Every finding on record at Complete Care at Corsica Hills LLC

Based on observation and interview, it was determined that the facility failed to provide a clean and homelike environment. This was evident in 1 (C) of 2 shower rooms, 6 (14, 24, 52, 54, 55, and 57) out of 12 resident rooms, and the C/D Nourishment Room observed during the recertification survey. The findings include: On 01/05/26 at 12:28 PM, the surveyors observed brown staining on the ceiling in room [ROOM NUMBER]. On 01/07/26 at 9:53 AM, the surveyors observed a dusty wall mounted ventilation unit, peeling bed board, indentation in the wall, and peeling paint at the base of the bathroom wall in room [ROOM NUMBER]. On 01/07/26 at 9:57 AM, the surveyors observed brown staining around the wall mounted ventilation unit in room [ROOM NUMBER] and room [ROOM NUMBER]. On 01/07/26 at 10:10 AM, the surveyors observed the C/D Nourishment Room. The refrigerator contained crumbs and brown and red stains. The room's floor also had trash, with black and brown staining visible on the tiles. On 01/07/2026 at 11:37 AM, the Nursing Home Administrator, Maintenance Regional Director, and the Maintenance Supervisor acknowledged the concerns found throughout the C/D unit and stated they would begin repairs. On 01/12/ 2026 at 11:15 AM, the surveyor conducted a tour of units A and B with the Maintenance Supervisor and the Administrator. The tour revealed a bathroom door in a state of disrepair in Resident #14's room, a large hole in the drywall, and multiple unsealed wall penetrations in Resident #24's bathroom. The Maintenance Supervisor confirmed that the necessary repairs would be expedited.

Based on kitchen observation, record review, and staff interview, it was determined that the facility failed to ensure that food storage complied with professional standards of food safety. This practice had the potential to impact all residents eating food prepared in the kitchen. The findings include: During the initial brief tour of the kitchen on 01/05/26 at 8:15 AM, the surveyors observed hard boiled eggs, salad, an opened carton of liquid eggs, opened dry pasta, and multiple Rita's Italian ices that were not labeled and dated. The surveyors also observed an uncovered container of rice. The dietary manager acknowledged that food should be labeled and dated once opened and the rice should be covered. On 01/10/26 at 10:11 AM, the surveyors observed the A/B and C/D Nourishment Rooms. The A/B Nourishment Room fridge had a green bag, 1 salad dressing bottle, and two bottles of thickened hydrolyte water that were not labeled and dated. The C/D Nourishment Room fridge had sticky colored residue in it. The Nursing Home Administrator acknowledged the concerns and arranged for the Nourishment Rooms to be cleaned. During the follow-up visit to the kitchen on 01/09/26 at 10:10 AM, the surveyors observed cups of juice in the walk in fridge that were not labeled and dated. The District Manager acknowledged that they were not labeled and stated that they would be used for lunch that day. On 01/12/26 at 1:00 PM, the Nursing Home Administrator acknowledged the findings of the kitchen visits.

Based on observation and interview, it was determined that the facility failed to provide a functional and sanitary environment. This was evident for 1 (C) out of 4 shower rooms observed during the recertification survey.On 01/07/2026 at 9:35 AM, the surveyors observed two drains covered in multicolored hair and a metal panel coming off of the bathroom wall. Unit Manager #10 and the Maintenance Regional Director acknowledged the concerns and stated the shower rooms are scheduled for renovation. On 01/07/2026 at 10:11 AM, the surveyors observed a dirty and stained floor with trash in the C/D Nourishment Room.On 01/07/2026 at 11:37 AM, The Nursing Home Administrator (NHA), Maintenance Regional Director, and Maintenance Supervisor acknowledged the concerns in the C/D Nourishment Room. On 01/08/2026 at 11:26 AM, the surveyors observed the ice machine dripping and black staining around the drain in the A/B Nourishment Room. On 01/09/2026 at 10:22 AM, surveyors showed the concerns in the A/B Nourishment Room to the NHA. The NHA stated that they would call for repair immediately.On 01/12/2026 11:35 AM, during observation of the laundry room, surveyors noted a dusty ceiling vent, a dusty hot water heater, trash in the drain, and missing and stained floor tiles.On 01/12/2026 at 11:26 AM, the Housekeeping Manager and the District Housekeeping Manager observed the above concerns and removed the trash from the drain. The NHA acknowledged the concerns found in the laundry room on 01/12/2026 at 11:57 AM.

Number of residents sampled: Number of residents cited: Based on observations and interviews with facility staff, it was determined that the facility failed to maintain clean and operational ventilation systems, thereby impairing proper airflow throughout the premises. This deficiency was observed in 4 of the 5 unit ventilation systems reviewed during the annual survey.The findings include: Local Exhaust Ventilation ([NAME]) systems are designed and engineered to capture and remove contaminants such as excessive heat, steam, condensation, vapor, smoke, odor, and fumes. This is achieved through the calibration of the total pressure, which is calculated as the sum of the static pressure exiting and entering the system, minus the velocity pressure entering the system. In addition, the fan speed, pressure, and power must be adjusted to account for the specific gravity of the contaminant being captured and removed by the [NAME] system, while considering the specific size and air changes of the room. On 01/5/2026 at 11:45 AM, the surveyor conducted an initial tour of units A and B. The following bathroom [NAME] in the resident rooms were found to be inoperable:room [ROOM NUMBER] inoperableroom [ROOM NUMBER] inoperableroom [ROOM NUMBER] inoperableOn 01/12/2026 at 11:12 AM, a tour of the facility was conducted with the Maintenance Supervisor and the Administrator. The Maintenance Supervisor placed a piece of toilet paper against the exhaust fan covers in residents' bathrooms [ROOM NUMBERS] to verify negative pressure and confirmed that these [NAME] systems were inoperable. The Maintenance Supervisor stated that he would reassess the fans located in the attic.At 12:00 PM, the Administrator confirmed that the fan belt had been replaced for the resident bathroom [NAME] to become functional in units A and B.On 01/12/2026 at 12:59 PM, the surveyor conducted a tour of units C and D with the Administrator and Staff #16. The functionality of the following residents' bathroom [NAME] was verified by placing a piece of toilet paper on the fan covers:room [ROOM NUMBER] inoperableroom [ROOM NUMBER] positive pressureroom [ROOM NUMBER] inoperableroom [ROOM NUMBER] positive pressureAt 1:06 PM, the Administrator stated that this information would be relayed to the Maintenance Supervisor to reassess the fans in units C and D to implement the necessary repairs.

Number of residents sampled:Number of residents cited:Based on record review and interview it was determined that the facility failed to provide a Resident's Representative the right to be involved in informed consent process. This was found evident in 1 (Resident #16) of 4 residents reviewed for advanced directives. The findings include: On 1/6/26 at 12:23 PM, the surveyor reviewed Resident #16's medical record. The review revealed a Medical Orders for Life-Sustaining Treatment (MOLST) dated 9/10/24 indicated Resident #16's MOLST decisions were done per the legal authority in accordance with all provisions of the Health Care Decision Act. On further review it was noted that on 11/11/25 and 11/14/25 two medical providers completed assessment/certifications related to medical condition decision-making and treatment limitations. Both providers determined that Resident #16 lacked capacity to make their own decisions and those related to medical necessity/prognosis. Next the surveyor reviewed the social service assessment completed on 11/12/25 by Social Worker #25. The assessment documented that Resident #16 was responsible for him/herself. On further review it was noted that Resident 16's consent for admission to facility and medical treatment was signed on the resident signature line and dated 11/10/25. The spot for the Resident Representative was left blank. Additionally, the psychotherapeutic medication informed consent dated 11-13-25 was signed on the patient's signature section and again the Representative Party (RP) was left blank. On 1/7/26 at 10:31 AM, the surveyor conducted an interview with the Nursing Home Administrator (NHA). During the interview the surveyor reviewed the concern that documentation was conflicting who should be responsible for giving consent for Resident #16's care. The NHA stated she would look into the matter and follow-up On 1/8/26 at 10:19 AM, the surveyor conducted a follow-up interview with the NHA. During the interview the NHA stated the MOLST completed at the hospital was marked in error and that Resident #16 had a surrogate making decisions for him/her. She further stated that Resident #16 should not have consented for him/herself and that currently Resident #16's son is in communication with the facility in regard to Resident #16's care.

Based on record review and interviews, it was determined that the facility failed to attempt a recommended gradual dose reduction for a psychotropic medication and/or failed to document contraindication rationale for why gradual dose reduction was not attempted. This was found evident in 1 (Resident #30) out of 6 residents reviewed for unnecessary medications. The findings include: Psychotropic medications are used to treat mental health disorders and are considered any drug that affects behavior, mood, thoughts, or perception. There are five main types of psychotropic medications, and each type has its own specific uses, benefits, and side effects. The five main types are: antidepressants, anti-anxiety, stimulants, antipsychotics and mood stabilizers. Mirtazapine, also known as Remeron, is used to treat depression. Mirtazapine belongs to a group of medicines called tetracyclic antidepressants and is considered a psychotropic medication. A common side effect is increased appetite. Gradual Dose Reduction (GDR) refers to the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued. On 1/6/25 at 9:20 AM, the surveyor observed Resident #30 resting in bed. When the surveyor attempted to engage in conversation, Resident #30 did not respond. Resident #30's roommate stated that his/her roommate does not talk much and rests quietly most of the time. On 1/7/26 at 9:58 AM, the surveyor reviewed Psychiatric Nurse Practitioner Staff #21's progress note written on 11/15/25. The note stated the reason for the consultation was for a gradual dose reduction (GDR) review. Staff #21 wrote Resident #30 was seen resting in bed with his/her eyes closed and did not answer questions. Staff #21 documented that Resident #30's roommate reports that the patient sleeps all the time. The assessment and plan recommended reducing Mirtazapine 7.5mg nightly. The surveyor noted a handwritten message on the note that stated, Declined by NP (Nurse Practitioner) and was signed and dated 11/24/25. Next the surveyor reviewed Resident #30's primary care provider notes following Staff #21's note. The next note was a monthly follow-up progress note was written by Physician #22 on 11/28/25. In the progress note Staff #22 reviewed Resident #30's medications and listed Mirtazapine 7.5mg to be given nightly with the reason for administration as dementia with failure to thrive. Nowhere in the progress note was there rationale for the decision to no attempt the GDR for this medication. On 1/7/26 at 10:12 AM, the surveyor reviewed Resident #30's care plan. A care plan initiated on 7/20/23 stated that Resident #30 uses antidepressant medication related to depression. On 1/7/26 at 10:36 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor asked why the GDR recommendations were declined. The DON stated that she documented the handwritten note after discussing the recommendation with the NP. She further stated that the recommendation was declined because the medication was written to help increase Resident #30's appetite and not related to behaviors. The surveyor reviewed the concern that the rationale for not reducing Resident's psychotropic medication, after being recommended to do so, was not addressed in Resident's medical record.

Based on record review, and interviews, it was determined that the facility failed to accurately document a Minimum Data Set (MDS) assessment in a Resident's medical record. This was found evident of 1 (Resident #5) of 33 residents reviewed in the survey. The findings include: On 1/6/26 at 9:15 AM, the surveyor interviewed Resident #5. During the interview Resident #5 stated that he/she had not had any teeth since being admitted to the facility. On 1/8/26 at 9:44 AM, the surveyor reviewed Resident #5's most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE]. In the oral dental assessment, there was a list that gave options to capture an abnormal evaluation. One option was, no natural teeth or tooth fragment(s) (edentulous) but this option was left blank. Resident #5 was coded as none of the above were present. Next, the surveyor reviewed Resident #5's care plan. A care plan initiated on 5/17/17 stated, Resident #5 is at risk for oral health or dental care problems as evidenced by: resident is edentulous. On 1/9/26 at 8:29 AM, the surveyor interviewed the Director of Nursing (DON) and the Nursing Home Administrator. During the interview they confirmed that Resident #5 was edentulous and both were not sure why the MDS assessment did not capture that in the assessment. On 1/9/26 at 12:02 PM, the surveyor interviewed the MDS coordinator Staff #26. During the interview Staff #26 stated that the oral/dental assessment is completed by looking at nursing assessments. She further stated that if the assessment was inaccurate then the MDS assessment would be inaccurate. Staff #26 confirmed that Resident #5 should have been coded edentulous and that she would correct the inaccurate assessments.

Number of residents sampled:Number of residents cited:Based on observation, interviews, and record review, it was determined that the facility failed to review and revise a Resident's care plan after a Resident's situation changed. This was found evident of 1 (Resident #9) out of 1 Residents reviewed for hearing and vision during the survey. The findings include: Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team. On 1/6/26 at 7:03 AM, the surveyor observed Resident #9 in his/her bedroom watching the television at a loud volume. The surveyor noted that Resident #9 did not have hearing aids at the time. On 1/8/26 at 9:45 AM, the surveyor reviewed resident #9's orders. Resident #9 had an order written on 9/18/25 that stated, continue use of amplification. (Hearing Aid) Patient is to wear hearing aid daily. Patient requires assistance with insertion and manipulation of hearing aids daily. (Every shift for Hearing Aid Devices) Next the surveyor reviewed the January 2026 Treatment Administration Record (TAR). On all three shifts, 1/1/26-1/7/26, there was a check mark documented, indicating that this treatment was completed for Resident #9. On 1/8/26 at 12:17 PM, the surveyor observed Resident #9 in the dining room. Resident #9 did not have hearing aids in. The surveyor then asked Resident #9 if he/she had hearing aids. Resident #9 stated that he/she had two hearing aids but preferred not to use them. On 1/8/26 at 12:30 PM, the surveyor reviewed Resident #9's care plan. A care plan was initiated on 12/18/22 that stated, Resident #9 had a communication problem related to being Hard of Hearing (HOH). One of the interventions was to offer hearing aids and put them in place. On 1/9/26 at 11:11 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the DON confirmed that Resident #9 does not utilize his/her hearing aids. The surveyor relayed the concern that the current plan of care does not reflect Resident #9's wishes and that the care plan is not accurate to current treatments.

Based on observations, record reviews, and interviews, it was determined that the facility failed to provide necessary services to maintain good personal hygiene for dependent residents. This was evident in 2 (Resident #66 and Resident #93) of 2 Residents reviewed for Activity of Daily Living (ADL) care during the annual survey.The findings include:1) On 1/12/2026 at 11:00 AM, the surveyor observed Resident #66 seated on the side of the bed, wearing wrist support braces on both hands. All 10 fingers appeared clean; however, the free edge of the fingernails was about 0.5 cm in length.The surveyor inquired of Resident #66 whether nail trimming was needed. The Resident said that the free edge of the nails was preferred to be shorter.At 11:30 AM, the surveyor informed Staff #19 of Resident #66's request for nail care.A review of the Resident's Minimum Data Set (MDS) and Care Plan dated 6/24/2024, indicated that the resident was dependent (requiring the helper to perform all effort) on ADL cares to maintain good personal hygiene. In addition, the BATHING/SHOWERING intervention notes specified that staff were required to check nail length, and trim and clean nails on bath days and as necessary.At 11:45 AM, a review of the resident's Task documentation for December 2025 revealed that Resident #66 refused a shower or bed bath on 12/9/2025, and did not receive a shower or bed bath on 12/12/2025. However, documentation for the next scheduled ADL care on 12/26/2025 was missing. In addition, there was no documentation indicating that nail care was provided for the Resident during December 2025. 2) On 1/12/2026 at 11:35 AM, the surveyor observed two nurses providing wound care for Resident #93. The surveyor was able to conduct a hygiene assessment but could not verify the condition of the toenails as the Resident was wearing a medical walking boot.Record reviews of Resident #93's MDS and Care Plan, dated 4/9/2025, showed that the Resident was also dependent on ADL cares to maintain good personal hygiene.At 11:48 AM, a review of Resident #93's Task documents for December 2025 revealed that the Resident refused a shower or bed bath on 12/2/2025, and a shower nor bed bath was not provided on 12/5/2025. The Resident refused a shower or bed bath again on 12/16/2025. However, documentation for the next scheduled shower or bed bath on 12/19/2025 was missing. At 12:15 PM, the surveyor conducted an interview with the DON and requested an explanation for the missed ADL cares for Resident #66 on 12/26/2025, and for Resident #93 on 12/19/2025. Furthermore, the lack of documentation for nail care for Resident#66 who had a care plan was questioned. The DON stated that staff were unable to recall the missed ADL cares and could not provide an explanation for the absence of nail care documentation in the PointClickCare (PCC) software application.At 2:00 PM, the surveyors were not provided with additional information regarding the missing ADL documentation for the two residents by the Administrator, the DON, or the Regional DON during the exit conference.

Based on observation, interviews, facility policy review, and record review, it was determined that the facility failed to provide respiratory care consistent with professional standards for oxygen administration. This was found evident of 1 (Resident #1) out of 2 residents reviewed for respiratory care during the survey. Pulse oximeter - a device that uses a light source to analyze the light that passes through a finger and can determine the percentage of oxygen in the red blood cells, referred to as a pulse ox (pox) Peripheral Oxygen Saturation (SPO2). Nasal cannula- a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels. The findings include: On 1/6/26 at 7:14 AM, the surveyor observed Resident #1 with an oxygen concentrator in his/her room, however the Resident was currently not receiving oxygen. Resident #1 stated that he/she had just gotten over pneumonia. On 1/7/26 at 11:11 AM, the surveyor reviewed Resident #1's orders. An order was written on 12/23/25 for oxygen 2 liters/minute via Nasal Cannula (NC) for SPO2 less than 92% every shift for shortness of breath. The oxygen order prior was stated on 12/2/25 and was written, oxygen 2 liter per minute via Nasal Cannula every shift for shortness of breath. On 1/7/26 at 12:50 PM, the surveyor reviewed the facility's Oxygen Administration policy. In assessment it stated, before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: #5. oxygen saturation, if applicable. Next the surveyor reviewed Resident #1's SPO2 readings and were as follows:1/6/26 97% on room air at 10:10 AM1/4/26 97% on room air at 9:53 AM12/26/25 94% on room air at 7:07 PM12/17/25 94% on room air at 8:55 AM12/12/25 96% room air at 8:44 AM12/2/25 88% room air at 2 PM Next the surveyor reviewed Resident #1's care plan. Resident #1 had a care plan initiated on 10/16/25 for altered respiratory status related to a left plural effusion (the buildup of excess fluid in the pleural space, the area between the lungs and the chest wall) and left lower lobe associated atelectasis (a condition where alveoli in your lung or a part of your lung deflates). One of the interventions listed was, monitor for signs and symptoms of respiratory distress and report to the physician as needed: Decreased pulse oximetry. On 1/7/26 at 11:32 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor asked if a Resident has an order for oxygen with Pox parameters how often should a pox be taken. The DON stated the Pox should be taken with vitals as ordered. She further stated that if the Resident was symptomatic that a pox should be taken. The surveyor relayed the concern that Resident #1 had an order for oxygen on 12/2/25-12/23/25 (23 days) for continuous oxygen and from 12/23/25 to current (16 days) to have oxygen if pox less than 92% and the pox was only documented and monitored 6 times.

Based on record review and interviews, it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards and practices by keeping complete documentation. This was found evident in 2 (Resident #1 and #7) out of 33 residents reviewed during the survey. The findings include:1) On 1/7/26 at 7:12 AM, the surveyor conducted an interview with Resident #1. During the interview the Resident stated that on occasion scheduled showers have not been given. On 1/7/26 at 11:31 AM, the surveyor requested shower documentation for Resident #1 from December of 2025 and January 2026. Next the surveyor reviewed the documentation. The surveyor noted that on Resident #1's scheduled shower days of 12/4/25, 12/8/25 and 12/11/25 the documentation was left blank. On 1/8/26 at 10:15 AM, the surveyor conducted an interview with the Nursing Home Administrator (NHA). During the interview the NHA stated that she had reached out to the 2 staff responsible for giving showers to Resident #1 on the days that there was no documentation. She stated the on 12/4/25 the staff stated that she had forgotten to document that Resident #1 refused the shower. The NHA further stated that the staff responsible for 12/8/25 and 12/11/25 stated that on the 8th she forgot to document that Resident #1 refused the shower and on 12/11/25 forgot to document that she gave a shower to Resident #1. The NHA stated that she had initiated re-education on the importance of shower documentation. 2) During a record review on 01/12/26 at 9:47 AM, the electronic medical record revealed that LPN #18 documented Yes on Resident #7 on 01/05/26 and 01/06/26, indicating that Resident #7 experienced behavior from their antianxiety medication. No documentation was found of interventions or outcomes in the progress notes as directed by the order. On 01/12/26 at 10:20 AM, the surveyors interviewed LPN #17 regarding the facility's expectation for staff documenting behavior monitoring. LPN #17 stated that they describe the side effects or symptoms the resident displayed, notify the doctor and the family and document under progress notes in electronic record. On 01/12/26 at 11:10 AM, the DON and Administrator were asked to provide documentation that the behavior monitoring triggered the electronic record were documented in the progress notes. The facility was unable to provide the requested documentation, acknowledged the concern and stated that education would be provided to staff.

Based on observation and interview, it was determined that the facility failed to maintain a sanitary environment in resident shared areas and the laundry room. This was evident in 2 (C, D) out of 4 shower rooms and the laundry room observed during the recertification survey.The findings include:On 01/07/2026 at 9:30 AM, the surveyors observed soiled linen on shower room D's floor. GNA #9 entered the shower room and picked up the linen from the floor saying I came in to make sure the shower was clean. GNA #9 stated that they did not know why there was soiled linen on the floor because the facility expects staff to place soiled linen in the hamper. The surveyors also observed a brown substance on the floor of a shower stall next to a brown-stained commode chair.On 01/07/2026 at 9:45 AM, Unit Manager #10 observed the findings in the shower stall and stated she would have the area cleaned.The Nursing Home Administration (NHA), Maintenance Regional Director, and Maintenance Supervisor acknowledged the concerns on 01/07/2026 at 11:37 AM. On 01/12/2026 at 11:26 AM, the surveyors observed multiple bags of linen on the floor of the soiled side of the laundry room and unbagged linen on the floor of the clean side. The Housekeeping Manager and the District Housekeeping Manager stated that the laundry staff was short-staffed the day before but the linen should not be stored on the floor. The NHA acknowledged the concerns found in the laundry room on 01/12/2026 at 11:57 AM and stated the shower rooms were already cleaned.

Based on medical record review and interview, and facility policy review, the facility staff failed to recognize abuse and take action to prevent abuse to residents (Resident #921, #919, #77, #905, #912, #916, #927, #2, #17, #66, #303) reviewed for abuse for 11 out of a total sample of 21 residents. These actions resulted in the finding of an Immediate Jeopardy which was identified on 7/10/24 at 4:30 PM. An IJ summary tool was provided to the facility on [DATE] at 4:48 PM. The facility submitted a draft of their plan to remove the immediacy on 7/10/24 at 6:30 PM and it was not accepted. The facility submitted a 2nd draft of their plan to remove the immediacy on 7/10/24 at 7:36 PM and it was not accepted. The facility submitted a 3rd plan on 7/10/24 at 8:30 PM and it was accepted by the state agency at 8:40 PM. After removal of the immediacy, the deficient practice remained with a scope and severity of H. The Immediate Jeopardy was removed on 7/12/24 at 9:30 AM after on-site confirmation of the completion of the facility's plan of removal. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. Brief Interview of Mental Status (BIMS) is a standardized test used to get a quick snapshot of the cognitive function and is a required screening tool used in nursing homes to assess cognition. A score of 13-15 points indicates an intact cognition, 8-12 points indicates moderately impaired cognition, and 0-7 points indicates severely impaired cognition. 1) A medical record review for Resident #921 on 7/10/24 at 6:51 PM revealed a MDS with an assessment reference date (ARD) of 2/4/24 that documented the resident had moderately impaired cognition, suffered from delusions, and exhibited physical and verbal behavior symptoms towards others. The resident wandered. Review of a physician's progress note dated 2/13/24 revealed the resident had the following, but not limited to diagnoses of dementia with behavioral disturbances. The resident had a care plan for aggressive behaviors which included an intervention to walk away and attempt care later if the resident becomes aggressive. On 7/10/24 at 7:15 PM a review of the facility's investigation file for self-reported incident #MD00203605 revealed a witness statement from geriatric nursing assistant (GNA) #130. The statement read that on 3/14/24 at approximately 6:00 AM, she and Registered Nurse (RN) #152 were attempting to move Resident #921 from one wheelchair to another. The resident was sitting in another resident's wheelchair. According to the statement, RN #152 was cussing at the resident telling him/her to sit down. The resident was agitated and became combative. The resident hit the nurse in the mouth. RN #152 responded by cursing and calling the resident names and slapped him/her on the head multiple times. GNA #130 wrote in her statement that she transferred Resident #921 to a regular chair, offered the resident something to eat and eventually the resident calmed down. A timeline of the events revealed that GNA #130 had not reported the incident to the Director of Nursing (DON) until 3/14/24 at 7:23 AM. This was 1 hour and 23 minutes that RN #152 continued to have access to vulnerable residents in the building. Further review revealed RN #152 was terminated and then referred to her state licensing board for review. A copy of Resident #921's order for a psychiatric consult was included. The Certified Registered Nurse Practitioner's (CRNP) note dated 3/18/24 was included, however it stated that the resident was being seen for hitting a nurse. There was no mention of the abuse endured by the resident. A review of RN #152's employee file revealed she last had dementia, behavioral health, and communication training in January of 2023. The training was required to be completed annually. An interview with Nurse Practice Educator on 7/11/24 at 11:54 AM revealed she had been hired in August of 2023. She reported that she was aware staff were due their annual trainings starting in January of 2023, and she was attempting to get staff to complete their required training. When asked the reason RN #152's training requirements were not up-to-date, she had no rationale to offer. An interview with the psychiatric CRNP on 7/11/24 at 2:44 PM revealed that she would have included in her note that the resident had been abused by a nurse had she been aware of the situation. Furthermore, she stated she has been seeing Resident #921 for quite a while and she would have seen the resident the same day of the incident of abuse if she had been aware. The DON was interviewed regarding the incident on 7/11/24 at 1:23 PM. She reported that she talked to the GNA about reporting to her immediately if she observed or received an allegation of abuse. When asked about the psychosocial/emotional support of the resident following abuse, she reported that the facility will refer them to psychiatric services. She reported that she and the Unit Managers will review the psychiatric notes. She stated that she was not aware that the visit psychiatric services had with Resident #921 on 7/18/24, had not addressed the abuse the resident endured. She reported that she was sure that the CRNP was aware of the incident for which she was seeing Resident #921. Furthermore, she was unable to provide a rationale for the resident waiting 4 days to be seen for psychosocial/emotional support. The concerns were reviewed 07/11/2024 3:33 PM with the Regional [NAME] President (RVP), Regional Clinical Consultant (RCC), and the DON. 2) A medical record review for Resident #919 on 7/9/24 at 11:50 AM revealed a physical therapy evaluation dated 1/17/24 that documented the resident needed partial/moderate assistance to go from a sitting position to a standing position and to transfer from one surface to another (such as the bed to the chair). However, to move around in bed the resident required substantial/maximal assistance. A physician progress note, dated 1/18/24, read that Resident #919 was admitted to the facility for rehabilitation services following an acute care admission. The resident was diagnosed with the following but not limited to: an acute upper right arm fracture and weakness in the upper and lower extremities. It was recommended that the resident remain NWB (non-weight bearing) with the right arm. Review of the MDS (minimum data set) with the assessment reference date of 1/22/24 revealed the resident had moderate impairment of cognition (the ability to think and process). Review of section J revealed the facility failed to do an assessment of the resident's pain. A review of the physician's orders revealed that the resident was non-weight-bearing for the right arm and was ordered to wear a sling upon admission. On 7/9/24 at 11:26 AM a review of the facility's investigation file revealed a written statement dated 2/26/24 from Registered Nurse (RN) #116 that read that at 7:45 PM on 2/26/24, Resident #919 reported to her that Geriatric Nursing Assistant (GNA) #140 had been rough with care and s/he was scared. RN #116 reported that the resident stated they had not been able to sleep for fear that GNA #140 was taking care of other residents. A handwritten interview (that had no date/time or who had conducted the interview, but later determined it was the Administrator) with GNA #81 revealed that she reported she had heard the resident yelling and went over to the resident's room. The resident stated that s/he wanted GNA #81 to stay with him/her because s/he thought GNA #140 was trying to kill him/her. A second handwritten interview that was in the same handwriting and green ink as the previous interview, however it had no name of the interviewee. The person being interviewed (which was later thought to be GNA #140 by the Director of Nursing) The interviewee had reported the resident had soiled themselves and the GNA was unable to change the bedding because the resident had difficulty moving. When asked if the resident told them to be careful with their arm, the interviewee confirmed that the resident had said that. The interviewee confirmed that the resident was yelling for help and that GNA #81 had responded. Facility staff failed to interview any other staff who may have had knowledge of the care provided by GNA #140 and to interview other residents who were within the GNA's care. A review of the final investigation report revealed that the facility determined that allegation of abuse was inconclusive. On 7/9/24 at 3:34 PM an interview with GNA #140, the accused GNA, she stated she could not recall the incident with Resident #919. An interview with RN #61 on 7/10/2024 at 10:19 AM, revealed that Resident #919 was a non-weight bearing status for the right arm. She stated that the resident should not be rolled onto his/her right side due to the broken arm because it would cause the resident pain. She reported that the resident wore the arm sling as ordered. When asked if a GNA came in to provide incontinence care would she expect them to roll the resident on the right side with a broken arm and she stated that she would not. An interview with GNA #81 on 7/10/2024 at 10:46 AM revealed she had been in the next room providing care to another resident on 2/26/24, when she heard Resident #919 yelling help me. She reported that she went over to the resident's room. When she walked in the resident was laying on his/her right side She stated the resident asked her to stay with her and asked that GNA #140 leave the room. She reported that she told GNA #140 that she would continue the care and GNA #140 left the room. When finished, GNA #81 reported the incident to the nurse assigned to the resident. During a subsequent interview with GNA #81 on 7/10/2024 at 11:15 AM she was asked how she provided care to the resident that day. She reported that the resident can stand and pivot, so she put the resident in a chair while she changed the bedding. Then she stood the resident to remove the brief and wash the resident. When asked again about how the resident had been lying in bed when she first walked in, she confirmed the resident was lying on their right side with the right arm under their body. An interview with RN #116 on 7/10/24 at 1:37 PM, via a phone call, revealed that the GNA #81 had told her that the resident wanted to see her. When she went in Resident #919 reported that GNA #140 had been rough with him/her during care. The resident reported fearing the GNA #140. RN #116 stated that she called the Director of Nursing (DON) to report the incident. She stated that she asked GNA #140 about the incident and the GNA reported that she had not meant to be rough with the resident, but the resident was hard to move so she had to push harder. RN #116 reported that after talking with GNA #140 the GNA was asked to leave the facility pending investigation. The concerns were reviewed 07/10/2024 4:30 PM with the Regional Clinical Consultant (RCC), and the DON. 36461 3) Review of a facility's policy titled, Compliance with Reporting Allegations of Abuse/ Neglect/ Exploitation, dated 03/22/23, indicated .It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment .Abuse .The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include .certain resident to resident altercations .Physical Abuse which includes hitting, slapping, pinching, kicking . 1. Review of R77's undated Admission Record, located in the resident's electronic medical record (EMR) under the profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Alzheimer's disease, anxiety, and depression. Review of R77's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/23/24 revealed a Brief Interview for Mental Status (BIMS) of three out of 15, which indicated the resident was severely cognitively impaired. Further review of the MDS with the ARD of 05/23/24 revealed R77 hallucinated and could be verbally aggressive during care but did not have refusals of care. Review of R77's EMR care plan, located under the care plan tab and dated 01/20/23, revealed the following focus area of .[R77] can be combative/resistant with hands on care . by pushing away at staff during care and with the intervention, .Make Resident [R77] aware of each step of the process of care before and during the care process. If resident resists with activities of daily living (ADLs), reassure resident, leave, and return 5-10 minutes later and try again . Review of a facility reported incident (FRI) with an incident dated 05/12/24 at 10:25 PM, Geriatric Nurse Aide (GNA) 139 reported .while caring for another resident, she heard this resident [R77] hollering out and went to check on [R77]. [GNA139] stated she heard [GNA138] reply to [R77] .shut up . in response to [R77's] non-sensical verbalizations. [GNA139] entered [R77's] room and [R77] was provided care by [GNA138]. [GNA139] educated [GNA138] on how to provide care while R77 is resistive to care. While in [R77's] room assisting [GNA138], [R77] stated to [GNA139] he [GNA138] is hurting me, (slapping his knee) and he punched me here (on his right thigh) . Continued review of the facility investigation revealed GNA139 failed to have GNA138 removed from providing care to R77, failed to report the allegation of physical abuse to the nurse on shift at the time of the incident and left a handwritten note for the Director of Nursing (DON) under her office door. The DON found the note on 05/13/24 at approximately 10:00 AM. During an interview on 07/10/24 at 1:00 PM, the DON stated GNA138 and GNA139 were both .agency staff . and they have not returned to the facility since the 05/12/24 incident. The DON also stated GNA138 was immediately placed on .administrative leave . while the investigation was in process. The DON stated GNA138's agency was notified of the allegation, and that he would not be allowed back to the facility. The DON further stated GNA139 was .educated . by the DON and Administrator regarding the facility policy and reporting any abuse concerns immediately to the DON or Administrator. During an interview on 07/10/24 at 1:30 PM, the DON verified that GNA138 worked .05/12/24 on the 3:00 PM to 11:00 PM shift on the memory care unit and then the 11:00 PM to 7:00 AM shift on the rehab unit . 30428 4) Documentation requested included any other change in conditions that occurred with Resident #913 after the reported incident on 11/6/22. Review on 7/12/24 at 9:28 AM revealed that on 12/22/22 Resident #913 was observed rubbing another resident's stomach in the common area. Resident #913 indicated I was pulling [resident's] shirt down. The DON at the time documented that the victim was moved to the nurse's station. The change in condition note however, was not completed until 12/30/22 and the interventions for Resident #913 that included placing him/her on a 1:1 was not implemented until 12/28/22 although the incident was reported to occur on 12/22/22 with the previous occurrence on 11/6/22 with no noted interventions. Resident #913 was seen by the facility psychiatrist on 12/30/22. The psychiatric note documented that s/he was evaluated 'again' for concerns with sexual impulse control after another patient reported concern though [Resident #913] reported no interactions with residents of the opposite sex and verbalized that s/he is supposed to be 6 feet away from the opposite sex. The only intervention recommended by the psychiatrist was for melatonin for sleep and to continue to monitor for worsening symptoms. According to physician orders and the medication administration record (MAR) Resident #913 remained on 1:1 from 12/30/22 through his/her discharge on 2/2024. This was verified on the physician orders and verified on the MAR for each shift according to a record review completed on 7/12/24 at 9:40 AM. However, on 7/21/23 Resident #913 was found in the room of Resident #912, alleged victim #3. According to this facility report Resident #912's diaper was down exposing the private area. Resident #913 was noted standing overtop of Resident #912 with [his/her] hands on Resident #912's incontinence product that was open. Resident #913 was seen looking in Resident #912's private area. A staff member interrupted and redirected Resident #913 out of the room. When Resident #913 was asked what s/he was doing, s/he stated that they were 'helping Resident #912' Resident #912 who had a BIMS of 4 assessed on 5/7/23 which indicated severe cognitive impairment and had a documented need for assistance with personal care. According to the facility reported incident related to the occurrence on 7/21/23 the facility interventions included to update the care plan for both residents. A review of the care plans on 7/12/24 revealed that there was no update or change for Resident #913. Intervention #2 included to move Resident #913 to a private room. A review of Resident #913's census report revealed that this did not occur. A concurrent review of Resident #913's MAR revealed that on the day of the 7/21/23 incident staff did sign off that 1:1 was in place. However, a closer review revealed that on the night shift of 7/22/22, 1 day later, staff signed off a '7, see nursing progress notes.' This was also on 7/13, 7/14, 7/15, 7/25. According to the corresponding progress notes the nurse stated, 'no one on one provided at night.' On 7/12/24 at 10:55 AM surveyor reviewed the concerns related to Resident #913 and the ongoing failed implementation of interventions related to his/her sexual preoccupation with residents of the opposite sex including the delay of the implementation of the 1:1 order from 12/28/22 and failure of the staff to follow through, monitor and implement the order to prevent additional occurrences. This was reviewed again with the facility Regional Clinical Consultant and Regional [NAME] President at exit on 7/12/24. At this time the Regional Clinical Consultant was asked again what happened and she stated that after the 7/21/23 incident they really 'buckled' down on the 1:1 monitoring with Resident #913 to ensure there were no more occurrences. 5) Review on 7/10/24 of a facility reported incident revealed that on 9/5/23 there was an allegation that while on the dementia unit, in the dining room, during a visit with their respective family identified as Resident #70, the visiting family member yelled at Resident #926 while pointing in his/her face, stating I've already told you to stop it multiple times. If you keep reaching, I'm going to give you a hand smack. GNA #76 intervened and moved Resident #926 away from that visiting family member and then proceeded to escort Resident #70 out of the dining room to their respective room. Upon their arrival to the residents' room or soon thereafter, Resident #70's roommate, Resident #916, who resided in the 'A' bed, was there. According to the GNA statement in the investigation packet, provided to the survey team, that was read and verified with GNA #76 on 7/10/24 at 11:11 AM, she did take Resident #70 out of the dining room and hoped that the family would follow. She also did state when asked, that she did leave the room for an unknown amount of time to go and get supplies. This left the family member and both residents in the room alone for an unknown amount of time. Interview concurrently on 7/10/24 at 11:11AM with the Memory Support Program Director, staff # 142 who also confirmed her statements from the incident. She stated that she was alerted to the incident that occurred in the dining room by staff #76. As she went to the resident's room, she could then hear an argument occurring between the family member and Resident #916, who resides in bed 'A.' At this time there was another GNA in the room in addition to staff #76 and staff #142. The other GNA stated that the family accused Resident #916 of taking Resident #70's items and wanted to go through her family members [resident #70's] personal items to confirm. An argument ensued between the family member and Resident #916. The family member continued to rant and argue with the resident and staff #142 who asked the family to calm down and notified the family of her inappropriate behavior, tone and body language. Staff #142 stated that there was another aide that was with Resident #916 that stayed with him/her at this time attempting to keep him/her content. However, as in the statement the family refused to leave, was argumentative and ranting and arguing. It was not until the Administrator and the DON arrived that they were able to get the family member to leave who continued to yell through the facility. A care plan meeting was held 1 week later along with further dementia care education with the family member. The family member was eventually allowed to visit in a separate area with her family member, Resident #70 away from other residents, unsupervised. A care plan was implemented at that time regarding this intervention. The DON was interviewed on 7/10/24 at 11:42 AM and asked about that care plan and why it was no longer in place as it was discontinued on 3/8/24. She stated that it was not needed anymore, and she believed that there was a follow up care plan meeting about it and would follow up. The DON was also asked if there had been other incidents with this identified family member. There was no follow-up information provided prior to exit. It was reported to the survey team that the family member was ill and had not been in for a while. Further review on 7/10/24 of the care plans for Resident #70 revealed that there was a care plan initiated a month after admission that the resident had historical episodes related to suicidal ideations and verbal expressions when frustrated and or feelings of hopelessness. This was updated to note that it occurred when this identified family member visits. Staff #142 who was interviewed on 7/10/24 at 11:11 AM was questioned about this. She stated that they, the staff, know residents get teary when family leave and it's a process, however, they were noting that Resident #70 was more upset and seemed to have more concerns after that family member had visited. There were no interventions related to that family member to prevent Resident #70 from any further distress. 6) Review of the facility reported incident on 7/11/24 at 12:02 PM that occurred on 11/9/22 revealed an allegation that GNA #151 allegedly pushed Resident #905 during care, hurting and scaring him/her and their roommate, Resident #927. After the incident both residents reported to the DON the next day that they were scared but at that time felt safe in the facility. Interventions reported to have been implemented to the OHCQ were not completed, including psychiatric, social work or emotional support for either resident and neither care plan was updated related to the incident. Resident #927 was only referred to psychiatry on 11/15/22 after the facility staff became concerned of his/her change in behavior after they had witnessed the incident between Resident #905 and GNA #151. In addition, no final report of the investigation was submitted to the OHCQ. A review of the employee file on 7/11/24 for staff GNA # 151 revealed that just 3 weeks prior she was written up and placed on suspension for unprofessional conduct. This was written as a 'final warning.' Corrective measures included customer service training to ensure a more positive approach when providing care and speaking with residents and staff. She also had a write up on 1/9/22 related to unprofessional conduct, 'observed by a coworker using profanity, being disrespectful in an unprofessional conduct. GNA #151 at this time was to complete customer service training with the then DON and follow code of conduct per handbook. For this allegation of abuse GNA #151 was given a 'last final warning,' was suspended during the investigation and upon return continued to work at this facility through 4/2023 34484 7) The facility failed to remove Staff #137 after an allegation of abuse and continued to allow Staff #137 to participate in Resident #2''s care. Review of a facility reported incident on 7/09/24 revealed Resident #2 reported on 1/4/22 Staff #137 was rough with care. Review of Resident #2 ' s medical record on 7/10/24 revealed the Resident was admitted to the facility with a diagnosis of quadriplegia, complete. Complete quadriplegia is characterized by a complete loss of control over the arms and legs. This is a near-total form of paralysis where a person is wholly unable to move their extremities aside from their head. Interview of Resident #2 on 7/9/24 at 8:45 AM, Resident #2 stated in January 2022 he/she was in the shower room with Staff #137 and Staff #77 and asked the staff to stop showering him/her because of the pain. Resident #2 stated Staff #77 stopped but Staff #137 continued to wash his/her hair. Resident #2 states he/she has rods in his/her neck and Staff #137 was too rough and caused him/her pain. Resident #2 stated he/she spit on Staff #137 until they stopped. Resident #2 stated he/she started counseling because of the incident and is still upset about it to this day. Resident stated with other the traumas in his/her life of his/her friend being shot, his/her accident that caused the paralysis over [AGE] years ago and being admitted to a nursing home, this is the first time he/she felt like he/she needed to get counseling. Interview with Staff #77 on 7/9/24 at 4:28 PM, Staff #77 stated when Resident #2 began yelling you are hurting me, she stopped care immediately but Staff #137 continued to rinse Resident #2's hair with a shower nozzle until I told her to get out. Further review of Resident #2 ' s medical record revealed Staff #137 ' s nurse note on 1/5/22 at 3:03 PM, Staff #137 stated at 2:00 PM this writer and A/B Unit manager (Staff #77) assisted resident to obtain a shower. This writer and Staff #77 transferred resident via hoyer lift to shower bed without complication. At no point did the resident verbally state he/she did not want this writer in his/her room or resident did not want this writer to assist resident in shower, this writer and Staff #77 entered the shower room and directed shower bed into the stall with feet first and head at the opening of the shower stall. This writer turned water on and allowed water to warm up. Resident asked this writer to place water on him so he/she could feel the temperature. This writer placed water on the resident ' s right leg. Resident stated, Of course you put it on my leg where I can ' t feel! This writer asked resident where resident would like water placed? Resident stated, Put it on my shoulder. This writer placed water on Resident ' s right shoulder. Resident stated, That ' s fine start with my head, one do my hair, and one wash my body. This writer wet resident hair and placed shampoo in hair, during this time Staff #77 wet washcloth on resident upper body, resident screamed I ' m hypersensitive! Staff #77 then removed all hands from resident. Staff #77 then lightly placed washcloth on resident abdomen. Resident then screamed get the f___ off of me! Staff #77 then put washcloth down and stepped away. This writer began to rinse shampoo out of resident hair. This writer never placed hands on resident during the rinsing process. Resident then began screaming get the f___ off me you b___h Resident then began to spit at this writer and Staff #77. This writer showed resident both hands and stated, my hands are right here, I am not touching you, I was only trying to rinse the shampoo out of your hair so it doesn ' t run in your eyes. Resident then began spitting again screaming I ' m calling the cops and filing charges get the F___ out of here you B___h! This writer turned off the water and stepped away leaving the shower room to go get help. Further review of Resident #2 ' s medical record on 7/10/24 revealed a nurse' s note on 1/4/22 at 4:25 PM that stated, Resident was heard by this RN yelling from the shower room on C wing. Staff #137 came out of the shower and reported the resident had spit in her face. Resident reports to this RN that Staff #137 was rough with him/her while washing his/her hair. This RN and a geriatric nursing assistant (GNA) assisted resident with the rest of his/her shower and put him/her back to bed. Resident wanted to call the police to report Staff #137 for being rough during his/her shower. Further review of Resident #2 ' s medical record revealed Staff #137 ' s nurse ' s note on 1/5/22 at 10:49 AM that stated, This writer informed Wound Nurse Practitioner (Staff #141) that I was not able to enter Resident room. This writer asked GNA to assist Staff #141 in holding resident over so Staff #141 could measure resident sacral wound. This writer never entered resident room and stood in the doorway still remaining in the hallway so this writer could document wound measurements as Staff #141 stated them verbally. As soon as resident heard my voice resident started yelling Get out of my F___ing room! This writer informed resident in fact was not in his/her room and was still standing in the hallway. Resident screamed again Get the F___ out of my room! Staff #141 stated calm down she is only documenting out in the hallway. Resident stated Then shut my f___ing door! This writer shut resident door and remained in hallway with Staff #141 and GNA in resident room. Review of the facility investigation on 7/10/24 revealed Staff #141 wrote, went to see patient today for wound rounds Staff #137 assisted by standing outside the room to write down measurements. Resident #2 heard Staff #137 outside the room and stated, "get her out of my room" Staff #137 proceeded to say that she was not in the room. Resident #2 shouted "get the f___ out of my room! and demanded that his/her door be shut. Further review of Resident #2 ' s medical record on 7/10/24 revealed a nurse ' s note on 1/6/24 at 6:59 AM that stated, Resident proceeded to tell me his/her version of an event that he/she states occurred in the shower room yesterday. He/she stated the nurse manager (Staff #137) was very rough with him/her and kept jerking his/her head back and forth. He/she stated he/she asked her to stop about 15 times and panicked when she would not stop. That is when he/she stated he/she began spitting at her as a defense mechanism and admitted to calling her a b___h. During interview with the Director of Nursing (DON) on 7/10/24 at 1:50 PM, the DON was asked if Staff #137 was suspended pending the investigation of Resident #2 ''s allegation of abuse on 1/4/22. The DON stated no. 12679 8) Review of R17's EMR Admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder. Review of R17's EMR quarterly MDS with an ARD of 06/22/23 indicated the resident had a BIMS score of 15 out of 15 which revealed the resident was cognitively intact. The assessment indicated the resident had no physical/verbal behaviors directed to others. Review of R17's EMR Care Plan located under the Care Plan tab, dated 08/04/23, indicated the resident had the potential to be physically/verbally aggressive towards others. During an interview on 07/08/24 at 10:30 AM, R17 stated she slapped her previous roommate (R66). R17 stated she was unsure why she slapped R66 and had never done it prior or since. R17 stated the police were involved. Review of R66s' EMR Admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of cognitive communication deficit. Review of R66's EMR annual MDS with an ARD [TRUNCATED]

Based on interviews, review of the facility documentation, and review of the facility policy, the facility failed to ensure policies and procedures were implemented to address the facility's Quality Assessment and Performance Improvement (QAPI) plan and program, in which data was gathered, analyzed, developed, implemented, and re-evaluated to address adverse events related to potential deficient practice of abuse. This had the potential to affect all 105 residents residing in the facility at the time of the survey. Findings include: Review of the facility's policy titled, [Facility Name] Quality Assurance and Performance Improvement (QAPI), dated 2020, indicated .To provide continuous evaluation of [Name of facility] systems with the objectives of keeping systems functioning satisfactorily, preventing points of accountability for ensuring quality of care and quality of life . A request was made for any Performance Improvement Plan (PIP) regarding the prevention of abuse from 01/01/22 to 07/11/24. The facility provided documents from 09/19/22, which indicated the facility had an action plan for timely reporting of abuse allegations and revealed there were no current issues. The action plan directed staff to provide training to the facility staff by 09/26/22. In addition, a review of multiple sign-in sheets, provided by the facility, revealed staff who attended abuse prevention training on 09/19/22, 09/20/22, and 06/14/23. There was no evidence the facility tracked, trended, and provided additional abuse prevention training as part of an effective QAPI program to sustain compliance. During an interview on 07/11/24 at 2:33 PM, the Regional Clinical Consultant (RCC) and the Director of Nursing (DON) were specifically asked if they had taken any abuse allegations through the QAPI process. The RCC stated the facility provided lots of abuse prevention training but there was no focus on sustaining compliance with abuse prevention through QAPI. The RCC stated there was no data, monitoring, or evaluation of data collected as part of their QAPI program which would show they were able to sustain compliance. The DON stated the QAPI meetings were held on a monthly basis and the facility had no additional information to provide on abuse prevention which would have been tracked, trended, monitored with an action plan developed as a result.

Based on interviews, record review, and facility policy review, the facility failed to ensure that grievances were promptly resolved and ensure all written grievance decisions included the date of the grievance, a summary of the resident's grievance, a summary of the findings, a statement as to whether the grievance was confirmed or not confirmed, corrective action taken as a result of the grievance, and the date the decision was issued. Specifically, the facility failed to ensure grievances voiced by residents during resident council were documented, investigated, resolved, and followed up on by the facility of 105 residents. This failure had the potential to cause further grievances to be unresolved for residents throughout the facility. Findings include: Review of the facility's policy titled, Resident Council Meetings, dated 04/25/23 and provided by the facility, revealed The facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decision to the Council. Review of the Resident Council Minutes provided by the facility, dated 11/27/23, revealed seven staff attended, including the Environmental Services Director and the Director of Nursing (DON). The Resident Council Minutes did not indicate the names of residents that attended. The concerns section of the Resident Council Minutes revealed aides have attitudes. In the Laundry section of the Resident Council Minutes revealed missing clothing, black clothing coming back brown. There was no indication in the Resident Council Minutes that these concerns were addressed or discussed. Review of the Resident Council Minutes provided by the facility, dated 01/18/24, revealed six staff attended, including the Environmental Services Director. The Resident Council Minutes did not indicate the names of residents that attended. The concerns section of the Resident Council Minutes revealed being put in bed with clothes on, showers not given. The Laundry section of the Resident Council Minutes revealed clothes coming out a different color. There was no indication on the Resident Council Minutes that this concern was addressed or discussed. Review of the Resident Council Minutes provided by the facility, dated 2/15/24, revealed staff did not attend the meeting. Resident Council Minutes did not indicate the names of residents that attended. The concerns section of the Resident Council Minutes revealed Showers, no name badge, call light not answered timely, not being changed. There was no indication on the Resident Council Minutes that these concerns were addressed or discussed. Review of the Resident Council Minutes provided by the facility, dated 5/23/24, revealed five staff attended, including the DON. The Resident Council Minutes did not indicate the names of residents that attended. The nursing concerns section of the Resident Council Minutes revealed Aides need to introduce themselves. There was no indication on the Resident Council Minutes that this concern was addressed or discussed. Review of the Resident Council Minutes provided by the facility, dated 6/20/24, revealed two staff attended. The Resident Council Minutes did not indicate the names of the residents that attended. The concerns section of the Resident Council Minutes Showers not being offered, Aides need to introduce themselves were nursing concerns from residents. There was no indication on the Resident Council Minutes that these concerns were addressed or discussed. During a resident group meeting held on 07/09/24 at 10:59 AM, Resident (R) 30) stated she had multiple black pants go to laundry and when they were returned, they were brown. She stated staff have never talked with her about this. Other residents agreed they had reported concerns about their laundry and had not received follow-up. Residents who attended also stated they were often uncertain who the aides were during the weekends and wished they would introduce themselves when they entered their room. Residents stated they were uncertain how to file a grievance. During an interview on 07/09/24 at 3:15 PM, the DON stated she had completed training for aides regarding introducing themselves when they entered a resident's room, showers, call lights, and their attitudes. She stated she had not provided education to all staff. The DON stated if a resident had personal items missing or items that were ruined in the laundry, a search should have been completed by staff and the items should have been replaced. She stated there should be follow-up with residents for all concerns. During an interview on 07/11/24 at 9:43 AM, the Activities Director (AD) stated the current process was if a department manager attended the resident council meeting and a resident voiced a concern related to the specific department, the department manager would immediately address the concern. She stated she would document the concern in the Resident Council Minutes. The AD stated there was no follow-up documentation on whether the situation was addressed or if there was a resolution. She stated the Administrator would always receive a copy of the Resident Council Minutes. Neither the AD nor the DON provided any follow-up documentation for the voiced concerns documented in the Resident Council Minutes.

Based on record review and interview it was determined that the facility failed to have a process in place to ensure the resident's safety directly following an allegation of abuse and to conduct a thorough investigation of the allegation. Evident for 3 (#913, #921 and #928) and Evident for 4 (#905, #911, #919 and #924) of 26 residents reviewed for abuse allegations during a recertification and complaint survey. The findings include: 1) A review of the facility's investigation file for the self-reported incident #MD00203605 on 7/10/24 at 7:15 PM revealed witness statements written by Geriatric Nursing Assistant (GNA) #130 and GNA #23 that read they had witnessed Registered Nurse #152 cursing and hitting Resident #921 on 3/14/24 at approximately 6:00 AM. However, the abuse was not reported to the Director of Nursing (DON) until 7:23 AM that morning. Therefore, RN #152 continued to have access to vulnerable residents for 1 hour and 23 minutes after she abused Resident #921. An interview with the DON on 7/11/24 at 1:11 PM revealed she was aware of the delayed reporting and offered no rationale. She reported that she educated the GNAs when they spoke. 2) A review of the facility's investigation file for the self-reported incident #MD00205149 on 7/10/24 at 5:31 PM revealed a resident interview sheet for Resident #928. Review of the interview revealed that Resident #928 had reported that s/he was abused. Further explaining that a staff member had been rough with him/her during care and had not talked very nicely to them. The staff member conducting the interview failed to sign the interview sheet. On the back of the interview sheet was a handwritten note that had not been signed or dated, indicating an additional interview was conducted with the resident. However, further review of the record revealed the facility had failed to investigate the allegation of abuse. An interview with the Director of Nursing (DON) on 7/11/24 at 1:11 PM with the Regional [NAME] President (RVP) present. The DON reported she was not sure who had conducted the interview with Resident #928. She agreed that this was an allegation of abuse and reported she had interviewed the resident (the handwritten note on the back of the interview sheet) and the resident had recanted it. However, she could not recall the date of the interview. The note stated, I [resident #928] had the same aide today. Which indicated the interview had been conducted the day after the original interview. 3) A review of the facility's investigation report for the facility self-reported incident #MD00205149 on 7/10/24 at 5:31 PM revealed that Resident #924's representative had reported that she came in on two occasions and found the resident soiled. Further review of the file revealed the facility failed to interview other staff who may have had knowledge of the care provided by the accused geriatric nursing assistant. This concern was reviewed with the DON on 7/11/24 at 1:11 PM, she stated that she understood why it was important to interview other staff who may have had knowledge of the incident. 4) A review of the facility's investigation file for the self-reported incident #MD00203010 on 7/9/24 at 11:26 AM revealed an interview with GNA #81 that read she overheard Resident #919 yelling for help. She responded to the room and found GNA #140 was in the room providing care. She reported the resident asked her to stay with them as they thought GNA #140 was trying to kill them. Further review of the file revealed that staff interviewed GNA #140 (the accused GNA), GNA #81, and RN #116. However, they failed to interview other staff who may have had knowledge of care provided by GNA #140. In addition, they failed to interview other residents who had received care from the GNA. The facility determined the abuse was inconclusive. An interview with GNA #81 on 7/10/24 at 10:06 AM revealed that the resident had been rolled completely over on their right side. She reported the resident had a broken right upper arm and it was in the sling. The resident was yelling for help and GNA #140 allowed the resident to remain in that position. GNA #81, who reported she finished caring for the resident, stated she assisted Resident #919 to a chair, while she changed the bedding. She then stood the resident and provided incontinence care and changed the resident's clothing. She stated she put the resident back to bed. She stated she cared for the resident in this manner to avoid causing the resident pain. The concerns were reviewed with the DON, Regional Clinical Consultant, and Regional [NAME] President on 7/11/24 at 3:33 PM. Cross Reference: F600 and F609. 37296 5) Review of a facility reported incident MD00187781 on 7/10/24, revealed the facility reported to the Office of Health Care Quality (OHCQ) on 1/14/23, Resident #911 reported alleged abuse by facility staff GNA #148. On 7/10/24 at 12 PM a review of the facility investigation report revealed the facility staff has no record of a complete investigation to include interviews with other residents on the unit. On 7/10/24 at 1:30 PM the Director of Nursing confirmed that the investigation failed to include interviews of other residents that was cared for by Staff #148. 30428 6) Review of the facility reported incidents regarding Resident #913 on 7/11/24 at 12:02 through exit on 7/12/24 failed to reveal documentation that the facility effectively implemented ordered interventions to prevent Resident #913 from being alone with residents of the opposite sex. This was identified as occurring on 11/6/22 with no interventions implemented and again on 7/21/23 after Resident #913 was already ordered to be on a 1:1 from 12/28/23. cross reference F600 7) Review of the facility reported incident occurring on 11/9/22 revealed an allegation of physical abuse between GNA #151 and Resident #905 where GNA #151 pushed Resident #905 during care, scaring him/her and the roommate, so much so the roommate got up and stayed in the bathroom. Further review of this facility report on 7/12/24 with the facility DON failed to reveal that a 5-day report was submitted showing the facilities findings. Additionally, there were no additional interviews with other residents or staff included in the investigation. The alleged perpetrator, GNA #151, had 2 writeups previously regarding unprofessional conduct including one 3 weeks prior that was a 'final' warning and given the same write up for this allegation and noted as a 'last final' warning. This employee continued to work in the facility as a GNA through 4/2023 when she was terminated for 'not fulfilling PRN (as needed) contract).' However was marked as eligible for re-hire. cross reference F600

Based on record review and interview it was determined that the facility staff failed to allow a resident the right to have a dignified existence by failing to be listening to the Resident during his/her care (Resident #911). This was evident for 1 of 73 residents reviewed during a complaint and recertification survey. The findings include: A review of the facility reported incident #MD00187781 on 7/10/24 at 10:30 AM revealed Resident #911 had reported an allegation of abuse on 1/14/23, because the GNA #148 turned me, and I yelled out in pain and asked her to stop and the GNA #148 continued working. An interview by the Director of Nursing on 1/14/23 revealed that Resident #911 felt that the GNA was not listening to me I instructed her how I like my care done and she would not listen. On 1/14/23 The roommate, Resident #929 called the manager to report that GNA #148 was mistreating my roommate, and he/she was not listening to him/her during his/her care. Resident #911 was no longer at the facility for an interview. On 7/10/24 at 12:30 PM, an interview with roommate Resident #929 revealed that he/she does not remember the incident. GNA #148 was placed on administrative leave on 1/14/23 and at the completion of the investigation GNA #148 was placed on a do not return list with the Agency. On 7/10/24 at 2:00 PM the Director of Nursing was made aware of the findings.

Based on record review and staff interview it was determined that the facility failed to ensure that residents and/or resident representatives were afforded the right to file a grievance and receive a response regarding the action taken by the facility (Resident #906). This was evident for 1 of 3 residents reviewed during a recertification and complaint survey. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. A review of the complaint #MD00186681 on 7/8/24 at 10:15 AM revealed that there were care concerns regarding Resident #908. The concerns included but were not limited to a nurse dispensing medications to four people at one time, staffing on the memory care unit was not consistent, the resident not being changed, wearing dirty clothing, and having body odor. An interview with the complainant on 7/8/24 at 10:31 AM revealed that the complainant had spoken to the Memory Support Program Director (MSPD), Director of Nursing (DON), and the Administrator on several occasions regarding the concerns. On 7/11/24 the DON was asked to provide any grievances that had been reported for Resident #908. The DON reported back on 7/12/24 that they did not have any records of grievance being filed. The Administrator was out of the facility at the time it was requested. A medical record review for Resident #906 on 7/12/24 at 8:32 AM revealed an MDS with an assessment reference date of 12/9/22 that documented the resident had severe cognitive impairment and relied on staff for activities of daily living (bathing, personal hygiene, toileting, getting in and out of bed). Review of the facility's Resident and Family Grievances policy revealed it had not been implemented until after these complaints on 4/5/23. An interview with the MSPD on 7/12/24 at 9:11 AM revealed that she had spoken with the resident's family frequently about care concerns. She stated that she had not completed a grievance form for the concerns. She stated that if she was able to address the issue immediately, she does not complete a grievance form. She reported that she remembered having a meeting with a family member and other administrative staff but could not recall who had attended. When asked if the family member's concerns required a meeting with administration would this not be considered a grievance, she replied that it would. The DON was made aware of the concerns on 7/12/24 at 11:18 AM and agreed that the grievance process should have been followed.

Based on interview, record review, and facility policy review the facility failed to report timely, within two hours and not later than 24 hours for initial notification of an allegation of staff to resident verbal and physical abuse, to the state survey agency (SSA) reviewed for facility reported incidents (FRIs) residents. This was evident for 4 of 26 residents (Resident #77, #303, #921, #928) reviewed for abuse during a recertification and complaint survey. Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 03/22/23, revealed . Reporting of all alleged violations to the Administrator within specified timeframes: immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse . 1) Review of R77's undated Admission Record, located in the resident's electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Alzheimer's disease, anxiety, and depression. Review of R77's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/23/24 revealed a Brief Interview for Mental Status (BIMS) of three out of 15 which indicated the resident was severely cognitively impaired. Review of a facility reported incident (FRI) with an incident dated 05/12/24 at 10:25 PM, Geriatric Nurse Aide (GNA) 139 reported .while caring for another resident, she heard this resident [R77] hollering out and went to check on [R77]. GNA139 stated she heard GNA138 reply to R77 .shut up . in response to R77's non-sensical verbalizations. GNA139 entered R77's room and R77 was provided care by GNA138. GNA139 educated GNA138 on how to provide care while R77 was resistive to care. While in R77's room assisting GNA138, .[R77] stated to [GNA139] he [GNA138] is hurting me, (slapping his knee) and he punched me here (on his right thigh) . Continued review of the facility investigation revealed GNA139 failed to report the allegation of physical and verbal abuse to the nurse on shift at the time of the incident and left a handwritten note for the Director of Nursing (DON) under her office door. The DON found the note on 05/13/24 at approximately 10:00 AM. During an interview on 07/10/24 at 1:00 PM, the DON stated GNA138 and GNA139 were both .agency staff . and they have not returned to the facility since the 05/12/24 incident. The DON further stated GNA139 was .educated . by the DON and Administrator regarding the facility policy and reporting any abuse concerns immediately to the DON or Administrator. DON further stated the initial allegation report was submitted to the SSA on 05/13/24 at 11:30 AM. 35690 2) Review of R303's Face Sheet, located in the electronic medical record (EMR) under the Profile tab, revealed R303 was admitted to the facility on [DATE] with a diagnosis of a rib fracture and adjustment disorder with anxiety. Review of R303's admission MDS with an ARD of 06/24/24 located in the EMR under the MDS tab, revealed R303 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Per the MDS, the resident did not exhibit any behavior during the assessment period. During an interview on 07/08/24 at 11:50 PM, R303 stated sometimes at night she was told by staff to go to the bathroom in her brief. She stated it felt awful and she did not like doing it. She stated sometimes she also had a bowel movement in her brief which felt very uncomfortable. She stated she would wiggle in the chair. She stated last night she was told this by a GNA who provided care. R303 stated she reported this to GNA148 this morning. During an interview on 07/11/24 at 2:26 PM, R303 stated she had told GNA148 about the overnight Certified Nurse Aide (CNA), when her shift started, at approximately 7:15 AM on 07/08/24. During an interview on 07/11/24 at 2:28 PM, DON said she had spoken with GNA148. She said GNA148 confirmed she had provided care with R303 in the morning of 07/08/24. She said GNA148 said R303 reported to her that overnight when R303 told her GNA she had to go to the bathroom. the GNA told her to pee in her diaper. The DON said GNA148 told the RN. The DON said that neither the nurse nor GNA148 reported the incident to the Administrator or the DON until after noon on 07/08/24. She said the report made by the surveyor and the report made by the nurse were made simultaneously. She said the report should have been made as soon as the RN heard about the incident so she (DON) or the Administrator could report the incident within the two-hour time frame. The incident was reported to the State Agency on 07/08/24 at 1:33 PM. 40927 3) A review of the facility's investigation file for the facility reported incident #MD00203605 on 7/10/24 at 7:15 PM revealed a witness statement from Geriatric Nursing Assistant (GNA) #130 stating that Resident #921 was observed being abused by RN #152 on 3/14/24 at approximately 6:00 AM. However, she waited until 7:23 AM to report the abuse to the Director of Nursing (DON). The DON documented in the self-report form that she sent it to the state agency (SA) on 3/14/24 at 9:18 AM. An interview with the DON on 7/11/24 at 3:33 PM revealed she was aware of the late reporting and had provided educated the GNA. 4) A review of the facility's investigation file for the facility reported incident #MD00205149 on 7/10/24 at 5:31 PM revealed that in response to an allegation of abuse the facility had interviewed Resident #928. The resident answered yes when asked if s/he had been abused and then elaborated that someone had been rough with him/her during care and didn't speak very nicely. There was no name of who interviewed the resident. On the back of the interview sheet was a handwritten note with no date or signature that stated, Resident interviewed - States I had the same aide today. I feel I may have made it up. This Indicated that this interview had been conducted the next day. However, there was no evidence that this allegation of abuse had been reported to the SA. An interview with the Director of Nursing on 7/11/24 at 1:11 PM revealed that she was unsure who had conducted the interviews. When asked if anyone reviewed the interviews conducted with residents, she stated that she and the Administrator reviewed them. She reported she wrote the note on the back of Resident #928's interview sheet and was unable to recall when the interview had been conducted. She stated that the resident had recanted the allegation, however it was uncertain when this interview was conducted and based on what was said it was the next day. Cross Reference: F600 and F610

Based on medical record review and interview with facility staff, it was determined that the facility failed to review and implement a care plan when there were noted changes in condition requiring further facility services and follow-up (Resident #905). This was evident for 1 of 73 residents reviewed during a complaint and recertification survey. A care plan is a comprehensive and personalized document that outlines the specific needs, goals, and preferences of a patient. Care plans also address the specific services needed to attain and maintain a resident's highest practicable well-being through focus, goals and interventions. The findings include: Review of the electronic health record for Resident # 905 on 7/11/24 at 2:00 PM failed to reveal updated care plans related to 2 allegations of abuse occurring on 11/6/22 and on 11/9/22 respectively involving Resident #905. Resident #905's care plans in place were noted to address depression and cognitive decline, however, nothing related to having been exposed to 2 incidents of abuse 4 days apart. This concern was reviewed with the DON and Regional [NAME] President at exit on 7/12/24. cross reference F600, F744

Based on interview with staff, review of medical records and closed medical records [REDACTED]. As a result, the resident experienced a delay in the treatment of [REDACTED].#60) 2) Administer a regularly scheduled pain patch (Resident # 71) and 3) follow a physician order [REDACTED].#109). This was evident in 1 of 30 (Resident #60) admission sample residents reviewed during stage 1, and 2 of 40 (Resident #71 and Resident #109) reviewed during stage two of the survey. The findings include: 1) On 1/20/17 at 6:30 PM, Resident #60's closed records was reviewed. This review revealed that the resident was admitted to the facility in November 2016 for rehabilitation after a left total knee replacement. Review of the physician orders [REDACTED]. Further review revealed the resident's treatment plan which included improve physical condition and improve overall and physical and occupational therapy for left knee. Review of the Director of Rehabilitation Concern/Grievance form revealed that on 11/21/16 around 10:00 AM the resident was scheduled to have 90 minutes of therapy, per documentation the resident was having 8/10 pain in his knee. The therapist asked staff #30 if the resident was able to have any pain medication due to the resident having 8/10 pain and scheduled for therapy. Further review of the documentation revealed that staff #30 informed the therapist that the resident received pain medication at 5:15 AM and that the resident would get medicated for pain when he/she was due. Further review of the concern/grievance form revealed that at 11:15 AM, the therapist returned the resident back to the nursing unit due to the resident being in pain. The therapist indicated that the resident had more therapy to do and requested that staff #30 medicate the resident for pain. Staff #30 informed the therapist that the resident could not have any pain medication until 12 noon because the resident received pain medication at 6:00 AM. Review of the controlled substance sign out sheet revealed the resident received [MEDICATION NAME] 2 tablets on 11/20/16 at 12 noon and 6:00 PM. Further review of the controlled substance log failed to reveal any [MEDICATION NAME] being removed prior to 12 noon on 11/21/16. During an interview with the therapist on 1/20/17, s/he revealed that staff #30 's attitude and behavior was unacceptable. The therapist felt that it was a power struggle between her/him and staff #30 with the resident being in the middle. S/he also revealed that even though the resident was in pain he/she continued with therapy with the understanding that he/she would receive pain medication when it was due. ¿When staff #30 eventually gave Resident #60 [MEDICATION NAME] at 12 PM on 11/20/16, review of the medication administration records, nurse ' s notes and pain assessments failed to reveal that Staff #30 documented giving [MEDICATION NAME] to Resident #60 in the Medication Administration Record [REDACTED]. During an interview with the Director of Nursing (DON) on 1/20/17 at 7:30 PM, s/he revealed that during her/his investigation s/he was told by staff #30 when s/he looked at the resident's Medication Administration Record [REDACTED]. The DON also revealed that staff #30 was disciplined for not reading the medication records accurately to determine the appropriate time to administer all PRN (as needed) medications and to properly administer pain medication when ordered. During the survey exit, all findings discussed with the Director of Nursing and the Administrator. 2) On 1/19/17, Resident #71's physician orders [REDACTED]. This review revealed a physician order [REDACTED]. January 15 was missing a signature indicating that the medication was not applied to the resident. During an interview with the nurse (staff #15) while reviewing the controlled substance log, s/he revealed that it was not signed out on January 15, 2017 and counting the number of [MEDICATION NAME]es in the box we did not run out. Staff #15 stated I don ' t know why s/he did not get it we had enough All findings discussed with the Director of Nursing and the Administrator during the survey exit. 3) On 1/19/17, review of Resident #109's medical record revealed that the resident has an indwelling urinary catheter and an order, in effect since 8/23/16, to change the catheter every month. Further review of the Treatment Administration Record (TAR) revealed that the catheter was due to be changed on 11/13/16. No documentation was found that the catheter was changed until 12/27/16, more than 6 weeks after it was due to be changed. On 1/19/17, the Director of Nursing reported that she cannot determine if the catheter change had been completed in November or not, stating that the nurse that did not sign off is no longer here.

Based on medical record review, observations and interviews, it was determined the Nurse Practitioner failed to initially assess the resident's leg and adequacy of the temporary splint upon notification of the fracture. The Nurse Practitioner also failed to periodically remove the temporary splint to relieve pressure on the resident's skin for five days resulting in a deep tissue injury. This was evident for 1 (Resident #50) of 36 residents reviewed in Stage 2. A deep tissue injury (DTI) presents as a purple or very dark area that is surrounded by profound redness, [MEDICAL CONDITION], or induration (hardness). Eschar is described as thick necrotic (dead) or devitalized tissue. Exudate is drainage due to inflammation or injury. A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. The findings included: Resident #50 was completely dependent on the staff for care, comfort and safety due to her end-stage dementia. Review of the medical record revealed a nurse's note dated 09/10/14 stating that the resident's left ankle was bruised, swollen and painful when touched. The Nurse Practitioner (NP) #4 was notified and ordered an x-ray of the left ankle and foot on 09/10/14. The initial report indicated no fracture was seen but due to the resident's symptoms of pain, swelling and bruising, NP #4 ordered a repeat x-ray on 09/11/14. Review of the x-ray done on 09/11/14 revealed a [MEDICAL CONDITION] ankle. Review of the medical record revealed that nurse #3 notified NP #4 of the x-ray results at 3:00 AM on 09/12/14. NP #4 ordered the following treatment: 1. Brace left leg and keep immobilized, 2. Nonweight bearing on the left leg, and 3. Monitor and check circulation, pulse and capillary refill (to monitor blood flow to tissues) on left toes and foot. Further review of the medical record revealed that NP #4 was in to examine the resident on 09/12/14. Review of the NP's note dated 09/12/14 revealed no assessment of the resident's fractured leg. Review of the NP's note did reveal a notation that the resident's leg was immobilized with a soft splint. On 09/12/14, NP #4 ordered "therapy to evaluate for immobilizer left ankle and chair seating." Review of the medical record revealed a Physical Therapy (PT) clarification order dated 09/12/14 for: PT 3-5 times a week for therapeutic activities, wheelchair and bed positioning and assessment of appropriate positioning devices for comfort and safety; establish and implement a functional maintenance plan for wheelchair and bed positioning. Further review of the orders revealed no order for nursing to unwrap the splint to monitor the resident's skin for changes. Review of the PT notes revealed that on 09/15/14 an air cast was ordered for the resident's left ankle. The medical record revealed an order written [REDACTED]." Again, NP #4 did not assess the resident's fractured leg or assess the adequacy of the temporary splint. Review of a PT note dated 09/16/14 revealed, "Patient found resting in wheelchair. Removed ACE wrap and cushioning prior to air cast fitting...left lateral lower leg presented with skin integrity impairment..." Review of the medical record revealed a nurse's noted dated 09/16/14 stating, "...wound nurse evaluating left lower extremity after immobilizer was removed by PT." Review of the Skin Integrity Report revealed two areas of painful DTI (deep tissue injury) identified on 09/16/14 after the "temporary" splint was removed: 1. dark purple area measuring 8cm (3 inches) long and 1.5 cm (half inch) wide with an intact blood blister; and 2. dark purple area measuring 5cm (2 inches) long and 2.5cm (1 inch) wide with an intact blister. Upon notification of the deep tissue injury to the resident's leg on 09/16/14, NP #4 ordered a mediBoot (a soft cushioned brace) to the left ankle and to remove the mediBoot to check the skin and circulation every shift. A physician progress notes [REDACTED]. She was put in a makeshift "splint" by nursing on 9/12 until therapy could see her later that day and stabilize her fracture with a more appropriate brace. Apparently PT didn't see her and this "splint" wasn't removed x 5 days and now she has skin injuries to her lower leg...left lower leg superior lesion-linear dark purple ecchymosis skin intact 8 x 1.5 - inferior lesion linear dark purple ecchymosis with overlying intact blister 5 x 2.5 older areas of bruising to ankle and foot secondary to fracture." During an interview on 10/30/14 at 1:00 PM with nurse #3 she reported, "when NP #4 told me to immobilize the resident's leg I went to the therapy gym and found what was available to splint the leg. I told the Nurse Practitioner that a type of "bubble wrap" was available. I told her I covered the "bubble wrap" in a pillow case, wrapped it around the resident's ankle and leg and held it in place with an ACE wrap from mid foot to mid calf. I left the resident's toes exposed so that we could check the circulation of her foot." During this interview with nurse #3, the Director of Nursing brought in a piece of the bubble wrap to show the survey team. The bubble wrap consisted of rectangular shaped air pockets In an interview with Physical Therapy Assistant (PTA) #7 on 10/30/14 at 1:20 PM, he/she reported that on 09/12/14, "I was instructed to assess for a more appropriate immobilizer but was told by the nursing staff that NP #4 did not want the temporary splint removed." Interview with NP #4 on 10/30/14 at 1:30 PM revealed that she did not remove the temporary splint to assess the resident's fractured leg or the adequacy of the temporary splint on 09/12/14. NP #4 stated, "I stepped out of the picture because PT (Physical Therapy) was to assess for a more appropriate method of immobilization."