022 for Resident #43 revealed she wrote, SLP will provide Korean meal for patient to increase meal intake on 05/26/2022 as requested by patient. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 05/26/2022 for Resident #43 revealed, the SLP wrote, SLP provided Korean food and maximum verbal cues and then wrote, Patient consumed 25% and stated she would eat the rest later but appeared to really enjoy the food. Returned to the room later and patient consumed 75% of food. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 05/31/2022 for Resident #43 revealed she wrote, Offered patient fruit and supplement and patient ate 100%. Further comments written by SLP were, the kitchen had provided Korean type foods the patient liked such as broth, hard boiled eggs, rice, and vegetables for lunch meals. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 06/06/2022 for Resident #43 read the SLP provided Korean food, Kimchi chicken, and the resident ate 50%s of the meal. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 06/08/2022 for Resident #43 revealed the SLP provided Kimchi chicken to assist with meeting nutritional needs, and the resident consumed the meal. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 06/09/2022 for Resident #43 read, Patient requested Kimchi and SLP provided a bowl of patients preference and patient consumed 100%. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 06/24/2022 for Resident #43 revealed she noted, Consumption of food provided by SLP (Korean type) accepted and 100% intake with set up only, the note meaning that the SLP provided the resident with her favorite food, and she ate all of it, and did not need coaxing. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 08/24/2022 for Resident #43 stated the resident had poor intake of meals and significant weight loss. The plan stated Resident #43 had previously receive therapy for service dated 05/18/2022 through 06/27/2022 and stated that the resident had made steady progress with stated goals and increasing her meal intake to 80 % of meals and snacks. The initial assessment for this date noted the resident had a significant weight loss. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 08/24/2022 for Resident #43 read, Patient presents with 0% intake of lunch meal. Patient provided with culturally sensitive food that the patient prefers, and patient consumed 50% of food provided. The SLP commented the following, patient and caregivers educated on foods the patient prefers to increase intake and maintain weight. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 08/26/2022 for Resident #43 read the SLP attempted to coax the resident to eat the lunch tray provided by the kitchen, and Resident #43 refused to eat any of the items on the tray, the SLP brought in an alternate meal and the resident ate 25% of the items on the tray. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 08/30/2022 for Resident #43 read the resident did not eat any of her lunch tray, so the SLP brought in an alternate meal of rice and vegetables and the resident ate 75% of the meal. The SLP wrote Resident #43 requires maximum assist for feeding and intake of meals. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 09/05/2022 for Resident #43 revealed the SLP had noted that she educated the Dietary Manager on the patient's intake of fresh fruits, and that she liked fruit and when provided with the fruit, she would eat 100% of the item. Observation on 09/19/2022 at 10:35 a.m., Resident #43 was in her room in bed, and stated not liking the food. CNA Q was removing Resident #43's breakfast tray, the only food item on the tray was a bowl of cereal and two boiled eggs, an untouched glass of milk, no other food items or supplements were observed on the tray. During an interview on 09/19/2022 at 10:40 am, CNA Q revealed that Resident #43 was a very picky eater and regularly refused meals, breakfast, lunch, and dinner. She denied trying to coax the resident to eat or offering an alternate because the resident did not ask for them. During an interview on 09/19/2022 at 1:30 PM, LVN Z revealed she was familiar of the resident and the problems with eating her meals. She said that it was important to check a Resident meal trays against meal tickets and sending back to the kitchen for correction if not matching and documenting accurate meals for each resident with weight loss problems. A staff member should be informing a charge nurse, dietician, or kitchen staff of a change in condition for residents not eating meals. Interview on 09/19/2022 at 10:45 AM, CNA R revealed she worked the 6:00 am to 2:00 PM shift and worked the 300 halls, she cared of Resident #43 and knew that she did not like the food served by the kitchen and said that SLP came to help her eat. She denied providing Resident #43 with an alternate meal, she said thought the SLP was taking care of the alternant meal because she saw her brining in foods from a Korean place. During an interview on 09/19/2022 at 11:30 AM with Registered Dietician, she was asked about the significant weight loss recorded on Resident #43's medical record and she replied that the resident was a very picky eater and did not like much of the food the kitchen would make. The Registered Dietician revealed that because the resident was Korean, she spoke to the Dietary Manager about what type of foods could be provided, Korean meals, and they had the idea to provide rice, noodles, and vegetables. The Dietician said the Dietary manager had gone to the grocery store to buy Korean frozen foods and rice and vegetables and they kept a box in kitchen specifically for Resident #43. This intervention came about after discussing Resident #43's weight loss during a weekly interdisciplinary meeting for residents with significant weight loss. During an interview on 09/19/2022 at 12:00 PM with Dietary Manager, she was asked about the location of Resident #43's personal box of preferred foods, she immediately guided the surveyor to the pantry and frantically looked for the box but was unable to locate it. The Dietary Manager then turned to seek help from Cook G to find the foods, Cook G said that she had no idea where the box was. The Dietary Manager said she had been on vacation a week prior and that before she left, the box was in the pantry, and revealed the last time she bought food for Resident #43 was a month ago in August. She said the administrator gave her the facility credit card and she went to local grocery store and bought rice, noodles, and vegetables as well as frozen Korean foods. The Dietary Manager said these types of foods were not available to order trough their current food distributer, and that was the reason she had to make the trip to the grocery store to buy the special items. Record review of receipt from Walmart dated 08/15/2022 revealed a purchase totaling $35.20 of the following items: -Bags of rice -ginger spice -and sweet chili Record review of the facility Petty Cas Reconciliation invoice dated 08/19/2022 revealed the amount of $35.20 that was paid to the grocery store was for, Food for Asian Resident that has had a weight loss. There were no other receipts provided during this investigation. During an interview on 09/20/2022 at 8:45 AM, the Director of Rehab (DOR), revealed the Restorative Aid does weights as ordered per the Registered Dietician, and that the Registered Dietician keeps up with weight loss on a weekly basis. She said that once a month, the Registered Dietician provides her with the monthly weights on residents who are flagged for weight loss, and she said, I conduct a monthly weight loss report, and get the weights off the electronic medical record where the Registered Dietician inputs the monthly percentages. She was asked why the electronic medical record only showed monthly weights, and she said the weekly weights are supposed to be in the system, but it is up to the Registered Dietician to input the weights. The DOR said that the interventions for treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the Registered Dietician is part of an Interdisciplinary team meeting every Thursday, and the team consist of Nursing, dietary and therapy and they come together weekly to discuss the interventions for weight loss, how to benefit the resident's intake of meals, and the interventions include new cues to initiate a person to eat, once the treatment is completed and hopefully the resident's weight increases, they are discharged from therapy. Sometimes even if the resident does not improve, they are discharged due to insurance problems. But it they do improve, the treatments are completed, and all interventions are discussed at meeting and nursing takes over after discharge to continue to monitor the resident for changes in condition. The DOR discussed Resident #43's case saying, Korean type foods were discussed with the dietary manager, Registered Dietician and the ADON, but with this particular resident, we found that her preferences changed, and it was a day-to-day task with her of finding out what she will like to eat, like today, I brought in Korean food, kimchee, hopefully she will like it. The DOR was asked how many times the therapy department was bringing in the Korean foods, she said once or twice a month, brought in by both herself and the SLP. During an interview on 09/22/22 at 12:07 PM, the Registered Dietician revealed she had been employed for 2 years and worked for campus. She was asked about the purpose for the interdisciplinary team meetings, she said that it was developed by her approximately in December 2022, she said because they had lost their DON, and said the team consisted of social work staff member, the ADON, the food service manager, and the minimal data set nurse. She said that the [NAME] president of nutrition gets an update on weight loss residents and the interventions discussed in the meeting. The Registered dietician said she inputs the orders for the interventions into the electronic medical record and she is in charge of notifying the physician of any new changes in condition and new interventions. The Registered Dietician said that the restorative aid is in charge of weighing people weekly, and that after the weekly weight loss meeting, she is provided with a list of residents every Monday that she must weigh weekly for 4 weeks and then monthly, a protocol the Registered Dietician said she put into place. The Registered Dietician said that the weekly weight the restorative aid records on her document goes into an Excel spread sheet that she generated and said she only inputs monthly weights into the facility electronic medical record and she was asked the purpose of not inputting the weekly weights into the facility electronic medical record, and she said, if I put in the weekly weights, the percentages would be skewed. The Registered Dietician was interviewed regarding the type of education she received after the incident was discovered, she said the [NAME] President of Nutrition discussed that she get more information from the families to find the residents likes and dislikes, and they discussed getting Resident #43 a snack when she is up getting and handing her finger foods. Also discussed was serving Resident #43 first, purchasing cultural foods, seasonings, and making out menus. The Registered Dietician said the facility was working on writing out a menu, three-day, three meals, 9 total, breakfast, lunch and dinner, the menu will not be repeated and the goal was to see which foods Resident #43 liked, and based on that the facility would continue to make menu's. The items included boiled eggs, sausage patties, sweet cakes, honey buns, and said the facility nursing and dietary departments would work closely with speech therapy to trial different foods. The Registered Dietician was asked why the interventions for weekly weights was not ordered by a physician, she said, we do not have to get orders, we just weigh them. The restorative aid weighs the resident as asked by myself and then brings me the list. During an interview on 09/20/2022 at 10:10 AM, the Speech Language Pathologist revealed that she occasionally brought in Korean type foods that Resident #1 had expressed she liked. The SLP stated that it took several attempts to coax the resident to eat some of her meals. She said the resident had a poor appetite, but when she brought in fresh foods, she would eat all of it. The SLP said that the kitchen manager was open to listening to her suggestions regarding Resident #43's likes and also her dislikes but said most times the kitchen provided the regular scheduled meals. The SLP said she was aware of the facilities weekly interdisciplinary team meetings and said that due to the residents monthly weight figures, it was decided to have speech therapy to assess the reason for the continued decline in Resident #43's weight. The SLP said that she had been bringing Korean foods at least once or twice since the resident was recommended to be assessed for weight loss in May of 2022. Interview on 09/21/2022 at 8:25 AM, Resident #43's physician, Physician BB, revealed his opinion about the residents weight loss was unanticipated, he said, my team saw her on 09/13/22 by my physician assistant, and there were no notes on her weight loss, he said that at this time the nursing staff is doing the maximum preventative methods at this time, and said he will repeat metabolic labs, and stated he knew that Resident #43 was a diabetic and that the resident may have kidney issues which can cause weight loss, he said that she had a recent [CONDITION(S)] and was on antibiotics. He said that he leaves the weight loss recommendations to the dietician and expects the staff to follow the suggestions and inform him of any significant changes in health conditions. He said that the facility should accommodate the resident with local foods, offer her with preferred foods, also they could try feeding assistance. He was asked if he was aware that the dietician suggested the use of [MEDICATION(S)], he said that it was not brought up to his attention and could be tried but it was a method that is not proven to really work to increase appetite. He reiterated that at this time everything was being done and mentioned other more invasive methods could be discussed such as a peg tube, but he did not think it was a good Idea due to the possibility for infections. He said that due to the residents' numerous comorbidities such as the progression of her dementia, the diseases could play a big role in weight loss. He said that because he was unaware of Resident #43's significant weight loss, the resident will be on his radar and will try to get to the bottom of the problem. He was asked about the one-time order for infusion of IV vitamins and said that method could have been helpful but said again it is not a proven method and it was not a preferred method for weight loss. Interview with on 9/22/2022 at 2:00 pm with Vice-President of Nutrition revealed, she was unaware the Registered Dietician was inputting the facility residents weekly weight loss changes in a separate spread sheet and only monthly weights into the facility residents flagged for significant weight loss monthly into their perspective health care records. She said the standard protocol was for the restorative aid to weigh the residents and that the Registered Dietician input the numbers in the health records on a weekly basis. The Vice-President of Nutrition denied knowing why the Registered Dietician had a separate file with the resident's weekly weights and denied knowing why nursing or dietary had not informed the physician of Resident #43's significant weight loss, she stated that Dietary Managers have the ability to order interventions and should also call the physician with significant changes in a residents health condition. An Immediate Jeopardy (IJ) was identified on 09/21/2022 at 14:29, the administrator, corporate nurse, MDs nurse was notified, due to the above failures. The administrator was notified of the IJ and the IJ template was provided to him, he verbalized understanding and a Plan of Removal was requested. The facility's plan of removal was accepted on 09/23/2022 at 2:29 p.m., and included: PLAN OF REMOVALFOR IMMEDIATE JEOPARDY Summary of Details which lead to outcomes The notification of the alleged immediate jeopardy states as follows: F692 - Nutrition and Hydration 1. The facility failed to provide foods of choice ordered for a [AGE] year-old Korean female resident's therapeutic diet needs. They are not providing preferred foods the resident is used to eating. The facility failed to help maintain the resident's acceptable parameter of nutritional status such as usual body w[TRUNCATED]

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program that included a system of surveillance designed to identify possible communicable diseases or infections before they could spread to other persons in the facility and a system based on national standards for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for six (Hall 100, Hall 200, Hall 300, Hall 400, Hall 500, and Hall 600) of six halls reviewed for infection control, impacting 99 residents in the facility. 1. The facility failed to implement and maintain contact precautions and ensure staff utilized Personal Protective Equipment (PPE) appropriately to prevent cross contamination between residents positive with COVID-19 and residents who were not positive for [MEDICAL CONDITION]. 2. The facility failed to ensure residents, especially those residents positive for COVID-19, were [MEDICATION NAME] social distancing to help prevent the spread of COVID-19. 3. The facility failed to track and trend infections of COVID-19 to prevent the spread of infection. An Immediate Jeopardy/Immediate Threat was identified on 04/28/20. While the Immediate Jeopardy was removed on 05/03/20, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. The facility was provided the Immediate Jeopardy template on 04/28/20. Findings included: An interview with the Administrator, DON, and Nurse Consultant on 04/28/20 at 1:35 PM revealed Resident #1 was the first person in the facility diagnosed with [REDACTED]. The resident passed away at the hospital. Review of the facility line listing (list of residents with dates of diagnosis), dated 04/30/20 revealed 11 residents (Resident #1-#11) passed away after developing COVID-19 in the facility. Thirty-six residents tested positive between 04/01/20-04/06/20. Three of the total 11 residents who passed away were diagnosed on [DATE] and 04/13/20. Twenty-one residents tested positive between 04/11/20-04/16/20. Twelve residents tested positive between 04/28/20-05/01/20. An interview on 04/30/20 at 12:30 PM with the Administrator and Nurse Consultant revealed the facility did not track and trend infections of COVID-19 to prevent the spread of infection through the facility. They said they did not review the dates of [DIAGNOSES REDACTED]. The Nurse Consultant reported she had not had time to do this and the DON was out for two weeks with [MEDICAL CONDITION]. They said they did not know if residents who had tested positive with one negative test could move to non-isolation halls and would have to look up the CDC guidelines to find out. Observations on 04/28/20 at 2:45 PM and 3:20 PM revealed the facility was structured like a wagon wheel with the nurse's station in the center. Observations of the hallways revealed: Hall 100, identified as an isolation unit, had the double doors closed. Isolation signs were posted. There were no PPE supplies available prior to entering the unit or an area with a hazard box to doff PPE prior to leaving the unit. Hall 200, identified as an isolation unit, had the double doors closed. Isolation signs were posted. There were no PPE supplies available prior to entering the unit or an area with a hazard box to doff PPE prior to leaving the unit. Hall 300, identified as an isolation unit, had the double doors closed. Isolation signs were posted. There were no PPE supplies available prior to entering the unit or an area with a hazard box to doff PPE prior to leaving the unit. The Dining Room had doors that connected it to Hall 300 and Hall 400. Halls 400, 500, and 600 were not identified as isolation units. Central supply was located in a room on Hall 600. Large amounts of resident equipment for use throughout the facility was in Hall 600. An observation and interview on 04/28/20 at 3:20 PM revealed Floor Tech O was leaving isolation Hall 300 with two barrels of linen. He did not remove his PPE or perform hand hygiene after exiting Hall 300. He walked past the nurse's station to Hall 600 (non-isolation hall) and placed the two barrels in a closet. Floor Tech O reported that he wore the same PPE all shift and never changed it or his gloves until the end of his shift. An interview on 04/28/20 at 3:25 PM with the Nurse Consultant, DON, and Administrator revealed staff were not expected to change their PPE when leaving an isolation hall and going to a non-isolation hall. The Nurse Consultant stated staff could wear the same PPE all shift and for any resident because everyone in the building was presumed positive. Review of an email, dated 04/06/20, from the County Health Department to the facility reflected: .Thank you for our discussion today. I understand that there is now at least one confirmed case in each of the 6 halls and you expressed it is no longer feasible to cohort residents into isolation units. As we discussed, since the confirmed cases are not all cohorted in the same halls, healthcare are advised to wear all recommended PPE for the care of all residents, regardless of presence of symptoms. Epidemiologist Q reviewed with you the CDC Strategies for Optimizing the Supply of PPE and Equipment for each PPE type . An interview on 4/29/20 at 12:35 PM with the County Health Department revealed staff were supposed to wear full PPE when entering the facility and where supposed to change their gown and gloves between each resident. He said he sent the facility an email with links regarding the use and conservation of their PPE. He said the facility was supposed to have designated staff working with positive residents only. Review of an email dated 04/16/20 at 4:20 PM from Epidemiologist R reflected: .Below are the recommendations made . 3. Recommend facility cohort COVID-19 positive residents and dedicate HCP (healthcare personnel) to only care for these residents. (They stated that they are unable to do this, but it was highly recommended to prevent in-facility transmission.) An interview with Epidemiologist Q on 04/29/20 at 10:30 AM revealed gowns and gloves had to be changed anytime a person exited an isolation hall and hand hygiene had to be performed. Observation and interview on 04/28/20 at 4:05 PM revealed CNA P was in Hall 300 (isolation hall). She was preparing linen to go into a resident's room. She took the linen and the dirty linen cart to the last resident's room on the hall. She exited Hall 300 wearing a gown, mask, face shield, and shoe covers and walked to the nurse's station. CNA P did not perform hand hygiene or change her gown when she left the isolation Hall 300. She stated she was Agency Staff and this was her first assignment with the agency since COVID-19 started. CNA P stated she did not change her gown between providing resident care, but she did change her gloves and perform hand hygiene. A male resident, name unknown, exited Hall 300 through the double doors and told CNA P he was ready for his shower. He was not wearing a mask. CNA P told the resident to give her 5 minutes and he entered back through the double doors to Hall 300. A different male resident then exited Hall 300 wearing a mask. He walked past the nurse's station and into a room on Hall 500 (non-isolation hall). An observation and interview on 04/28/20 at 6:45 PM with the Administrator revealed the smoking patio was entered by passing through the Dining Hall. One resident was observed smoking on the patio and the Administrator said the resident was COVID-19 positive and in Smoking Group One. We entered back into the dining room and another male resident was seated there. The Administrator said he was in Smoking Group 2, was COVID-19 negative, and was waiting for his turn to smoke. An observation on 04/28/20 at 7:00 PM revealed staff from the Texas Division of Emergency Management was speaking with facility administration and explaining the difference between hot, cold, and warm zones as it pertained to the COVID-19 virus. The Administrator reported to him that residents wandered between the isolation and non-isolation halls and that staff wore the same PPE going from positive halls to negative halls. An observation on 04/28/20 at 7:10 PM revealed Resident #12 (Refused COVID testing) exited Isolation Hall 300, passed by the nurse's station, and entered Isolation Hall 100. An observation on 04/29/20 at 9:00 AM revealed there were approximately eight residents smoking outside the back door of Hall 100. The residents were not social distancing (standing 6 feet apart). They were standing very close together. An interview on 04/29/20 at 9:20 AM with the Administrator, Nurse Consultant, and DON revealed that Resident #13 was sent to the hospital for lethargy overnight and was COVID-19 positive. The facility identified six new residents who tested positive for COVID-19 on Hall 600 on 04/28/20. They stated Hall 600 was changed to an isolation hall. They reported they did not know what resulted in the new positive results, but that the facility residents were not cohorted based on [DIAGNOSES REDACTED]. They said up until that point, there were COVID-19 positive residents on every hall. An interview on 04/29/20 at 12:45 PM with the Medical Director revealed the facility did not have any specific protocols regarding caring for residents positive for COVID-19. He said the residents were treated symptomatically and assessed once per shift. Staff were supposed to call him with any changes in condition. He said if residents had the same diagnosis, staff could wear the same PPE all shift, and not change it. He said glove changes and hand hygiene could be completed between residents. He said the PPE did not need to be necessarily changed in the facility because everyone in the facility had been exposed and there was nothing they could do to prevent the negative residents from developing it. He said this was his first visit to the facility since residents were COVID-19 positive, but he was in constant contact with the facility by phone and video. He said there was nothing that could have been done differently to prevent the spread of [MEDICAL CONDITION] in the building. An observation and interview on 04/30/20 at 10:45 AM with Resident #14 revealed he was seated in his wheelchair in the front room of the facility and was wearing a mask. He was alert and awake and reported he was feeling well. The Administrator reported Resident #14 resided on an isolation hall. The Nurse Consultant said the resident had tested positive for the COVID-19 virus and had one negative test result at that time and needed one more negative test to come out of isolation. An interview with RN J on 5/1/20 at 10:20 AM revealed she did not receive training to change her gown between each resident. She said changing her gown depended on the type of contact she provided for residents. RN J stated the residents on the isolation halls kept leaving the hall and had to be re-directed back to their room. She said the facility could have prevented the spread of [MEDICAL CONDITION] if they had stopped the positive residents from leaving their hall. She said she provided care to Resident #1 and Resident #9. Resident #1 spiked a temperature and he was transferred to an isolation room on Hall 600. Resident #9 passed away after she was found on the floor. She said she was doing hourly checks with Resident #9 because her oxygen saturation was low. She said the resident was constantly removing her oxygen tubing and she kept having to re-direct the resident to put it back on. RN J said on 04/13/20 she felt ill and went to the emergency room after work. She tested positive for the COVID-19 virus and had to stay home for 2 weeks. An interview with CNA S on 05/01/20 at 10:35 AM revealed he/she was trained that his/her gown only had to be changed if it was dirty and staff did not need to change PPE between residents. An interview with LVN T on 05/02/20 at 1:45 PM revealed she had been trained that PPE only needed to be changed if she went outside the facility. She said they had several residents who refused to stay on their hall and they were supposed to try and re-direct them. An interview with CNA U on 05/02/20 at 2:00 PM revealed he/she received training that staff were able to wear the same PPE for all residents and staff did not need to change PPE between residents. An interview with CNA V on 05/02/20 at 2:10 PM revealed she/he was trained that the same PPE could be worn for all residents and staff did not need to change PPE between residents. An interview with LVN W on 05/02/20 at 2:20 PM revealed she only changed her PPE when she left her assigned hall for the day and the facility had multiple residents who wandered onto other halls. She said she thought the spread of [MEDICAL CONDITION] could have been slowed if the facility would have tested everyone at the same time and isolated those who tested positive. An interview with the Nurse Consultant on 05/03/20 at 3:20 PM revealed Epidemiologist R asked if the facility had cohorted residents. The Nurse Consultant said the health department did not give instructions to do that. She said residents were not cohorted until 04/24/20. Review of the Facility Policy, Infection Control, dated May 2017 reflected: Policy .The program will: Perform surveillance and investigation to prevent .the spread of infection; Prevent and control outbreaks and control cross-contamination using transmission-based precautions in addition to standard precautions; . Implement hand hygiene (hand washing) . Review of the COVID-19 Focused Survey for Nursing Homes, dated 03/20/20, and filled out by the facility reflected the facility did not identify any concerns in the areas of: Do staff perform hand hygiene (even if gloves are used) in the following situations? Before and after contact with the resident . Is PPE appropriately removed and discarded after resident care, prior to leaving the room ., followed by hand hygiene? 2. Resident Care .is the facility restricting residents (to the extent possible) to their rooms except for medically necessary purposes? If there is a case in the facility, and residents have to leave their room, are they wearing a face mask, performing hand hygiene, limiting the movement in the facility, and performing social distancing? Has the facility isolated residents with known or suspected COVID-19 .? Review of the Centers for Disease Control and Prevention (CDC) guidance, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic revealed: . 2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection . If admitted , place a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection in a single-person room with the door closed. The patient should have a dedicated bathroom . As a measure to limit HCP exposure and conserve PPE, facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection. Dedicated means that HCP are assigned to care only for these patients during their shift. Determine how staffing needs will be met as the number of patients with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection increases and if HCP become ill and are excluded from work . To the extent possible, patients with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should be housed in the same room for the duration of their stay in the facility (e.g., minimize room transfers). Limit transport and movement of the patient outside of the room to medically essential purposes . Patients should wear a facemask or cloth face covering to contain secretions during transport. If patients cannot tolerate a facemask or cloth face covering or one is not available, they should use tissues to cover their mouth and nose while out of their room . Personal Protective Equipment HCP who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection . HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. HCP should perform hand hygiene by using ABHS with 60-95% alcohol or washing hands with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to ABHS. Healthcare facilities should ensure that hand hygiene supplies are readily available to all personnel in every care location. Personal Protective Equipment Training Employers should select appropriate PPE and provide it to HCP in accordance with OSHA PPE standards (29 CFR 1910 Subpart I) external icon. HCP must receive training on and demonstrate an understanding of: when to use PPE (,) what PPE is necessary how to properly don, use, and doff PPE in a manner to prevent self-contamination (,) how to properly dispose of or disinfect and maintain PPE (,) the limitations of PPE. Any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses. Facilities should have policies and procedures describing a recommended sequence for safely donning and doffing PPE. The PPE recommended when caring for a patient with suspected or confirmed COVID-19 includes the following: Respirator or Facemask (Cloth face coverings are NOT PPE and should not be worn for the care of patients with suspected or confirmed COVID-19 or other situations where use of a respirator or facemask is recommended.) Put on an N95 respirator (or equivalent or higher-level respirator) or facemask (if a respirator is not available) before entry into the patient room or care area, if not already wearing one as part of extended use strategies to optimize PPE supply. Disposable respirators and facemasks should be removed and discarded after exiting the patient's room or care area and closing the door unless implementing extended use or reuse. Perform hand hygiene after removing the respirator or facemask . Eye Protection Put on eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face) upon entry to the patient room or care area, if not already wearing as part of extended use strategies to optimize PPE supply. Personal eyeglasses and contact lenses are NOT considered adequate eye protection. Ensure that eye protection is compatible with the respirator so there is not interference with proper positioning of the eye protection or with the fit or seal of the respirator. Remove eye protection after leaving the patient room or care area, unless implementing extended use. Reusable eye protection (e.g., goggles) must be cleaned and disinfected according to manufacturer's reprocessing instructions prior to re-use. Disposable eye protection should be discarded after use unless following protocols for extended use or reuse. Gloves Put on clean, non-sterile gloves upon entry into the patient room or care area. Change gloves if they become torn or heavily contaminated. Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene. Gowns Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Cloth gowns should be laundered after each use. Accessed on 07/15/20 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.html An Immediate Jeopardy/Immediate Threat was identified on 04/28/20. The Administrator, Nurse Consultant, and DON were notified of the Immediate Jeopardy on 04/28/20 at 5:10 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 05/01/20 at 4:30 PM and reflected the following: All staff are being in-serviced on the correct donning of PPE. The following procedure will be followed: staff will don a set of the required PPE (goggles/face shield, gown and N95 mask). All staff will change their gowns out with each resident encounter. When a staff member leaves a positive hallway, they will doff their gown when coming out of the hallway, perform hand hygiene and don a clean gown. This in-service was started on 04/28/20 by the DON/designee. Facility will continue to have designated staff for the COVID-19 positive hallways. Current staffing patterns are the following: 100 Hall (positive) 1 dedicated nurse and 2 dedicated CNA, 200 Hall (positive) 1 dedicated nurse and 1 dedicated CNA, 300 Hall (residents predominately have 1 negative test) 1 dedicated nurse and 1 dedicated CNA, 400 and 500 hall (residents have either refused, or had 2 negative test or have had 1 negative test) will have a dedicated nurse and 2 CNA. The designated staff for each hallway will be responsible to enforce that COVID-19 positive residents to stay on their residing hallway. They will also make sure no residents from other hallways enter the positive hallway. Facility will continue to have separate smoke breaks for COVID-19 positive residents from the residents who are negative. During smoke breaks residents will maintain social distancing practices. An updated line listing of resident's status will be placed in the nurse's narcotic binders for the staff to have a quick reference to identify the testing stages of each resident. The DON/designee will be responsible to update the line listing in the narcotics books as changes occur. As residents have had two negative COVID-19 test they will be removed from isolation. The Administrator/Director of Nursing/Assistant Director of Nursing will assess all residents who have been potentially exposed to cross contamination. Administrator/Director of Nursing will consultant with the Vice President of Clinical, Vice President of Operations, Vice President of compliance and the Regional Nurse Consultant on any potential exposure related to any staff member/resident and CDC and state guidelines will be reviewed daily on the daily end of day call for 21 days after the last confirmed case. Residents will be monitored every shift for any changes of condition. Any changes of condition will be reported to the Director of Nursing and Assistant Director of Nursing immediately. DON/designee will monitor that the appropriate process for PPE is being followed for all hallways. This monitoring will be completed daily by the DON. The Regional Nurse Consultant will monitor the process completed by the DON. A social distancing monitoring tool has been created and will be utilized by nursing department supervisors to randomly make rounds per day on each positive COVID-19 hall to ensure compliance with [MEDICATION NAME] social distancing and remaining on their residing hallway. The Regional Nurse Consultant will monitor the process is completed by the DON. The DON/designee will be responsible to update the line listing in the narcotics books as changes occur. This will allow the staff to have a quick reference regarding resident COVID-19 status. The DON will do randomly ask staff to verbalize how they can obtain the information regarding the status of the resident regarding COVID-19 daily. The follow protocol from the Medical Director will be put in place for COVID-19 positive residents. Vital signs including temp, respirations, blood pressure, pulse and oxygen saturations will be completed every shift. A Respiratory Assessment will be completed every shift including auscultating lung sounds. The MD will be notified of any adverse lung sounds, diminished breathing, or respiratory distress. All COVID-19 positive residents will have standing Oxygen orders of 02 Saturation less than 92% will be placed on 2-5L oxygen via either nasal cannula or face mask. MD will be notified as well. A clinician will round on the positive residents 3 times a week and prn via telehealth. Any changes condition assessed the MD will be notified immediately. Monitoring of the facility's Plan of Removal included the following: Interviews and observations were conducted on 05/02/20 starting at 12:30 PM and continued through 05/03/20 at 3:45 PM with 15 staff members from various shifts regarding in-services which included the CDC guidelines for the use of PPE, staff assignments with COVID-19 positive residents, monitoring of residents, and facility monitoring of residents wandering. The staff members were able to: Describe the correct process for wearing PPE and performing hand hygiene. Describe the process for assigning staff and monitoring residents. Describe the monitoring process of COVID-19 positive residents. Identify residents who were COVID-19 positive and those who were not. Observations revealed residents were not wandering onto other halls, staff were changing their PPE per CDC guidelines, and residents were assigned to halls based on their [DIAGNOSES REDACTED]. Interviewed staff members and shifts were: LVN E- worked 6:00 AM to 2:00 PM CNA U- worked 6:00 AM to 2:00 PM CNA V- worked 6:00 AM to 2:00 PM LVN W- worked all shifts CNA X- worked 2:00 PM to 10:00 PM CMA Y- worked double shifts Restorative aide Z- worked 10:00 pm to 6:00 AM and 6:00 AM to 2:00 PM Kitchen Staff AA - worked day shift Kitchen Staff BB - worked day shift LVN K - worked 2:00 PM to 10:00 PM CNA CC - worked 2:00 PM to 10:00 PM LVN DD - worked double shifts LVN EE - worked double shifts CNA FF- worked 2:00 PM to 10:00 PM Dietary Aide GG- worked split shifts An interview with the Administrator on 05/03/20 at 12:55 PM revealed going forward the facility would be following the CDC guidelines and she would ensure the facility completed infection control surveillance, cohorting of residents and staff, and increased monitoring and auditing of staff infection control measures. An interview with the DON on 05/01/20 at 10:55 AM revealed going forward the facility would be following the CDC guidelines and the staff would be wearing their PPE appropriately, and as the Infection Control Preventionist he would be tracking and trending infection information. An interview with the Nurse Consultant on 01/19/18 at 1:50 PM revealed going forward the facility would be following the CDC guidelines for infection control and monitoring the spread of [MEDICAL CONDITION] in the facility. She said she would continue to update the facility line listing and send HHSC a summary of her findings daily. The Administrator was notified on 05/03/20 at 3:40 PM, the Immediate Jeopardy was removed. While the immediacy was removed on 05/03/20, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the plan of removal.

Based on observation, interview and record review, the facility failed to keep residents free from neglect for six (Residents #1, #2, #3, #4, #5 and #6) of eight residents reviewed for neglect. The facility failed to provide staff with training on the assessment and treatment of [REDACTED]. These failures were evidenced by: 1. The nursing staff failed to assess Resident #1's pressure ulcer on admission and failed to assess the condition of Resident #1's pressure ulcer from 08/03/18 until 08/30/18 for a total of 27 days. On 09/06/18, Resident #1 was transferred to the hospital where she was found to have five unstageable pressure ulcers and a DTI that had not been identified by the facility. 2. The nursing staff failed to provide Resident #2 with physician-ordered pressure ulcer treatment for [REDACTED]. 3. The facility failed to implement its Skin Integrity Monitoring System by failing to consistently perform weekly skin assessments for the presence of pressure ulcers and failing to conduct quarterly screening for the risk of pressure ulcer development for Residents #1, #2, #3, #4, #5, and #6. 4. The facility failed to ensure licensed nursing staff had the knowledge and skill to provide necessary care and services related to the identification, assessment, documentation, and treatment of [REDACTED].#1, #2, #3, #4, #5, and #6. An Immediate Jeopardy (IJ) was identified on 09/11/18. While the IJ was removed on 09/17/18, the facility remained out of compliance at isolated with actual harm that was not immediate jeopardy due to the facility's need to monitor the effectiveness of the Plan Removal. These failures affected 6 residents with pressure ulcers and placed 7 residents with pressure ulcers and 35 residents receiving preventive skin care at risk for developing new pressure ulcers, pain, deterioration in existing pressure ulcers, infection and even hospitalization . Findings included: (1) Review of Resident #1's facility nursing admission assessment dated [DATE] reflected the resident was admitted [DATE] with a right heel pressure ulcer. There was no documentation on the admission assessment of any assessment of the pressure ulcer to include a description, stage, measurements or other characteristics. Review of a nurse's weekly ulcer assessment form dated 03/27/18 revealed the resident had a Stage II pressure ulcer to the right heel. The wound bed was described as pink and there was no odor. There were no documented measurements of the pressure ulcer to reflect what size it was. Review of a nurse's weekly ulcer assessment form dated 04/03/18 revealed Resident #1 had a right heel DTI measuring 10.5 cm x 11.0 cm, with black eschar (eschar-thick black necrotic/dead tissue) in the wound bed and no odor. The assessment form incorrectly identified the ulcer type as arterial instead of pressure. (The National Pressure Ulcer Advisory Panel (NPUAP) web site (www.npuap.org) viewed on 09/20/18 defines a DTI-Deep Tissue Injury as a pressure injury resulting in persistent non-blanchable deep red, maroon or purple discoloration of intact or not intact skin). Review of nurse's weekly ulcer assessment dated [DATE] revealed the resident had an ulcer to the right heel measuring 4 cm x 7.9 cm. The color of the wound bed was black/eschar with 50% necrosis and the skin around the wound was macerated (softening and breaking down of skin resulting from prolonged exposure to moisture). with light bloody opaque or purulent exudate. This assessment incorrectly identified the ulcer type as diabetic instead of pressure. Attempts to interview the author of the assessment were unsuccessful. Review of Resident #1's undated Admission Record revealed the resident was a [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #1's care plan initiated 04/03/18 and revised 07/05/18 reflected the resident Has pressure ulcer or potential for pressure ulcer development. The goal was for the resident's pressure ulcer to show signs of healing and remain free from infection. Interventions included assess/record/monitor wound healing at least weekly, measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to MD. The resident's facility H&P dated 04/12/18 reflected it was a new visit and the resident had a history of [REDACTED]. The H&P reflected Resident #1 was admitted to the facility due to risk of elopement. The physical exam of the resident's skin only reflected normal temperature. Resident #1's MDS assessment dated [DATE] reflected a BIMS score of 9 indicating moderately impaired cognition. The MDS assessment further reflected the resident was frequently incontinent of bowel/bladder, required extensive two-person assistance for bed mobility, transfers, personal hygiene and dressing. Section M of the MDS assessment related to skin conditions, reflected the resident was at risk of developing a pressure ulcer and had a Stage IV pressure ulcer that was present on admission. The measurements were 4.2 cm x 3.4 cm x 0.4 cm. The MDS assessment reflected the resident had no arterial or [MEDICAL CONDITION]. Record review of the facility's discharge logs revealed Resident #1 was transferred to the hospital on [DATE]. Resident #1 was observed in the hospital on [DATE] at 10:00 a.m. resting in bed on the ICU with an indwelling urinary catheter, nasogastric tube, and the she was receiving intravenous antibiotic therapy. The ICU nurse stated there had been a plan to debride (to remove dead, contaminated, or adherent tissue that may promote infection and impede healing) the resident's right heel pressure ulcer yesterday (09/10/18), but the resident suffered a decline and it was postponed. The nurse stated surgical debridement of the resident's sacral pressure ulcer was scheduled for today (09/11/18). The nurse further stated the resident was admitted to the ICU directly from theER on [DATE] with multiple pressure ulcers that were still present. She stated she had just completed wound care but would remove them if the surveyor insisted. To prevent any further discomfort and distress to the resident the wounds were not observed. Review of the hospital H&P dated 09/06/18 revealed Resident #1 was arrived in the ER with lethargy, altered mental status and [MEDICAL CONDITION]. A Stage II pressure ulcer was noted to the left heel and a large foul-smelling necrotic wound was noted to the right heel. The H&P further reflected the resident's admitting [DIAGNOSES REDACTED].[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger [MEDICAL CONDITION] responses throughout the body. [MEDICAL CONDITION] progresses to septic shock, blood pressure drops dramatically, which may lead to death) with septic shock likely secondary to the necrotic heel wound, UTI and pneumonia and acute kidney injury secondary to [MEDICAL CONDITION] with shock. The resident was treated with intravenous fluids and intravenous antibiotics. Review of hospital records included photographic wound documentation dated 09/06/18 of 6 photos of pressure ulcers Resident #1was admitted with. The photographic wound documentation reflected the following: 1) Right heel pressure ulcer unstageable - 8 cm x 4 cm; 2) Left lateral lower extremity (leg) pressure ulcer unstageable - 5 cm x 3 cm; 3) Coccyx pressure ulcer unstagable - 6 cm x 7 cm; 4) Right elbow pressure ulcer unstageable - 3 cm x 2 cm; 5) Left heel pressure ulcer DTI - No measurements the DTI encompasses the entire heel; and 6) Left inner foot pressure ulcer unstageable - 1 cm x 1 cm; Review of the hospital's Present on Admit form dated 09/06/18 reflected all of Resident #1's pressure ulcers and skin impairments listed in the photographic wound documentation were present on admission to the hospital. Review of Resident #1's nurse's weekly skin assessments for the month of (MONTH) (YEAR) revealed the weekly assessments available reflected assessments were performed on 08/01/18, twenty-one days later, on 08/22/18 then seven days later, on 08/29/18. The three assessments reflected the resident had a DTI to the right heel. There was no documented assessment of the DTI pressure ulcer to include a description, measurements or other characteristics. The area on the assessment forms to check yes or no if the resident had a pressure injury were marked no. The instructions on the nurse's weekly skin assessment forms reflected if there was a pressure injury noted, a weekly pressure injury assessment form should be initiated, an assessment should be performed and documented weekly until healed. The nurse's weekly skin assessments incorrectly reflected the resident did not have a pressure injury. There were no weekly pressure injury assessment forms initiated or documented assessments performed as a result of the skin assessments dated 08/1/18, 08/22/18 or 08/29/18 which indicated the resident had a DTI. A list provided by the CRN G on 09/17/18 reflected Resident #1 had no hospital transfers and remained in the facility during the omitted weekly skin assessments. Nurse's notes dated 08/09/18 and timed 1:13 p.m. reflected Resident #1's pressure ulcer to the right heel appeared red and was noted with moderate drainage. There was no information related to the type of drainage, size, stage of the wound or if the physician had been notified of the findings. An interview with the facility's DON on 09/09/18 at 7:00 p.m. revealed she had been the DON for two weeks. She stated Resident #1 was transferred to the hospital on [DATE] due to respiratory distress. The DON stated she had seen the wounds of the two residents with the most severe pressure ulcers. She stated the facility had a new WCP whose first visit was on 09/04/18 and she ensured the residents with the most severe pressure ulcers (Resident #1 and Resident #3) were seen on 09/04/18. The DON further stated on Thursday (09/06/18) LVN A informed her Resident #1's right heel pressure ulcer appeared worse. On 09/09/18 the DON provided WCP notes/assessment dated [DATE] reflecting Resident #1 was assessed with [REDACTED]. The wound was surrounded by 11.0 cm x 11.0 cm of DTI. The wound was assessed with [REDACTED]. The WCP assessment reflected the pressure ulcer was debrided on 09/04/18. The treatment was changed to apply [MEDICATION NAME] (an antiseptic used to treat wounds and skin infections) every day and the antibiotic Bactrim DS was ordered to be administered orally two times a day for 10 days. WCP assessments in (MONTH) (YEAR) were dated 08/02/18 and 08/30/18. The assessment dated [DATE] reflected Resident #1 had a Stage IV pressure ulcer to the right heel with moderate drainage and 60% slough. Measurements were 4.2 cm x 3.4 cm x 0.4 cm. The next WCP assessment was dated twenty-eight days later, on 08/30/18. The assessment reflected the resident had a Stage IV pressure ulcer to the right heel with light bloody drainage and 100% slough. Necrotic tissue was removed at this visit via debridement and measurements were 4.5 cm x 4.0 cm x 0.6 cm. On 09/13/18/18 CRN G provided an additional nurse's notes dated 08/03/18 reflecting LVN A had documented an assessment of Resident #1's pressure ulcer. The note reflected the resident had a Stage IV to the right heel with moderate drainage. The measurements were the same as the WCP assessment dated [DATE] of 4.2 cm x 3.4 cm x 0.4 cm. (The National Pressure Ulcer Advisory Panel (NPUAP) web site (www.npuap.org) viewed on 09/20/18 defines a Stage IV pressure injury as a full thickness tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament cartilage or bone in the ulcer). There were no other documented assessments of the condition of Resident #1's pressure ulcer during the 28-days between the WCP visits/assessments on 08/02/18 and 08/30/18. The facility's records did not identify any other pressure ulcers other than the right heel. On 09/09/18 at 7:35 p.m. the ADON stated there were only three residents with pressure ulcers. Resident #1 who was currently in the hospital, admitted with a pressure ulcer to the right heel, Resident #2 admitted with a pressure ulcer to the right heel and Resident #3 developed a pressure ulcer to the coccyx in the facility. Review of Resident #1's Braden Scale pressure sore risk assessment dated [DATE] revealed a score of 16 and reflected the resident was at a low risk of developing pressure ulcers even though the resident currently had a pressure ulcer on 08/02/18 according to WCP notes/assessments. An interview with the DON on 09/09/18 at 8:02 p.m. revealed nurses were responsible for completing weekly skin assessments. She stated she was not aware of the incomplete/inaccurate skin assessments, omitted skin assessments or the lack of documented assessments of Resident #1's pressure ulcer. An interview with LVN A on 09/11/18 at 11:34 a.m. revealed she was the day shift charge nurse for Hall 200 where Resident #1 resided. She stated the resident admitted to the facility with a pressure ulcer to the right heel. The pressure ulcer was closed, dark colored, firm and unstageable. LVN A stated Resident #1 also had a skin tear to the right buttock and both skin tears were present when the resident was transferred to the hospital on [DATE]. The nurse further stated the resident's right heel pressure ulcer was getting worse when she returned from vacation on 08/20/18. LVN A stated she was unable to verbalize specifically how the pressure ulcer appeared worse she just recalls it was different. She then stated she noticed the pressure ulcer looking worse a few days before the WCP visited on 09/04/18. The nurse stated there was drainage but no odor. Additionally, LVN A stated she had a conversation with the DON about sending Resident #1 out for more aggressive wound care just before the resident was transferred to the hospital. She did not see any improvements in the pressure ulcer even though the WCP was treating the pressure ulcer and different treatments had been attempted. The right heel pressure ulcer was larger than a half dollar without odor or drainage. LVN A stated prior to the WCP visit on 09/04/18 there was an area on Resident #1's coccyx. The nurse was unable to recall when but stated it had been sometime after she returned from vacation on 08/20/18. She stated she was not sure if the WCP was aware of the area on the resident's coccyx. When queried about whether she had informed/called the physician or WCP she stated no, because the WCP came weekly and was scheduled to make a visit. She stated in the past the ADON scheduled the WCP visits and she did not know how to get in touch with the WCP. LVN A stated she was not that comfortable or knowledgeable about pressure ulcers and in the past the treatment nurse and later the former ADON had completed weekly skin assessments, kept up with pressure ulcers, treatments and weekly skin assessments. LVN A stated currently nurses were responsible for performing weekly skin assessments according to a schedule. The day shift nurses were assigned to residents residing in A-beds and the evening shift nurses were assigned to residents in the B-beds. (Resident #1 resided in an A bed). The nurse provided no information about why weekly skin assessments were not performed consistently for Resident #1. She stated the weekly skin assessment schedule changed often and she was not aware the assessments were not completed weekly. LVN A stated she found out last week she was to perform weekly pressure ulcer assessments for residents. She further stated she did not recall performing any weekly pressure ulcer assessments for Resident #1 because she had not been aware it was her responsibility to do so. The nurse stated she had not obtained any measurements of the Resident #1's pressure ulcer to the right heel or documented any other characteristics (description-color-appearance) of the pressure ulcer because the form did not ask for any additional information. An interview with CNA F on 09/12/18 at 11:10 p.m. revealed she provided care for Resident #1 routinely. She stated she was on duty during the day shift of 09/06/18 when the resident went to the hospital. She further stated she noticed a black area on the resident's buttock located near the middle of resident's lower back. She described the location of the black area as on that bone part. She stated the area was near the crack of the resident's buttock and not located on the butt cheeks. The CNA stated the area was very black and she had reported it to the charge nurse, LVN A on 08/29/18 a week prior to the resident's hospital transfer. CNA F stated the next day 08/30/18 she noticed an open area on the resident's left elbow that looked like a popped blister. She stated when she reported the skin issues to LVN A, the nurse came to look at the areas. CNA F further stated on the day Resident #1 went out to the hospital there was a dressing on both areas. A telephone interview with the facility's previous WCP (WCP D) on 09/11/18 at 3:15 p.m. revealed he saw residents in the facility for three weeks. He stated the facility had a DON who initially agreed to make wound rounds with him but did not follow through on the agreement. He stated he needed someone to open dressing on wounds and/or pressure ulcers and tell him something about the residents. He stated the next time he visited the facility the ADON assisted him and she was helpful and appeared interested. He stated none of the nurses knew anything about the resident's wounds and/or pressure ulcers. At one point he was told the nurses would be making wound rounds with him and assisting. He further stated the problem was that there was no treatment nurse or any one person who was aware of the wounds and/or pressure ulcers in the facility. He stated he was not able to recall exactly who Resident #1 was. Additionally, he stated the nurses never told him anything about the residents or the wounds and/or pressure ulcers. He stated he made rounds alone with his scribe who only documented. He stated the nurses were not involved, interested or willing to assist him. He stated it was possible a wound and/or pressure ulcer was not assessed or treated by him as no one ever told him anything. An interview was conducted with Resident #1's PCP on 09/12/18 at 11:42 a.m. about his knowledge of the condition of the resident's skin and pressure ulcers. He stated he provided mostly medical care and deferred wound care to the WCP. He stated if he was in the facility and the nurses needed him to assess a pressure ulcer he would do it. He further stated if there were concerns or problems related to pressure ulcers the nurses would contact the WCP. He did not recall any notifications regarding Resident #1's pressure ulcer. A telephone interview with the facility's current WCP (WCP E) on 09/12/18 at 12:44 p.m. revealed he recalled seeing Resident #1 for an initial consult. He stated after the initial visit his colleague (WCP D) saw the resident for approximately 3 weeks. He stated when he visited the facility he did not go looking around for patients to see. Nurses or the DON showed him and his colleague which residents with wounds they wanted them to see. WCP E further stated there had been problems with the facility's nurses showing he and his colleague which resident were to be seen. He stated it was a hit and miss sometimes as the nursing staff did not always show them which residents required visits. He stated the problem had been the previous DON and one other nurse who he was unable to recall the name. He stated he urged them to make some type of list and told them this on several occasions. The previous DON and nurse did not have a list and would attempt to recall from memory what patients had what wounds. WCP E was queried during this interview about why in (MONTH) (YEAR) there had been a 27-day period (08/02/18 and 08/30/18) between WCP assessments/visits for Resident #1. He stated it would be his guess the nurses/DON did not show the resident to the WCP. He stated he has a good rapport with the corporate staff and the problem had been with the previous DON. Additionally, he stated his records reflected only WCP visits for Resident #1 in (MONTH) were on 08/02/18 and 08/30/18. (2) Review of Resident #2's undated Admission Record revealed the resident was a [AGE] year old male initially admitted on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The physician's H&P dated 05/27/18 reflected Resident #2 had a history of [REDACTED]. There was no examination of the resident's skin. Observation of Resident #2 with the ADON on 09/09/18 at 9:15 p.m. revealed the resident was sleeping in bed with a dressing to the right heel dated 09/02/18. The ADON removed the dressing revealing a closed DTI with dark black edges formed in a circular pattern. The center of the DTI was pink. Measurements obtained by the ADON were 3.5 cm x 2.5 cm. A physician's orders [REDACTED]. Review of the resident's MDS assessment dated [DATE] and revealed the resident's BIMS score was 15 indicating his cognition was intact. Extensive assistance of one person was required for bed mobility, eating, dressing and personal hygiene. Transfers did not occur, and the resident was frequently incontinent of bowel/bladder. Section M skin condition reflected the resident was at risk for developing pressure ulcers but had no pressure ulcers. Review of Resident #2's Braden Scale pressure sore risk assessments dated 08/06/18 and 08/13/18 revealed the scores were 12. The assessments reflected the resident was at a high risk for developing of pressure ulcers. Resident #2's care plan initiated on 09/09/18 and revised on 09/10/18 reflected the resident had a pressure ulcer or potential for pressure ulcer development. Care plan goals to address the resident's actual pressure ulcer included remaining free of infection and having signs of healing. Interventions included assessing, recording, and monitoring wound healing at least weekly, measure length, width and dept where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD. Revised interventions added 09/10/18 included administering treatments as ordered and monitoring for effectiveness. An interview with LVN B on 09/11/18 at 12:35 p.m., revealed he provided care for Resident #2. He stated he was not aware the resident had any wounds or treatments other than for the left AKA. Review of Resident #2's (MONTH) (YEAR) TARs with LVN B on 09/11/18 revealed no treatment to the resident's right heel had been transcribed to the TARs. Further clinical record review revealed a physician's telephone order dated 09/10/18 to discontinue the Venelex to the right heel DTI. This treatment was still valid during the observation of Resident #2's right heel and dressing on 09/09/18 at 9:15 p.m. TARs dated (MONTH) (YEAR) were reviewed and reflected no treatment to the resident's right heel had been transcribed to the TARs. An interview with the CRN G on 09/1/183 at 1:10 p.m. Resident #2's TARs did not contain the order for the treatment to his right heel because nurses had not input the order in correctly to ensure it would post to TAR. She stated the nurses had input the order in to post to the wound care sheet, but the wound care sheet was not printed. Resident #2's weekly skin assessments for (MONTH) (YEAR) were reviewed and were dated 08/24/18 and 08/27/18. The weekly skin assessment dated [DATE] reflected the resident had a pressure ulcer. The assessment did not reflect a location, description, measurements or other characteristics about the pressure ulcer. A list provided by the CRN G on 09/17/18 reflected the resident had been out of the facility due to a hospital transfer on 08/20/18 (Admission record reflects the resident readmitted [DATE]). The resident remained in the facility during the omitted weekly skin assessments. The instructions on the nurse's weekly skin assessment forms reflected if there was a pressure injury noted, a weekly pressure injury assessment form should be initiated, an assessment should be performed and documented weekly until healed. The next weekly skin assessment was dated 08/27/18 and reflected the resident did not have a pressure ulcer/injury. Nurse's weekly pressure ulcer and pressure injury forms were dated 08/25/18 and 09/09/18. The assessments reflected the resident had a pressure ulcer to the right heel. The 08/25/18 assessment reflected the right heel ulcer was a Stage II measuring 4 cm x 3 cm and was first identified on 07/23/18. The 09/09/18 weekly pressure injury form reflected the resident had an unstageable pressure ulcer to the right heel measuring 3.5 cm x 2.6 cm x 0.2 cm in D and was first identified on 07/10/18. The WCP assessment dated [DATE] reflected Resident #2 was assessed with [REDACTED]. (3) Review of Resident #3's undated Admission Record revealed she was an [AGE] year old female admitted on [DATE]. [DIAGNOSES REDACTED]. The physician's H&P dated 06/16/18 reflected Resident #3 was a poor historian secondary to dementia. The physical exam of the resident's skin reflected the skin was intact with no rashes, skin breakdown or [MEDICAL CONDITION]. Review of the resident's MDS assessment dated [DATE] revealed cognitive skills for daily decision making were severely impaired, the resident was totally dependent on staff for all activities of daily living and was always incontinent of bowel/bladder. Section M of the MDS assessment related to skin condition reflected the resident was at risk for development of pressure ulcers but had no pressure ulcers. Observation of Resident #3 with the ADON on 09/09/18 at 8:50 p.m. revealed the resident was resting in bed with a dressing to the coccyx dated 09/09/18. The ADON removed the dressing revealing a dark brown/black open area with a moderate amount of serosanguinous (thin, watery, pale red to pink plasma with red blood cells) drainage on the old dressing. Measurements obtained by the ADON were 5 cm x 3.5 cm x 0.8 cm. The only care plan to address pressure ulcers was initiated 09/09/18 even though the MDS assessment reflected the resident was at risk for pressure ulcer development. The care plan reflected Resident #3 had a Stage II pressure ulcer to the coccyx. Goals were the pressure ulcer would show S/S of healing and remain free from infection. Interventions included assess/record/monitor wound healing at least weekly, measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD. Resident #3's weekly nurse's skin assessment dated [DATE] reflected the resident had no pressure ulcers. The only Braden Scale pressure sore risk assessment available was dated 09/14/18. The score was 9 and the assessment reflected the resident was at risk of developing of pressure ulcers. The next weekly skin assessment was dated two weeks later, on 08/30/18 and reflected Resident has open area to sacral area. The only nurse's weekly pressure injury form was dated 08/30/18. The form reflected a pressure ulcer to the coccyx was identified on 08/30/18. The measurements were 1.2 cm x 0.9 cm x 0.6 cm. A list provided by the CRN G on 09/17/18 reflected Resident #3 had no hospital transfers and remained in the facility during the omitted weekly skin assessments. The WCP assessment was also dated 08/30/18 and reflected Resident #3 had a Stage IV pressure ulcer to the coccyx measuring 1.2 cm in L X 0.9 cm in W X 0.6 cm in D. The WCP assessment dated [DATE] reflected the resident's coccyx pressure ulcer had an odor, was unstageable with 70% necrotic tissue and 10% slough. The orders were changed from Calcium Alginate daily to applying [MEDICATION NAME] daily and starting the antibiotic Bactrim DS one orally every day for ten days. During an interview on 09/09/18 at 10:45 p.m. the ADON stated a problem with nursing staff performing skin assessments and pressure ulcer assessments had been identified by the facility and training had been provided to nursing staff. The ADON provided in-service attendance records dated 04/30/18 related to weekly skin and pressure ulcer assessments. According to the attendance records provided the training began at 1:30 p.m. and completed ten minutes later at 1:40 p.m. The ADON stated she was not aware of any monitoring to determine the effectiveness of the training. On 09/11/18 at 11:10 a.m. the ADON and DON stated skin-assessments on all residents were initiated 09/09/18 and completed 09/10/18. The DON provided skin assessments and a WCP assessment dated [DATE]. A list provided by the CRN G on 09/17/18 reflected three additional residents (Resident #4, #5 and #6) were identified with pressure ulcers during the facility wide skin assessments conducted on 09/09/18 and 09/10/18. (4) Review of Resident #4's undated Admission Record revealed he was a [AGE] year old male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's MDS assessment dated [DATE] revealed cognitive skills for daily decision making were severely impaired, the resident was totally dependent on staff for all activities of daily living and was frequently incontinent of bowel/bladder. Section M of the MDS assessment related to skin condition reflected the resident was at risk for development of pressure ulcers but had no pressure ulcers. Observation with the ADON on 09/15/18 at 1:00 p.m. revealed Resident #4 was sitting in a Geri-chair in his room. A current dressing to the resident's sacrum was dated 09/15/18. Record review revealed Resident #4's only Braden Scale pressure sore risk assessment was dated 09/10/18. The score was 12 and the assessment reflected the resident was at a high risk for developing pressure ulcers. Resident #4's care plan initiated on 09/12/18 and revised on 09/12/18 reflected the resident had a shear wound to the right of the sacrum. A care plan initiated on 12/26/16 and revised on 09/12/18 reflected the resident had a DTI to the right heel. Care plan goals included remaining free of infection and having signs of healing. Interventions included administering treatments as ordered, monitoring for effectiveness, assess/record/monitor wound healing at least weekly, measure length, width and dept where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD. Nurse's weekly skin assessments were dated 08/15/18 and two weeks later on 08/29/18. The weekly skin assessment dated [DATE] reflected the resident had no pressure ulcer/injury. The weekly skin assessment dated [DATE] reflected Resident #4 had a pressure ulcer/injury. The assessment did not reflect a location, description, measurements or other characteristics about the pressure ulcer. The instructions on the nurse's

Based on observation, interview and record review, the facility failed to implement polices and procedures that prohibited neglect for six (Residents #1, #2, #3, #4, #5 and #6) of eight residents reviewed for neglect. The facility failed to provide staff with training on the assessment and treatment of [REDACTED]. These failures were evidenced by: 1. The nursing staff failed to assess Resident #1's pressure ulcer on admission and failed to assess the condition of Resident #1's pressure ulcer from 08/03/18 until 08/30/18 for a total of 27 days. On 09/06/18, Resident #1 was transferred to the hospital where she was found to have five unstageable pressure ulcers and a DTI that had not been identified by the facility. 2. The nursing staff failed to provide Resident #2 with physician-ordered pressure ulcer treatment for [REDACTED]. 3. The facility failed to implement its Skin Integrity Monitoring System by failing to consistently perform weekly skin assessments for the presence of pressure ulcers and failing to conduct quarterly screening for the risk of pressure ulcer development for Residents #1, #2, #3, #4, #5, and #6. 4. The facility failed to ensure licensed nursing staff had the knowledge and skill to provide necessary care and services related to the identification, assessment, documentation, and treatment of [REDACTED].#1, #2, #3, #4, #5, and #6. An Immediate Jeopardy (IJ) was identified on 09/11/18. While the IJ was removed on 09/17/18, the facility remained out of compliance at a isolated with actual harm that was not IJ due to the facility's need to monitor the effectiveness of the Plan Removal. These failures affected 6 residents with pressure ulcers and placed 7 residents with pressure ulcers and 35 residents receiving preventive skin care at risk for developing new pressure ulcers, pain, deterioration in existing pressure ulcers, infection and even hospitalization . Findings included: (1) The facility's current abuse prohibition policy and procedure, dated 05/20/17, was provided by CRN G on 09/16/18. The policy and procedure reflected the following It is the policy of this home to prohibit abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person The facility and its employees are neglectful when a reasonable person would conclude a deprivation of the omitted goods and services would cause, among other things, emotional distress The homes administration will prohibit neglect, verbal, mental or physical abuse. The facility's current Skin Integrity Monitoring System policy and procedured, dated 08/20/18, was provided by the Clinical Director on 09/13/18. The policy and procedure reflected: It is the policy of this home that: 1. A system will be in place to assure that all residents will be assessed and monitored for any type of skin breakdown. 2. A system will be in place to assure that all residents will be assessed, and preventative measures will be in place to prevent the development of pressure injuries 3. A system will be in place to assure any type of skin conditions that do not constitute pressure injuries, will be monitored closely for any type of complications. 1. (Braden Scale) will be completed within 24 hours of admission/readmission and every week times 4 weeks for new admits/readmits; prior to transfer out of the home (unless residents condition prevents); prior to a planned discharge; then quarterly and with any significant change in condition. 2. Residents will be screened daily through direct care provided and any deficits identified will be reported. In addition, the Nursing Assistant Daily Body Observation Form may also be used when assistance is provided during showers. 3. All residents will be assessed weekly using the (Weekly Skin Assessment) form for any type of skin integrity complications; this will include pressure injury and non-pressure related complications. The (Weekly Skin Assessment) will be documented on the (Weekly Skin Assessment). 4. When pressure injuries are identified, the assessment of the injury must be documented on the (Skin Assessment Flow Sheet -Pressure Injury) form. 5. When a pressure injury is identified, treatment orders are obtained from physician. 6. When a pressure injury is identified, dietary is to be notified. 7. When a pressure injury is identified, the Interdisciplinary Care Plan and the CNA Care Plan are to be updated to communicate changes to all care givers. 8. Director of Nursing, Dietary Service Manager, Administrator and the MDS nurse are to receive a copy of the weekly skin report each week. 9. Therapeutic devices are to be documented on the CNA care plan as well as the IDCPT care plan. 10. IDCPT will meet weekly to discuss skin condition to determine resident needs as they relate to pressure and non-pressure injuries. 11. Pictures will not be taken of resident's skin problems, by the home staff. Care planning in response to risk prediction must be completed. Care planning in response to the presence of pressure injury must be competed. (2) Review of Resident #1's undated Admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #1's facility nursing admission assessment dated [DATE] revealed the resident was admitted [DATE] with a right heel pressure ulcer. There was no documentation on the admission assessment of any assessment of the pressure ulcer to include a description, stage, measurements or other characteristics. Review of a nurse's weekly ulcer assessment form dated 03/27/18 revealed the resident had a Stage II pressure ulcer to the right heel. The wound bed was described as pink and there was no odor. There were no documented measurements of the pressure ulcer to reflect what size it was. Review of a nurse's weekly ulcer assessment form dated 04/03/18 revealed Resident #1 had a right heel DTI measuring 10.5 cm x 11.0 cm, with black eschar (eschar-thick black necrotic/dead tissue) in the wound bed and no odor. The assessment form incorrectly identified the ulcer type as arterial instead of pressure. (The National Pressure Ulcer Advisory Panel (NPUAP) web site (www.npuap.org) viewed on 09/20/18 defines a DTI-Deep Tissue Injury as a pressure injury resulting in persistent non-blanchable deep red, maroon or purple discoloration of intact or not intact skin). Review of a nurse's weekly ulcer assessment dated [DATE] revealed the resident had an ulcer to the right heel measuring 4 cm x 7.9 cm. The color of the wound bed was black/eschar with 50% necrosis and the skin around the wound was macerated (softening and breaking down of skin resulting from prolonged exposure to moisture). with light bloody opaque or purulent exudate. This assessment incorrectly identified the ulcer type as diabetic instead of pressure. Review of Resident #1's care plan initiated 04/03/18 and revised 07/05/18 reflected the resident, Has pressure ulcer or potential for pressure ulcer development. The goal was for the resident's pressure ulcer to show signs of healing and remain free from infection. Interventions included assess/record/monitor wound healing at least weekly, measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to MD. Review of the Resident #1's facility H&P dated 04/12/18 revealed this was a new visit. The H&P reflected the resident had a history of [REDACTED]. The H&P reflected Resident #1 was admitted to the facility due to risk of elopement. The physical exam of the resident's skin only revealed normal temperature. Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 9 indicating moderately impaired cognition. The MDS assessment further revealed the resident was frequently incontinent of bowel/bladder, required extensive two-person assistance for bed mobility, transfers, personal hygiene and dressing. Section M of the MDS assessment related to skin conditions, revealed the resident was at risk of developing a pressure ulcer and had a Stage IV pressure ulcer that was present on admission. The measurements were 4.2 cm x 3.4 cm x 0.4 cm. The MDS assessment revealed the resident had no arterial or [MEDICAL CONDITION]. Review of the facility's discharge logs revealed Resident #1 was transferred to the hospital on [DATE]. Resident #1 was observed in the hospital on [DATE] at 10:00 a.m. resting in bed on the ICU with an indwelling urinary catheter, nasogastric tube, and the she was receiving intravenous antibiotic therapy. The ICU nurse stated there had been a plan to debride (to remove dead, contaminated, or adherent tissue that may promote infection and impede healing) the resident's right heel pressure ulcer yesterday (09/10/18), but the resident suffered a decline and it was postponed. The nurse stated surgical debridement of the resident's sacral pressure ulcer was scheduled for today (09/11/18). The nurse further stated the resident was admitted to the ICU directly from theER on [DATE] with multiple pressure ulcers that were still present. Review of the hospital H&P dated 09/06/18 revealed Resident #1 was arrived in the ER with lethargy, altered mental status and [MEDICAL CONDITION]. A Stage II pressure ulcer was noted to the left heel and a large foul-smelling necrotic wound was noted to the right heel. The H&P further revealed the resident's admitting [DIAGNOSES REDACTED].[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger [MEDICAL CONDITION] responses throughout the body. [MEDICAL CONDITION] progresses to septic shock, blood pressure drops dramatically, which may lead to death) with septic shock likely secondary to the necrotic heel wound, UTI and pneumonia and acute kidney injury secondary to [MEDICAL CONDITION] with shock. The resident was treated with intravenous fluids and intravenous antibiotics. Review of hospital records included photographic wound documentation dated 09/06/18 of six photos of pressure ulcers Resident #1 was admitted with. The photographic wound documentation revealed the following: 1) Right heel pressure ulcer unstageable - 8 cm x 4 cm; 2) Left lateral lower extremity (leg) pressure ulcer unstageable - 5 cm x 3 cm; 3) Coccyx pressure ulcer unstageable - 6 cm x 7 cm; 4) Right elbow pressure ulcer unstageable - 3 cm x 2 cm; 5) Left heel pressure ulcer DTI - No measurements the DTI encompasses the entire heel; and 6) Left inner foot pressure ulcer unstageable - 1 cm x 1 cm. Review of the hospital's Present on Admit form dated 09/06/18 revealed all of Resident #1's pressure ulcers and skin impairments listed in the photographic wound documentation were present on admission to the hospital. Review of Resident #1's nurse's weekly skin assessments for the month of (MONTH) (YEAR) revealed the weekly assessments available revealed assessments were performed on 08/01/18, twenty-one days later, on 08/22/18 then seven days later, on 08/29/18. The three assessments revealed the resident had a DTI to the right heel. There was no documented assessment of the DTI pressure ulcer to include a description, measurements or other characteristics. The area on the assessment forms to check yes or no if the resident had a pressure injury were marked no. The instructions on the nurse's weekly skin assessment forms revealed if there was a pressure injury noted, a weekly pressure injury assessment form should be initiated, an assessment should be performed and documented weekly until healed. The nurse's weekly skin assessments incorrectly revealed the resident did not have a pressure injury. There were no weekly pressure injury assessment forms initiated or documented assessments performed as a result of the skin assessments dated 08/1/18, 08/22/18 or 08/29/18 which indicated the resident had a DTI. A list provided by CRN G on 09/17/18 revealed Resident #1 had no hospital transfers and remained in the facility during the omitted weekly skin assessments. Nurse's notes dated 08/09/18 and timed 1:13 p.m. revealed Resident #1's pressure ulcer to the right heel appeared red and was noted with moderate drainage. There was no information related to the type of drainage, size, stage of the wound or if the physician had been notified of the findings. An interview with the facility's DON on 09/09/18 at 7:00 p.m. revealed she had been the DON for two weeks. She stated Resident #1 was transferred to the hospital on [DATE] due to respiratory distress. The DON stated she had seen the wounds of the two residents with the most severe pressure ulcers. She stated the facility had a new WCP whose first visit was on 09/04/18 and she ensured the residents with the most severe pressure ulcers (Resident #1 and Resident #3) were seen on 09/04/18. The DON further stated on Thursday (09/06/18) LVN A informed her Resident #1's right heel pressure ulcer appeared worse. On 09/09/18 the DON provided WCP notes/assessment dated [DATE] reflecting Resident #1 was assessed with [REDACTED]. The wound was surrounded by 11.0 cm x 11.0 cm x of DTI. The wound was assessed with [REDACTED]. The WCP assessment revealed the pressure ulcer was debrided on 09/04/18. The treatment was changed to apply [MEDICATION NAME] (an antiseptic used to treat wounds and skin infections) every day and the antibiotic Bactrim DS was ordered to be administered orally two times a day for 10 days. WCP assessments in (MONTH) (YEAR) were dated 08/02/18 and 08/30/18. The assessment dated [DATE] revealed Resident #1 had a Stage IV pressure ulcer to the right heel with moderate drainage and 60% slough. Measurements were 4.2 cm x 3.4 cm x 0.4 cm. The next WCP assessment was dated twenty-eight days later, on 08/30/18. The assessment revealed the resident had a Stage IV pressure ulcer to the right heel with light bloody drainage and 100% slough. Necrotic tissue was removed at this visit via debridement and measurements were 4.5 cm x 4.0 cm x 0.6 cm. On 09/13/18/18 CRN G provided an additional nurse's notes dated 08/03/18 reflecting LVN A had documented an assessment of Resident #1's pressure ulcer. The note revealed the resident had a Stage IV to the right heel with moderate drainage. The measurements were the same as the WCP assessment dated [DATE] of 4.2 cm x 3.4 cm x 0.4 cm. (The National Pressure Ulcer Advisory Panel (NPUAP) web site (www.npuap.org) viewed on 09/20/18 defines a Stage IV pressure injury as a full thickness tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament cartilage or bone in the ulcer). There were no other documented assessments of the condition of Resident #1's pressure ulcer during the 28-days between the WCP visits/assessments on 08/02/18 and 08/30/18. The facility's records did not identify any other pressure ulcers other than the right heel. On 09/09/18 at 7:35 p.m. the ADON stated there were only three residents with pressure ulcers. Resident #1 who was currently in the hospital, admitted with a pressure ulcer to the right heel, Resident #2 admitted with a pressure ulcer to the right heel and Resident #3 developed a pressure ulcer to the coccyx in the facility. Review of Resident #1's Braden Scale pressure sore risk assessment dated [DATE] revealed a score of 16 and revealed the resident was at a low risk of developing pressure ulcers even though the resident currently had a pressure ulcer on 08/02/18 according to WCP notes/assessments. An interview with the DON on 09/09/18 at 8:02 p.m. revealed nurses were responsible for completing weekly skin assessments. She stated she was not aware of the incomplete/inaccurate skin assessments, omitted skin assessments or the lack of documented assessments of Resident #1's pressure ulcer. An interview with LVN A on 09/11/18 at 11:34 a.m. revealed she was the day shift charge nurse for Hall 200 where Resident #1 resided. She stated the resident admitted to the facility with a pressure ulcer to the right heel. The pressure ulcer was closed, dark colored, firm and unstageable. She stated, she recalled the resident having a skin tear to the elbow but was unable to recall what elbow. When asked how she knew it was a skin tear the nurse stated one of the weekend nurses told her it was a skin tear and when she saw the area it looked like a skin tear. LVN A stated Resident #1 also had a skin tear to the right buttock and both skin tears were present when the resident was transferred to the hospital on [DATE]. The nurse further stated the resident's right heel pressure ulcer was getting worse when she returned from vacation on 08/20/18. LVN A stated she was unable to verbalize specifically how the pressure ulcer appeared worse she just recalls it was different. She then stated she noticed the pressure ulcer looking worse a few days before the WCP visited on 09/04/18. The nurse stated there was drainage but no odor. Additionally, LVN A stated she had a conversation with the DON about sending Resident #1 out for more aggressive wound care just before the resident was transferred to the hospital. She did not see any improvements in the pressure ulcer even though the WCP was treating the pressure ulcer and different treatments had been attempted. The right heel pressure ulcer was larger than a half dollar without odor or drainage. LVN A stated prior to the WCP visit on 09/04/18 there was an area on Resident #1's coccyx. The nurse was unable to recall when but stated it had been sometime after she returned from vacation on 08/20/18. She stated she was not sure if the WCP was aware of the area on the resident's coccyx. When queried about whether she had informed/called the physician or WCP she stated no, because the WCP came weekly and was scheduled to make a visit. She stated in the past the ADON scheduled the WCP visits and she did not know how to get in touch with the WCP. LVN A stated she was not that comfortable or knowledgeable about pressure ulcers and in the past the treatment nurse and later the former ADON had completed weekly skin assessments, kept up with pressure ulcers, treatments and weekly skin assessments. LVN A stated currently nurses were responsible for performing weekly skin assessments according to a schedule. The day shift nurses were assigned to residents residing in A-beds and the evening shift nurses were assigned to residents in the B-beds. (Resident #1 resided in an A bed on Hall 200). The nurse provided no information about why weekly skin assessments were not performed consistently for Resident #1. She stated the weekly skin assessment schedule changed often and she was not aware the assessments were not completed weekly. LVN A stated she found out last week she was to perform weekly pressure ulcer assessments for residents. She further stated she did not recall performing any weekly pressure ulcer assessments for Resident #1 because she had not been aware it was her responsibility to do so. The nurse stated she had not obtained any measurements of the Resident #1's pressure ulcer to the right heel or documented any other characteristics (description-color-appearance) of the pressure ulcer because the form did not ask for any additional information. An interview with CNA F on 09/12/18 at 11:10 p.m. revealed she provided care for Resident #1 routinely. She stated she was on duty during the day shift of 09/06/18 when the resident went to the hospital. She further stated she noticed a black area on the resident's buttock located near the middle of resident's lower back. She described the location of the black area as on that bone part. She stated the area was near the crack of the resident's buttock and not located on the butt cheeks. The CNA stated the area was very black, and she had reported it to the charge nurse, LVN A on 08/29/18 a week prior to the resident's hospital transfer. She stated when she reported the skin issues to LVN A, the nurse came to look at the area. CNA F further stated on the day Resident #1 went out to the hospital there was a dressing on the area. A telephone interview with the facility's previous WCP (WCP D) on 09/11/18 at 3:15 p.m. revealed he saw residents in the facility for three weeks. He stated the facility had a DON who initially agreed to make wound rounds with him but did not follow through on the agreement. He stated he needed someone to open dressing on wounds and/or pressure ulcers and tell him something about the residents. He stated the next time he visited the facility the ADON assisted him and she was helpful and appeared interested. He stated none of the nurses knew anything about the resident's wounds and/or pressure ulcers. At one point he was told the nurses would be making wound rounds with him and assisting. He further stated the problem was that there was no treatment nurse or any one person who was aware of the wounds and/or pressure ulcers in the facility. He stated he was not able to recall exactly who Resident #1 was. Additionally, he stated the nurses never told him anything about the residents or the wounds and/or pressure ulcers. He stated he made rounds alone with his scribe who only documented. He stated the nurses were not involved, interested or willing to assist him. He stated it was possible a wound and/or pressure ulcer was not assessed or treated by him as no one ever told him anything. An interview was conducted with Resident #1's PCP on 09/12/18 at 11:42 a.m. about his knowledge of the condition of the resident's skin and pressure ulcers. He stated he provided mostly medical care and deferred wound care to the WCP. He stated if he was in the facility and the nurses needed him to assess a pressure ulcer he would do it. He further stated if there were concerns or problems related to pressure ulcers the nurses would contact the WCP. He did not recall any notifications regarding Resident #1's pressure ulcer. A telephone interview with the facility's current WCP (WCP E) on 09/12/18 at 12:44 p.m. revealed he recalled seeing Resident #1 for an initial consult. He stated after the initial visit his colleague (WCP D) saw the resident for approximately 3 weeks. He stated when he visited the facility he did not go looking around for patients to see. Nurses or the DON showed him and his colleague which residents with wounds they wanted them to see. WCP E further stated there had been problems with the facility's nurses showing he and his colleague which resident were to be seen. He stated it was a hit and miss sometimes as the nursing staff did not always show them which residents required visits. He stated the problem had been the previous DON and one other nurse who he was unable to recall the name. He stated he urged them to make some type of list and told them this on several occasions. The previous DON and nurse did not have a list and would attempt to recall from memory what patients had what wounds. WCP E was queried during this interview about why in (MONTH) (YEAR) there had been a 27-day period (08/02/18 and 08/30/18) between WCP assessments/visits for Resident #1. He stated it would be his guess the nurses/DON did not show the resident to the WCP. He stated he has a good rapport with the corporate staff and the problem had been with the previous DON. Additionally, he stated his records revealed only WCP visits for Resident #1 in (MONTH) were on 08/02/18 and 08/30/18. (3) Review of Resident #2's undated Admission Record revealed the resident was a [AGE] year old male initially admitted on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The physician's H&P dated 05/27/18 revealed Resident #2 had a history of [REDACTED]. There was no examination of the resident's skin. Observation of Resident #2 with the ADON on 09/09/18 at 9:15 p.m. revealed the resident was sleeping in bed with a dressing to the right heel dated 09/02/18. The ADON removed the dressing revealing a closed DTI with dark black edges formed in a circular isolated. The center of the DTI was pink. Measurements obtained by the ADON were 3.5 cm x 2.5 cm. A physician's orders [REDACTED]. Review of the resident's MDS assessment dated [DATE] and revealed the resident's BIMS score was 15 indicating his cognition was intact. Extensive assistance of one person was required for bed mobility, eating, dressing and personal hygiene. Transfers did not occur, and the resident was frequently incontinent of bowel/bladder. Section M skin condition revealed the resident was at risk for developing pressure ulcers but had no pressure ulcers. Review of Resident #2's Braden Scale pressure sore risk assessments dated 08/06/18 and 08/13/18 revealed the scores were 12. The assessments revealed the resident was at a high risk for developing of pressure ulcers. Resident #2's care plan initiated on 09/09/18 and revised on 09/10/18 revealed the resident had a pressure ulcer or potential for pressure ulcer development. Care plan goals to address the resident's actual pressure ulcer included remaining free of infection and having signs of healing. Interventions included assessing, recording, and monitoring wound healing at least weekly, measuring the length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD. Revised interventions added 09/10/18 included administering treatments as ordered and monitoring for effectiveness. An interview with LVN B on 09/11/18 at 12:35 p.m., revealed he provided care for Resident #2. He stated he was not aware the resident had any wounds or treatments other than for the left AKA. Review of Resident #2's (MONTH) (YEAR) TARs with LVN B on 09/11/18 revealed no treatment to the resident's right heel had been transcribed to the TARs. Further clinical record review revealed a physician's telephone order dated 09/10/18 to discontinue the Venelex to the right heel DTI. This treatment was still valid during the observation of Resident #2's right heel and dressing on 09/09/18 at 9:15 p.m. TARs dated (MONTH) (YEAR) were reviewed and revealed no treatment to the resident's right heel had been transcribed to the TARs. An interview with the CRN G on 09/1/183 at 1:10 p.m. Resident 2's TARs did not contain the order for the treatment to his right heel because nurses had not input the order in correctly to ensure it would post to TAR. She stated the nurses had input the order in to post to the wound care sheet, but the wound care sheet was not printed. Resident #2's weekly skin assessments for (MONTH) (YEAR) were reviewed and were dated 08/24/18 and 08/27/18. The weekly skin assessment dated [DATE] revealed the resident had a pressure ulcer. The assessment did not reflect a location, description, measurements or other characteristics about the pressure ulcer. A list provided by the CRN G on 09/17/18 revealed the resident had been out of the facility due to a hospital transfer on 08/20/18 (Admission record reflects the resident readmitted [DATE]). The resident remained in the facility during the omitted weekly skin assessments. The instructions on the nurse's weekly skin assessment forms revealed if there was a pressure injury noted, a weekly pressure injury assessment form should be initiated, an assessment should be performed and documented weekly until healed. The next weekly skin assessment was dated 08/27/18 and revealed the resident did not have a pressure ulcer/injury. Nurse's weekly pressure ulcer and pressure injury forms were dated 08/25/18 and 09/09/18. The assessments revealed the resident had a pressure ulcer to the right heel. The 08/25/18 assessment revealed the right heel ulcer was a Stage II measuring 4 cm x 3 cm and was first identified on 07/23/18. The 09/09/18 weekly pressure injury form revealed the resident had an unstageable pressure ulcer to the right heel measuring 3.5 cm x 2.6 cm x 0.2 cm and was first identified on 07/10/18. The WCP assessment dated [DATE] revealed Resident #2 was assessed with [REDACTED]. (4) Review of Resident #3's undated Admission Record revealed she was an [AGE] year old female admitted on [DATE]. [DIAGNOSES REDACTED]. The physician's H&P dated 06/16/18 revealed Resident #3 was a poor historian secondary to dementia. The physical exam of the resident's skin revealed the skin was intact with no rashes, skin breakdown or [MEDICAL CONDITION]. Review of the resident's MDS assessment dated [DATE] revealed cognitive skills for daily decision making were severely impaired, the resident was totally dependent on staff for all activities of daily living and was always incontinent of bowel/bladder. Section M of the MDS assessment related to skin condition revealed the resident was at risk for development of pressure ulcers but had no pressure ulcers. Observation of Resident #3 with the ADON on 09/09/18 at 8:50 p.m. revealed the resident was resting in bed with a dressing to the coccyx dated 09/09/18. The ADON removed the dressing revealing a dark brown/black open area with a moderate amount of serosanguinous drainage on the old dressing. Measurements obtained by the ADON were 5 cm x 3.5 cm x 0.8 cm. The only care plan to address pressure ulcers was initiated 09/09/18 even though the MDS assessment revealed the resident was at risk for pressure ulcer development. The care plan revealed Resident #3 had a Stage II pressure ulcer to the coccyx. Goals were the pressure ulcer would show S/S of healing and remain free from infection. Interventions included assess/record/monitor wound healing at least weekly, measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD. Resident #3's weekly nurse's skin assessments for (MONTH) (YEAR) were reviewed and were dated 08/03/18, 08/10/18, and 08/16/18. The assessments revealed Resident #3 had no pressure ulcers. The only Braden Scale pressure sore risk assessment available was dated 09/14/18. The score was 9 and the assessment revealed the resident was at risk of developing of pressure ulcers. The next weekly skin assessment was dated two weeks later, on 08/30/18 and reflectedResident has open area to sacral area. The only nurse's weekly pressure injury form was dated 08/30/18. The form revealed a pressure ulcer to the coccyx was identified on 08/30/18. The measurements were 1.2 cm x 0.9 cm x 0.6 cm. A list provided by the CRN G on 09/17/18 revealed Resident #3 had no hospital transfers and remained in the facility during the omitted weekly skin assessments. The WCP assessment was also dated 08/30/18 and revealed Resident #3 had a Stage IV pressure ulcer to the coccyx measuring 1.2 cm x 0.9 cm x 0.6 cm. The WCP assessment dated [DATE] revealed the resident's coccyx pressure ulcer had an odor, was unstageable with 70% necrotic tissue

Based on observation, interview, and record review the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for six (Residents #1, #2, #3, #4, #5 and #6) of eight residents reviewed for pressure ulcers. The DON and CRN G failed to: - sufficiently train and monitor nursing staff to ensure proper identification, assessment, and treatment of [REDACTED].#1, #2, #3, #4, #5, and #6; - ensure nursing staff assessed and documented a detailed description of Resident #1's pressure ulcer on admission; - ensure nursing staff assessed and documented the condition of Resident #1's pressure ulcer from 08/03/18 until 08/30/18 for a total of 27 days. When Resident #1 was transferred to the hospital on [DATE], the resident was found to have five unstageable pressure ulcers and DTIs that had not been identified by facility nursing staff; - ensure nursing staff provided Resident #2 with daily pressure ulcer treatment as ordered by the physician for seven days; and - implement and monitor the facility's Skin Integrity Monitoring System to ensure nursing staff were conducting weekly skin assessments and quarterly screenings for the risk of pressure ulcer development for residents including Residents #1, #2, #3, #4, and #6. An Immediate Jeopardy (IJ) was identified on 09/11/18. While the IJ was removed on 09/17/18, the facility remained out of compliance at isolated with actual harm that was not IJ due to the facility's need to monitor the effectiveness of the Plan Removal. These failures affected six residents with pressure ulcers and placed seven residents with pressure ulcers and 35 residents receiving preventive skin care at risk for developing new pressure ulcers, pain, deterioration in existing pressure ulcers, infection and even hospitalization . Findings included: (1) Review of Resident #1's facility nursing admission assessment dated [DATE] reflected the resident was admitted [DATE] with a right heel pressure ulcer. There was no documentation on the admission assessment of any assessment of the pressure ulcer to include a description, stage, measurements or other characteristics. Review of a nurse's weekly ulcer assessment form dated 03/27/18 revealed the resident had a Stage II pressure ulcer to the right heel. The wound bed was described as pink and there was no odor. There were no documented measurements of the pressure ulcer to reflect what size it was. Review of a nurse's weekly ulcer assessment form dated 04/03/18 revealed Resident #1 had a right heel DTI measuring 10.5 cm x 11.0 cm, with black eschar (Eschar-thick black necrotic/dead tissue) in the wound bed and no odor. The assessment form incorrectly identified the ulcer type as arterial instead of pressure. (The National Pressure Ulcer Advisory Panel (NPUAP) web site (www.npuap.org) viewed on 09/20/18 defines a DTI-Deep Tissue Injury as a pressure injury resulting in persistent non-blanchable deep red, maroon or purple discoloration of intact or not intact skin). Review of nurse's weekly ulcer assessment dated [DATE] revealed the resident had an ulcer to the right heel measuring 4 cm x 7.9 cm. The color of the wound bed was black/eschar with 50% necrosis and the skin around the wound was macerated (softening and breaking down of skin resulting from prolonged exposure to moisture). with light bloody opaque or purulent exudate. This assessment incorrectly identified the ulcer type as diabetic instead of pressure. Attempts to interview the author of the assessment were unsuccessful. Record review of the facility's discharge logs revealed Resident #1 was transferred to the hospital on [DATE]. Review of Resident #1's undated Admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #1's care plan initiated 04/03/18 and revised 07/05/18 reflected the resident: Has pressure ulcer or potential for pressure ulcer development. The goal was for the resident's pressure ulcer to show signs of healing and remain free from infection. Interventions included assess/record/monitor wound healing at least weekly, measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to MD. The resident's facility H&P dated 04/12/18 reflected it was a new visit and the resident had a history of [REDACTED]. The H&P reflected Resident #1 was admitted to the facility due to risk of elopement. The physical exam of the resident's skin only reflected normal temperature. Resident #1's MDS assessment dated [DATE] reflected a BIMS score of 9 indicating moderately impaired cognition. The MDS assessment further reflected the resident was frequently incontinent of bowel/bladder, required extensive two-person assistance for bed mobility, transfers, personal hygiene and dressing. Section M of the MDS assessment related to skin conditions, reflected the resident was at risk of developing a pressure ulcer and had a Stage IV pressure ulcer that was present on admission. The measurements were 4.2 cm x 3.4 cm x 0.4 cm. The MDS assessment reflected the resident had no arterial or [MEDICAL CONDITION]. Resident #1 was observed in the hospital on [DATE] at 10:00 a.m. resting in bed on the ICU with an indwelling urinary catheter, nasogastric tube, and the she was receiving intravenous antibiotic therapy. The ICU nurse stated there had been a plan to debride (to remove dead, contaminated, or adherent tissue that may promote infection and impede healing) the resident's right heel pressure ulcer yesterday (09/10/18), but the resident suffered a decline and it was postponed. The nurse stated surgical debridement of the resident's sacral pressure ulcer was scheduled for today (09/11/18). The nurse further stated the resident was admitted to the ICU directly from theER on [DATE] with multiple pressure ulcers that were still present. She stated she had just completed wound care but would remove them if the surveyor insisted. To prevent any further discomfort and distress to the resident the wounds were not observed. Review of the hospital H&P dated 09/06/18 revealed Resident #1 was arrived in the ER with lethargy, altered mental status and [MEDICAL CONDITION]. A Stage II pressure ulcer was noted to the left heel and a large foul-smelling necrotic wound was noted to the right heel. The H&P further reflected the resident's admitting [DIAGNOSES REDACTED].[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger [MEDICAL CONDITION] responses throughout the body. [MEDICAL CONDITION] progresses to septic shock, blood pressure drops dramatically, which may lead to death) with septic shock likely secondary to the necrotic heel wound, UTI and pneumonia and acute kidney injury secondary to [MEDICAL CONDITION] with shock. The resident was treated with intravenous fluids and intravenous antibiotics. Review of hospital records included photographic wound documentation dated 09/06/18 of 6 photos of pressure ulcers Resident #1was admitted with. The photographic wound documentation reflected the following: 1) Right heel pressure ulcer unstageable - 8 cm x 4 cm; 2) Left lateral lower extremity (leg) pressure ulcer unstageable - 5 cm x 3 cm; 3) Coccyx pressure ulcer unstagable - 6 cm x 7 cm; 4) Right elbow pressure ulcer unstageable - 3 cm x 2 cm; 5) Left heel pressure ulcer DTI - No measurements the DTI encompasses the entire heel; and 6) Left inner foot pressure ulcer unstageable - 1 cm x 1 cm. Review of the hospital's Present on Admit form dated 09/06/18 reflected all of Resident #1's pressure ulcers and skin impairments listed in the photographic wound documentation were present on admission to the hospital. Review of Resident #1's nurse's weekly skin assessments for the month of (MONTH) (YEAR) revealed the weekly assessments available reflected assessments were performed on 08/01/18, twenty-one days later, on 08/22/18 then seven days later, on 08/29/18. The three assessments reflected the resident had a DTI to the right heel. There was no documented assessment of the DTI pressure ulcer to include a description, measurements or other characteristics. The area on the assessment forms to check yes or no if the resident had a pressure injury were marked no. The instructions on the nurse's weekly skin assessment forms reflected if there was a pressure injury noted, a weekly pressure injury assessment form should be initiated, an assessment should be performed and documented weekly until healed. The nurse's weekly skin assessments incorrectly reflected the resident did not have a pressure injury. There were no weekly pressure injury assessment forms initiated or documented assessments performed as a result of the skin assessments dated 08/1/18, 08/22/18 or 08/29/18 which indicated the resident had a DTI. A list provided by the CRN G on 09/17/18 reflected Resident #1 had no hospital transfers and remained in the facility during the omitted weekly skin assessments. Nurse's notes dated 08/09/18 and timed 1:13 p.m. reflected Resident #1's pressure ulcer to the right heel appeared red and was noted with moderate drainage. There was no information related to the type of drainage, size, stage of the wound or if the physician had been notified of the findings. An interview with the facility's DON on 09/09/18 at 7:00 p.m. revealed she had been the DON for two weeks. She stated Resident #1 was transferred to the hospital on [DATE] due to respiratory distress. The DON stated she had seen the wounds of the two residents with the most severe pressure ulcers. She stated the facility had a new WCP whose first visit was on 09/04/18 and she ensured the residents with the most severe pressure ulcers (Resident #1 and Resident #3) were seen on 09/04/18. The DON further stated on Thursday (09/06/18) LVN A informed her Resident #1's right heel pressure ulcer appeared worse. On 09/09/18 the DON provided WCP notes/assessment dated [DATE] reflecting Resident #1 was assessed with [REDACTED]. The wound was surrounded by 11.0 cm x 11.0 cm of DTI. The wound was assessed with [REDACTED]. The WCP assessment reflected the pressure ulcer was debrided on 09/04/18. The treatment was changed to apply [MEDICATION NAME] (an antiseptic used to treat wounds and skin infections) every day and the antibiotic Bactrim DS was ordered to be administered orally two times a day for 10 days. WCP assessments in (MONTH) (YEAR) were dated 08/02/18 and 08/30/18. The assessment dated [DATE] reflected Resident #1 had a Stage IV pressure ulcer to the right heel with moderate drainage and 60% slough. Measurements were 4.2 cm x 3.4 cm x 0.4 cm. The next WCP assessment was dated twenty-eight days later, on 08/30/18. The assessment reflected the resident had a Stage IV pressure ulcer to the right heel with light bloody drainage and 100% slough. Necrotic tissue was removed at this visit via debridement and measurements were 4.5 cm x 4.0 cm x 0.6 cm. On 09/13/18/18 CRN G provided an additional nurse's notes dated 08/03/18 reflecting LVN A had documented an assessment of Resident #1's pressure ulcer. The note reflected the resident had a Stage IV to the right heel with moderate drainage. The measurements were the same as the WCP assessment dated [DATE] of 4.2 cm x 3.4 cm x 0.4 cm. (The National Pressure Ulcer Advisory Panel (NPUAP) web site (www.npuap.org) viewed on 09/20/18 defines a Stage IV pressure injury as a full thickness tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament cartilage or bone in the ulcer). There were no other documented assessments of the condition of Resident #1's pressure ulcer during the 28-days between the WCP visits/assessments on 08/02/18 and 08/30/18. The facility's records did not identify any other pressure ulcers other than the right heel. On 09/09/18 at 7:35 p.m. the ADON stated there were only three residents with pressure ulcers. Resident #1 who was currently in the hospital, admitted with a pressure ulcer to the right heel, Resident #2 admitted with a pressure ulcer to the right heel and Resident #3 developed a pressure ulcer to the coccyx in the facility. Review of Resident #1's Braden Scale pressure sore risk assessment dated [DATE] revealed a score of 16 and reflected the resident was at a low risk of developing pressure ulcers even though the resident currently had a pressure ulcer on 08/02/18 according to WCP notes/assessments. An interview with the DON on 09/09/18 at 8:02 p.m. revealed nurses were responsible for completing weekly skin assessments. She stated she was not aware of the incomplete/inaccurate skin assessments, omitted skin assessments or the lack of documented assessments of Resident #1's pressure ulcer. An interview with LVN A on 09/11/18 at 11:34 a.m. revealed she was the day shift charge nurse for Hall 200 where Resident #1 resided. She stated the resident admitted to the facility with a pressure ulcer to the right heel. The pressure ulcer was closed, dark colored, firm and unstageable. LVN A stated Resident #1 also had a skin tear to the right buttock and both skin tears were present when the resident was transferred to the hospital on [DATE]. The nurse further stated the resident's right heel pressure ulcer was getting worse when she returned from vacation on 08/20/18. LVN A stated she was unable to verbalize specifically how the pressure ulcer appeared worse she just recalls it was different. She then stated she noticed the pressure ulcer looking worse a few days before the WCP visited on 09/04/18. The nurse stated there was drainage but no odor. Additionally, LVN A stated she had a conversation with the DON about sending Resident #1 out for more aggressive wound care just before the resident was transferred to the hospital. She did not see any improvements in the pressure ulcer even though the WCP was treating the pressure ulcer and different treatments had been attempted. The right heel pressure ulcer was larger than a half dollar without odor or drainage. LVN A stated prior to the WCP visit on 09/04/18 there was an area on Resident #1's coccyx. The nurse was unable to recall when but stated it had been sometime after she returned from vacation on 08/20/18. She stated she was not sure if the WCP was aware of the area on the resident's coccyx. When queried about whether she had informed/called the physician or WCP she stated no, because the WCP came weekly and was scheduled to make a visit. She stated in the past the ADON scheduled the WCP visits and she did not know how to get in touch with the WCP. LVN A stated she was not that comfortable or knowledgeable about pressure ulcers and in the past the treatment nurse and later the former ADON had completed weekly skin assessments, kept up with pressure ulcers, treatments and weekly skin assessments. LVN A stated currently nurses were responsible for performing weekly skin assessments according to a schedule. The day shift nurses were assigned to residents residing in A-beds and the evening shift nurses were assigned to residents in the B-beds. (Resident #1 resided in an A bed). The nurse provided no information about why weekly skin assessments were not performed consistently for Resident #1. She stated the weekly skin assessment schedule changed often and she was not aware the assessments were not completed weekly. LVN A stated she found out last week she was to perform weekly pressure ulcer assessments for residents. She further stated she did not recall performing any weekly pressure ulcer assessments for Resident #1 because she had not been aware it was her responsibility to do so. The nurse stated she had not obtained any measurements of the Resident #1's pressure ulcer to the right heel or documented any other characteristics (description-color-appearance) of the pressure ulcer because the form did not ask for any additional information. An interview with CNA F on 09/12/18 at 11:10 p.m. revealed she provided care for Resident #1 routinely. She stated she was on duty during the day shift of 09/06/18 when the resident went to the hospital. She further stated she noticed a black area on the resident's buttock located near the middle of resident's lower back. She described the location of the black area as on that bone part. She stated the area was near the crack of the resident's buttock and not located on the butt cheeks. The CNA stated the area was very black and she had reported it to the charge nurse, LVN A on 08/29/18 a week prior to the resident's hospital transfer. CNA F stated the next day 08/30/18 she noticed an open area on the resident's left elbow that looked like a popped blister. She stated when she reported the skin issues to LVN A, the nurse came to look at the areas. CNA F further stated on the day Resident #1 went out to the hospital there was a dressing on both areas. A telephone interview with the facility's previous WCP (WCP D) on 09/11/18 at 3:15 p.m. revealed he saw residents in the facility for three weeks. He stated the facility had a DON who initially agreed to make wound rounds with him but did not follow through on the agreement. He stated he needed someone to open dressing on wounds and/or pressure ulcers and tell him something about the residents. He stated the next time he visited the facility the ADON assisted him and she was helpful and appeared interested. He stated none of the nurses knew anything about the resident's wounds and/or pressure ulcers. At one point he was told the nurses would be making wound rounds with him and assisting. He further stated the problem was that there was no treatment nurse or any one person who was aware of the wounds and/or pressure ulcers in the facility. He stated he was not able to recall exactly who Resident #1 was. Additionally, he stated the nurses never told him anything about the residents or the wounds and/or pressure ulcers. He stated he made rounds alone with his scribe who only documented. He stated the nurses were not involved, interested or willing to assist him. He stated it was possible a wound and/or pressure ulcer was not assessed or treated by him as no one ever told him anything. An interview was conducted with Resident #1's PCP on 09/12/18 at 11:42 a.m. about his knowledge of the condition of the resident's skin and pressure ulcers. He stated he provided mostly medical care and deferred wound care to the WCP. He stated if he was in the facility and the nurses needed him to assess a pressure ulcer he would do it. He further stated if there were concerns or problems related to pressure ulcers the nurses would contact the WCP. He did not recall any notifications regarding Resident #1's pressure ulcer. A telephone interview with the facility's current WCP (WCP E) on 09/12/18 at 12:44 p.m. revealed he recalled seeing Resident #1 for an initial consult. He stated after the initial visit his colleague (WCP D) saw the resident for approximately 3 weeks. He stated when he visited the facility he did not go looking around for patients to see. Nurses or the DON showed him and his colleague which residents with wounds they wanted them to see. WCP E further stated there had been problems with the facility's nurses showing he and his colleague which resident were to be seen. He stated it was a hit and miss sometimes as the nursing staff did not always show them which residents required visits. He stated the problem had been the previous DON and one other nurse who he was unable to recall the name. He stated he urged them to make some type of list and told them this on several occasions. The previous DON and nurse did not have a list and would attempt to recall from memory what patients had what wounds. WCP E was queried during this interview about why in (MONTH) (YEAR) there had been a 27-day period (08/02/18 and 08/30/18) between WCP assessments/visits for Resident #1. He stated it would be his guess the nurses/DON did not show the resident to the WCP. He stated he has a good rapport with the corporate staff and the problem had been with the previous DON. Additionally, he stated his records reflected only WCP visits for Resident #1 in (MONTH) were on 08/02/18 and 08/30/18. (2) Review of Resident #2's undated Admission Record revealed the resident was a [AGE] year old male initially admitted on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The physician's H&P dated 05/27/18 reflected Resident #2 had a history of [REDACTED]. There was no examination of the resident's skin. Observation of Resident #2 with the ADON on 09/09/18 at 9:15 p.m. revealed the resident was sleeping in bed with a dressing to the right heel dated 09/02/18. The ADON removed the dressing revealing a closed DTI with dark black edges formed in a circular pattern. The center of the DTI was pink. Measurements obtained by the ADON were 3.5 cm x 2.5 cm. A physician's orders [REDACTED]. Review of the resident's MDS assessment dated [DATE] and revealed the resident's BIMS score was 15 indicating his cognition was intact. Extensive assistance of one person was required for bed mobility, eating, dressing and personal hygiene. Transfers did not occur, and the resident was frequently incontinent of bowel/bladder. Section M skin condition reflected the resident was at risk for developing pressure ulcers but had no pressure ulcers. Review of Resident #2's Braden Scale pressure sore risk assessments dated 08/06/18 and 08/13/18 revealed the scores were 12. The assessments reflected the resident was at a high risk for developing of pressure ulcers. Resident #2's care plan initiated on 09/09/18 and revised on 09/10/18 reflected the resident had a pressure ulcer or potential for pressure ulcer development. Care plan goals to address the resident's actual pressure ulcer included remaining free of infection and having signs of healing. Interventions included assessing, recording, and monitoring wound healing at least weekly, measure length, width and dept where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD. Revised interventions added 09/10/18 included administering treatments as ordered and monitoring for effectiveness. An interview with LVN B on 09/11/18 at 12:35 p.m., revealed he provided care for Resident #2. He stated he was not aware the resident had any wounds or treatments other than for the left AKA. Review of Resident #2's (MONTH) (YEAR) TARs with LVN B on 09/11/18 revealed no treatment to the resident's right heel had been transcribed to the TARs. Further clinical record review revealed a physician's telephone order dated 09/10/18 to discontinue the Venelex to the right heel DTI. This treatment was still valid during the observation of Resident #2's right heel and dressing on 09/09/18 at 9:15 p.m. TARs dated (MONTH) (YEAR) were reviewed and reflected no treatment to the resident's right heel had been transcribed to the TARs. An interview with the CRN G on 09/1/183 at 1:10 p.m. Resident 2's TARs did not contain the order for the treatment to his right heel because nurses had not input the order in correctly to ensure it would post to TAR. She stated the nurses had input the order in to post to the wound care sheet, but the wound care sheet was not printed. Resident #2's weekly skin assessments for (MONTH) (YEAR) were reviewed and were dated 08/24/18 and 08/27/18. The weekly skin assessment dated [DATE] reflected the resident had a pressure ulcer. The assessment did not reflect a location, description, measurements or other characteristics about the pressure ulcer. A list provided by the CRN G on 09/17/18 reflected the resident had been out of the facility due to a hospital transfer on 08/20/18 (Admission record reflects the resident readmitted [DATE]). The resident remained in the facility during the omitted weekly skin assessments. The instructions on the nurse's weekly skin assessment forms reflected if there was a pressure injury noted, a weekly pressure injury assessment form should be initiated, an assessment should be performed and documented weekly until healed. The next weekly skin assessment was dated 08/27/18 and reflected the resident did not have a pressure ulcer/injury. Nurse's weekly pressure ulcer and pressure injury forms were dated 08/25/18 and 09/09/18. The assessments reflected the resident had a pressure ulcer to the right heel. The 08/25/18 assessment reflected the right heel ulcer was a Stage II measuring 4 cm x 3 cm and was first identified on 07/23/18. The 09/09/18 weekly pressure injury form reflected the resident had an unstageable pressure ulcer to the right heel measuring 3.5 cm x 2.6 cm x 0.2 cm and was first identified on 07/10/18. The WCP assessment dated [DATE] reflected Resident #2 was assessed with [REDACTED]. (3) Review of Resident #3's undated Admission Record revealed she was an [AGE] year-old female admitted on [DATE]. [DIAGNOSES REDACTED]. The physician's H&P dated 06/16/18 reflected Resident #3 was a poor historian secondary to dementia. The physical exam of the resident's skin reflected the skin was intact with no rashes, skin breakdown or [MEDICAL CONDITION]. Review of the resident's MDS assessment dated [DATE] revealed cognitive skills for daily decision making were severely impaired, the resident was totally dependent on staff for all activities of daily living and was always incontinent of bowel/bladder. Section M of the MDS assessment related to skin condition reflected the resident was at risk for development of pressure ulcers but had no pressure ulcers. Observation of Resident #3 with the ADON on 09/09/18 at 8:50 p.m. revealed the resident was resting in bed with a dressing to the coccyx dated 09/09/18. The ADON removed the dressing revealing a dark brown/black open area with a moderate amount of serosanguinous (thin, watery, pale red to pink plasma with red blood cells) drainage on the old dressing. Measurements obtained by the ADON were 5 cm x 3.5 cm x 0.8 cm. The only care plan to address pressure ulcers was initiated 09/09/18 even though the MDS assessment reflected the resident was at risk for pressure ulcer development. The care plan reflected Resident #3 had a Stage II pressure ulcer to the coccyx. Goals were the pressure ulcer would show S/S (signs and symptoms) of healing and remain free from infection. Interventions included assessing, recording, and monitoring wound healing at least weekly, measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD. Resident #3's weekly nurse's skin assessment dated [DATE] reflected the resident had no pressure ulcers. The only Braden Scale pressure sore risk assessment available was dated 09/14/18. The score was 9 and the assessment reflected the resident was at risk of developing of pressure ulcers. The next weekly skin assessment was dated two weeks later, on 08/30/18 and reflected Resident has open area to sacral area. The only nurse's weekly pressure injury form was dated 08/30/18. The form reflected a pressure ulcer to the coccyx was identified on 08/30/18. The measurements were 1.2 cm x 0.9 cm x 0.6 cm. A list provided by the CRN G on 09/17/18 reflected Resident #3 had no hospital transfers and remained in the facility during the omitted weekly skin assessments. The WCP assessment was also dated 08/30/18 and reflected Resident #3 had a Stage IV pressure ulcer to the coccyx measuring 1.2 cm x 0.9 cm x 0.6 cm. The WCP assessment dated [DATE] reflected the resident's coccyx pressure ulcer had an odor, was unstageable with 70% necrotic tissue and 10% slough. The orders were changed from Calcium Alginate daily to applying [MEDICATION NAME] daily and starting the antibiotic Bactrim DS one orally every day for ten days. During an interview on 09/09/18 at 10:45 p.m. the ADON stated a problem with nursing staff performing skin assessments and pressure ulcer assessments had been identified by the facility and training had been provided to nursing staff. The ADON provided in-service attendance records dated 04/30/18 related to weekly skin and pressure ulcer assessments. According to the attendance records provided the training began at 1:30 p.m. and completed ten minutes later at 1:40 p.m. The ADON stated she was not aware of any monitoring to determine the effectiveness of the training. On 09/11/18 at 11:10 a.m. the ADON and DON stated skin-assessments on all residents were initiated 09/09/18 and completed 09/10/18. The DON provided skin assessments and a WCP assessment dated [DATE]. A list provided by the CRN G on 09/17/18 reflected three additional residents (Resident #4, #5 and #6) were identified with pressure ulcers during the facility wide skin assessments conducted on 09/09/18 and 09/10/18. (4) Review of Resident #4's undated Admission Record revealed he was a [AGE] year old male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's MDS assessment dated [DATE] revealed cognitive skills for daily decision making were severely impaired, the resident was totally dependent on staff for all activities of daily living and was frequently incontinent of bowel/bladder. Section M of the MDS assessment related to skin condition reflected the resident was at risk for development of pressure ulcers but had no pressure ulcers. Observation with the ADON on 09/15/18 at 1:00 p.m. revealed Resident #4 was sitting in a Geri-chair in his room. A current dressing to the resident's sacrum was dated 09/15/18. Record review revealed Resident #4's only Braden Scale pressure sore risk assessment was dated 09/10/18. The score was 12 and the assessment reflected the resident was at a high risk for developing pressure ulcers. Resident #4's care plan initiated on 09/12/18 and revised on 09/12/18 reflected the resident had a shear wound to the right of the sacrum. A care plan initiated on 12/26/16 and revised on 09/12/18 reflected the resident had a DTI to the right heel. Care plan goals included remaining free of infection and having signs of healing. Interventions included administering treatments as ordered, monitoring for effectiveness, assess/record/monitor wound healing at least weekly, measure length, width and dept where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD. Nurse's weekly skin assessments were dated 08/15/18 and two weeks later on 08/29/18. The weekly skin assessment dated [DATE] reflected the resident had no pressure ulcer/injury. The weekly skin assessment dated [DATE] reflected Resident #4

Based on observations, interviews, and record reviews the facility's DON and CRN G failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for six (Residents #1, #2, #3, #4, #5 and #6) of eight residents reviewed for pressure ulcers. The DON and CRN G failed to: - sufficiently train and monitor nursing staff to ensure proper identification, assessment, and treatment of [REDACTED].#1, #2, #3, #4, #5, and #6. - ensure nursing staff assessed and documented a detailed description of Resident #1's pressure ulcer on admission; - ensure nursing staff assessed and documented the condition of Resident #1's pressure ulcer from 08/03/18 until 08/30/18 for a total of 27 days. When Resident #1 was transferred to the hospital on [DATE], the resident was found to have five unstageable pressure ulcers and DTIs that had not been identified by facility nursing staff; - ensure nursing staff provided Resident #2 with daily pressure ulcer treatment as ordered by the physician for seven days; and - implement and monitor the facility's Skin Integrity Monitoring System to ensure nursing staff were conducting weekly skin assessments and quarterly screening for the risk of pressure ulcer development for residents including Residents #1, #2, #3, #4, and #6. An Immediate Jeopardy (IJ) was identified on 09/11/18. While the IJ was removed on 09/17/18, the facility remained out of compliance at isolated with actual harm that was not IJ due to the facility's need to monitor the effectiveness of the Plan Removal. These failures affected six residents with pressure ulcers and placed seven residents with pressure ulcers and 35 residents receiving preventive skin care at risk for developing new pressure ulcers, pain, deterioration in existing pressure ulcers, infection and even hospitalization . Findings included: (1) Review of Resident #1's facility nursing admission assessment dated [DATE] reflected the resident was admitted [DATE] with a right heel pressure ulcer. There was no documentation on the admission assessment of any assessment of the pressure ulcer to include a description, stage, measurements or other characteristics. Review of a nurse's weekly ulcer assessment form dated 03/27/18 revealed the resident had a Stage II pressure ulcer to the right heel. The wound bed was described as pink and there was no odor. There were no documented measurements of the pressure ulcer to reflect what size it was. Review of a nurse's weekly ulcer assessment form dated 04/03/18 revealed Resident #1 had a right heel DTI measuring 10.5 cm x 11.0 cm, with black eschar (Eschar-thick black necrotic/dead tissue) in the wound bed and no odor. The assessment form incorrectly identified the ulcer type as arterial instead of pressure. (The National Pressure Ulcer Advisory Panel (NPUAP) web site (www.npuap.org) viewed on 09/20/18 defines a DTI-Deep Tissue Injury as a pressure injury resulting in persistent non-blanchable deep red, maroon or purple discoloration of intact or not intact skin). Review of nurse's weekly ulcer assessment dated [DATE] revealed the resident had an ulcer to the right heel measuring 4 cm x 7.9 cm. The color of the wound bed was black/eschar with 50% necrosis and the skin around the wound was macerated (softening and breaking down of skin resulting from prolonged exposure to moisture). with light bloody opaque or purulent exudate. This assessment incorrectly identified the ulcer type as diabetic instead of pressure. Attempts to interview the author of the assessment were unsuccessful. Record review of the facility's discharge logs revealed Resident #1 was transferred to the hospital on [DATE]. Review of Resident #1's undated Admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #1's care plan initiated 04/03/18 and revised 07/05/18 reflected the resident: Has pressure ulcer or potential for pressure ulcer development. The goal was for the resident's pressure ulcer to show signs of healing and remain free from infection. Interventions included assess/record/monitor wound healing at least weekly, measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to MD. The resident's facility H&P dated 04/12/18 reflected it was a new visit and the resident had a history of [REDACTED]. The H&P reflected Resident #1 was admitted to the facility due to risk of elopement. The physical exam of the resident's skin only reflected normal temperature. Resident #1's MDS assessment dated [DATE] reflected a BIMS score of 9 indicating moderately impaired cognition. The MDS assessment further reflected the resident was frequently incontinent of bowel/bladder, required extensive two-person assistance for bed mobility, transfers, personal hygiene and dressing. Section M of the MDS assessment related to skin conditions, reflected the resident was at risk of developing a pressure ulcer and had a Stage IV pressure ulcer that was present on admission. The measurements were 4.2 cm x 3.4 cm x 0.4 cm. The MDS assessment reflected the resident had no arterial or [MEDICAL CONDITION]. Resident #1 was observed in the hospital on [DATE] at 10:00 a.m. resting in bed on the ICU with an indwelling urinary catheter, nasogastric tube, and the she was receiving intravenous antibiotic therapy. The ICU nurse stated there had been a plan to debride (to remove dead, contaminated, or adherent tissue that may promote infection and impede healing) the resident's right heel pressure ulcer yesterday (09/10/18), but the resident suffered a decline and it was postponed. The nurse stated surgical debridement of the resident's sacral pressure ulcer was scheduled for today (09/11/18). The nurse further stated the resident was admitted to the ICU directly from theER on [DATE] with multiple pressure ulcers that were still present. She stated she had just completed wound care but would remove them if the surveyor insisted. To prevent any further discomfort and distress to the resident the wounds were not observed. Review of the hospital H&P dated 09/06/18 revealed Resident #1 was arrived in the ER with lethargy, altered mental status and [MEDICAL CONDITION]. A Stage II pressure ulcer was noted to the left heel and a large foul-smelling necrotic wound was noted to the right heel. The H&P further reflected the resident's admitting [DIAGNOSES REDACTED].[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger [MEDICAL CONDITION] responses throughout the body. [MEDICAL CONDITION] progresses to septic shock, blood pressure drops dramatically, which may lead to death) with septic shock likely secondary to the necrotic heel wound, UTI and pneumonia and acute kidney injury secondary to [MEDICAL CONDITION] with shock. The resident was treated with intravenous fluids and intravenous antibiotics. Review of hospital records included photographic wound documentation dated 09/06/18 of 6 photos of pressure ulcers Resident #1was admitted with. The photographic wound documentation reflected the following: 1) Right heel pressure ulcer unstageable - 8 cm x 4 cm; 2) Left lateral lower extremity (leg) pressure ulcer unstageable - 5 cm x 3 cm; 3) Coccyx pressure ulcer unstagable - 6 cm x 7 cm; 4) Right elbow pressure ulcer unstageable - 3 cm x 2 cm; 5) Left heel pressure ulcer DTI - No measurements the DTI encompasses the entire heel; and 6) Left inner foot pressure ulcer unstageable - 1 cm x 1 cm. Review of the hospital's Present on Admit form dated 09/06/18 reflected all of Resident #1's pressure ulcers and skin impairments listed in the photographic wound documentation were present on admission to the hospital. Review of Resident #1's nurse's weekly skin assessments for the month of (MONTH) (YEAR) revealed the weekly assessments available reflected assessments were performed on 08/01/18, twenty-one days later, on 08/22/18 then seven days later, on 08/29/18. The three assessments reflected the resident had a DTI to the right heel. There was no documented assessment of the DTI pressure ulcer to include a description, measurements or other characteristics. The area on the assessment forms to check yes or no if the resident had a pressure injury were marked no. The instructions on the nurse's weekly skin assessment forms reflected if there was a pressure injury noted, a weekly pressure injury assessment form should be initiated, an assessment should be performed and documented weekly until healed. The nurse's weekly skin assessments incorrectly reflected the resident did not have a pressure injury. There were no weekly pressure injury assessment forms initiated or documented assessments performed as a result of the skin assessments dated 08/1/18, 08/22/18 or 08/29/18 which indicated the resident had a DTI. A list provided by the CRN G on 09/17/18 reflected Resident #1 had no hospital transfers and remained in the facility during the omitted weekly skin assessments. Nurse's notes dated 08/09/18 and timed 1:13 p.m. reflected Resident #1's pressure ulcer to the right heel appeared red and was noted with moderate drainage. There was no information related to the type of drainage, size, stage of the wound or if the physician had been notified of the findings. An interview with the facility's DON on 09/09/18 at 7:00 p.m. revealed she had been the DON for two weeks. She stated Resident #1 was transferred to the hospital on [DATE] due to respiratory distress. The DON stated she had seen the wounds of the two residents with the most severe pressure ulcers. She stated the facility had a new WCP whose first visit was on 09/04/18 and she ensured the residents with the most severe pressure ulcers (Resident #1 and Resident #3) were seen on 09/04/18. The DON further stated on Thursday (09/06/18) LVN A informed her Resident #1's right heel pressure ulcer appeared worse. On 09/09/18 the DON provided WCP notes/assessment dated [DATE] reflecting Resident #1 was assessed with [REDACTED]. The wound was surrounded by 11.0 cm x 11.0 cm of DTI. The wound was assessed with [REDACTED]. The WCP assessment reflected the pressure ulcer was debrided on 09/04/18. The treatment was changed to apply [MEDICATION NAME] (an antiseptic used to treat wounds and skin infections) every day and the antibiotic Bactrim DS was ordered to be administered orally two times a day for 10 days. WCP assessments in (MONTH) (YEAR) were dated 08/02/18 and 08/30/18. The assessment dated [DATE] reflected Resident #1 had a Stage IV pressure ulcer to the right heel with moderate drainage and 60% slough. Measurements were 4.2 cm x 3.4 cm x 0.4 cm. The next WCP assessment was dated twenty-eight days later, on 08/30/18. The assessment reflected the resident had a Stage IV pressure ulcer to the right heel with light bloody drainage and 100% slough. Necrotic tissue was removed at this visit via debridement and measurements were 4.5 cm x 4.0 cm x 0.6 cm. On 09/13/18/18 CRN G provided an additional nurse's notes dated 08/03/18 reflecting LVN A had documented an assessment of Resident #1's pressure ulcer. The note reflected the resident had a Stage IV to the right heel with moderate drainage. The measurements were the same as the WCP assessment dated [DATE] of 4.2 cm x 3.4 cm x 0.4 cm. (The National Pressure Ulcer Advisory Panel (NPUAP) web site (www.npuap.org) viewed on 09/20/18 defines a Stage IV pressure injury as a full thickness tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament cartilage or bone in the ulcer). There were no other documented assessments of the condition of Resident #1's pressure ulcer during the 28-days between the WCP visits/assessments on 08/02/18 and 08/30/18. The facility's records did not identify any other pressure ulcers other than the right heel. On 09/09/18 at 7:35 p.m. the ADON stated there were only three residents with pressure ulcers. Resident #1 who was currently in the hospital, admitted with a pressure ulcer to the right heel, Resident #2 admitted with a pressure ulcer to the right heel and Resident #3 developed a pressure ulcer to the coccyx in the facility. Review of Resident #1's Braden Scale pressure sore risk assessment dated [DATE] revealed a score of 16 and reflected the resident was at a low risk of developing pressure ulcers even though the resident currently had a pressure ulcer on 08/02/18 according to WCP notes/assessments. An interview with the DON on 09/09/18 at 8:02 p.m. revealed nurses were responsible for completing weekly skin assessments. She stated she was not aware of the incomplete/inaccurate skin assessments, omitted skin assessments or the lack of documented assessments of Resident #1's pressure ulcer. An interview with LVN A on 09/11/18 at 11:34 a.m. revealed she was the day shift charge nurse for Hall 200 where Resident #1 resided. She stated the resident admitted to the facility with a pressure ulcer to the right heel. The pressure ulcer was closed, dark colored, firm and unstageable. LVN A stated Resident #1 also had a skin tear to the right buttock and both skin tears were present when the resident was transferred to the hospital on [DATE]. The nurse further stated the resident's right heel pressure ulcer was getting worse when she returned from vacation on 08/20/18. LVN A stated she was unable to verbalize specifically how the pressure ulcer appeared worse she just recalls it was different. She then stated she noticed the pressure ulcer looking worse a few days before the WCP visited on 09/04/18. The nurse stated there was drainage but no odor. Additionally, LVN A stated she had a conversation with the DON about sending Resident #1 out for more aggressive wound care just before the resident was transferred to the hospital. She did not see any improvements in the pressure ulcer even though the WCP was treating the pressure ulcer and different treatments had been attempted. The right heel pressure ulcer was larger than a half dollar without odor or drainage. LVN A stated prior to the WCP visit on 09/04/18 there was an area on Resident #1's coccyx. The nurse was unable to recall when but stated it had been sometime after she returned from vacation on 08/20/18. She stated she was not sure if the WCP was aware of the area on the resident's coccyx. When queried about whether she had informed/called the physician or WCP she stated no, because the WCP came weekly and was scheduled to make a visit. She stated in the past the ADON scheduled the WCP visits and she did not know how to get in touch with the WCP. LVN A stated she was not that comfortable or knowledgeable about pressure ulcers and in the past the treatment nurse and later the former ADON had completed weekly skin assessments, kept up with pressure ulcers, treatments and weekly skin assessments. LVN A stated currently nurses were responsible for performing weekly skin assessments according to a schedule. The day shift nurses were assigned to residents residing in A-beds and the evening shift nurses were assigned to residents in the B-beds. (Resident #1 resided in an A bed). The nurse provided no information about why weekly skin assessments were not performed consistently for Resident #1. She stated the weekly skin assessment schedule changed often and she was not aware the assessments were not completed weekly. LVN A stated she found out last week she was to perform weekly pressure ulcer assessments for residents. She further stated she did not recall performing any weekly pressure ulcer assessments for Resident #1 because she had not been aware it was her responsibility to do so. The nurse stated she had not obtained any measurements of the Resident #1's pressure ulcer to the right heel or documented any other characteristics (description-color-appearance) of the pressure ulcer because the form did not ask for any additional information. An interview with CNA F on 09/12/18 at 11:10 p.m. revealed she provided care for Resident #1 routinely. She stated she was on duty during the day shift of 09/06/18 when the resident went to the hospital. She further stated she noticed a black area on the resident's buttock located near the middle of resident's lower back. She described the location of the black area as on that bone part. She stated the area was near the crack of the resident's buttock and not located on the butt cheeks. The CNA stated the area was very black and she had reported it to the charge nurse, LVN A on 08/29/18 a week prior to the resident's hospital transfer. CNA F stated the next day 08/30/18 she noticed an open area on the resident's left elbow that looked like a popped blister. She stated when she reported the skin issues to LVN A, the nurse came to look at the areas. CNA F further stated on the day Resident #1 went out to the hospital there was a dressing on both areas. A telephone interview with the facility's previous WCP (WCP D) on 09/11/18 at 3:15 p.m. revealed he saw residents in the facility for three weeks. He stated the facility had a DON who initially agreed to make wound rounds with him but did not follow through on the agreement. He stated he needed someone to open dressing on wounds and/or pressure ulcers and tell him something about the residents. He stated the next time he visited the facility the ADON assisted him and she was helpful and appeared interested. He stated none of the nurses knew anything about the resident's wounds and/or pressure ulcers. At one point he was told the nurses would be making wound rounds with him and assisting. He further stated the problem was that there was no treatment nurse or any one person who was aware of the wounds and/or pressure ulcers in the facility. He stated he was not able to recall exactly who Resident #1 was. Additionally, he stated the nurses never told him anything about the residents or the wounds and/or pressure ulcers. He stated he made rounds alone with his scribe who only documented. He stated the nurses were not involved, interested or willing to assist him. He stated it was possible a wound and/or pressure ulcer was not assessed or treated by him as no one ever told him anything. An interview was conducted with Resident #1's PCP on 09/12/18 at 11:42 a.m. about his knowledge of the condition of the resident's skin and pressure ulcers. He stated he provided mostly medical care and deferred wound care to the WCP. He stated if he was in the facility and the nurses needed him to assess a pressure ulcer he would do it. He further stated if there were concerns or problems related to pressure ulcers the nurses would contact the WCP. He did not recall any notifications regarding Resident #1's pressure ulcer. A telephone interview with the facility's current WCP (WCP E) on 09/12/18 at 12:44 p.m. revealed he recalled seeing Resident #1 for an initial consult. He stated after the initial visit his colleague (WCP D) saw the resident for approximately 3 weeks. He stated when he visited the facility he did not go looking around for patients to see. Nurses or the DON showed him and his colleague which residents with wounds they wanted them to see. WCP E further stated there had been problems with the facility's nurses showing he and his colleague which resident were to be seen. He stated it was a hit and miss sometimes as the nursing staff did not always show them which residents required visits. He stated the problem had been the previous DON and one other nurse who he was unable to recall the name. He stated he urged them to make some type of list and told them this on several occasions. The previous DON and nurse did not have a list and would attempt to recall from memory what patients had what wounds. WCP E was queried during this interview about why in (MONTH) (YEAR) there had been a 27-day period (08/02/18 and 08/30/18) between WCP assessments/visits for Resident #1. He stated it would be his guess the nurses/DON did not show the resident to the WCP. He stated he has a good rapport with the corporate staff and the problem had been with the previous DON. Additionally, he stated his records reflected only WCP visits for Resident #1 in (MONTH) were on 08/02/18 and 08/30/18. (2) Review of Resident #2's undated Admission Record revealed the resident was a [AGE] year old male initially admitted on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The physician's H&P dated 05/27/18 reflected Resident #2 had a history of [REDACTED]. There was no examination of the resident's skin. Observation of Resident #2 with the ADON on 09/09/18 at 9:15 p.m. revealed the resident was sleeping in bed with a dressing to the right heel dated 09/02/18. The ADON removed the dressing revealing a closed DTI with dark black edges formed in a circular pattern. The center of the DTI was pink. Measurements obtained by the ADON were 3.5 cm x 2.5 cm. A physician's orders [REDACTED]. Review of the resident's MDS assessment dated [DATE] and revealed the resident's BIMS score was 15 indicating his cognition was intact. Extensive assistance of one person was required for bed mobility, eating, dressing and personal hygiene. Transfers did not occur, and the resident was frequently incontinent of bowel/bladder. Section M skin condition reflected the resident was at risk for developing pressure ulcers but had no pressure ulcers. Review of Resident #2's Braden Scale pressure sore risk assessments dated 08/06/18 and 08/13/18 revealed the scores were 12. The assessments reflected the resident was at a high risk for developing of pressure ulcers. Resident #2's care plan initiated on 09/09/18 and revised on 09/10/18 reflected the resident had a pressure ulcer or potential for pressure ulcer development. Care plan goals to address the resident's actual pressure ulcer included remaining free of infection and having signs of healing. Interventions included assessing, recording, and monitoring wound healing at least weekly, measure length, width and dept where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD. Revised interventions added 09/10/18 included administering treatments as ordered and monitoring for effectiveness. An interview with LVN B on 09/11/18 at 12:35 p.m., revealed he provided care for Resident #2. He stated he was not aware the resident had any wounds or treatments other than for the left AKA. Review of Resident #2's (MONTH) (YEAR) TARs with LVN B on 09/11/18 revealed no treatment to the resident's right heel had been transcribed to the TARs. Further clinical record review revealed a physician's telephone order dated 09/10/18 to discontinue the Venelex to the right heel DTI. This treatment was still valid during the observation of Resident #2's right heel and dressing on 09/09/18 at 9:15 p.m. TARs dated (MONTH) (YEAR) were reviewed and reflected no treatment to the resident's right heel had been transcribed to the TARs. An interview with the CRN G on 09/1/183 at 1:10 p.m. Resident 2's TARs did not contain the order for the treatment to his right heel because nurses had not input the order in correctly to ensure it would post to TAR. She stated the nurses had input the order in to post to the wound care sheet, but the wound care sheet was not printed. Resident #2's weekly skin assessments for (MONTH) (YEAR) were reviewed and were dated 08/24/18 and 08/27/18. The weekly skin assessment dated [DATE] reflected the resident had a pressure ulcer. The assessment did not reflect a location, description, measurements or other characteristics about the pressure ulcer. A list provided by the CRN G on 09/17/18 reflected the resident had been out of the facility due to a hospital transfer on 08/20/18 (Admission record reflects the resident readmitted [DATE]). The resident remained in the facility during the omitted weekly skin assessments. The instructions on the nurse's weekly skin assessment forms reflected if there was a pressure injury noted, a weekly pressure injury assessment form should be initiated, an assessment should be performed and documented weekly until healed. The next weekly skin assessment was dated 08/27/18 and reflected the resident did not have a pressure ulcer/injury. Nurse's weekly pressure ulcer and pressure injury forms were dated 08/25/18 and 09/09/18. The assessments reflected the resident had a pressure ulcer to the right heel. The 08/25/18 assessment reflected the right heel ulcer was a Stage II measuring 4 cm x 3 cm and was first identified on 07/23/18. The 09/09/18 weekly pressure injury form reflected the resident had an unstageable pressure ulcer to the right heel measuring 3.5 cm x 2.6 cm x 0.2 cm and was first identified on 07/10/18. The WCP assessment dated [DATE] reflected Resident #2 was assessed with [REDACTED]. (3) Review of Resident #3's undated Admission Record revealed she was an [AGE] year-old female admitted on [DATE]. [DIAGNOSES REDACTED]. The physician's H&P dated 06/16/18 reflected Resident #3 was a poor historian secondary to dementia. The physical exam of the resident's skin reflected the skin was intact with no rashes, skin breakdown or [MEDICAL CONDITION]. Review of the resident's MDS assessment dated [DATE] revealed cognitive skills for daily decision making were severely impaired, the resident was totally dependent on staff for all activities of daily living and was always incontinent of bowel/bladder. Section M of the MDS assessment related to skin condition reflected the resident was at risk for development of pressure ulcers but had no pressure ulcers. Observation of Resident #3 with the ADON on 09/09/18 at 8:50 p.m. revealed the resident was resting in bed with a dressing to the coccyx dated 09/09/18. The ADON removed the dressing revealing a dark brown/black open area with a moderate amount of serosanguinous (thin, watery, pale red to pink plasma with red blood cells) drainage on the old dressing. Measurements obtained by the ADON were 5 cm x 3.5 cm x 0.8 cm. The only care plan to address pressure ulcers was initiated 09/09/18 even though the MDS assessment reflected the resident was at risk for pressure ulcer development. The care plan reflected Resident #3 had a Stage II pressure ulcer to the coccyx. Goals were the pressure ulcer would show S/S (signs and symptoms) of healing and remain free from infection. Interventions included assessing, recording, and monitoring wound healing at least weekly, measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD. Resident #3's weekly nurse's skin assessment dated [DATE] reflected the resident had no pressure ulcers. The only Braden Scale pressure sore risk assessment available was dated 09/14/18. The score was 9 and the assessment reflected the resident was at risk of developing of pressure ulcers. The next weekly skin assessment was dated two weeks later, on 08/30/18 and reflected Resident has open area to sacral area. The only nurse's weekly pressure injury form was dated 08/30/18. The form reflected a pressure ulcer to the coccyx was identified on 08/30/18. The measurements were 1.2 cm x 0.9 cm x 0.6 cm. A list provided by the CRN G on 09/17/18 reflected Resident #3 had no hospital transfers and remained in the facility during the omitted weekly skin assessments. The WCP assessment was also dated 08/30/18 and reflected Resident #3 had a Stage IV pressure ulcer to the coccyx measuring 1.2 cm x 0.9 cm x 0.6 cm. The WCP assessment dated [DATE] reflected the resident's coccyx pressure ulcer had an odor, was unstageable with 70% necrotic tissue and 10% slough. The orders were changed from Calcium Alginate daily to applying [MEDICATION NAME] daily and starting the antibiotic Bactrim DS one orally every day for ten days. During an interview on 09/09/18 at 10:45 p.m. the ADON stated a problem with nursing staff performing skin assessments and pressure ulcer assessments had been identified by the facility and training had been provided to nursing staff. The ADON provided in-service attendance records dated 04/30/18 related to weekly skin and pressure ulcer assessments. According to the attendance records provided the training began at 1:30 p.m. and completed ten minutes later at 1:40 p.m. The ADON stated she was not aware of any monitoring to determine the effectiveness of the training. On 09/11/18 at 11:10 a.m. the ADON and DON stated skin-assessments on all residents were initiated 09/09/18 and completed 09/10/18. The DON provided skin assessments and a WCP assessment dated [DATE]. A list provided by the CRN G on 09/17/18 reflected three additional residents (Resident #4, #5 and #6) were identified with pressure ulcers during the facility wide skin assessments conducted on 09/09/18 and 09/10/18. (4) Review of Resident #4's undated Admission Record revealed he was a [AGE] year old male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's MDS assessment dated [DATE] revealed cognitive skills for daily decision making were severely impaired, the resident was totally dependent on staff for all activities of daily living and was frequently incontinent of bowel/bladder. Section M of the MDS assessment related to skin condition reflected the resident was at risk for development of pressure ulcers but had no pressure ulcers. Observation with the ADON on 09/15/18 at 1:00 p.m. revealed Resident #4 was sitting in a Geri-chair in his room. A current dressing to the resident's sacrum was dated 09/15/18. Record review revealed Resident #4's only Braden Scale pressure sore risk assessment was dated 09/10/18. The score was 12 and the assessment reflected the resident was at a high risk for developing pressure ulcers. Resident #4's care plan initiated on 09/12/18 and revised on 09/12/18 reflected the resident had a shear wound to the right of the sacrum. A care plan initiated on 12/26/16 and revised on 09/12/18 reflected the resident had a DTI to the right heel. Care plan goals included remaining free of infection and having signs of healing. Interventions included administering treatments as ordered, monitoring for effectiveness, assess/record/monitor wound healing at least weekly, measure length, width and dept where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD. Nurse's weekly skin assessments were dated 08/15/18 and two weeks later on 08/29/18. The weekly skin assessment dated [DATE] reflected the resident had no pressure ulcer/injury. The weekly skin assessment dated [DATE] reflected Resident #4 had a pressure ulcer/injury. The assessment did not reflect a location, description, measurements or other characteristics about the pressure ulcer. The instructions on the nurse's weekly skin assessment forms reflected if the

Based on observation, interview and record review, the facility failed to ensure one (Resident #16) of 19 residents reviewed for the right to be free from abuse was not verbally and mentally abused by facility staff. The facility failed to prevent Resident #16 from being verbally/mentally abused by Dietary Aide F. He felt like "a two-year old" when he was providing assistance with tray preparation and food service to the facility residents and Dietary Aide F spoke to him in a demeaning. He now avoided Dietary Aide F and no longer assisted with tray prep or food service, a job he enjoyed doing. He reported the incident to the Administrator and the Dietary Manager, but Dietary Aide F continued to work at the facility. These failures could affect the facility's other 107 residents, including Resident #16 and placed them at risk for abuse, which could result in low self-esteem, psychological distress, and physical injury. Findings included: Review of Resident #16's MDS assessment, dated 09/29/13, revealed the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The MDS assessment reflected his cognition was intact, and he did not exhibit any behaviors. He required set-up assistance with his ADLs. An interview with Resident #16 on 06/18/14 at 1:50 PM revealed he used to help with tray preparation and had enjoyed helping with food service in the dining room. He said he used to enjoy the activity very much, but last week, when he was tying to help with tray prep as usual, a female dietary aide (Dietary Aide F) spoke to him in a very unpleasant manner. Resident #16 stated since the verbal altercation, he avoided Dietary Aide F and no longer assisted with tray preparation and food service. Resident #16 stated, "It (the altercation with Dietary Aide F) made me feel like a two-year old. I pretty much just avoid that lady now and stay out of the room that she is in." He added he had told the Administrator and the Dietary Manager about the incident and his no longer wanting to work with Dietary Aide F. Resident #16 was a soft-spoken man and did not want to repeat the words Dietary Aide F spoke or the manner in which she had spoken them. Interview with the Administrator on 06/18/14 at 2:02 PM revealed there was no Incident Report written documenting Resident #16's allegation of verbal/mental abuse. When questioned about reporting the incident or investigating the incident between Resident #16 and Dietary Aide F, the Administrator revealed he had not reported the incident and there was no Investigation Report either. When asked what the Administrator did following Resident #16's allegation of verbal/mental abuse against Dietary Aide F, the Administrator, who was the designated Abuse Prohibition Coordinator, stated, "Oh well. I told the Dietary Manager." Interview with the Dietary Manager on 06/18/14 at 2:10 PM revealed Dietary Aide F was a new employee and did not know Resident #16 helped in the dining room. The Dietary Manager stated Dietary Aide F said she did not need him to help, but the Dietary Manager did not know the words used by Dietary Aide F, when she spoke to Resident #16. The Dietary Manager admitted he was trained in abuse prohibition, but stated he did not write an Incident Report or follow-up. He said he talked to Dietary Aide F and had written her up once before for talking to a nurse inappropriately. The Dietary Manager said Dietary Aide F talked loudly and her eyebrows were drawn on, so she was loud and could look rough, but she was really a very nice person. The Dietary Manager stated Resident #16 had told him (the Dietary Manager) he (Resident #16) could not work with Dietary Aide F, because he did not like how she talked. The Dietary Manager thought Resident #16 was satisfied not working with Dietary Aide F and no longer assisting with tray preparation and food service in the dining room. The Dietary Manager stated Resident #16 and Dietary Aide F seemed to be "okay" now. The Dietary Manager admitted , "It's my mistake for not writing it down." Review of Dietary Aide F's employee personnel file revealed written disciplinary actions in writing. On a form entitled Progressive Discipline for Unsatisfactory Conduct and/or Performance dated 04/27/14, Dietary Aide F was suspended for two days for a verbal conflict between her and a co-worker in front of residents and family members. Signed witness statements included comments of throwing a plastic spoon at an LVN accompanied by very intense arguing and cursing in front of residents, family members, and staff. The form reflected Dietary Aide F refused to sign the 04/27/14 suspension. Another verbal warning note dated 05/02/14, reflected that under no circumstances, loud boisterous or swearing language would be tolerated in the facility. Dietary Aide F had signed the 05/02/14 warning. Review of the facility's current Abuse/Neglect Prevention Policy, dated September 2006, revealed, "Mental/psychological abuse - Mistreatment...including....humiliation...or intimidation...Verbal Abuse - The use of any...disparaging or derogatory terms to a resident or within the resident's hearing distance...Residents must also be protected for ...all...forms of retaliation...(The facility) protects the reporter of abuse/neglect from retaliation both during and after the incident investigation. The reporter of abuse/neglect will not be treated negatively or receive any form of treatment that may be considered punishment...When abuse/neglect are suspected or alleged, the facility must immediately act to protect the residents...The Administrator would then begin an investigation...Questions used in the interview should identify who, what, why and when the incident occurred...For unidentified alleged perpetrators...document...hair style/color, clothing, and physical features...." The policy defined neglect as: "A deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental of physical injury, or harm or death to the resident." The policy did not include how the Administrator was supposed to investigate when abuse or neglect occurred. Included with the facility's abuse policy was a page dated January 2001, which reflected, "If you suspect abuse...take the necessary steps to protect the resident...ensure the Administrator and Director of Nursing are aware of the situation. The Administrator is the designated coordinator of the abuse program." Review on 06/17/14 of an undated document entitled, The Facility's Process when Suspected Abuse or Neglect, provided by the Clinical Campus Director on 06/17/14 revealed it was identified as the "new process currently being trained." The process reflected, "to protect the alleged victim by removing the threat: suspension of a staff member, isolating a resident identified as an alleged perpetrator, removing malfunctioning equipment, assigning a staff member to remain with the victim to ensure safety and/or comfort. Promptly notify Administrator, physician, and responsible party... Remove any staff considered to be identified as a threat until resolution can be determined... Notify TDADS of alleged incident... Submit a complete investigation within 5 working days of the allegation... Incidents/grievances will be discussed each morning at stand-up and reportable incidents will be called to TDADS by the administrator within 24 hours." The policy did not identify which incidents were reportable. A statement signed by the Administrator on 06/18/14 reflected, "Incidents identified as questionably reportable incidents due to lack of documentation were reported to TDADS on 6-17-14 by (the Administrator) at 5:05 PM. There were 26 incident reports involving 16 residents...." Review of the facility's Form CMS-672, Resident Census and Conditions of Residents, signed by ADON A on 06/17/14, revealed a census of 107 residents.

Based on interview and record review, it was determined the facility failed to implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents for three (Residents #7, #16 and #24) of 19 residents reviewed for abuse/neglect. 1. The facility failed to prevent Resident #7 from being injured and sustaining a three-centimeter laceration to his left eyebrow. The Administrator was unaware of the incident. Facility staff failed to protect Resident #7 by identifying the perpetrator, leaving Resident #7 and the facility's other residents unprotected. 2. Despite the absence of evidence or a completed investigation, facility staff determined Resident #24 was the perpetrator, who hit Resident #7, transferred him to the ER for a psych eval, and then transferred him to another building and were in the process of discharging him. 3. The facility failed to prevent Resident #16 from being verbally/mentally abused by Dietary Aide F. He felt like "a two-year old" when he was providing assistance with tray preparation and food service to the facility residents and Dietary Aide F spoke to him in a demeaning manner. He now avoided Dietary Aide F and no longer assisted with tray prep or food service, a job he enjoyed doing. He reported the incident to the Administrator and the Dietary Manager, but Dietary Aide F continued to work at the facility. There was no facility investigation. These failures could affect the facility's other 107 residents by placing them at risk for abuse and neglect, which could result in low self-esteem, psychological distress, and physical injury. Findings included: 1. Review of Resident #7's MDS assessment, dated 08/08/13, revealed the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #7 had short-term and long-term memory problems, had severely impaired decision-making skills, and was unable to focus. Resident #7 required extensive to total assistance with activities of daily living, and he had impairment on one side of one arm and one leg. Review of the facility's Resident Incident Report, dated 06/12/14, revealed physical contact had occurred at 8:50 PM and Resident #7 had sustained a three-centimeter laceration above his left eyelid. Immediate action taken was to cleanse the area with normal saline, pat dry, and apply steri-strips and a Band-Aid. Vital signs were taken and [MEDICATION NAME] was given for a pain complaint at a four on a scale of 0 to 10 with ten being the worst pain. Resident #7's family and physician were notified. The narrative of the incident reflected, "Resident states he got into a fight with a white/Hispanic male that told him to get out of the way then hit him on his eyebrow." Neurological Assessments checks were completed every 15 minutes from 8:50 PM until 9:30 PM and every 30 minutes from 9:30 PM until 10:30 PM. Interviews conducted did not reveal an actual witness. A witness statement signed by CNA D reflected, "Went room to room trying to help (Resident #7) identify the resident that caused his injury. He could not tell me who caused it." When asked on 06/17/14 at 4:00 PM about the appropriateness of the CNA taking the Resident #7 room to room to identify who hit him, the Clinical Campus Director was silent and turned her head side to side in disbelief. Nurse's Notes, dated 06/12/14 at 8:50 PM and signed by LVN E, reflected, "Nurse noticed this resident (Resident #7) coming down to (Hall) 200 with bloody shirt and pants when asked patient states, 'I got into a fight with another white/Hispanic resident he told me to get out of the way and he hit me.' Few residents questioned. Statements collected. Admin, ADON, RP made aware. Stat X-ray ordered. Cleanse area with normal saline pat dry steri-strips applied. Left upper eyebrow with 3 cm (centimeters) length and 1 cm depth. Icepack admin (administered) due to swelling every 30 min (minutes) prn (as needed). [MEDICATION NAME] 5/325 mg 1 tab (tablet) po (by mouth) administered. Neuro checks in progress." Nurse's Notes, dated 06/13/14 at 5:00 AM reflected an ice pack was applied to Resident #7's left eyebrow once that shift. Observation during the initial tour on 06/16/14 at 9:45 AM revealed Resident #7 had two steri-strip adhesive bandages affixed to a laceration above the resident's left eyebrow. When asked about the laceration, Resident #7 said "two guys" had tried to rob him, but they did not get anything, because he did not have any money. Resident #7 continued to say the "two guys" threatened him by telling him he better have some money next time and hit him. CNA C entered Resident #7's room, smiled, and asked, "Is he (Resident #7) telling stories?" Interview with LVN E on 06/16/14 at 2:55 PM revealed she was called to the 200 hall, because Resident #7 had a bloody face, shirt, and pants. She stated she asked Resident #7 if he had fallen, and he said "No." Resident #7 stated he did not move out of the way and someone hit him, who was white or Hispanic. A CNA (CNA D) took Resident 37 to the 400 hall, going room by room to identify the person who hit Resident #7. LVN E then expressed concern regarding Resident #24's behavior, who had a history of [REDACTED]. LVN E stated she suspected Resident #24 may have hit Resident #7. Resident #24 had anger issues and had often slammed the door in ADON A's face. The CNA (CNA D) reported to LVN E Resident #7 looked really scared when he was wheeled into Resident #24's room to see if Resident #7 could identify Resident #24 as the one who hit him. Resident #7 said he did not want to get anyone in trouble when asked if Resident #24 hit him. Resident #7 replied "No" when he was asked about all other residents. Interview with ADON A on 06/16/14 at 3:10 PM revealed she believed Resident #24 might have hit Resident #7, but no one witnessed it. ADON A said she thought Resident #24 got mad because Resident # 7 was in his way and hit him. ADON A stated CNA D "took him (Resident #7) room to room to room" to identify who hit him and when they got to Resident #24's room, Resident #7 said he did not want to get anyone in trouble. When asked how Resident #7 was being protected, ADON A said both Resident #7 and Resident #24 were accompanied by a staff member when out of their room. ADON A said she could not provide any documentation regarding this monitoring. She added Resident #24 had a 30-day discharge notice, but Resident #24's family member was appealing the discharge. Resident #24's family member would not take him home because he/she was afraid of him. ADON A revealed she had started an investigation report, but it was not completed. The plans were to get Resident #24 discharged and to continue monitoring both residents. ADON A could not provide any documentation regarding the continued monitoring. ADON A stated she had asked Resident #24 if he had hit Resident #7 and Resident #24 had denied everything. Interview with the Administrator on 06/16/14 at 10:30 AM revealed she had an Incident Report involving Resident #7, which occurred on 06/12/14. When asked about an Investigation Report, the Administrator stated no investigation had been started and no one had called the incident to the State Regulatory Agency. The Administrator then stated she had not reviewed the Incident Report yet (four days after the incident). Interview with the Clinical Campus Director and Administrator on 06/17/14 at 10:55 AM revealed there was a problem with the faciilty reporting incidents of abuse. The Administrator stated "no resident in the building was interviewable." The Clinical Campus Director added, "Not consistently or constructively." The Clinical Campus Director also said, "This area (reporting incidents) was very weak" and there had been oversights in reporting. The Clinical Campus Director felt there had not been neglect, but definitely a lack of documentation, and the facility had not been documenting bruises of unknown origin in Accident & Incident Reorts and Investigation Reports. The Clinical Campus Director continued by saying action plans were put in place "last night (06/16/14)" and the focus was what to look for with possible abuse. All incidents were to be reviewed by a team of administrators from several campus buildings at the daily 11:45 AM meeting. the Clinical Campus Director further stated protection (of the residents) was first and foremost. They had removed a suspected resident (Resident #24) to the emergency room for a psych eval and then to another building where he was receiving one-on-one monitoring. The move was temporary until he was discharged . Training staff was started yesterday (06/16/14) and was on-going. Quality care rounds were completed and no one was fearful. All incidents of bruising were reviewed on incidents beginning January 2014. The Clinical Campus Director stated many changes were made a few weeks ago. and an ADON was promoted to train as a Director of Nursing for the building. The Clinical Campus Director had instructed staff "late notes" were to be added by the nurses to complete documentation on the incident involving Resident #7. Nurse's Notes added "late" to Resident #7's clinical record after the initial review on 06/16/14 were completed by ADON A and LVN E. Nurse's Notes entered as "late entry" without a date or time of actual entry reflected on 06/13/14 at 9:00 AM, ADON A spoke with Resident #7 about the resident-to-resident contact, which occurred the previous night (06/12/14). When he was asked what happened, the resident stated he was hit by a white or Hispanic male but he could not identify who hit him or where he was. Resident #7 could not recall if the person who hit him was a resident, staff member, or visitor. Resident #7 stated he did not feel "unsafe." Two full pages of new Nurse's Notes were in Resident #7's clinical record on 06/17/14 and were completed by LVN E. The Notes, dated 06/12/14 and 06/13/14, were not labeled as "late entries." The Notes reflected on "6/12/14 at 9:15 AM...Stat skull series ordered due/to swelling to left upper eyebrow during care. Resident positive with facial grimacing. Bleeding stopped with pressure and 4x4 gauze. Surrounding skin cleansed with skin prep and steri-strips applied to laceration. Ice pack applied to swollen area every 15 minutes... with CNA x1 monitoring resident...On 6/13/14 at 8:00 PM...This nurse asks why resident did not want to get up. Resident states 'am just tired'...9:00 PM...Denies being afraid." Observation of Resident #24 on 06/30/14 at 12:30 PM revealed the resident had been transferred to another building on the facility campus. Resident #24, a male adult, was in the other building's dining room talking to another resident at the time of the observation. During an interview at that time, Resident #24 said he was much calmer in the new building, because there were not so many "old sick people" around him. The other resident present was another adult male approximately the age of Resident #24. They seemed to be friends. Interview with the Administrator and Clinical Campus Director on 06/16/14 at 4:00 PM revealed Resident #24 could not act "willingly" and so the incident was not called into the State Regulatory Agency. The incident was going to be called in that night and more investigation was required. The nurses had been advised to make their documentation in the clinical record clearer. Interview with the Social Worker on 06/17/14 at 11:40 AM revealed she was actively pursuing a discharge for Resident #24. Interview with ADON A on 06/16/14 at 3:10 PM revealed the facility was trying to get Resident #24 discharged . Monitoring for both Resident #24 and Resident #7 was ongoing; however, ADON A could not provide any documentation regarding the "monitoring." 2. Review of Resident #16's MDS assessment, dated 09/29/13, revealed the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The MDS assessment reflected his cognition was intact, and he did not exhibit any behaviors. He required set-up assistance with his ADLs. An interview with Resident #16 on 06/18/14 at 1:50 PM revealed he used to help with tray preparation and had enjoyed helping with food service in the dining room. He said he used to enjoy the activity very much, but last week, when he was tying to help with tray prep as usual, a female dietary aide (Dietary Aide F) spoke to him in a very unpleasant way. Resident #16 stated since the verbal altercation, he avoided Dietary Aide F and no longer assisted with tray preparation and food service. Resident #16 stated, "It (the altercation with Dietary Aide F) made me feel like a two-year old. I pretty much just avoid that lady now and stay out of the room that she is in." He added he had told the Administrator and the Dietary Manager about the incident and his no longer wanting to work with Dietary Aide F. Resident #16 was a soft-spoken man and did not want to repeat the words Dietary Aide F spoke or the manner in which she had spoken them. Interview with the Administrator on 06/18/14 at 2:02 PM revealed there was no Incident Report written documenting Resident #16's allegation of verbal/mental abuse. When questioned about reporting the incident or investigating the incident between Resident #16 and Dietary Aide F, the Administrator revealed he had not reported the incident and there was no Investigation Report either. When asked what the Administrator did following Resident #16's allegation of verbal/mental abuse against Dietary Aide F, the Administrator, who was the designated Abuse Prohibition Coordinator, stated, "Oh well. I told the Dietary Manager." Interview with the Dietary Manager on 06/18/14 at 2:10 PM revealed Dietary Aide F was a new employee and did not know Resident #16 helped in the dining room. The Dietary Manager stated Dietary Aide F said she did not need him to help, but the Dietary Manager did not know the words used by Dietary Aide F, when she spoke to Resident #16. The Dietary Manager admitted he was trained in abuse prohibition, but stated he did not write an Incident Report or follow-up. He said he talked to Dietary Aide F and had written her up once before for talking to a nurse inappropriately. The Dietary Manager said Dietary Aide F talked loudly and her eyebrows were drawn on, so she was loud and could look rough, but she was really a very nice person. The Dietary Manager stated Resident #16 had told him (the Dietary Manager) he (Resident #16) could not work with Dietary Aide F, because he did not like how she talked. The Dietary Manager thought Resident #16 was satisfied not working with Dietary Aide F and no longer assisting with tray preparation and food service in the dining room. The Dietary Manager stated Resident #16 and Dietary Aide F seemed to be "okay" now. The Dietary Manager admitted , "It's my mistake for not writing it down." Review of Dietary Aide F's employee personnel file revealed written disciplinary actions. On a form entitled Progressive Discipline for Unsatisfactory Conduct and/or Performance dated 04/27/14, Dietary Aide F was suspended for two days for a verbal conflict between her and a co-worker in front of residents and family members. Signed witness statements included comments of throwing a plastic spoon at an LVN accompanied by very intense arguing and cursing in front of residents, family members, and staff. The form reflected Dietary Aide F refused to sign the 04/27/14 suspension. Another verbal warning note dated 05/02/14, reflected that under no circumstances, loud boisterous or swearing language would be tolerated in the facility. Dietary Aide F had signed the 05/02/14 warning. 3. Review of the facility's current Abuse/Neglect Prevention Policy, dated September 2006, revealed, "Mental/psychological abuse - Mistreatment...including....humiliation...or intimidation...Verbal Abuse - The use of any...disparaging or derogatory terms to a resident or within the resident's hearing distance...Residents must also be protected for ...all...forms of retaliation...(The facility) protects the reporter of abuse/neglect from retaliation both during and after the incident investigation. The reporter of abuse/neglect will not be treated negatively or receive any form of treatment that may be considered punishment...When abuse/neglect are suspected or alleged, the facility must immediately act to protect the residents...The Administrator would then begin an investigation...Questions used in the interview should identify who, what, why and when the incident occurred...For unidentified alleged perpetrators...document...hair style/color, clothing, and physical features...." The policy defined neglect as: "A deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental of physical injury, or harm or death to the resident." The policy did not include how the Administrator was supposed to investigate when abuse or neglect occurred. Under the facility's abuse policy was a page dated January 2001, which reflected, "If you suspect abuse...take the necessary steps to protect the resident...ensure the administrator and Director of Nursing are aware of the situation. The Administrator is the designated coordinator of the abuse program." Review on 06/17/14 of an undated document provided by the Clinical Campus Director provided on 6/17/14 entitled the facility's Process when Suspected Abuse or Neglect <sic>, which was identified as the "new process currently being trained." The process reflected, "to protect the alleged victim by removing the threat: suspension of a staff member, isolating a resident identified as an alleged perpetrator, removing malfunctioning equipment, assigning a staff member to remain with the victim to ensure safety and/or comfort. Promptly notify Administrator, physician, and responsible party...Remove any staff considered to be identified as a threat until resolution can be determined...Notify TDADS of alleged incident...Submit a complete investigation within 5 working days of the allegation...Incidents/grievances will be discussed each morning at stand-up and reportable incidents will be called to TDADS by the administrator within 24 hours." The policy did not identify which incidents were reportable. Review of a statement signed by the Administrator on 06/18/14 reflected, "Incidents identified as questionably reportable incidents due to lack of documentation were reported to TDADS on 6-17-14 by (the Administrator) at 5:05 PM. There were 26 incident reports involving 16 residents...." 4. Review of the facility's Form CMS-672, Resident Census and Conditions of Residents, signed by ADON A on 06/17/14, revealed a census of 107 residents.

Based on observation, interview and record review, the facility failed to ensure all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source were reported immediately to the administrator of the facility and to other officials in accordance with State law including the State survey and certification agency, failed to have evidence all alleged violations were thoroughly investigated, and failed to protect residents to prevent further abuse, neglect, and mistreatment for [REDACTED].#7, #16 and #24) of 20 residents reviewed for abuse. 1. Resident #7 sustained an injury of unknown source: a three-centimeter laceration to his left eyebrow. Facility staff failed to immediately report the injury of unknown source to the Administrator and the State Certification Agency; failed to investigate the incident; and failed to protect Resident #7 and the other residents of the facility by trying to identify the perpetrator. Without an investigation, facility staff determined Resident #24 was the perpetrator, who had hit Resident #7. Resident #24 was transferred to another building and plans were made to continue the 30-day discharge. 2. Resident #16 reported an incident of verbal/mental abuse by Dietary Aide F to the Administrator. Facility staff failed to report the incident of alleged abuse of Resident #16 to the State Certification Agency, failed to investigate the incident and failed to protect Resident #16 from further abuse. These failures could affect the facility's 107 residents, including Residents #7, #16 and #24, and placed them at risk for further abuse and mistreatment, which could result in low self-esteem, psychological distress, and physical injury. Findings included: 1. Review of Resident #7's MDS assessment, dated 08/08/13, revealed the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #7 had short-term and long-term memory problems, had severely impaired decision-making skills, and was unable to focus. Resident #7 required extensive to total assistance with activities of daily living, and he had impairment on one side of one arm and one leg. Review of the facility's Resident Incident Report, dated 06/12/14, revealed physical contact had occurred at 8:50 PM and Resident #7 had sustained a three-centimeter laceration above his left eyelid. Immediate action taken was to cleanse the area with normal saline, pat dry, and apply steri-strips and a Band-Aid. Vital signs were taken and [MEDICATION NAME] was given for a pain complaint at a four on a scale of 0 to 10 with ten being the worst pain. Resident #7's family and physician were notified. The narrative of the incident reflected, "Resident states he got into a fight with a white/Hispanic male that told him to get out of the way then hit him on his eyebrow." Neurological Assessments checks were completed every 15 minutes from 8:50 PM until 9:30 PM and every 30 minutes from 9:30 PM until 10:30 PM. Interviews conducted did not reveal an actual witness. A witness statement signed by CNA D reflected, "Went room to room trying to help (Resident #7) identify the resident that caused his injury. He could not tell me who caused it." When asked on 06/17/14 at 4:00 PM about the appropriateness of the CNA taking the Resident #7 room to room to identify who hit him, the Clinical Campus Director was silent and turned her head side to side in disbelief. Nurse's Notes, dated 06/12/14 at 8:50 PM and signed by LVN E, reflected, "Nurse noticed this resident (Resident #7) coming down to (Hall) 200 with bloody shirt and pants when asked patient states, 'I got into a fight with another white/Hispanic resident he told me to get out of the way and he hit me.' Few residents questioned. Statements collected. Admin, ADON, RP made aware. Stat X-ray ordered. Cleanse area with normal saline pat dry steri-strips applied. Left upper eyebrow with 3 cm (centimeters) length and 1 cm depth. Icepack admin (administered) due to swelling every 30 min (minutes) prn (as needed). [MEDICATION NAME] 5/325 mg 1 tab (tablet) po (by mouth) administered. Neuro checks in progress." Nurse's Notes, dated 06/13/14 at 5:00 AM reflected an ice pack was applied to Resident #7's left eyebrow once that shift. Observation during the initial tour on 06/16/14 at 9:45 AM revealed Resident #7 had two steri-strip adhesive bandages affixed to a laceration above the resident's left eyebrow. When asked about the laceration, Resident #7 said "two guys" had tried to rob him, but they did not get anything, because he did not have any money. Resident #7 continued to say the "two guys" threatened him by telling him he better have some money next time and hit him. CNA C entered Resident #7's room, smiled, and asked, "Is he (Resident #7) telling stories?" Interview with LVN E on 06/16/14 at 2:55 PM revealed she was called to the 200 hall, because Resident #7 had a bloody face, shirt, and pants. She stated she asked Resident #7 if he had fallen, and he said "No." Resident #7 stated he did not move out of the way and someone hit him, who was white or Hispanic. A CNA (CNA D) took Resident 37 to the 400 hall, going room by room to identify the person who hit Resident #7. LVN E then expressed concern regarding Resident #24's behavior, who had a history of [REDACTED]. LVN E stated she suspected Resident #24 may have hit Resident #7. Resident #24 had anger issues and had often slammed the door in ADON A's face. The CNA (CNA D) reported to LVN E Resident #7 looked really scared when he was wheeled into Resident #24's room to see if Resident #7 could identify Resident #24 as the one who hit him. Resident #7 said he did not want to get anyone in trouble when asked if Resident #24 hit him. Resident #7 replied "No" when he was asked about all other residents. Interview with ADON A on 06/16/14 at 3:10 PM revealed she believed Resident #24 might have hit Resident #7, but no one witnessed it. ADON A said she thought Resident #24 got mad because Resident # 7 was in his way and hit him. ADON A stated CNA D "took him (Resident #7) room to room to room" to identify who hit him and when they got to Resident #24's room, Resident #7 said he did not want to get anyone in trouble. When asked how Resident #7 was being protected, ADON A said both Resident #7 and Resident #24 were accompanied by a staff member when out of their room. ADON A said she could not provide any documentation regarding this monitoring. She added Resident #24 had a 30-day discharge notice, but Resident #24's family member was appealing the discharge. Resident #24's family member would not take him home because he/she was afraid of him. ADON A revealed she had started an investigation report, but it was not completed. The plans were to get Resident #24 discharged and to continue monitoring both residents. ADON A could not provide any documentation regarding the continued monitoring. ADON A stated she had asked Resident #24 if he had hit Resident #7 and Resident #24 had denied everything. Interview with the Administrator on 06/16/14 at 10:30 AM revealed she had an Incident Report involving Resident #7, which occurred on 06/12/14. When asked about an Investigation Report, the Administrator stated no investigation had been started and no one had called the incident to the State Regulatory Agency. The Administrator then stated she had not reviewed the Incident Report yet (four days after the incident). Interview with the Clinical Campus Director and Administrator on 06/17/14 at 10:55 AM revealed there was a problem with the faciilty reporting incidents of abuse. The Administrator stated "no resident in the building was interviewable." The Clinical Campus Director added, "Not consistently or constructively." The Clinical Campus Director also said, "This area (reporting incidents) was very weak" and there had been oversights in reporting. The Clinical Campus Director felt there had not been neglect, but definitely a lack of documentation, and the facility had not been documenting bruises of unknown origin in Accident & Incident Reorts and Investigation Reports. The Clinical Campus Director continued by saying action plans were put in place "last night (06/16/14)" and the focus was what to look for with possible abuse. All incidents were to be reviewed by a team of administrators from several campus buildings at the daily 11:45 AM meeting. the Clinical Campus Director further stated protection (of the residents) was first and foremost. They had removed a suspected resident (Resident #24) to the emergency room for a psych eval and then to another building where he was receiving one-on-one monitoring. The move was temporary until he was discharged . Training staff was started yesterday (06/16/14) and was on-going. Quality care rounds were completed and no one was fearful. All incidents of bruising were reviewed on incidents beginning January 2014. The Clinical Campus Director stated many changes were made a few weeks ago. and an ADON was promoted to train as a Director of Nursing for the building. The Clinical Campus Director had instructed staff "late notes" were to be added by the nurses to complete documentation on the incident involving Resident #7. Nurse's Notes added "late" to Resident #7's clinical record after the initial review on 06/16/14 were completed by ADON A and LVN E. Nurse's Notes entered as "late entry" without a date or time of actual entry reflected on 06/13/14 at 9:00 AM, ADON A spoke with Resident #7 about the resident-to-resident contact, which occurred the previous night (06/12/14). When he was asked what happened, the resident stated he was hit by a white or Hispanic male but he could not identify who hit him or where he was. Resident #7 could not recall if the person who hit him was a resident, staff member, or visitor. Resident #7 stated he did not feel "unsafe." Two full pages of new Nurse's Notes were in Resident #7's clinical record on 06/17/14 and were completed by LVN E. The Notes, dated 06/12/14 and 06/13/14, were not labeled as "late entries." The Notes reflected on "6/12/14 at 9:15 AM...Stat skull series ordered due/to swelling to left upper eyebrow during care. Resident positive with facial grimacing. Bleeding stopped with pressure and 4x4 gauze. Surrounding skin cleansed with skin prep and steri-strips applied to laceration. Ice pack applied to swollen area every 15 minutes... with CNA x1 monitoring resident...On 6/13/14 at 8:00 PM...This nurse asks why resident did not want to get up. Resident states 'am just tired'...9:00 PM...Denies being afraid." Observation of Resident #24 on 06/30/14 at 12:30 PM revealed the resident had been transferred to another building on the facility campus. Resident #24, a male adult, was in the other building's dining room talking to another resident at the time of the observation. During an interview at that time, Resident #24 said he was much calmer in the new building, because there were not so many "old sick people" around him. The other resident present was another adult male approximately the age of Resident #24. They seemed to be friends. Interview with the Administrator and Clinical Campus Director on 06/16/14 at 4:00 PM revealed Resident #24 could not act "willingly" and so the incident was not called into the State Regulatory Agency. The incident was going to be called in that night and more investigation was required. The nurses had been advised to make their documentation in the clinical record clearer. Interview with the Social Worker on 06/17/14 at 11:40 AM revealed she was actively pursuing a discharge for Resident #24. Interview with ADON A on 06/16/14 at 3:10 PM revealed the facility was trying to get Resident #24 discharged . Monitoring for both Resident #24 and Resident #7 was ongoing; however, ADON A could not provide any documentation regarding the "monitoring." 2. Review of Resident #16's MDS assessment, dated 09/29/13, revealed the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The MDS assessment reflected his cognition was intact, and he did not exhibit any behaviors. He required set-up assistance with his ADLs. An interview with Resident #16 on 06/18/14 at 1:50 PM revealed he used to help with tray preparation and had enjoyed helping with food service in the dining room. He said he used to enjoy the activity very much, but last week, when he was tying to help with tray prep as usual, a female dietary aide (Dietary Aide F) spoke to him in a very unpleasant way. Resident #16 stated since the verbal altercation, he avoided Dietary Aide F and no longer assisted with tray preparation and food service. Resident #16 stated, "It (the altercation with Dietary Aide F) made me feel like a two-year old. I pretty much just avoid that lady now and stay out of the room that she is in." He added he had told the Administrator and the Dietary Manager about the incident and his no longer wanting to work with Dietary Aide F. Resident #16 was a soft-spoken man and did not want to repeat the words Dietary Aide F spoke or the manner in which she had spoken them. Interview with the Administrator on 06/18/14 at 2:02 PM revealed there was no Incident Report written documenting Resident #16's allegation of verbal/mental abuse. When questioned about reporting the incident or investigating the incident between Resident #16 and Dietary Aide F, the Administrator revealed he had not reported the incident and there was no Investigation Report either. When asked what the Administrator did following Resident #16's allegation of verbal/mental abuse against Dietary Aide F, the Administrator, who was the designated Abuse Prohibition Coordinator, stated, "Oh well. I told the Dietary Manager." Interview with the Dietary Manager on 06/18/14 at 2:10 PM revealed Dietary Aide F was a new employee and did not know Resident #16 helped in the dining room. The Dietary Manager stated Dietary Aide F said she did not need him to help, but the Dietary Manager did not know the words used by Dietary Aide F, when she spoke to Resident #16. The Dietary Manager admitted he was trained in abuse prohibition, but stated he did not write an Incident Report or follow-up. He said he talked to Dietary Aide F and had written her up once before for talking to a nurse inappropriately. The Dietary Manager said Dietary Aide F talked loudly and her eyebrows were drawn on, so she was loud and could look rough, but she was really a very nice person. The Dietary Manager stated Resident #16 had told him (the Dietary Manager) he (Resident #16) could not work with Dietary Aide F, because he did not like how she talked. The Dietary Manager thought Resident #16 was satisfied not working with Dietary Aide F and no longer assisting with tray preparation and food service in the dining room. The Dietary Manager stated Resident #16 and Dietary Aide F seemed to be "okay" now. The Dietary Manager admitted , "It's my mistake for not writing it down." Review of Dietary Aide F's employee personnel file revealed written disciplinary actions. On a form entitled Progressive Discipline for Unsatisfactory Conduct and/or Performance dated 04/27/14, Dietary Aide F was suspended for two days for a verbal conflict between her and a co-worker in front of residents and family members. Signed witness statements included comments of throwing a plastic spoon at an LVN accompanied by very intense arguing and cursing in front of residents, family members, and staff. The form reflected Dietary Aide F refused to sign the 04/27/14 suspension. Another verbal warning note dated 05/02/14, reflected that under no circumstances, loud boisterous or swearing language would be tolerated in the facility. Dietary Aide F had signed the 05/02/14 warning. 3. Review of the facility's current Abuse/Neglect Prevention Policy, dated September 2006, revealed, "Mental/psychological abuse - Mistreatment...including....humiliation...or intimidation...Verbal Abuse - The use of any...disparaging or derogatory terms to a resident or within the resident's hearing distance...Residents must also be protected for ...all...forms of retaliation...(The facility) protects the reporter of abuse/neglect from retaliation both during and after the incident investigation. The reporter of abuse/neglect will not be treated negatively or receive any form of treatment that may be considered punishment...When abuse/neglect are suspected or alleged, the facility must immediately act to protect the residents...The Administrator would then begin an investigation...Questions used in the interview should identify who, what, why and when the incident occurred...For unidentified alleged perpetrators...document...hair style/color, clothing, and physical features...." The policy defined neglect as: "A deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental of physical injury, or harm or death to the resident." The policy did not include how the Administrator was supposed to investigate when abuse or neglect occurred. Under the facility's abuse policy was a page dated January 2001, which reflected, "If you suspect abuse...take the necessary steps to protect the resident...ensure the administrator and Director of Nursing are aware of the situation. The Administrator is the designated coordinator of the abuse program." Review on 06/17/14 of an undated document provided by the Clinical Campus Director provided on 6/17/14 entitled the facility's Process when Suspected Abuse or Neglect <sic>, which was identified as the "new process currently being trained." The process reflected, "to protect the alleged victim by removing the threat: suspension of a staff member, isolating a resident identified as an alleged perpetrator, removing malfunctioning equipment, assigning a staff member to remain with the victim to ensure safety and/or comfort. Promptly notify Administrator, physician, and responsible party...Remove any staff considered to be identified as a threat until resolution can be determined...Notify TDADS of alleged incident...Submit a complete investigation within 5 working days of the allegation...Incidents/grievances will be discussed each morning at stand-up and reportable incidents will be called to TDADS by the administrator within 24 hours." The policy did not identify which incidents were reportable. Review of a statement signed by the Administrator on 06/18/14 reflected, "Incidents identified as questionably reportable incidents due to lack of documentation were reported to TDADS on 6-17-14 by (the Administrator) at 5:05 PM. There were 26 incident reports involving 16 residents...." 4. Review of the facility's Form CMS-672, Resident Census and Conditions of Residents, signed by ADON A on 06/17/14, revealed a census of 107 residents.

Based on interview and record review, it was determined the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for three (Residents #7, #16 and #24) of 20 residents reviewed for abuse/neglect. 1. The facility failed to prevent Resident #7 from being injured and sustaining a three-centimeter laceration to his left eyebrow. The Administrator was unaware of the incident. Facility staff failed to protect Resident #7 by identifying the perpetrator, leaving Resident #7 and the facility's other residents unprotected. 2. Despite the absence of evidence or a completed investigation, facility staff determined Resident #24 was the perpetrator, who hit Resident #7, and had transferred him to another building and were in the process of discharging him. 3. The facility failed to prevent Resident #16 from being verbally/mentally abused by Dietary Aide F. He felt like "a two-year old" when he was providing assistance with tray preparation and food service to the facility residents and Dietary Aide F spoke to him in a demeaning manner. He now avoided Dietary Aide F and no longer assisted with tray prep or food service, a job he enjoyed doing. He reported the incident to the Administrator and the Dietary Manager, but Dietary Aide F continued to work at the facility. There was no facility investigation. These failures could affect the facility's other 107 residents by placing them at risk for abuse and neglect, which could result in low self-esteem, psychological distress, and physical injury. Findings included: Review of the facility's current Abuse/Neglect Prevention Policy, dated September 2006, revealed, "Mental/psychological abuse - Mistreatment...including....humiliation...or intimidation...Verbal Abuse - The use of any...disparaging or derogatory terms to a resident or within the resident's hearing distance...Residents must also be protected for ...all...forms of retaliation...(The facility) protects the reporter of abuse/neglect from retaliation both during and after the incident investigation. The reporter of abuse/neglect will not be treated negatively or receive any form of treatment that may be considered punishment...When abuse/neglect are suspected or alleged, the facility must immediately act to protect the residents...The Administrator would then begin an investigation...Questions used in the interview should identify who, what, why and when the incident occurred...For unidentified alleged perpetrators...document...hair style/color, clothing, and physical features...." The policy defined neglect as: "A deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental of physical injury, or harm or death to the resident." The policy did not include how the Administrator was supposed to investigate when abuse or neglect occurred. Under the facility's abuse policy was a page dated January 2001, which reflected, "If you suspect abuse...take the necessary steps to protect the resident...ensure the administrator and Director of Nursing are aware of the situation. The Administrator is the designated coordinator of the abuse program." Review on 06/17/14 of an undated document provided by the Clinical Campus Director provided on 6/17/14 entitled the facility's Process when Suspected Abuse or Neglect <sic>, which was identified as the "new process currently being trained." The process reflected, "to protect the alleged victim by removing the threat: suspension of a staff member, isolating a resident identified as an alleged perpetrator, removing malfunctioning equipment, assigning a staff member to remain with the victim to ensure safety and/or comfort. Promptly notify Administrator, physician, and responsible party...Remove any staff considered to be identified as a threat until resolution can be determined...Notify TDADS of alleged incident...Submit a complete investigation within 5 working days of the allegation...Incidents/grievances will be discussed each morning at stand-up and reportable incidents will be called to TDADS by the administrator within 24 hours." The policy did not identify which incidents were reportable. Review of a statement signed by the Administrator on 06/18/14 reflected, "Incidents identified as questionably reportable incidents due to lack of documentation were reported to TDADS on 6-17-14 by (the Administrator) at 5:05 PM. There were 26 incident reports involving 16 residents...." 1. Review of Resident #7's MDS assessment, dated 08/08/13, revealed the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #7 had short-term and long-term memory problems, had severely impaired decision-making skills, and was unable to focus. Resident #7 required extensive to total assistance with activities of daily living, and he had impairment on one side of one arm and one leg. Review of the facility's Resident Incident Report, dated 06/12/14, revealed physical contact had occurred at 8:50 PM and Resident #7 had sustained a three-centimeter laceration above his left eyelid. Immediate action taken was to cleanse the area with normal saline, pat dry, and apply steri-strips and a Band-Aid. Vital signs were taken and [MEDICATION NAME] was given for a pain complaint at a four on a scale of 0 to 10 with ten being the worst pain. Resident #7's family and physician were notified. The narrative of the incident reflected, "Resident states he got into a fight with a white/Hispanic male that told him to get out of the way then hit him on his eyebrow." Neurological Assessments checks were completed every 15 minutes from 8:50 PM until 9:30 PM and every 30 minutes from 9:30 PM until 10:30 PM. Interviews conducted did not reveal an actual witness. A witness statement signed by CNA D reflected, "Went room to room trying to help (Resident #7) identify the resident that caused his injury. He could not tell me who caused it." When asked on 06/17/14 at 4:00 PM about the appropriateness of the CNA taking the Resident #7 room to room to identify who hit him, the Clinical Campus Director was silent and turned her head side to side in disbelief. Nurse's Notes, dated 06/12/14 at 8:50 PM and signed by LVN E, reflected, "Nurse noticed this resident (Resident #7) coming down to (Hall) 200 with bloody shirt and pants when asked patient states, 'I got into a fight with another white/Hispanic resident he told me to get out of the way and he hit me.' Few residents questioned. Statements collected. Admin, ADON, RP made aware. Stat X-ray ordered. Cleanse area with normal saline pat dry steri-strips applied. Left upper eyebrow with 3 cm (centimeters) length and 1 cm depth. Icepack admin (administered) due to swelling every 30 min (minutes) prn (as needed). [MEDICATION NAME] 5/325 mg 1 tab (tablet) po (by mouth) administered. Neuro checks in progress." Nurse's Notes, dated 06/13/14 at 5:00 AM reflected an ice pack was applied to Resident #7's left eyebrow once that shift. Observation during the initial tour on 06/16/14 at 9:45 AM revealed Resident #7 had two steri-strip adhesive bandages affixed to a laceration above the resident's left eyebrow. When asked about the laceration, Resident #7 said "two guys" had tried to rob him, but they did not get anything, because he did not have any money. Resident #7 continued to say the "two guys" threatened him by telling him he better have some money next time and hit him. CNA C entered Resident #7's room, smiled, and asked, "Is he (Resident #7) telling stories?" Interview with LVN E on 06/16/14 at 2:55 PM revealed she was called to the 200 hall, because Resident #7 had a bloody face, shirt, and pants. She stated she asked Resident #7 if he had fallen, and he said "No." Resident #7 stated he did not move out of the way and someone hit him, who was white or Hispanic. A CNA (CNA D) took Resident 37 to the 400 hall, going room by room to identify the person who hit Resident #7. LVN E then expressed concern regarding Resident #24's behavior, who had a history of [REDACTED]. LVN E stated she suspected Resident #24 may have hit Resident #7. Resident #24 had anger issues and had often slammed the door in ADON A's face. The CNA (CNA D) reported to LVN E Resident #7 looked really scared when he was wheeled into Resident #24's room to see if Resident #7 could identify Resident #24 as the one who hit him. Resident #7 said he did not want to get anyone in trouble when asked if Resident #24 hit him. Resident #7 replied "No" when he was asked about all other residents. Interview with ADON A on 06/16/14 at 3:10 PM revealed she believed Resident #24 might have hit Resident #7, but no one witnessed it. ADON A said she thought Resident #24 got mad because Resident # 7 was in his way and hit him. ADON A stated CNA D "took him (Resident #7) room to room to room" to identify who hit him and when they got to Resident #24's room, Resident #7 said he did not want to get anyone in trouble. When asked how Resident #7 was being protected, ADON A said both Resident #7 and Resident #24 were accompanied by a staff member when out of their room. ADON A said she could not provide any documentation regarding this monitoring. She added Resident #24 had a 30-day discharge notice, but Resident #24's family member was appealing the discharge. Resident #24's family member would not take him home because he/she was afraid of him. ADON A revealed she had started an investigation report, but it was not completed. The plans were to get Resident #24 discharged and to continue monitoring both residents. ADON A could not provide any documentation regarding the continued monitoring. ADON A stated she had asked Resident #24 if he had hit Resident #7 and Resident #24 had denied everything. Interview with the Administrator on 06/16/14 at 10:30 AM revealed she had an Incident Report involving Resident #7, which occurred on 06/12/14. When asked about an Investigation Report, the Administrator stated no investigation had been started and no one had called the incident to the State Regulatory Agency. The Administrator then stated she had not reviewed the Incident Report yet (four days after the incident). Interview with the Clinical Campus Director and Administrator on 06/17/14 at 10:55 AM revealed there was a problem with the faciilty reporting incidents of abuse. The Administrator stated "no resident in the building was interviewable." The Clinical Campus Director added, "Not consistently or constructively." The Clinical Campus Director also said, "This area (reporting incidents) was very weak" and there had been oversights in reporting. The Clinical Campus Director felt there had not been neglect, but definitely a lack of documentation, and the facility had not been documenting bruises of unknown origin in Accident & Incident Reorts and Investigation Reports. The Clinical Campus Director continued by saying action plans were put in place "last night (06/16/14)" and the focus was what to look for with possible abuse. All incidents were to be reviewed by a team of administrators from several campus buildings at the daily 11:45 AM meeting. the Clinical Campus Director further stated protection (of the residents) was first and foremost. They had removed a suspected resident (Resident #24) to the emergency room for a psych eval and then to another building where he was receiving one-on-one monitoring. The move was temporary until he was discharged . Training staff was started yesterday (06/16/14) and was on-going. Quality care rounds were completed and no one was fearful. All incidents of bruising were reviewed on incidents beginning January 2014. The Clinical Campus Director stated many changes were made a few weeks ago. and an ADON was promoted to train as a Director of Nursing for the building. The Clinical Campus Director had instructed staff "late notes" were to be added by the nurses to complete documentation on the incident involving Resident #7. Nurse's Notes added "late" to Resident #7's clinical record after the initial review on 06/16/14 were completed by ADON A and LVN E. Nurse's Notes entered as "late entry" without a date or time of actual entry reflected on 06/13/14 at 9:00 AM, ADON A spoke with Resident #7 about the resident-to-resident contact, which occurred the previous night (06/12/14). When he was asked what happened, the resident stated he was hit by a white or Hispanic male but he could not identify who hit him or where he was. Resident #7 could not recall if the person who hit him was a resident, staff member, or visitor. Resident #7 stated he did not feel "unsafe." Two full pages of new Nurse's Notes were in Resident #7's clinical record on 06/17/14 and were completed by LVN E. The Notes, dated 06/12/14 and 06/13/14, were not labeled as "late entries." The Notes reflected on "6/12/14 at 9:15 AM...Stat skull series ordered due/to swelling to left upper eyebrow during care. Resident positive with facial grimacing. Bleeding stopped with pressure and 4x4 gauze. Surrounding skin cleansed with skin prep and steri-strips applied to laceration. Ice pack applied to swollen area every 15 minutes... with CNA x1 monitoring resident...On 6/13/14 at 8:00 PM...This nurse asks why resident did not want to get up. Resident states 'am just tired'...9:00 PM...Denies being afraid." Observation of Resident #24 on 06/30/14 at 12:30 PM revealed the resident had been transferred to another building on the facility campus. Resident #24, a male adult, was in the other building's dining room talking to another resident at the time of the observation. During an interview at that time, Resident #24 said he was much calmer in the new building, because there were not so many "old sick people" around him. The other resident present was another adult male approximately the age of Resident #24. They seemed to be friends. Interview with the Administrator and Clinical Campus Director on 06/16/14 at 4:00 PM revealed Resident #24 could not act "willingly" and so the incident was not called into the State Regulatory Agency. The incident was going to be called in that night and more investigation was required. The nurses had been advised to make their documentation in the clinical record clearer. Interview with the Social Worker on 06/17/14 at 11:40 AM revealed she was actively pursuing a discharge for Resident #24. Interview with ADON A on 06/16/14 at 3:10 PM revealed the facility was trying to get Resident #24 discharged . Monitoring for both Resident #24 and Resident #7 was ongoing; however, ADON A could not provide any documentation regarding the "monitoring." 2. Review of Resident #16's MDS assessment, dated 09/29/13, revealed the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The MDS assessment reflected his cognition was intact, and he did not exhibit any behaviors. He required set-up assistance with his ADLs. An interview with Resident #16 on 06/18/14 at 1:50 PM revealed he used to help with tray preparation and had enjoyed helping with food service in the dining room. He said he used to enjoy the activity very much, but last week, when he was tying to help with tray prep as usual, a female dietary aide (Dietary Aide F) spoke to him in a very unpleasant way. Resident #16 stated since the verbal altercation, he avoided Dietary Aide F and no longer assisted with tray preparation and food service. Resident #16 stated, "It (the altercation with Dietary Aide F) made me feel like a two-year old. I pretty much just avoid that lady now and stay out of the room that she is in." He added he had told the Administrator and the Dietary Manager about the incident and his no longer wanting to work with Dietary Aide F. Resident #16 was a soft-spoken man and did not want to repeat the words Dietary Aide F spoke or the manner in which she had spoken them. Interview with the Administrator on 06/18/14 at 2:02 PM revealed there was no Incident Report written documenting Resident #16's allegation of verbal/mental abuse. When questioned about reporting the incident or investigating the incident between Resident #16 and Dietary Aide F, the Administrator revealed he had not reported the incident and there was no Investigation Report either. When asked what the Administrator did following Resident #16's allegation of verbal/mental abuse against Dietary Aide F, the Administrator, who was the designated Abuse Prohibition Coordinator, stated, "Oh well. I told the Dietary Manager." Interview with the Dietary Manager on 06/18/14 at 2:10 PM revealed Dietary Aide F was a new employee and did not know Resident #16 helped in the dining room. The Dietary Manager stated Dietary Aide F said she did not need him to help, but the Dietary Manager did not know the words used by Dietary Aide F, when she spoke to Resident #16. The Dietary Manager admitted he was trained in abuse prohibition, but stated he did not write an Incident Report or follow-up. He said he talked to Dietary Aide F and had written her up once before for talking to a nurse inappropriately. The Dietary Manager said Dietary Aide F talked loudly and her eyebrows were drawn on, so she was loud and could look rough, but she was really a very nice person. The Dietary Manager stated Resident #16 had told him (the Dietary Manager) he (Resident #16) could not work with Dietary Aide F, because he did not like how she talked. The Dietary Manager thought Resident #16 was satisfied not working with Dietary Aide F and no longer assisting with tray preparation and food service in the dining room. The Dietary Manager stated Resident #16 and Dietary Aide F seemed to be "okay" now. The Dietary Manager admitted , "It's my mistake for not writing it down." Review of Dietary Aide F's employee personnel file revealed written disciplinary actions. On a form entitled Progressive Discipline for Unsatisfactory Conduct and/or Performance dated 04/27/14, Dietary Aide F was suspended for two days for a verbal conflict between her and a co-worker in front of residents and family members. Signed witness statements included comments of throwing a plastic spoon at an LVN accompanied by very intense arguing and cursing in front of residents, family members, and staff. The form reflected Dietary Aide F refused to sign the 04/27/14 suspension. Another verbal warning note dated 05/02/14, reflected that under no circumstances, loud boisterous or swearing language would be tolerated in the facility. Dietary Aide F had signed the 05/02/14 warning. 3. Review of the facility's Form CMS-672, Resident Census and Conditions of Residents, signed by ADON A on 06/17/14, revealed a census of 107 residents.

Based on observation, interview and record review, it was determined the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality for three (Residents #11, #16 and #18,) of 13 residents reviewed for dignity concerns. 1. When Resident #16 was providing assistance with tray preparation and food service to the facility residents, Dietary Aide F spoke to Resident #16 in a demeaning manner, which made him feel "a two-year old." He now avoided Dietary Aide F and no longer assisted with tray prep or food service, a job he enjoyed doing. 2. Resident #11 was in bed and uncovered wearing incontinent briefs, which could be seen from the hallway. 3. Resident #18 was laughed at by ADON A. These failures could affect the facility's 107 residents, including Residents #11, #16 and #18 and could negatively impact the residents' feelings of self-worth and self-esteem. Findings included: 1. Review of Resident #16's MDS assessment, dated 09/29/13, revealed the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The MDS assessment reflected his cognition was intact, and he did not exhibit any behaviors. He required set-up assistance with his ADLs. An interview with Resident #16 on 06/18/14 at 1:50 PM revealed he used to help with tray preparation and had enjoyed helping with food service in the dining room. He said he used to enjoy the activity very much, but last week, when he was tying to help with tray prep as usual, a female dietary aide (Dietary Aide F) spoke to him in a very unpleasant way. Resident #16 stated since the verbal altercation, he avoided Dietary Aide F and no longer assisted with tray preparation and food service. Resident #16 stated, "It (the altercation with Dietary Aide F) made me feel like a two-year old. I pretty much just avoid that lady now and stay out of the room that she is in." He added he had told the Administrator and the Dietary Manager about the incident and his no longer wanting to work with Dietary Aide F. Resident #16 was a soft-spoken man and did not want to repeat the words Dietary Aide F spoke or the manner in which she had spoken them. Interview with the Administrator on 06/18/14 at 2:02 PM revealed there was no Incident Report written documenting Resident #16's allegation of verbal/mental abuse. When questioned about reporting the incident or investigating the incident between Resident #16 and Dietary Aide F, the Administrator revealed he had not reported the incident and there was no Investigation Report either. When asked what the Administrator did following Resident #16's allegation of verbal/mental abuse against Dietary Aide F, the Administrator, who was the designated Abuse Prohibition Coordinator, stated, "Oh well. I told the Dietary Manager." Interview with the Dietary Manager on 06/18/14 at 2:10 PM revealed Dietary Aide F was a new employee and did not know Resident #16 helped in the dining room. The Dietary Manager stated Dietary Aide F said she did not need him to help, but the Dietary Manager did not know the words used by Dietary Aide F, when she spoke to Resident #16. The Dietary Manager admitted he was trained in abuse prohibition, but stated he did not write an Incident Report or follow-up. He said he talked to Dietary Aide F and had written her up once before for talking to a nurse inappropriately. The Dietary Manager said Dietary Aide F talked loudly and her eyebrows were drawn on, so she was loud and could look rough, but she was really a very nice person. The Dietary Manager stated Resident #16 had told him (the Dietary Manager) he (Resident #16) could not work with Dietary Aide F, because he did not like how she talked. The Dietary Manager thought Resident #16 was satisfied not working with Dietary Aide F and no longer assisting with tray preparation and food service in the dining room. The Dietary Manager stated Resident #16 and Dietary Aide F seemed to be "okay" now. The Dietary Manager admitted , "It's my mistake for not writing it down." Review of Dietary Aide F's employee personnel file revealed written disciplinary actions. On a form entitled Progressive Discipline for Unsatisfactory Conduct and/or Performance dated 04/27/14, Dietary Aide F was suspended for two days for a verbal conflict between her and a co-worker in front of residents and family members. Signed witness statements included comments of throwing a plastic spoon at an LVN accompanied by very intense arguing and cursing in front of residents, family members, and staff. The form reflected Dietary Aide F refused to sign the 04/27/14 suspension. Another verbal warning note dated 05/02/14, reflected that under no circumstances, loud boisterous or swearing language would be tolerated in the facility. Dietary Aide F had signed the 05/02/14 warning. 1. Review of Resident #16's MDS assessment, dated 09/29/13, revealed the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The MDS assessment reflected his cognition was intact, and he did not exhibit any behaviors. He required set-up assistance with his ADLs. An interview with Resident #16 on 06/18/14 at 1:50 PM revealed he used to help with tray preparation and had enjoyed helping with food service in the dining room. He said he used to enjoy the activity very much, but last week, when he was tying to help with tray prep as usual, he was spoken to by a female dietary aide (Dietary Aide F) in a very unpleasant way. Resident #16 stated since the verbal altercation, he avoided Dietary Aide F and no longer assisted with tray preparation and food service. Resident #16 stated, "It (the altercation with Dietary Aide F) made me feel like a two-year old. I pretty much just avoid that lady now and stay out of the room that she is in." He added he had told the Administrator and the Dietary Manager about the incident and his no longer wanting to work with Dietary Aide F. Resident #16 was a soft-spoken man and did not want to repeat the words Dietary Aide F spoke or the manner in which she had spoken them. Interview with the Administrator on 06/18/14 at 2:02 PM revealed there was no Incident Report written documenting Resident #16's allegation of verbal/mental abuse. When questioned about reporting the incident or investigating the incident between Resident #16 and Dietary Aide F, the Administrator revealed there was no Investigation Report either. When asked what the Administrator did following Resident #16's allegation of verbal/mental abuse against Dietary Aide F, the Administrator, who was the designated Abuse Prohibition Coordinator, stated, "Oh well. I told the Dietary Manager." Interview with the Dietary Manager on 06/18/14 at 2:10 PM revealed Dietary Aide F was a new employee and did not know Resident #16 helped in the dining room. The Dietary Manager stated Dietary Aide F said she did not need him to help, but the Dietary Manager did not know the words used by Dietary Aide F, when she spoke to Resident #16. The Dietary Manager admitted he was trained in abuse prohibition, but stated he did not write an Incident Report or follow-up. He said he talked to Dietary Aide F and had written her up once before for talking to a nurse inappropriately. The Dietary Manager said Dietary Aide F talked loudly and her eyebrows were drawn on, so she was loud and could look rough, but she was really a very nice person. The Dietary Manager stated Resident #16 had told him (the Dietary Manager) he (Resident #16) could not work with Dietary Aide F, because he did not like how she talked. The Dietary Manager thought Resident #16 was satisfied not working with Dietary Aide F and no longer assisting with tray preparation and food service in the dining room. The Dietary Manager stated Resident #16 and Dietary Aide F seemed to be "okay" now. The Dietary Manager admitted , "It's my mistake for not writing it down." Review of Dietary Aide F's employee personnel file revealed serious disciplinary actions in writing. On a form entitled Progressive Discipline for Unsatisfactory Conduct and/or Performance dated 04/27/14, Dietary Aide F was suspended for two days for a verbal conflict between her and a co-worker in front of residents and family members. Signed witness statements included comments of throwing a plastic spoon at an LVN accompanied by very intense arguing and cursing in front of residents, family members, and staff. The form reflected Dietary Aide F refused to sign the 04/27/14 suspension. Another verbal warning note dated 05/02/14, reflected that under no circumstances, loud boisterous or swearing language would be tolerated in the facility. Dietary Aide F had signed the 05/02/14 warning. 2. The face sheet reflected Resident #11's face sheet reflected he was an [AGE] year-old male admitted to the facility on [DATE]. Resident #11's physician order [REDACTED]. Review of Resident #11's Minimum Data Set assessment dated [DATE], revealed the resident required the assistance of one for ADLs. Resident #11 was identified by ADON G during initial rounds on 6/16/14 at 9:00 AM as requiring total care and required the use of a Hoyer Lift and two staff for transfers. Resident #11 was observed on 06/16/14 at 9:15 AM during initial morning rounds. Resident #11 was observed to be a dependent resident and had a [MEDICAL CONDITION]. Resident #11 was in bed on his back with no cover covering him from the waist down. Resident #11 wore a hospital gown, which had pulled up and exposed Resident #11 mid-thigh to the hallway traffic. Resident #11's incontinent brief was visible to anyone walking down the hallway. On 06/17/14 at 10:15 AM, CNA H stated Resident #11 would become anxious with care at times. CNA H further stated Resident #11 would attempt to get up and stand at the side of the bed. A bed alarm pad was observed on the bed. 3. Resident #18's current physician's orders [REDACTED]. On 06/18/14 at 12:50 AM, Resident #18 was speaking with the surveyor across from the nurses' station. Resident #18 then began to shout and wave her arms. Resident #18 could be heard shouting, "This place needs to get organized. The Lord's telling me to say this." Resident #18 continued speaking loudly and shouting. ADON A began to laugh at Resident #18, alhtough the resident could not see the ADON. Resident #18 continued to shout and speak to the surveyor. ADON A could be seen with her hand over her mouth moving around the nurses' station laughing at Resident #18. ADON A finally reached a doorway, where she stood with Resident #18's back to the ADON. ADON A stood with her hand over her mouth laughing. At 1:20 PM on 06/18/14, ADON A came to the surveyor and said, "I am sorry (for laughing at Resident #18). I couldn't help myself." the surveyor informed ADON A she needed to apologize to Resident #18, not the surveyor. The facility form CMS 672, Resident Census and Conditions of Residents, dated 6/16/14 and signed by ADON A reflected the facility census was 107.

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for one (Resident #1) of nine residents reviewed for elopement. 1. The facility failed to search outside around the entire facility and count residents, after the Hall 200 exit door alarm sounded at approximately 3:00 AM on 04/02/13. 2. RN D failed to notify the Administrator, DON, and police, when Resident #1, who had a history of [REDACTED]. 3. Staff failed to keep the Hall 100 exit door alarm turned on, while Resident #1 was missing, to prevent anyone else from eloping. Resident #1 eloped from the facility and was missing for at least 24 hours. On 04/03/13, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 04/05/13, the facility remained out of compliance at a scope of "pattern" and a severity level "No actual harm with potential for more than minimal harm, that is not immediate jeopardy," because the facility was still in-servicing staff and monitoring the effectiveness of the Plan of Removal. These failures could affect the other 28 residents, who wandered, by placing them at at risk for elopement, accidents, and injuries. Findings included: Resident #1's Face Sheet, 05/23/12, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility's Census List dated, 04/03/13, reflected Resident #1 resided on Hall 600. Resident #1's Physician's Progress Note, from the previous nursing home, which was included in the resident's thinned medical records at his current facility, dated 09/28/11, reflected he eloped last weekend and the police found him and returned him to the previous facility. Resident #1's hospital Comprehensive History, dated 10/13/11, reflected the resident was a flight risk. An interview with the DON on 04/03/13 at approximately 11:02 AM revealed when she was shown Resident #1's hospital Comprehensive History and the Physician's Progress Note, she stated she was not the DON at the time of his admission, but someone should have looked at the information. Resident #1's MDS assessment, dated 10/30/12, reflected his cognition was severely impaired, he had delusions, and hallucinations, and he wandered, which placed him at risk of getting to a potentially dangerous place such as outside. The MDS assessment also reflected he ambulated independently, he needed assistance with dressing and personal hygiene, and bathing. Resident #1's Care Plan, dated 11/08/12 for "Behavioral Symptoms" reflected he wandered. The Care Plan's Interventions for his "Behavioral Symptoms" were as follows: assess for possible reasons for a decline in behavioral status; assess medications, appetite, labs, vital signs and changes to the environment for causes of decline; notify the physician of decline in behaviors; document behaviors in the clinical record; and psychiatric consult as needed. Resident #1's Care Plan, dated 11/08/12, did not reflect he was at risk for elopement or that he had a history of [REDACTED]. Resident #1's Risk Analysis Worksheet, dated 01/15/13, reflected he was at risk for wandering. Resident #1's Risk Analysis Worksheet, dated 01/15/13, did not address the resident was at risk for elopement. Resident #1's clinical record did not reflect an Elopement Risk Assessment. Resident #1's April 2013 physician's orders [REDACTED]." Resident #1's Interdisciplinary Notes dated 04/02/13 (time illegible) reflected the CNA informed the nurse the resident was not in his room. The Notes also reflected each room, closet, and bathroom were checked for the resident, but he was not found. Resident #1's Interdisciplinary Notes dated 04/02/13 and timed at 6:30 AM reflected the DON, Administrator, police, and the resident's responsible party were notified that the resident was missing. Resident #1's Interdisciplinary Notes dated 04/02/13 and timed at 6:45 AM reflected two police officers arrived at the facility and searched the resident's room. An interview with CNA C, who worked Hall 100, on 04/02/13 at approximately 9:30 PM revealed she worked the night shift, when Resident #1 went missing. She stated around 2:30 AM that day, she observed Resident #1 near the exit door for Hall 100 and redirected him away from the door. CNA C revealed Resident #1 then moved from the door. She stated at approximately 3:00 AM she heard the Hall 200 exit door alarm sound. CNA C revealed she rushed to Hall 200 and started asking where was the CNA and where was the nurse. She then stated CNA A came out of a room on Hall 200 and turned off the alarm. CNA C revealed she did not observe CNA A or anyone go outside and search the property. CNA C stated she suggested checking all resident rooms, but that was not done. She revealed she could verify and account for residents on Halls 100, 200 and 300 as her counterparts counted to ensure residents were in their rooms. CNA C stated she did not know if Halls 400, 500 and 600 were checked. She revealed at approximately 4:00 AM, CNA B informed her Resident #1 was missing. CNA C stated she knew something was wrong and staff "didn't take it serious." An interview with CNA A, who worked Hall 200, on 04/02/13 at approximately 10:25 PM revealed she heard the exit alarm door sound around 3:00 AM that day. She stated she was providing care to a resident, when she heard the alarm. CNA A revealed she did not know which alarm was sounding, until she stepped outside the room and noticed it was her hall. She stated she went outside and down the hill, but she did not see anything. CNA A revealed she did not look around the building, and when she returned to the facility, the nurses were calm, like nothing happened. CNA A stated no one was searching the facility. She revealed the Charge Nurse was at the Nurse's Station acting as if nothing had happened. An interview with CNA B, who worked Hall 600, on 04/02/13 at approximately 10:50 PM via telephone revealed he worked the night Resident #1 went missing. He stated he last saw Resident #1 around 3:00 AM sleeping in bed. CNA B revealed at approximately 3:30 AM he was assisting the RN D with care, when he heard the exit door alarm sound. He stated he and RN D continued with care. CNA B revealed around 4:15 AM, he began conducting rounds and noticed Resident #1 was not in his room. He stated he told the CNA on Hall 100 Resident #1 was missing and then informed RN D. An interview with the DON on 04/02/13 at approximately 10:00 PM revealed she knew the facility's policy and procedures for elopement were not followed. She stated, "It makes me sick" of the events which happened concerning Resident #1. Further interview with the DON on 04/02/13 at approximately 10:10 PM revealed CNA B clarified the time Resident #1 was missing as around 4:15 AM. She stated CNA B searched the facility and outside the facility and RN D called the other buildings. The DON revealed she and the Administrator were not notified Resident #1 was missing until approximately 6:00 AM. She also stated the police were not notified until approximately 6:00 AM. An interview with the Administrator and the Director of Clinical Services on 04/02/13 at 8:30 PM revealed Resident #1 eloped from the facility on 04/02/13 during the 10:00 PM to 6:00 AM shift. The Administrator stated she was unable to get an exact time when the incident occurred because she got several different times during her interviews with staff. She revealed an exit door alarm sounded between 3:00 AM and 3:30 AM on Hall 200. She stated CNA A looked outside, but did not see anyone at that time. The Administrator stated when the alarm sounded, staff did not look on all the halls to see if a resident was missing. She revealed at approximately 4:15 AM CNA B, who worked Hall 600 where Resident #1 lived, observed Resident #1 was not in his room. She stated CNA B then alerted other staff in the facility about the missing resident. The Administrator revealed she and the police were not notified until after 6:00 AM. When asked if the facility's Elopement policy and procedures were followed, the Administrator replied no. An interview was attempted on 04/02/13 at approximately 11:15 PM with RN D, who was the Charge Nurse when Resident #1 eloped, but there was no answer on her cell phone. A second interview was attempted via telephone on 04/03/13 at approximately 11:45 AM, but there was no answer. The facility's Provider Investigation Report, dated 04/08/13, reflected Resident #1 was discovered missing at approximately 3:00 AM on 04/02/13, and the Administrator, DON, and the local Police were not notified until after 6:00 AM on 04/02/13. The Report also reflected Resident #1 was found by the local Police Department and sent to a local hospital emergency roiagnom on [DATE]. Further review of the Report revealed all staff were re-educated on the facility's Elopement Policy and how to respond to exit door alarms sounding, RN D, who did not notify the Administrator, DON or police of the missing resident timely, was terminated, the DON planned to refer RN D to the Board of Nurse Examiners, and frequent door alarms drills were held on all shifts. An observation on 04/03/13 at approximately 11:18 AM revealed the Hall 100 exit door alarm did not sound, when the Maintenance Director opened the door. At this time, the Maintenance Director stated someone turned off the exit door alarm. The Maintenance Director turned the Hall 100 exit door alarm back on. The Maintenance Director stated he and the floor technicians were the only ones with keys to the exit door alarms. The Maintenance Director was unable to inform the surveyor who turned the alarm off on Hall 100. The DON was at the Nurse's Station and observed the Maintenance Director testing the exit door alarms. After the Hall 100 exit door alarm did not sound, the surveyor spoke with the DON about the alarm being turned off. The DON stated at this time she knew the alarm should be on, and she would try to find out who turned the alarm off. At this time, Resident #1 was still missing. An interview with the Maintenance Director on 04/03/13 at approximately 11:25 AM revealed he and his staff checked the Wander Guard alarm system along with the exit door alarms on a weekly basis. He stated he had a log where he documented the checks. The Maintenance Director revealed the Restorative CNAs were in charge of checking the individual wander guard bracelets on the residents. The facility's undated Wander Guard List reflected 29 residents were at risk for wandering. The facility's current, undated Elopement of a Resident policy reflected, 1. If staff heard a door alarm, all staff were to respond and check outside for a resident going around the building to ensure a resident was not outside. Staff were call to buildings 2, 3, and 4, to inform them a resident was missing. 2. All staff were to check inside the building in each open room, bathroom, office and dining areas for a resident who was missing. 3. Staff was to search the outside grounds and vehicles for the missing resident. 4. The Administrator and DON were to be notified immediately when a resident was missing. 5. 911 should be notified of the missing resident. 6. Staff should obtain a current photograph of the resident, with the height and weight and any identifying information. 7. Contact the physician who was responsible for the resident's care. 8. Contact resident's responsible party. 9. Start an Incident Report and get statements from all staff who were working. 10. This protocol should be followed anytime a resident was missing. All staff were to remain on site until the management team arrived. On 04/03/13 an IJ was identified. On 04/03/13 at 4:20 PM the Administrator and DON were informed of the IJ and a Plan of Removal was requested at that time. An interview with the DON and Consultant E on 04/04/13 at approximately 10:50 AM revealed she thought the IJ occurred for several reasons. She stated staff failed to look for the resident, and failed to contact the Administrator and DON when the incident occurred. The Consultant revealed there was a significant lapse in time from the time the resident went missing until the staff initiated the Elopement policy and procedure. The DON stated RN D did not follow through and was more concerned about being in trouble. The DON thought the IJ occurred because RN D did not follow the facility's Elopement policy and procedures. The Consultant stated if the nurse would have followed the Elopement policy the resident could have been found in a reasonable time. An interview with Consultant F on 04/04/13 at approximately 11:20 AM revealed she thought the IJ occurred when the CNA did not follow the proper Elopement policy and procedure protocol, and staff failed to report the incident to the Administrator and DON. On 04/04/13 the facility's Plan of Removal, dated 04/04/13, was accepted and reflected the following: RN D, who did not notify the Administrator and DON that Resident #1 was missing, was suspended on 04/02/13 by the DON. The DON also recommended to Human Resources, to terminate RN D's employment on 04/03/13 at 5:00 PM. CNA A, who responded to the Hall 200 emergency exit door alarm, but did not go around the building to check for residents, was suspended on 04/02/13 at 10:30 PM and would not return until she was trained by either the ADON or DON on the Elopement Protocol. An In-Service on the Elopement Protocol was initiated on 04/02/13 by the DON with all of the 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM shift of nursing staff and floor technicians present. On 04/03/13 the DON presented In-Services regarding the Elopement Protocol for CNAs who were not present on 04/02/13, Department Heads, Dietary staff, Housekeeping staff, Maintenance staff, and Nursing management. Staff who were not present for the In-Service would receive them prior to their next scheduled shift. The DON was keeping track of employees who received the Elopement Protocol training, so staff, who had not received the training, were identified and would attend the training. In-Service on the Elopement Protocol, including which residents were at risk for elopement and the At Risk Book with photos, was kept at the Nurse's Station. A list of the residents, who wore a Wander Guard bracelet, was placed on each Hall's linen cart, so the staff could identify the residents at risk for elopement. A second exit door alarm was placed on the Hall 100 and Hall 400 exit doors by Maintenance on 04/03/13. These doors were the only hall exit doors that did not already have two alarms installed. A sign, which reflected, "If alarm sounds, you must go outside and check who exited the building, before turning the alarm off," was placed on each Hall exit door. Beginning 04/03/13, Halls 100, 200, 300, 400, 500, and 600 exit door alarms would be checked on the 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM shifts Monday through Friday to ensure the alarms were on and functioning by the floor technician. The technician, who worked Saturdays and Sundays 7:00 AM to 7:00 PM, would check the alarms twice during the shift to ensure the exit door alarms were turned on. The night shift nurse would check the alarms on the 10:00 PM to 6:00 AM shift on the weekend. Staff members, who were checking the door alarms, would immediately notify the Administrator if the alarms were not functioning properly. The Administrator, would then give the direction to place a staff member at each exit door, which was not functioning correctly. The Administrator then would notify the Maintenance Director, to come repair the alarm. The Administrator would verify the alarm checks were being conducted by reviewing a log of the alarm checks on a daily basis. The Halls 100, 200, 300, 400, 500, and 600 emergency exit door alarms would be tested and checked three times a week by the Maintenance Director to ensure they were functioning properly. The Maintenance Director would test the exit door equipment with a Wander Guard alarm three times a week for proper function by using a Wander Guard bracelet to trigger the alarm. The Administrator would monitor compliance on a weekly basis by reviewing the log maintained by the Maintenance Director. The Restorative Aides would continue the system of monitoring the placement of the Wander Guard bracelets on the residents, the expiration date and proper functions on a daily basis. The MDS nurse would monitor the log maintained by the Restorative Aides to ensure compliance on a daily basis. Any alarms (WanderGuard or exit alarms) found not to be working would be reported by staff immediately to the Administrator. The Administrator, would then give direction to place a staff member at each exit door, which was not functioning correctly. The Administrator would then notify the Maintenance Director, to come repair the alarm. A resident's room hall emergency exit door alarm would be triggered by facility management staff twice weekly to ensure the alarms were functioning, and the staff were responding according to the Elopement Protocol. The emergency exit alarms on Halls 100 through 600 would be tested on a monthly basis, along with the prior drills, to ensure they were functioning and staff responded appropriately beginning with the scheduled fire drill for 04/04/13 at 5:20 PM and on the 10:00 PM to 6:00 AM shift on 04/04/13. On 04/05/13 an unannounced drill would occur on the 6:00 AM to 2:00 PM shift, and staff would be observed during the drill by management, to see if staff execute the Elopement Protocol effectively, and staff who do not respond effectively would receive an in-service. The local Police Department notified the Administrator at 1:30 PM on 04/03/13 that Resident #1 was located quite a distance away from the facility, and he was transported to an emergency room . Resident #1 was transported back to the facility by the Vice President of Operations and the MDS Coordinator on 04/03/13 at approximately 4:00 PM. He received a physical assessment upon his return by his Charge Nurse. Resident #1's assessment reflected he was alert and oriented to his room, answered simple direct questions, was able to transfer without assistance, and had a dressing with an Ace wrap on his right hand. Upon removal of the dressing, dried blood was over the inside of his palm of his right hand. There was a skin tear approximately 0.25 cm in the palm of his right hand. The area was cleansed with sterile water and a dry dressing was applied. Resident #1 was served a meal and ate 100% of the meal, feeding himself. Resident #1 complained of both hips hurting, and x-rays obtained were negative for injuries. A new Elopement Risk Assessment was completed on 04/03/13 by the Charge Nurse. His MDS assessment would be reviewed by the DON over the next 14 days to determine if a significant change in status assessment was required. His Care Plan was amended on 04/03/13 by the DON to reflect his elopement and continued elopement risk. His physician, guardian, and DADS were notified of his location and return to the facility on [DATE]. On 04/03/13 the DON reviewed 28 additional residents, who were at risk of elopement. Areas reviewed included elopement assessment, care plans and ADL sheets. All of the residents were fitted with a Wander Guard bracelet which was functional. The At-risk of Elopement book was at the Nurse's Station with current photographs of the 28 additional residents and Resident #1, which was reviewed for accuracy by the ADON and Charge Nurses. The Care Plans for the 28 at-risk residents and Resident #1, were being reviewed and amended by the DON, to include interventions specific to each resident. Changes to Resident #1's Care Plan specific to him were to redirect him off all halls where he did not live, as he tended to lie down in empty beds. If he attempted to exit the facility, redirect him to his room and have him lie down and put him on an every 15 minutes observation for 24 hours. This review was completed on 04/04/13. The Plan of Removal would be reviewed by the Quality Assurance and Assessment Team at 10:30 PM on 04/03/13. The members of the QA team in attendance included the Administrator, the DON, the the Nurse Consultants. The QA Committee members reviewed the incident and verification to determine the root causes that were associated. The members then developed a Plan of Removal to address the steps that would be instituted to prevent reoccurrence. The Medical Director was advised of the IJ situation. The Plan would be reviewed at least quarterly to ensure continued compliance with the plan and to make any recommendations for changes as needed. The next quarterly QA meeting was scheduled for 04/10/13. Resident #1's Admission/Readmission Assessment and Plan of Care, dated 04/03/13, reflected a [DIAGNOSES REDACTED]. Further review of the Assessment revealed Resident #1 had a puncture wound to his right hand, and he had a history of [REDACTED]." Resident #1's Risk Analysis Worksheet, dated 04/03/13, which was completed after his return to the facility, reflected he was still at risk for wandering. Resident #1's Care Plan for Behavioral Symptoms, updated 04/03/13, reflected, "Reviewed. cont (with) wander guard. If amb. (ambulating) hallway encourage res (resident) back to his hall, verbal redirection. If attempts to elope out door redirect & (and) monitor whereabouts, take to rm (room) & have him lie down." Observations on 04/05/13 from 2:20 PM through 2:30 PM revealed the Maintenance Director tested the exit door alarms on Hall 100 through 600 and all alarms sounded. The exit doors also had a posted sign, which reflected, "If alarm sounds you must go outside and check who exited the building before turning the alarm off." RN D's Progressive Discipline report, dated 04/02/13, reflected she received her second written warning or suspension. The Report also reflected she was suspended from 04/02/13 through 04/04/13 due to failure to report a missing resident to the Abuse Coordinator or the DON. In- Service Record dated 04/02/13 reflected CNA C attended the in-service regarding the Elopement Protocol and Abuse and Neglect. In-Service Record dated 04/03/13 at 9:50 PM reflected CNA B attended the in-service regarding the Elopement Protocol. In-Service Record dated 04/04/13 reflected CNA B attended the in-service. Elopement Drill dated 04/04/13 and timed at 10:08 PM reflected CNA B was involved in the drill and all staff responded appropriately. The facility's undated Elopement In-Service Employee List check off reflected 87 staff members had been in-serviced on the facility's Elopement Protocol. The facility's Elopement Drill Report dated 04/04/13 at 5:23 (PM or AM not specified) reflected staff responded appropriately to the Hall 200 exit door alarm. Another Elopement Drill report dated 04/04/13 at 10:08 PM reflected staff responded appropriately. Another Elopement Drill report dated 04/05/13 at 9:20 AM reflected staff responded appropriately. Interviews with CNA G, LVN H, LVN I, CNA B, CNA J, CNA K, CNA L, LVN M, RCNA N, CNA O, CNA Q, and LVN P on 04/05/13 from approximately 2:45 PM through 3:40 PM revealed they knew if an exit door alarm sounded they needed to go outside and look all around the facility, and if no resident was found, they needed to check all around the inside of the facility. They knew the At Risk Book was at the Nurse's Station and who needed to informed if there were problems. The DON faxed a new Risk for Wandering assessment on 04/11/13, which reflected, "A 'YES' answer to any question #1 through #8 means that the resident is at risk for elopement. Complete step 2 (see attached)." The attachment was an Elopement Risk Assessment Step 2. The IJ was removed on 04/05/13. The Administrator, DON, Consultant E and Consultant F were notified on 04/05/13 at 1:40 PM that the IJ was removed. While the IJ was removed on 04/05/13, the facility remained out of compliance at a scope of "pattern" and a severity level "No actual harm with potential for more than minimal harm, that is not immediate jeopardy," because the facility was still in-servicing staff and monitoring the effectiveness of the Plan of Removal. The facility's undated Wander Guard List reflected 29 residents were at risk for wandering including Resident #1.