Every finding on record at Dyersburg Health and Rehabilitation Center

Based on policy review, medical record review, observation, and interview, the facility failed to provide an environment free of hazardous materials for 1 of 68 (Resident #52) sampled for accident hazards. The findings include: 1. Review of the facility revised policy titled, Environmental Services Safety Procedures, dated 3/1/2025, revealed .It is the policy of this facility to ensure general safety procedures.Staff will ensure equipment ( .cords, ladders, or chemicals) is properly stored and not left unattended in areas that are accessible to residents. 2. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Anxiety, and Seizures. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #52 did not have a Brief Interview for Mental Status (BIMS) score completed and had modified independence for cognitive skills for daily decision making. Observation in Resident #52's room on 12/8/2025 at 9:47 AM and 10:57 AM, revealed a closed canister of Named Brand insect killer on the counter beside Resident #52's sink. During an observation and interview in Resident #52's room on 12/8/2025 at 10:59 AM, Licensed Practical Nurse (LPN) B was asked if the canister of insect killer should be left unsecured and unattended in a resident's room. LPN B stated, No, it shouldn't be in the room at all. During an interview on 12/11/2025 at 9:55 AM, the Director of Nursing (DON) was asked if a canister of insect killer should be left unsecured and unattended in a resident's room. The DON stated, No.

Based on policy review, medical record review, observation, and interview, the facility failed to follow physician's orders and provide care and services for oxygen therapy for 1 of 4 (Resident #7) sampled residents reviewed for respiratory care. The findings include: 1. Review of the undated facility policy titled, Oxygen Administration, revealed .Oxygen is administered to residents who need it, consistent with professional standards of practice.Oxygen is administered under orders of a physician. Review of the undated facility policy titled, Medication Administration, revealed .Medications are administered by licensed nurses.as ordered by the physician. 2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Paraplegia, Epilepsy, Tracheostomy, Muscle Weakness, and Chronic Obstructive Pulmonary Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 was severely cognitively impaired, coded for oxygen therapy, and Tracheostomy Care. Review of the Physician's Orders dated 10/23/2025, revealed, .Oxygen at (2) liters via [by way of] (Trach) continuous every shift. During an observation in Resident #7's room on 12/8/2025 at 9:21 AM and 2:51 PM, and on 12/19/25 at 9:21 AM and 2:51 PM, revealed Resident #7 was receiving 4 liters of oxygen per trach via oxygen concentrator. During an observation and interview in Resident #7's room on 12/9/2025 at 3:58 PM, Licensed Practical Nurse (LPN) A verified the oxygen concentrator was set on 4 liters. LPN A was asked what Resident #7 oxygen concentrator should be set at. LPN A reviewed the Physician's Order and stated, It should be 2 liters. During an interview on 12/11/2025 at 9:55 AM, the Director of Nursing (DON) was asked if oxygen should be administered at the rate prescribed by the physician. The DON stated, Yes .

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure that residents received the necessary treatment and services consistent with professional standards of practice to promote healing when the facility failed to document wound care treatments for 1 of 3 (Resident #1) sampled residents reviewed for pressure ulcers. The findings include: 1. Review of the facility policy titled, Wound Treatment Management, dated 12/3/2024, revealed .Wound treatments will be provided in accordance with physician orders .Treatments will be documented on the Treatment Administration Record . 2. Review of medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region, Pressure Ulcer of Sacral Stage 4, and Paraplegia. Review of the Physician's Order dated 5/11/2024, revealed .CLEAN L [left] GROIN W/ [with].SKIN PREP PERIWOUND MIX SSD [silver sulfadiazine a topical antibiotic] CREAM AND CRUSHED FLAGYL [antibiotic used to treat bacterial infections] APPLY TO WOUND BED PACK W/ DANKINS [antiseptic solution] SOAKED KERLEC [KERLEX gauze based bandage] OVER W/ ABD [abdominal] PAD AND SECURE W/TAPE ONCE DAILY AND PRN [as needed]. Review of the Treatment Administration Record (TAR) dated May 2024, revealed that treatments were not documented on 5/16/2024, 5/22/2024, 5/24/2024, 5/27/2024, and 5/30/2024.Review of the TAR dated June 2024, revealed treatments were not documented on 6/5/2024, 6/6/2024, 6/10/2024, 6/14/2024, 6/15/2024, 6/19/2024, 6/28/2024, 6/29/2024, and 6/30/2024. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #1 was cognitively intact. Resident was assessed for a Stage 4 Pressure Ulcer. Review of TAR dated July 2024, revealed treatments were not documented on 7/3/2024, 7/4/2024, 7/6/2024, 7/10/2024, 7/11/2024, 7/21/2024, 7/25/2024. During an interview on 10/6/2025 at 3:54 PM, the Director of Nursing (DON) was asked, if Resident refuses wound care, should the refusal be documented. The DON stated, Yes. The DON was asked if the TAR should have any blank days for wound care. The DON stated, No, it should be documented completed unless it was refused and then it should be documented as refused.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure respiratory equipment was stored properly and covered for 4 of 7 sampled residents (Resident #13, #28, #41, and #136) reviewed for respiratory care and 2 of 2 nurses (Licensed Practical Nurse (LPN) #3 and #4) failed to provide proper respiratory care for 1 of 1 sampled resident (Resident #22) observed for [CONDITION(S)] care. The findings include: Review of the facility's policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised 10/2010, revealed .Store in a plastic bag with the resident's name and the date on it . Review of the medical record, revealed Resident #13 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in the resident's room on 6/28/2021 at 8:56 AM, 11:52 AM, and 4:00 PM, on 6/29/2021 at 8:18 AM, and on 6/30/2021 at 8:14 AM, revealed Resident #13's [CONDITION(S)] machine sitting on the nightstand with the tubing and mask attached. The mask was lying uncovered on top of the [CONDITION(S)] machine. Review of the medical record, revealed Resident #41 was admitted to the facility on [DATE], with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of the resident's room on 6/28/2021 at 9:00 AM and 10:41 AM, on 6/29/2021 at 8:21 AM, and on 6/30/2021 at 8:13 AM, revealed Resident #41's nebulizer machine sitting on the nightstand with the tubing and mask attached. The mask was lying uncovered on top of the nebulizer machine. Review of the medical record, revealed Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in the resident's room on 6/28/2021 at 9:10 AM and 10:43 AM, on 6/29/2021 at 8:24 AM, and on 6/30/2021 at 8:18 AM, revealed Resident #28's [CONDITION(S)] machine sitting on the nightstand with the tubing and mask attached. The tubing was hanging out of the nightstand drawer and the mask was lying in the drawer uncovered with other personal items. Review of the medical record, revealed Resident #136 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in the resident's room on 6/30/2021 at 10:15 AM and 1:34 PM, revealed Resident #136's oxygen concentrator machine positioned at the right side of the head of the bed. The binasal cannula oxygen tubing was lying uncovered with no protective barrier on top of the oxygen concentrator. During an interview on 6/30/2021 at 9:30 AM, the Director of Nursing (DON) confirmed respiratory equipment should be stored in a plastic bag when not in use. During an interview on 6/30/2021 at 10:35 AM, LPN #2 confirmed that respiratory equipment should be stored in a plastic bag when not in use. Review of the facility's policy titled, [CONDITION(S)] Care, revised 8/2013, revealed .Sterile gloves must be used during aseptic procedures .Wash hands .Put exam gloves on both hands .Remove supplemental oxygen mask .Remove old dressing. Pull soiled gloves over dressing and discard into appropriate receptacle .Wash hands .Open [CONDITION(S)] cleaning kit .Set up supplies on sterile field .Put on sterile gloves .remove the inner cannula .Remove and discard gloves .wash hands and put on fresh gloves .Replace the cannula . Review of the medical record, revealed Resident #22 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Order Review History Report dated 6/30/2021, revealed .[CONDITION(S)] [[CONDITION(S)]] care every shift .Change inner [CONDITION(S)] cannula daily . Observation in the resident's room on 6/29/2021 at 2:00 PM, revealed LPN #3 preparing to perform [CONDITION(S)] care on Resident #22. LPN #3 washed her hands, donned gloves, positioned the over bed table next to the bed, obtained supplies from the top of the bedside table, and set up the supplies on the over bed table without placing a sterile barrier. LPN #3 removed a bottle of sterile water from the [CONDITION(S)] care tray, loosened the top, placed the bottle on the over bed table, removed her gloves, failed to perform hand hygiene, and donned a pair of sterile gloves. LPN #3 then picked up the sterile water bottle, poured water into a sterile suction tray, obtained a suction catheter from the tray, and suctioned Resident #22. LPN #3 then removed her gloves, failed to perform hand hygiene, donned sterile gloves, securing the outer neck plate with her left hand, removed the [CONDITION(S)] inner cannula with her right hand and without changing gloves and performing hand hygiene, picked up the new inner cannula with her right hand and inserted it. LPN #3 then picked up the [CONDITION(S)] brush and swabs from the sterile [CONDITION(S)] care tray, placed the brush back into the tray and poured [MEDICATION(S)] and sterile water into the tray compartment with the brush, then dipped the swabs and sterile gauze into the peroxide/water mixture and cleaned around the [CONDITION(S)] stoma. LPN #3 then cleaned around the stoma with saline soaked gauze, dried the site, replaced the [CONDITION(S)] collar, placed a split gauze around the [CONDITION(S)], cleaned up the supplies, picked up a piece of paper off of the floor and placed it in the trash, went to the other side of the bed and repositioned the oxygen tubing, removed her gloves, washed her hands and exited the room. Observation in the resident's room on 6/30/2021 at 4:51 PM, revealed LPN #4 preparing to perform [CONDITION(S)] care. LPN #4 washed her hands, placed the [CONDITION(S)] care supplies on the over bed table, donned gloves, disconnected the oxygen mask from the oxygen tubing and placed it in the trash, removed her gloves, failed to perform hand hygiene, then opened the [CONDITION(S)] care tray and donned a pair of sterile gloves, using the sterile glove package as barrier to lay supplies on. LPN #4 then poured peroxide and sterile water into the plastic tray, moistened the [CONDITION(S)] brush and cleaned around the outer neck plate, removed the old drain sponge from the [CONDITION(S)] and placed it in the trash, cleaned around the outer neck plate with swabs and dried with gauze, secured the outer neck plate with her left hand and removed the inner cannula with her right hand, then without changing gloves or performing hand hygiene, picked up the sterile replacement cannula, holding the inner cannula in both hands and touching the area to be inserted into the [CONDITION(S)]. LPN #4 explained the procedure to Resident #22, then inserted the cannula into the [CONDITION(S)], connected a new oxygen mask, changed the neck ties, placed the oxygen mask over the [CONDITION(S)], cleaned up her supplies, removed her gloves, washed her hands and exited the room. During an interview on 6/30/2021 at 9:15 PM, the DON confirmed that staff should follow the facilty policy and use hand hygiene between glove changes when performing [CONDITION(S)] care.

Based on policy review, Maintenance Supervisor job description, User's Information Manual, review of the maintenance supervisor's logbook documentation, review of the facility's census and condition (Centers of Medicare Medicaid Services (CMS) 672), observation and interview, the facility failed to ensure the environment was free from accident hazards when hot water temperatures were measured from 116 degrees Fahrenheit (F) to 144 degrees F in 48 of 63 resident rooms (room [ROOM NUMBER], #101, #102, #103, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, #114, #115, #116, #210, #211, #212, #214 #217, #218, #220, #301, #302, #304, #305, #306, #307, #308, #309, #310, #311, #313, #314 #315, #317, #318, #319, #400, #401, #402, #403, #404, #405, #406, and #407). The failure of the facility to maintain safe hot water temperatures placed the residents with access to these rooms in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment or death to a resident). The Administrator and Director of Maintenance were notified of the Immediate Jeopardy for F-689 on 1/12/2020 at 7:39 PM, in the Conference room. The facility was cited F-689 at a scope and severity of L, which is Substandard Quality of Care. The extended survey was conducted on 1/16/2020. The Immediate Jeopardy was effective 11/30/2019 through 1/21/2020. An acceptable Removal Plan, which removed immediacy of the jeopardy, was received on 1/21/2020 at 6:05 PM. The corrective actions were validated onsite by the surveyors on 1/21/2020 through 1/22/2020. The findings include: Review of the facility's policy titled, Water Temperatures, Safety, dated 12/2009, showed, .Tap water in the facility shall be kept within a temperature range to prevent scalding of resident. 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperature of no more than 120 degrees Fahrenheit, to the maximum allowable temperature per state regulation. 2. Maintenance staff shall conduct periodic tap water temperature checks 3. If at any time water temperatures feel excessive to the touch (i.e (that is), hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to the immediate supervisor. 4. Direct-care staff shall be informed of risk factors for scalding/burns that are more common in the elderly . Review of the Director of Maintenance job description dated 7/23/2019, and signed by the Director of Maintenance and the Administrator, showed, .performs maintenance and repair of physical structures of buildings by performing the following duties .6. Test facility hot water system on regular basis to evaluate water temperatures in essential locations of facility. Monitors acceptable range of temperatures and immediately starts repairs to eliminate hazards for facility residents, staff and others .16. Completes required documentation and record keeping of maintenance activities. Audits records of maintenance staff for accuracy and completeness .24. Attends continuing professional education programs and inservice education .SUPERVISORY RESPONSIBILITIES 1. Manages employees in the Maintenance Department. Is responsible for the over all direction, coordination and evaluation of this unit .Knowledge and experience in plumbing repairs such as water and heating .Informing: Provides the information people need to know to do their jobs . The manufacturer User's Information Manual Condensing Water Heater (advanced condensing tankless water heater) dated 5/23/2019, page 4, Safety Information showed, .DANGER HOT BURN .If your household has .elderly or disabled residents, consider using a lower temperature setting .Water Temperature 140 (symbol for degree) .Time in which .can suffer a full thickness (3rd degree) burn .1 second. Water Temperature 130 (symbol for degree) .Time in which .can suffer a full thickness (3rd degree) burn .10 second. Water Temperature 120 (symbol for degree) .Time in which .can suffer a full thickness (3rd degree) burn .10 minutes . No other information was provided on the other hot water heaters in the facility. Review of the facility maintenance log book showed no documentation water temperature checks were performed. Review of the RESIDENT CENSUS AND CONDITION OF RESIDENTS, dated 1/12/2020, showed 90 residents residing in the facility, with 58 of those residents being dependent on staff for bathing. The surveyors' thermometers were calibrated before water temperatures were obtained. The surveyor's observations of the hot water temperatures in residents' rooms on 1/12/2020 beginning at 10:51 AM, showed the following: a. room [ROOM NUMBER] was 135 degrees F. b. room [ROOM NUMBER] was 118 degrees F. c. room [ROOM NUMBER] was 128 degrees F. The surveyor's observations of the hot water temperatures in residents' rooms on 1/12/2020 beginning at 11:10 AM, showed the following: a. room [ROOM NUMBER] was 124 degrees F. b. room [ROOM NUMBER] was 130 degrees F. c. room [ROOM NUMBER] was 128 degrees F. d. room [ROOM NUMBER] was 130 degrees F. e. room [ROOM NUMBER] was 130 degrees F. f. room [ROOM NUMBER] was 130 degrees F. g. room [ROOM NUMBER] was 130 degrees F. h. room [ROOM NUMBER] was 130 degrees F. i. room [ROOM NUMBER] was 126 degrees F. j. room [ROOM NUMBER] was 126 degrees F. k. room [ROOM NUMBER] was 126 degrees F. l. room [ROOM NUMBER] was 126 degrees F. m. room [ROOM NUMBER] was 130 degrees F. n. room [ROOM NUMBER] was 130 degrees F. o. room [ROOM NUMBER] was 124 degrees F. p. room [ROOM NUMBER] was 124 degrees F. q. room [ROOM NUMBER] was 126 degrees F. r. room [ROOM NUMBER] was 120 degrees F. s. room [ROOM NUMBER] was 120 degrees F. t. room [ROOM NUMBER] was 120 degrees F. u. room [ROOM NUMBER] was 116 degrees F. v. room [ROOM NUMBER] was 140 degrees F. w. room [ROOM NUMBER] was 116 degrees F. x. room [ROOM NUMBER] was 138 degrees F. y. room [ROOM NUMBER] was 136 degrees F. z. room [ROOM NUMBER] was 130 degrees F. aa. room [ROOM NUMBER] was 128 degrees F. bb. room [ROOM NUMBER] was 128 degrees F. cc. room [ROOM NUMBER] was 120 degrees F. dd. room [ROOM NUMBER] was 120 degrees F. During an interview conducted on 1/12/2020 at 1:34 PM, the Director of Maintenance confirmed there were no water temperature logs. The Director of Maintenance was asked if he checked the water temperatures. The Director of Maintenance stated, Not every day .we set the tankless water heaters .nothing can go wrong .it puts out the same temp (temperature) all the time .there's no way they could never have hot water . The Director of Maintenance was asked what the water temperature range had been. The Director of Maintenance stated, .I think they're at 130 .all are the same .never has there been any problems with hot water . The Director of Maintenance was asked if he knew what the water temperature coming out of the faucets might be. The Director of Maintenance stated, I know they can't be too hot or too cold .it can't get too hot that's why they suggested these units (tankless) .I don't think anyone has been writing it down (keeping logs) .this is all new to me .It can't get over 130 . The surveyor's observations of the hot water temperatures in residents' rooms on 1/12/2020 beginning at 2:12 PM, showed the following: a. room [ROOM NUMBER] was 120 degrees F. b. room [ROOM NUMBER] was 120 degrees F. c. room [ROOM NUMBER] was 120 degrees F. d. room [ROOM NUMBER] was 120 degrees F. e. room [ROOM NUMBER] was 118 degrees F. f. room [ROOM NUMBER] was 118 degrees F. g. room [ROOM NUMBER] was 120 degrees F. h. room [ROOM NUMBER] was 134 degrees F. i. room [ROOM NUMBER] was 130 degrees F. j. room [ROOM NUMBER] was 116 degrees F. k. room [ROOM NUMBER] was 144 degrees F. l. room [ROOM NUMBER] was 116 degrees F. m. room [ROOM NUMBER] was 138 degrees F. n. room [ROOM NUMBER] was 136 degrees F. o. room [ROOM NUMBER] was 130 degrees F. p. room [ROOM NUMBER] was 128 degrees F. q. room [ROOM NUMBER] was 128 degrees F. r. room [ROOM NUMBER] was 130 degrees F. s. room [ROOM NUMBER] was 120 degrees F. t. room [ROOM NUMBER] was 120 degrees F. u. room [ROOM NUMBER] was 126 degrees F. v. room [ROOM NUMBER] was 120 degrees F. w. room [ROOM NUMBER] was 120 degrees F. x. room [ROOM NUMBER] was 126 degrees F. y. room [ROOM NUMBER] was 126 degrees F. During an observation and interview conducted on 1/12/2020 beginning at 2:12 PM, the Director of Maintenance verified the water temperatures in room [ROOM NUMBER] was 134 degrees F and room [ROOM NUMBER] was 144 degrees F. He stated, This is a digital meat thermometer (the thermometer the Director of Maintenance was using). The Director of Maintenance confirmed the water heater was set at 120 degrees F. During an interview conducted on 1/12/2020 at 2:14 PM, the Administrator was asked if she checked water temperatures in the rooms periodically. The Administrator stated, Just do a spot check .a random room, twice a month . The Administrator was asked what she expected the hot water temperature to be. The Administrator stated, 120. Observation of a shared bathroom sink for room [ROOM NUMBER] and #406, on 1/12/2020 at 2:30 PM, showed a hot water temperature of 126 degrees F. During an interview conducted on 1/12/2020 at 2:54 PM, Registered Nurse (RN) #2 stated, .This side of the hall (even numbered rooms on the 400 Hall) takes some time for it to warm up, the other side (odd numbered rooms on the 400 Hall) is scorching hot . RN #2 was asked what she did when this occurred. RN #2 stated, We just adjust it at the faucet . During an interview conducted on 1/12/2020 at 7:40 PM, the Director of Maintenance was asked if he was aware of the water temperature regulations. The Director of Maintenance stated, I was not aware . The surveyor's observations of the hot water temperatures in residents' rooms on 1/12/2020 beginning at 8:07 PM, showed the following: a. room [ROOM NUMBER] was 126 degrees F. b. room [ROOM NUMBER] was 130 degrees F. c. room [ROOM NUMBER] was 124 degrees F. d. room [ROOM NUMBER] was 124 degrees F. e. room [ROOM NUMBER] was 137 degrees F. f. room [ROOM NUMBER] was 134 degrees F g. room [ROOM NUMBER] was 135 degrees F. h. room [ROOM NUMBER] was 139 degrees F. i. room [ROOM NUMBER] was 124 degrees F. j. room [ROOM NUMBER] was 123 degrees F k. room [ROOM NUMBER] was 129 degrees F. During an interview conducted on 1/12/2020 at 8:17 PM, the Director of Maintenance stated, .Every single water heater in this building we have turned down .this does not make sense .it goes from 124-139 (degrees F) . The surveyor's observations of the hot water temperatures in residents' rooms on 1/13/2020 beginning at 9:45 AM, showed the following: a. room [ROOM NUMBER] was 124 degrees F. b. room [ROOM NUMBER] was 126 degrees F. c. room [ROOM NUMBER] was 130 degrees F. d. room [ROOM NUMBER] was 126 degrees F. e. room [ROOM NUMBER] was 124 degrees F. f. room [ROOM NUMBER] was 124 degrees F. During an interview conducted on 1/13/2020 at 10:55 AM, the Director of Maintenance was asked what training he had as Director of Maintenance. The Director of Maintenance shook his head no and stated, I came from (Named non-long term care business) .I thought if I turned down the temperature everything would be good. When I turned down the large tank, I did not know the kitchen temperature would fall . The surveyor's observations of the hot water temperatures in residents' rooms on 1/13/2020 beginning at 5:56 PM, showed the following: a. room [ROOM NUMBER] was 122 degrees F. b. room [ROOM NUMBER] was 128 degrees F. c. Room # 306 was 125 degrees F. d. room [ROOM NUMBER] was 116 degrees F. e. room [ROOM NUMBER] was 123 degrees F. f. room [ROOM NUMBER] was 130 degrees F. g. room [ROOM NUMBER] was 130 degrees F. During an interview conducted on 1/13/2020 at 5:59 PM, the Regional Liaison verified water temperatures in room [ROOM NUMBER] was 116 degrees F, and room [ROOM NUMBER] was 123 degrees F using the facility's thermometer. During an interview conducted on 1/17/2020 at 6:19 PM, the Director of Maintenance was asked if the water temperatures were within range. The Director of Maintenance stated, It's a large building. We're trying to decide .what other people have done . Director of Maintenance was asked if he had any training from the facility. The Director of Maintenance stated, No, ma'am . During an interview conducted on 1/17/2019 at 7:54 PM, the Regional Administrator stated, We have determined the reason is because our demand (for hot water) is greater than our supply . During an interview conducted on 1/19/2019 at 1:21 PM, Administration was notified water temperatures were checked by the survey team reading below range. The Regional Administrator stated, They are continuing to work on the water temperature levels .The only thing they say they have left to fix is a valve. It can fluctuate so the temperature goes up and down . The surveyor's observations of the hot water temperatures in residents' rooms on 1/20/2020 beginning at 7:57 PM, showed the following: a. room [ROOM NUMBER] was 118 degrees F. b. room [ROOM NUMBER] was 120 degrees F. c. room [ROOM NUMBER] was 118 degrees F. The surveyor's observations of the hot water temperatures in residents' rooms on 1/21/2020 beginning at 8:29 AM, showed the following: a. room [ROOM NUMBER] was 116 degrees F. b. room [ROOM NUMBER] was 124 degrees F. c. room [ROOM NUMBER] was 128 degrees F. d. room [ROOM NUMBER] was 120 degrees F. e. room [ROOM NUMBER] was 126 degrees F. f. room [ROOM NUMBER] was 116 degrees F. During an observation and interview conducted on 1/21/2020 beginning at 8:36 AM, the Director of Maintenance verified water temperatures in room [ROOM NUMBER] was 128 degrees F, #309 was 128 degrees F, #318 was 120 degrees F, and #319 was 126 degrees F using his thermometer. The surveyor's observations of the hot water temperatures in residents' rooms on 1/21/2020 beginning at 8:49 AM, showed the following: a. Shared bathroom between rooms [ROOM NUMBERS] was 118 degrees F. b. Shared bathroom between rooms [ROOM NUMBERS] was 120 degrees F. The surveyor's observations of the hot water temperatures in residents' rooms on 1/21/2020 beginning at 6:09 PM, showed the following: a. room [ROOM NUMBER] was 118 degrees F. b. room [ROOM NUMBER] was 124 degrees F. c. room [ROOM NUMBER] was 128 degrees F. d. room [ROOM NUMBER] was 124 degrees F. e. room [ROOM NUMBER] was 124 degrees F. During an observation and interview conducted on 1/21/2020 at 6:10 PM, the Director of Maintenance verified the water temperatures in Rooms #308 was 124 degrees F, #309 was 128 degrees F, #318 was 124 degrees F, and #319 was 124 degrees F. The facility failed to ensure hot water temperatures were monitored, documented, and maintained below dangerous levels. The Director of Maintenance and the Administrator confirmed they had no documentation of water temperature checks prior to the survey team entering the facility. The failure of the facility to monitor and maintain safe hot water temperatures (water exceeding 115 degrees F) in 48 of 63 (76.19%) rooms, placed the residents residing in these rooms in Immediate Jeopardy. The survey team verified the Removal Plan by: The Administrator (who was terminated on 1/17/2020) and the Director of Maintenance completed 100% audit around 1:00 PM of all room sinks water temperatures to include shower temperatures on 1/12/2020. Immediate education was completed by the Director of Nursing and the Administrator to the maintenance staff on 1/13/2020. Education including safe hot water temperature range, how to test water temperatures, reporting abnormal findings or water temperature complaints to Administrator and Maintenance. Education also included the risk [MEDICAL CONDITION] severity of harm to the skin with potential for second or third degree burns. Administration purchased and placed calibrated thermometers on every unit to be used before providing a shower, whirlpool, or bed bath, temperature logs were placed on every unit for recording of water temperatures before baths. A Licensed plumber was called to further investigate hot water temperature controls. Currently, on 1/22/2020, the hot water that supplied the residents sinks was turned off, with the exception of the East Wing, where the temperatures were in compliance with the regulations. The staff were in-serviced to use the alternate water source until permanent solution was in place. The survey team interviewed the Director of Maintenance and staff on each shift and validated the education for safe water temperatures, water temperature logs were placed, plumber was onsite, and hot water was cut off at the residents sinks except on the East wing (#100 Hall) and staff in-serviced on using alternate water source. Employee Education Attendance Records were reviewed for employee signatures. 2. The Interim Administrator and Maintenance staff reviewed all rooms and showers within the facility. All residents who receive a bed bath, shower, or whirlpool tub bath temperatures will be documented and reviewed daily by the administration and nurse management. The survey team validated the shower logs were reviewed and monitored by Administration and maintenance staff and interviewed administrative staff. 3. The maintenance team will conduct daily shift water checks to ensure that all sinks, showers, and whirlpool tubs are at the correct temperature every day for a month, weekly x 4 months, biweekly x 2 months, and then monthly x 2. Audited records will be reviewed by the Risk Management/Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee. The survey team validated the education provided to staff by interviewing the staff, reviewing temperature logs where water temperatures were checked and Quality Assurance Performance Improvement (QAPI) committee member interviews were done regarding hot water safety. Noncompliance of F-689 continues at a scope and severity of F and remains at Substandard Quality of Care for the monitoring and effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, Director of Maintenance job description, personnel file review, medical record review, and interview, Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain and maintain the highest practicable well-being of the residents. Administration failed to provide oversight to monitor and provide a safe resident environment related to hot water temperatures, to provide training of staff to prevent [MEDICAL CONDITION] residents when water temperatures rose to dangerous levels, to ensure injuries of unknown origin which could be indicative of abuse were identified and investigated, to ensure resident sitters were screened and trained for abuse, and to ensure coordination of care between the interdisciplinary team (IDT) to identify and assess residents' nutritional status. Administration failed to continue implementation of the plan of correction after the complaint survey on 7/22/2019 where Abuse was cited at an Immediate Jeopardy level. The failure of Administration placed residents in 48 of 63 resident rooms (room [ROOM NUMBER], #101, #102, #103, #104, #105, #106, #107, #108, #109, #110, #111, #113, #114, #115, #116, #210, #211, #212, #214, #217, #218, #220, #301, #302, #304, #305, #306, #307, #308, #309, #310, #311, #313, #314, #315, #317, #319, #318, #319, #400, #401, #402, #403, #404, #405, #406, and #407) in Immediate Jeopardy when water temperatures reached the dangerous range of 116-144 degrees Fahrenheit (F). The failure of Administration placed Resident #12 and #64 in Immediate Jeopardy when staff did not identify and investigate injuries of unknown origin which could be indicative of abuse. The failure of Administration placed Resident #51 in Immediate Jeopardy when abuse training, screening, and background checks were not performed for sitters. The failure of Administration to ensure staff identified, assessed, and provided interventions for severe weight loss caused actual Harm to Resident #55 when Resident #55 sustained severe weight loss. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator was notified of the Immediate Jeopardy (IJ) for F-835 on 1/17/2020 at 8:15 PM, in the Conference Room. The facility was cited at F-689, F-835, and F-867 at a scope and severity of [MI] The facility was cited at F-600, F610, and F-656 at a scope and severity of [NAME] F-600-J, F-610-J, and F-689-L are Substandard Quality of Care. An extended survey was conducted on 1/16/2020. The Immediate Jeopardy was removed onsite and was effective 11/30/2019 through 1/21/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 1/21/2020 at 6:05 PM, and the corrective actions were validated onsite by the survey team on 1/21/2020 and 1/22/2020 through in-service training records, auditing tools, policies, observations, and staff interviews. The findings include: Review of the facility's policy titled, Administration of Facility, revised 12/20/2019, showed, .This facility will provide policies and systems to ensure that it is administered in a manner that will focus on attaining and maintaining the highest practicable physical, mental and psychosocial well-being of each resident . Review of the facility's policy titled, Administrator, revised 4/2007, showed, .The governing board of this facility has appointed an Administrator who is duly licensed in accordance with current federal and state requirements. The Administrator is responsible for, but not limited to .managing day-to-day functions of the facility .Implementing established resident care policies .safety and security policies .other operational policies and procedures necessary to remain in compliance with current laws, regulations, and guidelines governing long-term care facilities .Serving as liaison to the governing board, medical staff, and other professional and supervisory staff .Evaluating and implementing recommendations from the facility's committees . Review of the facility's policy titled, Director of Nursing Services, revised 8/2006, showed, .The Nursing Services department is managed by the Director of Nursing Services .and is responsible for, but not necessarily limited to .Developing methods for coordination of nursing services with other resident services .Developing staff training programs for nursing service personnel .Ensuring that all health services notes are informative and descriptive of the supervision and care rendered including the resident's responses to his or her care .Participating in the development and implementation of the resident assessment .and comprehensive care plan .Assuring that nursing care personnel are administering care & (and) services in accordance with the resident's assessment and care plan . Review of the facility's policy titled, Abuse Investigation and Reporting, revised (MONTH) (YEAR), showed, .Role of the Administrator .If an incident or suspected incident of resident abuse .or injury of unknown source is reported .the Administrator will assign the investigation to an appropriate individual .The Administrator will ensure that any further potential abuse .is prevented .The Administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety .of the resident . Review of the facility's Maintenance Supervisor job description and personnel file, showed the Director of Maintenance was hired 2/1/2019 and his job description was not signed until 7/23/2019. The Maintenance Supervisor job description dated 7/23/2019, showed, .Tests facility hot water system on a regular basis to evaluate water temperatures in essential locations of facility. Monitors acceptable range of temperatures and immediately starts repairs to eliminate hazards for facility residents, staff and others .Completes required documentation and record keeping of maintenance activities .Implements approaches to improve department record keeping practices . During an interview conducted on 1/12/2020 at 1:34 PM, the Director of Maintenance was asked if he went into resident rooms and checked the water temperatures. The Director of Maintenance stated, We have in the past .not every day .we set the tankless water heaters so nothing can go wrong .you set the temp (temperature) on the heater so it will not get too hot or vary .puts out the same temp . The Director of Maintenance was asked what temperature he kept the tankless water heaters. The Director of Maintenance stated, I think they're at 130 .all of them are the same . During an observation and interview conducted in room [ROOM NUMBER] and #309 on 1/12/2020 beginning at 2:12 PM, with the Director of Maintenance and another member of the survey team, the Director of Maintenance verified the water temperature in room [ROOM NUMBER] was 134 degrees Fahrenheit and room [ROOM NUMBER] was 144 degrees Fahrenheit. The Director of Maintenance was asked was that the range of temperature of the water on the 300 Hall. The Director of Maintenance stated, Yes, ma'am, those are the most consistent .never has there been any problems with hot water . During an interview conducted on 1/17/2020 at 8:15 PM, the Administrator was asked what type of training the Director of Maintenance received. The Administrator stated, I do not know .would have to ask on that . The Administrator confirmed that she had given him some resources, .within the last couple of months . The Administrator was asked if that was documented anywhere. The Administrator stated, I did not. I should have. The Administrator was asked why the Director of Maintenance had not signed his Job Description until months after his hire date. The Administrator stated, We did an audit of personnel files and some were not done .we updated them .he was supposed to read it prior to signing . The Administrator confirmed that the Medical Director had not been notified of the issues with the hot water temperatures. During a telephone interview conducted on 1/20/2020 at 8:36 PM, the Director of Operations stated, .It's normal every day for the logs (water temperature) to be kept and temps (temperatures) to be checked .this is extremely upsetting and disturbing to us .kind of one of the first things they teach them in Administrator school . During an interview conducted on 1/21/2020 at 6:44 PM, the survey team notified the Regional Administrator, Regional Liaison, and Interim Administrator that the water temperatures still exceeded the regulation. The Regional Administrator stated, .We could check it now and it will be normal .we could check it 5 minutes from now and it would be high . Administration failed to provide oversight of staff to monitor and provide a safe resident environment when water temperatures reached dangerous levels of 116-144 degrees F in 48 of 63 (76.19%) resident rooms which resulted in IJ to the residents residing in these rooms. Refer to F-689. During an interview conducted on 1/17/2020 at 9:20 AM, the Administrator (the Abuse Coordinator)was asked what types of occurrences are investigated. The Administrator stated, Abuse, elopement, any kind of incidents or anything of unknown origin . The Administrator confirmed injuries of unknown origin should be investigated immediately. The Administrator confirmed that she was unaware of Resident #12 and #64's injuries of unknown origin. The Administrator was asked should she have been notified of the injuries of unknown origin since they were documented in the Nurses' Notes and the doctor was made aware. The Administrator stated, Yes ma'am. The Administrator confirmed that a full facility skin audit should have been conducted after identification of an injury of unknown origin. During an interview conducted on 1/17/2020 at 1:04 PM, the Director of Nursing (DON) was asked should the Administrator who was the Abuse Coordinator have been notified of Resident #12 and #64's injuries of unknown origin. The DON stated, .it wasn't an abuse situation . The DON was asked if she did an investigation for injuries of unknown origin. The DON stated, No, ma'am . The DON was asked if other residents were assessed after the injuries of unknown origin were identified. The DON stated, No, ma'am . During an interview with the Administrator on 1/17/2020 at 8:15 PM, The Administrator was asked about recent abuse training and the injuries of unknown origin and why an investigation was not completed when the 2 injuries of unknown origin were identified. The Administrator stated, .As far as it not being reported to me .I talked to (Named the DON) about that . The Administrator was asked if she reviewed all incident reports. The Administrator stated, I normally just review all falls and (Named Director of Nursing (DON)) reviews all of the incident reports . During an interview conducted on 1/17/2020 at 9:11 PM, after the Abuse IJ template was provided to the Administrator, the Regional Liaison stated, We don't know how this (Incident of Unknown Origin) came about .we've been harping on this (Abuse) for weeks .short of being here every day .we stress the importance of doing an investigation (for Abuse incidents and Injuries of Unknown Origin) . The Regional Liaison stated, .Part of that plan of correction on abuse we have terminated the Administrator . The Regional Liaison stated, We have to pretty much push people to get the documentation done . The facility failed to continue implementation of the plan of correction after the complaint survey on 7/22/2019 where Abuse was cited at an IJ level. During an interview conducted on 1/17/2020 at 1:47 PM, Confidential Staff Member #1 stated, If you are not consistent on anything you cannot expect it to change .once y'all (you all) leave it will go back to the way it was . Confidential Staff Member #1 was asked if the staff felt comfortable going to Administration with concerns. Confidential Staff member #1 stated, You can't talk to no one (anyone) .you go through all your chain of commands .you go tell her (Administrator) something .it will get right back to him (Director of Maintenance) .they don't discipline . Confidential Staff Member #1 was asked when things started getting worse. Confidential Staff Member #1 stated, When (Named Administrator) came through the door . During an interview conducted on 1/17/2020 at 4:10 PM, Licensed Practical Nurse (LPN) #9 was asked about communication between different departments. LPN #9 stated, It could be better .I'm old school .believe in teamwork .I just don't think we have found a team yet .I'm used to being included in what's going on .when I came, it was a whirlwind .I let my corporate person know it was really bad .I have tried to get the teamwork .and it's not coming together like I want it to . Administration failed to provide oversight of staff to ensure injuries of unknown origin which could be indicative of abuse were identified and investigated, which resulted in IJ for Resident #12 and #64. Refer to F-610. Administration failed to provide oversight of staff to ensure resident sitters were screened, trained, and background checks were performed on sitters, which resulted in IJ for Resident #51. Refer to F-600. Administration failed to provide oversight of staff to ensure coordination of care between the interdisciplinary team (IDT) to identify and assess residents' nutritional status which resulted in actual harm for Resident #55. Refer to F-692. The surveyors verified the Removal Plan by: 1. The Administrator of the facility was terminated on 1/17/2020, and the Administrator and Abuse Coordinator on record was updated to reflect the current Director of Nursing as Interim Administrator and signs were put around the facility informing staff of the change. The Assistant Director of Nursing (ADON) was put in as Interim DON. Nurse Management and the nursing team completed body audits on the current resident census on 1/17/ and 1/18/2020. Education was begun on 1/17/2020 for staff, on reporting alleged violations of abuse, neglect, including injuries of unknown source, how to conduct a thorough investigation. The survey team verified the updated Administrator and Abuse Coordinator signs were placed around the facility. The survey team reviewed the body audits and new areas found on residents were reviewed by the survey team, with no concerns identified. The survey team reviewed the in-service sign-in sheets and interviewed staff members on all shifts. 2. The DON reviewed all skin audits on residents in the facility, investigated any areas subject to possible abuse, and reviewed facility reported incidents. The survey team verified the review of skin audits through review of the skin audits and interview with the DON. 3. The DON, or designee, will conduct a random audit of 10 residents 2 times a week for 4 weeks, then 20 residents bi-weekly for 2 months, and then 30 residents monthly for 2 months. The residents will be assessed and interviewed to ensure any injuries are identified, properly investigated, and reported to the appropriate entities. The Interim Administrator will review daily progress notes, incidents reports, and skin audits to determine if further investigation should occur and reporting to regulatory agencies as applicable for 4 weeks, then weekly for 2 months, and then monthly. The survey team confirmed the plan of correction through review of audit tools and administrative staff interviews. 4. The interim Administrator and Maintenance staff reviewed all rooms and showers within the facility. All residents who receive a bed bath, shower, or whirlpool tub bath temperatures will be documented and reviewed daily by the administration and nurse management. The survey team validated the shower logs were reviewed and monitored by Administration and maintenance staff through review of logs and interviews with staff. 5. The maintenance team will conduct daily shift water checks to ensure that all sinks, showers, and whirlpool tubs are at the correct temperature for a month, weekly x 4 months, biweekly x 2 months, and then monthly x 2. Audited records will be reviewed by the Risk Management/Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee. The survey team reviewed the audit tools and interviewed administrative staff. Noncompliance continues at a scope and severity level of F for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on review of the Quality Assessment and Assurance policy, the Quality Assurance Plan, Administrator policy, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program when the committee did not recognize an accident hazard risk with excessively hot water temperatures in residents' rooms. The QAPI committee failed to ensure Abuse policies and procedures were followed when injuries of unknown origin which could be indicative of abuse were not identified and investigated. The QAPI committee failed to ensure resident sitters were appropriately screened for abuse, had criminal background checks, and received abuse training. The QAPI committee failed to ensure residents' nutritional status was assessed, monitored, and appropriate interventions were implemented when residents sustained severe weight loss. The failure of the QAPI committee to ensure the facility identified the root cause of the risks associated with hazardous water temperatures placed residents in 48 of 63 rooms (room [ROOM NUMBER], #101, #102, #103, #104, #105, #106, #107, #108, #109, #110, #111, #113, #114, #115, #116, #210, #211, #212, #214, #217, #218, #220, #301, #302, #304, #305, #306, #307, #308, #309, #310, #311, #313, #314, #315, #317, #319, #318, #319, #400, #401, #402, #403, #404, #405, #406, and #407) in Immediate Jeopardy (IJ) when hot water temperatures were 116-144 degrees Fahrenheit (F). The failure of the QAPI committee to ensure staff identified and investigated injuries of unknown origin which could be indicative of abuse placed Resident #12 and #64 in I[NAME] The failure of the QAPI committee to ensure staff provided abuse training, conducted abuse screening, and performed criminal background checks for sitters placed Resident #51 in I[NAME] The failure of the QAPI committee to ensure staff performed assessments for nutritional status, monitored weight loss, and implemented interventions resulted in actual harm to Resident #55 when Resident #55 sustained severe weight loss. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Interim Administrator was notified of the Immediate Jeopardy for F-867 on 1/18/2020 at 9:36 PM, in the Conference Room. The facility was cited at F-689, F-835, and F-867 at a scope and severity of [MI] The facility was cited at F-600, F-610, and F-656 at a scope and severity of [NAME] F-600-J, F-610-J, and F-689-L are Substandard Quality of Care. An extended survey was conducted on 1/16/2020. An acceptable Removal Plan which removed the immediacy of the Jeopardy, was received on 1/21/2020 at 6:05 PM. The corrective actions were validated onsite by the surveyors on 1/21/2020 and 1/22/2020 through in-service training records, auditing tools, policies, observations, and staff interviews. The IJ was effective from 11/30/2019 through 1/21/2020. The findings include: Review of the facility's undated policy titled, Quality Assessment and Assurance, showed, .This facility will operate a Quality Assessment and Assurance Committee to identify quality issues, and develop and implement appropriate plans of action to correct identified quality deficiencies within the facility through an interdisciplinary approach .The Committee will develop plans of correction or action to correct identified quality deficiencies, including monitoring the effect of implemented changes and revising the action plans as needed .Focus .All quality assurance activities will be integrated and coordinated among all departments and service providers providing direct or indirect resident care .Dietary Services .Duties and responsibilities .Developing comprehensive assessments of the dietary needs of each resident and developing their written dietary plan of care that identifies the dietary problems/needs of the resident, and the goals to be accomplished for each dietary problem/need identified .Nursing Services .Duties and responsibilities .Developing methods of coordinating nursing services with other resident services to ensure the flow of the resident's total regiment of care .Reviewing Nursing notes to determine if the care plan is being followed .Periodic review (at least monthly) of quality care indicators: weight loss .Maintenance Services .Duties and responsibilities .Assuring the water temperatures are checked and adjusted as necessary .Assuring that a preventive maintenance schedule is maintained to keep the facility equipment operable . Review of the facility's undated policy titled, Quality Assurance Committee Policy Statement, showed, .To provide a means whereby negative outcomes relative to resident care can be identified and resolved through an interdisciplinary approach, and positive outcomes can be reinforced through education and monitoring . Review of the facility's policy titled, Administrator, revised 4/2007, showed, .Serving as liaison to the governing board, medical staff, and other professional and supervisory staff .Evaluating and implementing recommendations from the facility's committees . During an interview conducted on 1/17/2020 at 8:15 PM, the Administrator was asked had she made the Medical Director aware of the hot water concerns. The Administrator stated, No ma'am .he knows y'all (you all, State Survey Team) are here but I have not notified him about the hot water yet . The Administrator confirmed she had not notified the Medical Director of the IJ in hot water temperatures 5 days after the facility was notified of the I[NAME] During an interview conducted on 1/17/2020 at 8:56 PM, the Director of Nursing (DON), the Regional Liaison, and Regional Administrator were asked about the investigation not conducted on Resident #12's injury of unknown origin. The DON stated, I didn't think it warranted an investigation. The Regional Liaison stated, .We don't know how this (abuse IJ-injuries of unknown origin) came about .we've been harping on them since the IJ in (MONTH) (complaint survey 7/22/2019 when Abuse was cited at the IJ level) .We see the area of concern . The Regional Liaison stated, .Short of being here every day .we stress the importance of doing an investigation .Part of that plan of corrections on abuse .The Administrator has been terminated .we take this very serious .We did not look into this incident . During an interview conducted on 1/18/2020 at 9:23 PM, the Interim Administrator stated, .In every QAPI meeting we discuss .with (Named Medical Director) .PAR (patients at risk) .pressure ulcers .2567 (Statement of Deficiencies) and P[NAME] (Plan of Correction) from our survey in (MONTH) .(abuse cited at IJ level) . The Interim Administrator was asked how the facility monitored the 2567 and plan of correction from the previous survey. The Interim Administrator stated, We have a P[NAME] book .it's got monitoring tools in it that we document every month . The Interim Administrator was asked how they were assuring staff knew what to do. The Interim Administrator stated, Ongoing education .If an abuse situation arises we in-service .Abuse Coordinator information all over the building .constantly talk about it . The facility failed to continue the implementation of the plan of correction after the complaint survey on 7/22/2019 where Abuse was cited at the IJ level. During a telephone interview conducted on 1/19/20/20 at 9:11 AM, the Medical Director confirmed that recertification and complaint surveys were discussed in QAPI. The Medical Director confirmed, .was supposed to supervise QA, address guidelines are being followed .measures to safeguard the patients . The Medical Director was asked if he had been notified of any of the findings of the current survey. The Medical Director stated, .A couple of things .the water found to be a little too warm .a suggestion of abuse of a patient . The Medical Director confirmed that hot water temperatures had not been discussed in QAPI prior to the survey. The Medical Director was asked did he expect the staff to investigate injuries of unknown origin. The Medical Director stated, Yes .I understand what you're saying .they should have followed up and at least documented .I'm going to make sure next meeting (QAPI) I address all these issues .part of the reason .there's been a lot of turnover in staff and maybe that's why they're not following policies and procedures . The Medical Director was asked did he expect to be notified of residents with significant weight loss. The Medical Director stated, Yes . The QAPI Committee failed to provide oversight of staff when they failed to identify and monitor water temperatures which reached hazardous levels of 116-144 degrees F in 48 of 63 (76.19%) resident rooms which resulted in I[NAME] Refer to F-689. The QAPI Committee failed to provide oversight of staff to ensure resident sitters received abuse training, abuse screening, and criminal background checks on sitters which resulted in IJ for Resident #51. Refer to F-600. The QAPI Committee failed to provide oversight of staff to ensure injuries of unknown origin were identified and investigated which resulted in IJ for Resident #12 and #64. The facility was cited IJ in abuse on 7/22/19 and did not continue the implementation of the plan of correction Refer to F-610. The facility's QAPI Committee failed to identify, develop, and implement appropriate plans of action to ensure care plans were reviewed, updated, and implemented for the care of residents with severe weight loss and injuries of unknown origin, which could be indicative of abuse. Refer to F-656. The QA Committee failed to provide oversight of staff to ensure coordination of care between the interdisciplinary team (IDT) to identify and assess residents' nutritional status which resulted in actual harm for Resident #55. Refer to F657 and F-692. The surveyors verified the Removal Plan by: 1. The Administrator was terminated as a result of the failure to develop a system for routine monitoring of hot water temperatures in the resident rooms and failure to implement a systemic approach to identifying, investigating, and attempting to determine the cause of injuries of unknown origin. The DON was placed into the Interim Administrator position and the Assistant Director of Nursing (ADON) was placed in the DON position. Notifications were placed at the time clock to see Administration before clocking in to be properly in-serviced. The interdisciplinary team (IDT) received QAPI/QA Committee training and education on 1/19/2020 to include the current citations, the systemic failures, and the monitoring plans for each I[NAME] Verbal education by telephone was conducted with the Medical Director on the current IJ citations, process and procedures on monitoring system failures, and performance improvement projects. The survey team validated in-service notifications, sign-in sheets, and interviewed staff on the IDT. 2. The Chief Clinical Officer completed an AdHoc (impromptu) QAPI meeting with the IDT on the current IJ citations, education, policies, and monitoring plans. Immediate education was conducted with the Interim Administrator and Interim DON on the QAPI/Quality Assurance and Assessment (QAA) policy and procedure. The survey team verified the corrective action through interviews with the Interim Administrator and Interim DON. 3. An in-service with the Interim Administrator and the Interim DON was completed on 1/19/2020 and AdHoc completed with the IDT. The next QAPI will be completed on 1/22/2020 and all citations and founded systemic issues will be discussed and monitored in QAPI. An AdHoc will be completed at the time of the identified issue and will be followed through QAPI until compliance is obtained and verified going forward. Education was completed with 100% of staff who had worked since citation identification and was to be continued ongoing. The survey team validated education was completed through review of in-service sign-in sheets and staff interviews on all shifts. 4. The Interim Administrator and the Interim DON will conduct the monthly QAPI on 1/22/2020 to include the AdHoc for the current IJ citations and any other identified failed systems. The performance improvements projects, AdHocs, and citations will be discussed at every monthly QAPI until monitoring is complete and the citation of failed system is in verified compliance. Findings of this audit will be discussed with the Resident Council. The Plan of Correction will be monitored at the monthly QA meeting until substantial compliance has been met. The survey team validated the corrective action through interview with members of the QAPI team. Noncompliance continues at a scope and severity level of F for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure abuse screening, training, and background checks were conducted for 2 of 5 sitters (Sitter #1 and #2) which placed Resident #51 at risk for potential abuse. The facility's failure to perform screening, training, abuse registry checks, and background checks placed Resident #51 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident). The Regional Administrator and the Regional Liaison was informed of the Immediate Jeopardy for F-600 on 1/21/2020 at 1:19 PM, in the Conference Room. The facility was cited F-600 at a scope and severity of J which is Substandard Quality of Care. An extended survey was conducted on 1/16/2020. The Immediate Jeopardy was removed onsite and was effective from 11/30/19 through 1/21/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received 1/21/2020 at 6:05 PM. The corrective actions were validated onsite by the survey team on 1/21/2020 and 1/22/2020 through review of completed screening and background checks of the current sitters, review of in-service training records, review of sign in sheets, review of monitoring procedures for future sitters, resident interviews, and staff interviews. The findings include: Review of the facility's policy titled, Abuse Prevention Program, dated 12/2016, showed .Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Conduct employee background checks .Require training/orientation programs . Review of the facility's policy titled, Private Duty Sitters dated 5/2017, showed .The use of private duty sitters will be permitted when approved by the resident's Attending Physician and the facility's Director of Nursing Services .May not administer direct care to the resident unless authorized in writing by the Attending Physician . The facility was unable to provide documentation of abuse screening, background checks, training, or written authorization by the attending physician for Sitter #1 and Sitter #2. Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE], showed Resident #51 had severely impaired cognitive skills for daily decision making, required supervision of one person with transfers and walking in the room, required limited assistance of one person to walk in corridor, dressing, eating, toilet use, and personal hygiene. Review of the Care Plan revised 1/5/2020, showed, .The resident has an ADL (Activities of Daily Living) self-care performance deficit .The resident requires (extensive assistance) by (1) staff to dress .The resident requires (limited assistance) by (1) staff to eat . Observation in the resident's room on 1/12/2020 at 9:38 AM, showed Sitter #2 assisting Resident #51 to the bathroom. During an interview conducted on 1/12/2020 at 9:45 AM, Sitter #2 was asked if she was a family friend or a Certified Nursing Assistant (CNA). Sitter #1 stated that she was a sitter. Observation in the Dining Room on 1/13/2020 at 5:59 PM, showed Sitter #1 assisting Resident #51 with her evening meal. During an interview conducted on 1/13/2020 at 6:34 PM, with Sitter #1, who was sitting with Resident #51, Sitter #1 was asked if she was a family friend or a Certified Nursing Assistant (CNA). Sitter #1 stated, .I'm not a CNA, but I have [AGE] years experience .I have been here a year on Thanksgiving (14 months) .At the other facility I was sitting, I had to give blood to make sure I don't have a disease, a background check .No, nothing here . During an interview conducted on 1/13/2020 at 7:05 PM, the Business Office Manager Assistant was asked for the personnel files (that should contain abuse screenings, training, and background checks) for Resident #51's sitters. She denied knowing (Named Sitter #1 and Sitter #2) . Observation in the Dining Room on 1/14/2020 at 12:32 PM, showed Sitter #1 assisting Resident #51 with her midday meal. During an interview conducted on 1/16/2020 at 2:28 PM, the Administrator was asked what steps were taken to screen private duty sitters for a history of abuse. The Administrator stated, We check the abuse registry and background checks . The facility failed to continue implementation of the plan of correction after the complaint survey on 7/22/2019 where Abuse was cited at the IJ level. The facility was unable to provide documentation the abuse screening or background checks had been performed on the sitters, which placed Resident #51 in Immediate Jeopardy. The survey team verified the Removal Plan by: 1. On 1/21/2020, the Private duty sitters background, sex offender, and [MEDICATION NAME] (TB) screenings were completed. Abuse training started immediately on 1/21/2020 with sitters in house. Communication with resident families in question was completed to ensure that all sitters before employment need to meet with administration before being invited to the facility to ensure applicable screenings and trainings are completed. The survey team reviewed the resident assessments, resident interview statements, and staff interview statements, and interviewed residents and staff regarding the education provided by the facility. 2. The Interim Administrator, the Interim Director of Nursing, the Admissions Nurse Liaison, the Admissions Coordinator, and the Human Resources Department had in-service education on the requirements of the resident families to have the sitters come in to have their abuse training/screenings, and their background checks completed. The survey team interviewed staff regarding the education provided by the facility. 3. The DON or her designee will check in with resident responsible parties and sitters daily to ensure that the sitter has a facility file before sitting with the resident on each shift and a running list will be kept on all sitters as they come into the facility with Human Resources (HR). The survey team reviewed personnel files and interviewed staff. Noncompliance of F-600 continues at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a Comprehensive Care Plan was developed for injuries of unknown origin and Care Plan interventions were followed for nutritional impairment for 3 of 28 sampled residents (Resident #12, #64, and #55) reviewed. The failure of the facility to develop a Comprehensive Care Plan for injuries of unknown origin that could be indicative of abuse with effective interventions and protect residents from further potential injury placed Resident #12 and #64 in Immediate Jeopardy. The failure of the facility to ensure Care Plan interventions were followed for nutritional impairment resulted in actual Harm when Resident #55 sustained severe weight loss. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility was cited F-656 at a scope and severity level of [NAME] The extended survey was conducted on 1/16/2020. The IJ was effective from 11/30/2019 through 1/21/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received 1/21/2020 at 6:05 PM. The corrective actions were validated onsite by the survey team on 1/21/2020 and 1/22/2020 through review of care plan revisions and updates, review of in-service training records, and staff interviews. The findings include: Review of the facility's policy titled, Unexplained Injuries, revised 12/20/2019, showed, .All unexplained injuries, including bruises .and injuries of unknown source .The facility shall modify the resident's plan of care as needed to prevent recurrence or to stabilize, reduce, or remove underlying risk factors contributing to the injury . Review of the facility's policy titled, Weight Assessment and Intervention, dated 12/2019, showed, .The threshold for significant unplanned and undesired weight loss will be based on the following criteria .a. 1 month-5% (percent) weight loss is significant; greater than 5% is severe .b. 3 months-7.5% weight loss is significant; greater than 7.5% is severe .c. 6 months-10% weight loss is significant; greater than 10% is severe .Care Planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or resident's legal surrogate .Individualized care plans shall address .Time frames and parameters for monitoring and reassessment . 1. Review of the medical record, showed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan dated 7/30/2019, showed Resident #12 was totally dependent on staff for all activities of daily living. Review of the quarterly Minimum Data Set ((MDS) dated [DATE], showed Resident #12 had severe cognitive impairment, no behaviors, walking did not occur, and was totally dependent on staff for all activities of daily living (ADLs). Review of the Incident Report, showed, .11/30/2019 .Incident Location: Unknown .Nursing Description .called to residents (resident's) room by (Named Certified Nursing Assistant (CNA) #5), upon entering .observed resident lying supine with bruising, redness, inflammation and pain to upper left arm .Resident Description: Resident Unable to give Description .Immediate Action Taken .Tylenol 500 mg (milligrams) given crushed PO (by mouth) without difficulty, (Named physician) notified and xray (X-ray) ordered stat (immediately) .upon moving ULE (upper left extremity) resident shows favor with grimace to face and stiffening of BUE (bilateral upper extremities) .Other info (information) .incident of unknown origin .No witnesses found . There was 1 staff statement signed by CNA #5 dated 11/30/2019 and attached to the incident report which showed, .When provide care for (Named Resident #12) She clings her arms to Body and It make (makes) it hard to put on her cloth (clothes) . There were no additional staff statements or interviews, no resident statements or interviews, and no resident assessments included. Review of the Radiology Results Report dated 11/30/2019, showed, .Reason for Study .PAIN IN LEFT SHOULDER .PAIN IN LEFT ARM .PAIN IN LEFT ELBOW .PAIN IN LEFT WRIST .Conclusion .Modest [MEDICAL CONDITION] joint disease of the left shoulder .no fracture or dislocation seen .Grossly intact left humerus .Grossly intact left elbow .Grossly intact osseous appearance of the left forearm .Mild to modest [MEDICAL CONDITION] joint disease of the left wrist .no fracture seen .mild soft tissue swelling . Review of the Weekly Skin Check dated 12/5/2019, showed Resident #12 had, .bruising to left upper arm . Review of the Care Plan dated 7/30/2019, showed a Comprehensive Care Plan was not developed to reflect the injury of unknown origin that was documented in an incident report dated 11/30/2019 and the Care Plan did not document any protective interventions to be implemented. 2. Review of the medical record, showed Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan revised 12/8/2019, showed Resident #64, .has an ADL self care deficit .Interventions .The resident is totally dependent on (1) staff to provide bath/shower .The resident requires extensive assistance by (1) staff to turn and reposition in bed .The resident is totally dependent on (1) staff for dressing .The resident requires extensive assistance by (1) staff to eat .The resident is totally dependent on (1) staff for personal hygiene and oral care .The resident is totally dependent on (1) staff for toilet use .The resident is totally dependent on (1) staff for transferring .The resident has potential/actual impairment to skin integrity due to fragile skin such as Skin Tears and Bruising . Review of the quarterly MDS dated [DATE], showed Resident #64 had severe cognitive impairment per the staff assessment, no behaviors, required staff assistance for all ADLs, and received anticoagulant medications daily for the past 7 days. The physician's orders [REDACTED]. Review of the Incident Report dated 12/18/2019, showed, .Location .Resident's Room .Nursing Description .Resident was lying in bed when this nurse entered the room and was covering resident up, resident had hand lying on his neck, when resident moved his hand this nurse observed purple colored marks .when asked CNA she states that resident has had that area around his neck for a long time, after assessing area the resident was observed with his hand resting back around his neck in the discolored area .Resident Description .Resident Unable to give Description .Mobility .Bedridden .purple bruising noted around the front of resident's neck .No Witnesses found . There was 1 staff statement signed by CNA #3 and dated 12/19/2019 attached to the incident report, which showed, .I have seen the discoloration around (Named Resident #64) neck for several weeks never thought anything about it except when I clean him I always have to remove his hand from around his neck . There were no additional staff statements or interviews, no resident statements or interviews, and no resident assessments included. Review of the Care Plan revised 12/8/2019, showed a Comprehensive Care Plan was not developed to reflect the bruising around Resident #64's neck and chest that was documented on 12/18/2019 on the incident report, and there was no documentation of any protective measures implemented. The Care Plan did not address the use of anticoagulant medications. During an interview conducted on 1/17/2020 at 4:02 PM, the MDS Coordinator was asked if Care Plans should reflect the current status of the residents. The MDS Coordinator stated, Yes. The MDS Coordinator was asked if Resident #12's Care Plan should reflect her arm and shoulder injury. The MDS Coordinator stated, Yes. The MDS Coordinator was asked if the bruising to Resident #64's neck and chest area should be addressed on the Care Plan. The MDS Coordinator stated, Yes. The MDS Coordinator was asked if the steps taken to prevent further injuries should be reflected in the Care Plans. The MDS Coordinator stated, I didn't put it on the Care Plan. (Named LPN #2) called and told me about it .I don't even know if anybody but her knew about it . The MDS Coordinator was asked if it should be documented on the Care Plan. The MDS Coordinator stated, Yes. It should be. The MDS Coordinator was asked if the use of the anticoagulant medication, Eliquis, should be documented on the Care Plan. The MDS Coordinator stated, It should be. The failure of the facility to develop Comprehensive Care Plans for injuries of unknown origin that could be indicative of abuse with effective interventions and protect residents from further potential injury placed Resident #12 and #64 in Immediate Jeopardy. Refer to F-610 3. Review of the medical record, showed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan dated 9/1/2019, showed Resident #55 had .Potential for impaired nutrition .Interventions .supplements to be given as ordered .Refer to .RD (Registered Dietitian) as needed . Review of the quarterly Minimum data set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment, a height of 66 inches, a weight of 134 pounds, and a weight loss of 5% or more in the past month or 10% or more in the last 6 months, and was not on a physician-prescribed weight-loss regimen. Review of the Weights and Vitals Summary showed the following weights for Resident #55: a. 7/1/2019 144 pounds (lbs) b. 7/3/2019 151 lbs c. 7/9/2019 155 lbs b. 8/1/2019 156 lbs c. 9/2/2019 152 lbs d. 10/1/2019 138 lbs (severe weight loss of 9.21% in 1 month, and 10.96% in 3 months) e. 11/6/2019 134 lbs (severe weight loss of 14.1% in 3 months) f. 12/19/2019 134 lbs (severe weight loss of 11.84% in 3 months) g. 1/6/2019 132.2 lbs (severe weight loss of 14.7% in 6 months) h. 1/17/2020 128.2 lbs (7.1% weight loss in 3 months, and severe weight loss of 17.29% in 6 months) Review of the physician's orders [REDACTED].@ (at) 3 pm R/T (related to) weight loss concerns . Review of a Nurse's Note dated 7/1/2019, showed, .4 oz mighty shake q day at 3 pm r/t weight loss concerns per dietary rec (recommendations) . Review of a Nutrition Note dated 7/11/2019, showed, .receiving 30 ml (milliliters) liquid protein BID (twice a day) .Recommend to continue current diet and supplements . Review of the (MONTH) 2019 Medication Administration Record [REDACTED].PROVIDE GOLD (liquid protein supplement) 30ML BY MOUTH TWICE DAILY .Started 10/23/18 . The MAR indicated [REDACTED]. There was no documentation Provide Gold was administered after 8/19/2019. Review of the (MONTH) 2019 MAR, showed Resident #55 had orders for, .HOUSE SUPPLEMENT (liquid supplement with increased calories) 120ML BY MOUTH THREE TIMES DAILY .Started 10/23/18 . The MAR indicated [REDACTED]. There was no documentation the House Supplement was administered after 8/19/2019. Review of the (MONTH) 2019 MAR, showed there was no documentation the Mighty Shake was administered to Resident #55. Review of the medical record showed, there was no documentation the House Supplement, protein supplement, or the Mighty Shakes had been discontinued by the physician. Review of the Nutrition Note dated 9/19/2019, showed Resident #55, .has now lost 4 lbs in a month .gets a Mighty shake at afternoon snack . Review of the Nutrition Note dated 10/3/2019, showed Resident #55, .has had a 10% weight loss in last 6 months .gets Mighty shakes at afternoon snacks .significant weight loss . Review of the (MONTH) 2019, (MONTH) 2019, (MONTH) 2019, (MONTH) 2019, and (MONTH) 2020 MARs, showed there was no documentation the House Supplement, Mighty Shake, or the Provide Gold were administered. The facility was unable to provide documentation the RD did any further assessments after 10/3/2019 on Resident #55. Resident #55 sustained severe weight loss on 10/1/2019 and continued to lose weight. Observation in the resident's room on 1/16/2020 from 1:45 PM to 2:30 PM, showed Resident #55 did not receive a supplement. During an interview on 1/16/2020 at 3:22 PM, CNA #10 (Restorative Aide) was asked about the process of obtaining weights. CNA #10 stated, .try to weigh consistently on the same day .if 3 pound difference up or down I reweigh then . CNA #10 was asked how often were the scales recalibrated. CNA #10 stated, .I am not sure, when I started in (MONTH) (Named DON) stated the scales had just been recalibrated . CNA #10 stated that she does not enter the weights into the Electronic Medical Record, the nurses enter the weekly weights into the record. CNA #10 stated, .I understood that the previous restorative person had inconsistent weights, not weighing on the same wheelchair, scale, or lift . There was no documentation of reweights in the medical record. During an interview on 1/16/2020 at 3:57 PM, Certified Nursing Assistant (CNA) #1 was asked who administered Resident #55's nutritional supplements. CNA #1 stated, The nurse brings it to him. During an interview conducted on 1/16/2020 at 4:00 PM, Licensed Practical Nurse (LPN #2) was asked who administered Resident #55's nutritional supplements. LPN #2 stated, The CNAs bring it to him. During an interview conducted on 1/21/2020 at 2:10 PM, the RD and LPN #2 were asked where to find documentation the supplements were administered. The RD and LPN #2 confirmed the orders for supplements had never been transcribed when the facility changed to electronic medical records in August, 2019, and the orders were never entered into the electronic medical record for administration. The RD confirmed she had not followed up to ensure her recommendations were followed. During an interview on 1/19/2020 at 4:47 PM, the RD stated that there had been concerns with calibrating the scales. The RD stated she had gone to the DON because there had been problems with the weights. The RD stated, .after you get them (weights) you have to wait and see if they're (staff are) reweighing .it has been a source of frustration . The facility was unable to provide documentation the mighty shakes, house supplements, or protein supplements were administered after 8/19/2019. The failure of the facility to follow the Care Plan interventions to provide supplements caused actual Harm when Resident #55 sustained severe weight loss. The survey team verified the Removal Plan by: 1. These residents' care plans were reviewed, interventions were made to the care plans, and revised interventions were input into the residents' record. In-service education was conducted with staff on implementation and revision of care plans, implementing interventions, and documenting the effectiveness of the interventions. The survey team verified the corrective action through review of care plans and interviews with staff on all shifts. 2. The DON, or designee, will conduct random audits of 10 residents weekly for 4 weeks, 15 residents bi-weekly for 2 months, and then 20 residents monthly for 2 months for care planning and putting interventions into place. Findings of this audit will be discussed and monitored in the monthly Quality Assurance meeting until substantial compliance is met. The survey team validated the corrective action through review of the audit tools and staff interviews. Noncompliance of F-656 continues at a scope and severity of D for monitoring and the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation, and interview, the facility failed to identify, thoroughly investigate, and protect vulnerable residents from further abuse for injuries of unknown source that could be indicative of abuse for 2 of 3 sampled residents (Resident #12 and #64) reviewed for abuse. The facility's failure to identify and thoroughly investigate bruising to Resident #12's left upper arm and posterior forearm and Resident #64's dark purple colored marks around the resident's neck, placed Resident #12 and #64 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was notified of the Immediate Jeopardy (IJ) for F-610 on 1/17/2020 at 8:15 PM, in the Conference Room. The facility was cited at F-610 at a scope and severity of J, which is Substandard Quality of Care. An extended survey was conducted on 1/16/2020. The IJ was effective from 11/30/2019 through 1/21/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received 1/21/2020 at 6:05 PM and the Removal Plan was validated onsite by the survey team on 1/21/2020 and 1/22/2020 through review of in-service training records and staff interviews. The findings include: Review of the facility's policy titled, Abuse Investigation and Reporting, revised 7/2017, showed, .All reports of resident abuse, neglect .injuries of unknown source .shall be .thoroughly investigated by facility management .Role of the Administrator .If an incident or suspected incident of resident abuse .or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual .The Administrator will ensure that any further potential abuse .is prevented .The Administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety .of the resident .Role of the Investigator .The individual conducting the investigation will, as a minimum .Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .Interview the resident's roommate, family members, and visitors .Interview other residents to whom the accused employee provides care or services .Review all events leading up to the alleged incident .The investigator will consult daily with the Administrator concerning the progress/findings of the investigation . Review of the facility's policy titled, Abuse and Neglect-Clinical Protocol, revised 3/2018, showed, .Assessment and Recognition .Assessment data will include .Injury assessment .bruising .swelling .Pain assessment .Current behavior .The nurse will report findings to the physician. As needed, the physician will assess the resident/patient to verify or clarify such findings, especially if the cause or source of the problem is unclear Cause Identification .The staff, with the physician's input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes . Review of the facility's policy titled, Unexplained Injuries, revised 12/20/2019, showed, .All unexplained injuries, including bruises, abrasions, and injuries of unknown source will be investigated .if the injury is of unknown source .investigation procedures shall be implemented in accordance with the facility's abuse policies and procedures .An injury should be classified as an 'injury of unknown source' when both of the following conditions are met .a .The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and .b .The injury is suspicious because of .The extent of the injury or .The location of the injury .the injury is located in an area not generally vulnerable to trauma .An injury of unknown source shall be investigated even if the resident is discharged .or an injury of unknown source is identified after discharge . Review of the facility's policy titled, Skin Assessment, revised 12/20/2019, showed, .A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter .The assessment may also be performed after a change of condition .Documentation of skin assessment .Include date and time of the assessment, your name, and position title .Document observations .skin conditions . 1. Review of the medical record, showed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan dated 7/3/2019, showed that Resident #12 had impaired decision making skills, short and long term memory problems, was totally dependent on (1) staff for eating, personal hygiene and oral care, dressing, and toilet use, and was totally dependent on (2) staff for transfers with a mechanical lift. Review of the quarterly Minimum Data Set ((MDS) dated [DATE], showed Resident #12 had severe cognitive impairment, no behaviors, walking did not occur, and was totally dependent on staff for all activities of daily living (ADLs). Review of the 24 Hour Report/Change of Condition Report dated 11/30/2019, showed, .Bruising, pain, swelling to (L) (left) Arm. Incident report done .stat (immediately) x-ray ordered . Review of the Radiology Results Report dated 11/30/2019, showed, .Reason for Study .PAIN IN LEFT SHOULDER .PAIN IN LEFT ARM .PAIN IN LEFT ELBOW .PAIN IN LEFT WRIST .Conclusion .Modest [MEDICAL CONDITION] joint disease of the left shoulder .no fracture or dislocation seen .Grossly intact left humerus .Grossly intact left elbow .Grossly intact osseous appearance of the left forearm .Mild to modest [MEDICAL CONDITION] joint disease of the left wrist .no fracture seen .mild soft tissue swelling . Review of the Incident Report, showed, .11/30/2019 .Incident Location: Unknown .Nursing Description .called to residents (resident's) room by (Named Certified Nursing Assistant (CNA) #5), upon entering I observed resident lying supine with bruising, redness, inflammation and pain to upper left arm .Resident Description: Resident Unable to give Description .Immediate Action Taken .Tylenol 500mg (milligrams) given crushed PO (by mouth) without difficulty, (Named physician) notified and xray (x-ray) ordered stat (immediately) .upon moving ULE (upper left extremity) resident shows favor with grimace to face and stiffening of BUE (bilateral upper extremities) .Other info (information) .incident of unknown origin .No witnesses found . There was 1 staff statement signed by CNA #5 and dated 11/30/2019 attached to the incident report which showed, .When provide care for (Named Resident #12) She clings her arms to Body and It make (makes) it hard to put on her cloth (clothes) . There were no additional staff statements or interviews, no resident statements or interviews, and no resident assessments included with the incident report. Review of the Weekly Skin Check dated 12/5/2019, showed Resident #12 had .bruising to left upper arm . The facility was unable to provide additional documentation for monitoring of the bruising for Resident #12. During an interview conducted on 1/16/2020 at 10:06 AM, the Administrator was asked if she was aware of the shoulder and arm bruising and swelling. The Administrator stated, No ma'am. The Administrator was asked if she should have been notified. The Administrator stated, Yes, ma'am. The Administrator was asked if she reviewed all the incident reports. The Administrator stated, .I don't review every single incident report. Observation in the resident's room on 1/17/2020 at 7:44 PM, revealed Resident #12 lying in bed with her bilateral arms contracted, her right hand fingers in her mouth, with a large greenish-colored bruise to her left upper arm and another greenish bruise to her left posterior forearm. During an interview conducted on 1/16/2020 at 11:16 AM, Licensed Practical Nurse (LPN) #5 was asked if she was aware of the bruising and swelling of Resident #12's arm that was documented on 11/30/2019. LPN #5 stated, It was shown to me and reported to the administration. LPN #5 was asked who showed it to her. LPN #5 stated, My aide that day .I don't know what caused the actual bruising. It was just shown to me and I reported it to the Administrator and called the doctor. LPN #5 was asked if Resident #12 moves around a lot. LPN #5 stated, No. She holds her arms up .to keep her hands in her mouth . LPN #5 was asked to describe what her arm and shoulder bruising and redness looked like when she saw it on 11/30/2019. LPN #5 stated, It was on her upper arm and here (pointed to forearm area). LPN #5 was asked if it was swollen. LPN #5 stated, Yes, and we x-rayed it. During an interview conducted on 1/17/2020 at 1:05 PM, the Director of Nursing (DON) was asked if she was aware of the incident that was documented as redness, bruising, and swelling to Resident #12's left arm on 11/30/2019. The DON stated, They came and got me on that one .I talked to staff. I got statements from the staff that takes care of her. The DON was asked if she only interviewed 1 staff member. The DON stated, She was the one that found it, and stated she does clench up when she does her changing of her clothes . The DON was asked if she informed the Administrator. The DON stated, We discuss them, but it wasn't an abuse situation. The DON was asked how she knew it was not abuse. The DON stated, .We investigated it and determined the cause of when it occurred from clenching her arms . Review of the facility's incident report, showed there was only 1 staff statement, but there was no investigation for Resident #12's injury of unknown origin. 2. Review of the medical record, showed Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE], showed Resident #64 had severe cognitive impairment per the staff assessment, no behaviors, required limited staff assistance for eating, required extensive staff assistance for bed mobility and dressing, was totally dependent on staff for toilet use, personal hygiene and bathing, walking and locomotion off the unit did not occur, transfers and locomotion on the unit only occurred once or twice with 1-person staff assistance. Review of the Care Plan revised 12/8/2019, showed that Resident #64 was totally dependent on (1) staff to provide bathing, required extensive assistance by (1) staff to turn and reposition in bed, was totally dependent on (1) staff for dressing, required extensive assistance by (1) staff to eat, was totally dependent on (1) staff for personal hygiene and oral care, was totally dependent on (1) staff for toilet use, was totally dependent on (1) staff for transferring, had potential/actual impairment to skin integrity due to fragile skin such as skin tears and bruising and interventions to follow facility protocols for treatment of [REDACTED]. Review of the 24 Hour Report/Change of Condition Report for the North hall dated 12/18/2019, showed, .(Named Resident # 64) .Incident .Bruising on neck . Review of the Incident Report dated 12/18/2019, showed, .Location .Resident's Room .Nursing Description .Resident was lying in bed .resident had hand lying on his neck, when resident moved his hand this nurse observed purple colored marks where resident's hand was resting, when asked CNA she states that resident has had that area around his neck for a long time, after assessing area the resident was observed with his hand resting back around his neck in the discolored area .Resident Description .Resident Unable to give Description .Mobility .Bedridden .purple bruising noted around the front of resident's neck .Resident keeps hand resting on resident's neck .No Witnesses found . There was 1 staff statement signed by CNA #3 and dated 12/19/2019 attached to the incident report, which showed, .I have seen the discoloration around (named Resident #64) neck for several weeks never thought anything about it except when I clean him I always have to remove his hand from around his neck . During a telephone interview with CNA #3 on 1/19/2020 at 9:51 AM, CNA #3 agreed with her statement and stated that she reported the bruise to Resident #64's nurse, and the nurse said it was because Resident #64 always kept his hand around his neck. There were no additional staff statements or interviews, no resident statements or interviews, and no resident assessments included. Review of the Nurse's Note dated 1/10/2020 at 11:23 AM, showed, .Dark purple bruising noted below neckline, upper portion of chest. Aide stated bruising has been noted before . Review of the Wound Measuring Guide dated 1/17/2020, showed the bruise to Resident #64's neck/chest area was 7.5 x 15 centimeters. Observation in the resident's room on 1/12/2020 at 8:49 PM, 1/13/2020 at 8:02 AM and 5:45 PM, 1/14/2020 at 7:59 AM, 8:59 AM, 9:48 AM, 12:58 PM, 3:52 PM, and 4:59 PM, 1/15/2020 at 4:53 PM, 1/16/2020 at 7:56 AM and 2:51 PM, 1/17/2020 at 3:07 PM, 1/18/2020 at 2:07 PM, 1/19/2020 at 10:56 AM, 1/20/2020 at 5:16 PM, and 1/21/2020 at 8:42 AM, showed Resident #62 did not have his hand resting around his throat or neck area during any of these observations. Observation in the resident's room on 1/13/2020 at 5:45 PM, showed Resident #64 with a large dark purple discolored area around the base of his neck and the collar bones, and narrow tubular shaped dark purple discolored areas extended around both sides of the neck. During an interview conducted on 1/14/2020 at 10:49 AM, LPN #3 was asked if he was aware of the bruising to Resident #64's neck and chest area. LPN #3 confirmed he was aware of the bruising but was not aware of how the bruise occurred. LPN #3 was asked who reported the bruise. LPN #3 stated, I'm not sure. During an interview conducted on 1/14/2020 at 10:53 AM, CNA #2 was asked if she was aware of the bruise to Resident #64's neck and chest area. CNA #2 stated, It started small. We didn't know what it was. It started as a small spot (pointed between collar bones on her own body). I went in there the other day and then it had spread all the way down. CNA #2 was asked when it started as a small spot. CNA #2 stated, It was probably about 5 weeks ago .I ended up letting (Named LPN #3) know about it . CNA #2 was asked when she notified the nurse. CNA #2 stated, I think it was last week. During an interview conducted on 1/14/2020 at 11:05 AM, CNA#1 confirmed she was aware of the bruise to Resident #64's neck and chest area. CNA #1 was asked if she knew who found it. CNA #1 stated, Probably me and (Named CNA #2). CNA #1 was asked what she did when she found it. CNA #1 stated, I'm not sure .I did tell (Named LPN #1). I do know that. CNA #1 was asked if she documented the bruise or that she had notified the nurse. CNA #1 stated, No. During an interview conducted on 1/15/2020 at 3:26 PM, LPN #1 stated she was not aware of the bruise to Resident #64's neck and chest area. LPN #1 confirmed CNA #1 had not reported it to her. During an interview conducted on 1/17/2020 at 9:15 AM, the Administrator was asked what was the procedure for injuries of unknown origins. The Administrator stated, We immediately start an investigation. The Administrator was asked what should be included in the investigation. The Administrator stated, We look at the documentation and talk to staff who have cared for the resident to figure out where or when it could have occurred. The Administrator was asked if they take staff statements. The Administrator stated, Yes. The Administrator was asked if other residents were interviewed. The Administrator stated, Yes. The Administrator was asked if the resident and other residents were assessed for injury. The Administrator stated, Yes. We normally do a full facility audit. The Administrator was asked if an investigation was done for the incident documented for Resident #64 on 12/18/2019. The Administrator did not answer. The Administrator was asked if she was aware of the bruising. The Administrator stated, No. The Administrator was asked if the incident should have been investigated. The Administrator stated, Yes. The Administrator was asked if an incident note and 1 staff statement was a thorough investigation. The Administrator stated, There should be more statements, more resident interviews and assessments. During an interview conducted on 1/17/2020 at 1:04 PM, the DON was asked if she was aware of the incident that was documented for Resident #64 on 12/18/2019. The DON stated, Yes. They (staff) came to me the day they did the incident report .said it looks like where he lays his hand on the chest .the aide said he does lay that hand on his chest constantly. The DON was asked if an investigation was done for the injury of unknown origin. The DON stated, No ma'am .It's an injury of unknown origin if you can't determine where something came from. The DON was asked how she knew what caused the bruising, and if he had always been placing his hands on his neck and chest since he had been admitted to the facility. The DON stated, I don't know how long he has been here. The DON was asked if this was a habit he had always had, then would the sudden large bruising be a red flag. The DON stated, I don't know . During a telephone interview conducted on 1/17/2020 at 1:22 PM, LPN #2 confirmed she had written the incident report for the bruising on 12/18/2019. LPN #2 was asked what she does when she finds something like that bruise. LPN #2 stated, Report it .I thought administrative staff always follow up on stuff like that. They have to sign off on our incidents. LPN #2 was asked if anyone ever came and interviewed her about the incident. LPN #2 stated, No. LPN #2 was asked if she had been asked to write a statement. LPN #2 stated, I did the incident report, but as far as a statement, no. During an interview conducted on 1/17/2020 at 8:47 PM, LPN #6 was asked what happened concerning the bruise on Resident #64's neck. LPN #6 stated, .I don't know what the deal is with that .I just saw it the other night. LPN #6 was asked if she reported it when she saw it. LPN #6 stated, I didn't report it . During an interview conducted on 1/17/2020 at 9:49 PM, the Regional Administrator was asked if an injury of unknown origin investigation should consist of only 1 interview. The Regional Administrator stated, No. You ask every person that worked in that time frame. Then you look at every resident on that hallway. See if it was the same staff that cared for them . During an interview conducted on 1/18/2020 at 2:07 PM, CNA #4 was asked when she first saw the bruise. CNA #4 stated, Tuesday (1/14/2020). I was giving him a bath. That was the first time I noticed it .I documented it Tuesday (1/14/2020) when I saw it .The nurse had told me if I see discoloration, I don't have to document it every day. They informed me don't be doing that. Just let her know it's there once. They said because that just makes more paperwork for the nurse. I have never heard of that before .When I first saw it my thing was Oh my God somebody has choked him. But the CNA in me knows .there are a lot of different factors. There should be documentation . During a telephone interview conducted on 1/19/2020 at 9:11 AM, the Medical Director was asked if he expected the staff to follow up on incidents like injuries of unknown origin and how long were they supposed to monitor. The Medical Director stated, .Generally, if there's a suspicion, we try to identify the reasons. Then afterward, the nursing staff is supposed to make sure the safety of the patient. The Medical Director was asked if he felt the incidents should be documented and followed up. The Medical Director stated, Oh yes, definitely. The Medical Director was asked if a bruise suddenly appeared, should an investigation be done. The Medical Director stated, .If just laying his (Resident #64's) hand there is causing that dark of a bruise I'm concerned .Yeah .if there's a hand print definitely should investigate . The Medical Director was then asked about Resident #12's bruising and swelling to her left arm that was documented on 11/30/2019 and not investigated. The Medical Director stated, .I think they should have looked into that .They should have followed up and at least documented . During an interview conducted on 1/22/2020 at 11:06 AM, LPN #4 was asked what she did when she became aware of and documented the bruise to Resident #64's neck on 1/10/2020. LPN #4 stated, I told the Administrator and she said that she would take care of it. The facility was unable to provide documentation that a thorough investigation was conducted to determine the cause of the injuries of unknown source and rule out abuse for Resident #12 and #64. The facility failed to continue implementation of the plan of correction after the complaint survey on 7/22/2019 where Abuse was cited at an IJ level. The facility failed to recognize the injuries to Resident #12 and #64 as an injuries of unknown origin, failed to thoroughly investigate the injuries that could be indicative of abuse, and failed to protect the residents from further potential abuse, which placed Resident #12 and #64 in Immediate Jeopardy. The survey team verified the Removal Plan by: 1. On 1/17/2020, the DON reassessed Resident #12 and #64 to verify locations and extents of the injuries. The DON interviewed staff on shifts before and after the incidents occurred. The nursing management and nursing team completed body audits on 100% of residents on 1/17/2020 and 1/18/2020. Education was started with 100% staff on 1/17/2020 on reporting alleged abuse allegations, including injuries of unknown origin and how to conduct a thorough investigation. On 1/19/2020, interviews were conducted with residents on the 200 and 400 halls, where the incidents occurred. The survey team reviewed the resident assessments, resident interview statements, and staff interview statements, and interviewed residents and staff regarding the education provided by the facility. 2. The facility determined that all admitted residents had the potential to be affected. The DON reviewed all the resident skin audits, and any areas subject to abuse were investigated. The survey team reviewed the skin audits and documentation was available for each area identified. 3. The DON and the Administrator conducted in-service education to direct care staff which addressed circumstances that required their responsibilities related to investigations. The survey team reviewed in-service sign in sheets and interviewed staff regarding the education provided by the facility. 4. The DON or her designee will conduct random audits of 10 residents twice weekly for 4 weeks, 20 residents biweekly for 2 months, then 30 residents monthly for 2 months. The residents will be assessed and interviewed to ensure that any injuries are identified and properly investigated. The audit findings will be discussed in Resident Council and the plan of correction will be monitored during the monthly Quality Assurance meeting. The survey team reviewed the audit tools and conducted administrative staff interviews. Noncompliance of F-610 continues at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure Care Plans were revised to reflect the residents' current status for severe weight loss and pressure ulcers for 3 of 28 sampled residents (Resident #55, #33, and #74) reviewed. The failure of the facility to revise the care plans for severe weight loss with effective interventions to prevent further weight loss resulted in actual Harm when Resident #55 sustained severe weight loss. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, showed, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The comprehensive, person-centered care plan will .Incorporate identified problem areas .Incorporate risk factors associated with identified problems .Identifying problem areas and their causes .are the endpoint of an interdisciplinary process .No single discipline can manage an approach in isolation .Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making .When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers .Care planning individual symptoms in isolation may have little, if any, benefit for the resident .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .The Interdisciplinary Team must review and update the care plan .When there has been a significant change in the resident's condition . Review of the facility's policy titled, Weight Assessment and Intervention, dated 12/2019, showed, .The threshold for significant unplanned and undesired weight loss will be based on the following criteria .a. 1 month-5% (percent) weight loss is significant; greater than 5% is severe .b. 3 months-7.5% weight loss is significant; greater than 7.5% is severe .c. 6 months-10% weight loss is significant; greater than 10% is severe . 1. Medical record review showed, Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan dated 9/1/2019, showed, .Potential for impaired nutrition and hydration .Interventions .Diet, fluids, and supplements to be given as ordered. Date Initiated: 09/01/2019 .Notify physician as needed. Date Initiated: 09/01/2019 .Refer to ST (Speech Therapy) and RD (Registered Dietician) as needed. Date Initiated: 09/01/2019 .Weigh per facility protocol and MD (Physician) orders. Date Initiated: 09/01/2019 . Review of the quarterly MDS assessment dated [DATE], showed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment, a height of 66 inches, a weight of 134 pounds, and a weight loss of 5% or more in the past month or 10% or more in the last 6 months, and was not on physician-prescribed weight-loss regimen. Review of the Weights and Vitals Summary showed the following weights: a. 7/9/2019 155 pounds b. 8/1/2019 156 pounds c. 9/2/2019 152 pounds d. 10/1/2019 138 pounds (severe weight loss of 9.21% in 1 month, and 10.96 % in 3 months) e. 11/6/2019 134 pounds (severe weight loss of 14.1% in 3 months) f. 12/19/2019 134 pounds (severe weight loss of 11.84% in 3 months) g. 1/6/2019 132.2 pounds (severe weight loss of 14.7% in 6 months) h. 1/17/2020 128.2 pounds (weight loss of 7.1% weight loss in 3 months, and severe weight loss of 17.29 % in 6 months) Review of the nutrition note dated 10/3/2019, showed, .has had a 10% weight loss in last 6 months .significant weight loss . The Care Plan was not revised to reflect Resident #55's current status for severe weight loss. The failure of the facility to revise the care plans for severe weight loss with effective interventions implemented to prevent further weight loss caused actual Harm when Resident #55 sustained severe weight loss. Refer to F-692 2. Review of the medical record showed, Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS dated [DATE], showed Resident #33 was severely cognitively impaired and had 1 unhealed Stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough). Review of the Care Plan dated 11/21/2019, showed Resident #33 had potential for impairment to skin integrity related to fragile skin, decreased mobility and incontinence. The Care Plan was not revised to reflect the current status of actual pressure ulcer. Observation in the resident's room on 1/14/2020 at 4:45 PM, showed Resident #33 had a pressure ulcer to his buttocks. During an interview conducted on 1/17/2020 at 3:37 PM, the MDS Coordinator confirmed that the Care Plan failed to reflect Resident #33's pressure ulcer. 3. Review of the medical record, showed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan dated 9/14/2019 showed, Pressure ulcer actual or at risk due to: Bed fast, Bowel Incontinence .Stage 4 sacrum .Administer Vitamins & (and Supplements as ordered .Conduct weekly skin inspection .Provide Wound Care . Review of the physician's orders [REDACTED].Clean sacral wound STAGE IV (4) (Full thickness tissue loss with exposed bone, tendon, or muscle) with wound cleanser, apply sureprep (liquid film forming dressing) to intact surrounding skin, window peri-wound (around wound) with drape, fill wound bed with green foam, cover with drape, apply wound vac (vacuum) at 120MMHG (millimeters of Mercury), change Mon (Monday) Wed (Wednesday) Fri (Friday) and prn (as needed) . Review of the physician's orders [REDACTED].Wed .Fri . Review of the Weekly Wound Evaluation dated 1/6/2020 showed, Resident #74 had a Stage 3 pressure ulcer (Full thickness tissue loss with subcutaneous fat that may be visible but bone, tendon, or muscle are not exposed) to his left outer ankle and a Stage 4 pressure ulcer to his sacrum. Review of the quarterly MDS dated [DATE], showed Resident #74 had a Stage 4 pressure ulcer. Observation in the resident's room on 1/15/ at 4:54 PM, showed Resident #74 had a pressure ulcer to his sacrum with a wound vac dressing in place, and a pressure ulcer to his left ankle. The Care Plan was not revised to reflect Resident #74's Stage 3 pressure ulcer. During an interview conducted on 1/17/20 at 3:37 PM, the MDS Coordinator confirmed wounds should have care plans and appropriate interventions. The MDS Coordinator stated, (Named LPN #1) has been turning in a list and I have been reviewing. It should have been on his care plan. It should show his wound vac .

Based on the Registered Dietitian Service Agreement, policy review, job description review, medical record review, observation, and interview, the facility failed to ensure residents maintained acceptable parameters of nutritional status, and failed to accurately assess, implement, and monitor interventions to prevent severe weight loss for 1 of 12 sampled residents (Resident #55) reviewed for weight loss. The facility's failure to identify, assess, implement, and monitor interventions to prevent severe weight loss resulted in actual Harm when Resident #55 sustained severe weight loss. The findings included: Review of the facility's policy titled, Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, dated 9/2017, showed .The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time .The staff and physician will define the individual's current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with anorexia, weight loss or gain, and significant risk for impaired nutrition . Review of the facility's policy titled, Weight Assessment and Intervention, dated 12/2019, showed, .The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter .Any weight change of 5% (percent) or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will notify the Dietitian by receipt of resident weights .The Dietitian will respond within a week of receipt of resident weights .The threshold for significant unplanned and undesired weight loss will be based on the following criteria .a. 1 month-5% weight loss is significant; greater than 5% is severe .b. 3 months-7.5% weight loss is significant; greater than 7.5% is severe .c. 6 months-10% weight loss is significant; greater than 10% is severe . Review of the undated facility's job description titled, Director of Dietary, showed, .Perform necessary nutritional screens for .dietitian and calculate nutritive intake within the scope of practice as defined by the Dietary Manager's Association (DMA) and/or American Diabetes Association (ADA) .Identify nutrition concerns and make appropriate referrals .Implement diet plans and physician's diet orders .Utilize standard nutrition care procedures . Review of the undated Consultant Registered Dietitian's (RD) Job Description, showed, .Duties and Responsibilities .The RD will review charts for residents identified on the flow sheet .The RD will assess the resident information provided and determine resident needs .Recommendations will be made based on the information assessed and provided by the facility .Charts will be updated including the RDs (RD's) assessment of resident's needs .The RD will discuss any questions regarding these assessments with facility staff, resident . Review of the Registered Dietitian Consulting Service Agreement, dated 1/19/2018, showed, .(Named Corporation) will provide Registered Dietitians to assistance (assist) with dining operations and nutritional care. The services provided will include .resident assessments/nutritional support .chart reviews . Review of the facility's undated policy titled, RESIDENT WEIGHT GATHERING/MONITORING/INTERVENTIONS .RESIDENT WEIGHT MONITORING, showed, .Each community is to have a Weight Team. The weight team should consist of a Weight Nurse Manager, who will be the Weight Team Coordinator, and a Dietetics Professional .WEIGHT TEAM COORDINATOR-RESPONSIBILITIES .Coordinate the weighing responsibilities of the nursing assistants (restorative aides) regarding weekly and monthly weight .Review weekly/monthly weights. Provide re-weight list for restorative aides .Follow policy and procedures for residents experiencing significant or trending weight loss .WEEKLY WEIGHT LOSS FORM is to be updated with the current weight and any pertinent information prior to the start of the meeting .Computer access during the meeting is essential for immediate documentation of interventions .Notify physician and RP (Responsible Party) of significant weight loss/gradual decline .Determine appropriate interventions .Weight loss must be addressed on the resident's care plan with realistic and attainable goals .5% WEIGHT LOSS IN 30 DAYS .10% WEIGHT LOSS IN 180 DAYS . Medical record review showed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan revised 9/1/2019, showed, .Potential for impaired nutrition .Interventions .Diet, fluids, and supplements to be given as ordered .Refer to .RD (Registered Dietitian) as needed . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment, required supervision/setup help with eating, a height of 66 inches, a weight of 134 pounds, and a weight loss of 5% or more in the past month or 10% or more in the last 6 months, and not on a physician-prescribed weight-loss regimen. Review of the Weights and Vitals Summary showed the following weights: a. 7/1/2019 144 pounds (lbs) b. 7/3/2019 151 lbs c. 7/9/2019 155 lbs d. 8/1/2019 156 lbs e. 9/2/2019 152 lbs f. 10/1/2019 138 lbs (severe weight loss of 9.21% in 1 month, and 10.96% in 3 months) g. 11/6/2019 134 lbs (severe weight loss of 14.1% in 3 months) h. 12/19/2019 134 lbs (severe weight loss of 11.84% in 3 months) i. 1/6/2020 132.2 lbs (severe weight loss of 14.7% in 6 months) k. 1/17/2020 128.2 lbs (severe weight loss of 7.1% weight loss in 3 months, and 17.29% in 6 months) Review of the Nutrition Note dated 6/27/2019, showed, .(Resident #55) is receiving Provide Gold protein (liquid protein supplement) BID (twice per day) .He is on a mechanical soft diet with fortified foods and large portions .Ice Cream with lunch and dinner .gets a sandwich at HS (bedtime) snack .Recommend a 4 oz. (ounces) Mighty shake (milkshake with increased calories) for afternoon snack due to weight loss . Review of the physician's orders [REDACTED].@ (at) 3 pm R/T (Related/To) weight loss concerns . Review of a Nurse's Note dated 7/1/2019, showed, .4 oz mighty shake q day at 3 pm r/t weight loss concerns per dietary rec (recommendations) . Review of a Nutrition Note dated 7/11/2019, showed, .receiving 30 ml (milliliters) liquid protein (Provide Gold) BID .Recommend to continue current diet and supplements . Review of the (MONTH) 2019 Medication Administration Record [REDACTED].Started 10/23/18 (2018) .HOUSE SUPPLEMENT (liquid supplement with increased calories) 120ML BY MOUTH THREE TIMES DAILY .Started 10/23/18 (2018) . The MAR indicated [REDACTED]. There was no documentation Provide Gold or House Supplement was administered after 8/19/2019. Review of the (MONTH) 2019 MAR, showed there was no documentation the Mighty Shake was administered. Review of the (MONTH) 2019 MAR, showed there was no documentation the House Supplement, Mighty Shake, or the Provide Gold was administered. Review of the Nutrition Note dated 9/19/2019, showed Resident #55, .has now lost 4 lbs in a month .gets a Mighty shake at afternoon snack . Review of the Nutrition Note dated 10/3/2019, showed, .has had a 10% weight loss in last 6 months .He is on a mechanical soft diet with thin liquids. He gets ice cream with lunch and supper. He gets Mighty shakes at afternoon snack and a sandwich and cola at HS snack .Recommend fortified foods due to 10% of body weight lost in last 6 months . The facility was unable to provide documentation the Registered Dietician (RD) did any further assessments on Resident #55 after 10/3/2019. Review of the (MONTH) 2019, (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019 MARs, showed there was no documentation the House Supplement, Mighty Shake, or the Provide Gold was administered. The facility was unable to provide documentation the mighty shakes, house supplements, or protein supplement were administered after 8/19/2019. Observation in the resident's room on 1/16/2020 from 1:45 PM to 2:30 PM, showed Resident #55 did not receive a supplement. During an interview conducted on 1/16/2020 at 9:53 AM, the RD confirmed Resident #55 was still losing weight, and her last nutrition note and assessment was in October, 2019. The RD was asked about Resident #55's severe weight loss follow-up. The RD stated, I dropped the ball . During an interview conducted on 1/16/2020 at 11:23 AM, the Dietary Manager was asked about Resident #55's severe weight loss. The Dietary Manager stated that she had discussed the Resident #55's weights with the Director of Nursing (DON) and she had assumed the DON had relayed the information to the RD. The Dietary Manager confirmed that a new intervention should have been implemented for Resident #55's severe weight loss. During an interview on 1/16/2020 at 3:57 PM, Certified Nursing Assistant (CNA) #1 was asked who administered Resident #55's nutritional supplement. CNA #1 stated, The nurse brings it to him. During an interview conducted on 1/16/2020 at 4:00 PM, Licensed Practical Nurse (LPN) #2 was asked who administered Resident #55's nutritional supplement. LPN #2 stated, The CNAs bring it to him. During an interview conducted on 1/17/2020 at 11:23 AM, the DON was asked if the RD was made aware of Resident #55's severe weight loss. The DON stated, She (RD) put all the weights into the computer herself, so she was aware. During an interview conducted on 1/19/2020 at 9:30 AM, the Medical Director (Resident #55's physician) was asked if he should be notified of a severe weight loss. The Medical Director stated, .For severe weight loss, one of the nursing staff should notify me. The Medical Director was asked if he expected the RD to follow-up with residents with significant or severe weight loss. The Medical Director stated, Yes, definitely. The Medical Director was asked if he was aware of Resident #55's severe weight loss of 17.29% in 6 months. The Medical Director stated, No. I don't recall that. During an interview conducted on 1/21/2020 at 2:10 PM, the RD and Licensed Practical Nurse (LPN) #2 were asked where to find documentation the supplements were administered. The RD and LPN #2 confirmed the orders for supplements had never been transcribed and were never entered into the electronic medical record for administration. The RD confirmed she had not followed up to ensure her recommendations were followed. The facility's failure to identify, assess, implement, and monitor interventions to prevent weight loss caused actual Harm when Resident #55 sustained severe weight loss.

Based on policy review, observation, and interview, the facility failed to properly store garbage in a covered dumpster on 5 of 11 days (1/15/2020, 1/17/2020, 1/18/2020, 1/20/2020, and 1/22/2020) of the survey. The findings include: Review of the facility policy titled, Food-Related Garbage and Refuse Disposal, revised 10/2017, showed, .Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter . Observation at the facility's outside dumpsters on 1/15/2020 at 1:51 PM and 7:45 PM, showed the gate of the fence surrounding the dumpsters opened, 2 bags of trash hanging out of left side of the large dumpster, gloves and loose trash lying on the ground around the dumpsters. Observation at the facility's outside dumpsters on 1/17/2020 at 7:15 PM, showed the gate of the fence surrounding the dumpsters opened, 3 garbage bags lying on the ground on the left side of the large dumpster, 1 trash bag hanging out of the left side of the large dumpster, and 1 trash bag hanging out of the top of the large dumpster. Observation of the facility's dumpsters on 1/18/2020 at 12:00 PM, showed the gate of the fence surrounding the dumpsters opened, 2 trash bags partially hanging out of the large dumpster on the right side, 8 garbage bags lying on the ground surrounding the dumpsters, and 1 bag lying on top of the small dumpster. Observation of the facility's dumpsters on 1/20/2020 at 2:00 PM, showed the gate of the fence surrounding the dumpsters opened, multiple bags on the ground around the dumpsters, the sides of the large dumpster open with bags hanging out, the top of large dumpster open with bags exposed, and bags on the ground. Observation of the facility's dumpsters on 1/22/2020 at 1:30 PM, showed the gate of the fence surrounding the dumpsters opened, numerous bags and gloves on the ground around the dumpsters, and the lid of the large dumpster was not closed. During an interview conducted on 1/18/2020 at 6:46 PM, the Regional Administrator was asked should the gates to the facility dumpster be left opened, trash bags hanging out of the dumpster, and gloves, loose trash, and trash bags lying on the ground around the dumpster. The Regional Administrator stated, No ma'am .should be cleaned daily .

Based on policy review, observation, and interview, the facility failed to promote and enhance the residents' dignity when staff did not close the blinds when performing pressure injury treatments, did not knock on the residents' doors prior to entering the residents' room, and did not close the blinds when weighing a resident for 5 of 25 sampled residents (Resident #75, #30, #47. #71, and #23) reviewed. The findings include: Review of the facility's policy titled, Quality of Life--Dignity, revised 8/2009, showed .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .Residents shall be treated with dignity and respect at all times .Staff will knock and request permission before entering residents' rooms . 1. Observation in the resident's room on 1/12/2020 at 2:30 PM, showed Registered Nurse (RN) #2 entered Resident #75's room without knocking or verbally announcing her presence. Observation in the residents' shared room on 1/13/2020 at 8:20 AM, showed Certified Nursing Assistant (CNA) #9 entered Resident #30 and Resident #47's room without knocking or verbally announcing her presence. Observation in the the resident's room on 1/15/2020 at 11:40 AM, showed RN #3 entered Resident #71's room without knocking or verbally announcing her presence. During an interview conducted on 1/17/2020 at 5:21 PM, the Director of Nursing (DON) confirmed staff should always knock or verbally announce their presence before entering a resident's room. 2. Observation in the resident's room on 1/14/2020 at 10:38 AM, showed Licensed Practical Nurse (LPN) #1 and LPN #8 entered Resident #23's room to perform a dressing change. LPN #8 closed the blinds but failed to lower them to the bottom of the window, leaving an area of approximately 1 foot open. Resident #23 was turned toward the window and her gown was raised to her upper torso, leaving the resident exposed from the upper torso to her feet. A truck was parked beside the window. While the treatment was in progress, a man walked beside the window and entered the truck. Resident #23 was exposed to the open window throughout the procedure. During an interview conducted on 1/14/2020 at 10:56 AM, LPN #1 confirmed the blinds were not completely closed. During an interview conducted on 1/17/2020 at 11:34 AM, the DON confirmed that the blinds should not be left partially raised during a dressing change and that the blinds should be closed completely. 3. Observation in the resident's room on 1/17/2020 at 9:45 AM, showed CNA #7 and CNA #8 placed the mechanical lift pad under Resident #71 to weigh him. During the weighing process, Resident #71's gown was up to his waist and his brief was exposed while the window blinds leading to the parking lot were left open. During an interview conducted on 1/17/2020 at 9:55 AM, LPN #7 stated, I was so focused on the weighing, I did not realize the blinds were open. During an interview conducted on 1/17/2020 at 11:35 AM, the DON confirmed that the blinds should have been closed when weighing the resident. The DON confirmed Resident #71's brief should not be visible.

Based on review of the Prevention and treatment of [REDACTED].#23, #32, #56, and #74) reviewed for pressure ulcers. The findings include: Review of the Prevention and treatment of [REDACTED].Stage I: Non blanchable (skin does not lose redness when pressure applied) [DIAGNOSES REDACTED] (redness of skin). Intact skin with non-blanchable redness of a localized area usually over a bony prominence .Stage II: Partial Thickness Skin Loss .presenting as a shallow open ulcer with a red pink wound bed .May also present as an intact or open/ruptured serum-filled blister .Stage III: Full Thickness Skin Loss .subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough (dead tissue) may be present .May include undermining and tunneling .Stage IV: Full Thickness Tissue Loss .with exposed bone, tendon, or muscle. Slough or eschar (a thick crust) may be present .Unstageable: Depth unknown, Full thickness tissue loss in which the base of the ulcer is covered by a slough (yellow, tan, gray, green, or brown) and or eschar (tan, brown, or black) in the wound bed .Suspected Deep Tissue Injury: Depth unknown. Purple maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure . Review of the facility's policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised 4/2018, showed, .Assessment and Recognition .The nursing staff and practitioner will assess and document .Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue .Current treatments .Treatment/Management .The physician will order pertinent wound treatments . Review of the facility's policy titled, Wound Care, revised 10/2010, showed, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Documentation .The following information should be recorded in the resident's medical record .The type of wound care given .The date and time the wound care was given .The signature and title of the person recording data . 1. Review of the medical record, showed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of An Interdisciplinary Progress Note dated 1/17/2019, showed Resident #23 was admitted to the facility with an unstageable pressure injury with eschar and slough present to the sacrum and a [DEVICE] and Santyl (an enzymatic [MEDICATION NAME] ointment) was the treatment. Review of an Interdisciplinary Progress Note dated 4/19/2019, showed, .continues to have unstg (unstageable) wound to sacrum ((symbol for with) appearance of stg (stage) 4) . Review of a Weekly Wound Evaluation dated 9/2/2019, showed, Unstageable .Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed .Site .Sacrum .Unstageable .Length: 4.2 (centimeters (cm)) .Width: 4 (cm) .Depth .1 (cm) .) .Wound Color: (checked) Pink . There was no documentation of slough or eschar present, and the wound had depth. Review of the Weekly Wound Evaluations from 9/2/2019 to 1/15/2020, showed the sacral pressure injury was classified as an unstageable pressure ulcer with depth and pink in color. There was no documentation of the wound bed being covered with eschar or slough. During an interview conducted on 1/16/2020 at 8:46 AM, the Nurse Practitioner stated, .once the slough or eschar comes off you can stage it . The Nurse Practitioner confirmed the pressure ulcer should have been assessed and staged once the slough and eschar were not present. During an interview conducted on 1/16/2020 at 2:42 PM, the Wound Care Nurse was asked what stage Resident #23's sacral pressure was on admission. The Wound care Nurse stated, It was unstageable when she admitted .slough in the wound bed . Review of a physician's orders [REDACTED].#23 had orders for, .clean unstageable (pressure injury) to sacrum with wound cleanser and apply calcium alginate (highly absorbent dressing) and cover with ABD (abdominal dressing) .one time a day .AND every 24 hours as needed . Review of the (MONTH) 2019 and (MONTH) 2019 Treatment Administration Records (TARs), showed no documentation these treatments were performed as ordered or refused on 9/14/2019, 9/15/2019, 9/19/2019, 9/28/2019, 9/29/2019, 10/8/2019, 10/9/2019, 10/12/2019, and 10/13/2019. Review of a physician's orders [REDACTED].#23 had orders for, .skin prep (liquid film forming dressing) to SDTI (Suspected Deep Tissue Injury) to pad of left foot one time a day . Review of the (MONTH) 2019 TAR, showed no documentation these treatments were performed as ordered or refused on 9/14/2019, 9/15/2019, 9/19/2019, 9/28/2019, and 9/29/2019. Review of a physician's orders [REDACTED].#23 had orders for, .clean unstageable to sacrum with wound cleanser and apply silver alginate (absorbent wound dressing) and cover with dressing one time a day AND every 24 hours as needed . Review of the (MONTH) and (MONTH) 2019 TARs, showed no documentation these treatments were performed as ordered on [DATE], 11/30/2019, 12/1/2019, 12/5/2019, and 12/7/2019. Review of a physician's orders [REDACTED].#23 had orders for, .clean open area to pad of left foot with wound cleanser and apply xeroform (petroleum gauze dressing) and dressing one time a day . Review of the (MONTH) 2019 and (MONTH) 2019 TARs, showed no documentation these treatments were performed as ordered or refused on 11/29/2019, 11/30/2019, 12/1/2019, 12/4/2019, and 12/7/2019. Review of a physician's orders [REDACTED].#23 had orders for, .clean unstageable to sacrum with wound cleanser and apply collagen (absorbent dressing) and cover with dressing one time a day . Review of the (MONTH) 2019 TAR showed there was no documentation these treatments were performed as ordered on [DATE], 12/21/2019, 12/22/2019, and 12/28/2019. During an interview conducted on 1/15/2020 at 4:20 PM, the Director of Nursing (DON) confirmed Resident #23's treatments for the sacrum and pad of left foot pressure injuries were not documented as performed on these dates. The DON was asked should pressure injury treatments be performed as ordered. The DON stated, Yes . Observation in the resident's room during wound care on 1/14/2020 beginning at 10:25 AM, showed the Wound Care Nurse removed the dressing from Resident #23's sacral pressure injury. The wound had a dark pink wound bed with no slough or eschar present which had the appearance of a Stage 3 pressure injury. 2. Review of the medical record, showed Resident #32 was admitted to the facility on [DATE] had [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#32 had orders to, .clean ruptured blister to sacrum with wound cleanser and apply hydrogel (wound gel dressing) and foam dressing one time a day evey Mon (Monday), Wed (Wednesday), Fri (Friday) . Review of the (MONTH) 2019 TAR, showed no documentation that the treatment was performed as ordered on [DATE]. Review of the physician's orders [REDACTED].#32 had orders for, .clean ruptured blood blister left heel with wound cleanser and apply dry dressing qd (every day) one time a day . Review of the (MONTH) 2019 TAR, showed no documentation these treatments were performed as ordered on [DATE] and 11/30/2019. Review of the physician's orders [REDACTED].#32 had orders for, .skin prep to blister to right great toe one time a day . Review of the (MONTH) 2019 TAR, showed no documentation these treatments were performed as ordered on [DATE] and 11/30/2019. 3. Review of the medical record showed, Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#56 had orders for, .skin prep to intact purple area to left heel one time a day-Start Date 11/27/2019-D/C (discontinue) Date-12/10/2019 . Review of the (MONTH) 2019 and (MONTH) 2019 TARs, showed no documentation these treatments were performed as ordered on [DATE], 11/30/2019, 12/1/2019, 12/6/2019, and 12/7/2019. 4. Review of the medical record, showed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan dated 9/14/2019 showed Resident #74 had, Pressure ulcer actual or at risk due to: Bed fast, Bowel Incontinence .Stage 4 sacrum .Administer Vitamins & (and Supplements as ordered .Conduct weekly skin inspection .Provide Wound Care . Review of the physician's orders [REDACTED].#74 had orders to, .Clean sacral wound STAGE IV with wound cleanser, apply sureprep (liquid film forming dressing) to intact surrounding skin, window peri-wound (around wound) with drape, fill wound bed with green foam, cover with drape, apply wound vac (vacuum) at 120MMHG (Millimeters of Mercury), change Mon Wed Fri and prn(as needed) . Review of the (MONTH) 2019 and (MONTH) 2019 TARs, showed no documentation these treatments were performed as ordered on [DATE] (Monday), 9/30/2019 (Monday), and 10/9/2019 (Wednesday). Review of Skin/Wound Note dated 10/10/2019 at 10:12 AM, showed, .wound vac was changed per this nurse due to wound vac not changed on 10/9/19 (2019) . Review of the (MONTH) 2019 TAR showed no documentation these treatments were performed as ordered on [DATE] (Friday). Review of the (MONTH) 2019 TAR showed no documentation these treatments were performed as ordered on [DATE] (Friday) and 12/23/2019 (Monday). During an interview conducted on 1/17/2020 at 9:04 AM, Licensed Practical Nurse (LPN) #1 confirmed treatments for the [DEVICE] were not documented as performed on 9/16/2019, 9/30/2019, 10/9/2019, 11/29/2019, 12/6/2019, and 12/23/2019. LPN #1 reviewed each missing day for documentation. LPN #1 stated, I'm not seeing it.

Based on medical record review, observation, and interview, the facility failed to provide and document treatments for arterial wounds for 1 of 1 sampled residents (Resident #47) reviewed with arterial wounds (wounds caused by poor blood perfusion and circulation to the lower extremities). The findings include: Review of the medical record, showed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set ((MDS) dated [DATE], showed Resident #47 had 1 venous/arterial wound. Review of the Care Plan revised 11/13/2019, showed, .Right Ankle Arterial wound .Interventions .administer .treatments as ordered . Review of the physician's orders [REDACTED]. 1. .Order Date .9/13/2019 .clean open area to right outer ankle with wound cleanser and apply xeroform (occlusive non adherent dressing), 4 x (by) 4 and wrap with gauze qd (every day) one time a day . Review of the TARs for September, 2019, showed no documentation that treatments were administered as ordered on [DATE], 9/19/2019, 9/22/2019, and 9/28/2019. 2. .Order Date .10/16/2019 .clean open area to right outer ankle with wound cleanser and apply xeroform, 4 x 4 and wrap with gauze qd as needed AND one time a day . Review of the TARs for October, 2019, showed no documentation that treatments were administered as ordered on [DATE], 10/12/2019, 10/13/2019, 10/16/2019, and 10/19/2019. 3. .Order Date .10/25/2019 .Restore Silver Dressing Pad (Wound Dressings) Apply to right outer ankle topically one time a day for arterial wound after cleaning with [MEDICATION NAME] (antibacterial and antimicrobial cleanser) and cover with 4 x 4 and wrap with gauze . Review of the TARs for November, 2019, showed no documentation that treatments were administered as ordered on [DATE], 11/3/2019, 11/15/2019, 11/17/2019, 11/18/2019, 11/22/2019, 11/29/2019, and 11/30/2019. 4. .Order Date .12/3/2019 .[MEDICATION NAME] Ointment 2 % (percent) (Mupirocin) (antibiotic) Apply to right outer ankle topically one time a day for wound after cleansing with wound cleanser then apply [MEDICATION NAME] (non adherent medicated pad), 4 x 4 and wrap with gauze and secure with tape . 5. .Order Date .12/9/2019 .[MEDICATION NAME] Ointment 2 % (Mupirocin) Apply to right outer ankle topically one time a day for wound after cleansing with wound cleanser then apply [MEDICATION NAME] and dressing . Review of the TARs for December, 2019, showed no documentation that treatments were administered as ordered on [DATE], 12/6/2019, 12/7/2019, 12/8/2019, 12/14/2019, and 12/18/2019. During an interview conducted on 1/13/2020 at 11:15 AM, Resident #47 was asked if she had any skin issues or wounds that required treatments or dressing changes. Resident #47 stated, .on my right foot .They do not treat it on the weekends .They will say we don't have time .We are too busy . Wound care observation in Resident #47's room on 1/15/2020 at 10:20 AM, showed a large open wound to Resident #47's right ankle with a red center and redness surrounding the wound. Licensed Practical Nurse #1 stated, .It is a little more red today than normal .it's an arterial wound . During an interview conducted on 1/15/2020 at 4:52 PM, the Nurse Practitioner (NP) was asked if she expected treatments to be completed as ordered. The DNP stated, Yes.

Based on the medical record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for antipsychotic medication use, pressure injuries, and anticoagulant medication use for 3 of 28 sampled residents (Resident #21, #23, and #30) reviewed. The findings include: 1. Review of the medical record, showed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE], showed Resident #21 had received antipsychotic medications for 7 days of the past 7 days (10/11/2019-10/17/2019). Review of the physician's orders [REDACTED].#21. Review of the Medication Administration Record [REDACTED]. During an interview conducted on 1/17/2020 at 1:02 PM, the MDS Coordinator confirmed that Resident #21 did not receive an antipsychotic medication in (MONTH) 2019 and that the MDS was coded incorrectly. 2. Review of the medical record, showed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan revised 10/14/2019, showed, .Pressure ulcer actual or at risk .7/31/2019 Unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown soft dead tissue) and/or eschar (tan, brown, or black dead tissue)) Sacrum ulcer .10/14/2019 SDTI (Suspected Deep Tissue Injury (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear)) . Review of a Weekly Wound Evaluation dated 10/17/2019, showed Resident #23 had a Suspected Deep Tissue Injury on the pad of the left foot and an unstageable pressure ulcer on the sacrum. Review of the quarterly MDS dated [DATE], showed Resident #23 was coded for an unstageable pressure ulcer and was not coded for a SDTI During an interview conducted on 1/17/2020 at 3:26 PM, the MDS Coordinator confirmed that Resident #23 had 2 pressure injuries and the MDS dated [DATE] was coded incorrectly for pressure injuries. 3. Review of the medical record, showed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE], showed Resident #30 received anticoagulant medications for 6 days of the past 7 days. Review of the MAR indicated [REDACTED]. During an interview conducted on 1/17/2020 at 1:02 PM, the MDS Coordinator confirmed the admission MDS was inaccurate related to the use of anticoagulant mediations.

Based on policy review, medical record review, observation, and interview, the facility failed to assess 2 of 2 sampled residents (Resident #36 and Resident #37) for medication self-administration. The findings include: Review of the facility's policy titled, Self-Administration of Medications, revised 12/2016, showed, .Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so .As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident .The staff and practitioner will periodically (for example, during quarterly MDS (Minimum Data Set) reviews) reevaluate a resident's ability to continue to self-administer medications . 1. Review of the medical record, showed Resident #36 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE], showed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment, and required staff assistance for all activities of daily living (ADLs). Review of the physician's orders [REDACTED].[MEDICATION NAME] SUL (Sulfate) 2.5 MG (milligrams)/ (per) 3ML (milliliters) .1 vial inhale orally four times a day related to [MEDICAL CONDITION] . Observation in the resident's room on 1/12/2020 at 10:04 AM, showed Resident #36 sitting up in bed with a breathing treatment per nebulizer mask in progress and no staff were present. During an interview conducted on 1/14/2020 at 12:26 PM, the Director of Nursing (DON) was asked if Resident #36 could self-administer medications. The DON stated, I could not find anything on that in the paper chart . The facility was unable to provide documentation that a medication self-administration assessment had been conducted for Resident #36. 2. Review of the medical record, showed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE], showed Resident #37 had a BIMS of 3, which indicated severe cognitive impairment, no behaviors, and required staff assistance for all ADLs. Review of the physician's orders [REDACTED].IPRAT-ALBUT ([MEDICATION NAME]-[MEDICATION NAME]) 0.5-3(2.5) MG/3 ML 1 vial inhale orally as needed for [MEDICAL CONDITION] .1 AMP ([MEDICATION NAME]) .EVERY 6 HOURS AS NEEDED . Review of the Nursing: Admission/Readmission Nursing Evaluations Packet Self-Medication Administration assessment dated [DATE], showed, .Does the resident WANT to Self-Administer his/her own medications .No .STOP HERE (do not complete any further documentation on the form) . Observation in the resident's room on 1/12/2020 at 10:06 AM, showed Resident #37 sitting in a wheelchair at the bedside with a nebulizer treatment in progress per mask and no staff were present. During an interview conducted on 1/14/2020 at 12:26 PM, the DON was asked if Resident #37 could self-administer nebulizer treatments. The DON confirmed that Resident #37 did not have an assessment to self-administer medications. The facility was unable to provide documentation that Resident #37 was able to safely self-administer medications.

Based on policy review, review of the Administrator's job description, review of the Director of Nursing Services (DON) job description, hospital record review, review of a hall camera monitoring system recording, review of a facility investigation, open and closed medical record review, observation, and interview, the Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain and maintain the highest practicable well-being of the residents. The facility's Administrator/Abuse Coordinator's failure to protect cognitively impaired vulnerable female residents on a Secure Unit from potential sexual abuse and the failure to thoroughly investigate an allegation of sexual abuse placed 11 females residing on the Secure Unit in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 7/20/19 at 6:20 PM in the Conference Room. F600, F610, and F835 were cited at a scope and severity of J. The facility was cited F600-J and F610-J which are Substandard Quality of Care. A partial-extended survey was conducted from 7/20/19 through 7/22/19. The Immediate Jeopardy was effective from 7/9/19 through 7/22/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on 7/22/19 at 10:25 AM, and corrective actions were validated onsite by the surveyors on 7/22/19. The findings include: The facility's Administrator policy dated 8/2007 documented, .The governing board of this facility has appointed an Administrator who is duly licensed in accordance with current federal and state requirements. The Administrator is responsible for, but not limited to: .Implementing established resident care policies, personnel policies, safety and security policies, and other operational policies and procedures necessary to remain in compliance with current laws, regulations, and guidelines governing long-term care facilities .In the absence of the Administrator, the .Director of Nursing Services is authorized to act in the Administrator's behalf . 1. The facility's Administration CEO (Chief Executive Officer) (Administrator) Job Description documented, .The CEO is responsible for the day to day operations and direction of the facility, and insures that the facility complies with all policies and procedures set forth by The company, as well as those required by regulatory agencies .also ensure that expectations of the corporation and our customers are met or exceeded on a continual basis . The JOB DESCRIPTION AND PERFORMANCE STANDARDS for the Director of Nursing Services (DON) documented, .The purpose of this position is to provide nursing management, set resident care standard for all direct care providers and provide complete supervision and management for the nursing department .Assume accountability for the development, organization and implementation of approved policies and procedures .Assume responsibility for nursing service compliance with federal, state and local regulations .Be responsible for safety of residents under his/her supervision .Perform other related duties as directed by the Administrator and/or governing body .Follow Residents' Rights policies at all times . Interview with the Administrator and DON on 7/19/19 at 12:45 PM in the Conference Room, the Administrator and the DON were asked about the suspicion of sexual abuse on 7/9/19. The Administrator and the DON revealed the DON had been informed of staff observations and had examined Resident #2, concluded there was no evidence of sexual abuse, had informed the Administrator of her findings, and had not investigated further. Interview with the Administrator/Abuse Coordinator on 7/20/19 at 3:30 PM, in the Conference Room, the Administrator was asked if she agreed with the DON that the suspicion of sexual abuse reported by staff on 7/9/19 did not need to be further investigated. The Administrator stated, Yes. 2. The facility's Administrative Management (Governing Board) policy documented, .The facility's governing board is the supreme authority and has full legal authority and responsibility for the management and operation of our facility . Interview with the Regional Administrator and National Liaison/ Registered Nurse (RN) (Governing Board members) on 7/22/19 at 3:35 PM in the Conference Room revealed, the Board had a system process in place through which Administrators are required to report critical events, problems or concerns about what was going on in the facility. The Board was not notified of the allegation of sexual abuse on 7/9/19, the family grievance on 7/12/19, or the complaint investigation beginning 7/17/19. On the evening of 7/20/19 the Regional Administrator revealed she had been notified of the Immediate Jeopardy at F600 and F610. At that time, the Administrator and DON were immediately in-serviced on the facility Abuse Prevention policy and Federal requirements for investigation of abuse. On 7/21/19 and 7/22/19 re-education continued on the Board's required reporting process and State and Federal regulation and guidance. Monitoring by the Board would continue weekly for 2 weeks and monthly for 2 months for compliance with the Board's expectations for reporting and State and Federal regulation. Interview with the Medical Director on 7/22/19 at 5:45 PM in the Conference Room, when asked about his duties and responsibilities in the facility and the allegation of sexual abuse on 7/9/19, the Medical Director revealed he had not been informed of the allegation until after Resident #2's family entered the facility on 7/12/19 wanting to know why they hadn't been notified that Resident #2 had been sexually abused in the facility. The Medical Director also revealed he had made it clear to Administration that he was to be notified immediately of all abuse allegations in the facility from this point forward and stated, .I am ultimately responsible . The Medical Director revealed he attended Quality Assurance and Performance Improvement meetings monthly although only required to do so quarterly because it was very important to him to be aware of what was happening in the facility. 3. Administration failed to ensure 11 cognitively impaired vulnerable female residents residing in the Secure Unit were safe and protected from potential sexual abuse and failed to ensure Resident #2 was protected from sexual abuse. Refer to F600. 4. Administration failed to ensure a suspicion of resident sexual abuse was thoroughly investigated. Refer to F610. The surveyors verified the A[NAME] by: 1. Administration was in-serviced by the Regional Clinical Director and Regional Administrator on 7/21/19 with competency testing, on the importance of Identifying, Reporting and Completing a thorough investigation of sexual abuse to include: Identifying the abuse coordinator, Identifying all types of abuse: Physical, Verbal, Mental, Sexual, Misappropriation of funds, Neglect, Involuntary Seclusion, and Corporal Punishment; Ensure that all alleged violations involving abuse, neglect, and exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property, are reported immediately, but no later than 2 hours after the unknown allegation is made, if the event that cause the allegation involves abuse or results in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and other officials (including the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Facility Abuse policy and Federal/State regulation and guidelines for abuse were reviewed with the Administrator and the DON. The surveyors reviewed in-service sign in sheets and interviewed the Administrator and DON, who confirmed they had received in-service on Abuse Policy and Federal and State regulations and guidelines 2. Administrator and DON will monitor compliance for correctly identifying types of abuse and following the abuse policy daily and ongoing. Regional Clinical Director and Regional Administrator will monitor compliance of Identifying, Reporting and Completing a thorough investigation of all abuse allegations weekly times 2 weeks then monthly times 2 months. Regional Clinical Director and Regional Administrator will attend Quality Assurance (QA) / Quality Assurance Performance Improvement (QAPI) meeting monthly times 2. National Liaison/RN will conduct a third level review to verify compliance in all aspects of abuse compliance. Findings will be reported to QA/QAPI meeting monthly. The surveyors reviewed the tools for education which include the State Regulations and Federal Guidance for abuse, the Performance Improvement Project and the Rapid Response tools. The surveyors interviewed the Regional Administrator and the National Liaison/RN to confirm ongoing monitoring for compliance of identifying, reporting and completing a thorough investigation of all abuse allegations and reviewed the audit forms. 3. The facility conducted a QA meeting on 7/22/19 attended by department heads and the Medical Director. The surveyors interviewed the Medical Director who confirmed he had attended QA meetings in the past and will continue to do so monthly. Noncompliance of F835 continues at a scope and severity level of D for monitoring of the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, facility investigation review, review of a hall camera monitoring system recording, hospital record review, open and closed medical record review, observation, and interview, the facility failed to thoroughly investigate a suspicion of resident sexual abuse for 1 of 7 (Resident #2) sampled residents reviewed after Resident #2 was observed ambulating in the hall with a disheveled appearance from Resident #1's room. Resident #1 had repeated sexually inappropriate behaviors (physical, gestures and comments), and also resided on the Secure Unit. The facility's failure to thoroughly investigate a suspicion of resident sexual abuse placed the 11 vulnerable cognitively impaired female residents residing in the Secure Unit at risk for sexual abuse, which resulted in Immediate Jeopardy. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 7/20/19 at 6:20 PM in the Conference Room. F610 was cited at a scope and severity of J. The facility was cited F610J which is Substandard Quality of Care. A partial-extended survey was conducted from 7/20/19 through 7/22/19. The Immediate Jeopardy was effective 7/9/19 through 7/22/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on 7/22/19 at 10:25 AM, and corrective actions were validated onsite by the surveyors on 7/22/19. The findings include: 1. Review of the facility's Abuse Prohibition policy and procedure dated (MONTH) (YEAR) documented, Residents have the right to be free from abuse, corporal punishment, and involuntary seclusion .The facility must have evidence that all violations, including allegations, are thoroughly investigated .All center staff will be advised that they must ensure the following protocols are followed: .No one may disturb the scene where the alleged abuse took place .The resident may not be cleansed, until authorization from authorities is received .A complete body audit will be conducted by nursing staff, which will note specifically: signs of trauma, bruising, bodily fluids, torn clothing or linens .Once the scene has been cleared by officials (police or other investigative parties) the clothing and linens must be bagged and kept in a secure location .The alleged victim must be sent out immediately for a rape kit to be completed at the hospital .Investigation guidelines include: Resident(s) and responsible party interviews, as applicable .Physical examination .Staff interviews and written statements, as applicable .Methods to support the individual and detect and prevent further victimization . 2. Closed medical record review revealed Resident #2 was admitted to the facility 10/19/15 with [DIAGNOSES REDACTED]. Closed medical record of the annual MDS assessment dated [DATE] revealed unclear speech, a cognitive score of 3, which indicated severe cognitive impairment, continuous inattention, physical symptoms directed toward others, daily rejection of care, daily wandering. Resident #2 required limited assistance of staff for transfer and ambulation, extensive assistance for dressing and eating, and was dependent on staff for toileting, personal hygiene and bathing, and was always incontinent of bowel and bladder. Closed medical review of the comprehensive care plan for Resident #2 initiated on 4/26/19 revealed a history of wandering and impaired safety awareness. 3. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Medical record review of psychiatric hospital records revealed the resident was admitted from 12/27/18-1/16/19 to the psychiatric hospital. The psychiatric hospital History and Physical dated 12/28/18 documented, .This patient was displaying inappropriate sexual behavior. He was asking residents and staff for sex. Per records, he touched a CNA (Certified Nursing Assistant) inappropriately between her legs. He was also asking other people to come and get in the bed with him. He is here for behavior and medication management . Medical record review of the psychiatric hospital Discharge Summary dated 1/16/19 revealed [MEDICATION NAME] (an antidepressant) was started and increased during his stay and appeared, .to be effective with decreasing sexual urges and inappropriate behavior . [MEDICATION NAME] (A medication which counteracts the effect of testosterone in males) was also ordered. Medical record review of Resident #1's initial care plan dated 1/17/19, which was initiated on his return to the facility from an inpatient psychiatric hospital, revealed the resident had a behavior concern of inappropriate sexual behavior. The care plan was updated on 7/9/19 to reflect the resident's move to a room closer to the nurse's station and 7/10/19 for visual checks every 15 minutes for location. Medical record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a cognitive score of 3, which indicated severe cognitive impairment, and required limited assistance of staff for all activities of daily living (ADL). Medical record review of the nursing progress notes for Resident #1 dated 7/3/19, 7/9/19, 7/10/19, 7/17/19, and 7/20/19 revealed the resident continued to have sexually inappropriate behaviors. Interview with Certified Nursing Assistant (CNA) #2 on 7/19/19 at 1:30 PM in the Conference Room and LPN #1 on 7/19/19 at 1:45 PM in the Conference Room confirmed Resident #1's history and ongoing sexually inappropriate behaviors and confirmed Resident #2's history of continually wandering on the unit. 4. Review of the hall monitoring camera recording dated 7/9/19 from 6:03 PM through 6:23 PM revealed the following: Resident #2 had been casually and appropriately dressed wandering on the unit, sat at the nurses station next to Resident #1, stood and began wandering down the hall and was followed by Resident #1. Resident #1 and Resident #2 were observed to enter Resident #1's room at the end of the hall at 6:06 PM together, Resident #1 was walking on Resident #2's left side and had his right arm around Resident #2's lower back and hand at the right side of her waist. Resident #1 guided Resident #2 into his room. At 6:20 PM Resident #2 exited the room alone, shut the door, and wandered into a room across the hall. After Resident #2 came out of Resident #1's room, one of her legs was bare and she appeared to be inappropriately dressed. The resident was observed by the Registered Nurse (RN) Supervisor and CNA #2 in the hall. The resident was assessed by the RN Supervisor who reported her observations to the DON. 5. Interview with the RN Supervisor on 7/18/19 at 12:15 PM, in the Conference Room, the RN Supervisor confirmed her written statement of her observations on 7/9/19. The RN Supervisor revealed both of Resident #2's legs were in one pant leg, her pants were inside out and her brief was missing. The RN Supervisor confirmed she had notified the DON, who came to the unit and examined the resident. After the RN Supervisor had written her statement, she had asked the DON if she should document her observations on an incident report or make any contacts and was told, .not at this point Interview with CNA #2 on 7/18/19 at 12:15 PM, in the Conference Room, CNA #2 confirmed her written statement of her observations on 7/9/19. CNA #2 revealed both of Resident #2's legs were in one pant leg, her pants were inside out and her brief was missing. Interview with the DON on 7/18/19 at 2:50 PM, in the Conference Room, the DON stated she checked Resident #2's brief in the trash can, and she only noticed fresh urine in the brief. Interview with the Nurse Practitioner on 7/18/19 at 4:15 PM, in the Conference Room, the Nurse Practitioner was asked if she was notified when this incident occurred. The Nurse Practitioner stated, .She (nurse) called me .told her (nurse) to call DON and Administrator and follow their policy and procedures . Interview with the Administrator and DON on 7/19/19 at 12:45 PM in the Conference Room, when asked about staff reporting their observations on 7/9/19, the DON revealed she had been notified 7/9/19, had examined Resident #2, had concluded there was no evidence of sexual abuse, had notified the Administrator of her findings and they had not investigated the incident further. The suspicion of sexual abuse occurred on 7/9/19, and Resident #2 was not sent to the hospital for a rape kit until 7/12/19, when the family insisted the resident be transferred to the hospital. Interview with the Administrator/Abuse Coordinator on 7/20/19 at 3:30 PM, in the Conference Room, the Administrator was asked if she agreed with the DON that the allegation of sexual abuse reported by staff on 7/9/19 did not need to be further investigated. The Administrator stated, Yes. The facility's failure to thoroughly investigate a suspicion of sexual abuse placed the 11 cognitively impaired female residents residing on the Secure Unit at risk of potential sexual abuse which resulted in Immediate Jeopardy. Refer to F 600. The surveyors verified the A[NAME] by: All staff were in-serviced by the facility Administrator and DON beginning on 7/17/19 with competency testing, on the importance of Identifying, Reporting and Completing a thorough investigation of sexual abuse to include: Identifying the Abuse Coordinator, Identifying all types of abuse: Physical, Verbal, Mental, Sexual, Misappropriation of funds, Neglect, Involuntary Seclusion, and Corporal Punishment, Ensure that all alleged violations involving abuse, neglect, and exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property, are reported immediately, but no later than 2 hours after the unknown allegation is made, if the event that caused the allegation involves abuse or results in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and other officials (including the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Facility abuse policy and Federal/State regulation and guidelines for abuse were reviewed with all staff. Upon hire all new employees will be in-serviced on the facility abuse policy as well as Federal/State regulations and employees will be in-serviced at least annually. Any employee not working will be in-serviced prior to returning to work. The surveyors reviewed in-service sign in sheets and interviewed staff on each shift. Noncompliance of F610 continues at a scope and severity level of D for monitoring of the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, hospital record review, review of a hall camera monitoring system recording, review of a facility investigation, open and closed medical record review, observation and interview, the facility failed to protect 1 of 7 (Resident #2) sampled residents reviewed from sexual abuse placing the 11 cognitively impaired female residents residing on a Secure Unit at risk for potential sexual abuse/neglect when Resident #2 was observed exiting a male resident's (Resident #1) room, and was not thoroughly assessed for possible sexual abuse resulting in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). Resident #1 was known to have repeated sexually inappropriate behaviors (physical, gestures and comments) who also resided on the Secure Unit. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 7/20/19 at 6:20 PM in the Conference Room. F600 was cited at a scope and severity of J. The facility was cited F600-J which is Substandard Quality of Care. A partial-extended survey was conducted from 7/20/19 through 7/22/19. the Immediate Jeopardy was effective 7/9/19 through 7/22/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on 7/22/19 at 10:25 AM and corrective actions were validated onsite by the surveyors on 7/22/19. The findings include: 1. Review of the facility's Abuse Prohibition policy and procedure dated (MONTH) (YEAR) documented, Residents have the right to be free from abuse, corporal punishment, and involuntary seclusion .The facility must have evidence that all violations, including allegations, are thoroughly investigated .All center staff will be advised that they must ensure the following protocols are followed: .No one may disturb the scene where the alleged abuse took place .The resident may not be cleansed, until authorization from authorities is received .A complete body audit will be conducted by nursing staff, which will note specifically: signs of trauma, bruising, bodily fluids, torn clothing or linens .Once the scene has been cleared by officials (police or other investigative parties) the clothing and linens must be bagged and kept in a secure location .The alleged victim must be sent out immediately for a rape kit to be completed at the hospital .Investigation guidelines include: Resident(s) and responsible party interviews, as applicable .Physical examination .Staff interviews and written statements, as applicable .Methods to support the individual and detect and prevent further victimization . 2. Closed medical record review revealed Resident #2 was admitted to the facility 10/19/15 with [DIAGNOSES REDACTED]. Closed medical record review of the comprehensive care plan initiated on 4/26/19 revealed a history of wandering and impaired safety awareness. Closed medical record review of the annual MDS assessment dated [DATE] revealed unclear speech, a cognitive score of 3 which indicated severe cognitive impairment, continuous inattention, physical symptoms directed toward others, daily rejection of care, and daily wandering. Resident #2 required limited assistance of staff for transfer and ambulation, extensive assistance for dressing and eating, was dependent on staff for toileting, personal hygiene and bathing, and was always incontinent of bowel and bladder. 3. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's psychiatric hospital record revealed the resident was admitted on [DATE]. The History and Physical dated 12/28/18 documented, .This patient was displaying inappropriate sexual behavior. He was asking residents and staff for sex. Per records, he touched a Certified Nursing Assistant (CNA) inappropriately between her legs. He was also asking other people to come and get in the bed with him. He is here for behavior and medication management . The psychiatric hospital Discharge Summary for Resident #1 dated 1/16/19 documented [MEDICATION NAME] (an antidepressant) was started and increased during his stay and appeared, .to be effective with decreasing sexual urges and inappropriate behavior . [MEDICATION NAME] (A medication which counteracts the effect of testosterone in males) was also started. Medical record review of Resident #1's initial care plan dated 1/17/19, on his return to the facility from an inpatient psychiatric hospital, revealed the resident had a behavior concern of inappropriate sexual behavior. Medical record review of a Baseline Care Plan dated 1/17/19 documented, .Behaviors concerns: Negative sexual behavior .Interventions administer meds (medications) as ordered. Monitor for inappropriate behaviors. Monitor for elopement. Other Conditions: Inappropriate behavior. talk sexually or grab staff or resident inappropriately. Monitor and redirect before they happen. Intervention: medication ([MEDICATION NAME]) 15 min checks . The care plan was updated on 7/9/19 to reflect the resident's move to a room closer to the nurse's station and 7/10/19 for visual checks every 15 minutes for location. Medical record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Resident #1 required limited assistance of staff for all activities of daily living (ADL). The nursing progress notes for Resident #1 documented the following: a. 7/3/19 at 3:25 AM - .CNA entering resident's bathroom to answer emergency light where resident was sitting on toilet when he attempted to grab cna's arm stating 'be my baby.' after (After) discovering resident did not need assistance and pulled emergency light string by accident CNA exited resident's room and notified this nurse of incident. resident (Resident) was educated that he could not grab staff resident did not express understanding . b. 7/9/19 at 10:12 PM - .Resident has made several advancements towards staff and has attempted to put arm around staff. Resident is redirected without success . c. 7/10/19 at 2:27 AM - .resident noted to be looking into random rooms, staff called him out of a female room when he started to step into door way. Resident backed out and returned to his room . d. 7/17/19 at 4:04 PM - .Resident exhibiting sexually inappropriate behavior. Staff reports resident repeatedly asking them to get into bed with him . e. 7/20/19 at 6:29 PM - .Resident exhibiting sexually inappropriate behavior - Staff reports resident attempting to pat them on the behind as they pass by . Observations of Resident #1 on initial tour and focused observations on 7/17/19 at 3:15 PM, 7/18/19 at 10:00 AM, 7/19/19 at 4:40 PM, 7/20/19 at 3:02 PM and 5:30 PM, 7/21/19 at 12:05 PM and 1:25 PM and 7/22/19 at 11:35 AM and 5:45 PM, revealed the resident had clear speech, was alert and oriented to person, and transferred and ambulated without assistance. Interview with CNA #2 on 7/19/19 at 1:30 PM in the Conference Room, when asked about Resident #1's and Resident #2's behavior symptoms, the CNA revealed Resident #1 had both verbal and physical inappropriate sexual behaviors and would try to get his arms around staff or grab their bottoms. When asked about behaviors toward other residents, CNA #2 revealed having seen the resident take female residents' hands and try to take them into his room. CNA #2 confirmed Resident #2 wandered in the halls and in and out of other residents' rooms. Interview with Licensed Practical Nurse (LPN) #1 on 7/19/19 at 1:45 PM in the Conference Room, when asked about Resident #1's and Resident #2's behavior symptoms, LPN #1 confirmed Resident #1 displayed inappropriate sexual behaviors and revealed the resident would catch the hands of ambulating female residents and try to take them to his room. LPN #1 revealed Resident #2 wandered on the unit and did go in and out of residents' rooms. 4. Review of the hall monitoring camera recording dated 7/9/19 revealed the following: a. 6:03 PM - Resident #2 wandered up the hall and sat down in a chair beside Resident #1 at the nurse's station. Resident #2 was appropriately dressed in lounging pants and a top. b. 6:05 PM - Resident #2 got up and wandered back down the hall. Resident #1 got up and joined her. Together they were observed walking toward the end of the hall. Resident #1 was walking on Resident #2's left side with his right arm around her low back and right hand on her waist. c. 6:06 PM - Resident #1 opened the door to his room at the end of the hall, Resident #1 guided Resident #2 into the room, both residents entered the room and the door closed. d. 6:20 PM - Resident #2 exited the room and closed the door. One of her legs was bare and her pants appeared to be inappropriately dressed. She wandered into a room across the hall. e. 6:21 PM - Resident #2 exited the room across the hall and was approached by the Registered Nurse (RN) Supervisor who spoke with her then immediately went into Resident #1's room, exited quickly and returned to Resident #2. CNA #1 joined them in the hall. f. 6:23 PM - The RN Supervisor entered Resident #1's room and CNA #1 walked with Resident #2 toward her room up the hall. Interview with the DON on 7/19/19 at 12:45 PM in the Conference Room, when asked about the facility's cameras and viewing terminal, the DON revealed the cameras recorded only in the facility's common areas. The camera footage could be viewed in the Administrator's office. Footage was reviewed on an as needed basis. The DON also revealed she had reviewed the footage documented above prior to leaving the facility the evening of 7/9/19. Review of a statement dated 7/9/19 written by CNA #1 revealed she had observed Resident #2 walk out of a resident's room with her pants inside out. CNA #1 asked Resident #2 if she was ok and Resident #2 said yes. The CNA also asked the resident if Resident #1 had touched her and Resident #2 said Yes. Everywhere. Interview with CNA #1 on 7/18/19 at 12:15 PM in the Conference Room, when asked about what occurred on the Secure Unit with Resident #1 and #2 on 7/9/19, the CNA confirmed her written statement and revealed Resident #2's pants had been inside out and 2 of her legs were in one pant leg. When she and the RN Supervisor had taken Resident #2 to her room and examined her, the resident's brief was missing. After the RN Supervisor examined the resident, the RN Supervisor left to get the DON. Review of a statement dated 7/9/19 written by the RN Supervisor, who was working in the Secure Unit, revealed she had observed Resident #2 coming out of another resident's room. Resident #2's pants were inside out, upside down and both of her legs in one pant leg. The RN Supervisor had taken Resident #2 to her room and examined her. There were no signs of trauma, redness or bruising seen. She then went to Resident #1's room and found Resident #2's brief in his trash can. She contacted the Nurse Practitioner (NP) on call, the DON, wrote a statement and went home. Interview with the RN Supervisor on 7/18/19 at 12:45 PM in the Conference Room, when asked about what had occurred on the Secure Unit with Resident #1 and #2 on 7/9/19, the RN Supervisor confirmed her written statement and revealed the NP had instructed her to follow the facility's policy and procedures. The RN Supervisor revealed the DON was present in the facility at the time and came to the unit and examined Resident #2. The RN Supervisor confirmed she had asked the DON if she needed to document her observations in an incident report or make any further notifications and was told .not at this point . Review of a statement dated 7/10/19 written by the DON revealed, on 7/9/19 at approximately 6:45 PM, she had been notified by staff members of their observations of Resident #1 and #2. The DON documented Resident #1 .has a history of exhibiting sexually inappropriate behaviors. Both residents have a BIMS (Brief Interview for Mental Status) on their most recent MDS of 3 (indicating severe cognitive impairment). Due to this, DON and staff conducted a full investigation to ensure the (there) was no allegation of abuse that should be reported . She had asked Resident #2 if Resident #1 had touched or hurt her and the resident had answered no. The DON performed a head to toe assessment of Resident #2 and found no unexplained marks on her body or redness, irritation or secretions and documented, .There was no indication per assessment that anything inappropriate had occurred . The DON then interviewed Resident #1 in his room and when asked, he reported Resident #2 had walked down to his room and then left and denied touching her in any way. The DON had noted the brief in Resident #1's trash can and documented Resident #1 .is continent, and the brief belonged to the female resident (Resident #2) .Resident sheets were clean except for a small stain . The DON then instructed staff to put both residents on 15 minute checks and left the unit to review camera footage. After reviewing the above documented camera footage, the DON returned to the unit and instructed staff to continue the 15 minute checks until the morning of 7/10/19 at which time Resident #1 would be moved .to an available room in view of nurse's station and commons area . Interview with the DON on 7/18/19 at 2:50 PM, in the Conference Room, the DON stated she checked Resident #2's brief in the trash can, and she only noticed fresh urine in the brief. The DON was then asked if she had done an examination of his genital area. The DON confirmed she had not. Interview with the Nurse Practitioner on 7/18/19 at 4:15 PM, in the Conference Room, the Nurse Practitioner was asked if she was notified when this incident occurred. The Nurse Practitioner stated, .She (nurse) called me .told her (nurse) to call DON and Administrator and follow their policy and procedures . Interview with the DON on 7/19/19 at 12:45 PM, the DON was asked why the investigation of an allegation or suspicion of sexual abuse was not continued for the incident on 7/9/19. The DON stated, .There was nothing to insinuate he (Resident #1) had done anything to her . The DON was asked why she had examined Resident #2 and the DON stated, .To ensure nothing had happened . The DON was then asked what would constitute an investigation, the DON stated, .If I had found anything - a mark, redness, or secretions . When asked if she had done a head to toe assessment on Resident #1, the DON stated, .I looked him over also. There was nothing visible . Interview with the Administrator (the Abuse Coordinator) on 7/19/19 at 12:45 PM in the Conference Room, when asked why the facility did not continue investigating and report a suspicion of abuse, the Administrator stated, .If we were to investigate every time she (Resident #2) went in and out of a male resident's room, there would be several investigations a day . 5. Review of the facility's investigation revealed the following: Review of a statement written by the DON dated 7/13/19 revealed on 7/12/19 at 8:52 PM, the DON had received a call from the facility informing the family of Resident #2 wanted to speak to the Administrator. She offered to speak with the family and did so over the phone. The family member wanted information about an abuse allegation involving Resident #2. The DON documented, .DON explained that we assessed the resident and investigated the situation as a precaution and that we found nothing to imply anything inappropriate had occurred .had we found anything to imply she had been abused, we would have immediately reported it to the state and police and she would have been notified . The written statement was verified by the DON on 7/20/19 at 3:25 PM. Review of a statement dated 7/13/19 revealed the Administrator received a voice mail from a nurse at the facility at approximately 8:50 PM on 7/12/19 informing her the family of Resident #2 were at the facility and wanted to speak with her. The Administrator returned to the facility. The Administrator documented, .they (family) felt like they should have been called, they were told that they were not called because there was nothing to call them about. (Resident #2) frequently wanders in and out of other residents rooms and stays in those room for minutes at a time, I told the family that if they would like for the facility to start calling them every time (Resident #2) wanders in another residents room that we could do that for them so that they would be aware .The family also demanded that (Resident #1) be sent out of the facility immediately, family was told that there was no reason to send him out because there was no proof that anything had happened .(Resident #2) was sent out to the (Named Hospital) on 7/12/19 per family request .(Resident #2) returned to the facility on [DATE] . The statement was verified by the Administrator on 7/20/19 at 3:30 PM. Review of a statement dated 7/16/19 written by the DON revealed Resident #2 returned to the facility on [DATE] and .was placed on the West hall of the building due to family refusing for (Resident #2) to go back to the secure unit . The statement also revealed on 7/15/19 the family of the resident requested referral be sent to a different long term care facility. The statement was verified by the DON on 7/20/19. Resident #2 was transferred to a different facility on 7/17/19. The facility's failure to protect the 11 cognitively impaired vulnerable female residents on the Secure Unit resulted in IJ. The surveyors verified the A[NAME] by: 1. Resident #1 was placed on 1:1 supervision on 7/20/19 and will remain until discharged to a psychiatric hospital for further evaluation. The surveyors observed Resident #1 was on 1:1 supervision on the Secure Unit on 7/21/19 and 7/22/19. The surveyors interviewed staff and confirmed Resident #1 was on 1:1 supervision until discharged for evaluation. 2. All residents on the Secure Unit have been assessed and no other cases of sexual abuse were found. Assessments were done by the DON with assistance of the nursing staff for possible physical indicators of sexual abuse that would require investigation by the facility and survey team which included but is not limited to: bruises around the breast, genital areas, or inner thighs, signs and symptoms of unexplained [MEDICAL CONDITION] or genital infections, unexplained vaginal or anal bleeding, and/or torn stained or bloody underclothing. All residents on the Secure Unit are non-interviewable; however, they did not show sudden or unexplained changes in behavior, there was no fear or avoidance of a person or place, of being left alone, of the dark, nightmares, and/or disturbed sleep. The surveyors reviewed the skin assessments provided on the residents residing in the Secure Unit. The surveyors interviewed the Regional Administrator who confirmed body audits and observations of residents on the Secure Unit were completed for indicators of sexual abuse and none were found. The surveyors' observations of residents on the Secure Unit revealed no fear or avoidance of person or place. 3. All facility personnel were in-serviced by the facility Administrator and DON beginning on 7/17/19 and are ongoing with competency testing, on the importance of Identifying, Reporting and Completing a thorough investigation of sexual abuse to include: Identifying the Abuse Coordinator, Identifying all types of abuse: Physical, Verbal, Mental, Sexual, Misappropriation of funds, Neglect, Involuntary Seclusion, and Corporal Punishment, Ensure that all alleged violations involving abuse, neglect, and exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property, are reported immediately, but no later than 2 hours after the unknown allegation is made, if the event that caused the allegation involves abuse or results in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and other officials (including the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Facility abuse policy and Federal/State regulation and guidelines for abuse were reviewed with all staff. Upon hire all new employees will be in-serviced on the facility abuse policy as well as Federal/State regulations and employees will be in-serviced at least annually. Any employee not working will be in-serviced prior to returning to work. The surveyors reviewed in-service sign in sheets and interviewed staff on each shift. Noncompliance of F600 continues at a scope and severity level of D for monitoring of the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on review of facility's standing constipation protocol, medical record review, observation and interview, it was determined the facility failed to provide care and services necessary to prevent constipation and fecal impaction as evidenced by not properly assessing the resident, not providing "as needed" medications for constipation and notifying the physician of a fecal impaction for 1 of 3 (Residents #94) sampled residents and failed to obtain a physician's orders [REDACTED].#77) sampled residents reviewed of the 48 residents included in the stage 2 review. The failure of the facility to assess and provide "as needed medications" for constipation per the facility constipation protocol resulted in actual harm when Resident #94 developed a fecal impaction. The findings included: 1. Review of the facility's standing constipation protocol documented, "...CONSTIPATION: (USE ONLY ONE OF THESE): MOM (Milk of Magnesia) 30-60 CC (cubic centimeter) EVERY OTHER NIGHT X (times) 1 WEEK [MEDICATION NAME] SUPPOSITORY (SUPP)- ONE RECTALLY EVERY OTHER NIGHT X (times) 1 WEEK FLEETS ENEMA - ONE RECTALLY X 1 SOAP SUDS ENEMA 250CC TO 500CC - ONE RECTALLY X 1 ONLY SENNA 8.6MG (milligrams) - TWO TABS (tablets) PO (by mouth) PR (per rectum)... QD (every day) X 1 WEEK [MEDICATION NAME] SODIUM 100MG - TWO TABS PO OR PER TUBE QD X 1 WEEK [MEDICATION NAME] 17GM (grams) (ONE HEAPING TBSP (tablespoon)) IN 8 OZ (ounce) WATER PO OR PER TUBE IN AM 2X / WK X 1 WEEK..." Medical record review for Resident #94 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a care plan dated 9/12/13 and reviewed 6/6/14 did not include problems or approaches for constipation or fecal impaction. Review of the Medication Administration Record [REDACTED]. Review of a physician's orders [REDACTED]. Review of a physician's orders [REDACTED]. Review of a nurses' note dated 2/28/14 documented, "...Res (resident) manually disempacted (disimpacted) @ (at) this x... some bleeding noted..." The facility was unable to provide documentation that the physician was notified of the impaction nor was there documentation the facility's constipation protocol was followed for providing PRN medication for constipation. Review of the bowel and bladder (B&B) report for Resident #94 from 3/1/14 through 6/16/14 had no documentation of a bowel movement as followed: a. From 3/4/14 through 4/5/14 (32 days). b. From 4/22/14 through 4/27/14 (6 days). c. From 4/29/14 through 5/8/14 (10 days). d. From 5/11/14 through 5/14/14 (4 days). e. From 5/17/14 through 5/20/14 (4 days). f. From 5/23/14 through 5/26/14 (4 days). g. From 6/2/14 through 6/5/14 (4 days). h. From 6/7/14 through 6/9/14 (3 days). The facility failed to provide PRN medications per the facility's constipation protocol when the resident went 3 or more days without a documented bowel movement. Review of a nurses' note dated 3/26/14 documented, "...Bowel sounds hypoactive. Manually extracted large amount of hard dry feces..." Review of a physician's orders [REDACTED]. (abdominal) /swelling..." Review of an abdominal x-ray dated 3/27/14 with a fax date stamp of 3/27/14 across the top of the page documented, "...FINDINGS... There is a moderate amount of stool throughout the visualized colon... IMPRESSION... Moderate amount of stool throughout the visualized bowel, which can be seen in the setting of constipation..." At the bottom of the x-ray results, "3/27/14 (ADON's Initials) RN 5:00 pm" was handwritten. During an interview in the conference room on 9/25/14 at 12:56 PM, the Assistant Director of Nursing (ADON) was asked about the note written on the x-ray dated 3/27/14 at 5:00 PM. The ADON stated, "I called the Doctor and let them know I was faxing a lab (laboratory test results). If the results are normal, I'll fax them to the doctor and give the lab results to the nurses." The ADON was asked when the doctor is faxed versus a phone call to notify him there is a fax coming. The ADON stated, "If there is something out of normal range. I will call the doctor's office and let them know I am sending a fax. Then I flag it in the chart for the nurses." The ADON was asked what was on the x-ray finding that was out of normal range. The ADON stated, "The moderate amount of stool" was why I called the Doctor's office." Review of a second copy of the same abdominal x-ray (as noted above) dated 3/27/14 with a fax stamp of 4/2/14 across the top of the page documented, "MD Notified" hand written at the bottom of the x-ray results. Review of a nurses' note dated 4/2/14 documented, "3pm Called (Named Physician's) office r/t (related to) KUB done states KUB results ok. (okay) ? (no) N.O (New Order)..." Review of a nurses' note dated 5/30/14 documented, "...D/C (discontinue) OTC (over the counter) MOM 30 cc PO QD PRN constipation, D/C OTC [MEDICATION NAME] ([MEDICATION NAME]) Suppository PRN constipation..." Review of a nurses' note dated 6/15/14 at 10:00 PM documented, "resident (#94) had bright red blood from rectum md (medical doctor) notified md ordered CBC (complete blood count) c (with) diff (differential) for AM (morning)..." Review of a nurses' note dated 6/16/14 at 11:40 AM documented, "...Bloody stool noted..." and at 4:30 PM, "...N.O. received from MD to send to ER (emergency room )..." During an interview in the medical records room on 9/24/14 beginning at 4:29 PM, Nurse #7 was asked about the protocol for bowel movements (BM). Nurse #7 stated, "The BM log flags in 3 days if they (residents) don't have one (BM). If they haven't had one, then we notify the MD and we have a standing protocol we follow..." Nurse #7 was then shown the telephone physician order [REDACTED]. Nurse #7 was asked what precipitated that order. Nurse #7 stated, "...Probably on her BM log we print off every morning. That's what alerted me to the problem." Nurse #7 was asked what she did about the problem. Nurse #7 stated, "I faxed the MD with the other issues." Nurse #7 was asked where it documents that. Nurse #7 stated, "I guess it doesn't. The 3 day log was reviewed and I initiated the BM protocol of Senna 2 tablets every night for 1 week." Nurse #7 was then asked if she recalled why the PRN orders (showing Nurse #7 the order) for Milk of Magnesia and [MEDICATION NAME] were discontinued on 5/30/14. Nurse #7 stated, "I don't." During an interview in the conference room on 9/25/14 at 1:56 PM, the Director of Nursing (DON) was asked what she expected the staff to do when a resident was constipated or impacted. The DON stated, "I expect them to notify the doctor to get an appropriate order. They should address it timely and monitor effectiveness - have a BM (bowel movement), if not, notify the doctor for additional orders. To follow the admission orders [REDACTED]. The DON stated, "I couldn't find one." During a telephone interview in the admissions office on 9/29/14 at 4:50 PM, Resident #94's primary care physician (PCP) was asked specifically about Resident #94's constipation. Resident #94's PCP stated, "They (facility) have a protocol they go by, but I cannot remember exactly what was in it. If the protocol doesn't work, then they call me and they would try something else. We would look at and possibly adjust their medicine." Resident #94's PCP was asked if he had received any calls regarding Resident #94. Resident #94's PCP stated, "We record all calls electronically and in looking at the record, we received one call about her on the 16th (June) about a rectal bleed and she was sent out to the hospital... that was the only call we had received about this (constipation)..." During an interview in the hospital emergency department (ED) Director's office on 9/30/14 beginning at 1:40 PM, Resident #94's family nurse practitioner (FNP) was asked about Resident #94 when she came to the ED. The FNP stated, "She had a severe fecal impaction. I was seriously concerned about (named Resident #94). She was a little thing, 40 Kilograms (88 pounds). My concern was monitoring I's and O's (Intake & Output) is basic to nursing. She had no one checking on her (in the nursing home)... her family was all out of town and there was no one checking in on her. This was the worst fecal impaction I have ever seen in my [AGE] years of nursing. It was the size of a fetus on x-ray and hard as a rock. If a nurse had been looking at her, someone would have noticed she hadn't had a BM. It was impossible for anything to come out around it. Someone should have noticed this lady had not had a BM. She was critically ill from the fecal impaction... She also had a UTI (urinary tract infection), with that much impact you cannot empty your bladder. Her rectum was stretched so much it was bleeding. It (the impaction) was the size of a basketball and I removed a softball size out of the middle of it. I never could feel the sides of the rectum." She was asked about palpating the abdomen." The FNP stated, "Her tummy was firm, with moderate distention and she was guarding her abdomen when I tried to palpate, she would grab my hands. I would have expected a note that she would have had something (given to her) for her constipation." During an interview in room [ROOM NUMBER] on 10/1/14 at 8:15 AM, Certified Nursing Assistant (CNA) #10 was asked about Resident #94 and was she aware of any constipation issues with Resident #94. CNA #10 stated, "Yes, she was constantly constipated, but she would have a bowel movement, but it was small. She was on the other side, then she moved to this side. She was really a slow eater. She was on Hospice. She would drink pretty good at times... When we changed her or did peri care and catheter care, she would holler out and complain of pain... I would tell the nurse about her pain, no matter which way we turned her, she would holler. Right at the very last she would complain of her stomach hurting. Another time, I remember her being impacted, when I changed her, her rectum was open and I could see stool and I notified the nurse." The failure of the facility to notify the physician of a fecal impaction, failure to assess and provide "as needed medications" for constipation resulted in actual harm when Resident #94 developed an impaction. 2. Medical Record Review for Resident #77 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the MAR for February 2014 documented Resident #77 received peritoneal [MEDICAL TREATMENT] from 2/10/14 through 2/16/14. Review of the facility's readmission orders [REDACTED]. Review of the nurses' notes dated for 2/10/14 documented, "...6:15 p (PM) Res (Resident #77) started on peritoneal [MEDICAL TREATMENT] at approximate 3:15 PM, (Named Nurse at the [MEDICAL TREATMENT] clinic) initiated [MEDICAL TREATMENT], blood tinged output noted to drainage bag d/t (due to) 1st round [MEDICAL TREATMENT] since cath (catheter) surgery." Review of the nurses' note dated 2/15/14 documented, "Nurse started [MEDICAL TREATMENT]. nurse was assisted by another LPN (Licensed Practical Nurse). [MEDICAL TREATMENT] ran all night (without) difficulty..." During an interview in the west hall nurses' station on 9/29/14 at 6:00 PM, Nurse #5 was asked about orders for Resident #77's peritoneal [MEDICAL TREATMENT]. Nurse #5 looked in the chart and said, "I don't see one and looks as if she started on peritoneal on 2/10/14 and the only order I see is one on 2/20/14 to continue peritoneal [MEDICAL TREATMENT]." During an interview in the west hall nurses' station on 9/29/14 at 6:15 PM, Nurse #6 was asked about an order to start peritoneal [MEDICAL TREATMENT] on 2/10/14. Nurse #6 stated, "I don't see one, and who ever wrote it on the MAR indicated [REDACTED] During an interview in the Director of Nursing's (DON) office on 9/30/14 at 10:05 AM, the DON was asked about an order for [REDACTED]. started [MEDICAL TREATMENT] that day. That nurse documented it wrong (nurses' notes 2/10/14). (Named Nurse at the [MEDICAL TREATMENT] clinic) stated the order was written on 2/14/14 for this type of [MEDICAL TREATMENT] treatment and the peritoneal [MEDICAL TREATMENT] was started on 2/15/14. The DON was asked shouldn't the facility have an order for [REDACTED].

Based on review of the facility's standing constipation protocol, medical record review and interview, it was determined the facility failed to provide care and services necessary to prevent neglect related to constipation and fecal impaction as evidenced by not properly assessing the resident and not providing "as needed" medications for constipation for 1 of 3 (Resident #94) sampled residents reviewed with constipation. The failure of the facility to to appropriately assess and provide "as needed medications" for constipation resulted in neglect with actual harm for Resident #94. The findings included: Review of the facility's standing constipation protocol documented, "...IF THE PROBLEM PERSISTS FOR ANY SYMPTOM... CONSTIPATION: (USE ONLY ONE OF THESE): MOM (Milk of Magnesia) 30- (to) 60 CC (cubic centimeter) EVERY OTHER NIGHT X (times) 1 WEEK [MEDICATION NAME] SUPPOSITORY (SUPP) - ONE RECTALLY EVERY OTHER NIGHT X 1 WEEK FLEETS ENEMA - ONE RECTALLY X 1 SOAP SUDS ENEMA 250CC TO 500CC - ONE RECTALLY X 1 ONLY SENNA 8.6MG (milligrams) - TWO TABS PO (by mouth) PR (per rectum)... QD (every day) X 1 WEEK [MEDICATION NAME] SODIUM 100MG - TWO TABS PO OR PER TUBE QD X 1 WEEK [MEDICATION NAME] 17GM (grams) (ONE HEAPING TBSP (tablespoon)) IN 8 OZ (ounce) WATER PO OR PER TUBE IN AM 2X / WK X 1 WEEK..." Medical Record Review for Resident #94 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a care plan dated 9/12/13 and reviewed 6/6/14 did not document any problems or approaches for constipation or fecal impaction. Review of a nurses' note dated 2/28/14 documented, "...Res (resident) manually disempacted (disimpacted) @ (at) this x (time)... some bleeding noted..." The facility was unable to provide documentation of any as needed (PRN) medication for constipation was given as per the facility's standing constipation protocol. Review of the Medication Administration Record [REDACTED]. Review of a physician's orders [REDACTED]. Review of a physician's orders [REDACTED]. Review of the bowel and bladder (B&B) report for Resident #94 from 3/1/14 through 6/16/14 had no documentation of a bowel movement as followed: a. From 3/4/14 through 4/5/14 (32 days). b. From 4/22/14 through 4/27/14 (6 days). c. From 4/29/14 through 5/8/14 (10 days). d. From 5/11/14 through 5/14/14 (4 days). e. From 5/17/14 through 5/20/14 (4 days). f. From 5/23/14 through 5/26/14 (4 days). g. From 6/2/14 through 6/5/14 (4 days). h. From 6/7/14 through 6/9/14 (3 days). The facility neglected to provide PRN medications per the facility's constipation protocol when the resident went 3 or more days without a documented bowel movement. Review of a nurses' note dated 3/26/14 documented, "...Bowel sounds hypoactive. Manually extracted large amount of hard dry feces..." Review of a physician's orders [REDACTED]. (abdominal) /swelling..." Review of an abdominal x-ray dated 3/27/14 with a fax date stamp of 3/27/14 across the top of the page documented, "...FINDINGS... There is a moderate amount of stool throughout the visualized colon... IMPRESSION... Moderate amount of stool throughout the visualized bowel, which can be seen in the setting of constipation..." At the bottom of the x-ray results, "3/27/14 (Assistant Director of Nursing (ADON's) initials) RN (Registered Nurse) 5:00 pm" was handwritten. During an interview in the conference room on 9/25/14 at 12:56 PM, the ADON was asked about the note written on the x-ray dated 3/27/14 at 5:00 PM. The ADON stated, "I called the Doctor and let them know I was faxing a lab (laboratory test results). If the results are normal, I'll fax them to the doctor and give the lab results to the nurses." The ADON was asked when the doctor is faxed versus a phone call to notify him there is a fax coming. The ADON stated, "If there is something out of normal range. I will call the doctor's office and let them know I am sending a fax. Then, I flag it in the chart for the nurses." The ADON was asked what was on the x-ray finding that was out of normal range. The ADON stated, "The moderate amount of stool" was why I called the Doctor's office." Review of a second copy of the same abdominal x-ray dated 3/27/14 with a fax stamp of 4/2/14 across the top of the page documented, "MD Notified" hand written at the bottom of the x-ray results. Review of a nurses' note dated 4/2/14 documented, "3pm Called (Named Physician's) office r/t KUB done states KUB results ok. (okay) ? (no) N.O (New Order)..." Review of a nurses' note dated 5/30/14 documented, "...D/C (discontinue) OTC (over the counter) MOM 30 cc PO QD PRN constipation, D/C OTC [MEDICATION NAME] Suppository PRN constipation..." Review of a nurses' note dated 6/15/14 at 10:00 PM documented, "resident had bright red blood from rectum md (medical doctor) notified md ordered CBC (complete blood count) c (with) diff (differential) for AM (morning)..." Review of a nurses' note dated 6/16/14 at 11:40 AM documented, "...Bloody stool noted..." and at 4:30 PM documented, "...N.O. received from MD to send to ER (emergency room )..." During an interview in the medical records room on 9/24/14 beginning at 4:29 PM, Nurse #7 was asked about the protocol for bowel movements (BM). Nurse #7 stated, "The BM log flags in 3 days if they (residents) don't have one (BM). If they haven't had one, then we notify the MD and we have a standing protocol we follow..." Nurse #7 was then shown the telephone physician order [REDACTED]. Nurse #7 was asked what precipitated that order. Nurse #7 stated, "...Probably on her BM log we print off every morning. That's what alerted me to the problem." Nurse #7 was asked what she did about the problem. Nurse #7 stated, "I faxed the MD with the other issues." Nurse #7 was asked where it documents that. Nurse #7 stated, "I guess it doesn't. The 3 day log was reviewed and I initiated the BM protocol of Senna 2 tablets every night for 1 week." Nurse #7 was then asked if she recalled why the PRN orders (showing Nurse #7 the order) for Milk of Magnesia and [MEDICATION NAME] were discontinued on 5/30/14. Nurse #7 stated, "I don't." During an interview in the conference room on 9/25/14 at 1:56 PM, the Director of Nursing (DON) was asked what she expected the staff to do when a resident was constipated or impacted. The DON stated, "I expect them to notify the doctor to get an appropriate order. They should address it timely and monitor effectiveness - have a BM (bowel movement), if not, notify the doctor for additional orders. To follow the admission orders [REDACTED]. The DON stated, "I couldn't find one." During a telephone interview in the admissions office on 9/29/14 at 4:50 PM, Resident #94's primary care physician (PCP) was asked specifically about Resident #94's constipation. Resident #94's PCP stated, "They (facility) have a protocol they go by, but I cannot remember exactly what was in it. If the protocol doesn't work, then they call me and they would try something else. We would look at and possibly adjust their medicine." Resident #94's PCP was asked if he had received any calls regarding Resident #94. Resident #94's PCP stated, "We record all calls electronically and in looking at the record, we received one call about her on the 16th (June) about a rectal bleed and she was sent out to the hospital... that was the only call we had received about this (constipation)..." During an interview in the hospital emergency department (ED) Director's office on 9/30/14 beginning at 1:40 PM, Resident #94's family nurse practitioner (FNP) was asked about Resident #94 when she came to the ED on 6/16/14. The FNP stated, "She had a severe fecal impaction. I was seriously concerned about (named Resident #94). She was a little thing, 40 Kilograms (88 pounds). My concern was monitoring I's and O's (Intake & Output) is basic to nursing. She had no one checking on her (in the nursing home)... her family was all out of town and there was no one checking in on her. This was the worst fecal impaction I have ever seen in my [AGE] years of nursing. It was the size of a fetus on x-ray and hard as a rock. If a nurse had been looking at her, someone would have noticed she hadn't had a BM. It was impossible for anything to come out around it. Someone should have noticed this lady had not had a BM. She was critically ill from the fecal impaction... She also had a UTI (urinary tract infection), with that much impact you cannot empty your bladder. Her rectum was stretched so much it was bleeding. It (the impaction) was the size of a basketball and I removed a softball size out of the middle of it. I never could feel the sides of the rectum." She was asked about palpating the abdomen." The FNP stated, "Her tummy was firm, with moderate distention and she was guarding her abdomen when I tried to palpate, she would grab my hands. I would have expected a note that she would have had something (given to her) for her constipation." During an interview in room [ROOM NUMBER] on 10/1/14 at 8:15 AM, Certified Nursing Assistant (CNA) #10 was asked about Resident #94 and was she aware of any constipation issues with Resident #94. CNA #10 stated, "Yes, she was constantly constipated, but she would have a bowel movement, but it was small. She was on the other side, then she moved to this side. She was really a slow eater. She was on Hospice. She would drink pretty good at times... When we changed her or did peri care and catheter care, she would holler out and complain of pain... I would tell the nurse about her pain, no matter which way we turned her, she would holler. Right at the very last she would complain of her stomach hurting. Another time, I remember her being impacted, when I changed her, her rectum was open and I could see stool and I notified the nurse." The failure of the facility to appropriately assess, provide "as needed medications" resulted in neglect with actual harm for Resident #94.

Intakes: TN 936 Based on review of the facility's occurrence / investigation reports, medical record reviews, interviews, and observations, it was determined the facility failed to ensure interventions were implemented to prevent accidents for 4 or 5 (Residents #1, 2, 3, and 5) sampled residents with a history of falls. The failure to implement planned interventions to protect Resident #5 resulted in actual harm when Resident #5 sustained a laceration above the left eye and facial bruising after she fell off of her bed which was not in the lowest position and which had a sensor alarm that was not turned on. The findings included: 1. Medical record review for Resident #5 documented an admission date of [DATE] with a readmission on 10/19/11 with [DIAGNOSES REDACTED]. The quarterly Minimal Data Set ((MDS) dated [DATE] documented a summary score of 4 on the Brief Interview for Mental Status (BIMS) which indicated severe impairment of Resident #5's cognitive patterns. The Fall Risk Assessment done on Resident #5 documented a score of 13 on 8/25/11; 16 on 1/20/12 and 12 on 4/20/12; a score of 10 or greater for that tool, was considered a high risk for falls. Review of Physician's telephone orders dated 6/3/12 documented, "Send to ER (emergency room ) for eval (evaluation) d/t (due to) fall..." Review of the Physician orders [REDACTED]. Review of the facility's occurrence report of 6/3/12 documented a fall with head injury for Resident #5. The report documented, "...CNA (Certified Nursing Assistant) answered the call light... Bed not in low locked position. Alarm not alarming. (Resident #5) on floor (L) (left) side with pool of blood on floor. 1" (inch) gash to top of L eye and bruising around the eye... to hospital... Immediate actions... bed lowered and locked, mat placed at bedside... bed alarm turned on... Investigation... CNAs from previous shift reprimanded for not monitoring alarms more closely... notified by second shift CNAs that no alarm on 400 hall was turned on..." The nurses' notes dated 6/3/12 documented, "2:30 PM called to resdt's (resident's) room STAT (immediate) CNA answered call light & (and) bed was not in low locked position & alarm not alarming. Resd (resident) observed in (on) floor on (L) (left) side, c (with) pool of blood in floor. Observed 1 in (inch) gash to top of (L) eye, & bruising around eye... EMS (emergency medical services) transported resident to ER..." Review of the June 2012 activity of daily living (ADL) worksheet for Resident #5 documented, "...SAFETY DEVICES... SENSOR PAD WHILE IN BED TO ALERT STAFF OF UNASSISTED TRANSFERS... KEEP BED IN LOWEST POSITION WHILE IN BED WITH FLOOR MAT PLACED BESIDE BED..." No initials were signed on the 7AM to 3PM shift on June 3, 2012 to indicate that the tasks were done. Review of the CNA assignment sheet dated 6/3/12, delineating special care needs to be given to residents documented, "...Resident #5... Falls (checked), Assistive Device - floor mat... Alarms - Bed..." The care plan dated 9/1/11 and reviewed 4/26/12 documented, "...Fall risk... 10-10-11 fall - educate staff the importance of making sure alarm is on and working properly... 1-16-12 Keep bed in lowest position c floor mat beside bed... Sensor pad WIB (while in bed) to alert staff of unassisted transfers..." During an interview in the Director of Nursing's (DON) office on 6/20/12 at 12:20 PM, Nurse #1 stated, "...I was at the nurses' station and called stat to her (Resident #5) room. She (Resident #5) was on the floor face down. The bed was at standard height (not lowest position) and the sensor pad alarm to the bed was turned off; it (bed alarm) was connected but not on. This happened at 2:30 (PM)... (We) checked all the alarms and all (of 400 Hall) alarms were turned off.... The alarm was on that AM before she (Resident #5) got out of bed. She gets up for breakfast and lunch and then back down (to bed). (Alarms) are off when the Resident is out of bed. After lunch and back (to bed) (alarm) should have been turned back on..." Nurse #1 was asked about her expectations for CNAs checking the sensor alarms. Nurse #1 stated, "(CNAs should) Check (alarms) on (their) arrival (to work), when residents get up, when residents are put back in bed... and finally, before they (CNAs) leave, PERIOD!" Observations in Resident #5's room at 6/19/12 at 11:45 AM, revealed Resident #5 dressed and sitting in a wheelchair beside her bed. Areas around Resident #5's eyes appeared to be resolving bruises with bluish and yellow tinges; the area around the left eye was more tinged than the right. Resident #5 sustained a fall on 6/3/12 that resulted in bruising around the eyes and a one inch gash to top of (L) eye, which required medical intervention. The facility failed to monitor the care given to Resident #5 to ensure that, as per care-plan, the bed was kept in a low position and the bed sensor pad was turned on whenever the Resident was in bed; that resulted in actual harm requiring medical attention because of that fall. 2. Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The significant change in status MDS dated [DATE] documented a score of 99 on the BIMS which indicated Resident #2 was unable to complete the interview. Fall Risk Assessment done on Resident #2 documented a score of 10 on 2/7/12, 5/10/12, and 6/12/12; a score of 10 or greater for that tool was considered a high risk for falls. Nurses' notes dated 6/4/12 documented, "... 10AM Notified by charge nurse of c/o (complaint of) pain to (L) lower leg... Resident had just been moved/transferred from her bed to the Geri chair... 12:30 X-ray results... (sign for positive) tibia/fibula fx (fracture) noted... 2:30 Res to ER..." The care plan for Resident #1 dated 5/10/12 documented, "... At risk for UTI (Urinary tract infection), skin breakdown... Approach Assist up in g/c (geri-chair) daily with lift and 2 person assist... At risk for contractures... Approaches... Get up in g/c daily with lift and 2 person assist... Potential for falls... Approaches... Use lift and 2 person assist when getting up in g/c... " Investigative notes of Nurse #4 dated 6/14/12/at 10:30 AM, documented, "...At 9:30 AM, CNA #1 went in room by herself and transferred (Resident #1) into her Geri Chair. (Resident #1) is care planed for a Hoyer lift..." Investigative notes of Nurse #4 (undated) documented, "Clarification from Statement received from (CNA #1) on 6/4/12. (CNA #1) admitted ... that she lifted (Resident #1) by herself from her bed, pivoted her and put her in her Geri-chair..." During an interview in the DON's office on 6/20/12 at 3:10 PM Resident #1's Physician stated, "...the best situation is using a Hoyer (lift). Hoyer is a good prevention for falls during transfer and once a fall, it is a bad out come and a great chance in her (Resident #1) situation for bones to break..." Resident #1's physician stated that with the Resident's demineralization of her bones, it would not take a lot of force to break her bone. The care plan interventions directing the transfer of Resident #1 from her bed to her Geri-chair and back to her bed with a lift and two person assist were not followed. 3. Medical record review for Resident #2 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] documented a summary score of 15 on the BIMS which indicated Resident #2 was cognitively intact. The Fall Risk Assessment done on Resident #2 documented a score of 24 on 10/10/11, and 24 on 1/3/12; a score of 10 or greater for that tool, was considered a high risk for falls. Nurses' notes dated 12/18/11 documented, "6:35 (AM) Heard resd hollering down hallway. As I went into resd room, she was lying on the floor on (R) (right) side..." The imaging report dated 12/18/11 documented, "...Comminuted fracture of the olecranon with major posterior fragment avulsed about 2 cm. (centimeters)..." Facility occurrence report dated 12/18/12, documented that the nursing intervention at the time of the fall was, "a sensor pad to bed and chair..." The care plan of 10/20/11, reviewed on 12/29/11 and 3/22/12 documented, "...12/18/11... intervention @ (at) x (time) of fall: sensor pad to bed/chair..." A Physician's telephone order dated 1/11/11 documented, "Bed sensor alarm pad to alert staff of unassisted transfer / ambulation d/t (due to) (arrow down) (decreased) safety awareness AEB (as evidenced by) hx (history) of falls..." Nurses' notes dated 1/3/12 documented, "0400 Res'd found in (on) floor between bedside commode & bed by CNA... Bed alarm put on bed..." The care plan of 10/20/11, reviewed on 12/29/11 and 3/22/12, "...1/3/12... fall 0 (no) injury, has UTI (urinary tract infection) taking antibiotics..." During an interview in the DON's office on 6/19/12 at 11:20, Nurse #2 looked at the records of Resident #2 and stated, "I'm beginning to think the sensor pad wasn't put on (the bed) on 12/18..." Resident #2 had a bed alarm put in place after a fall on 12/18/11. A second fall occurred on 1/3/12 and at that time it was documented that a bed alarm was put on the bed; Nurse #2 stated the bed probably did not have a bed alarm at that time (1/3/12). The interventions to prevent falls listed in the care plan of Resident #3 were not being followed. There also were no new care plan interventions documented after Resident #2 fell on [DATE]. 4. Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The yearly MDS dated [DATE] documented a summary score of 99 on the BIMS which indicated Resident #3 was unable to complete the BIMS. The Fall Risk Assessment done on Resident #3 documented a score of 14 on 11/10/11, and 12 on 2/7/12/12; a score of 10 or greater for this tool, was considered a high risk for falls. The facility's occurrence report for Resident#3 documented that on 4/28/12 "...CNA putting resdt to bed when BS (bed side) table came over resdt head and hit forehead... head hit by bedside table during transfer from geri-chair to bed using lift causing 1in (inch) lac (laceration) to (l) forehead..." Resident #3's care plan dated 2/9/12 documented, "...At risk for falls... Assist with all transfers with 2 person assist..." During an interview in the DON's office on 6/20/12 at 2:50 PM, Nurse #2 was asked about Resident #3 being care-planned for a two person assist and not a Hoyer lift, Nurse #2 stated, "...I know, but I've always seen them transfer her with a lift..." Resident #3's care plan dated 2/9/12 documented, "2/6/12... fall with head injury... Res (Resident) to have bed & chair alarm... Bed and chair alarm to alert staff of unassisted trying to transfer..." The Physician orders [REDACTED]. Observations in Resident #3's room on 6/20/12 at 9:20 AM, revealed Resident #3 sat in a Geri-chair that did not have a sensor alarm. During an interview in Resident #3's room on 6/20/12 at 9:22 AM, Nurse #3 was asked about the sensor alarms. Nurse #3 stated, "...She has a bed alarm but she doesn't have a chair alarm because she doesn't move in the Geri-chair..." Resident #3 was transferred by a Hoyer lift and the care-plan intervention delineated a transfer by a two person assist. Resident #3 did not have a chair sensor alarm and the care-plan delineated that the chair have a sensor alarm. The interventions to prevent falls listed in the care plan of Resident #3 were not followed. In the DON's office on 6/20/12 at 5:15 PM, the Assistant Director of Nursing (ADON), the Administrator, and the facility's Corporate Nurse were informed of the concerns seen on the survey. On 6/22/12, during a telephone conference call, exit was done with the ADON and the corporate nurse, they were informed that the concern expressed about Resident #5's falls were determined to be a harm. The facility's Corporate Nurse and the ADON expressed that they understood and had no further questions.