Every finding on record at Countryview Nursing & Rehabilitation

Based on observations, interviews, and record review, the facility failed to ensure residents were free from abuse for 1 (Resident #7) of 6 Residents reviewed for abuse.The facility failed to protect Resident #7 from verbal abuse when Resident #16 made mocking statements and gestures regarding Resident #7's personal hygiene, the Administrator, LVN B, DON and Social Worker were aware of the verbal abuse. The verbal abuse led to Resident #7 being fearful, avoiding Resident #16 and Resident #7's withdrawal from former social patterns in refusing to go to the dining room and activities. An IJ was identified on 08/14/25. The IJ template was provided to the facility on [DATE] at 10:13AM. While the IJ was removed on 08/15/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of RemovalThis failure could result in residents becoming fearful, refusing to go to the dining room, or participate in activities.Findings included: Record review of Resident #7's face sheet, dated 05/28/25, reflected the resident was a [AGE] year-old male, who admitted [DATE] with diagnoses of paranoid schizophrenia (a chronic mental health condition characterized by disruptions in thought, perception, and behavior). Record review of Resident #7's MDS dated [DATE] revealed he had a BIMS score of 10 indicating he had moderate cognitive impairment. Record review of Residents #7's care plan dated 4/23/2025 revealed he was on antipsychotic medications for diagnosis of paranoid schizophrenia. Interventions included administration of medication as ordered.Record review of Resident #16's face sheet, dated 08/01/25, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of depressive, dementia with other behavioral episodes.Record review of Resident# 16's MDS, dated [DATE], revealed he had a BIMS score of 6 indicating severe cognitive impairment.Record review of Resident #16's care plan, dated 08/19/24 and revised 08/12/25, revealed the resident had potential to demonstrate verbally abusive behavior, ineffective coping skills, and yelled loudly at staff, and called them names. Interventions included providing positive feedback for good behavior, assessing, and anticipating the resident's needs. During an interview on 08/12/25 at 12:30PM, Resident# 7 revealed he was scared of what Resident #16 would do to him based on past incidents when Resident #16 pinched his nose, yelled Resident #7 smelled, and followed him around.During an observation on 08/12/2025 at 12:30PM, it revealed the two resident room (Resident #7 and Resident #16) were in proximity/on the same hall/next door to one another. Resident #7 was well groomed, no body odor, or other smells noted. In an interview on 08/12/25 at 12:33PM Administrator revealed he was aware of a previous incident when Resident #7 reported to him Resident #16 said Resident#7 smelled. The administrator stated that he notified the social worker, and the social worker spoke to Resident #7 and Resident #16, and everything seemed to be okay. In an interview on 08/12/2025 at 4:45PM LVN B revealed that Resident #16 and Resident #7 did not like each other. LVN B stated that Resident #16 was the aggressor, he said mean things to people, especially the staff. Resident #7 kept to himself and avoided Resident #16. LVN B stated that he had been in serviced on abuse and neglect. He said the last in service was last pay day on 08/12/2025. He stated that the administrator and the DON were aware of the two Residents not getting along. In an interview on 08/12/25 at 2:58PM the DON revealed she was aware of an incident where that Regional nurse notified the DON that Resident #7 verbalized Resident#16 was holding his own nose yelling that Resident #7 smelled. The DON stated that she spoke with Resident #7 and Resident #16. The DON stated that Resident #16 denied the incident, and Resident #7 acted like nothing happened. No further interventions were implemented. Record review of Grievance, progress notes, social services notes for the dates of 04/01/25 through 08/15/25 reflected no documentation of the incident and interventions for Resident #7 or Resident #16.In an interview on 08/13/2025 at 11:20AM Social Worker revealed a few weeks ago, the Administrator notified her that Resident #7 reported that Resident #16 told Resident #7 that Resident #7 smelled. The Social Worker stated that she spoke with Resident #16 about him being mean to other residents and he denied it, but Resident #7 said that it did happen. Social Worker stated that she talked to both parties and Resident #7 said he was satisfied that she had talked to Resident #16. Social Worker stated that there was not follow up because it was just a passing conversation, and she did not realize that it was going to be a major issue. Social Worker stated Resident #7 was upset enough to bring it up. Social Worker stated that Resident #7 did not appear to have any psychosocial effects, but he must have been upset enough to report it to the administrator'. Social Worker stated that Resident #7's base line was that he got upset sometimes and he was on psych services. Social Worker stated that on 08/13/2025 the administrator notified her that the same issue came up at breakfast. Social Worker stated that the administrator told her that Resident #16 told Resident #7 that Resident #7 smelled. Social Worker stated that when she spoke to Resident #16, he told her he yelled that he spilled his coffee. Resident #7 said that it did happen, that Resident#16 yelled at him that he smelled. Social Worker stated that Resident #7 and Resident#16 were separated. Social Worker stated that after Resident #7 calmed down, Resident #7 was brought back to breakfast. Social Worker stated she documented the incident in EMR. Social Worker stated the facility moved Resident #16 to another hall Social Worker stated she had made a referral for Psych to evaluate both Resident #7 and Resident #16. Social Worker stated that Resident #16 had been discharged for counselling services, but she was going to restart counselling services. No psychosocial assessments done on him. Social Worker stated that Resident #16 was known to have verbal aggression.In an interview on 08/13/2025 at 3:23PM LVN A, revealed that before breakfast Resident #7 refused to go to the dining room when he saw Resident #16 was in the dining room. Resident #7 agreed to go to the dining room if LVN A was going to be in the dining room. LVN A stated at breakfast on 08/13/25, Resident#16 was holding his nose and yelling at Resident #7 stating that Resident #7 smelled. LVN A separated Resident #7 and Resident #16 and then reported to the administrator. She stated that Resident#16 had been moved to a different hall. LVN A stated Resident #16 always bothered Resident #7 and Resident #7 did not like going anywhere close to Resident #16. She stated that she mentioned to the administration before and that most of the staff were aware that the two residents did not get along. She stated that she had been in serviced on abuse and neglect and that was the reason that she reported the incident at breakfast as soon as it happened,In an interview on 08/13/2025 at 4:20 PM Physician revealed he was not aware of any previous Resident to Resident altercation between Resident #7 and Resident #16. He stated that he was notified by the DON on 08/13/2025 that Resident #16 was verbally aggressive to Resident #7 was reportable. The physician stated that if Resident #7 was upset when Resident#16 yelled that Resident#7 stinks then it was verbal abuse. The physician stated that the NP had a better understanding of the Residents. He stated he was notified that the facility had made plans to ensure that Resident#7 felt safe and had moved Resident#16 to a different hall. An interview was attempted 08/13/2025 at 4:30PM with NP Q but was unsuccessful, a voicemail was left with call back number.In an interview on 08/13/2025 at 3:45PM Activity Director, revealed that Resident #7 refused to attend activities when Resident #16 was in attendance because Resident #7 did not want to be in the same space with Resident #16. The activity Director stated that she thought Resident #7 and Resident #16 did not like each other. She stated that she had been in serviced on abuse and neglect on 08/13/2025.In an interview on 08/13/2025 at 6:51PM NP Q revealed that the DON and NP R had told them that the surveyors had inquired about changing Residents # 7s psych medication. NP Q stated that she did not agree to changes to Resident #7s medication because of his diagnosis of schizophrenia. NP Q stated she was concerned that it was the first time she was notified about verbal aggression by Resident #16 to Resident #7. The NP stated that she had known Resident #7 for almost 10 yrs and when she was at the facility Resident #7 always talked to her about what his fears were but had not mentioned Resident #16's verbal aggression. The NP Q stated she had tried to keep Resident #7 on minimum medications to control his paranoia. The NP stated that she was concerned at the number of staff that were aware Resident #7 verbalized verbal aggression from Resident #16 with no interventions. The NP stated that Resident #16 was mean and it would not surprise her that Resident #16 would be verbally aggressive to Resident #7. She stated that verbal aggression could affect Resident #7 psychologically because Resident #7 got fixated on things and he would be fixated on the verbal aggression for a long time. She was concerned the residents' rooms were close to each other. She verbalized the facility should ensure there was no contact between Resident #7 and Resident #16. She stated the staff should be aware to redirect both Residents to avoid them coming into close contact with each other. She stated that she would visit with Resident #7 to assess and give him an opportunity to vent.Record review of the facility policy of undated Abuse/ Neglect revealed: The Resident has the right to be free from abuse, neglect, misappropriation of Resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the Resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other Residents, consultants or volunteers, staff of other agencies serving the Resident, family members or legal guardians, friends, or other individuals.An IT was identified on 08/14/25. The IT template was provided to Administrator on 08/14/25 at 10:13 AM and a plan of removal was requested. The plan of removal was accepted 08/14/25 at 5:36 PM. The plan of removal reflected the following: Resident #16 was placed on 1:1 supervision by facility staff. The Administrator is responsible for ensuring Resident #16 remains on 1:1 until Resident is not exhibiting verbal behaviors. Admin/DON will be responsible for ensuring Resident #16 remains on 1:1 supervision as evidenced by documentation on 1:1 form as well as progress notes in [EMR]. Resident #16 will remain on 1:1 supervision until no signs of verbal behaviors are exhibited and the Resident is cleared to step down 1:1 supervision by the attending physician. The facility staff will be designated by the Admin/DON. The physician will provide the 1:1 discharge order when deemed safe. Completed 8/14/25. Resident #7 and Resident #16 were referred to and evaluated by psychological services on 8/13/25. Psych evaluation was completed for Resident #16 and Resident #7 by Senior Psych NP, NP [NAME] on 8/13/25. Resident #7's evaluation shows no concerns or lasting effects at this time. Follow up for Resident #7 will be weekly or as needed by the Senior Psych NP. Resident #16's evaluation shows no concerns or lasting effects at this time. Follow up for Resident #16 will be weekly or as needed by Senior Psych NP. Completed by 8/14/25. The facility social worker interviewed Resident #7 and Resident #16 and completed a trauma informed care assessment, and no new trauma was identified. Social services will visit Resident #7 and Resident #16 for 1-2 times weekly to rule out emotional distress for 4 weeks and on-going as needed. A head-to-toe skin assessment was completed on Resident #7 on 8/13/25 by the Charge Nurse. No signs of injuries were noted. Completed; reviewed on 8/14/25. All Residents in the facility who can be interviewed were interviewed by the social worker for any further allegations of abuse on 8/13/25 and reviewed 8/14/25. No additional allegations were noted. The DON reviewed all safe surveys that were completed by the SW. Completed; reviewed on 8/14/25. All Residents in the facility who are not interview able, will have a head-to-toe assessment completed for any signs of abuse by the DON/ADON/ Charge Nurse. No signs of injuries were noted. Completed; reviewed on 8/14/25. The Administrator and DON were in-serviced 1:1 on the following in-services by the Divisional Director of Clinical Services. Completed; reviewed on 8/14/25.oAbuse and Neglect Policy by the Divisional Director of Clinical Services on 8/13/25. The in-service included reporting immediately to the Abuse Coordinator (Admin) for all allegations of abuse and neglect. The alleged perpetrator will be placed on 1:1 immediately pending investigation. A thorough investigation will be conducted for all allegations of abuse and neglect including verbal abuse. Examples of verbal abuse include yelling and chastising a Resident that causes emotional distress or fear.oTrauma Informed Care Policy- The facility will ensure that Residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for Residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the Residents. The interventions will be added to the care plan and available in the POC Kardex. A trauma informed assessment will be completed upon admission based on the past history of trauma that is disclosed on the social history assessment. A trauma informed assessment will also be completed PRN when a Resident is involved in a traumatic event. The assessment will be completed by the social worker or designee. This will begin 8/14/25 and will continue indefinitely. oResident Rights Residents have the right to be free from abuse and neglect, including verbal abuse from other Residents. All allegations of verbal abuse should be reported and investigated immediately by Abuse Coordinator (Administrator) with appropriate interventions in place. oDocumentation Policy: The charge nurse or SW will document in the progress note any Resident-to-Resident behaviors or allegations of abuse after it is reported to Abuse Coordinator/Administrator. Completed 8/14/24. The Medical Director was notified of the immediate Threat situation on 8/14/25 by the Administrator. An ADHOC QAPI meeting was completed with the QA committee to include the Medical Director on 8/14/25 to discuss immediate Threat and the plan of removal. The following in-services were initiated by the DON and Regional Compliance Nurse for all staff. All staff not present beginning 8/13/25 and reviewed on 8/14/25 will be in-serviced prior to the start of their next shift. All new hires will be in-serviced during orientation. All agency staff will in serviced prior to the start of their shift. No staff will be allowed to work until they have been in-service. Completion date will be 8/14/25.oAbuse and Neglect Policy The in-service included reporting guidelines (2hrs) for all allegations of abuse and neglect including verbal abuse. The alleged perpetrator will be placed on 1:1 immediately pending investigation. A thorough investigation will be conducted for all allegations of abuse and neglect including verbal abuse. Examples of verbal abuse includes yelling and chastising a Resident that causes emotional distress or fear. oTrauma Informed Care Policy- The facility will ensure that Residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for Residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the Residents.Monitoring of the facility's Plan of Removal included the following:Interviews with the following staff from 08/15/25 at 06:56 AM to 3:04 PM who worked all shifts and all days of the week revealed they had been in-serviced on abuse and neglect, Residents Rights, and Trauma informed training: LVN A, LVN B, RN C, CNA D, CNA E, LVN F, LVN G , PTA CNA H, CNA I, RN J, LVN K, LVN L, CNA P, NP Q, , Laundry Aide, housekeeping N, housekeeping O, DON, Business office Manager, Dietary Manager, Maintenance Supervisor, Social Services Licensed, and, the Administrator.Record review of a QAPI Agenda, dated 08/14/25, reflected Administrator, MD, and DON were in attendance. Record reviews reflected that on 8/14/25, the Administrator and DON were in-serviced 1:1 by the Divisional Director of Clinical Services, on the following in-services: Abuse and Neglect Policy, Trauma Informed Care Policy, Resident Rights, Documentation Policy.Record review of in-service sign in sheets, dated 08/13/25, revised 08/14/2025 titled Abuse and Neglect reflected both the DON and Administrator had signed.Record review of Abuse and Neglect policy in-service dated 08/13/25 revised 08/14/2025, reflected 52 staff had been in-serviced. Record review of Trauma Informed policy in-service, dated 08/13/2025 revised on 08/14/25-08/15/2025, reflected 52 staff had been in-serviced.Record review of Residents Rights in-service, dated 08/13/25 revised 08/14/2025 reflected 52 staff had been in-serviced.In an interview on 8/13/2025 at 2:25PM the Administrator revealed that LVN A reported that Resident #16 was holding his nose and told Resident #7 that he smelled. The administrator stated that he was near the dining room, but he did not hear anything. The administrator stated that when he started to investigate Resident #16 stated that he yelled because he got coffee on his clothes. The administrator stated that Resident #7 was fine his only concern was that he was fearful that the state was going to kick him out of the facility. The administrator stated that resident #7 stated that he felt safe and comfortable at the facility, but he was not sure what Resident #16 might do. The administrator stated that he called the cooperate office because once Resident #7 stated that he was fearful the facility had to intervene and make sure he was safe. He stated that Resident #16 was moved to a different hall. He stated that he was reporting the allegation to the state and the facility was meeting the Resident #16's family to discuss finding him a different placement. The administrator stated that psychiatric practitioner had seen both resident and Resident #7 was at his baseline with no psychosocial problems identified.In an interview on 8/15/2025 at 1:34PM with the DON revealed that Resident #16 was in a different hall from Resident #7. She stated that in services on abuse and neglect, Residents rights, and Trauma in formed training were started on 08/13/2025 and revised on 8/14/2025. The in services will continue until all staff have been interviews and no staff will be allowed to start a shift before being in serviced. She stated that staff is aware to make sure that Resident#7 and Resident#16 do not come into close contact. She stated that the facility was trying to find placements for Resident #16 and the family had already been notified. In an interview on 8/15/2025 at 11:30AM Divisional Director of Clinical Services revealed that she was notified by the administrator on 08/12/2025 that Resident #7 had reported that Resident #16 had been verbally aggressive with him. She was again notified of the incident at breakfast on 8/13/2025 that was reported by the LVN A that Resident #16 was holding his nose telling Resident #7 that he smelled. She stated that the facility implemented interventions and moved Resident #16 to a different hall to ensure that Resident #16 and Resident #7 do not come in close contact. She stated that Resident #16 was placed on 1:1 monitoring. She stated that LVN F did a head-to-toe assessment on Resident #7. She stated that the social worker did psychiatric referral for both Resident #7 and Resident #16. Safe surveys were done on all residents and all residents verbalized that they felt safe at the facility. She stated that residents that were not interviewed had skin assessments completed. She stated that in serviced on abuse and neglect, residents right, Trauma informed were initiated and all staff must compete the in-service before returning to their next shift. She stated that she in-service the DON and the administrator on abuse and neglect, trauma informed, residents rights and documentation policies.Record Revies of nurse notes dated 08/13/2025 at 7:30 AM reflected Resident #7 was in DR this morning getting ready to eat breakfast when another Resident started yelling at him and holding his nose telling Resident he stinks. Resident states he is concerned about going in DR when the other Resident is in there. I (LVN A) explained to Resident #7 that as long as am in the DR he has nothing to worry about and then will go eat. Made Administrator aware of the situation this morning. The Adm went and SW the Resident along with SS . This entry was written by LVN ARecord review of Social Service Note dated 08/13/2025 7:40 AM reflected Note Text: LMSW was alerted at beginning of work shift regarding concern of previous verbal altercation between two Residents. LMSW recalled initial incident but was unable to substantiate initial occurrence at the time, where Resident one told [Resident #7] that he had odor emitting from his person. At that time, LMSW had spoken with other Resident, who did not confirm incident and wrapped up conversation, advising Resident one to be cognizant of other's feelings, which other Resident acknowledged. This morning at approximately, 07:20 hours, LMSW was alerted that other Resident was being rude to [Resident #7] in dining room. LMSW approached said Resident, who advised loudly (as he his hard of hearing) that he yelled because he spilled his coffee. LMSW then spoke with [Resident #7] who advised the other Resident was yelling at him because he 'stunk' LMSW advised [Resident #7] that she would speak with other Resident again and discuss utilizing kindness with others at facility. [Resident #7] acknowledged solution. LMSW also contacted NP R from Senior Psych Services via telephone updating her on incident. NP R advised she is en route to facility and would speak to both parties. LMSW will continue to follow up with both Residents to ensure comfortable setting for both parties. this entry was written by social worker.An observation on 8/13/2025 at 4PM revealed Resident #16 was on 1:1 supervision with staff on the 600 hall.In an interview on 8/13/2025 at 2:30PM with Resident #7 he thanked the surveyor and stated that Resident #16 had not bothered him since the surveyors intervened.In an interview on 8/14/2025 at 10:38AM NP Q revealed that she was notified of the Immediate Threat, and she stated that the facility had put sufficient interventions to ensure Resident #7 and other Residents remain safe from abuse. She stated that she had been informed by the social worker that they were sending referrals to find Resident #16 placement in another facility. Record review of Resident #7's Weekly Skin Assessment notes dated 08/13/2025 at 3:48 PM reflected Note Text : Skin Color: Normal, Temperature of skin: Warm. Bruise present: No, Skin Tear Present: No, Abrasion present: No, Laceration present: No, Surgical incision present: No, Rash present: No, Moisture Associated Skin Damage present: No, Pressure, venous, arterial, or diabetic ulcer present: No., Other skin findings present: Yes. Other skin findings: Birthmark on L upper arm. This entry was written by LVN F Record review of Resident #7's of Trauma Informed Assessment notes dated 08/13/2025 3:48 PM Note Text: Has a previously documented diagnosis of Mental Disorder. Have a diagnosis of PTSD: No Experiences: Reports no known negative experiences. Has the Resident been in a situation that was extremely frightening: No Has the Resident witnessed any extremely frightening situations: No Does or has the Resident have a close relationship with someone who experienced any extremely frightening situations: No this entry was written by the social worker.Record review of Resident#16 Psychiatric notes dates 08/13/2025 revealed that (Resident#16 name) is being seen today at the request of the [nursing facility] [social worker] and [DON]. He is seen in his room sitting up on the side of the bed. He has significant hearing loss, and his speech is difficult to understand at time. Some questions are asked by the provider writing down, letting the patient read the questions and the allowing the patient to answer the questions. He says he is doing pretty good and denies any concerns at this time. He reports a good appetite and sleeping well. He denies any physical or verbal aggression towards anyone, and he says he gets along well with others. Staff report the patient told another Resident that he smelled bad. [Resident# 16] admits to holding his nose when another Resident walked by him but denies telling him he smelled bad. He says the other Resident has not showered in 30 days. Discussed actions that can be perceived by others as hurtful, such as holding one's nose when someone walks by, and other alternative actions that can be taken to remove oneself from displeasing odors. Patient v/u and states, I'll be nice and agrees to quietly remove himself from odorous areas. HE denies any problems with depression, sadness, anxiety, or anger. He denies any AVH or SI/HI. this note was written by NP R.Record review of Resident #7's psychiatric notes dated 08/13/2025 revealed that [Residents#7] is being seen today at the request on [DON] and the facility [social worker]. The patient is seen ambulating in his room. He is pleasant and consents to the interview but presents with increase paranoia. The patient often exhibits increased paranoia with any changes in his normal routines and /or schedule. The reports that earlier, another Resident made fun of him and told him he smelled bad Staff report interventions have been put into place to provide space for both parties. discussed their interventions with [Resident#7] who voices appreciation having a good appetite and says he is sleeping well. He denies any AVH or SI/HI.Record review of Residents#7 psychiatric notes dated 08/13/2025 revealed- [Resident#7] is being seen today for a second time due to the request of [DON] of the facility . [DON] reports that the patients were seen by this provider and made statements of being fearful of another Resident. He is seen via audio and video conference with assistance of [DON]. Resident #7 is please and eager to engage. He consents to audio interviewing. He sates he is doing pretty good and says he is not fearful at this time. he states the staff at Country View make him feel safe and treat him well. He reports having times of being fearful of another Resident in the facility. He states the Resident in question has never physically or verbally threatened him. when asked why he is fearful of the Resident he states, because he I'm afraid he is going to come get me. Again, the patient is asked if the Resident in questions has ever verbally threatened him or been physically aggressive towards him. [Resident#7] responds No. Discussed the Resident in question moved to a different hall away from [Resident#7] and being wheelchair bound reminded patient that he [Resident#7] is ambulatory and can quickly get staff member if he feels threatened or fearful patient v/u and agrees to get a staff member when or if he feels fearful to threatened. Again, the Resident stated that the Resident in question has never been physically or verbally aggressive towards him. [Resident#7] has a long history of paranoia schizophrenia with mild paranoia being the patient's baseline. The patient is well managed under current treatment regimen and is able to function well with steady routine. Patient exhibits increased paranoia with any changed in routine such as state surveyors being in the building or changed in administration. In the past the patient returns to his normal baseline of paranoia, the patient responds well to active listening to his concerns addressing his concerns and therapeutic communication. An interview was attempted on 08/15/2025 at 11:24 AM to interview MD was unsuccessful his office was closed.An IT was identified on 08/14/25. The IT template was provided to the facility on [DATE] at 10:13 AM. While the IT was removed on 08/15/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on observations, interviews, and record review, the facility failed to notify residents or their representatives on how to file a grievance or complaint in an anonymous manner for The facility failed to notify residents or their representatives either individually or through prominent postings throughout the facility on how to file a grievance or complaint in an anonymous manner for 1 of 1 facilities reviewed. This failure could place residents at risk of not filing a grievance without the fear of discrimination, reprisal, retribution, and their right to anonymously file their grievance. Findings included:Interview on 08/12/2025 at 2:00PM with six residents during the confidential Resident Council revealed the residents were unaware where grievance forms were located. The residents stated that they did not know how to anonymously file a grievance.Observation of the common areas throughout the facility on 08/12/25 at 2:45PM revealed no grievance forms or a container to place the grievances. Interview on 08/13/25 at 6:20PM, the Activities Director said if anyone wanted to fill out a grievance they go to the Activities Director to get a form. Activities Director revealed she was not sure where else the residents would get a grievance form because she had the forms. The Activities Director revealed if a resident was able to get ahold of a grievance form and wanted to turn it in, they could turn it into the head nurse, same if the Activities Director was not on-site. Activities Director revealed if the resident could not fill out a grievance it would cause mental issues for the resident. Interview on 08/15/2025 at 10:45am with the DON revealed grievances are filled out in the EMR. The Activities Director distributed forms to residents and assisted to fill out the form, if needed. The Activities Directed gave the completed grievance forms to staff, unspecified, to enter in the electronic medical records. The DON revealed she did not know who specifically the Grievance Official was at the facility. DON revealed she was sure where and how to turn in grievances . Review of the facility's policy titled, Grievances dated 11/2/2016 revealed, Procedure1. The facility will notify residents on how to file a grievance orally, in writing, or anonymouslywith postings in prominent locations.2. The grievance official of this facility is the administrator or their designee. The grievance official will: Oversee the grievance process Receive and track grievances to their conclusionReview of the Resident's Rights subsection Grievances revealed, The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The facility must make information on how to file a grievance or complaint available to the resident.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed.The facility failed to ensure that 1 of 1 dented can was removed from the rack in the dry pantry areaThe facility failed to ensure that Dietary X properly used hair restraints during food preparation. This failure could place residents at risk for food exposed to adulteration or potential contaminants.Findings Included:Observation and interview on 08/12/25 at 9:15 AM, the Dietary Manager stated she had been employed at the facility for four years. The initial tour of the kitchen revealed that in the dry storage area 1 of 1 dented can on the rack with the other canned items, instead of in the area labeled as Dented Cans Only, do not use. Dietary Manager indicated the dented cans were used first. The Dietary Manager repeated a second time what was said about the use of the dented cans. During interview with the Dietary Manager on 08/15/2025 at 2:51pm in the dining room she stated she moved the dented can to a separate location away from the other cans for to be returned to the distributor. Dietary X had been observed on 8/15/25 at 2:57pm not properly using the hair restraint to cover all hair during food preparation. Dietary Manager stated on 8/15/25 at 2:57pm if someone ingested food that had been contaminated, there was a risk they could get an airborne illness and potentially cause harm and sickness. Interview with the Dietary [NAME] on 08/15/2025 at 3:00pm revealed dented food cans had a specific place in the corner and cannot be used but would be returned to the distributer. The Dietary [NAME] revealed dented food cans were not used due to cracks, leaking food, air or insects entering the can, possibly causing harm due to ingesting metal from the can, increase medical issues, possible internal micro cuts, and food poisoning. The Dietary [NAME] stated without the proper use of hair restraints, risks of biological contaminants (the presence of harmful biological agents, such as bacteria, viruses, fungi, parasites, or animal dander, in food, water, air, or on surfaces, which can cause disease, allergic reactions, or pose a risk to health and safety) with the harm of making a resident sick, especially if they already had a compromised immune system along with the overall decline of the quality of the food. Record review of the facilities policy titled Food Storage and Supplies, dated 2012 does not address dented cans. Review of U.S Department of Health and Human Services Food Code, dated 2017, revealed, 3-202.15 Package Integrity reflected: Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants.Review on 8/15/25 at 3:55pm of the U.S. Public Health Service Food Code dated 2017 reflected: .3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (7) Storing damaged, spoiled, or recalled food being held in the food establishment as specified under S 6-404.11; .

Based on observations, interviews, and record reviews the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for one medication cart (600 hall) of the facility's two medication carts reviewed for medication storage. The facility failed to ensure that opened insulin pens,1) Lantus 100 unit/ml and 2) Insulin pro 100units/ml were properly labeled and dated before storing in the 600-hall medication cart. This failure could place resident at risk by diminishing the effectiveness, and therapeutic benefits of the medications and/or result in medication error by giving the wrong resident the wrong insulin.The findings included:Observation on [DATE] at 11:03 AM with LVN B on the 600-hallway's medication cart revealed opened insulin pens: 1. Lantus 100 unit/ml and 2. Insulin pro 100 units/ml that had no patients' labels, and no dates indicating when the insulins were open.In an interview on [DATE] at 11:05 AM with LVN B he stated the nurses were responsible for checking all insulin pens and vials had patient labels and open dates. LVN B stated he did not realize the opened insulin pens Lantus 100 unit/ml and insulin pro 100 units/ml did not have labels and open dates. He stated that it was important to date opened insulins because opened insulins expire after 28 days. LVN B stated that the risk to the resident was receiving expired insulin that could cause negative drug effects that could harm the resident. He stated that having insulin in the medication cart that did not have the proper label could result in administering insulin to the wrong resident which may result in hospitalization. He stated that he knew that he was supposed to check and ensure all medications were within date before administering to the residents. LVN B stated that he had been in-serviced on medication storage and dating all opened insulins by online training and the administration. He stated that he would remove the unlabeled and undated insulin from the cart immediately.An interview on [DATE] at 1:47 PM with the DON, revealed that all insulin pens and vials should be labeled, and they should have an open date. She stated that it was the responsibility of every nurse to check the label and open date before administering insulin to a resident. The DON stated insulin was supposed to be dated because it expired 28 days after opening. She stated that failure to have open dates on insulin could result in administrating medication that was expired and could not be effective or that could have negative side effects to the resident. He stated the ADON audited the medication carts as needed, but there was not a set schedule. She stated that the pharmacist audited the medication carts monthly.Review of the facility policy PCU027 - Medication Storage in the Facility Policy reflected that: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to the procedures for medication.

Based on observation and interview, and record review, the facility failed to maintain an environment as free of accident hazards as is possible for 3 of 3 areas (1 shower room, and 1 wooden cabinet inside of the shower room and exterior/interior front door), reviewed for accidents and hazards. 1. The facility failed to ensure that the exterior door to the Shower Room in the facility's Secured Unit was locked and secured.2. The facility failed to ensure that the Master lock on the wooden cabinet inside the Shower Room in the facility's Secured Unit was locked and secured.3. The facility failed to ensure that Resident #7 was supervised and did not have access to the Nurses Station and access the red button to open the front door. These failures could place residents at risk of accidents, injury, elopement, and consuming hazardous products. Findings Include:Record review of Resident #7's admission face sheet dated 08/13/25 reflected he was a [AGE] year-old male was originally admitted to the facility on [DATE] and readmitted on [DATE] with active diagnoses that included: paranoid schizophrenia, hallucinations, psychotic disorder without hallucinations due to known physiological condition, brief psychotic disorder, major depressive disorder, single episode (unspecified), anxiety, unspecified intellectual disabilities, mild intellectual disabilities, and unspecified symptoms and signs involving cognitive functions and awareness . Record review of Resident #7's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 11 indicating that he had moderate cognitive impairment. Resident #7's MDS Assessment reflected that he had active diagnoses of anxiety, psychotic disorder, and schizophrenia. Resident #7 was prescribed narcotic medications for antipsychotic (type of drug used to treat symptoms of psychosis), antidepressant (prescription medicines to treat depression), and anticonvulsant (medication used to prevent or control seizures). Record review of Resident #7's Care Plan dated 03/26/2025 reflected, Focus:[Resident #7] has ID and is PASRR positive.Date Initiated: 04/08/2021Revision on: 07/17/2025Focus:[Resident #7] has episodes of delirium where he believes the FBI, space crafts, or other bizarre things are happening to him.Date Initiated: 04/15/2021Revision on: 04/01/2024Focus:[Resident #7] often believes that the state will take him away, that the facility management are wanting to get rid of him, or that workers here at the facility no longer like him. At times he is easily redirected with positive redirection but there's times that this belief is firmly held until resident has forgotten the subject.Date Initiated: 06/29/2022Revision on: 07/05/2022Focus:[Resident #7] has a dx of intellectual disability.Date Initiated: 09/09/2022Revision on: 09/09/2022Focus: [Resident #7] has impaired visual function d/t cataracts.Date Initiated: 03/02/2022Revision on: 09/09/2022Focus:[Resident #7] has mood problem r/t Disease Process schizophrenia.Date Initiated: 07/15/2025Revision on: 07/15/2025Focus:[Resident #7] has a dx of depression.Date Initiated: 09/09/2022Revision on: 04/23/2024Focus:[Resident #7] wanders aimlessly. Does not attempt or want to leave facility. [Resident #7] likes to sit in chairs in front of the facility outdoors, will walk to side of building where he keeps cans. [Resident #7] educated that if he does choose to leave the property to notify nurses.Date Initiated: 06/03/2021Revision on: 04/19/2023Focus:[Resident #7] is resistive to care r/t psych dx.Date Initiated: 06/04/2021Revision on: 07/26/2022 Focus:[Resident #7] is making verbal threats. Claims to take a roll of quarters and hit Someone.Date Initiated: 11/22/2022Revision on: 11/22/2022Focus:[Resident #7] needs out of room social, spiritual, and stimulus activities and mentalstimulation. [Resident #7] enjoys have small, odd jobs around the facility, such as helping clean, putting supplies away, ETC.Date Initiated: 04/22/2022Revision on: 04/27/2023Focus:[Resident #7] requires anti-psychotic medications for dx of paranoid schizophrenia.Date Initiated: 03/02/2021Revision on: 04/23/2024Focus:[Resident #7] requires antidepressant medication.Date Initiated: 11/03/2023Revision on: 11/03/2023Observation in the facility's Secured Unit on 08/12/25 at 10:50 AM, revealed the exterior door of the Shower Room was ajar and was unlocked and unsecured. The exterior door to the Shower Room had a touch pad lock. Upon entry into the Shower Room, there was a wooden cabinet with a Master Lock for a lock, but the lock was unsecured on the wooden cabinet. There was a key hanging from a chain beside the wooden cabinet that can be used to unlock the Master Lock on the wooden cabinet. Inside of the wooden cabinet were the following items: 1 open bottle of cleanser, one 128 fl. oz. container labeled, Spray Cleanser, 1 container of deodorant, 2 bottles of mouthwash, 1 unsealed package of twin-size razors, and 1 roll of toilet paper. On the top of the wooden cabinet, there was 1 gallon container labeled, Shampoo & Body Wash. On the floor there was 1 - 1 gallon container labeled, Shampoo & Body Wash. The storage rack contained several undergarments, towels, 2 bottles of mouthwash (1 bottle was open), 1 deodorant, 1 opened container of shaving cream, and 1 container of barrier cream.Observation on 08/12/25 at 11:15 AM revealed CNA M was playing bouncing ball with the residents in the Dining Hall. Observation in the facility's Secured Unit on 08/12/25 at 4:17 PM, revealed that the exterior door of the Shower Room was ajar, unlocked, and unsecured. The wooden cabinet inside of the Shower Room was unlocked and unsecured. On 08/12/25 at 11:36 AM attempts were made to interview the 6 residents in the Secured Unit but they were non-interviewable.Observation on 08/14/25 at 6:50 AM, 2 Surveyors arrived at the facility. There was no one observed at the Nurses Station and Resident #7 entered the Nurses Station and pressed the red button and the front door of the facility opened. Observation on 08/14/25 at 7:54 AM, 2 more Surveyors arrived at the facility. There was no one observed at the Nurses Station and Resident #7 entered the Nurses Station and pressed the red button and the front door of the facility opened. The Activities Director was observed in the Lobby of the facility doing activities with residents.Observation on 08/14/25 at 7:56 AM, revealed that there was no at the Nurses Station. There was a red button observed underneath a piece of paper. The red button was observed being used to open the front exterior doors at the facility. There was also a visitor standing outside of the facility with the surveyors and all parties entered the facility at the same time. In an interview with Resident #7 on 08/14/25 at 8:01 AM, revealed that he had been a resident at the facility for several years. Resident #7 said that he likes to help the staff at the facility by doing chores. Resident #7 said that his chores include picking up trash and emptying trash cans in the facility, which helps him stay busy. Resident #7 said that he had opened the front door for people several times and that staff told him that he was not supposed to enter the Nurses Station to press the button to open the door. Resident #7 said that he did not know why he opened the door for the surveyors earlier, he just wanted to make sure that the surveyors did not wait outside too long because the staff were busy. Resident #7 stated that he never opened the door to anyone dangerous.In an interview with the Social Worker on 08/14/25 at 8:15 AM, she stated that she had been employed at the facility for 1 year. The Social Worker stated that she was unaware that the exterior door to the Shower Room and the wooden cabinet inside of the Shower in the facility's Secured Unit were unlocked and unsecured during the surveyors observation. The Social Worker stated that during her walkthroughs and visits in the Secured Unit, the exterior door to the Shower Room was closed. The Social Worker stated that there was a risk for any resident that can gain access to the items in the Shower Room to ingest the fluids, and/or cut or harm themselves or others with the razors. She stated that she was aware that Resident #7 had opened the front door for staff/guests/visitors on a about 2-3 occasions. She stated that in the past when she observed Resident #7 walk behind the Nurses Station to open the front door, she would redirect him and tell him that he was not supposed to be the desk in the Nurses Station and press the red button to open the front door. She stated that she would tell [Resident #7] that only staff were permitted to behind the desk of the Nurses Station and told him that if anyone was outside and needed to be let inside, he should let staff know and someone would open the door for the visitors/guests. The Social Worker stated that she did not inform the Administrator or the DON about Resident #7 entering the Nurses Station and pressing the red button to open the front door for anyone standing outside the front door awaiting to enter the facility. She stated that she did not know why she did not notify the Administrator and DON about Resident #7 opening the front doors at the facility. She stated that Resident #7 liked to assist and help staff and he thought that him opening the front door for anyone at the front door was helping the staff. The Social Worker stated that there was a possible risk for danger to anyone inside of the building, if Resident #7 opens the front door to anyone who was not supposed to be in the building. In an interview with the Activities Director on 08/14/25 at 8:39 AM, she stated that she was unaware that the exterior door to the Shower Room and the wooden cabinet inside of the Shower in the facility's Secured Unit were unlocked and secured during the surveyors observation. The Activities Director stated that during her visits to the Secured Unit, the exterior door to the Shower Room was closed. She stated that she if she observed the exterior door to the Shower Room unlocked, open or unsecured she would close the door, notify the staff in the Secured Unit that the door was open and then she would notify the Administrator and DON. The Activities Director stated that if any residents have access to the Shower Room area, there are cleansers, shampoo and liquids in there that can be accidently ingested and could cause a resident to have stomach issues if that drank it. She stated that the razors in the Shower Room could be used by anyone to cut themselves, other residents or staff. The Activities Director stated that she was unaware that Resident #7 had opened the front door for 4 surveyors, and a visitor on 2 different times on 08/14/25. She stated that she was aware that Resident #7 had opened the front door for people in the past. She stated that she had told Resident #7 on a few occasions not to enter the Nurses Station and press the red button to open the front door for people awaiting to enter the building . She stated that in the past, she would redirect Resident #7 and educate him on not opening the door for people outside. The Activities Director stated that she did not inform other staff, including the DON and Administrator that Resident #7 had entered the Nurses Station and pressed the red button to open the front door for visitors. The Activities Director stated that she did not know why she did not inform her management team about Resident #7's behaviors. She stated that when Resident #7 opened the door for everyone awaiting to enter the building, there was a risk and a potential that he could let the wrong person or people in the building that could hurt or harm everyone in the building, which could cause people to be injured. In an interview with CNA S on 08/14/25 at 6:47 PM, revealed that she had been employed at the facility for 2 years. CNA S stated that she was unaware that the exterior door to the Shower Room and the wooden cabinet inside of the Shower in the facility's Secured Unit were unlocked and secured during the surveyors observation. CNA S stated that she had never observed both areas in the Secured Unit unlocked. CNA S stated that if she observed both areas unlocked and unsecured , she would immediately lock both areas and notify the DON about what she saw in both areas. CNA S stated that if the exterior door to the Shower Room was unlocked and unsecured, a resident or visitor could enter the area and have access to the restricted area, which was supposed to be locked. CNA S stated that if anyone had access to the unlocked Shower Room and the wooden cabinet inside of the Shower Room, they could accidently ingest some poisonous liquids, burn themselves with the liquid, and cut themselves with the razors. CNA S stated that if anyone ingests the hazardous liquids, such as the cleanser, it will cause them to have some health issues like stomach aches, injuries and damage to their bodies. In an interview with LVN T on 08/14/25 at 7:05 PM, revealed that she was unaware that the exterior door to the Shower Room and the wooden cabinet inside of the Shower in the facility's Secured Unit were unlocked and unsecured during the surveyors observation. LVN T stated that she had never observed both areas in the Secured Unit unlocked. LVN T stated that if she observed both areas unlocked and unsecured, she immediately would lock both areas and notify the DON and the Administrator about what she saw in both areas. LVN T stated that she would speak with staff that worked in the Secured Unit and inform them that everyone needed to keep both areas locked and unsecured at all times. LVN T stated that if the exterior door to the Shower Room was not secured and locked, anyone could have access to everything in the Shower Room. LVN T stated that the Shower Room area has cleansers, soaps, mouthwash and razors and there was a potential for anyone to hurt or harm themselves if they ingest the fluids and they can become sick. LVN T stated that which access to razors, someone could hurt or harm themselves or others. LVN T stated that she was unaware that Resident #7 entered the Nurses Station and opened the front door for the surveyors and the visitor. She stated that Resident #7 had been a resident at the facility for over 10 years. She stated that she did not think that he would open the front door to anyone he did not recognize to enter the facility. LVN T stated that Resident #7 gets bored and he collects soda cans and crushes them and keeps them in a bag to collect them. LVN T stated that Resident #7 is alert and had never observed him opening the front door for anyone to enter the facility. LVN T stated that there was security risk if Resident #7 opened the front door to the facility to allow anyone to enter the facility. LVN T stated that harm could be could if Resident #7 allows anyone into the facility. She stated that harm could be caused, but it was difficult to answer the question because Resident #7 is high functioning. LVN T stated that Resident #7 did not know the code at the front door to exit the facility. In an interview with the DON on 08/15/25 at 3:11 PM, she stated that she had been employed at the facility for 1 year. The DON stated that there are currently 6 residents in the Secured Unit. She stated that the facility recently opened the Secured Unit in July 2025. She stated that due to there being only 6 residents currently in the Secured Unit, there was only 1 CNA on duty every shift . The DON was advised of the surveyors observations in the Secured Unit. She stated that she was unaware that the exterior door to the Shower Room in the Secured Unit was unlocked and unsecured during the surveyors observation. She stated that her expectation for staff were to keep the exterior door to the Shower Room always closed due to there being shampoos, conditioners, cleansers, mouthwash, cleaning supplies and razors inside the Shower Room. The DON stated that she was unaware that the door to the wooden cabinet inside the Shower Room was also unlocked and unsecured during the surveyors observation. She stated that her expectation was the same as the exterior door to the Shower Room, both areas are to always be locked at always secured. She stated that both areas contained the same items and if a resident in the Secured Unit accidently wandered into the Shower Room, there was a risk for them to accidently ingest hazardous chemicals and could get sick. The DON stated that if a resident ingested any hazardous chemicals, they could become nauseated, have horrible vomiting episodes which could lead to potential harm. The DON stated that if a resident were to find some razors in the Shower Room and the wooden cabinet inside of the Shower Room, there was a potential for them to cut themselves, other residents, visitors, staff or anyone in the facility's Secured Unit which could be harmful. The DON stated that a resident in the Secured Unit were to touch some of the hazardous chemicals in the Shower Room, there was a potential for them to have a chemical burn or be allergic to the hazardous chemicals inside of the containers. The DON revealed that razors were to be kept in a secured area, which means they are to be always locked and never to be kept in an unlocked compartment. The DON stated that all staff are responsible for ensuring that doors and areas that are supposed to be locked at secured always. The DON stated that if staff observe a door that is unlocked and unsecured, her expectation is for her staff to immediately lock and secure the door and notify herself and the Administrator of their findings. The DON stated that she would immediately reeducate all staff on the dangers of leaving the exterior door and the wooden cabinet inside of the Secured Unit's Shower Room and all Shower Rooms locked and always secured. The DON stated that she was unaware that Resident #7 was observed by state surveyors on 2 separate times on 08/15/25 walking behind the Nurses Station and pressing the red button to open the front exterior doors of the facility to allow visitors/guests into the facility. The DON stated that Resident #7 likes to assist staff with tasks within the facility, but she did not know that he was opening the front doors of the facility for visitors/guests to enter the facility. The DON was advised that according to the Activities Director and the Social Worker, both have observed Resident #7 enter the Nurses Station and open the door for guests/visitors on several occasions but would redirect him not to open the doors front door for guests/visitors. The DON stated that both staff members have never notified her or the Administrator that Resident #7 had entered the Nurses Station to open the door for guests/visitors on several occasions. The DON stated that she would speak all staff in all departments and provide them with some In-Service Trainings on ensuring the safety of the residents and not allowing Resident #7 to have access to the Nurses Station and the red button to open the front door for guests/visitors. The DON stated that when Resident #7 opened the door to visitors/guests, there was a risk for someone to enter the facility that should not be in the facility to hurt and harm everyone in the facility. On 08/15/25 at 3:26 PM, an email was sent to the Administrator and DON requesting the facility's policies related to securing doors, locks, razor blade storage, cleaning supplies storage and accidents and hazards. In an interview with the DON on 08/15/2024 at 3:28 PM, the DON stated that the facility did not have any of the requested policies related to securing doors, locks, razor blade storage, cleaning supplies storage and accidents and hazards. In an interview with the Administrator on 08/15/2024 at 4:20 PM, he stated that he had been employed at the facility for 1 year. The Administrator was advised of the surveyors observations in the Secured Unit. He stated that he was unaware that the exterior door to the Shower Room in the Secured Unit was unlocked and secured during the surveyors observation. The Administrator stated that the exterior door to the Shower Room in the Secured Unit should always be locked and secured due to the items inside of the Shower Room, such as shampoos and cleansers. He stated that he was unaware that the wooden cabinet inside the Shower Room was also unlocked and secured and should be locked and secured always. The Administrator stated that he was unsure what items were inside of the wooden cabinet inside of the Shower Room. He stated that after the DON notified him about the exterior door to the Shower Room, he notified Maintenance and they would be repairing the door and the lock on the wooden cabinet inside of the shower room would be replaced. He stated that staff advised him that the door to the Shower Room is hard to close and he would be repairing both areas. The Administrator stated that there was a risk to anyone who has access to the items in the Shower Room area to ingest the chemicals. He stated that anyone who ingests chemicals and/or had access to razors, there was a potential that they can hurt or harm themselves. The Administrator stated that he was unaware that Resident #7 was observed by state surveyors on 2 separate times on 08/15/25 walking behind the Nurses Station and pressing the red button to open the front exterior doors of the facility to allow visitors/guests into the facility. The Administrator was advised that according to the Activities Director and the Social Worker, both have observed Resident #7 enter the Nurses Station and open the door for guests/visitors on several occasions but would redirect him not to open the doors front door for guests/visitors. The Administrator stated that both staff members had have never notified the DON or himself that Resident #7 had entered the Nurses Station to open the door for guests/visitors on several occasions. The DON stated that she would speak with staff and provide all staff with In-Service Trainings on safety, locks, securing door and not allowing Resident #7 to have access to the Nurses Station and the red button to open the front door for guests/visitors. The Administrator stated that the red button at the Nurses Station is no longer operable. He stated that all staff had been In-Serviced and were given directives to use the on the interior front door when allowing any and everyone into the building. The Administrator stated that when Resident #7 opened the door to visitors/guests, there was a risk for someone to enter the facility that he did not know. The Administrator stated that Resident #7 was good with face recognition and did not think that he would open the door to anyone he did not recognize. On 08/15/25 at 4:41 PM, an attempted telephone call to CNA M was unsuccessful .Record review of the maintenance logbook at the nurses' station, reflected no documentation of the repairs to the door or the broken lock on the wooden cabinet inside the Shower Room in the facility's Secured Unit.The facility did not provide any requested policies related to securing doors, razor blade storage, locks, cleaning supplies storage and accidents and hazards prior to the Survey Team exiting the facility on 08/15/25.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #2) of 6 residents reviewed for infection control. 1.LVN L failed to don (to put on) PPE prior to performing the high contact resident care activity on a resident who was on enhanced barrier precaution.This failure could place residents at risk for healthcare associated cross contamination and infections.Findings included:Record review of Resident #2's Quarterly MDS Assessment, dated 07/19/25, reflected the resident was a [AGE] year-old male, had a BIMs score of 8 indicating he was moderately cognitively impaired. The resident had diagnoses which included dysphagia (difficulty swallowing foods and liquids), Cerebrovascular accident (a disruption of blood flow to the brain, leading to brain cell damage).Record review of Resident #2's Comprehensive Care Plan, dated 07/16/25, reflected (Residents name) requires tube feeding swallowing difficulty r/t CVA. Facility interventions included: Monitor/document/report to MD PRN: aspiration - fever, SOB, tube dislodged, infection at tube site, self-extubation, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration.Record review of Resident #2's Comprehensive Care Plan, dated 04/25/25, reflected (Residents name) was on enhanced barrier precautions. Facility interventions included: Gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity.An observation on 08/13/25 at 8:46 AM, revealed Resident #2's room had an Enhance Barrier Precaution signage outside his room and cart set up with PPE. LVN L performed hand hygiene with sanitizer and entered Resident #2s' room, stopped the G tube feeding, administered medication via feeding tube and restarted the tube feeding Isosource 1.5 Cal . LVN L did not don PPE. An interview on 08/13/25 at 8:56 AM, revealed LVN L knew that Resident #2 was on enhanced barrier precaution, and she should have donned PPE before accessing the resident's (Resident#2) feeding tube. She stated that failure to use PPE could put the resident at risk for infection. She stated that she had been in-serviced on enhanced barrier precautions a few weeks ago.An interview on 08/13/25 at 1:41 PM with the DON revealed that her expectation was the staff should use appropriate PPE while providing care to residents on enhanced barrier precautions. She stated that risk to the patient was MDRO infection. She stated that the staff had been in-serviced on infection control and enhance barrier precautions. The facility policy titled Enhanced Barrier Precautions reflected: Multidrug-resistant organism (MDRO) transmission is common in long term care (LTC) facilities. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDROs. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities.EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. A single set of PPE cannot be used for more than 1 patient. EBP are indicated for residents with any of the following: Colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply (see MDRO list on page 3); or Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP

The facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of one (Resident #2) of four residents reviewed for medication administration.The facility failed to ensure LVN A administered each medication separately via Resident #2's g-tube per physician's orderThis failure could place residents at risk for potential significant medication interactions such as medication-medication or medication-food interactions.Findings included:Record review of Resident #2's Quarterly MDS Assessment, dated 07/19/25, reflected the Resident was a [AGE] year-old male, had a BIMs score of 8 indicating he was moderately cognitively impaired. The Resident had diagnoses which included dysphagia (difficulty swallowing foods and liquids), Cerebrovascular accident (a disruption of blood flow to the brain, leading to brain cell damage).Record review of Resident #2's Comprehensive Care Plan, revised 07/16/25, reflected [Resident# 2] requires tube feeding swallowing difficulty r/t CVA. Facility interventions included: The Resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders. Monitor/document/report to MD PRN: Aspiration- fever, SOB, Tube dislodged, Infection at tube site, Self-extubation, Tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension, tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Dehydration.Record review of Resident #2's physician orders reflected: Enteral Feed Order every shift check G/T placement prior to administration of meds and hanging enteral feedings Verbal Active 04/11/2025 04/12/2025. Enteral Feed Order every shift Check gastric residual volume. Hold feeding for 1 hour____ and notify physician for residual greater than ____60ml_. Verbal Active 04/11/2025 04/12/2025 Enteral Feed Order every shift Flush enteral tube with 30ml water pre/post medication administration and 10 ml water between each medication Verbal Active 04/15/2025 04/15/2025.An observation on 08/13/25 at 8:46 AM revealed Resident #2 had enteral feeding Isosource 1.5 Cal infusing via G tube at 75ml/hr. LVN L performed hand hygiene and donned clean gloves. LVN L verified and pulled Resident #2's medications per MAR. The medications included: Eliquis 5mg 1 tablet, Folic Acid 1mg 1 tablet, Multivitamin with minerals 1 tablet, Chewable aspirin 81mg 1 tablet, Baclofen 10MG 1 tablet, Thiamin 100mg 1 tablet. LVN L put all the tablets in one pill pouch and crushed all the medications together, then she put the crushed medication in an 8-ounce cup and filled the cup with water. LVN L removed gloves, sanitized her hands, donned clean gloves, and went into the Resident's room. LVN L stopped the G Tube feeding. LVN L checked for G Tube placement, and then she checked for residual with none noted. LVN L did not flush the G Tube before administering the medication. LVN L administered the medication using a syringe then after administering the medication LVN L flushed the G Tube with 60 cc of water. In interview on 08/13/25 at 8:56 AM revealed LVN L knew that G tube medication was not supposed to be crushed and given together, but she stated that she crushed them together because the medications were mostly vitamins and that she had spoken to NP Q and NP Q was okay with her crushing the medication. LVN L stated that she was aware that she was supposed to flush the G Tube before administering medication, but she did not because there was no residual. She stated that flushing the G Tube before administering medication was important to get food out of the way and to prevent medication food interaction. She stated that cocktailing medication can result in medication interaction that can harm the resident or be ineffective. She stated she had been in-serviced on medication administration to include G tube administration a few weeks ago.An interview on 08/13/25 at 1:41 PM, the DON revealed all G- tube medications were not to be cocktailed unless there was a physician's order. The DON stated that before administering medication, nurses should check and follow the physician orders. The DON stated the policy was to check for placement, check for residual, flush before medication administration, and flush after medication administration. The DON stated staff had been in-serviced on G tube medication and management. The inservice was done 8/13/2025. The DON stated the risk to the resident was interaction of medication that might not be safe to administer at the same time. The Resident could experience side effects such and nausea, vomiting, and diarrhea. In an interview on 08/14/2025 at 10:28AM, NP Q revealed that G tube medication should not be cocktailed unless there was a physician order. She stated she had not given an order to cocktail Resident #2's medication. She stated the policy was to check for placement, check for residual the flush before administering medication. NP Q stated the nurse should flush with water between medications then flush after completing medication administration. NP Q stated that cocktailing medications together could lead to medication-to-medication interaction. The risk to the patient was side effects of medication interactions that can make the resident sick.Review of the facility's policy Medication Administration Procedures reflected the following: Defining the schedules for administering medications to: Maximize the effectiveness (optimal therapeutic effect) of the medication Prevent potential significant medication interactions such as medication-medication or medication-food interactions.

Based on observation, interview and record review, the facility failed to ensure residents the right to be free from abuse and/or neglect for 1 (Resident #1) of 7 residents reviewed for abuse and/or neglect. The facility failed to ensure Resident #1 was free from physical abuse. CNA A grabbed Resident #1's arm and twisted it and then CNA A put her hands on Resident #1's neck and choked her. The incident occurred on 03/03/25. An IJ was identified on 4/22/25. The IJ began on 03/03/25 and removed on 03/03/25. The facility took action to remove the IJ before the survey began. While the IJ was removed on 03/03/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm because all staff had not been trained on behavior management procedures, abuse, and trauma informed care plans. These failures could place residents at risk of physical or emotional harm. Findings included: Record review of Resident #1's face sheet, dated 04/21/25, indicated she was a [AGE] year-old female, initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included hemiplegia (complete paralysis on one side of the body) and hemiparesis (refers to a weakness on one side of the body) following cerebral infarction (condition where a brain tissue area dies due to a lack of blood supply and oxygen) affecting right dominant side, vascular dementia (a type of dementia caused by brain damage due to impaired blood flow), bipolar disorder (a mental illness characterized by significant mood swings, ranging from extreme highs to extreme lows), and anxiety disorder (a group of mental health conditions characterized by excessive worry, fear, and anxiety that significantly impair daily functioning). Record review of Resident #1's Quarterly MDS assessment, dated 02/21/25, indicated she had a BIMS score of 11, which indicated moderate cognitive impairment. She was usually able to make herself understood and she was able to understand others. She did not exhibit behaviors of rejection of care or wandering. She had impairment on one side of both her upper and lower extremities. She used a cane/crutch and a wheelchair for mobility. She was able to independently complete activities of eating, oral hygiene, toileting hygiene, lower body dressing, putting on/taking off footwear, personal hygiene, sit-to-standing, and chair/bed-to-chair transfers, and toilet transfers. She required supervision or touching assistance with showering/bathing and tub/shower transfers. She required moderate assistance with upper body dressing. She was able to independently walk 150 feet. Record review of Resident #1's care plan, last revised on 03/03/25, indicated a focus of Resident #1 has a history of trauma that may have a negative impact. The trauma is related to domestic abuse, Resident #1 prefers not to talk about incident. Resident #1 has a history of trauma related to physical assault, she indicates she is ok and does not wish to continue talking about it. The goal was staff will assist in avoiding triggers through next review. Interventions included: *Consult with family regarding resident's condition as appropriate *If the resident has escalated, if at all possible do not touch the resident unless absolutely necessary for resident's or others safety *Monitor for escalating anxiety, depression or suicidal thought and report immediately to the nurse *Psych consult ordered *Social worker or designee to follow up for 3 days. The care plan addressed another focus of Resident #1 has a communication problem related to expressive aphasia. The goal was the resident will be able to make basic needs known on a daily basis through the review date. Interventions included: * Anticipate and meet needs * Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, Avoid isolation. * Monitor/document frustration level. Wait 30 seconds before providing resident with word. * Use communication techniques which enhance interaction: Allow adequate time to respond, repeat as necessary, do not rush, Request feedback, clarification from the resident, to ensure understanding, Face when speaking and make eye contact, Turn off TV/radio as needed to reduce environmental noise, ask yes/no questions if appropriate, use simple, brief, consistent words/cues, Use alternative communication tools as needed, such as communication book/board, writing pad, gestures, signs, and pictures. Record review of Resident #1's progress notes, dated 03/03/25 - 03/06/25 indicated the following: *03/03/25 at 5:30PM, by the ADON, indicated, .NP notified of altercation between resident and staff member. NP notified of scratches to residents left arm, bruising to both sides of neck, abrasion to left arm, and bruising to left arm. NP also notified of resident's refusal to go to ER for further evaluation. New orders received to clean scratches to left arm with [normal saline], apply TAO, cover with dry dressing if resident allows, if not leave open to air and monitor for changes. Notify MD/NP of changes. Monitor bruising to left arm and both sides of neck . *03/04/25 at 07:45AM, by the SW, indicated, LMSW spoke with resident concerning incident that occurred on 3/3/2025. Resident advised she was assaulted by CNA. Resident is unable to speak but showed LMSW that CNA had pulled her left arm behind her person while squeezing/placing pressure of left forearm. Resident then advised CNA grabbed her by the neck and squeezed, causing pain. LMSW observed what appeared to injuries sustained by nail markings and blue/green bruising to resident's left forearm and nail marking to both the right and left side of resident's neck. LMSW contacted/made referral .Psych services to follow up with resident, ensuring care of mental health. LMSW also asked if she feels safe at facility with remainder of staff or if there was anything needed to help with safety concerns. Resident advised she currently feels safe and advised she did not have further concerns at this point. Physical Therapy .also met with resident, resident advised [Rehab Director] that she is doing well and will participate in physical therapy on today's date (03/04/2025) LMSW will continue to follow-up with resident, ensuring she continues to feel safe and addressing if any other concerns present. *03/06/25 at 10:28AM, by the MDS Coordinator, indicated This nurse and administrator followed up with resident regarding incident with staff member .she is pleased that staff member is no longer employed here at facility, indicates that she feels safe, and that she is appreciative of the actions taken by management in this incident. No other concerns voiced/indicated. Record review of Resident #1's Initial Skin Assessment, dated 02/28/25, indicated she had normal skin color, with no bruising, skin tears, abrasions, lacerations, incisions, rashes, or ulcers. Record review of Resident #1's Weekly Skin Assessment, dated 03/03/25 at 05:08PM, and completed by the ADON, indicated she had right inner forearm- circular, dime-sized beginning of purplish bruising. She also had an abrasion to the right inner forearm - 0.5cm x 0.5cm. Further, she had other skin findings: scattered scratches to the right inner forearm: 1). 0.5cm x 0.5cm 2). 0.3cm x 0.5cm 3). 0.8cm x 0.3cm 4). 1.3cm x 0.3cm 5). 0.5cm x 0.2cm 3 red areas to right side of neck: 1). 1.2cm x 0.2cm 2). 0.5cm x 0.2cm 3). 2cm x 1cm 1.5cm x 0.5cm red area to left side of neck. Record review of a Physician's progress note, dated 03/06/25, indicated: .On 3/3 resident [and] staff had physical altercation in hallway. [patient] [care of] multiple scratches . scratches [and] bruising to [left] neck. States [left] arm sore but better. Tearful and quiet / states safe now . The note further indicated the resident had a skin tear, and a bruise to the left forearm and neck. Resident #1 was also anxious. During an interview and observation on 04/21/25 at 10:28AM, Resident #1 was lying in bed in her room. She was unable to verbalize most words, but she was able to point and act out her story with motions. She mostly spoke with no and nodded or shook her head to indicate yes or no. This surveyor asked her yes or no questions to gather the story. When asked if CNA A grabbed her arm she said yes. She made a motion to indicate that CNA A grabbed her arm and twisted it behind her back. When asked if it was the left arm she said no and pointed to her right arm. When asked if CNA A touched her neck she said yes, and then put her hands on her neck in a choking motion. When asked if CNA A choked her, she said yes. When asked if she could not breathe when CNA A choked her, she said yes. When asked if CNA A left marks and bruising on her, she said yes, and pointed to her right arm and neck. When asked if it was painful, she said yes. When asked if she had seen CNA A since the incident, she said no. When asked if she was upset and tearful by the incident she said yes. When asked if she felt safe at the facility now, she said yes. When asked who witnessed this event this surveyor gave several names of staff members and residents. She said yes that CNA B and Resident #2 had witnessed the incident. When asked if the police came to the facility she said yes. When asked if she pressed charges against CNA A she said yes. When asked if any other staff have tried to abuse her, she said no. Record review of Resident #2's face sheet, dated 04/21/25, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included hemiplegia (complete paralysis on one side of the body) and hemiparesis (refers to a weakness on one side of the body) following cerebral infarction (condition where a brain tissue area dies due to a lack of blood supply and oxygen) affecting unspecified side, dementia (a general term for the loss of memory and other thinking abilities that are severe enough to interfere with daily life), and major depressive disorder (a mental illness characterized by persistent low mood, loss of interest or pleasure in activities, and other symptoms that significantly impair daily functioning). Record review of Resident #2's quarterly MDS Assessment, dated 01/17/25, indicated she was sometimes understood, and sometimes able to understand others. Her vision was marked as adequate, indicated she was able to see fine detail, such as regular print in newspapers/books. She had a BIMS score of 12, which indicated moderate cognitive impairment. During an interview and observation on 04/21/25 at 11:58AM, Resident #2 was lying in bed in her room. She was unable to form some words. She was able to use hand motions to tell her story. This surveyor also asked yes or no questions. When asked if she remembered the incident with Resident #1 and CNA A she said yes. When asked if CNA A grabbed Resident #1, she said yes. When asked what happened, Resident #2 made a motion with her right arm and moved it behind her back. When asked if CNA A grabbed Resident #1's arm and twisted it she said yes. When asked if Resident #1 was swinging and trying to hit staff she said yes. This surveyor asked her to point at the arm that CNA A grabbed on Resident #1 she pointed to her right arm. When asked if she saw bruises and scratches, she said yes and pointed to her right arm. When asked what else CNA A did to Resident #1, she put her hand up towards her neck and made a choking sign. This surveyor asked her if CNA A used her hands, or her arms and the Resident pointed to her hand. When asked if Resident #1 hit CNA A and then CNA A choked Resident #1 she said yes. When asked if she had seen CNA A since the incident, she said no. When asked if she had observed any other abuse in the facility, she said no. Record review of an undated witness statement by the MDS coordinator indicated on [03/03/25] at approximately 3:15[PM], this nurse heard yelling, I went to the nurses station to investigate and noted [Resident #1] in front of the 500 hall with several staff members standing around her. When I asked her what was going on, she showed me her left forearm, at that time I noted several dark, half moon shaped indentions, a dark blue circular mark, and a scratch with a small amount of red blood. Resident was upset, had tears in her eyes and indicating towards hall 600. I looked up and saw [CNA A] coming from the 600 hall, who went to the time clock and I witnessed her walk out the front door. On seeing her, resident became even more upset, yelling and pointing at her. At that point, I assisted resident to the administrator's office. While talking with her with the administrator, she indicated that her arm was pulled backwards and that her neck was grabbed. When looking at her neck, I noted a bright red mark going from under her chin in the middle of her neck, to just below the corner [of] her jawbone noted a small abrasion with no bleeding, resident also had a small circular abrasion to her chin. This nurse stayed with resident in administrator's office talking with her and reassuring her until she calmed down and was no longer crying. She indicated that she wanted to leave the office, and headed to her room, she had her phone and indicated that she wanted to make a phone call. Record review of a witness statement by CNA B, dated 03/03/25, indicated [CNA B, CNA A, and CNA C] were in the linen room. [Resident #1] approached us and said 'no no' and was rubbing her body to let her aide know she wanted a shower. [CNA A] [continued] grabbing her linen. I walked away to answer one of my lights. When I came out [of] my resident room [CNA A] was at the end of the hall with her linen cart. [Resident #1] was blocking [CNA A] from passing by. [CNA A] asked her to move [and] she would not. [Resident #1] was hitting [CNA A]. [CNA A] was allowing it. After a while [CNA A] grabbed [Resident #1's] arm and told her to stop [and] she would not. [Resident #1] put her wheelchair in lock [and] stood up to hit [CNA A]. [CNA A] .put her hands on [Resident #1's] neck to calm her down. I grabbed [CNA A] and told her to walk away. Record review of a witness statement by CNA A, dated 03/03/25, indicated I was loading my linen cart when [Resident #1] stopped and asked for a shower. (after checking my computer chart I had my shower sheets available.) I informed [Resident #1] I had to prioritize those residents first before I take on the other responsibilities. After closing the linen closet, I asked her if she needed anything else - bed linen changes, a snack? She refused. Trying to get back to my hallway, I begin to push my cart. I thought I bumped her, so I stopped and apologized. Only to realize she was actively pushing my cart as she was rolling down the hall. She stopped near the nursing station and blocks my path. (another resident is no the other sides, so I wasn't able to fit with my linen cart). I pushed [Resident #1's] wheelchair slightly to the right after asking for space repeatedly. When I feel I have enough space I pull my linen cart between the residents. [Resident #1] locks her wheelchair and begins swinging at me. I grabbed her wrist to keep from getting hit. I informed her that she was about to hit another resident after releasing her wrist. She's still trying to attack me and elbows me and hits me in the face. I give her a hug and told her I love my job! When releasing from my embrace I grab my linen closet and take it back to my hall. During an interview on 04/21/25 at 1:09PM, the MDS Coordinator said she did not witness the incident between CNA A and Resident #1. She said she did hear yelling and went down to where the resident was. The incident was already over when she made it to the area. She said she did not see CNA A. She checked on Resident #1 and saw marks and scratches on her arm. She said she did not see blood. She said she also saw red marks on Resident #1's neck. She said Resident #1 was visibly upset and crying. During an interview on 04/21/25 at 1:12PM, the Treatment Nurse said she heard the screaming at the time of the incident. She said she came out and saw marks on Resident #1's arm. She said she saw dug in fingernail marks that were beginning to bruise. She said she saw 4-5 marks. She said she asked CNA A what had happened, and CNA A said she did not remember. During an interview on 04/21/25 at 1:21PM, CNA D said she heard the commotion of the incident. She said when she walked outside of the facility, she saw CNA A leaving the facility. She said did not see the Resident. She said it seemed out of character for the CNA. She said she had worked with the CNA in the past. She said the CNA seemed like something was wrong that day. During an interview on 04/21/25 at 1:28PM, CNA B said she witnessed the incident between CNA A and Resident #1. She said she was near the linen room with CNA A. She said Resident #1 came by and made a gesture that she wanted a shower. She said CNA A asked Resident #1 to give her a minute. She said at this point she had to walk away and complete a task with another resident. She said she then heard yelling. She said when she came back out to the hall, she saw Resident #1 standing out of her wheelchair and Resident #1 slapped CNA A. She said CNA A was holding Resident #1's arm to keep her from swinging and hitting her. She said CNA A then reached out and put her hands on Resident #1's neck and choked her. She said she intervened and split up the altercation and asked CNA A to walk away. She said she had not really worked with CNA A before, so she was unsure if this was out of character for her. She said it was not okay for a CNA or any health care staff to do this to a resident. She said she did not look at the resident's skin. She said at this point there was a bunch of people around and the nurses were assessing her. She said someone reported it to the Administrator. She said she wrote a statement. During an interview on 04/21/25 at 2:00PM, CNA A said on the day of the incident she was loading one of her hallway linen carts. She said another aide saw Resident #1 saying that she needed something. She said when she addressed Resident #1, she motioned that she needed a shower. She said she checked her shower sheets, and Resident #1 was not on her sheets for that day so she would take care of her after her scheduled showers were completed. She said the resident remained in the hallway. She said after she finished stocking her cart, the resident then asked again for a shower. She said she offered to strip Resident #1's bed so she would have clean linens. She said the resident refused. She said she started moving her linen cart down the hallway and she thought she ran into Resident #1 with the linen cart, so she stopped and apologized. She said she looked over and noticed Resident #1 had her hand up and was pushing the linen cart. She said she stopped walking and let the resident move away from her cart. She said she waited a few minutes and then tried to move again. She said Resident #1 blocked the end of the hallway from her leaving with the cart. She said she asked Resident #1 to move so she could pass. She said Resident #1 had a hard time communicating. She said Resident #1 was ignoring her request to move so she could get through and out of the hall. She said Resident #1 tried to swing at her. She said she was trying to protect herself from the resident hitting her. She said there was also another resident nearby she was trying to keep Resident #1 from hitting. She said Resident #1 elbowed her in the stomach and then hit her in the face. She said she hugged the resident and then clocked out and left. She said she did not hold Resident #1's hand. She said she was making contact with her wrist. She said she held Resident #1's shoulder when she gave her a hug. She said she did not grab Resident #1's arm and twist it. She said she did not put her hands on Resident #1's neck. She said she clocked out because she was afraid the situation would upset her and make her lose her job. She said she felt she had to leave the environment because she was not safe. She said CNA B was not around when she was talking to Resident #1. During an interview on 04/23/25 at 10:26AM, the Social Worker said she did a trauma assessment the next day following the incident for Resident #1. She said she spoke with the resident and the injuries lined up with her story. She said she observed bruising and scratches on Resident #1's arm. She said she saw a nail mark on the resident's neck at the time of the trauma assessment. She said the resident appeared to be in an okay state. She said the resident was relatively calm. She said she assured the Resident that she would be safe in the facility. She said the resident has a history of being a victim of domestic violence and sexual assault. She said she was unsure if the CNA abusing her could have been triggering for her considering that the resident had a history of being a victim of domestic violence and sexual abuse. She said she started the resident on psychological services to check on her. She said she was not in the facility at the time of the incident. During an interview on 04/23/25 at 10:35AM, the ADON said she was not in the facility on the day of the incident. She said she felt like CNA A abused Resident #1. She said she expected the CNA to not abuse the resident. She said the resident was calm the next day when she saw her. She said it was possible that due to the resident's history of being a victim of domestic violence and sexual abuse it could have been triggering for her. She said the CNA never showed any indication that she would hurt a resident. She said all the residents liked CNA A and she was shocked when it happened. She said Resident #1 had bruising and scratches on her arm and she had red marks on her neck after the incident. She said Resident #1 also had fingernail indentions on her arm. During an interview on 04/23/25 at 10:48AM, the DON said she was not in the facility when the incident between CNA A and Resident #1 occurred. She said she was sick with the flu and came back later that week. She said she did visit with the resident when she was able to come back. She said she could not remember if she saw anything on her neck when she came back, but she did have bruising and scratches on both arms. She said she felt like CNA A abused Resident #1. She said she expected her staff to not abuse residents. She said the measures to correct the noncompliance were in place on 03/03/25. She said this incident was probably triggering to Resident #1 considering she had a history of being a victim to domestic violence and sexual abuse. She said she checked on the resident on 04/22/25 and the resident was crying because she felt like she was reliving the incident when talking to this surveyor on 04/22/25. During an interview on 04/23/25 at 11:08AM, the Administrator said he was in the facility at the time of the incident between CNA A and Resident #1. He said his door was open and he was in his office. He said there was a bunch of noise in the common area. He said he came out and the other staff were gathered around Resident #1. He said he asked the staff what had happened. He said at this time CNA A had already walked out the front door of the facility. He said he initiated an investigation and checked on the resident's safety. He said CNA A had already removed herself from the facility. He said he took a statement from CNA A and suspended her. He said he called the police and notified them. He said several staff followed up with the resident. He said he ultimately substantiated abuse and terminated CNA A. He said after the incident he noticed the red marks to Resident #1 on both sides of her neck. He said there was a red mark that looked like a hand on her neck. He said he conducted in-services on abuse and neglect and behavior management. He said Resident # 1 felt better after he notified her that the CNA was not going to return. He said he felt like this incident could be triggering for the resident considering her history of being a victim of domestic violence and sexual abuse. He said it was 100% physical abuse of a resident. He said he did not expect the staff to abuse the residents. He said he has a zero tolerance for abuse or neglect. During an interview on 04/23/25 at 12:04PM, the MDS Coordinator said she conducted a trauma assessment on Resident #1 shortly after the incident between her and CNA A. She said at first when she checked on Resident #1, she was crying and visibly upset. She said the resident had crescent moon indentions on her arm and bruising. Her neck had a red mark that went from her back of her neck in a line towards the front. She said there were marks on the other side of her neck as well. Record review of the facility's policy, Abuse/Neglect, last revised 03/29/18, indicated: The Resident has the right to be free from abuse .as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion .Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights . .1. Abuse: abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Instance of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It included verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . The administrator was notified of the IJ on 04/22/25 at 11:30AM due to the above failures. The administrator was provided with the IJ template on 04/22/25 at 11:32AM. The surveyor confirmed the following measures had been implemented sufficiently to remove the Immediate Jeopardy on (03/03/25) by: - Reviewed completed facility self-reported incident to HHSC for Resident #1 dated 03/03/25 - This surveyor interviewed Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 on 04/21/25. Each resident indicated they had not been abused, and they enjoyed the facility staff. - Reviewed paperwork which indicated CNA A was suspended until completion of investigation which indicated the following: *dated 03/03/25 indicated .Type of Disciplinary Action: Investigatory Suspension .[CNA A] will be placed on an investigatory suspension pending an investigation into allegations of abuse .ADM .HR Director . - Reviewed paperwork which indicated CNA A was terminated after the allegation of abuse was investigated, which indicated the following: *dated 03/05/25 indicated .Type of Disciplinary Action: Discharge .[CNA A] failed to adhere to the Corporate Code of Conduct. [CNA A] was placed on an investigatory suspension pending an investigation into allegations of abuse; allegations were substantiated. [CNA A] is aware of all policies and procedures via their signature on the employee handbook acknowledgement. [CNA A] meets criteria for immediate termination .DON .ADM .HR Director . - Reviewed paperwork which indicated CNA A had a criminal history check before hire. CNA A had a criminal history check on 02/01/24 and her date of hire was 02/01/24. - Reviewed paperwork which indicated the incident between CNA A and Resident #1 was reported to the local police department. The local police were notified on 03/03/25. - Reviewed documented safe survey resident interviews conducted on 03/03/25 during the course of investigation. They indicated no residents complained of resident abuse/neglect or misappropriation. The sampled residents verified they felt safe in the facility, were treated well by the staff, they did not have any concerns to report, and that any concerns were to be reported to the abuse coordinator. - Record review of a facility conducted in-service, Abuse and neglect dated 03/03/25, indicated 26 of 49 facility staff were provided education on the topic. - Record review of a facility conducted in-service, Behavior Management dated 03/03/25, indicated 26 of 49 facility staff were provided education on the topic. - During interviews on 04/22/25, starting at 8:54AM, the MDS Coordinator, PTA F, the Rehab Director, the Maintenance Director, the Dietary Manager, Dietary [NAME] G, RN H, LVN K, CNA L, LVN M, CNA D, CNA N, the ADON, the Activity Director, the HR Director, the DON, CNA O, LVN P, CNA Q, and LVN R had been in serviced on abuse and neglect. They were able to identify an example of abuse and were able to verbalize to report any abuse to the abuse coordinator, (Administrator). They were also able to verbalize an understanding of behavior management, and proper de-escalation techniques for a resident that was trying to hit another staff or resident. - Record review of Resident #1's Trauma Informed PRN Assessment, dated 03/03/25, indicated a trauma assessment was completed by the MDS Coordinator.altercation with employee in this facility. Was handled by other facility staff, and feels safe now that the offending employee is no longer in the building . - Record review of Resident #1's Psych Visit Note, dated 03/04/25, indicated the resident was added to psych services and saw a provider this day. [Resident #1] is seen in her room. She is calm, pleasant and consents to the interview .The patient is unable to elaborate on what happened but reports feeling safe now that the staff member in question is no longer working at the facility. She reports no issues with any of the remaining staff and says they all treat her well. She denies being fearful . The noncompliance was identified as Past Immediate Jeopardy. The IJ began on 03/03/25 and was removed on 03/03/25. While the IJ was removed on 03/03/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm because all staff had not been trained on behavior management procedures, abuse, and trauma informed care plans.

Based on observation, interview and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature for 1 of 3 meals reviewed for palatability and temperature. The facility failed to provide food that was palatable and appetizing temperature for 1 of 3 meals observed on 7/29/24 (lunch) meal. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During an interview on 7/28/24 at 10:36 a.m., Resident #29 stated the food was not good at all, and no alternatives were offered. Resident #29 stated staff use to walk around and ask the residents for alternatives but did not walk around and ask the residents anymore. During an interview on 7/28/24 at 10:43 a.m., Resident #26 stated the dietary staff cooked too much chili powder and beans and her roll was burnt. During an interview on 7/28/24 at 12:44 p.m., Resident #15 stated her roll was burnt, the meat was hard, and the corn was cold. During an interview on 7/28/24 at 1:00p.m., Resident #27 stated the roll was burnt, the chicken fried steak was too hard to eat, and the facility alternatives were always bread and bologna. During an interview on 7/30/24 at 5:30 p.m., Resident #5 stated the tomato soup served on 7/30/24 for dinner was too salty. Record Review of the facility week 1 menu dated on 7/29/24, indicated the lunch meal (A) items included for the lunch meal Smashburger with grilled onions, waffle fries, zesty fry sauce, lettuce, tomato, pickles, ketchup, mustard, mayo, apple fried pie and iced tea; (Substitute) tuna sandwich, turkey sandwich, ham sandwich, grill cheese sandwich, chef salad and soup of the day. During an observation on 7/29/24 at 11:54 a.m., of food temperatures taken of the food on the steam table by [NAME] M revealed: the regular Smashburger with grilled onions was 195 F; the regular waffle fries were 138 F; the tomato soup was 63.5 F; the mechanical soft hamburger meat was 153 F; and the tea was 31 F. The zesty fry sauce, lettuce, tomato, pickles, ketchup, mustard, mayo, and regular apple fried pie were not temperature checked. During an observation, interview and test tray tasting revealed the Dietary Manager was observed tasting the regular lunch menu served on 7/29/24 at 12:51 p.m. The Dietary manager stated the regular waffle fries were cold. The Dietary manager stated the Smashburger was warm. The Dietary Manager stated the fried apple pie was cold. The Dietary manager stated the fried apple pie was supposed to be served hot. During an interview on 7/30/24 at 9:18 a.m., the Dietary Manager stated she had been employed as the dietary manager for two weeks. The Dietary Manager stated she worked Monday thru Friday and sometimes on weekends for any dietary staff that did not report on their scheduled day to work. The Dietary Manager stated the dietary staff, and the Dietary Manager was responsible for ensuring the food served was palatable, attractive, and at the correct temperature. The Dietary Manager stated the Administrator had not asked for test trays since she had been employed at the facility. The Dietary Manager stated, In the past when the dietary staff was cooking outside that the Administrator had come and grab a plate or something. The Dietary Manager stated she tasted the foods prior to serving at every meal. The Dietary Manager stated she had received food complaints last week from a resident stating their food was cold. The Dietary Manager stated she handled the complaints by ensuring the food was served hot by serving the trays to the resident personally. The Dietary Manager stated she encouraged the residents to try to make it to the dining room because she could not personally serve them their trays every day. The Dietary Manager stated sometimes resident's meals sat on the meal carts for 15 minutes or more before the nursing staff delivered it to the resident's room. The Dietary Manager stated she was not aware of the food needing to be temperature checked at 135 degrees (Fahrenheit) or higher for hot foods on the steam table. The Dietary Manager stated the dietary staff had not completed any in-services on palatability, attractiveness and serving at the correct temperatures. The Dietary Manager stated, If the food looked good it will taste good and it was very important for the residents. During an interview on 7/30/24 10:29 a.m., the Administrator stated he had been employed since May of 2024. The Administrator stated during resident counsel he had received complaints in the past about food being cold. The Administrator stated in the past the dietary staff had blamed the nursing staff about the food being delivered late. The Administrator stated since he had been the administrator he had not received any food complaints. The Administrator stated he asked some of the residents daily how the meal service was. The Administrator stated he did expect the dietary staff to ensure the food was served palatable, attractive and at the correct temperatures. The Administrator stated he had not received any test trays from the kitchen. The Administrator stated it was important to ensure the foods were palatable, attractive and served at the correct temperature for the residents because it was residents rights and courtesy that the food was palatable. The Administrator stated, Residents will not eat foods that was not palatable, attractive, and at the right temperature and that it could cause weight loss. Record review of the facility policy, titled, Resident Menus, dated 2012, indicated, We will strive to assure the resident's nutritional needs are provided based on the RDA. The standard menu will ensure nutritional adequacy of all diets, offer a variety of food in adequate amounts at each meal, and standardize food production. (1) Menus are planned to meet the Recommended Dietary Allowances of the Food and Nutritional Board, National Research Council, adjusted to the age, activity, and environment of the group involved . The Resident Menu policy did not address palatability, attractiveness or food temperatures.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services, in that: 1) The facility failed to label and date all food items. 2) Dietary staff failed to dispose of expired foods items. 3) Dietary staff failed to effectively reseal, label and date frozen food items. 4) Dietary staff failed to store dented cans on a separate shelf. 5) Dietary staff failed to remove scoop from sugar container. 6) Dietary staff failed to clean the deep fryer. These failures could place residents at risk for food contamination and foodborne illness. The findings included: During observations with [NAME] A on [DATE] beginning at 9:59 am, the following observations were made in the kitchen freezer (1 of 2): -(1) unopened 2 pound bag of yellow squash had no receive date. -(1) sealed gallon container of vanilla ice cream had no open date. -(1) sealed gallon size zip locked bag of an unlabeled food item had no open date, no expiration date and no receive date. -(1) unopened 3.5 pound bag of Italian breaded zucchini sticks had no receive date, no expiration date. -(1) opened bag of crinkled French fries was not placed in a sealed bag had no open date, no expiration date and no receive date. -(1) sealed bag of frozen biscuits prepared on [DATE] and had no expiration date. -(1) sealed bag of frozen kissed rolls prepared on [DATE] and had no expiration date. -(1) sealed bag of readymade frozen pancakes that had a preparation date of [DATE], no expiration date and receive date. -(1) sealed bag of frozen chicken nuggets had no label, no open date, no receive date and no expiration date. -(1) sealed frozen bag of steak fingers prepared on [DATE] and had no expiration date and no open date. -(1) sealed frozen bag of chicken not labeled, had no open date, no receive date and no expiration date. -(1) sealed zip locked bag of an unlabeled frozen food item that had no open date, no receive date and no expiration date. -(1) sealed bag of frozen meatballs prepared on [DATE] and had no open date and no expiration date. -(1) sealed bag of frozen ham prepared on [DATE] and had no open date and expired on [DATE]. -(1) unopened bag of a frozen food item not labeled, had no expiration date and no receive date. -(1) sealed zip locked bag of frozen chopped ham not labeled, had no open date, no receive date and no expiration date. -(1) frozen bag of chicken patties had a preparation date of [DATE] and had no open date and no receive date. -(1) sealed zip locked bag of corn dog that had no label, no open date, no receive and no expiration date. -(1) sealed zip locked bag of diced chicken that was not labeled, had no expiration date and no open date. -(1) bag of frozen chicken breast prepared on [DATE] and expired on [DATE]. During observations with [NAME] A on [DATE] beginning at 10:29 am, the following observations were made in the kitchen freezer (2 of 2): -(1) bag of frozen fish prepared on [DATE] and expired on [DATE]. -(1) bag of frozen meat of lunch that had a preparation date of [DATE] and expired [DATE]. -(1) zip locked bag of frozen mechanical soft meat prepared on [DATE] and expired on [DATE]. -(1) unopened bag of guacamole that was not labeled and had no receive date, no expiration date. -(2) unopened bag of frozen pork meat that had a receive date of [DATE] and expired on [DATE] During observations with the Dietary Manager on [DATE] beginning at 10:36 am, the following observations were made in the kitchen refrigerator (1 of 2): (1) clear package of thawed ham lunch meat unlabeled, no receive date and no expiration date. (1) clear package of thawed bologna lunch meat unlabeled, no receive date and no expiration date. (1) clear package of thawed salami lunch meat unlabeled, no receive date and no expiration date. (1) zip locked bag of turkey meat prepared on [DATE] and expired on [DATE]. During observations with the Dietary Manager on [DATE] beginning at 10:39 am, the following observations were made in the kitchen refrigerator (2 of 2): (1) zip locked bag of egg omelet not labeled, no preparation date and no expiration date. (1) gallon of whole milk that had no open date. (4) unopened gallons of whole milk that had no receive date. (1) container of minced garlic opened on [DATE], no receive date and no expiration date. During observations with the Dietary Manager on [DATE] beginning at 11:01 a.m., the following observations were made in the kitchen dry storage (1 of 1): -(2) 6 pound and 6 ounce cans of diced tomatoes that were dented on the undented can rack. -(1) 3.75 ounce bottle of sesame seed seasoning received on [DATE], and expired on [DATE]. -(1) 6 ounce bottle of rubbed sage seasoning received on [DATE], expired ono [DATE]. -(1) zip locked bag of marshmallows prepared on [DATE], no open date and no receive date. -(1) bag of cheese sauce prepared on [DATE] and expired on [DATE]. -(1) plastic wrapped bag of coffee creamer received on [DATE], not bagged, no open date and no expiration date -(1) unsealed packet of 3.2 ounce of [NAME] Farms Salad dressing that had no receive date, no open date and no expiration date. -(1) measuring cup found inside the sugar container bin. -(1) container of sugar that had a preparation date of 6//,d+[DATE] and no expiration date. -(1) container of flour that had a preparation date of [DATE] and no expiration date. During observation with the Dietary Manager on [DATE] at 11:30 a.m., revealed the deep fryer was not cleaned; the deep fryer grease was black in color and had bread crumps inside floating inside. During observations with the Dietary Manager on [DATE] beginning at 11:33 a.m., the following observations were made in the dining area (1 of 1 ): (1) container of Raisin Bran cereal had no open date and no expiration date. (1) container of honey nuts cereal had no open date and no expiration date. (1) pitcher of red juice that had no label, no open date and no expiration date. (1) pitcher of water that had no label, no open date and no expiration date. During an interview on [DATE] at 8:47 a.m., the Dietician stated she had been full time dietician for the past 4 years. The Dietician stated she oversaw the Dietary Manager. The Dietician stated the Dietary Manager oversaw the dietary staff. The Dietician stated she visited the facility once a month and today [DATE] was her monthly visit. The Dietician stated once a month she conducted walk throughs in the kitchen. The Dietician stated, not really, when asked if she had seen expired foods or foods not labeled correctly in the kitchen. The Dietician stated she was not aware of expired foods, non-labeled food items, dented cans with undented cans, and scoops in the sugar bin found in the kitchen on [DATE]. During an interview on [DATE] at 9:33 a.m., the Dietary Manager stated she had been the dietary manager for two weeks. The Dietary Manager stated in-services had not been completed on labeling and dating food items, disposing of expired food items, storing dented cans on another shelf, removing the scoop from sugar container and cleaning the deep fryer. The Dietary Manager stated was supposed to do walk throughs every morning, but she conducted walk throughs in the kitchen once a week. The Dietary Manager stated she was noticing that once a week walk throughs in the kitchen were too late. The Dietary Manager stated she needed to get back into a habit of walking through the kitchen every day. The Dietary Manager stated the Administrator never conducted walk throughs in the kitchen. The Dietary Manager stated the dietary staff were to clean the fryer and change the cooking grease every Monday. The Dietary Manager stated she agreed that the fryer grease needed to be changed due to how black in color it was. The Dietary Manager stated sometimes staff had the cooking grease up to high when cooking and this would burn the cooking grease. The Dietary Manager stated the Administrator oversaw her. The Dietary Manager stated it was important to ensure that the Dietary Staff was labeling and dating all food items and discarding expired foods because it was not healthy for the residents. During an interview on [DATE] at10:43 a.m., the Administrator stated he had been the Administrator since May of 2024. The Administrator stated he conducted weekly walk throughs in the kitchen. The Administrator stated he mainly went through dry storage and labeling and dating food items in the kitchen during his walk throughs. The Administrator stated in-services on labeling and dating had been completed. The Administrator stated he had not completed any in-services on using the fryer and cleaning the fryer recently. The Administrator stated hand sanitation in-services were completed on Sunday ([DATE]) and on Monday ([DATE]). The Administrator stated he expected staff to discard expired foods, label and date foods, reseal freezer food items and placing dented can with other dented can and to not leaving the scoop in the sugar container. The Administrator stated leaving the scoop in the sugar container was infection control. The Administrator stated, It was important for staff to label and date food items and dispose of expired food items to prevent health issues with residents because he does not want to serve expired foods to the residents. Record Review of the facility's Dietary policy titled Food Storage and Supplies dated 2012, indicated, (3) Best practice is that scoops should not be left in food containers or bins, but if so, handles should be upright and not contacting the food item. Containers are cleaned regularly (4) Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened. (6) when items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it so it is readily visible and noticeable. It is important to distinguish between an expiration date and a production date, or a best by or use by date. Production dates indicate when the product was manufactured, not when it expires and should not be interpreted as a best by or use by date. Best by or use by dates indicate when a product will have best flavor or quality and are not an indicator of the product's safety. As the quality may deteriorate after the date passes, the dietary manager should closely inspect any products that are past the best by date to determine if they are still good quality. If in doubt, discard the product. If any stamped date is unclear, contact the food vendor for clarification. -If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf-stable items will be stored in a first in, first out manner, to be used within one year. After one year, any product that is shelf stable will be inspected by the dietary manager to ensure that it is good quality before it is used. Any product with a stamped expiration date will be discarded once that date passes. (10) Frozen items that should be thawed before preparation should be stored under refrigeration until thawed and should be dated with the date removed from the freezer and used within 7 days. Any frozen food more than one year old will be inspected for food quality and freezer burn before being used.

Based on observation, interview, and record review, the facility failed to provide sufficient staff to effectively conduct food and nutrition services for the facility's main dining room. The facility failed to serve meals, at the specific times posted, in the main dining room. This failure placed residents at risk of increased hunger, thirst, frustration, and decreased feelings of self-worth. Findings included: Record review of the facility's posted meal service reflected the breakfast mealtime was 7:00 AM; the lunch mealtime was 12:00 PM; and the dinner mealtime was 5:00 PM. During an observation in the kitchen on 7/28/24 at 9:30 a.m., revealed only one Dietary Aide in the dining room; no other dietary staff were in the kitchen. During an observation and interview on 7/28/24 at 9:31 a.m., [NAME] A stated the Dietary Manager had gone on break. [NAME] A stated she called the Dietary Manager, and the Dietary Manager's spouse stated the Dietary Manager had gone to the grocery store. [NAME] A stated the Dietary Manager was supposed to be working on 7/28/24. [NAME] A stated she was the only dietary aide at the facility during this time. During an observation and record review on 07/28/24 at 11:30 AM, in the facility's dining room, revealed residents beginning to congregate for the lunch meal service. Residents were arriving on their own and residents were being assisted by staff. The meal hours posted on the wall just outside the dining room indicated lunch service was to begin at 12:00 PM. During an observation on 07/28/24 at 12:20 PM, in the facility's dining room, revealed the meal service had not begun and the residents had not begun to eat lunch. During an interview in the dining room on 7/29/24 at 12:01 p.m., Resident #18 stated that the lunch meal was always served late. Resident #18 stated breakfast meals were usually served on time. During an interview in the dining room on 7/29/24 at 12:01 p.m., Resident #15 stated breakfast was good for a change since state was in the building and the lunch was usually served late. During an observation on 7/2924 revealed the lunch meal was served at 12:10 p.m., in the dining room. During an observations on 7/30/24 at 7:30 a.m., reflected 4 residents waiting in the dining hall for breakfast. During an observation on 7/30/24 at 8:15 a.m., revealed hall 500's breakfast was leaving the kitchen. During an observation on 7/30/24 at 8:20 a.m., revealed hall 600's breakfast was leaving the kitchen. During an observation on 7/30/24 at 8:26 a.m., hall 800's and hall 900's breakfast was leaving the kitchen. During an observation and interview on 7/30/24 at 8:32 a., revealed CNA B was passing out the breakfast trays on hall 800 and hall 900. CNA B stated Resident #192's breakfast tray was missing. CNA B stated she informed the kitchen to make Resident #192's tray. CNA B stated the resident was not happy about not having her breakfast tray. During an observation on 7/30/24 at 8:36 a.m., revealed Resident #192 breakfast tray was delivered by CNA B to the resident's room. During observation on 7/30/24 at 8:37 a.m., Resident #37 walked from hall 900 where she resided and knocked on the kitchen door. Resident #37 asked the dietary staff where was her breakfast tray . The kitchen staff had informed Resident #37 that her breakfast tray was just delivered to her room. During an interview on 7/30/24 at 8:45a.m., Dietary Aide E stated the dietary kitchen was ready at 7am to serve breakfast on 7/30/24. Dietary Aide E stated she told the CNAs and nurses that the kitchen was ready to serve breakfast and she was told from a CNA it was going to be a minute because a resident had fallen on the900 hall. Dietary Aid E stated the CNAs and nurses showed up to the kitchen around 7:50 a.m. to start passing breakfast trays. Dietary Aide E stated she asked the ADON if she could come inspect the breakfast trays and the ADON had asked her, Where was the other nurses? Dietary Aide E stated the ADON did not help with getting the breakfast trays out on 7/30/24 after she had asked for help. Dietary Aide E stated she had been employed at the facility for 4 months. Dietary Aid E stated this was her second time being employed at the facility. Dietary Aide E stated she had worked previously in the facility in the past. Dietary Aid E stated in-services on getting the tray out timely was completed in morning meetings all the time. Dietary Aide E stated, It was important for the residents to eat timely because residents had feelings too and because the residents be ready to eat . During an interview on 7/30/24 at 8:54 a.m., the Dietary Manager stated she had been the Dietary Manager for two weeks. The Dietary Manager stated the meals served on 7/28/24 for lunch was late because the surveyor was in the kitchen checking stuff. The Dietary Manager stated lunch was served on time at 12:01 p.m., on 7/29/24. The Dietary Manager stated during the lunch meal on 7/29/24 that she had to wait until the nurses came at 12:05 p.m., to check the trays before serving meals to the residents on 7/29/24 for lunch. The Dietary Manager stated on 7/30/24 for the breakfast meal that she did not get to work until 8 a.m., and as she walked into the facility, the ADON had stated she asked one of the dietary aides for jelly because jelly was not on the trays and the dietary aide got an attitude with her and also breakfast was late. The Dietary Manager stated she had not asked her staff about what happened yet about breakfast being late on 7/30/24 but had planned to after the interview with the surveyor. The Dietary Manager stated she did expect staff to ensure they were serving meals on time. The Dietary Manager stated breakfast was to be served at 7am, lunch was to serve at 12 p.m., and dinner was to be served 5 p.m. The Dietary Manager stated she was always told by nursing staff that the dietary staff had to wait until the med pass had been completed or other tasks that nurses were doing were completed before they pass meal trays to the residents. The Dietary Manager stated she had reported the nursing issues with the nurses showing up late to the Administrator many times and nothing had been done. The Dietary Manager stated the dietary staff just had to wait on the nursing staff. The Dietary Manager stated the facility did not complete any in-services on making sure the meals were served timely with the dietary staff and nursing staff. The Dietary Manager stated it was very important for the meals be served on time, because the meals served timely was what got the resident's going through day. During an interview on 7/30/24 9:54a.m., the Administrator stated he has worked at the facility since May of 2024. The Administrator stated he expected staff to serve at the posted times. The Administrator stated the Dietary had been late in the past with serving meals timely. The Administrator stated at times a dietary staff member would have to run to the store for items for meals which had cause delays in the past with meals not being served on time. The Administrator stated in the past when he was notified of meals not served timely that he would check to see if the Dietary staff needed help. The Administrator stated he was made aware of lunch being served late on Sunday (7/28/24) by the Corporate Clinician on Sunday. The Administrator stated he had not been informed that breakfast was served late on Tuesday (7/30/24). The Administrator stated in-services on serving meals on time had not been completed. The Administrator stated mealtime was important because Waiting around for food the residents could get cranky. The Administrator stated residents should be served on time. During an interview on 7/30/24 at 2:33 p.m., the ADON stated she had been the ADON and Administrator in training for 20 days. The ADON stated she was paid salary and worked all the time at the facility. The ADON stated she did not refuse to help the kitchen during breakfast mealtimes on 7/30/24. The ADON stated she did not feel good today on (7/30/24). The ADON stated she had taken a COVID test which came back negative. The ADON stated she did not want to be around the residents feeling sick. The ADON stated she had been trying to make sure the facility had enough staff. The ADON stated the facility had advertised bonuses for CNA's and LVN's and the facility had not been successful in getting people to apply. The ADON stated the facility did not have a lot of staff. The ADON stated she was second in command to the CNA's at the facility. The ADON stated the CNA's were to first report their charge nurse and then report to her last. The ADON stated the Administrator oversaw here. Record review of the facility's Resident Meal Service and HS Snack policy, undated, indicated, We strive to provide meals and HS snacks to all residents in a timely manner. Resident meals will be served at regular hours with a maximum of fourteen hours between the evening meal and breakfast the following day. Mealtimes can be adjusted per resident preference at the direction of Resident Council. A bedtime snack is offered to all residents. Each facility has the ability to customize their menu through eMenuManage ([NAME]) based on regional or resident preferences, after approval from the Registered or Licensed Dietitian.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 18 residents( Resident #192, Resident #30, Resident #34, Resident #12, and Resident #23) and 7 of 8 staff (LVN A, LVN C, CNA C, CNA L, LVN K, CNA B, and CNA O) reviewed for infection control practices and transmission-based precautions. 1. LVN A failed to ensure Resident #192 had the proper cap in place to prevent infection in PICC line. 2. LVN A failed to wash his hands while passing medications to Resident #30 and Resident #34. 3.The facility failed to ensure the EBP (enhanced barrier precautions) were in place for Resident #192 on 07/28/24. 4.LVN C failed to properly store urine obtained for urinalysis. 5.CNA L failed to perform hand hygiene during Resident #12's continent care. 6.CNA L failed to perform catheter care when Resident #12 received incontinent care. 7.LVN K failed to clean and treat Resident #12's 6 pressure wounds individually. 8.LVN K failed to perform hand hygiene during Resident #12's wound care. 9.LVN K failed to properly handle soiled linen from Resident #12's bed. 10.The facility failed to ensure CNA B and CNA O don(on) their PPE prior to entering Resident #23's room. 11.The facility failed to ensure CNA B and CNA O performed hand hygiene after removing their gloves while providing incontinent care to Resident #23. 12.CNA B failed to sanitize hand between delivering meal trays on hall 800 and hall 900. These failures could place residents at increased risk for serious complications from a communicable disease that could diminish the resident's quality of life. Findings included: 1) Record review of Resident #192's face sheet dated 07/30/24 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of acute and chronic respiratory failure, diabetes mellitus type 2, Hypertension (high blood pressure), peripheral vascular disease (circulation condition in which causes decreased blood flow to the limbs), and bacteremia(blood stream infection). Record review of Resident #192's MDS schedule indicated she did not have an MDS completed because it was not due. Record review of Resident #192's care plan dated 07/28/24 indicated she had an IV access to be used for antibiotics with interventions to administer IV medications as ordered. Record review of the facility MDS Resident Matrix dated 07/28/24 indicated Resident #192 had intravenous therapy. Record review of Resident #192's order summary report dated as of 07/30/24 indicated she had an order for: Ampicillin Sodium Solution Reconstituted 2 GM Use 2 Gram intravenously every 4 hours for bacterial infection for 10 days with a start date of 07/27/24. During an observation on 07/28/24 at 10:16 AM revealed Resident #192 had no enhanced barrier precautions in place outside of her room. During an observation on 07/28/24 at 12:17 PM revealed Resident #192 had no enhanced barrier precautions in place outside of her room. During an observation on 07/29/24 08:30 AM revealed LVN A failed to complete hand hygiene. He then donned a gown and gloves and prepared IV antibiotics for Resident #192. LVN A went into Resident #192's room and hung the IV medication Ampicillin 2GM and then he said he forgot the most important step, washing his hands. He then went to wash his hands and completed the antibiotic administration. During an interview on 07/29/24 at 09:15 AM Resident #192 said none of the staff used gowns on yesterday (07/28/24), but the staff had been using gowns during care on that day (07/29/24). She said she did not recall her PICC line ever having a cap on it since she had been at the facility. Resident #192 said she just knew that LVN A had been hooking antibiotics to it. During an observation and interview on 07/29/24 at 10:27 AM revealed LVN A placed the red extension connector on the PICC line. He said the facility had not had the caps since Resident #192 entered the facility on 07/27/24 and that was the only thing he could find to place on the PICC line. He said the red extension connector would not prevent infection because it was still open on the end. LVN A said the cap the facility should have been using were usually yellow or green and it was capped off with alcohol inside. He said the failures placed a risk for infection. 2) Record review of a face sheet dated 08/05/2024, indicated Resident #34 was a [AGE] year-old male initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included cerebral infraction (stroke), unsteadiness on feet, osteoarthritis (degeneration of the bones), scoliosis (curvature of the back), diabetes mellitus (a lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar level), hyperlipidemia (high levels of fat participles in the blood). Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #34 was usually understood and sometimes understood by others. The MDS assessment indicated Resident #30 had a BIMS score of 7, which indicated his cognition was severely impaired. Record review of the care plan with revised date of 06/01/2024, indicated Resident #34 was care planned for hemiplegia/hemiparesis. The interventions included give medications per orders and monitor, document side effects and effectiveness. Record review of the order summary report dated 08/05/2024 indicated Resident #34 had an order for metoprolol tartrate oral tablet 50 mg give one tablet by mouth two times a day for hypertension with a start date of 06/01/2024. 3) Record review of a face sheet dated 08/05/2024, indicated Resident #30 was a [AGE] year-old male initially admitted to the facility on [DATE], with diagnoses which included left bundle branch block (a delay or blockage of electrical impulses to the left side of the heart), bradycardia (low heart rate), congestive heart failure (a chronic condition where the heart does not pump blood as well as it should), and hypertension (high blood pressure). Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #30 was sometimes understood and sometimes understood by others. The MDS assessment indicated Resident #30 had a BIMS score of 1, which indicated his cognition was severely impaired. Record review of the care plan with revised date of 01/01/2024, indicated Resident #30 was care planned for diuretic therapy. The interventions included give medications per orders and monitor, document side effects and effectiveness. Record review of the order summary report dated 08/05/2024 indicated Resident #30 had an order for Furosemide tablet 20 mg one tablet by mouth one time a day for congestive heart failure with a start date of 01/01/2024. During an observation on 07/29/24 at 08:08 AM LVN A prepared medications and gave them to Resident #30. LVN A failed to complete any hand hygiene before or after medications were given. During an observation and interview on 07/29/24 08:16 AM LVN A prepared medications and gave them to Resident #34. LVN A failed to complete any hand hygiene before or after medications were given. LVN A said he should have washed his hands or used hand sanitizer between the resident's medications. He said the failure placed a risk for cross contamination. 4) During an observation and interview on 07/29/24 at 08:29 PM revealed LVN C placed a specimen cup full of urine on the nurse's station desk with a paper towel covering it. LVN C said the specimen cup contained urine and then refused to answer any questions from the surveyor. During an interview on 07/30/24 at 07:45 AM the Administrator said the nurses were responsible for ensuring they obtained urine and properly placed it in designated bags. He said the failure placed a risk for cross contamination. During an interview on 07/30/24 at 06:05 PM LVN C said she should have stored the urine in the proper bag and cooler. She said the failure placed a risk for contamination and infection. 33249 5) Record review of a face sheet dated 7/30/2024 indicated Resident #12 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of rheumatoid arthritis end-stage (a chronic inflammatory disorder that can affect more than just your joints), fractured right femur (upper leg bone), and multiple pressure ulcers. Record review of the Quarterly MDS dated [DATE] indicated Resident #12 was understood and understands others. The MDS indicated Resident #12's BIMS score was 15 indicating no cognitive impairment. The MDS indicated Resident #12 was dependent with toileting hygiene. The MDS in Section H-Bladder and Bowel indicated Resident #12 had an indwelling catheter. Record review of the undated Comprehensive Care Plan Indicated Resident #12 had an indwelling catheter related to pressure ulcers. The care plan indicated Resident #12 required ADL care with the goal of she will maintain or improve current level of function in bed mobility, transfers, eating, dressing, toilet use, and personal hygiene. The interventions included Resident #12 required total assistance with personal hygiene care. Record review of the consolidated physician's orders dated July 30, 2024, indicated on 5/19/2024 Resident #12 was ordered catheter care every shift. During an observation on 7/28/2024 at 11:37 a.m. - 12:00 p.m., revealed CNA L entered the room washed her hands, obtained a pair of gloves, and obtained an under pad. LVN K indicated to CNA L one more person was required to assist with Resident #12's incontinent care due to having to hold Resident #12's fractured leg. CNA L removed her gloves and exited the room. CNA L returned to the room with RN P. CNA L donned another pair of gloves. CNA L cleaned Resident #12's peri area using a wipe with a wiping motion toward Resident #12's rectum. CNA L used another wipe and completed the wiping motion again. Resident #12 had a very small bowel movement, then CNA L grabbed a wipe and removed the bowel movement. CNA L then adjusted the draw sheet underneath Resident #12, then she took the disposable under pad, rolled the edge up and tucked the pad underneath Resident #12CNA L failed to provide catheter care during the incontinent care. CNA L then removed her gloves, and her PPE, and washed her hands. After CNA L performed incontinent care for Resident #12 LVN K began Resident #12's wound care. LVN K removed her gloves, then gathered dressing supplies from Resident #12's closet. The wound care supplies were in a shipping box sitting directly on the floor. LVN K obtained bordered dressings, 4x4 gauzes, calcium alginate sheets, and a bottle wound cleanser. LVN K then walked to Resident #12's dresser and obtained a box of gloves. LVN K then moved the trash container closer to her work area. LVN K opened each dressing sitting them on the package on Resident #12's bed. LVN K placed several opened dressings, opened calcium alginate sheets, a box of gloves, a bag of 4x4's gauze, and the wound cleaner bottle on the foot of Resident #12's bed. LVN K put on a pair of gloves, then removed the dressings to Resident #12's shoulder/back area. LVN K failed to perform hand hygiene. LVN K then obtained several 4x 4's sprayed them with wound cleanser and cleaned the wound on the shoulder discarded the 4x4's, obtained new 4x4's sprayed them with wound cleanser then cleaned the upper back wound area. LVN K then pushed the totality of 4x4's further down in the trash container. LVN K with her right hand obtained the calcium alginate and tore twos piece off and applied to the open wound bed of the shoulder/back wound then covered the wound with a bordered dressing. LVN K then removed the dressing to Resident #12's right hip and sacral wound. LVN K proceed to cleanse the sacral wound, the right hip and left hip with two wounds, applied calcium alginate to the wound beds, and covered each wound with a dry bordered dressing without changing her gloves or using hand sanitizer. After all the wound care was provided, Resident #12 was then repositioned for comfort, then LVN K removed her gloves, removed her PPE, and washed her hands. LVN K failed to perform hand hygiene during the wound care. During an interview on 7/28/2024 at 12:30 p.m., RN P said CNA L failed to change gloves and do hand hygiene between dirty and clean areas of incontinent care. RN P said she agreed she had not witnessed CNA L provide catheter care as well. RN P said she made a mistake by placing the dirty linen on the floor as well. RN P said Resident #12 was at risk for UTI's when catheter care and incontinent care was not provided correctly. RN P said putting soiled linen on the floor could cause infections to spread room to room. RN P said LVN K should have treated each wound independently of the others. RN P said LVN K should have changed her gloves and performed hand hygiene when she removed the dirty dressings, and after she cleaned the wound. RN P said she was unaware she could have stopped the process and corrected the incontinent care and wound care procedure. During an interview on 7/28/2024 at 1:09 p.m., LVN K said CNA L should have performed hand hygiene and changed gloves between dirty and clean during incontinent care with Resident #12. LVN K said she was unaware she could have corrected CNA L during the incontinent care procedure. LVN K said Resident #12 was at risk for urinary tract infections when incontinent care was not performed correctly. LVN K said she was unaware each wound should have had care provided separately. LVN K said she thought she changed her gloves and performed hand hygiene during wound care. LVN K said hand hygiene during wound care would prevent wound infections. LVN K said she had been employed for six months but had not been checked off on wound care. During an interview on 7/30/2024 at 8:01 a.m., CNA L said she had forgotten to perform hand hygiene and change her gloves between dirty and clean during incontinent care. CNA L said she had though she had performed catheter care. CNA L said Resident #12 was at risk of urinary tract infections when incontinent care was not performed correctly. During an interview on 7/30/2024 at 6:41 p.m., the ADON said she expected the CNAs to clean their hands by performing hand hygiene between dirty and clean areas of incontinent care. The ADON said not performing hand hygiene could cause infections. The ADON said this was monitored by the performance of skill check offs and random checks while performing incontinent care on a resident or the use of a mannequin. The ADON said she expected each wound to be provided care to separately from the other wounds. The ADON said she expected hand hygiene to be performed when the soiled dressing was removed, after cleaning the wound, and after care of the wound. During an interview on 7/30/2024 at 7:51 p.m., the RNC said she expected CNA L to perform hand hygiene when going from dirty to clean in the incontinent care process. The RNC said when this hand hygiene was not performed, and new gloves applied the resident was at risk of infection. The RNC said the nurse managers were responsible for ensuring appropriate incontinent care monitoring using random check offs and annual check offs. The RNC said she expected wound care to be performed with each wound independent from the other wound. The RNC said she expected hand hygiene to be performed during the wound care to prevent the spread of infection from one wound to another wound. During an interview on 7/30/2024 at 8:51 p.m., the Administrator said he expected the staff the perform hand hygiene between clean and dirty to prevent the spread of germs. The Administrator said the staff should be monitored by the nurse managers by competencies. Record review of a CNA Proficiency Audit dated 4/23/2024 indicated CNA L was assessed in the area of hand washing, catheter care, infection control awareness, and perineal care scoring a satisfactory in skill level. Record review of a Nurse Proficiency Audit dated 7/01/2024 indicated LVN K had been assessed for competency in treatment procedures such as dressing changes and had a satisfactory score in the skill level. 30527 10) Record review of Resident #23's face sheet, dated 07/30/2024, indicated Resident #23 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of end stage renal disease (occurs when chronic kidney disease - the gradual loss of kidney function - reaches an advanced state), type 2 diabetes mellitus with diabetic neuropathy (high blood sugar that has caused nerve damage), and encephalopathy (a disease that impacts the functioning of the brain). Record review of the MDS assessment, dated 07/12/2024, indicated Resident #23 had clear speech and was understood by staff. The MDS revealed Resident #23 was able to understand others. The MDS revealed Resident #23 had a BIMS score of 11, which indicated moderate cognitive impairment. The MDS assessment indicated Resident #23 was dependent with toileting, showering, and lower body dressing and personal hygiene. Resident #23 required substantial to maximal assistance with upper body dressing. Record review of Resident #23's comprehensive care plan revised on 06/04/2024, indicated Resident 23 was on enhanced barrier precautions related to pressure ulcer. The care plan interventions included gloves and gown should be donned if any of the following activities occur linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, bathing or high contact activity. During an observation on 07/28/2024 at 10:14 AM, revealed there was a sign indicating Resident #23 required enhanced barrier precautions on the door. During an observation on 07/29/2024 at 08:19 AM, revealed there was a sign indicating Resident #23 required enhanced barrier precautions on the door for contact isolation. During an observation on 07/29/2024 at 08:35 AM, revealed CNA B and CNA O went in Resident #23's room without a gown or gloves worn. CNA B repositioned Resident #23's pillow from her right back side. CNA O was standing at the left side of the bed waiting to assist CNA B. CNA B and CNA O provided incontinent care to Resident #23. CNA B cleansed Resident #23's front peri area removed her gloves and applied clean ones. CNA B did not perform hand hygiene after removing her dirty gloves, prior to applying clean gloves. CNA B and CNA O turned Resident #23 on her side. Resident #23's brief was soiled with feces. CNA B cleansed Resident #23's back peri area removed the soiled brief and handed it to CNA O. CNA O placed them in trash bags, removed her gloves, and applied clean ones. CNA O did not perform hand hygiene after removing her dirty gloves, prior to applying clean gloves. CNA B applied barrier cream to Resident #23's buttocks, removed her gloves, and applied clean ones. CNA O did not perform hand hygiene after removing her dirty gloves, prior to applying clean gloves. CNA B removed her dirty gloves and applied clean gloves. CNA B did not perform hand hygiene after removing her dirty gloves prior to applying clean gloves. CNA B and CNA O applied the clean brief, and repositioned Resident #23 in bed. CNA B and CNA O removed their gloves and performed hand hygiene. During an interview on 07/29/2024 at 09:00 AM, CNA B said hand hygiene should be performed in between glove changes. CNA B said she had not performed hand hygiene because she forgot due to being nervous. CNA B said it was important to perform hand hygiene during incontinent care for infection control. CNA B said this should be done to prevent cross contamination. When CNA B was asked why she did not don (put on) PPE prior to entering Resident #23's room, she stated I forgot. CNA B stated the risk associated with not wearing the correct PPE or performing hand hygiene was a spread of infection. During an interview on 07/29/2024 at 09:00 AM, CNA O said when providing incontinent care, she was supposed to perform hand hygiene after removing her gloves. CNA O said she had not performed hand hygiene in between glove changes because she did not have any hand sanitizer in her pocket. CNA O said she should have washed her hands in the bathroom, but she was trying to help. CNA O said it was important to perform hand hygiene while providing incontinent care, so she did not pass germs. When CNA O was asked why she did not don (put on) PPE prior to entering Resident #23's room, she stated I don't think we are doing that anymore. CNA O stated the risk associated with not wearing the correct PPE or performing hand hygiene was a spread of infection. During an interview on 07/29/2024 at 3:34 PM, the Regional Corporate Compliance Nurse said hand hygiene should be performed in between glove changes. The Regional Corporate Compliance Nurse said she, the charge nurses, the ADON, and the DON were responsible for ensuring the CNAs were performing adequate hand hygiene during incontinent care and wear PPE appropriately. The Regional Corporate Compliance Nurse said random checks with the CNAs to ensure they were performing proper hand hygiene and incontinent care and the proper use of wearing PPE should be done. The Regional Corporate Compliance Nurse said she had not completed any random checks. The Regional Corporate Compliance Nurse said it was important to perform hand hygiene and wear PPE properly and appropriately during incontinent care because the residents could get a urinary tract infection and sepsis (infection in the bloodstream) and spread other infections. During an interview on 07/29/2024 at 04:15 PM, the Administrator said he expected all the staff to follow the policy on hand washing, changing gloves, and wearing the PPE when instructed by the signs placed at the resident's door. The Administrator said the charge nurses and clinical management were responsible for ensuring the CNAs were performing hand hygiene and wearing appropriate PPE. The Administrator said not performing hand hygiene adequately during incontinent care and not wearing the appropriate PPE could lead to the spread of disease, bacteria, and infections. 47708 12) During observation on 7/27/24 at 12:26 p.m., revealed CNA B did not sanitize hand in between residents when passing lunch trays on hall 800 and hall 900. CNA B touched and helped the residents sit up to eat lunch on hall 800 and hall 900. During an interview on 7/29/24 at 12:50 p.m., CNA B stated had been employed at the facility for a few months. Stated she had forgot to sanitize her hands between each resident when passing out meal trays on hall 900 and hall 800. During observation and interview on 7/29/24 at 12:50 p.m., of CNA B passing trays on hall 900 and hall 800, the Dietary Manager stated, I had noticed that [CNA B] did not sanitize her hands between passing meal trays but did not want to say anything. During an interview on 7/30/24 at 10:59 a.m., the Administrator stated he had been employed since May of 2024.The Administrator stated he was made of CNA B that she did not sanitize her hands between passing meals on 7/29/24. The Administrator stated CNA B had informed him on 7/29/24 that she did not sanitize her hands when passing lunch trays on 7/29/24. The Administrator stated hand washing in-services had been completed recently. The Administrator stated hand sanitation in-services was completed on Sunday 7/28/24 and on Monday 7/29/24. The Administrator stated he did expect staff to wash and sanitize hand between meal passing. The Administrator stated it was important for the staff to sanitize hands in between passing the resident meals trays for infection control. During an interview on 7/30/24 11:51 a.m., CNA B stated she had completed hand washing in-services a few weeks ago. CNA B stated when she was passing tray that she was supposed to sanitize hands between each tray she had passed. CNA B stated the ADON oversaw her. CNA B stated it was important to sanitize hands for possible contamination and infection control. During an interview on 7/30/24 at 2:33 p.m., the ADON stated she had been the ADON and Administrator in training for 20 days. The ADON stated she was paid salary and worked all the time at the facility. The ADON stated she was not made aware CNA B not using hand sanitation between passing meals to the residents. The ADON stated CNA B was a newly employed CNA. The ADON stated she was second in command to the CNAs at the facility. The ADON stated hand hygiene in-services was last completed on 7/28/24 and 7/29/24. The ADON stated the CNAs were to first report their charge nurse and then report to her last. The ADON stated the Administrator oversaw her. The ADON stated Hand hygiene was important for infection control and because anything you touch has germs on it, Record review of the undated Hand Hygiene policy indicated you may use alcohol-based hand cleaner or soap/water for the following: When coming on duty Before and after performing any invasive procedure. Before and after entering isolation precautions settings. Before and after assisting a resident with personal care Before and after changing a dressing. After contact with a resident's mucous membranes and body fluids or excretions . After removing gloves. You must use soap/water for the following: (alcohol base cleaner is not recommended) When hands are visibly soiled After personal us of the toilet Before and After assisting a resident with toileting (hand washing with soap and water) . Record review of the Perineal Care policy dated 4/25/2022 and effective as of 5/11/2022 indicated an incontinent resident of urine and or bowel should be identified, assessed and provided appropriate treatment and services to restore as much normal bladder/bowel function as possible. Procedure: .10.Perform hand hygiene 11. Donn gloves .17. Gently perform perineal care, wiping from clean, urethral areas to dirty, rectal area, to avoid contaminating the urethral area-clean to dirty. Female resident: working from front to back, wipe on side of the labia majora, the outside folds of the perineal skin that protect the urinary meatus and the vaginal opening. Continue perineal care to the inner thigh. If applicable, gently wash the juncture of the Foley catheter tubing from the urethra down the catheter about 3 inches. Then wipe the other side. Use a clean area of the washcloth or pre-moistened cleansing wipes for each stroke 24. Doff gloves and PPE (means to remove personal protective equipment (PPE), such as gloves, in a way that avoids self-contamination) 25. Perform hand hygiene. Important Points: Doffing and discarding of gloves are required if visibly soiled. Always perform hand hygiene before and after glove use Record review of an Infection Control Policy dated 3/2023 indicated: Infection Control: The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection . Preventing Spread of Infection The facility will require staff to wash their hands after each direct resident contract for which hand washing is indicated by accepted professional practice. Linens Personnel will handle, store, process and transport linens so as to prevent the spread of infection. Intent: The intent of this policy is to ensure that the facility develops, implements, and maintains an Infection Prevention and Control Program in order to prevent, recognize and control, to the extent possible, the onset and spread of infection within the facility Record Review of the facility's policy titled Fundamentals of Infection Control Precautions updated on 3/2023, indicated a variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions. 1. Hand Hygiene . Upon and after coming in contact with a resident's intact skin ., before and after assisting resident with toileting ., after removing gloves 5. Gowns and protective apparel. 1. Gown and protective apparel are worn to provide barrier protection and reduce the opportunity for transmission of microorganism in the long-term care facility Isolation-Categories of Transmission-Based Precautions . transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents Contact Precautions (7) Staff and visitors were gloves when entering room. (8) Staff and visitors wear a disposable gown upon entering the room .

Based on interview and record review, the facility failed to ensure residents who require dialysis services receive such services consistent with professional standards of practice for 2 of 2 residents reviewed for dialysis services. (Residents #23 and Resident #24) The facility failed to keep ongoing communication with the dialysis facility for Resident #23 and Resident #24. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. The findings included: 1)Record review of Resident #23's face sheet, dated 07/30/2024, indicated Resident #23 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of end stage renal disease (occurs when chronic kidney disease - the gradual loss of kidney function - reaches an advanced state), type 2 diabetes mellitus with diabetic neuropathy (high blood sugar that has caused nerve damage), and encephalopathy (a disease that impacts the functioning of the brain). Record review of the order summary report, dated 07/30/2024, indicated Resident #23 had an order, which started on 05/22/2024, that stated dialysis on Tuesday, Thursday, and Saturday days. Record review of Resident #23's pre and post dialysis communication forms for July 2024, showed the following: 1. No dialysis communication form on 7/04/2024, 07/06/2024, 07/09/2024, and 07/11/2024. 2. No post-dialysis vital sign documentation filled out on 07/02/2024, 07/13/2024, 07/16/2024, 07/18/2024, 07/20/2024, 07/23/2024 and 07/25/2024. Record review of the Comprehensive MDS assessment, dated 07/12/2024, indicated Resident #23 had clear speech and was understood by staff. The MDS revealed Resident #23 was able to understand others. The MDS revealed Resident #23 had a BIMS score of 11, which indicated moderate cognitive impairment. The MDS revealed Resident #23 received dialysis while a resident during the 14-day look-back period. Record review of the comprehensive care plan, last revised on 05/24/2024, revealed Resident #23 received dialysis three times a week for end stage renal disease. 33249 2) Record review of a face sheet dated 7/30/2024 reflected Resident #24 was a 63 -year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of chronic kidney disease, dependence on renal dialysis, and heart failure. Record review of a Dehydration Risk Screener dated 7/14/2021 indicated Resident #24 was a dehydration risk. The screen indicated Resident #24 was on diuretic therapy, received medications, had a terminal illness, was incontinent and required assistance with ADLs. Record review of the comprehensive care plan dated 7/27/2021 and revised on 1/05/2023 indicated Resident #24 had a potential for fluid deficit. The care plan goal was Resident #24 would be free of symptoms of dehydration, maintain moist membranes and good skin turgor (elasticity). The care plan interventions included encourage to drink fluid of choice. The care plan failed to address the fluid restriction and interventions. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #24 understood and was understood by others. The MDS indicated Resident #24's BIMS score was 12 indicating moderate cognitive impairment. The MDS indicated Resident #24 was able to feed himself. The MDS in Section O- Special Treatments, Procedures, and Programs indicated Resident #24 received dialysis. Record review of the Consolidated Physician's orders dated July 2024 indicated Resident #24 was ordered dialysis on Monday, Wednesday, and Friday. Record review of the Dialysis Communication Form: Facility assessment pre-dialysis included: temperature, pulse, respirations, and blood pressure, assessed the access site, assessed the thrill and bruit , assessed the dressing, documented any medication changes, documented any condition changes. The Dialysis Center Section indicated: Pre-Dialysis: weight; temperature, pulse, respirations, and blood pressure. Post-Dialysis: weight; temperature, pulse, respirations, and blood pressure. Nursing Facility Post-Dialysis Documentation: Assessment of temperature, pulse, respirations, blood pressure, access site, thrill (buzz sound of blood flowing) and bruit (whooshing sound), dressing clean dry and intact, assessment of the resident, and any new orders. Record review of the Dialysis Communication Forms for the month of July 2024 indicated: 7/01/2024: Resident #24's pre-dialysis assessment was completed by the facility; the dialysis unit section was completed by the dialysis center; and the third section Nursing Facility Post Dialysis Documentation section was blank. 7/03/2024: Resident #24's pre-dialysis assessment was completed by the facility; the dialysis unit section was completed by the dialysis center; and the third section Nursing Facility Post Dialysis Documentation section was blank. 7/05/2024: Resident #24's pre-dialysis assessment was completed by the facility; the dialysis unit section was completed by the dialysis center; and the third section Nursing Facility Post Dialysis Documentation section was blank. 7/08/2024: Resident #24's pre-dialysis assessment was completed by the facility; the dialysis unit section was completed by the dialysis center; and the third section Nursing Facility Post Dialysis Documentation section was blank. 7/10/2024: no dialysis communication form was provided. 7/12/2024: Resident #24's pre-dialysis assessment was completed by the facility; the dialysis unit section was completed by the dialysis center and included an order for fluid restriction 1.5 liters for 24 hours; and the third section Nursing Facility Post Dialysis Documentation section was blank. 7/15/2024: Resident #24's pre-dialysis assessment was completed by the facility; the dialysis unit section was completed by the dialysis center; and the third section Nursing Facility Post Dialysis Documentation section was blank. 7/17/2024: Resident #24's pre-dialysis assessment was completed by the facility; the dialysis unit section was completed by the dialysis center; and the third section Nursing Facility Post Dialysis Documentation section was blank. 7/19/2024: Resident #24's pre-dialysis assessment was completed by the facility; the dialysis unit section was completed by the dialysis center; and the third section Nursing Facility Post Dialysis Documentation section was blank. 7/22/2024: Resident #24's pre-dialysis assessment was completed by the facility; the dialysis unit section was completed by the dialysis center; and the third section Nursing Facility Post Dialysis Documentation section was blank. 7/24/2024: Resident #24's pre-dialysis assessment was completed by the facility; the dialysis unit section was completed by the dialysis center; and the third section Nursing Facility Post Dialysis Documentation section was blank. 7/26/2024: Resident #24's pre-dialysis assessment was completed by the facility; the dialysis unit section was completed by the dialysis center; and the third section Nursing Facility Post Dialysis Documentation section was blank. Record review of Resident #24's blood pressures in the vital signs section of the electronic medical record for the month of July 2024 indicated: 7/01/2024: no blood pressure 7/03/2024: pre-dialysis at 9:47 a.m., 99/66 no other blood pressures documented. 7/05/2024: no pre-dialysis or post-dialysis blood pressure documentation. 7/08/2024: no pre-dialysis or post-dialysis blood pressure documentation. 7/10/2024: no pre-dialysis or post-dialysis blood pressure documentation. 7/12/2024: pre-dialysis at 10:55 a.m., 140/70 no other blood pressures documented. 7/15/2024: no pre-dialysis or post-dialysis blood pressure documentation. 7/17/2024: pre-dialysis at 10:42 a.m., 118/62 no other blood pressures documented. 7/19/2024: no pre-dialysis or post-dialysis blood pressure documentation. 7/22/2024: post-dialysis at 5:18 p.m., 133/73 no other blood pressures documented. 7/24/2024: no pre-dialysis or post-dialysis blood pressure documentation. 7/26/2024: pre-dialysis at 10:57 a.m., 108/68 no other blood pressures documented. During an interview on 7/30/2024 at 9:45 a.m., LVN A said Resident #24 should be assessed prior to leaving for dialysis and after he returns from dialysis. LVN A said the dialysis communication form should be filled out pre-dialysis and post-dialysis by the nurses. LVN A said usually Resident #24 returns around dinner time, and he waves at them as he passes by the nurse's station. LVN A said the assessment of Resident #24 was important to ensure his blood pressure was stable and he was not having low blood pressure. During an interview on 7/30/2024 at 7:17 p.m., the ADON stated dialysis communication forms should have been completed by the nurses . The ADON stated the nurses were expected to ensure both the pre and post dialysis documentation was completed. The ADON stated she was not aware the wrong forms were being utilized and did not have a space for post dialysis documentation. The ADON stated the importance of ensuring dialysis communication forms were filled out was to ensure continuity of care and to catch potential problems early on such as hypotension (low blood pressure). During an interview on 07/30/2024 at 08:11 PM, the RNC stated the charge nurses were responsible for appropriately filling out the pre and post information on the dialysis communication form. The RNC said she had recently replaced the form when it was brought to her attention there was no place to document post dialysis vital sign information. The RNC said the dialysis communication forms were important to find out if there were any issues with the resident. The regional corporate compliance nurse said if the forms were not completed, then the resident's vital signs could be out of line and staff would not know about it or the resident could get ill from a low blood pressure. During an interview on 07/30/2024 at 08:42 PM, the Administrator stated he expected dialysis communication forms to be completed. The Administrator stated the charge nurses were responsible for ensuring the communication forms were filled out. The Administrator said he expected the ADON and DON to oversee this process. The Administrator stated the importance of ensuring dialysis communication forms were filled out was to ensure the residents received proper documentation of their care. The Administrator stated if the communication forms were not done appropriately, it could result in residents having adverse reactions. Record review of the policy on Dialysis, revised November 2011 indicated, .19. The facility will monitor departures and returns from the dialysis center. The facility will document the resident's vital signs, general appearance, orientation and additional baseline data as needed. The resident clinical record will be documented with this information. The date and time of the resident's return to the facility will be recorded by the nurse. The facility will be observant of any of the following symptoms.

Based on observations, interviews, and record reviews the facility failed protect and promote the rights of the residents for 1 of 11 residents (Resident #27) reviewed for resident rights. The facility failed ensure LVN N provided privacy when she provided wound care to Resident #27 on 07/28/2024. This deficient practice could place residents at risk for loss of dignity. Findings included: Record review of Resident #27's face sheet dated 07/30/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), type 2 diabetes mellitus (long term condition in which the body has trouble controlling blood sugar and using for energy), malignant neoplasm of lung (lung cancer) and weakness. Record review of Resident #27's order summary report dated 07/20/2024, indicated Resident #27 had an order dated 01/24/2024 to cleanse wound to lower back with normal saline, pat dry, apply Triad paste and dry dressing one time a day for wound healing. Record review of Resident #27's comprehensive care plan dated 07/25/2024, indicated Resident #27 had a patchy area to lower back that, at times, she will scratch and cause it to open. The care plan interventions included follow facility protocols for treatment of injury and ongoing treatment in place. Record review of Resident #27's quarterly MDS assessment dated [DATE], indicated Resident #27 was able to understand others and was able to be understood. The MDS assessment indicated Resident #27 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #27 required substantial/maximal assistance with toileting, showering, lower body dressing and personal hygiene. Resident #27 required partial/moderate assistance with upper body dressing. During an observation and interview on 07/28/2024 at 01:35 PM, LVN N entered Resident #27's room to perform wound care on Resident #27. LVN N provided Resident #27's wound care by raising up the back side of her gown while Resident #27 sat on the side of the bed. LVN N failed to ensure Resident #27 had privacy when she left the door to her room open and did not pull the curtain around. LVN N completed Resident #27's wound care. LVN N said she forgot to close the door and/or pull the curtain. LVN N said by closing the door and pulling the curtain Resident #27 could have had privacy and would have felt more comfortable with care. LVN N said she was responsible for ensuring privacy was maintained during care. LVN N said by not providing privacy anyone could have walked in or by and viewed Resident #27 undressed and the wound care treatment. During an interview on 07/28/2024 at 02:35 PM, Resident #27 said it would have bothered her if someone she did not know walked in while wound care was performed because her back side was hanging out. During an interview on 07/30/2024 at 01:58 PM, the ADON said she expected privacy to be maintained when providing care to a resident. The ADON said it was her responsibility for ensuring the staff maintained privacy when providing care. The ADON said failure to provide privacy, when care was being provided, would place residents at risk for being seen by other people. During an interview on 07/30/2024 at 02:20 PM, the Regional Corporate Compliance Nurse said she expected LVN N to have closed the door and pulled the curtain when she provided wound care treatment for Resident #27. The Regional Corporate Compliance Nurse said it was the aides', nurses' and management's responsibility to ensure privacy was being maintained when providing care. The Regional Corporate Compliance Nurse said it was a dignity and privacy issue by not maintaining privacy with care. During an interview on 07/30/2024 at 09:10 PM, the Administrator said he expected staff to close the door and pull the curtain around when providing care to a resident. The Administrator said the person completing the task was responsible for ensuring the resident's privacy was maintained. The Administrator said management staff was responsible for ensuring the staff was knowledgeable in providing privacy to the residents. The Administrator said failure to provide a resident with privacy while providing care, was a privacy and dignity issue. Record review of the facility's policy and procedure Respect and Dignity: Resident's Rights for revised on 04/25/2022, indicated . The resident has a right to be treated with respect and dignity, including .7. Provide privacy and modesty by closing the door and/or curtain.

Based on interviews and record review, the facility failed to ensure residents and/or the residents' representatives the right to participate in the development and implementation of his or her person-centered plan of care for 1 of 18 residents (Residents #19) reviewed for care plans. The facility failed to invite and include the input of the resident (Resident #19) and/or resident's representatives as members of the interdisciplinary team in the Care Plan Conference meetings on 4/19/24 and 7/19/24. These failures could place residents at risk of not having needs met by depriving them the opportunity to participate in the decision making regarding their care. Findings included: Record review of Resident #19's face sheet dated 07/30/24 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of dementia (disease characterized by general decline in cognitive ability to perform everyday activities), cerebrovascular disease (disease that affects the blood vessels in the brain and cerebral circulation), heart failure (condition in which the heart does not pump blood as it should), and high blood pressure. Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated she made herself understood and understood others. The MDS also indicated she had a BIMS score of 3 which indicated she had severe cognitive impairment. Record review of Resident #19's care plan revised on 07/12/24 indicated she required total assistance from staff with transfers and requires 1 staff for toileting, bathing, bed mobility, and cueing for eating. Record review of Resident #19's care plan conference dated 04/19/24 indicated her representative attended the meeting, and the resident did not want to attend. Record review of Resident #19's care plan conference dated 07/16/24 indicated she attended the meeting, and her representative was unable to be reached with no documentation of when Resident #19's representative was called. During an interview on 07/29/24 at 05:00 PM Resident #19's family member said she had been requesting a care plan meeting since the resident admitted to the facility 12/2023 and an unknown head nurse told her they were behind schedule and would get one completed. The family member was worried that Resident #19 had discharged from hospice services, and she would not be able to keep up with her care She said she had never attended a care plan meeting in person or over the phone. During an interview on 07/30/24 at 02:16 PM the Hospice RN Q said Resident #19's family had reached out to her about the concern of not having care plan meetings. She said she was unaware of a care plan meeting. Hospice RN Q said when she reached out to the facility for the family an unknown person at the facility told her the facility did not have care plan meetings. She said it was important to keep residents and family involved in care. During an interview on 07/30/24 at 02:37 PM the MDS Nurse said she was responsible for care plan meetings and notifying the families about care plan meetings. She said they completed the care plan meetings quarterly and she calls the families to notify. The MDS nurse said sometimes she charts that she notified the family and sometimes she did not. She also said at times she placed a note in the chart in the care conference. She said she notifies hospice as well to notify of care plan meetings. She said she had notified Resident #19's family by phone about the care plan meetings. She said Resident #19's family was difficult to get a hold of. Resident #19's family was called on the phone for the meeting on 4/19/24 because she lives out of the country. She said she was unsure of why the documentation on the care plan conference had her attending the meeting because she did not attend. The MDS Nurse said she was unable to reach the family for the meeting 7/16/24. The MDS Nurse said she was unsure of the exact date she attempted to call Resident #19's representative and did not document the call. She said the hospice nurse said the family member wanted to talk to her about nursing, but she had not reached out to her yet. She said she invited the residents to the care plan meetings as well and the care plan meeting should have been documented to ensure the families are called. She said the facility had never mailed letters. She said she would have another care plan for the family because it was important since she knew that there were nursing concerns. During an interview on 07/30/24 at 06:34 PM The ADON said the MDS Nurse was responsible for care plan meetings and invitations for families and residents. She said she was not aware of ever having a care plan meeting for Resident #19. She said the care plan meetings were important for residents and family to discuss grievances, plan of care, and for family and resident to have input with the care. The care plan was also important to ensure medications and code statuses were correct. During an interview on 07/30/24 at 07:41 PM the DON said the MDS Nurse was responsible for care plan meetings and social worker if they had one. The DON said the care plan meetings should be completed quarterly and with significant changes. The DON said it was important the family and residents were invited and documented as invited to care plan meetings. She said the failure placed a risk for the family not being involved and placed a possibility of the facility not being able to meet expectations of the family. During an interview on 07/30/24 at 08:47 PM the Administrator said the MDS Nurse was responsible for care plan meetings and invitations of residents and families. He said Resident #19's family does not answer facility calls. The Administrator said he expected the MDS Nurse to document that the family was invited to the care plan meetings. He said the failure placed a risk to the resident and family to not be aware of the care changes or direction things are going with care. Record review of the undated facility policy Comprehensive Care Planning indicated: The facility will develop and implement a comprehensive person-centered care plan for each resident .Through the care planning process, facility staff will work with the resident and his/her representative, if applicable, to understand and meet the resident's preferences, choices, and goals during their stay at the facility.

Based on observation, interviews, and record reviews the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 18 (Resident #1) residents reviewed for accidents hazards and supervision. The facility failed to ensure Resident #1 did not keep cigarettes in her purse. The CNA D failed to ensure Resident #1 smoked only in the designated areas of the facility. These failures could place residents at risk for injury. The findings included: Record review of Resident #1's face sheet dated 07/30/24 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses multiple sclerosis(autoimmune disease in which the immune system eats away at the protective covering of the nerves and causes disruption of communication), major depressive disorder, and dementia. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated she made herself understood and understood others. The MDS also indicated she had a BIMS score of 11 which indicated she had moderately impaired cognition. Record review of Resident #1's care plan revised on 07/28/24 indicated that she chose to sign herself out of the facility to go off of the premises to smoke with interventions in place to ensure smoking occurred in designated smoking area and no smoking materials or igniters would be stored in the resident rooms. Record review of Resident #19's safe smoking assessment dated [DATE] indicated she was a safe smoke but need to keep materials at the nurse's station. During an observation on 07/29/24 at 01:39 PM Resident #1 was in her motorized wheelchair out in the designated smoking area at the end of the 400 hall and had her cigarettes stored in her purse. During an observation on 07/29/24 at 08:35 PM CNA D and Resident #1 were sitting beside the facility wall next to the front parking lot smoking cigarettes. During an interview on 07/30/24 at 03:15 PM CNA D said he apologized for smoking outside of the building on 07/29/24 when he knew that no staff nor resident should smoke outside of designated smoke area at the end of the hall 400. He said he knew neither him, nor the resident were supposed to smoke out front. CNA D said he was trying to be a good aide and follow the rules, but he said he was stressed from work, school, and life. During an interview on 07/30/24 at 03:17 PM Resident #1 said she talked with the administrator that is here now about going to an assisted living because she was tired of all the restrictions at the facility, and she was in her right mind. Resident #1 said the smoking was the biggest issue, but she must go off of their property to smoke to ensure they were not responsible for smoking outside of the times and areas. She said she liked to smoke when she wanted to smoke. Resident #1 said she kept her cigarettes and lighter on her and she signs out and goes to smoke. She said the policy was for the residents to keep cigarettes and lighters in the lock box and they get them out when they go for assigned smoke breaks. She said she was not keeping her cigarettes and lighter in the box because they would come up missing. During an interview on 07/30/24 at 06:36 PM the ADON said the staff had just taken the cigarettes and lighter away from Resident #19 and she was expected to keep her cigarettes and lighter in the lock box and get the items from the nurse's station at designated smoking times. The ADON also said staff and residents were not allowed to smoke in the parking lot by the building. She said Resident #1 was non-compliant and may need to find another placement. The ADON said the failure could result in oxygen exploding and fires but she said Resident #1 thinks there was no risk and she would not let the facility staff check her personal items and take the cigarettes and lighters. During an interview on 07/30/24 at 07:38 PM the Regional Corporate Compliance Nurse said Resident #1 was not supposed to have the cigarettes and lighters in her possession and she was supposed to turn the cigarettes and lighters in after the completion of smoke breaks. She said Resident #1 was her own responsible party and could sign herself out to smoke off the property because she liked to smoke when she was ready and it was outside of the designated times. She said no staff or residents should have been smoking on the property except in designated areas. The Regional Corporate Compliance Nurse said all staff were responsible for ensuring residents did not have cigarettes and lighters in their possession or in their rooms. She said Resident #1 should turn cigarettes and lighters in when she completed smoking breaks. The Regional Corporate Compliance Nurse said the risk for the failure was fires. During an interview on 07/30/24 at 08:44 PM The Administrator said his expectation was for Resident #1 to keep the cigarettes and lighters in the lock box at the nurse's station and check them out as needed prior to smoke breaks. He said neither Resident #1 nor CNA D should have been smoking on the property outside of designated smoking areas. He said he had confiscated cigarettes and lighters in the past from Resident #1 and she would go and buy more. He said the failures placed a risk for other residents getting the cigarettes and lighters and having fun with them which caused issues like fires. The Administrator said the purpose of residents and staff using designated smoking area is for safety and the designated areas have smoke blankets and fire extinguishers available. Record Review of the facility's policy titled, Smoking Policy revised on 11/01/2017 indicated, Smoking policies must be formulated and adopted by the facility .The facility is responsible for enforcement of smoking policies which must include at least the following provisions: 1. Matches, lighters or other ignition sources for smoking are not permitted to be kept or stored in a resident's room. Smoking is only allowed in designated smoking areas. Smoking is prohibited in any area labeled No Smoking .

33249 Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to the State Survey Agency for 1 of 8 residents (Resident #17) reviewed for abuse and neglect. The facility failed to report to the State Survey Agency on 8/16/2023 immediately but no later than 2 hours after becoming aware Resident #17 sustained a severe coffee burn to his right thigh. This failure could place residents at risk of further potential abuse or neglect. Findings included: Record review of a face sheet dated 7/30/2024 indicated Resident #17 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses heart failure, quadriplegia (paralysis of all four limbs), and other muscle spasms, contractures of the left and right hands (a condition where the one or more fingers bend toward the palm of the hand), lack of coordination, muscle weakness, muscle wasting and atrophy. Record review of the Comprehensive Care Plan dated 11/02/2023 indicated Resident #17 was at risk for burns due to hot liquids. The goal of Resident #17's care plan was he would not suffer any injury related to hot liquids. The interventions included coffee and other hot liquids should not be served if over 140 degrees, if hot liquid was spilled on self, staff should pour room temperature or lower temperature liquid over the affected area, he was to use his dominant hand for drinking, and should be seated in upright position with table or overbed table when hot liquids were being consumed. The Comprehensive Care Plan failed to indicate there was a hot liquid deficit prior to 11/02/2023. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #17 understood and was understood by others. The MDS indicated Resident #17's BIMS score was 15 indicating he had no cognitive deficits. Record review of a nursing progress note dated 8/16/2023 at 12:31p.m., RN F documented Resident #17 said he had a dry area to his right thigh. RN F documented upon assessment she noted a dry scabbed area measuring about 3.5 x 5 (no documented measurement system). The note indicated Resident #17 indicated he had a coffee cup sitting by the side of his wheelchair and it poured on him while he was trying to sit up. The note indicated RN F notified the nurse practitioner, and a new order was received to apply triple antibiotic ointment and cover with a dressing daily until resolved. Record review of a Nurse Practitioner Progress Note dated 8/21/2023 at 10:20 a.m., the nurse practitioner documented the chief complaint was a burn to the right upper thigh. The History of Present Illness section indicated Resident #17 was a [AGE] year old male The nurse practitioner note indicated Resident #17 was seen as requested by the DON due to a new wound to upper thigh. The note indicated Resident #17 said he spilled hot coffee and got burned. The note indicated Resident #17 said it was excruciating. The note indicated the burn was treated with the over-the-counter triple antibiotic cream and covered with a dressing daily. The note in the Section Current Problems: Burn of third degree of right thigh . Review of Systems section labeled Wounds: complaints of wound redness, discharge, pain, and opening of the wound. The note in Section Wound indicated: Traumatic burn to upper thigh right leg with the onset date of 8/14/2023, measuring 5.5 centimeters, 2.5 centimeters width, 0.3 centimeters depth. The note indicated the wound base was slough, with a small amount of serosanguinous drainage. The note indicated Resident #17's burn exposed the adipose tissue and was considered a full thickness wound. The note indicated Resident #17's burn was 51-75% slough; and 25-50% epithelialization and erythema present. The nurse practitioner note indicated Resident #17 was ordered cleanse the wound with normal saline, apply Silvadene, cover with a foam dressing twice daily. The note indicated the nurse practitioner applied a topical anesthetic, after explaining the risks and benefits of debridement (removal of dead tissue using a sharp instrument), debridement was performed without complications. During an attempted interview on 7/29/2024 at 11:36 a.m., the previous DON was called but she had her telephone going to voice mail and a message was left to return the call related to the investigation. During an observation and interview on 7/29/2024 at 11:45 a.m., Resident #17 said he had previously had a coffee spill that caused a burn to his leg. Resident #17 said he had received treatment for the burn. Resident #17 was drinking coffee from a spill proof coffee cup with a lid and a straw. Resident #17 said he had not had any other burns. Record review of the state agency reporting system for abuse and neglect revealed from 8/16/2023 -8/21/2023 there were no reported incidents regarding Resident #17's burn. During an interview on 7/30/2024 at 6:57 p.m., the ADON said she was not a staff member at the facility when Resident #17 had the coffee burn. The ADON said a burn was a reportable incident to the state agency. The ADON said the Administrator was the abuse coordinator and was responsible for reporting to the state agency. The ADON said she expected the facility abuse policy to be followed and report according to the required time frame of within 2 hours. The ADON said monitoring for incidents and accidents requiring reporting was done through morning meeting and review of the 24-hour report in the computer system. During an interview on 7/30/2024 at 8:02 p.m., the RNC said she was not an employee of the facility when the incident occurred with Resident #17. The RNC said she was unable to comment why the incident was not reported to the state agency, but she agreed the incident should have been reported. The RNC said the state agency should have been made aware of the incident within the two-hour time frame for reporting abuse. The RNC said when an abuse allegation was not reported timely then abuse could continue. The RNC said in morning meeting the incidents and accidents were reviewed. The RNC indicated this incident was not documented on an incident report but should have been. The RNC said in morning meeting the team also reviews the computerized documentation that flows to the 24-hour report. During an interview on 7/30/2024 at 8:51 p.m., the Administrator said when Resident #17 had his coffee burn, he was not the Administrator. The Administrator said he was the abuse coordinator, and the incident required reporting within 2 hours. The Administrator said the incident was not reported through his review. The Administrator said when abuse was not reported timely this could delay the care and services the resident would receive. Record review of an Abuse/Neglect policy dated 2003 and revised on 5/09/2017 indicated the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals . 2. Adverse event. An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof C. Prevention 4. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. The facility has in place a method to identify events such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse. All occurrences of potential abuse or criminal behavior will be investigated by the abuse preventionist and/or designee E. Reporting 3. Facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown sources to the facility administrator. The facility administrator or designee will report the allegation to HHSC. A. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation F. Investigation Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated.

Based on observation, interview and record review, the facility failed to provide an ongoing program of activities based on the comprehensive assessment to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 7 of 12 residents (Resident #24, Resident #27, and 5 confidential residents) reviewed for activities. The facility failed to ensure quarterly activity assessments were completed for Resident #24, Resident #27, and 5 confidential residents to provide activities to meet their interests. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. Findings included: 1) Record review of a face sheet dated 7/30/2024 reflected Resident #24 was a 63 -year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of chronic kidney disease, dependence on renal dialysis, and heart failure. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #24 understood and was understood by others. The MDS indicated Resident #24's BIMS score was 12 indicating moderate cognitive impairment. The MDS indicated Resident #24 was able to feed himself. Resident #24's activities were not addressed on the Quarterly MDS assessment. Record review of the comprehensive care plan dated 4/22/2022 and revised on 1/05/2023 indicated Resident #24 needed out of room social, spiritual, and stimulus activities and mental stimulation. The care plan goal was Resident #24 would attend activities of his choice, watch television, read, or socialize with other residents at least 2 times weekly. The care plan interventions included the activity director will encourage and remind the resident of current activities, the activity director will provide the resident with reading material for mental stimulation, and the activity director will praise the resident for attending activities of their choice. During an observation and interview on 7/28/2024 at 11:09 a.m., Resident #24 was sitting in his wheelchair in his room. Resident #24 said he was so bored. Resident #24 said there was only so much bingo and dominoes a person could play. Resident #24 said the resident council had asked the Activity Director for more activities and even some outings but nothing had transpired. Resident #24 said he had not been assessed for his desired activity needs by the activity director. Record review of the Activity Calendar dated July 2024 indicated: Sunday 7/28/2024: 10:00 a.m. word search; 11:00 a.m. puzzles; and 2:00 p.m. dominos Monday 7/29/2024: 8:30 a.m. Devotionals; 10:00 a.m. morning exercise; 11:00 a.m. Tasty Appetizers; 2:00 p.m. Fancy nails; 3:30 p.m. one on one Tuesday 7/30/2024: 8:30 a.m. pass out daily devotionals; 10:00 a.m. morning exercise; 11:00 a.m. Tasty Appetizers; 2:00 p.m. juice pong; 3:00 p.m. Skip-Bo; 6:00 p.m. arts and crafts. During an observation on 7/29/2024 at 10:05 a.m., there was no exercise activity happening in the dining room. During an observation and interview on 7/29/2024 at 10:11 a.m., the RNC said the exercise activity usually occurred in the main dining room. The RNC began looking for the AD. The RNC said the AD had run to the store and she should be back soon. During an observation on 7/29/2024 at 11:16 a.m., there was not a tasty appetizer activity in the dining room. During an observation and interview on 7/30/2024 at 7:31 a.m., the AD was walking in the hallway with a handful of papers. The AD said she was supposed to fill these forms out. The form for the month of July only had resident names listed. The AD provided a list activities for the month of July. The AD said she had not documented the individual residents who attend any activities. The AD said she often was pulled to work in the dietary department and other areas. During an interview on 7/30/2024 at 9:03 a.m., the AD said she had been in her position since March 2024. The AD said with the bedridden residents she does 1:1 activity, some residents do better in small groups, and the larger groups for the more outgoing residents. The AD said she had not been documenting when a resident attended activities in the computer charting area or on a log. The AD said she had just this weekend taken two residents to Walmart one on Saturday and one on Sunday. The AD said every time she had a planned outing there were not enough CNAs to go, the driver had to work the floor, or the van was scheduled for doctor appointments. The AD said she had mentioned these issues to the Administrator, and they had been trying to work through them. The AD said she had her family purchase board games as a donation but had not had the opportunity to go and obtain them. The AD said she often was pulled from her activity position to help with transportation in the past and in the dietary department. The AD said she had a budget for the activity department but it was based on census and was not much now. During a confidential interview on 7/30/2024 at 2:00 p.m., 5 residents said the activity program was terrible. The residents said they felt as though they were in prison. The residents said there used to be outings such as going out to eat at a local restaurant, there was family night, and there had been times when they were invited to other senior facilities for a game night. The residents said it has been a year since they were able to go out to eat, on an outing of any sort, or have a game night with other seniors. The residents said they had brought this up many times in the Resident Council Meetings and nothing has improved. Another resident said, we are in jail and we are still on lock-down. A resident said the Monopoly and checker game have missing pieces. Another resident said a chess game would be so nice. During an interview on 7/30/2024 at 7:07 p.m., the ADON said they should be providing 5 activities a day. The ADON said the activities should also be meaningful to the resident. The ADON said she expected the AD to preplan trips with the residents. The ADON said without meaningful activities a resident could become depressed. During an interview on 7/30/2024 at 8:15 p.m., the RNC said the activities should be meaningful and what the residents desire. The RNC said when activities were not meaningful a resident could become bored, loose interest, and potentially become depressed. The RNC said the Administrator had oversight of the AD and the department. The RNC said usually the activity concerns from the resident council would go to him to resolve. The RNC said she was unaware of the resident's concerns. During an interview on 7/30/2024 at 9:08 p.m., the Administrator said there was a budget for the activity department and the board games the residents wanted could be easily obtained. The Administrator said the activity department was designed to be life enrichment and he expected the activity department to be such. 30527 2. Record review of Resident #27's face sheet dated 07/30/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), type 2 diabetes mellitus (long term condition in which the body has trouble controlling blood sugar and using for energy), malignant neoplasm of lung (lung cancer) and weakness. Record review of Resident #27's order summary report dated 07/20/2024, indicated Resident #27 had an order dated 04/05/2022 Resident #27 may participate in activities per care plan. Record review of Resident #27's quarterly MDS assessment dated [DATE], indicated Resident #27 was able to understand others and was able to be understood. The MDS assessment indicated Resident #27 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #27 required substantial/maximal assistance with toileting, showering, lower body dressing. Record review of the care plan with a target date of 08/09/2023 indicated Resident #27 needed out of room social, spiritual, and stimulus activities and mental stimulation. The goal was for Resident #27 to attend activities of her choice, will watch TV, read and socialize with other residents at least 2 times weekly by next update. The interventions included the following: the activity director will encourage and remind the resident of current activities, the activity director will provide the resident reading material for mental stimulation, the activity director will praise the resident for attending activities of their choice. Record review of Resident #27's electronic health record indicated Resident #27 had no completed activity assessments. During an observation and interview on 07/28/2024 at 10:15 AM, Resident #27 was sitting in her bed without any lights on or blinds open. Resident #27 stated she had always participated in activities, but now with the new activity director, the only activity provided was on Tuesday evenings by a volunteer. Resident #27 stated she would at least like something to read occasionally, but nothing had been offered. Resident #27 had the activities calendar from July 2024 posted on her wall. Resident #27 stated those activities did not occur. Resident #27 stated the Activity Director before would take the residents out to eat occasionally, but that has not happened in over 6 months although it had been scheduled but later canceled. During an interview on 07/30/2024 at 09:10 AM the Activity Director said she had been in the position as Activity Director since March of 2024. The Activity Director said she had not completed any documentation to show Resident #27 was provided or that she had offered any activities. The Activity Director stated she had failed to document the activity assessment information because she was often pulled to help in the kitchen area and did not have enough time to document. The Activity Director said it was important to complete the activity assessments and documentation to know the resident's likes or dislikes and to prevent them from declining and show that she had provided the activities. The Activity Director stated the resident outings had been canceled on several occasions for different reasons such as the previous Administrator told them they could not go any longer. Record review of the facility's undated policy titled, Activity Programming indicated, The Activity Director and staff will provide for ongoing Activity programs. PRACTICE GUIDELINES: 1. Recreation programs are based on the interest and needs of the residents expressed through the activity assessment .10. The opportunity is provided for regular community outings/trips .

Based on observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents reviewed (Resident #12) for incontinent care, or catheter care. CNA L failed to perform hand hygiene during Resident #12's continent care. CNA L failed to perform catheter care when Resident #12 received incontinent care. This failure placed residents who required assistance with incontinent care at risk for urinary tract infections, skin breakdown, and hospitalization . Findings included: Record review of a face sheet dated 7/30/2024 indicated Resident #12 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of rheumatoid arthritis end-stage (a chronic inflammatory disorder that can affect more than just your joints), fractured right femur (upper leg bone), and multiple pressure ulcers. Record review of the consolidated physician's orders dated July 30, 2024, indicated on 5/19/2024 Resident #12 was ordered catheter care every shift. Record review of the undated Comprehensive Care Plan Indicated Resident #12 had an indwelling catheter related to pressure ulcers. The care plan indicated Resident #12 required ADL care with the goal of she will maintain or improve current level of function in bed mobility, transfers, eating, dressing, toilet use, and personal hygiene. The interventions included Resident #12 required total assistance with personal hygiene care. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #12 was understood and understands others. The MDS indicated Resident #12's BIMS score was 15 indicating no cognitive impairment. The MDS indicated Resident #12 was dependent with toileting hygiene. The MDS in Section H-Bladder and Bowel indicated Resident #12 had an indwelling catheter. Record review of a CNA Proficiency Audit dated 4/23/2024 indicated CNA L was assessed in the area of hand washing, catheter care, infection control awareness, and perineal care scoring a satisfactory in skill level. During an observation on 7/28/2024 at 11:37 a.m. - 12:00 p.m., CNA L entered the room, washed her hands, obtained a box of gloves, sat them on the foot of the bed, and obtained an under pad. CNA L donned another pair of gloves while LVN K held Resident #12's right leg, and RN P assisted Resident #12 to roll more toward her left side. CNA L cleaned Resident #12's peri area using a wipe with a wiping motion toward Resident #12's rectum. CNA L used another wipe and completed the wiping motion again. Resident #12 had a very small bowel movement, then CNA L grabbed a wipe and removed the bowel movement. CNA L then adjusted the draw sheet underneath Resident #12, then she took the disposable under pad, rolled the edge up, and tucked this pad underneath Resident #12. CNA L then removed her gloves, and her personal protective equipment, and washed her hands. CNA L failed to perform catheter care during the incontinent care process. During an interview on 7/28/2024 at 12:30 p.m., RN P said CNA L failed to change gloves and do hand hygiene between dirty and clean areas of incontinent care. RN P said she agreed she had not witnessed CNA L provide catheter care as well. RN P said she made a mistake by placing the dirty linen on the floor as well. RN P said Resident #12 was at risk for UTIs(urinary tract infection) when catheter care and incontinent care were not provided correctly. RN P said she was unaware she could have stopped the process and corrected the incontinent care procedure. During an interview on 7/28/2024 at 1:09 p.m., LVN K said CNA L should have performed hand hygiene and changed gloves between dirty and clean during incontinent care with Resident #12. LVN K said she was unaware she could have corrected CNA L during the incontinent care procedure. LVN K said Resident #12 was at risk for urinary tract infections when incontinent care was not performed correctly. During an interview on 7/30/2024 at 8:01 a.m., CNA L said she had forgotten to perform hand hygiene and change her gloves between dirty and clean during incontinent care. CNA L said she had though she had performed catheter care. CNA L said Resident #12 was at risk of urinary tract infections when incontinent care was not performed correctly. During an interview on 7/30/2024 at 6:41 p.m., the ADON said she expected the CNAs to clean their hands by performing hand hygiene between dirty and clean areas of incontinent care. The ADON said not performing hand hygiene could cause infections. The ADON said this was monitored by the performance of skill check offs and random checks while performing incontinent care on a resident or the use of a mannequin. During an interview on 7/30/2024 at 7:51 p.m., the RNC said she expected CNA L to perform hand hygiene when going from dirty to clean in the incontinent care process. The RNC said when this hand hygiene was not performed, and new gloves applied the resident was at risk of infection. The RNC said the nurse managers were responsible for ensuring appropriate incontinent care monitoring through the use of random check offs and annual check offs. During an interview on 7/30/2024 at 8:51 p.m., the Administrator said he expected the staff the perform hand hygiene between clean and dirty to prevent the spread of germs. The Administrator said the staff should be monitored by the nurse managers by competencies. Record review of the undated Hand Hygiene policy indicated you may use alcohol-based hand cleaner or soap/water for the following: When coming on duty Before and after performing any invasive procedure. Before and after entering isolation precautions settings. Before and after assisting a resident with personal care Before and after changing a dressing After contact with a resident's mucous membranes and body fluids or excretions . After removing gloves. You must use soap/water for the following: (alcohol based cleaner is not recommended) When hands are visibly soiled After personal use of the toilet Before and After assisting a resident with toileting (hand washing with soap and water) . Record review of the Perineal Care policy dated 4/25/2022 and effective as of 5/11/2022 indicated an incontinent resident of urine and or bowel should be identified, assessed and provided appropriate treatment and services to restore as much normal bladder/bowel function as possible. Procedure: .10.Perform hand hygiene 11. Donn gloves .17. Gently perform perineal care, wiping from clean, urethral areas to dirty, rectal area, to avoid contaminating the urethral area-clean to dirty. Female resident: working from front to back, wipe on side of the labia majora, the outside folds of the perineal skin that protect the urinary meatus and the vaginal opening. Continue perineal care to the inner thigh. If applicable, gently wash the juncture of the Foley catheter tubing from the urethra down the catheter about 3 inches. Then wipe the other side. Use a clean area of the washcloth or pre-moistened cleansing wipes for each stroke 24. Doff gloves and PPE 25. Perform hand hygiene. Important Points: Doffing and discarding of gloves are required if visibly soiled. Always perform hand hygiene before and after glove use.

33249 Based on observation, interview, and record review, the facility failed to implement their written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident's property of 1 of 1 resident reviewed for abuse, neglect, and exploitation. (Resident #17) The facility did not implement their policy to report to HHSC when Resident #17 sustained a severe coffee burn on 8/16/23. This failure could place the residents at risk for further potential abuse, neglect, and injuries of unknown origin. Findings included: Record review of an Abuse/Neglect policy dated 2003 and revised on 5/09/2017 indicated the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals . 2. Adverse event. An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof C. Prevention 4. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. The facility has in place a method to identify events such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse. All occurrences of potential abuse or criminal behavior will be investigated by the abuse preventionist and/or designee E. Reporting 3. Facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown sources to the facility administrator. The facility administrator or designee will report the allegation to HHSC. A. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation F. Investigation Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated. Record review of a face sheet dated 7/30/2024 indicated Resident #17 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses heart failure, quadriplegia (paralysis of all four limbs), and other muscle spasms, contractures of the left and right hands (a condition where the one or more fingers bend toward the palm of the hand), lack of coordination, muscle weakness, muscle wasting and atrophy. Record review of the Comprehensive Care Plan dated 11/02/2023 indicated Resident #17 was at risk for burns due to hot liquids. The goal of Resident #17's care plan was he would not suffer any injury related to hot liquids. The interventions included coffee and other hot liquids should not be served if over 140 degrees, if hot liquid was spilled on self, staff should pour room temperature or lower temperature liquid over the affected area, he was to use his dominant hand for drinking, and should be seated in upright position with table or overbed table when hot liquids were being consumed. The Comprehensive Care Plan failed to indicate there was a hot liquid deficit prior to 11/02/2023. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #17 understood and was understood by others. The MDS indicated Resident #17's BIMS score was 15 indicating he had no cognitive deficits. Record review of a nursing progress note dated 8/16/2023 at 12:31p.m., RN F documented Resident #17 said he had a dry area to his right thigh. RN F documented upon assessment she noted a dry scabbed area measuring about 3.5 x 5 (no documented measurement system). The note indicated Resident #17 indicated he had a coffee cup sitting by the side of his wheelchair and it poured on him while he was trying to sit up. The note indicated RN F notified the nurse practitioner, and a new order was received to apply triple antibiotic ointment and cover with a dressing daily until resolved. Record review of a Nurse Practitioner Progress Note dated 8/21/2023 at 10:20 a.m., the nurse practitioner documented the chief complaint was a burn to the right upper thigh. The History of Present Illness section indicated Resident #17 was a [AGE] year old male The nurse practitioner note indicated Resident #17 was seen as requested by the DON due to a new wound to upper thigh. The note indicated Resident #17 said he spilled hot coffee and got burned. The note indicated Resident #17 said it was excruciating. The note indicated the burn was treated with the over-the-counter triple antibiotic cream and covered with a dressing daily. The note in the Section Current Problems: Burn of third degree of right thigh . Review of Systems section labeled Wounds: complaints of wound redness, discharge, pain, and opening of the wound. The note in Section Wound indicated: Traumatic burn to upper thigh right leg with the onset date of 8/14/2023, measuring 5.5 centimeters, 2.5 centimeters width, 0.3 centimeters depth. The note indicated the wound base was slough, with a small amount of serosanguinous drainage. The note indicated Resident #17's burn exposed the adipose tissue and was considered a full thickness wound. The note indicated Resident #17's burn was 51-75% slough; and 25-50% epithelialization and erythema present. The nurse practitioner note indicated Resident #17 was ordered cleanse the wound with normal saline, apply Silvadene, cover with a foam dressing twice daily. The note indicated the nurse practitioner applied a topical anesthetic, after explaining the risks and benefits of debridement (removal of dead tissue using a sharp instrument), debridement was performed without complications. During an attempted interview on 7/29/2024 at 11:36 a.m., the previous DON was called but she had her telephone going to voice mail and a message was left to return the call related to the investigation. During an observation and interview on 7/29/2024 at 11:45 a.m., Resident #17 said he had previously had a coffee spill that caused a burn to his leg. Resident #17 said he had received treatment for the burn. Resident #17 was drinking coffee from a spill proof coffee cup with a lid and a straw. Resident #17 said he had not had any other burns. Record review of the state agency reporting system for abuse and neglect revealed from 8/16/2023 -8/21/2023 there were no reported incidents regarding Resident #17's burn. During an interview on 7/30/2024 at 6:57 p.m., the ADON said she was not a staff member at the facility when Resident #17 had the coffee burn. The ADON said a burn was a reportable incident to the state agency. The ADON said the Administrator was the abuse coordinator and was responsible for reporting to the state agency. The ADON said she expected the facility abuse policy to be followed and report according to the required time frame of within 2 hours. The ADON said monitoring for incidents and accidents requiring reporting was done through morning meeting and review of the 24-hour report in the computer system. During an interview on 7/30/2024 at 8:02 p.m., the RNC said she was not an employee of the facility when the incident occurred with Resident #17. The RNC said she was unable to comment why the incident was not reported to the state agency, but she agreed the incident should have been reported. The RNC said the state agency should have been made aware of the incident within the two-hour time frame for reporting abuse. The RNC said when an abuse allegation was not reported timely then abuse could continue. The RNC said in morning meeting the incidents and accidents were reviewed. The RNC indicated this incident was not documented on an incident report but should have been. The RNC said in morning meeting the team also reviews the computerized documentation that flows to the 24-hour report. During an interview on 7/30/2024 at 8:51 p.m., the Administrator said when Resident #17 had his coffee burn, he was not the Administrator. The Administrator said he was the abuse coordinator, and the incident required reporting within 2 hours. The Administrator said the incident was not reported through his review. The Administrator said when abuse was not reported timely this could delay the care and services the resident would receive.

Based on observation, interview, and record review the facility failed to ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision and assistance devices to prevent elopement for 1 of 5 residents (Resident #1) reviewed for accident hazards and supervision. 1. The facility failed to ensure Resident # 1 had adequate interventions to prevent elopement on [DATE] after he had verbalized and or attempted to leave the facility on [DATE], [DATE], [DATE], and [DATE]. 2. The facility failed to prevent Resident #1 from eloping from the facility on [DATE]. Resident #1 wheeled himself approximately 0.3 miles from the facility. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 5:51 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of serious injury or harm. Findings include: Record review of Resident #1's face sheet, dated [DATE], reflected Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #54 had diagnoses which included Dementia (loss of memory), stroke, diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), and seizures. Resident #1 was his own responsible party. Record review of Resident #1's comprehensive care plan dated [DATE], reflected Resident #1 had behavior issues because he would decide at times that he wanted to leave the facility and go homeless. Resident #1 was educated on safety and allowed to vent and express his frustrations. Resident #1 attempted multiple times to exit the building. Resident #1 voiced he wanted to leave. The staff interventions were if reasonable, to discuss the resident's behavior. Explain/reinforce why the behavior was inappropriate and/or unacceptable and praise for any indication of the resident's, progress/improvement in behavior. Record review of Resident #1's quarterly MDS assessment, dated [DATE], reflected Resident #1 understood and was understood by others. Resident #1's BIMS score was 03, which indicated he was severely cognitively impaired. Resident #1 required assistance with bathing and was independent with toileting, personal hygiene, transfer, dressing, bed mobility and eating. Record review of Resident # 1's Elopement assessment, dated [DATE], reflected Resident #1 was at risk for elopement. Record review of the progress noted, dated [DATE], written by LVN A, reflected Resident #1 attempted to leave the facility twice. He was redirected and brought back to the lobby. Record review of the progress noted, dated [DATE], written by LVN A, reflected Resident #1 attempted to leave the facility by the emergency exit on hall 500 when he was stopped by a CNA. He was later seen crawling toward the front door to leave the facility. LVN A notified the NP, DON, and Administrator and obtained orders to send him to the hospital. Record review of Resident #1's hospital visit, dated [DATE], reflected Resident #1 had a diagnosis of altered mental status (a disruption in how your brain works that causes a change in behavior). Record review of the progress noted, dated [DATE], written by LVN A, reflected Resident #1 was on the floor crawling toward the front door again after the hospital visit. Record review of Resident # 1's Elopement assessment, dated [DATE], reflected Resident #1 was at risk for elopement. Record review of the progress noted, dated [DATE], written by LVN A, reflected Resident #1 said he was going to leave the facility. Record review of an incident report, dated [DATE], written by LVN C at 5:52 p.m., reflected the MDS nurse was driving by the facility and noticed Resident #1 was in his wheelchair in the parking lot of the shopping center a few hundred yards away from the facility. LVN B and the MDS nurse assisted Resident #1 back to the facility. According to LVN B Resident #1 was last seen in the dining room eating supper about 20 minutes earlier. Record review of the progress noted, dated [DATE], written by LVN C, reflected she notified a family member of Resident #1's elopement and the family member stated she knew he had been trying to escape for over a month now. Record review of Resident #1's comprehensive care plan, dated [DATE], reflected Resident #1 was at risk for wandering related to history of attempts to leave the facility and voiced he wanted to leave the facility. Resident #1 tore the gate in the fenced-in smoke area and propelled himself about a block from the facility where staff observed him and assisted him back to the facility. The intervention was to place Resident #1 on 1:1 monitoring, apply a wander guard, and distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Resident #1's care plan did not address Resident #1's risk for elopement prior to [DATE]. Record review of the consolidated physician orders, dated [DATE], reflected Resident #1 to have a wander guard for wandering and staff to monitor every shift for the function of the wander guard. Resident #1 did not have an order for a wander guard before he eloped on [DATE]. Record review of Resident #1's electronic medical record, dated [DATE] through [DATE], did not reflect any documentation of changes in his condition that could have caused Resident #1 to make statements or attempt to leave the facility. Resident #1's electronic medical record did not reflect any interventions to prevent elopement except for redirection prior to his elopement on [DATE]. During an interview on [DATE] at 1:06 p.m., the RCN said she was the traveling DON and started with this facility on [DATE], and Resident #1 eloped on [DATE]. She said she was in the facility on the day Resident #1 had eloped. She said she left the facility before he eloped. She said staff called her at home to notify her of his elopement and they had located him and brought him back to the facility with no visual injuries noted. She said Resident #1 escaped out of the 400 hall exit door. She said the way he broke the door; the alarm did not go off to alert staff. She said she was amazed at how he escaped, she said he was determined by the way the door looked. She said she was unaware of any statements Resident #1 made before his elopement. She said she saw where he had a lot of falls according to the fall log and was trying to find out why. She said she had ordered labs, talked with the NP, and asked the pharmacist to review his medication. She said it was only after his elopement that she looked further into his medical records and realized he did not have sufficient documentation in his chart to show what the facility had done to prevent his elopement. She said she wrote orders for his wander guard and called the psychiatrist. She said he had a telehealth visit with the NP psychiatrist on [DATE]. She said the staff had already implemented the 1:1. She said they continued 1:1 until he was discharged from the facility on [DATE]. During an interview on [DATE] at 2:36 p.m., the MDS nurse said she was on her way home from the store when she noticed Resident #1 between the facility and the shopping center. She said she called the facility, spoke with LVN B, and told him what she saw. LVN B said he was not aware Resident #1 had left the facility. She said she parked her car and by then LVN B was outside of the facility. She said by the time she parked her car Resident #1 was in the shopping center parking lot a few hundred yards away. She said she and LVN B brought Resident #1 back to the facility. She said he did not have any injuries but was laughing and said he was going to leave again. She said she was aware of his threats to leave the facility and his going to the front door and pushing on the door. She said she did not think he was serious because he would wait until staff was around and then make the statement he was going to leave. She said I thought he did it more for attention. She said she had not care planned his attempts or statements of elopement before he eloped. She said she thought it was a behavior and had care planned his behaviors. During an interview on [DATE] at 3:16 p.m., the Psychiatrist NP said she had been seeing Resident #1. She said she knew he had behaviors but was not aware of his statements or attempts to leave the facility. She said they called her after he eloped on [DATE] and she did a telehealth visit (online doctor's visit) on [DATE]. She said her husband had been sick and she had missed the last few scheduled visits for Resident #1. She said she missed his [DATE], [DATE], and [DATE] visits. She said if she had known about his statements or attempts to leave the facility, she could have changed her visits, done a telehealth visit, or made medication adjustments. During an interview on [DATE] at 5:15 p.m., LVN A said she was aware of Resident #1's threats and attempts to leave the facility. She said she notified the Administrator, DON, and NP about most of Resident #1's attempts to leave the facility but was not sure about all his attempts. LVN A said on some occasions she was instructed to send him to the hospital but on other occasions, she monitored him closely. LVN A said she had not completed and did not know she needed to complete an elopement assessment, place him on every 30-minute checks, or update his care plan when he attempted to leave or made threats that he wanted to leave the facility. LVN A said Resident #1 could have injured himself on the uneven road or even died if a car had hit him. During an interview on [DATE] at 5:30 p.m., LVN C said she was the charge nurse when Resident #1 eloped on [DATE]. She said the MDS nurse notified her that Resident #1 was outside the facility between the facility and the shopping center. She said she was not aware Resident #1 had left the facility grounds. She said when she went outside LVN B and the MDS nurse were bringing Resident #1 into the facility. She said LVN B assessed Resident #1 with no visual injuries noted. She said she called the Administrator, the DON, and his family. She said Resident #1 was in the dining room eating his supper around 5:30 p.m. which was the last time she had seen him. She said without the staff knowing Resident #1 had left the facility he could have been injured or hit by a car. She said Resident #1 had attempted to leave the facility before but nothing like this. She said they just redirected him mostly. She said she did not do an elopement assessment or update his care plan on his attempts to leave the facility because she was not aware she needed to do them. She said she believed she told the Administrator and DON of his prior attempts. During an interview on [DATE] at 5:50 p.m., LVN C said he received a call from the MDS nurse on [DATE], but he was unable to recall at what time the phone call was received. He said the MDS nurse reported Resident #1 was outside the facility between the facility and the shopping center. He said he went outside and when he saw Resident #1, he was in the shopping center parking lot. He said he and the MDS nurse brought Resident #1 back to the facility. He said he assessed him with no visual injuries. He said Resident #1 made the statement he was going to do it again (leave the facility). He said he then went to see how Resident #1 left the facility. He said it appeared he unscrewed the bolts with his hands on the door and then kicked the door open. He said the magnetic hardware was still attached to the door therefore the alarm did not go off. He said he found the screws and screwed them back in. He said the maintenance staff was called, and they returned to the facility and retightened the screws. He said the door had been properly repaired since Resident #1's elopement. During an interview on [DATE] at 12:34 p.m., LVN D said she had been employed at the facility for about 6 months. She said Resident #1 had some changes in his behavior since mid-February and had escalated since that time. She said Resident #1 pulled on the front door several times before he eloped on [DATE]. She said she was instructed by the ADON and DON to redirect Resident #1 when she saw him near the exit doors and she instructed the aides to do the same. She said she was not aware of any elopement assessments, or how to update a care plan. She said she was a new nurse, and this was her first job. During an interview on [DATE] at 2:34 p.m., CNA EE said she knew Resident #1. She said Resident #1 was quiet when he came to the facility but over the last few months, he changed. She said he was coming out of his room and saying he wanted to leave the facility and he attempted to leave a few times before he eloped on [DATE]. She said the nurses were aware and they monitored him mostly. She said she remembered one time they sent him to the hospital because he would not leave the front door but when he returned, he was still saying he was going to leave the facility. The nurses on duty were aware, but she was unable to recall their names. During an attempted phone interview on [DATE] at 3:00 p.m., with the previous ADON was unsuccessful, a message was left. During an attempted phone interview on [DATE] at 3:10 p.m., with the previous Administrator was unsuccessful, a message was left. During a phone interview on [DATE] at 3:44 p.m., the facility NP said she was seeing Resident #1. She said she was aware of his threats to leave the facility, and of his previous attempts to leave the facility. She said he told her before he would rather be homeless or go to prison than reside at the facility. She said he received psychiatric services, and they were adjusting his medications. During an interview on [DATE] at 1:33 p.m., the previous ADON said Resident #1 was aggressive and an elopement risk. She said Resident #1 attempted to leave the facility on several occasions before he eloped on [DATE]. She said she had consulted psychiatric services, and she instructed staff to stay with the resident or call the police if needed when he attempted to leave the facility. She said she could not recall them making referrals to other facilities even after he had made statements and/or attempts to leave the facility. She said after Resident #1 eloped they placed him on 1:1, and shortly afterward gave him a 30-day notice. She said they started making referrals to other facilities and notified the Ombudsman. She said she did not know the facility's elopement policy. During an attempted phone interview on [DATE] at 2:00 PM, Resident #1 was unable to be reached. During an interview on [DATE] at 5:00 p.m., the previous Administrator said she was the Administrator when Resident #1 eloped. She said she was notified the MDS nurse drove by the facility and saw Resident #1 going towards the shopping center away from the facility. She said after they brought Resident #1 into the facility, they placed him on 1:1. She said there were times when Resident #1 said he wanted to leave the facility before he eloped on [DATE]. She said during the times Resident #1 attempted to leave the facility or made statements he wanted to leave the facility; they did not have a social worker; so, she was doing the best she could. She said looking back they should have placed him on 1:1 after he started making statements or attempted to leave the facility. She said she could not recall the elopement policy for the facility. Record review of the facility's policy, Elopement Prevention , dated ,d+[DATE], reflected, Policy Statement Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 1. The Elopement Risk Assessment will be completed upon admission. The assessment should be completed by reviewing the resident's medical history and social history. Information may be obtained by reviewing current medical records, if available, an interview with the resident/family, or a conference with the interdisciplinary team member. The assessment tool should be completed, and interventions implemented as indicated. The Elopement Risk Assessment is to be completed at least quarterly, after an elopement attempt, upon new exit-seeking behavior, and upon change of condition. 3. The resident's current chart and assessments will be reviewed to determine what changes have occurred that would trigger elopement episodes. 4. The resident's care plan will be modified to indicate the resident is at risk for elopement episodes. 5. Interventions into elopement episodes will be entered into the resident's care plan and medical record. Staff Training: Staff will receive training during their orientation process and then annually regarding: o Elopement prevention o Operation of all exit devices o Actions to take if elopement occurs effective transition of care. Record review of the facility's policy, Elopement Response, dated ,d+[DATE], reflected Policy Statement: Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented. Policy Interpretation and Implementation: 1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical. 4. Should an employee discover the resident is missing from the facility (Code Orange), he/she should: A. Report to the charge nurse 7. Post-return resident evaluation and care: C. The facility will evaluate its elopement prevention program and all residents will be reassessed for elopement risk. 8e Documentation: An event note is to be made out on all residents who, without knowledge of the staff, leave the facility. Including the following: o Date o Time resident was first determined missing o Responsible party notified and time o Attending physician notified and time o Emergency Personnel o Condition of resident when located o Where located and time located Complete and file an incident report and o Make appropriate entries into the resident's medical record. o After an elopement the care plan coordinator will reevaluate the resident's care plan. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 5:51 p.m. The Administrator was notified. The Administer was provided with the IJ template on [DATE] at 6:05 p.m. The following Plan of Removal submitted by the facility was accepted on [DATE] at 2:30 p.m.: 1. As of 7 /,d+[DATE], Resident #1 no longer resides in the facility. 2. Elopement risk assessments for all residents in the facility were completed and reviewed by the DON/ADON/Designee on [DATE]. No additional concerns were identified. 3. All elopement risk care plan interventions were reviewed on [DATE] by the Regional Compliance Nurse, DON, and ADON. All interventions are in place and care planned. 4. The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on [DATE] on the following: a. Elopement Prevention Policy to include implementing interventions for residents at risk. b. Elopement Response Policy 5. The Medical Director was notified of the immediate jeopardy on [DATE]. 6. An additional QAPI meeting was conducted on [DATE] to discuss the immediate jeopardy citation and subsequent plan of correction. In-services: 1. The Regional Compliance Nurse, Administrator, DON, and ADON will in-service all staff on the following topics below. All staff not present for the in-services will not be allowed to work their next shift until the in-service are completed. All new hires will be in-serviced during orientation prior to working their shift. All agency staff will be in-serviced prior to assuming their scheduled shift. a. All staff were in-serviced on the elopement response policy by the Compliance Nurse, Administrator and DON on [DATE]. b. All staff were in-serviced on elopement prevention by the Compliance Nurse, Administrator, and DON on [DATE]. Monitoring of the POR included the following: Observation of the 400 hall exit door revealed it was repaired. During Interviews on [DATE] from 9:26 a.m. until 2:30 p.m. with 1 RN 6 am-6 pm (RN L), 1 PRN RN (RN FF), 6 am-6 pm 4 LVN (LVN B, LVN D, LVN E, and LVN F), 3 PRN LVNs 6p-6a (LVN A, LVN Z, LVN CC), 3LVNs PRN (LVN X, LVN Y, and LVNAA), and 6 am-2 pm 4 CNAs (CNA G, CNA V, CNA H and CNA S), 2 pm-10 pm 1 CNA (CNA EE), 10 pm-6 am 2 CNAs (CNA R, CNA DD, ) 6 am-10 pm 1 CNA (CNA BB), 3 PRN CNAs (CNA J CNA W and CNA I), Dietary staff 4 Cooks (Cook O, [NAME] N, [NAME] M, and [NAME] Q), housekeeping department 2 housekeepers (Housekeeper L, Housekeeper K), Therapy Department 2 therapist (T and P) and the ADON, MDS, BOM, HR, Dietary manager, Maintenance supervisor, Housekeeping Supervisor, and activity director all who indicated they received a written in-service regarding the process of elopement prevention and response. Staff was able to state what to do if a resident made statements or attempts to leave the facility and what to do if a resident eloped from the facility. During a phone interview on [DATE] at 1:30 p.m., the facility medical doctor said he was aware of the IJ received and attended a QAPI meeting via phone. During an interview on [DATE] at 2:36 p.m. the DON said when a resident starts making statements, such as I want to leave, we do not dismiss the statements. Staff should report any statements or attempts to leave the facility to their management. She said even if staff believed a resident was joking, they should take any statements or attempts to leave the facility seriously. Staff should do another elopement assessment, update the care plan, and be thorough on what interventions they put in place. Resident #1 had a traumatic brain injury also known as TBI (damage to the brain which could affect the way a person thinks or behaves) so she said she would have done an in-service with staff about his disease process. She said she would educate staff on making sure they kept their eye on him and placed him on every 30-minute check. She said as management, she would coordinate with psychiatric services, the doctor, and any other outside resources. She said then she would have made referrals to a more equipped facility. She said the Administrator and herself were responsible for the safety and well-being of all residents. During an interview on [DATE] at 2:41 p.m., the RCN said the facility failed to follow its policy on prevention. She said when the facility became aware of Resident #1's statements to leave the facility or his attempts to leave the facility staff should have followed the policy on prevention and elopement. She said after he eloped the staff told her they tried to find him placement and other things but when she looked in his electronic medical records, she could not locate the information. She said during the POR they educated all staff on the facility's policy and felt if this situation ever happened again staff would implement their policy. She said the DON and the Administrator should have been responsible for following up on the statements and ensuring they had things in place to prevent the elopement. During an interview on [DATE] at 2:56 p.m., the Administrator said whenever a resident made statements about wanting to leave the facility staff should have done an elopement assessment, elopement drill, elopement in-service, staff education, and resident assessment. He said he would have placed Resident #1 on every 30-minute check until they could have placed him in a secure unit. He said his goal would have been to keep him safe until he was placed in a secure unit. He said staff were in-serviced on what to do if this situation ever arose again. Record review of the Elopement risk assessments for all residents in the facility completed on [DATE] revealed 5 residents at risk of elopement. Record review of the 5 identified residents at risk of elopement revealed their care plans and interventions were updated. Record review of the Elopement Response and Prevention in-service, dated [DATE], given by RCN, to the Administrator, Administrator in training, and DON revealed the policy on elopement response and prevention. Record review of the Elopement Response and Prevention in-service, dated [DATE], given by RCN, Administrator, and DON signed off by staff who attended or were phoned revealed they were instructed on the policy for elopement response and prevention. Record review of the sign-in sheet for the additional QAPI meeting conducted on [DATE] revealed, the QAPI team will update the elopement system with new interventions discussed to ensure compliance with the recommendations implemented as well as a plan in place for sustainability. An In-service was given to all staff including the Administrator, DON, and ADON on the following policies: 1. Elopement Prevention 2. Elopement Response. Once compliance was established Administrator and DON/ADON would monitor the system weekly, to ensure continuous compliance was met. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 2:30 p.m. The facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy and due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for 1 of 3 Residents reviewed for pharmaceutical services. (Resident #1) The facility failed to follow physician order to give Resident #1 Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month. Resident #1 missed Invega in October and began hearing voices telling him to harm himself and Resident #1 had to be admitted to a psychiatric facility. The facility failed to ensure their Medication Administration Policy was followed where a resident's medication will be administered in an accurate, safe, timely and sanitary manner. The facility failed to ensure Resident #1's script for Invega Sustenna prefilled syringe 234 MG/1.5ML injection medication were acquired from pharmacy. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 10/18/2023 and ended on 11/3/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications. Findings included: Record review of Resident #1's face sheet printed on 11/3/23, indicated Resident #1 was a [AGE] year-old male who originally admitted on [DATE] and readmitted on [DATE] and transferred on 11/01/23 to a psychiatric hospital with diagnoses including schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania) and major depressive disorder (so known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Record review of Resident #1's physician order printed on 11/3/23 indicated an order for Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month for psychosis related to schizoaffective disorder; Start Date: 8/23/23. During an interview on 11/4/23 at 3:51 p.m., at the acute psychiatric hospital, Resident #1 was escorted to the visitation area. He said he started hearing voices real bad telling him to hurt himself and he said he did not want to hurt himself. Resident #1 said he had a history of hearing voices but whenever he took his medications the voices were not that bad. Resident #1 said the facility explained he missed a psych medication, and they were going to send him to the psychiatric hospital to be evaluated and treated. Resident #1 said he felt better and was ready to return to the facility. During an interview on 11/14/23 at 2:31 p.m., The DON said in October 2023 she was working the floor as charge nurse and was giving meds to her assigned hall. She said she recalled that she could not locate Resident #1's Invega medication, so she placed an order and did not notify staff to administer Resident #1's medication when it arrived and as a result Resident #1 missed his October's Invega dosage because mediation was not available. During an interview with on 11/14/23 at 4:23 p.m., Doctor D said it was too hard to tell, and could not tell State Surveyor if it was possible the missed dosage of Invega Sustenna medication led to Resident #1's hallucinations telling him to harm himself. He said he was not 100% sure. Record review of Resident #1's revised care plan initiated 8/25/23 indicated Resident #1 required anti-psychotic medications. Goal: The resident will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness; Monitor/record occurrence of for target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. Record review of transfer form dated 11/1/23 indicated Resident #1 was transferred to an in-patient psychiatric hospital on 11/1/23 at 2:00pm. Reason for transfer: Resident #1 was having command hallucinations and voices telling him to hurt himself. Current primary diagnosis: schizoaffective disorder. Record Review of Resident #1's September's TAR revealed Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month for psychosis related to schizoaffective disorder, was administered on 9/20/23. Record Review of Resident #1's October's TAR revealed Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month for psychosis related to schizoaffective disorder, was coded 9 for 10/18/23. Per chart code 9 means other/ see nurse notes. Record review of Resident #1's Progress Note revealed the following: -On 10/18/23 at 6:59pm; Completed by DON: Invega Sustenna Intramuscular Suspension Prefilled Syringe 234 MG/1.5ML Inject 1 syringe intramuscularly one time a day every 28 day(s) for psychosis related to schizoaffective disorder was not available. -On 11/01/23 at 1:49pm; Completed by RN G: Resident #1 spoke with psych nurse and told her that he was having feelings of hurting himself. He spoke with nurse and said the same. Called the DON and she stated to call the police and they will take him to the psychiatric hospital for evaluation. Police was called and picked up x2 police officers. No acute distress noted. -On 11/01/23 at 2:05pm; Completed by DON: Resident #1 was transferred to hospital on 11/01/2023 2:00 PM related to Resident #1 was having command hallucinations and voices telling him to hurt himself. -On 11/02/23 at 12:04pm; Completed by Administrator: Called psychiatric hospital; Resident #1 was admitted with schizoaffective disorder and Bipolar. Informed they increased Lexapro for depression, increased Trazadone for insomnia, added Vistaril for anxiety PRN, Continue Invega. Informed staff that Resident #1 missed Invega injection in October. -On 11/7/23 at 9:30am; Completed by LVN H: Resident #1 returned from psychiatric hospital. Record review of Resident #1's psych individual therapy visit note revealed the following: Encounter date: 11/01/23; Content/Assessment: The purpose of psychotherapy was to alleviate emotional disturbance and improve function. Insight Oriented and Supportive psychotherapy was/were used in the session. Utilized cognitive-behavioral therapy, person centered therapy, rapport building, reflective listening, relaxation techniques, supportive therapy and validation therapy in session. Clinician met the client in a private area. Clinician reflectively listened as the client discussed the voices in his head and how they have gotten worse since he did not receive the medication he needs once a month to keep the voices at bay. Clinician went over the client's coping skills with him and what he does to manage the voices. Client spoke about how the voices tell him to hurt himself. Clinician checked the client for safety who stated that he did not feel safe. Clinician reported this to the facility who called 911 and the client was transported to the hospital. Patient's compliance had been good. Patient's mood was not changed after the session. Record review of undated written statement completed by The DON revealed the following: On October 19th, the Invega injection appeared on TAR to be given, and after several minutes of looking for the medication, she was unable to find it. At that time, she immediately reordered the medication. During an interview via email on 11/13/23 at 3:42 p.m., The Administrator said Resident #1's September dose was administered by a LVN who no longer was employed with facility. She said he should had reordered the Invega Sustenna prefilled syringe 234 MG/1.5ML injection med the same night he administered the last dose. That did not occur. The DON was working as Charge Nurse in October when the dose should have been administered again. It was not available, so she ordered it that evening. The DON did not note what had occurred. She did not communicate to anyone the need to administer the dose when it arrived. She did not obtain an order to administer it when it arrived or make a change in the program so it would alert on the MAR to administer it when it arrived. Therefore, when Resident #1's Invega Sustenna prefilled syringe 234 MG/1.5ML injection arrived, it was placed in stock for the November dose. The DON was suspended pending investigation. She was returned to work but received a written Employee Disciplinary Report for this. Interviews and record reviews were conducted on 11/3/23 from 12:15 p.m. through 5:00 p.m. and on 11/14/23 from 10:00 a.m. through 5:00 p.m., and included 2 LVNs, 1RN, and DON. Staff were able to explain the proper medication administration process, community's expected process for proper medication administration process, ensuring the correct resident, the correct medication, correct dose to be administered, correct route to be administered, correct documentation of administration. This included verifying the medication administered record to the actual medication. As well as documentation of medication administration, medication availability to include - receiving and accessing new medications and refilled medications in order to ensure that the medications were available on the carts for administration as ordered. Staff had knowledge on what to do if the medication was not on the cart and not available for administration. Nurses should also respond by contacting the dispensing pharmacy in order to order and/or re-order the medication timely to ensure a 5-7 days supply is present. Record review of the facility's plan to correct the noncompliance dated 11/1/23 indicated Problem: pharmacy services. Resident #1 was transferred to the Psychiatric Hospital on 11/1/2023 after notifying psych services that he was hearing voices that are telling him to harm himself. All medications ordered for Resident #1 were audited and verified that adequate supply is present. Audit completed by ADON/MDS nurse as of 11/1/23. Administrator/ADON reviewed Medication Reorder policy and Medication administration policy as of 11/1/2023. ADON or designee will review all orders daily to assure policies and procedures are being followed. Interventions: *As of 11/1/2023, 100% audit was completed on all resident medications including antipsychotics to ensure residents are receiving the physician ordered dose. The audit was completed by ADON and MDS Nurse. No additional omissions were discovered. *All resident medications including antipsychotic medications were verified that they match the ordered dose as of 11/1/2023 by ADON and MDS Nurse. All resident antipsychotic orders match current physician orders. *A Medication error completed as of 11/1/2023 by ADON utilizing the medication error form. *Pharmacy Consultant was called to notify of med error as of 11/1/2023 by ADON. A message was left for a return call. Consultant returned call on 11/2/23 and came to facility on 11/3/23. *QAPI meeting was completed with MD and IDT team as of 11/2/2023 to review med error and root cause analysis, and plan of removal. *The following in-services were initiated by the ADON/MDS completed as of 11/1/23 at 9pm. All Licensed Nurses not in serviced by 11/1/23 will be in-serviced prior to starting their next shift. In-services will be ongoing for all new hires before they assume their duties. The DON/ADON are responsible for conducting these in-services. Licensed Nurses will be in-serviced on: -5 Rights of Medication administration -Reporting Medication error that has occurred or found immediately to Physician and DON -Re-ordering medications timely to ensure a 5-7 day supply is present. Charge nurses are responsible for the re-ordering of medications. Charge nurses will be responsible for auditing carts and reviewing medication supply three times a week to ensure medications are ordered when needed. Medications need to be re-ordered as indicated on the medication card. The Charge nurse will review the order status in PCC under the residents MAR for medications needing to be reordered and reorder if needed. -Notification of the MD and ADON immediately for any resident medications that will not be administered as ordered. *The DON and ADON was in-serviced by the regional nurse on 11/3/23 on pulling the electronic transmission report to show which medications have been reordered and the status of the pharmacy refilling the medication. *The medical director was notified of missed medication. On 11/1, Admin called and left message for return. MD called back at 6am on 11/2 and spoke with Admin about the specifics. Monitoring: The DON / designee will review the med administration audit report 5 days per week to ensure all meds are administered as ordered. The DON/designee will review new pharmacy orders 5 days per week to ensure medications are available to be administered as ordered. The DON/ADON/Designee will audit medications on two carts per week to ensure an adequate supply of resident medications are available. Record review of employee disciplinary report dated 11/3/23 revealed the following: Staff: DON; Date of Infraction: 11/01/23; Specific reasons for disciplinary action: DON had failed to follow medication administration policies and procedures. On 11/01/23 the DON failed to administer medication to Resident #1 resulting in potential harm to the resident. The DON was aware of all facility policies and job duty expectations as indicated by her signature on her Employee Handbook Acknowledgement and job description. This was the first disciplinary action for the DON within a 12-month period. Record review of intake worksheet created and received on 11/01/2023 revealed the following: Date and time of incident: 11/1/23 at 6:00pm; Date facility first learned of incident: 11/1/23 at 6:00pm. Immediate action taken to protect client: Resident #1 transferred to psychiatric hospital to be evaluated and treated as indicated. *Results of hospital evaluation: admitted for Schizoaffective Disorder and Bipolar *What treatment was provided: Increased Lexapro for depression, increased Trazadone for insomnia, added Vistaril for anxiety PRN, Continue Invega. Narrative of The Incident: Resident #1 reported to staff that he was hearing voices telling him to harm himself and was having trouble controlling them. In a review of his medications, it was determined that he did not receive his Invega injection as ordered last month. Actions and Notifications: Resident #1 was transferred to acute psychiatric Hospital for evaluation and treatment as indicated. Allegation: Pharmaceutical Services. Record review of revised Medication Administration Procedure/Policy dated 10/25/17 revealed the following: .20) the 10 rights of medication should always be adhered to 1.Right patient 2. Right medication 3. Right dose 4. Right route 5. Right time 6. Right patient education 7. Right documentation 8. Right to refuse 9. Rights assessment 10. Right evaluation *Handwritten 21) Notify the MD and ADON or designee immediately of any resident medications that will not be administered as ordered.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for 1 of 3 Residents reviewed for pharmaceutical services. (Resident #1) The facility failed to follow physician order to give Resident #1 Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month. Resident #1 missed Invega in October and began hearing voices telling him to harm himself and Resident #1 had to be admitted to a psychiatric facility. The facility failed to ensure their Medication Administration Policy was followed where a resident's medication will be administered in an accurate, safe, timely and sanitary manner. The facility failed to ensure Resident #1's script for Invega Sustenna prefilled syringe 234 MG/1.5ML injection medication were acquired from pharmacy. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 10/18/2023 and ended on 11/3/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications. Findings included: Record review of Resident #1's face sheet printed on 11/3/23, indicated Resident #1 was a [AGE] year-old male who originally admitted on [DATE] and readmitted on [DATE] and transferred on 11/01/23 to a psychiatric hospital with diagnoses including schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania) and major depressive disorder (so known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Record review of Resident #1's physician order printed on 11/3/23 indicated an order for Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month for psychosis related to schizoaffective disorder; Start Date: 8/23/23. During an interview on 11/4/23 at 3:51 p.m., at the acute psychiatric hospital, Resident #1 was escorted to the visitation area. He said he started hearing voices real bad telling him to hurt himself and he said he did not want to hurt himself. Resident #1 said he had a history of hearing voices but whenever he took his medications the voices were not that bad. Resident #1 said the facility explained he missed a psych medication, and they were going to send him to the psychiatric hospital to be evaluated and treated. Resident #1 said he felt better and was ready to return to the facility. During an interview on 11/14/23 at 2:31 p.m., The DON said in October 2023 she was working the floor as charge nurse and was giving meds to her assigned hall. She said she recalled that she could not locate Resident #1's Invega medication, so she placed an order and did not notify staff to administer Resident #1's medication when it arrived and as a result Resident #1 missed his October's Invega dosage because mediation was not available. During an interview with on 11/14/23 at 4:23 p.m., Doctor D said it was too hard to tell, and could not tell State Surveyor if it was possible the missed dosage of Invega Sustenna medication led to Resident #1's hallucinations telling him to harm himself. He said he was not 100% sure. Record review of Resident #1's revised care plan initiated 8/25/23 indicated Resident #1 required anti-psychotic medications. Goal: The resident will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness; Monitor/record occurrence of for target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. Record review of transfer form dated 11/1/23 indicated Resident #1 was transferred to an in-patient psychiatric hospital on 11/1/23 at 2:00pm. Reason for transfer: Resident #1 was having command hallucinations and voices telling him to hurt himself. Current primary diagnosis: schizoaffective disorder. Record Review of Resident #1's September's TAR revealed Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month for psychosis related to schizoaffective disorder, was administered on 9/20/23. Record Review of Resident #1's October's TAR revealed Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month for psychosis related to schizoaffective disorder, was coded 9 for 10/18/23. Per chart code 9 means other/ see nurse notes. Record review of Resident #1's Progress Note revealed the following: -On 10/18/23 at 6:59pm; Completed by DON: Invega Sustenna Intramuscular Suspension Prefilled Syringe 234 MG/1.5ML Inject 1 syringe intramuscularly one time a day every 28 day(s) for psychosis related to schizoaffective disorder was not available. -On 11/01/23 at 1:49pm; Completed by RN G: Resident #1 spoke with psych nurse and told her that he was having feelings of hurting himself. He spoke with nurse and said the same. Called the DON and she stated to call the police and they will take him to the psychiatric hospital for evaluation. Police was called and picked up x2 police officers. No acute distress noted. -On 11/01/23 at 2:05pm; Completed by DON: Resident #1 was transferred to hospital on 11/01/2023 2:00 PM related to Resident #1 was having command hallucinations and voices telling him to hurt himself. -On 11/02/23 at 12:04pm; Completed by Administrator: Called psychiatric hospital; Resident #1 was admitted with schizoaffective disorder and Bipolar. Informed they increased Lexapro for depression, increased Trazadone for insomnia, added Vistaril for anxiety PRN, Continue Invega. Informed staff that Resident #1 missed Invega injection in October. -On 11/7/23 at 9:30am; Completed by LVN H: Resident #1 returned from psychiatric hospital. Record review of Resident #1's psych individual therapy visit note revealed the following: Encounter date: 11/01/23; Content/Assessment: The purpose of psychotherapy was to alleviate emotional disturbance and improve function. Insight Oriented and Supportive psychotherapy was/were used in the session. Utilized cognitive-behavioral therapy, person centered therapy, rapport building, reflective listening, relaxation techniques, supportive therapy and validation therapy in session. Clinician met the client in a private area. Clinician reflectively listened as the client discussed the voices in his head and how they have gotten worse since he did not receive the medication he needs once a month to keep the voices at bay. Clinician went over the client's coping skills with him and what he does to manage the voices. Client spoke about how the voices tell him to hurt himself. Clinician checked the client for safety who stated that he did not feel safe. Clinician reported this to the facility who called 911 and the client was transported to the hospital. Patient's compliance had been good. Patient's mood was not changed after the session. Record review of undated written statement completed by The DON revealed the following: On October 19th, the Invega injection appeared on TAR to be given, and after several minutes of looking for the medication, she was unable to find it. At that time, she immediately reordered the medication. During an interview via email on 11/13/23 at 3:42 p.m., The Administrator said Resident #1's September dose was administered by a LVN who no longer was employed with facility. She said he should had reordered the Invega Sustenna prefilled syringe 234 MG/1.5ML injection med the same night he administered the last dose. That did not occur. The DON was working as Charge Nurse in October when the dose should have been administered again. It was not available, so she ordered it that evening. The DON did not note what had occurred. She did not communicate to anyone the need to administer the dose when it arrived. She did not obtain an order to administer it when it arrived or make a change in the program so it would alert on the MAR to administer it when it arrived. Therefore, when Resident #1's Invega Sustenna prefilled syringe 234 MG/1.5ML injection arrived, it was placed in stock for the November dose. The DON was suspended pending investigation. She was returned to work but received a written Employee Disciplinary Report for this. Interviews and record reviews were conducted on 11/3/23 from 12:15 p.m. through 5:00 p.m. and on 11/14/23 from 10:00 a.m. through 5:00 p.m., and included 2 LVNs, 1RN, and DON. Staff were able to explain the proper medication administration process, community's expected process for proper medication administration process, ensuring the correct resident, the correct medication, correct dose to be administered, correct route to be administered, correct documentation of administration. This included verifying the medication administered record to the actual medication. As well as documentation of medication administration, medication availability to include - receiving and accessing new medications and refilled medications in order to ensure that the medications were available on the carts for administration as ordered. Staff had knowledge on what to do if the medication was not on the cart and not available for administration. Nurses should also respond by contacting the dispensing pharmacy in order to order and/or re-order the medication timely to ensure a 5-7 days supply is present. Record review of the facility's plan to correct the noncompliance dated 11/1/23 indicated Problem: pharmacy services. Resident #1 was transferred to the Psychiatric Hospital on 11/1/2023 after notifying psych services that he was hearing voices that are telling him to harm himself. All medications ordered for Resident #1 were audited and verified that adequate supply is present. Audit completed by ADON/MDS nurse as of 11/1/23. Administrator/ADON reviewed Medication Reorder policy and Medication administration policy as of 11/1/2023. ADON or designee will review all orders daily to assure policies and procedures are being followed. Interventions: *As of 11/1/2023, 100% audit was completed on all resident medications including antipsychotics to ensure residents are receiving the physician ordered dose. The audit was completed by ADON and MDS Nurse. No additional omissions were discovered. *All resident medications including antipsychotic medications were verified that they match the ordered dose as of 11/1/2023 by ADON and MDS Nurse. All resident antipsychotic orders match current physician orders. *A Medication error completed as of 11/1/2023 by ADON utilizing the medication error form. *Pharmacy Consultant was called to notify of med error as of 11/1/2023 by ADON. A message was left for a return call. Consultant returned call on 11/2/23 and came to facility on 11/3/23. *QAPI meeting was completed with MD and IDT team as of 11/2/2023 to review med error and root cause analysis, and plan of removal. *The following in-services were initiated by the ADON/MDS completed as of 11/1/23 at 9pm. All Licensed Nurses not in serviced by 11/1/23 will be in-serviced prior to starting their next shift. In-services will be ongoing for all new hires before they assume their duties. The DON/ADON are responsible for conducting these in-services. Licensed Nurses will be in-serviced on: -5 Rights of Medication administration -Reporting Medication error that has occurred or found immediately to Physician and DON -Re-ordering medications timely to ensure a 5-7 day supply is present. Charge nurses are responsible for the re-ordering of medications. Charge nurses will be responsible for auditing carts and reviewing medication supply three times a week to ensure medications are ordered when needed. Medications need to be re-ordered as indicated on the medication card. The Charge nurse will review the order status in PCC under the residents MAR for medications needing to be reordered and reorder if needed. -Notification of the MD and ADON immediately for any resident medications that will not be administered as ordered. *The DON and ADON was in-serviced by the regional nurse on 11/3/23 on pulling the electronic transmission report to show which medications have been reordered and the status of the pharmacy refilling the medication. *The medical director was notified of missed medication. On 11/1, Admin called and left message for return. MD called back at 6am on 11/2 and spoke with Admin about the specifics. Monitoring: The DON / designee will review the med administration audit report 5 days per week to ensure all meds are administered as ordered. The DON/designee will review new pharmacy orders 5 days per week to ensure medications are available to be administered as ordered. The DON/ADON/Designee will audit medications on two carts per week to ensure an adequate supply of resident medications are available. Record review of employee disciplinary report dated 11/3/23 revealed the following: Staff: DON; Date of Infraction: 11/01/23; Specific reasons for disciplinary action: DON had failed to follow medication administration policies and procedures. On 11/01/23 the DON failed to administer medication to Resident #1 resulting in potential harm to the resident. The DON was aware of all facility policies and job duty expectations as indicated by her signature on her Employee Handbook Acknowledgement and job description. This was the first disciplinary action for the DON within a 12-month period. Record review of intake worksheet created and received on 11/01/2023 revealed the following: Date and time of incident: 11/1/23 at 6:00pm; Date facility first learned of incident: 11/1/23 at 6:00pm. Immediate action taken to protect client: Resident #1 transferred to psychiatric hospital to be evaluated and treated as indicated. *Results of hospital evaluation: admitted for Schizoaffective Disorder and Bipolar *What treatment was provided: Increased Lexapro for depression, increased Trazadone for insomnia, added Vistaril for anxiety PRN, Continue Invega. Narrative of The Incident: Resident #1 reported to staff that he was hearing voices telling him to harm himself and was having trouble controlling them. In a review of his medications, it was determined that he did not receive his Invega injection as ordered last month. Actions and Notifications: Resident #1 was transferred to acute psychiatric Hospital for evaluation and treatment as indicated. Allegation: Pharmaceutical Services. Record review of revised Medication Administration Procedure/Policy dated 10/25/17 revealed the following: .20) the 10 rights of medication should always be adhered to 1.Right patient 2. Right medication 3. Right dose 4. Right route 5. Right time 6. Right patient education 7. Right documentation 8. Right to refuse 9. Rights assessment 10. Right evaluation *Handwritten 21) Notify the MD and ADON or designee immediately of any resident medications that will not be administered as ordered.

Based on interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 3 resident reviewed for accidents. (Resident #2) The facility failed to provide adequate supervision during breakfast meal which resulted in CNA C spilling hot coffee on Resident #2 abdomen and Resident #2 sustained blisters from the coffee. This failure could result in residents who drank coffee at risk of having burn accidents, pain, and a diminished quality of life. Findings included: Record review of Resident #2's face sheet, printed on 11/3/23, indicated she was a [AGE] year-old female who admitted to facility on 11/03/22 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side (paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one?sided weakness, but without complete paralysis due to having a stroke), cerebral infarction due to embolism of right middle cerebral artery (stroke occurs when blood flow from the middle cerebral artery, one of the largest arteries of the brain, is suddenly interrupted (ischemia ) or altogether stopped (infarction ). The loss of blood flow causes tissue death, leading to serious and potentially permanent brain injury), and dysphagia (the medical term for swallowing difficulties). During an interview and observation on 11/3/23 at 5:58 p.m., Resident #2 was in her room lying in bed eating dinner meal. She said the morning of the incident CNA C spilled Resident #2's hot coffee while trying to move the overbed table closer to Resident #2. Resident #2 said she felt like her stomach was burning and the facility was treating her burn with an ointment and bandage until healed. At 6:00pm the Charge nurse came in Resident #2's room to change Resident #2's bandage. Observed Resident #2's stomach there was visible red to color blisters. The Charge Nurse treated Resident #2's burn with Silvadene burn cream and applied a clean bandage burn. During a phone interview on 11/14/23 at 3:26 p.m., CNA C said she was setting up Resident #2's breakfast meal tray and was trying to move the tray closer to Resident #2 and the hot cup of coffee spilt onto Resident #2's abdomen. She said she immediately removed Resident #2's shirt to assess the burn, and then notified a nurse. CNA C said she had never injured a resident before and spilling the cup of coffee on Resident #2 was a terrible accident. CNA C said she was not suspended and was in-serviced on facility's guidelines for serving coffee and in-service on hot liquids. Record review of Resident #2's quarterly MDS dated [DATE] indicated she had clear comprehension and made herself understood. Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated she had moderately impaired cognition. Resident #2 required setup or clean-up assistance with eating and required substantial/maximal assistance with upper body dressing and dependent with shower/baths, lower body dressing, putting on/taking off footwear and dependent with personal hygiene. Record review of Resident #2's incident burn/blister report dated 10/31/23 completed by LVN E indicated the incident happened in Resident #2's room. Incident Description: Nursing Description - Went into Resident #2's room to administer morning medications and Resident #2 pointed out she had a burn from her coffee on her upper central abdomen, 7 x12 cm. Resident Description - Resident #2 stated I think CNA C accidently hit the cup closest to her and it spilt on her. Resident #2 was lying in bed with her eyes closed. CNA was as startled as her. Immediate Action Taken: Applied cold compress to area, notified family, NP and Administrator. Injuries observed at time of incident: None, Level of Pain: zero. Witness: CNA C. Record review of Resident #2's Progress notes indicated the following: -On 10/31/23 at 10:13am; completed by LVN E: Resident #2 notified nurse that she had a burn from spilling her coffee on her abdomen, measurement 7x12 cm, red in color, small blister 0.5x 1cm. N/O for cold moist compress as needed and Silvadene burn cream QD until resolved. -On 10/31/23 at 10:36am; completed by NP F: Resident #2 showed NP burn. NP agreed with the nurse assessment and gave orders for cold compresses as needed for comfort and Silvadene daily until healed. NP will re-eval on Thursday when in the building. Record review of intake worksheet created and received on 11/02/23 indicated: Date and time of the incident 10/31/23 at 8:00am; Date facility first learned of incident 10/31/23 at 10:00am. Immediate action taken to protect client: Temperature of coffee was checked and in range per policy . Hot Liquid Assessment was completed on all residents and safety interventions put in place as indicated. Staff in-service initiated regarding coffee service and reporting hot spills . Narrative of the incident: CNA C was serving Resident #2 her breakfast tray and accidently spilled some coffee on Resident #2 abdomen. Resident #2 reported to nurse that she got burned from the coffee. Resident #2 had small red area with small blister. Actions and Notifications: Nurse asked CNA C about the incident, and she reported the same information Resident #2 provided. Nurse obtained order to treat the burn. NP was on site and assessed as well. Physician and family were notified. Allegation: Neglect. Record review of nursing policy and procedure: hot liquid/food spills dated 2003 indicated Residents are at risk of having any hot liquid/food spilled on their person causing burns. Examples of hot liquids/food are coffee, tea, hot soup, oatmeal, or any other hot food or liquid substance. Procedure: 1) If any staff member observes a resident spill hot liquid or food on themselves or another resident, the staff member will attempt to dissipate the heat of the item spilled with at least a liquid that is at a temperature of room temperature or below, by pouring the room temperature or cooler liquid directly on the area affected. 2) The charge nurse is to be immediately notified so that an assessment of the resident can be completed. 3) The charge nurse will report any injury to the attending physician and responsible party and follow any further physician orders. 4) Staff will assist with changing of clothes as needed. 5) An incident report and investigation will then be completed and determine if the resident needs interventions to prevent future occurrences.

Based on interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, for 1 of 9 (Resident #1) reviewed for quality of care. The facility did not: *consult/notify nurse practitioner, hospice, ST, DOR or family when Resident #1 continued to pocket her food and medications in her mouth, and exhibited swallowing difficulties * have therapy thoroughly assess/screen Resident#1 for swallowing difficulties. Resident #1 was admitted to the hospital on 7/30/2021 for aspiration/[CONDITION(S)], she was intubated and placed in ICU on a ventilator. An Immediate Jeopardy (IJ) situation was identified on 8/4/2021. While the IJ was removed on 8/5/2021, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of injury, aspiration, and death. Findings included: Review of Resident #1's admission record (face sheet) revealed she was a [AGE] year-old female who was initially admitted into the facility on [DATE]. Review of Resident #1's MDS dated [DATE] revealed an admitted [DATE]. The assessment revealed her cognitive skills for daily decision making was severely impaired, she required total dependence of one-person physical assist for eating, and she had signs and symptoms of possible swallowing disorder which included loss of liquids/solids from mouth when eating and drinking, and she held food in mouth/cheeks or residual food in mouth after meals. Review of Resident #1's July 2021 Order Summary Report revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's hospice admission order dated 7/19/2021 revealed a diet order for mechanical soft diet with nectar thick liquids. Review of Resident #1's admission nursing note dated 7/19/2021 and timed 2:15 p.m. revealed she was admitted into the facility and was accompanied by her sister. It also revealed she had chewing problems, and she was on a regular mechanical soft diet with nectar thick liquids. LVN A electronically signed the admission nursing note. Review of Resident #1's nursing progress notes revealed the following: Dated 7/19/2021 and timed 3:07 p.m., Received Resident via wheelchair. She is accompanied by her sister. She is nonverbal and unable to make needs known Resident is a full code. Per her sister she eats a mechanical soft diet . Resident is total patient care. She is being admitted to hospice. The nursing note was electronically signed by LVN A. Review of Resident #1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse practitioner acknowledged the order on 7/20/2021 at 5:31 a.m. Review of Resident #1's history and physical dated 7/20/2021 revealed patient complains of hungry, but only holds food in mouth then spit out, not swallowing. Diet changed to puree, and this was signed by the nurse practitioner. Review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 8/3/2021 at 3:40 p.m., the nurse practitioner said she was the nurse practitioner for the facility and the hospice agency that was taking care of Resident #1. She said she was unaware Resident #1 had swallowing problems or that she pocketed her food and crushed medications. She stated if she would have been notified, she would have ordered a ST consult and would have spoken with the family She said if the resident's family would have declined the ST consult, then she would have discussed the family signing a dietary waiver. During a later telephone interview on 8/5/2021 at 10:04 a.m., the nurse practitioner said she wanted to apologize because after she reviewed her notes on Resident #1, it revealed documentation in her history and physical note dated 7/20/2021 that she was notified that Resident #1 was pocketing food and her diet was downgraded to puree. She said however, it's standard practice that anytime a diet is downgraded, ST would be notified to evaluate the resident. After reviewing her notes, she confirmed there was no order in the chart for ST to be consulted. Nurse practitioner said she told the nurse that changed the diet to puree, to have ST evaluate Resident #1's swallowing. She also stated she did not recall the facility notifying her after 7/20/2021, regarding Resident #1's continuing to have swallowing problems or that she continued to pocket her food and crushed medications. She said she was under the impression the resident was seen and evaluated by ST. Review of Resident #1's care plan, with an initiated date of 7/21/2021, revealed The resident has a swallowing problem related to holding food in mouth/cheeks (pocketing), loss of food/liquids from mouth while eating. The goal documented on the care plan was The resident will have no choking episodes when eating. Interventions on the care plan were as follows: *alternate small bites and sips. Use a teaspoon for eating *check mouth after meals for pocketed food and debris. Report to nurse. Provide oral care to remove debris *Monitor/document/report to nurse/dietitian and MD PRN for difficulty swallowing, holding food in mouth, prolonged swallowing time, repeated swallows per bite, coughing, throat clearing, drooling, pocketing food in mouth. Review of Resident #1's Multidisciplinary Therapy Screen form dated 7/20/2021 revealed the resident was screened because she was a new admit into the facility. The section for swallowing/choking/weight loss/decreased PO intake was blank. It was handwritten on the form that Resident #1 was not appropriate for therapy at this time. Hospice patient, family and hospice refused all therapy. The form was signed by the DOR. During an interview on 8/4/2021 at 2:28 p.m., the DOR said she screened Resident #1 on 7/20/2021 for therapy, because she was a new admit into the facility. She said when she screened the resident, she did not identify nor was she aware the resident was having any swallowing issues. She said if she would have known she would have notified ST to come in and screen the resident and she would have also reached out to hospice to see what they would like for the facility to do about the resident's swallowing. During a later interview on 8/5/2021 at 6:38 p.m., the DOR said when she screened Resident #1 on 7/20/2021 she did not observe the resident eating or being fed, and she did not discuss her swallowing abilities with the nurses or certified nurse aides. DOR said her screening process consisted of her relying on the information presented during the stand-up morning meetings and on the documentation in the nursing notes. She said since neither indicated the resident was having swallowing problems, she was unaware. Review of Resident #1's nursing progress notes revealed the following: Dated 7/22/2021 and timed 8:29 a.m., Potential swallowing problem. Diet was changed to puree. The nursing note was electronically signed by LVN A. Dated 7/22/2021 and timed 8:57 a.m., Potential Problem- hold food in mouth/cheeks or have residual food in mouth after meals. Resident has been changed to a puree diet and has no problems with swallowing. She will forget to swallow so she needs frequent cueing. The nursing note was electronically signed by LVN A. Dated 7/26/2021 and timed 11:02 a.m., Potential swallowing problem, resident has known swallowing problem, mechanically altered diet and honey thickened liquid ordered. The ADON electronically signed the note. Dated 7/28/2021 and timed 1:09 p.m., Resident has a trend of eating less than 51%. Resident holds her food in mouth. It takes a lot of prompting to get her to swallow. The nursing note was electronically signed by LVN A. Dated 7/29/2021 and timed 1:48 p.m., She continues to hold food in her mouth when being fed. The nursing note was electronically signed by LVN A. Dated 7/30/2021 and timed 2:40 p.m., Resident's sister came to the nursing station and stated that this resident had something in her mouth and was choking on it. I immediately got mouth swabs and went to her room. I attempted to clean her mouth but she was having copious amounts of thick clear sputum. I called another nurse to come assist. I then went to get a suction machine and started suctioning her. Hospice nurse came in and then I called 911. At 2:40 p.m. First responders here. At 2:45 p.m. EMS here. At 2:50 p.m. Resident left via stretcher. The nursing note was electronically signed by LVN A. Record review of Resident #1's nursing notes revealed no documentation that the physician, nurse practitioner, ST, dietitian, or hospice was notified of the resident continuing to hold and pocket food in her mouth. Record review of Resident #1's hospital history and physical dated 7/30/2021 and timed 6:19 p.m., revealed chief complaint was aspiration (when something enters your airway or lungs by accident), [CONDITION(S)] (low oxygen). She was diagnosed with aspiration pneumonia, [CONDITION(S)] secondary to the aspiration pneumonia, and acute hypoxic respiratory failure. It also documented the resident appears to have aspirated and suddenly had respiratory distress. Patient continued to have severe intractable coughing Patient continued to have severe respiratory distress and then had to be intubated. Patient currently on mechanical ventilation. Resident #1 was admitted to Intensive Care Unit (a unit in the hospital that provides critical care and life support to acutely ill and injured patients). During an interview on 8/4/2021 at 1:30 p.m., LVN A said she admitted Resident #1 into the facility on [DATE]. She said the resident's sister told her that the resident ate a mechanical soft diet at home prior to admission and the resident's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN A stated she fed Resident #1 a sandwich and a bowl of soup on 7/19/2021 and the soup had corn kernels in it. She noticed that Resident #1 was pocketing her food and was having trouble swallowing, so she wrote an order to change her diet from mechanical soft to pureed. She said she did not consult or notify the physician, DON, or nurse practitioner prior to downgrading the resident from mechanical soft to puree. She said she has worked at the facility since February 2021 and they have always been able to downgrade a diet prior to notifying the physician or nurse practitioner. She said she spoke with the NP on 7/20/2021 and told her that she changed the diet to puree. She said she notified the hospice nurse that she changed Resident #1's diet to puree because she pocketed and held food in her mouth and would not swallow it. She said she did not consult with the dietician or ST because the hospice nurse told her that they would not pay for speech therapy. LVN A stated, after the hospice nurse told me they do not pay for speech therapy I just left it alone, because I figured it was nothing else, they would do for Resident #1 and her swallowing. She said even after the diet was changed to puree with honey thickened liquids, Resident #1 continued to pocket food and medications in her mouth, and it took a lot of cuing to get her to swallow. During a telephone interview with the hospice nurse on 8/4/2021 at 2:46 p.m., she said the facility notified her on 7/21/2021 that Resident #1 was pocketing and holding food in her mouth. She said the staff told her Resident #1 was eating good. She also stated that no one discussed a ST consult with her for Resident #1. During an interview on 8/4/2021 at 3:12 p.m., the ADON said Resident #1 was admitted into the facility with swallowing difficulty. She stated she did not consult with ST, the doctor, nurse practitioner, dietitian or hospice regarding Resident #1's swallowing problems because the nurses were taking care of the residents swallowing issues. During an interview on 8/3/2021 at 4:18 p.m., MA B said she administered crushed medications in pudding to Resident #1. She said Resident #1 started having more difficulty swallowing and pocketing her medications on 7/22/2021. She said they continued to crush the resident's medications but, it started taking approximately 20 minutes for Resident #1 to swallow her medications because she would pocket them. She said because of this she had to make sure that she pushed water on the resident. She stated she reported it to LVN C. During a telephone interview on 8/3/2021 at 4:46 p.m., LVN C said Resident could not swallow good and she would hold food in her mouth and would let it dribble out. She said Resident #1 did that since the first day she was admitted into the facility, and speech therapy was not consulted because she was on hospice. During an interview on 8/4/2021 at 11:46 a.m., CNA D said on Wednesday (7/28/2021) she was in Resident #1's room when the aide was trying to feed her. She stated she could not remember the aide's name. She said Resident #1 only ate one bite because she was holding the food in her mouth, so the aide did not try to feed the resident anything else. She said she does not remember the aide cleaning the resident's mouth once she stopped feeding her. During an interview on 8/4/2021 at 12:06 p.m., CNA E said she fed Resident #1 lunch on 7/30/2021. She said Resident #1 took one bite and would hold the food in her mouth. She said she wiped as much of the food as she could from the resident's mouth after she stopped feeding her. She said she notified LVN A. She said on 7/26/2021 she also fed Resident #1 it took longer than usual to fed her because she was holding the food in her mouth. During an interview on 8/4/2021 at 3:58 p.m., the ST said she works at the facility on an as needed basis and she did not work full time. She said she was not notified regarding Resident #1 having swallowing problems nor that she was pocketing her food. She said even though Resident #1 was on hospice she would have screened/evaluated her for swallowing difficulties and she would have trained the staff how to monitor and assist her with eating and drinking, on how to clear residue out of the residents mouth and on how to use oral swabs to make sure all traces of food was removed from her mouth. During an interview on 8/4/2021 at 2:14 p.m., the DON said the nursing staff could downgrade a diet order prior to consulting with the physician or nurse practitioner. She also stated, the DOR screened Resident #1 for her swallowing. During a later interview with the DON on 8/4/2021 at 6:23 p.m., she stated that the facility did not obtain a dietary waiver for Resident #1 and a dietary waiver was not discussed with the family, the physician, nurse practitioner or hospice. She also stated the facility did not have any signed documentation that the family declined therapy for Resident #1. During a telephone interview on 8/9/2021 at 11:17 a.m., the administrator said he was aware that therapy screened the residents, but he was unaware of what the screening process consisted of. He said the screening form should have been completed thoroughly; however, since he was not clinical, he left it up to the clinical team to ensure if was done correctly. Record review of Thickened Liquid policy, with revision date of 2/13/2007 revealed . residents that have been diagnosed with swallowing difficulties may require thickened liquids as an intervention to avoid aspiration. The facility will ensure that the resident on thickened liquids can consume them in a safe and comfortable manner 9.) Residents with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse will be responsible for notifying ST of these significant changes. Record Review of Rehabilitation Services Policies and Procedures, with a revision date of September 2020 revealed .all residents are to be screened upon admit to the facility, readmission from hospital stay, after any fall and with any change in condition as deemed necessary by IDT. 1.A resident is referred for rehabilitation screen in response to any of the following: a. Status change in one or more of the following areas: iv. Self-feeding and swallowing difficulty 2.A rehab screen is a hands off process by which the therapist reviews the medical record, observes the patient/resident, and interviews the patient/resident, caregivers, interdisciplinary team, and or family to identify the patient's prior level of function, expectations for return of function and discharge plan. Review of Consistency Modifications policy dated 2012 revealed a. all consistency changes are approved by the physician. The initiating decisions can be made by the director of nursing, dietitian, and or speech therapist. The administrator, DON, DON in training and the regional corporate nurse was notified on 8/4/2021 at 6:25 p.m., that an IJ situation was identified related to quality of care due to the above failure. The administrator was provided the IJ template at this time. The facility's Plan of Removal was accepted on 8/5/2021 at 12:24 p.m., and included the following interventions: All residents at risk for aspiration will be assessed by a speech therapist on 8/5/21 to ensure appropriate interventions are in place. Screenings will be completed 8/5/2021 and documented on the Multidisciplinary screening form then uploaded into the resident's clinical record in PCC. The following in-services were initiated by the DON, ADON and Regional Nurse on 8/4/2021: Any staff member not present or in-serviced on 8/4/2021, will not be allowed to assume their duties until in-serviced. Licensed Nurses Promptly and correctly assessing a resident when a change of condition related to swallowing has been identified / reported. Reporting changes of condition to the physician or nurse practitioner. Implementing interventions to prevent aspiration in residents with swallowing difficulties as outlined below. Choking/Aspiration Choking and aspiration are common problems in the older adult. Choking is usually the result of chewing and swallowing (dysphagia) dysfunctions and can lead to aspiration. Chewing can be affected by poorly fitting dentures. Dysphagia can be related to unconscious states, disorders that cause a loss of or diminished swallowing reflex, or a decrease in muscle strength. Chewing and swallowing dysfunctions increase the possibility of aspiration of foods, fluids, salvia, [MEDICATION(S)], and other secretions. Inability to chew and swallow effectively allows for accumulation of foods and fluid and thus, aspiration into the trachea since the separation between the airway and the esophagus is rendered inadequate when swallowing is inadequate. Complications of aspiration and associated difficulties include aspiration pneumonia and malnutrition. Goals 1. The resident will control coughing, chewing, and swallowing activities to prevent possible aspiration. 2. The resident will be free from aspiration or airway obstruction associated with chewing or swallowing activities. Procedure 1. Wash hands. 2. Explain the purpose of assessments and procedure and expected results. 3. Place in semi-Fowler=s position for feedings and with head turned to the side depending on level of consciousness. 4. Become familiar with the ability to swallow and the possibility of coughing or choking while eating or drinking. 5. Facilitate eating by offering soft-textured foods and note ability to chew and swallow and motor control of the lips and tongue. 6. Maintain the head in an elevated position without hyperextension of the neck. 7. Note any accumulation of food or secretions and suction as needed. 8. Allow time for chewing and swallowing small amounts of food or fluids during meals. Non-licensed nursing staff Reporting changes in a resident's condition to a nurse immediately using Stop and Watch. After entering the change in the point of care, the non-licensed staff member is to verbally report the change to the nurse. Staff were in serviced on 8/4/2021 by the Director of Nursing and Regional Compliance nurse on proper procedure for assisting residents with swallowing difficulties to eat to be completed 8/5/21. Therapy will assist with ongoing education of staff on proper procedures to prevent choking/aspiration. Director of Rehab was in-serviced by the Regional Compliance Nurse on 8/5/21 on appropriately screening all new admits and nursing referrals as outlined below. Screening Residents Appropriately and Communicating with the Interdisciplinary Team Residents are to be screened appropriately, identifying what change whether it is an increase or decrease the resident is exhibiting in one or more of the following areas: Communication Cognition Swallowing/Choking/Weight Loss/Decreased PO Intake ADLS - Dressing, Feeding, Grooming, Toileting Pain - Indicating location and level of severity UE ROM/Strength LE ROM/Strength Contractures Seating/Positioning/Posture Transfers Ambulation Balance - Sitting/Standing Falls - indicating date, shift, and location Bed Mobility Wheelchair Mobility Wounds/[CONDITION(S)] The DOR is to screen residents observing level of function and communicating with direct care staff to determine changes that may not have been observed such as. Once the information is gathered the DOR will sign the Multidisciplinary Therapy screen and identify which eval is recommended. The medical director was notified of the immediate jeopardy situation on 8/4/2021 at 7:21pm. On 8/5/2021 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During interviews with 8 staff (DOR, 2 LVNs, DON, Regional Corporate Nurse, and 3 CNAs) the staff were successfully able to communicate interventions to prevent aspirations in residents with swallowing difficulties. During an interview on 8/5/2021 at 12:04 p.m., CNA E said that on 8/5/2021 was educated on using stopwatch and that if the resident had a change in condition, she would document it in the computer and would also notify the nurse. She said she was educated on identifying signs and symptoms of aspiration while feeding such as seeing tear drops, coughing, holding food in mouth and she was in-serviced to observe residents jaws for signs of them pocketing and or holding their food. CNA E said she was in-serviced of the proper way to feed a resident such as making sure that she is facing residents, how to put the food on the spoon correctly, and how to do a mouth check to ensure that the mouth is clear from food. She stated the current company had not trained her on these techniques prior to 8/5/2021. During an interview on 8/5/2021 at 12:12 p.m., CNA F said on 8/5/2021 the facility in-serviced her on how properly supervise and monitor residents when eating, to make sure they were sitting up straight and how to notice if they are not eating correctly, if there is anything out of the normal, and to document it and report it immediately to the nurse. She stated she was in-serviced on making sure the residents were are on the correct diet and if there was a discrepancy she must notify the nurse, make sure the residents are sitting straight up while eating, make sure the resident were not pocketing anything, and if they did she will try to remove it and then notify the nurse. She stated the current company had not provided her with any of these trainings prior to 8/5/2021. During an interview on 8/5/2021 at 12:25 p.m., CNA D said on 8/5/2021 the facility educated her on the proper way to feed residents. She said they trained her on how to cut up food, administer small bites to the resident, to make sure they were not holding food in their mouth, and on how to clear food out of the resident's mouth. She said she would notify the nurse immediately with changes in conditions. She stated that they document it in the PCC on the stopwatch and it will trigger for the nurses. She stated the current company had not provided her with any of these trainings prior to 8/5/2021. During an interview on 8/5/2021 at 12:35 p.m., LVN G said on 8/5/2021 she was in-serviced on residents with swallowing problems, the techniques to use to feed them, how to remove food from a resident's mouth. She said she would notify the doctor, family, and speech therapy of the residents swallowing problems. She said she would notify ST even if a resident was on hospice and she would notify hospice. During an interview on 8/5/2021 at 12:36 p.m. LVN A said she was in-serviced on how to feed residents to prevent aspiration precautions, on assessments to use for residents with changes in condition, when to call the doctor or nurse practitioner and notify them of all changes in conditions and to make sure she documented it in the residents. LVN A said, she would notify nurse practitioner, doctor, DON, and therapy and hospice if a resident was identified with swallowing problems. During an interview on 8/5/2021 at 12:41 p.m., DOR stated she was educated that she was to document all abnormal findings on the screening sheet, and during the screening she would conduct resident observations regarding all that's is listed on the screening sheet, she would speak with direct care staff, resident families and do chart review to get a thorough assessment of the screening. She stated that if there was a resident with swallowing difficulties, she would notify the ST for eval even if the resident was on hospice and she would contact hospice to notify them as well. During an interview on 8/5/2021 at 12:21 p.m., the DON said the facility had 15 CNA's and 14 nurses employed at the facility. She said 8 of the 15 CNA's and 11 of the 14 had completed the plan of removal training, and the rest of the employees would be educated and trained by the end of the day on 8/5/2021. During an interview on 8/5/2021 at 9:30 a.m., the regional nurse stated the ST would be in the facility on 8/5/2021 to assess all residents on mechanically altered diets. On 8/5/2021 at 1:26 p.m., the administrator, vice president of operations, ADON, DON, DON in training, regional corporate nurse and MDS nurse was informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems

Based on observation, interview and record review, the facility failed to ensure the physician was immediately notified of a significant change of condition for 1 of 4 residents reviewed for physician notification. (Resident #1) The facility did not immediately notify the physician when Resident #1 had an unwitnessed fall on 11/16/19. Resident #1 was not able to bear weight, she complained of leg pain and told staff her legs were broken. The resident who usually walked to the bathroom had incontinent episodes and refused care. After 2 days (11/16/19 at 2:15 a.m. until 11/18/19 at 2:30 p.m.) LVN D notified the nurse practitioner of the resident's fall on 11/18/19. The resident was sent to the hospital and was diagnosed with [REDACTED]. Resident #1 returned to the facility on [DATE] and used a wheelchair for mobility. This failure could place residents at risk for progression of disease process, decreased health and decreased quality of life. Findings included: A face sheet dated 11/26/19 indicated Resident #1 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 10/18/17 indicated Resident #1 was at risk for falls and interventions included to keep the environment clutter free, keep the bed in the lowest position, and observe the resident frequently. A fall risk assessment dated [DATE] indicated Resident #1 was at high risk for falls. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 had impaired cognition, sometimes made her needs known, and sometimes understood others. She was independent with transfers and walking in her room. Resident #1 required extensive assistance with bed mobility, dressing, and toilet use. She was incontinent of bowel and bladder. She had no history of falls. A care plan last revised 11/26/19 indicated Resident #1 was independent with bed mobility and transfers. She required extensive assistance with toileting and hygiene. Resident #1 was at risk for pain from recent right hip surgery and staff should assess her pain level and administer medication if necessary. Resident #1 was at risk for falls and staff should refer Resident #1 to therapy and ensure resident wore non-skid shoes or socks. A nursing note dated 11/16/19 at 2:00 a.m., by LVN A indicated Resident #1 was lying in her bed and crying that she could not feel her legs, her legs were broken, and she could not stand. A head to toe assessment was completed with swelling noted to Resident #1's feet. Resident #1 was weak to stand and could not bear weight to right leg. NP was called and received a new order for Tylenol #3 and brain natriuretic peptide (BNP) laboratory test. A nursing note dated 11/16/19 at 9:32 a.m., by LVN B indicated the NP was called and Resident #1 received a new order for [MEDICATION NAME] and Tylenol #3 was discontinued due to a [MEDICATION NAME] allergy. A 24-hour report dated 11/16/19 indicated Resident #1 complained of pain to her feet and had [MEDICAL CONDITION]. New order for Tylenol #3 and BNP. Tylenol #3 was discontinued due to an allergy and a new order was received for [MEDICATION NAME]. New order for [MEDICATION NAME] 60 mg and Potassium 30meq daily. A nursing note dated 11/17/19 at 10:18 a.m., by LVN B indicated Resident #1 had no complaints of pain except when moved. Resident #1 refused breakfast but accepted fluids when prompted. A nursing note dated 11/17/19 at 6:34 p.m., by LVN B indicated Resident #1 was in bed with her call light in reach. Resident #1 ate a small amount of dinner and accepted fluids when prompted. A 24-hour report dated 11/17/19 indicated Resident #1 complained of pain and had [MEDICAL CONDITION] to her feet. Resident #1 refused to be changed 3 times during the 2:00 p.m. to 10:00 p.m. shift. A nursing note dated 11/18/19 at 4:00 a.m., by LVN C indicated Resident #1 was propelling herself in her wheelchair. Resident #1 was grimacing with every attempt to propel herself. Resident #1 was offered pain medication 4 times throughout the night and the resident refused and said she would be alright. A nursing note dated 11/18/19 at 00:00, by LVN D indicated Resident #1 was sitting in her wheelchair in her room with her pants halfway up her legs. Resident #1 said she could not pull up her pants because her right knee and right leg hurt so bad. Resident #1 said she fell and sat on the floor for a while and then got back into her bed. Resident #1 had swelling to right knee. Pain medication was administered with morning medications. NP was notified and received new orders for x-rays of right hip and right knee. Resident #1 continued to have severe pain and resident was sent to a local hospital. A controlled substance emergency kit count sheet indicated Resident #1 received the following: * Tylenol #3 on 11/16/19 at 2:30 a.m., * [MEDICATION NAME] 50 mg on 11/17/19 at 9:00 a.m., *[MEDICATION NAME] 50mg on 11/18/19 at 8:00 a.m., and *[MEDICATION NAME] 50mg on 11/18/19 at 2:00 p.m. An incident report dated 11/18/19 indicated Resident #1 reported she fell in her room by her bed and pulled herself back into her bed. Resident #1 said the fall occurred the other night when it was dark. Resident #1 complained of right leg pain at a rate of 7 out of 10 on the pain scale. Resident #1 had rotation to her right leg and was unable to complete range of motion. A pelvic x-ray dated 11/18/19 indicated Resident #1 had a [MEDICAL CONDITION] femoral neck (top of the thigh bone). A history and physical report from the hospital dated 11/20/19 indicated Resident #1 had a fall on 11/16/19 and complained of right hip pain. A cat scan of Resident #1's pelvis indicated a right femoral neck fracture. Resident #1 had surgery to repair her right femoral neck fracture on 11/20/19. A provider investigation report dated 11/25/19 indicated on 11/18/19 Resident #1 alleged her leg was hurting, she fell and broke her leg, and she put herself back in bed. X-rays were ordered and Resident #1 was transported to a local hospital for further evaluation. Staff were in-serviced on abuse, neglect, falls, assessments, reporting, and residents with dementia. The report indicated it was unclear how Resident #1 broke her hip, but it was reasonable to believe she fell in her room. During an observation and interview on 11/26/19 at 1:05 p.m., Resident #1 was propelling herself in her wheelchair. She said she remembered one night her feet were cold, and she was going to get up to get socks. She said she thought the floor was slippery and she slipped down, she said she had a horrible pain to her right hip. Resident #1 said she used her covers and pulled herself back up in her bed. Resident #1 said she placed the pillow under her head a rested a little. She said she used her call light, but she could not remember who came in her room or what she told them. She said she continued to have pain in her leg, she said she may have had some pain in her feet, but her feet were cold. She said she could not remember what she reported to staff. Resident #1 said she used to walk but now she was using a wheelchair. She said the pain in her right leg was much better. During a telephone interview on 11/26/19 at 11:35 a.m., CNA [NAME] said she worked the night of 11/15/19. She said she checked on Resident #1 at 10:00 p.m. and Resident #1 was in her bed with her eyes closed. She said on 11/16/19 around 12:30 a.m., she heard Resident #1 hollering out. She said when she entered Resident #1's room, the resident was in the bed and hollering help me my leg is broken. CNA [NAME] said Resident #1 said her right leg was hurting and told her not to touch her leg. She said she called for LVN A and she came to the room and assessed Resident #1. She said Resident #1 normally did not call out in pain or say that her leg was broken. CNA [NAME] said Resident #1 was usually independent with ADLs and walked all over the facility without assistance. CNA [NAME] indicated she had been terminated from the facility. During an interview on 11/26/19 at 12:01 p.m., LVN A said she worked 11/15/19 and 11/16/19 from 10:00 p.m. to 6:00 a.m. She said she first saw Resident #1 a little after 10:00 p.m. on 11/15/19. She said Resident #1 was sleeping in her bed, she said it was normal for the resident to be in bed at that time. LVN A said around 2:15 a.m. to 2:30 a.m. on 11/16/19, CNA [NAME] called her to Resident #1's room. She said Resident #1 was in her bed and crying out that her legs were broken, and she could not walk. She said Resident #1 normally did not cry out in pain or say she could not walk. She said she assessed the resident from head to toe and Resident #1 had swelling to both her feet but no bruising or leg rotation. She said she called for LVN C who was working on another hall. LVN A said she and LVN C got Resident #1 out of bed to stand on her feet, Resident #1 could not bear weight on her right leg and screamed out in pain. She said she and LVN C placed Resident #1 back into bed and she called the NP. She said she notified the NP about Resident #1's swelling to her feet and her pain. She said she received an order for [REDACTED].#1's Tylenol #3 was discontinued due to an allergy and [MEDICATION NAME] was ordered. She said Resident #1 had a change of condition, but she thought it was from the [MEDICAL CONDITION] caused from her heart failure. She said Resident #1 normally was independent with ADLs and walked without assistance. During an interview on 11/26/19 at 11:21 a.m., CNA F said she worked 11/16/19 and she entered Resident #1's room about 6:05 a.m. She said Resident #1 was sitting on the side of her bed and was not acting her normal self. She said Resident #1 told her that she fell , and she was not feeling well. CNA F said she told LVN B that Resident #1 said she fell but LVN B said Resident #1 did not fall and she was out of it. CNA F said LVN B said it was charted the resident was acting out on the night shift. She said Resident #1 normally was up and walking the entire day but that day she was either in her bed or in her wheelchair. She said she also tried to call the former DON but was told to write her a note and leave it for her. CNA F said she left a note for the DON. During an interview on 11/23/19 at 10:15 a.m., LVN B said she worked 11/16/19 and 11/17/19 from 6:00 a.m. to 10:00 p.m. She said during shift report on 11/16/19 LVN A reported Resident #1 was having behaviors during the night shift and complained of leg pain. She said when she first saw Resident #1 on 11/16/19 she was sitting on the side of her bed and she did not notice any deformity but Resident #1 did complain that her legs were hurting. She said Resident #1 had swelling to her legs and thought the swelling caused her leg pain. She said Resident #1 was ordered Tylenol #3, but it was changed to [MEDICATION NAME] due to an allergy. She said Resident #3 did not get out of the bed during the weekend. She said Resident #3 received [MEDICATION NAME] as needed and slept well. She said she and CNA F changed Resident #1's brief on 11/17/19 and the resident resisted and complained of leg pain. She said she was not notified by CNA F that Resident #1 fell . She said it was not normal for Resident #1 to stay in bed during the weekend, but she was taking [MEDICATION NAME] and thought the medication was making the resident more tired. A witness statement dated 11/25/19 by LVN B indicated CNA F approached her in passing concerned that Resident #1 was not acting like her normal self and asked something along the lines if there was a fall. LVN B said she did not receive a report of a fall, but she had an active night with behaviors and had some medication changes. CNA F seemed satisfied and nothing else was brought up. During an interview on 11/26/19 at 12:20 p.m., CNA G said LVN B assisted her with Resident #1's incontinent care on 11/17/19. She said Resident #1 normally was up and walking around and took herself to the bathroom. She said on 11/17/19 Resident #1 was lying in her bed and was having incontinent episodes. She said while they changed Resident #1 the resident complained that she was in pain. During an interview on 11/26/19 at 1:39 p.m., LVN C said she worked the night of 11/15/19 but was not Resident #1's charge nurse. She said during the shift she heard Resident #1 screaming and LVN A went into Resident #1's room. She said LVN A asked her to go assist her with Resident #1 because CNA [NAME] would not go into the room. She said Resident #1 was in her bed, rubbing her knees, and she complained of pain. She said LVN A tried to get Resident #1 to stand up, but she was not able to bear weight. She said she did not work the night of 11/16/19. She said on the night of 11/17/19 Resident #1 was in her wheelchair and grimaced when she tried to propel herself. She said she offered pain medication several times but Resident #1 refused. During an interview on 11/26/19 at 10:12 a.m., LVN D said she worked 11/18/19 and during report from the night nurse, she was notified Resident #1 had swelling to her feet, she did not walk during the weekend, she stayed in bed or she used a wheelchair for mobility. LVN D said Resident #1 did not normally stay in her bed and she walked without assistance. She said sometimes Resident #1 would push a wheelchair while she walked behind it. She said when she left the faciity on [DATE], Resident #1 was walking with no assistance and had no complaints of pain. LVN D said she entered Resident #1's room on 11/18/19 and Resident #1 was sitting in her wheelchair with her pants around her legs. She said Resident #1 said she could not pull up her pants because her leg hurt, and she was rubbing her right hip. LVN D said she asked Resident #1 why she was hurting, and the resident said she fell by her bed, sat on the floor for a while, and pulled herself back up into her bed. LVN D said Resident #1 denied that someone helped her back into bed. LVN D said she assessed Resident #1 and she noted a slight outward rotation to her right leg and she had swelling to her right knee. She said she called the NP and received an order for [REDACTED].#1 had an obvious change of condition when she was staying in bed and using a wheelchair for mobility. She said Resident #1 normally walked all day and most of the night throughout the facility. During an interview on 11/26/19 at 12:25 p.m., the NP said Resident #1 had been a resident of the facility for many years and she was a wanderer and walked the halls independently and did not like to be in her bed and was independent with most of her ADLs. She said she received a call from LVN A early on 11/16/19 and was told that Resident #1 had complaints of being achy, hurting, and had swollen ankles. She said she asked LVN A if she assessed Resident #1 and LVN A said she did. She said she asked LVN A if Resident #1 fell and LVN A said the resident did not fall. The NP said Resident #1 had [MEDICAL CONDITION] and she ordered a pain medication and labs. She said LVN A did not say anything about Resident #1 crying in pain or complained that her legs were broken and could not bear weight. The NP said she called the facility on 11/17/19 and asked about Resident #1. She said she could not remember who she talked to but was told Resident #1 was fine. She said nothing was mentioned about Resident #1 staying in bed, unable to walk, or complaining of pain. She said on 11/18/19 she was notified by LVN D that Resident #1 was complaining of severe right hip and knee pain and the resident said she fell . The NP said she ordered a STAT x-ray, but the results were not received timely so Resident #1 was sent to the hospital. She said if she was notified about Resident #1's change in condition on 11/16/19 or 11/17/19 she would have either ordered x-rays or ordered the resident to be sent to the hospital. During an interview on 11/26/19 at 2:58 p.m., the administrator said Resident #1 had surgery for [REDACTED]. He said CNA [NAME] was terminated for insubordination. He said LVN A and LVN B were wrote up for failing to thoroughly assess Resident #1. He said the DON that worked at the facility during the time of the incident with Resident #1 was no longer at the facility. He said Resident #1 was assessed and received pain medications. He said Resident #1 did not have a witnessed fall and did not have a history of falls. The facility's change of condition policy dated (MONTH) (YEAR) indicated .when a resident is noted to have a change in condition including health and psychosocial status conduct a thorough evaluation using the SBAR (situation, background, appearance, review, and notify) form and compare against baseline. The attending physician should be notified by the charge nurse when the SBAR is completed .If necessary due to the seriousness of the change in condition or as ordered by the physician, transfer the resident to the hospital by ambulance or appropriate transportation .

Based on observation, interview and record review, the facility failed to ensure the assessment accurately reflected the status for 1 of 4 residents reviewed for assessments. (Resident #1) LVN A did not include an unwitnessed fall in the assessment of Resident #1 on 11/16/19. Resident #1 was not able to bear weight, she complained of leg pain and told staff her legs were broken. The resident who usually walked to the bathroom had incontinent episodes and refused care. After 2 days (11/16/19 at 2:15 a.m. until 11/18/19 at 2:30 p.m.) LVN D notified the nurse practitioner of the resident's fall on 11/18/19. The resident was sent to the hospital and was diagnosed with [REDACTED]. Resident #1 returned to the facility on [DATE] and used a wheelchair for mobility. This failure could place residents at risk of not receiving needed care and services in accordance with individually assessed needs. Findings included: A face sheet dated 11/26/19 indicated Resident #1 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 10/18/17 indicated Resident #1 was at risk for falls and interventions included to keep the environment clutter free, keep the bed in the lowest position, and observe the resident frequently. A fall risk assessment dated [DATE] indicated Resident #1 was at high risk for falls. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 had impaired cognition, sometimes made her needs known, and sometimes understood others. She was independent with transfers and walking in her room. Resident #1 required extensive assistance with bed mobility, dressing, and toilet use. She was incontinent of bowel and bladder. She had no history of falls. A care plan last revised 11/26/19 indicated Resident #1 was independent with bed mobility and transfers. She required extensive assistance with toileting and hygiene. Resident #1 was at risk for pain from recent right hip surgery and staff should assess her pain level and administer medication if necessary. Resident #1 was at risk for falls and staff should refer Resident #1 to therapy and ensure resident wore non-skid shoes or socks. A nursing note dated 11/16/19 at 2:00 a.m., by LVN A indicated Resident #1 was lying in her bed and crying that she could not feel her legs, her legs were broken, and she could not stand. A head to toe assessment was completed with swelling noted to Resident #1's feet. Resident #1 was weak to stand and could not bear weight to right leg. NP was called and received a new order for Tylenol #3 and brain natriuretic peptide (BNP) laboratory test. A nursing note dated 11/16/19 at 9:32 a.m., by LVN B indicated the NP was called and Resident #1 received a new order for [MEDICATION NAME] and Tylenol #3 was discontinued due to a [MEDICATION NAME] allergy. A 24-hour report dated 11/16/19 indicated Resident #1 complained of pain to her feet and had [MEDICAL CONDITION]. New order for Tylenol #3 and BNP. Tylenol #3 was discontinued due to an allergy and a new order was received for [MEDICATION NAME]. New order for [MEDICATION NAME] 60 mg and Potassium 30 meq daily. A nursing note dated 11/17/19 at 10:18 a.m., by LVN B indicated Resident #1 had no complaints of pain except when moved. Resident #1 refused breakfast but accepted fluids when prompted. A nursing note dated 11/17/19 at 6:34 p.m., by LVN B indicated Resident #1 was in bed with her call light in reach. Resident #1 ate a small amount of dinner and accepted fluids when prompted. A 24-hour report dated 11/17/19 indicated Resident #1 complained of pain and had [MEDICAL CONDITION] to her feet. Resident #1 refused to be changed 3 times during the 2:00 p.m. to 10:00 p.m. shift. A nursing note dated 11/18/19 at 4:00 a.m., by LVN C indicated Resident #1 was propelling herself in her wheelchair. Resident #1 was grimacing with every attempt to propel herself. Resident #1 was offered pain medication 4 times throughout the night and the resident refused and said she would be alright. A nursing note dated 11/18/19 at 00:00, by LVN D indicated Resident #1 was sitting in her wheelchair in her room with her pants halfway up her legs. Resident #1 said she could not pull up her pants because her right knee and right leg hurt so bad. Resident #1 said she fell and sat on the floor for a while and then got back into her bed. Resident #1 had swelling to right knee. Pain medication was administered with morning medications. NP was notified and received new orders for x-rays of right hip and right knee. Resident #1 continued to have severe pain and resident was sent to a local hospital. A controlled substance emergency kit count sheet indicated Resident #1 received the following: * Tylenol #3 on 11/16/19 at 2:30 a.m., * [MEDICATION NAME] 50 mg on 11/17/19 at 9:00 a.m., *[MEDICATION NAME] 50mg on 11/18/19 at 8:00 a.m., and *[MEDICATION NAME] 50mg on 11/18/19 at 2:00 p.m. An incident report dated 11/18/19 indicated Resident #1 reported she fell in her room by her bed and pulled herself back into her bed. Resident #1 said the fall occurred the other night when it was dark. Resident #1 complained of right leg pain at a rate of 7 out of 10 on the pain scale. Resident #1 had rotation to her right leg and was unable to complete range of motion. A pelvic x-ray dated 11/18/19 indicated Resident #1 had a [MEDICAL CONDITION] femoral neck (top of the thigh bone). A history and physical report from the hospital dated 11/20/19 indicated Resident #1 had a fall on 11/16/19 and complained of right hip pain. A cat scan of Resident #1's pelvis indicated a right femoral neck fracture. Resident #1 had surgery to repair her right femoral neck fracture on 11/20/19. A provider investigation report dated 11/25/19 indicated on 11/18/19 Resident #1 alleged her leg was hurting, she fell and broke her leg, and she put herself back in bed. X-rays were ordered and Resident #1 was transported to a local hospital for further evaluation. Staff were in-serviced on abuse, neglect, falls, assessments, reporting, and residents with dementia. The report indicated it was unclear how Resident #1 broke her hip, but it was reasonable to believe she fell in her room. During an observation and interview on 11/26/19 at 1:05 p.m., Resident #1 was propelling herself in her wheelchair. She said she remembered one night her feet were cold, and she was going to get up to get socks. She said she thought the floor was slippery and she slipped down, she said she had a horrible pain to her right hip. Resident #1 said she used her covers and pulled herself back up in her bed. Resident #1 said she placed the pillow under her head a rested a little. She said she used her call light, but she could not remember who came in her room or what she told them. She said she continued to have pain in her leg, she said she may have had some pain in her feet, but her feet were cold. She said she could not remember what she reported to staff. Resident #1 said she used to walk but now she was using a wheelchair. She said the pain in her right leg was much better. During a telephone interview on 11/26/19 at 11:35 a.m., CNA [NAME] said she worked the night of 11/15/19. She said she checked on Resident #1 at 10:00 p.m. and Resident #1 was in her bed with her eyes closed. She said on 11/16/19 around 12:30 a.m., she heard Resident #1 hollering out. She said when she entered Resident #1's room, the resident was in the bed and hollering help me my leg is broken. CNA [NAME] said Resident #1 said her right leg was hurting and told her not to touch her leg. She said she called for LVN A and she came to the room and assessed Resident #1. She said Resident #1 normally did not call out in pain or say that her leg was broken. CNA [NAME] said Resident #1 was usually independent with ADLs and walked all over the facility without assistance. CNA [NAME] indicated she had been terminated from the facility. During an interview on 11/26/19 at 12:01 p.m., LVN A said she worked 11/15/19 and 11/16/19 from 10:00 p.m. to 6:00 a.m. She said she first saw Resident #1 a little after 10:00 p.m. on 11/15/19. She said Resident #1 was sleeping in her bed, she said it was normal for the resident to be in bed at that time. LVN A said around 2:15 a.m. to 2:30 a.m. on 11/16/19, CNA [NAME] called her to Resident #1's room. She said Resident #1 was in her bed and crying out that her legs were broken, and she could not walk. She said Resident #1 normally did not cry out in pain or say she could not walk. She said she assessed the resident from head to toe and Resident #1 had swelling to both her feet but no bruising or leg rotation. She said she called for LVN C who was working on another hall. LVN A said she and LVN C got Resident #1 out of bed to stand on her feet, Resident #1 could not bear weight on her right leg and screamed out in pain. She said she and LVN C placed Resident #1 back into bed and she called the NP. She said she notified the NP about Resident #1's swelling to her feet and her pain. She said she received an order for [REDACTED].#1's Tylenol #3 was discontinued due to an allergy and [MEDICATION NAME] was ordered. She said Resident #1 had a change of condition, but she thought it was from the [MEDICAL CONDITION] caused from her heart failure. She said Resident #1 normally was independent with ADLs and walked without assistance. During an interview on 11/26/19 at 11:21 a.m., CNA F said she worked 11/16/19 and she entered Resident #1's room about 6:05 a.m. She said Resident #1 was sitting on the side of her bed and was not acting her normal self. She said Resident #1 told her that she fell , and she was not feeling well. CNA F said she told LVN B that Resident #1 said she fell but LVN B said Resident #1 did not fall and she was out of it. CNA F said LVN B said it was charted the resident was acting out on the night shift. She said Resident #1 normally was up and walking the entire day but that day she was either in her bed or in her wheelchair. She said she also tried to call the former DON but was told to write her a note and leave it for her. CNA F said she left a note for the DON. During an interview on 11/23/19 at 10:15 a.m., LVN B said she worked 11/16/19 and 11/17/19 from 6:00 a.m. to 10:00 p.m. She said during shift report on 11/16/19 LVN A reported Resident #1 was having behaviors during the night shift and complained of leg pain. She said when she first saw Resident #1 on 11/16/19 she was sitting on the side of her bed and she did not notice any deformity but Resident #1 did complain that her legs were hurting. She said Resident #1 had swelling to her legs and thought the swelling caused her leg pain. She said Resident #1 was ordered Tylenol #3, but it was changed to [MEDICATION NAME] due to an allergy. She said Resident #3 did not get out of the bed during the weekend. She said Resident #3 received [MEDICATION NAME] as needed and slept well. She said she and CNA F changed Resident #1's brief on 11/17/19 and the resident resisted and complained of leg pain. She said she was not notified by CNA F that Resident #1 fell . She said it was not normal for Resident #1 to stay in bed during the weekend, but she was taking [MEDICATION NAME] and thought the medication was making the resident more tired. A witness statement dated 11/25/19 by LVN B indicated CNA F approached her in passing concerned that Resident #1 was not acting like her normal self and asked something along the lines if there was a fall. LVN B said she did not receive a report of a fall, but she had an active night with behaviors and had some medication changes. CNA F seemed satisfied and nothing else was brought up. During an interview on 11/26/19 at 12:20 p.m., CNA G said LVN B assisted her with Resident #1's incontinent care on 11/17/19. She said Resident #1 normally was up and walking around and took herself to the bathroom. She said on 11/17/19 Resident #1 was lying in her bed and was having incontinent episodes. She said while they changed Resident #1 the resident complained that she was in pain. During an interview on 11/26/19 at 1:39 p.m., LVN C said she worked the night of 11/15/19 but was not Resident #1's charge nurse. She said during the shift she heard Resident #1 screaming and LVN A went into Resident #1's room. She said LVN A asked her to go assist her with Resident #1 because CNA [NAME] would not go into the room. She said Resident #1 was in her bed, rubbing her knees, and she complained of pain. She said LVN A tried to get Resident #1 to stand up, but she was not able to bear weight. She said she did not work the night of 11/16/19. She said on the night of 11/17/19 Resident #1 was in her wheelchair and grimaced when she tried to propel herself. She said she offered pain medication several times but Resident #1 refused. During an interview on 11/26/19 at 10:12 a.m., LVN D said she worked 11/18/19 and during report from the night nurse, she was notified Resident #1 had swelling to her feet, she did not walk during the weekend, she stayed in bed or she used a wheelchair for mobility. LVN D said Resident #1 did not normally stay in her bed and she walked without assistance. She said sometimes Resident #1 would push a wheelchair while she walked behind it. She said when she left the faciity on [DATE], Resident #1 was walking with no assistance and had no complaints of pain. LVN D said she entered Resident #1's room on 11/18/19 and Resident #1 was sitting in her wheelchair with her pants around her legs. She said Resident #1 said she could not pull up her pants because her leg hurt, and she was rubbing her right hip. LVN D said she asked Resident #1 why she was hurting, and the resident said she fell by her bed, sat on the floor for a while, and pulled herself back up into her bed. LVN D said Resident #1 denied that someone helped her back into bed. LVN D said she assessed Resident #1 and she noted a slight outward rotation to her right leg and she had swelling to her right knee. She said she called the NP and received an order for [REDACTED].#1 had an obvious change of condition when she was staying in bed and using a wheelchair for mobility. She said Resident #1 normally walked all day and most of the night throughout the facility. During an interview on 11/26/19 at 12:25 p.m., the NP said Resident #1 had been a resident of the facility for many years and she was a wanderer and walked the halls independently and did not like to be in her bed and was independent with most of her ADLs. She said she received a call from LVN A early on 11/16/19 and was told that Resident #1 had complaints of being achy, hurting, and had swollen ankles. She said she asked LVN A if she assessed Resident #1 and LVN A said she did. She said she asked LVN A if Resident #1 fell and LVN A said the resident did not fall. The NP said Resident #1 had [MEDICAL CONDITION] and she ordered a pain medication and labs. She said LVN A did not say anything about Resident #1 crying in pain or complained that her legs were broken and could not bear weight. The NP said she called the facility on 11/17/19 and asked about Resident #1. She said she could not remember who she talked to but was told Resident #1 was fine. She said nothing was mentioned about Resident #1 staying in bed, unable to walk, or complaining of pain. She said on 11/18/19 she was notified by LVN D that Resident #1 was complaining of severe right hip and knee pain and the resident said she fell . The NP said she ordered a STAT x-ray, but the results were not received timely so Resident #1 was sent to the hospital. She said if she was notified about Resident #1's change in condition on 11/16/19 or 11/17/19 she would have either ordered x-rays or ordered the resident to be sent to the hospital. During an interview on 11/26/19 at 2:58 p.m., the administrator said Resident #1 had surgery for [REDACTED]. He said CNA [NAME] was terminated for insubordination. He said LVN A and LVN B were wrote up for failing to thoroughly assess Resident #1. He said the DON that worked at the facility during the time of the incident with Resident #1 was no longer at the facility. He said Resident #1 was assessed and received pain medications. He said Resident #1 did not have a witnessed fall and did not have a history of falls. The facility's change of condition policy dated (MONTH) (YEAR) indicated .when a resident is noted to have a change in condition including health and psychosocial status conduct a thorough evaluation using the SBAR (situation, background, appearance, review, and notify) form and compare against baseline. The attending physician should be notified by the charge nurse when the SBAR is completed .If necessary due to the seriousness of the change in condition or as ordered by the physician, transfer the resident to the hospital by ambulance or appropriate transportation .

Based on observation, interview, and record review, the facility failed to ensure treatment and care was provided based on the comprehensive assessment and in accordance with standards of practice for 1 of 4 residents reviewed for quality of care. (Resident #1) The facility did not identify a change in condition when Resident #1 had a fall and was not able to bear weight, she complained of leg pain and told staff her legs were broken for approximately 2 days (11/16/19 at 2:15 a.m. until 11/18/19 at 2:30 p.m.). LVNs A, B, and C were aware the resident was not able to bear weight and they did not assess the resident. The LVNs did not notify the physician of the resident's fall. Resident #1 was sent to the hospital on [DATE] and was diagnosed with [REDACTED]. Resident #1 returned to the facility on [DATE] and used a wheelchair for mobility. This failure could place residents with a change of condition at risk of not receiving necessary care and services to meet their needs, serious impairment, or death. Findings included: A face sheet dated 11/26/19 indicated Resident #1 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 10/18/17 indicated Resident #1 was at risk for falls and interventions included to keep the environment clutter free, keep the bed in the lowest position, and observe the resident frequently. A fall risk assessment dated [DATE] indicated Resident #1 was at high risk for falls. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 had impaired cognition, sometimes made her needs known, and sometimes understood others. She was independent with transfers and walking in her room. Resident #1 required extensive assistance with bed mobility, dressing, and toilet use. She was incontinent of bowel and bladder. She had no history of falls. A care plan last revised 11/26/19 indicated Resident #1 was independent with bed mobility and transfers. She required extensive assistance with toileting and hygiene. Resident #1 was at risk for pain from recent right hip surgery and staff should assess her pain level and administer medication if necessary. Resident #1 was at risk for falls and staff should refer Resident #1 to therapy and ensure resident wore non-skid shoes or socks. A nursing note dated 11/16/19 at 2:00 a.m., by LVN A indicated Resident #1 was lying in her bed and crying that she could not feel her legs, her legs were broken, and she could not stand. A head to toe assessment was completed with swelling noted to Resident #1's feet. Resident #1 was weak to stand and could not bear weight to right leg. NP was called and received a new order for Tylenol #3 and brain natriuretic peptide (BNP) laboratory test. A nursing note dated 11/16/19 at 9:32 a.m., by LVN B indicated the NP was called and Resident #1 received a new order for [MEDICATION NAME] and Tylenol #3 was discontinued due to a [MEDICATION NAME] allergy. A 24-hour report dated 11/16/19 indicated Resident #1 complained of pain to her feet and had [MEDICAL CONDITION]. New order for Tylenol #3 and BNP. Tylenol #3 was discontinued due to an allergy and a new order was received for [MEDICATION NAME]. New order for [MEDICATION NAME] 60 mg and Potassium 30 meq daily. A nursing note dated 11/17/19 at 10:18 a.m., by LVN B indicated Resident #1 had no complaints of pain except when moved. Resident #1 refused breakfast but accepted fluids when prompted. A nursing note dated 11/17/19 at 6:34 p.m., by LVN B indicated Resident #1 was in bed with her call light in reach. Resident #1 ate a small amount of dinner and accepted fluids when prompted. A 24-hour report dated 11/17/19 indicated Resident #1 complained of pain and had [MEDICAL CONDITION] to her feet. Resident #1 refused to be changed 3 times during the 2:00 p.m. to 10:00 p.m. shift. A nursing note dated 11/18/19 at 4:00 a.m., by LVN C indicated Resident #1 was propelling herself in her wheelchair. Resident #1 was grimacing with every attempt to propel herself. Resident #1 was offered pain medication 4 times throughout the night and the resident refused and said she would be alright. A nursing note dated 11/18/19 at 00:00, by LVN D indicated Resident #1 was sitting in her wheelchair in her room with her pants halfway up her legs. Resident #1 said she could not pull up her pants because her right knee and right leg hurt so bad. Resident #1 said she fell and sat on the floor for a while and then got back into her bed. Resident #1 had swelling to right knee. Pain medication was administered with morning medications. NP was notified and received new orders for x-rays of right hip and right knee. Resident #1 continued to have severe pain and resident was sent to a local hospital. A controlled substance emergency kit count sheet indicated Resident #1 received the following: * Tylenol #3 on 11/16/19 at 2:30 a.m., * [MEDICATION NAME] 50 mg on 11/17/19 at 9:00 a.m., *[MEDICATION NAME] 50mg on 11/18/19 at 8:00 a.m., and *[MEDICATION NAME] 50mg on 11/18/19 at 2:00 p.m. An incident report dated 11/18/19 indicated Resident #1 reported she fell in her room by her bed and pulled herself back into her bed. Resident #1 said the fall occurred the other night when it was dark. Resident #1 complained of right leg pain at a rate of 7 out of 10 on the pain scale. Resident #1 had rotation to her right leg and was unable to complete range of motion. A pelvic x-ray dated 11/18/19 indicated Resident #1 had a [MEDICAL CONDITION] femoral neck (top of the thigh bone). A history and physical report from the hospital dated 11/20/19 indicated Resident #1 had a fall on 11/16/19 and complained of right hip pain. A cat scan of Resident #1's pelvis indicated a right femoral neck fracture. Resident #1 had surgery to repair her right femoral neck fracture on 11/20/19. A provider investigation report dated 11/25/19 indicated on 11/18/19 Resident #1 alleged her leg was hurting, she fell and broke her leg, and she put herself back in bed. X-rays were ordered and Resident #1 was transported to a local hospital for further evaluation. Staff were in-serviced on abuse, neglect, falls, assessments, reporting, and residents with dementia. The report indicated it was unclear how Resident #1 broke her hip, but it was reasonable to believe she fell in her room. During an observation and interview on 11/26/19 at 1:05 p.m., Resident #1 was propelling herself in her wheelchair. She said she remembered one night her feet were cold, and she was going to get up to get socks. She said she thought the floor was slippery and she slipped down, she said she had a horrible pain to her right hip. Resident #1 said she used her covers and pulled herself back up in her bed. Resident #1 said she placed the pillow under her head a rested a little. She said she used her call light, but she could not remember who came in her room or what she told them. She said she continued to have pain in her leg, she said she may have had some pain in her feet, but her feet were cold. She said she could not remember what she reported to staff. Resident #1 said she used to walk but now she was using a wheelchair. She said the pain in her right leg was much better. During a telephone interview on 11/26/19 at 11:35 a.m., CNA [NAME] said she worked the night of 11/15/19. She said she checked on Resident #1 at 10:00 p.m. and Resident #1 was in her bed with her eyes closed. She said on 11/16/19 around 12:30 a.m., she heard Resident #1 hollering out. She said when she entered Resident #1's room, the resident was in the bed and hollering help me my leg is broken. CNA [NAME] said Resident #1 said her right leg was hurting and told her not to touch her leg. She said she called for LVN A and she came to the room and assessed Resident #1. She said Resident #1 normally did not call out in pain or say that her leg was broken. CNA [NAME] said Resident #1 was usually independent with ADLs and walked all over the facility without assistance. CNA [NAME] indicated she had been terminated from the facility. During an interview on 11/26/19 at 12:01 p.m., LVN A said she worked 11/15/19 and 11/16/19 from 10:00 p.m. to 6:00 a.m. She said she first saw Resident #1 a little after 10:00 p.m. on 11/15/19. She said Resident #1 was sleeping in her bed, she said it was normal for the resident to be in bed at that time. LVN A said around 2:15 a.m. to 2:30 a.m. on 11/16/19, CNA [NAME] called her to Resident #1's room. She said Resident #1 was in her bed and crying out that her legs were broken, and she could not walk. She said Resident #1 normally did not cry out in pain or say she could not walk. She said she assessed the resident from head to toe and Resident #1 had swelling to both her feet but no bruising or leg rotation. She said she called for LVN C who was working on another hall. LVN A said she and LVN C got Resident #1 out of bed to stand on her feet, Resident #1 could not bear weight on her right leg and screamed out in pain. She said she and LVN C placed Resident #1 back into bed and she called the NP. She said she notified the NP about Resident #1's swelling to her feet and her pain. She said she received an order for [REDACTED].#1's Tylenol #3 was discontinued due to an allergy and [MEDICATION NAME] was ordered. She said Resident #1 had a change of condition, but she thought it was from the [MEDICAL CONDITION] caused from her heart failure. She said Resident #1 normally was independent with ADLs and walked without assistance. During an interview on 11/26/19 at 11:21 a.m., CNA F said she worked 11/16/19 and she entered Resident #1's room about 6:05 a.m. She said Resident #1 was sitting on the side of her bed and was not acting her normal self. She said Resident #1 told her that she fell , and she was not feeling well. CNA F said she told LVN B that Resident #1 said she fell but LVN B said Resident #1 did not fall and she was out of it. CNA F said LVN B said it was charted the resident was acting out on the night shift. She said Resident #1 normally was up and walking the entire day but that day she was either in her bed or in her wheelchair. She said she also tried to call the former DON but was told to write her a note and leave it for her. CNA F said she left a note for the DON. During an interview on 11/23/19 at 10:15 a.m., LVN B said she worked 11/16/19 and 11/17/19 from 6:00 a.m. to 10:00 p.m. She said during shift report on 11/16/19 LVN A reported Resident #1 was having behaviors during the night shift and complained of leg pain. She said when she first saw Resident #1 on 11/16/19 she was sitting on the side of her bed and she did not notice any deformity but Resident #1 did complain that her legs were hurting. She said Resident #1 had swelling to her legs and thought the swelling caused her leg pain. She said Resident #1 was ordered Tylenol #3, but it was changed to [MEDICATION NAME] due to an allergy. She said Resident #3 did not get out of the bed during the weekend. She said Resident #3 received [MEDICATION NAME] as needed and slept well. She said she and CNA F changed Resident #1's brief on 11/17/19 and the resident resisted and complained of leg pain. She said she was not notified by CNA F that Resident #1 fell . She said it was not normal for Resident #1 to stay in bed during the weekend, but she was taking [MEDICATION NAME] and thought the medication was making the resident more tired. A witness statement dated 11/25/19 by LVN B indicated CNA F approached her in passing concerned that Resident #1 was not acting like her normal self and asked something along the lines if there was a fall. LVN B said she did not receive a report of a fall, but she had an active night with behaviors and had some medication changes. CNA F seemed satisfied and nothing else was brought up. During an interview on 11/26/19 at 12:20 p.m., CNA G said LVN B assisted her with Resident #1's incontinent care on 11/17/19. She said Resident #1 normally was up and walking around and took herself to the bathroom. She said on 11/17/19 Resident #1 was lying in her bed and was having incontinent episodes. She said while they changed Resident #1 the resident complained that she was in pain. During an interview on 11/26/19 at 1:39 p.m., LVN C said she worked the night of 11/15/19 but was not Resident #1's charge nurse. She said during the shift she heard Resident #1 screaming and LVN A went into Resident #1's room. She said LVN A asked her to go assist her with Resident #1 because CNA [NAME] would not go into the room. She said Resident #1 was in her bed, rubbing her knees, and she complained of pain. She said LVN A tried to get Resident #1 to stand up, but she was not able to bear weight. She said she did not work the night of 11/16/19. She said on the night of 11/17/19 Resident #1 was in her wheelchair and grimaced when she tried to propel herself. She said she offered pain medication several times but Resident #1 refused. During an interview on 11/26/19 at 10:12 a.m., LVN D said she worked 11/18/19 and during report from the night nurse, she was notified Resident #1 had swelling to her feet, she did not walk during the weekend, she stayed in bed or she used a wheelchair for mobility. LVN D said Resident #1 did not normally stay in her bed and she walked without assistance. She said sometimes Resident #1 would push a wheelchair while she walked behind it. She said when she left the faciity on [DATE], Resident #1 was walking with no assistance and had no complaints of pain. LVN D said she entered Resident #1's room on 11/18/19 and Resident #1 was sitting in her wheelchair with her pants around her legs. She said Resident #1 said she could not pull up her pants because her leg hurt, and she was rubbing her right hip. LVN D said she asked Resident #1 why she was hurting, and the resident said she fell by her bed, sat on the floor for a while, and pulled herself back up into her bed. LVN D said Resident #1 denied that someone helped her back into bed. LVN D said she assessed Resident #1 and she noted a slight outward rotation to her right leg and she had swelling to her right knee. She said she called the NP and received an order for [REDACTED].#1 had an obvious change of condition when she was staying in bed and using a wheelchair for mobility. She said Resident #1 normally walked all day and most of the night throughout the facility. During an interview on 11/26/19 at 12:25 p.m., the NP said Resident #1 had been a resident of the facility for many years and she was a wanderer and walked the halls independently and did not like to be in her bed and was independent with most of her ADLs. She said she received a call from LVN A early on 11/16/19 and was told that Resident #1 had complaints of being achy, hurting, and had swollen ankles. She said she asked LVN A if she assessed Resident #1 and LVN A said she did. She said she asked LVN A if Resident #1 fell and LVN A said the resident did not fall. The NP said Resident #1 had [MEDICAL CONDITION] and she ordered a pain medication and labs. She said LVN A did not say anything about Resident #1 crying in pain or complained that her legs were broken and could not bear weight. The NP said she called the facility on 11/17/19 and asked about Resident #1. She said she could not remember who she talked to but was told Resident #1 was fine. She said nothing was mentioned about Resident #1 staying in bed, unable to walk, or complaining of pain. She said on 11/18/19 she was notified by LVN D that Resident #1 was complaining of severe right hip and knee pain and the resident said she fell . The NP said she ordered a STAT x-ray, but the results were not received timely so Resident #1 was sent to the hospital. She said if she was notified about Resident #1's change in condition on 11/16/19 or 11/17/19 she would have either ordered x-rays or ordered the resident to be sent to the hospital. During an interview on 11/26/19 at 2:58 p.m., the administrator said Resident #1 had surgery for [REDACTED]. He said CNA [NAME] was terminated for insubordination. He said LVN A and LVN B were wrote up for failing to thoroughly assess Resident #1. He said the DON that worked at the facility during the time of the incident with Resident #1 was no longer at the facility. He said Resident #1 was assessed and received pain medications. He said Resident #1 did not have a witnessed fall and did not have a history of falls. The facility's change of condition policy dated (MONTH) (YEAR) indicated .when a resident is noted to have a change in condition including health and psychosocial status conduct a thorough evaluation using the SBAR (situation, background, appearance, review, and notify) form and compare against baseline. The attending physician should be notified by the charge nurse when the SBAR is completed .If necessary due to the seriousness of the change in condition or as ordered by the physician, transfer the resident to the hospital by ambulance or appropriate transportation .

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for two (Residents #1 and #7) of 10 residents reviewed for quality of care. The facility failed to: 1) Provide accurate and complete assessments, document and notify the physician when Resident #1 experienced swelling to his penis caused by dependent [MEDICAL CONDITION] and experienced a severe rash to his groin; Clean Resident #1 appropriately, leaving feces on his skin causing excoriation to his thighs; and Secure Resident #1's catheter tubing to his leg in order to prevent trauma. These failures caused Resident #1 increased discomfort during care and placed him at risk for increased skin breakdown, urinary tract infection and/or trauma. These failures have the potential to affect the 16 residents who resided on the 500 and 600 halls and were assessed as incontinent. 2) Ensure Resident #7 received post-[MEDICAL TREATMENT] shunt assessments. This failure could affect Resident #7, who was the only resident receiving [MEDICAL TREATMENT] treatments, by placing her at risk for bleeding, infection, and cardiovascular complications. Findings included: 1) Resident #1 was an [AGE] year-old male who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed his cognition was moderately impaired, and he was totally dependent on staff for bed mobility, transfers, dressing, and hygiene. The MDS assessment reflected he was incontinent of bowel and required intermittent catheterization to empty his bladder. Resident #1's Care Plan dated 03/13/13 reflected, "Resident requires an indwelling Foley catheter...."Approaches included: "1. Provide foley catheter care every shift. Monitor for correct catheter placement every shift...7. Ensure proper positioning of tubing to prevent backflow or kinks. Place foley bag lower than body level..." On 05/22/13, the following problem was added: "Potential for injury r/t (related to) catheter" and added approach included: "Ensure tubing is secured to leg (with) leg strap Q (every) shift." Resident #1's Care Plan dated 04/16/13 reflected, "Resident has a [DIAGNOSES REDACTED]." Approaches included: "1. Monitor and report increasing signs of [MEDICAL CONDITION] to MD...5. Assess and document in resident's chart: location, degree of [MEDICAL CONDITION], pitting, discoloration, tightness, malaise, local/general, glossiness, heat, pain...7. Notify MD if no improvement observed. 8. Bilat (bilateral ted hose, On in am (morning) & (and) off @ HS (bedtime)." Review of Resident #1's consolidated physician's orders [REDACTED]. The Orders reflected an indwelling Foley catheter to be changed once a month and as needed. Resident #1's Nurse's Notes, dated 05/21/13 through 05/22/13 at midnight, did not reflect any entries related to changing the catheter, redness or swelling. Resident #1's Nurse's Notes, dated 05/22/13, reflected the following entries: 7:10 AM - "Incont (incontinent) care provided. This nurse notified of redness on both inner thighs. Penis [MEDICAL CONDITION]. Will monitor and contact NP/MD for orders. Resident transferred to Geri-chair." 8:45 AM - "Contacted (FNP S) advised (FNP S) of symptoms. N/O (new order) apply ice pack 10 min (minutes) - 15 min on penis Q shift. Apply Dermaseptom for both inner thighs for redness after each incontinent episode...." 1:30 PM - "Incont care provided. Ice Pack applied for 15 minutes as ordered. Tolerated pack well. Derma Septin applied on thigh areas as ordered. Resident requesting to rest and will stay in bed until dinner...." "ADDEN: (addendum) L (left) (upper) thigh-medial 2 fluid filled areas noted. #1 1.8 cc (sic) x 0.5 x <0 (less than 0). #2 0.6 cc (sic) 0.2 x <0. N/O clean (with) NS (normal saline). Pat dry. Apply skin prep and leave open to air Q shift until healed." Resident #1 was observed on 05/21/13 during initial tour at 8:53 AM, sitting near the nurse's station in a Geri-chair. He had heel protectors on both lower extremities and both lower extremities had 3 plus [MEDICAL CONDITION]. No TED (compression) hose were observed. Resident #1 was observed during incontinent care on 05/22/13 at 6:52 AM, with CNA/RA B and CNA C. Resident #1 had an indwelling catheter in place which was not secured to his leg. His penis was extremely swollen and inverted so that the tip could not be visualized. Resident #1's entire perineal area was covered with a thick layer of white cream. When CNA/RA B attempted to clean the tip of the penis at the catheter insertion area, she was unable to due to the swelling and thick layer of cream that had been applied. CNA/RA B commented the resident was "too greasy," and attempted to remove some of the cream, but was not successful. After removal of a portion of the cream, Resident #1 had dark red excoriation to both inner thighs and his scrotum. He was grimacing during care and complained of pain when wiped. When Resident #1 was turned onto his side so that his back could be cleaned, there was dried, brown stool on his coccyx area as well as both his upper, inner thighs. When the dried stool was cleaned from his thighs, the skin beneath was dark red and excoriated. There was no stool around his rectum. LVN I, Resident #1's Charge Nurse, was asked to assess Resident #1 before his incontinent brief was replaced. When LVN I pulled back the skin on Resident #1's penis, the meatus was dark red and there was a brown liquid around the catheter. LVN I stated she had not seen any of the redness on Resident #1 before. LVN I left the room and stated she was going to notify the physician. CNA/RA B and CNA C were asked whether they had ever seen leg straps or any anchoring devices on Resident #1 to secure his catheter tubing. Both stated they had not. They stated they had never been given any straps or training on the matter. During an interview on 05/22/13 at 8:23 AM, the DON stated she had been informed of Resident #1's condition after the incontinent care was completed. When queried about the swelling, the DON stated it was swollen "again," and explained the resident had lived at the facility during the previous year, and it was a recurring problem. When asked what they were doing about it, the DON replied, "Whatever (FNP S) says." When asked whether she had been told about his rash, the DON replied, "They said it was red and where BM (bowel movement) was, a little skin came off." When asked about the barrier cream, the DON explained the CNAs could apply the cream if they saw an area that was red or excoriated. When asked whether they could apply the cream first, or get the nurse, the DON stated they could apply the cream, but should tell the nurse. The DON stated she had called the night shift nurse who told her she had replaced Resident #1's catheter the night before and the brown liquid that was observed was the [MEDICATION NAME] (iodine) used to clean the area. During an interview on 05/22/13 at 8:41 AM, LVN I stated she checked Resident #1's catheter every shift for patency and had checked it the day before. She stated there was no swelling at that time. When asked about leg straps to secure the catheter to Resident #1's leg, LVN I stated she thought the facility had the straps, but she had not checked Resident #1 to see if he was using one. She stated he had a clip on his catheter bag and they secured it to the chair. LVN I added, "With him in a chair all day, he doesn't really need one." LVN I stated she was a fairly new nurse and did not recall receiving training about securing the catheter tubing. She stated Resident #1 was her first resident at the facility to have an indwelling catheter. Resident #1 was observed resting in bed on 05/22/13 at 2:26 PM. When asked how he was feeling, Resident #1 stated, "Fair." Interview with Resident #1 revealed he had pain during incontinent care. When asked if he had a history of [REDACTED]. An interview with LVN G on 05/22/13 at 2:40 PM, revealed it was the facility's policy to anchor catheter tubing to the resident's legs. She stated the facility used adhesive pads with Velcro straps. LVN G did not work with Resident #1. During another interview on 05/22/13 at 2:20 PM, LVN I stated she had applied an ice pack to Resident #1's groin as ordered by FNP S. She stated Resident #1 had had the same swelling the month before and she did not know why and it just went away. LVN I stated he had had no occurrences since that time. During an interview on 05/22/13 at 5:55 PM, the Medical Director, who was Resident #1's attending physician, stated he had examined Resident #1 and determined his rash was a fungal infection and the swelling was caused by dependent [MEDICAL CONDITION]. He stated both issues had been there at least "a few days." When asked about the treatment for [REDACTED]. The Medical Director explained cold packs were useful if used the first day or two but, afterward, warm packs were better. When told about Resident #1's catheter left unsecured, the Medical Director stated he did not believe it contributed to the [MEDICAL CONDITION], but he would expect it to be secured to prevent trauma and usually told the staff how to anchor it. He was not aware Resident #1's catheter had not been secured. During another interview on 05/23/13 at 10:47 AM, the Medical Director stated the [MEDICAL CONDITION] had been a problem for Resident #1 and it sometimes resolved with bed rest and elevation. He stated if left untreated, there was a potential for weeping at the site and skin breakdown. During an interview on 05/23/13 at 7:23 AM, LVN K stated she had replaced Resident #1's indwelling catheter the previous morning. When asked about the swelling, LVN K stated Resident #1 was chronically like that. She stated she was a new nurse and when she first saw him she was startled and asked her co-workers about it. She stated she was told by her co-workers that was normal for him and they applied ice packs during the day when needed. LVN K stated she was not aware of the severity of Resident #1's rash because he had been slathered with a heavy amount of barrier cream when she went to replace his catheter. She explained she used a great deal of [MEDICATION NAME] swabs to remove the cream on his penis. LVN K stated she had been aware of some skin irritation to his groin, but thought it was just mild irritation related to his incontinent briefs. She stated she had offered to remove the briefs at bedtime but he preferred to wear them. When asked why his catheter tubing had not been secured, LVN K stated she had no idea she was supposed to. She stated she was a new nurse and her prior experience was in a hospital where that was not routinely done. LVN K stated she had not been trained to secure catheters at the facility. When asked why she failed to document any of her findings, LVN K stated she should have documented better. She stated the other nurse working with her had left early and she was very busy at the end of the shift During an interview on 05/23/13 at 11:50 AM, the DON was asked what prompted Care Plan initiation. She stated she checked the 24-hour report and any changes and any orders she put into the computer, she would give the orders to the MDS Coordinator who did the quarterly and acute care plans. When asked whether she checked the care plans, the DON explained she usually checked them on most acute issues and really tried to watch the ones related to behaviors and weights. When asked whether anyone had initiated a care plan related to Resident #1's recurring swelling as they knew it was an issue, the DON stated she recalled implementing measures in the past for prevention, but there was no specific care plan initiated related to the swelling at his penis, only generalized [MEDICAL CONDITION]. During the interview, the DON stated she participated in Resident #1's skin assessments and "...looked at everything." When asked if she had ever noticed his catheter was not secured, the DON stated she had not. When asked if she had noticed the fungal rash on Resident #1, she replied, "No." During an interview on 05/23/13 at 2:50 PM, CNA D stated Resident #1's rash had been there the week before. When asked whether she reported it, she stated LVN L was in the room with her and had observed it. During an interview on 05/23/13 at 2:54 PM, LVN M stated she was aware of Resident #1's rash. When she was asked how long Resident #1 had had the rash, LVN M stated for the last 2-3 weeks, as long as she had been there, and she started on 05/01/13. When asked whether she had notified the physician, LVN M stated she had not. When asked why she had not called, LVN M stated she would call if it was "too red, like red, red, red." LVN M stated they were supposed to report to the DON if they found skin breakdown. When queried whether she had notified the DON, LVN M replied, "It wasn't red, red ,red. I didn't report it." The LVN stated the aides were putting skin protectant on it. When asked whether she had directed the aides to apply the cream, LVN M stated, "Usually they know." When LVN M was asked about Resident #1's catheter, she stated she did catheter care every shift and she had not observed any swelling. Review of Resident #1's Weekly Skin Assessment revealed an entry dated 05/20/13. The entry reflected a diagram of a body and had only an area marked on his left heel. No other skin entries were made and the information was entered by LVN L. Review of Resident #1's Nurses Notes revealed and entry made by LVN L on 05/20/13 at 7:35 PM. The entry reflected: "...Foley catheter in place and patent...skin assessment done...redness at peri (perineal) area, (CNA) applied moisturizing cream." A telephone call was placed to LVN L on 05/24/13 at 4:36 PM. The call was returned on 05/27/13 at 11:00 AM. When LVN L was asked about her head-to-toe assessment of Resident #1, she stated she usually checked while he was in the shower, but the CNA had forgotten to tell her. She stated the CNA reported to her Resident #1 had some irritation to his groin area, but she had already applied cream to the area. When she went to look, Resident #1 refused to let her. LVN L stated she had reported it to the oncoming nurse. During an interview on 05/23/13 at 5:54 PM, CNA T stated she had taken care of Resident #1 overnight on 05/21/13. CNA T stated she had changed Resident #1 two times that night by herself. She stated he did not have a bowel movement that night, but was "kind of leaking," and denied seeing any feces on Resident #1. CNA T further denied seeing a rash on Resident #1, but said his penis had been swollen since his last return from the hospital and he occasionally had drainage and bleeding around his catheter. CNA T stated she would report any unusual occurrences such as a rash to her charge nurse immediately. The facility's Policy and Procedure (P/P) entitled Skin Integrity Monitoring System, dated January 2008 and revised March 2012 reflected: "It is the policy of this home that: 1. A system will be in place to assure that all residents will be assessed and monitored for any type of skin breakdown...3. A system will be in place to assure any type of skin conditions that do not constitute pressure ulcers, will be monitored closely for any type of complications." Procedure: Assessment and Monitoring: "...2. Residents will be screened daily through the use of the (Nursing Assistant Daily Body Observation Form)..." Skin Integrity Management of Non-Pressure Ulcers, "Definitions - Non-Pressure Ulcer - Any skin integrity alteration not caused by pressure. May present as surgical site, bruise, skin tear, scratches, perineal [MEDICAL CONDITION], maceration, excoriation, rash, stasis ulcers or etc." Procedure: 1. Assessment of the skin area is documented...2. The charge nurse that notes the alteration in skin will complete incident report, when indicated. 3. Physician, interested party and resident are to be notified of alteration in skin. 4. Treatment orders are secured and noted on the Treatment Administration Record (TAR)...7. Skin alteration should be added to the care plan...9. Continue to assess the area(s) at least weekly and document...until resolved." The facility's P/P entitled "Catheters-Insertion and Care-Indwelling, Straight, Suprapubic and External" dated January 2008 and revised March 2013 reflected: "It is the policy of this home that the resident with a urinary catheter will be provided services in a safe and appropriate manner in order to minimize the risks of urinary tract complications." Procedure - Indwelling Catheter-Insertion reflected: "...7. Attach catheter strap to leg to assist in securing tubing...." The facility's P/P entitled Incontinent Care/Perineal Care with or without a Catheter, dated July 2010 and revised October 2012 reflected: "It is the policy of this home to provide incontinent care to residents in a manner which provides privacy, promoted dignity and ensures no cross contamination." Procedure for Male "1. Wash clean to dry...Wash perineum - remember front to back. Include scrotum using downward [MEDICAL CONDITION] and working toward thighs, pat dry, wash inner thighs - down to knees if necessary; pubic hair, abdomen..." "If indwelling catheter is present:...b. When washing and drying the urethral area; Gently was and dry around the juncture of the catheter and meatus. Then wash the catheter from the meatus down the tube about 3 inches." "Male and Female 1. Assist resident to turn on side with top leg slightly bent if able. 2. Gently wash and dry the rectal area and buttocks, wiping from base of labia backward over rectal area and continuing onward over buttocks until entire area is clean and dry...5. Observe for and report to charge nurse:...b. Skin changes such as rash, redness, irritation, bruising, swelling, discoloration, skin breakdown, drainage and foul odors..." The facility's Form CMS-802 provided 05/21/13 and identified as current by the DON, identified 16 residents as incontinent on the 500 and 600 Halls. 2) Resident #7 was a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review of this assessment revealed the resident was receiving [MEDICAL TREATMENT]. Review of Resident #7's "Comprehensive Plan of Care" last updated 04/10/13, revealed "Resident requires [MEDICAL TREATMENT]." The approaches included to observe the resident's shunt to her right upper extremity before and after [MEDICAL TREATMENT] treatments and document the assessment in the Nurse's Notes. During initial tour on 05/21/13 at approximately 9:00 AM, LVN G stated Resident #7 went to [MEDICAL TREATMENT] on Mondays, Wednesdays and Fridays. Review of Resident #7's "[MEDICAL TREATMENT] Communication Form" dated 05/20/13, revealed the form was completed for each [MEDICAL TREATMENT] visit. Further review of this form revealed the top half was a pre-[MEDICAL TREATMENT] assessment completed by the facility nurse and the bottom half was completed by the [MEDICAL TREATMENT] unit. Review of Resident #7's Nurse's Notes, dated April 2013 and May 2013, revealed post-[MEDICAL TREATMENT] assessments were documented on 04/01/13 and 04/29/13. Review of Resident #7's TARs (Treatment Administration Records) dated May 2013, revealed there were no treatment entries regarding AV (Arteriovenous) shunt assessments. During an interview on 05/24/13 at 1:45 PM, the surveyor asked the DON what assessments were completed on the [MEDICAL TREATMENT] residents, and the DON stated they only had one [MEDICAL TREATMENT] resident, Resident #7. The DON further stated the nurses completed a [MEDICAL TREATMENT] communication form, sent the form to [MEDICAL TREATMENT] with the resident, and the [MEDICAL TREATMENT] center did not always send the form back to the facility. The surveyor asked if the nurses did any type of assessment when the resident returned from [MEDICAL TREATMENT] and the DON stated, "No, not that I know of." During an interview on 05/24/13 at 3:45 PM, the surveyor asked RN H, Resident #7's charge nurse, when a resident returned from [MEDICAL TREATMENT] what was done and RN H stated, "We have to check her (Resident #7's) AV shunt when they (residents) return from [MEDICAL TREATMENT]. We should take blood pressures too, they could bottom out (blood pressure drop). It should be on the TAR. I just started this week." Review of the facility's policy and procedure "[MEDICAL TREATMENT] - General Guidelines and Management" dated March 2012 revealed: "...Check access site immediately when resident returns (from [MEDICAL TREATMENT])...." The CMS-672 (Resident Census and Conditions of Residents) dated 05/21/13 and signed by the DON, reflected one resident received [MEDICAL TREATMENT].

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of drugs to one (Resident #2) of seven residents reviewed for pain. These failures had the potential to cause unnecessary pain and discomfort to the residents. These failures could affect all 39 residents, including Resident #2, who were on a pain management regimen. Findings included: Review of the MDS assessment dated [DATE] revealed Resident #2 was assessed for pain on a daily basis. The Care Plan for Resident #2 dated 05/16/11 did not address Resident #2's pain issues and any steps which might be taken to alleviate his pain. Review of the History and Physical dated 05/15/11 revealed Resident #2 was admitted to the facility on [DATE] with a fractured ankle with an external fixating device on his right foot. On 06/26/11 at approximately 1:30 PM, the surveyor observed Resident #2 sitting in a wheelchair in the lobby. The surveyor observed Resident #2's right foot. The top of the right foot had a reddish color to it and was slightly swollen. There was a black spot on the bottom side of the foot. The stabilization pin, which exited both sides of the ankle, was crusty in appearance and had a yellowish-colored drainage oozing from the skin. The surveyor did not notice any redness around the pin site. On 06/27/11 at 9:51 AM the surveyor interviewed LVN H, who revealed Resident #2 was sent to the hospital earlier that morning because he complained of unrelieved pain to the ankle during the night. On 06/27/11, the surveyor reviewed the All Discipline Progress Notes dated 06/27/11, which revealed: "0140 Patient requested for Tramadol 100 mg for right leg pain 0240 Patient still in pain, medication not effective. 0340 He stated 'I need to see my own doctor, tramadol not working, I think am infected.' 0630 Res (resident) states 'I want to go to ER (emergency room ), my leg is killing me,' and 'I keep hitting my leg and bumping it,' res is non-compliant (with) care to site 0655 EMS (emergency medical services) called to transfer res. to ER for unrelieved R (Right) leg pain, res. informed of call, thanked nurse...." On 06/27/11 at 3:00 PM (while Resident #2 was at the hospital), the surveyor observed the medication cart with MA I. Resident #2 did not have any available narcotic pain medication in the medication cart. Furthermore, there was no Hydrocodone 10mg/325mg available for Resident #2 in the facility. (This was despite the fact current orders dated 05/25/11 existed for this medication.) Upon inquiry with the facility's only ADON on 06/27/11 at 3:15 PM, she revealed the medication probably came up missing between 05/26/11 and 05/28/11 while the resident was out to the hospital. The ADON did not remember seeing or counting the medication upon Resident #2's return from the hospital on [DATE]. She further revealed the 180 Hydrocodone tablets were not removed from the medication cart and given to the DON when the resident left the facility. Review of the Controlled Drug Individual Patient's Narcotic Record revealed Resident #2's last dose of Hydrocodone was administered on 06/24/11 at 5:00 PM. Review of the Medication Sheet dated 06/01/11 through 06/30/11 revealed the last dose of Hydrocodone 10 mg/325 mg documented as being administered was 06/19/11. Review of the Pharmacy Fax Communication Record dated 05/23/11 revealed Resident #2's Hydrocodone was reordered on [DATE] and 180 tablets were sent. Review of the shipping manifest dated 05/23/11 verified the facility received the Hydrocodone 10 mg/325 mg. Review of the Provider Investigation Report dated 06/08/11 at 8:05 AM revealed there were 180 tablets of Hydrocodone 10mg/325mg missing sometime between the delivery of these pills on 05/23/11 and the facility becoming aware they were missing on 06/08/11. The facility became aware of the missing medication when Resident #2 questioned them about a bill. A search of the facility did not result in finding the medication, nor the individual control record. The facility investigated the incident, but was unable to determine who took the pills. The provider response indicated the facility would in-service staff and report the incident to the police. The All Discipline Progress Notes for Resident #2 dated 06/27/11 also reflected: 6:15 PM- The resident was back in the facility. He had orders for antibiotics for Cellulitis at the pin site in his ankle. He also had orders for Hydrocodone 5 mg/500 mg one to two tablets by mouth every six hours as needed for pain. The resident expressed his pain level as being "9/10" on a scale with 10 being the worst. He told the nurse he needed "something fast (for pain)." The nurse administered Tramadol 50 mg two tablets at 6:25 PM. The resident also approved the facility ordering his medication as long as he was notified before getting any bills. 10:13 PM- The resident was given Hydrocodone 5 mg/500 mg two tablets for pain. He told the nurse his pain was "9/10 and climbing." 11:00 PM- The resident told the nurse he was "doing much better." He did not display any signs or symptoms of distress Review of the hospital Progress Notes dated 06/27/11 revealed Resident #2 fell on [DATE] and hit the calcaneal (heel) pin and reported "having chills and rigors on yesterday (06/26/11)." The hospital physical examination dated 06/27/11 reflected the right lateral pin area was red, swollen, and tender to touch with areas of dry drainage. The notes further reflected x-rays and laboratory work were done and all were essentially within normal limits. Resident #2 was given Toradol 30 mg IV (intravenous) for his pain. An Addendum note at the end of the 06/27/11 hospital Progress Notes reflected, "6/27/11 at 12:41 He needs pain medication: Hydrocodone 5mg/500mg of Tylenol 1-2 tabs po every 6 hours as needed for pain." This entry was underlined. On 06/28/11 at 8:55 AM an interview with the DON revealed the facility did not replace Resident #2's 180 tablets of Hydrocodone, which had been diverted on 06/08/11, because the resident still had some narcotic pain medication. The DON stated on that date, Resident #2 still had some Hydrocodone left over from a prescription filled by the hospital. The DON said Resident #2 used the last of this medication on 06/24/11. The DON stated she was not aware Resident #2 had been out of Hydrocodone since 06/24/11. She further revealed she would have ordered the medication needed as the facility was responsible to see the residents had the medication they needed. On 06/28/11 at 10:15 AM Resident #2 was observed lying in bed. In an interview with Resident #2 at this time, the resident revealed he slipped and fell on [DATE] and hit the pin. He said this initiated his severe pain. Resident #2 said that although it hurt, he initially thought he could deal with the pain. He said Tramadol (pain medication) did not relieve the pain, which he stated was "severe" and "unbearable." He said he was subsequently sent to the hospital on [DATE] and received Toradol intraveneously. Resident #2 stated he had been fine until he fell (on 06/24/11), the pain was severe, and medication the facility gave him did not work. During this same interview, the surveyor asked Resident #2 how he was feeling now. Resident #2 said he was much better than Sunday night (06/26/11-06/27/11). The resident reported he did not request pain medication because facililty staff had told him "last Monday or Tuesday" he was out of his narcotic pain pill. Resident #2 stated he took the Tramadol because facility staff told him to do so, but it was like "taking nothing. Taking Tramadol is like taking M&M's." On 06/28/11 at 10:25 AM, the surveyor interviewed the facility's only ADON regarding the reordering of Resident #2's Hydrocodone. The ADON revealed she did not remember if it was ordered, but she remembered being told it was low by the MA. The ADON stated that when she asked Resident #2 if he wanted me to reorder his medication he said no he did not want to have to pay another bill. The surveyor queried why this was said and she stated it was because he received a bill for 180 tablets of Hydrocodone and he had not seen them. The ADON revealed this occurred on 06/08/11 and that was when the facility learned the Hydrocodone 10mg/325mg 180 tablets had been diverted. The surveyor queried if she had told the DON Resident #2 was almost out of Hydrocodone 10mg/325mg, and she replied "No." The ADON stated she did not reorder the medication because the resident told her not to, but she did check with the resident. On 06/28/11 at 5:30 PM during an interview with the facility Administrator, she revealed the facility was responsible for seeing the residents had the medications they needed and had she known he was out of medication, she would have had it ordered. She stated she did not want to see any residents be in pain or go without their medications. On 06/30/11 at 11:30 AM during an interview with the ADON, it was revealed Resident #2 still did not have any Hydrocodone 10mg/325mg available for use. Resident #2 did have 10 tablets of 5mg/500 mg tablets of Hydrocodone that the ADON was going to reorder. Review of the Physician order [REDACTED]. A Physician's Telephone Order dated 05/28/11 reflected Resident #2 had an order for [REDACTED]. Review of the Physician order [REDACTED]. The orders also reflected: Hydrocodone 5mg/500 mg one to two tablets every six hours as needed for pain. Review of the facility's current policy "Medication Ordering and Receiving From Pharmacy Provider" Section 3.2 Ordering and Receiving Medications dated October 2007 revealed: "POLICY Medications and related products are received from the provider pharmacy on a timely basis. The nursing care center maintains accurate records of medication order and receipt. PROCEDURES 1. Ordering medications from provider pharmacy: a. Original medication orders are transmitted to the pharmacy. The medication order includes all required elements... e. ...Timely delivery of new orders is required so that medication administration is not delayed. If available, the emergency kit is used when the resident needs a medication prior to pharmacy delivery...." Review of the facility's current policy and procedure on Controlled Substances dated October 2007 revealed the following: "Policy Medication included in the Drug Enforcement Administraton (DEA) classifications as controlled substances are subject to special handling, storage, disposal, and record keeping at the nursing care center, in accordance with federal and state laws and regulations. Procedures ....2. The Director of Nursing and the Consultant Pharmacist monitor for compliance with federal and state laws and regualations in handling of controlled medications... 3. Controlled medications are obtained from a locked cabinet or safe, or medication cart. 4. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage:... a. Date and time of administration b. Amount administered c. Signature of the nurse administering the dose 5. Administer the controlled medication and document dose administration on the MAR... 7. At each shift change, a physical inventory of controlled medication, as defined by state regulation, is conducted by two licensed clinicians and is documented on the audit record... 9. Any discrepancy in a controlled substance medication count is reported to the director of nursing immediately. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies.... Review of the facility's other current policy and procedure on Medications: Controlled Substances dated January 2008 revealed the following: Policy It is the policy of this facility to ensure that controlled substances are stored and dispensed in accordance with State and Federal laws. Procedure 1. Controlled substances in Schedules II, III and IV are subject to special handling, storage, disposal and record-keeping requirements. Such drugs are to be accessible only to authorized nursing and pharmacy personnel. The Director of Nurses is responsible for the control of such drugs. 2. Drugs listed in Schedules II, III and IV are to be stored under double-lock conditions. The key to the separately locked storage areas is not the same key that is used to gain access to other drugs. The medication nurse or medication aide on duty at the time will maintain possession of the key. 3. The authorized person receiving and checking in a drug in Schedules II, III and IV is to prepare a controlled drug audit form for that medication, if not provided by the pharmacy. Thereafter, a physical inventory of that medication will be made at the change of each nursing shift. The persons performing the inventory will sign to verify that the inventory was done. All controlled substances are to be counted every shift, including any controlled substances that are in over-flow storage. 4. Any discrepancy in the inventory of a controlled substance is to be reported to the Director of Nurses as soon as possible. The Director of Nurses is responsible for investigating and making a reasonable effort to reconcile all reported discrepancies. If a discrepancy is not reconciled, the Director of Nurses is to document the details on the audit record, including the possible shift or persons responsible for the discrepancy, and the efforts made to reconcile it. If a major discrepancy or a pattern of discrepancies occurs, or there is obvious criminal activity, the Director of Nurses is to notify the administrator and the consultant pharmacist immediately. 5. Proof-of-use records in the form of a declining inventory record are to be maintained for all Schedule II, III and IV drugs. The following information will be recorded for each such controlled substance: a. name of the resident. b. physician's name. c. prescription number. d. name and strength of the drug. e. date received by the facility. f. original amount dispensed. g. date and time administered. h. dose administered. i. signature of the person administering the dose. 6. No more than one prescription is to be entered on any page of a declining inventory record. 7. Each line on the proof-of-use record is to represent one dose. If more than one sheet is needed for the number of doses checked in, then a sufficient number of sheets are to be prepared and each copy is to be numbered consecutively. 8. As soon as possible after each dose is administered, the individual administering the drug is to enter the required information on the proof-of-use record, but no later than the end of the shift in which the administration occurred. 9. Current proof-of-use records are to be kept at the nursing unit or medication room. When completed, these records are to be kept on file in the facility for two years. Review of the facility's current policy and procedure on Drug Diversion dated January 2008 revealed the following: Policy It is the policy of this facility to ensure drug diversions are investigated and reported to the proper authorities, per regulation. Procedure 1. Controlled substanced in Schedules II, III and IV are subject to special handling, storage, disposal and record-keeping requirements. Such drugs are to be accessible only to authorized nursing and pharmacy personnel. The Director of Nurses is responsible for the control of such drugs. 2. Drugs listed in Schedules II, III and IV are to be stored under double-lock conditions. The key to the separately locked storage areas is not the same key that is used to gain access to other drugs. The medication nurse or medication aide on duty at the time will maintain possession of the key. 3. A physical inventory of these medication will be made at the change of each nursing shift. The persons performing the inventory will sign to verify that the inventory was done. All controlled substances are to be counted every shift, including any controlled substances that are in over-flow storage. 4. Any discrepancy in the inventory of a controlled substance is to be reported to the Director of Nurses as soon as possible. The Director of Nurses is responsible for investigating and making a reasonable effort to reconcile all reported discrepancies. If a discrepancy is not reconciled, the Director of Nurses is to document the details on the audit record and Incident/Accident Report form, including the possible shift or persons responsible for the discrepancy, and the efforts made to reconcile it. If a major discrepancy or a pattern of discrepancies occurs, or there is obvious criminal activity, the Director of Nurses is to notify the administrator and the consultant pharmacist immediately. 5. The Administrator or Director of Nurses will be responsible to notify the local police and to immediately notify the appropriate state agency (DADS) when it is determined or there is reason to believe that the drug diversion was a result of theft. The Resident and Condition of Resident, CMS Form 672, reflected there were 39 residents in the facility.

Based on observation, interview, and record review, the facility failed to ensure one (Resident #2) of seven residents assessed for pain management was provided the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Resident #2 was admitted to the facility on [DATE] with a fractured ankle with an external fixating device on his right foot. On 06/24/11 the facility utilized the last of Resident #2's narcotic pain medication, [MEDICATION NAME] 10/325 mg, and failed to re-order more. On 06/27/11 Resident #2 was sent to the emergency room with uncontrolled pain. These failures could affect the 39 residents on a scheduled pain management program by placing them at risk of uncontrolled pain. Findings included: Review of the MDS assessment dated [DATE] revealed Resident #2 was assessed for pain on a daily basis. The Care Plan for Resident #2 dated 05/16/11 did not address Resident #2's pain issues and any steps which might be taken to alleviate his pain. Review of the History and Physical dated 05/15/11 revealed Resident #2 was admitted to the facility on [DATE] with a fractured ankle with an external fixating device on his right foot. On 06/26/11 at approximately 1:30 PM, the surveyor observed Resident #2 sitting in a wheelchair in the lobby. The surveyor observed Resident #2's right foot. The top of the right foot had a reddish color to it and was slightly swollen. There was a black spot on the bottom side of the foot. The stabilization pin, which exited both sides of the ankle, was crusty in appearance and had a yellowish-colored drainage oozing from the skin. The surveyor did not notice any redness around the pin site. On 06/27/11 at 9:51 AM the surveyor interviewed LVN H, who revealed Resident #2 was sent to the hospital earlier that morning because he complained of unrelieved pain to the ankle during the night. On 06/27/11, the surveyor reviewed the All Discipline Progress Notes dated 06/27/11, which revealed: "0140 Patient requested for [MEDICATION NAME] 100 mg for right leg pain 0240 Patient still in pain, medication not effective. 0340 He stated 'I need to see my own doctor, [MEDICATION NAME] not working, I think am infected.' 0630 Res (resident) states ' I want to go to ER (emergency room ), my leg is killing me,' and 'I keep hitting my leg and bumping it,' res is non-compliant (with) care to site 0655 EMS (emergency medical services) called to transfer res. to ER for unrelieved R (Right) leg pain, res. informed of call, thanked nurse...." On 06/27/11 at 3:00 PM (while Resident #2 was at the hospital), the surveyor observed the medication cart with MA I. Resident #2 did not have any available narcotic pain medication in the medication cart. Furthermore, there was no [MEDICATION NAME] 10mg/325mg available for Resident #2 in the facility. (This was despite the fact current orders dated 05/25/11 existed for this medication.) Upon inquiry with the facility's only ADON on 06/27/11 at 3:15 PM, she revealed the medication probably came up missing between 05/26/11 and 05/28/11 while the resident was out to the hospital. The ADON did not remember seeing or counting the medication upon Resident #2's return from the hospital on [DATE]. She further revealed the 180 [MEDICATION NAME] tablets were not removed from the medication cart and given to the DON when the resident left the facility. Review of the Controlled Drug Individual Patient's Narcotic Record revealed Resident #2's last dose of [MEDICATION NAME] was administered on 06/24/11 at 5:00 PM. Review of the Medication Sheet dated 06/01/11 through 06/30/11 revealed the last dose of [MEDICATION NAME] 10 mg/325 mg documented as being administered was 06/19/11. Review of the Pharmacy Fax Communication Record dated 05/23/11 revealed Resident #2's [MEDICATION NAME] was reordered on [DATE] and 180 tablets were sent. Review of the shipping manifest dated 05/23/11 verified the facility received the [MEDICATION NAME] 10 mg/325 mg. Review of the Provider Investigation Report dated 06/08/11 at 8:05 AM revealed there were 180 tablets of [MEDICATION NAME] 10mg/325mg missing sometime between the delivery of these pills on 05/23/11 and the facility becoming aware they were missing on 06/08/11. The facility became aware of the missing medication when Resident #2 questioned them about a bill. A search of the facility did not result in finding the medication, nor the individual control record. The facility investigated the incident, but was unable to determine who took the pills. The provider response indicated the facility would in-service staff and report the incident to the police. The All Discipline Progress Notes for Resident #2 dated 06/27/11 also reflected: 6:15 PM- The resident was back in the facility. He had orders for antibiotics for [MEDICAL CONDITION] at the pin site in his ankle. He also had orders for [MEDICATION NAME] 5 mg/500 mg one to two tablets by mouth every six hours as needed for pain. The resident expressed his pain level as being "9/10" on a scale with 10 being the worst. He told the nurse he needed "something fast (for pain)." The nurse administered [MEDICATION NAME] 50 mg two tablets at 6:25 PM. The resident also approved the facility ordering his medication as long as he was notified before getting any bills. 10:13 PM- The resident was given [MEDICATION NAME] 5 mg/500 mg two tablets for pain. He told the nurse his pain was "9/10 and climbing." 11:00 PM- The resident told the nurse he was "doing much better." He did not display any signs or symptoms of distress Review of the hospital Progress Notes dated 06/27/11 revealed Resident #2 fell on [DATE] and hit the calcaneal (heel) pin and reported "having chills and rigors on yesterday (06/26/11)." The hospital physical examination dated 06/27/11 reflected the right lateral pin area was red, swollen, and tender to touch with areas of dry drainage. The notes further reflected x-rays and laboratory work were done and all were essentially within normal limits. Resident #2 was given [MEDICATION NAME] 30 mg IV (intravenous) for his pain. An Addendum note at the end of the 06/27/11 hospital Progress Notes reflected, "6/27/11 at 12:41 He needs pain medication: [MEDICATION NAME] 5mg/500mg of Tylenol 1-2 tabs po every 6 hours as needed for pain." This entry was underlined. On 06/28/11 at 8:55 AM an interview with the DON revealed the facility did not replace Resident #2's 180 tablets of [MEDICATION NAME], which had been diverted on 06/08/11, because the resident still had some narcotic pain medication. On that date, Resident #2 still had some [MEDICATION NAME] left over from a prescription filled by the hospital. Resident #2 used the last of this medication on 06/24/11. The DON stated she was not aware Resident #2 had been out of [MEDICATION NAME] since 06/24/11. She further revealed she would have ordered the medication needed as the facility was responsible to see the residents had the medication they needed. On 06/28/11 at 10:15 AM Resident #2 was observed lying in bed. In an interview with Resident #2 at this time, the resident revealed he slipped and fell on [DATE] and hit the pin. He said this initiated his severe pain. Resident #2 said that although it hurt, he initially thought he could deal with the pain. He said [MEDICATION NAME] (pain medication) did not relieve the pain, which he stated was "severe" and "unbearable." He said he was subsequently sent to the hospital on [DATE] and received [MEDICATION NAME] intraveneously. Resident #2 stated he had been fine until he fell (on 06/24/11), the pain was severe, and medication the facility gave him did not work. During this same interview, the surveyor asked Resident #2 how he was feeling now. Resident #2 said he was much better than Sunday night (06/26/11-06/27/11). The resident reported he did not request pain medication because facililty staff had told him "last Monday or Tuesday" he was out of his narcotic pain pill. Resident #2 stated he took the [MEDICATION NAME] because facility staff told him to do so, but it was like "taking nothing. Taking [MEDICATION NAME] is like taking M&M's." On 06/28/11 at 10:25 AM, the surveyor interviewed the ADON regarding the reordering of Resident #2's [MEDICATION NAME]. The ADON revealed she did not remember if it was ordered, but she remembered being told it was low by the MA. The ADON stated that when she asked Resident #2 if he wanted me to reorder his medication he said no he did not want to have to pay another bill. The surveyor queried why this was said and she stated it was because he received a bill for 180 tablets of [MEDICATION NAME] and he had not seen them. The ADON revealed this occurred on 06/08/11 and that was when the facility learned the [MEDICATION NAME] 10mg/325mg 180 tablets had been diverted. The surveyor queried if she had told the DON Resident #2 was almost out of [MEDICATION NAME] 10mg/325mg, and she replied "No." The ADON stated she did not reorder the medication because the resident told her not to, but she did check with the resident. On 06/28/11 at 5:30 PM during an interview with the facility Administrator, she revealed the facility was responsible for seeing the residents had the medications they needed and had she known he was out of medication, she would have had it ordered. She stated she did not want to see any residents be in pain or go without their medications. On 06/30/11 at 11:30 AM during an interview with the ADON, it was revealed Resident #2 still did not have any [MEDICATION NAME] 10mg/325mg available for use. Resident #2 did have 10 tablets of 5mg/500 mg tablets of [MEDICATION NAME] that the ADON was going to reorder. Review of the Physician order [REDACTED]. A Physician's Telephone Order dated 05/28/11 reflected Resident #2 had an order for [REDACTED]. Review of the Physician order [REDACTED]. The orders also reflected: [MEDICATION NAME] 5mg/500 mg one to two tablets every six hours as needed for pain. Review of the facility's current policy "Medication Ordering and Receiving From Pharmacy Provider" Section 3.2 Ordering and Receiving Medications dated October 2007 revealed: "POLICY Medications and related products are received from the provider pharmacy on a timely basis. The nursing care center maintains accurate records of medication order and receipt. PROCEDURES 1. Ordering medications from provider pharmacy: a. Original medication orders are transmitted to the pharmacy. The medication order includes all required elements... e. ...Timely delivery of new orders is required so that medication administration is not delayed. If available, the emergency kit is used when the resident needs a medication prior to pharmacy delivery...." The facility's current Nursing Policy and Procedure dated August 2009 reflected the following: "HOW TO ASSESS PAIN. To assess pain properly, you will need to consider the resident's description and your observations of the resident's physical and behavioral responses. Start by Asking the following series of key questions: Where is the pain located? How long does it last? How often does it occur? What does the pain feel like? (Have the resident decribe it.) What relieves the pain or makes it worse? How do you usually get relief from it? Ask the resident to rank the pain using one of the Pain Intensity Scales. Observe the resident's behavioral and physiologic responses to pain...." The CMS Form 672, Resident Census and Conditions of Residents, dated 06/27/11 reflected there were 39 residents on pain management.

Based on observation, interview, and record review, it was determined the facility failed to ensure two (Residents #1 and #2) of 18 residents reviewed for falls received adequate supervision and assistance devices to prevent accidents resulting in injuries. 1) Resident #1 fell on [DATE] and sustained a hematoma, bruising, and lacerations to the face and jaw and multiple bruises to the extremities. The facility failed to implement a chair alarm as requested by the NP after the 12/29/10 fall. On 12/30/10 the resident fell again and was transported to the hospital for a closed head injury with lacerations that required sutures. The resident fell on [DATE] after returning from the hospital and again on 01/02/11. The facility did not assess the resident's fall behavior, plan for care, or implement measures to minimize the potential for future falls and injury for Resident #1. 2) Resident #2 fell on [DATE], which resulted in a fractured hip. After returning to the facility on [DATE], the facility did not assess the resident's fall risk or plan for the non-weightbearing care restrictions. On 12/16/10 and again on 01/03/11, Resident #2 fell while trying to care for herself. The facility did not assess, plan or implement measures to minimize the potential for future falls and injury for Resident #2. These failures could affect the 18 residents identified by the facility as falls risks, including Residents #1 and #2, which placed them at risk for the potential of falls by not implementing appropriate interventions to prevent further falls which could result in injury, undue pain and the need for hospitalization . Findings included: 1) Resident #1's undated Admission Face Sheet reflected she was admitted to the facility on [DATE]. A history and physical dated 01/04/11 reflected Resident #1 had [DIAGNOSES REDACTED]. The most current MDS assessment for Resident #1 was dated 06/11/10 and reflected the resident was oriented to the facility, easily distracted, had periods of altered perception as well as periods of restlessness, and mental function varied over the course of the day. The resident wandered and had a unsteady gait. The resident had a history of [REDACTED]. Observation on 01/04/11 at 9:10 AM revealed Resident #1 was sitting in a wheelchair in front of the nurse's station in the front lobby. Resident #1 had a large, purplish bruise on the left side of her forehead, and on the right side of the forehead she had a large bandage covering her forehead. There was no chair alarm on the resident's wheelchair. Resident #1 was unable to answer questions appropriately when questioned by the surveyor. Resident #1 was again observed at 9:30 AM in her room sitting in her wheelchair. There was no chair alarm observed on the resident's wheelchair or any additional assistive device. Resident #1 was able to move her wheelchair independently. At that time, Resident #1 was transferred to bed by CNA A and CNA G. The resident had a low bed on the floor with a pad next to the bed. CNA A stated she knew the resident well. The surveyor asked about the falls Resident #1 had experienced from the wheelchair. CNA A stated, "She (Resident #1) might need a chair alarm. She can roll her self forward." The Incident/Accident Report dated 12/29/10 at 6:30 PM reflected, "Patient (Resident #1) attempted to get out of a chair into wheelchair. Wheelchair was not locked, it rolled backwards, and patient fell face forward before I could catch her. Has a hematoma to left side of forehead. Physician was called, and nurse practitioner stated to apply chair alarm and monitor patient more closely, do neuro checks." Under the sections dealing with the incident investigation conclusion and interventions, it was noted the potential contributing factor was, "Resident was very disoriented, forgetful, attempt to walk, legs weak, short attention span. Intervention: Monitor closely. List interventions to attempt reoccurrence: Apply alarm to wheelchair." A review of the nurse's notes for Resident #1 dated 12/29/10 at 6:30 PM revealed, "this patient attempted to get out of her regular chair into her wheelchair. Wheelchair was not locked. It rolled backward and patient fell face forward before I could catch her. Assessment done. Has a purple hematoma to left side of face. Oriented to name only. Assisted up in wheelchair by two staff members. Other skin problems that were there before the fall on right jaw is a brown discoloration. On the back of her right hand is a fading purple bruise. On the lower right leg is a Band-Aid and purple bruise. On lower left leg, three purple bruises, and two light areas of discoloration. On 12/29/10 at 6:40 PM, ____, nurse practitioner, notified. He stated to apply chair alarm or something that will alert us when patient is attempting to get up. Monitor patient more closely. Do neuro checks." Review of an Incident/Accident Report dated 12/30/10 at 9:30 AM revealed Resident #1 had fallen again. The resident was found lying on the floor moaning. Her wheelchair was beside her. She had an open area 2 cm x 3 cm, which was bleeding on her right forehead. The physician ordered a transfer to a local hospital. Under the sections dealing with the incident investigation conclusion and interventions, it was noted Resident #1's cognitive status during the incident was described as confused and disoriented. It was further documented there had been no change in the resident's mental status last week, prior to the incident, and there had been no change to the resident's physical status last week, prior to the incident. The potential contributing factor related to the occurrence was recorded as "Resident was unable to remember that she cannot stand and ambulate. Interventions in place: Monitor closely and attempt to involve in activities." In the section dealing with interventions to prevent reoccurrence, the listed approach specified "Counsel staff and modify care plan." There were no notations a chair alarm or self-releasing seat belt be attempted as an intervention. Review of Resident #1's nurse's notes dated 12/30/10 revealed: At 9:30 AM, Resident #1 was found on the floor in the hallway with a "2 x 3 cm open area to right forehead, alert and oriented, covered open area with gauze and tape. Nurse Practitioner notified. Resident's ____ (family member) notified. Resident transferred to hospital." At 3:45 PM, "the patient returned from hospital, has a large bandage to right side of forehead, has a knot to right side of head. Alert and oriented to name only. Return with new [DIAGNOSES REDACTED]." A Provider Investigation Report dated 12/30/10 at 9:30 AM reflected Resident #1, "who required total assistance, was not able to ambulate independently, was not interviewable, did not have the capacity to make an informed decision, had a history of [REDACTED]. She was alert and oriented x 1 (to person). Description of injury: Open area, right forehead, 2 x 3 cm, with mod (moderate) amount of bright red blood on floor and Resident. Description of assessment: Found on floor by wheelchair with an open area, right forehead, was awake, alert, and oriented. Usual awareness. Provider response: Closed head injury, laceration of head, fall, neuro checks, and return to NH (nursing home) at 3:45 PM. Sutures x 4 to the forehead and dry dressing intact. Denies pain or discomfort. Provider action taken: Alert, return to her normal level of functioning. Sutures x 4, right forehead, and dry dressing intact." There were no new interventions noted in the provider response to address the resident's problem of falling. An additional nurse's note dated 12/30/10 at 5:30 PM reflected, "patient (Resident #1) got out of her wheelchair into another chair. She then attempted to get into wheelchair. Wheelchair was not locked. Staff got to patient in time to assist with transfer. CNA's instructed to dry patient because she was wet." The nurse's note for Resident #1 on 01/02/11 at 11:00 AM reflected, "Resident up in wheelchair attempting several times to get up and out of chair unassisted. Resident was taken to bathroom, made comfortable." Review of Resident #1's fall risk assessment completed 08/03/10 revealed Resident #1 had intermittent confusion, a history of three or more falls in the past month, was chair bound, had adequate vision, had problems with her balance while standing, had problems with her balance while walking, had decreased muscular coordination, required a wheelchair as an assistive device, and took more than three to four medications within the last seven days. The assessment reflected Resident #1 scored a 19 on the fall risk assessment. It was noted "if the total score is 10 or greater, the Resident should be considered a high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan." Resident #1's comprehensive plan of care dated 06/10/10 reflected Resident #1 had a history of [REDACTED]. Under the approaches section, the specified intervention was to "Encourage Resident to ask for assistance from staff, ensure call light is within reach - answer promptly, therapy to evaluate and treat per orders, anticipate Resident's need, provide prompt assistance, assure lighting is adequate and areas are free of clutter, and encourage socialization and activity attendance as tolerated." The care plan was reviewed on 09/21/10 and continued without change for another 90 days. The comprehensive plan of care was not updated following the resident's fall risk assessment on 08/03/10. The updated comprehensive care plan dated 12/30/10 reflected Resident #1's risk for falls was evident based on cognitive impairment, non-weightbearing, and physical impairment. Under approaches, a new approach had been added, "The Falling Star Program." On 01/04/11 at 9:28 AM, the Rehabilitation Director was interviewed about Resident #1's fall on 12/30/10. She stated the resident had a history of [REDACTED]. When asked about the falls when the resident was in her wheelchair, the director stated the resident "stays in her chair most of the time. The therapy department would screen the resident if something had changed, but nothing else had changed." In an interview with Resident #1's family member on 01/04/11 at 11:10 AM, the family member was asked about interventions the facility had used to prevent the resident from falling. The family member stated the facility had not discussed any interventions at all, and the family member had not seen any interventions being implemented, stating, "It probably would be a good idea." The family member stated Resident #1 "did not think about the consequences and by instinct she would get up and try to get out." The family member revealed in a previous facility in a different state, a bed alarm, a self-releasing seatbelt, and a chair alarm had been used to alert Resident #1 and staff. The family member thought this had helped. The family member stated Resident #1 used her wheelchair for mobility, and it was her "car" (indicating it was the resident's mode of transportation). In an interview with the facility's only ADON on 01/04/11 at 11:45 PM, the ADON was asked about Resident #1's falls and what interventions had been used to address the falls. The ADON stated she thought the facility had tried a chair alarm and self-releasing seatbelt. When asked about the other residents in the facility who were fall risks, the ADON replied the facility did not use chair alarms, because "everyone here" (staff) would just turn them off or take them off. When asked if she had tried chair alarms as a possible intervention for fall prevention, the ADON stated, "No." The ADON was queried about the nurse's note dated 12/29/10 that reflected the nurse practitioner had ordered a chair alarm. The ADON stated she was not aware of this. In an interview with LVN B on 01/04/11 at 11:55 AM, she identified herself as Resident #1's nurse. She stated the resident did not use her call light, and she was up in her wheelchair. The resident usually just sat around in her wheelchair. LVN B stated she had never observed a chair alarm on Resident #1's wheelchair, but stated that it would definitely assist with the staff response time. "If the resident had a chair alarm, someone could get to her quickly to assist her." LVN B was asked about the NP order for the chair alarm. LVN B stated she had heard something about it, but did not know what had been done. Review of Resident #1's complete facility chart revealed there was no evidence the facility had tried a chair alarm or a self-releasing seat belt for Resident #1. On 01/04/11 at 12:50 PM, when no evidence was found, the ADON was again queried regarding fall prevention interventions for Resident #1. The ADON stated she thought they had tried the self-releasing seat belt and chair alarm, but she was unable to provide any evidence. The ADON stated she was going to make an action plan; there was a communication breakdown. She further stated if a resident had two or three falls close together, then therapy would work with the resident. 2) The Admission Face Sheet dated 03/16/09 for Resident #2 reflected an admission date of [DATE] and listed the following Diagnoses: [REDACTED]. Resident #2's nurse's notes dated 11/24/10 reflected the resident had fallen on 11/24/10 at the facility and was sent to the hospital. Nurse's notes dated 11/30/10 reflected Resident #2 was readmitted to the facility on [DATE] with a new [DIAGNOSES REDACTED]. LVN D was interviewed on 01/04/11 at 1:50 PM and stated Resident #2 had fallen again on the day prior (01/03/11). A nurse's note for Resident #2 dated 01/03/11 at 11:45 AM reflected the following: "call to Resident room, Resident sitting on floor with back against wall, wheelchair locked and leg rests in front of wheelchair, wheelchair not off to side, range of motion goal, voices no complaint, call placed to family member." A previous fall on 12/16/10 at 7:25 PM was documented in Resident #2's nurse's notes, which reflected, "called to activity staff noted Resident laying on her left side on the floor near her bed, wheelchair next to her, brakes unlocked. She stated she was trying to go bed. Range of motion was within normal limits. Pain upon palpitation with bruising. Inspected skin again." Resident #2 was observed at 2:40 PM on 01/04/11 in the therapy department. She was sitting in a regular chair with a walker in front of her. She stated she had fallen and broken her hip, because she had walked away from her walker. When asked about her fall on the previous day (01/03/11), she stated she was trying to get up. In an interview at 2:40 PM on 01/04/11, the Rehabilitation Director stated Resident #2 had been on non-weightbearing precautions after she had fractured her hip. The resident had progressed and was now able to walk with therapy staff only. She stated when Resident #2 was not accompanied by therapy staff, the resident should be in a chair. She stated she had not been made aware Resident #2 had fallen the previous day. She stated Resident #2 had some memory deficits. When asked if the chair alarm would benefit the resident and help possibly in fall prevention, the therapist stated she did feel this would assist the resident when the alarm went off, as it would remind Resident #2 to sit down. Observation of Resident #2 on 01/04/11 at 3:50 PM revealed she was sitting in a wheelchair next to her bed watching television. Review of the most current MDS assessment for Resident #2 dated 05/27/10 revealed she was independent with transfers. There was no current MDS assessment to address the change in Resident #2's functional level following the hip fracture. Review of Resident #2's care plan dated 10/18/10 revealed the resident was at risk for falls as evidenced by cognitive impairment and other [DIAGNOSES REDACTED]. Under the approaches section, the following was documented: "Encourage Resident to ask for assistance from staff, encourage call light within reach, therapy to evaluate, anticipate needs, provide prompt assistance, ensure lighting is adequate and free of clutter, encourage socialization, activity attendance as tolerated, Falling Star Program, administer medications as ordered, make sure glasses are on when Resident is out of bed, encourage elevation of feet while sitting, administer diuretic as needed." Review of Resident #2's care plan updated on 11/30/10 revealed the resident "had a [DIAGNOSES REDACTED]. Approach: Administer medications as ordered by the MD, encourage rest periods to relieve pain, therapy as ordered by MD, assist with ambulation as needed, position Resident for comfort." Resident #2's most current fall risk assessment dated [DATE] reflected the resident had intermittent confusion, took one or two medications at least within the last seven days, and had predisposing diseases. The assessment score was "8," which was not indication of a high fall risk. Note: Resident #2's fall risk assessment had not been updated after Resident #2's fall with a fracture on 11/24/10. In an interview with the ADON at 12:50 PM on 01/04/11, the ADON stated she was not aware Resident #2 had fallen the previous day. The facility's policy and procedure regarding fall prevention was discussed with the ADON. When asked about the Falling Star Program, she stated she was not aware of the Falling Star Program. When asked about interventions put in place to address Resident #2's multiple falls, she revealed there were no new interventions to address the two falls Resident #2 had since she was readmitted from the hospital. 3) A review of the facility's current policy and procedure provided by the ADON with an effective date of January 2008, revealed the following: "It is the policy of this facility to evaluate Residents for their fall risk and develop interventions for prevention. Residents should be evaluated for their fall risk on admission/readmission to the facility; when the monthly system review is compete; following any change of status that may affect balance, mobility, or safety; following a fall and risk factors associated with a fall. Intrinsic risk factors for falls include changes that are part of the normal aging, as well as certain acute or chronic conditions and medications. The following are examples of common intrinsic risk factors: Gait and balance disorder, muscular weakness (particularly of the lower extremities), dizziness or vertigo, confusion, incontinence, stroke, Parkinson's disease, vision and hearing impairments, seizure disorder, depression, previous falls, certain medication classes - such as antipsychotics, sedatives, and hypnotics, ____ antidepressants, anxiolytics, certain antihypertensives - including diuretics that cause exacerbated orthostatic hypertension, the use of five or more different medications. Procedure: Upon admission, the nursing staff and Interdisciplinary Care Team should determine if the Resident is at risk for falls and develop appropriate interventions based on the evaluation. The goal was to prevent falls if possible and avoid any injury related to falls. The staff should not utilize a restraint to prevent falls unless they received written documentation to support the use of the restraint. A restraint should be the last intervention implemented by staff. The care plan should only specify a few interventions at a time, so that the staff can determine what intervention is not successful and needs to be changed. Following a fall, the following steps should be taken. Evaluate the Resident promptly in order to identify and treat injury. The Resident should not be moved until the licensed nurse has evaluated their condition, unless absolutely necessary. The evaluation should include vital signs and neurological status. If there is a loss of consciousness of the fall, it was unwitnessed, neuro signs should be initiated and checked at least 72 hours. Following the Residents evaluation, transfer the Resident to the appropriate surface and reevaluate. Evaluate the environment where the fall occurred, noting any factors that may contribute to the fall (i.e., wet floors, socks with skid resistance pads, assistive device out of reach, etc.). Ask the Resident what happened prior to the fall and what had caused the fall. Interventions suggested for fall prevention: Orient Resident to room on admission/readmission, demonstrate use of call system and ensure call cord within reach at all times, encourage Resident to request assistance with transfers and ambulation, encourage Resident to dangle feet/legs on the side of the bed for a minute prior to getting up, please place assistive devices (canes, walkers, wheelchairs, etc.) within easy reach, check tips on canes and walkers to ensure they intact and slip resistant, discuss wheelchair safety (locking wheels, raising footrest, etc.), and have Resident demonstrate measures, evaluate and implement toileting program if indicated, provide adequate lighting(night lights, keep bathroom light on at night, etc.), and remove obstacles in path, evaluate medications to determine if any can be discontinued or administration times can be changed, evaluate socks and shoes to determine if they are skid resistant. If Resident wears socks at night, provide nonskid socks. Encourage Resident to participate in exercise program, ensure personal items and water is within easy each, provide an elevated toilet seat and grab bars in the bathroom if indicated, provide trapeze bar next to bed, place bed in lowest position and lock wheels, position bed so that the exit is toward the Resident's side, utilize bed and/or chair alarms if necessary, refer Resident to PT or OT." 4) The "Daily Census Report" dated 01/04/11 reflected a total census of 79 residents. The "Resident Worksheet" provided by the facility on 01/04/10 identified 18 residents at risk for falls.