Every finding on record at Cityview Nursing and Rehabilitation Center

Based on interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 3 resident (Resident #1) reviewed for quality of care.The facility failed to identify and intervene timely after Resident #1 had an unwitnessed fall on 08/16/2026 at 5:45 AM. Resident #1 was found to have left hip pain on assessment and was not sent to the hospital until approximately 3.5 hours later at 9:10 AM. This failure could place residents at risk of delayed treatment and not receiving needed care. Findings included:Record review of Resident #1's admission MDS, dated [DATE], reflected an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included Non-Alzheimer's Dementia (conditions that impair memory, cognition, and daily functioning due to causes other than Alzheimer's) and muscle wasting and atrophy (thinning of muscle mass due to not using them or illness). Resident #1's BIMS score was 3, indicating severe cognitive impairment. Further review of the MDS reflected Resident #1 used a walker and required supervision or touching assistance with transfers. Record review of Resident #1's care plan, reflected the following: - [Resident #1] has an ADL selfcare performance deficit r/t slightly impaired mobility, confusion, radiculopathy (pinched nerve), dated 07/14/26. - [Resident #1] is at risk for falls r/t wandering, confusion, incontinence, impaired mobility, psychoactive medication, h/o falls, radiculopathy 8/16/26 Observed on floor- guarding L hip, s/s of pain: crying/shaking, speaking in tongues: L femoral neck fracture (broken left hip), dated 07/16/26 and revised on 08/24/26. Record review of Resident #1's August 2026 MAR reflected the following as administered on 08/16/26:- Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 1 tablet by mouth two times [NAME] for pain -Start Date- 07/21/2026 -D/C Date- 08/16/2026 - pain level 5.- traMADol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours as needed for pain -Start Date- 08/16/2026 -D/C Date- 08/16/2026 - pain level 5.Record review of Resident #1's progress notes, dated 08/16/26, written by LVN C, reflected, Resident was involved in an unwitnessed fall. Resident was observed sitting on the floor beside her roommate's bed. Resident was wearing non-skid socks and shoes at the time of discovery. Upon observation, resident was noted to be guarding her left hip and demonstrating signs of severe pain, including crying and shaking. Resident was also noted to be speaking in tongues. Resident was awake, alert, and responsive to this writer upon assessment. Resident appeared to be in significant distress and was repeatedly crying out in pain. When asked what happened, resident stated, 'I had to go pee pee.' Resident was unable to provide a numerical pain rating and repeatedly stated, 'Help me baby, help me please.' Resident was assessed while remaining on the floor prior to movement. No obvious external injury was noted at the time of initial assessment. Resident was noted to be guarding the left hip and unable to move the affected leg at this time due to pain. Vital signs obtained 139/76 82 18 97.5F O2 95% on room air. Resident was not independently ambulated or asked to bear weight due to severe left hip pain and inability to move the affected extremity. Resident was kept as still as possible while assessment was completed. D/T resident persistently trying to get up from the floor, this writer and CNA provided careful assistance with transfer from the floor to the bed using lateral draw sheet transfer avoiding unnecessary movement of the affected left hip/leg. Following transfer, a head-to-toe assessment was completed. No bruising, open areas, redness, swelling, bleeding, or other obvious external injuries were noted at this time. Resident continued to demonstrate significant pain and continued crying/screaming out. Routine Tylenol 500 mg administered as ordered. Resident continued to verbalize/express significant pain following administration. [Name], C-NP; [Name], DON; [Name], ADON; [Name], Weekend Supervisor; and the oncoming nurse were notified of the fall, resident's severe left hip pain, guarding of the left hip, and inability to move the affected extremity. Received new order for Tramadol 50 mg by mouth every 6 hours as needed for pain. Resident's [FM Name] was contacted regarding the fall and resident's condition. Unable to reach [FM]. Voicemail was left requesting a return call. Resident remains under close observation. Staff instructed to avoid unnecessary movement or weight-bearing through the affected extremity. [FM Name] called facility back at 0701 [7:01 AM] and informed of change in condition. [FM] states, 'Please give me an update with results as soon as possible. I'm about to shower and then I will be up there'. Fall precautions remain in place with neuro checks ongoing at this time.Record review of Resident #1's progress notes, dated 08/16/26, written by LVN D, reflected, Resident c/o unresolved pain to left hip/femur as result of fall in the previous shift. NP [Name] orders of stat Lt. hip x-ray and Tramadol 50mg PRN 6 hrs. for pain implemented. X-ray pending completion, Tramadol 50mg PRN; called the pharmacy for access to E-kit. At 0753hrs [7:53 AM] med obtained and administered. After 30 minutes pain remained unrelieved, res. continued crying and yelling for pain. NP [Name] contacted at 0830hrs [8:30 AM], new orders received to dc X-ray and transfer res to ER. At 0835 [8:35 AM] [FM Name] at bedside, updated and said that works. Resident continues on po ABT Cipro for UTI. Contacted non-emergency EMS, at 0910hrs [9:10 AM] res transfer to ER [Hospital Name] DON made aware.Record review of facility Provider Investigation Report (Form 3613), dated 08/24/26, reflected incident date and time was 08/16/26 at 5:45 AM with incident category of Injury of Unknown Origin. Description of allegation reflected, Resident fell in room on 08/16/26, she was transferred to hospital same day. Report from hospital with fracture sent 8/17/2026. The investigation summary reflected the following: Facility initiated an investigation on 08/16/2026 when [Resident #1] was suspected of having a fracture after being observed on the floor. [Resident #1] was living on station one, the secure unit and is alert with a BIMS of 3. She is dependent on staff for ADLS and can ambulate ad-lib. She was noted as a fall risk and has a history of falls with fractures. She has diagnosis of Fracture history, falls, degenerative disease of the nervous system, muscle wasting and atrophy, abnormal gait, dementia, malnutrition, HTN, anxiety, CAD, GERD, and osteoporosis (disease that makes bones thin, weak and likely to break). On the early morning of 08/16/2026, the CNA was alerted by [Resident #1's] roommate of the need for assistance, she entered the room and noted [Resident #1] on the floor by her roommate's bed. She alerted the nurse who entered the room and evaluated the resident who was calling out in pain and unable to move left extremity. Since she kept attempting to get up, she was lifted via drawsheet to the bed. She was medicated for pain and the physician was paged. Notifications were made to the [FM], DON and ADON. Orders for x-ray and Ultram were obtained from the practitioner. The Ultram was initiated but the medication was deemed ineffective and [Resident #1] was transferred to the hospital for evaluation. On 08/17/2026, the hospital report was obtained and showed that she had fractured her left femoral neck and was having surgery.MD, FM, Administrator, DON, Regional support team, and HHSC were notified of the fracture. Facility interviewed staff members that had taken care of [Resident #1], she had last been checked on by the CNA between the hours of 0430-0500 [4:30-5:00 AM]. She was clean and dry at that time and denied needing assistance to go to the restroom. Staff were in-serviced on abuse and neglect, incidents and accidents, osteoporosis with fractures and falls with assessments. With [Resident #1's] history of self-ambulating, and her history of fractures, all evidence supports that she got up and put her shoes on over her non-skid socks and fell while attempting to take herself to the restroom. She had surgical intervention and did not return to [Name of facility].The investigation confirms injury but does [sic] find evidence of abuse or neglect. The investigation does not support injury of unknown injury; it does support injury post fall after attempting to self-ambulate.Interview on 08/25/26 at 10:15 AM, LVN C stated she was the nurse on the unit when Resident #1 fell at 5:45 AM [on 08/16/26]. She stated CNA B told her Resident #1 was on the floor and when she arrived at the room, Resident #1 was sitting down by the roommate's bed, with her legs stretched out and holding and rubbing her left hip and thigh area. LVN C stated Resident #1 was trying to get up, was impatient and saying, help me please. LVN C said Resident #1 was crying and when she tried to assess, Resident #1 could barely lift her leg and was only able to lift it half an inch off the ground. LVN C stated she and CNA B transferred Resident #1 to the bed then she called the DON. LVN C stated normally with a fall, if it was severe, she would call 911, but she could not tell how severe it was, and if Resident #1 was just hurting or if it was a fracture. LVN C stated the reason she did not call 911 to send Resident #1 to the hospital was because it was facility protocol to have a doctor's order first. LVN C stated she rounded with the morning shift nurse (LVN D) around 6:15 AM and that was when she realized Resident #1's pain was severe because Resident #1 was screaming. LVN C stated she attempted to call Resident #1's FM while LVN D took care of contacting the provider for the pain medication. Interview on 08/25/26 at 10:53 AM, LVN D stated that day [on 08/16/26] LVN C gave report and told him about the fall, that she had contacted the family and doctor, and they were given orders to do an x-ray. He stated he went to Resident #1's room to do an assessment and that was when he found Resident #1 to be in a lot of pain. LVN D stated Resident #1 told him it hurts and help me. LVN D said the Tramadol was approved from the e-kit, he called the pharmacy to get access to the pain pill and was disconnected so he told the Weekend Supervisor who called the pharmacy back to tell them they needed access because the patient was in pain. LVN D said the Tramadol was immediately approved and he administered the medication to Resident #1 before 8:00 am. LVN D said Resident #1 was crying from pain and he informed the Weekend Supervisor and they both reached out to the Physician, NP and Resident #1's FM. He said the NP told the Weekend Supervisor to send Resident #1 out to the hospital. LVN D stated facility protocol was to call the Doctor for any change of condition or to send the resident to the hospital. He stated if he was not able to get a hold of the Provider, he was to call the DON. LVN D stated the risk of not sending a resident out by 911 was a delay, it may worsen pain and it may cause death. Interview on 08/25/26 at 11:39 AM, Resident #1's FM stated Resident #1 was not able to walk and not moving very well [after the fall on 08/16/26]. She said Resident #1 had a broken hip and had surgery. Resident #1's FM said when she was informed of the fall from staff she asked them to call an ambulance if the x-ray people were not there in an hour. Resident #1's FM said they should have sent Resident #1 out immediately. Interview on 08/25/26 at 11:50 AM, the Weekend Supervisor stated LVN C called and told him Resident #1 fell and complained of pain and gave her Tylenol. When asked when a patient was sent to the hospital after a fall he stated it was case by case, but if a pt fell and was stable, they would do x-rays and if there was a fracture they would send them out. The Weekend Supervisor stated Resident #1 was not stable. He stated staff did not have to wait for a physician order to send to hospital if there was a respiratory or cardiac arrest. Attempted interview on 08/25/26 at 12:31 PM by telephone, with Physician F, was unsuccessful, the call was disconnected and there was no option to leave a voicemail.Interview on 08/25/26 at 12:33 PM, by telephone, NP E stated when Resident #1 fell, she ordered x-rays and to give her Tramadol. NP E stated if somebody was screaming in pain they probably needed to go out to the hospital. NP E stated a resident was typically sent to the ER post fall based on pain or if there was a fracture, but they could not automatically send everyone that fell to the ER, and it was based on assessment. NP E stated if staff were not able to get in contact with the provider and the resident had severe pain post fall, staff would have to use their best judgement and if the patient needed to go out then they go out. Interview on 08/25/26 at 2:05 PM, the Administrator stated there was no policy on Quality of Care.Interview on 08/25/26 at 2:50 PM, ADON A stated if a resident fell, the nurse would assess the patient, if they were able to get the patient up, then contact the doctor, see what orders they have and medicate for pain, and contact the supervisor. She stated if the patient had a visible fracture they would just send the patient out. ADON A stated if a patient was screaming in pain and not trying to get themselves up after a fall she would send them out, but if a patient was squirming around on the floor and attempting to get up then she would get the patient up, call the doctor and give medication. ADON A stated if there was chest pain after nitroglycerin, a patient or family demanding to go to the hospital they did not need a physician order to send the patient out to the ER. When asked if a resident should be sent out to the ER with severe pain after a fall, ADON A said yes. ADON A stated if the resident was not sent out timely there was a risk of severe pain, fracture and a lot of things could have happened. Interview on 08/25/26 at 3:20 PM, the DON stated her expectation for when a resident fell and had severe pain was for staff to address the pain, medicate them and if pain was not controlled contact the physician and try a different route. The DON stated if staff could not get the provider they were to call her. She stated she did not think that was the case with Resident #1 because the Weekend Supervisor was in contact with the clinician. She said sometimes it takes 45 minutes for the clinical to get back to them after they page them. The DON stated she could not speculate on what could happen if a resident was not sent out with severe pain after a fall; she stated she could tell what happened with Resident #1 which was her vitals were stable, pain medication was not effective, and she was sent to the hospital. The DON stated generally staff needed to contact the physician before sending a resident to the hospital, unless someone was crashing (when a patient's health or vital signs suddenly and rapidly get worse), their O2 was low, if in respiratory distress (trouble breathing), their blood pressure was out of control or something like that then they could make the decision to send and notify the physician afterwards. The DON stated the nurse was trying to take the route of following what they normally do after a fall, tried to address the pain and when she saw it was ineffective Resident #1 was sent out. The DON stated there was no risk to Resident #1 not being sent out immediately since she was immobilized in bed and she was being monitored. Interview on 08/25/26 at 3:37 PM, the Administrator stated his expectation was for staff to use good nursing judgement when sending a resident out, however it was traumatic anytime a resident was sent to the hospital. He stated that was why there was so much pressure from hospitals on RTA (return to acute) which was a metric the hospitals used to track when residents were hospitalized . The Administrator stated if it had been a visual break they were not going to wait [to send her out]. The Administrator stated if staff could not get ahold of the provider after a fall they were to call the DON. He said there was nothing that said they could not send a resident out without an order [if it was an emergency] and they would have to use nursing judgement if they needed to be sent out. Record review of facility's, Fall Prevention Program policy, dated 08/15/22, reflected .8. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify Physician and family. e. Review the resident's care plan and update as indicated. F. Document all assessments and actions. g. Obtain witness statements in the case of injury.

Based on interview and record review, the facility failed to ensure that pain management was provided to residents who required such service, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 3 resident (Resident #1) reviewed for pain management. The facility failed to adequately address Resident #1's pain after she had an unwitnessed fall on 08/16/2026. This failure could place residents at risk of unnecessary pain, discomfort and a decreased quality of life.Findings included:Record review of Resident #1's admission MDS, dated [DATE], reflected an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included Non-Alzheimer's Dementia (conditions that impair memory, cognition, and daily functioning due to causes other than Alzheimer's) and muscle wasting and atrophy (thinning of muscle mass due to not using them or illness). Resident #1's BIMS score was 3, indicating severe cognitive impairment. Further review of the MDS reflected Resident #1 used a walker and required supervision or touching assistance with transfers. - [Resident #1] has an ADL selfcare performance deficit r/t slightly impaired mobility, confusion, radiculopathy (pinched nerve), dated 07/14/26. - [Resident #1] is at risk for falls r/t wandering, confusion, incontinence, impaired mobility, psychoactive medication, h/o falls, radiculopathy 8/16/26 Observed on floor- guarding L hip, s/s of pain: crying/shaking, speaking in tongues: L femoral neck fracture (broken left hip), dated 07/16/26 and revised on 08/24/26. Record review of Resident #1's August 2026 MAR reflected the following as administered on 08/16/26:- Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 1 tablet by mouth two times [NAME] for pain -Start Date- 07/21/2026 -D/C Date- 08/16/2026 - pain level 5.- traMADol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours as needed for pain -Start Date- 08/16/2026 -D/C Date- 08/16/2026 - pain level 5.Record review of Resident #1's progress notes, dated 08/16/26, written by LVN C, reflected, Resident was involved in an unwitnessed fall. Resident was observed sitting on the floor beside her roommate's bed. Resident was wearing non-skid socks and shoes at the time of discovery. Upon observation, resident was noted to be guarding her left hip and demonstrating signs of severe pain, including crying and shaking. Resident was also noted to be speaking in tongues. Resident was awake, alert, and responsive to this writer upon assessment. Resident appeared to be in significant distress and was repeatedly crying out in pain. When asked what happened, resident stated, 'I had to go pee pee.' Resident was unable to provide a numerical pain rating and repeatedly stated, 'Help me baby, help me please.' Resident was assessed while remaining on the floor prior to movement. No obvious external injury was noted at the time of initial assessment. Resident was noted to be guarding the left hip and unable to move the affected leg at this time due to pain. Vital signs obtained 139/76 82 18 97.5F O2 95% on room air. Resident was not independently ambulated or asked to bear weight due to severe left hip pain and inability to move the affected extremity. Resident was kept as still as possible while assessment was completed. D/T resident persistently trying to get up from the floor, this writer and CNA provided careful assistance with transfer from the floor to the bed using lateral draw sheet transfer avoiding unnecessary movement of the affected left hip/leg. Following transfer, a head-to-toe assessment was completed. No bruising, open areas, redness, swelling, bleeding, or other obvious external injuries were noted at this time. Resident continued to demonstrate significant pain and continued crying/screaming out. Routine Tylenol 500 mg administered as ordered. Resident continued to verbalize/express significant pain following administration. [Name], C-NP; [Name], DON; [Name], ADON; [Name], Weekend Supervisor; and the oncoming nurse were notified of the fall, resident's severe left hip pain, guarding of the left hip, and inability to move the affected extremity. Received new order for Tramadol 50 mg by mouth every 6 hours as needed for pain. Resident's [FM Name] was contacted regarding the fall and resident's condition. Unable to reach [FM]. Voicemail was left requesting a return call. Resident remains under close observation. Staff instructed to avoid unnecessary movement or weight-bearing through the affected extremity. [FM Name] called facility back at 0701 [7:01 AM] and informed of change in condition. [FM] states, 'Please give me an update with results as soon as possible. I'm about to shower and then I will be up there'. Fall precautions remain in place with neuro checks ongoing at this time.Record review of Resident #1's progress notes, dated 08/16/26, written by LVN D, reflected, Resident c/o unresolved pain to left hip/femur as result of fall in the previous shift. NP [Name] orders of stat Lt. hip x-ray and Tramadol 50mg PRN 6 hrs. for pain implemented. X-ray pending completion, Tramadol 50mg PRN; called the pharmacy for access to E-kit. At 0753hrs [7:53 AM] med obtained and administered. After 30 minutes pain remained unrelieved, res. continued crying and yelling for pain. NP [Name] contacted at 0830hrs [8:30 AM], new orders received to dc X-ray and transfer res to ER. At 0835 [8:35 AM] [FM Name] at bedside, updated and said that works. Resident continues on po ABT Cipro for UTI. Contacted non-emergency EMS, at 0910hrs [9:10 AM] res transfer to ER [Hospital Name] DON made aware.Record review of facility Provider Investigation Report (Form 3613), dated 08/24/26, reflected incident date and time was 08/16/26 at 5:45 AM with incident category of Injury of Unknown Origin. Description of allegation reflected, Resident fell in room on 08/16/26, she was transferred to hospital same day. Report from hospital with fracture sent 8/17/2026. The investigation summary reflected the following: Facility initiated an investigation on 08/16/2026 when [Resident #1] was suspected of having a fracture after being observed on the floor. [Resident #1] was living on station one, the secure unit and is alert with a BIMS of 3. She is dependent on staff for ADLS and can ambulate ad-lib. She was noted as a fall risk and has a history of falls with fractures. She has diagnosis of Fracture history, falls, degenerative disease of the nervous system, muscle wasting and atrophy, abnormal gait, dementia, malnutrition, HTN, anxiety, CAD, GERD, and osteoporosis(disease that makes bones thin, weak and likely to break). On the early morning of 08/16/2026, the CNA was alerted by [Resident #1's] roommate of the need for assistance, she entered the room and noted [Resident #1] on the floor by her roommate's bed. She alerted the nurse who entered the room and evaluated the resident who was calling out in pain and unable to move left extremity. Since she kept attempting to get up, she was lifted via drawsheet to the bed. She was medicated for pain and the physician was paged. Notifications were made to the [FM], DON and ADON. Orders for x-ray and Ultram were obtained from the practitioner. The Ultram was initiated but the medication was deemed ineffective and [Resident #1] was transferred to the hospital for evaluation. On 08/17/2026, the hospital report was obtained and showed that she had fractured her left femoral neck and was having surgery.MD, FM, Administrator, DON, Regional support team, and HHSC were notified of the fracture. Facility interviewed staff members that had taken care of [Resident #1], she had last been checked on by the CNA between the hours of 0430-0500 [4:30-5:00 AM]. She was clean and dry at that time and denied needing assistance to go to the restroom. Staff were in-serviced on abuse and neglect, incidents and accidents, osteoporosis with fractures and falls with assessments. With [Resident #1's] history of self-ambulating, and her history of fractures, all evidence supports that she got up and put her shoes on over her non-skid socks and fell while attempting to take herself to the restroom. She had surgical intervention and did not return to [Name of facility].The investigation confirms injury but does [sic] find evidence of abuse or neglect. The investigation does not support injury of unknown injury; it does support injury post fall after attempting to self-ambulate.Interview on 08/25/26 at 10:15 AM, LVN C stated she was the nurse on the unit when Resident #1 fell at 5:45 AM [on 08/16/26]. She stated CNA B told her Resident #1 was on the floor and when she arrived at the room, Resident #1 was sitting down by the roommate's bed, with her legs stretched out and holding and rubbing her left hip and thigh area. LVN C stated Resident #1 was trying to get up, was impatient and saying help me please. LVN C said she could tell Resident #1 was in pain because Resident #1 kept rubbing her left leg and her voice was more high-pitched than normal. LVN C said Resident #1 was crying and when she tried to assess, Resident #1 could barely lift her leg and was only able to lift it half an inch off the ground. LVN C stated she and CNA B transferred Resident #1 to the bed then she called the DON. LVN C stated normally with a fall, if it was severe, she would call 911, but she could not tell how severe it was, and if Resident #1 was just hurting or if it was a fracture. LVN C stated she had given Resident #1 her scheduled Tylenol. LVN C said she tried contacting the doctor to get something stronger, which took a little while, and the order for Tramadol came around 7:30 AM, which was about the time she left. LVN C stated she rounded with the morning shift nurse (LVN D) around 6:15 AM and that was when she realized Resident #1 pain was severe because Resident #1 was screaming. LVN C stated she had attempted to call Resident #1's FM while LVN D took care of contacting the provider for the pain medication. Interview on 08/25/26 at 10:53 AM, LVN D stated that day [on 08/16/26] LVN C gave report and told him about the fall, that she had contacted the family and doctor, and they were given orders to do an x-ray. He stated he went to Resident #1's room to do an assessment and that was when he found Resident #1 to be in a lot of pain. LVN D stated Resident #1 told him it hurts and help me. LVN D said the Tramadol was approved from the e-kit, he called the pharmacy to get access to the pain pill and was disconnected so he told the Weekend Supervisor who called the pharmacy back to tell them they needed access because the patient was in pain. LVN D said the Tramadol was immediately approved and he administered the medication to Resident #1 before 8:00 am. LVN D said Resident #1 was crying from pain and he informed the Weekend Supervisor and they both reached out to the Physician, NP and Resident #1's FM. He said the NP told the Weekend Supervisor to send Resident #1 out to the hospital. LVN D stated Resident #1's pain was unrelieved and the pain was terrible 30 minutes after Tramadol was given. LVN D said he knew Resident #1 had severe pain because Resident #1 was calling for help and he saw Resident #1 touching [her leg] and saying help. LVN D stated the risk of not sending a resident out by 911 was a delay, it may worsen pain and it may cause death. Interview on 08/25/26 at 11:20 AM, CNA B stated around 5:45 AM [on 08/16/26] Resident #1's roommate came in the hall, called for help and when she went to the room she saw Resident #1 on the ground. CNA B stated Resident #1 could not get up and was screaming so she went to get the nurse. She stated the nurse came and assessed Resident #1 and she helped LVN C put Resident #1 in the bed. CNA B stated when she first got to the room, Resident #1 screamed without stopping and was very loud. She said Resident #1 continued to scream while she was in bed.Interview on 08/25/26 at 11:39 AM, Resident #1's FM stated Resident #1 was not able to walk and not moving very well [after the fall on 08/16/26]. She said Resident #1 had a broken hip and had surgery. Resident #1's FM said she had missed a call about 5 something in the morning, called the facility back around 7 am and was told Resident #1 fell, Tylenol was given and x-rays were ordered. Resident #1's FM said she asked them to call an ambulance if the x-ray people were not there in an hour. She said when she got to the facility around 8:00 AM Resident #1 was screaming and writhing in pain. Resident #1's FM said they should have sent Resident #1 out immediately. Interview on 08/25/26 at 11:50 AM, the Weekend Supervisor stated LVN C called and told him Resident #1 fell and complained of pain and gave her Tylenol. He said LVN C asked to get something stronger because Resident #1 appeared to be in pain. The Weekend Supervisor stated at 6:30 AM, Physician F responded and gave an order for Tramadol. He said they monitored for effectiveness, realized the Tylenol was not working and gave Tramadol and when that was not working reached out to NP E who said to send to the hospital. He said they monitored Resident #1, medications were given and it was escalated because interventions were not effective and they sent the patient out. He said the risk if interventions were not effective was the agony the patient was in and pain was a concern. Attempted interview on 08/25/26 at 12:31 PM by telephone, with Physician F, was unsuccessful, the call was disconnected and there was no option to leave a voicemail.Interview on 08/25/26 at 12:33 PM, by phone, NP E stated when Resident #1 fell, she ordered x-rays and to give her Tramadol. NP E stated she did not know if she was told Resident #1 was in severe pain, just that she was in pain. NP E stated if somebody was screaming in pain they probably needed to go out to the hospital. NP E said they called her and said the pain was not any better after giving her the Tramadol and she cancelled the x-rays and said send her to the hospital. Interview on 08/25/26 at 2:50 PM, ADON A stated if a resident fell, the nurse would assess the patient, if they were able to get the patient up, then contact the doctor, see what orders they have and medicate for pain, and contact the supervisor. ShADON A stated if a patient was screaming in pain and not trying to get themselves up after a fall she would send them out, but if a patient was squirming around on the floor and attempting to get up then she would get the patient up, call the doctor and give medication. ADON A stated if she was not able to get a hold of the doctor and the patient was in pain she would send the patient out based on her nursing judgement. She said the risk of not doing so was the resident could be in pain and her symptoms would not be controlled. When asked if a resident should be send out to the ER with severe pain after a fall, ADON A said yes. ADON A stated if the resident was not sent out timely there was a risk of severe pain, fracture and a lot of things could have happened. Interview on 08/25/26 at 3:20 PM, the DON stated her expectation for when a resident fell and had severe pain was for staff to address the pain, medicate them and if pain was not controlled contact the physician and try a different route. The DON stated if staff could not get the provider they were to call her. The DON stated they had medicated Resident #1 with what she had, it was not effective so they the physician was called and got something else which was not effective. She stated a lot of times if they fall and broke something Tylenol and Ultram does control pain. She said they get residents from the hospital that have had surgery and get Ultram. The DON stated she could not speculate on what could happen if a resident was not sent out with severe pain after a fall; she stated she could tell what happened with Resident #1 which was her vitals were stable, pain medication was not effective, and she was sent to the hospital. The DON stated the nurse was trying to take the route of following what they normally do after a fall, tried to address the pain and when she saw it was ineffective, Resident #1 was sent out. The DON stated she was not here and went by what she was told, and when she was called she was not told Resident #1 was in excruciating pain. She said in hindsight, you can always look back on something and say things should have been done differently. The DON stated staff attempted to manage Resident #1's pain, but it was not managed and that was why she went to the hospital. Interview on 08/25/26 at 3:37 PM, the Administrator stated in this case, other than the time spent in discomfort, he was not sure if there was a risk or downside. He stated nobody wanted to be in pain and unless the hospital was able to give her something more than they did, he would assume the hospital did the same thing the facility did. Record review of facility's, Pain Management policy, dated 08/15/22, reflected, Policy: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.Recognition: 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will:.b. Evaluate .when a significant change in condition or status occurs (e.g. after a fall, change in behavior or mental status, new pain or an exacerbation of pain) c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. 2. Facility staff will observe for nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to: b. Loss of function or inability to perform activities of daily living (ADLs) (e.g. rubbing a specific location of the body, or guarding a limb or other body parts).d. Facial expressions (e.g. grimacing, frowning, fright, or clenching of the jaw).i. Negative vocalizations (e.g. groaning, crying, whimpering, or screaming).j. Decline in activity level.

Based on observation, interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #1) reviewed for quality of care. -The facility failed to ensure Resident #1, who was diagnosed with congestive heart failure, had physician orders in place for fluid restrictions and daily weights. This failure could place residents at risk for worsening of condition, which could lead to serious harm.Findings included:Record review of Resident #1's Discharge MDS Assessment, dated 05/05/26, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE], readmitted on [DATE], and discharged on 05/05/26. The MDS Assessment under Section C-Cognitive Patterns reflected Resident #1's BIMS score was not documented. The MDS Assessment under Section GG-Functional Abilities reflected Resident #1 required moderate assistance with most self-care ADLs. The MDS Assessment under Section I-Active Diagnoses reflected Resident #1's active diagnoses included: heart failure, chronic kidney disease, and unspecified dementia (brain disorder that causes loss of memory and thinking). Record review of Resident #1's Care Plan, revised 06/22/26, reflected Resident #1 required a structured environment on a secure unit r/t cognitive deficit. Interventions included: providing cues and reminders for ADLs and keeping a routine for bathing, dressing, and eating. The care plan also reflected Resident #1 had chest pain r/t angina (pain r/t to heart condition). Interventions included: giving nitroglycerin (medication used to treat chest pain) or other medication as ordered, identifying and documenting activities known to cause anginal pain, encouraging the resident to report pain, monitoring and documenting signs of edema (swelling of tissue), and monitoring vital signs during reported chest pain episodes. Record review of Resident #1's hospital records, dated 02/08/26, reflected in part the following: Chief complaint: Swelling and discoloration of the right foot and toe, and wheezing.Assessment and Plan:CHF exacerbation-Will admit inpatient-Cardiac monitoring-fluid restriction, daily weight and IV Lasix (water pill)-Cardiology consulted-[RP] will bring complete medication list from nursing home.[Resident #1] Discharge General InformationReason for visit: fluid overload.Discharge Instructions:Cardiac-fluid restrictions: limit 2000 mL/dayWeight monitoring: daily.discharge date : [DATE]. Record review of Resident #1's progress notes, dated 02/18/26 at 5:17 p.m. by LVN C, reflected the following: [Resident #1] returned to facility via transport from [hospital] Today. [Resident #1] is A/O to person only. [Resident #1] vitals weretaken upon arrival. 142/96 51, 18, 98% 97.4. Resident is currently on 2000ml per day fluid restriction intake. Family notified, Provider notifiedof return. Record review of Resident #1's progress notes, dated 02/09/26 at 8:14 a.m. by the ADON, reflected the following: [ADON] followed up with [RP] regarding [Resident #1] return to facility. [RP] stated that residentwas admitted to [hospital] on Saturday due to low heartrate. no further concerns at this time. Record review of Resident #1's vitals (weights) in the EHR, from 02/18/26-05/05/26, reflected the following documented weights:-02/18/26-190.4 lbs.-02/19/26-190.4 lbs.-02/26/26-190.4 lbs.-03/03/26-187.8 lbs.-03/05/26- 187.8 lbs.-04/01/26- 190.2 lbs.-05/01/26- 184.9 lbs. Record review of Resident #1's nurses' daily skilled notes, from 02/18/26-03/02/26, reflected the resident's weights were not assessed and documented daily. Further review of the resident's EHR reflected there were no documented daily skilled notes from 03/03/26-05/05/26. Record review of Resident #1's consolidated physician orders, dated 07/16/26, reflected the following:- Weigh weekly x 4 weeks, then monthly and PRN one time a day every 7 day(s). Start Date: 02/19/26Further review of this document reflected that the resident did not have orders for daily weights or fluid restrictions. In an attempted interview with Resident #1's RP on 07/16/26 at 10:35 a.m., the call was unsuccessful due to no response. Callback information was left on voicemail. In an interview on 07/16/26 at 11:38 a.m., the ADON stated Resident #1 was diagnosed with heart disease along with other comorbitities and was treated at the VA clinic. The ADON stated the facility coordinated Resident #1's care through a VA liaison. He stated Resident #1 was out on pass with the RP, then the RP reported that the resident had a change in condition and was admitted to the hospital on [DATE]. The ADON stated Resident #1 was discharged from the hospital on [DATE] and returned to the facility. The ADON was unaware that Resident #1 had a discharge order for fluid restrictions, but confirmed it after reviewing the hospital records. The ADON stated the expectation was for the receiving nurse to review discharge orders and notify the MD of any changes. The ADON stated all residents were weighed at least monthly unless otherwise ordered by the MD. However, the ADON stated the nurses completed daily skilled notes and were supposed to document a current weight. In an attempted interview with Resident #1's RP on 07/16/26 at 12:00 p.m., the call was unsuccessful due to no response. Callback information was left on voicemail. In an interview on 07/16/26 at 1:48 p.m., the MD stated Resident #1 had end-stage dementia and CHF, and it was important to monitor his fluid intake because his heart was unable to pump out excess fluids and daily weights could help monitor fluid retention. He stated not monitoring fluid intake and weights could place the resident at risk of increased heart and lung issues. The MD stated when a resident returned to the facility from the hospital, the expectation was for the nurses to notify him of any new orders. The MD stated Resident #1's RP would not always involve the facility in the care that Resident #1 was receiving from outside providers, and he did not believe the facility was responsible for any missed orders or appointments. In an interview on 07/16/26 at 2:03 p.m., LVN A stated she worked at the facility for 7 years and currently worked on the memory care unit. LVN A stated for safety reasons, staff kept pitchers of water out of the resident rooms and provided water as needed, so intake was monitored in general. However, LVN A stated an order was required for residents who were formally placed on fluid restrictions, and the nurses were responsible for ensuring that the order was carried out by tracking and documenting all fluid intake. LVN A stated all residents had monthly weights as a standard order, but some had a special order for weekly or daily weights. She stated that nurses also documented residents' most recent weights in their daily skilled notes. In an interview on 07/16/26 at 2:03 p.m., LVN B stated when a resident returned to the facility from the hospital, the nurses were responsible for reviewing the discharge summary to check for any new orders and any changes in behaviors and physical and mental health. LVN B stated any new orders had to be reported to the MD, who would likely agree and sign off, and the orders had to be updated into the system for everyone to be made aware. The facility's policies on physician orders and fluid restrictions were requested from the Administrator on 07/16/26 at 4:51 p.m. and they were not provided by exit. The Administrator stated the corporate resource was unable to find the specific policies.

Based on observation, interview, and record review, the facility failed to ensure residents were provided with a clean and comfortable environment by providing clean bed linens that are in good condition for 1 of 7 resident (Resident #1) reviewed for safe environment.The facility failed to ensure Resident #1' s bedding was changed when it was saturated in urine. This failure could place the resident at risk of skin breakdown and decreased feelings of self-worth. Findings included:Record review of Resident #1's admission MDS assessment, dated 12/05/25, indicated Resident #1 was a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included cancer of the intestines that had spread throughout the body, mass on the left kidney requiring the placement of a drainage tube, and acute kidney failure. His BIMS score was 14, indicating his cognition was intact. His Functional Ability assessment indicated he was dependent on staff for his toileting hygiene. His Bowel and Bladder assessment indicated he was occasionally incontinent of urine. Record review of Resident #1's care plan, dated 12/17/25, reflected Resident #1 had an ADL self-care deficit related to functional decline, he was incontinent of bowel and bladder, and was on a diuretic (medication use to remove excessive fluid from the body). Interview and observation on 01/29/26 at 11:09 AM revealed Resident #1 lying in bed the draw sheet under him was saturated with dried urine, as indicated by the brown color. The resident stated his bedding had not been changed since the previous evening. He stated no one had checked on him that morning. He stated he did not realize the bedding was wet, and was not sure when it happened, so he had not notified staff. Interview on 01/29/26 at 11:14 AM CNA-A she stated she had not checked on Resident #1 yet; she had been busy with other residents. She was unaware the resident was incontinent of urine. She did not feel overworked as there were other CNAs on the hall. Interview on 01/29/26 at 11:19 AM the ADON stated there was no reason Resident #1 should have been left on dirty linen. He stated the night shift should have noticed it and changed it, or CNA-A should have noted it earlier in her shift when she made rounds on all her residents. He stated his expectation was for the CNAs and nurses to round on all their residents at the beginning of their shift to assess for needs. He stated the risk of a resident lying in urine-soaked linen could result in skin breakdown or irritation. Observation on 01/29/26 at 11:25 AM of Resident #1's peri area and buttocks revealed no skin breakdown or excoriation. There was some redness present from lying on his back. Interviews on 01/29/26 from 11:35 AM to 12:00 PM with residents of the hall revealed no complaints about linen not being changed when dirty. Staff checked on them regularly, and needs were being met.Review of the facility's policy Activities of Daily Living, dated 5/26/23, did not address changing linen specifically. It did address: Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. 3. Toileting.

Based on observation, interview, and record review, the facility failed to ensure a resident who needs respiratory care, is provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 2 residents (Residents #19 and #37) reviewed for non-invasive ventilation care.1. The facility failed to ensure there were physician orders for the use of Resident #19's BiPAP machine, which is a non-invasive ventilation machine that is capable of generating two adjustable pressure levels.2 The facility failed to ensure there were physician orders for the use of Resident #37's CPAP machine, which is a non-invasive ventilation machine that involves the administration of air usually through the nose by an external device at a predetermined level of pressure.These failures placed residents at risk of not receiving adequate and necessary respiratory care.Record review of Resident #19's admission MDS, dated [DATE], reflected the was resident was admitted to the facility on [DATE]. The resident's diagnoses included obstructive sleep apnea, quadriplegia, and morbid obesity. Resident #19 had a BIMS score of 15, indicating he was cognitively intact. Resident #19 also required substantial assistance with his ADLs. His Special Treatments did not indicate the use of a Bi-PAP machine. Record review of Resident #19's care plan, dated 07/21/25, revealed he had altered respiratory status related to sleep apnea with interventions that included the use of a Bi-PAP machine on home settings and elevating head of bed as tolerated. Record review of Resident #19's physician orders revealed there was not an order for use of the Bi-PAP or what settings to use.Following surveyor inquiry, the DON added Bi-PAP orders and a respiratory consult on 08/20/25 for Resident #19.Observation and interview on 08/19/25 at 9:48 AM, revealed Resident #19 had a Bi-PAP machine with a face mask on his bedside table. Resident #19 stated the Bi-PAP machine was his from home, and he had been using it since he was admitted to the facility. He stated staff helped him clean his mask about once a week. He stated he had not met with a respiratory therapist that he knew of, but he was comfortable using the machine. Record review of Resident #37's admission MDS, dated [DATE], reflected the resident was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure, emphysema, and morbid obesity. Resident #37 had a BIMS score of 15, indicating she was cognitively intact. Resident #37 required substantial assistance with her ADLs. Her Special Treatments did not indicate the usage of CPAP. Record review of Resident #37's care plan dated 06/09/25 reflected she was on oxygen therapy, and she had a history of shortness of breath related to her emphysema and her heart failure with interventions of a nasal canula at 4 lpm. She had not been care planned for CPAP. Record review of Resident #37's physician orders revealed no order for use of the CPAP machine nor what settings to use. Following surveyor inquiry, the DON added CPAP orders and a respiratory therapy consult on 8/20/25 for Resident #37.Observation on 08/19/25 at 12:46 PM, revealed Resident #37 had a CPAP machine at her bedside.Interview on 08/19/25 at 1:30 PM, Resident #37 revealed the CPAP machine was not hers. She stated someone had brought it to her after she was admitted to the facility. She stated she used one at home and was familiar with how to use it. Resident #37 stated she had not met with a respiratory therapist that she knew of. Interview on 08/20/2025 at 12:45 PM, LVN A revealed the nurses were responsible for cleaning the resident's mask once a week. He stated this care was usually done during the night shift. He stated there should be an order for the settings from the physician, and it should also be in her care plan. LVN A stated he was not aware there was no physician order for CPAP. Interview on 08/20/25 at 12:49 PM, the DON revealed there should be a physician order for the CPAP, and it should be added to her care plan. She stated the night shift nurses cleaned the mask once a week and assisted the resident with putting it on. They should also check that there was a good seal. She was not aware there was no order for the resident's CPAP. The DON stated there was a Respiratory Therapist that would come to the facility when they were ordered to consult and then follow the resident while they were in the facility. The DON state she did not know if the therapist had seen Resident #37. Record review of the facility's policy Noninvasive Ventilation dated 03/12/25 reflected:.2. The facility will obtain an order for the use of a CPAP, BiPAP, or AVAPS device and settings from the practitioner.

Based on interview, and record review, the facility failed to provide residents and responsible parties the right to participate in the development and implementation of their person-centered plan of care for 1 of 9 residents (Resident #14) reviewed for quarterly care plans.The facility failed to provide Resident #14 and responsible parties with 4 quarterly care plan conference meetings for the last 12 months. Resident #14's last care plan meeting was dated 08/02/24.This failure could place residents at risk of not receiving inadequate interventions individualized to their care needs.Findings included:Record review of Resident #14's quarterly MDS assessment, dated 05/10/25, revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. The assessment reflected the resident's cognition was not documented. The resident had diagnoses which included stroke (medical emergency where blood flow to the brain is interrupted, leading to brain cell death from lack of oxygen and nutrients). Record review of Resident #14's care plan, 05/12/25 reflected Problem: [Resident #14] has impaired cognitive function/dementia or impaired thought processes r/t Dementia, difficulty making decisions, impaired decision making, long term memory loss/short term memory loss. Goal: [Resident #14] will maintain current level of cognitive function through the review date. Interventions: Communicate with [Resident #14]/family/caregivers regarding his capabilities and needs.Record review of Resident #14's progress notes reflected the last documentation from the Social Worker pertaining to a care conference was on 08/02/24, and the entry was: Telephone care conference was held with SWA, ADON and spouse of [Resident #14] . Observation and attempted interview on 08/19/25 at 11:28 AM, revealed Resident #14 in bed and awake. Resident #14 was not able to answer questions due to his condition. The resident did not appear to be in distress or discomfort.Interview on 08/19/25 at 2:54 PM with Resident #14's POA revealed, she was very involved in the Resident #14's care. She stated the facility staff were good about notifying her if the resident had a change in condition; however, she had not had a care plan meeting in a very long time. Resident #14's POA stated she could not recall when the last time a care plan was completed. She stated she had good communication with the facility, but she would like to have a care plan meeting to address any concerns. Interview and record review on 08/21/25 at 11:17 AM, with the Social Worker revealed she was the Social Worker assigned to Resident #14. She stated Resident #14's care plan meetings were usually held over the phone due to Resident #14's POA working. She stated the last care plan meeting was held either in June or July 2025, and she and the POA were the ones who attended the care plan meeting. She stated the previous care plan meeting was held in April 2025, but the exact date was not known. The Social Worker stated she had a close relationship with Resident #14's POA. The Social Worker reviewed Resident #14's clinical record, and she indicated on 07/10/25 there was not a care plan meeting but an update regarding Resident #14's dental care. She stated she could not recall when the last care plan meeting was, but she knew there was no care plan meeting in May 2025. She stated she did not know why a care plan meeting was not held, and she stated it had been overlooked. She stated there was no potential risk to the resident because Resident #14's POA was involved. Interview on 08/21/25 at 4:25 PM, with the DON revealed the Social Worker was responsible for the care plan meetings. She stated she could not recall the last care plan meeting she had attended for Resident #14. The DON stated the Social Worker and the ADONs completed the care plan meetings. She stated if she was needed, she would attend. The DON stated care plan meetings should be completed quarterly and as needed with family. She stated care plan meetings were needed to keep the family informed of the care being provided to the resident. Interview and record review on 08/21/25 at 4:45 PM, with ADON B revealed the Social Worker was responsible for scheduling the care plan meeting. ADON B stated she would attend the meetings. She stated she took over the ADON position in February 2025 and had not attended a care plan meeting for Resident #14. She stated she did not know when the last time a care plan meeting was held for Resident #14. ADON B reviewed Resident #14's Social Worker notes and stated the last documented care plan conference was August 2024. ADON B stated there was no potential risk because family was involved; however, care plan meetings were needed to address a resident's current condition and for family to be able to voice any concerns. Record review of the facility's Comprehensive Care Plan policy, dated 10/24/22 reflected the following: The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: .e. The resident and the resident's representative, to the extent practicable.

Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 resident of 9 residents (Resident #74) reviewed for care plans. The facility failed to develop a care plan addressing Resident #74's preference to provide self-care for his colostomy (an opening in the colon that lets stool pass from the body without going through the anus).The failure placed residents at risk of not having their care preferences care planned which could result in decreased quality of life. Findings included:Record review of Resident #74's quarterly MDS assessment, dated 07/18/25, reflected the resident was an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including colostomy status (an opening (stoma) in the colon (large intestine) to divert stool outside the body), vascular parkinsonism (blood vessel problems in the brain, such as small strokes, that damage the areas controlling movement), hypertension (high blood pressure), polyneuropathy (damage or disease affecting peripheral nerves), Non-Alzheimer's Dementia. Resident #74 had a BIMS score of 08, indicating severe cognitive impairment. Resident #74 required supervision or touching assistance with toileting hygiene meaning (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment.)Record review of Resident #74's care plan, revised 07/07/25, reflected: Problem: The resident has an alteration in gastrointestinal status r/t colostomy status d/t rectal resection r/t colon cancer. 7/3/25 Rash around stoma-Physician notified Goal: The resident will remain free from discomfort, complications or s/sx related to gastrointestinal alterations with colostomy status through review date. Interventions: Change colostomy bag as needed. Cut wafer to fit around stoma as needed. Colostomy care q shift & PRN burp bag as needed. Interview on 08/19/25 at 3:44 PM, with Resident #74 revealed he had an ostomy bag. Resident #74 stated he completed his own ostomy care because he did not like anyone helping him. Resident #74 stated he had been doing his own ostomy care for more than 20 years and liked it a certain way. Resident #74 stated he had some irritation around the stoma, but it had cleared. Resident #74 stated the staff were aware. Interview on 08/21/25 at 11:52 AM, with ADON B revealed Resident #74 liked doing his own ostomy care. She stated nurses either assisted or observed the resident do it. ADON B stated Resident #74 refused to let anyone assist him. She stated since it was Resident #74 preference was to complete his own ostomy care it should be care planned. ADON B stated the MDS Coordinator were responsible for care plans. ADON B reviewed Resident #74's care plan, and she revealed the resident's ostomy care preference was not care plan. Interview on 08/21/25 at 1:09 PM, with the MDS Coordinator revealed she had been employed for four months at the facility. She stated she was responsible for updating care plans for long term care residents. She stated she was not aware Resident #74 completed his own ostomy care. She stated it should had been care plan. She stated she was notified today (08/21/25) by ADON B of Resident #74's preference. She stated it should be care plan because all staff should know the resident plan of care and preference. Interview on 08/21/25 at 1:45 PM, with LVN D revealed she was the nurse for assigned to Resident #74. She stated Resident #74 refuses to let anyone assist him with his ostomy care. She stated Resident #74 prefers to do his own ostomy care. She stated it should be care plan because Resident #74 refuses the help and does not like anyone helping him. LVN D stated she was not sure who was responsible for care plans. Interview on 08/21/25 at 4:29 PM, with the DON revealed Resident #74 preferred to do his own ostomy care. The DON stated she was informed today (08/21/25) that it was not care plan and it should be. She stated the care plans should address the resident preference on providing his own care. Record review of the facility's Comprehensive Care Plan policy dated 10/24/22 reflected the following: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental psychosocial needs that are identified in the resident's comprehensive assessments.

Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 9 residents (Resident #14) for care plan revisions. The facility failed to review and revise Resident #14's comprehensive care plan after the MDS assessment was completed on 05/10/25. Resident #14's last care plan meeting was dated 08/02/24.This failure placed residents at risk of not having their individual needs met. Findings included:Record review of Resident #14's quarterly MDS assessment, dated 05/10/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and readmission on [DATE]. The assessment reflected the resident cognition was not documented. The resident had diagnoses which included stroke (medical emergency where blood flow to the brain is interrupted, leading to brain cell death from lack of oxygen and nutrients). Record review of Resident #14's care plan, 5/12/25 reflected Problem: [Resident #14] has impaired cognitive function/dementia or impaired thought processes r/t Dementia, difficulty making decisions, impaired decision making, long term memory loss/short term memory loss. Goal: [Resident #14] will maintain current level of cognitive function through the review date. Interventions: Communicate with [NAME]/family/caregivers regarding his capabilities and needs.Record review of Resident #14's progress notes revealed the last documentation from Social Worker pertaining care conference was on 08/02/24. Telephone care conference was held with SWA, ADON and spouse of [Resident #14] . Observation and attempted interview on 08/19/25 at 11:28 AM revealed Resident #14 in bed and awake. Resident #14 was not able to answer questions due to his condition. The resident did not appear to be in distress or discomfort.Interview on 08/19/25 at 2:54 PM, the Resident #14's POA revealed she was very involved in the resident's care. She stated the facility staff were good about notifying her of any change in the resident's condition; however, she had not had a care plan meeting in a very long time. Resident #14's POA stated she could not recall when the last time was a care plan was completed. She stated she had a good communication with the facility, but she would like to have a care plan meeting to address any concerns. Interview on 08/21/25 at 11:17 AM, the Social Worker revealed she was the Social Worker assigned to Resident #14. She stated Resident #14's care plan meetings were usually held over the phone due to Resident #14's POA working. She stated the last care plan meeting was held either June or July 2025 and it was only herself and the POA who attended the meeting. She stated the previous care plan meeting was held in April 2025, unknown of the exact date. The Social Worker stated she had a close relationship with Resident #14's POA. Record review of Resident #14's clinical records, Social Worker indicated on 07/10/25 was not a care plan meeting but an update regarding Resident #14's dental care. Social Worker stated she could not recall when the last care plan meeting was, she stated there was no care plan meeting for May 2025. She stated she does not know why a care plan meeting was not held, she stated it was overlooked. She stated there was no potential risk to the resident because Resident #14's POA was involved. Interview on 08/21/25 at 4:25 PM, the DON revealed the Social Worker was responsible for care plan meeting. She stated she could not recall the last care plan meeting she had attended for Resident #14. The DON stated the Social Worker and the ADONs complete the care plan meetings and if she was needed, she would attend. The DON stated care plan meetings should be completed quarterly and as needed with family. She stated care plan meetings were needed to keep family informed of the care being provided to the resident. Interview on 08/21/25 at 4:45 PM, the ADON B revealed the Social Worker was responsible for scheduling care plan meeting and ADON would attend. She stated she took over the ADON position in February 2025 and had not attended a care plan meeting for Resident #14. She stated she does not know when the last time a care plan meeting was held for Resident #14. ADON B reviewed Resident #14 Social Worker notes and stated the last documented care plan conference was August 2024. ADON B stated there was no potential risk because family was involved; however, care plan meetings were needed to address resident current condition and for family to be able to voice any concerns. Record review of facility Comprehensive Care Plan policy, dated 10/24/22 reflected the following: The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: .e. The resident and the resident's representative, to the extent practicable.

Based on observation, interview, and record review, the facility failed to ensure residents received proper treatment and care to maintain good foot health by providing foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 1 of 18 residents (Resident #74) reviewed for foot care.The facility failed to ensure Resident #74's toenails were clipped. This failure could result in residents developing fungal infections or other podiatric problems. Findings included:Record review of Resident #74's quarterly MDS assessment, dated 07/18/25, reflected the resident was an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including colostomy status (an opening (stoma) in the colon (large intestine) to divert stool outside the body), vascular parkinsonism (blood vessel problems in the brain, such as small strokes, that damage the areas controlling movement), hypertension (high blood pressure), polyneuropathy (damage or disease affecting peripheral nerves), Non-Alzheimer's Dementia. Resident #74 had a BIMS score of 08, indicating severe cognitive impairment. Resident #74 required partial/moderate assistance with his personal hygiene. Record review of Resident #74's care plan, revised 03/24/25, reflected: Problem: The resident has Peripheral Vascular Disease (PVD) DX. Goal: The resident will be free of s/sx of PVD through the review date. Interventions: Educate the resident on the importance of proper foot care including: proper fitting shoes, wash and dry feet thoroughly, keep toenails cut, inspect feet daily, daily change of hosiery and socks.Record review of the facility's podiatry visits for March 2025 through August 2025 reflected Resident #74 had not been seen by the Podiatrist. Observation and interview on 08/20/25 at 9:05 AM, revealed Resident #74 was in his wheelchair watching television. Resident #74 stated he was waiting on staff to come assist with putting his socks on. Observation of Resident #74's feet revealed the third and fourth toenails on his left foot and right foot were long and curving in. Resident #74 stated he had been asking staff to see a Podiatrist. He stated he could not recall the name of the staff; however, every time he asks the staff, the staff told him the Podiatrist had already come to the facility, and he had to wait for the next visit. Resident #74 stated he had been asking to see a Podiatrist since May 2025. He stated if he was able to bend over, he would cut them himself, but he cannot. Resident #74 stated he was not a diabetic resident. Interview on 08/21/25 at 1:24 PM, CNA C revealed she was the CNA assigned to Resident #74. She stated if a resident was diabetic fingernails were cut by the nurses and toenails were cut by the Podiatrist. She stated if the resident was not diabetic then the CNAs were able to file down fingernails and the nurses would cut toenails. CNA C stated she had observed Resident #74 toenails and noticed the toenails were curving in. She stated she notified the nurse, unknown of the nurse's name. She stated Resident #74 had not complained of pain. Interview on 08/21/25 at 1:33 PM, LVN D revealed the nurses were responsible for cutting nails unless the resident was diabetic. She stated podiatry comes to the facility but was not sure how often. LVN D stated she was not sure if Resident #74 had been seen by the Podiatrist. She stated Resident #74 had not complained about his toenails. Observation and follow-up interview on 08/21/25 at 2:01 PM, revealed Resident #74's right foot fourth toenail was long and curved in and left foot third and fourth toenails were long and curving in. LVN D stated Resident #74's toenails were overgrown and needed to be cut. Resident #74 denied any pain but would like them to be cut. LVN D stated the potential risk of not cutting the resident's toenails was that it could lead to the toenail cutting into the skin.Interview on 08/21/25 at 2:05 PM, ADON B revealed Resident #74 toenails needed to be cut by the Podiatrist. She stated she had asked the Social Worker for a podiatry referral on 05/15/25, but Resident #74 had not been seen by the Podiatrist. She stated she had not followed-up on this. ADON B stated Resident #74 had not requested to see the Podiatrist. She stated the potential risk of not cutting residents toenails would be residents not being able to wear shoes. Interview on 08/21/25 at 2:19 PM, the Social Worker revealed she was responsible for sending referrals. She stated she had just received a podiatry referral today (08/21/25) for Resident #74. She stated she was not aware Resident #74 needed to be seen by the Podiatrist. She stated normally she would get the order and then she put in the referral. She stated prior to today (08/21/25) she had not received a podiatry referral for Resident #74. Interview on 08/21/25 at 4:31 PM, the DON revealed she was made aware today (08/21/25) of Resident #74's toenails. She stated she was not aware Resident #74 had requested to see the Podiatrist. She stated the Social Worker was responsible for completing referrals to podiatry. She stated if a resident voiced a concern regarding podiatry, it was the responsibility of the ADONs to follow-up on the referrals. She stated residents' nails needed to be trimmed for comfort. Record review of facility Activities of Daily Living (ADLs), dated 05/26/23 reflected the following: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's ability in ADLs do not deteriorate unless deterioration is unavoidable.A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Policy did not address foot care.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 residents (Resident #14) reviewed for pharmacy procedures.1. ADON B failed to follow the facility policy of flushing Resident #14's gastrostomy tube with 5-10 mL (or prescribed amount) of water between medications, when she administered medication through gastronomy tube (feeding tube). 2. ADON B failed to check for residual through aspiration before administering medication to Resident #14. These failures could place residents at risk of physical and chemical incompatibilities leading to an altered therapeutic response and put residents who received medications via gastrostomy tube at risk for gastronomy tube blockage and medication interaction. Findings included:1. Record review of Resident #14's quarterly MDS assessment, dated 05/10/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. The assessment reflected the resident cognition was not documented. The resident had diagnoses which included stroke (a condition where blood flow to the brain is interrupted, leading to brain cell death from lack of oxygen and nutrients). The nutritional approaches revealed the resident received nutrition via a feeding tube. Review of Resident #14's August 2025 Physician Orders reflected there were no orders for flushing the resident's gastrostomy tube between medication administration. The orders reflected: Enteral Feed Order as needed Prior to use check placement of g-tube by observing change in external length or marking on the tube at the exit site to determine if tube has migrated AND observe for increase of volume of aspirate of gastric contents. Notify physician of change.Observation on 08/20/2025 at 8:49 AM, revealed ADON B prepared medications outside Resident #14's room. She prepared the following medications: Polyethylene glycol 3350 Powder for Oral Solution [MiraLAX] 17g mix with 6-8 OZ water via g-tube. apixaban 5 mg Oral Tablet [Eliquis]1 tablet via g-tube methocarbamol 500 mg 1 tablet daily via g-tube lactulose 30mls via g-tube daily via g-tube magnesium oxide 400 mg 1 tablet daily via g-tube meloxicam 7.5 mg 1 tablet via g-tube daily tizanidine 2 mg 1 tablet daily tramadol hydrochloride 50 mg 1 tablet daily via g-tube. levetiracetam 5 ML 100 mg/ml bid via g-tube. loratadine 10mgs 1 tablet daily via g-tube. metoclopramide 5 mg 1 tablet a day via g-tube and senna syrup 5 ml twice daily via g-tube ADON B crushed the medications and put them in separate cups and mixed with 5 ml of water. She then washed her hands, put on gloves and gown, and went to Resident #14's room. ADON B positioned Resident #14 in an upright position. She flushed the gastrostomy tube with 30 ml of water, and she proceeded to administer the medications one at a time. ADON B did not flush the gastrostomy tube with water between each medication. ADON B flushed the gastrostomy tube with 30 ml of water after she finished administering the medications. Interview with ADON B on 08/20/2025 9:28 AM, revealed she was aware of the order to flush the gastrostomy tube with 5-10 ml of water between medication administration through gastrostomy tube for Resident #14. She said she forgot to flush the gastrostomy tube between each medication administration. ADON B stated failure to flush in between the medications could lead to gastrostomy tube blockage and medication interactions. She also stated she was supposed to check for residual before administering medication through gastronomy tube. She stated failure to check for residual before administering medication could lead to aspiration. She stated she had received training on medication administration via gastrostomy tube, and she had also done skills check on g-tube. Interview with the DON on 08/21/2025 4:45 PM, revealed her expectation was for the nurses to crush medications for gastronomy tubes in different cups, mix with water, and flush the tube before, between, and after medication administration. She stated she was responsible for monitoring the nurses. She stated the risk of not flushing before between and after medication administration would be medication interactions. She also stated her expectation was all staff should verify placement visually and then they should aspirate to verify placement and residual before they administer medication. She stated if staff were not checking residual it could lead to aspiration and infection. Record review of the facility's current Medication Administration policy revised 10/01/2019, reflected the following: Flush with 5-I0ml warm water between each medication. Pinch tubing below the syringe tip when each volume of liquid clears the syringe to avoid excessive air from entering stomach. This can cause discomfort or emesis. I. Check gastric content for residual feeding. Return residual volumes to the stomach. Report any residual above l 00ml.

Based on observation, interview, and record review, the facility failed to ensure the residents had the right to be free of abuse for 3 of 5 residents (Residents #6, #7 and #8) reviewed for abuse. The facility failed to ensure Residents #7 and #8 had the right to be free from abuse when Resident #6 hit Resident #7 in the face on 06/26/25 and put his hands around Resident #8's neck on 07/02/25. An IJ was identified on 07/10/25. The IJ began on 06/26/25 and was removed on 07/06/25. The facility took action to remove the IJ before the abbreviated survey began. While the IJ was removed on 07/06/25, the facility remained out of compliance with a scope of pattern and severity level of no actual harm with potential for more than minimal harm . The failure placed residents at risk for abuse. Findings included:Record review of Resident #6's admission MDS, dated [DATE] and signed as complete by the DON on 06/25/25, reflected the resident was a [AGE] year-old male. The resident admitted from home to the facility on [DATE], and his diagnoses included Alzheimer's disease, non-Alzheimer's dementia, anxiety disorder, and depression. The resident had severe cognitive impairment with a BIMS score of zero, and he displayed disorganized thinking and intention continuously. The resident was assessed to have physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, disruptive sounds), and wandering, which all occurred 1 to 3 days during the assessment period. These behaviors were assessed to significantly intrude on the privacy or activity of others. The MDS also reflected the resident rejected evaluation or care that was necessary to achieve the resident's goals for health and well-being, which occurred 1 to 3 days during the assessment period. The MDS further reflected the resident was able to transfer and walk independently. Record review of Resident #6's Care Plan, initiated on 06/13/25, reflected Resident #6 had the potential to be verbally and physically aggressive related to poor impulse control. The Care Plan included the following: Problem: 6/12/25 angry look in his face, threw coloring book across the table Problem: 6/14/25 climbed into bed with peer combative, hitting/swinging at staff during redirection. Intervention: 6/14/25 attempted to remove from peer's bed, left alone [due to] agitation Date Initiated: 06/16/2025 Problem: 6/21/25 entered female peer's room and began hitting and grabbing at the CNA's clothes when she attempted to redirect him out of room, attempted to hit female peer Intervention: 6/21/25 attempted to redirect from room, CNA used her body to shield female resident from both men, [Resident #6] left room [status post] incident with male peer, refused skin assessment and VS, NP notified with N.O. anxiolytic topically Q 6hrs, RP/DON/ADON/weekend supervisor notified, placed on 1:1 supervision; 6/22/25.NP N.O. anxiolytic PO Q6hrs PRN, RP notified - Date Initiated: 06/23/2025. Problem: 6/24/25 agitated, striking out at staff. Intervention: 6/24/25 PRN anxiolytic administered - Date Initiated: 06/25/2025. Problem: 6/26/25 hit peer in the face with closed fist. Intervention: 6/26/25 separated from peer and escorted to room, encouraged to sit on bed and provided with books to color, MD/NP/RP/DON/ADON/Administrator notified, unable to obtain VS d/t agitation, SW completed updated BIMS assessment with BIMS 1. Date Initiated: 06/27/2025 Problem: 6/27/25 combative with sitter and peers. Intervention: 6/27/25 staff attempted to redirect, once calmed down he walked to his room, PRN medication administered, DON notified, taken out on patio x approximately 15 minutes. Date Initiated: 06/30/2025. Problem: 6/30/25 verbal/physical aggression towards staff: swinging/kicking/hitting, throwing items in room, swinging pencil. Intervention: 6/29/25 verbally redirected, assisted to bed, covered with blanket, assessed as able without waking [Resident #6] up, continued monitoring. Date Initiated: 06/30/2025. Intervention: 6/30/25 topical anxiolytic applied with assistance, pencils removed and placed in med room, NP witnessed episode, continues 1:1 monitoring. Date Initiated: 07/01/2025 Problem: 7/1/25 threw chair at sitter, then charged sitter and fell, stood up and charged at sitter again, pacing. Intervention: 7/1/25 assessed, area treated, DON/ADON/MD/RP notified with N.O. transfer to hospital r/t injury, unable to obtain VS, patio door opened, and [Resident #1] came in facility, RP arrived at facility, transferred to.hospital Problem: 7/2/25 kicked the table, entered peer's room and placed his hands around peer's neck. Intervention: 7/2/25 kicked table: assessed with trauma noted to R great toe, area cleansed and treated. 7/2/25 placed hands around peer's neck: separated from peer immediately, [head-to-toe assessment] completed, VS obtained, redirected, MD/RP notified; SWA sending clinicals to [Behavioral Health Hospitals]. Date Initiated:07/02/2025. The Care Plan also reflected the following additional interventions to address Resident #6's verbal and physical behavioral symptoms: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 06/13/2025Analyze times of day, places, circumstances, triggers, and what de-escalatesbehavior and document. Date Initiated: 06/13/2025Assess and address for contributing sensory deficits. Date Initiated: 06/13/2025. Assess [Resident #6's] needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. Date Initiated: 06/13/2025COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Date Initiated: 06/13/2025 Give [Resident #6] as many choices as possible about care and activities. Date Initiated: 06/13/2025 Modify environment adjust room temperature to comfortable level, reduce noise, dim lights, place familiar objects in room, keep door closed, etc. Record review of Resident #6's progress notes, dated 06/26/25, documented by LVN E reflected the following: This resident was observed standing in dining area talking with another resident who was sitting in a wheelchair. This resident hit the other resident in his face/cheek with his fist causing a reddened area to the other resident's cheek. The residents were separated and this resident was escorted to his room by the nurse and encouraged to sit on his bed and was given his crayon box and coloring book which he pushed away and then laid down on the bed.Review of Resident #6's progress notes dated 07/01/25, reflected the following: Resident on patio with 1/1 pacing and suddenly he picked up a chair and threw it and started running at Sitter and he fell on rt shoulder. Resident quickly got off ground charging at sitter. This nurse was passing window and saw resident chasing sitter. Resident pacing and holding rt arm, small skin tear noted to rt wrist Orders to transfer resident to hospital for injury Record review of Resident #6's progress notes, dated 07/02/25, documented by LVN F reflected the following: Resident observed going into another resident's room and placed his hands around his neck. Staff immediately separated [Resident #6] and was re-directed. Record review of the facility's Provider Investigation Report, completed by the DON on 07/03/25, reflected the following: The facility initiated an investigation on 06/26/2025 after two residents were involved in an altercation. [Resident #6] is a [AGE] year-old male who resides on the dementia unit. He was admitted on [DATE] with the diagnosis of Alzheimer's, HLD, depression, anxiety, hearing loss, HTN, and TIA's. He can walk ad lib and is dependent on staff for assistance with ADL's. He has a BIMS score of 0.[Resident #7] is a [AGE] year-old male who resides on the dementia unit. He admitted on [DATE] with the diagnosis of dementia, dysphagia, hypothyroidism, HLD, depression, HTN, DM, AFIB, CHF, COPD, cellulitis and anxiety. He uses a wheelchair for mobility and is dependent on staff for ADL's. He has a BIMS score of 1.On 06/26/2025 both residents were in the common area in front of the nurse's station. Both residents were calm and suddenly [Resident #6] struck [Resident #7] on the left cheek. The residents were separated immediately and assessed by the nurse. [Resident #7] had a reddened area to the cheek, v/s 106/64,76,97.8,18. The reddened area dissipated without bruising although there is discoloration to both cheeks that is permanent. [Resident #6] refused vital signs at the time due to his agitation. There have been no further incidents between these two residents. Neither resident could recall the incident when interviewed by the DON. There was no root cause identified as the event was unprovoked.Both families were notified. [Psychological Services], MD, Regional support team and HHSC were all notified. Both residents were seen by the Social [NAME] and [Psychiatric] N.P. [Resident #6] continues to have behaviors during one-on-one observation and remains on one-on-one with the facility seeking alternate placement. His medications were reviewed and adjusted without being effective in modifying his behaviors. Incident reports were completed, skin assessments and pain assessments were completed. Care plans were updated. Education was initiated on Abuse and Neglect and managing difficult behaviors. After through [sic] investigation, the incident did occur but due to the residents' lack of cognition, it was not an intentional act of abuse. Both residents have be monitored by administrative staff frequently. [Resident #7] remains in the facility with no distress or concerns noted. We are seeking a more appropriate placement for [Resident #6]. Record review of the facility's Provider Investigation Report, completed by the DON on 07/09/25, reflected the following: The facility initiated an investigation on 07/02/2025 after two residents were involved in an incident.[Resident #6] is a [AGE] year-old male who resides on the dementia unit. He was admitted on [DATE] with the diagnosis of Alzheimer's, HLD, depression, anxiety, hearing loss, HTN, and TIA's. He can walk ad lib and is dependent on staff for assistance with ADL's. He has a BIMS score of o.[Resident #8] is an [AGE] year-old male who resides on the dementia unit. He admitted on [DATE] with the diagnosis of dementia, dysphagia, CKD, COPD, DM, dysphagia, depression, HTN, and behavior disturbance with dementia. He uses a wheelchair for mobility and is dependent on staff for ADL's. He has a BIMS score of 01.On 07/02/2025 [Resident #6] entered [Resident #8['s room and placed his hands around his neck. The CNA was directly behind him and redirected him away from the resident immediately. [Resident #8[ was assessed and there was no redness, irritation, or bruising noted. He denied feeling anything. There was no injury.[Resident #8] was interviewed by Social Services and could not recall the incident. Neither resident could recall the incident when interviewed by the DON.Both families were notified. The police, [Psychological Services], MD, Regional support team and HHSC were all notified.Both residents were seen by the Social Services and [Resident #6] continues to be seen by the [Psychiatric] N.P. [Resident #6] continued to have behaviors during one-on-one observation and remained on one-on-one with the facility seeking alternate placement. His medications were reviewed and adjusted without being effective in modifying his behaviors. He was sent to [Hospital] on 07/06/2025 due to his agitation and aggression. He remains there currently.Incident reports were completed, skin assessments and pain assessments were completed. Care plans were updated. Education was initiated on Abuse and Neglect and managing difficult behaviors.Based on the investigation, there is no evidence of abuse.Both residents have be monitored by administrative staff frequently. [Resident #8[ remains in the facility with no distress or concerns noted. [Resident #6] is still at [Hospital], but we continue to look for a more appropriate placement for him. 2. Record review of Resident #7's quarterly MDS, dated [DATE], reflected the a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included stroke, non-Alzheimer's dementia and depression. Resident #7's BIM's was a 1, which indicated his cognition was severely impaired. The MDS further reflected Resident #7 used a wheelchair for mobility. 3. Record review of Resident #8's significant change MDS, dated [DATE], reflected an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included non-Alzheimer's dementia, depression and vascular dementia, mild with other behavioral disturbance. The resident had a BIM's of 1, which indicated his cognition was severely impaired. The MDS further reflected Resident #8 used a wheelchair for mobility. Observation and interview on 07/10/25 at 9:39 AM revealed Resident #7 was in the secure unit television/dining room area across from the nurses' station sitting in his wheelchair pleasantly talking to other residents. He was alert and oriented and able to answer simple/basic questions. The resident was asked about the incident where he was struck by Resident #6, but he was not able to recall the incident. Observation on 07/10/25 at 9:44 AM revealed Resident #8 was in a high back wheelchair in the television/dining area. The resident was able to answer simple basic questions but was not able to recall the incident between him and Resident #6. Interview on 07/10/25 at 10:26 AM with LVN E revealed she was at the nurse's station getting a weight on another resident and Resident #7 was sitting at the doorway of where the other resident's weight was being obtained. At that time Resident #6 approached Resident #7 and both residents began to have a normal conversation and there was not aggression when all of sudden Resident #6 struck Resident #7 on the cheek with a closed fist and Resident #7 yelled out he hit me. Both residents were separated immediately, and Resident #7 was assessed, and he denied any pain but his check was slightly reddened from where he had been struck and the following day the redness was gone. LVN F said Resident #6 was admitted with extreme behaviors and wandered in and out of other resident rooms and would become very physical throwing things and trying to hit at staff as they redirected. LVN F stated Resident #6 was unpredictable and at first the resident was easily redirected to his coloring books. LVN F further stated Resident #6 was put on 1:1 supervision due to his unpredictable physical behaviors but did not recall date. Interview on 07/10/25 at 10:37 AM with CNA G revealed she had just taken Resident #7 to the bathroom and pushed him into the TV area and Resident #6 was standing in front of the nurse's station and both residents began to talk to each other in a normal tone and then, suddenly, Resident #6 struck Resident #7 in the face with a closed fist. CNA G said she immediately removed Resident #7 from the area and LVN F assisted in separating the residents. CNA G said Resident #7 had some redness to his check where he was struck but said it had not lasted very long. CNA G stated she believed Resident #6 was put on 1:1 after the incident and she described Resident #6 as very unpredictable with his mood swings. They were told if they noticed Resident #6 becoming upset, they were to remove the other residents away from him and let him calm down because Resident #6 would become very physical when he was redirected. Interview on 07/10/25 with CNA H revealed Resident #6 was very quiet but they had to pay very close attention to him because the resident would quickly strike out at anyone that was around him including the staff who were watching him 1:1. CNA H said Resident #6 would become very physical when they tried to redirect him, and the behavior would come out of nowhere and described him as very unpredictable. Interview on 07/10/25 at 11:12 AM with CNA I revealed Resident #6 appeared to be relaxed and then, all of a sudden, he would throw things around his room and became physical with others. CNA I said the staff were instructed to keep other residents away from Resident #6 and kept their distance until the resident calmed down. Interview on 07/10/25 at 1:40 PM with CNA J revealed the night of the incident with Resident #8, 07/02/25, Resident #6 had been out to the hospital and his family had taken him out AMA and took him back to the facility around 2:00 AM or 3:00 AM. She said Resident #6 was already on 1:1 supervision and when he arrived, he appeared agitated and soon after the resident's family left. CNA J said Resident #6 left his room and he was trying to go into other resident's rooms and she kept redirecting him out. During one of times, she was redirecting the resident out of a room, as she was shutting the other resident's door, Resident #6 immediately ran into the room across the hall (Resident #8's room) and CNA J said she followed him and before she could redirect him, Resident #6 was seen bending over Resident #8 and put his hands around his neck. CNA J said she immediately got to Resident #6 before he could squeeze his neck and yelled for LVN F to assist. CNA J stated Resident #8 woke up at that time and yelled at the staff to get Resident #6 out of his room. She said as they were trying to redirect Resident #6, he kept trying to swing at them and they finally got the resident back to his room where he finally laid down. CNA J further stated that was the first time she experienced Resident #6's aggression during the night shift and the incident was all unprovoked. Attempts to interview LVN F on 07/10/25 were unsuccessful. Interview on 07/16/25 at 10:53 AM with the ADON revealed she was told about the incidents with Residents #6, #7, and #8. The ADON said Resident #6 was transferred from another facility and there was no documentation of his aggressive behaviors but once he got to their facility, the resident was very unpredictable with his physical behaviors. The ADON stated Resident #6 was put on 1:1 supervision after the first incident with Resident #7 and never came off that supervision. Interview on 07/10/25 at 2:13 PM with the DON revealed Resident #6 was admitted from another facility and they were not aware of any of his physical behaviors, or he would never have been accepted. The DON said as soon as Resident #6 was admitted he began to have aggressive behaviors, and they tried to adjust his medications and also tried diversional activities, but nothing seemed to work. The resident was immediately put on 1:1 when he began to show aggression towards staff. Resident #6 was on 1:1 supervision from 06/21/25 to 06/24/25 and had been taken off for a while due to some decreasing behaviors and was put back on 1:1 after the incident with Resident #7 on 06/26/25 and was on it until the remainder of his stay. The DON stated there was nothing that triggered his behavior and it was difficult to tell when he was about to escalate and that was why they decided to keep him on 1:1 until they could find alternate placement. The DON said the resident had been sent to the hospital (07/01/25) after he became physically aggressive with the 1:1 sitter and he had fallen back. The resident was sent to the hospital for an evaluation because he had fallen on his arm from his physical behaviors and the Resident's Family had taken him out of the hospital AMA stating she had gotten tired of waiting for Resident #6 to be seen. Finally Resident #6 was sent to the hospital again (07/06/25) because she wanted them to do a psychological evaluation where he remained as they had Resident #6 on a 4- point restraint due to his aggressive behaviors and would not be accepted back due to his aggressive behaviors. Monitoring for compliance included the following: Observation on 07/10/25 of Resident #9, who was on 1:1 supervision, revealed staff were providing the resident with 1:1 supervision. The resident was on 1:1 supervision due to behaviors exhibited towards staff and for exit-seeking. Record review of the incident/accident log reflected there were no resident-to-resident incidents/altercations in the facility following Resident #6's last incident on 07/02/25. Record review of in-services, dated 06/26/25 and 07/02/25, reflected staff were in-serviced on the types of abuse/neglect prior to the HHSC investigation. The staff were also in-serviced on what to do when resident behaviors escalated, notify the abuse prevention coordinator of the behaviors, and who to notify of any behavior/incidents. The staff were also in-serviced on tips of dealing with aggressive behaviors in residents with dementia,. 81 staff members participated in the in-service on 06/26/25 and 74 staff participated in the in-service on 07/02/25. The staff were from various titles and shifts. Interview with staff on 07/10/25 from 10:26 AM to 3:52 PM from various shifts (6:00 AM-2:00 PM; 2:00 PM-10:00 PM; and 10:00 PM-6:00 AM) included LVN E, LVN F, CNA G, CNA H, CNA I, CNA J, CNA K, LVN L, CNA M, CNA N, LVN O, CNA P and the ADON. All the staff were able identify the different types of abuse, identify when a resident was escalating, try to identify a trigger, use gently tone or try to calm the resident, move them to a calm environment, shift their attention to a different activity, remove themselves from the room or leave the resident for a while until they calm down and make sure other residents were safe from aggressive residents , and notify upper management if a resident behavior escalated for further instruction. Observation of the residents on the secured unit on 07/10/25 from 9:39 AM to 11:24 PM revealed none displayed verbal or physical aggression towards other residents. Facility staff on the secured unit were observed to provide adequate supervision, assistance, and redirection as needed to meet the residents' needs. Interview on 07/10/25 at 2:13 PM with the DON revealed they screened residents prior to admission, and they did not accept any residents with aggressive behaviors. Record review of the facility's Abuse, Neglect, and Exploitation policy, implemented on 08/15/22, reflected the following: PolicyIt is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures and prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. An IJ was identified on 07/10/25. The IJ began on 06/26/25 and was removed on 07/06/25. The facility took action to remove the IJ before the abbreviated survey began. While the IJ was removed on 07/06/25, the facility remained out of compliance with a scope of pattern and severity level of no actual harm with potential for more than minimal harm.

Based on observations, record reviews, and interviews the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 5 residents (Residents #1, #2, #3, #4, and #5) of 20 residents reviewed for accommodation of needs. The facility failed to ensure call lights were placed within reach of Residents #1, #2, #3, #4, and #5. This failures could place residents at risk of harm or inability to call for help.Observations on 7/10/25 from 11:03 AM-11:54 AM of the 300 and 400 Halls revealed call light cords were not within reach of Residents #1, #2, #3, #4, and #5. Resident #1's cord was stored in her bedside dresser. Resident #2's cord was under her mattress. Residents #3, #4, and #5's cords were hanging from the light above the head of the bed. All of the residents were in their beds, and their call lights were not within their reach. Follow up observations on 07/10/25 from 1:06 PM-1:24 PM of the 300 and 400 Halls revealed the call light cords remained in the same locations. Resident #1's cord was stored in her bedside dresser. Resident #2's cord was under her mattress. Residents #3, #4, and #5's cords were hanging from the light above the head of the bed. All of these call lights were not within reach of the residents. An interview was attempted on 07/10/25 at 11:03 AM with Resident #1; however, she did not respond when asked about her call light. In an interview on 07/10/25 at 11:06 AM, Resident #2 stated she was unable to locate her call light cord. The resident stated she was able to use her call light when needed, and it was not out of reach very often. An interview was attempted on 07/10/25 at 11:40 AM with Resident #3; however, the resident was non-responsive to questions. In an interview on 07/10/25 at 11:43 AM, Resident #4 stated she was unable to locate her call light cord. The resident stated she was able to use her call light when needed, and it was not out of reach very often. In an interview on 07/10/25 at 11:54 AM, Resident #5 stated she was unable to locate her call light cord. The resident stated she was able to use her call light when needed, and it was not out of reach very often. In an interview on 07/10/25 at 2:20 PM, RN A stated the call light cord needed to be within reach of the residents, so they could call for help if needed. He stated the risk of not having the call light within reach of the resident was the resident falling when trying to get up without assistance. In an interview on 07/10/25 at 2:23 PM, CNA B stated the residents' call lights had to be within reach of the residents, so they could call for help if needed. She stated she did not know why the call lights were not within reach of the residents. In an interview on 07/10/25 at 2:28 PM, LVN C stated call light cords had to be secured to the resident's bedding or the bed rail if they had one. She stated the call light needed to be within reach and easily located to prevent the resident from hurting themselves when trying to get out of bed and help themselves. She stated all staff were responsible for ensuring resident call lights were withing reach of the residents. In an interview on 07/10/25 at 2:32 PM, LVN D stated resident call light cords had to be within reach of the resident. She stated if the call light was not where they could reach it, the resident would not be able to call for assistance and could fall or have an accident. In an interview on 07/10/25 at 2:35 PM, the DON stated call light cords should always be left within reach of the resident. She preferred the cord was secured to the bedding or the bed rail so it would not slide off. She stated the biggest risk to the residents was not being able to call for assistance. She stated it could cause the resident to try to get up and help themselves and fall in the process. Record review of the facility's Call Lights: Accessibility and Timely Response policy, dated 10/13/22, reflected: The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance 5. Staff will ensure the call light is within reach of resident and secured as needed

Based on observation, interview and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 2 of 5 resident (Residents #1 and #2) reviewed for supervision. The facility failed to provide adequate supervision to Residents #1 and #2, who both had severe cognitive impairment and resided on the facility's memory care unit. On 02/02/25, Resident #1 was found fully clothed in Resident #2's bed, and Resident #2 had no clothing on below the waist. The noncompliance was identified as PNC. The noncompliance began on 02/02/25 and ended on 02/03/25. The facility had corrected the noncompliance before the survey began. The failure could place residents at risk for abuse. Findings include: Record review of Resident #1's face sheet, dated 06/17/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #1's quarterly MDS assessment, dated 06/11/25, reflected her diagnoses included Alzheimer's disease with late onset (brain disorder), unspecified dementia with mood disturbance and depression (loss of cognitive functioning). Resident #1's BIMS score was 00, which indicated severe cognitive impairment. Section E - Behaviors reflected Resident #1 exhibited wandering behaviors . Record review of Resident #1's care plan, dated 02/03/25, reflected Problem: [Resident #1] has sexually inappropriate behaviors. 2/2/25 in male peer's room fully dressed, male peer was undressed below hips attempting to engage with [Resident #1]. Goal: [Resident #1] will have no evidence of sexually inappropriate behaviors by review date. Interventions: 2/2/25 staff immediately intervened and separated [Resident #1] from peer, skin assessed, Administrator/DON/RP notified, [psychological/psychiatric services] referral, peer was placed on 1:1 supervision. Caregivers to provided opportunity for positive interaction, attention. Stop and talk with her as passing by. If reasonable, discuss [Resident #1] behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to her. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Minimize potential for [Resident #1] disruptive behaviors by offering tasks which divert attention. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Provide a program of activities that is of interest and accommodates [Resident #1] status . Record review of Resident #1's progress note, dated 02/02/25 at 22:43 [10:43 PM] by LVN B, reflected: Resident observed in male pt room, pt (fully dressed) male resident undressed below the hips. Male pt attempting to engage with female pt. nursing staff immediately intervened and separated the two. Both with Positive/affect. No s/s of pain/distress. Interventions: Skin assessment completed no acute skin concerns at time of assessment. Currently seated at nurses' station. On coming shift notified. reviewed residents' disposition after event, notified male resident is now 1:1. Family requested male pt name / denied HIPPA . Reviewed current intervention provided by nursing staff, family states their understanding, will continue with current Plan of care. Observation on 06/17/25 at 12:01 PM, revealed Resident #1 was observed in the memory care unit, sitting in the dining area. Resident #1 did not respond to any questions. 2. Record review of Resident #2's face sheet, dated 06/17/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Record review of Resident #2's quarterly MDS assessment, dated 03/11/25, reflected his diagnoses included unspecified dementia with agitation (loss of cognitive functioning), schizophrenia (chronic mental disorder that significantly impacts a person's thinking, feeling, and behavior), and high blood pressure. Resident #2's BIMS score was 14, which indicated his cognition was intact. Section E - Behaviors indicated Resident #2 did not exhibit any wandering behaviors . Record review of Resident #2's care plan, dated 02/03/25, reflected Problem: [Resident #2] has sexually inappropriate behaviors. 2/2/25 in his room with female peer undressed below his hips attempting to engage with female peer who was fully dressed. Goal: [Resident #2] will have no evidence of sexually inappropriate behavior problems by review date. Interventions: 2/2/25 staff immediately intervened and separated [Resident #2] from peer, skin assessed, DON notified, placed on 1:1 supervision, oncoming shift/Administrator/RP notified, [psychological/psychiatric services] referral. If reasonable, discuss [Resident #2] behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to him. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Minimize potential for [Resident #2] disruptive behaviors by offering tasks which divert attention. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. No prior sexual inappropriate behaviors documented in Resident #2's care plan. Record review of Resident #2's progress note, dated 02/02/25 at 10:20 PM by LVN B, reflected: Resident observed with female pt in room, resident undressed below the hips. Attempting to engage with female pt (fully dressed). Nursing staff immediately intervened and separated the two. Both with Positive/affect. No s/s of pain/distress. Resident denies situation/observed by staff. Interventions: Skin assessment completed no acute skin concerns at time of assessment. DON pt to be 1:1 until further notice, awaiting aid. On coming shift notified. Record review of Resident #2's progress note, dated 02/03/25 at 11:39 AM by Social Worker, reflected: SWA visited with resident and asked him if he was aware of an incident that took place in his room. Resident stated that a female resident came and got in his bed. He stated he was accused of being in bed with her with his pants off, but that it was not true. When asked how he feels about the situation, he said he just don't want people saying things about him that was not true. His countenance was calm and did not appear upset or distraught. Record review of the facility's Provider Investigation Report, completed by the Administrator on 02/07/25, reflected the following: 02/02/2025 The facility initiated an investigation on 02/02/2025, after two residents were involved in an alleged sexual interaction. [Resident #2] is a [AGE] year-old male that was residing on the dementia unit with a BIMS score of 1. His diagnosis includes unspecified dementia (loss of cognitive functioning), need for assistance with personal care, primary hypertension (high blood pressure), schizoaffective disorder-bipolar type ((chronic mental disorder that significantly impacts a person's thinking, feeling, and behavior), altered mental status (change in mental function), chronic glaucoma (eye condition that damages the optic nerve). He admitted on [DATE], he self ambulates. He is dependent upon staff for ADL's , can feed self. He has no history of sexual interactions and is seen by [psychological/psychiatric services]. [Resident #1] is a [AGE] year-old female resident who admitted on [DATE] and resides on the dementia unit with a BIMS score of a 2. Diagnosis's [sic] include Alzheimer's disease (brain disorder), Dementia (loss of cognitive functioning), Raynaud's Syndrome without gangrene (causes spasms in small blood vessels in your fingers and toes). She self ambulates. She is dependent upon staff for ADL's and can feed self. She has been referred to [psychological/psychiatric services]. On 02/02/2025 [Resident #2 and Resident #1] were observed in .[Resident #2's room] in the bed together, [Resident #1] was fully clothed while [Resident #2] was undressed from the waist down. There was no other resident in the room. [CNA A] walked into the room and intervened immediately. [Resident #2] was placed on a one-on-one until reviewed by psych . No further interactions or behaviors were noted the evening. Both residents were assessed with no signs of distress noted for either. Full skin assessment on [Resident #1] with no concerns. Families were notified. [Psychological/psychiatric services], MD , regional support team and HHSC were all notified. Both residents were seen by Social Services and [psychological/psychiatric services]. No distress was noted. Incident reports were completed, skin assessments were completed, care-plans were updated. Education was initiated on Abuse and Neglect and managing difficult behaviors. Both residents were visited by administrative staff daily and no distress or mood changes were noted. Record review of Employee Witness Statement by CNA A, dated 2/2/25, reflected: [CNA A] was covering rooms 101 to 109 on the locked unit and on her rounds, she entered room [ROOM NUMBER]. [CNA A] witnessed male resident [Resident #2] in the bed with no bottoms on, over a fully clothed, female resident. [CNA A] intervene immediately and asked the male resident to get dressed and asked for help. [LVN B] came immediately and they assisted the female resident out of the room. Interview on 06/17/25 at 11:42 AM, with Resident #2 revealed he used to reside in the memory care unit. He stated he recalled the incident where a lady entered his room and got into his bed. He stated he was sitting by the door when the lady entered his room. He stated he told the aide a lady was in his bed. He stated he could not recall the aide's name. He stated he did not know why the aide lied on him and said he had his pants down and was in bed with the lady. Resident #2 stated he never got in the bed or was naked. He stated he had clothes on. He stated nothing happened and never would. Resident #2 stated he did not want people to think he did something to that lady. Interview on 06/17/25 at 1:54 PM, CNA A revealed she was the CNA who found Resident #1 in Resident #2's bed. She stated at around 2:00 PM-2:30 PM, she was doing her rounds and she entered Resident #2's room. She stated she observed Resident #1 fully clothed in Resident #2's bed and Resident #2 was leaning towards Resident #1, one hand on the bed by Resident #1 head and the other hand on the bed by the hip area and appeared like he was putting on her pants. She stated the residents' bodies were not touching each other. She stated Resident #2 only had a shirt on, no pants or brief on. She stated she immediately intervened and asked Resident #2 what was he doing and to put some clothes on. She stated Resident #2 did not respond to any questions. She stated she redirected Resident #1 to get out of the bed and called LVN B to come assist. She stated by the time LVN B entered the room Resident #2 was changed and sitting by the door. She stated this was the first incident, Resident #2 did not have any known sexual behaviors. Interview on 06/17/25 at 2:03 PM, LVN B revealed she was the nurse assigned to the memory care unit when Resident #1 was found in Resident #2's bed. She stated she had worked a double shift, she stated prior to Resident #1 wandering into Resident #2's room, they were both observed in the dining area, she had finished doing activities with the residents. She stated the residents were not next to each other. She stated she could not recall much but she had gone to break and when she returned, she was at the nurse's station and heard one CNA call another CNA to Resident #2's room. She stated she went to go check what was going on, she observed Resident #1 sitting on the bed and Resident #2 sitting on a chair by the door. She stated both residents were dressed, she did not witness anything. She stated she was told by CNA A; Resident #2 was undressed while Resident #1 was in bed fully clothed. She stated it was unknown of the intent between Resident #1 and Resident #2. She stated she assessed both residents and Resident #2 was placed on 1:1 supervision for the rest of the night. She stated nothing happened between Resident #1 and Resident #2. She stated Resident #2 had no known sexual behaviors, she stated this was the first incident during her shift. Interview on 06/17/25 at 2:47 PM, ADON C revealed Resident #2 admitted to the facility memory care unit in November 2024. She stated when Resident #2 admitted to the memory care unit, the resident would not communicate and was an elopement risk. She stated Resident #2 was not known to wander into other residents' room or female rooms and did not have any sexual behaviors. She stated she was not working the day of the incident; but she was called and was told about the incident. She stated it was reported to her the newly admitted Resident #1 had wander into Resident #2's room and Resident #1 and Resident #2 were found together. She stated she could not recall but she was told Resident #2 was coming out of the restroom when he noticed Resident #1 in the bed. She stated she was told Resident #1 was fully clothed and Resident #2 was not wearing any pants and what appeared Resident #2 was trying to remove Resident #1's clothes. She stated she could not recall how they were found but nothing happened between them. She stated when she talked to Resident #2, he denied the incident and stated, a female resident entered his room and got in his bed. She stated Resident #2 told her he was in the service and would ever hurt anyone. Interview on 06/17/25 at 3:18 PM, the DON revealed she was notified a CNA was doing rounds and entered Resident #2's room and noticed Resident #1 in Resident #2's bed together. She stated Resident #2 was naked from the waist down. She stated the CNA intervened, separated them, and called the nurse. She stated nothing happened between Resident #1 and Resident #2. She stated Resident #1 was fully clothed when she was found in the bed. She stated nothing else was told to her about the incident and the intent was unknown. The DON stated she could not recall when the last time both residents were last seen. She stated it was Resident #1's second day in the memory care unit. She stated Resident #2 had never had any known sexual behaviors. The DON stated when she notified Resident #1's family about the incident, the family was not surprised and informed her Resident #1 had a history of those interactions , which the facility was not aware of. She stated as an intervention they placed Resident #2 on 1:1 supervision until the doctor said he was appropriate to be off, both residents were assessed, and psych services provided . She stated no further interactions or behaviors were noted. Interview on 06/17/25 at 5:12 PM, the Administrator revealed Resident #1 was newly admitted to the memory care unit and was confused. He stated Resident #1 was acclimating to the unit; however, wandered into Resident #2's room. He stated it was informed to him that the CNA entered Resident #2's room and found Resident #1 in Resident #2's bed. He stated he could not recall much but Resident #2 was in the room, coming out of the restroom when Resident #1 got in his bed and then Resident #2 got in the bed. The Administrator stated nothing sexual happened between the residents. He stated the CNA intervened immediately and removed Resident #1. He stated Resident #2 had not had any previous behaviors. He stated his expectations were for staff to monitor residents, keep a close eye on them, keep residents in the common area and frequent rounding. He stated the potential risk would be resident to resident interactions. Record review of the facility's Abuse and Neglect policy, dated 08/15/22, reflected the following: . VI. Protection of Resident - The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation . The facility took the following actions to correct the noncompliance: Observations completed on 06/17/25 from 11:00 AM through-4:45 PM in the memory care unit revealed 2 halls, one for male residents and the other one for female residents. Observed residents in the common area, staff monitored residents, redirected residents and frequent rounding in the halls. Activities were provided to residents . Observed 2 nurses, 3 CNA's and 1 Activity staff in the memory care unit. Interviews on 06/17/25 from 12:45 PM through 5:20 PM with CNA A, LVN B, ADON C, ADON D, LVN E, RN F, LVN G, CNA H, LVN I, CNA J, LVN K, Activities, LVN L, CNA M, CNA N, CNA O, LVN Q, and LVN R who work the shifts of 6:00 AM-2:00 PM, and 2PM-10PM. Facility staff were able to verify education was provided to them. The nursing staff stated they were educated on different types of abuse/neglect and behaviors. Staff monitoring behaviors through-out the shift, if a resident exhibits behavior resident placed on 1:1 supervision or every 15 minutes check, they document and notify the incoming staff. Redirecting residents when they start wandering into the opposite side of the unit, they provide activities through-out the day and round checking on residents every 1 or 2 hours. Redirecting residents when they start wandering into the opposite side of the unit, they provide activities through-out the day and round checking on residents every 1 or 2 hours. Staff stated they completed rounds during shift change with the incoming staff. Staff provided the types of abuse were physical, mental, financial, and verbal. Staff stated they would intervene if they witnessed any inappropriate behaviors, separate, redirect, ensure safety, and assess residents. Staff revealed they would report to the Abuse Coordinator, the Administrator, immediately if they witnessed or observed any of these behaviors. Record review of Resident #1 and Resident #2's Skin assessment, Pain assessment and change in condition Assessment completed on 02/02/25 and 02/03/25, documented no concerns. Record review of Resident #1 psych services reflected Resident #1 was seen on 02/03/25 and received an order for Depakote 1 capsule by mouth three times a day for mood/behaviors. Record review of Resident #2 psych services reflected Resident #2 was seen on 02/03/25. Visit note reflected Pt is 1:1 after a female pt was found in his room sleeping in the empty bed. Pt was unable to explain what was happening. The other pt is new and very confused. He presents no problems with his mood. Pt does not appear to be responding to internal stimuli. while pt can be irritable at times. he has not been known to pursue other pts. No medication changes were made for Resident #2. Record review of Resident #1 and Resident #2 clinical records reflected both residents were seen by Psych services on 02/03/25 and medications were reviewed. Record review of Safe surveys were completed with five residents with no issues noted. Record review of Resident #1 and Resident #2 Behavior Monitoring Symptoms tasks were being completed. Record review of Resident #2's clinical records reflected Resident #2 no longer resided in the memory care unit . Resident #2 was moved to another part of the facility when BIMS Score was reviewed on 03/27/25 and room was available on 04/02/25. Record review of the facility's In Service Training, dated 02/02/25, provided by the DON, reflected all facility staff were In Serviced on Resident to Resident education - Make sure that we are responding quickly and documenting any behavior escalations. Make sure the abuse prevention [coordinator] is notified or the back up and that all details of event are effectively communicated. MD and family to be notified of behaviors and an evaluation requested. 4. Notify provider if a resident is refusing medications/care. All behaviors must be care planned. Behaviors must be documented in the behavior monitoring forms .Abuse and Neglect - Please review the attached policy on abuse and neglect. You should be able to name the types of abuse and know what constitutes neglect. Types of abuse: verbal; physical; mental; sexual; involuntary seclusion; misappropriation of funds. Neglect: failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Abuse prevention Coordinator: [Administrator], Admin. Back up: [DON], RN .Please monitor your residents for sexual behaviors. If any behaviors are noted, please respond in a calm and respectful manner and separate the residents. Notify the nurse immediately. If you see a resident that is attempting to make sexual advances or comments, redirect them and notify the nurse. As the nurse you are to inform the family, physician and abuse prevention coordinator. Please review attached for managing sexual behaviors with dementia patients. The noncompliance was identified as PNC. The noncompliance began on 02/02/25 and ended on 02/03/25. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 of 6 (Resident #3, #4, and #5) residents reviewed for use of assistance devices for positioning and transfers. 1. On 01/13/25 Hospice Aide K failed to use a drawsheet when repositioning Resident #3 in bed and instead raised her up underneath her armpits hard to pull her up in bed and heard a loud crack or pop. The facility ordered x-rays, and it was determined the resident had sustained a displaced humeral neck fracture (shoulder/upper arm fracture) due to the improper transfer and failure to use a drawsheet to position her in bed. 2. The facility failed to ensure Hospice LVN BB and Hospice Aide CC used a transfer belt when transferring Resident #4 and Resident #5. An IJ was identified on 01/29/25. The IJ template was provided to the facility on [DATE] at 4:03 PM. While the IJ was removed on 01/31/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's continuation of in-servicing and monitoring the plan of removal. These failures placed residents at risk of serious harm. Findings included: Record review of Resident #3's face sheet, dated 01/16/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #3's MDS Quarterly Assessment, dated 10/28/24, reflected Resident #3 had a BIMs score of 02, indicating severe cognitive impairment. Resident #3 was dependent on staff for toileting and showering, toilet transfers, tub/shower transfers, chair bed to chair transfers, lying to sitting on side of the bed, and sit to lying. Resident #3 required substantial/maximum assistance with upper and lower body dressing, rolling left and right. Her diagnosis included High Blood Pressure, Alzheimer's Disease, Anxiety, Depression, and bipolar disorder and Dysphagia (difficulty swallowing). Resident #3 received hospice care. Record review of Resident #3's Care Plan, reviewed on 01/17/25, reflected: Focus: [Resident #3] has an Activity of Daily Living self-care performance deficit related to muscle wasting, lack of coordination and impaired mobility. Goal: Resident will maintain current level of function Intervention: [Resident #3] was dependent on staff for toileting and showering, toilet transfers, tub/shower transfers, chair bed to chair transfers, lying to sitting on side of the bed, and sit to lying. [Resident #3] required substantial/maximum assistance with upper and lower body dressing, rolling left and right. Bath/Showering: Provide sponge bath when showering was not tolerated, with assistance by 1 staff, Bed Mobility: Resident required extensive assistance by 1 staff to turn and reposition in bed, Dressing: Extensive assistance by 1 staff. Transfers: Limited to extensive assistance by 1 staff to move between surfaces. [Resident #3] has an alteration in musculoskeletal status related to acute Left humeral neck fracture, moderate to severe glenohumeral osteoarthritis. 1/13/25 complaint of pain L shoulder during shower with hospice CNA. Goal: [Resident #3] will remain free from pain or at a level of discomfort acceptable to her. Interventions:1/13/25 assessed, Nurse Practitioner notified with new order STAT X-Ray Left shoulder, Representative notified. X-Ray results: Acute humeral neck fracture. Moderate to severe glenohumeral osteoarthritis. Nurse Practitioner /Responsible Party/hospice/DON notified; routine pain medication administered. Record review of the facility's Provider Investigation Report, dated 01/21/25, reflected: Incident date: 01/13/25, Time of Incident 7:15 AM. Person(s) or Resident (s) involved: [Resident #3] Alleged Perpetrator(s)(AP): [Hospice Aide K] Description of the Allegation: [Resident #3] complained of pain in her left shoulder after having a bath with the hospice aide, [Hospice Aide K]. Assessment: Date 1/13/25 Time: 8:43AM by [RN I] -Resident c/o pain to the left shoulder when she was given her a shower. Assessment performed ablet to squeeze my fingers c/o pain when lifting the arm. NP in the facility notified and ordered x-ray. Facility Investigation Findings: Confirmed. Provider Action taken post-investigation: [Resident #3] [is] being monitored for pain and medicated as indicated. Education continues with staff on abuse and neglect and turning and repositioning. Hospice aides are being re-educated also. Facility initiated an investigation on 01/14/2025 after [Resident #3] made a complaint of pain in her shoulder and an x-ray that was ordered, returned with an Internal and external rotation views of the shoulder were obtained. There [is] a minimally displaced humeral neck fracture (a fracture in the neck of the upper arm bone where the broken bone pieces are only slightly out of alignment). Gleno-humeral joint space loss and spurring are noted (a space withing the shoulder joint is narrowed, and there are visible bone growths present, indicating the development of degeneration of joint cartilage and the underlying bone in the shoulder). There is no shoulder separation. There is no calcific tendinopathy (the formation of calcium deposits in tendons, leading to inflammation and pain). Diffuse osteopenia (generalized decrease in bone mineral density) is demonstrated. IMPRESSION: Acute humeral neck fracture. Moderate to severe gleno-humeral osteoarthritis. .[Hospice Aide K] came in for the interview and stated that he was repositioning [Resident #3] in the bed and did not use the draw sheet. He was informed of the injury and Hospice [Name] nurse was informed that he would need to removed from our building pending the investigation. Other residents who were under Hospice [Name] care were evaluated for pain, distress or injury with none noted. Staff were re-educated on our abuse-neglect policy and turning and repositioning when in bed and bathing. Hospice Aide K statement dated 01/14/25: On 01/13/20[24] I came to provide care for [Resident #3], [I] have been her aide since 12/21/2023. [I] usually give her bed bath but yesterday she had stool on her, so I took her to the shower. After showering her [I] dried her off and dressed her and assisted her back to the bed. She [is] a one-person transfer. After [I] put her back in bed, [I] adjusted her legs, but [I] noticed that she was still too far down in the bed. [I] went behind the headboard and lifted her under her arms to pull her up. [I] usually use the draw sheet but this time I just grabbed her under her arms. [I] did hear a pop at this time, and she said that her arm hurt. [I] reported to the nurse that she was complaining of pain, and he went to assess her. [I] reported it to my supervisor at Hospice [Name]. [Today], [I] was informed that there is a fracture. It was a complete accident. [I] didn't use the draw sheet like [I] was supposed to and was trained to do so by my company. [I] take pride in the work [I] do and always try to always ensure safety. [I] care so much for my patients and made a mistake that will never happen again. 1/14/25 hospice nurse in and assessed with pain medication adjustments, increase anxiolytic (medications to treat anxiety disorders), hold anticoagulant x 3-day, Blood Pressure medication, as needed anticholinergic (drugs that block the action of the neurotransmitter) related to secretions, Representative notified, 2 Person Assist provided with turning and repositioning, call light in reach. 1/15/25 hospice new order antibiotic therapy twice a day x 7day prophylactically (actions taken to prevent or guard against a disease or infection). 1/16/25 Left arm elevated on pillow for comfort, assisted with repositioning. Assist Resident #3 to change positions. Alternate periods of rest with activity out of bed as tolerated/allowed in order to prevent respiratory complications, dependent edema (swelling that occurs in the lower extremities), flexion deformity (joint is permanently bent in a flexed position) and skin pressure areas. Be sure call light is within reach and respond promptly to all requests for assistance. Educate resident /family/caregivers on joint conservation techniques. Give analgesics (pain reliever) as ordered by the physician. Monitor and document for side effects and effectiveness. Monitor for any side effects to NSAIDS such as GI bleeding or renal impairment. Monitor/document for risk of falls. Educate resident/family/caregivers on safety measures that need to be taken in order to reduce risk of falls. Monitor/document/report as needed signs and symptoms or complications related to arthritis: Joint pain. Joint stiffness, usually worse on wakening; Swelling; Decline in mobility; Decline in self-care ability; Contracture formation/joint shape changes; Crepitus (creaking or clicking with joint movement); pain after exercise or weight bearing. Record review of Resident #3's x-ray results dated 01/13/25 reflected x-rays of the resident's left shoulder showed the following findings: .Findings: Internal and external rotation views of the should were obtained. There is a minimally displaced humeral neck fracture. Gleno-humeral joint space loss and spurring (bony growths that form in your joints) are noted. There is no shoulder separation. There is no calcific tendinopathy. Diffuse osteopenia is demonstrated. Impression: Acute humeral neck fracture. Moderate to severe gleno-humeral osteoarthritis. Record review of Resident #3's progress notes reflected the following entries: - 01/13/25 10:32 AM written by RN L: Hospice aide reported to the RN L that resident complained of pain to the left shoulder when he was giving her a shower. Assessment performed able to squeeze my fingers complained of pain when lifting the arm. Nurse Practitioner in the facility notified and ordered x-ray. Called .mobile x-ray and an order was placed family notified and will continue to monitor. - 01/13/25 11:34 AM written by RN L : left shoulder pain, started 01/13/25, since started it has gotten worse. Things that make the condition worse: movement. Things that make the condition better: calm. - 01/13/25 6:30 PM: Left shoulder X-ray results received with the following findings: Acute humeral neck fracture and moderate to severe gleno-humeral osteoarthritis. Nurse Practitioner notified pending new orders, call placed to family and Hospice awaiting call back from Hospice. DON notified. Routine pain medications administered as per orders. - 01/14/25 8:42 AM written ADON B: Resident complained of left arm pain 1/13/25. Nurse Practitioner was in the building and notified. X-ray positive for fracture. Pain controlled by Tylenol #3. - 01/14/25 2:13 PM written by ADON B: Hospice nurse in the facility to examine resident. She gave the following orders: 1. Discontinue Routine Tylenol #3 2. Start Tylenol #3 2 tabs every 6 hours as needed for pain. 3. Start Hydrocodone 10/325 1 by mouth every 6 hours routine. 4. Discontinue Tylenol #3 when hydrocodone arrives. 5. Morphine 20 mg/ml give 0.25 - 0.5 ml under the tongue every hour as needed for severe pain/short of breath. 6. Tylenol 650 mg suppository give one recetally every 4 hours as needed for fever greater than 100.5 Do not exceed 3gm Tylenol in 24 hours. 7. Give Tylenol #3 2 tabs now for severe pain. - 01/14/25 2:30 PM written by ADON B: Resident's family member was contacted via phone regarding change of condition/arm fracture. Explained to her how resident obtained injury and the plan moving forward to provide comfort care. New orders from hospice reviewed with family member. Family member in agreement with not pursuing aggressive measure and is ok with comfort measures. - 01/14/25 10:02 PM: Resident was stared on Norco 10/325 mg routine, medication administered this as per orders for left shoulder pain. Resident stable and able to voice needs. Incontinent care provided by staff. Call light in reach. Observation of Resident #3 on 01/15/25 at 2:00 PM revealed the resident was in bed resting. The resident responded that she felt okay and closed her eyes. Observation and interview on 01/16/25 at 2:00 PM with Resident #3 revealed her in bed. Resident #3 revealed she did not have any pain and did not display any signs or symptoms of distress. Resident #3 was not able to effectively communicate about her arm injury. Interview on 01/16/25 at 2:05 PM with CNA J revealed Resident #3 was currently on hospice, she was informed there had been an injury with Resident #3's left arm. CNA J stated Resident #3 allowed incontinent care however was very protective of her left arm. CNA J stated Resident #3 had a great relationship with Hospice Aide K and looked forward to his visits. According CNA J stated she was aware to use a draw sheet to reposition residents and never to pull on their body parts. CNA J stated Resident #3 had been asking for Hospice Aide K because it had been a couple of days since he had returned. Interview on 01/16/25 at 3:12 PM with RN L revealed Resident #3 received bed baths and showers from hospice, RN L stated on 1/13/25 Resident #3 received a shower from Hospice Aide K after placing her back in bed, Hospice Aide K alerted me that Resident #3 complained of pain to the right shoulder. RN L stated he went in room to complete assessment and Resident #3 stated that when Hospice Aide K pulled her up in bed, she heard a pop and had pain soon after. RN L stated the Nurse Practitioner was in the building and after alerting her she ordered x-ray. RN L stated Hospice Aide K revealed that he showered Resident #3 and placed her back in bed, she was low in bed, so he stepped behind the bed lifting her placing his arms underneath her shoulders and lifted her up in bed, heard a pop, then she complained of pain. Interview on 01/16/25 at 3:25 PM with Hospice Aide K revealed he has been working with Resident #3 for over a year coming to the facility Monday, Wednesday and Friday to provide mostly bed baths. He stated on 01/13/25 Resident #3 was heavily soiled and required a shower. Hospice Aide K stated after transferring Resident #3 to her bed she was still too low in bed. Hospice Aide K stated In order to get her pulled up I always raise the bed and feet up with the controller to allow gravity to assist me. I put my arms under her arm pits. I usually grab the sheet. This time I did not grab the sheet. I put my weight against the headboard. This time when I lifted her, I did so hard there was this loud cracking sound. I can not say why I repositioned her this way, without the use of a draw sheet He stated when he pulled her up there was a loud cracking, popping noise from the left shoulder. Hospice Aide K stated, When I heard that, I ran to alert the nurse. During the assessment Resident #3 reported her left shoulder was hurting, an x-ray was ordered, and the following day it was reported Resident #3 had a fracture. Interview on 01/16/25 at 4:10 PM with DON revealed she was informed Resident #3 complained of pain of the left shoulder. The DON stated the Nurse Practitioner had ordered an x-ray that revealed findings of a fracture. The DON stated she went to speak with Resident #3 when she expressed Hospice Aide K was bathing her and she heard a loud pop. The DON stated she called Hospice Aide K; he confirmed the there was a loud pop to the shoulder which resulted in Resident #3 having pain. Interview on 01/16/25 at 4:27 PM with ADON B revealed he had been informed by RN L that Resident #3 had received a shower from Hospice Aide K, he attempted repositioning her in bed by pulling Resident #3 up by placing his arms underneath her shoulders and not using the draw sheet. ADON B stated x-ray results came revealing a fracture leading us to make all the notifications to the DON, physician, hospice and Family Member. ADON B stated Resident #3 was kept comfortable and orders for Tylenol 3, Norco and Morphine was administered. ADON B stated inservices were started to train staff to always have help with repositioning, use draw sheet, do not pull-on resident body parts. ADON B stated all aides including hospice staff were responsible for asking for assistance from other aides, charge nurses or ADONs to reposition residents, not doing so placed residents at risk of injury or fall. Interview on 01/16/25 at 4:45 PM with the DON revealed she was currently completing the investigation and inservices for Resident #3. The DON stated staff were being inserviced on repositing residents, using draw sheet, asking for assistance when repositioning residents. Record review of Inservice Training Report dated 01/14/25 Abuse and Neglect; also 01/14/25 Turning and Repositioning/lift extremities/monitor for discomfort reflected the following: Each resident should have a draw sheet placed under them when in bed. When turning and repositions a resident in bed, [you] should never pull them by their arms or legs. Use the draw sheet for all turning, repositioning, and pulling them in the bed. GENTLY, lift the arm and legs when off loading or moving for comfort. If a patient shows signs of discomfort during any aspect of care, STOP what [you[ are doing and get your nurse. (Make sure the resident is safe). Remember, pain is not always expressed verbally. Monitor facial expressions. At no time should we refer to a resident as being dead weight. 2. Record review of Resident #4's face sheet, dated 01/29/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #4's quarterly MDS assessment, dated 01/08/25, reflected a BIMS score of 06, which indicated severe cognitive impairment. Her diagnoses included unspecified dementia, dysphagia, hypertension (high blood pressure). The MDS further revealed Section GG - Functional Abilities indicated Resident #4 needed substantial/maximal assistance (helper does more than half the effort lifts or holds trunk or limbs and provides more than half the effort) for chair/bed-to- chair transfer. Record review of Resident #4's care plan revised date 01/13/25 reflected: Problem: [Resident #4] has an ADL self-care performance deficit r/t impaired mobility. Goal: [Resident #4] will maintain current level of function in ADLs through the review date. Interventions: FUNCTIONAL PERFORMANCE: CHAIR/BED-TO-CHAIR TRANSFER: [Resident #4] requires substantial/maximal assistance to transfer to and from a bed to a chair (or wheelchair). BATHING/SHOWERING: [Resident #4] requires total assistance by 1 staff with bathing/showering. Observation on 01/29/25 at 10:23 AM revealed Hospice LVN BB performed a transfer for Resident #4 from the wheelchair to the bed to provide the resident a bed bath. Hospice LVN BB explained the procedure to Resident #4. Hospice LVN BB then locked the resident's wheelchair and told Resident #4 to hug her. Hospice LVN BB was observed to put her arms around Resident #4 underneath the resident's arms and lifted the resident up. She then turned the resident and sat her on the bed. Resident #4 was not able to stand her own and depended on the hospice nurse to do the transfer. Hospice LVN BB did not use a transfer belt when performimg the transfer. Record review of Resident #5's face sheet, dated 01/29/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #5's significant change in status MDS assessment, dated 12/27/24, reflected a BIMS score of 11, which indicated moderate cognitive impairment. Her diagnoses included old myocardial infarctio n (previous heart attack that's no longer active), malnutrition, dysphagia, hypertension (high blood pressure). The MDS further revealed Section GG - Functional Abilities indicated Resident #5 needed substantial/maximal assistance (helper does more than half the effort lifts or holds trunk or limbs and provides more than half the effort) for chair/bed-to- chair transfer. Record review of Resident #5's care plan revised date 01/16/25 reflected: Problem: [Resident #5] has an ADL self-care performance deficit r/t impaired mobility, declining health. Goal: [Resident #5] will maintain current level of function in ADLs through the review date. Interventions: FUNCTIONAL PERFORMANCE: CHAIR/BED-TO-CHAIR TRANSFER: [Resident #5] requires substantial/maximal assistance to transfer to and from a bed to a chair (or wheelchair). BATHING/SHOWERING: [Resident #5] requires total assistance by 1 staff with bathing/showering. Observation on 01/29/25 at 10:30 AM revealed Hospice Aide CC performed a transfer for Resident #5 from the bed to the wheelchair, so she could take the resident to the shower room. Hospice Aide CC explained the procedure to Resident #5. Hospice Aide CC then helped Resident #5 sit on the side of the bed. Hospice Aide CC lifted the resident by holding onto the resident's waistband, and the resident stood up. Hospice Aide CC next told the resident to hold onto her like she was hugging her. Hospice Aide CC held the Resident #5 by the waist with both hands, lifted her, and placed the resident to the wheelchair. Hospice Aide CC did not use a transfer belt, and Resident #5 was not able to stand her own and depended on the hospice Aide to do the transfer. Interview on 01/29/25 at 11:03 AM with Hospice LVN BB revealed she was the aide and the nurse assigned to Resident #4. She stated today 01/29/25 was the first-time meeting Resident #4. She stated she was covering for another hospice staff. She stated when she came in, she told the facility who she was visiting and obtained report from the charge nurse. She stated she was told about Resident #4's transfer. She stated Resident #4 was a one person assist. She stated she also got report last week from the resident's Case Manager, and she was told the resident was a one-person transfer. She stated she had access to Resident #4's hospice care plan, and the care plan only stated Resident #4 could transfer to the bed and the chair with assist, but she could not see by how many people and with what device. She stated she could get more information from her office. Hospice LVN BB stated when she was told Resident #4 was a one person transfer it was not specified whether to use a gait belt or not. She stated she only followed what the resident's care plan stated which was one person transfer. Hospice LVN BB stated if more information was required, the hospice company needed to be contacted to obtain the information. Interview on 01/29/25 at 11:51 AM with Hospice Aide CC revealed she was the hospice aide for Resident #5. She stated she visited Resident #5 five days a week. She stated when transferring Resident #5 from the bed to the wheelchair or the wheelchair to the bed, Resident #5 was able to hold onto her and able to stand. She stated Resident #5 was a one person assist for transfer. She stated it was unknown if any devices were needed to complete the transfer. Hospice Aide CC stated the charting system provided a summary of the patient's care. She stated for a transfer it did not specify if a gait belt was needed. She stated the facility had not provided any information if a gait belt was needed to transfer Resident #5. She stated any transfer training she had received was from her hospice company. Interview on 01/29/25 at 12:03 PM with RN I revealed when hospice came in to visit residents, the Hospice staff sometimes communicated with the nurse on duty; however, sometimes they did not because Hospice staff already knew the resident care. He stated he did not provide hospice staff any oversight on care or transfers. He stated the hospice aides should get the details of the care plan and any information regarding transfers and positioning from their hospice nurse. Interview on 01/29/25 at 12:20 PN with the Nurse Practitioner revealed Resident #3 was on hospice services and her orders and care were managed by hospice. She stated the day of the incident she was in the facility, and she gave orders for x-rays since Resident #3 needed one urgently but when results were back, she told staff to report to the hospice nurse. Interview on 01/29/25 at 12:24 PM with LVN Z revealed she had residents on her hall who were seen by hospice. LVN Z stated when the hospice staff visited, she provided them with report and gave them any updated information on the resident. She stated if the resident was two person assist, she would notify the hospice staff and would let them know to come get her when they were ready to transfer. She stated the only information she would provide the hospice staff would be any change of condition updates and if the resident was a one person or two persons assist. She stated she could not recall if they used any devices when transferring but they should use a draw sheet when repositioning or turning the resident. Interview on 01/29/25 at 1:33 PM with ADON B revealed when a hospice staff came to the facility, the charge nurse was responsible to provide report or any change of condition to the hospice staff. ADON B stated he was not sure if the facility staff provided any information regarding transfers or if they required the use of a gait belt when transferring a resident. He stated it was the responsibility of the hospice staff to ensure they knew the resident's care plan and if the resident was a one person or two person assist. ADON B stated it was the responsibility of the hospice company to in-service all hospice staff. He stated facility staff were in-serviced on repositioning and transfers after Resident #3's incident. He stated today (01/29/25) he contacted all hospice companies to let them know of the incident regarding repositioning and they expected for all hospice staff to be trained. ADON B stated he could not answer the question of who was responsible or who provided hospice staff of any oversight on care or transfer. Interview on 01/29/25 at 1:46 PM with ADON A revealed she had 9 residents on the secure unit. She stated when a hospice staff came in, they provided the hospice staff with any information regarding the resident. She stated the hospice staff reviewed the care plan on their own system and they knew if the resident was a one person, or two persons assist. ADON A stated if the hospice staff needed assistance with transfer they would assist. She stated it was unknown who provided training to the hospice staff. Interview on 01/29/25 at 2:05 PM with the DON revealed after Resident #3's incident, the facility had implemented education of facility staff regarding turning and repositioning/lifting extremities, monitoring for discomfort, abuse and neglect, and use of a draw sheet. She stated Hospice Aide K was removed from the facility. She stated Resident #3 was assessed, pain medication provided, a conference with the family and skin assessments were completed on all other hospice residents. She stated they also completed a QAPI meeting on 01/14/25. The DON stated the hospice companies were responsible for their own staff and checked for competencies and training. She stated she had not in-serviced any hospice staff and only completed a 1:1 with Hospice Aide K after the incident. She stated her expectations were for hospice companies to train their own staff, and when hospice staff visited, they must check in with the charge nurse to make sure the resident did not have any changes in their care plans. She stated prior to signing any contract with a hospice company the facility provided them with the facility expectations and their responsibilities. She stated one of the responsibilities was for them to train their staff. The DON stated her expectations were for staff to use a draw sheet when turning and repositioning a resident. She stated if a resident was not able to 100 percent transfer own their own, staff were expected to use a gait belt. She stated staff should know how to transfer a resident with the use of a [NAME] belt, it was part of their competencies. She stated the resident Kardex (a medical-patient information system) stated whether the resident was a one- or two-person transfer. She stated staff and residents should not be bear hugging each other when transferring. She stated hospice staff should follow their care plans and gait belts were part of their uniforms. She stated when a resident was a one-person transfer staff should use a gait belt for safety. The potential risk would be the resident falling or staff falling on top of the resident. A policy regarding Positioning and Transfers was requested; however, the DON stated the facility did not have a policy regarding Positioning and Transfers. Interview on 01/30/25 at 10:16 AM with the Assistant Rehabilitation Director revealed for a resident who needed assistance with transferring from a wheelchair to the bed or the bed to a wheelchair staff were recommended to use a gait belt. She stated when transferring a resident, if the staff must touch the resident to complete the transfer, they should use a gait belt. She stated the potential risk would be injury, or the resident falling. She stated if a resident needed to be repositioned on the bed staff should use a draw sheet. She stated it was not okay to use their arms to pull on them as it could cause injuries. She stated Resident #4 and Resident #5 were able to transfer but with the assistance of staff they could not transfer own their own. She stated it was recommended for staff to use a gait belt when transferring Resident #4 and Resident #5. This was determined to be an Immediate Jeopardy (IJ) on 01/29/24 at 3:40 PM. The Administrator and DON were notified. The Administrator was provided with the IJ template on 01/29/25 at 4:03 PM. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 01/30/25 at 12:13 PM and reflected the following: Actions Taken: For those Identified: Skin and pain evaluations were completed for Resident # 1 [4] & 2 [5] by the Licensed Nurse on 1/29/25. No skin alterations or pain was observed. To Identify Other Residents: Eighteen (18) residents were identified as being in Hospice Services in the center on 1/29/25. All were evaluated for skin alterations and pain by the licensed nurse on 1/29/25. All were evaluated for assistive devices to prevent accidents and harm to residents by the Licensed Nurse on 1/29/25. Education/ System Change: The center will ensure the necessary devices are available for positioning and transferring for Hospice Staff. On 1/29/25, the Director of Nursing/designee educated the Director of Nursing at the eight (8) Hospice Companies that are contracted to provide hospice services at the center that the Hospice Company will: o Have current clinical positioning and transferring competencies for their staff providing services in the center will be provided to the facility on [DATE]. o That their staff are to meet with the center's Licensed Nurse prior to providing care to discuss coordination of care per the resident's care plan including having and using the necessary assistive devices for positioning and transferring residents. All Hospice Staff will be educated by the Director of Nursing and/ or designee prior to working with the Hospice resident. Education will continue until all Hospice Staff have completed the required education. Beginning 1/29/25, and ongoing, new Hospice Staff will receive this training prior to providing care to the Hospice residents and transfer from bed to wheelchair competency will be completed. Education topics include: o Incidents & Accidents Facility Policy to include use of necessary assistive devices to prevent accidents o Use of necessary assistive devices for positioning and transferring per the resident's plan of care o Hospice staff will check in with licensed nurses upon arrival at the facility to review resident Kardex and ensure that necessary assistive devices are utilized during care to provide safe positioning and transfers o Gait/Transfer belt will be available to the Hospice staff in the resident room or in the unit and license nurse will ch [TRUNCATED]

Based on interview and record review, the facility failed to ensure the right to be free from abuse for 1 of 10 residents (Resident #2) reviewed for abuse. The facility failed to ensure Resident #2 was free from abuse when Resident #1 hit Resident #2 on both arms, causing a 9.0 cm x 6.0 cm bruise to the right forearm and a 11.0 cm x 7.0 cm bruise to the left forearm and a skin tear on the resident's middle finger, on [DATE] with a closed fist during a verbal altercation on the secured unit. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for abuse and psychological harm. Findings included: Record review of Resident #1's Quarterly MDS Assessment, dated [DATE], reflected the resident was a [AGE] year-old male who admitted on [DATE]. Resident #1 had diagnoses of dementia (disease that results in loss of memory, language problem, problem-solving and other thinking abilities that are severe enough to interfere with daily life), diabetes mellitus (disease that results in too much blood sugar in the blood), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Resident #1 also had a BIMS score of nine meaning the resident had moderate cognitive impairment. Resident #1's Quarterly MDS reflected the resident had physical and behavioral symptoms directed toward others one to three days per week. Record review of Resident #1's EHR reflected Resident #1 was transferred to hospital on [DATE] for respiratory issues and did not return to the facility. Record review of Resident #1's Care Plan, dated [DATE], reflected Resident #1 was an elopement risk/wanderer relating to impaired safety awareness, wanders. Resident #1's care plan reflected Resident #1 had the potential to be physically aggressive towards others. The care plan reflected on [DATE] peer backed into Resident #1's wheelchair and Resident #1 kicked his peer causing his peer to fall. Resident #1 stated he would do it again, and next time hit his peer with his fist. Resident #1's goal was not to harm self or others through the review date. The care plan reflected interventions for Resident #1 included: educated on inappropriate behavior initiated on [DATE], administer medications as ordered, analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document, assess and address for contributing sensory deficits, assess Resident #1's needs including pain, food, give resident choices about care and activities, provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated, modify environment, psychiatric consult as indicated, and intervene before agitation escalates including guide away from source of distress and engage calmly in conversation (if aggressive walk away calmly). The care plan did not reflect any physical aggressive incidents in August and therefore did have any new interventions following the incident Resident #2. Resident #1 refused to be assessed. Record review of Resident #2's Quarterly MDS Assessment, dated [DATE], reflected Resident #2 was a [AGE] year-old male at the time of the incident. Resident #2 was admitted on [DATE] with diagnoses of Alzheimer's disease (disease that results in loss of memory, language problem, problem-solving and other thinking abilities that are severe enough to interfere with daily life), non-Alzheimer's disease (disease that results in loss of memory, language problem, problem-solving and other thinking abilities that are severe enough to interfere with daily life), cerebrovascular accident (damage to the brain from interruption of its blood supply), and hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles). The MDS reflected physical behavior symptoms and other behavior symptoms toward others one to three days per week. Record review of Resident #2's Care Plan dated, [DATE], reflected Resident #2 was dependent on staff for meeting his cognitive deficits and physical limitations. Resident #2's care plan also reflected that Resident #2 had an ADL self-care performance deficit relating to Alzheimer's, impaired mobility. Resident #2's care plan also reflected that Resident #2 had an impaired cognitive function/dementia or impaired thought processes relating to Alzheimer's, with disorganized thinking and episodes of inattention. Interventions included partial to maximal assist by staff. Record review of Resident #2's EHR reflected Resident #2 expired on [DATE]. Record review of the Provider Investigation Report dated [DATE] revealed on [DATE] that LVN D heard Resident #1 and Resident #2 yelling at each other and slapping at each other. The report reflected LVN D witnessed Resident #1 strike Resident #2 with a closed fist to his forearms. Both residents were immediately separated and monitored for behaviors or agitation. The report also reflected supervision was increased with both residents becomnig calm. Resident #2 had a small skin tear to left middle finger and bruising to bilateral forearms. Resident #2 had a 9 x 6 cm bruise to the right forearm and 11 x 7 cm bruise to left forearm. The report further reflected following the incident Resident #1 was assisted by the Social Worker in finding alternate placement, and the facility provided education to staff regarding managing behaviors and abuse/neglect. Record review of witness statement dated [DATE] reflected LVN D heard Resident #1 and Resident #2 yelling at each other and slapping at each other. Provider Investigation Report also revealed LVN D witnessed Resident #1 then begin striking Resident #2 with a closed fist to his forearms. Both residents were immediately separated. Both men were calmed down and stayed in respective areas of separation. No further altercations were noted. Interview on [DATE] at 2:30 PM revealed CNA C saw Resident #1 and Resident #2 in their wheelchairs. CNA C said he heard the noise and turned around and separated the residents. CNA C stated he did not recall any specific details of the incident because it was five months ago. Interview via telephone on [DATE] at 10:45 AM with LVN D revealed she observed Residents #1 and #2 in front of her in the dining room. LVN D stated Resident #1 said, If you don't stop talking, I am going to hit you to Resident #2. LVN D said Resident #2 did not stop talking, and Resident #1 hit Resident #2. LVN D stated she notified the ADON and the family. LVN D revealed she could not recall the exact date of her last in-service on resident-to-resident altercations and abuse and neglect, but she knew it was recently and immediately following this incident. LVN D stated when the altercation began, she attempted to get to the residents as fast as she could. LVN D separated the residents and completed the assessment on Resident #2. Resident #1 was non-compliant and refused to be assessed. LVN D did not say if she knew what to do with Resident #1 if he became aggressive prior to the incident. Interview on [DATE] at 1:57 PM with ADON A revealed she was notified about the incident after it had occurred. ADON A stated as best as she could remember that Resident #2's wheelchair hit Resident #1's wheelchair. ADON A said Resident #1 then hit Resident #2. Interview on [DATE] at 4:14 PM with DON revealed the DON retrieved the Provider Investigation Report and read it. She revealed she did not recall any other information. Record review of the facility's Abuse, Neglect, and Exploitation policy, revised on implemented on [DATE], reflected: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Prior to the HHSC investigation, the facility took the following actions to correct the noncompliance: Incident/Accident log was reviewed with no issues noted. Grievances were reviewed with no issues noted. The facility did not complete a safe survey following the incident on the secured unit. Both residents were discharged prior to the investigation, so they could not be interviewed regarding the incident. In-Service with staff on Abuse and Neglect and Managing Behaviors with Dementia on [DATE] initiated from DON to all facility staff and completed. Interview on [DATE] at 11:31 AM with CNA E revealed she would first separate the residents. Then she would report the incident to her charge nurse. CNA E stated they attempt to keep residents who do not get along from sitting together to prevent altercations. CNA E stated she was last in-serviced on last Monday on abuse and neglect and resident to resident abuse. CNA stated the types of abuse are physical, mental, sexual, emotional, and verbal. CNA stated she would report abuse to the administrator who was the Abuse Coordinator. Interview on [DATE] at 11:45 AM with CNA F revealed she would first separate residents who were in an altercation. CNA F stated the three types of abuse are physical, mental, and emotional. CNA F said signs of abuse could be residents isolating themselves, changes in behaviors, crying, and outbursts. CNA F stated she would report these changes in behavior to her charge nurse, her ADON, and her Abuse Coordinator (Administrator). Interview on [DATE] at 6:08 PM with LVN G revealed when residents had behaviors, they should be separated first. LVN G stated an incident report was completed after the residents were assessed. LVN G revealed after an altercation, the residents' family members were notified as well as management. LVN G stated she was last in-serviced last week on abuse and neglect and resident -to-resident behaviors. Interview on [DATE] at 6:49 PM with CNA H revealed staff tried to keep residents apart when they did not get along. CNA H stated when resident had an altercation, she would report it to her charge nurse. CNA H could not recall the last in-service on resident-to-resident altercations and abuse and neglect in-services. Interview on [DATE] at 1:48 PM with RN I revealed residents should be separated if they had an altercation. RN I stated the residents should then be assessed for injuries, and the incident report should be completed. RN I said the families should be notified of the incident. RN I stated he was last in-serviced about a week ago on resident-to-resident abuse.

Based on observation, interview, and records review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 4 residents (Resident #1) reviewed for pain management. The facility failed to obtain physician orders for the intrathecal pain pump from the Pain Physician for Resident #1 upon admission on 09/07/24 for immediate care and needs. After the orders were obtained, the facility failed to assist Resident #1 with a patient controlled bolus as needed for breakthrough pain via a surgically implanted pain pump per the Pain Medicine Physician Orders dated 09/10/24 at 2:25 PM. The facility failed to assist Resident #1 with a patient controlled bolus (a single dose of a drug or other medicinal preparation given all at once) of a combination pain medication infusion (Baclofen 15.0 mcg [skeletal muscle relaxant]; Hydromorphone 2.73 mcg [treats moderate to severe pain]; Clonidine 0.511 mcg [for post-spinal cord injury related pain]; and Droperidol 0.273 mcg [to prevent nausea and vomiting]), every 6 hours as needed for breakthrough pain via an intrathecal pain pump (a surgically implanted device that delivers medication directly to the fluid surrounding the spinal cord) on 09/07/24 - 09/13/24. Resident #1 could self-administer the bolus dose by pressing the button on a personal therapy manager device but the device was kept out of the resident's reach . The facility failed to assess and evaluate Resident #1 for pain. Upon admission on 09/07/24, Resident #1 verbalized pain and requested assistance with the patient controlled bolus via the pain pump. Resident #1 verbalized pain and requested assistance with the pain medication for 7 days (09/07/24 - 09/13/24). Resident #1 received her first patient controlled dose of pain medication for breakthrough pain on 09/14/24 at 9:27 PM. Resident #1's pain level ranged between a 6 to an 8 out of 10 from 09/07/24 to 09/14/24. An IJ was identified on 09/15/24. The IJ template was provided to the facility on [DATE] at 5:00 PM. While the IJ was removed on 09/17/24, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could cause residents on pain medications to experience unnecessary pain, an abnormal response to pain, or serious harm. Findings included: Record review of Resident #1's Admission MDS assessment, dated 09/11/24, reflected a [AGE] year-old female who admitted from an inpatient rehabilitation hospital to the facility on [DATE] with diagnoses: Neuromuscular Dysfunction of Bladder (urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem); Osteoporosis (a bone disease that causes bones to become brittle and break easily); Quadriplegia, incomplete (weakness or paralysis of all four limbs); Pressure ulcer of sacral region, stage 4; Pressure ulcer of unspecified buttock, stage 4; and Anxiety. A BIMS score of 15 suggested Resident #1 was cognitively intact. Resident #1 required maximum assistance to total dependence for ADLs. Section J - Health Conditions of the Admission MDS assessment reflected Resident #1 received scheduled pain medication. Response(s) in the pain assessment interview revealed No to pain presence. All other questions related to pain were skipped based on the answer No if [Resident #1] had pain or hurting at any time in the last 5 days? A response was not selected if the Staff Assessment for Pain be Conducted? Record review of Resident #1's Order Summary Report, dated 09/14/24 at 2:06 PM, reflected: - Order date 09/07/24: Vital signs every shift. [BP, Temp, Pulse, Resp, O2 Sats, Pain Level] - Order date 09/07/24: Monitor for pain every shift. Use 0 - 10 scale for alert residents. - Order date 09/07/24: Gabapentin Capsule 300 mg. Give 2 capsules by mouth two times a day for Neuropathy (nerve damage condition). - Order date 09/07/24: Gabapentin Capsule 300 mg. Give 4 capsules by mouth at bedtime for Neuropathy. - Order date 09/07/24: Myrbetriq extended release 24-hour tablet [NO DOSE]. Give 1 tablet by mouth two times a day for Bladder Spasms. - Order date 09/07/24: Pyridium 100 mg tablet. Give 2 tablets by mouth as needed for urinary discomfort TID. - Order date 09/10/24 (The DON discontinued this order after surveyor intercession on 09/14/24): DO NOT give bolus on resident's Pain Pump. - Order date: 09/14/24 (The DON discontinued this order after surveyor intercession on 09/14/24): Resident has pain pump RLQ that delivers: Baclofen, hydromorphone, clonidine and Droperidol. Staff is not to access pump. Pump is to be refilled prior to 12/07/24. Must contact pain management if dislodged or malfunctioning. - Order date: 09/14/24 (The DON entered this order after surveyor intercession on 09/14/24): Resident has pain pump RLQ that delivers: Baclofen 285.1 mcg, hydromorphone 51.83 mcg, clonidine 9.719 mcg and Droperidol 5.183 mcg/24 hours. Pump is to be refilled prior to 12/07/24. Must contact pain management if dislodged or malfunctioning. - Order date: 09/14/24 (The DON entered this order after surveyor intercession on 09/14/24): Baclofen Solution 15 mcg via implant every 6 hours as needed for Pain related to Quadriplegia. Supervised self-administration bolus includes Hydromorphone 2.73 mcg, clonidine 0.511 mcg and Droperidol 0.273 mcg. Place personal therapy manager device on implanted device to RLQ so she [Resident #1] can self-administer medication bolus. Record review of the Pain Medicine Physician Orders faxed to the facility on [DATE] at 2:24 PM, effective 04/15/24, reflected: - A simple continuous 24-hour pain medication infusion (Baclofen 2,200.0 mcg/mL; Hydromorphone 400.0 mcg/mL; Clonidine 75.0 mcg/mL; and Droperidol 40.0 mcg/mL) in a 39.0 mL reservoir. - The 24 hour dose infused Baclofen 10.8 mcg/hr (259.8 mcg/day); Hydromorphone 1.97 mcg/hr (47.25 mcg/day); Clonidine 0.369 mcg/hr (8.859 mcg/day); and Droperidol 0.197 mcg/hr (4.725 mcg/day). - The bolus dose infused Baclofen 15.0 mcg; Hydromorphone 2.73 mcg; Clonidine 0.511 mcg; and Droperidol 0.273 mcg, 1 bolus every 6 hours as needed for breakthrough pain. The bolus duration was for 1 minute. There was a 6-hour bolus restriction window (lockout duration 6 hours). Record review of Resident #1's Baseline care plan, printed 09/14/24 at 3:24 PM, reflected: - [Resident #1] was on pain medication therapy (Date initiated: 09/07/24; Revised on 09/14/24). Interventions initiated on 09/07/24 included, Ask physician to review medication if side effects persist; For respiratory depression: Monitor respiratory rate, depth, and effort after administration of pain medications; Monitor/document/report PRN adverse reactions to analgesic therapy .; and Review for pain medication efficacy . The goal reflected [Resident #1] will be free of any discomfort or adverse side effects from pain medication through the review date. - Interventions added (revised) by the DON on 09/14/24 after surveyor intercession: Administer po Analgesic medications as ordered by physician. Monitor/document side effects and effectiveness every shift; Facility Dr. offered to switch to PO medications; Resident has pain pump. Staff is not to access must go see pain mgmt. doctor when needed if pump not functioning or dislodged contact MD and pain management doctor. Pump delivers: Baclofen, hydromorphone, clonidine and Droperidol. Needs refill prior to 12/07/24. Record review of Resident #1's September 2024 MAR reflected nurse initials that attested to medication/treatment administration as ordered on 09/07/24 - 09/14/24. The Baclofen Solution bolus was initiated on 09/14/24 at 9:27 PM. Pain monitoring every shift revealed zeros each shift (2:00 PM-10:00 PM and 10:00 PM-6:00 AM) on 09/07/24; three times a day (6:00 AM-2:00 PM, 2:00 PM-10:00 PM, 10:00 PM-6:00 AM) on 09/08/24 - 09/14/24. The pain level entered 09/14/24 10:00 PM-6:00 AM shift revealed 5 out of 10. The vital signs reflected zeros for the pain level on 09/07/24 - 09/13/24. Vital signs were not entered on 09/14/24 (6:00 AM-2:00 PM). The pain level was a 4 out of 10 on 09/14/24 (2:00 PM-10:00 PM). Record review of the Medication Reconciliation Report for discharge date d 09/03/24 at 4:49 PM, sent from the rehabilitation hospital, reflected an incomplete order for a Baclofen Pump. The order did not list the medications infused via the Baclofen pump, doses, or frequency. Record review of the Discharge Orders dated 09/07/24 did not reflect the Baclofen Pump. During an interview on 09/14/24 at 2:14 PM, LVN A said that she worked weekend doubles (6:00 AM-2:00 PM and 2:00 PM-10:00 PM) and was the admission nurse for Resident #1 on 09/07/24. LVN A said that she did not know about the pain pump until she performed the head-to-toe skin assessment. LVN A said the pain pump was located at the right lower quadrant of [Resident #1] abdomen. LVN A said that she brought it to the other nurse (RN B) she worked alongside. LVN A said that she had heard of a pain pump but did not have experience with hands-on medication administration via the pump. LVN A said that Resident #1 indicated she needed the bolus dose via the pain pump for pain. LVN A said she did not recall the pain level. LVN A could not explain why the admission pain assessment reflected Resident #1 did not have pain. During an interview on 09/14/24 at 4:28 PM, ADON C stated on 09/09/24, the 6:00 AM-2:00 PM nurse (LVN D) reported that Resident #1 asked for assistance with a bolus dose from the pain pump. ADON C said that he was unaware of the pain pump. ADON C said during the morning clinical meeting, the Medical Director (the facility PCP) stated that the nurses should not access the pain pump to administer a bolus dose. ADON C indicated that the facility was concerned about the amount of pain medication Resident #1 received and if the bolus was administered, Resident #1 could overdose. ADON C said that he completed the pain assessment on 09/09/24 and entered no pain because [Resident #1] had a pain pump and received medicine for pain. ADON C said that he did not ask Resident #1 her pain level. During an observation and interview on 09/14/24 at 4:59 PM, Resident #1 was observed in bed lying on her back, head of bed raised approximately 30 degrees, head propped on pillows. Resident #1 right hip off loaded and heel protectors on both feet. Resident #1 had partial movement of right hand and arm, limited movement of left hand, and paralyzed below the waist. Resident #1 was alert and oriented x 4 (to self, place, time, and situation). Resident #1 had a flat affect. Resident #1 verbalized a current pain level of 6 out of 10. Resident #1 described the pain as a constant dull ache, throbbing, burning, shooting, and stinging pain. Resident #1 said the pain was generalized and fluctuated between a 6-8 out of 10 during various times on 06/07/24 - 06/14/24. Resident #1 said her pain level was a 3-4 out of 10 when her pain was managed. Resident #1 said when the pain level increased it could be persistent if not controlled by the bolus dose of medicine from her pain pump. Resident #1 said that she could activate the bolus dose by pressing the button on a personal therapy manager device if it was within reach, or if necessary, could teach the staff what to do. Resident #1 said that she asked the nurse (LVN A) to assist her with the bolus dose for pain on the day she admitted (09/07/24). Resident #1 said that LVN A told her that she [LVN A] needed to check with another nurse because she was not familiar with the pain pump. Resident #1 said that she asked the next shift (09/07/24 at 10:00 PM-6:00 AM) to assist with the bolus dose for pain but the nurse told [Resident #1] she could not assist with the bolus administration. Resident #1 said the facility PCP visited on 09/08/24 and said that it was unusual for nurses to administer extra doses from the pump because the pump infused pain medication for 24 hours and an extra dose was not possible. Resident #1 said that the facility PCP said that he could order her something to take as needed by mouth for pain. Resident #1 said she told the facility PCP she could show the facility staff how to activate the bolus dose if she [Resident #1] was not allowed to self-administer. Resident #1 said she asked the nurse on the evening shift (09/08/24 on 10:00 PM-6:00 AM) to assist with the bolus dose for pain and the nurse said she would check with the facility PCP. Resident #1 said that she asked the charge nurse on Monday, 09/09/24 (6:00 AM-2:00 PM) to assist with the bolus dose for pain and the nurse (LVN D) said he would have to ask someone what he should do. Resident #1 said (LVN D) did not come back for 1 and 1/2 hours and told her that he forgot. Resident #1 said (LVN D) never acknowledged her request or offered alternative pain measures during his shift. Resident #1 said that the facility PCP visited on 09/09/24 and offered Dilaudid to take by mouth as needed for pain. Resident #1 said she declined because it was against her pain medication doctors advise and did not feel comfortable with taking other medications in addition to the pain pump for fear she could overdose. Resident #1 said that if her pain was not managed, she could experience AD (Autonomic Dysreflexia a life-threatening condition that can occur in people who have had a spinal cord injury. It is an abnormal response to pain or discomfort). Resident #1 said that she had not received the bolus dose from 09/07/24 - 09/14/24. Resident #1 said that the personal therapy device was in the top drawer of the nightstand. The personal therapy device was packed inside a travel case. Resident #1 said no one asked how to administer the bolus dose or asked about the personal therapy device. During an interview on 09/14/24 at 5:35 PM, the facility PCP said that he was Board Certified for Pain Management, and he did not know of a pain pump that allowed the patient to self-administer a bolus dose of medicine. The facility PCP said that he talked with Resident #1 about alternative pain measures and was willing to write a prescription for Dilaudid that Resident #1 could take by mouth as needed every 6 hours for pain. The facility PCP said that Resident #1 refused, and he told her he could write an order for whatever she wanted to take for breakthrough pain. The facility PCP offered to write a prescription for Dilaudid (the brand name for hydromorphone) that belonged to a class of drugs called opioids for breakthrough pain as needed. The facility PCP said that he told Resident #1 that he would also order Narcan in case she had an overdose from the medications. The facility PCP said that he asked the charge nurse (LVN D) on Monday (09/09/24) to contact the pain doctor and get a list of medications that were infused via the pain pump so he could write an order for pain medication that would not interact. The facility PCP did not ask Resident #1 how the bolus dose was administered. Record review of Hydromorphone (2023) revealed hydromorphone (Brand name: Dilaudid) is utilized to effectively manage and treat moderate-to-severe pain and severe chronic pain in patients. Hydromorphone also exerts its effects centrally, leading to respiratory depression, interactions, and potential toxicity. Objectives included to screen patients for contraindications, potential risks, and drug interactions before prescribing; and collaborate with interprofessional healthcare team members to monitor for adverse effects and to ensure comprehensive patient care. Abi-Aad KR, [NAME] A. Hydromorphone. [Updated 2023 [DATE]]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470393/ During an interview on 09/14/24 at 6:30 PM, the DON said she did not know that Resident #1 had a pain pump prior to admission. The DON said the facility did not typically accept residents with pain pumps. The DON said the Clinical Liaison/Marketer made the decision about residents who could admit to the facility. The DON denied that she reviewed the clinicals (pre-admission paperwork) to make an informed decision about potential residents for admission. The DON said that she did not learn about the pain pump until Tuesday (09/10/24) and that was when she entered the order to Do Not access resident pain pump. The DON said that she had not assessed or evaluated Resident #1's pain level. The DON said that she did not speak with Resident #1 to obtain more information about the pain pump or how to administer the bolus dose. During an interview on 09/15/24 at 10:30 AM, the DON said that she conducted a self-administration medications assessment with Resident #1. The DON said that the staff should have inquired more about the bolus dose and how Resident #1 would administer the dose. The DON said that the staff should have conducted a self-administration medication assessment once it was determined Resident #1 had a patient-controlled option with the pain pump. The DON said that Resident #1 demonstrated the ability to administer the bolus dose with the assistance by nurses to place the device within reach. The DON said that she updated the orders to reflect the medication, dose, and frequency on the administration record and the PRN dose every six hours. During an interview on 09/15/24 at 1:57 PM, RN B said that she was not assigned to and did not provide direct care to Resident #1. RN B said that she assisted LVN A with Resident #1's admission (on 09/07/24). RN B said that she entered the orders from the Discharge Medication Orders and the orders did not reflect the pain pump or the medications infused via the pain pump. RN B said that it was important to know the medications, even if the nurses did not physically administer, to reflect the medications on the medication profile for the Pharmacy to review for interactions, and to have a full clinical picture of a resident. RN B said that best practice would be to contact the pain management physician for orders related to the pain pump. Record review of the facility's Physician Visits and Physician Delegation policy, implemented 10/24/22, reflected the Physician must provide orders for the resident's immediate care and needs. Record review of the facility's Self-Administration of Medications policy, revised 10/01/19, reflected the facility's overall goal to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team determined that the practice would be safe. Procedure: An assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility. For residents who self-administer, the interdisciplinary team verifies the resident's ability to self-administer medications by means of a skill assessment conducted on a quarterly basis or significant change in condition. Review of the facility's Pain Management Program Policy revised January 2023, indicated the facility will ensure that residents receive the treatment and care in accordance with professional management. The Nurse will assess the resident q shift for pain, depending on the type of resident being assessed, using the PAINAD or [NAME] Pain Evaluation Scale as indicated on the MAR. If a resident is assessed as experiencing pain during that shift, then pain medication and or alternative therapies should be administered as ordered. Effectiveness of the intervention should be documented to determine if pain is reduced or alleviated appropriately. The DON and the RCS were notified of an Immediate Jeopardy (IJ) on 09/15/24 at 5:00 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal (POR) was accepted on 09/16/24 at 6:27 PM and included: September 15, 2024 [Name of Facility] LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Attention Sir or Madam: On September 15, 2024, the Facility was notified by the surveyor that immediate jeopardy had been called and the Facility needed to submit a letter of removal. The Facility respectfully submits this Letter for a Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy is as follows: Issue: F697 Pain Management 1.The facility failed to obtain admission medication orders for a surgically implanted device that delivers medication directly to the spinal cord to help control chronic pain. The surgically implanted device delivers pain medication solution at a continuous rate and an on-demand dose as needed for breakthrough pain. The on-demand dose must be manually administered by pushing a button to tell the surgically implanted device to administer an as needed dose. 2. The facility failed to assist the resident with the on-demand dose by placing the on-demand button out of the reach of the resident. 3. The facility ordered do not give bolus (on demand) on resident's pain pump. 4. The facility physician recommended Dilaudid pain medication by mouth for breakthrough pain instead of allowing the resident to self-administer pain medication from the surgically implanted device. (Taking Dilaudid and the medication ([Baclofen (muscle relaxer) /Hydromorphone (opioid medication to treat moderate to severe pain) /Clonidine (alternative use for chronic pain) /Droperidol (prevents nausea and vomiting)] can lead to serious side effects such as profound sedation, respiratory distress, coma, and death). 5. The facility failed to conduct a self-administration medication assessment to determine if the resident was capable of self-administering the on-demand dose of pain medication via the surgically implanted device. 6. The facility failed to provide pain management to a resident experiencing pain that was in accordance with the care plan and resident's goals for care and preferences. Actions Taken: For those Identified: Resident # 1 was assessed for signs and symptoms of pain by the Licensed Nurse on 9/15/24 - her pain level was a 6. After medication administration, pain level assessed as effective. Order for prn bolus is every 6 hours was entered in the PCC orders 9/15/24. Self-Administration of meds was completed 9/14/24 for resident involved. Pain care plan was updated by DON/ designee 9/14/24. Included signs and symptoms of medication side effects, pain medication therapy, chronic pain, pain pump management. To Identify Other Residents: No other residents in the center have a pain pump. All residents have been evaluated for pain beginning 9/15/24. All residents' pain needs are being met. No other residents were identified as affected by failure to manage residents' pain. Education/ System Change: Director of Nursing or designee educated the licensed nurses on the following educational components beginning 9/15/24: o Medication orders need to include; name of medication, dosage, frequency of administration and route o Pain Management includes evaluation of pain and administering medication as ordered by the attending physician. o If a medication is unavailable and you can obtain from E-Kit. o Nursing staff training on use of implanted pain pump use o Completion of the self-administration of medication evaluation All Licensed Nurses will be educated by the Director of Nursing and/ or designee prior to working their next shift. Education will continue until all Licensed Nurses have completed the required education. The Licensed Nurses that are PRN (as needed) and/or out on FMLA/LOA will have the education completed prior to working their next scheduled shift before providing care to residents. Beginning 9/15/24, and ongoing, newly hired Licensed Nurses will receive this training during orientation prior to providing care to the residents. Director of Nursing educated by the regional clinical specialist on 9/15/24. Administrator educated by the regional clinical specialist on 9/16/24. The training will include the above-stated educational components. The Director of Nursing and/ or designee will review new admissions in the morning clinical meeting to review new admission and reconcile new admission orders. Education provided by the regional clinical specialist on 9/15/24. On 9/15/24, an Ad Hoc QAPI meeting was held with the Medical Director, facility Administrator, Director of Nursing, and Regional Clinical Specialist to review the IJ Template and the Plan for Removal. Monitoring: Beginning 9/15/24 and going forward, The Director of Nursing/ designee will review new admissions for residents that may have implanted pain pumps to ensure necessary assessment, orders, notifications, and care plans are implemented. The Director of Nursing will monitor to ensure the process is in place daily (Monday-Friday) for three months, and the weekend supervisor on Saturday and Sunday. Education provided by regional clinical specialist on 9/15/24. Trends will be presented and discussed in the monthly QAPI meeting for three months. On 09/16/24 the investigator began monitoring if the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of Resident #1's self-administration of medication assessment performed on 09/14/24 at 8:27 PM revealed Resident #1's ability to self-administer the bolus dose via pain pump, knowledge of medications and side effects, understanding that there is a 6-hour lock out, and was cognitively intact to self-administer the bolus dose via the pain pump. Record review of Resident #1's Active Order History reflected the medications infused via the pain pump, dose, frequency, and the PRN bolus dose every 6 hours. The staff are to assist by placing the device within Resident #1's reach and provide standby assistance as needed. Record review of Resident #1's September 2024 MAR reflected a PRN bolus dose (Baclofen 15.0 mcg; Hydromorphone 2.73 mcg; Clonidine 0.511 mcg; and Droperidol 0.273 mcg) was administered on 09/14/24 at 9:27 PM. Record review of Resident #1's care plan printed 09/17/24, reflected updated interventions for pain management on 09/14/24. The interventions reflected pain pump management, pain medication therapy, and signs of medication side effects. On 09/17/24 (10:30 AM-11:00 AM), interviews with random residents revealed staff provided as needed pain medications or other pain relief alternatives in a timely manner. The residents denied unmanaged pain relief during their stay at the facility. During an observation and interview on 09/17/24 at 11:02 AM, Resident #1 was observed lying in a left lateral position in bed. With the assistance of (RN B), Resident #1 demonstrated how to self-administer the bolus medication via the pain pump when the nurse placed the device within reach. The screen of the device revealed it was too soon to administer a bolus. Resident #1 said that her current pain level was a 4 out of 10 and it was getting better. Resident #1 said that the goal was to maintain her pain level at a 2 or 3 out of 10 with the continuous infusion of medication via the pain pump. Record review of an in-service conducted by the RCS dated 09/15/24 with the NFA and DON reviewed care of residents with pain pumps and the management of pain pumps. Objectives of the in-service included necessary assessment(s), orders, notifications, and care plans. Record review of in-services conducted by the DON dated 09/15/24 with all nursing staff were on-going. Topics of the in-services included Policy on pain management, Intrathecal Pump, and Pain Assessments. Handouts that covered related policies and [Resident #1's specific] pain pump overview were provided to staff. The nursing staff were required to demonstrate how to assist Resident #1 with the personal therapy manager device and verbalized reportable signs and symptoms to ensure understanding of the information provided and steps of procedure. Interviews conducted with nurses scheduled (09/16/24 and 09/17/24) on the 6:00 AM-2:00 PM shift [LVN D and RN B], on the 2:00 PM-10:00 PM shift [RN E and RN C], 10:00 PM-6:00 AM shift [LVN G], and Weekend Doubles - 6:00 AM-2:00 PM and 2:00 PM-10:00 PM shift [LVN A] indicated they participated in the in-service trainings. The staff stated topics of discussion included pain management and how to care for a resident with a pain pump. Each nurse stated in their own words reportable concerns regarding the pain pump, signs and symptoms of pain, and pain assessment. During an interview on 09/17/24 at 11:38 AM, LVN D said he worked Monday - Friday 6:00 AM-2:00 PM shift. LVN D said Resident #1 was a new admission from over the weekend and on Monday, 09/09/24, while he conducted rounds, Resident #1 told [LVN D] that she needed something for pain and asked if [LVN D] would assist with the bolus dose from her pain pump. LVN D said he asked how to (administer the bolus dose via the pain pump) and Resident #1 replied that the device was in her nightstand drawer and needed somebody to give it to her. LVN D said that he never provided care to a resident with a pain pump in [AGE] years and was not familiar with a resident self-administering medication via a pain pump. LVN D said he told Resident #1 that he needed to speak with the doctor. LVN D said that Resident #1 stated she could demonstrate to the staff how to administer the bolus dose if needed. LVN D said on Tuesday (09/10/24) staff were informed not to administer the bolus dose via [Resident #1] pain pump. LVN D said that he did not know the reason why. LVN D said he requested the orders from the pain management physician (on 09/10/24) per the facility PCP request. LVN D said that he gave the (pain management physician) orders to the DON when they arrive via fax on 09/10/24. The DON and RCS were informed the Immediate Jeopardy was removed on 09/17/24 at 4:00 PM. The facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and records review, the facility failed to ensure that licensed nurses have the knowledge, competencies and skill sets to provide care and respond to each resident's individualized needs as identified in his/her assessment and care plan for one (Resident #1) of one resident reviewed for nursing care/services, in that: Prior to admission, the facility failed to determine the knowledge, competencies, or skill sets of nursing staff to meet the needs of Resident #1 with an intrathecal pain pump (a surgically implanted device that delivers medication directly to the fluid surrounding the spinal cord). The facility failed to educate, train, and assess nursing staff performance for the effective application of knowledge and skill provide competencies and skills sets necessary to provide care to Resident #1 who is a quadriplegic with chronic pain, a surgically implanted pain pump, and the risk of Autonomic Dysreflexia a life-threatening condition that can occur in people who have had a spinal cord injury, when there is unmanaged pain or discomfort. An IJ was identified on 09/15/24. The IJ template was provided to the facility on [DATE] at 5:00 PM. While the IJ was removed on 09/17/24, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could cause residents on pain medications to experience unnecessary pain, an abnormal response to pain, or serious harm. Findings included: Record review of Resident #1's Admission MDS assessment, dated 09/11/24, reflected a [AGE] year-old female who admitted from an inpatient rehabilitation hospital to the facility on [DATE] with Neuromuscular Dysfunction of Bladder (urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem); Osteoporosis (a bone disease that causes bones to become brittle and break easily); Quadriplegia, incomplete (weakness or paralysis of all four limbs); Pressure ulcer of sacral region, stage 4; Pressure ulcer of unspecified buttock, stage 4; and Anxiety. A BIMS score of 15 suggested Resident #1 was cognitively intact. Resident #1 required maximum assistance to total dependence for ADLs. Section J - Health Conditions of the Admission MDS assessment reflected Resident #1 received scheduled pain medication. Response(s) in the pain assessment interview revealed No to pain presence. All other questions related to pain were skipped based on the answer No if [Resident #1] had pain or hurting at any time in the last 5 days? A response was not selected if the Staff Assessment for Pain be Conducted? Resident #1's Order Summary Report, dated 09/14/24 at 2:06 PM, reflected: - Order date 09/07/24: Vital signs every shift. [BP, Temp, Pulse, Resp, O2 Sats, Pain Level] - Order date 09/07/24: Monitor for pain every shift. Use 0 - 10 scale for alert residents. - Order date 09/07/24: Gabapentin Capsule 300 mg. Give 2 capsules by mouth two times a day for Neuropathy (nerve damage condition). - Order date 09/07/24: Gabapentin Capsule 300 mg. Give 4 capsules by mouth at bedtime for Neuropathy. - Order date 09/07/24: Myrbetriq extended release 24-hour tablet [NO DOSE]. Give 1 tablet by mouth two times a day for Bladder Spasms. - Order date 09/07/24: Pyridium 100 mg tablet. Give 2 tablets by mouth as needed for urinary discomfort TID. - Order date 09/10/24 (The DON discontinued this order after surveyor intercession on 09/14/24): DO NOT give bolus on resident's Pain Pump. - Order date: 09/14/24 (The DON discontinued this order after surveyor intercession on 09/14/24): Resident has pain pump RLQ that delivers: Baclofen, hydromorphone, clonidine and Droperidol. Staff is not to access pump. Pump is to be refilled prior to 12/07/24. Must contact pain management if dislodged or malfunctioning. - Order date: 09/14/24 (The DON entered this order after surveyor intercession on 09/14/24): Resident has pain pump RLQ that delivers: Baclofen 285.1 mcg, hydromorphone 51.83 mcg, clonidine 9.719 mcg and Droperidol 5.183 mcg/24 hours. Pump is to be refilled prior to 12/07/24. Must contact pain management if dislodged or malfunctioning. - Order date: 09/14/24 (The DON entered this order after surveyor intercession on 09/14/24): Baclofen Solution 15 mcg via implant every 6 hours as needed for Pain related to Quadriplegia. Supervised self-administration bolus includes Hydromorphone 2.73 mcg, clonidine 0.511 mcg and Droperidol 0.273 mcg. Place personal therapy manager device on implanted device to RLQ so she [Resident #1] can self-administer medication bolus. Record review of the Pain Medicine Physician Orders faxed to the facility on [DATE] at 2:24 PM, effective 04/15/24, reflected: - A simple continuous 24-hour pain medication infusion (Baclofen 2,200.0 mcg/mL; Hydromorphone 400.0 mcg/mL; Clonidine 75.0 mcg/mL; and Droperidol 40.0 mcg/mL) in a 39.0 mL reservoir. - The 24 hour dose infused Baclofen 10.8 mcg/hr (259.8 mcg/day); Hydromorphone 1.97 mcg/hr (47.25 mcg/day); Clonidine 0.369 mcg/hr (8.859 mcg/day); and Droperidol 0.197 mcg/hr (4.725 mcg/day). - The bolus dose infused Baclofen 15.0 mcg; Hydromorphone 2.73 mcg; Clonidine 0.511 mcg; and Droperidol 0.273 mcg, 1 bolus every 6 hours as needed for breakthrough pain. The bolus duration was for 1 minute. There was a 6-hour bolus restriction window (lockout duration 6 hours). Record review of Resident #1's Baseline care plan, printed 09/14/24 at 3:24 PM, reflected: - [Resident #1] was on pain medication therapy (Date initiated: 09/07/24; Revised on 09/14/24). Interventions initiated on 09/07/24 included, Ask physician to review medication if side effects persist; For respiratory depression: Monitor respiratory rate, depth, and effort after administration of pain medications; Monitor/document/report PRN adverse reactions to analgesic therapy .; and Review for pain medication efficacy . The goal reflected [Resident #1] will be free of any discomfort or adverse side effects from pain medication through the review date. - Interventions added (revised) by the DON on 09/14/24 after surveyor intercession: Administer po Analgesic medications as ordered by physician. Monitor/document side effects and effectiveness every shift; Facility Dr. offered to switch to PO medications; Resident has pain pump. Staff is not to access must go see pain mgmt. doctor when needed if pump not functioning or dislodged contact MD and pain management doctor. Pump delivers: Baclofen, hydromorphone, clonidine and Droperidol. Needs refill prior to 12/07/24. Record review of Resident #1's September 2024 MAR reflected nurse initials that attested to medication/treatment administration as ordered on 09/07/24 - 09/14/24. Pain monitoring every shift revealed zeros each shift (2:00 PM-10:00 PM and 10:00 PM-6:00 AM) on 09/07/24; three times a day (6:00 AM-2:00 PM, 2:00 PM-10:00 PM, 10:00 PM-6:00 AM) on 09/08/24 - 09/14/24. The vital signs reflected zeros for the pain level on 09/07/24 - 09/13/24. Record review of the Medication Reconciliation Report for discharge date d 09/03/24 at 4:49 PM, sent from the rehabilitation hospital, reflected an incomplete order for a Baclofen Pump. The order did not list the medications infused via the Baclofen pump, doses, or frequency. Record review of the Discharge Orders dated 09/07/24 did not reflect the Baclofen Pump. During an interview on 09/14/24 at 2:14 PM, LVN A said that she worked weekend doubles (6:00 AM-2:000 PM and 2:00 PM-10:00 PM) and was the admission nurse for Resident #1 on 09/07/24. LVN A said that she was responsible for up to 17 residents on a regular basis during her shift(s). LVN A said she had enough time to complete required assignments each day. LVN A said that she did not know about the pain pump until she performed the head-to-toe skin assessment. LVN A said the pain pump was located at the right lower quadrant of [Resident #1] abdomen. LVN A said that she worked alongside with (RN B) who was a reliable resource to her. LVN A said that she asked RN B was she familiar with care of a resident with a pain pump. LVN A could not explain why the admission pain assessment reflected Resident #1 did not have pain. LVN A said that she had heard of a pain pump but did not have experience with hands-on medication administration via the pump. LVN A said that she did not receive training or in-services about pain pumps in her on-hire orientation. LVN A said she received report from the off-going nurse during change of shift. LVN A said the care plan would outline a resident care need(s). During an interview on 09/14/24 at 4:28 PM, ADON C stated on 09/09/24, the 6:00 AM-2:00 PM nurse (LVN D) reported that Resident #1 asked for assistance with a bolus dose from the pain pump. ADON C said that he was unaware that Resident #1 had a pain pump and was not experienced with providing care to a resident with a pain pump. ADON C said during the morning clinical meeting, the Medical Director (the facility PCP) stated that the nurses should not access the pain pump to administer a bolus dose. ADON C indicated that the facility was concerned about the amount of pain medication Resident #1 received and if the bolus was administered, Resident #1 could overdose. ADON C said that he completed the pain assessment on 09/09/24 and entered no pain because [Resident #1] had a pain pump and received medicine for pain. ADON C said that he did not ask Resident #1 her pain level. ADON C said that he did not receive training or in-services about pain pumps in his on-hire orientation or annual training(s). ADON C said that he reviewed the care plan to know if a resident required specific care need(s). During an observation and interview on 09/14/24 at 4:59 PM, Resident #1 observed in bed lying on her back, head of bed raised approximately 30 degrees, head propped on pillows. Resident #1 right hip off loaded and heel protectors on both feet. Resident #1 had partial movement of right hand and arm, limited movement of left hand, and paralyzed below the waist. Resident #1 was alert and oriented x 4 (to self, place, time, and situation). Resident #1 had a flat affect. Resident #1 verbalized a pain level of 6 out of 10. Resident #1 described the pain as a constant dull ache, throbbing, burning, shooting, and stinging pain. Resident #1 said the pain was generalized. Resident #1 said her pain level was a 3 - 4 out of 10 when her pain was managed. Resident #1 said when the pain level increased it could be persistent if not controlled by the bolus dose of medicine from her pain pump. Resident #1 said that she could activate the bolus dose by pressing the button on a personal therapy manager device if it was within reach, or if necessary, could teach the staff what to do. The Resident #1 said that she asked the nurse (LVN A) to assist her with the bolus dose on the day she admitted (09/07/24). Resident #1 said that LVN A told her that she [LVN A] needed to check with another nurse because she was not familiar with the pain pump. Resident #1 said that she asked the next shift (09/07/24 at 10P - 6A) to assist with the bolus dose but the nurse told [Resident #1] she could not assist with the bolus administration. Resident #1 said the facility PCP visited on 09/08/24 and said that it was unusual for nurses to administer extra doses from the pump because the pump infused medication for 24 hours and an extra dose was not possible. Resident #1 said that the facility PCP said that he could order her something to take as needed by mouth for pain. Resident #1 said she told the facility PCP she could show the facility staff how to activate the bolus dose if she [Resident #1] was not allowed to self-administer. Resident #1 said she asked the nurse on the evening shift (09/08/24 on 10:00 PM-6:00 AM) and the nurse said she would check with the facility PCP. Resident #1 said that she asked the charge nurse on Monday, 09/09/24 (6:00 AM-2:00 PM) to assist with the bolus dose and the nurse (LVN D) said he would have to ask someone what he should do. Resident #1 said (LVN D) did not come back for 1 and 1/2 hours and told her that he forgot. Resident #1 said (LVN D) never acknowledged her request or offered alternative pain measures during his shift. Resident #1 said that the facility PCP visited on 09/09/24 and offered Dilaudid to take by mouth as needed for pain. Resident #1 said she declined because it was against her pain medication doctors advise and did not feel comfortable with taking other medications in addition to the pain pump for fear she could overdose. Resident #1 said that if her pain was not managed, she could experience AD (Autonomic Dysreflexia a life-threatening condition that can occur in people who have had a spinal cord injury. It is an abnormal response to pain or discomfort). Resident #1 said that she had not received the bolus dose from 09/07/24-09/14/24. Resident #1 said that the personal therapy device was in the top drawer of the nightstand. The personal therapy device was packed inside a travel case. Resident #1 said no one asked how to administer the bolus dose or asked about the personal therapy device. During an interview on 09/14/24 at 5:35 PM, the facility PCP said that he was Board Certified for Pain Management, and he did not know of a pain pump that allowed the patient to self-administer a bolus dose of medicine. The facility PCP said that he talked with Resident #1 about alternative pain measures and was willing to write a prescription for Dilaudid that Resident #1 could take by mouth as needed every 6 hours for pain. The facility PCP said that Resident #1 refused, and he told her he could write an order for whatever she wanted to take for breakthrough pain. The facility PCP offered to write a prescription for Dilaudid (the brand name for hydromorphone) that belonged to a class of drugs called opioids for breakthrough pain as needed. The facility PCP said that he told Resident #1 that he would also order Narcan in case she had an overdose from the medications. The facility PCP said that he asked the charge nurse (LVN D) on Monday (09/09/24) to contact the pain doctor and get a list of medications that were infused via the pain pump so he could write an order for pain medication that would not interact. The facility PCP did not ask Resident #1 how the bolus dose was administered. Record review of Hydromorphone (2023) revealed hydromorphone (Brand name: Dilaudid) is utilized to effectively manage and treat moderate-to-severe pain and severe chronic pain in patients. Hydromorphone also exerts its effects centrally, leading to respiratory depression, interactions, and potential toxicity. Objectives included to screen patients for contraindications, potential risks, and drug interactions before prescribing; and collaborate with interprofessional healthcare team members to monitor for adverse effects and to ensure comprehensive patient care. Abi-Aad KR, [NAME] A. Hydromorphone. [Updated 2023 [DATE]]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470393/ During an interview on 09/14/24 at 6:30 PM, the DON said that she did not know that Resident #1 had a pain pump prior to admission. The DON said that the facility did not typically accept residents with pain pumps. The DON said that the Clinical Liaison/Marketer made the decision about residents who could admit to the facility. The DON denied that she reviewed the clinicals (pre-admission paperwork) to make an informed decision about potential residents for admission. The DON could not give a direct answer to how she determined the competency needed to meet each resident's needs each day and during emergencies. The DON could not give a direct answer to how she assured that staff were appropriately assigned to meet the needs of residents and implemented care-planned approaches for each resident on each shift and unit. The DON said that resident status and care plan appropriateness was discussed each morning during a clinical meeting. The DON said that nurses were assigned a preceptor during their on-board orientation and training. The DON said that the preceptor was responsible for assessment and observation of the new-hire nurse's skill sets and competencies. The DON said that nurses were assessed for different types of clinical skill sets such as, IV therapy, wound care, and catheter care. The DON could not state for sure if nurses were checked off for pain pump competency. The DON said that she was initially checked off for her competencies when she was hired. The DON did not recall if she was checked off for knowledge and understanding of pain pumps. The DON denied that staff, residents, or family members have brought about concerns related to staff competency. The DON said that the facility did not utilize temporary/contract staff. The DON said that PRN staff participated in the same training and in-services as full-time staff. During an interview on 09/15/24 at 1:57 PM, RN B said that she was not assigned to and did not provide direct care to Resident #1. RN B said that she assisted LVN A with Resident #1's admission (on 09/07/24). RN B said that she entered the orders from the Discharge Medication Orders and the orders did not reflect the pain pump or the medications infused via the pain pump. RN B said that it was important to know the medications, even if the nurses did not physically administer, to reflect the medications on the medication profile for the Pharmacy to review for interactions, and to have a full clinical picture of a resident. RN B said that best practice would be to contact the pain management physician for orders related to the pain pump. RN B said that she provided care to residents with a pain pump before, however, never experienced a resident with a pain pump that had patient-controlled bolus doses. RN B said that she did not receive training or in-services about pain pumps during her on-hire orientation or annual training(s). RN B said that she familiarized herself with a resident care need(s) by reviewing the care plan and orders. RN B said that if it was a resident was a new admission, she reviewed the discharge paperwork from the transferring facility to learn more about the resident. Review of the Facility Assessment Tool dated 08/22/24 reflected services provided included Pharmacy ancillary services (medical services that are not provided by acute care hospitals, doctors, or health care professionals). General care for pain management included assessment of pain, pharmacological and nonpharmacological pain management. General care for medication administration included administration of medications that residents need by intravenous route. The Facility Assessment Tool revealed residents present in the facility included special care needs -quadriplegia and clinical needs - IV therapy and transfusions. The clinical profile reflected residents with intravenous therapy, on pain management program, and on opioids. Record review of RN/LVN Orientation Skills Checklists (signed and dated when completed) for licensed nurses did not reflect competency skills/duties for medication administration via intrathecal administration (A parenteral route, intravenous administration of nutrition and medications by bypassing the gastrointestinal system) pain pump, demonstrated proficiency or understanding. Review of the facility's Nursing Services and Sufficient Staff policy implemented 10/24/22, reflected the facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for resident's needs as identified through resident assessments and described in the plan of care. Providing care includes, but is not limited to, assessing, evaluating, planning, and implementing resident care plans and responding to resident's needs. The DON and the RCS were notified of an Immediate Jeopardy (IJ) on 09/15/24 at 5:00 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal (POR) was accepted on 09/16/24 at 6:27 PM and included: September 15, 2024 [Name of Facility] LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Attention Sir or Madam: On September 15, 2024, the Facility was notified by the surveyor that immediate jeopardy had been called and the Facility needed to submit a letter of removal. The Facility respectfully submits this Letter for a Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy is as follows: Issue: F726 Competent Nursing Staff Prior to admission, the facility failed to determine if they could meet the needs of a resident with a surgically implanted device that delivers pain medication directly to the spinal cord. The facility failed to provide competencies and skill sets necessary to provide nursing services related to admission orders for a resident receiving pain medication via a surgically implanted device. The facility failed to provide competencies and skill sets necessary to ensure each resident has an accurate medication profile. The facility failed to provide competencies and skill sets necessary to provide nursing services related to care of a resident with a surgically implanted device that administers pain medication. The facility failed to provide competencies and skill sets necessary to provide nursing services for pain assessment and pain management. The facility failed to provide competencies and skills sets necessary to ensure the resident has the right to be pain free. The facility failed to provide competencies and skill sets necessary to have a resident participate in care. The facility failed to provide competencies and skills sets necessary to assess if a resident is able to self-administer medications. Actions Taken: For those Identified: Resident # 1 was assessed for signs and symptoms of pain by the Licensed Nurse on 9/15/24 - her pain level was a 6. After medication administration, pain level assessed as effective. Order for prn bolus is every 6 hours was entered in the PCC orders 9/15/24. Self-Administration of meds was completed 9/14/24 for resident involved. Pain care plan was updated by DON/ designee 9/14/24. Included signs and symptoms of medication side effects, pain medication therapy, chronic pain, pain pump management. To Identify Other Residents: No other residents in the center have a pain pump. All residents have been evaluated for pain beginning 9/15/24. All residents' pain needs are being met. No other residents were identified as affected by failure to manage residents' pain. Education/ System Change: Director of Nursing or designee educated the licensed nurses on the following educational components beginning 9/15/24: o Pain Management includes evaluation of pain and administering medication as ordered by the attending physician. o If a medication is unavailable and you can obtain from E-Kit. o Nursing staff training on use of implanted pain pump use o Completion of the self-administration of medication evaluation o The regional clinical specialist educated the director of nursing and admissions director on 7/15/24 for reviewing preadmission screening and admission documents as much as they are available prior to admission. All Licensed Nurses will be educated by the Director of Nursing and/ or designee prior to working their next shift. Education will continue until all Licensed Nurses have completed the required education. The Licensed Nurses that are PRN (as needed) and/or out on FMLA/LOA will have the education completed prior to working their next scheduled shift before providing care to residents. Beginning 9/15/24, and ongoing, newly hired Licensed Nurses will receive this training during orientation prior to providing care to the residents. Director of Nursing educated by the regional clinical specialist on 9/15/24. Administrator educated by the regional clinical specialist on 9/16/24. The training will include the above-stated educational components. The Director of Nursing and/ or designee will review new admissions in the morning clinical meeting to review new admission and reconcile new admission orders. Education provided by the regional clinical specialist on 9/15/24. On 9/15/24, an Ad Hoc QAPI meeting was held with the Medical Director, facility Administrator, Director of Nursing, and Regional Clinical Specialist to review the IJ Template and the Plan for Removal. Monitoring: Beginning 9/15/24 and going forward, The Director of Nursing/ designee will review new admissions for residents that may have implanted pain pumps to ensure necessary assessment, orders, notifications, and care plans are implemented. The Director of Nursing will monitor to ensure the process is in place daily (Monday-Friday) for three months, and the weekend supervisor on Saturday and Sunday. Education provided by regional clinical specialist on 9/15/24. Trends will be presented and discussed in the monthly QAPI meeting for three months. Beginning 9/16/24, the administrator will ensure that the director of nursing and the admissions coordinator are reviewing preadmission screening and admission documents prior to admission to ensure that medication orders / equipment / DME are available upon admission for resident condition. On 09/16/24 the investigator began monitoring if the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of an in-service conducted by the RCS dated 09/15/24 with the NFA and DON discussion overview included preadmission screening and admission documents reviewed prior to resident admission. Objectives of the in-service included necessary assessment(s), orders, notifications, and care plans for residents with pain pumps. Record review of in-services conducted by the DON dated 09/15/24 with all nursing staff were on-going. Topics of the in-services included Policy on pain management, Intrathecal Pump, and Pain Assessments. Handouts that covered related policies and [Resident #1's specific] pain pump overview were provided to staff. The nursing staff were required to demonstrate how to assist Resident #1 with the personal therapy manager device and verbalized reportable signs and symptoms to ensure understanding of the information provided and steps of procedure. During an observation and interview on 09/17/24 at 11:02 AM, Resident #1 was observed lying in a left lateral position in bed. With the assistance of the nurse, Resident #1 demonstrated how to self-administer the bolus medication via the pain pump when the nurse placed the device within reach. The screen of the device revealed it was too soon to administer a bolus. Resident #1 said that her current pain level was a 4 out of 10 and it was getting better. Resident #1 said that the goal was to maintain her pain level at a 2 or 3 out of 10 with the continuous infusion of medication via the pain pump. During an interview on 09/17/24 at 11:38 AM, LVN D said he worked Monday-Friday 6:00 AM-2:00 PM shift. LVN D said Resident #1 was a new admission from over the weekend and on Monday, 09/09/24, while conducted rounds, Resident #1 told [LVN D] that she needed something for pain and asked if [LVN D] would assist with the bolus dose from her pain pump. LVN D said he asked how to (administer the bolus dose via the pain pump) and Resident #1 replied that the device was in her nightstand drawer and needed somebody to give it to her. LVN D said that he never provided care to a resident with a pain pump in [AGE] years and was not familiar with a resident self-administering medication via a pain pump. LVN D said he told Resident #1 that he needed to speak with the doctor. LVN D said that Resident #1 stated she could demonstrate to the staff how to administer the bolus dose if needed. LVN D said on Tuesday (09/10/24) staff were informed not to administer the bolus dose via [Resident #1] pain pump. LVN D said that he did not know the reason why. LVN D said he requested the orders from the pain management physician (on 09/10/24) per the facility PCP request. LVN D said that he gave the (pain management physician) orders to the DON when they arrive via fax on 09/10/24. LVN D said that he did not receive training or in-services about pain pumps during her on-hire orientation or annual training(s). Interviews conducted with nurses scheduled (09/16/24 and 09/17/24) on the 6:00 AM-2:00 PM shift [LVN D and RN B], on the 2:00 PM-10:00 PM shift [RN E and RN C], 10:00 PM-6:00 AM shift [LVN G], and Weekend Doubles - 6:00 AM-2:00 PM and 2:00 PM-10:00 PM shift [LVN A] indicated they participated in the in-service trainings. The staff stated topics of discussion included pain management and how to care for a resident with a pain pump. Each nurse stated in their own words reportable concerns regarding the pain pump, signs and symptoms of pain, and pain assessment. The DON and RCS were informed the Immediate Jeopardy was removed on 09/17/24 at 4:00 PM. The facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food items were kept away from potential airborne contaminants (dust and fuzz) on the ceiling vents. This failure could place residents at risk for food contamination and food-borne illness. Findings included: Observation on 07/23/24 at 8:55 AM revealed a total of ten air conditioning vents in the kitchen area were observed to have built-up fuzz and dust stuck to them. Interview on 07/24/24 at 11:55 AM with Dietary Aide revealed all kitchen staff were responsible for cleaning kitchen equipment. She stated all kitchen staff had daily assignments. Dietary Aide stated maintenance staff were responsible for cleaning the air vents. She stated she could not recall when was the last time air vents were cleaned. She stated the air vents needed to be clean because of all the build-up. She stated kitchen staff would report to the Food Service Supervisor and the Food Service Supervisor would notify the maintenance staff. Dietary Aide stated the risk of air vents not being cleaned could lead to build-up falling in the food. Interview on 07/24/24 at 11:59 AM with [NAME] revealed kitchen staff had daily scheduled assignments to clean the kitchen. He stated he could not recall if the air vents were cleaned by an outside vendor or by maintenance staff. He stated he could not recall when was the last time air vents were cleaned. [NAME] stated the risk of air vents not being cleaned could lead into dust falling in the food. Interview on 07/24/24 at 12:02 PM with Food Service Supervisor revealed the kitchen staff had a daily, weekly, and monthly cleaning schedule to clean the kitchen. She stated the maintenance staff were responsible for cleaning the air vents. She stated the last time the air vents were last cleaned was about 6 months ago. The Food Service Supervisor stated last month in June 2024 they had a Quality Assurance Monitor (QA) audit and the ceiling vents was one of the requirements that were not met. She stated she had reported to maintenance staff the air vents needed to be cleaned. She stated the risk of air vents not being cleaned could lead to build-up falling in the food. Interview on 07/25/24 at 4:20 PM with Maintenance Director revealed the kitchen air vents were cleaned by kitchen staff and maintenance staff. He stated a couple of weeks ago it was reported to him that the kitchen air vents needed to be cleaned. He stated he could not recall the exact date; however, they had a system where requests are put in and the maintenance staff had 30 days to complete the request. He stated it was his responsibility to ensure task were completed. Maintenance Supervisor stated he had not had the opportunity to get it done. Record review of facility Quality Assurance Monitor l Kitchen/Food Service Observation dated 06/04/24 reflected Section 2: General Sanitation and Cleanliness - General appearance of kitchen clean: floors, walls, ceilings, vents ., was marked No. Record review of the facility's policy titled Sanitization dated January 2013, reflected the following: The food service area shall be maintained in a clean and sanitary manner. All kitchen, kitchen areas and dining areas shall be kept clean . Record review of the Federal Food Code 2022 reflected the following: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on observation, interview, and record review the facility failed to provide a private meeting space for the residents' monthly group meetings for 10 of 10 confidential residents reviewed for resident council. The facility failed to provide a private space for resident group meetings. This failure could place residents, who attended resident group meetings, at risk of not being able to voice concerns due to a lack of privacy. Findings included: Interview on 07/23/24 at 9:21 AM with the Activity Director revealed the resident group meetings were being held up stairs in the open middle area. Activity Director stated the only other space would be the conference room which was where the survey team was working. Observation and interview on 07/24/24 beginning at 10:30 AM, during a confidential resident group meeting with 10 residents, revealed the meeting was held in the activity/dining room. There were doors that closed off the space from one hall to another hall; however, in between the hall there was several offices to include the DON's office, the Social Worker's office, the HR office, and the Staffing Coordinator's office and several more along with the elevator and a large open area to the bottom floor. There were no signs posted to indicate that a confidential meeting was being held; however, multiple staff walked through the space to get from one hall to the next hall. The residents who were attending the resident council meeting stated they felt intimidated and uncomfortable having real discussions in the open area because staff might retaliate. Residents Interview on 07/25/24 at 4:24 PM with the Activity Director revealed she had been employed at the facility for [AGE] years. He stated he was responsible for organizing the resident council meetings. She stated resident group meetings were held on the last Tuesday of every month. The Activity Director stated the resident group meetings were always held in the open middle dining area. She stated she knew the meetings were confidential and had to be held in a private space. The Activity Director stated they started having the resident group meetings in the open space upstairs because it was difficult for the last Resident meeting President to fit through the doors of the conference room. The Activity Staff stated the risk of not holding resident group meetings in a private space was the residents not feeling comfortable talking about their concerns and fearing that staff would hear them. Interview on 07/25/24 at 6:58 PM with the Administrator revealed the resident group meetings were held in the conference room. He stated normally 10 to 12 residents would usually attend resident group meetings. He stated they had limited spaces in the facility, that the meetings being held in the middle space upstairs was temporary to accommodate all residents and their mobility devices. He stated he had not had any residents complain to him about resident group meetings not being in a private area. The Administrator stated his expectation was for the meetings to be held in a private space for the residents to voice their concerns openly. Record review of the resident council minutes revealed no requests for a private area. The facility was asked to provide policies regarding resident rights, privacy, resident council however the policy was not provided by exit.

44937 48236 Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 4 of 6 residents (Residents #334, #386, #88 and #109) reviewed for ADLs. 1.The facility failed to ensure Resident #334 received showers as scheduled. 2. The facility failed to ensure Resident #386 received showers as scheduled. 3. The facility failed to provide Resident #88 assistance with daily oral care. 4. The facility failed to provide Resident #109 assistance with daily oral care. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem. The findings include: 1.Review of Resident #334's face sheet, dated 07/25/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Review of Resident #334's admission MDS Assessment, dated 07/19/24, reflected a BIMS score of 14, which indicated his cognition was intact. His diagnosis included unspecified osteoarthritis, other osteoporosis without current pathological fracture, unsteadiness on feet acute pain due to trauma and muscle wasting and atrophy. MDS further review reflected Resident #334 was dependent on staff regarding bathing. Review of Resident #334's Initial Baseline/Advance Care Plan, dated 07/15/24, reflected Resident required assistance with ADLs. Problem: The resident has an ADL self-care performance deficit r/t. Interventions: Bathing/Showering. Review of Resident #334's POC Response History for July 2024 reflected the following under Task - ADL- Bathing revealed no showers or bed baths provided since being admitted on [DATE]. No indications of refusals. Observation and interview on 07/23/24 at 3:03 PM, Resident #334 was lying in bed watching television. Resident #334 appeared clean and well-groomed. Resident #334 stated he admitted to the facility 07/15/24 and he had not received a shower. Resident #334 revealed his shower days were Tuesday, Thursdays, and Saturdays. Resident #334 stated he had not been offered a shower and he had requested to get a shower; however, he had not received it. Resident #334 could not recall the name of the staff who he had told. Resident #334 stated he felt dirty and would like to feel clean. Resident #334 denied any skin breakdowns. Interview on 07/24/24 at 5:08 PM, Nurse Aide N revealed she was the staff assigned to Resident #334. Nurse Aide stated Resident #334 should had received a shower yesterday 07/23/24 and his next shower would be Thursday 07/25/24. She stated even room number showers were provided Monday, Wednesdays, and Fridays for A bed during 6AM-2PM and B bed during 2PM-10PM, and odd room number showers were provided Tuesday, Thursdays and Fridays for A bed during 6AM-2PM and B bed during 2PM-10PM. Nurse Aide N stated she was not sure if Resident #334 received a shower yesterday (7/23/24). Nurse Aide N reviewed Resident #334 POC and stated based on the documentation it showed resident was not provided with a shower and there was no documentation of refusal. Interview on 07/24/24 at 5:43 PM, RN M revealed she was the nurse assigned to Resident #334. She stated CNAs were responsible for providing showers to residents on their shower days. She stated she observed Resident #334 receive a bed bath but could not recall the day. She stated Resident #334 refuses his showers because of his hip fracture resident does not want to get up from his bed. RN M stated based on the documentation it shows that Resident #334 had not received a shower. RN M stated if residents did not receive their showers or baths like they were supposed to, it could lead to them developing skin breakdowns. Follow up interview on 07/24/24 at 5:50 PM, Resident #334 stated he had not received a bed bath. Resident #334 stated staff came in his room and told him that he had received a bed bath but he was sure he did not. Resident #334 then stated [I] might not remember what happened a year ago but [I] do remember what happened in the last week. Resident #334 stated he was told he would receive a shower today (07/24/24). Interview on 07/25/24 at 2:00 PM, the ADON revealed her expectations are for residents to be given their showers and for staff to document in the POC. She stated if a resident refuses a shower, it was the CNAs responsibility to document and report to the nurse and it was the nurse responsibility to follow up with the resident. She stated if residents did not receive their showers or bed baths like they were supposed to, it could lead to them developing skin breakdowns and infections. Interview on 07/25/24 at 6:10 PM, the Acting DON revealed her expectations are for staff to provide residents with showers on their shower days and to document if showers were provided or refused. She stated CNAs should offer showers and if the resident refuses after the third attempt the nurses should follow up and then document. She stated the potential risk of showers not being provided would be skin integrity and resident rights. 2. Record review of Resident #386's face sheet, dated 07/25/2024, indicated Resident #386 was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #386's admission MDS assessment, dated 06/22/2024, indicated Resident #386 had the ability to make himself understood and understood others. The assessment indicated Resident #386's BIMS score was 12, which indicated his cognition was intact. Resident assessment also indicated partial/moderate assistance with eating and oral hygiene, substantial/maximum assistance with shower/bathing, personal hygiene, and upper body dressing. Resident #386 was dependent on staff with toileting, lower body dressing, and footwear. Record review of Resident #386 care plan, undated, indicated Resident #386 had an ADL self-care performance deficit related to impaired mobility. Goal: Resident #386 will maintain current level of function in ADLs. Interventions included: Functional Performance: Resident #386 required partial/moderate assistance with Oral Hygiene, substantial/maximum assistance with one staff to Shower/Bathe Self and Personal Hygiene, dependent on staff with Toilet Hygiene and Tub/Shower transfer. When bathing/showering: check nail length and trim and clean on bath day and as necessary. Record review of Resident #386's task for ADL care revealed from 07/19/24 - 07/25/24 Resident #386 had indicated last bath/shower was 07/20/24. Observation and interview on 07/23/24 at 11:29 AM, with Resident #386 revealed him in bed, hair oily and in disarray, facial hair grown out, nails were long with dark substance underneath nails. According to Resident #386 he was waiting to receive a shower. Resident #386 stated he was looking forward to a shower to have a shave, he stated his facial hair was longer than he preferred and was growing underneath his neck area. Resident #386 stated he did not know what the substance was underneath his nails but would like to have them trimmed. Observation and interview on 07/24/24 at 5:25 PM, ADON C revealed Resident #386 had not received a bath, shower shave or nail care. ADON C spoke with Resident #386 and ensured he would receive a shower today and apologized for the delay. According to ADON C aides were responsible for ensuring Resident #386 received a shower or bath along with nail care and a shave if he wanted. According to ADON C not providing ADL care to residents placed them at risk of infections and having dignity issues. ADON C stated she expected aides and nursing staff to ensure residents were having their showers/baths on their scheduled days, if not report any refusals or missed opportunities. ADON C stated charge nurses and herself were responsible to ensure aides were providing adequate ADL care. Observation of Resident #386 on 07/25/24 at 8:18 AM, revealed Resident #386 was in bed with same bedding and clothing as the previous days indicating he had not had a shower or bath. Resident #386 had a partial shave leaving patches of missed hair on his face, Resident #386 still had grown hair under his neck about an inch long. Resident's nails were still long with substance underneath. 3. Record review of Resident #88's face sheet, dated 07/25/2024, indicated Resident #88 was a [AGE] year-old female, admitted to the facility on [DATE]. Record review of Resident #88's admission MDS assessment, dated 06/29/2024, indicated Resident #88 had the ability to make herself understood and understood others. The assessment indicated Resident #88's BIMS score was 15, which indicated her cognition was intact. Resident assessment also indicated extensive assistance with two or more persons with bed mobility and toileting, Supervision with eating by one person. Resident #88's diagnosis included chronic obstructive pulmonary disease, chronic respiratory failure, morbid (severe) obesity, essential hypertension (high blood pressure), heart failure. Record review of Resident #88's care plan, undated, indicated Resident #88 has an ADL self-care performance deficit related to impaired mobility, obesity. Goal: Resident #88 will maintain current level of function in ADLs. Interventions included: Functional Performance: Resident #88 required dependent assistance by one staff for Oral Hygiene, Personal Hygiene, Toilet Hygiene, Tub/Shower transfer, Shower/Bathe Self. When bathing/showering: check nail length and trim and clean on bath day and as necessary. Record review of Resident #88's task for ADL care revealed from 07/11/24 - 07/24/24 Resident #88 had taken a bed bath on 07/15/24 and 07/19/24, all other dates were indicated as not applicable. Observation and interview on 07/23/24 at 3:35 PM, revealed Resident #88 had long nails with brown, red, and white substance underneath nails on both hands, hair was greasy/oily with appearance that it had not been combed over days. Resident #88 had facial hair growing around her upper lip and chin area. According to Resident #88 her nails were longer than she particularly liked, Resident stated she did not know what the substance was underneath her nails. Resident stated staff had never cut or trimmed her nails and had not ever asked her about the length. Resident #88 stated she went to dialysis three days a week and sometimes would get a wipe down before leaving but could not say when the last time she had a shower or bed bath. Resident #88 stated she did not know she had facial hair, no one had mentioned it and stated she rather not have facial hair. Resident #88 stated she hardly had her washed or combed. Observation and interview on 07/25/24 at 8:51 AM, LVN H revealed Resident #386, LVN H stated it appeared resident had not had a shower, LVN H stated it appeared someone attempted to shave him however it was hit and miss with the shave. Observation of Resident #88 revealed she had dirty long nails and hospital gown with stains, when asked about a shower, Resident #88 stated staff had not attempted to provide a shower or bath for her. LVN H stated aides were responsible for ensuring showers were completed on shower days which included hair, nails, and a shave. LVN H stated not providing proper hygiene placed residents at risk for infection, disease, and skin damage. 4. Record review of Resident #109's electronic face sheet, dated 07/25/24, revealed an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #109 had diagnoses which included senile degeneration of the brain, unspecified dementia, need for assistance for with personal care, and adjustment disorder with depressed mood. Record review of Resident #109's Comprehensive MDS assessment, dated 06/19/24, revealed Resident #109 had a BIMS score of 4, which indicated her cognition was severely impaired. Further review revealed section GG 5. B. Oral Hygiene indicated code 2 (substantial/maximal assistance), which meant Helper does more than half the effort; Helper lifts or hold the trunk or limbs and provides more than half the effort. Record review of Resident #109's care plan, dated 07/25/24, revealed Resident #109 required substantial/maximal assistance from staff for oral hygiene from staff. Resident #109 is encouraged to participate to the fullest extent possible with each interaction. Record review of Resident #109's orders, dated 07/25/2024, revealed no dental consult order for Resident #109 since admitted . Observation on 07/23/24 at 12:11 PM, revealed that Resident #109 had extremely bad breath and it did not appear that her teeth had been brushed. Her teeth had white buildup that was along the top of her top teeth and the bottom of her bottom teeth. Observation on 07/25/24 at 12:26 PM, revealed Resident #109 had extremely bad breath and it did not appear that her teeth had been brushed. Her teeth had white buildup that was along the top of her top teeth and the bottom of her bottom teeth on them and food throughout the teeth. Resident #109 did not appear to wear dentures. Resident #109 also appeared to be missing several teeth including one on the bottom and one on the top in the front. Interview on 07/23/24 at 12:15 PM, with Resident #109 revealed that she was unsure if her teeth had been brushed. Interview on 07/23/24 at 2:41 PM, CNA E stated that brushing the resident's teeth is part of the daily skills for the resident. CNA E also stated that Resident #109 had two loose teeth and will not allow her to come close to the two teeth and therefore can't brush her teeth. CNA E confirmed that it is important to brush the residents' teeth as part of their morning grooming because it affects their health. CNA E also stated that the resident can be at risk for gingivitis. Interview on 07/25/24 at 02:41 PM, LVN F revealed that CNAs are supposed to brush the residents' teeth in the morning and the evening. However, LVN F stated that she is not in the room when it occurs. LVN F also revealed that a resident has the right to refuse oral care. LVN F said Resident #109 overall predominantly accepts oral care most of the time. LVN F continued by stating that she was unaware if the white build-up comes off Resident #109's teeth. And, LVN F said that the risk to oral care is infection, gum disease, rotten teeth, appetite changing, and physical decline. Interview on 07/25/24 at 02:58 PM, ADON A revealed that CNAs are supposed to perform oral care in the morning. ADON A also revealed that the resident is at risk for bad breath, infection, dental cavities, and a decline in health. Interview on 07/25/24 at 05:06 PM, the SS Director revealed that nurses do not automatically put a resident on the list for dental services. The SS Director stated that residents are asked quarterly if they want to receive services. The SS Director also added that she would call Resident #109's family to get permission to send the referral to the dental company so that the resident can be placed on the list to be seen by a dentist. She also revealed that the importance of being seen by a dentist is so that the resident will maintain good oral hygiene. The SS Director stated that if the resident does not have good oral hygiene, it can lead the resident to not eating, bacteria, etc. Interview on 07/25/24 at 06:56 PM, the Acting DON revealed that CNAs are supposed to offer oral care. The Acting DON stated that if the resident does not receive proper oral care both by a dentist and daily brushing, there is a risk for infection and a risk for nutritional decline. This will result in an overall health decline for the resident. Review of the facility policy Activities of Daily Living (ADLs) dated 05/26/23, reflected the following: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. 2. The facility may provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment. 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview and record review, the facility failed to provide quality of care based on the comprehensive assessment and in accordance with professional standards of practice for one (Resident #1) of three residents reviewed for quality of care. Resident#1 was not provided immediate treatment when diagnostic results revealed multiple fractures and ligament injury to his foot. As treatment delayed, the resident subsequently developed a decubitus ulcer on the right foot while at the nursing facility. This failure placed residents at risk of delay in care and services, which could result in a significant decline in health, serious injury or illness, or hospitalization . Findings included: Review of Resident #1's undated Admission Record revealed Resident #1, a [AGE] year-old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. (The resident was then discharged on [DATE] and admitted to the hospital.) Review of Resident #1's significant change MDS (Minimum Data Set) assessment reference dated 10/09/20, revealed he had severe cognitive impairment with a BIMS (Brief Interview for Mental Status) Summary Score of 4. The resident was ambulatory in the room and corridor with physical assistance from staff. He required physical assistance from staff with bed mobility, transfers, dressing, eating, toileting, and hygiene. The resident had a history of [REDACTED]. The resident was identified as being at risk for pressure ulcers with preventative treatments of pressure reducing devices for his chair and his bed. The assessment made no mention of other wounds or skin conditions. Nor did the assessment make any mention of fractures under active diagnoses. A review of Resident #1's care plan revealed it was updated on 9/30/20 under potential for impairment to skin integrity related to fragile skin, [MEDICAL CONDITION], and incontinence. The update revealed that his right foot was red and swollen with bruising to his 2nd toe. The resident rated pain a 5 out of 10 at that time. A review of Resident #1's PT (Physical Therapy) treatment notes revealed a note dated 9/30/20 that indicated Resident #1 had been seen for PT in the gym. The resident was documented as walking 50 feet twice. The resident had no complaints and tolerated the session well. On 10/27/20 at 5:05 p.m. an interview was conducted with the Physical Therapist. The therapist stated as of 9/30/20, the resident had been doing well walking and making good progress. A review of Resident #1's nursing notes revealed an entry dated 9/30/20 that indicated Resident #1's right foot was red and swollen and bruised over the second toe. The nurse documented notification of the resident's daughter and the physician who ordered a doppler ultrasound of the right lower extremity, chest x-ray and stat blood labs. The resident's pain was 5 out of 10. The nurse documented she gave the resident Tylenol 500 mg for pain. A review of Resident #1's MAR (Medication Administration Record) for September 2020 revealed no documentation the nurse administered Tylenol to Resident #1 on 09/30/20 after the injury was noted. An interview on 10/29/20 at 9:25 a.m. with the RN A revealed that she made a mistake and failed to document the administration of Tylenol on the MAR. Thus, there was no documentation if the Tylenol had been effective or if the resident was still in pain after receiving the medication. A review of Resident #1' nursing note dated 10/01/20 revealed the resident was seen by the physician and they were awaiting results of the venous doppler ultrasound. The nurse wrote, no new order at this time. A review of the clinical record revealed no documented progress note dated 10/01/20 from the physician after he had seen the resident. Review of a Physical Therapist (PT) treatment note dated 10/01/20 revealed Resident #1 stated his right lower extremity (knee) had discomfort. The therapy note indicated the resident Didn't perform as well as pervious Days. On 10/28/20 at 5:45 p.m., an interview was conducted with the Physical Therapist E (PT E) regarding walking the resident on 10/01/20 after nursing had identified he had an injury on his right foot the prior day on 9/30/20. PT E stated that no one had said anything to him that the resident had a foot injury. So the physical therapist did provide physical therapy on 10/1/20, not aware of his foot injury. He stated the resident did have shoes on because he never walks him without shoes but he noticed the resident did not do as well as previous days. He did not walk as far and had complaints of lower right extremity pain (knee). He stated it was not until the next day (10/02/20) when he came into the resident's room and noticed his right foot was wrapped that he had a foot injury. The PT E stated after he realized the resident was he cleared with the physician to hold all upright therapy due to the resident's injury. A review of Resident #1's PT treatment note dated 10/02/20 revealed the resident's right foot was bruised and swollen. The therapist planned to continue therapy but no upright activities until his foot was cleared by the medical doctor. The physical therapist noted that the residents venous doppler was negative. A review of Resident #1'snursing note dated 10/02/20 revealed the residents right foot continued to be swollen and bruised. For comfort the resident's feet were offloaded. A review of Resident #1's physician orders [REDACTED]. A review of Resident #1's nursing notes dated 10/03/20, 10/04/20, and 10/05/20 revealed the resident's bandage remained intact, his foot was elevated for comfort per physician orders [REDACTED]. A note dated 10/05/20 revealed per therapy the resident was unable to stand on his foot. The right foot continued to be swollen and bruised. There was no report of pain but the ACE bandage and elevation of the foot continued. A review of Resident #1's nurse note dated 10/06/20 revealed the residents right foot continued to be bruised with swelling slightly decreased the resident was seen by the physician on his rounds. The physician ordered a right foot x-ray and continued with ACE bandage and offloading his feet. The resident denied pain. A review of Resident #1's clinical record revealed no documented progress note dated 10/06/20 from the physician after he had seen the resident. A review of a nursing note dated 10/06/20 revealed the resident had been in bed most of the shift. The x-ray of the right foot was done with results revealed a Medial dislocation and probable Lisfranc avulsion (an injury to the bone in which the tendon or ligament pulls off a piece of the bone) at the base of the first metatarsal (bone in the foot just behind the big toe) of uncertain chronicity. The nurse notified the physician and new orders were received for a CT scan of the right foot and referral to an orthopedic physician. The nurse documented she gave the resident Tylenol for pain in the nursing note. Review of Resident #1's MAR for October 2020 a review of the MAR indicated [REDACTED]. A review of Resident #1's nursing note dated 10/07/20 revealed an appointment for the CT scan of the right foot was scheduled for 10/09/20. A review of Resident #1's nursing note dated 10/08/20 revealed that nursing staff was unable to make an appointment with the orthopedic physician. The resident's physician was notified. Nursing then set up an appt with a podiatrist instead on 10/15/20. Interview with the RN A on 10/28/20 at 11:20 AM revealed the resident's doctor initially wanted him to be seen by an orthopedic surgeon. However, the orthopedic physician said he did not do foot injuries, so he recommended that the resident be seen by a podiatrist instead. She stated the resident never saw an orthopedic physician instead an appointment with a podiatrist was made instead. She stated she made the first new patient appointment available with the podiatrist which was on 10/15/20. The nurse was unsure why the physician did not send the resident to the emergency room or to the hospital for fracture treatment instead of waiting over a week to be seen by a podiatrist. She stated she just made the appointment as ordered by the physician. A review of Resident #1's nursing note dated 10/09/20 revealed the resident had his CT scan of the right foot completed and results were pending. (No documentation in the clinical record revealed the facility ever received the CT scan results. In an interview on 10/27/20 at 4:30 p.m. ADON B was asked for the CT results. He looked in the computer and said he could not find the results to print off a copy. In an interview on 10/28/20 at 1:30 p.m. the Medical Record Director stated the facility never received a copy of the CT results, that they were missed and never added to the clinical record until 10/28/20, after the surveyor requested the results.) A review of the CT completed on 10/09/20 and read by the radiologist on 10/11/20 revealed the following impression: 1. Nondisplaced fracture base of second metatarsal. 2. Injury to the Lisfranc ligament with dorsal and medial subluxation of the first metatarsal and widening of the space between the first and second metatarsal additional small fracture fragment off the medial cuniform and base metatarsal. A review of the resident's clinical record revealed no nursing notes describing the residents right foot injury on 10/10/20 or 10/11/20. On 10/12/20, a nursing note revealed the nurse observed a purple discoloration on his right foot which measured 6 cm x 3 cm. The wound care nurse was notified, and new physician orders [REDACTED]. A review of Resident #1's care plan revealed it as updated on 10/12/20, to reflect a purple discoloration of his right food that measured 6 cm x 3 cm described as a [MEDICAL CONDITION]. A review of the resident's TAR (Treatment Administration Record) for October 2020 revealed the physicians order to cleanse the resident's right heel with normal saline, pat dry with gauze, apply [MEDICATION NAME] soaked gauze, and cover with a dry dressing every day shift was started on 10/13/20. A review of Resident #1's nursing note and wound care note dated 10/13/20 revealed the resident had been seen by the wound doctor. The resident was assessed as having a new right heel diabetic ulcer which measured 2.5 cm x 3 cm with an undetermined depth. The physician ordered [MEDICATION NAME] moistened gauze daily on the wound. No nursing or clinical record notes dated 10/14/20 or 10/15/20 described the residents right foot injury or the new ulcer of his right heel. On 10/15/20, a nursing note documented that the resident was sent to his podiatry appointment accompanied by a family member. A review of Resident #1's podiatrist progress note dated 10/15/20 revealed, The podiatrist assessment/plan included: a dislocation of tarsometatarsal joint of right foot, a closed displaced fracture of second metarasal bone of right foot and a diabetic ulcer of the right heel. The podiatrist also noted that with dusky tissue noted to the medial midfoot he is at risk for pending ulceration of the midfoot, which puts him at risk for amputation on the right lower extremity. The podiatrist spoke to the resident's family member about having the resident go to the emergency room and admitted to the hospital for vascular workup, evaluation by the medicine team, and surgical optimization of the foot. The podiatrist also discussed with the family member the likely need for surgery for [REDACTED]. On 10/27/20 at 3:00 p.m., a telephone interview was conducted with the Podiatrist. He stated he assessed Resident #1 in his office on 10/15/20. He had never seen the patient before, so he was a new patient visit. He said the resident's injury was not acute, it had not just happened. He stated by the time he saw the resident the injury was at least a week old. The physician questioned why the resident had not been provide services before he was brought to his office. He stated, It should have been addressed sooner. It was not an acute injury, it had happened at least a week or more prior. The physician questioned why, it wasn't addressed more quickly because the injury was to the extent it resulted in foot deformity resulting in skin injury. He stated the bones were pushing out under the skin leaving a purple blistered area with an obvious injury and dislocation. He also stated that the resident's heel had an ulcer on it because the resident's foot had not been off loaded or placed in protective boots to prevent skin breakdown. The physician stated the resident was sent directly to the hospital and began the workup for surgical repair of his foot. A review of hospital surgeon notes dated 10/20/20 revealed the resident had been residing at a nursing home. The resident was not brought to the podiatry clinic until 3 weeks after he was found to have 1st tarsometatarsal dislocation with tenting of the skin. The pre-op [DIAGNOSES REDACTED].>1. Tarsometatarsal dislocation right foot 2. First and Second metarasal fracture right foot, close 3. Diabetic heel decubitus ulcer right foot The procedure to repair the residents right foot injury and decubitus ulcer included: 1. Open reduction tarsometatarsal dislocation right foot 2. First Tarsometatarsal arthrodesis right foot 3. Open management 2nd metatarsal fracture right foot 4. Wound bed prep right heel wound 5. Application amniotic wound matrix right foot 6. Application multi-plane external fixation right foot and ankle. On 10/28/20 at 3:36 p.m., an interview was conducted with Resident #1's nursing facility physician/MD (Medical Director). He stated he remembered the resident very well. He stated the resident had injured his foot. He was not sure how the injury occurred, but nursing staff told him the resident would drag his foot when he was up in his wheelchair, which possibly caused the injury. He stated he ordered a doppler on his foot because he feared the resident had a blood clot. When the doppler was negative he ordered a foot x-ray. When it came back with fractures he ordered a CT scan of the foot and for the resident to have an appointment made with an orthopedic physician. He stated the orthopedic physician stated he did not provide care to foot injuries and the resident would be better off seeing a podiatrist. So, he ordered for the resident to have an appointment with a podiatrist. During the interview, the surveyor mentioned that the resident injury was noticed on 9/30/20 however the resident was not provided treatment for [REDACTED]. When asked regarding the delay of treatment or why the resident was not sent to the hospital sooner, the MD stated there was no need for him to go to the hospital. The MD stated he did not send patients to the hospital for stuff like that. The MD stated he had them schedule an appointment with a podiatrist instead. He said the resident had a broken foot but was not ambulatory, so it was not an emergency since he wasn't walking anyways. The MD was not concerned about the delay in treatment for [REDACTED]. On 10/29/20 at 4:00 p.m. a second telephone interview was conduct with the nursing facility MD. It was found out that the resident had been ambulating before the injury with physical therapy. During the interview, the MD stated he did not realize Resident #1 had been receiving physical therapy (although he had written an order on 9/21/20 for physical therapy) or had been walking with therapy. He stated even if he had been walking he still would not have sent the resident to the hospital for immediate care of the broken foot. He stated, I don't think he needed to go to the hospital and Not all fractures are sent to the hospital. The MD was then asked about his progress notes when he assessed the resident on 10/01/20 and 10/06/20. He stated that his office was checking into them. On 10/29/20 at 8:50 a.m. a telephone interview was conducted with Resident #1's RP (Responsible Party). The RP stated that on 9/30/20 she received a call from the nurse notifying her that the resident had hurt his foot. She spoke to the nurse over the phone and then asked if the nurse could facetime her, so she could see the resident's foot. She stated the whole top of the resident's foot was bruised and swollen so bad. The nurse did not know how the injury happened. On 10/15/20, the RP accompanied Resident #1 to his podiatrist appoint. She stated the doctor took x-rays of the resident's foot. When the x-ray result came up on the screen she and the physician both gasped at the extent of the injury on the x-ray. She stated the residents big toe was completely detached from his foot. The physician then looked at the RP and talked to her about the sore on his foot, the bone that was starting to protrude under the skin, and the possible risk of foot amputation. The physician told the RP that the resident was not going to go back to the nursing home, that he was going to go straight to the hospital for surgery preparation. She stated she called the nursing home, the nursing home driver picked the resident up and took him straight to the hospital. At the end of the interview the RP began to cry stating she wish she had taken Resident #1 out of the nursing home sooner. She stated she felt he had been neglected and should have been taken to a physician sooner to get immediate care for his injured foot because he could have lost his foot.

Based on observation, interview, and record review, the facility failed to ensure residents were free from neglect for three (Residents #1, #2, and #3) of six residents reviewed for pressure ulcers. 1. The facility failed to prevent Resident #1 from developing Stage IV pressure ulcers on the inner aspect of each knee on 10/11/18 and surgically debrided (removing dead tissue resulting in a bleeding wound bed) the pressure ulcers without the consent of the resident's family on 10/17/18. As a result, Resident #1's pressure ulcers deteriorated until the resident's passing at the facility on 10/22/18. The resident developed severe pain and was unable to tolerate wound care for the pressure ulcers starting on 10/20/18. 2. The facility failed to implement pressure ulcer prevention measures to prevent worsening of pressure ulcers on Resident #2. As a result, Resident #2 had pressure ulcers on both of her heels that worsened. 3. The facility failed to implement pressure ulcer prevention measures, outside of the use of an air loss mattress, to prevent worsening of pressure ulcers and development of new pressure ulcers for Resident #3. As a result, Resident #3 had pressure ulcers on her left foot and heel that worsened, and a new pressure ulcer that developed on her left foot. An Immediate Jeopardy (IJ) was identified on 10/24/18. While the Immediate Jeopardy was removed on 10/26/18, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy, and at a scope of pattern because the facility was still monitoring the Plan of Removal. These failures had the potential to affect residents by placing them at risk of receiving treatments without having given informed consent and the development or worsening of pressure ulcers. Findings included: 1. Resident #1's MDS assessment, dated 08/16/18, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She had moderate cognitive impairment. She required extensive assistance of two or more staff for bed mobility. She was always incontinent of bladder and bowel. The resident was at risk for the development of pressure ulcers and was receiving Hospice care. Resident #1's Care Plan, dated 06/21/18, revealed the resident was at risk for skin breakdown related to contractures, incontinence, limited mobility, and friction risks. Facility interventions included to assist the resident in methods to reduce friction, Braden assessments (pressure ulcer risk assessment) per policy and evaluate for skin risk factors per protocol. There were no specific interventions listed regarding how to reduce friction for the resident, or any specifics for offloading or cushioning any areas of the resident's body. Resident #1's Braden Scale for Predicting Pressure Sore Risk Assessment, dated 06/23/18, revealed the resident was at mild risk for the development of pressure ulcers. There were no further assessments available for review. Resident #1's Physician Orders, dated (MONTH) (YEAR), revealed the resident had an order for [REDACTED].>Resident #1's Progress Notes revealed: 10/11/18 at 5:00 p.m. - LVN A notified the Wound Care Nurse regarding wounds found by CNA B to both inner knees. Upon assessment the Wound Care Nurse noted the inner right knee had eschar (dry dead tissue) with yellow slough (moist dead tissue) in the wound bed, measuring 7.0 cm x 4.0 cm. The wound to the left inner knee had eschar tissue with yellow slough in the wound bed. The wounds had a foul odor. The Wound Care Physician and DON were notified, and orders were received to clean both wounds with wound cleanser, apply Santyl ([MEDICATION NAME] ointment), and apply calcium alginate (dressing that absorbs drainage). Cover the wounds with dry dressings daily. Resident #1's Weekly Skin Inspection Assessment, dated 10/11/18 revealed the resident had developed new pressure ulcers on the inner aspects of both knees. The right knee had eschar measuring 7.0 centimeters (cm) x 4.0 cm. The left knee had a wound, but the area could not be measured due to her leg contracture. Skin assessments prior to 10/11/18 did not have these wounds documented. Resident #1's Wound Evaluation and Management Summary, dated 10/17/18, and signed by the Wound Care Physician revealed the resident had a Stage IV pressure ulcer on the inner aspect of both knees. The pressure ulcer on her left inner knee measured 8.0 cm x 4.5 cm x 0.3 cm. The pressure ulcer on her right inner knee measured 11.0 cm x 8.0 cm x 0.3 cm. The resident required surgical debridement of both knees to remove necrotic tissue. The document indicated consent had been received for the surgical debridement. Hospice Company C Certification and Plan of Care, dated 08/09/18, reflected: .Hospice Skilled Nurse to assess wounds every visit .Hospice nurse to coordinate plan of care with facility staff . Hospice Company C Notes: 10/18/18 Skin Integrity - Wounds not assessed. An observation of Resident #1 on 10/22/18 at 4:32 p.m. revealed the resident was lying in bed. Hospice was at the bedside due to the resident's decline in status. The resident was actively dying and passed away shortly after entering the facility. The resident was asleep and not able to communicate during observation. The resident did not respond to verbal stimuli. She was lying on her right side with her legs drawn up in a contracted, fetal position. There was a wound dressing on both knees. There was no barrier in place to prevent the knees from touching each other. The wound dressings were removed by staff and revealed each knee had white tissue/bone that was exposed, with a large amount of drainage, slough, and dead tissue. The wounds had a foul odor. An interview with CNA B on 10/23/18 at 4:25 p.m. for Resident #1 revealed on 10/11/18 he walked into the resident's room and smelled a foul odor. CNA B pulled the blankets back and found the resident's knees were touching and each knee had a wound on it. He notified LVN A. CNA B stated staff would sometimes place a pillow between the resident's knees to keep them from touching, but not always. He stated the pillow was not there on 10/11/18. He stated he was able to do incontinent care for the resident by separating her legs and knees to clean her, but otherwise her knees and legs had a history of [REDACTED]. Interviews with LVN A on 10/23/18 at 4:15 p.m. and 10/25/18 at 2:55 p.m. for Resident #1 revealed on 10/11/18, CNA B notified him that the resident had wounds between her knees. The wounds were open, draining, and had a foul odor. The resident's legs and knees stayed in a contracted position with the knees touching. He stated the resident did not have a pillow in place between her knees. He stated he notified the Wound Care Nurse to assess the wounds. Residents were supposed to be turned every two hours as needed. Pillows and pillow boots were supposed to be used to offload heels and bony prominences. He stated Resident #1 developed pressure ulcers between her knees because she was contracted and was supposed to always have a pillow in place between her knees. He stated he did not know if the resident had the intervention care planned. LVN A stated he considered neglect to be anything staff were supposed to do but failed to do for residents. He stated he had received multiple facility in-services for neglect identification, prevention, and reporting. Interviews with the Wound Care Nurse on 10/23/18 at 9:25 a.m. and 10/24/18 at 10:50 a.m. for Resident #1 revealed the facility had an ownership change on 10/01/18. She started doing wound care at the facility in (MONTH) (YEAR). In (MONTH) (YEAR) she received some training on her role as the wound care nurse and documented her notes in the computer. When the new ownership took over on 10/01/18, she was told she would be trained, but was not. She was told that she would be documenting on new forms and would be instructed on how to use them. The Wound Care Nurse said that as of 10/24/18, she still had not received all of the training she needed for her role as the facility wound care nurse. She received an in-service on 10/23/18 (after the surveyor had entered on 10/22/18) that included responsibilities she did not know she had. She said the new responsibilities included to communicate with the families on a weekly basis regarding wound care and update care plans. She stated that prior to 10/23/18, she would update care plans regarding the wound size changes, but did not know she was supposed to include interventions to prevent the development/worsening of new pressure ulcers and had not previously included that information. She stated she had signed an in-service form which had instructions on when and how to use pressure relief measures and devices, but she did not actually read it or receive training on it. The Wound Care Nurse stated she was notified on about the discovery of wounds between Resident #1's knees on 10/11/18. The resident did not have a pillow or other barrier between the knees when she saw her. The resident had a wound on the inner aspect of each knee. Her legs were very contracted and difficult to pull apart. She examined them and contacted the Wound Care Physician to get orders for treatment. She contacted the DON who notified Hospice Company C. She also contacted the resident's family. She stated she and the Wound Care Physician had assessed the resident on 10/10/18, but the resident did not have wounds on her inner knees at that time. She stated they discussed the resident's contracted legs and the risk for pressure ulcer development between the resident's knees. The Wound Care Nurse stated sometimes staff would place a pillow between the resident's knees to keep them from touching, but there were no orders or care plans to keep a pillow or other barrier in place. She stated she asked the resident's family on 10/11/18 to purchase thin pillows that would be more comfortable for the resident to place between her contracted legs to keep the knees from touching after the wound was found, but she did not get an order or care plan the interventions because she did not know she was supposed to. The Wound Care Nurse stated the Wound Care Physician did not evaluate Resident #1's wounds until 10/17/18, and at that time he stated the resident's wounds were Stage IV pressure ulcers. She did not stage them when they were first found, but they were large, open, and draining. The Wound Care Physician had to surgically debride dead tissue from the knee wounds on 10/17/18. After the debridement, the wounds worsened with an increase in size, drainage, and odor. She stated she did not notify the family, DON, Wound Care Physician, or Medical Director about the wound changes because the resident was on Hospice and she thought the charge nurses were supposed to do notifications. She stated she did notify the Hospice Nurse and requested an order from the Hospice Physician for antibiotics or treatment to address the wound odor. The Hospice Nurse did not call her back and she did not follow-up with anyone else regarding the wounds. The Wound Care Nurse stated she changed the dressings on 10/11/18, 10/12/18, and 10/15/18-10/22/18 based on a calendar she was looking at for October. The resident went on continuous Hospice Care on 10/20/18 and the family requested the wound care dressings not be changed after that due to the pain of the dressing changes. The resident passed away at the facility on 10/22/18. An interview with the Wound Care Physician on 10/23/18 at 12:20 p.m. for Resident #1 revealed on 10/10/18 he and the Wound Care Nurse made rounds to look at a healing pressure ulcer on her foot. He noticed the resident had her legs contracted in a fetal position with her knees touching. She did not have any skin breakdown between her knees at that time. He discussed with the wound care nurse that the resident needed a measure in place to prevent the knees from touching to prevent pressure ulcers from developing. He did not write new orders but stated the Wound Care Nurse told him staff would place a pillow between her knees. He stated on 10/11/18, the resident was found with new wounds between her knees, but with constant pressure with her knees touching and her compromised nutrition, the wounds could have developed overnight. On 10/17/18 the wounds required surgical debridement to remove a lot of dead tissue. He stated the resident was nutritionally compromised, and once the ulcers developed, they deteriorated very quickly. He stated the wound on the inner aspect of each knee was a Stage IV on 10/17/18, and that was the last day he assessed the wounds. He stated for surgical debridement, the facility was responsible for obtaining consent. Interviews with Charge Nurse LVN D on 10/23/18 at 11:20 a.m. and 10/24/18 at 9:05 a.m. for Resident #1 revealed the resident admitted to the facility and had a gradual decline in her health. Hospice Company C started caring for her due to her [DIAGNOSES REDACTED]. The resident had her legs contracted and her knees were clamped together and constantly touching. The resident was very thin with bony prominences exposed. She stated after the wounds were found, the Wound Care Nurse contacted the family to purchase thin pillows to keep placed between the resident's knees. Prior to that she stated staff were supposed to put a pillow between her knees or a towel wrapped in a pillowcase to keep the knees from touching. She stated when she cared for the resident and found she did not have a pillow between her knees, she would place one and tell the CNA that she was supposed to have one. She said she did not know how staff were supposed to know about the intervention, but she told the staff she worked with about it. An interview with LVN G on 10/25/18 at 11:50 a.m. for Resident #1 revealed she was supposed to have a pillow between her knees to prevent pressure ulcers from developing, and the intervention should have been documented on the resident's care plan. She considered neglect to be anything that should have been done for a resident that was not done. She stated she had received multiple facility in-services on identifying, preventing, and reporting neglect. She stated to prevent pressure ulcers, staff had to make sure that pressure points were off-loaded, and a barrier was in place to prevent the pressure points from touching. An interview with LVN H on 10/25/18 at 1:45 p.m. for Resident #1 revealed on 10/14/18, she saw pressure ulcers on the inner side of both knees. She stated the wounds were draining through the dressings and onto the pillow between her legs and had a foul odor. She stated she did not notify the physician about the wound. She stated the resident was supposed to have had a pillow kept between her knees to prevent pressure ulcer development. Residents were all supposed to have an updated activities of daily living (ADL) Kardex so staff would know which interventions were in place, but she did not know if the resident had one. Nurses were supposed to notify the physician and family with any changes in condition. She considered neglect to be: not having the resident's call light in reach, not offering water, not giving showers, not changing or turning, and not offloading pressure points to prevent pressure ulcers. She stated she had received multiple facility in-services on identifying, preventing, and reporting neglect. She stated to prevent pressure ulcers, staff had to off-load pressure points, reposition residents every 2 hours, and provide adequate nutrition and hydration. An interview with ADON I on 10/25/18 at 1:05 p.m. for Resident #1 revealed she considered neglect to be anything the staff did to not meet the needs of the resident. She stated she had received multiple facility in-services on neglect identification, prevention, and reporting requirements. She stated to prevent pressure ulcer development, staff were supposed to offload pressure sites and have devices in place to prevent the pressure sites from touching. She stated Resident #1 developed a pressure ulcer between her knees because there were no interventions in place to prevent their development. She stated the information should have been on the resident's care plan and Kardex and all nurses were able to update them. She did not know if the resident had one or not. Interviews with the DON on 10/23/18 at 12:45 p.m., 10/24/18 at 9:30 a.m. and 10:40 a.m. for Resident #1 revealed she saw the wounds on her inner knees on 10/11/18. She stated at that time they had a small amount of slough. She stated she never spoke to the physician about the wounds, but the Wound Care Nurse did. The resident was receiving Hospice care and the facility was managing the resident's wound care. She stated the resident was at risk for pressure ulcer development between her knees because she had low [MEDICATION NAME], low protein, contractures, was bed bound, and had weight loss. Staff were supposed to keep a pillow or pressure-relieving device between her knees to prevent pressure ulcers from developing. Staff were supposed to know to keep a pillow between her knees by reviewing the care plan, but the intervention was not listed. The facility also utilized a resident Kardex that was easy to access for staff, but the resident did not have a Kardex either. She stated the Kardex was supposed to be developed from the resident's care plan and if the interventions to prevent pressure ulcer development/worsening was not in the care plan, the information was not included on the Kardex. Orders were not required to be written as of 10/01/18, because new ownership took over and they did not allow orders to include pressure ulcer prevention measures. The DON stated prior to the ownership change on 10/01/18 she provided oversight to the Wound Care Nurse by doing spot checks on wounds. After the ownership changed, she only looked at and assessed new wounds. She stated all staff, including the wound care nurse had received yearly in-service training that included pressure ulcer prevention measures. An interview on 10/23/18 at 11:45 a.m. with Hospice CNA E (Hospice Company C) for Resident #1 revealed she bathed the resident on Mondays, Wednesdays, and Fridays. The resident did not have pressure ulcers between her knees on 10/10/18. She stated the resident was very contracted and she would have to pull the resident's knees apart to do incontinent care. An interview with Hospice RN F (Hospice Company C) on 10/23/18 at 1:35 p.m. for Resident #1 revealed she saw the resident on 10/02/18, 10/19/18, and 10/22/18. On 10/19/18 the resident had dressings that were soiled on each knee. The wounds had a foul odor. She notified the facility Wound Care Nurse to change the dressings. She stated she did not see the wounds because Hospice did not undress and redress wounds. She stated there was not any discussion with the family about more aggressive treatment for [REDACTED]. Interviews with the Medical Director on 10/23/18 2:00 p.m. and 10/26/18 at 10:44 a.m. for Resident #1 revealed he did not remember if he saw the resident's pressure ulcers because the Wound Care Physician was providing wound care. He stated he was responsible for all residents in the facility and if the resident had a different primary care physician, the facility could still call him with resident needs. He stated he did not oversee the care the Wound Care Physician provided. 2. Resident #2's MDS assessment, dated 10/18/18, revealed the resident was a 79 -year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She had severe cognitive impairment. She required extensive assistance of two or more staff for bed mobility and one staff was needed for wheelchair transfers. She was always incontinent of bladder and bowel. The resident had two unstageable/deep tissue injuries present on admission. The resident was using pressure reducing devices in her bed and wheelchair. Resident #2's Care Plans dated 10/24/18 revealed the resident had a deep tissue injury on both heels. Facility interventions included to provide the resident with heel protectors while in bed and to float her heels while she was in bed. Review of Resident #2's clinical record revealed there were no documented Braden Scale for Predicting Pressure Sore Risk Assessments for the resident. Resident #2's Physician Orders, dated (MONTH) (YEAR), revealed an order to clean unstageable pressure ulcers on the left heel and the right heel with wound cleanser and pat dry. Apply skin prep daily until healed. There were no orders to offload the resident's heels while in bed or in her wheelchair. Resident #2's Progress Notes revealed the following: 09/26/18 1:37 p.m. - Resident admitted to the facility. The resident had a Braden Score of 12 (high risk for pressure ulcer development); however, there was no actual assessment reflecting this information. Resident #2's Wound Evaluation and Management Summary signed by the Wound Care Physician revealed: 10/17/18: Wound Progress - No Change Unstageable wound to the right heel - 1.5 cm x 3.0 cm x not measurable depth. Unstageable wound to the left heel - 1.0 cm x 2.0 cm x not measurable depth. 10/24/18: Wound Progress - Deteriorated Unstageable wound to the right heel - 2.5 cm x 3.5 cm x not measurable depth. Unstageable wound to the left heel - 2.0 cm x 1.5 cm x not measurable depth. An observation of Wound Care for Resident #2 on 10/23/18 at 10:50 a.m. with the Wound Care Nurse revealed the resident was seated in her wheelchair. She was wearing socks only and her feet were resting on the foot rests of the wheelchair. Her heels were not off-loaded. Her heels were resting flat against the foot rests. The Wound Care Nurse stated the resident was supposed to have her heels off-loaded in bed and she had to wear soft pillow boots in bed, but there were no interventions ordered or care planned to prevent/reduce pressure on her heels while she was in her wheelchair. The right heel had an area of dry eschar which measured approximately 2.0 cm x 1.0 cm. The left heel had an area of dry eschar which measured approximately 2.0 cm x 1.0 cm. An interview with Charge Nurse LVN O on 10/25/18 at 12:25 p.m. for Resident #2 revealed the resident was always supposed to wear soft boots, but she would sometimes take them off. She did not know if the intervention or refusals were documented on the care plan or Kardex, but it was every nurse's responsibility to keep them updated. She considered neglect to occur anytime staff did not meet the needs of residents. She had received multiple facility in-services regarding neglect identification, prevention, and reporting requirements and pressure ulcer prevention measures were repositioning, off-loading bony prominences, skin cleanliness, hydration and nutrition. An interview with LVN P on 10/25/18 at 2:30 p.m. for Resident #2 revealed she had unstageable ulcers on her heels, but staff failed to keep the resident's heels off-loaded while she was in her wheelchair. He was not aware if the resident's care plans were updated to reflect pressure relief measures. He considered neglect to occur anytime care was not provided to residents. LVN P stated he had received multiple facility in-services regarding neglect identification, prevention, and reporting requirements and pressure ulcer prevention measures were repositioning, off-loading bony prominences, skin cleanliness, hydration and nutrition. An interview with ADON RN M on 10/25/18 at 3:40 p.m. for Resident #3 revealed she was supposed to wear soft pillow boots when she was in her wheelchair, but she did not know why the intervention was not care planned. She stated the resident had a history of [REDACTED]. She considered neglect to be anytime a needed service was not provided to a resident and that she had completed multiple in-services on neglect identification, prevention, and reporting. Pressure ulcer prevention measures staff were to use were, cushions for wheelchairs, support pillows, off-loading, air mattresses, and soft pillow boots. 3. Resident #3's MDS assessment, dated 10/11/18, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She had severe cognitive impairment. She required extensive assistance of one staff for bed mobility. She was always incontinent of bladder and bowel. The resident had facility acquired pressure ulcers: one Stage II, one unstageable, and six unstageable/deep tissue injuries. The resident was using a pressure reducing device in bed and receiving Hospice care. Resident #3's Care Plans dated 09/19/18 revealed the resident was at risk for skin breakdown and had developed pressure ulcers. Facility interventions included pressure relief mattress. There were no other interventions in place to prevent the development or worsening of pressure ulcers for the resident. Resident #3's Braden Scale for Predicting Pressure Sore Risk Assessment, dated 11/02/17, revealed the resident was not at risk for pressure ulcer development. There were no other assessments available for review. Resident #3's Physician Orders, dated (MONTH) (YEAR), revealed: 10/10/18 orders: Stage II pressure ulcer, left foot, lateral heel - cleanse with wound cleanser, apply Xeroform (antibacterial dressing), wrap with Kerlix and Coban (compression wrap) Unstageable deep tissue injury, left foot, lateral side - cleanse with wound cleanser, pat dry, apply skin prep daily Unstageable deep tissue injury, left foot, distal side - cleanse with wound cleanser, pat dry, apply skin prep daily Unstageable deep tissue injury to left foot, medial ankle - cleanse with wound cleanser, pat dry, apply skin prep daily Unstageable deep tissue injury to left foot, medial heel - cleanse with wound cleanser, pat dry, apply skin prep daily Unstageable deep tissue injury to left foot, medial side - cleanse with wound cleanser, pat dry, apply skin prep daily Unstageable deep tissue injury to left foot, distal, medial side - cleanse with wound cleanser, pat dry, apply skin prep daily 10/14/18: Order for Hospice Services Resident #3's Progress Notes revealed the following: 09/19/18 3:12 p.m. - Wound Care Physician at the facility to see new wounds on the resident's left foot. Resident #3's Wound Evaluation and Management Summary signed by the Wound Care Physician revealed: 10/17/18: Wound Progress - No Change Stage II pressure ulcer, left foot, lateral heel - 0.5 cm x 3.0 cm x 0 cm. Unstageable deep tissue injury, left foot, lateral side - 0.8 cm x 1.0 x not measurable depth Unstageable deep tissue injury, left foot, distal side - 0.7 cm x 0.7 cm x not measurable depth Unstageable deep tissue injury to left foot, medial ankle - 2.0 cm x 2.0 cm x not measurable depth Unstageable deep tissue injury to left foot, medial heel - 3.0 cm x 3.0 cm x not measurable depth Unstageable deep tissue injury to left foot, medial side - 1.1 cm x 1.5 cm x not measurable depth Unstageable deep tissue injury to left foot, distal, medial side - 1.0 cm x 1.0 cm x not measurable depth 10/24/18: Wound Progress - Deteriorated Unstageable deep tissue injury, left foot, lateral heel - 6.5 cm x 4.0 cm x not measurable depth Unstageable deep tissue injury, left foot, lateral side - 1.0 cm x 3.0 cm x not measurable depth Unstageable deep tissue injury, left foot, distal side - 0.7 cm x 0.7 cm x not measurable depth Unstageable deep tissue injury to left foot, medial ankle - 2.0 cm x 2.0 cm x not measurable depth Unstageable deep tissue injury to left foot, medial heel - 3.0 cm x 2.0 cm x not measurable depth Unstageable deep tissue injury to left foot, medial side - 1.5 cm x 2.5 cm x not measurable depth Unstageable deep tissue injury to left foot, distal, medial side - 1.0 cm x 1.0 cm x not measurable depth New Wound: Unstageable deep tissue injury to left foot, ankle, lateral side - 1.7 cm x 1.0 cm x not measurable depth Resident #1's Hospice Company J Notes reflected: 10/23/18 Skin Integrity - Wound Care provided by facility wound care nurse. 10/16/18 Skin Integrity - Wound Care provided by facility wound care nurse. Observations of Resident #3 and interview on 10/23/18 at 2:45 p.m. and 10/26/18 at 10:35 a.m. revealed she was lying in bed on a low air loss mattress. She stated she had a sore on her foot. LVN K entered the room and removed the covers to reveal the resident's left foot lying on the mattress and not off-loaded. The left foot had a dressing in place. LVN K stated the resident was supposed to be wearing soft pillow boots on her feet to prevent pressure sores. LVN K found the resident's soft pillow boots and put them on her feet. The resident was also repositioned so that her left foot was off-loaded. The Wound Care Nurse unwrapped the wound dressing on the left foot to reveal the resident had five areas of eschar on the left foot and open areas on the left heel of foot with minimal bloody drainage. An interview with CNA N on 10/25/18 at 11:20 a.m. for Resident #3 revealed the resident was always supposed to wear soft pillow boots. She stated she would find the resident not wearing them because not all staff knew she needed to wear them. Staff did not always know the interventions because the care plan and Kardex for residents was not always updated. She considered neglect to be anytime a resident would ask for assistance, but staff did not respond or assist them. She stated staff were supposed to anticipate resident needs and she had received multiple facility in-services on neglect identification, prevention, and reporting requirements. Pressure ulcer prevention measures included turning residents every two hours, using barrier cream, and making sure a resident's legs and heels were offloaded and separated to prevent bone on bone touching. An interview with Hospice RN L (Hospice Company J) on 10/28/18 at 1:15 p.m. for Resident #3 revealed she assessed and evaluated the resident's wounds on a weekly basis. She stated she was not aware the resident did not have interventions in place (not including the air loss mattress) to prevent pressure ulcer worsening or development. A follow-up interview with the DON on 10/26/18 at 9:15 a.m. and 12:25 p.m. revealed she was responsible for all residents in the facility and considered neglect the failure to provide care to a resident. She stated staff were supposed to reposition residents and offload their pressure points to prevent pressure ulcers. She stated the staff had received multiple in-services to identify, prevent, and reporting neglect. She stated with Resident #1 there was an allegation of neglect because there were no interventions in place to prevent the pressure ulcers between her knees from developing. She did not know that Resident #2 did not have interventions in place when she was in her wheelchair, and she did not know Resident #3 did not have interventions in place to off-load her feet. She stated interventions were supposed to be documented in the resident's care plan. Braden scales were to be completed by charge nurses on admit, weekly every four weeks, and then every 3 months according to the MDS schedule. The DON revealed she had a schedule that included dates she stated the Wound Care Nurse was in-serviced on her responsibilities including the training for the Facility's Skin Integrity Care Delivery Process, dated 06/01/16. A follow-up interview with the Wound Care Nurse on 10/26/18 at 11:45 a.m. revealed she was responsible for all residents with wounds but did not know it was her responsibility to add needed pressure relief interventions to the care plans or Kardex until she was in-serviced on 10/23/18. She considered neglect to be the

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prevented neglect for three (Residents #1, #2, and #3) of six residents reviewed for pressure ulcers. 1. The facility failed to prevent Resident #1 from developing Stage IV pressure ulcers on the inner aspect of each knee on 10/11/18 and surgically debrided (removing dead tissue resulting in a bleeding wound bed) the pressure ulcers without the consent of the resident's family on 10/17/18. As a result, Resident #1's pressure ulcers deteriorated until the resident's passing at the facility on 10/22/18. The resident developed severe pain and was unable to tolerate wound care for the pressure ulcers starting on 10/20/18. 2. The facility failed to implement pressure ulcer prevention measures to prevent worsening of pressure ulcers on Resident #2. As a result, Resident #2 had pressure ulcers on both of her heels that worsened. 3. The facility failed to implement pressure ulcer prevention measures, outside of the use of an air loss mattress, to prevent worsening of pressure ulcers and development of new pressure ulcers for Resident #3. As a result, Resident #3 had pressure ulcers on her left foot and heel that worsened, and a new pressure ulcer that developed on her left foot. An Immediate Jeopardy (IJ) was identified on 10/24/18 at 12:35 PM. While the Immediate Jeopardy was removed on 10/26/18, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy, and at a scope of pattern because the facility was still monitoring the Plan of Removal. These failures had the potential to affect residents by placing them at risk of receiving treatments without having given informed consent and the development or worsening of pressure ulcers. Findings included: 1. The Facility's Abuse, Neglect, and Exploitation Policy, dated (MONTH) (YEAR), reflected: .f. Neglect is defined as failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness. 2. Resident #1's MDS assessment, dated 08/16/18, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She had moderate cognitive impairment. She required extensive assistance of two or more staff for bed mobility. She was always incontinent of bladder and bowel. The resident was at risk for the development of pressure ulcers and was receiving Hospice care. Resident #1's Care Plan, dated 06/21/18, revealed the resident was at risk for skin breakdown related to contractures, incontinence, limited mobility, and friction risks. Facility interventions included to assist the resident in methods to reduce friction, Braden assessments (pressure ulcer risk assessment) per policy and evaluate for skin risk factors per protocol. There were no specific interventions listed regarding how to reduce friction for the resident, or any specifics for offloading or cushioning any areas of the resident's body. Resident #1's Braden Scale for Predicting Pressure Sore Risk Assessment, dated 06/23/18, revealed the resident was at mild risk for the development of pressure ulcers. There were no further assessments available for review. Resident #1's Physician Orders, dated (MONTH) (YEAR), revealed the resident had an order for [REDACTED].>Resident #1's Progress Notes revealed: 10/11/18 at 5:00 p.m. - LVN A notified the Wound Care Nurse regarding wounds found by CNA B to both inner knees. Upon assessment the Wound Care Nurse noted the inner right knee had eschar (dry dead tissue) with yellow slough (moist dead tissue) in the wound bed, measuring 7.0 cm x 4.0 cm. The wound to the left inner knee had eschar tissue with yellow slough in the wound bed. The wounds had a foul odor. The Wound Care Physician and DON were notified, and orders were received to clean both wounds with wound cleanser, apply Santyl ([MEDICATION NAME] ointment), and apply calcium alginate (dressing that absorbs drainage). Cover the wounds with dry dressings daily. Resident #1's Weekly Skin Inspection Assessment, dated 10/11/18 revealed the resident had developed new pressure ulcers on the inner aspects of both knees. The right knee had eschar measuring 7.0 centimeters (cm) x 4.0 cm. The left knee had a wound, but the area could not be measured due to her leg contracture. Skin assessments prior to 10/11/18 did not have these wounds documented. Resident #1's Wound Evaluation and Management Summary, dated 10/17/18, and signed by the Wound Care Physician revealed the resident had a Stage IV pressure ulcer on the inner aspect of both knees. The pressure ulcer on her left inner knee measured 8.0 cm x 4.5 cm x 0.3 cm. The pressure ulcer on her right inner knee measured 11.0 cm x 8.0 cm x 0.3 cm. The resident required surgical debridement of both knees to remove necrotic tissue. The document indicated consent had been received for the surgical debridement. Hospice Company C Certification and Plan of Care, dated 08/09/18, reflected: .Hospice Skilled Nurse to assess wounds every visit .Hospice nurse to coordinate plan of care with facility staff . Hospice Company C Notes: 10/18/18 Skin Integrity - Wounds not assessed. An observation of Resident #1 on 10/22/18 at 4:32 p.m. revealed the resident was lying in bed. Hospice was at the bedside due to the resident's decline in status. The resident was actively dying and passed away shortly after entering the facility. The resident was asleep and not able to communicate during observation. The resident did not respond to verbal stimuli. She was lying on her right side with her legs drawn up in a contracted, fetal position. There was a wound dressing on both knees. There was no barrier in place to prevent the knees from touching each other. The wound dressings were removed by staff and revealed each knee had white tissue/bone that was exposed, with a large amount of drainage, slough, and dead tissue. The wounds had a foul odor. An interview with CNA B on 10/23/18 at 4:25 p.m. for Resident #1 revealed on 10/11/18 he walked into the resident's room and smelled a foul odor. CNA B pulled the blankets back and found the resident's knees were touching and each knee had a wound on it. He notified LVN A. CNA B stated staff would sometimes place a pillow between the resident's knees to keep them from touching, but not always. He stated the pillow was not there on 10/11/18. He stated he was able to do incontinent care for the resident by separating her legs and knees to clean her, but otherwise her knees and legs had a history of [REDACTED]. Interviews with LVN A on 10/23/18 at 4:15 p.m. and 10/25/18 at 2:55 p.m. for Resident #1 revealed on 10/11/18, CNA B notified him that the resident had wounds between her knees. The wounds were open, draining, and had a foul odor. The resident's legs and knees stayed in a contracted position with the knees touching. He stated the resident did not have a pillow in place between her knees. He stated he notified the Wound Care Nurse to assess the wounds. Residents were supposed to be turned every two hours as needed. Pillows and pillow boots were supposed to be used to offload heels and bony prominences. He stated Resident #1 developed pressure ulcers between her knees because she was contracted and was supposed to always have a pillow in place between her knees. He stated he did not know if the resident had the intervention care planned. LVN A stated he considered neglect to be anything staff were supposed to do but failed to do for residents. He stated he had received multiple facility in-services for neglect identification, prevention, and reporting. Interviews with the Wound Care Nurse on 10/23/18 at 9:25 a.m. and 10/24/18 at 10:50 a.m. for Resident #1 revealed the facility had an ownership change on 10/01/18. She started doing wound care at the facility in (MONTH) (YEAR). In (MONTH) (YEAR) she received some training on her role as the wound care nurse and documented her notes in the computer. When the new ownership took over on 10/01/18, she was told she would be trained, but was not. She was told that she would be documenting on new forms and would be instructed on how to use them. The Wound Care Nurse said that as of 10/24/18, she still had not received all of the training she needed for her role as the facility wound care nurse. She received an in-service on 10/23/18 (after the surveyor had entered on 10/22/18) that included responsibilities she did not know she had. She said the new responsibilities included to communicate with the families on a weekly basis regarding wound care and update care plans. She stated that prior to 10/23/18, she would update care plans regarding the wound size changes, but did not know she was supposed to include interventions to prevent the development/worsening of new pressure ulcers and had not previously included that information. She stated she had signed an in-service form which had instructions on when and how to use pressure relief measures and devices, but she did not actually read it or receive training on it. The Wound Care Nurse stated she was notified on about the discovery of wounds between Resident #1's knees on 10/11/18. The resident did not have a pillow or other barrier between the knees when she saw her. The resident had a wound on the inner aspect of each knee. Her legs were very contracted and difficult to pull apart. She examined them and contacted the Wound Care Physician to get orders for treatment. She contacted the DON who notified Hospice Company C. She also contacted the resident's family. She stated she and the Wound Care Physician had assessed the resident on 10/10/18, but the resident did not have wounds on her inner knees at that time. She stated they discussed the resident's contracted legs and the risk for pressure ulcer development between the resident's knees. The Wound Care Nurse stated sometimes staff would place a pillow between the resident's knees to keep them from touching, but there were no orders or care plans to keep a pillow or other barrier in place. She stated she asked the resident's family on 10/11/18 to purchase thin pillows that would be more comfortable for the resident to place between her contracted legs to keep the knees from touching after the wound was found, but she did not get an order or care plan the interventions because she did not know she was supposed to. The Wound Care Nurse stated the Wound Care Physician did not evaluate Resident #1's wounds until 10/17/18, and at that time he stated the resident's wounds were Stage IV pressure ulcers. She did not stage them when they were first found, but they were large, open, and draining. The Wound Care Physician had to surgically debride dead tissue from the knee wounds on 10/17/18. After the debridement, the wounds worsened with an increase in size, drainage, and odor. She stated she did not notify the family, DON, Wound Care Physician, or Medical Director about the wound changes because the resident was on Hospice and she thought the charge nurses were supposed to do notifications. She stated she did notify the Hospice Nurse and requested an order from the Hospice Physician for antibiotics or treatment to address the wound odor. The Hospice Nurse did not call her back and she did not follow-up with anyone else regarding the wounds. The Wound Care Nurse stated she changed the dressings on 10/11/18, 10/12/18, and 10/15/18-10/22/18 based on a calendar she was looking at for October. The resident went on continuous Hospice Care on 10/20/18 and the family requested the wound care dressings not be changed after that due to the pain of the dressing changes. The resident passed away at the facility on 10/22/18. An interview with the Wound Care Physician on 10/23/18 at 12:20 p.m. for Resident #1 revealed on 10/10/18 he and the Wound Care Nurse made rounds to look at a healing pressure ulcer on her foot. He noticed the resident had her legs contracted in a fetal position with her knees touching. She did not have any skin breakdown between her knees at that time. He discussed with the wound care nurse that the resident needed a measure in place to prevent the knees from touching to prevent pressure ulcers from developing. He did not write new orders but stated the Wound Care Nurse told him staff would place a pillow between her knees. He stated on 10/11/18, the resident was found with new wounds between her knees, but with constant pressure with her knees touching and her compromised nutrition, the wounds could have developed overnight. On 10/17/18 the wounds required surgical debridement to remove a lot of dead tissue. He stated the resident was nutritionally compromised, and once the ulcers developed, they deteriorated very quickly. He stated the wound on the inner aspect of each knee was a Stage IV on 10/17/18, and that was the last day he assessed the wounds. He stated for surgical debridement, the facility was responsible for obtaining consent. Interviews with Charge Nurse LVN D on 10/23/18 at 11:20 a.m. and 10/24/18 at 9:05 a.m. for Resident #1 revealed the resident admitted to the facility and had a gradual decline in her health. Hospice Company C started caring for her due to her [DIAGNOSES REDACTED]. The resident had her legs contracted and her knees were clamped together and constantly touching. The resident was very thin with bony prominences exposed. She stated after the wounds were found, the Wound Care Nurse contacted the family to purchase thin pillows to keep placed between the resident's knees. Prior to that she stated staff were supposed to put a pillow between her knees or a towel wrapped in a pillowcase to keep the knees from touching. She stated when she cared for the resident and found she did not have a pillow between her knees, she would place one and tell the CNA that she was supposed to have one. She said she did not know how staff were supposed to know about the intervention, but she told the staff she worked with about it. An interview with LVN G on 10/25/18 at 11:50 a.m. for Resident #1 revealed she was supposed to have a pillow between her knees to prevent pressure ulcers from developing, and the intervention should have been documented on the resident's care plan. She considered neglect to be anything that should have been done for a resident that was not done. She stated she had received multiple facility in-services on identifying, preventing, and reporting neglect. She stated to prevent pressure ulcers, staff had to make sure that pressure points were off-loaded, and a barrier was in place to prevent the pressure points from touching. An interview with LVN H on 10/25/18 at 1:45 p.m. for Resident #1 revealed on 10/14/18, she saw pressure ulcers on the inner side of both knees. She stated the wounds were draining through the dressings and onto the pillow between her legs and had a foul odor. She stated she did not notify the physician about the wound. She stated the resident was supposed to have had a pillow kept between her knees to prevent pressure ulcer development. Residents were all supposed to have an updated activities of daily living (ADL) Kardex so staff would know which interventions were in place, but she did not know if the resident had one. Nurses were supposed to notify the physician and family with any changes in condition. She considered neglect to be: not having the resident's call light in reach, not offering water, not giving showers, not changing or turning, and not offloading pressure points to prevent pressure ulcers. She stated she had received multiple facility in-services on identifying, preventing, and reporting neglect. She stated to prevent pressure ulcers, staff had to off-load pressure points, reposition residents every 2 hours, and provide adequate nutrition and hydration. An interview with ADON I on 10/25/18 at 1:05 p.m. for Resident #1 revealed she considered neglect to be anything the staff did to not meet the needs of the resident. She stated she had received multiple facility in-services on neglect identification, prevention, and reporting requirements. She stated to prevent pressure ulcer development, staff were supposed to offload pressure sites and have devices in place to prevent the pressure sites from touching. She stated Resident #1 developed a pressure ulcer between her knees because there were no interventions in place to prevent their development. She stated the information should have been on the resident's care plan and Kardex and all nurses were able to update them. She did not know if the resident had one or not. Interviews with the DON on 10/23/18 at 12:45 p.m., 10/24/18 at 9:30 a.m. and 10:40 a.m. for Resident #1 revealed she saw the wounds on her inner knees on 10/11/18. She stated at that time they had a small amount of slough. She stated she never spoke to the physician about the wounds, but the Wound Care Nurse did. The resident was receiving Hospice care and the facility was managing the resident's wound care. She stated the resident was at risk for pressure ulcer development between her knees because she had low [MEDICATION NAME], low protein, contractures, was bed bound, and had weight loss. Staff were supposed to keep a pillow or pressure-relieving device between her knees to prevent pressure ulcers from developing. Staff were supposed to know to keep a pillow between her knees by reviewing the care plan, but the intervention was not listed. The facility also utilized a resident Kardex that was easy to access for staff, but the resident did not have a Kardex either. She stated the Kardex was supposed to be developed from the resident's care plan and if the interventions to prevent pressure ulcer development/worsening was not in the care plan, the information was not included on the Kardex. Orders were not required to be written as of 10/01/18, because new ownership took over and they did not allow orders to include pressure ulcer prevention measures. The DON stated prior to the ownership change on 10/01/18 she provided oversight to the Wound Care Nurse by doing spot checks on wounds. After the ownership changed, she only looked at and assessed new wounds. She stated all staff, including the wound care nurse had received yearly in-service training that included pressure ulcer prevention measures. An interview on 10/23/18 at 11:45 a.m. with Hospice CNA E (Hospice Company C) for Resident #1 revealed she bathed the resident on Mondays, Wednesdays, and Fridays. The resident did not have pressure ulcers between her knees on 10/10/18. She stated the resident was very contracted and she would have to pull the resident's knees apart to do incontinent care. An interview with Hospice RN F (Hospice Company C) on 10/23/18 at 1:35 p.m. for Resident #1 revealed she saw the resident on 10/02/18, 10/19/18, and 10/22/18. On 10/19/18 the resident had dressings that were soiled on each knee. The wounds had a foul odor. She notified the facility Wound Care Nurse to change the dressings. She stated she did not see the wounds because Hospice did not undress and redress wounds. She stated there was not any discussion with the family about more aggressive treatment for [REDACTED]. Interviews with the Medical Director on 10/23/18 2:00 p.m. and 10/26/18 at 10:44 a.m. for Resident #1 revealed he did not remember if he saw the resident's pressure ulcers because the Wound Care Physician was providing wound care. He stated he was responsible for all residents in the facility and if the resident had a different primary care physician, the facility could still call him with resident needs. He stated he did not oversee the care the Wound Care Physician provided. 3. Resident #2's MDS assessment, dated 10/18/18, revealed the resident was a 79 -year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She had severe cognitive impairment. She required extensive assistance of two or more staff for bed mobility and one staff was needed for wheelchair transfers. She was always incontinent of bladder and bowel. The resident had two unstageable/deep tissue injuries present on admission. The resident was using pressure reducing devices in her bed and wheelchair. Resident #2's Care Plans dated 10/24/18 revealed the resident had a deep tissue injury on both heels. Facility interventions included to provide the resident with heel protectors while in bed and to float her heels while she was in bed. Review of Resident #2's clinical record revealed there were no documented Braden Scale for Predicting Pressure Sore Risk Assessments for the resident. Resident #2's Physician Orders, dated (MONTH) (YEAR), revealed an order to clean unstageable pressure ulcers on the left heel and the right heel with wound cleanser and pat dry. Apply skin prep daily until healed. There were no orders to offload the resident's heels while in bed or in her wheelchair. Resident #2's Progress Notes revealed the following: 09/26/18 1:37 p.m. - Resident admitted to the facility. The resident had a Braden Score of 12 (high risk for pressure ulcer development); however, there was no actual assessment reflecting this information. Resident #2's Wound Evaluation and Management Summary signed by the Wound Care Physician revealed: 10/17/18: Wound Progress - No Change Unstageable wound to the right heel - 1.5 cm x 3.0 cm x not measurable depth. Unstageable wound to the left heel - 1.0 cm x 2.0 cm x not measurable depth. 10/24/18: Wound Progress - Deteriorated Unstageable wound to the right heel - 2.5 cm x 3.5 cm x not measurable depth. Unstageable wound to the left heel - 2.0 cm x 1.5 cm x not measurable depth. An observation of Wound Care for Resident #2 on 10/23/18 at 10:50 a.m. with the Wound Care Nurse revealed the resident was seated in her wheelchair. She was wearing socks only and her feet were resting on the foot rests of the wheelchair. Her heels were not off-loaded. Her heels were resting flat against the foot rests. The Wound Care Nurse stated the resident was supposed to have her heels off-loaded in bed and she had to wear soft pillow boots in bed, but there were no interventions ordered or care planned to prevent/reduce pressure on her heels while she was in her wheelchair. The right heel had an area of dry eschar which measured approximately 2.0 cm x 1.0 cm. The left heel had an area of dry eschar which measured approximately 2.0 cm x 1.0 cm. An interview with Charge Nurse LVN O on 10/25/18 at 12:25 p.m. for Resident #2 revealed the resident was always supposed to wear soft boots, but she would sometimes take them off. She did not know if the intervention or refusals were documented on the care plan or Kardex, but it was every nurse's responsibility to keep them updated. She considered neglect to occur anytime staff did not meet the needs of residents. She had received multiple facility in-services regarding neglect identification, prevention, and reporting requirements and pressure ulcer prevention measures were repositioning, off-loading bony prominences, skin cleanliness, hydration and nutrition. An interview with LVN P on 10/25/18 at 2:30 p.m. for Resident #2 revealed she had unstageable ulcers on her heels, but staff failed to keep the resident's heels off-loaded while she was in her wheelchair. He was not aware if the resident's care plans were updated to reflect pressure relief measures. He considered neglect to occur anytime care was not provided to residents. LVN P stated he had received multiple facility in-services regarding neglect identification, prevention, and reporting requirements and pressure ulcer prevention measures were repositioning, off-loading bony prominences, skin cleanliness, hydration and nutrition. An interview with ADON RN M on 10/25/18 at 3:40 p.m. for Resident #3 revealed she was supposed to wear soft pillow boots when she was in her wheelchair, but she did not know why the intervention was not care planned. She stated the resident had a history of [REDACTED]. She considered neglect to be anytime a needed service was not provided to a resident and that she had completed multiple in-services on neglect identification, prevention, and reporting. Pressure ulcer prevention measures staff were to use were, cushions for wheelchairs, support pillows, off-loading, air mattresses, and soft pillow boots. 4. Resident #3's MDS assessment, dated 10/11/18, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She had severe cognitive impairment. She required extensive assistance of one staff for bed mobility. She was always incontinent of bladder and bowel. The resident had facility acquired pressure ulcers: one Stage II, one unstageable, and six unstageable/deep tissue injuries. The resident was using a pressure reducing device in bed and receiving Hospice care. Resident #3's Care Plans dated 09/19/18 revealed the resident was at risk for skin breakdown and had developed pressure ulcers. Facility interventions included pressure relief mattress. There were no other interventions in place to prevent the development or worsening of pressure ulcers for the resident. Resident #3's Braden Scale for Predicting Pressure Sore Risk Assessment, dated 11/02/17, revealed the resident was not at risk for pressure ulcer development. There were no other assessments available for review. Resident #3's Physician Orders, dated (MONTH) (YEAR), revealed: 10/10/18 orders: Stage II pressure ulcer, left foot, lateral heel - cleanse with wound cleanser, apply Xeroform (antibacterial dressing), wrap with Kerlix and Coban (compression wrap) Unstageable deep tissue injury, left foot, lateral side - cleanse with wound cleanser, pat dry, apply skin prep daily Unstageable deep tissue injury, left foot, distal side - cleanse with wound cleanser, pat dry, apply skin prep daily Unstageable deep tissue injury to left foot, medial ankle - cleanse with wound cleanser, pat dry, apply skin prep daily Unstageable deep tissue injury to left foot, medial heel - cleanse with wound cleanser, pat dry, apply skin prep daily Unstageable deep tissue injury to left foot, medial side - cleanse with wound cleanser, pat dry, apply skin prep daily Unstageable deep tissue injury to left foot, distal, medial side - cleanse with wound cleanser, pat dry, apply skin prep daily 10/14/18: Order for Hospice Services Resident #3's Progress Notes revealed the following: 09/19/18 3:12 p.m. - Wound Care Physician at the facility to see new wounds on the resident's left foot. Resident #3's Wound Evaluation and Management Summary signed by the Wound Care Physician revealed: 10/17/18: Wound Progress - No Change Stage II pressure ulcer, left foot, lateral heel - 0.5 cm x 3.0 cm x 0 cm. Unstageable deep tissue injury, left foot, lateral side - 0.8 cm x 1.0 x not measurable depth Unstageable deep tissue injury, left foot, distal side - 0.7 cm x 0.7 cm x not measurable depth Unstageable deep tissue injury to left foot, medial ankle - 2.0 cm x 2.0 cm x not measurable depth Unstageable deep tissue injury to left foot, medial heel - 3.0 cm x 3.0 cm x not measurable depth Unstageable deep tissue injury to left foot, medial side - 1.1 cm x 1.5 cm x not measurable depth Unstageable deep tissue injury to left foot, distal, medial side - 1.0 cm x 1.0 cm x not measurable depth 10/24/18: Wound Progress - Deteriorated Unstageable deep tissue injury, left foot, lateral heel - 6.5 cm x 4.0 cm x not measurable depth Unstageable deep tissue injury, left foot, lateral side - 1.0 cm x 3.0 cm x not measurable depth Unstageable deep tissue injury, left foot, distal side - 0.7 cm x 0.7 cm x not measurable depth Unstageable deep tissue injury to left foot, medial ankle - 2.0 cm x 2.0 cm x not measurable depth Unstageable deep tissue injury to left foot, medial heel - 3.0 cm x 2.0 cm x not measurable depth Unstageable deep tissue injury to left foot, medial side - 1.5 cm x 2.5 cm x not measurable depth Unstageable deep tissue injury to left foot, distal, medial side - 1.0 cm x 1.0 cm x not measurable depth New Wound: Unstageable deep tissue injury to left foot, ankle, lateral side - 1.7 cm x 1.0 cm x not measurable depth Resident #1's Hospice Company J Notes reflected: 10/23/18 Skin Integrity - Wound Care provided by facility wound care nurse. 10/16/18 Skin Integrity - Wound Care provided by facility wound care nurse. Observations of Resident #3 and interview on 10/23/18 at 2:45 p.m. and 10/26/18 at 10:35 a.m. revealed she was lying in bed on a low air loss mattress. She stated she had a sore on her foot. LVN K entered the room and removed the covers to reveal the resident's left foot lying on the mattress and not off-loaded. The left foot had a dressing in place. LVN K stated the resident was supposed to be wearing soft pillow boots on her feet to prevent pressure sores. LVN K found the resident's soft pillow boots and put them on her feet. The resident was also repositioned so that her left foot was off-loaded. The Wound Care Nurse unwrapped the wound dressing on the left foot to reveal the resident had five areas of eschar on the left foot and open areas on the left heel of foot with minimal bloody drainage. An interview with CNA N on 10/25/18 at 11:20 a.m. for Resident #3 revealed the resident was always supposed to wear soft pillow boots. She stated she would find the resident not wearing them because not all staff knew she needed to wear them. Staff did not always know the interventions because the care plan and Kardex for residents was not always updated. She considered neglect to be anytime a resident would ask for assistance, but staff did not respond or assist them. She stated staff were supposed to anticipate resident needs and she had received multiple facility in-services on neglect identification, prevention, and reporting requirements. Pressure ulcer prevention measures included turning residents every two hours, using barrier cream, and making sure a resident's legs and heels were offloaded and separated to prevent bone on bone touching. An interview with Hospice RN L (Hospice Company J) on 10/28/18 at 1:15 p.m. for Resident #3 revealed she assessed and evaluated the resident's wounds on a weekly basis. She stated she was not aware the resident did not have interventions in place (not including the air loss mattress) to prevent pressure ulcer worsening or development. A follow-up interview with the DON on 10/26/18 at 9:15 a.m. and 12:25 p.m. revealed she was responsible for all residents in the facility and considered neglect the failure to provide care to a resident. She stated staff were supposed to reposition residents and offload their pressure points to prevent pressure ulcers. She stated the staff had received multiple in-services to identify, prevent, and reporting neglect. She stated with Resident #1 there was an allegation of neglect because there were no interventions in place to prevent the pressure ulcers between her knees from developing. She did not know that Resident #2 did not have interventions in place when she was in her wheelchair, and she did not know Resident #3 did not have interventions in place to off-load her feet. She stated interventions were supposed to be documented in the resident's care plan. Braden scales were to be completed by charge nurses on admit, weekly every four weeks, and then every 3 months according to the MDS schedule. The DON revealed she had a schedule that included dates she stated the Wound Care Nurse was in-serviced on her responsibilities including the training for the Facility's Skin Integrity Care Delivery Process, dated 06/01/16. A follow-up interview with the Wound

Based on observation, interview, and record review, the facility failed to ensure residents received care to prevent pressure ulcers and residents with pressure ulcers received the necessary treatment and services, to promote healing and prevent new ulcers from developing for three (Residents #1, #2, and #3) of six residents reviewed for pressure ulcers. 1. The facility failed to prevent Resident #1 from developing Stage IV pressure ulcers on the inner aspect of each knee on 10/11/18, and surgically debrided (removing dead tissue resulting in a bleeding wound bed) the pressure ulcers without the consent of the resident's family on 10/17/18. As a result, Resident #1's pressure ulcers deteriorated until the resident's passing at the facility on 10/22/18. The resident developed severe pain and was unable to tolerate wound care for the pressure ulcers starting on 10/20/18. 2. The facility failed to implement pressure ulcer prevention measures to prevent worsening of pressure ulcers on Resident #2. As a result, Resident #2 had pressure ulcers on both of her heels that worsened. 3. The facility failed to implement pressure ulcer prevention measures, outside of the use of an air loss mattress, to prevent worsening of pressure ulcers and development of new pressure ulcers for Resident #3. As a result, Resident #3 had pressure ulcers on her left foot and heel that worsened, and a new pressure ulcer that developed on her left foot. An Immediate Jeopardy (IJ) was identified on 10/24/18. While the Immediate Jeopardy was removed on 10/26/18, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy, and at a scope of pattern because the facility was still monitoring the Plan of Removal. These failures had the potential to affect residents by placing them at risk of receiving treatments without having given informed consent and the development or worsening of pressure ulcers. Findings included: 1. Resident #1's MDS assessment, dated 08/16/18, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She had moderate cognitive impairment. She required extensive assistance of two or more staff for bed mobility. She was always incontinent of bladder and bowel. The resident was at risk for the development of pressure ulcers and was receiving Hospice care. Resident #1's Care Plan, dated 06/21/18, revealed the resident was at risk for skin breakdown related to contractures, incontinence, limited mobility, and friction risks. Facility interventions included to assist the resident in methods to reduce friction, Braden assessments (pressure ulcer risk assessment) per policy and evaluate for skin risk factors per protocol. There were no specific interventions listed regarding how to reduce friction for the resident, or any specifics for offloading or cushioning any areas of the resident's body. Resident #1's Braden Scale for Predicting Pressure Sore Risk Assessment, dated 06/23/18, revealed the resident was at mild risk for the development of pressure ulcers. There were no further assessments available for review. Resident #1's Physician Orders, dated (MONTH) (YEAR), revealed the resident had an order for [REDACTED].>Resident #1's Progress Notes revealed: 10/11/18 at 5:00 p.m. - LVN A notified the Wound Care Nurse regarding wounds found by CNA B to both inner knees. Upon assessment the Wound Care Nurse noted the inner right knee had eschar (dry dead tissue) with yellow slough (moist dead tissue) in the wound bed, measuring 7.0 cm x 4.0 cm. The wound to the left inner knee had eschar tissue with yellow slough in the wound bed. The wounds had a foul odor. The Wound Care Physician and DON were notified, and orders were received to clean both wounds with wound cleanser, apply Santyl ([MEDICATION NAME] ointment), and apply calcium alginate (dressing that absorbs drainage). Cover the wounds with dry dressings daily. Resident #1's Weekly Skin Inspection assessment dated [DATE] revealed the resident had developed new pressure ulcers on the inner aspects of both knees. The right knee had eschar measuring 7.0 cm x 4.0 cm. The left knee had a wound, but the area could not be measured due to her leg contracture. Review of Resident #1's skin assessments prior to 10/11/18 revealed no documentation regarding these pressure ulcers. Resident #1's Wound Evaluation and Management Summary, dated 10/17/18, and signed by the Wound Care Physician revealed the resident had a Stage IV pressure ulcer on the inner aspect of both knees. The pressure ulcer on her left inner knee measured 8.0 cm x 4.5 cm x 0.3 cm. The pressure ulcer on her right inner knee measured 11.0 cm x 8.0 cm x 0.3 cm. The resident required surgical debridement of both knees to remove necrotic tissue. The document indicated consent had been received for the surgical debridement. Hospice Company C Certification and Plan of Care, dated 08/09/18, reflected: .Hospice Skilled Nurse to assess wounds every visit .Hospice nurse to coordinate plan of care with facility staff . Hospice Company C Notes, dated 10/18/18, reflected no documentation regarding the wounds. An observation of Resident #1 on 10/22/18 at 4:32 p.m. revealed the resident was lying in bed. Hospice was at the bedside due to the resident's decline in status. The resident was actively dying and passed away shortly after entering the facility. The resident was asleep and not able to communicate during observation. The resident did not respond to verbal stimuli. She was lying on her right side with her legs drawn up in a contracted, fetal position. There was a wound dressing on both knees. There was no barrier in place to prevent the knees from touching each other. The wound dressings were removed by staff and revealed each knee had white tissue/bone that was exposed, with a large amount of drainage, slough, and dead tissue. The wounds had a foul odor. An interview with CNA B on 10/23/18 at 4:25 p.m. for Resident #1 revealed on 10/11/18 he walked into the resident's room and smelled a foul odor. CNA B pulled the blankets back and found the resident's knees were touching and each knee had a wound on it. He notified LVN A. CNA B stated staff would sometimes place a pillow between the resident's knees to keep them from touching, but not always. He stated the pillow was not there on 10/11/18. He stated he was able to do incontinent care for the resident by separating her legs and knees to clean her, but otherwise her knees and legs had a history of [REDACTED]. Interviews with LVN A on 10/23/18 at 4:15 p.m. and 10/25/18 at 2:55 p.m. for Resident #1 revealed on 10/11/18, CNA B notified him that the resident had wounds between her knees. The wounds were open, draining, and had a foul odor. The resident's legs and knees stayed in a contracted position with the knees touching. He stated the resident did not have a pillow in place between her knees. He stated he notified the Wound Care Nurse to assess the wounds. Residents were supposed to be turned every two hours as needed. Pillows and pillow boots were supposed to be used to offload heels and bony prominences. He stated Resident #1 developed pressure ulcers between her knees because she was contracted and was supposed to always have a pillow in place between her knees. He stated he did not know if the resident had the intervention care planned. Interviews with the Wound Care Nurse on 10/23/18 at 9:25 a.m. and 10/24/18 at 10:50 a.m. for Resident #1 revealed the facility had an ownership change on 10/01/18. She started doing wound care at the facility in (MONTH) (YEAR). In (MONTH) (YEAR) she received some training on her role as the wound care nurse and documented her notes in the computer. When the new ownership took over on 10/01/18, she was told she would be trained, but was not. She was told that she would be documenting on new forms and would be instructed on how to use them. The Wound Care Nurse said that as of 10/24/18, she still had not received all of the training she needed for her role as the facility wound care nurse. She received an in-service on 10/23/18 (after the surveyor had entered on 10/22/18) that included responsibilities she did not know she had. She said the new responsibilities included to communicate with the families on a weekly basis regarding wound care and update care plans. She stated that prior to 10/23/18, she would update care plans regarding the wound size changes, but did not know she was supposed to include interventions to prevent the development/worsening of new pressure ulcers and had not previously included that information. She stated she had signed an in-service form which had instructions on when and how to use pressure relief measures and devices, but she did not actually read it or receive training on it. On 10/11/18, she was notified on about the discovery of wounds between Resident #1's knees. The resident did not have a pillow or other barrier between the knees when she saw her. The resident had a wound on the inner aspect of each knee. Her legs were very contracted and difficult to pull apart. She examined them and contacted the Wound Care Physician to get orders for treatment. She contacted the DON who notified Hospice Company C. She also contacted the resident's family. She stated she and the Wound Care Physician had assessed the resident on 10/10/18, but the resident did not have wounds on her inner knees at that time. She stated they discussed the resident's contracted legs and the risk for pressure ulcer development between the resident's knees. The Wound Care Nurse stated sometimes staff would place a pillow between the resident's knees to keep them from touching, but there were no orders or care plans to keep a pillow or other barrier in place. She stated she asked the family on 10/11/18 to purchase thin pillows that would be more comfortable for the resident to place between her contracted legs to keep the knees from touching after the wound was found, but she did not get an order or care plan the interventions because she did not know she was supposed to. She stated the Wound Care Physician did not evaluate the wounds until 10/17/18, and at that time he stated the resident's wounds were Stage IV pressure ulcers. She did not stage them when they were first found, but they were large, open, and draining. The Wound Care Physician had to surgically debride dead tissue from the knee wounds on 10/17/18. The Wound Care Nurse said after the debridement, the wounds worsened with an increase in size, drainage, and odor. She stated she did not notify the family, DON, Wound Care Physician, or Medical Director about the wound changes because the resident was on Hospice and she thought the charge nurses were supposed to do notifications. She stated she did notify the Hospice Nurse and requested an order from the Hospice Physician for antibiotics or treatment to address the wound odor. The Hospice Nurse did not call her back and she did not follow-up with anyone else regarding the wounds. The Wound Care Nurse changed the dressings on 10/11/18, 10/12/18, and 10/15/18-10/22/18 based on a calendar she was looking at for October. The resident went on continuous Hospice Care on 10/20/18 and the family requested the wound care dressings not be changed after that due to the pain of the dressing changes. The resident passed away at the facility on 10/22/18. An interview with the Wound Care Physician on 10/23/18 at 12:20 p.m. for Resident #1 revealed on 10/10/18 he and the Wound Care Nurse made rounds to look at a healing pressure ulcer on her foot. He noticed the resident had her legs contracted in a fetal position with her knees touching. She did not have any skin breakdown between her knees at that time. He discussed with the wound care nurse that the resident needed a measure in place to prevent the knees from touching to prevent pressure ulcers from developing. He did not write new orders but stated the Wound Care Nurse told him staff would place a pillow between her knees. He stated on 10/11/18, the resident was found with new wounds between her knees, but with constant pressure with her knees touching and her compromised nutrition, the wounds could have developed overnight. On 10/17/18 the wounds required surgical debridement to remove a lot of dead tissue. He stated the resident was nutritionally compromised, and once the ulcers developed, they deteriorated very quickly. He stated the wound on the inner aspect of each knee was a Stage IV on 10/17/18, and that was the last day he assessed the wounds. He stated for surgical debridement, the facility was responsible for obtaining consent. Interviews with Charge Nurse LVN D on 10/23/18 at 11:20 a.m. and 10/24/18 at 9:05 a.m. for Resident #1 revealed the resident admitted to the facility and had a gradual decline in her health. Hospice Company C started caring for her due to her [DIAGNOSES REDACTED]. The resident had her legs contracted and her knees were clamped together and constantly touching. The resident was very thin with bony prominences exposed. She stated after the wounds were found, the Wound Care Nurse contacted the family to purchase thin pillows to keep placed between the resident's knees. Prior to that she stated staff were supposed to put a pillow between her knees or a towel wrapped in a pillowcase to keep the knees from touching. She stated when she cared for the resident and found she did not have a pillow between her knees, she would place one and tell the CNA that she was supposed to have one. She said she did not know how staff were supposed to know about the intervention, but she told the staff she worked with about it. An interview with LVN G on 10/25/18 at 11:50 a.m. for Resident #1 revealed she was supposed to have a pillow between her knees to prevent pressure ulcers from developing, and the intervention should have been documented on the resident's care plan. She stated to prevent pressure ulcers, staff had to make sure that pressure points were off-loaded, and a barrier was in place to prevent the pressure points from touching. An interview with LVN H on 10/25/18 at 1:45 p.m. for Resident #1 revealed on 10/14/18, she saw pressure ulcers on the inner side of both knees. She stated the wounds were draining through the dressings and onto the pillow between her legs and had a foul odor. She stated she did not notify the physician about the wound. She stated the resident was supposed to have had a pillow kept between her knees to prevent pressure ulcer development. Residents were all supposed to have an updated activities of daily living (ADL) Kardex so staff would know which interventions were in place, but she did not know if the resident had one. Nurses were supposed to notify the physician and family with any changes in condition. She stated to prevent pressure ulcers, staff had to off-load pressure points, reposition residents every 2 hours, and provide adequate nutrition and hydration. An interview with ADON I on 10/25/18 at 1:05 p.m. for Resident #1 revealed to prevent pressure ulcer development, staff were supposed to offload pressure sites and have devices in place to prevent the pressure sites from touching. She stated Resident #1 developed a pressure ulcer between her knees because there were no interventions in place to prevent their development. She stated the information should have been on the resident's care plan and Kardex and all nurses were able to update them. She did not know if the resident had one or not. Interviews with the DON on 10/23/18 at 12:45 p.m., 10/24/18 at 9:30 a.m. and 10:40 a.m. for Resident #1 revealed she saw the wounds on her inner knees on 10/11/18. She stated at that time they had a small amount of slough. She stated she never spoke to the physician about the wounds, but the Wound Care Nurse did. The resident was receiving Hospice care and the facility was managing the resident's wound care. She stated the resident was at risk for pressure ulcer development between her knees because she had low [MEDICATION NAME], low protein, contractures, was bed bound, and had weight loss. Staff were supposed to keep a pillow or pressure-relieving device between her knees to prevent pressure ulcers from developing. Staff were supposed to know to keep a pillow between her knees by reviewing the care plan, but the intervention was not listed. The facility also utilized a resident Kardex that was easy to access for staff, but the resident did not have a Kardex either. She stated the Kardex was supposed to be developed from the resident's care plan and if the interventions to prevent pressure ulcer development/worsening was not in the care plan, the information was not included on the Kardex. Orders were not required to be written as of 10/01/18, because new ownership took over and they did not allow orders to include pressure ulcer prevention measures. The DON stated prior to the ownership change on 10/01/18 she provided oversight to the Wound Care Nurse by doing spot checks on wounds. After the ownership changed, she only looked at and assessed new wounds. She stated all staff, including the wound care nurse had received yearly in-service training that included pressure ulcer prevention measures. An interview on 10/23/18 at 11:45 a.m. with Hospice CNA E (Hospice Company C) for Resident #1 revealed she bathed the resident on Mondays, Wednesdays, and Fridays. The resident did not have wounds pressure ulcers between her knees on 10/10/18. She stated the resident was very contracted and she would have to pull the resident's knees apart to do incontinent care. An interview with Hospice RN F (Hospice Company C) on 10/23/18 at 1:35 p.m. for Resident #1 revealed she saw the resident on 10/02/18, 10/19/18, and 10/22/18. On 10/19/18 the resident had dressings that were soiled on each knee. The wounds had a foul odor. She notified the facility Wound Care Nurse to change the dressings. She stated she did not see the wounds because Hospice did not undress and redress wounds. She stated there was not any discussion with the family about more aggressive treatment for [REDACTED]. Interviews with the Medical Director on 10/23/18 at 2:00 p.m. and 10/26/18 at 10:44 a.m. for Resident #1 revealed he did not remember if he saw the resident's pressure ulcers because the Wound Care Physician was providing wound care. He stated he was responsible for all residents in the facility and if the resident had a different primary care physician, the facility could still call him with resident needs. He stated he did not oversee the care the Wound Care Physician provided. 2. Resident #2's MDS assessment, dated 10/18/18, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She had severe cognitive impairment. She required extensive assistance of two or more staff for bed mobility and one staff was needed for wheelchair transfers. She was always incontinent of bladder and bowel. The resident had two unstageable/deep tissue injuries present on admission. The resident was using pressure reducing devices in her bed and wheelchair. Resident #2's Care Plans dated 10/24/18 revealed the resident had a deep tissue injury on both heels. Facility interventions included to provide the resident with heel protectors while in bed and to float her heels while she was in bed. Review of Resident #2's clinical record revealed no documentation reflecting Braden Scale for Predicting Pressure Sore Risk Assessments had been completed. Resident #2's Physician Orders, dated (MONTH) (YEAR), revealed an order to clean unstageable pressure ulcers on the left heel and the right heel with wound cleanser and pat dry. Apply skin prep daily until healed. There were no orders to offload the resident's heels while in bed or in her wheelchair. Resident #2's Progress Notes revealed the following: 09/26/18 1:37 p.m. - Resident admitted to the facility. The resident had a Braden Score of 12 (high risk for pressure ulcer development); however, there was no assessment in the resident's record to reflect this information. Resident #2's Wound Evaluation and Management Summary signed by the Wound Care Physician revealed: 10/17/18: Wound Progress - No Change Unstageable wound to the right heel - 1.5 cm x 3.0 cm x not measurable depth. Unstageable wound to the left heel - 1.0 cm x 2.0 cm x not measurable depth. 10/24/18: Wound Progress - Deteriorated Unstageable wound to the right heel - 2.5 cm x 3.5 cm x not measurable depth. Unstageable wound to the left heel - 2.0 cm x 1.5 cm x not measurable depth. An observation of Wound Care for Resident #2 on 10/23/18 at 10:50 a.m. with the Wound Care Nurse revealed the resident was seated in her wheelchair. She was wearing socks only and her feet were resting on the foot rests of the wheelchair. Her heels were not off-loaded. Her heels were resting flat against the foot rests. The Wound Care Nurse stated the resident was supposed to have her heels off-loaded in bed and she had to wear soft pillow boots in bed, but there were no interventions ordered or care planned to prevent/reduce pressure on her heels while she was in her wheelchair. The right heel had an area of dry eschar which measured approximately 2.0 cm x 1.0 cm. The left heel had an area of dry eschar which measured approximately 2.0 cm x 1.0 cm. An interview with Charge Nurse LVN O on 10/25/18 at 12:25 p.m. for Resident #2 revealed the resident was always supposed to wear soft boots, but she would sometimes take them off. She did not know if the intervention or refusals were documented on the care plan or Kardex, but it was every nurse's responsibility to keep them updated. She stated pressure ulcer prevention measures were repositioning, off-loading bony prominences, skin cleanliness, hydration and nutrition. An interview with LVN P on 10/25/18 at 2:30 p.m. for Resident #2 revealed she had unstageable ulcers on her heels, but staff failed to keep the resident's heels off-loaded while she was in her wheelchair. He was not aware if the resident's care plans were updated to reflect pressure relief measures. LVN P stated pressure ulcer prevention measures were repositioning, off-loading bony prominences, skin cleanliness, hydration and nutrition. An interview with ADON RN M on 10/25/18 at 3:40 p.m. for Resident #3 revealed she was supposed to wear soft pillow boots when she was in her wheelchair, but she did not know why the intervention was not care planned. She stated the resident had a history of [REDACTED]. Pressure ulcer prevention measures staff were to use were, cushions for wheelchairs, support pillows, off-loading, air mattresses, and soft pillow boots. 3. Resident #3's MDS assessment, dated 10/11/18, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She had severe cognitive impairment. She required extensive assistance of one staff for bed mobility. She was always incontinent of bladder and bowel. The resident had facility acquired pressure ulcers: one Stage II, one unstageable, and six unstageable/deep tissue injuries. The resident was using a pressure reducing device in bed and receiving Hospice care. Resident #3's Care Plans dated 09/19/18 revealed the resident was at risk for skin breakdown and had developed pressure ulcers. Facility interventions included pressure relief mattress. There were no other interventions in place to prevent the development or worsening of pressure ulcers for the resident. Resident #3's Braden Scale for Predicting Pressure Sore Risk Assessment, dated 11/02/17, revealed the resident was not at risk for pressure ulcer development. There were no other assessments available for review. Resident #3's Physician Orders, dated (MONTH) (YEAR), revealed: 10/10/18 orders: Stage II pressure ulcer, left foot, lateral heel - cleanse with wound cleanser, apply Xeroform (antibacterial dressing), wrap with Kerlix and Coban (compression wrap) Unstageable deep tissue injury, left foot, lateral side - cleanse with wound cleanser, pat dry, apply skin prep daily Unstageable deep tissue injury, left foot, distal side - cleanse with wound cleanser, pat dry, apply skin prep daily Unstageable deep tissue injury to left foot, medial ankle - cleanse with wound cleanser, pat dry, apply skin prep daily Unstageable deep tissue injury to left foot, medial heel - cleanse with wound cleanser, pat dry, apply skin prep daily Unstageable deep tissue injury to left foot, medial side - cleanse with wound cleanser, pat dry, apply skin prep daily Unstageable deep tissue injury to left foot, distal, medial side - cleanse with wound cleanser, pat dry, apply skin prep daily 10/14/18: Order for Hospice Services Resident #3's Progress Notes revealed the following: 09/19/18 3:12 p.m. - Wound Care Physician at the facility to see new wounds on the resident's left foot. Resident #3's Wound Evaluation and Management Summary signed by the Wound Care Physician revealed: 10/17/18: Wound Progress - No Change Stage II pressure ulcer, left foot, lateral heel - 0.5 cm x 3.0 cm x 0 cm. Unstageable deep tissue injury, left foot, lateral side - 0.8 cm x 1.0 x not measurable depth Unstageable deep tissue injury, left foot, distal side - 0.7 cm x 0.7 cm x not measurable depth Unstageable deep tissue injury to left foot, medial ankle - 2.0 cm x 2.0 cm x not measurable depth Unstageable deep tissue injury to left foot, medial heel - 3.0 cm x 3.0 cm x not measurable depth Unstageable deep tissue injury to left foot, medial side - 1.1 cm x 1.5 cm x not measurable depth Unstageable deep tissue injury to left foot, distal, medial side - 1.0 cm x 1.0 cm x not measurable depth 10/24/18: Wound Progress - Deteriorated Unstageable deep tissue injury, left foot, lateral heel - 6.5 cm x 4.0 cm x not measurable depth Unstageable deep tissue injury, left foot, lateral side - 1.0 cm x 3.0 cm x not measurable depth Unstageable deep tissue injury, left foot, distal side - 0.7 cm x 0.7 cm x not measurable depth Unstageable deep tissue injury to left foot, medial ankle - 2.0 cm x 2.0 cm x not measurable depth Unstageable deep tissue injury to left foot, medial heel - 3.0 cm x 2.0 cm x not measurable depth Unstageable deep tissue injury to left foot, medial side - 1.5 cm x 2.5 cm x not measurable depth Unstageable deep tissue injury to left foot, distal, medial side - 1.0 cm x 1.0 cm x not measurable depth New Wound: Unstageable deep tissue injury to left foot, ankle, lateral side - 1.7 cm x 1.0 cm x not measurable depth Resident #1's Hospice Company J Notes reflected: 10/23/18 Skin Integrity - Wound Care provided by facility wound care nurse. 10/16/18 Skin Integrity - Wound Care provided by facility wound care nurse. Observations of Resident #3 and interview on 10/23/18 at 2:45 p.m. and 10/26/18 at 10:35 a.m. revealed she was lying in bed on a low air loss mattress. She stated she had a sore on her foot. LVN K entered the room and removed the covers to reveal the resident's left foot lying on the mattress and not off-loaded. The left foot had a dressing in place. LVN K stated the resident was supposed to be wearing soft pillow boots on her feet to prevent pressure sores. LVN K found the resident's soft pillow boots and put them on her feet. The resident was also repositioned so that her left foot was off-loaded. The Wound Care Nurse unwrapped the wound dressing on the left foot to reveal the resident had five areas of eschar on the left foot and open areas on the left heel of foot with minimal bloody drainage. An interview with CNA N on 10/25/18 at 11:20 a.m. for Resident #3 revealed the resident was always supposed to wear soft pillow boots. She stated she would find the resident not wearing them because not all staff knew she needed to wear them. Staff did not always know the interventions because the care plan and Kardex for residents was not always updated. Pressure ulcer prevention measures included turning residents every two hours, using barrier cream, and making sure a resident's legs and heels were offloaded and separated to prevent bone on bone touching. An interview with Hospice RN L (Hospice Company J) on 10/28/18 at 1:15 p.m. for Resident #3 revealed she assessed and evaluated the resident's wounds on a weekly basis. She stated she was not aware the resident did not have interventions in place (not including the air loss mattress) to prevent pressure ulcer worsening or development. A follow-up interview with the Wound Care Nurse on 10/26/18 at 11:45 a.m. revealed she was responsible for all residents with wounds but did not know it was her responsibility to add needed pressure relief interventions to the care plans or Kardex until she was in-serviced on 10/23/18. To prevent pressure ulcer development, staff were supposed to keep the resident's skin dry, provide nutrition, fluids, and offload pressure points. She stated Residents #1, #2, and #3 were neglected because the facility failed to provide care to prevent pressure ulcer worsening or new development for residents. She stated that for Residents #2 and #3, she would off-load their feet anytime they were in bed. A follow-up interview with the DON on 10/26/18 at 12:25 p.m. revealed she was responsible for all residents in the facility. She stated staff were supposed to reposition residents and offload their pressure points to prevent pressure ulcers. She stated with Resident #1 there was an allegation of neglect because there were no interventions in place to prevent the pressure ulcers between her knees from developing. She did not know that Resident #2 did not have interventions in place when she was in her wheelchair, and she did not know Resident #3 did not have interventions in place to off-load her feet. She stated interventions were supposed to be documented in the resident's care plan. Braden scales were to be completed by charge nurses on admit, weekly every four weeks, and then every three months according to the MDS schedule. Review of Pressure redistributing devices for the prevention of heel pressure ulcers from The Prevention and Management of Pressure Ulcers in Primary and Secondary Care, dated (MONTH) 2014 and obtained from https://www.ncbi.nlm.nih.gov/books/NBK 1/ on 11/05/18, reflected: : .13.2.5.1.5. Eggcrate suspension boot heel elevation device plus a pressure redistributing support surface versus a pressure redistributing surface alone One study (n=239) showed an eggcrate suspension boot heel elevation device plus a pressure redistributing support surface is more clinically effective at reducing the incidence of heel pressure ulcers when compared to a pressure redistributing surface alone (low quality). The Facility's Skin Integrity Care Delivery Process, dated 06/01/16, reflected: Pressure Ulcer/Injury Prevention Guideline .Avoid/limit skin to skin contact, friction, or shearing forces. (MONTH) use pillows, heel, or elbow protectors to keep bony prominences from rubbing .Position body with pillows and foam support devices .float heels . The Facility's Care Planning Policy, dated (MONTH) (YEAR), reflected: A comprehensive, person-centered care plan is developed and implemented for each resident to meet the resident's physical, psychosocial, and functional needs. An Immediate Jeopardy (IJ) was identified on 10/24/18 at 12:35 p.m The Administrator and DON were informed, and a Plan of Removal was requested at that time. The Plan of Removal was accepted on 10/24/18. The Plan of Removal revealed the following: The facility failed to implement preventative measures for pressure ulcers, train and supervise

Based on interview and record review, the facility failed to ensure the resident was informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred for one (Resident #1) of six residents reviewed for pressure ulcers. 1. The facility and physician failed to communicate risks and benefits of proposed care, or treatment and treatment alternatives, with Resident #1's family before surgically [MEDICATION NAME] (removing dead tissue resulting in a bleeding wound bed) the resident's pressure ulcers on 10/17/18 that had developed on the insides of both knees on 10/11/18. Each pressure ulcer was a Stage IV ulcer. The family stated if they had been informed, they would have removed the resident from Hospice care and placed her in the hospital for aggressive wound care. 2. The facility failed to notify the family when Resident #1's pressure ulcers deteriorated. An Immediate Jeopardy (IJ) was identified on 10/24/18. While the Immediate Jeopardy was removed on 10/26/18, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy, and at a scope of pattern because the facility was still monitoring the Plan of Removal. These failures had the potential to affect residents by placing them at risk of receiving treatments without having given informed consent and the development or worsening of pressure ulcers. Findings included: 1. Resident #1's MDS assessment, dated 08/16/18, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She had moderate cognitive impairment. She required extensive assistance of two or more staff for bed mobility. She was always incontinent of bladder and bowel. The resident was at risk for the development of pressure ulcers and was receiving Hospice care. Resident #1's Care Plan, dated 06/21/18, revealed the resident was at risk for skin breakdown related to contractures, incontinence, limited mobility, and friction risks. Facility interventions included to assist the resident in methods to reduce friction, Braden assessments (pressure ulcer risk assessment) per policy and evaluate for skin risk factors per protocol. There were no specific interventions listed regarding how to reduce friction for the resident, or any specifics for offloading or cushioning any areas of the resident's body. Resident #1's Braden Scale for Predicting Pressure Sore Risk Assessment, dated 06/23/18, revealed the resident was at mild risk for the development of pressure ulcers. There were no further assessments available for review. Resident #1's Physician Orders, dated (MONTH) (YEAR), revealed the resident had an order for [REDACTED].>Resident #1's Progress Notes revealed: 10/11/18 at 5:00 p.m. - LVN A notified the Wound Care Nurse regarding wounds found by CNA B to both inner knees. Upon assessment the Wound Care Nurse noted the inner right knee had eschar (dry dead tissue) with yellow slough (moist dead tissue) in the wound bed, measuring 7.0 cm x 4.0 cm. The wound to the left inner knee had eschar tissue with yellow slough in the wound bed. The wounds had a foul odor. The Wound Care Physician and DON were notified, and orders were received to clean both wounds with wound cleanser, apply Santyl ([MEDICATION NAME] ointment), and apply calcium alginate (dressing that absorbs drainage). Cover the wounds with dry dressings daily. Resident #1's Weekly Skin Inspection Assessment, dated 10/11/18 revealed the resident had developed new pressure ulcers on the inner aspects of both knees. The right knee had eschar measuring 7.0 centimeters (cm) x 4.0 cm. The left knee had a wound, but the area could not be measured due to her leg contracture. Skin assessments prior to 10/11/18 did not have these wounds documented. Resident #1's Wound Evaluation and Management Summary, dated 10/17/18, and signed by the Wound Care Physician revealed the resident had a Stage IV pressure ulcer on the inner aspect of both knees. The pressure ulcer on her left inner knee measured 8.0 cm x 4.5 cm x 0.3 cm. The pressure ulcer on her right inner knee measured 11.0 cm x 8.0 cm x 0.3 cm. The resident required surgical debridement of both knees to remove necrotic tissue. The document indicated consent had been received for the surgical debridement. Review of Hospice Company C's Certification and Plan of Care, dated 08/09/18, reflected: .Hospice Skilled Nurse to assess wounds every visit .Hospice nurse to coordinate plan of care with facility staff . Review of Hospice Company C's notes, dated 10/18/18, reflected no wounds were assessed. An observation of Resident #1 on 10/22/18 at 4:32 p.m. revealed the resident was lying in bed. Hospice was at the bedside due to the resident's decline in status. The resident was actively dying and passed away shortly after entering the facility. The resident was asleep and not able to communicate during observation. The resident did not respond to verbal stimuli. She was lying on her right side with her legs drawn up in a contracted, fetal position. There was a wound dressing on both knees. There was no barrier in place to prevent the knees from touching each other. The wound dressings were removed by staff and revealed each knee had white tissue/bone that was exposed, with a large amount of drainage, slough, and dead tissue. The wounds had a foul odor. An interview with CNA B on 10/23/18 at 4:25 p.m. for Resident #1 revealed on 10/11/18 he walked into the resident's room and smelled a foul odor. CNA B pulled the blankets back and found the resident's knees were touching and each knee had a wound on it. He notified LVN A. CNA B stated staff would sometimes place a pillow between the resident's knees to keep them from touching, but not always. He stated the pillow was not there on 10/11/18. He stated he was able to provide incontinence care for the resident by separating her legs and knees to clean her, but otherwise her knees and legs had a history of [REDACTED]. Interviews with LVN A on 10/23/18 at 4:15 p.m. and 10/25/18 at 2:55 p.m. for Resident #1 revealed on 10/11/18, CNA B notified him that the resident had wounds between her knees. The wounds were open, draining, and had a foul odor. The resident's legs and knees stayed in a contracted position with the knees touching. He stated the resident did not have a pillow in place between her knees. He stated he notified the Wound Care Nurse to assess the wounds. He stated Resident #1 developed pressure ulcers between her knees because she was contracted and was supposed to always have a pillow in place between her knees. He stated he did not know if the resident had the intervention care planned. Interviews with the Wound Care Nurse on 10/23/18 at 9:25 a.m. and 10/24/18 at 10:50 a.m. for Resident #1 revealed the facility had an ownership change on 10/01/18. She started doing wound care at the facility in (MONTH) (YEAR). In (MONTH) (YEAR) she received some training on her role as the wound care nurse and documented her notes in the computer. When the new ownership took over on 10/01/18, she was told she would be trained, but was not. She was told that she would be documenting on new forms and would be instructed on how to use them. The Wound Care Nurse said that as of 10/24/18, she still had not received all of the training she needed for her role as the facility wound care nurse. She received an in-service on 10/23/18 (after the surveyor had entered on 10/22/18) that included responsibilities she did not know she had. She said the new responsibilities included to communicate with the families on a weekly basis regarding wound care and update care plans. She stated that prior to 10/23/18, she would update care plans regarding the wound size changes, but did not know she was supposed to include interventions to prevent the development/worsening of new pressure ulcers and had not previously included that information. She stated she had signed an in-service form which had instructions on when and how to use pressure relief measures and devices, but she did not actually read it or receive training on it. On 10/11/18, she was notified on about the discovery of wounds between Resident #1's knees. The resident did not have a pillow or other barrier between the knees when she saw her. The resident had a wound on the inner aspect of each knee. Her legs were very contracted and difficult to pull apart. She examined them and contacted the Wound Care Physician to get orders for treatment. She contacted the DON who notified Hospice Company C. She also contacted the resident's family. She stated she and the Wound Care Physician had assessed the resident on 10/10/18, but the resident did not have wounds on her inner knees at that time. She stated they discussed the resident's contracted legs and the risk for pressure ulcer development between the resident's knees on that visit. The Wound Care Nurse stated sometimes staff would place a pillow between the resident's knees to keep them from touching, but there were no orders or care plans to keep a pillow or other barrier in place. She stated she asked the family on 10/11/18 to purchase thin pillows that would be more comfortable for the resident to place between her contracted legs to keep the knees from touching after the wounds were found, but she did not get an order or care plan the interventions. She stated she did not speak to the family again about the wounds after 10/11/18 and did not contact them weekly with wound updates because she did not know she was supposed to. She stated the Wound Care Physician did not evaluate the wounds until 10/17/18 because he only saw wounds on a weekly basis, and at that time he stated the resident's wounds were Stage IV pressure ulcers. The Wound Care Physician had to surgically debride dead tissue from the knee wounds. After the debridement, the wounds worsened with an increase in size, drainage, and odor. The Wound Care Nurse stated she did not notify the family, DON, Wound Care Physician, or Medical Director about the wound changes because the resident was on Hospice. She stated she did notify the Hospice Nurse and requested an order from the Hospice Physician for antibiotics or treatment to address the wound odor. The Hospice Nurse did not call her back and she did not follow-up with anyone else regarding the wounds. The Wound Care Nurse changed the dressings on 10/11/18, 10/12/18, and 10/15/18-10/22/18 based on calendar she was looking at for October. The resident went on continuous Hospice Care on 10/20/18 and the family requested the wound care dressings not be changed after that due to the pain of the dressing changes. The resident passed away at the facility on 10/22/18. On 10/22/18, the family asked her about the surgical debridement of the wounds on 10/17/18 and she apologized for not calling them prior to the treatment. The Wound Care Nurse stated she did not know she was supposed to obtain consent for wound treatments and she did not discuss any treatment options with the family. She did not speak to the Medical Director about the wounds, because there were standing orders in place to contact the Wound Care Physician for wound evaluations and treatments. An interview with the Wound Care Physician on 10/23/18 at 12:20 p.m. for Resident #1 revealed on 10/10/18 he and the Wound Care Nurse made rounds to look at a healing pressure ulcer on her foot. He noticed the resident had her legs contracted in a fetal position with her knees touching. She did not have any skin breakdown between her knees at that time. He discussed with the wound care nurse that the resident needed a measure in place to prevent the knees from touching to prevent pressure ulcers from developing. He did not write new orders but stated the Wound Care Nurse told him staff would place a pillow between her knees. He stated on 10/11/18 the resident was found with new wounds between her knees, but with constant pressure with her knees touching and her compromised nutrition, the wounds could have developed over night. On 10/17/18 the wounds required surgical debridement to remove a lot of dead tissue. He stated the resident was nutritionally compromised and once the ulcers developed, they deteriorated very quickly. He stated the wound on the inner aspect of each knee was a Stage IV on 10/17/18 and that was the last day he assessed the wounds. He stated for surgical debridement, the facility was responsible for obtaining consent and that he did not contact the family prior to the procedure. An interview with the family of Resident #1 on 10/23/18 at 4:00 p.m. revealed they were notified on 10/11/18 about wounds found on the resident between her knees and were asked to purchase thin pillows to keep between her knees. They were not contacted about the wounds following that day. The family stated they thought the facility could handle the wounds and did not know the resident was being evaluated by the Wound Care Physician. They stated they saw the wounds on 10/22/18 and the bone on each knee was exposed. They were never notified the pressure ulcers were that bad, and if they had been notified they would have removed the resident from Hospice and had her transferred to the hospital for more aggressive treatment. They stated they did not know the resident required surgical debridement and did not give consent for the procedure. Interviews with Charge Nurse LVN D on 10/23/18 at 11:20 a.m. and 10/24/18 at 9:05 a.m. for Resident #1 revealed the resident admitted to the facility and had a gradual decline in her health. Hospice Company C started caring for her due to her [DIAGNOSES REDACTED]. The resident had her legs contracted and her knees were clamped together and constantly touching. The resident was very thin with bony prominences exposed. She stated after the wounds were found, the Wound Care Nurse contacted the family to purchase thin pillows to keep placed between the resident's knees. Prior to that she stated staff were supposed to put a pillow between her knees or a towel wrapped in a pillowcase to keep the knees from touching. She stated when she cared for the resident and found she did not have a pillow between her knees, she would tell the CNA that she needed one. She saw the wounds with the wound care nurse on 10/19/18 and they looked bad because the resident's body was breaking down. The resident was at the end of her life and she had an end of life smell. She stated she did not contact the family about the wounds because she thought the Wound Care Nurse did. She said she would update the Medical Director weekly about wounds and he would say the Wound Care Physician was managing the wounds. An interview with ADON I on 10/25/18 at 1:05 p.m. for Resident #1 revealed the resident developed a pressure ulcer between her knees because there were no interventions in place to prevent their development. ADON I saw the wounds on 10/11/18 only. She stated the information should have been on the resident's care plan. She stated an allegation of neglect had been stated because the family was not aware of the wound status and the facility did not have consents in place for her wound treatments. Interviews with the DON on 10/23/18 at 12:45 p.m., 10/23/18 at 4:55 p.m., and 10/24/18 at 9:30 a.m. for Resident #1 revealed she saw the wounds on the resident's inner knees on 10/11/18. She stated at that time they had a small amount of slough. She stated she never spoke to the physician about the wounds, but the Wound Care Nurse did. She did not contact the family because the Wound Care Nurse did. The resident was receiving Hospice care and the facility was managing the resident's wound care. She stated the resident was at risk for pressure ulcer development between her knees because she had low [MEDICATION NAME], low protein, contractures, was bed bound, and had weight loss. Staff were supposed to keep a pillow or pressure-relieving device between her knees to prevent pressure ulcers from developing. Staff were supposed to know to keep a pillow between her knees by reviewing the care plan, but the intervention was not listed. The facility also utilized a resident Kardex that was easy to access for staff, but the resident did not have a Kardex either. She stated the Kardex was supposed to be developed from the resident's care plan and if the interventions to prevent pressure ulcer development/worsening was not in the care plan, the information was not included on the Kardex. Orders were not required to be written as of 10/01/18, because new ownership took over and they did not allow orders to include pressure ulcer prevention measures. The DON stated prior to the ownership change on 10/01/18 she provided oversight to the Wound Care Nurse by doing spot checks on wounds. After the ownership changed, she only looked at and assessed new wounds. She stated all staff, including the wound care nurse had received yearly in-service training that included pressure ulcer prevention measures. The facility also utilized a resident Kardex that was easy to access for staff, but the resident did not have a Kardex either. The DON stated the Wound Care Physician was responsible for obtaining his own consents prior to procedures. She stated the Wound Care Nurse was responsible for contacting the family with weekly updates on wound status and that she had been trained to do so. The DON was not able to provide training documentation to show the Wound Care Nurse knew to keep the family updated weekly. The DON stated the staff had been trained to notify the family and physician with changes in resident condition. An interview on 10/23/18 at 11:45 a.m. with Hospice CNA E (Hospice Company C) for Resident #1 revealed she bathed the resident on Mondays, Wednesdays, and Fridays. The resident did not have wounds between her knees on 10/10/18. She stated the resident was very contracted and she would have to pull the resident's knees apart to do incontinence care. An interview with Hospice RN F (Hospice Company C) on 10/23/18 at 1:35 p.m. for Resident #1 revealed she saw the resident on 10/02/18, 10/19/18, and 10/22/18. On 10/19/18 the resident had dressings that were soiled on each knee. The wounds had a foul odor. She notified the facility Wound Care Nurse to change the dressings. She stated she did not see the wounds because Hospice did not undress and redress wounds. She stated there was not any discussion with the family about more aggressive treatment for [REDACTED]. Interviews with the Medical Director on 10/23/18 at 2:00 p.m. and 10/26/18 at 10:44 am for Resident #1 revealed he did not remember if he saw the resident's pressure ulcers because the Wound Care Physician was providing wound care. He stated he was responsible for all residents in the facility and if the resident had a different primary care physician, the facility could still call him with resident needs. He stated he did not oversee the care the Wound Care Physician provided. The Facility's Change in Condition Policy, dated (MONTH) (YEAR), reflected: Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the medical/mental condition and/or status . An Immediate Jeopardy (IJ) was identified on 10/24/18 at 12:35 p.m. The Administrator and DON were informed, and a Plan of Removal was requested at that time. The Plan of Removal was reviewed and accepted on 10/24/18. The Plan of Removal revealed the following: On 10/23/18, the Wound Care Nurse was educated by the Regional Consultant Nurse on completing skin assessments, documentation, notification, weekly assessments, and the wound report. On 10/23/18, the Assistant Director of Nurses, Wound Nurse, and Director of Nurses were educated by the Regional Consultant Nurse on notification to all respective parties (family/RP (responsible party), Physician, Hospice Provider, etc.) On 10/23/18, the Director of Nurses educated the Wound Nurse on treatment responsibilities and expectations to include: physician orders, skin assessments, notification/documentation of wound status, weekly updates to all parties, care plan/Kardex update, clinical unavoidable skin condition, and reaching out to Nurse Management/Regional Consultants if any assistance was needed. On 10/24/18, the Administrator spoke with the Medical Director and the Wound Physician regarding communication and coordination of care. The Medical Director will begin to review the Wound notes from the Wound Physician and sign off weekly. On 10/24/18 the Administrator reviewed the contract with the Wound Physician on obtaining consent to treat prior to initiating treatments and documenting person contacted. Interviews began on 10/25/18 at 11:20 a.m. and continued through 10/26/18 at 12:50 p.m. with 16 staff members. Direct care staff interviewed were: 6:00 a.m. - 2:00 p.m. shift: LVN A, CNA R 2:00 p.m. - 10:00 p.m. shift: LVN H, CNA N 10:00 p.m. - 6:00 a.m. shift: CNA Q All shifts: LVN P, LVN O, LVN G The interviews revealed the staff had been in-serviced on: Preventing skin breakdown, types of preventative measures to use, communication of skin concerns to family and physicians, documentation of skin concerns, preventative measures for pressure ulcers, and how to locate resident care plans. Administrative staff interviewed were: Administrator, DON, ADON I, ADON RN M, Wound Care Nurse, Wound Care Physician, Medical Director, Social Worker The interviews revealed the Wound Care Nurse had received in-service training on: Pressure Ulcers and Preventing Pressure Ulcers: documentation, notification of family and physicians, weekly assessments, and the wound report, notification, identify high risk residents, treatment responsibilities and expectations to include physician orders, skin assessments, notification/ documentation of wound status, weekly updates to all parties, care plan updates Interviews with the ADONs revealed they had been in-serviced on: Collaborating with the Wound Nurse on updating and revising the care plan and Kardex as needed, and ensuring preventive devices are in place for the residents An interview with the DON revealed she had been in-serviced on: Overseeing the care provided by the Wound Care Nurse and the wound program and reviewing Braden scores. An interview with the Medical Director revealed he had been in-serviced on: Coordinating care and communicating with the Wound Care Physician. An interview with the Social Worker revealed he had been in-serviced on: Coordinating care with Hospice providers, initiating care plan meetings to ensure responsible parties and families could make informed decisions about care for Hospice residents. An interview with the Wound Care Physician revealed he had been in-serviced on: Obtaining consent to treat prior to initiating treatments. An interview with the Administrator on 10/25/18 at 3:15 p.m. revealed she was responsible for all residents in the facility. She stated the Wound Care Nurse should have kept the Medical Director, Wound Care Physician, DON, Hospice, and family members up-to-date regarding the worsening of Resident #1's wounds. The Quality Assurance Committee would be meeting monthly and as needed to review systems in place for neglect and discuss any other needed systems. The Administrator was notified on 10/26/18 the IJ was removed. While the Immediate Jeopardy was removed on 10/26/18, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy, and at a scope of pattern because the facility was still monitoring the Plan of Removal.

Based on interview and record review, the facility failed to ensure all allegations of abuse were thoroughly investigated; and failed to protect residents from further abuse while the investigation was ongoing for two (Residents #15 and #24) of 21 residents reviewed for abuse and neglect. 1. The Administrator, who was the Abuse Prevention Coordinator, failed to thoroughly investigate an allegation of verbal and physical abuse made by Resident #24 towards CNA A. The Administrator submitted her investigation findings of the incident to the Texas Department of Aging and Disability Services prior to talking with the alleged perpetrator (CNA A). 2. The Administrator failed to ensure the alleged perpetrator (CNA A) received in-service training on abuse prior to returning to work. The Administrator allowed CNA A to return to work before receiving training on abuse. 3. The Administrator failed to protect the residents, to include Residents #15 and #24, when she did not suspend CNA B and delayed suspension of CNA A when separate allegations of abuse were made against them. An Immediate Jeopardy was identified on 09/16/2015. While the IJ was removed on 09/18/15, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm that is not immediate jeopardy and a scope of widespread because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. These failures had the potential to place all 150 residents who resided at the facility at risk for further abuse. Findings included: 1. Resident #24 ' s Admission Face Sheet dated 08/03/2015, reflected she was admitted to the facility on [DATE]. Resident #24 ' s MDS assessment dated [DATE] reflected Resident #24 was an [AGE] year old female with active [DIAGNOSES REDACTED]. The MDS assessment also revealed the resident had clear speech, was understood, and understood others. Her BIMS score was 12 reflecting she was moderately cognitively intact. The assessment also reflected the resident used a wheelchair for ambulation and required physical help with part of the bathing. Review of the Provider ' s Investigation Report dated 8/31/15, revealed on 08/30/2015 Resident #24 stated CNA A was rude and grabbed her in a rough manner causing bruising to her right arm and pushed the shower chair so hard it hit a door causing a skin tear to Resident #24 ' s arm. The report revealed the facility learned of the incident on 8/31/15. On 8/31/15, the facility' concluded it's investigation and listed the investigation findings as inconclusive. On 9/15/15 at 2:00 PM, the administrator provided additional documentation that she talked with the alleged perpetrator CNA A via the telephone on 09/03/15 (three days after submitting her investigation conclusion and investigation findings to the Texas Department of Aging and Disability Services.) On 09/15/2015 at 2:30 PM, the administer was asked if she had submitted her final investigation findings of Resident #24 ' s allegation of abuse against CNA A as inconclusive prior to speaking with the alleged perpetrator, CNA A. She stated, Yes . She was then asked if she felt she had done a thorough investigation. She stated, Yes . On 9/16/15 at 11:15 AM, the administrator confirmed she was the abuse coordinator. The administrator acknowledged she was responsible for the completeness and the thoroughness of all investigations. She was unable to explain why she submitted her investigation findings in less than 24 hours and without talking to or obtaining a written statement from the alleged perpetrator. On 09/16/2015 at 11:15 AM, the administrator was asked what a thorough investigation would include. She stated a thorough investigation included obtaining written statements from the victim, other cognitive residents, staff and the alleged perpetrator; and in-servicing staff were all part of a thorough investigation. On 09/16/2015 at 11:15 AM, the administrator was asked if she would expect her designee to obtain written statements as part of a thorough investigation. She stated, Yes. in addition she further stated normally she would have handled the investigation but had asked the ADON to interview Resident #24 and the Assistant Administrator interview some other residents. The Provider's Investigation revealed CNA A was suspended on 8/31/15. On 09/16/2015 at 11:45 AM, the assistant administrator was asked for a list of residents she had interviewed regarding care they received from CNA A. She stated, I didn ' t get their names, I just asked the charge nurse to get me two cognitive residents to interview. The assistant administrator was asked if she felt it was important to get the names of the residents she interviewed. She stated, Yes it is, I agree. I went back and got their names yesterday (16 days after the final investigation findings were submitted to DADS). On 09/16/15 at 11:15 AM, the administrator stated when investigating an allegation of abuse, her number one priority was protection of the residents. She stated suspending the alleged perpetrator and ensuring the alleged perpetrator was re-educated and in-serviced on abuse prior to returning to work was an important part of protecting and ensuring resident safety. On 09/15/2015 at 5:00 PM, the Director of Nurses stated, CNA A was suspended during the investigation until 9/11/15, at which time, CNA A was in-serviced on abuse by the Staff Development Coordinator. On 09/15/2015 at 5:10 PM, the Staff Development Coordinator stated, she conducted the in-service training on abuse with CNA A on 09/11/2015. She stated she was very clear on the date because she came in early to do it and it was on a payday and her anniversary. The staff development Coordinator was then asked if she documented the in-service training on abuse with CNA A and she stated, No . A time-clock punch detail provided by the administrator on 09/16/2015 reflected CNA A returned to work on 09/07/2015 and not 09/11/2015. When the DON was shown the clock punch detail, she stated I did not know that and that she guessed CNA A had worked on 09/07/2015. The time-clock punch detail reflected CNA A was suspended from 8/31/15 until 9/6/15. 2. The Admission Face Sheet dated 03/24/2015, reflected Resident #15 was admitted to the facility on [DATE]. The MDS assessment dated [DATE] reflected Resident #15 was an [AGE] year old female with active [DIAGNOSES REDACTED]. The MDS assessment reflected the resident required extensive assistance with bed mobility and had a BIMS score of 3 which indicated severe cognitive impairment. Review of the Provider Investigation Report dated 9/9/15, revealed that on 09/08/2015 a family member alleged that when she made allegations of rough handling of Resident #15 by facility staff, CNA B retaliated by threatening the resident. The family member stated CNA B told Resident #15 if she didn't stop reporting them (facility staff) to her daughter, she (the resident) would not be allowed to go to activities and would be discharged from the facility. On 09/16/2015 at 2:30 PM, the administrator was asked if CNA B was suspended upon learning of the allegation of verbal abuse made by a family member of Resident 15 against CNA B. She stated, Yes . On 09/16/2015 at 3:30 PM CNA B stated she worked: Tuesday 9/8/15, Wednesday 9/9/15, Thursday 9/10/15 and Friday 9/11/15. CNA B stated she did not work on Saturday 9/12/15 or Sunday 9/13/15 because those were her scheduled days off. A time clock punch detail confirmed CNA B worked Tuesday 9/8/15, Wednesday (09/09/15), Thursday, (09/10/15) and Friday (09/11/15). A review of the personnel file for CNA B revealed no documentation that CNA B was suspended once the facility was aware of an allegation of verbal abuse against CNA B. At 09/16/2015 at 2:30 PM, The DON was shown the clock punch detail for CNA B. She stated, She thought CNA B had been suspended and was unaware that CNA B had not been suspended. On 09/16/2015 at 3:00 PM, the administrator was unable to provide an explanation when shown the time clock punch detail which reflected CNA B worked and was not suspended. A copy of the facility' s abuse policy revised 7/1/05, provided by the administrator revealed the following: Purpose to ensure the resident's rights are protected by providing a method for the prevention, reporting and investigationof any type of alleged resident abuse. .POLICY It is the policy of this center to maintain the resident ' s right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property . .INVESTIGATION .B.interview of other residents who may receive care from the alleged perpetrator .D. Investigation results will be recorded and organized to include actual statements of witnesses . .PROTECTION .Suspension of an employee pending the investigation. On 9/16/15 at 11:22 AM, the Administrator and DON were notified that an Immediate Jeopardy (IJ) was identified. 3. On 9/18/15 at 9:30 AM, the Administrator, DON and the RN Corporate Manager of Clinical Operations were notified the facility's Plan of Removal (POR) was accepted. 4. The POR reflected the following immediate action included the following: On 9/16/15, the facility's administrative staff which consisted of the Administrator, Assistant Administrator and DON were re-educated and in-serviced by the RN Manager of Clinical Operations on abuse , neglect, investigation process, resident protection during investigations and suspension of alleged perpetrators. The re-education included training on the'Abuse Neglect Exploitation Incident Investigation Checklist to be used when conducting an investigation. On 9/16/15, an audit of facility investigations, accident/ incident reports was conducted by the RN Corporate Manager of Clinical Operations. No concerns were identified. On 9/16/15, the Administrator initiated facility staff re-education on abuse and neglect. Post test were utilized to verify staff competency. On 9/16/18, the Administrator and DON began re-investigations of the allegations made against CNA A and CNA B. CNA A and CNA B were suspended pending the outcome of the re-investigation. On 9/16/15 13 Resident Satisfaction Surveys were conducted by the Social Worker to assess for any additional allegations of abuse. No new allegations were made. Resident concerns, incident/accident, and reportable events would be reviewed by the Adm and DON daily during facility stand up meetings using the abuse, neglect checklist. The POR reflected the facility's Administrative staff would be monitored on their process of responding to resident and/or family allegations and conducting thorough investigations by the Regional Vice President of Operations and by the RN Manager of Clinical Operations. The POR reflected this oversight would be on-going. To verify the facility implemented their POR, the following was conducted: 5. Interviews conducted on 9/18/15 at 10:00 AM, with: CNA C, LVN D, CNA E, LVN F, LVN G, LVN H, CNA I, CNA J, LVN K, CNA L, CNA M, RN N and RN O, revealed they attended the abuse neglect in-service on 9/16/15. All staff interviewed were found to have an understanding of what abuse was, and when and who to report allegations. 6. The Administrator was interviewed on 9/17/15 and stated she would be the primary person moving forward to handle all [MEDICATION NAME]. The Administrator confirmed she had been given guidelines by Corporate to follow when conducting investigations. 7. The DON was interviewed on 9/17/15 and stated the facility had not thoroughly investigated incidences of abuse and neglect and that moving forward there would be better communication amongst administrative staff when conducting investigations. 8. On 9/18/15, additional residents interviews were conducted, no additional allegations of abuse or neglect were made. 9. On 9/18/15 the RN Manager of Clinical Operations, stated on -going monitoring of the facility administrative staff would be conducted by the Corporate/Regional team to ensure all allegations were thoroughly investigated and alleged perpetrators were immediately suspended. 10. Thirteen Resident Satisfaction Surveys were conducted by the Social Worker and documentation provided to the survey team. 11. Post tests on abuse and neglect completed by facility staff were reviewed. The post tests addressed: who and how to report allegations of abuse and neglect, that when an allegation of abuse and/or neglect was made against an employee , the employee would not be allowed to return to work until the investigation was deemed completed and a finding of unsubstantiated. The post tests listed the requirements for a thorough investigation. On 9/24/15, the Administrator, Assistant Adminstrator and DON were notified the IJ was lifted on 9/18/15. Staff sign-in sheets reflected CNA A worked station 2 and CNA B worked station 1. This encompassed two of four facility halls. According to the CMS Form 672, Resident Census and Conditions of Residents, completed by the DON on 9/18/15, reflected 150 residents currently resided at the facility.

Based on interview and record review, it was determined the facility failed to implement it's written policies and procedures that prohibit abuse for two (Residents #15 and #24) of 21 residents reviewed for abuse and neglect. 1. The Administrator, who was the Abuse Prevention Coordinator, failed to thoroughly investigate an allegation of verbal and physical abuse made by Resident #24 towards CNA A. The Administrator submitted her investigation findings of the incident to the Texas Department of Aging and Disability Services prior to talking with the alleged perpetrator (CNA A). 2. The Administrator failed to ensure the alleged perpetrator (CNA A) received in-service training on abuse prior to returning to work. The Administrator allowed CNA A to return to work before receiving training on abuse. 3. The Administrator failed to protect the residents, to include Residents #15 and #24, when she did not suspend CNA B and delayed suspension of CNA A when separate allegations of abuse were made against them. An Immediate Jeopardy was identified on 09/16/2015. While the IJ was removed on 09/18/15, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm that is not immediate jeopardy and a scope of widespread because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. These failures had the potential to place all 150 residents who resided at the facility at risk for further abuse. Findings included: A copy of the facility' s abuse policy revised 7/1/05, provided by the administrator revealed the following: Purpose to ensure the resident's rights are protected by providing a method for the prevention, reporting and investigationof any type of alleged resident abuse. .POLICY It is the policy of this center to maintain the resident ' s right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property . .INVESTIGATION .B.interview of other residents who may receive care from the alleged perpetrator .D. Investigation results will be recorded and organized to include actual statements of witnesses . .PROTECTION .Suspension of an employee pending the investigation. 1. Resident #24 ' s Admission Face Sheet dated 08/03/2015, reflected she was admitted to the facility on [DATE]. Resident #24 ' s MDS assessment dated [DATE] reflected Resident #24 was an [AGE] year old female with active [DIAGNOSES REDACTED]. The MDS assessment also revealed the resident had clear speech, was understood, and understood others. Her BIMS score was 12 reflecting she was moderately cognitively intact. The assessment also reflected the resident used a wheelchair for ambulation and required physical help with part of the bathing. Review of the Provider' s Investigation Report dated 8/31/15, revealed on 08/30/2015 Resident #24 stated CNA A was rude and grabbed her in a rough manner causing bruising to her right arm and pushed the shower chair so hard it hit a door causing a skin tear to Resident #24 ' s arm. The report revealed the facility learned of the incident on 8/31/15. On 8/31/15, the facility' concluded it's investigation and listed the investigation findings as inconclusive. On 9/15/15 at 2:00 PM, the administrator provided additional documentation that she talked with the alleged perpetrator CNA A via the telephone on 09/03/15 (three days after submitting her investigation conclusion and investigation findings to the Texas Department of Aging and Disability Services.) On 09/15/2015 at 2:30 PM, the administer was asked if she had submitted her final investigation findings of Resident #24 ' s allegation of abuse against CNA A as inconclusive prior to speaking with the alleged perpetrator, CNA A. She stated, Yes . She was then asked if she felt she had done a thorough investigation. She stated, Yes . On 9/16/15 at 11:15 AM, the administrator confirmed she was the abuse coordinator. The administrator acknowledged she was responsible for the completeness and the thoroughness of all investigations. She was unable to explain why she submitted her investigation findings in less than 24 hours and without talking to or obtaining a written statement from the alleged perpetrator. On 09/16/2015 at 11:15 AM, the administrator was asked what a thorough investigation would include. She stated a thorough investigation included obtaining written statements from the victim, other cognitive residents, staff and the alleged perpetrator; and in-servicing staff were all part of a thorough investigation. On 09/16/2015 at 11:15 AM, the administrator was asked if she would expect her designee to obtain written statements as part of a thorough investigation. She stated, Yes. in addition she further stated normally she would have handled the investigation but had asked the ADON to interview Resident #24 and the Assistant Administrator interview some other residents. The Provider's Investigation revealed CNA A was suspended on 8/31/15. On 09/16/2015 at 11:45 AM, the assistant administrator was asked for a list of residents she had interviewed regarding care they received from CNA A. She stated, I didn ' t get their names, I just asked the charge nurse to get me two cognitive residents to interview. The assistant administrator was asked if she felt it was important to get the names of the residents she interviewed. She stated, Yes it is, I agree. I went back and got their names yesterday (16 days after the final investigation findings were submitted to DADS). On 09/16/15 at 11:15 AM, the administrator stated when investigating an allegation of abuse, her number one priority was protection of the residents. She stated suspending the alleged perpetrator and ensuring the alleged perpetrator was re-educated and in-serviced on abuse prior to returning to work was an important part of protecting and ensuring resident safety. On 09/15/2015 at 5:00 PM, the Director of Nurses stated, CNA A was suspended during the investigation until 9/11/15, at which time, CNA A was in-serviced on abuse by the Staff Development Coordinator. On 09/15/2015 at 5:10 PM, the Staff Development Coordinator stated, she conducted the in-service training on abuse with CNA A on 09/11/2015. She stated she was very clear on the date because she came in early to do it and it was on a payday and her anniversary. The staff development Coordinator was then asked if she documented the in-service training on abuse with CNA A and she stated, No . A time-clock punch detail provided by the administrator on 09/16/2015 reflected CNA A returned to work on 09/07/2015 and not 09/11/2015. When the DON was shown the clock punch detail, she stated I did not know that and that she guessed CNA A had worked on 09/07/2015. The time-clock punch detail reflected CNA A was suspended from 8/31/15 until 9/6/15. 2. The Admission Face Sheet dated 03/24/2015, reflected Resident #15 was admitted to the facility on [DATE]. The MDS assessment dated [DATE] reflected Resident #15 was an [AGE] year old female with active [DIAGNOSES REDACTED]. The MDS assessment reflected the resident required extensive assistance with bed mobility and had a BIMS score of 3 which indicated severe cognitive impairment. Review of the Provider Investigation Report dated 9/9/15, revealed that on 09/08/2015 a family member alleged that when she made allegations of rough handling of Resident #15 by facility staff, CNA B retaliated by threatening the resident. The family member stated CNA B told Resident #15 if she didn't stop reporting them (facility staff) to her daughter, she (the resident) would not be allowed to go to activities and would be discharged from the facility. On 09/16/2015 at 2:30 PM, the administrator was asked if CNA B was suspended upon learning of the allegation of verbal abuse made by a family member of Resident 15 against CNA B. She stated, Yes . On 09/16/2015 at 3:30 PM CNA B stated she worked: Tuesday 9/8/15, Wednesday 9/9/15, Thursday 9/10/15 and Friday 9/11/15. CNA B stated she did not work on Saturday 9/12/15 or Sunday 9/13/15 because those were her scheduled days off. A time clock punch detail confirmed CNA B worked Tuesday 9/8/15, Wednesday (09/09/15), Thursday, (09/10/15) and Friday (09/11/15). A review of the personnel file for CNA B revealed no documentation that CNA B was suspended once the facility was aware of an allegation of verbal abuse against CNA B. At 09/16/2015 at 2:30 PM, The DON was shown the clock punch detail for CNA B. She stated, She thought CNA B had been suspended and was unaware that CNA B had not been suspended. On 09/16/2015 at 3:00 PM, the administrator was unable to provide an explanation when shown the time clock punch detail which reflected CNA B worked and was not suspended. On 9/16/15 at 11:22 AM, the Administrator and DON were notified that an Immediate Jeopardy (IJ) was identified. 3. On 9/18/15 at 9:30 AM, the Administrator, DON and the RN Corporate Manager of Clinical Operations were notified the facility's Plan of Removal (POR) was accepted. 4. The POR reflected the following immediate action included the following: On 9/16/15, the facility's administrative staff which consisted of the Administrator, Assistant Administrator and DON were re-educated and in-serviced by the RN Manager of Clinical Operations on abuse , neglect, investigation process, resident protection during investigations and suspension of alleged perpetrators. The re-education included training on the'Abuse Neglect Exploitation Incident Investigation Checklist to be used when conducting an investigation. On 9/16/15, an audit of facility investigations, accident/ incident reports was conducted by the RN Corporate Manager of Clinical Operations. No concerns were identified. On 9/16/15, the Administrator initiated facility staff re-education on abuse and neglect. Post test were utilized to verify staff competency. On 9/16/18, the Administrator and DON began re-investigations of the allegations made against CNA A and CNA B. CNA A and CNA B were suspended pending the outcome of the re-investigation. On 9/16/15 13 Resident Satisfaction Surveys were conducted by the Social Worker to assess for any additional allegations of abuse. No new allegations were made. Resident concerns, incident/accident, and reportable events would be reviewed by the Adm and DON daily during facility stand up meetings using the abuse, neglect checklist. The POR reflected the facility's Administrative staff would be monitored on their process of responding to resident and/or family allegations and conducting thorough investigations by the Regional Vice President of Operations and by the RN Manager of Clinical Operations. The POR reflected this oversight would be on-going. To verify the facility implemented their POR, the following was conducted: 5. Interviews conducted on 9/18/15 at 10:00 AM, with: CNA C, LVN D, CNA E, LVN F, LVN G, LVN H, CNA I, CNA J, LVN K, CNA L, CNA M, RN N and RN O, revealed they attended the abuse neglect in-service on 9/16/15. All staff interviewed were found to have an understanding of what abuse was, and when and who to report allegations. 6. The Administrator was interviewed on 9/17/15 and stated she would be the primary person moving forward to handle all [MEDICATION NAME]. The Administrator confirmed she had been given guidelines by Corporate to follow when conducting investigations. 7. The DON was interviewed on 9/17/15 and stated the facility had not thoroughly investigated incidences of abuse and neglect and that moving forward there would be better communication amongst administrative staff when conducting investigations. 8. On 9/18/15, additional residents interviews were conducted, no additional allegations of abuse or neglect were made. 9. On 9/18/15 the RN Manager of Clinical Operations, stated on -going monitoring of the facility administrative staff would be conducted by the Corporate/Regional team to ensure all allegations were thoroughly investigated and alleged perpetrators were immediately suspended. 10. Thirteen Resident Satisfaction Surveys were conducted by the Social Worker and documentation provided to the survey team. 11. Post tests on abuse and neglect completed by facility staff were reviewed. The post tests addressed: who and how to report allegations of abuse and neglect, that when an allegation of abuse and/or neglect was made against an employee , the employee would not be allowed to return to work until the investigation was deemed completed and a finding of unsubstantiated. The post tests listed the requirements for a thorough investigation. On 9/24/15, the Administrator, Assistant Adminstrator and DON were notified the IJ was lifted on 9/18/15. Staff sign-in sheets reflected CNA A worked station 2 and CNA B worked station 1. This encompassed two of four facility halls. According to the CMS Form 672, Resident Census and Conditions of Residents, completed by the DON on 9/18/15, reflected 150 residents currently resided at the facility.

Based on observation, interview and record review, it was determined the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for two (Residents #15 and #24 ) of 21 residents reviewed for abuse and neglect. 1. The Administrator,who was the Abuse Prevention Coordinator, failed to implement the facility's Abuse and Neglect Policy and Procedures. 2. The Administrator failed to conduct a thorough investigation when allegations of abuse were made against two staff members. 3. The Administrator failed to protect residents, to include Residents #15 and #24) from abuse by allowing the alleged perpetrators (CNA A and CNA B) to continue working during the investigation. An Immediate Jeopardy was identified on 09/16/2015 at 11:22 AM. While the IJ was removed on 09/18/15, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of widespread because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. These failures by the Administrator to take recognize and take appropriate action could affect the 150 residents that resided in the facility by placing them at risk for abuse. Findings included: 1. Resident #24 ' s Admission Face Sheet dated 08/03/2015, reflected she was admitted to the facility on [DATE]. Resident #24 ' s MDS assessment dated [DATE] reflected Resident #24 was an [AGE] year old female with active [DIAGNOSES REDACTED]. The MDS assessment also revealed the resident had clear speech, was understood, and understood others; and she was cognitively intact with a BIMS score of 12. The assessment also reflected the resident used a wheelchair for ambulation and required physical help with part of the bathing. Review of the Provider' s Investigation Report dated 8/31/15, revealed on 08/30/2015 Resident #24 stated CNA A was rude and grabbed her in a rough manner causing bruising to her right arm and pushed the shower chair so hard it hit a door causing a skin tear to Resident #24 ' s arm. The report revealed the facility learned of the incident on 8/31/15. On 8/31/15, the facility' concluded it's investigation and listed the investigation findings as inconclusive. On 9/15/15 at 2:00 PM, the administrator provided additional documentation she talked with the alleged perpetrator CNA A via the telephone on 09/03/15 (three days after submitting her investigation conclusion and investigation findings to the Texas Department of Aging and Disability Services.) On 09/15/2015 at 2:30 PM, the administer was asked if she had submitted her final investigation findings of Resident #24 ' s allegation of abuse against CNA A as inconclusive prior to speaking with the alleged perpetrator, CNA A. She stated, Yes . She was then asked if she felt she had done a thorough investigation. She stated, Yes . On 9/16/15 at 11:15 AM, the administrator confirmed she was the abuse coordinator. The administrator acknowledged she was responsible for the completeness and the thoroughness of all investigations. She was unable to explain why she submitted her investigation findings in less than 24 hours and without talking to or obtaining a written statement from the alleged perpetrator. On 09/16/2015 at 11:15 AM, the administrator was asked what a thorough investigation would include. She stated a thorough investigation included obtaining written statements from the victim, other cognitive residents, staff and the alleged perpetrator; and in-servicing staff were all part of a thorough investigation. On 09/16/2015 at 11:15 AM, the administrator was asked if she would expect her designee to obtain written statements as part of a thorough investigation. She stated, Yes. She went on to say she normally would have handled the investigaton but had sked the ADON to interview Resident #24 and the assistant administrator interview some residents. On 09/16/2015 at 11:45 AM, the assistant administrator was asked for a list of residents she had interviewed regarding care they received from CNA A. She stated, I didn' t get their names, I just asked the charge nurse to get me two cognitive residents to interview. The assistant administrator was asked if she felt it was important to get the names of the residents she interviewed. She stated, Yes it is, I agree. I went back and got their names yesterday (16 days after the final investigation findings were submitted to DADS). On 09/16/15 at 11:15 AM, the administrator stated when investigating an allegation of abuse, her number one priority was protection of the residents. She stated suspending the alleged perpetrator and ensuring the alleged perpetrator was re-educated and in-serviced on abuse prior to returning to work was an important part of protecting and ensuring resident safety. On 09/15/2015 at 5:00 PM, the Director of Nurses stated, CNA A was suspended during the investigation until 9/11/15, at which time, CNA A was in-serviced on abuse by the Staff Development Coordinator. On 09/15/2015 at 5:10 PM, the Staff Development Coordinator stated, she conducted the in-service training on abuse with CNA A on 09/11/2015. She stated she was very clear on the date because she came in early to do it and it was on a payday and her anniversary. The staff development Coordinator was then asked if she documented the in-service training on abuse with CNA A and she stated, No . A time-clock punch detail provided by the administrator on 09/16/2015 reflected CNA A returned to work on 09/07/2015 and not 09/11/2015. When the DON was shown the clock punch detail, she stated I did not know that and that she guessed CNA A had worked on 09/07/2015. 2. The Admission Face Sheet dated 03/24/2015, reflected Resident #15 was admitted to the facility on [DATE]. The MDS assessment dated [DATE] reflected Resident #15 was an [AGE] year old female with active [DIAGNOSES REDACTED]. The MDS assessment reflected the resident required extensive assistance with bed mobility and had a BIMS score of 3 which indicated severe cognitive impairment. Review of the Provider Investigation Report dated 9/9/15, revealed that on 09/08/2015 a family member alleged that when she made allegations of rough handling of Resident #15 by facility staff, Resident #15 was intimidated by CNA B. The family stated CNA B told Resident #15 if she didn't stop reporting them (facility staff) to her daughter, she (the resident) would not be allowed to go to activities and would be discharged from the facility. On 09/16/2015 at 2:30 PM, the administrator was asked if CNA B was suspended upon learning of the allegation of verbal abuse made by a family member of Resident 15 against CNA B. She stated, Yes . On 09/16/2015 at 3:30 PM CNA B stated she worked: Tuesday 9/8/15, Wednesday 9/9/15, Thursday 9/10/15 and Friday 9/11/15. CNA B stated she did not work on Saturday 9/12/15 or Sunday 9/13/15 because those were her scheduled days off. A time clock punch detail confirmed CNA B worked Tuesday 9/8/15, Wednesday (09/09/15), Thursday, (09/10/15) and Friday (09/11/15). A review of the personnel file for CNA B revealed no documentation that CNA B was suspended once the facility was aware of an allegation of verbal abuse against CNA B. At 09/16/2015 at 2:30 PM, The DON was shown the clock punch detail for CNA B. She stated, She thought CNA B had been suspended and was unaware that CNA B had not been suspended. On 09/16/2015 at 3:00 PM, the administrator was unable to provide an explanation when shown the time clock punch detail which reflected CNA B worked and was not suspended. A copy of the facility' s abuse policy revised 7/1/05, provided by the administrator revealed the following: Purpose to ensure the resident's rights are protected by providing a method for the prevention, reporting and investigationof any type of alleged resident abuse. .POLICY It is the policy of this center to maintain the resident ' s right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property . .INVESTIGATION .B.interview of other residents who may receive care from the alleged perpetrator .D. Investigation results will be recorded and organized to include actual statements of witnesses . .PROTECTION .Suspension of an employee pending the investigation. 3. On 9/16/15 at 11:22 AM, the Administrator and DON were notified that an Immediate Jeopardy (IJ) was identified. On 9/17/15 at 11:25 AM, when asked what procedures were in place to ensure residents needs were met, the Administrator stated Administrative staff attend morning stand up meetings and that she made rounds every morning and afternoon. On 9/18/15, when asked why she thought the IJ had occurred, the Administrator stated it was a miscommunication. The administrator stated comments made by the family member were misinterpreted by the Assistant Administrator. On 9/17/15 11:15 AM, the DON stated she ensures direct care staff are competent in their skills by interviewing residents and staff. She also stated she conducted rounding observations to assess care. On 9/18/15, when the DON was asked why she though the IJ had occurred, the DON also stated it was a miscommunication issue. 4. On 9/18/15 at 9:30 AM, the Administrator, DON and the RN Corporate Manager of Clinical Operations were notified the facility's Plan of Removal (POR) was accepted. 5. The POR reflected the following immediate action included the following: On 9/16/15, the facility's administrative staff which consisted of the Administrator, Assistant Administrator and DON were re-educated and in-serviced by the RN Manager of Clinical Operations on abuse , neglect, investigation process, resident protection during investigations and suspension of alleged perpetrators. The re-education included training on the'Abuse Neglect Exploitation Incident Investigation Checklist to be used when conducting an investigation. On 9/16/15, an audit of facility investigations, accident/ incident reports was conducted by the RN Corporate Manager of Clinical Operations. No concerns were identified. On 9/16/15, the Administrator initiated facility staff re-education on abuse and neglect. Post test were utilized to verify staff competency. On 9/16/18, the Administrator and DON began re-investigations of the allegations made against CNA A and CNA B. CNA A and CNA B were suspended pending the outcome of the re-investigation. On 9/16/15 13 Resident Satisfaction Surveys were conducted by the Social Worker to assess for any additional allegations of abuse. No new allegations were made. Resident concerns, incident/accident, and reportable events would be reviewed by the Adm and DON daily during facility stand up meetings using the abuse, neglect checklist. The POR reflected the facility's Administrative staff would be monitored on their process of responding to resident and/or family allegations and conducting thorough investigations by the Regional Vice President of Operations and by the RN Manager of Clinical Operations. The POR reflected this oversight would be on-going. To verify the facility implemented their POR, the following was conducted: 6. Interviews conducted on 9/18/15 at 10:00 AM, with: CNA C, LVN D, CNA E, LVN F, LVN G, LVN H, CNA I, CNA J, LVN K, CNA L, CNA M, RN N and RN O, revealed they attended the abuse neglect in-service on 9/16/15. All staff interviewed were found to have an understanding of what abuse was, and when and who to report allegations. 7. The Administrator was interviewed on 9/17/15 and stated she would be the primary person moving forward to handle all [MEDICATION NAME]. The Administrator confirmed she had been given guidelines by Corporate to follow when conducting investigations. 8. The DON was interviewed on 9/17/15 and stated the facility had not thoroughly investigated incidences of abuse and neglect and that moving forward there would be better communication amongst administrative staff when conducting investigations. 9. On 9/18/15, additional residents interviews were conducted, no additional allegations of abuse or neglect were made. 10. On 9/18/15 the RN Manager of Clinical Operations, stated on -going monitoring of the facility administrative staff would be conducted by the Corporate/Regional team to ensure all allegations were thoroughly investigated and alleged perpetrators were immediately suspended. 11. Thirteen Resident Satisfaction Surveys were conducted by the Social Worker and documentation provided to the survey team. 12. Post tests on abuse and neglect completed by facility staff were reviewed. The post tests addressed: who and how to report allegations of abuse and neglect, that when an allegation of abuse and/or neglect was made against an employee , the employee would not be allowed to return to work until the investigation was deemed completed and a finding of unsubstantiated. The post tests listed the requirements for a thorough investigation. On 9/24/15, the Administrator, Assistant Adminstrator and DON were notified the IJ was lifted on 9/18/15. According to the CMS Form 672, Resident Census and Conditions of Residents, completed by the DON on 9/18/15, reflected 150 residents currently resided at the facility.

Based on interview and record review, it was determined the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical status for one (Resident #1) of four residents reviewed whose doctors were not notified of significant change in condition and an altered mental status that resulted [MEDICAL CONDITION] and a deep wound infection. Resident #1 was admitted from the hospital on [DATE] with a [DIAGNOSES REDACTED]. The incision site to the lower back was not draining upon admission. There was a hospital discharge order to change the dressing every day until dry, which was not transcribed onto the facility admission orders [REDACTED]. The incision site had a dressing applied several times without an order. The physician was never notified of ongoing drainage. A wound care order was never obtained. On 02/04/12 Resident #1's pulse was 142 at approximately 8:00 AM. On 02/04/12 at approximately 3:30 PM, Resident #1's BP was 88/58 and pulse was 130. Without rechecking Resident #1's BP, LVN A administered [MEDICATION NAME] (for hypertension), at approximately 8:00 PM on 02/04/12. The physician was not notified of Resident #1's decreased blood pressure and increased pulse. Resident #1's BP after 11:00 PM was 105/61. On 02/05/12, Resident #1 was lethargic, complaining of pain all over, and his blood pressure was dropping. Resident #1's last BP before being sent to the hospital was 63/37 and her pulse was not detectable. Resident #1 was diagnosed with [REDACTED]. Resident #1 required surgery to her lumbar incision due to the deep infection. These failures could affect the potential 16 residents, including Resident #1, who resided in Rooms 210-217 and were assigned to receive care from LVN A and placed them at risk for not receiving the care and services they needed to maintain their well-being, comfort and free of infection to ensure they live the life they desired. Findings included: 1) Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Resident (MDS) data set [DATE] at 2:00 PM revealed Resident #1 was admitted to the facility from the hospital with post-operative lumbar decompression and fusion surgery. "Hospital nurse reports her vs (vital signs) have been normal and she has not had pain agents (medications) x (times) two days." Under the "skin" section of the admission paperwork, there was a pen line drawn down the middle of the back of the full-body diagram indicating Resident #1's post-operative incision ran down the middle of her back and extended from a level with the armpits past the sacrum. There were handwritten words next to the diagram, which reflected "incision open to air." There was no further description of the wound. The Skilled Nurses Note dated 01/28/12 at 4:00 PM reflected LVN A left a message for Physician E to confirm he would be Resident #1's admitting physician. Physician F was on call and instructed LVN A to follow up with Physician E's office on 01/30/12. There was no evidence to reflect this follow-up phone call to confirm Physician E would follow Resident #1 occurred. During an interview on 02/10/12 at 8:25 AM, LVN A stated she admitted Resident #1 from the hospital. LVN A stated Resident #1 had a lower back incision, with staples and no drainage. The surveyor queried LVN A if she measured the incision site, and LVN A stated, "No" The surveyor reviewed with LVN A the hospital discharge orders, which included to change the dressing (to the back incision) daily until dry, which was transcribed to the facility admission orders I thought I went through the whole thing (hospital discharge orders)." The surveyor queried LVN A, "Do you normally go through all the discharge orders from the hospital?" LVN A responded, "I try to." There were five pages of hospital discharge orders. During an interview on 02/09/12 at 10:10 AM, the DON stated, "We (facility nurses) have a responsibility to honor the hospital transfer orders, unless we speak with the doctor and get a discontinue order." During an interview on 02/08/12 at 3:51 PM, ADON G stated,"When we get orders from the hospital, we call the physician and check what should be transcribed." Facility Transfer Orders from the hospital dated 01/27/12 reflected: "Change dressing - Daily, ...Routine. Comments: Until Dry. Remove dressing if incision is dry, then discontinue dressing. Comments: Remove dressing if incision is dry, then discontinue dressing. May leave dressing off if wound dry, if wound has drainage, change daily or after shower (op-site) (post-operative site) with shower." Resident #1's Skin Assessment sheet dated 01/28/12 was completed by LVN A. The narrative notes section reflected: "She (Resident #1) has a spine incision open to dry, no orders to apply a dressing." Review of the Skilled Nurses Note dated 01/29/12 revealed under the heading "Days," Resident #1's BP was 146/74 and pulse was 106. Under the heading "Evenings," her BP was 109/67 and pulse 87. At 8:00 PM, the resident had blood-tinged drainage coming from her back incision. LVN A documented she applied a dressing to the resident's back incision. On 02/08/12 at 3:42 PM the surveyor queried LVN A if she found it unusual to have drainage from the incision site since there was no drainage upon admission and LVN A stated, "No. She (Resident #1) didn't complain of pain and (there was) no green/yellow drainage." During an interview on 02/10/12 at 8:25 AM the surveyor queried LVN A if she could apply a dressing to a resident without a physician order [REDACTED]." The Skilled Nurses Note dated 01/30/12 at 12:50 PM reflected Resident #1 fell in the hallway while ambulating. The physician was notified of the resident's fall and constipation. There was no documentation regarding Resident #1's back incision or evidence to indicate the physician had been informed the resident's incision was draining. During an interview on 02/09/12 at 9:31 AM, COTA H stated she was getting Resident #1 a wheelchair when she fell . COTA H further stated Resident #1's "stitches were leaking. It (drainage) was on the gown." COTA H stated, "Some (of the drainage) was wet and some was darker. The COTA described the drainage size as "larger than a football." During an interview on 02/08/12 at 4:15 PM, Wound Care Nurse - LVN D stated she always looked at newly-admitted residents to have an idea what their surgical sites looked like. Wound Care Nurse - LVN D stated she assessed Resident #1's surgical incision on 01/31/12, and it measured 15 by 0.5 cm with 12 sutures and "no staples." Wound Care Nurse - LVN D further stated the incision had a moderate amount of serosanguinous (bloody) drainage at that time when she assessed it. Wound Care Nurse - LVN D stated Resident #1 had fallen earlier that day and had a hematoma on the left side of her head, which measured 5 by 5 cm. Wound Care Nurse - LVN D stated she did not see this resident again, because the incision was not dehisced (separation of the incision). Wound Care Nurse - LVN D stated her notes and observations would not be in Resident #1's medical record. She stated she documented her findings on a small note pad, which she kept in her possession. Review of the Skilled Nurses Note dated 01/31/12 revealed under the heading "Days," Resident #1's BP was 86/66. At 9:00 AM, Resident #1's surgical site had a moderate amount of serosanguinous drainage. The Note reflected Resident #1 complained of pain to her lower back (at the incision site) and her lower extremities. There was no evidence the resident's BP was re-assessed for "Days." Review of the Skilled Nurses Note dated 02/01/12 revealed Resident #1 had serosanguinous drainage observed on the dressing to her incision site. There was no evidence to indicate the dressing was changed. Review of the Skilled Nurses Note dated 02/02/12 revealed Resident #1's dressing was changed (to incision site) due to serosanguinous drainage. The Skilled Nurses Note dated 02/03/12 reflected Resident #1 had a small amount of serosanguinous drainage from her incision, and her pulse was 114. Skilled Nursing Notes written by LVN A dated 02/04/12 reflected under the heading "Days" Resident #1's BP was 110/63 and her pulse was 142. Under the heading "Evenings," Resident #1's BP was 88/58 and her pulse was 130. At 8:20 AM, documentation reflected Resident #1 stated she "doesn't feel strong at best today." At 3:00 PM, Resident #1 continued to verbalize to the nurse "she (Resident #1) doesn't feel well." At 6:45 PM, "she was awakened enough to eat a small amount of her dinner tray." Review of the Routine Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview on 02/10/12 at 8:25 AM, LVN A stated she would hold a resident's BP medication if the BP was less than 90/55. The surveyor queried LVN A if she would notify the physician if a resident's BP was less than 90/55, and LVN A stated, "Well... no." LVN A stated she worked 16 hours on Saturdays and Sundays and she took the residents' vital signs, including BP. She stated the "Days" BP were taken around 8:00 AM, and the "Evenings" BP were taken between 2:30 PM and 3:30 PM. The surveyor queried LVN A if she would take a resident's BP again before administering 8:00 PM BP medications, and LVN A stated, "No." The surveyor reviewed with LVN A Resident #1's BP on 02/04/12 on "Evenings," which was 88/58 and her pulse of 130. The surveyor queried LVN A if she administered [MEDICATION NAME] and [MEDICATION NAME] at 8:00 PM, and LVN A stated, "Yes. I probably shouldn't have given it to her, but her heart rate (pulse) was still up, and I know she takes it for that." The surveyor queried LVN A if she saw Resident #1 again that night, and LVN A stated, "No." LVN A stated, "She (Resident #1) never complained of chest pain." The surveyor queried LVN A if vital signs were irrelevant if the resident did not have chest pain and LVN A stated, "Yes to me, because she was on medication for heart rate." The surveyor queried LVN A if BP was irrelevant without chest pain, and LVN A stated, "Yes." During an interview on 02/08/12 at 4:02 PM, LVN B stated she would hold BP medication if a resident's blood pressure was less than 100/60 and would call the doctor if the BP was out of normal ranges for the resident. Review of the Skilled Nursing Note dated 02/05/12, between 12:00 AM and 6:00 AM, revealed Resident #1 was noted with a change in condition. She was lethargic and complained of pain all over. The resident appeared jaundiced and weak, her BP was dropping rapidly and her pulse was high. The last BP reading before the resident was transferred to the hospital was 63/37. The Note reflected: "Not able to get pulse reading @ (at) last v/s (vital signs) check." A hospital consultation report dated 02/05/12 at 6:52 PM reflected: "History of Present Illness: ....presented to the emergency room today with a chief complaint of altered mental status, [MEDICAL CONDITION], and [MEDICAL CONDITION] Workup in the ER (emergency room ) demonstrated urinary tract infection as well as dehiscence, and maceration of the postoperative lumbar incision... Lumbar Spine: Significant skin maceration around sutures and staples with no approximation of the incisional edges. [DIAGNOSES REDACTED] is associated with drainage, as well as some skin reaction, with blistering from the prior tape from the dressing... Laboratories and Studies: ...She has positive UTI with an elevated white count of 39,000... She had a fever of 102 in the emergency room ...." A hospital consultation report dated 02/05/12 at 6:27 PM reflected: "...Impressions: 1.[MEDICAL CONDITION] syndrome with mild hemodynamic instability... ...3 ....Apparently the bandage had not been changed over her wound in some time. There was some milky drainage when she arrived in the ICU (Intensive Care Unit)... Physical Examination: General: Reportedly when she arrived in the ICU, she had pinpoint pupils and was very poorly responsive... Diagnostic Data: White count was 39,000." A hospital consultation report dated 02/05/12 at 6:19 AM reflected: "HPI: ....The ____ (facility name) staff reports the pt (patient) (Resident #1) has had [MEDICAL CONDITIONS] for about a week...." A hospital procedure report dated 02/05/12 at 11:29 AM reflected: "...Patient unresponsive, no response to painful stimuli...." A hospital consultation report dated 02/07/12 at 9:09 AM reflected: "...Preoperative Diagnosis: [REDACTED]. Postoperative Diagnosis: [REDACTED]. Operative Procedure: Incision, drainage, and debridement of deep lumbar wound infection with debridement of skin, muscle, and fascia... Findings: Abscess and purulent material within the skin, subcutaneous and deep, as well as abscess deep to the lumbodorsal fascia and muscle...." A hospital consultation report dated 02/06/12 at 8:13 PM reflected: "...Reason for Consult: bacteremia and wound infection. History of present illness: Patient (Resident #1) is about two weeks post op lumbar fusion and instrumentation. She was discharged to _____ (facility name) where her wound was never redressed... She was taken to surgery today and had findings of deep infection. She has two positive blood cultures for gram positive cocci and the wound is growing positive staph...." A hospital consultation report dated 02/08/12 at 10:48 AM reflected: "Blood Culture: Final Report. In both bottles Staphylococcus aureus... Urine Culture: Final Report. 10,000 to 50,000 CFU/ml Multiple Gram Positive Species... Wound Culture: Preliminary Report: Moderate Staphylococcus species, coagulase positive...." Review of Resident #1's entire facility clincal record dated from 01/28/12 through 02/05/12 revealed the resident's physician was only notified twice: on 01/28/12 on admission and on 01/30/12 after the resident fell . During an interview on 02/08/12 at 3:42 PM, LVN B stated she would change Resident #1's dressing (to the incision site) when the resident asked her to. The surveyor queried why she would change a dressing if there was no order, and LVN B stated, "Everyone with a surgical wound has an order (to change the dressing)." During an interview on 02/10/12 at 8:25 AM, LVN A stated she told Resident #1's family member, after the resident was sent back to the hospital, the dressing to Resident #1's incision site should be left on until it fell off. LVN A added, "That's what the nurse at _____ (the hospital) told me. When the dressing falls off, it (the incision) should be open to air." During an interview on 02/09/12 at 3:50 PM, the Weekend Supervisor stated his job responsibilities on the weekend included introducing himself to the new residents and to review the physician orders. The surveyor reviewed the admission documentation of Resident #1's incision site and noted there were no measurements noted. It was also noted there were no wound care orders on Resident #1's admission orders [REDACTED]. The Weekend Supervisor stated, "She (Resident #1) was being skilled for that wound. They (facility nurses) should have done a better job than that." The surveyor queried the Weekend Supervisor regarding BP parameters and he stated, "I would call the doctor if the blood pressure was less than 100/60 or the pulse was greater than 120." 2) Review of the facility'a current policy entitled "Physician Notification of Change in Resident Condition" dated November 2005 revealed: "Purpose: To keep the physician, resident and resident's responsible party informed of changes in resident's condition so that timely interventions can be obtained...." Review of the facility's current policy entitled "Admission of Resident" dated May 2004 revealed, "...10. Notify physician of admission and obtain orders and current diagnoses...." Review of the facility's current policy entitled "Physician Services" dated May 2004 revealed "...9. If the attending physician does not respond promptly, a call to the alternative physician should be made. If neither is available, the Medical Director should be contacted to attend the resident...." 3) The facility list provided by the Administrator on 02/10/12 reflected there was a potential of 16 residents, including Resident #1, who resided in Rooms 210-217 who were assigned to LVN A.

Based on observation, interview and record review, it was determined the facility failed to implement the facility's policies and procedures that prohibited neglect for one (Resident #1) of four residents reviewed for neglect, who was not receiving wound care according to physician's orders [REDACTED]. Resident #1 was admitted from the hospital on [DATE] with a [DIAGNOSES REDACTED]. The incision site to the lower back was not draining upon admission. There was a hospital discharge order to change the dressing every day until dry, which was not transcribed onto the facility admission orders [REDACTED]. The incision site had a dressing applied several times without an order. The physician was never notified of ongoing drainage. A wound care order was never obtained. On 02/04/12 Resident #1's pulse was 142 at approximately 8:00 AM. On 02/04/12 at approximately 3:30 PM, Resident #1's BP was 88/58 and pulse was 130. Without rechecking Resident #1's BP, LVN A administered [MEDICATION NAME] (for hypertension), at approximately 8:00 PM on 02/04/12. The physician was not notified of Resident #1's decreased blood pressure and increased pulse. Resident #1's BP after 11:00 PM was 105/61. On 02/05/12, Resident #1 was lethargic, complaining of pain all over, and his blood pressure was dropping. Resident #1's last BP before being sent to the hospital was 63/37 and her pulse was not detectable. Resident #1 was diagnosed with [REDACTED]. Resident #1 required surgery to her lumbar incision due to the deep infection. These failures could affect the potential 16 residents, including Resident #1, who resided in Rooms 210-217 and were assigned to receive care from LVN A and placed them at risk for not receiving the care and services they needed to maintain their well-being, comfort and free of infection to ensure they live the life they desired. Findings included: 1) Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Resident (MDS) data set [DATE] at 2:00 PM revealed Resident #1 was admitted to the facility from the hospital with post-operative lumbar decompression and fusion surgery. "Hospital nurse reports her vs (vital signs) have been normal and she has not had pain agents (medications) x (times) two days." Under the "skin" section of the admission paperwork, there was a pen line drawn down the middle of the back of the full-body diagram indicating Resident #1's post-operative incision ran down the middle of her back and extended from a level with the armpits past the sacrum. There were handwritten words next to the diagram, which reflected "incision open to air." There was no further description of the wound. The Skilled Nurses Note dated 01/28/12 at 4:00 PM reflected LVN A left a message for Physician E to confirm he would be Resident #1's admitting physician. Physician F was on call and instructed LVN A to follow up with Physician E's office on 01/30/12. There was no evidence to reflect this follow-up phone call to confirm Physician E would follow Resident #1 occurred. During an interview on 02/10/12 at 8:25 AM, LVN A stated she admitted Resident #1 from the hospital. LVN A stated Resident #1 had a lower back incision, with staples and no drainage. The surveyor queried LVN A if she measured the incision site, and LVN A stated, "No" The surveyor reviewed with LVN A the hospital discharge orders, which included to change the dressing (to the back incision) daily until dry, which was transcribed to the facility admission orders I thought I went through the whole thing (hospital discharge orders)." The surveyor queried LVN A, "Do you normally go through all the discharge orders from the hospital?" LVN A responded, "I try to." There were five pages of hospital discharge orders. During an interview on 02/09/12 at 10:10 AM, the DON stated, "We (facility nurses) have a responsibility to honor the hospital transfer orders, unless we speak with the doctor and get a discontinue order." During an interview on 02/08/12 at 3:51 PM, ADON G stated,"When we get orders from the hospital, we call the physician and check what should be transcribed." Facility Transfer Orders from the hospital dated 01/27/12 reflected: "Change dressing - Daily, ...Routine. Comments: Until Dry. Remove dressing if incision is dry, then discontinue dressing. Comments: Remove dressing if incision is dry, then discontinue dressing. May leave dressing off if wound dry, if wound has drainage, change daily or after shower (op-site) (post-operative site) with shower." Resident #1's Skin Assessment sheet dated 01/28/12 was completed by LVN A. The narrative notes section reflected: "She (Resident #1) has a spine incision open to dry, no orders to apply a dressing." Review of the Skilled Nurses Note dated 01/29/12 revealed under the heading "Days," Resident #1's BP was 146/74 and pulse was 106. Under the heading "Evenings," her BP was 109/67 and pulse 87. At 8:00 PM, the resident had blood-tinged drainage coming from her back incision. LVN A documented she applied a dressing to the resident's back incision. On 02/08/12 at 3:42 PM the surveyor queried LVN A if she found it unusual to have drainage from the incision site since there was no drainage upon admission and LVN A stated, "No. She (Resident #1) didn't complain of pain and (there was) no green/yellow drainage." During an interview on 02/10/12 at 8:25 AM the surveyor queried LVN A if she could apply a dressing to a resident without a physician order [REDACTED]." The Skilled Nurses Note dated 01/30/12 at 12:50 PM reflected Resident #1 fell in the hallway while ambulating. The physician was notified of the resident's fall and constipation. There was no documentation regarding Resident #1's back incision or evidence to indicate the physician had been informed the resident's incision was draining. During an interview on 02/09/12 at 9:31 AM, COTA H stated she was getting Resident #1 a wheelchair when she fell . COTA H further stated Resident #1's "stitches were leaking. It (drainage) was on the gown." COTA H stated, "Some (of the drainage) was wet and some was darker. The COTA described the drainage size as "larger than a football." During an interview on 02/08/12 at 4:15 PM, Wound Care Nurse - LVN D stated she always looked at newly-admitted residents to have an idea what their surgical sites looked like. Wound Care Nurse - LVN D stated she assessed Resident #1's surgical incision on 01/31/12, and it measured 15 by 0.5 cm with 12 sutures and "no staples." Wound Care Nurse - LVN D further stated the incision had a moderate amount of serosanguinous (bloody) drainage at that time when she assessed it. Wound Care Nurse - LVN D stated Resident #1 had fallen earlier that day and had a hematoma on the left side of her head, which measured 5 by 5 cm. Wound Care Nurse - LVN D stated she did not see this resident again, because the incision was not dehisced (separation of the incision). Wound Care Nurse - LVN D stated her notes and observations would not be in Resident #1's medical record. She stated she documented her findings on a small note pad, which she kept in her possession. Review of the Skilled Nurses Note dated 01/31/12 revealed under the heading "Days," Resident #1's BP was 86/66. At 9:00 AM, Resident #1's surgical site had a moderate amount of serosanguinous drainage. The Note reflected Resident #1 complained of pain to her lower back (at the incision site) and her lower extremities. There was no evidence the resident's BP was re-assessed for "Days." Review of the Skilled Nurses Note dated 02/01/12 revealed Resident #1 had serosanguinous drainage observed on the dressing to her incision site. There was no evidence to indicate the dressing was changed. Review of the Skilled Nurses Note dated 02/02/12 revealed Resident #1's dressing was changed (to incision site) due to serosanguinous drainage. The Skilled Nurses Note dated 02/03/12 reflected Resident #1 had a small amount of serosanguinous drainage from her incision, and her pulse was 114. Skilled Nursing Notes written by LVN A dated 02/04/12 reflected under the heading "Days" Resident #1's BP was 110/63 and her pulse was 142. Under the heading "Evenings," Resident #1's BP was 88/58 and her pulse was 130. At 8:20 AM, documentation reflected Resident #1 stated she "doesn't feel strong at best today." At 3:00 PM, Resident #1 continued to verbalize to the nurse "she (Resident #1) doesn't feel well." At 6:45 PM, "she was awakened enough to eat a small amount of her dinner tray." Review of the Routine Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview on 02/10/12 at 8:25 AM, LVN A stated she would hold a resident's BP medication if the BP was less than 90/55. The surveyor queried LVN A if she would notify the physician if a resident's BP was less than 90/55, and LVN A stated, "Well... no." LVN A stated she worked 16 hours on Saturdays and Sundays and she took the residents' vital signs, including BP. She stated the "Days" BP were taken around 8:00 AM, and the "Evenings" BP were taken between 2:30 PM and 3:30 PM. The surveyor queried LVN A if she would take a resident's BP again before administering 8:00 PM BP medications, and LVN A stated, "No." The surveyor reviewed with LVN A Resident #1's BP on 02/04/12 on "Evenings," which was 88/58 and her pulse of 130. The surveyor queried LVN A if she administered [MEDICATION NAME] and [MEDICATION NAME] at 8:00 PM, and LVN A stated, "Yes. I probably shouldn't have given it to her, but her heart rate (pulse) was still up, and I know she takes it for that." The surveyor queried LVN A if she saw Resident #1 again that night, and LVN A stated, "No." LVN A stated, "She (Resident #1) never complained of chest pain." The surveyor queried LVN A if vital signs were irrelevant if the resident did not have chest pain and LVN A stated, "Yes to me, because she was on medication for heart rate." The surveyor queried LVN A if BP was irrelevant without chest pain, and LVN A stated, "Yes." During an interview on 02/08/12 at 4:02 PM, LVN B stated she would hold BP medication if a resident's blood pressure was less than 100/60 and would call the doctor if the BP was out of normal ranges for the resident. Review of the Skilled Nursing Note dated 02/05/12, between 12:00 AM and 6:00 AM, revealed Resident #1 was noted with a change in condition. She was lethargic and complained of pain all over. The resident appeared jaundiced and weak, her BP was dropping rapidly and her pulse was high. The last BP reading before the resident was transferred to the hospital was 63/37. The Note reflected: "Not able to get pulse reading @ (at) last v/s (vital signs) check." A hospital consultation report dated 02/05/12 at 6:52 PM reflected: "History of Present Illness: ....presented to the emergency room today with a chief complaint of altered mental status, [MEDICAL CONDITION], and [MEDICAL CONDITION] Workup in the ER (emergency room ) demonstrated urinary tract infection as well as dehiscence, and maceration of the postoperative lumbar incision... Lumbar Spine: Significant skin maceration around sutures and staples with no approximation of the incisional edges. [DIAGNOSES REDACTED] is associated with drainage, as well as some skin reaction, with blistering from the prior tape from the dressing... Laboratories and Studies: ...She has positive UTI with an elevated white count of 39,000... She had a fever of 102 in the emergency room ...." A hospital consultation report dated 02/05/12 at 6:27 PM reflected: "...Impressions: 1.[MEDICAL CONDITION] syndrome with mild hemodynamic instability... ...3 ....Apparently the bandage had not been changed over her wound in some time. There was some milky drainage when she arrived in the ICU (Intensive Care Unit)... Physical Examination: General: Reportedly when she arrived in the ICU, she had pinpoint pupils and was very poorly responsive... Diagnostic Data: White count was 39,000." A hospital consultation report dated 02/05/12 at 6:19 AM reflected: "HPI: ....The ____ (facility name) staff reports the pt (patient) (Resident #1) has had [MEDICAL CONDITIONS] for about a week...." A hospital procedure report dated 02/05/12 at 11:29 AM reflected: "...Patient unresponsive, no response to painful stimuli...." A hospital consultation report dated 02/07/12 at 9:09 AM reflected: "...Preoperative Diagnosis: [REDACTED]. Postoperative Diagnosis: [REDACTED]. Operative Procedure: Incision, drainage, and debridement of deep lumbar wound infection with debridement of skin, muscle, and fascia... Findings: Abscess and purulent material within the skin, subcutaneous and deep, as well as abscess deep to the lumbodorsal fascia and muscle...." A hospital consultation report dated 02/06/12 at 8:13 PM reflected: "...Reason for Consult: bacteremia and wound infection. History of present illness: Patient (Resident #1) is about two weeks post op lumbar fusion and instrumentation. She was discharged to _____ (facility name) where her wound was never redressed... She was taken to surgery today and had findings of deep infection. She has two positive blood cultures for gram positive cocci and the wound is growing positive staph...." A hospital consultation report dated 02/08/12 at 10:48 AM reflected: "Blood Culture: Final Report. In both bottles Staphylococcus aureus... Urine Culture: Final Report. 10,000 to 50,000 CFU/ml Multiple Gram Positive Species... Wound Culture: Preliminary Report: Moderate Staphylococcus species, coagulase positive...." Review of Resident #1's entire facility clincal record dated from 01/28/12 through 02/05/12 revealed the resident's physician was only notified twice: on 01/28/12 on admission and on 01/30/12 after the resident fell . During an interview on 02/08/12 at 3:42 PM, LVN B stated she would change Resident #1's dressing (to the incision site) when the resident asked her to. The surveyor queried why she would change a dressing if there was no order, and LVN B stated, "Everyone with a surgical wound has an order (to change the dressing)." During an interview on 02/10/12 at 8:25 AM, LVN A stated she told Resident #1's family member, after the resident was sent back to the hospital, the dressing to Resident #1's incision site should be left on until it fell off. LVN A added, "That's what the nurse at _____ (the hospital) told me. When the dressing falls off, it (the incision) should be open to air." During an interview on 02/09/12 at 3:50 PM, the Weekend Supervisor stated his job responsibilities on the weekend included introducing himself to the new residents and to review the physician orders. The surveyor reviewed the admission documentation of Resident #1's incision site and noted there were no measurements noted. It was also noted there were no wound care orders on Resident #1's admission orders [REDACTED]. The Weekend Supervisor stated, "She (Resident #1) was being skilled for that wound. They (facility nurses) should have done a better job than that." The surveyor queried the Weekend Supervisor regarding BP parameters and he stated, "I would call the doctor if the blood pressure was less than 100/60 or the pulse was greater than 120." 2) Review of the facility'a current policy entitled "Physician Notification of Change in Resident Condition" dated November 2005 revealed: "Purpose: To keep the physician, resident and resident's responsible party informed of changes in resident's condition so that timely interventions can be obtained...." Review of the facility's current policy entitled "Admission of Resident" dated May 2004 revealed, "...10. Notify physician of admission and obtain orders and current diagnoses...." Review of the facility's current policy entitled "Physician Services" dated May 2004 revealed "...9. If the attending physician does not respond promptly, a call to the alternative physician should be made. If neither is available, the Medical Director should be contacted to attend the resident...." 3) The facility list provided by the Administrator on 02/10/12 reflected there was a potential of 16 residents, including Resident #1, who resided in Rooms 210-217 who were assigned to LVN A.

Based on observation, interview and record review, it was determined the facility failed to implement the facility's policies and procedures that prohibited neglect for one (Resident #1) of four residents reviewed for neglect, who was not receiving wound care according to physician's orders [REDACTED]. Resident #1 was admitted from the hospital on [DATE] with a [DIAGNOSES REDACTED]. The incision site to the lower back was not draining upon admission. There was a hospital discharge order to change the dressing every day until dry, which was not transcribed onto the facility admission orders [REDACTED]. The incision site had a dressing applied several times without an order. The physician was never notified of ongoing drainage. A wound care order was never obtained. On 02/04/12 Resident #1's pulse was 142 at approximately 8:00 AM. On 02/04/12 at approximately 3:30 PM, Resident #1's BP was 88/58 and pulse was 130. Without rechecking Resident #1's BP, LVN A administered [MEDICATION NAME] (for hypertension), at approximately 8:00 PM on 02/04/12. The physician was not notified of Resident #1's decreased blood pressure and increased pulse. Resident #1's BP after 11:00 PM was 105/61. On 02/05/12, Resident #1 was lethargic, complaining of pain all over, and his blood pressure was dropping. Resident #1's last BP before being sent to the hospital was 63/37 and her pulse was not detectable. Resident #1 was diagnosed with [REDACTED]. Resident #1 required surgery to her lumbar incision due to the deep infection. These failures could affect the potential 16 residents, including Resident #1, who resided in Rooms 210-217 and were assigned to receive care from LVN A and placed them at risk for not receiving the care and services they needed to maintain their well-being, comfort and free of infection to ensure they live the life they desired. Findings included: 1. Record review of the facility's current policy and procedures entitled Abuse Prevention policy with a revised date of 07/01/05 provided by the Administrator reflected the following: POLICY: It is the policy of this Center to maintain the resident's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property. FUNDEMENTAL INFORMATION: Purpose: To ensure the resident's rights are protected by providing a method for the prevention, reporting and investigation of any type of alleged resident abuse. PROCEDURE: The Center shall take the following steps to prevent, detect and report allegations of abuse, neglect, injuries of unknown source and misappropriation of resident property. III. PREVENTION ... ...4. Analysis of: .....d. Assessment, care planning and monitoring of residents with need and behavior which might lead to conflict or neglect, such as ... those that require heaving nursing care and / or are totally dependent on staff ... ... V. INVESTIGATION .....2. Medical assessment of the resident, if appropriate (e.g. vital signs, range of motion, changes in condition, x-rays, etc.) .... 2) Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Resident (MDS) data set [DATE] at 2:00 PM revealed Resident #1 was admitted to the facility from the hospital with post-operative lumbar decompression and fusion surgery. "Hospital nurse reports her vs (vital signs) have been normal and she has not had pain agents (medications) x (times) two days." Under the "skin" section of the admission paperwork, there was a pen line drawn down the middle of the back of the full-body diagram indicating Resident #1's post-operative incision ran down the middle of her back and extended from a level with the armpits past the sacrum. There were handwritten words next to the diagram, which reflected "incision open to air." There was no further description of the wound. The Skilled Nurses Note dated 01/28/12 at 4:00 PM reflected LVN A left a message for Physician E to confirm he would be Resident #1's admitting physician. Physician F was on call and instructed LVN A to follow up with Physician E's office on 01/30/12. There was no evidence to reflect this follow-up phone call to confirm Physician E would follow Resident #1 occurred. During an interview on 02/10/12 at 8:25 AM, LVN A stated she admitted Resident #1 from the hospital. LVN A stated Resident #1 had a lower back incision, with staples and no drainage. The surveyor queried LVN A if she measured the incision site, and LVN A stated, "No" The surveyor reviewed with LVN A the hospital discharge orders, which included to change the dressing (to the back incision) daily until dry, which was transcribed to the facility admission orders I thought I went through the whole thing (hospital discharge orders)." The surveyor queried LVN A, "Do you normally go through all the discharge orders from the hospital?" LVN A responded, "I try to." There were five pages of hospital discharge orders. During an interview on 02/09/12 at 10:10 AM, the DON stated, "We (facility nurses) have a responsibility to honor the hospital transfer orders, unless we speak with the doctor and get a discontinue order." During an interview on 02/08/12 at 3:51 PM, ADON G stated,"When we get orders from the hospital, we call the physician and check what should be transcribed." Facility Transfer Orders from the hospital dated 01/27/12 reflected: "Change dressing - Daily, ...Routine. Comments: Until Dry. Remove dressing if incision is dry, then discontinue dressing. Comments: Remove dressing if incision is dry, then discontinue dressing. May leave dressing off if wound dry, if wound has drainage, change daily or after shower (op-site) (post-operative site) with shower." Resident #1's Skin Assessment sheet dated 01/28/12 was completed by LVN A. The narrative notes section reflected: "She (Resident #1) has a spine incision open to dry, no orders to apply a dressing." Review of the Skilled Nurses Note dated 01/29/12 revealed under the heading "Days," Resident #1's BP was 146/74 and pulse was 106. Under the heading "Evenings," her BP was 109/67 and pulse 87. At 8:00 PM, the resident had blood-tinged drainage coming from her back incision. LVN A documented she applied a dressing to the resident's back incision. On 02/08/12 at 3:42 PM the surveyor queried LVN A if she found it unusual to have drainage from the incision site since there was no drainage upon admission and LVN A stated, "No. She (Resident #1) didn't complain of pain and (there was) no green/yellow drainage." During an interview on 02/10/12 at 8:25 AM the surveyor queried LVN A if she could apply a dressing to a resident without a physician order [REDACTED]." The Skilled Nurses Note dated 01/30/12 at 12:50 PM reflected Resident #1 fell in the hallway while ambulating. The physician was notified of the resident's fall and constipation. There was no documentation regarding Resident #1's back incision or evidence to indicate the physician had been informed the resident's incision was draining. During an interview on 02/09/12 at 9:31 AM, COTA H stated she was getting Resident #1 a wheelchair when she fell . COTA H further stated Resident #1's "stitches were leaking. It (drainage) was on the gown." COTA H stated, "Some (of the drainage) was wet and some was darker. The COTA described the drainage size as "larger than a football." During an interview on 02/08/12 at 4:15 PM, Wound Care Nurse - LVN D stated she always looked at newly-admitted residents to have an idea what their surgical sites looked like. Wound Care Nurse - LVN D stated she assessed Resident #1's surgical incision on 01/31/12, and it measured 15 by 0.5 cm with 12 sutures and "no staples." Wound Care Nurse - LVN D further stated the incision had a moderate amount of serosanguinous (bloody) drainage at that time when she assessed it. Wound Care Nurse - LVN D stated Resident #1 had fallen earlier that day and had a hematoma on the left side of her head, which measured 5 by 5 cm. Wound Care Nurse - LVN D stated she did not see this resident again, because the incision was not dehisced (separation of the incision). Wound Care Nurse - LVN D stated her notes and observations would not be in Resident #1's medical record. She stated she documented her findings on a small note pad, which she kept in her possession. Review of the Skilled Nurses Note dated 01/31/12 revealed under the heading "Days," Resident #1's BP was 86/66. At 9:00 AM, Resident #1's surgical site had a moderate amount of serosanguinous drainage. The Note reflected Resident #1 complained of pain to her lower back (at the incision site) and her lower extremities. There was no evidence the resident's BP was re-assessed for "Days." Review of the Skilled Nurses Note dated 02/01/12 revealed Resident #1 had serosanguinous drainage observed on the dressing to her incision site. There was no evidence to indicate the dressing was changed. Review of the Skilled Nurses Note dated 02/02/12 revealed Resident #1's dressing was changed (to incision site) due to serosanguinous drainage. The Skilled Nurses Note dated 02/03/12 reflected Resident #1 had a small amount of serosanguinous drainage from her incision, and her pulse was 114. Skilled Nursing Notes written by LVN A dated 02/04/12 reflected under the heading "Days" Resident #1's BP was 110/63 and her pulse was 142. Under the heading "Evenings," Resident #1's BP was 88/58 and her pulse was 130. At 8:20 AM, documentation reflected Resident #1 stated she "doesn't feel strong at best today." At 3:00 PM, Resident #1 continued to verbalize to the nurse "she (Resident #1) doesn't feel well." At 6:45 PM, "she was awakened enough to eat a small amount of her dinner tray." Review of the Routine Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview on 02/10/12 at 8:25 AM, LVN A stated she would hold a resident's BP medication if the BP was less than 90/55. The surveyor queried LVN A if she would notify the physician if a resident's BP was less than 90/55, and LVN A stated, "Well... no." LVN A stated she worked 16 hours on Saturdays and Sundays and she took the residents' vital signs, including BP. She stated the "Days" BP were taken around 8:00 AM, and the "Evenings" BP were taken between 2:30 PM and 3:30 PM. The surveyor queried LVN A if she would take a resident's BP again before administering 8:00 PM BP medications, and LVN A stated, "No." The surveyor reviewed with LVN A Resident #1's BP on 02/04/12 on "Evenings," which was 88/58 and her pulse of 130. The surveyor queried LVN A if she administered [MEDICATION NAME] and [MEDICATION NAME] at 8:00 PM, and LVN A stated, "Yes. I probably shouldn't have given it to her, but her heart rate (pulse) was still up, and I know she takes it for that." The surveyor queried LVN A if she saw Resident #1 again that night, and LVN A stated, "No." LVN A stated, "She (Resident #1) never complained of chest pain." The surveyor queried LVN A if vital signs were irrelevant if the resident did not have chest pain and LVN A stated, "Yes to me, because she was on medication for heart rate." The surveyor queried LVN A if BP was irrelevant without chest pain, and LVN A stated, "Yes." During an interview on 02/08/12 at 4:02 PM, LVN B stated she would hold BP medication if a resident's blood pressure was less than 100/60 and would call the doctor if the BP was out of normal ranges for the resident. Review of the Skilled Nursing Note dated 02/05/12, between 12:00 AM and 6:00 AM, revealed Resident #1 was noted with a change in condition. She was lethargic and complained of pain all over. The resident appeared jaundiced and weak, her BP was dropping rapidly and her pulse was high. The last BP reading before the resident was transferred to the hospital was 63/37. The Note reflected: "Not able to get pulse reading @ (at) last v/s (vital signs) check." A hospital consultation report dated 02/05/12 at 6:52 PM reflected: "History of Present Illness: ....presented to the emergency room today with a chief complaint of altered mental status, [MEDICAL CONDITION], and [MEDICAL CONDITION] Workup in the ER (emergency room ) demonstrated urinary tract infection as well as dehiscence, and maceration of the postoperative lumbar incision... Lumbar Spine: Significant skin maceration around sutures and staples with no approximation of the incisional edges. [DIAGNOSES REDACTED] is associated with drainage, as well as some skin reaction, with blistering from the prior tape from the dressing... Laboratories and Studies: ...She has positive UTI with an elevated white count of 39,000... She had a fever of 102 in the emergency room ...." A hospital consultation report dated 02/05/12 at 6:27 PM reflected: "...Impressions: 1.[MEDICAL CONDITION] syndrome with mild hemodynamic instability... ...3 ....Apparently the bandage had not been changed over her wound in some time. There was some milky drainage when she arrived in the ICU (Intensive Care Unit)... Physical Examination: General: Reportedly when she arrived in the ICU, she had pinpoint pupils and was very poorly responsive... Diagnostic Data: White count was 39,000." A hospital consultation report dated 02/05/12 at 6:19 AM reflected: "HPI: ....The ____ (facility name) staff reports the pt (patient) (Resident #1) has had [MEDICAL CONDITIONS] for about a week...." A hospital procedure report dated 02/05/12 at 11:29 AM reflected: "...Patient unresponsive, no response to painful stimuli...." A hospital consultation report dated 02/07/12 at 9:09 AM reflected: "...Preoperative Diagnosis: [REDACTED]. Postoperative Diagnosis: [REDACTED]. Operative Procedure: Incision, drainage, and debridement of deep lumbar wound infection with debridement of skin, muscle, and fascia... Findings: Abscess and purulent material within the skin, subcutaneous and deep, as well as abscess deep to the lumbodorsal fascia and muscle...." A hospital consultation report dated 02/06/12 at 8:13 PM reflected: "...Reason for Consult: bacteremia and wound infection. History of present illness: Patient (Resident #1) is about two weeks post op lumbar fusion and instrumentation. She was discharged to _____ (facility name) where her wound was never redressed... She was taken to surgery today and had findings of deep infection. She has two positive blood cultures for gram positive cocci and the wound is growing positive staph...." A hospital consultation report dated 02/08/12 at 10:48 AM reflected: "Blood Culture: Final Report. In both bottles Staphylococcus aureus... Urine Culture: Final Report. 10,000 to 50,000 CFU/ml Multiple Gram Positive Species... Wound Culture: Preliminary Report: Moderate Staphylococcus species, coagulase positive...." Review of Resident #1's entire facility clincal record dated from 01/28/12 through 02/05/12 revealed the resident's physician was only notified twice: on 01/28/12 on admission and on 01/30/12 after the resident fell . During an interview on 02/08/12 at 3:42 PM, LVN B stated she would change Resident #1's dressing (to the incision site) when the resident asked her to. The surveyor queried why she would change a dressing if there was no order, and LVN B stated, "Everyone with a surgical wound has an order (to change the dressing)." During an interview on 02/10/12 at 8:25 AM, LVN A stated she told Resident #1's family member, after the resident was sent back to the hospital, the dressing to Resident #1's incision site should be left on until it fell off. LVN A added, "That's what the nurse at _____ (the hospital) told me. When the dressing falls off, it (the incision) should be open to air." During an interview on 02/09/12 at 3:50 PM, the Weekend Supervisor stated his job responsibilities on the weekend included introducing himself to the new residents and to review the physician orders. The surveyor reviewed the admission documentation of Resident #1's incision site and noted there were no measurements noted. It was also noted there were no wound care orders on Resident #1's admission orders [REDACTED]. The Weekend Supervisor stated, "She (Resident #1) was being skilled for that wound. They (facility nurses) should have done a better job than that." The surveyor queried the Weekend Supervisor regarding BP parameters and he stated, "I would call the doctor if the blood pressure was less than 100/60 or the pulse was greater than 120." 3) Review of the facility'a current policy entitled "Physician Notification of Change in Resident Condition" dated November 2005 revealed: "Purpose: To keep the physician, resident and resident's responsible party informed of changes in resident's condition so that timely interventions can be obtained...." Review of the facility's current policy entitled "Admission of Resident" dated May 2004 revealed, "...10. Notify physician of admission and obtain orders and current diagnoses...." Review of the facility's current policy entitled "Physician Services" dated May 2004 revealed "...9. If the attending physician does not respond promptly, a call to the alternative physician should be made. If neither is available, the Medical Director should be contacted to attend the resident...." 4) The facility list provided by the Administrator on 02/10/12 reflected there was a potential of 16 residents, including Resident #1, who resided in Rooms 210-217 who were assigned to LVN A.

Based on interview and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of four residents reviewed for quality of care, who was not receiving wound care according to Doctor's orders, not having Doctor's notified of significant change in condition, not receiving routine pain assessments when complaining of pain, had an altered mental status and ended up [MEDICAL CONDITION] and a deep wound infection. Resident #1 was admitted from the hospital on [DATE] with a [DIAGNOSES REDACTED]. The incision site to the lower back was not draining upon admission. There was a hospital discharge order to change the dressing every day until dry, which was not transcribed onto the facility admission orders [REDACTED]. The incision site had a dressing applied several times without an order. The physician was never notified of ongoing drainage. A wound care order was never obtained. On 02/04/12 Resident #1's pulse was 142 at approximately 8:00 AM. On 02/04/12 at approximately 3:30 PM, Resident #1's BP was 88/58 and pulse was 130. Without rechecking Resident #1's BP, LVN A administered [MEDICATION NAME] (for hypertension), at approximately 8:00 PM on 02/04/12. The physician was not notified of Resident #1's decreased blood pressure and increased pulse. Resident #1's BP after 11:00 PM was 105/61. On 02/05/12, Resident #1 was lethargic, complaining of pain all over, and his blood pressure was dropping. Resident #1's last BP before being sent to the hospital was 63/37 and her pulse was not detectable. Resident #1 was diagnosed with [REDACTED]. Resident #1 required surgery to her lumbar incision due to the deep infection. These failures could affect the potential 16 residents, including Resident #1, who resided in Rooms 210-217 and were assigned to receive care from LVN A and placed them at risk for not receiving the care and services they needed to maintain their well-being, comfort and free of infection to ensure they live the life they desired. Findings included: 1) Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Resident (MDS) data set [DATE] at 2:00 PM revealed Resident #1 was admitted to the facility from the hospital with post-operative lumbar decompression and fusion surgery. "Hospital nurse reports her vs (vital signs) have been normal and she has not had pain agents (medications) x (times) two days." Under the "skin" section of the admission paperwork, there was a pen line drawn down the middle of the back of the full-body diagram indicating Resident #1's post-operative incision ran down the middle of her back and extended from a level with the armpits past the sacrum. There were handwritten words next to the diagram, which reflected "incision open to air." There was no further description of the wound. The Skilled Nurses Note dated 01/28/12 at 4:00 PM reflected LVN A left a message for Physician E to confirm he would be Resident #1's admitting physician. Physician F was on call and instructed LVN A to follow up with Physician E's office on 01/30/12. There was no evidence to reflect this follow-up phone call to confirm Physician E would follow Resident #1 occurred. During an interview on 02/10/12 at 8:25 AM, LVN A stated she admitted Resident #1 from the hospital. LVN A stated Resident #1 had a lower back incision, with staples and no drainage. The surveyor queried LVN A if she measured the incision site, and LVN A stated, "No" The surveyor reviewed with LVN A the hospital discharge orders, which included to change the dressing (to the back incision) daily until dry, which was transcribed to the facility admission orders I thought I went through the whole thing (hospital discharge orders)." The surveyor queried LVN A, "Do you normally go through all the discharge orders from the hospital?" LVN A responded, "I try to." There were five pages of hospital discharge orders. During an interview on 02/09/12 at 10:10 AM, the DON stated, "We (facility nurses) have a responsibility to honor the hospital transfer orders, unless we speak with the doctor and get a discontinue order." During an interview on 02/08/12 at 3:51 PM, ADON G stated,"When we get orders from the hospital, we call the physician and check what should be transcribed." Facility Transfer Orders from the hospital dated 01/27/12 reflected: "Change dressing - Daily, ...Routine. Comments: Until Dry. Remove dressing if incision is dry, then discontinue dressing. Comments: Remove dressing if incision is dry, then discontinue dressing. May leave dressing off if wound dry, if wound has drainage, change daily or after shower (op-site) (post-operative site) with shower." Resident #1's Skin Assessment sheet dated 01/28/12 was completed by LVN A. The narrative notes section reflected: "She (Resident #1) has a spine incision open to dry, no orders to apply a dressing." Review of the Skilled Nurses Note dated 01/29/12 revealed under the heading "Days," Resident #1's BP was 146/74 and pulse was 106. Under the heading "Evenings," her BP was 109/67 and pulse 87. At 8:00 PM, the resident had blood-tinged drainage coming from her back incision. LVN A documented she applied a dressing to the resident's back incision. On 02/08/12 at 3:42 PM the surveyor queried LVN A if she found it unusual to have drainage from the incision site since there was no drainage upon admission and LVN A stated, "No. She (Resident #1) didn't complain of pain and (there was) no green/yellow drainage." During an interview on 02/10/12 at 8:25 AM the surveyor queried LVN A if she could apply a dressing to a resident without a physician order [REDACTED]." The Skilled Nurses Note dated 01/30/12 at 12:50 PM reflected Resident #1 fell in the hallway while ambulating. The physician was notified of the resident's fall and constipation. There was no documentation regarding Resident #1's back incision or evidence to indicate the physician had been informed the resident's incision was draining. During an interview on 02/09/12 at 9:31 AM, COTA H stated she was getting Resident #1 a wheelchair when she fell . COTA H further stated Resident #1's "stitches were leaking. It (drainage) was on the gown." COTA H stated, "Some (of the drainage) was wet and some was darker. The COTA described the drainage size as "larger than a football." During an interview on 02/08/12 at 4:15 PM, Wound Care Nurse - LVN D stated she always looked at newly-admitted residents to have an idea what their surgical sites looked like. Wound Care Nurse - LVN D stated she assessed Resident #1's surgical incision on 01/31/12, and it measured 15 by 0.5 cm with 12 sutures and "no staples." Wound Care Nurse - LVN D further stated the incision had a moderate amount of serosanguinous (bloody) drainage at that time when she assessed it. Wound Care Nurse - LVN D stated Resident #1 had fallen earlier that day and had a hematoma on the left side of her head, which measured 5 by 5 cm. Wound Care Nurse - LVN D stated she did not see this resident again, because the incision was not dehisced (separation of the incision). Wound Care Nurse - LVN D stated her notes and observations would not be in Resident #1's medical record. She stated she documented her findings on a small note pad, which she kept in her possession. Review of the Skilled Nurses Note dated 01/31/12 revealed under the heading "Days," Resident #1's BP was 86/66. At 9:00 AM, Resident #1's surgical site had a moderate amount of serosanguinous drainage. The Note reflected Resident #1 complained of pain to her lower back (at the incision site) and her lower extremities. There was no evidence the resident's BP was re-assessed for "Days." Review of the Skilled Nurses Note dated 02/01/12 revealed Resident #1 had serosanguinous drainage observed on the dressing to her incision site. There was no evidence to indicate the dressing was changed. Review of the Skilled Nurses Note dated 02/02/12 revealed Resident #1's dressing was changed (to incision site) due to serosanguinous drainage. The Skilled Nurses Note dated 02/03/12 reflected Resident #1 had a small amount of serosanguinous drainage from her incision, and her pulse was 114. Skilled Nursing Notes written by LVN A dated 02/04/12 reflected under the heading "Days" Resident #1's BP was 110/63 and her pulse was 142. Under the heading "Evenings," Resident #1's BP was 88/58 and her pulse was 130. At 8:20 AM, documentation reflected Resident #1 stated she "doesn't feel strong at best today." At 3:00 PM, Resident #1 continued to verbalize to the nurse "she (Resident #1) doesn't feel well." At 6:45 PM, "she was awakened enough to eat a small amount of her dinner tray." Review of the Routine Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview on 02/10/12 at 8:25 AM, LVN A stated she would hold a resident's BP medication if the BP was less than 90/55. The surveyor queried LVN A if she would notify the physician if a resident's BP was less than 90/55, and LVN A stated, "Well... no." LVN A stated she worked 16 hours on Saturdays and Sundays and she took the residents' vital signs, including BP. She stated the "Days" BP were taken around 8:00 AM, and the "Evenings" BP were taken between 2:30 PM and 3:30 PM. The surveyor queried LVN A if she would take a resident's BP again before administering 8:00 PM BP medications, and LVN A stated, "No." The surveyor reviewed with LVN A Resident #1's BP on 02/04/12 on "Evenings," which was 88/58 and her pulse of 130. The surveyor queried LVN A if she administered [MEDICATION NAME] and [MEDICATION NAME] at 8:00 PM, and LVN A stated, "Yes. I probably shouldn't have given it to her, but her heart rate (pulse) was still up, and I know she takes it for that." The surveyor queried LVN A if she saw Resident #1 again that night, and LVN A stated, "No." LVN A stated, "She (Resident #1) never complained of chest pain." The surveyor queried LVN A if vital signs were irrelevant if the resident did not have chest pain and LVN A stated, "Yes to me, because she was on medication for heart rate." The surveyor queried LVN A if BP was irrelevant without chest pain, and LVN A stated, "Yes." During an interview on 02/08/12 at 4:02 PM, LVN B stated she would hold BP medication if a resident's blood pressure was less than 100/60 and would call the doctor if the BP was out of normal ranges for the resident. Review of the Skilled Nursing Note dated 02/05/12, between 12:00 AM and 6:00 AM, revealed Resident #1 was noted with a change in condition. She was lethargic and complained of pain all over. The resident appeared jaundiced and weak, her BP was dropping rapidly and her pulse was high. The last BP reading before the resident was transferred to the hospital was 63/37. The Note reflected: "Not able to get pulse reading @ (at) last v/s (vital signs) check." A hospital consultation report dated 02/05/12 at 6:52 PM reflected: "History of Present Illness: ....presented to the emergency room today with a chief complaint of altered mental status, [MEDICAL CONDITION], and [MEDICAL CONDITION] Workup in the ER (emergency room ) demonstrated urinary tract infection as well as dehiscence, and maceration of the postoperative lumbar incision... Lumbar Spine: Significant skin maceration around sutures and staples with no approximation of the incisional edges. [DIAGNOSES REDACTED] is associated with drainage, as well as some skin reaction, with blistering from the prior tape from the dressing... Laboratories and Studies: ...She has positive UTI with an elevated white count of 39,000... She had a fever of 102 in the emergency room ...." A hospital consultation report dated 02/05/12 at 6:27 PM reflected: "...Impressions: 1.[MEDICAL CONDITION] syndrome with mild hemodynamic instability... ...3 ....Apparently the bandage had not been changed over her wound in some time. There was some milky drainage when she arrived in the ICU (Intensive Care Unit)... Physical Examination: General: Reportedly when she arrived in the ICU, she had pinpoint pupils and was very poorly responsive... Diagnostic Data: White count was 39,000." A hospital consultation report dated 02/05/12 at 6:19 AM reflected: "HPI: ....The ____ (facility name) staff reports the pt (patient) (Resident #1) has had [MEDICAL CONDITIONS] for about a week...." A hospital procedure report dated 02/05/12 at 11:29 AM reflected: "...Patient unresponsive, no response to painful stimuli...." A hospital consultation report dated 02/07/12 at 9:09 AM reflected: "...Preoperative Diagnosis: [REDACTED]. Postoperative Diagnosis: [REDACTED]. Operative Procedure: Incision, drainage, and debridement of deep lumbar wound infection with debridement of skin, muscle, and fascia... Findings: Abscess and purulent material within the skin, subcutaneous and deep, as well as abscess deep to the lumbodorsal fascia and muscle...." A hospital consultation report dated 02/06/12 at 8:13 PM reflected: "...Reason for Consult: bacteremia and wound infection. History of present illness: Patient (Resident #1) is about two weeks post op lumbar fusion and instrumentation. She was discharged to _____ (facility name) where her wound was never redressed... She was taken to surgery today and had findings of deep infection. She has two positive blood cultures for gram positive cocci and the wound is growing positive staph...." A hospital consultation report dated 02/08/12 at 10:48 AM reflected: "Blood Culture: Final Report. In both bottles Staphylococcus aureus... Urine Culture: Final Report. 10,000 to 50,000 CFU/ml Multiple Gram Positive Species... Wound Culture: Preliminary Report: Moderate Staphylococcus species, coagulase positive...." Review of Resident #1's entire facility clincal record dated from 01/28/12 through 02/05/12 revealed the resident's physician was only notified twice: on 01/28/12 on admission and on 01/30/12 after the resident fell . During an interview on 02/08/12 at 3:42 PM, LVN B stated she would change Resident #1's dressing (to the incision site) when the resident asked her to. The surveyor queried why she would change a dressing if there was no order, and LVN B stated, "Everyone with a surgical wound has an order (to change the dressing)." During an interview on 02/10/12 at 8:25 AM, LVN A stated she told Resident #1's family member, after the resident was sent back to the hospital, the dressing to Resident #1's incision site should be left on until it fell off. LVN A added, "That's what the nurse at _____ (the hospital) told me. When the dressing falls off, it (the incision) should be open to air." During an interview on 02/09/12 at 3:50 PM, the Weekend Supervisor stated his job responsibilities on the weekend included introducing himself to the new residents and to review the physician orders. The surveyor reviewed the admission documentation of Resident #1's incision site and noted there were no measurements noted. It was also noted there were no wound care orders on Resident #1's admission orders [REDACTED]. The Weekend Supervisor stated, "She (Resident #1) was being skilled for that wound. They (facility nurses) should have done a better job than that." The surveyor queried the Weekend Supervisor regarding BP parameters and he stated, "I would call the doctor if the blood pressure was less than 100/60 or the pulse was greater than 120." 2) Review of the facility'a current policy entitled "Physician Notification of Change in Resident Condition" dated November 2005 revealed: "Purpose: To keep the physician, resident and resident's responsible party informed of changes in resident's condition so that timely interventions can be obtained...." Review of the facility's current policy entitled "Admission of Resident" dated May 2004 revealed, "...10. Notify physician of admission and obtain orders and current diagnoses...." Review of the facility's current policy entitled "Physician Services" dated May 2004 revealed "...9. If the attending physician does not respond promptly, a call to the alternative physician should be made. If neither is available, the Medical Director should be contacted to attend the resident...." 3) The facility list provided by the Administrator on 02/10/12 reflected there was a potential of 16 residents, including Resident #1, who resided in Rooms 210-217 who were assigned to LVN A.

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for one (Resident #1) of 4 residents reviewed for medication administration. Resident #1 was given [MEDICATION NAME] 12.5 mg (used to treat high blood pressure) and [MEDICATION NAME] 15 mg (sleeping pill) on 02/04/12 at 8:00 PM. Resident #1's BP was 88/58. This failure could affect the 13 residents, including Resident #1 who were administered medications by LVN A by placing them at risk for adverse medication side effects including severe [MEDICAL CONDITION] resulting in [MEDICAL CONDITION], dizziness and potential coma. Findings included: Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 1. In an interview on 02/10/12 at 8:25 AM LVN A stated she worked Saturdays and Sundays from 6:00 AM to 10:00 PM, on the 200 hall and was one of two nurses. She stated she took vital signs (BP, Temp, Pulse, Resp) on her residents at 8:00 AM (Days) and again between 2:30 PM and 3:30 PM (Evenings). LVN A stated she would hold a resident's BP medication if the BP was less than 90/55. Review of a "Skilled Nursing Notes" dated 02/04/12 revealed "Days: BP - 110/63, Temp - 97.2, Pulse - 142, Resp -24. Evenings: BP - 88/58, Pulse - 130, Resp - 22," completed by LVN A. Note: the physician was not notified. Review of the "Routine Medication Administration Record" dated 02/04/12 revealed [MEDICATION NAME] 12.5 mg and [MEDICATION NAME] 15 mg were administered to Resident #1 at 8:00 PM. During an interview on 02/10/12 at 8:25 AM LVN A stated she would hold a resident's blood pressure medication if the blood pressure was less than 90/55. The surveyor queried LVN A if she would notify the physician if a resident's blood pressure was less than 90/55 and LVN A stated, "Well, no." The surveyor queried LVN A if she would take a resident's blood pressure again before administering the 8:00 PM blood pressure medications and LVN A stated, "No." The surveyor reviewed with LVN A Resident #1's blood pressure on 02/04/12 "Evenings" of 88/58 and pulse 130. The surveyor queried LVN A if she administered [MEDICATION NAME] and [MEDICATION NAME] at 8:00 PM and LVN A stated, "Yes, I probably shouldn't have given it to her but her heart rate (pulse) was still up and I know she takes it for that." The surveyor queried LVN A if she saw Resident #1 again that night and LVN A stated "no." LVN A stated, "She (Resident #1) never complained of chest pain." The surveyor queried LVN A if vital signs were irrelevant if the resident did not have chest pain and LVN A stated, "Yes to me because she was on medication for heart rate." The surveyor queried LVN A if blood pressure was irrelevant without chest pain and LVN A stated, "Yes." An interview on 02/08/12 at 4:02 PM LVN B stated she would hold blood pressure medication if a resident's blood pressure was less than 100/60 and would call the doctor if the blood pressure was out of normal ranges. During an interview on 02/09/12 at 3:50 PM the weekend Supervisor stated he would hold a resident's BP medication if the BP was less than 100/60 and call the physician. He further stated he would also call the physician if the residents pulse was greater than 120. Nursing 2011 "Drug Handbook," 31st Edition, Copyright 2011, Pages 380 - 382, reflected Metaprolol is used for hypertension. Further review revealed "Nursing Considerations ...Monitor the blood pressure frequently; drug masks common signs and symptoms of shock ..." 2. On 02/10/12 the Administrator provided a list which reflected 8 resident rooms (13 residents) LVN A was assigned to. LVN A's assignments included resident assessments and administering medications.