Every finding on record at Cass Valley Healthcare Center

Based on observations, record reviews and interviews, the facility failed to ensure a resident was free from verbal and physical abuse by staff for 1 of 4 sample residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from abuse on 03/13/2026 when CNA A physically and verbally abused Resident #1 during care. This failure placed residents at risk of abuse, neglect, trauma, and psychosocial harm. Findings included: Review of Resident #1's face sheet reflected a [AGE] year old male admitted to the facility on [DATE] with the following diagnoses Alzheimer's disease (A type of brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition.), diabetes mellites (A condition results from insufficient production of insulin, causing high blood sugar.) dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), and bipolar disorder (A serious mental illness characterized by extreme mood swings.). Review of Resident #1's annual MDS dated [DATE] reflected Resident #1 was assessed to not have a BIMS assessment done indicating the resident was rarely/ never understood and had severe cognitive impairment. Resident #1 was assessed to not have behavior during the assessment period. The MDS reflected Resident #1 had short and long- term memory problems and was severely impaired in daily decision making. The MDS also reflected Resident #1 continuously had inattention, disorganized thinking, was short tempered and easily annoyed. The MDS further reflected Resident #1 was functionally dependent on staff for transfers, bathing, toileting, and all activities of daily living. Review of Resident #1's comprehensive care plan dated 07/12/2024 reflected there was an electronic monitoring device in his room that family has consented to. The Care Plan dated 05/27/2024 reflected Resident #1 had ADL self-care performance deficit related to dementia and ADLs fluctuate related to the disease process. The Care Plan revised 10/21/2024 reflected Resident #1 was resistive to care related to dementia and refuses glucose checks, ADL care, incontinence care, medications, and showers. Interventions included to allow the resident to make decisions in treatment to provide a sense of control; give clear explanations of treatment and if residents resist with ADLS to leave and return 5-10 minutes later and try again. The Care plan revised on 02/11/2025 reflected Resident #1 had the potential to be physically aggressive related to dementia and has hit, push, bite, or slap staff. Interventions included to communicate to alleviate anxiety, give the resident choices about care when resident agitated or distressed, staff is to walk away calmly and approach later. The Care plan on 03/13/26 added interventions for behavior problems that reflected that two person staff to slowly approach the resident when providing care and if escalated reattempt and provide care later. Observation and interview with Resident #1 on 04/21/2026 at 10:40 AM revealed Resident #1 in room in his bed. The bed was low to the floor with fall matt in place. Resident #1 was confused and did not answer questions. Resident #1 was clean and without odors. Review of the video footage recorded on 03/13/2026 at 5:30 AM revealed CNA A was in Resident #1's room interacting with the resident. Resident #1 was in his bed with CNA A attempting to change the resident's incontinence brief. CNA A entered the room, stated moving the bed up, and turned the light on while the resident appeared to be asleep. Resident #1 immediately responded with arms up, and CNA A swatted and pushed Resident #1's arms down onto his body and the resident began thrashing in bed. The video audio revealed CNA A speaking to Resident #1. CNA A stated to Resident #1 that if he did not stop CNA A would act. During the interaction, CNA A was physically pushing down and holding Resident #1's arms and legs. Resident #1 kicked and pushed at CNA A, and CNA A pushed the resident down into the mattress and lifted the resident's legs up above both of their heads and against the wall. As CNA A moved and held Resident #1, Resident #1 became more aggressive with CNA A. At one point Resident #1 kicked CNA A into the bedside table that was across the room. CNA A continued to attempt to change Resident #1's brief. Continued review of the video revealed Resident #1 was pushed around, picked up, and pushed down into the mattress multiple times while CNA A attempted to control the resident's movements and change his brief. The video footage revealed CNA A did not approach Resident #1 in a calm manner or explain what she was doing. The video footage further revealed CNA A at no point stopped what she was doing to get assistance once Resident #1 became aggressive. Review of Resident #1's nursing progress note dated 03/13/2026 at 06:10am written by LVN B, reflected a skin/wound assessment that was conducted after the allegation of abuse. A skin assessment dated [DATE] noted that there was no evidence of any skin alterations or discoloration to his arms, leg, face/head, back, hands or feet. A second skin check was performed on 03/14/2026 by the ADON at 1:30 am and Resident #1 is noted to be cooperative with staff and no new skin wound issues charted. Attempts to contact CNA A on 04/21/2026 at 10:45 AM and 2:30 PM and again on 04/22/2026 were unsuccessful. Review of a statement provided by CNA A to the facility verbally dated 03/13/2026 reflected spoke to [CNA A] about the reported incident with [Resident #1]. She stated she went to change him and he 'went to punching me and I put my hand on him. I raised him up and turned him over.' When asked about 'giving him a shove', she stated 'I pushed him over on his side. He was in the bed, and I put his hands on his chest so he would hit himself instead of me'. She added that 'he kicked her and knocked her into the over bed table, and it fell over.' In an interview on 04/21/2026 at 12:01 PM LVN B stated It was the end of our shift, and I went to pass out morning medications. The two aides were in another resident's room changing a resident across the hall. When I walked by the room and [CNA A], one of the other CNAs told me, she gave resident a good push when resident was swinging legs and arms. Just wanted to tell me. LVN B stated she did not see what occurred, she only knew what CNA A told her occurred. She stated, I looked at [Resident #1], and he was walking around the area, and did not look injured at all. She stated she finished passing out medications and day shift arrived. She stated she talked to the day nurse that came on and asked if she needed to contact the DON. She stated the day nurse told her to write a statement and leave it for the DON. She stated she sat in the conference room and wrote the statement. She stated she told the DON that CNA A just told her that she gave Resident #1 a push. Review of the statement provided to the facility dated 03/13/2026 from LVN B reflected During the interview, the former DON reported that she arrived to work on Friday morning and became aware of the situation after learning what CNA A had shared with LVN B regarding the alleged incident involving Resident #1. The former DON stated that she was surprised by the information, noting that she had recently completed a competency evaluation with the employee involved. During that observation, the former reported that the employee demonstrated compassionate care practices and was attentive to residents' comfort, including awareness of potential pain during care delivery. Ther former DON further reported that she had not previously identified any concerns regarding this employee's interactions with residents or delivery of care prior to this incident. Review of the facility's investigation dated 03/13/2026 at 11:09 am reflected CNA A reported to her charge nurse (LVN B) at the end of her shift that Resident #1 became combative, resisting care and that he had hit her several times, punching and kicking. LVN B reported to DON and Administrator that CNA A stated she gave Resident #1 a shove. A Head to toe assessment was conducted by LVN B at 6:10 am. Head to toe assessment revealed no bruising, no injury. Subsequent assessments performed revealed no bruising, no injury, no pain. Resident monitored for 72 hours with no further signs/symptoms of injury nor emotional distress. Further review of the facility investigation revealed provider response Alleged Perpetrator, CNA A, suspended pending investigation. Alleged Perpetrator HR file reviewed. All background checks and training in place. Nursing competencies completed with her on 02/18/2026 with good reviews. Head-to-toe assessment performed on resident. No findings. Emotional assessment performed on resident. No findings. Family notified. Physician notified. Ombudsman notified. Sheriff's office notified. Resident Interviews performed regarding Physical Abuse with no findings. Peer interviews performed regarding Alleged Perpetrator with no findings. Full head-to-toe assessments performed on all residents in the secure unit with no findings. Alleged perpetrator only worked in Secure Unit. Abuse drills started with all staff. Multiple scenarios presented for education purposes. Drills to continue. Monitored victim for 72 hours for any signs and symptoms of abuse/injury. No findings. Upon becoming aware of the allegation, the facility immediately initiated an investigation in accordance with the facility's Abuse Prohibition Policy and Procedures to ensure resident safety and determine the circumstances surrounding the incident. The facility maintains a comprehensive abuse prevention program designed to ensure residents are protected from abuse, neglect, and exploitation. All employees receive education on abuse prevention, appropriate resident interactions, and mandatory reporting requirements during new hire orientation and through ongoing in-service training throughout the course of their employment. Staff are educated on maintaining resident dignity, responding appropriately to behavioral escalations, and utilizing de-escalation techniques when residents become agitated or combative. As part of routine supervisory oversight and competency validation, nursing leadership conducts regular observations of staff providing resident care. The employee involved in this incident had been recently evaluated by the Director of Nursing within the past several weeks regarding patient handling and care delivery. During that evaluation, the employee demonstrated appropriate care techniques and resident interactions, and the Director of Nursing provided positive feedback regarding the employee's handling of residents and delivery of care. The investigation reviewed the circumstances surrounding the resident interaction. Documentation and staff interviews indicated that during the provision of care, the resident became agitated and combative, which can occur with residents experiencing confusion, cognitive impairment, or distress during personal care activities. Staff are trained to respond to these situations using de-escalation techniques such as pausing care, allowing the resident time to calm, speaking calmly, and requesting assistance when necessary. During this interaction, the employee reacted inappropriately to the resident's behavior and engaged in actions that were not consistent with the training, expectations, or abuse prevention policies of the facility. Staff are expected to maintain professional conduct at all times and utilize appropriate behavioral management techniques when residents become combative. As part of the investigation, the facility reviewed available video footage, conducted staff interviews, and reviewed relevant documentation. Based on the review of the video evidence and information obtained during the investigation, the facility confirmed that the employee engaged in inappropriate physical contact with the resident which was not consistent with the facility's abuse prevention policies or staff training. Based on the findings of the investigation, the facility determined that the employee's actions represented a deviation from established policies, procedures, and training, and did not reflect the standards of care or the culture of resident dignity and safety promoted within the facility. Consistent with the facility's zero-tolerance policy for abuse, the employee was immediately removed from resident care and subsequently terminated from employment. Appropriate notifications were made in accordance with regulatory requirements, including reporting the incident to law enforcement. The facility has reinforced staff education related to abuse prevention, appropriate resident approach techniques, and management of combative resident behaviors, and has implemented additional monitoring to ensure continued adherence to resident rights and abuse prevention standards. Based on the investigation findings, the facility determined that the employee's actions were inconsistent with the facility's abuse prohibition policies, staff training, and expectations for resident care. In an interview on 04/21/2026 at 12:09 PM the Administrator stated that she obtained a video from the in-room camera provided by Resident #1's family to review the interaction with Resident #1. After viewing the video of the incident, she concluded that according to the facility's policy Abuse Prohibition Policy and Procedures CNA A reacted inappropriately to Resident #1's behavior and engaging in actions that were not consistent with training, expectations, or abuse prevention policies. The Administrator stated CNA A did have staff training and was provided with staff expectations of the facility for resident care. The Administrator stated the CNA's behavior was out of character. The Administrator stated after the incident, another CNA reported that CNA A did not seem herself and felt something was wrong. According to the Administrator, who conducted the investigation, the allegation was confirmed that the CNA A acted aggressively with Resident #1 and CNA A was immediately suspended and terminated from the facility. In an interview on 04/21/2026 at 12:30 PM the DON confirmed that staff were trained to provide care in a manner that maintained the residents' dignity and prohibited any form of abuse, including verbal and physical abuse. The DON stated she had recently completed a competency evaluation with the CNA A and reported no identified concerns with CNA A's interactions with residents or care prior to this incident. Review of CNA A's certified nursing assistant competencies reflected CNA A completed behavioral competencies on 02/18/2026 which covered aggressive behaviors and conflict resolution with aggressive residents. Review of CNA A's personnel record reflected she had no written or verbal write up regarding resident care. CNA A's background checks were completed Review of CNA A's personnel action form dated 03/13/2026 reflected the aide was terminated for substantiated resident abuse with the last day she worked documented as 03/13/2026. Review of the facility's Abuse Prohibition Policy dated 02/26/2026 reflected This protocol was intended to assist in the prevention of abuse, neglect and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse. 1. The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents. 2.The facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations. Abuse means the willful infliction of injury, withholding or misappropriating property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical abuse includes, hitting, slapping, kicking, shoving, pinching and controlling behavior through corporal punishment.Verbal abuse is defined as the use of, oral, written or gestured language that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Examples of verbal/mental abuse include, but are not limited to, cursing, yelling, saying things to frighten a resident, denying food or care, isolating a resident.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute food under sanitary conditions in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure Dietary [NAME] changed her gloves during food preparation after wiping her nose with her fingers on her left hand. This failure could place residents who ate food from the kitchen at risk for foodborne illness.Findings include:Observation on 09/24/2025 at 11:40 AM, Dietary [NAME] was wearing gloves when she was pureeing biscuits. She wiped the left side of her nose with the forefinger and middle finger on her left hand. She did not change her gloves and continued to prepare puree biscuits and put her left hand on the spatula she was using to pour the puree biscuits into a silver container, while standing over the puree biscuits on the food prep table. In an interview on 09/24/2025 at 11:49 AM, Dietary [NAME] B stated at one time during preparation of pureed biscuits, she was wearing gloves when she wiped her nose with her left hand. Dietary [NAME] B stated she continued to puree the biscuits and pour the biscuits in the silver container without changing her gloves or washing her hands. She stated there was a possibility she did touch the biscuits with her left hand. Dietary [NAME] B stated her gloves was considered contaminated and if a resident ate the biscuits with bacteria on the biscuits there was a possibility the resident may become sick and have diarrhea or upset stomach. She stated she had been in-service on hand hygiene; however, she was unable to recall the date of the in-service. In an interview on09/25/2025 at 11:45 AM The Administrator stated the dietary staff was expected to change their gloves if they touched anything considered contaminated. She stated touching their nose would be considered contaminating the gloves. The Administrator stated there was a possibility a resident may become physically ill with stomach issues if they ingested some type of food with bacteria in the food. She stated a resident may become nauseated and possibility have diarrhea. The Administrator stated the Dietary Manager was responsible for monitoring the kitchen. The Administrator stated she was responsible to monitor the Dietary Manager. In an interview on 09/25/2025 at 12:40 PM the Dietary Manager stated she expected all staff to change gloves and wash hands in between tasks and when the staff touched their clothes, nose, or anything considered contaminated. She stated she had in serviced all dietary staff on hand hygiene. The Dietary Manager stated she could not recall the date of the in-service. She stated Dietary [NAME] B was expected to change her gloves and wash her hands if she touched anything when she prepared pureed biscuits. She stated a resident could become ill if a resident ate any contaminated food. She stated the resident may develop stomach issues such as vomiting and diarrhea. The Dietary Manager stated she was responsible to ensure all the staff in the kitchen followed hand hygiene protocol. Record review of the facility's policy on Handwashing-Hand Hygiene, dated 2020, reflected The facility considers hand hygiene the primary means to prevent the spread of infections.

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 of eight residents (Resident # 5, and Resident #18) reviewed for activities. The facility failed to provide Resident #5, and Resident #18 in room activities on the dates of 09/01/2025 thru 09/21/2025. This failure could place residents at risk for boredom, depression, and a diminished quality of life. Findings included:1.Record review of Resident # 5's face sheet, dated 09/25/2025, reflected a [AGE] year-old male, admitted [DATE] and readmitted [DATE]. Resident #5 had diagnoses which included major depressive disorder, recurrent, severe with psychotic symptoms (a mood disorder that causes a persistent feeling of sadness and loss of interest and seeing or hearing things that are not real or false beliefs), anxiety disorder, unspecified (a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed), other lack of coordination ( the body's movements are not smooth, controlled, or precise resulting in unsteadiness, and difficulty with everyday tasks) and unspecified dementia, unspecified moderate, with behavioral disturbance ( a condition where individuals experience cognitive decline consistent memory loss, and impaired thinking, with behaviors). Record review of Resident #5's annual MDS Assessment, dated 05/19/2025, reflected Resident #5 had a BIMS score of 1, indicating severely impaired cognition. Resident #5 indicated the following activities was somewhat important: participating in religious services or practices, doing favorite activity, and do things with groups of people. Record review of Resident #5's Quarterly MDS Assessment, dated 08/18/2025, reflected Resident #5 had a BIMS score of 2, indicating severely impaired cognition. He had disorganized thinking (rambling or irrelevant conversation).Record review of Resident #5's Comprehensive Care Plan, with completion date of 09/18/2025, reflected Resident #5 had little or no activity involvement related to he wishes not to participate (Problem, Goal and Intervention- Resident initiated on 07/11/2024). Goal Resident # 5 will participate in activities of choice (1-3) times per week. Intervention: Remind Resident #5 he may leave activities at any time and was not required to stay for entire activity. Resident #5 needed a variety of activity types and locations to maintain interests. Resident # 5 required assistance to activity functions. (Problem and intervention initiated on 05/27/2024) Resident #5 was an elopement risk related to dementia. Intervention: Resident #5 will be provided memory boxes. Record review of Resident #5's Participation Record, dated September 2025, reflected Resident # 5 did not receive in room activities from 09/01/2025 thru 09/21/2025. Observation and interview on 09/23/2025 at 11:05 AM Resident #5 were lying in bed. He did not respond to questions asked about his activities or about his care. During an interview on 09/23/2025 at 11:45 AM, the Activity Director stated Resident #5 did not want to attend very many group activities and changed his activity program during the month of July 2025 to receive in room activities 3 times per week. The Activity Director stated she was expected to ensure all residents received activities based on their preferences and their physical abilities. She stated if residents were not coming out of their room, the residents were to be provided in room activities. The Activity Director stated she provided in room activities at least three times a week. She stated there was no excuse why Resident #5 did not receive in room visits. The Activity Director stated if a resident was not receiving activities on a consistent basis there was a potential a resident may become bored, depressed, or have a decline in their quality of life. She also stated Resident #5 did not have a memory box. 2.Record review of Resident # 18's face sheet, dated 09/25/2025, reflected an [AGE] year-old female, admitted on [DATE]. Resident #18 had diagnoses which included unspecified dementia, unspecified severity, with behavioral disturbance (a condition where individuals experience cognitive decline consistent memory loss, and impaired thinking, with behaviors), generalized anxiety disorder (a persistent mental health condition characterized by excessive and difficult-to-control worry interfering with daily life), and cognitive communication deficit ( problems or weaknesses in mental functions such as thinking, memory, attention, language, and problem-solving). Record review of Resident # 18's Annual MDS Assessment, dated 03/09/2025, reflected Resident #18 had a BIMS score of 4, which indicated her cognition was severely impaired. Further review reflected Resident #18 indicated keeping up with the news, being with group of people, doing favorite activity, going outside to get fresh air and, participating in religious services or practices was somewhat important to Resident #18. Record review of Resident#18's Quarterly MDS Assessment, dated 09/07/2025, reflected Resident #18 had a BIMS score of 3, which indicated his cognition was severely impaired. Resident #18 had disorganized thinking (rambling or irrelevant conversation, unclear flow of ideas, unpredictable switching from subject to subject). Record review of Resident #18's Comprehensive Care Plan, reflected Resident #18 (date initiated on 11/03/2023) was a wanderer risk related to decreased in safety awareness. Intervention: Resident #18 will be engaged in diversional activities as needed. Encourage Resident #18 to participate in activities of her preference. (Problem and Interventions dated initiated 09/23/2025) Resident #18 will attend activities of choice in order to meet emotional, intellectual, physical, and social needs. Interventions: Assist with arranging community activities. Arrange transportation. Invite Resident #18 to scheduled activities. Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility. Record review of Resident #18's Participation Record, dated September 2025, reflected Resident #18's did not receive in room activities from 09/01/2025 thru 09/21/2025. During an observation and interview on 09/23/2025 at 11:30 AM, Resident #18 was lying in bed in her room. She did not respond appropriately to questions about activities or her care. She mumbled when asked questions and during conversation. Interview on 09/23/2025 at 11:45 AM, the Activity Director stated Resident # 18 has been on the in-room activity program since June 2025. She stated Resident #18 responded better during in room activities than in a group. The Activity Director stated Resident #18 was not interested in group activities. She stated she was not physically or mentally able to go on a community outing. She stated it would be a risk of her wandering from the group if she was on an outing in the community. She stated Resident #18's activity care plan was expected to reflect Resident #18 was receiving in room activities three times per week and not attending group activities or going on community outings. She stated she did attend care plan meetings. The Activity Director stated she did not have an explanation of why Resident #18 did not receive in room activities during the time frame of 09/01/2025 thru 09/21/2025. Interview on 09/25/2025 at 9:40 AM, the Activity Director stated she was expected to ensure all residents received activities based on their preferences and their physical abilities. She stated if residents were not coming out of their room, had a decline of attending group activities, the residents were to be provided activities in their room. She stated if a resident was not receiving activities there was a possibility the resident may have become isolated, have a decline in their mental status, or become depressed. She stated it was her responsibility to provide in room activities. The Activity Director stated she forgot to visit Resident # 5 and Resident #18 from 09/01/2025 thru 09/21/2025 when she added both residents to the in-room activity program. Interview on 09/25/2025 at 11:00 AM, the Administrator stated he expected in room activities be provided to the residents needing these types of activities. He stated if a resident was not receiving in room activities there was a possibility a resident may become depressed, bored and isolated. He stated the Activity Director was responsible for all activities in the facility. He stated the Administrator would be responsible for monitoring the Activity Director. Record review of the Activity Director's personnel file revealed she was began working at the facility June 2025 and was enrolled in National Certification Council Activity Program Training. Record review of The Facility's Activity Programming, dated 2001, revealed Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. The activities program is ongoing and includes facility-organized group activities, independent individual activities, and assisted individual activities. Record review of The Facility's Activity Documentation-General Guidelines, January 2020, revealed the following records, at a minimum, are maintained by activity department personnel:a. Activities evaluationb. Attendance recordsc. Activities calendard. Activity progress notes; and e. Individualized activities care plan or activities portion of the comprehensive care plan. The activity director is responsible for ensuring that activity documentation is completed and maintained. Record review of the Activity Job Description, signed on 06/13/2025, reflected basic function: provide an ongoing program of activities designed to meet the interests and physical, mental, and psychosocial well-being of each patient. Care and Services:1. Completes assessments, MDS, care plans and gathers information to design activities that are multi-faceted, meets residents' functional levels, and reflects needs and interests of each patient.2. Through activities, provides stimulation or solace, promotes physical, cognitive and/or emotional health.3. Offers activities that enhance, to the extent practicable, each resident's physical and mental status.4. Promotes each resident's self -respect by providing activities that support self-expression and choice. 5. Provides residents who are confined or choose to remain in their rooms within room activities in keeping with life-long interest.

Based on observation, interview and record review the facility failed to ensure that all drugs and biologicals used in the facility are labeled in accordance with professional standards, including expiration dates and with appropriate accessory and cautionary instructions for 1 (Resident # 5) of 30 residents reviewed for medication storage and labeling The facility failed to ensure medication for Resident # 5 was stored and labeled as it was received. The facility failed to ensure that expired medication package was destroyed or sent back to the pharmacy. These failures could place the residents at risk for receiving the wrong medication or not receiving the therapeutic effect of the prescribed medication.Findings include: In observation of medication room refrigerator on [DATE] at 1400 with LVN A present, revealed a zip lock plastic bag with a prescription sticker label for Resident #5 for Lispro100 units/ML Pen from Pharmacy A with expiration date of [DATE]. The medication that was on the prescription sticker label on the zip lock bag for Lispro 100 units/ML Pen was not present in the zip lock bag. Inside the zip lock plastic bag was a box with a prescription label for Novolog flex pen (insulin aspart)100 U/ML INJ from Pharmacy B with use by date [DATE] on the prescription sticker for Resident #5. Medication packaging indicates that medication does not expire until the year 2026. In record review of Resident #5's physician orders revealed HumaLOG KwikPen (Insulin Lispro)100 UNIT/ML. Further review revealed Resident #5 was not prescribed Novolog (insulin aspart) while living in the facility. In an interview with LVN A on [DATE]at 1419 she stated she has worked in the facility for 2 years. She stated she was in-serviced frequently on abuse, neglect, exploitation, medication administration, and medication storage and labeling. LVN A stated that medication boxes should only be placed in packages they were received in. LVN A states that Resident #5 was on HumaLOG not Novolog. LVN A stated they have HumaLOG for his sliding scale. LVN A stated the medication was in the incorrect bag and it all should have been removed as the Resident was not on Novolog insulin and it was not from the facilities pharmacy. LVN A stated the medications are both rapid acting insulins, they have different absorption rates. LVN A stated she would need an order from the provider to give the alternate medication. LVN A stated it was not okay to place a medication box for one medication in the packaging for another medication. LVN A stated the medication being placed in the incorrect packaging could have led to a medication error. She stated medication errors can potentially harm the Residents. LVN A stated that all nurses are responsible for ensuring medication that is expired or discontinued are removed. In an interview with DON on [DATE] at 1426 she stated they frequently Inservice the staff on abuse, neglect, exploitation, medication administration, and medication labeling and storage. She stated medication should not be placed in packaging supplied for any other medication. They stated it was their expectation that all nurses who have access to the medication room and the medication carts to ensure all expired or discontinued medication are removed to prevent medication errors. The DON stated if medication such as insulin was put into a zip lock plastic bag labeled for a different insulin that was expired the medication could be given and cause harm to the Resident. The DON states t the medication discussed should have been placed in the destruction box and not left in the refrigerator. In an interview with the Administrator on [DATE] at 1430 she stated all staff are in-serviced frequently on abuse, neglect and exploitation. She stated the DON frequently in-serviced nurses on medication administration and medication storage and labeling. She states the nurses are responsible for following the Storage of medication policy. Record Review of facility policy titled Storage of medication last reviewed [DATE] reflected the following: The Facility stores all drugs and biologicals in a safe, secure and orderly manner. 2. Drugs and biologicals used in the facility are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 4 Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for 2 (Resident #5 and Resident #18) of 6 residents reviewed for comprehensive care plans. The facility failed to update Resident #5's and Resident #18's care plan to reflect current activity needs for in-room activities. This failure could place residents at risk of not receiving necessary services or having important needs identified and met. Findings included:1.Record review of Resident # 5's face sheet, dated 09/25/2025, reflected a [AGE] year-old male, admitted [DATE] and readmitted [DATE]. Resident #5 had diagnoses which included major depressive disorder, recurrent, severe with psychotic symptoms (a mood disorder that causes a persistent feeling of sadness and loss of interest and seeing or hearing things that are not real or false beliefs), anxiety disorder, unspecified (a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed), other lack of coordination ( the body's movements are not smooth, controlled, or precise resulting in unsteadiness, and difficulty with everyday tasks) and unspecified dementia, unspecified moderate, with behavioral disturbance ( a condition where individuals experience cognitive decline consistent memory loss, and impaired thinking, with behaviors). Record review of Resident #5's annual MDS Assessment, dated 05/19/2025, reflected Resident #5 had a BIMS score of 1, indicating severely impaired cognition. Resident #5 indicated the following activities was somewhat important: participating in religious services or practices, doing favorite activity, and doing things with groups of people. Record review of Resident #5's Quarterly MDS Assessment, dated 08/18/2025, reflected Resident #5 had a BIMS score of 2, indicating severely impaired cognition. He had disorganized thinking (rambling or irrelevant conversation). Record review of Resident #5's Comprehensive Care Plan, with completion date of 09/18/2025, reflected no revisions of activity preferences and needs assessed in June 2025. Resident #5 had a problem identified in June 2025 as needing in room activities 3 times per week related to a decline in attending group activities. No interventions in place regarding in-room activities.Record review of Activity in Room Resident List, not dated, on 09/22/2025 reflected Resident #5's name was on the list to receive in room activities.2.Record review of Resident # 18's face sheet, dated 09/25/2025, reflected an [AGE] year-old female, admitted on [DATE]. Resident #18 had diagnoses which included unspecified dementia, unspecified severity, with behavioral disturbance (a condition where individuals experience cognitive decline consistent memory loss, and impaired thinking, with behaviors), generalized anxiety disorder (a persistent mental health condition characterized by excessive and difficult-to-control worry interfering with daily life), and cognitive communication deficit ( problems or weaknesses in mental functions such as thinking, memory, attention, language, and problem-solving). Record review of Resident # 18's Annual MDS Assessment, dated 03/09/2025, reflected Resident #18 had a BIMS score of 4, which indicated her cognition was severely impaired. Further review reflected Resident #18 indicated keeping up with the news, being with group of people, doing favorite activity, going outside to get fresh air and, participating in religious services or practices was somewhat important to Resident #18.Record review of Resident#18's Quarterly MDS Assessment, dated 09/07/2025, reflected Resident #18 had a BIMS score of 3, which indicated his cognition was severely impaired. Resident #18 had disorganized thinking (rambling or irrelevant conversation, unclear flow of ideas, unpredictable switching from subject to subject).Record review of Resident #18's Comprehensive Care Plan, reflected Resident #18 (date initiated on 11/03/2023) was a wanderer risk related to decreased in safety awareness. Intervention: Resident #18 will be engaged in diversional activities as needed. Encourage Resident #18 to participate in activities of her preference. (Problem and Interventions dated initiated 09/23/2025) Resident #18 will attend activities of choice in order to meet emotional, intellectual, physical, and social needs. Interventions: Assist with arranging community activities. Arrange transportation. Invite Resident #18 to scheduled activities. Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility.Record review of Resident #18's Participation Record, dated September 2025, reflected Resident #18's did not receive in room activities from 09/01/2025 thru 09/21/2025. Interview on 09/25/2025 at 8:30 AM, the Activity Director stated Resident # 5's and Resident #18's care plans were not revised from June 2025 thru September 2025 to reflect their changes in activity needs such as being provided in room activities. She stated anytime a resident's activity preference or activity abilities changed; the residents care plan was expected to be revised to reflect these changes. She stated if a resident was having behaviors or was depressed and staff reviewed the care plan; the staff would not know the accurate activities interventions to provide for the resident. She stated she had been in-serviced on care plans but did not recall the date. She stated she did not recall why the care plan was not revised. Interview on 09/25/2025 at 11:05 AM MDS Coordinator stated any time there was a change in a resident's physical condition, cognition, or activity preferences. The residents care plan was expected to be revised to reflect any changes with the resident. She stated if a resident needed in room activities after the comprehensive care plan was completed, the Activity Director was expected to revise the activity care plan and inform the IDT of the changes. She stated the Activity Director had opportunity to inform the IDT in morning meetings. The MDS Coordinator stated any residents in the facility she was not aware of any changes in their activity level or preferences.Interview on 09/25/2025 at 11:45 AM, the Administrator stated all care plans was expected to be revised anytime there was a change of physical condition, mental status, or activity preferences. She stated if a resident activity level changed and needed different type of activities, such as in room activities, the residents care plan was expected to be revised to reflect resident activity needs and preferences. She stated the care plan was a tool the staff used to know how to treat a resident's physical needs, cognitive needs, interventions of any type of behaviors, activity preferences, etc. She stated a care plan could be revised at any time. She stated if there were any changes in activity level or activity preferences with a resident the Activity Director was expected to revise the care plan to reflect their current activity needs. Record review of the Facility's Care Plan, reviewed 06/02/2025, reflected Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interviews, and record reviews the facility failed to ensure each residents' environment remained free of accident hazards for one (Resident #1) of four residents reviewed for accidents and hazards. The facility failed to ensure CNA A did not unlock the wheels and move Resident #1's bed during peri care, causing Resident #1 to fall. This resulted in Resident #1 being sent to the hospital with fractures and lacerations. An Immediate Jeopardy (IJ) existed from 05/31/2025 - 06/02/2025. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation. This failure could result in residents experiencing accidents, injuries, and diminished quality of life. Findings included: Review of Resident #1's face sheet, dated 06/10/2025, reflected Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: history of falling ( person experienced past falls), muscle wasting and atrophy, not elsewhere classified (decrease in size and strength of muscle tissue), lack of coordination (the inability to smoothly and accurately control body movements), hypertensive heart disease without heart failure (the heart conditions caused by long-term high blood pressure- a condition where the force of blood against the artery walls is consistently too high, making the heart work harder to pump blood- that do not involve heart failure). Review of Resident #1's MDS Assessment, dated 05/28/2025, reflected Resident #1 was unable to complete brief interview for mental status. Resident #1 had poor short- and long-term memory recall. Her decision-making ability was severely impaired. She was dependent on staff for the following: eating, oral hygiene, toileting hygiene, showers, upper and lower dressing, personal hygiene, and transfers. She was incontinent of bowel and bladder. Review of Resident #1's Comprehensive Care Plan, revision date of 05/31/2025, reflected Resident #1 had an actual fall. Interventions: Bed mobility and toileting use two person assist. Inservice staff on amount of assist needed and update Kardex. Continue interventions on the at-risk plan. Monitor/document/report as needed to MD for signs and symptoms of pain, bruises, and change of mental status. New Onset of the following: confusion, sleepiness, inability to maintain posture, and agitation. Resident #1 had an ADL self-care performance deficit. She was dependent on staff for bed mobility, eating, toileting, oral hygiene, showers, dressing (upper and lower body), personal hygiene, and transfers. Review of Resident #1's hospital records, dated 05/31/2025, reflected Resident #1 was transferred to the emergency room at local hospital on [DATE]. She had x-rays and was assessed by medical doctors. Resident #1 was discharged back to the facility on [DATE] with diagnosis of right anterior superior iliac spine fracture (a break in the bony projection on the front and upper part of the right hip bone), forehead laceration (a jagged or irregular tear or cut in the skin or other soft body tissue), right elbow soft tissue foreign body (refers to the presence of an object, like a splinter, thorn or, metal, that has entered the skin and become embedded in the soft tissues) and right pulmonary nodule (a small, discrete spot or growth in the right lung that appears denser than the surrounding lung tissue). Review of written statement by CNA A reflected on 05/31/2025 at 9:50 AM, Resident #1 was lying in bed receiving peri care from CNA A. There was a lot of loose BM everywhere on the bed. CNA A began to provide peri-care to Resident #1. CNA A had cleaned Resident #1 on one side and needed to be on the side of the bed located against the wall. CNA A moved the bed away from the wall to have easy access to Resident #1. When CNA A was moving the bed, Resident #1 fell off the bed. CNA A confirmed there was loose stool on the alternating air mattress causing the air mattress to be slick. An Immediate Jeopardy (IJ) existed from 05/31/2025-06/02/2025. The IJ was determined to be at past noncompliance as the facility had implemented the following actions prior to investigation start: Review of facility's Inservice records, dated 05/31/2025, reflected all nursing staff received in-services on abuse/neglect policies and fall with injury protocol. Review of the facility's accident hazards/supervision devices quiz, completed on 05/31/2025 and was ongoing, reflected all nursing staff completed this quiz and passed. Review of the facility's safe peri care and bed mobility for high-risk resident's quiz, completed on 05/31/2025, reflected all nursing staff had completed the quiz and passed. Review of the facility's interviews with interviewable residents, dated 06/01/2025, reflected 9 residents had received care from CNA A and they all knew CNA A. The following was asked of the residents: 1. Do you know CNA A- Yes 2. Do you know who to report to if you had problems with any staff? - Yes. 3. Has CNA A provided you with care- Yes. 4. Do you feel safe when CNA A provided care for you? Yes 5. Do you feel safe at this facility? Yes Review of the facility's skin assessments, on 06/10/2025, of all Residents after the incident on 05/31/2025. There were no new skin concerns. Review of the facility's maintenance records, on 06/10/2025, reflected all beds were checked for any issues such as locking the bed or any malfunction of the beds. There were no concerns of all Residents beds. Review of Resident #1's medical records, on 06/10/2025, reflected Resident #1 was being monitored for signs of pain post-incident. There was no concerns of pain. Review of Resident #1's Kardex, on 06/10/2025, reflected peri care assistance was added to her Kardex on 05/30/2025. Review of the facility's investigation, on 06/10/2025, reflected all residents Kardex was updated on 05/30/2025 to reflect peri-care assistance. Review of CNA A's personnel record, on 06/10/2025, reflected she was suspended on 05/31/2025 until investigation was completed. CNA A returned to work on 06/06/2025. CNA A's misconduct was up to date and no concerns noted. Observation on 06/10/2025 at 9:05 AM, Resident #1 was lying in bed. She was not interviewable. Resident #1 was lying in bed. She was in a fetal position facing the wall. She made eye contact and did mumble. Resident did not exhibit signs of being in pain such as: grimacing, tense body posture, restlessness, moaning, etc. Resident #1's bed was in lowest position. Interview on 06/10/2025 at 9:18 AM, CNA B stated she did receive in-service on abuse and neglect within the past 2 weeks. She stated she did not recall the exact date. She stated examples of abuse was yelling at a resident, hitting a resident, or can be sexual abuse. CNA B stated neglect was when staff refused to give resident food, water and/or assist resident to the bathroom. CNA B stated she had been in-service on fall protocol. She stated never move a resident when they fall. She stated a nurse was required to assess the resident and give instructions to the CNA after she completed her assessment. CNA B stated she did take a quiz on falls and peri care. She stated she was reminded if a resident was a one person assist, to always ask for assistance if there was a safety issue. CNA B stated staff was never to move a bed during peri-care. She stated if a bed needed to be move this was expected to be completed prior to beginning peri-care and to ask another staff for assistance. CNA B stated peri care assistance was not on the Kardex until after the incident with Resident #1. Interview on 06/10/2205 at 9:40 AM, CNA C stated she had received in-service on abuse and neglect, fall protocol, and peri care end of May. She stated she did not recall the exact date; however, it was the last weekend of May 2025. She stated the following was types of neglect: refusing to give resident a shower, feeding a resident, give resident water, etc. CNA C stated abuse was when someone hit, cussed, or yelled at a resident. She stated she did take quizzes on falls and peri care. She stated she was a new CNA and she learned to always ask for assistance with a resident required one person assist, if there was any safety concerns. She stated she would never move a bed during peri-care. She stated if a bed needs to be moved to reach one side of the resident, the bed was expected to be moved prior to peri-care and it was always in good practice to have two staff in the room when moving a bed. CNA C stated assistance with peri-care was not on the Kardex until after the incident with Resident #1. Interview on 06/10/2025 at 10:58 AM, CNA D stated she was walking by Resident #1's room and opened the door to check on Resident #1. She stated CNA A was giving peri-care to Resident #1. CNA D stated Resident #1 was on her right side while lying in bed. She stated she exited the room and did not witness Resident #1 fall. She stated she was given quizzes on pericare and falls. CNA D stated she had been in-service on fall protocol and abuse/neglect. She stated abuse was when a staff kicked or yelled at a resident. She stated touching resident in private areas was also considered abuse. CNA D stated neglect was not changing a resident brief, not giving resident food, or not assisting a resident to the bathroom. She stated if a resident fell or was found on the floor only the nurse was trained to assess the resident. She stated the CNA was not to move the resident until the nurse completed all her assessments and gave directions to the CNA of what to do after the assessments. She stated when giving peri care the bed was to remain locked. She stated during the in-service the DON explained if a staff needed assistance for the staff to use call light and walkie talkies would be provided to the staff to use whenever they may need assistance with a resident. CNA D stated if a resident is a one person assist and a staff felt the resident may need more than one person the staff was expected to call for assistance. She stated peri care assistance was not on the Kardex prior to the incident with Resident #1. She stated after the incident with Resident #1 peri care assistance was on all residents Kardex. Interview on 06/10/2025 at 10:35 AM, CNA A stated she began peri-care and cleaning Resident #1 on 05/30/2025 around 9:30 AM. She stated there was a lot of feces and some of it was loose stools. She stated feces were all over the bed. CNA A stated Resident #1 was lying on her back. She stated she needed to be on the right side of Resident #1 to finish cleaning the feces off Resident #1. She stated she rolled Resident #1 to the right side of the bed facing the wall. CNA A stated after she rolled Resident #1 to the right side she walked to the end of the bed and unlocked the bed. CNA A stated she began to move the bed away from the wall and this is when Resident #1 fell off the bed. She stated Resident #1 fell between the bed and the wall. CNA A stated she was at the end of the bed and attempted to catch Resident #1 prior to her falling. CNA A stated she was trained not to move the bed during peri-care. She stated the training was prior to the incident, however, she did not recall the date. CNA A stated she was required to unlock the bed prior to peri care and ask for assistance if there was any issues with giving peri-care. CNA A stated Resident #1 peri care was not on the Kardex. She stated she had given care to Resident #1 several times and she was a one person assist with peri-care. She stated she did ask a nurse a few months ago and this was the nurse's instructions of peri care on Resident #1 being 1 person assist. CNA A did not recall the name of the nurse or the date she questioned Resident #1's peri care. She stated she was in-service on peri-care, fall protocol, abuse, and neglect, prior to her returning from her suspension. CNA A stated neglect was when a staff refused to change a resident dirty brief, refused to feed a resident, refused to give resident water, etc. She stated slapping, yelling, or cussing a resident was abuse. CNA A stated she learned to always ask for assistance when needing to move a bed and never to move a bed during peri-care. She stated only move a bed prior to peri-care and ensure another staff was in the room for any assistance. CNA A stated she was the only witness to the fall of Resident #1. Interview on 06/10/2025 at 2:17 PM, the Director of Nurses stated her expectations for peri care was for each CNA to gather their supplies before they enter a resident's room. She stated the CNAs were expected to position the resident in bed according to what type of peri-care is needed. The Director of Nurses stated the staff may raise the bed to the height level of the staff to provide peri-care. She sated the CNAs were expected to follow PPE guidance during peri-care. The Director of Nurses stated if the staff needed to unlock the bed, the CNA was expected to ensure the resident was stable in the bed. She stated the bed was to be moved prior to giving peri care and it was safe practice to have two staff in the room when moving a bed as a precaution. The Director of Nurses stated one staff would be on the left side of the bed and the other staff would be on the right side of the bed. She stated moving a bed when staff was at the foot of the bed was not best practice. She stated CNA A did not follow the correct protocol when moving the bed. The Director of Nurses stated CNA A was not to move the bed when standing at the foot of the bed and during peri-care. She stated the facility had purchased walkie-talkies for all staff to use when they may need assistance. The Director or Nurses stated she expected the walkie-talkies to be always with the staff and to use them when they are needing assistance with anything related to a resident care. She stated random checks was being completed with CNA A and the other CNAs during peri-care. The Director of Nurses stated the training and in servicing was ongoing. She stated they were beginning unannounced abuse drills, and this would be follow-up in QAPI. Interview on 06/10/2025 at 3:02 PM, the Administrator stated her expectations for peri-care was for staff to ask for assistance, if there was any question about safety concerns. She stated the bed was required to be locked during peri-care. The Administrator stated CNA A was not to move Resident #1's bed during peri-care. She stated if Resident #1's bed needed to be moved, CNA A was expected to move it prior to beginning peri-care. She stated moving Resident #1's bed when CNA A was standing at the end of the bed may have contributed to Resident #1's fall. The Administrator stated the facility's investigation was inconclusive. Facility Policy on Perineal Care, revised 04/16/2024, reflected The Purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritations, and to observe the resident's skin condition. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. (note: Enhanced Barrier Precautions would be used during peri care if resident has any qualifying condition). Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure: 1. Wash basin. 2. Towels 3. Washcloth 4. Soap (or other authorized cleansing agent) or cleaning wipes and 5. Trash bag and personal protective equipment (gowns, gloves, mask, etc., as needed) Steps in the Procedure 1. Place the equipment on the beside stand. Arrange the supplies so they can be easily reached. 2. Explain the procedure to resident. 3. Provide privacy. 4. Wash hands and apply gloves. Toilet resident if on the toileting program and or remove brief. 5. Place bed protector under resident's buttocks. 6. Position resident with legs apart (if possible) avoid unnecessary exposure. Use wet washcloth/ cleaning wipes and apply soap/peri wash. For a Female resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area (between the anus and the vagina), wiping from front to back. (1) Separate labia (the fleshy folds of skin that make up the external female genitalia) and wash area downward from front to back (Note: if the resident has an indwelling catheter, gently wash the juncture tubing from the urethra (the tube that lets urine leave your bladder) down the catheter about three inches. Gently rinse and dry the area.) (2) Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in the same directions, using fresh water and a clean washcloth. (3) Gently Dry perineum. c. Ask the resident to turn on her side with her top leg slightly bent, if able. d. Rinse wash cloth and apply soap or skin cleansing agent. e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. f. Rinse and dry thoroughly. Facility Policy on Fall Prevention Program, reviewed on 06/10/2024, reflected a fall can be defined as: when a resident is found on the floor; a resident slides to the floor unassisted; a resident rolls off the bed/chair onto the floor, including bedside mat; and a resident fall off any apparatus/equipment used for transfers.

Based on record review and interviews, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one (1) of one resident reviewed for transfer and discharge rights. (Resident #1) The facility failed to make arrangements for a safe discharge for Resident #1. This failure could place residents at risk for not receiving care and services to meet their needs upon discharge. Findings included: Review of Resident #1's Face Sheet reflected a [AGE] year-old male admitted [DATE] with diagnoses of unspecified systolic congestive heart failure (the left ventricle loses its ability to contract normally. The heart can't pump with enough force to push enough blood into circulation), essential primary hypertension (abnormally high blood pressure that not caused by a medical condition), major depressive disorder (persistent low mood and loss of interest in activities that people enjoy), and insomnia (a sleep disorder that makes it hard to fall asleep, stay asleep, or get quality sleep). Review of Resident #1's Quarterly MDS dated [DATE] reflected a BIMS score of 15 indicating no cognitive impairment. Resident #1 required set up or clean up assistance in the areas of eating, oral hygiene, upper body dressing, and personal hygiene, Resident #1 required partial/moderate assistance in the areas of lower body dressing and shower/bathe self. Resident #1 required substantial/maximal assistance in the areas of toileting hygiene and putting on/taking off footwear. Review of Resident #1's care plan dated 12/10/24, revealed Resident #1 was care planned for the following: Resident #1 wished to be discharged to an apartment. Review of Resident #1's 30-day discharge letter dated 10/09/24, revealed Resident #1 was given the 30-day discharge letter on the same date (10/09/24) he was discharged to the psych facility. Review of Resident #1's Interdisciplinary Discharge Summary date 10/11/24, revealed Resident #1 was sent to the psychiatric facility for evaluation and treatment. During an interview on 12/10/24 at 1:20 p.m., the SW stated that the resident was having several behaviors such as putting the remote to the tv in his pants, threatening other residents, and forced his roommate to watch gay porn. The SW stated Resident #1's former roommate was discharged from the facility as well but provided the investigator his face sheet with a phone number attached. The SW stated that the facility got an Application for Emergency Apprehension and Detention warrant for Resident #1 to be seen at a psychiatric facility. The SW stated that Resident #1 was given his 30-day discharge notice on 10/09/24 with a discharge date of [DATE]. SW stated Resident #1 discharged from the psychiatric facility to another facility on 10/30/24. The SW stated that she nor anyone else was involved in the process of assisting with finding a new facility for Resident #1 once he left the psychiatric facility. During an interview on 12/10/24 at 2:35 p.m., the BOM stated that she was not involved in the transfer process when Resident #1 was sent to the psychiatric facility. The BOM stated Resident #1 was aware that he was going to the psychiatric facility on 10/09/24. The BOM stated that she gave Resident #1 his 30-day discharge letter on 10/09/24 with a discharge date of [DATE]. The BOM stated that she thought that the SW, the DON, and the ADM had placement for Resident #1 once he was discharged from the psychiatric facility. During an interview on 12/10/24 at 4:00 p.m., Resident #1 stated that he was doing fine and was safe at his new facility. Resident #1 stated that the psychiatric facility referred him to the new facility. Resident #1 stated that he was very happy and pleased at his new facility and expected to get his own apartment after discharge. During an interview on 12/10/24 at 4:30 p.m., the DON stated she was not working at the facility at the time of the incident. The DON stated that the facility should have coordinated a transfer for Resident #1 due to him coming from their facility. The DON stated that she was not sure who was responsible to assist with coordinating a safe transfer due to her being new at the facility. The DON stated the failure could affect the resident by not having a safe place to discharge after discharging from the psychiatric facility. During an interview on 12/10/24 at 4:55 p.m., the ADM stated that Resident #1 was sent to the psychiatric facility on her first day working at the facility. The ADM stated that she thought the facility and coordinated a facility for Resident #1 to go to after he left the psychiatric facility. The ADM stated she was not involved in the discharge process for Resident #1. The ADM stated that IDT team was responsible for discussing the needs to ensure a safe discharge/transfer occurs and the SW was responsible for coordination with the psychiatric facility about finding a new placement for the resident. The ADM stated the failure could have affect the resident by not having a safe discharge. Review of facility's Transfer or Discharge Notice policy dated Revised January 2023 reflected Residents and/or representatives are notified in writing, and in a language and format they understand, at least (30) days prior to a transfer or discharge. Policy, Interpretation, and Implementation 1. Transfers and discharge includes movement of a resident from a certified bed in the facility to a non-certified bed in another part of the facility, or to a non certified bed outside the facility. Transfer and discharge does not refer to movement to a bed within the same certified facility, Specifically: a. Transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility; and b. Discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected. 3. Except as specified below, the resident and his or her representative are given a thirty (30) days advance written notice of the impending transfer or discharge from this facility. 4. Under the following circumstances, the notice is given as soon as is it practicable but before the transfer or discharge: a. The safety of individuals in the facility would be endangered; b. The health of individuals in the facility would be endangered; c. The resident's health improves sufficiently to allow a more immediate transfer or discharge; d. An immediate transfer or discharge is required by the resident's urgent medical needs; e. The resident has not resided in the facility for thirty (30) days.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 6 residents (Resident #1) reviewed for a clean and homelike environment. The facility failed to ensure Resident #1's urinal was emptied appropriately on 09/04/24. This failure placed residents at risk of decreased feelings of self-worth and a diminished quality of life. Findings included: A record review of Resident #1's face sheet dated 09/04/24 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnoses included personal history of traumatic brain injury (someone who had a previous traumatic brain injury), muscle wasting and atrophy (loss of muscle tissue), major depressive disorder (persistent low mood and loss of interest in activities that people enjoy), epileptic seizures (a sudden burst of electrical activity in the brain that cause symptoms such as jerking and shaking), primary essential hypertension (high blood pressure that doesn't have a known secondary cause), and muscle weakness (loss of muscle strength). A record review of Resident #1's Quarterly MDS assessment, dated 08/12/24, reflected Resident #1 had a BIMS score of 13, which indicated cognitively intact. Resident #1's Quarterly MDS Section GG Functional Abilities and Goals reflected that Resident #1 required substantial/maximal assistance in the area of toileting hygiene and partial moderate assistance in the areas of eating, oral hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. A record review of Resident #1's care plan, dated 09/04/24, reflected Resident #1 was care planned for ADL self-care performance deficit r/t disease process TBI, limited physical mobility r/t TBI, and impaired cognitive function/dementia or impaired thought process r/t neurological symptoms. During an observation on 09/04/24 at 9:20am, Resident #1's urinal had yellowish liquid in it that appeared to be urine. During an observation on 09/04/24 at 11:28am, Resident #1's urinal appeared to have yellowish liquid in it that appeared to be urine. During an observation on 09/04/24 at 1248pm, Resident #1's urinal appeared to have yellowish liquid in it that appeared to be urine. During an observation on 09/04/24 at 2:42pm, Resident #1's urinal appeared to have yellowish liquid in it that appeared to be urine. During an interview on 09/04/24 at 9:20am, Resident #1 stated that the urinal had been on his nightstand for a long time. Resident #1 stated the CNAs only empty his urinal during the night shift. Resident #1 stated that his urinal was not emptied the night before. During an interview on 09/04/23 at 1:00pm, LVN A stated that CNAs should make rounds at least every two hours. LVN A stated that CNAs should be looking to see if a resident needs assistance, ensuring call lights were within reach, and making sure all residents were comfortable. LVN A stated that it's anyone's responsibility that walked into the resident's room to ensure that the urinal was emptied appropriately. LVN A stated that if a resident's urinal was not emptied appropriately then that would be a resident's rights issue, the resident's room would have a foul smell, or the resident could knock over the urinal creating a slippery floor. During an interview on 09/04/23 at 3:30pm, the DON stated that CNAs should ensure that the resident's urinals have been emptied when rounds were made. The DON stated anyone who entered the resident's room should ensure the resident's urinal was emptied appropriately. The DON stated if a resident's urinal was not emptied appropriately that would be a resident's right violation, and an infection control issue. During an interview on 09/04/23 at 4:00pm, the ADM stated that CNAs should ensure that the resident's urinals have been emptied when rounds were made. The ADM stated anyone who entered the resident's room should ensure the resident's urinal was emptied appropriately. The ADM stated if a resident's urinal was not emptied appropriately that would be a resident's right violation, there would be an odor from the urinal, and an infection control issue. Review of the facility's Bedpan/Urinal, Offering/Removing policy, revised February 2018, reflected, Purpose: The purpose of the procedure is to provide the resident with bedpan and/or a urinal assistance. Preparation 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. General Guidelines 1. Check to see if the resident is on intake and output before discarding the urine and feces. 2. Do not allow the resident to sit on a bedpan for extended periods. This is not only uncomfortable to the resident, it also causes skin breakdown. 3. If the resident prefers to keep a urinal at his bedside, check if frequently. Empty and clean it as necessary.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 (Resident #22) of 4 residents reviewed for abuse. The facility failed to prevent physical abuse against Resident #22 by CNA H as seen on video surveillance. The noncompliance was identified as PNC IJ. The IJ began on 07/04/2024 and ended on 07/05/2024. The facility had corrected the noncompliance before the survey began. This failure placed the resident at risk of physical and psychological harm. Findings include: Observation of Resident #22's video surveillance revealed CNA H assaulting the resident on three occasions during the 6:00 PM to 6:00 AM shift on 07/04/2024. The video captured CNA H striking Resident #22 with an open hand and the strikes were clearly heard on the audio. Due to the angle of the camera, it was difficult to identify where exactly on his body Resident #22 was slapped, but it appeared to be on the right arm and the backside. No observable reaction was noted by Resident #22 in the videos. Review of Resident #22's face sheet reflected a [AGE] year old male admitted to the facility on [DATE] and again on 12/22/2023 with diagnoses of Peripheral Vascular Disease (A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), Cognitive Communication Deficit (may have trouble reasoning and making decision while communicating, have trouble responding in an appropriate manner), and Amnesia (memory loss). Review of Resident #22's comprehensive MDS, dated [DATE], reflected resident was rarely or never able to understand verbal communication, cognitive skills for daily decision making were severely impaired and the resident was always incontinent of bowel and bladder. Review of Resident #22's Care Plan, revised 06/12/2024, reflected resident had an electronic monitoring device in his room with consent signed, resident was moved to memory care wing, resident required staff assistance for meeting emotional, intellectual, physical and social needs related to dementia. Care Plan also reflected resident had potential to be physically aggressive with staff and would hit staff during incontinence brief change. Interventions included in-service staff on Abuse Prohibition Policy, analyze times of day, places, circumstances, triggers and what de-escalates behavior and document, and provide physical and verbal cues to alleviate anxiety. In an interview on 08/20/204 at 2:20 PM, the ADON stated the for Resident #22 came to the facility and showed the DON the video of CNA H abusing Resident #22. She stated CNA H was employed by the Staffing agency. She stated the facility agreed it was abuse and law enforcement put out a warrant for CNA H's arrest. In an interview on 08/21/2024 at 10:45 AM, Resident #22's RP (FM 1) stated that himself or FM 2 monitored the video surveillance camera in Resident #22's room daily. FM 1 stated the evening of the incident 07/04/2024 FM 2 reviewed the video and observed CNA H being rough and slapping the resident. FM 2 went to the facility and showed the DON the video. FM1 stated the DON at the time called in the incident to the state and FM 2 met with the sheriff's office and filed a report. FM 1 stated he believed the suspect had been arrested. He stated there was a lot of turnover with the administrator and DON but he felt the facility handled the investigation well. FM 1 stated he did not notice a change in Resident #22's behavior follwing the incident. Observations and interviews with Resident #4, Resident #6, and Resident #21 revealed none had concerns with abuse and all felt safe at the facility. Interviews with direct care staff revealed all were knowledgeable of abuse prohibition policy. In an interview 08/22/2024 at 3:51 PM, CNA C stated she received abuse training several times a year. She stated if she witnessed abuse she would report it to the administrator. In an interview on 08/22/2024 at 4:10 PM, LVN A stated she was trained on abuse in July. She stated if she witnessed abuse she would report it to the administrator immediately. In an interview on 08/22/2024 at 5:30 PM, the interim DON stated the staff are trained on Abuse Prohibition Policy annually and as needed. She stated that staff are screened for history of abuse before hire. In an interview on 08/22/2024 at 5:50 PM, the Administrator stated staff are trained on Abuse Prohibition Policy annually and after every reportable event. She stated they run abuse/neglect registry checks before hire for all new staff. Attempted interview with CNA H with no return communication. The Administrator and DON at the time of the incident are no longer employed at the facility. Review of reports received from the Staffing Agency reflected a background check was completed for CNA H on 03/13/2024, with clear status. Records also reflected CNA H was deactivated from the Staffing Agency platform as of 07/06/2024 and her account had been permanently disabled. Review of the facility investigation, dated 07/12/2024, reflected the Administrator at the time took the appropriate actions to ensure the safety of the residents after the incident and provided education for the staff. Behavior monitoring was conducted for all residents on the memory care unit for 72 hours, weekly random check-offs were implemented for staff members providing direct care, and Abuse/Neglect in-service and drills were conducted. The report further reflected CNA H was immediately, on 07/05/2024, reported to the Staffing Agency and taken off the facility schedule. A skin assessment was completed on Resident #22 and all other residents that received care from CNA H with no issues/injuries noted. Per facility report, Resident #22 continued same meal intake, sleep pattern and no increased behaviors following the incident. CNA H only worked that one shift at the facility and has been banned from working at any company facility. Facility investigation report reflected 5 direct care staff completed an abuse questionnaire on 07/11/2024, abuse drill evaluations were completed as well as an in-service on abuse policy. Review of the questionnaire reflected staff were aware of how and when to report abuse to the Abuse Prohibition Coordinator (Administrator). The abuse policy in-service, dated 07/05/2024, was signed by 49 employees. Review of the police report, dated 07/08/2024, reflected CNA H intentionally and knowingly caused physical contact with Resident #22, by striking the resident several times with an open hand and should have believed that the resident would regard the contact as offensive or provocative. Review of facility Abuse Prohibition Policy, dated 05/17/2024, reflected physical abuse defined as . slapping . and controlling behavior through corporal punishment. The policy reflected the facility would investigate alleged abuse and provide notification of information to the proper authorities according to state and federal regulations. It also reflected employees will receive training and reinforcement on all aspects of abuse program at the time of initial orientation, annually and through ongoing in -services. The noncompliance was identified as PNC IJ. The IJ began on 07/04/2024 and ended on 07/05/2024. The facility had corrected the noncompliance before the survey began.

Based on observation, interviews, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 4 of 8 (Resident #12, Resident #18, Resident #25, and Resident #28) residents reviewed for ADL care. 1. The facility failed to ensure Resident # 12, Resident #18, Resident #25, and Resident #28 nails were cleaned and did not have any rough edges. These failures placed residents at risk of a decline in their hygiene, loss of dignity and decreased quality of life. Findings included: 1. Record review of Resident # 12's Face Sheet dated, 08/22/2024, reflected a [AGE] year-old male admitted on [DATE] with diagnoses of type 2 diabetes mellitus without complications (high levels of blood glucose can damage the blood vessels and nerves that control the heart), lack of coordination (a problem with movement that can manifest in a variety of ways, such as difficulty with fine motor skills), anxiety disorder (worry endlessly over everyday issues such as health, money, family problems-even if the person realizes there's little cause for concern). Record review of Resident #12's Quarterly MDS Assessment, dated 07/19/2024, reflected the resident had a BIMS score of 07 indicated his cognition was severely impaired. Resident #12 required assistance with personal hygiene, dressing, transfers, and showers/bathing. Resident #12 had a behavior problem of picking at skin on his hand. Record review of Resident #12's Comprehensive Care Plan, dated 08/14/2024 reflected Resident #12 had an ADL self-care performance deficit. Intervention: Resident required assistance with personal hygiene, dressing, transfers, bed mobility, and toileting. Observation on 08/20/2023 at 10:50 AM, Resident # 12's nails was rough around the edges on his right hand. He also had blackish substance underneath his nails on his middle and ring fingers on his right hand. Resident was sitting in wheelchair in his room. There was an odor of feces on residents' fingers. In an interview on 08/20/3034 at 10:53 AM, Resident #12 stated he sometimes scratched his bottom at night and he got poop ( a word for feces) on my fingers. He stated he asked someone to clean it last night and the lady said she would come back and clean his fingers. Resident #12 said no one came back to his room. He did not respond to questions about his fingernails being rough around the edges. 2. Record review of Resident # 18's Face Sheet dated, 08/22/2024, reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] diagnoses of : type two diabetes mellitus without complications (high levels of blood glucose can damage the blood vessels and nerves that control the heart), muscle weakness- generalized (loss of muscle strength), combined forms of age-related cataract, bilateral ( when the lens in both eyes becomes cloudy from age, injury or disease), other lack of coordination (a problem with movement that can manifest in a variety of ways, such as difficulty with fine motor skills), hemiplegia , unspecified affecting left non dominant side ( left side paralysis- the loss ability to move). Record review of Resident #18's Quarterly MDS Assessment, dated 07/18/2024, reflected Resident #18 had a BIMS score of 10 indicated her cognition was moderately impaired. She required assistance from staff with personal hygiene, dressing, transfers, eating and bathing. Record review of Resident #18's Comprehensive Care Plan, dated 07/31/2024, reflected Resident #18 wished to have long fingernails. Intervention: keep fingernails smooth and clean. Monitor for any skin impairments related to long fingernails. Resident #18 makes poor safety choices. Intervention: Attempt to monitor Resident #18 in regard to safety choices that place resident at risk. Educate Resident #18 on risks associated with poor safety choices. Resident #18 had an ADL self-care performance deficit. Intervention: Resident #18 was dependent on staff for personal hygiene. Observation on 08/20/2024 at 11:15 AM, Resident #18 was in her room sitting in wheelchair. Resident #18 nails were approximately 1-2 inches long on both hands. Resident #18's left hand had nails on her ring finger, middle finger, and fore finger rough around the edges. In an interview on 08/202/2024 at 11:17 AM, Resident #18 stated she preferred her nails long but wanted her nails to be filed so they would not be so uneven and rough. She stated she always had a lot of pride in her fingernails and loved them long but did not prefer them to be unkept with not being filed. Resident #18 stated she was not able to file her nails any longer. She stated she asked someone on Saturday and on Sunday to file her nails and both of the ladies that worked at this facility told her that was not their job she would need to speak to the person who does activities she was the only staff that filed nails. Resident #18 stated she scratched her arm a little with one of her nails as she pointed to her right arm. Observed on 08/20/2024 at 11:19 AM, Resident #18's right arm and there was a small scratch, however, it was not a skin tear. 3. Record review of Resident #25's Face Sheet, dated 06/17/2024, reflected a [AGE] year-old male admitted on [DATE] with a diagnoses of lack of coordination (a problem with movement that can manifest in a variety of ways, such as difficulty with fine motor skills), age-related physical debility ( frail patients often present with symptoms including weakness, fatigue, medical complexity, and reduced tolerance to medical and surgical interventions), muscle weakness (loss of muscle strength), muscle wasting and atrophy, not elsewhere classified, other site ( muscle atrophy - the wasting or thinning of muscle mass, muscle wasting- weakening, shrinking, and loss of muscle caused by disease or lack of use), and anxiety disorder due to known physiological condition ( when anxiety symptoms (startle easily and can't relax) are a direct result of a physical health problem). Record review of Resident #25's Admission MDS Assessment, dated 06/21/2024, reflected Resident #25 had a BIMS score of 9 indicated Resident cognition was moderately impaired. He required assistance with personal hygiene, showers, dressing and toileting hygiene. Record review of Resident #25's Comprehensive Care Plan, dated 07/12/2024, reflected Resident #25 had an ADL self-care performance deficit. Intervention: Resident #25 required assistance with personal hygiene, toileting hygiene, showers, and dressing. Resident #25 was resistive to care related to anxiety (startle easily and can't relax) he will refuse turning and repositioning and repositioning to offload areas and therapy participation sometimes. Intervention: Allow Resident #25 to make decisions about treatment regimen, to provide sense of control. Resident #25 had a communication problem related to aphasia ( a language disorder that affects a person's ability to understand and express language, including reading and writing). Resident #25 had a mood problem anxiety related to disease process of CVA ( a medical conditions that occurs when blood flow to the brain is suddenly cut off - this diagnosis was not listed on the face sheet) Intervention: Monitor/record/ report to medical doctor as needed acute episode feelings or sadness; feelings of worthlessness or guilt or change in psychomotor (movement-oriented activities that require practice and involved characteristics such as coordination, strength, speed and flexibility). Observation on 08/20/2024 at 11:30 AM, Resident #25 was lying in bed. His nails were approximately three inches long on all fingers on both hands. All of his fingernails on the left hand were rough around the edges. His right hand had blackish substance of a bowel movement (the process of moving waste through the intestines after eating or drinking) odor. There was a blackish substance on the tips of his middle and forefinger on his right hand. Resident #25 had a blackish substance underneath his nails on his fore finger, middle finger, and ring finger of the right hand. Attempted interview on 08/20/2024 at 11:34 AM, Resident #25 did not want to be interviewed. Attempted interview on 08/20/2024 at 3:05 PM, Resident #25 did not want to be interviewed. 4. Record review of Resident # 28's Face Sheet, dated, 08/22/2024, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of type 2 diabetes mellitus without complications (high levels of blood glucose can damage the blood vessels and nerves that control the heart), lack of coordination (a problem with movement that can manifest in a variety of ways, such as difficulty with fine motor skills), muscle weakness (loss of muscle strength), muscle wasting and atrophy, not elsewhere classified, other site ( muscle atrophy - the wasting or thinning of muscle mass, muscle wasting- weakening, shrinking, and loss of muscle caused by disease or lack of use), unspecified dementia, unspecified severity, with anxiety ( a condition in which a person loses the ability to think and solve problems. Unspecified severity- a medical classification for dementia that does not have a specific diagnosis and does not have a specified severity. Anxiety with dementia- often related directly to worries about coping with the condition and what the future holds). Record review of Resident #28's Admission MDS Assessment, dated 07/27/2024, reflected Resident #28 had a BIMS score of 6 indicated his cognitive status is severely impaired. He required assistance with bathing, dressing, personal hygiene, and transfers. Record review of Resident #28's Comprehensive Care Plan, dated 08/14/2024, reflected Resident #28 needed had an ADL self-care performance deficit. Intervention: Resident #25 required assistance with personal hygiene, toileting hygiene, showers, and dressing. Observation on 8/20/2024 at 1:03 PM, reflected Resident # 28 was sitting in his wheelchair in his room. He had approximately 2-3 inches of long nails on his right and left hand. Resident #28's forefinger nail had a sharp nail only in the corner of the finger on his left hand. Resident #28's ring finger, thumb, small finger, and middle fingernails on his left hand was rough around the edges. Resident #28 had a very long nail approximately 4 inches long on his right hand. Resident #28 right hand had a sharp nail and rough around the edges in the corner of his ring finger. His right-hand fingernails on his middle finger and fore finger had a blackish substance underneath these nails. There was an odor of bowel movement (the process of moving waste through the intestines after eating or drinking) odor. In an interview on 08/20/2024 at 1:06 PM Resident #28 stated when he nails gets long and he can not find anyone to cut his nails, he will bend his nails until they break. He stated that is why you see that sharp nails in the corners. Resident #28 also stated when he bends his nails they don't break smoothly and causes a sharp point on some of his nails. He stated if someone does not want to cut his nails he will do it himself. Resident #28 stated he was a diabetic (high levels of blood glucose can damage the blood vessels and nerves that control the heart), and he knew his nails may become infected if his nails was not cut properly. Resident #28 stated he did have to use the bathroom last night and did have poop (a slang word for feces- waste matter from the bowels after food had been digested) to come out his bottom. Resident #28 stated he did scratch his bottom and got poop on his hands and he tried to get most of it off his hand (he raised his right hand when he was discussing where the poop was located). In an interview on 08/22/2024 at 1:30 PM, ADON G stated if a resident had rough edges around the nail there was a possibility the resident may scratch themselves or someone else and develop a skin tear. She stated if a resident ingested blackish substance on their fingers or underneath their fingernails, there was a possibility the substance may be some type of bacteria. She stated a resident may develop a stomach illness with symptoms of diarrhea and vomiting. ADON G stated it was according to what the bacteria was to determine if a resident would become ill. ADON G stated the nurses completed all nail care for residents with a diagnosis of diabetes (high levels of blood glucose can damage the blood vessels and nerves that control the heart). She stated if a staff was not certain if they were to file someone nails the staff was expected to ask their nurse supervisor. ADON G stated all residents was expected to receive nail care during showers and as needed. She stated it was the nurse supervisor responsibility to monitor nail care. ADON G stated she would need to review the electronic medical record to determine if any residents refused nail care. In an interview on 08/22/2024 at 4:45 PM, CNA K stated the nurses completed all diabetic (high levels of blood glucose can damage the blood vessels and nerves that control the heart) fingernails and the CNAs were responsible for all other residents' nails. CNA K stated the CNAs were responsible to complete nail care such as trimming, filing, and cleaning the nails during showers and as needed. CNA K stated if a resident had blackish substance underneath their nails, it was probably some type of bacteria such as bowel movements (the process of moving waste through the intestines after eating or drinking). She stated if a resident swallowed bacteria it was a potential the resident may become ill and may develop major stomach problems such as diarrhea or vomiting. CNA K stated if a resident became severely ill the resident may need to be transferred to emergency room for more care. She stated she worked with Resident #12, Resident #18, Resident #25, and Resident #28. CNA K stated the only resident she knew resisted care was Resident #25. CNA K stated Resident #25 resisted being turned or repositioned she was not aware of him refusing nail care. and Resident #31, and she was not aware of them refusing nail care. She stated if a resident's nails were rough around the edges there was a possibility the resident may scratch themselves and develop a skin tear, or possibly scratch their eye and cause a tear on their eyeball. CNA K stated she had been in-service on nail care but did not remember the date of the in-service. In an interview on 08/22/2024 at 5:05 PM, CNA C stated the CNAs was responsible for cleaning, trimming, and filing all residents' nails except for the residents with diagnosis of diabetes (high levels of blood glucose can damage the blood vessels and nerves that control the heart) and the nurses was responsible for residents with diabetes. CNA C stated the nurses was responsible for all residents' nails with diagnosis of diabetes. CNA C stated if a resident had a rough nails or their nails were dirty, nail care was expected to be completed as needed. CNA C stated if a resident nails was rough around the edges there was a possibility a resident may scratch themselves or another resident. CNA C stated the scratch may develop into a skin tear. CNA C stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill with stomach issues such as vomiting. She stated she worked at this facility as needed. CNA C also stated she had given care to Resident # 28, Resident #12, Resident #18, and Resident #25. She stated she was not aware of any of these residents refusing nail care. She stated she had been in-serviced on nail care but did not recall the date. In an interview on 08/22/2024 at 5:35 PM, LVN A stated the nurses and the CNAs were responsible for nail care. She stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes (high levels of blood glucose can damage the blood vessels and nerves that control the heart). LVN A stated it was the CNAs responsibility to clean and trim all other residents' nails. She stated she was not aware of Resident #10, Resident #28, Resident #12 or Resident #25 refused nail care. She stated Resident # 25 would refuse to be turned or off load his heels but not nail care. LVN A stated if there was a blackish substance underneath the residents' nails, there was a possibility the substance had bacteria underneath the residents' nails. She stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with stomach issues such as diarrhea and vomiting. LVN A stated if a resident scratched themselves with rough nails there was a potential a resident may develop a skin tear and there was a possibility the resident may scratch another resident and cause a skin tear on another resident. She stated she had been in-serviced on nail care but did not recall the date of the in-service.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 5 residents (Resident #4, Resident #14, Resident #31, Resident # 9, and Resident #8) out of 10 resident rooms reviewed for environment. The facility failed to ensure walls and floors were clean and in good repair for Resident # 4, Resident #14, Resident #31, Resident #9, and Resident #8's room. This failure could affect all residents, staff, and the public by placing them at risk for diminished quality of life due to the lack of a well-kept environment. Findings include: Observation on 08/20/2024 at 03:10 PM in Resident # 4 and Resident # 14's room revealed large (approximately 2 ft) long holes in the wall behind Resident #14's bed. The bed was pushed up into the wall and there was a white powdery substance on the floor behind the bed. Observation in the room further revealed a cable outlet hanging from the wall next to the dresser. Behind Resident #4's bed there were holes in the wall, unable to see the size due to the bed. In an interview on 08/20/2024 at 03:10 PM, Resident # 4 stated he did not know about the holes behind the bed, but he knew about damaged wall where the cable outlet was. He stated it had been that way for a while. Resident #14 was not interview able. Observation on 08/20/2024 at 4:00 PM in Resident # 31's room revealed scratch marks and missing paint behind and next to the resident's bed. There was a brown substance on the floor and white debris on the floor. Observation on 08/20/2024 at 4:10 PM, in Resident # 8 and Resident #9's room revealed missing trim and paint under the windowsill with exposed drywall. Resident # 8's bed was up against the wall under the window with pillows and bedding by the damaged wall. Observation behind Resident #9's bed revealed the bed pushed up into the wall with damaged drywall and white debris/powder on the floor. In an interview on 08/20/2024 at 4:12 PM, Resident #9 stated she did not know about the holes behind her bed, but she knew they pushed the bed in the wall to get the door closed. In an interview on 08/22/2024 at 4:45 PM, Housekeeping supervisor D stated debris falls on the floor every time the bed hits the wall. She stated they do their best to keep the floors clean, but she needs assistance from the nursing staff to move the resident's bed out of the way because she cannot do it herself. She stated they clean the rooms and floors everyday and try to deep clean often. She stated they do not have a floor crew anymore and she does the best she can with the staff they do have. In an interview on 08/22/2024 at 5:00 PM, Maintenance supervisor E stated there have been damages to the walls since March of 2023. He stated he began working in the maintenance department in May of 2024 and started repairing the damaged walls using sheetrock that was previously ordered by someone else but realized it was the wrong material. He stated the administrator told him to hold off until they get the correct supplies. He stated the reason for the damaged walls was because there is no tolerance for door clearance if the bed is pulled away from the wall. He further stated the damaged walls were not homelike and could cause illness due to the drywall dust and could cause depression and make the residents feel unnoticed. He was not aware of the cable wire hanging from the wall and said he would take care of that immediately. In an interview on 08/22/2024 at 5:50 PM, the Administrator stated they were working on fixing the holes in the walls. She stated she contacted a maintenance person from another building to assist. She stated they plan to replace the drywall and place some type of bumper on the walls to prevent further damage. She stated she is unsure how long the holes have been there and did not realize how big they were. She stated maintenance was scheduled to come back this week but delayed due to the survey. She further stated the damaged walls could cause potential harm or risk to the resident from the drywall dust and possible pest problem from the holes. She stated the damages are not homelike. Regarding the dirty floors she stated she has spoken with housekeeping already and expects the floors to be cleaned every day. Review of facility Homelike Environment policy, dated February 2021, reflected residents are provided with a safe, clean, comfortable and homelike environment . the staff and management maximizes the characteristics of a homelike setting . including a clean, sanitary and orderly environment.

49851 Based on observation, interview, and record review, the facility failed to establish and maintain an infection and prevention 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 5 (Resident #1, Resident #11, Resident #28, Resident #4, and Resident #17) of 35 residents reviewed for infection control. 1. LVN B failed to clean the reusable blood pressure (BP) cuff between resident use. 2. LVN A failed to perform hand hygiene and clean the catheter tip before performing catheter irrigation for Resident #17's suprapubic catheter (a flexible tube that drains urine from the bladder through a small incision in the lower abdomen) 3. The facility failed to ensure LVN I sanitized or washed her hands after touching contaminated items when delivering meal trays to residents, when setting up Resident #1, Resident #11 and, Resident #28's meal trays and during feeding of Resident #11 on 08/20/2024. These failures could place residents at risk for cross contamination and infection. Findings include: 1. Review of Resident #4's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hemiplegia (paralysis or severe weakness in one side of the body) and cerebral infarction (stroke). Review of Resident #4's Optional MDS, dated [DATE], reflected a BIMS score of 11 indicating moderate cognitive impairment. Review of Resident #4's Care Plan reflected resident requires staff assistance for meeting needs and has hypertension requiring BP monitoring and medication. Observation during med pass on 08/21/2024 at 08:30 AM, revealed LVN B checked the vital signs for Resident #6 and placed the BP cuff back on the medication cart without cleaning it. She then used the BP cuff to take vital signs for Resident #4 without cleaning the cuff first. In an interview on 08/21/2024 at 08:36 AM, LVN B stated she should have cleaned the BP machine in between resident use but didn't. She stated it is policy to clean it before and after use because of the germs and risk for infection. 2. Review of Resident #17's face sheet reflected an [AGE] year old male admitted to the facility on [DATE] and again on 09/02/2022 with diagnoses of incomplete quadriplegia ( paralysis that affects a person's limbs and body from the neck down), chronic obstructive pulmonary disease (a group of lung disease that blocks airflow and makes it difficult to breathe), and overactive bladder (a problem with bladder function that causes the sudden need to urinate). Review of Resident #17's care plan, dated 07/16/2024, reflected resident has a suprapubic catheter and foley care should be provided every shift and as needed. Review of Resident #17's orders, date 07/17/2024, reflected an order to flush the catheter with 120-180 milliliters of sterile water every other day. Observation on 08/21/2024 at 09:56 AM, during suprapubic catheter irrigation procedure for Resident #17 revealed LVN A sanitize her hands and don gloves and gown. She placed the irrigation tray and supplies on the bedside table, opened the kit and then disconnected the draining bag from Resident #17's catheter and handed it to the resident to hold. She then poured the sterile water into the container and drew up some in the syringe. She connected the syringe to the catheter without cleaning the catheter tip first. She then began attempting to flush the catheter. She was not able to flush the catheter and called for assistance. She then reconnected the old drainage bag to the catheter while waiting for assistance. In an interview on 08/21/2024 at 11:10 AM, LVN A stated she forgot to clean the catheter before and after she attempted irrigation and reconnected the old bag. She stated not cleaning her hands and the catheter before irrigation placed the resident at risk for bladder infection. In an interview on 08/22/2024 at 5:30 PM, the interim DON stated reusable medical equipment should be sanitized before every use to prevent the spread of infection. She stated she would expect staff to follow procedure for aseptic technique during catheter irrigation to prevent the spread of infection. In an interview on 08/22/2024 at 5:50 PM, the Administrator stated the BP cuff should be cleaned in between residents for infection control. She stated she is not a nurse but would expect staff to follow procedure for catheter flushing to prevent the resident from getting an infection. Review of facility policy for reusable medical equipment, dated 03/2023, reflected items that come in contact with intact skin but not mucous membranes, such as BP cuffs, should be cleaned and disinfected between residents. Review of facility policy for catheter care, dated March 2024, reflected staff should use aseptic technique when there is a break in the closed system and clean technique when handling the catheter, tubing, or drainage bag. The policy does not specifically address the procedure for catheter irrigation. 3. Observation on 09/20/2024 at 12:13 PM to 12:35 PM, reflected LVN I entered the dining room from the hall. She touched her clothes and moved her hair away from her face. LVN I began to speak to residents and touched the residents' clothes and wheelchair handles. She began to look at the meal trays on the meal tray cart. LVN I picked up one lid of a meal tray and touched the tines ( the pointed prongs that allow you to spear and pick up the food) of the fork of Resident #28's meal tray. LVN I delivered Resident #28's meal tray to him in the dining room and did not change his fork. LVN I returned to the meal tray cart and did not sanitize her hands. She had the meal tray and touched the dirty dishwasher doorknob to enter the dishwasher room and placed meal tray on top of dirty plates and the middle finger, forefinger and ring finger touched dirty dishes in the dishwasher room. She exited the dishwasher room and proceeded to the meal cart without sanitizing or washing her hands. She picked up a meal tray off the meal cart and delivered the meal tray to Resident #1. When LVN I sat the meal tray on the table in front of Resident #1 she opened the thickened liquid water and the top part of her middle finger and fore finger on her right hand touched inside the container and touched the thickened water. LVN J asked LVN I to go into the hall and sanitize her hands. LVN I did not go into the hall to sanitize her hands or attempt to wash her hands. LVN I continued to pass out meal trays. LVN I delivered Resident #11's meal tray to her. She touched resident's hand and her specialty chair. LVN I opened Resident #11's thickened liquid and her forefinger and middle finger touched the thickened liquid and when she removed the lid off of Resident #11's plate of food she touched the green beans. After setting up the meal tray LVN I sat in a chair to begin to feed Resident #11. LVN I was given hand sanitizer and did sanitize her hands prior to feeding Resident #11. During feeding Resident #11, LVN I touched with her fore finger, ring finger and middle finger on her right hand the following: the arms of the chair she was sitting in, touched her own clothes and touched Resident #11's Hoyer lift sling to reposition the sling in Resident #11's chair. She also touched Resident #11's right hand. LVN I did not re-sanitize or wash her hands. LVN I picked up Resident #11's napkin to wipe off Resident #11's mouth. When LVN I wiped Resident #11's mouth she touched the side of Resident #11's upper lip with her fore finger and middle finger on her right hand. LVN J was sanitizing her hands every time she touched the table, chair or any object may be considered contaminated. She was feeding Resident #3. In an interview on 08/20/2024 at 1:33 PM, LVN I stated she never sanitized her hands during the time she was passing out meal trays and setting up meal trays for the residents. LVN I stated she was expected to sanitize or wash her hands when passing out meal trays and when she was setting up meal trays for the residents. She stated she did not recall if she touched the tips of the fork, napkins, inside the thickened liquids container for Resident #1 and Resident #11. LVN I stated she did touch the door knob leading into the dishwashing room and she may have touched dirty dishes. She stated she did not recall touching her clothes, her hair, resident's wheelchair, or sling in Resident #11's specialty chair. She stated it was possible she did touch all of this but she was focused on delivering meal trays and feeding Resident #11 instead of what she was touching. LVN I stated it is impossible for staff to sanitize their hands if they touch anything may be contaminated. She stated the only time she sanitized her hands was when she sat on a chair to feed Resident #11. She stated she did touch arm of her chair; the sling Resident was sitting on in her specialty chair and possibly her own clothes. LVN I stated it is crazy to expect staff to sanitize their hands every time they touch an object that may be contaminated. She stated this was impossible. LVN I stated she did wipe Resident #11's mouth and she may have touched the side of her lip with her fingers. She stated if she had touched anything contaminated it was a possibility bacteria could cross contaminate onto the fluids, food, napkin, and Resident #11's mouth. LVN I stated she did not believe it was necessary to sanitize her hands every time she touched any type of object that may be contaminated. She stated staff would be sanitizing their hands every few seconds. LVN I stated she had been in-serviced on passing out meal trays and feeding the residents. She stated during in-service it was explained to wash or sanitize hands in between delivering meal trays to the residents and when feeding the residents. LVN I did not answer the question if a resident may become ill if they did ingest some type of bacteria that potentially transferred from her fingers or hands onto the resident's food or drink. In an interview on 08/20/2024 at 00:00, LVN J stated she did ask LVN I to sanitize her hands. She stated LVN I did not sanitize her hands when she was passing out meal trays and setting up meal trays for residents. LVN J stated all staff was expected to sanitize or wash hands during each meal tray delivered to a resident. LVN J stated all staff was to sanitize their hands when they touch their hair, clothes or any object that was considered contaminated. She stated they had been in-serviced on hand hygiene during dining room service. LVN J stated she did not recall the date of the in-service. She stated if a resident did swallow some type of bacteria the resident had a potential of becoming physically ill such as vomiting or diarrhea. In an interview on 08/22/2024 at 1:30 PM, ADON G stated all staff was expected to sanitize their hands prior to delivering meal trays and in between each meal tray delivered to a resident. She stated if staff touched any type of object such as doorknob, wheelchair, resident or staff clothes, hair, Hoyer sling, arms of a chair and/ or table, the staff was expected to sanitize or wash their hands after each contact with anything may be considered contaminated. ADON G stated if staff were not washing or sanitizing their hands during meal service and was touching residents' drinks, food or even plates it was a possibility bacteria may cross contaminate food, utensils such as fork and or the resident's plates. She stated if a resident ingested bacteria there was a possibility a resident may become sick with some type of food borne illness. She stated she had only been working at the facility about three weeks and she only knows about the in-services she had completed since she had been employed at this particular facility. In an interview with the Administrator on 8/22/2024 at 2:05 PM, she stated all staff was expected to wash or sanitize hands prior and in between each meal tray delivered to the residents. She stated the staff was expected to sanitize or wash hands whenever they became in contact with anything considered contaminated such as: hair, clothes, dirty dishes, wheelchair, arms of a chair, etc. The Administrator stated there was a potential a resident may develop a food borne illness if a resident's food or drink was cross contaminated by bacteria on a staff fingers or hands. She stated she began working at this facility approximately two weeks ago and she was trying to look at a lot of things and the in-services been given in the past she had not looked at the in-services at this time and could not answer if an in-service had been given on dining room hand hygiene. Review of facility policy for reusable medical equipment, dated 03/2023, reflected items that come in contact with intact skin but not mucous membranes, such as BP cuffs, should be cleaned and disinfected between residents. Review of facility policy for catheter care, dated March 2024, reflected staff should use aseptic technique when there is a break in the closed system and clean technique when handling the catheter, tubing, or drainage bag. The policy does not specifically address the procedure for catheter irrigation. Review of the Facility Policy of Hand Hygiene, revised on 10-2020 reflected This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained on the importance of hand hygiene in preventing the transmission of healthcare- associated infections. Use and alcohol-based hand rub containing at least 62 % alcohol; or , alternatively, soap and water for the following situations: 1. Before and after direct contact with residents. 2. After direct contact with a resident's intact skin.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with profession standards for food safety for 1 of 1 kitchen reviewed for food and safety and sanitation. 1. The facility failed to appropriately thaw frozen meant defrost on 08/20/2024. 2. The facility failed to store boxes of food off the floor, ensure the floor of the refrigerator was free of debris in the walk- in refrigerator on 08/20/2024. 3. The facility failed to ensure Dietary Aide P washed or sanitized her hands prior to placing new gloves on her hands when she was giving a resident some zip lock bags on 08/21/2024. These failures placed residents at risk for health complications and foodborne illness. Findings included: Observation on 08/20/2024 at 9:05 AM, there was approximately 10 pound of frozen hamburger meat in a clear plastic round tube shape located in a pot sitting in the kitchen sink. The hamburger meat was not thawed and more than half was frozen. There was not any running water over the frozen hamburger meat. There was approximately half of the frozen hamburger meat not submerge in the water. Only half of the hamburger meat was submerged in the water. In an interview on 08/20/2024 at 9:08 AM, Dietary Aide P stated all the hamburger meat was required to be in the water to be defrosted. She stated running water was also expected to be running over the hamburger meat while it was being defrosted. Dietary Aide P stated she forgot to run the water over the hamburger meat and place the hamburger meat in a larger pot. Dietary Aide P stated she was in a hurry and forgot. She stated if the hamburger meat was not defrosted properly there was a possibility the hamburger meat may be ruined from being defrosted at room temperature. She stated it was a possibility a resident may become ill with stomach issues if the resident ate ruined meat. 2. Observation on 08/20/2204 at 9:13 AM, there were four boxes of food stacked on top of one another located in the walk-in refrigerator floor. There were also some paper napkins on the floor and one was stuck to the surveyors shoe. In the corner of the walk-in refrigerator was some type of crumbled food. 3. Observation on 08/22/2024 at 11: 15 AM, Dietary Aide P removed gloves from her hand and placed them in garbage can. She did not wash or sanitize hands after removing the gloves. Dietary Aide P touched her clothes and picked up 2 new gloves from the glove container. She touched the outside of the gloves such as fourchettes (slender pieces of fabric or rubber that forms the sides of the finger). Dietary Aide P placed the gloves on her hands and picked up approximately 3 zip plastic bags and placed her fingers inside two of the plastic bags and gave it to a resident. Interview on 08/22/2024 at 11:20 AM, Dietary P stated she did touch her shirt after she removed her gloves. She stated she did not sanitize or wash her hands prior to placing new gloves on her hands. Dietary aide stated she did pick up the gloves where the fingers go inside the gloves. She stated she was expected to wash her hands prior to placing new gloves on her hands. Dietary Aide P stated she had been in-serviced on hand hygiene and wearing gloves when changing tasks or touching anything not sanitary. Interview on 08/22/2024 at 2:05 PM, the Administrator stated all boxes located in the walk-in refrigerator was expected to be on a crate or on the shelves. She stated no boxes was to be stored on the floor of the refrigerator. She stated the boxes may become damp and the food inside of the boxes had a potential of being wet or damp. She also stated it was a possibility of a safety hazard if the boxes were stacked on each other they could fall and injure a staff. The Administrator stated all frozen meat was required to be defrosted on a flat pan located in the refrigerator on the bottom shelf. She stated if the dietary staff was defrosting hamburger meat in the sink all of the hamburger meat was expected to be submerged in water with running water pouring over the frozen hamburger meat. She stated it was a possibility the meat may ruin if not defrosted correctly but there was a slight chance of this occurring when defrosting. The Administrator stated all staff was to wash and sanitize their hands when they removed gloves and prior to placing new gloves on their hands. She stated if the dietary aide P did not sanitize her hands and touched inside the zip plastic bags to give to a resident there was a possibility the bags could become cross contaminated. She stated there should not be any paper napkins on the floor in the walk-in refrigerator. The Administrator stated all areas of the kitchen including walk-in refrigerator was expected to be kept clean and organized. In an interview on 08/22/2024 at 3:45 PM, Dietary Manager L stated all meat was required to be defrosted either in the refrigerator on a flat pan located on the bottom shelf of the refrigerator or in the sink in a container with running water pouring over the meat. She stated the hamburger meat was to be submerged in the pot and be defrosted with running water over the entire hamburger meat. Dietary Manger L stated there was a possibility the portion of the hamburger meat not submerged in the water would not be defrosted correctly and may cause illness with a resident if the hamburger meat was ruined. She stated any time dietary staff removes their gloves they were expected to wash their hands immediately before doing any other type of task including placing new gloves on their hands. Dietary Manger L stated if Dietary Aide P touched the outside of the new gloves with her contaminated hands there was a possibility bacteria could cross contaminated inside of the plastic bags. She stated if the resident was placing food inside of those bags there was a potential where bacteria touch the food. Dietary Manger L stated if a resident ate contaminated food the resident may become sick with any type of stomach issues such as vomiting and diarrhea. She stated the boxes located in the walk-in refrigerator was not to be stored on the floor. She stated they were expected to be stored on pallets or on the shelves in the refrigerator. Dietary Manager L stated this had a potential of becoming a safety hazard due to the boxes was stacked on top of each other and if they feel a staff may become injured. She stated there should never been any type of napkins or paper on the floor in the walk-in refrigerator or anywhere in the kitchen. Dietary Manager L stated this was not sanitary. She stated there should never be any type of food on the refrigerator floor. She stated this was also not sanitary. Review of the facility policy on Food Preparation and Service, dated 10/2022, reflected Foods will not be thawed at room temperature. Thawing procedures include: a. Thawing in the refrigerator in a drip-proof container. b. Completely submerging the item in cold running water (70 F or below) that is running fast enough to agitate and remove loose ice particles. c. Thawing in a microwave oven and then cooking and serving immediately; or d. Thawing as part of a continuous cooking process Facility policy of Refrigerators and Freezers, dated 10/2022, reflected This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on scheduled basis and more often as necessary. Facility policy on Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, reviewed 06/12/2024, reflected Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Employees must wash their hands during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or after engaging in other activities that contaminate the hands.

Based on observation, interview and record review, the facility failed, 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, individual activities, 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 3 of 8 residents ( Resident #10, Resident #19, and Resident #25) reviewed for activities. The facility failed to develop an activity program based on preferences of Resident #10, Resident #19, Resident #25 during the months of July to August 2024. These failures placed residents at risk of boredom, depression, increased behaviors, and diminished quality of life. Findings include: 1. Record review of Resident #10's Face Sheet, dated 08/22/2024, reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis depression unspecified (used when a person's symptoms do not clearly align with a specific mental disorder or where there is insufficient information for a more definitive diagnosis), other secondary parkinsonism ( caused by brain injuries or brain disorders), and cognitive communication deficit (can effect both verbal and nonverbal communication, such as speaking, listening, reading, writing, and social interaction skills). Record review of Resident #10's Annual MDS Assessment, dated 01/30/2024, reflected Resident #10 was rarely/never understood. She had poor short (unable to recall after 5 minutes and long (unable to recall long past memories) term memory recall. Resident #10 does not have speech (absence of spoken words). Resident #10 activity preferences was listening to music and participating in religious activities or practices. Record review of Resident #10s Quarterly MDS Assessment, dated 07/30/2024, reflected Resident #10 had poor short (unable to recall events after 5 minutes) and long-term memory recall (unable to recall past events). Resident #10 was rarely/ never understood or rarely/never understands others. Record review of Resident 10's Comprehensive Care Plan, dated 08/14/2024, reflected Resident #10 required staff assistance for meeting emotional, intellectual, physical, and social needs related to disease process and immobility. Intervention: Resident #10 needed in-room visits and activities. Record review of Resident #10's in room activity participation record in the electronic medical record reflected Resident #10 did not have any documentation of receiving in room activities or attending group activities. The record review was completed with the Activity Director M. She stated she did not have any participation records on Resident #10. Observation on 8/20/2024 at 10:31 AM. Resident #10 was sitting in the lobby asleep. Observation on 08/20/2024 at 4:00 PM, Resident #10 was in bed. Her door to her room was slightly opened. Resident #10 was awake there was no lights on in her room. Television was not on and did not observe any radio in her room which music was her favorite activity. Resident #10's room was dark and she was moving her eyes side to side. Resident had sad expression (forehead wrinkled and eyebrows were brought together -signs of sad expression). In an interview on 8/20/2024 at 4:05 AM, Resident #10 was not interview able. Observation on 08/21/2024 at 7:45 AM, Resident #10 was in bed. Her door to her room was slightly opened. Resident #10 was awake and there were no lights on in her room and no stimulation such as a radio in her room which is her favorite activity listening to music. Resident #10 did not have television on in room. In an interview on 8/21/2024 at 8:15 AM, Activity Director M stated she did not have any in room or group participation records for the month of July 2024 and August 2024 for Resident #10. She stated she would print all of the in-room participation records for the months of July 2024 and August 2024 In an interview on 08/21/2024 at 8:45 AM, Activity Director M stated after the activity in room participation records were printed Resident #10 did not have any in room or group participation records for the months of July 2024 or August 2024. She stated she did not know if she received in room activities or attended group activities during the months of July 2024 and August 2024. Activity Director M stated if a resident had a diagnosis of depression and was not physically able to do activities without assist from another person, there was a possibility Resident # 10 may become more depressed and may become very lonely. She stated Resident #10 quality of life may decrease. She stated Resident #10 does sit in the lobby but sleeps most of the time and she was not receiving any activities in the lobby. She stated it was her responsibility to ensure all residents received activities according to their past and current interest. 2. Record review of Resident #19's Face Sheet, dated 08/22/2024, reflected a 94- year-old female admitted to the facility on [DATE] with diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition in which a person loses the ability to think and solve problems. Unspecified severity- a medical classification for dementia that does not have a specific diagnosis and does not have a specified severity), major depressive disorder ( feelings of guilt or worthlessness, lack of energy, agitation ( unable to stay calm) and /or sleep disturbances), and unspecified glaucoma (a group of eye diseases that cause increased pressure in the eye, which can damage vision). Record review of Resident #19's Admission MDS Assessment, dated 10/18/2024, reflected Resident #19 had a BIMS score of a 15 indicated her cognition was intact. Resident #19's activity preferences were the following: go outside and get fresh air when weather permitted, participate in religious services or practices, listen to music, reading such as: books, newspapers, and magazines. Participating in groups activities was not very important to Resident #19. Record review of Resident #19's Quarterly MDS Assessment, dated 07/17/2024, reflected Resident #19 had a BIMS score of 15 indicated her cognition was intact. Resident #19 had moderately impaired vision- not able to see newspaper headlines but can identify objects. She was assessed to feel down, depressed, or hopeless. Resident #19 also felt tired and bad about herself, had difficulty concentrating on things such as: reading or watching television. Record review of Resident #19's Comprehensive Care Plan, dated 07/31/2024, reflected Resident #19 required staff assistance for meeting emotional, intellectual, physical, and social needs related to immobility. Intervention Resident #19 needed in room visits and activities if unable to attend out of room events. Resident was resistive to care related to adjustment to nursing home and dementia (a condition in which a person loses the ability to think and solve problems). Resident #19 refused to get out of bed. Intervention: All Resident #10 to make decisions about treatment regime, to provide sense of control. Resident #19 had impaired cognitive function/dementia (a condition in which a person loses the ability to think and solve problems). Intervention: Reminisce with Resident #19 using photos of family and friends. Observation on 8/20/2024 at 11:30 AM, Resident #19 was in her room lying in bed. The door to her room was barely opened and she did not have television on and did not see a radio or other stimulation in her room. Resident #19 had sad expression on her face such as (forehead wrinkled, and eyebrows were brought together -signs of sad expression). Resident #19 was staring toward the ceiling. In an interview on 08/202/2024 at 11:33 AM, Resident #19 stated she was lonely and there was not anything for her to do except watch television and she was tired of television. She stated she did not receive in room visits or activities from anyone and she did not know what in room visits or in room activities was until now. Resident #19 stated she never heard of in room activities. Resident #19 stated she did not prefer to attend group activities it made her feel uncomfortable being around others in a group. She stated if someone would just bring her a radio or something for her to listen to music. Resident #19 stated she loved Gospel music and liked country music. She stated if there was gospel or country music on television she never knew about it or ever saw it on television. Resident #19 stated music was her favorite thing to do. She stated she never liked to read very much due to her vision. Resident #19 stated her neighbor had books on tape and her neighbor would listen to different types of books. Resident #19 stated she might enjoy listening to books but she would need to try it before she made decision if she liked to listen to books. Resident #19 stated no one had ever offered her anything to read and with her poor vision it would need to be very large print. Resident #19 stated she did like to go outside in the spring and fall sometimes. She stated she did not recall anyone assisting her to sit outside. Resident #19 stated that would be nice sometimes not every day or every week but maybe once or twice a month when weather was cooler. She stated she did like to listen to devotionals. She stated it would be nice if someone read the bible to her or a devotional to her once a week. Resident #19 stated there is never anything to do and no one comes by and will sit and talk to me. She stated do you think you can talk to someone and ask them if they would visit with me sometimes and bring me something to do instead of watching television all the time. In an interview on 08/21/2024 at 8:15 AM, Activity Director M stated Resident #19 was not on the in-room activity program. She stated she did not realize Resident #19 was not getting out of bed very often. The Activity Director M stated she did not have any participation records for Resident #19 during months of July 2024 and August 2024. She stated she had not been reminiscing using photos of Resident #19's family and friends. Activity Director M stated if Resident #19 did not want to attend group activities she needed to be receiving in room activities. Activity Director M stated she did not realize it was on Resident #19's care plan she was to receive in room activities reminiscing about family or friends' photos. She stated Resident #19 had a potential of becoming bored and depressed if she was not doing the activities she preferred or not doing any type of activities in her room. Activity Director M stated she had not been offering her large print books to read, books on tape or a radios. She stated if music, religious activities and going outside was her favorite activities these type of activities was expected to be provide to Resident #19. She stated it was her responsibility to ensure all residents received activities according to their past and current interest. 3. Record review of Resident #25's Face Sheet, dated 06/17/2024, reflected a [AGE] year-old male admitted on [DATE] with a diagnoses of lack of coordination (a problem with movement that can manifest in a variety of ways, such as difficulty with fine motor skills), age-related physical debility ( frail patients often present with symptoms including weakness, fatigue, medical complexity, and reduced tolerance to medical and surgical interventions), muscle weakness (loss of muscle strength), muscle wasting and atrophy, not elsewhere classified, other site ( muscle atrophy - the wasting or thinning of muscle mass, muscle wasting- weakening, shrinking, and loss of muscle caused by disease or lack of use), and anxiety disorder due to known physiological condition ( when anxiety symptoms (startle easily and can't relax) are a direct result of a physical health problem). Record review of Resident #25's Admission MDS Assessment, dated 06/21/2024, reflected Resident #25 had a BIMS score of 9 indicated Resident cognition was moderately impaired. Resident#25's activity preference was the following: have books, newspaper, and magazines to read, listen to music, watching news, go outside to get fresh air when the weather was good, and participating in religious services or practices. Record review of Resident #25's Comprehensive Care Plan, dated 07/12/2024, reflected Resident #25 had a mood problem anxiety related to disease process of CVA ( a medical conditions that occurs when blood flow to the brain is suddenly cut off - this diagnosis was not listed on the face sheet) Intervention: Monitor/record/ report to medical doctor as needed acute episode feelings or sadness; feelings of worthlessness or guilt or change in psychomotor (movement-oriented activities that require practice and involved characteristics such as coordination, strength, speed and flexibility). Resident # 25 had impaired cognitive function/dementia or impaired thought process (a condition in which a person loses the ability to think and solve problems). Intervention Reminisce with Resident #25 using photos of family and friends. Observation on 08/20/2024 at 11:30 AM, Resident #25 was lying in bed. The lights were off in his room and the door was slightly open leading into his room. He did not want to discuss anything about his nails. He made eye contact with Surveyor O when mentioned in room activities or in room visits. Resident #25 also clinched his mouth / jaw (sign of stress) when surveyor O mentioned if he received in room visits talking about pictures of his family and friends. Resident #25 did not have any stimulation in his room. Interview on 08/20/2024 at 11:34 AM, Resident #25 stated no when asked if he received activities or visits in his room showing him pictures of his family and friends. Resident #25 stated no when asked if he liked to do anything with a group of people. In an interview on 08/21/2024 at 8:15 AM, Activity Director M stated Resident #25 was on the in-room activity program due to Resident #25 did not attend group activities. She stated her schedule was to visit all in room residents Monday to Friday in the morning. Activity Director M stated according to Resident #25's participation records he only received two in room activities during the month of July 2024 and did not receive any in room activities during month of August 2024. She stated Resident #25 had a potential of becoming depressed, lonely and may have a decrease of quality of life. She stated she had not reminisced with Resident #25 with photos of his family and friends. She stated Resident #25 was expected to receive in room visits/ activities Monday thru Friday. Activity Director M stated she did not have any excuse why she did not visit Resident #25 to provide in room activities/ visits. She stated it was her responsibility to ensure all residents received activities according to their past and current interest. In an interview on 08/22/2024 at 2:05 PM, the Administrator stated all activities including in room visits was expected to be documented on the date the activity occurred with the residents. She stated if the Activity Director M did not document any activities, the activity did not occur with the resident or residents. The Administrator stated a resident may become depressed, lonely and have a diminish quality of life if they were not receiving activities of their preferences on a daily or weekly basis. She stated she had been in this facility approximately two weeks and would definitely be making observations of the activity programming. Record review of the Facility's Policy on Activity Programs, revised on 06/2018, reflected activity programs are designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Activities offered are based on the comprehensive resident -centered assessment and the preferences of each resident. All activities are documented in the resident's medical record.

Based on observation, interview, and record review, the facility failed to ensure the communication system which allows residents to call for staff assistance was within reach for 5 (Resident #4, Resident # 21, Resident # 31, Resident #26, and Resident #20) out of 17 residents reviewed for call system placement. The facility failed to ensure Resident #4, Resident #21, Resident #31, Resident #26 and Resident #20's call light was within reach. The failure could place residents at risk for being unable to call for assistance from staff. Findings include: Review of Resident #4's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hemiplegia (paralysis or severe weakness in one side of the body) and cerebral infarction (stroke). Review of Resident #4's Optional MDS, dated [DATE], reflected a BIMS score of 11 indicating moderate cognitive impairment. MDS further reflected resident required substantial assistance with sitting on side of bed and transferring to the toilet. Review of Resident #4's Care Plan, dated 05/13/2024, reflected resident requires staff assistance for meeting needs. Care plan reflected resident had an ADL self-care performance deficit and required extensive 2-person transfer and dependence for toileting needs. Interventions included to encourage resident to use call bell to call for assistance. Observation and interview on 08/20/2024 at 09:15 AM, revealed Resident #4 lying in bed by the window with the call bell hanging from the back wall out of the resident's reach. Resident #4 stated he did not know where the call bell was and shrugged his shoulders when asked further questions. 2. Review of Resident #21 face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), personal history of traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head), an anxiety disorder (feelings of worry, anxiety or fear). Review of Resident #21's MDS, dated [DATE], reflected a BIMS score of 13 indicating resident was cognitively intact. MDS further reflected resident required moderate assistance with eating and substantial assistance with toileting. Review of Resident #21's Care Plan, dated 05/13/2024, reflected resident had an ADL self-care performance deficit and required assistance with transfers, eating and toileting. Interventions included to encourage resident to use call bell to call for assistance. Observation and interview on 08/20/2024 at 09:45 AM, revealed Resident #21 sitting in wheelchair alone in his room with call bell hanging against back wall and behind furniture. Resident #21 stated he did not know where the call bell was and that he never uses it. He stated he goes out of the room to get someone if he needs something. 3. Review of Resident #31's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with readmission on 05/01/2024 with diagnoses of nontraumatic intracerebral hemorrhage (bleeding in the brain that occurs without surgery or trauma), encephalopathy (brain disease that alters brain function), hemiplegia and hemiparesis (weakness and paralysis on one side of the body). Review of Resident #31's MDS, dated [DATE], reflected a BIMS score of 03 indicating severe cognitive impairment. MDS reflected resident was dependent on staff for toileting and hygiene needs. Review of Resident #31's care plan, dated 07/08/2024, reflected resident had an ADL self-care performance deficit and required assistance with transfers, eating and toileting. Interventions included to encourage resident to use call bell to call for assistance. Observation and interview on 08/20/2024 at 10:00 AM, revealed Resident #31 alone in the room, lying in bed with the call bell draped across the chair on the other side of the room. Resident # 31 was difficult to understand but stated he did not know about his call bell. 4. Review of Resident #26's face sheet reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of metabolic encephalopathy (brain dysfunction caused by a chemical imbalance in the blood from an underlying condition that affects metabolism), Alzheimer's disease (progressive disease that destroys memory and other mental functions), and transient cerebral ischemic attack (mini stroke). Review of Resident #26's MDS, dated [DATE], reflected a BIMS of 10 indicating moderate cognitive impairment. MDS indicated resident required moderate assistance with toileting and showering. Review of Resident #26's Care Plan, dated 07/09/2024, reflected resident had an ADL self-care performance deficit and required assistance with transfers, eating and toileting. Interventions included to encourage resident to use call bell to call for assistance. Observation and interview on 08/20/2024 at 10:15 AM, revealed Resident # 26 alone in room lying in bed by the window with the call bell across the room out of reach. Resident #26 stated he never has a call bell where he can reach it. 5. Review of Resident #20's face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (progressive disease that destroys memory and other mental functions), Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and Dementia (impairment of brain functions such as memory loss and judgement). Review of Resident #20's MDS, dated [DATE], reflected a BIMS of 04 indicating severe cognitive impairment. MDS reflected resident required supervision with toileting and shower. Review of Resident #20's Care Plan, dated 06/09/2024 reflected resident had an ADL self-care performance deficit and required assistance with toileting and supervision/setup with eating and transfers. Interventions included to encourage resident to use call bell to call for assistance. Observation on 08/2024 at 11:00 AM, revealed Resident #20 resting in bed with her call bell out of reach, hanging from back wall onto the floor. Resident was not interviewable. In an interview on 08/22/2024 at 3:51 PM, CNA C stated it was the nursing staff's responsibility to ensure the residents call bell was within reach or it could place the resident at risk for falls. She stated the nurses at the nurses station would only be able to hear some of the residents if they were to cry out for help. In an interview on 08/22/2024 at 4:10 PM, LVN A stated it was everyone's responsibility to ensure the call bells are within the residents reach and to tell the residents to call if they need anything. She stated a resident could fall while trying to get up and reach the call bell. She stated the nurses at the nurse station would only be able to hear some residents if they were to holler for help. In an interview on 08/22/2024 at 5:30 PM, Interim DON stated the call bells should be within reach at all times. She stated the staff have received in-services on call bells and she has started making rounds in the facility to monitor compliance. She stated when the call bell is not within reach it places the resident at risk for injury and not being able to get what they need. Review of in-service training, dated 03/27/2024, reflected call lights are everyone's responsibility and something anyone can help with. The training reflected the staff are to make sure call bells are within reach every time the staff enter and exit the room.

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 disease and infections for 19 out 19. residents (Residents #1 - #19). The facility failed to: 1. ensure staff donned/doffed PPE/outside/inside rooms for residents on transmission-based precautions. 2. ensure staff wore the proper PPE inside the rooms for residents on transmission-based precautions. 3. ensure the facility had the proper PPE outside the rooms for residents on transmission-based precautions. On 12/22/23 at 6:13 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 12/24/23 at 3:37 PM, the facility remained out of compliance at a severity level of actual harm that is not immediate to resident health or safety and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could affect residents by placing them at risk for communicable diseases that could lead to infection and hospitalization . Findings included: Record review of Resident #1's undated face sheet revealed resident is a [AGE] year-old Female admitted to the facility on [DATE] with unspecified dementia(mild memory disturbance), hypertensive heart, chronic kidney disease without heart failure (diseased kidneys are less able to help regulate blood pressure), and shortness of breath. Record review of Resident #2's undated face sheet revealed resident is a [AGE] year-old Male admitted to the facility on [DATE] with diagnoses including dementia (memory loss), atherosclerotic heart disease of native coronary artery without angina pe (heart forced to work harder than normal), and essential primary hypertension (abnormal high blood pressure). Record review of Resident #3's undated face sheet revealed resident is a [AGE] year-old Male admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease of native coronary artery without angina pe (heart forced to work harder than normal), acute respiratory failure with hypoxia (acute or chronic impairment of gas exchange between the lungs), and unspecified systolic congestive heart failure (heart failure that occurs in the heart's left ventricle). Record review of Resident #4's undated face sheet revealed resident is a [AGE] year-old Female admitted to the facility on [DATE] with diagnoses including hypertensive heart disease without heart failure (a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation), personal history of Covid-19, and major depressive disorder (sadness). Record review of Resident #5's undated face sheet revealed resident is a [AGE] year-old Male admitted to the facility on [DATE] with diagnoses including major depressive disorder (sadness), atherosclerotic heart disease of native coronary artery without angina pectoris (heart forced to work harder than normal), and unspecified systolic congestive heart failure (heart failure that occurs in the heart's left ventricle). Record review of Resident #6's undated face sheet revealed resident is a [AGE] year-old Male admitted to the facility on [DATE] with diagnoses including major depressive disorder (sadness), essential primary hypertension (abnormal high blood pressure), and anxiety disorder (pounding or racing heart). Record review of Resident #7's undated face sheet revealed resident is an [AGE] year-old Female admitted to the facility on [DATE] with diagnoses including dementia (sadness) and Alzheimer's (brain disorder destroying memory and thinking skills). Record review of Resident #8's undated face sheet revealed resident is an [AGE] year-old Female admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (airflow blockage and breathing-related problem), dementia (memory loss), and essential primary hypertension (abnormal high blood pressure). Record review of Resident #9's undated face sheet revealed resident is an [AGE] year-old Male admitted to the facility on [DATE] with diagnoses including dementia (memory loss) paroxysmal atrial fibrillation (irregular rapid heartbeat causing poor blood flow), and essential primary hypertension (abnormal high blood pressure). Record review of Resident #10's undated face sheet revealed resident is a [AGE] year-old Female admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris (heart forced to work harder than normal) acute respiratory failure with hypoxia (acute or chronic impairment of gas exchange between the lungs), and essential primary hypertension (abnormal high blood pressure). Record review of Resident #11's undated face sheet revealed resident is a [AGE] year-old Female admitted to the facility on [DATE] with diagnoses including hypertensive heart disease without heart failure (a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation), major depressive disorder(sadness), and peripheral vascular disease (narrowed blood vessels reducing blood flow of limbs). Record review of Resident #12's undated face sheet revealed resident is a [AGE] year-old Female admitted to the facility on [DATE] with mild cognitive impairment (early-stage memory loss), cerebral palsy (congenital disorder of movement, muscle tone, or posture), and cognitive communication deficit (difficulty with thinking and how someone uses language). Record review of Resident #13's undated face sheet revealed resident is a [AGE] year-old Female admitted to the facility on [DATE] with diagnoses including essential primary hypertension (abnormal high blood pressure), dementia (loss of memory), and major depressive disorder (sadness). Record review of Resident #14's undated face sheet revealed resident is a [AGE] year-old Female admitted to the facility on [DATE] with diagnoses including dementia (loss of memory) diabetes (sugar in the blood high glucose), and cognitive communication deficit (difficulty with thinking and how someone uses language). Record review of Resident #15's undated face sheet revealed resident is a [AGE] year-old Female admitted to the facility on [DATE] with diagnoses including dementia (memory loss), chronic obstructive pulmonary disease (airflow block with difficulty breathing, and anxiety (feeling of worry). Record review of Resident #16's undated face sheet revealed resident is a [AGE] year-old Female admitted to the facility on [DATE] with diagnoses including dementia (loss of memory), chronic kidney disease (unable to filter blood), and shortness of breath. Record review of Resident #17's undated face sheet revealed resident is an [AGE] year-old Male admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (blocked airflow with difficulty breathing), diabetes (sugar in blood high glucose), and hypertension (pressure in blood vessels to high). Record review of Resident #18's undated face sheet revealed resident is a [AGE] year-old Female admitted to the facility on [DATE] with diagnoses including edema (swelling), essential primary hypertension (abnormal high blood pressure), and chronic kidney disease (not able to filter blood). Record review of Resident #19's undated face sheet revealed resident is a [AGE] year-old Male admitted to the facility on [DATE] with diagnoses including hypertension (pressure in blood vessels to high), major depressive disorder (sadness), and chronic embolism (blockage of pulmonary arteries). Record review of the facility list of COVID positive residents revealed that Resident #1 through Resident #19 were positve for COVID on 12/12/23 through 12/19/23. In an observation on 12/22/23 between 11:50 PM and 12:00 PM staff were observed with no N-95 mask on assisting residents with room doors open. Observed staff with no faceshields assiting COVID positive residents. Observed staff going into COVID positive rooms with surgical masks and PPE gowns not placed on correctly with no face shields. Observed no N-95 mask worn by staff assisting residents with COVID. Observed COVID positive resident's doors were open along with non-COVID residents while staff was assisting in between residents. Observed no PPE set up at the doors of the COVID positive residents on Halls 1,2, and 3. In an interview with the Business Office Manager on 12/22/22 at 12:00 PM, she stated there were 18 residents positive for COVID-19 and the outbreak started on 12/12/23. There were no warm or hot halls and all the residents in the facility were in their rooms. The Business Office Manager stated the surgical mask was what staff had been wearing to care for the residents and the surgical mask was the only mask available to the staff. The Business Office Manager could not give a reason as to why the N-95 mask or face shields was not available to staff and that she was filling in to help since the interim Administrator, the DON, and the ADON were out sick. In an interview with CNA A on 12/22/22 at 12:18 PM, she stated on 12/08/23 the DON/ADON locked the COVID tests in the office as they did not want to test residents and follow the COVID guidelines of wearing masks and PPE. The residents were showing signs of illness and symptoms on 12/08/23 and the DON and the ADON were notified. CNA A stated the breakout of COVID began on 12/12/23 and there were currently 18 residents positive. CNA A stated during the outbreak PPE was not encouraged to be worn and some staff were seen not using masks or protective gear when the outbreak occurred. Staff had to redirect the COVID positive residents back into their rooms when they came out into the halls without masks. CNA A stated no staff in the building were wearing N-95 masks or face shields during the outbreak or while caring for residents. CNA A stated that there were no N-95 masks in the building and did not know why. CNA A stated she had not had any recent training on Infection Control or protocol to follow during the outbreak. In observations on 12/22/23 between 1:05 PM and 1:30 PM, the Rehab Director was passing out food trays on hall 5 to COVID positive and non-COVID positive residents without an N-95 mask, no face shield, PPE gown was not properly fastened, and without gloves. In an interview with The Rehab Director on 12/22/23 at 1:30 PM, stated the surgical mask that she was wearing was the only mask they had in the building. The Rehab Director stated the surgical mask was what she had been using to care for the residents with COVID. The Rehab Director could not give me a reason as to why there were not any N-95 masks, or face shields in the building or who the Infection Control Preventionist was. The Rehab Director stated she did not have face a shield on passing trays to Covid positive residents as there were not any in the building and she stated she used hand sanitizer when she came out of resident's rooms. The Rehab Director stated she had not had any recent training in infection control. In observations on 12/22/23 between 1:45 PM and 2:00 PM revealed LVN A without an N-95 mask, face shield, and PPE gown not properly fastened on hall 1 assisting COVID positive residents. In an interview with LVN A om 12/22/23 at 2:00 PM stated that she did not want to be named in fear of retaliation. LVN A stated it was known that COVID Positive residents were on the same hall as non-COVID residents. LVN A stated she had not had any training recently on COVID. LVN A stated the surgical mask that she was wearing was the only mask they had in the facility. There were no N-95 masks in the facility or face shields. The surgical mask is what she used when she cared for COVID positive residents. LVN A stated around December 8th, 2023 the DON and the ADON withheld COVID testing. The DON/ADON were aware that residents had become ill. LVN A stated she felt that the DON and the ADON did not want to deal with testing the residents. LVN A stated she observed staff not wearing PPE or surgical masks during the outbreak. LVN A stated that when she was given direction by the DON/ADON to test residents that was when she tested the residents. LVN A stated she last tested residents for COVID on 12-19-2023. 18 were positive on 12-19-2023. LVN A stated she did not know who the infection control preventionist was and she believed the COVID transmission came from not wearing the proper PPE during the outbreak. Attempted to interview on 12/22/23 between 2:44 PM and 3:29 the interim Administrator, the DON, and the ADON. The Business Office Manager stated they were all out sick. Left voice mail messages for a return call with no call returned while in the facility. In an interview with LVN B on 12/22/23 at 4:18 PM, she stated the surgical masks were what staff used to care for the residents. There were no N-95 masks and did not know the reason why there were not any in the facility with the outbreak. LVN B observed staff not wearing PPE properly. Residents with COVID were redirected back in their rooms when they came out in the halls. In an interview with The Regional Director on 12/22/23 at 4:47 PM, she stated that the facility followed the CDC guidelines along with the facility policy. The Regional Director stated she was on the road driving and unsure and unable to quote the policy on isolation of residents and the surgical masks being worn during the outbreak. The Regional Director stated the Infection Control Preventionist at the facility was the DON/ADON. Record review of the policy on hand hygiene dated (revised August 2019) revealed hand hygiene was the primary means of preventing the spread of infection. Hand hygiene should be done before and after direct contact with residents. Record review of the undated policy on donning and doffing revealed 1. Identify and gather the proper PPE to DONN 2. Perform hand hygiene using hand sanitizer 3. Put on isolation gown 4. Put on approved N-95 filtering facepiece respirator or higher 5. Put on face shield or goggles 6. Put on gloves 7 Health care professional may now enter patient room. To DOFF 1. Remove gloves 2. Remove gown, 3. Health care professionals may now exit patient room. 4. Perform hand hygiene 5. Remove face shield or goggles 6. Remove and discard respirator (or facemask if used instead of respirator) 7. Perform hand hygiene after removing the respirator/facemask. Record review of the policy on infection prevention and COVID-19 revised 09/15/23 revealed, an infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Source control healthcare personnel will wear recommended PPE when caring for those in transmission base precaution status regardless of community transmission rates or outbreak status. For all Quarantine and isolation rooms 1. Post signs on the door or wall outside the resident's room that clearly describe the type of precautions needed and require PPE. 2. All PPE is single use per room encounter 3. Make PPE, including facemasks, eye protection, gowns, and gloves, available immediately outside of the resident room [ROOM NUMBER]. Perform hand hygiene upon exiting patient room [ROOM NUMBER]. Minimize contact with Quarantine and Isolated residents by bundling time in the room, utilizing technology when feasible and applicable avoiding creating unnecessary isolation or unnecessary mobility limitations. This was determined to be an Immediate Jeopardy (IJ) on 12/22/23 at 6:13 PM. The corporate nurse was notified. The corporate nurse was provided with the IJ template on 12/22/23 at 6:13 PM The following Plan of Removal submitted by the facility was accepted on 12/24/23 at 3:37 PM: Immediately on December 22, 2023, N-95 masks were brought to the facility and made available to all staff. All staff were given an N-95 mask and staff working confirmed to be wearing by Corporate Clinical Specialist (CCS). The staff were required to wear N-95 masks while providing care or working with COVID 19 residents. An order for additional masks was placed by Regional [NAME] President of Operations. The DON will be responsible for ordering PPE for the facility and tracking via par levels. PPE will be kept in a centralized storage room on hall 100 as of December 22, 2023, and ongoing. All staff will be inserviced on location of PPE on December 22, 2023. They will be inserviced before the start of their next shift. Immediately on December 22, 2023, the doors to the COVID rooms were closed. Corporate Clinical Specialist was responsible for ensuring doors were closed and completed on December 22, 2023 Immediately on December 22, 2023, the COVID 19 residents were moved from the non-COVID 19 residents. Corporate Clinical Specialist was responsible and completed on December 22, 2023. Immediately on December 22, 2023, CCS in-serviced the DON and the LNFA on Infection Control policy and procedures to include proper masks required for COVID 19 outbreak, PPE, and the protocol for closing of the doors for the COVID 19 positive residents. In-service was completed on December 22, 2023. The Medical Director was notified of the Immediate Jeopardy and the plan of removal by Corporate Clinical Specialist on December 22, 2023. The Medical Director did not have any further recommendations. On December 22, 2023, the CCS initiated in-services with the staff. In-services included the following: Infection control policy and procedures to include masking when in outbreak, PPE, and the protocol for closing of the doors for COVID 19 positive residents. The completion date for staff in-services and competency evaluations was December 22, 2023. Nursing staff will not be allowed to work until in-service has been completed. In-services was completed on December 22, 2023. The above training material which included the Infection Control policy and procedures to include proper masks required for COVID 19, PPE, location of PPE, and the protocol for closing of the doors for COVID 19 positive residents will be incorporated into the new hire nursing orientation by the CCS, effective December 22, 2023, and ongoing. PRN staff and agency staff will be trained by the DON/Designee prior to being allowed to work the floor. In order to monitor the current residents for potential risk, the DON/designee will monitor the facility COVID status daily and masking of employees starting December 22, 2023 and will continue for 90 days. The DON compliance will be monitored weekly by Corporate Clinical Specialist for 90 days. The facility QA Committee will meet weekly for the next eight weeks starting December 22, 2023, to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. POR monitoring . In an observation on 12/23/23 at 9:45 AM there was no hand sanitizer in the dispenser next to room [ROOM NUMBER] and the door marked storage. In an interview with LVN C on 12/23/23 at 10:10 AM, LVN C stated that there were only four COVID positive residents in the facility today. All other COVID positive residents came off isolation as of today. LVN C stated today was the 11th day from the date of a positive COVID test. In an interview with Resident #19 on 12/23/23 at 10:15 AM, she stated that staff used gloves, but he had not observed any hand sanitation or handwashing. Resident #19 stated that the facility should have taken COVID seriously a month ago and not just now. Resident #19 stated he had told, unnamed staff and titles unknown, that he wanted a booster and did not get one. Resident #19 stated that when he went to Wal-Mart pharmacy to pick up his glasses, thatwas when he received the COVID immunization. In an observation on 12/23/23 at 10:24 AM all staff were seen wearing N-95 masks. In an interview with ADON B on 12/23 23 at 11:26 AM, she stated there were approximately seven staff overall who had not been in-serviced on COVID policy/procedures, PPE, and hand hygiene at this time. ADON B stated the DON is in-servicing staff by phone from home and she did not have the exact number of staff left that needed to be in-serviced. Record review on 12/23/23 at 11:30 AM revealed in-service content and sign-in sheet, employee check-off sheets on hand hygiene, use of PPE, and the in-service post-test. In an interview with CNA B on 12/23/23 at 11:55 AM, she stated that she received the in-service training on PPE and hand hygiene. CNA B stated that the PPE were kept outside the COVID-19 positive resident's doors. CNA B was able to state who to notify when PPE runs low when caring for COVID residents. CNA B stated that she needed to wear an N-95 mask when caring for COVID positive residents. In an interview with LVN C on 12/23/23 at 11:56 AM, she stated she checked off on FaceTime video 12/22/23 for in-service on hand hygiene and the use of PPE with the DON. LVN C stated the facility had enough PPE and she knew who to notify when PPE was low. In an interview with Housekeeper A on 12/23/23 at 12:00 PM, she stated the facility had enough PPE and she was aware who to notify when supplies ran low. Housekeeper A stated she was in-serviced this morning on hand hygiene and applying PPE. Housekeeper A stated she had been trained to wear an N-95 mask when treating COVID positive rooms. In an interview with Housekeeper B on 12/23/23 at 12:05 PM, she stated that she was in-serviced this morning on hand hygiene and applying PPE. Housekeeper B stated she had the PPE necessary to clean COVID positive rooms. Housekeeper B stated she was trained to wear an N-95 mask when there were COVID positive residents in the facility. In an interview with ADON B on 12/23/23 at 12:15 PM, she stated she had confirmed that there were seven staff left to be in-serviced. ADON B stated messages had been left for those staff to indicate that they would not work again until they had been in-serviced. In an observation on 12/23/23 at 12:24 PM ADON B was able to show what the equipment was cleaned with. The equipment was cleaned with Micro-Kill one germicidal alcohol wipes. ADON B was able to show the supply of containers available. In an observation on 12/23/23 at 12:30 PM all hand sanitizers that were wall-mounted outside the doors of each room was found to be working with the exception of the one outside room [ROOM NUMBER] that was observed earlier. CNA B was observed using disinfecting wipes to wipe down the Hoyer lift. CNA B stated that the equipment was wiped down after use so that it was clean for the next resident. CNA B stated the disinfecting wipes were used to wipe down equipment on multiple residents. In an observation on 12/25/23 at 11:50 AM of PPE supply in the facility: 3 COVID Positive Rooms: There were plastic bins placed outside of the rooms filled with PPE. Inside of the rooms are biohazard boxes (one for trash and one for laundry). Storage Rooms: On Hall 100, there were 3 different storage rooms. One for PPE, one for the biohazard materials, and one for supplies. Positive Resident's Doors The doors were observed to be closed with bins located outside of the rooms stocked with PPE. Record review of the below In-service Training Reports and Sign-In Sheets for: 1) PPE - COVID - Droplet Precaution - 12/22/2023 2) Handwashing - Hand Sanitizer - 12/22/2023 3) COVID/Infection Control (COVID-19 Policy and Procedures) - 12/22/2023 4) Handwashing, PPE, and Infection Control Policy, Proper Masking During COVID - 12/22/2023 5) PPE - COVID+ Residents and location - 12/22/2023 6) COVID In-service: -N-95 masks must be worn at all times -Proper PPE when entering positive COVID residents' rooms -Remove PPE prior to leaving positive COVID residents' rooms -N-95 must be changed as well -Proper hand hygiene -Encourage all residents' doors to remain closed with Positive COVID status -Donning/Doffing -Proper wearing of PPE Training Material: Observed the Clinical Performance Evaluation Checklist: Handwashing completed and signed on 12/22/2023 and 12/23/2023. Each staff member received a satisfactory checkmark. In an interview with The Activities Director on 12/25/23 at 12:20 PM, she stated that she was contacted by phone on 12/22/23 and was in-serviced on COVID protocol. The Activities Director stated she was contacted by the DON and that she did not learn anything new it was a refresher to her. The Activities Director stated she had passed the quiz and when she worked with a COVID resident she used full PPE. The activities Director stated prior to the exit of the resident's room she doffed inside the room and disposed of all the PPE in the biohazard box. The Activities Director stated everyone that was positive should have been moved to one hall to control the spread. The Activities Director stated they should not have allowed a positive resident to remain in the room with their negative roommate. The Activities Director stated she was told to pull the curtain as that was going to protect the negative resident. In an interview with RN A on 12/25/23 at 12:35 PM, she stated she was in-serviced on handwashing policies and procedures. RN A stated you must separate positive residents from negative residents and wear N-95 masks whenever there is an outbreak. RN A stated she completed the in-service with the DON and completed a quiz. RN A stated she learned to put her gown, mask, face shield, and gloves on. In an interview with LVN D on 12/25/23 at 12:50 PM, she stated she was in-serviced on wearing N-95 masks at all times during a COVID outbreak. LVN D stated that residents cannot be commingled with positive and negative. LVN D stated the door must remain closed for all positive residents and PPE is kept outside of each room. LVN D stated handwashing and proper hand hygiene must be ongoing. LVN D stated you must Donn in full PPE prior to entering the room and Doff prior to exiting. In an interview with CNA C on 12/25/23 at 1:05 PM, she stated she was in-serviced on handwashing, properly wearing PPE, and Infection Control procedures. CNA C stated she completed the in-service with the DON. CNA C stated she did not learn anything new and that it was more of a refresher. CNA C stated although she already knew these things, they were not being implemented in the facility. In an interview with Housekeeper C on 12/25/23 at 1:15 PM, she stated prior to entering the resident's rooms she must suit up in full PPE. Housekeeper C stated she wiped down all high-touch areas in the rooms, especially the bedside tables. Housekeeper C stated before exiting the room she would unsuit and leave all the used PPE in the biohazard box. Housekeeper C stated she kept hand sanitizer on her cart at all times. Housekeeper C stated the in-service was a refresher for her. In an interview with The Dietary Manager on 12/25/23 at 1:30 PM, she stated she was in-serviced on separating positive residents from negative residents, proper PPE, handwashing, Infection Control, and COVID Protocol. The Dietaryy Manager stated she did not learn anything new and it was more of a reeducation for her. The Dietary Manager stated her in-service was completed by the DON. In an interview with the interim Administrator on 12/25/23 at 1:40 PM, she stated since the IJ was called they completed in-services for everyone and made sure N-95 masks were in the building. The interim Administrator stated they have completed a QAPI via phone. The interim Administrator stated they have completed a competency on handwashing, closing doors, proper isolation, and completed a 5-question Quiz. The interim Administrator stated they will monitor for the next 8 weeks to ensure everything is done correctly. The interim Administrator was informed the Immediate Jeopardy (IJ) was removed on 12/24/23 at 3:37 PM. The facility remained out of compliance at a severity level of actual harm to resident health or safety and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one of five residents (Resident #1) reviewed for injuries and supervision. The facility failed to ensure staff properly transferred Resident #1 from her wheelchair to her bed resulting in a fractured left leg causing severe pain. An Immediate Jeopardy (IJ) situation was identified 4:37 PM and on 10/18/2023 at and Immediate Jeopardy template was presented to the facility on [DATE] at 4:39 PM. While the IJ was removed on 10/19/2023 at the facility remained out of compliance at a severity level of actual harm at a scope of isolation due to staff needing more time to monitor the plan of removal for effectiveness. This failure could result in residents experiencing accidents, injuries, unrelieved pain, and diminished quality of life. Findings included: Record review of Resident #1's face sheet, dated 09/22/2023, revealed Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses which included low back pain (pain between the lower edge of the ribs), signs symptoms of musculoskeletal system (mild to severe aches, low back pain, numbness, tingling, atrophy, and weakness), muscle weakness (a lack of strength in the muscles), osteoporosis without current pathological fracture (generally caused by a fall from a standing height or lower and usually involves the spine, hip or wrist), lack of coordination (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements), left foot drop (caused by weakness of the muscles involved in lifting the front part of the foot) and, abnormalities of gait and mobility (when a person is unable to walk in the usually way). Record review of Resident #1's Annual MDS assessment, dated 07/28/2023, reflected Resident #1 had a BIMS score of fifteen, which indicated the resident's cognition was intact. Resident #1 did not reject care. Resident #1 was assessed to require extensive assistance by two staff members for transfers. She required extensive assistance by one staff for bed mobility and toileting. Resident #1 was also assessed to require limited assistance by one staff for personal hygiene. She was assessed to require staff to stabilize her when moving from a seated to standing position, moving on and off the toilet, and surface-to-surface transfers. Resident #1 was on scheduled pain medication and PRN pain medication. She had frequent pain. Resident #1 did not exhibit any behaviors. Record review of Resident #1's Comprehensive Care Plan completed on 08/17/2023 reflected Resident #1 had an ADL self-care performance deficit. Interventions included that the resident required extensive assistance by two staff members with transfers. Resident #1 required extensive assistance by one staff member with bed mobility. Resident #1 was at risk for falls related to gait/balance problems. She had limited physical mobility. Resident had chronic pain related to osteoporosis (a condition when bone strength weakens) Interventions included to anticipate the resident's need for pain relief and respond immediately to any complaint of pain; identify and record previous pain history and management of that pain and impact of function; identify previous response to analgesia(treatment that prevents you from feeling pain while you are awake) including pain relief, side effects and impact on function; monitor/document for probable cause of each pian episode; and remove/limit causes where possible. Resident #1's further interventions were: monitor/document for side effects of pain medication; administer analgesia as per orders; give 1/2 hour before treatments or care; notify the physician if interventions are unsuccessful or if current complaint is a significant change from resident's experience of pain; provide the resident and family with information about pain and options available for pain management; and discuss and residents' preferences. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:26 AM, reflected the x-Ray company was unable to do the x-ray at the facility for Resident #1's left knee. Resident #1 would be transferred via EMS to the hospital for an x-ray to her left knee. Resident #1 aware and the family was notified. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:44 AM, reflected EMS was at the facility to transport the resident to hospital. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:47 AM, reflected the pain medication was ineffective and follow-up pain was a five (moderately strong pain). Resident #1 was transferred to emergency room for evaluation and treatment. Record review of Resident #1's pain assessments reflected there was only one pain assessment completed from 07/21/2023 through 09/19/2023. Record review of Resident #1's pain assessment dated [DATE] reflected Resident #1 had been in pain for the past five days. She frequently had pain. Resident #1 was assessed she had difficulty completing her day-to-day activities as related to her pain. Her pain was moderate. Resident #1 was on scheduled pain medication. Signed by the MDS Coordinator. Record review of Resident #1's hospital records from the emergency room Hospital A dated 09/19/2023 reflected Resident #1 was transferred by EMS with a complaint of knee pain. She was being transferred between the bed and wheelchair yesterday (09/18/2023) in the facility where she resided when her knee twisted and then became painful and swollen. EMS reported she was given 7.5 milligram of pain medication this AM (09/19/2023) for pain. The EMS did not know the time the pain medication was administered. Admission: Urgent, Admission Source: Nursing Home. Nursing Assessment: extremity lower. There was obvious swelling to the knee and there appeared to be slight angulation (two ends of the broken bone are at an angle to each other) of the leg. No bruising or open wounds noted to the knee. Record review of Resident #1's doctors note from the emergency room Hospital A dated 09/19/2023 reflected Resident #1was transferred to the hospital on 09/19/2023 from the nursing home where she resided. On 09/18/2023 Resident #1 was being rotated out of her wheelchair when the staff heard a popping noise from her left knee, and she had called out in pain. The staff noticed on 09/19/2023 the knee continued to be swollen and very painful for the patient when she was moving her knee. Resident #1 was transferred to emergency room for evaluation for possible knee dislocation or knee fracture or any injury. Resident #1was able to express that she felt a significant amount of pain when her left knee was mobilized. The x-ray result reflected Resident #1 had traumatic fracture of the distal femur (where the bone flares out like an upside-down funnel). Record review of Resident #1's emergency room clinical course and plan reflected, Resident #1 had a distal femur fracture. The fracture was acutely comminuted fracture (a type of fracture where broken bones fracture into more than three separate pieces). Resident #1's pain was under control if the leg was immobile. Two rigid boards were placed on the side of the knee and an ace bandage was used to wrap around the knee for compression and stability. Resident #1 would be transferred to a hospital with orthopedics. Resident #1 required a higher level of care. Record review of Resident #1's emergency room history and physical from a hospital B dated 09/20/2023 reflected chief complaint of Resident #1: Left knee pain after hearing a pop, being lifted from wheelchair to bed. Resident #1 was transferred from the nursing home following left knee pain during the time when the staff were trying to transition her from her wheelchair to her bed. There was a popping noise and Resident #1 had immediate pain. Resident #1 was seen today (09/20/2023) in the hospital bed with her left leg splinted. Imaging studies reflected: X-ray of the left knee, two views reflected impression, acute mildly comminuted fracture of the distal femur medtadiaphysis (a type of fracture where broken bones fracture more than three separated places - medtadiaphysis is a term used to describe the combined region of a long bone and the shaft of the bone. Lesions that span both regions). Plan: to admit to surgical unit. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by the family revealed on 09/18/2023 revealed the following: - At 05:44 PM, the COTA/Marketing Coordinator stated to Resident #1 she had not transferred Resident #1 before and asked Resident #1 if she was able to help during transfers or did, she need a gait belt. The PT/Marketing Coordinator stated she was going to find a gait belt. -At 05:49 PM, the COTA/ Marketing Coordinator and PTA began transferring Resident #1 from the recliner to the wheelchair ( on 09/18/2023 PM). Resident #1 complained about her back hurting but was not yelling. -At 05:52 PM, the COTA/Marketing Coordinator and PTA began to transfer Resident #1 ( by 2 person assist with gait belt) from her wheelchair to her bed in PM. Resident #1 was not yelling or complaining about pain. PTA C was standing behind the wheelchair to the left when COTA/ Marketing Coordinator was standing in front of Resident #1. Resident #1 had her right hand on COTA / Marketing Coordinator upper left arm and her left hand on COTA/ Marketing Coordinator upper right arm. Resident was in wheelchair and the left side of resident was next to the bed. PTA C was standing behind the wheelchair. PTA C had her hand on Resident #1 upper back and continued to stand behind the wheelchair when COTA/Marketing Coordinator transferred Resident #1 from wheelchair to the bed. During the transfer PTA C did grab Resident #1's pants. PTA C was not to the side of resident or in front of resident where she could view Resident #1's left foot or assist with the left foot due to Resident #1 having left foot drop. - Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 05:53 PM Resident #1 was yelling my knee is hurting and my leg broken. Resident #1 began to rub her left leg as she continued to yell. At 6:00 PM. Resident #1 stated to PTA that they turned her around and Resident #1 was looking at PTA as she made the statement. The PTA stated to Resident #1 they did not mean to hurt her. In an interview on 10/15/2023 at 10:40 AM, LVN D stated Resident #1 required 2 staff assist with a gait belt when Resident #1 was transferred. LVN D stated she had assisted Resident #1 with transfers from her wheelchair to her bed. She stated for a successful transfer with Resident #1 it was easier to place the wheelchair near the bed where there was enough room for one staff be between the bed and the wheelchair. She stated one staff would be on Resident #1's left side and one staff would be on Resident #1's right side. LVN D also stated the staff on the left side of Resident #1 would be observing her left foot to ensure it didn't drag on the floor or would hang on the wheelchair. LVN D stated it was best practice if the left foot (one had the foot drop) was not next to the bed when transferring Resident #1 and her right foot was positioned next to the bed during transfers. She stated if staff transferred Resident #1 this way the left foot would not get caught between the wheelchair and the bed. There were less of a chance the left foot would be injured during transfer She stated Resident #1's had a left foot drop and sometimes she would place the left foot on the floor, however, most of the time she would keep the left foot raised a few inches off the floor during transfer. She stated if no one was on the left side of Resident #1 it would be very difficult to monitor the left foot to ensure it didn't drag on floor or get caught on wheelchair. LVN D also stated this type of transfer was more efficient with Resident #1. She also stated the two staff would have one hand on the gait belt, and the two staff would transfer Resident #1 together with one staff on her left side ensured her left foot was not dragging and not touching the floor. She stated the left foot would be smooth turn with her right foot and it would be in sync at the same time. She stated Resident #1's hips and feet would go at the same time, and it would be a smooth transfer. She stated the most important information with Resident #1's transfer was to watch the left foot. LVN D stated Resident #1 always wore non-skid socks and did not have regular socks in her room. She stated she would have shoes on or her non-skid socks when out of bed and when she was in bed, she preferred to wear her non-skid socks. LVN D stated Resident #1 did have weight bearing on her right foot, however, did not have very much if any weight bearing on her left foot. LVN D stated if someone was behind Resident #1's wheelchair and someone was in front of Resident #1 it would be difficult for anyone to observe her left foot. She stated someone needed to be by the left foot to prevent it from dragging or hitting anything. She stated it was best if the left foot (one had the foot drop) was not next to the bed when transferring Resident #1 and her right foot was positioned next to the bed during transfers. She stated if staff transferred Resident #1 this way the left foot would not get caught between the wheelchair and the bed. There were less of a chance the left foot would be injured during transfer. In an interview on 10/15/2023 at 11:00 AM, CNA M stated she had transferred Resident #1 in the past. She stated she began working at the facility 07/12/2023. She stated she had been assigned to Resident #1 or have assisted other staff in transferring Resident #1 at least 4-5 times per week. CNA M stated Resident #1 had problems with her left foot. She stated she was not capable of placing her left foot on the floor but for a few seconds. She stated Resident #1 did not have but very little weight bearing on her right foot and none on her left foot when she assisted Resident #1 with transfers. CNA M stated Resident #1 was a two person gait belt transfer. She stated there was no issues in transferring Resident #1 when one staff stood on one side of Resident #1 and another staff stood on the other side of Resident #1. She stated the staff on the left side was the one observing the left foot to ensure the left foot did not hit anything or drag on the floor during the transfer. CNA M stated Resident #1 would sometimes put her left foot on the floor during transfer and this is when the staff would reposition her foot. She stated if staff left room between the wheelchair and the bed it was very easily for one staff to be on each side of Resident #1. CNA M also stated Resident #1 would put some weight on her right foot but not all the time when she was assisted to the standing position. She stated Resident #1 left foot required to be watched the entire time of transfers due to having left foot drop and she could put her foot down and not have any control of the left foot. She stated this is why having one person on each side of Resident #1 was very important with her transfer. CNA M stated the staff did most of the transfers with Resident #1. She also stated it would be very difficult to transfer Resident #1 with one staff standing in front of her and one staff behind the wheelchair and hold onto her shirt or pants. She stated who would be observing the left foot and reposition it if needed. She stated Resident #1 left foot needed to be watched during the entire transfer process and someone may need to reposition the foot if it was dragging on the floor or if it hit the wheelchair. She stated unless someone was on each side of Resident #1 no one would be able to reposition the left foot if it was dragging. In an interview on 10/15/2023 at 11:16 AM, TNA N stated she had been a TNA approximately 4 months. She stated she had assisted in transferring Resident #1. She stated Resident #1 left foot would drop and she could not use very much weight on the left foot. She stated she would place her right foot on the floor, however, was not able to use right foot very much. She stated Resident #1 was a two staff person assist using a gait belt. TNA N stated the staff was required to do most of the work when transferring Resident #1. She stated Resident #1 had a left foot drop and the staff needed to watch the left foot when transferring Resident #1. She stated Resident #1 would hold her foot up a few inches off the floor but sometimes would put her left foot down during transfer and this is when the staff on the left side could reposition the left foot. She stated during transfers of Resident #1 one staff always watched her left foot to prevent it from dropping and getting caught in the wheelchair or anything during the transfer. She stated resident was very fragile and everyone needed to be extremely careful when transferring Resident #1. She stated if staff was standing behind Resident #1 and staff in front of Resident #1 that would be very difficult to transfer her due to someone needed to be on her left side to watch the left foot. In an interview on 10/15/2023 at 11:31 AM, the MDS Coordinator/LVN stated Resident #1 required extensive assistance with two staff using a gait belt to transfer Resident #1. She stated Resident #1was minimal weight bearing on right foot when standing. She stated Resident #1 had a left foot drop and was not capable of placing full weight on her left foot. The MDS Coordinator stated when transferring Resident #1 the right foot was expected to be next to the bed. She also stated if the right foot was next to the bed and when staff transferred Resident #1 there was less chance of the left foot getting caught on the wheelchair or dropping her foot on the floor during transfer. She stated one staff needed to be on each side of Resident #1 to observe the left foot and reposition it during transfer if needed. MDS Coordinator stated she had not transferred Resident #1 or observed anyone transfer Resident #1. She stated based on Resident #1's physical condition she needed someone to observe the left foot during transfers. She also stated if a staff was behind Resident #1 and a staff was in front of Resident #1 it would be very difficult for staff to observe the left foot during transfer. She stated with Resident #1 she believed transferring her with one staff on each side of resident was the most efficient transfer. She also stated if a staff made a statement of never transferring Resident #1 and asked Resident #1 what type of transfer did she require, she stated she would assume the staff did not know how to transfer Resident #1. In an interview on 10/15/2023 at 11:45 AM,RN O stated she began working at the facility on 09/16/2023 and 09/17/2023. She stated Resident #1 did not complain of any type of pain in her left leg or left knee the entire weekend. She stated she had never transferred or observed Resident #1 being transferred. She stated she administered medication to Resident #1. She stated all staff should be familiar with what type of transfers each resident required before attempting to transfer a resident. RN O stated the staff was expected to view the electronic medical record to gather information on transfers. She stated it was not appropriate to ask a resident what type of transfer they required and ask if the resident needed a gait belt. She stated any resident may become confused at that time and may give the correct information. In an interview on 10/15/2023 at 12:10 PM, the ADON stated she did not know about Resident #1 weight bearing on either foot. She stated she knew she was receiving PT. The ADON looked at the electronic medical records and reviewed the Physician Orders and stated Resident #1 was not on PT she was on OT. She stated she had not observed any staff transferring Resident #1. She also stated Resident #1 was a two person assist during transfers. ADON stated she expected there be one staff on each side of Resident #1. She stated one staff needed to watch Resident #1's left foot to prevent the left foot from dragging. ADON stated Resident #1's right foot should be next to the bed. She stated during transfer the left foot would not become tangled on the wheelchair or anything else. ADON also stated the therapy department did proper transfers. ADON stated if a staff is in front of Resident #1 and a staff is behind Resident #1 wheelchair during a transfer this would not be considered a proper transfer. In an interview on 10/15/2023 at 2:50 PM, the Administrator stated the facility could not be held responsible for the actions of any employee if the employees did not perform their job correctly. She stated if the staff had been in serviced and received training the facility did all they were required to do, and the facility did nothing wrong. She stated the employees are the ones that needs to be corrected and not the facility. She stated the facility was not responsible for the employees' actions. The Administrator stated she was not clinical and did not know anything about transfers and what was required of transfers. She stated she was the administrator and not clinical whenever asked about the facilities protocol of transfers, injuries, and investigations of injuries. She stated that was clinical responsibility. In an interview on 10/18/2023 at 10:00 AM the Director of Rehabilitation stated Resident #1 was on her caseload for OT. She stated Resident #1's right leg was full weight bearing. She also stated Resident #1 was able to put weight on her left foot as tolerated during therapy sessions. She stated transferred Resident #1 without any other staff assisting her. She stated it was different when residents were in therapy than when the resident was being transferred by CNAs or Nurses. Rehab Coordinator stated she did attend care plans and had attended care plan on Resident #1 and did make suggestions. She stated anytime a staff made suggestions it was discussed as a group. Rehab Coordinator stated she was not required to follow Resident #1's care plan or any residents care plan. The therapy department was not a part of the facility. She stated she did not know what was written on Resident #1's care plan. Rehab Coordinator stated she did attend Resident #1's care plan meetings. She stated she did not know how to answer the question when asked if therapy was expected to follow the facilities care plans. Rehab Coordinator also stated the therapy department was expected to follow Resident #1's care plans. She stated any transfer with Mrs. Hill needed to be very observant during the entire transfer. She stated if a staff asked a resident how they are transferred and if the resident required a gait belt, she believed the staff did not know what type of transfer the resident required. She also stated Resident #1 could be transferred from the front and from the back of the wheelchair. She stated if Resident #1 left leg was dragging or got caught on something the person behind the wheelchair would need to move the wheelchair out of the way to reposition Resident #1's left leg. She also stated there was a possibility of an injury during a transfer with Resident #1 related to her being so fragile. In an interview on 10/18/2023 at 11:35 AM, the Director of Nurses (DON) stated Resident #1 required two staff assistance using a gait belt She stated Resident #1 was very fragile and had left foot drop. She stated during a transfer with Resident #1 her left foot was expected not to be next to the bed. She stated there needed to be enough room between the bed and wheelchair where one person would be on each side of Resident #1. The Director of Nurses stated one staff needed to observe Resident #1's left foot during the transfer to ensure Resident #1 did not drag or hit anything. She stated with the one staff observing the left foot the staff could reposition the left foot as needed or stop the transfer and assist resident to the wheelchair until Resident #1 was ready for the transfer. She stated if staff was behind the resident and staff in front of the resident, she would consider this a one person transfer. She stated with Resident #1 she needed someone to watch the left foot and be able to get to the left foot if it was dragging on the floor or was caught in the wheelchair or anything could happen and someone would need to immediately reposition the left foot She stated if staff was behind the wheelchair during the transfer it would be very difficult for that person to move the wheelchair to reposition Resident #1's left foot. Director of Nurses also stated all staff including therapy was expected to follow residents care plans. She stated therapy care was on the facilities care plans in the electronic medical records and they were expected to follow care plans. In an interview on 10/18/2023 at 2:17 PM, the MDS Coordinator/LVN stated the Therapy Coordinator had attended Resident #1's care plan meetings. She stated all staff in the facility including therapy was expected to follow facilities care plans. She stated she had not been informed of the Therapy Department not attending care plan meetings or follow what is documented on the resident's care plans including transfers. She also stated therapy department has their own interventions on resident problems. MDS Coordinator/ LVN stated the Therapy Coordinator attends care plan meetings and makes suggestions and the suggestions is discussed during the meetings with the interdisciplinary team. In an interview on 10/19/2023 at 10:50 AM, CNA P stated she was not working at this facility when Resident #1 was residing at the facility. She stated she had been a CNA since 1996 and received a lot of training on transfers. She stated she was never taught in all the years of being a CNA for one staff stand behind the wheelchair and a staff stand in front of a resident during a transfer. She stated if a staff is behind the wheelchair and resident had issues with their foot/ leg it would be difficult for the person behind the wheelchair to observe the foot/leg to ensure the leg/foot was not caught on wheelchair or anything during the transfer. CNA P stated the weaker foot needed to be away from the bed and the foot without any issues needed to be next to the bed. She stated that is how she was taught to transfer a resident with weakness or unable to have full weight bearing on a particular foot/ leg. In an interview on 10/19/2023 at 1:15 PM, the Administrator stated I am not answering any questions about transfers. I am not clinical and not responsible for training on transfers. She stated she was in serviced on 10/18/2023 of how to transfer residents using Hoyer lift, two person assist with gait belt and one person assist. She stated she would not answer any questions about transfers related to Resident #1. The administrator left the conference room before finishing the interview. Record review of the facility's policy on Gait Belt Transfer Techniques dated July 2017 reflected two person stand pivot transfer to be utilized when transferring residents who can bear weight through at least one lower extremity and require the assistance of two persons due to weakness, confusion, or weight: 1. Place the gait belt around the resident's waist securely. 2. Bring resident to upright position and to the edge of the surface where they are seated. 3. Place the transfer surfaces at a 45 degree angle to one another and secure breaks. 4. One person stands in the space between the wheelchair and the transfer surfaces ( to the side of the resident) 5. The other person stands in front of the resident to block the knees. 6. Reach around the resident and grasp the belt in the mid back area (avoid grasping on the side due to risk of injury) 7. Assure that the residents' feet are placed firmly on the floor. 8. Bring the resident forward close to your trunk and shift your weight backward while pulling/ guiding the resident up. 9. The person on the side will grasp onto the gait belt and guide the pelvis to the transfer surface. 10. Cue the resident to shift his/her weight and move the feet in small steps towards the transfer surface. 11. Guide/gently lower the resident on to the transfer surface. 12. If needed, the person on the side can move back on the surface while the person in front guides the knees. 13. Once the resident is seated/ positioned safely, remove the gait belt. The Administrator and Director of Nurses was notified on 10/18/2023 at 4:39 PM that an Immediate Jeopardy had been identified due to the above failure and an IJ template was provided. The POR was requested at this time. The following POR was accepted on 10/19/2023 at 10:40 AM and indicated the following: On 09/21/2023 an abbreviated survey was initiated at (facility). On 10/19/2023 at 4:39 PM the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Threat states as follows: On 09/21/2023 an abbreviated survey was initiated at facility. On 10/19/2023 the surveyor provided an Immediate Threat (IT) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. Investigate Accidents and Hazards applies treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Action Taken: Monitoring was completed from 10/19/2023 and was as follows: Immediately, the two employees who were reported to have improperly transfer on the video viewed by HHSC were suspended pending investigation. Immediately, on October 18, 2023, all residents plan of care were validated by assessing resident transfer status to ensure they are receiving proper transfer and assistance and Kardex reflects the appropriate level of care by Corporate Clinical Specialist Immediately, on October 18, 2023, Physical Therapist Area Director of Operations in serviced Director of Rehab, DON, and ADON on resident transfers to include policy and procedure for on one person , two person, and Hoyer transfers to follow resident plan of care for transfers and repositioning. In-service will include staff education regarding what to do in the event of an acute change of condition or injury during a transfer. Education to include escalation if the nurse does not respond including calling for alternate nurse, DON, Administrator, or 911 as needed. Training and competency validation by return demonstration for DOR/DON/ ADON was completed on 10/18/2023 by using the transfer, mobility, repositioning techniques checkoff. Training on resident transfers to include policy procedure on one person, two person, and Hoyer transfers staff education regarding what to do in the event of an acute change of condition or injury during a transfer. Education to include escalation if nurse does not respond including calling for alternate nurse, DON, ADM, or 911 as needed material will be incorporated into the new hire nursing orientation by DON/Designee effective October 18, 2023, and ongoing. DON/Designee will monitor compliance of resident transfers by performing observations and competency validation on 2 staff per week for 12 weeks, then every other week for 12 weeks. Thereafter, DON/Designee will monitor residents for safe transfers once monthly for 3 months. DOR/DON/Designee compliance will be monitored weekly by Corporate clinical nurse for 90 days. Thereafter, QA will monitor quarterly for up to a year for compliance. If any issues are identified the employee will be taken off the floor and retrained unt [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (Resident #1) of five residents reviewed for quality of care. The facility failed to assess and obtain x-ray when Resident #1 began complaining acute pain and her knee/leg was broken in her left leg. The facility failed to order x-ray on 09/18/2023. An Immediate Jeopardy (IJ) situation was identified and on 09/21/2023 and Immediate Jeopardy template was presented to the facility on [DATE] at 3:37 PM. While the IJ was removed on 09/23/2023 the facility remained out of compliance at a severity level of actual harm at a scope of isolation due to staff needing more time to monitor the plan of removal for effectiveness. This failure placed residents at risk for potential delay in medical intervention, uncontrolled pain, decline in health and a decreased quality of life. Findings included: Record review of Resident #1's face sheet, dated 09/22/2023, revealed Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses which included low back pain ( pain between the lower edge of the ribs), signs symptoms of musculoskeletal system ( mild to severe aches, low back pain, numbness, tingling, atrophy, and weakness), muscle weakness ( a lack of strength in the muscles), osteoporosis without current pathological fracture (generally caused by a fall from a standing height or lower and usually involves the spine, hip or wrist), lack of coordination (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements) left foot drop ( caused by weakness of the muscles involved in lifting the front part of the foot) and, abnormalities of gait and mobility (when a person is unable to walk in the usually way). Record review of Resident #1's Annual MDS assessment, dated 07/28/2023, reflected Resident #1 had a BIMS score of fifteen, which indicated the residents' cognition was intact. Resident did not reject care. Resident #1 was assessed to require extensive assistance by two staff members for transfers. She required extensive assistance by one staff for bed mobility and toileting. Resident #1 was also assessed to require limited assistance by one staff for personal hygiene. She was assessed require staff to stabilize her when moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer. Resident #1 was on scheduled pain medication and PRN pain medication. She had frequent pain. Resident #1 did not exhibit any behaviors. Record review of Resident #1's Comprehensive Care Plan completed on 08/17/2023 reflected Resident #1 had an ADL self-care performance deficit. Interventions: resident required extensive assistance by two staff members. Resident #1 required extensive assistance by one staff members with bed mobility. Resident #1 was at risk for falls related to gait/balance problems. She had limited physical mobility. Resident had chronic pain related to osteoporosis (a condition when bone strength weakens) Interventions: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Identify and record previous pain history and management of that pain and impact of function. Identify previous response to analgesia including pain relief, side effects and impact on function. Monitor/ document for probable cause of each pian episode. Remove/limit causes where possible. Resident #1's further interventions were: Monitor/document for side effects of pain medication. Administer analgesia as per orders. Give 1/2 hour before treatments or care. Notify the physician if interventions are unsuccessful or if current complaint is a significant change from resident's experience of pain. Provide the resident and family with information about pain and options available for pain management. Discuss and resident preferences . Record review of Resident #1's nurses notes dated 09/18/2023 at 6:50 PM, reflected pain medication was given by mouth every four hours for pain. Resident #1 complained of left knee pain and requested pain medication. Record review of Resident #1's nurses notes dated 09/18/2023 at 8:10 PM, reflected the MD was notified of resident complain of pain to the left knee and left knee slightly swollen, awaiting return call. Record review of Resident #1's nurses notes dates 09/18/2023 at 9:14 PM, reflected the MD returned call and received an order for an x-ray to left knee. Record review of Resident #1's nurses notes dated 09/18/2023 at 11:41 PM, reflected pain medication was given by mouth every four hours as needed for pain. Resident #1 reported pain to knee. ( Did not specify which knee). Record review of Resident #1's nurses note dated 09/19/2023 at 1:05 AM, reflected the pain medication was effective and follow-up pain scale was zero Record review of Resident #1's nurses note dated 09/19/2023 at 4:15 AM, reflected the pain medication was given to the resident. Resident #1 complaining of pain in left knee and requested pain medication. Record review of Resident #1's nurses note dated 09/19/2023 at 8:09 AM, reflected report received from LVN A concerning Resident #1 had an order for left knee x-ray. LVN B notified the X-ray company and was informed x-ray company would be at the facility as soon as possible. Resident aware. Signed by LVN B Record review of Resident #1's nurses note dated 09/19/2023 at 10:05 AM, reflected Was the resident in pain? 0-no pain, 1-3 - mild, 4-6- moderate, 7-10- severe. Every shift follows MD orders. Resident #1 complained of pain to left knee. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:06 AM, reflected pain medication administered. Give one tablet by mouth every four hours as needed for pain. Record review of Resident #1's nurses notes dated 09/ 19/2023 at 10:26 AM, reflected the X-Ray company was unable to do the x-ray at the facility for resident #1 left knee. Resident #1 will be transferred via EMS to a hospital for x-ray to left knee. Resident #1 aware and notified family. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:44 AM, reflected EMS at the facility to transport resident to hospital. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:47 AM , reflected the pain medication was ineffective and follow-up pain was a five. Resident #1 transferred to emergency room for evaluation and treatment. Record review of Resident #1's hospital records from the emergency room hospital A dated 09/19/2023 reflected Resident #1 was transferred by EMS with a complaint of knee pain. She was being transferred between the bed and wheelchair yesterday (09/18/2023) in the facility where she resided when her knee twisted and then became painful and swollen. EMS reported she was given 7.5 milligram of pain medication this AM (09/19/2023) for pain. The EMS did not know the time the pain medication was administered. Admission: Urgent, Admission Source: Nursing Home. Nursing Assessment: extremity lower. There was obvious swelling to the knee and there appeared to be slight angulation (two ends of the broken bone are at an angle to each other) of the leg. No bruising or open wounds noted to the knee. Record review of Resident #1's doctors notes from the emergency room Hospital A dated 09/19/2023 reflected Resident #1was transferred to the hospital on 09/19/2023 from the nursing home where she resided. On 09/18/2023 Resident #1 was being rotated out of her wheelchair when the staff heard a popping noise from her left knee, and she had called out in pain. The staff noticed on 09/19/2023 the knee continued to be swollen and very painful for the patient when she was moving her knee. Resident #1 was transferred to emergency room for evaluation for possible knee dislocation or knee fracture or any injury. Resident #1was able to express that she felt a significant amount of pain when her left knee was mobilized. The x-ray result reflected Resident #1 had traumatic fracture of the distal femur ( where the bone flares out like an upside-down funnel). Record review of Resident #1's emergency room clinical course and plan reflected, Resident #1 had a distal femur fracture. The fracture was acutely comminuted fracture (a type of fracture where broken bones fracture into more than three separate pieces). Resident #1's pain was under control if the leg was immobile. Two rigid boards were placed on the side of the knee and an ace bandage was used to wrap around the knee for compression and stability. Resident #1 would be transferred to a hospital with orthopedics. Resident #1 required a higher level of care. Record review of Resident #1's emergency room history and physical from a hospital B dated 09/20/2023 reflected chief complaint of Resident #1: Left knee pain after hearing a pop, being lifted from wheelchair to bed. Resident #1 was transferred from the nursing home following left knee pain during the time when the staff were trying to transition her from her wheelchair to her bed. There was a popping noise and Resident #1 had immediate pain. Resident #1 was seen today (09/20/2023) in the hospital bed with her left leg splinted. Imaging studies reflected: X-ray of the left knee, two views reflected impression, acute mildly comminuted fracture of the distal femur medtadiaphysis (a type of fracture where broken bones fracture more than three separated places - medtadiaphysis is a term used to describe the combined region of a long bone and the shaft of the bone. Lesions that span both regions). Plan: to admit to surgical unit. Record review of Resident #1's pain assessments reflected there was only one pain assessment completed from 07/21/2023 through 09/19/2023. Record review of Resident #1's pain assessment dated [DATE] reflected Resident #1 had been in pain for the past five days. She frequently had pain. Resident #1 was assessed she had difficulty completing her day-to-day activities as related to her pain. Her pain was moderate. Resident #1 was on scheduled pain medication. Signed by MDS Coordinator. Record review of the Daily Nurses Schedule for 09/18/2023 for the 6:00 PM - 6:00 AM shift reflected LVN A was the only nurse in the facility. The staff did not have another nurse in the facility to report of Resident #1's pain and knee swelling. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 05:52 PM COTA/ Marketing Coordinator and PTA began to transfer Resident #1 from her wheelchair to her bed. Resident #1 was not yelling or complaining about pain. Resident #1 was transferred to her bed and as soon as she sat on the bed, she began to yell my knee is hurting my knee is broken. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 05:53 PM Resident #1 was yelling my knee is hurting and my leg broken. Resident #1 began to rub her left leg as she continued to yell. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 Resident #1 continued to yell when staff would touch her left leg or move her left leg. Resident would scream she was hurting. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 6:00 PM, Resident #1 stated you ( PTA) turned me around and Resident #1 was looking at PTA as she made this statement. The PTA stated, we did not mean to hurt you. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 7:58 PM, CNA H was in Resident #1 room she lifted Resident #1 left leg up and Resident # 1 began to scream, and CNA let the left leg fall onto the bed and began to exit Resident #1 room. CNA H was not providing care to Resident #1. Resident #1 was screaming the entire time she lifted her leg and when she lowered the left leg on the bed. Resident #1 was not yelling prior to CNA H picking up her leg. She stated as she was walking out Resident #1's room , you have that camera in your room, and you are acting all crazy. In an interview on 09/20/2023 at 2:41 PM the COTA/ Marketing Coordinator stated she heard Resident #1 yelling for help around 6:00 PM on 09/18/2023. She stated when she entered Resident #1 room approximately 6:05 PM Resident #1 was needing assistance to be transferred to bed from her recliner. She stated she explained to resident she needed to find a gait belt and get someone to help her with the transfer. The COTA/ Marketing Coordinator stated she asked the PTA C to assist her transferring Resident #1. She stated PTA assisted her with Resident #1's transfer from the recliner to wheelchair. She stated Resident #1 complained about back pain. COTA/Marketing Coordinator also stated Resident #1 wheelchair was positioned beside the bed to transfer onto her bed. She stated she was in front of the resident, and they placed the gait belt on resident and assisted her from the wheelchair and pivoted resident for her to sit on the bed. She stated resident was not yelling during the transfer, however, within a few seconds of resident sitting on the bed the resident began to yell my knee hurts. She stated Resident #1 repeated stating her knee hurts. COTA/ Marketing Coordinator stated she and the PTA C assisted resident to lie in bed in supine position and this is when she noticed Resident #1's knee begins to swell. She stated Resident #1 complained of her pain being at 10 on a pain scale of 0 being in no pain to 10 being in extreme pain. She stated the PTA stayed in the room and she left the room to report this to the LVN A approximately 6:30 PM She stated LVN A did not go to Resident #1's room to assess resident. She stated LVN A was at her nurses' cart preparing to administer medications. She stated she explained to LVN A Resident #1 was in extreme pain in her left knee and the knee was swelling. She stated she stayed at the facility until she knew Resident #1 was going to be seen by the nurse. She stated it was approximately 8:30 PM when the nurse entered Resident #1's room for the first time after reported to LVN A of Resident being in pain. She stated she did become frustrated with LVN A ignoring Resident #1 pain and knee swelling that she told her just give me the medicine and she will give it to her. She stated she could not stand to see Resident #1 in pain any longer and the nurse would not come to the Resident #1's room. The COTA/ Marketing coordinator stated she got the pain medication from the nurse and took it to Resident and gave the pain medication to Resident #1. She stated she reported to LVN A Resident #1 was complaining her leg/knee was broken and LVN A stated resident is always complaining about something hurting this was not anything new. The COTA/ Marketing Coordinator stated she was so upset because she stated she kept reporting to LVN A about Resident #1's condition with her left knee and she continued to ignore her. She also stated she called the Administrator on 09/18/2023 ( did not recall the time). She stated she informed the Administrator of Resident #1 had pain and swelling in the left knee. She stated the Administrator advised her to speak with the nurse and explain to the nurse to call the MD and have x-rays ordered. She stated she spoke with LVN A and explained the Administrator stated to call the MD and have x-rays ordered. She stated LVN A was organizing to pass out medications and began to pass medications and there was not an emergency occurring where she could not stop what she was doing and come to Resident #1's room. She stated she did not feel comfortable leaving Resident #1 on 09/18/2023 due to LVN A not coming to Resident #1's room to complete an assessment on her or giving her pain medication when Resident #1 was in pain more than an hour before LVN D gave me the pain medication to give to Resident #1. She stated she had to do something because Resident #1's left knee swelling was increasing, and the pain was getting a lot worse. She also stated LVN A stated Resident #1's left knee doesn't look any different than it has in the past. LVN A told COTA/Marketing Coordinator and PTA C to go home she had this and promised to take care of Resident # 1. The PT/Marketing Coordinator stated when she came on duty on 09/19/2023 the ambulance was in front of the facility transferring Resident #1 to the hospital for x-rays. She stated she saw Resident #1 being transferred to the ambulance. She stated she was shocked and could not believe LVN A allowed Resident #1 to remain in the facility that night without getting an x-ray or doing anything to ensure Resident #1 did not have any broken bones. She stated after she got home, she was afraid Resident #1 might have known she had a broken bone, and she may lie in the bed all night without any treatment. In an interview on 09/20/2023 at 8:11 PM Resident #1's family member stated he reviewed the video in Resident #1's room from his house. He stated on 09/18/2023 when the COTA and PTA transferred Resident #1 from the wheelchair to the bed Resident #1 began yelling as soon as she sat on the bed that her knee was hurting, and her leg was broken . He stated she was rubbing her left leg. He stated the COTA and PTA C assisted the resident in her bed and she continued to yell. He stated his concern was the staff allowed Resident #1 to lay in the bed until the next day in pain and complaining her leg was broken and they did not do anything but put an ice pack on her knee and put a small pillow under her left knee. He also stated everything was on the video of what occurred, and the facility failed to provide Resident #1 care when she was in extreme pain and complaining her leg was broken. In an interview on 09/21/2023 at 11:00 AM, attempted to contact LVN A and was unable to leave message. LVN A was in the facility when Resident #1 was in pain. In an interview on 09/21/2023 at 11:05 AM, attempted to contact CNA H and left voice message of name, agency, and phone number. CNA H was in Resident #1 room for a short time when Resident #1 was in pain on 09/18/2023 In an interview on 09/21/2023 at 11:10 AM, attempted to contact CNA I and left voice message of name, agency and phone number . CNA I was in the facility and was in Resident #1's room when she was in pain. In an interview on 09/21/2023 at 12:00 PM, PTA C stated the COTA/ Marketing Coordinator asked her to help her to transfer Resident #1 from her recliner to the wheelchair and then to the bed. She stated this occurred approximately 6:00 PM. She stated Resident #1 was transferred from the recliner to the wheelchair and Resident #1 complained about her back hurting after the transfer. She stated Resident #1 was assisted by the bed in her wheelchair to prepare for the transfer from the wheelchair to the bed. She stated once Resident #1 was in her wheelchair by the bed she was calm and quit complaining about her back hurting. PTA C stated the COTA/ Marketing Coordinator was in front of resident and placed the gait belt around the resident waist. She stated they began to transfer Resident #1 to the bed and as soon as they pivoted Resident #1 onto the bed, she began to yell my knee hurts. PTA C stated she assumed it was similar of her complaining about her pain in her back. She stated Resident #1 at some point stated her left leg was broken. PTA C also stated she realized this was a different type of pain than what she has complained in the past. She stated COTA/ Marketing Coordinator left the room to report to LVN A. She stated they kept waiting on pain medication or the nurse to come assess Resident #1 due to her knee continued to swell and was becoming larger. She stated Resident #1 would yell in pain when her leg was barely touched or moved. Resident #1 would rub her knee and below the knee onto her left leg and stated it was broken. PTA C stated LVN A would not come to Resident #1 room to give her pain medication or assess her. She stated the nurse gave COTA/ Marketing Coordinator the pain medication and the COTA/ Marketing Coordinator gave Resident #1 pain medication. PTA C stated she did not recall the time, but she thought it was around 7:00 PM. She stated LVN A entered Resident #1's room approximately 8:30 PM. She stated she was in the room while LVN A talked to Resident #1. PTA C stated LVN A looked at Resident #1's knee approximately 5 seconds and stated her knee is fine. PTA C stated LVN A did not assess Resident #1 or ask her if she hurting in other areas. She stated LVN A did not ask Resident #1 what her pain level was or if the pain medication was effective. She also stated LVN A did not realize PTA C was in the room. PTA C stated when LVN A saw her in the room she stated oh are you a family member I didn't know anyone was in the room. PTA C stated no I am not a family member I am a Physical Therapist Assistant at this facility, and I helped assist Resident #1 to be when she began complaining about her knee. PTA C stated LVN A did not ask her any questions about the transfer or anything about Resident #1. PTA C stated she informed LVN A that she and COTA/ Marketing Coordinator had been in the room with Resident #1 since around 6:00 PM after she began complaining about pain in left knee and stating her left leg was broken. She stated LVN A walked out of the room and stated she is fine she always complains about pain. She also stated LVN A was preparing to pass out medications and began to pass out meds to residents and there was not an emergency. LVN A could have stopped what she was doing and came to Resident #1's room. She also stated LVN A stated Resident #1's left knee does not look any different than it has in the past. LVN A told the COTA/Marketing Coordinator and the PTA C to go home she had this and promised to take care of Resident # 1. In an interview on 09/21/2023 at 2:45 PM the Administrator stated the COTA/ Marketing Coordinator contacted her on 09/18/2023 in the evening. She stated she did not recall the exact time. She stated was informed Resident #1 had pain and some swelling in her left knee. She stated she asked COTA/Marketing Coordinator to inform the nurse to contact the physician and have an x-ray ordered. The Administrator stated anytime a Resident complains of pain whether it is an old or new pain she expected a pain assessment to be completed. She stated LVN A was expected to assess Resident #1 and ask the staff questions and contact the DON with the information. She stated LVN A did not follow protocol of assessing Resident #1,completing a pain assessment, and asked questions reason Resident #1 knee began to swell and why Resident # 1 believed her leg was broken. The Administrator stated Resident #1 needed an x-ray on 09/18/2023 and if the x-ray company could not come to the facility, the nurse was expected to call MD and request for Resident #1 to be sent to the emergency room that night. She stated if Resident #1 was in pain and complaining of her left knee being broken on 09/18/2023, 911 needed to be called and EMS transfer her to the emergency room . She stated anytime a Resident complains of pain the nurse was expected to ask the resident where the pain was located , the level of the pain, and to document all this information in the nurses notes and complete a pain assessment. She stated if Resident #1 had a new pain after a transfer, the nurse was expected to ask the staff questions about the transfer, immediately do an assessment, and begin an incident report if needed. She stated the nurse was expected to contact the DON with the information and after she contacted the physician and call 911 to transfer Resident #1 to emergency room . The Administrator stated it was not best practice to have a resident in the facility from the night of 09/18/2023 until the morning of 09/19/2023 in pain with a possible left leg or knee fracture. She stated based on the information she learned today (09/21/2023) of Resident #1's new physical concerns she endured on 09/18/2023 Resident #1 was required to be assessed by a physician in the emergency room and have x-rays on her left leg and left knee as soon as possible on 09/18/2023. She stated the facility had protocols in place to ensure the residents were receiving the best care for their physical condition whether it was a new physical issue or an old physical issue. She stated the nursing staff on 09/18/2023 did not follow the facility's protocol and there was a system failure. She stated it was the DON's responsibility to monitor the nurses to ensure they were following protocol. In an interview on 09/22/2023 at 9:05 AM, LVN B stated Resident #1 did complain about pain frequently. LVN B stated if it was reported to the nurse that Resident #1 was in pain, she would have immediately assessed Resident #1. She stated LVN A did not follow proper protocol to ensure Resident #1 was receiving the medical care she needed the night of 09/18/2023. She stated Resident #1 needed to be transferred to the hospital on 09/18/2023 . LVN B stated she was the oncoming nurse after LVN A. In an interview on 09/22/2023 at 9:55 AM, LVN F stated if any staff reported a resident was having a new pain and their knee was swelling, she stated she would immediately go to that resident's room and assess the resident. She stated she would complete a pain assessment and if resident were in severe pain and has stated her leg was broken, she would contact the MD immediately and if the MD did not return call within 5 minutes, she would immediately call 911. She stated if a nurse did not complete an assessment on the resident or ask the other staff questions of what might have caused the knee to swell, she did not follow proper protocol. LVN F stated nurse was expected to assess residents whenever there is a change of condition and a new pain in the knee with it swelling and the resident yelling her leg was broken that is a change of condition. She stated she did not give care very often to Resident #1, but she did know Resident #1 would yell when she was only in pain. She stated Resident #1 should not have stayed in the facility all night if she said her left leg was broken if her left knee was swelling, and she was in extreme pain . She stated Resident #1 needed to be transferred to the emergency room the night of 09/18/2023. She stated anytime a resident voices pain to a nurse, or another staff reports a resident was in pain the nurses was to complete pain assessment. She stated the nurse was required to ask resident where the pain is located and the pain level using the pain scale of zero - not having any pain and ten- having extreme pain. She stated a nurse was expected to document this in nurses notes when they administer pain medication and if a resident is in pain an assessment was required to be completed. She stated LVN A was expected to go immediately to Resident #1's room to complete an assessment and if Resident #1 was complaining about extreme pain and stated her leg/ knee was broken, Resident #1 needed to be sent to the emergency room immediately. In an interview on 09/22/2023 at 10:30 AM, the ADON stated anytime a Resident had pain whether a new pain or an ongoing pain the nurse was expected to assess the resident and complete a pain scale with the resident. ADON stated pain scale was when zero - no pain and ten- extreme pain. She stated any time a resident reported pain the nurse was to complete a pain assessment and document in the nurses notes where the pain is located and the pain scale. She stated Resident #1 only had one pain assessment completed and it was completed at the time of the MDS Assessment. She stated Resident #1 did complain about pain frequently, however, she expected the nurses to complete pain assessments each time the resident had a pain higher than a zero. She stated the nurses will document pain once a shift on the MAR, however, that does not indicate the resident did not have any pain that shift. The ADON stated there was a pain assessment in the electronic medical record and it was expected for the nurses to complete pain assessment each time a resident complained of being in pain. She stated there was a possibility something else may be occurring with the residents' physical condition and completing an assessment it will ensure the nurse will not be missing any other acute physical issues with the resident. She stated if LVN A had completed a pain assessment on Resident #1 she would have known the extent of the pain and Resident #1 needed to be transferred to the hospital immediately. She also stated if it was reported to LVN A Resident #1 was complaining of her leg being broken the nurse was expected to call 911 immediately, contact the physician and the family. She stated there was a failure in the facility's protocol regarding Resident #1's care on 09/18/2023. In an interview on 09/22/2023 at 1:36 PM, attempted to contact LVN A and was unable to leave message. LVN A was in the facility when Resident #1 was complaining of pain and her left knee hurting Review of Resident #1's Facility Policy on Pain Management Program dated 01/2023 reflected the facility will ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management. The facility will assess everyone for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. The facility will identify the characteristics of pain such as location, intensity, frequency, pattern , and severity. The facility will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. The facility will evaluate how pain is affecting mood, activities of daily living, sleep, and the resident's quality of life, as well as how pain may be contributing to complications such as gait disturbances, social isolation, and falls. The interdisciplinary team will make attempts to determine root cause of the pain and collaborate with physician to conduct necessary diagnostics and evaluation to identify potential source of pain and determine plan of care. The Administrator and Director of Nurses was notified on 09/21/2023 at 3:37 PM than an Immediate Jeopardy had been identified due to the above failure and an IJ template was provided and POR was requested at this time. The following POR was accepted on 09/23/2023 at 7:38 AM: On 09/21/2023 an abbreviated survey was initiated at (facility). On 09/21/2023 the surveyor provided an Immediate Threat (IT) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Threat states as follows: On 09/21/2023 an abbreviated survey was initiated at facility. On 09/21/2023 the surveyor provided an Immediate Threat (IT) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Threat states as follows: F684: Quality of Care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. DON/Designee conducted pain assessment for all residents on September 21, 2023, to ensure that no other resident effected. Documents are in POR binder and uploaded to resident's chart. The facility will follow [NAME] [TRUNCATED]

Based on interview, observation and record review, the facility failed to implement their written policies and procedures that prohibit and prevent the abuse/neglect of residents for one Resident #1) of three residents reviewed for abuse and neglect. The facility failed to implement their abuse/neglect policy when LVN A was notified of Resident #1's pain and the administrator was notified of the incident by the COTAand the administrator failed to investigate the injury per policy. This failure could place residents at risk of abuse, neglect, physical harm, pain, mental anguish, emotional distress, and serious harm. Findings include: Record review of Facility Policy on Prohibition of Abuse, Neglect and Misappropriation of Property dated 05/01/01 reflected each resident had the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion, and financial abuse. The facility will investigate of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations. 1. Abuse means: the willful infliction of injury, withholding or misappropriating property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. 2. Verbal abuse is defined as the use of , oral, written, or gestured language that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Staff responsibility to immediately report any violations or alleged violations. 3. Neglect: was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The facility will track all occurrences, trends or patterns that could potentially constitute abuse or neglect. All incidences of unknown origin will be investigated. Record review of Resident #1's face sheet, dated 09/22/2023, revealed Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses which included low back pain ( pain between the lower edge of the ribs), signs symptoms of musculoskeletal system ( mild to severe aches, low back pain, numbness, tingling, atrophy, and weakness), muscle weakness ( a lack of strength in the muscles), osteoporosis without current pathological fracture (generally caused by a fall from a standing height or lower and usually involves the spine, hip or wrist), lack of coordination (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements) left foot drop ( caused by weakness of the muscles involved in lifting the front part of the foot) and, abnormalities of gait and mobility (when a person is unable to walk in the usually way). Record review of Resident #1's Annual MDS assessment, dated 07/28/2023, reflected Resident #1 had a BIMS score of fifteen, which indicated the residents' cognition was intact. Resident did not reject care. Resident #1 was assessed to require extensive assistance by two staff members for transfers. She required extensive assistance by one staff for bed mobility and toileting. Resident #1 was also assessed to require limited assistance by one staff for personal hygiene. She was assessed require staff to stabilize her when moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer. Resident #1 was on scheduled pain medication and PRN pain medication. She had frequent pain. Resident #1 did not exhibit any behaviors. Record review of Resident #1's Comprehensive Care Plan completed on 08/17/2023 reflected Resident #1 had an ADL self-care performance deficit. Interventions: resident required extensive assistance by two staff members. Resident #1 required extensive assistance by one staff members with bed mobility. Resident #1 was at risk for falls related to gait/balance problems. She had limited physical mobility. Resident had chronic pain related to osteoporosis (a condition when bone strength weakens) Interventions: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Identify and record previous pain history and management of that pain and impact of function. Identify previous response to analgesia including pain relief, side effects and impact on function. Monitor/ document for probable cause of each pian episode. Remove/limit causes where possible. Resident #1's further interventions were: Monitor/document for side effects of pain medication. Administer analgesia as per orders. Give 1/2 hour before treatments or care. Notify the physician if interventions are unsuccessful or if current complaint is a significant change from resident's experience of pain. Provide the resident and family with information about pain and options available for pain management. Discuss and record preferences. Record review of the Daily Nurses Schedule for 09/18/2023 for the 6:00 PM - 6:00 AM shift reflected LVN A was the only nurse in the facility. The staff did not have another nurse in the facility to report of Resident #1's pain. Record review of Resident #1's nurses notes dated 09/18/2023 at 6:50 PM, reflected pain medication was given by mouth every four hours for pain. Resident #1 complained of left knee pain and requested pain medication. Record review of Resident #1's nurses notes dated 09/18/2023 at 8:10 PM, reflected the MD was notified of resident's complaint of pain to the left knee and left knee was slightly swollen. Awaiting return call. Record review of Resident #1's nurses notes dates 09/18/2023 at 9:14 PM, reflected the MD returned call and ordered an x-ray to the left knee. Record review of Resident #1's nurses notes dated 09/18/2023 at 11:41 PM, reflected pain medication was given by mouth every four hours as needed for pain. Resident #1 reported pain to her knee. (Did not specify which knee). Record review of Resident #1's nurses note dated 09/19/2023 at 1:05 AM, reflected the pain medication was effective and follow-up pain scale was zero Record review of Resident #1's nurses note dated 09/19/2023 at 4:15 AM, reflected pain medication was given to the resident. Resident #1 was complaining of pain to her left knee and requested pain medication. Record review of Resident #1's nurses note dated 09/19/2023 at 8:09 AM, reflected report was received from LVN A concerning Resident #1 had an order for a left knee x-ray. LVN B notified the x-ray company and was informed the x-ray company would be at the facility as soon as possible. Resident aware. Signed by LVN B Record review of Resident #1's nurses note dated 09/19/2023 at 10:05 AM, reflected Was the resident in pain? 0-no pain, 1-3 - mild pain , 4-6- moderate pain , 7-10- severe pain. Every shift follows MD orders. Resident #1 complained of pain to left knee. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:06 AM, reflected pain medication was administered. Give one tablet by mouth every four hours as needed for pain. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:26 AM, reflected the x-Ray company was unable to do the x-ray at the facility for Resident #1's left knee. Resident #1 would be transferred via EMS to the hospital for an x-ray to her left knee. Resident #1 aware and the family was notified. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:44 AM, reflected EMS was at the facility to transport the resident to hospital. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:47 AM, reflected the pain medication was ineffective and follow-up pain was a five (moderately strong pain). Resident #1 was transferred to emergency room for evaluation and treatment. Record review of Resident #1's pain assessments reflected there was only one pain assessment completed from 07/21/2023 through 09/19/2023. Record review of Resident #1's pain assessment dated [DATE] reflected Resident #1 had been in pain for the past five days. She frequently had pain. Resident #1 was assessed she had difficulty completing her day-to-day activities as related to her pain. Her pain was moderate. Resident #1 was on scheduled pain medication. Signed by the MDS Coordinator. Record review of Resident #1's hospital records from the emergency room hospital A dated 09/19/2023 reflected Resident #1 was transferred by EMS with a complaint of knee pain. She was being transferred between the bed and wheelchair yesterday (09/18/2023) in the facility where she resided when her knee twisted and then became painful and swollen. EMS reported she was given 7.5 milligram of pain medication this AM (09/19/2023) for pain. The EMS did not know the time the pain medication was administered. Admission: Urgent, Admission Source: Nursing Home. Nursing Assessment: extremity lower. There was obvious swelling to the knee and there appeared to be slight angulation (two ends of the broken bone are at an angle to each other) of the leg. No bruising or open wounds noted to the knee. Record review of Resident #1's doctors notes from the emergency room Hospital A dated 09/19/2023 reflected Resident #1was transferred to the hospital on 09/19/2023 from the nursing home where she resided. On 09/18/2023 Resident #1 was being rotated out of her wheelchair when the staff heard a popping noise from her left knee, and she had called out in pain. The staff noticed on 09/19/2023 the knee continued to be swollen and very painful for the patient when she was moving her knee. Resident #1 was transferred to emergency room for evaluation for possible knee dislocation or knee fracture or any injury. Resident #1was able to express that she felt a significant amount of pain when her left knee was mobilized. The x-ray result reflected Resident #1 had traumatic fracture of the distal femur (where the bone flares out like an upside-down funnel). Record review of Resident #1's emergency room clinical course and plan reflected, Resident #1 had a distal femur fracture. The fracture was acutely comminuted fracture (a type of fracture where broken bones fracture into more than three separate pieces). Resident #1's pain was under control if the leg was immobile. Two rigid boards were placed on the side of the knee and an ace bandage was used to wrap around the knee for compression and stability. Resident #1 would be transferred to a hospital with orthopedics. Resident #1 required a higher level of care. Record review of Resident #1's emergency room history and physical from a hospital B dated 09/20/2023 reflected chief complaint of Resident #1: Left knee pain after hearing a pop, being lifted from wheelchair to bed. Resident #1 was transferred from the nursing home following left knee pain during the time when the staff were trying to transition her from her wheelchair to her bed. There was a popping noise and Resident #1 had immediate pain. Resident #1 was seen today (09/20/2023) in the hospital bed with her left leg splinted. Imaging studies reflected: X-ray of the left knee, two views reflected impression, acute mildly comminuted fracture of the distal femur medtadiaphysis (a type of fracture where broken bones fracture more than three separated places - medtadiaphysis is a term used to describe the combined region of a long bone and the shaft of the bone. Lesions that span both regions). Plan: to admit to surgical unit. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 05:52 PM COTA/ Marketing Coordinator and PTA began to transfer Resident #1 from her wheelchair to her bed. Resident #1 was not yelling or complaining about pain. Resident #1 was transferred to her bed and as soon as she sat on the bed, she began to yell my knee is hurting my knee is broken. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 05:53 PM Resident #1 was yelling my knee is hurting and my leg broken. Resident #1 began to rub her left leg as she continued to yell. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 Resident #1 continued to yell when staff would touch her left leg or move her left leg. Resident would scream she was hurting. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 6:00 PM, Resident #1 stated you ( PTA) turned me around and Resident #1 was looking at PTA as she made this statement. The PTA stated, we did not mean to hurt you. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 7:58 PM, CNA H was in Resident #1 room she lifted Resident #1 left leg up and Resident # 1 began to scream, and CNA let the left leg fall onto the bed and began to exit Resident #1 room. CNA H was not providing care to Resident #1. Resident #1 was screaming the entire time she lifted her leg and when she lowered the left leg on the bed. Resident #1 was not yelling prior to CNA H picking up her leg. She stated as she was walking out Resident #1's room , you have that camera in your room, and you are acting all crazy. In an interview on 09/20/2023 at 8:11 PM Resident #1's family member stated he witnessed from the camera in Resident #1's room on 09/18/23 at 5:51 PM staff breaking Resident #1's leg, Resident #1 complaining of pain and staff saying back to Resident #1 you know you're not hurt. You've complained about your back hurting before too and it was nothing. He stated staff did not call the family to notify them of the incident until 9/19/2023 at 10:44 AM and an ambulance was called to take Resident #1 to the hospital on 9/19/2023 at 10:44 AM. He stated there was also video of a CNA checking Resident #1's leg, picking the broken leg up and dropping it back on the bed and telling Resident #1 she was not hurt. Resident #1's family member also stated in the video after CNA dropped Resident #1 leg and began toward the door the CNA stated to Resident #1 you are crazy. He also stated the facility did not do anything for Resident #1 except give her pain medication she was already receiving. He stated he did not believe this medication helped Resident #1 due to Resident #1 continued to be in pain. He also stated Resident #1 was neglected and she needed to be in the hospital for x-rays immediately when Resident #1 began to yell she was in pain and her leg was broken. He stated she would rub on her left leg and by her expression from the video footage he noticed she was in pain. He stated he did not view the videos until 09/19/2023 after family received a phone call Resident #1 was going to be transferred to the hospital. He stated if he had seen the videos from Resident #1's room on 09/18/2023 he would have drove two hours to ensure she was getting the treatment she needed and was sent to the hospital immediately. He stated that was a new pain for Resident #1 and she had not been complaining about her knee. He also stated it was a new symptom for her knee to swell. In an interview on 09/20/2023 at 2:41 PM the COTA/ Marketing Coordinator stated she reported to LVN A on 09/18/2023 from 6:00 PM, until approximately 09/18/2023 at 8:25 PM of Resident #1 complaining of pain in knee and left leg. She stated she also reported to LVN A that Resident #1 was making statements her knee was broken. She stated she explained to LVN A Resident #1 was in severe pain. She stated LVN A made the remark that that is normal for Resident #1, she was always complaining about being in pain and that was nothing new. The COTA/ Marketing Coordinator stated LVN A was informed of the information at approximately 6:10 PM and LVN A did not go to Resident #1's room until approximately 8:30 PM. She stated either she or the PTA was always in Resident #1's room from around 6:00 PM until 8:45 PM. She stated LVN A would not go to Resident #1's room to administer pain medication and the resident was in pain for at almost 2 hours. She stated she asked LVN A to give her the pain medication and she would administer it to Resident #1. She stated LVN A gave her the pain medication (narco) and she gave it to Resident #1. She stated she could not sit by and watch Resident #1 be in pain for an hour or more and the nurse refused to go to Resident #1's room due to believing Resident #1 was complaining for no reason. She stated it was difficult to even talk to LVN A due to her expressing no compassion towards Resident #1 and not wanting to assess her to determine if anything was wrong with Resident #1. She also stated she called the Administrator on 09/18/2023 ( did not recall the time). She stated she informed the Administrator of Resident #1's pain and swelling in the left knee. She stated the Administrator advised her to speak with the nurse and explain to the nurse to call the MD and have x-rays ordered. She stated she spoke with LVN A and explained the Administrator stated to call the MD and have x-rays ordered. She stated LVN A was organizing to pass out medications and began to pass medications and there was not an emergency occurring where she could not stop what she was doing to go to Resident #1's room. She stated she did not feel comfortable leaving Resident #1 on 09/18/2023 due to LVN A not going to Resident #1's room to complete an assessment or make any type of observation of why Resident #1 was in extreme pain. She stated Resident #1's left knee continued to become larger, and she was going to report Resident #1's condition approximately every 10 minutes and the nurse stated to the COTA/Marketing Coordinator that Resident #1 was ok, that is the way Resident #1 always was and there was not anything wrong with Resident #1. She stated around 8:30 PM LVN A entered Resident #1's room and stated Resident #1's left knee does not look any different than it has in the past. The COTA/Marketing Coordinator stated that LVN A informed her and PTA C to go home, she had this and promised to take care of Resident # 1. She stated LVN A did not assess Resident #1. The COTA/Marketing Coordinator stated when she came on duty on 09/19/2023 the ambulance was in front of the facility transferring Resident #1 to the hospital. She stated she was shocked and could not believe LVN A allowed Resident #1 to remain in the facility that night without getting an x-ray or doing anything to ensure Resident #1 did not have any broken bones. The COTA/Marketing Coordinator stated she did believe LVN A was neglecting Resident #1. She stated LVN A refused to go to Resident #1's room and complete an assessment approximately 2 hours after being informed of Resident #1's left knee/ leg pain and Resident #1 stating she thought her leg was broken. She stated she was upset, and the nurse ignored her whenever she reported anything about Resident #1. She stated LVN A neglected Resident #1 on 09/18/2023. In an interview on 09/20/2023 at 3:41 PM LVN D stated Resident #1 yelled out frequently. She stated when she was yelling, she was in pain. LVN D stated resident complains about her back hurting. She stated everyone knew Resident #1 yelled frequently when she was in pain. She stated there were times when she was speaking to Resident #1, and she was complaining/ yelling with pain, and she would administer her ordered pain medication without asking Resident #1 where she was hurting or her pain level. She stated she has not ever completed a pain assessment on Resident #1 but now she realized she was required to complete pain assessment and document in nurses notes about Resident #1's pain. She also stated the nurses was expected to ask where the pain was located and the pain level on a scale of zero-ten. She stated zero - no pain and ten- extreme pain. She stated due to Resident #1 complaining about pain all the time the nurses would give her the pain medication if it was scheduled and not ask her any questions. She stated if she had been working on the night of 09/18/2023 and Resident #1 was complaining about pain in her knee she would have given her pain medication and probably would not have asked any questions or completed any type of incident reports or pain assessments due to this was how Resident #1 she was always complained about pain. She stated this was her normal behavior. LVN D stated resident did not have any behavior problems. She stated she would yell but only when she was in pain. She stated Resident #1 was cooperative with staff and did not have any behavior issues. LVN D stated she has given care to Resident #1 numerous times. She stated it varied from week to week, but she was very familiar with Resident #1 physical condition, moods, and behaviors. She also stated when Resident #1 was in pain she did not assess the resident to determine if it was a new pain or pain from her back. She stated everyone in the facility was aware if Resident #1 was in pain she will yell, and we don't assess the pain very closely when giving pain medication. She stated we give her anti -anxiety medication to prevent her from yelling. She also stated she did not believe any assessment was required when she was yelling about pain in her knee. She stated she was not working on 09/18/2023 but she would not have completed a pain assessment on resident. She also stated if a nurse was informed by staff over an hour that Resident #1's knee had increased in size due to swelling, Resident #1 was yelling in pain and Resident #1 stated she thought she broke her leg/knee, a nurse was expected to go to that room immediately due to that was a new pain for Resident #1; and anytime a resident stated they thought their leg/knee was broken that was serious. She stated if a nurse did not visit Resident #1 immediately after allegedly being informed every 10 minutes of her change in physical condition, that would be considered neglect. She stated unless there was an emergency with another resident. She stated a nurse could not ignore when staff was concerned about a resident's physical condition, and they felt there was a major concern for resident's physical health. She stated if a nurse continued to refuse to go to Resident #1's room for almost 2 hours, they did neglect Resident #1. She stated if the staff did not know why Resident # 1's knee was swelling, very painful to touch and Resident #1 allegedly stating her leg was broken, that would be considered an injury of unknown origin and would need to be investigated. In an interview on 09/21/2023 at 11:00 AM, attempted to contact LVN A and was unable to leave message. LVN A was in the facility when Resident was in pain and complaining of her left knee hurting In an interview on 09/21/2023 at 12:00 PM, PTA C stated the COTA/ Marketing Coordinator asked her to help her to transfer Resident #1 from her recliner to the wheelchair and then to the bed. She stated this occurred approximately 6:00 PM. She stated Resident #1 was transferred from the recliner to the wheelchair and Resident #1 complained about her back hurting after the transfer. She stated Resident #1 was assisted by the bed in her wheelchair to prepare for the transfer from the wheelchair to the bed. She stated once Resident #1 was in her wheelchair by the bed she was calm and quit complaining about her back hurting. PTA C stated the COTA/ Marketing Coordinator was in front of resident and placed the gait belt around the resident waist. She stated they began to transfer Resident #1 to the bed and as soon as they pivoted Resident #1 onto the bed, she began to yell my knee hurts. PTA C stated she assumed it was similar of her complaining about her pain in her back. She stated Resident #1 at some point stated her left leg was broken. PTA C also stated she realized this was a different type of pain than what she has complained in the past. She stated COTA/ Marketing Coordinator left the room to report to LVN A. She stated they kept waiting on pain medication or the nurse to come assess Resident #1 due to her knee continued to swell and was becoming larger. She stated Resident #1 would yell in pain when her leg was barely touched or moved. Resident #1 would rub her knee and below the knee onto her left leg and stated it was broken. PTA C stated LVN A would not come to Resident #1 room to give her pain medication or assess her. She stated the nurse gave COTA/ Marketing Coordinator the pain medication and the COTA/ Marketing Coordinator gave Resident #1 pain medication. PTA C stated she did not recall the time, but she thought it was around 7:00 PM. She stated LVN A entered Resident #1's room approximately 8:30 PM. She stated she was in the room while LVN A talked to Resident #1. PTA C stated LVN A looked at Resident #1's knee approximately 5 seconds and stated her knee is fine. PTA C stated LVN A did not assess Resident #1 or ask her if she hurting in other areas. She stated LVN A did not ask Resident #1 what her pain level was or if the pain medication was effective. She also stated LVN A did not realize PTA C was in the room. PTA C stated when LVN A saw her in the room she stated oh are you a family member I didn't know anyone was in the room. PTA C stated no I am not a family member I am a Physical Therapist Assistant at this facility, and I helped assist Resident #1 to be when she began complaining about her knee. PTA C stated LVN A did not ask her any questions about the transfer or anything about Resident #1. PTA C stated she informed LVN A that she and COTA/ Marketing Coordinator had been in the room with Resident #1 since around 6:00 PM after she began complaining about pain in left knee and stating her left leg was broken. She stated LVN A walked out of the room and stated she is fine she always complains about pain. She also stated LVN A was preparing to pass out medications and began to pass out meds to residents and there was not an emergency. LVN A could have stopped what she was doing and came to Resident #1's room to complete an assessment. She stated if an assessment had been completed and LVN A would have went to Resident #1's room at approximately 6:10 PM she believed Resident #1 would have been sent to the hospital for evaluation that night. She stated she did believe LVN A was neglecting Resident #1. She stated the statements from LVN A was that Resident #1 was always like that and she was always complaining about something, and there was not anything wrong with her. She stated that was deliberate neglect from LVN A . In an interview on 09/21/2023 at 2:45 PM the Administrator stated the COTA/ Marketing Coordinator contacted her on 09/18/2023 in the evening. She stated she did not recall the exact time. She stated she was informed of Resident #1 had pain and some swelling in her left knee. She stated she asked COTA/Marketing Coordinator to inform the nurse to contact the physician and have an x-ray ordered. The Administrator stated anytime a Resident complains of pain whether it is an old or new pain she expected a pain assessment to be completed. She stated LVN A was expected to assess Resident #1 and ask the staff questions and contact the DON with the information. She stated LVN A did not follow protocol of assessing Resident #1,completing a pain assessment, and asked questions reason Resident #1 knee began to swell and why Resident # 1 believed her leg was broken. The Administrator stated Resident #1 needed an x-ray on 09/18/2023 and if the x-ray company could not come to the facility, the nurse was expected to call MD and request for Resident #1 to be sent to the emergency room that night. She stated if Resident #1 was in pain and complaining of her left knee being broken on 09/18/2023, 911 needed to be called and EMS transfer her to the emergency room . She stated anytime a Resident complains of pain the nurse was expected to ask the resident where the pain was located , the level of the pain, and to document all this information in the nurses notes and complete a pain assessment. She stated if Resident #1 had a new pain after a transfer, the nurse was expected to ask the staff questions about the transfer, immediately do an assessment, and begin an incident report if needed. She stated the nurse was expected to contact the DON with the information and after she contacted the physician and call 911 to transfer Resident #1 to emergency room . The Administrator stated it was not best practice to have a resident in the facility from the night of 09/18/2023 until the morning of 09/19/2023 in pain with a possible left leg or knee fracture. She stated based on the information she learned today (09/21/2023) of Resident #1's new physical concerns she endured on 09/18/2023 Resident #1 required to be assessed by a physician in the emergency room and have x-rays on her left leg and left knee as soon as possible on 09/18/2023. She stated the facility had protocols in place to ensure the residents was receiving the best care for their physical condition whether it was a new physical issue or an old physical issue. She stated the nursing staff on 09/18/2023 did not follow the facility's protocol and there was a system failure. She stated it was the DON's responsibility to monitor the nurses to ensure they were following protocol. She stated it was discussed in the morning meeting on 09/19/2023 about Resident #1's knee and leg. She stated it was discussed Resident #1 needed an X-Ray. She stated the staff was not interviewed and there was not any questioning of what happened to Resident #1's left knee or left leg. The Administrator stated after today ( 09/21/2023) she realized either she or the DON needed to complete an investigation of what happened with Resident #1. She stated if a nurse continued to refuse to assess a resident after being asked several times by the staff, she would consider that neglect. She also stated if a staff knew Resident #1 was in extreme pain in her left leg and they lifted the left leg in the air and did not gently place the left leg on the bed she would consider that abuse. She also stated if staff made a statement to Resident #1 as she was leaving the room that Resident #1 was crazy, she stated that was verbal abuse. She stated in the abuse and neglect policy and protocol it was clear what to do if anything was suspected and she stated they did not follow protocol to investigate what occurred with Resident #1 on 09/18/2023. The Administrator also stated if Resident #1 complained that her leg was broken, her knee continued to swell and she was in extreme pain within a few seconds after she was transferred from a wheelchair to the bed, there was a potential of an injury of unknown origin. She stated no one reported that to her. The Administrator did not see the electronic video given from family; however, she heard the video and the Administrator stated Resident #1 stated her leg was broken. In an interview on 09/22/2023 at 9:05 AM, LVN B stated Resident #1 did complain about pain frequently. LVN B stated if it was reported to the nurse of Resident #1 having pain and swelling in her left knee and Resident #1 believed her left knee or left leg was broken, LVN A did not follow proper protocol to ensure Resident #1 was receiving the medical care she needed the night of 09/18/2023. She stated Resident #1 needed to be transferred to the hospital on 09/18/2023. LVN B stated if staff continued to report to LVN A over an hour that Resident #1 was in pain, the swelling in left knee had increased in size and Resident #1 stated her leg/knee was broken, LVN A was expected to go to Resident #1's room immediately. She stated if LVN A continued to refuse to assess Resident #1 that would be considered neglect, unless there was an emergency with another resident. She stated if it was verified there was not an emergency every time staff was reporting the new physical condition Resident #1 was in , LVN A did neglect Resident #1. She also stated on Tuesday 09/19/2023 at approximately 9:00 AM in the staff meeting she reported Resident #1's knee was swollen, and she had

Based on observation and record review the facility failed to ensure residents were free from physical and verbal abuse for one (Resident #1) of five residents reviewed for abuse. The facility failed to ensure Resident #1 was protected verbal abuse on 09/18/2023 when CNA H made a derogatory comment regarding Resident #1 within earshot of Resident #1 and failed to assess Resident #1's pain before adjusting her swollen leg. This failure could place residents at risk for injury, mental anguish, depression, intimidation, and a diminished quality of life. Findings included : Record review of Resident #1's face sheet, dated 09/22/2023, revealed Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses which included low back pain ( pain between the lower edge of the ribs), signs symptoms of musculoskeletal system ( mild to severe aches, low back pain, numbness, tingling, atrophy, and weakness), muscle weakness ( a lack of strength in the muscles), osteoporosis without current pathological fracture (generally caused by a fall from a standing height or lower and usually involves the spine, hip or wrist), lack of coordination (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements) left foot drop ( caused by weakness of the muscles involved in lifting the front part of the foot) and, abnormalities of gait and mobility (when a person is unable to walk in the usually way). Record review of Resident #1's Annual MDS assessment, dated 07/28/2023, reflected Resident #1 had a BIMS score of fifteen, which indicated the residents' cognition was intact. Resident did not reject care. Resident #1 was assessed to require extensive assistance by two staff members for transfers. She required extensive assistance by one staff for bed mobility and toileting. Resident #1 was also assessed to require limited assistance by one staff for personal hygiene. She was assessed require staff to stabilize her when moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer. Resident #1 was on scheduled pain medication and PRN pain medication. She had frequent pain. Resident #1 did not exhibit any behaviors. Record review of Resident #1's Comprehensive Care Plan completed on 08/17/2023 reflected Resident #1 had an ADL self-care performance deficit. Interventions: resident required extensive assistance by two staff members. Resident #1 required extensive assistance by one staff members with bed mobility. Resident #1 was at risk for falls related to gait/balance problems. She had limited physical mobility. Resident had chronic pain related to osteoporosis (a condition when bone strength weakens) Interventions: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Identify and record previous pain history and management of that pain and impact of function. Identify previous response to analgesia including pain relief, side effects and impact on function. Monitor/ document for probable cause of each pian episode. Remove/limit causes where possible. Resident #1's further interventions were: Monitor/document for side effects of pain medication. Administer analgesia as per orders. Give 1/2 hour before treatments or care. Notify the physician if interventions are unsuccessful or if current complaint is a significant change from resident's experience of pain. Provide the resident and family with information about pain and options available for pain management. Discuss and record preferences. Record review of the Daily Nurses Schedule for 09/18/2023 for the 6:00 PM - 6:00 AM shift reflected LVN A was the only nurse in the facility. The staff did not have access to receive assistance for Resident #1 from another nurse. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 05:52 PM COTA/ Marketing Coordinator and PTA began to transfer Resident #1 from her wheelchair to her bed. Resident #1 was not yelling or complaining about pain. Resident #1 was transferred to her bed and as soon as she sat on the bed, she began to yell my knee is hurting my knee is broken. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 05:53 PM Resident #1 was yelling my knee is hurting and my leg broken. Resident #1 began to rub her left leg as she continued to yell. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 Resident #1 continued to yell when staff would touch her left leg or move her left leg. Resident would scream she was hurting. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 6:00 PM, Resident #1 stated you ( PTA) turned me around and Resident #1 was looking at PTA as she made this statement. The PTA stated, we did not mean to hurt you. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 7:58 PM, CNA H was in Resident #1's room. She lifted Resident #1's left leg up and Resident #1 began to scream. CNA H let Resident #1's the left leg fall onto the bed and began to exit Resident #1's room. CNA H was not providing care to Resident #1. Resident #1 was screaming the entire time CNA H lifted her leg and when Resident #1 lowered the left leg on the bed. Resident #1 was not yelling prior to CNA H picking up her leg. As she was walking out Resident #1's room she stated you are acting all crazy. In an interview on 09/20/2023 at 8:11 PM Resident #1's family stated he witnessed from the camera in Resident #1's room on 09/18/2023 at 5:51PM, staff breaking Resident #1's leg, Resident #1 complaining of pain and staff saying back to Resident #1 you know you are not hurt. You had complained about your back hurting before too and it was nothing. He stated staff did not call the family to notify them of the incident until 09/19/2023 and an ambulance was called to transfer Resident #1 to the hospital on 09/19/2023. He also stated a staff came into Resident #1's room on 09/18/2023 ( the staff was identified by the DON as CNA H) and staff picked up Resident #1's leg dropped it back on the bed and stated to Resident #1, she was not hurt. He stated in the video after staff (CNA H) began walking toward the door they stated to Resident #1 you are crazy . He also stated when the staff began to realize Resident #1 was in pain one of the staff turned the volume up on the television where it was difficult at times after these statements to hear what staff was saying. He also stated Resident #1 was in surgical unit at Hospital B and awaiting surgery. He stated Resident #1 was not available for interview. He did not want to show the video to administration except to identify the staff in the video. In an interview/observation on 09/21/2023 at 10:30 AM the Director of Nurses stated if Resident #1 were having severe pain in her left leg and CNA H picked up Resident #1's left leg and did not place the leg gently on the bed with Resident #1 yelling the entire time I would consider this physical abuse. She also stated if CNA H allegedly stated to Resident #1 you are crazy as CNA H was exiting the room this is verbal abuse. She stated staff had been in serviced on abuse and neglect numerous times. She stated this was abuse. The Director of Nurses was required to identify the staff in the video. Director of Nurses viewed the electronic monitoring video provided by the family on 09/21/2023 and observed CNA H pick up Resident #1's leg and lower it and heard CNA H state you are crazy as CNA H was exiting the room. The Director of Nurses stated this was verbal and physical abuse by CNA H. In an interview on 09/21/2023 at 11:00 AM, attempted to contact LVN A and was unable to leave message. LVN A was working the night of 09/18/2023. In an interview on 09/21/2023 at 11:05 AM, attempted to contact CNA H and left voice message of name, agency, and phone number. In an interview on 09/21/2023 at 11:10 AM, attempted to contact CNA I and left voice message of name, agency, and phone number . CNA I was in Resident #1's room when Resident #1 was complaining of pain. CNA I may have heard in the hall what CNA H stated to Resident #1. In an interview on 09/21/2023 at 2:45 PM the Administrator stated if Resident #1 was having severe pain in her left knee and left leg, and if CNA H was aware Resident #1 had pain and was not given care to Resident #1 and lifted her left leg up and resident yelling from pain and did not lay the left leg softly on the bed, she stated that would be considered abuse. She also stated if CNA H was exiting Resident #1's room and allegedly stated you are crazy, that was considered verbal abuse. The Administrator stated it was her, the DON, ADON and all staff's responsibility to monitor for any type of abuse and report it immediately to her, the DON, ADON or the staff's supervisor . In an interview on 09/20/2023 at 8:40 AM Med Aide E stated she had been in-serviced on abuse and neglect. She stated she did not recall the last time she was in-serviced. She also stated if a CNA picked up a resident's leg and was aware the resident had pain and swelling in the knee and pain in that leg and was not providing care, she stated if the resident were screaming when the CNA did that, she would consider that physical abuse. She stated if a CNA stated you are crazy as she was exiting a resident's room that would be verbal abuse. She stated the Administrator was abuse coordinator. In an interview on 09/22/2023 at 10:30 AM, the ADON stated if a CNA picked up Resident #1's leg and if they knew Resident #1 was in severe pain and her knee was swollen, that would be considered physical abuse. She also stated if a CNA was exiting Resident #1's room and allegedly made the statement you are crazy , that was verbal abuse. The ADON stated an abuse and neglect in-service was given recently, however, she did not recall the date. She stated the Administrator was the abuse coordinator. In an interview on 09/22/2023 at 1:36 PM, attempted to contact LVN A and was unable to leave message. LVN A was in the facility on the night of 09/18/2023 and needed to interview LVN A to determine if she heard what CNA H stated to Resident #1 or if she knew about CNA H picking up Resident #1's leg. In an interview on 09/22/2023 at 1:40 PM, attempted to contact CNA H and left voice message of name, agency, and phone number. In an interview on 09/22/2023 at 1:47 PM, attempted to contact CNA I and left voice message of name, agency, and phone number. CNA I was in the facility on 09/18/2023 and may have witnessed what CNA H stated from the hallway. Record review of the facility's policy for Prohibition of Abuse, Neglect and Misappropriation of Property dated 05/01/01 reflected each resident had the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion, and financial abuse. Abuse means: the willful infliction of injury, withholding or misappropriating property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Verbal abuse is defined as the use of , oral, written or gestured language that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.

Based on Observation, interview, and record review the facility failed to ensure residents were free from abuse for 1of 8 residents (Resident #1) reviewed for Abuse. The facility failed to ensure Resident # 1 was free from Abuse, as a result Resident #1 was assaulted by Resident #2 on two different occasions and was injured. This failure placed all residents at risk for being assaulted by Resident # 2. Findings included: Review of Resident #1's face sheet reflected that he was a 62- year- old man, admitted to the facility on [DATE]. The face sheet reflected Resident # 1 had a diagnosis of Chronic Congestive heart failure (A chronic condition in which the heart doesn't pump blood as well as it should), Type 2 Diabetes with kidney complication ( a chronic condition that affects the way the body processes blood sugar), Chronic Kidney disease (A loss of kidney function) , Obesity (A disorder involving excessive body fat that increases the risk of health problems), age related cataract (when the lens you're the eyes start to break down and clump together), partial traumatic amputation ( when some of the soft tissue still remains) at knee level, left lower leg. Review of Resident # 1's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 15 which indicated Resident # 1 had the cognitive ability to make his wants and needs known. Section G functional status of the MDS reflected Resident # 1 required extensive assistance with toileting, bathing, dressing and transfers. Review of Resident # 1's care plan dated 4/21/2023 reflected the following goal: Resident # 1 was at risk of loss of ROM (range of motion). Resident # 1 had the following goal: Resident # 1 will improve current level of function in ADL's. The plan had the following interventions 1. Bed mobility: Supervision x1 2. Transfer limited: Limited x1 3. Toileting: Extensive x1 4. Eating: Supervision with set up help 5. Staff assist with ROM (range of motion) daily when direct care is provided to help prevent loss Review of Resident # 2's face sheet reflected, a [AGE] year-old man, admitted to the facility on [DATE]. Resident # 2 had a diagnosis of Unspecified Dementia (A mental disorder in which a person loses the ability to think, remember, learn, make decisions, and sole problems) and Cognitive Communication deficit (difficulty with thinking and how someone uses language). Review of Resident # 2's quarterly MDS, dated [DATE] reflected a BIMS score of 99 which indicated the interview was not able to be completed. Section G functional status of the MDS reflected Resident #2 required extensive assistance with dressing, total dependence with bathing, eating and some assistance with walking at least 50 feet with turns. Review of Resident # 2's care plan dated 4/14/2023, focus Resident # 2 was evaluated as a wandering risk, decreased safety awareness, confusion, and wandering behavior. The care plan reflected the following goal. Resident # 2 will remain free of injuries associated with wandering behaviors. The plan had the following interventions: 1. Encourage to participate in activities of preference 2. Utilize a wander bracelet 3. Observe fore signs/symptoms of agitation, pacing, repetitive verbalizations of wanting to leave, restlessness 4. Provide re-orientation as needed 5. Check wander guard by nurse for placement and function if wander guard is removed replace or place on increased monitoring of resident's whereabouts Resident # 2care plan reflected the following focus: Resident #2 has potential to be physically aggressive/Dementia. Goal: Resident # 2 will demonstrate effective coping skills. The care plan had the following interventions: 1. Resident's triggers for physical aggression are loud noises. 2. Administer medication as ordered 3. Analyze times of day, places, circumstances, triggers 4. Provide physical and verbal cues to alleviate anxiety, give positive feedback 5. Family to provide sitters in the evenings to monitor resident 1:1 6. Monitor resident every 15 min. continuously 7. When resident becomes agitated: Intervene before agitation escalates 8. Guide from source of distress Resident # 2 care plan reflected the following focus: Resident # 2 has impaired cognitive function/dementia or impaired thought processes. Goal: To improve current level of cognitive function. The care plan has the following interventions: 1. Cue, orient, supervise as needed Record review of progress note dated 4/2/6/2023 by LVN reflected Resident # 1 was heard yelling help. The note reflected when the LVN got to Resident # 's room she found Resident # 1 hanging halfway off the right side of his bed and Resident # 2 standing at the foot of Resident # 1's bed. The LVN stated she assisted Resident # 1 back into his bed, and Resident # 1 was observed to have redness to the left side of his face. Resident # 1 stated Resident # 2 came into his room and when he asked him to leave, he started hitting him with both hands and with a closed fist. Record review of progress note dated 4/30/2023 by LPN reflected there was screaming heard coming from Resident #1's room. LPN stated someone yelled that two Resident's hitting each other. LPN stated when she arrived at Resident # 1's room she observed another staff already in the room that had Resident # 2 from behind and directed him out of Resident # 1's room. The LPN stated Resident # 1 was assessed to have a scratch to the right side of his chest next to an old surgery wound, redness to the back of the neck, his gown was torn from where Resident # 2 had pulled and grabbed Resident # 1, and he complained of pain however, did not want to go to the hospital. The note reflected Resident # 1 reported that Resident # 2 came into his room and punched him multiple times. The note reflected Resident # 1 wanted to call the police and file charges against Resident # 2. Record review of progress note dated 4/20/23 by LPN reflected Resident # 2 got behind another resident unknown in a wheelchair and gripped the back of the resident's chair. Resident # 2 was asked to let go of the resident's chair; Resident #2 became upset and gripped the chair tighter and started cursing and shaking his hand in the nurse's face. The note reflected Resident # 2 tried to hit the resident in the wheelchair. Observation on 5/15/2023 at 3:30pm, revealed Resident # 2 observed wandering the halls by the nurse's station. Resident was observed going into the nurse's station where they were working. Resident was redirected by staff at the time. Resident was not on 1:1 supervision. Resident # 2 was not able to be formally interviewed by surveyor as he did not have the cognitive ability to understand. Observation and interview conducted on 5/16/2023 at 11:00am, revealed Resident # 1's injuries. Resident # 1 had two scratches approximately 3inches long to his right leg, the skin was raised they appeared to be in the healing stage. Resident # 1 had a scratch to the center of his chest approximately 3 inches that was also in the healing stage. This scratch was on top of a previous surgery area on the chest. Resident # 1 stated the scratch to his chest hurt the most because the skin on his chest is thin from a previous surgery he had. Resident # 1 was observed with his left leg amputated. Resident # 1 reported he stayed in his room most of the time. During an interview on 5/16/2023 at 11:00am with Resident #1, revealed there was more than one incident. Resident # 1 stated 4/26/2023 was the first incident when Resident # 2 wandered into his room. He stated he told Resident # 2 to get out of his room and stated Resident # 2 started hitting him; he stated he yelled for help. Resident # 1 stated Resident # 2 almost pulled him to the ground when he was hitting him. Resident # 1 stated he spoke with the ADM and stated the ADM assured him that he would take care of the problem and would not allow the resident to come back into his room. Resident # 1 stated the next incident happened on 4/30/2023. He stated Resident # 2 wandered back into his room, and again he stated he told Resident #2 to get out of his room and Resident # 2 started hitting him again. Resident # 1 stated again he yelled for help and staff came to assist. Resident # 1 stated he has welts on his legs from where Resident # 2 was hitting him and Resident # 2 had scratched him on his arm and on his chest. Resident # 1 stated he asked that they call the police, he wanted to file charges against Resident # 2 for his injuries. Resident # 1 stated when he made his report to the police; the police spoke with the facility. Resident # 1 stated the police advised him that the facility advised of Resident # 2's diagnosis and that they would monitor him more closely. Resident # 1 stated Resident # 2 was supposed to be supervised however, he is not because he had been down his hall several times the next day with no supervision, and he doesn't want Resident # 2 hitting on him anymore. During a phone interview on 5/15/2023 at 8:42am a Facility visitor, revealed she had visited the facility on 4/30/2023 when the incident between Resident # 1 and Resident # 2 occurred. She stated she heard a resident yelling, and when she went to see what was going on she saw Resident # 2 shaking Resident #1 very aggressively. She stated she asked Resident # 2 if he would come out the room; She stated Resident # 2 grabbed Resident # 1 again and shook him she stated she called for help. The Facility visitor stated Resident # 2 would move all over the building and had caused problems with other residents, she stated she doesn't think he had the appropriate supervision. The Facility visitor stated Resident # 2 is strong and had grabbed her arm before in the past; So she knew how strong he was. Facility visitor stated Resident # 2 had gotten into with other residents and stated staff just sit behind the desk at the nurse's station. During an interview on 5/15/2023 at 11:55am with the ADON, revealed when the incident initially happened between Resident # 1 and Resident # 2, they tried to monitor Resident # 2 they did not start the 1:1 monitoring of Resident # 2 until the 2nd incident between them happened that's when Resident # 2 was placed on 1:1 supervision. ADON stated they had a care plan meeting the next day on 5/1/2023 and Resident # 2 was taken off the 1:1 monitoring the staff and family would monitor Resident # 2 movements throughout the day. Interview on 5/15/2023 at 1:30pm with LVN A, revealed Resident # 2 had a wander guard and they took turns monitoring the resident throughout the day. LVN A stated Resident # 2 was a wanderer and does wander into other resident's rooms. She stated Resident # 2 had shown aggressive behaviors when provoked by loud noises or if someone was physical with him first. Interview on 5/16/2023 at 11:30am with the other State agency worker, who revealed she had spoken with Resident # 1 earlier today and stated that he was afraid that Resident # 2 would come back in his room and start hitting him again. She stated that she advised Resident #1 that Resident # 2 was on 1:1 supervision. In an interview on 5/16/2023 at 1:15pm with CNA A, revealed she worked the day of the incident on 4/30/3034 between Resident #1 and Resident # 2. CNA A stated she worked on another hall that day and heard Resident # 1 yelling for Resident # 2 to get out of his room. She stated Resident # 2 got upset and started to swing at Resident # 1. CNA A stated Resident # 2 would often go into resident's rooms. She stated when Resident # 2 would get upset he would hit other residents and had hit staff before. CNA A stated they all tried to keep an eye on him and intervene before something happened. She stated Resident # 2 was on 15minute checks and everyone pitched in and monitored. An interview on 5/16/2023 at 1:30pm with the House- keeping staff, revealed he worked the day on the 1st incident on 4/26/2023 between Resident # 1 and Resident # 2. He stated the heard Resident # 1 screaming. He stated he proceeded to Resident # 1's along with another staff member and stated Resident # 2 was standing at the end of Resident # 1's bed, Resident #1 stated Resident # 2 was hitting and beating on him. House- keeping staff stated he walked Resident # 2 out of Resident # 1 's room and Resident # 2 was very agitated. House- keeping staff stated Resident # 2 had wandered into other resident's rooms and stated they will just tell him to get out and he will leave. An interview on 5/16/2023 at 3:30pm with the Activity Director, revealed she worked the day of the incident on 4/30/203. She stated she heard Resident #1 yelling for help and stated when she stood up she could see another staff had already approached Resident # 1's room. Activity Director stated when she made it down to Resident # 1's room she observed Resident # 1 hanging halfway off his bed almost to the floor. She stated she assisted Resident # 1 back up into his bed and stated he said, [Resident # 2] was hitting him. Activity director stated she also observed Resident # 1 left side of his face was red and Resident # 1 stated Resident # 2 had hit him in his face. A phone interview on 5/16/2023 at 4:00pm with Resident # 2's Family member revealed, that there were two incidents of physical aggression that recently took place with Resident # 2. He stated the facility provided 1:1 supervision, moved his room and adjusted his medication. Family member stated the facility asked if he could assist with the supervision but stated he was not able to assist due to his work schedule, so the facility was providing the 1:1 supervision. An interview on 5/16/2023 at 4:30pm with the DON, stated she started at facility about a week ago, she stated she expected staff would monitor all residents who are wanders to ensure their safety. She stated that she worked on a new training for staff to know what behaviors to look for and would intervene when residents get agitated before aggression occurred. The DON stated the 1:1 monitoring was the only intervention in place for Resident # 2, staff would monitor and redirect when needed. An interview on 5/16/2023 at 4:45pm with ADM, revealed it was his expectation that staff intervene during any resident-to-resident altercations. He stated staff should separate the residents and keep them safe. The ADM stated when their numbers increased, they would increase staff. He stated all staff had been trained on abuse/neglect and understand the expectation if they see or suspect abuse/ neglect. The ADM stated it is his expectation that staff would monitor any residents who wander throughout the day and try to keep them within line of sight. Record Review of policy report dated 4/30/2023, reflected the police responded to a simple assault at the facility. The report reflected that the facility would increase supervision of Resident # 2 by getting a sitter to provided 1:1 supervision throughout the day, and the facility would check to see if the wander guard alarm could be placed on the halls to alarm when he goes on certain halls of the facility. The report reflected Resident # 1 stated he just did not want Resident # 2 back him his room hitting on him. The report reflected the report was closed out due to Resident # 2's diagnosis and the facility put interventions in place. Record Review of 1:1 monitoring reflected monitoring was started on 4/26/2023 and ended on 5/1/2023. Record Review of the following in-services had been completed with staff: 5/8/2023- Interventions for Residents with agitation/behaviors 5/2/2023- 1:1 monitoring 4/27/2013- Resident # 2 behavior/agitation how to handle 4/27/2023- Resident to Resident altercation Review of QAPI - (Quality Assurance and Performance Improvement) dated Feb. 2023 - April 2023 focusing on Resident Centered culture. Record review of facility Abuse/Neglect policy dated 10/2022 stated the following: Each resident has the right to be free from abuse. Mistreatment, neglect, and corporal punishment, involuntary seclusion and financial abuse. The facility will prohibit neglect, mental or physical abuse including involuntary seclusion and the misappropriation of property or finances or residents. The facility Quality Assurance /Improvement committee will review the abuse policy to assure effectiveness

Based on observation, interview and record reviews the facility failed to ensure that acceptable parameters of nutritional status were maintained for 1 of 13 residents (Resident #5) reviewed for diet orders. The facility failed to provide Resident #5 with the dietitian recommended and physician ordered diet on 05/24/2022 for the morning and noon meals. The staff indicated the resident had been receiving cereal for all three meals for about one year. The resident had a weight of 98 pounds (lbs.) in February 2022 and a current weight of 84 lbs. These failures resulted in an Immediate Jeopardy (IJ) situation on 06/07/2022. While the IJ was removed on 06/09/2022, the facility remained out of compliance at a severity level of harm at a scope of isolated due to the need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents with significant weight loss at risk for further weight loss and decline in health caused by malnutrition. Findings included: Review of Resident #5's face sheet dated 05/24/2022 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses of metabolic encephalopathy (is a broad category that describes abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function.), anxiety, nutritional anemia and severe protein-calorie malnutrition. Review of Resident #5's Quarterly MDS assessment dated [DATE] reflected Resident #5 was assessed to have a BIMS score of 1, which indicated severe cognitive impairment. The resident required extensive assist with ADLs and supervision with eating. Resident #5 was assessed to have weight loss of 5% or more in the last month. Review of Resident #5's Comprehensive Care Plan reflected a problem with the start date of 04/14/2022 Resident #5 is on Terminal care with hospice. Further review of Resident #5's care plan reflected a problem dated 03/22/2022 Resident has diagnosis of severe protein-calorie nutrition with goal that resident will eat 75% of meal. Approaches included were a regular soft diet with thin liquids; add fortified foods to all meals, provide 180 ml of 2.0 house supplement three times daily, encourage oral intake of food and fluids, provide cueing and encouragement assistance for meals. Further review of Resident #5's care plan reflected a problem with ADL Functional/ Rehabilitation Potential dated 05/17/2022 , the approach indicated Resident #5 has short attention span and requires repeated cueing to eat. Review of Resident #5's Consolidated Physician orders dated 04/25/2022 through 05/25/2022 reflected the following dietary orders: -Give ice cream with lunch and supper dated 06/01/2020, -Regular mechanical soft diet with thin liquids add fortified foods to all meals dated 06/01/2020, -Double deserts with meals dated 03/19/2021, -Give 180mgl of 2.0 house supplement three times daily dated 03/19/202. Further review of Resident #5's physician orders reflected an order for hospice services dated 03/23/2022. Review of Resident #5's progress note dated 04/25/2022 by the RD indicated Summary: Res has significant weight loss of -15.2% x 193 days, res refused to be weighed last month but shows continued trend of weight loss -4.5% x 60 days, -5.2% x 95days. Resident remains on hospice care and is receiving multiple nutrition interventions to ensure resident enjoys meals. Res eats loves cheerio cereal, recommended 1. Honor resident food preferences and offer resident cheerios as alternative 2. Offer resident snacks 3. Continue ready care 2.0 180ml TID. Primary goal due to hospice care for resident to be comfortable and enjoy meals. RD will continue to monitor and follow up as needed. Observation on 05/24/2022 at 08:35 AM Resident #5 was in her room in bed. NA D was removing Resident #5's breakfast tray, the only food item on the tray was a bowl of cereal, no other food items or supplements were observed on the tray. In an interview on 05/24/2022 at 8:37 AM Resident #5 was asked if she was still hungry Resident #5 did not answer. There was no water noted at bedside. NA D was asked why Resident #5 did not had any water in her room today and NA D stated she gave her water yesterday and she gave Resident #5 milk this morning with breakfast. When asked if the milk was for the cereal she stated yes. NA D was asked if there was a reason Resident #5 could not have a pitcher of water in her room NA D stated Resident #5 spills it. Observation on 05/24/22 at 9:45 AM Resident #5 was in bed. MA K handed Resident #5 her medication which was added to her supplement (med pass 2.0 a protein supplement). Resident #5 drank all her supplement, stating repeatedly that is good. Observation on 05/24/22 at 12:05 PM Resident #5 was in her room eating in bed, the only food on the tray was a bowl of cereal. There were no supplements or other food was noted. Resident #5 was feeding herself, using the bowl to bring to her lips to eat the cereal. The only fluid on the meal tray was the milk for her cereal. In an interview on 05/25/2022 at 10:00 AM, the DM pulled Resident #5 diet card which indicated Resident #5 was to have a fortified meal plan and stated the staff told her not to put the food on her tray because she will not eat it. The DM stated if the resident had an order then the food should be on the tray. The DM stated she did not give Resident #5 the diet she had ordered because the staff told her not to. The DM stated she only gave Resident #5 cereal yesterday for breakfast and lunch. In an interview on 05/25/2022 at 10:10 AM the DON stated if the resident has a physician ordered food order it should be given to the resident as ordered. In an interview on 05/25/2022 at 10:21 AM, the RNC stated if a resident only eats cereal and was not eating the diet that was ordered it should be care planed and the physician notified. In an interview on 05/25/2022 at 10:54 AM, the RNC stated she investigated the issue with Resident #5 diet orders and stated the staff took it upon there selves to tell the kitchen not to send Resident #5 her food because they felt like she would not eat it. The RNC stated she in serviced the staff that it was not appropriate. Observation and Interview on 05/25/2022 at 11:48 AM Resident #5 was in room eating lunch. Resident #5 received her fortified food and was eating. Resident #5 stated it was good and drank all of her ice cream milk shake. Observation and Interview on 06/07/2022 PM at 1:15, Resident # 5 was in her room lying in bed. Her eyes were slightly open and stated she was sleeping. When asked what she like to eat, she stated I don't know. When asked what she had for lunch she stated, I don't remember. Resident stated she was tired and did not want to talk. Interview with LVN F on 06/07/2022 at 1:30 PM revealed Resident #5 has received only fruit loops and milk, in the past refusing other foods, which was why the resident received only fruit loops and milk on her tray. LVN F stated fruit loops are a mechanical soft diet, with no other explanation as to why dietary card was not followed or why other items were not on the tray. She stated that Resident receives multiple health shakes per day. Interview with CNA H on 06/07/2022 at 1:45 PM revealed she was familiar with Resident #5 and worked Resident #5's hallway. She was trained on ensuring the tray matched the dietary card. She stated she was aware Resident #5 only received fruit loops and milk and would often only consume fruit loops and milk three meals a day. She stated about a year ago, she noticed the dietary card did not match the meal so she took it to the kitchen and kitchen personnel told her that fruit loops and milk were the only items the resident ate so that's what she gets. She stated staff noticed last year the resident liked fruit loops and would eat them when refusing other meal items, over time fruit loops were on tray with meals and then just fruit loops with milk on tray. She stated facility staff all know resident only ate fruit loops and milk and was familiar the resident only received that on her tray. She stated she does not want to make waves so stopped notifying kitchen staff and nursing. She stated that she had not talked to any other staff regarding this situation. CNA H revealed when she entered the meal consumption percentage in the electronic health record, she based that on what was consumed from the tray, no matter if it were cereal and milk or cereal, milk, and a food item. CNA H also revealed there was no way to tell from past meal consumption records if Resident #5 received just cereal and milk or cereal, milk and other food. Interview with the DM on 06/07/2022 at 2:15 PM revealed she learned from the previous Dietary supervisor that Resident #5 only received fruit loops and milk on her tray. She stated if the kitchen was out of fruit loops and other menu items are put on Resident's tray, she will eat it. She said she knows that putting only fruit loops on the tray was not what was done for other residents, but she goes along with it so the nursing staff did not complain at her about it. She stated Resident #5 was the only resident who's diet differs from the dietary card. She stated she knows this was not accurate but it's always been done that way and has continued to do this as to not make waves. She stated the resident should have had a full meal and she didn't think it was right the resident was only getting fruit loops and milk. She stated she had no way to identify resident orders. She only finds out about orders by nurses slipping a piece of paper under the door to her office. She has requested access but was told by the Administrator that she doesn't need it. She stated she had to rely on nurses to tell her the orders and order changes . She stated she should have been looking at orders. She did not indicate whether or not she had notified her supervisors regarding her concerns. Interview with ADM on 06/07/2022 at 3:00 PM revealed the current DM was previously a cook who was promoted to the DM position after the previous one quit without notice. The ADM stated the DM had no training but was enrolled to attend training in August 2022. The ADM stated she quit working at this facility a while ago, and was recently rehired and was not aware t Resident #5 was only receiving cereal and milk. Her expectations are that residents are offered the meal on the menu with their food preferences. All dietary cards should match the food on the tray and be checked by kitchen staff before they leave the kitchen as well as by nursing staff to ensure accuracy. If trays do not match meal cards, the trays should be corrected. She stated the DM should have been given training by the previous employee but that she did not get that training. Interview with the MD on 06/07/2022 at 4:30 PM revealed he was not aware of changes to dietary orders for Resident #5 to only offer cereal and milk. The MD stated only eating fruit loops and milk could contribute to weight loss. The MD stated he was not in his office and did not have current access to Resident #5 medical file but did not think only eating fruit loops and milk would provide sufficient calories to sustain life. He stated he was not contacted regarding changing Resident #5's dietary orders and was not aware of Resident #5's refusal to be weighed. He was not able to state that malnutrition was a result of the cereal only diet. Interview with the RP for Resident #5 on 06/07/2022 at 4:45 PM revealed he was notified of weight loss but not the fact the resident was only receiving cereal and milk. He stated the resident would often refuse foods but loved sweets. He stated the facility had not discussed food options with him nor the fact that Resident #5 refused to be weighed. Observation of dinner service on 06/07/2022 at 4:58 PM revealed dietary cards did not match meal on plates. Dietary cards listed ground baked chicken and chicken gravy. Both meals had mechanically separated chicken in king ranch casserole. The meat was mechanically separated but not ground per the dietary card. Menu posted in the dining area dated 06/06/2022 revealed menu item was king ranch casserole. Resident #5 received full tray with fruit loops and milk in a separate bowl. Interview with the ADM on 06/07/2022 at 5:14 PM revealed she had no idea why both residents dietary card said baked chicken when both received king ranch casserole. She stated all Resident's dietary cards should have listed king ranch casserole. She said the baked chicken was in the casserole. She stated the facility system must have been malfunctioning and would call the facility parent company for more information and to correct the issue. Interview with ADM on 06/07/2022 at 6:00 PM revealed the DON should have been notified by nursing staff that Resident #5 was not receiving meals that matched her dietary card. She stated the DON was responsible for notifying family and physician for changes in orders, changes in condition and any other issues that occur with the resident. She stated she thought this had been done by the DON and was surprised the RP and MD were not aware of Resident #5 only receiving fruit loops and milk for some meals. Review of the facility policy Food and Nutrition Services dated 09/2021 reflected Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident .Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive . The Administrator was notified on 6/7/2022 at 8:52 PM an IJ (Immediate Jeopardy) situation was identified due to the above failures and the IJ template was provided. On 06/09/2022 at 3:00 PM an interview with LVN C revealed she is knowledgeable of facility abuse prohibition procedures; checking Resident meal trays against meal tickets and sending back to the kitchen for correction if not matching; documenting accurate meals for each Resident with new tracking system; informing charge nurse of change in condition for residents; informing charge nurse if meal does not match meal ticket; use of supplements as ordered. On 06/09/2022 at 3:15 PM an interview with CNA H revealed she is knowledgeable of facility abuse prohibition procedures; checking Resident meal trays against meal tickets and sending back to the kitchen for correction if not matching; documenting accurate meals for each Resident with new tracking system; informing charge nurse of change in condition for residents; informing charge nurse if meal does not match meal ticket; use of supplements as ordered. On 06/09/2022 at 3:30 PM an interview with DA L revealed she is knowledgeable of facility abuse prohibition procedures; checking Resident meal trays against meal tickets and sending back to the kitchen for correction if not matching; if the trays don't match the tickets, they are to be remade. On 06/09/2022 at 3:40 PM an interview with Cook M revealed she is knowledgeable of facility abuse prohibition procedures; checking Resident meal trays against meal tickets and sending back to the kitchen for correction if not matching; if the trays don't match the tickets, they are to be remade. On 06/09/2022 at 4:15 PM an interview with LVN G revealed she is knowledgeable of facility abuse prohibition procedures; checking Resident meal trays against meal tickets and sending back to the kitchen for correction if not matching; documenting accurate meals for each Resident with new tracking system; informing charge nurse of change in condition for residents; informing charge nurse if meal does not match meal ticket; use of supplements as ordered. On 06/09/2022 at 4:30 PM an interview with DOR revealed she is knowledgeable of facility abuse prohibition procedures; checking Resident meal trays against meal tickets and sending back to the kitchen for correction if not matching; documenting accurate meals for each Resident with new tracking system; informing charge nurse of change in condition for residents; informing charge nurse if meal does not match meal ticket; use of supplements as ordered. On 06/09/2022 at 4:45 PM an interview with CNA K revealed she is knowledgeable of facility abuse prohibition procedures; checking Resident meal trays against meal tickets and sending back to the kitchen for correction if not matching; documenting accurate meals for each Resident with new tracking system; informing charge nurse of change in condition for residents; informing charge nurse if meal does not match meal ticket; use of supplements as ordered. The facility's plan of removal was accepted on 6/9/22 at 3:37 PM and included: Plan of Removal Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on June 08th, 2022 for neglecting to obtain weights for residents and provide proper nutritional intervention. 27 residents had the potential to be affected by this deficient practice. 1. Action: To ensure identification of weight loss and risk for weight loss, center licensed nursing staff conducted and documented an audit of all center residents' current weight and diet orders reviewed with IDT to include registered dietician. If new weight loss is noted during weekly or monthly weights, the attending physician, registered dietician, and nursing management will be notified to obtain orders as indicated and a change of care plan will be initiated and ongoing. Actual weight loss and potential risk factors will be care planned to meet individual resident needs. The Clinical Standup & Standards of Care meeting is an ongoing meeting monitored by the Administrator and the Director of Nursing Completion Timeline: Beginning June 8th, 2022 and ending June 9th, 2022. Responsible: Administrator/DON/RNM/RD 2. Action: Nursing Administration to conduct education with licensed nursing staff regarding: 1) Notification of nursing management upon identification of resident change in weight to include. 2) Inspection and documentation of weekly weights times 4 weeks upon admission, as recommended by RD/IDT, and monthly weights for all stable residents. Beginning June 8th, 2022 licensed nurses (agency, PRN, new hires) who have not received the above stated education will be educated by Nursing Administration prior to providing resident direct care. The Clinical Standup & Standards of Care meeting is an ongoing meeting monitored by the Administrator and the Director of Nursing Completion Timeline: Beginning June 8th, 2022 and ending June 9th, 2022. Responsible: Director of Nursing and regional nurse manager 3. Action: Nursing Administration to conduct education with certified/temporary nursing assistants regarding notification of charge nurse upon identification of resident change in weight and/or meal intake percentage. Meal intake will be recorded based on the entire meal. Beginning June 8th, 2022, certified/temporary nursing assistants (agency, PRN, new hires) who have not received the above stated education will be educated by Nursing Administration prior to providing resident direct care. The Clinical Standup & Standards of Care meeting is an ongoing meeting monitored by the Administrator and the Director of Nursing Completion Timeline: Beginning June 8th, 2022 and ending June 9th, 2022. Responsible: Director of Nursing and Regional Nurse Manage 4. Nursing Administration began auditing the electronic medical record of each resident to ensure weekly/monthly weights are scheduled to be performed by a licensed nurse. The Clinical Standup & Standards of Care meeting is an ongoing meeting monitored by the Administrator and the Director of Nursing Completion Timeline: Beginning June 8th, 2022 and ending June 9th, 2022. Responsible: Director of Nursing and Regional Nurse Manager 5. Nursing Administration will conduct education with certified/temporary nursing assistants and licensed nurses regarding diet types, how to confirm with resident menu tray ticket, and for nursing staff to notify the Dietary Manager if diet does not match resident menu tray ticket. Beginning June 8th, 2022, certified/temporary nursing assistants, licensed nurses (agency, PRN, new hires) who have not received the above stated education will be educated by Nursing Administration prior to providing resident direct care. The Clinical Standup & Standards of Care meeting is an ongoing meeting monitored by the Administrator and the Director of Nursing Completion Timeline: Beginning June 8th, 2022 and ending June 9th, 2022. Responsible: Nursing Administration Administrator, Registered Dietitian, Director of Nursing 6. Nursing Administration will conduct education with Next Level Dietary Team regarding access to dietary orders in MatrixCare to compare diet orders in Next Level's Sno System, Registered Dietitian Recommendations are provided to Dietary Manager monthly by email, and dietary change communication form process is initiated on any dietary charges. Beginning June 8th 2022, Next Level Dietary Team (PRN, new hires) who have not received the above stated education will be educated by Nursing Administration prior to working in the Dietary Department. The Clinical Standup & Standards of Care meeting is an ongoing meeting monitored by the Administrator and the Director of Nursing and by RD during monthly Visits Completion Timeline: Beginning June 8th, 2022 and ending June 9th, 2022. Responsible: Director of Nursing, Next Level Area Manager and Registered Dietitian Action: Beginning on June 9, 2022 and for the Director of Nursing will utilize the Daily Clinical Meeting Process to validate charge nurse compliance with inspection, notification, and documentation of resident weights which are to be conducted upon admission and weekly and/or monthly thereafter. QAPI Committee will be notified of identified non-compliance. QAPI Committee will develop a Performance Improvement Plan to address identified non-compliance to include staff education and/or disciplinary action. These are ongoing processes to assist the Administrator and DON to manage clinical processes. Completion Timeline: Beginning June 9, 2022 and ending June 10, 2022. Responsible: Administrator, and Director of Nursing Action: Beginning on June 8th, 2022 a significant change assessment was opened Resident #5. Would only occur if another change in resident #5 medical condition Completion timeline: Opened June 8, 2022 with completion in seven days. Responsible: MDS coordinator, Director of nursing Action: Resident #5 care plan be updated to reflect interventions on June 8th, 2022, to reflect current status. Weekly IDT meeting/morning clinical meeting to include weekly weights. Weight on 6/8/22 87pounds. RD to assess additional supplements. Current supplements include fortified foods with comfort foods of the resident's choosing and supplement drink. This would on occur with another change in the resident's status. Completion timeline: Updated May 8, 2022. Responsible: MDS coordinator, Director of nursing Action: Labs to be ordered for Resident #5 on June 8th, 2022 Completion timeline: Ordered on June 8th, 2022, to be drawn June 8th, 2022. The results will be shared with the Medical Director and await any new orders Responsible: Director of Nursing, Physician Action: Change of Condition Resident #5 to be completed on June 8, 2022. Change of condition notification includes the physician. Will only occur if any change with the resident #5 medical condition Completion timeline: June 8th,2022 Responsible: Administrator, Director of Nursing. Action: Adhoc QAPI meeting with Dr [NAME] and IDT was completed at 11:15a.am. June 8, 2022. The purpose of the Ad hoc QPAI was to inform the Medical Director of the IJ Situation and to review Plan of Removal. Completion timeline: June 8th, 2022 Responsible: Administrator, Director of Nursing Action: Nursing administration to educate staff on procedure for tray card utilization and ensuring physician ordered diet is followed. Nursing staff to sign and submit tray card for all residents including Resident 5 to Director of Nursing following each mealtime 30 days. The intent is to monitor compliance with diet orders review by nursing for 30 days and kick to QAPI. If compliance is not met, monitoring of dietary orders will continue in the clinical standup and standards of care meeting. Completion timeline: June 9th,2022 Responsible: Administrator, Director of Nursing. The surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Observation of Resident #5 on 06/08/2022 11:30 AM revealed she was in dining room sitting in her wheelchair at a dining table. Resident had items matching the dietary card along with a bowl of fruit loops. Resident was observed to eat the cereal and milk with her spoon. Resident ambulated away from the table after eating several spoonsful of food. Resident was later seen ambulating in the hallway with a mug of purple liquid. Resident stated she ate dog shit for lunch. Interview with CRD on 06/08/2022 at 12:30 PM revealed she had been working with the facility since August of 2021. She stated the facility should have provided Resident #5 with a mechanical soft diet as written in the residents orders. She stated offering the resident just cereal milk was not acceptable and could lead to resident weight loss. She stated if the resident had food preferences, the facility was to provide Resident's preferences in addition to the ordered diet. She stated when residents are on hospice care the facility wanted to honor resident's food preferences and the primary goal of hospice care was to ensure the resident was comfortable but the facility must still offer meal along with alternative as preferred. She stated the resident received multiple supplements daily (180 ml of health shakes, 1680 calories and 60 grams of protein). She stated the DM should have been trained on how to change meal tickets to match the facility system and ensure the tray tickets matched the food on the resident trays. She stated she was not aware of how long the DM was without a manager to ensure proper training. She stated communication regarding the residents meal needs should be passed from nursing staff to kitchen staff, the kitchen staff ensure when trays go out for meals, and the meals match the dietary orders; and the nurses should also check trays to ensure the dietary card matches what was on the tray. She stated she was a consultant for the facility and reviewed diets and provided high risk Resident's diet recommendations once per month. She stated if she had known about Resident #5 only receiving cereal and milk, she would have spoken with the DM. She stated the DM was supposed to be following the recipes provided by facility parent company. Interview with the Clinic Manager on 06/08/2022 at 1:00 PM revealed Resident #5 was last seen by primary physician in February 2022. The Clinic manager stated the physician's note revealed the resident weighed 98 lbs. When informed of the Residents current weight of 84 lbs. she stated wow, that's pretty extreme. She stated the Hospice doctors and nurses should be ensuring Resident's care. She stated if there are current orders for Hospice, then the Resident's care falls under hospice and if no current orders are in place, care falls back to the facility medical director. Interview with DON on 06/09/2022 at 1:35 PM revealed she was not aware of the fruit loop and milk diet until the full book survey in May 2022. She stated her training was if Resident meal tray does not match the meal ticket, it was sent back to the kitchen. She stated this expectation extends to nurses and CNA's. She stated she had never observed this as she sometimes assists passing trays in the dining area. She stated this may have occurred after Resident's injury, when she was receiving meal trays in her room. She stated she could not recall how often she assisted in the dining room but assisted as needed. She stated none of the nursing staff told her Resident #5s tray sometimes was only cereal and milk. The DON said having only cereal and milk could lead to the resident not consuming enough calories and contributing to weight loss. The DON stated the kitchen staff should be getting nutritional orders from their computer system and they do not need access to Matrix. She stated she was not aware that the kitchen staff did not know how to get updates on resident orders for diets. She stated during morning meetings the kitchen staff should request knowledge of changes if they are unsure about a particular resident's diet. The DON was driving in her car during the interview and the interview ended due to the DON was having difficulty answering questions. On 06/09/2022, the Adm was informed the IJ was removed; however, the facility remained out of compliance at a severity level of harm at a scope of isolated due to the need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of five residents reviewed for falls (Resident #1). Resident #1 was transferred and left standing alone and fell and broke her leg. After Resident #1's fall and fracture, the staff did not use a gait belt when transferring Resident #1 who was non-weight bearing with her left leg. Failure to adequately supervise and assist13 residents identified as requiring assistance with transfers can lead to falls and broken bones and a decreased quality of life. Findings Included: Review of Resident #1's Face Sheet reflected she was a [AGE] year old female admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set ((MDS) dated [DATE] (before her fall and fractured leg) reflected she had a Brief Interview of Mental Status score of 15 which indicated she was cognitively intact. She was assessed as requiring extensive assistance of one person for transferring, toilet use and personal hygiene. She was assessed as not steady, only able to stabilize with staff assistance for moving from seated to standing position, turning around and surface to surface transfers (bed to wheelchair). Review of Resident #1's Care Plan dated 09/18/2016 reflected Resident #1 was at risk for falls and had left sided weakness related to having had a stroke. Resident #1 was not to transfer without assistance. Resident #1 had a history of [REDACTED].#1 was to wear proper footwear and did not list a gait belt as an intervention. Review of the Incident Report dated 12/13/2016 at 7:45 AM reflected Resident #1 was being transferred from the bed to the wheelchair. Wheelchair break was not secured and wheelchair rolled out from behind the resident. Resident fell to ground. Did not hit her head. Witness CNA I. Completed by LVN D. Review of the Incident Investigation for Resident #1's fall on 12/13/2016 at 7:45 AM reflected LVN D assessed and documented: Wheelchair rolled, the resident required assist of one to transfer and Resident #1 leaned forward and to the side. LVN D documented the transfer technique was not correct and Resident #1 should have had a gait belt. Review of Resident #1's Nurse Note dated 12/13/2016 at 8:50 AM reflected Resident #1 was on the floor and her left leg had rotation, a large bruise was noted to the left thigh and she had extreme pain. Resident #1 was sent to the hospital by ambulance after her left leg was placed in traction. Review of Resident #1's Physician order [REDACTED].#1 had an order to be non-weight bearing to her left leg and staff was to encourage her to be no weight bearing to the left leg. The order was initiated on 12/19/2016 when she returned from the hospital. Review of Resident #1's Significant Change in Status MDS dated [DATE] reflected she had a Brief Interview of Mental Status score of 13 which indicated she was cognitively intact. She was assessed as requiring total dependence of two people for transferring, and toilet use. She was assessed as not steady, only able to stabilize with staff assistance with surface to surface transfer (bed to wheelchair). She was coded as activity did not occur for seated to standing, walking and turning around. Review of Resident #1's Care Plan dated 01/03/2017 reflected she was at risk of pain related to a fractured femur from a fall transferring from bed to wheelchair. Interventions included utilize transfer aide with every transfer. Further review of the care plan reflected she was at risk for falls and the staff was to utilize gait belt with transfers. In an interview on 01/31/2017 at 10:35 AM Resident #1 was sitting in a wheelchair watching TV. She stated on the day she fell and broke her leg CNA I was assisting her to get up for the day. Resident #1 stated she was getting into her wheelchair and it wasn't locked on both sides and it rolled out from under her. She stated she did not have a gait belt on at the time and the staff was not using gait belts to transfer her. Resident #1 stated No one uses a belt. Resident #1 stated she was not able to put any weight on her leg and she holds around the CNA's neck while they hug her and lift her and put her in the chair. She stated sometimes it was one aide and sometimes it was two. She further stated the CNA assisting her when she fell was a very caring person and she did not want the CNA fired. Resident #1 stated she had to get plates and pins put in her leg. In an interview on 02/01/2017 at 9:33 AM CNA I stated she was the CNA with Resident #1 when she fell and broke her leg. CNA I stated the routine was to put clothes on Resident #1 then when Resident #1 stood up, CNA I pulled her pants up and put her jacket on her. CNA I stated she did not use a gait belt on Resident #1 at that time and staff still does not use a gait belt; We don't use a gait belt on her. CNA I stated usually the jacket was on the wheelchair but the morning Resident #1 fell , CNA I left Resident #1 standing at the bedside and went to the closet to retrieve the jacket. CNA I stated while she was at the closet she heard Resident #1 begin yelling a saw her do a slow motion fall to the floor. CNA I stated she usually doesn't try to sit down without me. In an interview on 02/01/2017 at 10:00 AM CNA J stated to transfer Resident #1 the staff did a two person transfer most of the time if there were two staff available. CNA J stated she gets her (Resident #1) under the arms and she stands then she pivots and sits. She holds on to my neck. We haven't been using a gait belt with her. She doesn't weigh much. Review of the Provider Self Report Investigation dated 12/16/16 reflected CNA I gave a written statement stating she did not use a gait belt or lock both sides of the wheelchair as she left the resident standing while she got her jacket. The facility summary was the CNA did not follow policy and procedure as she was not using a gait belt while standing with the resident and she did not lock both brakes when placing the wheelchair near the resident. Review of the Facility In-service dated 12/13/2016 reflected CNA I had signed an in-service to use proper technique during transfers. Review of the Facility In-service dated 12/14/2016 reflected CNA J had signed the in-service to use gait belts during transfers. In an interview on 02/01/2017 at 9:57 AM the MDS Nurse stated what Resident #1 says is reliable most of the time. She further stated staff was supposed to be using a gait belt with Resident #1 before she fell and staff were supposed to be using a gait belt when transferring Resident #1 since she fell (and has no weight bearing for the left leg). In an interview on 02/01/2017 at 10:10 AM the Administrator stated she expected the staff to use gait belts with transfers. Review of the print out Transfer - Caregiver Assisted Sit to Stand and Pivot Transfer reflected the pictures showed a resident in a wheelchair with a gait belt on. Lock the wheelchair next to the bed with the wheels against the bed frame. Lock the brakes. Apply the gait belt. 4. Assist as needed with the gait belt. Review of the facility CMS form 672 reflected the facility had 13 residents who required assistance with transfers.

Based on observation, interview, and record review the facility failed to ensure that a resident who entered the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrated that they were unavoidable; and a resident having pressure sores received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for two (2) of four (4) residents (Residents #3 and Resident #7) reviewed for high risk of pressure sores. A) The facility failed to prevent and promote healing of pressure sores for Resident #3. Resident #3 developed a pressure sore on her right ischium on 08/18/2016 in the facility. The pressure sore enlarged, increased in depth and declined to an unstageable wound that was 50% covered in necrotic eschar. The treatment was not changed to clean the wound out until surveyor intervention on 09/28/2016. Resident #3 did not have a pressure reduction cushion in her chair. B) The facility failed to prevent and promote healing of pressure sores for Resident #7 when he developed a stage 2 pressure sore on 09/14/2016 on his sacrum and the area had declined by 09/29/2016 to a stage 3. The facility also did not utilize a pressure relieving device in Resident #7's gerichair. These deficient practices affected two (2) residents with pressure sores and nine (9) residents at high risk for pressure sores at risk for skin infections, development of more pressure sores, further decline in current pressure sores, and a decreased quality of life. Findings include: A) Review of Resident #3's Face Sheet reflected an [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly MDS dated [DATE], reflected she had severely impaired cognition and was totally dependent on staff for every ADL. The MDS reflected she was at risk for pressure sores and did not have any pressure sores; but also was coded as not having any pressure reducing devices on the bed or chair. Review of Resident #3's Care Plan dated 06/19/2016 and updated on 09/06/2016 for being at risk for pressure sores with interventions of; avoid shearing, keep clean and dry, keep linens wrinkle free, and report any signs of skin breakdown. The Care Plan also included Resident #3 was on Hospice and to turn and reposition every three to four hours instead of every two hours due to pain and the ADL care plan reflected for the staff to use positioning devices if needed. The Geri-chair Care Plan reflected for the staff to provide a geri-chair for Resident #3 to enable her to get out of bed and to reposition her as needed and observe for tolerance. Review of Resident #3's Care Plan dated 09/27/2016, reflected a problem of Pressure Ulcer and interventions included low air loss mattress and timely incontinent care, turning and repositioning. Geri-chair cushion was not on the care plan. Review of Resident #3's facility Consolidated Physician order [REDACTED]. an order for [REDACTED]. In an interview on 09/27/2016 at 10:35 AM, LVN C stated Resident #3 was totally confused, required total care for ADLs, required a mechanical lift for transfers and was on Hospice. Observation on 09/27/2016 at 10:00 AM, reflected Resident #3 was in the lobby in a geri-chair significantly leaning to the left. She did not have any pillows or positioning devices in place. Her knees were drawn up to the point her heels were on her hips. Observation on 09/27/2016 at 10:35 AM, Resident #3 had a low air loss mattress on her bed and there were no positioning devices in her room. In an observation on 09/27/2016 at 12:30 PM, Resident #3 was in her geri-chair in the Dining Room with no pillows or cushions in place. In an observation on 09/28/2016 at 11:10 AM, CNA G and CNA H transferred Resident #3 to the geri-chair and did not put a pillow under her or any pressure reducing device. No pillows were used for positioning. In an interview on 09/28/2016 at 11:06 AM, CNA H stated Resident #3 gets up in her chair for every meal. CNA G stated Resident #3 gets up every day at this time and is up for every meal in her geri-chair. CNA H stated she is put back to bed after every meal. Review of Resident #3's form labeled Clinically unavoidable pressure ulcer form, reflected no pressure ulcers were present it was signed by the Primary MD on 03/04/2016. The form listed the interventions in place were; barrier cream, turn every two hours, mechanical lift and off-load boney prominences. There were no checks by: pressure reducing equipment in chair, pressure reducing mattress, or other positioning devices. In the section labeled for reasons for the unavoidable pressure ulcer that may occur was; incontinence, Dementia and decreased Mobility. It was noted on the form there would be no further labs drawn. An observation on 09/28/2016 at 9:17 AM, reflected LVN B changed the dressing for Resident #3 on her right ischium (center of the lower buttock). Observation of the wound, reflected it was Unstageable due to being approximately 50% covered in black eschar (Unstageable: full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan brown or black) in the wound bed). The pressure sore was approximately 5.0 cm x 4.5 cm x 3.0 cm deep (approximately slightly bigger than half a golf ball in size). The wound bed had yellow slough in the center and black/gray eschar across half the wound bed. The wound was eroding (tunneling) into the muscle at the top (towards the upper buttock) approximately one centimeter under the overlying skin. In an interview on Wednesday, 09/28/2016 at 9:19 AM, LVN B stated the plan was to change the treatment because the facility had been doing the same treatment since the ulcer developed. She stated the ulcer was not improving and she had called the Hospice that morning (Wednesday) asking for a new treatment. She stated she could see eschar, slough and now the wound was tunneling. LVN B stated she did not have any wound care training. When asked who she consulted with regarding wound changes, failure to heal and what dressing was appropriate, she stated she would ask the Hospice Nurse and she would always say, Well, what do you think? LVN B further stated when she asked the doctor for direction, the physician responded, What would you like to do? LVN B stated she searched the Internet for what her options were for treatment dressings. LVN B further stated she was responsible for measuring and staging the wounds on Thursdays and with significant changes. She stated a significant change was when the wound grew by two or three centimeters. Review of Resident #3's August and September 2016 Treatment Flow sheets reflected an order dated 08/18/2016; Clean area to right ischium with normal saline, pat dry, apply calcium silver and bordered dressing daily and as needed for soilage. It was signed by either LVN B or the DON almost every day. Review of Resident #3's Weekly Skin Documentation reflected the pressure sore was identified on 08/18/2016 to her right ischium: · 8/18/2016; 4.5 x 1.5 and 0.1 cm deep it had drainage of clear fluids and blood and [MEDICATION NAME] tissue was present, Stage 2. (Stage 2 - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. NPUAP guidelines). · 08/25/2016; (7 days) it had increased in size to 7.2 cm x 3.5 cm x 0.4 cm deep. It was documented as a Stage 2. (This was mis-staged due to depth. It should have been staged a Stage 3). (Stage 3 - full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. NPUAP guidelines). · 09/01/2016; 10 cm x 7.2 cm x 3.0 cm deep, Stage 3. Granulate tissue, dark red. (The wound was less than half a centimeter deep seven days previous and on 09/01/2016 was documented to be three centimeters deep.) · 09/08/2016; 10.2 cm x 6.0 cm x 4.0 cm, Eschar 50%, yellow green drainage, moderate amount, with an odor, Stage 3. (Eschar- tan, brown or black in the wound base-NPUAP guidelines.) (At 50% eschar the physician needed to be notified so that a new treatment could remove the eschar.) · 09/22/2016; 11.0 cm x 10.0 cm x 5.2 cm deep, Stage 4. Granulate and [MEDICATION NAME] tissue. (Stage 4 - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling- NPUAP guidelines). · 09/29/2016; 5.0 cm x 4.5 cm x 3.4 cm gray/yellow slough to upper/lower and center of wound bed. 1.7 cm tunneling. Unstageable. (Unstageable- Full thickness tissue loss in which the base of the ulcer is covered by slough- NPUAP guidelines. Tunneling - an invagination or a blind opening into the tissue; facility Wound Document Guidelines 02/15/2012). Review of Resident #3's Daily Pressure Ulcer documentation reflected: on 08/31/2016, when the wound depth was significantly increased; Hospice aware of change in wound. On 09/06/2016, LVN B documented Eschar noted to lower approximately half of the wound. Upper half noted with healthy pink/red beefy granulate tissue. 09/07/2016 Continues with Eschar and granulate tissue to wound bed same as 09/06/2016. The notes did not reflect any notification of the Hospice MD or the Primary MD. The treatment was not changed to remove the eschar tissue. Review of Resident #3's Nurse Notes reflected there were no entries made in the chart from 08/21/2016 until 09/14/2016. From 09/14/2016 to 09/27/2016, there were no notes regarding notification of the Primary MD or the Hospice MD of the decline in the pressure sore. There was no note requesting a change of treatment until 09/28/2016, during the survey. In an interview on 09/28/2016 at 1:10 PM, the DON stated LVN B did the facility staging of wounds. He further stated he did not have training in wound care staging or wound dressings. The DON stated the facility had a wound care protocol on the nurse desk and he could use it if needed. He stated he would just compare the wound to the pictures to stage the wound. The DON stated he changed Resident #3's dressing on Sunday and saw it was black and had yellow in it and was beginning to tunnel. The DON stated he told LVN B on Monday and she agreed with him it was tunneling. He stated he did not call the doctor Sunday or Monday, but he believed LVN B did on Monday. The DON stated Resident #3 was positioned mainly on the left side to keep her off the pressure sore. He further stated the facility used pillows to assist with positioning. He stated the facility did not have any pressure reduction cushions for the geri-chairs and the low air loss mattress had been in place for over a year. He stated he sent an electronic report of all the wounds in the building to the RN Consultant on Thursdays to review. The DON stated he is the charge nurse on the weekends and did Resident #3's pressure sore treatment every week at least once. In an interview on 09/28/2016 at 2:23 PM, Resident #3's Primary MD stated the facility night nurse had called her on Monday 09/26/2016, regarding Resident #3's pressure ulcer and told her it wasn't getting any better. The Primary MD stated the last time she saw Resident #3 was in July 2016 and Resident #3 did not have the pressure sore then. She stated she had not been told anything else about the pressure sore until Monday, 09/26/2016, by the night shift charge nurse. She stated she was Resident #3's attending physician, even though Resident #3 was on Hospice. The Primary MD stated when a wound develops eschar or slough it needs a [MEDICATION NAME] agent to clean out the dead tissue. She stated she would have expected the facility to have pressure reduction devices in place in the geri-chair. In an interview on 0928/2016 at 4:09 PM, the DON stated no one had mentioned to him Resident #3 needed a pressure relieving device in a geri-chair. In an interview on 09/28/2016 at 3:57 PM, the Administrator stated LVN B was a charge nurse and she staged the wounds. The Administrator stated LVN B was in school to be an RN. The Administrator stated she would have expected Resident #3 to have a pressure relieving device in her geri-chair. In an interview on 09/29/2016 at 2:00 PM, LVN B stated she did not know anything about a cushion for geri-chairs or Resident #3 needing a cushion. LVN B stated the pressure on Resident #3's hip would have to be from the geri-chair, because she only lies on her left side in the bed. LVN B stated the geri-chair is the only hard surface Resident #3 had her hip on. She stated the contractures made the pressure worse on the hip in the chair. LVN B stated the CNAs leave Resident #3 up in the geri chair after breakfast and she waits for the Hospice Aide to give her a shower. They coordinate whether a bed bath or a shower some days, Monday through Friday. LVN B stated she had not realized Resident #3 was still up in the geri-chair in the front lobby at 10:30 AM on Tuesday, 09/27/2016. In an interview on 09/29/2016 at 2:30 PM, CNA G stated she did leave Resident #3 up in the chair waiting for the Hospice Aide to come give her a shower earlier in the week. CNA G stated Resident #3 gets a shower every other day usually, and sometimes she is put to bed right after breakfast. She stated the Hospice aide gets there usually anywhere from 8:00 to 9:00 AM, but is occasionally later. CNA G further stated Resident #3 has never had a cushion in her chair. Review of Resident #3's Hospice orders, reflected the Hospice Nurse RN initiated the order on 08/19/2016 for treatment of [REDACTED]. In an interview on 09/29/2016 at 9:03 AM, the Hospice Nurse RN stated she had probably seen Resident #3's wound a week ago. She stated Hospice really doesn't treat wounds, but is more aware of pain management. She stated the last time she saw the wound, last week, it was really nasty, Stage 3 and about 50% black. She stated she occasionally looked at wound documentation, but really did not remember looking at Resident #3's documentation. She further stated she saw what the wound looked like when LVN B showed her a picture of it. She stated she did not provide treatment recommendations. Hospice Nurse RN did not say she had informed the Hospice MD of the decline. In an interview on 09/28/2016 at 6:00 PM, the Primary MD had just observed Resident #3's pressure ulcer to her right ischium (on day two (2) of the survey), and stated the dressing orders needed to be changed; and she would have ordered a dressing to remove the eschar sooner, if she had known it was present. The Primary MD further stated it would be helpful if the staff knew how to correctly stage wounds, so that she would know better what they were observing when they communicated with her. She stated a cushion in the geri-chair may have helped somewhat relieve pressure and the contracture in her right leg caused her to sit in the fetal position and on her right hip. In an interview on 09/29/2016 at 4:30 PM, the Hospice MD was asked who should the staff be notifying of Resident #3's worsening wound. The Hospice MD stated he had not met Resident #3 or seen her pressure ulcer. When asked if he had been notified of the pressure ulcer, he stated he was sure he had been because the Hospice staff discussed her care every two weeks. He stated he could not remember anything discussed and could not access his computerized notes at the interview time. After surveyor informed the Hospice MD about Resident #3's pressure ulcer status, he stated Resident #3 probably did need a cushion in her geri-chair and some debridement of the eschar. He stated he would have ordered a chemical debridement ointment if he had known it was 50% eschar. He stated he did not recall anyone asking him for any specific advice on wound dressings or treatments for Resident #3. Review of Resident #3's Physician order [REDACTED]. Review of Resident #3's Physician order [REDACTED]. In an interview on 09/29/2016 at 4:37 PM, the DON stated he expected the residents at high risk for pressure ulcers to have a cushion in their chairs; and he expected the staff to be able to stage wounds correctly, including himself. He expected the staff to notify the MD of wound declines and changes. In an interview on 09/29/2016 at 5:20 PM, the Administrator was informed Resident #3 was observed to be up in her geri-chair at 10:30 AM on day one of the survey and the staff stated they leave her up for her shower at times. The Administrator stated the staff tells her they put Resident #3 to bed immediately after meal service and yet they are not truly doing that after breakfast. In an interview on 09/29/2016 at 9:30 AM, the RN Consultant stated a pressure sore that was over 0.1 cm deep could not be a stage 2, but was worse and LVN B had mis-staged the wound on 08/25/2016. He further stated when 50% eschar was present the wound should not have been staged at a stage 3, but could not be staged because the wound base was not visible. He further stated he thought the DON was qualified to stage wounds because of his history of being with a Hospice agency for years. The RN Consultant stated he did not realize in the DON's job interview that the DON did not possess those skills. The RN Consultant stated it would have been okay for LVN B to stage the wounds, if she would have had the proper training; which she did not have. He further stated ultimately it was his responsibility to make sure the facility was taking proper care to prevent and treat pressure ulcers. The RN Consultant did not answer when asked whether Resident #3 should have had a pressure reduction device in her chair and if that would have prevented the pressure sore. B) Review of the Face Sheet for Resident #7 reflected an [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the Quarterly MDS assessment dated [DATE] for Resident #7, reflected a BIMS score of three (3) indicated severe cognitive impairment. He required extensive assistance of two (2) staff for bed mobility and toileting, he was always incontinent of bladder and bowel. Resident #7 was at risk for pressure sores, but at this time did not have a pressure sore. He received ointments or medications for skin treatments. Review of the Care Plan for Resident #7 dated 09/14/2016, reflected he had a Stage 2 pressure sore to his sacral area and right buttock. The staff were to reposition him, keep him clean and dry, provide the treatment as ordered by his physician, encourage meal intake, provide him with an air mattress, provide range of motion, and report any drainage from the pressure sore to the physician. The Care Plan was updated on 09/29/2016 to reflect the pressure sore declined to a Stage 3. The Care Plan also reflected on 09/19/2016, Resident #7 was totally dependent on one to two staff for his ADLs. Observation on 09/28/2016, revealed Resident #7 sitting in a gerichair in the dining room to eat. He did not have a cushion underneath him in the gerichair. He had the hoyer lift sling underneath him. In an interview on 09/28/2016 at 5:53 PM, LVN D stated Resident #7 was not sitting on any type of cushion in his gerichair. Review of the Physician order [REDACTED].#7 dated 09/01/2016-09/30/2016, reflected no orders for a cushion in the gerichair. Observation on 09/29/2016 at 10:55 AM, revealed Resident #7 lying in his bed with an air mattress in place ready for wound care. The DON performed the wound care. Resident #7 had a stage 3 pressure sore on his sacrum that measured approximately 3 cm x 4 cm x 0.2 cm. The wound bed was a beefy red color. There was also a stage 2 pressure sore on the right buttock near the sacrum that measured approximately 1 cm x 1 cm x less than 0.1 cm. In an interview on 09/29/2016 at 11:00 AM, the DON stated he would have to look at the paperwork before he staged the pressure sore. He also stated the pressure sores would be measured the next day, not today. The DON stated he performed the treatment to the pressure sore on the weekends, so he had seen the pressure sores several times. Review of the Weekly Skin Documentation for Resident #7 reflected on 09/14/2016 he had an in-house stage 2 to his sacral area measured 6.0 cm x 4.0 cm x 0.1 cm with the tissue type as granulate & [MEDICATION NAME]. On 09/23/2016 the area measured 5.2 cm x 3.4 cm x 0.1 cm. On 09/29/2016 the sacral area worsened to a stage 3 and measured 2.9 cm x 3.4 cm x 0.2 cm with the wound bed beefy red. The other open area to the right buttock was not measured on 09/29/2016, but opened on 09/14/2016 as a stage 2 measured 1.0 cm x 1.0 cm x 0.1 cm, and re-measured as the same on 09/16/2016 and 09/23/2016. In an interview on 09/29/2016 at 11:30 AM, the RN Consultant stated he had measured the pressure sore on Resident #7's sacrum and the measurements were 2.9 cm x 3.9 cm x 0.2 cm. He also stated the pressure sore was a stage 3. He stated since the pressure sore declined, the pressure sore should have been measured by the DON today 09/29/2016. In an interview on 09/29/2016 at 1:55 PM, the RN Consultant stated Resident #7 should have had a cushion in his gerichair and the pressure sore was avoidable. Review of the facility's Pressure Ulcer Prediction, Prevention, and Treatment Pathway dated 11/2007, reflected on the flow sheet to address the possible risk factors in the chair including a pressure relieving cushion. Review of the facility's policy entitled Skin System revised on 02/15/2012, reflected Residents with pressure ulcers on the buttocks/posterior area need to have an appropriate pressure-relieving device in chairs. Review of the facility Wound Management Program reflected: Pressure Ulcer Prediction, Prevention and Treatment Pathway. Complete skin risk assessment. Complete Care Plan problem and identify at risk related to identified risk factors. Care Plan actual skin problem. Address risk factors. Chair: pressure relieving cushion, assessment of chair fit, repositioning schedule. Review of the Corporate Skin system dated 02/15/2012 reflected: 13. If a Resident has a pressure ulcer, pay close attention to the treatment evaluation date, treatment failure is reviewed at least every 14 days and the physician is notified of the assessment. 14. The DON monitors the care plan and the appropriateness of interventions. 21. A Pressure Ulcer Surveillance Report should be completed weekly the DON and uploaded to the Corporate site by 5 PM on Thursdays. 24. Review of support surfaces on Resident chairs and beds is required and documented weekly on both the weekly Pressure Ulcer Assessment form as well as the corporate site. 25. Cushions are available for purchase through a supplier. Residents with pressure ulcers on the buttocks/posterior area need to have an appropriate pressure relieving device in chairs. The facility provided a list of two (2) residents with pressure sores and nine (9) residents at high risk for pressure sores.

Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly for one (1) of six (6) residents reviewed for notification (Resident #3). Resident #3 developed a pressure sore in the facility, which declined to unstageable and 50% covered in eschar. The physician was not timely informed of the need for a new treatment, when the pressure sore advanced to three (3) cm deep or when it contained eschar so the eschar could be removed. Failure to notify the MD to get a new treatment when a pressure ulcer declines could result in wound infection, [MEDICAL CONDITION]. Findings Include: Review of Resident #3's Face Sheet reflected an [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly MDS dated [DATE], reflected she had severely impaired cognition and was totally dependent on staff for every ADL. The MDS reflected she was at risk for pressure sores and did not have any pressure sores; but also was coded as not having any pressure reducing devices on the bed or chair. Review of Resident #3's Care Plan dated 06/19/2016 and updated on 09/06/2016 for being at risk for pressure sores with interventions of; avoid shearing, keep clean and dry, keep linens wrinkle free, and report any signs of skin breakdown. Review of Resident #3's Care Plan dated 09/27/2016, reflected a problem of Pressure Ulcer and interventions included low air loss mattress and timely incontinent care, turning and repositioning. Review of Resident #3's facility Consolidated Physician Orders dated 09/01/2016 to 09/30/2016, reflected there was an order for [REDACTED]. Review of Resident #3's Hospice orders, reflected the Hospice Nurse RN initiated the order on 08/19/2016 for treatment of [REDACTED]. Observation on 09/27/2016 at 10:00 AM, reflected Resident #3 was in the lobby in a geri-chair significantly leaning to the left. In an observation on 09/28/2016 at 9:17 AM, reflected LVN B changed the dressing for Resident #3 on her right ischium (center of the lower buttock). Observation of the wound reflected it was Unstageable due to being approximately 50% covered in black eschar (Unstageable: full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan brown or black) in the wound bed). The pressure sore was approximately 5.0 cm x 4.5 cm x 3.0 cm deep (approximately slightly bigger than half a golf ball in size). The wound bed had yellow slough in the center and black/gray eschar across half the wound bed. The wound was eroding (tunneling) into the muscle at the top (towards the upper buttock), approximately one centimeter under the overlying skin. In an interview on Wednesday, 09/28/2016 at 9:19 AM, LVN B stated the plan was to change the treatment because the facility had been doing the same treatment since the ulcer developed. She stated the ulcer was not improving and she had called Hospice that morning asking for a new treatment. She stated she could see eschar, slough, and now the wound was tunneling. LVN B stated she did not have any wound care training. When asked who she consulted with regarding wound changes, failure to heal and what dressing was appropriate, she stated she would ask the Hospice Nurse and she would always say, Well, what do you think? LVN B further stated when she asked the doctor for direction, the physician responded, What would you like to do? LVN B stated she searched the Internet for what her options were for treatment dressings. LVN B further stated she was responsible for measuring and staging the wounds on Thursdays and with significant changes. She stated a significant change was when the wound grew by two or three centimeters. Review of Resident #3's August and September 2016 Treatment Flow sheets, reflected an order dated 08/18/2016; Clean area to right ischium with normal saline, pat dry, apply calcium silver and bordered dressing daily and as needed for soilage. It was signed by either LVN B or the DON almost every day. Review of Resident #3's Weekly Skin Documentation reflected the pressure sore was identified on 08/18/2016 to her right ischium: · 8/18/2016 4.5 x 1.5 and 0.1 cm deep it had drainage of clear fluids and blood and [MEDICATION NAME] tissue was present, Stage 2. (Stage 2 - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. NPUAP guidelines). · 08/25/2016 (7 days) it had increased in size to 7.2 cm x 3.5 cm x 0.4 cm deep. It was documented as a Stage 2. (This was mis-staged due to depth. It should have been staged a Stage 3). (Stage 3 - full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. NPUAP guidelines). · 09/01/2016 10 cm x 7.2 cm x 3.0 cm deep, Stage 3. Granulate tissue, dark red. (The wound was less than half a centimeter deep seven days previous and now was documented to be three full centimeters deep.) · 09/08/2016 10.2 cm x 6.0 cm x 4.0 cm, Eschar 50%, yellow green drainage, moderate amount, with an odor, Stage 3. (Eschar- tan, brown or black in the wound base-NPUAP guidelines.) (At 50% eschar the physician needed to be notified so that a new treatment could remove the eschar.) · 09/22/2016 11.0 cm x 10.0 cm x 5.2 cm deep, Stage 4. Granulate and [MEDICATION NAME] tissue. (Stage 4 - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling- NPUAP guidelines). · 09/29/2016 5.0 cm x 4.5 cm x 3.4 cm gray/yellow slough to upper/lower and center of wound bed. 1.7 cm tunneling. Unstageable. (Unstageable- Full thickness tissue loss in which the base of the ulcer is covered by slough- NPUAP guidelines. Tunneling - an invagination or a blind opening into the tissue; facility Wound Document Guidelines 02/15/2012). Review of Resident #3's Daily Pressure Ulcer documentation reflected: on 08/31/2016 when the wound depth was significantly increased; Hospice aware of change in wound. On 09/06/2016, LVN B documented Eschar noted to lower approximately half of the wound. Upper half noted with healthy pink/red beefy granulate tissue. 09/07/2016 Continues with Eschar and granulate tissue to wound bed same as 09/06/2016. The notes did not reflect any notification of the Hospice MD or the Primary MD. The treatment was not changed to remove the eschar tissue. Review of Resident #3's Nurse Notes reflected there were no entries made in the chart from 08/21/2016 until 09/14/2016. From 09/14/2016 to 09/27/2016 there were no notes regarding notification of the Primary MD or the Hospice MD of the decline in the pressure sore. There was no note requesting a change of treatment until 09/28/2016 during the survey. In an interview on 09/28/2016 at 1:10 PM the DON stated LVN B did the facility staging of wounds. The DON stated he changed Resident #3's dressing on Sunday and saw it was black and had yellow in it and was beginning to tunnel. The DON stated he told LVN B on Monday and she agreed with him it was tunneling. He stated he did not call the doctor Sunday or Monday but he believed LVN B did on Monday. The DON stated he is the charge nurse on the weekends and did Resident #3's pressure sore treatment every week at least once. In an interview on 09/28/2016 at 2:23 PM Resident #3's Primary MD stated the facility night nurse had called her on Monday 09/26/2016 regarding Resident #3's pressure ulcer and told her it wasn't getting any better. The Primary MD stated the last time she saw Resident #3 was in July 2016 and Resident #3 did not have the pressure sore then. She stated she had not been told anything else about the pressure sore until Monday 09/26/2016 by the night shift charge nurse. She stated she was Resident #3's attending physician even though Resident #3 was on Hospice. The Primary MD stated when a wound develops eschar or slough it needs a [MEDICATION NAME] agent to clean out the dead tissue. In an interview on 09/29/2016 at 9:03 AM the Hospice Nurse RN stated she had probably seen Resident #3's wound a week ago. She stated the Hospice really doesn't treat wounds but is more aware of pain management. She stated the last time she saw the wound, last week, it was really nasty, Stage 3 and about 50% black. She stated she occasionally looked at wound documentation but really did not remember looking at Resident #3's documentation. She further stated she saw what the wound looked like when LVN B showed her a picture of it. She stated she did not provide treatment recommendations. Hospice Nurse RN did not say she had informed the Hospice MD of the decline. In an interview on 09/29/2016 at 4:30 PM the Hospice MD was asked who should the staff be notifying of Resident #3's worsening wound. The Hospice MD stated he had not met Resident #3 or seen her pressure ulcer. When asked if he had been notified of the pressure ulcer he stated he was sure he had been because the Hospice staff discussed her care every two weeks. He stated he could not remember anything discussed and could not access his computerized notes at the interview time. After surveyor informed the Hospice MD about Resident #3's pressure sore status, he stated Resident #3 probably did need a cushion in her geri-chair and some debridement of the eschar. He stated he would have ordered a chemical debridement ointment if he had known it was 50% eschar. He stated he did not recall anyone asking him for any specific advice on wound dressings or treatments for Resident #3. In an interview on 09/28/2016 at 6:00 PM right after Resident #3's Primary MD had just observed her pressure sore to her right ischium (on day two (2) of the survey), the Primary MD stated the dressing order needed to be changed and she would have ordered a dressing to remove the dead tissue sooner if she had known the eschar was present. She further stated it would have been helpful if the staff knew how to correctly stage wounds so that she would know better what they were observing when they communicated with her. Review of Resident #3's Physician order dated 09/28/2016 reflected to discontinue the previous dressing and start a daily wet to dry dressing to debride the eschar, place a geri chair pad and notify the MD when the slough/eschar is removed for further treatment orders. Review of Resident #3's Physician order dated 09/29/2016, reflected to discontinue the wet to dry dressing and use an ointment to cause chemical debridement daily to dissolve the eschar. In an interview on 09/29/2016 at 4:37 PM, the DON stated he expected the staff to notify the MD of wound declines and changes. In an interview on 09/28/2016 at 3:57 PM, the Administrator stated LVN B is a charge nurse in nursing school to become an RN and she stages the wounds. In an interview on 09/29/2016 at 9:30 AM, the facility's RN Consultant stated a pressure sore that was over 0.1 cm deep could not be a stage 2, but was worse and LVN B had miss-staged the wound on 08/25/2016. He further stated when 50% eschar is present the wound should not have been staged at a stage 3 but could not be staged because the wound base was not visible. He further stated ultimately it was his responsibility to make sure the facility was taking proper care to prevent and treat pressure sores. Review of the facility policy; Change in a Resident's Condition or Status revised 07/24/2014 reflected; 1. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: e. a need to alter treatment significantly. The facility provided a list of two (2) residents with pressure sores at risk for not having the correct treatment in place.

Based on observation, interview and record review the facility failed to maintain acceptable parameters of nutritional status such as body weight for one (1) of two (2) residents (Resident #2) reviewed for weight loss and for two (2) of nine (9) residents (Resident #4 and Resident #17) reviewed for Dietary recommendations. A) The facility failed to maintain or increase Resident #2's weight and did not provide physician ordered health shakes to the resident as ordered from 07/15/2015 to 08/12/15 when surveyor intervened. Resident # 2 had a significant weight loss of 5.26% in one month's time. This deficient practice affected Resident # 2 and placed one (1) other resident at risk for significant weight loss and malnutrition which could lead to a decreased quality of life, dehydration and infection. B) The facility failed to follow-up on Resident #4's Dietary Recommendation on 06/24/2015 for 2 cal supplement 90 cc TID with meals with the physician and failed to provide the physician ordered health shakes as ordered to Resident #17. This deficient practice could place 7 residents at risk for significant weight loss and malnutrition which could lead to a decreased quality of life, dehydration and infection. Findings Include: A) Review of Resident #2's Face Sheet reflected a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2 ' s Quarterly MDS assessment dated [DATE] reflected her cognitive skills for daily decision making to be severely impaired. It further reflected her height to be 56 inches (4 feet 8 inches) and her weight to be 68 pounds. It further reflected none or unknown weight loss. Review of the facility's weight variance report for Resident #2 reflected her monthly weights: · 05/05/15: 71.2 pounds · 06/05/15: 71.6 pounds · 07/08/15: 68.4 pounds · 08/07/15: 64.8 pounds Resident # 2 had 3.6 lb weight loss (5.26%) from 07/08/15 to 08/07/15, which is a 30 day time period. Resident #2 had 6.4 lb weight loss (8.98%) from 05/05/15 to 08/07/15, which is a 3- month time period. These are both notably severe weight losses, defined as greater than 5% in 1 month and greater than 7.5% in 3 months time period. During an Interview on 8/12/15 at 10:26 am, when was asked about Resident #2's eating habits, LVN A stated resident refuses snacks and often refuses meals if unfamiliar face tries to feed resident. She further stated that resident has become more picky about what she wants to eat. She furher stated that they offered Resident #2 snacks TID and that sometimes resident accepted. Then she further stated that Resident #2 was given supplement QD either with lunch or dinner. In an interview on 08/13/15 at 10:25 am the Dietary Manager stated the facility had ran out on Monday (08/10/15) for health shakes for all residents and LVN A was notified about the health shakes being out of stock. In an interview on 08/13/2015 at 10:30 AM LVN A stated she found out Monday morning the facility was out of health shakes so she started supplementing 2 cal to the residents who would drink it but did not contact the doctor. Review of Resident #2's most recent dietary progress note dated 07/15/15 reflected: weight varies often- continues with good meal intake usually .mechanical soft diet, food of choice per request .snacks TID, 30 ml protein QD .recommendation: add health shake QD x 60 days. Goal: maintain weight or gradual gain. Review of dietary communication order dated 07/15/15 reflected Resident #2 had gradual weight loss and a recommendation of adding a health shake to her diet QD was made by facility's RD. The order further reflected the attending physician agreed and signed the order on 07/28/15 and noted by Charge Nurse, LVN A on 07/29/15. Review of consolidated physician order [REDACTED]. Further review reflected the start date of this order to be 07/29/15. Observation on 08/12/15 at 12:48 PM of Resident #2 revealed no health shake offered to resident during lunch meal. Further observation on 08/12/15 at 5:30 PM of Resident #2 revealed no health shake offered to resident during dinner meal. During an interview on 08/13/15 at 10:29 AM the Dietary Manager stated she did not receive notification that Resident #2 was supposed to receive health shakes. She further stated that she had not been providing any health shakes to Resident #2 and that health shakes are only given by kitchen staff. Review of Resident #2's meal tickets from 08/13/15 did not include health shakes to be given with the meals. During an interview on 08/13/15 at 10:43 AM LVN A stated after the doctor had signed the order for addition of health shakes to Resident #2's diet then LVN A wrote the order and gave communication order to dietary manager on 07/29/15. During an interview on 08/13/15 at 11:04 AM the facility's Registered Dietitian (RD) stated she is in the facility once monthly and she follows up on her orders the following month when she returns to the facility. She further stated the facility should call her if there is a problem. During an interview on 08/13/15 at 3:30 PM the DON stated she sent the order for addition of health shakes to Resident # 2's diet via fax to the doctor on 07/16/15 and then sent a second request on 07/27/15. The DON further stated someone in the office of the doctor is not getting the order to the doctor timely. The DON stated she expected the doctor to reply to the order within 72 hours; and if the order was not received and in the chart by the nursing staff that the order would be refaxed concurrently. She further stated she did not follow through with the order in the 72 hours following when the fax was originally sent out. In an interview on 08/13/15 at 8:15 PM the facility's RD stated she had no way of knowing if Resident #2 would have accepted the shake she had recommended and there was only a possibility that if she accepted the shake she may not have lost as much weight over the past month. The RD also stated she expected the staff to enact the orders when the physician signed the order. She stated it would be up to the facility to determine what a reasonable time frame to act on her recommendations and get them in place would be. The RD stated her goal was for the resident to maintain her weight. In an interview on 08/13/15 at 8:45 PM, the Medical Director stated she expected the staff to enact orders when she signed them. She stated the resident's main calorie intake should always be the meal. She stated the shake may have helped prevent some of the weight loss but the shake would not be the main meal. Review of facility's Weight System: Weight Documentation policy dated 05/21/14 reflected: DON/designee will be responsible for reviewing residents ' weights to determine significant weight loss and initiate weekly weight plan/intervention as necessary .physician, consultant dietitian will be notified of significant weight loss .implement additional interventions or recommendations as made by notification. The facility provided a list of two (2) residents with significant weight loss. B) Review of Resident #4's Face Sheet reflected an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #4's Quarterly MDS assessment dated [DATE] reflected no significant weight loss. The Quarterly MDS Assessment reflected a BIMS score of 3 indicating she was severely cognitively impaired. Review of Resident #4's Comprehensive Care Plan initiated on 06/01/2015 reflected Resident #4 had health shakes with meals and approach included to make sure Resident #4 received any supplements ordered by the doctor. Review of Resident #4's Dietary Recommendation dated 06/24/2015, signed by the Registered Dietitian, reflected the Resident had gradual weight loss this quarter and recommended to increase 2 cal sup 90 cc TID w/ meal pass x 90 days. The Dietary recommendation was not signed by the doctor. Review of Resident #4's Consolidated Physician order [REDACTED]. Observation on 08/11/2015 at 5:35 PM revealed Resident #4 did not have a health shake with her dinner meal. In an interview on 08/13/2015 at 10:25 AM the Dietary Manager stated Resident #4 was on the list to be given health shakes, but the facility had ran out on Monday for health shakes for all residents and LVN A was notified about the health shakes being out of stock. In an interview on 08/13/2015 at 10:30 AM LVN A stated she found out Monday morning the facility was out of health shakes so she started supplementing 2 cal to the residents who would drink it but did not contact the doctor. LVN A stated she was not marking on the Meal Intake Record if a resident refused or accepted the health shake. LVN A stated she was used to it being on the MAR for each resident but it was not on there either. In an interview on 08/13/2015 at 8:50 AM the DON stated the RD gave her the Dietary recommendation and she faxed it to the doctor on 06/25/2015. The DON stated she should have followed up with the doctor to get a physician order [REDACTED].#4's Meal Intake Record if Resident accepted or refused the health shake. The DON stated the LVNs were not documenting it correctly so the only way she knew if Resident #4 was receiving and drinking her shake at her meals was if the DON was in the dining room observing Resident #4. Review of Resident #17's face sheet reflected a [AGE] year old female with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED].#17 dated 08/01/2015- 09/29/2015 reflected a diet order for pureed diet with honey thickened liquids and health shakes four times a day; between meals and at night (thickened to honey consistency). During an interview on 8/13/15 at 7:16 PM, LVN B stated Resident #17's diet was puree with honey thick liquids. When asked about her health shakes, LVN B stated Resident #17 gets shakes with meals and not at night/bedtime. LVN B then read the order and stated, So is she getting it 5 times a day? Then LVN B stated she should receive supplements at 8:00 am, 1:00 pm, 5:30pm, and 8:00 pm. Review of Resident #17's meal intake record for August 2015 reflected a slash through the supplement column for lunch time on 08/01/15-08/04/15 and 08/09/15. It further reflected a slash through dinner time in the supplement column for 08/01/15-08/09/15 and 08/12/15. It further reflected blank documentation on HS (bedtime) supplements between 08/01/15-08/13/15 not including 08/10/15 and 08/12/15 were there were slashes instead. In an interview on 08/13/2015 at 10:30 AM the LVN A stated she was not marking on the Meal Intake Record if a resident refused or accepted the health shake. LVN A stated she was used to it being on the MAR for each resident but it was not on there either. Review of facility's policy Alternative Nutrition Interventions Modular Supplements dated 05/01/2014 reflected Modular supplementation will be provided per physician's orders [REDACTED]. The policy reflected nursing was responsible for charting documentation of supplements. The facility provided a list of 5 residents with physician ordered health shake supplements. This list did not include Resident #2 and Resident #17 who are listed above. Total residents on health shakes should reflect 7.

Based on observation, interview, and record review the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for two (2) of 12 residents (Residents #1, and #7) reviewed for abuse and neglect when: A) The facility did not identify a Stage II Pressure Sore that declined to a Stage III Pressure Sore and did not identify a separate Stage III Pressure Sore for Resident # 1 until Surveyor Intervention. B) Resident #7 was found to be sitting in a urine soaked brief and dress and had not been checked for incontinence or changed by staff for over four hours. Resident #7's skin showed signs of moisture-associated skin damage (MASD) which caused pain and discomfort for Resident #7 during incontinent care. This deficient practice affected two residents (Resident # 1 and # 7) and placed and additional eight (8) residents at risk for development of new pressure sores, infection and worsening of current pressure sore. This deficient practice placed two (2) residents at risk of further weight loss or gain, increased risk of pressure ulcers and an overall decline in their physical and psychosocial condition. This deficient practice placed 18 incontient residents of at risk for loss of dignity, self-worth, skin breakdown and pain. Findings Include: Review of the facility's policy Abuse and Neglect Policy and Procedure dated 11/11/2011 reflected "Our facility implements an effective system for the prevention of abuse and neglect...1. Identify, assess, care-plan, and monitor residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents with self-injurious behaviors, residents with communication disorders, and those that require heavy nursing care or are totally dependent on staff...To assist our facility's staff members in recognizing incidents of abuse, the following definitions of abuse are provided...g. Neglect is defined as failure to provide goods and service necessary to avoid physical harm, mental anguish, or mental illness." A) Review of Resident #1's Face Sheet reflected an [AGE] year old male admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #1 had a BIMS's of zero (0) indicating he had severe cognitive impairment. Resident #1 was assessed to require total assist with all ADL's. Resident #1 was assessed to have one (1) Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.) pressure ulcer with the identification of 06/24/2014. The pressure sore was assessed to have granulation tissue. Review of Resident #1's Comprehensive Care Plan reflected a problem with a start date of 05/09/2014 "Resident is at risk for pressure ulcers R/T (related to) bowel incontinence, age and the need for assist with ADL's." Under approach " Report any signs of skin breakdown (sore, tender, red, or broken areas) ...Monitor and record intake of food." Review of Resident #1's Acute Care Plan dated 06/26/2014 reflected " I have a Stg (Stage) two (2) decub (decubitus) on my buttocks." Handwritten under the problem was a measurement 1.5 cm by 1 cm. Under Approaches " ...Notify my MD of any changes better or worse ....Make sure I get the proper nutrition so that my Stg two (2) decub will heal. " The care plan did not state which buttock the pressure sore was on. Review of Resident #1's Consolidated Physician order [REDACTED]. " dated 06/24/2014. The order did not address a location of the pressure sore. Observation on 07/14/2014 at 6:30 PM revealed Resident #1 up in his wheelchair in the living room asleep. Observation on 07/15/2014 at 9:50 AM revealed Resident #1 in bed. Resident #1 was on an air mattress. Bilateral knee contractures were noted. Resident #1 was unable to communicate with the Surveyor. In an interview on 07/15/2014 at 11:00 AM LVN C stated she already completed Resident #1's skin assessment and his treatments for his pressure sore. Review of Resident #1's Weekly Skin Documentation dated 07/8/2014 reflected Resident #1 had a Stage II pressure sore to his left buttock. The documented measurements were 0.8 cm long with width of 0.7 cm no depth was documented; no further description was documented. The assessment was signed by LVN C. The assessment did not reflect any other skin conditions for Resident #1. Review of Resident #1's Treatment Administration Record (TAR) for July 2014 reflected Resident #1 had a head to toe skin assessment completed on 07/09/2014 and signed by LVN C. The TAR further reflected an order to cleanse Stg. (Stage) 2 Decub. (Decubitus) with NS apply [MEDICATION NAME] alginate in wound bed cover with 4 x 4 drsg. (Dressing) once a day. The order was initialed by LVN C on 07/14/2014 and 07/15/2014. The order did not reflect a location of the pressure sore. Review of Resident #1's Weekly Skin Documentation dated 07/15/2014 no time reflected Resident #1 had a Stage II on his left buttock. The documented measurements were 0.8 cm long with width of 0.7 cm no depth was documented not further description was documented. The assessment was signed by LVN C. The assessment did not reflect any other skin conditions for Resident #1. Observation on 07/15/2014 at 3:55 PM revealed CNA G and CNA H in Resident #1's room to perform incontinent care. Resident #1 was in bed. CNA G and CNA H rolled Resident #1 to his left side. Resident #1 was noted to have a dressing over his right buttock and left buttock. Resident #1 was incontinent of bowel. During the incontinent care Resident #1's dressings became soiled with bowel movement. CNA G removed the dressings (which was not dated or initialed) stating she was going to get the nurse and tell her she removed to dressings. CNA G removed the dressing which revealed: Resident #1 to have a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendons or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. It may include undermining and tunneling) pressure sore to his right buttock approximately 2 cm by 2 cm with greater than 0.1 cm depth. The pressure sore wound bed had yellow slough (a type of dead tissue) from 8 o'clock to 4 o'clock and shiny red granulation tissue from 4 o'clock to 8 o'clock. The wound edges were macerated and a pale gray color extending out approximately 0.3 cm. The peri-wound extended out approximately 1 cm around pressure sore and was slightly red. No drainage was noted. Further observation revealed Resident #1 to have a Stage III pressure sore to his left buttock approximately 0.8 cm long by 0.6 cm wide with greater than 0.1 cm depth. The pressure sore wound bed had shiny red granulation tissue. The wound edges were beveled. The peri-wound extended out approximately 1.5 cm and were pale gray. (Approximations by Surveyor) CNA H went to get Resident #1's nurse and Director of Nursing (DON). Review of the <http://www.woundsource.com/article/identifying-types-tissues-found-pressure-ulcers> website reflected "Granulation tissue- The formation of granulation tissue is thought to be an intermediate step in the healing process of full-thickness wounds. Granulation tissue is shiny red and granular in appearance when it is healthy; when inadequate blood flow exists, granulation tissue may pale in color. Slough- Slough is indicative of full-thickness Stage 3 pressure ulcers or stage 4 pressure ulcers. Slough can easily be confused with normal anatomical tissues such as tendons or ligaments because of their frequently yellowish coloration. " In an interview on 07/15/2014 at 4:05 PM CNA G stated she worked with Resident #1 every day she worked and she stated the pressure sore on his right buttock had been there at least since last Wednesday (7/09/2014) because she came back after vacation and it was there. CNA G stated she reported it to the nurse LVN E. Observation on 07/15/2014 at 4:10 PM revealed the DON and LVN E entering Resident #1's room to assess Resident #1's pressure sores. During this observation LVN E stated the area on his right buttock was new and she had not seen it before and did not know about it. LVN E further stated Resident #1 skin assessments were done on the day shift so she was unsure about the pressure sore decline on his left buttock. In an interview on 07/15/2014 at 4:15 PM after the DON observed Resident #1's right buttock pressure sore she stated " That is new. I only knew about the left buttock and that one (pointing to the right buttock pressure sore) was not there last week (07/08/14) when I looked at his skin on his skin assessment day." The DON stated she observed Resident # 1's skin assessment last week on 07/08/2014. When asked what stage the pressure sores were the DON stated they were Stage III. The DON further stated the pressure sore on Resident #1's left buttock was a Stage III and had declined since last week. When asked about the skin assessment performed this morning by LVN C the DON stated she was going to look into the situation. In an interview on 07/15/2014 at 4:40 PM the DON stated she spoke with LVN C who stated to her Resident # 1 had barrier cream on his right buttock and she did not see the right buttock pressure sore. The DON further stated she called Resident # 1's Physician for orders on the right and left buttock pressure sores. The DON stated she expected the nursing staff to complete head to toe assessments weekly on the residents and if there was barrier cream to remove it to do a complete assessment. The DON further stated the nurses are not documenting the pressure sores correctly. The DON stated the nurses are suppose4d to document the wound bed and peri-wound and wound margins and they are not. The DON stated LVN C did not fill out the assessment fully or perform a correct assessment. Review of Resident #1's Physician Telephone Order dated 07/15/2014 no time reflected the following orders after Surveyor intervention "Cleanse Stg. III decub on right buttock with NS (normal saline) apply wound gel cover with bordered gauze q day. Cleanse Stg. III decub on left buttock with NS apply wound gel cover with bordered gauze q day. Once Santyl arrives in facility, Cleanse right buttock with NS apply Santyl and cover with bordered gauze. Cleanse left buttock Stg. III decub with NS apply Santyl and cover with bordered gauze q day." In an interview on 07/16/2014 8:32 AM LVN C stated Resident #1's had barrier cream on his right buttock and she did not see anything. LVN C further stated " I honestly only looked at the one area" (referring to his left buttock) and did not do a complete assessment. LVN C stated she did not remember seeing any other areas except the left buttock while doing the skin assessment the week before. LVN C did not know who put the dressing on Resident #1's right buttock. LVN C stated that she has not had any skills check offs or training since she's been employed at the facility. In an interview on 07/16/2014 at 9:30 AM CNA I stated Resident #1 had the pressure sore on his right buttock when she saw it, about a week ago. CNA I stated she was not sure exactly how long but that she reported the area to LVN C. In an interview on 07/16/2014 at 5:03 PM the DON stated is did not know who does the competency and skills check offs and training with the nurses for wound care. The DON stated she did not do them. DON stated that Regional Nurse A just informed her that there was a wound care competency skills check off in the facility's SharePoint program in the computer. The DON stated that she will start using them for the nurses and denied doing any wound care training for LVN C. Review of Resident #1's Dietary Consultant recommendation dated 05/16/2014 reflected "Problem or Concern: ....-underweight; has unstageable wound. Recommendations: Add 2 cal supplement 60 cc QID with med pass, Add Arginiad one (1) packet BID, Add large portion at all meals, Consider ST (Speech Therapy) eval d/t (due to) possible diet texture upgrade." Further review reflected the dietary recommendation was signed by Resident #1's Physician on 06/03/2014 (18 days later). Review of Resident #1's Physician Telephone orders reflected an order written [REDACTED]." Review of the Dietary progress notes dated 06/19/2014 reflected "Weight down 16 pounds in one (1) month (12%) down five (5) pounds since last visit. Has Stage II wound to Left buttocks, unstageable to right heel. Has MBSS (modified [MEDICATION NAME] swallow study) ordered." In an interview on 07/16/2014 at 5:00 PM the DON stated she faxed the dietary recommendation to the Physician and waited on him to respond. The DON stated she was responsible to follow up on dietary recommendation and further stated "I guess I need to call the Physician if he does not respond in a few days or fax the Physician back." In an interview on 07/17/2014 at 10:00 AM the Dietary Consultant stated she expected recommendations to follow up on timely. The Dietary Consultant stated "It would have helped Resident #1 to have the extra protein and calories especially with his pressure ulcers." In an interview on 07/17/2014 at 8:50 AM the Medial Director stated he expected the nursing staff to do a thorough head to toe assessment weekly and notify the Physician right away with any finding. The Medical Director further stated staff should monitor skin daily during care and report if any pressure sores found so treatment can be initiated. The Medical Director stated if the dietary consultant makes recommendations he expected the facility to follow up on them on one (1) to two (2) days. Review of the Facility's Policy Skin System dated 02/15/2012 reflected " 6. The Weekly Skin Assessment form is completed weekly for Residents with presence of skin interruptions of any type. If no skin interruption is identified, the nurse assessor will document the assessment performed weekly on the TAR. 7. The facility DON is responsible for assignment of weekly skin assessments ... 10. The facility DON should visualize areas related to pressure weekly and be able to report observations to the Standards of Care Team members. The DON is validating the accuracy of the description of the pressure ulcer documentation on the weekly assessment form." Review of the facility's policy Weight system dated 05/21/2014 reflected "7. DON/designee will be responsible for reviewing residents' weights to determine significant weight loss/gain and initiate weekly weight plan/intervention as necessary. 8. Physician, Consultant Dietitian, and resident/family will be notified of significant weight loss/gain. (i.e.. 5% one month or 10% six months). Implement additional interventions or recommendations as made by notification...12. The standards of care committee will review significant weight losses and gains weekly and document recommendations/ interventions...Care plans should be updated at this time." B) Review of Resident #7's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #7's Annual MDS assessment dated [DATE] reflected Resident #7 was assessed to have a BIMS score of 2 indicating the Resident had severe cognitive impairment. Resident #7 was assessed to require extensive assistance with one (1) person physical assist for bed mobility, locomotion on the unit, and with eating. Resident #7 was assessed and observed to be totally dependent and required full staff performance of one (1) person physical assist with ADLs including locomotion off the unit (wheel chair), dressing, toileting, personal hygiene and bathing. Resident #7's MDS reflected two (2) person physical assist was required for transfers and Resident #7 did not ambulate. Resident #7 was assessed to be always incontinent of urine and stool and at risk for pressure ulcers. Review of Resident #7's Care Plan dated 05/02/2014 reflected the Resident to be at risk for skin breakdown if she is not cleaned properly and regularly due to urinary and bowel incontinence, cognitive loss, and Diabetes Mellitus. A goal reflected Resident #7's skin remains clean and dry and intact. Approaches reflected Resident #7's skin be kept as clean and dry as possible, to minimize skin exposure to moisture, to provide incontinent care after each incontinent episode, to keep linens clean dry, wrinkle free, to observe and report red areas noted, and to avoid shearing of skin during repositioning and transfers. Observation on 07/16/2014 at 8:55AM of a two (2) person assistance transfer revealed CNA I and CNA J used a gait belt to lift Resident # 7 up from her wheelchair and transferred her onto the bed. Resident #7 had urine dripping from her brief and the urine saturated dress she was wearing. A strong urine odor was observed after the transfer. CNA I stated to CNA J that the chair was wet and she would have to wipe it down. Resident #7's wheelchair cushion revealed scattered wet spots on top of it. CNA I told CNA J that they needed to do incontinent care on Resident #7. Resident #7 was assisted into a lying position onto her back in the bed while supplies were gathered. Resident #7 touched the back of her dress and stated "My seat's wet and its cold! " CNA J informed Resident #7 that CNA I was getting stuff together so they could get her cleaned up. Observation on 07/16/2014 at 9:00 AM of incontinent care revealed Resident #7 flinched and grimaced as CNA I was wiping urine from Resident #7's buttocks and thighs. Resident # 7 stated "Oh! It hurts all over right there." Resident #7's left and right buttocks were dark red from top to bottom and the back of the left upper thigh was also dark red. The coccyx and sacral area revealed a raised white discoloration of the skin (maceration - to soften and wear away especially as a result of being wetted or steeped) with multiple linear skin breaks and cracks (fissures - a break or slit in tissue usually at the junction of skin and mucous membrane) to the center of the white (macerated) raised area. CNA I told Resident #7 that her skin was red and she was going to let the nurse know so that someone could put something on it to make it feel better. In an interview on 07/16/2014 at 9:15 AM CNA I stated that Resident #7's skin was not normally red or white and doesn't usually have cracking like that. CNA I stated she was going to notify the nurse so something could be put on it. CNA I stated that this was the first time Resident #7 was checked for incontinence on her shift because Resident #7 was on the list for 10-6 shift to get up and get ready for breakfast. CNA I stated that first rounds were started after breakfast at 8:30 AM for the Residents that they don't get up in the morning. Observation on 07/16/2014 at 9:20 AM revealed the DON at bedside assessing Resident #7's abnormalities to her bilateral buttocks and to the back of the Resident's left upper thigh. The DON stated "This looks like it's caused from moisture being against her skin when she wets and it doesn't help in the way that she wiggles around in her chair." CNA I then stated to the DON that Resident #7 does move around a lot. In an interview on 07/16/2014 at 11:00 AM CNA M (who worked the 10PM-6AM shift on 7/15/14 - 7/16/14) stated Resident #7 was checked for incontinence and had to be changed every two hours because Resident #7 was found wet on each round last night on the 10P-6A shift. CNA M stated she made a last round and changed Resident #7 at about 4:30AM or 4:45 AM this morning when she got her up and dressed for breakfast. CNA M stated Resident #7 did not have any redness or sores to her skin. The Surveyor asked CNA M how she remembered what time she changed Resident #7 on that last round. CNA M stated "I remember because she was the last person I changed right before I stopped to take a five minute break. I wheeled her up to the front sitting area on my way outside. I looked at my clock and it was 4:55 AM and that's when I went outside for a five minute break." CNA M stated after the break she returned to make rounds on the rest of her residents and completed the last rounds between 5:30 AM and 5:45 AM. In an interview on 07/16/2014 at 5:03 PM the DON stated the CNA's are given an assignment sheet to follow that reflects the ADL care that is needed for all Residents on their assigned halls. The DON reviewed the assignment sheet for Resident #7 and stated it reflected the 10PM -6 AM CNA's get Resident #7 up for breakfast in the morning. The Surveyor informed the DON Resident #7 went over four (4) hours without being checked for incontinence or changed between the hours 4:30 AM and 9 :00 AM. The DON stated it is facility policy to check all Residents that are incontinent every two (2) hours and that she expected that to be done regardless of which shift gets a Resident up for breakfast. The DON stated the nurses help supervise the CNA's and make changes to the assignment sheets and further stated she needed to inservice the staff b/c she susspects the CNA's on 6A-2P shift are not making rounds on the Residents that the 10 P - 6A shift gets up for breakfast. until after breakfast. DON stated that she also needed to make some changes to the assignment sheets. The DON stated Resident #7's doctor had been notified of her skin redness and moisture problem to the buttocks and thighs and that a moisture barrier cream was ordered to treat the areas. The DON stated Resident #7's doctor also instructed staff to keep an eye on the areas and to notify him if they got worse. . In an interview on 07/17/2014 at 8:50 AM the Medical Director stated he expected staff to make rounds every two (2) hours and provide care when needed. The Medical Director stated it was not appropriate for a resident to go four (4) hours without care which could cause skin issues. The Medical Director further stated he felt the nurse aides were overwhelmed because there was so much heavy care at the facility and not enough help. In an interview on 07/17/2014 at 2:15 PM CNA I stated that Resident #7's skin was still red and that they were checking and changing her every two hours and using cream on her. CNA I stated that Resident #7's pain was still the same today stating that Resident #7 complains that areas feel sore during care same as yesterday. Review of the Website: <http://www.ncbi.nlm.nih.gov/pubmed/ 547>: reflected " Moisture-associated skin damage (MASD) is caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents. MASD is characterized by inflammation of the skin, occurring with or without erosion or secondary cutaneous infection. Multiple conditions may result in MASD; 4 of the most common forms are incontinence-associated [MEDICAL CONDITION], intertriginous [MEDICAL CONDITION], periwound moisture-associated [MEDICAL CONDITION], and [MEDICATION NAME] moisture-associated [MEDICAL CONDITION] ...To prevent MASD, clinicians need to be vigilant both in maintaining optimal skin conditions and in diagnosing and treating minor cases of MASD prior to progression and skin breakdown. " Review of the facility's policy for Nursing Assistant Guidelines (no date) reflected the policy did not address following the residents plan of care or how often care should be provided. The facility provided a list of ten (10) residents at risk for development of new pressure sores, two (2) residents at risk of weight loss and 18 incontinent residents.

Based on observation, interview, and record review the facility failed to implement policies and procedures to prohibit neglect for two (2) of 12 residents (Resident #1 and #7) reviewed for abuse and neglect when: A) The facility did not identify a Stage II Pressure Sore that declined to a Stage III Pressure Sore and did not identify a separate Stage III Pressure Sore for Resident # 1 until Surveyor Intervention. B) Resident #7 was found to be sitting in a urine soaked brief and dress and had not been checked for incontinence or changed by staff for over four hours. Resident #7's skin showed signs of moisture-associated skin damage (MASD) which caused pain and discomfort for Resident #7 during incontinent care. This deficient practice affected two (2) Residents (Resident # 1 and # 7) and placed an additional eight (8) residents at risk for development of new pressure sores, infection and worsening of current pressure sore. This deficient practice placed 18 incontinent residents at risk for loss of dignity, self-worth, skin breakdown and pain. Findings Include: Review of the facility's policy Abuse and Neglect Policy and Procedure dated 11/11/2011 reflected "Our facility implements an effective system for the prevention of abuse and neglect...1. Identify, assess, care-plan, and monitor residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents with self-injurious behaviors, residents with communication disorders, and those that require heavy nursing care or are totally dependent on staff...To assist our facility's staff members in recognizing incidents of abuse, the following definitions of abuse are provided...g. Neglect is defined as failure to provide goods and service necessary to avoid physical harm, mental anguish, or mental illness." A) Review of Resident #1's Face Sheet reflected an [AGE] year old male admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #1 had a BIMS's of zero (0) indicating he had severe cognitive impairment. Resident #1 was assessed to require total assist with all ADL's. Resident #1 was assessed to have one (1) Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.) pressure ulcer with the identification of 06/24/2014. The pressure sore was assessed to have granulation tissue. Review of Resident #1's Comprehensive Care Plan reflected a problem with a start date of 05/09/2014 "Resident is at risk for pressure ulcers R/T (related to) bowel incontinence, age and the need for assist with ADL's." Under approach " Report any signs of skin breakdown (sore, tender, red, or broken areas) ...Monitor and record intake of food." Review of Resident #1's Acute Care Plan dated 06/26/2014 reflected " I have a Stg (Stage) two (2) decub (decubitus) on my buttocks." Handwritten under the problem was a measurement 1.5 cm by 1 cm. Under Approaches " ...Notify my MD of any changes better or worse ....Make sure I get the proper nutrition so that my Stg two (2) decub will heal. " The care plan did not state which buttock the pressure sore was on. Review of Resident #1's Consolidated Physician order [REDACTED]. " dated 06/24/2014. The order did not address a location of the pressure sore. Observation on 07/14/2014 at 6:30 PM revealed Resident #1 up in his wheelchair in the living room asleep. Observation on 07/15/2014 at 9:50 AM revealed Resident #1 in bed. Resident #1 was on an air mattress. Bilateral knee contractures were noted. Resident #1 was unable to communicate with the Surveyor. In an interview on 07/15/2014 at 11:00 AM LVN C stated she already completed Resident #1's skin assessment and his treatments for his pressure sore. Review of Resident #1's Weekly Skin Documentation dated 07/8/2014 reflected Resident #1 had a Stage II pressure sore to his left buttock. The documented measurements were 0.8 cm long with width of 0.7 cm no depth was documented; no further description was documented. The assessment was signed by LVN C. The assessment did not reflect any other skin conditions for Resident #1. Review of Resident #1's Treatment Administration Record (TAR) for July 2014 reflected Resident #1 had a head to toe skin assessment completed on 07/09/2014 and signed by LVN C. The TAR further reflected an order to cleanse Stg. (Stage) 2 Decub. (Decubitus) with NS apply [MEDICATION NAME] alginate in wound bed cover with 4 x 4 drsg. (Dressing) once a day. The order was initialed by LVN C on 07/14/2014 and 07/15/2014. The order did not reflect a location of the pressure sore. Review of Resident #1's Weekly Skin Documentation dated 07/15/2014 no time reflected Resident #1 had a Stage II on his left buttock. The documented measurements were 0.8 cm long with width of 0.7 cm no depth was documented not further description was documented. The assessment was signed by LVN C. The assessment did not reflect any other skin conditions for Resident #1. Observation on 07/15/2014 at 3:55 PM revealed CNA G and CNA H in Resident #1's room to perform incontinent care. Resident #1 was in bed. CNA G and CNA H rolled Resident #1 to his left side. Resident #1 was noted to have a dressing over his right buttock and left buttock. Resident #1 was incontinent of bowel. During the incontinent care Resident #1's dressings became soiled with bowel movement. CNA G removed the dressings (which was not dated or initialed) stating she was going to get the nurse and tell her she removed to dressings. CNA G removed the dressing which revealed: Resident #1 to have a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendons or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. It may include undermining and tunneling) pressure sore to his right buttock approximately 2 cm by 2 cm with greater than 0.1 cm depth. The pressure sore wound bed had yellow slough (a type of dead tissue) from 8 o'clock to 4 o'clock and shiny red granulation tissue from 4 o'clock to 8 o'clock. The wound edges were macerated and a pale gray color extending out approximately 0.3 cm. The peri-wound extended out approximately 1 cm around pressure sore and was slightly red. No drainage was noted. Further observation revealed Resident #1 to have a Stage III pressure sore to his left buttock approximately 0.8 cm long by 0.6 cm wide with greater than 0.1 cm depth. The pressure sore wound bed had shiny red granulation tissue. The wound edges were beveled. The peri-wound extended out approximately 1.5 cm and were pale gray. (Approximations by Surveyor) CNA H went to get Resident #1's nurse and Director of Nursing (DON). Review of the <http://www.woundsource.com/article/identifying-types-tissues-found-pressure-ulcers> website reflected "Granulation tissue- The formation of granulation tissue is thought to be an intermediate step in the healing process of full-thickness wounds. Granulation tissue is shiny red and granular in appearance when it is healthy; when inadequate blood flow exists, granulation tissue may pale in color. Slough- Slough is indicative of full-thickness Stage 3 pressure ulcers or stage 4 pressure ulcers. Slough can easily be confused with normal anatomical tissues such as tendons or ligaments because of their frequently yellowish coloration. " In an interview on 07/15/2014 at 4:05 PM CNA G stated she worked with Resident #1 every day she worked and she stated the pressure sore on his right buttock had been there at least since last Wednesday (7/09/2014) because she came back after vacation and it was there. CNA G stated she reported it to the nurse LVN E. Observation on 07/15/2014 at 4:10 PM revealed the DON and LVN E entering Resident #1's room to assess Resident #1's pressure sores. During this observation LVN E stated the area on his right buttock was new and she had not seen it before and did not know about it. LVN E further stated Resident #1 skin assessments were done on the day shift so she was unsure about the pressure sore decline on his left buttock. In an interview on 07/15/2014 at 4:15 PM after the DON observed Resident #1's right buttock pressure sore she stated " That is new. I only knew about the left buttock and that one (pointing to the right buttock pressure sore) was not there last week (07/08/14) when I looked at his skin on his skin assessment day." The DON stated she observed Resident # 1's skin assessment last week on 07/08/2014. When asked what stage the pressure sores were the DON stated they were Stage III. The DON further stated the pressure sore on Resident #1's left buttock was a Stage III and had declined since last week. When asked about the skin assessment performed this morning by LVN C the DON stated she was going to look into the situation. In an interview on 07/15/2014 at 4:40 PM the DON stated she spoke with LVN C who stated to her Resident # 1 had barrier cream on his right buttock and she did not see the right buttock pressure sore. The DON further stated she called Resident # 1's Physician for orders on the right and left buttock pressure sores. The DON stated she expected the nursing staff to complete head to toe assessments weekly on the residents and if there was barrier cream to remove it to do a complete assessment. The DON further stated the nurses are not documenting the pressure sores correctly. The DON stated the nurses are suppose4d to document the wound bed and peri-wound and wound margins and they are not. The DON stated LVN C did not fill out the assessment fully or perform a correct assessment. Review of Resident #1's Physician Telephone Order dated 07/15/2014 no time reflected the following orders after Surveyor intervention "Cleanse Stg. III decub on right buttock with NS (normal saline) apply wound gel cover with bordered gauze q day. Cleanse Stg. III decub on left buttock with NS apply wound gel cover with bordered gauze q day. Once Santyl arrives in facility, Cleanse right buttock with NS apply Santyl and cover with bordered gauze. Cleanse left buttock Stg. III decub with NS apply Santyl and cover with bordered gauze q day." In an interview on 07/16/2014 8:32 AM LVN C stated Resident #1's had barrier cream on his right buttock and she did not see anything. LVN C further stated " I honestly only looked at the one area" (referring to his left buttock) and did not do a complete assessment. LVN C stated she did not remember seeing any other areas except the left buttock while doing the skin assessment the week before. LVN C did not know who put the dressing on Resident #1's right buttock. LVN C stated that she has not had any skills check offs or training since she's been employed at the facility. In an interview on 07/16/2014 at 9:30 AM CNA I stated Resident #1 had the pressure sore on his right buttock when she saw it, about a week ago. CNA I stated she was not sure exactly how long but that she reported the area to LVN C. In an interview on 07/16/2014 at 5:03 PM the DON stated is did not know who does the competency and skills check offs and training with the nurses for wound care. The DON stated she did not do them. DON stated that Regional Nurse A just informed her that there was a wound care competency skills check off in the facility's SharePoint program in the computer. The DON stated that she will start using them for the nurses and denied doing any wound care training for LVN C. Review of Resident #1's Dietary Consultant recommendation dated 05/16/2014 reflected "Problem or Concern: ....-underweight; has unstageable wound. Recommendations: Add 2 cal supplement 60 cc QID with med pass, Add Arginiad one (1) packet BID, Add large portion at all meals, Consider ST (Speech Therapy) eval d/t (due to) possible diet texture upgrade." Further review reflected the dietary recommendation was signed by Resident #1's Physician on 06/03/2014 (18 days later). Review of Resident #1's Physician Telephone orders reflected an order written [REDACTED]." Review of the Dietary progress notes dated 06/19/2014 reflected "Weight down 16 pounds in one (1) month (12%) down five (5) pounds since last visit. Has Stage II wound to Left buttocks, unstageable to right heel. Has MBSS (modified [MEDICATION NAME] swallow study) ordered." In an interview on 07/16/2014 at 5:00 PM the DON stated she faxed the dietary recommendation to the Physician and waited on him to respond. The DON stated she was responsible to follow up on dietary recommendation and further stated "I guess I need to call the Physician if he does not respond in a few days or fax the Physician back." In an interview on 07/17/2014 at 10:00 AM the Dietary Consultant stated she expected recommendations to follow up on timely. The Dietary Consultant stated "It would have helped Resident #1 to have the extra protein and calories especially with his pressure ulcers." In an interview on 07/17/2014 at 8:50 AM the Medial Director stated he expected the nursing staff to do a thorough head to toe assessment weekly and notify the Physician right away with any finding. The Medical Director further stated staff should monitor skin daily during care and report if any pressure sores found so treatment can be initiated. The Medical Director stated if the dietary consultant makes recommendations he expected the facility to follow up on them on one (1) to two (2) days. Review of the Facility's Policy Skin System dated 02/15/2012 reflected " 6. The Weekly Skin Assessment form is completed weekly for Residents with presence of skin interruptions of any type. If no skin interruption is identified, the nurse assessor will document the assessment performed weekly on the TAR. 7. The facility DON is responsible for assignment of weekly skin assessments ... 10. The facility DON should visualize areas related to pressure weekly and be able to report observations to the Standards of Care Team members. The DON is validating the accuracy of the description of the pressure ulcer documentation on the weekly assessment form." Review of the facility's policy Weight system dated 05/21/2014 reflected "7. DON/designee will be responsible for reviewing residents' weights to determine significant weight loss/gain and initiate weekly weight plan/intervention as necessary. 8. Physician, Consultant Dietitian, and resident/family will be notified of significant weight loss/gain. (i.e.. 5% one month or 10% six months). Implement additional interventions or recommendations as made by notification...12. The standards of care committee will review significant weight losses and gains weekly and document recommendations/ interventions...Care plans should be updated at this time." B) Review of Resident #7's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #7's Annual MDS assessment dated [DATE] reflected Resident #7 was assessed to have a BIMS score of 2 indicating the Resident had severe cognitive impairment. Resident #7 was assessed to require extensive assistance with one (1) person physical assist for bed mobility, locomotion on the unit, and with eating. Resident #7 was assessed and observed to be totally dependent and required full staff performance of one (1) person physical assist with ADLs including locomotion off the unit (wheel chair), dressing, toileting, personal hygiene and bathing. Resident #7's MDS reflected two (2) person physical assist was required for transfers and Resident #7 did not ambulate. Resident #7 was assessed to be always incontinent of urine and stool and at risk for pressure ulcers. Review of Resident #7's Care Plan dated 05/02/2014 reflected the Resident to be at risk for skin breakdown if she is not cleaned properly and regularly due to urinary and bowel incontinence, cognitive loss, and Diabetes Mellitus. A goal reflected Resident #7's skin remains clean and dry and intact. Approaches reflected Resident #7's skin be kept as clean and dry as possible, to minimize skin exposure to moisture, to provide incontinent care after each incontinent episode, to keep linens clean dry, wrinkle free, to observe and report red areas noted, and to avoid shearing of skin during repositioning and transfers. Observation on 07/16/2014 at 8:55AM of a two (2) person assistance transfer revealed CNA I and CNA J used a gait belt to lift Resident # 7 up from her wheelchair and transferred her onto the bed. Resident #7 had urine dripping from her brief and the urine saturated dress she was wearing. A strong urine odor was observed after the transfer. CNA I stated to CNA J that the chair was wet and she would have to wipe it down. Resident #7's wheelchair cushion revealed scattered wet spots on top of it. CNA I told CNA J that they needed to do incontinent care on Resident #7. Resident #7 was assisted into a lying position onto her back in the bed while supplies were gathered. Resident #7 touched the back of her dress and stated "My seat's wet and its cold! " CNA J informed Resident #7 that CNA I was getting stuff together so they could get her cleaned up. Observation on 07/16/2014 at 9:00 AM of incontinent care revealed Resident #7 flinched and grimaced as CNA I was wiping urine from Resident #7's buttocks and thighs. Resident # 7 stated "Oh! It hurts all over right there." Resident #7's left and right buttocks were dark red from top to bottom and the back of the left upper thigh was also dark red. The coccyx and sacral area revealed a raised white discoloration of the skin (maceration - to soften and wear away especially as a result of being wetted or steeped) with multiple linear skin breaks and cracks (fissures - a break or slit in tissue usually at the junction of skin and mucous membrane) to the center of the white (macerated) raised area. CNA I told Resident #7 that her skin was red and she was going to let the nurse know so that someone could put something on it to make it feel better. In an interview on 07/16/2014 at 9:15 AM CNA I stated that Resident #7's skin was not normally red or white and doesn't usually have cracking like that. CNA I stated she was going to notify the nurse so something could be put on it. CNA I stated that this was the first time Resident #7 was checked for incontinence on her shift because Resident #7 was on the list for 10-6 shift to get up and get ready for breakfast. CNA I stated that first rounds were started after breakfast at 8:30 AM for the Residents that they don't get up in the morning. Observation on 07/16/2014 at 9:20 AM revealed the DON at bedside assessing Resident #7's abnormalities to her bilateral buttocks and to the back of the Resident's left upper thigh. The DON stated "This looks like it's caused from moisture being against her skin when she wets and it doesn't help in the way that she wiggles around in her chair." CNA I then stated to the DON that Resident #7 does move around a lot. In an interview on 07/16/2014 at 11:00 AM CNA M (who worked the 10PM-6AM shift on 7/15/14 - 7/16/14) stated Resident #7 was checked for incontinence and had to be changed every two hours because Resident #7 was found wet on each round last night on the 10P-6A shift. CNA M stated she made a last round and changed Resident #7 at about 4:30AM or 4:45 AM this morning when she got her up and dressed for breakfast. CNA M stated Resident #7 did not have any redness or sores to her skin. The Surveyor asked CNA M how she remembered what time she changed Resident #7 on that last round. CNA M stated "I remember because she was the last person I changed right before I stopped to take a five minute break. I wheeled her up to the front sitting area on my way outside. I looked at my clock and it was 4:55 AM and that's when I went outside for a five minute break." CNA M stated after the break she returned to make rounds on the rest of her residents and completed the last rounds between 5:30 AM and 5:45 AM. In an interview on 07/16/2014 at 5:03 PM the DON stated the CNA's are given an assignment sheet to follow that reflects the ADL care that is needed for all Residents on their assigned halls. The DON reviewed the assignment sheet for Resident #7 and stated it reflected the 10PM -6 AM CNA's get Resident #7 up for breakfast in the morning. The Surveyor informed the DON Resident #7 went over four (4) hours without being checked for incontinence or changed between the hours 4:30 AM and 9 :00 AM. The DON stated it is facility policy to check all Residents that are incontinent every two (2) hours and that she expected that to be done regardless of which shift gets a Resident up for breakfast. The DON stated the nurses help supervise the CNA's and make changes to the assignment sheets and further stated she needed to inservice the staff and make some changes to the assignment sheets. The DON stated Resident #7's doctor had been notified of her skin redness and moisture problem to the buttocks and thighs and that a moisture barrier cream was ordered to treat the areas. The DON stated Resident #7's doctor also instructed staff to keep an eye on the areas and to notify him if they got worse. In an interview on 07/17/2014 at 8:50 AM the Medical Director stated he expected staff to make rounds every two (2) hours and provide care when needed. The Medical Director stated it was not appropriate for a resident to go four (4) hours without care which could cause skin issues. The Medical Director further stated he felt the nurse aides were overwhelmed because there was so much heavy care at the facility and not enough help. In an interview on 07/17/2014 at 2:15 PM CNA I stated that Resident #7's skin was still red and that they were checking and changing her every two hours and using cream on her. CNA I stated that Resident #7's pain was still the same today stating that Resident #7 complains that areas feel sore during care same as yesterday. Review of the Website: <http://www.ncbi.nlm.nih.gov/pubmed/ 547>: reflected " Moisture-associated skin damage (MASD) is caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents. MASD is characterized by inflammation of the skin, occurring with or without erosion or secondary cutaneous infection. Multiple conditions may result in MASD; 4 of the most common forms are incontinence-associated [MEDICAL CONDITION], intertriginous [MEDICAL CONDITION], periwound moisture-associated [MEDICAL CONDITION], and [MEDICATION NAME] moisture-associated [MEDICAL CONDITION] ...To prevent MASD, clinicians need to be vigilant both in maintaining optimal skin conditions and in diagnosing and treating minor cases of MASD prior to progression and skin breakdown. " Review of the facility's policy for Nursing Assistant Guidelines (no date) reflected the policy did not address following the residents plan of care or how often care should be provided. Review of the facility's policy Abuse and Neglect Policy and Procedure dated 11/11/2011 reflected "Our facility implements an effective system for the prevention of abuse and neglect...1. Identify, assess, care-plan, and monitor residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents with self-injurious behaviors, residents with communication disorders, and those that require heavy nursing care or are totally dependent on staff...To assist our facility's staff members in recognizing incidents of abuse, the following definitions of abuse are provided...g. Neglect is defined as failure to provide goods and service necessary to avoid physical harm, mental anguish, or mental illness." The facility provided a list of ten (10) residents at risk for development of new pressure sores, two (2) residents at risk of weight loss and 18 incontinent residents.

Based on observation, interview, and record review the facility failed to provide services that meet professional standards of quality for one (1) of one (1) LVN reviewed for skin assessments, when: A) LVN C failed to perform a physician ordered head to toe assessment on Resident # 1 when she documented she completed a head to to assessment but failed to identify the Resident's Stage II pressure sore to his left buttock that had declined to a Stage III pressure sore. LVN C also failed to identify a separate Stage III pressure sore to Resident # 1's right buttock. B) LVN C, who had documented she assessed Resident # 6's skin, failed to perform the physician ordered head to toe assessment and failed to identify Resident #6's open wound on her right lower lumbar area, located in the skin fold. This deficient practice affected two (2) residents (Resident # 1 and # 6) and placed an additional eight (8) residents with wounds at risk for wounds not being assessed, a decline in wounds, infection, and pain. Finding Include: Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11 Standards of Nursing Practice (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; (G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices; (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications; (O) Implement measures to prevent exposure to infectious pathogens and communicable conditions; (P) Collaborate with the client, members of the health care team and, when appropriate, the client's significant other(s) in the interest of the client's health care; (Q) Consult with, utilize, and make referrals to appropriate community agencies and health care resources to provide continuity of care; (U) Supervise nursing care provided by others for whom the nurse is professionally responsible; (2) Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and: (A) Shall utilize a systematic approach to provide individualized, goal-directed nursing care by: (i) collecting data and performing focused nursing assessments; (ii) participating in the planning of nursing care needs for clients; (iii) participating in the development and modification of the comprehensive nursing care plan for assigned clients; (iv) implementing appropriate aspects of care within the LVN's scope of practice; and (v) assisting in the evaluation of the client's responses to nursing interventions and the identification of client needs; (B) Shall assign specific tasks, activities and functions to unlicensed personnel commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made and shall maintain appropriate supervision of unlicensed personnel. (C) May perform other acts that require education and training as prescribed by board rules and policies, commensurate with the licensed vocational nurse's experience, continuing education, and demonstrated licensed vocational nurse competencies. A) Review of Resident #1's Face Sheet reflected an [AGE] year old male admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #1 had a BIMS's of zero (0) indicating he had severe cognitive impairment. Resident #1 was assessed to require total assist with all ADL's. Resident #1 was assessed to have one (1) Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.) pressure ulcer with the identification of 06/24/2014. The pressure sore was assessed to have granulation tissue. Review of Resident #1's Comprehensive Care Plan reflected a problem with a start date of 05/09/2014 "Resident is at risk for pressure ulcers R/T (related to) bowel incontinence, age and the need for assist with ADL's." Under approach " Report any signs of skin breakdown (sore, tender, red, or broken areas) ...Monitor and record intake of food." Review of Resident #1's Acute Care Plan dated 06/26/2014 reflected " I have a Stg (Stage) two (2) decub (decubitus) on my buttocks." Handwritten under the problem was a measurement 1.5 cm by 1 cm. Under Approaches " ...Notify my MD of any changes better or worse ....Make sure I get the proper nutrition so that my Stg two (2) decub will heal. " The care plan did not state which buttock the pressure sore was on. Review of Resident #1's Consolidated Physician order [REDACTED]. " dated 06/24/2014. The order did not address a location of the pressure sore. Observation on 07/14/2014 at 6:30 PM revealed Resident #1 up in his wheelchair in the living room asleep. Observation on 07/15/2014 at 9:50 AM revealed Resident #1 in bed. Resident #1 was on an air mattress. Bilateral knee contractures were noted. Resident #1 was unable to communicate with the Surveyor. In an interview on 07/15/2014 at 11:00 AM LVN C stated she already completed Resident #1's skin assessment and his treatments for his pressure sore. Review of Resident #1's Weekly Skin Documentation dated 07/8/2014 reflected Resident #1 had a Stage II pressure sore to his left buttock. The documented measurements were 0.8 cm long with width of 0.7 cm no depth was documented; no further description was documented. The assessment was signed by LVN C. The assessment did not reflect any other skin conditions for Resident #1. Review of Resident #1's Treatment Administration Record (TAR) for July 2014 reflected Resident #1 had a head to toe skin assessment completed on 07/09/2014 and signed by LVN C. The TAR further reflected an order to cleanse Stg. (Stage) 2 Decub. (Decubitus) with NS apply [MEDICATION NAME] alginate in wound bed cover with 4 x 4 drsg. (Dressing) once a day. The order was initialed by LVN C on 07/14/2014 and 07/15/2014. The order did not reflect a location of the pressure sore. Review of Resident #1's Weekly Skin Documentation dated 07/15/2014 no time reflected Resident #1 had a Stage II on his left buttock. The documented measurements were 0.8 cm long with width of 0.7 cm no depth was documented not further description was documented. The assessment was signed by LVN C. The assessment did not reflect any other skin conditions for Resident #1. Observation on 07/15/2014 at 3:55 PM revealed CNA G and CNA H in Resident #1's room to perform incontinent care. Resident #1 was in bed. CNA G and CNA H rolled Resident #1 to his left side. Resident #1 was noted to have a dressing over his right buttock and left buttock. Resident #1 was incontinent of bowel. During the incontinent care Resident #1's dressings became soiled with bowel movement. CNA G removed the dressings (which was not dated or initialed) stating she was going to get the nurse and tell her she removed two dressings. CNA G removed the dressing which revealed: Resident #1 to have a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendons or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. It may include undermining and tunneling) pressure sore to his right buttock approximately 2 cm by 2 cm with greater than 0.1 cm depth. The pressure sore wound bed had yellow slough (a type of dead tissue) from 8 o'clock to 4 o'clock and shiny red granulation tissue from 4 o'clock to 8 o'clock. The wound edges were macerated and a pale gray color extending out approximately 0.3 cm. The peri-wound extended out approximately 1 cm around pressure sore and was slightly red. No drainage was noted. Further observation revealed Resident #1 to have a Stage III pressure sore to his left buttock approximately 0.8 cm long by 0.6 cm wide with greater than 0.1 cm depth. The pressure sore wound bed had shiny red granulation tissue. The wound edges were beveled. The peri-wound extended out approximately 1.5 cm and were pale gray. (Approximations by Surveyor) CNA H went to get Resident #1's nurse and Director of Nursing (DON). Review of the <http://www.woundsource.com/article/identifying-types-tissues-found-pressure-ulcers> website reflected "Granulation tissue- The formation of granulation tissue is thought to be an intermediate step in the healing process of full-thickness wounds. Granulation tissue is shiny red and granular in appearance when it is healthy; when inadequate blood flow exists, granulation tissue may pale in color. Slough- Slough is indicative of full-thickness Stage 3 pressure ulcers or stage 4 pressure ulcers. Slough can easily be confused with normal anatomical tissues such as tendons or ligaments because of their frequently yellowish coloration. " In an interview on 07/15/2014 at 4:05 PM CNA G stated she worked with Resident #1 every day she worked and she stated that the pressure sore on his right buttock had been there at least since last Wednesday (7/09/2014) because she came back after vacation and it was there. CNA G stated she reported it to the nurse LVN E. Observation on 07/15/2014 at 4:10 PM revealed the DON and LVN E entering Resident #1's room to assess Resident #1's pressure sores. During this observation LVN E stated the area on his right buttock was new and she had not seen it before and did not know about it. LVN E further stated Resident #1 skin assessments were done on the day shift so she was unsure about the pressure sore decline on his left buttock. In an interview on 07/15/2014 at 4:15 PM after the DON observed Resident #1's right buttock pressure sore she stated " That is new. I only knew about the left buttock and that one (pointing to the right buttock pressure sore) was not there last week (07/08/14) when I looked at his skin on his skin assessment day." The DON stated she observed Resident # 1's skin assessment last week on 07/08/2014. When asked what stage the pressure sores were the DON stated they were Stage III. The DON further stated the pressure sore on Resident #1's left buttock was a Stage III and had declined since last week. When asked about the skin assessment performed this morning by LVN C the DON stated she was going to look into the situation. In an interview on 07/16/2014 8:32 AM LVN C stated Resident #1's had barrier cream on his right buttock and she did not see anything. LVN C further stated " I honestly only looked at the one area" (referring to his left buttock) and did not do a complete assessment. LVN C stated she did not remember seeing any other areas except the left buttock while doing the skin assessment the week before. LVN C did not know who put the dressing on Resident #1's right buttock. LVN C stated that she has not had any skills check offs or training since she's been employed at the facility. In an interview on 07/15/2014 at 4:40 PM the DON stated she spoke with LVN C who stated to her Resident # 1 had barrier cream on his right buttock and she did not see the right buttock pressure sore. The DON further stated she called Resident # 1's Physician for orders on the right and left buttock pressure sores. The DON stated she expected the nursing staff to complete head to toe assessments weekly on the residents and if there was barrier cream to remove it to do a complete assessment. The DON further stated the nurses are not documenting the pressure sores correctly. The DON stated the nurses are suppose4d to document the wound bed and peri-wound and wound margins and they are not. The DON stated LVN C did not fill out the assessment fully or perform a correct assessment. Review of Resident #1's Physician Telephone Order dated 07/15/2014 no time reflected the following orders after Surveyor intervention "Cleanse Stg. III decub on right buttock with NS (normal saline) apply wound gel cover with bordered gauze q day. Cleanse Stg. III decub on left buttock with NS apply wound gel cover with bordered gauze q day. Once Santyl arrives in facility, Cleanse right buttock with NS apply Santyl and cover with bordered gauze. Cleanse left buttock Stg. III decub with NS apply Santyl and cover with bordered gauze q day." In an interview on 07/16/2014 at 9:30 AM CNA I stated Resident #1 had the pressure sore on his right buttock when she saw it, about a week ago. CNA I stated she was not sure exactly how long but that she reported the area to LVN C. In an interview on 07/16/2014 at 5:03 PM the DON stated is did not know who does the competency and skills check offs and training with the nurses for wound care. The DON stated she did not do them. DON stated that Regional Nurse A just informed her that there was a wound care competency skills check off in the facility's SharePoint program in the computer. The DON stated that she will start using them for the nurses and denied doing any wound care training for LVN C. Review of Resident #1's Dietary Consultant recommendation dated 05/16/2014 reflected "Problem or Concern: ....-underweight; has unstageable wound. Recommendations: Add 2 cal supplement 60 cc QID with med pass, Add Arginiad one (1) packet BID, Add large portion at all meals, Consider ST (Speech Therapy) eval d/t (due to) possible diet texture upgrade." Further review reflected the dietary recommendation was signed by Resident #1's Physician on 06/03/2014 (18 days later). Review of Resident #1's Physician Telephone orders reflected an order written [REDACTED]." Review of the Dietary progress notes dated 06/19/2014 reflected "Weight down 16 pounds in one (1) month (12%) down five (5) pounds since last visit. Has Stage II wound to Left buttocks, unstageable to right heel. Has MBSS (modified [MEDICATION NAME] swallow study) ordered." In an interview on 07/16/2014 at 5:00 PM the DON stated she faxed the dietary recommendation to the Physician and waited on him to respond. The DON stated she was responsible to follow up on dietary recommendation and further stated "I guess I need to call the Physician if he does not respond in a few days or fax the Physician back." In an interview on 07/17/2014 at 10:00 AM the Dietary Consultant stated she expected recommendations to follow up on timely. The Dietary Consultant stated "It would have helped Resident #1 to have the extra protein and calories especially with his pressure ulcers." B) Review of Resident #6's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #6's Quarterly MDS dated [DATE] reflected Resident #6 was assessed to have a BIMS score of 13 indicating Resident #6 was cognitively intact. Resident #6 was assessed to have a behavior of rejection care four (4) to six (6) days a week. Resident #6 was assessed to require supervision with one (1) person physical assist with ADLs including dressing, toileting, and personal hygiene. Resident #6's MDS reflected bathing did not occur for Resident #6. Resident #6 was assessed to be at risk for pressure ulcers and had two (2) Stage 2 pressure ulcers. Resident #6 was assessed to use a wheelchair and walker for ambulation. Review of Resident #6's Acute Care Plan dated 06/4/2014 reflected Resident #6 had a "Stage 2 pressure ulcer on my lumbar and sacral region", and approaches included "encourage Resident #6 to turn, reposition, and keep skin clear and dry." Approaches also included monitoring Resident #6's lumbar and sacral region and notifying her physician of any changes." Review of Resident #6's Weight record reflected on 07/03/2014 that Resident #6 weighed 398 pounds. Review of Resident #6's Consolidated Physician order [REDACTED].#6's Consolidated Physician order [REDACTED]." Review of Resident #6's Telephone Physician order [REDACTED]." In an interview on 07/14/2014 at 6:50 PM during initial tour CNA H stated Resident #6 was independent in all ADL's and was continent of Bowel and Bladder. CNA H further stated Resident #6 had a sore on her bottom and stated it was healing. Review of Resident #6's Weekly Skin assessment documentation signed by LVN C and dated 07/08/2014 reflected Resident #6's skin was clear. Review of Resident #6's Weekly Skin assessment documentation dated 07/15/2014 reflected Resident #6's skin was clear. Assessment was signed by LVN C. Observation on 07/16/2014 at 9:40 AM revealed the DON and LVN D in Resident #6's room to assess her skin. LVN D removed a dressing from Resident #6's right lower lumbar area to reveal a open area approximately 3.5 cm long by 1.5 cm. The wound edges were scabbed. The wound bed was red granulation tissue. The dressing removed from the wound had yellow drainage. The open area was in a skin fold. (approximations by surveyor) Further observation revealed Resident #6 to have a closed, scabbed, pink area over her sacral area. In an inteview on 07/16/2014 at 10:00 AM LVN C stated "I honestly did not assess her skin yesterday" referring to Resident #6. "I just documented I did." In an interview on 07/16/2014 at 1:00 PM the DON stated that LVN C did not do a assessment of Resident #6's skin or the area would of been found. The DON stated she went and assessed the Residents that LVN C assessed last night. The DON stated she found the pressure ulcer on Resident #6. Review of Resident #6's Nurses Notes dated 07/15/2014 at 8:30 PM reflected "Physician notified lumbar region on right side dry scaly red wound bed, order received wound gel cover with dressing after cleaning with normal saline." Review of Resident #6's Physician order [REDACTED]. (decubitus) on lumbar right side and apply wound gel and cover with bordered dressing daily. In an interview on 07/16/2014 at 5:03 PM the DON stated is did not know who does the competency and skills check offs and training with the nurses for wound care. The DON stated she did not do them. DON stated that Regional Nurse A just informed her that there was a wound care competency skills check off in the facility's SharePoint program in the computer. The DON stated that she will start using them for the nurses and denied doing any wound care training for LVN C. In an interview on 07/17/2014 at 8:50 AM the Medial Director stated he expected the nursing staff to do a thorough head to toe assessment weekly and notify the Physician right away with any finding. The Medical Director further stated staff should monitor skin daily during care and report if any pressure sores found so treatment can be initiated. The Medical Director stated if the dietary consultant makes recommendations he expected the facility to follow up on them on one (1) to two (2) days. Review of the Facility's Policy Skin System dated 02/15/2012 reflected " 6. The Weekly Skin Assessment form is completed weekly for Residents with presence of skin interruptions of any type. If no skin interruption is identified, the nurse assessor will document the assessment performed weekly on the TAR. 7. The facility DON is responsible for assignment of weekly skin assessments ... 10. The facility DON should visualize areas related to pressure weekly and be able to report observations to the Standards of Care Team members. The DON is validating the accuracy of the description of the pressure ulcer documentation on the weekly assessment form." Review of the Facility's Policy Pressure Ulcer definition dated 02/15/2012 reflected "A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction...Stage II...This stage should not be used to describe skin tears, tap burns, perineal [MEDICAL CONDITION], maceration or excoriation." The facility provided a list of 12 residents with wounds.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for one (1) of six (6) residents (Resident #6) reviewed for skin assessments and one (1) of 12 residents (Resident #7 ) reviewed for activities of daily living when: A) Resident #7 was found sitting in a urine soaked brief and dress and had not been checked for incontinence or changed by staff for over four hours. Resident #7's skin showed signs of moisture-associated skin damage (MASD) which caused pain and discomfort for Resident #7 during incontinent care. B) Resident #6 had a open wound on her right lower lumbar area, located in the skin fold, not on a bony prominence. LVN C, who had documented she assessed Resident # 6's skin, failed to perform a physician ordered head to toe assessment. This deficient practice affected two (2) residents (Resident #7 and #6) and placed an additional ten (10) residents with wounds at risk for development of infection, pain and worsening of current wounds and placed 18 incontient residents of at risk for loss of dignity, self-worth, skin breakdown and pain. Findings Include: A) Review of Resident #7's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #7's Annual MDS assessment dated [DATE] reflected Resident #7 was assessed to have a BIMS score of 2 indicating the Resident had severe cognitive impairment. Resident #7 was assessed to require extensive assistance with one (1) person physical assist for bed mobility, locomotion on the unit, and with eating. Resident #7 was assessed and observed to be totally dependent and required full staff performance of one (1) person physical assist with ADLs including locomotion off the unit (wheel chair), dressing, toileting, personal hygiene and bathing. Resident #7's MDS reflected two (2) person physical assist was required for transfers and Resident #7 did not ambulate. Resident #7 was assessed to be always incontinent of urine and stool and at risk for pressure ulcers. Review of Resident #7's Care Plan dated 05/02/2014 reflected the Resident to be at risk for skin breakdown if she is not cleaned properly and regularly due to urinary and bowel incontinence, cognitive loss, and Diabetes Mellitus. A goal reflected Resident #7's skin remains clean and dry and intact. Approaches reflected Resident #7's skin be kept as clean and dry as possible, to minimize skin exposure to moisture, to provide incontinent care after each incontinent episode, to keep linens clean dry, wrinkle free, to observe and report red areas noted, and to avoid shearing of skin during repositioning and transfers. Observation on 07/16/2014 at 8:55AM of a two (2) person assistance transfer revealed CNA I and CNA J used a gait belt to lift Resident # 7 up from her wheelchair and transferred her onto the bed. Resident #7 had urine dripping from her brief and the urine saturated dress she was wearing. A strong urine odor was observed after the transfer. CNA I stated to CNA J that the chair was wet and she would have to wipe it down. Resident #7's wheelchair cushion revealed scattered wet spots on top of it. CNA I told CNA J that they needed to do incontinent care on Resident #7. Resident #7 was assisted into a lying position onto her back in the bed while supplies were gathered. Resident #7 touched the back of her dress and stated "My seat's wet and its cold! " CNA J informed Resident #7 that CNA I was getting stuff together so they could get her cleaned up. Observation on 07/16/2014 at 9:00 AM of incontinent care revealed Resident #7 flinched and grimaced as CNA I was wiping urine from Resident #7's buttocks and thighs. Resident # 7 stated "Oh! It hurts all over right there." Resident #7's left and right buttocks were dark red from top to bottom and the back of the left upper thigh was also dark red. The coccyx and sacral area revealed a raised white discoloration of the skin (maceration - to soften and wear away especially as a result of being wetted or steeped) with multiple linear skin breaks and cracks (fissures - a break or slit in tissue usually at the junction of skin and mucous membrane) to the center of the white (macerated) raised area. CNA I told Resident #7 that her skin was red and she was going to let the nurse know so that someone could put something on it to make it feel better. In an interview on 07/16/2014 at 9:15 AM CNA I stated that Resident #7's skin was not normally red or white and doesn't usually have cracking like that. CNA I stated she was going to notify the nurse so something could be put on it. CNA I stated that this was the first time Resident #7 was checked for incontinence on her shift because Resident #7 was on the list for 10-6 shift to get up and get ready for breakfast. CNA I stated that first rounds were started after breakfast at 8:30 AM for the Residents that they don't get up in the morning. Observation on 07/16/2014 at 9:20 AM revealed the DON at bedside assessing Resident #7's abnormalities to her bilateral buttocks and to the back of the Resident's left upper thigh. The DON stated "This looks like it's caused from moisture being against her skin when she wets and it doesn't help in the way that she wiggles around in her chair." CNA I then stated to the DON that Resident #7 does move around a lot. In an interview on 07/16/2014 at 11:00 AM CNA M (who worked the 10PM-6AM shift on 7/15/14 - 7/16/14) stated Resident #7 was checked for incontinence and had to be changed every two hours because Resident #7 was found wet on each round last night on the 10P-6A shift. CNA M stated she made a last round and changed Resident #7 at about 4:30AM or 4:45 AM this morning when she got her up and dressed for breakfast. CNA M stated Resident #7 did not have any redness or sores to her skin. The Surveyor asked CNA M how she remembered what time she changed Resident #7 on that last round. CNA M stated "I remember because she was the last person I changed right before I stopped to take a five minute break. I wheeled her up to the front sitting area on my way outside. I looked at my clock and it was 4:55 AM and that's when I went outside for a five minute break." CNA M stated after the break she returned to make rounds on the rest of her residents and completed the last rounds between 5:30 AM and 5:45 AM. In an interview on 07/16/2014 at 5:03 PM the DON stated the CNA's are given an assignment sheet to follow that reflects the ADL care that is needed for all Residents on their assigned halls. The DON reviewed the assignment sheet for Resident #7 and stated it reflected the 10PM -6 AM CNA's get Resident #7 up for breakfast in the morning. The Surveyor informed the DON Resident #7 went over four (4) hours without being checked for incontinence or changed between the hours 4:30 AM and 9 :00 AM. The DON stated it is facility policy to check all Residents that are incontinent every two (2) hours and that she expected that to be done regardless of which shift gets a Resident up for breakfast. The DON stated the nurses help supervise the CNA's and make changes to the assignment sheets and further stated she needed to inservice the staff and make some changes to the assignment sheets. The DON stated Resident #7's doctor had been notified of her skin redness and moisture problem to the buttocks and thighs and that a moisture barrier cream was ordered to treat the areas. The DON stated Resident #7's doctor also instructed staff to keep an eye on the areas and to notify him if they got worse. In an interview on 07/17/2014 at 8:50 AM the Medical Director stated he expected staff to make rounds every two (2) hours and provide care when needed. The Medical Director stated it was not appropriate for a resident to go four (4) hours without care which could cause skin issues. The Medical Director further stated he felt the nurse aides were overwhelmed because there was so much heavy care at the facility and not enough help. In an interview on 07/17/2014 at 2:15 PM CNA M stated Resident #7's skin was still red and they were checking and changing her every two hours. CNA M stated Resident #7's pain was still the same and Resident #7 complains that areas feel sore during care the same as yesterday. Review of the facility's policy for Nursing Assistant Guidelines (no date) reflected the policy did not address following the residents plan of care or how often care should be provided. B) Review of Resident #6's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #6's Quarterly MDS assessment dated [DATE] reflected Resident #6 was assessed to have a BIMS score of 13 indicating Resident #6 was cognitively intact. Resident #6 was assessed to have a behavior of rejection care four (4) to six (6) days a week. Resident #6 was assessed to require supervision with one (1) person physical assist with ADLs including dressing, toileting, and personal hygiene. Resident #6's MDS reflected bathing did not occur. Resident #6 was assessed to be at risk for pressure ulcers and had two (2) Stage 2 pressure ulcers. Resident #6 was assessed to use a wheelchair and walker for ambulation. Review of Resident #6's Acute Care Plan dated 06/4/2014 reflected Resident #6 had a "Stage 2 pressure ulcer on my lumbar and sacral region", and approaches included "encourage Resident #6 to turn, reposition, and keep skin clear and dry." Approaches also included monitoring Resident #6's lumbar and sacral region and notifying her physician of any changes." Review of Resident #6's Weight record reflected on 07/03/2014 that Resident #6 weighed 398 pounds. Review of Resident #6's Consolidated Physician order [REDACTED].#6's Consolidated Physician order [REDACTED]." Review of Resident #6's Telephone Physician order [REDACTED]." In an interview on 07/14/2014 at 6:50 PM during initial tour CNA H stated Resident #6 was independent in all ADL's and was continent of Bowel and Bladder. CNA H further stated Resident #6 had a sore on her bottom and stated it was healing. Review of Resident #6's Weekly Skin assessment documentation dated 07/08/2014 reflected Resident #6's skin was clear. The assessment was signed by LVN C. Review of Resident #6's Weekly Skin assessment documentation dated 07/15/2014 reflected Resident #6's skin was clear. The assessment was signed by LVN C. Observation on 07/16/2014 at 9:40 AM revealed the DON and LVN D in Resident #6's room to assess her skin. LVN D removed a dressing from Resident #6's right lower lumbar area to reveal a open area approximately 3.5 cm long by 1.5 cm wide. The wound edges were scabbed. The wound bed was red granulation tissue. The dressing removed from the wound had yellow drainage. The open area was in a skin fold. (approximations by surveyor) Further observation revealed Resident #6 had a closed, scabbed, pink area over her sacral area. In an inteview on 07/16/2014 at 10:00 AM LVN C stated "I honestly did not assess her skin yesterday" referring to Resident #6. "I just documented I did." In an interview on 07/16/2014 at 1:00 PM the DON stated that LVN C did not do a assessment of Resident #6's skin or the area would of been found. The DON stated she went and assessed the Residents that LVN C assessed last night. The DON stated she found the pressure ulcer on Resident #6. Review of Resident #6's Nurses Notes dated 07/15/2014 at 8:30 PM reflected "Physician notified lumbar region on right side dry scaly red wound bed, order received wound gel cover with dressing after cleaning with normal saline." Review of Resident #6's Physician order [REDACTED]. (decubitus) on lumbar right side and apply wound gel and cover with bordered dressing daily. In an interview on 07/16/2014 at 5:03 PM the DON stated is did not know who does the competency and skills check offs and training with the nurses for wound care. The DON stated she did not do them. DON stated that Regional Nurse A just informed her that there was a wound care competency skills check off in the facility's SharePoint program in the computer. The DON stated that she will start using them for the nurses and denied doing any wound care training for LVN C. In an interview on 07/17/2014 at 8:50 AM the Medical Director stated he expected the nursing staff to do a thorough head to toe assessment weekly and notify the Physician right away with any finding. The Medical Director further stated staff should monitor skin daily during care and report if any skin issues are found so treatment can be initiated. Review of the Facility's Policy Skin System dated 02/15/2012 reflected "6. The Weekly Skin Assessment form is completed weekly for Residents with presence of skin interruptions of any type. If no skin interruption is identified, the nurse assessor will document the assessment performed weekly on the TAR. 7. The facility DON is responsible for assignment of weekly skin assessments ... 10. The facility DON should visualize areas related to pressure weekly and be able to report observations to the Standards of Care Team members. The DON is validating the accuracy of the description of the pressure ulcer documentation on the weekly assessment form." Review of the Facility's Policy Pressure Ulcer definition dated 02/15/2012 reflected "A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction...Stage II...This stage should not be used to describe skin tears, tap burns, perineal [MEDICAL CONDITION], maceration or excoriation." The facility provided a list of 12 residents with wounds and 18 incontinent residents.

Based on observation, interview and record review the facility failed to ensure a resident who is unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygeine for two (2) of 12 Residents (Resident #4 and #7) reviewed for activites of daily living when: A) Resident #7 was totally dependent on staff to provide ADL care. Resident #7 required assistance with toileting (incontinent care) and personal hygeine. ADL care for incontinence was not provided to Resident #7 every two hours per facility practice. Resident #7 was found sitting in a urine soaked brief and dress and had not been checked for incontinence or changed by staff for over four hours. Resident #7's skin showed signs of moisture-associated skin damage (MASD) which caused pain and discomfort for Resident #7 during incontinent care. B) Resident #4 required assistance for transfers, personal hygeine, and bathing. Resident #4 was not provided assistance with ADL's as needed. This failure affected one (1) residents (Resident # 7) and placed an additional 15 residents who required assistance with ADLs at risk for discomfort, skin breakdown, embarrassment, decreased self-esteem, poor physical hygiene, and isolation from others due to body odor. Findings included: A.) Review of Resident # 7's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #7's annual MDS dated [DATE] reflected Resident #7 was assessed to have a BIMS score of two (2) indicating Resident #7 had moderate cognitive impairment. Resident #7 was assessed to require extensive assistance with one (1) person physical assist with ADLs including bed mobility, locomotion on the unit, and with eating. Resident #7 was assessed and observed to be totally dependent and required full staff performance of one (1) person physical assist with ADLs including locomotion off the unit, dressing, toileting, personal hygiene and bathing. Resident #7's MDS reflected that two (2) person physical assist was required for ADL transfers and Resident # 7 did not ambulate. Resident #7 was assessed to be always incontinent of urine and stool. Resident #7 was assessed to be at risk for pressure ulcers. Resident #7 was assessed to use a wheelchair. Review of Review of Resident #7's Care Plan dated 05/02/2014 reflected Resident #7 to be at risk for skin breakdown if she is not cleaned properly and regularly due to urinary and bowel incontinence, cognitive loss, and Diabetes Mellitus. A goal reflected Resident #7's skin remains clean and dry and intact. Approaches reflected Resident #7's skin be kept as clean and dry as possible, to minimize skin exposure to moisture, to provide incontinent care after each incontinent episode, to keep linens clean dry, wrinkle free, to observe and report red areas noted, and to avoid shearing of skin during repositioning and transfers. Observation on 07/16/2014 at 8:55 AM of a two person assistance transfer revealed CNA I and CNA J use a gait belt to lift Resident #7 up from her wheelchair and transfered her onto the bed. Resident #7 had urine dripping from her brief and the urine saturated dress she was wearing. A strong urine odor was observed after the transfer. CNA I stated to CNA J that the chair was wet and she would have to wipe it down. Resident #7's wheelchair cushion revealed scattered wet spots on top of it. CNA I told CNA J that they needed to do incontinent care on Resident #7. Resident was assisted into a lying position onto her back in the bed while supplies were gathered. Resident touched the back of her dress and stated "My seats wet and its cold!" CNA J informed Resident #7 that CNA I was getting stuff together so they could get her cleaned up. Observation on 07/16/2014 at 9:00 AM of incontinent care revealed Resident #7 flinching and grimacing as CNA I was wiping urine from Resident #7's buttocks and thighs. Resident # 7 stated "Oh! It hurts all over right there." Resident #7's left and right buttocks were dark red from top to bottom and the back of the left upper thigh was also dark red. The coccyx and sacral area revealed a raised white discoloration of the skin (maceration) with multiple linear skin breaks and cracks (fissures) to the center of the white (macerated) raised area. CNA I told Resident #7 that her skin was red and she was going to let the nurse know so that someone could put something on it to make it feel better. In an interview on 07/16/2014 at 9:15 AM CNA I stated that Resident #7's skin was not normally red or white and doesn't usually have cracking like that. CNA I stated she was going to notify the nurse so something could be put on it . CNA I stated that this was the first time Resident #7 was checked for incontinence on her shift because Resident #7 was on the list for 10-6 shift to get up and get ready for breakfast. CNA I stated that first rounds were started after breakfast at 8:30 AM for the Residents that they dont get up in the morning. Observation on 07/16/2014 at 9:20 AM revealed DON at bedside assessing Resident #7's abnormalities to her bilateral buttocks and to the back of left upper thigh. DON stated "This looks like it's caused from moisture being against her skin when she wets and it doesn't help in the way that she wiggles around in her chair." CNA I then stated to the DON that Resident #7 does move around a lot. In an interview on 07/16/2014 at 11:00 AM CNA M (who worked the 10PM-6AM shift on 7/15/14 - 7/16/14) stated that Resident #7 was checked for incontinence and had to be changeed every two hours because Resident #7 was found wet on each round last night on the 10P-6A shift. CNA M stated that she made a last round and changed Resident #7 at about 4:30AM or 4:45 AM this morning when she got her up and dressed for breakfast. CNA M stated that Resident #7 did not have any redness or sores to her skin. Surveyor asked CNA M how she remembered what time she changed Resident #7 on that last round. CNA M stated "I remember because she was the last person I changed right before I stopped to take a five minute break. I wheeled her up to the front sitting area on my way outside. I looked at my clock and it was 4:55 AM and that's when I went outside for a five minute break. CNA M stated that after the break she returned to make rounds on the rest of her residents and completed the last rounds between 5:30 AM and 5:45 AM. In an interview on 07/16/2014 at 5:03 PM the DON stated that the CNA's are given an assignment sheet to follow that reflects the the ADL care that is needed for all Residents on their assigned halls. DON reviewed the assignment sheet for Resident #7 and stated that it reflects that the 10PM -6 AM CNA's get Resident #7 up for breakfast in the morning. Surveyor informed the DON that Resident #7 went over four (4) hours without being checked for incontinence or changed between the hours 4:30 AM and 9 :00 AM. DON stated that it is facility policy to check all Residents that are incontinent every two (2) hours and that she expected that to be done regardless of which shift gets a Resident up for breakfast. DON stated that the nurses help supervise the CNA's and make changes to the assignment sheets. DON stated that she needed to inservice the staff and make some changes to the assignment sheets. DON stated that Resident #7's doctor had been notified of her skin redness and moisture problem to the buttocks and thighs and that a moisture barrier cream was ordered to treat the areas. DON stated that Resident #7's doctor also instructed staff to keep an eye on the areas and to notify him if they got worse. In an interview on 07/17/2014 at 8:50 AM the Medical Director stated he expected staff to make rounds every two (2) hours and provide care when needed. The Medical Director stated it was not appropriate for a resident to go four (4) hours without care which could cause skin issues. The Medical Director further stated he felt the nurse aides were overwhelmed because there was so much heavy care at the facility and not enough help. In an interview on 07/17/2014 at 2:15 PM CNA I stated that Resident #7's skin was still red and that they were checking and changing her every two hours. CNA I stated that Resident #7's pain was still the same stating that Resident #7 complains that areas feel sore during care, the same as yesterday. B) Review of Resident #4's Face Sheet reflected a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident # 4's Quarterly MDS assessment for ADL care dated 06/12/2014 reflected Resident #4 should be interviewed for Mental Status (BIMS). Resident #4 was assesed and his BIMS summary score was a 12 indicating Resident #4 had moderate cognitive impairment. Resident #4 required extensive physical assistance of one person for eating, and Resident #4 was dependent and required full staff performance every time for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Resident #4 assessed to use a mechanical lift and two person assistance for transfers. Review of Resident #4's Comprehensive Plan of Care dated 04/08/2014 reflected Resident #4 needed total assistance for all ADL's and that two staff members assistance was required for transfers and bathing due to [MEDICAL CONDITION]. A goal for Resident #4 reflected Resident #4's ADL needs will be met. One of the approaches listed was to give Resident #4 choices and encourage him to make decisions while giving him care. In an interview on 07/16/2014 at 1:30 PM Resident #4 stated that he would like to talk about some changes that either the Administrator or the corporation made that affected his life. Resident #4 stated that since he moved here, it has been his routine to get up every day after breakfast and that he is up by 1:00 PM and 1:30 PM at the lastest and it was never a problem. Resident #4 stated now he's been having to wait a lot longer for the aides to get him up. Resident #4 stated that it all started a few months ago when the corporate people fired the medication aides, made the nurses start passing pills, and they also made the aides start taking one hour lunches. Resident #4 stated that those one hour (required) lunches puts the aides behind and they have been late with our care since, for about the past two (2) or three (3) months. Resident #4 stated that sometimes they tell him that they can't get him up at all, because they only have one aide and don't have enough staff to help. Resident #4 stated that he couldn't get himself up and that he's tired of it, and ready to move out of the place. Surveyor asked Resident #4 how frequently he has to wait or can't get up and Resident #4 stated that it happens all the time and that they didn't have enough people to get him up the other day. In interview on 07/16/2014 at CNA H stated that she was unable to get Resident #4 up for supper (5:00 PM) when he requested and that he let CNA H know that was not happy about not being able to get up on 07/14/2014. CNA H stated that she explained to Resident #4 that she was the only CNA in the facility and that the Nurse was doing blood sugars, and that it takes two people to use the mechanical lift to get him up. CNA H stated that Resident #4 was more understanding after explaining to him that there was only one CNA on duty till 5:30 PM but she felt bad that she couldn't get him up when he wanted to get up.CNA H stated that she was unable to give showers that were due on 07/14/2014 because she ran out of time. Observation on 07/14/2014 at 7:30 PM revealed Resident #4 in his bed being fed fried chicken strips, from a Dairy Queen box, by a male visitor in his room. Review of Resident #4's point of care ADL report (used by CNA's to record Resident care performed) dated 07/14/2014 reflected that Resident #4 was not transferred out of bed and up on the second shift as he requested. In an interview on 07/17/2014 at 2:30 PM the Administrator informed surveyor that Resident #4 was requesting to talk to Surveyor. In an interview on 07/17/2014 at 2:35 PM Resident #4 stated that he just made two complaints to the Administrator that his bowel program was changed by his doctor without discussing it with him first and that he was left in bed by the first shift aide. Resident #4 stated that this was an example of him having to wait to get up and he wanted to point it out to the surveyor so that maybe something would get done about the way that they did stuff in facility. Resident #4 stated that he asked CNA J to get him up after breakfast and that CNA J told him that he might have to wait till around 2:00 PM today, because they were running around here and there doing this and that. Resident #4 stated that he waited, but it is now after 2:30 PM and he was still in the bed waiting and that he did not even get his wipe down bath he requested either. Resident #4 stated that he was so glad the surveyors were still here to see it. Surveyor informed Resident #4 that the survey team will follow-up with the Administrator to ensure that his grievances were being investigated. Resident #4 thanked surveyor for coming to see him. In an interview on 07/17/2014 at 2:45 PM the Administrator stated that he was aware of Resident # 4's complaints about the bowel program and being left in bed and that he was already on it and taking care of it. In an interview on 07/16/2014 at 5:03 PM the DON stated that the CNA's are given an assignment sheet to follow that reflects the the ADL care that is needed for all Residents on their assigned halls. Review of CNA J work list for hall 4L, 5, and 6 dated 07/17/2014 reflected Resident #4 was on the list to get up on the 6-2 shift. Review of the facility's policy for Nursing Assistant Guidelines (no date) reflected the policy did not address following the residents plan of care or how often care should be provided. The facility provided a list of 16 residents, who were incontinent of bowel and bladder and required extensive ADL assist.

Based on observation, interview and record review the facility failed to ensure one (1) of 12 Residents (Resident # 1) reviewed for pressure sores received necessary treatment and services to promote healing and prevent new sores from developing. The facility did not identify a Stage II Pressure Sore that declined to a Stage III Pressure Sore and did not identify a separate Stage III Pressure Sore for Resident # 1 until Surveyor Intervention. This deficient practice affected Resident # 1 and placed nine (9) additional residents at risk for development of new pressure sores, infection and worsening of current pressure sores. Finding Include: Review of Resident #1's Face Sheet reflected an [AGE] year old male admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #1 had a BIMS's of zero (0) indicating he had severe cognitive impairment. Resident #1 was assessed to require total assist with all ADL's. Resident #1 was assessed to have one (1) Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.) pressure ulcer with the identification of 06/24/2014. The pressure sore was assessed to have granulation tissue. Review of Resident #1's Comprehensive Care Plan reflected a problem with a start date of 05/09/2014 "Resident is at risk for pressure ulcers R/T (related to) bowel incontinence, age and the need for assist with ADL's." Under approach " Report any signs of skin breakdown (sore, tender, red, or broken areas) ...Monitor and record intake of food." Review of Resident #1's Acute Care Plan dated 06/26/2014 reflected " I have a Stg (Stage) two (2) decub (decubitus) on my buttocks." Handwritten under the problem was a measurement 1.5 cm by 1 cm. Under Approaches " ...Notify my MD of any changes better or worse ....Make sure I get the proper nutrition so that my Stg two (2) decub will heal. " The care plan did not state which buttock the pressure sore was on. Review of Resident #1's Consolidated Physician order [REDACTED]. " dated 06/24/2014. The order did not address a location of the pressure sore. Observation on 07/14/2014 at 6:30 PM revealed Resident #1 up in his wheelchair in the living room asleep. Observation on 07/15/2014 at 9:50 AM revealed Resident #1 in bed. Resident #1 was on an air mattress. Bilateral knee contractures were noted. Resident #1 was unable to communicate with the Surveyor. In an interview on 07/15/2014 at 11:00 AM LVN C stated she already completed Resident #1's skin assessment and his treatments for his pressure sore. Review of Resident #1's Weekly Skin Documentation dated 07/8/2014 reflected Resident #1 had a Stage II pressure sore to his left buttock. The documented measurements were 0.8 cm long with width of 0.7 cm no depth was documented; no further description was documented. The assessment was signed by LVN C. The assessment did not reflect any other skin conditions for Resident #1. Review of Resident #1's Treatment Administration Record (TAR) for July 2014 reflected Resident #1 had a head to toe skin assessment completed on 07/09/2014 and signed by LVN C. The TAR further reflected an order to cleanse Stg. (Stage) 2 Decub. (Decubitus) with NS apply [MEDICATION NAME] alginate in wound bed cover with 4 x 4 drsg. (Dressing) once a day. The order was initialed by LVN C on 07/14/2014 and 07/15/2014. The order did not reflect a location of the pressure sore. Review of Resident #1's Weekly Skin Documentation dated 07/15/2014 no time reflected Resident #1 had a Stage II on his left buttock. The documented measurements were 0.8 cm long with width of 0.7 cm no depth was documented not further description was documented. The assessment was signed by LVN C. The assessment did not reflect any other skin conditions for Resident #1. Observation on 07/15/2014 at 3:55 PM revealed CNA G and CNA H in Resident #1's room to perform incontinent care. Resident #1 was in bed. CNA G and CNA H rolled Resident #1 to his left side. Resident #1 was noted to have a dressing over his right buttock and left buttock. Resident #1 was incontinent of bowel. During the incontinent care Resident #1's dressings became soiled with bowel movement. CNA G removed the dressings (which was not dated or initialed) stating she was going to get the nurse and tell her she removed to dressings. CNA G removed the dressing which revealed: Resident #1 to have a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendons or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. It may include undermining and tunneling) pressure sore to his right buttock approximately 2 cm by 2 cm with greater than 0.1 cm depth. The pressure sore wound bed had yellow slough (a type of dead tissue) from 8 o'clock to 4 o'clock and shiny red granulation tissue from 4 o'clock to 8 o'clock. The wound edges were macerated and a pale gray color extending out approximately 0.3 cm. The peri-wound extended out approximately 1 cm around pressure sore and was slightly red. No drainage was noted. Further observation revealed Resident #1 to have a Stage III pressure sore to his left buttock approximately 0.8 cm long by 0.6 cm wide with greater than 0.1 cm depth. The pressure sore wound bed had shiny red granulation tissue. The wound edges were beveled. The peri-wound extended out approximately 1.5 cm and were pale gray. (Approximations by Surveyor) CNA H went to get Resident #1's nurse and Director of Nursing (DON). Review of the <http://www.woundsource.com/article/identifying-types-tissues-found-pressure-ulcers> website reflected "Granulation tissue- The formation of granulation tissue is thought to be an intermediate step in the healing process of full-thickness wounds. Granulation tissue is shiny red and granular in appearance when it is healthy; when inadequate blood flow exists, granulation tissue may pale in color. Slough- Slough is indicative of full-thickness Stage 3 pressure ulcers or stage 4 pressure ulcers. Slough can easily be confused with normal anatomical tissues such as tendons or ligaments because of their frequently yellowish coloration. " In an interview on 07/15/2014 at 4:05 PM CNA G stated she worked with Resident #1 every day she worked and she stated the pressure sore on his right buttock had been there at least since last Wednesday (7/09/2014) because she came back after vacation and it was there. CNA G stated she reported it to the nurse LVN E. Observation on 07/15/2014 at 4:10 PM revealed the DON and LVN E entering Resident #1's room to assess Resident #1's pressure sores. During this observation LVN E stated the area on his right buttock was new and she had not seen it before and did not know about it. LVN E further stated Resident #1 skin assessments were done on the day shift so she was unsure about the pressure sore decline on his left buttock. In an interview on 07/15/2014 at 4:15 PM after the DON observed Resident #1's right buttock pressure sore she stated " That is new. I only knew about the left buttock and that one (pointing to the right buttock pressure sore) was not there last week (07/08/14) when I looked at his skin on his skin assessment day." The DON stated she observed Resident # 1's skin assessment last week on 07/08/2014. When asked what stage the pressure sores were the DON stated they were Stage III. The DON further stated the pressure sore on Resident #1's left buttock was a Stage III and had declined since last week. When asked about the skin assessment performed this morning by LVN C the DON stated she was going to look into the situation. In an interview on 07/15/2014 at 4:40 PM the DON stated she spoke with LVN C who stated to her Resident # 1 had barrier cream on his right buttock and she did not see the right buttock pressure sore. The DON further stated she called Resident # 1's Physician for orders on the right and left buttock pressure sores. The DON stated she expected the nursing staff to complete head to toe assessments weekly on the residents and if there was barrier cream to remove it to do a complete assessment. The DON further stated the nurses are not documenting the pressure sores correctly. The DON stated the nurses are suppose4d to document the wound bed and peri-wound and wound margins and they are not. The DON stated LVN C did not fill out the assessment fully or perform a correct assessment. Review of Resident #1's Physician Telephone Order dated 07/15/2014 no time reflected the following orders after Surveyor intervention "Cleanse Stg. III decub on right buttock with NS (normal saline) apply wound gel cover with bordered gauze q day. Cleanse Stg. III decub on left buttock with NS apply wound gel cover with bordered gauze q day. Once Santyl arrives in facility, Cleanse right buttock with NS apply Santyl and cover with bordered gauze. Cleanse left buttock Stg. III decub with NS apply Santyl and cover with bordered gauze q day." In an interview on 07/16/2014 8:32 AM LVN C stated Resident #1's had barrier cream on his right buttock and she did not see anything. LVN C further stated " I honestly only looked at the one area" (referring to his left buttock) and did not do a complete assessment. LVN C stated she did not remember seeing any other areas except the left buttock while doing the skin assessment the week before. LVN C did not know who put the dressing on Resident #1's right buttock. LVN C stated that she has not had any skills check offs or training since she's been employed at the facility. In an interview on 07/16/2014 at 9:30 AM CNA I stated Resident #1 had the pressure sore on his right buttock when she saw it, about a week ago. CNA I stated she was not sure exactly how long but that she reported the area to LVN C. In an interview on 07/16/2014 at 5:03 PM the DON stated is did not know who does the competency and skills check offs and training with the nurses for wound care. The DON stated she did not do them. DON stated that Regional Nurse A just informed her that there was a wound care competency skills check off in the facility's SharePoint program in the computer. The DON stated that she will start using them for the nurses and denied doing any wound care training for LVN C. Review of Resident #1's Dietary Consultant recommendation dated 05/16/2014 reflected "Problem or Concern: ....-underweight; has unstageable wound. Recommendations: Add 2 cal supplement 60 cc QID with med pass, Add Arginiad one (1) packet BID, Add large portion at all meals, Consider ST (Speech Therapy) eval d/t (due to) possible diet texture upgrade." Further review reflected the dietary recommendation was signed by Resident #1's Physician on 06/03/2014 (18 days later). Review of Resident #1's Physician Telephone orders reflected an order written [REDACTED]." Review of the Dietary progress notes dated 06/19/2014 reflected "Weight down 16 pounds in one (1) month (12%) down five (5) pounds since last visit. Has Stage II wound to Left buttocks, unstageable to right heel. Has MBSS (modified [MEDICATION NAME] swallow study) ordered." In an interview on 07/16/2014 at 5:00 PM the DON stated she faxed the dietary recommendation to the Physician and waited on him to respond. The DON stated she was responsible to follow up on dietary recommendation and further stated "I guess I need to call the Physician if he does not respond in a few days or fax the Physician back." In an interview on 07/17/2014 at 10:00 AM the Dietary Consultant stated she expected recommendations to follow up on timely. The Dietary Consultant stated "It would have helped Resident #1 to have the extra protein and calories especially with his pressure ulcers." In an interview on 07/17/2014 at 8:50 AM the Medial Director stated he expected the nursing staff to do a thorough head to toe assessment weekly and notify the Physician right away with any finding. The Medical Director further stated staff should monitor skin daily during care and report if any pressure sores found so treatment can be initiated. The Medical Director stated if the dietary consultant makes recommendations he expected the facility to follow up on them on one (1) to two (2) days. Review of the Facility's Policy Skin System dated 02/15/2012 reflected " 6. The Weekly Skin Assessment form is completed weekly for Residents with presence of skin interruptions of any type. If no skin interruption is identified, the nurse assessor will document the assessment performed weekly on the TAR. 7. The facility DON is responsible for assignment of weekly skin assessments ... 10. The facility DON should visualize areas related to pressure weekly and be able to report observations to the Standards of Care Team members. The DON is validating the accuracy of the description of the pressure ulcer documentation on the weekly assessment form." The facility provided a list of 10 residents with pressure ulcers.