Every finding on record at Crestwood Health and Rehabilitation Center

Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 5 residents (Resident #85) reviewed for PASRR Level I screenings.The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #85. The PASRR 1 Level screening did not indicate a diagnosis of mental illness, although the diagnosis was present upon admission. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs. Findings included:Record review of Resident #85's face sheet, dated 01/05/2026, indicated she was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including bipolar disorder, chronic kidney disease stage 4, and frontotemporal neurocognitive disorder. Record review of Resident #85's admission MDS assessment, dated 09/1520/25, indicated section A1500 was marked 0 or no. this indicated she was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section A1510 was not marked for level II PASRR conditions. The assessment indicated she had a BIMS score of 12, which indicated intact cognition. Section I (Active Diagnoses) indicated the resident had bipolar disorder. Record review of Resident #85's PL 1 screening, dated 09/15/2025, indicated section C0100 Mental illness was marked no, which indicated there was no evidence or an indicator that she had a mental illness.During an interview on 01/07/26 at 9:44AM, the MDS Coordinator said she was responsible for the MDS and PASRRs at the time of Resident #85's admission on [DATE] from an assisted living facility. After viewing the PL1 in the PASRR software she said the PL1 was marked no on dementia, mental illness, developmental disability and intellectual disability. After viewing the admission MDS dated [DATE] she agreed section I (Active Diagnoses) was marked positive for bipolar disorder. She said bipolar disorder would be a possible qualifying diagnosis for PASRR specialized services. She said she would notify the local authority the PL1 was incorrect. She said it was important the PL1 be correctly marked as yes for mental illness so a PASRR Evaluation could be performed by the local authority. She said the resident could possibly qualify for specialized services and would miss receiving them.During an interview on 01/07/2026 at 10:20 AM, the DON said she was not aware of Resident #85's PL1 was incorrectly marked as no for mental illness. She said it was possible if her PL1 was marked positive for mental illness she may have qualified for specialized services for her mental health.During an interview on 01/07/2026 at 10:30 AM, the Administrator said Resident #85 could possibly miss out on receiving specialized services if her PL1 was incorrectly marked as no for mental illness. Record review of the facility's policy, PASRR Policy and Procedures, revised 1/2022, indicated: .ALL residents have received a PASRR Level 1 screening. If Facility serves a resident with a positive PASRR Level I screening, the facility MUST have obtained A PASRR Level II evaluation.

Based on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 1 of 18 residents reviewed for laboratory services (Resident #9). The facility failed to obtain Resident #9's CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel) every Monday for 4 weeks as ordered. This failure could place residents at risk of not receiving timely diagnoses, treatment, and services to meet their needs.Findings included: Record review of Resident #9's undated face sheet revealed he was an [AGE] year-old male that admitted on [DATE] with a readmit date of 12/3/25. Record review of Resident #9's physician's orders dated 1/7/26 indicated he had diagnoses that included: Dependence on Renal Dialysis (life-sustaining treatment for kidney failure that artificially filters waste products and excess fluid from the blood), End Stage Renal Disease (the kidneys can no longer filter waste and fluids effectively requiring dialysis or a kidney transplant for survival), Encephalopathy (diffuse disease or brain injury that alters brain function causing symptoms like confusion, memory loss, and personality changes), and Type 2 Diabetes (a form of diabetes characterized by high blood sugar and insulin resistance).The physician's orders indicated:12/4/25 CBC, CMP, every Monday for 4 weeks. Record review of the admission MDS dated [DATE] indicated Resident #9 had a BIMS score of 15 indicating he was cognitively intact. He received dialysis. Record review of the undated care plan indicated Resident #9 needed hemodialysis on Monday, Wednesday, and Friday for renal failure. He had fluid overload or potential fluid volume overload related to kidney failure. The care plan did not address labs or orders for labs. During an interview on 1/6/26, Resident #9 was sitting in his chair. He said the staff was nice to him and he went to dialysis three times per week. During an interview 1/07/2026 at 11:11 AM, RN A said they do not have all the labs for Resident #9. She provided labs for Resident #9 dated 12/5/25 and said they did not have any other labs for him. She confirmed there were no labs drawn on Resident #9 on Monday 12/8/25, Monday 12/15/25, Monday 12/22/25 or Monday 12/29/25. During an interview on 01/07/2026 at 11:12 AM, the ADON said they did not have all the labs for Resident #9. They only had labs from 12/5/25. The other labs were not done. During an interview on 1/07/2026 at 11:42 AM The DON said she thought the PA did not realize Resident #9 was a dialysis patient and if he had realized that he would not have ordered weekly labs because dialysis did his labs. She said she called dialysis and they said he did not need labs more than monthly at this time and he had labs done 12/5/25 and labs were due again today. Record review of a progress notes written by the PA indicated: 1/2/26.We're continuing to follow weekly labs and patient plans to discharge home. 12/5/25.Patient is a recent new admission to the facility from the hospital resting comfortably in bed and no acute distress patient's workup at the hospital revealed UTI (urinary tract infection), end-stage renal disease, .and patient will continue with hemodialysis three times weekly on Monday, Wednesdays, and Fridays. During an interview and record review on 1/07/2026 at 11:49 AM, the DON provided a progress note she wrote for Resident #9 dated 1/7/26 indicating: Writer noted order for weekly labs x 4. Resident is a dialysis patient, and labs are drawn routinely at dialysis. Spoke to PA new order noted to d/c that order. PA stated with resident being a dialysis patient and receiving routine labs, order for weekly x 4 was not necessary. Interview on 01/07/2026 at 1:55 PM, the ADON said if labs were ordered by the MD or PA, they should be done per the order unless the order changed or was discontinued. She said there were no notes or documentation that the PA changed or discontinued the lab orders for Resident #9 before today. She said the PA put in the order for the labs and did not realize that dialysis did them monthly, so there was no indication for them. She said the risk of a resident not getting labs done were multiple. She said if there was an order indicating labs should continue, they could not track the labs if they had not been done. The ADON said they did not have the weekly labs for Resident #9. She said dialysis did his labs monthly. During an interview on 1/07/2026 at 2:03 PM, the DON said she thought the PA did not realize Resident #9 was on dialysis when he put in the orders for the weekly labs. She talked to the PA today and he discontinued the order for weekly labs for Resident #9 dated 12/4/25. She said the labs were not done. She said dialysis did all his labs as they were needed and she confirmed that today by calling the dialysis center. She said the PA discontinued that order today when she called him. The risk of Resident #9 not getting his labs as ordered were negative consequences to the resident, if the labs were not in normal range. She said that order should have been caught before today. She said a new nurse, RN B, should have put that lab order for Resident #9 on the 24-hour report and everyone would have been aware of the order, and she could have asked the PA about it. But, she said it was not on the 24-hour report. She said it was her responsibility to make sure all lab orders were completed. Orders were reviewed by the IDT team which included the DON, ADON, ADM, and all dept heads, and it was just missed somehow. They have done a full lab audit today. On 1/7/25 at 2:17 PM, a phone interview was attempted with RN B. No return call was received. During an interview and record review on 1/07/2026 at 2:20 PM, the DON provided the 24-hour reports dated 12/4/25 and 12/5/25. She said there was nothing on them regarding the orders for Resident #9's labs. During an interview and record review on 1/07/26 at 2:30 PM, the Regional Nurse said the physician's orders policy they provided was all they had for following physician's orders. Record review of a Physician's Orders, Telephone Orders and Recapitulation Process policy dated 11/2007 indicated: .2.All orders must be specific and complete with all necessary details to carry out the prescribed order without any question. Record review of Diagnostic Tests/Laboratory Services Policy dated 5/2007 with a revised date of 7/2015 indicated: Policy: It is the policy of this facility to provide for laboratory services under contract with an independent laboratory. A physician's order is required. Procedures: 1.A licensed Nurse will communicate order to laboratory. An order from the physician is necessary for lab work.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents reviewed for infection control practices (Resident #60). The facility failed to ensure CNA C changed her gloves and performed hand hygiene appropriately while providing incontinent care for Resident #60. She touched Resident 60's arm, gown, and leg with her dirty gloves. This failure could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: Record review of Resident #60's undated face sheet indicated she was a [AGE] year-old female that admitted [DATE]. Record review of the physician's orders dated 1/7/26 indicated Resident #60 had diagnoses that included: Dementia (severe cognitive decline interfering with daily life), Parkinson's Disease (a neurodegenerative disease of the central nervous system affecting both motor and non-motor symptoms), and senile degeneration of the brain (age related cognitive decline). Record review of the quarterly MDS dated [DATE] indicated Resident #60 had no speech, was rarely or never understood and rarely or never understood others. She had short-term and long-term memory problems. The MDS indicated she was dependent on staff for toileting hygiene. She was always incontinent of urine and bowel. Record review of the undated care plan indicated Resident #60 had Parkinson's Disease and had impaired thought processes related to dementia. The care plan indicated she required assistance for activities of daily living care and staff would change her brief and provide assistance as needed. During an observation on 1/07/2026 at 10:30 AM, CNA C and CNA D provided incontinent care for Resident #60. CNA C cleaned Resident #60's front peri area then without changing her gloves or sanitizing her hands she touched Resident #60's gown, arm and upper thigh before changing her gloves and washing her hands. During an interview on 1/7/26 at 10:46 AM CNA C said she was nervous, forgot to change her gloves, and touched Resident #60's gown, arm and thigh with her dirty gloves. She said she should have changed her gloves and cleaned her hands before touching the resident. She said that could cause contamination and infection to residents and staff. During an interview on 1/7/26 at 10:48,AM, CNA D said she was nervous and did not realize CNA C had not changed her gloves when she was supposed to. She said CNA C should have changed her gloves and sanitized her hands before touching Resident #60's gown, arm, and leg. She said touching a resident with dirty gloves could cause cross contamination and infection to residents and staff. During an interview on 1/07/2026 at 10:51 AM, LVN E said staff should always change their gloves and sanitize their hands after performing a dirty procedure. She said touching a resident with dirty gloves was a risk of cross contamination and infection to residents and staff. During an interview on 1/07/2026 at 1:55 PM, the ADON said during incontinent care a staff or CNA should change and sanitize their hands if their gloves were dirty. She said if a staff touched a resident with gloves they had used to clean a resident's peri area, they would be considered dirty and/or contaminated and that could cause infection control issues for staff and residents. She said CNA's and staff were taught to always change their gloves after a dirty procedure. During an interview on 1/07/2026 2:03 PM, the DON said during incontinent care staff should change their gloves when they were dirty. She said if a staff cleaned the peri area of a resident, then touched the resident or any items, those items would be considered contaminated or dirty. Gloves should be changed anytime they were considered dirty. She said the CNA's and staff were educated on infection control and hand hygiene practices and they knew what they were supposed to do. Staff not changing gloves when they were dirty could cause a risk of contaminating something or increasing the risk of infection to residents and staff. During an interview and record review on 1/07/2026 at 2:32 PM, the Regional Nurse said they did not have an incontinent care proficiency for CNA C. She provided a computer program print out that indicated CNA C was proficient in Infection Prevention and Control Basics on 1/3/26. Record review of a Perineal Care Policy with a revised date of 7/2013 did not address glove changes or sanitizing hands during incontinent care. Record review of a Hand Hygiene Policy with a revised date of 4/2025 indicated: PolicyIt is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene, which is one of the most effective measures to prevent the spread of infection, based on accepted standards. Residents, family, and visitors will be encouraged to practice hand hygiene.2.Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .b.Before and after direct contact with residents;.h. Before moving from a contaminated body site to a clean body site during resident care;i. After contact with a resident's intact skin;j.After contact with blood or bodily fluids;.m. After removing gloves.

Based on interview and record review, the facility failed to ensure residents were informed orally, of their rights, for 6 of 6 residents interviewed during a group meeting (Resident #13, #14, #21, #32, #49 and #53). Residents #13, #14, #21, #32, #49 and #53 were not orally informed of their rights, during their stay in the facility. This failure placed the residents at risk of a decreased quality of life, decreased awareness of their rights and decreased execution of their rights. Findings included: During an interview on 10/15/2024 at 9:00 AM, Residents #13, #14, #21, #32, #49 and #53 said, the new AD has not reviewed resident rights with them or explained any resident rights to them, since she became the AD. During record review of resident council meeting minutes, for 10/09/2024, 09/03/2024, 08/02/2024, 07/02/2024, and 06/07/2024, revealed that resident rights were not reviewed over the past five months; October, September, August, July, and June 2024. During an interview on 10/16/2024 at 3:25 PM, the AD said she became the AD after receiving her certification in March 2024. She said she was still learning, and she was not aware that she should have been reviewing the resident rights with residents during resident council meetings. She said she would make sure she reviewed resident rights. During an interview on 10/16/2024 at 3:50 PM, the Operations Manager said the residents received a copy of the resident rights, in the admission packet and the AD should be going over resident rights in the resident council meetings. Review of a document titled Resident Right and Responsibility, Notice of, with a revised date of 12/2023, reflected Policy: It is the policy of this facility to inform the resident both orally and in writing of their rights as a resident, as well as the regulations .

Based on observation, interview and record review the facility failed to report to state agency emergency situations that pose a threat to resident health and safety immediately, but not later than 24 hours after the incident occurs or is suspected for 1 of 1 secured locked unit reviewed for physical environment. The facility failed to report to the State Survey Agency on 8/29/24 immediately but no later than 24 hours after becoming aware the facility's roof collapsed on the secured locked unit. This failure could place residents at risk of further potential abuse or neglect. Findings included: During observation of facility on 8/30/24 from 10:57am to 7:50pm a contract roofing company was working on the roof, the locked unit was taped off due to not in use because of the damages caused by the roof collapsing. All residents on 100 hall were relocated to the 200 hall and there was no visible bruising, skin tears or marks. Residents did not show signs of fear when interacting with staff. Record review of provider investigation report date 9/5/24 revealed: Date reported to HHSC - 8/3024 at 5:30pm. The incident date: 8/29/24; Time of incident: 1-6pm; Description of Allegation: Roof begun leaking during a storm due to roof construction and lack of sufficient covering. Investigation Summary - Roof/ceiling leak caused by rain while partial roofing was uncovered by contracted repair company. Fire panel restarted within four hours. Fire alarm down in the secure unit (no residents on hall) during repairs - fire watch ending. During an interview on 8/30/24 at 2:06 p.m., the ADOR said he worked the day of the incident on 8/29/24 and it occurred a little after 1:00pm when the fire alarm went off, he said he walked around to see what was going on and as he walked by the business office he saw water was dripping from the sprinkler head, he placed a trashcan under the drip to catch the drip and at that time he said he assumed the sprinkler head was just damaged. The ADOR said he continued down the hall and looked through the door window of the secured locked unit and he saw water pouring from the ceiling on the main sitting area of the locked unit; he said he started going room by room on the locked unit and at that time he witnessed the ceiling collapsed in one of the rooms and he immediately at that time ran to the one bedbound resident who resided on the locked unit and wheeled the bedbound resident's bed into the halls off of the unit and handed the resident off to another staff. The ADOR said himself and several other staff started assisting the residents who resided on the locked unit into the halls and to the main dining room outside the unit. He said water was pouring into the building from anything that was attached to the ceiling for example the lights, smoke detectors, the exit signs etc . The ADOR said none of the residents on the locked unit or in the building were hurt or received injuries. During an interview on 8/30/24 at 6:44 p.m., The Director of Operations said he had been filling in for the facility's administrator for about a week. He said on 8/29/24 he started receiving several phone calls around 1:40pm, and throughout the afternoon regarding water pouring from the ceiling into the building on the secured locked unit, he said he was coming from out of town because he was at a corporate meeting and arrived around 6pm to the facility. The Director of Operations said he reported the incident to State Office on 8/30/24 after 6pm and thought he was incompliance with reporting within the required 24-hour timeframe, said he was not aware he had to report the incident to state office before 2pm because that was when he was first notified of the incident . Record review of long-term care regulation prover letter 2024-14 dated 8/29/24 provided by the facility as the guidance they used reflected 1.0 Subject and Purpose: This letter provides guidance for reporting incidents to HHSC and adds information about when providers must report communicable disease to Complaint and Incident intake (CII). It also clarifies the types of events that are not reportable to HHSC, and updates rule references. To aid providers in understanding the reporting requirements. 2.0 Policy Details and Provider Responsibilities: 2.1 Incidents that a NF Must Report to HHSC - A NF must report to CII the following types of incidents, in accordance with applicable state and federal requirements: .Emergency situations that pose a threat to resident health and safety . 2.4 Reportable Incidents and Timeframes: . Do Report: an incident that does not result in serious bodily injury but that involves any of the following: .Emergency situations that pose a threat to resident health and safety When to Report: Immediately, but not later than 24 hours after the incident occurs or is suspected.

Based on interview and record review, the facility failed to ensure an accurate MDS was completed for 12 of 18 residents (Resident #s 7, 9, 15, 18, 24, 32, 46, 49, 50, 51, 55, and 56) reviewed for MDS assessment accuracy. The facility did not accurately code Resident #s 7, 15, 32, 46, 49, 50, and 55's MDS for BIMS score (cognitive patterns), mood score, and daily routine and activity preferences. The facility did not accurately code Resident #s 9, 18, 24, 51, and 56's MDS assessment for BIMS score (cognitive patterns) and mood score. These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: 1.A review of Resident #7's face sheet dated 08/23/2023 indicated Resident #7 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including diabetes, low back pain, high blood pressure, gastro-esophageal reflux disease (indigestion), fractures of first and fourth lumbar vertebrae, and muscle weakness. An admission BIMS (brief interview for mental status) score, dated 01/09/2023, was 13 indicating the resident was cognitively intact. A review of Resident #7's admission MDS (Sections F0300, F0400, F0600) dated 01/09/2023 indicated an interview for Daily and Activity Preferences should be conducted and the interview was not completed to indicate the resident's preferences for daily options and activity options. A review of Resident #7's quarterly MDS (Sections C0100, C0200, C0300, C0400, C0500, D0100, D0200, D0300), dated 04/11/2023, indicated a BIMS interview and an interview for mood should be conducted and the interviews were not completed to indicate the resident's cognitive status and mood status. A review of Resident #7's quarterly MDS (Sections C0100, C0200, C0300, C0400, C0500, D0100, D0200, D0300), dated 05/29/2023, indicated a BIMS interview and an interview for mood should be conducted and the interviews were not completed to indicate the resident's cognitive status and mood status. 2. A review of Resident #9's face sheet dated 08/23/2023 indicated Resident #9 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including diabetes, heart disease, schizoaffective disorder bipolar type (mental health condition with symptoms of schizophrenia and mood disorders), atrial fibrillation (irregular often rapid heart rate that causes poor blood flow), anxiety, depression, insomnia, peripheral vascular disease a circulatory condition where narrowed blood vessels reduces blood flow to the limbs), high blood pressure, indigestion, and morbid obesity. An annual BIMS (brief interview for mental status) score, dated 07/21/2023, was 14 indicating the resident was cognitively intact. A review of Resident #9's significant change MDS (Sections C0100, C0200, C0300, C0400, C0500, D0100, D0200, D0300), dated 05/01/2023, indicated a BIMS interview and an interview for mood should be conducted and the interviews were not completed to indicate the resident's cognitive status and mood status. 3. A review of Resident #15's face sheet dated 08/23/2023 indicated Resident #7 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including dementia, diabetes, chronic obstructive pulmonary disease (lung disease with airflow blockage), major depression, insomnia, chronic pain, anxiety, and heart failure. An annual BIMS (brief interview for mental status) score, dated 03/28/2023, was 09 indicating the resident was mildly compromised cognitively. A review of Resident #15's annual MDS (Sections F0300, F0400, F0600) dated 03/28/2023 indicated an interview for Daily and Activity Preferences should be conducted and the interview was not completed to indicate the resident's preferences for daily options and activity options. A review of Resident #15's quarterly MDS (Sections C0100, C0200, C0300, C0400, C0500, D0100, D0200, D0300), dated 06/28/2023, indicated a BIMS interview and an interview for mood should be conducted and the interviews were not completed to indicate the resident's cognitive status and mood status. A review of Resident #15's quarterly MDS (Sections C0100, C0200, C0300, C0400, C0500, D0100, D0200, D0300), dated 07/26/2023, indicated a BIMS interview and an interview for mood should be conducted and the interviews were not completed to indicate the resident's cognitive status and mood status. 4. A review of Resident #18's face sheet dated 08/23/2023 indicated Resident #18 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses including diabetes, morbid obesity, heart disease, chronic obstructive pulmonary disease (lung disease with airflow blockage), gout, chronic kidney disease, high blood pressure, anxiety, congestive heart failure, and depressive disorders. A quarterly BIMS (brief interview for mental status) score, dated 08/07/2023, was 14 indicating the resident was cognitively intact. A review of Resident #18's annual MDS (Sections C0100, C0200, C0300, C0400, C0500, D0100, D0200, D0300), dated 04/06/2023, indicated a BIMS interview and an interview for mood should be conducted and the interviews were not completed to indicate the resident's cognitive status and mood status. A review of Resident #18's quarterly MDS (Sections C0100, C0200, C0300, C0400, C0500, D0100, D0200, D0300), dated 05/07/2023, indicated a BIMS interview and an interview for mood should be conducted and the interviews were not completed to indicate the resident's cognitive status and mood status. 5. A Review of Resident #24's electronic face sheet for August 2023 indicated Resident #51 was admitted to the facility on [DATE] with diagnoses including emphysema, shortness of breath, major depression, chronic pneumonia. A Review of Resident #24's MDS assessment dated [DATE] for sections C (section C - Cognitive Patterns) and D (Mood) had not completed for assessment. 6. A review of Resident #32's's face sheet for August 2023 indicated she was an [AGE] year-old female who readmitted to the facility on [DATE] with diagnoses including dementia, anxiety, and chronic obstructive pulmonary disease. A review of Resident #32's Quarterly MDS dated [DATE] indicated she should receive a Brief Interview for Mental Status (BIMS). This same MDS further indicated this interview was not conducted and Resident #32 was not assessed for mental status. A review of Resident #32's Quarterly MDS dated [DATE] indicated she should receive a Resident Mood Interview. This same MDS further indicated this interview was not conducted and Resident #32 was not assessed for mood. A review of Resident #32's Comprehensive MDS dated [DATE] indicated she should have an Interview for Daily and Activity Preferences. This same MDS indicated this interview was not conducted and Resident # 32 was not assessed for daily routine and activity preferences. 7. A review of Resident #46's's face sheet for August 2023 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including dementia, anxiety, glaucoma (vision disorder), and history of falls. A review of Resident #46's Quarterly MDS dated [DATE] and Comprehensive MDS dated [DATE] indicated she should receive a Brief Interview for Mental Status (BIMS) on both assessments. These same MDS assessments further indicated this interview was not conducted and Resident #46 was not assessed for mental status at either time. A review of Resident #46's Quarterly MDS dated [DATE] and Comprehensive MDS dated [DATE] indicated she should receive a Resident Mood Interview. These same MDS assessments further indicated this interview was not conducted and Resident #32 was not assessed for mood at either time. A review of Resident #46's Comprehensive MDS dated [DATE] indicated she should receive an Interview for Daily and Activity Preferences. This same MDS indicated this interview was not conducted and Resident # 46 was not assessed for daily routine and activity preferences. 8. A review of Resident #49's face sheet dated 08/23/2023 indicated Resident #49 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including anxiety, insomnia, osteoporosis, dementia, falls, and hallucinations. An annual BIMS (brief interview for mental status) score, dated 04/29/2023, was 03 indicating the resident was severely Impaired cognitively A review of Resident #49's significant change MDS (Sections F0300, F0400, F0600) dated 07/29/2023 indicated an interview for Daily and Activity Preferences should be conducted and the interview was not completed to indicate the resident's preferences for daily options and activity options. A review of Resident #49's significant change MDS (Sections C0100, C0200, C0300, C0400, C0500, D0100, D0200, D0300), dated 07/29/2023, indicated a BIMS interview and an interview for mood should be conducted and the interviews were not completed to indicate the resident's cognitive status and mood status. 9. A review of Resident #50's's face sheet for August 2023 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses including depression, anxiety, intellectual disabilities and dementia. A review of Resident #50's Quarterly MDS dated [DATE], Comprehensive MDS dated [DATE], and Quarterly MDS dated [DATE] indicated he should receive a Brief Interview for Mental Status (BIMS) on each of these assessments. These same MDS assessments further indicated this interview was not conducted and Resident #50 was not assessed for mental status on any of these three assessments. A review of Resident #50's Quarterly MDS dated [DATE], Comprehensive MDS dated [DATE], and Quarterly MDS dated [DATE] indicated he should receive a Resident Mood Interview. These same MDS assessments further indicated this interview was not conducted and Resident #50 was not assessed for mental status on any of these three assessments. 10. A review of Resident #51's face sheet for August 2023 indicated Resident #51 was a 84 -year-old male who was admitted to the facility on [DATE] with diagnoses including: full code with use of AED, Alzheimer, unsteadiness on fee, history of falls, cognitive communication deficit, need for assistance with personal care, dysphagia, muscle weakness, attention deficit, dementia, anxiety disorder, repeated falls, hyperlipidemia, migraine, hypertension, benign prostatic hyperplasia. A review of Resident #51's Quarterly MDS, dated [DATE],6/8/23, 3/8/23 and 2/6/23 for sections C (section C - Cognitive Patterns) and D (Mood) had not completed for assessment. 11. A Review of Resident #55's electronic face sheet for August 2023 indicated Resident #55 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, hypothyroidism, Dementia, delusional, major depressive disorder, aphasia, urinary tract infection history of malignant neoplasm of breast and ovary. A review of Resident #55's MDS assessment dated [DATE] for sections C (section C - Cognitive Patterns) and D (Mood) had not completed for assessment. MDS assessment dated [DATE] for section F (preferences for customary routine and activities) had not completed for assessment. 12. A review of Resident #56's electronic face sheet dated for August 2023 indicated Resident #56 was admitted to the facility on [DATE]with diagnosis including: Anxiety, hypertension, cognitive communication deficit, urinary tract infection, herpes zoster A review of Resident #56's MDS dated [DATE] and 7/6/2023 for sections C (section C - Cognitive Patterns) and D (Mood) had not completed for assessment. During an interview on 08/23/2023 at 10:10 AM with the RN MDS Resource Nurse, she said the RAI manual was used as the guideline for conducting the MDS assessment. She said the RAI did not indicate the MDS had to be done by a particular person or certain sections have to be done by a particular person. She said at their facilities the SW usually completed sections B, C, D, and Q. She said any staff member could complete these sections of the MDS if they are trained to do them and did not have to be the SW. She said she was not sure why those sections were not completed and not sure if there was a policy regarding certain sections of the MDS being assigned to any particular staff. During an interview on 08/23/2023 at 11:00 AM the RN MDS Resource Nurse said the facility did not have a specific policy that assigns any section of the MDS to any particular person to complete. She said at mmost of their facilities the social worker completed the cognitive patterns and mood sections of the MDS. She said the activity sections information came from teh activity director. A review of the RAI Version 3.0 Manual for MDS Section C: Cognitive Patterns indicated the following: When cognitive impairment is incorrectly diagnosed or missed, appropriate communication, worthwhile activities and therapies may not be offered. A review of the RAI Version 3.0 Manual for MDS Section D: Mood indicated the following: It is particularly important to identify signs and symptoms of mood distress among nursing home residents because these signs and symptoms can be treatable. A review of the RAI Version 3.0 Manual for MDS Section F: Preferences for Customary Routine and Activities indicated the following: The intent of items in this section is to obtain information regarding the resident's preferences for his or her daily routine and activities. Quality of life can be greatly enhanced when care respects the resident's choice regarding anything that is important to the resident. 41695 47204

Based on observation, interview, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene that promotes maintenance or enhancement of his or her quality of life, for resident (Resident #51) review for quality of life. The facility failed to provide Resident #51 with personal grooming for nail care These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: Record review of Resident #51's admission record dated 11/2/2022 reflected Resident #51 was an [AGE] year-old male, diagnosis included full code with use of AED, Alzheimer's, unsteadiness on feet, history of falls, cognitive communication deficit, need for assistance with personal care, dysphagia, muscle weakness, attention deficit, dementia, anxiety disorder, repeated falls, hyperlipidemia (an excess of lipids or fats in your blood), migraine, hypertension, benign prostatic hyperplasia. Record review of Resident #51's MDS assessment, dated 07/27/23, reflected the following:-resident's cognitive status: not assessed -requiring extensive assistance for transfers, bed mobility. -required supervision for dressing, eating, and extensive assistance with toilet use and personal hygiene. Record review of Resident #51's care plans, initiated on 07/10/23, reflected Resident #51 had an ADL Self Care Performance Deficit r/t Dementia, memory loss, h/o falls, anxiety, Resident has history of L Hip fracture will need assistance with ADL's. Record review of resident #51's podiatry care dated 1/5/2023 reflected nails were trimmed and debrided reduced in length and thickness in 2 mm, progress notes stated: trimmed and debrided nails(s) to patient's tolerance. Reviewed medical record, patient to follow up in 2 months. Record review of Resident #51's nail task history dated 11/2/22 at time of admission nail care was shown as a related focus, with no reflection of staff following up with any nail care. Record review of Shower Report dated 08/21/2023 for resident #51 revealed complete bed bath given, linens changed no indication of nail care given, Shower scheduled revealed that Resident #51 received showers on Monday, Wednesday, and Fridays. There were no other shower reports to be reviewed. An interview and observation on 8/21/2023 at 9:43 a.m. with Resident #51 revealed he had elongated (longer than the nail bed) thick, discolored toenails to both right and left feet. The resident said they bothered him sometimes. He said he told the nurse, but he could not remember when or and when he last saw the foot doctor. During an Interview on 8/23,23 at 10:00 A.M. with DON, she said that in the case of no Podiatrist that nurses were responsible for foot care. Poor foot hygiene could put residents at an increased risk for infection. Fungal nail infections were common infections of the toenails that could cause the nail to become discolored, thick, and more likely to crack and break. During an Interview on 8/23/23 at 2:20 pm with Agency LVN, said the CNAs performed foot care, but she did not know anything about residents that needed foot care. She said CNAs would notify them if foot care needed to be done. During an Interview on 8/23/23 at 2:45 p.m. with Agency CNA, she said she did not perform nail care. During an interview with the ADON on 8/23/23 at 3:00 p.m., she said there was a broken system regarding shower schedules and that the administration was working on it. She said broken system meaning, not all CNAs were using the paper system charting or charting their nail care in the electronic chart. She said it was nursing administration responsiblity to correct this problem, which they were working on. Record Review of the facility's Policy for Foot Care, dated 05/2007 Policy #NCRP 31(Nail Care Routine Procedures 31) POLICY: It is the policy of this facility to clean feet and to increase circulation. PROCEDURES: Equipment: mild soap and water, towel and washcloth, toenail clippers or nail scissors, nail file and lotion. * Examine feet carefully for evidence of discoloration, redness, blisters or skin tears. Report any irregularities to charge nurse. Note: Do not perform Nail Care nor Foot Care on residents with Diabetes and Peripheral Vascular Disease.

Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for 2 of 2 residents (Resident #24 and #42) reviewed for oxygen therapy, in that: 1. The facility failed to ensure Resident #24's oxygen rate was set at 3-4 LPM (liters per minute) CONTINUOUS and not 2 LPM. 2. The facility failed to ensure monitoring of oxygen Saturation as ordered by the physician (maintain O2 saturation above 90%) 3. The facility failed to ensure there was an order for Resident #42 to receive oxygen. These failures could place residents who received oxygen therapy at risk for respiratory distress Record Review of Resident #24's electronic face sheet for August 2023 indicated she was admitted to the facility on [DATE] with diagnoses including emphysema, shortness of breath, major depression, chronic pneumonia. Review of Resident #24's MDS assessment dated [DATE] had not been completed. A review of Resident #24's physician orders for August 2023 indicated she was to receive oxygen via nasal canula at 2 -3 LPM (liters per minute) to maintain oxygen saturation above 90%. During observations Resident #24 was receiving oxygen at 2 LPM on the following dates and times: - 08/21/2023 at 3:00 pm - 08/22/2023 at 4:00 p.m. Record review on 8/21/23 and 8/22/23 there was no oxygen saturation recorded in the electronic chart. During an interview on 08/22/2023 at 04:07 pm with ADON, she said Resident #24's oxygen rate was ordered for 3-4 LPM for oxygen saturation to maintain at 90%. She was asked if she could show where the saturation is recorded, she said it is in the flow chart and nurses' medication administration record, she could not find any recent recording, the last recorded saturation was 8/11/2023. She said she would get that corrected immediately. Review of Resident #42's electronic face sheet for August 2023 indicated she was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, congestive heart failure, hypoxia (the state in which oxygen is not available in sufficient amount at the tissue level to maintain adequate homeostasis), major depression, chronic obstructive pulmonary disease, shortness of breath. Review of Resident #42's MDS assessment dated [DATE] indicated she scored 12 out of 15 which indicated she was cognitively intact. A review of Resident #42's physicians orders for August 2023 did not indicate any orders for oxygen. During an interview on 08/22/2023 at 04:07 pm with the ADON, she stated she could not find an order for Resident #42 to have oxygen. She stated Resident #42's oxygen rate was observed at 3 LPM, She said she would get that corrected immediately. She said Resident #42 had been in and out of the hospital and that order was missed. A review of the facility's Oxygen Administration Policy dated 05/2007 indicated the following: It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained. 1. Obtain appropriate physician orders for oxygen administration. 17. Document all appropriate information in medical record. *Oxygen therapy, Respiratory assessment findings, method of oxygen delivery, flow rate, residents' response, any adverse reaction or side effects .

Based on observation, interview, and record review, the facility failed to ensure that the daily nurse staffing was posted as required for 3 of 3 days (8/19/23, 8/20/23 and 8/21/23) reviewed for nursing services. The facility failed to update the daily staffing information posting. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census. Findings included: Record review on 08/21/23 at 08:30 a.m., revealed the daily staffing pattern was posted on the desk by the front door in a clear acrylic holder and dated 08/18/23, which did not reflect the current date. During a record review on 08/22/23 at 8:30 a.m., the required nurse staffing data was posted on the desk in the front lobby, dated 08/22/23. During an interview with the Nursing scheduler/Recruiter on 8/23/23 at 3:00 p.m., she said it was her responsibility to make sure nurse staffing is posted. She said she would call the facility and talk to the nurse in charge to make sure the posting was changed. However, that weekend, she could not get in touch with anyone, so she sent a text and did not follow up. During interviews on 08/23/23 at 4:00 PM with the DON, the DON said the Staffing Scheduler was responsible for ensuring the nurse staffing data was posted, but the whole process is a work in process that the facility is working on. The DON said the facility did not have a policy on required staffing posting. The facility did not provide a policy on nursing staff postings at time of exit.

Based on interviews and record review the facility failed to ensure the residents received mail for 5 of 5 residents reviewed for resident rights. (Residents #2, #18, #37, #57 and #61). The facility did not ensure residents received their mail promptly. This failure could place the residents at risk of not receiving mail in a timely manner and a diminished quality of life. Findings included: During a group interview on 08/22/2023 at 9:00 AM, Residents #18, #37 and #57 said the mail was delivered on Saturday, but they only received mail Monday through Friday. Residents #2 and # 61 nodded in agreement with the other residents' statement. During an interview on 08/23/2023 at 10:25 AM, the receptionist said she worked Monday through Friday. She said she does work the weekend when scheduled. She said when she worked the weekend and received the mail, she placed it at the reception desk for Monday. She said when she came in on Monday, she would sort the weekend mail, she gave the business office the business mail and she delivered the resident mail to the residents who received mail over the weekend. During an interview on 08/23/2023 at 10:30 AM., the weekday manager on duty said he worked the weekend of 08/19/2023 and 08/20/2023 and he received the weekend mail. He said he placed the mail on the desk for the receptionist who works Monday through Friday. He said when the receptionist came in on Monday, the receptionist sorted the mail and brought the business mail to the business office. He said he did not sort the mail that came in on the weekend, he said that was done by the receptionist who came in on Monday. Record review of the facility's policy: Privacy and Confidentiality, dated 10/04/2016, revealed, the right to send and promptly receive unopen mail and other letters, packages and other materials delivered to the facility for you .

Based on interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of 1 of 4 residents reviewed for pharmacy services. (Resident #1). The facility failed to ensure intravenous antibiotic medications were administered as ordered to Resident #1. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: 1. Record review of Resident #1's face sheet, dated 04/17/23, indicated he was a [AGE] year-old male, admitted to the facility on [DATE] at 7:17 PM. He had diagnoses which included acute endocarditis (infection of the heart's inner lining), high blood pressure, heart disease, atrial fibrillation (irregular heartbeat), atrial flutter (upper chambers of the heart beats too quickly), removal of internal fixation device from fracture repair, and severe sepsis (harmful microorganisms in the blood) without septic shock (body's response to sepsis). The face sheet indicated the resident was his own responsible party and no other family or friends were indicated. Record review of Resident #1's admission skilled nurses' notes, dated 04/17/23, indicated he was alert and oriented to person, place, time and situation; his heart rate and rhythm were within baseline; respiratory rate and rhythm and sound were within baseline and he may use oxygen when needed at 2 liters/minute; urine was clear, yellow and odorless; no musculoskeletal changes, had a rolling walker but could become short of breath when ambulating; independent with supervision with ADLs; continent of bowel and bladder. He had a BIMS of 12 indicating he was cognitively intact. Record review of Resident #1's hospital discharge physician's orders, dated 04/15/23, indicated Resident #1 was ordered the following intravenous medications: start sodium chloride 0.9% solution 100 ml with ampicillin 2 grams injected into the vein every 6 hours (last dose given 04/15/23 at 3:12 AM) and start sodium chloride 0.9% solution 100 ml with ceftriaxone (Rocephin) 2 grams (2,000 mg) injected into the vein every 12 hours (last dose given 04/15/23 at 3:12 AM). Both antibiotics were to be administered for a duration of 8 weeks, start 04/13/23-stop 06/07/23. A PICC (peripherally inserted central catheter) line was present for long term intravenous use. Oral medications including allopurinol (for gout), amiodarone (for high blood pressure), apixaban (for atrial fibrillation), carvedilol (for high blood pressure and heart failure), dapagliflozin (for blood sugar), digoxin (for heart function), furosemide (for water retention), gabapentin (for peripheral pain), hydralazine (for blood pressure), methocarbamol (for muscle spasms), pantoprazole (for acid indigestion), potassium chloride (supplement replacement), rosuvastatin (for high cholesterol), trazadone (for insomnia), and vitamin B-12. Record review of Resident #1's nurses' MAR, dated 04/2023, indicated there were no entries on the MAR for any intravenous medications to be administered on 04/15/23 and 04/16/23. The intravenous medications were not listed on the nurses' MAR. Oral medications were present on the medication aide's MAR and given as ordered beginning on 04/16/23. Record review of Resident #1's Progress Notes indicated the following: on 04/15/23 at 7:17 PM the resident arrived at the facility via private car accompanied by a friend. He was alert and oriented and had no signs of distress or complaints of pain or discomfort. He walked with a rolling walker without difficulty. He was able to make his needs known and able to ambulate to the restroom without assistance. He was continent of bowel and bladder. The resident had a single lumen PICC line in his right upper arm as he was to receive intravenous antibiotics while at the facility. On 04/16/23 at 9:52 PM Resident #1 left the facility with a family member. The family member asked why the resident had not received his medications and the nurse explained the medications had been ordered but had not been received from the pharmacy. The family member got angry and accused the facility of neglect and left the facility. The resident's vital signs were within normal limits. Record review of the pharmacy manifest dated 04/15/23 indicated the pharmacy received the orders for the oral medications ordered by the facility through the integrated system. The orders dated 04/15/23 to the pharmacy did not contain orders for the IV antibiotics. Record review of a Provider Investigation Report written by the previous administrator dated 04/16/23 indicated the facility reported to the state agency an allegation of neglect regarding timeliness of medication administration for Resident #1 alleged by the resident's family member. The summary indicated the DON informed the administrator by text on 04/16/23 at 9:55 PM Resident #1 had left the facility and went home due to not receiving intravenous medications. She was not sure if the resident would be returning. The report indicated Resident #1 returned to the facility with his faly member on 04/17/23 at 9:30 AM. The DON explained to the family member, at that time, the Rocephin medication was available in the emergency medication kit and she could administer that medication and could order the ampicillin and it would be at the facility within 4 hours of when the call was placed to the pharmacy. The family member refused to allow the administration of the medication and said she wanted him evaluated by a physician before he received the antibiotics and said she was taking him to the hospital. She said at the time she left they would not be back. Further record review of the Provider Investigation Report dated 04/16/23 indicated a written statement from LVN H Resident #1 arrived at the facility with a friend. The friend stated he had no paperwork he was just giving the resident a ride. LVN H indicated she saw no discharge paperwork from the hospital. She indicated another nurse at the facility told her she had entered all the orders that were sent from the hospital. Resident #1 told LVN H he was at the facility to receive IV antibiotics and she told him the physician would have to clarify the antibiotic orders. She indicated she was told to verify the orders that were already in the computer so that his medications could be ordered from the pharmacy. She indicated she reported to the day shift that Resident #1's medication did not come in on the night shift and to please follow up with the pharmacy that morning. A written statement from LVN D indicated the nurse on Hall 200 had received a report from the hospital on 04/15/23 around 2:00 PM for a new resident (Resident #1) and she asked LVN D for assistance because she still had numerous tasks to complete before the end of her shift. LVN D indicated around 2:25 PM the paperwork was available and she printed the referral paperwork so she could enter the most current diagnoses and medications. She indicated she had completed entering the orders around 4:00 PM and she took the paperwork to the charge nurse and told her she would need to enter the antibiotic order from her report or from the discharge orders due to the referral paperwork being unclear. LVN D indicated she let the nurse know when the resident arrives and gets into his room she would need to confirm medication orders to make them active and the nurse expressed understanding. LVN D indicated when she checked out at the end of her shift and she asked the 200 hall nurses if there had been any problems getting the new resident into the system and was informed the resident had just arrived and she stopped to make sure the agency nurse covering the night shift was able to get the resident moved from waiting list to current resident list, able to confirm orders, and she told her about the antibiotic order needing to be entered from the discharge paperwork. LVN D indicated she made sure the nurse was able to confirm orders and she exited the facility at that time. The report indicated all nurses were inserviced 04/17/23 on new admission order process/medication reconciliation, medication rights, physician orders policy, medication error policy, pharmacy services policy, missed medications, and how to order medications from the pharmacy after hours. Signatures indicated they had read and understood the policies and procedures. Record review of the hospital encounter summary for Resident #1 dated 04/17/23 indicated he arrived at 11:44 AM and his vital signs upon arrival were blood pressure 147/57, pulse 66, temperature 97.6, respiratory rate 18, and oxygen saturation 95%. The social worker notes indicated the facility was contacted on 04/17/23 at 12:23 PM and the facility explained the family was upset because the resident had not received the 2 IV antibiotics over the weekend. The facility said they had offered the Rocephin that morning and it had been refused and the ampicillin would be delivered that day. The facility reported the resident left AMA and could take him back but he would have to commit to staying. The physician's evaluation on 04/17/23 at 11:57 AM indicated the resident had stayed at the hospital previously from 4/11/23 until 04/15/23 for mitral valve endocarditis (infection of the heart's inner lining affecting a heart valve), and was supposed to have received ampicillin and Rocephin through his PICC line since the diagnosis. The rehab facility did not have the medications. He denied any fever or complaints at the time. The physical exam indicated no acute distress, normal heart rate and rhythm, normal pulmonary effort and no distress with normal breath sounds, and alert and oriented in all spheres. Lab work, dated 04/17/23, indicated white blood cells 9.1 (4.5-11.0), red blood cells 3.43 (4.5-5.90), hemoglobin 9.9 (13.5-17.5), hematocrit 30.6 (41.0-53.0), other findings were within normal limits. Resident #1 received 2 doses of 2 grams of ampicillin at 3:40 PM and 5:53 PM and one dose of Rocephin 2,000 mg at 1:48 PM. The social worker was attempting to find other rehab facility placement but due to his leaving AMA he was not accepted at any another facility. He agreed to return to the facility. The resident discharged from the hospital emergency department on 04/17/23 at 6:33 PM in good condition. Record review of Resident #1's Progress Notes indicated he returned to the facility on [DATE] at 7:45 PM. He received ampicillin 2 gm intravenously beginning on 04/18/23 every 6 hours at midnight, 6:00 AM, noon, and 6:00 PM. He received one dose of Rocephin 2,000 mg on 04/17/23 at 9:00 PM. The times for administration for the Rocephin were changed on 04/18/23 by nursing staff to be given at 1:00 AM and 1:00 PM and he received the medication as ordered. During an interview on 06/21/23 at 9:00 AM LVN D said the DON at the time of the reportable incident was fired on 04/17/23. She said the administrator at the time of the reportable incident left last week. She said she had just been elevated to ADON, treatment nurse, and infection preventionist. LVN D said she was working the day shift (6 AM-6 PM) on 04/15/23 in the memory care unit. She said the day shift nurse on 200 hall (new admissions) was very busy and she came out to assist her with a new admission coming later that day. She said the nurses can type in the basic medication orders when they are expecting a new admission. She said the medications and diagnoses can be typed in prior to admission but just not activated (ordered). She said she typed in the information for Resident #1. She said those referral orders are not the final orders and she said those orders did not have any IV or oral antibiotics listed. She said she told the charge nurse she would have to double check the orders when the resident arrived at the facility with the final discharge orders and the physician or NP. She said he did not arrive before she left her shift at 6 PM. She said new admission orders are entered into the computer but not activated because the resident was not yet admitted to the facility. She said they are pending until they had final orders in hand. She said she thought an agency nurse was working the 6PM-6 AM on 04/15/23. She said the hospital will send a packet of paperwork that would contain discharge information, notes from day 1 of the hospital stay, discharge medication orders and what medications had been given at time of the discharge. She said the charge nurses are to call the physician or NP at the time of entry and go over the list and the physician or NP will decide what they want to keep giving or if they want to change any of the medications. She said that was not a new practice and they had always done new admissions in that way. She said the physician also had standing lab orders they like to get at the time of admission. She said the next shift nurse usually checks or re-reads the new admission orders. She said the 400 hall charge nurse was an employee of the facility and would have been available to assist the agency nurse if she had needed any assistance. She said only regular staff and not agency staff have access to the emergency medication kit (e-kit) so any medications needed to be pulled would need to be a facility employee. She said the nurses have to call the pharmacy for orders received on the weekend after hours. She said they can still get immediately needed medications they just have to call the pharmacy instead of it being ordered through the integrated system. LVN D said to her knowledge there were no IV antibiotics in the e-kit but some oral antibiotics were available. She said she was not aware of any problems with receiving medications they needed after hours. She said if there was a problem with obtaining a medication the physician would be called and asked what he wanted them to do and how should they proceed until the medication was available. She said medication orders were reviewed during the morning meeting held every weekday morning. She said the department heads, MDS, DON, BOM, and charge nurses would review the 24-hour report. She said weekend admissions were reviewed on Monday. During an interview on 06/21/23 at 10:40 AM RN E, a corporate resource nurse, said there were no residents in the facility currently receiving IV antibiotics. She said the DON at the time of the reported incident was let go but not entirely due to the incident. She said there were other issues the DON had not been following through on. She said the DON told her she had called the pharmacy on Sunday 04/16/23 and spent hours on the phone with them. RN E said if any medications are needed over the weekend and it was after the pharmacy closed, the pharmacy had to be physically called with the order. If the medication was just ordered through the integrated system it would just stay in the pharmacy received file until they opened for their regular hours. She said IV Rocephin was available in the e-kit but the ampicillin was not. She said Resident #1 left the faciity on [DATE] at 9:52 PM and returned between 9:30-10:00 AM on 4/17/23 and was angry due to not receiving IV medications. She said the granddaughter was very vocal and the DON tried to assist her and tell her they could give the Rocephin and order the ampicillin and it would be there within 4 hours. She said the granddaughter said they were leaving and would not be back. She said when he returned on 04/17/23 at 7:45 PM he received a dose of Rocephin at 9:00 PM. RN E said neither of the IV antibiotics were administered on 04/15/23 and 04/16/23. She said the facility began inservicing employees on medications ordering, after hours ordering, and a packet was developed to give to agency and new staff explaining how to use the electronic record software as well as how to order from the pharmacy when something was needed quickly. She said a new procedure was also put in place for new admissions. She said the medical record would be reviewed within 24 hours including orders by nurse management. She said nurse management included the DON, MDS person, the resource nurse and it would be checked every day regardless of weekend days. During an interview on 06/21/23 at 12:15 PM RN E said it came to the attention of resources at 9:30-10:00 AM on 04/17/23, during the morning stand up meeting, that Resident #1 was to be receiving IV antibiotics and was not receiving them. The DON knew of the IV antibiotic therapy on 04/16/23 at 9:55 PM when the family member/neighbor was taking the resident out of the facility due to not receiving his medications. RN E said she had called the pharmacy and their records indicated they received the oral medications order on 04/15/23 and they did not receive an order for IV antibiotic medication until 04/17/23 when it was ordered stat (high priority to be delivered within 4 hours). During an interview on 06/21/23 at 11:50 AM LVN A said he had not witnessed any neglect. He said he would report it to the administrator if he did. He said there is enough staff to meet the needs of residents and he was not aware of any resident going without needed care. He said staff made rounds at least every two hours to check on the needs of residents. He was able to define neglect and give examples. He said he had been in-serviced on processing new admission orders with a focus on validating hospital discharge orders, ordering medications from the pharmacy during and after hours, and notifying the DON or his/her designee of any problems associated with obtaining needed medications. During an interview on 06/21/23 at 12:05 PM LVN B said she worked on an as needed basis (prn) and had not witnessed any neglect. She said she would report it to the administrator or DON if she did. She said she was not aware of any resident going without needed care. She said she checked residents at least every two hours. She was able to define neglect and give examples. She said she had not received any in-services on the new admission process nor the ordering of medications during or after hours. She said she would ask for assistance from one of the other nurses at the facility if she had any questions or needed help with admitting a new resident. She said she would either ask one of the other nurses or call the on-call nurse if she had any problems with obtaining needed medications. During an interview on 06/21/23 at 12:21 PM LVN C said she had not witnessed any neglect and would report it to the administrator or DON if she did. She said she was not aware of any residents going without care. She was able to define neglect and give examples. She said she had been in-serviced on processing new admission orders with a focus on validating hospital discharge orders, ordering medications from the pharmacy during and after hours, and notifying the DON or his/her designee of any problems associated with obtaining needed medications. She said would notify the DON, ADON, or on-call nurse if she had any problems obtaining medications from the pharmacy. During an interview on 06/21/23 at 1:25 PM RN F (DON for a sister facility) said when pending orders are entered into the computer they are automatically sent to the pharmacy and they would need to call if it was after hours and the medications were needed immediately. During an interview on 06/21/23 at 2:55 PM RN G, a corporate resource nurse, said she would immediately train LVN B on medication ordering since she had indicated she had not received any training. RN G said she was not sure who would be doing the training since the current DON had just started work that week. Record review of hospital discharge orders for Resident #2 dated 06/13/2023 were reviewed and used to verify the accuracy of the facility's admission orders dated 06/13/2023 with no issues or concerns noted. The Medication Administration Record (MAR) was noted to be consistent with the discharge orders and medications were noted as being initiated upon admission and in a timely manner. Record review of hospital discharge orders for Resident #3 dated 06/13/2023 were reviewed and used to verify the accuracy of the facility's admission orders dated 06/13/2023 with no issues or concerns noted. The Medication Administration Record (MAR) was noted to be consistent with the discharge orders and medications were noted as being initiated upon admission and in a timely manner. Record review of hospital discharge orders for Resident #4 dated 06/08/2023 were reviewed and used to verify the accuracy of the facility's admission orders dated 06/08/2023 with no issues or concerns noted. The Medication Administration Record (MAR) was noted to be consistent with the discharge orders and medications were noted as being initiated upon admission and in a timely manner including orders for antibiotic therapy. Record review of facility policy Administration of Medications and/or Intravenous fluids dated 12/2019 indicated medications and intravenous fluids shall be administered as prescribed by the attending physician. Record review of an undated facility procedure indicated all new admission orders would be entered and reconciled with the physician prior to administration of any first dose. Nursing must document that medication reconciliation was completed and entered into the progress notes. All new admissions would be reviewed by the ADON/DON within 24 hours to assure for accuracy and completion. Record review of an undated facility Agency Orientation Packet indicated a licensed nurse reference guideline on entering of specific types of orders as well as notes, assessments, admitting and discharging residents in the software used in the electronic record. Included in the packet was information regarding the facility pharmacy hours of operation, delivery schedule, phone and fax numbers with an indication in large letters all stat (orders faxed after cut-off times) orders must be faxed and followed up with a phone call.

Based on observations, interviews, and record reviews the facility failed to ensure a resident who is unable to carry out activities of daily living receives, the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident#1) reviewed for oral hygiene. The facility failed to assist Resident #1's with cleaning his dentures. This failure could place residents at risk of not receiving services/care, oral diseases, decreased self-esteem, and decreased quality of life. The findings included: Record review of a face sheet dated 08/06/22 indicated Resident #1 was a [AGE] year-old male, admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of an MDS dated [DATE] indicated Resident #1 was cognitively intact. Resident #1 could make himself understood and was able to understand others. Resident #1 had no behaviors or rejection of care. Resident #1 required one person assistance with walking and only occurred once or twice. Resident #1 required extensive one person assistance with personal hygiene and used a wheelchair or walker for mobility. Resident #1 was not steady on his feet and only able to stabilize with staff assistance. Record review of a care plan dated 07/14/22 indicated Resident #1 had an ADL (Activities of Daily Living) self-care performance deficit and interventions included staff to assist with toileting, transfers, bed mobility and bathing. Resident #1 was at risk for falls related to generalized weakness and interventions included staff to anticipate and meet his needs. Resident #1's care plan had no documented behaviors or rejection of care. Resident #1's care plan did not address his dentures. During an observation and interview on 09/08/22 at 3:13 p.m. Resident #1 was in his room lying in bed. There was a buildup of a light brown substance on Resident #1's top and bottom dentures between his teeth and gum line (the line separating the gum from the exposed part of the tooth). Resident #1 said he had top and bottom dentures and needed someone to clean them for him because he was unable to walk to his bathroom to do it himself. Resident #1 said his dentures were dirty and needed to be cleaned because the last time someone cleaned them was two days ago. Resident #1 said he wished someone would clean his denture every day because his mouth felt better when they were clean. During an interview on 09/08/22 at 5:20 p.m. CNA A said she worked the 6 a.m.- 6 p.m. shift and provided care for Resident #1. CNA A said if a resident required assistance with personal hygiene, staff should assist them with oral care daily and as needed to prevent infections and gum disease. CNA A said Resident #1 had food stuck in between his teeth and they needed to be cleaned. CNA A said she tried to clean Resident #1's teeth with an oral swab yesterday when she worked but he refused. CNA A said she has not cleaned Resident#1's dentures the past two days she has worked because she did not know he had them and would have cleaned them daily if she had known. CNA A said she didn't know when the last time Resident #1's dentures were cleaned, and she was going to his room to clean them now. During an interview on 09/08/22 at 6:02 p.m. CNA B said she worked the 6 p.m.- 6 a.m. shift and provided care for Resident #1. CNA B said if a resident required assistance with personal hygiene, staff should assist them with oral care daily and as needed to prevent infections and gum disease. CNA B said Resident #1 had dentures and they should be cleaned daily. CNA B said she did not clean Resident #1's dentures or offer to do so last night when she worked because she thought he was able to do it himself. During an interview on 09/08/22 at 7:06 p.m. the DON said she was responsible for monitoring the residents ADL care. The DON said she monitored the resident by conducting random spot checks on several residents each week by looking at each resident's ADL reports that were generated from their electronic chart. The DON said she expected the nursing staff to provide residents with oral care daily and as needed. The DON said she was unaware Resident #1 was not receiving daily oral care and he should have. The DON said a resident's dentures should be taken out at night to be cleaned then put back in in the morning. The DON said a resident's mouth and gums should be assessed for any open sores to prevent infections and gum disease. Record review of the facility policy Oral Hygiene revised on 05/2007 indicated, It is the policy of this facility to: Clean the mouth, teeth and gums, Remove particle of food, Remove bacteria and odor .6. If a resident has dentures, ask resident to remove them for cleaning .7. Put dentures in denture cup and take to appropriate area for cleaning. 8. Clean with tap water and denture cleaning product. Brush up and down rather than across dentures. Check for broken places. 9. Rinse dentures with tap water. 10. Rinse denture cup or storage container. 11. Return dentures to resident or bedside for storage. 12. If the resident does not put dentures back in his mouth, the denture cup should be filled with water or mouthwash .Check the resident's mouth for unusual sores. Report any unusual observations to charge nurse .

Based on observation, interview, and record review, the facility failed to ensure that residents received and consumed foods with the appropriate nutritive content as prescribed by the physician for 1 of 1 resident reviewed for therapeutic diets. (Resident #45). The facility did not prepare or serve a fortified food product to Resident #45 on 07/10/2022 and 07/11/22 as indicated on the dietary slips and physician orders. This failure could place residents at risk for weight loss and not having their nutritional needs met. Findings included: Review of Resident #45's physician's orders dated July 2022 indicated Resident #45 was an [AGE] year-old female readmitted to the facility on [DATE] with diagnoses including dementia, Parkinson's disease, psychotic disorder and weight loss. The orders indicated she was to receive a regular diet, pureed texture on the fortified meal plan. She was also to receive Resource (liquid nutritional supplement) 120 ml three times a day during the medication pass. The physician's orders indicated the resident was receiving Remeron (mirtazapine) 7.5 mg. daily at bedtime for weight loss. Review of Resident #45's annual MDS dated [DATE] indicated Resident #45 was severely cognitively impaired, required extensive assistance of one staff with eating, and had unplanned weight loss. Review of Resident #45's progress notes and weight logs indicated the following: *On 05/09/2022 11:06 AM: Magic Cup and Resource 2.0 were discontinued due to a BMI of 24. The weight log dated 05/05/2022 indicated Resident #45 weighed 140 lbs. *On 06/01/2022 the weight log indicated the resident weighed 116.2 lbs. *On 06/03/2022 11:05 AM: Resident #45 had Resource TID 120 ml for weight loss for 14 days. Resident #45 was assisted with meals to encourage food intake. FMP for 7 days. The MD and family were notified. The weight log dated 05/26/2022 indicated Resident #45 weighed 119.6 lbs. The Dietary Manager and DON met for an interdisciplinary team meeting to address the weight loss, resident had eaten 75% of breakfast, Resource 120 ml, FMP, MD orders entered and would continue to encourage the resident to eat. The family notified. *On 06/09/2022 01:22 PM: The MD was contacted, and an order was received for Remeron (appetite stimulant) 7.5 mg orally at bedtime. The staff would continue to monitor weekly weights. Resident #45 was on FMP and Resource 2.0. *On 06/14/2022 03:37 PM the Registered Dietitian note indicated the resident had an order for FMP and Resource 2.0 120 ml for 14 days. The new recommendation was to continue Resource 2.0 120 ml three times a day for 90 days. *On 06/23/2022 08:22 AM: Per the Dietitian's recommendation and physician's approval a new order reflected Resident #45 had an order for FMP and Resource 2.0 120 ml for 14 days; and a recommendation to continue Resource 2.0 120 ml three times a day for 90 days. *On 06/30/2022 03:35 PM the weight log indicated the resident weighed 120.4 lbs. *On 07/05/2022 07:22 PM the weight log indicated the resident weighed 118.2 lbs. *On 07/12/2022 10:45 AM the Registered Dietitian's note indicated weight loss, had ordered FMP and Resource 2.0 120 ml three times a day. Resident #45 had 75-100% intake reported by staff. The new recommendation was to increase Resource 2.0 to 240 mL three times a day. During an observation on 07/10/2022 on the memory care unit at 12:30 PM, Resident #45's diet slip indicated she was to receive fortified foods. Observation of Resident #45's meal reflected she did not receive any fortified food items or extra butter. She received pureed baked chicken, baked beans and corn, as well as chocolate pudding for dessert. During an observation and interview on 07/10/2022 on the memory care unit at 12:39 PM, LVN A said she let Resident #45 eat as much of her lunch by herself as she could, then she would help her a bit. LVN A was observed feeding Resident #45 and the resident ate 100% of the food served. During an observation of tray line service in the kitchen on 07/11/2022 at 11:50 AM, the holding temperatures were taken on food prepared for the noon meal. The pureed items were ham, pinto beans, and broccoli. There were no fortified foods prepared on the steam table. Resident #45's meal tray was on the memory unit cart and left the kitchen at 12:08 PM and her tray did not contain a fortified food item. During an observation on 07/11/2022 at 12:13 PM, Resident #45 did not receive any fortified food item or extra butter. She received ham, pinto beans and broccoli in a pureed form. Her diet slip indicated she was to receive fortified foods. During an interview and observation on 07/12/2022 at 3:30 PM, the DM said the FMP consisted of extra butter (3 pats) placed on the tray and the nursing staff were to mix it into the food. She said the dietary department also prepared fortified items with extra butter and canned milk, like mashed potatoes and pudding. She said other fortified products could be used like a Magic Cup (frozen nutritional treat), ice cream, or health shake. She said oatmeal or cream of wheat at breakfast were prepared with extra butter and canned milk, but all residents received the fortified hot cereal. She said the dietary department placed the extra items on the trays. She said those were extra foods and did not replace a dessert or vegetable that was part of the meal. She checked the evening meal trays for 07/12/2022 that were partially set up with dietary slips and silverware and she pulled out Resident #45's meal tray and dietary slip. The dietary slip indicated FMP. She said the cook was to prepare any fortified foods. The DM was asked for a resident dietary roster, but it was not provided. During an interview on 07/12/2022 at 3:35 PM, the DM asked Cook B if she had prepared any fortified foods for the noon meals on 07/10/2022 and 07/11/2022. Cook B said she did not prepare any fortified foods because she was not aware any resident was receiving fortified foods. During an interview on 07/12/2022 at 5:15 PM, the DON said Resident #45 was receiving Resource 2.0 as a nutritional supplement.

Based on interviews and record review, the facility failed to ensure the residents received mail for 6 of 6 residents reviewed for rights to forms of communication. (Resident #s #9, #13, #28, #31, #44 and #112). The facility did not ensure residents received their mail promptly. This failure could place the residents at risk of not receiving mail in a timely manner and a diminished quality of life. Findings included: During an group interview on 07/11/2022 at 10:30 a.m., Residents #9, #13, #28, #31, #44 and #112 said they did not know if mail was delivered on Saturday's. The residents said they only received mail Monday through Friday. During an interview on 07/11/2022 at 10:40 a.m., the Activity Director said she is not sure who handles the mail on the weekend. She said the Receptionist brings her the mail during the week and she distributes it to the residents. She said she is not sure how the mail is handled on the weekend. During an interview on 07/12/2022 at 10:49 a.m., the weekday Receptionist said she received the mail Monday through Friday, she sorts it and takes the remainder to the Business Officer Manager. She said the Business Office Manager sorts it and gives her the mail for the residents and she takes that mail to the Activity Director. The Receptionist said the weekend mail is collected by the weekend receptionist on Saturday and locked in the desk drawer. She said when she arrives on Monday, she retrieves the mail, sorts it, and she takes the remaining mail to the Business Office Manager. She said she receives the residents' mail back from the Business Office Manager and takes it to the Activity Director for distribution. During an interview on 07/12/2022 at 11:01 a.m., the Business Office Manager said she receives the mail from the weekday Receptionist Monday through Friday. She said she sorts it and gives the residents' mail back to the Receptionist to give to the Activity Director. She said Saturday mail is locked in the desk drawer until Monday, when the weekday Receptionist gets it and brings it to her. Record review of the facility's Policy/Procedure; Resident Rights and Responsibility Notice of: Privacy and Confidentiality, dated 11/23/2016, revealed, 3. personal privacy, including the right to privacy in your oral (that is, spoken), written, and electronic communications, including the right to promptly receive unopened mail and other letters, packages and other materials delivered to the facility for you .

Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident within 48 hours of admission that includes the instructions needed to provide effective, person-centered care of the resident for 1 of 4 residents reviewed for baseline care plans. (Resident #152) -The facility failed to develop a baseline care plan that addressed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #152. This failure could place new residents at risk of not receiving necessary care and services or having important care needs identified. Findings included: Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] A baseline care plan dated 04/08/21 for Resident #152 had no indication of care plans for her [CONDITION(S)] or antianxiety/antidepressant medications. During an interview on 04/15/21 at 03:25 p.m. the DON said she was responsible for the care plans. She said baseline care plans should include information from diagnoses, physician orders, history and physical, and hospital discharge paperwork. She said Resident #152 should have a care plan for her [CONDITION(S)] and her antianxiety/antidepressant medications. She said she just missed it.

Based on interview and record review, the facility failed to ensure necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure injuries from developing for 1 of 3 residents reviewed for wounds. (Resident #1) The facility did not thoroughly assess Resident #1's wounds when the wounds were discovered and upon readmission to the facility. This failure could place residents with wounds at risk for infection and worsening of existing wounds or pressure injuries. Findings included: A face sheet dated 08/15/19 indicated Resident #1 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 usually made her needs known and usually understood others. She required extensive assistance with ADLs, was incontinent of bowel and bladder. The MDS indicated Resident #1 was at risk of developing pressure injuries but did not have pressure injuries. An undated care plan indicated Resident #1 had potential for pressure injury development and interventions included treatments as ordered and monitor for effectiveness, weekly treatment documentation to included measurement of each area of skin breakdown' width, length, depth, and exudate, and document and report any changes in skin status (appearance, color, wound healing, signs of infection, wound measurements, and stage of wound). Resident #1 had altered skin integrity to her right inner ankle, coccyx, and buttocks area and staff should complete a skin assessment upon admission and weekly thereafter. Physician orders [REDACTED].#1 included a pressure relieving mattress and a pressure reducing cushion for her wheelchair. A nursing note dated 08/03/19 indicated Resident #1 had a skin tear to her left buttock. The area was cleaned with normal saline and covered with a dressing. The nursing note did not indicate if Resident #1's physician was notified. A nursing note dated 08/05/19 indicated Resident #1 had a large fluid filled blister to her right inner ankle. Resident #1's physician was notified by fax and the wound care physician was faxed for a consultation. A physician order [REDACTED].#1 was ordered a wound consultation for wounds to her buttocks and right inner ankle. A weekly wound log last updated 08/05/19 did not include Resident #1's blister to her right ankle or skin tear to her buttocks. A nursing note dated 08/06/19 indicated Resident #1 was ordered 1% silver [MEDICATION NAME] cream to ankle. A weekly skin assessment dated [DATE] indicated Resident #1 had redness and skin breakdown to her left buttock and a blister to her right inner ankle. The skin assessment did not include measurements or description of the wounds. A nursing note dated 08/07/19 at 6:45 a.m. indicated Resident #1 was transported to a local hospital for blood in her urine and not responding to verbal stimuli. A hospital wound report dated 08/13/19 indicated Resident #1 had an unstageable pressure injury to her left buttocks, an unstageable pressure injury to her coccyx, and a wound ulceration to her right foot that were present on 08/07/19. A nursing note dated 08/13/19 indicated Resident #1 readmitted to the facility and her physician was notified about her skin issues. A nursing admission assessment dated [DATE] indicated Resident #1 readmitted to the facility with a red, opened area to her coccyx (reported as a stage 3) and a red area with broken skin (an open blister with skin peeling back measuring 8.0 cm x 3.5 cm) to her left ankle. A nursing note dated 08/14/19 at 11:20 a.m. indicated a fax was sent to the wound care physician requesting a consultation for Resident #1. During an interview on 08/16/19 at 10:45 a.m., LVN B said she sent Resident #1 out to the hospital on [DATE] for a critical BUN level on 08/07/19 and was notified in shift change report that she had a blister to her right ankle. She said when she first saw the blister to Resident #1's ankle, the blister had opened and there was an order for [REDACTED].#'1's wounds to her left buttock and coccyx area on 08/07/19 but they looked more like a skin tear. She said she readmitted Resident #1 on 08/13/19 and measured the wound to her right ankle but she did not measure the wounds to her buttocks and coccyx. LVN B said she should have measured all of Resident #1's wounds. She said Resident #1's wounds appeared worse when she readmitted to the facility. During an interview on 08/15/19 at 5:29 p.m., CNA [NAME] said she worked with Resident #1 on 08/13/19. She said Resident #1 had a wound on her right ankle that was a blister that had burst, and a wound on her bottom. She said she positioned Resident #1 while the nurse completed the wound care treatment to her buttocks. CNA [NAME] said she saw one wound on Resident #'1 s buttocks. A braden scale for predicting pressure injury form dated 08/13/19 indicated Resident #1 was at very high risk of developing pressure injuries. A weekly skin assessment dated [DATE] indicated Resident #1 had an open area to right inner ankle from a blister and skin breakdown to the middle of her buttocks and left of the midline of her buttocks. The skin assessment did not include measurements or description of the wounds. A daily skilled nurse note dated 08/14/19 at 5:52 p.m. indicated Resident #1 had a pressure injury located on the midline of her buttocks and an open [MEDICAL CONDITION] to her right inner ankle. A daily skilled nurse note dated 08/15/19 at 3:31 a.m. indicated Resident #1 had a pressure injury. The nurse note did not describe the pressure injury or name the location of the pressure injury. A daily skilled nurse note dated 08/15/19 at 8:24 a.m. indicated Resident #1 had a pressure injury located on the midline of her buttocks and an open lesion to her right inner ankle. During an observation and interview on 08/15/19 at 9:30 a.m., Resident #1 was lying in her bed. Resident #1's right foot had a circular area from her inner right ankle to her inner right heel that was approximately the size of a baseball that had an open wound with an area with black discoloration near her heel. Resident #1's right heel had areas of red and black discoloration that covered her entire heel. Resident #1's left heel had a small reddish-brown area of discoloration with the skin intact. Resident #1 had a wound to her left buttocks that was approximately the size of a quarter with black eschar covering the wound bed. The immediate surrounding area was white in color with a ring of pinkish-red skin around the area of white. Resident #1 had a wound to her coccyx that was approximately the size of a dime with black eschar covering the wound bed. The surrounding skin was pink in color. There was minimal yellowish-pink drainage on the dressing. Resident #1 was unable to say how long she had the wounds. During an interview on 08/15/19 at 9:34 a.m., RN A said CNA C notified her of Resident #1's blister to her right ankle. She said the blister was fluid filled and she notified Resident #1's physician of the blister. She said Resident #1's physician order [REDACTED]. She said the blister opened up the next day and Resident #1 received an order for [REDACTED].#1's wound to her coccyx appeared larger since she returned from the hospital. She said the orders for Resident #1's wounds to her left buttock and coccyx were to clean with normal saline and cover with a dry dressing. She said the wounds were measured when they were found but had not been measured again. During an interview on 08/15/19 at 1:08 a.m., CNA C said she discovered Resident #1's blister to her right foot. She said the blister was fluid filled and she reported the blister to RN [NAME] She said she did not discover the wounds to Resident #1's buttock and was not aware of how long she had them. She said Resident #1's coccyx wound appeared larger since she returned from the hospital. A treatment administration record (TAR) dated (MONTH) 2019 indicated skin prep was applied to Resident #1's heels and right inner ankle on 08/06/19. [MEDICATION NAME] cream was applied to Resident #1's right inner ankle on 08/06/19 and 08/07/19. The TAR had no documentation of treatments performed to Resident #1's buttocks or coccyx. A physician order [REDACTED].#1 indicated a treatment to cleanse area to buttocks with normal saline, apply calcium alginate, and cover with dressing once a day. Resident #1 was ordered skin prep to right inner ankle twice a day until wound consult. A weekly skin assessment dated [DATE], after surveyor intervention, indicated Resident #1 had a wound to her coccyx measuring 1.5 cm x 1.0 cm, a wound to her left buttock measuring 3.0 cm x 1.5 cm, an open lesion to her right inner ankle measuring 7.5 cm x 9.0 cm, an open lesion to her right heel measuring 10 cm x 5 cm, an unopened area to her left heel measuring 1.5 cm x 1.5 cm, and an unopen area to the bottom of her foot, below her toes measuring 2.0 cm x 1.0 cm. The assessment did not describe the wounds. During an interview on 08/19/19 at 3:53 p.m., the nurse for Resident #1's physician said the only notification from the facility they received was on 08/05/19 regarding Resident #1's blister to her right ankle. She said Resident #1's physician had a standing order for any of his residents with wounds to clean with normal saline and apply [MEDICATION NAME] or [MEDICATION NAME] cream. She said Resident #1's physician was not notified about any wounds to her buttock or coccyx and they did not receive notification about a wound care consult for Resident #1. During an interview on 08/15/19 at 2:16 p.m., ADON D said Resident #1 had an order to see the wound care physician but was in the hospital when the wound care physician was in the facility. She said typically wounds were measured by the wound physician to ensure consistency. She said she was not aware of the severity of Resident #1's wounds and was told her coccyx wound was a small reddened area. ADON D said Resident #1's wounds should have been measured and she indicated the wounds were not on the wound log. During an interview on 08/15/19 at 5:51 p.m., the administrator said she expected staff to complete a thorough assessment of skin and staff should have documented a description of Resident #1's wounds. The administrator said staff should have notified the ADONs of any changes in Resident #1's wounds. She said the facility had a wound care physician come to the facility on ce a week to manage resident wounds. She said the wound physician came to the facility when Resident #1 was at the hospital. She said they did not notify the wound care physician when Resident #1 returned to the facility. The administrator said the facility did not have specific policies regarding wound care. The facility's undated skin management policy indicated .it is the policy of this center to provide care based on each resident's comprehensive assessment to ensure that a resident who enters the facility without pressure injury does not develop pressure injury unless pressure injuries are unavoidable due to the predictable patterns of the resident's clinical condition or refusal of care .based on each resident's comprehensive assessment, appropriate treatment and services are provided to prevent the formation of pressure injury. Residents having pressure injures receive necessary treatment and services to promote healing, prevent infection, and prevent new pressure injuries from developing .

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. The facility failed to ensure the DM was certified. This failure could place the residents at risk for not receiving the appropriate food and nutrition services. Findings included: During an interview on 08/05/19 at 09:25 AM, the DM said he had been at the facility for 9 months and was not certified. During an observation an interview on 08/06/19 at 10:50 AM, a DM from another facility in the region presented her certification documentation. She said the contract group instructed her to come to the facility since state had entered and the DM was not certified. During an interview on 08/06/19 at 10:55 AM, the DM said he had not taken any dietary classes in hopes the state would accept his transcript from a culinary school. He did not provide any documentation regarding his training, he said he had worked for the contract company for a year. During an interview on 08/08/19 at 02:45 PM, the administrator said the acting DM came to the facility about 8-9 months ago after working at another facility for the same contract group. She said she thought he had been with them over a year. She did not know for sure if he was certified because he worked for the contracted services group. She said she knew they should have a certified dietary manager. The facility did not have any documentation to provide regarding the certification status of the DM.

Based on observation and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen. The facility did not ensure utensils were free from grease and food debris. The facility did not ensure bulk containers did not have utensils left inside. This failure could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During an observation on 08/05/19 of the main kitchen the following was noted: *at 09:40 AM the utensil drawer under the prep table by the stove contained: food debris in the bottom of the drawer, the liner paper was stained and had food debris, a 4 oz slotted utensil was greasy to touch; a one-cup stainless steel measuring cup had food debris stuck on the inside; a plastic spatula had grease on the paddle; utensil handles on 3 spatulas were greasy to touch. The DM removed the drawer and took the utensils to the dish room. *at 09:45 AM the bulk corn meal had a plastic measuring cup inside on the surface of the cornmeal. *at 09:50 AM in the dry pantry 1 bulk package of raisin bran was opened and not re-sealed properly. During an observation on 08/06/19 at 11:05 AM the bulk cornmeal container had a plastic measuring cup laying on top of the cornmeal. The visiting DM removed the plastic measuring cup. The Texas Food Establishment Rules dated (MONTH) (YEAR) indicated §228.68. Preventing Contamination From Equipment, Utensils, and Linens. (a) Food shall only contact surfaces of: (1) equipment and utensils that are cleaned as specified under §§228.113, 228.114 and 228.115 of this title and sanitized as specified under §§228.116, 228.117 and 228.118 of this title; .

Based on observation, interview, and record review, the facility failed to ensure residents maintained a desirable body weight for 2 of 6 residents reviewed for nutrition. (Resident #s 21 and 41) The facility did not ensure that recommendations made by the Registered Dietician for Resident #21 were communicated to the physician for review The facility did not provide Resident #41 a nutritional supplement (house shake) 3 times a day with meals and 1 ½ entrée portions after significant weight loss (from 148 pounds to 140 pounds over a 3 month period). This failure could place residents with orders for nutritional supplements and increased food portions at risk for significant weight loss, skin breakdown, illness and decreased quality of life. Findings included: 1. A face sheet dated 08/08/19 indicated Resident #21 was a [AGE] year old female admitted [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #21 had a BIMS score of 01, indicating severe cognitive impairment. An undated care plan indicated Resident #21 had altered nutritional status and required assist with meals, monitoring for daily intake, weight and lab monitoring and to notification of MD for concerns. During an observation on 08/05/19 at 12:45 PM Resident #21consumed 50% of her lunch meal. She said she was very full and could not eat another bite. She said the food was delicious. During an observation on 08/06/19 at 12:55 PM Resident #21 consumed 50% of her lunch meal. She said the food was good, but that she was too full to eat any more. During an observation on 08/07/19 at 12:50 PM Resident #21 consumed 50% of her lunch meal. She said she really liked the food, but they always gave her too much to eat. She said she always liked the dessert. A dietician recommendations note dated 07/23/19 for Resident #21 indicated she had weight loss for the month, decreased appetite and weakness. The note indicated to continues with [MEDICATION NAME] (appetite stimulant), and recommend adding 2.0 supplement 90cc twice a day and weigh weekly. During an interview on 08/08/19 at 01:50 PM, the DON and ADON C said the dietician communicates the dietary recommendations to the DON and ADONs via email, she said they fax to the physician. They both indicated if the physician agrees orders are provided accordingly. ADON C said she is responsible for ensuring the dietary recommendations and orders are followed up on, carried out, and entered in the computer. The DON said the email the dietician sent on 07/23/19 did not mention Resident #21. The DON and ADON said they discuss everything on the 24-hour report every morning. The DON and ADON C said they did not know how the dietician recommendations for Resident #21 were missed on the 24-hour report. 2. Physician orders [REDACTED].#41 was an [AGE] year-old male admitted [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #41 was able to make his needs known, had the ability to understand others, required extensive assistance with activities of daily living of one to two staff and was always incontinent of bowel and bladder. The MDS indicated no significant weight loss. An undated care plan for Resident #41 indicated altered nutritional status and interventions included: house shake with meals, house supplement 2.0 - 90 ml four times a day, and pureed diet with nectar thick liquids. There was no indication for the 1.5 entrée portion. A quarterly nutrition progress note by the RD dated 05/06/19 indicated Resident #41 had a weight gain but due to unstageable pressure area the resident had increased nutritional needs. The not indicate a recommendation to provide adequate nutrition for weight maintenance and wound healing was to continue diet and house supplement and add 30 ml liquid protein twice a day. A nutrition services note dated 05/20/19 indicated Resident #41 had significant weight loss over 90 days but had slowed since February, although current weight level was unstable. The recommendations were to serve 1.5 portion entrée at all meals, house shake with all meals, add house supplement 90 ml twice a day and [MEDICATION NAME] twice a day. A Nutrition Services Note dated 06/12/19 for Resident #41 indicated a sudden weight loss that was significant x 30 days. There was a noted fluctuation of intake and coughing while eating. Recommendations were to continue current orders and increase house supplement to four times a day and give house shake with meals. A Nutrition Services Note dated 07/16/19 for Resident #41 indicated significant weight loss but had lost only 4.2 lbs. in one month. The recommendations were to continue with recent diet changes for supplement between meals and health shakes with meals. During an observation on 08/05/19 at 12:40 PM, Resident #41 was sitting in a geri-chair in the dining CNA D assisted him with his puree meal. Resident #41 received pureed chicken parmesan, noodles, green beans, and bread, and a thickened beverage. He did not have a health shake with his tray and he did not receive a 1.5 portion of chicken. During an interview on 08/05/19 at 12:55 PM the DM said he did not have any frozen nutritional treats. He said he had a few on Friday but guess they used them up over the weekend. He said there were not too many residents that received the frozen nutritional treats. He said he did not have any house shakes thawed for the lunch service. He said he would put some out to thaw for supper. During an observation on 08/06/19 at 12:37 PM, Resident #41 was sitting in a geri-chair in the dining room at the dining table, his meal tray was on the table beside him. He was served garlic herbed pork loin, zucchini and onions, mashed potatoes, bread and applesauce. He did not receive a 1.5 portion of the entrée or a house shake with his meal. During an observation on 08/07/19 at 12:25 PM, Resident #41 was being assisted with his meal by MA F in the dining room. He tray consisted of pureed pork chop, red beans, mashed potatoes, bread, and applesauce. Resident #41 did not receive a 1.5 portion of entrée or a healthshake as indicated on the dietary slip.

Based on observation, interview, and record review, the facility failed to provide nutritional services in accordance with each resident's assessed needs for 4 of 24 residents reviewed for dietary recommendations and physician orders. (Resident #21, 41, 4 and 26) The facility did not communicate dietary reccomendations to the physician for review for Resident #21. The facility did not serve Resident #41 a nutritional supplement (house shake) 3 times a day with meals and 1 ½ entrée portions as ordered by the physician. The facility did not serve frozen nutritional treat with meals and regular portions as ordered by the physician for Resident #4. The facility did not serve milk and a frozen nutritional treat with meals as ordered by the physician for Resident #26. This failure could place residents at risk of not having their nutritional needs addressed and experiencing unplanned weight loss. Findings included: A face sheet dated 08/08/19 indicated Resident #21 was a [AGE] year old female admitted [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #21 had a BIMS score of 01, indicating severe cognitive impairment. An undated care plan indicated Resident #21 had altered nutritional status and required assist with meals, monitoring for daily intake, weight and lab monitoring and to notification of MD for concerns. During an observation on 08/05/19 at 12:45 PM Resident #21consumed 50% of her lunch meal. She said she was very full and could not eat another bite. She said the food was delicious. During an observation on 08/06/19 at 12:55 PM Resident #21 consumed 50% of her lunch meal. She said the food was good, but that she was too full to eat any more. During an observation on 08/07/19 at 12:50 PM Resident #21 consumed 50% of her lunch meal. She said she really liked the food, but they always gave her too much to eat. She said she always liked the dessert. A dietician recommendations note dated 07/23/19 for Resident #21 indicated she had weight loss for the month, decreased appetite and weakness. The note indicated to continues with [MEDICATION NAME] (appetite stimulant), and recommend adding 2.0 supplement 90cc twice a day and weigh weekly. During an interview on 08/08/19 at 01:50 PM, the DON and ADON C said the dietician communicates the dietary recommendations to the DON and ADONs via email, she said they fax to the physician. They both indicated if the physician agrees orders are provided accordingly. ADON C said she is responsible for ensuring the dietary recommendations and orders are followed up on, carried out, and entered in the computer. The DON said the email the dietician sent on 07/23/19 did not mention Resident #21. The DON and ADON said they discuss everything on the 24-hour report every morning. The DON and ADON C said they did not know how the dietician recommendations for Resident #21 were missed on the 24-hour report. 2. Physician orders [REDACTED].#41 was an [AGE] year-old male admitted [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #41 was able to make his needs known, had the ability to understand others, required extensive assistance with activities of daily living of one to two staff and was always incontinent of bowel and bladder. The MDS indicated no significant weight loss. An undated care plan for Resident #41 indicated altered nutritional status and interventions included: house shake with meals, house supplement 2.0 - 90 ml four times a day, and pureed diet with nectar thick liquids. There was no indication for the 1.5 entrée portion. A quarterly nutrition progress note by the RD dated 05/06/19 indicated Resident #41 had a weight gain but due to unstageable pressure area the resident had increased nutritional needs. The not indicate a recommendation to provide adequate nutrition for weight maintenance and wound healing was to continue diet and house supplement and add 30 ml liquid protein twice a day. A nutrition services note dated 05/20/19 indicated Resident #41 had significant weight loss over 90 days but had slowed since February, although current weight level was unstable. The recommendations were to serve 1.5 portion entrée at all meals, house shake with all meals, add house supplement 90 ml twice a day and [MEDICATION NAME] twice a day. A Nutrition Services Note dated 06/12/19 for Resident #41 indicated a sudden weight loss that was significant x 30 days. There was a noted fluctuation of intake and coughing while eating. Recommendations were to continue current orders and increase house supplement to four times a day and give house shake with meals. A Nutrition Services Note dated 07/16/19 for Resident #41 indicated significant weight loss but had lost only 4.2 lbs. in one month. The recommendations were to continue with recent diet changes for supplement between meals and health shakes with meals. During an observation on 08/05/19 at 12:40 PM, Resident #41 was sitting in a geri-chair in the dining CNA D assisted him with his puree meal. Resident #41 received pureed chicken parmesan, noodles, green beans, and bread, and a thickened beverage. He did not have a health shake with his tray and he did not receive a 1.5 portion of chicken. During an interview on 08/05/19 at 12:55 PM the DM said he did not have any frozen nutritional treats. He said he had a few on Friday but guess they used them up over the weekend. He said there were not too many residents that received the frozen nutritional treats. He said he did not have any house shakes thawed for the lunch service. He said he would put some out to thaw for supper. During an observation on 08/06/19 at 12:37 PM, Resident #41 was sitting in a geri-chair in the dining room at the dining table, his meal tray was on the table beside him. He was served garlic herbed pork loin, zucchini and onions, mashed potatoes, bread and applesauce. He did not receive a 1.5 portion of the entrée or a house shake with his meal. During an observation on 08/07/19 at 12:25 PM, Resident #41 was being assisted with his meal by MA F in the dining room. He tray consisted of pureed pork chop, red beans, mashed potatoes, bread, and applesauce. Resident #41 did not receive a 1.5 portion of entrée or a healthshake as indicated on the dietary slip. 3. Physician order [REDACTED].#4 was a [AGE] year old male admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The order indicated the resident was to receive a frozen nutritional treat with meals (started 5/22/18) and to receive mechanical soft diet, mechanical soft texture, resident upgrade to thin liquids. The most recent MDS dated [DATE] indicated Resident #4 had no significant weight loss. An undated care plan for Resident #4 indicated he had a potential nutritional problem due to poor dental status. The resident requires mechanical soft diet with thin liquids, interventions included to provide and serve supplements as ordered: frozen nutritional treat with meals, and a mechanical soft diet. A special request detail report printed on 8/8/19 indicated Resident #4 was to receive frozen nutritional treats with breakfast, lunch and dinner. During an observation of the lunch meal on 8/6/19 at 12:23 p.m., Resident # 4 received double portion meat and was not served a frozen treat. During an observation of the lunch meal on 8/7/19 at 12:08 p.m., Resident # 4 received double portion meat and was not served a frozen treat. A meal ticket dated 8/6/19 for Resident #4 indicated he was to receive double portions. The order listing report printed on 8/5/19 indicated Resident #4 was to have a frozen treat with meals The census list printed on 8/5/19 and on 8/7/19 indicated Resident #4 was to have regular mechanical soft diet with double portions with all meals. During an interview on 8/7/19 at 12:48 p.m., CNA G said she did not serve the frozen treats with meals, the MA or whoever passed medications are the ones who give the residents their frozen treats. During an interview on 8/7/19 at 12:38 p.m., LVN H said they did not have any residents who received frozen treats with lunch meals. She said the MA or whoever passed the medications would give the resident their frozen treat. LVN H said they are to give the frozen treat according to the physician order. She said the frozen treats were kept in the freezer on the unit but did not know they did not have any in freezer. During an interview on 8/7/19 at 12:40 p.m., LVN J said she passed the medications on the unit for that day. She said she did not give any residents frozen treats with meals and that she gave the frozen treat with the morning medications. LVN J said Resident #4 had an order to receive a frozen treat with meals, and she assumed that since it was entered at 8 a.m. she was to give the frozen treat with the morning medications and not with the meals. During an interview on 8/8/19 at 2:00 p.m., the DM said Resident #4 was to receive double portion meat with all meals, he said his staff was always accurate about making sure residents received the correct portions. The DM said whenever a resident had a diet change staff would notify him by communication note and he would change the information in his system to reflect the new order/recommendation. The DM said Resident #4 was to get a frozen treat with all meals. He said the frozen treats came from the kitchen and he put the frozen treats on the cart to be delivered, he said the MA passed them out. He said over the weekend they ran out of frozen treats and had to reorder some. During an interview on 8/8/19 at 2:16 p.m., the DON and ADON K said double portions were discontinued for Resident #4 on 8/5/19 at 1:52 p.m. The ADON said Resident #4 should not had received double portions on 8/6/19 or 8/7/19. The DON said the frozen treats came from the kitchen with the meals. They said they were not aware the aides were not passing the frozen treats with each meal. The DON said she expects staff to follow physician orders. During an interview on 8/8/19 at 2:23 p.m., the DM said he was not aware Resident #4's diet had changed and was not sure if he received a communication note. He said if he had received a communication note then he would have updated Resident #4's information in the system. The DM said once the system is updated the meal ticket would no longer reflect double portions, he said his staff made the residents trays according to their meal tickets. 4. Physician order [REDACTED].#26 was a [AGE] year old male who admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. A undated care plan indicated Resident #26 was at risk for nutritional problems or potential nutritional problems due to Dementia, Depression, [MEDICAL CONDITION], Anxiety, Cognition. (Currently on regular diet with milk will all meals) During an observation of the lunch meal on 8/6/19 at 12:20pm , Resident #26 did not receive milk with his tray, four cups of milk were noted on the serving cart. During an observation of the lunch meal on 8/7/19 at 12:05 p.m., Resident #26 was served cup of pink lemonade and no milk, cups of milk were noted on the serving cart. A meal ticket dated 8/6/19 indicated Resident #26 was to be served milk only at all meals. A special request detail report printed on 8/8/19 indicated Resident #26 was to receive milk with breakfast, lunch and dinner. The nutrition quarterly progress note dated 5/29/19 indicated for Resident #26 in the comment section Will initiate increased caloric support to give milk with all meals. During an interview on 8/7/19 at 12:40 p.m., LVN J said she did not pay attention to the meal tickets because it had random information that was not always accurate. She said most of the time the information on the meal tickets were from information gathered at the time of admit. She said she just normally gave the residents whatever she thought they liked and not necessarily what was on the meal tickets. She said she never notified the kitchen staff, nor a department head that milk was not needed on the meal ticket for Resident #26. During an interview on 8/7/19 at 12:48 p.m., CNA G said she always gave Resident #26 either tea or Kool-Aid. During an interview on 8/8/19 at 2:10 p.m., the DM said Resident #26 was to get milk with each meal. During an interview on 8/8/19 at 2:35 p.m., the DON said staff need to follow the physician order [REDACTED].

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent neglect for 1 of 6 residents reviewed for neglect. (Resident # 1) The facility did not respond to a change in condition when Resident #1 was lethargic and non-responsive to verbal stimuli after he had a low finger stick blood sugar (FSBS) reading. The physician was notified of the resident's low FSBS reading and decreased level of consciousness and ordered to monitor and send the resident to the hospital if there was no improvement. The resident continued to have a decreased level of consciousness and lethargy for approximately 7 more hours. Resident #1's physician was not notified of the resident not improving and he was not sent to the hospital. He was found on the floor without a pulse until emergency medical services arrived and transported him to the hospital. He died approximately 5 hours later. An Immediate Jeopardy was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]; however, the facility remained out of compliance at an isolated incident of actual harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 16 residents who were diabetics at risk for [DIAGNOSES REDACTED], [MEDICAL CONDITION], and/or death. Findings included: The undated Abuse/Neglect prohibition policy indicated .each resident has the right to be free from mental and physical abuse, corporal punishment, involuntary seclusion, unreasonable confinement, intimidation, neglect . Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The hospital orders dated [DATE] indicated Resident #1 had [DIAGNOSES REDACTED]. The physician orders [REDACTED].#1 indicated FSBS every four hours. Resident #1 was ordered Humalog insulin 100 unit/milliliters (ml) with a sliding scale. A care plan dated [DATE] indicated Resident #1 had diabetes and interventions included .administering hypoglycemic medications as ordered, monitor for signs/symptoms of hyper/[DIAGNOSES REDACTED] and intervene as ordered, and notify the MD of any acute episodes of hyper/[DIAGNOSES REDACTED] as needed . Resident #1 had [MEDICAL CONDITION] disease and interventions included .providing oxygen and monitoring oxygen saturation . An MDS dated [DATE] indicated Resident #1 made his needs known and understood others. He required extensive assistance with ADLs. The physician orders [REDACTED].#1 indicated the order for FSBS every 4 hours was discontinued and replaced with FSBS at 6:30 a.m. and 5:00 p.m., daily. There was an order to wear a bilevel positive airway pressure ([MEDICAL CONDITION]) machine, every night for sleep apnea. A MAR indicated [REDACTED]. The nursing notes dated [DATE] for Resident #1 indicated the following: * at 1:40 p.m.-The nurse (LVN A) was called to Resident #1's room by CNA because the resident was not responding to her. The resident was cold, clammy, and not responding to verbal or tactile stimuli. FSBS was checked with a result of 38. Glycogen was given at this time. * at 1:45 p.m., FSBS result was 47, resident remained non-responsive to stimuli; * at 1:50 p.m., FSBS result was 57, resident remained non-responsive to stimuli; * at 2:00 p.m., FSBS result was 58, Glycogen given at this time; * at 2:02 p.m., resident began to respond to tactile stimuli, opening eyes and looking around; * at 2:15 p.m., FSBS result was now 191 and resident continued to be drowsy, awakened with verbal and tactile stimuli. His color returned to normal, no longer clammy. The note indicated will continue to monitor and report any changes. * at 3:51 p.m., Resident #1 continued to be non-responsive to verbal stimuli, only responds to hard sternum rub, grimaces and moans. Blood sugar 151, oxygen saturation 97% using accessory muscles to breath, respirations 10 breaths per minute. The DON assessed the resident and said he did not appear to be in any distress. The physician was notified of the resident's condition and said to continue monitoring the resident. If the resident's condition did not improve, then he would need to be sent out. * at 5:39 p.m., Resident #1 continued to be non-responsive to anything but tactile stimuli. He was unable to eat at this time, insulin held. * at 5:55 p.m., The resident was more easily roused and opened his eyes when his name was called. He turned on his side and able to shake his head when asked if he was cold. The resident closed eyes and did not respond to verbal stimuli any longer. * at 6:56 p.m., Resident #1 was in bed, lethargic, and his blood sugar was 98. Oxygen in place at 3 liters. The notes did not indicate if the physician was notified of his level of consciousness. During an interview on [DATE] at 4:23 p.m., LVN A said she last spoke to Resident #1 on [DATE] around breakfast time. Resident #1's blood sugar dropped to 38 and they were able to stabilize it after giving him Glycogen. She said Resident #1 was difficult to rouse after his blood sugar dropped and only responded to tactile stimuli. LVN A said she notified Resident #1's physician of his low blood sugar. She said the physician said to send Resident #1 out to the hospital if he did not improve. She said she worked until 6:00 p.m. and Resident #1 stayed about the same until the time she left. LVN A said she wanted to send the resident to the hospital, but the DON said Resident #1 was stable and they could treat him in-house. She said the DON told her Resident #1 would be sleepy because his blood sugar had gotten so low. During an interview on [DATE] at 8:46 a.m., CNA C said she worked [DATE] from 10:00 p.m. to 6:00 a.m. and Resident #1 was alert and oriented. She said when she came back to work on [DATE] at 10:00 p.m. Resident #1 was non-responsive and was not the same person that she saw that morning. She said Resident #1 did not speak during the entire shift. She said she asked LVN F to get the crash cart ready because Resident #1 looked bad. She said she asked LVN F if she could override the DON's order of keeping Resident #1 in-house and send him out. She said she checked on him several times and he was non-responsive each time she saw him. During an interview on [DATE] at 44:1 p.m., LVN F said she worked [DATE] from 7:30 p.m. until [DATE] at 6:00 a.m. She said she received report from LVN A and was told about Resident #1. LVN F said during report, LVN A told her Resident #1 was lethargic and not responding appropriately. LVN A told her the DON said that was Resident #1's new baseline and there was a standing order for Resident #1 to be sent out if he worsened from his new baseline. She said LVN A said she tried to send Resident #1 out to the hospital, during her shift, but was not allowed by the DON. She said she was Resident #1's nurse the previous day and Resident #1 was very alert. She said she checked on Resident #1 around 7:30 p.m. and he was not his normal self. She said Resident #1 was not talking and only responded to tactile stimuli. She said she wanted to send him to the hospital, but did not want to overstep the DONs orders. She said she asked CNA C to get the crash cart ready because she knew something was wrong with Resident #1. LVN F said the DON called around 11:00 p.m. and asked if Resident #1 was fine. She said she told the DON he was not fine, but his vital signs were stable. She said she and CNA C went into Resident #1's room at 11:03 p.m. and repositioned him and put on his [MEDICAL CONDITION]. She said Resident #1 would jerk back to his right side, but he would not respond verbally. She said he definitely had a change in condition. She said about 11:45 p.m., she picked up the phone to call the physician because she was going to send him out regardless of him having stable vital signs, but then CNA C yelled for her to come down the hall. She said she went into Resident #1's room and he had fallen out of his bed with his [MEDICAL CONDITION] still on his face. She said he did not have a pulse. She said she started cardiopulmonary resuscitation (CPR) and told CNA C to call 911. She said it took the paramedics a while to get to the facility, but they were able to get a pulse on Resident #1. She said the paramedics took him to a local hospital and then he was transferred to another hospital, where he died . The physician orders [REDACTED].#1 had a new baseline for lethargy and decrease responsiveness and would not be sent out if he remained at the baseline. The nursing notes dated [DATE] for Resident #1 indicated the following: * at 8:23 p.m., He was in bed, responsive to tactile stimuli only, blood pressure ,[DATE], pulse 64, respirations 12, oxygen saturation 94% on 2 liters of oxygen. The notes did not indicate if the physician was notified of his level of consciousness. * at 11:09 p.m., The resident was in bed, responsive to tactile stimuli. His heart rate was 117 and irregular and his respirations were 10 breaths per minute and deep and labored, with 5 seconds of apnea noted. FSBS was 180. Vital signs were stable, but he had a change in level of consciousness. The notes indicated the physician was notified but did not address what the physician's response was. * at 11:25 p.m., The resident was in bed, positioned on his right side. There was no acute respiratory distress noted. The notes did not address his level of consciousness. * at 11:45 p.m., Resident #1 was in bed and responded to tactile stimuli only. There was noted apnea periods increasing to ,[DATE] seconds, with respirations at 9 breaths per minute, oxygen saturation 94%, heart rate 137, and blood pressure ,[DATE]. The notes indicated there no further interventions needed. * at 11:55 p.m., The nurse (LVN F) attempted to call Resident #1's physician to send resident out for mild respiratory distress with periods of apnea, bilateral upper lobe rales, and change in level of consciousness. CNA said to come quick and the nurse hung up phone. * at 11:56 p.m., The resident was on the floor, non-responsive and no pulse palpated. The notes indicated began chest compressions, CNA called 911 and pulled crash cart. The emergency medical service (EMS) arrived, resident showed no heart rate on the automated external defibrillator, (AED) resident remained non-responsive. EMS suctioned the resident and the resident continued to be without a pulse. * [DATE] at 12:28 a.m., EMS obtained a pulse; however, the resident was non-responsive. He was transferred to the hospital. The hospital records dated [DATE] indicated Resident #1 arrived at the hospital on [DATE] at 1:07 a.m. Resident #1 was extremely hypotensive, (low blood pressure) unresponsive, and was significant for extremely elevated [MEDICATION NAME]. (may be an indication of lack of oxygen ([MEDICAL CONDITION]) or the presence of other conditions that cause excess production or insufficient clearing of [MEDICATION NAME] from the blood) Resident #1 was given antibiotics for [MEDICAL CONDITION]. Resident #1 had significant metabolic abnormalities including lactic acidosis, anion gap metabolic acidosis, elevated liver function tests (LFTs), which were likely related to [MEDICAL CONDITION]/shock state. Resident #1 went into [MEDICAL CONDITION] and could not be revived. He was declared dead at 6:53 a.m. on [DATE]. During an interview on [DATE] at 4:32 p.m., CNA D said she worked [DATE] from 6:00 a.m. to 2:00 p.m. She said when she first saw Resident #1 that morning he was alert and using his call light. She said he was able to communicate with staff and verbalize his needs. CNA D said at lunch, Resident #1 was not his normal self. She said his eyes were closed, but he opened his eyes when she called his name. She said she came back to Resident #1's room and tried to help him eat his lunch which was not normal for him. She said she notified LVN A of Resident #1's condition and they gave him juice and medicine. She said Resident #1 was still not responding. During an interview on [DATE] at 5:38 p.m., the DON said on [DATE] after lunch, Resident #1's blood sugar was 38. She said interventions were provided and his blood sugar eventually came up to 190. The DON said Resident #1's vital signs were stable and he was responding to staff. She said the last time she saw Resident #1 was around 4:30 p.m., and he continued to be stable. The DON said LVN A called Resident #1's physician about his low blood sugar and decreased level of consciousness and the physician said to send Resident #1 if he did not stabilize or if he worsened. She said Resident #1 was stable throughout the day. She said she called the facility around 10:00 p.m., that night, spoke to LVN F, and was told Resident #1 was good. She said she got a call on [DATE] at 12:45 a.m. from the facility saying that Resident #1 had coded at the facility and EMS was taking him to the hospital. During an interview on [DATE] at 9:48 a.m., Resident #1's physician said he expected the nurses to use nursing judgment and send a resident out if they had a change in condition. Resident #1's physician said if a resident is non-responsive, regardless if they have stable vital signs, they should have been sent to the hospital. The undated change of condition policy indicated .the nurse will notify the resident's attending physician when there has been a significant change in the resident's physical/emotional/mental condition .need to transfer the resident to a hospital. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention . The administrator was notified on [DATE] at 1:18 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 8:08 p.m., and included: 1. Nursing staff will be in-serviced regarding resident change of condition, use of Interact, SBAR completion, and notification of physician. ([DATE]) 2. Auditing of charts of diabetics and monitor blood sugars and adjustments needed to prevent change of condition. ([DATE]) 3. Facility will document any items that need follow up and assign responsibility using morning clinical meeting form. ([DATE]) 4. Nursing staff will refer to Change of Condition Policy and notify Physician accordingly. On [DATE], the surveyors confirmed the plan of removal had been implemented sufficiently to remove the Immediate Jeopardy by: During an interview on [DATE] at 2:26 p.m., the regional nurse said she in-serviced the DON on abuse, neglect, change of condition, physician notification, and medication parameters. During an interview on [DATE] at 2:28 p.m., the DON said she and the regional nurse have been in-servicing nursing staff on abuse, neglect, change of condition, physician notification, and medication parameters. She said almost everyone had been in-serviced and nursing staff would complete in-servicing on [DATE]. During interviews on [DATE] from 2:31 p.m. to 4:58 p.m., 5 nurses (3 from day shift and 2 from night shift) and 6 CNAs (2 from day shift, 2 from evening shift, and 2 from night shift) and one MA (evening shift) were interviewed and said they received training on abuse, neglect, change of condition, and who to notify when there was a change of condition. The nurses and MAs said they received training on medication parameters. During an interview on [DATE] at 4:57 p.m., the regional nurse said Resident #3 had a change of condition and was being sent to the hospital for further evaluation. On [DATE] at 5:45 p.m., the administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at an isolated incident of actual harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A list completed by the DON on [DATE], indicated 16 residents were diabetics.

Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice and based on the comprehensive assessment for 1 of 6 residents reviewed for assessment. (Resident #1) The facility did not respond to a change in condition when Resident #1 was lethargic and non-responsive to verbal stimuli after he had a low finger stick blood sugar (FSBS) reading. The physician was notified of the resident's low FSBS reading and decreased level of consciousness and ordered to monitor and send the resident to the hospital if there was no improvement. The resident continued to have a decreased level of consciousness and lethargy for approximately 7 more hours. Resident #1's physician was not notified of the resident not improving and he was not sent to the hospital. He was found on the floor without a pulse until emergency medical services arrived and transported him to the hospital. He died approximately 5 hours later. An Immediate Jeopardy was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]; however, the facility remained out of compliance at an isolated incident of actual harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 16 residents who were diabetics at risk for [DIAGNOSES REDACTED], [MEDICAL CONDITION], and/or death. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The hospital orders dated [DATE] indicated Resident #1 had [DIAGNOSES REDACTED]. The physician orders [REDACTED].#1 indicated finger sticks every four hours. Resident #1 was ordered Humalog insulin 100 unit/milliliters (ml) with a sliding scale. A care plan dated [DATE] indicated Resident #1 had diabetes and interventions included .administering hypoglycemic medications as ordered, monitor for signs/symptoms of hyper/[DIAGNOSES REDACTED] and intervene as ordered, and notify the MD of any acute episodes of hyper/[DIAGNOSES REDACTED] as needed . Resident #1 had [MEDICAL CONDITION] disease and interventions included .providing oxygen and monitoring oxygen saturation . An MDS dated [DATE] indicated Resident #1 made his needs known and understood others. He required extensive assistance with ADLs. The physician orders [REDACTED].#1 indicated the order for FSBS every 4 hours was discontinued and replaced with FSBS at 6:30 a.m. and 5:00 p.m., daily. There was an order to wear a bilevel positive airway pressure ([MEDICAL CONDITION]) machine, every night for sleep apnea. A MAR indicated [REDACTED]. The nursing notes dated [DATE] for Resident #1 indicated the following: * at 1:40 p.m.-The nurse (LVN A) was called to Resident #1's room by CNA because the resident was not responding to her. The resident was cold, clammy, and not responding to verbal or tactile stimuli. FSBS was checked with a result of 38. Glycogen was given at this time. * at 1:45 p.m., FSBS result was 47, resident remained non-responsive to stimuli; * at 1:50 p.m., FSBS result was 57, resident remained non-responsive to stimuli; * at 2:00 p.m., FSBS result was 58, Glycogen given at this time; * at 2:02 p.m., resident began to respond to tactile stimuli, opening eyes and looking around; * at 2:15 p.m., FSBS result was now 191 and resident continued to be drowsy, awakened with verbal and tactile stimuli. His color returned to normal, no longer clammy. The note indicated will continue to monitor and report any changes. * at 3:51 p.m., Resident #1 continued to be non-responsive to verbal stimuli, only responds to hard sternum rub, grimaces and moans. Blood sugar 151, oxygen saturation 97% using accessory muscles to breath, respirations 10 breaths per minute. The DON assessed the resident and said he did not appear to be in any distress. The physician was notified of the resident's condition and said to continue monitoring the resident. If the resident's condition did not improve, then he would need to be sent out. * at 5:39 p.m., Resident #1 continued to be non-responsive to anything, but tactile stimuli. He was unable to eat at this time, insulin held. * at 5:55 p.m., The resident was more easily aroused and opened his eyes when his name was called. He turned on his side and able to shake his head when asked if he was cold. The resident closed eyes and did not respond to verbal stimuli any longer. * at 6:56 p.m., Resident #1 was in bed, lethargic, and his blood sugar was 98. Oxygen in place at 3 liters. The notes did not indicate if the physician was notified of his level of consciousness. During an interview on [DATE] at 4:23 p.m., LVN A said she last spoke to Resident #1 on [DATE] around breakfast time. Resident #1's blood sugar dropped to 38 and they were able to stabilize it after giving him Glycogen. She said Resident #1 was difficult to rouse after his blood sugar dropped and only responded to tactile stimuli. LVN A said she notified Resident #1's physician of his low blood sugar. She said the physician said to send Resident #1 out to the hospital if he did not improve. She said she worked until 6:00 p.m. and Resident #1 stayed about the same until the time she left. LVN A said she wanted to send the resident to the hospital, but the DON said Resident #1 was stable and they could treat him in-house. She said the DON told her Resident #1 would be sleepy because his blood sugar had gotten so low. During an interview on [DATE] at 8:46 a.m., CNA C said she worked [DATE] from 10:00 p.m. to 6:00 a.m. and Resident #1 was alert and oriented. She said when she came back to work on [DATE] at 10:00 p.m. Resident #1 was non-responsive and was not the same person that she saw that morning. She said Resident #1 did not speak during the entire shift. She said she asked LVN F to get the crash cart ready because Resident #1 looked bad. She said she asked LVN F if she could override the DON's order of keeping Resident #1 in-house and send him out. She said she checked on him several times and he was non-responsive each time she saw him. During an interview on [DATE] at 44:1 p.m., LVN F said she worked [DATE] from 7:30 p.m. until [DATE] at 6:00 a.m. She said she received report from LVN A and was told about Resident #1. LVN F said during report, LVN A told her Resident #1 was lethargic and not responding appropriately. LVN A told her the DON said that was Resident #1's new baseline and there was a standing order for Resident #1 to be sent out if he worsened from his new baseline. She said LVN A said she tried to send Resident #1 out to the hospital, during her shift, but was not allowed by the DON. She said she was Resident #1's nurse the previous day and Resident #1 was very alert. She said she checked on Resident #1 around 7:30 p.m. and he was not his normal self. She said Resident #1 was not talking and only responded to tactile stimuli. She said she wanted to send him to the hospital, but did not want to overstep the DONs orders. She said she asked CNA C to get the crash cart ready because she knew something was wrong with Resident #1. LVN F said the DON called around 11:00 p.m. and asked if Resident #1 was fine. She said she told the DON he was not fine, but his vital signs were stable. She said she and CNA C went into Resident #1's room at 11:03 p.m. and repositioned him and put on his [MEDICAL CONDITION]. She said Resident #1 would jerk back to his right side, but he would not respond verbally. She said he definitely had a change in condition. She said about 11:45 p.m., she picked up the phone to call the physician because she was going to send him out regardless of him having stable vital signs, but then CNA C yelled for her to come down the hall. She said she went into Resident #1's room and he had fallen out of his bed with his [MEDICAL CONDITION] still on his face. She said he did not have a pulse. She said she started cardiopulmonary resuscitation (CPR) and told CNA C to call 911. She said it took the paramedics a while to get to the facility, but they were able to get a pulse on Resident #1. She said the paramedics took him to a local hospital and then he was transferred to another hospital, where he died . The physician orders [REDACTED].#1 had a new baseline for lethargy and decrease responsiveness and would not be sent out if he remained at the baseline. The nursing notes dated [DATE] for Resident #1 indicated the following: * at 8:23 p.m., He was in bed, responsive to tactile stimuli only, blood pressure ,[DATE], pulse 64, respirations 12, oxygen saturation 94% on 2 liters of oxygen. The notes did not indicate if the physician was notified of his level of consciousness. * at 11:09 p.m., The resident was in bed, responsive to tactile stimuli. His heart rate was 117 and irregular and his respirations were 10 breaths per minute and deep and labored, with 5 seconds of apnea noted. FSBS was 180. Vital signs were stable, but he had a change in level of consciousness. The notes indicated the physician was notified but did not address what the physician's response was. * at 11:25 p.m., The resident was in bed, positioned on his right side. There was no acute respiratory distress noted. The notes did not address his level of consciousness. * at 11:45 p.m., Resident #1 was in bed and responded to tactile stimuli only. There was noted apnea periods increasing to ,[DATE] seconds, with respirations at 9 breaths per minute, oxygen saturation 94%, heart rate 137, and blood pressure ,[DATE]. The notes indicated there no further interventions needed. * at 11:55 p.m., The nurse (LVN F) attempted to call Resident #1's physician to send resident out for mild respiratory distress with periods of apnea, bilateral upper lobe rales, and change in level of consciousness. CNA said to come quick and the nurse hung up phone. * at 11:56 p.m., The resident was on the floor, non-responsive and no pulse palpated. The notes indicated began chest compressions, CNA called 911 and pulled crash cart. The emergency medical service (EMS) arrived, resident showed no heart rate on the automated external defibrillator, (AED) resident remained non-responsive. EMS suctioned the resident and the resident continued to be without a pulse. * [DATE] at 12:28 a.m., EMS obtained a pulse; however, the resident was non-responsive. He was transferred to the hospital. The hospital records dated [DATE] indicated Resident #1 arrived at the hospital on [DATE] at 1:07 a.m. Resident #1 was extremely hypotensive, (low blood pressure) unresponsive, and was significant for extremely elevated [MEDICATION NAME]. (may be an indication of lack of oxygen ([MEDICAL CONDITION]) or the presence of other conditions that cause excess production or insufficient clearing of [MEDICATION NAME] from the blood) Resident #1 was given antibiotics for [MEDICAL CONDITION]. Resident #1 had significant metabolic abnormalities including lactic acidosis, anion gap metabolic acidosis, elevated liver function tests (LFTs), which were likely related to [MEDICAL CONDITION]/shock state. Resident #1 went into [MEDICAL CONDITION] and could not be revived. He was declared dead at 6:53 a.m. on [DATE]. During an interview on [DATE] at 4:32 p.m., CNA D said she worked [DATE] from 6:00 a.m. to 2:00 p.m. She said when she first saw Resident #1 that morning he was alert and using his call light. She said he was able to communicate with staff and verbalize his needs. CNA D said at lunch, Resident #1 was not his normal self. She said his eyes were closed, but he opened his eyes when she called his name. She said she came back to Resident #1's room and tried to help him eat his lunch which was not normal for him. She said she notified LVN A of Resident #1's condition and they gave him juice and medicine. She said Resident #1 was still not responding. During an interview on [DATE] at 5:38 p.m., the DON said on [DATE] after lunch, Resident #1's blood sugar was 38. She said interventions were provided and his blood sugar eventually came up to 190. The DON said Resident #1's vital signs were stable and he was responding to staff. She said the last time she saw Resident #1 was around 4:30 p.m., and he continued to be stable. The DON said LVN A called Resident #1's physician about his low blood sugar and decreased level of consciousness and the physician said to send Resident #1 if he did not stabilize or if he worsened. She said Resident #1 was stable throughout the day. She said she called the facility around 10:00 p.m., that night, spoke to LVN F, and was told Resident #1 was good. She said she got a call on [DATE] at 12:45 a.m. from the facility saying that Resident #1 had coded at the facility and EMS was taking him to the hospital. During an interview on [DATE] at 9:48 a.m., Resident #1's physician said he expected the nurses to use nursing judgment and send a resident out if they had a change in condition. Resident #1's physician said if a resident is non-responsive, regardless if they have stable vital signs, they should have been sent to the hospital. The undated change of condition policy indicated .the nurse will notify the resident's attending physician when there has been a significant change in the resident's physical/emotional/mental condition .need to transfer the resident to a hospital. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention . The administrator was notified on [DATE] at 1:18 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 8:08 p.m., and included: 1. Nursing staff will be in-serviced regarding resident change of condition, use of Interact, SBAR completion, and notification of physician. ([DATE]) 2. Auditing of charts of diabetics and monitor blood sugars and adjustments needed to prevent change of condition. ([DATE]) 3. Facility will document any items that need follow up and assign responsibility using morning clinical meeting form. ([DATE]) 4. Nursing staff will refer to Change of Condition Policy and notify Physician accordingly. On [DATE], the surveyors confirmed the plan of removal had been implemented sufficiently to remove the Immediate Jeopardy by: During an interview on [DATE] at 2:26 p.m., the regional nurse said she in-serviced the DON on abuse, neglect, change of condition, physician notification, and medication parameters. During an interview on [DATE] at 2:28 p.m., the DON said she and the regional nurse had been in-servicing nursing staff on abuse, neglect, change of condition, physician notification, and medication parameters. She said almost everyone had been in-serviced and nursing staff would complete in-servicing on [DATE]. During interviews on [DATE] from 2:31 p.m. to 4:58 p.m., 5 nurses (3 from day shift and 2 from night shift) and 6 CNAs (2 from day shift, 2 from evening shift, and 2 from night shift) and one MA (evening shift) were interviewed and said they received training on abuse, neglect, change of condition, and who to notify when there was a change of condition. The nurses and MAs said they received training on medication parameters. During an interview on [DATE] at 4:57 p.m., the regional nurse said Resident #3 had a change of condition and was being sent to the hospital for further evaluation. On [DATE] at 5:45 p.m., the administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at an isolated incident of actual harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A list completed by the DON on [DATE], indicated 16 residents were diabetics.

Based on interview and record review, the facility failed to ensure residents were protected from neglect for 1 of 6 residents reviewed for neglect. (Resident # 1) The facility did not respond to a change in condition when Resident #1 was lethargic and non-responsive to verbal stimuli after he had a low finger stick blood sugar (FSBS) reading. The physician was notified of the resident's low FSBS reading and decreased level of consciousness and ordered to monitor and send the resident to the hospital if there was no improvement. The resident continued to have a decreased level of consciousness and lethargy for approximately 7 more hours. Resident #1's physician was not notified of the resident not improving and he was not sent to the hospital. He was found on the floor without a pulse until emergency medical services arrived and transported him to the hospital. He died approximately 5 hours later. An Immediate Jeopardy was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]; however, the facility remained out of compliance at an isolated incident of actual harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 16 residents who were diabetics at risk for [DIAGNOSES REDACTED], [MEDICAL CONDITION], and/or death. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The hospital orders dated [DATE] indicated Resident #1 had [DIAGNOSES REDACTED]. The physician orders [REDACTED].#1 indicated finger sticks every four hours. Resident #1 was ordered Humalog insulin 100 unit/milliliters (ml) with a sliding scale. A care plan dated [DATE] indicated Resident #1 had diabetes and interventions included .administering hypoglycemic medications as ordered, monitor for signs/symptoms of hyper/[DIAGNOSES REDACTED] and intervene as ordered, and notify the MD of any acute episodes of hyper/[DIAGNOSES REDACTED] as needed . Resident #1 had [MEDICAL CONDITION] disease and interventions included .providing oxygen and monitoring oxygen saturation . An MDS dated [DATE] indicated Resident #1 made his needs known and understood others. He required extensive assistance with ADLs. The physician orders [REDACTED].#1 indicated the order for FSBS every 4 hours was discontinued and replaced with FSBS at 6:30 a.m. and 5:00 p.m., daily. There was an order to wear a bilevel positive airway pressure ([MEDICAL CONDITION]) machine, every night for sleep apnea. A MAR indicated [REDACTED]. The nursing notes dated [DATE] for Resident #1 indicated the following: * at 1:40 p.m.-The nurse (LVN A) was called to Resident #1's room by CNA because the resident was not responding to her. The resident was cold, clammy, and not responding to verbal or tactile stimuli. FSBS was checked with a result of 38. Glycogen was given at this time. * at 1:45 p.m., FSBS result was 47, resident remained non-responsive to stimuli; * at 1:50 p.m., FSBS result was 57, resident remained non-responsive to stimuli; * at 2:00 p.m., FSBS result was 58, Glycogen given at this time; * at 2:02 p.m., resident began to respond to tactile stimuli, opening eyes and looking around; * at 2:15 p.m., FSBS result was now 191 and resident continued to be drowsy, awakened with verbal and tactile stimuli. His color returned to normal, no longer clammy. The note indicated will continue to monitor and report any changes. * at 3:51 p.m., Resident #1 continued to be non-responsive to verbal stimuli, only responds to hard sternum rub, grimaces and moans. Blood sugar 151, oxygen saturation 97% using accessory muscles to breath, respirations 10 breaths per minute. The DON assessed the resident and said he did not appear to be in any distress. The physician was notified of the resident's condition and said to continue monitoring the resident. If the resident's condition did not improve, then he would need to be sent out. * at 5:39 p.m., Resident #1 continued to be non-responsive to anything but tactile stimuli. He was unable to eat at this time, insulin held. * at 5:55 p.m., The resident was more easily aroused and opened his eyes when his name was called. He turned on his side and able to shake his head when asked if he was cold. The resident closed eyes and did not respond to verbal stimuli any longer. * at 6:56 p.m., Resident #1 was in bed, lethargic, and his blood sugar was 98. Oxygen in place at 3 liters. The notes did not indicate if the physician was notified of his level of consciousness. During an interview on [DATE] at 4:23 p.m., LVN A said she last spoke to Resident #1 on [DATE] around breakfast time. Resident #1's blood sugar dropped to 38 and they were able to stabilize it after giving him Glycogen. She said Resident #1 was difficult to rouse after his blood sugar dropped and only responded to tactile stimuli. LVN A said she notified Resident #1's physician of his low blood sugar. She said the physician said to send Resident #1 out to the hospital if he did not improve. She said she worked until 6:00 p.m. and Resident #1 stayed about the same until the time she left. LVN A said she wanted to send the resident to the hospital, but the DON said Resident #1 was stable and they could treat him in-house. She said the DON told her Resident #1 would be sleepy because his blood sugar had gotten so low. During an interview on [DATE] at 8:46 a.m., CNA C said she worked [DATE] from 10:00 p.m. to 6:00 a.m. and Resident #1 was alert and oriented. She said when she came back to work on [DATE] at 10:00 p.m. Resident #1 was non-responsive and was not the same person that she saw that morning. She said Resident #1 did not speak during the entire shift. She said she asked LVN F to get the crash cart ready because Resident #1 looked bad. She said she asked LVN F if she could override the DONs order of keeping Resident #1 in-house and send him out. She said she checked on him several times and he was non-responsive each time she saw him. During an interview on [DATE] at 44:1 p.m., LVN F said she worked [DATE] from 7:30 p.m. until [DATE] at 6:00 a.m. She said she received report from LVN A and was told about Resident #1. LVN F said during report, LVN A told her Resident #1 was lethargic and not responding appropriately. LVN A told her the DON said that was Resident #1's new baseline and there was a standing order for Resident #1 to be sent out if he worsened from his new baseline. She said LVN A said she tried to send Resident #1 out to the hospital, during her shift, but was not allowed by the DON. She said she was Resident #1's nurse the previous day and Resident #1 was very alert. She said she checked on Resident #1 around 7:30 p.m. and he was not his normal self. She said Resident #1 was not talking and only responded to tactile stimuli. She said she wanted to send him to the hospital, but did not want to overstep the DONs orders. She said she asked CNA C to get the crash cart ready because she knew something was wrong with Resident #1. LVN F said the DON called around 11:00 p.m. and asked if Resident #1 was fine. She said she told the DON he was not fine, but his vital signs were stable. She said she and CNA C went into Resident #1's room at 11:03 p.m. and repositioned him and put on his [MEDICAL CONDITION]. She said Resident #1 would jerk back to his right side, but he would not respond verbally. She said he definitely had a change in condition. She said about 11:45 p.m., she picked up the phone to call the physician because she was going to send him out regardless of him having stable vital signs, but then CNA C yelled for her to come down the hall. She said she went into Resident #1's room and he had fallen out of his bed with his [MEDICAL CONDITION] still on his face. She said he did not have a pulse. She said she started cardiopulmonary resuscitation (CPR) and told CNA C to call 911. She said it took the paramedics a while to get to the facility, but they were able to get a pulse on Resident #1. She said the paramedics took him to a local hospital and then he was transferred to another hospital, where he died . The physician orders [REDACTED].#1 had a new baseline for lethargy and decreased responsiveness and would not be sent out if he remained at the baseline. The nursing notes dated [DATE] for Resident #1 indicated the following: * at 8:23 p.m., He was in bed, responsive to tactile stimuli only, blood pressure ,[DATE], pulse 64, respirations 12, oxygen saturation 94% on 2 liters of oxygen. The notes did not indicate if the physician was notified of Resident #1's level of consciousness. * at 11:09 p.m., The resident was in bed, responsive to tactile stimuli. His heart rate was 117 and irregular and his respirations were 10 breaths per minute and deep and labored, with 5 seconds of apnea noted. FSBS was 180. Vital signs were stable, but he had a change in level of consciousness. The notes indicated the physician was notified but did not address what the physician's response was. * at 11:25 p.m., The resident was in bed, positioned on his right side. There was no acute respiratory distress noted. The notes did not address his level of consciousness. * at 11:45 p.m., Resident #1 was in bed and responded to tactile stimuli only. There was noted apnea periods increasing to ,[DATE] seconds, with respirations at 9 breaths per minute, oxygen saturation 94%, heart rate 137, and blood pressure ,[DATE]. The notes indicated there no further interventions needed. * at 11:55 p.m., The nurse (LVN F) attempted to call Resident #1's physician to send the resident out for mild respiratory distress with periods of apnea, bilateral upper lobe rales, and change in level of consciousness. CNA said to come quick and the nurse hung up phone. * at 11:56 p.m., The resident was on the floor, non-responsive and no pulse palpated. The notes indicated began chest compressions, CNA called 911 and pulled crash cart. The emergency medical service (EMS) arrived, resident showed no heart rate on the automated external defibrillator, (AED) resident remained non-responsive. EMS suctioned the resident and the resident continued to be without a pulse. * [DATE] at 12:28 a.m., EMS obtained a pulse; however, the resident was non-responsive. He was transferred to the hospital. The hospital records dated [DATE] indicated Resident #1 arrived at the hospital on [DATE] at 1:07 a.m. Resident #1 was extremely hypotensive, (low blood pressure) unresponsive, and was significant for extremely elevated [MEDICATION NAME]. (may be an indication of lack of oxygen ([MEDICAL CONDITION]) or the presence of other conditions that cause excess production or insufficient clearing of [MEDICATION NAME] from the blood) Resident #1 was given antibiotics for [MEDICAL CONDITION]. Resident #1 had significant metabolic abnormalities including lactic acidosis, anion gap metabolic acidosis, elevated liver function tests (LFTs), which were likely related to [MEDICAL CONDITION]/shock state. Resident #1 went into [MEDICAL CONDITION] and could not be revived. He was declared dead at 6:53 a.m. on [DATE]. During an interview on [DATE] at 4:32 p.m., CNA D said she worked [DATE] from 6:00 a.m. to 2:00 p.m. She said when she first saw Resident #1 that morning he was alert and using his call light. She said he was able to communicate with staff and verbalize his needs. CNA D said at lunch, Resident #1 was not his normal self. She said his eyes were closed, but he opened his eyes when she called his name. She said she came back to Resident #1's room and tried to help him eat his lunch which was not normal for him. She said she notified LVN A of Resident #1's condition and they gave him juice and medicine. She said Resident #1 was still not responding. During an interview on [DATE] at 5:38 p.m., the DON said on [DATE] after lunch, Resident #1's blood sugar was 38. She said interventions were provided and his blood sugar eventually came up to 190. The DON said Resident #1's vital signs were stable and he was responding to staff. She said the last time she saw Resident #1 was around 4:30 p.m., and he continued to be stable. The DON said LVN A called Resident #1's physician about his low blood sugar and decreased level of consciousness and the physician said to send Resident #1 if he did not stabilize or if he worsened. She said Resident #1 was stable throughout the day. She said she called the facility around 10:00 p.m., that night, spoke to LVN F, and was told Resident #1 was good. She said she got a call on [DATE] at 12:45 a.m. from the facility saying that Resident #1 had coded at the facility and EMS was taking him to the hospital. During an interview on [DATE] at 9:48 a.m., Resident #1's physician said he expected the nurses to use nursing judgment and send a resident out if they had a change in condition. Resident #1's physician said if a resident is non-responsive, regardless if they have stable vital signs, they should have been sent to the hospital. The undated Abuse/Neglect prohibition policy indicated .each resident has the right to be free from mental and physical abuse, corporal punishment, involuntary seclusion, unreasonable confinement, intimidation, neglect . The undated change of condition policy indicated .the nurse will notify the resident's attending physician when there has been a significant change in the resident's physical/emotional/mental condition .need to transfer the resident to a hospital. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention . The administrator was notified on [DATE] at 1:18 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 8:08 p.m., and included: 1. Nursing staff will be in-serviced regarding resident change of condition, use of Interact, SBAR completion, and notification of physician. ([DATE]) 2. Auditing of charts of diabetics and monitor blood sugars and adjustments needed to prevent change of condition. ([DATE]) 3. Facility will document any items that need follow up and assign responsibility using morning clinical meeting form. ([DATE]) 4. Nursing staff will refer to Change of Condition Policy and notify Physician accordingly. On [DATE], the surveyors confirmed the plan of removal had been implemented sufficiently to remove the Immediate Jeopardy by: During an interview on [DATE] at 2:26 p.m., the regional nurse said she in-serviced the DON on abuse, neglect, change of condition, physician notification, and medication parameters. During an interview on [DATE] at 2:28 p.m., the DON said she and the regional nurse had been in-servicing nursing staff on abuse, neglect, change of condition, physician notification, and medication parameters. She said almost everyone had been in-serviced and nursing staff would complete in-servicing on [DATE]. During interviews on [DATE] from 2:31 p.m. to 4:58 p.m., 5 nurses (3 from day shift and 2 from night shift) and 6 CNAs (2 from day shift, 2 from evening shift, and 2 from night shift) and one MA (evening shift) were interviewed and said they received training on abuse, neglect, change of condition, and who to notify when there was a change of condition. The nurses and MAs said they received training on medication parameters. During an interview on [DATE] at 4:57 p.m., the regional nurse said Resident #3 had a change of condition and was being sent to the hospital for further evaluation. On [DATE] at 5:45 p.m., the administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at an isolated incident of actual harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A list completed by the DON on [DATE], indicated 16 residents were diabetics.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent injury for 1 of 7 residents reviewed for accidents. (Resident #1) The facility did not provide adequate assistive devices for smoking to Resident #1 who recently acquired a 3rd degree burn from smoking. This failure could place 7 residents who smoked at risk for injury from burns. Findings included: A face sheet dated 04/19/18 indicated Resident #1 was [AGE] years old, admitted on [DATE], with [DIAGNOSES REDACTED]. An initial smoking assessment dated [DATE] indicated Resident #1 did not have dexterity problems and did not need adaptive equipment for safety. Hospital records dated 03/29/18 indicated Resident #1 had a 3rd degree burn to her right hand from a burning cigarette. Intravenous antibiotics were initiated. There was no incident report regarding Resident #1's cigarette burn to her right hand. A smoking assessment dated [DATE] indicated Resident #1 had dexterity problems and a smoking apron and cigarette holder were needed for safety. Physician orders [REDACTED].#1 indicated to apply [MEDICATION NAME] ointment [MEDICAL CONDITION] her fingers twice a day. An MDS dated [DATE] indicated Resident #1 made her needs known and understood others. She required extensive assistance with ADLs. Resident #1 had contractures and impairments in her upper and lower extremities. A care plan initiated 04/16/18 indicated Resident #1 was a smoker and would wear a smoke apron during smoke breaks and would use hemostats to hold her cigarettes. During an observation and interview on 04/17/18 at 8:51 a.m., Resident #1 was reclined in her wheelchair and her legs were elevated by the footrest. Resident #1 was contracted in all four extremities. Resident #1 had a scabbed area on the 3rd finger of her right hand. She said she got the burn when smoking a cigarette and letting the cigarette burn too close to the cigarette butt. She said she did not remember when the burn occurred. She said she was given a cigarette holder that was kept with her cigarettes at the nursing station. During an observation on 04/19/18 at 9:34 a.m., Resident #1 was outside in the courtyard with CNA C. Resident #1 was reclined in her wheelchair, smoking a cigarette. Resident #1 was not wearing a smoking apron and was not using a cigarette holder. Resident #1 was using her right hand to smoke her cigarette. During an interview on 04/19/18 at 10:06 a.m., CNA C said Resident #1 did not wear a smoking apron and did not use a cigarette holder when she took Resident #1 to smoke on the morning of 04/19/18. She said she did not usually take Resident #1 out to smoke and did not know she was supposed to wear a smoking apron and use a cigarette holder. During an interview on 04/19/18 at 10:31 a.m., LVN D said she did not know how Resident #1 burned her hand. During an interview on 04/19/18 at 3:34 p.m., the DON said she expected staff to ensure Resident #1 wore a smoking apron and used a cigarette holder each time Resident #1 went to smoke. The DON said she educated staff on ensuring Resident #1 wore her smoking apron and used a cigarette holder. The facility's smoking policy dated 06/08/16 indicated .the resident's capabilities and deficits are assessed to determine supervision required and to notify staff so they will know the correct procedure for each resident . During an interview on 04/20/18 at 11:48 a.m., the DON said there were 7 residents that smoked at the facility.

Based on observation, interview, and record review, the facility failed to provide necessary treatment and services, based on the comprehensive assessment, to promote healing and prevent worsening pressure injuries from developing for of 1 of 3 residents reviewed for pressure injuries. (Resident #7) The facility did not provide Resident #7 with interventions to prevent an avoidable stage 2 pressure injury from deteriorating to a stage 3. The treatment nurse did not identify 2 new facility acquired unstageable pressure injuries on Resident #7's buttocks until after the wound care specialist identified them. The resident developed multiple opened wounds and 2 dark purple areas on her coccyx and buttocks that were not being assessed or treated. This failure could place 3 residents with pressure injuries at risk of worsening pressure injuries. Findings included: Physician orders [REDACTED].#7 was [AGE] years old, admitted on [DATE], with [DIAGNOSES REDACTED]. An order dated 5/25/17 indicated to clean the resident's pressure injures with normal saline, apply collagen to the wound beds, and cover with a dressing daily. A care plan dated 03/22/17 indicated Resident #7 was at risk for impaired skin and she had 2 stage 2 pressure injuries on her coccyx area. Interventions included monitoring and reporting new areas of skin breakdown, redness, blisters, and discoloration. The care plan indicated Resident #7 refused to turn and reposition and interventions included encouraging the resident to use the assist bars to assist with turning and repositioning. A daily skilled nursing note dated 03/23/17 indicated there were no concerns with Resident #7's skin. The note indicted the resident did not have any pressure injuries. An admission skin assessment dated [DATE] indicated Resident #7 had no skin issues or concerns. A Braden scale assessment dated [DATE] indicated Resident #7 was at moderate risk for developing pressure injuries. A weekly skin assessment dated [DATE] indicated Resident #7 developed blisters on her coccyx area. The skin assessment did not include measurements. The skin assessment did not indicate if the physician was notified or if a treatment was started. An MDS dated [DATE] indicated Resident #7 understood others and made her needs known. She required limited assistance with bed mobility, transfers, and toilet use. The MDS indicated Resident #7 admitted with and currently had 2 stage 2 pressure injuries. The MDS indicated Resident #7 did not have any other skin issues. A weekly pressure injury log dated 03/30/17 indicated Resident #7 had a facility- acquired stage 2 pressure injury on her coccyx area measuring 3.3 cm x 4.1 cm. Interventions included offloading and pressure relief. The log did not indicate there were any treatments ordered and the pressure injury was not staged. A weekly pressure injury log dated 04/06/17 indicated Resident #7's pressure injury on her coccyx area was not staged and measured 3.3 cm x 4.1 cm. The log indicated the treatment for [REDACTED]. Interventions included offloading and vitamin therapy. A weekly pressure injury log dated 04/13/17 indicated Resident #7's pressure injury on her coccyx area was a stage 2 and measured 3.3 cm x 4.1 cm. The log indicated there was a new DTI pressure injury on her coccyx area, but it did not include measurements. The log did not indicate if the physician was notified of the new DTI. The treatment to the pressure injury (unclear of which pressure injury) was Santyl. Interventions included offloading and vitamin therapy. A weekly skin assessment dated [DATE] indicated Resident #7 had an open area on her coccyx area and her buttocks were macerated around the pressure injury. The skin assessment did not address the DTI on her coccyx area. A weekly pressure injury log dated 04/20/17 indicated Resident #7's pressure injury on her coccyx area was a stage 2 and measured 3.5 cm x 4.0 cm. The treatment included zinc. Interventions were offloading and vitamin therapy. The log did not address the DTI on her coccyx area. A nursing note dated 04/23/17 indicated Resident #7 had a low air loss mattress on her bed. Physician orders [REDACTED].#7 may have a low air loss mattress. A weekly skin assessment dated [DATE] indicated Resident #7 had a stage 3 pressure injury to her coccyx area and redness to her buttocks. There were no other description of the wound bed. The DTI on her coccyx area was not addressed. A weekly pressure injury log dated 04/27/17 indicated Resident #7's pressure injury on her coccyx was a stage 2 and measured 3.5 cm x 3.1 cm and treatment included zinc. Interventions included offloading and vitamin therapy. A wound care physician evaluation dated 05/01/17 indicated Resident #7 had a stage 3 pressure injury on her coccyx area. The pressure injury was measured at 4 cm x 2 cm x 0.5 cm. Treatment included Santyl (topical debridement ointment) and calcium alginate (used for wounds with heavy drainage). A weekly skin assessment dated [DATE] indicated Resident #7 had a stage 3 pressure injury to her coccyx area and redness on her buttocks. The assessment indicated she had 2 hard knots to her right buttocks. No other description was noted. A weekly pressure injury log dated 05/04/17 indicated Resident #7's pressure injury on her coccyx area deteriorated from a stage 2 to a stage 3 on 05/01/17 and measured 3.5 cm x 3.0 cm x 0.5 cm. Interventions included offloading and vitamin therapy. No new interventions were listed. The log indicated treatment included Santyl and calcium alginate. A care plan dated 05/08/17 indicated Resident #7 had a stage 3 pressure injury on her coccyx area. Interventions included to turn and reposition, notify physician if no improvement, and off load heels. The care plan indicated Resident #7 refused to be turned and repositioned and interventions included not arguing with the resident. A weekly skin assessment dated [DATE] indicated Resident #7 had a stage 3 pressure injury on her coccyx area and redness to her buttocks. The assessment indicated she had 2 hard knots her to right buttocks. No other description was noted. A weekly pressure injury log dated 05/11/17 indicated Resident #7 had a stage 3 pressure injury on her coccyx area that measured 3.5 cm x 3.0 cm x 0.5 cm. Treatment included Santyl and calcium alginate. Interventions included offloading and vitamin therapy. A wound care specialist evaluation dated 05/15/17 indicated Resident # 7's coccyx area pressure injury measured 4 cm x 2.5 cm x 1.5 cm. A weekly skin assessment dated [DATE] indicated Resident #7 had a stage 3 pressure injury on her coccyx area and redness on her buttocks. The assessment indicated she had 2 hard knots her to right buttocks. No other description was noted. An MDS dated [DATE] indicated Resident #7 understood others and made her needs known. She required extensive 2 person assistance with bed mobility, transfers, and toilet use. Resident #7 had a catheter and was incontinent of bowel. The MDS indicated Resident #7 had a stage 3 pressure injury that was not present upon on admission. A weekly pressure injury log dated 05/18/17 indicated Resident #7 had a stage 3 pressure injury on her coccyx area that measured 4.0 cm x 2.5 cm x 1.5 cm. Treatment included Santyl and calcium alginate. Interventions included dietary and offloading. No new interventions were listed. No other pressure injuries were noted. A wound care specialist evaluation dated 05/22/17 indicated Resident #7's coccyx pressure injury measured 4 cm x 3.5 cm x 2 cm. The evaluation indicated Resident #7 had a left buttock pressure injury that measured 2 cm x 1.5 cm with 50% necrotic tissue and a right buttock pressure injury that measured 2 cm x 3 cm with 50% necrotic tissue. The evaluation indicated Resident #7's left and right buttock pressure injuries were debrided at the bedside. A weekly pressure injury log dated 05/25/17 indicated Resident #7 had the following pressure injuries: *stage 3 coccyx pressure injury measured 4.0 cm x 3.5 cm x 2.0 cm. *Facility acquired (5/23/17) DTI on her left buttock measured 2.0 cm by 1.5 cm. *Facility acquired (5/23/17) DTI on her right buttock measured 2.0 cm x 3.0 cm A weekly skin assessment dated [DATE] indicated Resident #7 had a stage 3 pressure injury on her coccyx area, an unstageable pressure injury on her left buttock, and an unstageable pressure injury to her right buttock. Resident #7 had redness to her buttocks and the knots to her right buttocks resolved. A weekly pressure injury log dated 06/08/17 indicated Resident #7 had the following pressure injuries: *stage 3 coccyx area that measured 2.7 cm by 2.0 cm by 1.0 cm *left buttocks with eschar/necrotic tissue and measured 2.0 cm by 1.0 cm *right buttocks with eschar/necrotic tissue and measured 1.8 cm by 1.5 cm A weekly skin assessment dated [DATE] indicated Resident #7 had an open area on her left buttock and redness to her buttocks. During an observation on 06/13/17 at 1:38 p.m., Resident #7 was lying flat on her back on a low air loss mattress. A wound care specialist evaluation dated 06/12/17 indicated Resident #7 had the following pressure injuries: *stage 3 coccyx area measuring 2 cm x 2.5 cm x 1.0 cm. *unstageable on the left buttock measuring 1.5 cm x 1 cm. *unstageable on the right buttock measuring 1 cm x 1.5 cm. During an observation and interview on 06/13/17 at 2:35 p.m., Resident #7 was lying flat on her back with an indwelling urinary catheter. When CNA B turned Resident #7 onto her side, the resident was unable to assist with turning. Resident #7 said turning onto her side was painful, but she did not mind turning. Resident #7 said she would do whatever she needed to do to help heal her wounds. Resident #7 said she was unable to turn without assistance. Resident #7 had one dressing on her buttocks that covered all 3 pressure injuries. LVN A removed the old dressing from Resident #7's buttocks and there was reddish-pink and light yellow drainage on the dressing. There was a foul odor that presented when LVN A removed the dressing. LVN A said the odor was caused from Resident #7 being incontinent. Resident #7's buttocks was reddish-pink with multiple opened areas. LVN A said Resident #7 had 3 pressure injuries that she was treating. Resident #7 had the following wounds: **Coccyx area - 1) Coccyx area pressure injury at 3.3 cm x 2.25 cm and the wound bed was unable to be seen. 2) Open area to the right of her coccyx wound that had a dark red wound bed that was approximately the size of a pencil eraser. 3) Open area just above the resident's coccyx wound that was red and opened. **Left buttock- 4) Pressure injury measuring 1.5 cm x 1.0 cm. with a bright red wound bed. No eschar or necrotic tissue in the wound bed. The surrounding skin was a mixture of pink, purple, and white flaky skin. 5) Open area with a red wound bed approximately the size of a dime with pink skin surrounding the wound bed **Right buttock - 6) Pressure injury measuring 1.5 cm x 1.5 cm with a light pink wound bed in the middle and darker pink and red on the outside park of the wound bed. There was no necrotic tissue in the wound bed and the surrounding tissue was a mixture of pink and white flaky skin. 7) and 8) 2 additional dark purple areas on Resident #7's right buttocks. LVN A covered the coccyx, left buttock, and right buttock wounds with collagen and covered Resident #7's entire buttocks with a dry dressing. She did not address any other areas on Resident #7's buttocks. During an interview on 06/13/17 at 5:49 p.m., LVN A said she was treating Resident #7's 3 pressure injuries. She said Resident #7's buttocks had been red and the CNAs were applying barrier cream on Resident #7's buttocks during incontinent care. She said no other treatments were being done for the other multiple open areas on Resident #7's buttocks. During an interview on 06/13/17 at 1:46 p.m., LVN A said she was the treatment nurse and transferred to the position in early May 2017. She said she had not been a treatment nurse before and had not had training on pressure injuries. During an interview on 06/13/17 at 3:53 p.m., the DON refused to comment about Resident #7's pressure injuries. During an interview on 06/13/17 at 1:57 p.m., CNA B said there was no place to document when CNAs turned and repositioned residents. She said they just watched the clock. During an interview on 06/13/17 at 2:38 p.m., CNA B indicated Resident #7 did refuse to be turned; however, she complained of pain in her shoulders when she was turned. During an observation on 06/13/17 at 5:21 p.m., Resident #7 was lying flat on her back. During an observation and interview on 06/13/17 at 6:08 p.m., Resident #7 was lying flat on her back. The DON, ADON C, and LVN B observed Resident #7's entire buttocks. The DON said the resident's buttocks looked bad. The DON would not comment any further on the resident's pressure injuries. During an interview on 06/13/17 at 4:18 p.m., the wound care physician said he saw Resident #7 in the facility on 06/12/17. He said he only treated and was aware of her 3 pressure areas and her excoriation. He said he would expect the treatment nurse to implement interventions to aide in the healing of pressure injuries. He said Resident #7's coccyx area pressure injury was a stage 3 and had some depth to it. He said Resident #7's left and right buttock pressure injuries were unstageable due to necrosis. He said he was aware that Resident #7's pressure injuries had an odor and whenever necrotic tissue was present, there would be an odor. According to www.npuap.com, accessed 06/14/17, indicated a .Stage 3 Pressure Injury: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury . The undated facility's wound care policy indicated .based on each resident's comprehensive assessment, appropriate treatment and services are provided to prevent the formation of pressure ulcers. Residents having pressure ulcers receive necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. A list dated 06/13/17, provided by ADON C, indicated 3 residents had pressure injuries.

Based on observation, interview, and record review, the facility failed to develop and implement their written policies and procedures to prohibit neglect for 3 of 7 residents reviewed for neglect. (Residents #1, #2, and #3) The facility did not prevent Resident #1, who had a history of [REDACTED].#2 in the head and shoving Resident #3 to the floor, breaking her arm. Following the incident with Resident #3, Resident #1 was to be on one-on-one supervision, but the staff did not provide the required supervision. An Immediate Jeopardy situation was identified on 06/23/16. The Immediate Jeopardy was removed on 06/24/16; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the 23 residents on the secure unit at risk for serious injury or possible death. Findings included: The undated Abuse/Neglect Policy indicated in the area of resident-to-resident abuse, the facility will immediately protect the resident being abused and all other residents in the facility. The facility would monitor the perpetrator one-on-one to protect all other residents until the time of discharge. Physician orders [REDACTED].#1, admitted [DATE] and discharged on [DATE] to a behavioral health hospital, was [AGE] years old with [DIAGNOSES REDACTED]. An initial psychological evaluation dated 03/31/16 indicated Resident #1 had behavioral issues that included urinating on the floor, attempting to elope, wandering into other residents' rooms, and placing pillows over residents' heads. Resident #1 had visual hallucinations of fires, bulldogs, and other people. His wife reported that Resident #1 had a history of [REDACTED]. A psychological consult dated 04/21/16 indicated Resident #1 had severe disorientation, confusion, tension, anger, and hostility. He had very severe wandering and restlessness. A psychological consult dated 04/28/16 indicated Resident #1 had severe mood swings, anxiety, disorientation, confusion, tension, anger, and hostility. He had severe verbal combativeness, agitation, wandering, and restlessness. A psychological consult dated 05/12/16 indicated Resident #1 had very severe wandering and restlessness. He had severe disorientation, confusion, anxiety, and delusions. A psychological consult dated 05/19/16 indicated Resident #1 had moderate disorientation, confusion, wandering, restlessness, and anxiety. An electronic mail dated 06/27/16 indicated the administrator said there were no further psychological consultations for Resident #1 after 05/19/16. An incident report dated 06/09/16 indicated Resident #1 was sitting at the dining table, stood up from the table, and hit Resident #2 on the head. The residents were separated and a head to toe assessment was performed. No injuries were noted. Resident #1 and Resident #2 were roommates. Nursing notes dated 06/09/16 at 1:00 p.m., indicated Resident #1 stood up from the dining table and hit Resident #2 on the head. No injuries were found upon assessment. During an interview on 06/23/16 at 6:14 a.m., CNA C said she worked the day Resident #1 hit Resident #2 in the head, but she did not witness it. She said she thought the altercation was over a female resident. She said Resident #1 and Resident #2 continued to be roommates after the incident and during the survey. Nursing notes dated 06/10/16 at 10:00 a.m., indicated Resident #1 was restless and went out the back door, setting off the alarm. Nursing notes dated 06/10/16 at 11:00 a.m., indicated Resident #1 was moving a table and chairs. Resident #1 remained anxious and restless, but was not physically combative. Nursing notes dated 06/18/16 at 1:40 p.m., indicated Resident #1 was pacing and went through other residents things in the common area. Resident #1 attempted to get in the closet across from the restroom, tried to grab others' food at times. A care plan last updated 06/21/16 indicated Resident #1 required [MEDICAL CONDITION] medications due to his [MEDICAL CONDITION]. Interventions included administer [MEDICAL CONDITION] medications as ordered, complete behavior monitoring, noting behavior, intervention, and effectiveness. Confer with doctor for dose reduction and side effects. Resident #1 did not have a care plan that addressed his aggressive behaviors. Nursing notes dated 06/22/16 at 10:45 a.m., indicated Resident #1 wandered around the secure unit. A physical therapist said Oh, he just shoved her across the floor. Resident #3 was noted to be on the floor. Resident #1 walked to the activity desk, picked up the desk, put it down, and punched the desk. Nursing notes dated 06/22/16 at 10:45 a.m., indicated Resident #3 was lying on her back on the floor after being pushed to the floor by Resident #1. Resident #3 complained of severe pain to her left arm, left shoulder, and coccyx. There was noted protrusion of Resident #3's left clavicle. Resident #3 was unable to move her left arm. Resident #3 had a hematoma to the right side of the back of her head. EMS was called and transferred Resident #3 to the ER. An x-ray taken on 06/22/16 at 2:03 p.m., indicated Resident #3 had a fracture and displacement to her left upper arm bone. During an interview on 06/23/16 at 5:38 a.m., LVN B said on 06/22/16, Resident #1 pushed Resident #3 to the ground and it was witnessed by a physical therapist. She said Resident #3 broke her arm, but she was returned to the secure unit the same day. Resident #3 had an appointment with an orthopedic surgeon the following week. During an interview on 06/23/16 at 9:26 a.m., a PT G said she was at the nursing station in the secure unit, talking to a resident when the incident occurred between Resident #1 and Resident #3. She said out of the corner of her eye she saw Resident #1 use both of his hands and push Resident #3 to the floor. She said Resident #3 landed on the floor and slid across the floor before coming to a stop. She said she did not see the 2 residents have any kind of interaction before the incident. During an observation and interview on 06/23/16 at 8:25 a.m., Resident #3 was sitting on the side of her bed with her left upper arm wrapped in an elastic bandage from her shoulder to her elbow. She was unable to answer questions appropriately. Nursing notes dated 06/22/16 indicated Resident #1 was placed on one-on-one supervision after the incident with Resident #3. Resident #1 remained restless and wandered in and out of other residents' rooms. He removed cushions from the furniture and played with them and he was talking to a person who was not visible. During an interview on 06/23/16 at 11:42 a.m., the administrator said after the incident with Resident #1 and Resident #3 on 06/22/16, Resident #1 was placed on one-on-one supervision. During an observation on 06/23/16 at 5:29 a.m., Resident #1 came out of his room wearing boxer shorts and a tee shirt. He was confused and mumbled words to CNA A. CNA A told Resident #1 to go back to his room and she would help him get dressed in a little bit. CNA A continued to walk down the hall and Resident #1 went back to his room alone. His roommate, Resident #2 was lying in his bed with his eyes closed. Observations on 06/23/16 from 6:58 a.m. to 7:58 a.m. indicated the following: *at 6:58 a.m., Resident #1 was in his room with his roommate, Resident #2, total of 6 residents in the common area, staff were in residents' rooms for 8 minutes; *at 7:06 a.m., CNA C brought another resident to common area in her wheelchair, left to get another resident dressed; *at 7:08 a.m., CNA C brought another resident to common area in her wheelchair, left to get another resident; *at 7:09 a.m., 8 residents in common area, staff were in residents' rooms for 7 minutes; *at 7:17 a.m., 2 more residents walked into the common area, total of 10 residents in common area, Resident #1 in his room; *7:19 a.m., CNA C brought another resident to the common area in her wheelchair, left of get another resident, total of 11 residents in the common area; *at 7:35 a.m., Resident #1 walked from his room into the common area alone and sat down in a chair; *at 7:42 a.m., LVN D and CNA C left the common area, 15 residents in the common area that included Resident #1 were left alone; *at 7:45 a.m., CNA C and CNA E took Resident #4 to the bathroom, 17 residents in common area that included Resident #1 were left alone for 8 minutes; *at 7:53 a.m., CNA C and CNA E brought Resident #4 back to her geri chair and pulled her to the table, RN F entered the secure unit; *at 7:58 a.m., 2 more residents walked into the common area, total of 19 residents in common area that included Resident #1; *at 8:00 a.m., Resident #1 got up from his chair and walked across the common area and sat down at a table with Resident #2 to eat breakfast. He received his breakfast tray and began to eat. During an observation on 06/23/16 at 10:28 a.m., CNA E walked Resident #3 to the common area. Resident #3 sat down at a dining table and began to work a puzzle. Resident #1 was sitting on the other side of the unit in a chair talking to Resident #2. There were no staff in the immediate area. During an observation on 06/23/16 at 10:50 a.m., Resident #3 was sitting at the dining table facing the window and her back was towards the residents in the common area. Resident #1 got up from his chair and quickly walked across the common area towards Resident #3. Resident #3 did not see Resident #1 walking towards her. CNA E ran towards Resident #1 and asked him where he was going. Resident #1 said he wanted to go outside and continued to watch Resident #3. CNA E told Resident #1 it was hot outside and redirected him to the other side of the common area. During an observation on 06/23/16 at 11:28 a.m., Resident #1 paced around the secure unit and walked by Resident #3, who was sitting with her family member. Resident #1 moved chairs around the dining tables, attempted to pick up a dining table, picked up a wet floor sign, attempted to open a closet door, and picked up a notebook from the medication cart and held it under his arm. CNA E asked Resident #1 to put the book down and he sat the book down on the medication cart after being asked several times. During an interview on 06/23/16 at 11:30 a.m., CNA E said Resident #1 paced around the secure unit, picked up items, and was restless 06/22/16 before the incident with Resident #3. During an observation on 06/23/16 at 11:32 a.m., Resident #1 walked down the hall, stopped three times, and scratched at the floor. He walked back to the common area and looked out the window by the nursing station. During an interview on 06/23/16 at 11:42 a.m., the administrator said two CNAs were scheduled on each shift for the secure unit. He said a nurse was scheduled 8:00 a.m. to 5:00 p.m. on the secure unit and from 5:00 p.m. to 8:00 a.m., one nurse worked the secure unit and a hall outside the secure unit. During an interview on 06/23/16 at 12:33 p.m., RN F, CNA C, and CNA E said Resident #1 was not being supervised one-on-one by staff on the morning of 06/23/16. They said they were in residents' rooms getting residents up and dressed for breakfast. During an interview on 06/23/16 at 12:42 p.m., RN F and CNA C said they did not know Resident #1 was supposed to be on one-on-one supervision on 06/23/16. During an interview on 06/23/16 at 12:43 p.m., CNA E said she knew on 06/22/16 that Resident #1 was supposed to be on one-on-one supervision on 06/23/16. CNA E said one-on-one supervision meant to stay with Resident #1 at all times, but she needed to get other residents up and ready. The administrator was notified on 06/23/16 at 12:49 p.m., an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on 06/23/16 at 5:19 p.m. and included: POR 6/23/16 Free State Crestwood Nursing and Rehabilitation Please accept this as the Plan Of Removal How will the facility correct the deficient practice for those residents identified in the deficiency? (Local hospital) has accepted (Resident #1) for medication evaluation and adjustments. (Resident #1) was discharged from the facility on 6/23/16 at 3:30 p.m. Spouse and attending physician have been notified of transfer. Each resident on secured unit has been interviewed and asked about their safety and /or concerns of being harmed. No negative responses reported. Staff will be in serviced on Abuse and Neglect along with One to One Monitoring Policy which includes how to identify escalating or aggressive behaviors on 6/23/16. Complete a Behavior risk assessment of all residents on the secure unit. All residents on the secure unit will be assessed from Head to toe for injury. Updated One to One Policy as of 6/23/16. How will the facility identify those at risk for similar deficient practice? Residents on secured unit, due to the disease process, have the potential to be effected. Resident behavior risk assessment to be completed prior to admission and quarterly thereafter. What will be done to prevent the deficient practice from recurring? All secured unit staff will be in-serviced on the Abuse/Neglect policy and will demonstrate proficiency through return demonstration of Abuse and Neglect and One to One in servicing prior to returning to their current positions within the secured unit by 6/23/16 by 11:00 pm. Any staff away from facility will be in serviced prior to beginning working the secured unit. How will the facility monitor its own corrective action? Nursing Administration will monitor by doing compliance rounds. Quality of Life representatives will monitor their assigned residents for health and safety issues and report to the Administrator at scheduled morning QA meeting. The process improvement plan will be reviewed monthly at QAPI team. In service training will continue to be done on hire of all new fac. staff. (sic) On 6/24/16 the surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: One physical therapist, 3 CNAs, 2 RNs, 1 medical records staff, and 1 LVN (ADON) who worked on the secure unit were interviewed and said they were in-serviced about abuse/neglect, one on one supervision, how to identify escalating behaviors, reporting to oncoming staff regarding individual resident requirements, and what to report. They also said they understood that it did not require a physician order [REDACTED]. The policy for one-on-one supervision was reviewed and was changed to include that a resident on one-on-one supervision would never be out of the staff's line of sight and would be evaluated by a nurse at least every shift. Resident #1 was discharged to a local behavioral hospital on [DATE]. The revised assessments for all residents on the secure unit were reviewed and included information for any at risk for displaying aggressive behaviors; none were noted. On 06/24/16 at 11:15 a.m., the administrator, executive director, corporate nurse, and president of divisions were informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The resident roster dated 06/23/16 indicated there were 23 residents on the secure unit.

Based on observation, interview, and record review, the facility failed to ensure that alleged violations involving neglect or abuse were reported immediately to the State agency (SA) and residents were protected from further neglect for 3 of 7 residents reviewed for neglect. (Residents #1, #2, and #3) The facility did not report to the SA when Resident #1, who had a history of [REDACTED].#2 on the head and shoved Resident #3 to the floor, breaking her arm. The facility did not protect residents from injury from Resident #1. An Immediate Jeopardy situation was identified on 06/23/16. The Immediate Jeopardy was removed on 06/24/16; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the 23 residents on the secure unit at risk for serious injury or possible death. Findings included: Physician orders [REDACTED].#1, admitted [DATE] and discharged on [DATE] to a behavioral health hospital, was [AGE] years old with [DIAGNOSES REDACTED]. An initial psychological evaluation dated 03/31/16 indicated Resident #1 had behavioral issues that included urinating on the floor, attempting to elope, wandering into other residents' rooms, and placing pillows over residents' heads. Resident #1 had visual hallucinations of fires, bulldogs, and other people. His wife reported that Resident #1 had a history of [REDACTED]. A psychological consult dated 04/21/16 indicated Resident #1 had severe disorientation, confusion, tension, anger, and hostility. He had very severe wandering and restlessness. A psychological consult dated 04/28/16 indicated Resident #1 had severe mood swings, anxiety, disorientation, confusion, tension, anger, and hostility. He had severe verbal combativeness, agitation, wandering, and restlessness. A psychological consult dated 05/12/16 indicated Resident #1 had very severe wandering and restlessness. He had severe disorientation, confusion, anxiety, and delusions. A psychological consult dated 05/19/16 indicated Resident #1 had moderate disorientation, confusion, wandering, restlessness, and anxiety. An electronic mail dated 06/27/16 indicated the administrator said there were no further psychological consultations for Resident #1 after 05/19/16. An incident report dated 06/09/16 indicated Resident #1 was sitting at the dining table, stood up from the table, and hit Resident #2 on the head. The residents were separated and a head to toe assessment was performed. No injuries were noted. Resident #1 and Resident #2 were roommates. Nursing notes dated 06/09/16 at 1:00 p.m., indicated Resident #1 stood up from the dining table and hit Resident #2 on the head. No injuries were found upon assessment. During an interview on 06/23/16 at 6:14 a.m., CNA C said she worked the day Resident #1 hit Resident #2 in the head, but she did not witness it. She said she thought the altercation was over a female resident. She said Resident #1 and Resident #2 continued to be roommates after the incident and during the survey. Nursing notes dated 06/10/16 at 10:00 a.m., indicated Resident #1 was restless and went out the back door, setting off the alarm. Nursing notes dated 06/10/16 at 11:00 a.m., indicated Resident #1 was moving a table and chairs. Resident #1 remained anxious and restless, but was not physically combative. Nursing notes dated 06/18/16 at 1:40 p.m., indicated Resident #1 was pacing and went through other residents things in the common area. Resident #1 attempted to get in the closet across from the restroom, tried to grab others' food at times. A care plan last updated 06/21/16 indicated Resident #1 required [MEDICAL CONDITION] medications due to his [MEDICAL CONDITION]. Interventions included administer [MEDICAL CONDITION] medications as ordered, complete behavior monitoring, noting behavior, intervention, and effectiveness. Confer with doctor for dose reduction and side effects. Resident #1 did not have a care plan that addressed his aggressive behaviors. Nursing notes dated 06/22/16 at 10:45 a.m., indicated Resident #1 wandered around the secure unit. A physical therapist said Oh, he just shoved her across the floor. Resident #3 was noted to be on the floor. Resident #1 walked to the activity desk, picked up the desk, put it down, and punched the desk. Nursing notes dated 06/22/16 at 10:45 a.m., indicated Resident #3 was lying on her back on the floor after being pushed to the floor by Resident #1. Resident #3 complained of severe pain to her left arm, left shoulder, and coccyx. There was noted protrusion of Resident #3's left clavicle. Resident #3 was unable to move her left arm. Resident #3 had a hematoma to the right side of the back of her head. EMS was called and transferred Resident #3 to the ER. An x-ray taken on 06/22/16 at 2:03 p.m., indicated Resident #3 had a fracture and displacement to her left upper arm bone. During an interview on 06/23/16 at 5:38 a.m., LVN B said on 06/22/16, Resident #1 pushed Resident #3 to the ground and it was witnessed by a physical therapist. She said Resident #3 broke her arm, but she was returned to the secure unit the same day. Resident #3 had an appointment with an orthopedic surgeon the following week. During an interview on 06/23/16 at 9:26 a.m., PT G said she was at the nursing station in the secure unit, talking to a resident when the incident occurred between Resident #1 and Resident #3. She said out of the corner of her eye she saw Resident #1 use both of his hands and push Resident #3 to the floor. She said Resident #3 landed on the floor and slid across the floor before coming to a stop. She said she did not see the 2 residents have any kind of interaction before the incident. During an observation and interview on 06/23/16 at 8:25 a.m., Resident #3 was sitting on the side of her bed with her left upper arm wrapped in an elastic bandage from her shoulder to her elbow. She was unable to answer questions appropriately. Nursing notes dated 06/22/16 indicated Resident #1 was placed on one-on-one supervision after the incident with Resident #3. Resident #1 remained restless and wandered in and out of other residents' rooms. He removed cushions from the furniture and played with them and he was talking to a person who was not visible. During an interview on 06/23/16 at 11:42 a.m., the administrator said after the incident with Resident #1 and Resident #3 on 06/22/16, Resident #1 was placed on one-on-one supervision. During an observation on 06/23/16 at 5:29 a.m., Resident #1 came out of his room wearing boxer shorts and a tee shirt. He was confused and mumbled words to CNA A. CNA A told Resident #1 to go back to his room and she would help him get dressed in a little bit. CNA A continued to walk down the hall and Resident #1 went back to his room alone. His roommate, Resident #2 was lying in his bed with his eyes closed. Observations on 06/23/16 from 6:58 a.m. to 7:58 a.m. indicated the following: *at 6:58 a.m., Resident #1 was in his room with his roommate, Resident #2, total of 6 residents in the common area, staff were in residents' rooms for 8 minutes; *at 7:06 a.m., CNA C brought another resident to common area in her wheelchair, left to get another resident dressed; *at 7:08 a.m., CNA C brought another resident to common area in her wheelchair, left to get another resident; *at 7:09 a.m., 8 residents in common area, staff were in residents' rooms for 7 minutes; *at 7:17 a.m., 2 more residents walked into the common area, total of 10 residents in common area, Resident #1 in his room; *7:19 a.m., CNA C brought another resident to the common area in her wheelchair, left of get another resident, total of 11 residents in the common area; *at 7:35 a.m., Resident #1 walked from his room into the common area alone and sat down in a chair; *at 7:42 a.m., LVN D and CNA C left the common area, 15 residents in the common area that included Resident #1 were left alone; *at 7:45 a.m., CNA C and CNA E took Resident #4 to the bathroom, 17 residents in common area that included Resident #1 were left alone for 8 minutes; *at 7:53 a.m., CNA C and CNA E brought Resident #4 back to her geri chair and pulled her to the table, RN F entered the secure unit; *at 7:58 a.m., 2 more residents walked into the common area, total of 19 residents in common area that included Resident #1; *at 8:00 a.m., Resident #1 got up from his chair and walked across the common area and sat down at a table with Resident #2 to eat breakfast. He received his breakfast tray and began to eat. During an observation on 06/23/16 at 10:28 a.m., CNA E walked Resident #3 to the common area. Resident #3 sat down at a dining table and began to work a puzzle. Resident #1 was sitting on the other side of the unit in a chair talking to Resident #2. There were no staff in the immediate area. During an observation on 06/23/16 at 10:50 a.m., Resident #3 was sitting at the dining table facing the window and her back was towards the residents in the common area. Resident #1 got up from his chair and quickly walked across the common area towards Resident #3. Resident #3 did not see Resident #1 walking towards her. CNA E ran towards Resident #1 and asked him where he was going. Resident #1 said he wanted to go outside and continued to watch Resident #3. CNA E told Resident #1 it was hot outside and redirected him to the other side of the common area. During an observation on 06/23/16 at 11:28 a.m., Resident #1 paced around the secure unit and walked by Resident #3, who was sitting with her family member. Resident #1 moved chairs around the dining tables, attempted to pick up a dining table, picked up a wet floor sign, attempted to open a closet door, and picked up a notebook from the medication cart and held it under his arm. CNA E asked Resident #1 to put the book down and he sat the book down on the medication cart after being asked several times. During an interview on 06/23/16 at 11:30 a.m., CNA E said Resident #1 paced around the secure unit, picked up items, and was restless 06/22/16 before the incident with Resident #3. During an observation on 06/23/16 at 11:32 a.m., Resident #1 walked down the hall, stopped three times, and scratched at the floor. He walked back to the common area and looked out the window by the nursing station. During an interview on 06/23/16 at 11:42 a.m., the administrator said two CNAs were scheduled on each shift for the secure unit. He said a nurse was scheduled 8:00 a.m. to 5:00 p.m. on the secure unit and from 5:00 p.m. to 8:00 a.m., one nurse worked the secure unit and a hall outside the secure unit. During an interview on 06/23/16 at 12:33 p.m., RN F, CNA C, and CNA E said Resident #1 was not being supervised one-on-one by staff on the morning of 06/23/16. They said they were in residents' rooms getting residents up and dressed for breakfast. During an interview on 06/23/16 at 12:42 p.m., RN F and CNA C said they did not know Resident #1 was supposed to be on one-on-one supervision on 06/23/16. During an interview on 06/23/16 at 12:43 p.m., CNA E said she knew on 06/22/16 that Resident #1 was supposed to be on one-on-one supervision on 06/23/16 CNA E said one-on-one supervision meant to stay with Resident #1 at all times, but she needed to get other residents up and ready. The undated Abuse/Neglect Policy indicated in the area of resident-to-resident abuse, the facility will immediately protect the resident being abused and all other residents in the facility. The facility would monitor the perpetrator one-on-one to protect all other residents until the time of discharge. The administrator was notified on 06/23/16 at 12:49 p.m., an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on 06/23/16 at 5:19 p.m. and included: POR 6/23/16 Free State Crestwood Nursing and Rehabilitation Please accept this as the Plan Of Removal How will the facility correct the deficient practice for those residents identified in the deficiency? (Local hospital) has accepted (Resident #1) for medication evaluation and adjustments. (Resident #1) was discharged from the facility on 6/23/16 at 3:30 p.m. Spouse and attending physician have been notified of transfer. Each resident on secured unit has been interviewed and asked about their safety and /or concerns of being harmed. No negative responses reported. Staff will be in serviced on Abuse and Neglect along with One to One Monitoring Policy which includes how to identify escalating or aggressive behaviors on 6/23/16. Complete a Behavior risk assessment of all residents on the secure unit. All residents on the secure unit will be assessed from Head to toe for injury. Updated One to One Policy as of 6/23/16. How will the facility identify those at risk for similar deficient practice? Residents on secured unit, due to the disease process, have the potential to be effected. Resident behavior risk assessment to be completed prior to admission and quarterly thereafter. What will be done to prevent the deficient practice from recurring? All secured unit staff will be in-serviced on the Abuse/Neglect policy and will demonstrate proficiency through return demonstration of Abuse and Neglect and One to One in servicing prior to returning to their current positions within the secured unit by 6/23/16 by 11:00 pm. Any staff away from facility will be in serviced prior to beginning working the secured unit. How will the facility monitor its own corrective action? Nursing Administration will monitor by doing compliance rounds. Quality of Life representatives will monitor their assigned residents for health and safety issues and report to the Administrator at scheduled morning QA meeting. The process improvement plan will be reviewed monthly at QAPI team. In service training will continue to be done on hire of all new fac. staff. (sic) On 6/24/16 the surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: One physical therapist, 3 CNAs, 2 RNs, 1 medical records staff, and 1 LVN (ADON) who worked on the secure unit were interviewed and said they were in-serviced about abuse/neglect, one on one supervision, how to identify escalating behaviors, reporting to oncoming staff regarding individual resident requirements, and what to report. They also said they understood that it did not require a physician order [REDACTED]. The policy for one-on-one supervision was reviewed and was changed to include that a resident on one-on-one supervision would never be out of the staff's line of sight and would be evaluated by a nurse at least every shift. Resident #1 was discharged to a local behavioral hospital on [DATE]. The revised assessments for all residents on the secure unit were reviewed and included information for any at risk for displaying aggressive behaviors; none were noted. On 06/24/16 at 11:15 a.m., the administrator, executive director, corporate nurse, and president of divisions were informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The resident roster dated 06/23/16 indicated there were 23 residents on the secure unit.

Based on observation, interview, and record review, the facility failed to develop and implement their policies and procedures to prohibit neglect for 3 of 7 residents reviewed for neglect. (Residents #1,#2, and #3) The facility did not prevent Resident #1, who had a history of [REDACTED].#2 in the head and shoving Resident #3 to the floor, breaking her arm. Following the incident with Resident #3, Resident #1 was to be on one-on-one supervision, but the staff did not provide the required supervision. An Immediate Jeopardy situation was identified on 06/23/16. The Immediate Jeopardy was removed on 06/24/16; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the 23 residents on the secure unit at risk for serious injury or possible death. Findings included: Physician orders [REDACTED].#1, admitted [DATE] and discharged on [DATE] to a behavioral health hospital, was [AGE] years old with [DIAGNOSES REDACTED]. An initial psychological evaluation dated 03/31/16 indicated Resident #1 had behavioral issues that included urinating on the floor, attempting to elope, wandering into other residents' rooms, and placing pillows over residents' heads. Resident #1 had visual hallucinations of fires, bulldogs, and other people. His wife reported that Resident #1 had a history of [REDACTED]. A psychological consult dated 04/21/16 indicated Resident #1 had severe disorientation, confusion, tension, anger, and hostility. He had very severe wandering and restlessness. A psychological consult dated 04/28/16 indicated Resident #1 had severe mood swings, anxiety, disorientation, confusion, tension, anger, and hostility. He had severe verbal combativeness, agitation, wandering, and restlessness. A psychological consult dated 05/12/16 indicated Resident #1 had very severe wandering and restlessness. He had severe disorientation, confusion, anxiety, and delusions. A psychological consult dated 05/19/16 indicated Resident #1 had moderate disorientation, confusion, wandering, restlessness, and anxiety. An electronic mail dated 06/27/16 indicated the administrator said there were no further psychological consultations for Resident #1 after 05/19/16. An incident report dated 06/09/16 indicated Resident #1 was sitting at the dining table, stood up from the table, and hit Resident #2 on the head. The residents were separated and a head to toe assessment was performed. No injuries were noted. Resident #1 and Resident #2 were roommates. Nursing notes dated 06/09/16 at 1:00 p.m., indicated Resident #1 stood up from the dining table and hit Resident #2 on the head. No injuries were found upon assessment. During an interview on 06/23/16 at 6:14 a.m., CNA C said she worked the day Resident #1 hit Resident #2 in the head, but she did not witness it. She said she thought the altercation was over a female resident. She said Resident #1 and Resident #2 continued to be roommates after the incident and during the survey. Nursing notes dated 06/10/16 at 10:00 a.m., indicated Resident #1 was restless and went out the back door, setting off the alarm. Nursing notes dated 06/10/16 at 11:00 a.m., indicated Resident #1 was moving a table and chairs. Resident #1 remained anxious and restless, but was not physically combative. Nursing notes dated 06/18/16 at 1:40 p.m., indicated Resident #1 was pacing and went through other residents things in the common area. Resident #1 attempted to get in the closet across from the restroom, tried to grab others' food at times. A care plan last updated 06/21/16 indicated Resident #1 required [MEDICAL CONDITION] medications due to his [MEDICAL CONDITION]. Interventions included administer [MEDICAL CONDITION] medications as ordered, complete behavior monitoring, noting behavior, intervention, and effectiveness. Confer with doctor for dose reduction and side effects. Resident #1 did not have a care plan that addressed his aggressive behaviors. Nursing notes dated 06/22/16 at 10:45 a.m., indicated Resident #1 wandered around the secure unit. A physical therapist said Oh, he just shoved her across the floor. Resident #3 was noted to be on the floor. Resident #1 walked to the activity desk, picked up the desk, put it down, and punched the desk. Nursing notes dated 06/22/16 at 10:45 a.m., indicated Resident #3 was lying on her back on the floor after being pushed to the floor by Resident #1. Resident #3 complained of severe pain to her left arm, left shoulder, and coccyx. There was noted protrusion of Resident #3's left clavicle. Resident #3 was unable to move her left arm. Resident #3 had a hematoma to the right side of the back of her head. EMS was called and transferred Resident #3 to the ER. An x-ray taken on 06/22/16 at 2:03 p.m., indicated Resident #3 had a fracture and displacement to her left upper arm bone. During an interview on 06/23/16 at 5:38 a.m., LVN B said on 06/22/16, Resident #1 pushed Resident #3 to the ground and it was witnessed by a physical therapist. She said Resident #3 broke her arm, but she was returned to the secure unit the same day. Resident #3 had an appointment with an orthopedic surgeon the following week. During an interview on 06/23/16 at 9:26 a.m., PT G said she was at the nursing station in the secure unit, talking to a resident when the incident occurred between Resident #1 and Resident #3. She said out of the corner of her eye she saw Resident #1 use both of his hands and push Resident #3 to the floor. She said Resident #3 landed on the floor and slid across the floor before coming to a stop. She said she did not see the 2 residents have any kind of interaction before the incident. During an observation and interview on 06/23/16 at 8:25 a.m., Resident #3 was sitting on the side of her bed with her left upper arm wrapped in an elastic bandage from her shoulder to her elbow. She was unable to answer questions appropriately. Nursing notes dated 06/22/16 indicated Resident #1 was placed on one-on-one supervision after the incident with Resident #3. Resident #1 remained restless and wandered in and out of other residents' rooms. He removed cushions from the furniture and played with them and he was talking to a person who was not visible. During an interview on 06/23/16 at 11:42 a.m., the administrator said after the incident with Resident #1 and Resident #3 on 06/22/16, Resident #1 was placed on one-on-one supervision. During an observation on 06/23/16 at 5:29 a.m., Resident #1 came out of his room wearing boxer shorts and a tee shirt. He was confused and mumbled words to CNA A. CNA A told Resident #1 to go back to his room and she would help him get dressed in a little bit. CNA A continued to walk down the hall and Resident #1 went back to his room alone. His roommate, Resident #2 was lying in his bed with his eyes closed. Observations on 06/23/16 from 6:58 a.m. to 7:58 a.m. indicated the following: *at 6:58 a.m., Resident #1 was in his room with his roommate, Resident #2, total of 6 residents in the common area, staff were in residents' rooms for 8 minutes; *at 7:06 a.m., CNA C brought another resident to common area in her wheelchair, left to get another resident dressed; *at 7:08 a.m., CNA C brought another resident to common area in her wheelchair, left to get another resident; *at 7:09 a.m., 8 residents in common area, staff were in residents' rooms for 7 minutes; *at 7:17 a.m., 2 more residents walked into the common area, total of 10 residents in common area, Resident #1 in his room; *7:19 a.m., CNA C brought another resident to the common area in her wheelchair, left of get another resident, total of 11 residents in the common area; *at 7:35 a.m., Resident #1 walked from his room into the common area alone and sat down in a chair; *at 7:42 a.m., LVN D and CNA C left the common area, 15 residents in the common area that included Resident #1 were left alone; *at 7:45 a.m., CNA C and CNA E took Resident #4 to the bathroom, 17 residents in common area that included Resident #1 were left alone for 8 minutes; *at 7:53 a.m., CNA C and CNA E brought Resident #4 back to her geri chair and pulled her to the table, RN F entered the secure unit; *at 7:58 a.m., 2 more residents walked into the common area, total of 19 residents in common area that included Resident #1; *at 8:00 a.m., Resident #1 got up from his chair and walked across the common area and sat down at a table with Resident #2 to eat breakfast. He received his breakfast tray and began to eat. During an observation on 06/23/16 at 10:28 a.m., CNA E walked Resident #3 to the common area. Resident #3 sat down at a dining table and began to work a puzzle. Resident #1 was sitting on the other side of the unit in a chair talking to Resident #2. There were no staff in the immediate area. During an observation on 06/23/16 at 10:50 a.m., Resident #3 was sitting at the dining table facing the window and her back was towards the residents in the common area. Resident #1 got up from his chair and quickly walked across the common area towards Resident #3. Resident #3 did not see Resident #1 walking towards her. CNA E ran towards Resident #1 and asked him where he was going. Resident #1 said he wanted to go outside and continued to watch Resident #3. CNA E told Resident #1 it was hot outside and redirected him to the other side of the common area. During an observation on 06/23/16 at 11:28 a.m., Resident #1 paced around the secure unit and walked by Resident #3, who was sitting with her family member. Resident #1 moved chairs around the dining tables, attempted to pick up a dining table, picked up a wet floor sign, attempted to open a closet door, and picked up a notebook from the medication cart and held it under his arm. CNA E asked Resident #1 to put the book down and he sat the book down on the medication cart after being asked several times. During an interview on 06/23/16 at 11:30 a.m., CNA E said Resident #1 paced around the secure unit, picked up items, and was restless 06/22/16 before the incident with Resident #3. During an observation on 06/23/16 at 11:32 a.m., Resident #1 walked down the hall, stopped three times, and scratched at the floor. He walked back to the common area and looked out the window by the nursing station. During an interview on 06/23/16 at 11:42 a.m., the administrator said two CNAs were scheduled on each shift for the secure unit. He said a nurse was scheduled 8:00 a.m. to 5:00 p.m. on the secure unit and from 5:00 p.m. to 8:00 a.m., one nurse worked the secure unit and a hall outside the secure unit. During an interview on 06/23/16 at 12:33 p.m., RN F, CNA C, and CNA E said Resident #1 was not being supervised one-on-one by staff on the morning of 06/23/16. They said they were in residents' rooms getting residents up and dressed for breakfast. During an interview on 06/23/16 at 12:42 p.m., RN F and CNA C said they did not know Resident #1 was supposed to be on one-on-one supervision on 06/23/16. During an interview on 06/23/16 at 12:43 p.m., CNA E said she knew on 06/22/16 that Resident #1 was supposed to be on one-on-one supervision on 06/23/16. CNA E said one-on-one supervision meant to stay with Resident #1 at all times, but she needed to get other residents up and ready. The undated Abuse/Neglect Policy indicated in the area of resident-to-resident abuse, the facility will immediately protect the resident being abused and all other residents in the facility. The facility would monitor the perpetrator one-on-one to protect all other residents until the time of discharge. The administrator was notified on 06/23/16 at 12:49 p.m., an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on 06/23/16 at 5:19 p.m. and included: POR 6/23/16 Free State Crestwood Nursing and Rehabilitation Please accept this as the Plan Of Removal How will the facility correct the deficient practice for those residents identified in the deficiency? (Local hospital) has accepted (Resident #1) for medication evaluation and adjustments. (Resident #1) was discharged from the facility on 6/23/16 at 3:30 p.m. Spouse and attending physician have been notified of transfer. Each resident on secured unit has been interviewed and asked about their safety and /or concerns of being harmed. No negative responses reported. Staff will be in serviced on Abuse and Neglect along with One to One Monitoring Policy which includes how to identify escalating or aggressive behaviors on 6/23/16. Complete a Behavior risk assessment of all residents on the secure unit. All residents on the secure unit will be assessed from Head to toe for injury. Updated One to One Policy as of 6/23/16. How will the facility identify those at risk for similar deficient practice? Residents on secured unit, due to the disease process, have the potential to be effected. Resident behavior risk assessment to be completed prior to admission and quarterly thereafter. What will be done to prevent the deficient practice from recurring? All secured unit staff will be in-serviced on the Abuse/Neglect policy and will demonstrate proficiency through return demonstration of Abuse and Neglect and One to One in servicing prior to returning to their current positions within the secured unit by 6/23/16 by 11:00 pm. Any staff away from facility will be in serviced prior to beginning working the secured unit. How will the facility monitor its own corrective action? Nursing Administration will monitor by doing compliance rounds. Quality of Life representatives will monitor their assigned residents for health and safety issues and report to the Administrator at scheduled morning QA meeting. The process improvement plan will be reviewed monthly at QAPI team. In service training will continue to be done on hire of all new fac. staff. (sic) On 6/24/16 the surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: One physical therapist, 3 CNAs, 2 RNs, 1 medical records staff, and 1 LVN (ADON) who worked on the secure unit were interviewed and said they were in-serviced about abuse/neglect, one on one supervision, how to identify escalating behaviors, reporting to oncoming staff regarding individual resident requirements, and what to report. They also said they understood that it did not require a physician order [REDACTED]. The policy for one-on-one supervision was reviewed and was changed to include that a resident on one-on-one supervision would never be out of the staff's line of sight and would be evaluated by a nurse at least every shift. Resident #1 was discharged to a local behavioral hospital on [DATE]. The revised assessments for all residents on the secure unit were reviewed and included information for any at risk for displaying aggressive behaviors; none were noted. On 06/24/16 at 11:15 a.m., the administrator, executive director, corporate nurse, and president of divisions were informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The resident roster dated 06/23/16 indicated there were 23 residents on the secure unit.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained free of accident hazards for 1 or 5 residents reviewed for hazards. (Resident #1) Resident #1 had a history of [REDACTED]. Resident #1 had extensive bruising and a broken rib on 6/29/15. The facility did not have interventions in place to prevent continued injury. This deficient practice could place 27 residents with behavior health care needs at risk for injury. Findings included: Consolidated physician order [REDACTED].#1 was an [AGE] year old female, admitted on [DATE], with [DIAGNOSES REDACTED]. Orders indicated she was prescribed aspirin (blood thinner) 81 milligrams (mg) once daily and Plavix (blood clot inhibitor) 75 mg once daily. She also had an order for [REDACTED]. An MDS dated [DATE] indicated Resident #1's cognitive status was severely impaired. She rejected care 1 to 3 days a week, required extensive assistance of two people for bed mobility, and required two person physical assist for transfers. The MDS indicated transfer bars were not used. A care plan last updated 6/10/15 indicated Resident #1 was at risk for skin integrity issues due to decreased mobility and positioning. One of the interventions was transfer bars to the bed as an enabler to turn and reposition. An ADL care plan dated 6/1/15 indicated Resident #1 required extensive assist with ADL functions with two or more people. An incident report dated 5/19/15 indicated, at 8:30 a.m., an aide provided care to Resident #1 and reported a skin injury on the side of the lower right arm. The report indicated the resident has a history of hitting the transfer bars and over bed table. The report indicated the resident's arms were wrapped and the transfer bars were padded. An incident report dated 6/27/15 indicated, at 9:15 p.m., an aide entered Resident #1's room and the resident became upset. Resident #1 banged her right arm on the transfer bars causing a V shaped skin tear, approximately 4 centimeters (cm) with moderate bleeding noted; bruising was noted around the wound about 6 cm in diameter, with various bruises on the arm noted. During an observation and interview on 7/15/15 at 8:50 a.m., Resident #1 had bruises on the right hand with a bandage on the right arm below the elbow. ADON A said it was a skin tear. The upper arm had a large bruise about the size of an orange. The left hand had a large bruise and around the left arm pit was a faded yellow bruise. The right shoulder, above the breast, had a large raised area about the size of half a grapefruit that also had a faded yellowish bruise. Under the right breast was bruising and down the right side from the end of the breast area to the beginning of the brief was a purple bruise about an inch and a half to two inches wide. ADON A said Resident #1 does not get up. Resident #1 responded appropriately to questions but would not respond to how she got the bruises. During an observation on 7/15/15 at 11:55 a.m., Resident #1's transfer bars were not padded and could be taken off the bed. Nursing notes for Resident #1 indicated: * On 6/18/15 at 1:30 p.m., Resident #1's husband was upset about a small skin tear on her arm. He said he was tired of the nightshift cutting her up. * On 6/24/15 at 9:00 a.m., the hospice aide attempted to provide care to Resident #1. Resident #1 was cursing, screaming, hitting, scratching at aid and told to get the H out and the hospice aide left. At 10:00 a.m., two aides were able to provide incontinent care; Resident #1 continued to hit, scratch, and curse staff. *On 6/27/15 at 9:15 p.m., an aide entered Resident #1's room to perform incontinent care on Resident #1. She became upset and banged her right arm on the transfer bar. There was moderate bleeding noted, the area was cleaned and stei-strips were applied with a dry dressing. *On 6/29/15 at 2:00 a.m., Resident #1 continued combative behaviors, swinging her arms and grabbing staff clothes, necklaces, stethoscopes, cursing and refusing care. The staff left the room and came back with several attempts, she did allow care. A Weekly Skin Integrity Review sheet dated 6/29/15 indicated Resident #1 had four bruises to the left lower legs which measured 3.5 x 4 cm and appeared blue to yellow in color, a bruise which measured 4.5 x 3 cm and appeared blue to yellow, a bruise which measured 6 x 1 cm and appeared purple, and one bruise to the left knee which measured 2 x 4 cm and appeared blue to yellow. There was one hematoma to the right lower leg which measured 3 x 3.3 cm. Resident #1 had a bruise to the middle chest which measured 9 x 10 cm and appeared yellow to purple, a bruise to the right breast, side and back which measured 15 x 22 cm and appeared dark purple to yellow, and swelling to the upper right chest. A Provider Investigation Report dated 6/30/15 indicated Resident #1's husband alleged the facility staff abused his wife due to the bruising. The description of the injury was yellowish brown discoloration (old bruising) to the right breast and right rib area. The report indicated there was minimal bluish bruising below the right breast, and minimal swelling above the right breast. The last weekly skin assessment was noted as completed on 6/22/15 by the ADON and no bruising was noted at that time which indicated the injury occurred between 6/22 and 6/29/15. The report indicated staff were interviewed, but were unable to describe a specific event where the injury occurred. Resident #1 was sent to the hospital on [DATE] for an assessment of the right breast and it was diagnosed as a hematoma. The report indicated the cause of the injury was likely due to a Hoyer lift for transfers and a draw sheet would be utilized for all future transfers. An x-ray report dated 6/29/15 indicated Resident #1 had an irregularity in the left posterior 8th rib; likely a sub-acute rib fracture. The study was compared to a prior study dated 10/18/14; the fracture was not visible on the prior study. During an interview on 7/15/15 at 8:05 a.m., the administrator said Resident #1 had an injury of unknown origin reported to them by the hospice aide. He said they could not determine where the bruises came from and the husband had concerns of abuse. He said they reported the incident to the state agency. He said Resident #1 had bruises on her chest, side, both arms, and under her breast; she is a total care resident. During an interview on 7/15/15 at 8:35 a.m., the hospice aide said she worked with Resident #1 on 6/26/15 and the resident had a few scattered bruises on her arms as usual. She said on 06/29/15, when she came to give Resident #1 a shower, the resident had a large bruise on her breast and all over her arms; below her right breast and down her side. The hospice aide said Resident #1 will curse, hit, and spit on staff if she does not want to be bothered. She said after the bruising, she seemed to be different, and more cooperative to care. The hospice aide said Resident #1 would not say anything when asked what happened to cause the bruising. During an interview on 7/15/15 at 8:50 a.m., LVN B said Resident #1 only gets up a couple of times a week, maybe. LVN B said she was informed of the bruises and swelling of Resident #1 on 6/29/15. She said the area on her breast has gone down some and the resident gets frequent bruising. She said Resident #1 took Plavix and aspirin and she is combative with care. She said the resident had the transfer bars, but does not use them. LVN B said Resident #1 has her days/moments when she is able to voice her needs and others when she is not. During an interview on 7/15/15 at 8:55 a.m., LVN C said Resident #1 had bruises and no one knew how she got them. LVN C said Resident #1 will swing her arms around and hit the bar, fight and spit on staff during care. She said on 7/2/15 the resident was sent to the hospital to see what the area was over her right breast and the hospital diagnosed it as a hematoma. During an interview on 7/15/15 at 9:03 a.m., CNA D said she was not aware how Resident #1's bruising occurred but it was not there on 6/26/15. She said Resident #1 was total care with all ADLs. She said the resident would fight, and she will also spit on staff during care. During an interview on 7/15/15 at 9:07 a.m., CNA E said she was in the building when the hospice aide reported the bruising but she had no idea how Resident #1 received the injury. She said the last time she worked with Resident #1 she did not have the bruising. During an interview on 7/15/15 at 9:10 a.m., CNA F said she worked 6/28/15 with Resident #1. She said Resident #1 did not get up that day and she did not have the bruises. During an interview on 7/15/15 at 10:49 a.m., the DON said she assessed Resident #1 on 6/29/15 and noted old bruises. She said her investigation did not turn up anything unusual. She said they found the fracture on the left rib and the bruise above her right breast was determined to be a hematoma. She said the primary physician discontinued aspirin and Plavix. The DON said she did not know why Resident #1 had transfer bars. During an interview on 7/15/15 at 11:00 a.m., ADON G said Resident #1 cannot hold on to the transfer bars. She said Resident #1 will become combative and swing her arms. ADON G said she saw Resident #1 hit her hands on the transfer bars in the past. ADON G said she completed a full skin assessment of Resident #1 on 6/22/15 and noted some bruising on her arms as usual. During a telephone interview on 7/15/15 at 12:06 p.m., LVN H said on 6/28-6/29/15 on the 10 p.m. to 6 a.m. shift, Resident #1 was combative. She said she was in the room with her staff when incontinent care was provided on two occasions and she did not see any mistreatment of [REDACTED]. During an interview on 7/15/15 at 1:17 p.m., a physical therapist said Resident #1's transfer bars needed to be removed because she does not use them, they are not padded, and they are at least partly responsible for some of Resident #1 bruising on her arms. She said her recommendation would be body pillows to keep the resident from rolling out of the bed, if she does roll. The facility CMS 672 dated 7/15/15 indicated there were 27 residents with behavioral healthcare needs.

Based on interview and record review, the facility failed to provide supervision to prevent an accident for 1 of 8 residents reviewed for accidents. (Resident #1) Resident #1 was assessed as exhibiting wandering behaviors and required supervision and redirection for wandering behaviors. When her wandering behaviors changed, no other interventions were put into place to reduce the resident's risk for injuries. Resident #1 wandered into Resident #2's room. Resident #2 pushed Resident #1 causing her to fall and break her hip and knee. This failure contributed to Resident # 1's hospitalization for a fractured hip and knee. This failure could place 3 residents who require supervision for wandering at risk for accidents or injury. Findings included: Resident #1 Physician orders [REDACTED].#1, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 had memory issues, ambulated independently, and exhibited wandering behaviors. A care plan revised 05/28/14 indicated Resident #1 wandered around the facility and required redirection as necessary. No other interventions were recommended or implemented. Resident #2 Physician orders [REDACTED].#2, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #2 exhibited psychosis. An Incident Report dated 05/23/14 indicated on 05/23/14 at 2:30 a.m., Resident #1 wandered into Resident #2's room. Resident #2 pushed Resident #1 and she fell in the hallway. Resident #1 was unable to stand afterwards and was sent to the emergency room for evaluation. A radiology report dated 05/23/14 indicated Resident #1 had fractures of the left hip and knee. During an observation on 06/01/14 at 3:00 p.m. and on 06/02/14 at 8:30 a.m., Resident #1 was lying in bed not able to get up. During an interview on 06/02/14 at 11:45 a.m., CNA A said Resident #1 wandered the halls on the 10 p.m. to 6 a.m. shift. CNA A said (on 05/23/14) she heard Resident #2 call out for staff. She said she witnessed Resident #2 push Resident #1 onto the floor. She said Resident #1 complained of knee pain and was sent to the emergency room . During an interview on 06/02/14 at 1:40 p.m., the DON said Resident #1 had wandering behaviors from the time of her admission, but she recently changed her pattern. The DON said Resident #1 had changed to wandering at night, but no different interventions were implemented after this change occurred to protect the resident from accidents or injuries. She said Resident #1's family refused to allow the resident to reside on the facility's secure unit. She said Resident #1 wandered into Resident #2's room one night and Resident #2 pushed her down to the floor. The DON said Resident #1 sustained a fractured hip and knee and was immobilized due to her injuries. During an interview on 06/02/14 at 1:40 p.m, the DON said 3 residents exhibited wandering behaviors.