Every finding on record at Estates Healthcare and Rehabilitation Center

Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 3 residents (Resident #1) reviewed for rights. The facility failed to ensure the Treatment Nurse knocked on Resident 1's door when entering the resident's room on 08/26/26. This failure could place residents at risk of feeling their privacy was invaded. Findings included:Record review of Resident #1's Quarterly MDS assessment, dated 06/04/26, reflected he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included paraplegia (paralysis of the lower half of the body) and pressure ulcer stage 4 (areas of damaged skin and tissue caused by sustained pressure) Resident #1's BIMS score was 15, indicating intact cognition. Observation and interview on 08/26/26 at 11:55 AM, Resident #1 was lying in bed in his room. During the interview with Resident #1, the Treatment Nurse entered the room without knocking and left. Resident #1 stated that happened a lot, but some staff did knock before entering. Resident #1 stated it did bother him when staff did not knock. He stated what if he was undressed, or for instance right now, he was having a conversation, and they just walked in. Interview on 08/26/26 at 12:00 PM, the Treatment Nurse stated he had been trained on resident rights and was supposed to knock before entering Resident #1's for the resident's privacy. He stated it was their home and could be an invasion of privacy.Interview on 08/26/26 at 1:19 PM, the Corporate DON stated her expectation was that all staff were to knock on doors prior to entry to any resident's room. She stated the risk was residents could feel uncomfortable and they had a right to privacy. Interview on 08/26/26 at 1:28 PM, the Administrator stated she expected all staff to knock on a resident's door before entering for the resident's privacy. Record review of the facility's current, undated Resident Rights policy reflected: . The resident has a right to be treated with respect and dignity.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for one of three residents (Resident #1) reviewed for supervision. Staff failed to ensure Resident #1 turned his smoking materials in to staff to be locked up, in order for him to only have use of them during scheduled, supervised smoking breaks. This failure could place residents at risk of injury.Findings included: Review of Resident #1's admission Record, dated 07/23/26, reflected he was a [AGE] year-old male, originally admitted on [DATE]. Resident #1 was his own Responsible Party. He had diagnoses of cerebral infarction (stroke in which a blocked blood vessel causes part of the brain tissue to die), heart disease, hemiplegia and hemiparesis affecting left non-dominant side (paralysis or weakness to one side of the body, caused by damage to the brain on the opposite side of the body), and unspecified dementia (unknown underlying cause of cognitive decline or memory loss.) Review of Resident #1's quarterly MDS, dated [DATE], reflected he had adequate hearing and vision, and clear speech. Resident #1 was able to understand others and be understood by others. He had a BIMS score of 15 out of 15, indicating intact cognition. Resident #1 exhibited no behavioral issues or psychosis during the assessment period. His range of motion was limited on one side of his upper body, and both sides of his lower body, and he used a wheelchair with which he was able to move himself throughout the facility. He only required set-up or clean-up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.) for eating, moving himself around in bed, and transferring to and from his bed. He was dependent on staff for bathing, dressing, and hygiene activities. Review of Resident #1's care plans reflected the following care plans:- Resident signing out of facility and returning intoxicated, dated 03/12/26- Resident signed himself out of facility to go across the street to the store, dated 11/19/25- Impaired cognitive function/dementia or impaired thought processes, dated 03/15/24- Resident was non-compliant with medication administration related to resident purchasing OTC medication at the store and keeping OTC medication in his personal lock box, dated 11/19/25- Resident was a smoker, and was non-compliant with smoking policy at times, dated 03/17/24, revised on 09/29/25 with a goal of the resident being able to smoke without causing injury. Interventions included the following; ensuring he smoke in a designated smoking area, ensuring he was aware of the smoking policy, no smoking materials or igniters (lighters) would be stored in his room, monthly safe smoking assessments, staff re-educating the resident on the smoking policy and schedule, staff confiscating smoking materials when they saw them and placing them in the locked area for smoking items at the nursing station, and supervision by a visitor or staff member at all times the resident was smoking.- Resident was a smoker, and was non-compliant with the smoking policy at times, dated 09/29/25, with a goal of the resident smoking in designated areas without the occurrence of injury over the next 90 days. Interventions included: Perform smoking assessment according to facility policy. Explain or show the resident where designated smoking areas were and smoking times to be repeated as needed, monitor the resident when smoking to assure resident safety as needed, keep all smoking material at nurses station, and staff will re-educate resident on smoking policy and schedule, and confiscate smoking materials when seen and place with smoking items at nursing station. Review of Resident #1's Safe Smoking Assessment, dated 06/27/26, reflected the resident had no history of burns or other smoking accidents, and was able to manage the process of smoking independently. The document reflected he had no issues of tremors, sleeping while smoking, dexterity problems or other impediments which would affect safe smoking ability. The document indicated Resident #1 was safe to smoke unsupervised, his smoking materials will be kept at the nurses' station, and the smoking evaluation had been discussed with the resident, and explained to the family or responsible party. An observation on 07/23/26 at 12:31 PM revealed two male residents were seated at a table outside on a covered patio, which served as the facility's designated smoking area, with the Floor Tech. One of the residents, Resident #1, was smoking a cigarette. An observation on 07/23/26 at 12:32 revealed the Floor Tech left the residents, and entered the building, leaving the two male residents at the table, and two other residents who were seated on the other side of the patio. An interview on 07/23/26 at 12:34 PM with the ADON revealed she was able to identify the residents, and she said Resident #1 and a few others were non-compliant with the smoking rules, and signed themselves out and bought what they wanted and smoked when they wanted. She said the staff always supervised the smoking breaks at the scheduled times, but they could not stop them from doing what they wanted, when they were completely able to sign themselves out. An observation on 07/23/26 at 12:36 PM the RCN went outside with the ADON and SW, and could be heard talking to the residents at the table about the smoking policy, telling them they could not keep cigarettes on their person or in their room and needed to turn them in when they came back from outings, and could not smoke unless it was a scheduled smoke break. An interview on 07/23/26 at 12:42 PM with the RCN revealed the residents knew they were breaking policy, and they knew that they were supposed to turn their smoking materials in to staff. An interview on 07/23/26 at 1:13 PM with the Floor Tech revealed he never supervised smoking breaks, so was not aware that he was supposed to stay with the residents when they were smoking. He said he didn't know the smoking policy before, but the RCN had just gone over it with him, and now he knew he had to stay with them, and ask for their cigarettes and lighters when they finished, then go to the nurse with the smoking materials. He said he thought the housekeepers or nursing staff usually supervised the smoking breaks, and there were particular times they did that. An interview on 07/23/26 at 1:30 PM with CNA A revealed she did sometimes find that residents had smoking materials with them, and she had taken them to be locked up when she did. She said she did not often have time to be in the part of the building near the smoking area, so had not seen residents smoking by themselves, but if she did she would tell the nurse immediately, because for safety reasons they were supposed to have supervision. An interview and observation on 07/23/26 at 1:38 PM revealed it was a scheduled smoke break time, and residents were supervised by the ADON and another staff member. Resident #1 was waiting for his turn and said he had been smoking for 45 years, and he knew how. He said he had never burned holes in his clothes, or burnt himself, and he knew to never smoke around a person who was on oxygen. He said he did not know he was supposed to turn his cigarettes in to staff, but he did now. An observation on 07/23/26 at 1:42 PM revealed the RCN talking to the group of approximately ten smokers about the smoking policy. An interview on 07/23/26 at 3:00 PM with CNA B revealed she sometimes saw residents smoking without a staff member, and she always reported it to the nurse. She said it happens a lot because family members would buy smoking materials for residents and leave them with the resident, or she would sometimes see some of the residents going to the convenience store, where they would buy their own. An interview on 07/23/26 at 3:17 PM with the SW revealed they had gone over the smoking policy, designated times, and that a staff member had to be with a resident who was smoking. She said some residents had additional safety interventions, like wearing a smoking apron, so everyone needed to adhere to the scheduled times and supervision. She said a few months prior they had a meeting with the smokers, and went over the entire smoking policy, and had them sign a contract. She said Resident #1 was there, and he signed. She returned a few minutes later to provide a copy of the smoking contract signature page. At this time review of the In-Service Training Attendance Roster for Smoking policies, turning in cigarettes, lighter, dated 02/18/26, reflected handwritten names, and signatures of nine residents, many of them illegible. She said though some of the signatures were illegible, she knew Resident #1 was there, and he did sign it. An interview on 07/23/26 at 4:19 PM with the RCN revealed at the time she initially went out to talk to the residents (12:36 PM), none were smoking, but she let them know they were all alert and oriented, and aware of the smoking times and policies, including that they were not supposed to be out there smoking unattended. She said some of them bought smoking materials and did not turn them in to the staff, and she told them that they agreed to follow the policies, and if they did not follow the policies they could get a 30-day discharge notice. She said she explained the reasons for the safety precautions, which were there for resident safety, and that there could be repercussions they might not have thought of, like the Administrator and DON's licenses being affected if something bad happened as a result of them not following the rules. She said they had ample smoking breaks, and there were some residents who would smoke off the property, so there was no reason for them to not follow the policy. While she was out there she asked them to hand over their cigarettes, and put them away. She said she went over the policy with the staff, and told them if they saw a resident smoking unattended, to sit with them until they finish their cigarette, then ask for the rest of their cigarettes, to be marked with their name, and locked up with the rest, after which the nurse was to be informed. She said if they saw that someone was on oxygen while a resident was smoking nearby, to immediately inform the nurse. Review of the undated Uniform Smoke Free Policy reflected: The resident and responsible party, if applicable, will be informed of the smoking policy upon admission and in conjunction with care plan meetings thereafter. Smoking by residents classified as unsafe will be prohibited except when the resident will be directly supervised by facility personnel. (.) It will be the responsibility of the management personnel to enforce the no smoking policy. Smoking tobacco, matches, lighters or other smoking paraphernalia are not permitted to be kept or stored in a resident's room. A resident, who is assessed safe to smoke unsupervised, will be instructed to obtain their smoking paraphernalia from a designated, secured area. The resident will be instructed to return the smoking paraphernalia following the smoking session. The resident may smoke at their request, unless the time interferes with resident care. A resident, who is assessed unsafe to smoke without supervision, will be notified of the facilities site specific smoking times, at which time the resident will have supervision and assistance as needed. (.) A resident who is assessed unsafe to smoke unsupervised must be in direct view of the smoking supervisor, in reasonably close proximity of the supervisor, and the supervisor must be able to quickly respond in the event of an emergency. Additionally, the supervisor, whether staff or visitor, must be aware of these responsibilities.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 3 residents (Resident #1 and #2) reviewed for clinical records.The facility failed to have complete records for Resident #1 and #2 's wound care for June 2026.This failure could place residents at risk for incomplete and inaccurately documented medical records that included their progress treatment, services, and interventions that would lead to slowing on the healing of wounds .[ Findings include:1.Review of Resident #1's Quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included osteomyelitis (infection and inflammation of the bone, primarily caused by bacteria or fungi). The resident had a BIMS of 11, indicating his cognition was moderately impaired. The MDS further reflected the resident had pressure ulcer of other site, stage 4.Review of Resident #1's care plan updated on 04/27/26 reflected Resident#1 had pressure ulcer at multiple sites, stage 4 of left hip and stage 4 of right hip. The goal was Resident #1's Pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions were to administer medications as ordered. Monitor/document for side effects andeffectiveness.Review of Resident #1's physician orders for June 2026 . right hip: cleanse with 0.125% Dakin's solution, pat dry, apply medical grade honey to base of wound, apply abdominal pad, apply superabsorbent, and seal with med fix tape daily and prn until healed/resolved, every day shift for pressure injury stage 4 may add hydrofera blue (an advanced antibacterial foam wound dressing). cut in spiraling direction . Start date of 06/01/2026 . right hip: cleanse with wound cleanser, pat dry with dry gauze, apply Santyl to base of wound, apply abdominal pad, apply superabsorbent, and seal with medfix tape daily and prn until healed/resolved, every day shift for pressure injury stage 4 may add hydrofera blue. cut in spiraling direction. discontinued date of 06/14/2026 . left hip: cleanse with normal saline, pat dry with dry gauze, apply calcium alginate with silver to base of wound, apply abdominal pad, apply superabsorbent, and seal with medfix tape daily and prn until healed/resolved, every day shift for state 4 pressure injury. start date of 06/01/2026.Review of Resident #1's wound care report for June 2026 reflected wound care was not completed on the Right hip on these dates:*06/01/26,*06/03/26,*06/04/26,*06/05/26,*06/08/26,*06/10/26, *06/11/26, *06/12/26,*06/13/26,*06/19/26,*06/23/26,*06/25/26,*06/26/26,*06/29/26 and *06/30/26.Review of Resident #1's wound care report for June 2026 reflected wound care was not completed on the left hip on these dates:*06/01/26, *06/03/26,*06/04/26,*06/05/26,*06/08/26,*06/10/26,*06/11/26,*06/12/26,*06/13/26,*06/19/26,*06/23/26,*06/25/26,*06/26/26,*06/29/26 and* 06/30/26.Review of Resident#1's wound care report by the wound care doctor for June 2026 reflected the resident was being seen and treated weekly and there was no evidence the wound deteriorated.Observation on 07/08/26 at 11:66PM with Wound care nurse , providing Resident #1 with wound care revealed, he disinfected the table and left it to dry . He removed gloves, washed hands, and put the supplies together. He washed hands and put on PPE. He wheeled the table to Resident #1's bedside. He then washed his hands and put on gloves. He removed the old dressing on the right hip. He removed gloves and performed hand hygiene. He cleansed the wound with normal saline, removed his gloves, washed his hands, and put on new gloves. The wound was observed clean no drainage or signs of infection observed. He applied Santyl and mitred gauze with normal saline and then abdominal pad and then dry dressing dated 07/08/26. He removed gloves and washed hands. He removed the old dressing on the left hip. He removed gloves and performed hand hygiene. He cleansed the wound with normal saline, removed his gloves, washed his hands, and put on new gloves. The wound was observed clean no drainage or signs of infection observed. He applied calcium alginate with normal saline and then abdominal pad and then dry dressing dated 07/08/26. He removed the persona Protective equipment, washed hands and left resident #1 comfortable.2.Review of Resident #2's Quarterly MDS dated [DATE] reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included osteomyelitis (infection and inflammation of the bone, primarily caused by bacteria or fungi). The resident had a BIMS of 03, indicating her cognition was severely impaired. The MDS further reflected the resident had pressure ulcer of sacral region, stage 4, and unstageable deep tissue injury.Review of Resident #2's care plan dated on 04/13/26 reflected Resident#2 had pressure ulcer or potential for pressure ulcer development. stage 4 pressure ulcer of the sacrum and stage 4 Pressure injury right heel. The goal for Resident #2's Pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions were to follow facility policies/protocols for the prevention/treatment of skin breakdown.Review of Resident #2's physician orders for June 2026 reflected the following: - . Cleanse to right heel with normal saline, pat dry with dry gauze, and apply betadine daily, and leave open to air until healed/resolved, every day shift for deep tissue injury pressure ulcer . start date of 04/15/26 . Cleanse with NS/wound cleanser, pat dry with dry gauze, apply medical grade honey to base of wound, and cover with superabsorbent bordered dressing daily and PRN until healed/resolved, every day shift for Unstageable Pressure injury. start date of 06/01/2026 . cleanse with Dakins solution 0.125%, pat dry with dry gauze, applyDakins moisten fluffed gauze to base of wound, and cover withsuperabsorbent bordered dressing daily and prn until healed/resolved.every day shift for unstageable pressure injury. Start date 06/21/26Review of Resident #2's wound care report for June 2026 reflected wound care was not completed on the Right heel on these dates:*06/01/26,*06/03/26,*06/04/26,*06/05/26,*06/08/26,*06/10/26, *06/11/26, *06/19/26,*06/20/26,*06/23/26,*06/25/26*,06/26/26,*06/29/26 and *06/30/26.Review of Resident #2's wound care report for June 2026 reflected wound care was not completed on the Unstageable Pressure Injury on these dates: *06/01/26,*06/03/26,*06/04/26,*06/05/26,*06/08/26,*06/10/26,*06/11/26, *06/19/26,*06/20/26,*06/23/26,*06/25/26,*06/26/26,*06/29/26 and *06/30/26.Review of Resident #2's wound care report by the wound care doctor for June 2026 reflected the resident was being seen and treated weekly and there was no evidence the wound deteriorated.Interview on 07/08/25 at 12:42 PM with the Wound Care Nurse revealed he was responsible for Resident #1 and Resident #2's wound care Monday through Friday and on the weekends, it was done by charge nurses. The Wound Care Nurse said Resident #1's Right hip wound care was done on 06/01/2606/03/2606/04/2606/05/2606/08/2606/10/26 06/11/26 06/12/2606/13/26,06/19/2606/23/2606/25/2606/26/2606/29/26 and 06/30/26.The left hip wound care was done on 06/01/2606/03/2606/04/2606/05/2606/08/2606/10/2606/11/2606/12/2606/13/2606/19/2606/23/2606/25/2606/26/2606/29/26 and 06/30/26. He also said Resident#2 wound care was completed on the unstageable pressure injury on these dates:*06/01/26,*06/03/26,*06/04/26,*06/05/26,*06/08/26,*06/10/26, *06/11/26, *06/12/26,*06/13/26,*06/19/26,*06/23/26,*06/25/26,*06/26/26,*06/29/26 and *06/30/26. And wound care was completed on the right heel on these dates:*06/01/26, *06/03/26,*06/04/26,*06/05/26,*06/08/26,*06/10/26,*06/11/26,*06/12/26,*06/13/26,*06/19/26,*06/23/26,*06/25/26,*06/26/26,*06/29/26 and* 06/30/26 and he did not manage to document either because he forgot or because of time management. He said he administered treatment as scheduled, but he was not documenting and he was aware he was supposed to document after performing wound care. The Wound Care Nurse acknowledged the wound care report not being completed would indicate the wound care was not done. He said the risk of not documenting would lead to delay in healing and infection. He said the DON was aware of the wound not documented and she told him to document care every day, but time management was his problem. Interview on 07/08/26 at 02:19 PM with the DON revealed the expectation was that when treatment nurse provide care he would document on wound care report within 12 hours that care was provided as per physician's orders. She said she was aware the treatment nurse was not documenting care and she had requested him to go back and document, but she failed to follow up to ensure he was documenting care. She said she was responsible of auditing care after the nurse treatment every morning. She said if the wound report were being left blank that could indicate that wound care was not given even if it were provided to the residents including Resident #1 and Resident#2. She said failure to document could lead to residents missing wound care. Review of the facility's policy titled Skin Integrity Management revised on 05/2016 reflected the following:.3.Wound care should be performed as ordered by the physician Policy on documentation on clinical records was requested and was not provided [

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #1) reviewed for infection control practices. While providing Resident #1, who was on EBP due to having a feeding tube and urinary catheter, with incontinence care, CNA A failed to wear a gown and failed to secure her identification lanyard badge, which resulted in the badge touching the resident's perineal area, buttocks, and feces.These failures could place residents at risk of cross-contamination and infections. Findings included: Record review of Resident #1's Face Sheet, dated 06/17/26, revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed he had the following diagnoses: cerebral palsy (neurological disorder that affects movement and posture), neurogenic bladder (lack of bladder control caused by nerve damage), constipation, and contractures of bilateral elbows and knees (permanent shortening of muscles, tendons, or tissues that cause joints to stiffen and lock). The MDS also reflected Resident #1's cognitive skills were severely impaired, indicating he was unable to make decisions. In addition, the MDS reflected that Resident #1 was: dependent on staff for all care, incontinent of bowel, had an indwelling urinary catheter (tube inserted into the bladder to drain urine), and had a feeding tube for nutrition.Record review of Resident #1's Care Plan, revised on 01/20/26, revealed he required tube feeding, and had an indwelling catheter with interventions to monitor signs and symptoms of UTI. The care plan reflected Resident #1 had an ADL self-care performance deficit and was dependent on staff for incontinence care and transfers. The care plan also revealed Resident #1 was on enhanced barrier precautions with an intervention to wear gloves and gown with resident hygiene, toileting/incontinent care, bed mobility, etc. Observation at 06/17/26 at 11:17 AM revealed the enhanced barrier precautions sign outside of Resident #1's room. A second EBP sign was observed at the head of Resident #1's bed on the wall. The sign revealed the following: Enhanced Barrier precautions. Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities. Dressing, bathing/showering, transferring, changing linens, providing hygiene. Observation also revealed PPE was available inside the room. Observation on 06/17/26 at 11:20 AM revealed CNA A entered Resident #1's room, washed hands, and applied gloves. No gown was put on prior to care. Resident #1 was observed lying in bed. CNA A closed the door and pulled the privacy curtain. Resident #1's brief was unlatched and feces was observed. CNA A began cleaning Resident #1's perineal area and was observed wearing a lanyard identification badge. While CNA A was leaning over Resident #1 to clean the feces, the badge was in the perineal area. Resident #1 was turned on his left side and CNA A was wiping the buttocks. The badge was observed dangling on Resident #1's buttocks and in the feces. CNA A completed incontinence care on Resident #1 with no further concerns. After the care, CNA A removed his gloves and washed hands. CNA A did not apply a gown for EBP and did not secure his identification badge before providing incontinence care.During an interview on 06/17/26 at 1:51 PM, CNA A revealed he had worked at the facility for 2 years. CNA A stated when a resident was on EBP, he should wear a gown and gloves. CNA A stated he did not think he needed to wear a gown with Resident #1 because it was only a BM and not blood. CNA A stated Resident #1 did have a catheter and feeding tube but was unable to state what EBP was or the risk of not wearing a gown. CNA A stated he probably had been trained on enhanced barrier precautions but could not recall. CNA A stated his badge did get in the way of the incontinent care. He stated it was touching the feces. CNA A stated not securing his badge was an infection control risk. CNA A stated he does not usually wear this badge, but he forgot his normal one. During an interview on 06/17/26 at 2:00 PM, LVN B revealed she worked at the facility for 1.5 years. LVN A stated she was the nurse for Resident #1. LVN A stated she expected the aides to wear a gown and gloves for incontinent care if a resident was on EBP. She stated it was an extra barrier precaution for a resident with a catheter, wounds, or other tubes into the body. LVN A stated if aides were not following EBP, the risk was spreading infection. LVN A stated if a badge was hanging, it should be removed or secured before any care. LVN A stated the badge could fall into the BM or urine and spread infection or carry something onto clothes to the next resident. During an interview on 06/17/26 at 3:30 PM, ADON C revealed she had worked at the facility for 24 years. She stated the staff were supposed to gown up and put on gloves (PPE) for any resident on EBP. ADON C stated the PPE was for protecting the staff and the patient. ADON C stated Resident #1 was on EBP for his catheter and feeding tube. ADON C stated the risk of not wearing the gown was an infection risk. ADON C stated a dangly badge should be tucked inside or taken off during any care. She stated the badge could collect stuff and staff may not remember to wipe it off. ADON C stated if a badge was hanging down for Resident #1, it was an infection risk. She stated Resident #1 had a history of infections and it could affect him more. ADON C stated staff had been educated and trained on EBP. She stated they also have assignments to stock the EBP bins on the staffing schedule. ADON C stated there was a sign outside the door, and one by the headboard so staff knew what resident was on EBP. She stated the supplies were also in the room. During an interview on 06/17/26 at 4:02 PM, the DON revealed she had worked at the facility since May 2025. She stated she expected staff to wear proper PPE for residents on EBP. The DON stated any residents with a wound or tubes were on EBP. She stated Resident #1 was on EBP and that staff should be wearing a gown and gloves for incontinent care. The DON stated the risk of not wearing proper PPE was risk to the residents, that they could get sick. The DON stated the gown protected the residents from staff and prevented cross contamination. She stated staff know what residents were on EBP from the sign outside the door, the sign above the resident's bed, and the container with PPE inside the room. The DON stated it was an infection control risk if staff were wearing a badge on a lanyard. The DON stated she expected her staff to clean them and wear the gown for Resident #1 so it would have been out of the way. The DON stated they have started staff education on infection control and EBP. Record review of the facility's Enhanced Barrier Precautions Policy, dated 04/01/24, reflected the following: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. A single set of PPE cannot be used for more than 1 patient. EBP are indicated for residents with any of the following: .Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies.Record review of the facility's Infection Control Plan: Overview policy, dated 2019, reflected the following: The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.

Based on interviews and record reviews the facility failed to ensure resident records were accurately documented for 17 of 86 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, and #17) reviewed for resident records. The facility failed to ensure on 06/03/26 CNA A did not use CNA B's log in credentials when she documented care provided for Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, and #17.This failure could place residents at risk of inaccurate reporting of their care. Findings included:Record review of Resident #1's EHR revealed CNA care for 06/03/26 documented by CNA-B. Record review of the facility's staffing for 06/03/26 revealed CNA-B was not working. CNA-A was working the 100 Hall where Resident #1 resided. Record review of Resident #2's EHR also reflected CNA care for 06/03/26 documented by CNA-BRecord review for the 15 remaining residents, Residents #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, and #17, who resided on 100 Hall revealed the same documentation as being completed by CNA-B. The care documented consisted of ADL assistance, bathing, turning, incontinence care, and amount of meal tray consumed. In an interview on 06/03/26 at 1:50 PM, CNA-A stated she had used CNA-B's log in credentials for her documentation because her log in credentials were not working. CNA-A stated this was her second shift at the facility and on her first shift her credentials did not work when she tried to log in and CNA-B had given her log in so she could document her care for the shift. CNA-A stated she had not asked the charge nurse of anyone else about fixing her log in credentials before going home. On 06/03/26 she did not ask the ADON, HR, DON, or anyone in administration about fixing her log-in credentials, she just continued to work. CNA-A stated she knew she was not supposed to use anyone else's log in to document. She stated as part of her orientation training last week she knew log ins were not to be shared with anyone else. She did not see the risk of documenting as another CNA. In a phone interview on 06/03/26 at 2:00 PM, CNA-B stated she had given her credentials to CNA-A on her first shift, which was a 2 PM- 10 PM shift, because there was no one from administration around to fix her credentials. She stated CNAs cannot leave their shift until all their cares have been documented. CNA-B stated CNA-A was only supposed to use her log in for that shift and then see about someone fixing her log in before her next shift. CNA-B stated she was aware she was not supposed to share her credentials with anyone else. She stated documenting as someone else would be creating a false record, and she could be responsible for any errors made by CNA-A.In an interview on 06/03/26 at 2:05 PM the DON stated CNA-B was not working, she had called in sick. She stated she was not aware there was documentation by CNA-B in the EHR of all the residents of the 100 Hall. The DON stated she asked CNA-A if she had documented using CNA-B's log-in credentials, CNA-A stated she had. The DON stated she asked CNA-A if she was aware she was not supposed to use someone else's log in, and CNA-A stated she was aware of that. The DON stated it could be considered false documentation if CNA-A used CNA-B's log-in credentials. She stated the EHR was supposed to be accurate, which included accuracy of who completed what care was provided. She stated her expectation would have been that CNA-A to notify the ADON or herself that her credentials were not working. If it was after hours, the DON stated the CNA should have called the ADON. The DON stated she was unable to locate a policy that addressed log in credential confidentiality or accuracy of documentation.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of 24 residents (Resident #17) reviewed for abuse. The facility failed to ensure CNA Z did not abuse Resident #17 on 04/30/2026 during incontinent care. An IJ (Immediate Jeopardy) was identified on 04/30/26. The IJ template was provided to the facility on [DATE] at 4:50 PM. While the IJ was removed on 05/01/26, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on the plan of removal. This failure could place residents at risk for abuse, physical harm, mental anguish and emotional distress.Findings included: Review of Resident #17's quarterly MDS dated [DATE] reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included heart failure, hypertension (high blood pressure), end stage renal disease (the final permanent state of kidney failure), Alzheimer's disease, stroke, and non-Alzheimer's dementia. The resident had a BIMS of 0 which indicated his cognition was severely impaired. The MDS reflected Resident #17 did not have any behaviors. The MDS indicated the resident was dependent on ADLs. Review of Resident #17's care plan initiated on 04/14/25 reflected the resident had ADL self-care performance deficit. Interventions included the assistance of 1 staff member for ADLs. Review of Resident #17's event nurses' note dated 04/30/26 documented by RN D reflected the following: .Resident reported that the previous night a tall man slapped him on his cheeks. Resident denied pain at this time. Head to toe assessment completed, normal skin color, vital signs within normal limit. No visible signs of bruises or swelling/injury at this time.Review of Resident #17's skin assessment dated [DATE] documented by ADON J indicated there were no bruises, skin tears, abrasions, or lacerations. Observation of Resident #17's video footage the morning of 04/30/26 at 4:57 AM revealed CNA Z entered Resident #17's room, turned on the light and removed the resident's covers and did not speak to the resident. CNA Z raised the resident's bed. Resident #17 was lying on his back and CNA Z was seen grabbing the resident's wrists and forcefully and aggressively turning the resident on his left side and CNA Z put his right hand on the resident's shoulder and forcefully put all of his weight on his left shoulder while he removed the resident's brief all while the resident yelled out in distress. Resident #17 is then seen on his back again and is heard saying to CNA Z what did I do, what did I do and the CNA did not respond. CNA Z then got a clean brief and pushed the resident to his right side and with his left hand held on to the resident's knees and with his right hand grabbed Resident #17's right wrist and again forcefully and aggressively yanked the resident onto his left side and part of the resident's upper extremity is seen hitting the left repositioning side rail all while the resident continued to moan. As CNA Z attempted to put on Resident #17's clean brief, the CNA grabbed both of the resident's wrists, crossed them across his chest, pulled the resident's gown over his wrists and held the resident down with his right hand while his left hand adjusted the brief while the resident continued to moan. The resident's hand remained with the gown over them and CNA Z was seen grabbing the resident's ankles and slightly throwing them to the center of the bed. CNA Z then grabbed the blankets and covered the resident back up, lowered the bed and the resident is heard saying again, what did I do and continued to moan. During the entire incident, CNA Z did not speak. Observation and interview on 04/30/26 at 11:28 AM of Resident #17 revealed he was in his room sitting in his wheelchair while family visited. The resident was asked about the incident, and he said a man had entered his room last night and beat him as Resident #17 pointed to his right face. There did not appear to be any injuries noted to his face at the time. Resident #17 said it made him feel fearful of the man and during the incident, he kept asking the man why he was doing that to him because he did not know him. The resident said he continued to yell out and cry, but the man did not stop and he did not want that man in his room again. The Resident's family said they were called and told about the incident and were asked to review the camera and that is when they saw the aide (CNA Z) mistreat the resident during care. The family stated they often reviewed the camera and had never witnessed that type of abuse and the resident had never mentioned any type of mistreatment. Interview on 04/30/26 at 12:33 PM, CNA I stated that morning (04/30/26) as he got Resident #17 up to change him, MA AA was in the room with the resident when he said that a tall man had went into his room and held him down and hit him. CNA I said he did not see any injuries or bruises on the resident. CNA I said Resident #17 repeated his story and it remained consistent, so they reported the incident to the Administrator and the DON. CNA I said Resident #17 was not combative during care and allowed staff to provide care. He stated Resident #17 was alert and oriented and had never made that type of allegation.Interview on 04/30/26 at 12:51 PM, CNA Z stated he went in to change Resident #17 during his last round and the resident was a little combative during care. He said he did get a little rough and restrained the resident while he put on the resident's brief. CNA Z stated he forcefully and aggressively turned the resident on his side and put his weight on the resident and CNA Z also admitted he restrained the resident's hand to his chest and the aide said he did that because the resident had a history of resisting care. CNA Z said if a resident became combative, they were to stop providing care and report to the nurse. CNA Z said he probably should have stopped when the resident was yelling and asking him to stop but he was used to the resident being combative so that is why he did it. Surveyor observation on 04/30/26 at 1:30 PM of Resident #17 a full body assessment of Resident #17 performed by the DON and RN D revealed the resident did complain of pain. The resident did not have any bruising, redness, or deformity to his back, shoulders, chest, or wrists. Resident #17 did not display any aggression and was very cooperative and did not appear afraid of staff. Interview on 04/30/26 at 2:37 PM, RN D said he was told by CNA I and MA AA that Resident #17 said a tall man has hit him on the cheek. RN D said he went into the room to talk to Resident #17, and the resident told him that a tall man had beat him up last night and said he hit his cheek. RN D said he reported the incident to the Administrator and the DON. He said he performed a head-to-toe assessment of Resident #17 and he did not have any injuries. RN D said the resident was very cognitive and had never made any similar type of allegation. RN D stated Resident #17 was not combative during care. Interview on 04/30/26 at 3:29 PM, LVN BB stated she worked that morning (04/30/26) and she did not hear any resident yell or hear any resident that appeared to be in distress.Interview on 04/30/26 at 5:01 PM, with MA AA stated that morning (04/30/26) she went into Resident #17's room to take his vitals he refused and said mama I got to tell you something, the man beat me up last night and I was crying asking him what I had done to deserve that but he kept going and it didn't make him stop. MA AA said she thought the resident was dreaming when he made the comment, but the resident continued to repeat the story. She said at that time CNA I entered the room and heard what the resident said. MA AA said they reported what Resident #17 said to the Administrator and the DON. MA AA stated it was not normal for the resident to make that type of statement. She said she had never provided the resident with direct care other than giving him his medication, but he was always compliant and no one had mentioned the resident was combative during care. Interview on 04/30/26 at 5:28 PM, CNA CC stated she provided care for Resident #17 and he had never been combative during care. She said he was always compliant and never tried to reach out to grab anyone. Interview on 05/01/26 at 5:37 AM, CNA R stated she has worked that morning (04/30/26) and she did not hear any resident yell or cry during her shift. She stated she did not see any resident that appeared to be in distress. Interview on 05/01/26 at 6:22 AM, the DON stated CNA I and MA AA made her aware the morning of 04/30/26 that Resident #17 had told them a tall man had hit him in the face during the night. The DON said she then let ADON J and the Administrator know and they both (ADON J and Administrator) went to speak with the resident and the resident's story remained consistent with what he had told everyone else. The DON said they called Resident #17's family and asked them to review the camera footage and the family showed them and they were able to see CNA Z being very aggressive while he provided care. The DON said CNA Z was suspended pending the investigation and immediately terminated once they were able to view the video. The DON said Resident #17 had never made that type of comment in the past and the resident was not combative during care. Interview on 05/01/26 at 8:05 AM, ADON J stated she was told Resident #17 had told CNA I and MA AA that a tall black man had beat him so she (ADON J) and the Administrator went to talk with the resident and his story remained consistent with what he had told everyone else. She said the family was then contacted so they could review the footage and they saw CNA Z was very rough, tugging the resident and forcibly holding Resident #17 down during care. ADON J said CNA Z was terminated after they watched the video while they continued with the investigation. ADON J said no one had ever reported to her that Resident #17 was combative during care. Interview on 05/01/26 at 8:27 AM, the Administrator said MA AA told her that Resident #17 told her someone had gone into his room during the night and beat him up and he described him as a tall black man. The Administrator said she and the DON went to speak with the resident and his story had remained consistent so the family was contacted so they could review the camera footage. The Administrator said the video showed CNA Z was abusive to Resident #17 during care and CNA Z was then terminated. The Administrator said CNA Z denied the allegations when she called to get his statement. Review of the facility's policy titled Abuse/Neglect revised 03/2018 reflected the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property exploitation.This includes but Is not limited to freedom of corporal punishment, involuntary seclusion, and any physical or chemical restraint.Resident should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies.The facility will provide and ensure the promotion of resident rights.An Immediate Jeopardy/Immediate Threat was identified on 04/30/26. The Administrator, DON and the Regional Director of Operations were notified of the Immediate Jeopardy on 04/30/26 at 4:45 PM. The IJ template was provided to the facility on [DATE] at 4:50 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 04/30/26 at 8:52 PM and reflected the following: Interventions: CNA was suspended on 04/30/26 by the Administrator, terminated and reported to the nurse aide registry. Completed 04/30/26. Resident #1 had a head-to-toe assessment completed by the charge nurse. No injuries noted. Completed 04/30/26. Weekly skin assessment was completed on all residents by DON/ADON/Compliance Nurse. Completed 04/30/26. A Trauma informed care assessment was completed by charge nurse on resident #1 and documented in the chart. No new findings were assessed. Completed 04/30/26. On 04/30/26, safe surveys were completed for all residents who are able to be interviewed by the Social Worker. No additional allegations of abuse from residents were disclosed. Completed 04/30/26. On 04/30/26 staff interviews were conducted by the Department managers. No additional allegations of abuse towards residents were disclosed. Completed 04/30/26. The medical director was notified of the immediate jeopardy by the Administrator on 04/30/26. An ADHOC QAPI meeting was completed with the Administrator, Regional Compliance Nurse, IDT Team and Medical Director to discuss the immediate jeopardy and plan of removal. Completed 04/30/26.Monitoring Monitoring Tools for actual/alleged abuse will be completed by Admin/DON. Admin/DON will interview 15-20 staff members per week about situational questions related to abuse. Monitoring will be on-going to prevent further abuse. Social Worker will complete 5 resident interviews per week about how staff is treating them. Monitoring will be on-going to prevent further abuse. Weekly skin assessments will completed on all residents to rule out abuse. The Administrator, DON, ADON were in-serviced 1:1 by the ADO on the following policy. Completed 04/30/26.Abuse and Neglect Policy - Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology.Trauma Informed Care PolicyIn-services: The following in-services were initiated by Regional Compliance Nurse, Administrator, and ADON for all staff. Any staff member not present or in-serviced as of 04/30/26 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment. Completion date 04/30/26.Abuse and Neglect Policy - Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Trauma Informed Care Policy Pain Management Notification of Change Customer Service and Bedside CareMonitoring of facility's Plan of Removal included the following:Review of the resident skin assessment completed on 04/30/26 of all the residents did not reflect any issues/concerns.Review of Resident #17's Trauma Informed Care assessment dated [DATE] reflected the following: No previously documented diagnosis of mental disorder, psychological adjustment difficulty, or trauma.Have a diagnosis of PTSD: NoExperiences:Reports no known negative experiences.Has the resident been in a situation that was extremely frightening: NoHas the resident witnessed any extremely frightening situations: NoDoes or has the resident have a close relationship with someone who experienced any extremely frightening situations: NoInterview from 04/30/26 to 05/01/26 with 10 alert and oriented residents revealed they felt safe and did not have any concerns of abuse from staff. Review of the in-services on 05/01/26 completed on 04/30/26 revealed all staff were re-educated on Trauma Informed Pain Management, Notification of Change, Customer Service and Bedside Care. Interviews on 04/30/26 at 12:33 PM to 05/01/26 at 8:29AM with staff from various shifts were Administrator, DON, ADON J, MDS Coordinator L, MDS Coordinator M, Treatment Nuse, Activities Director, RN D, MA E, MA F, CNA G, CNA H, CNA I, CNA N, LVN O, LVN P, LVN Q, CNA R, CNA S, Housekeeping T, CNA U, MA V, LVN W, CNA X, CNA Y, MA AA, LVN BB, CNA CC, RN DD, CNA EE, PTA FF, MA GG, Dietary Manager, CNA HH, HR Coordinator, Medical Records, Floor Maintenance, CNA JJ, and CNA KK All staff were able to identify the following:- The different types of abuse and who to immediate report to. They were to report to the Administrator and if she were not available, they were to report to the DON- Signs/symptoms of pain in residents and who report to.- Identify resident change in condition and who to immediately report to.- Customer service and proper bedside manner during care- Education on trauma informed care and ensure all residents who are trauma survivors receive competent trauma informed care and eliminate triggers that may cause re-traumatization of the residentAn IJ was identified on 04/30/26. The IJ template was provided to the facility on [DATE] at 4:50 PM. While the IJ was removed on 05/01/26, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on the plan of removal.

Based on observation, interview, and record review, the facility failed to provide a private meeting space for the residents' monthly council meetings for 15 of 15 confidential residents reviewed for resident council. The facility failed to provide a private space for resident council meetings.This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy. Findings included:Observation and interview on 04/29/26 at 9:30 AM during a confidential resident group meeting with 12 residents, revealed the resident council meetings were held once a month in the dining room. There were two entrances to the dining room, and both doors were closed and the Activity Director posted do not enter signs on each door. During the meeting three staff members entered the dining room even with the signs posted on the door. The residents stated being interrupted during their resident council meetings was a frequent occurrence and they felt like they could not speak freely with the staff interruptions. Interview on 04/30/26 at 6:25 PM, the Activity Director stated staff interrupted the resident council meetings by entering or attempting to enter the dining room and she would ask the staff to leave. She said the expectation was that no staff should enter during the meeting and the meetings should stay private, so residents had the opportunity to express their concerns without feeling intimidated that staff were listening to what the residents said. Interview on 05/01/26 at 8:22 AM with the Administrator revealed expectations were that facility staff respect the residents' privacy during the resident council meetings. The Administrator said it was important that staff do not enter the meetings because it was residents opportunity to express their concerns without feeling intimidated. Review of the facility's policy titled Resident Council revised on 12/2016 reflected the following: .The facility will provide the resident council with private space;.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 3 (Residents #7, #23, and #97) of 18 residents reviewed for smoking.The facility failed to follow their smoking policy when Residents #7, #23, and #97 were observed to be smoking on the patio without supervision.This failure placed residents at risk of harm and/or serious injury.Findings included: Review of Resident #7's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility 12/16/25. The resident's diagnoses included heart disease, heart failure, hypertension (high blood pressure), and depression. Resident #7 had a BIMS score of 11 which indicated her cognition was moderately impaired. Review of Resident #7's smoking assessment updated 05/01/26 reflected the resident was safe to smoke. The smoking assessment further reflected the resident required direct supervision while smoking, all smoking materials would be kept at nurse station, and the evaluation had been discussed with the resident. Review of Resident #23's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included non-Alzheimer's dementia, anxiety disorder, and schizophrenia. Resident #23 had a BIMS scoreof 9 which indicated her cognition was moderately impaired. Review of Resident #23's care plan revised on 09/29/25 reflected the resident smoked and was non-compliant with smoking policy at times. Interventions included to monitor as needed when smoking to assure resident safety and staff will re-educate resident on smoking policy. Review of Resident #23's smoking assessment dated [DATE] reflected the resident was safe to smoke but required direct supervision. Review of Resident #97's face sheet printed on 05/01/26 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included lumbar vertebra fracture (a break in one of the five vertebrae in the lower back), anxiety disorder, COPD (progressive lung disease causing chronic coughing, wheezing, and severe breathlessness due to damaged airways), and cerebral infarction (type of stroke caused by a blockage that reduces oxygen to the brain). Review of Resident #97's smoking assessment dated [DATE] reflected he was safe to smoke and required direct supervision while smoking. The smoking assessment further reflected that all smoking materials would be kept at the nurse station and the evaluation was discussed with the resident. Observation and interview on 04/29/26 at 8:38 AM revealed there were three residents (Resident #7, #23, and #97) smoking outside on the patio with no staff present. Resident #97 was sharing a cigarette with Resident #23. Resident #7 sat at another table smoking alone on the patio. Resident #7 was asked if he should be smoking unsupervised and he said he happened to find an extra cigarette in his walker bag and that guy (pointed at Resident #97) had let him borrow the lighter. At that time, CNA Y walked out to the patio with the smoking paraphernalia in a lock box. CNA Y said the residents should not have been smoking unsupervised and she did not know where they had gotten their cigarettes and lighter. At that time Resident #97 tucked 4 cigarettes and a lighter under his leg and CNA Y said she would take care of it. Interview on 04/29/26 at 1:59 PM with Resident #97 revealed he had recently been admitted to the facility and had been informed of the smoking policy. The resident denied he was smoking on the patio and said he would never keep cigarettes or lighter on his person. Resident #97 also denied he shared his cigarette with Resident #23. Interview on 04/30/26 at 6:27 PM with the DON revealed residents were not allowed to smoke unsupervised or have smoking paraphernalia on them. The DON said she was not aware the residents were smoking with no supervision and said all residents needed to be supervised for their safety and could be fire hazard. The DON further stated some residents would sign themselves out and go the store and purchase their own smoking paraphernalia. Interview on 05/01/26 at 8:00 AM with ADON J revealed residents were not allowed to smoke unsupervised or have cigarettes or lighters on them for safety reasons and a was a fire hazard. ADON J said she was not aware residents had paraphernalia on their person and said it was difficult to monitor because the residents would sign themselves out and buy more at the store. Interview on 05/01/26 at 8:18 PM with the Administrator revealed residents were not allowed to have cigarettes or lighters on them because it could be a danger to themselves or others around. The Administrator said they had gone over the smoking with the residents and somehow, they continued to get cigarettes and lighters, and they would take them away when the residents were seen with them. Review of the facility's undated policy titled Smoking Policy reflected the following: .1. Matches, lighters, or other ignition sources for smoking are not permitted to be kept or stored in a resident's room 2.The resident must be within direct view of the smoking supervisor, in reasonably close proximity of the supervisor, and the supervisor must be able to quickly respond in the event of an emergency.

Based on observations, interviews, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #4) of 8 residents reviewed for infection controlStaff left a graduated cylinder, used to measure urine output, on the resident's bedside table. This failure could cause cross contamination from an unclean item to the clean items on the bedside table. Findings included:Observation on 04/28/26 at 8:38 a.m. Resident #4's bedside table contained her water cup, hairbrush, her book, and a graduated cylinder with traces of a yellow liquid at the bottom.In an interview on 4/28/26 at 8:38 a.m. Resident #4 stated the cylinder was used to measure the urine from her urinary catheter collection bag. She stated it had been left on her bedside table a couple of other times in the past. She stated she had asked the CNAs not to put it there, but they forget and do it anyway. Resident #4 stated she could not access her bathroom with her wheelchair so she could not put the cylinder in the bathroom herself. Resident #4 stated the cylinder had been there since the night shift emptied her collection bag around 6:00 a.m. She stated she was concerned that the CNAs would do the same thing with a resident who might be confused, and that resident might drink from it. In an interview on 04/30/26 at 9:36 a.m. the DON stated the graduated cylinder should not have been left on the resident's bedside table. The bedside table was considered clean, and the cylinder was definitely not clean. She stated the risk of placing it there could be cross contamination with the resident's food and drink, and if the resident was confused, they may try to drink from it. She did not know who had left it on the bedside table. In an interview on 04/30/26 at 9:50 a.m. CNA-G stated the graduated cylinder could not be left on the bedside table due to the risk of cross contamination with other items on the table like the drink cup or food. In an interview on 04/30/26 at 9:53 a.m. RN-B stated the graduated cylinder could not be left on a bedside table due to the risk of cross contamination. Dirty items like the cylinder could not share the same space as clean items like a drink cup or food. In an interview on 04/30/26 at 9:56 a.m. LVN-C stated dirty items could not be kept with clean items because of the risk of cross contamination. A resident's bedside table was generally considered a clean environment, and dirty items like urine measuring cups could not be left there. In an interview on 04/30/26 at 10:00 a.m. CNA-H stated the cylinders used to empty urine bags should always be rinsed out and left in the bathroom, not put back on the bedside table. She stated it was unsanitary and gross. She stated the cylinder looked like something that could be drunk from, and a confused resident might try to drink from it. In an interview on 04/30/26 at 10:04 a.m. CNA-I stated dirty items like the cylinder should be kept off the bedside table where other clean items were. He stated there was a risk of cross contamination as well as it being unpleasant for the residents. Review of the facility's undated policy Fundamentals of Infection Control Precautions, reflected: Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections.

Based on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #10) of 8 residents reviewed for comprehensive care plans.The facility failed to ensure Resident #10's care plan addressed resident's behavior of picking at her face.This failure could place residents at risk of not having their individual needs met, not receiving necessary care and services, and a decreased quality of life. The findings include:Record review of Resident #10's admission MDS Assessment, dated 02/11/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #10's diagnoses included multiple sclerosis (autoimmune condition that affects your brain and spinal cord), chronic pulmonary edema (condition caused by too much fluid in the lungs), lymphedema (lymph builds up in tissues and causes swelling), essential hypertension (high blood pressure) and Non-Alzheimer's Dementia (brain condition that slowly damages your memory, thinking, learning and organizing skills). Resident #10's BIMS score was 10 which indicated moderate cognitive impairment. Record review of Resident #10's care plan, dated 02/13/26, did not address Resident #10's had a behavior of picking at her face, causing redness and skin-breakdown. Observation and interview on 04/28/26 at 7:18 a.m. revealed Resident #10 in her room, sitting in her wheelchair. Resident #10 was observed to have small red areas on her face. Resident #10 stated she was told by staff that the red areas on her face were caused by her scratching on herself. Resident #10 stated she washes her face every day and she picks at them because the scabbing itches. Resident #10 stated the staff put ointment on the red spots. Interview on 04/30/26 at 3:02 p.m., CNA N stated Resident #10 has had skin-breakdown around her face for a while. She stated the red spots come and go. She stated the red spots would start healing and scab up but then the scabs would come off. She stated she had not seen Resident #10 pick on her face, but it appeared like Resident #10 does pick on the scabs. Interview on 04/30/26 at 3:05 p.m., LVN O stated Resident #10 had the tendency of picking on her face causing skin-breakdown areas on her face. She stated they had physician orders to apply Bactrim. LVN O stated the red areas were looking better and healing but Resident #10 would start picking and removing the scabs on them. LVN O stated they try to redirect and educate Resident #10 to stop picking on her skin. LVN O stated it was a behavior that Resident #10 had and the behavior should be care plan. She stated she was not aware it was not care planned. She stated it was the responsibility of the MDS Coordinator to care plan behaviors. LVN O stated if it was not care plan staff would not know Resident #10's behavior picking on her face. Interview on 04/30/26 at 3:07 p.m., MDS Coordinator L stated the MDS Coordinators were responsible for the initial care plan, and updating the care plan. MDS Coordinator L stated each department was also responsible for updating care plans. She stated the care plans should address any diagnosis, medications and behaviors that the residents were exhibiting. MDS Coordinator L stated she was aware of Resident #10 having a behavior of picking on her face. She stated the Treatment Nurse would be responsible for care planning any skin issues. MDS Coordinator L reviewed Resident #10's care plan and stated the behavior was not care plan. She stated potential risk of not care planning the behavior would be staff not knowing what is going on with the resident. Interview on 04/30/26 at 5:28 p.m., the Treatment Nurse stated he was aware of Resident #10 picking on her face. He stated the nurses were responsible for applying medications. He stated he does not provide any wound care to Resident #10's face. The Treatment Nurse stated Resident #10 behavior of picking on her face should be care plan and it was the responsibility of the nurses to care plan. He stated he was only responsible for care planning wounds. Interview on 05/01/26 at 6:43 a.m., the DON stated Resident #10 face was being treated with antibiotics. She stated Resident #10 had a behavior of picking on her scabs. She stated the red open spot on Resident #10's face were healing but Resident #10 would scratch or pick on the scabs. The DON stated Resident #10 did not admit to the facility with that behavior, it was something that the resident started to do. She stated the behavior should be care plan and she was not aware it was not. She stated it was the responsibility of the MDS Coordinators and nursing to update care plans. She stated her main focus was the resident acute care. The DON stated the behavior should be care plan so that the staff would be aware, alert and know the resident's baseline. Interview on 05/01/26 at 8:19 a.m., ADON K stated she was the ADON assigned to the memory care unit. She stated Resident #10 had a behavior of picking on her skin and it was a behavior she had started at the facility. She stated the red spots on her face were healing but the resident would take the scabs off. ADON K stated they had been treating the skin breakdown, educating the resident to not mess with it. She stated the behavior should be care plan so that the staff were aware. She stated it was her and the DONs responsibility to care plan the behavior. She stated it was missed and she was not aware it was not care plan. ADON K stated the potential risk of not care plan Resident #10's behavior would be infection and staff not knowing that the resident had that behavior. Record review of facility Comprehensive Care Planning policy, undated, reflected the following: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.

Based on observation, interview, and record review, the facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to prevent complications for 1 of 4 residents (Resident #11) reviewed for feeding tubes.RN D failed to follow physician orders and added the wrong amount of water during the flush to Resident #11's formula g-tube (device inserted through the belly into the stomach to deliver nutrition, fluids, and medications) during the feeding on 04/30/26. This failure could place residents at risk for a decline in health or adverse effects due to inappropriate management of G-tube care.Findings included:Review of Resident #11's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included aphasia (language disorder caused by brain damage that impairs speaking, understanding, reading, writing), stroke, hemiplegia (paralysis of one side of the body), and cerebral infarction (blockage in blood vessels supplying the brain resulting in tissue death). Resident #11 had a BIMS score of 0 which indicated her cognition was severely impaired. The MDS further reflected the resident was on a feeding tube. Review of Resident #11's care plan revised on 02/11/25 reflected the resident required a tube feeding related to impaired swallowing. Interventions included follow MD order for current feeding orders. Review of Resident 11's Order Summary Report for May 2026 reflected the following: Enteral Feed Order every shift Flush tube with 60 ml water before and after medication and feedingsEvery 4 hours Flush enteral tube with 30ml water pre/post medication administration and 5-10 ml water between each medicationObservation on 04/30/26 at 9:03 AM, revealed RN D checked Resident #11's g-tube placement prior to the resident's feeding. RN D poured 30ml of water into the syringe attached to the g-tube and let it flow to gravity. RN D then poured the formula into the syringe. After the formula had run through the syringe via gravity, he proceeded to flush with 30 ml of water after the feeding. Interview and observation on 04/30/26 at 9:29 AM with RN D revealed he flushed Resident #11's g-tube with 30 ml of water before and after the feeding. RN D looked at the flush order and said he had read it wrong, and the order was 60 ml of water. RN D further stated it was important to flush with the right amount of water because that was the resident's hydration. Interview on 05/01/26 at 6:17 PM with the DON revealed if Resident #11's g-tube water flush was 60ml per the physician order, then it should have been followed. The DON said it was important, so the resident's g-tube lines stayed clear and free of clogs during the feedings. Interview on 05/01/26 at 7:53 AM with ADON J revealed Resident #11 had two orders, one of the orders read to flush with 30ml before and after medications and the other order was to flush the g-tube with 60ml before and after medications and feedings. ADON J said they called the hospice company and clarified the order and the correct flush before and after feedings should be 60ml. ADON J further stated it was important for physician orders to be followed because flushing with too much water could overload the resident and flushing with too little could dehydrate the resident. Review of the facility's policy titled Enteral Tube Medication Administration dated 2025 reflected the following: PolicyThe facility assures the safe and effective administration of enteral formulas and medications. Selection of enteral formulas, routes, and methods of administration, and the decision to administer medications via enteral tubes are based on nursing assessment of the resident condition, in consultation with the physician.

Based on observations, interviews and record reviews the facility failed to ensure all drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys for 1 of 5 carts reviewed for medication storage. LVN-A failed to secure her medication cart prior to walking away from it on 04/28/26. This failure could place residents at risk of accessing medications not prescribed for them. Observation on 04/28/26 at 5:30 a.m. a medication cart located outside the only nurses' station was unlocked. All drawers were able to be opened, and multiple prescription and over the counter medications were in the drawers. In an interview on 04/28/26 at 5:33 a.m. LVN-A stated she had walked away for just a minute to talk with someone. She stated she knew her cart should have been locked prior to walking away but did not think she was going to be gone very long and most of the residents were still in bed. She stated the risk of leaving the cart unlocked was residents accessing medications not prescribed for them. In an interview on 04/30/26 at 9:39 a.m. the DON stated all medication carts were required to be locked if the nurse or medication aide was not directly in control of the cart. If they walked away from the cart, no matter how long they were going to be away, they must lock the cart. She stated the risk of leaving the cart unlocked was a resident gaining access to medications that were not prescribed for them. In an interview on 04/30/26 at 9:54 a.m. RN-B stated that anytime she walked away from her cart, she was supposed to lock it. She stated locking it prevented anyone not authorized from accessing the cart, or a resident from gaining access to medications they were not prescribed. In an interview on 04/30/26 at 9:58 a.m. LVN-C stated that anytime she was not directly at her cart, she had to lock it to prevent anyone else from gaining access to the medications inside. She stated residents could access medications not prescribed for them. In an interview on 04/30/262/6 at 9:58 a.m. RN-D stated he always locked his medication cart any time he was away from it. Failing to do so could allow residents to access medications that were not prescribed for them and possibly having a reaction to them. In an interview on 04/30/26 at 10:04 a.m. MA-E stated her cart had to be secured any time she walked away from it. She stated leaving it unlocked could allow another resident to get access to medications that might not be theirs. In an interview on 04/30/26 at 10:08 a.m. MA-F stated her cart had to be locked any time she was not directly in front of it. It was kept secured to prevent anyone from accessing the medications inside and taking a medication not prescribed for them. Review of the facility's policy Medication Storage in the Facility, dated 2025, reflected: Medications and biologicals are stored safely, securely, and properly. The medication supply is accessible to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications

Based on observation, interview and record review the facility failed to ensure that each resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 of 5 residents (Resident #1) facility reviewed for nutrition. The facility failed to recognize, evaluate and address Resident #1's weight loss when there was a documented 15.9 % loss from 02/10/26-03/09/26. This failure could place residents at risk for malnutrition or mismanagement of underlying medical conditions.Findings include: Record review of Resident #1's Annual MDS Assessment, dated 03/15/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. He had a BIMS score of 9, which indicated moderate cognitive impairment. Section I-Active Diagnoses reflected Resident # 1's active diagnoses included non-Alzheimer's Dementia (brain disorder that affects memory, thinking, and behavior), Parkinson's Disease ( progressive movement disorder of the nervous system), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), schizophrenia (chronic brain disorder characterized by hallucinations and delusions), history of alcohol abuse, cirrhosis (scarring and damage of the liver), metabolic encephalopathy (brain dysfunction that causes confusion), benign neoplasm of sigmoid colon (non-cancerous growth on inner wall of colon). Section K-Swallowing/Nutritional Status reflected Resident #1 was 66 inches in height and 145 pounds in weight, with no or unknown weight loss. Record review of Resident #1's Care Plan, dated 05/14/25, reflected the resident had dental health problems with interventions that included: coordinating and arranging for dental care and transportation, monitoring, documenting, and reporting to MD any s/sx of dental problems needing attention such as pain, abscesses, debris in mouth, and cracked or bleeding lips, missing or damaged teeth, and providing mouth care as per ADL personal hygiene. Further review of this document reflected Resident #1 did not have a focus or interventions regarding nutrition and weight loss. Record review of Resident #1's EHR under vitals reflected in part the following:-01/09/26-148.2 lbs.-02/10/26-145.5 lbs.-03/09/26-122.4 lbs.Further review reflected there were no documented re-weighs. Record review of Resident #1's lab work, dated 03/02/26, reflected in part the following:Glucose-68 (reference range 82-115)-the body's main energy source, derived from food and regulated by insulinAlbumin-3.3. (reference range 3.4-5.0)-vital protein produced by the liver that transports hormones, drugs, and nutrients throughout the body Record review of Resident #1's consolidated physician orders, dated 03/23/26, reflected in part the following: Dietary-Regular diet: mechanical soft texture, regular consistency; start date: 11/24/25Further review reflected there were no orders to address weight loss. Record review of Resident #1's weights and vitals summary, dated 03/24/26, reflected the following: 03/09/26 at 1:18 PM 122.4 lbs. ([mechanical lift scale]):-5.0% change [Comparison Weight 2/10/2026, 145.5 lbs., -15.9%, -23.1 lbs.] Record review of a document provided by the DON of the facility's weekly resident review on 03/12/26 reflected there were no triggers for weight loss in 30 days, and Resident #1 was not reviewed. In an observation on 3/23/26 at 12:45 PM, Resident #1 was observed being assisted with lunch. Resident #1 ate about 75% of his meal. In an observation on 03/23/26 at 3:45 PM, the mechanical lift scale reflected that Resident #1 weighed 132.0 lbs. An attempted interview with Resident #1's RP on 03/23/26 at 11:15 AM was unsuccessful due to no response to call. In an interview on 03/23/26 at 3:12 PM, CNA A stated she worked at the facility for 7 months. She stated she worked with Resident #1 sometimes and although he was able to physically feed himself, he required supervision. CNA A stated Resident #1 usually ate all his food but preferred food from outside or from his family. She stated she recently worked with Resident #1, and he appeared to have lost a little bit of weight and the nurses were aware. CNA A stated the aides were responsible for reporting any changes of condition to the nurses, which included any changes in a resident's appetite or weight. In an interview on 03/23/26 at 4:15 PM, the DON stated Resident #1 did not appear physically smaller nor had it been reported by any of the nurses. She stated Resident #1 had a good appetite and ate a lot. The DON stated she entered all weights into PCC and must have missed Resident #1's weight loss. She stated a weight loss of over 5% would have been immediately reported to the MD, RD and family. The DON stated the IDT had discussed seeking outside sources to assess Resident #1 for other health conditions such as a tumor to explain his increased behaviors and now weight loss. In an observation on 03/24/26 at 9:02 AM, Resident #1 was being assisted with eating a bowl of cereal. The Interim Administrator stated Resident #1 had already had breakfast and was eating seconds with the bowl of cereal. Resident #1 was observed to be dressed and well-groomed with no visible marks or bruises. Resident #1 did not appear to be malnourished or severely underweight. In an interview on 03/24/26 at 9:10 AM, Resident #1 stated he was well and did not feel like he was losing any weight. Resident #1 stated he ate enough food at the facility and was even provided with his cultural food from outside when he wanted it. In an interview on 03/24/26 at 9:52 AM, the MD stated his expectation was for the facility to notify him of any changes in weight over a 5% gain or loss and consult with the Dietitian. The MD stated he was aware Resident #1 was at risk of weight loss due to diagnosis of cirrhosis and due to his behaviors of constant moving and sliding down to the floor; however, it had not been reported that the resident had a significant weight loss. The MD stated the facility recently reported having issues with their mechanical lift scale and were advised to fix the issue and re-weigh any residents with discrepancies. The MD stated he recently ordered lab work for Resident #1, and he had no concerns because the abnormal lab values were related to the resident's cirrhosis and not from malnutrition. The MD stated it was reported very clearly that Resident #1 ate well and the facility even purchased outside food to satisfy the resident's preference, so there was no concern for the resident's appetite. The MD stated if Resident #1's documented weights were accurate, the fact he was eating well and still losing weight raised concerns for other issues. The MD stated he would order new labs to check Resident #1 for underlying conditions like cancer. The orders were submitted but had not been completed prior to surveyor's exit. An attempted interview with Resident #1's RP on 03/24/26 at 10:00 AM was unsuccessful due to no response to call. In an interview on 03/24/26 at 10:27 AM, the RD stated she was no longer the permanent Dietitian at the facility; however, she was covering until the new Dietitian was able to return to work. The RD stated the new Dietitian informed her she visited the facility on 03/11/26 and found not all residents had current weights entered in the system, so she was going to have to return on a later date as they had the entire month to address any issues. The RD stated during her time working with Resident #1, she did not recall the resident having any skin (wounds) or dietary concerns or signs of weight loss that needed to be addressed, and it was reported Resident #1 had a good appetite. The RD stated Resident #1's weight remained stable. The RD stated if a resident had a weigh loss of more than 5% within a month, she would expect the facility to notify her immediately. She stated she would advise the facility to re-weigh the resident for accuracy, then implement a fortified diet and/or supplements as needed with weekly weights for close monitoring. In an interview on 03/24/26 at 11:15 AM, the Compliance Nurse stated if a resident had significant weight loss the expectation would be for the nurse to re-weigh, then notify the MD, Dietitian, and family. The Compliance Nurse stated the care plan would be updated to include interventions such as weekly weights and the Red Glass nutrition program which would alert staff the resident was at risk for weight loss. The Compliance Nurse stated staff would also need to be in-serviced regarding any new interventions implemented. She stated the facility reported having recent issues with their scale but received a new one last week The Compliance Nurse could not state if Resident #1's weight was accurate or why there was not a documented re-weigh for accuracy. She stated she had the facility to start an in-service on weight monitoring and audit all residents' weights. In an interview on 03/24/26 at 11:30 AM, the Activity Director stated she was also a medication aid and was responsible for taking weights of all residents. She stated the residents were weighed at least monthly unless their order or care plan said differently, and Resident #1 was weighed once a month. The Activity Director stated she would write down the weights and provide the weights to the DON. She stated she was not responsible for putting the weights in PCC or monitoring the numbers for significant changes; however, all staff were responsible for reporting any changes of physical condition to the DON. The Activity Director stated she had not noticed any changes in Resident #1's physical condition regarding his weight, and she was the one who weighed him on 02/10/26 and 03/09/26 using the mechanical lift scale. She stated she also assisted him with eating and he always ate most, if not all his food. In an interview on 03/24/26 at 1:08 PM, the DON stated they had weekly meetings to review residents who triggered alerts for ADL declines, which included weight loss, and the team would discuss implementing interventions. The DON stated Resident #1 did not trigger an alert for weight loss during the weekly meeting on 3/12/26 because she had not entered the resident's weight from 03/09/26. The DON stated she was busy with training that week and was behind on documentation. She stated the following week they had a QAPI meeting and Resident #1's current weight still had not been entered, so his weight loss was missed again. The DON stated the Activity Director was responsible for taking all weights and documenting them on paper. The DON stated the Activity Director would not notice any significant changes in weights based on the numbers because the facility did not keep a running log of weights on the paper document to prevent falsification. The DON stated it was her responsibility to record all weights from the paper document into PCC (the facility's electronic health record system), and the facility's policy stated weights and documentation was supposed to be completed by the 10th of each month. She stated it was after the 15th before she recorded Resident #1's weight from 03/09/26, otherwise the weight loss would have been caught by the MDS Nurse when she updated the resident's annual MDS assessment on 03/15/26. The DON stated this caused the MDS assessment to be inaccurate and another missed opportunity to catch Resident #1's weight loss. The DON stated that missing significant weight loss could place the residents at risk of untreated serious health conditions. Record review of the facility's policy titled Resident Weight, revised 02/13/2007, reflected the following: All residents will be weighed by the 10th of the month and their weights documented correctly. The appropriate actions regarding significant changes will be carried out. Procedure: Weights shall be obtained and documented at admission, readmission, and monthly unless ordered otherwise by the physician, or unless dictated more frequently by the resident's condition. Factors indicating the need for more frequent weights include significant weight loss, drastic decrease in food consumption, prolonged nausea, vomiting, or diarrhea, significant weight gain, swelling or edema, poor appetite during adjustment period to the facility, recent change from tube feeding to oral intake, or pressure ulcers that are not resolving as expected. Monthly weights will be obtained prior to the 10th of the month. The DON or designee will review all weights to determine the need for any re-weighs. Re-weighs will be completed within 24 hours of the first weight. Significant Weight LossThe facility reviews resident weights after monthly weights are obtained, to determine residents with significant weight changes. A significant weight change will be defined as 5% or greater in one month, 7.5% or greater in three months, or 10% or greater in six months. The weight change will be recorded on the appropriate weight watcher's form along with interventions, and follow-up will also be recorded the designated location. The physician and family will be notified. In addition, an acute care plan for weight loss will be initiated and the clinical record reviewed for possible need of a significant change of condition MDS assessment. Assess the resident for possible reason for weight loss.

Based on interviews and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 10 residents (Resident #2) reviewed for quality of care. The facility failed to treat Resident #2's constipation as ordered by the physician.This failure could place residents at risk of developing an obstruction, or a rupture of the intestines. Findings include:Record review of Resident #2's admission MDS assessment, dated 01/14/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included diabetes, amputation of both legs above the knees, heart failure, and constipation . His BIMS score was 15, which indicated he was cognitively intact. His Functional Ability assessment indicated he needed partial assistance with toileting. Record review of Resident #2's care plan, dated 01/15/26, reflected he had a self-care deficit, and was a fall risk related to his leg amputations. Record review of Resident #2's Bowel Continence flow sheet, from 03/11/26 to 03/24/26, reflected the resident had no bowel movement since 03/17/26. Record review of Resident #2's physician orders revealed an order written by RN B, dated 03/14/26, which reflected: Dulcolax Rectal Suppository 10 mg (Bisacodyl). Insert 1 suppository rectally every 12 hours as needed for Constipation BM x 48 hours.Record review of Resident #2's Nurse Administration Record reflected the suppository was given on 03/14/26 and 03/24/26. In an interview on 03/24/26 at 9:50 AM, Resident #2 stated he needed something for constipation. He stated he was having some abdominal discomfort, and he thought his last bowel movement was the previous week sometime. Resident #2 stated he asked RN-B for an enema, and the nurse stated he would have to contact the physician for that because he only had an order for a suppository. Resident #2 stated he could wait to see what the doctor said. In an interview on 03/24/26 at 12:05 PM, RN-B stated he contacted the physician about the Resident #2 wanting an enema. The physician advised him to administer the suppository first, and if there were no results call him back. RN-B stated he followed up with Resident #2, who agreed to try the suppository. RN B stated he administered the suppository around 11:15 AM on 3/24/26. RN-B stated the resident had a large bowel movement about 30 minutes after the suppository had been administered. RN-B stated he was not aware the resident had not had a bowel movement since last week. RN-B stated when he assessed the resident that morning, he had bowel sounds in all four quadrants of his abdomen and was educated on letting the nurse know if he had not had a bowel movement in more than 12 hours. RN-B stated the CNAs were responsible for documenting the resident bowel movements on the flow sheet and notifying the nurse if it had been more than 2 days since the resident had a bowel movement. In an interview on 03/24/26 at 12:50 PM, CNA-C stated Resident #2 had not complained to her about not having a bowel movement since the previous week. She stated the only way the CNA could see the resident's bowel movement pattern would be to go into the Kardex and review it. She stated the CNAs didn't normally have to do that because the nurse was notified by the computer somehow. In an interview on 03/24/26 at 1:25 PM, the DON stated the residents should not go more than 3 days without a bowel movement because of the risk of constipation and possibly having a rupture of their bowels in the extreme situation. She stated the CNAs documented bowel patterns via the flowsheet, and if no bowel movement was documented in 2 days the nurse received a Clinical Alert in the form of a message and a red bell symbol at the top of the resident's dashboard. The DON stated she did not know if the nurses had not seen the alert, or if one had acknowledged it and did not follow up on it. She stated she would have to interview the staff who cared for him and check with the IT department to see if the alert did not activate for some reason. The DON stated the facility did not have a policy addressing constipation specifically, just resident assessments. In a follow-up interview on 03/24/26 at 1:40 PM, Resident #2 stated he had results from the suppository and felt better. He stated he would still like to have an enema to make sure he was cleaned out, and he would talk to the nurse about that . Record review of the facility's policy Resident Assessment, dated 2003, reflected: 2. The assessment will include at least the following: a. Medically defined conditions and prior medical history

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to develop a comprehensive care plan for Resident #1 to address the resident's recent significant weight loss. This failure could place residents at risk for missed care needs and continued decline in health.Findings include: Record review of Resident #1's Annual MDS Assessment, dated 03/15/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. He had a BIMS score of 9, which indicated moderate cognitive impairment. Section I-Active Diagnoses reflected Resident # 1's active diagnoses included non-Alzheimer's Dementia (brain disorder that affects memory, thinking, and behavior), Parkinson's Disease (progressive movement disorder of the nervous system), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), schizophrenia (chronic brain disorder characterized by hallucinations and delusions), history of alcohol abuse, cirrhosis (scarring and damage of the liver), metabolic encephalopathy (brain dysfunction that causes confusion), benign neoplasm of sigmoid colon (non-cancerous growth on inner wall of colon). Section K-Swallowing/Nutritional Status reflected Resident #1 was 66 inches in height and 145 pounds in weight, with no or unknown weight loss. Record review of Resident #1's Care Plan, dated 05/14/25, reflected the resident had dental health problems with interventions that included: coordinating and arranging for dental care and transportation, monitoring, documenting, and reporting to MD any s/sx of dental problems needing attention such as pain, abscesses, debris in mouth, and cracked or bleeding lips, missing or damaged teeth, and providing mouth care as per ADL personal hygiene. Further review of this document reflected Resident #1 did not have a focus or interventions regarding nutrition and weight loss. Record review of Resident #1's EHR under vitals reflected in part the following:-01/09/26-148.2 lbs.-02/10/26-145.5 lbs.-03/09/26-122.4 lbs. Further review revealed there were no documented re-weighs Record review of Resident #1's weights and vitals summary, dated 03/24/26, reflected the following:03/09/26 at 1:18 PM 122.4 lbs. ([mechanical lift]):-5.0% change [Comparison Weight 2/10/2026, 145.5 lbs., -15.9%, -23.1 lbs.] Record review of a document provided by the DON of the facility's weekly resident review on 03/12/26 reflected there were no triggers for weight loss in 30 days, and Resident #1 was not reviewed. In an interview on 03/24/26 at 9:45 AM, the MDS Nurse stated she had been the MDS nurse for about 11 months. She stated MDS assessments were completed quarterly, annually, and if there was a significant change. The MDS Nurse stated significant weight loss would be considered a change and would trigger an alert in the system for her to update the MDS Assessment. The MDS Nurse stated she completed Resident #1's annual MDS assessment on 03/15/26 and there was not an alert for weight loss. The MDS Nurse stated the current weights were not always entered immediately into the system, and she used the data for weight that was available. The MDS Nurse stated she was familiar with Resident #1 and knew that he ate well and would often ask for seconds, so it would not have been typical for him to have a significant weight loss. She stated interventions in the care plan were derived from information in the MDS assessment, so inaccurate information could place the resident at risk for missed interventions for a change in condition. In an interview on 03/24/26 at 1:08 PM, the DON stated they had weekly meetings to review residents who triggered alerts for ADL declines, which included weight loss, and the team would discuss implementing interventions. The DON stated Resident #1 did not trigger an alert for weight loss during the weekly meeting on 3/12/26, because she had not entered the resident's weight from 03/09/26. The DON stated she was busy with training that week and was behind on documentation. She stated the following week they had a QAPI meeting and Resident #1's current weight still had not been entered, so his weight loss was missed again. The DON stated the Activity Director was responsible for taking all weights and documenting them on paper. The DON stated the Activity Director would not notice any significant changes in weights based on the numbers because the facility did not keep a running log of weights on the paper document to prevent falsification. The DON stated it was her responsibility to record all weights from the paper document into PCC, and the facility's policy stated weights and documentation were supposed to be completed by the 10th of each month. She stated it was after the 15th before she recorded Resident #1's weight from 03/09/26, otherwise the weight loss would have been caught by the MDS Nurse when she updated the resident's annual MDS assessment on 03/15/26 to include interventions for weight loss on the resident's care plan. The DON stated this caused the MDS assessment to be inaccurate and another missed opportunity to catch Resident #1's weight loss. The DON stated missing significant weight loss could place the resident at risk of untreated serious health conditions. Record review of the facility's, undated, policy titled Comprehensive Care Planning, reflected in part the following: The facility will develop and implement a comprehensive person-centered care plan for each resident,consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following - The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and the right to refuse treatment.When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set(MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services. If a Care Area Assessment (CAA) is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing or currently has a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident. Documentation regarding these assessments and the facility'srationale for deciding whether or not to proceed with care planning for each area triggered will be recorded inthe medical record. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 8 residents (Resident #1) reviewed for assessments. The MDS Nurse failed to ensure Resident #1's annual MDS assessment, updated on 03/15/26, was accurate and reflected the resident's recent significant weight loss. This failure could place residents at risk for missed care needs and continued decline in health.Findings include: Record review of Resident #1's Annual MDS Assessment, dated 03/15/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. He had a BIMS score of 9, which indicated moderate cognitive impairment. Section I-Active Diagnoses reflected Resident # 1's active diagnoses included non-Alzheimer's Dementia (brain disorder that affects memory, thinking, and behavior), Parkinson's Disease (progressive movement disorder of the nervous system), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), schizophrenia (chronic brain disorder characterized by hallucinations and delusions), history of alcohol abuse, cirrhosis (scarring and damage of the liver), metabolic encephalopathy (brain dysfunction that causes confusion), benign neoplasm of sigmoid colon (non-cancerous growth on inner wall of colon). Section K-Swallowing/Nutritional Status reflected Resident #1 was 66 inches in height and 145 pounds in weight, with no or unknown weight loss. Record review of Resident #1's Care Plan, dated 05/14/25, reflected the resident had dental health problems with interventions that included: coordinating and arranging for dental care and transportation, monitoring, documenting, and reporting to MD any s/sx of dental problems needing attention such as pain, abscesses, debris in mouth, and cracked or bleeding lips, missing or damaged teeth, and providing mouth care as per ADL personal hygiene. Further review of this document reflected Resident #1 did not have a focus or interventions regarding nutrition and weight loss. Record review of Resident #1's EHR under vitals reflected in part the following:-01/09/26-148.2 lbs.-02/10/26-145.5 lbs.-03/09/26-122.4 lbs. Further review revealed there were no documented re-weighs Record review of Resident #1's weights and vitals summary, dated 03/24/26, reflected the following:03/09/26 at 1:18 PM 122.4 lbs. ([mechanical lift]):-5.0% change [Comparison Weight 2/10/2026, 145.5 lbs., -15.9%, -23.1 lbs.] Record review of a document provided by the DON of the facility's weekly resident review on 03/12/26 reflected there were no triggers for weight loss in 30 days, and Resident #1 was not reviewed. In an interview on 03/24/26 at 9:45 AM, the MDS Nurse stated she had been the MDS nurse for about 11 months. She stated MDS assessments were completed quarterly, annually, and if there was a significant change. The MDS Nurse stated significant weight loss would be considered a change and would trigger an alert in the system for her to update the MDS Assessment. The MDS Nurse stated she completed Resident #1's annual MDS assessment on 03/15/26 and there was not an alert for weight loss. The MDS Nurse stated the current weights were not always entered immediately into the system, and she used the data for weight that was available. The MDS Nurse stated she was familiar with Resident #1 and knew that he ate well and would often ask for seconds, so it would not have been typical for him to have a significant weight loss. She stated interventions in the care plan were derived from information in the MDS assessment, so inaccurate information could place the resident at risk for missed interventions for a change in condition. In an interview on 03/24/26 at 1:08 PM, the DON stated they had weekly meetings to review residents who triggered alerts for ADL declines, which included weight loss, and the team would discuss implementing interventions. The DON stated Resident #1 did not trigger an alert for weight loss during the weekly meeting on 3/12/26, because she had not entered the resident's weight from 03/09/26. The DON stated she was busy with training that week and was behind on documentation. She stated the following week they had a QAPI meeting and Resident #1's current weight still had not been entered, so his weight loss was missed again. The DON stated the Activity Director was responsible for taking all weights and documenting them on paper. The DON stated the Activity Director would not notice any significant changes in weights based on the numbers because the facility did not keep a running log of weights on the paper document to prevent falsification. The DON stated it was her responsibility to record all weights from the paper document into PCC, and the facility's policy stated weights and documentation were supposed to be completed by the 10th of each month. She stated it was after the 15th before she recorded Resident #1's weight from 03/09/26, otherwise the weight loss would have been caught by the MDS Nurse when she updated the resident's annual MDS assessment on 03/15/26 to include interventions for weight loss on the resident's care plan. The DON stated this caused the MDS assessment to be inaccurate and another missed opportunity to catch Resident #1's weight loss. The DON stated missing significant weight loss could place the resident at risk of untreated serious health conditions. Record review of the facility's, undated, policy titled Comprehensive Care Planning, reflected in part the following: The facility will develop and implement a comprehensive person-centered care plan for each resident,consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following - The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and the right to refuse treatment.When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set(MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services. If a Care Area Assessment (CAA) is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing or currently has a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident. Documentation regarding these assessments and the facility'srationale for deciding whether or not to proceed with care planning for each area triggered will be recorded inthe medical record. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #1) facility reviewed for nutrition. The facility failed to immediately notify the physician when Resident #1's weight showed a 15.9% loss from 02/10/26-03/09/26. This failure could place residents at risk for malnutrition or mismanagement of underlying medical conditions.Findings include: Record review of Resident #1's Annual MDS Assessment, dated 03/15/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. He had a BIMS score of 9, which indicated moderate cognitive impairment. Section I-Active Diagnoses reflected Resident # 1's active diagnoses included non-Alzheimer's Dementia (brain disorder that affects memory, thinking, and behavior), Parkinson's Disease ( progressive movement disorder of the nervous system), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), schizophrenia (chronic brain disorder characterized by hallucinations and delusions), history of alcohol abuse, cirrhosis (scarring and damage of the liver), metabolic encephalopathy (brain dysfunction that causes confusion), benign neoplasm of sigmoid colon (non-cancerous growth on inner wall of colon). Section K-Swallowing/Nutritional Status reflected Resident #1 was 66 inches in height and 145 pounds in weight, with no or unknown weight loss. Record review of Resident #1's Care Plan, dated 05/14/25, reflected the resident had dental health problems with interventions that included: coordinating and arranging for dental care and transportation, monitoring, documenting, and reporting to MD any s/sx of dental problems needing attention such as pain, abscesses, debris in mouth, and cracked or bleeding lips, missing or damaged teeth, and providing mouth care as per ADL personal hygiene. Further review of this document reflected Resident #1 did not have a focus or interventions regarding nutrition and weight loss. Record review of Resident #1's EHR under vitals reflected in part the following:-01/09/26-148.2 lbs.-02/10/26-145.5 lbs.-03/09/26-122.4 lbs.Further review reflected there were no documented re-weighs. Record review of Resident #1's lab work, dated 03/02/26, reflected in part the following:Glucose-68 (reference range 82-115)-the body's main energy source, derived from food and regulated by insulinAlbumin-3.3. (reference range 3.4-5.0)-vital protein produced by the liver that transports hormones, drugs, and nutrients throughout the body Record review of Resident #1's consolidated physician orders, dated 03/23/26, reflected in part the following: Dietary-Regular diet: mechanical soft texture, regular consistency; start date: 11/24/25Further review reflected there were no orders to address weight loss. Record review of Resident #1's weights and vitals summary, dated 03/24/26, reflected the following: 03/09/26 at 1:18 PM 122.4 lbs. ([mechanical lift scale]):-5.0% change [Comparison Weight 2/10/2026, 145.5 lbs., -15.9%, -23.1 lbs.] Record review of a document provided by the DON of the facility's weekly resident review on 03/12/26 reflected there were no triggers for weight loss in 30 days, and Resident #1 was not reviewed. In an observation on 3/23/26 at 12:45 PM, Resident #1 was observed being assisted with lunch. Resident #1 ate about 75% of his meal. In an observation on 03/23/26 at 3:45 PM, the mechanical lift scale reflected that Resident #1 weighed 132.0 lbs. An attempted interview with Resident #1's RP on 03/23/26 at 11:15 AM was unsuccessful due to no response to call. In an interview on 03/23/26 at 3:12 PM, CNA A stated she worked at the facility for 7 months. She stated she worked with Resident #1 sometimes and although he was able to physically feed himself, he required supervision. CNA A stated Resident #1 usually ate all his food but preferred food from outside or from his family. She stated she recently worked with Resident #1, and he appeared to have lost a little bit of weight and the nurses were aware. CNA A stated the aides were responsible for reporting any changes of condition to the nurses, which included any changes in a resident's appetite or weight. In an interview on 03/23/26 at 4:15 PM, the DON stated Resident #1 did not appear physically smaller nor had it been reported by any of the nurses. She stated Resident #1 had a good appetite and ate a lot. The DON stated she entered all weights into PCC and must have missed Resident #1's weight loss. She stated a weight loss of over 5% would have been immediately reported to the MD, RD and family. The DON stated the IDT had discussed seeking outside sources to assess Resident #1 for other health conditions such as a tumor to explain his increased behaviors and now weight loss. In an observation on 03/24/26 at 9:02 AM, Resident #1 was being assisted with eating a bowl of cereal. The Interim Administrator stated Resident #1 had already had breakfast and was eating seconds with the bowl of cereal. Resident #1 was observed to be dressed and well-groomed with no visible marks or bruises. Resident #1 did not appear to be malnourished or severely underweight. In an interview on 03/24/26 at 9:10 AM, Resident #1 stated he was well and did not feel like he was losing any weight. Resident #1 stated he ate enough food at the facility and was even provided with his cultural food from outside when he wanted it. In an interview on 03/24/26 at 9:52 AM, the MD stated his expectation was for the facility to notify him of any changes in weight over a 5% gain or loss and consult with the Dietitian. The MD stated he was aware Resident #1 was at risk of weight loss due to diagnosis of cirrhosis and due to his behaviors of constant moving and sliding down to the floor; however, it had not been reported that the resident had a significant weight loss. The MD stated the facility recently reported having issues with their mechanical lift scale and were advised to fix the issue and re-weigh any residents with discrepancies. The MD stated he recently ordered lab work for Resident #1, and he had no concerns because the abnormal lab values were related to the resident's cirrhosis and not from malnutrition. The MD stated it was reported very clearly that Resident #1 ate well and the facility even purchased outside food to satisfy the resident's preference, so there was no concern for the resident's appetite. The MD stated if Resident #1's documented weights were accurate, the fact he was eating well and still losing weight raised concerns for other issues. The MD stated he would order new labs to check Resident #1 for underlying conditions like cancer. The orders were submitted but had not been completed prior to surveyor's exit. An attempted interview with Resident #1's RP on 03/24/26 at 10:00 AM was unsuccessful due to no response to call. In an interview on 03/24/26 at 10:27 AM, the RD stated she was no longer the permanent Dietitian at the facility; however, she was covering until the new Dietitian was able to return to work. The RD stated the new Dietitian informed her she visited the facility on 03/11/26 and found not all residents had current weights entered in the system, so she was going to have to return on a later date as they had the entire month to address any issues. The RD stated during her time working with Resident #1, she did not recall the resident having any skin (wounds) or dietary concerns or signs of weight loss that needed to be addressed, and it was reported Resident #1 had a good appetite. The RD stated Resident #1's weight remained stable. The RD stated if a resident had a weigh loss of more than 5% within a month, she would expect the facility to notify her immediately. She stated she would advise the facility to re-weigh the resident for accuracy, then implement a fortified diet and/or supplements as needed with weekly weights for close monitoring. In an interview on 03/24/26 at 11:15 AM, the Compliance Nurse stated if a resident had significant weight loss the expectation would be for the nurse to re-weigh, then notify the MD, Dietitian, and family. The Compliance Nurse stated the care plan would be updated to include interventions such as weekly weights and the Red Glass nutrition program which would alert staff the resident was at risk for weight loss. The Compliance Nurse stated staff would also need to be in-serviced regarding any new interventions implemented. She stated the facility reported having recent issues with their scale but received a new one last week The Compliance Nurse could not state if Resident #1's weight was accurate or why there was not a documented re-weigh for accuracy. She stated she had the facility to start an in-service on weight monitoring and audit all residents' weights. In an interview on 03/24/26 at 11:30 AM, the Activity Director stated she was also a medication aid and was responsible for taking weights of all residents. She stated the residents were weighed at least monthly unless their order or care plan said differently, and Resident #1 was weighed once a month. The Activity Director stated she would write down the weights and provide the weights to the DON. She stated she was not responsible for putting the weights in PCC or monitoring the numbers for significant changes; however, all staff were responsible for reporting any changes of physical condition to the DON. The Activity Director stated she had not noticed any changes in Resident #1's physical condition regarding his weight, and she was the one who weighed him on 02/10/26 and 03/09/26 using the mechanical lift scale. She stated she also assisted him with eating and he always ate most, if not all his food. In an interview on 03/24/26 at 1:08 PM, the DON stated they had weekly meetings to review residents who triggered alerts for ADL declines, which included weight loss, and the team would discuss implementing interventions. The DON stated Resident #1 did not trigger an alert for weight loss during the weekly meeting on 3/12/26 because she had not entered the resident's weight from 03/09/26. The DON stated she was busy with training that week and was behind on documentation. She stated the following week they had a QAPI meeting and Resident #1's current weight still had not been entered, so his weight loss was missed again. The DON stated the Activity Director was responsible for taking all weights and documenting them on paper. The DON stated the Activity Director would not notice any significant changes in weights based on the numbers because the facility did not keep a running log of weights on the paper document to prevent falsification. The DON stated it was her responsibility to record all weights from the paper document into PCC (the facility's electronic health record system), and the facility's policy stated weights, and documentation was supposed to be completed by the 10th of each month. She stated it was after the 15th before she recorded Resident #1's weight from 03/09/26, otherwise the weight loss would have been caught by the MDS Nurse when she updated the resident's annual MDS assessment on 03/15/26. The DON stated this caused the MDS assessment to be inaccurate and another missed opportunity to catch Resident #1's weight loss. The DON stated that missing significant weight loss could place the residents at risk of untreated serious health conditions. Record review of the facility's policy titled Notifying the Physician of Change in Status, undated, reflected the following: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. The facility utilizes the INTERACT tool, Change in condition -When to notify the MD/NP/PA to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Work day notification of the physician.The nurse will notify the physician or their dckgated nurse practitioner or physician assistant with change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implt::mented in the resident's clinical record.Before the physician is contacted, the nurse will gather and organize resident information. Applicable information will include current medications, vital signs, signs and symptoms initiating call, currentlaboratory information, and interventions that have currently been implemented Record review of the facility's policy titled Resident Weight, revised 02/13/2007, reflected the following: All residents will be weighed by the 10th of the month and their weights documented correctly. The appropriate actions regarding significant changes will be carried out. Procedure: Weights shall be obtained and documented at admission, readmission, and monthly unless ordered otherwise by the physician, or unless dictated more frequently by the resident's condition. Factors indicating the need for more frequent weights include significant weight loss, drastic decrease in food consumption, prolonged nausea, vomiting, or diarrhea, significant weight gain, swelling or edema, poor appetite during adjustment period to the facility, recent change from tube feeding to oral intake, or pressure ulcers that are not resolving as expected. Monthly weights will be obtained prior to the 10th of the month. The DON or designee will review all weights to determine the need for any re-weighs. Re-weighs will be completed within 24 hours of the first weight. Significant Weight LossThe facility reviews resident weights after monthly weights are obtained, to determine residents with significant weight changes. A significant weight change will be defined as 5% or greater in one month, 7.5% or greater in three months, or 10% or greater in six months. The weight change will be recorded on the appropriate weight watcher's form along with interventions, and follow-up will also be recorded the designated location. The physician and family will be notified. In addition, an acute care plan for weight loss will be initiated and the clinical record reviewed for possible need of a significant change of condition MDS assessment. Assess the resident for possible reason for weight loss.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Residents #9) reviewed for environment. 1. LVN-W, CNA-R, and MA failed to ensure the linen cart located on the 100 hall was covered when not in use. 2. LVN-W and CNA-U failed to properly discard a red biohazard bag, after providing care when the bag was left in the hallway of Hall 300 outside Resident #9's room. This deficient practice placed staff and residents at risk for infections and human body fluids.Findings included:During an observation and interview on 09/01/2025 at 1:15 PM revealed the clean linen cart located on Hall 100 had the cover up and over the top of the cart, which left the linen exposed to the environment and contamination. LVN-W and MA were observed working on the hall and passing the linen cart. The MA stated the cart was left by CNA-R, who was caring for a resident. The MA stated CNA-R was the last staff accessing the linen cart. The MA then she closed the cart. There were no residents in the hallway at the time of the observation. During an observation on 09/19/2025 at 1:20 PM of Hall 300 revealed a small sealed red biohazard plastic bag on the floor midway on the left side of the hall outside Resident #9's room. There were no residents in the hallway at the time of the observation. During an interview on 09/19/2025 at 1:35 PM with CNA-R revealed he pulled linen from the linen cart to change resident linen. CNA-R said he was not sure who left the cart exposed. CNA-R said linen carts must remain covered when not in use to prevent resident and visitor access and maintain sanitary conditions for linen. During an interview on 09/19/2025 at 1:59 PM with the MA revealed CNA-R was the last observed accessing the linen cart. The MA revealed the protocol for maintaining clean linen was to ensure the linen cart was properly covered to prevent exposure and cross-contamination. She stated it was all staff's responsibility to ensure the environment and tools for care were sanitary. During an interview on 09/19/2025 at 2:02 PM with CNA-U revealed she was working on Hall 300. She stated she saw the red bag lying on the floor outside of Resident #9's room. CNA-U said she did not pick the bag up when she initially saw it. CNA-U said LVN-W dropped the bag in the hallway after wound care. CNA-U stated she did not notify the charge nurse or LVN W that she dropped the bio-hazard bag. CNA-U said while walking down the hall for the interview with surveyor, she picked the red bag up with gloves and discarded it in the biohazard room. CNA-U said all staff were responsible for maintaining sanitary conditions in the environment, to prevent contamination or resident access. During an interview on 09/19/2025 at 2:15 PM with LVN-W revealed she had completed wound care on the hall earlier and dropped the biohazard bag upon leaving the resident's room to discard. She stated she returned to look for the bag, and it was gone. LVN-W stated all staff were responsible for maintaining sanitary conditions in the environment, to prevent contamination or resident access. She said leaving the bag could result in a resident accessing and touching contents from wound cleaning. During an interview on 09/19/2025 at 2:35 PM with the Administrator revealed it was her expectation for the staff to ensure the environment and equipment were sanitary and properly stored to prevent contamination. During an interview on 09/19/2025 at 3:32 PM with the DON. She stated it was her expectation for the staff to discard the biohazard bag in the appropriate placement immediately after completing care. DON stated that failing to discard the bio-hazard bags could lead to unsanitary conditions and resident infection. The DON stated that the nursing staff are trained to ensure the linen carts was covered to maintain sanitation. The DON said failing to properly secure the linen cart to prevent environment contamination. DON stated that it was all staff's responsibility to maintain a sanitary environment for residents. Record review of the facility's Infection Control Policy and Procedure Manual revealed an undated Communication of Hazards to Employees policy which reflected: All labels and signs will reflect the biohazard legend and international sign.All biohazard labels will be affixed to containers of regulated waste, refrigerators used to store biohazard materials, freezers containing blood or blood components, containers used to store, transport, or ship blood or other potentially infectious materials.All biohazard labels will be fluorescent orange or orange-red with the lettering or symbols in a contrasting color.Red bags or containers lined with red bags may be substituted for labels.Containers of blood, blood components, or blood products that are labeled as to their contents and have been released for transfusion or other clinical use are exempted from labeling requirements.Individual containers of blood or other potentially infectious materials that are placed in a labeled container during storage, transport, shipments, or disposal are exempted from the labeling requirement.Soiled Linen from a resident on isolation will be placed in a yellow bag Staff will be communicated to verbally of all residents on isolation. Record review of the facility's Infection Control Policy and Procedure Manual revealed an undated Communication of Hazards to Employees policy which reflected: All clean linen will be stored in a secured area. The linen cart will be covered. Nothing is to be kept on top of linen carts in the hallways.Clean and soiled linens will be stored in separate areas. Employees will ensure that hands are clean and dry before handling clean linen.Linen storage areas will be cleaned regularly using a disinfectant-detergent. See cleaning schedule.

Based on interviews and record reviews, the facility failed to ensure the assessments accurately reflected the resident's status for 2 of 4 residents (Residents #1 and #2) reviewed for accuracy of assessments. The facility failed to ensure Resident #1 and Resident #2's MDS assessments were accurate and coded for behavior and mood. This failure could place residents at risk for receiving inadequate care and services based on an inaccurate assessment. Findings included:Record review of Resident #1's face sheet dated 09/19/2025 reflected the resident was a [AGE] year-old male, who admitted to the facility on [DATE]. The face sheet reflected he was discharged on 09/17/2025 to the hospital. The resident's current diagnoses included: Chronic Respiratory Failure, Unspecified Whether with Hypoxia or Hypercapnia (a condition where the lungs fail to adequately exchange oxygen and carbon dioxide over a prolonged period) Need for Assistance with Personal Care (staff assistance with ADL's); Anxiety (fear and worrying) disorder due to known physiological condition, non-compliance with Medical Treatment and regimens, generalized Anxiety (fear and worrying). Record review of Resident #1's Quarterly MDS dated [DATE] reflected a BIMS score of 15, indicating he was cognitively intact. Sections D Mood score 0 and listed no moods. Section E score 0 Behaviors did not address behaviors. Resident required partial and moderate assistance from staff for ADL's, treatments included oxygen treatment for asthma, congestive heart, and Respiratory failure.Record review of Resident # 1's quarterly care plan dated 09/03/2025 reflected Resident has Emphysema/COPD report to nurse if observed with difficulty breathing.[Resident #1] has oxygen therapy Give medications as ordered by physician. Monitor/document side effects and effectiveness. Monitor for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry (measure oxygen saturation levels), Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis (collapsed lung), Hemoptysis (coughing up blood or bloody mucus, Cough, Pleuritic pain (sharp pains in the checklist), Accessory muscle usage, Skin color. [Resident #1] has behavior problems as evidenced by making false accusations towards staff, refusing care and medications.[Resident #1] has attention-seeking behavior. Assist residents to develop more appropriate methods of coping with and interacting with staff. Encourage residents to express their feelings appropriately. Monitor behavior episodes and attempt to determine underlying causes. Consider location, time of day, persons involved and situations. Document all behaviors and potential causes. Staff will encourage residents to make choices that are consistent with goals of care. Staff will provide education re: medications to ensure resident adheres to medication regimen. The resident has an ADL Self Care Performance Deficit. The residents will maintain or improve their current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score) through the review date. Encourage the resident to participate to the fullest extent possible with each interaction.Encourage the resident to use bell to call for assistance. The resident has a behavior of calling 911. Record review of Resident #1's physician orders reflected the following orders:- 08/28/2025 - Bumetanide oral tablet 2 mg (Bumex) give 1 tablet by mouth two times a day for edema related to chronic systolic (congestive) heart failure - 08/30/2025 - Duloxetine HCl Capsule Delayed Release Particles 30 MG Give 1 capsule by mouth one time a day for depression related to anxiety disorder due to known physiological condition.Psychiatric referral dated 09/17/2025 Record review of Resident #1's progress notes written by LVN M, dated 09/17/2025 12:00 PM, reflected: [Resident #1] was transferred to the hospital related to complaints of incorrect medication. This is intended to serve as notice of an emergency transfer. This notice was provided to emergency transportation EMT. Record review of Resident #1's progress notes written by the DON, dated 09/17/2025 2:59 PM, reflected: Resident has called facility numerous times today, threatening to call 911. He believes that the Bumex is not the correct pill, but instead a medication for schizophrenia. Later he reported Bumex pill was for his heart, and he did not have any heart issues. Resident has not been able to be effectively redirected. He raises his voice and will talk over staff when they attempt to explain.he believes the Bumex is causing s/sx of pain and aching. Record review of Resident #1's progress notes written by the DON, dated 09/17/2025 at 3:15 PM , reflected: [MD-J] was made aware of resident behaviors today, verbal order for psych referral per [MD J]. Interview on 09/19/2025 at 10:04 PM with the SW revealed Resident #1 had anxiety and refused care and treatment often. She stated she had met with the resident on numerous occasions along with the DON to address his concerns of being administered wrong treatment and medications. She stated she had made a psychiatric referral; however, the resident refused to participate in the assessment. She stated Resident #1 was alert and oriented and his last grievance was in August 2025. RESIDENT #2Record review of Resident #2's factsheet dated 09/19/2025 reflected the resident was a [AGE] year-old-female, who initially admitted to the facility on [DATE]. The resident's diagnoses included: Unspecified Dementia with unspecified severity, without behavioral disturbances, psychotic disturbance, mood disturbance and anxiety dated 06/29/2024. Mood Disorder due to known psychological (mental health) conditions with mixed features, schizoaffective disorder (mental health condition mood disorder associated with depression bi-polar and schizophrenia persistent combination of psychotic symptoms.) depressive type, Depression, Major Depressive disorder, recurrent, severe with psychotic symptoms (mental health condition persistent sadness hopelessness and loss of interest or pleasure of activities.) Record review of Resident #2's Quarterly MDS dated [DATE] reflected the resident had a BIMS score of 7 indicating she had moderate cognitive impairment. Resident #2 required total assistance for all ADL. Resident #2 MDS Sections D Mood and E for Behavior was 0 indicating no behaviors. Section I addressed Resident #2's diagnosis of Anxiety, Depression, Bi-polar, and schizophrenia. Record review of Resident #2 care plan dated reflected [Resident #2] is at risk for harm to self, suicidal plan, refusing to eat or drink, refusing medications or therapies, hopelessness, helpless ness, impaired judgment or safety awareness, at risk for harming others increased [NAME], labile mood agitations, interventions included provide physical and verbal c to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out staff member when agitated guide away from source of distress. If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. Monitor/document/report to MD prn ongoing s/s of depression unaltered by antidepressant meds: Sa irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. mood/comments, slowed movement , agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with b functions, anxiety, constant reassurance.Monitor/record occurrence of for target behavior symptoms (pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc. (and so forth) and document per facility protocol.Notify the charge nurse of any abusive behaviors. Record review of Resident #2's physician orders, dated 09/05/2025, reflected the following orders:- Depakote oral Tablet Delayed Release 125 mg. give 3 capsules by mouth in the evening for mood regulation. - Namenda oral Tablet 5mg give 1 tablet by mouth in the evening related to unspecified dementia twice daily in the morning and evening. - Zoloft Oral tablet 50 mg, give 1 tablet by mouth one time a day related to generalized anxiety.- Seroquel give 2 tablets by mouth every 12 hours related to major depressive disorder. Interview on 09/19/2025 at 10:40 AM with the MDS Coordinator revealed the MDS assessments for Resident #1 and Resident #2 were completed; however, she was not sure that Sections D for mood and Section E for behaviors were addressed. She stated she would review the documents for accuracy. The MDS Coordinator stated she would not answer any more questions about MDS assessments. Interview on 09/19/2025 at 10:20 AM with the ADON revealed Resident #1 and Resident #2 had behaviors of refusing care and treatment, as well as, diagnosis with mood disorders. The ADON stated the MDS Coordinator was responsible for ensuring the assessment accurately reflects the residents medical conditions, level of functioning, diagnosis, and treatment for care while at the facility. She stated an inaccurate assessment could lead to residents' decline in care. She stated a resident's MDS should have reflected that they had mood and behavior to be accurate. The ADON stated she and the DON would review for accuracy and notify the Administrator and MDS Coordinator to correct immediately. Interview with MD K on 09/19/2025 at 12:06 PM revealed he was the Cardiologist for Resident #1. He said his last visit was on 09/17/2025 at 8:47 AM. He stated Resident #1 did have behaviors of increased anxiety and hyperfixation (constant focus and fear) with his breathing being abnormal. He stated staff reported Resident #1 had frequent moods and behaviors of refusing to comply with medical treatments and care. He said Resident #1 was afraid that he would stop breathing in his sleep. Observation and interview on 09/11/2025 at 1:05 PM revealed Resident #2 sitting in a chair outside her room. The resident denied abuse and neglect, and she would not respond to any other questions. Interview on 09/19/2025 at 1:08 PM with Resident #2's Family Member revealed Resident #2 had mental health diagnosis and behavior problems with memory, anger outburst, aggression, and dementia. She stated she had no concerns with Resident #2's care and treatment. Interview on 09/19/2025 at 3:32 PM with the DON revealed the MDS Coordinator was responsible for completing accurate MDS on all residents to ensure documentation of individualized care and treatment. She stated failing to document accurate resident statuses placed them at risk of not receiving services. She said it was the ADON and DON responsibility to monitor and review assessments for accuracy. Interview on 09/19/2025 at 3:35 PM with the Administrator revealed she expected the MDS staff to complete assessments timely and accurately reflecting resident care, treatment, and abilities, as well as problem areas. She stated she expected the ADON and DON to conduct ongoing monitoring of all assessments to ensure resident care was accurate. She stated the MDS Coordinator was responsible for completing the MDS assessment. She was asked to provide policy for MDS assessments.

Based on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 4 residents (Residents #4 and #8) reviewed for respiratory care. 1. The facility failed to ensure Resident #4's nasal cannula and tubing were bagged when not in use. 2. The facility failed to ensure Resident #8's CPAP mask was bagged when not in use. These failures could place residents at risk for respiratory infection. Findings included:Record review of Resident #4's face sheet dated 09/19/2025 reflected the resident was a [AGE] year-old-female, who admitted to the facility on [DATE] and initially on 04/10/2025. The resident's diagnoses included: Heart Failure, asthma (chronic lung condition that causes inflammation in the airway) and COPD (an ongoing lung condition caused by damage to the lungs. The damage results in swelling and irritation, also called inflammation, inside the airways.) respiratory failure (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide). Record review of Resident #4's MDS dated [DATE] reflected the resident's cognition was intact with a BIMS score of 15. The resident required total assistance for all ADLs, and she required oxygen therapy.Record review of Resident #4's quarterly care plan dated 06/20/2025 reflected: Adverse medication effect and behavior.The resident will be free from adverse medication effects Date Initiated: 06/20/2025 Target Date: 09/18/2025.Continually monitor for behaviors and medication adverse effects and notify the MD, LVN or NP as required. In addition, note any behaviors and adverse effects on the Weekly RN .Monitor/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Monitor for escalating anxiety, depression or suicidal thought and report . immediately to the nurse Date Initiated: 06/20/2025 Monitor for escalating anxiety, depression, sleep disturbance, substance abuse, or suicidal thoughts and report immediately to the physician and to the mental health provider.Resident refuses to utilize CPAP. 2.Staff will monitor changes in health. Staff will explain the risk and consequences of her refusing to utilize CPAP. Staff will listen to residents' concerns. The resident has altered respiratory status/Difficulty Breathing / Shortness of Breath.The resident has oxygen therapy, notify the nurse if the oxygen is off the resident.Record review of Resident #4's physician orders dated 09/19/2025 reflected an order Oxygen LPM: 3 Via: NC @HS at bedtime for Oxygen Usage at HS, Assessment every shift related to chronic obstructive pulmonary disease, unspecified (J44.9) Assess 02 Sat, Resp. Rate, Pulse, Breath sounds. Total time to assess. Observation 0n 09/19/2025 at 1:25 PM revealed Resident #4 lying in her bed on her back with the head of bed partially raised. The NC tubing was stored in a blue emesis bag (a disposable container used to collect and contain vomit) attached to her concentrator dated 09/15/2025. The nasal cannula tubing was not appropriately stored and dated in a bag to prevent exposure to the environment and bacteria. Observation and interview on 09/19/2025 at 1:25 PM with Resident #4 revealed she used oxygen at night. Resident #4 stated she did not recall when the tubing was last changed. She stated the staff usually stored the tubing in a plastic bag.2. Record review of Resident #8's face sheet dated 09/19/2025reflected reflected the resident was a [AGE] year-old-male, who admitted to the facility on [DATE]. The resident's diagnoses included: Acute respiratory Failure with Hypoxia (is a serious medical condition where the body doesn't get enough oxygen), Shortness of Breath, Obstructive Sleep Disorder (is a condition where your airway becomes blocked, causing breathing to pause during sleep.) Record review of Resident #8's entry MDS dated [DATE] reflected he has a BIMS score of 15, indicating he was cognitively intact. He was a short-term general hospital resident. Record review of Resident #8's Care Plan dated 09/12/2025 reflected: Resident requires the use of CPAP/BIPAP (to assist with breathing for people with certain respiratory conditions by delivering higher air pressure on inhalation and lower pressure on exhalation, making it easier to breathe.) r/t sleep apnea resident will maintain oxygen saturations 90% or greater over the next90 days.CPAP settings: Resident will use device as ordered.Staff to monitor saturation as ordered. Record review of Resident #8's physician orders reflected 09/19/2025 reflected: BiPAP-BiPAP-RATE 10 @ 30% at bedtime related to obstructive sleep Apnea (a disorder where breathing repeatedly stops and starts during sleep.) Asses 02 Sat, Resp. rate, pulse, and breath sounds and total time to assess. Record review of Resident #8's progress note written by the SW dated 09/16/2025 at 11:58 AM reflected: admission Care Plan: admission care plan held to discuss resident's care while in the facility. Care plan was held with resident only. Resident is admitted as a short-term care resident. Resident's discharge plan is to return home with provider services in place. Resident's code status is a full code. Resident had no nursing concerns. SW completed social history assessment. Resident educated on ancillary services (providing support to the primary activities or operation of an organization, system). Res chooses not to opt into ancillary services as he will be returning home. Resident educated on facility activities. SW will continue to follow up, arrange for resident's discharge and provide support as needed. Record review of Resident #8's physician progress note dated 09/15/2025 reflected History of Present Illness: Patient is seen today for initial psychiatric evaluation following a referral [MD-J]. Patient coming to us following a recent hospitalization and was recently admitted the facility on 09/11/2025. Patients has a past medical history of acute respiratory failure, SOB, systolic congestive heart failure, morbid obesity, hypertension, chronic atrial fibrillation, and physical debility. Patient consents to psychiatric evaluation. Patient appears stable on current treatment plan. Will continue to monitor closely MD orders reflected 09/19/2025 reflected BiPAP-BiPAP-RATE 10 @ 30% at bedtime related to obstructive sleep Apnea. Asses 02 Sat, Resp. rate, pulse, and breath sounds and total time to assess.Observation and interview on 09/19/2025 at 1:15 PM revealed Resident #8's CPAP was observed on the nightstand with the mask unbagged in the resident's room. Resident #8 revealed he was recently admitted . He stated he cleaned his own CPAP mask and tubing. He stated the tubing has not been bagged since he had been a resident at the facility. Interview on 09/19/2025 at 2:52 PM with the ADON revealed she was the assigned nurse for Resident #4 and Resident #8 today. The ADON said the nasal cannula tubing should be stored properly to prevent cross contamination and respiratory infections. She said nursing staff on duty as well as the person who administered the treatment was responsible for storing it in a plastic bag and ensuring physician orders were completed upon initiation of care task. The ADON stated she failed to notice the items were unbagged and that Resident #4 and Resident #8 did not have active MD orders for oxygen and CPAP. She said the expectation was for the staff to bag the NC and BiPAP when not in use and replace it if seen not bagged. She said she would coordinate with the DON to do an in-service about the issue. Interview on 09/19/2025 at 3:32 PM with the DON revealed Resident #4's tubing NC and BiPAP should be stored inside a plastic bag when not in use. The DON stated she expected the assigned nursing staff to monitor oxygen storage during rounds and ensure the tubing was bagged when not in use. The DON said failure to properly store NC and BiPAP tubing in a clean dated plastic could result in the resident acquiring infections and active physician orders for each care task. She stated she and ADON were responsible for monitoring and ensuring protocol for respiratory and active physician orders were completed prior oxygen and CPAP orders were documented before treatment. Interview on 09/19/2025 at 3:35 PM with the Administrator revealed she expected the nursing staff to ensure that tubing was changed weekly each Sunday on the 10:00 PM to 6:00 PM shift, as well, as store and date in a clear plastic bag when not in use to prevent exposure to the environment. She stated expected the same for CPAP mask when not in use. She said it was the responsibility of the ADON and DON to ensure all resident's had active orders for oxygen and CPAP. She expected all nursing staff to ensure proper safe storage of tubing when not in use. She stated she expected the ADON and DON to monitor all assessments for accuracy to prevent residents from missing or inaccurate care. The Administrator stated the MDS Coordinator was responsible for completing the MDS assessment. Record review of the facility's current, undated Oxygen Administration policy reflected: Change the tubing (including any nasal prongs or mask) that is in use on one patient when it malfunctions or becomes visibly contaminated.Change or clean oxygen concentrator filters according to manufactures' recommendations.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 5 of 6 residents (Residents #1, #2, #3, #8, and #9) reviewed for abuse. 1. The facility failed to ensure adequate supervision was provided to prevent a physical altercation between Residents #8 and #9 on the facility's memory care unit on 06/17/25 and failed to ensure the nurse on the unit, RN K, had visual access to the residents to be able to intervene timely. Resident #9 punched Resident #8 approximately eight times in the face/head resulting in Resident #8 having an abrasion and swelling on the left side of his face. 2. The facility failed to ensure Resident #1 was free from verbal abuse when he was verbally abused by CNA #1 on 09/04/25. 3. The facility failed to ensure Resident #3 were free from abuse on 05/13/25 when Resident #2 punched him in the face. The noncompliance was identified as a past non-compliance. The Immediate Jeopardy (IJ) began on 05/13/25 and ended on 09/05/25. The facility had corrected the noncompliance before the abbreviated survey began. These failures could place residents at risk of abuse, trauma, and psychological harm. Findings included:1. Record review of Resident #8's most recent Quarterly MDS Assessment, dated 04/06/25, reflected the resident was a [AGE] year-old male, who admitted to the facility on [DATE]. Resident #8's cognition was moderately impaired with a BIMS score of 6. The resident's diagnoses included: non-Alzheimer's dementia (various types of dementia), unspecified dementia, unspecified severity, with other behavioral disturbances, coronary artery disease (general decline in cognitive abilities that affect a person's ability to perform everyday activities) and high blood pressure. Resident #8's MDS indicated he had shown no signs of behavior or mood swings. Record review of Resident #8's undated care plan reflected the following care plans that had been developed:- Resident #8 had a history of trauma that may have a negative impact related to physical aggression from another resident. The care plan goals included: maintain resident's safety and integrity during post trauma episode, using appropriate interventions. The care plan interventions included consult with family regarding the resident's condition as appropriate. Identify situation/event/images that trigger recollections of the traumatic event and limit the resident's exposure to these as much as possible. These triggers could include physical aggression from others. - Resident #8 had delirium or an acute confusional episode related to change in condition. The care plan goal reflected: Resident will be free of signs and symptoms of delirium (changes in behavior, mood, cognitive function, communication, level of consciousness, restlessness. The care plan interventions included to consult with family and interdisciplinary team, review chart to establish baseline level of functioning. Educate resident/family/caregivers to observe for and report any signs or symptoms of delirium. Ensure fluid intake of at least 1500 cc /24 hours. - Resident #8's had potential to demonstrate physical behaviors Dementia, History of harm to other, poor impulse control. The care plan goals included: The resident will demonstrate effective coping skills. The care plan interventions included: analyze [sic] of key times, places, circumstances, triggers, and what deescalates behaviors and document. Assess and address for contributing sensory deficits. Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain. If resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately. Resident to be 1:1 for 24 hours, every 15minutes for 24 hours, every 30 minutes for 24 hours, every 1 hour for 24 hours, every 8 hours for 24 hours. When resident becomes agitated: intervene before agitation escalates; Guide away from the source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away; and approach later. - Resident #8 resided in the Secure Care Unit, related to diagnosis of dementia and risk for elopement. Disease Process, Disoriented to place, Memory loss. Goal: Resident will not have feelings of isolation and will feel safe and secure in the care received while on the Secure Care Unit. Interventions included: Admit to Secure Care unit per physician orders, Engage resident in group activities and provide them with individualized meaningful projects that they will accomplish throughout the day, Involve resident in daily activities designed for Secure Care Unit, Monitor for S/S of depression, withdrawal from usual activities, Notify MD of any changes, Psych services per MD orders. Record review of Resident #8's progress notes written by RN K on 06/17/25 at 12:00 PM reflected: Writer heard yelling, saw patients Resident #8 and Resident #9 hitting one another and rolling on the dry floor. RN K went out and grabbed Resident #8's arm to prevent him from hitting and telling him to let go of Resident #9's shirt. After he let go then I pulled him away. Resident #9 then sat on the couch. Resident #8 laid on the floor. Vitals were taken. Neuros taken. All withing normal limits. Resident #8 complaint of face hurting. Resident #9 complaint of right-hand hurting. RN K notified ADON C. RN K placed ice pack on Resident #8's left side of face and assisted him to chair. Record review of Resident #8's progress note Initial Skin Assessment written by ADON C on 06/17/25 at 12:30 PM revealed Skin Color: Normal; Temperature of skin: Warm; Bruise present: Yes. Location, measurements of bruising: left facial abrasion; Skin Tear Present: No; Abrasion present: Yes. Location, measurements of abrasion: left side facial abrasion; Laceration present: No; Surgical incision present: No; Rash present: No; Moisture Associated Skin Damage present: No; Pressure, venous, arterial, or diabetic ulcer present: No; Other skin findings: Left facial abrasion / swollen. Record review of Resident #8 progress note Transfer Notification written by ADON C on 06/17/25 at 1:00 PM revealed Resident #8 was transferred to a hospital on [DATE] 1:00 PM related to Unresponsive. This is intended to serve as notice of an emergency transfer. Record review of Resident #8's progress note Activity Note written by LVN L on 06/17/25 at 8:32 PM revealed resident returned from emergency room with no new orders. Resident remains alert and confused, resident at baseline. resident neuros restarted as per facility protocol. Resident assessed, resident noted with left facial swelling with bruising noted, abrasion to left lower leg. Physician notified of return new order to increase tramadol 50mg one po daily to bid. Resident's Responsible Party made aware of return, made aware of resident overall condition and any new findings and new orders. Responsible Party had no questions or concerns at this time. Record review of Resident #9's most recent Quarterly MDS (Minimum Data Set) Assessment, dated 05/22/25, reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #6 had BIMS of 06 indicating moderate cognitive impairment. Diagnosis included Unspecified Dementia (various types of dementia), Unspecified severity, without behavioral/psychotic/mood/anxiety disturbances (general decline in cognitive abilities that affect a person's ability to perform everyday activities). Depression (persistent feeling of sadness and loss of interest), and high blood pressure. Resident #'s MDS indicated he had shown mood signs of little interest or pleasure in doing things and feeling down, depressed, or hopeless with no signs of behaviors. Record review of Resident #9's care plan last revised 06/17/25 revealed Resident #9 had been identified as having Resident at risk to exhibit physical aggression. Goal: Resident to not have any episodes of physical aggression. Intervention include resident to remain 1:1 related to physical aggression. Care Plan revealed: Resident #9 has potential to demonstrate physical behaviors Anger, Dementia, Poor impulse control was put on by another resident and responded by pushing leading to altercation. Goal: The resident will demonstrate effective coping skills. Interventions included: 1:1 supervision prn physical aggression or other aggressive behavior. Analyze [sic] of key times, places, circumstances, triggers, and what de-escalates. Assess and address for contributing sensory deficits. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately. Secure care consult for behavior management. Send to emergency room for psychiatric evaluation as needed. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Care Plan revealed: Resident #9 resides in the Secure Care Unit, related to diagnosis of dementia (or related diagnosis) and risk for elopement. Goal: Resident will not have feelings of isolation and will feel safe and secure in the care received while on the Secure Care Unit. Interventions include: Admit to Secure Care unit per physician orders. Engage resident in group activities and provide them with individualized meaningful projects that they will accomplish throughout the day. Involve resident in daily activities designed for Secure Care Unit. Monitor for signs and symptoms of depression, withdrawal from usual activities. Notify physician of any changes. Psych services as doctor orders. Record review of Resident #'s progress note Neuro Assessment written by ADON C on 06/17/25 at 12:02 PM revealed the physician was notified of a negative change. Comments and/or new orders: Transfer to the hospital. Record review of Resident #9's progress note written by RN K on 06/17/25 at 12:11 PM revealed Writer heard yelling and saw Resident #8 and Resident #9 on the dry floor rolling and hitting one another. I held Resident #8 arm and told him to let go of Resident #9's shirt. After several minutes he let go and Resident #9 got up and sat on the couch. Resident #9 then went to his room and changed his shirt. Vital signs, neuros, blood sugar done. Resident #9 to be transferred to hospital. Record review of Resident #9's progress note written by Social Services Director on 0617/25 at 3:06 PM reflected: Social Services Director met with the resident to assess any trauma after an incident between he and another resident. Resident denies any trauma. Social Services Director did not observe any trauma symptoms or behaviors. Resident continues to state he feels safe in the facility and not fearful of the other resident. Resident will be transported to the hospital for further assessment. Observation of the facility's surveillance video dated 06/17/25 at 11:42 AM revealed the nurse office door was closed and both Resident #8 and Resident #9 were in the television room within feet of each other, Resident #8 stood between a female resident in her wheelchair sitting next to the exit door and a credenza in front the television wall. As Resident #9 headed towards the exit he passed Resident #8 and pushed him in the back. As Resident #8 stumbled a couple of feet he went after Resident #9 almost tripping over the wheelchair. Both residents stepped out of the camera, within seconds they returned back in the frame tussling at each other. Resident #9 began punching Resident #8 eight times in the face. This continued until they both fell onto the floor holding onto each other's shirts. At 11:43.25 the door opened, however, RN K did not exit the office to assist until 11:43.51, at this time she walked over to Resident #8 and placed her hand on his wrist. The video ended. Record review of the provider investigator report revealed on 06/17/25 at 11:45 AM Residents were in the secure unit living area when they began to have a verbal altercation. Resident #9 pushed Resident #8 in the back and then proceeded to punch Resident #8 in the face several times before both residents went to the ground and continued to hold each other by the clothing before Charge Nurse, RN K, separated residents. Resident #8 was sent to the emergency room for further evaluation due to facial swelling - no further injuries noted. Immediate discharge notice delivered to Resident #9 at hospital due to aggression and unable to be redirected during altercation. Staff interviews completed. In-services regarding abuse/neglect, resident rights, how to deal with residents aggressive behavior, behavior management. Record review of hospital records for Resident #8 reflected on 06/17/25 Resident #8 presented with a fall after an assault at the nursing home. The resident was punched in the face at least 10 times per Emergency Medical Service. It reflected the resident was assaulted at 11:00 AM. The resident then walked to the dining room on his own, had lunch, fell, and was then unresponsive. Emergency Medical Service stated the resident was found down supine, no blood thinners, and the resident's blood sugar was 375. The hospital findings reflected Resident #8 had no fractures, no acute intracranial abnormality (no immediate or urgent issues detected in the brain), no acute osseous cervical spine abnormality (no severe bone issues). Record review of facility log 15 Minute Monitoring revealed Resident #9 was placed on 15-minute monitoring starting at 12:30 PM until he exited the building to hospital for further evaluation at 2:30 PM . Record review of RN K statement dated 06/17/25 I [RN K] was sitting in the office when [Resident #8 and Resident #9] were heard making a lot of commotion. I had the door partially open. As I began to open the door to see what was going on the I noticed the two residents were rolling on the floor. I felt I was in shock at what I was seeing and thinking to myself what was going on and what was I going to do? I then thought of separating the two of them. I tried to separate them, but it was hard. I did not think to yell for help. Record review of Employee Disciplinary Report dated 06/17/25 revealed Investigation Suspension: [RN K] will be placed on an investigatory suspension pending an investigation into allegations of failing to meet their job duty/responsibility expectations. Corrective plan of Action: Due to the allegations, [RN K] will be placed on unpaid investigatory suspension. [RN K] will remain on investigatory suspension until the investigation is completed into the above allegation. [RN K] will be notified when the investigation is completed. [RN K] may provide a written statement. Employee comments: I think I tried to remain calm during the action of the residents. Interview on 09/09/25 on 11:28 AM with CNA I revealed during the time of the incident she was in the shower room with another resident leaving RN on the floor and charting in the nurse office. CNA I stated when she finished in the shower she was informed there had been an altercation between Resident #8 and Resident #9. CNA I stated she saw Resident #8 after the fight and observed swelling on Resident #8's face while in the dining room, he ate well, however soon after lunch he became nonresponsive and was sent out to the hospital. Resident #9 was also sent to the hospital for evaluation and had not returned. According to CNA I, she was inserviced over resident-to-resident altercations, resident confrontations, ensure to separate residents immediately and report. CNA I stated not monitoring residents and separating immediately during an altercation placed residents at risk for injuries or hospitalization. Attempted interview on 09/09/25 at 1:30 PM with RN K was unsuccessful. Attempted interview on 09/09/25 at 1:32 PM with LVN L was unsuccessful. Interview on 09/09/25 at 2:25 PM with ADON C revealed on video, Resident #9 was offering Resident #8 a chair to sit but Resident #8 was spitting on Resident #9, as they passed each other Resident #9 pushed Resident #8. Resident #8 then turned and started hitting Resident #9, both residents ended up on the floor. ADON C stated RN K was in the office when she heard commotion and stepped out. ADON C stated RN K was slow to react to the commotion and in separating the residents. ADON C stated emergency services was called, Resident #9 was placed on one-on-one monitoring until he was sent to the hospital for evaluation due to his aggressive behavior, punching Resident #8 causing a scratch and swelling to the left side of Resident #8's face. According to ADON C Resident #8 was also placed on one-to-one monitoring, assessed and injuries cleaned, and started neuro checks. ADON C further stated after the altercation there were no further signs or symptoms of injury, after lunch RN K called her to say Resident #8 was unresponsive, emergency services was called to send him to the hospital. ADON C stated in-service trainings were completed over abuse and neglect and staff surveys to ensure staff were knowledgeable about what to do during resident-to-resident altercations. ADON C stated all staff including CNAs and Nurses were responsible for monitoring and engaging with residents, not reacting quickly to altercations placed residents at risk of harm. Interview on 09/10/25 at 11:32 AM with the DON revealed she was not in the facility during the time of the incident however when she returned she followed up on the incident. The DON stated she reviewed the video revealing both residents ended up on the floor hitting each other. The DON stated the video also revealed RN K in the nurse office with the door closed and her slow to respond to the altercation. The DON stated RN K was suspended immediately and terminated due to the evolvement of the incident. The DON stated she expected staff on the secure unit to be out in the open and engaged with residents, not behind closed doors. The DON stated resident safety is top priority, so getting residents separated during altercations are immediate and to follow up with assessments. The DON stated Resident #8 was placed one on one, and Resident #9 was sent to the hospital with an immediate discharge. The DON stated staff were provided in-service training on abuse, neglect, resident rights, residents with dementia and aggressive behavior, separate during altercations, and one to one and behavior management. The DON stated nurses were responsible for always having eyes on residents especially on the secure unit, along with the one or two aides on duty. The DON further stated not doing so placed residents at risk of their safety, someone could fall and hit their head and possibly die. Interview on 09/10/25 at 11:56 AM with the Administrator revealed she was notified by ADON C of resident-to-resident altercation on the memory care unit, upon return she was able to review the video which showed the altercation between Resident #8 and Resident #9. The Administrator stated Resident #9 was sent to the hospital for further evaluation and immediate discharge. The Administrator stated Resident #8 was placed on one-on-one monitoring and neuro checks, he had lunch with no further signs of injury or distress, until he started showing signs of being non-responsive and altered status. The Administrator stated Resident #8 was sent to the hospital by emergency medical services and returned with no findings or new orders. The Administrator stated upon review of the video it showed RN K was slow to respond to the altercation between the two residents, RN K was in the office behind closed door allowing residents altercation to last close to 2 minutes before she slowly exited the office to separate them. The Administrator stated the nurses should be out of the office as much as possible; both nurses and aides were responsible for always having eyes on residents. The Administrator further stated not having a clear sightline of residents placed them at risk of abuse and harm. The facility took the following actions to correct the non-compliance prior to the investigation: Record review of an in-service, dated 06/17/25, reflected 29 staff including nurses, CNAs, housekeepers, medication aide, Business Office Manager, dietary aides were provided with training on resident-to-resident altercations. The in-service training covered: abuse and neglect; resident rights; how to deal with residents with dementia and aggressive behaviors; immediately separating residents from physical or verbal altercations; placing the aggressor on one-to-one supervision for resident safety; and behavior management Record review of an in-service, dated 06/17/25, reflected 29 staff that included nurses, nurse's aides, housekeeping, medication aide, Business Office Manager, dietary aides were in-serviced regarding: Abuse/Neglect Policy Record review of Resident #8's 15 minute checks dated 06/17/25 revealed monitoring from 12:30 PM until 06/19/25. Record review of Resident #9's 15 minute checks dated 06/17/25 revealed monitoring on 06/17/25 12:30 PM until 06/17/25 12:30 PM. Record review of Resident #9's clinical records revealed Resident #9 was placed one-on-one supervision on 06/17/25 12:30 PM until 06/17/25 2:30 PM until he was sent to the hospital for further evaluation and issued immediate discharge . Record review of Resident #8 and Resident #9's care plans were updated. Record review of Resident #8's clinical records revealed Resident #8 was assessed and transported to the emergency room for further evaluation with no findings or new orders. Record review of Resident #8's clinical records revealed Resident #8 was being monitored for behaviors throughout each shift upon his return from the hospital on [DATE] 8:30 PM until 06/19/25 at 6:00 PM until with no further signs of aggression or agitation. Record review of Staff Surveys were conducted on 06/17/25 - 06/18/25 by 24 staff over what signs and symptoms to look for when resident had a change in condition, how to respond when witnessed a resident-to-resident altercation, who do you report abuse/neglect allegations to? All with the understanding to immediately separate residents during resident-to-resident altercation and report to the nurse and the abuse coordinator which was the Administrator. Observation on 09/09/25 10:00 AM - 09/10/25 4:00 PM throughout investigation revealed the door to the office on the memory care unit has been removed. Both nurse and aide were making constant rounds to visibly check on each resident on the unit. Staff were engaging with residents and not seen in the nurse's office. Interviews on 09/09/25 from 11:22 AM through 09/10/25 3:30 PM with MDS Coordinator, CNA A, LVN B, ADON C, ADON D, LVN E, MA F, LVN G, LVN H, CNA I, CNA J, Social Services Director, Director of Rehabilitation, DON, and the Administrator, Activity Director, Housekeeping Supervisor, The facility staff were able to verify education was provided to them. Facility staff were able to accurately summarize abuse and neglect, how to work with residents with behaviors, immediately separate residents in altercations and report. Facility staff stated they monitor residents throughout the shifts, if behaviors were identified staff stated they were trained to redirect residents or placed them on 1:1 or q15 checks depending on the behavior. Staff stated for residents who have had altercations or incidents they monitor closely, keep them separated to prevent any further incidents. Staff stated they provide activities to keep them engaged and provide snacks throughout the day. Staff stated upon shift change they will notify the incoming staff of any incidents or behaviors. 2. Record review of Resident #1's Annual MDS, dated [DATE], reflected the resident was a [AGE] year-old male, who admitted to the facility on [DATE]. Th resident was cognitively intact with a BIMS (mental status assessment) score of 15. His diagnoses included Type 2 diabetes mellitus (metabolic disorder marked my insulin resistance and impaired insulin secretion); chronic pain syndrome (multifactorial condition characterized by persistent pain lasting longer than 3-6 months, often accompanied by psychological and functional impairment); and cognitive communication deficit (impaired communication due to deficits in attention, memory, or executive function). The MDS reflected Resident #1 did not have any physical or verbal behaviors towards others. The MDS also reflected Resident #1 was dependent upon staff for assistance with ADLs. Record review of Resident #1's Care Plan, initiated on 11/15/24 and revised on 09/05/25, reflected: Focus: Resident has a history of making false accusations, related to but not limited to: the staff, showers, activities of daily living, and preferences. Resident instigates staff by cursing at them and calling them derogatory names. Goal: Reductions or absence or false accusation. Interventions: Anticipate and meet the resident's needs. Assist the resident to develop more appropriate methods of coping and interacting with staff. Encourage the resident to express feelings appropriately. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Interview on 09/09/25 at 9:48 AM with Resident #1 revealed on 09/04/25, his roommate called CNA A to his room. Resident #1 said CNA A walked into the room asked who had called her, to which he responded with none ya. Resident #1 said he heard CNA A say fuck you to him, and she immediately walked out of the room. Resident #1 said CNA A saying that made him cry, feel put down, and made him feel uncomfortable. Resident #1 said right after it happened, he told his nurse (LVN B). Resident #1 revealed LVN B switched aides, so CNA A no longer cared for him. Interview on 09/09/25 at 10:17 AM with Resident #4 revealed he was Resident #1's roommate. Resident #4 reported on 09/04/25 CNA A came into the room and was helping Resident #1 get ready for bed. Resident #4 said Resident #1 was cussing and fighting with CNA A when CNA A told Resident #1, Fuck you. Resident #4 stated after it was said, CNA A walked out of the room and another aide came to help Resident #1 finish getting ready. Resident #4 stated CNA A appeared calm when she cussed at Resident #1. Resident #4 revealed he had no issues with CNA A or any other staff members. Interview on 09/09/25 at 2:23 PM with LVN B revealed Resident #1 came to her after the incident with CNA A on 09/04/25. LVN B stated Resident #1 and CNA A used the F word to each other. LVN B said when Resident #1 reported it to her, he appeared visibly upset by it. LVN B said she switched the aides out, so CNA A was no longer caring for Resident #1. LVN B stated she had to calm Resident #1 down, and she went to the Administrator because it was verbal abuse to Resident #1. Interview on 09/09/25 at 2:38 PM with CNA A revealed she was called into Resident#1's room. CNA A asked Resident #1 to turn the call light off twice, and he replied to CNA A by saying, Fuck you. CNA A stated she said Fuck you back to Resident #1. CNA A stated she knew it was not right to say that to any resident, but it slipped out. CNA A confirmed it was verbal abuse. Interview on 09/10/25 at 3:10 PM with the Social Worker revealed on 09/05/25, Resident #1 came and told her that a CNA last night had cussed him out by saying fuck you. The Social Worker reported that Resident #1 was visibly upset when he described what had happened. The Social Worker stated she immediately reported it to the Administrator who was the Abuse Coordinator due to it being verbal abuse. Interview on 09/10/25 at 11:31 AM with the DON revealed she was told about the incident between Resident #1 and CNA A on 09/05/25 by the Social Worker right after he reported it to her. The DON stated it was reported to her that Resident #1 was baiting CNA A by saying, Fuck you first, but then CNA A said it back. The DON stated CNA A admitted it was wrong to say that to a resident. The DON revealed they suspended and then terminated CNA on 09/05/25. The DON stated telling a resident Fuck you was considered verbal abuse which was why CNA A had to be terminated. The DON stated her expectation was for staff to keep all residents safe and free from abuse. Interview on 09/10/25 at 11:56 AM with the Administrator revealed CNA A told Resident #1 Fuck you the previous night (09/04/25) around 6:00 PM. During her interview with Resident #1, he told her that CNA A cursed at him unprovoked. Resident #1's roommate also confirmed that CNA A did say that to Resident #1. The Administrator stated this was considered verbal abuse, and CNA A was terminated after admitting to the allegation. The Administrator reported that verbal abuse could put residents at risk of psychological harm. The Administrator stated she expected her staff to treat residents with respect and to report any abuse immediately. The Administrator stated her number was posted throughout the building, and she wants to be notified at any time if abuse occurs or is suspected. Observation on 09/10/25 at 3:15 PM revealed the Administrator's phone number was posted in multiple locations, including at the nurses' station and in the hallway. Record review of CNA A's personnel file reflected CNA A was suspended and terminated on 09/05/25. Record review of facility's current, undated Abuse/Neglect Policy reflected the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility . Verbal abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend or disability . Prior to the HHSC investigation, the facility took the following actions to correct the noncompliance: Record review of Resident #1's Trauma Informed PRN Assessment had been completed on 09/05/25 with no concerns identified. Record review of the facility's Skin Monitoring: Comprehensive CNA Shower Record review had been completed on seven residents on 09/05/25. Record review of safe surveys completed on 09/05/25 showed that nine residents had been interviewed by the facility with no issues noted. Record review of In-Service Training record reflected 41 staff had been provided in-service training on abuse/neglect, resident rights, and behavior management on 09/05/25. Interviews between 09/09/25 from 9:30 AM through 09/10/25 3:15 PM with the Social Worker, LVN B, LVN E, ADON C, ADON D, Housekeeper M, MA F, LVN G, Speech and Language Therapist, LVN H, CNA I, and CNA J revealed the facility staff were able to verify education was provided to them. The staff stated they were educated on different types of abuse and neglect. Staff stated they would intervene if they witnessed any type of abuse and immediately report to the Abuse Coordinator. 3. Record review of Resident #2's Annual MDS, dated [DATE], reflected the resident was a [AGE] year-old male, who admitted to the facility on [DATE]. The resident's diagnoses included hemi[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 2 of 5 residents (Resident #8 and Resident #9) reviewed for supervision. The facility failed to ensure adequate supervision was provided to prevent a physical altercation between Residents #8 and #9 on the facility's memory care unit on 06/17/25 and failed to ensure the nurse on the unit, RN K, had visual access to the residents to be able to intervene timely. Resident #9 punched Resident #8 approximately eight times in the face/head resulting in Resident #8 having an abrasion and swelling on the left side of his face. The noncompliance was identified as a past non-compliance. The Immediate Jeopardy (IJ) began on 06/17/25 and ended on 06/19/25. The facility had corrected the noncompliance before the abbreviated survey began. This failure placed residents at risk of harm and/or serious injury. Findings included: Record review of Resident #8's most recent Quarterly MDS Assessment, dated 04/06/25, reflected the resident was a [AGE] year-old male, who admitted to the facility on [DATE]. Resident #8's cognition was moderately impaired with a BIMS score of 6. The resident's diagnoses included: non-Alzheimer's dementia (various types of dementia), unspecified dementia, unspecified severity, with other behavioral disturbances, coronary artery disease (general decline in cognitive abilities that affect a person's ability to perform everyday activities) and high blood pressure. Resident #8's MDS indicated he had shown no signs of behavior or mood swings. Record review of Resident #8's undated care plan reflected the following care plans that had been developed:- Resident #8 had a history of trauma that may have a negative impact related to physical aggression from another resident. The care plan goals included: maintain resident's safety and integrity during post trauma episode, using appropriate interventions. The care plan interventions included consult with family regarding the resident's condition as appropriate. Identify situation/event/images that trigger recollections of the traumatic event and limit the resident's exposure to these as much as possible. These triggers could include physical aggression from others. - Resident #8 had delirium or an acute confusional episode related to change in condition. The care plan goal reflected: Resident will be free of signs and symptoms of delirium (changes in behavior, mood, cognitive function, communication, level of consciousness, restlessness. The care plan interventions included to consult with family and interdisciplinary team, review chart to establish baseline level of functioning. Educate resident/family/caregivers to observe for and report any signs or symptoms of delirium. Ensure fluid intake of at least 1500 cc /24 hours. - Resident #8's had potential to demonstrate physical behaviors Dementia, History of harm to other, poor impulse control. The care plan goals included: The resident will demonstrate effective coping skills. The care plan interventions included: analyze [sic] of key times, places, circumstances, triggers, and what deescalates behaviors and document. Assess and address for contributing sensory deficits. Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain. If resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately. Resident to be 1:1 for 24 hours, every 15minutes for 24 hours, every 30 minutes for 24 hours, every 1 hour for 24 hours, every 8 hours for 24 hours. When resident becomes agitated: intervene before agitation escalates; Guide away from the source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away; and approach later. - Resident #8 resided in the Secure Care Unit, related to diagnosis of dementia and risk for elopement. Disease Process, Disoriented to place, Memory loss. Goal: Resident will not have feelings of isolation and will feel safe and secure in the care received while on the Secure Care Unit. Interventions included: Admit to Secure Care unit per physician orders, Engage resident in group activities and provide them with individualized meaningful projects that they will accomplish throughout the day, Involve resident in daily activities designed for Secure Care Unit, Monitor for S/S of depression, withdrawal from usual activities, Notify MD of any changes, Psych services per MD orders.Record review of Resident #8's progress notes written by RN K on 06/17/25 at 12:00 PM revealed Writer heard yelling, saw patients Resident #8 and Resident #9 hitting one another and rolling on the dry floor. RN K went out and grabbed Resident #8's arm to prevent him from hitting and telling him to let go of Resident #9's shirt. After he let go then I pulled him away. Resident #9 then sat on the couch. Resident #8 laid on the floor. Vitals were taken. Neuros taken. All withing normal limits. Resident #8 complaint of face hurting. Resident #9 complaint of right-hand hurting. RN K notified ADON C. RN K placed ice pack on Resident #8's left side of face and assisted him to chair. Record review of Resident #8's progress note Initial Skin Assessment written by ADON C on 06/17/25 at 12:30 PM revealed Skin Color: Normal; Temperature of skin: Warm; Bruise present: Yes. Location, measurements of bruising: left facial abrasion; Skin Tear Present: No; Abrasion present: Yes. Location, measurements of abrasion: left side facial abrasion; Laceration present: No; Surgical incision present: No; Rash present: No; Moisture Associated Skin Damage present: No; Pressure, venous, arterial, or diabetic ulcer present: No; Other skin findings: Left facial abrasion / swollen. Record review of Resident #8 progress note Transfer Notification written by ADON C on 06/17/25 at 1:00 PM revealed Resident #8 was transferred to a hospital on [DATE] 1:00 PM related to Unresponsive. This is intended to serve as notice of an emergency transfer. Record review of Resident #8's progress note Activity Note written by LVN L on 06/17/25 at 8:32 PM revealed resident returned from emergency room with no new orders. Resident remains alert and confused, resident at baseline. resident neuros restarted as per facility protocol. Resident assessed, resident noted with left facial swelling with bruising noted, abrasion to left lower leg. Physician notified of return new order to increase tramadol 50mg one po daily to bid. Resident's Responsible Party made aware of return, made aware of resident overall condition and any new findings and new orders. Responsible Party had no questions or concerns at this time. Record review of Resident #9's most recent Quarterly MDS (Minimum Data Set) Assessment, dated 05/22/25, reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #6 had BIMS of 06 indicating moderate cognitive impairment. Diagnosis included Unspecified Dementia (various types of dementia), Unspecified severity, without behavioral/psychotic/mood/anxiety disturbances (general decline in cognitive abilities that affect a person's ability to perform everyday activities). Depression (persistent feeling of sadness and loss of interest), and high blood pressure. Resident #'s MDS indicated he had shown mood signs of little interest or pleasure in doing things and feeling down, depressed, or hopeless with no signs of behaviors. Record review of Resident #9's care plan last revised 06/17/25 revealed Resident #9 had been identified as having Resident at risk to exhibit physical aggression. Goal: Resident to not have any episodes of physical aggression. Intervention include resident to remain 1:1 related to physical aggression. Care Plan revealed: Resident #9 has potential to demonstrate physical behaviors Anger, Dementia, Poor impulse control was put on by another resident and responded by pushing leading to altercation. Goal: The resident will demonstrate effective coping skills. Interventions included: 1:1 supervision prn physical aggression or other aggressive behavior. Analyze [sic] of key times, places, circumstances, triggers, and what de-escalates. Assess and address for contributing sensory deficits. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately. Secure care consult for behavior management. Send to emergency room for psychiatric evaluation as needed. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Care Plan revealed: Resident #9 resides in the Secure Care Unit, related to diagnosis of dementia (or related diagnosis) and risk for elopement. Goal: Resident will not have feelings of isolation and will feel safe and secure in the care received while on the Secure Care Unit. Interventions include: Admit to Secure Care unit per physician orders. Engage resident in group activities and provide them with individualized meaningful projects that they will accomplish throughout the day. Involve resident in daily activities designed for Secure Care Unit. Monitor for signs and symptoms of depression, withdrawal from usual activities. Notify physician of any changes. Psych services as doctor orders. Record review of Resident #'s progress note Neuro Assessment written by ADON C on 06/17/25 at 12:02 PM revealed the physician was notified of a negative change. Comments and/or new orders: Transfer to the hospital. Record review of Resident #9's progress note written by RN K on 06/17/25 at 12:11 PM revealed Writer heard yelling and saw Resident #8 and Resident #9 on the dry floor rolling and hitting one another. I held Resident #8 arm and told him to let go of Resident #9's shirt. After several minutes he let go and Resident #9 got up and sat on the couch. Resident #9 then went to his room and changed his shirt. Vital signs, neuros, blood sugar done. Resident #9 to be transferred to hospital. Record review of Resident #9's progress note written by Social Services Director on 0617/25 at 3:06 PM reflected: Social Services Director met with the resident to assess any trauma after an incident between he and another resident. Resident denies any trauma. Social Services Director did not observe any trauma symptoms or behaviors. Resident continues to state he feels safe in the facility and not fearful of the other resident. Resident will be transported to the hospital for further assessment. Observation of the facility's surveillance video dated 06/17/25 at 11:42 AM revealed the nurse office door was closed and both Resident #8 and Resident #9 were in the television room within feet of each other, Resident #8 stood between a female resident in her wheelchair sitting next to the exit door and a credenza in front the television wall. As Resident #9 headed towards the exit he passed Resident #8 and pushed him in the back. As Resident #8 stumbled a couple of feet he went after Resident #9 almost tripping over the wheelchair. Both residents stepped out of the camera, within seconds they returned back in the frame tussling at each other. Resident #9 began punching Resident #8 eight times in the face. This continued until they both fell onto the floor holding onto each other's shirts. At 11:43.25 the door opened, however, RN K did not exit the office to assist until 11:43.51, at this time she walked over to Resident #8 and placed her hand on his wrist. The video ended. Record review of the provider investigator report revealed on 06/17/25 at 11:45 AM Residents were in the secure unit living area when they began to have a verbal altercation. Resident #9 pushed Resident #8 in the back and then proceeded to punch Resident #8 in the face several times before both residents went to the ground and continued to hold each other by the clothing before Charge Nurse, RN K, separated residents. Resident #8 was sent to the emergency room for further evaluation due to facial swelling - no further injuries noted. Immediate discharge notice delivered to Resident #9 at hospital due to aggression and unable to be redirected during altercation. Staff interviews completed. In-services regarding abuse/neglect, resident rights, how to deal with residents aggressive behavior, behavior management. Record review of hospital records for Resident #8 reflected on 06/17/25 Resident #8 presented with a fall after an assault at the nursing home. The resident was punched in the face at least 10 times per Emergency Medical Service. It reflected the resident was assaulted at 11:00 AM. The resident then walked to the dining room on his own, had lunch, fell, and was then unresponsive. Emergency Medical Service stated the resident was found down supine, no blood thinners, and the resident's blood sugar was 375. The hospital findings reflected Resident #8 had no fractures, no acute intracranial abnormality (no immediate or urgent issues detected in the brain), no acute osseous cervical spine abnormality (no severe bone issues). Record review of facility log 15 Minute Monitoring revealed Resident #9 was placed on 15-minute monitoring starting at 12:30 PM until he exited the building to hospital for further evaluation at 2:30 PM . Record review of RN K statement dated 06/17/25 I [RN K] was sitting in the office when [Resident #8 and Resident #9] were heard making a lot of commotion. I had the door partially open. As I began to open the door to see what was going on the I noticed the two residents were rolling on the floor. I felt I was in shock at what I was seeing and thinking to myself what was going on and what was I going to do? I then thought of separating the two of them. I tried to separate them, but it was hard. I did not think to yell for help. Record review of Employee Disciplinary Report dated 06/17/25 revealed Investigation Suspension: [RN K] will be placed on an investigatory suspension pending an investigation into allegations of failing to meet their job duty/responsibility expectations. Corrective plan of Action: Due to the allegations, [RN K] will be placed on unpaid investigatory suspension. [RN K] will remain on investigatory suspension until the investigation is completed into the above allegation. [RN K] will be notified when the investigation is completed. [RN K] may provide a written statement. Employee comments: I think I tried to remain calm during the action of the residents. Interview on 09/09/25 on 11:28 AM with CNA I revealed during the time of the incident she was in the shower room with another resident leaving RN on the floor and charting in the nurse office. CNA I stated when she finished in the shower she was informed there had been an altercation between Resident #8 and Resident #9. CNA I stated she saw Resident #8 after the fight and observed swelling on Resident #8's face while in the dining room, he ate well, however soon after lunch he became nonresponsive and was sent out to the hospital. Resident #9 was also sent to the hospital for evaluation and had not returned. According to CNA I, she was inserviced over resident-to-resident altercations, resident confrontations, ensure to separate residents immediately and report. CNA I stated not monitoring residents and separating immediately during an altercation placed residents at risk for injuries or hospitalization. Attempted interview on 09/09/25 at 1:30 PM with RN K was unsuccessful. Attempted interview on 09/09/25 at 1:32 PM with LVN L was unsuccessful. Interview on 09/09/25 at 2:25 PM with ADON C revealed on video, Resident #9 was offering Resident #8 a chair to sit but Resident #8 was spitting on Resident #9, as they passed each other Resident #9 pushed Resident #8. Resident #8 then turned and started hitting Resident #9, both residents ended up on the floor. ADON C stated RN K was in the office when she heard commotion and stepped out. ADON C stated RN K was slow to react to the commotion and in separating the residents. ADON C stated emergency serivces was called, Resident #9 was placed on one-on-one monitoring until he was sent to the hospital for evaluation due to his aggressive behavior, punching Resident #8 causing a scratch and swelling to the left side of Resident #8's face. According to ADON C Resident #8 was also placed on one-to-one monitoring, assessed and injuries cleaned, and started neuro checks. ADON C further stated after the altercation there were no further signs or symptoms of injury, after lunch RN K called her to say Resident #8 was unresponsive, emergency services was called to send him to the hospital. ADON C stated in-service trainings were completed over abuse and neglect and staff surveys to ensure staff were knowledgeable about what to do during resident-to-resident altercations. ADON C stated all staff including CNAs and Nurses were responsible for monitoring and engaging with residents, not reacting quickly to altercations placed residents at risk of harm. Interview on 09/10/25 at 11:32 AM with the DON revealed she was not in the facility during the time of the incident however when she returned she followed up on the incident. The DON stated she reviewed the video revealing both residents ended up on the floor hitting each other. The DON stated the video also revealed RN K in the nurse office with the door closed and her slow to respond to the altercation. The DON stated RN K was suspended immediately and terminated due to the evolvement of the incident. The DON stated she expected staff on the secure unit to be out in the open and engaged with residents, not behind closed doors. The DON stated resident safety is top priority, so getting residents separated during altercations are immediate and to follow up with assessments. The DON stated Resident #8 was placed one on one, and Resident #9 was sent to the hospital with an immediate discharge. The DON stated staff were provided in-service training on abuse, neglect, resident rights, residents with dementia and aggressive behavior, separate during altercations, and one to one and behavior management. The DON stated nurses were responsible for always having eyes on residents especially on the secure unit, along with the one or two aides on duty. The DON further stated not doing so placed residents at risk of their safety, someone could fall and hit their head and possibly die. Interview on 09/10/25 at 11:56 AM with the Administrator revealed she was notified by ADON C of resident-to-resident altercation on the memory care unit, upon return she was able to review the video which showed the altercation between Resident #8 and Resident #9. The Administrator stated Resident #9 was sent to the hospital for further evaluation and immediate discharge. The Administrator stated Resident #8 was placed on one-on-one monitoring and neuro checks, he had lunch with no further signs of injury or distress, until he started showing signs of being non-responsive and altered status. The Administrator stated Resident #8 was sent to the hospital by emergency medical services and returned with no findings or new orders. The Administrator stated upon review of the video it showed RN K was slow to respond to the altercation between the two residents, RN K was in the office behind closed door allowing residents altercation to last close to 2 minutes before she slowly exited the office to separate them. The Administrator stated the nurses should be out of the office as much as possible; both nurses and aides were responsible for always having eyes on residents. The Administrator further stated not having a clear sightline of residents placed them at risk of abuse and harm. The facility took the following actions to correct the non-compliance prior to the investigation: Record review of an in-service, dated 06/17/25, reflected 29 staff including nurses, CNAs, housekeepers, medication aide, Business Office Manager, dietary aides were provided with training on resident-to-resident altercations. The in-service training covered: abuse and neglect; resident rights; how to deal with residents with dementia and aggressive behaviors; immediately separating residents from physical or verbal altercations; placing the aggressor on one-to-one supervision for resident safety; and behavior management Record review of an in-service, dated 06/17/25, reflected 29 staff that included nurses, nurse's aides, housekeeping, medication aide, Business Office Manager, dietary aides were in-serviced regarding: Abuse/Neglect Policy Record review of Resident #8's 15 minute checks dated 06/17/25 revealed monitoring from 12:30 PM until 06/19/25. Record review of Resident #9's 15 minute checks dated 06/17/25 revealed monitoring on 06/17/25 12:30 PM until 06/17/25 12:30 PM. Record review of Resident #9's clinical records revealed Resident #9 was placed one-on-one supervision on 06/17/25 12:30 PM until 06/17/25 2:30 PM until he was sent to the hospital for further evaluation and issued immediate discharge . Record review of Resident #8 and Resident #9's care plans were updated. Record review of Resident #8's clinical records revealed Resident #8 was assessed and transported to the emergency room for further evaluation with no findings or new orders. Record review of Resident #8's clinical records revealed Resident #8 was being monitored for behaviors throughout each shift upon his return from the hospital on [DATE] 8:30 PM until 06/19/25 at 6:00 PM until with no further signs of aggression or agitation. Record review of Staff Surveys were conducted on 06/17/25 - 06/18/25 by 24 staff over what signs and symptoms to look for when resident had a change in condition, how to respond when witnessed a resident-to-resident altercation, who do you report abuse/neglect allegations to? All with the understanding to immediately separate residents during resident-to-resident altercation and report to the nurse and the abuse coordinator which was the Administrator. Observation on 09/09/25 10:00 AM - 09/10/25 4:00 PM throughout investigation revealed the door to the office on the memory care unit has been removed. Both nurse and aide were making constant rounds to visibly check on each resident on the unit. Staff were engaging with residents and not seen in the nurse's office. Interviews on 09/09/25 from 11:22 AM through 09/10/25 3:30 PM with MDS Coordinator, CNA A, LVN B, ADON C, ADON D, LVN E, MA F, LVN G, LVN H, CNA I, CNA J, Social Services Director, Director of Rehabilitation, DON, and the Administrator, Activity Director, Housekeeping Supervisor, The facility staff were able to verify education was provided to them. Facility staff were able to accurately summarize abuse and neglect, how to work with residents with behaviors, immediately separate residents in altercations and report. Facility staff stated they monitor residents throughout the shifts, if behaviors were identified staff stated they were trained to redirect residents or placed them on 1:1 or q15 checks depending on the behavior. Staff stated for residents who have had altercations or incidents they monitor closely, keep them separated to prevent any further incidents. Staff stated they provide activities to keep them engaged and provide snacks throughout the day. Staff stated upon shift change they will notify the incoming staff of any incidents or behaviors. On 09/10/25 at 3:30 PM, the Administrator and DON stated they were working with corporate to locate a policy on accident and hazards, supervision or quality of care; however, the policies were not provided prior to exit. The noncompliance was identified as PNC. The IJ began on 06/17/25 and ended on 06/19/25. The facility had corrected the noncompliance before the abbreviated survey began.

Based on interview and record review, the facility failed to ensure residents were free from abuse for 3 of 6 residents (Resident #4, Resident #6, and Resident #7) reviewed for abuse. 1. The facility failed to ensure Resident #4 was free from emotional and mental abuse. Video footage identified CNA A antagonizing Resident #4 when she went to check on him on 02/18/25 . The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 02/18/25 and ended on 02/19/25. The facility had corrected the noncompliance before the investigation began. 2. The facility failed to ensure Resident #6, and Resident #7 were free from abuse on 03/11/25 when Resident #6 verbally abused Resident #7 which cause Resident #7 to physically abuse Resident #6 by hitting him on the face. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 03/11/25 and ended on 03/14/25. The facility had corrected the noncompliance before the investigation began. These failures could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and psychological harm. Findings included: 1. Record review of Resident #4's Face sheet dated 05/01/25, revealed the resident was a [AGE] year-old male with an admitted [DATE] and readmitted on [DATE]. Record review of Resident #4's quarterly MDS, dated [DATE], reflected his diagnoses included anxiety disorder, vascular dementia, and mild cognitive impairment. Resident #4's BIMS score was 04 which indicated his cognition was severely impaired. The MDS Section E - Behaviors reflected Resident #4 did not exhibit any physical or verbal behaviors towards others. The MDS Section GG - Functional Abilities also reflected Resident #4 was dependent of staff to assist with ADLs. Record review of Resident #4's Care Plan revised date 03/11/25, reflected Focus: The resident has a behavior problem r/t hx of stroke, resident will become difficult to manage. Resident yells out loudly and will use cursive language. Resident is very adament toward care, sports, etc and will yell out at staff and curse. Goal: The resident will have fewer episode by review date. Interventions: Anticipate and meet the resident's needs. Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Redirection techniques will include offering alternatives to the current activity. Record review of the Provider Investigation Report dated 02/25/25 reflected, Resident responsible party had address to [Administrator] a concern of a staff member being rough with the resident when trying to readjust on the bed. When [Responsible party name], the resident's responsible party, entered [Administrator] office and informed [Administrator] of an incident that occurred the previous night, [Administrator] contacted the CNA [CNA A] to discuss the matter. [Administrator] informed her about the responsible party reported aggressive behavior toward the resident [Resident #4] and confirmed that she had indeed acted aggressively toward [Resident #4] due to [Resident #4] cussing at him and she was trying to correct him. [Administrator] informed her that she would be suspended until further notice. Safe surveys conducted no noted concern. Skin assessment completed and no noticed concerns, pain assessment no noted concerns, Trauma assessment no concerns noted. The Provider Investigation Report also reflected that the result of the investigation was inconclusive, but CNA A was terminated. Record review of CNA A's Statement dated 02/29/25, reflected Went to resident's room cause he was hanging off the bed and yelling. [CNA A] told the resident to put his legs back in the bed before he ended up on the floor. That's when the resident call me a bitch and to leave him alone. [CNA A] told him not till he in bed right that if keeps hanging out the bed like that he was going to be on the floor and the floor hursts and wins every time. He then proceeded to call me a bitch again. [CNA A] told him to don't be disrespectful to me cause [CNA A] wouldn't do him like that and that I'm someone sister daughter and mother and that he wouldn't like it if [CNA A] called the women in his family that name. [CNA A] also asked him what was wrong with him. Observation of Video Footage time stamped 02/18/2025 05:44:24 CST [5:44 AM] revealed: Resident #4 sitting at the edge of the bed. CNA A (who was a tall, heavy-set woman) entered Resident #4's room stating, What are you doing [Resident #4's name]. Resident #4 states What are you talking about bitch. CNA A stated what. Resident #4 stated What are you talking. CNA A standing in front of Resident #4. CNA A then proceed to tell Resident #4 twice to put those legs back in the bed. Resident #4 asked CNA A Why?''. CNA A tells Resident #4 you can't walk [you] will end up on the floor. Resident #4 tells her No I won't. CNA A responded, Okay bet, but I am going to put your legs back on the bed. Resident #4 asked why again. CNA A responded, I don't have to explain why. Resident #4 asked CNA A why are [you] going too and CNA A stated, because I am going too. Resident #4 stated you not going too. CNA A observed leaning forward and grabbed the control for the bed. Resident #4 stated Get your fucking hands of me bitch, I will fuck you up. CNA A asked resident What did [you] say? and Resident #4 stated, I will fuck you up, get your fucking hands off of me. CNA A observed to lean forward put her right hand on Resident #4's right knee. CNA A then stated My hand is on you. What are [you] going to do? Nothing, and [you] better quit calling me out of my name because [you] wouldn't like if [I] called your momma, sister, or anybody in your family out of their name, don't be disrespectful to [me] because I am not being disrespectful to [you], [you] understand. Resident #4 agreed with CNA A and CNA A removed her hand from Resident #4's knee. CNA A states I don't know where you get that being disrespectful from, that [ain't] going to get you nothing , that [ain't] going to get you no help, that is going to get you talk ed about, don't be disrespectful, and you wait until someone comes in here to help you, you got me? CNA A proceed to adjust Resident #4's legs on the bed. Resident #4 stated I hear that CNA A states Alright then, I am not about to play with you, cause you end up on the floor, you end up on the floor and the floor hurts and it wins every time. Resident #4 stated yeah right. CNA A states Yeah right, you got a real smart mouth, what is wrong with you, what is your problem tonight. Resident state I got a problem with you. CNA response No, I [ain't] your problem, Resident stated oh yeah. CNA A stated, I just came in here to help you. CNA A proceeded to walk out the room and stated, you better act like you got some sense. Video was about 2 minutes long. CNA A hand was on Resident #4's knee for about 32 second. Interview on 04/30/25 at 11:14 AM, Resident #4 revealed he was doing well and feeling safe at the facility. Resident #4 was not a good historian; resident could not recall incident with CNA A. Interview on 04/30/25 at 12:46 PM, Resident #4 Family Member revealed she reviewed the video footage a day after the incident and notified the Administrator. She stated the incident happened on 02/18/25, Resident #4 was sitting on his bed and the staff was observed entering the room. She stated on the video footage it was observed Resident #4 being disrespectful toward the staff; however, the staff was rude and antagonizing the situation. She stated on the video it was observed Resident #4 saying keep your hands off of me and then staff proceed to put her hand on his knee. Family Member stated she agreed with the staff redirecting and telling Resident #4 to stop cursing at her; however, the staff putting her hand on him was what concerned her. She stated the staff was antagonizing the situation by putting her hand on Resident #4. Family Member stated after the Administrator was notified, the facility investigated the incident and terminated the staff. Interview by phone on 05/01/25 at 9:27 AM, CNA A revealed she was doing her last round, when she heard Resident #4 screaming. She stated she entered the room and observed Resident #4 was hanging on the side of the bed. She stated she asked Resident #4 what he was doing, and Resident #4 started to curse at her and got mad because she told him to get back in bed. CNA A stated Resident #4 was calling her a bitch and being disrespectful to her. She stated she told Resident #4 to stop, to not called her like that because he would not like for someone to call his mom, sister or daughter that. She stated Resident #4 stated he would not like that. She stated she only touched Resident #4 when repositioning him back to bed. CNA A stated she was not supposed to correct Resident #4. She stated she was wrong for telling him to stop being disrespectful because they were told residents were always right. CNA A stated she never touched the resident or disrespected the resident. CNA A stated she was suspended and then let go. Interview on 05/01/25 at 2:16 PM, Corporate Compliance RN revealed she reviewed the video footage regarding CNA A and Resident #4. She stated CNA A should lose her license. She stated CNA A was verbally abusive towards Resident #4, she stated when CNA A put her hand on Resident #4' she was antagonizing the situation. She stated CNA A should had stepped away. Regional Compliance stated Resident #4 had no adverse effects from the incident. She stated CNA A was terminated. Interview on 05/01/25 at 2:36 PM, the Administrator revealed Resident #4 family informed him about the incident and he immediately suspended CNA A. He stated skin assessment was completed on Resident #4 with no injuries, safe surveys and quality of life checks were completed with no concerns. The Administrator stated after reviewing the video footage it was determined CNA A was considered being verbally abusive and was terminated for abuse. He stated CNA A admitted to what she did wrong. He stated his expectations were for his staff to respect residents, care for them and to report any abuse and neglect allegations to him to protect the residents. Record Review of CNA A's personnel file, reflected CNA A was suspended and terminated on 02/19/25. Record review of facility Abuse/Neglect policy, revised 09/09/24, reflected the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Prior to the HHSC investigation, the facility took the following actions to correct the noncompliance: Record review of Resident #4's Skin assessment, Pain assessment and Trauma Assessment completed on 02/19/25, no concerns noted. Record review of Safe surveys were completed on 02/19/25 with five residents with no issues noted. Record review of facility In Service Training dated 02/19/25, provided by Administrator and Corporate Compliance RN reflected staff were In Serviced on Abuse and Neglect Policy to include - Arguing with, antagonizing, and touching a resident against their will is considered Abuse. If [you] see a staff member or resident engaging in this activity, the Administrator must be notified immediately. The Administrator is the abuse coordinator. If [you] can't get a hold of the administrator, notify the DON or ADON immediately. Staff should not continue to work their shift, they must be suspended immediately, Resident Rights Record review of facility In Service Training dated 02/19/25, provided by Corporate Compliance RN reflected staff were In Serviced on Abuse and Neglect, Resident Rights. Interviews on 04/30/25 from 1:21 PM through 05/01/25 to 3:45 PM with ADON Y, ADON U, BOM, FM, CNA B, LVN C, CNA D, CNA F, CNA H, CNA E, Van Driver, CNA I, CNA F, LVN G, LVN K, LVN L, CNA V, LVN X revealed the facility staff were able to verify education was provided to them. The nursing staff stated they were educated on different types of abuse/neglect and resident rights. Staff provided the types of abuse were physical, mental, financial, and verbal. Staff stated the three signs of abuse occur when the resident avoids eye contact, bruises, and the resident withdraws from care. Staff stated they would intervene if witness any type of abuse from a staff. Staff revealed they would report these and other signs to the Abuse Coordinator, the Administrator, immediately if they witness or observed any of these signs. 2. Record review of Resident #6's Face sheet dated 05/01/25, revealed the resident was a [AGE] year-old male with an admitted [DATE] and readmitted on [DATE]. Record review of Resident #6's quarterly MDS, dated [DATE], reflected his diagnoses included bipolar disorder, dementia, and cognitive communication deficit. Resident #6's BIMS score was 12 which indicated his cognition was moderately impaired. The MDS Section E - Behaviors reflected Resident #6 did not exhibit any physical or verbal behaviors towards others. The MDS Section GG - Functional Abilities also reflected Resident #6 needed substantial/maximal assistance with ADLs. Record review of Resident #6's care plan, revised 03/11/25, reflected Focus: The resident has a history of trauma that may have a negative impact. The trauma is r/t: Resident with hx of physical altercation with another resident. Goal: Maintain resident's safety and integrity post trauma episode, using appropriate interventions. Interventions: Perform the following de escalation techniques as required: redirection, and deep breathing. Psychiatric services adjusted medication. Record review of Resident #7's face sheet dated 05/01/25, revealed the resident was a [AGE] year-old male with an admitted [DATE] and readmitted on [DATE]. Record review of Resident #7's admission MDS, dated [DATE], reflected his diagnoses included anxiety disorder, major depressive disorder, schizoaffective disorder, restlessness and agitation and cognitive communication deficit. Resident #6's BIMS score was 13 which indicated his cognition was cognitively intact. The MDS Section E - Behaviors reflected Resident #7 did not exhibit any physical or verbal behaviors towards others. The MDS Section GG - Functional Abilities also reflected Resident #7 was independent for ADLs. Record review of Resident #7's care plan, revised 04/14/25, reflected Focus: The resident has potential to demonstrate physical behaviors related to paranoid schizophrenia, schizoaffective disorder as evidence by: Physical aggression demonstration due to being provoke when cussed at. Goal: The resident will seek out staff/caregiver when agitation occurs through the review date. Interventions: If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately. Record review of the Provider Investigation Report dated 03/18/25 reflected, [Speech and Language Therapist] witness [Resident #7] hit [Resident #6] due to an altercation they were having an immediately separate them both. During investigation, Resident #7 reported that Resident #6 was using inappropriate language to him and repeatedly told him to stop. When Resident #6 continued, Resident #7 became frustrated and end up hitting him. Upon witnessing the incident, [Speech Therapy] quickly intervene to separate the two residents and called for assistance. Both residents were promptly separated, and a 1:1 supervision was implemented until a psychiatric evaluation could be performed. Record review of Witness Statement from Speech and Language Therapist dated 03/11/25 reflected, My name is [Name]. [Speech and Language Therapist ] am an employee at the [Facility Name]. [Speech and Language Therapist] am the speech language pathologist. At approximately 10:15 a.m., [Speech and Language Therapist] witnessed two residents [Resident #6 and Resident #7] in a physical altercation in the dining room. [Speech and Language Therapist] heard [Resident #7] say to [Resident #6] call me a bitch one more time. [Resident #6] responded and then [Resident #7] struck [Resident #6] about two times. Immediately, [Speech and Language Therapist] intervened to ensure both men were safe. [Resident #7] left the dining room. Once [Resident #7] left the dining room, [Speech and Language Therapist] asked [Resident #6] if he was okay and if he could tell me what happened. [Resident #6] replied, he's just mad because [Speech and Language Therapist] wouldn't give him a cigarette. Once both individuals were safe, [Speech and Language Therapist] immediately told [Administrator]. Interview on 04/30/25 at 10:45 AM, Resident #6 stated he was doing well. Resident #6 stated he had an incident with Resident #7. Resident #6 stated Resident #7 got frustrated with him, and Resident #7 kept telling him to not say anything to him. Resident #6 stated he told Resident #7 that he was coming in and needed him to get out of the way, he stated Resident #7 got more frustrated and hit him on the side of the face. Resident #6 stated the police was called but he did not pressed charges. Resident #6 stated he was only hit once on the side of his face. Resident #6 stated he was not hurt. Resident #6 stated he never called Resident #7 any names. Interview on 04/30/25 at 12:26 PM, Resident #7 stated he was doing well. Resident #7 stated he got into an altercation with Resident #6. Resident #7 stated for a week Resident #6 was messing with him and calling him out of his name. Resident #7 stated he never told anyone about it. Resident #7 stated on the day of the altercation Resident #6 called him a bitch and he asked Resident #6 to stop but he continued to call him a bitch. Resident #7 stated he got mad, and he hit him on the face once. Resident #7 stated he was tired of Resident #6 calling him a bitch. Resident #7 stated after the altercation, he keeps his distance from Resident #6. Interview on 05/01/25 at 9:49 AM, the Administrator revealed Speech and Language Therapist was out on leave. Interview on 05/01/25 at 1:38P PM, ADON Y stated Resident #6 and Resident #7 had an altercation in the dining room on 3/11/25. She stated it was a witnessed altercation by Speech Therapy. She stated she was not sure what started the altercation, but Resident #7 got upset and hit Resident #6 in the face. She stated there had been no previous incidents between them. She stated both residents were assessed with no injuries and placed on 1:1 monitoring until psych services consult. She stated the incident was considered abuse from Resident #7 hitting Resident #6. Interview on 05/01/25 at 2:16 PM, Corporate Compliance RN revealed she was made aware of the incident between Resident #6 and Resident #7. She stated she was informed Resident #7 slapped Resident #6 on the face. She stated she was unsure what started the argument. She stated the incident was considered abuse from Resident #7 to Resident #6. She stated Resident #7 was placed 1:1 supervision, a psych services consult was completed, medications were adjusted, and Resident #7 was moved to another hall. Resident #6 had no injures to him and also received a psych service consult. Interview on 05/01/25 at 2:36 PM, the Administrator revealed Speech and Language Therapist observed Resident #6 and Resident #7 talking and then observed Resident #7 slapped Resident #6 on the face. He stated the Speech and Language Therapist intervene and separated both residents. The Administrator stated the police was called, skin assessment, trauma and pain assessment completed on both residents with no concerns. He stated families were notified of the incidents. The Administrator stated Resident #7 was placed on 1:1 monitoring, and then Resident #7 requested to go home after the incident. He stated two weeks later Resident #7 returned to the facility and he got a new room in a different hall. The Administrator stated both residents used to get along and joke with each other, he stated he was not sure what happened between them. The Administrator stated a resident-to-resident altercation was considered abuse, and every resident had the right to be free from abuse and neglect. Record review of facility Abuse/Neglect policy, revised 09/09/24, reflected the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Resident to Resident - The above policy will apply to potential resident-to-resident abuse. Prior to the HHSC investigation, the facility took the following actions to correct the noncompliance: Record review Resident #6 progress notes dated 03/11/25 14:58 [2:58 PM] new order for busPirone HCL Oral tablet 15 mg (Buspirone HCl) Give 1 tablet by mouth every 12 hours for anxiety. Record review of facility 15 Minute Monitoring dated 3/11/15, reflected Resident #7 was being monitored every 15 minutes starting at 10:15AM and ended at 11:45 AM. Record review Resident #7 progress notes dated 03/11/25 15:24 [3:24 PM] Psych NP [Resident #7] telehealth with the resident. New order obtained for HydroXizne HLC tablet 25 MG give 1 tablet by mouth every 8 hours as needed for anxiety x 14 days and to monitor behaviors q shift. Record review Resident #7 progress notes dated 03/11/25 15:55 [3:55 PM] reflected, [Resident #7] the Psych NP discontinued 1:1 resident stable with no behavior issues exhibited at the moment. Record review of Resident #6 and Resident #7 Trauma Informed PRN Assessment, Skin Assessment and Pain Assessment completed on 03/11/25 with no concerns. Record review of Safe surveys were completed with 10 residents with no issues noted. Record review of facility In Service Training dated 03/11/25 and 3/13/25, provided by Administrator reflected staff were In Serviced on Abuse and Neglect, Resident Rights, Safe environment and De-escalation methods for residents with behaviors. Record review of facility In Service Training dated 3/14/25, provided by Corporate Compliance RN reflected staff were In Serviced on Abuse and Neglect, Resident Rights, Notification of Changes. Interviews on 04/30/25 from 1:21 PM through 05/01/25 to 3:45 PM with ADON Y, ADON U, BOM, FM, CNA B, LVN C, CNA D, CNA F, CNA H, CNA E, Van Driver, CNA I, CNA F, LVN G, LVN K, LVN L, CNA V, LVN X revealed the facility staff were able to verify education was provided to them. The nursing staff stated they were educated on different types of abuse/neglect, resident rights, notification of changes and de-escalation methods. Staff stated they monitor behaviors. Staff provided the types of abuse were physical, mental, financial, and verbal. Staff stated the three signs of abuse occur when the resident avoids eye contact, bruises, and the resident withdraws from care. Staff revealed they would report these and other signs to the Abuse Coordinator, the Administrator, immediately if they witness or observed any of these signs.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 1 (Resident #5) of 3 residents reviewed for accidents. The facility failed to keep Resident #5 free of accidents after his anti-tippers were removed from his wheelchair during his dialysis treatment on 04/01/25 when he was on the van's lift and fell backwards, hitting his head on the grate of the lift and sustaining an injury. The noncompliance was identified as PNC. The noncompliance began on 04/01/25 and ended on 04/02/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of severe injury, hospitalization , and decline in quality of life. Findings included: Record review of Resident #5's Admission Record, dated 05/01/25, reflected the resident was a [AGE] year-old male who was originally admitted to the facility on [DATE], readmitted on [DATE], and discharged on [DATE]. Record review of Resident #5's Quarterly MDS Assessment, dated 04/12/25, reflected he had a BIMS of 15, indicating he did not have cognitive impairment. His active diagnoses included depression (mental disorder characterized by sadness, loss of interest or pleasure in activities, and persistent symptoms), obstructive uropathy (a condition characterized by a blockage that prevents normal urine flow), and diabetes (a chronic disease that affects how the body uses insulin and glucose). The assessment revealed he had not had any falls prior to 04/12/25. Further review revealed Resident #5 used a manual wheelchair, had no limitation to his range of motion on his upper extremities but did have limitation to his range of motion on his lower extremities. Record review of Resident #5's physician's orders, dated 05/01/25, reflected the following: -skull series 3 views r/t fall on 04/01/25. -Aspririn Oral Tablet Chewable 81 MG (Asprin), Give 1 tablet by mouth one time a day for Chest Pain -Eliquis Oral Tablet 2.5 MG (Apixaban), Give 1 tablet by mouth two times a day for Anticoagulant Record review of Resident #5's care plan, revised on 04/02/25, reflected the following: Focus: The resident is risk [sic] for falls r/t unsteady gait upon transition, decreased mobility. weakness. [sic] .Interventions: Anti-tip device to w/c .therapy to drop w/c. Record review of Resident #5's progress notes reflected the following: -Details: Chief complaint: Fall with injury Abrasion/Avulsion Occipital region / Abrasion to Right Elbow [sic] fell at Dialysis- Refused to go to acute Care Facility/ER .Notified by DON that patient fell outside of Dialysis clinic and refused to be transforted [sic] to ER for imaging (most likely CT Scan). Patient is on ASA and eliquis anticogulants [sic] and is advisable to have imaging to check brain injury or bleeding. DON and administrator tried to convience [sic] to reconsider came back [sic] to the facility. Ordered Skull series/ . Right [sic] arm xray. Hold ASA/ Eliquis [sic] x 2 days. Neuro checks per facility protocol. Patient is alert and oriented to baseline mentation and vital signs are normal. Nursing to monitor for problemswith [sic] mentation or sleepiness, nausea or vomiting. Patient advised he needed a CT of his head but refused. [Physician Z] aware. Nursing instructed to notify his [family member] of his refusal to go to acute care after his fall. Patient had a circular skin abrasion/Avulsion [sic] on occiptal [sic] region of the back of his head. Treatment nurse to clease [sic] and dress wounds on head and right elbow. Written on 04/01/25 at by Physician Z at 12:00 AM. -Resident had a fall. Location: Outside [sic] Fall information: Hit Head, . [sic] .Resident statement: ' I [sic] told dialysis center to remove tippers. I tried to put myself on life and fell over. I did it.' Interventions in place prior to fall: anti-tippers to back of w/c. Interventions initiated in response to fall: Therapy request to drop w/c, Anti-tippers re-applied. Facility education is ongoing, area maintenance director to inspect w/c. Written on 04/01/25 by the previous Interim DON at 3:45 PM -New order obtained for Skull [sic] series 3 views, results received indicating no evidence of displaced fracture or dislocation. The overlying soft tissues are unremarkable. Negative skull bones study. Limited single lateral view. Rp [sic] and the resident made aware of the results expressed gratitude. Written by ADON Y on 04/01/25 at 7:12 PM -Pt continues on Neuro checks. Pt able to answer questions with correct answers. Pt denies pain to the back of skull and elbows. [Physician Z] informed of results of Xray of skull 4 views with no evidence of displaced FX or dislocation Care ongoing. Written by LVN X on 04/02/25 Record review of Resident #5's electronic health record, specifically the assessments portion of his chart reflected neuro assessments and post fall assessments were completed from 04/01/25 to 04/04/25. Record review of Resident #5's Negotiated Risk Assessment, dated 04/01/25, reflected the following: Resident refused to be transported to ER for further evaluation post fall with head injury .Resident wishes to remain in facility and not seek further treatment .Head injury leading to further mobility and health deficits, infection, concussion, and death .Facility contacted residents [sic] [family member] to persuade resident to seek further treatment at ER. NP informed resident of recommendations for CT of head .Resident will remain in facility. Nurse to continue neuro checks per facility protocol. Treatment for abrasion to be provided by facility staff. Record review of Resident #5's fall risk assessment, dated 03/14/25, reflected a score of 6 (this was not indicated in the electronic health chart as being high risk). Record review of Resident #5's Incident Report, dated 04/01/25, reflected the following: CONCLUSION: Received call from facility transport driver stating that resident has sustained fall [sic]. Van driver facetimed DON. Resident noted on van lift with w/c tipped over. van [sic] is flushed with ground. DON instructed van driver to contact EMS to evaluate resident. Upon EMS arrival Resident [sic] refused to be transported to ER multiple times (times 4 attempts). Resident transported back to facility and neuro checks initiated upon arrival .INTERVENTION: Anti-tip device re-applied to w/c. Therapy to drop w/c. Neuro checks are ongoing. Admin to speak to dialysis center regarding servicing our equipment. Area Maintenance director [sic] inspected w/c upon resident's return to facility and found no defect. Skull series x-ray preformed [sic]. Record review of Resident #5's skin assessment, dated 04/01/25, reflected he had an abrasion described as RT LOWER LEG, back of head 6cm x 3.5cm [sic]. Record review of Resident #5's pain assessment, dated 04/01/25, reflected he had no complaints of pain. Record review of a provider investigation report, dated 04/08/25, reflected the following: Description of the Allegation: Resident had fallen when staff [the Van Driver] was attempting to assist the resident to be lifted in the facility van .Investigation Summary: Resident sustained fall while transferring to facility van lift. Per resident statement, resident was trying to place self on van lift with his back facing the driver seat. Facility van driver was present and instructed resident that she could not place him in the van in that direction. Resident continued to attempt to place self on lift in this manner. During this action resident tipped his wheelchair over sustaining fall on van lift. Lift was flush with ground at time of fall. Facility van driver called [ADON Y] and initiated face-time call with [ADON Y], Admin, and DON. DON instructed van driver to call 911 to evaluate resident. At time of EMS arrival resident refused to be transported to ER for further evaluation. Resident further stated that he had the dialysis center remove the anti-tip device on the back of his wheelchair because he did not like them. Resident returned to facility and neuro check initiated. Neuros are intact at this time. Abrasion noted to back of head measuring 6cm x 3.5cm. bright red blood noted, site cleared and dressed. Resident remains alert and oriented x4 and answers questions appropriately. No complaints of pain at any site reported at this time. BIMs=15. Resident remains able to recall details of incident .Facility Investigation Findings: Confirmed .Provider Action Taken Post-Investigation: Wheelchair evaluated: Ant [sic] Tip device placed back on the wheelchair Staff in-service: abuse and neglect, residents rights, Fall Prevention Transport Driver re educated on van. Safe Surveys conducted: No concerns noted. Record review of a witness statement, dated 04/01/25, signed by Resident #5 reflected the following: I [Resident #5] was wheeling back on the lift plate of the van as it was on the ground. [The Van Driver] had told me to stop 3 times, but I continued to back my wheelchair on to the ramp and fell backward. The paramedics were called, and I refused to go to the hospital as I just wanted to go home. I am perfectly fine and do not want any medical attention I just wanted to go home at the time. I did have tilt bars on my wheelchair but I did not want them any more so I had asked the Dialysis [sic] staff to remove them and I placed on [sic] the side of my wheelchair. Phone interview on 04/30/25 at 2:25 PM and 2:37 PM with Resident #5's POA revealed the resident was in the hospital and not at the facility at the time. Resident #5's POA said the resident told him that he had tried to go down the ramp to the van at the dialysis center. Resident #5's POA said he flipped over backwards and hit his head, but that it was the resident's fault. Resident #5's POA said that's all the information he had about the situation from Resident #5. Interview on 04/30/25 at 2:41 PM with the Van Driver revealed Resident #5 came to the van, turned his wheelchair around with his back turned towards the van instead of facing it, and wheeled himself onto the ramp to the van. The Van Driver said she asked him to turn around multiple times but he refused. The Van Driver said Resident #5 made a motion in his wheelchair where he extended his arms on his armrests and then his wheelchair flipped backwards. The Van Driver said Resident #5 hit his head on the back of the ramp that was in an up position. The Van Driver said she asked Resident #5 if he was okay and called 911. The Van Driver said she then called the facility to let them know what happened as well. The Van Driver said the ambulance came and Resident #5 refused to leave with them or receive any treatment by them. The Van Driver said Resident #5 was stable and the EMT's picked the resident up and put him back in his wheelchair. The Van Driver said she transported Resident #5 back to the facility. The Van Driver said it depended on the day, but some times Resident #5 wheeled himself to the lift of the van and sometimes she would wheel him onto the lift of the van. The Van Driver said residents needed to be facing the van in order to be strapped in and safe to transport, and Resident #5 knew that. The Van Driver said Resident #5 appeared to be upset when he was approaching the van and she thought that was why he faced himself the opposite way when getting on the lift. The Van Driver said normally, Resident #5 had anti-tippers on his wheelchair but when he left the dialysis center he did not have them on his wheelchair. The Van Driver said Resident #5 told her that he had the dialysis center staff take off anti-tippers while he was there. The Van Driver said she did not notice the anti-tippers were not on his wheelchair when he came out of the dialysis center. The Van Driver said she noticed his anti-tippers were in his personal bag that he carried to the dialysis center each time he went. The Van Driver said she made sure that Resident #5's anti-tippers were on his wheelchair when she dropped him off for dialysis. The Van Driver said she was in-serviced after the incident occurred and knew to always check to ensure Resident #5's anti-tippers were on his wheelchair at all times. Phone interview on 04/30/25 at 2:55 PM with the Dialysis Center's Receptionist revealed the nurse for Resident #5 had left for the day but would be back tomorrow to discuss what happened on 04/01/25. The Dialysis Center's Receptionist said she saw what happened that day (04/01/25) from the inside of the building after Resident #5 had already fallen. The Dialysis Center's Receptionist said she noticed there was a commotion outside the center, saw the van was parked, and saw Resident #5 was tipped backwards on the ground with his head on the ground. The Dialysis Center's Receptionist said Resident #5's head was towards the van near the bumper area and his feet were in the air. The Dialysis Center's Receptionist said once the resident passed the door of the lobby to go outside they do not monitor them or have anything to do with them. The Dialysis Center's Receptionist said Resident #5 liked to wait outside for the facility van, although they preferred the resident to wait inside the lobby area. The Dialysis Center's Receptionist said typically, the center would not take off a resident's anti-tippers and she was not sure who would have done that. Phone interview on 05/01/25 at 9:44 AM with Resident #5's Dialysis Nurse revealed he did not remove any parts from Resident #5's wheelchair. Resident #5's Dialysis Nurse said he never touched anything on Resident #5's wheelchair and the only thing he would touch would be the brakes to unlock/lock the wheelchair. Resident #5's Dialysis Nurse said he would not modify or take off a resident's anti-tippers from his wheelchair. Resident #5's Dialysis Nurse said he did not know what anti-tippers were. Interview on 05/01/25 at 9:52 AM with the DOR revealed Resident #5 had anti-tippers on his wheelchair for as long as he's had a wheelchair that she knew of. The DOR said she started working at the facility in October and he had them since then at least. The DOR said she took Resident #5's anti-tippers off the van when he returned to the facility from dialysis on 04/01/25. The DOR said she talked to Resident #5 and he seemed upset that day but he told her that he had the dialysis staff take off his anti-tippers. The DOR said she was not sure why Resident #5 would have someone remove them from his wheelchair. The DOR said Resident #5's anti-tippers were easy to take off but the resident would not have been able to do it himself. The DOR said it was not a normal thing for dialysis staff to take off Resident #5's anti-tippers. The DOR said the purpose of the anti-tippers was to keep the resident from tipping backwards. The DOR said Resident #5 had them on his wheelchair because he was a high fall risk and since he was a double amputee his balance could be off at any time. The DOR said if the anti-tippers were removed, then Resident #5 would be able to flip his wheelchair fully backwards. The DOR said Resident #5's wheelchair was still in the facility and had the anti-tippers still on them. Observation on 05/01/25 at 10:00 AM with the DOR of four random residents in the facility revealed they all had anti-tip devices on the backs of their wheelchairs. Observation on 05/01/25 at 10:05 AM with the DOR of Resident #5's wheelchair in his empty room revealed his wheelchair had both anti-tip devices on the back of it. Interview on 05/01/25 at 11:20 AM with CNA V revealed she cared for Resident #5 every day and he used anti-tippers on his wheelchair. CNA V said she was not there the day the incident happened (04/01/25) but heard that Resident #5 fell back and hit his head. Interview on 05/01/25 at 11:52 AM with ADON U revealed she heard that Resident #5's fall happened outside of the dialysis center and when he returned to the facility she looked at his head but did not know how he fell . ADON U said Resident #5 refused to go to the hospital so they started neuro checks on him. ADON U said she saw he had 2 abrasions to the back of his head, so they watched him for four days and they resolved on their own. ADON U said she was newer to the facility and was not sure if Resident #5 used anti-tippers prior to this incident. Phone interview on 05/01/25 at 1:01 PM with the previous Interim DON revealed she received a call from the Van Driver saying Resident #5 had a fall on 04/01/25. The previous Interim DON said they initiated a video call so she could see the resident. The previous Interim DON said the Van Driver told her that Resident #5 was upset when he came out of the dialysis center and he was trying to put himself on the van lift improperly when she told him multiple times to let her assist him but he refused. The previous Interim DON said the Van Driver said Resident #5 was able to get his wheelchair over the ramp on the van lift that was flushed with the ground, and he flipped backwards sustaining an abrasion to the back of his head. The previous Interim DON said the Van Driver called 911 but Resident #5 refused any treatment from the EMT's and refused to go to the hospital. The previous Interim DON said Resident #5 returned to the facility and a head-to-toe assessment was done and his wounds were dressed. The previous Interim DON said the facility notified Resident #5's Family Member and they also tried to convince him to go to the hospital but he still refused. The previous Interim DON said the x-ray company was currently in the facility at the time and they were asked to complete the skull series x-rays on Resident #5. The previous Interim DON said the results came back and were negative. The previous Interim DON said when he talked to Resident #5, he told her it was his fault and that the Van Driver told him not to get on the van that way but he was mad and he did it anyway and fell . The previous Interim DON said Resident #5 was supposed to have anti-tippers on his wheelchair as an intervention and he reported that he requested the dialysis center staff to take them off. The previous Interim DON said when she found that out, the facility immediately went to put them back on Resident #5's wheelchair. The previous Interim DON said the Maintenance Director also checked Resident #5's wheelchair to make sure that it was functioning properly and it was. The previous Interim DON said someone reached out to the dialysis center to request they not alter any resident's wheelchair and if they do, they need to communicate with the facility about it. Interview on 05/01/25 at 1:50 PM with ADON Y revealed she understood that the dialysis center removed Resident #5's anti-tippers from his wheelchair. ADON Y said Resident #5 was getting into the van in his wheelchair and according to the Van Driver, he tilted himself on purpose because he wanted attention and fell backwards. ADON Y said Resident #5 refused to go to the hospital to be checked out further. ADON Y said Resident #5 sustained a laceration to the back of his head. ADON Y said Resident #5 always had anti-tippers on his wheelchair and she was not sure why the dialysis center would take them off. ADON Y said she was not sure if that was normal for the dialysis center staff to take off a resident's anti-tippers. ADON Y said since Resident #5 was a double amputee it was easy for him to fall back in his wheelchair. ADON Y said when Resident #5 got back to the facility, staff complete neuro checks and monitored him for three days. ADON Y said a skull series was ordered and everything was negative. Interview on 05/01/25 at 2:35 PM with the Administrator revealed Resident #5 went to dialysis and was upset because they made him wait for something while he was there. The Administrator said he was told when Resident #5 came out of the dialysis center, he wheeled himself backwards onto the van lift and when he rolled back his chair tilted back and he fell . The Administrator said Resident #5 had tilt assists on his wheelchair but he asked the dialysis staff to take them off because he did not want them. The Administrator said when Resident #5 came back to the facility, trauma and skin assessments were completed and staff had encouraged him to go to the hospital but he kept refusing. The Administrator said staff monitored him, completed neuro checks, and ordered for a skull series to be done which was negative. The Administrator said Resident #5 did have an abrasion to his head which was treated while at the facility. The Administrator said he also called Resident #5's dialysis center to talk to the staff about not touching their resident's equipment because all of it was there for a reason. The Administrator said in theory if Resident #5 had the anti-tippers on his wheelchair on 04/01/25 he would not have fallen because they would have prevented him from being able to lean all the way back. The Administrator said the Van Driver would have been responsible for making sure Resident #5's anti-tippers were on his wheelchair before she dropped him off, which she did. The Administrator said afterwards, the Van Driver completed trainings and in-services about safe transfers in the van. The Administrator said the Van Driver would have been responsible for assisting Resident #5 to get on and off the van and for keeping him safe. The Administrator said he did not document any communication with the dialysis center staff about removing the anti-tippers from his wheelchair. Record review of an abuse and neglect in-service, dated 04/01/25, reflected 24 staff had been in-serviced. Record review of a resident rights in-service, dated 04/01/25, reflected 24 staff had been in-serviced. Record review of a fall prevention in-service, dated 04/01/25, reflected 24 staff had been in-serviced. Record review of an Employee Auto Training Handbook reflected the Van Driver had a road test completed on 04/01/25. An acknowledgement form was signed by the Van Driver on 04/02/25 regarding the Employee Auto Training Handbook. Record review of the facility's policy, revised 10/05/16, and titled Preventive Strategies to Reduce Fall Risk reflected: Procedure: 3. Residents at risk will be care planned for fall prevention. 4. After risk is assessed, individualized nursing care plans will be implemented to prevent falls. The resident and family members will be educated on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family, implementing rehabilitation programs to improve functional ability, and care monitoring of the medication side effects.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two of six residents (Resident #67 and Resident #99) reviewed for accidents. 1. The facility failed to provide adequate supervision to prevent Resident #99, who had cognitive impairment and resided on the secure unit, from eloping from the facility on 02/03/25 when the resident pried open the window in his room and made it 0.9 miles away from the facility. An Immediate Jeopardy was identified on 02/12/25 at 3:50 PM. While the Immediate Jeopardy was removed on 02/14/25, the facility remained out of compliance at the severity level of Potential for more than minimal harm that was not immediate jeopardy and a scope of Isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. 2. The facility failed to provide adequate supervision and assistive devices to Resident #67 on 02/06/25 when he was not properly secured on the facility's van, which resulted in the resident falling backwards in his wheelchair and hitting his head on the floor of the van during takeoff in the facility's parking lot. Resident #67 was sent to hospital resulting where he was evaluated and treated for head injury and a contusion of the right hand . An IJ was identified on 02/13/25. The IJ template was provided to the facility on [DATE] at 5:20 PM. While the IJ was removed on 02/14/25, the facility remained out of compliance at a scope of Isolated and a severity level potential for more than minimal harm that was not Immediate Jeopardy, due to the facility's need to implement corrective systems. This failure could place residents at risk for severe injury or harm, decline in health, and decreased quality of life and death. Findings included: 1. Record review of Resident #99's Admission Record dated, 02/12/25, reflected the resident was a [AGE] year old male with an initial admitted [DATE] and readmitted [DATE]. Resident #99's diagnoses included: unspecified dementia, muscle wasting and atrophy, depression, and chronic kidney disease. Record review of Resident #99's Optional State Assessment MDS dated , 01/18/25, reflected the resident's original admitted [DATE] and readmitted [DATE]. Resident #99's MDS also reflected the resident was mildly impaired with a BIMS of 8. The MDS also reflected in Section E900 Wandering Frequency occurred 1 to 3 days per week. Record review of Resident #99's undated Care Plan reflected the resident was at risk for wandering and elopement as evidenced by dementia and previous elopement when the resident convinced the hospital to discharge him to home rather than the facility. The goal was for the resident to not leave the facility unattended using interventions such as distract resident from wandering by offering pleasant diversions, structed activities, food conversation, television, and book. The Care Plan also revealed if the resident was exit seeking, the staff were to stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc . Also, the care plan reflected that the staff were to use interventions such as supervise closely and make regular compliance rounds whenever Resident #99 was in his room. The Care Plan also reflected if the resident was using statements such as I'm leaving and I'm going home or attempted to elope from the facility or hospital, it was to be reported to the MD. Record review of Resident #99's progress notes dated 02/03/25 at 5:47 AM by the DON reflected Resident #99 left the facility through his room window and jumped the fence. Per the progress note, the resident was noted to not be in his room or in the secure unit at about 5:30 AM. Nurse was made the staff aware and they began looking for the resident. The resident was noted to have an open window, staff began looking outside. Resident #99 was discovered at the gas station down the road per the progress note. The progress notes also reflected the resident was missing 15 minutes. DON documented that Resident #99 gave no statement when he returned. Progress note reflected the RP was notified and the intervention would be one on one supervision. At 6:28 AM Progress Notes reflected LVN E attempted to redirect the resident, resident became aggressive and he stated he ready to leave. MD notified new order received, send to [hospital] ER emergency room for further evaluation. Resident put on one on one until EMS arrive. At 6:45 AM progress notes reflected that Resident #99 was transferred to a hospital initiated by an emergency transfer order per physician order documented by LVN E. Record review of progress notes 01/30/25 by PA reflected Dementia with elopement risk .requiring placement in a secure unit due to risk of elopement. Excessive seeking behavior noted. Continue placement in secure unit. Monitor behavior. Review of Resident #99's Elopement Evaluation dated 01/14/25 reflected Resident #99 was at risk for elopement. Interview on 02/11/25 at 10:04 AM with the Administrator revealed that immediately after the resident eloped, he in-serviced on elopement prevention, elopement, abuse/neglect, and resident rights with all staff. The Administrator stated that the CNA and nurse on the secured unit were responsible for making rounds on the residents every two hours. He stated that if a resident eloped from the facility, the resident had a risk of being hurt. The Administrator stated that since Resident #99's elopement, he daily made rounds in the secured unit and checked all the residents' windows to ensure they were properly secured. Administrator also stated that he checked the unit doors and ensured that they were alarmed and secured. The Administrator also stated that he checked the exit door's alarm to ensure that it worked correctly daily. The Administrator stated that he changed the door codes to the secured unit monthly also. The Administrator said that he conducted elopement drills on each shift as well. Interviews on 02/11/25 at 6:12 PM and 02/12/25 at 9:12 AM were attempted with Resident #99's RP but were unsuccessful because the RP did not return calls. Interview via phone on 02/11/25 at 6:33 PM with LVN G revealed that she was the nurse on the 200 and 300 halls when LVN E reported to her that Resident #99 was missing from the secured unit. LVN G stated the staff conducted a room-by-room head count, but they could not locate the resident. LVN G stated she then got into her personal car and drove the area and soon located the resident. Resident #99 was approximately .9 miles away crossing the street in front of a local gas station. LVN E got out of her car and attempted to get the resident into her car. However, he became aggressive. LVN G revealed that Resident #99 had a dinner knife, a fork, and a shaving razor. Resident #99 began to swing at LVN G with his weapons and scratched LVN G on her arms and face. LVN G was not sure which item left the scratches on her. LVN G notified LVN E because she could not persuade Resident #99 to get inside her car. LVN E came immediately. Both nurses, LVN G and LVN E, stated that they were able to persuade Resident #99 to get inside LVN E's car, and she returned him to the facility. LVN G said that LVN E notified the Administrator, DON, and 911 that the resident was located. LVN G stated that if a resident eloped, they could fall. LVN G revealed that after this incident she was in-serviced on abuse/neglect, elopement procedures, and elopement response. Interview via phone on 02/11/25 at 6:49 PM with LVN E revealed that when she went in to give Resident #99 his medications at approximately 5:30 AM, he was not in his room. LVN E stated she checked his restroom, but he was not in it. LVN E said that she then asked CNA F where Resident #99 was located. CNA F told LVN E that she saw the resident in his room about 5:00 AM. LVN E said that she went to the room's window and raised the blinds. LVN E stated that she then observed the window screen lying on the ground. LVN E said at that point she came out and told the aide that the resident had jumped out the window. LVN E then alerted the staff and began a facility wide search for Resident #99. LVN E stated that she eventually found the Resident in the street near a local gas station walking. LVN E got Resident #99 into her car and took him back to the building where he remained on one-on-one supervision until transport arrived. LVN E stated that Resident #99's elopement was a surprise to her because she never heard him talk about leaving and had not seen him exit seeking. LVN E also said that Resident #99 was quiet and just enjoyed watching television in his room alone. LVN E stated that it was the nurse's and CNA's responsibility to make rounds in the secured unit. LVN E stated that if a resident eloped, they could be injured in the process of trying to elope, they could fall, or get run over. LVN E revealed that she was in-serviced after the elopement regarding elopement procedure, elopement precautions, and abuse/neglect. She stated that for an elopement, a code was called, and the facility participates in an all-staff search for the missing resident as well as conduct a head count for all residents to ensure safety of the remaining residents. LVN E concluded by stating that administration should be notified throughout the process. Interview via phone on 02/11/25 at 7:23 PM with CNA F revealed that she heard a loud noise at approximately 4:40 AM that came from Resident #99' Room. CNA F stated that she thought it was Resident #99 coming out of his bathroom and the heavy door shutting. CNA F then said that she went into his room while making her rounds in the secured unit about 5:00 AM. Resident #99 was in his room in his bed. CNA F stated that the nurse went into Resident #99's room at about 5:30 AM to give him his medication. Then she was notified by the nurse that Resident #99 was not in his room or bathroom. CNA F stated that she stayed in the secure unit while the nurse left the unit to search for the resident. CNA F stated that she went into his room and observed his window up. CNA F stated she also observed his bedside table across the secured courtyard next to the privacy fence. CNA F revealed that the previous night when she arrived at the building and began her rounds, she spoke with Resident #99. CNA F said that Resident #99 was awake in bed and said that he was doing ok. CNA F said that it was all staff's responsibility to ensure that residents did not elope. CNA F said that she was in-serviced on abuse/neglect, elopement prevention, and elopement response beginning approximately 1 hour after the elopement. Interview via phone on 02/11/25 at 7:40 PM with LVN H revealed that Resident #99 was a quiet resident who isolated in his room. LVN H stated that she worked the night shift. LVN H said that she made rounds on the resident every two hours. LVN H also revealed that she never heard Resident #99 talk about eloping, and it was not passed down through report that he was exit seeking or talking about elopement. LVN H said that it was all the staff on the unit's responsibility to watch the residents to ensure that they do not elope. LVN H said that if residents elope, they could go missing. LVN H did not recall the elopement in-services following the resident's elopement. But she stated that staff was normally in-serviced following an elopement. Interview on 02/12/25 at 9:42 AM with CNA J revealed that Resident #99 was a quiet and pleasant resident who did not exit seek. CNA J also stated that Resident #99 did not discuss leaving the facility and did not pack his belongings. CNA J stated that she checked on Resident #99 every two hours and more often because the residents on the secure unit need more attention. CNA J also stated that the last time she showered the resident that she did not shave the resident. Therefore, she was unsure how he acquired a razor. CNA J said that she was unsure how Resident #99 had dining utensils because the CNAs and nurses check to ensure that utensils are with the trays when they pick them up from the residents. CNA said that Resident #99 did not have a Wonder guard on him that would signal if he eloped. CNA concluded by stating that there were no residents on the unit that were currently exit seeking. Interview on 02/12/25 at 9:43 AM with LVN I, who worked day shift, revealed that Resident #99 did not show signs of elopement. LVN, I stated that Resident #99 shaved himself. And therefore, Resident #99 could have placed the razor in his pocket. LVN I also revealed that because the Resident primarily stayed in his room and took all his meals in his room, he must have kept a dinner knife and fork from one of the trays. LVN, I stated that it was all staff's responsibility to keep staff safe and to ensure that utensils and razor are not kept by the residents. LVN, I said that residents could injure themselves or another resident if they kept utensils and razors. LVN I also stated that if residents eloped, they would risk not receiving their medications timely, being hurt, etc. Interview on 02/12/25 at 11:36 AM with the DON revealed that Resident #99 usually stayed in his bed and watched television in his room in the secured unit. The DON stated the staff in the secured unit increased rounding on Resident #99 since his admission from the hospital to ensure he was comfortable, The DON stated that the windows in the secured unit are screwed in place so that the windows cannot be raised more than four inches. The DON stated that she did not think that Resident #99 would be capable of getting the screws out of the windows. The DON also said that the windows do not have alarms on them. Therefore, staff were not alerted when the window went up. The DON also stated that because the secured unit's door alarm systems was working correctly, there were no other measures in place to monitor the residents for elopements excluding the secured units entrance/exit door. The DON revealed that the risk to Resident #99's elopement was possible injury. The DON also stated that it was the nurse and the aide's responsibility on the unit to ensure that no elopement occurred, and residents were kept safe at all times. Interview on 02/13/25 at 10:17 AM with the Administrator revealed that he began to in-service all staff on 02/12/25 after the notification of the IJ at 4:00 PM on 02/12/25. The Administrator stated that he in-serviced all staff on elopement prevention, elopement response, and abuse/neglect. The Administrator revealed that the in-service was completed via a text service that went to all facility staff and copies were provided evidencing it. The Administrator also said that the DON and her staff spoke with the staff about the in-service topics before they began their shifts in addition to the text that went out to all facility staff. The Administrator said that as part of the elopement prevention, nurses were instructed to complete elopement assessments. The administrator stated that he made daily rounds and checked all the windows on the secured unit to ensure that they were secured and not tampered. The Administrator also stated that he tested the exit door alarm daily and will change the code monthly. The Administrator said that as part of his abuse/neglect in-service, he spoke with residents to ensure their needs were met. The Administrator revealed that as part of the elopement response in-service, the Administrator informed staff to immediately conduct a head count and then notify the staff in the building before beginning the search. The Administrator then said that the authorities were to be notified if the resident was not found in 30 minutes. The Administrator stated that the nurses were in-serviced to notify the family, the DON, Ombudsman, IDT , (Interdisciplinary Team) and the physician. Record review of the facility's revised January 2023 Elopement Response policy reflected: Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented. 1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical. 2. Determination of missing resident either by routine nursing rounds or door alarms: A. Note: A resident is determined to be missing when he/she leaves the facility without the staff's knowledge. C. A resident must demonstrate a free and willful intent to leave the facility without prior notification of staff or is a wandering, confused resident who leaves the facility unattended. 4. Should an employee discover the resident is missing from the facility (Code Orange), he/she should: Report to the charge Nurse .Make a thorough search of the building and premises. And if not located, contact the DON, RP, physician .Make and extensive search of the surrounding area. 6. If unable to located resident in the building, proceed as follows: B. Affected Area-Charge Nurse assigns staff to specific outside areas to ensure that all surrounding areas are searched. C. After 30 minutes, if the resident has not been found, the following calls must be made: .Report missing resident to the police . Record review of the facility's revised January 2023 Elopement Prevention policy reflected: Every effort will be made to prevent elopement episodes while maintain the lease restrictive environment for resident who are at risk for elopement. 1. The Elopement Risk will be completed upon admission . Physical Plant 1. All facility exits what resident have access to will have a device in place to alert staff of elopement attempts. Examples include- Wanderguard Wander management Ssystem Placement of the residents' device to alarm the system will be verified each shift and documented on a treatment or other flow record Keypad exit magnetic locks. Keyed alarms Secured Unit Or a combination of the above .Staff Training. Staff will receive training during their orientation process and then annually regarding: Elopement prevention. Operation of all exit devices. Actions to take if elopement occurs . Record review of the facility's revised 05/09/17 Abuse/Neglect Policy reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultant or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Record review of in-services reflected: Elopement Response completed on 02/12/25, Elopement Prevention completed on 02/12/25, and Abuse/Neglect completed on 02/12/25. Record review of in-services completed prior to survey entry reflected: Elopement completed on 02/03/25, Elopement Prevention completed on 02/03/25, Abuse/Neglect completed on 02/03/25, and Resident Rights completed on 02/03/25. This was determined to be an Immediate Jeopardy (IJ) on 02/12/25 at 3:50 PM. The Administrator was notified of the IJ and was provided the IJ template on 02/12/25 at 4:00 PM and a plan of removal was requested. The following plan of removal submitted by the facility was accepted on 02/13/25 at 9:51 AM and included the following: Plan of Removal Problem: F689 Free from Accidents/Hazards/Supervision Interventions: Record review of elopement drills completed 02/03/25, 02/05/25, 02/07/25, and 02/10/25 reviewed on 02/19/25. 1. Administrator, DON, and/or designee will initiate an in-service regarding: a. Elopement Response b. Elopement Prevention c. Abuse/Neglect All staff scheduled to work through 02/12/25 will be in-serviced by end of day and prior to next shift worked. Completed. 2. The Administrator will conduct 3 elopement drills per week. Administrator began. 3. The Administrator, DON, and ADON were in-serviced by the ADO and Regional Compliance Nurse and completed as of 02/12/25 on Elopement Prevention Policy to include implementing interventions for residents at risk for elopement, Elopement Response Policy, and Abuse/Neglect. Completed on 02/10/25 at 0900, 02/03/25 at 0545, 02/05/25 at 1000, and 02/07/25 at 1600. By Administrator 4. Elopement Risks will be completed for all residents on the secured unit. Completed and provided. 5. AD Hoc QAPI Contributors will meet and review the elopement risk for all residents residing on the secured unit. Completed on 02/12/25. 6. All elopement events were reviewed by the facility QAPI committee members and are completed as of 02/12/25. 7. All elopement risk care plan interventions will be reviewed and have been completed/updated as of 02/12/25 by the Regional Compliance Nurse, DON, and ADON. All interventions are in place and care planned. 8. Administrator will monitor the locking mechanism on all the exit doors and windows in the secured unit (This question was confirmed as Question #1 by administrator on the Missing Resident/Elopement Monitoring form Week 2) on 02/13/25. 02/03/25, 02/04/25, 02/05/25, 02/06/25, 02/07/25, 02/10/25, 02/11/25, 02/12/25, 02/13/25, 02/14/25 - By Administrator 9. Administrator will review for 1:1 monitoring in the secured unit. Completed. 02/03/25, 02/04/25, 02/05/25, 02/06/25, 02/07/25, 02/10/25, 02/11/25, 02/12/25, 02/13/25, 02/14/25- By Administrator Only 02/03/25 had1:1 monitoring. 10. Through daily rounds and duties at least five times per week, observe for visitors allowing residents to exit the facility unsupervised. Completed. No issues noted. 02/03/25, 02/04/25, 02/05/25, 02/06/25, 02/07/25, 02/10/25, 02/11/25, 02/12/25, 02/13/25, 02/14/25- By Administrator 11. Change the door code monthly. Completed. Did not provide the date the code was changed. Only that it was changed. - By Administrator 12. The medical directed was notified of the IJ situation. Identified Residents at Risk: Only 1 resident was affected regarding this incident. The resident was not harmed as a result of this elopement. Systemic Changes: 1. The Administrator will monitor the residents' windows in the secured unit for signs of tampering. 2. The Administrator will also monitor the facility entrance and secured unit doors to ensure their locks are functioning properly as well as their alarms. 3. Elopement drills will be continued so that all shifts are prepared for elopements. Responsibility: It is the Administrator, or designee, and the Director of Nursing, or designee's responsibility to follow the actions and the systematic changes listed above. The Administrator, or designee, and the Director of Nursing, or designee, will report their findings of the above actions and systematic changes through their QAPI [Quality Assessment Performance Improvement] Process. Monitoring the Plan of Removal: The Administrator and DON in-serviced all staff on the following: 1. Elopement Response completed on 02/12/25. 2. Elopement Prevention completed on 02/12/25. 3. Abuse/Neglect completed on 02/12/25. Monitoring interviews for the Immediate Jeopardy were started on 02/13/25 at 10:00 AM and continued through 02/14/25 at 12:00 PM with 40 staff across all three shifts, including weekdays and weekends, including all departments. The staff were interviewed about elopement response, elopement prevention, and abuse/neglect. The following staff's in-service logs were reviewed, and they were interviewed during the monitoring time frame. The were able to articulate what they were taught including the correct protocols and procedures related to elopement prevention, elopement response, and abuse/neglect: RN D, LVN E, CNA F, LVN G, LVN H, LVN I, CNA J, CNA K, MA L, LVN M, CNA N, CNA O, MA P, CNA Q, CNA R, CNA S, CNA T, CNA U, CNA V, CNA W, CNA X, CNA Y, CNA Z, CNA AA, LVN BB, MA CC, CNA DD, MA EE, RN FF, Administrator, DON, ADON A, HR, Laundry Aide, Social Services, Housekeeping Aide, Activities Director, COTA, and Medical Records. 2. Record review of Resident #67's face sheet reflected the resident was [AGE] years old male who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #67's quarterly MDS assessment, dated 11/28/24, reflected a BIMS score of 14, which indicated his cognition was intact. His diagnoses included osteomyelitis (bone infection that causes inflammation and destruction of bone tissue), paraplegia (the inability to voluntarily move the lower parts of the body), neurogenic bladder (the bladder muscles and nerves do not function properly), anxiety disorder, pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of unspecified buttock, unspecified stage and need for assistance with personal care. The MDS further revealed Section M - Skin Conditions - Skin and Ulcer/Injury Treatment indicated the resident's required pressure ulcer/injury care and surgical wound care. Record review of Resident #67's Care plan, revised date 01/29/25, reflected: Focus: [Resident #67] at risk for falls paraplegia. Goal: The resident will be free of falls through the review date. [Resident#67] will not sustain serious injury through the review date. Interventions: Anticipate and meet the resident's needs. Staff x 1 to assist with transfers. Record review of Resident #67's progress notes written by RN GG dated 02/06/25 at 1:41 PM reflected Resident had a fall. Location: while on leave . Fall information: Hit Head. Cognition/Behavior at Time of Event: Oriented/no problem, Resident assisted to chair from the fall while in transport van, Resident stated hit his head, Resident stated blacked out, Physician Assistant on site, sent to emergency room for further evaluation. Appears and /or states to be in pain. Describes the pain as: continuous, chronic. Location of pain: head, right wrist pain relieving intervention used at this time: sent to emergency room for evaluation. Initial Treatment/New Orders: send to emergency room . Resident Statement: I hit my head and I want to go to the hospital. Record review of Resident #67's progress notes written by RN GG dated 02/06/25 at 2:51 PM reflected Resident #67 was transferred to a hospital on 02/06/25 at 1:55 PM related to transport van patient had fallen backwards in wheelchair, hitting head. Sent to hospital for evaluation. Record review of Resident #67's progress notes written by LVN G, dated 02/06/25 at 10:58 PM reflected At 8:17 PM. Resident #67 come back from hospital on non-emergency transportation on diagnosis of fall encounter Head injury, contusion of right hand. Initial encounter. Blood pressure 121/69, pulse 67, respiratory 18 saturation 98 percent, Alert, and oriented x 4, able to voice needs and concerns, did head to toe skin assessment. Change both hip dressing to Wet to Dry dressing, ongoing care, call light in reach. Record review of Resident #67's after visit summary dated 02/06/25 reflected Reason for visit: Fall, Diagnoses: Fall, initial encounter, Head injury, initial encounter, Contusion of right hand, initial encounter, History of paraplegia. CT head without contrast, chest x ray, hand x ray. Medications given: Oxycodone-acetaminophen, Instructions: Follow up with provider in two weeks around 02/20/25 if symptoms worsen. Record review of Resident #67's incident report dated 02/10/25 reflected Conclusion: resident in 3rd party transport van, his chair has no anti tippers or brakes. Resident fell backward due to inertia upon the driver taking off. Intervention: parts have been ordered for resident chair, and resident to use transport chair vs personal wheelchair. Therapy to screen. Interview on 02/11/25 at 11:37 AM with Resident #67 revealed on 02/06/25 he had a urology appointment and after he was loaded on the van, he fell backwards hitting his head. According to Resident #67 he had a headache and pain in his right hand from the fall. Resident #67 stated it was not the facility van driver, but an outside provider that was taking him to his appointment. Resident #67 stated he took off like a race car driver in the parking lot and I fell backwards, hitting my head on the floor, and blacked out. Resident #67 stated the van driver did not strap me down correctly, so when he took off, I fell backwards and hit my head, and was sent to the hospital. Interview on 02/13/25 at 12:28 PM the DON revealed she knew Resident #67 was scheduled for urology appointment on 02/06/25, she stated the facility van had other appointments, so he was to be transported by an outside transport provider. The Social Worker stated she did not see Resident #67 exit the building for his appointment. The DON stated she was alerted to come outside. When she got outside, she saw Resident #67 still in his wheelchair; straps were still attached. According to the DON she jumped in the van and removed 2 straps, she stated Resident #67 had to be removed from the chair so they could get the wheelchair out the van. Once the wheelchair was removed from the van, Resident #67 was placed back in the wheelchair, assessed and was one on one with nurse until the emergency medical services arrived to take him to the hospital. The DON stated Resident #67 was delirious and was not able to support his body while sitting in the wheelchair, he was not at his baseline , he complained of head pain and stated that he lost consciousness. The DON stated she did not speak to the Van Driver; she did not recall if an incident report was completed. According to the DON drivers were responsible for entering the facility to transport residents out and back inside upon returning to the facility. Interview on 02/13/25 at 2:47 PM with Social Worker revealed when residents require an outside appointment, they will leave notification for the Facility Transportation Driver to schedule the appointment with the provider and arrange transportation. According to the Social Worker, she was alerted by the Van Driver coming to the door saying, your patient has flipped out here in the van, the Social Worker stated at that point she alerted either the Administrator or the DON. The Social Worker stated when she got outside, she saw Resident #67 laying on his back yelling at the Van Driver you fucking dropped me, there was no way I was strapped in. According to the Social Worker Resident #67 and the Van Driver was going back and forth indicating Resident #67 was upset. The Social Worker stated she saw he was strapped in however could not tell if it was done correctly. She stated there was one strap on each front wheel but did not recall if the back wheels had any straps, she further stated there were straps caught in the wheels and it was a lot of trouble getting the straps out the wheelbase. Interview on 02/13/25 at 3:07 PM with Facility Transportation Driver revealed she was responsible for scheduling appointments and transportation for residents who have appointments outside the facility. The Facility Transportation Driver stated when appointment times conflict it would become a need to outsource the transportation. The Facility Transportation Driver stated on 02/06/25 the facility van was booked with resident appointments, therefore she needed to outsource transportation for Resident #67's urology appointment. The Facility Transportation Driver stated she contacted Resident #67's insuran [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 4 residents (Resident #67) reviewed for quality of care. RN C failed to assess Resident #67 for a change in condition in a timely manner when he reported he was not feeling well on 02/09/25 at approximately 7:30 AM, and RN C noticed he did not look well and offered to send the resident to the hospital. An IJ was identified on 02/13/25. The IJ template was provided to the facility on [DATE] at 5:20 PM. While the IJ was removed on 02/14/25, the facility remained out of compliance at a scope of isolated and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems. These failures could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition and/or the need for hospitalization and prolonged treatment. Findings included: Record review of Resident #67's face sheet reflected the resident was [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #67's quarterly MDS assessment, dated 11/28/24, reflected a BIMS score of 14, which indicated his cognition was intact. His diagnoses included paraplegia (the inability to voluntarily move the lower parts of the body), neurogenic bladder (the bladder muscles and nerves do not function properly), anxiety disorder, pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of unspecified buttock, unspecified stage and need for assistance with personal care. The MDS further reflected Section M - Skin Conditions - Skin and Ulcer/Injury Treatment indicated the resident's required pressure ulcer/injury care and surgical wound care. Record review of Resident #67's Care plan, revised date 01/29/25, reflected: Focus: [Resident #67] has a pressure at multiple sites. Please see physician orders and [MAR ] for wound and treatment. Goal: [Resident #67] Pressure ulcer will show signs of healing and remain free form infection by/through review date. Interventions: Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressing PRN .Wound Vac ordered. Record review of Resident #67's February 2025 MAR physician orders, reflected: Clean the left hip and right ischial ulcer with N/S, Tap Dry, apply granular foam into the ulcer, cover with a drape, connect to Wound VAC with 125 MM mercury pressure, change Q Monday, Wednesday, Friday, and as Needed. In the morning every Mon, Wed, Fri for wound treatment. Record review of Resident #67's February 2025 MAR physician orders, reflected: If Wound VAC is not available, clean bilateral hip ulcer and hip ischial ulcer with normal saline, tap with dry dressing, apply silver alginate rope into all the ulcer, cover with multiple layers of 4 x 4s ABD, secure with [medipore] (cloth) tape , change the dressing every other day and as needed for wound discharge. Every 12 hours as needed for wound treatment related to Pressure Ulcer of Unspecified Buttock, Unspecified state. Record review of Resident #67's physician orders reflected: If wound vac is not available, clean bilateral hip ulcer and hip ischial ulcer with normal saline, tap with dry dressing, apply silver alginate rope into all the ulcer, cover with multiple layers of 4 x 4 s abdominal pads, secure with medipore (cloth) tape, change the dressing every other day and as needed for wound discharge. Every 12 hours as needed for wound treatment related to pressure ulcer of unspecified buttock, unspecified stage 1/9/2025 Clean the left hip and right ischial ulcer with n/s, tap dry, apply granular foam into the ulcer, cover with a drape, connect to wound vac with 125 mm mercury pressure, change every Monday, Wednesday, Friday. and as needed. In the morning every Monday, Wednesday, Friday for wound treatment 01/09/25, Record review of Resident #67's February 2025 MAR reflected Resident #67 was provided care to clean the left hip and right ischial ulcer with normal saline, tap dry, apply granular foam into the ulcer, cover with drape, connect to wound vac with 125 mm mercury pressure, change every Monday, Wednesday, Friday, and as needed. In the morning every Monday, Wednesday, Friday for wound treatment on day 02/03/25, 02/05/25, 02/07/25 and did not indicate care was provided on 02/09/25, and care was not provided on 02/10/25. Record review of Resident #67's progress notes dated 02/09/25 at 1:48 PM written by RN C reflected patient had come to nursing desk and stated he did not feel well, and that wound vac was not working right on left hip. Lips were pale, sclera pale. Went to patient room and discussed going to hospital. Discussed with patient removal of wound vac dressing and placement of wet to dry dressing. Patient refused wet to dry and said he was going to wait until he spoke with his wife and stated that he would let this writer know of his decision. Record review of Resident #67's progress notes dated 02/9/25 at 1:55 PM written by RN C reflected This writer had went to patient room to ask what his decision was. He stated that he wanted left hip wound dressing to be changed. He was informed that dressing would be changed as soon as possible. patient verbalized understanding Record review of Resident #67's progress notes dated 2/9/25 at 7:58 PM written by RN C reflected wound vac dressing change had been done to left hip. patient then informed this writer that his right hip dressing needed to be changed. informed supplies would need to be gathered. Wife present at bedside and offered to change dressing. Wife changed dressing to demonstrate how was taught to change dressing. Pt tolerated well. Record review of Resident #67's progress notes dated 2/10/25 at 12:19 AM written by RN C reflected Patient tolerated MN medications, pt alert, able to answer questions writer asked. Pt held water, accepted snack at this time. Fluids at bedside Gatorade and ice water. Wound vac on, dressing intact upon observation. Pt declined any needs that need to be addressed at this time. Care ongoing. Interview on 02/11/25 11:37 AM with Resident #67 revealed the resident in bed, Resident #67 asked if he could include his Family Member and made a phone call. Resident #67 and Family Member stated there has been a lot of issues in regard to his wound care, stated that the facility staff were not properly trained in providing wound care. Resident #67 stated there had been several times he needed assistance with care with his wound vacuum or needed his dressing changed and he felt staff would ignore him because they did not want to provide wound care. Resident #67 stated he and his Family Member had been speaking with the Administrator and the DON to have consistent and timely wound care. According to the Family Member and Resident #67, nursing staff to include the LVN M were rude and lacked customer service and bedside manner, staff would not want to complete his wound care. Resident #67 stated when the LVN M was not available or had a day off wound care could not be completed because other nurses, they lack the proper training to assist him with administering the wound vacuum. Resident #67 stated he has a wound on each hip and one right below his right butt check. Resident #67 stated upon speaking with the Administrator, wound care and placement of the wound vacuum should be completed early in the mornings at the start of shift. Resident #67 stated on last Sunday (02/09/25) he alerted RN C about 7:30 AM-7:45 AM that he did not feel well, and needed to have his wounds cleaned and vacuum replaced because the wounds were leaking all over his bed and wheelchair. Resident #67 stated RN C did not return to assess, clean, and connect the wound vacuum until 5:30 PM just prior to the end of her shift, at that time it was discovered RN C did not have enough supplies to complete care which resulted in a prolonged wait to get care. According to Resident #67 the vacuum machine was malfunctioning early in the morning hours, it was off and not working, the bandages were coming off allowing the wound to drain and leak all day which was disgusting. Interview on 02/12/25 at 5:38 PM with RN C revealed she worked with Resident #67 on 02/09/25, she stated Resident #67 came to the nursing station around 7:30 - 7:45 AM he stated I'm not feeling good, I had been laying in this, I am leaking all over my bed, myself, and now my wheelchair. RN C stated Resident #67 looked pale, he looked sick (lips were pale, sclera pale). The wound looked like his wound was leaking, and the dressing needed to be changed. RN C stated she then told Resident #67 to contact Family Member and discuss being sent out to the hospital because she did not want to complete the care with a new canister if he was going out. She stated, I needed to know which supplies to use, if he was going to the hospital, I would need to use wet to day supplies. RN C stated she was waiting on Resident #67 to come back to her with a response from Family Member, on what they had decided about him going to the hospital or if he would stay in the facility. RN C stated I should not have waited so long; I should not have allowed him to be last to complete care. RN C stated when she got around to checking on Resident #67 it was after 5:00 PM. RN C stated I completed care on the right hip, and I did not know if you did one side you needed to do the other side as well, there was not enough supplies to complete the left side. I reached out to the DON because I did not have enough supplies to complete wound care for the left side, she then gave me LVN M's number to contact her about obtaining supplies. After contacting LVN M, she came to the facility to provide me with supplies, this was around 6:00 PM. RN C stated, I had other things going on and could not prioritize him above other situations, I did not intently neglect him. RN C stated she never made rounds to check on Resident #67 throughout the shift however she was responsible for ensuring wound care for Resident #67 was completed in a timely manner, not doing so placed him at risk of him being in sepsis and making wounds worst with no suction. RN C stated she did not reach out to anyone during her shift for assistance to provide care for Resident #67, she stated she just thought she would get to him prior to the end of her shift. RN C stated the Family Member entered Resident #67's room upset about him not receiving timely care and completed the wound care with RN C observing. According to RN C she received a video in-service on 02/10/25 and she was also expected to do one on one training with the LVN M on how to use wound vacuum. According to RN C she was trained on wound vacuum in prior positions however, not the way it was requested by Resident #67 and Family Member . RN C stated not providing care to Resident #67 in a timely manner was neglect and she did not intend on neglecting him by not addressing his wounds, not assessing him when he stated he did not feel well and when Resident #67 did not look like he felt well, as well as when she did not follow up on him until the end of her shift which was 10 hours later. RN C stated she had been inserviced several times on neglect, which was what I had done to Resident #67. RN C stated when Resident #67 looked pale, he looked sick (lips were pale, sclera pale). The wound looked like his wound was leaking, and the dressing needed to be changed, she recognized he had a change in condition and should have reported this change to the DON and the Physician. Interview on 02/13/25 at 12:28 PM with the DON revealed she received a call from RN C around 5:30 PM indicating there were no supplies available to complete wound care for Resident #67, that she thought the wound vacuum was messed up. According to the DON, she instructed RN C to look at the vacuum and contact the LVN M for supplies. The DON stated she called LVN M to bring supplies and was on the phone with the LVN M when she entered the facility to deliver supplies. According to the DON, only a limited number of supplies are put out on the wound cart or in the medication room, when additional supplies are needed, the LVN M was contacted so she can tell us where to get more or she will come to the facility to get them from her office. The DON stated she got confirmation from RN C that the vacuum was changed and working properly. According to the DON, she was in communication with RN C throughout the day and she never reported Resident #67 was not feeling well or did not look well. The DON stated she heard from Family Member that Resident #67 requested earlier in the day to have his wounds changed and machine inspected. The DON stated she would have expected RN C to address Resident #67's concerns with his wounds and wound care in a timely manner, not wait the entire shift to complete care. The DON stated she sent a video to RN C on Monday and had been having all nursing staff to shadow one on one wound care with LVN M, that started weeks ago. The DON stated she started this process, so nurses were comfortable changing the wound vacuum and the supplies, and what to do when wound vacuums were beeping. The DON stated the RN was responsible for addressing Resident #67's needs for his wounds, and reporting when residents have a change in condition to the physician, the DON, and the Administrator. The DON further stated, not completing care in a timely manner placed Resident #67 at risk of sepsis, wound breakdown, hospitalization , and septic shock and because of that we took disciplinary action . According to DON, RN C neglected Resident #67 when she did not provide care in a timely manner when she saw that his wound was leaking and she saw the he did not look as if he was feeling well. DON stated when you are not addressing these concerns you are basically neglect the resident. DON stated when his condition changed, him not looking at his baseline, RN C should have notified myself and the Physician, not providing care or notifying the physician of Resident #67's condition was neglectful and went against facility policy. Interview on 02/13/25 at 4:27 PM with the Administrator revealed he received a call from the Family Member on 02/09/25 that RN C was refusing to replace the wound vacuum for Resident #67 and she was trying to send him out to the hospital instead. According to the Administrator, the Family Member reported she saw supplies in the room. The Administrator stated, I don't know if the nurse knew what she was doing and he expected the nursing staff to address any wound changes or resident needs in a timely manner. The Administrator stated it was reported back to him the dressings and wound care was completed. The Administrator stated he expected nurses to ensure they were following doctor orders, not doing so placed Resident #67 at risk of having to be sent out to the hospital for not addressing his need for wound care. The Administrator stated he did not have the full story of events and he did not investigate the incident; he did not feel he needed to because the wound care was completed . According to the Administrator the DON and ADONs were responsible for ensuring the nurses were trained to complete wound care. The Administrator stated not providing wound care, when the wound is leaking and Resident #67 stated he did not feel well, and not checking on Resident #67 for the entire shift would be a form of neglect, placing Resident #67 at risk of infection or the need to be sent to the hospital. Interview on 02/14/25 at 1:16 PM with the Physician revealed he was not made aware that Resident #67 looked as if he was not feeling well by RN C, that he had a change in condition. The Physician stated he expected to be notified by the facility if there was change in condition with residents. The Physician stated if the wound vacuum machine was beeping that indicated the wound vacuum needed to be checked. The Physician stated at that time the wound should be assessed with the possibility of the dressings to be changed . According the Physician waiting to the end of the shift to address Resident #67's needs, change in condition and assess his wounds was a form of neglect, waiting 10 hours could place the resident at risk of several things and the need to be sent to the hospital. Record review of the facility policy revised 09/09/24 titled Abuse/Neglect Policy reflected The resident has the right to be free from Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of the facility's Skin Integrity Management policy, dated 10/05/16 reflected: Wound care should be performed as ordered by the physician. Skin should be cleansed at the time of soiling and the routine intervals. The frequency of skin cleansing should be individualized according to need/and or resident preference. Minimize skin exposure to moisture due to incontinence, perspiration, or wound drainage. Record review of the facility's Physician Orders policy, dated 2015, reflected: to monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and activities of daily living order for each resident. Record review of the facility's Notifying the Physician of Change in Status policy, revised 03/11/23, reflected: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptom of signification change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. This was determined to be an Immediate Jeopardy (IJ) on 02/13/25 at 5:25 PM. The Administrator was notified. The Administrator was provided the IJ template on 02/13/25 at 5:26 PM and a plan of removal was requested. The following plan of removal submitted by the facility was accepted on 02/14/25 at 1:40 PM and included the following: Facility: The {facility} Date: 2/14/25 Plan of Removal Problem: F600 Free from Abuse and Neglect Interventions: As of 2/13/25 [Resident #1] had a complete head to assessment performed by the Treatment Nurse On 2/14/25 [Resident #1] had a head-to-toe assessment completed by the Regional Compliance Nurse, DON, and Tx Nurse. The MD was notified of all wounds by the DON. Orders were received. Wound vac dressing changed on 2.14.25 by the Treatment Nurse. All residents in the facility will receive a head-to-toe skin assessment. Wound treatments including wound vacs will be verified as completed according to MD orders by the Regional Compliance Nurse, DON, ADON. Completion date 2/13/25. Treatment nurse was educated on checking daily, Monday-Friday, to ensure that all wound care supplies is readily available. Completion date 2/14/25. All nurses were educated on the location of wound care supplies. If not available, they need to notify the DON and Administrator immediately. Completion date 2/14/25. The DON and ADON were in-serviced 1:1 on following topics by the Regional Compliance Nurse. Completed 2/13/25. Dressing Change Procedure- procedure to include wound vac dressings . Abuse and Neglect: failure to complete a dressing change according to MD orders including wound vacs could be considered abuse and neglect. Notification of Change in Condition: including notifying a MD for a change in a resident's condition. Resident Rights: to respect a resident's right to request care including dressing changes. The medical director was notified of the immediate jeopardy on 2/13/25. An ADHOC QAPI meeting was completed on 2/13/25 with IDT team including the Medical Director to discuss the immediate jeopardy and plan of removal. In-services: All nursing staff will be in-serviced on 2/13/25 regarding the following topics below by the ADO, the Regional Compliance Nurse, the Administrator, the DON, and the ADON. All staff not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-serviced on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment. Completion date 2/14/25. Dressing Change Procedure- procedure to include wound vac dressings. Dressing Supplies- all supplies needed for treatment services are in the medication room. Notify the DON and Administrator if not available. Abuse and Neglect: failure to complete a dressing change according to MD orders including wound vacs could be considered abuse and neglect. Notification of Change in Condition: including notifying a MD for a change in a resident's condition. Resident Rights: to respect a resident's right to request care including dressing changes. The following Plan of Removal monitoring was conducted: Inservice Training Topic: -Dressing Change Procedure - Procedure to include wound vac dressings. -Abuse and Neglect: Failure to complete a dressing change according to MD order including wound vacs could be considered abuse and neglect. -Notification of Change in Condition: including notifying MD for a change in a resident's condition. -Resident Rights: to respect a resident's right to request care including dressing changes. Date and Time Conducted: 2/13/24. Instructor: Regional DON Attendees: Administrator, ADON A, ADON B, DON Inservice Training Topic: Wound Care Supplies Being Readily Available The wound nurse will ensure that all necessary wound care supplies are readily accessible for nursing staff. If staff encounter any difficulties in finding the supplies, she will guide them on where to locate the required items. From Monday to Friday, the wound nurse will verify that supplies are adequately stocked in the medication room, and on Fridays, she will also confirm that the supplies are prepared for the weekend. Date Conducted: 02/13/25. Instructor: Regional DON Attendees: LVN M Inservice Training Topic: Notification of Changes - see attached policy regarding notification of changes. Date Conducted: 02/13/25. Instructor: Regional DON Attendees to include MA P, MA EE, CNA F, CNA K, CNA N, CNA Q, CNA V, CNA X, CNA BB, RN D, RN GG, LVN H, LVN M, ADON A, CNA HH, CNA II, CNA JJ, CNA KK, CNA LL, CNA DD Inservice Training Topic: Abuse and Neglect Resident Rights Date Conducted: 02/13/25. Instructor: DON Attendees to include: ADON B, LVN H, CNA X, LVN BB, MA CC, MA EE, RN GG, CNA F, CNA JJ, CNA HH, RN D, MA P, CNA K, CNA Q, Med Rec, LVN M, CNA LL Inservice Training Topic: Wound Dressing Care and Changes Date Conducted: 02/13/25. Instructor: Regional DON Attendees to include: ADON B, LVN H, LVN BB, MA CC, CNA LL, MA EE, RN GG, RN D, CNA N, CNA Q, CNA T, LVN M, ADON B, CNA AA, CNA DD Inservice Training Topic: A resident request a change to the wound vac, immediately address the resident, do NOT delay treatment. Call the DON and Wound Care Nurse if there are any issues in applying the wound vac. Monitor the wound vac for changes to suction, taping, leakage, tubing kinked and any other concerns. Operating Manual Revision Date: 2024-08-16 titled extriCARE 3000 Negative Pressure Wound Therapy System Date Conducted: 02/13/25. Instructor: DON Attendees to include: LVN I, LVN BB, ADON B, ADON A, LVN H, MA CC, MA EE, RN D, RN GG, CNA Q, CNA T Interviews conducted with the above staff indicated they had understanding to identify when a resident has a change of condition, signs of abuse/neglect, the need to honor resident rights. Nursing staff was able to reveal where wound care supplies were kept; how and who to notify to restock if items were low, and Nurses stated they understood how to complete wound care on residents with wound vacuums. The Administrator was informed the Immediate Jeopardy was removed on 02/14/2025 at 7:10 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interviews, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of pressure ulcers for 1 (Resident #67) of 2 residents reviewed for pressure ulcers with use of a wound vacuum. RN C failed to provide Resident #67 with wound care when he reported to her on 02/09/25 at approximately 7:30 AM that he was not feeling well and needed his dressing changed because his wound vac was leaking. RN C did not follow-up with Resident #67 for care until 5:30 PM at which time she discovered she did not have enough supplies to complete wound care. The wound care was not provided for approximately 10 hours after the resident had asked to have the dressing changed, which resulted in resident discomfort and wound drainage getting on the resident, his wheelchair, and bed linens. An IJ was identified on 02/13/25. The IJ template was provided to the facility on [DATE] at 5:20 PM. While the IJ was removed on 02/14/25, the facility remained out of compliance at a scope of isolated and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems. These failures placed residents with wounds at risk of wound deterioration, wound development, and infection. Findings included: Record review of Resident #67's face sheet reflected the resident was [AGE] years old male who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #67's quarterly MDS assessment, dated 11/28/24, reflected a BIMS score of 14, which indicated his cognition was intact. His diagnoses included paraplegia (the inability to voluntarily move the lower parts of the body), neurogenic bladder (the bladder muscles and nerves do not function properly), anxiety disorder, pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of unspecified buttock, unspecified stage and need for assistance with personal care. The MDS further revealed Section M - Skin Conditions - Skin and Ulcer/Injury Treatment indicated the resident's required pressure ulcer/injury care and surgical wound care. Record review of Resident #67's Care plan, revised date 01/29/25, reflected: Focus: [Resident #67] has a pressure at multiple sites. Please see physician orders and [MAR] for wound and treatment. Goal: [Resident #67] Pressure ulcer will show signs of healing and remain free form infection by/through review date. Interventions: Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressing PRN . Wound Vac ordered. Record review of Resident #67's February 2025 MAR physician orders reflected: Clean the left hip and right ischial ulcer with N/S, Tap Dry, apply granular foam into the ulcer, cover with a drape, connect to Wound VAC with 125 MM mercury pressure, change Q Monday, Wednesday, Friday, and as Needed. In the morning every Mon, Wed, Fri for wound treatment. Record review of Resident #67's February 2025 MAR physician orders reflected: If Wound VAC is not available, clean bilateral hip ulcer and hip ischial ulcer with normal saline, tap with dry dressing, apply silver alginate rope into all the ulcer, cover with multiple layers of 4 x 4s ABD, secure with medipore (cloth) tape, change the dressing every other day and as needed for wound discharge. Every 12 hours as needed for wound treatment related to Pressure Ulcer of Unspecified Buttock, Unspecified state. Record review of Resident #67's physician orders revealed: If wound vac is not available, clean bilateral hip ulcer and hip ischial ulcer with normal saline, tap with dry dressing, apply silver alginate rope into all the ulcer, cover with multiple layers of 4 x 4 s abdominal pads, secure with medipore (cloth) tape, change the dressing every other day and as needed for wound discharge. Every 12 hours as needed for wound treatment related to pressure ulcer of unspecified buttock, unspecified stage 1/9/2025 Clean the left hip and right ischial ulcer with n/s, tap dry, apply granular foam into the ulcer, cover with a drape, connect to wound vac with 125 mm mercury pressure, change every Monday, Wednesday, Friday. and as needed. In the morning every Monday, Wednesday, Friday for wound treatment 1/9/2025 Record review of Resident #67's MAR, for the month of February 2025 (02/01/25 - 02/14/25) revealed Resident #67 was provided care to clean the left hip and right ischial ulcer with normal saline, tap dry, apply granular foam into the ulcer, cover with drape, connect to wound vac with 125MM mercury pressure, change every Monday, Wednesday, Friday, and as needed. In the morning every Monday, Wednesday, Friday for wound treatment on day 02/03/25, 02/05/25, 02/07/25 and did not indicate care was provided on 02/09/25, and care was not provided on 02/10/25. Record review of Resident #67's Wound Evaluation and Management Summary dated 02/12/25 reflected: Chief Complaint - Patient has wounds on his right hip; left hip; left ischium. Focused Wound Exam (Site 1) Stage 4 Pressure Wound of the Left Ischium Full Thickness Etiology (quality) . Pressure MDS 3.0 Stage . 4 Duration . Greater than 395 days Objective . Healing/Maintain Healing Wound Size (LxWxD): . 2 x 1.5 x 1.5 cm Surface Area . 3.00 cm Undermining . 4.2 cm at 3 o'clock Exudate . Moderate Serous Granulation tissue . 100 % Wound progress . Improved evidenced by decrease in depth Focused Wound Exam (Site 2) Stage 4 Pressure Wound of the Left Ischium Full Thickness Etiology (quality) . Pressure MDS 3.0 Stage . 4 Duration . Greater than 345 days Objective . Healing/Maintain Healing Wound Size (LxWxD): . 4.5x 5 x 0.6 cm Surface Area . 22.50 cm Undermining . 3 cm at 9 o'clock Exudate . Moderate Serous Granulation tissue . 100 % Wound progress . Not at Goal Dressing Treatment Plan - Negative pressure wound therapy apply three times per week for 10 days; NPWT , Coarse (green) foam, 120 mmHg suction, continuous mode, change 3 x week and PRN; Irrigate and cleanse wound with 1/4 % Dakin's with wound vac dressing changes apply three times per week for 10 days Focused Wound Exam (Site 3) Stage 4 Pressure Wound of the Left Ischium Full Thickness Etiology (quality) . Pressure MDS 3.0 Stage . 4 Duration . Greater than 365 days Objective . Healing/Maintain Healing Wound Size (LxWxD): . 6 x 5 x 1 cm Surface Area . 30.00 cm Undermining . 2 cm at 6 o'clock Exudate . Moderate Serous Granulation tissue . 30 % Wound progress . Improved evidenced by decrease in depth Dressing Treatment Plan - Negative pressure wound therapy apply three times per week for 10 days; Continuous suction at 120 mmHg. Bridge dressing onto left anterior thigh; irrigate and cleanse wound with 1/4 % Dakin's with wound vac dressing changes apply three times per week for 10 days Record review of Resident #67's progress notes dated 2/9/25 at 1:48 PM written by RN C revealed patient had come to nursing desk and stated he did not feel well, and that wound vac was not working right on left hip. Lips were pale, sclera pale. Went to patient room and discussed going to hospital. Discussed with patient removal of wound vac dressing and placement of wet to dry dressing. Patient refused wet to dry and said he was going to wait until he spoke with his wife and stated that he would let this writer know of his decision. Record review of Resident #67's progress notes dated 02/9/25 at 1:55 PM written by RN C revealed This writer had gone to patient room to ask what his decision was. He stated that he wanted left hip wound dressing to be changed. He was informed that dressing would be changed as soon as possible. patient verbalized understanding Record review of Resident #67's progress notes dated 2/9/25 at 7:58 PM written by RN C revealed wound vac dressing change had been done to left hip. patient then informed this writer that his right hip dressing needed to be changed. informed supplies would need to be gathered. Wife present at bedside and offered to change dressing. Wife changed dressing to demonstrate how was taught to change dressing. Pt tolerated well. Record review of Resident #67's progress notes dated 2/10/25 at 12:19 AM written by RN C revealed Patient tolerated MN medications, pt alert, able to answer questions writer asked. Pt held water, accepted snack at this time. Fluids at bedside Gatorade and ice water. Wound vac on, dressing intact upon observation. Pt declined any needs that need to be addressed at this time. Care ongoing. Interview on 02/11/25 11:37 AM with Resident #67 revealed the resident in bed, Resident #67 asked if he could include his Family Member and made a phone call. Resident #67 and Family Member stated there has been a lot of issues in regard to his wound care. Resident #67 stated he and his Family Member had been speaking with the Administrator and the DON to have consistent and timely wound care. According to the Family Member and Resident #67, nursing staff to include the LVN M were rude and lacked customer service and bedside manner, staff would not want to complete his wound care. Resident #67 stated when the LVN M was not available or had a day off wound care could not be completed because other nurses, they lack the proper training to assist him with administering the wound vacuum. Resident #67 stated he has a wound on each hip and one right below his right butt check. Resident #67 stated upon speaking with the Administrator, wound care and placement of the wound vacuum should be completed early in the mornings at the start of shift. Resident #67 stated on last Sunday (02/09/25) he alerted RN C about 7:30 - 7:45 AM that he did not feel well, and needed to have his wounds cleaned and vacuum replaced because the wounds were leaking all over his bed and wheelchair. Resident #67 stated RN C did not return to assess, clean, and connect the wound vacuum until 5:30 PM just prior to the end of her shift, at that time it was discovered RN C did not have enough supplies to complete care which resulted in a prolonged wait to get care. According to Resident #67 the vacuum machine was malfunctioning early in the morning hours, it was off and not working, the bandages were coming off allowing the wound to drain and leak all day which was disgusting. Observation on 02/12/25 at 10:55 AM of Resident #67's wound care for Resident #67 with LVN M she explained the procedure was to wash her hands and put all the supplies together then donn PPE. Resident #67 was positioned, and the wound vacuum was disconnected. She removed the old dressings on the left hip and ischium. The wound looks clean no signs of swelling, redness, or bleeding was observed. She cleansed the area with gauze soaked with solution inside out with each swipe. She patted dry. The wound doctor measured the wound. She cleansed again and patted dry. She sprayed the edges with skin prep and waited to dry. She applied xeroform on an open area on the hip. She then applied the film to cover the hip. She cut the film to the size of the wound and applied the black foam. She doffed and washed hands and repeated the same procedure for the ischium. She doffed gloves and washed her hands. She applied the film to cover both areas and a bridge sponge was applied. She applied the tubing and then covered with film, and she anchored the tubing not to touch the body. She washed hands and donned gloves. She removed the old dressing on the right hip. The wound was observed, no swelling, no odor, and no bleeding was observed or redness. The same procedure was applied to the right hip. LVN M then connected both tubes from both hips and connected to a new canister and put it on. The pressure was at 125 mm mercury pressure. The wound vac was left working properly. Observation and interview on 02/12/25 at 11:39 AM with the Wound Care Doctor revealed him stating both wounds are measuring about the same maybe a bit smaller in diameter (left ischium 2x1.5x1.5 cm, left hip 4.5x5x.06 cm, and right hip 6x5x1 cm). According to the Wound Care Doctor, he was not notified about the wound vacuum malfunctioning on 02/09/25. He further stated, Resident #67 left the facility a lot and that may have to do with the reason for the vacuum disconnecting, and I don't think they have staff over the weekend that is able to address that issue. The Wound Care Doctor stated therefore it has to be addressed on the following business day and Resident #67 would usually inform me when I come on Wednesday. The Wound Care Doctor stated he would like the wound to be cared for in a timely manner, and there should be staff trained to address the issue. The Wound Care Doctor stated not caring for the wound or replacing the dressing could place Resident #67 at risk of infection and needing to be sent to the hospital for sepsis. He further stated, I have no concerns with his care and the wound treatments . Interview on 02/12/25 at 1:15 PM with the LVN M revealed she had been working with Resident #67 on wound care. She stated she was notified on 02/09/25 by RN C there were no supplies to complete wound care for Resident #67. LVN M stated she came to the facility to replenish supplies and left some in Resident #67's room. LVN M stated supplies were normally kept on the wound cart and the medication room located behind the nursing station. She stated that she could be contacted, if needed, to gather supplies out of her office if needed. LVN M stated when she arrived at the facility RN C asked her to provide care to Resident #67's wound, she said she responded No, today is my off day and she left the facility. According to the LVN M, Central Supply was responsible to keep supplies stocked, not doing so could place the residents at risk of not receiving timely care as needed. Interview on 02/12/25 at 5:38 PM with RN C revealed she worked with Resident #67 on 02/09/25. She stated Resident #67 came to the nursing station around 7:30 - 7:45 AM. He stated, I'm not feeling good, I had been laying in this, I am leaking all over my bed, myself, and now my wheelchair. RN C stated Resident #67 looked pale, he looked sick (lips were pale, sclera pale). The wound looked like it was leaking, and it needed to be changed. RN C stated she then told Resident #67 to contact Family Member and discuss being sent out to the hospital because she did not want to complete the care with the new canister if he was going out. She stated, I needed to know which supplies to use, if he was going to the hospital, I would need to use wet to day supplies. RN C stated she was waiting on Resident #67 to come back to her with a response from Family Member, on what they had decided about going to the hospital. RN C stated when she got around to checking on Resident #67 it was after 5:00 PM, she stated I completed care on the right hip, and I did not know if you did one side you needed to do the other side as well, there was not enough supplies to complete the left side. I reached out to the DON, and she gave me the LVN M's number to contact her, she then came to the facility to bring me supplies, this was around 6:00 PM. RN C stated, I had other things going on and could not prioritize him, I did not intently neglect him. RN C stated she was responsible for ensuring wound care for Resident #67 was completed in a timely manner, not doing so placed him at risk of him being in sepsis and making wounds worst with no suction. RN C stated the Family Member entered Resident #67's room upset about him not receiving timely care and completed the wound care with RN C observing. According to RN C she received a video in-service on 02/10/25 and she was also expected to do one on one training with the LVN M on how to use wound vacuum. According to RN C she was trained on wound vacuum in prior positions however, not the way it was requested by Resident #67 and Family Member. Interview on 02/13/25 at 12:28 PM with the DON revealed she received a call from RN C around 5:30 PM indicating there was no supplies available to complete wound care for Resident #67, that she thought the wound vacuum was messed up, According to the DON she instructed RN C to look at the vacuum and contact the LVN M for supplies. The DON stated she also called the LVN M to bring supplies and was on the phone with the LVN M when she entered the facility to deliver supplies. According to the DON only a limited number of supplies are put out on the wound cart or in the medication room, when additional supplies are needed, the LVN M was contacted so she can tell us where to get more or she will come to the facility to get them from her office. The DON stated she got confirmation from RN C that the vacuum was changed and working properly. According to the DON she was in communication with RN C throughout the day and she never reported Resident #67 was not feeling or did not look well. The DON stated she heard from Family Member that Resident #67 requested earlier in the day to have his wounds changed and machine inspected. The DON stated she would have expected RN C to address Resident #67's concerns with his wounds and wound care in a timely manner, not wait the entire shift to complete care. The DON stated she sent a you tube video to RN C on Monday and had been having all nursing staff to shadow one on one wound care with the LVN M that started weeks ago. The DON stated she started this process, so nurses were comfortable changing the wound vacuum and the supplies, and what to do when wound vacuums are beeping. The DON stated RN was responsible for addressing Resident #67's needs for his wounds, and reporting when residents have a change in condition to the physician, DON, and the Administrator. The DON further stated, not completing care in a timely manner placed Resident #67 at risk of sepsis, wound breakdown, hospitalization , and septic shock and because of that we took disciplinary action. Interview on 02/13/25 at 4:27 PM with the Administrator revealed he received a call from the Family Member on 02/09/25 that RN C was refusing to replace the wound vacuum for Resident #67, that she was trying to send him out to the hospital instead. According to the Administrator the Family Member reported she saw supplies in the room. The Administrator stated, I don't know if the nurse knew what she was doing and that he expected the nursing staff to address any wound changes or resident needs in a timely manner. According to the Administrator the DON and ADONs were responsible for ensuring the nurses were trained to complete wound care. The Administrator stated it was reported back to him the dressings and wound care was completed that day. The Administrator stated he expected nurses to ensure they are following doctor orders, not doing so placed Resident #67 at risk of infections and having to be sent out to the hospital for not addressing his need for wound care. The Administrator stated he did not have the full story of events and he did not investigate the incident; he did not feel he needed to because the wound care was completed . The Administrator stated that he expected Resident #67's wound care to have been completed in the mornings at the beginning of the 6:00 AM shift. The Administrator stated not providing wound care, when the wound is leaking and Resident #67 stated he did not feel well, and not checking on Resident #67 for the entire shift would be a form of neglect. Interview on 02/14/25 at 1:16 PM with the Physician revealed he was not made aware that Resident #67 had a change in condition, the Physician stated he expected to be notified by the facility if there was change in condition with residents. The Physician stated if the wound vacuum machine was beeping that indicated the wound vacuum needed to be checked. The Physician stated at that time the wound should be assessed with the possibility of the dressings to be changed . According the Physician waiting 10 hours could place the resident at risk of several things and the need to be sent to the hospital Record review of facility policy revised 10/05/16 titled Skin Integrity Management reflected: Wound care should be performed as ordered by the physician. Skin should be cleansed at the time of soiling and the routine intervals. The frequency of skin cleansing should be individualized according to need/and or resident preference. Minimize skin exposure to moisture due to incontinence, perspiration, or wound drainage. Record review of facility policy dated 2015 titled Physician Orders reflected to monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and activities of daily living order for each resident. Record review of facility policy revised 03/11/23 titled Notifying the Physician of Change in Status reflected The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptom of signification change, time/date of call to physician, and intervention s that were implemented in the resident's clinical record. This was determined to be an Immediate Jeopardy (IJ) on 02/13/25 at 5:25 PM. The Administration was notified. The Administrator was provided the IJ template on 02/13/25 at 5:26 PM and a plan of removal was requested. The following plan of removal submitted by the facility was accepted on 02/14/25 at 1:40 PM and included the following: Plan of Removal Problem: F686 Failure to Prevent Pressure Ulcers Interventions: As of 2/13/25 resident #1 had a complete head to assessment performed by the Treatment Nurse As of 2/13/25 the wound MD was notified. The wound MD assessed and measured all of resident #1 wounds. No additional orders were received. All residents in the facility will receive a head-to-toe skin assessment. Wound treatments including wound vacs will be verified as completed according to MD orders by the Regional Compliance Nurse, DON, ADON. Completion date 2/13/25. Treatment nurse was educated on checking daily, Monday-Friday, to ensure that all wound care supplies is readily available. Completion date 2/14/25. All nurses were educated on the location of wound care supplies. If not available, they need to notify the DON and Administrator immediately. Completion date 2/14/25. The DON and ADON were in-serviced 1:1 on following topics by the Regional Compliance Nurse. Completed 2/13/25. Dressing Change Procedure- procedure to include wound vac dressings. Abuse and Neglect: failure to complete a dressing change according to MD orders including wound vacs could be considered abuse and neglect. Notification of Change in Condition: including notifying a MD for a change in a resident's condition. Resident Rights: to respect a resident's right to request care including dressing changes. The medical director was notified of the immediate jeopardy on 2/13/25. An ADHOC QAPI meeting was completed on 2/13/25 with IDT team including the Medical Director to discuss the immediate jeopardy and plan of removal. In-services: All nursing staff will be in-serviced on 2/13/25 regarding the following topics below by the and ADO, Regional Compliance Nurse, Administrator, DON, and ADON. All staff not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-service on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment. Completion date 2/14/25. Dressing Change Procedure- procedure to include wound vac dressings. Dressing Supplies- all supplies needed for treatment services are in the medication room. Notify the DON and Administrator if not available. Abuse and Neglect: failure to complete a dressing change according to MD orders including wound vacs could be considered abuse and neglect. Notification of Change in Condition: including notifying a MD for a change in a resident's condition. Resident Rights: to respect a resident's right to request care including dressing changes. Monitoring of POR: Inservice Training Topic: Dressing Change Procedure - Procedure to include wound vac dressings. Abuse and Neglect: Failure to complete a dressing change according to MD order including wound vacs could be considered abuse and neglect. Notification of Change in Condition: including notifying MD for a change in a resident's condition. Resident Rights: to respect a resident's right to request care including dressing changes. Date and Time Conducted: 2/13/24. Instructor: Regional DON Attendees: Administrator, ADON A, ADON B, DON Inservice Training Topic: Wound Care Supplies Being Readily Available The wound nurse will ensure that all necessary wound care supplies are readily accessible for nursing staff. If staff encounter any difficulties in finding the supplies, she will guide them on where to locate the required items. From Monday to Friday, the wound nurse will verify that supplies are adequately stocked in the medication room, and on Fridays, she will also confirm that the supplies are prepared for the weekend. Date Conducted: 02/13/25. Instructor: Regional DON Attendees: LVN M Inservice Training Topic: Notification of Changes - see attached policy regarding notification of changes. Date Conducted: 02/13/25. Instructor: Regional DON Attendees to include MA P, MA EE, CNA F, CNA K, CNA N, CNA Q, CNA V, CNA X, CNA BB, RN D, RN GG, LVN H, LVN M, ADON A, CNA HH, CNA II, CNA JJ, CNA KK, CNA LL, CNA DD Inservice Training Topic: Abuse and Neglect Resident Rights Date Conducted: 02/13/25. Instructor: DON Attendees to include: ADON B, LVN H, CNA X, LVN BB, MA CC, MA EE, RN GG, CNA F, CNA JJ, CNA HH, RN D, MA P, CNA K, CNA Q, Med Rec, LVN M, CNA LL Inservice Training Topic: Wound Dressing Care and Changes Date Conducted: 02/13/25. Instructor: Regional DON Attendees to include: ADON B, LVN H, LVN BB, MA CC, CNA LL, MA EE, RN GG, RN D, CNA N, CNA Q, CNA T, LVN M, ADON B, CNA AA, CNA DD Inservice Training Topic: A resident request a change to the wound vac, immediately address the resident, do NOT delay treatment. Call the DON and Wound Care Nurse if there are any issues in applying the wound vac. Monitor the wound vac for changes to suction, taping, leakage, tubing kinked and any other concerns. Operating Manual Revision Date: 2024-08-16 titled extriCARE 3000 Negative Pressure Wound Therapy System Date Conducted: 02/13/25. Instructor: DON Attendees to include: LVN I, LVN BB, ADON B, ADON A, LVN H, MA CC, MA EE, RN D, RN GG, CNA Q, CNA T Interviews conducted with the above staff indicated they had understanding to identify when a resident has a change of condition, signs of abuse/neglect, the need to honor resident rights. Nursing staff was able to reveal where wound care supplies were kept; how and who to notify to restock if items were low, and Nurses stated they understood how to complete wound care on residents with wound vacuums. The Administrator was informed the Immediate Jeopardy was removed on 02/14/2025 at 7:10 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents. CNA A failed to get assistance from another staff member when providing Resident #1, who required two staff for assistance with all ADLs, a bed bath on 12/05/24. During the bed bath, CNA A asked Resident #1 to turn to her side. When the resident turned she fell to the floor, which resulted in the resident sustaining a fracture of her right femur (thigh bone). The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 12/05/24 and ended on 12/05/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life. Findings included: Record review of Resident #1's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), seizure disorder, cellulitis of right lower limb (bacterial infection that affects the skin and underlying tissue), fibromyalgia (chronic condition that causes widespread pain and tenderness in the body), and muscle wasting. The resident had a BIMS score of 9 which indicated her cognition was moderately impaired. The MDS further reflected Resident #1 was dependent for shower/bathing which indicated the helper did all the effort or the assistance of two or more helpers was required for the resident to complete the activity. Record review of Resident #1's care plan revised on 12/16/24 reflected the resident had an ADL self-care performance deficit. Interventions included the resident required the assistance of two staff for bathing and bed mobility. Record review of Resident #1's bathing status in the Kardex system (documentation system used by reference key resident information for their nursing care plan) printed on 01/13/25 reflected the resident required the assistance of two staff members. Record review of the facility's Provider Investigation Report dated 12/05/24 reflected the following: The resident experienced a fall while in bed during care by the CNA [CNA A]. The CNA [CNA A] notified the nurse and had discovered the resident on the floor, resting against the bed. The resident has skin tears on both great toes, the let wrist, and beneath the right breast The resident reports generalized pain, with a particular emphasis on greater discomfort in her legs compared to other areas. When inquired about the incident, the resident explained 'I threw my foot over too far and fell .' The resident was transferred to the hospital due to experiencing pain the X-ray indicated a fracture in the left femur (left femur was facility documentation error; fracture was on the right leg). The resident subsequently underwent surgery to address the fracture Record review of Resident #1's hospital records dated 12/05/24 reflected the resident was diagnosed with a comminuted distal femoral fracture (a broken bone that has been shattered into multiple pieces and are usually caused by severe trauma) of the right leg. Observation and interview on 01/08/25 at 10:26 PM revealed Resident #1 in bed watching television. The resident was alert and oriented and able to recall the incident when she fell during care. The resident said CNA A was giving her a bed bath, and the aide asked her to turn to her side. The resident said she was turning over onto her side as she was holding on the repositioning bar and fell on the floor. She said CNA A was usually able to catch her when she rolled over, but this time she was not able to. Resident #1 said she was sent to the hospital and had surgery on her leg, as she pointed to her right leg. Resident #1 stated CNA A usually bathed her alone and never had a helper. The resident stated she preferred two people because she felt safer. Resident #1 said she was not experiencing much pain from her fracture but had discomfort due to the cellulitis in her legs. Interview on 01/08/25 at 1:05 PM with CNA A revealed she was giving Resident #1 a bed bath and asked the resident to turn to her side. She stated the resident grabbed the repositioning bar on the bed, threw her leg over her left leg and that was when the resident fell over on to the floor. CNA A stated she then called for the nurse to assist, and the resident was assessed. CNA A stated Resident #1 was on an air mattress, and it was inflating at the time the resident was turning to her side. CNA A said she was aware Resident #1 required two staff for care, but she was not able to find someone to help her. CNA A said she asked another CNA, whose name she could recall, for help. She stated she did not get any help, so she bathed the resident alone. She stated she had bathed the resident alone in the past. The CNA said she felt safe bathing the resident alone because the resident was able to help turn in bed. Interview on 01/13/25 at 1:23 PM with LVN B revealed she was called by CNA A to Resident #1's room and noticed the resident was on the floor. CNA A told her the resident was trying to turn in bed during a bed bath, and the resident fell . LVN B said during Resident #1's assessment, the resident was complaining of pain and noticed the resident's toes were bleeding and other areas of her body such as her side, so she was transferred to the hospital via EMS. LVN B stated Resident #1 required two staff member for care because she was a bariatric resident and for safety. The LVN said she did not know CNA A was caring for Resident #1 alone, and she did not recall the aide asking anyone for help during the bed bath. LVN B further stated the aides could look in the Kardex system to verify if a resident required one or two staff members during care or ask a charge nurse. Interview on 01/08/25 at 1:28 PM with CNA D revealed she had worked at the facility for about a year and cared for Resident #1. CNA D said Resident #1 was bed bound per choice and required two staff members for assistance for all care because the resident was bariatric and could not be care for by one staff member. Interview on 01/08/25 at 2:07 PM with CNA E revealed she worked with Resident #1 and the resident was bed bound. CNA E said the resident required two staff members for all care including bed baths because she was bariatric and needed more support. CNA E further stated Resident #1 had never been a one-person care resident. Interview on 01/08/25 at 2:39 PM with RN F revealed Resident #1 was bed bound and required two staff members for all care including bed baths because the resident was bariatric and one staff member could not adequately care or clean the resident up during ADL care. Interview on 01/08/25 at 2:29 PM the ADON revealed Resident #1 was bed bound and rarely got out of bed. She said the resident was a two-person assist for all care at all times because she was on an air mattress and could easily roll out of bed and for overall safety. The ADON was made aware CNA A had bathed Resident #1 alone, but the aide was not able to explain why she had not requested for help but only stated she had not seen anyone else. The ADON stated it appeared to her that CNA A had not looked for anyone to help her with the resident. The ADON further stated they immediately began to re-in-service (training) for all nursing staff re-educating them on the importance of using two staff member if the resident required it. They also identified all the residents that required two staff members for care they were monitoring and making observations to ensure two staff were assisting when needed. The monitoring began after the incident with Resident #1 and would be on-going for six weeks to ensure safety. Interview on 01/13/25 at 8:36 AM with the DON revealed she was told Resident #1 was getting a bed bath by CNA A and while the resident was turning to her left side with the assistance of the repositioning rail, Resident threw her leg over too far and continued to roll until she fell out of the bed. Resident #1 was assessed, and they noticed she had bruising to the top of her feet and was complaining of pain throughout her body but mostly to her right knee. The resident was transferred to the hospital where she was diagnosed with a right leg fracture. The DON said Resident #1 required two staff members for care due to being a bariatric resident and for safety. The DON stated CNA A admitted knowing Resident #1 required two staff members for care, but the aide told them she had not been able to find assistance but if she would asked her (DON) she would have assisted. The DON also said if aides did not know if a resident was a one or two person for care, they could look in their Kardex computer system. After the incident, CNA A was suspended pending their investigation and had a 1:1 counseling and re-in-service (training) on resident care and the aide was pulled from working with Resident #1. The other nursing staff were re-educated on using the Kardex computer system to ensure a resident required a one- or two-person assistance during care. The DON further stated they had identified all the residents that required two people and were going to monitor but watching care for those resident for 6 weeks. Record review of the facility's Safe Patient Handling policy revised December 2005 reflected the following: The facility has a program to promote and assure safe patient handling for both the resident and the employee. The policy includes identification, assessment and interventions to provide a comfortable, safer transfer, repositioning and resident movement. .3. Nurses will be educated in the identification, assessment and control of risks of injury to resident and nurses during patient handling .5. Nurses will be educated regarding correct safe handling procedures, to report concerns or the inability to perform resident handling or movement that the nurse believes in good faith will expose a resident or nurse to an unacceptable risk of injury Record review of 1:1 in-service with CNA A dated 12/05/24 revealed she had been re-educated on using the Kardex system to communicate the resident's needs and information to all the CNA's to ensure appropriate resident care. CNA was also re-educated on fall prevention strategies and safe patient handling and abuse and neglect policy. Record review of in-services dated 12/05/24 with all direct nursing reflected the staff had been re-educated using the Kardex system to communicate the resident's needs and information to all the CNAs to ensure appropriate resident care. CNAs were also re-educated on fall prevention strategies and safe patient handling and abuse and neglect policy. Interview on 01/08/25 at 1:05 PM with CNA A revealed she had been re-in-serviced 1:1 on abuse and neglect, ensure to always use two staff members during care for residents that required it and using the Kardex system to check the care of the residents if they were unsure. Interviews on 01/08/25 from 11:12 AM to 5:14 PM and on 01/13/25 from 10:01 AM to 1:23 PM with nursing staff from various shifts to include LVN B, CNA C, CNA D, CNA E, RN F, LVN G, CNA H, CNA I, CNA J, and CNA K all revealed they have been in-serviced on abuse/neglect, using the Kardex system to verify if a resident required one or two staff members for care, and fall prevention to avoid accidents. Record review of the direct care monitoring sheets reflected it included to watch at least 10 episodes of incontinent care or assist with bed mobility weekly to ensure staff was performing correctly and the care-planned number of staff were assisting. The monitoring dates reviewed began 12/05/24 and would continue for 6 weeks, and end on 01/15/25. Observation on 01/08/25 at 11:07 AM revealed Resident #2 was transferred from the bed to the chair via mechanical lift by two staff members. Observation on 01/13/25 at 3:32 PM revealed Resident #3 was transferred to bed via mechanical lift by two staff members.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents. Staff failed to ensure Resident #1 did not receive a burn blister to her left wrist on 08/09/24 when she was drinking coffee from the dining room and spilled it on herself. The noncompliance was identified as PNC. The noncompliance began on 08/09/24 and ended on 08/09/24. The facility had corrected the noncompliance before the survey began. This deficient practice could affect residents at the facility who drank hot liquids that could cause burns from the facility's kitchen. Findings included: Review of Resident #1's admission record, dated 08/21/24, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Review of Resident #1's Admission MDS Assessment, dated 07/06/24, reflected she had a BIMS score of 07, indicating severe cognitive impairment. Further review indicated Resident #1 required supervision or touching assistance in regard to eating which was the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal was placed before the resident. Resident #1 had active diagnoses of cerebrovascular accident (stroke), transient ischemic attack (a brief episode of neurological dysfunction resulting from an interruption in the blood supply to the brain), and non-Alzheimer's dementia (a form of dementia). Review of the facility's Provider Investigation Report, dated 08/16/24, reflected under the section for Provider Response reflected: .Resident was provided a lid when drinking hot liquids in a cup/mug/glass. Facility staff inserviced on abuse and neglect, hot liquids, food spills, resident rights, and cooling coffee. 100% audit of residents to identify if any other residents had the potential for burns and to validate interventions were in place as indicated. Further review revealed under the section Investigation Summary reflected: Upon my investigation the resident states she had gone into the dinning area after breakfast serve out to get another cup of coffee and as she was pouring coffee into a cup she lost grip of the cup due to the gloves she wears to prevent scratching her skin. When she had spilled the coffee she did not think much about it at the time as she was wearing a long sleeve sweater. She did not notify anyone when it happened as she stated she felt fine when it happened and felt no pain. Due to the long sleeved sweater she was wearing she didn't notice anything until she started to itch and rolled up her sleeve and notice she had a blisters on her left wrist. She then notified the nurse around 2:30 pm if she could get something for her wrist. That is when the nurse asked what happened. The physician was notified and orders were given on how to proceed to treat her wrist. Safe surveys conducted with no negative findings. Temperature logs were reviewed with no deviations in findings. Coffee was temped to validate accuracy of temperature logs [sic]. Further review under the section Facility Investigation Findings reflected: Confirmed. Review of Resident #1's physician's orders reflected the following: Triple Antibiotic Plus External Ointment 1 % (Neomycin-Bacitracin-Polymyxin-Pramoxine) Apply to left forearm topically one time a day for burn/blister for 14 days with a start date of 08/10/24 and end date of 08/24/24. Review of Resident #1's August 2024 MAR/TAR reflected the following: Triple Antibiotic External Ointment (Neomycin-Bacitracin-Polymyxin) Apply to left foream arm topically one time only for burn for 1 Day apply to the left forearm x 1 [sic] and indicated she received the treatment on 08/10/24 and Triple Antibiotic Plus External Ointment 1 % (Neomycin-Bacitracin-Polymyxin-Pramoxine) Apply to left forearm topically one time a day for burn/blister for 14 days and indicated she received treatment each day from 08/10/24 to 08/21/24. Review of Resident #1's care plan, updated 08/09/24, reflected the following: Focus: Risk of burns due to hot liquids .Goal: Resident will not suffer any injury related to hot liquids .Interventions: Coffee and other hot liquids should not be served if over 140 degrees [Fahrenheit]. If hot liquid is spilled on self, staff should pour room temperature or lower temp liquid on the affected area of the resident. Resident to use the dominant hand for drinking. Should be seated in upright position with table or overbed table when hot liquids are being consumed. Review of Resident #1's Event Nurses' Note- Burn, dated 08/09/24, reflected the following: .10. Burn/Blister, 1. Location of Event Occurred .4) Dining Room, a. Check all that apply: 1. Caused by coffee, tea, or other hot liquid, b. Part of body burned: left forearm, c. Details of injury: type of injury, dimensions, appearance, etc.: 5.5 cm x 3.2 cm blister .e. Nursing description of the event: Resident approached nurse to present burn to arm. Resident states she spilled coffee over her hand this morning at breakfast. When asked why resident didn't notify nursing staff she responded that she didn't know it was going to blister. Contacted MD [MD A] received n/o for triple abt ointment for 14 days. Wrap lightly with gauze wrap. Resident reports having no pain associated with burn. Completed by LVN B. Review of Resident #1's Hot Liquids Assessment, dated 08/09/24, reflected the following: 1. Check all conditions that apply to this resident. 1. Moderate to Severe Cognition Impairment. 2. Frequent impulsive acts or short tempered 8. Other condition or reason that puts the resident at risk for potential spills (specify below) .1a. Specify other condition or reason (blank) .2. Resident can consume hot liquids/food without special interventions? 2. No .A. Interventions to decrease potential burns with coffee or other hot liquid. Check all that apply .6. Should be seated in upright position with table or overbed table . This was the only Hot Liquids Assessment noted in Resident #1's electronic health record. Review of Resident #1's progress notes reflected the following on 08/09/24 written by the DON: Administrator and DON notified of burn to resident wrist. Resident was in her room when Administrator and DON arrived. Resident asked about how the burn happened. Resident stated that she was getting another cup of coffee after breakfast had finished and she lost her grip on her cup, due to her gloves she wears, and her coffee spilled on her and the floor. Resident asked why she didn't tell anyone she spilled coffee on herself and she replied that she did not because she did not think it was bad. Resident said she saw it was blistering and decided to tell someone. Resident stated no pain to burn site. Resident stated she feels safe within the facility. Nurse applied TAO, non-adherent pad, and gauze wrap. MD notified with new orders for TAO and gauze for 14 days. Family notified. Resident left sitting comfortably in her wheelchair in her room [sic]. Observation and interview on 08/21/24 at 9:45 AM with Resident #1 revealed she was sitting in her wheelchair in her room watching television. Resident #1 had a bandage to her left forearm near her wrist area. Resident #1 said she went to the dining room one morning to get coffee like normal and spilled it on herself and that caused a blister. Resident #1 said the blister opened up, but staff had been treating it and bandaging it up. Resident #1 said it hurt sometimes but was getting better, and she was now more careful with the coffee. Resident #1 said she had not burned herself with the coffee since and had not noticed it being too hot for her. Interview via telephone on 08/21/24 at 10:28 AM with Resident #1's Responsible Party revealed he lived out of state, but the facility had called him about Resident #1 getting burned by coffee. Resident #1's Responsible Party said he was upset because he was not sure why the facility would serve coffee to a resident that was too hot to cause a burn. He said he wanted to make sure the facility was not going to do that again. Interview on 08/21/24 at 11:20 AM with the Dietary Manager revealed she was prepping the coffee to be served during the lunch meal service. She stated everyone working in the kitchen prepped the coffee for the breakfast and lunch meal services and also kept coffee out in the dining room during the day. She said the temperature the coffee should be served at was between 135-140 degrees Fahrenheit. Interview on 08/21/24 at 11:25 AM with Dietary Aide C revealed she made coffee for the residents' meals and knew not to serve the coffee if it was over 140 degrees Fahrenheit. She said she used ice to cool the coffee down to the right temperature before being served. She said she also logged the served temperature on the coffee temperature log. Interview on 08/21/24 at 11:27 AM with Dietary Aide D revealed she made coffee for the residents' meals and knew not to serve the coffee if it was over 140 degrees Fahrenheit. She said she used ice to cool the coffee down to the right temperature before being served. She said she also logged the served temperature on the coffee temperature log. Interview on 08/21/24 at 11:29 AM with [NAME] E revealed she made coffee for the residents' meals and knew not to serve the coffee if it was over 140 degrees Fahrenheit. [NAME] E said she used ice to cool the coffee down to the right temperature before being served. [NAME] E said she also logged the served temperature on the coffee temperature log. Interview on 08/21/24 at 11:31 with Dietary Aide F revealed he made coffee for the residents' meals and knew to not serve it if it was over 140 degrees Fahrenheit. He said he used ice to cool the coffee down to the right temperature before being served. He said he also logged the served temperature on the coffee temperature log. Observation on 08/21/24 at 11:33 AM revealed the Dietary Manager prepping coffee after it was done brewing. She poured coffee into a cup and took the temperature of the coffee which read at 170 degrees Fahrenheit. The Dietary Manager then began adding ice to the coffee container and after a few seconds poured an additional cup of coffee. She took the temperature of the coffee which now read at 139 degrees Fahrenheit. Next to the coffee maker was the facility's policy and procedures for serving hot liquids to residents and what to do to lower the temperature of the coffee if it was not at the right temperature of 140 degrees Fahrenheit or less. Follow-up interview on 08/21/24 at 11:34 AM with the Dietary Manager revealed she typically put out porcelain and plastic cups for residents to use to pour their coffee in. She said residents served themselves their own coffee because they liked to be independent. She said there were staff in the dining room to assist a resident in getting coffee if they wanted or needed the help. The Dietary Manager said the facility initiated checking the temperature of the coffee before being served a few months ago because a resident in another facility was burned by hot coffee. She said everyone was in-serviced at that time to ensure they did not serve coffee that was over 140 degrees Fahrenheit. She said she also put up the policies and procedures on how to make the coffee and what temperature it should be served at next the coffee maker, so staff would not forget. Review of the facility's coffee temperature logs for August 2024 reflected staff were logging temperatures between 135 and 140-degrees Fahrenheit for each day and coffee pot served; including the coffee served on 08/09/24. Observation on 08/21/24 at 11:35 AM of the dining room revealed Resident #1 was sitting at a table waiting for her lunch to be served. Resident #1 had a hard re-usable plastic cup that was specifically used for coffee or other hot liquids. The cup had coffee in it in and was placed on the table in front of her. Resident #1 did not have gloves on and there was no steam coming from the cup. Resident #1 said her coffee was warm and tasted good today. Staff were noted to be in the dining room to assist during meals and also for activities. Interview via telephone on 08/21/24 at 12:51 PM with LVN B revealed residents could only get coffee from the dining room which came from the kitchen. Regarding the incident, LVN B said Resident #1 told her that she spilled coffee on herself earlier in the day, and she now had a blister. LVN B said she assessed Resident #1 and asked if she was having any pain to her wrist and Resident #1 told her she was not in pain. LVN B said she called Resident #1's doctor and got orders to treat the blister with a cream and bandage. Follow-up interview on 08/21/24 at 1:43 PM with the Dietary Manager revealed she only knew that Resident #1 came to the dining room to get her own coffee one morning. She said Resident #1 usually wore thick gloves that prevented her from being able to hold a lot of things with her hands. She said her expectation was that staff checked the temperature of the coffee before being served to residents. The Dietary Manager said she was not sure if the kitchen staff checked the temperature of the coffee before being served that day. She said the purpose of that was to make sure the coffee was not too hot and could burn a resident. The Dietary Manager said all the kitchen staff were in-serviced regarding serving hot liquids to residents after Resident #1 was burned with the hot coffee. Interview on 08/21/24 at 2:52 PM with the Administrator revealed the DON was not at the facility during the investigation. The Administrator said he was not sure how Resident #1 spilled the coffee on herself. The Administrator said Resident #1 told him she spilled the coffee on herself in the morning time and because of her gloves she was wearing the cup slipped. The Administrator said Resident #1 was not in any pain at that time and staff began to call the doctor to get orders to treat her. He said he went to the kitchen and looked at the coffee temperature log from that morning and saw that the temperatures were correct. He said he started his investigation into what happened and also took the temperature of the coffee that was already out being served to residents which was 128 degrees Fahrenheit. The Administrator said the coffee temperature log from that morning showed the coffee was served at 140 degrees Fahrenheit. He said the kitchen staff had already been trained to check the temperature of the coffee prior to being served because of an incident that happened at a different facility. The Administrator said after Resident #1 was burned the facility re-inserviced all kitchen staff on what the temperatures needed to be when being served to a resident. He said the steps and policies were also posted in the kitchen on the wall as well for staff to see in case they forgot. He said he started monitoring the coffee temperature logs after Resident #1 was burned to ensure the kitchen staff were not serving too hot coffee. He said the risk of serving a liquid that was too hot was it could burn a resident. The Administrator said coffee was only served from the kitchen and they were responsible for making the coffee, taking the temperature of the coffee, and ensuring the temperature was not higher than 140 degrees Fahrenheit before being served. Review of an in-service record, dated 08/09/24, and titled Record of Departmental In Service and Meetings reflected the following: Summary/Objectives: Brew coffee until complete take brew temp and ice to bring coffee to 140 degrees screw lid on tight if coffee is below 135 discard and repeat process [sic] signed by 10 dietary staff members. Review of an undated in-service record titled Hot Liquid/Burns reflected 44 facility staff had been in-serviced regarding the facility's hot liquid/food spills policy and procedures. Review of the facility's undated Guidelines on Serving Coffee in the Nursing Facility policy reflected the following: .2. The standard for coffee service will be 140 degrees .If coffee is served at 140 degrees, it will cool to 136 degrees when dispensed into a room-temperature coffee cup or mug, and per 'Time and Temperature Relationship to Serious Burns' from the American Burn Association website, this temperature will allow approximately 15 seconds before a serious burn will occur, based on the physical condition of the individual person. Review of the facility's Hot Liquid/Food Spills policy, dated 2003, reflected the following: Residents are at risk of having any hot liquid/food spilled on their person causing burns. Examples of hot liquids/food are: coffee, tea, hot soup, oatmeal, or any other hot food or liquid substance .1. Brew coffee in kitchen until brewing process is complete. 2. Add xxx (change the xxx to the amount of ice needed to cool the coffee at your facility)- 8 oz cups of ice to TF server, stir well until ice is dissolved. 3. Take temperature of coffee in TF server, if it is 135-140, then screw on lid tightly and take to dining room to be served. 4. If it is still over 140 degrees, stir until it reaches 140 degrees or less, or add ice, a few cubes at a time, until it reaches 140 degrees or less. Then screw on lid and take to dining room to be served

Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse and neglect for 2 of 5 residents (Resident #1 and Resident # 2) reviewed for abuse and neglect. The facility failed to prevent Resident #3 from physically abusing Resident #2, when Resident #3 punched Resident #2 in the face on 08/24/23. The facility failed to ensure Resident #1 was free from abuse and neglect by not providing adequate supervision and services, when the facility allowed Resident #3, who had a history of physically assaulting residents and staff, to continue to reside in the facility. Resident #3 assaulted Resident #1 on 12/08/23, which caused her to be hospitalized with a subdural hematoma (is a type of brain bleed that results in a tear in a blood vessel below the dura mater, a membrane layer between the brain and the skull), contusion of face (small blood vessels get torn and leak blood under the skin), neck sprain, and closed fracture of transverse process (broken bone) of lumbar vertebra (located between the rib cage and the pelvis). The noncompliance was identified as PNC. The IJ began on 12/08/23 and ended on 12/08/23. The facility had corrected the noncompliance before the survey began. This failure could place residents who were in the memory care at risk for abuse and neglect. The findings include: Resident #1 Record review of Resident #1's electronic Face Sheet dated 12/12/23 reflected Resident #1 was a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #1 had the following diagnoses: unspecified dementia; muscle wasting and atrophy ; unsteadiness on feet; age-related osteoporosis (causes bones to become weak and brittle) without fracture; and wandering in diseases. Record review of Resident #1's Comprehensive MDS assessment dated [DATE] indicated a BIMS score of 3, which indicated the resident's cognition was severely impaired. The MDS reflected Resident #1 demonstrated wandering behaviors. Record review of Resident #1's Care Plan dated 10/29/23 indicated a focus on area of a history of exit seeking, so she has been placed on the Secured Unit and the intervention included staff will monitor residents location for safety. The Care Plan indicated a focus area of Resident has delirium or an acute [confusional] episode r/t Dementia, but the Care Plan did not include any interventions. Record review of facility's document titled Event Nurse's Note 12hr , dated 12/8/23 at 5:18 AM, by the ADON, reflected Summoned to hallway, CNA voiced that resident was bleeding, this nurse has just administered medication to resident (Resident #1) at 0435 and at 0500 she asked staff for more water and voiced she was thirsty. This nurse gave resident ice water and took her to her room and encouraged her to lay down Resident stated she would and nurse left to go to administer meds to the other residents. When this nurse entered 400 hall resident immediately stated, that man attacked me! . When male resident (Resident #3) was approached noted blood on his right hand and noted blood on his walking cane . Record review of Resident #1's hospital records, dated 12/08/23, reflected Resident #1 entered theER on [DATE] at 6:42 AM. The ER summary reflected 78 y.o. (year old) female presents to the ED via EMS (ground) coming from a dementia facility for head injury onset this AM after being assaulted by another resident. Sustained facial swelling and pain and L (left) sided body pain. No LOC (level of consciousness), per NH (nursing home) staff. Pt is on Plavix. Per EMS, pt given 2 rounds of 50 mcg of Fentanyl en (in) route. Imaging in ED shows transverse process fx of L3 (fracture of lumber vertebra) and subdural hematoma. Resident #1's physical exam reflected L sided facial swelling. L periorbital ecchymosis (blood tracking along tissue, causing discoloration in the upper and lower eyelids) and edema (swelling caused by too much fluid trapped in the body's tissues). Large contusion (a region of injured tissue or skin in which blood capillaries have been ruptured) to occiput (the back of the head or skull) and Subconjunctival hemorrhage to L (when a blood vessel breaks in the white of the eye). Resident #1 was diagnosed with the following: subdural hematoma; Assault; Contusion of face; Neck sprain; and Closed fracture of transverse process of lumbar vertebra. The hospital records indicated Resident #1 was transferred to a trauma unit because she required a higher level of care. Resident #2 Record review of Resident #2's electronic Face Sheet dated 12/12/23 reflected Resident #2 was a [AGE] year-old male, who admitted to the facility on [DATE]. Resident #2 had the following diagnoses: Alzheimer's disease; dementia; muscle weakness; and repeated falls. Record review of Resident #2's Comprehensive MDS assessment dated [DATE] indicated a BIMS score of 3, which indicated the resident's cognition was severely impaired. The MDS reflected Resident #2 did not have Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others), nor Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). Record review of Resident #2's electronic record indicated there was not a Care Plan established and Resident #2 was at the facility for 5 days of respite care. Record review of the form titled Admission Nurse Note, dated 08/21/23 at 9:00 AM, reflected Resident #2 had memory problem, was organized in daily routine and made safe decisions in familiar situations, but experienced some difficulty in decision making when faced with new tasks or situations, and required one person assistance with ADLs for bed mobility, transferring, toileting, dressing/hygiene, and bathing. The document indicated Resident #2 had no behaviors that required interventions. A record review of Resident #2's Progress Notes, dated 08/24/23 at 4:39 PM, by LVN C, reflected This nurse was called into pt room by aid, I ran down the hall and immediately heard yelling and cursing. Residents' roommate (Resident #3) assaulted resident by punching him in the face per resident. Resident abuse protocol followed. Head to toe completed on resident and negative injuries noted. Informed [family member]. [Family member] informed me she will be in tonight to pick him up. Resident #3 Record review of Resident #3's electronic Face Sheet dated 12/12/23 reflected Resident #3 was a [AGE] year-old male, who admitted to the facility on [DATE]. Resident #3 had the following diagnoses: unspecified dementia with psychotic disturbance and agitation; muscle wasting and atrophy; and other specified depressive episodes. Record review of Resident #3's Quarterly MDS assessment dated [DATE] indicated a BIMS score of 5, which indicated the resident's cognition was severely impaired. The MDS reflected Resident #3 did not have Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others), nor Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). Record review of Resident #3's Care Plan dated 10/29/23 indicated a focus area that Resident #3 had potential to demonstrate physical behaviors and the goal was he would not harm self or others. The intervention included If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately; Notify the charge nurse of any physically abusive behaviors; Psych (psychiatric) eval due to increased aggression towards staff when refusing care Psych added Seroquel routine; Resident sent to [hospital] Psych for eval and treatment Roommate was moved from the room Resident placed in a room by himself upon return to the facility Medication change made ----> Depakote; and When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Record review of Resident #3's Progress Notes, dated 08/23/23 at 9:35 PM, by LVN D, reflected Resident upset because there is a roommate in his room tonight. Spanish speaking. Talking on the phone with [family member] (who was also here this evening) at this time. [Family Member] states that he says he is going to sneak out tonight because he would rather be in jail. Reassured [family member] that I will call her for behaviors tonight. Record review of Resident #3's Progress Notes, dated 08/24/23 at 4:50 PM, by LVN C, reflected Assaulted roommate by punching him in the face. Resident (aggressor) sent to [psychiatric hospital] via EMT . Pt was aggressive with staff, however when EMT arrived he went with them with no problem. Record review of Resident #3's Progress Notes, dated 11/06/23 at 5:59 PM, by the ADON, reflected This nurse was asked by CNA, to please speak with the resident because he refused his shower, when this nurse approached room CNA and nurse went in, resident was informed that CNA has picked out a beautiful pants and shirt for resident and encouraged him to please take his shower, assessed him for pain and he denied pain when this turned around resident violently struck her twice on the left arm with a closed fist and kicked her four times in the abdomen, and kicked the CNA in the face. Resident yelled out, send me back to prison, I want to go to prison, I am going to kill all of you, I am going to go to prison. [Family member] called and informed and stated, I know exactly what you are saying because I experiences the same thing, No one in the area would take him, and that is why he is at your place, because he beat me so many times at my house, [family member]said he could not come back, he is my [family member], but he is a stranger to me, I did not know he was this violent, he was in prison all my childhood and I thought it was a good thing bringing him to live with me but it was not. [MD] called and informed and orders received to send resident to the hospital for Psych to evaluate and treat. Psych, NP, [psych NP] in house and made aware of the resident's behavior and stated since he is on his way to the hospital he will assess him when he returns. [Family member] called and informed of resident's behavior. 911 called and dispatcher states police will escort EMT. Resident transport to [psychiatric hospital] for Psych to evaluate and treat. Record review of Resident #3's Progress Notes, dated 11/06/23 at 10:02 PM, by the NP, reflected Notified the primary nurse and the nursing assistant working with the patient that they were both reportedly assaulted by the patient. The primary nurse reports that she obtained an order to transfer the patient to a more acute care setting. I will reevaluate the patient upon return. Record review of Resident #3's Progress Notes, dated 12/08/23 at 9:23 AM, by the ADON, reflected Female Resident immediately stated, that man attacked me! She was looking down the hallway, when this nurse looked, a male resident, stated I did it, I will fuck you up too if you come near me! This nurse noticed blood on the male resident's right hand. Nurse assessed the female resident, and noted copious (abundant in supply or quantity) amount of fresh red blood from the back of her head and when site assessed noted a hematoma that was 5cm x 3cm, ice applied and noted bleeding stopped. Noted face to be swollen, +3 edematous her whole face was swollen as well as her nose, and noted blood on her nose. Male resident refused for staff to assess him he kept yelling out at staff, I will fuck yall up and he took his walker and rammed it into the legs of staff and attempted to hit staff. [Family member] called and informed of the incident and she stated she was on her way to get resident, informed her that the police will be called, when [family member] arrived she came in with her [family member] as well and [family member], stated he is very violent and he use to beat my [family member] also and he attacked me before. She went onto say she has encourage to leave, but he refused and she asked when will the police be here. Finally, 0649 resident agreed to leave with [family member]. Police arrived shortly after, at 0655 and resident had already left, [police officers] informed of the incident and [police officer], gave administrator the incident number. Record review of Resident #3's Progress Notes, dated 12/08/23 at 10:40 AM, by the ADON, reflected Resident stated that he attacked resident, when she wandered into his room, resident became very aggressive and agitated, he would not allow staff to come into his room and assess him and refused all staff to do one on one care, staff was able to stand outside his door while he was in his room and was able to do one on one while standing out his door . Record review of Resident #3's Progress Notes, dated 12/08/23 at 10:54 AM, by the ADON, reflected Resident's [family member] informed this nurse that she is trying to take resident out of the facility, but resident would not leave, [family member] encouraged this nurse to call the police and resident, voiced call, the police! Resident went back to bed. This nurse informed [family member], that the police has been called and at that point, resident stated he will go with his [family member]. [Family member], stated, I am just going to take him because I now, you have to protect the other residents. Resident went with his [family member], and his [family member] also accompanied them. In an interview on 12/12/23 at 10:07 AM, the ADON stated on 12/8/23 she was filling in as a nurse for 100/400 halls. The ADON stated about 4:35 AM she gave Resident #1 her meds and left to go to the 100 hall to pass meds. She stated CNA A was doing rounds because the shift change was coming up. The ADON stated CNA A notified her that something happened on the 400 hall, while she was in another resident' room changing them. The ADON stated Resident #1 was bleeding from her face and head and kept saying look what he did to me. She stated Resident #3 was standing in front of his door screaming yes I did it. The ADON stated when she approached Resident #3's door he tried to hit her with his walker and slammed his door. She stated Resident #3 was saying he would kill her and Resident #1. The ADON stated she left him in the room and called 911, the MD, both residents' families, and the Administrator. She stated she felt bad because Resident #3 had attacked her before, so she knew how strong he was and felt so bad he had attacked Resident #1 because she was very petite and frail. The ADON stated Resident #1 was not aware of what was really happening due to her dementia. She stated she was being very calm and was not crying or yelling in pain. The ADON stated the EMS arrived and was working on Resident #1. She stated Resident #3 was standing in his door entrance watching everything. The ADON stated she attempted to approach Resident #3 again to assess him and she could see he had blood on his hands and clothes, and she saw his cane in the doorway, which had blood on it too. She stated she believed he attacked her with the cane based on the blood being on his cane and Resident #1's serious injuries. The ADON stated Resident #3 was yelling to get away from my door or I will kill you. She stated Resident #3's family member came right away and picked him up. She stated the family member arrived before the police. The ADON stated Resident #3's family member told her how he had beat her up a few times when trying to help him. The ADON stated Resident #3 had attacked her and CNA B in November. She stated she believed it happened on the 6th. The ADON stated CNA B went into his room to try to give him a bath and he kicked her in the head. She stated she went to Resident #3's room and asked him if he wanted a bath. The ADON stated Resident #3 attacked her and punched her in the stomach about 3-4 times. She stated CNA B had to help get Resident #3 off her. The ADON stated she contacted Resident #3's family, the MD, and the police. She stated the police came and said there was nothing they could do, so she got an order for him to be transported to a psychiatric hospital. She stated Resident #3 was only at the hospital for a few hours and brought him back to the facility. The ADON stated the psychiatric NP had adjusted Resident #3's medication. She stated as far as she knew there were no other incidents with him being physical until 12/08/23. The ADON stated Resident #3 did have a resident-to-resident altercation sometime in September, but she did not witness the incident. In an interview on 12/12/23 at 10:48 AM, CNA B stated Resident #3 yells and curses at residents and staff. CNA B stated there was an incident in November in which she went to give him a shower and he said no. She stated they were supposed to encourage the residents to shower when they refused, so she was trying to encourage him, but he got mad and started punching and kicking at her. She stated she blocked most of it, but she did get kicked in the forehead. CNA B stated she reported the incident to the ADON. CNA B stated the ADON went to Resident #3's room to ask if he wanted a shower, and he attacked her as well. She stated Resident #3 was punching the ADON in the arm and stomach. CNA B stated she intervened and pulled the ADON away. She stated they did contact the police and he was sent out. CNA B stated she was aware of an altercation in which Resident #3 tried to hit Resident #4. She stated Resident #3 did not like people to come into his room, so he would set at the entrance to his room and yell and curse at people to get away if they approached his door. She stated Resident #4 wandered all day and approached Resident #3's doorway. She stated Resident #3 started yelling and cursing at him and then tried to hit him as he approached the doorway. CNA B stated she jumped in front of Resident #4 to block him from hitting Resident #4. She stated he missed hitting her as well. CNA B stated she moved Resident #4 away from Resident #3 and reported it to the nurse. She could not remember, which nurse was working, that she reported it to. CNA B stated she did not believe it was safe for him to be at the facility. In an interview on 12/12/23 at 12:43 PM, CNA A stated on 12/08/23 about 3:30/4:00 AM Resident #1 got up from bed. CNA A stated Resident #1 had habits of going into other's room and saying, get your ass out of my house and would start hitting their beds to get up. She stated they had to always watch Resident #1 because Resident #3 did not like people going into his room. CNA A stated she gave Resident #1 a snack and then moved her into the living room area and turned on the TV. She stated she was content at the time. CNA A stated about 4:00/4:30 AM the nurse had to leave the unit to give meds on another hall and she started doing rounds. CNA A stated she was in another resident's room changing them and when she left the room, Resident #1 was in the hall and looked as if someone had thrown a bucket of blood on her. CNA A stated Resident #1 stated look what that man did to me and was pointing at Resident #4. She stated she knew Resident #4 did not do that to her because he did not have any blood on him and looked normal. She stated Resident #3 was in hall heading back to his room and did not say anything. CNA A stated she went to get the ADON. She stated the ADON immediately started assessing Resident #1. CNA A stated they saw Resident #3 come out of his room and they noticed the blood on his hands and clothes. She stated the ADON asked Resident #3 if he did that to Resident #1 and he said yes and I'll kick your ass too. CNA A stated he was trying to charge at the ADON with his walker and then went into his room and closed the door. CNA A stated she went into his room because he was always calm with her. She stated Resident #3 let her come in and said Resident #1 went into his room and told him to get his ass out of her house and he told her that was his house and to get out. CNA A stated Resident #3 said Resident #1 would not get out so he beat her ass. CNA A stated Resident #3's family member arrived and told Resident #3 he had to leave the facility and he told her no. She stated the family member was speaking in Spanish to Resident #3, so she did not know what they were saying, but suddenly, he assaulted the family member and the ADON had to break it up. CNA A stated Resident #3 then tried to charge at the ADON again. She stated the family member was finally able to get Resident #3 out of the facility. CNA A stated there was normally two people overnight, but the facility was short nurses, so they had the ADON covering two halls. She stated since the incident with Resident #3, they make sure to always have two people in memory care. In an interview on 12/13/23 at 9:08 AM, the Administrator stated on 12/08/23 she was contacted by the ADON early in the morning and stated that Resident #3 had assaulted Resident #1 when she wandered into his room. The Administrator stated Resident #1 received very serious injuries, so she issued Resident #3 an immediate discharge. She stated until Resident #3's family came to pick him up, they had him on 1 to 1 supervision. The Administrator stated their company took over the facility in October and she started on 11/13/23, so she was not at the facility when Resident #3 was involved in the resident-to-resident incident in August or the incident in which he attacked the ADON and CNA B in November. She stated if she was the Administrator during the second incident on 11/06/23, she would have issued a 30-day discharge and helped the family find a more appropriate facility. The Administrator stated following the incident, they immediately in-serviced staff on abuse and neglect including resident-to-resident altercations, resident rights, behavior management, and customer service. She stated on 12/8/23 they had an AD Hoc QAPI meeting with Corporate Compliance Nurse, Divisional [NAME] President of Clinical Service, Divisional [NAME] President of Operations, and the facility's MD. She stated in the meeting they reviewed the residents and any resident with behavioral issues, they ensured there was appropriate interventions in place on their care plans and some of the resident's medications were adjusted. The Administrator since the incident, they have made sure there was always two people in memory care . She stated even when staff takes their breaks, they had been instructed to get coverage from other halls. A record review of the facility's schedule dated 12/09/23, 12/10/23, 12/11/23, 12/12/23, and 12/13/23 reflected there were always two staff members in the memory care unit. In an interview on 12/13/23 at 2:03 PM, LVN C stated she was called to Resident #3's room in August because he punched his roommate. LVN C stated she did not actually witness the incident but Resident #2 stated Resident #3 punched him in the face. She stated the residents were separated. LVN C stated she contacted the MD and received an order to send Resident #3 to the psychiatric hospital. LVN C stated Resident #3 did not like anyone in his room and would often sit in his doorway and yell if anyone came near. She stated they had to often redirect residents who wandered away from his door. LVN C stated due to this behavior she felt it was not safe to have Resident #3 at the facility because wandering was typical behavior in memory care. Record review of the facility's policy titled Abuse and Neglect, dated 03/29/18, reflected The resident has the right to be free from abuse, neglect . Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents . The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation . Definitions: 1. Abuse: Abuse is the willful infliction of injury . with resulting physical harm, pain or mental anguish . Procedure: . C. Prevention: The facility will provide the residents, families, and staff an environment free from abuse and neglect . 4. The facility will be responsible to identify, correct, and intervene in situation of possible abuse/neglect. The facility has in place a method to identify events . occurrences, patterns, and trends that may constitute abuse . G. Protection: The facility will take necessary measures to protect residents and employees from harm during and following an abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property investigation . Resident to Resident: The above policy will apply to potential resident-to-resident abuse . An Immediate Jeopardy (IJ) was identified to have existed from 12/08/23 through 12/08/23. On 12/13/23 the IJ was determined to be past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. The facility took the following actions to correct the non-compliance prior to the investigation: An observation on 12/12/23 at 9:10 AM revealed Resident #3 was no longer at the facility. Record review of the facility's census, dated 12/12/23, reflected Resident #3 was no longer at the facility. Record review of Resident #3's Progress Notes, dated 12/08/23 at 10:00 AM, by the Administrator, reflected Administrator called resident's [family member] and explained immediate discharge process. Immediate discharge notice emailed to resident's [family member] and Ombudsman. Resident's [family member] is taking resident to [psychiatric hospital] for further evaluation. Administrator advised [family member] that facility will assist in seeking alternate placement for resident due to resident is a danger to others. [Family member] verbalized understanding. Record review of the facility's in-services, dated 12/08/23, reflected all staff, were educated on abuse and neglect including resident to resident, resident rights, behavioral management, and customer service. Record review of a document titled Resident to Resident Monitoring dated 12/8/23 to 12/11/23 reflected 10 staff members within the week were asked if they noticed any inappropriate behavior among residents, and if so, verify what the staff member did and if it was reported properly. There were no inappropriate behaviors reported on the document. Record review of document AD Hoc QAPI Contributors, dated 12/8/23, reflected the Administrator, DON, Corporate Compliance Nurse, Divisional [NAME] President of Clinical Service, Divisional [NAME] President of Operations, Assistant Director of Operations and the MD attended the meeting regarding Resident to Resident Physical Aggression and completed checklist that included self-report to state within 2 hours, 1 on 1 monitoring for resident who initiated the encounter or was the aggressor until further notice from the IDT, interview residents involved in the encounter, determine new interventions, the aggressor is capable of staying in the facility, interview staff regarding if they have observed any potential physical abuse among residents, after interviews determine if other residents have the potential to be physically aggressive to other resident, if so act accordingly with new interventions for the resident, initiate risk management entry for behavior related incident and complete event note, notify police if applicable and medical director. Interviews were conducted from 12/12/23 to 12/13/23 at various times, with four nurses, seven CNAs, two Med Aides, and ADON, from various shifts. The staff all stated they had been in-serviced on abuse and neglect including resident to resident, resident rights, behavioral management, and customer service. The staff were able to identify and define abuse, were knowledge on procedures for reporting and preventing abuse, and interventions of resident o resident abuse. The staff were knowledgeable of procedures and interventions for resident with behavioral issues.

Based on interview and record review the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of four residents (Resident #1) reviewed for pain. The facility failed to administer Resident #1's pain medications of [MEDICATION(S)] 325 mg, ordered for pain by the physician. Resident #1 experienced pain as a result. This facility failure could place residents on pain management at risk for unnecessary pain, discomfort, and decreased quality of life. Findings include: Record review Resident#1's face sheet, dated 10/04/22, reflected a [AGE] year old- female admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's MDS assessment, dated 07/29/22 revealed a BIMS score of 13, which indicated the resident was cognitively intact. The resident required extensive assistance with activities of daily living. The pain assessment reflected Resident #1 received scheduled pain medication regimen. Record review of Resident #1's care plan, dated 09/19/22, reflected the resident had pressure ulcers. The care reflected the resident had chronic pain the facility interventions included assistance with administering medication, all medical needs, and fulfilling doctor's orders. Review of the Order summary for Resident #1 dated 10/04/22 revealed '[MEDICATION(S)]-Acetaminophen tablet 10-325 mg, give 1 tablet by mouth every 4 hours for pain, start date 10/01/22. Record review of Resident #1's medication administration record for the month of October 2022, revealed on 10/03/22 Resident #1 did not receive [MEDICATION(S)]-Acetaminophen tablet 10-325 mg at 12 a.m. and 4 a.m. as listed on the medication Administration record . Review of Resident#1's nursing care progress notes as of 10/04/22 revealed no evidence of the missed medication. There was no evidence of the complaint of pain. An interview with CNA B on 10/03/22 at 9:22 a.m. revealed she had received a complaint from Resident #1, that she had not received her medication overnight. CNA B stated she informed the nurse the resident had not received her medication. She stated Resident #1 had never made any similar complaints prior. An interview with LVN D on 10/03/22 at 9:42 a.m. revealed she had been informed by CNA B that Resident #1 had not received her pain medication overnight. She stated the MAR also reflected the resident did not receive her 12 a.m. and 4 a.m. pain medication earlier that morning. She administered the residents 8 a.m. pain medication and informed the ADON . An interview with Resident #1 on 10/03/22 at 10:34 a.m. revealed she had not received pain medications every 4 hours. She stated she received pain medication on 10/02/22 last at 8 p.m She stated she did not receive pain medication on 10/03/22 at 12 a.m. and 4 a.m. as she requested. She stated at midnight she pressed the call light, an aide (unknown) responded and she informed the aide she wanted her pain medication. Resident #1 stated the aide returned and informed her the nurse stated she was not her aide and could not give the pain medication. She stated at 4 a.m. she pressed the call light for assistance another (unknown) aide responded and she informed the aide she wanted her pain medication for 4 a.m. and was told the nurse stated she was not her resident, again. She stated she was not given her pain medication until 10/03/22 around 9 a.m Resident #1 stated during the time she was requesting the pain medication she was in pain. Her pain was 10/10. An interview with the DON on 10/03/22 at 11:25 a.m. revealed she had been informed by the nurse Resident #1 had not received her overnight/morning routine pain medications. She stated the MAR and the narcotic count sheet, both of which reflected Resident #1 did not receive her pain medication overnight. She stated she had begun an investigation and had started calling staff that worked overnight. An interview with LVN F on 10/03/22 at 2:14 p.m. revealed he worked overnight from 10/02/22 to 10/03/22. He stated one of the facility nurses did not show for work. LVN F stated LVN P was the nurse manager and informed him they would be dividing the 100 hallway by 3 staff, each covering 5 rooms. LVN F stated LVN M was responsible for Resident #1. He stated he was not aware of Resident #1's request for pain medication. An interview with LVN M on 10/03/22 at 2:39 p.m. revealed she worked overnight from 10/02/22 to 10/03/22. She stated she only worked the 300 hallway. She stated she was not aware of having to provide medications to residents on the 100 hallway, were Resident #1 was located. She stated she had not been informed by the aide Resident #1 requested pain medicine. An interview with LVN P on 10/04/22 at 8:48 a.m. revealed she worked overnight from 10/02/22 to 10/03/22. She stated she was not originally scheduled to work; however 2 nurses had called in off from work. She stated she arrived at the facility and noticed there was no nurse to work the 100 hallway (Resident #1's hall). She stated she devised a plan to have each of the nurses including herself to work 5 rooms on the 100 hallway. LVN P stated LVN M was responsible for Resident #1. She stated she gave (unknown) the aide a piece of paper with the assignment to give to the nurse. She stated she watched the (unknown) aide give the paper with the assignment to the nurse. She stated she had not been made aware of Resident #1's request for pain medication. On 10/04/22 at 9:56 am calls were made to CNA H and CNA C whom were aides assigned on 10/03/22 and 10/04/22. The calls were not returned. Review of the facility's Pain Management policy dated January 2021 revealed in part of the pain management guidelines ,the facility would provide consistent evaluation, management and documentation of pain in order to provide maximum comfort and enhanced quality of life

Based on interview, and record review the facility failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure Resident #3 received CPR, according to her wishes and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This was determined to be past-noncompliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation. This failure placed residents, who wished to receive CPR, at risk of not receiving life sustaining measures that could result in death. Findings included: Record Review of Resident #3's Admission Record dated [DATE], indicated the [AGE] year-old female resident was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #3's MDS dated [DATE], indicated the resident was severely cognitively impaired with a BIMS score of 6 (a score of ,d+[DATE] indicated severe cognitive impairment). She required limited assistance for most of her activities of daily living. Record Review of Resident #3's Care Plan dated [DATE], indicated the resident was a full code and CPR would be performed as ordered. Record Review of Resident #3's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #3's Progress Note dated [DATE] at 1:42 PM, indicated the resident suffered a fall and reported right hip pain. She was sent to the hospital for further evaluation. Record Review of Resident #3's Progress Note dated [DATE] at 10:30 PM, indicated the resident returned to the facility, from the hospital, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record Review of Resident #3's Progress Note dated [DATE] 1:25 PM, indicated, LVN A documented, the resident was non-responsive, with her eyes closed and no signs of breathing were noted. The resident had no rise and fall of her chest. The DON was notified. The resident was assessed by LVN A and the DON. Record Review of Resident #3's Progress Note dated [DATE] 1:58 PM, indicated the DON was notified LVN A called at 12:57 PM, via his cell phone to request the DON to pronounce Resident #3's death. The DON documented; Resident #3 was found lying in bed with the head of the bed elevated at 15 degrees. Her eyes were visibly closed and upon further examination, there was no audible heart sounds upon auscultation, no presence of breath sounds or respiration. The resident was cold to the touch, no radial or carotid pulse felt upon palpation. EMS was called by the DON. The MD, who was present at the facility was notified. The MD proceeded to the covid unit. EMS arrived at the facility via the entrance from the covid unit, charge nurse, DON, and MD present at the time of arrival. EMS was able to communicate with the DON and MD who then proceeded to exit the unit. The resident was pronounced deceased at 1:17 PM. The MD asked for the DON to notify the resident's family concerning her passing. Record Review of Resident #3's Physician's Discharge Summary dated [DATE] indicated, This is an [AGE] year-old female who was found to be without a pulse and not breathing. Patient was recently diagnosed with COVID-19 and was sent to the hospital. She was sent back to the nursing home facility and monitored in the isolation unit for COVID-19. Today it was noted that the patient had rigor mortis when it was discovered that she was not breathing or had a pulse. It also appears that the patient was a full code however resuscitation was not initiated. On my arrival EMS was already present. It was discussed with the EMT that CPR would not be initiated as it was already un-initiated, and patient had rigor mortis set in. The time of death was 1:17 PM. The cause of death was, likely resulting from side effects of COVID-19 possibly including hyper coagulopathy involving pulmonary embolism. In an interview on [DATE] at 1:08 PM, Resident #3's MD, who was also the facility's Medical Director, said on [DATE] he was called to the COVID-19 unit by the DON because Resident #3 had expired. He said he examined Resident #3 and believed she had been expired approximately 45 minutes before anyone knew she had passed away. He said the resident was a full code and LVN A should have initiated CPR upon finding the resident un-responsive. He said LVN's were to initiate CPR and are not qualified to make a clinical determination of death. He said EMS arrived and did not initiate CPR because the resident had signs of rigor mortis. He said he believed the resident's recent hip fracture, immobility and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He said a meeting was conducted with the DON and Administrator, immediately after the incident. He said staff were in-serviced to immediately begin CPR on residents who were a full code regardless of signs or symptoms of death. In an interview on [DATE] at 2:32 PM, LVN A said he was the only staff working the COVID unit on [DATE]. He said the unit was manageable for one staff because some of the residents had moved off the unit and the residents that remained were not ill and independent. He said a CNA worked with on the unit as needed. He said he gave Resident #3 her medications around 9:30 AM and she ate some breakfast. He said the resident's vital signs were within normal limits and she was going to be moved off the COVID unit the next day ([DATE]) because she had completed her 14 days of isolation. He said he checked on Resident #3 again between 10:30 AM - 11:00 AM and she was doing well. He said the OT came back on the COVID unit to work with Resident #3. He said around 12:45 PM the OT was in the resident's room and was unable to get a pulse oxygen reading on the resident. He said he assessed the resident and found her to deceased . He said he called the DON to come to the unit to pronounce the resident deceased . He said the DON came back to the unit and assessed the resident and found her to be deceased . He said the DON did not initiate CPR. He said the DON called 911 because the resident was a full code and asked the MD to come to the unit. He said the MD assessed the resident and did not initiate CPR. He said EMS arrived and did not initiate CPR or take the resident to the hospital. He said this all happened between 12:45 PM - 1:15 PM. He said the residents' code statuses were in the electronic medical record. He said he did not know if LVNs were required to initiate CPR if signs of rigor mortis were present. He said, in hindsight, he should have initiated CPR, but the resident was stiff and difficult to move. He said the facility policy regarding CPR indicated if there were signs of rigor mortis, CPR should not be initiated. He said he had training on CPR and the facility conducted an in-service, after Resident #3's death, and instructed the nurses to initiate CPR on all full code residents regardless of the signs of death. Record Review of LVN A's CPR Certification dated [DATE] indicated it was valid for two years. In an interview on [DATE] at 10:52 AM, the OT said on [DATE] he went to the COVID unit to work with Resident #3. He said she had been doing well and he was working with her on sitting up on the side of the bed. He said he knocked on her door, she did not respond, her eyes were closed. He said he always checked her oxygen saturation prior to working with her due to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He said he got no reading from the pulse ox. He said he had been in the room no more than 5 minutes when he asked LVN A to assess the resident. He said he observed the LVN do a thorough assessment of the resident. He said the LVN told him the resident was deceased . He said it was his first time to experience finding a resident deceased , so he asked the LVN how he knew the resident was deceased and he explained the signs of death he observed. He said he then left the room and the facility. He said the LVN did not ask him to call any other staff or for any assistance. He said he was trained in CPR but the contracted therapy company he worked for required the therapists to notify the nurses and not initiate CPR themselves. In an interview on [DATE] at 3:28 PM, the DON said she was called back to the COVID unit by LVN A, to pronounce Resident #3's death. She said Resident #3 had no pulse, was cold to touch and very stiff. She said Resident #3 was a full code, so she called EMS but did not initiate CPR because she believed the resident to be deceased . She said the MD also assessed the resident and instructed staff not to begin CPR because the resident had signs of rigor mortis. She said EMS arrived and said CPR did not need to be initiated. She said LVNs are required to initiate CPR and LVN A did not. She said the LVN told her he did not initiate CPR because the resident had signs of rigor mortis. She said LVNs were not clinically able to make decisions regarding whether rigor mortis was present and had to initiate CPR. She said residents' code statuses were documented in their electronic medical record. In an interview on [DATE] at 3:24 PM, the Administrator said LVNs were to initiate CPR and continue CPR until an RN or other medical personnel pronounced death. She said after this incident a QA meeting was held with staff and the MD. She said staff had been in-serviced to initiate CPR on full code residents regardless of the signs of death. In an interview on [DATE] at 3:57 PM, the DON and Administrator said on [DATE] they met with the MD and discussed the incident and response. On [DATE] the facility began education with staff on the CPR policy. The DON contacted the corporate office regarding clarification of the CPR policy on [DATE] because the policy indicated CPR should not be initiated if rigor mortis was present; however, LVNs cannot make that determination. She said she reviews resident deaths the same or next day to ensure compliance with code status and the QA committee meets monthly. She said the corporate office had not sent a clarification on the written CPR policy, but she would follow-up. The surveyor determined the facility was in non-compliance from [DATE] to [DATE]. The facility took the following actions to correct the non-compliance: Record Review of the CPR Policy In-Service Training Record dated [DATE] - [DATE], conducted by the DON, indicated all staff were educated on the CPR Policy: Basic life support, including the initiation of CPR, is provided to a resident who experiences [CONDITION(S)] (cessation of respiration and /or pulse) in accordance with the resident's advanced directive and any related physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on [DATE] at 4:16 PM, CNA E said she received training on [DATE] regarding CPR and was in-serviced to immediately call the nurse on any resident found un-responsive, even if you think the resident is already deceased . In an interview on [DATE] at 5:13 PM, LVN F said the CPR policy was, if rigor mortis, was present the nurses should not initiate CPR but in a recent in-service staff was told to go ahead and initiate CPR on a full code resident, even if rigor mortis was present because LVNs cannot make clinical decisions related to rigor mortis and death. In an interview on [DATE] at 5:31 PM, Contract LVN G said CPR was to be initiated on any resident who was a full code even if you think they are already deceased . In an interview on [DATE] at 5:35 PM, MA H said she was in-serviced to call the nurse immediately on any resident who was found un-responsive. In an interview on [DATE] at 10:00 AM, MA B said she received in-service training to notify the nurse immediately upon finding a resident un-responsive. In an interview on [DATE] at 10:16 AM, LVN C said CPR had to be started immediately on a resident that was a full code. In an interview on [DATE] at 10:20 AM, LPN I said she would start CPR immediately on full code residents. In a telephone interview on [DATE] at 10:44 AM, LVN D said LVNs are to start CPR no matter what if a resident is a full code. She said the facility in-serviced staff regarding CPR. In an interview on [DATE] at 12:11 PM, the DON said it was important for the LVNs to initiate CPR on full code residents to honor residents' wishes and the nurses' duty to attempt life sustaining measures. Record Review of the Texas Board of Nursing Laws & Rules, at bon.texas.gov, indicated rule 15.2, The Role of the Licensed Vocation Nurse in the Pronouncement of Death: Licensed vocational nurses (LVNs) do not have the authority to legally determine death, diagnose death, or otherwise pronounce death in the State of Texas. Regardless of practice setting, the importance of initiating cardiopulmonary resuscitation (CPR) in cases where no clear do-not-resuscitate (DNR) orders exist is imperative. Record Review of the facility's CPR policy dated [DATE], indicated: Basic life support, including initiation of CPR, is provided to a resident who experiences [CONDITION(S)] (cessation of respiration and/or pulse) who do not show obvious clinical signs of irreversible death, (e.g. rigor mortis, dependent lividity, decapitation, transection, of decomposition) and in accordance with the resident's advanced directive an any related physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview and record review, the facility failed to ensure residents were free of neglect for 1 of 6 residents (Resident # 1) reviewed for neglect. 1. The facility failed to adequately monitor Resident #1's pain by documenting using an appropriate pain scale and follow-up method, and did not offer non-pharmacological interventions to try to relieve the resident's pain. The facility staff has knowledge of Resident #1's pain and failed to to provide effective pain management. As a result, the resident continued to experience significant and unrelieved pain, and refused to participate in treatments and activities of daily living. Resident #1 visited the emergency roiagnom on [DATE] due to her pain severity. 2. The facility failed to have Resident #1's PRN Tylenol 3 available from 01/27/18 through 02/01/18. 3. The facility failed to have Resident #1's routine [MEDICATION NAME] available on 01/02/18 and 01/13/18 through 01/14/18. 4. The facility failed to have Resident #1's routine [MEDICATION NAME] available on 01/30/18. 5. The facility failed to ensure Resident #1 who had previously been compliant with wound care, began refusing wound care 01/17/17 as a result of intolerable pain, received appropriate pain management and resulted in new pressure ulcers on 01/29/18 Stage II pressure ulcer left posterior buttock on 02/01/18 Left lateral hip blister, Left posterior thigh blister and left medial thigh blister. An immediate Jeopardy (IJ) was identified on 02/02/18. While the IJ was removed on 02/03/18, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. This failure could affect all 102 residents, who relied on facility staff to ensure their needs were met and placed them at risk for lack of appropriate care and treatment. Findings included: 1. Resident #1's MDS assessment dated [DATE], reflected she was a [AGE] year-old female, who was re-admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had a moderately impaired cognition and had no behaviors. She required the assistance of one person with ADLs and was incontinent of both bowel and bladder. She had limited mobility in one lower extremity and required the assistance of one person with transfers to her wheelchair. She was considered at risk for pressure ulcers. She received routine and as needed (PRN) opioid pain medication. She had frequent pain at a level of 5/10 using a 0-10 pain scale, with 0 being no pain and 10 being the worst pain imaginable. Resident #1's Admission Clinical Health Status assessment dated [DATE] reflected the resident complained of frequent, moderate, radiating pain, described as stabbing and throbbing which impacted her daily life affecting her sleeping and mood. Symptoms associated with the pain were anxiety. Possible causes of the pain were listed as arthritis and pressure wounds. She was resistant to care. The Skin Condition component of the assessment had not been completed. A narrative note revealed Pt (patient) complains of chronic lower back spasms and hip pain . Resident #1's Care Plan updated 12/11/17 reflected; Problem Onset: 07/20/16, I am at risk for or am experiencing the presence of constant pain related to [MEDICAL CONDITION]. Goal and Target Date: I will verbalize relief of pain 11/28/17 Approaches included: Evaluate my pain daily using 1-10 pain scale, administer my pain medications as ordered, monitor for worsening of my pain symptoms and report to physician, assess need for preventive pain measures prior to ADLs, treatments etc. There had been no updates to the pain plan of care since 07/20/16. physician's orders [REDACTED]. Order Start date 08/24/17: Tylenol 325mg table 1 tablet every 6 hours as needed for pain Order Start date 08/24/17: [MEDICATION NAME] ER 30mg 1 tablet every 12 hours Order Start date 08/24/17: [MEDICATION NAME] ([MEDICATION NAME]) 5/325mg 1 tablet every 4 hours while awake Order Start date 08/24/17: [MEDICATION NAME] 500mg 1 tablet twice a day - off-label use in neuropathic pain Order Start date 08/25/17: Tylenol with [MEDICATION NAME] 300/30 mg 2 tablets every 6 hours as needed for pain Order Start date 10/30/17:[MEDICATION NAME](muscle relaxant) 350mg 1 tablet every 12 hours Review of Resident #1's Individual Control Drug Records, which indicated the date the medication was delivered to the facility on the label affixed to the record, revealed Tylenol #3 2 tablets every 6 hours as needed for pain, delivery date 12/20/17 01/08/18 at 8:00 p.m. only 1 Tylenol #3 was administered 01/14/18 at 11:00 a.m. only 1 Tylenol #3 was administered then there was no medication left to count (LTC) Record delivery date 01/09/18 01/23/18 at 10:00 a.m. only 1 Tylenol #3 was administered 01/24/18 at 11:00 a.m. only 1 Tylenol #3 was administered 01/27/18 at 08:00 a.m. 2 Tylenol #3 were administered then there was no medication LTC Review of Resident #1's Individual Control Drug Records for [MEDICATION NAME] ER 30mg 1 tablet every 12 hours Revealed Record delivery date 12/28/17 reflected; 01/02/18 at 09:00 a.m. 1 tablet administered then there was no medication LTC Record delivery date 01/02/18 reflected; 01/03/18 at 07:00 a.m. 1 tablet administered There was no medication available and the resident was not given a dose on 01/02/18 at 9:00 p.m. Record delivery date 01/07/18 reflected; 01/13/18 at 08:00 a.m. 1 tablet administered then there was no medication LTC Record delivery date 01/15/18 reflected; 01/15/18 at 8:00 a.m. 1 tablet administered There was no medication available and the resident did not receive a dose on 01/13/18 at 8:00 p.m., on 01/14/18 at 08:00 a.m. and 8:00 p.m. Online resource https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 23/ accessed 02/16/18 revealed ER (extended release) formulations are specifically designed to allow a controlled release of the active agent to provide relatively consistent and prolonged plasma drug levels with lower maximum concentration and fewer peak-to-trough fluctuations .In contrast, ER formulations are dosed less frequently (one to three times per day or fewer), allowing for less fluctuation and affording an elongated duration within the therapeutic window. Review of Resident #1's Individual Control Drug Records for [MEDICATION NAME] 1 tablet every 4 hours revealed Record delivery date 01/24/18 reflected; 01/30/18 at 12:00 a.m. 1 tablet administered then there was no medication LTC Record delivery date 01/30/18 reflected; 01/30/18 at 4:00 p.m. 1 tablet administered There was no medication available and the resident did not receive a dose of [MEDICATION NAME] on 01/30/18 at 04:00 a.m., 08:00 a.m. and 12:00 p.m. Review of a Situation, Background, Assessment, Recommendation, (SBAR) dated 01/18/18 and completed by LVN A, revealed Resident #1 had worsening uncontrolled pain rated 10/10. The resident appeared grossly agitated and stated her medication was not working and she needed something else. The origin of the pain was listed as [MEDICAL CONDITION] and chronic, non-healing pressure ulcers. An assessment of how pain had interfered with the resident's ability to perform ADLs within the prior 24 hours, from 0-10 with 0 being Does not interfere and 10 being completely interferes, the resident scored 7/10. The areas affected were indicated as; ability to ambulate, bathing, dressing, enjoyment of daily activities, mood, sleeping and toileting. An assessment of how much pain relief the resident had received from pain medication and/or therapy provided with 0% being no relief and 100% being relief of pain, the resident had 50% relief of pain with pain medication. A progress note on the SBAR revealed LVN A called the resident's family member and notified him/her the resident (was) not allowing ADL care stating that she is in pain. And that she wanted to go to the ER (emergency room ) . The resident's physician was notified at 1:00 p.m. of the resident's status and the resident was transferred to the emergency room by ambulance. emergency room discharge instructions printed 01/19/18 at 12:10 a.m. reflected a [DIAGNOSES REDACTED]. She received two liters of normal saline via intravenous infusion, blood tests, a urinalysis, x-rays of her left foot and pelvis and a computed tomography (CT) imaging of her chest, abdomen and pelvis. Discharge Instructions for Chronic Pain included; .Treatment .You may be referred to a pain specialist. He or she may prescribe medicine or therapies, such as: Mindfulness meditation or yoga Shots (injections) of numbing or pain-relieving medicines into the spine or area of pain Local electrical stimulation Acupuncture Massage Therapy Aroma, color, light, or sound therapy Biofeedback Working with a physical therapist to keep from getting stiff Regular, gentle exercises Cognitive or behavioral therapy Group support Sometimes, surgery may be recommended. Results of the testing performed while in the emergency room were not available at the facility. 2. Resident #1's MDS assessment dated [DATE], reflected she had an unstageable pressure ulcer of the right heel which was present upon re-admission to the facility (08/24/17) that measured 3cm length (L) x 3cm width (W) x 1 cm depth (D). She had no other pressure ulcers documented. Review of Resident #1's Wound Care Physician's initial evaluation of Resident #1, dated 08/28/17, reflected; Site #1: Stage II Pressure wound of right lateral hip 0.7 x 1 x 0.1cm Site #2: Stage II Pressure wound of the Medial Sacrum (low back) 07 x 0.7 x 0.1cm Site #3: Unstageable DTI (deep tissue injury) of the Left Lateral Foot 2.5 x 2 x Not measurable Site #4: Unstageable DTI of the Right Distal, Medial Foot 2 x 1.2 x Not Measurable Site #5: Unstageable DTI of Right Medial Heel 6 x 5 x Not Measurable Factors complicating wound healing: Diabetes Mellitus without mention of complication . Recommendations included to reposition per facility policy Height 52 inches, weight 171 lbs Review of the Resident #1's subsequent Wound Care evaluations revealed: 09/04/17 Site #4 DTI of the Right Distal, Medial Foot wound had resolved. Twelve evaluations presented for review, dated from 11/06/17 through 01/22/18, revealed there was no further mention of sites other than Site #5 Unstageable DTI, which was debrided of necrotic (dead) tissue five times, and on 01/22/18 Site #5 measured 0.44 x 0.6 x 0.3 cm. On 01/29/18, Site #6 was added as a Stage II of left posterior buttock measuring 4.5 x 0.6 x 0.1 (Initial evaluation). Site #5 remained an unstageable DTI measuring 0.4 x 0.6 x 0.3cm. Factors complicating wound healing were documented as including, Non-adherence to plan of care. Appetite was listed as Good. Online resource accessed on 02/09/18 at 11:45 a.m. The National Pressure Ulcer Advisory Panel (NPUAP) http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages reflected: Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis .may also present as an intact or ruptured serum-filled blister .These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration .This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue .are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Review of Resident #1's physician's orders [REDACTED]. 1. Start Date: 01/29/18 left posterior buttock wound 2. Start Date: 01/29/18 Pressure ulcer of right medial heel, unspecified stage 3. Start Date: 02/01/18 Left lateral hip blister 4. Start Date: 02/01/18 Left posterior thigh blister 5. Start Date: 02/01/18 left medial thigh blister Online resource accessed on 02/09/18 at 11:45 a.m. The National Pressure Ulcer Advisory Panel (NPUAP) http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis .may also present as an intact or ruptured serum-filled blister .These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration .This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue .are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Review of Resident #1's electronic Treatment Administration Record (eTAR) and eTAR Notes, dated (MONTH) (YEAR) revealed when the wound care treatment was performed the nurse would indicate this with her initials. When the procedure was not performed an N would take the place of the nurses' initials and the reason the procedure was not performed was documented in the eTAR notes. The following information was provided on the eTAR regarding the resident's treatements: Start Date: 10/04/17 Apply [MEDICATION NAME] to coccyx area daily at 9:30 p.m. The resident received all treatments except 01/17/18 was refused by resident Treatment was discontinued on 01/23/18 Start Date: 10/12/17 Cleanse right hip area with normal saline or wound cleanser, pat dry apply collagen and anecept then foam dressing daily and PRN until healed to be performed at 9:30 p.m. The resident received all treatments until 01/17/18 was refused by resident Treatment was discontinued on 01/19/18 Start Date: Cleanse right heel with normal saline or wound cleanser, apply santyl with metro gel 1% then calcium alginate then cover with border gauze daily at 9:30 p.m. The resident received all treatments except 01/17/18, 01/21/18 and 01/24/18 was refused by resident Treatment was discontinued on 01/29/18 Start Date: 11/28/17 Cleanse skin tear on left hip with normal saline pat dry apply [MEDICATION NAME] with dressing daily at 9:30 p.m. The resident received all treatments except 01/17/18 and 01/19/18 was refused by resident Treatment was discontinued on 01/19/18 Start Date: 01/12/18 Cleanse wound on left hip and left back with normal saline pat dry and apply [MEDICATION NAME] with dry dressing. The resident received all treatments except 01/17/18, 01/19/18, 01/21/18 and 01/22/18 was refused by resident Treatment was discontinued on 01/23/18 Start Date: 01/23/18 Cleanse wound to left hip with normal saline or wound cleanser, pat dry, then apply collagen, [MEDICATION NAME] with foam dressing daily and PRN at 9:30 p.m. The resident received all treatments except 01/24/18 was refused by resident Treatment was discontinued on 01/29/18 Start Date: 01/29/18 Cleanse right medial heel with normal saline or wound cleanser, apply skin prep to peri-wound, then apply calcium alginate, collagen then cover with foam dressing daily until healed The resident received all treatments through 01/31/18 The resident did not receive a treatment on 02/01/18 was refused by resident Start Date: 02/01/18 Left lateral hip blister apply skin prep and leave open to air until healed The resident did not receive a treatment on 02/01/18 was refused by resident Start Date: 02/01/18 Left medial thigh blister apply skin prep and leave open to air until healed The resident did not receive a treatment on 02/01/18 was refused by resident Start Date: 01/29/18 Cleanse wound on left posterior buttock with normal saline or wound cleanser, pat dry, then apply collagen with foam dressing daily until healed The resident received all treatments through 01/31/18 The resident did not receive a treatment on 02/01/18 was refused by resident Nurses Notes, dated 01/12/18 at 9:48 p.m. reflected Resident #1 was noted to have an open wound on the left side of her back and an open blister on her left hip. The nurse informed Resident #1 that, resident needs to start allowing the Certified Nurses' Aide (CNA) to turn her to her right side because (the) resident is constantly on her left side, during wound care resident will not allow this nurse and CNA to turn her to right side and clean the wound, resident noted to be screaming, after several attempt resident allow {sic} this nurse and CNA to turn her, resident responsible party (name) notified, DNS (Director of Nursing Services) called message left to call facility back. Nurses Notes, dated 01/13/18 at 1:48 a.m. reflected Staff x 2 assist resident with repositioning on to back. As needed pain medication administered to relief of pain . Nurses Notes, dated 01/13/18 at 05:53 a.m. reflected Resident refuses to allow staff to reposition in bed. Resident states, 'I just positioned myself to where I am comfortable.' Staff encourage resident to allow staff to reposition. Resident refused . Nurses Notes, dated 01/15/18 at 6:09 p.m. reflected This nurse in resident room for wound care to left back and left hip, resident in room crying screaming will no (sic) allow this nurse or CNA to turn her, after several attempt (sic) and education resident allow this nurse to clean her wound and apply dressing per order resident noted screaming and crying, after wound care this nurse and CNA try to reposition resident to her right side resident refuse (sic) started screaming and crying loud, will not allow this nurse and CNA to turn her to right side. Nurses Notes, dated 01/16/18 at 12:17 a.m. reflected Resident refused to allow staff to turn to right side. Resident allow (sic) staff to turn slightly to back using pillow . Nurses Notes, dated 01/17/18 at 1:48 a.m. reflected This nurse received a call from resident responsible party (name) inform (sic) this nurse that resident called to tell her she (sic) not feeling good . in resident room to assess resident, resident inform (sic) this nurse that she is having pain on both hips rate pain 8/10 . offer to reposition resident, resident refuse (sic), routine [MEDICATION NAME] and [MEDICATION NAME] administer {sic) to resident, resident refuse (sic) to eat her supper .resident (family member) notified that resident refuse to allow this nurse and CNA to turn her . resident will not allow this nurse to do wound care, after two hours PRN Tylenol #3 administer (sic) to resident, resident reassessed after one hour medication effective. Nurses Notes, dated 01/17/18 at 11:47 p.m. reflected, .in room to reposition resident. Resident states 'No, I have been hurting all day and I am just getting settled down .No don't move my bed it may get my hip to hurting again moving the bed around' Routine [MEDICATION NAME] given. Call light within reach. Nurses Notes, dated 01/18/18 at 2:56 p.m. reflected . informed (family member) that resident not allowing ADL care stating she is in pain. And that she wanted to go to the ER. Phoned NP (Nurse Practitioner) informing of situation and new orders were to send to ER . Nurses Notes, dated 01/19/18 at 1:46 a.m. reflected Resident returned from (hospital name) with no new orders noted . Resident noted yelling out 'No' when staff attempting to remove soiled linens . Resident grabbing staff stating 'it hurts' while providing care. Resident given Tylenol #3 upon return from hospital for complaints of pain. Resident refusing to allow staff to position with pillows or turn on back . Nurses Notes, dated 01/19/18 at 9:49 p.m. reflected the nurse advised Resident #1 she needed to assess the dressing to the wound on her back to ensure it was intact, the resident stated I cannot turn to the right side for you but I will turn a little to the right the nurse determined the dressing required changing and informed the resident who stated she could not turn for wound care to be performed, she allowed the nurse to perform wound care to her right heel, the resident refused a shower. Routine [MEDICATION NAME] and [MEDICATION NAME] had been administered 30 minutes prior to wound care. Nurses Notes, dated 01/24/18 at 9:45 p.m. reflected the resident refused wound care stating she had sat in her wheelchair too long on 01/23/18 and she did not want to be touched. The resident informed the nurse she would allow her to perform wound care on 01/25/18. The nurse administered routine pain medications and after one hour, Tylenol #3 was administered, the resident continued to refuse wound care. Nurses Notes, dated 01/30/18 at 12:48 p.m. reflected a late entry for 01/29/18 the wound care physician had seen the resident. Notes reflected; Unstageable to right medial heel 0.4 x 0.6 x 0.3 with 100% granulated tissue and moderate serous drainage. Wound noted with improvement from last week. Wound doctor using chemical cauterization of hypergranulated tissue using topical anesthetic for pain management. Resident tolerating procedure well. Stage 2 pressure ulcer to left posterior buttock 4.5 x 0.6 x 0.1 with moderate serous drainage. Treatment orders Collagen with foam dressing. Resident with no complaint of pain to wound area. Resident complains of pain to right hip. Medications given per MD orders. Resident is consistent with noncompliance with turning and repositioning. She refuses showers and ADL care daily. Nurses Notes, dated 01/31/18 at 5:05 p.m. reflected the resident complained of pain and refused to allow staff to turn her and perform incontinent care although she was heavily soiled and bed sheets required changing. Resident stated that she needed to talk to someone because she feels that her family has just left her in the facility to rot. She can't see her grandchildren. Her phone is not working and that she can't talk to anyone. Resident began crying stating 'I want to see my family, I feel alone.' The nurse advised the resident she would notify Social Services of her request to speak with a psychiatrist. Pain medication was administered and staff returned to perform ADL care. Resident crying and yelling before staff touched the bed stating 'I want to see my family'. ADL care performed with staff being very gentle. Assessment of the resident's skin revealed: Fluid-filled blister to left lateral hip measuring 3.0 x 1.0cm Fluid-filled blister to left posterior thigh 1.6 x 1.4cm. The physician was notified of the new [MEDICAL CONDITION] and new orders were received. Nurses Notes, dated 02/01/18 at 1:40 p.m. reflected the nurse had attempted multiple times to perform wound care to the residents hip, thigh, heel and buttocks but the resident complained of pain 7-10/10 'all over.' Resident visibly crying out in pain saying Don't touch me I hurt too bad. Scheduled nurse notified. Nurses Notes, dated 02/01/18 at 2:30 p.m. reflected Resident #1 complained of pain 7/10 and refused wound care. Resident was visibly crying out in pain. Resident stated 'I am just in too much pain right now to get my wounds done' Resident not letting aides turn her. Resident stated 'I am constantly in pain and my pain level never goes below 3/10. The pain medicine helps a lot but my body continues to ache.' Resident states she is currently at a 3/10.' Educated resident on the importance of her being changed frequently and resident stated 'I know but when I am in too much pain, I just can't be touched. It hurts too much.' Pulled PRN Tylenol #3 out of e-kit for breakthrough pain. Observation of Resident #1 on 02/01/18 at 9:17 a.m. revealed she was lying in bed on her left side with her head almost covered by a sheet. Her right hand was open and lying on her right hip in a protective manner. When questioned, the resident spoke quietly and with a facial grimace as she complained she was experiencing spasms in her right hip at a pain level of 7/10. She stated she had just been given her pain medication and the pain was decreasing. She stated the pain medication usually decreased her pain for two to three hours, but her pain never went away. She further stated, if her pain was down to a level of 2-3/10, she was able to sit on the side of her bed. She said that she would like to get up into her wheelchair but it was too painful for her. She would request a PRN pain medication, but that only helped a little. She stated that on 01/18/18 she called 911 because she was in severe pain and no-one would listen to me. She stated she told the CNA but staff just closed her door because she was screaming and hollering for help. When she returned from the hospital someone told her she should have told someone and they would have called 911. She told the person she did, but no-one would listen. She stated the pressure ulcer on her right hip had healed, but she screams and hollers due to the pain from arthritis in her hips and knees. She stated she has refused peri-care and wound care and showers due to pain. She stated it was too painful for her to sit in the shower chair so she would give herself a bed bath and sometimes staff would assist her. She stated staff had put her in a bed lift but it hurt too badly, even when she put towels on each hip to try to cushion them. Interview on 01/26/18 at 2:32 p.m. with the EMT Paramedic who transported Resident #1 to the emergency room (ER) on 01/18/18 revealed Resident #1 had contacted 911 herself. When Emergency Medical Services (EMS) arrived at the facility, staff was aware that the resident had contacted 911 and was giving the resident a pain medication. He stated the resident was in bed and was crying out in pain when EMS arrived. The resident stated she had two pressure ulcers and they were the cause of her pain. Facility staff (unknown name) confirmed the resident had two pressure ulcers that were causing her pain. The staff person stated she had just given the resident her routine pain medication and that the resident would not allow them to change her brief and keep her clean. The Paramedic stated the resident was covered in urine and feces. EMS transported the resident to the hospital. Interview on 02/01/18 at 9:45 a.m. with LVN B, Resident #1's nurse, stated Resident #1 complained of pain a lot. She stated when she went in to give resident her [MEDICATION NAME] and [MEDICATION NAME] medications this morning, the resident was crying and complained of a pain level of 10/10. The best the resident's pain ever got was 3/10, but the pain never went away. She stated the resident also had an order for [REDACTED]. She stated she had not spoken with the resident's physician regarding the resident's pain, but she believed the 2:00 p.m. to 10:00 p.m. nurse had told him the resident wanted to get out of bed but could not due to the increased pain this caused. She stated the resident would allow perineal care to be provided, but she will be screaming in pain. She stated the wound care nurse would arrive to provide the resident's wound care at 9:00 a.m. in order to allow time for the morning pain medications to work, but even with the medication, the resident will scream during wound care. Observation on 02/01/18 at 10:44 a.m. with LVN C, who stated the usual wound care nurse was absent today so she would be providing Resident #1's wound care, revealed Resident #1 refused to allow wound care to be performed stating she was having spasms in her right hip with a pain level of 7/10. The resident refused to allow LVN C to reposition her, stating she hurt too badly. LVN C advised the resident she would check with her nurse and get a PRN pain medication. Observation on 02/01/18 at 10:46 a.m. revealed LVN C spoke with LVN A and requested PRN pain medication for Resident #1. LVN A stated the resident had no Tylenol #3 available, so she had given the resident a PRN Tylenol 500mg tablet this morning and she did not think the resident could have another one yet. LVN A stated the resident's next scheduled pain medication was at noon. On 02/01/18 at 12:43 p.m. a phone call was placed to Resident #1's physician the mailbox was full. On 02/01/18 a phone call was placed to the physician's answering service and requested the physician contact me. Interview on 02/01/18 at 12:47 p.m. with Resident #1's Physician's Assistant revealed Resident#1's physician was on vacation. The Physician's Assistant did not remember Resident #1 and did not remember the resident's physician speaking of her. He was unable to access the files of Resident #1. He stated he would have Resident #1's physician make contact to assist with answering questions regarding the resident. No contact from the resident's physician was received prior to the completion of the investigation on 02/03/18. On 02/01/18 at 1:00 p.m., a phone call was placed to Resident #1's Wound Care Physician and a voicemail was left requesting he call regarding Resident #1. Interview on 02/01/18 at 1:43 p.m. with the Director of Nursing Services (DNS), who stated she had been the DNS at the facility since 12/29/17, revealed LVN B had obtained Tylenol #3 tablets from the emergency medication kit (e-kit) and administered them to Resident #1 at 11:00 a.m. She stated the pharmacy must have a triplicate in hand in order to allow the nurse to access the e-kit. A request to see the e-kit Medication Administration Record [REDACTED]. The DON stated of the resident's controlled pain medications, only Tylenol #3 was available in the e-kit. She stated she had spoken with the resident's physician on 01/18/18 regarding pain control and he had said he did not want to order more pain medication for the resident as he did not want the resident sleeping all the time. He said the resident should be sent to the ER. She stated no new pain medication was ordered following the resident's visit to theER on [DATE] for uncontrolled pain. Upon review of Resident #1's controlled drug records along with the DNS, she stated she had not been aware the resident had been out of medications. She believed each nurse thought the other had re-ordered the pain medications and this was why medications had not been available at times. She would have expected the nurses to order the medications early enough to ensure the resident did not run out. She said the goal of pain management was to keep the resident comfortable with routine pain medication. If the resident required more than occasional use of PRN pain medication then the pain regimen should be reviewed as it would indicate the current pain regimen was no longer working. When questioned as to what other modalities of pain management were being used to attempt to control Resident #1's pain, such as referral to a pain management specialist for a comprehensive pain management program that included psychiatric services, she stat (TRUNCATED)

Based on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of 1 (Resident #1) of 6 residents reviewed for pharmacy services. The facility failed to ensure physician ordered pain medications were available for Resident #1. There was no medication available and the resident was not given a dose of [MEDICATION NAME] on 01/02/18 at 9:00 p.m., on 01/13/18 at 8:00 p.m., on 01/14/18 at 08:00 a.m. and 8:00 p.m. There was no medication available and the resident was not given a dose of her [MEDICATION NAME] on 01/30/18 at 04:00 a.m., 08:00 a.m. and 12:00 p.m. Review of the resident's Tylenol #3's narcotic count sheet on 02/01/18 revealed there had been no Tylenol #3 available for the resident for PRN use since 01/27/18 at 08:00 a.m. as a result the resident called 911 on 01/18/18 for uncontrolled pain. The facility failed to ensure Resident #1 who had previously been compliant with wound care, began refusing wound care 01/17/17 as a result of intolerable pain, received appropriate pain management and resulted in new pressure ulcers on 01/29/18 Stage II pressure ulcer left posterior buttock on 02/01/18 Left lateral hip blister, Left posterior thigh blister and left medial thigh blister An immediate Jeopardy (IJ) was identified on 02/02/18. While the IJ was removed on 02/03/18, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. This failure could affect 48 residents, who were identified by the facility as being dependent on controlled medications for pain control. Findings included: Resident #1's MDS assessment dated [DATE], reflected she was a [AGE] year-old female, who was re-admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had a moderately impaired cognition and had no behaviors. She required the assistance of one person with ADL's and was incontinent of both bowel and bladder. She had limited mobility in one lower extremity and required the assistance of one person with transfers to her wheelchair. She was considered at risk for pressure ulcers. She received routine and as needed (PRN) opioid pain medication. She had frequent pain at a level of 5/10 using a 0-10 pain scale, with 0 being no pain and 10 being the worst pain imaginable. Resident #1's Admission Clinical Health Status assessment dated [DATE] reflected the resident complained of frequent, moderate, radiating pain, described as stabbing and throbbing which impacted her daily life affecting her sleeping and mood. Symptoms associated with the pain were anxiety. Possible causes of the pain were listed as arthritis and pressure wounds. She was resistant to care. The Skin Condition component of the assessment had not been completed. A narrative note revealed Pt (patient) complains of chronic lower back spasms and hip pain . Resident #1's Care Plan updated 12/11/17 reflected; Problem Onset: 07/20/16, I am at risk for or am experiencing the presence of constant pain related to [MEDICAL CONDITION]. Goal and Target Date: I will verbalize relief of pain 11/28/17. Approaches included: Evaluate my pain daily using 1-10 pain scale, administer my pain medications as ordered, monitor for worsening of my pain symptoms and report to physician, assess need for preventive pain measures prior to ADLs, treatments etc. There had been no updates to the pain plan of care since 07/20/16. physician's orders [REDACTED]. Order Start date 08/24/17: Tylenol 325mg table 1 tablet every 6hours as needed for pain Order Start date 08/24/17: [MEDICATION NAME] ER 30mg 1 tablet every 12 hours Order Start date 08/24/17: [MEDICATION NAME] ([MEDICATION NAME]) 5/325mg 1 tablet every 4 hours while awake Order Start date 08/24/17: [MEDICATION NAME] 500mg 1 tablet twice a day - off-label use in neuropathic pain Order Start date 08/25/17: Tylenol with [MEDICATION NAME] 300/30 mg 2 tablets every 6 hours as needed for pain Order Start date 10/30/17:[MEDICATION NAME](muscle relaxant) 350mg 1 tablet every 12 hours Review of Resident #1's Individual Control Drug Records which indicate the date the medication was delivered to the facility on the label affixed to the record revealed; Tylenol #3 2 tablets every 6 hours as needed for pain, delivery date 12/20/17 reflected; 01/08/18 at 8:00 p.m. only 1 Tylenol #3 was administered 01/14/18 at 11:00 a.m. only 1 Tylenol #3 was administered then there was no medication left to count (LTC) Record delivery date 01/09/18 01/23/18 at 10:00 a.m. only 1 Tylenol #3 was administered 01/24/18 at 11:00 a.m. only 1 Tylenol #3 was administered 01/27/18 at 08:00 a.m. 2 Tylenol #3 were administered then there was no medication LTC Record delivery date 02/02/18 02/03/18 at 05:30 a.m. 2 Tylenol #3 were administered. Resident #1 had no PRN Tylenol #3 available for administration from 01/27/18 through 02/02/18 Review of Resident #1's Individual Control Drug Records for [MEDICATION NAME] ER 30mg 1 tablet every 12 hours revealed; Record delivery date 12/28/17 reflected; 01/02/18 at 09:00 a.m. 1 tablet administered then there was no medication LTC Record delivery date 01/02/18 reflected; 01/03/18 at 07:00 a.m. 1 tablet administered There was no medication available and the resident was not given a dose on 01/02/18 at 9:00 p.m. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 23/ accessed 02/16/18 revealed ER (extended release) formulations are specifically designed to allow a controlled release of the active agent to provide relatively consistent and prolonged plasma drug levels with lower maximum concentration and fewer peak-to-trough fluctuations .In contrast, ER formulations are dosed less frequently (one to three times per day or fewer), allowing for less fluctuation and affording an elongated duration within the therapeutic window. Record delivery date 01/07/18 reflected; 01/13/18 at 08:00 a.m. 1 tablet administered then there was no medication LTC Record delivery date 01/15/18 reflected; 01/15/18 at 8:00 a.m. 1 tablet administered There was no medication available and the resident did not receive a dose on 01/13/18 at 8:00 p.m., on 01/14/18 at 08:00 a.m. and 8:00 p.m. Review of Resident #1's Individual Control Drug Records for [MEDICATION NAME] 1 tablet every 4 hours revealed; Record delivery date 01/24/18 reflected; 01/30/18 at 12:00 a.m. 1 tablet administered then there was no medication LTC Record delivery date 01/30/18 reflected; 01/30/18 at 4:00 p.m. 1 tablet administered There was no medication available and the resident did not receive a dose of [MEDICATION NAME] on 01/30/18 at 04:00 a.m., 08:00 a.m. and 12:00 p.m. Review of a Situation, Background, Assessment, Recommendation, (SBAR) dated 01/18/18 and completed by LVN A, revealed Resident #1 had worsening uncontrolled pain rated 10/10. The resident appeared grossly agitated and stated her medication was not working and she needed something else. The origin of the pain was listed as [MEDICAL CONDITION] and chronic, non-healing pressure ulcers. An assessment of how pain has interfered with the resident's ability to perform ADL's within the prior 24 hours, from 0-10 with 0 being Does not interfere and 10 being completely interferes the resident scored 7/10. The areas affected were indicated as; ability to ambulate, bathing, dressing, enjoyment of daily activities, mood, sleeping and toileting. An assessment of how much pain relief the resident had received from pain medication and/or therapy provided with 0% being no relief and 100% being relief of pain, the resident had 50% relief of pain with pain medication. A progress note on the SBAR revealed LVN A called the resident's family member and notified him/her the resident (was) not allowing ADL care stating that she is in pain. And that she wanted to go to the ER (emergency room ) . The resident's physician was notified at 1:00 p.m. of the resident's status and the resident was transferred to the emergency room by ambulance. emergency room discharge instructions printed 01/19/18 at 12:10 a.m. reflected a [DIAGNOSES REDACTED]. She received two liters of normal saline via intravenous infusion, blood tests, a urinalysis, x-rays of her left foot and pelvis and a computed tomography (CT) imaging of her chest, abdomen and pelvis. Discharge Instructions for Chronic Pain included; .Treatment .You may be referred to a pain specialist. He or she may prescribe medicine or therapies, such as: Mindfulness meditation or yoga Shots (injections) of numbing or pain-relieving medicines into the spine or area of pain Local electrical stimulation Acupuncture Massage Therapy Aroma, color, light, or sound therapy Biofeedback Working with a physical therapist to keep from getting stiff Regular, gentle exercises Cognitive or behavioral therapy Group support Sometimes, surgery may be recommended Results of the testing performed while in the emergency room were not available at the facility. Resident #1's MDS assessment dated [DATE], reflected she had an unstageable pressure ulcer of the right heel which was present upon re-admission to the facility (08/24/17) that measured 3cm length (L) x 3cm width (W) x 1 cm depth (D). She had no other pressure ulcers documented. Review of Resident #1's Wound Care Physician's initial evaluation of Resident #1dated 08/28/17 reflected; Site #1: Stage II Pressure wound of right lateral hip 0.7 x 1 x 0.1cm Site #2: Stage II Pressure wound of the Medial Sacrum (low back) 07 x 0.7 x 0.1cm Site #3: Unstageable DTI (deep tissue injury) of the Left Lateral Foot 2.5 x 2 x Not measurable Site #4: Unstageable DTI of the Right Distal, Medial Foot 2 x 1.2 x Not Measurable Site #5: Unstageable DTI of Right Medial Heel 6 x 5 x Not Measurable Factors complicating wound healing: Diabetes Mellitus without mention of complication . Recommendations included to reposition per facility policy Height 52 inches, weight 171 lb's Review of the Resident#1's subsequent Wound Care evaluations revealed; 09/04/17 Site#4 wound had resolved Twelve evaluations presented for reviewed from 11/06/17 through 01/22/18 revealed there was no further mention of sites other than Site #5 Unstageable DTI, which was debrided of necrotic (dead) tissue five times and on 01/22/18 Site #5 measured 0.44 x 0.6 x 0.3cm On 01/29/18 Site#6 Stage II of left posterior buttock 4.5 x 0.6 x 0.1 (Initial evaluation) Site #5 remained an unstageable DTI measuring 0.4 x 0.6 x 0.3cm Factors complicating wound healing included Non-adherence to plan of care. Appetite was listed as Good Review of Resident #1's physician's orders [REDACTED]. 1. Start Date: 01/29/18 left posterior buttock wound 2. Start Date: 01/29/18 Pressure ulcer of right medial heel, unspecified stage 3. Start Date: 02/01/18 Left lateral hip blister 4. Start Date: 02/01/18 Left posterior thigh blister 5. Start Date: 02/01/18 left medial thigh blister Online resource accessed on 02/09/18 at 11:45 a.m. The National Pressure Ulcer Advisory Panel (NPUAP) http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis .may also present as an intact or ruptured serum-filled blister .These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration .This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue .are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Review of Resident #1's electronic Treatment Administration Record (eTAR) and eTAR Notes, dated (MONTH) (YEAR) revealed when the wound care treatment was performed the nurse would indicate this with her initials. When the procedure was not performed an N would take the place of the nurses' initials and the reason the procedure was not performed was documented in the eTAR notes; Start Date: 10/04/17 Apply [MEDICATION NAME] to coccyx area daily at 9:30 p.m. The resident received all treatments except 01/17/18 was refused by resident Treatment was discontinued on 01/23/18 Start Date: 10/12/17 Cleanse right hip area with normal saline or wound cleanser, pat dry apply collagen and anecept then foam dressing daily and PRN until healed to be performed at 9:30 p.m. The resident received all treatments until 01/17/18 was refused by resident Treatment was discontinued on 01/19/18 Start Date: Cleanse right heel with normal saline or wound cleanser, apply santyl with metro gel 1% then calcium alginate then cover with border gauze daily at 9:30 p.m. The resident received all treatments except 01/17/18, 01/21/18 and 01/24/18 was refused by resident Treatment was discontinued on 01/29/18 Start Date: 11/28/17 Cleanse skin tear on left hip with normal saline pat dry apply [MEDICATION NAME] with dressing daily at 9:30 p.m. The resident received all treatments except 01/17/18 and 01/19/18was refused by resident Treatment was discontinued on 01/19/18 Start Date: 01/12/18 Cleanse wound on left hip and left back with normal saline pat dry and apply [MEDICATION NAME] with dry dressing. The resident received all treatments except 01/17/18, 01/19/18, 01/21/18 and 01/22/18 was refused by resident Treatment was discontinued on 01/23/18 Start Date: 01/23/18 Cleanse wound to left hip with normal saline or wound cleanser, pat dry, then apply collagen, [MEDICATION NAME] with foam dressing daily and PRN at 9:30 p.m. The resident received all treatments except 01/24/18 was refused by resident Treatment was discontinued on 01/29/18 Start Date: 01/29/18 Cleanse right medial heel with normal saline or wound cleanser, apply skin prep to peri-wound, then apply calcium alginate, collagen then cover with foam dressing daily until healed The resident received all treatments through 01/31/18 The resident did not receive a treatment on 02/01/18 was refused by resident Start Date: 02/01/18 Left lateral hip blister apply skin prep and leave open to air until healed The resident did not receive a treatment on 02/01/18 was refused by resident Start Date: 02/01/18 Left medial thigh blister apply skin prep and leave open to air until healed The resident did not receive a treatment on 02/01/18 was refused by resident Start Date: 01/29/18 Cleanse wound on left posterior buttock with normal saline or wound cleanser, pat dry, then apply collagen with foam dressing daily until healed The resident received all treatments through 01/31/18 The resident did not receive a treatment on 02/01/18 was refused by resident Interview 02/06/18 at 12:50 p.m. with LVN A, Wound Care Nurse, she stated she assumed wound care responsibility for Resident #1 approximately 2 weeks ago. She stated other nurses had advised her the resident would frequently refuse wound care but the resident had not refused WC during the time she has been caring for the resident. She stated she ensured pain medication and PRN pain medication had been given prior to wound care. She stated when she had assisted the wound care physician on 02/05/18 they entered Resident #1's room and found she was lying on her right side, which, she said was unusual as the resident usually always lies on her left side due to right hip pain. She stated wound care was performed and the resident tolerated it well. She stated the resident appeared to be in less pain than usual. She stated she was the nurse caring for the resident on 01/18/18, the resident had complained of pain, that did not appear more severe than usual, but she had refused PRN pain medication, the next thing I knew she had called the ambulance. She stated the resident did accept pain medication when EMS arrived but she was unsure what medication she had given the resident. She stated that upon re-admission (08/24/17) the resident had a pressure ulcer on her heel which has healed. She then had pressure ulcers on her right and left hip which have healed. Currently she has boils which can be caused by unclean skin, on her left thigh, left hip and her inner Left thigh. She was not aware the resident was out of pain medications at any time. She stated she had spoken with the resident's physician regarding the resident's pain and he had ordered [MEDICATION NAME] ER. Interview 02/06/18 at 07:57 a.m. with Resident #1's Wound Care physician who stated several months ago he was concerned due to the resident's extreme amount of pain when turned so he ordered hip x-rays. The x-rays showed no significant arthritis but the resident did need hip replacement surgery but no-one would touch her due to underlying health issues. He stated he believed some of the resident's pain may be related to psychological issues. He stated Resident #1 had refused to allow him to perform wound care on 1-2 occasions, he was not sure if it was due to the resident being in pain or that she did not want him moving her. The resident refused to straighten her right leg and had started to get contractures. He stated I absolutely believe her refusal to allow turning, peri-care and showers is a cause of her further pressure ulcers and the current skin infections! He stated the resident's right hip pain was causing her refusal of care and her heel ulcer was from the resident not allowing staff to turn her. He stated the resident tended to stay on her left side and the resident's left hip started with blisters that now look like pin-point holes due to infection from lying in feces. He stated he saw the resident on 02/05/18 (following addition of a [MEDICATION NAME] on 02/03/18) and she was much more receptive to being turned and allowing care to be performed. Nurses Notes, dated 01/12/18 at 9:48 p.m. reflected Resident #1 was noted to have an open wound on the left side of her back and an open blister on her left hip. The nurse informed Resident #1 that resident needs to start allowing the Certified Nurses' Aide (CNA) to turn her to her right side because (the) resident is constantly on her left side, during wound care resident will not allow this nurse and CNA to turn her to right side and clean the wound, resident noted to be screaming, after several attempt resident allow {sic} this nurse and CNA to turn her, resident responsible party (name) notified, DNS (Director of Nursing Services) called message left to call facility back. Nurses Notes, dated 01/13/18 at 1:48 a.m. reflected Staff x 2 assist resident with repositioning on to back. As needed pain medication administered to relief of pain . Nurses Notes, dated 01/13/18 at 05:53 a.m. reflected Resident refuses to allow staff to reposition in bed. Resident states 'I just positioned myself to where I am comfortable.' Staff encourage resident to allow staff to reposition. Resident refused . Nurses Notes, dated 01/15/18 at 6:09 p.m. reflected This nurse in resident room for wound care to left back and left hip, resident in room crying screaming will no (sic) allow this nurse or CNA to turn her, after several attempt (sic) and education resident allow this nurse to clean her wound and apply dressing per order resident noted screaming and crying, after wound care this nurse and CNA try to reposition resident to her right side resident refuse (sic) started screaming and crying loud, will not allow this nurse and CNA to turn her to right side. Nurses Notes, dated 01/16/18 at 12:17 a.m. reflected Resident refused to allow staff to turn to right side. Resident allow (sic) staff to turn slightly to back using pillow . Nurses Notes, dated 01/17/18 at 1:48 a.m. reflected This nurse received a call from resident responsible party (name) inform (sic) this nurse that resident called to tell her she (sic) not feeling good . in resident room to assess resident, resident inform (sic) this nurse that she is having pain on both hips rate pain 8/10 . offer to reposition resident, resident refuse (sic), routine [MEDICATION NAME] and [MEDICATION NAME] administer {sic) to resident, resident refuse (sic) to eat her supper .resident (family member) notified that resident refuse to allow this nurse and CNA to turn her . resident will not allow this nurse to do wound care, after two hours PRN Tylenol #3 administer (sic) to resident, resident reassessed after one hour medication effective. Nurses Notes, dated 01/17/18 at 11:47 p.m. reflected .in room to reposition resident. Resident states 'No, I have been hurting all day and I am just getting settled down .No don't move my bed it may get my hip to hurting again moving the bed around' Routine [MEDICATION NAME] given. Call light within reach. Nurses Notes, dated 01/18/18 at 2:56 p.m. reflected . informed (family member) that resident not allowing ADL care stating she is in pain. And that she wanted to go to the ER. Phoned NP (Nurse Practitioner) informing of situation and new orders were to send to ER . Nurses Notes, dated 01/19/18 at 1:46 a.m. reflected Resident returned from (hospital name) with no new orders noted . Resident noted yelling out 'No' when staff attempting to remove soiled linens . Resident grabbing staff stating 'it hurts' while providing care. Resident given Tylenol #3 upon return from hospital for complaints of pain. Resident refusing to allow staff to position with pillows or turn on back . Nurses Notes, dated 01/19/18 at 9:49 p.m. reflected the nurse advised Resident #1 she needed to assess the dressing to the wound on her back to ensure it was intact, the resident stated I cannot turn to the right side for you but I will turn a little to the right the nurse determined the dressing required changing and informed the resident who stated she could not turn for wound care to be performed, she allowed the nurse to perform wound care to her right heel, the resident refused a shower. Routine [MEDICATION NAME] and [MEDICATION NAME] had been administered 30 minutes prior to wound care. Nurses Notes, dated 01/24/18 at 9:45 p.m. reflected the resident refused wound care stating she had sat in her wheelchair too long on 01/23/18 and she did not want to be touched. The resident informed the nurse she would allow her to perform wound care on 01/25/18. The nurse administered routine pain medications and after one hour, Tylenol #3 was administered, the resident continued to refuse wound care. Nurses Notes, dated 01/30/18 at 12:48 p.m. reflected a late entry for 01/29/18 the wound care physician had seen the resident. Notes reflected; Unstageable to right medial heel 0.4 x 0.6 x 0.3 with 100% granulated tissue and moderate serous drainage. Wound noted with improvement from last week. Wound doctor using chemical cauterization of hypergranulated tissue using topical anesthetic for pain management. Resident tolerating procedure well. Stage 2 pressure ulcer to left posterior buttock 4.5 x 0.6 x 0.1 with moderate serous drainage. Treatment orders Collagen with foam dressing. Resident with no complaint of pain to wound area. Resident complains of pain to right hip. Medications given per MD orders. Resident is consistent with noncompliance with turning and repositioning. She refuses showers and ADL care daily. Nurses Notes, dated 01/31/18 at 5:05 p.m. reflected the resident complained of pain and refused to allow staff to turn her and perform incontinent care although she was heavily soiled and bed sheets required changing. Resident stated that she needed to talk to someone because she feels that her family has just left her in the facility to rot. She can't see her grandchildren. Her phone is not working and that she can't talk to anyone. Resident began crying stating 'I want to see my family, I feel alone. The nurse advised the resident she would notify Social Services of her request to speak with a psychiatrist. Pain medication was administered and staff returned to perform ADL care. Resident crying and yelling before staff touched the bed stating 'I want to see my family'. ADL care performed with staff being very gentle. Assessment of the resident's skin revealed; Fluid-filled blister to left lateral hip measuring 3.0 x 1.0cm Fluid-filled blister to left posterior thigh 1.6 x 1.4cm The physician was notified of the new [MEDICAL CONDITION] and new orders were received. Nurses Notes, dated 02/01/18 at 1:40 p.m. reflected the nurse had attempted multiple times to perform wound care to the residents hip, thigh, heel and buttocks but the resident complained of pain 7-10/10 all over. Resident visibly crying out in pain saying Don't touch me I hurt too bad. Scheduled nurse notified. Nurses Notes, dated 02/01/18 at 2:30 p.m. reflected Resident #1 complained of pain 7/10 and refused wound care. Resident was visibly crying out in pain. Resident stated 'I am just in too much pain right now to get my wounds done' Resident not letting aides turn her. Resident stated 'I am constantly in pain and my pain level never goes below 3/10. The pain medicine helps a lot but my body continues to ache.' Resident states she is currently at a 3/10.' Educated resident on the importance of her being changed frequently and resident stated 'I know but when I am in too much pain, I just can't be touched. It hurts too much. Pulled PRN Tylenol #3 out of e-kit for breakthrough pain. Observation of Resident #1 on 02/01/18 at 09:17 a.m. revealed she was lying in bed on her left side with her head almost covered by a sheet. Her right hand was open and lying on her right hip in a protective manner. When questioned, the resident spoke quietly and with a facial grimace as she complained she was experiencing spasms in her right hip at a pain level of 7/10. She stated she had just been given her pain medication and the pain was decreasing. She stated the pain medication usually decreased her pain for two to three hours but her pain never went away. She further stated, if her pain was down to a level of 2-3/10 she was able to sit on the side of her bed, that she would like to get up into her wheelchair but it was too painful for her. She would request a PRN pain medication but that only helped a little. She stated that on 01/18/18 she called 911 because she was in severe pain and no-one would listen to me she stated she told the CNA but staff just closed her door because she was screaming and hollering for help. When she returned from the hospital someone told her she should have told someone and they would have called 911. She told the person she did, but no-one would listen. She stated the bed sore on her Right hip had healed but she screams and hollers due to the pain from arthritis in her hips and knees. She stated she has refused peri-care and wound care and showers due to pain. She stated it was too painful for her to sit in the shower chair so she would give herself a bed bath and sometimes staff would assist her. She stated staff had put her in a bed lift but it hurt too badly, even when she put towels on each hip to try to cushion them. Interview 01/26/1/ at 2:32 p.m. with the EMT-Paramedic who transported Resident #1 to the emergency room (ER) on 01/18/18. He/she stated Resident #1 had contacted 911 herself, when Emergency Medical Services (EMS) arrived at the facility, staff was aware that the resident had contacted 911 and was giving the resident a pain medication. He stated the resident was in bed and was crying out in pain when EMS arrived. The resident stated she had two pressure ulcers and they were the cause of her pain. Facility staff (unknown name) confirmed the resident had two pressure ulcers that were causing her pain. The staff person stated she had just given the resident her routine pain medication and that the resident would not allow them to change her brief and keep her clean. The Paramedic stated the resident was covered in urine and feces. EMS transported the resident to the hospital Interview 02/01/18 at 09:45 a.m. with LVN B, Resident #1's nurse who stated Resident #1 complained of pain a lot. She stated when she went in to give resident her [MEDICATION NAME] and [MEDICATION NAME] medications this morning the resident was crying and complained of a pain level of 10/10. The best the resident's pain ever got was 3/10 but the pain never went away. She stated the resident also had an order for [REDACTED]. She stated she had not spoken with the resident's physician regarding the resident's pain but she believed the 2:00 p.m. to 10:00 p.m. nurse had told him the resident wanted to get out of bed but couldn't due to the increased pain this caused. She stated the resident would allow peri-care to be performed but she will be screaming in pain. She stated the wound care nurse would arrive to perform the resident's wound care at 09:00 a.m. in order to allow time for the morning pain medications to work, but even with the medication, the resident will scream during wound care. Observation 02/01/18 at 10:44 a.m. with LVN C who stated the usual wound care nurse was absent today so she would perform Resident #1's wound care. Resident#1 refused to allow wound care to be performed stating she was having spasms in her right hip with a pain level of 7/10. The resident refused to allow LVN C to re-position her, stating she hurt too badly. LVN C advised the resident she would check with her nurse and get a PRN pain medication. Observation 02/01/18 at 10:46 a.m. LVN C spoke with LVN A and requested PRN pain medication for Resident #1. LVN A stated the resident had no Tylenol #3 available, she had given the resident a PRN Tylenol 500mg tablet this morning and she did not think the resident could have another one yet. LVN A stated the resident's next scheduled pain medication was at noon. On 02/01/18 at 12:43 p.m. A phone call was placed to Resident #1's physician the mailbox was full. On 02/01/18 a phone call was placed to the physician's answering service and requested the physician contact me. Interview 02/01/18 at 12: 47 p.m. Resident #1's Physician's Assistant returned my call. He stated Resident#1's physician was on vacation. He did not remember Resident #1 and did not remember the resident's physician speaking of her. He was unable to access the files of Resident #1. He stated he would have Resident #1's physician contact me. No contact from the resident's physician was received prior to the completion of the investigation on 02/03/18. On 02/01/18 at 1:00 p.m. a phone call was placed to Resident #1's Wound Care Physician and a voicemail was left requesting he call regarding Resident #1. Interview 02/01/18 at 1:43 p.m. with the Director of Nursing Services (DNS) who stated she had been the DNS at the facility since 12/29/17. She stated LVN B had obtained Tylenol #3 tablets from the emergency medication kit (e-kit)

Based on observation, interview and record review, the facility failed to ensure that 1 of 6 residents (Resident # 1) reviewed for pain management received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. 1. The facility failed to adequately monitor Resident #1's pain by documenting using an appropriate pain scale and follow-up method, and did not offer non-pharmacological interventions to try to relieve the resident's pain. As a result, the resident continued to experience significant and unrelieved pain, and refused to participate in treatments and activities of daily living. Resident #1 visited the emergency roiagnom on [DATE] due to her pain severity. 2. The facility failed to have Resident #1's PRN Tylenol 3 available from 01/27/18 through 02/01/18. 3. The facility failed to have Resident #1's routine [MEDICATION NAME] available on 01/02/18 and 01/13/18 through 01/14/18. 4. The facility failed to have Resident #1's routine [MEDICATION NAME] available on 01/30/18. An immediate Jeopardy (IJ) was identified on 02/02/18. While the IJ was removed on 02/03/18, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. This failure could affect all 102 residents, who relied on facility staff to ensure their needs were met and placed them at risk for lack of appropriate care and treatment. Findings included: 1. Resident #1's MDS assessment dated [DATE], reflected she was a [AGE] year-old female, who was re-admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had a moderately impaired cognition and had no behaviors. She required the assistance of one person with ADLs and was incontinent of both bowel and bladder. She had limited mobility in one lower extremity and required the assistance of one person with transfers to her wheelchair. She was considered at risk for pressure ulcers. She received routine and as needed (PRN) opioid pain medication. She had frequent pain at a level of 5/10 using a 0-10 pain scale, with 0 being no pain and 10 being the worst pain imaginable. Resident #1's Admission Clinical Health Status assessment dated [DATE] reflected the resident complained of frequent, moderate, radiating pain, described as stabbing and throbbing which impacted her daily life affecting her sleeping and mood. Symptoms associated with the pain were anxiety. Possible causes of the pain were listed as arthritis and pressure wounds. She was resistant to care. The Skin Condition component of the assessment had not been completed. A narrative note revealed Pt (patient) complains of chronic lower back spasms and hip pain . Resident #1's Care Plan updated 12/11/17 reflected; Problem Onset: 07/20/16, I am at risk for or am experiencing the presence of constant pain related to [MEDICAL CONDITION]. Goal and Target Date: I will verbalize relief of pain 11/28/17 Approaches included: Evaluate my pain daily using 1-10 pain scale, administer my pain medications as ordered, monitor for worsening of my pain symptoms and report to physician, assess need for preventive pain measures prior to ADLs, treatments etc. There had been no updates to the pain plan of care since 07/20/16. physician's orders [REDACTED]. Order Start date 08/24/17: Tylenol 325mg table 1 tablet every 6 hours as needed for pain Order Start date 08/24/17: [MEDICATION NAME] ER 30mg 1 tablet every 12 hours Order Start date 08/24/17: [MEDICATION NAME] ([MEDICATION NAME]) 5/325mg 1 tablet every 4 hours while awake Order Start date 08/24/17: [MEDICATION NAME] 500mg 1 tablet twice a day - off-label use in neuropathic pain Order Start date 08/25/17: Tylenol with [MEDICATION NAME] 300/30 mg 2 tablets every 6 hours as needed for pain Order Start date 10/30/17:[MEDICATION NAME](muscle relaxant) 350mg 1 tablet every 12 hours Review of Resident #1's Individual Control Drug Records, which indicated the date the medication was delivered to the facility on the label affixed to the record, revealed Tylenol #3 2 tablets every 6 hours as needed for pain, delivery date 12/20/17 01/08/18 at 8:00 p.m. only 1 Tylenol #3 was administered 01/14/18 at 11:00 a.m. only 1 Tylenol #3 was administered then there was no medication left to count (LTC) Record delivery date 01/09/18 01/23/18 at 10:00 a.m. only 1 Tylenol #3 was administered 01/24/18 at 11:00 a.m. only 1 Tylenol #3 was administered 01/27/18 at 08:00 a.m. 2 Tylenol #3 were administered then there was no medication LTC Review of Resident #1's Individual Control Drug Records for [MEDICATION NAME] ER 30mg 1 tablet every 12 hours Revealed Record delivery date 12/28/17 reflected; 01/02/18 at 09:00 a.m. 1 tablet administered then there was no medication LTC Record delivery date 01/02/18 reflected; 01/03/18 at 07:00 a.m. 1 tablet administered There was no medication available and the resident was not given a dose on 01/02/18 at 9:00 p.m. Online resource https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 23/ accessed 02/16/18 revealed ER (extended release) formulations are specifically designed to allow a controlled release of the active agent to provide relatively consistent and prolonged plasma drug levels with lower maximum concentration and fewer peak-to-trough fluctuations .In contrast, ER formulations are dosed less frequently (one to three times per day or fewer), allowing for less fluctuation and affording an elongated duration within the therapeutic window. Record delivery date 01/07/18 reflected; 01/13/18 at 08:00 a.m. 1 tablet administered then there was no medication LTC Record delivery date 01/15/18 reflected; 01/15/18 at 8:00 a.m. 1 tablet administered There was no medication available and the resident did not receive a dose on 01/13/18 at 8:00 p.m., on 01/14/18 at 08:00 a.m. and 8:00 p.m. Review of Resident #1's Individual Control Drug Records for [MEDICATION NAME] 1 tablet every 4 hours revealed Record delivery date 01/24/18 reflected; 01/30/18 at 12:00 a.m. 1 tablet administered then there was no medication LTC Record delivery date 01/30/18 reflected; 01/30/18 at 4:00 p.m. 1 tablet administered There was no medication available and the resident did not receive a dose of [MEDICATION NAME] on 01/30/18 at 04:00 a.m., 08:00 a.m. and 12:00 p.m. Review of a Situation, Background, Assessment, Recommendation, (SBAR) dated 01/18/18 and completed by LVN A, revealed Resident #1 had worsening uncontrolled pain rated 10/10. The resident appeared grossly agitated and stated her medication was not working and she needed something else. The origin of the pain was listed as [MEDICAL CONDITION] and chronic, non-healing pressure ulcers. An assessment of how pain had interfered with the resident's ability to perform ADLs within the prior 24 hours, from 0-10 with 0 being Does not interfere and 10 being completely interferes, the resident scored 7/10. The areas affected were indicated as; ability to ambulate, bathing, dressing, enjoyment of daily activities, mood, sleeping and toileting. An assessment of how much pain relief the resident had received from pain medication and/or therapy provided with 0% being no relief and 100% being relief of pain, the resident had 50% relief of pain with pain medication. A progress note on the SBAR revealed LVN A called the resident's family member and notified him/her the resident (was) not allowing ADL care stating that she is in pain. And that she wanted to go to the ER (emergency room ) . The resident's physician was notified at 1:00 p.m. of the resident's status and the resident was transferred to the emergency room by ambulance. emergency room discharge instructions printed 01/19/18 at 12:10 a.m. reflected a [DIAGNOSES REDACTED]. She received two liters of normal saline via intravenous infusion, blood tests, a urinalysis, x-rays of her left foot and pelvis and a computed tomography (CT) imaging of her chest, abdomen and pelvis. Discharge Instructions for Chronic Pain included; .Treatment .You may be referred to a pain specialist. He or she may prescribe medicine or therapies, such as:Mindfulness meditation or yoga. Shots (injections) of numbing or pain-relieving medicines into the spine or area of pain. Local electrical stimulation. Acupuncture. Massage Therapy. Aroma, color, light, or sound therapy BiofeedbackWorking with a physical therapist to keep from getting stiff regular, gentle exercisesCognitive or behavioral therapy Group support, Sometimes, surgery may be recommended. Results of the testing performed while in the emergency room were not available at the facility. 2. Resident #1's MDS assessment dated [DATE], reflected she had an unstageable pressure ulcer of the right heel which was present upon re-admission to the facility (08/24/17) that measured 3cm length (L) x 3cm width (W) x 1 cm depth (D). She had no other pressure ulcers documented. Nurses Notes, dated 01/17/18 at 1:48 a.m. reflected This nurse received a call from resident responsible party (name) inform (sic) this nurse that resident called to tell her she (sic) not feeling good . in resident room to assess resident, resident inform (sic) this nurse that she is having pain on both hips rate pain 8/10 . offer to reposition resident, resident refuse (sic), routine [MEDICATION NAME] and [MEDICATION NAME] administer {sic) to resident, resident refuse (sic) to eat her supper .resident (family member) notified that resident refuse to allow this nurse and CNA to turn her . resident will not allow this nurse to do wound care, after two hours PRN Tylenol #3 administer (sic) to resident, resident reassessed after one hour medication effective. Nurses Notes, dated 01/17/18 at 11:47 p.m. reflected, .in room to reposition resident. Resident states 'No, I have been hurting all day and I am just getting settled down .No don't move my bed it may get my hip to hurting again moving the bed around' Routine [MEDICATION NAME] given. Call light within reach. Nurses Notes, dated 01/18/18 at 2:56 p.m. reflected . informed (family member) that resident not allowing ADL care stating she is in pain. And that she wanted to go to the ER. Phoned NP (Nurse Practitioner) informing of situation and new orders were to send to ER . Nurses Notes, dated 01/19/18 at 1:46 a.m. reflected Resident returned from (hospital name) with no new orders noted . Resident noted yelling out 'No' when staff attempting to remove soiled linens . Resident grabbing staff stating 'it hurts' while providing care. Resident given Tylenol #3 upon return from hospital for complaints of pain. Resident refusing to allow staff to position with pillows or turn on back . Nurses Notes, dated 01/19/18 at 9:49 p.m. reflected the nurse advised Resident #1 she needed to assess the dressing to the wound on her back to ensure it was intact, the resident stated I cannot turn to the right side for you but I will turn a little to the right the nurse determined the dressing required changing and informed the resident who stated she could not turn for wound care to be performed, she allowed the nurse to perform wound care to her right heel, the resident refused a shower. Routine [MEDICATION NAME] and [MEDICATION NAME] had been administered 30 minutes prior to wound care. Nurses Notes, dated 01/24/18 at 9:45 p.m. reflected the resident refused wound care stating she had sat in her wheelchair too long on 01/23/18 and she did not want to be touched. The resident informed the nurse she would allow her to perform wound care on 01/25/18. The nurse administered routine pain medications and after one hour, Tylenol #3 was administered, the resident continued to refuse wound care. Nurses Notes, dated 01/31/18 at 5:05 p.m. reflected the resident complained of pain and refused to allow staff to turn her and perform incontinent care although she was heavily soiled and bed sheets required changing. Resident stated that she needed to talk to someone because she feels that her family has just left her in the facility to rot. She can't see her grandchildren. Her phone is not working and that she can't talk to anyone. Resident began crying stating 'I want to see my family, I feel alone.' The nurse advised the resident she would notify Social Services of her request to speak with a psychiatrist. Pain medication was administered and staff returned to perform ADL care. Resident crying and yelling before staff touched the bed stating 'I want to see my family'. ADL care performed with staff being very gentle. Assessment of the resident's skin revealed: Fluid-filled blister to left lateral hip measuring 3.0 x 1.0cm Fluid-filled blister to left posterior thigh 1.6 x 1.4cm. The physician was notified of the new [MEDICAL CONDITION] and new orders were received. Nurses Notes, dated 02/01/18 at 2:30 p.m. reflected Resident #1 complained of pain 7/10 and refused wound care. Resident was visibly crying out in pain. Resident stated 'I am just in too much pain right now to get my wounds done' Resident not letting aides turn her. Resident stated 'I am constantly in pain and my pain level never goes below 3/10. The pain medicine helps a lot but my body continues to ache.' Resident states she is currently at a 3/10.' Educated resident on the importance of her being changed frequently and resident stated 'I know but when I am in too much pain, I just can't be touched. It hurts too much.' Pulled PRN Tylenol #3 out of e-kit for breakthrough pain. Observation of Resident #1 on 02/01/18 at 9:17 a.m. revealed she was lying in bed on her left side with her head almost covered by a sheet. Her right hand was open and lying on her right hip in a protective manner. When questioned, the resident spoke quietly and with a facial grimace as she complained she was experiencing spasms in her right hip at a pain level of 7/10. She stated she had just been given her pain medication and the pain was decreasing. She stated the pain medication usually decreased her pain for two to three hours, but her pain never went away. She further stated, if her pain was down to a level of 2-3/10, she was able to sit on the side of her bed. She said that she would like to get up into her wheelchair but it was too painful for her. She would request a PRN pain medication, but that only helped a little. She stated that on 01/18/18 she called 911 because she was in severe pain and no-one would listen to me. She stated she told the CNA but staff just closed her door because she was screaming and hollering for help. When she returned from the hospital someone told her she should have told someone and they would have called 911. She told the person she did, but no-one would listen. She stated the pressure ulcer on her right hip had healed, but she screams and hollers due to the pain from arthritis in her hips and knees. She stated she has refused peri-care and wound care and showers due to pain. She stated it was too painful for her to sit in the shower chair so she would give herself a bed bath and sometimes staff would assist her. She stated staff had put her in a bed lift but it hurt too badly, even when she put towels on each hip to try to cushion them. Interview on 01/26/18 at 2:32 p.m. with the EMT Paramedic who transported Resident #1 to the emergency room (ER) on 01/18/18 revealed Resident #1 had contacted 911 herself. When Emergency Medical Services (EMS) arrived at the facility, staff was aware that the resident had contacted 911 and was giving the resident a pain medication. He stated the resident was in bed and was crying out in pain when EMS arrived. The resident stated she had two pressure ulcers and they were the cause of her pain. Facility staff (unknown name) confirmed the resident had two pressure ulcers that were causing her pain. The staff person stated she had just given the resident her routine pain medication and that the resident would not allow them to change her brief and keep her clean. The Paramedic stated the resident was covered in urine and feces. EMS transported the resident to the hospital. Interview on 02/01/18 at 9:45 a.m. with LVN B, Resident #1's nurse, stated Resident #1 complained of pain a lot. She stated when she went in to give resident her [MEDICATION NAME] and [MEDICATION NAME] medications this morning, the resident was crying and complained of a pain level of 10/10. The best the resident's pain ever got was 3/10, but the pain never went away. She stated the resident also had an order for [REDACTED]. She stated staff did get the resident out of bed on 01/31/18 and she was able to propel herself around the building, but usually the resident refuses to get up due to pain. She stated she had not spoken with the resident's physician regarding the resident's pain, but she believed the 2:00 p.m. to 10:00 p.m. nurse had told him the resident wanted to get out of bed but could not due to the increased pain this caused. She stated the resident would allow perineal care to be provided, but she will be screaming in pain. She stated the wound care nurse would arrive to provide the resident's wound care at 9:00 a.m. in order to allow time for the morning pain medications to work, but even with the medication, the resident will scream during wound care. Observation on 02/01/18 at 10:44 a.m. with LVN C, who stated the usual wound care nurse was absent today so she would be providing Resident #1's wound care, revealed Resident #1 refused to allow wound care to be performed stating she was having spasms in her right hip with a pain level of 7/10. The resident refused to allow LVN C to reposition her, stating she hurt too badly. LVN C advised the resident she would check with her nurse and get a PRN pain medication. Observation on 02/01/18 at 10:46 a.m. revealed LVN C spoke with LVN A and requested PRN pain medication for Resident #1. LVN A stated the resident had no Tylenol #3 available, so she had given the resident a PRN Tylenol 500mg tablet this morning and she did not think the resident could have another one yet. LVN A stated the resident's next scheduled pain medication was at noon. On 02/01/18 at 12:43 p.m. a phone call was placed to Resident #1's physician the mailbox was full. On 02/01/18 a phone call was placed to the physician's answering service and requested the physician contact me. Interview on 02/01/18 at 12:47 p.m. with Resident #1's Physician's Assistant revealed Resident#1's physician was on vacation. The Physician's Assistant did not remember Resident #1 and did not remember the resident's physician speaking of her. He was unable to access the files of Resident #1. He stated he would have Resident #1's physician make contact to assist with answering questions regarding the resident. No contact from the resident's physician was received prior to the completion of the investigation on 02/03/18. On 02/01/18 at 1:00 p.m., a phone call was placed to Resident #1's Wound Care Physician and a voicemail was left requesting he call regarding Resident #1. Interview on 02/01/18 at 1:43 p.m. with the Director of Nursing Services (DNS), who stated she had been the DNS at the facility since 12/29/17, revealed LVN B had obtained Tylenol #3 tablets from the emergency medication kit (e-kit) and administered them to Resident #1 at 11:00 a.m. She stated the pharmacy must have a triplicate in hand in order to allow the nurse to access the e-kit. A request to see the e-kit Medication Administration Record from 01/01/18 to 02/01/18 to see if Resident #1 was administered Tylenol #3 from the e-kit on previous occasions revealed the resident was only administered Tylenol #3 on 02/01/18. The DON stated of the resident's controlled pain medications, only Tylenol #3 was available in the e-kit. She stated she had spoken with the resident's physician on 01/18/18 regarding pain control and he had said he did not want to order more pain medication for the resident as he did not want the resident sleeping all the time. He said the resident should be sent to the ER. She stated no new pain medication was ordered following the resident's visit to theER on [DATE] for uncontrolled pain. Upon review of Resident #1's controlled drug records along with the DNS, she stated she had not been aware the resident had been out of medications. She believed each nurse thought the other had re-ordered the pain medications and this was why medications had not been available at times. She would have expected the nurses to order the medications early enough to ensure the resident did not run out. She said the goal of pain management was to keep the resident comfortable with routine pain medication. If the resident required more than occasional use of PRN pain medication then the pain regimen should be reviewed as it would indicate the current pain regimen was no longer working. When questioned as to what other modalities of pain management were being used to attempt to control Resident #1's pain, such as referral to a pain management specialist for a comprehensive pain management program that included psychiatric services, she stated that a nurse practitioner had seen the resident to evaluate her for psychiatric services. (She was unable to provide documentation of the visits prior to the completion of the investigation on 02/03/18) and stated the resident had no order for an evaluation for psychiatric services. The DNS stated Resident #1 was very unhappy because her daughter had refused to bring her grandchildren to see the resident because the resident was not complying with the care plan which included ADL care, repositioning and wound care. In an interview on 02/01/18 at 1:57 p.m. with the facility's Social Worker (LMSW), she stated Resident#1 was seen by a nurse practitioner from a psychiatric service but she believed they were waiting for verification of psychiatric coverage by the resident's insurance, but she was not sure. A request to see any proof of nurse practitioner visits or contact with the resident's insurance for coverage concerns was not provided prior to the completion of the investigation 02/03/18. Observation and interview on 02/01/18 at 2:50 p.m. with Resident #1, who was positioned on her left side, revealed she complained of pain 5-6/10. She stated she would like to have no pain, but the lowest her pain ever got was 3/10 and she would sometimes be awoken during the night by painful spasms. She stated her last shower was 01/29/18 and was very painful for her. She stated she was able to turn herself a little today, but she had to turn back onto her left side because it was just too painful. She stated the facility had run out of her medication several times, and when they ran out of her [MEDICATION NAME] her pain became really severe. She was not sure what, or if, they gave her anything else instead. She said, I think they gave me Tylenol. When they run out of Tylenol #3 they give me regular Tylenol. Tylenol #3 doesn't help much and regular Tylenol doesn't help at all. She stated when the facility did not have her [MEDICATION NAME] she refused to have wound care or have her brief changed because the pain was too severe. She stated she did get up and into her wheelchair on 01/31/18 but the chair hurt her lower back and hips. She stated her right knee hurt her constantly and she slowly removed her top cover to reveal a swollen right knee. A pillow was placed between her right and left legs. The resident stated she gets very depressed because she is not used to being away from her family. She requested to see a psychiatrist, but she has not heard any more about it. Her pastor comes to see her and she talks to her, which helps. She stated she thought it would help if she could see a psychiatrist. Interview on 02/01/18 at 3:20 p.m. with LVN D revealed Resident #1 was always in pain. She stated when the resident first came to hall 100 (10/30/17), she was friendly and smiling even though she remained in bed most of the time. Now she did not seem as happy. She stated the resident may sit in her wheelchair, but only for about 30 minutes then she will have pain and start crying and need to get back into bed. The shower chair hurts her, and recently they had been using a shower bed, and the resident still had pain but it was better than the shower chair. On 01/17/18 she worked and the resident was having pain as usual, so she gave her [MEDICATION NAME] and a Tylenol #3. She was in a lot of pain, but nothing out of the ordinary. She stated when she came to work on 01/18/18 at 2:00 p.m., the resident was already at the hospital. She stated when a resident had only 10 tablets left of a controlled drug, she would fax the physician a request for a triplicate. She said she may refax it the next day or call the physician if they do not receive the triplicate. If there was any problem getting a medication, she would normally tell the DNS. She corrected herself and specified she would tell the former DNS as the new one had not been at the facility very long. She stated she would keep calling the physician until the medication arrived. Observation on 02/02/18 at 10:09 a.m. revealed Resident #1 lying on her left side, her right hand was covering her right hip and she was crying quietly. She complained her pain was 10/10. Upon questioning, the resident stated she had already had a PRN pain medication this morning and it was too soon to ask for more. Interview on 02/02/18 at 10:10 a.m. with LVN B and the Assistant Director of Nurses (the only ADON in the facility) at the medication care revealed LVN B was Resident #1's nurse that day (02/02/18). Upon advising her and the ADON that Resident #1 was crying and complained of pain 10/10, LVN B stated she had seen the resident at 8:00 a.m. that morning and her pain had been 6/10 at that time. When questioned, she stated it was not required that staff follow up to determine if the pain medication had been effective unless it was a PRN medication, so she did not see the resident again until 9:30 a.m. when the resident still complained of pain 6/10. She stated the resident had refused to allow staff to reposition her due to pain. When questioned if she had done anything to assist the resident with her pain at that time, she stated Resident #1 was constantly in pain. She stated the resident had not requested a PRN pain medicine at the time and she had not offered the resident one. She stated the lowest the resident's pain ever got was 3/10. She reviewed the MAR and stated the resident had not been administered a PRN pain medication that morning. Interview on 02/02/18 at 10:16 a.m. with the ADON, who when questioned as to what she would have done differently than LVN B when Resident #1 had no relief of pain following routine pain medication, she answered that when she was working on the floor, she would constantly ask the resident what her pain was because the resident was constantly in pain. She would try to monitor her pain between the routine pain medication doses to make sure the medication worked. Observation 02/02/18 at 10:21 a.m. LVN B and the ADON remained at the medication cart after being notified of Resident #1 pain level of 10/10. Observation and interview on 02/02/18 at 10:33 a.m. revealed Resident #1 lying on her left side crying and moaning with a reported pain level of 10/10. When asked if any staff had been in to see her, she stated, No, they haven't given me anything yet. Observation and interview on 02/02/18 at 10:34 a.m. revealed LVN B entered Resident #1's room and then returned to her medication cart. LVN B stated Resident #1 was crying and said she was having real bad muscle spasms, so she was going to give her a [MEDICATION NAME](muscle relaxant). In an interview on 02/02/18 at 10:51 a.m. with the DNS, she stated to monitor the effectiveness of pain medication she would be notified if a triplicate request for PRN pain medication was required prior to the expected date which would indicate more PRN pain medication doses had been administered than expected. If that were the case, she would consult with the physician or nurse practitioner (NP) to see what other modalities could be utilized, such as involving activities and family involvement, she would have the social worker get involved and reach out to psychiatric services, and possibly use [MEDICATION NAME] on the resident's pillow. She stated LVN B should have monitored the effectiveness of Resident #1's routine pain medication within 30 minutes of pain medication administration. When LVN B spoke to the resident at 9:30 a.m. and the resident was still experiencing pain, she should have determined if the resident had anything ordered to bring the pain under control. The DNS stated she was unable to provide any documentation that LVN B had received training on pain assessment and pain management since she was hired 12/22/17. She stated in order to ensure residents received appropriate pain management, residents who had pain issues were monitored for pain each shift, and each unit manager reviewed pain monitoring results to ensure pain medication was effective. She was unsure how frequently this was performed, but at least quarterly. A review of Resident #1's (MONTH) (YEAR) Medication Administration Record (MAR) along with the DNS revealed: Document signs/symptoms of pain or expresses discomfort 0= No 1= Yes, if yes, document on pain management form. Start date 08/25/17 The DNS stated she had not realized that pain was not documented using the 0-10 pain scale. She was not aware of a Pain Management Form. She stated there was no monitoring of pain pre- and post- administration of routine pain medication. She stated she should put something in place to monitor pre- and post- pain medication administration. In an interview on 02/02/18 at 11:30 a.m. with the Regional Nurse Consultant (RNC), she stated if a staff member indicated on the MAR the resident was experiencing pain by choosing 1 for Yes, then a pop-up on the computer would prompt the nurse to give a PRN pain medication. When the PRN pain medication had been administered the nurse would be prompted to re-evaluate the residents' pain and choose Yes/No to the presence of pain. The Pain Management Form alluded to on the MAR was actually the notes section within the electronic MAR where the follow-up pain assessment was documented. She stated there was only a prompt for re-evaluation of the pain if a PRN pain medication was administered. When questioned as to what would happen if the resident continued to experience pain following a PRN pain medication and staff chose 1/Yes again, she stated she believed other prompts would come up, but she was not sure what they were. She stated if a routine or PRN pain medication was given, the nurse was expected to follow up and notify the physician if the medication was not effective. Review of Resident #1's eMAR notes from 01/01/18 through 02/01/18 and the resident's eMAR notes from 01/21/18 through 01/31/18 revealed the following instructions: Document signs/symptoms of pain or expresses discomfort 0= No 1 = Yes, If yes document on Pain Management Form A request for Resident #1's Pain Management Forms from 01/01/18 through 02/02/18 were returned as Resident #1's Pain Management Form which was actually entitled Administration Record, e-TAR notes for (MONTH) (YEAR), from 01/01/18 through 01/19/18. Review of the provided Administration R (TRUNCATED)

Based on observation, interview and record review, the facility failed to ensure that 1 of 2 residents (Resident # 1) reviewed for pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to provide wound healing, prevent infection and prevent new ulcers from developing. The facility failed to ensure Resident #1 who had previously been compliant with wound care, began refusing wound care on 01/17/17 as a result of intolerable pain, received appropriate pain management and resulted in new pressure ulcers on 01/29/18 Stage II pressure ulcer left posterior buttock on 02/01/18 Left lateral hip blister, Left posterior thigh blister and left medial thigh blister. The facility failed to ensure physician ordered pain medications were available for Resident #1. There was no medication available and the resident was not given a dose of [MEDICATION NAME] ER 30mg 1 every 12 hours, on 01/02/18 at 9:00 p.m., on 01/13/18 at 8:00 p.m., on 01/14/18 at 08:00 a.m. and 8:00 p.m. There was no medication available and the resident was not given a dose of her [MEDICATION NAME] 5/325mg 1 every 4 hours, on 01/30/18 at 04:00 a.m., 08:00 a.m. and 12:00 p.m. Review of the resident's Tylenol #3, 2 tablets every 6 hours if needed(PRN) narcotic count sheet on 02/01/18 revealed there had been no Tylenol #3 available for the resident for PRN use since 01/27/18 at 08:00 a.m. as a result the resident called 911 on 01/18/18 for uncontrolled pain. An immediate Jeopardy (IJ) was identified on 02/02/18. While the IJ was removed on 02/03/18, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. This deficient practice could affect 2 residents, who were identified by the facility as having pressure ulcers at risk of worsening of the wound, infection, and inappropriate treatment. Findings included: Resident #1's MDS assessment dated [DATE], reflected she was a [AGE] year-old female, who was re-admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. She had no other [MEDICAL CONDITION]. The resident had a moderately impaired cognition and had no behaviors. She required the assistance of one person with ADL's and was incontinent of both bowel and bladder. She had limited mobility in one lower extremity and required the assistance of one person with transfers to her wheelchair. She was considered at risk for pressure ulcers. She received routine and as needed (PRN) opioid pain medication. She had frequent pain at a level of 5/10 using a 0-10 pain scale, with 0 being no pain and 10 being the worst pain imaginable. Resident #1's most recent Braden Scale Assessment Risk History Report dated 11/17/17 revealed the resident had a score of 13, and indicated she was at moderate risk for pressure ulcers Resident #1's Admission Clinical Health Status assessment dated [DATE] reflected the resident complained of frequent, moderate, radiating pain, described as stabbing and throbbing which impacted her daily life affecting her sleeping and mood. Symptoms associated with the pain were anxiety. Possible causes of the pain were listed as arthritis and pressure wounds. She was resistant to care. The Skin Condition component of the assessment had not been addressed. A narrative note revealed Pt (patient) complains of chronic lower back spasms and hip pain . Resident #1's Care Plan updated 12/28/17 reflected she was at risk for pressure ulcers, she had a skin tear to her left hip and was at risk of constant pain related to [MEDICAL CONDITION] for which staff was to assess need for preventive pain measures prior to ADLs, treatments etc. Resident #1's MDS assessment dated [DATE], reflected she had an unstageable pressure ulcer of the right heel which was present upon re-admission to the facility (08/24/17) that measured 3cm length (L) x 3cm width (W) x 1 cm depth (D). She had no other pressure ulcers documented. Review of Resident #1's Wound Care Physician's initial evaluation of Resident #1dated 08/28/17 reflected; Site #1: Stage II Pressure wound of right lateral hip 0.7 x 1 x 0.1cm Site #2: Stage II Pressure wound of the Medial Sacrum (low back) 07 x 0.7 x 0.1cm Site #3: Unstageable DTI (deep tissue injury) of the Left Lateral Foot 2.5 x 2 x Not measurable Site #4: Unstageable DTI of the Right Distal, Medial Foot 2 x 1.2 x Not Measurable Site #5: Unstageable DTI of Right Medial Heel 6 x 5 x Not Measurable Factors complicating wound healing: Diabetes Mellitus without mention of complication . Recommendations included to reposition per facility policy Height 52 inches, weight 171 lb's Review of the Resident#1's subsequent Wound Care evaluations revealed; 09/04/17 Site#4 wound had resolved Twelve evaluations presented for reviewed from 11/06/17 through 01/22/18 revealed there was no further mention of sites other than Site #5 Unstageable DTI, which was debrided of necrotic (dead) tissue five times and on 01/22/18 Site #5 measured 0.44 x 0.6 x 0.3cm On 01/29/18 Site#6 Stage II of left posterior buttock 4.5 x 0.6 x 0.1 (Initial evaluation) Site #5 remained an unstageable DTI measuring 0.4 x 0.6 x 0.3cm Factors complicating wound healing included Non-adherence to plan of care. Appetite was listed as Good Review of Resident #1's physician's orders [REDACTED]. 1. Start Date: 01/29/18 left posterior buttock wound 2. Start Date: 01/29/18 Pressure ulcer of right medial heel, unspecified stage 3. Start Date: 02/01/18 Left lateral hip blister 4. Start Date: 02/01/18 Left posterior thigh blister 5. Start Date: 02/01/18 left medial thigh blister Nurses Notes, dated 01/31/18 at 5:05 p.m. by LVN A/Wound Care Nurse, reflected; Assessment of the resident's skin revealed; Fluid-filled blister to left lateral hip measuring 3.0 x 1.0cm Fluid-filled blister to left posterior thigh 1.6 x 1.4cm The physician was notified of the new [MEDICAL CONDITION] and new orders were received. Online resource accessed on 02/09/18 at 11:45 a.m. The National Pressure Ulcer Advisory Panel (NPUAP) http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis .may also present as an intact or ruptured serum-filled blister .These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration .This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue .are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Review of Resident #1's electronic Treatment Administration Record (eTAR) and eTAR Notes, dated (MONTH) (YEAR) revealed when the wound care treatment was performed the nurse would indicate this with her initials. When the procedure was not performed an N would take the place of the nurses' initials and the reason the procedure was not performed was documented in the eTAR notes. The resident was in the emergency roiagnom on [DATE] and so did not receive any treatments on that day. Start Date: 10/04/17 Apply [MEDICATION NAME] to coccyx area daily at 9:30 p.m. The resident received all treatments except 01/17/18 was refused by resident Treatment was discontinued on 01/23/18 Start Date: 10/12/17 Cleanse right hip area with normal saline or wound cleanser, pat dry apply collagen and anecept then foam dressing daily and PRN until healed to be performed at 9:30 p.m. The resident received all treatments until 01/17/18 was refused by resident Treatment was discontinued on 01/19/18 Start Date: Cleanse right heel with normal saline or wound cleanser, apply santyl with metro gel 1% then calcium alginate then cover with border gauze daily at 9:30 p.m. The resident received all treatments except 01/17/18, 01/21/18 and 01/24/18 was refused by resident Treatment was discontinued on 01/29/18 Start Date: 11/28/17 Cleanse skin tear on left hip with normal saline pat dry apply [MEDICATION NAME] with dressing daily at 9:30 p.m. The resident received all treatments except 01/17/18 and 01/19/18was refused by resident Treatment was discontinued on 01/19/18 Start Date: 01/12/18 Cleanse wound on left hip and left back with normal saline pat dry and apply [MEDICATION NAME] with dry dressing. The resident received all treatments except 01/17/18, 01/19/18, 01/21/18 and 01/22/18 was refused by resident Treatment was discontinued on 01/23/18 Start Date: 01/23/18 Cleanse wound to left hip with normal saline or wound cleanser, pat dry, then apply collagen, [MEDICATION NAME] with foam dressing daily and PRN at 9:30 p.m. The resident received all treatments except 01/24/18 was refused by resident Treatment was discontinued on 01/29/18 Start Date: 01/29/18 Cleanse right medial heel with normal saline or wound cleanser, apply skin prep to peri-wound, then apply calcium alginate, collagen then cover with foam dressing daily until healed The resident received all treatments through 01/31/18 The resident did not receive a treatment on 02/01/18 was refused by resident Start Date: 02/01/18 Left lateral hip blister apply skin prep and leave open to air until healed The resident did not receive a treatment on 02/01/18 was refused by resident Start Date: 02/01/18 Left medial thigh blister apply skin prep and leave open to air until healed The resident did not receive a treatment on 02/01/18 was refused by resident Start Date: 01/29/18 Cleanse wound on left posterior buttock with normal saline or wound cleanser, pat dry, then apply collagen with foam dressing daily until healed The resident received all treatments through 01/31/18 The resident did not receive a treatment on 02/01/18 was refused by resident Problem Onset: 07/20/16, I am at risk for or am experiencing the presence of constant pain related to [MEDICAL CONDITION]. Goal and Target Date: I will verbalize relief of pain 11/28/17 Approaches included: Evaluate my pain daily using 1-10 pain scale, administer my pain medications as ordered, monitor for worsening of my pain symptoms and report to physician, assess need for preventive pain measures prior to ADLs, treatments etc. There had been no updates to the pain plan of care since 07/20/16. physician's orders [REDACTED]. Order Start date 08/24/17: Tylenol 325mg table 1 tablet every 6hours as needed for pain Order Start date 08/24/17: [MEDICATION NAME] ER 30mg 1 tablet every 12 hours Order Start date 08/24/17: [MEDICATION NAME] ([MEDICATION NAME]) 5/325mg 1 tablet every 4 hours while awake Order Start date 08/24/17: [MEDICATION NAME] 500mg 1 tablet twice a day - off-label use in neuropathic pain Order Start date 08/25/17: Tylenol with [MEDICATION NAME] 300/30 mg 2 tablets every 6 hours as needed for pain Order Start date 10/30/17:[MEDICATION NAME](muscle relaxant) 350mg 1 tablet every 12 hours Review of Resident #1's Individual Control Drug Records which indicate the date the medication was delivered to the facility on the label affixed to the record revealed; Tylenol #3 2 tablets every 6 hours as needed for pain, delivery date 12/20/17 reflected; 01/08/18 at 8:00 p.m. only 1 Tylenol #3 was administered 01/14/18 at 11:00 a.m. only 1 Tylenol #3 was administered then there was no medication left to count (LTC) Record delivery date 01/09/18 01/23/18 at 10:00 a.m. only 1 Tylenol #3 was administered 01/24/18 at 11:00 a.m. only 1 Tylenol #3 was administered 01/27/18 at 08:00 a.m. 2 Tylenol #3 were administered then there was no medication LTC Record delivery date 02/02/18 02/03/18 at 05:30 a.m. 2 Tylenol #3 were administered. Resident #1 had no PRN Tylenol #3 available for administration from 01/27/18 through 02/02/18 Review of Resident #1's Individual Control Drug Records for [MEDICATION NAME] ER 30mg 1 tablet every 12 hours revealed; Record delivery date 12/28/17 reflected; 01/02/18 at 09:00 a.m. 1 tablet administered then there was no medication LTC Record delivery date 01/02/18 reflected; 01/03/18 at 07:00 a.m. 1 tablet administered There was no medication available and the resident was not given a dose on 01/02/18 at 9:00 p.m. Record delivery date 01/07/18 reflected; 01/13/18 at 08:00 a.m. 1 tablet administered then there was no medication LTC Record delivery date 01/15/18 reflected; 01/15/18 at 8:00 a.m. 1 tablet administered There was no medication available and the resident did not receive a dose on 01/13/18 at 8:00 p.m., on 01/14/18 at 08:00 a.m. and 8:00 p.m. Online resource https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 23/ accessed 02/16/18 revealed ER (extended release) formulations are specifically designed to allow a controlled release of the active agent to provide relatively consistent and prolonged plasma drug levels with lower maximum concentration (Cmax) and fewer peak-to-trough fluctuations .In contrast, ER formulations are dosed less frequently (one to three times per day or fewer), allowing for less fluctuation and affording an elongated duration within the therapeutic window. Review of Resident #1's Individual Control Drug Records for [MEDICATION NAME] 1 tablet every 4 hours revealed; Record delivery date 01/24/18 reflected; 01/30/18 at 12:00 a.m. 1 tablet administered then there was no medication LTC Record delivery date 01/30/18 reflected; 01/30/18 at 4:00 p.m. 1 tablet administered There was no medication available and the resident did not receive a dose of [MEDICATION NAME] on 01/30/18 at 04:00 a.m., 08:00 a.m. and 12:00 p.m. Review of a Situation, Background, Assessment, Recommendation, (SBAR) dated 01/18/18 and completed by LVN A, revealed Resident #1 had worsening uncontrolled pain rated 10/10. The resident appeared grossly agitated and stated her medication was not working and she needed something else. The origin of the pain was listed as [MEDICAL CONDITION] and chronic, non-healing pressure ulcers. An assessment of how pain has interfered with the resident's ability to perform ADL's within the prior 24 hours, from 0-10 with 0 being Does not interfere and 10 being completely interferes the resident scored 7/10. The areas affected were indicated as; ability to ambulate, bathing, dressing, enjoyment of daily activities, mood, sleeping and toileting. An assessment of how much pain relief the resident had received from pain medication and/or therapy provided with 0% being no relief and 100% being relief of pain, the resident had 50% relief of pain with pain medication. A progress note on the SBAR revealed LVN A called the resident's family member and notified him/her the resident (was) not allowing ADL care stating that she is in pain. And that she wanted to go to the ER (emergency room ) . The resident's physician was notified at 1:00 p.m. of the resident's status and the resident was transferred to the emergency room by ambulance. emergency room discharge instructions printed 01/19/18 at 12:10 a.m. reflected a [DIAGNOSES REDACTED]. She received two liters of normal saline via intravenous infusion, blood tests, a urinalysis, x-rays of her left foot and pelvis and a computed tomography (CT) imaging of her chest, abdomen and pelvis. Discharge Instructions for Chronic Pain included; .Treatment .You may be referred to a pain specialist. He or she may prescribe medicine or therapies, such as: Mindfulness meditation or yoga Shots (injections) of numbing or pain-relieving medicines into the spine or area of pain Local electrical stimulation Acupuncture Massage Therapy Aroma, color, light, or sound therapy Biofeedback Working with a physical therapist to keep from getting stiff Regular, gentle exercises Cognitive or behavioral therapy Group support Sometimes, surgery may be recommended Results of the testing performed while in the emergency room were not available at the facility. Interview 02/06/18 at 07:57 a.m. with Resident #1's Wound Care physician who stated several months ago he was concerned due to the resident's extreme amount of pain when turned so he ordered hip x-rays. The x-rays showed no significant arthritis but the resident did need hip replacement surgery but no-one would touch her due to underlying health issues. He stated he believed some of the resident's pain may be related to psychological issues. He stated Resident #1 had refused to allow him to perform wound care on 1-2 occasions, he was not sure if it was due to the resident being in pain or that she did not want him moving her. The resident refused to straighten her right leg and had started to get contractures. He stated I absolutely believe her refusal to allow turning, peri-care and showers is a cause of her further pressure ulcers and the current skin infections! He stated the resident's right hip pain was causing her refusal of care and her heel ulcer was from the resident not allowing staff to turn her. He stated the resident tended to stay on her left side and the resident's left hip started with blisters that now look like pin-point holes due to infection from lying in feces. He stated he saw the resident on 02/05/18 (following addition of a [MEDICATION NAME] on 02/03/18) and she was much more receptive to being turned and allowing care to be performed. Interview 02/06/18 at 12:50 p.m. with LVN A, Wound Care Nurse, she stated she assumed wound care responsibility for Resident #1 approximately 2 weeks ago. The resident's wound care (WC) was previously performed on the night shift. She stated the resident had not refused WC during the time she has been caring for the resident. States she ensures pain medication and PRN pain medication has been given prior to wound care. States she was with the wound care physician to assist in wound care on 02/05/18 and the resident was able to lie on her right side, which was unusual as she usually always lies on her left side due to right hip pain. She stated wound care was performed and the resident tolerated it well. She stated the resident appeared to be in less pain than usual. She stated she was the nurse caring for the resident on 01/18/18, the resident had complained of pain, that did not appear more severe than usual, but she had refused PRN pain medication, the next thing I knew she had called the ambulance. She stated the resident did accept pain medication when EMS arrived but she was unsure what medication she had given the resident. She stated that upon re-admission (08/24/17) the resident had a pressure ulcer on her heel which has healed. She then had pressure ulcers on her right and left hip which have healed. Currently she has boils which can be caused by unclean skin, on her left thigh, left hip and her inner Left thigh. She was not aware the resident was out of pain medications at any time. She stated she had spoken with the resident's physician regarding the resident's pain and he had ordered [MEDICATION NAME] ER. Nurses Notes, dated 01/12/18 at 9:48 p.m. reflected Resident #1 was noted to have an open wound on the left side of her back and an open blister on her left hip. The nurse informed Resident #1 that resident needs to start allowing the Certified Nurses' Aide (CNA) to turn her to her right side because (the) resident is constantly on her left side, during wound care resident will not allow this nurse and CNA to turn her to right side and clean the wound, resident noted to be screaming, after several attempt resident allow {sic} this nurse and CNA to turn her, resident responsible party (name) notified, DNS (Director of Nursing Services) called message left to call facility back. Nurses Notes, dated 01/13/18 at 05:53 a.m. reflected Resident refuses to allow staff to reposition in bed. Resident states 'I just positioned myself to where I am comfortable.' Staff encourage resident to allow staff to reposition. Resident refused . Nurses Notes, dated 01/15/18 at 6:09 p.m. reflected This nurse in resident room for wound care to left back and left hip, resident in room crying screaming will no (sic) allow this nurse or CNA to turn her, after several attempt (sic) and education resident allow this nurse to clean her wound and apply dressing per order resident noted screaming and crying, after wound care this nurse and CNA try to reposition resident to her right side resident refuse (sic) started screaming and crying loud, will not allow this nurse and CNA to turn her to right side. Nurses Notes, dated 01/16/18 at 12:17 a.m. reflected Resident refused to allow staff to turn to right side. Resident allow (sic) staff to turn slightly to back using pillow . Nurses Notes, dated 01/17/18 at 1:48 a.m. reflected . in resident room to assess resident, resident inform (sic) this nurse that she is having pain on both hips rate pain 8/10 . offer to reposition resident, resident refuse (sic), routine [MEDICATION NAME] and [MEDICATION NAME] administer {sic) to resident, resident refuse (sic) to eat her supper .resident (family member) notified that resident refuse (sic) to allow this nurse and CNA to turn her . resident will not allow this nurse to do wound care, after two hours PRN Tylenol #3 administer (sic) to resident, resident reassessed after one hour medication effective. Nurses Notes, dated 01/17/18 at 11:47 p.m. reflected .in room to reposition resident. Resident states 'No, I have been hurting all day and I am just getting settled down .No don't move my bed it may get my hip to hurting again moving the bed around' Routine [MEDICATION NAME] given. Call light within reach. Nurses Notes, dated 01/18/18 at 2:56 p.m. reflected . informed (family member) that resident not allowing ADL care stating she is in pain. And that she wanted to go to the ER. Phoned NP (Nurse Practitioner) informing of situation and new orders were to send to ER . Nurses Notes, dated 01/19/18 at 1:46 a.m. reflected Resident returned from (hospital name) with no new orders noted . Resident noted yelling out 'No' when staff attempting to remove soiled linens . Resident grabbing staff stating 'it hurts' while providing care. Resident given Tylenol #3 upon return from hospital for complaints of pain. Resident refusing to allow staff to position with pillows or turn on back . Nurses Notes, dated 01/19/18 at 9:49 p.m. reflected the nurse advised Resident #1 she needed to assess the dressing to the wound on her back to ensure it was intact, the resident stated I cannot turn to the right side for you but I will turn a little to the right the nurse determined the dressing required changing and informed the resident who stated she could not turn for wound care to be performed, she allowed the nurse to perform wound care to her right heel, the resident refused a shower. Routine [MEDICATION NAME] and [MEDICATION NAME] had been administered 30 minutes prior to wound care. Nurses Notes, dated 01/24/18 at 9:45 p.m. reflected the resident refused wound care stating she had sat in her wheelchair too long on 01/23/18 and she did not want to be touched. The resident informed the nurse she would allow her to perform wound care on 01/25/18. The nurse administered routine pain medications and after one hour, Tylenol #3 was administered, the resident continued to refuse wound care. Nurses Notes, dated 01/30/18 at 12:48 p.m. reflected a late entry for 01/29/18 the wound care physician had seen the resident. Notes reflected; Unstageable to right medial heel 0.4 x 0.6 x 0.3 with 100% granulated tissue and moderate serous drainage. Wound noted with improvement from last week. Wound doctor using chemical cauterization of hypergranulated tissue using topical anesthetic for pain management. Resident tolerating procedure well. Stage 2 pressure ulcer to left posterior buttock 4.5 x 0.6 x 0.1 with moderate serous drainage. Treatment orders Collagen with foam dressing. Resident with no complaint of pain to wound area. Resident complains of pain to right hip. Medications given per MD orders. Resident is consistent with noncompliance with turning and repositioning. She refuses showers and ADL care daily. Nurses Notes, dated 01/31/18 at 5:05 p.m. by LVN A/Wound Care Nurse, reflected the resident complained of pain and refused to allow staff to turn her and perform incontinent care although she was heavily soiled and bed sheets required changing. Resident stated that she needed to talk to someone because she feels that her family has just left her in the facility to rot. She can't see her grandchildren. Her phone is not working and that she can't talk to anyone. Resident began crying stating 'I want to see my family, I feel alone. The nurse advised the resident she would notify Social Services of her request to speak with a psychiatrist. Pain medication was administered and staff returned to perform ADL care. Resident crying and yelling before staff touched the bed stating 'I want to see my family'. ADL care performed with staff being very gentle. Assessment of the resident's skin revealed; Fluid-filled blister to left lateral hip measuring 3.0 x 1.0cm Fluid-filled blister to left posterior thigh 1.6 x 1.4cm The physician was notified of the new [MEDICAL CONDITION] and new orders were received. Nurses Notes, dated 02/01/18 at 1:40 p.m. reflected the nurse had attempted multiple times to perform wound care to the residents hip, thigh, heel and buttocks but the resident complained of pain 7-10/10 all over. Resident visibly crying out in pain saying 'Don't touch me I hurt too bad.' Scheduled nurse notified. Nurses Notes, dated 02/01/18 at 2:30 p.m. reflected Resident #1 complained of pain 7/10 and refused wound care. Resident was visibly crying out in pain. Resident stated 'I am just in too much pain right now to get my wounds done' Resident not letting aides turn her. Resident stated 'I am constantly in pain and my pain level never goes below 3/10. The pain medicine helps a lot but my body continues to ache.' Resident states she is currently at a 3/10.' Educated resident on the importance of her being changed frequently and resident stated 'I know but when I am in too much pain, I just can't be touched. It hurts too much. Pulled PRN Tylenol #3 out of e-kit for breakthrough pain. Observation of Resident #1 on 02/01/18 at 09:17 a.m. revealed she was lying in bed on her left side with her head almost covered by a sheet. Her right hand was open and lying on her right hip in a protective manner. When questioned, the resident spoke quietly and with a facial grimace as she complained she was experiencing spasms in her right hip at a pain level of 7/10. She stated she had just been given her pain medication and the pain was decreasing. She stated the pain medication usually decreased her pain for two to three hours but her pain never went away. She further stated, if her pain was down to a level of 2-3/10 she was able to sit on the side of her bed, that she would like to get up into her wheelchair but it was too painful for her. She would request a PRN pain medication but that only helped a little. She stated that on 01/18/18 she called 911 because she was in severe pain and no-one would listen to me she stated she told the CNA but staff just closed her door because she was screaming and hollering for help. When she returned from the hospital someone told her she should have told someone and they would have called 911. She told the person she did, but no-one would listen. She stated the bed sore on her Right hip had healed but she screams and hollers due to the pain from arthritis in her hips and knees. She stated she has refused peri-care and wound care and showers due to pain. She stated it was too painful for her to sit in the shower chair so she would give herself a bed bath and sometimes staff would assist her. She stated staff had put her in a bed lift but it hurt too badly, even when she put towels on each hip to try to cushion them. Review of a Situation, Background, Assessment, Recommendation, (SBAR) dated 01/18/18 and completed by LVN A, revealed Resident #1 had worsening uncontrolled pain rated 10/10. The resident appeared grossly agitated and stated her medication was not working and she needed something else. The origin of the pain was listed as [MEDICAL CONDITION] and chronic, non-healing pressure ulcers.An assessment of how pain has interfered with the resident's ability to perform ADL's within the prior 24 hours, from 0-10 with 0 being Does not interfere and 10 being completely interferes the resident scored 7/10. The areas affected were indicated as; ability to ambulate, bathing, dressing, enjoyment of daily activities, mood, sleeping and toileting. An assessment of how much pain relief the resident had received from pain medication and/or therapy provided with 0% being no relief and 100% being relief of pain, the resident had 50% relief of pain with pain medication. A progress note on the SBAR revealed LVN A called the resident's family member and notified him/her the resident (was) not allowing ADL care stating that she is in pain. And that she wanted to go to the ER (emergency room ) . The resident's physician was notified at 1:00 p.m. of the resident's status and the resident was transferred to the emergency room by ambulance. Interview 01/26/1/ at 2:32 p.m. with the EMT-Paramedic who transported Resident #1 to the emergency room (ER) on 01/18/18. He/she stated Resident #1 had contacted 911 herself, when Emergency Medical Services (EMS) arrived at the facility, staff was aware that the resident had contacted 911 and was giving the resident a pain medication. He stated the resident was in bed and was crying out in pain when EMS arrived. The resident stated she had two pressure ulcers and they were the cause of her pain. Facility staff (unknown name) confirmed the resident had two pressure ulcers that were causing her pain. The staff person stated she had just given the resident her routine pain medication and that the resident would not allow them to change her brief and keep her clean. The Paramedic stated the resident was covered in urine and feces. EMS transported the resident to the hospital Interview 02/01/18 at 09:45 a.m. with LVN B, Resident #1's nurse who stated Resident #1 complained of pain a lot. She stated when she went in to give resident her [MEDICATION NAME] and [MEDICATION NAME] medications this morning the resident was crying and complained of a pain level of 10/10. The best the resident's pain ever got was 3/10 but the pain never went away. She stated the resident also had an order for [REDACTED]. She stated she had not spoken with the resident's physician regarding the resident's pain but she believed the 2:00 p.m. to 10:00 p.m. nurse had told him the resident wanted to get out of bed but couldn't due to the increased pain this caused. She stated the resident would allow peri-care to be performed but she will be screaming in pain. She stated the wound care nu(TRUNCATED)

Based on observation, interview and record review, the facility failed to prohiont and prevent neglect for 1 of 6 residents (Resident # 1) reviewed for neglect. 1. The facility failed to adequately monitor Resident #1's pain by documenting using an appropriate pain scale and follow-up method, and did not offer non-pharmacological interventions to try to relieve the resident's pain. As a result, the resident continued to experience significant and unrelieved pain, and refused to participate in treatments and activities of daily living. Resident #1 visited the emergency roiagnom on [DATE] due to her pain severity. 2. The facility failed to have Resident #1's PRN Tylenol 3 available from 01/27/18 through 02/01/18. 3. The facility failed to have Resident #1's routine [MEDICATION NAME] available on 01/02/18 and 01/13/18 through 01/14/18. 4. The facility failed to have Resident #1's routine [MEDICATION NAME] available on 01/30/18. 5. The facility failed to ensure Resident #1 who had previously been compliant with wound care, began refusing wound care 01/17/17 as a result of intolerable pain, received appropriate pain management and resulted in new pressure ulcers on 01/29/18 Stage II pressure ulcer left posterior buttock on 02/01/18 Left lateral hip blister, Left posterior thigh blister and left medial thigh blister. An immediate Jeopardy (IJ) was identified on 02/02/18. While the IJ was removed on 02/03/18, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. This failure could affect all 102 residents, who relied on facility staff to ensure their needs were met and placed them at risk for lack of appropriate care and treatment. Findings included: The facility's Abuse Policy dated (MONTH) (YEAR) reflected; Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or emotional distress The facility's Pain Management Policy dated (MONTH) (YEAR) reflected; Purpose. To provide guidelines for consistent evaluation, management and documentation of pain in order to provide maximum comfort and enhanced quality of life. Pain is to be evaluated upon admission using a Numeric Rating Scale. Ongoing pain monitoring and effectiveness of interventions is noted in the electronic medical record through the EMAR system and progress notes. The IDT evaluate the effectiveness of each resident's pain management on admission, quarterly and upon an acute and significant change. Key Elements included; .There are resident specific interventions on the Caregiver Guide and Plan of Care related to applicable pain management need. Follow up to evaluate the effectiveness of pain interventions. Non-pharmacological interventions are incorporated in pain management plan. 1. Resident #1's MDS assessment dated [DATE], reflected she was a [AGE] year-old female, who was re-admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had a moderately impaired cognition and had no behaviors. She required the assistance of one person with ADLs and was incontinent of both bowel and bladder. She had limited mobility in one lower extremity and required the assistance of one person with transfers to her wheelchair. She was considered at risk for pressure ulcers. She received routine and as needed (PRN) opioid pain medication. She had frequent pain at a level of 5/10 using a 0-10 pain scale, with 0 being no pain and 10 being the worst pain imaginable. Resident #1's Admission Clinical Health Status assessment dated [DATE] reflected the resident complained of frequent, moderate, radiating pain, described as stabbing and throbbing which impacted her daily life affecting her sleeping and mood. Symptoms associated with the pain were anxiety. Possible causes of the pain were listed as arthritis and pressure wounds. She was resistant to care. The Skin Condition component of the assessment had not been completed. A narrative note revealed Pt (patient) complains of chronic lower back spasms and hip pain . Resident #1's Care Plan updated 12/11/17 reflected; Problem Onset: 07/20/16, I am at risk for or am experiencing the presence of constant pain related to [MEDICAL CONDITION]. Goal and Target Date: I will verbalize relief of pain 11/28/17 Approaches included: Evaluate my pain daily using 1-10 pain scale, administer my pain medications as ordered, monitor for worsening of my pain symptoms and report to physician, assess need for preventive pain measures prior to ADLs, treatments etc. There had been no updates to the pain plan of care since 07/20/16. physician's orders [REDACTED]. Order Start date 08/24/17: Tylenol 325mg table 1 tablet every 6 hours as needed for pain Order Start date 08/24/17: [MEDICATION NAME] ER 30mg 1 tablet every 12 hours Order Start date 08/24/17: [MEDICATION NAME] ([MEDICATION NAME]) 5/325mg 1 tablet every 4 hours while awake Order Start date 08/24/17: [MEDICATION NAME] 500mg 1 tablet twice a day - off-label use in neuropathic pain Order Start date 08/25/17: Tylenol with [MEDICATION NAME] 300/30 mg 2 tablets every 6 hours as needed for pain Order Start date 10/30/17:[MEDICATION NAME](muscle relaxant) 350mg 1 tablet every 12 hours Review of Resident #1's Individual Control Drug Records, which indicated the date the medication was delivered to the facility on the label affixed to the record, revealed Tylenol #3 2 tablets every 6 hours as needed for pain, delivery date 12/20/17 01/08/18 at 8:00 p.m. only 1 Tylenol #3 was administered 01/14/18 at 11:00 a.m. only 1 Tylenol #3 was administered then there was no medication left to count (LTC) Record delivery date 01/09/18 01/23/18 at 10:00 a.m. only 1 Tylenol #3 was administered 01/24/18 at 11:00 a.m. only 1 Tylenol #3 was administered 01/27/18 at 08:00 a.m. 2 Tylenol #3 were administered then there was no medication LTC Review of Resident #1's Individual Control Drug Records for [MEDICATION NAME] ER 30mg 1 tablet every 12 hours Revealed Record delivery date 12/28/17 reflected; 01/02/18 at 09:00 a.m. 1 tablet administered then there was no medication LTC Record delivery date 01/02/18 reflected; 01/03/18 at 07:00 a.m. 1 tablet administered There was no medication available and the resident was not given a dose on 01/02/18 at 9:00 p.m. Record delivery date 01/07/18 reflected; 01/13/18 at 08:00 a.m. 1 tablet administered then there was no medication LTC Record delivery date 01/15/18 reflected; 01/15/18 at 8:00 a.m. 1 tablet administered There was no medication available and the resident did not receive a dose on 01/13/18 at 8:00 p.m., on 01/14/18 at 08:00 a.m. and 8:00 p.m. Online resourse https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 23/ accessed 02/16/18 revealed ER (extended release) formulations are specifically designed to allow a controlled release of the active agent to provide relatively consistent and prolonged plasma drug levels with lower maximum concentration (Cmax) and fewer peak-to-trough fluctuations .In contrast, ER formulations are dosed less frequently (one to three times per day or fewer), allowing for less fluctuation and affording an elongated duration within the therapeutic window. Review of Resident #1's Individual Control Drug Records for [MEDICATION NAME] 1 tablet every 4 hours revealed Record delivery date 01/24/18 reflected; 01/30/18 at 12:00 a.m. 1 tablet administered then there was no medication LTC Record delivery date 01/30/18 reflected; 01/30/18 at 4:00 p.m. 1 tablet administered There was no medication available and the resident did not receive a dose of [MEDICATION NAME] on 01/30/18 at 04:00 a.m., 08:00 a.m. and 12:00 p.m. Review of a Situation, Background, Assessment, Recommendation, (SBAR) dated 01/18/18 and completed by LVN A, revealed Resident #1 had worsening uncontrolled pain rated 10/10. The resident appeared grossly agitated and stated her medication was not working and she needed something else. The origin of the pain was listed as [MEDICAL CONDITION] and chronic, non-healing pressure ulcers. An assessment of how pain had interfered with the resident's ability to perform ADLs within the prior 24 hours, from 0-10 with 0 being Does not interfere and 10 being completely interferes, the resident scored 7/10. The areas affected were indicated as; ability to ambulate, bathing, dressing, enjoyment of daily activities, mood, sleeping and toileting. An assessment of how much pain relief the resident had received from pain medication and/or therapy provided with 0% being no relief and 100% being relief of pain, the resident had 50% relief of pain with pain medication. A progress note on the SBAR revealed LVN A called the resident's family member and notified him/her the resident (was) not allowing ADL care stating that she is in pain. And that she wanted to go to the ER (emergency room ) . The resident's physician was notified at 1:00 p.m. of the resident's status and the resident was transferred to the emergency room by ambulance. emergency room discharge instructions printed 01/19/18 at 12:10 a.m. reflected a [DIAGNOSES REDACTED]. She received two liters of normal saline via intravenous infusion, blood tests, a urinalysis, x-rays of her left foot and pelvis and a computed tomography (CT) imaging of her chest, abdomen and pelvis. Discharge Instructions for Chronic Pain included; .Treatment .You may be referred to a pain specialist. He or she may prescribe medicine or therapies, such as: Mindfulness meditation or yoga Shots (injections) of numbing or pain-relieving medicines into the spine or area of pain Local electrical stimulation Acupuncture Massage Therapy Aroma, color, light, or sound therapy Biofeedback Working with a physical therapist to keep from getting stiff Regular, gentle exercises Cognitive or behavioral therapy Group support Sometimes, surgery may be recommended. Results of the testing performed while in the emergency room were not available at the facility. 2. Resident #1's MDS assessment dated [DATE], reflected she had an unstageable pressure ulcer of the right heel which was present upon re-admission to the facility (08/24/17) that measured 3cm length (L) x 3cm width (W) x 1 cm depth (D). She had no other pressure ulcers documented. Review of Resident #1's Wound Care Physician's initial evaluation of Resident #1, dated 08/28/17, reflected; Site #1: Stage II Pressure wound of right lateral hip 0.7 x 1 x 0.1cm Site #2: Stage II Pressure wound of the Medial Sacrum (low back) 07 x 0.7 x 0.1cm Site #3: Unstageable DTI (deep tissue injury) of the Left Lateral Foot 2.5 x 2 x Not measurable Site #4: Unstageable DTI of the Right Distal, Medial Foot 2 x 1.2 x Not Measurable Site #5: Unstageable DTI of Right Medial Heel 6 x 5 x Not Measurable Factors complicating wound healing: Diabetes Mellitus without mention of complication . Recommendations included to reposition per facility policy Height 52 inches, weight 171 lbs Review of the Resident #1's subsequent Wound Care evaluations revealed: 09/04/17 Site #4 DTI of the Right Distal, Medial Foot wound had resolved. Twelve evaluations presented for review, dated from 11/06/17 through 01/22/18, revealed there was no further mention of sites other than Site #5 Unstageable DTI, which was debrided of necrotic (dead) tissue five times, and on 01/22/18 Site #5 measured 0.44 x 0.6 x 0.3 cm. On 01/29/18, Site #6 was added as a Stage II of left posterior buttock measuring 4.5 x 0.6 x 0.1 (Initial evaluation). Site #5 remained an unstageable DTI measuring 0.4 x 0.6 x 0.3cm. Factors complicating wound healing were documented as including, Non-adherence to plan of care. Appetite was listed as Good. Online resource accessed on 02/09/18 at 11:45 a.m. The National Pressure Ulcer Advisory Panel (NPUAP) http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages reflected: Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis .may also present as an intact or ruptured serum-filled blister .These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration .This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue .are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Review of Resident #1's physician's orders [REDACTED]. 1. Start Date: 01/29/18 left posterior buttock wound 2. Start Date: 01/29/18 Pressure ulcer of right medial heel, unspecified stage 3. Start Date: 02/01/18 Left lateral hip blister 4. Start Date: 02/01/18 Left posterior thigh blister 5. Start Date: 02/01/18 left medial thigh blister Online resource accessed on 02/09/18 at 11:45 a.m. The National Pressure Ulcer Advisory Panel (NPUAP) http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis .may also present as an intact or ruptured serum-filled blister .These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration .This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue .are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). MOVE UP Review of Resident #1's electronic Treatment Administration Record (eTAR) and eTAR Notes, dated (MONTH) (YEAR) revealed when the wound care treatment was performed the nurse would indicate this with her initials. When the procedure was not performed an N would take the place of the nurses' initials and the reason the procedure was not performed was documented in the eTAR notes. The following information was provided on the eTAR regarding the resident's treatements: Start Date: 10/04/17 Apply [MEDICATION NAME] to coccyx area daily at 9:30 p.m. The resident received all treatments except 01/17/18 was refused by resident Treatment was discontinued on 01/23/18 Start Date: 10/12/17 Cleanse right hip area with normal saline or wound cleanser, pat dry apply collagen and anecept then foam dressing daily and PRN until healed to be performed at 9:30 p.m. The resident received all treatments until 01/17/18 was refused by resident Treatment was discontinued on 01/19/18 Start Date: Cleanse right heel with normal saline or wound cleanser, apply santyl with metro gel 1% then calcium alginate then cover with border gauze daily at 9:30 p.m. The resident received all treatments except 01/17/18, 01/21/18 and 01/24/18 was refused by resident Treatment was discontinued on 01/29/18 Start Date: 11/28/17 Cleanse skin tear on left hip with normal saline pat dry apply [MEDICATION NAME] with dressing daily at 9:30 p.m. The resident received all treatments except 01/17/18 and 01/19/18 was refused by resident Treatment was discontinued on 01/19/18 Start Date: 01/12/18 Cleanse wound on left hip and left back with normal saline pat dry and apply [MEDICATION NAME] with dry dressing. The resident received all treatments except 01/17/18, 01/19/18, 01/21/18 and 01/22/18 was refused by resident Treatment was discontinued on 01/23/18 Start Date: 01/23/18 Cleanse wound to left hip with normal saline or wound cleanser, pat dry, then apply collagen, [MEDICATION NAME] with foam dressing daily and PRN at 9:30 p.m. The resident received all treatments except 01/24/18 was refused by resident Treatment was discontinued on 01/29/18 Start Date: 01/29/18 Cleanse right medial heel with normal saline or wound cleanser, apply skin prep to peri-wound, then apply calcium alginate, collagen then cover with foam dressing daily until healed The resident received all treatments through 01/31/18 The resident did not receive a treatment on 02/01/18 was refused by resident Start Date: 02/01/18 Left lateral hip blister apply skin prep and leave open to air until healed The resident did not receive a treatment on 02/01/18 was refused by resident Start Date: 02/01/18 Left medial thigh blister apply skin prep and leave open to air until healed The resident did not receive a treatment on 02/01/18 was refused by resident Start Date: 01/29/18 Cleanse wound on left posterior buttock with normal saline or wound cleanser, pat dry, then apply collagen with foam dressing daily until healed The resident received all treatments through 01/31/18 The resident did not receive a treatment on 02/01/18 was refused by resident Nurses Notes, dated 01/12/18 at 9:48 p.m. reflected Resident #1 was noted to have an open wound on the left side of her back and an open blister on her left hip. The nurse informed Resident #1 that, resident needs to start allowing the Certified Nurses' Aide (CNA) to turn her to her right side because (the) resident is constantly on her left side, during wound care resident will not allow this nurse and CNA to turn her to right side and clean the wound, resident noted to be screaming, after several attempt resident allow {sic} this nurse and CNA to turn her, resident responsible party (name) notified, DNS (Director of Nursing Services) called message left to call facility back. Nurses Notes, dated 01/13/18 at 1:48 a.m. reflected Staff x 2 assist resident with repositioning on to back. As needed pain medication administered to relief of pain . Nurses Notes, dated 01/13/18 at 05:53 a.m. reflected Resident refuses to allow staff to reposition in bed. Resident states, 'I just positioned myself to where I am comfortable.' Staff encourage resident to allow staff to reposition. Resident refused . Nurses Notes, dated 01/15/18 at 6:09 p.m. reflected This nurse in resident room for wound care to left back and left hip, resident in room crying screaming will no (sic) allow this nurse or CNA to turn her, after several attempt (sic) and education resident allow this nurse to clean her wound and apply dressing per order resident noted screaming and crying, after wound care this nurse and CNA try to reposition resident to her right side resident refuse (sic) started screaming and crying loud, will not allow this nurse and CNA to turn her to right side. Nurses Notes, dated 01/16/18 at 12:17 a.m. reflected Resident refused to allow staff to turn to right side. Resident allow (sic) staff to turn slightly to back using pillow . Nurses Notes, dated 01/17/18 at 1:48 a.m. reflected This nurse received a call from resident responsible party (name) inform (sic) this nurse that resident called to tell her she (sic) not feeling good . in resident room to assess resident, resident inform (sic) this nurse that she is having pain on both hips rate pain 8/10 . offer to reposition resident, resident refuse (sic), routine [MEDICATION NAME] and [MEDICATION NAME] administer {sic) to resident, resident refuse (sic) to eat her supper .resident (family member) notified that resident refuse to allow this nurse and CNA to turn her . resident will not allow this nurse to do wound care, after two hours PRN Tylenol #3 administer (sic) to resident, resident reassessed after one hour medication effective. Nurses Notes, dated 01/17/18 at 11:47 p.m. reflected, .in room to reposition resident. Resident states 'No, I have been hurting all day and I am just getting settled down .No don't move my bed it may get my hip to hurting again moving the bed around' Routine [MEDICATION NAME] given. Call light within reach. Nurses Notes, dated 01/18/18 at 2:56 p.m. reflected . informed (family member) that resident not allowing ADL care stating she is in pain. And that she wanted to go to the ER. Phoned NP (Nurse Practitioner) informing of situation and new orders were to send to ER . Nurses Notes, dated 01/19/18 at 1:46 a.m. reflected Resident returned from (hospital name) with no new orders noted . Resident noted yelling out 'No' when staff attempting to remove soiled linens . Resident grabbing staff stating 'it hurts' while providing care. Resident given Tylenol #3 upon return from hospital for complaints of pain. Resident refusing to allow staff to position with pillows or turn on back . Nurses Notes, dated 01/19/18 at 9:49 p.m. reflected the nurse advised Resident #1 she needed to assess the dressing to the wound on her back to ensure it was intact, the resident stated I cannot turn to the right side for you but I will turn a little to the right the nurse determined the dressing required changing and informed the resident who stated she could not turn for wound care to be performed, she allowed the nurse to perform wound care to her right heel, the resident refused a shower. Routine [MEDICATION NAME] and [MEDICATION NAME] had been administered 30 minutes prior to wound care. Nurses Notes, dated 01/24/18 at 9:45 p.m. reflected the resident refused wound care stating she had sat in her wheelchair too long on 01/23/18 and she did not want to be touched. The resident informed the nurse she would allow her to perform wound care on 01/25/18. The nurse administered routine pain medications and after one hour, Tylenol #3 was administered, the resident continued to refuse wound care. Nurses Notes, dated 01/30/18 at 12:48 p.m. reflected a late entry for 01/29/18 the wound care physician had seen the resident. Notes reflected; Unstageable to right medial heel 0.4 x 0.6 x 0.3 with 100% granulated tissue and moderate serous drainage. Wound noted with improvement from last week. Wound doctor using chemical cauterization of hypergranulated tissue using topical anesthetic for pain management. Resident tolerating procedure well. Stage 2 pressure ulcer to left posterior buttock 4.5 x 0.6 x 0.1 with moderate serous drainage. Treatment orders Collagen with foam dressing. Resident with no complaint of pain to wound area. Resident complains of pain to right hip. Medications given per MD orders. Resident is consistent with noncompliance with turning and repositioning. She refuses showers and ADL care daily. Nurses Notes, dated 01/31/18 at 5:05 p.m. reflected the resident complained of pain and refused to allow staff to turn her and perform incontinent care although she was heavily soiled and bed sheets required changing. Resident stated that she needed to talk to someone because she feels that her family has just left her in the facility to rot. She can't see her grandchildren. Her phone is not working and that she can't talk to anyone. Resident began crying stating 'I want to see my family, I feel alone.' The nurse advised the resident she would notify Social Services of her request to speak with a psychiatrist. Pain medication was administered and staff returned to perform ADL care. Resident crying and yelling before staff touched the bed stating 'I want to see my family'. ADL care performed with staff being very gentle. Assessment of the resident's skin revealed: Fluid-filled blister to left lateral hip measuring 3.0 x 1.0cm Fluid-filled blister to left posterior thigh 1.6 x 1.4cm. The physician was notified of the new [MEDICAL CONDITION] and new orders were received. Nurses Notes, dated 02/01/18 at 1:40 p.m. reflected the nurse had attempted multiple times to perform wound care to the residents hip, thigh, heel and buttocks but the resident complained of pain 7-10/10 'all over.' Resident visibly crying out in pain saying Don't touch me I hurt too bad. Scheduled nurse notified. Nurses Notes, dated 02/01/18 at 2:30 p.m. reflected Resident #1 complained of pain 7/10 and refused wound care. Resident was visibly crying out in pain. Resident stated 'I am just in too much pain right now to get my wounds done' Resident not letting aides turn her. Resident stated 'I am constantly in pain and my pain level never goes below 3/10. The pain medicine helps a lot but my body continues to ache.' Resident states she is currently at a 3/10.' Educated resident on the importance of her being changed frequently and resident stated 'I know but when I am in too much pain, I just can't be touched. It hurts too much.' Pulled PRN Tylenol #3 out of e-kit for breakthrough pain. Observation of Resident #1 on 02/01/18 at 9:17 a.m. revealed she was lying in bed on her left side with her head almost covered by a sheet. Her right hand was open and lying on her right hip in a protective manner. When questioned, the resident spoke quietly and with a facial grimace as she complained she was experiencing spasms in her right hip at a pain level of 7/10. She stated she had just been given her pain medication and the pain was decreasing. She stated the pain medication usually decreased her pain for two to three hours, but her pain never went away. She further stated, if her pain was down to a level of 2-3/10, she was able to sit on the side of her bed. She said that she would like to get up into her wheelchair but it was too painful for her. She would request a PRN pain medication, but that only helped a little. She stated that on 01/18/18 she called 911 because she was in severe pain and no-one would listen to me. She stated she told the CNA but staff just closed her door because she was screaming and hollering for help. When she returned from the hospital someone told her she should have told someone and they would have called 911. She told the person she did, but no-one would listen. She stated the pressure ulcer on her right hip had healed, but she screams and hollers due to the pain from arthritis in her hips and knees. She stated she has refused peri-care and wound care and showers due to pain. She stated it was too painful for her to sit in the shower chair so she would give herself a bed bath and sometimes staff would assist her. She stated staff had put her in a bed lift but it hurt too badly, even when she put towels on each hip to try to cushion them. Interview on 01/26/18 at 2:32 p.m. with the EMT Paramedic who transported Resident #1 to the emergency room (ER) on 01/18/18 revealed Resident #1 had contacted 911 herself. When Emergency Medical Services (EMS) arrived at the facility, staff was aware that the resident had contacted 911 and was giving the resident a pain medication. He stated the resident was in bed and was crying out in pain when EMS arrived. The resident stated she had two pressure ulcers and they were the cause of her pain. Facility staff (unknown name) confirmed the resident had two pressure ulcers that were causing her pain. The staff person stated she had just given the resident her routine pain medication and that the resident would not allow them to change her brief and keep her clean. The Paramedic stated the resident was covered in urine and feces. EMS transported the resident to the hospital. Interview on 02/01/18 at 9:45 a.m. with LVN B, Resident #1's nurse, stated Resident #1 complained of pain a lot. She stated when she went in to give resident her [MEDICATION NAME] and [MEDICATION NAME] medications this morning, the resident was crying and complained of a pain level of 10/10. The best the resident's pain ever got was 3/10, but the pain never went away. She stated the resident also had an order for [REDACTED]. She stated she had not spoken with the resident's physician regarding the resident's pain, but she believed the 2:00 p.m. to 10:00 p.m. nurse had told him the resident wanted to get out of bed but could not due to the increased pain this caused. She stated the resident would allow perineal care to be provided, but she will be screaming in pain. She stated the wound care nurse would arrive to provide the resident's wound care at 9:00 a.m. in order to allow time for the morning pain medications to work, but even with the medication, the resident will scream during wound care. Observation on 02/01/18 at 10:44 a.m. with LVN C, who stated the usual wound care nurse was absent today so she would be providing Resident #1's wound care, revealed Resident #1 refused to allow wound care to be performed stating she was having spasms in her right hip with a pain level of 7/10. The resident refused to allow LVN C to reposition her, stating she hurt too badly. LVN C advised the resident she would check with her nurse and get a PRN pain medication. Observation on 02/01/18 at 10:46 a.m. revealed LVN C spoke with LVN A and requested PRN pain medication for Resident #1. LVN A stated the resident had no Tylenol #3 available, so she had given the resident a PRN Tylenol 500mg tablet this morning and she did not think the resident could have another one yet. LVN A stated the resident's next scheduled pain medication was at noon. On 02/01/18 at 12:43 p.m. a phone call was placed to Resident #1's physician the mailbox was full. On 02/01/18 a phone call was placed to the physician's answering service and requested the physician contact me. Interview on 02/01/18 at 12:47 p.m. with Resident #1's Physician's Assistant revealed Resident#1's physician was on vacation. The Physician's Assistant did not remember Resident #1 and did not remember the resident's physician speaking of her. He was unable to access the files of Resident #1. He stated he would have Resident #1's physician make contact to assist with answering questions regarding the resident. No contact from the resident's physician was received prior to the completion of the investigation on 02/03/18. On 02/01/18 at 1:00 p.m., a phone call was placed to Resident #1's Wound Care Physician and a voicemail was left requesting he call regarding Resident #1. Interview on 02/01/18 at 1:43 p.m. with the Director of Nursing Services (DNS), who stated she had been the DNS at the facility since 12/29/17, revealed LVN B had obtained Tylenol #3 tablets from the emergency medication kit (e-kit) and administered them to Resident #1 at 11:00 a.m. She stated the pharmacy must have a triplicate in hand in order to allow the nurse to access the e-kit. A request to see the e-kit Medication Administration Record [REDACTED]. The DON stated of the resident's controlled pain medications, only Tylenol #3 was available in the e-kit. She stated she had spoken with the resident's physician on 01/18/18 regarding pain control and he had said he did not want to order more pain medication for the resident as he did not want the resident sleeping all the time. He said the resident should be sent to the ER. She stated no new pain medication was ordered following the resident's visit to theER on [DATE] for uncontrol (TRUNCATED)

Based on observation, interview and neglect, the facility failed to develop and implement written policies and procedure that prohibited and prevent neglect for one (Resident #1) of five residents reviewed for neglect. CNAs A and B failed to use the correct assistance device for Resident #1 when they transferred the resident using the wrong mechanical lift. Resident #1 sustained a tibia/fibula (lower leg) fracture injury as a result of the incorrect transfer. This was determined to be past non-compliance from due to the facility having implemented actions that corrected the noncompliance prior to the beginning of the investigation. The non-compliance occurred from 07/20/17 to 08/03/17. This failure could affect the nine residents on the 200 hall, where CNA B worked who required a mechanical lift for transfer and by placing them at risks for falls, fractures and the need for hospitalization s. Findings included: Review of the facility's abuse policy dated February 2017 reflected Neglect- means failure to provide goods and services necessary to avoid physical harm, mental anguish or emotional distress Resident #1's MDS assessment dated [DATE] revealed a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1's BIMS score indicated a severe cognitive impairment and she required extensive assistance with at least two persons for transfers. Resident #1's lift transfer evaluation dated 09/07/16 and completed by RN D reflected the resident required a Hoyer lift transfer with two persons. Sit-to-stand lifts are designed to help patients who lack the strength or muscle control to rise to a standing position from a bed, wheelchair, chair, or commode.The limitations of sit-to-stand lifts is that patients must be able to first sit up and second to physically support their own weight while in a standing position in order to use these devices. Retrieved from https://www.amicamedicalsupply.com/products/patient-lifts-and-accessories/stand-up-lifts.html Resident #1's Care Plan updated on 08/04/17 reflected she required extensive assistance with transfers, mobility, dressing, toileting, bathing and personal hygiene. She needed to be assisted with repositioning and required a two person's Hoyer lift transfer. Incident report dated 07/20/17 reflected during Resident #1's transfer on 07/2017 from bed to wheelchair staff reported that resident was sliding down in sling and her foot twisted .staff lowered her down into her wheelchair and resident complained of pain. The post-incident action report on 07/2017 noted staff educated on proper use of lift equipment, performing timely assessment, and reporting incidents in a timely manner. Review of Resident #1's x-ray results dated 07/20/17 reflected the resident had a fracture involving distal tibia and fibula with no displacement .acute ankle fracture Interview on 08/04/17 at 10:25 AM with LVN M revealed Resident #1 was alert to self and place, able to voice her needs, had left side weakness, required extensive assistance with her ADLs, and was transferred with two people using a Hoyer lift. Interview on 08/04/17 at 12:41 PM with CNA B she started working in the facility in June 2017. She stated on 07/20/17, herself and CNA A wanted to transfer Resident #1 from the bed to the wheelchair. She stated when she entered the room; CNA A already had the resident already in a seated position with the straps around her upper torso area. She stated the resident was seated too close to the edge of the bed. She stated she informed CNA A of her observation and CNA A just proceeded with the transfer so the resident would not fall. CNA B stated once the resident was a standing position, Resident #1 had complained of her right leg hurting. CNA #1 stated she observed the resident's leg to be turned inward. Resident #1 was put on her wheelchair, she complained of leg pain and LVN E was notified. CNA B stated she was familiar with Resident #1 who needed assistance with transfers and mobility. She stated she was given a care card on the day of the incident but each time she had seen the resident transferred, it was with the facility's stand-up lift. She stated that was the reason the stand up lift was used to transfer the resident. CNA B stated she had only worked on the 200 hall. Resident #1's care card dated 07/20/17 reflected the resident required a Hoyer lift with two persons for transfers. Interview on 08/04/17 at 1:30 PM with the DON revealed Resident #1 complained of leg pain after a transfer, an x-ray order STAT was called and the results showed the resident had an acute fracture. She stated Resident #1 was taken to the hospital for treatment and evaluation. The DON stated the facility's investigation could not confirm the resident had fallen as initially alleged by the resident. She stated they were able to determine Resident #1 was transferred with a stand-up lift instead of a hoyer lift and sustained an injury as a result. She stated Resident #1 had poor trunk control and was physically unable to assist with transfers which made her inappropriate for the stand-up lift. She stated the CNAs (CNA A and CNA B) involved were initially suspended, and during investigation LVN E withheld pertinent information and was later terminated. She stated CNA A was terminated due to failure to cooperate in the investigation and did not return for four consecutive shifts. The DON stated the CNAs receive care cards every day, on every shift by their nurses. She stated the care cards were instructions given to CNAs as a guide to show them the level of functional status each resident required. She stated CNA A and CNA B had their care cards but failed to use the correct equipment. Interview on 08/04/17 at 3:50 PM with Resident #1 revealed the facility recently told her she had a broken leg and was taken to the hospital. She stated before the incident, a different type of lift was being used to get her up but since returned from the hospital, a Hoyer lift was now being used for her transfer. She stated she does not get up daily just when she feels like it. Interview on 08/04/17 at 4:37 PM with RN D revealed she was the facility's clinical educator. She stated Resident #1 care card reflected a Hoyer lift not a stand-up lift was required for her transfers. RN D stated Resident #1 would not have been able to assist using a stand up lift and could not bear her own weight. She stated since the incident with Resident #1, she re-educated the CNAs on paying attention to their care cards instructions before performing care with any resident. As part of the monitoring phase, she observes three CNAs daily as they transfer residents throughout the facility and ensure the care cards were being utilized and the correct equipments was being used. RN D stated as part of the new hire orientation, new CNAs were provided education on mechanical lifts being used in the facility and they perform return demonstration to ensure they were competent in the task. The following were the action plans initiated by the facility in order to prevent a re-occurrence of the incident. - The DON reviewed Residents care cards to assure appropriate lifts were noted. - Three daily observations of mechanical lifts transfers with residents will be done with CNAs and conducted by RN D for one month and as needed. - The DON to maintain responsible for ensuring care cards were reviewed and updated as needed at clinical start-up. Care concerns or grievances will be discussed immediately with Admin/DON with follow-up at next stand up or stand down meeting. Review of CNA B in-service training dated 07/27/17 on lift procedures, care card usage, abuse and neglect report and change of condition procedures. Review of CNA A, CNA B, and LVN E disciplinary reports dated 07/27/17 were in their personnel files and CNA A and LVN E were terminated after the investigation. Review of in-service training dated 07/20/17 and 08/02/17 on care cards, lifts with return demonstration, appropriate life usage, change in condition and reporting abuse and neglect was conducted by the DON and RN D for all nursing staff. Review of the facility's RN D daily transfer observation/monitor sheets dated 07/25/17 through 08/03/17 reflected signatures from different CNAs. Observations on 08/04/17 made on the first and second shifts revealed CNAs (B, C, F, G, H, I , J, K) had possession of the resident's care cards and reviewed it before transfer of residents. Observation on 08/04/17 at 11:45 AM revealed Resident #5 was transferred with a Hoyer lift from the wheelchair to the bed by CNA C and CNA F. The staffs demonstrated safe transfer techniques and the correct equipment (lifts) were being utilized. Observation on 08/04/17 at 11:56 AM revealed Resident #6 was transferred with a Stand-up lift from the wheelchair to the bed by CNA G and CNA B. The staffs demonstrated safe transfer techniques and the correct equipment (lifts) were being utilized. Observation on 08/04/17 at 2:50 PM revealed Resident #4 was transferred with a Stand-up lift from the wheelchair to the bed by CNA J and CNA K. The staffs demonstrated safe transfer techniques and the correct equipment (lifts) were being utilized. Observation on 08/04/17 at 3:02 PM revealed Resident #7 was transferred with a Hoyer lift from the bed to the wheelchair by CNA H and CNA I. The staffs demonstrated safe transfer techniques and the correct equipment (lifts) were being utilized. Interview on 08/04/17 with Resident #2, #3, and #4 revealed they were transferred with mechanical lifts, and denied any accidents or fall during their transfers. Review of these Residents care plans revealed the appropriate lifts were being utilized during transfers. Interviews conducted on 08/04/17 with CNA B, CNA C, CNA F, CNA G, CNA H, CNA I, CNA J and CNA K revealed they received their care cards daily from their nurses on each shift. They stated they used the care cards to ensure residents received care according to their care plan. Review of the list of residents that required mechanical lifts ( Hoyer and Stand up) transfer on the 200 hall reflected a total of nine residents. This list was provided by LVN L.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate assistance to prevent accidents for 1 (Resident #1) of 5 residents reviewed for incidents and accidents. CNAs A and B failed to use the correct assistance device for Resident #1 when they transferred the resident using the wrong mechanical lift. Resident #1 sustained a tibia/fibula (lower leg) fracture injury as a result of the incorrect transfer. This was determined to be past non-compliance from due to the facility having implemented actions that corrected the noncompliance prior to the beginning of the investigation. The non-compliance occured from 07/20/17 to 08/03/17. This failure could affect the nine residents on the 200 hall, where CNA B worked who required a mechanical lift for transfer and by placing them at risks for falls, fractures and the need for hospitalization s. Findings included: Resident #1's MDS assessment dated [DATE] revealed a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1's BIMS score indicated a severe cognitive impairment and she required extensive assistance with at least two persons for transfers. Resident #1's lift transfer evaluation dated 09/07/16 and completed by RN D reflected the resident required a Hoyer lift transfer with two persons. Sit-to-stand lifts are designed to help patients who lack the strength or muscle control to rise to a standing position from a bed, wheelchair, chair, or commode.The limitations of sit-to-stand lifts is that patients must be able to first sit up and second to physically support their own weight while in a standing position in order to use these devices. Retrieved from https://www.amicamedicalsupply.com/products/patient-lifts-and-accessories/stand-up-lifts.html Resident #1's Care Plan updated on 08/04/17 reflected she required extensive assistance with transfers, mobility, dressing, toileting, bathing and personal hygiene. She needed to be assisted with repositioning and required a two person's Hoyer lift transfer. Incident report dated 07/20/17 reflected during Resident #1's transfer on 07/2017 from bed to wheelchair staff reported that resident was sliding down in sling and her foot twisted .staff lowered her down into her wheelchair and resident complained of pain. The post-incident action report on 07/2017 noted staff educated on proper use of lift equipment, performing timely assessment, and reporting incidents in a timely manner. Review of Resident #1's x-ray results dated 07/20/17 reflected the resident had a fracture involving distal tibia and fibula with no displacement .acute ankle fracture Interview on 08/04/17 at 10:25 AM with LVN M revealed Resident #1 was alert to self and place, able to voice her needs, had left side weakness, required extensive assistance with her ADLs, and was transferred with two people using a Hoyer lift. Interview on 08/04/17 at 12:41 PM with CNA B she started working in the facility in June 2017. She stated on 07/20/17, herself and CNA A wanted to transfer Resident #1 from the bed to the wheelchair. She stated when she entered the room; CNA A already had the resident already in a seated position with the straps around her upper torso area. She stated the resident was seated too close to the edge of the bed. She stated she informed CNA A of her observation and CNA A just proceeded with the transfer so the resident would not fall. CNA B stated once the resident was a standing position, Resident #1 had complained of her right leg hurting. CNA #1 stated she observed the resident's leg to be turned inward. Resident #1 was put on her wheelchair, she complained of leg pain and LVN E was notified. CNA B stated she was familiar with Resident #1 who needed assistance with transfers and mobility. She stated she was given a care card on the day of the incident but each time she had seen the resident transferred, it was with the facility's stand-up lift. She stated that was the reason the stand up lift was used to transfer the resident. CNA B stated she had only worked on the 200 hall. Resident #1's care card dated 07/20/17 reflected the resident required a Hoyer lift with two persons for transfers. Interview on 08/04/17 at 1:30 PM with the DON revealed Resident #1 complained of leg pain after a transfer, an x-ray order STAT was called and the results showed the resident had an acute fracture. She stated Resident #1 was taken to the hospital for treatment and evaluation. The DON stated the facility's investigation could not confirm the resident had fallen as initially alleged by the resident. She stated they were able to determine Resident #1 was transferred with a stand-up lift instead of a hoyer lift and sustained an injury as a result. She stated Resident #1 had poor trunk control and was physically unable to assist with transfers which made her inappropriate for the stand-up lift. She stated the CNAs (CNA A and CNA B) involved were initially suspended, and during investigation LVN E withheld pertinent information and was later terminated. She stated CNA A was terminated due to failure to cooperate in the investigation and did not return for four consecutive shifts. The DON stated the CNAs receive care cards every day, on every shift by their nurses. She stated the care cards were instructions given to CNAs as a guide to show them the level of functional status each resident required. She stated CNA A and CNA B had their care cards but failed to use the correct equipment. Interview on 08/04/17 at 3:50 PM with Resident #1 revealed the facility recently told her she had a broken leg and was taken to the hospital. She stated before the incident, a different type of lift was being used to get her up but since returned from the hospital, a Hoyer lift was now being used for her transfer. She stated she does not get up daily just when she feels like it. Interview on 08/04/17 at 4:37 PM with RN D revealed she was the facility's clinical educator. She stated Resident #1 care card reflected a Hoyer lift not a stand-up lift was required for her transfers. RN D stated Resident #1 would not have been able to assist using a stand up lift and could not bear her own weight. She stated since the incident with Resident #1, she re-educated the CNAs on paying attention to their care cards instructions before performing care with any resident. As part of the monitoring phase, she observes three CNAs daily as they transfer residents throughout the facility and ensure the care cards were being utilized and the correct equipments was being used. RN D stated as part of the new hire orientation, new CNAs were provided education on mechanical lifts being used in the facility and they perform return demonstration to ensure they were competent in the task. The following were the action plans initiated by the facility in order to prevent a re-occurrence of the incident. - The DON reviewed Residents care cards to assure appropriate lifts were noted. - Three daily observations of mechanical lifts transfers with residents will be done with CNAs and conducted by RN D for one month and as needed. - The DON to maintain responsible for ensuring care cards were reviewed and updated as needed at clinical start-up. Care concerns or grievances will be discussed immediately with Admin/DON with follow-up at next stand up or stand down meeting. Review of CNA B in-service training dated 07/27/17 on lift procedures, care card usage, abuse and neglect report and change of condition procedures. Review of CNA A, CNA B, and LVN E disciplinary reports dated 07/27/17 were in their personnel files and CNA A and LVN E were terminated after the investigation. Review of in-service training dated 07/20/17 and 08/02/17 on care cards, lifts with return demonstration, appropriate life usage, change in condition and reporting abuse and neglect was conducted by the DON and RN D for all nursing staff. Review of the facility's RN D daily transfer observation/monitor sheets dated 07/25/17 through 08/03/17 reflected signatures from different CNAs. Observations on 08/04/17 made on the first and second shifts revealed CNAs (B, C, F, G, H, I , J, K) had possession of the resident's care cards and reviewed it before transfer of residents. Observation on 08/04/17 at 11:45 AM revealed Resident #5 was transferred with a Hoyer lift from the wheelchair to the bed by CNA C and CNA F. The staffs demonstrated safe transfer techniques and the correct equipment (lifts) were being utilized. Observation on 08/04/17 at 11:56 AM revealed Resident #6 was transferred with a Stand-up lift from the wheelchair to the bed by CNA G and CNA B. The staffs demonstrated safe transfer techniques and the correct equipment (lifts) were being utilized. Observation on 08/04/17 at 2:50 PM revealed Resident #4 was transferred with a Stand-up lift from the wheelchair to the bed by CNA J and CNA K. The staffs demonstrated safe transfer techniques and the correct equipment (lifts) were being utilized. Observation on 08/04/17 at 3:02 PM revealed Resident #7 was transferred with a Hoyer lift from the bed to the wheelchair by CNA H and CNA I. The staffs demonstrated safe transfer techniques and the correct equipment (lifts) were being utilized. Interview on 08/04/17 with Resident #2, #3, and #4 revealed they were transferred with mechanical lifts, and denied any accidents or fall during their transfers. Review of these Residents care plans revealed the appropriate lifts were being utilized during transfers. Interviews conducted on 08/04/17 with CNA B, CNA C, CNA F, CNA G, CNA H, CNA I, CNA J and CNA K revealed they received their care cards daily from their nurses on each shift. They stated they used the care cards to ensure residents received care according to their care plan. Review of the list of residents that required mechanical lifts ( Hoyer and Stand up) transfer on the 200 hall reflected a total of nine residents. This list was provided by LVN L.

Based on observation, interview and record review, the facility failed to ensure each resident was free from neglect, for one (Resident #1) of five residents reviewed for neglect. CNAs A and B failed to use the correct assistance device for Resident #1 when they transferred the resident using the wrong mechanical lift. Resident #1 sustained a tibia/fibula (lower leg) fracture injury as a result of the incorrect transfer. This was determined to be past non-compliance from due to the facility having implemented actions that corrected the noncompliance prior to the beginning of the investigation. The non-compliance occured from 07/20/17 to 08/03/17. This failure could affect the nine residents on the 200 hall, where CNA B worked who required a mechanical lift for transfer and by placing them at risks for falls, fractures and the need for hospitalization s. Findings included: Resident #1's MDS assessment dated [DATE] revealed a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1's BIMS score indicated a severe cognitive impairment and she required extensive assistance with at least two persons for transfers. Resident #1's lift transfer evaluation dated 09/07/16 and completed by RN D reflected the resident required a Hoyer lift transfer with two persons. Sit-to-stand lifts are designed to help patients who lack the strength or muscle control to rise to a standing position from a bed, wheelchair, chair, or commode.The limitations of sit-to-stand lifts is that patients must be able to first sit up and second to physically support their own weight while in a standing position in order to use these devices. Retrieved from https://www.amicamedicalsupply.com/products/patient-lifts-and-accessories/stand-up-lifts.html Resident #1's Care Plan updated on 08/04/17 reflected she required extensive assistance with transfers, mobility, dressing, toileting, bathing and personal hygiene. She needed to be assisted with repositioning and required a two person's Hoyer lift transfer. Incident report dated 07/20/17 reflected during Resident #1's transfer on 07/2017 from bed to wheelchair staff reported that resident was sliding down in sling and her foot twisted .staff lowered her down into her wheelchair and resident complained of pain. The post-incident action report on 07/2017 noted staff educated on proper use of lift equipment, performing timely assessment, and reporting incidents in a timely manner. Review of Resident #1's x-ray results dated 07/20/17 reflected the resident had a fracture involving distal tibia and fibula with no displacement .acute ankle fracture Interview on 08/04/17 at 10:25 AM with LVN M revealed Resident #1 was alert to self and place, able to voice her needs, had left side weakness, required extensive assistance with her ADLs, and was transferred with two people using a Hoyer lift. Interview on 08/04/17 at 12:41 PM with CNA B she started working in the facility in June 2017. She stated on 07/20/17, herself and CNA A wanted to transfer Resident #1 from the bed to the wheelchair. She stated when she entered the room; CNA A already had the resident already in a seated position with the straps around her upper torso area. She stated the resident was seated too close to the edge of the bed. She stated she informed CNA A of her observation and CNA A just proceeded with the transfer so the resident would not fall. CNA B stated once the resident was a standing position, Resident #1 had complained of her right leg hurting. CNA #1 stated she observed the resident's leg to be turned inward. Resident #1 was put on her wheelchair, she complained of leg pain and LVN E was notified. CNA B stated she was familiar with Resident #1 who needed assistance with transfers and mobility. She stated she was given a care card on the day of the incident but each time she had seen the resident transferred, it was with the facility's stand-up lift. She stated that was the reason the stand up lift was used to transfer the resident. CNA B stated she had only worked on the 200 hall. Resident #1's care card dated 07/20/17 reflected the resident required a Hoyer lift with two persons for transfers. Interview on 08/04/17 at 1:30 PM with the DON revealed Resident #1 complained of leg pain after a transfer, an x-ray order STAT was called and the results showed the resident had an acute fracture. She stated Resident #1 was taken to the hospital for treatment and evaluation. The DON stated the facility's investigation could not confirm the resident had fallen as initially alleged by the resident. She stated they were able to determine Resident #1 was transferred with a stand-up lift instead of a hoyer lift and sustained an injury as a result. She stated Resident #1 had poor trunk control and was physically unable to assist with transfers which made her inappropriate for the stand-up lift. She stated the CNAs (CNA A and CNA B) involved were initially suspended, and during investigation LVN E withheld pertinent information and was later terminated. She stated CNA A was terminated due to failure to cooperate in the investigation and did not return for four consecutive shifts. The DON stated the CNAs receive care cards every day, on every shift by their nurses. She stated the care cards were instructions given to CNAs as a guide to show them the level of functional status each resident required. She stated CNA A and CNA B had their care cards but failed to use the correct equipment. Interview on 08/04/17 at 3:50 PM with Resident #1 revealed the facility recently told her she had a broken leg and was taken to the hospital. She stated before the incident, a different type of lift was being used to get her up but since returned from the hospital, a Hoyer lift was now being used for her transfer. She stated she does not get up daily just when she feels like it. Interview on 08/04/17 at 4:37 PM with RN D revealed she was the facility's clinical educator. She stated Resident #1 care card reflected a Hoyer lift not a stand-up lift was required for her transfers. RN D stated Resident #1 would not have been able to assist using a stand up lift and could not bear her own weight. She stated since the incident with Resident #1, she re-educated the CNAs on paying attention to their care cards instructions before performing care with any resident. As part of the monitoring phase, she observes three CNAs daily as they transfer residents throughout the facility and ensure the care cards were being utilized and the correct equipments was being used. RN D stated as part of the new hire orientation, new CNAs were provided education on mechanical lifts being used in the facility and they perform return demonstration to ensure they were competent in the task. The following were the action plans initiated by the facility in order to prevent a re-occurrence of the incident. - The DON reviewed Residents care cards to assure appropriate lifts were noted. - Three daily observations of mechanical lifts transfers with residents will be done with CNAs and conducted by RN D for one month and as needed. - The DON to maintain responsible for ensuring care cards were reviewed and updated as needed at clinical start-up. Care concerns or grievances will be discussed immediately with Admin/DON with follow-up at next stand up or stand down meeting. Review of CNA B in-service training dated 07/27/17 on lift procedures, care card usage, abuse and neglect report and change of condition procedures. Review of CNA A, CNA B, and LVN E disciplinary reports dated 07/27/17 were in their personnel files and CNA A and LVN E were terminated after the investigation. Review of in-service training dated 07/20/17 and 08/02/17 on care cards, lifts with return demonstration, appropriate life usage, change in condition and reporting abuse and neglect was conducted by the DON and RN D for all nursing staff. Review of the facility's RN D daily transfer observation/monitor sheets dated 07/25/17 through 08/03/17 reflected signatures from different CNAs. Observations on 08/04/17 made on the first and second shifts revealed CNAs (B, C, F, G, H, I , J, K) had possession of the resident's care cards and reviewed it before transfer of residents. Observation on 08/04/17 at 11:45 AM revealed Resident #5 was transferred with a Hoyer lift from the wheelchair to the bed by CNA C and CNA F. The staffs demonstrated safe transfer techniques and the correct equipment (lifts) were being utilized. Observation on 08/04/17 at 11:56 AM revealed Resident #6 was transferred with a Stand-up lift from the wheelchair to the bed by CNA G and CNA B. The staffs demonstrated safe transfer techniques and the correct equipment (lifts) were being utilized. Observation on 08/04/17 at 2:50 PM revealed Resident #4 was transferred with a Stand-up lift from the wheelchair to the bed by CNA J and CNA K. The staffs demonstrated safe transfer techniques and the correct equipment (lifts) were being utilized. Observation on 08/04/17 at 3:02 PM revealed Resident #7 was transferred with a Hoyer lift from the bed to the wheelchair by CNA H and CNA I. The staffs demonstrated safe transfer techniques and the correct equipment (lifts) were being utilized. Interview on 08/04/17 with Resident #2, #3, and #4 revealed they were transferred with mechanical lifts, and denied any accidents or fall during their transfers. Review of these Residents care plans revealed the appropriate lifts were being utilized during transfers. Interviews conducted on 08/04/17 with CNA B, CNA C, CNA F, CNA G, CNA H, CNA I, CNA J and CNA K revealed they received their care cards daily from their nurses on each shift. They stated they used the care cards to ensure residents received care according to their care plan. Review of the list of residents that required mechanical lifts ( Hoyer and Stand up) transfer on the 200 hall reflected a total of nine residents. This list was provided by LVN L.

Based on observation, interview and record review, it was determined the Administrator and the DON failed to use the facility's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psycho-social well-being of five (Residents #1, #2, #3, #5, and #11) of six residents reviewed for neglect. 1) The Administrator failed to ensure the current Abuse Neglect and Elopement/Missing Resident Policies were reflective of the facility and implemented to protect the residents. Resident #1, who was missing more than eight hours was not reported to the State agency immediately. 2) The Administrator failed to supervise the DON to ensure all staff were trained regarding residents at risk for elopement and when residents were discovered missing. 3) The DON failed to ensure: --Staff knew which residents were at risk for elopement. --Staff knew about the Resident Elopement Book, which contained pictures and information of residents at risk for elopement. --Staff could identify residents at risk for elopement by more than merely seeing the residents had wander-guards. --All residents were assessed for elopement risk. --Care plans were updated identifying residents at risk for eloping and appropriate interventions. --Staff were in-serviced on policies and procedures regarding residents at risk for elopement and for missing residents. These failures resulted in the following: 1) Resident #1 was transferred from the secured unit on 06/22/12 because the space was needed for another resident. --No elopement assessment was completed to indicate if it was safe for the resident to be transferred from the secured unit even though he had already been identified as an elopement risk. --No wander-guard was applied until three days later by the DON. --The SW was notified by a family member prior to the resident's elopement that the resident wanted to leave but the social worker did not take any action. --The resident's roommate voiced a concern to staff about Resident #1's interest in the room's window, which could be fully opened. --CNA P was aware the resident's interest in the TV room was abnormal, but night staff were not aware of it. --Night staff were not aware Resident #1 was an elopement risk. --Resident #1 was left alone in the TV room, which had a door accessible to residents which opened to the outside. --Resident #1 eloped from the facility on 07/08/12, and his decomposing body was found approximately four to five blocks from the facility on 07/10/12 and identified by the Medical Examiner on 07/15/12. 2) Resident #2 was admitted on [DATE]. --with a history of exit- seeking behaviors. --A history of leaving the facility without informing staff. --had the potential to wander into unsafe situations. --was ambulatory, --was not considered an elopement risk. He was added to the Elopement Risk list after surveyor intervention on 07/18/12. 3) Resident #3 was identified by the facility as being at risk for elopement. --He was allowed to keep his door closed frequently. --His room window opened to an unsecured outside area. --He had a wander-guard not easily seen. 4) Resident #5 had a history of [REDACTED]." --He was not considered an elopement risk. --He did not have a wander-guard. --He was added to the Elopement Risk list following surveyor intervention on 07/18/12. 5) Resident #11 did not reside on the secured unit. --The facility assessed her as an elopement on 07/09/12. --Did not have a wander-guard. --Had a wander-guard placed 07/17/12. An Immediate Jeopardy was identified on 07/17/12. While the Immediate Jeopardy was removed on 07/18/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the implementation of the Plan of Removal. These failures likely caused the death of Resident #1 and could affect the 39 residents, identified as elopement risks, and could result in the potential for attempts at elopement, successful elopements, resulting in the potential for injury, exacerbation of their [DIAGNOSES REDACTED]. Findings included: 1) The Face Sheet dated 07/15/12 reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The unsigned Resident Elopement assessment dated [DATE] reflected Resident #1 was at risk for elopement due to a history of elopement. The Risk of Elopement Review, dated 06/01/12 reflected three of 14 risk questions were positive, and Resident #1 was considered at risk for elopement. Resident #1's nurse's notes reflected: On 06/01/12 Resident #1 was admitted from home and placed on the secured unit. On 06/04/12 and 06/05/12 Resident #1 wandered the hallway with exit-seeking behavior requiring redirection from the secured unit's locked exit. The Departmental Notes dated 06/06/12 reflected the SW called a family member to discuss moving Resident #1 off the secured unit. Resident #1's family member informed the SW Resident #1 told him/her last night (06/05/12), he wanted to leave the facility and would try to "escape" if given the chance. The Notes reflected when he was living at home, Resident #1 had gone outside without clothes and had wandered around the neighborhood. Resident #1's current Care Plan, dated 06/14/12, reflected Resident #1 only understood very simple English words and was at risk for wandering into unsafe situations. The nurse's notes dated 06/19/12 at 2:39 a.m. reflected Resident #1 was anxious, dressed and voiced a desire to go home. The Room Changes form dated 06/22/12 was signed by the SW and reflected Resident #1 did not qualify for the Light House (secured unit) and was moved off the secured unit. There was no record of an elopement risk assessment completed at the time of Resident #1's transfer off the secured unit. The Risk of Elopement Review dated 06/27/12 reflected four of 14 risk questions were positive (including the same three risk questions on the previous review) and Resident #1 was not considered at risk for elopement. The nurse's notes dated 07/07/12 at 10:00 p.m. reflected Resident #1 was standing in the hall and returned to his room. At 2:30 a.m., Resident #1 ambulated from his room and stood in the TV room. The nurse encouraged Resident #1 to return to his room, but he did not. At 2:40 a.m., Resident #1 was observed sitting in the TV room. Review of the facility's Provider Investigation Report, signed and revised by the ADM on 07/17/12, revealed the incident occurred on 07/08/12 at 3:00 a.m. and was reported to the State agency on 07/13/12. For Level of Supervision, "No special supervision" was marked. Resident #1 was identified with a history of wandering and had "extensive and minimal" Functional Ability. The capacity to make informed decisions was marked "N" for no. A description of the Allegation on the Provider Investigation Report reflected the resident eloped from the facility at approximately 3:00 a.m. on Sunday, 07/08/12. The resident was seen in the living area by the charge nurse at 2:40 a.m. and the CNA last spotted him in the living area at 2:50 a.m. At 3:00 a.m., the nurse noticed Resident #1 was not in the living area and began looking for him without finding him. An investigation summary attached to the Provider Investigation Report, dated 07/16/12, reflected the following: The DON reported Resident #1 missing from the facility. The ADM initiated calls for all administrative team leaders to come in for search, review the incident, and communicate with authorities. The police department was notified. The summary reflected Resident #1 was admitted to the facility on [DATE] to the Lighthouse Unit (secured unit) but was found to be inappropriate for the area. He was more cognizant of his environment and recognized he was different from the other residents. Resident #1 was moved to the open unit with a wander-guard in place on 06/22/12. He had not exhibited any indication he was trying to leave according to staff. The facility was unable to reach Resident #1's family by phone. All phone numbers for the family were inactive or no longer in service. The local Police Department issued a Silver Alert throughout the area. On 07/10/12, the Silver Alert was removed. A time line attached to the investigation and signed by the DON reflected she, the DON, was informed via text of the missing resident, Resident #1, on 07/08/12 at 3:15 a.m. She stayed informed with the staff and at 3:35 a.m. the police were notified. At 7:30 a.m., the DON called the Administrator and confirmed she was aware of the situation. All Department Managers were being called by the Administrator to "begin search." A search was made of a five-mile radius by the managers. At 12:00 p.m., the managers met back at the facility, spoke with the police and called off the search. The Administrative Summary of Findings reflected, "After thoroughly investigating the events of this incident there does not appear to be any concern of neglect or failure to supervise or equipment issues which caused the resident to elope without notice." The Facility Action Taken reflected, the following: "education of the administrative team regarding the policy and procedures of missing resident/elopement, moving or transferring residents from or admissions to the LHU (Lighthouse Unit), and review of assessments. Staff training regarding Elopement Policy and safe monitoring of the residents at risk for elopement. Approved vendor inspected the wander-guard system for effectiveness/functionality. Other residents were assessed at risk for elopement had their assessments updated and all wander-guards were checked and verified their functionality. Resident discharged from the facility 07/10/12 when search ended." During an interview on 07/17/12 at 8:45 a.m. with the ADM and the DON, the ADM stated Resident #1 had been observed watching television in the day room at 2:40 a.m. on 07/08/12. The ADM stated a nurse had encouraged Resident #1 to go to bed, but the resident did not want to go to bed. The ADM revealed Resident #1 was last seen at 3:00 a.m. on 07/08/12. The ADM revealed at 3:30 a.m., the police were notified that the resident was missing. The ADM stated the facility attempted to call the family, but they could not be reached. Once the police got involved, the police went to several of the family members' homes. The ADM stated Resident #1 was not on the secured unit when the incident occurred. The ADM stated Resident #1 had expressed to his family he wanted to get out of the facility, but his statement was never conveyed to the facility until after his elopement. The ADM stated the front desk was occupied during the week from 7:00 a.m. to 5:30 p.m. and 8:00 a.m. to 6:30 p.m. on the weekend. She stated the back door did not have one-on-one monitoring but had an alarm. The ADM stated to their knowledge the resident wore a wander-guard, but not the night of his elopement; no alarms sounded or alerts were heard. She stated the resident was capable of removing his wander-guard and they presumed Resident #1 had cut it off. The ADM stated the area (did not specify) was searched by the family and police several times. The ADM stated if Resident #1 was mad or angry he knew enough to hide. The ADM stated the functionality of the wander-guard system was tested every evening. She stated if something was wrong with the door alarms they monitored it one-on-one. She stated the front door and the back door were on the wander-guard system. The ADM stated Resident #1 had dinner with a family member the evening prior to his elopement (Saturday night, 07/07/12) at approximately 6:00 p.m. The ADM stated that initially the resident's family thought Resident #1 might be at a homeless shelter, but the shelter had not seen the resident. She stated an employee from a local restaurant reportedly saw Resident #1 with two men at approximately 7:00 a.m. on 07/09/12. On 07/10/12 the family reported they had found a body. During the interview on 07/17/12 at 8:45 a.m. the DON stated Resident #1 expressed to one of his family members the nursing home was a "prison." She stated Resident #1's behavior did not indicate he was "exit seeking." She stated Resident #1 was initially admitted to the secured unit where he stayed for three weeks. During that time, Resident #1 stayed in his room and watched TV. She stated the resident was then moved out of the secured unit, but he mostly stayed in his room and watched TV. The DON revealed Resident #1 had been out of the secured unit for approximately two weeks. When queried about Resident #1's abilities, the DON stated Resident #1 had a cane and could walk "a few feet." Interview with CNA F on 07/17/12 at 8:45 a.m. revealed she saw Resident #1 in the TV room at approximately 11:25 p.m. on 07/07/12. CNA F stated Resident #1 had his head hung down low against his chest and did not speak to her when she passed by him. CNA F was unaware if this was Resident #1's normal demeanor because she was unfamiliar with Resident #1. CNA F stated she was not aware of Resident #1 being an elopement risk or not. CNA F said she left Resident #1 alone in the TV room where an outside door was accessible to the residents. When questioned regarding how to identify residents at risk for elopement, CNA F stated residents were identified at risk by seeing a wander guard on their ankle. She was uncertain whether Resident #1 was wearing a wander guard or not because he was in long pants covering his ankles. Interview on 07/17/12 at 12:53 p.m. with the Director of Maintenance revealed the alarms were checked every morning. He stated a transmitter was used. The Director of Maintenance stated the residents' wander-guards were changed every year and had an expiration date on them. He stated the residents' wander-guards were changed in February 2012. The surveyor asked the Director of Maintenance how the residents' wander-guards were checked. He stated he received a list of resident names every month. He stated he used the transmitter to check their wander-guards. Interview on 07/17/12 at 11:25 a.m. with CNA F revealed she worked the 10:00 p.m. to 6:00 a.m. shift. CNA F stated she did not work on Resident #1's hall. She stated she had seen the resident before but did not work with him. CNA F stated on 07/07/12 when she saw Resident #1 sitting in the TV room, she asked Resident #1 if he should be in bed. He did not respond to her. She stated that was the last time she saw him. When questioned regarding how to identify residents at risk for elopement, CNA F stated residents were identified at risk by seeing a wander-guard on their ankle. She was uncertain whether Resident #1 was wearing a wander-guard or not because he was in long pants that covered his ankles. Interview on 07/17/12 at 11:41 a.m. with CNA G revealed she worked the 10:00 p.m. to 6:00 a.m. shift. She stated she was not familiar with Resident #1. CNA G stated the evening of 07/07/12, prior to the incident, she had finished her rounds on hall 200 and went to help on hall 100. CNA G stated LVN B asked her and CNA A if they had seen Resident #1. CNA G stated she asked LVN B who Resident #1 was. CNA G stated CNA A revealed she had seen the resident at approximately 1:00 a.m. on the (back) patio. CNA G stated they checked the rooms on hall 500 for Resident #1. She stated they did not locate him on hall 500. CNA G stated CNA A and she walked to a local restaurant (approximately 0.1 mile from the facility per Google maps) to search for the resident. They did not see him. CNA G stated LVN B and CNA F also searched for the resident. CNA G stated she overheard Resident #1's nurse, LVN H, being asked if she had notified anyone regarding Resident #1 and LVN H and stated, "No." CNA G stated the police eventually showed up. When questioned how to identify a resident who was at risk of elopement, CNA G stated that a resident was identified as an elopement risk by seeing a wander-guard on their ankle. Interview on 07/17/12 at 2:50 p.m. with CNA A revealed she worked the third shift the morning Resident #1 was missing. CNA A stated she observed an elderly male swinging a cane back and forth in the back courtyard on 07/08/12 at approximately 1:15 a.m. The man exited the courtyard gate at approximately 1:35 a.m., ambulated into the parking lot, and did not return. CNA A stated she did not report the incident to anyone at that time but reported it later that morning after the nurse told her a resident was missing. CNA A stated she only knew the residents on the hall she worked on and did not know residents on the other halls. CNA A stated she did not know in the past or presently which residents were at risk for elopement. When queried which residents were at risk for elopement, CNA A stated she did not know who they were but if she saw a wander-guard on the residents, they were the residents at risk for elopement. Telephone interview on 07/17/12 at 3:40 p.m. with LVN B revealed she saw Resident #1 at approximately 11:30 p.m. the night before he was missing in the Day Room. (The Day Room was near the back door, the courtyard, and back parking lot.) LVN B stated she did not work on the hall Resident #1 resided on. LVN B helped search inside the building, the area outside, and drove around in the area but did not find Resident #1. The Police were at the facility when she returned to the building. When queried which residents were at risk for elopement, LVN B stated at the time of the incident she only knew the residents on her hall that were at risk for elopement. LVN B stated she presently knew some residents on the other halls who were at risk for elopement but did not know presently which residents on the 500 hall were at risk for elopement. (Note: Resident #1 resided on hall 500 before he eloped.) LVN B stated an alarm would sound if a resident with a wander-guard attempted to exit the front or back doors but if a resident did not have a wander-guard, they would be able to exit the doors without staff knowledge. Interview on 07/17/12 at 4:07 p.m. with CNA O revealed she was informed by CNA N to watch Resident #1 closely because he would leave if he had an opportunity. CNA O stated she was assigned to work the hall where Resident #1 resided after being moved from the secured unit. CNA O stated she was not familiar with Resident #1 as she had only worked with him "a couple of times." She was not aware if he wore a wander-guard or not and was only concerned about his elopement risk because of the conversation she had with CNA N. When questioned how to identify a resident who was at risk for elopement, CNA O stated, "The residents at risk for elopement are the residents who have alarms or wander-guards on." Interview on 07/17/12 at 4:15 p.m. with CNA N revealed she voiced concerns to her nurse on 06/20/12 regarding an incident when Resident #1 raised a window while on the secured unit and verbalized the desire to go home. CNA N stated she was very familiar with Resident #1 and was concerned regarding Resident #1's move off the secured unit on 06/22/12. CNA N stated she informed her friend, CNA O, of her concern and requested CNA O to "keep an eye on him." When questioned regarding how to identify residents at risk for elopement, CNA N stated the residents at risk for elopement were the residents with wander-guards. Interview on 07/17/12 at 4:20 p.m. with CNA C revealed she worked for three months on the same hall and did not know residents on the other halls, who were at risk for elopement. Interview on 07/17/12 at 4:22 p.m. with CNA L revealed he recognized a resident at risk for elopement by seeing a wander-guard on the resident's ankle or wheelchair. CNA L normally worked the 2:00 p.m. to 10:00 p.m. shift on hall 100. CNA L stated he was unfamiliar with Resident #1 and he was not sure if the resident wore a wander-guard or was at risk for elopement. CNA L stated he worked 07/07/12 but had gotten off work at his normal time around 10:00 p.m. CNA L stated he did not work on 07/08/12. Interview on 07/17/12 at 4:30 p.m. with CNA D revealed she had worked for two years on all halls and stated only two residents were at risk for elopement in the facility. When queried which residents had wander-guards, CNA D named ten people and stated there were quite a few with wander-guards. CNA D stated an alarm sounded if a resident with a wander-guard attempted to exit, and staff would go see who was at the door. Interview on 07/17/12 at 4:35 p.m. with CNA E revealed she had worked at the facility for three years and residents who were at risk for elopement were residents who wore wander-guards. An alarm would sound if one of those residents went near the door and staff would check to make sure the resident did not go out. Interview on 07/17/12 at 4:40 p.m. with CNA P revealed he was very familiar with Resident #1. His regular hall assignment was the one in which Resident #1 resided. CNA P stated anybody who was familiar with Resident #1 would have known it was very unusual for him to be in the TV room. CNA P stated when he became aware of the incident and the resident's location in the TV room during the early morning hours, CNA P was concerned none of the staff caring for Resident #1 knew the behavior to be abnormal. When questioned regarding communication among staff about residents who were at risk for elopement, CNA P stated the staff should be informed by nurses of who was at risk for elopement. CNA P stated he was not informed of Resident #1 being at risk for elopement. He stated he was uncertain whether Resident #1 had a wander-guard on or not. CNA P was not aware of an elopement book at the nurse's station or any identifiers letting staff know when a resident was at risk for elopement other than the wander-guard being worn on the ankle. Interview on 07/18/12 at 11:23 a.m. with Resident #6 revealed he had been Resident #1's roommate (not the secured unit) and had voiced concerns to staff Resident #1 frequently stood by the window. Resident #6's concern was Resident #1 might open the window and go outside. Resident #6 was concerned because the windows did not have an alarm and were easy to open for exit. Resident #6 demonstrated to the surveyor at that time, the window could be opened all the way to the top of the window frame. Telephone interview on 07/18/12 at 1:45 p.m. with Medical Examiner's staff revealed Resident #1's body was identified that day (07/18/12) and the cause of death was undetermined. Interview on 07/18/12 at 2:35 p.m. with the DON revealed a wander-guard was found in the trash Saturday night on 07/14/12, a week after Resident #1's elopement at approximately 10:00 p.m. The wander-guard had set off the alarm when a CNA took out the trash. The CNA gave the wander-guard to the charge nurse but the charge nurse did not report it until the next shift. There was no way to know for sure if the wander-guard was used on Resident #1. The DON stated Resident #1's family member had visited him the previous Saturday night (07/07/12). The DON stated the family member might have cut the wander-guard off at that time. The DON stated the family member told the Detective to search for Resident #1 under a particular nearby bridge but the resident was not found there at that time. At a later date, Resident #1's family members found Resident #1's body under the same nearby bridge that was previously searched. 2) Observation on 07/18/12 at 10:45 a.m. revealed Resident #2 was dressed and ambulating independently on the 300 hall, where he resided. A wander-guard was not visible. The Face Sheet dated 07/18/12 reflected Resident #2 was a [AGE] year-old male admitted to the facility 06/15/12 with [DIAGNOSES REDACTED]. The Care Plan dated 06/28/12 reflected Resident #2 had a history of [REDACTED]. Staff were to note which exits Resident #2 favored for elopement and alert staff working near those areas. The Risk of Elopement Review dated 07/09/12 reflected Resident #2 was cognitively impaired with poor decision-making skills; ambulated independently; had [DIAGNOSES REDACTED]. The Elopement Risk list provided by the facility on 07/17/12 reflected Resident #2 was not at risk for elopement. After surveyor intervention, the Elopement risk list was updated by the facility on 07/18/12 and reflected Resident #2 was added to the list for residents at risk for elopement. Observation on 07/18/12 at 11:00 a.m. revealed the back door to the courtyard area was easy to open, going out and coming in either by pushing easily on the door or by pushing the large handicapped button beside the door for automatic door opening. Resident #2 sat in a chair at the table with a staff member. Resident #2's wander-guard was not visible and the courtyard gate was open to the back parking lot. The surveyor noted the gate was easy to open, going out and coming in, and the courtyard gate and fence was approximately four feet high. 3) The Face Sheet reflected Resident #3, a [AGE] year-old male, was admitted to the facility 12/06/11 with [DIAGNOSES REDACTED]. Observation on 07/18/12 at 10:45 a.m. revealed the door to Resident #3's room on the 300 hall was shut with a sign on the door that said to leave the door shut while he was sleeping and at night. The Elopement risk list provided by the facility on 07/17/12 reflected Resident #3 was at risk for elopement. Observation on 07/18/12 at 11:35 a.m. revealed Resident #3 was dressed, sat in the dining room near the front door and the wander-guard was not visible. 4) The Face Sheet revealed Resident #5 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The Elopement Risk list provided by the facility on 07/17/12 reflected Resident #5 was not at risk for elopement. The Care Plan dated 04/18/12 revealed Resident #5 had a history of [REDACTED]." After surveyor intervention, the Elopement Risk list dated 07/18/12 reflected Resident #5 was at risk for elopement and had a wander-guard placed. Resident #5 could not be observed for he was not in the facility. 5) The Face Sheet reflected Resident #11, an [AGE] year-old female, was initially admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. She did not reside in the Secured Unit. Review of the Risk of Elopement Review revealed Resident #11 was assessed as at risk for elopement on 07/09/12. Review of physician's orders [REDACTED]. The Care Plan dated 07/17/12 reflected Resident #11 was at risk for wandering behavior. Observation on 07/18/12 at 1:09 p.m. revealed Resident #11 was in the community/TV room in a wheelchair with a wander-guard attached to the back of her wheelchair. 6) The facility's policy and procedure, "Elopement from Designated Area of Facility" dated 12/01/10 and identified as current by the DON on 07/18/12 at 9:50 a.m. reflected the following procedure: "1. Any staff member who becomes aware of a resident not being at the designated area or activity shall proceed to notify the charge nurse, Director of Nursing and the Administrator. 2. The wandering resident's charge nurse shall assign direct care staff to look for the resident. 3. If the resident is not located in the buildings or the grounds within fifteen minutes, the charge nurse shall notify the Director of Nursing and the Administrator to implement the plan to locate the resident...." The procedure further reflected the Police Department, family member and attending physician would be notified. The State agency would be notified "per state specific reporting guidelines. (Note: Provider Letter 2006-43 provides: "If a resident is not located during a search of the facility, facility grounds, and immediate vicinity, and there are circumstances that place the resident's health, safety and/or welfare at risk, the report must be made as soon as the facility becomes aware the resident is missing and cannot be located. Regardless of the circumstances, any resident missing for eight hours and not yet located must be reported at that time. In addition must contact the DADS Consumer Rights and Services Section daily until the resident is found.") The facility's Abuse, Neglect and Exploitation policy, dated, 05/01/12 and initialed by the ADM, reflected the following: "PURPOSE To prevent abuse, neglect or exploitation of residents, to the extent possible and ensure proper investigation and reporting of suspected cases, in compliance with applicable state and federal regulations. POLICY STATEMENT Each Region shall have in place procedures for the prevention of and handling of abuse, neglect and exploitation of residents. Systems shall be in place to monitor the facilities' performance in this area. PROCEDURE Each Regional Vice President shall ensure the development of policies, in the Region that provide for the following actions: 1. Protect the resident...." 7) An IJ was identified on 07/17/12. On 07/17/12 at 6:30 p.m., the Administrator and the DON were informed an IJ was identified in the area of Resident Behavior/Facility Practice and Administration. The Administrator and the DON were requested to provide a Plan of Removal for the IJ. 8) The facility's Plan of Removal for the IJ dated 07/17/12, which was accepted on 07/18/12, reflected the following: Facility Post Action Abatement: " 1) All residents on the secured unit were reassessed using the elopement risk assessment form by ____, ADON (the facility's only ADON), ____ Lighthouse Unit Manager (LVN S), and ____, LVN (LVN R) on 07/09/12. All other residents' elopement assessments will be updated as of 07/17/12 by 5:00 p.m. All elopement care plans updated and completed 07/17/12 by ____, MDS coordinator (MDS Coordinator T) and ____, MDS coordinator, LVN (LVN U). 2) Resident elopement book was updated by ___, Medical Records and was completed on 07/17/12. 3) An identifier for elopement has been placed on the residents' door frame as of 07/17/12 at 10:00 p.m. to alert all staff of potential risk. 4) The residents' care card will be updated for all residents and place in room inside closet door for care staff to refer to. Direct care staff will be in serviced on the care cards by 07/18/12 by DON, ADON, and SDC. 5) ____, Administrator initiated education to key administrative staff on 07/08/12 on elopement policy and procedures. All remaining staff have been or will be educated related to the policy and procedure for elopement, facility wander elopement book, and facility identifier for elopement risk residents on by SDC on 07/18/12. 6) Any staff unavailable for education will be removed from the schedule and not allowed to work. Employees will have until 07/25/12 to attend in-service. If the employee is out on leave or vacation and has not completed by this time, they will be permanently removed from schedule until education is completed. 7) Validation of effectiveness of training will occur via employee interviews by staff development coordinator and will be reviewed by the CQI Committee on a weekly basis for 4 weeks and monthly for 3 months. 8) Clinical staff will visually validate placement of code alert at the beginning of their shift and document on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 9) Charge nurses

Based on observation, interview and record review, the facility failed to implement their written policies and procedures that prohibited neglect for five (Residents #1, #2, #3, #5, and #11) of six residents reviewed for neglect. 1) Resident #1 was transferred from the secured unit on 06/22/12 because the space was needed for another resident. --No elopement assessment was completed to indicate if it was safe for the resident to be transferred from the secured unit even though he had already been identified as an elopement risk. --No wander-guard was applied until three days later by the DON. --The SW was notified by a family member prior to the resident's elopement that the resident wanted to leave but the social worker did not take any action. --The resident's roommate voiced a concern to staff about Resident #1's interest in the room's window, which could be fully opened. --CNA P was aware the resident's interest in the TV room was abnormal, but night staff were not aware of it. --Night staff were not aware Resident #1 was an elopement risk. --Resident #1 was left alone in the TV room, which had a door accessible to residents which opened to the outside. --Resident #1 eloped from the facility on 07/08/12, and his decomposing body was found approximately four to five blocks from the facility on 07/10/12 and identified by the Medical Examiner on 07/15/12. 2) Resident #2 was admitted on [DATE]. --with a history of exit- seeking behaviors. --A history of leaving the facility without informing staff. --had the potential to wander into unsafe situations. --was ambulatory, --was not considered an elopement risk. He was added to the Elopement Risk list after surveyor intervention on 07/18/12. 3) Resident #3 was identified by the facility as being at risk for elopement. --He was allowed to keep his door closed frequently. --His room window opened to an unsecured outside area. --He had a wander-guard not easily seen. 4) Resident #5 had a history of [REDACTED]." --He was not considered an elopement risk. --He did not have a wander-guard. --He was added to the Elopement Risk list following surveyor intervention on 07/18/12. 5) Resident #11 did not reside on the secured unit. --The facility assessed her as an elopement on 07/09/12. --Did not have a wander-guard. --Had a wander-guard placed 07/17/12. 6) Staff did not know which residents were at risk for elopement. --Staff did not know about the Resident Elopement Book, which contained pictures and information of residents at risk for elopement. --Staff identified residents at risk for elopement by seeing their wander-guards. --A wander-guard with the band cut was found in the trash but residents were not checked for missing wander-guards until the following morning. --Residents who did not reside on the secured unit were not always assessed for elopement risk. --Care plans were not updated identifying residents at risk for eloping until surveyor intervention on 07/17/12. --Staff were in-serviced on policies and procedures regarding residents at risk for elopement and for missing residents on 07/17/12 after surveyor intervention. An Immediate Jeopardy was identified on 07/17/12. While the Immediate Jeopardy was removed on 07/18/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the implementation of the Plan of Removal. These failures likely caused the death of Resident #1 and could affect the 39 residents, identified as elopement risks, and could result in the potential for attempts at elopement, successful elopements, resulting in the potential for injury, exacerbation of their [DIAGNOSES REDACTED]. Findings included: 1) The facility's Abuse, Neglect and Exploitation policy, dated, 05/01/12 and initialed by the ADM, reflected the following: PURPOSE To prevent abuse, neglect or exploitation of residents, to the extent possible and ensure proper investigation and reporting of suspected cases, in compliance with applicable state and federal regulations. POLICY STATEMENT Each Region shall have in place procedures for the prevention of and handling of abuse, neglect and exploitation of residents. Systems shall be in place to monitor the facilities' performance in this area. PROCEDURE Each Regional Vice President shall ensure the development of policies, in the Region that provide for the following actions: 1. Protect the resident...." 7) The policy and procedure, "Elopement from Designated Area of Facility" dated 12/01/10 and identified as current by the DON on 07/18/12 at 9:50 a.m. reflected the following procedure: 1. Any staff member who becomes aware of a resident not being at the designated area or activity shall proceed to notify the charge nurse, Director of Nursing and the Administrator. 2. The wandering resident's charge nurse shall assign direct care staff to look for the resident. 3. If the resident is not located in the buildings or the grounds within fifteen minutes, the charge nurse shall notify the Director of Nursing and the Administrator to implement the plan to locate the resident...." The procedure further reflected the Police Department, family member and attending physician would be notified. The State agency would be notified "per state specific reporting guidelines." (Note: Provider Letter 2006-43 states: "If a resident is not located during a search of the facility, facility grounds, and immediate vicinity, and there are circumstances that place the resident's health, safety and/or welfare at risk, the report must be made as soon as the facility becomes aware the resident is missing and cannot be located. Regardless of the circumstances, any resident missing for eight hours and not yet located must be reported at that time. In addition must contact the DADS Consumer Rights and Services Section daily until the resident is found.") 2) The Face Sheet dated 07/15/12 reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The unsigned Resident Elopement assessment dated [DATE] reflected Resident #1 was at risk for elopement due to a history of elopement. The Risk of Elopement Review, dated 06/01/12 reflected three of 14 risk questions were positive, and Resident #1 was considered at risk for elopement. Resident #1's nurse's notes reflected: On 06/01/12 Resident #1 was admitted from home and placed on the secured unit. On 06/04/12 and 06/05/12 Resident #1 wandered the hallway with exit-seeking behavior requiring redirection from the secured unit's locked exit. The Departmental Notes dated 06/06/12 reflected the SW called a family member to discuss moving Resident #1 off the secured unit. Resident #1's family member informed the SW Resident #1 told him/her last night (06/05/12), he wanted to leave the facility and would try to "escape" if given the chance. The Notes reflected when he was living at home, Resident #1 had gone outside without clothes and had wandered around the neighborhood. Resident #1's current Care Plan, dated 06/14/12, reflected Resident #1 only understood very simple English words and was at risk for wandering into unsafe situations. The nurse's notes dated 06/19/12 at 2:39 a.m. reflected Resident #1 was anxious, dressed and voiced a desire to go home. The Room Changes form dated 06/22/12 was signed by the SW and reflected Resident #1 did not qualify for the Light House (secured unit) and was moved off the secured unit. There was no record of an elopement risk assessment completed at the time of Resident #1's transfer off the secured unit. The Risk of Elopement Review dated 06/27/12 reflected four of 14 risk questions were positive (including the same three risk questions on the previous review) and Resident #1 was not considered at risk for elopement. The nurse's notes dated 07/07/12 at 10:00 p.m. reflected Resident #1 was standing in the hall and returned to his room. At 2:30 a.m., Resident #1 ambulated from his room and stood in the TV room. The nurse encouraged Resident #1 to return to his room, but he did not. At 2:40 a.m., Resident #1 was observed sitting in the TV room. Review of the facility's Provider Investigation Report, signed and revised by the ADM on 07/17/12, revealed the incident occurred on 07/08/12 at 3:00 a.m. and was reported to the State agency on 07/13/12. For Level of Supervision, "No special supervision" was marked. Resident #1 was identified with a history of wandering and had "extensive and minimal" Functional Ability. The capacity to make informed decisions was marked "N" for no. A description of the Allegation on the Provider Investigation Report reflected the resident eloped from the facility at approximately 3:00 a.m. on Sunday, 07/08/12. The resident was seen in the living area by the charge nurse at 2:40 a.m. and the CNA last spotted him in the living area at 2:50 a.m. At 3:00 a.m., the nurse noticed Resident #1 was not in the living area and began looking for him without finding him. An investigation summary attached to the Provider Investigation Report, dated 07/16/12, reflected the following: The DON reported Resident #1 missing from the facility. The ADM initiated calls for all administrative team leaders to come in for search, review the incident, and communicate with authorities. The police department was notified. The summary reflected Resident #1 was admitted to the facility on [DATE] to the Lighthouse Unit (secured unit) but was found to be inappropriate for the area. He was more cognizant of his environment and recognized he was different from the other residents. Resident #1 was moved to the open unit with a wander-guard in place on 06/22/12. He had not exhibited any indication he was trying to leave according to staff. The facility was unable to reach Resident #1's family by phone. All phone numbers for the family were inactive or no longer in service. The local Police Department issued a Silver Alert throughout the area. On 07/10/12, the Silver Alert was removed. A time line attached to the investigation and signed by the DON reflected she, the DON, was informed via text of the missing resident, Resident #1, on 07/08/12 at 3:15 a.m. She stayed informed with the staff and at 3:35 a.m. the police were notified. At 7:30 a.m., the DON called the Administrator and confirmed she was aware of the situation. All Department Managers were being called by the Administrator to "begin search." A search was made of a five-mile radius by the managers. At 12:00 p.m., the managers met back at the facility, spoke with the police and called off the search. The Administrative Summary of Findings reflected, "After thoroughly investigating the events of this incident there does not appear to be any concern of neglect or failure to supervise or equipment issues which caused the resident to elope without notice." The Facility Action Taken reflected, the following: "education of the administrative team regarding the policy and procedures of missing resident/elopement, moving or transferring residents from or admissions to the LHU (Lighthouse Unit), and review of assessments. Staff training regarding Elopement Policy and safe monitoring of the residents at risk for elopement. Approved vendor inspected the wander-guard system for effectiveness/functionality. Other residents were assessed at risk for elopement had their assessments updated and all wander-guards were checked and verified their functionality. Resident discharged from the facility 07/10/12 when search ended." During an interview on 07/17/12 at 8:45 a.m. with the ADM and the DON, the ADM stated Resident #1 had been observed watching television in the day room at 2:40 a.m. on 07/08/12. The ADM stated a nurse had encouraged Resident #1 to go to bed, but the resident did not want to go to bed. The ADM revealed Resident #1 was last seen at 3:00 a.m. on 07/08/12. The ADM revealed at 3:30 a.m., the police were notified that the resident was missing. The ADM stated the facility attempted to call the family, but they could not be reached. Once the police got involved, the police went to several of the family members' homes. The ADM stated Resident #1 was not on the secured unit when the incident occurred. The ADM stated Resident #1 had expressed to his family he wanted to get out of the facility, but his statement was never conveyed to the facility until after his elopement. The ADM stated the front desk was occupied during the week from 7:00 a.m. to 5:30 p.m. and 8:00 a.m. to 6:30 p.m. on the weekend. She stated the back door did not have one-on-one monitoring but had an alarm. The ADM stated to their knowledge the resident wore a wander-guard, but not the night of his elopement; no alarms sounded or alerts were heard. She stated the resident was capable of removing his wander-guard and they presumed Resident #1 had cut it off. The ADM stated the area (did not specify) was searched by the family and police several times. The ADM stated if Resident #1 was mad or angry he knew enough to hide. The ADM stated the functionality of the wander-guard system was tested every evening. She stated if something was wrong with the door alarms they monitored it one-on-one. She stated the front door and the back door were on the wander-guard system. The ADM stated Resident #1 had dinner with a family member the evening prior to his elopement (Saturday night, 07/07/12) at approximately 6:00 p.m. The ADM stated that initially the resident's family thought Resident #1 might be at a homeless shelter, but the shelter had not seen the resident. She stated an employee from a local restaurant reportedly saw Resident #1 with two men at approximately 7:00 a.m. on 07/09/12. On 07/10/12 the family reported they had found a body. During the interview on 07/17/12 at 8:45 a.m. the DON stated Resident #1 expressed to one of his family members the nursing home was a "prison." She stated Resident #1's behavior did not indicate he was "exit seeking." She stated Resident #1 was initially admitted to the secured unit where he stayed for three weeks. During that time, Resident #1 stayed in his room and watched TV. She stated the resident was then moved out of the secured unit, but he mostly stayed in his room and watched TV. The DON revealed Resident #1 had been out of the secured unit for approximately two weeks. When queried about Resident #1's abilities, the DON stated Resident #1 had a cane and could walk "a few feet." Interview with CNA F on 07/17/12 at 8:45 a.m. revealed she saw Resident #1 in the TV room at approximately 11:25 p.m. on 07/07/12. CNA F stated Resident #1 had his head hung down low against his chest and did not speak to her when she passed by him. CNA F was unaware if this was Resident #1's normal demeanor because she was unfamiliar with Resident #1. CNA F stated she was not aware of Resident #1 being an elopement risk or not. CNA F said she left Resident #1 alone in the TV room where an outside door was accessible to the residents. When questioned regarding how to identify residents at risk for elopement, CNA F stated residents were identified at risk by seeing a wander guard on their ankle. She was uncertain whether Resident #1 was wearing a wander guard or not because he was in long pants covering his ankles. Interview on 07/17/12 at 12:53 p.m. with the Director of Maintenance revealed the alarms were checked every morning. He stated a transmitter was used. The Director of Maintenance stated the residents' wander-guards were changed every year and had an expiration date on them. He stated the residents' wander-guards were changed in February 2012. The surveyor asked the Director of Maintenance how the residents' wander-guards were checked. He stated he received a list of resident names every month. He stated he used the transmitter to check their wander-guards. Interview on 07/17/12 at 11:25 a.m. with CNA F revealed she worked the 10:00 p.m. to 6:00 a.m. shift. CNA F stated she did not work on Resident #1's hall. She stated she had seen the resident before but did not work with him. CNA F stated on 07/07/12 when she saw Resident #1 sitting in the TV room, she asked Resident #1 if he should be in bed. He did not respond to her. She stated that was the last time she saw him. When questioned regarding how to identify residents at risk for elopement, CNA F stated residents were identified at risk by seeing a wander-guard on their ankle. She was uncertain whether Resident #1 was wearing a wander-guard or not because he was in long pants that covered his ankles. Interview on 07/17/12 at 11:41 a.m. with CNA G revealed she worked the 10:00 p.m. to 6:00 a.m. shift. She stated she was not familiar with Resident #1. CNA G stated the evening of 07/07/12, prior to the incident, she had finished her rounds on hall 200 and went to help on hall 100. CNA G stated LVN B asked her and CNA A if they had seen Resident #1. CNA G stated she asked LVN B who Resident #1 was. CNA G stated CNA A revealed she had seen the resident at approximately 1:00 a.m. on the (back) patio. CNA G stated they checked the rooms on hall 500 for Resident #1. She stated they did not locate him on hall 500. CNA G stated CNA A and she walked to a local restaurant (approximately 0.1 mile from the facility per Google maps) to search for the resident. They did not see him. CNA G stated LVN B and CNA F also searched for the resident. CNA G stated she overheard Resident #1's nurse, LVN H, being asked if she had notified anyone regarding Resident #1 and LVN H and stated, "No." CNA G stated the police eventually showed up. When questioned how to identify a resident who was at risk of elopement, CNA G stated that a resident was identified as an elopement risk by seeing a wander-guard on their ankle. Interview on 07/17/12 at 2:50 p.m. with CNA A revealed she worked the third shift the morning Resident #1 was missing. CNA A stated she observed an elderly male swinging a cane back and forth in the back courtyard on 07/08/12 at approximately 1:15 a.m. The man exited the courtyard gate at approximately 1:35 a.m., ambulated into the parking lot, and did not return. CNA A stated she did not report the incident to anyone at that time but reported it later that morning after the nurse told her a resident was missing. CNA A stated she only knew the residents on the hall she worked on and did not know residents on the other halls. CNA A stated she did not know in the past or presently which residents were at risk for elopement. When queried which residents were at risk for elopement, CNA A stated she did not know who they were but if she saw a wander-guard on the residents, they were the residents at risk for elopement. Telephone interview on 07/17/12 at 3:40 p.m. with LVN B revealed she saw Resident #1 at approximately 11:30 p.m. the night before he was missing in the Day Room. (The Day Room was near the back door, the courtyard, and back parking lot.) LVN B stated she did not work on the hall Resident #1 resided on. LVN B helped search inside the building, the area outside, and drove around in the area but did not find Resident #1. The Police were at the facility when she returned to the building. When queried which residents were at risk for elopement, LVN B stated at the time of the incident she only knew the residents on her hall that were at risk for elopement. LVN B stated she presently knew some residents on the other halls who were at risk for elopement but did not know presently which residents on the 500 hall were at risk for elopement. (Note: Resident #1 resided on hall 500 before he eloped.) LVN B stated an alarm would sound if a resident with a wander-guard attempted to exit the front or back doors but if a resident did not have a wander-guard, they would be able to exit the doors without staff knowledge. Interview on 07/17/12 at 4:07 p.m. with CNA O revealed she was informed by CNA N to watch Resident #1 closely because he would leave if he had an opportunity. CNA O stated she was assigned to work the hall where Resident #1 resided after being moved from the secured unit. CNA O stated she was not familiar with Resident #1 as she had only worked with him "a couple of times." She was not aware if he wore a wander-guard or not and was only concerned about his elopement risk because of the conversation she had with CNA N. When questioned how to identify a resident who was at risk for elopement, CNA O stated, "The residents at risk for elopement are the residents who have alarms or wander-guards on." Interview on 07/17/12 at 4:15 p.m. with CNA N revealed she voiced concerns to her nurse on 06/20/12 regarding an incident when Resident #1 raised a window while on the secured unit and verbalized the desire to go home. CNA N stated she was very familiar with Resident #1 and was concerned regarding Resident #1's move off the secured unit on 06/22/12. CNA N stated she informed her friend, CNA O, of her concern and requested CNA O to "keep an eye on him." When questioned regarding how to identify residents at risk for elopement, CNA N stated the residents at risk for elopement were the residents with wander-guards. Interview on 07/17/12 at 4:20 p.m. with CNA C revealed she worked for three months on the same hall and did not know residents on the other halls, who were at risk for elopement. Interview on 07/17/12 at 4:22 p.m. with CNA L revealed he recognized a resident at risk for elopement by seeing a wander-guard on the resident's ankle or wheelchair. CNA L normally worked the 2:00 p.m. to 10:00 p.m. shift on hall 100. CNA L stated he was unfamiliar with Resident #1 and he was not sure if the resident wore a wander-guard or was at risk for elopement. CNA L stated he worked 07/07/12 but had gotten off work at his normal time around 10:00 p.m. CNA L stated he did not work on 07/08/12. Interview on 07/17/12 at 4:30 p.m. with CNA D revealed she had worked for two years on all halls and stated only two residents were at risk for elopement in the facility. When queried which residents had wander-guards, CNA D named ten people and stated there were quite a few with wander-guards. CNA D stated an alarm sounded if a resident with a wander-guard attempted to exit, and staff would go see who was at the door. Interview on 07/17/12 at 4:35 p.m. with CNA E revealed she had worked at the facility for three years and residents who were at risk for elopement were residents who wore wander-guards. An alarm would sound if one of those residents went near the door and staff would check to make sure the resident did not go out. Interview on 07/17/12 at 4:40 p.m. with CNA P revealed he was very familiar with Resident #1. His regular hall assignment was the one in which Resident #1 resided. CNA P stated anybody who was familiar with Resident #1 would have known it was very unusual for him to be in the TV room. CNA P stated when he became aware of the incident and the resident's location in the TV room during the early morning hours, CNA P was concerned none of the staff caring for Resident #1 knew the behavior to be abnormal. When questioned regarding communication among staff about residents who were at risk for elopement, CNA P stated the staff should be informed by nurses of who was at risk for elopement. CNA P stated he was not informed of Resident #1 being at risk for elopement. He stated he was uncertain whether Resident #1 had a wander-guard on or not. CNA P was not aware of an elopement book at the nurse's station or any identifiers letting staff know when a resident was at risk for elopement other than the wander-guard being worn on the ankle. Interview on 07/18/12 at 11:23 a.m. with Resident #6 revealed he had been Resident #1's roommate (not the secured unit) and had voiced concerns to staff Resident #1 frequently stood by the window. Resident #6's concern was Resident #1 might open the window and go outside. Resident #6 was concerned because the windows did not have an alarm and were easy to open for exit. Resident #6 demonstrated to the surveyor at that time, the window could be opened all the way to the top of the window frame. Telephone interview on 07/18/12 at 1:45 p.m. with Medical Examiner's staff revealed Resident #1's body was identified that day (07/18/12) and the cause of death was undetermined. Interview on 07/18/12 at 2:35 p.m. with the DON revealed a wander-guard was found in the trash Saturday night on 07/14/12, a week after Resident #1's elopement at approximately 10:00 p.m. The wander-guard had set off the alarm when a CNA took out the trash. The CNA gave the wander-guard to the charge nurse but the charge nurse did not report it until the next shift. There was no way to know for sure if the wander-guard was used on Resident #1. The DON stated Resident #1's family member had visited him the previous Saturday night (07/07/12). The DON stated the family member might have cut the wander-guard off at that time. The DON stated the family member told the Detective to search for Resident #1 under a particular nearby bridge but the resident was not found there at that time. At a later date, Resident #1's family members found Resident #1's body under the same nearby bridge that was previously searched. 3) Observation on 07/18/12 at 10:45 a.m. revealed Resident #2 was dressed and ambulating independently on the 300 hall, where he resided. A wander-guard was not visible. The Face Sheet dated 07/18/12 reflected Resident #2 was a [AGE] year-old male admitted to the facility 06/15/12 with [DIAGNOSES REDACTED]. The Care Plan dated 06/28/12 reflected Resident #2 had a history of [REDACTED]. Staff were to note which exits Resident #2 favored for elopement and alert staff working near those areas. The Risk of Elopement Review dated 07/09/12 reflected Resident #2 was cognitively impaired with poor decision-making skills; ambulated independently; had [DIAGNOSES REDACTED]. The Elopement Risk list provided by the facility on 07/17/12 reflected Resident #2 was not at risk for elopement. After surveyor intervention, the Elopement risk list was updated by the facility on 07/18/12 and reflected Resident #2 was added to the list for residents at risk for elopement. Observation on 07/18/12 at 11:00 a.m. revealed the back door to the courtyard area was easy to open, going out and coming in either by pushing easily on the door or by pushing the large handicapped button beside the door for automatic door opening. Resident #2 sat in a chair at the table with a staff member. Resident #2's wander-guard was not visible and the courtyard gate was open to the back parking lot. The surveyor noted the gate was easy to open, going out and coming in, and the courtyard gate and fence was approximately four feet high. 4) The Face Sheet reflected Resident #3, a [AGE] year-old male, was admitted to the facility 12/06/11 with [DIAGNOSES REDACTED]. Observation on 07/18/12 at 10:45 a.m. revealed the door to Resident #3's room on the 300 hall was shut with a sign on the door that said to leave the door shut while he was sleeping and at night. The Elopement risk list provided by the facility on 07/17/12 reflected Resident #3 was at risk for elopement. Observation on 07/18/12 at 11:35 a.m. revealed Resident #3 was dressed, sat in the dining room near the front door and the wander-guard was not visible. 5) The Face Sheet revealed Resident #5 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The Elopement Risk list provided by the facility on 07/17/12 reflected Resident #5 was not at risk for elopement. The Care Plan dated 04/18/12 revealed Resident #5 had a history of [REDACTED]." After surveyor intervention, the Elopement Risk list dated 07/18/12 reflected Resident #5 was at risk for elopement and had a wander-guard placed. Resident #5 could not be observed for he was not in the facility. 6) The Face Sheet reflected Resident #11, an [AGE] year-old female, was initially admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. She did not reside in the Secured Unit. Review of the Risk of Elopement Review revealed Resident #11 was assessed as at risk for elopement on 07/09/12. Review of physician's orders [REDACTED]. The Care Plan dated 07/17/12 reflected Resident #11 was at risk for wandering behavior. Observation on 07/18/12 at 1:09 p.m. revealed Resident #11 was in the community/TV room in a wheelchair with a wander-guard attached to the back of her wheelchair. 7) An IJ was identified on 07/17/12. On 07/17/12 at 6:30 p.m., the Administrator and the DON were informed an IJ was identified in the area of Resident Behavior/Facility Practice and Administration. The Administrator and the DON were requested to provide a Plan of Removal for the IJ. 8) The facility's Plan of Removal for the IJ dated 07/17/12, which was accepted on 07/18/12, reflected the following: Facility Post Action Abatement: " 1) All residents on the secured unit were reassessed using the elopement risk assessment form by ____, ADON (the facility's only ADON), ____ Lighthouse Unit Manager (LVN S), and ____, LVN (LVN R) on 07/09/12. All other residents' elopement assessments will be updated as of 07/17/12 by 5:00 p.m. All elopement care plans updated and completed 07/17/12 by ____, MDS coordinator (MDS Coordinator T) and ____, MDS coordinator, LVN (LVN U). 2) Resident elopement book was updated by ___, Medical Records and was completed on 07/17/12. 3) An identifier for elopement has been placed on the residents' door frame as of 07/17/12 at 10:00 p.m. to alert all staff of potential risk. 4) The residents' care card will be updated for all residents and place in room inside closet door for care staff to refer to. Direct care staff will be in serviced on the care cards by 07/18/12 by DON, ADON, and SDC. 5) ____, Administrator initiated education to key administrative staff on 07/08/12 on elopement policy and procedures. All remaining staff have been or will be educated related to the policy and procedure for elopement, facility wander elopement book, and facility identifier for elopement risk residents on by SDC on 07/18/12. 6) Any staff unavailable for education will be removed from the schedule and not allowed to work. Employees will have until 07/25/12 to attend in-service. If the employee is out on leave or vacation and has not completed by this time, they will be permanently removed from schedule until education is completed. 7) Validation of effectiveness of training will occur via employee interviews by staff development coordinator and will be reviewed by the CQI Committee on a weekly basis for 4 weeks and monthly for 3 months. 8) Clinical staff will visually validate placement of code alert at the beginning of their shift and document on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 9) Charge nurses will do shift to shift head count of residents identified at risk for elopement. They will document this on the 24 hour report. 10) Facility staff monitoring of residents at risk for elopement will occur throughout the shift. Frequency will be increased based on changed in resident behavior or routine or as indicted by the elopement risk assessment. " 9) Review of the current facility in-services revealed staff was in

Based on observation, interview and record review, the facility failed to ensure all alleged violations involving neglect were reported immediately to other officials in accordance with State law through established procedures (including to the State survey and certification agency) and have evidence a thorough investigation was conducted for one (Resident #1) of six residents reviewed for neglect. Resident #1 eloped from the facility on 07/08/12 at approximately 3:00 a.m. When Resident #1 was missing from the facility for more than eight hours, the State agency was not notified until 07/13/12 (five days later) when the investigation was sent to the State agency. On 07/10/12, Resident #1's decomposed body was found approximately four to five blocks from the facility. The facility's investigation did not recognize or determine the following: 1) Resident #1 was transferred from the secured unit on 06/22/12 because the space was needed for another resident. --No elopement assessment was completed to indicate if it was safe for the resident to be transferred from the secured unit even though he had already been identified as an elopement risk. --No wander-guard was applied until three days later by the DON. --The SW was notified by a family member prior to the resident's elopement that the resident wanted to leave, but did not take any action. --The resident's roommate voiced a concern to staff about Resident #1's interest in the room's window, which could be fully opened. --CNA P was aware the resident's interest in the TV room was unusual, but night staff were not aware of it. --Night staff were not aware Resident #1 was an elopement risk. --Resident #1 was left alone in the TV room, which had a door accessible to residents which opened to the outside. --Resident #1 eloped from the facility on 07/08/12, and his decomposing body was found approximately four to five blocks from the facility on 07/10/12 and identified by the Medical Examiner on 07/15/12. 2) Resident #2 was admitted on [DATE]. --with a history of exit- seeking behaviors. --A history of leaving the facility without informing staff. --had the potential to wander into unsafe situations. --was ambulatory, --was not considered an elopement risk. He was added to the Elopement Risk list after surveyor intervention on 07/18/12. 3) Resident #3 was identified by the facility as being at risk for elopement. --He was allowed to keep his door closed frequently. --His room window opened to an unsecured outside area. --He had a wander-guard not easily seen. 4) Resident #5 had a history of [REDACTED]." --He was not considered an elopement risk. --He did not have a wander-guard. --He was added to the Elopement Risk list following surveyor intervention on 07/18/12. 5) Resident #11 did not reside on the secured unit. --The facility assessed her as an elopement on 07/09/12. --Did not have a wander-guard. --Had a wander-guard placed 07/17/12. 6) Staff did not know which residents were at risk for elopement. --Staff did not know about the Resident Elopement Book, which contained pictures and information of residents at risk for elopement. --Staff identified residents at risk for elopement by seeing their wander-guards. --A wander-guard with the band cut was found in the trash but residents were not checked for missing wander-guards until the following morning. --Residents who did not reside on the secured unit were not always assessed for elopement risk. --Care plans were not updated identifying residents at risk for eloping until surveyor intervention on 07/17/12. --Staff were in-serviced on policies and procedures regarding residents at risk for elopement and for missing residents on 07/17/12 after surveyor intervention. An Immediate Jeopardy was identified on 07/17/12. While the Immediate Jeopardy was removed on 07/18/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the implementation of the Plan of Removal. These failures likely caused the death of Resident #1 and could affect the 39 residents, identified as elopement risks, and could result in the potential for attempts at elopement, successful elopements, resulting in the potential for injury, exacerbation of their [DIAGNOSES REDACTED]. Findings included: 1) The Face Sheet dated 07/15/12 reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The unsigned Resident Elopement assessment dated [DATE] reflected Resident #1 was at risk for elopement due to a history of elopement. The Risk of Elopement Review, dated 06/01/12 reflected three of 14 risk questions were positive, and Resident #1 was considered at risk for elopement. Resident #1's nurse's notes reflected: On 06/01/12 Resident #1 was admitted from home and placed on the secured unit. On 06/04/12 and 06/05/12 Resident #1 wandered the hallway with exit-seeking behavior requiring redirection from the secured unit's locked exit. The Departmental Notes dated 06/06/12 reflected the SW called a family member to discuss moving Resident #1 off the secured unit. Resident #1's family member informed the SW Resident #1 told him/her last night (06/05/12), he wanted to leave the facility and would try to "escape" if given the chance. The Notes reflected when he was living at home, Resident #1 had gone outside without clothes and had wandered around the neighborhood. Resident #1's current Care Plan, dated 06/14/12, reflected Resident #1 only understood very simple English words and was at risk for wandering into unsafe situations. The nurse's notes dated 06/19/12 at 2:39 a.m. reflected Resident #1 was anxious, dressed and voiced a desire to go home. The Room Changes form dated 06/22/12 was signed by the SW and reflected Resident #1 did not qualify for the Light House (secured unit) and was moved off the secured unit. There was no record of an elopement risk assessment completed at the time of Resident #1's transfer off the secured unit. The Risk of Elopement Review dated 06/27/12 reflected four of 14 risk questions were positive (including the same three risk questions on the previous review) and Resident #1 was not considered at risk for elopement. The nurse's notes dated 07/07/12 at 10:00 p.m. reflected Resident #1 was standing in the hall and returned to his room. At 2:30 a.m., Resident #1 ambulated from his room and stood in the TV room. The nurse encouraged Resident #1 to return to his room, but he did not. At 2:40 a.m., Resident #1 was observed sitting in the TV room. Review of the facility's Provider Investigation Report, signed and revised by the ADM on 07/17/12, revealed the incident occurred on 07/08/12 at 3:00 a.m. and was reported to the State agency on 07/13/12. For Level of Supervision, "No special supervision" was marked. Resident #1 was identified with a history of wandering and had "extensive and minimal" Functional Ability. The capacity to make informed decisions was marked "N" for no. A description of the Allegation on the Provider Investigation Report reflected the resident eloped from the facility at approximately 3:00 a.m. on Sunday, 07/08/12. The resident was seen in the living area by the charge nurse at 2:40 a.m. and the CNA last spotted him in the living area at 2:50 a.m. At 3:00 a.m., the nurse noticed Resident #1 was not in the living area and began looking for him without finding him. An investigation summary attached to the Provider Investigation Report, dated 07/16/12, reflected the following: The DON reported Resident #1 missing from the facility. The ADM initiated calls for all administrative team leaders to come in for search, review the incident, and communicate with authorities. The police department was notified. The summary reflected Resident #1 was admitted to the facility on [DATE] to the Lighthouse Unit (secured unit) but was found to be inappropriate for the area. He was more cognizant of his environment and recognized he was different from the other residents. Resident #1 was moved to the open unit with a wander-guard in place on 06/22/12. He had not exhibited any indication he was trying to leave according to staff. The facility was unable to reach Resident #1's family by phone. All phone numbers for the family were inactive or no longer in service. The local Police Department issued a Silver Alert throughout the area. On 07/10/12, the Silver Alert was removed. A time line attached to the investigation and signed by the DON reflected she, the DON, was informed via text of the missing resident, Resident #1, on 07/08/12 at 3:15 a.m. She stayed informed with the staff and at 3:35 a.m. the police were notified. At 7:30 a.m., the DON called the Administrator and confirmed she was aware of the situation. All Department Managers were being called by the Administrator to "begin search." A search was made of a five-mile radius by the managers. At 12:00 p.m., the managers met back at the facility, spoke with the police and called off the search. The Administrative Summary of Findings reflected, "After thoroughly investigating the events of this incident there does not appear to be any concern of neglect or failure to supervise or equipment issues which caused the resident to elope without notice." The Facility Action Taken reflected, the following: "education of the administrative team regarding the policy and procedures of missing resident/elopement, moving or transferring residents from or admissions to the LHU (Lighthouse Unit), and review of assessments. Staff training regarding Elopement Policy and safe monitoring of the residents at risk for elopement. Approved vendor inspected the wander-guard system for effectiveness/functionality. Other residents were assessed at risk for elopement had their assessments updated and all wander-guards were checked and verified their functionality. Resident discharged from the facility 07/10/12 when search ended." During an interview on 07/17/12 at 8:45 a.m. with the ADM and the DON, the ADM stated Resident #1 had been observed watching television in the day room at 2:40 a.m. on 07/08/12. The ADM stated a nurse had encouraged Resident #1 to go to bed, but the resident did not want to go to bed. The ADM revealed Resident #1 was last seen at 3:00 a.m. on 07/08/12. The ADM revealed at 3:30 a.m., the police were notified that the resident was missing. The ADM stated the facility attempted to call the family, but they could not be reached. Once the police got involved, the police went to several of the family members' homes. The ADM stated Resident #1 was not on the secured unit when the incident occurred. The ADM stated Resident #1 had expressed to his family he wanted to get out of the facility, but his statement was never conveyed to the facility until after his elopement. The ADM stated the front desk was occupied during the week from 7:00 a.m. to 5:30 p.m. and 8:00 a.m. to 6:30 p.m. on the weekend. She stated the back door did not have one-on-one monitoring but had an alarm. The ADM stated to their knowledge the resident wore a wander-guard, but not the night of his elopement; no alarms sounded or alerts were heard. She stated the resident was capable of removing his wander-guard and they presumed Resident #1 had cut it off. The ADM stated the area (did not specify) was searched by the family and police several times. The ADM stated if Resident #1 was mad or angry he knew enough to hide. The ADM stated the functionality of the wander-guard system was tested every evening. She stated if something was wrong with the door alarms they monitored it one-on-one. She stated the front door and the back door were on the wander-guard system. The ADM stated Resident #1 had dinner with a family member the evening prior to his elopement (Saturday night, 07/07/12) at approximately 6:00 p.m. The ADM stated that initially the resident's family thought Resident #1 might be at a homeless shelter, but the shelter had not seen the resident. She stated an employee from a local restaurant reportedly saw Resident #1 with two men at approximately 7:00 a.m. on 07/09/12. On 07/10/12 the family reported they had found a body. During the interview on 07/17/12 at 8:45 a.m. the DON stated Resident #1 expressed to one of his family members the nursing home was a "prison." She stated Resident #1's behavior did not indicate he was "exit seeking." She stated Resident #1 was initially admitted to the secured unit where he stayed for three weeks. During that time, Resident #1 stayed in his room and watched TV. She stated the resident was then moved out of the secured unit, but he mostly stayed in his room and watched TV. The DON revealed Resident #1 had been out of the secured unit for approximately two weeks. When queried about Resident #1's abilities, the DON stated Resident #1 had a cane and could walk "a few feet." Interview with CNA F on 07/17/12 at 8:45 a.m. revealed she saw Resident #1 in the TV room at approximately 11:25 p.m. on 07/07/12. CNA F stated Resident #1 had his head hung down low against his chest and did not speak to her when she passed by him. CNA F was unaware if this was Resident #1's normal demeanor because she was unfamiliar with Resident #1. CNA F stated she was not aware of Resident #1 being an elopement risk or not. CNA F said she left Resident #1 alone in the TV room where an outside door was accessible to the residents. When questioned regarding how to identify residents at risk for elopement, CNA F stated residents were identified at risk by seeing a wander guard on their ankle. She was uncertain whether Resident #1 was wearing a wander guard or not because he was in long pants covering his ankles. Interview on 07/17/12 at 12:53 p.m. with the Director of Maintenance revealed the alarms were checked every morning. He stated a transmitter was used. The Director of Maintenance stated the residents' wander-guards were changed every year and had an expiration date on them. He stated the residents' wander-guards were changed in February 2012. The surveyor asked the Director of Maintenance how the residents' wander-guards were checked. He stated he received a list of resident names every month. He stated he used the transmitter to check their wander-guards. Interview on 07/17/12 at 11:25 a.m. with CNA F revealed she worked the 10:00 p.m. to 6:00 a.m. shift. CNA F stated she did not work on Resident #1's hall. She stated she had seen the resident before but did not work with him. CNA F stated on 07/07/12 when she saw Resident #1 sitting in the TV room, she asked Resident #1 if he should be in bed. He did not respond to her. She stated that was the last time she saw him. When questioned regarding how to identify residents at risk for elopement, CNA F stated residents were identified at risk by seeing a wander-guard on their ankle. She was uncertain whether Resident #1 was wearing a wander-guard or not because he was in long pants that covered his ankles. Interview on 07/17/12 at 11:41 a.m. with CNA G revealed she worked the 10:00 p.m. to 6:00 a.m. shift. She stated she was not familiar with Resident #1. CNA G stated the evening of 07/07/12, prior to the incident, she had finished her rounds on hall 200 and went to help on hall 100. CNA G stated LVN B asked her and CNA A if they had seen Resident #1. CNA G stated she asked LVN B who Resident #1 was. CNA G stated CNA A revealed she had seen the resident at approximately 1:00 a.m. on the (back) patio. CNA G stated they checked the rooms on hall 500 for Resident #1. She stated they did not locate him on hall 500. CNA G stated CNA A and she walked to a local restaurant (approximately 0.1 mile from the facility per Google maps) to search for the resident. They did not see him. CNA G stated LVN B and CNA F also searched for the resident. CNA G stated she overheard Resident #1's nurse, LVN H, being asked if she had notified anyone regarding Resident #1 and LVN H and stated, "No." CNA G stated the police eventually showed up. When questioned how to identify a resident who was at risk of elopement, CNA G stated that a resident was identified as an elopement risk by seeing a wander-guard on their ankle. Interview on 07/17/12 at 2:50 p.m. with CNA A revealed she worked the third shift the morning Resident #1 was missing. CNA A stated she observed an elderly male swinging a cane back and forth in the back courtyard on 07/08/12 at approximately 1:15 a.m. The man exited the courtyard gate at approximately 1:35 a.m., ambulated into the parking lot, and did not return. CNA A stated she did not report the incident to anyone at that time but reported it later that morning after the nurse told her a resident was missing. CNA A stated she only knew the residents on the hall she worked on and did not know residents on the other halls. CNA A stated she did not know in the past or presently which residents were at risk for elopement. When queried which residents were at risk for elopement, CNA A stated she did not know who they were but if she saw a wander-guard on the residents, they were the residents at risk for elopement. Telephone interview on 07/17/12 at 3:40 p.m. with LVN B revealed she saw Resident #1 at approximately 11:30 p.m. the night before he was missing in the Day Room. (The Day Room was near the back door, the courtyard, and back parking lot.) LVN B stated she did not work on the hall Resident #1 resided on. LVN B helped search inside the building, the area outside, and drove around in the area but did not find Resident #1. The Police were at the facility when she returned to the building. When queried which residents were at risk for elopement, LVN B stated at the time of the incident she only knew the residents on her hall that were at risk for elopement. LVN B stated she presently knew some residents on the other halls who were at risk for elopement but did not know presently which residents on the 500 hall were at risk for elopement. (Note: Resident #1 resided on hall 500 before he eloped.) LVN B stated an alarm would sound if a resident with a wander-guard attempted to exit the front or back doors but if a resident did not have a wander-guard, they would be able to exit the doors without staff knowledge. Interview on 07/17/12 at 4:07 p.m. with CNA O revealed she was informed by CNA N to watch Resident #1 closely because he would leave if he had an opportunity. CNA O stated she was assigned to work the hall where Resident #1 resided after being moved from the secured unit. CNA O stated she was not familiar with Resident #1 as she had only worked with him "a couple of times." She was not aware if he wore a wander-guard or not and was only concerned about his elopement risk because of the conversation she had with CNA N. When questioned how to identify a resident who was at risk for elopement, CNA O stated, "The residents at risk for elopement are the residents who have alarms or wander-guards on." Interview on 07/17/12 at 4:15 p.m. with CNA N revealed she voiced concerns to her nurse on 06/20/12 regarding an incident when Resident #1 raised a window while on the secured unit and verbalized the desire to go home. CNA N stated she was very familiar with Resident #1 and was concerned regarding Resident #1's move off the secured unit on 06/22/12. CNA N stated she informed her friend, CNA O, of her concern and requested CNA O to "keep an eye on him." When questioned regarding how to identify residents at risk for elopement, CNA N stated the residents at risk for elopement were the residents with wander-guards. Interview on 07/17/12 at 4:20 p.m. with CNA C revealed she worked for three months on the same hall and did not know residents on the other halls, who were at risk for elopement. Interview on 07/17/12 at 4:22 p.m. with CNA L revealed he recognized a resident at risk for elopement by seeing a wander-guard on the resident's ankle or wheelchair. CNA L normally worked the 2:00 p.m. to 10:00 p.m. shift on hall 100. CNA L stated he was unfamiliar with Resident #1 and he was not sure if the resident wore a wander-guard or was at risk for elopement. CNA L stated he worked 07/07/12 but had gotten off work at his normal time around 10:00 p.m. CNA L stated he did not work on 07/08/12. Interview on 07/17/12 at 4:30 p.m. with CNA D revealed she had worked for two years on all halls and stated only two residents were at risk for elopement in the facility. When queried which residents had wander-guards, CNA D named ten people and stated there were quite a few with wander-guards. CNA D stated an alarm sounded if a resident with a wander-guard attempted to exit, and staff would go see who was at the door. Interview on 07/17/12 at 4:35 p.m. with CNA E revealed she had worked at the facility for three years and residents who were at risk for elopement were residents who wore wander-guards. An alarm would sound if one of those residents went near the door and staff would check to make sure the resident did not go out. Interview on 07/17/12 at 4:40 p.m. with CNA P revealed he was very familiar with Resident #1. His regular hall assignment was the one in which Resident #1 resided. CNA P stated anybody who was familiar with Resident #1 would have known it was very unusual for him to be in the TV room. CNA P stated when he became aware of the incident and the resident's location in the TV room during the early morning hours, CNA P was concerned none of the staff caring for Resident #1 knew the behavior to be abnormal. When questioned regarding communication among staff about residents who were at risk for elopement, CNA P stated the staff should be informed by nurses of who was at risk for elopement. CNA P stated he was not informed of Resident #1 being at risk for elopement. He stated he was uncertain whether Resident #1 had a wander-guard on or not. CNA P was not aware of an elopement book at the nurse's station or any identifiers letting staff know when a resident was at risk for elopement other than the wander-guard being worn on the ankle. Interview on 07/18/12 at 11:23 a.m. with Resident #6 revealed he had been Resident #1's roommate (not the secured unit) and had voiced concerns to staff Resident #1 frequently stood by the window. Resident #6's concern was Resident #1 might open the window and go outside. Resident #6 was concerned because the windows did not have an alarm and were easy to open for exit. Resident #6 demonstrated to the surveyor at that time, the window could be opened all the way to the top of the window frame. Telephone interview on 07/18/12 at 1:45 p.m. with Medical Examiner's staff revealed Resident #1's body was identified that day (07/18/12) and the cause of death was undetermined. Interview on 07/18/12 at 2:35 p.m. with the DON revealed a wander-guard was found in the trash Saturday night on 07/14/12, a week after Resident #1's elopement at approximately 10:00 p.m. The wander-guard had set off the alarm when a CNA took out the trash. The CNA gave the wander-guard to the charge nurse but the charge nurse did not report it until the next shift. There was no way to know for sure if the wander-guard was used on Resident #1. The DON stated Resident #1's family member had visited him the previous Saturday night (07/07/12). The DON stated the family member might have cut the wander-guard off at that time. The DON stated the family member told the Detective to search for Resident #1 under a particular nearby bridge but the resident was not found there at that time. At a later date, Resident #1's family members found Resident #1's body under the same nearby bridge that was previously searched. 2) Observation on 07/18/12 at 10:45 a.m. revealed Resident #2 was dressed and ambulating independently on the 300 hall, where he resided. A wander-guard was not visible. The Face Sheet dated 07/18/12 reflected Resident #2 was a [AGE] year-old male admitted to the facility 06/15/12 with [DIAGNOSES REDACTED]. The Care Plan dated 06/28/12 reflected Resident #2 had a history of [REDACTED]. Staff were to note which exits Resident #2 favored for elopement and alert staff working near those areas. The Risk of Elopement Review dated 07/09/12 reflected Resident #2 was cognitively impaired with poor decision-making skills; ambulated independently; had [DIAGNOSES REDACTED]. The Elopement Risk list provided by the facility on 07/17/12 reflected Resident #2 was not at risk for elopement. After surveyor intervention, the Elopement risk list was updated by the facility on 07/18/12 and reflected Resident #2 was added to the list for residents at risk for elopement. Observation on 07/18/12 at 11:00 a.m. revealed the back door to the courtyard area was easy to open, going out and coming in either by pushing easily on the door or by pushing the large handicapped button beside the door for automatic door opening. Resident #2 sat in a chair at the table with a staff member. Resident #2's wander-guard was not visible and the courtyard gate was open to the back parking lot. The surveyor noted the gate was easy to open, going out and coming in, and the courtyard gate and fence was approximately four feet high. 3) The Face Sheet reflected Resident #3, a [AGE] year-old male, was admitted to the facility 12/06/11 with [DIAGNOSES REDACTED]. Observation on 07/18/12 at 10:45 a.m. revealed the door to Resident #3's room on the 300 hall was shut with a sign on the door that said to leave the door shut while he was sleeping and at night. The Elopement risk list provided by the facility on 07/17/12 reflected Resident #3 was at risk for elopement. Observation on 07/18/12 at 11:35 a.m. revealed Resident #3 was dressed, sat in the dining room near the front door and the wander-guard was not visible. 4) The Face Sheet revealed Resident #5 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The Elopement Risk list provided by the facility on 07/17/12 reflected Resident #5 was not at risk for elopement. The Care Plan dated 04/18/12 revealed Resident #5 had a history of [REDACTED]." After surveyor intervention, the Elopement Risk list dated 07/18/12 reflected Resident #5 was at risk for elopement and had a wander-guard placed. Resident #5 could not be observed for he was not in the facility. 5) The Face Sheet reflected Resident #11, an [AGE] year-old female, was initially admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. She did not reside in the Secured Unit. Review of the Risk of Elopement Review revealed Resident #11 was assessed as at risk for elopement on 07/09/12. Review of physician's orders [REDACTED]. The Care Plan dated 07/17/12 reflected Resident #11 was at risk for wandering behavior. Observation on 07/18/12 at 1:09 p.m. revealed Resident #11 was in the community/TV room in a wheelchair with a wander-guard attached to the back of her wheelchair. 6) The facility's policy and procedure, "Elopement from Designated Area of Facility" dated 12/01/10 and identified as current by the DON on 07/18/12 at 9:50 a.m. reflected the following procedure: "1. Any staff member who becomes aware of a resident not being at the designated area or activity shall proceed to notify the charge nurse, Director of Nursing and the Administrator. 2. The wandering resident's charge nurse shall assign direct care staff to look for the resident. 3. If the resident is not located in the buildings or the grounds within fifteen minutes, the charge nurse shall notify the Director of Nursing and the Administrator to implement the plan to locate the resident...." The procedure further reflected the Police Department, family member and attending physician would be notified. The State agency would be notified "per state specific reporting guidelines. (Note: Provider Letter 2006-43 provides: "If a resident is not located during a search of the facility, facility grounds, and immediate vicinity, and there are circumstances that place the resident's health, safety and/or welfare at risk, the report must be made as soon as the facility becomes aware the resident is missing and cannot be located. Regardless of the circumstances, any resident missing for eight hours and not yet located must be reported at that time. In addition must contact the DADS Consumer Rights and Services Section daily until the resident is found.") The facility's Abuse, Neglect and Exploitation policy, dated, 05/01/12 and initialed by the ADM, reflected the following: "PURPOSE To prevent abuse, neglect or exploitation of residents, to the extent possible and ensure proper investigation and reporting of suspected cases, in compliance with applicable state and federal regulations. POLICY STATEMENT Each Region shall have in place procedures for the prevention of and handling of abuse, neglect and exploitation of residents. Systems shall be in place to monitor the facilities' performance in this area. PROCEDURE Each Regional Vice President shall ensure the development of policies, in the Region that provide for the following actions: 1. Protect the resident...." 7) An IJ was identified on 07/17/12. On 07/17/12 at 6:30 p.m., the Administrator and the DON were informed an IJ was identified in the area of Resident Behavior/Facility Practice and Administration. The Administrator and the DON were requested to provide a Plan of Removal for the IJ. 8) The facility's Plan of Removal for the IJ dated 07/17/12, which was accepted on 07/18/12, reflected the following: Facility Post Action Abatement: " 1) All residents on the secured unit were reassessed using the elopement risk assessment form by ____, ADON (the facility's only ADON), ____ Lighthouse Unit Manager (LVN S), and ____, LVN (LVN R) on 07/09/12. All other residents' elopement assessments will be updated as of 07/17/12 by 5:00 p.m. All elopement care plans updated and completed 07/17/12 by ____, MDS coordinator (MDS Coordinator T) and ____, MDS coordinator, LVN (LVN U). 2) Resident elopement book was updated by ___, Medical Records and was completed on 07/17/12. 3) An identifier for elopement has been placed on the residents' door frame as of 07/17/12 at 10:00 p.m. to alert all staff of potential risk. 4) The residents' care card will be updated for all residents and place in room inside closet door for care staff to refer to. Direct care staff will be in serviced on the care cards by 07/18/12 by DON, ADON, and SDC. 5) ____, Administrator initiated education to key administrative staff on 07/08/12 on elopement policy and procedures. All remaining staff have been or will be educated related to the policy and procedure for elopement, facility wander elopement book, and facility identifier for elopement risk residents on by SDC on 07/18/12. 6) Any staff unavailable for education will be removed from the schedule and not allowed to work. Employees will have until 07/25/12 to attend in-service. If the employee is out on leave or vacation and has not completed by this time, they will be permanently removed from schedule until education is completed. 7) Validation of effectiveness of training will occur via employee interviews by staff development coordinator and will be reviewed by the CQI Committee on a weekly basis for 4 weeks and monthly

Based on observation, interview, and record review, it was determined the facility failed to implement the facility's policies and procedures that prohibited neglect for five (Residents #1, #2, #3, #5, and #11) of six residents reviewed for neglect. 1) Resident #1 was transferred from the secured unit on 06/22/12 because the space was needed for another resident. --No elopement assessment was completed to indicate if it was safe for the resident to be transferred from the secured unit even though he had already been identified as an elopement risk. --No wander-guard was applied until three days later by the DON. --The SW was notified by a family member prior to the resident's elopement that the resident wanted to leave but the social worker did not take any action. --The resident's roommate voiced a concern to staff about Resident #1's interest in the room's window, which could be fully opened. --CNA P was aware the resident's interest in the TV room was unusual, but night staff were not aware of it. --Night staff were not aware Resident #1 was an elopement risk. --Resident #1 was left alone in the TV room, which had a door accessible to residents, which opened to the outside. --Resident #1 eloped from the facility on 07/08/12, and his decomposing body was found approximately four to five blocks from the facility on 07/10/12 and identified by the Medical Examiner on 07/15/12. 2) Resident #2 was admitted on [DATE]. --with a history of exit- seeking behaviors. --A history of leaving the facility without informing staff. --had the potential to wander into unsafe situations. --was ambulatory, --was not considered an elopement risk. He was added to the Elopement Risk list after surveyor intervention on 07/18/12. 3) Resident #3 was identified by the facility as being at risk for elopement. --He was allowed to keep his door closed frequently. --His room window opened to an unsecured outside area. --He had a wander-guard not easily seen. 4) Resident #5 had a history of [REDACTED]." --He was not considered an elopement risk. --He did not have a wander-guard. --He was added to the Elopement Risk list following surveyor intervention on 07/18/12. 5) Resident #11 did not reside on the secured unit. --The facility assessed her as an elopement risk on 07/09/12. --Did not have a wander-guard. --Had a wander-guard placed 07/17/12. 6) Staff did not know which residents were at risk for elopement. --Staff did not know about the Resident Elopement Book, which contained pictures and information of residents at risk for elopement. --Staff identified residents at risk for elopement by seeing their wander-guards. --A wander-guard with the band cut was found in the trash but residents were not checked for missing wander-guards until the following morning. --Residents who did not reside on the secured unit were not always assessed for elopement risk. --Care plans were not updated identifying residents at risk for eloping until surveyor intervention on 07/17/12. --Staff were in-serviced on policies and procedures regarding residents at risk for elopement and for missing residents on 07/17/12 after surveyor intervention. An Immediate Jeopardy was identified on 07/17/12. While the Immediate Jeopardy was removed on 07/18/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the implementation of the Plan of Removal. These failures likely caused the death of Resident #1 and could affect the 39 residents, identified as elopement risks, and could result in the potential for attempts at elopement, successful elopements, resulting in the potential for injury, exacerbation of their [DIAGNOSES REDACTED]. Findings included: 1) The Face Sheet dated 07/15/12 reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The unsigned Resident Elopement assessment dated [DATE] reflected Resident #1 was at risk for elopement due to a history of elopement. The Risk of Elopement Review, dated 06/01/12 reflected three of 14 risk questions were positive, and Resident #1 was considered at risk for elopement. Resident #1's nurse's notes reflected: On 06/01/12 Resident #1 was admitted from home and placed on the secured unit. On 06/04/12 and 06/05/12 Resident #1 wandered the hallway with exit-seeking behavior requiring redirection from the secured unit's locked exit. The Departmental Notes dated 06/06/12 reflected the SW called a family member to discuss moving Resident #1 off the secured unit. Resident #1's family member informed the SW Resident #1 told him/her last night (06/05/12), he wanted to leave the facility and would try to "escape" if given the chance. The Notes reflected when he was living at home, Resident #1 had gone outside without clothes and had wandered around the neighborhood. Resident #1's current Care Plan, dated 06/14/12, reflected Resident #1 only understood very simple English words and was at risk for wandering into unsafe situations. The nurse's notes dated 06/19/12 at 2:39 a.m. reflected Resident #1 was anxious, dressed and voiced a desire to go home. The Room Changes form dated 06/22/12 was signed by the SW and reflected Resident #1 did not qualify for the Light House (secured unit) and was moved off the secured unit. There was no record of an elopement risk assessment completed at the time of Resident #1's transfer off the secured unit. The Risk of Elopement Review dated 06/27/12 reflected four of 14 risk questions were positive (including the same three risk questions on the previous review) and Resident #1 was not considered at risk for elopement. The nurse's notes dated 07/07/12 at 10:00 p.m. reflected Resident #1 was standing in the hall and returned to his room. At 2:30 a.m., Resident #1 ambulated from his room and stood in the TV room. The nurse encouraged Resident #1 to return to his room, but he did not. At 2:40 a.m., Resident #1 was observed sitting in the TV room. Review of the facility's Provider Investigation Report, signed and revised by the ADM on 07/17/12, revealed the incident occurred on 07/08/12 at 3:00 a.m. and was reported to the State agency on 07/13/12. For Level of Supervision, "No special supervision" was marked. Resident #1 was identified with a history of wandering and had "extensive and minimal" Functional Ability. The capacity to make informed decisions was marked "N" for no. A description of the Allegation on the Provider Investigation Report reflected the resident eloped from the facility at approximately 3:00 a.m. on Sunday, 07/08/12. The resident was seen in the living area by the charge nurse at 2:40 a.m. and the CNA last spotted him in the living area at 2:50 a.m. At 3:00 a.m., the nurse noticed Resident #1 was not in the living area and began looking for him without finding him. An investigation summary attached to the Provider Investigation Report, dated 07/16/12, reflected the following: The DON reported Resident #1 missing from the facility. The ADM initiated calls for all administrative team leaders to come in for search, review the incident, and communicate with authorities. The police department was notified. The summary reflected Resident #1 was admitted to the facility on [DATE] to the Lighthouse Unit (secured unit) but was found to be inappropriate for the area. He was more cognizant of his environment and recognized he was different from the other residents. Resident #1 was moved to the open unit with a wander-guard in place on 06/22/12. He had not exhibited any indication he was trying to leave according to staff. The facility was unable to reach Resident #1's family by phone. All phone numbers for the family were inactive or no longer in service. The local Police Department issued a Silver Alert throughout the area. On 07/10/12, the Silver Alert was removed. A time line attached to the investigation and signed by the DON reflected she, the DON, was informed via text of the missing resident, Resident #1, on 07/08/12 at 3:15 a.m. She stayed informed with the staff and at 3:35 a.m. the police were notified. At 7:30 a.m., the DON called the Administrator and confirmed she was aware of the situation. All Department Managers were being called by the Administrator to "begin search." A search was made of a five-mile radius by the managers. At 12:00 p.m., the managers met back at the facility, spoke with the police and called off the search. The Administrative Summary of Findings reflected, "After thoroughly investigating the events of this incident there does not appear to be any concern of neglect or failure to supervise or equipment issues which caused the resident to elope without notice." The Facility Action Taken reflected, the following: "education of the administrative team regarding the policy and procedures of missing resident/elopement, moving or transferring residents from or admissions to the LHU (Lighthouse Unit), and review of assessments. Staff training regarding Elopement Policy and safe monitoring of the residents at risk for elopement. Approved vendor inspected the wander-guard system for effectiveness/functionality. Other residents were assessed at risk for elopement had their assessments updated and all wander-guards were checked and verified their functionality. Resident discharged from the facility 07/10/12 when search ended." During an interview on 07/17/12 at 8:45 a.m. with the ADM and the DON, the ADM stated Resident #1 had been observed watching television in the day room at 2:40 a.m. on 07/08/12. The ADM stated a nurse had encouraged Resident #1 to go to bed, but the resident did not want to go to bed. The ADM revealed Resident #1 was last seen at 3:00 a.m. on 07/08/12. The ADM revealed at 3:30 a.m., the police were notified that the resident was missing. The ADM stated the facility attempted to call the family, but they could not be reached. Once the police got involved, the police went to several of the family members' homes. The ADM stated Resident #1 was not on the secured unit when the incident occurred. The ADM stated Resident #1 had expressed to his family he wanted to get out of the facility, but his statement was never conveyed to the facility until after his elopement. The ADM stated the front desk was occupied during the week from 7:00 a.m. to 5:30 p.m. and 8:00 a.m. to 6:30 p.m. on the weekend. She stated the back door did not have one-on-one monitoring but had an alarm. The ADM stated to their knowledge the resident wore a wander-guard, but not the night of his elopement; no alarms sounded or alerts were heard. She stated the resident was capable of removing his wander-guard and they presumed Resident #1 had cut it off. The ADM stated the area (did not specify) was searched by the family and police several times. The ADM stated if Resident #1 was mad or angry he knew enough to hide. The ADM stated the functionality of the wander-guard system was tested every evening. She stated if something was wrong with the door alarms they monitored it one-on-one. She stated the front door and the back door were on the wander-guard system. The ADM stated Resident #1 had dinner with a family member the evening prior to his elopement (Saturday night, 07/07/12) at approximately 6:00 p.m. The ADM stated that initially the resident's family thought Resident #1 might be at a homeless shelter, but the shelter had not seen the resident. She stated an employee from a local restaurant reportedly saw Resident #1 with two men at approximately 7:00 a.m. on 07/09/12. On 07/10/12 the family reported they had found a body. During the interview on 07/17/12 at 8:45 a.m. the DON stated Resident #1 expressed to one of his family members the nursing home was a "prison." She stated Resident #1's behavior did not indicate he was "exit seeking." She stated Resident #1 was initially admitted to the secured unit where he stayed for three weeks. During that time, Resident #1 stayed in his room and watched TV. She stated the resident was then moved out of the secured unit, but he mostly stayed in his room and watched TV. The DON revealed Resident #1 had been out of the secured unit for approximately two weeks. When queried about Resident #1's abilities, the DON stated Resident #1 had a cane and could walk "a few feet." Interview with CNA F on 07/17/12 at 8:45 a.m. revealed she saw Resident #1 in the TV room at approximately 11:25 p.m. on 07/07/12. CNA F stated Resident #1 had his head hung down low against his chest and did not speak to her when she passed by him. CNA F was unaware if this was Resident #1's normal demeanor because she was unfamiliar with Resident #1. CNA F stated she was not aware of Resident #1 being an elopement risk or not. CNA F said she left Resident #1 alone in the TV room where an outside door was accessible to the residents. When questioned regarding how to identify residents at risk for elopement, CNA F stated residents were identified at risk by seeing a wander guard on their ankle. She was uncertain whether Resident #1 was wearing a wander guard or not because he was in long pants covering his ankles. Interview on 07/17/12 at 12:53 p.m. with the Director of Maintenance revealed the alarms were checked every morning. He stated a transmitter was used. The Director of Maintenance stated the residents' wander-guards were changed every year and had an expiration date on them. He stated the residents' wander-guards were changed in February 2012. The surveyor asked the Director of Maintenance how the residents' wander-guards were checked. He stated he received a list of resident names every month. He stated he used the transmitter to check their wander-guards. Interview on 07/17/12 at 11:25 a.m. with CNA F revealed she worked the 10:00 p.m. to 6:00 a.m. shift. CNA F stated she did not work on Resident #1's hall. She stated she had seen the resident before but did not work with him. CNA F stated on 07/07/12 when she saw Resident #1 sitting in the TV room, she asked Resident #1 if he should be in bed. He did not respond to her. She stated that was the last time she saw him. When questioned regarding how to identify residents at risk for elopement, CNA F stated residents were identified at risk by seeing a wander-guard on their ankle. She was uncertain whether Resident #1 was wearing a wander-guard or not because he was in long pants that covered his ankles. Interview on 07/17/12 at 11:41 a.m. with CNA G revealed she worked the 10:00 p.m. to 6:00 a.m. shift. She stated she was not familiar with Resident #1. CNA G stated the evening of 07/07/12, prior to the incident, she had finished her rounds on hall 200 and went to help on hall 100. CNA G stated LVN B asked her and CNA A if they had seen Resident #1. CNA G stated she asked LVN B who Resident #1 was. CNA G stated CNA A revealed she had seen the resident at approximately 1:00 a.m. on the (back) patio. CNA G stated they checked the rooms on hall 500 for Resident #1. She stated they did not locate him on hall 500. CNA G stated CNA A and she walked to a local restaurant (approximately 0.1 mile from the facility per Google maps) to search for the resident. They did not see him. CNA G stated LVN B and CNA F also searched for the resident. CNA G stated she overheard Resident #1's nurse, LVN H, being asked if she had notified anyone regarding Resident #1 and LVN H and stated, "No." CNA G stated the police eventually showed up. When questioned how to identify a resident who was at risk of elopement, CNA G stated that a resident was identified as an elopement risk by seeing a wander-guard on their ankle. Interview on 07/17/12 at 2:50 p.m. with CNA A revealed she worked the third shift the morning Resident #1 was missing. CNA A stated she observed an elderly male swinging a cane back and forth in the back courtyard on 07/08/12 at approximately 1:15 a.m. The man exited the courtyard gate at approximately 1:35 a.m., ambulated into the parking lot, and did not return. CNA A stated she did not report the incident to anyone at that time but reported it later that morning after the nurse told her a resident was missing. CNA A stated she only knew the residents on the hall she worked on and did not know residents on the other halls. CNA A stated she did not know in the past or presently which residents were at risk for elopement. When queried which residents were at risk for elopement, CNA A stated she did not know who they were but if she saw a wander-guard on the residents, they were the residents at risk for elopement. Telephone interview on 07/17/12 at 3:40 p.m. with LVN B revealed she saw Resident #1 at approximately 11:30 p.m. the night before he was missing in the Day Room. (The Day Room was near the back door, the courtyard, and back parking lot.) LVN B stated she did not work on the hall Resident #1 resided on. LVN B helped search inside the building, the area outside, and drove around in the area but did not find Resident #1. The Police were at the facility when she returned to the building. When queried which residents were at risk for elopement, LVN B stated at the time of the incident she only knew the residents on her hall that were at risk for elopement. LVN B stated she presently knew some residents on the other halls who were at risk for elopement but did not know presently which residents on the 500 hall were at risk for elopement. (Note: Resident #1 resided on hall 500 before he eloped.) LVN B stated an alarm would sound if a resident with a wander-guard attempted to exit the front or back doors but if a resident did not have a wander-guard, they would be able to exit the doors without staff knowledge. Interview on 07/17/12 at 4:07 p.m. with CNA O revealed she was informed by CNA N to watch Resident #1 closely because he would leave if he had an opportunity. CNA O stated she was assigned to work the hall where Resident #1 resided after being moved from the secured unit. CNA O stated she was not familiar with Resident #1 as she had only worked with him "a couple of times." She was not aware if he wore a wander-guard or not and was only concerned about his elopement risk because of the conversation she had with CNA N. When questioned how to identify a resident who was at risk for elopement, CNA O stated, "The residents at risk for elopement are the residents who have alarms or wander-guards on." Interview on 07/17/12 at 4:15 p.m. with CNA N revealed she voiced concerns to her nurse on 06/20/12 regarding an incident when Resident #1 raised a window while on the secured unit and verbalized the desire to go home. CNA N stated she was very familiar with Resident #1 and was concerned regarding Resident #1's move off the secured unit on 06/22/12. CNA N stated she informed her friend, CNA O, of her concern and requested CNA O to "keep an eye on him." When questioned regarding how to identify residents at risk for elopement, CNA N stated the residents at risk for elopement were the residents with wander-guards. Interview on 07/17/12 at 4:20 p.m. with CNA C revealed she worked for three months on the same hall and did not know residents on the other halls, who were at risk for elopement. Interview on 07/17/12 at 4:22 p.m. with CNA L revealed he recognized a resident at risk for elopement by seeing a wander-guard on the resident's ankle or wheelchair. CNA L normally worked the 2:00 p.m. to 10:00 p.m. shift on hall 100. CNA L stated he was unfamiliar with Resident #1 and he was not sure if the resident wore a wander-guard or was at risk for elopement. CNA L stated he worked 07/07/12 but had gotten off work at his normal time around 10:00 p.m. CNA L stated he did not work on 07/08/12. Interview on 07/17/12 at 4:30 p.m. with CNA D revealed she had worked for two years on all halls and stated only two residents were at risk for elopement in the facility. When queried which residents had wander-guards, CNA D named ten people and stated there were quite a few with wander-guards. CNA D stated an alarm sounded if a resident with a wander-guard attempted to exit, and staff would go see who was at the door. Interview on 07/17/12 at 4:35 p.m. with CNA E revealed she had worked at the facility for three years and residents who were at risk for elopement were residents who wore wander-guards. An alarm would sound if one of those residents went near the door and staff would check to make sure the resident did not go out. Interview on 07/17/12 at 4:40 p.m. with CNA P revealed he was very familiar with Resident #1. His regular hall assignment was the one in which Resident #1 resided. CNA P stated anybody who was familiar with Resident #1 would have known it was very unusual for him to be in the TV room. CNA P stated when he became aware of the incident and the resident's location in the TV room during the early morning hours, CNA P was concerned none of the staff caring for Resident #1 knew the behavior to be abnormal. When questioned regarding communication among staff about residents who were at risk for elopement, CNA P stated the staff should be informed by nurses of who was at risk for elopement. CNA P stated he was not informed of Resident #1 being at risk for elopement. He stated he was uncertain whether Resident #1 had a wander-guard on or not. CNA P was not aware of an elopement book at the nurse's station or any identifiers letting staff know when a resident was at risk for elopement other than the wander-guard being worn on the ankle. Interview on 07/18/12 at 11:23 a.m. with Resident #6 revealed he had been Resident #1's roommate (not the secured unit) and had voiced concerns to staff Resident #1 frequently stood by the window. Resident #6's concern was Resident #1 might open the window and go outside. Resident #6 was concerned because the windows did not have an alarm and were easy to open for exit. Resident #6 demonstrated to the surveyor at that time, the window could be opened all the way to the top of the window frame. Telephone interview on 07/18/12 at 1:45 p.m. with Medical Examiner's staff revealed Resident #1's body was identified that day (07/18/12) and the cause of death was undetermined. Interview on 07/18/12 at 2:35 p.m. with the DON revealed a wander-guard was found in the trash Saturday night on 07/14/12, a week after Resident #1's elopement at approximately 10:00 p.m. The wander-guard had set off the alarm when a CNA took out the trash. The CNA gave the wander-guard to the charge nurse but the charge nurse did not report it until the next shift. There was no way to know for sure if the wander-guard was used on Resident #1. The DON stated Resident #1's family member had visited him the previous Saturday night (07/07/12). The DON stated the family member might have cut the wander-guard off at that time. The DON stated the family member told the Detective to search for Resident #1 under a particular nearby bridge but the resident was not found there at that time. At a later date, Resident #1's family members found Resident #1's body under the same nearby bridge that was previously searched. 2) Observation on 07/18/12 at 10:45 a.m. revealed Resident #2 was dressed and ambulating independently on the 300 hall, where he resided. A wander-guard was not visible. The Face Sheet dated 07/18/12 reflected Resident #2 was a [AGE] year-old male admitted to the facility 06/15/12 with [DIAGNOSES REDACTED]. The Care Plan dated 06/28/12 reflected Resident #2 had a history of [REDACTED]. Staff were to note which exits Resident #2 favored for elopement and alert staff working near those areas. The Risk of Elopement Review dated 07/09/12 reflected Resident #2 was cognitively impaired with poor decision-making skills; ambulated independently; had [DIAGNOSES REDACTED]. The Elopement Risk list provided by the facility on 07/17/12 reflected Resident #2 was not at risk for elopement. After surveyor intervention, the Elopement risk list was updated by the facility on 07/18/12 and reflected Resident #2 was added to the list for residents at risk for elopement. Observation on 07/18/12 at 11:00 a.m. revealed the back door to the courtyard area was easy to open, going out and coming in either by pushing easily on the door or by pushing the large handicapped button beside the door for automatic door opening. Resident #2 sat in a chair at the table with a staff member. Resident #2's wander-guard was not visible and the courtyard gate was open to the back parking lot. The surveyor noted the gate was easy to open, going out and coming in, and the courtyard gate and fence was approximately four feet high. 3) The Face Sheet reflected Resident #3, a [AGE] year-old male, was admitted to the facility 12/06/11 with [DIAGNOSES REDACTED]. Observation on 07/18/12 at 10:45 a.m. revealed the door to Resident #3's room on the 300 hall was shut with a sign on the door that said to leave the door shut while he was sleeping and at night. The Elopement risk list provided by the facility on 07/17/12 reflected Resident #3 was at risk for elopement. Observation on 07/18/12 at 11:35 a.m. revealed Resident #3 was dressed, sat in the dining room near the front door and the wander-guard was not visible. 4) The Face Sheet revealed Resident #5 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The Elopement Risk list provided by the facility on 07/17/12 reflected Resident #5 was not at risk for elopement. The Care Plan dated 04/18/12 revealed Resident #5 had a history of [REDACTED]." After surveyor intervention, the Elopement Risk list dated 07/18/12 reflected Resident #5 was at risk for elopement and had a wander-guard placed. Resident #5 could not be observed for he was not in the facility. 5) The Face Sheet reflected Resident #11, an [AGE] year-old female, was initially admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. She did not reside in the Secured Unit. Review of the Risk of Elopement Review revealed Resident #11 was assessed as at risk for elopement on 07/09/12. Review of physician's orders [REDACTED]. The Care Plan dated 07/17/12 reflected Resident #11 was at risk for wandering behavior. Observation on 07/18/12 at 1:09 p.m. revealed Resident #11 was in the community/TV room in a wheelchair with a wander-guard attached to the back of her wheelchair. 6) The facility's policy and procedure, "Elopement from Designated Area of Facility" dated 12/01/10 and identified as current by the DON on 07/18/12 at 9:50 a.m. reflected the following procedure: "1. Any staff member who becomes aware of a resident not being at the designated area or activity shall proceed to notify the charge nurse, Director of Nursing and the Administrator. 2. The wandering resident's charge nurse shall assign direct care staff to look for the resident. 3. If the resident is not located in the buildings or the grounds within fifteen minutes, the charge nurse shall notify the Director of Nursing and the Administrator to implement the plan to locate the resident...." The procedure further reflected the Police Department, family member and attending physician would be notified. The State agency would be notified "per state specific reporting guidelines. (Note: Provider Letter 2006-43 provides: "If a resident is not located during a search of the facility, facility grounds, and immediate vicinity, and there are circumstances that place the resident's health, safety and/or welfare at risk, the report must be made as soon as the facility becomes aware the resident is missing and cannot be located. Regardless of the circumstances, any resident missing for eight hours and not yet located must be reported at that time. In addition must contact the DADS Consumer Rights and Services Section daily until the resident is found.") The facility's Abuse, Neglect and Exploitation policy, dated, 05/01/12 and initialed by the ADM, reflected the following: "PURPOSE To prevent abuse, neglect or exploitation of residents, to the extent possible and ensure proper investigation and reporting of suspected cases, in compliance with applicable state and federal regulations. POLICY STATEMENT Each Region shall have in place procedures for the prevention of and handling of abuse, neglect and exploitation of residents. Systems shall be in place to monitor the facilities' performance in this area. PROCEDURE Each Regional Vice President shall ensure the development of policies, in the Region that provide for the following actions: 1. Protect the resident...." 7) An IJ was identified on 07/17/12. On 07/17/12 at 6:30 p.m., the Administrator and the DON were informed an IJ was identified in the area of Resident Behavior/Facility Practice and Administration. The Administrator and the DON were requested to provide a Plan of Removal for the IJ. 8) The facility's Plan of Removal for the IJ dated 07/17/12, which was accepted on 07/18/12, reflected the following: Facility Post Action Abatement: " 1) All residents on the secured unit were reassessed using the elopement risk assessment form by ____, ADON (the facility's only ADON), ____ Lighthouse Unit Manager (LVN S), and ____, LVN (LVN R) on 07/09/12. All other residents' elopement assessments will be updated as of 07/17/12 by 5:00 p.m. All elopement care plans updated and completed 07/17/12 by ____, MDS coordinator (MDS Coordinator T) and ____, MDS coordinator, LVN (LVN U). 2) Resident elopement book was updated by ___, Medical Records and was completed on 07/17/12. 3) An identifier for elopement has been placed on the residents' door frame as of 07/17/12 at 10:00 p.m. to alert all staff of potential risk. 4) The residents' care card will be updated for all residents and place in room inside closet door for care staff to refer to. Direct care staff will be in serviced on the care cards by 07/18/12 by DON, ADON, and SDC. 5) ____, Administrator initiated education to key administrative staff on 07/08/12 on elopement policy and procedures. All remaining staff have been or will be educated related to the policy and procedure for elopement, facility wander elopement book, and facility identifier for elopement risk residents on by SDC on 07/18/12. 6) Any staff unavailable for education will be removed from the schedule and not allowed to work. Employees will have until 07/25/12 to attend in-service. If the employee is out on leave or vacation and has not completed by this time, they will be permanently removed from schedule until education is completed. 7) Validation of effectiveness of training will occur via employee interviews by staff development coordinator and will be reviewed by the CQI Committee on a weekly basis for 4 weeks and monthly for 3 months. 8) Clinical staff will visually validate placement of code alert at the beginning of their shift and document on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 9) Charge nurses will do shift to shift head count of residents identified at risk for elopement. They will document this on the 24 hour report. 10) Facility staff monitoring of residents at risk for elopement will occur throughout the shift. Frequency will be increased based on changed in resident behavior or routine or as indicted by the elopement risk assessment. " 9) Review of the current fa